【作者】 叶勇光；

【导师】 汪青春；

【作者基本信息】 南方医科大学 ， 中西医结合临床， 2008， 硕士

【摘要】 【目的】1.对强直性脊柱炎(ankylosing spondylitis,AS)患者和健康志愿者行脊旁肌肌电图检查,同时检测两组病例指地距、枕墙距、Schober试验、疼痛和疲劳评分等相关参数,对两组数据进行统计学处理,探讨AS患者脊旁肌的特征性肌电图改变及在协助诊疗AS的临床意义。2.研究银质针治疗方法对AS患者腰部活动功能的改善及脊旁肌肌电图改变,评价其治疗效果,探讨银质针在临床应用中的价值。【材料和方法】1.病例资料的收集1.1病例来源32例AS患者来自南方医院中医正骨科与风湿病科2006年9月至2007年3月的门诊和住院病人。健康志愿者均为我校在校学生或医院工作人员,均为我校在校学生或医院工作人员。1.2纳入标准符合1984年修订的纽约标准:①下腰背痛的病程至少持续3个月,疼痛随活动改善,但休息不减轻;②腰椎在前后和侧屈方向活动受限;③胸廓扩展范围小于同年龄和性别的正常值;④双侧骶髂关节炎Ⅱ～Ⅳ级,或单侧骶髂关节炎Ⅲ-Ⅳ级。如果患者具备④并分别附加①～③条中的任何1条可确诊为AS。1.3排除标准(有任何一项者):(1)年龄小于16岁或大于60岁者;妊娠或哺乳期妇女;(2)合并心脑血管等严重基础疾病者;(3)X线示脊柱小关节间隙消失或骨性强直者。2.参数及其测量方法2.1肌电图检查方法在室温25℃的屏蔽室,采用美国产Nicolet VikingⅣ肌电图仪,用同心圆针电极对所有受试者行脊旁肌肌电图检测。检测步骤:①受试者俯卧位,腹部垫一薄枕。在腰部标记出L1、L4棘突位置,以旁开中线2cm为肌电图检查进针点。②针电极消毒后,垂直进针,观察指标为肌肉轻用力收缩时肌肉20个运动单位电位平均时限、波幅。2.2银质针微创手术方法首先,用紫药水在针刺部位做出标记,常规消毒皮肤,在无菌操作下于每个进针点作0.5%利多卡因皮内注射形成直径约5mm的皮丘,以备留针艾炷燃烧不会产生皮肤刺痛与灼痛。局部麻醉下根据不同部位选择不同规格的无菌银质针,对准深层病变方向行垂直或斜刺进针,针距为1cm,直达肌膜附着的骨面,引出强烈针感为止。要求针尖直达骨面,留针时在每一根银针的末端套上一个长2.0-2.5cm艾炷,然后点燃加热,以患者能耐受为度,针灸期间注意保护皮肤不被烫伤,过热则用注射器向针柄喷洒生理盐水降温。待艾炷燃尽,针身余温消退后起针。若有出血点注意按压止血。逐一起针后在每一针眼处涂2%碘酒。让其暴露(夏秋)或纱布覆盖(冬春),3天内勿与水接触,以避免进针点感染。2.3其他参数指标:①枕墙距:患者直立,背靠与墙,记录枕骨隆突距墙壁的垂直距离,正常为0。②指地距:患者直立,双脚并拢,双侧下肢保持直立后向前弯腰双手中指尽量触地,记录左右手中指离地的距离,取平均值。③腰椎屈曲度:通过矢状面的Schober试验的测定法,在直立位时腰骶交界处作一标志,然后在此标记中线上10cm和其下5cm各作一标志,让患者最大限度向前弯腰,正常时腰椎运动两点之间距离增加至少5cm。④疼痛和疲劳:采用视觉模拟尺评分法(VAS)评估患者的疼痛和疲劳程度。2.4误差控制各参数由两人独立测量,取其测量者之平均值。测量前对两名测量者进行测量标准培训。3.病例分组3.1 32例AS患者作为病例组,32例健康成人作为对照组,分别行肌电图检查。3.2 32例AS患者就诊时即行脊旁肌肌电图检查同时检测腰部活动功能、疲劳及疼痛等指标。全部患者先行药物治疗一个疗程(治疗一个月),口服西乐葆(0.1g Bid)+柳氮磺吡啶(1g Tid)治疗。治疗后一月按就诊先后顺序编号1,2,3,……,通过查看随机数表的方法,单盲随机分为两组,一组继续药物治疗即对照组;另一组在继续药物治疗的基础上采用银质针治疗即治疗组。治疗两个疗程后再次检测两组患者的肌电指标及其他参数指标。4.统计方法治疗组与对照组间比较采用两独立样本t检验(Independent-Samples T Test);两组治疗前后各自比较采用配对样本t检验(Paired-Samples T Test)。相关性分析中,双变量正态分布资料选用Pearson相关系数;非双变量正态分布资料选用Spearman相关系数。统计分析采用SPSS13.0软件包,可信区间取95%,即P＜0.05有统计学意义。【结果】1.AS患者脊旁肌肌电指标与对照组比较有显著性差异(P=0.000＜0.01),呈短时限、低波幅表现;肌电指标与腰部活动功能、疼痛呈显著性相关(P=0.000＜0.01,P=0.000＜0.01)。2.对照组治疗前后各检测值均有显著性差异(P＜0.01),银质针组各项检测指标治疗前后差异均有显著性意义(P＜0.01)。两组患者经治疗后各项检测结果行协方差分析显示指地距与Schober试验有显著性差异(P=0.000＜0.01),肌电指标中仅L4时限差异有显著性意义(P=0.016＜0.05)。【结论】1.肌电图检查能较好反映腰部肌肉状态及间接反应AS腰部活动功能,可作为诊疗AS患者的有效指标。2.单纯药物治疗与药物合银质针治疗两种治疗方法均能改善患者疲劳及疼痛症状,银质针治疗还能改善AS患者肌电指标、脊柱活动功能。银质针治疗能够松解AS患者脊旁软组织,对改善脊柱活动功能、疲劳及疼痛症状有良好的作用效果。更多还原

【Abstract】 Objectives:1. To compare paraspinal muscle activity as measured by electromyography (EMG) of patients with ankylosing Spondylitis (AS) and healthy volunteers. And also measured the finger-floor distance, pulvinar-wall distance, Schober test results, level of fatigue and pain, and to investigate the value of EMG in the evaluation of therapeutic efficacy on patients with AS.2. Electromyography about silver needle acupuncture treatment in patients with ankylosing Spondylitis, evaluate the therapeutic efficacy. To investigate the value of silver needle acupuncture treatment in clinical application.Materials and Methods:data and case 32 patients of AS come from traditional Chinese medicine orthopedics and rheumatic division of Nanfang hospital. 32 healthy volunteer come from medical examination center of Nanfang hospital.Internalize standard To accord with revised standard in New York in 1984. Unremitting and intermittent pain from low back, it last more than three months. Limitation of activity in lumbar spine. Bony thorax enlargement diminutive than the normal value of the similar age and sex.Two sides sacroilitis ofⅡ～Ⅳcaste, or half sacroilitis ofⅢ～Ⅳcaste. If patient to have three of these, then it may final diagnosis for AS.Exclusion standard Less than sixteen years old and exceed sixty years old. Femme who at encyesis or lactation. The one who complicating disease of Cerebral vessels. The X-ray showed the joint space of dorsal spine had been abolition. Parameters and measures:1. Check of EMG: In the shielded enclosure with temperature at 25℃,the meter of electromyogram Nicolet VikingⅣwas made in American. All the subjects detected the paraspinal muscle by cocenric citcle electrode. Step of detection: First, all the subjects with prone position, indicated the location of L1、L4 in pars lumbalis. By means of 2cm aside linea mediana as needling point of EMG exam. Second, after the needle electrode degermed, needling verticality, the indicatrix of observation were the latitude and wave amplitude of motor unit potential(MUP).2. Other parameter index: finger-floor distance; pulvinar-wall distance,;Schober test results; level of fatigue and pain.Cases and Grouping:1. Thirty-two patients with AS as disease group. And 32 healthy volunteers as normal control group. All of them received EMG checking.2. Thirty-two patients with AS fractionate two sets trabantly. One set received simple drug healing, the other received drug and silver needle acupuncture treatment. Detected all the patients before and after treatment.Statistical methods Compared with two means on t test of independent sampler. Compared before and after treatment on t test of paired-sampler. Bivariation normal distribution data adoption the Pearson correlation, un-bivariation normal distribution data adoption the Spearman correlation. Confidence interval was 95%, P < 0.05 had significant difference.Results:1. EMG activity was significantly lower in patients with AS than in the controls(P<0.01).The shorten of latitude and decline of amplitude appeared in the EMG of the AS group after contraction with little strength. It was found that EMG activity was highly correlated with the Schober test results and the level of pain(P<0.01).2. The value of each detection before and after simple drug treatment were significant difference(P<0.01). The value of each detection before and after drug and silver needle acupuncture treatment are also significant difference(P<0.01).Conclusion:1. EMG can effectively reflect paraspinal muscle activity and spinal mobility, what could be an effective way to evaluat of therapeutic efficacy on patients with AS.2. Level of fatigue and pain could be treated by simple drug treatment both drug and silver needle acupuncture treatment. Myoelectrictty index and dorsal spine function also improved by drug and silver needle acupuncture treatment. The curative effect of this method was exact, it deserved to extend in clinical application.更多还原