缺血性卒中后抑郁中医证候要素演变规律及辨证干预的临床研究
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摘要
目的①探寻缺血性卒中后抑郁(PSD)事件发生与性别、年龄、卒中部位、神经功能缺损程度、中医证候要素等之间的关系,筛选可能促成PSD发生的危险因素,并对PSD发生、发展过程中的中医证候演变规律进行初步的研究,为中医药干预治疗提供理论依据。②在中医学辨证论治的核心思想的指导下,对防郁小复方干预PSD进行临床研究,探讨其在缺血性卒中后减少PSD发病的作用,拓展中医药防治PSD的领域。
方法①回顾性调查研究急性缺血性卒中患者,研究首发急性缺血性中风患者的中医证候要素的动态演变规律及与神经功能改善、卒中后抑郁发生之间的关系,寻找可能促成PSD发生的危险因素。②采用随机对照的研究方法,针对前期研究中发现的PSD发生中最重要的三个中医证素：痰、瘀、气虚,根据三者出现时期及程度的不同,辨证予防郁小复方,方随证变,干预治疗。
结果：①对缺血性卒中急性期证候动态演变规律的研究发现发病初期最为突出证素为风证,而后风证概率显著下降；随着病情变化,气虚的症状逐渐显现,痰、瘀逐渐上升为主导证素,贯穿了整个急性期。其中医证候是以多种证候要素组合存在的,在证候组合关系动态变化中,起始以风为主导的证候组合,随着病情发展,气虚、痰湿、血瘀的证候组合逐渐增多。②研究中未发现年龄、性别、卒中部位在左、右或双侧大脑半球与PSD的发生相关,但多发性梗死,或在脑叶的梗塞似乎更易发生PSD。③神经功能缺损的程度与抑郁的发生及程度互为影响,神经功能损伤越严重、恢复越差的患者发生PSD的可能性越大、其程度可能越重。神经功能缺损是影响PSD发生的危险因素之一。④对PSD发生过程中中医证候要素的演变规律的研究发现,相较non-PSD患者,PSD患者痰湿证、血瘀证、气虚证的上升趋势更为明显,表明痰湿证、血瘀证、气虚证可能是影响PSD发生的主要证素。⑤通过神经网络技术结合Logistic回归及ROC分析中医证候要素对早期预测PSD的价值可知,痰湿、血瘀、气虚等证素可能是导致发生PSD的决定因素。发病初期的痰证积分>9.5分,血瘀积分>13.5分的患者其以后发生PSD事件可能性较大。到14d时通过痰湿、血瘀、气虚等证素预测PSD灵敏度及特异度均较好。对在这个时间点上述证素较突出的患者可进行重点关注其今后病情演变,必要时予以早期干预,降低PSD的发生率。⑥对急性缺血性卒中患者发病初期即辨证使用防郁小复方的患者PSD的发生率亦较对照组下降,两组间比较有统计学差异,P<0.05。其神经功能恢复明显好于对照组,两组间比较有统计学差异,P<0.01。
结论①PSD发生过程中中医证候演变规律发现,痰湿证、血瘀证、气虚证可能是影响其发生的主要证素。OCSP分型、神经功能缺损也是影响PSD发生的危险因素之一。②动态观察急性缺血性卒中患者中医证候要素演变,尤其对疾病发展过程中痰湿、血瘀、气虚证明显的患者积极做好PSD的二级预防工作,减少PSD事件的发生。③通过中医证候学的研究,对中医证候要素动态演变的观测使早期预测PSD成为可能,为开展中医药早期防治PSD提供了理论依据。对中医证候要素的观测简单可行,方便临床对急性缺血性卒中患者进行PSD高危人群的筛查,具有较高的临床价值和实践意义。④防郁小复方的配伍组合体现了方随证变,方证相应的中医学辨证论治的精髓,使痰化、瘀祛、正扶、络通、郁解,能显著改善卒中后神经功能缺损程度,减少PSD发病率,体现了中医学治未病的思想。
Objective①To Explore the relationship between the post-stroke depression (PSD) with gender, age, stroke site, the degree of neurological deficit and TCM syndrome elements, and to look for risk factors that may have contributed to PSD.②A Randomized Controlled Trial was Designed to Explore the role of Small Compound Prescriptions to reduce PSD incidence after acute ischemic stroke under guidance of the theory of TCM.
Methods①To study the dynamic evolution of TCM syndrome elements of the first acute ischemic stroke patients and to look for the risk factors which may have contributed to the PSD by Retrospective study with acute ischemic stroke patients.②Previous study found that the most important of the three TCM syndrome factors in PSD were phlegm, blood stasis and qi deficiency. According to the different period the three syndrome factors appeared and their different degrees, the patients of acute ischemic stroke was given the small compound Prescriptions under guidance of the theory of TCM by Randomized controlled study.
Results①The study found the most prominent early onset syndrome factor was wind syndrome, which significant declines with time passing.At the same time, qi deficiency symptoms raised gradually, and phlegm syndrome, blood stasis syndrome Gradually increased as the dominant factors which persisted the entire acute phase.②The study found there was no Correlations between the age, gender, Left or right side of the lesion in the brain with PSD. But it seems more likely to occur in the brain lobe infarction or multiple infarction.③The more serious neurological deficit, the greater the likelihood of PSD. Neurological deficit is one of the risk factors affect the PSD occurred.④Phlegm syndrome, blood stasis, qi deficiency were the main TCM syndrome factors which impact of PSD occurs.⑤The area under the ROC curve to predicted PSD after ischemic stroke of NIHSS score, phlegm and blood stasis syndrome accumulated scores were0.737,0.760,0.652respectively. Their diagnostic cut off points were9.5,9.5, and13.5scores which could be good for the early diagnosis of PSD.⑥PSD incidence of the treatment group compared with the control group decreased, there is statistical difference between the two groups, P<0.05. Recovery of neurological function was significantly better than the control group, there is statistical difference between the two groups, P<0.01.
Conclusion①Phlegm syndrome, blood stasis and qi deficiency may the main syndrome factors that will promote PSD occurred after ischemic stroke.②Clinicians could pay attention to the development of Syndrome Factors, especially the phlegm, blood stasis and qi deficiency.③Through the observation of the TCM syndrome factors can prediction PSD in advance. It provides the theoretical basis for the treatment of PSD by TCM.④The formula combination of anti-depression small Compound Prescriptions reflects the principles of TCM diagnosis and treatment. It can reduce phlegm, Invigorate the circulation, supply qi, Improve the neurological deficit after stroke and reduce the incidence of PSD. This method reflects the theory of traditional Chinese medicine to prevent disease.
方法①回顾性调查研究急性缺血性卒中患者,研究首发急性缺血性中风患者的中医证候要素的动态演变规律及与神经功能改善、卒中后抑郁发生之间的关系,寻找可能促成PSD发生的危险因素。②采用随机对照的研究方法,针对前期研究中发现的PSD发生中最重要的三个中医证素：痰、瘀、气虚,根据三者出现时期及程度的不同,辨证予防郁小复方,方随证变,干预治疗。
结果：①对缺血性卒中急性期证候动态演变规律的研究发现发病初期最为突出证素为风证,而后风证概率显著下降；随着病情变化,气虚的症状逐渐显现,痰、瘀逐渐上升为主导证素,贯穿了整个急性期。其中医证候是以多种证候要素组合存在的,在证候组合关系动态变化中,起始以风为主导的证候组合,随着病情发展,气虚、痰湿、血瘀的证候组合逐渐增多。②研究中未发现年龄、性别、卒中部位在左、右或双侧大脑半球与PSD的发生相关,但多发性梗死,或在脑叶的梗塞似乎更易发生PSD。③神经功能缺损的程度与抑郁的发生及程度互为影响,神经功能损伤越严重、恢复越差的患者发生PSD的可能性越大、其程度可能越重。神经功能缺损是影响PSD发生的危险因素之一。④对PSD发生过程中中医证候要素的演变规律的研究发现,相较non-PSD患者,PSD患者痰湿证、血瘀证、气虚证的上升趋势更为明显,表明痰湿证、血瘀证、气虚证可能是影响PSD发生的主要证素。⑤通过神经网络技术结合Logistic回归及ROC分析中医证候要素对早期预测PSD的价值可知,痰湿、血瘀、气虚等证素可能是导致发生PSD的决定因素。发病初期的痰证积分>9.5分,血瘀积分>13.5分的患者其以后发生PSD事件可能性较大。到14d时通过痰湿、血瘀、气虚等证素预测PSD灵敏度及特异度均较好。对在这个时间点上述证素较突出的患者可进行重点关注其今后病情演变,必要时予以早期干预,降低PSD的发生率。⑥对急性缺血性卒中患者发病初期即辨证使用防郁小复方的患者PSD的发生率亦较对照组下降,两组间比较有统计学差异,P<0.05。其神经功能恢复明显好于对照组,两组间比较有统计学差异,P<0.01。
结论①PSD发生过程中中医证候演变规律发现,痰湿证、血瘀证、气虚证可能是影响其发生的主要证素。OCSP分型、神经功能缺损也是影响PSD发生的危险因素之一。②动态观察急性缺血性卒中患者中医证候要素演变,尤其对疾病发展过程中痰湿、血瘀、气虚证明显的患者积极做好PSD的二级预防工作,减少PSD事件的发生。③通过中医证候学的研究,对中医证候要素动态演变的观测使早期预测PSD成为可能,为开展中医药早期防治PSD提供了理论依据。对中医证候要素的观测简单可行,方便临床对急性缺血性卒中患者进行PSD高危人群的筛查,具有较高的临床价值和实践意义。④防郁小复方的配伍组合体现了方随证变,方证相应的中医学辨证论治的精髓,使痰化、瘀祛、正扶、络通、郁解,能显著改善卒中后神经功能缺损程度,减少PSD发病率,体现了中医学治未病的思想。
Objective①To Explore the relationship between the post-stroke depression (PSD) with gender, age, stroke site, the degree of neurological deficit and TCM syndrome elements, and to look for risk factors that may have contributed to PSD.②A Randomized Controlled Trial was Designed to Explore the role of Small Compound Prescriptions to reduce PSD incidence after acute ischemic stroke under guidance of the theory of TCM.
Methods①To study the dynamic evolution of TCM syndrome elements of the first acute ischemic stroke patients and to look for the risk factors which may have contributed to the PSD by Retrospective study with acute ischemic stroke patients.②Previous study found that the most important of the three TCM syndrome factors in PSD were phlegm, blood stasis and qi deficiency. According to the different period the three syndrome factors appeared and their different degrees, the patients of acute ischemic stroke was given the small compound Prescriptions under guidance of the theory of TCM by Randomized controlled study.
Results①The study found the most prominent early onset syndrome factor was wind syndrome, which significant declines with time passing.At the same time, qi deficiency symptoms raised gradually, and phlegm syndrome, blood stasis syndrome Gradually increased as the dominant factors which persisted the entire acute phase.②The study found there was no Correlations between the age, gender, Left or right side of the lesion in the brain with PSD. But it seems more likely to occur in the brain lobe infarction or multiple infarction.③The more serious neurological deficit, the greater the likelihood of PSD. Neurological deficit is one of the risk factors affect the PSD occurred.④Phlegm syndrome, blood stasis, qi deficiency were the main TCM syndrome factors which impact of PSD occurs.⑤The area under the ROC curve to predicted PSD after ischemic stroke of NIHSS score, phlegm and blood stasis syndrome accumulated scores were0.737,0.760,0.652respectively. Their diagnostic cut off points were9.5,9.5, and13.5scores which could be good for the early diagnosis of PSD.⑥PSD incidence of the treatment group compared with the control group decreased, there is statistical difference between the two groups, P<0.05. Recovery of neurological function was significantly better than the control group, there is statistical difference between the two groups, P<0.01.
Conclusion①Phlegm syndrome, blood stasis and qi deficiency may the main syndrome factors that will promote PSD occurred after ischemic stroke.②Clinicians could pay attention to the development of Syndrome Factors, especially the phlegm, blood stasis and qi deficiency.③Through the observation of the TCM syndrome factors can prediction PSD in advance. It provides the theoretical basis for the treatment of PSD by TCM.④The formula combination of anti-depression small Compound Prescriptions reflects the principles of TCM diagnosis and treatment. It can reduce phlegm, Invigorate the circulation, supply qi, Improve the neurological deficit after stroke and reduce the incidence of PSD. This method reflects the theory of traditional Chinese medicine to prevent disease.
引文
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