膝关节骨关节炎经筋辨证规律的临床研究
|
摘要
目的：
用现代的方法研究中医经筋理论,阐明经筋病的生理病理特征,提高经筋临床诊疗技术,推进经筋疗法临床规范化及标准化。通过研究膝关节骨关节炎经筋辨证的临床特征规律,进一步完善膝骨关节炎经筋辨证体系的内容；对足阳明经筋型膝骨关节炎患者进行临床及影像学特征的回顾性研究,初步归纳该筋型的临床特征及影像学特点,完善膝骨关节炎的中医外治辨证体系,深度挖掘祖国传统医学经典理论的闪光点,试图为传统经筋理论取得现代的循证医学依据及医学影像学的有效解释。
方法：
收集符合纳入标准的KOA患者基本资料及相关症状体征,根据KOA经筋辨证情况调查表及病灶分布表,对患者进行经筋辨证调查分析,描述KOA的经筋证型分布规律；对各经筋证型的影像学特征,临床特点,脏腑辨证规律进行相关性研究；并选取本次研究中最多见的足阳明经筋病变进行基于髌股关系的影像学及临床特征回顾性研究,采用SPSS19.0软件建立数据库,运用卡方检验、t检验、单因素相关性分析等归纳足阳明经型膝骨关节炎的影像学及临床特征。
成果：
本次研究共获得KOA患者180例,共208个膝关节。本次研究发现：1.单一足阳明经筋型膝骨关节炎31例,占所有经筋分型的14.9%,是单一筋型中出现率最高。阳明-三阴型是所有证型出现率最高,共37例,占所有经筋分型的17.8%。2.本研究发现常见的经筋证型在性别分布中存在统计学差异,经卡方检验,用Pearson Chi-Square, x2=12.07, P<0.007。3.本研究180例患者中,年龄最小45岁,最大75岁,平均59.70±9.68(岁)；将年龄分成3组,13个单元格(43.3%)的理论频数小于5,最小理论频数2.91,采用Fisher的精确检验,x2=78.899,P<0.001,提示各经筋证型在不同年龄段的分布有统计学差异。病程长短与经筋证型进行t检验,t=-3.221,P=0.001,提示两者病程长短有统计学差异,复合型经筋病变患者病程时间更长。4.单一型经筋分型影像学病情分级主要分布在0级、Ⅰ级、Ⅱ级,复合型经筋分型主要分布在ⅢI级及Ⅳ级；常见的经筋证型(足阳明经筋、阳明-太阳经筋、阳明-三阴经筋及太阳-三阴经筋)进行秩和检验,U=58.776,P<0.05,提示经筋证型在影像学病情分级分布有统计学差异。经筋分型与KOA影像学病位分型经卡方检验,26个单元格(65.0%)的理论频数小于5,最小理论频数1.38,采用Fisher的精确检验x2203.396,P<0.05；提示KOA影像学病位分型在经筋分布上有统计学差异。5.单一与复合筋型在膝关节功能评分有统计学差异,经t检验,t=4.159,P<0.05,提示复合型经筋病变lysholms膝关节功能评分更低。6.本次研究发现膝骨关节炎中医症候以正虚邪实为主：虚证证素以肾虚,肝虚,阳虚为主；实证以血瘀,气滞,痰湿为主；病位主要在肾肝脾三脏。单一型经筋病变主要与血瘀,痰湿,阳虚证素相关；复合型经筋病变主要与肾虚,脾虚,肝虚证素相关,经筋病变后期筋骨衰惫与肝肾亏虚密切相关。7.本次研究发现早期KOA患者以自觉疼痛,局部压痛为主要表现；中期可触及结节样,条索样病变,严重者发现浅表静脉曲张及胭窝囊肿；晚期有皮色改变,色素沉着等病变。8.第二部分临床研究31例足阳明经筋型KOA临床研究发现：阳明经筋型与空白组部分影像学指标有统计学差异：两组髌股指数比较,阳明经筋组平均比值为1.50±0.24,空白组平均比值为1.03±0.19,经t检验,P<0.001,提示两组有统计学差异；两组髌股协调角比较,阳明经筋组平均角度为5.65±3.78,空白组平均比值为2.31±2.90,经t检验,P<0.001,提示两组有统计学差异；两组外侧髌骨角度比较,阳明经筋组平均角度为6.31±1.58,空白组平均比值为9.11±1.78,经t检验,P<0.001,提示两组有统计学差异。
结论：
1.膝骨关节炎患者存在多种经筋证型,经筋证型与患者年龄、病程、膝关节功能评分密切相关。
2.经筋证型的分布与膝骨关节炎影像学改变密切相关。随着经筋证型从单一型向复合型转变,影像学改变也随之变化。
3.膝骨关节炎中医症候以正虚邪实为主；虚证以肾虚,肝虚,阳虚为主；实证以血瘀,气滞,痰湿为主；病位主要在肾、肝、脾三脏。经筋病变后期筋骨衰惫与肝肾亏虚密切相关。
4.足阳明经筋型膝骨关节炎多发病于髌股关节,髌股关系紊乱是足阳明经筋病变特征之一。
Objective:
To clarify the physiological and pathological features of the meridian-muscle syndrome by using modern methods of TCM theory so as to improve the clinical diagnosis technique for this kind of diseases and promote the normalization and standardization of the meridian-muscle therapies clinically. In this paper, by studying the clinical features and regularities of meridian-muscle syndrome in knee osteoarthritis (KOA), the TCM knowledge of this disease was further expanded; the retrospective study on the clinical and imaging features of Foot-Yangming meridian-muscle syndrome of KOA was performed for an initial summary so as to perfect the TCM external treatment for this disease and deeply verify some general conclusions from classical TCM theory, thereby providing some evidences and effective interpretations for traditional meridian-muscle theory on perspectives of modern evidence-based medicine and medical imaging.
Method:
The data of the basic information and related symptoms and signs of KOA patients who met the inclusion criteria were collected, according to the syndrome questionnaire and lesions distribution table of these patients, an analysis was performed on their data so as to describe their KOA meridian-muscle distribution; a correlational research was performed among the imaging features, clinical characteristics, visceral syndrome law for various meridian-muscle syndromes; then the most common seen Foot-Yangming meridian-muscle syndrome in this study was selected as a typical condition for a retrospective research based on imaging and clinical features of patellofemoral relationship. The imaging and clinical features of patellofemoral relationship in Foot-Yangming meridian-muscle syndrome was concluded by using SPSS19.0software to establish a database, and using chi-square test, Student's t test, univariate correlation analysis.
Results:
In this study, a total of180patients (208knees) were included. The study found that:1. There were31cases of KOA patients with single Foot-Yangming meridian-muscle syndrome, accounting for14.9%of all meridian-muscle syndromes, this syndrome accounted for the highest incidence of all single meridian-muscle syndromes. While Foot Yangming-Three Yin syndrome had the highest incidence in all meridian-muscle syndromes,37cases, accounting for17.8%of all meridian-muscle syndromes.2. The gender distribution of the common meridian-muscle syndromes found by this study had significant difference, by chi-square test, the results of Pearson Chi-Square showed that x2=12.07, P<0.05.3. In all180patients, the youngest was45-year-old, the oldest was75-year-old, their average age was59.70±9.68(years); The ages were divided into3sections, by chi-square test, the theoretical frequencies of13cells (43.3%) were less than5, the minimum theoretical frequency was2.91, the results of Fishers exact test showed that χ2=78.899, P<0.05, suggesting that the age distribution of all meridian-muscle syndromes found had significant difference. The Student's t test between disease syndrome duration of and meridian-muscle syndromes showed that t=-3.221, P=0.001, suggesting that the meridian-muscle syndromes trend to complex with the increase in duration.4. The imaging severity grading of single meridian-muscle syndrome mainly distributed in grade0, grade Ⅰ and grade Ⅱ, the complex meridian-muscle syndrome mainly distributed in grade Ⅲ, grade Ⅳ; The results of the rank sum test performed for common meridian-muscle syndromes (Foot-Yangming meridian-muscle syndrome, Foot Yangming-Taiyang meridian-muscle syndrome, Foot Yangming-Three yin meridian-muscle syndrome, Foot Taiyang-Three yin meridian-muscle syndrome) showed that U=58.776, P <0.05, suggesting that the imaging severity grading distribution of all these meridian-muscle syndromes had significant difference. The meridian-muscle syndrome differentiation and imaging lesion classification were verified by chi-square test, the results showed that the theoretical frequencies of26cells (65.0%) were less than5, the minimum theoretical frequency was1.38. The results of Fisher's exact test showed that χ2=203.396, P<0.05, suggesting that the meridian-muscle syndrome differentiation and imaging lesion classification for KOA diagnosis had significant difference.5. The difference knee function in single meridian-muscle syndrome and that in complex meridian-muscle syndrome was statistically significant, the results of Student's t test showed that t=4.159, P<0.05; suggesting that the knee function score decreased with the increase in the number of meridian-muscle lesions, they were negatively correlated.6. The most common TCM symptoms for KOA patients in this study were healthy energy deficiency and evil excess: the main factors for deficiency syndrome were kidney deficiency, liver deficiency and Yang deficiency. The main factors for pathogenic syndrome were blood stasis, Qi stagnation, phlegm. The lesions mainly occurred in kidney, liver and spleen. The single meridian-muscle syndrome was mainly associated with blood stasis, phlegm and Yang deficiency, while the complex meridian-muscle syndrome was mainly associated to kidney deficiency, spleen deficiency and liver deficiency, in addition, the degradation and exhaustion of bones and muscles in advanced stage of meridian-muscle syndrome were closely associated with liver and kidney deficiency.7. In early stage of KOA patients, they mainly had chief complaints such as perceived pain, focal tenderness; in the middle stage of KOA patients, they mainly had palpable nodular cord-like lesions, some serve patients even had superficial varicose veins and popliteal cyst; in the advanced stage of KOA patients, they mainly had changes in skin color, pigmentation and other symptoms.8. The second part of the clinical study was performed for31cases of KOA patients with Foot-Yangming meridian-muscle syndrome, the results showed that some radiographic parameters of patients with Foot-Yangming meridian-muscle syndrome and that of blank group were significantly different:in compassion of patellofemoral indexes between both group, the average ratio of Foot-Yangming meridian-muscle syndrome group was1.50±0.24, while that of blank group was1.03±0.19, the results of Student's t-test showed that P<0.05, suggesting that there were significant difference between these two groups; in compassion of lateral patellofemoral angle between both group, the average angle of Foot-Yangming meridian-muscle syndrome group was6.31±1.58, while that of blank group was9.11±1.78, the results of Student's t-test showed that P<0.05, suggesting that there were significant difference between these two groups.
Conclusion:
1. There are various meridian-muscle syndromes in KOA patients, these syndromes are closely corrected to the ages, durations, knee function scores of these patients.
2. The distributions of the meridian-muscle syndromes are closely corrected to the imaging changes in KOA patients. If the single meridian-muscle syndrome of a patient developed into complex meridian-muscle syndrome, his/her imaging changes would occur at the same time.
3. The main TCM symptoms of KOA patients are healthy energy deficiency and evil excess, in which, the main factors for deficiency syndrome are kidney deficiency, liver deficiency and Yang deficiency, and the main factors for pathogenic syndrome are blood stasis, Qi stagnation, phlegm, in addition, the degradation and exhaustion of bones and muscles in advanced stage of meridian-muscle syndrome were closely associated with liver and kidney deficiency.
4. The Foot-Yangming meridian-muscle syndrome of KOA mainly occurred in the patellofemoral joint, the patellofemoral relationship disorder is one of lesion characteristics in Foot-Yangming meridian-muscle syndrome.
用现代的方法研究中医经筋理论,阐明经筋病的生理病理特征,提高经筋临床诊疗技术,推进经筋疗法临床规范化及标准化。通过研究膝关节骨关节炎经筋辨证的临床特征规律,进一步完善膝骨关节炎经筋辨证体系的内容；对足阳明经筋型膝骨关节炎患者进行临床及影像学特征的回顾性研究,初步归纳该筋型的临床特征及影像学特点,完善膝骨关节炎的中医外治辨证体系,深度挖掘祖国传统医学经典理论的闪光点,试图为传统经筋理论取得现代的循证医学依据及医学影像学的有效解释。
方法：
收集符合纳入标准的KOA患者基本资料及相关症状体征,根据KOA经筋辨证情况调查表及病灶分布表,对患者进行经筋辨证调查分析,描述KOA的经筋证型分布规律；对各经筋证型的影像学特征,临床特点,脏腑辨证规律进行相关性研究；并选取本次研究中最多见的足阳明经筋病变进行基于髌股关系的影像学及临床特征回顾性研究,采用SPSS19.0软件建立数据库,运用卡方检验、t检验、单因素相关性分析等归纳足阳明经型膝骨关节炎的影像学及临床特征。
成果：
本次研究共获得KOA患者180例,共208个膝关节。本次研究发现：1.单一足阳明经筋型膝骨关节炎31例,占所有经筋分型的14.9%,是单一筋型中出现率最高。阳明-三阴型是所有证型出现率最高,共37例,占所有经筋分型的17.8%。2.本研究发现常见的经筋证型在性别分布中存在统计学差异,经卡方检验,用Pearson Chi-Square, x2=12.07, P<0.007。3.本研究180例患者中,年龄最小45岁,最大75岁,平均59.70±9.68(岁)；将年龄分成3组,13个单元格(43.3%)的理论频数小于5,最小理论频数2.91,采用Fisher的精确检验,x2=78.899,P<0.001,提示各经筋证型在不同年龄段的分布有统计学差异。病程长短与经筋证型进行t检验,t=-3.221,P=0.001,提示两者病程长短有统计学差异,复合型经筋病变患者病程时间更长。4.单一型经筋分型影像学病情分级主要分布在0级、Ⅰ级、Ⅱ级,复合型经筋分型主要分布在ⅢI级及Ⅳ级；常见的经筋证型(足阳明经筋、阳明-太阳经筋、阳明-三阴经筋及太阳-三阴经筋)进行秩和检验,U=58.776,P<0.05,提示经筋证型在影像学病情分级分布有统计学差异。经筋分型与KOA影像学病位分型经卡方检验,26个单元格(65.0%)的理论频数小于5,最小理论频数1.38,采用Fisher的精确检验x2203.396,P<0.05；提示KOA影像学病位分型在经筋分布上有统计学差异。5.单一与复合筋型在膝关节功能评分有统计学差异,经t检验,t=4.159,P<0.05,提示复合型经筋病变lysholms膝关节功能评分更低。6.本次研究发现膝骨关节炎中医症候以正虚邪实为主：虚证证素以肾虚,肝虚,阳虚为主；实证以血瘀,气滞,痰湿为主；病位主要在肾肝脾三脏。单一型经筋病变主要与血瘀,痰湿,阳虚证素相关；复合型经筋病变主要与肾虚,脾虚,肝虚证素相关,经筋病变后期筋骨衰惫与肝肾亏虚密切相关。7.本次研究发现早期KOA患者以自觉疼痛,局部压痛为主要表现；中期可触及结节样,条索样病变,严重者发现浅表静脉曲张及胭窝囊肿；晚期有皮色改变,色素沉着等病变。8.第二部分临床研究31例足阳明经筋型KOA临床研究发现：阳明经筋型与空白组部分影像学指标有统计学差异：两组髌股指数比较,阳明经筋组平均比值为1.50±0.24,空白组平均比值为1.03±0.19,经t检验,P<0.001,提示两组有统计学差异；两组髌股协调角比较,阳明经筋组平均角度为5.65±3.78,空白组平均比值为2.31±2.90,经t检验,P<0.001,提示两组有统计学差异；两组外侧髌骨角度比较,阳明经筋组平均角度为6.31±1.58,空白组平均比值为9.11±1.78,经t检验,P<0.001,提示两组有统计学差异。
结论：
1.膝骨关节炎患者存在多种经筋证型,经筋证型与患者年龄、病程、膝关节功能评分密切相关。
2.经筋证型的分布与膝骨关节炎影像学改变密切相关。随着经筋证型从单一型向复合型转变,影像学改变也随之变化。
3.膝骨关节炎中医症候以正虚邪实为主；虚证以肾虚,肝虚,阳虚为主；实证以血瘀,气滞,痰湿为主；病位主要在肾、肝、脾三脏。经筋病变后期筋骨衰惫与肝肾亏虚密切相关。
4.足阳明经筋型膝骨关节炎多发病于髌股关节,髌股关系紊乱是足阳明经筋病变特征之一。
Objective:
To clarify the physiological and pathological features of the meridian-muscle syndrome by using modern methods of TCM theory so as to improve the clinical diagnosis technique for this kind of diseases and promote the normalization and standardization of the meridian-muscle therapies clinically. In this paper, by studying the clinical features and regularities of meridian-muscle syndrome in knee osteoarthritis (KOA), the TCM knowledge of this disease was further expanded; the retrospective study on the clinical and imaging features of Foot-Yangming meridian-muscle syndrome of KOA was performed for an initial summary so as to perfect the TCM external treatment for this disease and deeply verify some general conclusions from classical TCM theory, thereby providing some evidences and effective interpretations for traditional meridian-muscle theory on perspectives of modern evidence-based medicine and medical imaging.
Method:
The data of the basic information and related symptoms and signs of KOA patients who met the inclusion criteria were collected, according to the syndrome questionnaire and lesions distribution table of these patients, an analysis was performed on their data so as to describe their KOA meridian-muscle distribution; a correlational research was performed among the imaging features, clinical characteristics, visceral syndrome law for various meridian-muscle syndromes; then the most common seen Foot-Yangming meridian-muscle syndrome in this study was selected as a typical condition for a retrospective research based on imaging and clinical features of patellofemoral relationship. The imaging and clinical features of patellofemoral relationship in Foot-Yangming meridian-muscle syndrome was concluded by using SPSS19.0software to establish a database, and using chi-square test, Student's t test, univariate correlation analysis.
Results:
In this study, a total of180patients (208knees) were included. The study found that:1. There were31cases of KOA patients with single Foot-Yangming meridian-muscle syndrome, accounting for14.9%of all meridian-muscle syndromes, this syndrome accounted for the highest incidence of all single meridian-muscle syndromes. While Foot Yangming-Three Yin syndrome had the highest incidence in all meridian-muscle syndromes,37cases, accounting for17.8%of all meridian-muscle syndromes.2. The gender distribution of the common meridian-muscle syndromes found by this study had significant difference, by chi-square test, the results of Pearson Chi-Square showed that x2=12.07, P<0.05.3. In all180patients, the youngest was45-year-old, the oldest was75-year-old, their average age was59.70±9.68(years); The ages were divided into3sections, by chi-square test, the theoretical frequencies of13cells (43.3%) were less than5, the minimum theoretical frequency was2.91, the results of Fishers exact test showed that χ2=78.899, P<0.05, suggesting that the age distribution of all meridian-muscle syndromes found had significant difference. The Student's t test between disease syndrome duration of and meridian-muscle syndromes showed that t=-3.221, P=0.001, suggesting that the meridian-muscle syndromes trend to complex with the increase in duration.4. The imaging severity grading of single meridian-muscle syndrome mainly distributed in grade0, grade Ⅰ and grade Ⅱ, the complex meridian-muscle syndrome mainly distributed in grade Ⅲ, grade Ⅳ; The results of the rank sum test performed for common meridian-muscle syndromes (Foot-Yangming meridian-muscle syndrome, Foot Yangming-Taiyang meridian-muscle syndrome, Foot Yangming-Three yin meridian-muscle syndrome, Foot Taiyang-Three yin meridian-muscle syndrome) showed that U=58.776, P <0.05, suggesting that the imaging severity grading distribution of all these meridian-muscle syndromes had significant difference. The meridian-muscle syndrome differentiation and imaging lesion classification were verified by chi-square test, the results showed that the theoretical frequencies of26cells (65.0%) were less than5, the minimum theoretical frequency was1.38. The results of Fisher's exact test showed that χ2=203.396, P<0.05, suggesting that the meridian-muscle syndrome differentiation and imaging lesion classification for KOA diagnosis had significant difference.5. The difference knee function in single meridian-muscle syndrome and that in complex meridian-muscle syndrome was statistically significant, the results of Student's t test showed that t=4.159, P<0.05; suggesting that the knee function score decreased with the increase in the number of meridian-muscle lesions, they were negatively correlated.6. The most common TCM symptoms for KOA patients in this study were healthy energy deficiency and evil excess: the main factors for deficiency syndrome were kidney deficiency, liver deficiency and Yang deficiency. The main factors for pathogenic syndrome were blood stasis, Qi stagnation, phlegm. The lesions mainly occurred in kidney, liver and spleen. The single meridian-muscle syndrome was mainly associated with blood stasis, phlegm and Yang deficiency, while the complex meridian-muscle syndrome was mainly associated to kidney deficiency, spleen deficiency and liver deficiency, in addition, the degradation and exhaustion of bones and muscles in advanced stage of meridian-muscle syndrome were closely associated with liver and kidney deficiency.7. In early stage of KOA patients, they mainly had chief complaints such as perceived pain, focal tenderness; in the middle stage of KOA patients, they mainly had palpable nodular cord-like lesions, some serve patients even had superficial varicose veins and popliteal cyst; in the advanced stage of KOA patients, they mainly had changes in skin color, pigmentation and other symptoms.8. The second part of the clinical study was performed for31cases of KOA patients with Foot-Yangming meridian-muscle syndrome, the results showed that some radiographic parameters of patients with Foot-Yangming meridian-muscle syndrome and that of blank group were significantly different:in compassion of patellofemoral indexes between both group, the average ratio of Foot-Yangming meridian-muscle syndrome group was1.50±0.24, while that of blank group was1.03±0.19, the results of Student's t-test showed that P<0.05, suggesting that there were significant difference between these two groups; in compassion of lateral patellofemoral angle between both group, the average angle of Foot-Yangming meridian-muscle syndrome group was6.31±1.58, while that of blank group was9.11±1.78, the results of Student's t-test showed that P<0.05, suggesting that there were significant difference between these two groups.
Conclusion:
1. There are various meridian-muscle syndromes in KOA patients, these syndromes are closely corrected to the ages, durations, knee function scores of these patients.
2. The distributions of the meridian-muscle syndromes are closely corrected to the imaging changes in KOA patients. If the single meridian-muscle syndrome of a patient developed into complex meridian-muscle syndrome, his/her imaging changes would occur at the same time.
3. The main TCM symptoms of KOA patients are healthy energy deficiency and evil excess, in which, the main factors for deficiency syndrome are kidney deficiency, liver deficiency and Yang deficiency, and the main factors for pathogenic syndrome are blood stasis, Qi stagnation, phlegm, in addition, the degradation and exhaustion of bones and muscles in advanced stage of meridian-muscle syndrome were closely associated with liver and kidney deficiency.
4. The Foot-Yangming meridian-muscle syndrome of KOA mainly occurred in the patellofemoral joint, the patellofemoral relationship disorder is one of lesion characteristics in Foot-Yangming meridian-muscle syndrome.
引文
[1]申延清,刘风霞,曹红,马爱国.膝骨关节炎患者的临床表现及相关影响因素[J].中国组织工程研究与临床康复.2011.(09)：1643-1646.
[2]刘健,赵文海.对骨性关节炎发病机制的研究概况[J].辽宁中医药大学学报.2008.(02)：80-82.
[3]黄涛.骨性关节炎病因和发病机制研究进展[J].福建中医药.2005.(04)：57-58.
[4]Sun B H. Wu CW, Kalunian K C. New developments in osteoarthritis[J]. Rheum Dis Clin N Am,2007,33 (1):1352148.
[5]高仰贤.骨性关节炎发病机制的国内研究进展[J].中医正骨.2005.(04)：55-57.
[6]周洪保,张曦,吕正祥.膝关节骨性关节炎治疗进展[J].中医药导报,2012,18(2)：87-89.
[7]Ding M. Danielsen CC. Hvid I. The effects of bone remodeling inhibition by alendronate on three-dimensional microarchitecture of subchondral bone tissue in genea pig pramary osteoarthrosis.Calcif Tissue Int,2008;82(1):77-86
[8]王晶.膝关节软骨下BMLs和OAPC与软骨下骨承受应力改变关系的研究.硕士论文.河北医科大学,23-66,2010
[9]郭敦明.人膝骨性关节炎关节软骨差异表达蛋白质组学研究[J].现代医学.2007.(02)
[10]Radin EL. Subchondral bone change and cartilage damage[J]. Equine Vet J.1995;31 (2):94-95
[11]Paul D. Subchondral bone should be the main target for the treatment of pain and disease progression in osteoarthritis[J]. Osteoarthritis and cartilage.1999;7:325-326
[12]Cathering B.Effects of calcitonin on subchondral trabecular bone change and on osteoarthritic cartilage lesions after acute anterior cruciate ligament deficiency[J]. Journal of bone and mineral research.2004;11 (19):P1821-831
[13]Janet M, Anderson-MacKenzie, Helen-L et al. Fundamental subchondral bone changes in spontaneous knee osteoarthritis[J]. The international Journal of Biochimistry& Cell biology.2004;10:1-13
[14]Jean-Pierre.Pelletier, Christelle Boileau, Julie Brunet,et al. The inhibition of subchondral bone resorption in the early phase of experimental dog osteoarthritis by licofelone is associated with a reduction in the synthesis of MMP-13 and cathepsin K[J].bone 2004;34:527-538
[15]崔建岭,任进军,石俊岭等.膝关节软骨下骨局灶性病变与应力改变的相关性研究[J].临床放射学杂志.2009.(04)：540-544.
[16]梁正洋,王友,安丙辰.骨关节炎中滑膜炎组织病理学评估[J].国际骨科学杂志.2011. (01)：27-29.
[17]L EWEK M D, RUDOPL EH K S, SN YDER-MACKL ER L. Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis [J]. J Ort hop Res,2004,22 (1):1102115.
[18]SL EMENDA C, BRANDT K D, HEIMAN D K, et al. Quadriceps weakness andosteoart hritis of the knee [J]. Ann Intern Med,1997,127:972104.
[19]FINK B, EGL M, SINGER J, et al. Morphologic changes in the vastus medialis muscle in patient s with osteoarthritis of t he knee [J]. Arthritis Rheum,2007,56 (11):362623633
[20]DOI T, A KAI M, FUJ INO K, et al. Effect of home exercise of quadriceps on knee osteoarthritis compared with nonsteroidal and tiinflammatory drugs:a randomized cont rolled trial [J]. Am J Phys Med Rehabil,2008,87 (4):2582269.
[21]MIKESKY A E, MAZZUCA S A, BRANDT K D, et al. Effects of strength training on the incidence and progression of knee osteoarthritis[J]. Arthritis Rheum,2006,55 (5):6902699.
[22]孙奎,鲍学梅,刘德春等.针刺配合手法调整膝关节肌力平衡治疗膝骨性关节炎的临床对照试验[J].中国骨伤.2010.(12)：895-898.
[23]郭蕾.试论经筋体系形成的思想基础[J].中医临床研究.2011.(01)：67-68.
[24]薛立功.经筋理论与长圆针疗法高级临床研修班[J].中国针灸.2010.(10)：797.
[25]韦嵩,陈志煌,孙维峰等.从“经筋”论治痹证及其机理探讨[J].中国中医急症.2011.(09)：1408-1409.
[26]李厚臣,杨晓倩,汤立新.经筋理论概述[J].中国中医药现代远程教育.2009.(11)：4-6.
[27]韦英才.浅释经筋与经脉的异同及其临床意义[J].广州中医药大学学报,2007,24(3)：247-248.
[28]韩清民,黄旭东,王跃辉.运用肝脾相关理论治疗膝骨关节炎探讨[J].时珍国医国药.2010.(08)：2019.
[29]韩清民,王跃辉,易志勇.膝骨关节炎从筋论治思路探讨[J].新中医.2009.(01)：5-6.
[30]秦玉革. 《内经》经筋的实质是神经[J].中国针灸.2006.(02)：147-150.
[31]栾萍,吴金鹏等.中医外治法的筋膜学基础理论研究[J].推拿与康复医学.2011.(57)：
[32]张茉莉,王昭琦,刘萍等.循经筋阿是穴治疗膝骨性关节炎的疗效观察[J].按摩与康复医学2012,3(5)：156-157。
[33]韦英才,粱树勇,王凤德.“燔针劫刺”配合经筋手法治疗膝关节滑膜炎58例[J].四川中医,2008,6(26)：111-112.
[34]田有粮,李月,李茜等.长圆针治疗对膝关节骨性关节炎的作用[J].中国康复：2010.25(6).444-446
[35]薛立功.经筋辨治膝退行性变合并膝痛364例分析[J].中医药学报.03,8(21)：1377-1388.
[36]梁树勇,韦英才.经筋疗法治疗膝关节骨性关节炎80例疗效观察[J].云南中医中药杂志：2008.29(3).9-10
[37]石宇熊.推拿手法结合功能锻炼治疗膝骨性关节炎76例[J].陕西中医：2010(10).1389-1390
[38]王春雷,刘保延,黄敬伟等.经筋疗法的有关研究与展望[C]广东省针灸学会第十一次学术研讨会广州.中国.2010
[39]骨关节炎诊治指南(2007年版)[J].中国临床医生：2008(01).28-30
[40]董宝强,韩煜,管宏钟.长圆针解结法治疗膝骨关节炎的随机、单盲、多中心临床研究[J].中华中医药杂志.2011.(08)：883-885.
[41]林建宁,孙笑非,阮狄克.膝关节lysholms评分等级评价膝关节功能[J].中国骨与关节损伤杂志.2008.(03)：230-231.
[42]刘向前.中西医结合治疗膝关节骨关节病[M]人民军医出版社,2011：92
[43]朱文锋.中医主症鉴别诊断学[M]长沙：湖南科学技术出版社,2000：316-331
[44]李灿东,甘慧娟,朱文锋腑病等病位证素特征症的提取[J]福建中医药,2008,39(2)：1-3.
[45]陈百成,张静.骨关节炎[M].人民卫生出版社.2004：1-3
[46]朱媛媛,文海鹏.电针结合股四头肌康复训练治疗髌骨软化症的疗效观察[J].临床合理用药杂志.2011.(03)：38-39.
[47]王跃辉,韩清民.膝骨性关节炎影像学分析与经筋辨证关系研究[J].新中医,2008,40(5)：66
[48]邓铁涛,郑洪.中医五脏相关学说研究——从五行到五脏相关[J].中国工程科学,2008,10(2)：7
[49]冯学烽,韩清民.经筋手法治疗阳明经筋病膝骨性关节炎31例[J].河南中医.2011.(04)
[50]陈宇,冯学烽,韩清民.经筋疗法治疗阳明经筋型膝骨关节炎的疗效观察[J].广州中医药大学学报.2013.(01)：30-32+36.
[51]易志勇.膝骨关节炎经筋贴敷疗法的初步研究.硕士论文.广州中医药大学,44,2010
[52]明华宇,陈世孝,钟立明.髌骨软化症184例临床X线分析[J].西部医学.2004.(03)：243-244.
[53]曹龙军,章礼勤,黄力平.膝关节骨性关节炎患者股四头肌动员能力和肌力储备改变的研究[J].中国康复医学杂志.2012.(01)：30-34.
[54]马秀山,王中伟,徐英杰等.髌骨不稳定所致髌股关节撞击的影像学改变[J].吉林医学.2011.(01)：44-45.
[2]刘健,赵文海.对骨性关节炎发病机制的研究概况[J].辽宁中医药大学学报.2008.(02)：80-82.
[3]黄涛.骨性关节炎病因和发病机制研究进展[J].福建中医药.2005.(04)：57-58.
[4]Sun B H. Wu CW, Kalunian K C. New developments in osteoarthritis[J]. Rheum Dis Clin N Am,2007,33 (1):1352148.
[5]高仰贤.骨性关节炎发病机制的国内研究进展[J].中医正骨.2005.(04)：55-57.
[6]周洪保,张曦,吕正祥.膝关节骨性关节炎治疗进展[J].中医药导报,2012,18(2)：87-89.
[7]Ding M. Danielsen CC. Hvid I. The effects of bone remodeling inhibition by alendronate on three-dimensional microarchitecture of subchondral bone tissue in genea pig pramary osteoarthrosis.Calcif Tissue Int,2008;82(1):77-86
[8]王晶.膝关节软骨下BMLs和OAPC与软骨下骨承受应力改变关系的研究.硕士论文.河北医科大学,23-66,2010
[9]郭敦明.人膝骨性关节炎关节软骨差异表达蛋白质组学研究[J].现代医学.2007.(02)
[10]Radin EL. Subchondral bone change and cartilage damage[J]. Equine Vet J.1995;31 (2):94-95
[11]Paul D. Subchondral bone should be the main target for the treatment of pain and disease progression in osteoarthritis[J]. Osteoarthritis and cartilage.1999;7:325-326
[12]Cathering B.Effects of calcitonin on subchondral trabecular bone change and on osteoarthritic cartilage lesions after acute anterior cruciate ligament deficiency[J]. Journal of bone and mineral research.2004;11 (19):P1821-831
[13]Janet M, Anderson-MacKenzie, Helen-L et al. Fundamental subchondral bone changes in spontaneous knee osteoarthritis[J]. The international Journal of Biochimistry& Cell biology.2004;10:1-13
[14]Jean-Pierre.Pelletier, Christelle Boileau, Julie Brunet,et al. The inhibition of subchondral bone resorption in the early phase of experimental dog osteoarthritis by licofelone is associated with a reduction in the synthesis of MMP-13 and cathepsin K[J].bone 2004;34:527-538
[15]崔建岭,任进军,石俊岭等.膝关节软骨下骨局灶性病变与应力改变的相关性研究[J].临床放射学杂志.2009.(04)：540-544.
[16]梁正洋,王友,安丙辰.骨关节炎中滑膜炎组织病理学评估[J].国际骨科学杂志.2011. (01)：27-29.
[17]L EWEK M D, RUDOPL EH K S, SN YDER-MACKL ER L. Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis [J]. J Ort hop Res,2004,22 (1):1102115.
[18]SL EMENDA C, BRANDT K D, HEIMAN D K, et al. Quadriceps weakness andosteoart hritis of the knee [J]. Ann Intern Med,1997,127:972104.
[19]FINK B, EGL M, SINGER J, et al. Morphologic changes in the vastus medialis muscle in patient s with osteoarthritis of t he knee [J]. Arthritis Rheum,2007,56 (11):362623633
[20]DOI T, A KAI M, FUJ INO K, et al. Effect of home exercise of quadriceps on knee osteoarthritis compared with nonsteroidal and tiinflammatory drugs:a randomized cont rolled trial [J]. Am J Phys Med Rehabil,2008,87 (4):2582269.
[21]MIKESKY A E, MAZZUCA S A, BRANDT K D, et al. Effects of strength training on the incidence and progression of knee osteoarthritis[J]. Arthritis Rheum,2006,55 (5):6902699.
[22]孙奎,鲍学梅,刘德春等.针刺配合手法调整膝关节肌力平衡治疗膝骨性关节炎的临床对照试验[J].中国骨伤.2010.(12)：895-898.
[23]郭蕾.试论经筋体系形成的思想基础[J].中医临床研究.2011.(01)：67-68.
[24]薛立功.经筋理论与长圆针疗法高级临床研修班[J].中国针灸.2010.(10)：797.
[25]韦嵩,陈志煌,孙维峰等.从“经筋”论治痹证及其机理探讨[J].中国中医急症.2011.(09)：1408-1409.
[26]李厚臣,杨晓倩,汤立新.经筋理论概述[J].中国中医药现代远程教育.2009.(11)：4-6.
[27]韦英才.浅释经筋与经脉的异同及其临床意义[J].广州中医药大学学报,2007,24(3)：247-248.
[28]韩清民,黄旭东,王跃辉.运用肝脾相关理论治疗膝骨关节炎探讨[J].时珍国医国药.2010.(08)：2019.
[29]韩清民,王跃辉,易志勇.膝骨关节炎从筋论治思路探讨[J].新中医.2009.(01)：5-6.
[30]秦玉革. 《内经》经筋的实质是神经[J].中国针灸.2006.(02)：147-150.
[31]栾萍,吴金鹏等.中医外治法的筋膜学基础理论研究[J].推拿与康复医学.2011.(57)：
[32]张茉莉,王昭琦,刘萍等.循经筋阿是穴治疗膝骨性关节炎的疗效观察[J].按摩与康复医学2012,3(5)：156-157。
[33]韦英才,粱树勇,王凤德.“燔针劫刺”配合经筋手法治疗膝关节滑膜炎58例[J].四川中医,2008,6(26)：111-112.
[34]田有粮,李月,李茜等.长圆针治疗对膝关节骨性关节炎的作用[J].中国康复：2010.25(6).444-446
[35]薛立功.经筋辨治膝退行性变合并膝痛364例分析[J].中医药学报.03,8(21)：1377-1388.
[36]梁树勇,韦英才.经筋疗法治疗膝关节骨性关节炎80例疗效观察[J].云南中医中药杂志：2008.29(3).9-10
[37]石宇熊.推拿手法结合功能锻炼治疗膝骨性关节炎76例[J].陕西中医：2010(10).1389-1390
[38]王春雷,刘保延,黄敬伟等.经筋疗法的有关研究与展望[C]广东省针灸学会第十一次学术研讨会广州.中国.2010
[39]骨关节炎诊治指南(2007年版)[J].中国临床医生：2008(01).28-30
[40]董宝强,韩煜,管宏钟.长圆针解结法治疗膝骨关节炎的随机、单盲、多中心临床研究[J].中华中医药杂志.2011.(08)：883-885.
[41]林建宁,孙笑非,阮狄克.膝关节lysholms评分等级评价膝关节功能[J].中国骨与关节损伤杂志.2008.(03)：230-231.
[42]刘向前.中西医结合治疗膝关节骨关节病[M]人民军医出版社,2011：92
[43]朱文锋.中医主症鉴别诊断学[M]长沙：湖南科学技术出版社,2000：316-331
[44]李灿东,甘慧娟,朱文锋腑病等病位证素特征症的提取[J]福建中医药,2008,39(2)：1-3.
[45]陈百成,张静.骨关节炎[M].人民卫生出版社.2004：1-3
[46]朱媛媛,文海鹏.电针结合股四头肌康复训练治疗髌骨软化症的疗效观察[J].临床合理用药杂志.2011.(03)：38-39.
[47]王跃辉,韩清民.膝骨性关节炎影像学分析与经筋辨证关系研究[J].新中医,2008,40(5)：66
[48]邓铁涛,郑洪.中医五脏相关学说研究——从五行到五脏相关[J].中国工程科学,2008,10(2)：7
[49]冯学烽,韩清民.经筋手法治疗阳明经筋病膝骨性关节炎31例[J].河南中医.2011.(04)
[50]陈宇,冯学烽,韩清民.经筋疗法治疗阳明经筋型膝骨关节炎的疗效观察[J].广州中医药大学学报.2013.(01)：30-32+36.
[51]易志勇.膝骨关节炎经筋贴敷疗法的初步研究.硕士论文.广州中医药大学,44,2010
[52]明华宇,陈世孝,钟立明.髌骨软化症184例临床X线分析[J].西部医学.2004.(03)：243-244.
[53]曹龙军,章礼勤,黄力平.膝关节骨性关节炎患者股四头肌动员能力和肌力储备改变的研究[J].中国康复医学杂志.2012.(01)：30-34.
[54]马秀山,王中伟,徐英杰等.髌骨不稳定所致髌股关节撞击的影像学改变[J].吉林医学.2011.(01)：44-45.