颞三针配合挛三针治疗中风后痉挛性偏瘫的临床研究
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摘要
世卫组织数据显示,我国脑卒中发病率正以每年8.7%的速度上升,比美国高出1倍。中国现存脑卒中病人700多万,相当于中国香港2010年初的总人口数。随着急救技术的发展,脑卒中的死亡率大幅度下降,随之而来的致残率明显上升,约有80%的患者遗留不同程度的功能障碍,其中又以偏瘫的发生率最高；在发病后3周内,约90%的患者会出现肢体痉挛,表现为肌群的肌张力增高、协调异常的特定模式,严重影响生存质量。
痉挛性偏瘫的发病机制尚未完全明确,通常认为,是由于上运动神经元损伤后脊髓反射活动增高引起,以速度依赖性牵张反射增强为特征的肌肉张力异常,是以牵张反射亢进为核心的运动控制紊乱所致。脑卒中后由于中枢系统的α运动神经元和Y运动神经元相互制约、相互作用关系失衡,形成γ运动神经元占优势的局面,导致中枢性运动抑制系统作用减弱,使脊髓等下一级中枢的原始功能失去抑制状态,以致运动环路的兴奋性增强,使患肢肌张力增高,出现痉挛状态。在临床上多表现为上肢屈肌群和下肢伸肌群肌张力增高,即所谓的Wernicke-Mann体位。
这种患肢痉挛状态的存在对肢体的功能活动有严重影响,所以,目前的共识是打破这种模式并促使患肢尽快出现分离运动。患肢的痉挛一般出现在发病的3周后,一般持续3个月左右,不恰当或不正确的治疗可使这种痉挛状态被固定下来.直接影响偏瘫康复疗效的提高。因此,如何有效地缓解中风后患肢偏瘫的痉挛状态成为当前康复医学界的重要课题之一。
近年来对脑卒中后痉挛性偏瘫的治疗研究表明,中西医对此已经有一定的认识,治疗方法较多。但西药治疗不良反应较多,如四肢乏力、嗜睡、消化道反应、精神病(精神压抑)及偶有肝肾功能异常等,且其远期疗效有待进一步观察。外科治疗难度大,对技术要求高,费用高,不容易被推广应用。物理治疗如功能性电刺激等等,由于缺少基础研究的论证,再加上研究多为小范围或无随机分组对照,所以,对这一疗法仍难以作出令人信服的科学结论。
随着近年来我国康复医学的发展,针灸疗法对中风后痉挛性偏瘫的治疗显示出独特的优势,国内外临床医学工作者对此疗法开展了大量的临床观察及研究工作,亦肯定了该疗法的临床疗效。但存在临床报道中评定标准不统一、没有规范的病例纳入排出标准、有些没有随机对照等缺陷,而且往往只着重强调了取穴,如痉挛侧取穴、拮抗侧取穴、痉挛拮抗侧同时取穴等,而忽视了针刺手法应用的区别。
“靳三针”疗法作为岭南针灸学派的重要学术内容,目前广泛应用于临床实践。早在八十年代早期,靳瑞教授应用“靳三针”疗法在治疗卒中后偏瘫、失语、假性球麻痹等方面相继开展了多项临床研究工作,对该病的治疗积累了丰富的经验。针对中风后痉挛性偏瘫引起的患肢肌肉萎缩、关节挛缩及变形的一系列临床症状,以及临床上存在的疑难点,导师庄礼兴教授进一步完善了靳三针理论,总结出挛三针,并应用于临床。
本研究将在既往临床经验积累的基础上,进一步探讨其可能的作用机制,进而为提高中风痉挛性偏瘫患者的生存质量提供有效方法。
1.研究目的
1.1中风后痉挛性偏瘫的机制尚不明确,缺乏针对性的药物治疗,外科治疗难度大,不容易被推广应用,物理治疗缺少基础研究的论证,拟通过本项对照研究,验证靳三针治疗中风后痉挛性偏瘫的疗效以及对患者综合功能的影响。
1.2初步探求靳三针治疗中风后痉挛性偏瘫的作用机制。
1.3完善颞三针、挛三针治疗中风后痉挛性偏瘫的方案,讨论其推广价值。
2.研究方法
2.1文献研究
文献研究部分重点回顾了近年来对中风后痉挛性偏瘫的机制研究,从病理学、电生理学、分子生物学、药理学等方面分别进行阐述：从中医学阴阳理论、脏腑理论、营卫理论等方面进行分析。并且对针刺治疗中风后痉挛性偏瘫的机制研究进行了详细回顾。
2.2临床研究
将100例符合纳入标准的中风后痉挛性偏瘫患者分为靳三针组、康复组和联合组,所有入组患者的基础药物治疗均参照《中国脑血管病防治指南》(卫生部疾病控制司、中华医学会神经病学会,2005)的方案控制血压、血糖、调节血脂、防止血小板聚集,以及对症治疗、防治并发症、营养支持等。
靳三针组采用颞三针配合挛三针为主穴治疗,康复组采用康复训练治疗,联合组采用靳三针联合康复训练治疗,14天为1疗程,在治疗前、治疗7天、14天后分别对患者进行功能综合评定量表(FCA)、临床神经功能缺损程度评分(NDS)、四肢简化Fugl-Meyer评分(FMA)、临床痉挛指数(CSI)评定。疗程结束3个月后进行随访,并评定上述量表。
3.研究结果
3.1文献研究结果表明,中风后痉挛性偏瘫的机制尚不明确,针灸疗法日益显示出独特的优势,国内外临床医学工作者对此疗法开展了大量的临床观察及研究工作,近年来,靳三针疗法逐渐成为其中的热点。
3.2一般资料
入组患者在平均年龄、平均病程及性别构成方面差异无统计学意义,提示基线资料基本一致,具有较好的可比性。在量表评分方面,治疗前3组FCA、NDS、FMA、CSI评分经比较差异亦无统计学意义。
3.3FCA评分结果
研究结果表明,3组比较差异有统计学意义(P=0.013),提示3种治疗方法存在组间差别。患者的FCA评分在不同阶段变化的趋势不同,其中联合组FCA评分高于靳三针组和康复组(P分别为0.034、0.004)；靳三针组与康复组比较差异无统计学意义(P>0.05),提示FCA评分基本一致。
3.4NDS评分结果
在NDS评分方面,3组比较差异有显著统计学意义(P=0.007),提示3种治疗方法存在组间差别。患者的NDS评分在不同阶段变化的趋势不同,其中联合组NDS评分低于靳三针组和康复组(P分别为0.012、0.003)；靳三针组与康复组比较差异无统计学意义(P＞0.05),提示NDS评分基本一致。
3.5FMA评分结果
结果表明,在FMA评分方面,3组比较差异有显著统计学意义(P=0.000),提示3种治疗方法存在组间差别。患者的FMA评分在不同阶段变化的趋势不同,其中联合组FMA评分高于靳三针组和康复组(P分别为0.003、0.000)；靳三针组与康复组比较差异无统计学意义(P＞0.05),提示FMA评分基本一致。
3.6CSI评分结果
CSI评分方面,3组比较差异有显著统计学意义(P=0.001),提示3种治疗方法存在组间差别。患者的CSI评分在不同阶段变化的趋势不同,其中联合组CSI评分高于靳三针组和康复组(P分别为0.000、0.005)；靳三针组与康复组比较差异无统计学意义(P>0.05),提示CSI评分基本一致。
3.7研究计划内随访结果
该部分患者为疗程结束后未继续原治疗方案,或返回家中,或居于养老院,部分患者定期门诊复诊。共有病例数30人,其中靳三针组12人,康复组10人,联合组8人。
从随访结果看,在FCA评分方面,3组比较差异有统计学意义(P=0.034),提示3组随访结果存在组间差别。联合组随访FCA评分高于靳三针组和康复组(P分别为0.044、0.012),提示联合组FCA评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示FCA随访评分基本一致。
在NDS评分方面,3组比较差异有统计学意义(P=0.017),提示3组随访结果存在组间差别。联合组随访NDS评分低于靳三针组和康复组(P分别为0.026、0.006),提示联合组NDS评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示NDS随访评分基本一致。
在FMA评分方面,3组比较差异有显著统计学意义(P=0.000),提示3组随访结果存在组间差别。联合组随访FMA评分高于靳三针组和康复组(P分别为0.005、0.000),提示联合组FMA评分远期效果优于其他2组。靳三针组与康复组比较差异有显著统计学意义(P=0.000),提示靳三针组FMA随访评分优于康复组。
在CSI评分方面,3组比较差异有显著统计学意义(P=0.002),提示3组随访结果存在组间差别。联合组随访CSI评分低于靳三针组和康复组(P分别为0.001、0.010),提示联合组CSI评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示CSI随访评分基本一致。
3.8研究计划外随访结果
该部分患者为疗程结束后继续门诊或住院治疗者,所有患者均按照在院期间的治疗方案执行。共有病例22人,其中靳三针组5人,康复组7人,联合组10人。
在FCA评分方面,3组比较差异有显著统计学意义(P=0.000),提示3组随访结果存在组间差别。联合组随访FCA评分高于靳三针组和康复组(P分别为0.000、0.001),提示联合组FCA评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P＞0.05),提示FCA随访评分基本一致。
在NDS评分方面,3组比较差异有统计学意义(P=0.030),提示3组随访结果存在组间差别。联合组随访NDS评分低于靳三针组和康复组(P分别为0.047、0.016),提示联合组NDS评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示NDS随访评分基本一致。
在FMA评分方面,3组比较差异有显著统计学意义(P=0.000),提示3组随访结果存在组间差别。联合组随访FMA评分高于靳三针组和康复组(P分别为0.042、0.000),提示联合组FMA评分远期效果优于其他2组。靳三针组与康复组比较差异有显著统计学意义(P=0.007),提示靳三针组FMA随访评分优于康复组。
在CSI评分方面,3组比较差异有统计学意义(P=0.040),提示3组随访结果存在组间差别。联合组随访CSI评分低于靳三针组和康复组(P分别为0.044、0.026),提示联合组CSI评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示CSI随访评分基本一致。
4.结论
4.1颞三针配合挛三针可有效改善中风后痉挛性偏瘫状态。
本研究表明,靳三针(颞三针配合挛三针)可有效改善中风后患者的痉挛性偏瘫状态,量表评分显示,可缓解痉挛程度、改善肢体功能,与康复训练效果基本一致；而两者联合使用时效果更加显著,究其原因,针刺在改善肢体运动功能方面的作用已得到广泛证实,尤其是在中风发病早期,康复训练在此方面稍显不足。
4.2靳三针疗法的推广普及有利于康复医学的发展。
从本研究结果看,靳三针治疗组能够有效缓解中风后患肢的痉挛程度,减轻功能障碍,通过疗程结束后的随访结果可以看出,持续的靳三针治疗有利于功能障碍和痉挛程度的进一步缓解。靳三针疗法具有配穴灵活、取穴精简的特点。同时,在治疗方案中,原则上以三针为主,再结合辨证配穴；有是证用是穴,可完善和补充各类三针处方,加强治疗效果。三针加以配穴则主次分明,诚如中药处方中的君、臣、佐、使；其治疗方案体现了穴位与病证相适宜,是针灸处方中难得的模式。
正是基于上述特点,在社区、基层医院中推广普及靳三针疗法将有利于社区康复的发展,解决其对设备、人员的过分依赖；而且,靳三针疗法治疗范围广阔,也利于针灸疗法的普及。
4.3协调和平衡主动肌与拮抗肌、提高康复训练效果可能是颞三针配合挛三针治疗中风后痉挛性偏瘫的作用机制。
协调和平衡主动肌与拮抗肌之肌张力,促进共同运动向分离运动转化是治疗痉挛性偏瘫的重点,挛三针的取穴和手法正是依据于这一理论。在手挛三针中,以极泉、尺泽、内关为主穴,采用提插捻转泻法,强刺激,以抑制上肢内收肌的肌张力；足挛三针采用鼠蹊、阴陵泉、三阴交为主穴,鼠蹊、阴陵泉穴采用提插捻转平补平泻手法,以平衡内外侧肌群肌力,三阴交穴采用提插捻转泻法,可使过强的肌张力得到抑制,有助于解除肌挛缩和关节的畸形、僵直状态。
除缓解痉挛状态外,针刺对康复训练具有类似或优于易化作用的促进作用,并能提高患者接受康复治疗的意识。这可能是颞三针配合挛三针治疗中风后痉挛性偏瘫的作用机制。
4.4持续的、中西结合康复治疗对患者有利。
随访研究结果表明,经组间比较,研究计划外随访患者在FCA、NDS、FMA、CSI评分方面普遍优于研究计划内随访患者,差异有统计学意义。联合组在各个量表评分方面均优于单纯针刺治疗和康复训练,显示出中西结合康复治疗的重要性和必要性。
按照本研究的设计方案,计划内随访患者为严格执行方案者,即疗程结束后未续实施任何本方案内的康复治疗；而计划外随访患者已经脱离了研究方案,临床实施过程中,该部分患者有持续康复治疗进而回归社会、家庭的愿望,故给予了原治疗方案。故依据上述结果可以认为,早期、持续的中西结合康复治疗对中风后痉挛性偏瘫和其他功能障碍的改善有较好帮助。
5.本研究的创新之处
5.1充分体现靳三针的整体观念
靳三针治疗中风后偏瘫临床方案注重整体观,注重头部局部取穴与循经取穴相结合,对中风后偏瘫根据弛缓瘫和痉挛瘫的不同,采用不同的三针疗法；针对痉挛性偏瘫症状的复杂性,采用踝三针、开三针等组穴对症治疗；针对中风后偏瘫的不同伴随症状,采用口三针、舌下三针等组穴随症治疗。整个治疗方案体现了靳三针疗法配穴灵活,取穴精简的特点。
5.2评价标准更加全面、规范和客观
本项目采用目前通行的功能综合评定量表(FCA)、临床神经功能缺损程度评分(NDS)、四肢简化Fugl-Meyer评分(FMA)、临床痉挛指数(CSI)评定,使靳三针治疗中风后痉挛性偏瘫的评价标准更加全面、规范和客观。
5.3随访研究对针灸、康复训练的远期疗效进行对比,分析早期、持续康复治疗的重要性和必要性。
According to the data from the World Health Organization, the morbidi ty of stroke in China was increasing at the rate of8.7%every year, whic h was twice compared with that of America. The number of patient in strok e in our country now is about7million, which is almost the gross popula tion of Hongkong at the beginning of2010.So, from these number, we know that stroke is a common disease. With improvement of the diagnosis and th e level of emergency treatment, the mortality rate has dropped dramatical ly, however the morbidity is significantly increased. In China, about80%of patients left over from the different degrees of physical dysfunction, among which, the incidence of hemiplegia was the highest, about90%of p atients with limb spasticity occurs within3post burn weeks, The quality of life was seriously affect. Spasm refers to muscle or muscle group int ermittent or persistent involuntary contraction, performance increased mu scle tone muscles, abnormal coordination particular model.
The mechanism of spastic hemiplegia was not yet entirely clear. It is generally believed that the spasm caused by increased spinal reflex activity in the upper motor neuron injury, abnormal muscle tone is characterized by speed-dependent stretch reflex enhanced, due to motion control disorders; its core is abnormal stretch reflex hyperactivity. Post-stroke central movement suppression system disorders, a motor neurons and Y motor nerve cell mutual restraint, interaction imbalance, caused y movement neurons dominant, the central movement to inhibit system weakened, resulting in low-level center of the originalrelease, resulting in the motion loop enhance the excitability of the affected limb increased muscle tone, was spasticity. Clinical practice, upper limb flexors and lower limb extensors increased muscle tone, forms the so-called Wernicke-Mann position. In other words, the post-stroke hemiplegic limb spasticity of spinal cord excitability increase is caused by enhanced activity of α-γ loop.
Limb spasticity seriously impeded the completion of activities of limb function, so that how to break the pattern and to promote the limb separation movement has become an important key to the treatment of stroke hemiplegia spasm as soon as possible. The stroke hemiplegia spasm comes about three weeks after the onset of spasms usually lasts about three months, mostly due to wrong treatment or loss of governance spasticity permanently fixed, it directly affects the improvement of stroke hemiplegia rehabilitation effects. Therefore, the search effectively alleviate the treatment of hemiplegia spasticity become an important issue for the medical profession. Hemiplegia spasticity clinical treatment more difficulty, is still lack of a better therapeutic means, and how to reduce spasm is still the main content and problems of rehabilitation medical research.
Summary of recent post-stroke spastic hemiplegia treatment research, from which can be seen in Western and Chinese medicine have certain understanding. There are more treatment, and the efficacy of various treatments is sure. But western medicine has adverse reactions, such as limb weakness, drowsiness, gastrointestinal reactions, psychosis (mental depression) and occasional liver and kidney dysfunction, and the long-term efficacy needs to be further investigated. Surgical treatment is difficult, technically demanding, high cost, and is not easy to promote. The use of Physical therapy, such as functional electrical stimulation, due to the lack of basic research demonstration, coupled with the small-scale research or non-randomized controlled, this therapy is still difficult to make a convincing scientific conclusions.
In recent years, with China's development of rehabilitation medicine, acupuncture treatment of spastic hemiplegia after stroke shows unique advantages, this therapy carried out a large number of clinical observation and research in clinical medicine workers at home and abroad and certainly thethe clinical efficacy of the therapy. But the presence of clinical reports assessment standards are not uniform, there is no specification of the cases included in the discharge standard, some are not randomized controlled defects, and often only highlighted the acupoints, spasm side acupoints, the antagonistic side acupoints, spasm antagonistic side at the same timeacupoints, while ignoring the difference between acupuncture manipulation applications.
Jin needle therapy as an important academic content of the Lingnan school of acupuncture is widely used in clinical practice. As early as the early1980s, Professor Rui Jin founded Jin needle therapy in the treatment of post-stroke hemiplegia, aphasia, pseudobulbar palsy and other aspects, and has been carrying out a number of clinical studies; the treatment of the disease has accumulated a wealth of experience. For limb muscle atrophy, joint contractures and deformation of a series of clinical symptoms caused by spastic hemiplegia after a stroke and clinical difficult point mentor Professor Li Xing Zhuang further improved Jin-pin theory, summed up the twin needle, and the applyclinical, and clinical observation proved have got good effect.
On the basis of past clinical experience accumulated, this study further investigated the possible mechanism of action, and thus to find the effective ways to improve the quality of life of stroke patients with spastic hemiplegia.
1. Objectives
1.1The mechanism of spastic hemiplegia after stroke was unclear, the lack of targeted drug therapy, surgical treatment is difficult, so that it is not easy to be popularized, the use of physical therapy is lack of basic research demonstration, so that make it a clear that the efficacy Jin acupuncture treatment of hemiplegia by the spastic in the after a stroke as well as the impact on the patients'comprehensive functionality by the controlled study.
1.2Preliminary explores the mechanism of Jin-pin the spastic hemiplegia role in the treatment of stroke.
1.3Improve the temporal three-pin, twin three-pin the spastic hemiplegia solution in the treatment of stroke, to discuss its promotional value.
2. Methods
2.1Literature Research
Literature section focus on reviewing the mechanism of spastic hemiplegia after stroke in recent years, were described in terms of pathology, physiology, molecular biology, pharmacology; From medical theory of yin and yang, viscera theory to make analysis. And it carried out a detailed review of the mechanism of acupuncture treatment for stroke spastic hemiplegia.
2.2Clinical Research
100patients was divided into Jin three-needle group, rehabilitation and combined groups, met the inclusion criteria of post-stroke patients with spastic hemiplegia, All patients on the basis of drug therapy with reference to cerebrovascular disease prevention and treatment guidelines (Ministry of Health, Department of Disease Control, Chinese Medical Association Academy of Neurology,2005), to control blood pressure, blood sugar, regulate blood fat, prevent platelet aggregation, and give symptomatic treatment, prevention of complications, nutritional support, and so on.
Jin three-needle group using temporal acupuncture combined with twin three-pin main point in the treatment, rehabilitation therapy rehabilitation group, the combined group Jin three-pin joint rehabilitation training, the14-day course of treatment, before treatment,7days,14days, functional comprehensive assessment (FCA) respectively, for patients with clinical neurological deficit score (NDS), limbs simplify the Fugl-Meyer score (FMA), assessment the clinical spasms index (CS1). Follow-up at the end of treatment after3months and assess these scale.
3Results
3.1Literature results show that after a stroke the spastic hemiplegia mechanism is not yet clear, acupuncture is increasingly shows unique advantages, this therapy carried out a large number of clinical observation and research in clinical medicine workers at home and abroad in recent years, Jin pin the therapy gradually become one of the hot spots.
3.2General information
Patients enrolled in the research on the aspects of the average age, the average duration and gender composition difference was not statistically significant, prompt baseline data consistent with good comparability. Before treatment, FCA, NDS, FMA, CSI rated by comparison has no significant difference in scale score.
3.3The results of FCA
From the study results we know that, the difference among three groups was statistically significant (P=0.013), which meant that three treatment had within-group difference. The changing trend was different at different stage on the aspect of FCA score, which showed that the score of Combined Group was higher than that of Jin three-needle group and rehabilitation group(P respectively0.034,0.004). However, the score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which meant that the scores between two groups was nearly the same.
3.4The results of NDS
From the study results we know that, the difference among three groups was statistically significant (P=0.007), which meant that three treatment had within-group difference. The changing trend was different at different stage on the aspect of NDS score, which showed that the score of Combined Group was lower than that of Jin three-needle group and rehabilitation group (P respectively0.012,0.003). However, the score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which meant that the scores between two groups was nearly the same.
3.5The results of FMA
From the study results we know that, the difference among three groups was statistically significant (P=0.000), which meant that three treatment had within-group difference. The changing trend was different at different stage on the aspect of FMA score, which showed that the score of Combined Group was lower than that of Jin three-needle group and rehabilitation group(P respectively0.003,0.000). However, the score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which meant that the scores between two groups was almost the same.
3.6The results of CSI
From the study results we know that, the difference among three groups was statistically significant (P=0.001), which meant that three treatment had within-group difference. The changing trend was different at different stage on the aspect of NDS score, which showed that the score of Combined Group was lower than that of Jin three-needle group and rehabilitation group(P respectively0.000,0.005). However, the score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which meant that the scores between two groups was almost the same.
3.7The follow-up results of the planned the research program
That some patients did not continue the original treatment plan after the end of treatment, or to return home, or living in a nursing home, some patients regularly out-patient referral. The total number of cases is30, Jin-pin group of12people,10people in the rehabilitation group and the combined group of8people.
We can see from the follow-up results that the three groups had statistical difference on the aspect of FCA score(P=0.034), which meant that the follow-up result had within-group difference. The follow-up FCA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.044,0.012), which indicated that the long-term FCA score was better than that of the other groups. However, the follow-up score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which indicated that the follow-up scores between two groups was almost the same.
Meanwhile, the three groups had significant statistical significance on the aspect of NDS score (P=0.034), which meant that the follow-up result had within-group difference. The follow-up NDS score of combined group was lower than that of Jin three-needle group and rehabilitation group (P respectively0.044,0.012), which indicated that the long-term NDS score was better than that of the other groups. However, the follow-up NDS score of Jin three-needle group had no statistical difference compared with that of rehabilitation group(P>0.05), which indicated that the follow-up NDS scores between two groups was almost the same.
The three groups had significant statistical significance on the aspect of FMA score(P=0.000), which meant that the follow-up result had within-group difference. The follow-up FMA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.005,0.000), which indicated that the long-term FMA score was better than that of the other groups. However, the follow-up FMA score of Jin three-needle group had statistical difference compared with that of rehabilitation group(P=0.000), which indicated that the follow-up FMA scores of Jin three-needle group was better than that of rehabilitation group.
The three groups had significant statistical significance on the aspect of CSI score (P=0.002), which meant that the follow-up result had within-group difference. The follow-up FMA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.001,0.010), which indicated that the long-term CSI score was better than that of the other groups. However, the follow-up CSI score of Jin three-needle group had no statistical difference compared with that of rehabilitation group(P>0.05), which indicated that the follow-up CSI scores between two groups was almost the same.
3.8The unplanned follow-up research results
After the end of treatment, some patients continued to outpatient or hospital treatment, all patients were in accordance with the treatment options in the hospital during the execution. There are a total of22cases, including5in Jin three-needle group,7in the rehabilitation group, and the combined group of10people.
We can see from the follow-up results that the three groups had statistical difference on the aspect of FCA score (P=0.000), which meant that the follow-up result had within-group difference. The follow-up FCA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.000,0.001), which indicated that the long-term FCA score was better than that of the other groups. However, the follow-up score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which indicated that the follow-up scores between two groups was almost the same.
Meanwhile, the three groups had significant statistical significance on the aspect of NDS score(P=0.030), which meant that the follow-up result had within-group difference. The follow-up NDS score of combined group was lower than that of Jin three-needle group and rehabilitation group (P respectively0.047,0.016), which indicated that the long-term NDS score was better than that of the other groups. However, the follow-up NDS score of Jin three-needle group had no statistical difference compared with that of rehabilitation group(P>0.05), which indicated that the follow-up NDS scores between two groups was almost the same.
The three groups had significant statistical significance on the aspect of FMA score(P=0.000), which meant that the follow-up result had within-group difference. The follow-up FMA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.042,0.000), which indicated that the long-term FMA score was better than that of the other groups. However, the follow-up FMA score of Jin three-needle group had statistical difference compared with that of rehabilitation group(P=0.007), which indicated that the follow-up FMA scores of Jin three-needle group was better than that of rehabilitation group.
The three groups had significant statistical significance on the aspect of CSI score (P=0.040), which meant that the follow-up result had within-group difference. The follow-up FMA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.044,0.026), which indicated that the long-term CSI score was better than that of the other groups. However, the follow-up CSI score of Jin three-needle group had no statistical difference compared with that of rehabilitation group(P>0.05), which indicated that the follow-up CSI scores between two groups was almost the same.
4Conclusions
4.1Temporal three-pin with twin three-pin could effectively relieve the spastic hemiplegia state of post-stroke patients.
Studies had shown that Jin three-needle (temporal three-pin with twin three-pin) could relieve spastic hemiplegia state of post-stroke patients, in FCA, NDS, FMA scale scores, limb function in the three groups of patients after14days of treatment were all improved; effect showed in the7days after treatment relative to the rehabilitation group, Jin three-needle group, and the combined group, the role of acupuncture can not be ignored. Acupuncture role in improving motor function had been widely confirmed, especially in early onset of stroke while rehabilitation is slightly insufficient in this aspect.
4.2The popularization of Jin three-needle therapy was conducive to the development of rehabilitation medicine.
Results from this study, the Jin three-needle group could effectively alleviate limb spasticity after stroke, reduced dysfunction, after the end of treatment follow-up results could be seen Jin three-needle treatment in favor dysfunction and spasm the degree of further ease. Jin three-needle therapy has the acupoints flexible, and acupoints streamlined. Meanwhile, in the treatment regimen, in principle, three-pin main and TCM acupoints; card with points to improve and supplement the various types of three-pin prescription, to enhance the therapeutic effect. Three-pin with points to be prioritized, as stated in the Chinese medicine prescription Jun, Chen Zuo, so; treatment program reflected the points and the syndromes suitable acupuncture prescription rare model.
Based on the above characteristics, to popularize Jin three needle therapy in the community hospitals and grass-roots hospitals will be conducive to the development of rehabilitation in these hospitals. And this therapy also solved the problem that these hospitals relied too much on equipment and personnel. Jin three-needle therapy was for a wide range, but also conducive to acupuncture the popularity.
4.3The mechanism lied likely in coordination and balance agonist with antagonistic muscles and tension muscle as well as improvement on the effect of rehabilitation training.
Coordination and balance agonist with antagonistic muscles and tension muscle, promote common motion is converted to the separatist movement is the focus of treatment of spastic hemiplegia, the acupoints and practices twin30-pin It is based on this theory. The main points in hand twin needle to the pole spring, Chize, the customs, the use of lift and thrust twist and twirl, strong stimulation to suppress the upper limb adductor muscle tension; foot twin three-pin groin, Yin LingQuan, Sanyinjiao main points, groin, yinlingquan point, put plug Twist flat reinforcing-reducing techniques Sanyinjiao lift and thrust twist and twirl muscles balance inside and outside, can make strong muscle tonebe suppressed, and helps to relieve muscle.
In addition to relieve spasticity, has a role in promoting similar or better than the facilitatory effect of acupuncture on rehabilitation training, and can improve the awareness of patients receiving rehabilitation treatment. This may be temporal acupuncture combined with twin three-pin the spastic hemiplegia role in the treatment of stroke mechanism.
5. The innovation of study
5.1It fully reflects the whole concept of Jin three-needle therapy
Jin needle treatment of post-stroke hemiplegia clinical programs focus on the wholel concept, focus on head local points acupoints along meridians, a different three-pin therapy applied to flaccid paralysis and spastic paralysis post-stroke hemiplegia,; for spasticthe hemiplegia symptoms complexity, the use of three-pin ankle, open three-pin and other acupoints symptomatic treatment; different symptoms associated with hemiplegia after stroke, three-pin port, treatment of sublingual needles and other points with the disease. The entire treatment program reflects the acupoints of Jin three-needle therapy flexible and acupoints streamlined.
5.2Evaluation criteria more comprehensive, standardized and objective
This project uses the current prevailing functional comprehensive assessment (FCA), clinical neurological deficit score (NDS), limbs simplified Fugl-Meyer score (FMA), the clinical spasms Index (CSI) assessment, Jin three-needle treatment of strokespastic hemiplegia evaluation criteria are more comprehensive, standardized and objective. The study has played a good role model in acupuncture cl inical standardization, standardization research.
5.3Follow-up studies on long-term efficacy of acupuncture and rehabilitation contrast, analysis of the importance and necessity of early and continuing rehabilitation.
痉挛性偏瘫的发病机制尚未完全明确,通常认为,是由于上运动神经元损伤后脊髓反射活动增高引起,以速度依赖性牵张反射增强为特征的肌肉张力异常,是以牵张反射亢进为核心的运动控制紊乱所致。脑卒中后由于中枢系统的α运动神经元和Y运动神经元相互制约、相互作用关系失衡,形成γ运动神经元占优势的局面,导致中枢性运动抑制系统作用减弱,使脊髓等下一级中枢的原始功能失去抑制状态,以致运动环路的兴奋性增强,使患肢肌张力增高,出现痉挛状态。在临床上多表现为上肢屈肌群和下肢伸肌群肌张力增高,即所谓的Wernicke-Mann体位。
这种患肢痉挛状态的存在对肢体的功能活动有严重影响,所以,目前的共识是打破这种模式并促使患肢尽快出现分离运动。患肢的痉挛一般出现在发病的3周后,一般持续3个月左右,不恰当或不正确的治疗可使这种痉挛状态被固定下来.直接影响偏瘫康复疗效的提高。因此,如何有效地缓解中风后患肢偏瘫的痉挛状态成为当前康复医学界的重要课题之一。
近年来对脑卒中后痉挛性偏瘫的治疗研究表明,中西医对此已经有一定的认识,治疗方法较多。但西药治疗不良反应较多,如四肢乏力、嗜睡、消化道反应、精神病(精神压抑)及偶有肝肾功能异常等,且其远期疗效有待进一步观察。外科治疗难度大,对技术要求高,费用高,不容易被推广应用。物理治疗如功能性电刺激等等,由于缺少基础研究的论证,再加上研究多为小范围或无随机分组对照,所以,对这一疗法仍难以作出令人信服的科学结论。
随着近年来我国康复医学的发展,针灸疗法对中风后痉挛性偏瘫的治疗显示出独特的优势,国内外临床医学工作者对此疗法开展了大量的临床观察及研究工作,亦肯定了该疗法的临床疗效。但存在临床报道中评定标准不统一、没有规范的病例纳入排出标准、有些没有随机对照等缺陷,而且往往只着重强调了取穴,如痉挛侧取穴、拮抗侧取穴、痉挛拮抗侧同时取穴等,而忽视了针刺手法应用的区别。
“靳三针”疗法作为岭南针灸学派的重要学术内容,目前广泛应用于临床实践。早在八十年代早期,靳瑞教授应用“靳三针”疗法在治疗卒中后偏瘫、失语、假性球麻痹等方面相继开展了多项临床研究工作,对该病的治疗积累了丰富的经验。针对中风后痉挛性偏瘫引起的患肢肌肉萎缩、关节挛缩及变形的一系列临床症状,以及临床上存在的疑难点,导师庄礼兴教授进一步完善了靳三针理论,总结出挛三针,并应用于临床。
本研究将在既往临床经验积累的基础上,进一步探讨其可能的作用机制,进而为提高中风痉挛性偏瘫患者的生存质量提供有效方法。
1.研究目的
1.1中风后痉挛性偏瘫的机制尚不明确,缺乏针对性的药物治疗,外科治疗难度大,不容易被推广应用,物理治疗缺少基础研究的论证,拟通过本项对照研究,验证靳三针治疗中风后痉挛性偏瘫的疗效以及对患者综合功能的影响。
1.2初步探求靳三针治疗中风后痉挛性偏瘫的作用机制。
1.3完善颞三针、挛三针治疗中风后痉挛性偏瘫的方案,讨论其推广价值。
2.研究方法
2.1文献研究
文献研究部分重点回顾了近年来对中风后痉挛性偏瘫的机制研究,从病理学、电生理学、分子生物学、药理学等方面分别进行阐述：从中医学阴阳理论、脏腑理论、营卫理论等方面进行分析。并且对针刺治疗中风后痉挛性偏瘫的机制研究进行了详细回顾。
2.2临床研究
将100例符合纳入标准的中风后痉挛性偏瘫患者分为靳三针组、康复组和联合组,所有入组患者的基础药物治疗均参照《中国脑血管病防治指南》(卫生部疾病控制司、中华医学会神经病学会,2005)的方案控制血压、血糖、调节血脂、防止血小板聚集,以及对症治疗、防治并发症、营养支持等。
靳三针组采用颞三针配合挛三针为主穴治疗,康复组采用康复训练治疗,联合组采用靳三针联合康复训练治疗,14天为1疗程,在治疗前、治疗7天、14天后分别对患者进行功能综合评定量表(FCA)、临床神经功能缺损程度评分(NDS)、四肢简化Fugl-Meyer评分(FMA)、临床痉挛指数(CSI)评定。疗程结束3个月后进行随访,并评定上述量表。
3.研究结果
3.1文献研究结果表明,中风后痉挛性偏瘫的机制尚不明确,针灸疗法日益显示出独特的优势,国内外临床医学工作者对此疗法开展了大量的临床观察及研究工作,近年来,靳三针疗法逐渐成为其中的热点。
3.2一般资料
入组患者在平均年龄、平均病程及性别构成方面差异无统计学意义,提示基线资料基本一致,具有较好的可比性。在量表评分方面,治疗前3组FCA、NDS、FMA、CSI评分经比较差异亦无统计学意义。
3.3FCA评分结果
研究结果表明,3组比较差异有统计学意义(P=0.013),提示3种治疗方法存在组间差别。患者的FCA评分在不同阶段变化的趋势不同,其中联合组FCA评分高于靳三针组和康复组(P分别为0.034、0.004)；靳三针组与康复组比较差异无统计学意义(P>0.05),提示FCA评分基本一致。
3.4NDS评分结果
在NDS评分方面,3组比较差异有显著统计学意义(P=0.007),提示3种治疗方法存在组间差别。患者的NDS评分在不同阶段变化的趋势不同,其中联合组NDS评分低于靳三针组和康复组(P分别为0.012、0.003)；靳三针组与康复组比较差异无统计学意义(P＞0.05),提示NDS评分基本一致。
3.5FMA评分结果
结果表明,在FMA评分方面,3组比较差异有显著统计学意义(P=0.000),提示3种治疗方法存在组间差别。患者的FMA评分在不同阶段变化的趋势不同,其中联合组FMA评分高于靳三针组和康复组(P分别为0.003、0.000)；靳三针组与康复组比较差异无统计学意义(P＞0.05),提示FMA评分基本一致。
3.6CSI评分结果
CSI评分方面,3组比较差异有显著统计学意义(P=0.001),提示3种治疗方法存在组间差别。患者的CSI评分在不同阶段变化的趋势不同,其中联合组CSI评分高于靳三针组和康复组(P分别为0.000、0.005)；靳三针组与康复组比较差异无统计学意义(P>0.05),提示CSI评分基本一致。
3.7研究计划内随访结果
该部分患者为疗程结束后未继续原治疗方案,或返回家中,或居于养老院,部分患者定期门诊复诊。共有病例数30人,其中靳三针组12人,康复组10人,联合组8人。
从随访结果看,在FCA评分方面,3组比较差异有统计学意义(P=0.034),提示3组随访结果存在组间差别。联合组随访FCA评分高于靳三针组和康复组(P分别为0.044、0.012),提示联合组FCA评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示FCA随访评分基本一致。
在NDS评分方面,3组比较差异有统计学意义(P=0.017),提示3组随访结果存在组间差别。联合组随访NDS评分低于靳三针组和康复组(P分别为0.026、0.006),提示联合组NDS评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示NDS随访评分基本一致。
在FMA评分方面,3组比较差异有显著统计学意义(P=0.000),提示3组随访结果存在组间差别。联合组随访FMA评分高于靳三针组和康复组(P分别为0.005、0.000),提示联合组FMA评分远期效果优于其他2组。靳三针组与康复组比较差异有显著统计学意义(P=0.000),提示靳三针组FMA随访评分优于康复组。
在CSI评分方面,3组比较差异有显著统计学意义(P=0.002),提示3组随访结果存在组间差别。联合组随访CSI评分低于靳三针组和康复组(P分别为0.001、0.010),提示联合组CSI评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示CSI随访评分基本一致。
3.8研究计划外随访结果
该部分患者为疗程结束后继续门诊或住院治疗者,所有患者均按照在院期间的治疗方案执行。共有病例22人,其中靳三针组5人,康复组7人,联合组10人。
在FCA评分方面,3组比较差异有显著统计学意义(P=0.000),提示3组随访结果存在组间差别。联合组随访FCA评分高于靳三针组和康复组(P分别为0.000、0.001),提示联合组FCA评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P＞0.05),提示FCA随访评分基本一致。
在NDS评分方面,3组比较差异有统计学意义(P=0.030),提示3组随访结果存在组间差别。联合组随访NDS评分低于靳三针组和康复组(P分别为0.047、0.016),提示联合组NDS评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示NDS随访评分基本一致。
在FMA评分方面,3组比较差异有显著统计学意义(P=0.000),提示3组随访结果存在组间差别。联合组随访FMA评分高于靳三针组和康复组(P分别为0.042、0.000),提示联合组FMA评分远期效果优于其他2组。靳三针组与康复组比较差异有显著统计学意义(P=0.007),提示靳三针组FMA随访评分优于康复组。
在CSI评分方面,3组比较差异有统计学意义(P=0.040),提示3组随访结果存在组间差别。联合组随访CSI评分低于靳三针组和康复组(P分别为0.044、0.026),提示联合组CSI评分远期效果优于其他2组。靳三针组与康复组比较差异无统计学意义(P>0.05),提示CSI随访评分基本一致。
4.结论
4.1颞三针配合挛三针可有效改善中风后痉挛性偏瘫状态。
本研究表明,靳三针(颞三针配合挛三针)可有效改善中风后患者的痉挛性偏瘫状态,量表评分显示,可缓解痉挛程度、改善肢体功能,与康复训练效果基本一致；而两者联合使用时效果更加显著,究其原因,针刺在改善肢体运动功能方面的作用已得到广泛证实,尤其是在中风发病早期,康复训练在此方面稍显不足。
4.2靳三针疗法的推广普及有利于康复医学的发展。
从本研究结果看,靳三针治疗组能够有效缓解中风后患肢的痉挛程度,减轻功能障碍,通过疗程结束后的随访结果可以看出,持续的靳三针治疗有利于功能障碍和痉挛程度的进一步缓解。靳三针疗法具有配穴灵活、取穴精简的特点。同时,在治疗方案中,原则上以三针为主,再结合辨证配穴；有是证用是穴,可完善和补充各类三针处方,加强治疗效果。三针加以配穴则主次分明,诚如中药处方中的君、臣、佐、使；其治疗方案体现了穴位与病证相适宜,是针灸处方中难得的模式。
正是基于上述特点,在社区、基层医院中推广普及靳三针疗法将有利于社区康复的发展,解决其对设备、人员的过分依赖；而且,靳三针疗法治疗范围广阔,也利于针灸疗法的普及。
4.3协调和平衡主动肌与拮抗肌、提高康复训练效果可能是颞三针配合挛三针治疗中风后痉挛性偏瘫的作用机制。
协调和平衡主动肌与拮抗肌之肌张力,促进共同运动向分离运动转化是治疗痉挛性偏瘫的重点,挛三针的取穴和手法正是依据于这一理论。在手挛三针中,以极泉、尺泽、内关为主穴,采用提插捻转泻法,强刺激,以抑制上肢内收肌的肌张力；足挛三针采用鼠蹊、阴陵泉、三阴交为主穴,鼠蹊、阴陵泉穴采用提插捻转平补平泻手法,以平衡内外侧肌群肌力,三阴交穴采用提插捻转泻法,可使过强的肌张力得到抑制,有助于解除肌挛缩和关节的畸形、僵直状态。
除缓解痉挛状态外,针刺对康复训练具有类似或优于易化作用的促进作用,并能提高患者接受康复治疗的意识。这可能是颞三针配合挛三针治疗中风后痉挛性偏瘫的作用机制。
4.4持续的、中西结合康复治疗对患者有利。
随访研究结果表明,经组间比较,研究计划外随访患者在FCA、NDS、FMA、CSI评分方面普遍优于研究计划内随访患者,差异有统计学意义。联合组在各个量表评分方面均优于单纯针刺治疗和康复训练,显示出中西结合康复治疗的重要性和必要性。
按照本研究的设计方案,计划内随访患者为严格执行方案者,即疗程结束后未续实施任何本方案内的康复治疗；而计划外随访患者已经脱离了研究方案,临床实施过程中,该部分患者有持续康复治疗进而回归社会、家庭的愿望,故给予了原治疗方案。故依据上述结果可以认为,早期、持续的中西结合康复治疗对中风后痉挛性偏瘫和其他功能障碍的改善有较好帮助。
5.本研究的创新之处
5.1充分体现靳三针的整体观念
靳三针治疗中风后偏瘫临床方案注重整体观,注重头部局部取穴与循经取穴相结合,对中风后偏瘫根据弛缓瘫和痉挛瘫的不同,采用不同的三针疗法；针对痉挛性偏瘫症状的复杂性,采用踝三针、开三针等组穴对症治疗；针对中风后偏瘫的不同伴随症状,采用口三针、舌下三针等组穴随症治疗。整个治疗方案体现了靳三针疗法配穴灵活,取穴精简的特点。
5.2评价标准更加全面、规范和客观
本项目采用目前通行的功能综合评定量表(FCA)、临床神经功能缺损程度评分(NDS)、四肢简化Fugl-Meyer评分(FMA)、临床痉挛指数(CSI)评定,使靳三针治疗中风后痉挛性偏瘫的评价标准更加全面、规范和客观。
5.3随访研究对针灸、康复训练的远期疗效进行对比,分析早期、持续康复治疗的重要性和必要性。
According to the data from the World Health Organization, the morbidi ty of stroke in China was increasing at the rate of8.7%every year, whic h was twice compared with that of America. The number of patient in strok e in our country now is about7million, which is almost the gross popula tion of Hongkong at the beginning of2010.So, from these number, we know that stroke is a common disease. With improvement of the diagnosis and th e level of emergency treatment, the mortality rate has dropped dramatical ly, however the morbidity is significantly increased. In China, about80%of patients left over from the different degrees of physical dysfunction, among which, the incidence of hemiplegia was the highest, about90%of p atients with limb spasticity occurs within3post burn weeks, The quality of life was seriously affect. Spasm refers to muscle or muscle group int ermittent or persistent involuntary contraction, performance increased mu scle tone muscles, abnormal coordination particular model.
The mechanism of spastic hemiplegia was not yet entirely clear. It is generally believed that the spasm caused by increased spinal reflex activity in the upper motor neuron injury, abnormal muscle tone is characterized by speed-dependent stretch reflex enhanced, due to motion control disorders; its core is abnormal stretch reflex hyperactivity. Post-stroke central movement suppression system disorders, a motor neurons and Y motor nerve cell mutual restraint, interaction imbalance, caused y movement neurons dominant, the central movement to inhibit system weakened, resulting in low-level center of the originalrelease, resulting in the motion loop enhance the excitability of the affected limb increased muscle tone, was spasticity. Clinical practice, upper limb flexors and lower limb extensors increased muscle tone, forms the so-called Wernicke-Mann position. In other words, the post-stroke hemiplegic limb spasticity of spinal cord excitability increase is caused by enhanced activity of α-γ loop.
Limb spasticity seriously impeded the completion of activities of limb function, so that how to break the pattern and to promote the limb separation movement has become an important key to the treatment of stroke hemiplegia spasm as soon as possible. The stroke hemiplegia spasm comes about three weeks after the onset of spasms usually lasts about three months, mostly due to wrong treatment or loss of governance spasticity permanently fixed, it directly affects the improvement of stroke hemiplegia rehabilitation effects. Therefore, the search effectively alleviate the treatment of hemiplegia spasticity become an important issue for the medical profession. Hemiplegia spasticity clinical treatment more difficulty, is still lack of a better therapeutic means, and how to reduce spasm is still the main content and problems of rehabilitation medical research.
Summary of recent post-stroke spastic hemiplegia treatment research, from which can be seen in Western and Chinese medicine have certain understanding. There are more treatment, and the efficacy of various treatments is sure. But western medicine has adverse reactions, such as limb weakness, drowsiness, gastrointestinal reactions, psychosis (mental depression) and occasional liver and kidney dysfunction, and the long-term efficacy needs to be further investigated. Surgical treatment is difficult, technically demanding, high cost, and is not easy to promote. The use of Physical therapy, such as functional electrical stimulation, due to the lack of basic research demonstration, coupled with the small-scale research or non-randomized controlled, this therapy is still difficult to make a convincing scientific conclusions.
In recent years, with China's development of rehabilitation medicine, acupuncture treatment of spastic hemiplegia after stroke shows unique advantages, this therapy carried out a large number of clinical observation and research in clinical medicine workers at home and abroad and certainly thethe clinical efficacy of the therapy. But the presence of clinical reports assessment standards are not uniform, there is no specification of the cases included in the discharge standard, some are not randomized controlled defects, and often only highlighted the acupoints, spasm side acupoints, the antagonistic side acupoints, spasm antagonistic side at the same timeacupoints, while ignoring the difference between acupuncture manipulation applications.
Jin needle therapy as an important academic content of the Lingnan school of acupuncture is widely used in clinical practice. As early as the early1980s, Professor Rui Jin founded Jin needle therapy in the treatment of post-stroke hemiplegia, aphasia, pseudobulbar palsy and other aspects, and has been carrying out a number of clinical studies; the treatment of the disease has accumulated a wealth of experience. For limb muscle atrophy, joint contractures and deformation of a series of clinical symptoms caused by spastic hemiplegia after a stroke and clinical difficult point mentor Professor Li Xing Zhuang further improved Jin-pin theory, summed up the twin needle, and the applyclinical, and clinical observation proved have got good effect.
On the basis of past clinical experience accumulated, this study further investigated the possible mechanism of action, and thus to find the effective ways to improve the quality of life of stroke patients with spastic hemiplegia.
1. Objectives
1.1The mechanism of spastic hemiplegia after stroke was unclear, the lack of targeted drug therapy, surgical treatment is difficult, so that it is not easy to be popularized, the use of physical therapy is lack of basic research demonstration, so that make it a clear that the efficacy Jin acupuncture treatment of hemiplegia by the spastic in the after a stroke as well as the impact on the patients'comprehensive functionality by the controlled study.
1.2Preliminary explores the mechanism of Jin-pin the spastic hemiplegia role in the treatment of stroke.
1.3Improve the temporal three-pin, twin three-pin the spastic hemiplegia solution in the treatment of stroke, to discuss its promotional value.
2. Methods
2.1Literature Research
Literature section focus on reviewing the mechanism of spastic hemiplegia after stroke in recent years, were described in terms of pathology, physiology, molecular biology, pharmacology; From medical theory of yin and yang, viscera theory to make analysis. And it carried out a detailed review of the mechanism of acupuncture treatment for stroke spastic hemiplegia.
2.2Clinical Research
100patients was divided into Jin three-needle group, rehabilitation and combined groups, met the inclusion criteria of post-stroke patients with spastic hemiplegia, All patients on the basis of drug therapy with reference to cerebrovascular disease prevention and treatment guidelines (Ministry of Health, Department of Disease Control, Chinese Medical Association Academy of Neurology,2005), to control blood pressure, blood sugar, regulate blood fat, prevent platelet aggregation, and give symptomatic treatment, prevention of complications, nutritional support, and so on.
Jin three-needle group using temporal acupuncture combined with twin three-pin main point in the treatment, rehabilitation therapy rehabilitation group, the combined group Jin three-pin joint rehabilitation training, the14-day course of treatment, before treatment,7days,14days, functional comprehensive assessment (FCA) respectively, for patients with clinical neurological deficit score (NDS), limbs simplify the Fugl-Meyer score (FMA), assessment the clinical spasms index (CS1). Follow-up at the end of treatment after3months and assess these scale.
3Results
3.1Literature results show that after a stroke the spastic hemiplegia mechanism is not yet clear, acupuncture is increasingly shows unique advantages, this therapy carried out a large number of clinical observation and research in clinical medicine workers at home and abroad in recent years, Jin pin the therapy gradually become one of the hot spots.
3.2General information
Patients enrolled in the research on the aspects of the average age, the average duration and gender composition difference was not statistically significant, prompt baseline data consistent with good comparability. Before treatment, FCA, NDS, FMA, CSI rated by comparison has no significant difference in scale score.
3.3The results of FCA
From the study results we know that, the difference among three groups was statistically significant (P=0.013), which meant that three treatment had within-group difference. The changing trend was different at different stage on the aspect of FCA score, which showed that the score of Combined Group was higher than that of Jin three-needle group and rehabilitation group(P respectively0.034,0.004). However, the score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which meant that the scores between two groups was nearly the same.
3.4The results of NDS
From the study results we know that, the difference among three groups was statistically significant (P=0.007), which meant that three treatment had within-group difference. The changing trend was different at different stage on the aspect of NDS score, which showed that the score of Combined Group was lower than that of Jin three-needle group and rehabilitation group (P respectively0.012,0.003). However, the score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which meant that the scores between two groups was nearly the same.
3.5The results of FMA
From the study results we know that, the difference among three groups was statistically significant (P=0.000), which meant that three treatment had within-group difference. The changing trend was different at different stage on the aspect of FMA score, which showed that the score of Combined Group was lower than that of Jin three-needle group and rehabilitation group(P respectively0.003,0.000). However, the score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which meant that the scores between two groups was almost the same.
3.6The results of CSI
From the study results we know that, the difference among three groups was statistically significant (P=0.001), which meant that three treatment had within-group difference. The changing trend was different at different stage on the aspect of NDS score, which showed that the score of Combined Group was lower than that of Jin three-needle group and rehabilitation group(P respectively0.000,0.005). However, the score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which meant that the scores between two groups was almost the same.
3.7The follow-up results of the planned the research program
That some patients did not continue the original treatment plan after the end of treatment, or to return home, or living in a nursing home, some patients regularly out-patient referral. The total number of cases is30, Jin-pin group of12people,10people in the rehabilitation group and the combined group of8people.
We can see from the follow-up results that the three groups had statistical difference on the aspect of FCA score(P=0.034), which meant that the follow-up result had within-group difference. The follow-up FCA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.044,0.012), which indicated that the long-term FCA score was better than that of the other groups. However, the follow-up score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which indicated that the follow-up scores between two groups was almost the same.
Meanwhile, the three groups had significant statistical significance on the aspect of NDS score (P=0.034), which meant that the follow-up result had within-group difference. The follow-up NDS score of combined group was lower than that of Jin three-needle group and rehabilitation group (P respectively0.044,0.012), which indicated that the long-term NDS score was better than that of the other groups. However, the follow-up NDS score of Jin three-needle group had no statistical difference compared with that of rehabilitation group(P>0.05), which indicated that the follow-up NDS scores between two groups was almost the same.
The three groups had significant statistical significance on the aspect of FMA score(P=0.000), which meant that the follow-up result had within-group difference. The follow-up FMA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.005,0.000), which indicated that the long-term FMA score was better than that of the other groups. However, the follow-up FMA score of Jin three-needle group had statistical difference compared with that of rehabilitation group(P=0.000), which indicated that the follow-up FMA scores of Jin three-needle group was better than that of rehabilitation group.
The three groups had significant statistical significance on the aspect of CSI score (P=0.002), which meant that the follow-up result had within-group difference. The follow-up FMA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.001,0.010), which indicated that the long-term CSI score was better than that of the other groups. However, the follow-up CSI score of Jin three-needle group had no statistical difference compared with that of rehabilitation group(P>0.05), which indicated that the follow-up CSI scores between two groups was almost the same.
3.8The unplanned follow-up research results
After the end of treatment, some patients continued to outpatient or hospital treatment, all patients were in accordance with the treatment options in the hospital during the execution. There are a total of22cases, including5in Jin three-needle group,7in the rehabilitation group, and the combined group of10people.
We can see from the follow-up results that the three groups had statistical difference on the aspect of FCA score (P=0.000), which meant that the follow-up result had within-group difference. The follow-up FCA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.000,0.001), which indicated that the long-term FCA score was better than that of the other groups. However, the follow-up score of Jin three-needle group had no statistical difference compared with that of rehabilitation group (P>0.05), which indicated that the follow-up scores between two groups was almost the same.
Meanwhile, the three groups had significant statistical significance on the aspect of NDS score(P=0.030), which meant that the follow-up result had within-group difference. The follow-up NDS score of combined group was lower than that of Jin three-needle group and rehabilitation group (P respectively0.047,0.016), which indicated that the long-term NDS score was better than that of the other groups. However, the follow-up NDS score of Jin three-needle group had no statistical difference compared with that of rehabilitation group(P>0.05), which indicated that the follow-up NDS scores between two groups was almost the same.
The three groups had significant statistical significance on the aspect of FMA score(P=0.000), which meant that the follow-up result had within-group difference. The follow-up FMA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.042,0.000), which indicated that the long-term FMA score was better than that of the other groups. However, the follow-up FMA score of Jin three-needle group had statistical difference compared with that of rehabilitation group(P=0.007), which indicated that the follow-up FMA scores of Jin three-needle group was better than that of rehabilitation group.
The three groups had significant statistical significance on the aspect of CSI score (P=0.040), which meant that the follow-up result had within-group difference. The follow-up FMA score of combined group was higher than that of Jin three-needle group and rehabilitation group (P respectively0.044,0.026), which indicated that the long-term CSI score was better than that of the other groups. However, the follow-up CSI score of Jin three-needle group had no statistical difference compared with that of rehabilitation group(P>0.05), which indicated that the follow-up CSI scores between two groups was almost the same.
4Conclusions
4.1Temporal three-pin with twin three-pin could effectively relieve the spastic hemiplegia state of post-stroke patients.
Studies had shown that Jin three-needle (temporal three-pin with twin three-pin) could relieve spastic hemiplegia state of post-stroke patients, in FCA, NDS, FMA scale scores, limb function in the three groups of patients after14days of treatment were all improved; effect showed in the7days after treatment relative to the rehabilitation group, Jin three-needle group, and the combined group, the role of acupuncture can not be ignored. Acupuncture role in improving motor function had been widely confirmed, especially in early onset of stroke while rehabilitation is slightly insufficient in this aspect.
4.2The popularization of Jin three-needle therapy was conducive to the development of rehabilitation medicine.
Results from this study, the Jin three-needle group could effectively alleviate limb spasticity after stroke, reduced dysfunction, after the end of treatment follow-up results could be seen Jin three-needle treatment in favor dysfunction and spasm the degree of further ease. Jin three-needle therapy has the acupoints flexible, and acupoints streamlined. Meanwhile, in the treatment regimen, in principle, three-pin main and TCM acupoints; card with points to improve and supplement the various types of three-pin prescription, to enhance the therapeutic effect. Three-pin with points to be prioritized, as stated in the Chinese medicine prescription Jun, Chen Zuo, so; treatment program reflected the points and the syndromes suitable acupuncture prescription rare model.
Based on the above characteristics, to popularize Jin three needle therapy in the community hospitals and grass-roots hospitals will be conducive to the development of rehabilitation in these hospitals. And this therapy also solved the problem that these hospitals relied too much on equipment and personnel. Jin three-needle therapy was for a wide range, but also conducive to acupuncture the popularity.
4.3The mechanism lied likely in coordination and balance agonist with antagonistic muscles and tension muscle as well as improvement on the effect of rehabilitation training.
Coordination and balance agonist with antagonistic muscles and tension muscle, promote common motion is converted to the separatist movement is the focus of treatment of spastic hemiplegia, the acupoints and practices twin30-pin It is based on this theory. The main points in hand twin needle to the pole spring, Chize, the customs, the use of lift and thrust twist and twirl, strong stimulation to suppress the upper limb adductor muscle tension; foot twin three-pin groin, Yin LingQuan, Sanyinjiao main points, groin, yinlingquan point, put plug Twist flat reinforcing-reducing techniques Sanyinjiao lift and thrust twist and twirl muscles balance inside and outside, can make strong muscle tonebe suppressed, and helps to relieve muscle.
In addition to relieve spasticity, has a role in promoting similar or better than the facilitatory effect of acupuncture on rehabilitation training, and can improve the awareness of patients receiving rehabilitation treatment. This may be temporal acupuncture combined with twin three-pin the spastic hemiplegia role in the treatment of stroke mechanism.
5. The innovation of study
5.1It fully reflects the whole concept of Jin three-needle therapy
Jin needle treatment of post-stroke hemiplegia clinical programs focus on the wholel concept, focus on head local points acupoints along meridians, a different three-pin therapy applied to flaccid paralysis and spastic paralysis post-stroke hemiplegia,; for spasticthe hemiplegia symptoms complexity, the use of three-pin ankle, open three-pin and other acupoints symptomatic treatment; different symptoms associated with hemiplegia after stroke, three-pin port, treatment of sublingual needles and other points with the disease. The entire treatment program reflects the acupoints of Jin three-needle therapy flexible and acupoints streamlined.
5.2Evaluation criteria more comprehensive, standardized and objective
This project uses the current prevailing functional comprehensive assessment (FCA), clinical neurological deficit score (NDS), limbs simplified Fugl-Meyer score (FMA), the clinical spasms Index (CSI) assessment, Jin three-needle treatment of strokespastic hemiplegia evaluation criteria are more comprehensive, standardized and objective. The study has played a good role model in acupuncture cl inical standardization, standardization research.
5.3Follow-up studies on long-term efficacy of acupuncture and rehabilitation contrast, analysis of the importance and necessity of early and continuing rehabilitation.
引文
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