第一论文网免费提供临床医学论文范文,临床医学论文格式模板下载

鍉圆针系统痧疗对不同证型膝痹病的临床观察

  • 投稿
  • 更新时间2023-02-22
  • 阅读量39次
  • 评分0

摘    要:目的:探讨鍉圆针系统痧疗对不同证型膝痹病的临床疗效。方法:将123例患者按照中医证型分为4组,风寒湿痹组、风湿热痹组、瘀血闭阻组、肝肾亏虚组,均采用鍉圆针系统痧疗+中频电疗。评估各组治疗前、后WOMAC骨关节炎指数评分、中医证候积分、检测C反应蛋白(CRP),进行统计分析。结果:20次治疗结束后,四组WOMAC骨关节炎指数评分均下降,四组治疗前后比较均具有统计学意义(P<0.01),经多重比较发现,瘀血闭阻组与风寒湿痹组评分无统计学意义(P ≥0.05),风寒湿痹组与风湿热痹组评分无统计学意义(P ≥0.05),瘀血闭阻组评分低于风湿热痹组, 具有统计学意义(P<0.05),瘀血闭阻组评分低于肝肾亏虚组, 具有统计学意义(P<0.01), 风寒湿痹组评分低于肝肾亏虚组, 具有统计学意义(P<0.01), 风湿热痹组评分低于肝肾亏虚组, 具有统计学意义(P<0.01)。说明瘀血闭阻组和风寒湿痹组疗效优于肝肾亏虚组,瘀血闭阻组和风寒湿痹组疗效相当。C反应蛋白(CRP)数值有变化,但无统计学意义(P ≥0.05)。治疗后中医证候积分评分均下降,四组治疗前后比较均具有统计学意义(P<0.01),经多重比较发现,瘀血闭阻组与风寒湿痹组评分无统计学意义(P ≥0.05),瘀血闭阻组评分低于风湿热痹组,瘀血闭阻组评分低于肝肾亏虚组,风寒湿痹组评分低于风湿热痹组,风寒湿痹组评分低于肝肾亏虚组,风湿热痹组评分低于肝肾亏虚组,均具有统计学意义(P<0.01),说明瘀血闭阻组和风寒湿痹组疗效优于风湿热痹组和肝肾亏虚组,瘀血闭阻组和风寒湿痹组疗效相当。治疗后四组患者有效率差异具有统计学意义(χ2=22.847,P<0.001),经多重比较发现,风寒湿痹组、风湿热痹组和瘀血闭阻组疗效无差异,(P≥0.05)。说明风寒湿痹组、风湿热痹组和瘀血闭阻组疗效优于肝肾亏虚组,风寒湿痹组、风湿热痹组和瘀血闭阻组疗效相当。结论:鍉圆针系统痧疗对不同中医证型膝痹病患者的疗效存在差异,以瘀血闭阻证者和风寒湿痹证疗效最佳。


关键词:膝痹;錕圆针系统痧疗; WOMAC骨关节炎指数评分;骨关节中医证候积分分级量化评分;


The clinical effect of round needle quantitative scaling therapy on different syndromes of

knee arthralgia

Wang Yan Niu Xiuru Gao Zhiguang

Hu Guangqin

Li Danhong Li Hongli Zhao Xinying

Bejing Longfu Hospital Beiig Mingyi Mingyao Traditional Chinese Medicine Research Institute

Co.. Ltd Bejing 100024 National Museum of Traditional Chinese Medicine


Abstract:Objective: Discuss the effect of round needle quantitative scaling therapy on different types of Bi syndrome. Method: 123 patients were divided into 4 groups according to TCM syndromes,Wind-Cold-Dampness arthralgia, Wind-Dampness-Heat arthralgia, Arthralgia due to stagnation of blood stasis, Deficiency of liver and kidney due to protracted arthralgia. All patients were treated with round needle quantitative scaling therapy+ intermediate frequency. Evaluate and make statistical analysis of WOMAC osteoarthritis index score, TCM syndrome score and C-reaction index in the four groups before and after treatment. Results: After twenty times treatment, WOMAC osteoarthritis index score decreased in four groups. It had statistically significant difference after comparing the index before and after the treatment in four groups,(P<0.01). There is no statistically significant difference between Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia after comparison,(P ≥0.05). There is no statistically significant difference between Wind-Cold-Dampness arthralgia and Wind-Dampness-Heat arthralgia,(P ≥0.05). It had statistically significant difference of Arthralgia due to stagnation of blood stasis as compared with Wind-Dampness-Heat arthralgia,(P<0.05).It had statistically significant difference of Arthralgia due to stagnation of blood stasis as compared with Deficiency of liver and kidney due to protracted arthralgia,(P<0.01). It had statistically significant difference of Wind-Cold-Dampness arthralgia as compared with Deficiency of liver and kidney due to protracted arthralgia,(P<0.01). It had statistically significant difference of Wind-Dampness-Heat arthralgia as compared with Deficiency of liver and kidney due to protracted arthralgia,(P<0.01). It indicates that the efficacy of Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia is superior to that of Deficiency of liver and kidney due to protracted arthralgia, and the efficacy of Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia is equivalent. There is no statistically significant difference of C-reaction index,(P ≥0.05). Here is statistically significant difference in all group of TCM syndrome score after comparing the results before and after treatment,(P<0.01).There is no statistically significant difference between Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia, (P ≥0.05). TCM syndrome score of Arthralgia due to stagnation of blood stasis is lower than Wind-Dampness-Heat arthralgia and Deficiency of liver and kidney due to protracted arthralgia. TCM syndrome score of Wind-Cold-Dampness arthralgia is lower than Wind-Dampness-Heat arthralgia and Deficiency of liver and kidney due to protracted arthralgia. TCM syndrome score of Wind-Dampness-Heat arthralgia is lower than Deficiency of liver and kidney due to protracted arthralgia. All these have statistically significant difference (P<0.01). It indicates that the efficacy of Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia is superior to that of Wind-Dampness-Heat arthralgia and Deficiency of liver and kidney due to protracted arthralgia, and the efficacy of Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia is equivalent. The effect of the four groups all have statistically significance (χ2=22.847, P<0.001). There is no statistically significant difference (P≥0.05) on the treatment effect among Wind-Cold-Dampness arthralgia、Wind-Dampness-Heat arthralgia and Arthralgia due to stagnation of blood stasis. It indicates that the efficacy of Wind-Cold-Dampness arthralgia、Wind-Dampness-Heat arthralgia and Arthralgia due to stagnation of blood stasis is superior to that of Deficiency of liver and kidney due to protracted arthralgia, and the efficacy of Wind-Cold-Dampness arthralgia、Wind-Dampness-Heat arthralgia and Arthralgia due to stagnation of blood stasis is equivalent. Conclusion: The effect of round needle quantitative scaling therapy are different on different type of Bi syndrome patients and the effect are best in Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia.


Keyword:Knee arthralgia; Round needle quantitative scaling therapy; WOMAC osteoarthritis index score; TCM syndrome score;


膝关节骨性关节炎(Knee Osteoarthritis,KOA),中医学中又名“膝痹病”,主要表现为关节肿胀、疼痛、功能活动受限等症状。临床将膝痹病辨证分型分为风寒湿痹证、风湿热痹证、瘀血闭阻证、肝肾亏虚证[1,2,3,4]。胡广芹教授首次提出“鍉圆针系统痧疗”,并根据《黄帝内经·灵枢》“九针”中的两种无创针具鍉针、圆针和《五十二病方》角法理论,应用新材料,新工艺,发明鍉圆针痧疗器,获得国家专利[5,6,7]。经前期研究观察,鍉圆针系统痧疗可有效改善膝痹病患者膝关节疼痛、肿胀、活动受限,有效降低WOMAC骨关节炎指数评分、骨关节中医证候积分分级量化评分,改善关节功能。可作为临床安全、有效的治疗方法。本研究进一步探讨鍉圆针系统痧疗对不同证型膝痹病的临床疗效。现汇报如下。


1 资料和方法

1.1 一般资料

选取2020年10月至2022年4月于本科室门诊就诊的膝痹病患者123例,按照证型分为4组,风寒湿痹组、风湿热痹组、瘀血闭阻组、肝肾亏虚组。本研究通过本院伦理委员会批准。


1.1.1 纳入标准

纳入标准:西医诊断标准(参照中华医学会骨科学分会《骨关节诊治指南》(2007年版)诊断标准进行诊断。)①近1个月内反复膝关节疼痛;②X线片(站立或负重位)示关节间隙变窄、软骨下骨硬化和(或)囊性变、关节缘骨赘形成;③关节液(至少2次)清亮、粘稠,WBC<2000个/ml;④中老年患者(≥40岁);⑤晨僵≤30分钟;⑥活动时有骨擦音(感)。综合临床、实验室及X线检查,符合①+②条或①+③+⑤+⑥条或①+④+⑤+⑥条,可诊断膝关节骨性关节炎。中医诊断标准(参照膝痹病(膝关节骨性关节炎)诊疗方案(2017年版),参照中国中医药研究促进会骨科专业委员会、中国中西医结合学会骨伤科专业委员会关节工作委员会《膝骨关节炎中医诊疗专家共识》( 2015 年版)。)①初起膝关节隐隐作痛,屈伸不利,轻微活动稍缓解,气候变化加重,反复缠绵不愈。②起病隐袭,发病缓慢,多常见中老年人。③膝部可轻度肿胀,活动时关节常有咔嚓声和摩擦声。④X线检查可见骨质疏松,关节间隙变窄,软骨下骨质硬化,边缘唇样改变,骨赘形成。膝痹病的中医辨证:①风寒湿痹证:肢体关节酸楚疼痛、痛处固定,有如刀割或有明显重着感或者表现肿胀感,关节活动欠灵活,畏风寒,得热则舒。舌质淡,苔白腻,脉紧或濡。②风湿热痹证:起病较急,病变关节红肿、灼热、疼痛,甚至痛不可触,得冷则舒为特征;可伴有全身发热,或皮肤发热,或皮肤红斑、硬结。舌质红,苔黄,脉滑数。③瘀血闭阻证:肢体关节刺痛,痛处固定,局部有僵硬感,或麻木不仁,舌质紫暗,苔白而干涩。④肝肾亏虚证:膝关节隐隐作痛,腰酸软无力,酸困疼痛,遇劳更甚,舌质红、少苔,脉细无力。


1.1.2 排除标准

①不符合相关诊断分型标准者;②已使用过治疗药物者;③有严重传染病或其他严重原发性疾病;④施术部位有瘢痕或破损等;⑤妊娠妇女;⑥有严重精神疾患者;⑦行动不便,无法保证按时治疗,或依从性差者;⑧经耐心讲解说明,对本课题仍不了解者。


1.2 方法

1.2.1 治疗方法

将123例患者按照中医证型分为4组,风寒湿痹组、风湿热痹组、瘀血闭阻组、肝肾亏虚组。均采用鍉圆针系统痧疗+中频电治疗。四组鍉圆针定量痧疗器(鍉圆针定量痧疗器(生产厂家:山东明医明药生物医药有限公司,备案号:鲁淄械备20180038号,型号:SL-1-1、2、3、4、7),配以舒爽精华油(山东明医明药生物医药有限公司,鲁妆20170040,执行标准:GB/T4075-2010))。中频电疗均应用中频电疗仪(BA2008-III型电脑中频治疗仪,北京奔奥新技术有限公司,注册号:京食药监械(准)字2014第2260689号。)将2个电极于膝关节内外侧对置或痛点放置。每次中频电疗20分钟,强度患者耐受,不引起疼痛不适为度。隔日1次,共治疗20次。


1.2.2 操作过程

①备齐用物,携至床旁,做好解释,取得患者配合。②协助患者取合适体位,暴露治疗部位,冬季注意保暖。③检查器具边缘是否光滑、有无缺损,以免划破皮肤。④手持器具,蘸专用舒爽精华油,在选定的部位,从上至下刮擦皮肤,要向单一方向,不要来回刮。用力要均匀,禁用暴力。⑤刮动数次后,当器具干涩时,需及时蘸专用舒爽精华油,直至皮下呈现红色或紫红色为度,一般每一部位刮20次左右。⑥刮治过程中,随时询问患者有无不适,观察病情及局部皮肤颜色变化,及时调节手法力度。⑦治疗完毕,清洁局部皮肤,协助患者衣着。⑧清理用物,归还原处。嘱患者施术后注意保暖。操作部位和穴位:应用SL-1-2、3号鍉圆针定量痧疗器刮足阳明胃经:伏兔至梁丘,足三里至条口与丰隆;应用SL-1-7号鍉圆针定量痧疗器点按双膝眼;应用SL-1-4号鍉圆针定量痧疗器刮足少阳胆经:风市至膝阳关,阳陵泉至悬钟;SL-1-1号刮足太阳膀胱经:承扶至委中、委阳、承山;刮足太阴脾经:箕门至血海,阴陵泉至三阴交。


1.3 观察指标

①治疗开始前进行WOMAC骨关节炎指数评分、中医证候积分分级量化评分、复查C反应蛋白(CRP),并于20次治疗结束后,重新进行量表评分,复查C反应蛋白(CRP)。中医证候积分分级量化评分从关节疼痛、肿胀、晨僵、关节活动不利、关节冷痛喜暖恶寒、关节灼热、关节酸软乏力、关节变形、头晕耳鸣、骨蒸烦热、面色无华心悸气短、舌象(舌质、舌苔)、脉象十四个方面综合评估骨关节炎情况,评分越高、症状越重。WOMAC骨关节炎指数评分从关节疼痛、晨僵、进行日常活动的难度三大方面对患者骨关节进行评定,结合C反应蛋白(CRP)结果,完成西医疗效评估。②中医疗效判定标准:疾病疗效判定标准:临床控制:疼痛、肿胀症状消失,关节活动正常,积分减少≥95%;显效:疼痛、肿胀症状消失,关节活动不受限,积分减少≥70%,﹤95%;有效:疼痛、 症状基本消除,关节活动轻度受限,积分减少≥30%,﹤70%;无效:疼痛、肿胀症状与关节活动无明显改善,积分减少﹤30。注:疼痛、肿胀、关节活动3项症状/体征为判定指标。注:计算公式(尼莫地平法)为:(治疗前积分-治疗后积分)/治疗前积分×100%。


1.4 统计学分析

应用SPSS 23.0统计软件分析结果。计量资料先进行正态分布检验,若符合正态分布且方差齐性,应用均数±标准差(x±s)的形式进行描述。组间比较采用独立样本t检验(三组及以上采用方差分析);组内不同时间点比较,采用配对样本t检验。计量资料若不符合正态分布,采用中位数(下四分位数,上四分位数),组间比较采用Kruskal-Wallis H检验,采用Bonferroni校正法进行多重比较,组内比较采用wilcoxon秩和检验。计数资料采用频数(百分比)进行描述,组间比较采用卡方。以P≤0.05为差异具有统计学意义。


2 结果

参考临床研究中的排除标准,纳入本研究123例,其中有5例患者先后因为膝痛、腰痛手术治疗;膝痛、腰痛口服止痛药;拔牙使用抗生素,终止试验,脱落。一般资料对比见表1。


表1 四组病例一般资料的比较


Abstract:

Objective: Discuss the effect of round needle quantitative scaling therapy on different types of Bi syndrome. Method: 123 patients were divided into 4 groups according to TCM syndromes,Wind-Cold-Dampness arthralgia, Wind-Dampness-Heat arthralgia, Arthralgia due to stagnation of blood stasis, Deficiency of liver and kidney due to protracted arthralgia. All patients were treated with round needle quantitative scaling therapy+ intermediate frequency. Evaluate and make statistical analysis of WOMAC osteoarthritis index score, TCM syndrome score and C-reaction index in the four groups before and after treatment. Results: After twenty times treatment, WOMAC osteoarthritis index score decreased in four groups. It had statistically significant difference after comparing the index before and after the treatment in four groups,(P<0.01). There is no statistically significant difference between Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia after comparison,(P ≥0.05). There is no statistically significant difference between Wind-Cold-Dampness arthralgia and Wind-Dampness-Heat arthralgia,(P ≥0.05). It had statistically significant difference of Arthralgia due to stagnation of blood stasis as compared with Wind-Dampness-Heat arthralgia,(P<0.05).It had statistically significant difference of Arthralgia due to stagnation of blood stasis as compared with Deficiency of liver and kidney due to protracted arthralgia,(P<0.01). It had statistically significant difference of Wind-Cold-Dampness arthralgia as compared with Deficiency of liver and kidney due to protracted arthralgia,(P<0.01). It had statistically significant difference of Wind-Dampness-Heat arthralgia as compared with Deficiency of liver and kidney due to protracted arthralgia,(P<0.01). It indicates that the efficacy of Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia is superior to that of Deficiency of liver and kidney due to protracted arthralgia, and the efficacy of Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia is equivalent. There is no statistically significant difference of C-reaction index,(P ≥0.05). Here is statistically significant difference in all group of TCM syndrome score after comparing the results before and after treatment,(P<0.01).There is no statistically significant difference between Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia, (P ≥0.05). TCM syndrome score of Arthralgia due to stagnation of blood stasis is lower than Wind-Dampness-Heat arthralgia and Deficiency of liver and kidney due to protracted arthralgia. TCM syndrome score of Wind-Cold-Dampness arthralgia is lower than Wind-Dampness-Heat arthralgia and Deficiency of liver and kidney due to protracted arthralgia. TCM syndrome score of Wind-Dampness-Heat arthralgia is lower than Deficiency of liver and kidney due to protracted arthralgia. All these have statistically significant difference (P<0.01). It indicates that the efficacy of Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia is superior to that of Wind-Dampness-Heat arthralgia and Deficiency of liver and kidney due to protracted arthralgia, and the efficacy of Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia is equivalent. The effect of the four groups all have statistically significance (χ2=22.847, P<0.001). There is no statistically significant difference (P≥0.05) on the treatment effect among Wind-Cold-Dampness arthralgia、Wind-Dampness-Heat arthralgia and Arthralgia due to stagnation of blood stasis. It indicates that the efficacy of Wind-Cold-Dampness arthralgia、Wind-Dampness-Heat arthralgia and Arthralgia due to stagnation of blood stasis is superior to that of Deficiency of liver and kidney due to protracted arthralgia, and the efficacy of Wind-Cold-Dampness arthralgia、Wind-Dampness-Heat arthralgia and Arthralgia due to stagnation of blood stasis is equivalent. Conclusion: The effect of round needle quantitative scaling therapy are different on different type of Bi syndrome patients and the effect are best in Arthralgia due to stagnation of blood stasis and Wind-Cold-Dampness arthralgia.


Keyword:

Knee arthralgia; Round needle quantitative scaling therapy; WOMAC osteoarthritis index score; TCM syndrome score;


膝关节骨性关节炎(Knee Osteoarthritis,KOA),中医学中又名“膝痹病”,主要表现为关节肿胀、疼痛、功能活动受限等症状。临床将膝痹病辨证分型分为风寒湿痹证、风湿热痹证、瘀血闭阻证、肝肾亏虚证[1,2,3,4]。胡广芹教授首次提出“鍉圆针系统痧疗”,并根据《黄帝内经·灵枢》“九针”中的两种无创针具鍉针、圆针和《五十二病方》角法理论,应用新材料,新工艺,发明鍉圆针痧疗器,获得国家专利[5,6,7]。经前期研究观察,鍉圆针系统痧疗可有效改善膝痹病患者膝关节疼痛、肿胀、活动受限,有效降低WOMAC骨关节炎指数评分、骨关节中医证候积分分级量化评分,改善关节功能。可作为临床安全、有效的治疗方法。本研究进一步探讨鍉圆针系统痧疗对不同证型膝痹病的临床疗效。现汇报如下。


1 资料和方法

1.1 一般资料

选取2020年10月至2022年4月于本科室门诊就诊的膝痹病患者123例,按照证型分为4组,风寒湿痹组、风湿热痹组、瘀血闭阻组、肝肾亏虚组。本研究通过本院伦理委员会批准。


1.1.1 纳入标准

纳入标准:西医诊断标准(参照中华医学会骨科学分会《骨关节诊治指南》(2007年版)诊断标准进行诊断。)①近1个月内反复膝关节疼痛;②X线片(站立或负重位)示关节间隙变窄、软骨下骨硬化和(或)囊性变、关节缘骨赘形成;③关节液(至少2次)清亮、粘稠,WBC<2000个/ml;④中老年患者(≥40岁);⑤晨僵≤30分钟;⑥活动时有骨擦音(感)。综合临床、实验室及X线检查,符合①+②条或①+③+⑤+⑥条或①+④+⑤+⑥条,可诊断膝关节骨性关节炎。中医诊断标准(参照膝痹病(膝关节骨性关节炎)诊疗方案(2017年版),参照中国中医药研究促进会骨科专业委员会、中国中西医结合学会骨伤科专业委员会关节工作委员会《膝骨关节炎中医诊疗专家共识》( 2015 年版)。)①初起膝关节隐隐作痛,屈伸不利,轻微活动稍缓解,气候变化加重,反复缠绵不愈。②起病隐袭,发病缓慢,多常见中老年人。③膝部可轻度肿胀,活动时关节常有咔嚓声和摩擦声。④X线检查可见骨质疏松,关节间隙变窄,软骨下骨质硬化,边缘唇样改变,骨赘形成。膝痹病的中医辨证:①风寒湿痹证:肢体关节酸楚疼痛、痛处固定,有如刀割或有明显重着感或者表现肿胀感,关节活动欠灵活,畏风寒,得热则舒。舌质淡,苔白腻,脉紧或濡。②风湿热痹证:起病较急,病变关节红肿、灼热、疼痛,甚至痛不可触,得冷则舒为特征;可伴有全身发热,或皮肤发热,或皮肤红斑、硬结。舌质红,苔黄,脉滑数。③瘀血闭阻证:肢体关节刺痛,痛处固定,局部有僵硬感,或麻木不仁,舌质紫暗,苔白而干涩。④肝肾亏虚证:膝关节隐隐作痛,腰酸软无力,酸困疼痛,遇劳更甚,舌质红、少苔,脉细无力。


1.1.2 排除标准

①不符合相关诊断分型标准者;②已使用过治疗药物者;③有严重传染病或其他严重原发性疾病;④施术部位有瘢痕或破损等;⑤妊娠妇女;⑥有严重精神疾患者;⑦行动不便,无法保证按时治疗,或依从性差者;⑧经耐心讲解说明,对本课题仍不了解者。


1.2 方法

1.2.1 治疗方法

将123例患者按照中医证型分为4组,风寒湿痹组、风湿热痹组、瘀血闭阻组、肝肾亏虚组。均采用鍉圆针系统痧疗+中频电治疗。四组鍉圆针定量痧疗器(鍉圆针定量痧疗器(生产厂家:山东明医明药生物医药有限公司,备案号:鲁淄械备20180038号,型号:SL-1-1、2、3、4、7),配以舒爽精华油(山东明医明药生物医药有限公司,鲁妆20170040,执行标准:GB/T4075-2010))。中频电疗均应用中频电疗仪(BA2008-III型电脑中频治疗仪,北京奔奥新技术有限公司,注册号:京食药监械(准)字2014第2260689号。)将2个电极于膝关节内外侧对置或痛点放置。每次中频电疗20分钟,强度患者耐受,不引起疼痛不适为度。隔日1次,共治疗20次。


1.2.2 操作过程

①备齐用物,携至床旁,做好解释,取得患者配合。②协助患者取合适体位,暴露治疗部位,冬季注意保暖。③检查器具边缘是否光滑、有无缺损,以免划破皮肤。④手持器具,蘸专用舒爽精华油,在选定的部位,从上至下刮擦皮肤,要向单一方向,不要来回刮。用力要均匀,禁用暴力。⑤刮动数次后,当器具干涩时,需及时蘸专用舒爽精华油,直至皮下呈现红色或紫红色为度,一般每一部位刮20次左右。⑥刮治过程中,随时询问患者有无不适,观察病情及局部皮肤颜色变化,及时调节手法力度。⑦治疗完毕,清洁局部皮肤,协助患者衣着。⑧清理用物,归还原处。嘱患者施术后注意保暖。操作部位和穴位:应用SL-1-2、3号鍉圆针定量痧疗器刮足阳明胃经:伏兔至梁丘,足三里至条口与丰隆;应用SL-1-7号鍉圆针定量痧疗器点按双膝眼;应用SL-1-4号鍉圆针定量痧疗器刮足少阳胆经:风市至膝阳关,阳陵泉至悬钟;SL-1-1号刮足太阳膀胱经:承扶至委中、委阳、承山;刮足太阴脾经:箕门至血海,阴陵泉至三阴交。


1.3 观察指标

①治疗开始前进行WOMAC骨关节炎指数评分、中医证候积分分级量化评分、复查C反应蛋白(CRP),并于20次治疗结束后,重新进行量表评分,复查C反应蛋白(CRP)。中医证候积分分级量化评分从关节疼痛、肿胀、晨僵、关节活动不利、关节冷痛喜暖恶寒、关节灼热、关节酸软乏力、关节变形、头晕耳鸣、骨蒸烦热、面色无华心悸气短、舌象(舌质、舌苔)、脉象十四个方面综合评估骨关节炎情况,评分越高、症状越重。WOMAC骨关节炎指数评分从关节疼痛、晨僵、进行日常活动的难度三大方面对患者骨关节进行评定,结合C反应蛋白(CRP)结果,完成西医疗效评估。②中医疗效判定标准:疾病疗效判定标准:临床控制:疼痛、肿胀症状消失,关节活动正常,积分减少≥95%;显效:疼痛、肿胀症状消失,关节活动不受限,积分减少≥70%,﹤95%;有效:疼痛、 症状基本消除,关节活动轻度受限,积分减少≥30%,﹤70%;无效:疼痛、肿胀症状与关节活动无明显改善,积分减少﹤30。注:疼痛、肿胀、关节活动3项症状/体征为判定指标。注:计算公式(尼莫地平法)为:(治疗前积分-治疗后积分)/治疗前积分×100%。


1.4 统计学分析

应用SPSS 23.0统计软件分析结果。计量资料先进行正态分布检验,若符合正态分布且方差齐性,应用均数±标准差(x±s)的形式进行描述。组间比较采用独立样本t检验(三组及以上采用方差分析);组内不同时间点比较,采用配对样本t检验。计量资料若不符合正态分布,采用中位数(下四分位数,上四分位数),组间比较采用Kruskal-Wallis H检验,采用Bonferroni校正法进行多重比较,组内比较采用wilcoxon秩和检验。计数资料采用频数(百分比)进行描述,组间比较采用卡方。以P≤0.05为差异具有统计学意义。


2 结果

参考临床研究中的排除标准,纳入本研究123例,其中有5例患者先后因为膝痛、腰痛手术治疗;膝痛、腰痛口服止痛药;拔牙使用抗生素,终止试验,脱落。一般资料对比见表1。


表1 四组病例一般资料的比较


四组基线一致,无统计学意义。治疗开始前进行WOMAC骨关节炎指数评分、C反应蛋白检测、中医证候积分分级量化评分,并于20次治疗结束后,重新进行量表评分及检测。经统计分析,数据如下,见表2、3、4。


表2 四组WOMAC骨关节炎指数评分及C-反应蛋白(mg/L)指标的比较


如表2所示,分析如下:


①WOMAC骨关节炎指数:a.治疗前四组间比较,评分无统计学意义(P ≥0.05);b.治疗后四组间比较,评分具有统计学意义(P<0.01);c. 组内对比,治疗后WOMAC骨关节炎指数评分均下降,四组治疗前后比较均具有统计学意义(P<0.01);d.经多重比较发现,瘀血闭阻组与风寒湿痹组评分无统计学意义(P ≥0.05),风寒湿痹组与风湿热痹组评分无统计学意义(P ≥0.05),瘀血闭阻组评分低于风湿热痹组, 具有统计学意义(P<0.05),瘀血闭阻组评分低于肝肾亏虚组, 具有统计学意义(P<0.01), 风寒湿痹组评分低于肝肾亏虚组, 具有统计学意义(P<0.01), 风湿热痹组评分低于肝肾亏虚组, 具有统计学意义(P<0.01)。说明瘀血闭阻组和风寒湿痹组疗效优于肝肾亏虚组,瘀血闭阻组和风寒湿痹组疗效相当。


②C-反应蛋白:a.治疗前四组间比较,评分无统计学意义(P ≥0.05);b.治疗后四组间比较,评分无统计学意义(P ≥0.05);c.组内对比,风寒湿痹组、风湿热痹组、瘀血闭阻组治疗后数值较前降低,但无统计学意义(P ≥0.05)。肝肾亏虚组治疗后数值较前稍有增高,但无统计学意义(P ≥0.05)。


表3 四组中医证候积分评分的比较[分, M(P25,P75)]


如表3所示,分析如下:a.治疗前四组间比较,评分无统计学意义(P ≥0.05);b.治疗后四组间比较,评分具有统计学意义(P<0.01);c.组内对比,治疗后中医证候积分评分均下降,四组治疗前后比较均具有统计学意义(P<0.01);d.经多重比较发现,瘀血闭阻组与风寒湿痹组评分无统计学意义(P ≥0.05),瘀血闭阻组评分低于风湿热痹组, 具有统计学意义(P<0.01),瘀血闭阻组评分低于肝肾亏虚组, 具有统计学意义(P<0.01), 风寒湿痹组评分低于风湿热痹组, 具有统计学意义(P<0.01),风寒湿痹组评分低于肝肾亏虚组, 具有统计学意义(P<0.01), 风湿热痹组评分低于肝肾亏虚组, 具有统计学意义(P<0.01)。说明瘀血闭阻组和风寒湿痹组疗效优于风湿热痹组和肝肾亏虚组,瘀血闭阻组和风寒湿痹组疗效相当。


表4四组中医证候疗效比较


如表4所示,分析如下:治疗后四组患者有效率差异具有统计学意义(P<0.01)。经多重比较发现,风寒湿痹组、风湿热痹组和瘀血闭阻组疗效无差异,(P≥0.05)。说明风寒湿痹组、风湿热痹组和瘀血闭阻组疗效优于肝肾亏虚组,风寒湿痹组、风湿热痹组和瘀血闭阻组疗效相当。


综合WOMAC骨关节炎指数、中医证候积分评分和中医证候疗效比较,鍉圆针系统痧疗对瘀血闭阻组和风寒湿痹组膝痹病疗效最佳。


3 讨论

膝关节骨性关节炎(KOA)发病主要由进行性、局限性关节软骨破坏引发边缘性骨软骨形成、软骨下骨质变密、关节畸形所致。在中医学中属于“膝痹病”、“骨痹”、“痹证”、“痿证”、“鹤膝风”等范畴,患者发病与筋骨失养、肝肾虚亏,风寒湿热外邪侵犯,气机阻滞则湿盛瘀积、经络不通,不通则痛,引发KOA。根据《膝痹病(膝关节骨性关节炎)诊疗方案(2019年版)》,将膝痹病分为四型:风寒湿痹、风湿热痹、瘀血闭阻、肝肾亏虚[1,2,3,4]。


胡广芹教授在临床运用痧疗法治疗膝痹病已十余年,并发明了鍉圆针定量痧疗器。痧疗法可解表祛邪、调畅气血、疏通经络,鍉圆针系统痧疗则整合了刮痧、推拿按摩、点穴、毫针针刺、针刀拨筋、走罐手法的优势,采用点、按、揉、刮、提、捏、揪、扯、吸、拔、拨、摩、擦、搓、拍等不同的操作手法,达到祛除疾病、预防保健等目的的中医外治疗法[8,9,10,11]。本研究采用刮足阳明胃经、足少阳胆经、足太阳膀胱经、足太阴脾经,点按双膝眼,并选取配穴,风寒湿痹证选取关元,温经散寒;风湿热痹症选取血海、曲池、大椎,清利湿热;瘀血闭阻证选取血海、隔俞、太冲,活血通络;肝肾亏虚证选取太溪、肝俞、肾俞,补益肝肾,最终达到通络祛痛的作用[12,13,14,15,16]。


本研究观察鍉圆针系统痧疗对不同证型膝痹病的临床疗效,综合WOMAC骨关节炎指数、中医证候积分评分和中医证候疗效比较,初步提示鍉圆针系统痧疗对瘀血闭阻组和风寒湿痹组膝痹病疗效最佳。分析其原因,考虑痧疗法反复刮拭特定部位皮肤,可以改善局部血液循环,通过改善局部血液循环提高局部组织痛阈,从而减轻疼痛症状[17,18,19,20]。对于瘀血阻滞、寒凝经脉、经络不通所致疼痛,疗效明显。C反应蛋白(CRP)数值反应全身机体状况,干扰因素较多,在本次研究中通过治疗,C反应蛋白(CRP)数值有所改变,但无统计学意义,希望今后能够进一步开展大规模高质量临床研究进一步探讨。


参考文献

[1] 许辉,康冰心,孙松涛,等.膝关节骨性关节炎的中医临床研究进展[J].中医学报,2019,34(10):2124-2129.

[2] 中华医学会风湿病学分会.骨关节炎诊断及治疗指南[J].中华风湿病学杂志,2010,14(6):416-419.

[3] 中华中医药学会.中医骨伤科临床诊疗指南·膝痹病(膝骨关节炎) [J].康复学报,2019,29(3):1-7.

[4] 中华中医药学会骨伤科分会膝痹病(膝骨关节炎)临床诊疗指南制定工作组.中医骨伤科临床诊疗指南·膝痹病(膝骨关节炎)[J]. 康复学报, 2019,(3):1-7.

[5] 胡广芹. 鍉圆九针无创理疗工具[P]. 北京市:CN208851978U, 2019-05-14.

[6] 胡广芹, 高之光. 痧疗器具(一)[P]. 北京:CN304090675S, 2017-03-29.

[7] 杨云,杨婷,胡广芹. 鍉圆针刮痧治疗闭经案[J]. 世界最新医学信息文摘(连续型电子期刊),2021,21(10):301,313.

[8] 胡广芹, 孟向文. 痧疗与罐疗[M]. 北京: 中国中医药出版社, 2016.12: 1.

[9] 叶稳田,易珍,胡广芹,等.鍉圆针定量痧疗术对改善脑卒中后睡眠障碍的临床观察[J].当代医学,2020,26(16):12-14.

[10] 郑娟霞,郑娟丽,张慧敏,等. 虎符铜砭刮痧治疗膝痹的效果研究[J]. 护理研究,2019,33(20):3636-3638.

[11] 兰玉兰,黄云,黄利娟,等. 中医特色护理联合鍉圆针定量痧疗术治疗周围性面瘫的临床观察[J]. 全科护理,2021,19(19):2692-2694.

[12] 方涛,周晓红,等.循经刮痧联合针刺治疗内侧间室膝骨关节炎[J].中医正骨,2021,33(10):74-76.

[13] 李继岳,等.综合方法治疗膝关节骨性关节炎床观察[J].实用中医药杂志,2022,38(1):113-114.

[14] 朱婉婷,赵延红,等.毫火针结合铜砭刮痧疗法治疗膝关节骨性关节炎临床观察[J].光明中医,2022,37(4):651-654.

[15] 黄锦庆,等.温针灸配合刮痧疗法治疗膝关节骨性关节炎的临床分析[J].中医临床研究,2021,13(8):97-99.

[16] 朱婉婷,赵延红,于世芳,等. 毫火针结合铜砭刮痧疗法治疗膝关节骨性关节炎临床观察[J]. 光明中医,2022,37(4):651-654.

[17] 李洁,姜荣荣,徐桂华.刮痧法治疗腰椎间盘突出症的研究进展[J].陕西中医,2013,34(1):118-120.

[18] 杨红,王光义,陈晓霞.通阳刮痧疗法对腰椎间盘突出大鼠炎性细胞因子及机体免疫功能的影响[J].中国老年学杂志,2018,38(10)2477-2479.

[19] 李芳,姚建华,段哲萍,等. 不同证型膝骨关节炎患者红细胞免疫功能变化及痹祺胶囊的干预效果研究[J]. 中国全科医学,2016, 19(24):2939-2942.

[20] 张磊,李萌.针刺“膝周十穴”联合痹祺胶囊治疗轻中度膝骨关节炎疗效观察[J].首都食品与医药,2022,29(2):127-129