摘要
研究背景
神经根型颈椎病(Cervical Spondylotic Radiculopathy, CSR)占各型颈椎病的比例约50%-60%,其中患者中80%有根性疼痛。神经根型颈椎病CSR是由于颈椎间盘和周围结构逐渐发生退行性变、骨质增生、或颈椎生理曲线改变后刺激或压迫颈神经引起的一组综合症。
古今中外医学研究CSR病发的病因病机非为单一性,所以对CSR的治疗方式各有不同;有些患者因为疼痛难忍而选择借助于消炎镇痛类止痛药物来缓解疼痛症状,但缺点是大多具有一定的副作用,而且复发率极高：因为颈部结构复杂部位重要,是众多重要神经、血管、中枢系统通过的部位,是牵一发动全身的关键部位,所以CSR患者若寻求手术疗法,即对医生的技术水平要求相当高,因为手术稍有不慎,就会造成瘫痪等无法挽回的后患;更因为颈椎病是一种退行性改变疾病,即使经过手术治疗还是无法达到一劳永逸的效果。目前,对于神经根型颈椎病的临床治疗,除了少数有典型手术指征的患者采用手术疗法及微创手术外,大多数患者仍倾向于采用非手术治疗。
临床研究观察神经根型颈椎病CSR发病特点是发病较慢,且容易反复发作;病发的年龄也愈呈年轻趋势,发病高危险群集中在长期曲颈工作的白领及手机计算机低头族,每年来院就诊人数日益增多,高占疼痛门诊治疗的人数比例,而接受不当的治疗或长期未愈转诊而来的也不在少数。
所以在本人在多年的临床实践中,继承导师赖新生教授在《灵枢.官针》古典针法针刺镇痛的思想及多年临床经验的基础上,希望在传统中医疗法中寻找一种方法,一种可帮助患者有效而迅速的控制该疾病的临床症状,改善患者的生活质量及恢复生活的机能的综合性疗法
研究目的
研究探讨《灵枢.官针篇》中专治骨痹病症的古典针法之短刺输刺法,结合脊柱矫正手法治疗神经根型颈椎病的临床疗效及综合疗法的疗效机制,并且比较针推并用、单针刺、非侵入性单手法治疗神经根型颈椎病的临床疗效及之间的疗效及应用差异性,探索治疗神经根型颈椎病具有疗效巩固、临床疗效显着、安全性高的综合疗法,期能找出值得推广的非手术性、价廉、效速、免药物、少副作用以及低复发率的治疗方法,以提供指导临床应用。
研究方法
本研究选取于2011年9月至2012年12月在台湾新北市吉仁医院、台北市正记中医诊所及广州中医药大学附设医院针灸科门诊确诊的患者,根据纳入标准和排除标准,选取神经根型颈椎病患者共120例。
根据入院顺序,按完全随机设计的方法分为治疗组A和对照组B、C两组共三组,每组各40例。治疗组A疗法是采用短刺输刺法结合脊柱矫正手法,而对照组B是采用单纯短刺输刺法疗法,至于对照组C则采用单纯脊柱矫正手法疗法。
疗效评定观察比较三组的症状积分,采用神经根型颈椎病的20分法症状与功能量表和疼痛的简化McGill量表作为观察和疗效判定指标,并且以不同证型、复发率追踪、达到相同疗效时治疗的平均次数比较为次观察和疗效判定指标辅助评定疗效。
研究结果
1.本研究治疗组A入组40例,剔除2例,完成38例;对照组B入组40例,剔除1例,完成39例;治疗组C入组40例,剔除2例,完成38例;全部共完成115例。
2.三组病人性别构成情况,经χ2检定,p值为0.892>0.05,故性别分布没有差异无统计学意义,说明两者男女比例无差异。三组病人年龄分布情况,经χ2检定,p值为0.314>0.05,说明年龄分布没有差异无统计学意义。
3.三组病人治疗前病程分布情况,经χ2检定,p值为0.311>0.05,说明分组内的病程分布没有差异。三组病人治疗前病情分级情况,经χ2检定,p值为0.329>0.05,说明分组内治疗前的病情分级分布没有差异。
4.比较治疗前后临床症状、体征积分差值和改善指数,经K-W检定,p<0.05,三组比较具有显着性差异,说明治疗组更能改善该病患者的临床症状和体征。经两组别分别以Mann-Whitney检定,说明治疗组A比对照组B、C更能改善该病患者的临床症状和体征,其中对照组C优于对照组B。
3.治疗前后疼痛评分比较结果,与对照组相比,经K-W检定,p<0.05,三组比较具有显着性差异。经两组别分别以Mann-Whitney检定,说明治疗组A比对照组B、C更能改善该病患者的临床疼痛症状和体征,但其中对照组C优于对照组B。
4.治疗前后疼痛积分差值的比较结果,经K-W检定,p值皆小于0.05,p*<0.05,p**<0.001,三组比较具有显着性差异,说明经过三种不同的治疗方法治疗后,治疗组A对疼痛的不同方面的改善要优于对照组B、C,而对照组C优于对照组B。
5.治疗前后疼痛总分(PRI总分)改善与疗程的关系,经秩和检定,第一疗程与治疗前比较,p<0.05,说明在第一疗程结束后,三种治疗方法对于PRI疼痛总分的改善,治疗组A显着优于治疗组C,治疗组C显着优于治疗组B,说明针推并用的治疗方法能有效降低患者的PRI疼痛总分；与前一疗程相比,p<0.05,说明三种治疗方法皆可使患者于第二疗程结束时之PRI疼痛总分降低,表示三种方法对于患者的疼痛感皆有所改善,且以同期对照患者PRI疼痛总分后,p<0.05,推论治疗组A的患者PRI疼痛总分改善明显优于对照组B、对照组C,表示针推并用的疗法于治疗进程中能给予病患较多的疼痛改善。临床疗效的比较,治疗组A和对照组B、C的优良率分别为100%,71%,97%,经K-W检定,三组临床总体优良率疗效比较具有显着性差异,p<0.05,说明治疗组疗效要优于对照组。
6.临床疗效的比较,治疗组A和对照组B、C的优良率分别为100%,71%,97%,经K-W检定,三组临床总体疗效比较具有显着性差异,p<0.05,说明治疗组疗效要优于对照组。
7.将患者年龄分组后,经K-W检定,四组不同年龄病患之疗效具有显着性差异,P<0.05,故差异有显着性意义,经过治疗分析疗效可以看出,三种疗法对轻壮年患者(年龄<40岁;40～60岁)疗效显着,对年老者疗效较差。
8.经K-W检定不同病程之患者与疗效的关系,p<0.05,说明不同病程之患者在疗效间具有显着性差异,经计算优良率后,发现病程<6月的患者疗效最高,即病程越短,疗效越好。
9.从疗效看,三组疗法均能起效,治疗两个疗程后也都能达到有效、治愈。达到疗效为有效时的平均次数,经K-W检定后达显着差异,p<0.05,表示三种治疗方法治疗患者达到有效的平均次数有显着差异,但达到疗效为有效时的平均次数以治疗组A为最少；以疗效达到治愈的平均次数,以经K-W检定,p<0.05,达显着差异,表示三种治疗方法治疗患者达到治愈效果的平均次数是有差异可比性的,其中以治疗组A为最少,经上述检定结果,可推论以治疗组A的治疗平均次数为最少,治疗疗效较为速效。
10.不同证型与三组疗效的关系,以K-W检定,风寒湿型、痰瘀阻络、气滞血瘀、气血亏虚各型之间疗效比较,无显着性差异,x2值分别为8.801(p>0.05)、31.505(p<0.05)、6.209(p>0.05),表示不同证型患者在分别施以三种不同疗法之后,治疗组A和对照组C在组内的疗效得分无无显着性差异,在对照组B中,肝肾不足之证型患者,在疗效的得分上显着低于其他各组,进一步分析肝肾不足型的患者在三种治疗方法之疗效得分,以K-W检定后,具有显着性差异,x2值为17.455,p<0.05,表示肝肾不足型患者经施以对照组B疗法后的疗效较差,说明三组不同疗法中,针灸治疗于肝肾不足型之病患可能疗效较差。
11.三组复发病率比较,以K-W检定,p=0.012**<0.05,表示三组疗法的复发率,具有显着性差异,其中治疗组B最容易复发。
结论
本研究结果显示,三组疗法治疗神经根型颈椎病的效果皆有良好的疗效,并且说明治疗CSR病患年龄越小、病程愈短疗效越好。研究中所建立的短刺输刺法结合脊柱矫正手法治疗神经根型颈椎病CSR具有很好的疗效,具有高疗效、低疗程疗次、低复发率、不分证型的特点。综合疗法发挥了各种疗法的协同作用,临床疗效显着,提高及巩固了疗效,各方面的疗效皆优于单纯针刺及单纯脊柱矫正手法治疗本病,可供临床应用及指导推广。
Study Background
Cervical spondylotic radiculopathy CSR accounted for theproportion of each type of cervical spondylosis about50%-60%, with80%of patients with radicularpain. CSR cervical radiculopathy due to cervical disc and surrounding structures gradually degeneration, osteoarthritis, or cervical curve after changing the cervical nerve irritation or compression syndrome caused by a group.
Ancient and modern medical research CSR disease path ogenesis not for unity, so the treatment of CSR in different ways; some patients because of pain and the choice of means of anti-inflammatory analgesicpain medications to relievepain, but the drawback is Most have some side effects, and high relapse rate; because important parts of the complex structure of the neck, is one of many important nerves, blood vessels, the central nervous system through the site, is topull one of the keyparts of the body, so if CSR patients seek surgical therapy, it's technical standards for doctors is very high, because the surgery slightest mistake, it will cause irreversible paralysis and other troubles; also because of changes in cervical disease is a degenerative disease, even after surgery or the effect can not be achieved once and for all. Currently, the CSR clinical treatment, except for a few patients with typical indications for surgery and minimally invasive surgery using surgical therapy, most patients still prefer non-surgical treatment.
Clinical studies of CSR disease is characterized by slower onset, and easy to repeated attacks; disease showed a younger age are more trends, the incidence of high-risk groups concentrated in white-collar work long curved neck bow and mobile computer family, the annual increasing the number of visits to the hospital, the high number of people accounted for theproportion of outpatient treatment of pain, while receiving inappropriate treatment or referral from long-healed are also many.
In my so much years of clinical practice, inherited mentor professor LAI Xin-sheng " Lingshu. Officer pin papers" classical needle acupuncture analgesia thought and clinical-experience in many years, based on the traditional Chinese medicine to find a way one kind treatment can help patients effectively and efficiently control the clinical symptoms of the disease, improve the patient's quality of life and restore the function of living CSR treatment achieved good results, especially in addressing the CSR root pain, the effect is very good; then in the tutor under the guidance of professor LAI Xin-sheng, in order to obtain a more comprehensive treatment, so on the classical clinical acupuncture combined Chiropractic techniques of integrated therapy
Objective
Study investigated the " Lingshu. Officer pin papers "cures illnesses Gubi classical acupuncture needling of Short spines method and Transmission spines method, corrective spinal manipulative therapy combined with Chiropractic clinical efficacy and mechanism of combination therapy efficacy and compared with push-pin, single needle, non-invasive technique single Chiropractic treatment of clinical efficacy and the difference between the efficacy and application, exploratory treatment of CSR has the effect of the consolidation, significant clinical efficacy, safety of the combination therapy, hoping identify worthy non-surgical, inexpensive, effective speed, free drugs, fewer side effects and a low recurrence rate treatments toprovide clinical applications.
Methods
Duiring theperiod of September2011to December2012, we selected120simple CSRpatients who accepted treatment in New Taipei City, Taiwan, Ren Ji Hospital.. Taipei Ching Kee Chinese Medicine Clinic and Hospital of Guangzhou University of Traditional Chinese acupuncture clinic。
According to the inclusion and exclusion criteria, Under hospital's order, according to a completely randomized design methods into the treatment group A and group B, C groups of three groups of40each. A treatment group therapy is the use of acupuncture method of Short spines and Transmission spines method combined with Chiropractic, while the control group B is the use of acupuncture method of Short spines and Transmission spines needling therapy, group C is used as a simple Chiropractic.
The evaluation observed and compared three groups of symptom score, using the CSR20points symptoms and functional scale and simplify the McGillpain scale observation and therapeutic efficacy as indicators, and with different syndromes, the recurrence rate tracking, reaching the same treatment efficacy when compared to the average number of observations and determine the efficacy of secondary indicators evaluated.
Results
In this study, the treatment group A into the group of40cases, excluding two cases, the completion of38cases; control group B into the group of40cases, excluding one case, the completion of39cases; treatment group C into the group of40cases, excluding two cases, the completion of38cases; All completed a total of115cases.
Gender composition of the three groups of patients, the x2test, p value0.892>0.05, so no difference in gender distribution was not statistically significant, indicating no difference in theproportion of both men and women. Three groups of patients age distribution, the x2test, p value0.314>0.05, indicating no difference in age distribution was not statistically significant.
Three groups of patients before treatment duration distribution, the x2test, p value0.311>0.05, indicating the duration of the distribution group no difference. Three groups of patients before treatment, disease classification case, the x2test, p value0.329>0.05, indicating thatpre-treatment of the disease within thepacket classification distribution did not differ.
Comparative clinical symptoms, signs and improving indexpoints difference, the K-W test,p<0.05, three groups have significant difference, indicating that the treatment group improved more clinical disease signs and symptoms. The two groups respectively, Mann-Whitney test, indicating that the treatment group A than in the control group, B, C can better improve disease clinical symptoms and signs, which the control group than the control group C、B.
Pain scores before and after treatment comparison results, compared with the control group, the K-W test, p<0.05, three groups have significant difference. The two groups respectively, Mann-Whitney test, indicating that the treatment group A than in the control group B、C can better improve clinical disease signs and symptoms ofpain, but the control group than the control group C、B.
Difference in pain scores before and after treatment comparison results, the K-W test, p values were less than0.05,p*<0.05,p**<0.001, compared three groups had significant difference, indicating three different treatments after treatment, the treatment group A on different aspects of improvement ofpain is superior to the control group B、C, the control group C than the control group B.
Before and after treatmentpain score to improve the relationship with the treatment by rank test, the first course of treatment compared with before treatment, p<0.05, described in the first course of treatment after three treatments forpain scorepRI improvement in the treatment group A was significantly better than the treatment group C, the treatment group C was significantly better than the treatment group B, description and use of Acupuncture treatments can effectively reduce the patient'spain scorepRI; compared with theprevious course of treatment, p <0.05, indicating three treatments can makepatients at the end of the second course ofpRIpain score decreased, which means that three methods forpain patients have been improved, and the controlpatients in the sameperiodpain score after the PRI,p <0.05, Corollary treatment group ApatientspRIpain score improved significantly better than the control group B, group C, and use the needle topush theprocess of therapy in the treatment of patients can be given morepain relief.
Clinical efficacy in the treatment group A and group B、C excellent rates were100%,71%,97%, the K-W test, three groups compare the clinical efficacy of the overall satisfactory rate was a significant difference, p<0.05, To illustrate the treatment group than the control group.
Clinical efficacy in the treatment group A and group B、C excellent rates were100%,71%,97%, the K-W test, three groups compared with the overall efficacy of clinical significant difference,p<0.05, indicating that the treatment group efficacy is superior to the control group.
The patient's age group, after K-W test, four groups of patients of different ages with significant efficacy difference, p<0.05, so the difference was statistically significant, it can be seen after treatment efficacy analysis, three kinds of therapy young adultspatients (aged<40years;40to60years) a significant effect on the elderly are less effective.
The K-W test the efficacy of different duration of the relationship with the patient, p<0.05, illustrate different course of treatment amongpatients with significant differences in the calculated good rate, we found that duration<6months of the highest efficacy in patients that shorter duration the better the effect.
From efficacy perspective, three groups therapy can take effect, after two courses of treatment to achieve effective cure. Achieve the effect of the average number of active,-the K-W after significant difference test,p<0.05, which means that patients treated with three treatments to achieve effective average number of significant differences, but achieve the effect of the average number of effective to treat A group of at least; to effect a cure, the average number of times, based on the K-W test,p<0.05, significant difference, which means that patients treated with three treatment methods to cure the effect of differences in the average number is comparable, in which treatment A group of at least, after the above test results, the treatment group A corollary to the average number of treatments for a minimum of treatment efficacy is quick.
Group with three different syndromes efficacy relationships to K-W test, wind cold type, phlegm and blood stasis, qi stagnation, blood deficiency efficacy differences between various types, no significant difference, x2values were8.801(p>0.05),31.505(p<0.05),6.209(p>0.05), which means that different syndromes patients were treated with three different therapies, the treatment group A and group C in the group efficacy score Nil significant differences in the control group B, the liver and kidney deficiency syndromepatients in the efficacy scores were significantly lower than other groups, further analysis of liver and kidney insufficiency of patients in the three treatment methods efficacy score to K-W test, we have significant differences, x2value of17.455, p<0.05, which means that patients with renal insufficiency subjected to the control group B after treatment less effective, indicating three different therapies, acupuncture treatment in liver and kidney insufficiency may be less effective in patients.
Three groups of patients relapse rate compared to K-W test, p=0.012**<0.05, which means that the recurrence rate of three groups of therapy, with a significant difference between the treatment group B most likely to relapse.
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