毫火针配合康复训练治疗肱骨外上髁炎的临床观察
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摘要
背景：
肱骨外上髁炎,俗称网球肘,是以肘部外侧筋肉局部微热、压痛,作伸腕握物并前臂旋后活动时肱骨外上髁部疼痛等为主要表现的慢性损伤性疾病。根据临床统计,患肱骨外上髁炎之肘痛患者多为40岁左右之中年人,其人群中的流行率是1%-3%,最高发病率发生在40-50岁,在42～46岁的女人中,发病率可增加到10%。随着近现代科技发展,工作、生活模式的不断改变,长时间的面对电脑、伏案工作,运动姿势不良、肘部防护不当等原因导致肱骨外上髁炎出现发病率增高并低龄化的现象。
本病可由手肘突然用力不当而首次诱发,但多数患者起病缓慢,逐渐出现单方向性用力疼痛,患者常在作拿取重物、扭绞毛巾时或提茶壶倒水、扫地等动作时,发生手肘部位的疼痛或剧痛；有的症状轻微时隐时现,经数月或数日可自然痊愈；较重者,可反复发作,为持续性疼痛、手臂无力,甚至持物掉落地上,在前臂旋前伸时,也常因疼痛而活动受限,严重影响患者工作及生活。
现代医学对于肱骨外上髁炎的确切发病机理依然不明确。与其它软组织损伤一样,大多数患者并未进行外科治疗,所以病理材料较少,目前主要有四种学说：微血管神经束卡压学说、伸肌总腱起始部损伤学说、环状韧带创伤性炎症、变性学说、桡神经分支受累学说。普遍被认可的理论为肱骨外上髁肌群附着处局部变性、机化、粘连等,形成无菌性炎症,其病理变化为伸肌总腱的撕裂、瘢痕形成,伸肌总腱下滑囊炎,肱骨外上髁骨膜炎、骨炎,肱桡关节滑膜皱襞增生、肥厚,血管神经束筋膜嵌顿以及环状韧带变性等。而在祖国医学中,《素问·长刺节论》记载：“病在筋,筋挛节痛,不可以行,名曰筋痹”,故肱骨外上髁炎可属于“伤筋”、“痹症”的范畴；因其肘部疼痛,肘关节运动功能障碍,又称为“肘痛”、“肘劳”。中医认为该病主要是慢性劳损所致,多由体质素弱、气血亏虚、风寒湿邪侵袭而瘀阻经筋,致血不荣筋,筋骨失养而发病。并根据病因将其分为风寒阻络、湿热内蕴、气血亏虚三个证型。
治疗方面,中医治疗本病的方法众多,目前主要采用的治疗方法包括：常规针刺、灸法、温针灸、火针、推拿手法、针刀、穴位注射等。其中温针灸疗法结合针刺与灸法,能够起到行气活血、温经通络、改善循环、抗炎止痛的作用。毫火针在火针基础上进行改良,不仅保留火针直接刺激病灶及反射点,迅速消除或改善局部组织病理变化、加快循环和代谢,促进局部修复的特点,更因其针体细、易操作、疼痛少、无交叉感染危险等优势受到患者的接受。
西医学到目前为止尚未有任何一种方法被证明对网球肘绝对有效。目前临床使用最广泛的西医治疗手段为局部注射、封闭治疗,注射药物包括：皮质激素、肉毒杆菌毒素、玻璃酸钠、自体血液制品及组织工程细胞等。该疗法可暂时缓解疼痛,但复发率较高。康复治疗在患者的自我功能恢复过程中有重要的作用,其中以行为干预及功能练习较为重要。Stasinopoulos等研究发现,缓慢渐进的离心运动练习和桡侧腕短伸肌的静力牵拉练习能够有效缓解患者肱骨外上髁疼痛,改善肘部功能,对于患者易于操作练习。且正确的家庭自我练习能够节省患者时间,无需康复医师的治疗与协助,便于患者早期及随时自我治疗。
因此,本研究以风寒阻络、气血亏虚型肱骨外上髁炎患者为研究对象,针对患者肘外侧疼痛及肘关节功能损伤,采用康复训练为基础治疗,探索毫火针与温针灸在缓解患者肘外侧疼痛,改善患者肘部功能等方面的差异,优选临床疗效好、安全性高、简便廉价的复合疗法,并为其临床推广提供理论依据。
目的：
1.通过文献研究,系统归纳总结西医学和中医学对肱骨外上髁炎疾病范畴、流行病学特征、病因病机、临床诊断和治疗的研究概况。
2.通过开展计量学分析,系统总结归纳目前针灸治疗肱骨外上髁炎的热点研究方向、主要治疗手段及其取穴规律等特点,对近三年针灸治疗肱骨外上髁炎方法及取穴进行优选,为临床医生的应用提供依据。
3.通过开展毫火针配合康复训练治疗虚寒型肱骨外上髁炎的临床研究,并与温针灸配合康复训练作比较,观察不同治疗方法干预下患者疼痛缓解情况、症状改善情况、功能提高情况以及随访情况等。
4.为寻找临床防治肱骨外上髁炎的有效、简便、廉价、长效的优化治疗方案提供指导和参考。
方法：
1.文献研究：通过检索中国期刊全文数据库(CNKI,包库)、维普中文期刊数据库(VIP)、万方学术期刊全文数据库(含中华医学会期刊)等数据库,筛选相关文献,分别运用综述、计量学分析的手段分析归纳中医、西医对肱骨外上髁炎的认识、研究及诊疗进展；总结针灸治疗肱骨外上髁炎的主要研究方法、治疗方法及取穴规律。
2.临床研究：严格按照诊断标准、纳入标准和排除标准收集风寒阻络、气血亏虚型肱骨外上髁炎患者120例,根据随机数字表法随机分为毫火针组和温针灸组两组,每组各60例。分别接受毫火针配合康复训练和温针灸配合康复训练治疗。选穴：以阿是穴为主穴,曲池、手三里、合谷为配穴。毫火针组以毫火针针刺阿是穴,配穴采用普通针刺；温针灸组在阿是穴行温针灸,配穴采用普通针刺；康复训练主要包括离心运动练习及桡侧腕短伸肌的静力牵拉练习。针灸治疗间隔2日治疗1次,每周治疗2次,共治疗4周；康复训练周一至周五连续练习5次,周末休息,共进行4周。分别于治疗前、治疗后2周、4周对患者进行评价,主要采用的量表为简化McGill量表(SF-McGill)、肘功能评定表；主要评定指标包括：镇痛效果,临床疗效,治疗前后SF-McGill量表总分及PRI、VAS和PPI项目得分变化,治疗前后肘功能评定表总分及临床症状体征、日常生活项目得分变化,治疗过程中不良事件的发生,以及随访4周时不同训练次数对疗效的影响等。所得数据由专人整理,并采用SPSS22.0统计软件进行统计分析。
结果：
1.文献研究结果：
(1)计量学分析结果：针灸治疗肱骨外上髁炎的文献报道三年分布较均衡,主要集中在广东、浙江、湖北等地进行研究,主要参与研究机构为医院,主要刊登杂志为统计源杂志,报道最多的研究类型为防治措施研究,主要采用的诊断标准和临床疗效标准均为《中医病证诊断疗效标准》,主要采用的治疗方法为刺灸综合法、中医综合疗法、针刺疗法。
(2)取穴规律研究结果：针灸治疗肱骨外上髁炎取穴以局部取穴为主,配合临近取穴与循经取穴,所取穴位以阿是穴使用频次最多,其次为手三里、曲池、合谷；主要以肘关节周围取穴为主；最常用的经脉为手阳明大肠经、手少阳三焦经、手太阴肺经。
2.临床研究结果：
(1)基线指标比较结果：两组患者在性别、年龄、病程和和治疗前SF-McGill总分、肘功能评定总分等方面,比较差异无统计学意义(P>0.05),可认为两组间基线具有可比性。
(2)临床有效率的比较：
①临床疗效比较：毫火针组和温针灸组的总有效率分别为94.83%和88.89%。经Wilcoxon秩和检验,P=0.03,即两组之间具有统计学差异。即毫火针配合康复训练临床疗效显著优于温针灸配合康复训练。
②镇痛效果比较：对两组患者镇痛效果进行比较,毫火针组镇痛效果显效率为56.90%,温针灸组镇痛效果显效率为38.89%,总有效率分别为94.83%和88.89%,Wilcoxon秩和检验后可得P=0.046,显示两组患者镇痛效果有统计学差异,毫火针组镇痛效果明显优于温针组。
(3)治疗前后各观察指标的比较
①SF-McGill量表比较：重复测量方差分析显示随着治疗时间的延长,两组患者SF-McGill量表总分、项目得分均显著降低,且治疗后2周和4周较治疗前均有明显改善(P<0.01)。在治疗后2周和4周两组间比较提示,毫火针组的总分显著低于温针组(P<0.05)。各项目分组间比较提示治疗2周后,毫火针组各项目得分均显著低于温针组；而治疗4周后,毫火针组的VAS、PPI两个项目分显著低于温针组。
②肘功能评定的比较：重复测量方差分析显示随着治疗时间的延长,两组患者肘功能评定量表总分、项目得分均显著升高(P<0.01)；且治疗后2周和4周较治疗前均有明显改善(P<0.05)；但治疗2周后和治疗4周后组间比较差异无统计学意义(P>0.05)。组间比较则发现治疗2周后毫火针组症状体征评分显著高于温针灸组(P<0.01),而温针灸组日常生活评分则显著高于毫火针组(P<0.05)；但治疗4周后两组症状体征、日常生活差异无显著性(P>0.05)。
(4)4周随访期间康复训练次数对各评定项目的影响：
根据治疗后4周的随访记录情况,将患者按康复训练次数分组后,比较各项指标发现,训练次数少于10次,各项目得分随访前后均无显著性差异,大于10次训练的两组,随访前后差异具有显著性。随访4周后,训练15次以上与少于10次比较,各项目得分差异均具有显著性；训练15次以上与10-15次比较,除PRI之外其余项目均有差异；而训练10-15次与少于10次比较,仅肘功能量表总分及日常生活分项目得分差异显著。
(5)不良反应发生情况：
治疗过程中,毫火针组有8例患者配穴普通针刺出针时有出血现象,按压后止血,不影响治疗,未出现晕针、感染、滞针等不良事件。温针灸组有1例患者在首次治疗时出现晕针,经处理后好转,未影响治疗；有6例患者发生出针后出血,按压止血不影响治疗,未出现感染、滞针、烫伤等不良事件。
结论：
本课题通过对针灸治疗肱骨外上髁炎相关文献的分析归纳总结,发现,针灸治疗肱骨外上髁炎的研究在近三年分布较平均,形成热点地区、集中研究防治措施、治疗方法繁多、取穴遵循局部取穴配合临近取穴、循经取穴的规律,初步优选了针灸治疗肱骨外上髁炎治疗方法及取穴,为临床治疗肱骨外上髁炎提供一定的依据。
通过对临床研究数据的处理、分析可知：1.毫火针、温针灸配合康复训练均能有效缓解虚寒型肱骨外上髁炎患者肘部疼痛、改善临床症状和体征以及提高日常生活能力；2.毫火针配合康复训练在缓解虚寒型肱骨外上髁炎患者肘部疼痛方面效果较温针灸显著,且起效较快；3.改善临床症状体征方面,毫火针配合康复训练比温针灸短期效果好,长期疗效相当；4.在日常生活改善方面,温针灸配合康复训练短期疗效优于毫火针,长期疗效相当；5.针灸治疗结束后,坚持规范长期的康复训练能够有效缓肱骨外上髁炎患者遗留疼痛、改善症状体征及提高日常生活能力。
综上,针灸治疗肱骨外上髁炎疗效明显,但方法繁杂且较难规范统一,毫火针结合康复训练与温针灸结合康复训练均能有效提高临床疗效,镇痛、改善患者肘功能；短期观察毫火针善于镇痛、温针灸善于改善肘功能；长期治疗毫火针镇痛效果好,二者改善功能效果相当；坚持长期规范的康复训练自我功能锻炼能够增进临床疗效。加之不良反应少、医疗费用相对较低、操作简便易学、患者主动参与疾病治疗等特点,临床医师可根据医疗环境、患者情况及急迫需要解决之问题选择治疗方案治疗虚寒型肱骨外上髁炎；康复训练自我功能锻炼适于临床推广用于肱骨外上髁炎的预防与治疗。
本课题仍存在一些不足之处：1.未对肱骨外上髁炎患者进行不同辨证分型、单双手病变等分类之间的疗效比较；2.毫火针操作要求较严格,在穴位定位、针刺深度、针刺手法等方面还需进一步规范化；3.未设置单纯康复训练组,比较康复训练配合温针灸和康复训练配合毫火针疗效是否由于单纯康复训练；4.康复训练需要患者配合,需要较高的依从性,在患者依从性及其考察方面还需进一步提高；5.样本量较小,观察指标和评估工具以量表为主,对握力改变以定性评价为主,没有定量评估,故对观察指标和评估工具的选择是否恰当全面还需进一步商榷及完善。
随后可进一步增加研究组别,扩大样本量,进行大样本随机对照试验；进行不同亚组进行比较；寻找提高患者依从性的监督机制；探讨毫火针及康复训练的作用机制。
Background:
Lateral epicondylitis, commonly known as Tennis elbow, is a chronic injury with main clinical manifestations of local eupyrexia and tenderness on elbow lateral brawn, pain on lateral epicondyle of humerus when stretching wrist to grip objects and supinating forearm. According to clinical statistics, middle-aged about40years old often suffered with lateral epicondylitis with elbow pain, the prevalence rate is1%-3%. The highest incidence occurred in40to50years old, in42～46years old woman, the morbidity of this disease can be increased to10%. With the development of modern science and technology, the change of work and life mode, such as a long time work at the desk in front of the computer, the wrong motion and post, the unsuitable protection of elbow are the reasons lead to high morbidity with younger age on lateral epicondylitis.
The disease can be firstly induced by suddenly improper power when using elbow, but most of the patients have a slow onset, gradual pain when exerting single directional force, such as takimg the weight, twisting towel or lifting the teapot to pour water, sweeping the floor, all these actions could induce elbow pain or baryodynia. Some slight symptoms disappearing and reappear could recover naturally after a few months or a few days. Some serious and recurrent symptoms, as persistent pain, arm weakness, even unable to hold things, and restricted movement because of the pain when pronating and protracting the forearm, seriously influenced patient's work and daily life.
The exact pathogenesis in modern medicine for lateral epicondylitis is still unclear. As other soft tissue injuries, most of the patients didn't receive surgical treatment, with collecting less pathological material. At present there are four main theories:microvascular nerve bundle entrapment theory, origin of common extensor tendon damage theory, the annular ligament traumatic inflammation and degeneration theory, branch of radial nerve damage theory. Generally accepted theory is tendon of muscle group attached to lateral epicondyle of humerus degenerated, organized, adhesive, which induced aseptic inflammation. The pathological changes is the tear and scarring of the common extensor tendon, the bursitis below extensor tendon, periostitis and osteitis of lateral epicondyle of humerus, the hyperplasia and hypertrophy of medial plica of humeroradial joint, the fascia incarceration of neurovascular bundle, and the degeneration of annular ligament and so on. In Chinese medicine,"Su Wen (Plain Question)" recorded:"Disease in the tendon, cramps and pain, without movement, called Jin Bi", as lateral epicondylitis could belong to the "Shang Jin","Bi Zheng" category. Because of the elbow pain and elbow joint movement dysfunction, lateral epicondylitis also known as the "Elbow Pain". TCM considered that the disease is mainly caused by chronic labor injury, much by weak habitus, deficiency of qi and blood, wind, cold and damp evil invaded body caused the blood stasis resistance to the tendons. So the blood could not support the tendons, bones and tendons malnutrition induced the disease. Based on the causes, it can be divided into three syndrome types:wind-cold resistance, damp-heat accumulation, deficiency of Qi and blood.
There are lots of TCM treatment methods on lateral epicondylitis, the main adoptive treatment methods include general acupuncture, moxibustion, warm acupuncture, fire needle, Tui na, acupotomy, acupoint injection and so on. The warm acupuncture combined with acupuncture and moxibustion to promote Qi and activate blood, warm and activate meridian, improve circulation, relieve pain by anti-inflammatory. Filiform needle improved by the fire needle, not only retains the direct stimulation of lesions and the reflection point, quickly eliminate or improve local tissue pathological changes, promote the circulation, metabolism, and the local restoration, but also be accepted by patients because of its fine needle, easy operation, less pain, without the advantages of the cross infection risk.
As so far there is no any kind of method is proved effective for lateral epicondylitis absolutely in modern medicine. Currently the most widely used western medicine clinical treatments for lateral epicondylitis are local injections, local blocking treatment. The injectable drugs include corticosteroids, botulinum toxin, sodium hyaluronate, autologous blood and tissue engineering cells, etc. This therapy could relieve pain temporarily, but the recurrence rate is higher. Rehabilitation therapy has an important role in the process of functional recovery in patients with self-practice and behavioral interventions and functional exercises are more important. The study by Stasinopoulos D found that the slow and gradual centrifugal movement exercises and extensor carpi radialis brevis static tractive exercises could effectively relieve lateral epicondyle of humerus pain and improve the elbow function, and easy to practice for patients. Correct family self-exercise could save patients' time, without treating and assisting by rehabilitation physicians. It's advantageous for the patients with early and self-treatment at any time.
Based on this, we have studied on the lateral epicondylitis patients receiving rehabilitation training as basic treatment, comparing filiform needle and worm needle by observing the improvement of clinical effect, analgesic effect and the elbow function, to provide clinical evidence for treating this disorder with more effect, safe and easy therapy.
Objective:
1. To sum up all the literatures about the lateral epicondylitis to analyse its category, epidemiological characterstics, pathophysiological mechanisms, pathogenesis, clinical diagnosis and treatment both of Western medicine and TCM.
2. To sum up the characteristics of hot research direction, the main treatment and the rules of acupoints selection on the lateral epicondylitis treated with acupuncture by bibliometric analysis. To preliminarily built methods and acupoints selection databases for the acupuncture treatments on lateral epicondylitis, to provide the basis for the application by clinical doctors.
3. To observe the relief of pain, the improvement of symptoms and elbow function of the lateral epicondylitis by comparing and analysing filiform needle and worm needle based on rehabilitation training.
4. To find a better therapeutic regimen for treating the lateral epicondylitis in clinic.
Methods:
1. Literature research:Filtrate the literatures about the lateral epicondylitis treated with acupuncture and acupuncture combined with other therapies through searching several databases, such as the CNKI, the VIP, the WanfangData and so on. Analyze the hot research direction, the main treatment and the rules of acupoints selection on the lateral epicondylitis treated with acupuncture by bibliometric analysis. And conclude the development of lateral epicondylitis in both Western medicine and TCM.
2. Clinical research:120cases of lateral epicondylitis patients gathered strictly according to the inclusion criteria and the exclusion criteria were randomly divided into2groups. Each group including60patients received rehabilitation training combined with filiform needle and worm needle respectively. A-shi point was selected as the main acupoint, Quchi (LI11), Shousanli (LI10), Hegu (LI4) as the assistant acupoints. The main acupoint was operated by filiform needle and worm needlerespectively in2groups with common needling in assistant points.The rehabilitation training included the slow and gradual centrifugal movement exercises and extensor carpi radialis brevis static tractive exercises. All the patients were treated for4weeks, with4weeks follow-up. The short-form of McGill scale (SF-McGill) and the elbow functional assessment before and2,4week after treatment were evaluated. The main indicators included:analgesic effect, the clinical curative effect, the total score of the SF-McGill and PRI, VAS and PPI projects scores change before and after treatment, the total score of the elbow functional assessment and clinical symptoms and signs, daily life function item scores change before and after treatment, adverse events occurred in the process of treatment, the affect of rehabilitation training or not in4weeks follow-up and so on. Specially assigned persons performed all data analysis with the software SPSS22.0.
Results:
1. Results of literature research:
(1) Results of bibliometric analysis:The distribution of the number of the reported literatures about treatment for lateral epicondylitis with acupuncture is balanced in the recent3years. The researches are mainly carried out in hospitals located in Guangdong, Zhejiang and HubeiProvinces. The literatures are principally published in statistical source magazines with the prevention and treatment control measures asthe most reported research type.Themost criterions of diagnosis and therapeutical effect are "Disease of TCM syndrome diagnosis curative standard".The mainly adopted methods in these researches are acupuncture and moxibustion, comprehensive methods of Chinese traditional medicine and integrative therapy of Chinese and Western medicine.
(2) The result of rules of selecting points:Acupoints in treating lateral epicondylitis were selected from the local pain points and according to the meridians. The most often used meridians were the Large Intestine Meridian of Hand-Yangming, the Sanjiao Meridian of Hand-Shaoyang, and the Lung Meridian of Hand-Taiyang. The most frequently selected acupoint was A-shi point, located at the elbow part. Other points used frequently were Shousanli (LI10), Quchi (LI11), Zhouliao (LI12),Chize (LU5),Hegu (LI4),Waiguan (SJ5),Zhongzhu (SJ3), which all around the elbow.
2. Results of clinical research:
(1) Results of the baseline index:There were no significant differences from the gender composition, the aging, the total scores of SF-McGill and the elbow functional assessment between the2groups (P>0.05), so the data of the2groups could be compared.
(2) Comparison of the clinical effect
①Result of clinical efficacy:The total clinical effective rate of2groups was94.83%in filiform needle group and88.89%in worm needle group respectively, the difference between groups was significant(P=0.03), by Wilcoxonrank sum test.
②Result of analgesic effect:The analgesic effective rate of2groups was56.90%in filiform needle group and38.89%in worm needle grouprespectively, and the total analgesic effective rate was94.83%a nd88.89%, the difference between groups is significant(P=0.046), by Wilcoxonrank sum test.
(3) Comparison of observational indexes before and after treatment
①Result of the improvement of the SF-McGill scale:Repeated ANOVA of intra-group comparison was taken in112patients, the result showed thatboth2therapies could reduce the SF-McGill scores significantly as the extension of treatment time, comparation between each time point showed that the SF-McGilltotal score at2weeks and4weeks after treatment was both lower than the score before treatment (P<0.01). Individual Sample T test was performed in the analysis of inter-group comparison, and the results showed significant difference between2groups on reduction of the SF-McGill scores at2and4weeks after treatment (P<0.05). The comparison of item scores of the SF-McGill showed that both2therapies could reduce the PRI, VAS and PPI item scores significantly, and the reduction of filiform needle combined with rehabilitation training was significantly better than worm needle combined with rehabilitation training at2weeks after treatment. At4weeks after treatment the VAS and PPI scores was significantly different between2groups(P<0.05).
②Result of the improvement of the elbow functional assessment:Repeated ANOVA of intra-group comparison showed significant difference between2groups on the total scores of the elbow functional assessment and clinical symptoms, clinical signs, daily life function item scoresas the extension of treatment time (P<0.05). Moreover, the improvement of clinical symptoms and clinical signs in filiform needle group was significantly better than worm needle group, but not the improvement ofthe elbow functionat2weeks after treatment (P<0.05). There was no significant difference between2groups at4weeks after treatment (P>0.05).
(4) Result of the recurrence during4weeks follow-up after treatment:
Following up the frequency rehabilitation training for4weeks, the patients were devided into3groups as:<10times,10-15times,>15times. After analysis of all the indexes before and after follow up, we found there was difference for the other2group training more than10times, but not the group training less than10 times between before and after follow-up. Training more than15times could significantly improve the elbow function and reduce the pain of elbow than that taining less than10times.
(5) Result of the adverse reactions:
There were some adverse reactions, such as pain when needling, and feeling faints when needling in both2groups. Eight patients in filiform needle group felt bleeding for common acupuncture but not affect the treatment,1patient in worm needle group felt faintng during acupuncture,6patients felt bleeding. There was no hematoma, banding needle or sticking of needle, and empyrosis in both2groups.
Conclusions:
By systematically summarizing the related literatures in this project, we find that the distribution of the number of the reported literatures is balanced in recent3yearsand the hot spots aresought out with the main methods of prevention and treatment. There are various therapeutic methods on the acupoints selected by the rulesof selecting local pain points or according to the meridians. We preliminarily established a database about therapeutic methods of lateral epicondylitis and rules of selecting points for the treatment in clinical.
The clinical research data and analysis shows:1. All the filiform needle and worm needle combined with rehabilitation training therapy can effectively relieve the elbow pain, improve the clinical symptoms and signs, and elbow function in the lateral epicondylitis patients.2. The relief of pain by filiform needle combined with rehabilitation training therapy is better and faster than worm needle combined with rehabilitation training therapy.3. The improvement of clinical symptoms and signsby filiform needle combined with rehabilitation training therapy is better and faster than worm needle combined with rehabilitation training therapy, but not for long time.4. The improvement of elbow function in daily life byworm needle combined with rehabilitation training group is better than filiform needle combined with rehabilitation training therapy, but not for long time.5. After acupuncture treatment, long time and normative training could effectively improve the symptoms and signs, and elbow function in the follow-up.
In conclusion, curative effect on acupuncture treating lateral epicondylitis is significantly, but the methods are various and more difficult to standardize. Both filiform needle and worm needle combined with rehabilitation training therapy not only can improve the clinical efficacy, strengthen the analgesia effect, improve the function of elbow vertebrae, prevent disease recurrence, but also has less adverse reactions, low medical costs, unified standard, easy operation and the active participation of patient. Therefore, the physicians should use suit therapy by medical condition, patients' needin clinical to prevent and treat the lateral epicondylitis.
But there is still some weakness in our clinical research, for example, the small sample size, the operation of filiform needle, the obedience of patients, the selecting of measuring scale and questionnaire. In the future, we would mend our weakness above, enlarge the sample size and take a further study on mechanism of filiform needle combined with rehabilitation training therapy treating the lateral epicondylitis.
肱骨外上髁炎,俗称网球肘,是以肘部外侧筋肉局部微热、压痛,作伸腕握物并前臂旋后活动时肱骨外上髁部疼痛等为主要表现的慢性损伤性疾病。根据临床统计,患肱骨外上髁炎之肘痛患者多为40岁左右之中年人,其人群中的流行率是1%-3%,最高发病率发生在40-50岁,在42～46岁的女人中,发病率可增加到10%。随着近现代科技发展,工作、生活模式的不断改变,长时间的面对电脑、伏案工作,运动姿势不良、肘部防护不当等原因导致肱骨外上髁炎出现发病率增高并低龄化的现象。
本病可由手肘突然用力不当而首次诱发,但多数患者起病缓慢,逐渐出现单方向性用力疼痛,患者常在作拿取重物、扭绞毛巾时或提茶壶倒水、扫地等动作时,发生手肘部位的疼痛或剧痛；有的症状轻微时隐时现,经数月或数日可自然痊愈；较重者,可反复发作,为持续性疼痛、手臂无力,甚至持物掉落地上,在前臂旋前伸时,也常因疼痛而活动受限,严重影响患者工作及生活。
现代医学对于肱骨外上髁炎的确切发病机理依然不明确。与其它软组织损伤一样,大多数患者并未进行外科治疗,所以病理材料较少,目前主要有四种学说：微血管神经束卡压学说、伸肌总腱起始部损伤学说、环状韧带创伤性炎症、变性学说、桡神经分支受累学说。普遍被认可的理论为肱骨外上髁肌群附着处局部变性、机化、粘连等,形成无菌性炎症,其病理变化为伸肌总腱的撕裂、瘢痕形成,伸肌总腱下滑囊炎,肱骨外上髁骨膜炎、骨炎,肱桡关节滑膜皱襞增生、肥厚,血管神经束筋膜嵌顿以及环状韧带变性等。而在祖国医学中,《素问·长刺节论》记载：“病在筋,筋挛节痛,不可以行,名曰筋痹”,故肱骨外上髁炎可属于“伤筋”、“痹症”的范畴；因其肘部疼痛,肘关节运动功能障碍,又称为“肘痛”、“肘劳”。中医认为该病主要是慢性劳损所致,多由体质素弱、气血亏虚、风寒湿邪侵袭而瘀阻经筋,致血不荣筋,筋骨失养而发病。并根据病因将其分为风寒阻络、湿热内蕴、气血亏虚三个证型。
治疗方面,中医治疗本病的方法众多,目前主要采用的治疗方法包括：常规针刺、灸法、温针灸、火针、推拿手法、针刀、穴位注射等。其中温针灸疗法结合针刺与灸法,能够起到行气活血、温经通络、改善循环、抗炎止痛的作用。毫火针在火针基础上进行改良,不仅保留火针直接刺激病灶及反射点,迅速消除或改善局部组织病理变化、加快循环和代谢,促进局部修复的特点,更因其针体细、易操作、疼痛少、无交叉感染危险等优势受到患者的接受。
西医学到目前为止尚未有任何一种方法被证明对网球肘绝对有效。目前临床使用最广泛的西医治疗手段为局部注射、封闭治疗,注射药物包括：皮质激素、肉毒杆菌毒素、玻璃酸钠、自体血液制品及组织工程细胞等。该疗法可暂时缓解疼痛,但复发率较高。康复治疗在患者的自我功能恢复过程中有重要的作用,其中以行为干预及功能练习较为重要。Stasinopoulos等研究发现,缓慢渐进的离心运动练习和桡侧腕短伸肌的静力牵拉练习能够有效缓解患者肱骨外上髁疼痛,改善肘部功能,对于患者易于操作练习。且正确的家庭自我练习能够节省患者时间,无需康复医师的治疗与协助,便于患者早期及随时自我治疗。
因此,本研究以风寒阻络、气血亏虚型肱骨外上髁炎患者为研究对象,针对患者肘外侧疼痛及肘关节功能损伤,采用康复训练为基础治疗,探索毫火针与温针灸在缓解患者肘外侧疼痛,改善患者肘部功能等方面的差异,优选临床疗效好、安全性高、简便廉价的复合疗法,并为其临床推广提供理论依据。
目的：
1.通过文献研究,系统归纳总结西医学和中医学对肱骨外上髁炎疾病范畴、流行病学特征、病因病机、临床诊断和治疗的研究概况。
2.通过开展计量学分析,系统总结归纳目前针灸治疗肱骨外上髁炎的热点研究方向、主要治疗手段及其取穴规律等特点,对近三年针灸治疗肱骨外上髁炎方法及取穴进行优选,为临床医生的应用提供依据。
3.通过开展毫火针配合康复训练治疗虚寒型肱骨外上髁炎的临床研究,并与温针灸配合康复训练作比较,观察不同治疗方法干预下患者疼痛缓解情况、症状改善情况、功能提高情况以及随访情况等。
4.为寻找临床防治肱骨外上髁炎的有效、简便、廉价、长效的优化治疗方案提供指导和参考。
方法：
1.文献研究：通过检索中国期刊全文数据库(CNKI,包库)、维普中文期刊数据库(VIP)、万方学术期刊全文数据库(含中华医学会期刊)等数据库,筛选相关文献,分别运用综述、计量学分析的手段分析归纳中医、西医对肱骨外上髁炎的认识、研究及诊疗进展；总结针灸治疗肱骨外上髁炎的主要研究方法、治疗方法及取穴规律。
2.临床研究：严格按照诊断标准、纳入标准和排除标准收集风寒阻络、气血亏虚型肱骨外上髁炎患者120例,根据随机数字表法随机分为毫火针组和温针灸组两组,每组各60例。分别接受毫火针配合康复训练和温针灸配合康复训练治疗。选穴：以阿是穴为主穴,曲池、手三里、合谷为配穴。毫火针组以毫火针针刺阿是穴,配穴采用普通针刺；温针灸组在阿是穴行温针灸,配穴采用普通针刺；康复训练主要包括离心运动练习及桡侧腕短伸肌的静力牵拉练习。针灸治疗间隔2日治疗1次,每周治疗2次,共治疗4周；康复训练周一至周五连续练习5次,周末休息,共进行4周。分别于治疗前、治疗后2周、4周对患者进行评价,主要采用的量表为简化McGill量表(SF-McGill)、肘功能评定表；主要评定指标包括：镇痛效果,临床疗效,治疗前后SF-McGill量表总分及PRI、VAS和PPI项目得分变化,治疗前后肘功能评定表总分及临床症状体征、日常生活项目得分变化,治疗过程中不良事件的发生,以及随访4周时不同训练次数对疗效的影响等。所得数据由专人整理,并采用SPSS22.0统计软件进行统计分析。
结果：
1.文献研究结果：
(1)计量学分析结果：针灸治疗肱骨外上髁炎的文献报道三年分布较均衡,主要集中在广东、浙江、湖北等地进行研究,主要参与研究机构为医院,主要刊登杂志为统计源杂志,报道最多的研究类型为防治措施研究,主要采用的诊断标准和临床疗效标准均为《中医病证诊断疗效标准》,主要采用的治疗方法为刺灸综合法、中医综合疗法、针刺疗法。
(2)取穴规律研究结果：针灸治疗肱骨外上髁炎取穴以局部取穴为主,配合临近取穴与循经取穴,所取穴位以阿是穴使用频次最多,其次为手三里、曲池、合谷；主要以肘关节周围取穴为主；最常用的经脉为手阳明大肠经、手少阳三焦经、手太阴肺经。
2.临床研究结果：
(1)基线指标比较结果：两组患者在性别、年龄、病程和和治疗前SF-McGill总分、肘功能评定总分等方面,比较差异无统计学意义(P>0.05),可认为两组间基线具有可比性。
(2)临床有效率的比较：
①临床疗效比较：毫火针组和温针灸组的总有效率分别为94.83%和88.89%。经Wilcoxon秩和检验,P=0.03,即两组之间具有统计学差异。即毫火针配合康复训练临床疗效显著优于温针灸配合康复训练。
②镇痛效果比较：对两组患者镇痛效果进行比较,毫火针组镇痛效果显效率为56.90%,温针灸组镇痛效果显效率为38.89%,总有效率分别为94.83%和88.89%,Wilcoxon秩和检验后可得P=0.046,显示两组患者镇痛效果有统计学差异,毫火针组镇痛效果明显优于温针组。
(3)治疗前后各观察指标的比较
①SF-McGill量表比较：重复测量方差分析显示随着治疗时间的延长,两组患者SF-McGill量表总分、项目得分均显著降低,且治疗后2周和4周较治疗前均有明显改善(P<0.01)。在治疗后2周和4周两组间比较提示,毫火针组的总分显著低于温针组(P<0.05)。各项目分组间比较提示治疗2周后,毫火针组各项目得分均显著低于温针组；而治疗4周后,毫火针组的VAS、PPI两个项目分显著低于温针组。
②肘功能评定的比较：重复测量方差分析显示随着治疗时间的延长,两组患者肘功能评定量表总分、项目得分均显著升高(P<0.01)；且治疗后2周和4周较治疗前均有明显改善(P<0.05)；但治疗2周后和治疗4周后组间比较差异无统计学意义(P>0.05)。组间比较则发现治疗2周后毫火针组症状体征评分显著高于温针灸组(P<0.01),而温针灸组日常生活评分则显著高于毫火针组(P<0.05)；但治疗4周后两组症状体征、日常生活差异无显著性(P>0.05)。
(4)4周随访期间康复训练次数对各评定项目的影响：
根据治疗后4周的随访记录情况,将患者按康复训练次数分组后,比较各项指标发现,训练次数少于10次,各项目得分随访前后均无显著性差异,大于10次训练的两组,随访前后差异具有显著性。随访4周后,训练15次以上与少于10次比较,各项目得分差异均具有显著性；训练15次以上与10-15次比较,除PRI之外其余项目均有差异；而训练10-15次与少于10次比较,仅肘功能量表总分及日常生活分项目得分差异显著。
(5)不良反应发生情况：
治疗过程中,毫火针组有8例患者配穴普通针刺出针时有出血现象,按压后止血,不影响治疗,未出现晕针、感染、滞针等不良事件。温针灸组有1例患者在首次治疗时出现晕针,经处理后好转,未影响治疗；有6例患者发生出针后出血,按压止血不影响治疗,未出现感染、滞针、烫伤等不良事件。
结论：
本课题通过对针灸治疗肱骨外上髁炎相关文献的分析归纳总结,发现,针灸治疗肱骨外上髁炎的研究在近三年分布较平均,形成热点地区、集中研究防治措施、治疗方法繁多、取穴遵循局部取穴配合临近取穴、循经取穴的规律,初步优选了针灸治疗肱骨外上髁炎治疗方法及取穴,为临床治疗肱骨外上髁炎提供一定的依据。
通过对临床研究数据的处理、分析可知：1.毫火针、温针灸配合康复训练均能有效缓解虚寒型肱骨外上髁炎患者肘部疼痛、改善临床症状和体征以及提高日常生活能力；2.毫火针配合康复训练在缓解虚寒型肱骨外上髁炎患者肘部疼痛方面效果较温针灸显著,且起效较快；3.改善临床症状体征方面,毫火针配合康复训练比温针灸短期效果好,长期疗效相当；4.在日常生活改善方面,温针灸配合康复训练短期疗效优于毫火针,长期疗效相当；5.针灸治疗结束后,坚持规范长期的康复训练能够有效缓肱骨外上髁炎患者遗留疼痛、改善症状体征及提高日常生活能力。
综上,针灸治疗肱骨外上髁炎疗效明显,但方法繁杂且较难规范统一,毫火针结合康复训练与温针灸结合康复训练均能有效提高临床疗效,镇痛、改善患者肘功能；短期观察毫火针善于镇痛、温针灸善于改善肘功能；长期治疗毫火针镇痛效果好,二者改善功能效果相当；坚持长期规范的康复训练自我功能锻炼能够增进临床疗效。加之不良反应少、医疗费用相对较低、操作简便易学、患者主动参与疾病治疗等特点,临床医师可根据医疗环境、患者情况及急迫需要解决之问题选择治疗方案治疗虚寒型肱骨外上髁炎；康复训练自我功能锻炼适于临床推广用于肱骨外上髁炎的预防与治疗。
本课题仍存在一些不足之处：1.未对肱骨外上髁炎患者进行不同辨证分型、单双手病变等分类之间的疗效比较；2.毫火针操作要求较严格,在穴位定位、针刺深度、针刺手法等方面还需进一步规范化；3.未设置单纯康复训练组,比较康复训练配合温针灸和康复训练配合毫火针疗效是否由于单纯康复训练；4.康复训练需要患者配合,需要较高的依从性,在患者依从性及其考察方面还需进一步提高；5.样本量较小,观察指标和评估工具以量表为主,对握力改变以定性评价为主,没有定量评估,故对观察指标和评估工具的选择是否恰当全面还需进一步商榷及完善。
随后可进一步增加研究组别,扩大样本量,进行大样本随机对照试验；进行不同亚组进行比较；寻找提高患者依从性的监督机制；探讨毫火针及康复训练的作用机制。
Background:
Lateral epicondylitis, commonly known as Tennis elbow, is a chronic injury with main clinical manifestations of local eupyrexia and tenderness on elbow lateral brawn, pain on lateral epicondyle of humerus when stretching wrist to grip objects and supinating forearm. According to clinical statistics, middle-aged about40years old often suffered with lateral epicondylitis with elbow pain, the prevalence rate is1%-3%. The highest incidence occurred in40to50years old, in42～46years old woman, the morbidity of this disease can be increased to10%. With the development of modern science and technology, the change of work and life mode, such as a long time work at the desk in front of the computer, the wrong motion and post, the unsuitable protection of elbow are the reasons lead to high morbidity with younger age on lateral epicondylitis.
The disease can be firstly induced by suddenly improper power when using elbow, but most of the patients have a slow onset, gradual pain when exerting single directional force, such as takimg the weight, twisting towel or lifting the teapot to pour water, sweeping the floor, all these actions could induce elbow pain or baryodynia. Some slight symptoms disappearing and reappear could recover naturally after a few months or a few days. Some serious and recurrent symptoms, as persistent pain, arm weakness, even unable to hold things, and restricted movement because of the pain when pronating and protracting the forearm, seriously influenced patient's work and daily life.
The exact pathogenesis in modern medicine for lateral epicondylitis is still unclear. As other soft tissue injuries, most of the patients didn't receive surgical treatment, with collecting less pathological material. At present there are four main theories:microvascular nerve bundle entrapment theory, origin of common extensor tendon damage theory, the annular ligament traumatic inflammation and degeneration theory, branch of radial nerve damage theory. Generally accepted theory is tendon of muscle group attached to lateral epicondyle of humerus degenerated, organized, adhesive, which induced aseptic inflammation. The pathological changes is the tear and scarring of the common extensor tendon, the bursitis below extensor tendon, periostitis and osteitis of lateral epicondyle of humerus, the hyperplasia and hypertrophy of medial plica of humeroradial joint, the fascia incarceration of neurovascular bundle, and the degeneration of annular ligament and so on. In Chinese medicine,"Su Wen (Plain Question)" recorded:"Disease in the tendon, cramps and pain, without movement, called Jin Bi", as lateral epicondylitis could belong to the "Shang Jin","Bi Zheng" category. Because of the elbow pain and elbow joint movement dysfunction, lateral epicondylitis also known as the "Elbow Pain". TCM considered that the disease is mainly caused by chronic labor injury, much by weak habitus, deficiency of qi and blood, wind, cold and damp evil invaded body caused the blood stasis resistance to the tendons. So the blood could not support the tendons, bones and tendons malnutrition induced the disease. Based on the causes, it can be divided into three syndrome types:wind-cold resistance, damp-heat accumulation, deficiency of Qi and blood.
There are lots of TCM treatment methods on lateral epicondylitis, the main adoptive treatment methods include general acupuncture, moxibustion, warm acupuncture, fire needle, Tui na, acupotomy, acupoint injection and so on. The warm acupuncture combined with acupuncture and moxibustion to promote Qi and activate blood, warm and activate meridian, improve circulation, relieve pain by anti-inflammatory. Filiform needle improved by the fire needle, not only retains the direct stimulation of lesions and the reflection point, quickly eliminate or improve local tissue pathological changes, promote the circulation, metabolism, and the local restoration, but also be accepted by patients because of its fine needle, easy operation, less pain, without the advantages of the cross infection risk.
As so far there is no any kind of method is proved effective for lateral epicondylitis absolutely in modern medicine. Currently the most widely used western medicine clinical treatments for lateral epicondylitis are local injections, local blocking treatment. The injectable drugs include corticosteroids, botulinum toxin, sodium hyaluronate, autologous blood and tissue engineering cells, etc. This therapy could relieve pain temporarily, but the recurrence rate is higher. Rehabilitation therapy has an important role in the process of functional recovery in patients with self-practice and behavioral interventions and functional exercises are more important. The study by Stasinopoulos D found that the slow and gradual centrifugal movement exercises and extensor carpi radialis brevis static tractive exercises could effectively relieve lateral epicondyle of humerus pain and improve the elbow function, and easy to practice for patients. Correct family self-exercise could save patients' time, without treating and assisting by rehabilitation physicians. It's advantageous for the patients with early and self-treatment at any time.
Based on this, we have studied on the lateral epicondylitis patients receiving rehabilitation training as basic treatment, comparing filiform needle and worm needle by observing the improvement of clinical effect, analgesic effect and the elbow function, to provide clinical evidence for treating this disorder with more effect, safe and easy therapy.
Objective:
1. To sum up all the literatures about the lateral epicondylitis to analyse its category, epidemiological characterstics, pathophysiological mechanisms, pathogenesis, clinical diagnosis and treatment both of Western medicine and TCM.
2. To sum up the characteristics of hot research direction, the main treatment and the rules of acupoints selection on the lateral epicondylitis treated with acupuncture by bibliometric analysis. To preliminarily built methods and acupoints selection databases for the acupuncture treatments on lateral epicondylitis, to provide the basis for the application by clinical doctors.
3. To observe the relief of pain, the improvement of symptoms and elbow function of the lateral epicondylitis by comparing and analysing filiform needle and worm needle based on rehabilitation training.
4. To find a better therapeutic regimen for treating the lateral epicondylitis in clinic.
Methods:
1. Literature research:Filtrate the literatures about the lateral epicondylitis treated with acupuncture and acupuncture combined with other therapies through searching several databases, such as the CNKI, the VIP, the WanfangData and so on. Analyze the hot research direction, the main treatment and the rules of acupoints selection on the lateral epicondylitis treated with acupuncture by bibliometric analysis. And conclude the development of lateral epicondylitis in both Western medicine and TCM.
2. Clinical research:120cases of lateral epicondylitis patients gathered strictly according to the inclusion criteria and the exclusion criteria were randomly divided into2groups. Each group including60patients received rehabilitation training combined with filiform needle and worm needle respectively. A-shi point was selected as the main acupoint, Quchi (LI11), Shousanli (LI10), Hegu (LI4) as the assistant acupoints. The main acupoint was operated by filiform needle and worm needlerespectively in2groups with common needling in assistant points.The rehabilitation training included the slow and gradual centrifugal movement exercises and extensor carpi radialis brevis static tractive exercises. All the patients were treated for4weeks, with4weeks follow-up. The short-form of McGill scale (SF-McGill) and the elbow functional assessment before and2,4week after treatment were evaluated. The main indicators included:analgesic effect, the clinical curative effect, the total score of the SF-McGill and PRI, VAS and PPI projects scores change before and after treatment, the total score of the elbow functional assessment and clinical symptoms and signs, daily life function item scores change before and after treatment, adverse events occurred in the process of treatment, the affect of rehabilitation training or not in4weeks follow-up and so on. Specially assigned persons performed all data analysis with the software SPSS22.0.
Results:
1. Results of literature research:
(1) Results of bibliometric analysis:The distribution of the number of the reported literatures about treatment for lateral epicondylitis with acupuncture is balanced in the recent3years. The researches are mainly carried out in hospitals located in Guangdong, Zhejiang and HubeiProvinces. The literatures are principally published in statistical source magazines with the prevention and treatment control measures asthe most reported research type.Themost criterions of diagnosis and therapeutical effect are "Disease of TCM syndrome diagnosis curative standard".The mainly adopted methods in these researches are acupuncture and moxibustion, comprehensive methods of Chinese traditional medicine and integrative therapy of Chinese and Western medicine.
(2) The result of rules of selecting points:Acupoints in treating lateral epicondylitis were selected from the local pain points and according to the meridians. The most often used meridians were the Large Intestine Meridian of Hand-Yangming, the Sanjiao Meridian of Hand-Shaoyang, and the Lung Meridian of Hand-Taiyang. The most frequently selected acupoint was A-shi point, located at the elbow part. Other points used frequently were Shousanli (LI10), Quchi (LI11), Zhouliao (LI12),Chize (LU5),Hegu (LI4),Waiguan (SJ5),Zhongzhu (SJ3), which all around the elbow.
2. Results of clinical research:
(1) Results of the baseline index:There were no significant differences from the gender composition, the aging, the total scores of SF-McGill and the elbow functional assessment between the2groups (P>0.05), so the data of the2groups could be compared.
(2) Comparison of the clinical effect
①Result of clinical efficacy:The total clinical effective rate of2groups was94.83%in filiform needle group and88.89%in worm needle group respectively, the difference between groups was significant(P=0.03), by Wilcoxonrank sum test.
②Result of analgesic effect:The analgesic effective rate of2groups was56.90%in filiform needle group and38.89%in worm needle grouprespectively, and the total analgesic effective rate was94.83%a nd88.89%, the difference between groups is significant(P=0.046), by Wilcoxonrank sum test.
(3) Comparison of observational indexes before and after treatment
①Result of the improvement of the SF-McGill scale:Repeated ANOVA of intra-group comparison was taken in112patients, the result showed thatboth2therapies could reduce the SF-McGill scores significantly as the extension of treatment time, comparation between each time point showed that the SF-McGilltotal score at2weeks and4weeks after treatment was both lower than the score before treatment (P<0.01). Individual Sample T test was performed in the analysis of inter-group comparison, and the results showed significant difference between2groups on reduction of the SF-McGill scores at2and4weeks after treatment (P<0.05). The comparison of item scores of the SF-McGill showed that both2therapies could reduce the PRI, VAS and PPI item scores significantly, and the reduction of filiform needle combined with rehabilitation training was significantly better than worm needle combined with rehabilitation training at2weeks after treatment. At4weeks after treatment the VAS and PPI scores was significantly different between2groups(P<0.05).
②Result of the improvement of the elbow functional assessment:Repeated ANOVA of intra-group comparison showed significant difference between2groups on the total scores of the elbow functional assessment and clinical symptoms, clinical signs, daily life function item scoresas the extension of treatment time (P<0.05). Moreover, the improvement of clinical symptoms and clinical signs in filiform needle group was significantly better than worm needle group, but not the improvement ofthe elbow functionat2weeks after treatment (P<0.05). There was no significant difference between2groups at4weeks after treatment (P>0.05).
(4) Result of the recurrence during4weeks follow-up after treatment:
Following up the frequency rehabilitation training for4weeks, the patients were devided into3groups as:<10times,10-15times,>15times. After analysis of all the indexes before and after follow up, we found there was difference for the other2group training more than10times, but not the group training less than10 times between before and after follow-up. Training more than15times could significantly improve the elbow function and reduce the pain of elbow than that taining less than10times.
(5) Result of the adverse reactions:
There were some adverse reactions, such as pain when needling, and feeling faints when needling in both2groups. Eight patients in filiform needle group felt bleeding for common acupuncture but not affect the treatment,1patient in worm needle group felt faintng during acupuncture,6patients felt bleeding. There was no hematoma, banding needle or sticking of needle, and empyrosis in both2groups.
Conclusions:
By systematically summarizing the related literatures in this project, we find that the distribution of the number of the reported literatures is balanced in recent3yearsand the hot spots aresought out with the main methods of prevention and treatment. There are various therapeutic methods on the acupoints selected by the rulesof selecting local pain points or according to the meridians. We preliminarily established a database about therapeutic methods of lateral epicondylitis and rules of selecting points for the treatment in clinical.
The clinical research data and analysis shows:1. All the filiform needle and worm needle combined with rehabilitation training therapy can effectively relieve the elbow pain, improve the clinical symptoms and signs, and elbow function in the lateral epicondylitis patients.2. The relief of pain by filiform needle combined with rehabilitation training therapy is better and faster than worm needle combined with rehabilitation training therapy.3. The improvement of clinical symptoms and signsby filiform needle combined with rehabilitation training therapy is better and faster than worm needle combined with rehabilitation training therapy, but not for long time.4. The improvement of elbow function in daily life byworm needle combined with rehabilitation training group is better than filiform needle combined with rehabilitation training therapy, but not for long time.5. After acupuncture treatment, long time and normative training could effectively improve the symptoms and signs, and elbow function in the follow-up.
In conclusion, curative effect on acupuncture treating lateral epicondylitis is significantly, but the methods are various and more difficult to standardize. Both filiform needle and worm needle combined with rehabilitation training therapy not only can improve the clinical efficacy, strengthen the analgesia effect, improve the function of elbow vertebrae, prevent disease recurrence, but also has less adverse reactions, low medical costs, unified standard, easy operation and the active participation of patient. Therefore, the physicians should use suit therapy by medical condition, patients' needin clinical to prevent and treat the lateral epicondylitis.
But there is still some weakness in our clinical research, for example, the small sample size, the operation of filiform needle, the obedience of patients, the selecting of measuring scale and questionnaire. In the future, we would mend our weakness above, enlarge the sample size and take a further study on mechanism of filiform needle combined with rehabilitation training therapy treating the lateral epicondylitis.
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