针刺治疗缺血性脑卒中随机对照初步研究
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摘要
目的：探讨针刺是否能改善缺血性脑卒中病人的日常运动功能与认知功能，降低残废率、复发率。方法：从入住我科的352例急性缺血性脑卒中病人中纳入符合入选病例88例，随机分为针刺组43例，非针刺组45例，针刺组在常规治疗基础上加针刺，针刺治疗每周五次，共计三周，一共完成15次。非针刺组进行常规治疗(对症、抗血小板聚集药、抗凝药、钙阻滞剂、活血化瘀药、扩容药、降颅压药、脑营养药、防治并发症)；疗效判定指标：神经功能缺损变化，采用斯堪的纳维亚脑卒中量表(Scandinavian Stroke Scale，SSS)；认知功能改变，采用神经行为认知状态测试(Neurobehavioral Cognitive Status Examination，NCSE)；6个月死亡／残障率；6个月卒中复发率；6个月MRS(Modified Rankin Scale)评分；6个月ADL(activities of daily living)function，使用Barthel Index评分；不良反应。结果：两组病例基线具有均衡可比性(P＞0.05)；神经功能缺损评分(SSS)针刺组(10.95±6.00)稍优于非针刺组(8.40±8.27)，但无统计意义(P＞0.05)；NCSE评测，针刺组(3.73±0.69)明显优于非针刺组(1.19±0.49)，统计分析差异有显著意义(P＜0.01)；6个月针刺组死亡／残障率的相对危险度(RR)为0.582、95％CI(0.212 1.597)，优势比(OR)为0.526，95％CI(0.161 1.720)，两组不具有显著差异(P＞0.05)；6个月针刺组卒中复发率RR为1.572，95％CI(0.276 8.924)，OR为1.613，95％CI(0.256 10.156)，两组不具有显著差异(P＞0.05)；MRS评测：针刺组(0.55±0.10)优于非针刺组(0.11±0.08)，经统计分析差异显著(P＜0.05)，且非针刺组组内比较经统计分析差异无显著意义；(ADL)BI评测：针刺组(7.32±1.74)优于非针刺组(2.73±0.77)，且经统计分析差异显著(P＜0.05)；针刺组尚未发现严重不良反应，随访率达97.73％。结论：针刺对缺血性脑卒中恢
复期的生活质量的提高、认知功能的改善有效，在治疗急性缺血性脑卒中患者中，
针刺是一种值得应用的疗法。但应扩大样本量进一步研究，以验证针刺治疗是否
能改善急性缺血性脑卒中的远期终点事件。
Objective:To test whether acupuncture can improve function of daily motion and cognition of the patients with acute ischemic stroke and reduce dependency and recurrence of stroke.Methods:88 patients of 352 in-patients with acute ischemic stroke in department of neurology of the first affiliated hospital of KunMing medical college were included and randomly allocated to a treatment group in which 43 patients were treated with acupuncture and a control group in which 45 patients were treated with a normal treatment. Acupuncture was conducted 3-10 days after stroke onset based on normal trentment,which was applied 5 times a week for 3 weeks.The outcome variables included Scandinavian Stroke Scale scores applied to assess neurological function deficits,and Neurobehavioral Cognitive Status Examination carried out to test cognitive disorder,and also death or dependency at the 6th month,and recurrence of stroke and Modified Rankin Scale and Barthel Index scores at the 6th month,and also the adverse events of acupun
cture.All outcomes were assessed blindly.Results: At baseline,patients in each group were closely similar in all important prognostic variables. At 3 week no statistically significant differences were observed between the 2 groups for 3S
outcome,but had statistically significant differences for NCSE. At 6th month,follow up rate was 97.73%. no statistically significant differences were observed between the 2 groups for death or dependency and recurrence of stroke . But there were clinically important or statistically significant differences for the outcome of MRS and BI in the treatment group with acupuncture as compared with the control one,and the former is prior to the latter.No major adverse events were found in the group with acupuncture. Conclusions :Acupuncture had beneficial effect on improving quality of daily living and cognitive disorder of the patients with acute ischemic stroke,acupuncture is an applicable means in treating acute ischemic stroke.But because of limited sample size,we didn't draw a firm conclusion on effectiveness of treating acute ischemic stroke with acupuncture, we should expand the sample size to make progressive study to investigate whether acupuncture have important value to long-term end events.
复期的生活质量的提高、认知功能的改善有效，在治疗急性缺血性脑卒中患者中，
针刺是一种值得应用的疗法。但应扩大样本量进一步研究，以验证针刺治疗是否
能改善急性缺血性脑卒中的远期终点事件。
Objective:To test whether acupuncture can improve function of daily motion and cognition of the patients with acute ischemic stroke and reduce dependency and recurrence of stroke.Methods:88 patients of 352 in-patients with acute ischemic stroke in department of neurology of the first affiliated hospital of KunMing medical college were included and randomly allocated to a treatment group in which 43 patients were treated with acupuncture and a control group in which 45 patients were treated with a normal treatment. Acupuncture was conducted 3-10 days after stroke onset based on normal trentment,which was applied 5 times a week for 3 weeks.The outcome variables included Scandinavian Stroke Scale scores applied to assess neurological function deficits,and Neurobehavioral Cognitive Status Examination carried out to test cognitive disorder,and also death or dependency at the 6th month,and recurrence of stroke and Modified Rankin Scale and Barthel Index scores at the 6th month,and also the adverse events of acupun
cture.All outcomes were assessed blindly.Results: At baseline,patients in each group were closely similar in all important prognostic variables. At 3 week no statistically significant differences were observed between the 2 groups for 3S
outcome,but had statistically significant differences for NCSE. At 6th month,follow up rate was 97.73%. no statistically significant differences were observed between the 2 groups for death or dependency and recurrence of stroke . But there were clinically important or statistically significant differences for the outcome of MRS and BI in the treatment group with acupuncture as compared with the control one,and the former is prior to the latter.No major adverse events were found in the group with acupuncture. Conclusions :Acupuncture had beneficial effect on improving quality of daily living and cognitive disorder of the patients with acute ischemic stroke,acupuncture is an applicable means in treating acute ischemic stroke.But because of limited sample size,we didn't draw a firm conclusion on effectiveness of treating acute ischemic stroke with acupuncture, we should expand the sample size to make progressive study to investigate whether acupuncture have important value to long-term end events.
引文
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2．魏岗之，急性缺血性脑卒中的治疗，中华内科杂志，2001，40(12)：795-798
3．陈蓓、王耀山、脑血管性痴呆，实用内科杂志，1989，9(4)：206
4. The International stroke trial (IST):a randomised trial of aspirin,subcut.aneous heparin,both, or neither among 19435 patients with acute ischaemic stroke, Lancet, 1997,349:1569-1581
5. Chinese acute stroke trial (CAST):randomised placebo-controlled trial of early aspirin use in 20000 patient with acute ischaemic stroke,Lancet, 1997,349:1641-1649
6. P.D.lyden,MD;J.C.Grotta, MD;S.R.Levine,MD, et al,Intravenous thrombolysis for acute stroke, neurology, 1997,49:14-29
7. Zhengming Chen,MD,PHD,Peter Sandercock,MD,Jin—xiang Zie,MD,Richard Peto,MSC, Rory Collins,MD,MSC,and Li—Sheng Liu,MD.Hospital Management of Acute Ischemic Stroke in China, Journal of Stroke and Cerebrovacular Diseases. 1997,6(5):pp361—367
8. Silvert M.Acupuncture wins BMA approval.BMJ.2000,321(7252): 11
9. Mayer DJ,Acupuncture:an evidence-based review of the clinical literature, Annual review of medicine,2000,51,49-63
10．刘美娟，潘中允，陈泽明。用SPECT研究针刺对脑缺血性病变局部血流的影响，中国针灸，1997，17(3)：133—134
11．陈邦国，针刺治疗脑血栓形成的微循环观察，上海针灸杂志，1997，16(2)：13
12．张寸生，张慧勇，马春燕，等。醒脑开窍法治疗中风后遗症的临床与基础实验研究，针刺研究，1998，23(1)：11
13．赵颖，王进。针刺对急性缺血性中风患者血浆TXB_2和6-K-P的影响，上海针灸杂志，1997，16(2)：9
14．李家康，焦扬，赤勺注射液穴位注射对中风患者的影响，中国针灸，1999，19(7)：429
15．唐胜修，头针为主治疗缺血性中风后遗症的临床研究，上海针灸杂志，2001，20：16-7
16．田元祥，赵建新，曹刚，电针肾俞、膈俞，百会穴对拟血管性痴呆小鼠海马组织乙酰胆碱酯酶活力的影响，中国医药学报，2000，15(5)：67-69
17．黄飞智，李建强，雷立屏，等。电针对血管性痴呆大鼠学习记忆及下丘脑促肾上腺皮质激素的影响，针刺研究，2000，3，25：170-173
18．赖新生，王黎，江雪华，等。电针对实验性血管性痴呆大鼠学习记忆及SOD和MDA的影响，中国针灸，2000，8：497-500
19．聂卉，电缇针对中风偏瘫患者体感诱发电位的动态观察，中国针灸，1999，19(6)：369
20．张齐昌，罗丽彬，于丽，等。应用“治瘫六穴位”治疗急性期中风中经络145例临床疗效观察，针灸临床杂志，1999，15(3)：46-48
21．沈卫东，支惠萍，李静，等。针灸治疗多发梗塞性痴呆的临床初步研究，上海中医药大学学报，2000，3，14(1)：30—32
22. Barbrois,Johansson,MD,PHD Evahaker, PHD;Magnus Vonarbin,MD,PHD;et al;Acupun- cture and transcutaneohs nerve stimulation in stroke rehabilitation. Stroke.2001, 32;707—713
23. Guilla Gosman-Hedstron,OT, MSC;Lisbert claesson,OT, MSC;Ulrika klingenstiema, RPT, MSC.Effects of acupuncture treatment on daily life activities and quality of life.Stroke,1998,29,2100-2108
24. Asplund K,Tuomilehto J,Stegmayr B,Wester PO, Tunstall-Pedoe H,Diagnostic criteria and quality control of the registration of stroke events in the MONICA Project,Acta med Stand Suppl.1988;728:26-39
25．石学敏，脑卒中病与醒脑开窍针刺法，天津：天津科学技术出版社，1998，112-117
26. Granger CV, Devis LS, Peters MC, Sherwood CC, Barrett JE. Stroke rehabilitation: analysis of repeated Barthel Index measures. Arch Phys Med Rehabil. 1979,60:14-17
27. D'Olhaberriague L, Litvan I, Mitsias P, Mansbach HH. A reappraisal of reliability and validity studies in stroke. Stroke. 1996;27:2331-2336
28. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJA, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988; 19: 604-607
29. Mahoney FJ,Barthel DW, Function evaluation: The Barthel Index.Md State Med J, 1965, 14:61-65
30. Lindenstrom E,Boysen G, Christiansen LW, et al,Reliability of Scandinavian Neurological Stroke Scale .Cerebrovasc Dis, 1991,1:103-107
31．许涛，尤春景，黄晓琳，等。神经行为认知状态检查表信度与效度的初步测定，中华物理医学与康复杂志，2002，24：451-453
32. Plum F.Dementia:an approaching epidemic.Nature. 1979;279:372-3
33. Terry RD,Katzrnan R.Senile Dementia of the Alzheimer type.Ann Neurol. 1983; 14:497-506
34．李力，针灸学家石学敏教授学术经验，上海针灸杂志，1994，13：49-50
35．石学敏，针灸临床研究进展概述，针刺研究，1998，2：85-90
36．马岩瑶，王舒，鲁斌，等。醒脑开窍针刺法干预实验性脑梗塞大鼠热休克蛋白基因表达的研究，中国针灸，2001，21(2)：107-112
37．王舒，郑灏泳，李谈，“醒脑开窍”针法对大脑中动脉阻断后局灶性脑缺血大鼠神经细胞功能的影响，现代康复，2001，5(3)：53、65
38．韩景献，王旭慧，董承超，等。针刺对快速老化痴呆模型小白鼠SAM-P／8脑组织儿茶酚胺神经递质影响的实验研究，中国自然医学杂志，2000，2(4)：202-204
39．翟义得，应用“醒脑开窍法”针刺治疗279例中风患者临床观察，中国针灸，1988，5：10-11
40．王立存，周智梁，郭家奎，等。“谓神通络”针法治疗急性脑梗塞临床研究，针刺研究，2001，26(1)：32-34
41．解庆凡，田胜利，张秀娟，等。大全息针法治疗中风偏瘫230例临床观察，北京中医药大学学报，2000，23(3)：74-75
42．赖新生，张家维，莫飞智，等。针刺治疗血管性痴呆临床疗效观察，中国针灸，1997，12：713-716
43．沈卫东，支惠萍，李静，等，针灸治疗多发梗塞性痴呆的临床初步研究，上海中医药大学学报，2000，14(1)：30-32
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46．朱燕，王毅，王文敏，神经行为认知状态检查介绍(NCSE)，中国临床心理学杂志，2003，11(2)：151-152，147
47．段国俊，唐强，张国英，等，不同部位缺血性脑卒中针刺效应比较，中国针究，1997，10：591-593
48．金竹青，顾法隆，陈汝兴，等，督脉穴位针刺对急性缺血性脑卒中患者的治疗作用，针刺研究，1999，1：5-7
49．陈松清，王一萍，李怡新，颈部针刺治疗急性缺血性脑卒中95例，中国康复理论与实
践，1997，3：61-62
50．吴波，刘鸣，脑卒中临床试验疗效判定指标现状及趋势，中华神经科杂志，2002，35：177-179
51．何俐，韩钊，刘呜，等，我国神经疾病防治性研究随机对照试验现状的初步分析，中华神经科杂志，1999，32：92-93
52. Sze FK, Wong E,Yi X,et al.Does acupuncture have additional value to standard poststroke motor rehabilitation?Stroke,2002,33:186-194
2．魏岗之，急性缺血性脑卒中的治疗，中华内科杂志，2001，40(12)：795-798
3．陈蓓、王耀山、脑血管性痴呆，实用内科杂志，1989，9(4)：206
4. The International stroke trial (IST):a randomised trial of aspirin,subcut.aneous heparin,both, or neither among 19435 patients with acute ischaemic stroke, Lancet, 1997,349:1569-1581
5. Chinese acute stroke trial (CAST):randomised placebo-controlled trial of early aspirin use in 20000 patient with acute ischaemic stroke,Lancet, 1997,349:1641-1649
6. P.D.lyden,MD;J.C.Grotta, MD;S.R.Levine,MD, et al,Intravenous thrombolysis for acute stroke, neurology, 1997,49:14-29
7. Zhengming Chen,MD,PHD,Peter Sandercock,MD,Jin—xiang Zie,MD,Richard Peto,MSC, Rory Collins,MD,MSC,and Li—Sheng Liu,MD.Hospital Management of Acute Ischemic Stroke in China, Journal of Stroke and Cerebrovacular Diseases. 1997,6(5):pp361—367
8. Silvert M.Acupuncture wins BMA approval.BMJ.2000,321(7252): 11
9. Mayer DJ,Acupuncture:an evidence-based review of the clinical literature, Annual review of medicine,2000,51,49-63
10．刘美娟，潘中允，陈泽明。用SPECT研究针刺对脑缺血性病变局部血流的影响，中国针灸，1997，17(3)：133—134
11．陈邦国，针刺治疗脑血栓形成的微循环观察，上海针灸杂志，1997，16(2)：13
12．张寸生，张慧勇，马春燕，等。醒脑开窍法治疗中风后遗症的临床与基础实验研究，针刺研究，1998，23(1)：11
13．赵颖，王进。针刺对急性缺血性中风患者血浆TXB_2和6-K-P的影响，上海针灸杂志，1997，16(2)：9
14．李家康，焦扬，赤勺注射液穴位注射对中风患者的影响，中国针灸，1999，19(7)：429
15．唐胜修，头针为主治疗缺血性中风后遗症的临床研究，上海针灸杂志，2001，20：16-7
16．田元祥，赵建新，曹刚，电针肾俞、膈俞，百会穴对拟血管性痴呆小鼠海马组织乙酰胆碱酯酶活力的影响，中国医药学报，2000，15(5)：67-69
17．黄飞智，李建强，雷立屏，等。电针对血管性痴呆大鼠学习记忆及下丘脑促肾上腺皮质激素的影响，针刺研究，2000，3，25：170-173
18．赖新生，王黎，江雪华，等。电针对实验性血管性痴呆大鼠学习记忆及SOD和MDA的影响，中国针灸，2000，8：497-500
19．聂卉，电缇针对中风偏瘫患者体感诱发电位的动态观察，中国针灸，1999，19(6)：369
20．张齐昌，罗丽彬，于丽，等。应用“治瘫六穴位”治疗急性期中风中经络145例临床疗效观察，针灸临床杂志，1999，15(3)：46-48
21．沈卫东，支惠萍，李静，等。针灸治疗多发梗塞性痴呆的临床初步研究，上海中医药大学学报，2000，3，14(1)：30—32
22. Barbrois,Johansson,MD,PHD Evahaker, PHD;Magnus Vonarbin,MD,PHD;et al;Acupun- cture and transcutaneohs nerve stimulation in stroke rehabilitation. Stroke.2001, 32;707—713
23. Guilla Gosman-Hedstron,OT, MSC;Lisbert claesson,OT, MSC;Ulrika klingenstiema, RPT, MSC.Effects of acupuncture treatment on daily life activities and quality of life.Stroke,1998,29,2100-2108
24. Asplund K,Tuomilehto J,Stegmayr B,Wester PO, Tunstall-Pedoe H,Diagnostic criteria and quality control of the registration of stroke events in the MONICA Project,Acta med Stand Suppl.1988;728:26-39
25．石学敏，脑卒中病与醒脑开窍针刺法，天津：天津科学技术出版社，1998，112-117
26. Granger CV, Devis LS, Peters MC, Sherwood CC, Barrett JE. Stroke rehabilitation: analysis of repeated Barthel Index measures. Arch Phys Med Rehabil. 1979,60:14-17
27. D'Olhaberriague L, Litvan I, Mitsias P, Mansbach HH. A reappraisal of reliability and validity studies in stroke. Stroke. 1996;27:2331-2336
28. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJA, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988; 19: 604-607
29. Mahoney FJ,Barthel DW, Function evaluation: The Barthel Index.Md State Med J, 1965, 14:61-65
30. Lindenstrom E,Boysen G, Christiansen LW, et al,Reliability of Scandinavian Neurological Stroke Scale .Cerebrovasc Dis, 1991,1:103-107
31．许涛，尤春景，黄晓琳，等。神经行为认知状态检查表信度与效度的初步测定，中华物理医学与康复杂志，2002，24：451-453
32. Plum F.Dementia:an approaching epidemic.Nature. 1979;279:372-3
33. Terry RD,Katzrnan R.Senile Dementia of the Alzheimer type.Ann Neurol. 1983; 14:497-506
34．李力，针灸学家石学敏教授学术经验，上海针灸杂志，1994，13：49-50
35．石学敏，针灸临床研究进展概述，针刺研究，1998，2：85-90
36．马岩瑶，王舒，鲁斌，等。醒脑开窍针刺法干预实验性脑梗塞大鼠热休克蛋白基因表达的研究，中国针灸，2001，21(2)：107-112
37．王舒，郑灏泳，李谈，“醒脑开窍”针法对大脑中动脉阻断后局灶性脑缺血大鼠神经细胞功能的影响，现代康复，2001，5(3)：53、65
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