标本理论指导透刺法治疗无先兆型偏头痛的临床研究
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摘要
偏头痛(migranine)是一种常见发作性神经血管疾病,其特征是发作性、多为偏侧的、中重度、博动样头痛,一般持续4-72h,可伴有恶心、呕吐,光、声或活动可加重头痛。发病率在欧美等国家为10%-15%。偏头痛是临床上一种较难治愈的周期性发作性疾病。由于其发病率较高,发作时头痛剧烈,且反复发作、迁延难愈,给患者的日常生活及学习工作造成严重不良影响,WHO将严重偏头痛定为最致残的慢性疾病之一。
偏头痛的发病机制涉及诸多因素,至今仍未完全定论,但目前的研究提示可能与以下机制有关：血管源性学说、三又神经血管学说、遗传学基础等；偏头痛急性发作和预防性药物治疗方面都获得一些临床证据,但对其适当的药物治疗,仍不甚理想。我国传统中药或中西药结合疗法对偏头痛的治疗也取得满意疗效。针灸治疗作为在中国沿用两千多年的一种治疗方法,以其显著的疗效得到了国内外医学界的公认。近年来国内学者对针刺治疗该病进行了不少有益的研究与探讨。经过研究探讨得出针刺治疗偏头痛具有作用镇痛、抗炎、改善脑部的血液循环、双向调节、促进人体内微量元素的生成、对人体内分泌系统起调节等作用
标本理论始见于《灵枢·卫气》篇,木之根日“本”,木之末曰“标”。经脉的“本”,指经气集中于四肢部位；“标”,指经气扩散于头身一定的部位,借此以阐明四肢与头面躯干之间气血运行的升降关系。末梢与根本,其位置有上下之分。《灵枢·卫气》云：“足少阳之本在窍阴之间,标在窗笼之前。窗笼者,耳也……手少阳之本在小指次指之间上二寸。标在耳后上角下外眦也。”明确指出足少阳的标部在耳前,其穴有听会等,手少阳的标部“在耳后上角下外眦”,约当丝竹空穴所在。
透穴疗法是指将针刺入穴位后,针尖透达对侧或邻部穴位,但针尖不穿出皮肤的一种针刺方法,该法首载于元代王国瑞《扁鹊神应针灸玉龙经》,当时虽无“透穴针法”之名,但已明确指出了“一针两穴”的针刺方法。古代医家运用透穴针法治疗各种疾病,积累了丰富的临床经验,现常用于治疗某些慢性病和顽固性疾病。偏头痛属于中医学“头痛”、“头风”的范畴。本病是由于风、痰、瘀和正虚等多病因致病,导致气机失常,血行缓滞,瘀阻脑窍而致不通则痛。虽然内、外、虚、实有别。偏头痛病位在头侧部,《灵枢·卫气》明确指出足少阳的标部在耳前,其穴有听会等,手少阳的标部“在耳后上角下外眦”,约当丝竹空穴所在。治疗时可分别针刺头面标部的丝竹空、率谷等穴。采用一针透两穴通三经的方法,以增强针刺感应,方收“气至病除”之佳效。透穴疗法治疗偏头痛具有独特的功能和良好的功效,但仍然存在很多问题,主要表现在：诊断标准、病例纳入标准、排除标准、疗效判定标准缺乏客观统一的规范。因此,有必要加强大样本的临床方法学、临床疗效学研究,提高疗效的特异性和可重复性。针对于此,本研究过程严格按照循证医学的临床科研方法,设立治疗组与对照组,进行临床对照研究,观察透刺法治疗偏头痛的效果及可能机制。
研究目的：
以标本理论为指导,旨在通过本研究进行临床对照研究,观察透刺法治疗偏头痛的效果及可能机制。
研究方法：
文献研究部分综述了偏头痛发病机制、治疗的进展,针灸治疗偏头痛取得的成绩,以及目前存在的主要问题。
临床研究部分选择符合纳入标准的病例60例,按首次来诊的先后顺序,用随机数字表法将所观察的病例随机分为两组,治疗组30例,对照组30例。治疗组依据标本理论及元代王国瑞《扁鹊神应针灸玉龙经》：“偏正头风痛难医,丝竹金针亦可施,沿皮向后透率谷,一针两穴世间稀”,穴取丝竹空、率谷,采用透刺法。对照组采用普通针刺法,参照《针灸治疗学》(第五版)穴取双侧风池、百会,患侧太阳。治疗3个疗程后观察疼痛强度、头痛程度分级、健康状况量表(SF-36)以及生存质量量表简表(WHOQOL-BREF)。
研究结果：
对两组的性别、年龄、病程进行分析,差异无显著性意义(P>0.05),说明两组患者上述各方面资料基本相同,具有可比性。
两种针刺方法均能改善VAS评分、疼痛分级,以透刺法效果更好(P<0.05)。治疗前两组评分比较,P>0.05,提示两组患者疼痛程度相当,具有可比性。经治疗后评分均较治疗前明显下降,差异均有统计学意义(P<0.05),提示两种治疗方法均可以有效的缓解头痛症状。治疗后组间比较可知,治疗组评分下降更为显著,差异有统计学意义(P<0.05),提示治疗组疼痛改善明显。
偏头痛患者在SF-36、WHOQOL—BREF评分方面显示出对自身健康状况的忧虑,以及在社会关系领域、环境领域存在一定不足,进而影响到生活质量。治疗前两组评分比较,P>0.05,提示两组患者SF-36评分相当,具有可比性。在生理领域、心理领域、社会关系领域、环境领域方面的评分比较,差异无显著性意义(P>0.05),提示组间具有可比性。经治疗后评分均较治疗前明显提高,差异均有统计学意义(P<0.05),提示两种治疗方法均可以有效的提高生活质量。治疗后组间比较可知,治疗组评分上升更为显著,差异有统计学意义(P<0.05),提示治疗组改善更加明显。治疗前两组施加干预措施后除对照组环境领域外其他各方面评分均较治疗前提高,差异均有统计学意义(P<0.05),提示生活质量较前有提高；进一步行组间比较可知,在生理领域、环境领域方面治疗组评分高于对照组,差异有统计学意义(P<0.05),提示在上述两个方面治疗组效果优于对照组。因此可知,两种针刺方法均可改善SF-36、WHOQOL—BREF评分(P<0.01,P<0.05),组间比较则尤以透刺治疗显著(P<0.05)。
研究结论：
标本理论指导透刺法治疗无先兆型偏头痛临床疗效确切,可显著改善患者疼痛症状以及生活质量,优于普通针刺法,而且安全、简便,是一种值得广泛应用的方法。
Objective:Migraine (migranine) is a common onset neural vascular disease, whose character is onset, many for partial side, moderate to severe, bo dynamic sample headache, lasts 4-72h, may be associated with nausea, vomiting, light, sound or activities may increase the headache. The incidence of European and American countries for 10%-15%. WHO will be the most severe migraine disabled as one of chronic disease.
Combination of traditional Chinese medicine or traditional treatments for migraine therapy, acupuncture therapy with satisfactory results in China continue as a kind of more than 2,000 years treatment with its remarkable curative effect, the medical recognized by foreign and domestic.
Ancient physicians use through acupuncture point acupuncture treat various diseases, accumulated the rich clinical experience, is often used in the treatment of some chronic and stubborn disease. "Spirit, atlas and defended gas" explicitly pointed out feet in the standard of less Yang, the holes before Samuel hearings, a hand of "less Yang standard in the top corner behind the ears, angular," under cavitation is about as silk. Migraine disease bits in the first side parts respectively, when treatment of acupuncture front-man standard parts such as bamboo empty, rate valley hole. Use a needle through both points of the three methods to enhance acupuncture induction, square accept "gas to disease in addition to" better effect. Through hole treatments for migraine of unique function and good efficacy, but still has many problems, mainly displays in:diagnostic criteria, cases inclusion criteria, exclusion standard, efficacy criteria to judge objectively unified specification. Lack of Based on the above-mentioned problems, the present study followed the principle of randomized, strive to diagnosis, objective research through thorn method for migraines effect and the possible mechanism.
Methods:60 patients with migraine patients were randomly divided into the treatment group and control group of 30 cases of 30 cases, the treatment group, the method of using temperature acupuncture treatment group is conventional acupuncture, after three treatment pain intensity, headache degree observed grading, health scale (SF-36) and survival quality scale JianBiao (WHOQOL-BREF).
Results:2 groups of patients after treatment than before treatment VAS ratings declined obviously, clew 2 groups of patients pain symptoms were improved, a statistically significant difference. Groups of comparison shows, the treatment group ratings decline is more apparent, a statistically significant difference that the treatment group effect more significant.
2 groups of patients after treatment, the pain intensity grading score more before treatment dropped significantly, clew 2 groups of patients pain symptoms were improved, a statistically significant difference, hint 2 treatment all have certain effect. Groups of comparison shows, the treatment group ratings decline is more apparent, a statistically significant difference, indicating that the treatment group improve headache degree classification effect more apparent.
2 groups of patients after treatment, health rating scale than before treatment, hint 2 significantly greater pain symptom groups of patients are improved, a statistically significant difference, hint 2 treatment all have certain effect. Groups of comparison shows,the treatment group score heighten is more apparent, a statistically significant difference, indicating that the treatment group improve more apparent.
In the quality of life in JianBiao scoring was physiological field, environmental field treatment group than in control group, differences have ratings in the statistical significance, suggests that the two aspects the treatment group than in control group effect. In psychological field, social relations field, two treatment efficacy saw no significant differences.
Conclusion:Specimen theoretical guidance through thorn treatments for migraine without aura of clinical curative effect of patients with exactly, can significantly improve quality of life, and pain symptoms than ordinary acupuncture method, and safe, simple, is a worthy of widely used methods.
偏头痛的发病机制涉及诸多因素,至今仍未完全定论,但目前的研究提示可能与以下机制有关：血管源性学说、三又神经血管学说、遗传学基础等；偏头痛急性发作和预防性药物治疗方面都获得一些临床证据,但对其适当的药物治疗,仍不甚理想。我国传统中药或中西药结合疗法对偏头痛的治疗也取得满意疗效。针灸治疗作为在中国沿用两千多年的一种治疗方法,以其显著的疗效得到了国内外医学界的公认。近年来国内学者对针刺治疗该病进行了不少有益的研究与探讨。经过研究探讨得出针刺治疗偏头痛具有作用镇痛、抗炎、改善脑部的血液循环、双向调节、促进人体内微量元素的生成、对人体内分泌系统起调节等作用
标本理论始见于《灵枢·卫气》篇,木之根日“本”,木之末曰“标”。经脉的“本”,指经气集中于四肢部位；“标”,指经气扩散于头身一定的部位,借此以阐明四肢与头面躯干之间气血运行的升降关系。末梢与根本,其位置有上下之分。《灵枢·卫气》云：“足少阳之本在窍阴之间,标在窗笼之前。窗笼者,耳也……手少阳之本在小指次指之间上二寸。标在耳后上角下外眦也。”明确指出足少阳的标部在耳前,其穴有听会等,手少阳的标部“在耳后上角下外眦”,约当丝竹空穴所在。
透穴疗法是指将针刺入穴位后,针尖透达对侧或邻部穴位,但针尖不穿出皮肤的一种针刺方法,该法首载于元代王国瑞《扁鹊神应针灸玉龙经》,当时虽无“透穴针法”之名,但已明确指出了“一针两穴”的针刺方法。古代医家运用透穴针法治疗各种疾病,积累了丰富的临床经验,现常用于治疗某些慢性病和顽固性疾病。偏头痛属于中医学“头痛”、“头风”的范畴。本病是由于风、痰、瘀和正虚等多病因致病,导致气机失常,血行缓滞,瘀阻脑窍而致不通则痛。虽然内、外、虚、实有别。偏头痛病位在头侧部,《灵枢·卫气》明确指出足少阳的标部在耳前,其穴有听会等,手少阳的标部“在耳后上角下外眦”,约当丝竹空穴所在。治疗时可分别针刺头面标部的丝竹空、率谷等穴。采用一针透两穴通三经的方法,以增强针刺感应,方收“气至病除”之佳效。透穴疗法治疗偏头痛具有独特的功能和良好的功效,但仍然存在很多问题,主要表现在：诊断标准、病例纳入标准、排除标准、疗效判定标准缺乏客观统一的规范。因此,有必要加强大样本的临床方法学、临床疗效学研究,提高疗效的特异性和可重复性。针对于此,本研究过程严格按照循证医学的临床科研方法,设立治疗组与对照组,进行临床对照研究,观察透刺法治疗偏头痛的效果及可能机制。
研究目的：
以标本理论为指导,旨在通过本研究进行临床对照研究,观察透刺法治疗偏头痛的效果及可能机制。
研究方法：
文献研究部分综述了偏头痛发病机制、治疗的进展,针灸治疗偏头痛取得的成绩,以及目前存在的主要问题。
临床研究部分选择符合纳入标准的病例60例,按首次来诊的先后顺序,用随机数字表法将所观察的病例随机分为两组,治疗组30例,对照组30例。治疗组依据标本理论及元代王国瑞《扁鹊神应针灸玉龙经》：“偏正头风痛难医,丝竹金针亦可施,沿皮向后透率谷,一针两穴世间稀”,穴取丝竹空、率谷,采用透刺法。对照组采用普通针刺法,参照《针灸治疗学》(第五版)穴取双侧风池、百会,患侧太阳。治疗3个疗程后观察疼痛强度、头痛程度分级、健康状况量表(SF-36)以及生存质量量表简表(WHOQOL-BREF)。
研究结果：
对两组的性别、年龄、病程进行分析,差异无显著性意义(P>0.05),说明两组患者上述各方面资料基本相同,具有可比性。
两种针刺方法均能改善VAS评分、疼痛分级,以透刺法效果更好(P<0.05)。治疗前两组评分比较,P>0.05,提示两组患者疼痛程度相当,具有可比性。经治疗后评分均较治疗前明显下降,差异均有统计学意义(P<0.05),提示两种治疗方法均可以有效的缓解头痛症状。治疗后组间比较可知,治疗组评分下降更为显著,差异有统计学意义(P<0.05),提示治疗组疼痛改善明显。
偏头痛患者在SF-36、WHOQOL—BREF评分方面显示出对自身健康状况的忧虑,以及在社会关系领域、环境领域存在一定不足,进而影响到生活质量。治疗前两组评分比较,P>0.05,提示两组患者SF-36评分相当,具有可比性。在生理领域、心理领域、社会关系领域、环境领域方面的评分比较,差异无显著性意义(P>0.05),提示组间具有可比性。经治疗后评分均较治疗前明显提高,差异均有统计学意义(P<0.05),提示两种治疗方法均可以有效的提高生活质量。治疗后组间比较可知,治疗组评分上升更为显著,差异有统计学意义(P<0.05),提示治疗组改善更加明显。治疗前两组施加干预措施后除对照组环境领域外其他各方面评分均较治疗前提高,差异均有统计学意义(P<0.05),提示生活质量较前有提高；进一步行组间比较可知,在生理领域、环境领域方面治疗组评分高于对照组,差异有统计学意义(P<0.05),提示在上述两个方面治疗组效果优于对照组。因此可知,两种针刺方法均可改善SF-36、WHOQOL—BREF评分(P<0.01,P<0.05),组间比较则尤以透刺治疗显著(P<0.05)。
研究结论：
标本理论指导透刺法治疗无先兆型偏头痛临床疗效确切,可显著改善患者疼痛症状以及生活质量,优于普通针刺法,而且安全、简便,是一种值得广泛应用的方法。
Objective:Migraine (migranine) is a common onset neural vascular disease, whose character is onset, many for partial side, moderate to severe, bo dynamic sample headache, lasts 4-72h, may be associated with nausea, vomiting, light, sound or activities may increase the headache. The incidence of European and American countries for 10%-15%. WHO will be the most severe migraine disabled as one of chronic disease.
Combination of traditional Chinese medicine or traditional treatments for migraine therapy, acupuncture therapy with satisfactory results in China continue as a kind of more than 2,000 years treatment with its remarkable curative effect, the medical recognized by foreign and domestic.
Ancient physicians use through acupuncture point acupuncture treat various diseases, accumulated the rich clinical experience, is often used in the treatment of some chronic and stubborn disease. "Spirit, atlas and defended gas" explicitly pointed out feet in the standard of less Yang, the holes before Samuel hearings, a hand of "less Yang standard in the top corner behind the ears, angular," under cavitation is about as silk. Migraine disease bits in the first side parts respectively, when treatment of acupuncture front-man standard parts such as bamboo empty, rate valley hole. Use a needle through both points of the three methods to enhance acupuncture induction, square accept "gas to disease in addition to" better effect. Through hole treatments for migraine of unique function and good efficacy, but still has many problems, mainly displays in:diagnostic criteria, cases inclusion criteria, exclusion standard, efficacy criteria to judge objectively unified specification. Lack of Based on the above-mentioned problems, the present study followed the principle of randomized, strive to diagnosis, objective research through thorn method for migraines effect and the possible mechanism.
Methods:60 patients with migraine patients were randomly divided into the treatment group and control group of 30 cases of 30 cases, the treatment group, the method of using temperature acupuncture treatment group is conventional acupuncture, after three treatment pain intensity, headache degree observed grading, health scale (SF-36) and survival quality scale JianBiao (WHOQOL-BREF).
Results:2 groups of patients after treatment than before treatment VAS ratings declined obviously, clew 2 groups of patients pain symptoms were improved, a statistically significant difference. Groups of comparison shows, the treatment group ratings decline is more apparent, a statistically significant difference that the treatment group effect more significant.
2 groups of patients after treatment, the pain intensity grading score more before treatment dropped significantly, clew 2 groups of patients pain symptoms were improved, a statistically significant difference, hint 2 treatment all have certain effect. Groups of comparison shows, the treatment group ratings decline is more apparent, a statistically significant difference, indicating that the treatment group improve headache degree classification effect more apparent.
2 groups of patients after treatment, health rating scale than before treatment, hint 2 significantly greater pain symptom groups of patients are improved, a statistically significant difference, hint 2 treatment all have certain effect. Groups of comparison shows,the treatment group score heighten is more apparent, a statistically significant difference, indicating that the treatment group improve more apparent.
In the quality of life in JianBiao scoring was physiological field, environmental field treatment group than in control group, differences have ratings in the statistical significance, suggests that the two aspects the treatment group than in control group effect. In psychological field, social relations field, two treatment efficacy saw no significant differences.
Conclusion:Specimen theoretical guidance through thorn treatments for migraine without aura of clinical curative effect of patients with exactly, can significantly improve quality of life, and pain symptoms than ordinary acupuncture method, and safe, simple, is a worthy of widely used methods.
引文
[1]偏头痛诊断与防治专家共识组.偏头痛诊断与防治专家共识.中华内科杂志,2006,8(45)：694-696
[2]叶晓菊,胡兴越.偏头痛发病机制的研究进展.国外医学.神经病学神经外科学分册,2005,32(3)：280-283.
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