摘要
目的
本课题采用简易精神状态检查量表(MMSE)、修订长谷川智力量表(HDS-R)、日常生活活动能力量表(ADL),中医辨证量表(SDSVD)和血液流变学分析,脑血流动力学等指标来观察智三针与焦氏头针对血管性痴呆治疗前后各量表积分的变化以及血液流变学和脑血流动力学改变,并进行比较分析,探讨两种针法对以上量表和指标的改善情况,为针灸治疗VD提供新的思路和线索,进而为智三针治疗VD的临床推广应用提供理论依据。
方法
有62例病例被纳入研究,根据简单随机化分组设计,将符合纳入标准、经排除标准筛选出来的病例分为智三针组和焦氏头针组。脱落4例,按方案完成观察58例,其中智三针组30例,焦式头针组28例。智三针组取穴：神庭,本神双。焦式头针组取穴：足运感区双,精神情感区双。两组均选用环球牌0.30×mm针灸针,沿头皮成15-30。角从上往下斜刺进帽状腱膜下,快速捻转,一般频率200次/分钟以上,针体左右旋转各两转,约持续1分钟,治疗30分钟,中间行针1次,约1分钟。同时配合辨证配穴：肾精亏虚证配太溪、悬钟；痰浊阻窍证配丰隆、中脘；瘀血阻络证配膈俞、血海；肝阳上亢证配太冲、肝俞；火热内盛证配内庭、曲池；腑滞浊留证配中脘、天枢；气血亏虚证配足三里、气海。针法采用提插与捻转补泻手法,随证补泻。每日针刺1次,每周5次后休息2天,治疗4周。同时配合常规基础药物治疗。观察项目主要有以下量表①简易精神状态检查表(MMSE)②修订长谷川智力量表(HDS-R)③日常生活活动能力量表(ADL)④中医辨证量表(SDSVD)以及血液流变学检测和脑血流动力学检测。以上观察项目治疗前后分别检查一次。应用SPSS19.0统计软件进行统计学处理,计量资料数据用均数±标准差表示,符合正态分布的数据,采用独立样本t检验,多分类无序资料采用R×C列联表χ2检验,两分类指标采用四表格分析,两组等级资料比较采用两样本秩和检验。
结果
本研究共收集58例合格受试者,其中智三针组30例(男16例,女14例),焦氏头针组28例(男13例,女15例),两组平均年龄分别为70.50岁和69.96岁,平均病程4.50年和4.18年。两组患者基线数据的可比性分析中,两组在性别、年龄、病程、文化程度、常见合并病分布情况、治疗前各项量表积分、患者痴呆程度分布情况等方面,经分析均无统计学意义,说明两组间的基线数据具有可比性。治疗四周后,结果显示：
1.智三针组MMSE、HDS-R量表治疗后积分较治疗前有显著性差异(P<0.01),焦氏头针组MMSE、HDS-R量表治疗后积分较治疗前无显著差异(P>0.05)。
2.两组ADL、SDSVD量表治疗后积分较治疗前均有显著性差异(P<0.01)。智三针ADL、SDSVD量表治疗后积分较焦氏头针组无显著性差异(P>0.05)。说明两种针法对日常生活能力和中医证候均有较好的改善作用,且两者差别不明显。
3.两组对VD患者血液流变学各项指标均有明显的改善作用(P<0.05, P<0.01)：尤其是对全血粘度低切、纤维蛋白原、血沉方程K值有明显的改善作用(P<0.01)。两组治疗后血液流变学指标经独立样本t检验,全血粘度低切、全血粘度中切、全血粘度高切、血浆粘度、纤维蛋白原无显著性差异,智三针组对红细胞压积、血沉方程K值的改善较焦氏头针明显(P<0.01)。
4.智三针组治疗前后Vm比较,LMCA、LACA、RMCA、RACA、RVA等脑血管的Vm明显升高(P<0.01,P<0.05),其中以MCA的Vm于治疗前后差异显著,经统计学比较P<0.01。焦氏头针组治疗前后Vm比较,LMCA、RMCA、RACA等脑血管的Vm明显升高(P<0.05),其余脑血管的Vm于治疗前后无显著差异。智三针组治疗前后PI比较,LMCA、RMCA脑血管的PI明显升高(P<0.01),其余脑血管的PI于治疗前后无显著差异。焦氏头针组治疗前后PI比较,所有脑血管的PI于治疗前后均无显著差异。两组治疗后Vm比较,各脑血管均无显著性差异。两组治疗后PI比较,智三针组RMCA、RPCA、BA较焦氏头针组有显著性差异(P<0.01,P<0.05)。
结论
1.智三针对VD患者认知能力,痴呆程度的改善疗效肯定。焦氏头针在此方面未见有统计学意义的疗效。
2.智三针与焦氏头针对日常生活能力、中医证候均有较好的改善作用,且两者差别不明显。
3.智三针与焦氏头针对血液流变学各项指标均有较好的改善作用,尤其是对全血粘度低切、纤维蛋白原、血沉方程K值有明显的改善作用。智三针组对红细胞压积、血沉方程K值的改善较焦氏头针明显。
4.智三针可明显升高LMCA、LACA、RMCA、RACA、RVA等脑血管的平均血流速度,其中以大脑中动脉于治疗前后差异显著；焦氏头针对LMCA、RMCA、RACA等脑血管的平均血流速度有改善。
5.智三针对大脑中动脉的搏动指数有改善,焦氏头针对所有脑血管的搏动指数均无统计学意义上的改善。
Objective
The subject using the Mini-Mental State Examination (MMSE), revised Hasegawa Dementia Scale (HDS-R), Activities of Daily Living Scale (ADL), Scale for the Differentiation of Syndromes of Vascular Dementia scale (SDSVD) and Analysis of blood rheology, transcranial Doppler index to observe zhisanzhen and jiao's scalp acupuncture changes before and after the treatment of vascular dementia scale integration and hemorheology and cerebral hemodynamics, and comparative analysis, to understand the clinical curative effect of the zhisanzhen treatment of vascular dementia, especially improve the advantages in intelligence, so as to provide clinical basis for the popularization and application of clinical zhisanzhen treatment VD.
Methods
62cases were included in the study, based on simple randomized grouping design, will meet the inclusion criteria, exclusion criteria after screening out the case for zhisanzhen group and jiao's scalp acupuncture group. Fall off in4cases, completed the observation of58cases, including30cases of type zhisanzhen group, jiao's scalp acupuncture group of28cases. Zhisanzhen group acupoints:Court of God, the God of double. Jiao's type scalp acupuncture group acupuncture:foot motor sensory area, emotional district. The two groups were selected global brand0.30X25mm along the scalp acupuncture needle,15～30°angle down from the oblique in the subgaleal, rapid twirling, the general frequency of200times/min, the needle body rotating around the turn of two, and continued for about1minutes,30minutes treatment, middle needle1times, about1minutes. At the same time with the dialectical acupoints: syndrome of deficiency of kidney essence with too streams, hang a bell; phlegm blocking orifices with Hong Leong, intermediate people's court; blood stasis syndrome with Geshu, blood; hyperactivity of liver Yang and Taichong, liver Yu; fiery syndrome with inner chamber, Quchi; viscera stagnation and turbid leaving certificate with the court, Tianshu; Qi and blood deficiency syndrome with Zusanli, qihai. Method using lifting,thrusting, twirling reinforcing reducing method, along with the card reinforcing-reducing. Acupuncture1times a day,5times a week after a break of2days,4weeks treatment. At the same time with the conventional drug therapy. Observation items include①Mini-mental stat examination②Revised Hasegawa Dementia Scale③Activities of daily living scale④Scale for the Differentiation of Syndromes of Vascular Dementia and Analysis of blood rheology, transcranial Doppler. The above observation items were examined before and after treatment. Application SPSS19.0statistical software for statistical processing, the measurement data with the mean standard deviation, accord with the normal distribution of the data, using/test, comparison between groups was performed with/test, group and compared using the paired t test, multiple classification of disordered data using R*C table χ2test, four forms of the two classification index, two groups of grade data were compared with two sample rank sum test.
Results
This study collected58cases of eligible subjects, which zhisanzhen group30cases (male16cases, female14cases), jiao's scalp acupuncture group of28cases (male13cases, female15cases), two groups of average age was70.50years old and69.96years old, the average duration of4.50years and4.18years. The baseline data of two groups of patients with comparable analysis, two groups in gender, age, course of disease, degree of culture, common disease associated with distribution, before treatment the scale scores, dementia degree distribution, there was no statistical significance analysis, base line data between the two groups were comparable in. After treatment, the results showed:
1. Zhisanzhen group MMSE, HDS-R scale after treatment scores had significant difference (P<0.01), jiao's scalp acupuncture group MMSE, HDS-R scale after treatment score before treatment had no significant difference (P>0.05).
2. Two groups of ADL, SDSVD scale after treatment scores were significantly different (P<0.01). Zhisanzhen ADL, SDSVD scale after treatment of integral with jiao's scalp acupuncture group had no significant difference (P>0.05). That improvement two kinds of acupuncture on ability of daily life and syndromes of traditional Chinese medicine is better, and the difference is not obvious.
3. Two groups of indexes on blood rheology in patients with VD were significantly improved (p<0.05, P<0.01); especially for the whole blood viscosity, fibrinogen, ESR equation K value obviously improved (P<0.01). The two groups after treatment the blood rheology indexes with independent sample t-test, the whole blood viscosity at low-cut shear viscosity of whole blood,, whole blood high-cut shear viscosity, plasma viscosity, fibrinogen had no significant difference, K value of ESR zhisanzhen group on hematocrit, better than jiao's scalp acupuncture significantly (P<0.01).
4. Comparison of Vm before and after treatment of LMCA, zhisanzhen group, LACA, RMCA, RACA, RVA and other cerebrovascular Vm increased significantly (P <0.01, P<0.05), in which MCA Vm before and after treatment was significantly, P<0.01. Comparison of Vm before and after jiao's scalp acupuncture treatment group, LMCA, RMCA, RACA and other cerebrovascular Vm increased significantly (P<0.05), the rest of cerebral vascular Vm before and after treatment no significant differences. Comparison of PI before and after treatment LMCA, RMCA zhisanzhen group, cerebral vascular PI increased significantly (P<0.01), the rest of cerebral vascular PI before and after treatment no significant differences. Comparison of PI before and after jiao's scalp acupuncture treatment group, all the blood vessels of the brain PI showed no significant difference before and after treatment. Comparison of two groups after treatment with Vm, there was no significant difference of the cerebral vascular. Comparison of two groups after treatment with PI, there were significant differences in RMCA, RPCA, BA (P<0.01, P<0.05).
Conclusion
1. Zhisanzhen for VD patients cognitive ability certainly improve the efficacy of the degree of dementia, jiao's Scalp acupuncture no statistically significant efficacy in this regard.
2. Effects of zhisanzhen and jiao's scalp acupuncture on ability of daily life, TCM syndromes were better, and the difference is not obvious
3. Zhisanzhen and jiao's scalp acupuncture improvement indicators have better on blood rheology, especially on the whole blood viscosity, fibrinogen, ESR equation K value have obvious improvement. ESR equation K value of ESR zhisanzhen group on hematocrit, better than jiao's scalp acupuncture significantly
4. The average flow velocity zhisanzhen can significantly increase LMCA, LACA, RMCA, RACA, RVA and other blood vessels of the brain, the cerebral artery before and after treatment with significant difference; jiao's scalp acupuncture mean blood flow velocity of LMCA, RMCA, RACA and other cerebrovascular have improved.
5. Zhisanzhen cerebral artery pulsatility index improved, jiao's scalp acupuncture for all cerebrovascular pulsatility index no statistically significant improvement
引文
[1]于存娟,姜林芳,张志凡.血管性痴呆中医辫治体会[J].陕西中医,2005,26(1)：94-95.
[2]陈桂铭.血管性痴呆中医临床研究[J].中华实用中西医志,2004,17(4)：3198-3199.
[3]傅仁杰.脑血管性痴呆的辨证与治疗经验[J].北京中医杂志,1998,21(15)：27-29
[4]王永炎,刘金民,谢颖祯.中风病智能障碍的中医康复.北京中医药大学40周年校庆论文汇编[C].北京：学苑出版社,1996：561-563
[5]田金洲,韩明向,涂晋文等.血管性痴呆的诊断、辨证及疗效判断标准[J].北京中医药大学学报,2000,23(5)：16.
[6]封臻,王媛.马云枝教授三期论治血管性痴呆经验撷英[J].中国中医药现代远程育,2008,6(10)：1156
[7]周文泉.关于老年期痴呆中医药治疗的思考[J].暨南大学学报(医学版)1999,20(6)：14-16
[8]闰乐法.智灵汤治疗老年期血管性痴呆临床研究[J].中国中西医结合杂志,1998,18(7)：388-391.
[9]于向东,张洪斌,崔军.康脑灵胶囊治疗血管性痴呆的临床研究[J].中国医药学报,2003,18(2)：93-95
[10]周建英,刘涛,孙长春.益气复智颗粒治疗血管性痴呆病的临床研究[J].上海中医药杂志,2005,39(3)：11-13
[11]赵惠,孙忠人,孙远征,等.原络配穴为主治疗血管性痴呆疗效观察[J].中国针灸,2004,24(8)：525-527.
[12]王玲.针刺夹脊穴治疗血管性痴呆38例[J].上海针灸杂志,2005,24(7)：27.
[13]周婷,杨骏.针刺相关井穴治疗血管性痴呆的临床观察[J].中国实用医药,2008,3(15)：123.
[14]于晓曦.电针治疗血管性痴呆46例临床观察[J].针灸临床杂志,2003,19(9)：27.
[15]牛文民,刘海洋.头针治疗血管性痴呆的临床研究[J].上海针灸杂志,2007,26(10)：4-5
[16]赖新生,黄泳.百会、水沟、神门治疗血管性痴呆的比较研究[J].中国针灸,2005,25(8)：559-562.
[17]黄泳,Win Moe Htut,陈静,等.针刺百会人中神门治疗血管性痴呆的临床比较研究[J].云南中医中药杂志,2005,26(1)：41
[18]梅成,苏云海,周振坤.头部电针透刺疗法对血管性痴呆患者痴呆量表的影响[J].中国初级卫生保健,2007,21(6)：72.
[19]王惠明.电针法治疗血管性痴呆临床疗效观察[J].天津中医,2007,24(3)：218-220
[20]金君梅,金明兰.针灸配合药物治疗血管性痴呆30例临床观察[J].中国中医药科技,2004,11(5)：304.
[21]吕红霞.针刺加穴注治疗血管性痴呆的临床观察[J].心血管康复医学杂志,2005,14(3)：250.
[22]李滋平.舌针为主治疗血管性痴呆临床观察[J].针灸临床杂志,2008,24(7)：29-30.
[23]江红.眼针治疗血管性痴呆的临床观察[J].辽宁中医杂志,2006,33(10)：1333-1334
[24]谭纪萍,王莹,王鲁宁.血管性痴呆的危险因素探讨[J].中华老年心脑血管病杂志,2005,10(2)：118-120
[25]周红杰,王景周.血管性痴呆的危险因素及神经病理学研究[J].国外医学脑血管疾病分册1999,7(6)：344-347.
[26]刘举祥,张冬梅,蒋建章,张振峰.老年人脑卒中后痴呆危险因素分析[J].中国实用内科杂志.2000,20(2)：725-726.
[27]Brands A M, Biessels GJ, de Haan EH, et al. The effects of Type 1 diabetes on cognitive performance:a meta analysis[J]. Diabetes Care,2005,28(3):726-735.
[28]Smid J, Nitrini R, Bahia VS,et al. Clinical charaeterization of vaseular dementia:retrospective evaluation of an outpatient sample[J]. Arq Neuropsiquiatr,2001,9(2):390-393.
[29]Di Rosa M, Dell, Ombra N, Zambito AM, et al. Chitotriosidase and inflammatory mediator levels in Alzheimer's disease and cerebrovaseular dementia[J]. European Journal of Neuroseience,2006,3(10):2648-2656.
[30]Van Oi jen M, Witteman JC, Hofman A, et al. Fibrinogen is assoeiated with an inerease drisk of Alzheimer's disease and vaseular dementia[J]. Stroke,2005,36(12):2637-2641.
[31]邵福源,黄流清,薛红.血管性痴呆研究[J].中国临床神经科学,2001,9(1)：92-95
[32]李丹萍,易莉,陈强.针刺对脑缺血损伤级联反应和再灌注影响的研究进展[J].中国康复医学杂志,2005,20(11)：865-866.
[33]陈慧芳,哈志远.血管性痴呆与细胞因子[J].脑与神经疾病杂志,2006,14(6)：470-472.
[34]Gregg EW, Yaffe K, Cauley TA, et al. Is diabetes associated with cognitive impairment and cognitive decline aging older women[J]. Arch Intern Med.2000,160:174-180.
[35]JD. Curb, MD, B. L. Rodriguez, MD, R. D. Abbott. Longitudinal association of vascularand Alzheimer's dementias, diabetes, and glucose tolerance[J]. Neurology.1999,52:971-975.
[36]季永侠,袁荣峰.血管性痴呆研究进展[J].医学综述,2003,52(2)：481-486.
[37]Lindsay J, Hebert R, Roekwood K. The Canadian study of health and aging:risk factors for vaseular dementia[J]. Stroke,1997,28:526-530.
[38]吕传真.血管性痴呆的诊断标准[J].中国临床神经科学,2000,8(3)：22.
[39]Gorelick PB. Status of risk factors for dementia associated with stroke. Stroke,1997; 28(2):459-463.
[40]Galasko D, Klauber MR, Hofstetter CR, et al.The Mini-Mental State Examination in the early diagnosis of Alzheimer's disease[J]. Arch Neurol 1990,47:49-52.
[41]徐群,李焰生.血管性痴呆的治疗进展[J].国外医学-脑血管疾病分册,2005,13(9)：681-685
[42]肖军,韦永胜,黄雨兰,等.卡巴拉汀对血管性痴呆认知功能的影响[J].实用医学临床杂 志,2004,1(2)：22-23
[43]张丽慧,张士善.毗拉西坦促记忆作用与谷氨酸受体的关系(摘要)[J].温州医学院学报,1991,12(02)：145
[44]周红宇,郑国统,张十善.毗拉西坦促记忆作用原理的研究进展[J].中国药理学通报,1996,(02)
[45]Sudhir K. Memantine:Pharmaeological properties and clinical uses [J].Neurol India,2004,52(4):307-311.
[46]陈存国,金小红.尼莫同、刺五加联合治疗血管性痴呆疗效观察[J].临床医学,2004,24(11)：14-16
[47]Roman Gustavo C, Cholinergic dysfunction in vascular dementia [J]. CurrPsychiat Rep, 2005,7(1):18-26.
[48]刘会安.化浊益智针法治疗血管性痴呆的临床疗效观察及机理研究[J].中国针灸,1997,13(9)：52
[49]刘秋秋,李姣兰.头针治疗脑卒中42例的经颅多普勒观察[J].湖南医学,1998,(5)：304-305.
[50]杜广中,张登部,卜彦青,头体针对缺血性中风脑血管功能影响的对比观察[J].中国针灸,1999,(5)：265-266.
[51]关建军,姬军风,吴世卫等.针灸益气活血方对血管性痴呆大鼠突触可塑性的实验研究[J].陕西中医,2008：29(10)：1416-1417.
[52]章小平,胡小新.CT定位头部围针治疗中风偏瘫的疗效观察[J].中华中医药学刊,2004,22(10)：20-21.
[53]赖新生,余瑾.电针治疗血管性痴呆的动物实验研究[J].中国老年医学杂志,2001,21(1)：38-42.
[54]黄春元,王健,王鹏琴.头针疗法治疗血管性痴呆大鼠的实验研究[J].现代中西医结合杂志.2006,15(22)：3041.
[55]费兰波.中国头针疗法[M].北京：科学技术文献出版社,2000：24-76.
[56]黄文川,刘丽莉,赵跃,等.针刺对多发性脑梗塞患者脑电图的影响[J].针灸学报,1992,13(2)：13-15
[57]韩献景,王旭慧,董承超,等.针刺对快速老化痴呆小白鼠SAM-P/8脑组织儿茶酚胺类神经递质影响的实验研究[J].中国自然医学杂志,2000,2(4)：202.
[58]黄泳,唐安戊,李求实,等.头电针对正常人脑葡萄糖代谢的影响[J].中国针灸,2004,24(11)：779
[59]黄琴峰,刘婕.针灸治疗痴呆的临床规律探讨[J].中西医结合心脑血管病杂志,2010,8(7)：799-801
[60]Fuh JL,Teng EL, et al. The Informant Questionnaire on Cognitive Decline in the Elderly(IQCODE) as a sereening tool for dementia for a Predominantly illiterate Chinese PoPulation [J]. Neurology,1995,45:92-97.
[61]Narasimhalu K, Lee J, et al. ImProving detection of dementia in Asian Patients with low edueation:combining the Mini-Mental State Examination and the Informant Questiormaire on Cognitive Deeline in the Elderiy[J]. Dement Geriatr Cogn Disord,2008,25:17-23.
[62]黄泳,陈静等.百会、人中、神门治疗血管性痴呆的比较研究[J].江苏中医药,2005,26(3)：11-13