摘要
原发性痛经是指非盆腔器质性病变引起的痛经,为子宫内在功能障碍所致,多发于月经初潮后2～3年的青春期少女或未生育的年轻妇女,因其高发病率及治疗棘手,给女性的身心健康和工作学习带来了严重的影响。西医治疗尚无令人满意的方法,针灸疗法以其疗效显著、操作简便、无毒副作用而被广泛应用。热敏灸疗法是一种创新性灸疗方法,它是以辨敏施灸为要点,以个体的饱和灸量为施灸量,注重经气感传,通过灸感、灸位、灸量等各影响因素的改善作用,最大发挥艾灸的治疗作用。本课题以原发性痛经为研究内容,从文献研究和临床实验研究两个方面对灸感与灸效的关系进行了探讨。
第一部分：文献研究
文献研究的第一部分内容系统论述现代医学对原发性痛经的机理认识与研究,以及古代医家对痛经的病因病机、证治规律等的认识,以指导临床诊断、治疗及科学研究。文献研究第二部分着重介绍了腧穴热敏化的理论及临床研究进展,全面对这一创新性理论做了阐释与总结,以期发现研究中存在的不足和今后发展的方向。文献研究第三部分介绍了红外热成像技术原理、在医学界的应用情况及红外热像技术在针灸经络研究中的应用情况,从而为红外热成像在热敏灸技术方面的应用成为可能。
第二部分：实验研究
研究一、灸感法与红外法检测原发性痛经患者关元穴热敏态的对比研究
目的：以原发性痛经患者为研究对象,通过灸感法与红外热成像法检测关元穴的热敏状态的对比研究,检测红外热成像法的敏感性(真阳性率)、特异性(真阴性率)、准确性,从而为灸感是否可以在一定程度上被红外热成像客观显示提供客观依据。
方法：纳入原发性痛经患者80例,灸感法以热感扩散或传导的长径≥10cm为关元穴区热敏态阳性,反之<10cm为关元穴区热敏态阴性。红外法以①艾灸前关元穴区与对照点区平均温度的差值△F≥0.3℃为关元穴区热敏态阳性(由成像系统自动计算得出,单位℃),反之<0.3℃为关元穴区热敏态阴性；②艾灸关元穴区后产生沿腹部正中纵向扩散(任脉)或横向扩散(带脉)的红外辐射增强区域(温度升高0.5℃以上)的长径≥10cm为关元穴区热敏态阳性(由成像系统自动计算得出,单位℃),反之<10cm为关元穴区热敏态阴性。计算红外热成像法的敏感性(真阳性率)、特异性(真阴性率)、准确性。
结果：热敏化关元穴区静态,其红外辐射强度多数显示低温特征,与灸感法比较,其敏感性(真阳性率)为75.5%,特异性(真阴性率)为74.1%,准确性为75.0%；艾灸关元穴区后,发生热敏化的关元穴区产生明显沿腹部正中产生纵向扩散(任脉)或横向扩散(带脉)的红外辐射增强区域,与灸感法比较,其敏感性(真阳性率)为77.4%,特异性(真阴性率)为70.4%,准确性为75.0%。
结论：静态与敏化态的热敏化腧穴在一定程度上都可被红外热成像技术所反应,红外热成像技术可以应用到腧穴热敏化客观显示的研究中,为腧穴热敏化的临床研究提供客观依据。
研究二、热敏灸治疗原发性痛经(寒湿凝滞型)灸感与灸效相关性研究
目的：通过对原发性痛经患者临床量表评分的观察以及痛经相关实验数据的检测,观察热敏灸治疗原发性痛经的疗效,从而检测灸感与灸效的相关性。
方法：纳入117例原发性痛经患者,以灸感法与红外热成像结合的热敏化腧穴定性检测法进行实验分组,按照穴位是否热敏化,将穴位组自动分为热敏态组与非热敏态组。共治疗3个疗程,随访3个月。记录灸感、量表评分,生化指标检测。
结果：①原发性痛经(寒湿凝滞型)患者关元穴热敏化率达52.1%；②第一疗程关元穴的热敏化平均为5.17天,第二疗程为4.27天,第三疗程平均为3.06天；③本研究热敏化组的平均饱和灸量为63.20±16.08分钟；④通过对原发性痛经症状积分、McGill疼痛量表、COX痛经症状量表等几项观察指标进行评估,热敏态组与非热敏态组对于原发性痛经(寒湿凝滞型)近期疗效都有明显疗效,但热敏态组明显优于非热敏态组；随访3个月,热敏态组病情未复发,非热敏态组病情有复发,刺激热敏态穴位的远期疗效明显优于非热敏态穴位。⑤通过对原发性痛经经血中PGF2α、PGE2、AVP的检测,热敏态组与非热敏态组对PGF2α/PGE2、AVP均有较明显的改善作用,但两组之间比较有非常显著性差异。在治疗结束后3个月与治疗结束时比较,热敏态组疗效稳定,而非热敏态组疗效不稳定,病情有复发,从客观指标反映,热敏态组的远期疗效远好于非热敏态组。
结论：关元穴热敏化出现的概率与病情有高度相关性；原发性痛经的饱和灸量为1小时左右；热敏态腧穴的近期疗效与远期疗效皆优于非热敏态腧穴。
Primary dysmenorrhea refers to dysmenorrhea caused by the non-pelvic organic disease, and it is due to urerine intrinsic dysfunction. It always begins from2or3years after menarche of adolescent girls or young women without childbearing. It takes serious impact on women's physical and mental health because of its high incidence and difficult treatment. There is no satisfactory method with western medical treatment, while acupuncture and moxibustion is widely used for its efficacy, easy to operate, non-toxic side effects. Heat-sensitive moxibustion is an innovative moxibustion method. The key point is its treatment based on sensitivity differentiation. Its capacity for moxibustion bases on individual saturated quantity. It pays attention to channel transmission and maximizes the therapeutic effect of moxibustion through improve moxibustion sense, moxibustion point and moxibustion quantity. This subject will research from literature and clinical
Part I:Literature Search
The first part of the literature systematically discusses the mechanism of primary dysmenorrhea from the point of view of modern medical knowledge, as well as the pathogenesis and therapeutic rules of diseases from the point of view of ancient physicians. It is used to guide the clinical diagnosis, treatment and scientific research. The second part focuses on the theoretical and clinical advances of heat-sensitive moxibustion, interprets and summarizes this innovative theory to find disadvantage and guide the direction of development. The third part introduces the theory of infrared thermal imaging technology, as well as the application in medicine and in acupuncture-meridian research, which makes it possible to apple the infrared thermal imaging to heat-sensitive moxibustion technology.
Part II:Experimental study
Study one:The comparative study between moxibustion sense and infrared thermal imaging through detecting heat-sensitive Guanyuan of primary dysmenorrhea
Objective:Primary dysmenorrhea patients are studied. Through the comparative study between moxibustion sense and infrared thermal imaging, detects the sensibility(true positive rate), specificity(true negative rate) and veracity of infrared thermal imaging, provides objective basis for moxibustion sense can be objectively displayed by infrared thermal imaging from a certain extent.
Methods:80primary dysmenorrhea cases were studied. Moxibustion sense method make thermal diffusion or conduction length≥10cm as the Guanyuan area thermal state positive, and vice versa<10cm for the thermal state of Guanyuan area negative. Infrared Method:①The average temperature difference between Guanyuan and control piont ΔF>0.3℃befor operate is positive(calculated automatically by the imaging system, the unit℃), and vice versa<0.3℃is negative.②See the diameter of infrared radiation region (the temperature rises above0.5℃) produced along the abdominal median longitudinal diffusion (Ren) or lateral diffusion (Dai) afer Moxibustion>10cm as the Guanyuan area thermal state positive, and vice versa<10cm for the thermal state of Guanyuan area negative. Calculate the sensitivity (true positive rate), specificity (true negative rate) and accuracy of the infrared heat image method.
Results:Under the resting state of heat-sensitive Guanyuan, the majority of the infrared radiation intensity displayed low temperature characteristics. Compared with moxibustion sense method, the sensitivity was75.5%, the specificity was74.1%and the accuracy was75.0%. The heat-sensitized Guanyuan produced obvious infrared radiation region along the abdominal median longitudinal diffusion (Ren) or lateral diffusion (Dai) afer Moxibustion. Compared with moxibustion sense method, the sensitivity of thermal infrared imager was77.4%, the specificity was70.4%and the accuracy was75.0%.
Conclusion:Heat-sensitive points in resting state or functional state could be reacted by infrared thermal imaging technology to a certain extent. Infrared thermal imaging technology could be applied to objective display research on heat-sensitive point and provide objective basis for clinical research of heat-sensitive point.
Study Two:The correlated study between moxibustion sense and moxibustion effect through heat-sensitive moxibustion treating primary dysmenorrhea
Objective:Through observation on the clinical scale scores of patients with primary dysmenorrhea and the detection of experimental data related to dysmenorrhea, detect the effect of heat sensitive moxibustion and the correlation between moxibustion sense and moxibustion effect.
Methods:117cases of patients with primary dysmenorrhea were studied. The groups were divided up by the combined method of moxibustion sense and infrared thermal. According to whether the point was heat-senstized, patients were divided automaticlly into heat-sensitized group and non-heat-sensitized group. Treated3courses, follow-up visit3months and writed down moxibustion sense, scale scores and biochemical indicators.
Results:①The heat-sensitized rate of Guanyuan point was52.1%in patients with primary dysmenorrhea.②The average days of heat-sensitized Guanyuan was5.17days in the first course,4.27days in the second course and3.06days in the third course.③The average amount of saturated quantity of moxibustion was63.20±16.08minutes in heat-sensitized group.④Though the assessments of symptom scores, McGillPain Questionnaire, COX scale of primary dysmenorrhea, recent treatment results were significant for both heat-sensitized group and non-heat-sensitized group in treating primary dysmenorrhea, heat-sensitized group was obviously better than non-heat-sensitized group; Follow-up of3months, symptoms of heat-sensitized group was not recurrence, while symptoms of non-heat-sensitized group recured. The long-term efficacy of heat-sensitized group was significantly better than the non-heat-sensitized group.⑤Through the detection of PGF2α、PGE2、AVP in primary dysmenorrhea menses, recent treatment results were significant for both heat-sensitized group and non-heat-sensitized group in improvement of PGF2a/PGE2、AVP, but heat-sensitized group was obviously better than non-heat-sensitized group; Follow-up of3months, symptoms of heat-sensitized group was not recurrence, while symptoms of non-heat-sensitized group recured. Reflected by objective indicator, the long-term efficacy of heat-sensitized group was significantly better than the non-heat-sensitized group.
Conclusion:The probability of occurrence of heat-sensitive Guanyuan are high related with the state of illness; The saturated quantity of moxibustion is about1hour. The short-term effect and long-term efficacy of heat-sensitized point are superior to non-heat-sensitized point.
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