摘要
研究背景：
脑血管病具有发病率高、致残率高、死亡率高的“三高”特点,是威胁人类尤其是中老年人健康的常见疾病、多发病,所以日益受到政府和医学界的重视。针刺疗法是借助毫针刺激人体穴位和经络治疗疾病的一种常见的治疗方法,它简便易行,疗效显著,无副作用。针灸治疗缺血性脑病具有的临床疗效已经被证实。目前针刺对缺血性脑病的临床研究尚缺乏高质量的随机对照研究支持,以本研究项目针灸治疗中风后遗症的疗效为例,以往文献尚存在不同程度缺陷,缺乏多中心、大样本的随机对照试验,很难为针灸治疗中风后遗症提供循证医学依据,使针灸治疗中风后遗症的疗效得到国内外公认。所以需要我们从循证医学的角度建立中风后遗症的针刺优选方案,从针刺穴位、深度、手法及治疗时间等方面制定适宜的治疗标准,观察靳三针治疗患者偏瘫肢体运动功能和日常生活活动能力,提出针刺治疗中风后遗症的优化方案和临床指南。
本研究的实验部分是在以上临床的基础上,采用现代分子生物学技术对其针刺机制的进一步探讨。脑缺血损伤引起的神经元结构破坏和缺失是引起功能障碍的病理关键。针对脑缺血损伤引起的生化、代谢改变,保护神经元免于受损,或促进脑缺血损伤后神经细胞再生成为干预损伤、恢复功能的重要策略。目前药物性的神经保护研究和临床应用仍欠理想。骨髓间充质干细胞(bone marrow stromal stem cells, BMSCs)具有较强的增殖能力和多向分化潜能,可以分化为神经元、星形胶质细胞和少突胶质细胞等神经细胞,成为脑缺血损伤后神经细胞再生理想的种子来源。故对体外纯化、扩增培养的骨髓间充质干细胞移植脑内以治疗脑缺血损伤成为近年来研究的热点。因此,开展骨髓间充质干细胞移植在神经细胞再生和神经功能修复方面的研究对脑缺血损伤机制具有重要意义。近年来许多中医药联合骨髓间充质干细胞移植治疗脑缺血损伤取得一定成绩,而针刺对BMSCs移植后在活体内影响其存活、分化方面的研究少见。鉴于此,开展靳三针协同骨髓间充质干细胞移植治疗脑缺血损伤研究具有重要意义。
目的：
通过实验与临床研究,阐明靳三针对缺血性脑卒中的疗效及其作用机理,为靳三针的推广应用提供科学的理论和实践依据。方法：
(一)临床研究：采用随机、分组及分析者(即第三者)盲法方法将135例分组为靳三针针刺组45例,康复组45例,靳三针加康复组45例,在药物对症治疗基础上,分别应用靳三针针刺治疗、康复治疗、靳三针针刺加康复治疗,于治疗前后用Fugl-Meyer法及Barthel指数评定两组患者偏瘫肢体运动功能和日常生活活动能力。
(二)实验研究：采用线栓法制作大鼠大脑中动脉缺血再灌注损伤模型,并采用神经功能评分、TTC染色、HE染色、荧光显微镜等方法,分别对假手术组、脑缺血组(模型组)、骨髓基质干细胞组、靳三针针刺组、靳三针协同骨髓基质干细胞组的缺血后大鼠神经功能缺失征象、梗死体积、形态学、每切片中转染后的骨髓间充质干细胞进入脑实质的数量等进行观察。
结果：
(一)临床研究：靳三针组、康复组及靳三针加康复组各组分别在治疗前、治疗14后、治疗28天后Fugl-Meyer值及Barthel指数积分存在显著统计学差异(P<0.01),治疗前及治疗14天后三组之间比较Fugl-Meyer值及Barthel指数积分相近,差异无显著性(P>0.05)；治疗28天后靳三针组及靳三针加康复组Fugl-Meyer值分别与康复组比较有统计学差异(P<0.05),治疗28天后靳三针加康复组Barthel指数积分与康复组比较有统计学差异(P<0.05)。
(二)实验研究：通过对脑缺血大鼠神经功能改善的影响进行观测和比较,与BMSCs组、靳三针针刺组比较,靳三针协同BMSCs组均可改善神经缺失症状,减少缺血体积(P<0.05),但靳三针协同BMSCs组中转染后的骨髓间充质干细胞进入脑实质数量与BMSCs组无明显统计学差异。
结论：
临床观察表明靳三针针刺疗法能促进中风后偏瘫患者偏瘫肢体运动功能和日常生活活动能力。若与康复配合能达到更理想的疗效。故靳三针是治疗缺血性脑卒中的理想方法之一,值得推广应用。实验研究认为靳三针协同BMSCs组能改善神经缺失症状,减少缺血体积,发挥对抗缺血损伤的作用,具有显著的脑保护作用,但靳三针协同BMSCs组中转染后的骨髓间充质干细胞进入脑实质数量与BMSCs组无明显统计学差异,但我们观察到,靳三针协同BMSCs组中转染后的骨髓间充质干细胞进入脑实质后向缺血灶迁移、聚集尚存在一定的优势。
Objective:To evaluate the influence of Jin'3-needle therapy on the hemiplegia motor functionandactivities of daily living in patients with apoplectic hemiplegia, and to investigate the effect and mechanism of Jin'3-needle therapy intreating apoplectic hemiplegia by experimental study and provide using Jin' 3-needle and bone marrow stem cells(BMSCs) therapy in apoplectic hemiplegia.
Method:
Clinical study:one hundred and thirty-five patients were equally randomized into three groups.Jin'3-needle therapy group (45cases)、Rehabilitation group (45cases)、Jin'3-needle and rehabilitation group (45cases), The degree ofhemiplegia motor functionandactivities of daily living in patients with apoplectic hemiplegia were assessed with Fugl—eyer assessment(FMA)'and Barthel index before and after treatment.
Animal experimental study:forty SD rats were randomly divided into five groups: the pseudo operated group, the model group (operated), Jin'3-needle therapy group, BMSCs groups, Jin'3-needle and BMSCs therapy group. The rats cerebral ischemic strokemodel were subjected to focal ischemic by middle cerebral artery occlusion(MCAO)using intraluminal thread. The neurologic impairment scoring, cerebral ischemic area measured by TTC-staining were observed and compared between groups.
Results:
Clinical study:After 14 days and 28 days treatment, the FMA and Barthel index values of all of the three groups are better than before (P<0.01).After 14 days, there were no significant difference among the three group with the values of FMA and Barthel index;after 28 days, there were significant difference between the Jin'3-needle therapy group and rehabilitation group with the values of FMA, there were significant difference between the Jin' 3-needle and rehabilitation group and rehabilitation group with the values of FMA, there were significant difference between the Jin'3-needle therapy group and rehabilitation group with the values of Barthel index. And there was no severe adverse reactions in patients caused by Jin'3-needle therapy. Animal experimental study:to compare the pseudo operated group、the model group (operated), Jin'3-needle therapy group, BMSCs groups, Jin'3-needle and BMSC therapy group has improved neurologic impairment, cerebral ischemic area measured by TTC-staining, and Jin'3-needle and BMSCs therapy group has more BMSCs in prostomial ganglion.
Conclusion:Jin'3-needle therapy on the patients of apoplectic hemiplegiahas a difinite therapeutic effect on the hemiplegia motor functionandactivities of daily living. There will be a better therapeutic effect if to match rehabilitation. Jin'3-needle has no obvious function to has more BMSCs in prostomial ganglion, but the effect of to focuses is obvious in the pictures of animal experimental study.
引文
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