本文關(guān)鍵詞：易罐結(jié)合針刺治療網(wǎng)球肘的臨床研究及作用機(jī)制初探　出處：《廣州中醫(yī)藥大學(xué)》2017年博士論文　論文類型：學(xué)位論文

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【摘要】：網(wǎng)球肘(Tennis Elbow)又被稱為肱骨外上髁炎、肘外側(cè)疼痛綜合征,多由于長期累積性的反復(fù)牽拉伸肌腱,導(dǎo)致前臂肌肉群及肌腱的微損傷,形成局部勞損,造成伸肌肌腱退變的一種肘外側(cè)部的肌腱病(Lateral elbow tendinopathy,LET)。本病多見于需要長期反復(fù)用力伸腕的工作者或運(yùn)動(dòng)員,尤其是經(jīng)常性地轉(zhuǎn)動(dòng)前臂者,如攪拌工、網(wǎng)球運(yùn)動(dòng)員、小提琴手、挖木工等,以40-50歲成人發(fā)病居多,男性網(wǎng)球運(yùn)動(dòng)員發(fā)生率高于女性,但在一般人群中男女患病比例基本相同。西醫(yī)認(rèn)為網(wǎng)球肘的主要致病機(jī)理是手腕伸展肌群過度使用,導(dǎo)致外上髁附著處的肌肉或肌腱微小創(chuàng)傷,長期積累而無法修復(fù),肌腱退行性變,形成慢性無菌性炎癥,并最終引起肘外側(cè)部疼痛。網(wǎng)球肘是一種自身局限性的無菌炎癥反應(yīng),90%的患者不經(jīng)過治療,依靠自身的修復(fù)可以痊愈。然而網(wǎng)球肘自身的修復(fù)時(shí)間周期比較長,疼痛難以忍受,復(fù)發(fā)率高,容易形成頑固性網(wǎng)球肘,增加治療難度。臨床治療以保守療法為主,包括疼痛緩解藥物、局部類固醇注射、體外沖擊波治療、運(yùn)動(dòng)療法、肘部護(hù)具等。中醫(yī)認(rèn)為網(wǎng)球肘是由于外傷、勞損,風(fēng)寒濕邪閉阻導(dǎo)致肘關(guān)節(jié)氣血凝滯不通,絡(luò)脈淤阻,遷延日久,不通則痛;或素體虧虛,血不榮筋,筋骨長期得不到有效的潤養(yǎng),不榮則痛。中醫(yī)治療"肘痹"的歷史比較悠久,已經(jīng)形成了自己獨(dú)特的理論及臨床實(shí)踐方案,在治療網(wǎng)球肘的過程中,總體較西醫(yī)的外科手術(shù)、激素療法、沖擊波療法等副作用要小,復(fù)發(fā)率低,也無不良并發(fā)癥,受到眾多患者的青睞。因此,本研究主要從中醫(yī)療法治療網(wǎng)球肘的臨床效應(yīng)入手。研究目的:由于針刺和易罐療法在治療網(wǎng)球肘方面具有獨(dú)特的優(yōu)勢,兩種療法結(jié)合在臨床治療中取得了不錯(cuò)的臨床效果。本課題研究擬結(jié)合針刺和易罐的治療方法給予網(wǎng)球肘患者治療,將單純傳統(tǒng)針刺療法作為比較,進(jìn)行臨床隨機(jī)對(duì)照試驗(yàn),探討其治療網(wǎng)球肘的臨床療效及可能的作用機(jī)制,為臨床醫(yī)生治療網(wǎng)球肘提供了優(yōu)選治療方案。研究方法:在香港荃灣區(qū)吳氏中醫(yī)診療所招募到的符合試驗(yàn)納入標(biāo)準(zhǔn)的60例網(wǎng)球肘患者作為研究對(duì)象。將研究對(duì)象按照隨機(jī)對(duì)照分組的原則均分試驗(yàn)組和對(duì)照組各30例。試驗(yàn)組網(wǎng)球肘患者給予傳統(tǒng)針刺結(jié)合易罐的療法治療�；颊呷≌�,將患肢前臂平放于治療桌上,常規(guī)消毒后,針刺阿是穴、曲池、外關(guān)、手三里、合谷、支溝、中渚穴,得氣后施行平補(bǔ)平瀉手法,留針30分鐘。出針后進(jìn)行易罐治療,時(shí)間為10分鐘。隔天治療1次,10次為1療程。對(duì)照組只進(jìn)行以上所述的傳統(tǒng)針刺治療,治療方法與療程與試驗(yàn)組一致。在進(jìn)行治療前,先對(duì)納入試驗(yàn)的所有病例包括試驗(yàn)組和對(duì)照組進(jìn)行試驗(yàn)治療前病情簡單評(píng)價(jià),評(píng)價(jià)項(xiàng)目包括JOA肘部功能評(píng)分、ADL日常生活活動(dòng)能力評(píng)分、臨床癥狀積分、簡化McGill疼痛問卷、患肢痛點(diǎn)紅外成像的最高溫度五個(gè)項(xiàng)目指標(biāo),同時(shí)分析納入對(duì)象的性別構(gòu)成及年齡分布,以確保研究對(duì)象的基線具有一致性。在網(wǎng)球肘患者進(jìn)行第一次治療結(jié)束后15min,采用SF-MPQ量表中的VAS評(píng)分量表為評(píng)價(jià)標(biāo)準(zhǔn)及對(duì)患處進(jìn)行紅外熱成像檢測,進(jìn)行即時(shí)止痛效果療效評(píng)價(jià),探索分析兩種治療方法的即時(shí)止痛效果。整個(gè)療程10天的治療結(jié)束后,對(duì)兩組網(wǎng)球肘患者治療后的JOA肘部功能評(píng)分、ADL日常生活活動(dòng)能力評(píng)分、臨床癥狀積分簡化McGill疼痛問卷、患肢痛點(diǎn)紅外成像的最高溫度再進(jìn)行一次評(píng)分測量,通過對(duì)比治療前的基礎(chǔ)指標(biāo),統(tǒng)計(jì)分析兩種治療方法的療效。完成治療后的1個(gè)月,以電話或面談的方式對(duì)參與治療的全部網(wǎng)球肘患者進(jìn)行隨訪,隨訪記錄日常生活活動(dòng)能力,并采用ADL量表打分以評(píng)價(jià)遠(yuǎn)期治療效果。研究結(jié)果:本次臨床研究共60例網(wǎng)球肘患者納入試驗(yàn)研究,治療期間患者積極配合,整個(gè)試驗(yàn)過程中沒有出現(xiàn)剔除或脫落的病例。根據(jù)臨床試驗(yàn)的隨機(jī)分組原則,試驗(yàn)組和治療組各30例,對(duì)兩組網(wǎng)球肘患者的性別構(gòu)成及其年齡分布情況進(jìn)行統(tǒng)計(jì)學(xué)分析,均無統(tǒng)計(jì)學(xué)差異(P0.05),說明試驗(yàn)組和治療組的病人在性別構(gòu)成、年齡分布上一致性較好。在進(jìn)行試驗(yàn)治療前,先對(duì)納入試驗(yàn)研究的患者進(jìn)行JOA肘功能評(píng)分,試驗(yàn)組和對(duì)照組治療前評(píng)分相比較無統(tǒng)計(jì)學(xué)差異(P0.05),即可認(rèn)為兩組患者治療前肘部受限活動(dòng)程度較一致。ADL日常生活活動(dòng)能力評(píng)分是評(píng)價(jià)患者肘部疾患對(duì)日常生活自理能力的影響。試驗(yàn)組和對(duì)照組治療前評(píng)分相比較無統(tǒng)計(jì)學(xué)差異(P0.05),兩組網(wǎng)球肘患者的日常生活自理能力較一致。臨床癥狀積分是醫(yī)生對(duì)患者進(jìn)行體格檢查所得到的較客觀的病情量化評(píng)價(jià)積分。醫(yī)者先對(duì)試驗(yàn)組和治療組被納入試驗(yàn)的研究對(duì)象進(jìn)行臨床癥狀檢查并給予客觀評(píng)價(jià),試驗(yàn)組和對(duì)照組治療前評(píng)分相比較無統(tǒng)計(jì)學(xué)差異(P0.05),可知治療前兩組患者的臨床癥狀嚴(yán)重程度相近。SF-MPQ評(píng)分問卷包含三項(xiàng)內(nèi)容,分別在疼痛等級(jí)、患者疼痛視覺評(píng)分、現(xiàn)時(shí)疼痛程度三個(gè)方面綜合評(píng)價(jià)患者的疼痛感受。兩組患者治療前的PRI、VAS、PPI評(píng)分相比較無統(tǒng)計(jì)學(xué)差異(P0.05),說明兩組患者的疼痛程度的一致性較好。紅外成像儀測得的患者肘部痛點(diǎn)處最高溫度,是疼痛局部炎癥的較為直觀的量化評(píng)價(jià)指標(biāo)。兩組患者治療前的局部最高溫度相比較無統(tǒng)計(jì)學(xué)差異(P0.05),說明兩組患者治療前疼痛局部皮溫接近。接受治療所有的網(wǎng)球肘患者,在接受第一次治療結(jié)束后的15min,立即進(jìn)行VAS評(píng)分,并進(jìn)行統(tǒng)計(jì)學(xué)分析。第一次治療結(jié)束后,試驗(yàn)組、對(duì)照組的治療前后進(jìn)行比較,均有顯著統(tǒng)計(jì)學(xué)差異(P0.01),說明針刺加易罐療法及單獨(dú)針刺治療都能改善患者的VAS評(píng)分。試驗(yàn)組和對(duì)照組相比VAS評(píng)分差值組間比較有顯著統(tǒng)計(jì)學(xué)差異(P0.01),說明針刺加易罐療法對(duì)網(wǎng)球肘患者VAS評(píng)分法的改善程度較單獨(dú)針刺治療組的改善程度要好。第一次治療結(jié)束后痛點(diǎn)溫度,試驗(yàn)組、對(duì)照組的治療前后進(jìn)行比較,均有顯著統(tǒng)計(jì)學(xué)差異(P0.01),說明針刺加易罐療法及單獨(dú)針刺治療都能使網(wǎng)球肘患者損傷局部皮溫降低。試驗(yàn)組和對(duì)照組痛點(diǎn)溫度改善程度組間比較,試驗(yàn)組痛點(diǎn)溫度差改善更為明顯,對(duì)比有統(tǒng)計(jì)學(xué)意義(P0.01),即針刺加易罐療法對(duì)網(wǎng)球肘患者局部痛點(diǎn)溫度改善程度較單純針刺治療要高。所有研究對(duì)象完成第一個(gè)療程治療結(jié)束后兩組的JOA功能評(píng)分、日常生活活動(dòng)能力ADL量表評(píng)分、臨床癥狀積分、簡化McGill疼痛問卷中各項(xiàng)的評(píng)分、痛點(diǎn)處最高溫度,治療后試驗(yàn)組及對(duì)照組均較治療前的評(píng)分顯著改善(P0.01),說明針刺加易罐療法及單純針刺治療法都有不錯(cuò)的治療效果。進(jìn)一步統(tǒng)計(jì)分析療程治療后試驗(yàn)組和對(duì)照組組間的數(shù)據(jù),試驗(yàn)組較對(duì)照組JOA量表評(píng)分差值改變程度更顯著(P0.01);試驗(yàn)組ADL量表評(píng)分差值較對(duì)照組有改善(P0.05);試驗(yàn)組臨床癥狀積分差改善程度與對(duì)照組的改善程度之間無統(tǒng)計(jì)學(xué)差異(P0.05);試驗(yàn)組簡化McGill疼痛問卷中的PRI、VAS、PPI評(píng)分與對(duì)照組相比無統(tǒng)計(jì)學(xué)差異(P0.05);試驗(yàn)組治療前后痛點(diǎn)最高溫度差與對(duì)照組相比無統(tǒng)計(jì)學(xué)差異(P0.05)。隨訪ADL量表評(píng)分組間比較,試驗(yàn)組ADL評(píng)分較對(duì)照組評(píng)分高,且有統(tǒng)計(jì)學(xué)意義(P0.05)。試驗(yàn)組對(duì)比對(duì)照組,雖然在療程療效的臨床癥狀積分、簡化McGill疼痛問卷、紅外成像的痛點(diǎn)溫度等方面兩組之間沒有明顯差別,但試驗(yàn)組的優(yōu)勢在于:對(duì)首次治療結(jié)束后的VAS評(píng)分和紅外成像的痛點(diǎn)溫度的改善,療程療效的JOA肘功能量表和ADL量表的改善,還有遠(yuǎn)期療效的ADL量表的改善。即試驗(yàn)組的療法可以更好地產(chǎn)生即時(shí)的止痛效果,更好地促進(jìn)治療后肘部功能的恢復(fù),以及對(duì)于治療后和遠(yuǎn)期的日常生活活動(dòng)能力的改善。研究結(jié)論:①單純針刺治療及針刺結(jié)合易罐療法都能改善網(wǎng)球肘的JOA肘部功能評(píng)分、ADL 口常生活活動(dòng)能力評(píng)分、臨床癥狀積分、簡化McGill疼痛問卷評(píng)分和痛點(diǎn)局部最高溫度,治療網(wǎng)球肘有效;②針刺結(jié)合易罐療法的即時(shí)止痛效果及遠(yuǎn)期療效均優(yōu)于單純針刺療法。
[Abstract]:Tennis elbow (Tennis Elbow) is also known as lateral epicondylitis, lateral elbow pain syndrome, due to long-term accumulation of cyclic tensile tendons, resulting in forearm muscles and tendons micro damage, the formation of local strain, muscle tendon disease caused by degeneration of the extensor tendon of a lateral elbow Department (Lateral elbow tendinopathy LET). The disease is more common in long-term repeated hard wrist workers or athletes, especially frequently turn the forearm, such as mixer, tennis player, violinist, dig woodworking etc with 40-50 year old adult onset mostly male tennis players were higher than those in women, but in the general population prevalence ratio of men is basically the same. According to western medicine, the main pathogenesis of tennis elbow is the excessive use of extensor muscles of wrist, resulting in minor injuries of muscles or tendons at the attachment of external epicondyle, which can not be repaired for a long time, degenerative tendons, forming chronic aseptic inflammation, and eventually causing pain on the lateral elbow. Tennis elbow is a self limiting reaction of aseptic inflammation, and 90% of the patients are cured without treatment and can be cured by their own repair. However, the repair time of tennis elbow is long, the pain is unbearable, the recurrence rate is high, it is easy to form the stubborn tennis elbow and increase the difficulty of treatment. Clinical treatment is mainly conservative therapy, including pain relief drugs, local steroid injection, extracorporeal shock wave therapy, exercise therapy, elbow protector and so on. Chinese medicine believes that tennis elbow is due to injury and strain, the wind cold dampness stagnation caused elbow blood stagnation barrier, obstruction of collaterals, protracted, no pain; or ferrite deficiency, may B. and long-term lack of effective moistening, not glory pain. Chinese medicine treatment of "elbow Bi" has a long history, has formed its own unique theory and clinical practice, in the process of treating tennis elbow in general surgery compared with western medicine, hormone therapy, shock wave therapy and other side effects of small, low recurrence rate, no adverse complications, by many patients favor. Therefore, this study mainly starts with the clinical effect of traditional Chinese medicine therapy for tennis elbow. Research purposes: Acupuncture and cupping therapy have unique advantages in the treatment of tennis elbow. The two therapies have achieved good clinical results in clinical treatment. This research intends to acupuncture therapy and combined treatment with easy tank tennis elbow, simple traditional acupuncture therapy as compared to randomized clinical trials, to investigate the clinical curative effect for the treatment of tennis elbow and the possible mechanism, providing optimal treatment for clinical treatment of tennis elbow. Research methods: in Hongkong traditional Chinese medicine clinics in Tsuen Wan District Wu recruited to meet the 60 cases of patients with tennis elbow test standards as the research object. The subjects were divided into 30 cases in the test group and the control group according to the principle of the randomized controlled group. The experimental group of tennis elbow patients was treated with traditional acupuncture combined with easy canister therapy. Patients take seat, limb forearm flat on the treatment table, after routine disinfection, acupuncture point, Quchi, Waiguan, hand three years, Hegu, ditch, Zhongzhu point, after the gas as reinforcing reducing techniques, for 30 minutes. After the needle was released, the time was 10 minutes. 1 times a day, 10 times for 1 courses. The control group only carried out the traditional acupuncture treatment mentioned above, and the treatment method and the course of treatment were in accordance with the experimental group. In the treatment before, first of all test cases including experimental group and control group were tested before treatment simple evaluation, evaluation of the project include JOA ADL elbow function score, ADL score, clinical symptom score, simplified McGill pain questionnaire, limb pain point infrared imaging the highest temperature of the five items index. The analysis included gender and age distribution of the object, to ensure that the baseline is consistent with the research object. After the first treatment of tennis elbow patients, 15min used the VAS scale of SF-MPQ scale as the evaluation standard and the infrared thermography of the affected part to evaluate the effect of immediate analgesic effect, and explored the immediate analgesic effect of the two treatments. Over the entire course of treatment after 10 days of treatment in two group score, tennis elbow after elbow function JOA ADL ADL score, clinical symptoms of simplified McGill pain questionnaire, the highest temperature of phantom pain IR imaging to a score based index measurement, compared to before the treatment, statistical analysis of efficacy two treatment methods. 1 months after the completion of treatment, all tennis elbow patients who participated in the treatment were followed up by telephone or interview. Their activities of daily living were followed up, and the ADL scale was used to score the long-term effect. Results: a total of 60 tennis elbow patients were included in the experimental study. During the treatment period, the patients were actively coordinated, and no cases of rejection or falling out were found during the whole experiment. According to the principles of randomized clinical trials, experimental group and treatment group with 30 cases in each group, the statistical analysis on the gender and age distribution of two groups of patients with tennis elbow, there was no significant difference (P0.05), the experimental group and the treatment group of patients in the gender composition, age distribution, good consistency. Before the experimental treatment, the JOA elbow function score of the patients who were included in the experimental study was first scored. There was no significant difference in the score between the experimental group and the control group before treatment (P0.05). It could be considered that the elbow activity of the two groups was more consistent before treatment. The ADL daily living ability score is an evaluation of the effect of the elbow disease on the self-care ability of the daily life. There was no statistical difference between the test group and the control group before the treatment (P0.05). The daily life self-care ability of the two groups of tennis elbow patients was more consistent. The clinical symptom score is the doctor's physical examination of the patient
【學(xué)位授予單位】：廣州中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R246.9

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