【摘要】：目的:本研究通過先期的文獻(xiàn)循證醫(yī)學(xué)分析——系統(tǒng)評(píng)價(jià)和薈萃分析等文獻(xiàn)分析方法�？偨Y(jié)運(yùn)動(dòng)療法在腹膜透析患者人群的具體應(yīng)用以及指導(dǎo)方案。緊接著參照文獻(xiàn)循證醫(yī)學(xué)分析的證據(jù),選擇具有中醫(yī)治療保健作用的傳統(tǒng)運(yùn)動(dòng)功法——八段錦,應(yīng)用于本中心的腹膜透析患者人群中,研究八段錦傳統(tǒng)運(yùn)動(dòng)功法對(duì)腹膜透析患者的療效作用。揭示中醫(yī)傳統(tǒng)功法在腹膜透析患者人群中的治療效果與應(yīng)用規(guī)律,為中醫(yī)臨床的實(shí)踐指導(dǎo)起到豐富和論證效果。方法:研究一:制定相關(guān)的檢索策略,使用國(guó)內(nèi)外的權(quán)威文獻(xiàn)數(shù)據(jù)庫(kù),圍繞"腹膜透析患者的運(yùn)動(dòng)干預(yù)研究"這個(gè)主題進(jìn)行檢索。運(yùn)用文獻(xiàn)定性與定量分析相結(jié)合的Review Manager 5.3軟件對(duì)數(shù)據(jù)統(tǒng)計(jì)分析,包括定性的文獻(xiàn)系統(tǒng)評(píng)價(jià)和定量的Meta分析。依據(jù)情況,采用不同的效應(yīng)模型計(jì)算效應(yīng)指標(biāo);適時(shí)行亞組分析及敏感分析等;并對(duì)結(jié)果進(jìn)行森林圖以及漏斗圖展示。研究二:對(duì)在廣東省中醫(yī)院慢性疾病門診中心規(guī)律隨診的腹膜透析患者,進(jìn)行八段錦傳統(tǒng)功法干預(yù)研究的篩查,納入符合相關(guān)標(biāo)準(zhǔn)的受試對(duì)象。簽署知情同意后,依照患者的意愿進(jìn)行非隨機(jī)化分配,運(yùn)動(dòng)組在日常活動(dòng)中,進(jìn)行八段錦傳統(tǒng)功法習(xí)練,對(duì)照組維持原有的治療和活動(dòng)量;維持三個(gè)月的觀察期后,比較兩組間的干預(yù)前后各項(xiàng)指標(biāo)的變化。研究三:探索八段錦傳統(tǒng)功法在腹膜透析的抗氧化能力、微炎癥狀態(tài)以及免疫功能方面的作用,所以在研究二的基礎(chǔ)上,抽取受試者的適量血液樣本,采用雙抗體一步夾心法酶聯(lián)免疫吸附試驗(yàn)對(duì)總抗氧化能力(T-AOC)、超氧化物歧化酶(SOD)活性和丙二醛(MDA)含量、白細(xì)胞介素-2(IL-2)、白細(xì)胞介素-6(IL-6)、干擾素(INF-γ)和腫瘤壞死因子(TNF-a)等指標(biāo)進(jìn)行檢測(cè),對(duì)比干預(yù)前后的變化情況。結(jié)果:研究一:最終收錄國(guó)內(nèi)外文獻(xiàn)7篇文獻(xiàn)。共納入254例腹膜透析患者。各研究間的觀測(cè)時(shí)間跨度以及觀測(cè)的結(jié)局指標(biāo)有較大差異。觀測(cè)時(shí)間跨度最大為10個(gè)月,最少的有8周。運(yùn)動(dòng)干預(yù)措施有散步、跑步、騎車、游泳、滑雪、太極等。運(yùn)動(dòng)干預(yù)的持續(xù)時(shí)間推薦20~30分鐘為多。各個(gè)研究均具有可對(duì)比性,但在研究的隨機(jī)方法上存在較大的風(fēng)險(xiǎn)以及提供的隨機(jī)方案未能詳盡提供。Meta分析結(jié)果,收縮壓的總效應(yīng)量,MD=8.16,95%CI 為 4.17~12.15,Z=4.01,P=0.0001;舒張壓的 MD=4.24,95%CI 為0.85~7.62,Z=2.45,P=0.01;超濾量為MD=21.87,95%CI為6.05~37.70,Z=2.71,P=0.007;疲乏程度總效應(yīng)量,MD=0.97,95%CI 為 0.77~1.16,Z=9.82,P0.01;以上幾個(gè)指標(biāo)均具有統(tǒng)計(jì)學(xué)意義。研究二:兩組間的基線情況,年齡、性別、體重指數(shù)、原發(fā)性腎病、透析歷齡、超濾量、殘余尿量等均無統(tǒng)計(jì)學(xué)差異(P0.05)。生命體征方面,運(yùn)動(dòng)組干預(yù)前后收縮壓、舒張壓、心率的變化差異有統(tǒng)計(jì)學(xué)意義(P0.05);對(duì)照組的收縮壓和舒張壓前后比較,差異沒有統(tǒng)計(jì)學(xué)意義(P0.05)。心率的差值,兩組間的比較具有統(tǒng)計(jì)學(xué)差異(P0.05)。對(duì)照組的呼吸頻率在觀測(cè)期間的變化情況有統(tǒng)計(jì)學(xué)意義(P0.05),差值與運(yùn)動(dòng)組的比較具有統(tǒng)計(jì)學(xué)差異(P0.05)。能量代謝方面,靜息能量消耗(REE)、靜息能耗與閥值比(REE/Pred)的變化情況,兩組均具有統(tǒng)計(jì)學(xué)意義(P0.05)。其他前后各項(xiàng)指標(biāo)比較,差異均沒有統(tǒng)計(jì)學(xué)意義(P0.05)。人體成分方面,肌肉容積(LTM)、體細(xì)胞含量(BCM)、脂肪組織含量(ATM)、脂肪含量(Fat)的前后各項(xiàng)指標(biāo)比較,差異均沒有統(tǒng)計(jì)學(xué)意義(P0.05)。運(yùn)動(dòng)組干預(yù)前后"過多水分"(0H)指標(biāo)的變化情況,差異有統(tǒng)計(jì)學(xué)意義(P0.05);對(duì)照組觀測(cè)期的ICW值在前后對(duì)照中,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。營(yíng)養(yǎng)指標(biāo)方面,運(yùn)動(dòng)組干預(yù)前后皮褶厚度、體重指數(shù)、總蛋白、白蛋白、血鈣、血清鈉、血鉀、葡萄糖、總膽固醇的變化差異均有統(tǒng)計(jì)學(xué)意義(P0.05);對(duì)照組的這些指標(biāo)前后比較,差異沒有統(tǒng)計(jì)學(xué)意義(P0.05)。研究三:兩組間的總抗氧化能力、超氧化物歧化酶活性、白細(xì)胞介素-2、白細(xì)胞介素-6、干擾素和腫瘤壞死因子基線情況沒有統(tǒng)計(jì)學(xué)差異(P0.05);丙二醛含量具有統(tǒng)計(jì)學(xué)意義(P0.05)�？寡趸芰Ψ矫�,T-AOC和SOD活性,兩組間的前后對(duì)比均具有統(tǒng)計(jì)學(xué)差異(P0.05),兩組間的前后差值比較同樣具有統(tǒng)計(jì)學(xué)意義(P0.05)。微炎癥狀態(tài)方面,IL-2和IL-6指標(biāo)在兩組間的前后對(duì)比均具有統(tǒng)計(jì)學(xué)差異(P0.05),兩組間的前后差值比較無統(tǒng)計(jì)學(xué)意義(P0.05)。免疫系統(tǒng)功能方面,INF-丫和TNF-a,兩組間的前后對(duì)比均具有統(tǒng)計(jì)學(xué)差異(P0.05),TNF-a的兩組間前后差值比較有統(tǒng)計(jì)學(xué)意義(P0.05);INF-丫的兩組間前后差值比較無統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:一、循證醫(yī)學(xué)的薈萃分析總結(jié),運(yùn)動(dòng)療法對(duì)腹膜透析患者的收縮壓和舒張壓均具有改善作用,運(yùn)動(dòng)干預(yù)能夠減低腹透患者的收縮壓和舒張壓。在日超濾量方面,運(yùn)動(dòng)干預(yù)同樣具有促進(jìn)作用,能提升腹膜透析患者的日超濾量,這也是腹膜透析患者血壓下降的可能原因。在生活質(zhì)量方面,運(yùn)動(dòng)能夠改善透析患者的疲乏程度。二、八段錦傳統(tǒng)功法對(duì)腹膜透析患者的臨床療效干預(yù)試驗(yàn)結(jié)果提示,八段錦運(yùn)動(dòng)療法能夠?qū)Ω雇富颊叩氖湛s壓和舒張壓起到調(diào)節(jié)作用。八段錦傳統(tǒng)功法干預(yù)可能對(duì)支配血管的交感神經(jīng)起到興奮性降低效果,從而對(duì)血管的舒張功能起到維持作用。心率方面,八段錦功法能夠降低腹膜透析患者的心率。八段錦運(yùn)動(dòng)的段式本身具有"去心火"功效,對(duì)腎虛的虛火心悸、心率不齊等具有效果。呼吸頻率方面,八段錦功法通過增強(qiáng)患者的呼吸功率,進(jìn)而降低腹透患者的呼吸頻率。三、能量代謝方面,八段錦功法可以提高腹膜透析患者的REE和REE/Pred水平。運(yùn)動(dòng)本身能夠帶來人體能量需求的增加,自身的基礎(chǔ)代謝率相應(yīng)得到提升。八段錦傳統(tǒng)功法能夠固護(hù)人體腎氣,腎氣的健旺進(jìn)而促進(jìn)機(jī)體新陳代謝。四、液體容量方面,八段錦傳統(tǒng)功法可以減少腹膜透析患者的水液容量負(fù)荷。八段錦運(yùn)動(dòng)通過疏理人體三焦氣機(jī),運(yùn)化脾胃?jìng)鬏敼δ懿鼗I氣對(duì)人體的水液代謝起到促進(jìn)作用,祛除機(jī)體過多的液體容量負(fù)荷。五、營(yíng)養(yǎng)指標(biāo)方面,通過習(xí)練八段錦功法可以提高腹膜透析患者的營(yíng)養(yǎng)狀態(tài)。八段錦功法能夠調(diào)理人體臟腑的功能,促進(jìn)脾胃的運(yùn)化,有助于對(duì)飲食精微物質(zhì)的吸收,進(jìn)而改善機(jī)體的營(yíng)養(yǎng)狀態(tài)。六、八段錦傳統(tǒng)功法對(duì)腹膜透析患者的實(shí)驗(yàn)結(jié)果提示,習(xí)練八段錦功法可以提高腹膜透析患者的抗氧化能力。傳統(tǒng)功法具有固護(hù)腰腎等作用,八段錦運(yùn)動(dòng)的調(diào)息練氣,促進(jìn)腎中精氣的溫陽化氣,并轉(zhuǎn)樞三焦調(diào)理全身氣機(jī),達(dá)到抗氧化作用。七、微炎癥狀態(tài)方面,八段錦傳統(tǒng)功法可能具有降低腹膜透析患者的IL-6水平。通過減少促炎癥因子的活性和數(shù)量,從而減少對(duì)機(jī)體腎臟的損害。腹膜透析患者的血清鈣水平與腹膜透析患者的微炎癥狀態(tài)要結(jié)合起來研究。八、免疫功能方面,八段錦傳統(tǒng)功法可以提高腹膜透析患者機(jī)體的免疫功能。八段錦運(yùn)動(dòng)能夠扶正祛邪,增強(qiáng)人體的正氣,對(duì)病邪的祛除以及疾病的康復(fù)具有正性作用,尤適于氣虛型的腎病患者。建議慢性腎病患者應(yīng)當(dāng)加強(qiáng)運(yùn)動(dòng)療法,尤其是在慢性腎臟病3期之后,對(duì)腎病的進(jìn)展具有延緩的作用。九、本研究通過運(yùn)用循證醫(yī)學(xué)的文獻(xiàn)研究方法,對(duì)腹膜透析患者的運(yùn)動(dòng)方案進(jìn)行薈萃分析,為腹膜透析患者的八段錦運(yùn)動(dòng)臨床干預(yù)提供了應(yīng)用指導(dǎo)基礎(chǔ)。八段錦傳統(tǒng)功法的臨床干預(yù)試驗(yàn)又為腹膜透析患者提供了一定的運(yùn)動(dòng)療法醫(yī)學(xué)證據(jù)和指導(dǎo)意見。發(fā)揮傳統(tǒng)中醫(yī)療法在慢性腎臟病的防治優(yōu)勢(shì),改善患者的生活質(zhì)量和疾病狀態(tài),具有一定的可行性和有效性。
[Abstract]:OBJECTIVE: To summarize the specific application and guiding scheme of exercise therapy in peritoneal dialysis patients through literature evidence-based medicine analysis, such as systematic evaluation and meta-analysis. Baduanjin was applied to the peritoneal dialysis patients in our center to study the curative effect of Baduanjin traditional exercise method on the peritoneal dialysis patients. Relevant retrieval strategies were searched around the theme of "Sports Intervention Research in Peritoneal Dialysis Patients" using authoritative literature databases at home and abroad. Data were analyzed by Review Manager 5.3 software, which combines qualitative and quantitative analysis of literature, including qualitative literature system evaluation and quantitative meta-analysis. Different effect models were used to calculate effect indices, subgroup analysis and sensitivity analysis were performed in time, and forest maps and funnel maps were used to display the results. After signing the informed consent, the subjects were randomized according to the patients'wishes. In the exercise group, the traditional Baduanjin exercises were carried out in daily activities, while the control group maintained the original treatment and activity. After three months of observation, the changes of indexes before and after the intervention were compared between the two groups. The effects of traditional methods on the antioxidant capacity, Micro-inflammatory State and immune function of peritoneal dialysis patients were studied. On the basis of study 2, appropriate blood samples were taken and the total antioxidant capacity (T-AOC), superoxide dismutase (SOD) activity and malondialdehyde (MDA) content were measured by enzyme-linked immunosorbent assay (ELISA). Interleukin-2 (IL-2), interleukin-6 (IL-6), interferon-gamma (INF-gamma) and tumor necrosis factor (TNF-a) were measured before and after intervention, and the changes were compared. RESULTS: Study 1: 7 literatures were collected at home and abroad. A total of 254 peritoneal dialysis patients were enrolled in the study. The maximum observation time span is 10 months and the minimum observation time is 8 weeks. The intervention measures include walking, running, cycling, swimming, skiing, Tai chi, etc. The duration of exercise intervention is recommended to be more than 20-30 minutes. Meta analysis showed that the total effective dose of systolic blood pressure (MD = 8.16,95% CI = 4.17-12.15, Z = 4.01, P = 0.0001; MD = 4.24, 95% CI = 0.85-7.62, Z = 2.45, P = 0.01; ultrafiltration (MD = 21.87, 95% CI = 21.87, 95% CI = 6.05-37.70, Z = 2.71, Z = 2.71, P = 0.007; total effective dose of fatigdegree (MD = 0.97, 95% CI = 0.97, 95% CI = 0.97, 95% CI 0.77, 95% CI 0.77, 1.77, 1.95% CI 0.77, 1.77, 95% CI 0.77-1.01; above Study 2: There was no significant difference in baseline, age, sex, body mass index, primary nephropathy, duration of dialysis, ultrafiltration, residual urine volume between the two groups (P 0.05). The difference of heart rate between the two groups was statistically significant (P 0.05). The change of respiratory frequency in the control group was statistically significant (P 0.05), and the difference was statistically significant (P 0.05) compared with the exercise group. (REE), resting energy consumption and threshold ratio (REE / Pred) changes, the two groups were statistically significant (P 0.05). Other indicators before and after the comparison, the difference was not statistically significant (P 0.05). Human body composition, muscle volume (LTM), somatic cell content (BCM), fat tissue content (ATM), fat content (Fat) before and after the comparison of indicators, the difference was all significant. There was no statistical significance (P 0.05). The changes of "excessive water" (0H) index in the exercise group before and after the intervention were statistically significant (P 0.05); the ICW value in the control group during the observation period was statistically significant (P 0.05). Nutritional indicators, the exercise group before and after the intervention skin fold thickness, body mass index, total protein, albumin, blood calcium, serum. The changes of sodium, potassium, glucose and total cholesterol were statistically significant (P 0.05); there was no significant difference between the control group and the control group (P 0.05). There were statistical differences (P 0.05); Malondialdehyde content was statistically significant (P 0.05). Antioxidant capacity, T-AOC and SOD activity, before and after the comparison between the two groups were statistically significant (P 0.05), the difference between the two groups was also statistically significant (P 0.05). Micro-inflammatory state, IL-2 and IL-6 indicators in the two groups before and after the comparison. There was no significant difference between the two groups (P 0.05). In terms of immune system function, INF-Ya and TNF-a, there was significant difference between the two groups (P 0.05). The difference between the two groups of TNF-a was statistically significant (P 0.05). Conclusion: 1. Exercise therapy can improve the systolic and diastolic blood pressure of peritoneal dialysis patients, and exercise intervention can reduce the systolic and diastolic blood pressure of peritoneal dialysis patients. In terms of quality of life, exercise can improve the fatigue of dialysis patients. 2. The results of the intervention test of Baduanjin traditional Gong method on the clinical efficacy of peritoneal dialysis patients suggest that Baduanjin exercise therapy can regulate the systolic and diastolic blood pressure of peritoneal dialysis patients. Duan Jin's traditional skill intervention may reduce the excitability of sympathetic nerve innervating blood vessels and maintain the diastolic function of blood vessels. As for heart rate, Ba Duan Jin's skill therapy can reduce the heart rate of peritoneal dialysis patients. Respiratory frequency, Baduan Jingong method by enhancing the patient's respiratory power, thereby reducing the respiratory rate of peritoneal dialysis patients. 3, energy metabolism, Baduan Jingong method can improve the REE and REE/Pred levels of peritoneal dialysis patients. Baduanjin traditional methods can protect the human kidney Qi, kidney Qi and promote metabolism. 4, liquid capacity, Baduanjin traditional methods can reduce the volume of peritoneal dialysis patients with water load. Baduanjin exercise by regulating the human triple Jiao Qi machine, transporting the spleen and stomach function and warming the kidney Qi to the human body's water. Fluid metabolism plays a role in promoting the elimination of excessive body fluid volume load. Fifth, nutritional indicators, through the practice of Baduan Jingong method can improve the nutritional status of peritoneal dialysis patients. Baduan Jingong method can regulate the function of the human viscera, promote the operation of the spleen and stomach, help to absorb the fine substances of diet, and thus improve the operation of the body. Sixth, Baduanjin traditional Gong method of peritoneal dialysis patients with experimental results suggest that the practice of Baduanjin method can improve the antioxidant capacity of peritoneal dialysis patients. Seventh, the traditional method of Baduanjin may reduce the level of IL-6 in peritoneal dialysis patients. By reducing the activity and quantity of pro-inflammatory factors, thereby reducing the damage to the kidney. Peritoneal dialysis patients'serum calcium level and peritoneal dialysis patients' Micro-inflammatory State should be combined to study. Eighth, immunity. In terms of function, Baduanjin exercise can improve the immune function of peritoneal dialysis patients. Baduanjin exercise can strengthen the body's healthy qi, eliminate pathogens, especially for patients with kidney disease of Qi deficiency type. Ninth, through the use of evidence-based medicine literature research methods, peritoneal dialysis patients with exercise program meta-analysis, for peritoneal dialysis patients with Baduanjin exercise clinical intervention provides guidance. It also provides some medical evidence and guidance for peritoneal dialysis patients. It is feasible and effective to give full play to the advantages of traditional Chinese medicine in the prevention and treatment of chronic kidney disease and improve the quality of life and disease status of patients.
【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)】：R247.3

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