本文選題：合谷穴區(qū) + 去運(yùn)動(dòng)傳出　； 參考：《廣州中醫(yī)藥大學(xué)》2016年博士論文

【摘要】：目的：有研究表明,“面口合谷收”存在單向聯(lián)系,即刺激合谷穴區(qū)可以誘發(fā)口面部的肌電反應(yīng),但反過來刺激口面部不能誘發(fā)合谷穴區(qū)的肌電反應(yīng)。本研究采用經(jīng)顱磁刺激(TMS)的方法,觀察健康志愿者、截指和臂叢神經(jīng)損傷患者運(yùn)動(dòng)皮層手面區(qū)的分布特點(diǎn)及針刺的影響,探討合谷穴區(qū)去運(yùn)動(dòng)傳出后大腦運(yùn)動(dòng)皮層功能重組的規(guī)律,闡釋“面口合谷收”單向聯(lián)系的生物學(xué)機(jī)制。方法：試驗(yàn)共分為三個(gè)部分：(一)生理狀態(tài)下針刺單側(cè)合谷對(duì)運(yùn)動(dòng)皮層手區(qū)與面區(qū)的作用研究：本部分研究共納入健康志愿者20例,均符合納入標(biāo)準(zhǔn)并簽署知情同意書。整個(gè)試驗(yàn)過程分為針刺前和針刺后兩個(gè)階段,并且是在同一屏蔽室由同一研究者負(fù)責(zé)操作。所有受試者均要在針刺前和針刺后進(jìn)行TMS檢查。針刺前,受試者取坐位,經(jīng)TMS刺激運(yùn)動(dòng)皮層手區(qū)與面區(qū),分別記錄雙側(cè)第一骨間背側(cè)肌(FDI)和眼輪匝肌(00)的運(yùn)動(dòng)誘發(fā)電位(MEPs)的運(yùn)動(dòng)閾值、潛伏期、振幅以及有效刺激面積,并繪制二維圖像,確定運(yùn)動(dòng)皮層手區(qū)與面區(qū)的分布位置；確定手區(qū)與面區(qū)的有效刺激面積后,取受試者右側(cè)合谷穴予以電針針刺,采用1寸毫針針刺合谷穴,得氣后,于針刺部位旁開1cm內(nèi)另刺1針用以連接電針電極。電針儀采用韓氏電針儀,電針參數(shù)設(shè)置為連續(xù)波,恒流lmA,頻率2Hz,持續(xù)電針30min,取針后按照上述TMS操作執(zhí)行,確定針刺合谷穴后手區(qū)與面區(qū)的有效刺激面積,并繪制二維圖像。數(shù)據(jù)采集完畢,對(duì)比分析針刺合谷穴前后受試者肌肉誘發(fā)電位的相關(guān)參數(shù)及運(yùn)動(dòng)皮層手區(qū)與面區(qū)位域圖的變化情況。(二)合谷穴區(qū)去運(yùn)動(dòng)傳出后(截指)運(yùn)動(dòng)皮層功能重組及針刺作用的研究：本部分研究共納入健康志愿者5例,左手截指患者5例,均符合納入標(biāo)準(zhǔn)并簽署知情同意書。健康受試者數(shù)據(jù)采集,5例健康志愿者采集雙側(cè)第一骨間背側(cè)肌和眼輪匝肌運(yùn)動(dòng)誘發(fā)電位的相關(guān)參數(shù)。受試者取坐位,經(jīng)TMS刺激雙側(cè)手區(qū)和面區(qū),分別記錄雙側(cè)第一骨間背側(cè)肌和眼輪匝肌的運(yùn)動(dòng)誘發(fā)電位(MEPs)的運(yùn)動(dòng)閾值、潛伏期、振幅以及有效刺激面積,并繪制二維圖像,確定雙側(cè)手區(qū)和面區(qū)的皮層分布位置。截指患者數(shù)據(jù)采集,分為針刺前和針刺后兩部分。針刺前,患者取坐位,經(jīng)TMS刺激運(yùn)動(dòng)皮層手區(qū)和面區(qū),記錄雙側(cè)第一骨間背側(cè)肌和眼輪匝肌運(yùn)動(dòng)誘發(fā)電位(MEPs)的運(yùn)動(dòng)閾值、潛伏期、振幅以及有效刺激面積,并繪制二維圖像,確定運(yùn)動(dòng)皮層手區(qū)和面區(qū)的分布位置；確定手區(qū)和面區(qū)的有效刺激面積后,取患者右側(cè)合谷穴予以電針針刺,采用1寸毫針針刺合谷穴,得氣后,于針刺部位旁開lcm內(nèi)另刺1針用以連接電針電極。電針儀采用韓氏電針儀,電針參數(shù)設(shè)置為連續(xù)波,恒流1mA,頻率2Hz,持續(xù)電針30min,取針后按照上述TMS操作執(zhí)行,記錄運(yùn)動(dòng)誘發(fā)電位相關(guān)參數(shù),確定針刺合谷穴后手區(qū)和面區(qū)的有效刺激面積,并繪制二維圖像。數(shù)據(jù)采集完畢,處理和分析數(shù)據(jù)。(三)外周神經(jīng)損傷后運(yùn)動(dòng)皮層功能重組及針刺作用的研究：本部分研究共納入健康志愿者5例,右側(cè)臂叢神經(jīng)損傷患者5例,均符合納入標(biāo)準(zhǔn)并簽署知情同意書。健康受試者數(shù)據(jù)采集,5例健康志愿者采集雙側(cè)第一骨間背側(cè)肌、眼輪匝肌、肱二頭肌和三角肌運(yùn)動(dòng)誘發(fā)電位的相關(guān)參數(shù)。受試者取坐位,經(jīng)TMS刺激雙側(cè)手區(qū)、面區(qū)、肩區(qū)和肘區(qū),分別記錄雙側(cè)第一骨間背側(cè)肌、眼輪匝肌、三角肌和肱二頭肌的運(yùn)動(dòng)誘發(fā)電位(MEPs)的運(yùn)動(dòng)閾值、潛伏期、振幅以及有效刺激面積,并繪制二維圖像,確定雙側(cè)手區(qū)、面區(qū)、肩區(qū)和肘區(qū)的皮層分布位置。臂叢神經(jīng)損傷患者的數(shù)據(jù)采集,分為針刺治療前和針刺治療后兩個(gè)階段,并且針刺治療和TMS檢查由同一研究者負(fù)責(zé)操作。所有受試者均要在針刺治療前和針刺治療后進(jìn)行上肢運(yùn)動(dòng)功能評(píng)分(Fugl-Meyer評(píng)分)和TMS檢查。針刺治療前,受試者取坐位,經(jīng)TMS刺激運(yùn)動(dòng)皮層手區(qū)與面區(qū),分別記錄左側(cè)第一骨間背側(cè)肌和雙側(cè)眼輪匝肌的運(yùn)動(dòng)誘發(fā)電位(MEPs)的運(yùn)動(dòng)閾值、潛伏期、振幅以及有效刺激面積,并繪制二維圖像,確定右半球運(yùn)動(dòng)皮層手區(qū)與雙側(cè)半球面區(qū)的分布位置；同時(shí),經(jīng)TMS刺激雙側(cè)肩區(qū)和肘區(qū),分別記錄雙側(cè)三角肌和肱二頭肌的運(yùn)動(dòng)誘發(fā)電位(MEPs)的運(yùn)動(dòng)閾值、潛伏期、振幅以及有效刺激面積,并繪制二維圖像,確定雙側(cè)肩區(qū)和肘區(qū)的分布位置。按照“十二五”針灸學(xué)規(guī)劃教材痿證相關(guān)取穴,對(duì)患者進(jìn)行1個(gè)月的針刺治療,經(jīng)針刺治療后,對(duì)患者進(jìn)行上肢運(yùn)動(dòng)功能評(píng)分,并按照上述方法采集針刺治療后的相關(guān)數(shù)據(jù)。數(shù)據(jù)采集完畢,處理和分析數(shù)據(jù)。結(jié)果：(一)生理狀態(tài)下針刺單側(cè)合谷對(duì)運(yùn)動(dòng)皮層手區(qū)與面區(qū)的作用研究1、針刺后對(duì)側(cè)運(yùn)動(dòng)皮層面區(qū)潛伏期縮短、振幅升高、閾值降低、有效刺激面積增大(P0.05)；同側(cè)運(yùn)動(dòng)皮層面區(qū)潛伏期無變化,振幅升高、閾值降低、有效刺激面積增大(P0.05)。2、針刺后對(duì)側(cè)運(yùn)動(dòng)皮層手區(qū)潛伏期、閾值無變化；振幅升高,有效刺激面積增大(P0.05)；同側(cè)運(yùn)動(dòng)皮層手區(qū)潛伏期延長、振幅降低、閾值升高、有效刺激面積減小(P0.05)。3、針刺合谷可使面區(qū)與手區(qū)的皮層興奮性提高,其中雙側(cè)面區(qū)總振幅、有效刺激面積針刺前后相比無變化；在雙側(cè)手區(qū)比較中,針刺后對(duì)側(cè)手區(qū)總振幅明顯高于右半球(P0.05),同時(shí)針刺后對(duì)側(cè)總振幅大于針刺前(P0.05),而同側(cè)總振幅小于針刺前(P0.05)。4、針刺后,雙側(cè)運(yùn)動(dòng)皮層面區(qū)與手區(qū)的重心均出現(xiàn)不同程度的偏移,其中面區(qū)重心向手區(qū)偏移,最大位移距離對(duì)側(cè)可達(dá)3.3mm,同側(cè)可達(dá)4.5mm；手區(qū)重心不發(fā)生明顯偏移或者向手區(qū)分布方向偏移,垂直位移距離對(duì)側(cè)可達(dá)5.3mm,同側(cè)可達(dá)9.1mm。(二)合谷穴區(qū)去運(yùn)動(dòng)傳出后(截指)運(yùn)動(dòng)皮層功能重組及針刺作用的研究1、合谷穴區(qū)去運(yùn)動(dòng)傳出后,患者左半球手區(qū)面積與右半球手區(qū)面積的比值小于健康志愿者的比值的最小值；面區(qū)有效刺激面積的比值與健康者志愿者的比值無明顯差異。2、針刺后,截指患者雙側(cè)手區(qū)MEPs閾值、潛伏期、有效刺激面積無變化,振幅均降低(P0.05)；雙側(cè)面區(qū)潛伏期縮短、振幅升高、閾值降低、有效刺激面積增大(P0.05),手區(qū)與面區(qū)交叉重疊區(qū)域增大。針刺后截指患者雙側(cè)手區(qū)的重心發(fā)生偏移,且向遠(yuǎn)離面區(qū)發(fā)生位移。(三)外周神經(jīng)損傷后運(yùn)動(dòng)皮層功能重組及針刺作用的研究1、臂叢神經(jīng)損傷后,患者左半球肩區(qū)、肘區(qū)的面積與右半球肩區(qū)、肘區(qū)面積的比值大于健康志愿者的比值的最大值；面區(qū)有效刺激面積的比值較健康者的沒有明顯差異。2、對(duì)臂叢神經(jīng)損傷患者進(jìn)行為期一個(gè)月的針刺治療,治療后患者自覺上肢運(yùn)動(dòng)功能未有明顯改善,行上肢運(yùn)動(dòng)功能評(píng)分,針刺治療后無明顯變化。3、針刺后,臂叢神經(jīng)損傷患者肘區(qū)MEPs潛伏期無變化,雙側(cè)皮層振幅均降低(P0.05),有效刺激面積無變化；肩區(qū)MEPs潛伏期無變化,雙側(cè)皮層振幅均降低(P0.05),有效刺激面積無變化。臂叢神經(jīng)損傷患者對(duì)側(cè)面區(qū)MEPs潛伏期縮短、振幅升高、閾值降低、有效刺激面積增大(P0.05)；同側(cè)手區(qū)MEPs潛伏期無變化,振幅降低、閾值升高、有效刺激面積減小(P0.05)。針刺后臂叢神經(jīng)損傷患者雙側(cè)肘區(qū)和肩區(qū)的重心均發(fā)生不同程度的位移,表現(xiàn)為遠(yuǎn)離手區(qū)分布區(qū)域。結(jié)論：1、合谷穴區(qū)去運(yùn)動(dòng)傳出后,大腦運(yùn)動(dòng)皮層出現(xiàn)功能重組：在截指患者運(yùn)動(dòng)皮層內(nèi)表現(xiàn)為受損部位的皮層代表區(qū)鄰近皮層的擴(kuò)大入侵；在臂叢神經(jīng)損傷患者運(yùn)動(dòng)皮層內(nèi)表現(xiàn)為肩區(qū)和肘區(qū)的擴(kuò)大并向鄰近受損部位的皮層代表區(qū)的擴(kuò)大入侵,均沒有出現(xiàn)鄰近面區(qū)向受損部位皮層代表區(qū)的擴(kuò)大入侵,提示運(yùn)動(dòng)皮層的功能重組表現(xiàn)為單向性。運(yùn)動(dòng)皮層的手區(qū)與面區(qū)之間單向功能重組可能是“面口合谷收”單向聯(lián)系的生物學(xué)機(jī)制。2、生理狀態(tài)下,針刺單側(cè)合谷可以興奮雙側(cè)面區(qū)和對(duì)側(cè)手區(qū),抑制同側(cè)手區(qū),對(duì)運(yùn)動(dòng)皮層手區(qū)與面區(qū)均產(chǎn)生影響；病理狀態(tài)下,針刺可以抑制入侵皮層的興奮性,加強(qiáng)受損皮層代表區(qū)與鄰近皮層的功能聯(lián)系,這種調(diào)節(jié)作用的實(shí)現(xiàn)可能為臨床選用合谷穴治療口面部疾病提供了理論依據(jù)。
[Abstract]:Objective: some studies have shown that there is a one-way connection between "Hekou and valley harvest", that is, stimulation of Hegu acupoint can induce EMG response to the mouth and face, but in turn, the stimulation of the mouth and face can not induce the electromyography of the Hegu area. This study uses transcranial magnetic stimulation (TMS) to observe the skin of healthy volunteers, truncated fingers and brachial plexus nerve injuries. The distribution characteristics of the layer area and the influence of acupuncture on the function of the functional reorganization of the cerebral motor cortex after the movement of the Hegu area to explain the biological mechanism of the unidirectional contact of the "face to the mouth and the valley". Methods: the experiment is divided into three parts: (1) the effect of the single side of the needle on the hand area and the surface area of the motor cortex under the physiological state A total of 20 healthy volunteers were included in this part, all in accordance with the inclusion criteria and signed informed consent. The whole test process was divided into two stages before and after acupuncture, and the same researcher was responsible for the operation in the same screening room. All the subjects were to undergo TMS examination before and after acupuncture. Before acupuncture, the subjects were taken to take a seat. The motion threshold of the motor evoked potential (MEPs) of the dorsal lateral interosseous (FDI) and orbicularis oculi muscle (00) of the bilateral first interosseous interosseous (MEPs), the latent period, the amplitude and the effective stimulation area were recorded, and the two-dimensional images were drawn to determine the distribution position of the hand area and the surface area of the motor cortex, and to determine the effective spines in the hand area and the surface area. After the area was stimulated, the subjects were acupuncturing on the right Hegu acupoint with 1 inches of needle acupuncture at Hegu Point. After getting gas, the electroacupuncture electrode was connected to another 1 needles in 1cm by the acupuncture site. The electroacupuncture instrument was composed of the Han's electroacupuncture instrument, the electroacupuncture parameters were set to continuous wave, the constant current lmA, the frequency 2Hz, and the continuous Electroacupuncture of 30min. After taking the needle, the operation was carried out according to the above TMS operation. To determine the effective area of stimulation in the posterior hand area and the surface area of the acupuncture point of Hegu Point, and draw a two-dimensional image. After the data collection, the related parameters of the muscle evoked potential of the subjects before and after the acupuncture at the Hegu Point and the change of the area map of the hand area and the surface area of the motor cortex were compared and analyzed. (two) the function weight of the motor cortex after the movement of the Hegu area was carried out. Study on the role of group and acupuncture: 5 healthy volunteers were included in this study, and 5 cases of left hand truncated patients were all conformed to the inclusion criteria and signed informed consent. The data collected by healthy subjects, 5 healthy volunteers collected the related parameters of the motor potential of the dorsi dorsi and orbicularis oculi muscles of the first bone. The subjects were taken sitting position, TMS The motion threshold of the motor evoked potential (MEPs), latent period, amplitude and effective stimulation area of bilateral first interosseous dorsi and orbicularis oculi muscles were recorded, and two-dimensional images were drawn to determine the position of cortical distribution in bilateral hand and surface areas. The data collection of the patients was divided into two parts before acupuncture and after acupuncture. Before acupuncture, the patient took the seat and stimulated the motion evoked potential (MEPs) of the dorsi and orbicularis muscle of the first bone, the latent period, the amplitude and the effective stimulation area, and drew a two-dimensional image to determine the distribution position of the hand area and the surface area of the motor cortex, and determine the effectiveness of the hand area and the surface area by TMS. After the stimulation of the area, the patient's right Hegu acupoint was acupuncturing by electroacupuncture and 1 inch needle acupuncture at Hegu acupoint was used. After getting gas, the electroacupuncture electrode was connected to another 1 needles in LCM beside the needle position. The electroacupuncture instrument was set up by the Han's electroacupuncture instrument, the Electroacupuncture Parameters were set to continuous waves, the constant current 1mA, the frequency 2Hz, and the continuous Electroacupuncture of the electroacupuncture were carried out in accordance with the above TMS operation. The related parameters of motor evoked potential were recorded, and the effective area of stimulation in the hand and surface areas of Hegu acupuncture point was determined and two-dimensional images were drawn. Data acquisition, processing and analysis of data were completed. (three) the study of functional reorganization and acupuncture of motor cortex after peripheral nerve injury: 5 cases of healthy volunteers, right brachial plexus God in this part of the study 5 cases of injured patients were in accordance with the inclusion criteria and signed informed consent. Data collection of healthy subjects, 5 healthy volunteers collected the parameters related to the motor evoked potential of the bilateral first interosseous dorsi, orbicularis oculi, biceps and deltoid. The subjects were taken sitting position, and the bilateral hand area, face area, shoulder area and elbow area were recorded by TMS, respectively. The motion threshold of the dorsi interosseous dorsi interosseous, orbicularis oculi, deltoid and biceps brachii muscle motor evoked potential (MEPs), latent period, amplitude and effective stimulation area, and drawing two-dimensional images to determine the position of cortical distribution in the bilateral hand, facial, shoulder and elbow areas. Data collection of brachial plexus injury patients is divided into acupuncture treatment before and before acupuncture treatment. Acupuncture treatment and TMS examination were performed by the same researcher. All the subjects were required to perform the upper limb motor function score (Fugl-Meyer score) and TMS examination before and after the acupuncture treatment. Before the acupuncture treatment, the subjects were taken the seat, and the left hand area and the surface area were stimulated by TMS to record the left side, respectively. The motion threshold of the motor evoked potential (MEPs), latent period, amplitude and effective stimulation area of the lateral interosseous dorsi and bilateral orbicularis oculi muscles were measured, and two-dimensional images were drawn to determine the distribution position of the hand and bilateral hemispherical areas of the right hemisphere. At the same time, bilateral deltoid and humerus were recorded by TMS stimulation of the bilateral shoulder and elbow areas. The motion evoked potential (MEPs) of the two head muscle, the latent period, the amplitude and the effective stimulation area, and draw a two-dimensional image to determine the position of the bilateral shoulder area and the elbow area. According to the "12th Five-Year" acupuncture and moxibustion program, the patients were treated with acupuncture for 1 months. After the acupuncture treatment, the patients were treated with the upper limbs. Exercise function score, and collect relevant data after acupuncture treatment according to the above methods. Data acquisition, processing and analysis of data. Results: (1) study on the effect of acupuncture on the hand area and surface area of the motor cortex under physiological state 1. After acupuncture, the latency of the lateral motor cortex is shortened, the amplitude is increased, the threshold is reduced and the stimulation is effective. The area increased (P0.05); there was no change in the latent period of the cortical area of the ipsilateral motor cortex, the amplitude increased, the threshold decreased and the effective stimulation area increased (P0.05).2. The threshold of the hand area of the lateral motor cortex was not changed after acupuncture; the amplitude increased and the effective stimulation area increased (P0.05); the latent period of the hand area of the ipsilateral motor cortex was prolonged, the amplitude was reduced and the threshold increased, The effective stimulation area decreased (P0.05).3, and acupuncture of Hegu could improve the cortical excitability of the area and the hand area, in which the total amplitude of the double side area and the effective stimulation area were not changed before and after acupuncture. In the bilateral hand area comparison, the total amplitude of the lateral hand area after acupuncture was significantly higher than that of the right half ball (P0.05), and the total amplitude of the contralateral side after acupuncture was greater than that before acupuncture (P 0.05), the total amplitude of the same side is less than before the acupuncture (P0.05).4. After the acupuncture, the center of gravity of the bilateral motor cortex and the hand area all deviate in varying degrees. The center of gravity is shifted to the hand area, the maximum displacement distance is up to 3.3mm, and the same side can reach 4.5mm; the center of gravity of the hand area does not deviate obviously or offset to the hand area distribution direction, vertical position. The distance to the opposite side can reach 5.3mm, and the same side can reach 9.1mm. (two) Hegu (two) Hegu area after moving out. 1. After the movement of the Hegu area, the ratio of the hand area of the left hemisphere to the right hemisphere hand area is smaller than the ratio of the healthy volunteers; the area of the area is effectively stimulated. There was no significant difference in the ratio of the ratio of the healthy volunteers to the healthy volunteers.2. After the acupuncture, the MEPs threshold in the bilateral hand area of the finger and the latent period, the effective stimulation area was not changed, the amplitude decreased (P0.05), the latent period of the double side region shortened, the amplitude increased, the threshold decreased, the effective stimulus Ji Zengda (P0.05), and the overlapping area between the hand area and the surface area increased. The center of gravity of the bilateral hand area of the posterior finger patients shifted and moved away from the area. (three) study on the functional reorganization and acupuncture of the motor cortex after peripheral nerve injury. 1, after brachial plexus injury, the ratio of the area of the left hemisphere to the left hemisphere, the area of the elbow area and the right hemisphere shoulder area, the elbow area is greater than the ratio of the healthy volunteers. There was no significant difference in the ratio of effective stimulation area of the area to the healthy person.2. The patients with brachial plexus nerve injury were treated with acupuncture for one month. After the treatment, the motor function of the upper limb was not obviously improved. The function score of the upper limb and the acupuncture treatment did not change.3. After acupuncture, the elbow area of the brachial plexus injured patients was MEPs The latent period was not changed, the amplitude of bilateral cortex was reduced (P0.05), the area of effective stimulation was not changed, the latency of MEPs in the shoulder area was not changed, the amplitude of bilateral cortex decreased (P0.05), and the effective stimulation area was not changed. The patients with brachial plexus nerve injury shortened the latency of the MEPs in the side area, increased the amplitude, reduced the threshold, increased the effective area (P0.05), and the same side. The latent period of MEPs in the hand area was not changed, the amplitude decreased, the threshold increased and the effective stimulation area decreased (P0.05). The center of gravity of the elbow and shoulder areas of the patients with brachial plexus injury after acupuncture had different degrees of displacement, which was far away from the area of the hand area. Conclusion: 1, after the movement of the Hegu acupoint movement, the functional reorganization of the cerebral motor cortex appears in the cerebral motor cortex. An enlarged invasion of the cortical area adjacent to the damaged part of the motor cortex was found in the motor cortex of the patients. The enlargement of the shoulder area and elbow area in the motor cortex of the brachial plexus injury patients and the enlargement of the cortical area adjacent to the adjacent damaged parts did not appear to be enlarged in the adjacent area to the cortex of the damaged cortex. It suggests that the functional reorganization of the motor cortex is unidirectional. The unilateral functional reorganization between the hand area and the surface area of the motor cortex is probably the biological mechanism of the unilateral connection between the face and the mouth and the valley. In the physiological state, the unilateral valley of the acupuncture can excite the double side and the contralateral hand areas and inhibit the same side hand area, and the hand area and the surface area of the motor cortex are both.2. In the pathological condition, acupuncture can inhibit the excitability of the invasive cortex and strengthen the functional relation between the damaged cortex and the adjacent cortex. The realization of this regulation may provide a theoretical basis for the clinical selection of Hegu acupoint for the treatment of oral and facial diseases.
【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】：2016
【分類號(hào)】：R246

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