项针疗法联合rTMS治疗气虚血瘀型脑梗死恢复期患者的临床研究.pdf

Hainan Med J,Aug.2023,Vol.34,No.15海南医学2023年8月第34卷第15期项针疗法联合rTMS治疗气虚血瘀型脑梗死恢复期患者的临床研究任庆萍1，赵嘉诚2，林海1西安市中医医院脑病科二病区1、针灸推拿康复科2，陕西西安710021【摘要】目的探讨项针疗法联合重复经颅磁刺激(rTMS)对气虚血瘀型脑梗死恢复期患者的治疗效果。方法选择2021年7月至2022 年7 月西安市中医医院收治的90例气虚血瘀型脑梗死恢复期患者，按随机数表法分为观察组和对照组各45例。对照组患者采用rTMS治疗，观察组患者则在对照组治疗的基础上联合项针疗法，均持续治疗4周。比较两组患者治疗后的临床疗效，以及治疗前后的功能性经口摄食评价量表(FOIS)评分、美国国立卫生研究院卒中量表(NIHSS)评分、Fugl-Meyer(FMA)评分、日常生活能力(Barthel指数)、大脑中动脉平均血流速度(Vm)、搏动指数(PI)的变化和治疗期间的不良反应发生情况。结果治疗后，观察组患者的临床疗效总有效率为91.11%，明显高于对照组的71.11%，差异有统计学意义(P0.05)；治疗后，观察组患者的FIOS评分、NIHSS评分分别为(5.140.48)分、(11.321.38)分，明显低于对照组的(4.620.51)分、(13.161.47)分，差异均有统计学意义(P0.05)；治疗后，观察组患者的FMA评分、BI指数分别为(69.826.45)分、(62.245.63)分，明显高于对照组的(60.535.27)分、(53.025.19)分，差异均有统计学意义(P0.05)；治疗后，观察组患者的大脑中动脉Vm为(37.242.51)cm/s，明显高于对照组的(33.982.70)cm/s，PI为0.870.12，明显低于对照组的1.000.06，差异均有统计学意义(P0.05)；治疗期间，两组患者均无明显不良反应发生。结论项针疗法联合rTMS治疗气虚血瘀型脑梗死恢复期患者的临床疗效显著，具有临床应用价值。【关键词】脑梗死；气虚血瘀型；重复经颅磁刺激；项针；中医；疗效【中图分类号】R743.3【文献标识码】A【文章编号】10036350（2023）15215904Clinical study on neck acupuncture combined with rTMS in the treatment of patients with cerebral infarction ofQi deficiency and blood stasis type in the recovery stage.REN Qing-ping1,ZHAO Jia-cheng2,LIN Hai1.SecondWard of Encephalopathy Department1,Department of Acupuncture and Moxibustion,Massage,and Rehabilitation2,XianTraditional Chinese Medicine Hospital,Xian 710021,Shaanxi,CHINA【Abstract】ObjectiveTo explore the therapeutic effect of neck acupuncture combined with repetitive transcra-nial magnetic stimulation(rTMS)in the treatment of patients with cerebral infarction of Qi deficiency and blood stasistype in the recovery stage.MethodsNinety patients with cerebral infarction of Qi deficiency and blood stasis type inthe recovery period admitted to Xian Traditional Chinese Medicine Hospital from July 2021 to July 2022 were selectedand randomly divided into an observation group and a control group,each with 45 cases.Patients in the control groupwere treated with rTMS,while those in the observation group were treated with neck acupuncture therapy on the basis ofthe control group,both for 4 weeks.The clinical efficacy of two groups after treatment were compared between the twogroups,as well as the changes in Functional Oral Intake Scale(FOIS)score,National Institutes of Health Stroke Scale(NIHSS)score,Fugl Meyer Assessment(FMA)score,daily living ability(Barthel index),mean blood flow velocity(Vm)of middle cerebral artery,pulsatile index(PI)before and after treatment,and the occurrence of adverse reactions dur-ing treatment.ResultsAfter treatment,the total effective rate of clinical efficacy in the observation group was 91.11%,which was significantly higher than 71.11%in the control group(P0.05).After treatment,the FIOS score and NIHSSscore of the observation group were(5.140.48)points and(11.321.38)points,which were significantly lower than(4.620.51)points and(13.161.47)points in the control group(P0.05);the FMA score and BI index of the observationgroup were(69.826.45)points and(62.245.63)points,which were significantly higher than(60.535.27)points and(53.025.19)points in the control group(P0.05);the Vm of the middle cerebral artery in the observation group was(37.242.51)cm/s,which was significantly higher than(33.982.70)cm/s in the control group,and the PI was 0.870.12,which were significantly lower than 1.000.06 in the control group,with statistically significant differences(P0.05)，具有可比性，见表1。本研究经医院医学伦理委员会批准。表1两组患者的一般资料比较x-s，例(%)Table 1Comparison of general information between the two groups x-s,n(%)组别观察组对照组2/t值P值例数4545男性30(66.67)32(71.11)女性15(33.33)13(28.89)年龄(岁)63.726.1864.105.920.2980.767体质量指数(kg/m2)23.743.0523.812.760.1140.909病程(月)1.690.311.720.290.4740.637高血压27(60.00)25(55.56)0.1820.670冠心病13(28.89)11(24.44)0.2270.634糖尿病10(22.22)12(26.67)0.2410.624性别0.2070.6491.2治疗方法对照组患者采用rTMS治疗。选择武汉依瑞德公司生成的YRD-CCY 型经颅刺激仪，治疗线圈置于右侧背外侧前额皮质所对应的头皮部位，频率设置为10 Hz，运动阈值设置为90%，电流输出调整为1 mA，治疗时间20 min，1次/d，每周治疗5次。观察组患者在对照组治疗的基础上联合项针疗法。主要取穴包括风池穴、吞咽(新穴)穴、供血(新穴)穴、翳风穴和风府穴。根据患者病情程度选择合适体位，无偏瘫患者选择俯坐位或仰靠坐位，肢体偏瘫患者可在帮助下选择侧卧位或仰卧位。其中风池穴至喉结部位刺入1.5寸作用，使用捻转补法，吞咽穴押手至外推开颈总动脉部位，针刺入内侧约3分，供血穴直刺，刺入约1.5寸。翳风穴由内前下方进行斜刺，约1.5寸。风府穴针尖向斜下方刺入，约1寸，进针得气后均留置20 min，1次/d，每周治疗6次。两组患者均持续接受4周的治疗。1.3观察指标与评价方法(1)临床疗效：治疗4周后，根据美国国立卫生研究院卒中量表(NIHSS)评分8的变化评价。基本痊愈：NIHSS降低幅度 90%100%；显效：NIHSS评分降低幅度90%且46%；有效：NIHSS评分降低幅度46%且18%；无效：NIHSS评分降低幅度18%。总有效率=基本痊愈+显效+有效。(2)吞咽功能、神经功能：分别于治疗前、治疗4周后评价，功能性经口摄食评价量表(FOIS)评分范围17分，分数越高则代表患者吞咽功能越好9；NIHSS评分范围042分，结果越高则代表患者的神经功能越差。(3)肢体功能、日常生活能力(Barthel指数)：分别于治疗前、治疗4周后评价，采用Fugl-Meyer(FMA)评分评价肢体运动功能，分值越高则代表肢体功能越好10；Barthel 指数越高则表示患者日常生活能力越好11。(4)脑部血流动力学：分别于治疗前、治疗4周后，使用经颅多普勒超声诊断仪测定两组患者大脑中动脉平均血流速度(Vm)、搏动指数(PI)。(5)不良反应：记录两组患者治疗期间的不良反应发生情况。1.4统计学方法应用SPSS26.0软件包进行数据统计分析。计量资料以均数标准差(x-s)表示，组间比较采用t检验，计数资料比较采用2检验。以P0.05表示差异具有统计学意义。2结果2.1两组患者的临床疗效比较观察组患者的临床疗效总有效率为91.11%，明显高于对照组的71.11%，差异有统计学意义(2=5.874，P=0.0150.05)，见表2。表2两组患者的临床疗效比较(例)Table 2Comparison of clinical efficacy between the two groups(n)组别观察组对照组例数4545基本痊愈31显效2015有效1816无效413总有效率(%)91.1171.112160Hainan Med J,Aug.2023,Vol.34,No.15海南医学2023年8月第34卷第15期2.2两组患者治疗前后的FIOS评分、NIHSS评分比较治疗后，两组患者的FIOS评分、NIHSS评分均降低，且观察组患者的FIOS评分、NIHSS评分明显低于对照组，差异均有统计学意义(P0.05)，见表3。2.3两组患者治疗前后的FMA评分、BI指数比较治疗后，两组患者的FMA评分、BI指数均升高，且观察组患者的FMA评分、BI指数明显高于对照组，差异均有统计学意义(P0.05)，见表4。2.4两组患者治疗前后的脑部血流动力学比较治疗后，两组患者的大脑中动脉Vm均升高，PI均降低，且观察组大脑中动脉Vm明显高于对照组，PI明显低于对照组，差异均有统计学意义(P0.05)，见表5。2.5安全性评价治疗期间，两组患者均无明显不良反应发生。3讨论随着近年来人们生活方式和饮食习惯的不断改变，脑梗死在临床上发病率也逐年升高，且发病年龄也有年轻化的趋势，对人体健康带来较大威胁。当前，虽然关于脑梗死的治疗已取得较大发展，但是患者治疗后也存在较长时间的病情恢复期，对于该阶段的治疗和处置也占据着重要地位。rTMS是一种神经电生理技术，对大脑皮质神经元有兴奋作用，可提升脑组织神经递质的活性，起到脑组织修复作用，从而明显改善脑梗死患者的记忆、神经功能，但是单独使用该方式治疗的总体疗效仍有待提升。中医治疗脑卒中患者有着较长的历史，它们认为，该病的病位在脑，并涉及到心、脾、肝、肾等多个脏腑，属本虚标实之证，气虚血瘀是发病之本，气虚可致血行不畅，瘀血内阻，故而经脉不畅，形成“中风”，治疗原则应以“活血通络、补气扶正”为主12。项针疗法是中医特色治疗方式，主要是通过对头颈部相关穴位进行针刺，从而产生相应的治疗效果。相关研究显示，项针疗法有助于改善脑卒中恢复期患者的吞咽功能，进而改善患者的生活质量13。尚亚新等14报道中显示，项针对脑部功效、脑组织的能量代谢也具有调节作用，能促进神经营养物质的分泌，并对相关蛋白通路发挥调控作用，达到改善认知功能的效果，在脑梗死患者中有较好的应用价值。本研究采用项针疗法联合rTMS对脑梗死恢复期气虚血瘀型患者进行治疗，其中项针疗法的取穴方式中，风池穴是治风要穴，具有平肝潜阳、豁痰利窍之效，翳风穴具有益气补阳之功，风府穴可通关开窍、疏风通络，而吞咽穴是治疗吞咽功能障碍的穴，供血穴可活血通络。本研究结果显示，项针疗法联合rTMS治疗的患者FIOS评分、NIHSS评分、FMA评分、BI指数及大脑中动脉血流动力学的改善程度更明显，同时临床疗效总有效率也更高，差异均有统计学意义(P0.05)。经分析，风府穴是全身督脉的要穴，能调节全身气机，而翳风穴下含有颈内动脉、耳后动脉等，对脑动脉的血液循环有调节作用。风池穴对锥-基底动脉血供有较好的改善效果，针刺该穴位对神经递质的分泌有促进作用，产生舒张血管、提升交感神经兴奋性、改善脑组织血液循环等作用，对脑细胞起到保护作用，同时该穴位还能抑制神经细胞凋亡15。并有研究显示，吞咽穴可达到咽缩肌部位，此部分富含喉上神经分值，对吞咽困难等症状有较好的改善作用，而供血穴的深部为椎动脉、颈内动脉，对该穴位进行针刺有助于调节大脑血液循环，对神经元的兴奋性起到改善效果。由此可见，联合项针疗法能更好的调节脑梗死恢复期患者的血液循环、促进神经元兴奋，从而帮助患者神经功能、肢体功能得到更好的恢复，提高日常生活能力16。综上所述，项针疗法联合rTMS治疗气虚血瘀型脑梗死恢复期患者有助于促进患者功能恢复，临床疗表3两组患者治疗前后的FIOS评分、NIHSS评分比较(x-s，分)Table 3Comparison of FIOS scores and NIHSS scores between thetwo groups before and after treatment(x-s,points)组别观察组对照组t值P值例数4545治疗前3.620.543.570.590.4190.676治疗后5.140.48a4.620.51a4.9810.001治疗前16.282.1715.962.500.6480.518治疗后11.321.38a13.161.47a6.1220.001注：与本组治疗前比较，aP0.05。Note:Compared with that in the same group before treatment,aP0.05.FIOS评分NIHSS评分表5两组患者治疗前后的脑部血流动力学比较(x-s)Table 5Comparison of cerebral hemodynamics between the twogroups before and after treatment(x-s)组别观察组对照组t值P值例数4545治疗前29.833.1730.022.760.3030.762治疗后37.242.51a33.982.70a5.9320.000治疗前1.100.111.120.090.9440.348治疗后0.870.12a1.000.06a6.5000.000注：与本组治疗前比较，aP0.05。Note:Compared with that in the same group before treatment,aP0.05.Vm(cm/s)PI表4两组患者治疗前后FMA评分、BI指数比较(x-s，分)Table 4Comparison of FMA scores and BI between the two groupsbefore and after treatment(x-s,points)组别观察组对照组t值P值例数4545治疗前51.725.5352.334.920.5530.582治疗后69.826.45a60.535.27a7.4820.001治疗前45.024.8645.814.270.8190.415治疗后62.245.63a53.025.19a8.0770.001注：与本组治疗前比较，aP0.05。Note:Compared with that in the same group before treatment,aP0.05.FMA评分BI指数2161海南医学2023年8月第34卷第15期Hainan Med J,Aug.2023,Vol.34,No.15效显著，且安全性较高。然而，本研究仍有不足，例如研究时间较短，未能持续观察患者更长期的疗效及安全性等，且总体样本量较少，今后有待持续开展更高质量的临床研究进一步加以证实。参考文献1Hurford R,Sekhar A,Hughes TAT,et al.Diagnosis and managementof acute ischaemic stroke J.Pract Neurol,2020,20(4):304-316.2Byrd EM,Jablonski RJ,Vance DE.Understanding anosognosia forhemiplegia after stroke J.Rehabil Nurs,2020,45(1):3-15.3Zhao JJ,Jiang RA.Effect of low-frequency rTMS combined with in-telligent motor feedback training on motor function of convalescentpatients with cerebral infarction J.Hainan Medical Journal,2022,33(17):2192-2195.赵娇娇,江容安.低频rTMS联合智能运动反馈训练对脑梗死恢复期患者运动功能的影响J.海南医学,2022,33(17):2192-2195.4Wang T,Wang M,Hu N.Investigation of TCM syndrome types andself-management 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