针药结合治疗缺血性中风病

1,针药结合治疗缺血性中风病的系统研究,ThesystemresearchofAcupunctureandherbstotreatischemicstroke,石学敏SHIXuemin天津中医药大学第一附属医院TheFirstTeachingHospitalofTianjinUniversityofTraditionalChineseMedicine,中风病的治疗难点Theproblemoftreatingapoplexy,如何减轻血管神经单元的损害、促进重构神经组织、重建脑组织循环是神经功能恢复的根本。中风病治疗的难点及突破点，聚焦在神经与血管的新生。Howtoreducethedamageofneurovascularunit,promotereconstructionnervetissueandreconstructionbraincirculationisneurologicalrecovery.Thetreatmentofstroke,focusonproblemsandbreakthroughofnewbloodvesselsandnerves.,目前，治疗中风病最有效的方法是卒中单元，但是现代医学意义上的卒中单元需要较高的软硬件配备，无法于现有医疗资源基础上推广应用。所以，如何利用有效的中医手段构建符合中国特色的“中风单元”是今后重要的研究方向。Currently,thetreatmentofstrokearethemosteffectivewaystostroke,butmodernmedicalunitonthesignificanceofthesoftwareandhardwareunitneedshigherstrokewithexistingmedicalresources,notinbasedonapplication.Therefore,howtoeffectivelyusethetraditionalmethodtosetupChinesecharacteristicstrokeunitisanimportantresearchdirectioninfuture.,针刺和有效中药制剂是我国治疗中风病的重要手段，也是构建“中风单元”的主要因素。由“醒脑开窍针刺法”、“丹芪偏瘫胶囊”相结合为关键内核的“石氏中风单元”，在临床上取得了显著疗效，并被国家列为重大科技推广项目。AcupunctureandherbsareeffectivetreatmentinChinaandanimportantfactorofstrokeunit.“Shisstrokeunit“whichbemadeof“XNKQ”acupuncturetherapyandDanqihemiplegiacapsule,getgreatclinicaleffect,andhasachievedremarkablelistedbythestatescienceandtechnologymajorpromotionprojects,“醒脑开窍”针法简介,在选穴上以阴经和督脉穴为主，并强调针刺手法量学规范，有别于传统的取穴和针刺方法。ThepointsonYinmeridiansandDumeridianaremainlyselectedandstandardquantitativemanipulationsareappliedemphatically,whicharequitedifferentfromtraditionalpointselectionandacupuncturemanipulationsintreatmentofapoplexy.,治疗方法Treatment,1.处方主穴：内关(手厥阴心包经)人中(督脉)三阴交(足太阴脾经)1.PointPrescriptionMainpoints:Neiguan(PC6,thePericardiumMeridianofHand-Juejin)Renzhong(DU26,theDUMeridian)Sanjinjiao(SP6,theSpleenMeridianofFoot-Taiyin),辅穴：极泉(手少阴心经)委中(足太阳膀胱经)尺泽(手太阴肺经)Supplementarypoints：Jiquan(HT1,theHeartMeridianofHand-shaoyin)Weizhong(BL40,theBladderMeridianofFoot-Taiyang)Chize(LU5,theLungMeridianofHand-Taiyin),配穴：吞咽障碍加风池、翳风、完骨；手指握固加合谷；语言不利加上廉泉，金津、玉液放血；足内翻加丘墟透照海。PointModification：Fordifficultyofswallowing,Fengchi(GB20),Yifeng(SJ17)andWangu(GB12)areadded.Forfailingtoextendfingerswithstiffness,Hegu(LI4)isadded.Forslurredspeech,Shanglianquan(EX-HN)isadded,andJinjin(EX-HN12)andYuye(EX-HN13)areusedwithblood-lettingmethod.Forstrephenopodia,penetratingmethodfromQiuxu(GB40)toZhaohai(KI6)isused.,2.操作方法Manipulation,内关Neiguan(PC6),直刺0.51寸，采用捻转提插结合泻法，施手法1分钟；,FirstpuncturebilateralNeiguan(PC6)perpendicularlyfor0.5-1cun,usingcombinativereducingmethodoflifting-thrustingandtwirling-rotatingtheneedlefor1minute;,补法（左侧顺时针；右侧逆时针）,泻法（左侧逆时针；右侧顺时针）,右R,左L,左L,右R,人中Renzhong(DU26),SecondlypunctureRenzhong(DU26)obliquelyupwardstothenasalseptumfor0.3-0.5cunwithheavybird-peckingmethoduntilthepatientseyeballsaremoistenedortearsflowdown.,向鼻中隔方向斜刺0.30.5寸，用重雀啄法，至眼球湿润或流泪为度；,三阴交Sanyinjiao(SP6),沿胫骨内侧缘与皮肤呈45度角斜刺，进针11.5，用提插补法，使患侧下肢抽动3次为度ThirdlypunctureSanyinjiao(SP6)obliquelyfor1-1.5cun,attheangleof45degreeswiththeskinsurfacealongtheposteriorborderofthemedialaspectofthetibia,withreinforcingmethodofliftingandthrustingtheneedletomaketheaffectedlowlimbhaveticforthreetimes.,极泉Jiquan(HT1),原穴沿经下移1寸，避开腋毛，直刺11.5寸，用提插泻法，以患侧上肢抽动3次为度。,SelectJiquan(HT1)pointat1cunbelowtheoriginallocationalongtheheartmeridiantokeepawayfromthearmpithair,punctureperpendicularlyfor1-1.5cunwithreducingmethodofliftingandthrustingtheneedletomaketheaffectedupperlimbhaveticforthreetimes.,尺泽Chize(LU5),屈肘成120度角，直刺1寸，用提插泻法，使患者前臂、手指抽动3次为度。,PerpendicularlypunctureChize(LU5)for1cundepthwhiletheforearmbendstoformanangleof120degreeswithreducingmanipulationofliftingandthrustingtheneedleuntiltheaffectedarmandfingershaveticforthreetimes.,委中Weizhong(BL40),仰卧直腿抬高取穴，直刺0.51寸，施提插泻法，使患侧下肢抽动3次为度。,SelectWeizhong(BL40)pointwiththesupinepositionandthelowerlimblifted,punctureperpendicularlyfor0.5-1cun,withreducingmethodofliftingandthrustingtomakethelowerlimbhaveticfor3times.,风池、完骨、翳风Fengchi(GB20)Wangu(GB12)Yifeng(SJ17),针向结喉，进针22.5寸采用小幅度高频率捻转补法，每穴施手法1分钟；,PunctureFengchi(GB20),Wangu(GB12)andYifeng(SJ17)inthedirectionofthelaryngealprotuberancefor2-2.5cun,withreinforcingmanipulationoftwirlingandrotatingtheneedleinhighfrequencyandsmallamplitudefor1minutetoeachacupoint.,合谷针向三间穴Hegu(LI4)toSanjian(LI3),进针11.5寸，采用提插泻法，使患者第二手指抽动或五指自然伸展为度；,PunctureHegu(LI4)1-1.5cunindepthwiththeneedletiptowardSanjian(LI3),withreducingmethodofliftingandthrustingtomakethepatientssecondfingerorfivefingersextendedfreely.,上廉泉Shanglianquan(EX-HN),针向舌根1.52寸，用提插泻法；,PunctureShanglianquan(EX-HN)for1.5-2cun,withtheneedletiptowardstherootofthetongueandreducingmethodofliftingandthrustingtheneedle.,金津、玉液Jinjin(EX-HN12)Yuye(EX-HN13),用三棱针点刺放血，出血12毫升；,PrickJinjin(EX-HN12)andYuye(EX-HN13)withthethree-edgedneedletocausebleedingfor1-2ml.,丘墟透向照海穴Qiuxu(GB40)toZhaohai(KI6),约1.52寸，局部酸胀为度。,PunctureQiuxu(GB40)1.5-2cunindepthwiththeneedletiptowardZhaohai(KI6),untilsorenessanddistensionoccurredlocally.,中风病其他并发症的治疗TreatmentofComplications,便秘：针外水道、外归来、丰隆。,Constipation:PunctureWaishuidao(EX-CA),Waiguilai(EX-CA)andFenglong(ST40),(2)呼衰：针刺双侧气舍,RespiratoryFailure:PuncturebilateralQishe(ST11),(3)尿失禁、尿潴留：针中极、曲骨、关元、局部施灸、按摩或热敷,IncontinenceofUrine,RetentionofUrine:PunctureZhongji(RN3),Qugu(RN4),Sanyinjiao(SP6),Yinlingquan(SP9).Moxibustionisappliedonthelocalarea,whilemassageandhotcompressareapplicabletoo.,(4)共济失调：针风府、哑门、颈椎夹脊穴。,Ataxia:PunctureFengfu(DU16),Yamen(DU15)andcervicalJiajipoints(EX-B2).,颈椎夹脊穴,CervicalJiajiPoints(EX-B2),(5)复视：针天柱、晴明、球后,DoubleVision:PunctureFengchi(GB20),Tianzhu(BL10),Jingming(BL1)andQiuhou(EX-HN7),(6)癫痫：针大陵、鸠尾,Epilepsy:PunctureDaling(PC7),Jiuwei(RN15),(7)肩周炎：针肩髃、肩髎、肩内陵、肩贞、肩中俞、肩外俞，痛点刺络拔罐,PeriarthritisofShoulder:PunctureJianneiling(EX-UE),Jianliao(SJ14),Jianzhen(SI9),Jianzhongshu(SI15),Jianwaishu(SI14).Applybloodlettingandcuppingmethodtothelocalpainpoint.,(8)血管性痴呆：针百会、四神聪、四白、太冲,VascularDementia:PunctureBaihui(DU20),Sishencong(EX-HN1),Sibai(ST2)andTaichong(LR3).,太冲,Taichong(LR3),(9)睡眠倒错：针上星、神门,ParadoxicSleep:PunctureShangxing(DU23),Shenmen(HT7).,“醒脑开窍”针法最新研究进展,在30余年的临床实践中，逐步形成了针刺治疗缺血性中风病及其并发症的诊疗规范和评价体系。近年来更是引入先进的研究方法和手段，对其疗效进行了综合系统的评价，获得了高级别的临床证据，并结合现代科学技术，系统地阐明了针刺治疗缺血性中风病的科学内涵及疗效机理。Inmorethan30yearsofclinicalpractice,graduallyformedtheacupuncturetreatmentofischemicapoplexyandthetreatmentofcomplicationnormsandevaluationsystem.Inrecentyearsisintroducedadvancedresearchmethodsanditseffectonthecomprehensiveevaluationsystem,advancedclinicalevidence,andcombinedwiththemodernscienceandtechnology,systematicallyexpoundstheacupuncturetreatmentofischemicstrokemechanismofscientificconnotationandcurativeeffect.,37,针刺可明显改善各期中风患者神经功能缺损程度Acupuncturecanobviouslyimprovetheneurologicdeficitsinstrokepatients,NIHSS,CSS,SSS,临床研究严格按照循证医学原则进行RCT试验证明：Clinicalstudiesinstrictaccordancewiththeprincipleofevidence-basedmedicineRCTexperimentsprove：,BI,BI改变量,针刺可改善各期中风患者日常生活能力，急性期的改善尤其明显Acupuncturemayimprovethestrokepatientsindailylife,especiallyintheacutephaseofimprovement,39,神经功能缺损（SSS）,日常生活能力（SS-QOL）,6个月随访证实，针刺可改善各期中风患者神经功能缺损及日常生活能力的作用6monthsfollow-up,acupuncturecanimprovethestrokepatientsneurologicdeficitsanddailylife,急性期,恢复期,后遗症期,牛津残障评分（OHS）,针刺可降低各期中风患者残障程度Acupuncturemayreducethedegreeofdisabilityinstrokepatients,33%,40%,40%,66%,76%,63%,针刺可降低缺血性中风病患者的复发率和死亡率Acupuncturemayreducetherecurrenceofpatientswithischemicstrokemortality,终点指标：Endindex：,15.9%,28.8%,6.7%,3.3%,4.3%,2.2%,急性期,恢复期,后遗症期,1.1%,0.86%,0,1.1%,1.7%,2.2%,复发率,死亡率,不良反应：未出现严重不良反应Adversereaction:didnotappearseriousadversereactions极少数出现轻微不良反应，主要有皮下出血，血肿，疼痛。Amildadversereactions,subcutaneousbleeding,hematoma,pain,安全性评价：Safetyevaluation,本研究获得了天津市科技进步一等奖Theresearchofthetianjinscienceandtechnologyprogressprize,机理研究紧扣中风病的治疗难点及突破点，聚焦在神经与血管的再生。研究针刺手段促进损伤后脑循环重建及神经细胞再生的作用，从形态学、生物化学、中枢神经机制、分子生物学等方面开展了二十余项基础实验。Definesthemechanismresearchandtreatmentofapoplexy,focusingonnerveandbreakthroughofbloodvessels.Researchmethodstopromotetheheadinjuryacupunctureandnervecellsregenerationcycle,fromthemorphology,biochemistry,molecularbiology,centralnervousmechanismformorethantwentyexperiments.,针刺治疗缺血性中风病的机理研究ThemechanismresearchofAcupuncturetreatmentischemicstroke,45,形态学研究，证明针刺可促进侧枝循环建立Morphologyresearchthatacupuncturecanpromotecollateralcirculation,梗塞半球脑表面缺血区Cerebralinfarctionhemispheresurfaceischemia,阻断大脑中动脉后，大脑表面缺血区所见：Blockaftermiddlecerebralarterysurfacearea,thebrainischemia,缺血后自身代偿情况Aftercompensatory.Theirischemia,针刺干预情况Acupunctureintervention,醒脑开窍针刺法对缺血区脑组织的改善“XNKQ”canimprovethebrainischemiaarea,针刺前：神经细胞溶解、破坏,针刺3h后：线粒体轻度肿胀,针刺6h后：线粒体肿胀减轻,针刺12h后：线粒体完整，出现微管微丝,针刺24h后：神经细胞基本正常,针刺保护细胞形态、减轻神经元损伤、12h内促进微管微丝等细胞的“骨架”的再生与修复Acupunctureprotectcellsform,reducedamage,promoteneurons12hmicrotubulesmicrofilamentcellsskeletonrenewableandrepair,醒脑开窍针刺法对病变神经元结构的修复Acupuncturetorepairpathologicalneuronstructure,47,醒脑开窍针法对脑梗死患者脑葡萄糖代谢的影响Acupunctureinpatientswithcerebralinfarctionofthebrainglucosemetabolism,醒脑开窍针刺法可以：促进病灶周围功能重组Promotesurroundingfunctionrestructuring激活运动功能区域Activationfunctionarea促使正常脑区的代偿Todecompensationthenormalbrainareas改善与记忆、认知、语言功能和情绪等相关区域的代谢。Improvememory,cognition,emotionandlanguagefunctionsrelatedareasofmetabolism,丹芪偏瘫胶囊治疗中风病的最新成果,治疗中风病恢复期的国家新药，纯中药制剂。Treatmentofnationaldrugstrokerecovery,traditionalChinesemedicinepreparation具有补气活血、豁痰熄风的功效Fillwithblood,andtheefficacyofwindtax-exemptphlegmoff2001年获国家新药证书（国药准字z20010105）2001wasapprovedbythestatedrugcertificate(z20010105)2002年获得国家GMP认证并投产上市2002obtainsthenationalGMPauthenticationandproduction,丹芪偏瘫胶囊的药物组成及功效Thecapsuleandpartialdrugefficacy处方：黄芪、丹参、川芎、水蛭、人工牛黄、全蝎、石菖蒲等。Prescription:astragalus,danshen,artificialbezoarandleeches,chuanxiongrhizoma,wholexie,etc.功能：益气活血，豁痰熄风。Function:qi,sputumextinguishwind.Tax-exempt,药物作用及特点Drugandcharacteristics1.减少脑梗死面积：药理实验表明，该药可以有效降低脑梗塞组织百分比，改善实验动物行为障碍。1.Reducecerebralinfarctionarea:thepharmacologicalexperimentsshowthatcaneffectivelyreducecerebralinfarction,theimprovementofexperimentalanimalspercentageorganizationbehavior.2.保护及修复受损脑细胞：药理实验表明，该药增加脑供血，有效恢复受损脑细胞功能。2.protectionandrepairdamagedbraincells:thatthedrugincreasespharmacologicalexperiments,recoverdamagedbraincellscerebralblood.,3.有效恢复肢体功能：临床实验结果显示，该药对改善肢体功能效果明显。3.effectivelyrestorelimbfunction:clinicalexperimentresultsshowthatthedrugtoimprovefunctionaleffectisobvious.4.降低血粘度：药理实验及临床实验表明，该药改善血液流变学指标，降低血粘度。4reducedbloodviscosity,pharmacologicalexperimentalandclinicalexperimentsshowedthatthedrugimprovinghemorheologyindices,reducebloodviscosity.,5.重病重剂，起效迅速：脑卒中病情较重，不用重剂难以起效，故每日每次用量较大，经过临床观察，该药对恢复早期脑卒中患者，起效迅速。5Illnessweight,agentquickly:strokediseaseisheavier,notheavyagenttoeffect,soeverylargedosage,dailyclinicalobservation,thedrugforearlystrokepatients,quickly.6.全成分提取生产工艺先进：采用韩国技术制造的动态提取设备，充分提取有效成份。6.Allcomponentsextractionadvancedproductiontechnology,USESthesouthKoreantechnologyofmanufacturingequipment,fullydynamicextractingeffectivecomponentsextraction.,丹芪偏瘫胶囊，已获得国际认可Hemiplegiacapsule,hasgainedinternationalrecognition,题目：DianqiPiantangJiaonang(DJ),atraditionalChineseMedicineinpost-strokerecovery中药丹芪偏瘫胶囊在中风后的康复作用杂志：Stroke卒中（美国）影响因子：6.499作者：ChristopherChen,MD;(新加坡国立大学药理学博士)结论：经过对605例患者进行随机对照研究证明，与对照中成药相比丹芪偏瘫胶囊可显著改善患者神经功能缺损，提高生活质量，且具有较好的安全性。Afterpatientsrequiredfor605randomizedstudycomparedwithcontrols,proprietaryhemiplegiacapsulescansignificantlyimprovepatientneurologicdeficits,andimprovethequalityoflife,andhasgoodsafety.,题目：NeuroprotectiveandneuroproliferativeactivitiesofNeuroAid(MLC601,MLC901),aChinesemedicine,invitroandinvivo中药丹芪偏瘫胶囊(MLC601,MLC901)在体内、体外的神经保护及再生作用杂志：Neuropharmacology神经药理学杂志（英国）影响因子：3.383作者：C.Heurteaux（法国瓦勒堡尼斯大学）摘要：丹芪偏瘫胶囊可以防止神经元死亡，促进神经再生，促进细胞增殖、神经突起生长，促进密集性的轴突、树突网络的发展。中风超早期应用本品可以降低死亡率，对于中风不同时期的治疗有着重要的意义。Hemiplegiacapsulescanpreventneurons,promotenerveregenerationdeath,promotecellproliferation,nervegrowthandpromoteprotuberantcoarctationofaxons,dendriticnetworkdevelopment.Usethisproductsuperearlystrokereducesmortality,differentperiodoftreatmentforstrokehasimportantsignificance.,题目：DanqiPiantanJiaonangDoesNotModifyHemostasis,Hematology,andBiochemistryinNormalsubjectsandStrokePatients丹芪偏瘫胶囊对正常受试者和中风病人凝血、生化指标的影响杂志：cerebrovasculardiseases脑血管病杂志瑞士影响因子：3.041作者：RobertGan新加坡国立脑神经医学院结论：丹