卒中后肩痛不同时期针刺刺法的多因素优选方案分析

Analysis of optimal plan of multiple acupuncture manipulations for shoulder pain after stroke at different stages

目的：观察针刺结合康复训练与单纯康复训练对比治疗卒中后肩痛的疗效差异,并通过正交设计选择不同时期针刺刺法的最优方案。方法：选取90例患者,均接受综合康复训练,其中9例分入对照组不予针刺治疗,81例为进行正交设计的患者接受采用相同穴位、相同疗程的针刺治疗,以疼痛视觉模拟评分（VAS）及其加权值为观察指标,比较各针刺组与对照组疗效差异,优选第1个疗程后（早期）及第3个疗程后（后期）针刺刺法的最优方案,研究包括针刺深度（A因素：AⅠ：浅〈25mm,AⅡ：中25~40mm,AⅢ：深40~50mm）、针刺角度（B因素：BⅠ：直刺,BⅡ：横刺,BⅢ：斜刺）、行针次数（C因素：CⅠ：0次,CⅡ：1次,CⅢ：3次）、留针时间（D因素：DⅠ：20 min,DⅡ：30min,DⅢ：60min）,分析不同时期针刺刺法各因素间及主要因素不同水平间的差异性。结果：1针刺结合康复训练治疗卒中后肩痛无论在早期或后期均较单纯的康复训练疗效改善显著（均P〈0.01）;2针刺刺法优选方案：早期为AⅢBⅢCⅠDⅠ,即深刺、斜刺、行针次数为0次、留针时间为20min;后期AⅢBⅢCⅢDⅠ,即深刺、斜刺、行针次数为3次,留针时间为20min;3针刺刺法影响因素显著性分析,早期针刺深度与针刺角度有显著性（均P〈0.01）,后期针刺深度、针刺角度与行针次数有显著性（均P〈0.05）;4针刺刺法主要因素各水平差异分析的多重比较：早期,针刺深度中Ⅰ与Ⅱ、Ⅰ与Ⅲ、Ⅱ与Ⅲ差异有统计学意义（P〈0.05,P〈0.01）;针刺角度Ⅰ与Ⅲ差异有统计学意义（P〈0.01）。后期,针刺深度中Ⅰ与Ⅲ、Ⅲ与Ⅱ、Ⅰ与Ⅱ差异有统计学意义（P〈0.05,P〈0.01）;行针次数中Ⅰ与Ⅲ、Ⅱ与Ⅲ差异有统计学意义（P〈0.05）。结论：采用针刺结合康复训练治疗卒中后肩痛,早期针刺刺法优选方案为深刺、斜刺、行针次数为0次、留针时间为20min;后期优选方案则为深刺、斜刺、行针次数为3次,留针时间为20min。

Objective To observe the effects between acupuncture combined with rehabilitation and simple rehabilitation for shoulder pain after stroke,and to select the best plan of acupuncture manipulations at different stages by orthogonal design. Methods Ninety patients were treated with comprehensive rehabilitation,and nine cases without acupuncture were arranged into a control group. Eighty-one patients of orthogonal design were ap- plied by acupuncture with the same acupoints and course. The VAS score and its weighted value were regarded as the observation indices,and the effects between the acupuncture group and the control group were compared. The optimal plans of acupuncture manipulations of the early stage and the later stage were chosen after the first course treatment and the third course treatment separately. The acupuncture depth（ factor A： A l ： shallow depth less than 2 5 mm, A Ⅱ ： modest depth 2 5 - 4 0 mm, A Ⅲ ： deep depth 4 0 - 5 0 mm）, the acupuncture angle（ factor B： B1 ：perpendicular insertion, Bn ： horizontal insertion, B Ⅲ ： oblique insertion）, needle manipulated frequency （factor C： Ci ：zero time,Cn ：one time,Cn ：three times） and needle retained time（factor D：DI ：20 min,Dn ：30 min,Dn ：60 min） were studied. The differences among all factors and the diversity among major factors at different stages were analyzed. Results （1） Acupuncture combined with rehabilitation at the early and the later stage acquired better improvement than simple rehabilitation （all P〈0.01）. （2） The optimal acupuncture manipulation plan at the early stage was An Bm CI DI , which was deep acupuncture and oblique insertion for 20 rain with zero-time manipulation; the optimal acupuncture manipulation plan at the later stage was AⅢ BⅢCⅢ DⅠ . which was deep acupuncture and oblique insertion for 20 min with three-time manipulation. （3）There was significance for acupuncture depth and angle at the early stage（both P〈0. 01） and there was s;gnificance for insertion depth, acupuncture angle and manipulating frequency at the later stage（all P〈0.05）. （4）At the early stage,the insertion depth was statistically significant between At and AⅡ ,AⅠ and AⅢ ,AⅡ and AⅢ （P〈0. 05,P〈0.01）,and the statistical significance was existed between B1 and BⅢ （P〈0. 01）. At the later stage, the insertion depth was statistically significant between AI and AⅢ , AⅢ and AⅡ ,AⅠ and AH （P〈0.05 .P〈0.01） .and the statistical significance was existed between CⅠ and CⅢ ,CⅡ and CⅢ （P〈0.05）. Conclusion Acupuncture combined with rehabilitation acquire apparent effect for shoulder pain after stroke. At the early stage,the optimal plan is deep and oblique insertion for 20 min with zerotime manipulation. At the later stage,the best plan is deep and oblique insertion for 20 min with 3-time manipulation.