基于正交设计针刺治疗中风后肩手综合征优化方案研究

Screening of optimized acupuncture therapeutic schemes through orthogonal design in the treatment of post-stroke shoulder-hand syndrome

目的筛选针刺治疗中风后肩手综合征(SHS)的临床优化方案。方法收集2015年1月至2016年6月上海浦东新区中医医院、上海中医药大学附属龙华医院针灸科或康复科住院及门诊就诊的中风后SHS受试者90例,采用随机数字表法随机分为9组,每组10例。按正交设计方案设立SHS治疗的4个因素穴位配伍(A)、留针时间(B)、频次(C)、疗程(D)及3个常见水平。选取有代表性的9种治疗方案:(1)头皮针配阳经穴,留针10 min,隔日1次,疗程2周;(2)头皮针配阳经穴,留针20 min,每日1次,疗程4周;(3)头皮针配阳经穴,留针30 min,每日2次,疗程8周;(4)头皮针配阴经穴,留针10 min,每日1次,疗程8周;(5)头皮针配阴经穴,留针20 min,每日2次,疗程2周;(6)头皮针配阴经穴,留针30 min,治疗隔日1次,疗程4周;(7)头皮针配阴、阳经穴,留针10 min,每日2次,疗程4周;(8)头皮针配阴、阳经穴,留针20 min,隔日1次,疗程8周;(9)头皮针配阴、阳经穴,留针30 min,每日1次,疗程2周。对9组受试者进行治疗,观察治疗前后疼痛视觉模拟评分(VAS)、Fugl-Meyer上肢运动功能评分、改良的Barthel(BI)指数评分的变化,从而对中风后SHS患者针刺治疗方案进行优选。基线资料采用方差分析及秩和检验进行统计分析,VAS评分、FMA评分、BI评分比较资料采用正交设计极差分析及方差分析进行统计学分析。结果 9组中风后SHS受试者治疗前年龄、病程,VAS评分、FMA评分、BI评分比较差异无统计学意义。对于VAS评分的改善方面,A、C、D为显著因素(F=7.382、3.742、15.775,P均<0.05),最优方案为头皮针+阳、阴经穴,隔日1次,留针20 min,疗程8周。对FMA评分的改善方面,A、B、D为极显著因素(F=5.629、11.006、32.305,P均<0.01),最优方案为头皮针+阳、阴经穴,隔日1次,留针20 min,疗程4周。对于BI评分的改善方面,B、D为极显著因素(F=6. 269、19. 919,P均<0. 01),最优方案为头皮针+阳、阴经穴,隔日1次,留针20min,疗程4周。根据临床经验可知,治疗时间长则疗效更佳。结论选取头皮针加阳、阴经穴,留针20 min,隔日1次,治疗8周,为针刺治疗中风后SHS的优选方案,能有效减轻患肢的疼痛程度,改善上肢运动功能,提高日常活动能力。

Objective To optimize the treatment schemes of acupuncture in the treatment of post-stroke shoulder-hand syndrome. Methods Ninety eligible patients with post-stroke shoulder-hand syndrome visiting the Rehabilitation Department or Acupuncture Department of Pudong New Area Traditional Chinese Medicine Hospital and Longhua Hospital were divided into nine groups by using the random number table, with tenpatients in each group. Then four factors were set up： adopting acupoint selection（ A）, needle retaining time（ B）, treatment frequency（ C）, and course of treatment（ D） as well as three levels by the orthogonal experimental design and nine typical treatment protocols were selected for our study： 1. Scalp acupuncture combined with yang meridians, retaining the needles for ten minutes, treating once every other day for two weeks; 2. Scalp acupuncture combined with yang meridians, retaining the needles for twenty minutes,treating once every day for four weeks; 3. Scalp acupuncture combined with yang meridians, retaining the needles for thirty minutes, treating twice every day for eight weeks; 4. Scalp acupuncture combined with yin meridians, retaining the needles for ten minutes, treating once every day for eight weeks; 5. Scalp acupuncture combined with yin meridians, retaining the needles for twenty minutes, treating twice every day for two weeks; 6. Scalp acupuncture combined with yin meridians, retaining the needles for thirty minutes, treating once every other day for four weeks; 7. Scalp acupuncture combined with yang meridians and yin meridians,retaining the needles for ten minutes, treating twice every day for four weeks; 8. Scalp acupuncture combined with yang meridians and yin meridians, retaining the needles for twenty minutes, treating once every day for eight weeks; 9. Scalp acupuncture combined with yang meridians and yin meridians, retaining the needles for thirty minutes, treating once every day for two weeks; Each group was scored by using the Visual analogue scale（ VAS）, Fugl-Meyer upper-extremity score and modified Barthel index（ BI） score before and after the treatment. Baseline data were analyzed by variance analysis and rank test, while VAS scale, Fugl-Meyer scale and Barthel scale were analyzed by range analysis and variance analysis of the orthogonal experimental design.Results The baseline data like age, course of the disease, VAS scale, Fugl-Meyer scale and Barthel scale before treatment were no statistical significance. For the improvement of VAS scale, A, C, D were the significant factors（ F = 7.382,3.742,15.775,all P〈0.05）. The best treatment scheme was the scalp acupuncture combined with yang meridians and yin meridians, retaining the needles for twenty minutes, and treating once every other day for eight weeks. For the improvement of FMA scale, A, B, D were the significant factors（ F = 5.629,11.006,32.305,all P〈0.01）. The best treatment scheme was the scalp acupuncture combined with yang meridians and yin meridians, retaining the needles for twenty minutes, and treating once every other day for four weeks. For the improvement of BI scale, B, D were the significant factors（ F = 6.269,19.919,all P〈0.01）. The best treatment scheme was the scalp acupuncture combined with yang meridians and yin meridians, retaining the needles for twenty minutes, treating once every other day for four weeks. According to clinical experience, treatment for longer time has better curative effect. Conclusion Selecting the scalp acupuncture combined with yang meridians and yin meridians, retaining the needles for 20 min, and treating once every other day for eight weeks is the best scheme for the treatment of post-stroke shoulder-hand syndrome, which can effectively ease the pain degree of low limbs, improve the motor function of upper-extremity and patients’ daily activities.