针灸治疗脊髓损伤后神经源性膀胱研究进展

Review of Acupuncture and Moxibustion Treatment of Neurogenic Bladder after Spinal Cord Injury

文章总结归纳针灸治疗脊髓损伤(SCI)后神经源性膀胱(NB)的国内外研究现状,主要从针灸治疗SCI后NB的作用机制、针灸方法应用、取穴特点、治疗时机、结局指标选择等方面进行阐述。针灸可促进SCI后NB患者神经干细胞增殖从而刺激神经再生,改善受损神经系统功能;可以有效诱导神经营养因子的表达,促进SCI后组织的修复;可以降低SCI后促炎和促细胞凋亡因子的表达,从而抑制神经细胞凋亡,保护神经细胞。针灸治疗SCI后NB的常用治疗方法主要包括针刺、艾灸、穴位注射及综合疗法。针灸治疗SCI后NB取穴多遵循循经取穴和局部取穴相结合的原则,关于治疗时间窗的选择尚无统一认识。多数研究认为在脊髓损伤后,排尿系统暂时失去了中枢系统的控制,但未完全受损时,早期予以针灸治疗,使该区域保持一定的感觉冲动刺激,可为后期重建反射性排尿提供良好的基础。针灸治疗SCI后NB的主要结局指标应是评价治疗前后排尿功能的差异,主要包括24 h平均排尿次数、漏尿次数、排尿量及尿失禁次数、间歇导尿次数及标准化尿垫测试等;次要结局指标包括尿动力学、生活质量、治疗有效率、安全结局指标等。但其临床疗效评价的科学性仍存在一定争议,主要体现在循证证据不强;未严格开展随机对照试验;研究对象基线不平衡;评价工具缺乏特异性;临床试验注册程序不规范等方面。在下一步研究中还需开展多中心、大样本、严格的随机对照试验,完善临床试验注册程序,科学合理地根据SCI后NB患者分型选择适宜的针灸治疗方案,并探索科学、客观的结局评价指标,以提高相关研究的科学性和可信度。

This paper summarizes the research status of acupuncture and moxibustion in the treatment of neurogenic bladder(NB)after spinal cord injury(SCI)at home and abroad,mainly from the mechanism of acupuncture treatment of NB after SCI,the application of acupuncture methods,characteristics of acupoints selection,treatment timing,selection of outcome indicators,etc.Acupuncture can promote the proliferation of neural stem cells in patients with NB after SCI,so as to stimulate nerve regeneration and improve the function of the damaged nervous system;it can effectively induce the expression of neurotrophic factors and promote the repair of tissues after SCI;it can reduce the expression of pro-inflammatory and pro-apoptotic factors after SCI,so as to inhibit the apoptosis of nerve cells and protect nerve cells.Acupuncture,moxibustion,acupoint injection and comprehensive therapy were commonly used in the treatment of NB after SCI.In the acupuncture and moxibustion treatment of NB after SCI,acupoints selection mostly follow the principle of meridian selection and local acupoint selection.There is no unified understanding about the time window selection of acupuncture treatment NB after SCI.Most studies believe that the urination system temporarily loses the control of the central system after spinal cord injury,but it is not completely damaged.Early acupuncture treatment can maintain certain sensory impulse stimulation in the region,which can provide a good basis for the later reconstruction of reflex urination.The main outcome indicators of acupuncture treatment NB after SCI should be the difference of urination function before and after treatment,mainly including 24-hour average urination frequency,leakage frequency,voiding volume and incontinence frequency,intermittent catheterization frequency and standardized urine pad test,etc.Secondary outcome indicators include urodynamics,quality of life,treatment efficiency,safety outcome indicators,etc.However,there are still some controversies about the scientificity of clinical efficacy evaluation,which mainly includes the following aspects:the evidence-based evidence is not strong,randomized controlled trials are not strictly carried out,the baseline of research objects is unbalanced,the evaluation tools are lack of specificity,and the registration procedures of clinical trials are not standardized.In the next step,we should carry out multi center,large sample and strict randomized controlled trials,improve the registration procedures of clinical trials,scientifically and reasonably select appropriate acupuncture treatment programs according to the classification of patients with NB after SCI,and explore scientific and objective outcome evaluation indicators,so as to improve the scientificity and credibility of relevant research.