賀氏火針溫通法治療肱骨外上髁炎臨床觀察

薛立文1，王云峰2

(1.首都醫(yī)科大學(xué)附屬北京中醫(yī)醫(yī)院針灸科，北京100010；

2.北京盧溝橋社區(qū)衛(wèi)生服務(wù)中心，北京100072)

[摘要]目的觀察賀氏火針溫通法對肱骨外上髁炎的療效。方法收集2014年1月至2014年12月首都醫(yī)科大學(xué)附屬北京中醫(yī)醫(yī)院針灸科肱骨外上髁炎患者60例，按就診順序?qū)⒒颊叻譃橹委熃M和對照組，每組30例。對照組每日毫針刺肘髎、曲池、手三里、合谷穴，治療組加用賀氏火針隔日點(diǎn)刺阿是穴，兩組均連續(xù)治療10 d。以疼痛視覺模擬量表(visual analogue scale，VAS)、Mayo肘關(guān)節(jié)功能評分表(mayo elbow performance score，MEPS)為觀察指標(biāo)，判定臨床療效。結(jié)果與治療前比較，治療后兩組VAS評分均顯著降低(P<0.05)，MEPS評分均顯著升高(P<0.05)，治療組VAS評分降低值和MEPS評分升高值均顯著大于對照組(P<0.05)。結(jié)論賀氏火針溫通法可有效緩解肱骨外上髁炎的疼痛程度，改善肘關(guān)節(jié)功能。

[關(guān)鍵詞]肱骨外上髁炎；火針；溫通法

[中圖分類號]R681.7[DOI]10.3969/j.issn.2095-7246.2015.05.017

基金項(xiàng)目：國家重點(diǎn)基礎(chǔ)研究發(fā)展計(jì)劃項(xiàng)目(2014CB543203)國家重點(diǎn)基礎(chǔ)研究發(fā)展計(jì)劃項(xiàng)目(2014CB543203)

作者簡介：薛立文(1970-)，女，碩士，副主任醫(yī)師

收稿日期：(2015-09-17；編輯：曹健)

肱骨外上髁炎(external humeral epicondylitis，EHE)俗稱“網(wǎng)球肘”，是指由于急、慢性損傷造成的肱骨外上髁周圍軟組織創(chuàng)傷性炎癥，表現(xiàn)為肘外側(cè)--------------------

酸痛，肘關(guān)節(jié)功能活動(dòng)受限，持物無力等?，F(xiàn)又稱作“肘外側(cè)疼痛綜合征”“前臂伸肌總腱炎”“橈側(cè)伸腕短肌與環(huán)狀韌帶纖維組織炎”等，屬中醫(yī)學(xué)“傷筋”“筋痹”范疇。在英國、荷蘭和斯堪的納維亞發(fā)生率為0.4%~0.7%[1]；在國內(nèi)是針灸科、骨科常見病，好發(fā)于前臂勞動(dòng)強(qiáng)度較大的中老年人及職業(yè)工人、運(yùn)動(dòng)員等[2]。目前中西醫(yī)采用針灸、針刀、封閉、康復(fù)、口服藥物、手術(shù)等治療手段，雖取得一定療效，但治療期相對較長，患者常畏懼有創(chuàng)操作，擔(dān)心藥物毒性及不良反應(yīng)，故尋找一種快速有效、安全經(jīng)濟(jì)、易于接受的治療措施成為目前臨床研究熱點(diǎn)。筆者總結(jié)北京中醫(yī)醫(yī)院針灸科國醫(yī)大師賀普仁臨床經(jīng)驗(yàn)，采用賀氏火針治療該病，擬探討溫通法對EHE的治療效果，進(jìn)而為溫通法治療經(jīng)筋病提供臨床依據(jù)。

Effects of Acupuncture on Recovery of Gastrointestinal Function and Gastrointestinal Hormone Secretion after Abdominal Surgery

HUANGLong,YUQing-sheng,PANJin-fang,SHUAIJian-feng,LIANGJiu-yin,ZHANGQi,LIUJu-da,WANGZhen,ZHOUFu-hai

(1.DepartmentofGeneralSurgery,TheFirstHospitalAffiliatedtoAnhuiUniversityofChineseMedicine&InstituteofChineseTraditionalSurgery,AnhuiAcademyofChineseMedicine,AnhuiHefei230031,China)

Abstract[] ObjectiveTo investigate the effects of acupuncture on recovery of gastrointestinal function and gastrointestinal hormone secretion after abdominal surgery. MethodsOne hundred patients who received abdominal surgery were randomly and equally divided into acupuncture group and control group. Patients in both groups received conventional therapy, and patients in the acupuncture group received acupuncture therapy in addition. The treatment lasted for 7 days. The recovery of gastrointestinal function after treatment was observed in each group. Levels of serum gastrin, plasma somatostatin, and plasma motilin were determined using radioimmunoassay. ResultsCompared with the control group, the acupuncture group had significantly shortened postoperative time to first flatus, first defecation, first bowel sound, extubation, and first eating (P<0.05). Moreover, the acupuncture group had a significantly lower level of serum gastrin and significantly higher levels of plasma somatostatin and motilin compared with the control group (P<0.05). There was no significant difference in the incidence of complications between the two groups (P>0.05). ConclusionThe impacts of acupuncture on recovery of gastrointestinal function after abdominal surgery are associated with the regulation of gastrointestinal hormone secretion.

[Key words]gastrin; somatostatin; motilin; gastric motility; gastrointestinal hormone

1　臨床資料

1.1納入標(biāo)準(zhǔn)①符合EHE中西醫(yī)診斷標(biāo)準(zhǔn)，且疼痛發(fā)生在1個(gè)月內(nèi)，未接受過針刀、手術(shù)及服用西藥者；②疼痛視覺模擬量表(visual analogue scale，VAS)評分≥4分者；③年齡18～65歲者；④簽署知情同意書，志愿受試，知情同意過程符合GCP的規(guī)定。

1.2排除標(biāo)準(zhǔn)①患有關(guān)節(jié)炎及其他免疫系統(tǒng)疾病者；②近1個(gè)月內(nèi)接受過針灸治療該病者；③合并有心血管、腦血管、肝、腎和造血系統(tǒng)等嚴(yán)重原發(fā)性疾病及精神病患者；④對針刺不能耐受或有暈針史者；⑤正在參加其他臨床試驗(yàn)的患者。

1.3一般資料將60例合格門診患者按接診順序分為治療組(火針加常規(guī)針刺組)和對照組(常規(guī)針刺組)各30例。治療組男13例，女17例；年齡23～56歲，平均年齡(41.11±9.12)歲；病程1～15 d，平均病程(5.72±3.86)d。對照組男12例，女18例；年齡25～59歲，平均年齡(42.72±9.01)歲；病程1～14 d，平均病程(5.40±3.60)d。兩組患者性別、年齡、病程比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，具有可比性。

2　方法

2.1治療方法

2.1.1治療組采用特制0.5 mm×23 mm賀氏細(xì)火針。選擇壓痛最明顯處作為阿是穴，常規(guī)無菌操作皮膚，火針加熱至通紅，采用密刺法于阿是穴及旁開0.5 cm范圍內(nèi)快刺4~5針。再以0.35 mm×40 mm毫針，直刺患側(cè)肘髎、曲池、手三里、合谷，留針30 min?；疳樃羧罩委?次，毫針每日治療1次，連續(xù)治療10 d。

2.1.2對照組采用0.35 mm×40 mm毫針，直刺患側(cè)肘髎、曲池、手三里、合谷，留針30 min，每日治療1次，連續(xù)治療10 d。

2.2觀察指標(biāo)及方法治療前后(即第0天和第11天)進(jìn)行VAS及Mayo肘關(guān)節(jié)功能評分表(mayo elbow performance score，MEPS)[3]測評。

2.2.1VAS評分在紙上畫一條長10 cm的線段，兩端分別表示“無痛”(0分)和“想象中劇烈疼痛”(10分)，共10分?；颊吒鶕?jù)自身對疼痛的感受程度，在線段上作記號以表示疼痛強(qiáng)度，從起點(diǎn)至記號之間的距離即為VAS評分。

2.2.2MEPS評分MEPS滿分為100分，其中包括疼痛(疼痛程度、是否需服止疼藥、疼痛是否影響關(guān)節(jié)活動(dòng))45分，運(yùn)動(dòng)功能(關(guān)節(jié)運(yùn)動(dòng)弧大小)20分，穩(wěn)定性(內(nèi)外翻是否穩(wěn)定)10分，日常活動(dòng)(梳頭、吃飯、個(gè)人衛(wèi)生、穿襯衣、穿鞋)25分?？偡?90分為優(yōu)，75～89分為良，60～74分為中，<60分為差。

3　結(jié)果

兩組治療前VAS和MEPS評分比較，差異均無統(tǒng)計(jì)學(xué)意義(P<0.05)；與治療前比較，治療后兩組VAS評分均顯著降低(P<0.05)，MEPS評分均顯著升高(P<0.05)，治療組VAS評分降低值和MEPS評分升高值均顯著大于對照組(P<0.05)。結(jié)果提示，兩種療法均可明顯降低VAS評分和升高M(jìn)EPS評分，但治療組在降低VAS評分和升高M(jìn)EPS評分方面明顯優(yōu)于對照組。見表1。

表1　兩組患者VAS評分、MEPS評分比較( ± s)

注：與同組治療前比較，*P<0.05；與對照組差值比較，#P<0.05。

4　討論

EHE是由急性損傷或慢性勞損引起前臂伸肌群聯(lián)合總腱在肱骨外上髁附著部出現(xiàn)牽拉、撕裂傷，局部出血、水腫，進(jìn)而發(fā)生粘連，甚至出現(xiàn)纖維變性而致。本病屬中醫(yī)學(xué)“經(jīng)筋病”或“傷筋病”范疇，多由風(fēng)寒濕邪積聚肘關(guān)節(jié)，以致勞傷氣血或斂縮脈道，筋經(jīng)、脈絡(luò)失和而發(fā)。《靈樞·經(jīng)筋》認(rèn)為經(jīng)筋病和筋痛“治在燔針劫刺，以知為數(shù)，以痛為輸”，說明EHE適宜以“燔針劫刺”“以痛為輸”治則進(jìn)行治療。國醫(yī)大師賀普仁經(jīng)對火針療法的挖掘整理，將其納入“賀氏三通法”的溫通法范疇，并開發(fā)出自制賀氏火針針具，用“燔針劫刺”治療包括EHE在內(nèi)的各種疾病。本病以阿是穴火針密刺法深達(dá)腱膜，通透深層筋脈，使局部血運(yùn)通暢而病除；配以局部穴位肘髎、曲池、手三里疏通肘部氣血，循經(jīng)選取陽明經(jīng)止痛要穴合谷通經(jīng)活絡(luò)、鎮(zhèn)靜止痛。

EHE的治療除口服藥物、封閉等常規(guī)手段外，國外最新研究圍繞富血小板血漿療法[4]及基因研究[5]展開，但價(jià)格昂貴、需忍受治療帶來的痛苦等問題將大部分患者拒之門外，且療效未獲得一致認(rèn)可[6]。本研究應(yīng)用賀普仁臨床經(jīng)驗(yàn)，以VAS和MEPS評分作為量化指標(biāo)，結(jié)果顯示兩種療法均有明顯療效，但治療組在降低VAS評分和升高M(jìn)EPS評分方面效果更突出，說明賀氏火針溫通療法治療該病較普通毫針刺法具有更強(qiáng)的舒筋止痛作用。MEPS評分是一個(gè)綜合性指標(biāo)，EHE最主要的癥狀是疼痛，火針止痛效果突出，患者日?；顒?dòng)能力及運(yùn)動(dòng)功能隨疼痛的減輕而逐漸恢復(fù)，后續(xù)研究可適當(dāng)延長觀察期，以期對MEPS評分的變化規(guī)律作進(jìn)一步研究。

本研究證實(shí)賀氏火針溫通法治療EHE能有效減輕疼痛，改善肘關(guān)節(jié)功能，且操作簡便，易被患者接受，是對名老中醫(yī)寶貴臨床經(jīng)驗(yàn)的總結(jié)與傳承。

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[3]戴閩，羅軍.骨科運(yùn)動(dòng)康復(fù)[M].北京:人民衛(wèi)生出版社，2008:221-222.

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Clinical Effect of He’s Fire Needle and Warming Method in Treatment of External Humeral Epicondylitis

XUELi-wen1,WANGYun-feng2

(1.DepartmentofAcupunctureandMoxibustion,BeijingHospitalofTraditionalChineseMedicineAffiliatedtoCapitalUniversityofMedicalSciences,Beijing100010,China; 2.LugouqiaoCommunityHealthServiceCenter,Beijing100072,China)

Abstract[] ObjectiveTo observe the therapeutic effect of He’s fire needle and warming method in the treatment of external humeral epicondylitis. MethodsSixty patients with external humeral epicondylitis who were treated in Department of Acupuncture and Moxibustion, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University from January to December, 2014 were divided into treatment group (n=30) and control group (n=30) in the visiting order. The patients in the control group received routine acupuncture with filiform needle at Zhouliao, Quchi, Shousanli, and Hegu points; the patients in the treatment group received acupuncture with He’s fire needle at Ashi point every other day in addition to the therapy for the control group. Both groups received the treatment for 10 consecutive days. Pain Visual Analogue Scale (VAS) and Mayo Elbow Performance Score (MEPS) were applied as indices for observation to determine the therapeutic effect. ResultsAfter treatment, both groups had significantly reduced VAS scores (P<0.05) and significantly increased MEPS scores (P<0.05); compared with the control group, the treatment group had significantly greater decrease in VAS score and increase in MEPS score (P<0.05). ConclusionHe’s fire needle and warming method can effectively relieve the pain in external humeral epicondylitis and improve elbow function.

[Key words] external humeral epicondylitis; fire needle; warming method