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中医内服外治治疗强直性脊柱炎的研究进展论文

发布时间:2020-04-24 15:05:53 文章来源:SCI论文网 我要评论














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摘要:强直性脊柱炎(AS)是一种发病机制目前在临床上暂未明确,常与遗传基因、免疫因素、环境因素等有关,在人体白细胞抗原HLA-B27上呈高度关联,以脊柱附着点和骶髂关节炎症产生疼痛感及酸胀感为主要症状的疾病。目前暂无彻底治愈方法,中医内服外治法治疗强直性脊柱炎具有效果显著、低风险、副作用小等特点,可有效缓解症状,因而被广泛运用于强直性脊柱炎的临床治疗当中。

关键词:强直性脊柱炎;中医内服外治;综述

Research Progress of Internal and External Treatment of Ankylosaur Spondylitis in Traditional Chinese Medicine

HUANG Jun-li 1,LIN Zong-han 2*

(1.Guangxi University of Traditional Chinese Medicine,Nanning Guangxi;2.Ruikang Hospital Affiliated to Guangxi University of Traditional Chinese Medicine,Nanning Guangxi)

ABSTRACT:Ankylosing spondylitis(AS)is a disease whose pathogenesis is not yet clear in clinic.It is often related to genetic,immune and environmental factors.It is highly correlated with human leukocyte antigen HLA-B27.The main symptoms of AS are pain and acid swelling caused by spinal attachment and sacroiliac joint inflammation.At present,there is no thorough cure method.Internal and external treatment of ankylosing spondylitis in traditional Chinese medicine has obvious effect,low risk,small side effects and other characteristics,which can effectively alleviate symptoms,so it is widely used in the clinical treatment of ankylosing spondylitis.

KEY WORDS:Ankylosing spondylitis;Internal and external treatment of traditional Chinese medicine;Summary

0引言

强直性脊柱炎是临床常见的自身免疫性疾病,发生率较高,主要表现为中轴骨骨关节慢性炎症,多发于青少年群体。强直性脊柱炎病因尚不明确,多数认为与遗传、内分泌失调、环境、代谢障碍、感染等因素存在联系。目前西医治疗AS药物主要包括非甾体类抗炎药、免疫抑制剂、抗风湿药物等,但临床疗效不稳定,且常有肝、肾功能,以及血液系统、胃肠道等损害或不良反应[1]。

1中医认识

近些年,中医治疗强直性脊柱炎越发受到临床关注,虽然中医学中并没有“强直性脊柱炎”这一病名记载,但可根据其屈伸不利、腰背疼痛为主的症状特点,将其纳入为“痹证”“骨痹”“肾痹”“大偻”“脊强”“背偻”“厉节风”“偻痹”等范畴[2]。《诸病源候论·风诸病下篇》曰:“历节风之状,短气,白汗出,历节疼痛不可忍,屈伸不得是也”。从中医角度来解释强直性脊柱炎的发病机制[3]主要是肝肾亏虚,加以风、寒、湿邪内侵,致使经络痹阻,或夹瘀夹湿,故中医主张使用具有祛风除湿、散寒通经、补益肝肾等药效的药材来治疗该疾病。常用的方药有肾着汤、四妙散、当归四逆汤等。

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2中医治疗方法

2.1中药内服


中药内服医治强直性脊柱炎有着悠久的历史并取得令人满意的疗效,在所有治疗的方法中占有绝对的地位,中医内服可因人、因地、因时制宜,根据症状的不同而施加加减用药,辩证论治,且对胃肠道刺激小,并未发现其它明显不良反应,较西药具有无可比拟的优势,近年来通过大量临床及试验研究也进一步论证了口服中药制剂治疗强直性脊柱炎的科学性和合理性。中医认为强直性脊柱炎主要是先天或者后天的肝肾不足,还有寒邪侵犯,督脉闭阻所致。治疗中药治疗要选择通络止痛,助阳养阳,补益肝肾的方剂。董树平等[4]选取滋阴益肾汤作为主要研究对象,滋阴益肾汤由熟地黄、黄柏、菟丝子、牛膝、知母、白芍、白术、当归、枸杞、山药组成,通过联合常用免疫抑制剂柳氮磺吡啶与否进行比较疗效。选取诊断为肝肾阴虚型的强直性脊柱炎患者90例。按等份45例随机分为治疗组和对照组,治疗组以滋阴益肾汤合并柳氮磺吡啶片口服,而对照组只服用柳氮磺吡啶片,两组所服用的柳氮磺吡啶药量及频次一致。一个疗程约为3个月,观察症状变化两个疗程。

治疗前和治疗6个月后均复查常规检查项目,包括血常规、尿常规、粪便常规、血沉、肝肾功能以及CRP,并且在治疗三个月后复查肝肾功能和尿常规。两组均治疗6个月,观察两组患者CRP和ESR的变化,记录患者的疼痛VAS评分以及强直性脊柱炎病情活动度BASDAI的变化。结论是滋阴益肾汤配合柳氮磺吡啶治疗肝肾不足阴虚型强直性脊柱炎能够可明显改善患者的疼痛症状、下调CRP、血沉等观察指标,不良作用较单纯服用西药少,使患者的生活质量得到提升,值得更多地应用于临床治疗上。高成选[5]对中医三痹汤医进行深入研究,对32例强直性脊柱炎的临床效果进行对比以及分析。三痹汤由黄芪、续断、人参、茯苓、甘草、当归、川芎、白芍、生地、杜仲、川牛膝、细辛、秦艽、川独活、防风、生姜、大枣组成,具有益气活血、补肾驱寒、祛风除湿的作用。利用分组对照法等分并各自给予两组患者中、西医治疗方案,在疗程结束后进行随访。结论:中医三痹汤对寒邪侵犯,督脉闭阻型强直性脊柱炎疗效显著,具有祛除寒邪、舒筋通络补虚,临床副作用小,值得多应用于临床。

2.2针刺

针灸是一种中国特有的治疗疾病的方法,是一种“内病外治”的独特疗法,具有针刺工具方便携带、适应证广、操作简便、疗效显著、成本低、不良反应少等特点,具有调和阴阳、疏通经络、扶正祛邪的作用。研究表明,针灸能调节炎性介质表达,改善局部血液微循环,恢复腰骶部关节功能。吴佳等[6]纳入四川省骨科医院风湿骨关节科收治初次诊断为强直性脊柱炎的患者70例并将入选病例随机分成两组:治疗组和对照组。对照组使用非甾体抗炎药物和改变病情药物治疗。治疗组在使用同种药物基础上加用运动针法,针刺申脉、赵海二穴治疗。治疗结束后进行疗效评价,利用统计软件分析数据对比分析。朱巍[7]选取初次诊断为强直性脊柱炎的患者80例,按随机数字表法分为对照组40例和研究组40例。对照组应用柳氮磺吡啶治疗,研究组在使用柳氮磺吡啶的基础上给予针灸治疗。针刺穴位选取:足三里、阳陵泉、照海、三焦俞、肾俞、关元俞、轶边、环跳、腰阳关、命门、阿是穴。结果:研究组有效率90.00%,对照组有效率62.00%,研究组明显胜过对照组,差异有统计学意义(P<0.05);研究组治疗后Bath强直性脊柱炎病情活动指数、Bath强直性脊柱炎功能指数评分高于对照组,差异有统计学意义(P<0.05);研究组治疗后C反应蛋白水平、基质金属蛋白酶-3、肿瘤坏死因子-α优于对照组,差异有统计学意义(P<0.05)。结论:针灸配合中药内服治疗强直性脊柱炎效果明显,可有效减轻炎症所引起的症状,改善临床症状。

2.3艾灸

艾灸在中医治疗方法占有相当总要的地位,主要通过燃烧艾绒产生的高温传送到体内经络,影响气血运行,激活经气,以调节因慢性炎症导致紊乱的生物化学功能,从而达到治病防病的一种手段。艾灸能够对局部进行热刺激,行气通络,温经散寒,被广泛应用于治疗引起关节屈伸活动不利的相关疾病,包括强直性脊柱炎、肩关节炎、膝关节炎等。叶雪英等[8]对逐经督脉灸疗法进行深入研究并运用到治疗肾虚督寒型强直性脊柱炎的治疗当中。严格挑选已经明确诊断为肾虚督寒型强直性脊柱炎的患者60人,采用常规运用的回顾性方法,将入选患者随机分成等份,给予对照组传统艾灸灸督脉,艾灸穴位选取腰阳关、命门、肾俞及酸胀感强烈的体表投影皮肤位置。治疗组给予自制逐经灸自动艾灸机、特制空心艾条逐经灸督脉。结果显示逐经督脉灸疗法治疗肾虚督寒型强直性脊柱炎效果显著,可改善中医证候,应该多进行推广应用。长蛇灸,因其在胸腰椎脊柱表面皮肤上铺敷姜、蒜或药物,形同一条长蛇而命名,属于艾灸中的一条分支,是众多艾灸工作者在民间探索应用并通过总结而成的一种方法,常应用于类风湿性关节炎或慢性肝炎,近年来有不少中医医师将长蛇灸运用到强直性脊柱炎的治疗中并取得不错的疗效,引发更多学者的关注。长蛇灸接触面更广,温通能力更足,火力更旺盛,散寒祛湿比一般常用的灸法效果更好。朱小燕等[9]探讨长蛇灸疗法对强直性脊柱炎的疗效及TRACP、BGP、IL-12水平的影响。艾灸穴位选取循行于督脉的穴位,包括长强、腰俞、腰阳关、命门、悬枢、脊中、筋缩、至阳、灵台、神道、神柱、陶道、大椎。结果治疗后两组IL-12、TRACP、含量下降,BGP水平上升,且观察组上述指标较对照组更佳(P<0.05);2组治疗后丙二醛(MDA)与超氧化物歧化酶(SOD)水平均有所降低,观察组氧化指标优于对照组(P<0.05);2组治疗后VAS疼痛评分、中医证候评分有不同程度地下降,生活质量总积分不断提高,组间差异有统计学意义(P<0.05);观察组治疗总有效率为89.1%,远远高于对照组的56.5%,差异有统计学意义(P<0.05)。结论:长蛇灸治疗强直性脊柱炎患者的临床疗效突出,能改善腰痛、脊柱僵硬等症状,促进关节功能的恢复,恢复患者的生活质量,适合临床推广及应用。近年来有学者尝试将中药内服联合艾柱温灸观察治疗强直性脊柱炎的临床疗效。阎晓霞等[10]运用温灸治疗比较强直性脊柱炎的临床疗效。结论:益肾强脊方配合粗艾柱温灸治疗强直性脊柱炎疗效确切。

2.4中药外治

中药熏蒸是中医外治的一种重要手段,通过煎煮出来的中药熏蒸炎症引起疼痛的部位,利用高温加速局部血液循环,扩张毛细血管,促进炎症介质吸收,从而达到修复损伤组织、缓解疼痛的目的。岳辉[11]探讨中药蒸气浴治疗强直性脊柱炎患者的应用效果。

将60例强直性脊柱炎患者随机分成两组,对照组采用针灸推拿治疗,观察组采用中药蒸气浴治疗,熏蒸部位选取腰部酸胀明显部位的体表投影位置皮肤,对2组患者治疗后进行疼痛评分。结果显示观察组疼痛评分2.01显著低于对照组疼痛评分4.23,差异有统计学意义(P<0.05)。结论是对强直性脊柱炎患者实施中药蒸气浴治疗,可有效促进康复,降低疼痛度,恢复生活质量。

2.5手法

推拿手法是指以治疗、保健为目的,用手或肢体其他部位如指尖,大小鱼际、肘部,按特定技巧动作对身体部位或腧穴。阿是穴进行操作的方法。手法治疗的特点是简便易施行,无需任何医疗器械工具,全凭双手操作,且安全性极高,容易被普遍患者接受。长期的慢性炎症容易导致关节竹节样改变、颈腰椎受累受压,进而引起肌肉痉挛萎缩,伴随关节僵硬感、疼痛以及其他全身性症状,给患者带来相当大的困扰。手法治疗具有活血化瘀、强健筋骨、疏通经脉的作用,既可使局部症状消退,还能加速恢复患处功能,在临床各种疾病中广泛应用,亦适用于强直性脊柱炎的治疗。于飞等[12]将76例强直性脊柱炎患者随机分成两组,对照组采用中药治疗,观察组采用中药配合手法治疗,包括拇指点法、弹法、拨法、双手摩法、压法、立滚法、侧滚法等,对2组患者治疗后进行活动度、疼痛评分。结论是对强直性脊柱炎患者施行手法按摩,可增加患者颈腰椎活动度,促进康复,减少疼痛度,值得推广应用。

3问题与展望

强直性脊柱炎发病率高,病因机制尚未研究清楚,缺乏明确诊断标准,给患者带来了严重的困扰,目前该病的治疗仍以个体方案治疗和对症治疗为主。目前治疗上主要以非甾体抗炎药、免疫抑制剂、缓解病情抗风湿药为主,并无标准的达标治疗及维持缓解手段。随着对强直性脊柱炎的不断研究,一些新的药物和治疗方法逐渐应用在临床上,不断改善着患者的症状,但这些药物和治疗方法仍需要在临床上进一步评估。

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