脏腑辨证指导下绝经后妇女KOA经筋病变的治疗及经筋通方干预机制研究

发布时间：2018-01-03 02:41

  本文关键词：脏腑辨证指导下绝经后妇女KOA经筋病变的治疗及经筋通方干预机制研究　出处：《广州中医药大学》2017年博士论文　论文类型：学位论文

  更多相关文章： 绝经后妇女 膝骨关节炎 经筋辨证 脏腑辨证 经筋通方

【摘要】：目的:分析膝骨关节炎(Knee Osteoarthritis,KOA)经筋分型与中医证型、证素对应关系,观察在脏腑辨证指导下采用经筋通方治疗绝经后妇女KOA经筋病变的临床疗效,进而采用去势大鼠KOA模型模拟绝经后妇女膝关节软骨退变微环境,探讨经筋通方治疗去势大鼠KOA筋骨病变的分子机制。以明确在脏腑辨证指导下采用经筋通方治疗绝经后妇女KOA经筋病变体现治病求本、筋骨并重中医学术思想。方法:选取广州中医药大学第三附属医院门诊绝经后KOA患者,制定选择标准,将符合标准的患者纳入研究,采用脏腑辨证获取中医证型、证素,经筋辨证获取经筋分型,将所获得资料建立数据库,观察经筋分型在中医证型、证素中分布情况,采用SPSS18.0软件进行对应分析研究。将选取的研究对象分为观察组和对照组,观察组口服经筋通方,每天1次,每周6次,2周为1个疗程,连续服用3个疗程,对照组采用经络电针疗法治疗,每2天1次,每周3次,2周为1疗程,连续治疗3个疗程。治疗结束后采用WOMAC、JOA、Lysholm评分评价膝关节功能,采用VAS评分评价疼痛缓解程度,记录治疗期间并发症发生情况,观察两组疗效之间的差异。运用SPSS18.0软件对数据进行统计处理,首先进行方差齐性检验,若方差齐选用独立样本t检验,若方差不齐选用Kruskal-Wallis非参数方差分析,并发症的比较采用χ2检验,疗效比较采用Wilcoxon秩和检验。18只6月龄雌性SD大鼠采用随机数字表法随机分为OVX+KOA组、OVX组和Sham组,每组6只。OVX+KOA组大鼠去势2周后建立KOA模型,OVX组大鼠去势后仅行膝关节脱位处理,Sham组摘除卵巢旁边的脂肪组织和膝关节脱位处理,所有大鼠造模1周后在动物实验跑台跑道中奔跑2周,1.5个月后采用ELISA检测血清E2、COMP含量,采用HE染色观察膝关节软骨和腓肠肌形态学变化。数据的统计与处理采用SPSS18.0软件,首先进行方差齐性检验,若方差齐选用单因素方差分析LSD法,若方差不齐选用Kruskal-Wallis非参数方差分析。72只6月龄雌性SD大鼠采用随机数字表法随机分为假手术组、模型组、经筋通高剂量组、经筋通中剂量组、经筋通低剂量组和阳性对照组,每组12只。OVX+KOA模型建立1周后在动物实验跑台奔跑,同时给予药物干预。经筋通高、中、低剂量组给予经筋通方,阳性对照组给予塞来昔布胶囊。经筋通高剂量组给药剂量为3.80g/100g/d,经筋通中剂量组给药剂量为1.90g/100g/d,经筋通低剂量组给药剂量为0.95g/100g/d,阳性对照组给药剂量为2.06mg/100g/d,假手术组和模型组给予同体积的生理盐水。每天给药1次,每周给药6天,休息1天。每周称1次体重,根据体重调整给药剂量,给药时间持续1.5个月。给药结束后采用ELISA检测血清E2、COMP含量,RT-PCR检测膝关节软骨ERRa、PGC-1a、Sox9、IL-1βmRNA表达,免疫组化检测腓肠肌Ⅱ型胶原表达。数据的统计与处理采用SPSS18.0软件,首先进行方差齐性检验,若方差齐选用单因素方差分析LSD法,若方差不齐选用Kruskal-Wallis非参数方差分析。结果:共有84例绝经后KOA患者符合选择标准纳入研究,其中经筋病变以足阳明经筋为主,其次为足太阳经筋、足三阴经筋和足少阳经筋,所占比例分别为39%、23%、20%及18%;中医证型以瘀血闭阻为主,其次为肝肾亏虚、风寒湿痹和风湿热痹,所占比例为44.45%、30.95%、26.19%及17.86%;中医证型与经筋分型对应分析显示,两者间存在属性关联且有统计学意义(χ2=38.814,P=0.000)。以中医证型与经筋分型点与点的距离观察,足阳明经筋病变和足少阳经筋病变与风寒湿痹、风湿热痹关系密切,足三阴经筋病变与瘀血闭阻关系密切,足太阳经筋病变与肝肾亏虚关系密切。中医证素中足阳明经筋病变以湿邪、瘀血及脾虚为主,足太阳经筋病变以肾虚、肝虚为主,足少阳经筋病变以瘀血、湿邪为主,足三阴经筋病变以瘀血、肝虚为主;中医证素与经筋分型对应分析显示,两者间不存在属性关联且无统计学意义(χ2=24.688,P=0.423)。将上述84例绝经后KOA患者纳入本次研究,12例不满足选择标准予以剔除,剩余72例符合选择标准纳入研究,其中观察组38例,对照组34例。两组患者年龄、体重、身高、BMI、绝经年限、病程、侧别和Kellgren-Lawrence分级比较,差异无统计学意义(P0.05),具有可比性。治疗后,两组患者WOMAC评分中疼痛、僵硬、活动难度和总评分显著降低,与治疗前比较差异具有统计学意义(P0.05),但两组间比较,差异无统计学意义(P0.05),两组差值比较,差异无统计学意义(P0.05);两组患者JOA、Lysholm评分显著增高,与治疗前比较差异具有统计学意义(P0.05),但两组间比较,差异无统计学意义(P0.05),两组差值比较,差异无统计学意义(P0.05);两组患者VAS评分显著降低,与治疗前比较差异具有统计学意义(P0.05),但两组间比较,差异无统计学意义(P0.05),两组差值比较,差异无统计学意义(P0.05);观察组总有效率为89.47%,对照组总有效率为88.24%,两组间经Wilcoxon秩和检验,差异无统计学意义(Z=-0.367,P=0.714)。治疗期间,两组患者未诉明显不适,未发现恶心、呕吐等消化系统症状,未发现心痛、心悸等心血管系统症状,未出现晕针、针柄断裂、过敏反应等并发症,未出现其他经筋及复合经筋病变。造模后1.5个月,大鼠处死前三组体重比较经方差齐性检验P=0.5270.05,说明具有方差齐性,采用单因素方差分析LSD法,经分析差异无统计学意义(P0.05),具有可比性。OVX+KOA组和OVX组血清E2含量明显低于Sham组(P0.05),OVX+KOA组与OVX组比较,组间差异无统计学意义(P0.05);OVX组血清COMP含量高于Sham组,但两组间比较差异无统计学意义(P0.05),OVX+KOA组血清COMP含量高于OVX组和Sham组,与OVX组比较,差异无统计学意义(P0.05),与Sham组比较,差异具有统计学意义(P0.05)。HE染色见OVX+KOA组软骨表面粗糙不平,皲裂或锯齿状改变,软骨表层纤维化,软骨细胞数量减少,细胞核呈蓝色,细胞外基质呈红色,软骨陷窝空虚,潮线上移、中断或多重潮线;三组腓肠肌可见细胞核呈蓝色,分布于肌纤维之间,肌纤维呈多角形,OVX+KOA组肌纤维粘连,排列紊乱,OVX组和Sham组肌纤维排列整齐,与Sham组比较,OVX+KOA组和OVX组肌细胞核数量减少,OVX组肌纤维间距增宽。药物干预1.5个月后,多组间各个指标比较经方差齐性检验P0.005,不符合方差齐性,采用Kruskal-Wallis非参数方差分析。模型组与假手术组比较,血清E2、COMP含量差异具有统计学意义(P0.05);经筋通高、中剂量组及阳性对照组与模型组比较,血清E2、COMP含量差异具有统计学意义(P0.05);经筋通高、中剂量组与阳性对照组比较,血清E2含量差异具有统计学意义(P0.05)。与假手术组比较,模型组ERRα、SOX9mRNA表达量明显降低(P0.05),PGC-1α、IL-1βmRNA表达量明显增高(P0.05)。采用经筋通方干预后,与模型组比较,经筋通高剂量组ERR α、SOX9 mRNA表达量明显升高(P0.05),PGC-1α、IL-1βmRNA表达量明显降低(P0.05),经筋通中剂量组ERRα mRNA表达量明显升高(P0.05),PGC-1 α、IL-1 β mRNA表达量明显降低(P0.05),经筋通低剂量组PGC-1α、IL-1βmRNA表达量明显降低(P0.05)。与阳性对照组比较,经筋通高剂量组ERRα、SOX9 mRNA表达量明显升高(P0.05),经筋通中剂量组PGC-1α、IL-1βmRNA表达量明显升高(P0.05),经筋通低剂量组ERR α、SOX9 mRNA表达量明显降低(P0.05),PGC-1α、IL-1 β mRNA表达量明显升高(P0.05)。与假手术组比较,模型组Co12αl蛋白阳性评分明显降低(P0.05)。与模型组比较,经筋通高、中剂量组和阳性对照组Col2α1蛋白阳性评分明显升高(P0.05)。与阳性对照组比较,经筋通高、中剂量组Col2α1蛋白阳性评分明显升高(P0.05),经筋通低剂量组明显降低(P0.05)。结论:KOA经筋分型和中医证型存在对应关系,在脏腑辨证指导下采用经筋通方治疗绝经后妇女KOA经筋病变能够取得良好临床疗效。去势大鼠KOA模型存在膝关节软骨和腓肠肌病变,能够较好地模拟绝经后妇女膝关节退变微环境。经筋通方能够调节去势大鼠KOA膝关节软骨IL-1 β/ERR α/PGC-1 α/SOX9信号通路表达,提高腓肠肌Ⅱ型胶原蛋白表达,从而发挥治疗KOA筋骨病变的作用。综合分析可知,在脏腑辨证指导下采用经筋通方治疗绝经后妇女KOA经筋病变可能是通过调节膝关节软骨IL-1 β/ERRα/PGC-1 α/SOX9信号通路表达,提高腓肠肌Ⅱ型胶原蛋白表达而发挥治疗作用,体现治病求本、筋骨并重学术思想。
[Abstract]:Objective: to analyze the knee osteoarthritis (Knee Osteoarthritis, KOA) tendons and TCM syndromes, syndrome element relationship, observe the in viscera syndrome differentiation under the guidance of Jingjin Decoction in treating postmenopausal women KOA clinical efficacy of tendon lesions, then the ovariectomized rats KOA model of postmenopausal women with knee joint cartilage the degeneration of micro environment, and to explore the molecular mechanism of Jingjin Decoction in treating ovariectomized rats and KOA lesions. In order to make clear in the viscera and under the guidance of the Jin Tong Decoction in the treatment of postmenopausal women with KOA tendon lesion for the treatment of bones, Chinese academic thought. Methods: a total of Third Affiliated Hospital of Guangzhou University of Chinese Medicine of postmenopausal KOA patients. Set the selection criteria, will meet the criteria were included in the study, the acquisition of viscera syndrome differentiation of TCM, syndrome, meridian sinew differentiation obtained by reinforcement type, the obtained data database, observe the bar type In TCM, syndrome distribution were studied. Corresponding analysis using SPSS18.0 software to study were divided into observation group and control group, observation group received by Jin Tong, 1 times a day, 6 times a week, 2 weeks for 1 courses, for taking 3 courses, the control group. With the meridian electro acupuncture therapy treatment, 1 times every 2 days, 3 times a week, 2 weeks as 1 course of treatment, continuous treatment of 3 courses. After treatment with WOMAC, JOA, Lysholm score of knee joint function was evaluated with VAS degree of pain relief and complications were recorded during treatment, observe the differences between the two groups. Using SPSS18.0 software for statistical data processing, firstly, homogeneity of variance test, if the variance using independent sample t test, if the variance is not homogeneous with Kruskal-Wallis non parametric analysis of variance, were compared using 2 test, the curative effect was compared with Wilcoxon and rank Test.18 June old female SD rats were randomly divided into OVX+KOA group, OVX group and Sham group, each group of 6 rats in the.OVX+KOA group were ovariectomized for 2 weeks to establish KOA model, OVX group of castrated rats were only knee dislocation treatment, Sham group ovariectomy beside the adipose tissue and knee joint dislocation treatment, all rats after 1 weeks in the experimental animal treadmill running in the runway for 2 weeks, 1.5 months after the detection of serum E2, ELISA content of COMP, HE staining was used to observe the articular cartilage of the knee and calf muscle morphological changes. Statistics and data processing using SPSS18.0 software, the first test of homogeneity of variance if the variance, using single factor analysis of variance LSD method, if the homogeneity of variance using Kruskal-Wallis non parametric analysis of variance.72 June old female SD rats were randomly divided into sham operation group, model group, high dose group of tendons, tendon through middle dose The Jin Tong Group, low dose group and positive control group, 12 rats in each group 1 weeks after the establishment of.OVX+KOA model in animal experiments of treadmill running, given the drug intervention at the same time. The band pass high, low dose group was treated with Jin Tong, the positive control group was given by Celecoxib Capsules. The high dose group was administered through the bars the amount is 3.80g/100g/d, the reinforcement through the middle dose group was administered at a dose of 1.90g/100g/d tendons through low dose group the dosage was 0.95g/100g/d, the positive control group the dosage was 2.06mg/100g/d, sham operation group and model group were given the same volume of saline. Administered 1 times daily, weekly administration of 6 days, the rest of the 1 day. Weekly said 1 times according to the weight, weight adjusted dosage, dosing time lasts for 1.5 months. After the end of dosing by detection of serum E2 and ELISA content of COMP, RT-PCR detection of articular cartilage ERRa, PGC-1a, Sox9, the expression of IL-1 beta mRNA, immunohistochemical detection of gastrocnemius muscle of type II collagen sheet Da. Statistics and data processing by SPSS18.0 software, firstly, homogeneity of variance test, if the variance using single factor analysis of variance LSD method, if the homogeneity of variance using Kruskal-Wallis nonparametric variance analysis. Results: a total of 84 cases of postmenopausal KOA patients met the selection criteria included in the study, the tendon lesion with Foot Yangming the tendons, followed by meridian tendons, three yin meridians of the foot tendons and Zu Shaoyang tendons, the proportion was 39%, 23%, 20% and 18%; TCM syndrome type of blood stasis obstructing, followed by liver and kidney deficiency, cold and dampness and rheumatic fever, accounted for 44.45%, 30.95% 26.19%, and 17.86%; TCM syndrome type and the reinforcement type correspondence analysis showed that attribute correlation exist between them and there was statistical significance (2=38.814, P=0.000). The TCM syndrome type and the reinforcement type and the distance of observation, Foot Yangming Meridian of foot Shao Yang rib lesions and tendon lesion with cold dampness Arthritis, rheumatic fever is closely related to the three yin meridians of foot muscle lesions and blood stasis obstructing closely meridian tendon lesion with deficiency of liver and kidney are closely related. TCM syndrome factors of Foot Yangming Meridian tendon lesion to dampness, blood stasis and spleen deficiency, meridian tendons disease with kidney deficiency, liver deficiency, foot Shaoyang tendon lesion with blood stasis and dampness, three yin meridians of foot tendon lesion with blood stasis, liver deficiency; TCM syndrome elements and the reinforcement type correspondence analysis showed that between the two there is no association and not statistically significant (2=24.688, P=0.423). This study will be included in the 84 cases of postmenopausal KOA patients in 12 cases, does not meet the selection criteria to be removed, the remaining 72 cases meet the selection criteria in the study, 38 cases in the observation group, 34 cases in the control group. Two groups of age, weight, height, BMI, menopause, duration, comparison side and Kellgren-Lawrence classification, there was no statistically significant difference (P0.05), with Comparable. After treatment, the pain, the WOMAC score of the two groups in stiffness, difficulty and the total score decreased significantly, compared with before treatment, the difference was statistically significant (P0.05), but the comparison between the two groups, the difference was not statistically significant (P0.05), compare the difference between the two groups, the difference was not statistically significant (P0.05); two groups of patients JOA, Lysholm were significantly increased, compared with before treatment, the difference was statistically significant (P0.05), but the comparison between the two groups, the difference was not statistically significant (P0.05), compare the difference between the two groups, the difference was not statistically significant (P0.05); the two groups of patients VAS score decreased significantly, compared with before treatment with statistical difference meaning (P0.05), but the comparison between the two groups, the difference was not statistically significant (P0.05), compare the difference between the two groups, the difference was not statistically significant (P0.05); the total efficiency of the observation group was 89.47%, control group total effective rate was 88.24%, between the two groups by Wilcoxon rank sum test, no statistical difference Learn the meaning of (Z=-0.367, P=0.714). During the treatment, two patients were not told not found obvious discomfort, nausea, vomiting and other gastrointestinal symptoms, found no heartache, palpitations and other symptoms of cardiovascular system, without treatment, the needle handle fracture, allergic reactions and other complications, he did not appear the tendons and tendon lesion composite at 1.5 months after modeling, rats were sacrificed before the three groups by weight difference test of homogeneity of P=0.5270.05, indicating the homogeneity of variance, LSD analysis by single factor variance analysis, the difference was not statistically significant (P0.05), comparable to.OVX+KOA group and OVX group serum E2 content was significantly lower than in group Sham (P0.05), OVX+KOA group and OVX group, no significant difference between the groups (P0.05); OVX serum COMP was higher than Sham group, but there was no significant difference between the two groups (P0.05), OVX+KOA group of serum COMP content was higher than OVX group and Sham group compared with OVX group, no significant difference Statistically significant (P0.05), compared with Sham group, the difference was statistically significant (P0.05).HE staining group OVX+KOA cartilage surface is rough, chapped or jagged, cartilage surface cartilage fibrosis, decrease in the number of cells, nuclei were blue, extracellular matrix of cartilage lacuna was red, empty, tide line up, or interrupt multiple tidal line; three groups of gastrocnemius muscle cell nuclei were blue, distributed in the muscle fibers, muscle fibers were polygonal, group OVX+KOA muscle fiber adhesion, disorder, OVX group and Sham group of muscle fibers arranged neatly, compared with Sham group, OVX+KOA group and OVX group to reduce the number of muscle cells, OVX muscle fiber spacing increases wide. 1.5 months after drug intervention, the homogeneity test of P0.005 of each index by variance comparison among multiple groups, does not meet the homogeneity of variance, the variance analysis of non Kruskal-Wallis parameters. The model group and the sham group compared with serum E2, COMP content difference 缁熻�″�︽剰涔，

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