靳三针疗法治疗中风后痉挛性瘫痪的多因素分析临床研究

发布时间：2018-05-11 22:21

  本文选题：靳三针疗法 + 中风后痉挛性偏瘫　； 参考：《广州中医药大学》2016年博士论文

【摘要】：中风后痉挛性瘫痪是指脑卒中后大部分肌群出现肌张力增高,腱反射亢进,运动时阻力增加,生硬,肢体常被拉向肌群痉挛方向,不能产生协调运动,并可造成患肢肌肉萎缩、关节挛缩及变形的一系列临床症状,是脑卒中患者存在的最常见的残障表现之一,也是康复治疗中最棘手的后遗症。随着医学水平的不断提高,脑卒中后生存率不断上升,使得脑卒中后肢体恢复问题日益突显,脑卒中后肢体出现痉挛性瘫痪不仅严重影响患者的日常生活能力,而且给家庭和社会带来沉重的负担。目的：“靳三针”疗法是广州中医药大学首席教授靳瑞创治,采用靳三针在治疗中风后痉挛性瘫痪已开展了多项临床研究工作,对该病的治疗积累了丰富的经验,具有确切肯定的临床疗效。为观察靳三针疗法治疗中风后痉挛性瘫痪的针刺干预时机及选穴位配伍,优化治疗方案,研究采用多因素分析法,对影响临床疗效的两个重要因素(针刺时机、选穴配伍)进行2×2析因分组,以探讨该疗法治疗痉挛性瘫痪的最优选穴配伍及针刺时机。寻求在在针刺时机、穴位配伍这两个关键技术要点上有新的突破,为该疗法进一步地推广应用提供理论依据。方法：本研究严格按照循证医学的方法,进行大样本、随机研究,采用统一的药物治疗,并采用统一的诊断及疗效判定标准,用多因素分析法(2×2析因统计)进行穴位配伍、针刺时机分析,以中风后痉挛性偏瘫患者为研究对象。其方法是：将影响靳三针疗法的两个重要因素(针刺时机、选穴配伍)进行2×2析因组合,取针刺时机、选穴配伍两个因素,分为2个水平(中风后-14天/中风后15-30天、颞三针+手足挛三针/颞三针+手足三针)进行两两组合后进行比较,将观察对象分为四组(1组：中风后I-14天+颞三针、手足挛三针组；2组：中风后-14天+颞三针、手足三针组；3组：中风后15-30-天+颞三针、手足挛三针组；4组：中风后15-30天+颞三针、手足三针组)。治疗时间为每日1次,每次30min,每周连续针刺5天,隔2日,再行下周治疗,2周为1个疗程,一共治疗2个疗程,相关指标评测于治疗前、疗程结束后观察患者改良Ashworth痉挛量表(MAS)、临床痉挛指数(CSI)量表、临床神经功能缺损程度评分(NDS)、四肢简化Fugl-Meyer运动功能评分、日常生活活动能力AQL (Barthel)指数,进行评定后进入统计分析处理。结果：1临床疗效1.1在临床疗效方面,临床治愈率从高到低分别为：1组(中风后-14天+颞三针、手足挛三针)临床治愈率最高,为19.0%；2组(中风后-14天+颞三针、手足三针)；3组(中风后15-30天+颞三针、手足挛三针)、4组(中风后15-30天+颞三针、手足三针)的临床治愈率分别为9.8%、8.5%和5.0%,组间疗效相比,经统计学处理有异常显著性差异(P0.01)；1组与其它三组临床治愈率相比,经统计学处理有异常显著性差异(P0.01)；2、3两组临床治愈率相仿,经统计学处理,无显著性差异(P0.05)。总有效率方面：1组(中风后1-14天+颞三针、手足挛三针)总有效率为94.90%；2组(中风后1-14天+颞三针、手足三针)、3组(中风后15-30天+颞三针、手足挛三针)、4组(中风后15-30天+颞三针、手足挛三针)的总有效率分别为90.2%、89.0%和83.75%,组间疗效相比,经统计学处理有异常显著性差异(P0.01)；1组与其它三组总有效率相比,经统计学处理有异常显著性差异(P0.01、P0.05)；2、3两组总有效率相仿,经统计学处理,无显著性差异(P0.05)。综上结论：在内科及常规治疗同等的基础上,在中风后1-14天介入针刺疗法,采用靳三针(颞三针+手足挛三针)治疗,对改善中风后痉挛性瘫痪患者的痉挛程度临床疗效最佳。2临床痉挛指数(CSI)评分2.1疗程结束后,在针刺时机相同的前提下,比较痉挛指数(CSI)评分显示：1组(中风后1-14天+颞三针、手足挛三针)与2组(中风后-14天+颞三针、手足三针)两组相比,以1组为优,有显著性差异(P0.05)；3组(中风后15-30天+颞三针、手足挛三针)与4组(中风后15-30天+颞三针、手足三针)两组相比,以3组为优,有异常显著性差异(P0.01)。提示：在介入针刺时机相同的前提下,在改善痉挛指数(CSI)得分方面,选用颞三针+手足挛三针组临床疗效更佳(P0.01、P0.05)。2.2疗程结束后,在选穴配伍相同的前提下,比较痉挛指数(CSI)评分得分显示：1组(中风后-14天+颞三针、手足挛三针)与3组(中风后15-30天+颞三针、手足挛三针)两组相比,以1组为优,有显著性差异(P0.05)；2组(中风后-14天+颞三针、手足三针)与4组(中风后15-30天+颞三针、手足三针)两组相比,以2组为优,有异常显著性差异(P0.01)。提示：在选穴配伍相同的前提下,在改善痉挛指数(CSI)得分方面,早介入针刺治疗组(中风后-14天)在疗效更佳(P0.01、P0.05)。3日常生活能力ADL (Barthel)指数评分3.1疗程结束后,在针刺时机相同的前提下,比较日常生活能力(ADL Barther指数)显示：1组(中风后-14天+颞三针、手足挛三针)与2组(中风后1-14天+颞三针、手足三针)两组相比,以1组为优,有异常显著性差异(P0.01)；3组(中风后15-30天+颞三针、手足挛三针)与4组(中风后15-30天+颞三针、手足三针)两组相比,以3组为优,有异常显著性差异(P0.01)。提示：在时间因素固定的前提下,在改善日常生活能力ADL (Barthel指数)方面,选用颞三针+手足挛三针组临床疗效更佳(P0.01)。3.2疗程结束后,在选穴配伍相同的前提下,比较日常生活能力(ADL Barthel指数)显示：1组(中风后1-14天+颞三针、手足挛三针)与3组(中风后15-30天+颞三针、手足挛三针)两组相比,以1组为优,有异常显著性差异(P0.01)；2组(中风后1-14天+颞三针、手足三针)与4组(中风后15-30天+颞三针、手足三针)两组相比,以2组为优,有异常显著性差异(P0.01)。提示：在选穴配伍相同的前提下,在日常生活能力ADL (Barthel)指数方面,早介入针刺治疗组(中风后1-14天)在疗效更佳(P0.01)。4神经功能缺损程度(NDS)评分表4.1疗程结束后,在针刺时机相同的前提下,比较神经功能缺损(NDS)评分显示：1组(中风后1-14天+颞三针、手足挛三针)与2组(中风后1-14天+颞三针、手足三针)两组相比,以1组为优,有异常显著性差异(P0.01)；3组(中风后15-30天+颞三针、手足挛三针)与4组(中风后15-30天+颞三针、手足三针)两组相比,以3组为优,有显著性差异(P0.05)。提示：介入针刺时机相同的前提下,在改善神经功能缺损(NDS)评分方面,选用颞三针+手足挛三针组临床疗效更佳(P0.01、P0.05)。4.2疗程结束后,在选穴配伍相同的前提下,比较神经功能缺损(NDS)评分显示：1组(中风后1-14天+颞三针、手足挛三针)与3组(中风后15-30天+颞三针、手足挛三针)两组相比,以1组为优,有异常显著性差异(P0.01)；2组(中风后1-14天+颞三针、手足三针)与4组(中风后15-30天+颞三针、手足三针)两组相比,以2组为优,有显著性差异(P0.05)。提示：在选穴配伍相同的前提下,在改善神经功能缺损(NDS)评分方面,早介入针刺治疗组(中风后1-14天)在疗效更佳(P0.01、P0.05)。5简化FugI-Meyer运动功能评定5.1疗程结束后,在介入针刺时机相同的前提下,比较Fugl-Meyer运动功能得分显示：1组(中风后1-14天+颞三针、手足挛三针)与2组(中风后1-14天+颞三针、手足三针)两组相比,以1组为优,有异常显著性差异(P0.01)；3组(中风后15-30天+颞三针、手足挛三针)与4组(中风后15-30天+颞三针、手足三针)两组相比,以3组为优,有异常显著性差异(P0.01)。提示：介入针刺时机相同的前提下,在改善Fugl-Meyer得分方面,选用颞三针+手足挛三针组临床疗效更佳(P0.01)。5.2疗程结束后,在选穴配伍相同的前提下,比较Fugl-Meyer得分显示：1组(中风后1-14天+颞三针、手足挛三针)与3组(中风后15-30天+颞三针、手足挛三针)两组相比,以1组为优,有异常显著性差异(P0.01)；2组(中风后1-14天+颞三针、手足三针)与4组(中风后15-30天+颞三针、手足三针)两组相比,以2组为优,有异常显著性差异(P0.01)。提示：在选穴配伍相同的前提下,在改善Fugl-Meyer得分方面,早介入针刺治疗组(中风后1-14天)在疗效更佳(P0.01)。6针刺时机和选穴配伍联合干预作用分析6.1痉挛指数(CSI)评分针刺时机和选穴配伍联合作用(中风后1-14天早期针刺干预+颞三针、手足挛三针治疗中风后痉挛性偏瘫患者在痉挛指数(CSI)评分虽然统计学分析上无存在明显的协同、交互干预作用点,但根据交叉作用图(见图八、图九),应有良好的交叉作用趋势；根据选穴配伍、针刺时机的固定因素分析,联合作用后可显著降低中风后痉挛性偏瘫患者痉挛指数CSI评分(P0.01)有效缓解偏瘫肢体肌张力紧张状态、改善偏瘫肢体痉挛程度。6.2日常生活能力ADL (Barthel)指数评分针刺时机和选穴配伍联合作用(中风后1-14天早期针刺干预+颞三针、手足挛三针治疗中风后痉挛性偏瘫患者在日常生活能力ADL (Barthel)指数评分存在良好的协同、交互干预作用；联合作用后可显著提高中风后痉挛性偏瘫患者日常生活能力ADL(Barthel)指数评分((见图十一、图十二)有效提高患者的日常生活能力,提高患者的生活质量。6.3神经功能缺损(NDS)评分针刺时机和选穴配伍联合作用(中风后1-14天早期针刺干预+颞三针、手足挛三针治疗中风后痉挛性偏瘫患者在神经功能缺损(NDS)评分虽然统计学分析上无存在明显的协同、交互干预作用点,但根据交叉作用图(见图十四、图十五),应有良好的交叉作用趋势；根据选穴配伍、针刺时机的固定因素分析,联合作用后可显著降低中风后痉挛性偏瘫患者神经功能缺损(NDS)评分有效促进偏瘫患者神经功能康复,提高了患者的生活质量。6.4简化Fugl-Meyer运动功能评定针刺时机和选穴配伍联合作用(中风后1-14天早期针刺干预+颞三针、手足挛三针)治疗中风后痉挛性偏瘫患者在简化Fugl-Meyer运动功能存在良好的协同、交互干预作用；联合作用后可显著提高中风后痉挛性偏瘫患者简化Fugl-Meyer运动功能评分(见图十七、图十八P0.01),有效改善中风后痉挛性偏瘫患者肢体运动功能能力。结论：在中风后-14天或中风后15-30天开始介入靳三针疗法(针刺颞三针+手足挛三针或颞三针+手足三针)治疗中风后痉挛性偏瘫患者,均能有效缓解患者偏瘫肢体紧张程度,降低患者神经缺损程度,改善肢体的运动能力,提高日常生活能力,可获得良好的临床疗效。治疗中风后痉挛性偏瘫最优先方案：中风后1-14天配合颞三针、手足挛三针
[Abstract]:Spastic paralysis after apoplexy refers to the most common symptoms of stroke patients, such as increased muscle tension, hyperreflexiism, increased resistance, stiffness, and limbs often pulling into the direction of spasm of the muscle group, which can not produce coordinated movement, and can cause limb muscle atrophy, joint contracture and deformation. One of the manifestations of disability is also the most difficult sequelae in the rehabilitation treatment. With the continuous improvement of medical level, the survival rate of stroke is increasing, which makes the problem of limb recovery more and more obvious after stroke. Spastic paralysis of limbs after stroke not only seriously affects the daily living ability of patients, but also brings family and society to the family and society. Objective: Jin three needles, the chief professor of Guangzhou University of Chinese Medicine, Jin Rui Chuang Zhi, has carried out several clinical studies on the treatment of spastic paralysis after apoplexy with Jin three needles, and has accumulated rich experience in the treatment of the disease and has a definite curative effect on the bed. The timing of the acupuncture intervention for the acupoint and the compatibility of acupoints, the optimization of the treatment plan, the study of the multiple factor analysis, the two important factors (the timing of acupuncture, the compatibility of the acupoint selection) and the 2 x 2 factorial grouping to explore the best combination of the acupoints and the timing of acupuncture for the treatment of spastic paralysis. There are new breakthroughs in the two key technical points of compatibility, which provide theoretical basis for further application of this therapy. Methods: This study is strictly based on the method of evidence-based medicine to carry out large sample, random study, unified drug treatment, unified diagnostic and therapeutic criteria, and multi factor analysis (2 x 2 factorial analysis). Statistics) acupoint compatibility, the timing analysis of acupuncture, with spastic hemiplegic patients after apoplexy as the research object. The method is: the two important factors (acupuncture timing, selection of acupoints compatibility) to carry on the 2 x 2 factorial combination, take the timing of acupuncture, select the combination of two factors, divided into 2 levels (after apoplexy -14 days / 15-30 days after apoplexy, temporomandibular) After three needles + hand, foot and foot -, three needles, temporal three needles + hand foot three needles and three needles, they were divided into four groups (1 groups: 1 groups: I-14 days after apoplexy + temporal three needles, hand foot and foot three needles; 2 groups after apoplexy + temporal three needles, hand foot three needle groups; 3 groups after apoplexy 15-30- days + temporal three needles, hand and foot tus three needles; 4: 15-30 days + temporal after apoplexy. Three needles, hand and foot three needle groups). The treatment time was 1 times a day, 30min each time, 5 days of continuous acupuncture, 2 days, next week, 2 weeks for 1 courses, and 2 courses of treatment. The related indexes were evaluated before the treatment. After the treatment, the modified Ashworth spasmodic scale (MAS), the clinical spasm index (CSI) scale, and the clinical nerve function defect were observed. The degree score (NDS), the limb simplified Fugl-Meyer motor function score and the daily living ability AQL (Barthel) index were evaluated and entered into statistical analysis. Results: 1 clinical curative effect 1.1 in clinical curative effect, the clinical cure rate is from high to low respectively: 1 groups (after medium wind -14 days + temporal three needles, hand foot and foot three needles) have the highest clinical cure rate. 19%, 2 groups (-14 days after apoplexy + temporal three needles, hand and foot three needles); 3 groups (15-30 days after apoplexy + temporal three needles, hand foot and foot three needles), 4 groups (15-30 days after stroke + temporal three needles, three hands of hand and foot three needles), respectively, 9.8%, 8.5% and 5%, compared with statistical treatment, statistically significant difference (P0.01); 1 group and other clinical treatment of other groups. There was a significant difference in statistical treatment (P0.01); the clinical cure rate of 2,3 two groups was similar, and there was no significant difference (P0.05). The total effective rate of 1 groups (1-14 days after apoplexy + temporal three needles and hand foot and foot three needles) was 94.90%; 2 groups (1-14 days after apoplexy + temporal three needles, hand foot three needles), 3 groups (15-30 after stroke 15-30) The total effective rate of the 4 groups (15-30 days after apoplexy after 15-30 + temporal three needles and hand foot and foot three needles) was 90.2%, 89% and 83.75%, respectively. Compared with the other groups, there were statistically significant differences (P0.01), and the 1 groups were significantly different from the other three groups (P0.01, P0.05); 2,3 two The total effective rate of the group was similar, with no significant difference (P0.05). Conclusion: on the basis of the same medicine and routine treatment, acupuncture therapy was intervened 1-14 days after the stroke, and the treatment of Jin Sanzhen (temporal three needles + hand and foot three needles) was used to improve the clinical effect of the spasticity of the patients with spastic paralysis after apoplexy, the best clinical spasm of.2. After the end of the index (CSI) score of 2.1 courses, the comparative spasm index (CSI) score showed that 1 groups (1-14 days after apoplexy + temporal three needles, hand and foot twin three needles) and two groups (P0.05 after -14 + temporal three needles and three hands and feet) were compared with the two groups, and there were significant differences (P0.05); 3 groups (15-30 days after stroke + temporal three needles, hand foot and foot) Three needle) and 4 groups (15-30 days after apoplexy + temporal three needles, hand and foot three needles), compared with the two groups, the 3 groups were superior and had abnormal significant difference (P0.01). On the same basis of the acupoint compatibility, the score of the comparative spasm index (CSI) score showed that the 1 groups (-14 days after stroke + temporal three needles, hand and foot tus three needles) were compared with the 3 groups (15-30 days after apoplexy + temporal three needles and three hands of hand and foot three), with 1 groups of excellent differences (P0.05); 2 groups (after Apoplectic -14 days + temporal three needles, hand foot three needles) and 4 groups (15-30 days after apoplexy + temporomandibular) Three needles, hand and foot three needles in the two groups, compared with the 2 groups, there was an abnormal significant difference (P0.01). Prompt: in the same premise of the compatibility of the acupoints, in the improvement of the spastic index (CSI) score, early intervention group (-14 days after stroke) in the better curative effect (P0.01, P0.05).3 daily living ability ADL (Barthel) index score after the end of 3.1 courses, On the premise of the same timing of acupuncture, the daily living ability (ADL Barther index) showed that 1 groups (-14 days after apoplexy + temporal three needles, hand foot and foot three needles) were compared with the 2 groups (1-14 days after apoplexy + temporal three needles and three hands of hand and foot), with 1 groups of excellent and abnormal significant differences (P0.01); 3 groups (15-30 days after stroke + temporal three needles, hand, foot - and - foot three needles) and 4 groups (middle 15-30 days after the wind (15-30 days + temporal three needles, hand foot and foot three needles), compared with the two groups, the 3 groups were superior and had abnormal significant difference (P0.01). It was suggested that, on the premise of fixed time factors, the clinical curative effect of temporal three needles + hand and foot - and three needle group was better (P0.01) after the end of the.3.2 course of.3.2. Compared with the daily living ability (ADL Barthel index), 1 groups (1-14 days after apoplexy + temporal three needles, hand and foot tus three needles) and 3 groups (15-30 days after apoplexy + temporal three needles and three hand and foot TUS) were compared with the two groups of 1 groups, with abnormal significant difference (P0.01); 2 groups (1-14 days after stroke + temporal three needles, hand foot three needles) and 4 group (15-30 days after stroke + temporal three) Acupuncture, hand and foot three needles in the two groups, compared with the 2 groups, there was an abnormal significant difference (P0.01). It was suggested that in the same premise of the compatibility of the acupoints, the early intervention group (Barthel) index (1-14 days after the stroke) was in the better effect (P0.01).4 nerve function defect (NDS) score after the 4.1 course of treatment, at the end of the 4.1 course of treatment. On the premise of the same time, the comparison of nerve function defect (NDS) scores showed that 1 groups (1-14 days after apoplexy + temporal three needles, hand and foot twin three needles) and two groups (1-14 days after apoplexy + temporal three needles and three hands and feet) were compared with 1 groups, with abnormal significant difference (P0.01), 3 groups (15-30 days after stroke + temporal three needles, hand and foot - and three needles) and 4 group (after stroke 15-30) Day + temporal three needles, hand foot and foot three needles, compared with 3 groups, there were significant differences (P0.05). Hint: on the premise of the same timing of acupuncture, in improving the nerve function defect (NDS) score, the temporal three needles + hand - foot - and - foot three needle group had better clinical effect (P0.01, P0.05).4.2 course. The function defect (NDS) score showed that 1 groups (1-14 days after apoplexy + temporal three needles, hand and foot - and three needles) and 3 groups (15-30 days after apoplexy + temporal three needles and three hand and foot - and - foot) were superior in 1 groups, with abnormal significant difference (P0.01); 2 groups (1-14 days after stroke + temporal three needles, hand foot three needles) and 4 group (after stroke 15-30 days + temporal three needles, hand foot three needles) Compared with the 2 groups, there were significant differences (P0.05). It was suggested that in the same premise of the compatibility of the acupoints, in the improvement of the neurological deficit (NDS) score, the early intervention acupuncture group (1-14 days after the stroke) was in better curative effect (P0.01, P0.05).5 simplified FugI-Meyer exercise ability to evaluate the 5.1 course of treatment after the intervention of the same timing of acupuncture. The score of Fugl-Meyer motor function showed that 1 groups (1-14 days after apoplexy + temporal three needles, hand and foot - and three needles) and 2 groups (1-14 days after apoplexy + temporal three needles and three hands and feet) were compared with 1 groups, with abnormal significant difference (P0.01); 3 groups (15-30 days after stroke + temporal three needles, hand foot and foot three needles) and 4 group (15-30 days after stroke + temporal three needles, hand foot three needles) Two groups, compared with 3 groups, there were significant difference (P0.01). Hint: on the premise of the same timing of intervention acupuncture, in improving the score of Fugl-Meyer, the clinical curative effect of the temporal three needles + hand and foot double three needle group was better (P0.01).5.2 treatment end, and the Fugl-Meyer score was compared to the same premise, and the score of Fugl-Meyer was compared, and the 1 groups (1-14 after stroke) were compared. The day + temporal three needles, hand and foot three needles, compared with the 3 groups (15-30 days after apoplexy + temporal three needles and hand foot and foot three needles), were superior in 1 groups and had abnormal significant difference (P0.01); the 2 group (1-14 days after stroke + temporal three needles, hand foot three needles) and 4 groups (15-30 days after apoplexy + temporal three needles and hands and feet three needles) were superior to the two groups, and had abnormal significant difference (P0.01). To improve the score of Fugl-Meyer, early intervention in acupuncture treatment group (1-14 days after apoplexy) in the treatment group (1-14 days after apoplexy) in the treatment of better curative effect (P0.01) in the treatment group (1-14 days after apoplexy) in the treatment of better therapeutic effect (P0.01) the timing of acupuncture and the combination of combination intervention analysis of the combined intervention analysis of the timing of the acupuncture time and the combination of the selection of acupoints (CSI) (acupuncture intervention after 1-14 days after apoplexy + temporal three needling. There was no obvious synergy in spasticity index (CSI) score of spastic hemiplegic patients after apoplexy with three needles, although there was no obvious synergy and interactive intervention point, but according to the cross action map (see figure eight, figure nine), there should be a good cross effect trend. According to the compatibility of acupoints, the fixed factor analysis of the timing of acupuncture, after combined effect, can be used. The spasticity index CSI score (P0.01) of patients with spastic hemiplegia after apoplexy can effectively alleviate the tension of hemiplegic limbs, improve the degree of hemiplegic limb spasticity,.6.2 daily living ability, ADL (Barthel) index score of acupuncture timing and combination of selection of acupoints (1-14 days after apoplexy acupuncture intervention + temporal three needles, hand foot and foot three needles treatment) Patients with spastic hemiplegic after apoplexy have good synergy and interactive intervention in the ADL (Barthel) index of daily living ability. After combined action, the ADL (Barthel) index score of patients with spastic hemiplegia after apoplexy can be significantly improved (see Figure eleven, figure twelve) effectively improving the patient's daily living ability and improving the patient. Quality of life.6.3 nerve function defect (NDS) score of acupuncture timing and combined combination of selection of acupoints (1-14 days after apoplexy acupuncture intervention + temporal three needles, hand foot and foot three needles in the treatment of spastic hemiplegic patients after apoplexy, although there is no obvious synergy in the statistical analysis of neural function defect (NDS) score, but the interaction point of intervention, but according to the results. The cross action diagram (see Figure fourteen, figure fifteen) should have a good cross effect trend. According to the combination of acupoints compatibility and the fixed factor analysis of the timing of acupuncture, the combined effect can significantly reduce the neurological function defect (NDS) score of patients with hemiplegic hemiplegia after apoplexy to effectively promote the rehabilitation of neurologic function in hemiplegic patients and improve the quality of life of patients with simplified F. Ugl-Meyer motor function evaluation: the combined effect of acupuncture timing and acupoint compatibility (1-14 days after stroke, acupuncture intervention + time three needling, hand foot and foot three).

【学位授予单位】：广州中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R246.6
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本文编号：1875873