合谷穴区去运动传出后运动皮层功能重组及针刺作用的研究

发布时间：2018-06-19 06:40

本文选题：合谷穴区 + 去运动传出　；参考：《广州中医药大学》2016年博士论文

【摘要】：目的：有研究表明,“面口合谷收”存在单向联系,即刺激合谷穴区可以诱发口面部的肌电反应,但反过来刺激口面部不能诱发合谷穴区的肌电反应。本研究采用经颅磁刺激(TMS)的方法,观察健康志愿者、截指和臂丛神经损伤患者运动皮层手面区的分布特点及针刺的影响,探讨合谷穴区去运动传出后大脑运动皮层功能重组的规律,阐释“面口合谷收”单向联系的生物学机制。方法：试验共分为三个部分：(一)生理状态下针刺单侧合谷对运动皮层手区与面区的作用研究：本部分研究共纳入健康志愿者20例,均符合纳入标准并签署知情同意书。整个试验过程分为针刺前和针刺后两个阶段,并且是在同一屏蔽室由同一研究者负责操作。所有受试者均要在针刺前和针刺后进行TMS检查。针刺前,受试者取坐位,经TMS刺激运动皮层手区与面区,分别记录双侧第一骨间背侧肌(FDI)和眼轮匝肌(00)的运动诱发电位(MEPs)的运动阈值、潜伏期、振幅以及有效刺激面积,并绘制二维图像,确定运动皮层手区与面区的分布位置；确定手区与面区的有效刺激面积后,取受试者右侧合谷穴予以电针针刺,采用1寸毫针针刺合谷穴,得气后,于针刺部位旁开1cm内另刺1针用以连接电针电极。电针仪采用韩氏电针仪,电针参数设置为连续波,恒流lmA,频率2Hz,持续电针30min,取针后按照上述TMS操作执行,确定针刺合谷穴后手区与面区的有效刺激面积,并绘制二维图像。数据采集完毕,对比分析针刺合谷穴前后受试者肌肉诱发电位的相关参数及运动皮层手区与面区位域图的变化情况。(二)合谷穴区去运动传出后(截指)运动皮层功能重组及针刺作用的研究：本部分研究共纳入健康志愿者5例,左手截指患者5例,均符合纳入标准并签署知情同意书。健康受试者数据采集,5例健康志愿者采集双侧第一骨间背侧肌和眼轮匝肌运动诱发电位的相关参数。受试者取坐位,经TMS刺激双侧手区和面区,分别记录双侧第一骨间背侧肌和眼轮匝肌的运动诱发电位(MEPs)的运动阈值、潜伏期、振幅以及有效刺激面积,并绘制二维图像,确定双侧手区和面区的皮层分布位置。截指患者数据采集,分为针刺前和针刺后两部分。针刺前,患者取坐位,经TMS刺激运动皮层手区和面区,记录双侧第一骨间背侧肌和眼轮匝肌运动诱发电位(MEPs)的运动阈值、潜伏期、振幅以及有效刺激面积,并绘制二维图像,确定运动皮层手区和面区的分布位置；确定手区和面区的有效刺激面积后,取患者右侧合谷穴予以电针针刺,采用1寸毫针针刺合谷穴,得气后,于针刺部位旁开lcm内另刺1针用以连接电针电极。电针仪采用韩氏电针仪,电针参数设置为连续波,恒流1mA,频率2Hz,持续电针30min,取针后按照上述TMS操作执行,记录运动诱发电位相关参数,确定针刺合谷穴后手区和面区的有效刺激面积,并绘制二维图像。数据采集完毕,处理和分析数据。(三)外周神经损伤后运动皮层功能重组及针刺作用的研究：本部分研究共纳入健康志愿者5例,右侧臂丛神经损伤患者5例,均符合纳入标准并签署知情同意书。健康受试者数据采集,5例健康志愿者采集双侧第一骨间背侧肌、眼轮匝肌、肱二头肌和三角肌运动诱发电位的相关参数。受试者取坐位,经TMS刺激双侧手区、面区、肩区和肘区,分别记录双侧第一骨间背侧肌、眼轮匝肌、三角肌和肱二头肌的运动诱发电位(MEPs)的运动阈值、潜伏期、振幅以及有效刺激面积,并绘制二维图像,确定双侧手区、面区、肩区和肘区的皮层分布位置。臂丛神经损伤患者的数据采集,分为针刺治疗前和针刺治疗后两个阶段,并且针刺治疗和TMS检查由同一研究者负责操作。所有受试者均要在针刺治疗前和针刺治疗后进行上肢运动功能评分(Fugl-Meyer评分)和TMS检查。针刺治疗前,受试者取坐位,经TMS刺激运动皮层手区与面区,分别记录左侧第一骨间背侧肌和双侧眼轮匝肌的运动诱发电位(MEPs)的运动阈值、潜伏期、振幅以及有效刺激面积,并绘制二维图像,确定右半球运动皮层手区与双侧半球面区的分布位置；同时,经TMS刺激双侧肩区和肘区,分别记录双侧三角肌和肱二头肌的运动诱发电位(MEPs)的运动阈值、潜伏期、振幅以及有效刺激面积,并绘制二维图像,确定双侧肩区和肘区的分布位置。按照“十二五”针灸学规划教材痿证相关取穴,对患者进行1个月的针刺治疗,经针刺治疗后,对患者进行上肢运动功能评分,并按照上述方法采集针刺治疗后的相关数据。数据采集完毕,处理和分析数据。结果：(一)生理状态下针刺单侧合谷对运动皮层手区与面区的作用研究1、针刺后对侧运动皮层面区潜伏期缩短、振幅升高、阈值降低、有效刺激面积增大(P0.05)；同侧运动皮层面区潜伏期无变化,振幅升高、阈值降低、有效刺激面积增大(P0.05)。2、针刺后对侧运动皮层手区潜伏期、阈值无变化；振幅升高,有效刺激面积增大(P0.05)；同侧运动皮层手区潜伏期延长、振幅降低、阈值升高、有效刺激面积减小(P0.05)。3、针刺合谷可使面区与手区的皮层兴奋性提高,其中双侧面区总振幅、有效刺激面积针刺前后相比无变化；在双侧手区比较中,针刺后对侧手区总振幅明显高于右半球(P0.05),同时针刺后对侧总振幅大于针刺前(P0.05),而同侧总振幅小于针刺前(P0.05)。4、针刺后,双侧运动皮层面区与手区的重心均出现不同程度的偏移,其中面区重心向手区偏移,最大位移距离对侧可达3.3mm,同侧可达4.5mm；手区重心不发生明显偏移或者向手区分布方向偏移,垂直位移距离对侧可达5.3mm,同侧可达9.1mm。(二)合谷穴区去运动传出后(截指)运动皮层功能重组及针刺作用的研究1、合谷穴区去运动传出后,患者左半球手区面积与右半球手区面积的比值小于健康志愿者的比值的最小值；面区有效刺激面积的比值与健康者志愿者的比值无明显差异。2、针刺后,截指患者双侧手区MEPs阈值、潜伏期、有效刺激面积无变化,振幅均降低(P0.05)；双侧面区潜伏期缩短、振幅升高、阈值降低、有效刺激面积增大(P0.05),手区与面区交叉重叠区域增大。针刺后截指患者双侧手区的重心发生偏移,且向远离面区发生位移。(三)外周神经损伤后运动皮层功能重组及针刺作用的研究1、臂丛神经损伤后,患者左半球肩区、肘区的面积与右半球肩区、肘区面积的比值大于健康志愿者的比值的最大值；面区有效刺激面积的比值较健康者的没有明显差异。2、对臂丛神经损伤患者进行为期一个月的针刺治疗,治疗后患者自觉上肢运动功能未有明显改善,行上肢运动功能评分,针刺治疗后无明显变化。3、针刺后,臂丛神经损伤患者肘区MEPs潜伏期无变化,双侧皮层振幅均降低(P0.05),有效刺激面积无变化；肩区MEPs潜伏期无变化,双侧皮层振幅均降低(P0.05),有效刺激面积无变化。臂丛神经损伤患者对侧面区MEPs潜伏期缩短、振幅升高、阈值降低、有效刺激面积增大(P0.05)；同侧手区MEPs潜伏期无变化,振幅降低、阈值升高、有效刺激面积减小(P0.05)。针刺后臂丛神经损伤患者双侧肘区和肩区的重心均发生不同程度的位移,表现为远离手区分布区域。结论：1、合谷穴区去运动传出后,大脑运动皮层出现功能重组：在截指患者运动皮层内表现为受损部位的皮层代表区邻近皮层的扩大入侵；在臂丛神经损伤患者运动皮层内表现为肩区和肘区的扩大并向邻近受损部位的皮层代表区的扩大入侵,均没有出现邻近面区向受损部位皮层代表区的扩大入侵,提示运动皮层的功能重组表现为单向性。运动皮层的手区与面区之间单向功能重组可能是“面口合谷收”单向联系的生物学机制。2、生理状态下,针刺单侧合谷可以兴奋双侧面区和对侧手区,抑制同侧手区,对运动皮层手区与面区均产生影响；病理状态下,针刺可以抑制入侵皮层的兴奋性,加强受损皮层代表区与邻近皮层的功能联系,这种调节作用的实现可能为临床选用合谷穴治疗口面部疾病提供了理论依据。
[Abstract]:Objective: some studies have shown that there is a one-way connection between "Hekou and valley harvest", that is, stimulation of Hegu acupoint can induce EMG response to the mouth and face, but in turn, the stimulation of the mouth and face can not induce the electromyography of the Hegu area. This study uses transcranial magnetic stimulation (TMS) to observe the skin of healthy volunteers, truncated fingers and brachial plexus nerve injuries. The distribution characteristics of the layer area and the influence of acupuncture on the function of the functional reorganization of the cerebral motor cortex after the movement of the Hegu area to explain the biological mechanism of the unidirectional contact of the "face to the mouth and the valley". Methods: the experiment is divided into three parts: (1) the effect of the single side of the needle on the hand area and the surface area of the motor cortex under the physiological state A total of 20 healthy volunteers were included in this part, all in accordance with the inclusion criteria and signed informed consent. The whole test process was divided into two stages before and after acupuncture, and the same researcher was responsible for the operation in the same screening room. All the subjects were to undergo TMS examination before and after acupuncture. Before acupuncture, the subjects were taken to take a seat. The motion threshold of the motor evoked potential (MEPs) of the dorsal lateral interosseous (FDI) and orbicularis oculi muscle (00) of the bilateral first interosseous interosseous (MEPs), the latent period, the amplitude and the effective stimulation area were recorded, and the two-dimensional images were drawn to determine the distribution position of the hand area and the surface area of the motor cortex, and to determine the effective spines in the hand area and the surface area. After the area was stimulated, the subjects were acupuncturing on the right Hegu acupoint with 1 inches of needle acupuncture at Hegu Point. After getting gas, the electroacupuncture electrode was connected to another 1 needles in 1cm by the acupuncture site. The electroacupuncture instrument was composed of the Han's electroacupuncture instrument, the electroacupuncture parameters were set to continuous wave, the constant current lmA, the frequency 2Hz, and the continuous Electroacupuncture of 30min. After taking the needle, the operation was carried out according to the above TMS operation. To determine the effective area of stimulation in the posterior hand area and the surface area of the acupuncture point of Hegu Point, and draw a two-dimensional image. After the data collection, the related parameters of the muscle evoked potential of the subjects before and after the acupuncture at the Hegu Point and the change of the area map of the hand area and the surface area of the motor cortex were compared and analyzed. (two) the function weight of the motor cortex after the movement of the Hegu area was carried out. Study on the role of group and acupuncture: 5 healthy volunteers were included in this study, and 5 cases of left hand truncated patients were all conformed to the inclusion criteria and signed informed consent. The data collected by healthy subjects, 5 healthy volunteers collected the related parameters of the motor potential of the dorsi dorsi and orbicularis oculi muscles of the first bone. The subjects were taken sitting position, TMS The motion threshold of the motor evoked potential (MEPs), latent period, amplitude and effective stimulation area of bilateral first interosseous dorsi and orbicularis oculi muscles were recorded, and two-dimensional images were drawn to determine the position of cortical distribution in bilateral hand and surface areas. The data collection of the patients was divided into two parts before acupuncture and after acupuncture. Before acupuncture, the patient took the seat and stimulated the motion evoked potential (MEPs) of the dorsi and orbicularis muscle of the first bone, the latent period, the amplitude and the effective stimulation area, and drew a two-dimensional image to determine the distribution position of the hand area and the surface area of the motor cortex, and determine the effectiveness of the hand area and the surface area by TMS. After the stimulation of the area, the patient's right Hegu acupoint was acupuncturing by electroacupuncture and 1 inch needle acupuncture at Hegu acupoint was used. After getting gas, the electroacupuncture electrode was connected to another 1 needles in LCM beside the needle position. The electroacupuncture instrument was set up by the Han's electroacupuncture instrument, the Electroacupuncture Parameters were set to continuous waves, the constant current 1mA, the frequency 2Hz, and the continuous Electroacupuncture of the electroacupuncture were carried out in accordance with the above TMS operation. The related parameters of motor evoked potential were recorded, and the effective area of stimulation in the hand and surface areas of Hegu acupuncture point was determined and two-dimensional images were drawn. Data acquisition, processing and analysis of data were completed. (three) the study of functional reorganization and acupuncture of motor cortex after peripheral nerve injury: 5 cases of healthy volunteers, right brachial plexus God in this part of the study 5 cases of injured patients were in accordance with the inclusion criteria and signed informed consent. Data collection of healthy subjects, 5 healthy volunteers collected the parameters related to the motor evoked potential of the bilateral first interosseous dorsi, orbicularis oculi, biceps and deltoid. The subjects were taken sitting position, and the bilateral hand area, face area, shoulder area and elbow area were recorded by TMS, respectively. The motion threshold of the dorsi interosseous dorsi interosseous, orbicularis oculi, deltoid and biceps brachii muscle motor evoked potential (MEPs), latent period, amplitude and effective stimulation area, and drawing two-dimensional images to determine the position of cortical distribution in the bilateral hand, facial, shoulder and elbow areas. Data collection of brachial plexus injury patients is divided into acupuncture treatment before and before acupuncture treatment. Acupuncture treatment and TMS examination were performed by the same researcher. All the subjects were required to perform the upper limb motor function score (Fugl-Meyer score) and TMS examination before and after the acupuncture treatment. Before the acupuncture treatment, the subjects were taken the seat, and the left hand area and the surface area were stimulated by TMS to record the left side, respectively. The motion threshold of the motor evoked potential (MEPs), latent period, amplitude and effective stimulation area of the lateral interosseous dorsi and bilateral orbicularis oculi muscles were measured, and two-dimensional images were drawn to determine the distribution position of the hand and bilateral hemispherical areas of the right hemisphere. At the same time, bilateral deltoid and humerus were recorded by TMS stimulation of the bilateral shoulder and elbow areas. The motion evoked potential (MEPs) of the two head muscle, the latent period, the amplitude and the effective stimulation area, and draw a two-dimensional image to determine the position of the bilateral shoulder area and the elbow area. According to the "12th Five-Year" acupuncture and moxibustion program, the patients were treated with acupuncture for 1 months. After the acupuncture treatment, the patients were treated with the upper limbs. Exercise function score, and collect relevant data after acupuncture treatment according to the above methods. Data acquisition, processing and analysis of data. Results: (1) study on the effect of acupuncture on the hand area and surface area of the motor cortex under physiological state 1. After acupuncture, the latency of the lateral motor cortex is shortened, the amplitude is increased, the threshold is reduced and the stimulation is effective. The area increased (P0.05); there was no change in the latent period of the cortical area of the ipsilateral motor cortex, the amplitude increased, the threshold decreased and the effective stimulation area increased (P0.05).2. The threshold of the hand area of the lateral motor cortex was not changed after acupuncture; the amplitude increased and the effective stimulation area increased (P0.05); the latent period of the hand area of the ipsilateral motor cortex was prolonged, the amplitude was reduced and the threshold increased, The effective stimulation area decreased (P0.05).3, and acupuncture of Hegu could improve the cortical excitability of the area and the hand area, in which the total amplitude of the double side area and the effective stimulation area were not changed before and after acupuncture. In the bilateral hand area comparison, the total amplitude of the lateral hand area after acupuncture was significantly higher than that of the right half ball (P0.05), and the total amplitude of the contralateral side after acupuncture was greater than that before acupuncture (P 0.05), the total amplitude of the same side is less than before the acupuncture (P0.05).4. After the acupuncture, the center of gravity of the bilateral motor cortex and the hand area all deviate in varying degrees. The center of gravity is shifted to the hand area, the maximum displacement distance is up to 3.3mm, and the same side can reach 4.5mm; the center of gravity of the hand area does not deviate obviously or offset to the hand area distribution direction, vertical position. The distance to the opposite side can reach 5.3mm, and the same side can reach 9.1mm. (two) Hegu (two) Hegu area after moving out. 1. After the movement of the Hegu area, the ratio of the hand area of the left hemisphere to the right hemisphere hand area is smaller than the ratio of the healthy volunteers; the area of the area is effectively stimulated. There was no significant difference in the ratio of the ratio of the healthy volunteers to the healthy volunteers.2. After the acupuncture, the MEPs threshold in the bilateral hand area of the finger and the latent period, the effective stimulation area was not changed, the amplitude decreased (P0.05), the latent period of the double side region shortened, the amplitude increased, the threshold decreased, the effective stimulus Ji Zengda (P0.05), and the overlapping area between the hand area and the surface area increased. The center of gravity of the bilateral hand area of the posterior finger patients shifted and moved away from the area. (three) study on the functional reorganization and acupuncture of the motor cortex after peripheral nerve injury. 1, after brachial plexus injury, the ratio of the area of the left hemisphere to the left hemisphere, the area of the elbow area and the right hemisphere shoulder area, the elbow area is greater than the ratio of the healthy volunteers. There was no significant difference in the ratio of effective stimulation area of the area to the healthy person.2. The patients with brachial plexus nerve injury were treated with acupuncture for one month. After the treatment, the motor function of the upper limb was not obviously improved. The function score of the upper limb and the acupuncture treatment did not change.3. After acupuncture, the elbow area of the brachial plexus injured patients was MEPs The latent period was not changed, the amplitude of bilateral cortex was reduced (P0.05), the area of effective stimulation was not changed, the latency of MEPs in the shoulder area was not changed, the amplitude of bilateral cortex decreased (P0.05), and the effective stimulation area was not changed. The patients with brachial plexus nerve injury shortened the latency of the MEPs in the side area, increased the amplitude, reduced the threshold, increased the effective area (P0.05), and the same side. The latent period of MEPs in the hand area was not changed, the amplitude decreased, the threshold increased and the effective stimulation area decreased (P0.05). The center of gravity of the elbow and shoulder areas of the patients with brachial plexus injury after acupuncture had different degrees of displacement, which was far away from the area of the hand area. Conclusion: 1, after the movement of the Hegu acupoint movement, the functional reorganization of the cerebral motor cortex appears in the cerebral motor cortex. An enlarged invasion of the cortical area adjacent to the damaged part of the motor cortex was found in the motor cortex of the patients. The enlargement of the shoulder area and elbow area in the motor cortex of the brachial plexus injury patients and the enlargement of the cortical area adjacent to the adjacent damaged parts did not appear to be enlarged in the adjacent area to the cortex of the damaged cortex. It suggests that the functional reorganization of the motor cortex is unidirectional. The unilateral functional reorganization between the hand area and the surface area of the motor cortex is probably the biological mechanism of the unilateral connection between the face and the mouth and the valley. In the physiological state, the unilateral valley of the acupuncture can excite the double side and the contralateral hand areas and inhibit the same side hand area, and the hand area and the surface area of the motor cortex are both.2. In the pathological condition, acupuncture can inhibit the excitability of the invasive cortex and strengthen the functional relation between the damaged cortex and the adjacent cortex. The realization of this regulation may provide a theoretical basis for the clinical selection of Hegu acupoint for the treatment of oral and facial diseases.
【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

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