不安，心绪(xu)低落，言语少，反(fan)应缓慢等。临床(chuang)治疗应紧(jin)紧(jin)抓住核(he)心病机(ji)，本着《素(su)问•六元正(zheng)纪大论》“木 郁(yu)达之”和(he)《论治汇补•郁(yu)证》所论：“郁(yu)病虽多，皆固气不周(zhou)流，法当顺气为先。”的(de)原(yuan)则，以疏肝解郁(yu) 为基本治法，随证化裁(cai)；从病机(ji)演化的(de)趋势(shi)，还须实施疏肝、柔肝、平肝、清(qing)肝等的(de)综(zong)合(he)调治。我(wo)们在四(si) 逆散原(yuan)方的(de)基础上化裁(cai)出加(jia)味(wei)四(si)逆散（J1W）, 中去甘草，加(jia)入干地黄和(he)枸杞子以配合(he)白芍(shao)清(qing)热滋阴(yin)

养血柔肝(gan)(gan)(gan)；增加(jia)(jia)梔子清(qing)热(re)以防肝(gan)(gan)(gan)郁(yu)化热(re)（火），加(jia)(jia)入石(shi)决明(ming)以清(qing)肝(gan)(gan)(gan)平(ping)肝(gan)(gan)(gan)。全(quan)方体现出(chu)疏肝(gan)(gan)(gan)、柔肝(gan)(gan)(gan)、平(ping)肝(gan)(gan)(gan)、清(qing) 肝(gan)(gan)(gan)等综合调治的(de)(de)思想。我们在以往的(de)(de)临床和实验研(yan)(yan)究中得到证实⑹：具(ju)有(you)(you)显(xian)(xian)著的(de)(de)抗抑郁(yu)作用。本研(yan)(yan)究结(jie)果(guo)(guo) 表(biao)明(ming)，席的(de)(de)临床治疗(liao)PSD有(you)(you)确(que)切(qie)的(de)(de)效果(guo)(guo)，总有(you)(you)效率为80.77%,优于西药(yao)百忧(you)解。表(biao)现为可明(ming)显(xian)(xian)降低HAMD评(ping) 分(fen)，降低神(shen)经功(gong)能(neng)缺损（SSS）评(ping)分(fen)，加(jia)(jia)快神(shen)经功(gong)能(neng)缺损程(cheng)度的(de)(de)改善；显(xian)(xian)著升高(gao)日(ri)常生活活动能(neng)力（ADL） 评(ping)分(fen)（Barthel指数），提(ti)高(gao)PSD患(huan)者的(de)(de)日(ri)常生活活动能(neng)力。此(ci)外，在临床应用的(de)(de)不(bu)良反(fan)应方面，我们的(de)(de)观察 结(jie)果(guo)(guo)表(biao)明(ming)，刀(dao)例5没有(you)(you)明(ming)显(xian)(xian)的(de)(de)副(fu)反(fan)应，与(yu)西药(yao)相比，具(ju)有(you)(you)安全(quan)、长效和稳效的(de)(de)优势的(de)(de)特(te)点，显(xian)(xian)示出(chu)临床应用 的(de)(de)广阔前景。

   经颅磁电疗仪对脑卒中后肩手综合征的效果研究

武(wu)丹(dan)娜河北医科(ke)大(da)学第四医院神(shen)经内(nei)科(ke) 050000

    肩手(shou)(shou)(shou)综合征（shoulder-hand syndrome）是脑(nao)卒中后(hou)(hou)(hou)患侧出现(xian)肩关(guan)节及(ji)手(shou)(shou)(shou)部(bu)肿痛(tong)、活(huo)动(dong)(dong)(dong)受(shou)(shou)(shou)限(xian)或伴(ban)有(you)皮(pi) 色(se)改变(bian)。其早期(qi)表现(xian)为患手(shou)(shou)(shou)肿胀，手(shou)(shou)(shou)指变(bian)粗，皮(pi)纹消(xiao)失，皮(pi)肤呈粉红色(se)或紫红色(se);关(guan)节活(huo)动(dong)(dong)(dong)受(shou)(shou)(shou)限(xian)表现(xian)为手(shou)(shou)(shou)被(bei) 动(dong)(dong)(dong)旋后(hou)(hou)(hou)，腕背伸受(shou)(shou)(shou)限(xian)，手(shou)(shou)(shou)指间关(guan)节处于(yu)伸展位，屈曲时受(shou)(shou)(shou)限(xian)，被(bei)动(dong)(dong)(dong)活(huo)动(dong)(dong)(dong)时可引(yin)起疼痛(tong)，严(yan)重(zhong)(zhong)者可有(you)静息(xi)性 肩部(bu)自发(fa)痛(tong)，若不给于(yu)及(ji)时正确的(de)治(zhi)疗，则(ze)症状(zhuang)越来越明显，疼痛(tong)加重(zhong)(zhong)，不能忍受(shou)(shou)(shou)任何对手(shou)(shou)(shou)和手(shou)(shou)(shou)指的(de)压力， 后(hou)(hou)(hou)遗症期(qi)手(shou)(shou)(shou)将变(bian)成(cheng)固定(ding)畸(ji)形，虽然水肿和疼痛(tong)消(xiao)失，但(dan)关(guan)节永(yong)久丧失活(huo)动(dong)(dong)(dong)能力，严(yan)重(zhong)(zhong)影响患者的(de)康复进程 和疗效(xiao)，影响患者的(de)生活(huo)质量。目前国内(nei)将肩手(shou)(shou)(shou)综合征分为三期(qi)⑴。我科(ke)自2012年9月以来，釆用在康复 训练基础上(shang)利用经颅磁电疗仪对 例脑(nao)卒中后(hou)(hou)(hou)伴(ban)I期(qi)肩手(shou)(shou)(shou)综合征的(de)患者进行治(zhi)疗，取得了(le)良(liang)好(hao)的(de)临床效(xiao)果， 现(xian)报道如下：

1资料与方法

1. 1临床资料

共(gong)选(xuan)取2012年9月(yue)至(zhi)2014年9月(yue)间在我科住院的脑(nao)卒(zu)中患(huan)者56例(li)，男30例(li)，女26例(li)，年龄45~72 岁，经头颅CT或MRI检査(cha)诊(zhen)断(duan)为(wei)脑(nao)卒(zu)中，其中脑(nao)梗死54例(li)，脑(nao)出血2例(li)，患(huan)者的临(lin)床(chuang)表现符(fu)合I期肩手 综(zong)合征的诊(zhen)断(duan)标准(zhun)，并且排除其它原因，如肩周炎、颈椎病(bing)、心肌梗塞等(deng)引起的疼痛。

1.2方法

1.2. 1作(zuo)用原理经(jing)颅磁(ci)电疗仪(yi)釆用重(zhong)复(fu)经(jing)颅磁(ci)刺(ci)激和仿真生物电刺(ci)激，对脑(nao)部进(jin)行磁(ci)、电刺(ci)激，脉冲 磁(ci)场(chang)在皮层中间(jian)神(shen)(shen)经(jing)元产(chan)生感应电流，作(zuo)用于脊髓前角运动神(shen)(shen)经(jing)元，产(chan)生兴奋性(xing)突(tu)触后电位，冲动沿轴(zhou)突(tu) 下(xia)行至支(zhi)配肌肉，使其产(chan)生收缩动作(zuo)，可扩张脑(nao)血(xue)管、改善微循环、提(ti)高脑(nao)部血(xue)流量，保(bao)护(hu)神(shen)(shen)经(jing)细胞，促 进(jin)神(shen)(shen)经(jing)功(gong)能恢复(fu)，同时作(zuo)用于患(huan)肢肌肉神(shen)(shen)经(jing)，起到改善神(shen)(shen)经(jing)系(xi)统传导功(gong)能的(de)作(zuo)用。

1.2.2治疗(liao)(liao)方法在康复锻炼的基础上利用(yong)经颅磁电疗(liao)(liao)仪(yi)进行(xing)治疗(liao)(liao)。康复锻炼包括(kuo)患(huan)(huan)肢(zhi)的正确(que)摆(bai)放、避(bi) 免(mian)腕关节(jie)屈曲，同(tong)时配(pei)合主被动运动改善关节(jie)活动范围。在进行(xing)仪(yi)器治疗(liao)(liao)前，用(yong)医(yi)用(yong)酒精对患(huan)(huan)者(zhe)耳(er)(er)后乳(ru)(ru)突(tu) 处及患(huan)(huan)侧肢(zhi)体进行(xing)清洁，将导联线扣与(yu)电极扣相(xiang)连接，将耳(er)(er)后主电极片导电胶面牢固(gu)粘贴(tie)于耳(er)(er)后乳(ru)(ru)突(tu)处， 并(bing)将肢(zhi)体辅电极片粘贴(tie)于患(huan)(huan)侧肢(zhi)体，所有(you)入组患(huan)(huan)者(zhe)均将经颅磁电疗(liao)(liao)仪(yi)调节(jie)主频为(wei)7,辅频为(wei)3,并(bing)根据患(huan)(huan)者(zhe) 的感受(shou)与(yu)主诉调节(jie)主强与(yu)辅强，作(zuo)用(yong)时间(jian)为(wei)40分钟(zhong)。每日做一次治疗(liao)(liao)，14天(tian)为(wei)1个(ge)疗(liao)(liao)程(cheng)，中间(jian)休息(xi)2天(tian)， 再进行(xing)第二个(ge)疗(liao)(liao)程(cheng)14天(tian)，共30天(tian)。

1. 3疗效分析与评定方法

1.3.1肩手综合征疗(liao)效(xiao)评定标准(zhun)⑵ 显效(xiao)：关节水肿(zhong)、疼痛消失(shi)，活动功能(neng)无明(ming)显受限，手部小肌肉无

64 萎缩；有效(xiao)：关(guan)节水(shui)肿(zhong)基(ji)本消失，疼痛基(ji)本缓解，关(guan)节活动轻度(du)受限(xian)，手部肌肉萎缩不明(ming)(ming)显；无效(xiao)：患者(zhe) 症状，体征无明(ming)(ming)显改(gai)善(shan)，关(guan)节活动功(gong)能明(ming)(ming)显受限(xian)，肌肉萎缩逐渐加(jia)重。

1. 3. 2疼痛程度 采用数字评分法（NRS）:用数字0-10代替文字来表示疼痛的程度。0分为无痛，10 分为剧痛，中间次序表示疼痛的不同程度。

1.3.3水肿(zhong)评分(fen)标准0分(fen)为(wei)无水肿(zhong)，2分(fen)为(wei)轻(qing)度水肿(zhong)，4分(fen)为(wei)中度水肿(zhong)，6分(fen)为(wei)严重水肿(zhong)⑶。

1. 3. 4 ±肢关节运动范围、功能评定采用Fugl-Meyer量表进行评定⑷

2结果

本研究(jiu)中56例(li)患者经过28天的经颅磁(ci)刺激治(zhi)疗后(hou)，其(qi)病情较治(zhi)疗前(qian)(qian)均(jun)有(you)显(xian)著改(gai)(gai)善(shan)，其(qi)中显(xian)效36例(li) （62.5%）,有(you)效20例(li)（37.5 %）,无效0例(li)；患者治(zhi)疗后(hou)的上(shang)肢关节被动(dong)运(yun)动(dong)范(fan)围、上(shang)肢及(ji)(ji)腕手关节的运(yun) 动(dong)功能(neng)均(jun)较治(zhi)疗前(qian)(qian)有(you)明显(xian)改(gai)(gai)善(shan)（均(jun)P<0. 05），上(shang)肢疼痛及(ji)(ji)水(shui)肿程度亦均(jun)较治(zhi)疗前(qian)(qian)明显(xian)降低(di)（均(jun)P<0. 05）»具 体数据详(xiang)见表1.

表1 56例(li)肩手综合(he)征患者治疗前(qian)、后疗效比较（分，~X±S）

注：与治疗前比较(jiao)，*P<0. 05

3讨论

肩(jian)(jian)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)综(zong)(zong)(zong)合征(zheng)(zheng)（RSD）是(shi)指(zhi)患(huan)(huan)者患(huan)(huan)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)突然(ran)浮肿疼(teng)痛(tong)(tong)(tong)(tong)(tong)及肩(jian)(jian)关(guan)(guan)(guan)(guan)节(jie)疼(teng)痛(tong)(tong)(tong)(tong)(tong)，并(bing)(bing)(bing)使手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)功(gong)(gong)(gong)能(neng)受(shou)(shou)(shou)(shou)限。因(yin)(yin)(yin)(yin)疼(teng)痛(tong)(tong)(tong)(tong)(tong)较(jiao)重(zhong)(zhong)并(bing)(bing)(bing)发(fa)率缩， 成为(wei)康(kang)复(fu)的(de)(de)(de)(de)(de)阻碍因(yin)(yin)(yin)(yin)子(zi)，引(yin)起(qi)(qi)肩(jian)(jian)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)综(zong)(zong)(zong)合征(zheng)(zheng)的(de)(de)(de)(de)(de)疾(ji)病(bing)(bing)(bing)：中(zhong)风(feng)，心梗，颈椎病(bing)(bing)(bing)，上肢外伤(shang)，截瘫(tan)，肺疾(ji)病(bing)(bing)(bing)，肩(jian)(jian)关(guan)(guan)(guan)(guan)节(jie) 疾(ji)病(bing)(bing)(bing)，还有(you)原因(yin)(yin)(yin)(yin)不(bu)明者。它可(ke)以是(shi)原发(fa)的(de)(de)(de)(de)(de)，但也可(ke)由不(bu)同因(yin)(yin)(yin)(yin)素(su)促发(fa)，如轻微的(de)(de)(de)(de)(de)周围神经损伤(shang)及中(zhong)枢神经障 碍，急性(xing)(xing)中(zhong)风(feng)和(he)(he)(he)脊(ji)髓(sui)损伤(shang)，内分(fen)泌疾(ji)病(bing)(bing)(bing)和(he)(he)(he)心肌梗塞(sai)都可(ke)引(yin)起(qi)(qi)RSD。RSD是(shi)引(yin)起(qi)(qi)残疾(ji)的(de)(de)(de)(de)(de)主要原因(yin)(yin)(yin)(yin)，它通常影(ying)响 一个肢体，但也可(ke)影(ying)响多个肢体或(huo)身体的(de)(de)(de)(de)(de)任何部分(fen)，仅有(you)1/5的(de)(de)(de)(de)(de)病(bing)(bing)(bing)人能(neng)够完全恢复(fu)以前(qian)的(de)(de)(de)(de)(de)活(huo)动(dong)(dong)(dong)(dong)(dong)。目(mu)前(qian)认为(wei) 无论病(bing)(bing)(bing)因(yin)(yin)(yin)(yin)为(wei)何，均影(ying)响自律交感神经，造成末梢神经血(xue)管(guan)(guan)障碍。或(huo)是(shi)潜(qian)在的(de)(de)(de)(de)(de)其(qi)他因(yin)(yin)(yin)(yin)素(su)：伴发(fa)关(guan)(guan)(guan)(guan)节(jie)退行性(xing)(xing)变(bian)(bian)， 肩(jian)(jian)关(guan)(guan)(guan)(guan)节(jie)微小损伤(shang)，长期(qi)(qi)(qi)不(bu)运(yun)动(dong)(dong)(dong)(dong)(dong)造成的(de)(de)(de)(de)(de)废用性(xing)(xing)萎缩，造成血(xue)管(guan)(guan)神经反射异常。目(mu)前(qian)国内将肩(jian)(jian)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)综(zong)(zong)(zong)合征(zheng)(zheng)分(fen)为(wei)HI 期(qi)(qi)(qi)：包括(kuo)第(di)(di)I期(qi)(qi)(qi)（早期(qi)(qi)(qi)）：患(huan)(huan)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)骤然(ran)出(chu)(chu)(chu)现肿胀：水肿以手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)背(bei)(bei)明显，包括(kuo)掌指(zhi)关(guan)(guan)(guan)(guan)节(jie)和(he)(he)(he)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)指(zhi)，皮肤皱纹消失，水 肿处柔软膨隆，向近(jin)端(duan)(duan)止(zhi)于(yu)腕(wan)关(guan)(guan)(guan)(guan)节(jie)，看不(bu)清手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)上的(de)(de)(de)(de)(de)肌腱。手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)的(de)(de)(de)(de)(de)颜色发(fa)生变(bian)(bian)化，呈粉红或(huo)淡紫色，尤其(qi)是(shi)患(huan)(huan) 臂垂于(yu)体侧(ce)时(shi)更明显，手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)温(wen)热，有(you)时(shi)呈潮湿(shi)状(zhuang)，指(zhi)甲(jia)较(jiao)健(jian)侧(ce)白(bai)或(huo)无光泽。关(guan)(guan)(guan)(guan)节(jie)活(huo)动(dong)(dong)(dong)(dong)(dong)度(du)受(shou)(shou)(shou)(shou)限：手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)被动(dong)(dong)(dong)(dong)(dong)旋(xuan)后受(shou)(shou)(shou)(shou) 限，并(bing)(bing)(bing)常感腕(wan)部疼(teng)痛(tong)(tong)(tong)(tong)(tong);腕(wan)背(bei)(bei)伸(shen)(shen)受(shou)(shou)(shou)(shou)限，当(dang)被动(dong)(dong)(dong)(dong)(dong)增(zeng)加(jia)背(bei)(bei)伸(shen)(shen)活(huo)动(dong)(dong)(dong)(dong)(dong)度(du)时(shi)及做手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)负重(zhong)(zhong)活(huo)动(dong)(dong)(dong)(dong)(dong)时(shi)均可(ke)出(chu)(chu)(chu)现疼(teng)痛(tong)(tong)(tong)(tong)(tong);掌指(zhi)关(guan)(guan)(guan)(guan)节(jie)屈(qu) 曲(qu)明显受(shou)(shou)(shou)(shou)限，看不(bu)见骨性(xing)(xing)隆凸;手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)指(zhi)外展严重(zhong)(zhong)受(shou)(shou)(shou)(shou)阻，双手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)越(yue)来越(yue)难以叉(cha)握(wo)到一起(qi)(qi);近(jin)端(duan)(duan)指(zhi)间(jian)(jian)关(guan)(guan)(guan)(guan)节(jie)强(qiang)直(zhi)肿大， 只(zhi)能(neng)微屈(qu)，也不(bu)能(neng)完全伸(shen)(shen)直(zhi)，若被动(dong)(dong)(dong)(dong)(dong)屈(qu)曲(qu)，则(ze)出(chu)(chu)(chu)现疼(teng)痛(tong)(tong)(tong)(tong)(tong);远(yuan)端(duan)(duan)指(zhi)间(jian)(jian)关(guan)(guan)(guan)(guan)节(jie)伸(shen)(shen)直(zhi)位，不(bu)能(neng)或(huo)只(zhi)能(neng)微屈(qu)，若被动(dong)(dong)(dong)(dong)(dong)屈(qu) 曲(qu)，则(ze)出(chu)(chu)(chu)现疼(teng)痛(tong)(tong)(tong)(tong)(tong)并(bing)(bing)(bing)受(shou)(shou)(shou)(shou)限。第(di)(di)II期(qi)(qi)(qi)（后期(qi)(qi)(qi)）：若早期(qi)(qi)(qi)没有(you)进行正确的(de)(de)(de)(de)(de)治疗(liao)，症状(zhuang)会越(yue)来越(yue)明显，疼(teng)痛(tong)(tong)(tong)(tong)(tong)加(jia)重(zhong)(zhong)，直(zhi) 至不(bu)能(neng)忍(ren)受(shou)(shou)(shou)(shou)任何对手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)和(he)(he)(he)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)指(zhi)的(de)(de)(de)(de)(de)压(ya)力。X线检查可(ke)出(chu)(chu)(chu)现骨质(zhi)的(de)(de)(de)(de)(de)变(bian)(bian)化。在背(bei)(bei)侧(ce)腕(wan)骨连接区的(de)(de)(de)(de)(de)中(zhong)部，出(chu)(chu)(chu)现明显坚(jian)硬 的(de)(de)(de)(de)(de)隆凸。第(di)(di)HI期(qi)(qi)(qi)（末期(qi)(qi)(qi)或(huo)后遗症期(qi)(qi)(qi)）：未治疗(liao)的(de)(de)(de)(de)(de)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)变(bian)(bian)成固(gu)定(ding)的(de)(de)(de)(de)(de)典型(xing)畸形，水肿和(he)(he)(he)疼(teng)痛(tong)(tong)(tong)(tong)(tong)可(ke)完全消失，但关(guan)(guan)(guan)(guan)节(jie)活(huo) 动(dong)(dong)(dong)(dong)(dong)度(du)则(ze)永久丧失。通过(guo)康(kang)复(fu)训练（包括(kuo)患(huan)(huan)肢的(de)(de)(de)(de)(de)正确摆放、避免腕(wan)关(guan)(guan)(guan)(guan)节(jie)屈(qu)曲(qu)，同时(shi)配(pei)合主被动(dong)(dong)(dong)(dong)(dong)运(yun)动(dong)(dong)(dong)(dong)(dong)改善关(guan)(guan)(guan)(guan)节(jie) 活(huo)动(dong)(dong)(dong)(dong)(dong)范围）及经颅(lu)磁电疗(liao)仪的(de)(de)(de)(de)(de)重(zhong)(zhong)复(fu)性(xing)(xing)磁刺(ci)激(ji)兴奋多水平方向的(de)(de)(de)(de)(de)神经元，不(bu)仅引(yin)起(qi)(qi)生物学效(xiao)(xiao)应，影(ying)响刺(ci)激(ji)局 部和(he)(he)(he)功(gong)(gong)(gong)能(neng)相关(guan)(guan)(guan)(guan)的(de)(de)(de)(de)(de)远(yuan)隔皮层功(gong)(gong)(gong)能(neng)，实现皮层功(gong)(gong)(gong)能(neng)区域性(xing)(xing)重(zhong)(zhong)建，而且产生的(de)(de)(de)(de)(de)生物学效(xiao)(xiao)应可(ke)持续到刺(ci)激(ji)停(ting)止(zhi)后的(de)(de)(de)(de)(de) 一段(duan)时(shi)间(jian)(jian)，因(yin)(yin)(yin)(yin)此，本文结果提示在康(kang)复(fu)锻(duan)炼的(de)(de)(de)(de)(de)基础上应用经颅(lu)磁电疗(liao)仪治疗(liao)脑卒中(zhong)后肩(jian)(jian)手(shou)(shou)(shou)(shou)(shou)(shou)(shou)(shou)综(zong)(zong)(zong)合征(zheng)(zheng)患(huan)(huan)者的(de)(de)(de)(de)(de)疗(liao) 效(xiao)(xiao)显著(zhu)，其(qi)生活(huo)质(zhi)量(liang)明显提高。