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1、醒脑开窍针刺法的临床应用及基础研究 Clinical Application and Research on XNKQ Acupuncture,石学敏 教授Shi Xuemin Prof.全国针灸临床研究中心天津中医学院第一附属医院The National Acupuncture Clinical Research Center of ChinaNo.1 Teaching Hospital of Tianjin University of Traditional Chinese Medicine,2013年底，新院区将竣工并投入使用。,At the end of 2013，the new ho
2、spital compound will be completed and in operation.,中风病是危害人类健康的四大主病之一，发病率在我国居首位，其死亡率高、后遗症多，给家庭和社会带来了巨大的负担。Stroke is one of four main diseases that endangers human health.Its morbidity lies in the first place in China and its mortality is very high.It is accompanied by many complications,and has brou
3、ght a heavy burden to both the society and families.,近些年来，全国各医疗及科研部门，对中风病的诊断、治疗及机理开展了多方面、多层次的研究，使得中风病的诊断与治疗水平日趋提高，发病和治疗机理的研究已达到了分子水平和基因水平。In recent years,many medical institutes and hospitals all over the country have performed research on the diagnosis,treatment and mechanism of stroke in various a
4、spects.This has raised its standard of diagnosis and therapy rapidly.Research on its pathogenesis and therapeutic mechanism have already been reached molecular and gene levels.,自1972年，我提出醒脑开窍针刺法以来，我们对于中风的诊断、治疗、机理探讨开展了系统的临床研究和深入的基础研究，临床治疗患者达 200 万人次，形成了一套以针灸治疗为中心的中风诊疗体系。Since 1972 when I had proposed
5、 the treatment principle of“Xing Nao Kai Qiao”(XNKQ,awakening brain and opening orifices),this acupuncture method has been widely applied to more than two million patients with stroke.In addition,a series of in-dept systematic research in the mechanism,diagnosis and treatment of stroke have been car
6、ried,forming a system that mainly uses acupuncture for stroke treatment.,醒脑开窍针刺法“醒脑开窍”法是针对中风病的基本病机为瘀血、肝风、痰浊等病理因素蒙蔽脑窍致“窍闭神匿，神不导气”而提出的治疗法则和针刺方法。XNKQ ACUPUNCTURE THERAPY“XNKQ”acupuncture therapy was formulated on the fundamental pathogenesis of stroke which is due to obstruction of brain orifices and h
7、iding of vitality resulting from upward invasion of blood stasis,liver wind and phlegm.,在选穴上以阴经和督脉穴为主，并强调针刺手法量学规范，有别于传统的取穴和针刺方法。The points on Yin meridians and Du meridian are selected mainly and standard quantitative manipulations are applied,which are quite different from traditional point selecti
8、on and acupuncture manipulations in treatment of stroke.,临 床 研 究 部 分CLINICAL RESEARCH,一 般 资 料 General Data,中风病住院患者9005例：男性6029人；女性2976人，年龄最小19岁，最大87岁。病种：脑出血3077例；脑梗死5928例，合并缺血性球麻痹者521例。9005 stroke inpatients:male 6029;female 2976,the youngest 19 years,the oldest 87 years.Categories:3077 cases with c
9、erebral hemorrhage,5928 cases with cerebral infarction;521 cases with stroke with complication of ischemic bulbar paralysis.,病程：最短2小时，最长2年。首次发病6765例，两次以上发病者2240例。Course of disease：the shortest 2 hours,the longest 2 years.First time onset 6765cases,more than two time onset 2240 cases.,治 疗 方 法 Treatme
10、nt,1.处 方 主穴：内关(手厥阴心包经)人中(督脉)三阴交(足太阴脾经)1.Point PrescriptionMainpoints:Neiguan(PC 6,Pericardium Meridian of Hand-Jueyin)Renzhong(DU 26,DU Meridian)Sanyinjiao(SP 6,Spleen Meridian of Foot-Taiyin),辅穴：极泉(手少阴心经)委中(足太阳膀胱经)尺泽(手太阴肺经)Supplementary points：Jiquan(HT 1,Heart Meridian of Hand-Shaoyin)Weizhong(BL
11、40,Bladder Meridian of Foot-Taiyang)Chize(LU 5,Lung Meridian of Hand-Taiyin),位于腕横纹中点直上2寸，两筋间，直刺 0.51.0寸，采用提插捻转结合泻法。内关穴采用作用力方向的捻转泻法，即左侧逆时针捻转用力自然退回；右侧顺时针捻转用力自然退回。配合提插，双侧同时操作，施手法1分钟。,内关PC6,2 cun above the crease of the wrist,between the tendons.Puncture bilateral Neiguan(PC 6)perpendicularly for 0.5-1
12、cun,using combinative reducing method(lifting-thrusting and twirling-rotating)for 1 minute.,补法（左侧顺时针；右侧逆时针）,泻法（左侧逆时针；右侧顺时针）,右R,左L,左L,右R,于鼻唇沟上1/3 处，向鼻中隔方向斜刺0.30.5寸，采用重雀啄手法。针体刺入穴位后，将针体向一个方向捻转 360，使肌纤维缠绕在针体上，再施雀啄手法，以流泪或眼球湿润为度。,人中DU 26,The junction of upper 1/3 and middle 1/3 of the nasolabial fold.Punc
13、ture Renzhong(DU 26)obliquely upwards to the nasal septum for 0.3-0.5 cun with heavy bird-pecking method until the patients eyeballs are moistened or tears flow.,三 阴 交Sanyinjiao(SP 6),沿胫骨内侧缘与皮肤呈45度角斜刺，进针11.5，用提插补法，使患侧下肢抽动3次为度Thirdly puncture Sanyinjiao(SP 6)obliquely for 1-1.5 cun,at the angle of 45
14、 degrees with the skin surface along the posterior border of the medial aspect of the tibia,with reinforcing method of lifting and thrusting the needle to make the affected low limb have tic for three times.,极泉，部分古籍记载极泉穴为禁针穴，究其原由有以下几点：极泉穴部位腋毛茂密，不易消毒；极泉穴部位的汗腺丰盛，细菌容易滋生；极泉穴部位组织疏松，对穴位部位中的血管缺少压迫，容易出现皮下血肿
15、。Some ancient books said that HT1 is a forbidden area and the reasons are as follows:first is the dense axillary hair which is difficult to disinfect;second is that it is rich in sweat gland where bacteria breeds easily;third is the tissue is loose,and lacking in vascular compression,therefore prone
16、 to subcutaneous hematoma.,根据极泉穴的解剖特点，醒脑开窍针刺法将其延经下移12寸，避开腋毛，在肌肉丰厚的位置取穴。直刺 11.5寸，施用提插泻法，以上肢抽动3次为度。,极泉HT 1,Select Jiquan(HT 1)point at 1 cun below the original location along the heart meridian to avoid the armpit hair.Puncture perpendicularly for 1-1.5 cun with reducing method of lifting and thrustin
17、g the needle to make the affected upper limb jerk for three times.,取穴应屈肘为内角120，术者用手托住患肢腕关节，直刺0.50.8寸，用提插泻法，针感从肘关节传到手指或手动外旋，以手外旋抽动3次为度。,尺 泽LU 5,Perpendicularly puncture Chize(LU 5)for 1 cun while the forearm bends to form an angle of 120 degrees.Perform reducing manipulation of lifting and until the
18、affected arm and fingers twitch for three times.,仰卧位抬起患侧下肢取穴，术者用左手握住患肢踝关节，以术者肘部顶住患肢膝关节，刺入穴位后，针尖向外 15，进针 11.5寸，用提插泻法：以下肢抽动3次为度。,委中BL 40,Select Weizhong(BL 40)point with the patient in supine position and the lower limb lifted.Puncture perpendicularly for 0.5-1 cun,with reducing method of lifting and
19、thrusting to make the lower limb jerk for 3 times.,中风病其他并发症的治疗Treatment of Complications,中风病根据颅脑损伤的不同部位和原发病灶，可并发诸多不同临床表现的并发症及合并症。我们根据不同的并发症、合并症设立了相应的配穴治疗，通过大量临床适应症研究均收到非常理想的临床疗效。According to the affected area of the brain and primary lesion of stroke,different complications might occur.Academician S
20、hi Xuemin proposed XNKQ Acupuncture and made different coordination acupoints for different complications.It has been proved to be effective clinically.,配穴是根据脑卒中的不同临床表现或合并症、并发症针对性的选穴。醒脑开窍针刺法的主穴、辅穴体现了祖国医学“辨病证”抓主要矛盾的学术思想；配穴体现了祖国医学“辨症候群”抓特异矛盾的个性化治疗。两者相得益彰共同体现了祖国医学“辨证论治”的真谛。Coordinate acupoints are chos
21、en for different clinical manifestations and complications.Main points of XNKQ Acupuncture reflect disease differentition while coordinate points reflect syndrome differentiation.,（1）改善椎-基底动脉供血 椎基底动脉系统是颅脑供血的一部分，负责颅内1/3的血供，与颈内动脉系统有丰富的吻合支。是脑卒中病人侧枝循环建立的重要组成部分。处方：双侧风池（GB20，足少阳胆经）双侧完骨（GBl2，足少阳胆经）双侧天柱（BL1
22、0，足太阳膀胱经）颈椎夹脊刺（EX-B2，经外奇穴）1.Improving Blood Supply of Vertebro-Basilar ArteryVertebro-Basilar system is part of the brains blood supply,which in responsible for one third of the brains blood supply and has lots of anastomotic branches of the internal carotid artery system.It is an important artery i
23、n the collateral circulation establishment of stroke patients.Prescription:bilateral GB20,bilateral GB12,bilateral BL10,颅底Willi动脉环,双侧风池，向对侧眼角直刺11.5寸，双侧完骨、双侧天柱，直刺11.5寸，均施用小幅度；高频率捻转补法，即捻转幅度小于90；捻转频率为120160转/分钟，行手法 1分钟。要求双手操作，留针15分钟。,风池、完骨、天柱GB 20、GB 12、BL10,Puncture Fengchi(GB 20),Wangu(GB 12)and Tian
24、zhu(BL10)in the direction of the laryngeal prominence for 1-1.5 cun.Perform reinforcing manipulation of twirling and rotating using high frequency and small amplitude for 1 minute each.,颈椎夹脊刺Cervical Jiaji Points(EX-B2),颈椎正中线旁开5分，直刺0.50.8寸，施用小幅度；高频率捻转补法，即捻转幅度小于 90；捻转频率为120 160转/分钟，行手法1分钟。,These poin
25、ts are located on the neck and back.Puncture perpendicularly 0.5-0.8 cun with twirling method of reinforcing manipulation for 1 min.,（2）吞咽困难 2005年中国脑血管病防治指南正式将中风后发生的吞咽障碍、震咳不能、构音障碍、饮水咳呛等症状确定为“卒中后吞咽困难”。彻底改变了传统的“假性延髓麻痹”诊断理念。石学敏院士自70年代开始对该病进行了广泛深入的治疗研究，取得了非常理想的疗效。DysphagiaThe symptoms such as dysphagia,
26、inability to cough,dysarthria,cough after drinking were defined as Dysphagia after Stroke by the 2005 Chinese Cerebrovascular Diseases Prevention and Treatment Guidelines.It completely changed the traditional definition of pseudobular palsy.Academician Shi Xuemin has carried out numerous studies on
27、stroke and has achieved good effects.,传统认识的“假性延髓麻痹”是指由于双侧皮质脑干束损伤导致延髓疑核功能紊乱。出现吞咽困难、震咳不能、构音障碍、饮水咳呛。多年研究，我认为我们所治疗的吞咽困难不仅是上运动神经元所致，部分延髓血管病可以直接导致疑核缺血，出现功能障碍，应该属于下运动神经元病变。但是与运动神经元退行性病变的“进行性延髓麻痹”有着本质的区别，针灸治疗该病也收到非常理想的疗效。The conventional knowledge of pseudobulbar palsy refers to bilateral corticobulbar trac
28、t injury leading to swallowing difficulties,inability to cough and dysarthria.Academician Shi Xuemin believes that the dysphagia is not only due to upper motor neurons but also due to certain diseases of the medulla oblongata,which belong to the lower motor neuron.However it is of a different nature
29、 from progressive bullar paralysis and acupuncture is effective against it.,延髓疑核缺血性病变导致的下运动神经元性吞咽障碍，由于发病迅速、损伤弥散，早期并非出现明显的下运动神经元病变特点，未得到合理治疗的数月或更长时间后可以出现舌肌萎缩、舌肌纤维震颤等症候。因此，早期对吞咽困难的上下运动神经元的诊断，只能依据影像学的病变部位而判定。Lower motor neuron deglutition disorders caused by ischemia of nucleus ambiguous has clinical m
30、anifestation of lingual amyotrophy,lingual fibrillation etc.It has rapid onset,and has early symptoms of lower motor neuron disorders.Therefore,early diagnosis of dysphagia to differentiate upper or lower motor neuron depends on imaging techniques.,脑卒中后吞咽困难至今为止除了康复训练外，仍然是现代医学无法积极治疗的疑难病，消极的支持疗法，不能保证患
31、者的生活质量。往往因感染、代谢紊乱等多种原因，导致患者死亡。醒脑开窍针刺法及其配穴的应用有非常理想的治疗效果。临床观察住院病历 521 例，临床治愈率达64.68%；显效率达19.39%。这部分患者均可以撤消鼻饲，正常饮食。Patients of dysphagia usually die of infection,malnutrition,metabolic disorders etc,yet there are no positive treatment for dysphagia except rehabilitation.But XNKQ Acupuncture has good ef
32、fects.In a study with 521 cases,the clinical recovery rate reached to 64.68%while the effective rate is 19.39%.A portion of these patients can eat normally without nasal feed.,处方：双侧风池（GB 20，足少阳胆经）双侧完骨（GB l2，足少阳胆经）双侧翳风（TE l7，手少阳三焦经）咽后壁点刺Prescription:Bilateral fengchi(GB20)Bilateral wangu(GB12)Bilater
33、al yifeng(TE17)Pricking of the posterior wall of pharynx,三穴均向喉结方向斜刺，进针22.5寸。施用小幅度；高频率捻转补法，即捻转幅度小于90；捻转频率为120160转/分钟，行手法1分钟。要求双手操作同时捻转，留针15分钟。,风池、完骨、翳风GB 20、GB 12、SJ 17,Puncture Fengchi(GB 20),Wangu(GB 12)and Yifeng(SJ 17)in the direction of the laryngeal prominence for 2-2.5 cun,with reinforcing man
34、ipulation of twirling and rotating the needle in high frequency and small amplitude for 1 minute each acupoint.,以3寸毫针或圆利针于咽后壁点刺Use 3 cun needle to prick the posterior wall of pharynx,咽后壁点刺,（3）语言謇涩或舌强不语 语言是人类生命活动中的重要交流工具，脑卒中病人语言恢复亦是康复治疗中的重要环节之一。语言恢复除了语言矫正和训练之外，针刺治疗也起到重要作用。尤其是语言謇涩或舌强不语，以下的腧穴可收奏效。Langu
35、age is an important communication tool in life.Speech therapy is an important element of rehabilitation for stroke patients suffering from aphasia 处方：上廉泉(RN23，任脉)金津、玉液点刺放血（EX-HN 12、EX-HN 13，经外奇穴）,位于任脉走行线上，舌骨上缘至下颌之间 1/2处，向舌根部斜刺 2 寸，施用提插泻法，以舌根部麻胀感为度。,上廉泉EX-HN,Puncture Shanglianquan(EX-HN)for 1.5-2 cun
36、,with the tip of the needle pointing towards the root of the tongue.Perform reducing method of lifting and thrusting.,用舌钳或无菌巾将患者舌体拉起，在舌下可见两支静脉，用三棱针点刺舌下静脉，以出血13毫升为度。,金津玉液EX-HN12、EX-HN13,Prick Jinjin(EX-HN12)and Yuye(EX-HN13)with the three-edged needle to cause bleeding of 1-3ml.,（4）手指握固或手指功能障碍 脑卒中后遗症
37、患者多由于上肢屈肌张力增高出现手指握固，严重影响患者的生活自理。脑卒中肢体功能康复中，手指功能康复是非常重要的。因此，改善脑卒中患者的手指运动功能是康复疗法中非常重要的环节之一。Upper limb muscle hypertonia is a sequelae of stroke.It leads to gripping fingers,that affect the lives of the patients seriously.Therefore,improving motor function of the fingers is one important aspect of reha
38、bilitation therapy.处方：患侧合谷（LI 4，手阳明大肠经）患侧上八邪（EX-UE 9，经外奇穴）,向三间穴方向（既第二指掌关节基底部）透刺11.5寸，施用提插泻法，以握固的手指自然伸展或食指不自主抽动 3 次为度；再取1.5 寸毫针 1支，仍在合谷穴位置针刺向第一指掌关节基底部透刺，进针 11.5 寸，施用提插泻法，以拇指不自主抽动3次为度，合谷穴两针均留针15分钟以上。,合 谷LI 4,Puncture Hegu(LI 4)1-1.5 cun in depth with the needle tip toward Sanjian(LI 3).Use the reducin
39、g method of lifting and thrusting to make the patients index finger or five fingers extended freely.,分别在23、34、45指掌关节上1寸，向指掌关节基底部斜刺，进针 11.5寸，施用提插泻法，以各手指分别不自主抽动3次为度，留针15分钟以上。,上八邪,Four points 1 cun up each metacarpal joint on dorsum of each hand.Puncture to the base metacarpal joint 1-1.5cun,with lifti
40、ng and thrusting method of reducing manipulation,and let the fingers twitch 3 times.,（5）足内翻 Varus 足内翻是脑卒中后遗症中多见的并发症之一，由于足内翻将严重地影响脑卒中患者的下肢运动。Varus is one of the common complications of stroke.The inward angulation of the ankle will seriously affect the motor function of the lower limbs in stroke.处方：患
41、侧丘墟透照海（GB40，足少阳胆经;KI6，足少阴肾经）。,自丘墟穴进针向照海部位透刺，透刺应缓慢前进，从踝关节的诸骨缝隙间逐渐透过，进针为22.5寸，以照海穴部位见针尖蠕动即可，施用作用力方向的捻转泻法，即左侧逆时针；右侧顺时针捻转用力，针体自然退回，行手法 30 秒钟，手法结束后，将针体提出 11.5 寸，留针15分钟。,丘墟透照海GB 40 to KI 6,Puncture Qiuxu(GB 40)2-2.5 cun in depth with the needle tip towards Zhaohai(KI 6),until soreness and distension occur
42、 locally.,（6）共济障碍 Incoordination 脑干血管病共济障碍是非常多见的临床症状之一，临床表现以平衡运动、协调运动及震颤为主。石学敏院士设定两个穴位，收到非常理想的疗效。但是穴位针刺操作规范非常严格。Incoordination after brainstem vascular disease is a common symptom.It manifests as imbalance,uncoordinated movement and tremor.The points that Prof.Shi suggest have good effects on this.处
43、方：风府或哑门（DU 15；DU 16，督脉）,风府,哑门,风府、哑门两穴每次仅选其一，令患者坐位俯首（低头），以2.53寸针，针向喉结。针体进入皮下后，以震颤手法逐渐进针，每次进针深度不得超过 0.5毫米，至患者出现全身抖动立即出针，不留针，严禁针体捻转。每周仅针12次即可。,（7）症状性癫痫 症状性癫痫是一个脑卒中多发的并发症之一，尤其是额、顶、颞区皮层梗塞，并发症状性癫痫的机遇相当高。症状性癫痫多发生于恢复期或后遗症,脑卒中患病1个月后或更长时间，3个月、半年后发作癫痫最为多见，发病早期发生癫痫的反而少见。针刺治疗症状性癫痫有较好的控制症状；减少或停止抗癫痫药物的应用的作用。Sympto
44、matic epilepsy is one of the complications of stroke,particularly due to infarction in frontal,parietal,and temporal lobe of the cortex.Symptomatic epilepsy usually occurs in the recovery stages,especially at 1 month,or 3 or 6 months after.Acupuncture has good effect for symptomatic epilepsy and can
45、 help to withdraw from epileptic drugs.处方：双侧大陵（PC7，手厥阴心包经）鸠尾（RN15，任脉）,位于内侧腕横纹中央，于皮肤呈75角，稍向掌心斜刺0.30.5寸，施作用力方向的捻转泻法，即左侧逆时针；右侧顺时针捻转用力，针体自然退回，行手法 1 分钟，留针15分钟。,大 陵PC 7,It is located at the midpoint of the wrist crease.Puncture at 75angle to the skin for 0.3-0.5 cun,with twirling reducing manipulation for
46、 1 min.,位于腹正中线上，剑突下。施术前必须认真触诊，患者是否存在剑突下肝大。如果肝大，鸠尾穴应避免使用。施术时令患者双手抱头，将胸廓提起，吸气时进针，直刺1寸，施用捻转平补平泻 30 秒钟，不留针。,鸠 尾RN15,It located on the upper abdomen and on the anterior midline,below the xiphoid.Patients with enlarged liver should not use this point.Puncture perpendicularly 1 cun with uniform reinforcing
47、-reducing manipulation for 30s.,（8）高血压 Hypertension 高血压是脑卒中最多见的合并症之一，持续的超高血压，直接影响脑卒中的疾病转归，也是脑卒中再次发病的重要危险因素之一。有效地调整和控制血压是治疗和预防脑卒中的重要手段之一。Hypertension is one of the most common complications in stroke,continued hypertension will directly affects the prognosis of stroke,and is one of the important risk
48、 factors of recurrent stroke.,处方：双侧人迎（ST9，足阳明胃经）双侧曲池（LI11，手阳明大肠经）双侧合谷（LI4，手阳明大肠经）双侧太冲（LR3，足厥阴肝经）双侧足三里（ST36，足阳明胃经）Prescription:ST9,LI11,LI4,LR3,ST36,位于喉结旁开1.5 寸，胸锁乳突肌前缘，直刺1.5 寸，视针体随动脉搏动节律而晃动时，施用小幅度；高频率捻转补法，即捻转幅度小于90；捻转频率为120160转/分钟，行手法1分钟，留针15分钟。,人 迎ST9,Perpendicular puncture for 1-1.5 cun,with needl
49、e moving with the carotid pulse.Manipulate for 1 min with twirling reinforcing method.Retain for 15 min.,曲肘时，肘横纹桡侧端与尺骨鹰嘴连线1/2处，直刺11.5寸，施用作用力方向的捻转泻法，即左侧逆时针；右侧顺时针捻转用力，针体自然退回，行手法 1 分钟，留针15分钟。,曲池LI11,Perpendicular puncture for 1 min.manipulate for 1 min with twirling reinforcing method.Retain for 15 min
50、.,分别直刺0.81寸，施用作用力方向的捻转泻法，即左侧逆时针；右侧顺时针捻转用力，针体自然退回，行手法1分钟，留针15分钟。,太 冲LR3,合 谷LI4,Perpendicular puncture for 0.8-1 cun with twirling method of reducing manipulation for 1 min.Retain for 15min.,足三里ST36,足三里直刺，进针11.5寸，施用作用力方向的捻转补法，即左侧顺时针捻转用力自然退回；右侧逆时针捻转用力自然退回。施手法1分钟。,Perpendicular puncture and manipulate f
