Abstract
目的
观测电针治疗对肩袖损伤模型大鼠的肌腱愈合和功能恢复的治疗作用, 检测关节液介素-1β(IL-1β)、IL-6、α肿瘤坏死因子(TNF-α)等3种炎症因子表达以及肩袖生物力学的影响, 探讨电针治疗肩袖损伤的疗效及机制。
方法
选取90只SD大鼠, 随机分为电针组、对照组及空白组各30例, 其中电针组和对照组行肩袖损伤造模手术, 空白组不做处理。术后电针组给予电针干预, 空白组与对照组不予干预, 分别于造模术后2、4、8周测定各组大鼠的右前足足底热缩足潜伏期(TWL), 关节液IL-1β、IL-6、TNF-α含量以及肩袖的最大拉力负荷。
结果
术后2、4、8周, 对照组TWL值均低于空白组, 均高于对照组(P < 0.05);在3个观测时间点, 对照组IL-1β、IL-6和TNF-α含量均高于空白组, 电针组的IL-1β、IL-6和TNF-α含量均低于对照组(P < 0.05);在造模术后2周时, 电针组与对照组最大载荷均小于空白组(P < 0.05)。术后4、8周时, 电针干预组的最大拉力载荷高于对照组(P < 0.05)。
结论
电针疗法既能有效降低炎症因子的表达以缓解疼痛, 又能促进损伤组织的修复以提高肩袖的生物力学性能, 是肩袖损伤的有效治疗方法。
Keywords: 电针干预, 肩袖损伤, 关节液, 炎症因子, 功能康复
Abstract
Objective
To observe the therapeutic effect of electro-acupuncture on tendon healing and functional recovery of rotator cuff injury in rats and explore the therapeutic mechanism of electro-acupuncture.
Methods
Ninety SD rats were randomly divided into electro-acupuncture group, model group and blank control group, and models of rotator cuff injury were established in the former two groups.The rats in electro-acupuncture group was treated with electro-acupuncture after the operation, and those in the other two groups received no treatment.The right forefoot thermal withdrawal latency (TWL), the contents of IL-1β, IL-6 and TNF-α in the synovial fluid and the maximum tension load of supraspinatus tendon were measured at 2, 4 and 8 weeks after the operation.
Results
TWL in the model group was significantly lower than that in the blank control group and electro-acupuncture group at 2, 4 and 8 weeks after the operation (P < 0.05).At all these time points, the contents of IL-1β, IL-6 and TNF-α in the synovial fluid were significantly higher in the model group than in the blank control group and electro-acupuncture group (P < 0.05).At 2 weeks, the maximum load in electro-acupuncture group and model group were significantly lower than that in the blank control group (P < 0.05).At 4 and 8 weeks after the operation, the maximum pull load was significantly greater in electro-acupuncture group than in the model group (P < 0.05).
Conclusion
Electro-acupuncture treatment not only effectively reduces the expression of inflammatory factors to relieve pain, but also promotes the repair of damaged tissue to improve the biomechanical properties of rotator cuff in the rat models.
Keywords: electro-acupuncture intervention, rotator cuff injury, joint fluid, inflammatory cytokines, functional rehabilitation
肩袖损伤是肩关节疼痛及功能障碍的最主要原因，占肩关节疾患的17%~41% [1-2]。肩袖损伤常发生于中老年人，随着老龄社会的加重其发病率也逐年攀升[3]。在美国每年超过51%的80岁以上老年人患有肩袖损伤，相关医疗花费甚至超过70亿美元[1-4]。目前大部分轻中度患者采用非手术治疗即可获得良好的治疗效果，但其也存在多种并发症[5-8]。因此，寻找更加安全有效的治疗方式，成为临床亟待解决的问题。电针疗法具有良好的镇静、镇痛效果，在骨伤科及康复科等多种临床学科中普遍开展，对骨质疏松、肌筋膜痛和骨关节炎的治疗上取得了满意的临床疗效[9-10]。也有将其应用于肩关节疾病的治疗，但多为个案报道，样本数量小且缺乏随机对照，也缺乏相关基础机制探讨[11-14]。本研究通过对肩袖损伤大鼠进行电针干预，观察其肌腱强度的恢复情况，以及电针对患肢的疼痛评分、局部生物因子的影响。探讨电针治疗肩袖损伤的机制，以期为临床应用提供理论依据。
1. 材料和方法
1.1. 实验动物
鼠龄3月雄性SD大鼠90只（承德医学院实验动物中心），体质量（285±22）g。根据随机数据表法将其随机分为电针干预模型组（简称电针组）、无干预模型组（简称对照组）和不做处理组（空白组），每组30只。均在相同标准环境下分笼饲养。实验过程中对动物的处置参照国家科学技术部2006年发布的《关于善待实验动物的指导性意见》。
1.2. 试剂及设备
戊巴比妥钠（北京华业寰宇化工有限公司）；IL-1β、IL-6、TNF-α ELISA试剂盒（碧云天生物技术有限公司）；酶标仪（CliniBio）；全能台式高速冷冻离心机（Thermo）；热辐射测痛仪（UGO BASILE）；MTS-858生物力学试验机（MTS）。
1.3. 大鼠肩袖损伤模型制备
电针组和对照组大鼠均参照经典肩袖损伤模型方法造模[15]。按40 mg/kg腹腔注射10%戊巴比妥钠对大鼠进行麻醉。在右侧肩胛区备皮、消毒，于右肩胛冈肩峰端作一长约1.5 cm纵行切口，分离浅筋膜以及斜方肌，显露并分离大鼠冈上肌腱肱骨大结节止点，将冈上肌腱横行切断约1/2，压迫止血，逐层缝合切口。术后单笼饲养，自由饮食、饮水，并予以肌注青霉素（40万单位/d），持续1周。空白组不做处理。
1.4. 干预方法
造模后第2天开始电针治疗。电针组大鼠，舒适固定，暴露上肢，参照余曙光《实验针灸学》（第2版），取“肩前”、“肩贞”、“肩髃”等3个穴位，采用0.20 mm×15 mm一次性针灸针，直刺进针0.3~0.5 cm后，选穴连接电针仪，胶带要牢固的固定电针，防止在实验过程中脱落，选用疏密波2/100 Hz，电流强度0.5~1 mA [16]，以大鼠局部肢体微微抖动而无嘶叫挣扎甩尾等反应为适宜，按人和动物药物等效剂量换算治疗时间15 min，1次/d，每周为1疗程（针刺6 d，休息1 d）。治疗8周。空白组、对照组与电针组同一时间抓取、固定，不进行针刺干预。
1.5. 热缩足反射潜伏期（TWL）检测
于造模前、以及获取标本处死前，采用热辐射测痛仪检测3组大鼠手术侧肢体TWL，以观察大鼠患侧痛阈变化。室温保持25±2 ℃的环境中，先将大鼠置于测试仪上方的透明有机玻璃格中，自由活动，适应20~30 min，安静后将测痛仪上的光源瞄准器对准手术侧（右前）足底中央并避开足垫，开启35 ℃红光照射直至至大鼠逃避性抬腿回缩，仪器自动切断热源并显示照射持续时间，此即为TWL。测量3次，每次间隔5 min。取其平均值为测定结果。为防止大鼠热辐射烫伤，将大鼠的TWL测定时间上限值设定为20 s。
1.6. 标本取材与制备
于术后第2、4、8周在3组中各取10只大鼠，用过量的戊巴比妥进行处死，按原切口进入（空白组取相同切口收集组织）。切取肩关节囊及滑膜放入一定量的PBS（pH7.4）中，使关节液充分解析出并融入其中，取出关节囊及滑膜，对PBS进行离心，取上清液备测生物因子。小心剔除肩胛骨和其它软组织，保留冈上肌及其止点，解剖出肱骨近端－冈上肌复合体标本，用被生理盐水浸润的纱布包裹标本，暂存于-40 ℃冰箱中预备做生物力学测试。
1.7. IL-1β、IL-6和TNF-α含量测定
采用酶联免疫吸附试验(ELISA)方法对前述上清液检测其TNF-α、IL-1β、IL-6水平，严格按ELISA试剂盒说明书进行检测操作，每个标本重复3次试验，取其结果平均值。完成后使用酶标仪于450 nm波长下测得光密度值（A）。根据标准品的浓度及对应的A450计算出标准曲线方程，再依据样品A450计算出相应IL-1β、IL-6和TNF-α的含量。
1.8. 生物力学测试
将各组10个标本从冰箱取出、常温解冻，用牙托粉包埋肱骨远端，并使用专用夹具固定标本放置于MTS-858生物力学试验机上行拉断试验。先行预处理，每个标本给予2N的拉力，持续20 s，共3次。然后行拉断实验，拉伸速度为5 mm/min，记录最大拉力负荷（N）。
1.9. 统计方法
所有的统计分析均采用IBM SPSS 22.0统计软件数进行处理。经检验后呈正态分布的数据表示为均数±标准差。3组间各结局指标统计学差异均采用重复测量方差分析。设定P < 0.05为差异具有统计学意义。
2. 结果
2.1. 一般情况
电针组和对照组大鼠造模当天即自主进食，但均有不同程度的摄食减少，术后大鼠即出现跛行、患肢不敢着地等保护患肢现象，电针组大约4~10 d后逐渐恢复正常；对照组食量3~7 d恢复，跛行步态持续存在；所有大鼠术口均未发生红肿感染，实验中途未见死亡脱落。空白组大鼠自由摄食水。
2.2. TWL检测结果
TWL检测结果如表 1。造模之前3组大鼠基础TWL值比较，差异无统计学意义（P > 0.05），具有可比性。术后电针组和对照组呈现先降后升趋势，电针组的TWL值上升较早；对照组大鼠的TWL值上升很慢，术后整个实验期间持续维持在较低水平，术后2、4、8周均低于电针组与空白组，差异有显著性（P < 0.05）；电针组术后2、4周时，TWL值低于空白组，差异有统计学意义（P < 0.05），术后8周时，对比空白组，差异无统计学意义（P > 0.05）。
1.
3组大鼠右前足痛阈比较
Comparison of right anterior foot pain threshold among the 3 groups (Mean±SD, second, n=10)
| Groups | Pre-operation | 2 weeks after operation | 4 weeks after operation | 8 weeks after operation |
| a: The difference is statistically significant compared with control group (P < 0.05); b: The difference is statistically significant compared with blank group group (P < 0.05). | ||||
| Control group | 11.43±1.25 | 4.78±0.92b | 6.14±1.28b | 8.03±1.19b |
| EA group | 11.37±1.42 | 7.31±1.02ab | 9.17±0.96ab | 10.45±0.83a |
| Blank group | 11.34±1.33 | 11.32±1.36 | 11.29±1.35 | 11.24±1.29 |
2.3. IL-1β含量
在3个观察时点，对照组的IL-1β含量均高于空白组，电针组的IL-1β含量均低于对照组，差异均有统计学意义（P < 0.05）。在术后2、4周时，电针组IL- 1β含量高于空白组，差异均有统计学意义（P < 0.05），在8周时与空白组差异无统计学意义（P > 0.05，表 2）。
2.
3组之间IL- 1β含量的对比
Comparison of IL-1 β content among the 3 groups (pg/mL, n=10)
| Groups | 2 weeks after operation | 4 weeks after operation | 8 weeks after operation |
| a: The difference is statistically significant compared with control group (P < 0.05); b: The difference is statistically significant compared with blank group group (P < 0.05). | |||
| Control group | 11.35±1.28b | 10.24±1.36b | 9.81±1.25b |
| EA group | 9.58±1.31ab | 7.16±1.59ab | 5.73±1.47a |
| Blank group | 5.69±1.35 | 5.65±1.28 | 5.66±1.31 |
2.4. IL-6含量
在3个观察时点，对照组的IL-6含量均高于空白组，电针组的IL-6含量均低于对照组，差异均有统计学意义（P < 0.05）。在术后2、4周时，电针组IL-6含量高于空白组，差异均有统计学意义（P < 0.05），在8周时与空白组差异无统计学意义（P > 0.05，表 3）。
3.
3组之间IL- 6含量的对比
Comparison of IL-6 content among the 3 groups (ng/mL, n=10)
| Groups | 2 weeks after operation | 4 weeks after operation | 8 weeks after operation |
| a: The difference is statistically significant compared with control group (P < 0.05); b: The difference is statistically significant compared with blank group group (P < 0.05). | |||
| Control group | 118.82±12.27b | 99.63±9.56b | 84.75±8.62b |
| EA group | 92.76±10.48ab | 64.86±7.73ab | 48.37±8.95a |
| Blank group | 47.79±8.64 | 48.10±8.78 | 47.98±8.86 |
2.5. TNF-α含量
在3个观察时点，对照组TNF-α含量均高于空白组，电针组的TNF-α含量均低于对照组，差异均有统计学意义（P < 0.05）。在术后2、4周时，电针组TNF-α含量高于空白组，差异均有统计学意义（P < 0.05），在8周时与空白组差异无统计学意义（P > 0.05，表 4）。
4.
3组之间TNF-α含量的对比
Comparison of TNF-α content among the 3 groups (ng/mL, n=10)
| Groups | 2 weeks after operation | 4 weeks after operation | 8 weeks after operation |
| a: The difference is statistically significant compared with control group (P < 0.05); b:The difference is statistically significant compared with blank group group (P < 0.05). | |||
| Control group | 22.17±4.75b | 16.92±2.38b | 10.65±3.42b |
| EA group | 16.19±2.53ab | 10.81±3.06ab | 7.45±2.75a |
| Blank group | 7.23±2.10 | 7.30±2.34 | 7.34±2.32 |
2.6. 肩袖生物力学测试结果
实验结果表明，所有断裂均在造模时的剪裂处，随术后时间的延长，对照组和电针组大鼠的最大拉力载荷逐渐增强，但对照组的增强趋势明显较缓。2周时，电针组与对照组之间的最大载荷比较无统计学意义（P > 0.05）。在造模术后4、8周时，电针干预组的最大拉力载荷高于对照组，有显著性差异（P < 0.05）。在术后2、4周时，电针组电针干预组的最大拉力载荷低于空白组，有显著性差异（P < 0.05），而8周时与空白组差异无统计学意义（P > 0.05）。对照组在2、4、8周时最大拉力载荷均小于空白组，有显著性差异（P < 0.05，表 5）。
5.
3组大鼠肩袖最大拉力载荷
Comparison of maximum tension load of rotator cuff among the groups (N, n=10)
| Groups | 2 weeks after operation | 4 weeks after operation | 8 weeks after operation |
| a: The difference is statistically significant compared with control group (P < 0.05); b: The difference is statistically significant compared with blank group group (P < 0.05). | |||
| Control group | 6.92±2.31b | 11.72±2.20b | 18.42±2.82b |
| EA group | 7.24±1.72b | 16.31±3.11ab | 28.20±3.61a |
| Blank group | 30.10±3.21 | 30.14±3.01 | 30.20±3.15 |
3. 讨论
肩袖损伤是导致肩关节功能障碍和疼痛的最重要原因[17]。其发病率随着年龄的增长而增加，20岁以上人群中患病率约为20%，而在60岁以上人群中，这一比例上升至高达54% [18]，由此可见肩袖损伤患者趋于老龄化。目前大部分轻中肩袖损伤患者，多采用保守治疗，如口服药物或局部封闭等，但面对老龄化严重的肩袖损伤时，弊端也随之暴露，如Akgun[7]等报道发现注射类固醇可促进胶原蛋白降解，破坏肌腱结构，增加肌腱撕裂风险；口服药物虽然可以选择COX-2-选择性抑制剂，但其依然可引起胃肠道不良反应，具有肾脏、血液学及神经学等相关疾病副作用，这些副作用的不良影响在老年患者中会更加显著。因此，寻找安全、无创、有效的治疗方式，成为临床亟待解决的问题。
目前电针在骨伤科及康复科已得到广泛应用，对骨质疏松、肌筋膜痛和骨关节炎的治疗上取得了满意的临床疗效[21-22]。但对肩袖损伤相关针灸研究仍非常有限，缺乏基础研究，临床研究仅见个案报道，如Settergren [13]报道应用针灸治疗一名冈上肌损伤患者，治疗6天后，患者肩部疼痛缓解50%。治疗10 d后患者疼痛完全缓解。Osborne [14]也对4名冈下肌与和小圆肌疼痛的排球运动员进行了针灸治疗，在治疗后1，2，3和7 d随访时发现患者VAS疼痛评分明显降低，关节活动范围显著增大，在第7天时关节功能基本恢复正常。为了进一步证明电针对肩袖损伤的治疗疗效，我们采用大鼠建模，以冈上肌肌腱剪断1/2制作临床最为常见的肩袖撕裂模型，选取电针干预后2、4、8周这3个时间点上分别进行大鼠行为学分析，炎症因子测定和生物力学实验，结果发现电针的治疗效果显著。其中行为学分析指标采用TWL进行评估，我们发现经过电针治疗组在很短时间（2周）时，大鼠的热辐射疼痛反应时间就明显高于对照组，说明电针治疗可以快速提高大鼠的热痛阈值，较快的缓解和改善大鼠的疼痛症状，具有起效快的特点。随后的4周和8周时，电针治疗组大鼠痛阈依然明显高于对照，证明了电针对于镇痛的持久作用。我们的研究从动物实验的角度证明了电针对改善肩袖损伤患者症状的积极作用，对以往的临床研究是一个有益的补充。
肩袖损伤导致疼痛的确切机制目前尚不清楚，通常认为肩袖损伤疼痛是由于局部损伤肌腱牵拉而引起。近年来，关节液中生物因子表达变化及其与关节疾病的关系越来越受到国内外学者的重视。当关节出现病变时，损伤组织代谢释放入关节液中的生物因子，不仅可以反映关节组织损伤病情进展，往往还发挥其生物学作用，参与疾病的发生和发展，能更直接更敏感的反映关节的生理病理情况[23]。在实验中我们测量不同时间点的关节液炎症因子发现，随着治疗的延续，电针组大鼠关节液中TNF-α、IL-1β与IL-6的水平显著降低，并且电针治疗组大鼠关节液中炎性因子的水平较同时间点的对照组显著降低，并在8周时趋近于空白组，大鼠疼痛也逐渐改善，这一点与大鼠行为学的改善不谋而合。既往临床研究中，Siu KK等[24]研究发现肩袖损伤患者关节液中的IL-1β和IL-6水平与患者肩关节功能与疼痛程度密切相关，随着IL-1β和IL-6水平的降低，患者的关节功能和症状逐渐改善。Tajana等[25]研究进一步证明，肩袖损伤患者关节液中炎性因子的含量与患者肩袖损伤的程度也成正相关。由此可见关节炎中的炎症因子不仅是患者症状的诱发因素，还可以作为关节症状和功能恢复的生物标记物。因此可见，电针治疗可以通过降低炎症因子水平起到了缓解肩袖损伤疼痛与改善功能的作用。
此外在本研究中，也观察到电针对于促进肌腱愈合的积极效果。生物力学实验结果显示在术后4周和8周时，电针治疗组的最大拉力载荷显著高于对照组，在8周时对比空白组无显著差异。这一结果充分证明了电针治疗可以促进撕裂肩袖愈合，显著增强其生物力学性能，是治疗肩袖损伤的有效措施。值得注意的是，在2周时，两组肩袖的最大拉力载荷差异无统计学意义，这可能是由于治疗时间较短，促进肌腱组织愈合的效果并不明显，因此两组生物力学结果无差异。随着治疗时间的延长，其促进肩袖愈合的作用逐渐显现出来。既往研究中Almeida等[26]将大鼠分成空白对照组，模型组（仅切断跟腱）和观察组（切断跟腱并电针治疗），电针治疗6个疗程后（20 min/疗程）后生化定量分析检测发现观察组大鼠胶原蛋白含量显著上升，病理检测发现胶原纤维束组织增生，排列整齐，提高了跟腱的机械强度。另一项研究[27]同样采用大鼠跟腱损伤模型，实验分为正常组，跟腱损伤组和电针治疗组，结果显示14 d和21 d时电针治疗组的胶原纤维直径与重组情况都显著高于其他两组。这些动物研究和随后的临床分析都支持了我们的研究结果，进一步证明了电针对肌腱愈合有着积极的促进作用[28-30]。
综上所述，电针治疗肩袖损伤，一方面有效降低炎症因子的表达，抑制过激的炎性反应，缓解疼痛以“治标”；另一方面，电针可促进损伤组织的修复，提高肩袖的最大载荷，改善肩关节的生物力学性能以“治本”。电针疗法在肩袖损伤的治疗中能标本兼治，从而使患者尽早恢复到正常的生活和工作中。
Biography
宋文秀, 硕士, E-mail: 30442372@qq.com
Funding Statement
广东省中医药局中医药科研项目(20202040);广州市科技计划重大项目(201604020095)
Contributor Information
宋 文秀 (Wenxiu SONG), Email: 30442372@qq.com.
王 华军 (Huajun WANG), Email: whj323@126.com.
郑 小飞 (Xiaofei ZHENG), Email: 303482272@qq.com.
References
- 1.Ueda Y, Sugaya H, Takahashi N, et al. Prevalence and site of rotator cuff lesions in shoulders with recurrent anterior instability in a young population. Orthop J Sports Med. 2019;7(6):2325967119849876. doi: 10.1177/2325967119849876. [Ueda Y, Sugaya H, Takahashi N, et al. Prevalence and site of rotator cuff lesions in shoulders with recurrent anterior instability in a young population[J]. Orthop J Sports Med, 2019, 7(6): 2325967119849876.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Yoshida M, Collin P, Josseaume T, et al. Post-operative rotator cuff integrity, based on Sugaya's classification, can reflect abduction muscle strength of the shoulder. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):161–8. doi: 10.1007/s00167-017-4608-5. [Yoshida M, Collin P, Josseaume T, et al. Post-operative rotator cuff integrity, based on Sugaya's classification, can reflect abduction muscle strength of the shoulder[J]. Knee Surg Sports Traumatol Arthrosc, 2018, 26(1): 161-8.] [DOI] [PubMed] [Google Scholar]
- 3.Jo YH, Lee KH, Kim SJ, et al. National trends in surgery for rotator cuff disease in Korea. J Korean Med Sci. 2017;32(2):357–64. doi: 10.3346/jkms.2017.32.2.357. [Jo YH, Lee KH, Kim SJ, et al. National trends in surgery for rotator cuff disease in Korea[J]. J Korean Med Sci, 2017, 32(2): 357-64.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rashid MS, Cooper C, Cook J, et al. Increasing age and tear size reduce rotator cuff repair healing rate at 1 year. Acta Orthop. 2017;88(6):606–11. doi: 10.1080/17453674.2017.1370844. [Rashid MS, Cooper C, Cook J, et al. Increasing age and tear size reduce rotator cuff repair healing rate at 1 year[J]. Acta Orthop, 2017, 88(6): 606-11.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22(10):1371–9. doi: 10.1016/j.jse.2013.01.026. [Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study[J]. J Shoulder Elbow Surg, 2013, 22(10): 1371-9.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop Relat Res. 1992;(275):165–73. [Itoi E, Tabata S. Conservative treatment of rotator cuff tears[J]. Clin Orthop Relat Res, 1992(275): 165-73.] [PubMed] [Google Scholar]
- 7.Akgün K, Birtane M, Akarirmak U. Is local subacromial corticosteroid injection beneficial in subacromial impingement syndrome? Clin Rheumatol. 2004;23(6):496–500. doi: 10.1007/s10067-004-0930-7. [Akgün K, Birtane M, Akarirmak U. Is local subacromial corticosteroid injection beneficial in subacromial impingement syndrome[J]? Clin Rheumatol, 2004, 23(6): 496-500.] [DOI] [PubMed] [Google Scholar]
- 8.Longo UG, Franceschi F, Berton A, et al. Conservative treatment and rotator cuff tear progression. https://www.researchgate.net/profile/Nicola_Maffulli/publication/51708030_Rotator_Cuff_Tear/links/00b7d52bd29faafb46000000.pdf. Med Sport Sci. 2012;57:90–9. doi: 10.1159/000328910. [Longo UG, Franceschi F, Berton A, et al. Conservative treatment and rotator cuff tear progression[J]. Med Sport Sci, 2012, 57: 90-9.] [DOI] [PubMed] [Google Scholar]
- 9.Zeng YX, Liu Y, Liu SX, et al. Initial effects of electroacupuncture for chronic severe functional constipation and the potential underlying factors: secondary analysis of a randomized controlled trial. https://www.ncbi.nlm.nih.gov/pubmed/31198430. Evid Based Complement Alternat Med. 2019;2019:7457219. doi: 10.1155/2019/7457219. [Zeng YX, Liu Y, Liu SX, et al. Initial effects of electroacupuncture for chronic severe functional constipation and the potential underlying factors: secondary analysis of a randomized controlled trial[J]. Evid Based Complement Alternat Med, 2019, 2019: 7457219.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Zhang Q, Gong J, Dong HX, et al. Acupuncture for chronic fatigue syndrome: a systematic review and meta-analysis. https://pubmed.ncbi.nlm.nih.gov/31204859/ Acupunct Med. 2019;37(4):211–22. doi: 10.1136/acupmed-2017-011582. [Zhang Q, Gong J, Dong HX, et al. Acupuncture for chronic fatigue syndrome: a systematic review and meta-analysis[J]. Acupunct Med, 2019, 37(4): 211-22.] [DOI] [PubMed] [Google Scholar]
- 11.Schröder S, Meyer-Hamme G, Friedemann T, et al. Immediate pain relief in adhesive capsulitis by acupuncture-A randomized controlled double-blinded study. Pain Med. 2017;18(11):2235–47. doi: 10.1093/pm/pnx052. [Schröder S, Meyer-Hamme G, Friedemann T, et al. Immediate pain relief in adhesive capsulitis by acupuncture-A randomized controlled double-blinded study[J]. Pain Med, 2017, 18(11): 2235-47.] [DOI] [PubMed] [Google Scholar]
- 12.Dong W, Goost H, Lin XB, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine (Baltimore) 2015;94(10):e510. doi: 10.1097/MD.0000000000000510. [Dong W, Goost H, Lin XB, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis [J]. Medicine (Baltimore), 2015, 94(10): e510.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Settergren R. Treatment of supraspinatus tendinopathy with ultrasound guided dry needling. J Chiropr Med. 2013;12(1):26–9. doi: 10.1016/j.jcm.2012.11.002. [Settergren R. Treatment of supraspinatus tendinopathy with ultrasound guided dry needling[J]. J Chiropr Med, 2013, 12(1): 26-9.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Osborne NJ, Gatt IT. Management of shoulder injuries using dry needling in elite volleyball players. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=HighWire000002965297. Acupunct Med. 2010;28(1):42–5. doi: 10.1136/aim.2009.001560. [Osborne NJ, Gatt IT. Management of shoulder injuries using dry needling in elite volleyball players[J]. Acupunct Med, 2010, 28(1): 42-5.] [DOI] [PubMed] [Google Scholar]
- 15.Reuther KE, Thomas SJ, Sarver JJ, et al. Effect of return to overuse activity following an isolated supraspinatus tendon tear on adjacent intact tendons and glenoid cartilage in a rat model. J Orthop Res. 2013;31(5):710–5. doi: 10.1002/jor.22295. [Reuther KE, Thomas SJ, Sarver JJ, et al. Effect of return to overuse activity following an isolated supraspinatus tendon tear on adjacent intact tendons and glenoid cartilage in a rat model[J]. J Orthop Res, 2013, 31(5): 710-5.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.陈 贞羽, 龚 杰, 庄 晟坚, et al. 炎性痛电针镇痛参数优选及对炎性因子的影响. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zjzyzz201902011. 浙江中医杂志. 2019;54(2):100–1. [陈贞羽, 龚杰, 庄晟坚, 等.炎性痛电针镇痛参数优选及对炎性因子的影响[J].浙江中医杂志, 2019, 54(2): 100-1.] [Google Scholar]
- 17.Chakravarty K, Webley M. Shoulder joint movement and its relationship to disability in the elderly. J Rheumatol. 1993;20(8):1359–61. [Chakravarty K, Webley M. Shoulder joint movement and its relationship to disability in the elderly[J]. J Rheumatol, 1993, 20(8): 1359-61.] [PubMed] [Google Scholar]
- 18.Barnes LA, Kim HM, Caldwell JM, et al. Satisfaction, function and repair integrity after arthroscopic versus mini-open rotator cuff repair. Bone Joint J. 2017;99-B(2):245–9. doi: 10.1302/0301-620X.99B2.BJJ-2016-0055.R1. [Barnes LA, Kim HM, Caldwell JM, et al. Satisfaction, function and repair integrity after arthroscopic versus mini-open rotator cuff repair[J]. Bone Joint J, 2017, 99-B(2): 245-9.] [DOI] [PubMed] [Google Scholar]
- 19.陈 超, 刘 炜宏, 王 宏才, et al. 国外临床实践指南相关针灸内容的调查与分析. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zgzj201804022. 中国针灸. 2018;38(4):425–9. [陈超, 刘炜宏, 王宏才, 等.国外临床实践指南相关针灸内容的调查与分析[J].中国针灸, 2018, 38(4): 425-9.] [Google Scholar]
- 20.杨 明晓, 赵 凌, 杨 洁, et al. 国内针灸病谱研究规律的文献计量学分析及趋势展望. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zcyj201403014. 针刺研究. 2014;39(3):247–51. [杨明晓, 赵凌, 杨洁, 等.国内针灸病谱研究规律的文献计量学分析及趋势展望[J].针刺研究, 2014, 39(3): 247-51.] [PubMed] [Google Scholar]
- 21.余 鸿斌, 于 柏清, 杨 汉晖, et al. 针灸加电针疗法促进骨折愈合的临床观察. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=jkr201531051. 中国当代医药. 2015;22(31):152–4. [余鸿斌, 于柏清, 杨汉晖, 等.针灸加电针疗法促进骨折愈合的临床观察[J].中国当代医药, 2015, 22(31): 152-4.] [Google Scholar]
- 22.郑 祥, 王 金丽, 朱 洪江, et al. 电针对老年跟腱断裂损伤修补术后运动功能恢复的影响. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zglnxzz201804046. 中国老年学杂志. 2018;38(4):876–8. [郑祥, 王金丽, 朱洪江, 等.电针对老年跟腱断裂损伤修补术后运动功能恢复的影响[J].中国老年学杂志, 2018, 38(4): 876-8.] [Google Scholar]
- 23.Yamazaki H, Ochiai N, Kenmoku T, et al. Assessment of painrelated behavior and pro-inflammatory cytokine levels in the rat rotator cuff tear model. http://europepmc.org/abstract/med/24018624. J Orthop Res. 2014;32(2):286–90. doi: 10.1002/jor.22486. [Yamazaki H, Ochiai N, Kenmoku T, et al. Assessment of painrelated behavior and pro-inflammatory cytokine levels in the rat rotator cuff tear model[J]. J Orthop Res, 2014, 32(2): 286-90.] [DOI] [PubMed] [Google Scholar]
- 24.Siu KK, Zheng LB, Ko JY, et al. Increased interleukin 1β levels in the subacromial fluid in diabetic patients with rotator cuff lesions compared with nondiabetic patients. J Shoulder Elb Surg. 2013;22(11):1547–51. doi: 10.1016/j.jse.2013.01.011. [Siu KK, Zheng LB, Ko JY, et al. Increased interleukin 1β levels in the subacromial fluid in diabetic patients with rotator cuff lesions compared with nondiabetic patients[J]. J Shoulder Elb Surg, 2013, 22(11): 1547-51.] [DOI] [PubMed] [Google Scholar]
- 25.Tajana MS, Murena L, Valli F, et al. Correlations between biochemical markers in the synovial fluid and severity of rotator cuff disease. https://www.ncbi.nlm.nih.gov/pubmed/19711169. Chir Organi Mov. 2009;93(Suppl 1):S41–8. doi: 10.1007/s12306-009-0004-8. [Tajana MS, Murena L, Valli F, et al. Correlations between biochemical markers in the synovial fluid and severity of rotator cuff disease[J]. Chir Organi Mov, 2009, 93(Suppl 1): S41-8.] [DOI] [PubMed] [Google Scholar]
- 26.de Almeida Mdos S, de Aro AA, Guerra Fda R, et al. Electroacupuncture increases the concentration and organization of collagen in a tendon healing model in rats. Connect Tissue Res. 2012;53(6):542–7. doi: 10.3109/03008207.2012.710671. [de Almeida Mdos S, de Aro AA, Guerra Fda R, et al. Electroacupuncture increases the concentration and organization of collagen in a tendon healing model in rats[J]. Connect Tissue Res, 2012, 53(6): 542-7.] [DOI] [PubMed] [Google Scholar]
- 27.de Almeida Mdos S, de Freitas KM, Oliveira LP, et al. Acupuncture increases the diameter and reorganisation of collagen fibrils during rat tendon healing. https://journals.sagepub.com/doi/10.1136/acupmed-2014-010548. Acupunct Med. 2015;33(1):51–7. doi: 10.1136/acupmed-2014-010548. [de Almeida Mdos S, de Freitas KM, Oliveira LP, et al. Acupuncture increases the diameter and reorganisation of collagen fibrils during rat tendon healing[J]. Acupunct Med, 2015, 33(1): 51-7.] [DOI] [PubMed] [Google Scholar]
- 28.TANG H, LUO F, FAN H, et al. Acupuncture and manual therapy for rotator cuff tears: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2020;99(21):e20377. doi: 10.1097/MD.0000000000020377. [TANG H, LUO F, FAN H, et al. Acupuncture and manual therapy for rotator cuff tears: A protocol for systematic review and meta analysis. Medicine (Baltimore), 2020, 99(21): e20377.] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.YANG G, JUNG B, KIM MR, et al. Acromioplasty rates in patients with shoulder disorders with and without acupuncture treatment: a retrospective propensity score-matched cohort study. https://pubmed.ncbi.nlm.nih.gov/32310005/ Acupunct Med. 2020;20:964528419895529. doi: 10.1177/0964528419895529. [YANG G, JUNG B, KIM MR, et al. Acromioplasty rates in patients with shoulder disorders with and without acupuncture treatment: a retrospective propensity score-matched cohort study. Acupunct Med, 2020, 20: 964528419895529.] [DOI] [PubMed] [Google Scholar]
- 30.Choi S, Kim KH. Acupuncture for symptomatic rotator cuff disease: Protocol for a systematic review and meta-analysis. https://pubmed.ncbi.nlm.nih.gov/31914084/ Medicine (Baltimore) 2020;99(2):e18716. doi: 10.1097/MD.0000000000018716. [Choi S, Kim KH. Acupuncture for symptomatic rotator cuff disease: Protocol for a systematic review and meta-analysis[J]. Medicine (Baltimore), 2020, 99(2): e18716.] [DOI] [PMC free article] [PubMed] [Google Scholar]