Part 6

运动疗法对糖尿病病人具有重要意义，它与饮食疗法、心身疗 法共同构成糖尿病的基本疗法。我国是世界上最早提出运动疗法 治疗糖尿病的国家，隋代巢元方《诸病源候论 ·消渴侯》中说："先行 一百二十步，多者千步，然后食"。唐代王焘在《外台秘要》中也指 出：消渴病人应当"食毕即行步，稍畅而坐",唐代孙思邈主张每餐 食毕，出庭散步五六十至一二百步，或根据情况出门行二三百步或 二三里。以上说明我国古代医家在医疗实践中已经认识到，适度 有节制的坚持长期的运动疗法是治疗糖尿病的重要方法。 (一)运动疗法的意义 长期坚持适度的体育锻炼，能增加热量的消耗，促进肌肉等组 织对葡萄糖的利用。同时，运动可使肌肉、肝脏、脂肪等组织对胰 岛素的敏感性增强，从而使血糖下降。坚持长期有效地体力活动 可以增强人体内脂蛋白酯酶的活性，加速脂肪的分解，并促进脂 肪、胆固醇及游离脂肪酸的利用，使过盛的脂肪组织消耗，起到减 肥和降血脂的作用。并且由于减肥，使体内胰岛素受体数目增多， 对胰岛素的敏感性增强，使血糖下降。坚持适度的体力活动锻炼， 可增强心肺功能，有利于促进血液循环，改善血流动力学障碍，促 使全身代谢旺盛，有利于血糖的消耗。运动疗法可增强体力和抗 病能力，减少糖尿病并发症的发生。同时，适度的体力活动可使病 人心情愉快、思想开朗，有利于调节神经系统兴奋、抑制功能，改善 病人的精神状态，增添生活情趣。并能提高睡眠质量，提高病人的 耐受力、决断力、自制力；增强病人对感染、创伤的抗病能力。运动 疗法可调整人体的神经、内分泌功能，有利于预防高血压、高血脂、 动脉硬化等病变。 (二)运动疗法应注意的问题 (1)运动疗法必须长期坚持，持之以恒才能有效。不能三天打 鱼，两天晒网，练练停停，那样是收不到治疗效果的。 (2)运动疗法要掌握好运动量，过度劳累也不利于糖尿病的控 制，反而可能引起低血糖或酮症而加重病情。 (3)对于糖尿病重症并发症，如冠心病、心肌梗塞、糖尿病肾 病、糖尿病视网膜病变，以及糖尿病并发各种急性感染、肺结核、病 毒性肝炎等，应积极治疗并发症，不宜于运动疗法。可以根据病 情，适当地做一些轻度的活动。 (4)对于病情控制不良的1型糖尿病及妊娠糖尿病患者，也不 适宜于运动疗法。 (5)对于老年糖尿病体衰者、易于发生低血糖反应的糖尿病患 者、严重的糖尿病神经病变患者以及糖尿病足患者，均不适宜进行 运动疗法。 (三)糖尿病运动疗法的实施 糖尿病的运动疗法指的是长期的、适度的、持续性的慢性运动 疗法。应根据每个病人的病情和具体情况，制订合理的实施方案。 1.运动强度 一般情况下，开始锻炼时应选择运动量小、活 动时间短的运动，随着体质的增强，再慢慢增加运动量。如体重 60kg 的病人快步行走，每天2次~3次，每次15~30min 为宜。运 动量以每次运动结束时，脉搏数以不超过170-年龄数为合适。 运动时宜从容和缓，不宜出现疲乏、大汗、呼吸急促的情况。 2.运动项目 ①应选择容易掌握的运动项目；②应选择个人 能够进行的主动性项目，如快步走或慢跑等；③应选择不受时间、 地点、设备限制的，能够长期坚持的项目，如广播操、太极拳等运 动；④应选择个人感兴趣的运动项目；⑤应选择竞技性不强、不决 定胜负的运动项目。 3 .运动时机不宜于空腹运动，以免发生低血糖反应。也不 宜于在餐后立即运动，所谓"饭后百步走"。因为餐后立即运动可 影响食物的消化、吸收，所以一般应在餐后1h运动较为合适。 4.运动的持续时间 中等强度的运动一般可在每日三餐后 1h各活动20~30min。 5.运动频度 运动疗法必须长期坚持才能有效，最好每天坚 持运动，不要中断，至少每星期坚持三天运动。为增加对运动疗法 的兴趣，可适当变换活动内容。 第三节心身治疗 心身疗法是糖尿病的基本疗法之一，因为糖尿病的发生、发展与病人的情志有密切关系，所以，心身疗法对糖尿病的防治有重要 意义。对于轻症的糖尿病患者，实施心身疗法可以不用或少用降 糖药物；对中、重度患者，心身疗法也能有效缓解病情，减少降糖药 物的用量。

传统中医历来重视喜、怒、忧、思、悲、恐、惊等情志变化对消 渴、消瘦的影响。《灵枢 ·五变篇》说："刚则多怒，怒则气上逆，胸中 蓄积，血气逆留，髋皮充肌，血脉不行，转而为热，热则消肌肤，故为 消痒",清代叶天士在<临证指南医案 ·三消》中也指出："能食、善 饥、日加瘪瘦。心境愁郁，内火自燃，乃消渴大病。"以上论述说明， 长期遭受精神刺激可导致气机郁结，日久不解则郁而化热、耗伤津 液，遂成消渴。心身治疗的作用早在<灵枢 · 师传篇》已明确指出： "人之情，莫不恶死而乐生。告之以其败，语之以其善，导之以其所 变，开之以其所苦",说明自古以来，中医学已很重视心身治疗对疾 病的作用。通过心身治疗，可以消除病人对糖尿病的误解、紧张和 恐惧心理，使之正确地认识和对待自己的病情，有利于病人树立信 心、坚持长期综合治疗，达到带病延年的目的。

(一)心身疗法的主要内容 1 .精神疗法，应针对每个病人的病情和思想情况，耐心、细 致地分析病情及应注意事项，讲解有关糖尿病防治的科普知识，教 会病人自己掌握饮食疗法和运动疗法的内容，以及自我监测血糖、 尿糖，使用药物的方法，防止病人产生对糖尿病及并发症的恐惧心 理和悲观、焦虑、孤独忧郁等心理负担，帮助病人建立战胜疾病的 信心，掌握科学的治疗方法，使病人保持乐观情绪，有利于糖尿病 的恢复。 2. 气功疗法 具有心身疗法和运动疗法的双重作用，对防病 治病、健身、延年益寿有良好作用。包括静功如吐纳法、意守法和 放松法，以及动功如太极功、步行功、自发功等。 3. 其他心身疗法 音乐疗法，通过欣赏轻松愉快的音乐，使 人心情舒畅，有利于改善心理状态；矿泉水疗法，幽雅安静的治疗 环境，加上矿泉水对人体的良性刺激作用，可以活血通络，改善血 液循环，有利于防治糖尿病并发症。 (二)糖尿病教育的意义 糖尿病教育主要指对糖尿病患者及其家庭的教育。大量事实 证明，糖尿病教育是有效地治疗和预防并发症的基础。凡是接受 过糖尿病教育的患者，其病愈的时间明显缩短，控制病情的程度较 好。教育的目的是使糖尿病病人对疾病的发生发展和预后有明确 认识，然后配合医生共同采取综合措施，有效控制疾病。经过教育 的糖尿病病人，自已掌握了监测病情的方法，治疗就会及时恰当， 就会使病情得到良好控制，提高了病人的生活质量，增强控制和缓 解病情的希望和信心，使病人能够享受和健康人一样的生活乐趣， 能够和健康人一样的工作和生活，达到正常的预期寿命。 第四节中医治疗 大量临床实践证实，中医药不仅可减轻糖尿病的症状、缓解病 情，而且还可与口服降糖药和胰岛素协同治疗，减少降糖药的用 量，明显降低血糖、血脂，改善糖耐量和微循环，减轻或延缓糖尿病 并发症的发生发展。 一、中医辨证施治 一般将糖尿病辨证分型为阴虚热盛型、气阴两虚型和阴阳两 虚型，分别见于疾病的初、中、后期，并认为糖尿病慢性并发症是本 虚标实证，表现为兼有血淤证、脂淤证、糖淤证及湿浊停聚等证候 (一)阴虚热盛型 主证为口干舌燥、烦渴多饮、尿频量多，多食易饥，疲乏消瘦 大便秘结，舌红少津，脉弦数或细数。根据本型病位的不同，又口 分为以下四型辨证施治。 1.肺胃热盛型 除具有阴虚热盛型的主证外，突出表现口渴 多饮，饮一溲一的证候，舌红苔黄，脉细数。治法：清泄肺胃、生津 止渴。方药：白虎汤合二冬汤加减。生石膏30g,知母、天花粉各 15g, 天冬、麦冬、黄芩各10g, 太子参20g, 荷 叶 9g, 甘 草 5g。加减： 口渴显著者加五味子、石斛各10g,以甘酸化阴、生津止渴；倦怠乏 力、渴而汗出者，太子参改为西洋参10g,以增强益气生津止渴之 力 。 2. 胃火独盛型 有阴虚热盛型的主证，加渴喜冷饮、口舌生 疮、牙龈肿痛、口臭、舌红苔黄，脉滑数。治法：清泻胃火。方药：玉 女煎合增液汤加味。生石膏30g, 怀牛膝15g, 生地、玄参各12g, 天冬、麦冬、栀子、知母各10g, 黄 连 6g, 竹 叶 5g。加减：大便秘结 者加大黄10g,以荡涤肠胃，清热泻火；心烦失眠者加柏子仁、酸枣仁各15g,以养心安神。3.心火过旺型有阴虚热盛型主证，突出渴欲冷饮，心烦失眠，心悸怔忡，小便短赤，大便秘结，舌红苔黄，脉细数。治法：滋阴 降火，养心安神。方药：天王补心丹合三子养阴汤加减。女贞子、 沙苑子、枸杞子、五味子、天冬、麦冬、杭菊花各10g, 太子参、生地、 玄参、酸枣仁、柏子仁各15g, 黄连、竹叶、莲子心各6g。加减：心烦 躁扰不宁者加肉桂2g、黄 连 4g,以清心泻火，温补肾阳。

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4. Yin Deficiency and Yang Excess Type: Presents with the main syndrome of Yin deficiency and excessive heat, accompanied by dizziness, red face and eyes, irritability, a red tongue with yellow coating, and a wiry, rapid pulse. Treatment principle: Nourish Yin and subdue Yang. Formula: Tianma Gouteng Decoction combined with Zhibai Dihuang Tang, with modifications. Ingredients: 10g each of Tianma, Gouteng, Yujiaoteng, Huangbo, Zhimu, Zexie, Danpi, and Zhizi; 10g each of Baishao, Shengdi, and Fuling; 20g each of Shijueming and Shanyurou; and 6g of Chaihu. Modifications: For those with obvious liver Yin deficiency and severe dizziness, add 10g of Gouqizǐ to tonify the liver and nourish the kidney; for those with excessive Liver-Gallbladder fire resulting in bitter taste and red eyes, add 10g of Longdancao to clear the excess heat from the Liver and Gallbladder. (ii) Qi and Yin Deficiency Type The main symptoms include polydipsia and polyuria, emaciation and fatigue, dizziness and tinnitus, shortness of breath and spontaneous sweating, aversion to cold, a haggard appearance, impotence and premature ejaculation, menstrual irregularities in women, a pale tongue with white coating, and a deep, fine, and weak pulse. This type can further be divided into five subtypes based on different affected organs and corresponding syndromes, with tailored treatment for each:
5. Heart-Lung Deficiency Type: Presents with the main syndrome of Qi and Yin deficiency, characterized by marked fatigue, spontaneous sweating, palpitations, vexation, forgetfulness, and a red tongue with thin coating, along with a fine, rapid pulse. Treatment principle: Tonify Qi and nourish Yin, calm the heart and consolidate the lungs. Formula: Shengmai San combined with Bufei Tang, with modifications. Ingredients: 15g each of Taizishen and Huangqi; 10g each of Maidong, Wuweizi, Zhimu, and Yuanzhi; 12g each of Suanzaoren, Baiziren, and Shengdi. Modifications: For those with pronounced thirst and polydipsia, add 15g each of Shihu and Yuanshen, plus 10g of Tianhuafen, to nourish Yin, generate fluids, and quench thirst.
6. Heart-Spleen Deficiency Type: Presents with the main syndrome of Qi and Yin deficiency, accompanied by palpitations, forgetfulness, insomnia and frequent dreams, a sallow complexion, abdominal distension and loose stools, a pale tongue with thin white coating, and a fine, weak pulse. Treatment principle: Tonify the heart and spleen. Formula: Guipi Tang with modifications: 20g of Huangqi, 15g of Dangshen, 12g each of Yunling, Shengdi, Yuanshou, and Chaozaoren, 10g each of Baizhu and Maidong, and 5g of Muxiang. Modifications: For those with insufficient heart Yin and excessive heart fire leading to oral ulcers, add 10g of Zhuye and 6g of Huanglian to clear the heart fire; for those with spleen deficiency and poor appetite, add 6g of Sharen and 10g of Jineijin to regulate qi and harmonize the middle jiao; for those with loose stools, add 15g of Dafupi and 20g of Chao Yiren to strengthen the spleen and promote diuresis; for those with abdominal distension, add 10g of Houpu to regulate qi and relieve fullness.
7. Heart-Kidney Deficiency Type: Presents with the main syndrome of Qi and Yin deficiency, but with prominent symptoms of restlessness and insomnia, palpitations, forgetfulness, and dizziness and tinnitus; lower back and knee soreness, frequent nocturnal urination, spermatorrhea and night sweats, a red tongue with little coating, and a fine pulse. Treatment principle: Nourish Yin and reduce fire, facilitate communication between the heart and kidneys. Formula: Huanglian A Jiao Tang combined with Jiaotai Wan, with modifications. Ingredients: 6g of Huanglian, 3g of Rougui, 9g each of Ajiao (melted) and Huangqin, 12g each of Baishao, Chaozaoren, and Baiziren, plus 2 egg yolks. Modifications: For those with upward-flaming heart fire and oral ulcers, add 10g of Zhuye and 12g of Lianqiao to clear the heart fire; for those with kidney Yin deficiency and unstable essence, leading to spermatorrhea and premature ejaculation, add 15g of Jin Yingzi and 10g of Fubanzi to astringe and consolidate essence; for those with insufficient kidney Yin and rising yang causing dizziness and vertigo, add 15g each of Shenglonggu and Shengmuli to tranquilize and subdue yang; for those with restlessness and vexation, add 10g of Jiaozhizi to clear virtual heat.
8. Heart-Liver Deficiency Type: Presents with the main syndrome of Qi and Yin deficiency, but with prominent symptoms of dizziness, palpitations, irritability, blurred vision; numbness or stiffness in the limbs, a red tongue with thin coating, and a wiry, rapid pulse. Treatment principle: Nourish the heart and calm the spirit, tonify the liver blood. Formula: Buhu Tang with modifications. Ingredients: 10g each of Danggui, Baishao, Chuanxiong, Fushen, and Maidong; 15g each of Shudi, Jixueteng, Chaozaoren, Baiziren, and Mugua. Modifications: For those with significant blood deficiency in the heart and marked palpitations, irritability, and insomnia, add 10g of Ajiao (melted), 6g of Huanglian, and 2 egg yolks to enhance blood-nourishing and calming effects; for those with insufficient liver blood and excessive liver yang manifesting as irritability and severe dizziness, add 15g each of Shenglonggu, Shengmuli, and Gouteng to tranquilize and subdue the liver yang; for those with both heart blood and heart qi deficiency and severe palpitations and shortness of breath, add 10g each of Renshen and Wuweizi to tonify heart qi, and 15g of Danshen to nourish heart blood.
9. Lung-Qi and Yin Deficiency Type: Presents with the main syndrome of Qi and Yin deficiency, accompanied by dry cough and shortness of breath, a pale complexion, dry mouth and throat, vexation in all five centers, spontaneous and night sweats, a red tongue with little fluid, and a fine, rapid pulse. Treatment principle: Tonify lung qi, nourish yin and moisten the lungs, and reduce fire. Formula: Sijunzi Tang combined with Ziyin Jianghuo Tang, with modifications. Ingredients: 15g each of Huangqi, Taizishen, and Shengdi; 10g each of Baizhu, Yunling, Baishao, Danggui, Tiandong, and Maidong; 6g each of Zhimu and Huangbo; plus 5g of Zhigancao. Modifications: For those with dry cough without phlegm, add 10g each of Kuandonghua, Ziyuan, and Xingren to moisten the lungs, stop coughing, and transform phlegm; for those with severe cough and wheezing, add 10g each of Laifuzi and Suzi to descend qi and relieve asthma; for those with excessive spontaneous sweating, add 30g of Fumai wheat to consolidate the exterior and restrain sweat.

(iii) Yin and Yang Deficiency Type

The main symptoms include dry mouth and throat, frequent nocturnal urination, aversion to cold and cold limbs, fatigue, dizziness and tinnitus, vexation in all five centers, loose stools and edema, spermatorrhea and impotence, a swollen tongue with white coating, and a fine, weak pulse. This type can further be divided into five subtypes based on different affected organs and corresponding syndromes, with tailored treatment for each:

1. Kidney Yin and Yang Deficiency Type: Presents with the main syndrome of Yin and Yang deficiency, characterized by aversion to cold and lying down, vexation in all five centers, dry mouth and throat, clear or dribbling urine, spermatorrhea and impotence, infertility or thin vaginal discharge in women, a pale tongue with white coating, and a deep, fine pulse. Treatment principle: Warmly tonify kidney yang and nourish kidney yin. Formula: Yougui Yin combined with Zhibai Dihuang Tang, with modifications. Ingredients: 15g each of Shengdi, Shudi, Shanyao, and Duzhong; 9g each of Wuyurou, Gouqizǐ, Danpi, Zhimu, and Huangbo; 6g of Zhi Fupian; and 3g of Rougui. Modifications: For those with frequent and copious urination, add 10g each of Sangpiaoshuo and Fubanzi to tonify the kidneys and reduce urination; for those with premature ejaculation, add 15g of Jin Yingzi and 10g of Qianshi to astringe and consolidate essence; for those with impotence, add 10g each of Yangqishi, Xianmao, and Xianlingpi to warm the kidneys and boost yang.

2. Spleen-Kidney Yang Deficiency Type: Presents with the main syndrome of Yin and Yang deficiency, characterized by aversion to cold and a pale complexion, fatigue, lower back and knee soreness, frequent urination, residual dribbling, facial edema and limb swelling, diarrhea or watery stools at dawn, a pale and swollen tongue, and a deep, weak pulse. Treatment principle: Warmly tonify the spleen and kidneys. Formula: For those with edema as the main symptom, use Shibi Yin with modifications; for those with diarrhea as the main symptom, use Sishen Wan combined with Fuzi Lizhong Tang with modifications. Shibi Yin with modifications: 12g each of Baizhu, Yunling, Zhuling, and Taiwuyao; 9g each of Mugua, Dafupi, Houpu, Ginger, and Gui Zhi; 6g each of Ganjiang and Zhi Fupian; plus 6 dates. Sishen Wan combined with Fuzi Lizhong Tang with modifications: 10g each of Dangshen, Yunling, and Buguzhi; 6g each of Rou Doukou, Zhi Fupian, Wuweizi, and Gan

38 Integrated Chinese and Western Medicine Treatment for Diabetes