針刺治療疼痛現(xiàn)狀及對(duì)策

1、首都醫(yī)科大學(xué)附屬北京中醫(yī)醫(yī)院 王麟鵬,針刺治療疼痛現(xiàn)狀及對(duì)策,疼痛是神經(jīng)系統(tǒng)被激發(fā)的一種感覺和情緒上的感受，是主觀性的。 疼痛性質(zhì)：尖銳的或鈍性的，疼痛時(shí)間：發(fā)作的或持續(xù)的，疼痛部位：局部或全身的（流感）。 有時(shí)疼痛的好處可提醒我們防止疾病的損害，慢性疼痛常是人體慢性疾病的損害。但持續(xù)周、月、年的疼痛會(huì)造成痛苦，長期疼痛?？墒共∪送床挥?。劇烈的疼痛可引發(fā)休克等一系列機(jī)體功能變化而成為 致病、致殘、

2、致死的原因 。,,針灸中心,針灸治療疼痛的現(xiàn)狀既有在全球的廣泛應(yīng)用，卻又被認(rèn)為存在很多問題。如何能進(jìn)行更深入的研究以使對(duì)針刺治痛有更準(zhǔn)確的認(rèn)識(shí)呢？主要問題是什么,It is concluded that there is good evidence from controlled studies for the short-term effectiveness of acupuncture in relieving cl

3、inical pain. The extent of therapeutic effects produced has varied from study to study, but the proportion of patients helped has commonly fallen in the 50–80% range.

4、 Pain, Vol 24(1), Jan 1986, 15-40. doi,1、應(yīng)用廣泛，方法眾多但缺少規(guī)范與指南。 2007年美國NIH調(diào)查有1.4%(310萬)近期接受過CAM，7/10與疼痛相關(guān)。美國的另一項(xiàng)全國性調(diào)查發(fā)現(xiàn)，超過三分之一的美國成年人中有四分之一最近經(jīng)歷了那種持續(xù)超過一天的疼痛痛苦。除了傳統(tǒng)的治療，如過度的非處方和處方藥，人們可能會(huì)嘗試針灸，以努力減輕疼痛。 中國沒有接受針刺治療人數(shù)的數(shù)據(jù)

5、，但假針作為placebo在國內(nèi)的clinic trial 中無法使用就是針刺具有深厚背景的證明。,全球的針刺治痛方法包括了針刺、灸法、電針、火針、皮膚針、放血、腹針、TENs、針刀等針具和各種各樣的刺法。但是，針刺方法一直缺少臨床的規(guī)范與指南，各種經(jīng)驗(yàn)性治療層出不窮，雖有助于充滿活力，但卻會(huì)因大量的難于總結(jié)的重復(fù)性使用而不利于整體水平的提高。,Acupuncture has been studied for a wide range

6、of pain conditions, such as postoperative dental pain（包括其他多種術(shù)后痛）, carpal tunnel syndrome, fibromyalgia, headache, low-back pain, menstrual cramps, myofascial pain, osteoarthritis, and tennis elbow.,2、大量的臨床研究和系統(tǒng)評(píng)價(jià)在針刺治療痛證方

7、面得出的結(jié)論具有共性。如文獻(xiàn)質(zhì)量低，設(shè)計(jì)水平低，難于科學(xué)評(píng)價(jià)其作用，于對(duì)照方法相比，難于得出針刺有效地結(jié)論。Overall, it can be very difficult to compare acupuncture research results from study to study and to draw conclusions from the cumulative body of evidence. and outc

8、ome measures.,這種研究的結(jié)論主要是從現(xiàn)代醫(yī)學(xué)臨床研究方法學(xué)角度得出的結(jié)論。已經(jīng)表達(dá)了多年，也有方法學(xué)研究的學(xué)者不斷在呼吁讓針灸臨床研究者提高研究質(zhì)量。但收效甚微。 主要問題是我們很多人在具體的臨床研究中不善于總結(jié)文獻(xiàn)，對(duì)具體的項(xiàng)目設(shè)計(jì)存在問題。下面就舉具體的例子以說明,一、肩周炎Acupuncture for shoulder pain (Review) Sally Green1, Rachelle Buchbind

9、er2, Sarah E Hetrick3 Australia Authors’ conclusionsDue to a small number of clinical and methodologically diverse trials, little can be concluded from this review. There is little evidence to support or refute the us

10、e of acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function. There is a need for further well designed clinical trials.,What causes shoulder pain診斷問題and how can acupunctu

11、re help? Shoulder pain can be caused by a number of different conditions. It can be caused by rotator cuff disease（肩袖）, periarthritis（肩周炎） or adhesive capsulitis（關(guān)節(jié)囊粘連） (frozen shoulder). Shoulder pain can sometimes go

12、 away on its own but may last up to 12 to 18 months（自愈）. Drug and non-drug treatments are used to relieve pain and/or swelling.（治療目的是減少疼痛和水腫）,Acupuncture is a non-drug therapy being used more and more to treat shoulder p

13、ain. It is thought that acupuncture works either by releasing chemical compounds in the body that relieve pain, by overriding pain signals in the nerves or by allowing energy (Qi) or blood to flow freely through the body

14、. It is not known whether acupuncture works,Does acupuncture work for treating shoulder pain?評(píng)價(jià)To answer this question, scientists found and analyzed 9 research studies. The studies tested over 500 people who had should

15、er pain. People had either acupuncture, a placebo (fake therapy), ultrasound, gentle movement or exercises usually for 20-30 minutes, two to three times a week for 3 to 6 weeks. (治療時(shí)間)Even though the studies were small a

16、nd not of the highest quality, this Cochrane review provides the best evidence we have today.,How well does acupuncture work?The improvements with acupuncture for pain and function were about the same as the effects of

17、receiving a fake （安慰法）therapy for 2 to 4 weeks. One study showed that acupuncture improved shoulder function more than fake therapy after 4weeks.But after 4months, improvements were about the same with only an improve

18、ment of 4 more points on a scale of 0 to 100 with acupuncture. One small study showed that acupuncture plus exercise was better than just exercise for improving pain, range of motion and function for up to 5 months.,中國的研

19、究1 中國針灸，2008 目的:科學(xué)評(píng)價(jià)使用一次性×針的有效性及安全性。方法:將60例肩周炎患者隨機(jī)分為×針組和常規(guī)針組,×針組采用特制的×針針具治療,常規(guī)針組采用直徑0.38mm、長40mm的一次性針灸針治療,對(duì)比治療前后患者最受限方位的關(guān)節(jié)活動(dòng)度、肩關(guān)節(jié)活動(dòng)中軟組織疼痛自評(píng)分及肩部壓痛自評(píng)分,以及2組患者分別在治療進(jìn)針、掃散、留針過程中發(fā)生刺痛的次數(shù)、出針時(shí)出血情況等不適情況。結(jié)果:活

20、動(dòng)相關(guān)性疼痛、壓痛、最受限方位的關(guān)節(jié)活動(dòng)程度的改善均為×針組優(yōu)于常規(guī)針組,提示×針組的即刻療效明顯優(yōu)于常規(guī)針組;進(jìn)針過程中的刺痛次數(shù)×針組少于常規(guī)針組,留針時(shí)的刺痛次數(shù)以及出針時(shí)出血次數(shù),2組差別無統(tǒng)計(jì)學(xué)意義。結(jié)論:從本試驗(yàn)看,在×針療法中使用一次性×針比常規(guī)針灸針更為有效、更為安全。,分析：診斷、治療時(shí)間、評(píng)價(jià)方法、對(duì)照組設(shè)計(jì)均存在問題,中國的研究2 中國針灸，2008目的:探尋

21、治療急性肩關(guān)節(jié)周圍軟組織損傷的有效方法。方法:將120例患者隨機(jī)分為觀察組、對(duì)照組1、對(duì)照組2。觀察組采用運(yùn)動(dòng)針、電針加TDP治療,穴取肩髃、肩髎、肩貞等穴;對(duì)照組1采用電針加TDP,穴同觀察組;對(duì)照組2口服布洛芬緩釋膠囊(芬必得)。通過疼痛視覺模擬評(píng)分(VAS)對(duì)患者首次治療后、1個(gè)療程后及1個(gè)月后隨訪情況進(jìn)行評(píng)價(jià)及比較。結(jié)果:觀察組總有效率100.0%、愈顯率95.0%優(yōu)于對(duì)照組1的90.0%、75.0%和對(duì)照組2的70.0%、

22、45.0%(P<0.01或P<0.05);觀察組治療1次后、1個(gè)療程后、治療后1個(gè)月隨訪VAS評(píng)分均明顯低于2個(gè)對(duì)照組(P<0.05)。結(jié)論:運(yùn)動(dòng)針、電針加TDP綜合療法是治療急性肩關(guān)節(jié)周圍軟組織損傷的良好康復(fù)方法。,分析：診斷、治療時(shí)間、評(píng)價(jià)方法、對(duì)照組設(shè)計(jì)均存在問題,二、下腰痛Acupuncture and dry-needling for low back pain (Review) Andrea D Fur

23、lan1, Maurits W van Tulder2, Dan Cherkin3, Hiroshi Tsukayama4 , Lixing Lao5, Bart W Koes6, Brian M Berman5Selection criteriaRandomized trials of acupuncture (that involves needling) for adults with non-specific (sub)ac

24、ute or chronic low-back pain, or dry needling for myofascial pain syndrome in the low-back region.（診斷）Authors’ conclusionsThe data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back

25、 pain. For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not mo

26、re effective than other conventional and “alternative” treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain. Because most of the studies were

27、of lower methodological quality, there certainly is a further need for higher quality trials in this area.,Types of outcome measuresRCTs were included that used at least one of the four outcome measures considered to be

28、 important in the field of low-back pain: pain intensity (e.g., visual analog scale (VAS)), a global measure (e.g., overall improvement, proportion of patients recovered, subjective improvement of symptoms), back specifi

29、c functional status (e.g., Roland Disability Scale, Oswestry Scale) and return to work (e.g., return to work status, number of days off work).,The primary outcomes for this review were pain and functional status. Physiol

30、ogical outcomes of physical examination (e.g., range of motion, spinal flexibility, degrees of straight leg raising or muscle strength), generic health status (e.g., SF-36, Nottingham Health Profile, Sickness Impact Prof

31、ile) and other symptoms, such as medication use and side effects were considered secondary outcomes.,中國的研究 中國康復(fù)醫(yī)學(xué)雜志2004目的:觀察小針刀治療對(duì)慢性下腰痛患者腰屈曲活動(dòng)度和生存質(zhì)量的影響。方法:將265例下腰痛患者隨機(jī)分為兩組,Ⅰ組為對(duì)照組(132例),采用超短波、調(diào)制中頻電、推拿及功能訓(xùn)練治療。Ⅱ組為針刀組(133

32、例),采用小針刀,輔以封閉和功能訓(xùn)練,兩組治療前后均測量腰屈曲活動(dòng)度,并采用改良的Oswestry腰痛問卷進(jìn)行評(píng)分,以評(píng)定生存質(zhì)量。結(jié)果:針刀組患者治療后腰屈曲活動(dòng)度明顯改善且Oswestry腰痛問卷評(píng)分分值明顯下降,與對(duì)照組比較,差異均有顯著性意義(P<0.01)。兩組患者隨訪6—48個(gè)月,平均隨訪10.85±5.74個(gè)月,針刀組療效穩(wěn)定,與對(duì)照組比較,差異有顯著性意義(P<0.01)。結(jié)論:小針刀治療可明顯

33、改善慢性下腰痛患者腰屈曲活動(dòng)度及生存質(zhì)量,且遠(yuǎn)期療效穩(wěn)定。,國內(nèi)綜述：下腰痛的中西醫(yī)結(jié)合治療-中國臨床康復(fù)2006 下腰痛已是現(xiàn)代社會(huì)最常見的、花費(fèi)最多的肌肉骨骼疼痛綜合征。因其病因復(fù)雜, 治療方法雖多, 但并無特效方法, 且有治療顯效慢、易復(fù)發(fā)的特點(diǎn), 嚴(yán)重影響了患者的生活和工作。目前有關(guān)本病的機(jī)制、診斷標(biāo)準(zhǔn)、治療方法仍不完善, 尚需進(jìn)一步研究, 本文應(yīng)用計(jì)算機(jī)檢索萬方數(shù)據(jù)庫2001- 06 /2006- 07 及Ovid 2

34、001- 06 /2006- 07 有關(guān)下腰痛臨床治療方面的文獻(xiàn), 主要對(duì)其臨床治療方法的研究進(jìn)展進(jìn)行回顧。,原發(fā)性痛經(jīng)Acupuncture for primary dysmenorrhoea (Review) Caroline A Smith1, Xiaoshu Zhu2, Lin He3, Jing Song4Inclusion criteriaWomen needed to meet the following crite

35、ria to be included in the review:? primary dysmenorrhoea, i.e. no identifiable pelvic pathology as indicated by pelvic examination, ultrasound scans, or laparoscopy;? primary dysmenorrhoea (self-reported pain) during t

36、hemajority of the menstrual cycles or for three consecutive menstrual cycles;? moderate to severe primary dysmenorrhoea (pain that does not respond well to analgesics, affects daily activities, or has a high baseline s

37、core on a validated pain scale).Authors’ conclusionsAcupuncture may reduce period pain, however there is a need for further well-designed randomised controlled trials,Primary outcomes1. Pain relief measured by a visua

38、l analogue scale (VAS) or othervalidated scales, or measured as dichotomous outcomes (i.e. painrelief: yes or no).Secondary outcomes1. Overall improvement in generic menstrual-related symptoms(e.g. nausea, tiredness

39、) measured by changes in overall dysmenorrhoeicsymptoms that were either self reported or investigatorobserved, or any other similar measures.2. Reported use of additional medication measured as the proportionof wome

40、n requiring analgesics.3. Restriction of daily life activities measured as the proportion ofwomen who reported activity restrictions.4. Absence from work or school measured as the proportion ofwomen reporting absence

41、s from work or school, and also as hoursand days of absence as a more selective measure.5. Quality of life measured by a validated scale, for example theShort Form (SF) 36.6. Adverse effects from treatment measured a

42、s incidence of sideeffects and types of side effects.,Outcome: pain reliefData was presented for short-term outcomes at three monthsAuthors’ conclusionsFuture studies may need to consider the use of both effectivenes

43、scomparative designs using medication, for example NSAIDs or other forms of standard care, and efficacy designs using placebo controls. Future studies should also give consideration to including long-term evaluation of