針刺治療疼痛現狀及對策課件

首都醫(yī)科大學附屬北京中醫(yī)醫(yī)院王麟鵬針刺治療疼痛現狀及對策疼痛是神經系統(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：鋒利的或鈍性的，疼痛時間：發(fā)作的或持續(xù)的，疼痛部位：局部或全身的〔流感〕。有時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)休克等一系列機體功能變化而成為

致病、致殘、致死的原因

。針灸中心針灸治療疼痛的現狀既有在全球的廣泛應用，卻又被認為存在很多問題。如何能進行更深入的研究以使對針刺治痛有更準確的認識呢？主要問題是什么Itisconcludedthatthereisgoodevidencefromcontrolledstudiesfortheshort-termeffectivenessofacupunctureinrelievingclinicalpain.Theextentoftherapeuticeffectsproducedhasvariedfromstudytostudy,buttheproportionofpatientshelpedhascommonlyfalleninthe50–80%range.Pain,Vol24(1),Jan1986,15-40.doi

1、應用廣泛，方法眾多但缺少標準與指南。

2007年美國NIH調查有1.4%(310萬)近期接受過CAM，7/10與疼痛相關。美國的另一項全國性調查發(fā)現，超過三分之一的美國成年人中有四分之一最近經歷了那種持續(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，人們可能會嘗試針灸，以努力減輕疼痛。

中國沒有接受針刺治療人數的數據，但假針作為placebo在國內的clinictrial中無法使用就是針刺具有深厚背景的證明。2、大量的臨床研究和系統(tǒng)評價在針刺治療痛證方面得出的結論具有共性。如文獻質量低，設計水平低，難于科學評價其作用，于對照方法相比，難于得出針刺有效地結論。Overall,itcanbeverydifficulttocompareacupunctureresearchresultsfromstudytostudyandtodrawconclusionsfromthecumulativebodyofevidence.andoutcomemeasures.這種研究的結論主要是從現代醫(yī)學臨床研究方法學角度得出的結論。已經表達了多年，也有方法學研究的學者不斷在呼吁讓針灸臨床研究者提高研究質量。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文獻，對具體的工程設計存在問題。下面就舉具體的例子以說明一、肩周炎Acupunctureforshoulderpain(Review)

SallyGreen1,RachelleBuchbinder2,SarahEHetrick3Australia

Authors’conclusionsDuetoasmallnumberofclinicalandmethodologicallydiversetrials,littlecanbeconcludedfromthisreview.Thereislittleevidencetosupportorrefutetheuseofacupunctureforshoulderpainalthoughtheremaybeshort-termbenefitwithrespecttopainandfunction.Thereisaneedforfurtherwelldesignedclinicaltrials.Whatcausesshoulderpain診斷問題andhowcanacupuncturehelp?Shoulderpaincanbecausedbyanumberofdifferentconditions.Itcanbecausedbyrotatorcuffdisease〔肩袖〕,periarthritis〔肩周炎〕oradhesivecapsulitis〔關節(jié)囊粘連〕(frozenshoulder).Shoulderpaincansometimesgoawayonitsownbutmaylastupto12to18months〔自愈〕.Drugandnon-drugtreatmentsareusedtorelievepainand/orswelling.〔治療目的是減少疼痛和水腫〕Acupunctureisanon-drugtherapybeingusedmoreandmoretotreatshoulderpain.Itisthoughtthatacupunctureworkseitherbyreleasingchemicalcompoundsinthebodythatrelievepain,byoverridingpainsignalsinthenervesorbyallowingenergy(Qi)orbloodtoflowfreelythroughthebody.Itisnotknownwhetheracupunctureworks

Doesacupunctureworkfortreatingshoulderpain?評價Toanswerthisquestion,scientistsfoundandanalyzed9researchstudies.Thestudiestestedover500peoplewhohadshoulderpain.Peoplehadeitheracupuncture,aplacebo(faketherapy),ultrasound,gentlemovementorexercisesusuallyfor20-30minutes,twotothreetimesaweekfor3to6weeks.(治療時間)Eventhoughthestudiesweresmallandnotofthehighestquality,thisCochranereviewprovidesthebestevidencewehavetoday.Howwelldoesacupuncturework?Theimprovementswithacupunctureforpainandfunctionwereaboutthesameastheeffectsofreceivingafake〔撫慰法〕therapyfor2to4weeks.Onestudyshowedthatacupunctureimprovedshoulderfunctionmorethanfaketherapyafter4weeks.Butafter4months,improvementswereaboutthesamewithonlyanimprovementof4morepointsonascaleof0to100withacupuncture.Onesmallstudyshowedthatacupunctureplusexercisewasbetterthanjustexerciseforimprovingpain,rangeofmotionandfunctionforupto5months.中國的研究1中國針灸，2021目的:科學評價使用一次性×針的有效性及平安性。方法:將60例肩周炎患者隨機分為×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,比照治療前后患者最受限方位的關節(jié)活動度、肩關節(jié)活動中軟組織疼痛自評分及肩部壓痛自評分,以及2組患者分別在治療進針、掃散、留針過程中發(fā)生刺痛的次數、出針時出血情況等不適情況。結果:活動相關性疼痛、壓痛、最受限方位的關節(jié)活動程度的改善均為×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;進針過程中的刺痛次數×針組少于常規(guī)針組,留針時的刺痛次數以及出針時出血次數,2組差異無統(tǒng)計學意義。結論:從本試驗看,在×針療法中使用一次性×針比常規(guī)針灸針更為有效、更為平安。分析：診斷、治療時間、評價方法、對照組設計均存在問題中國的研究2中國針灸，2021目的:探尋治療急性肩關節(jié)周圍軟組織損傷的有效方法。方法:將120例患者隨機分為觀察組、對照組1、對照組2。觀察組采用運動針、電針加TDP治療,穴取肩髃、肩髎、肩貞等穴;對照組1采用電針加TDP,穴同觀察組;對照組2口服布洛芬緩釋膠囊(芬必得)。通過疼痛視覺模擬評分(VAS)對患者首次治療后、1個療程后及1個月后隨訪情況進行評價及比較。結果:觀察組總有效率100.0%、愈顯率95.0%優(yōu)于對照組1的90.0%、75.0%和對照組2的70.0%、45.0%(P<0.01或P<0.05);觀察組治療1次后、1個療程后、治療后1個月隨訪VAS評分均明顯低于2個對照組(P<0.05)。結論:運動針、電針加TDP綜合療法是治療急性肩關節(jié)周圍軟組織損傷的良好康復方法。分析：診斷、治療時間、評價方法、對照組設計均存在問題二、下腰痛Acupunctureanddry-needlingforlowbackpain(Review)AndreaDFurlan1,MauritsWvanTulder2,DanCherkin3,HiroshiTsukayama4,LixingLao5,BartWKoes6,BrianMBerman5SelectioncriteriaRandomizedtrialsofacupuncture(thatinvolvesneedling)foradultswithnon-specific(sub)acuteorchroniclow-backpain,ordryneedlingformyofascialpainsyndromeinthelow-backregion.〔診斷〕Authors’conclusionsThedatadonotallowfirmconclusionsabouttheeffectivenessofacupunctureforacutelow-backpain.Forchroniclow-backpain,acupunctureismoreeffectiveforpainreliefandfunctionalimprovementthannotreatmentorshamtreatmentimmediatelyaftertreatmentandintheshort-termonly.Acupunctureisnotmoreeffectivethanotherconventionaland“alternative〞treatments.Thedatasuggestthatacupunctureanddry-needlingmaybeusefuladjunctstoothertherapiesforchroniclow-backpain.Becausemostofthestudieswereoflowermethodologicalquality,therecertainlyisafurtherneedforhigherqualitytrialsinthisarea.TypesofoutcomemeasuresRCTswereincludedthatusedatleastoneofthefouroutcomemeasuresconsideredtobeimportantinthefieldoflow-backpain:painintensity(e.g.,visualanalogscale(VAS)),aglobalmeasure(e.g.,overallimprovement,proportionofpatientsrecovered,subjectiveimprovementofsymptoms),backspecificfunctionalstatus(e.g.,RolandDisabilityScale,OswestryScale)andreturntowork(e.g.,returntoworkstatus,numberofdaysoffwork).Theprimaryoutcomesforthisreviewwerepainandfunctionalstatus.Physiologicaloutcomesofphysicalexamination(e.g.,rangeofmotion,spinalflexibility,degreesofstraightlegraisingormusclestrength),generichealthstatus(e.g.,SF-36,NottinghamHealthProfile,SicknessImpactProfile)andothersymptoms,suchasmedicationuseandsideeffectswereconsideredsecondaryoutcomes.中國的研究中國康復醫(yī)學雜志2004目的:觀察小針刀治療對慢性下腰痛患者腰屈曲活動度和生存質量的影響。方法:將265例下腰痛患者隨機分為兩組,Ⅰ組為對照組(132例),采用超短波、調制中頻電、推拿及功能訓練治療。Ⅱ組為針刀組(133例),采用小針刀,輔以封閉和功能訓練,兩組治療前后均測量腰屈曲活動度,并采用改進的Oswestry腰痛問卷進行評分,以評定生存質量。結果:針刀組患者治療后腰屈曲活動度明顯改善且Oswestry腰痛問卷評分分值明顯下降,與對照組比較,差異均有顯著性意義(P<0.01)。兩組患者隨訪6—48個月,平均隨訪10.85±5.74個月,針刀組療效穩(wěn)定,與對照組比較,差異有顯著性意義(P<0.01)。結論:小針刀治療可明顯改善慢性下腰痛患者腰屈曲活動度及生存質量,且遠期療效穩(wěn)定。原發(fā)性痛經Acupunctureforprimarydysmenorrhoea(Review)CarolineASmith1,XiaoshuZhu2,LinHe3,JingSong4InclusioncriteriaWomenneededtomeetthefollowingcriteriatobeincludedinthereview:?primarydysmenorrhoea,i.e.noidentifiablepelvicpathologyasindicatedbypelvicexamination,ultrasoundscans,orlaparoscopy;?primarydysmenorrhoea(self-reportedpain)duringthemajorityofthemenstrualcyclesorforthreeconsecutivemenstrualcycles;?moderatetosevereprimarydysmenorrhoea(painthatdoesnotrespondwelltoanalgesics,affectsdailyactivities,orhasahighbaselinescoreonavalidatedpainscale).Authors’conclusionsAcupuncturemayreduceperiodpain,howeverthereisaneedforfurtherwell-designedrandomisedcontrolledtrialsPrimaryoutcomes1.Painreliefmeasuredbyavisualanaloguescale(VAS)orothervalidatedscales,ormeasuredasdichotomousoutcomes(i.e.painrelief:yesorno).Secondaryoutcomes1.Overallimprovementingenericmenstrual-relatedsymptoms(e.g.nausea,tiredness)measuredbychangesinoveralldysmenorrhoeicsymptomsthatwereeitherselfreportedorinvestigatorobserved,oranyothersimilarmeasures.2.Reporteduseofadditionalmedicationmeasuredastheproportionofwomenrequiringanalgesics.3.Restrictionofdailylifeactivitiesmeasuredasth