针刺治疗疼痛现状及对策

首都医科大学附属北京中医医院 王麟鹏,针刺治疗疼痛现状及对策,疼痛是神经系统被激发的一种感觉和情绪上的感受，是主观性的。 疼痛性质：尖锐的或钝性的，疼痛时间：发作的或持续的，疼痛部位：局部或全身的（流感）。 有时疼痛的好处可提醒我们防止疾病的损害，慢性疼痛常是人体慢性疾病的损害。但持续周、月、年的疼痛会造成痛苦，长期疼痛常可使病人痛不欲生。剧烈的疼痛可引发休克等一系列机体功能变化而成为致病、致残、致死的原因。,针灸中心,针灸治疗疼痛的现状既有在全球的广泛应用，却又被认为存在很多问题。如何能进行更深入的研究以使对针刺治痛有更准确的认识呢？主要问题是什么,It is concluded that there is good evidence from controlled studies for the short-term effectiveness of acupuncture in relieving clinical pain. The extent of therapeutic effects produced has varied from study to study, but the proportion of patients helped has commonly fallen in the 5080% range. Pain, Vol 24(1), Jan 1986, 15-40. doi,1、应用广泛，方法众多但缺少规范与指南。 2007年美国NIH调查有1.4%(310万)近期接受过CAM，7/10与疼痛相关。美国的另一项全国性调查发现，超过三分之一的美国成年人中有四分之一最近经历了那种持续超过一天的疼痛痛苦。除了传统的治疗，如过度的非处方和处方药，人们可能会尝试针灸，以努力减轻疼痛。 中国没有接受针刺治疗人数的数据，但假针作为placebo在国内的clinic trial 中无法使用就是针刺具有深厚背景的证明。,全球的针刺治痛方法包括了针刺、灸法、电针、火针、皮肤针、放血、腹针、TENs、针刀等针具和各种各样的刺法。但是，针刺方法一直缺少临床的规范与指南，各种经验性治疗层出不穷，虽有助于充满活力，但却会因大量的难于总结的重复性使用而不利于整体水平的提高。,Acupuncture has been studied for a wide range of pain conditions, such as postoperative dental pain（包括其他多种术后痛）, carpal tunnel syndrome, fibromyalgia, headache, low-back pain, menstrual cramps, myofascial pain, osteoarthritis, and tennis elbow.,2、大量的临床研究和系统评价在针刺治疗痛证方面得出的结论具有共性。如文献质量低，设计水平低，难于科学评价其作用，于对照方法相比，难于得出针刺有效地结论。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 outcome measures.,这种研究的结论主要是从现代医学临床研究方法学角度得出的结论。已经表达了多年，也有方法学研究的学者不断在呼吁让针灸临床研究者提高研究质量。但收效甚微。 主要问题是我们很多人在具体的临床研究中不善于总结文献，对具体的项目设计存在问题。下面就举具体的例子以说明,一、肩周炎Acupuncture for shoulder pain (Review) Sally Green1, Rachelle Buchbinder2, 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 use 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诊断问题and how can acupuncture 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（关节囊粘连） (frozen shoulder). Shoulder pain can sometimes go 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.（治疗目的是减少疼痛和水肿）,Acupuncture is a non-drug therapy being used more and more to treat shoulder pain. 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. It is not known whether acupuncture works,Does acupuncture work for treating shoulder pain?评价To answer this question, scientists found and analyzed 9 research studies. The studies tested over 500 people who had shoulder 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. (治疗时间)Even though the studies were small and 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 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 improvement 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.,中国的研究1 中国针灸，2008 目的:科学评价使用一次性针的有效性及安全性。方法:将60例肩周炎患者随机分为针组和常规针组,针组采用特制的针针具治疗,常规针组采用直径0.38mm、长40mm的一次性针灸针治疗,对比治疗前后患者最受限方位的关节活动度、肩关节活动中软组织疼痛自评分及肩部压痛自评分,以及2组患者分别在治疗进针、扫散、留针过程中发生刺痛的次数、出针时出血情况等不适情况。结果:活动相关性疼痛、压痛、最受限方位的关节活动程度的改善均为针组优于常规针组,提示针组的即刻疗效明显优于常规针组;进针过程中的刺痛次数针组少于常规针组,留针时的刺痛次数以及出针时出血次数,2组差别无统计学意义。结论:从本试验看,在针疗法中使用一次性针比常规针灸针更为有效、更为安全。,分析：诊断、治疗时间、评价方法、对照组设计均存在问题,中国的研究2 中国针灸，2008目的:探寻治疗急性肩关节周围软组织损伤的有效方法。方法:将120例患者随机分为观察组、对照组1、对照组2。观察组采用运动针、电针加TDP治疗,穴取肩髃、肩髎、肩贞等穴;对照组1采用电针加TDP,穴同观察组;对照组2口服布洛芬缓释胶囊(芬必得)。通过疼痛视觉模拟评分(VAS)对患者首次治疗后、1个疗程后及1个月后随访情况进行评价及比较。结果:观察组总有效率100.0%、愈显率95.0%优于对照组1的90.0%、75.0%和对照组2的70.0%、45.0%(P0.01或P0.05);观察组治疗1次后、1个疗程后、治疗后1个月随访VAS评分均明显低于2个对照组(P0.05)。结论:运动针、电针加TDP综合疗法是治疗急性肩关节周围软组织损伤的良好康复方法。,分析：诊断、治疗时间、评价方法、对照组设计均存在问题,二、下腰痛Acupuncture and dry-needling for low back pain (Review) Andrea D Furlan1, 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)acute or chronic low-back pain, or dry needling for myofascial pain syndrome in the low-back region.（诊断）Authors conclusionsThe data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back 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 more 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 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 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 specific 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. Physiological 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 Profile) and other symptoms, such as medication use and side effects were considered secondary outcomes.,中国的研究 中国康复医学杂志2004目的:观察小针刀治疗对慢性下腰痛患者腰屈曲活动度和生存质量的影响。方法:将265例下腰痛患者随机分为两组,组为对照组(132例),采用超短波、调制中频电、推拿及功能训练治疗。组为针刀组(133例),采用小针刀,辅以封闭和功能训练,两组治疗前后均测量腰屈曲活动度,并采用改良的Oswestry腰痛问卷进行评分,以评定生存质量。结果:针刀组患者治疗后腰屈曲活动度明显改善且Oswestry腰痛问卷评分分值明显下降,与对照组比较,差异均有显著性意义(P0.01)。两组患者随访648个月,平均随访10.855.74个月,针刀组疗效稳定,与对照组比较,差异有显著性意义(P0.01)。结论:小针刀治疗可明显改善慢性下腰痛患者腰屈曲活动度及生存质量,且远期疗效稳定。,国内综述：下腰痛的中西医结合治疗-中国临床康复2006 下腰痛已是现代社会最常见的、花费最多的肌肉骨骼疼痛综合征。因其病因复杂, 治疗方法虽多, 但并无特效方法, 且有治疗显效慢、易复发的特点, 严重影响了患者的生活和工作。目前有关本病的机制、诊断标准、治疗方法仍不完善, 尚需进一步研究, 本文应用计算机检索万方数据库2001- 06 /2006- 07 及Ovid 2001- 06 /2006- 07 有关下腰痛临床治疗方面的文献, 主要对其临床治疗方法的研究进展进行回顾。,原发性痛经Acupuncture for primary dysmenorrhoea (Review) Caroline A Smith1, Xiaoshu Zhu2, Lin He3, Jing Song4Inclusion criteriaWomen needed to meet the following criteria 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 themajority 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 score 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 visual 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) 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 women requiring analgesic