针刺治疗疼痛现状及对策.pptx

首都医科大学附属北京中医医院首都医科大学附属北京中医医院 王麟鹏王麟鹏针刺治疗疼痛现状及对策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。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）。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，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列机体功能变化而成为致病、致残、致死的原因致病、致残、致死的原因。针灸中心针灸中心针灸治疗疼痛的现状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。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？识呢？主要问题是什么主要问题是什么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 1、应用广泛，方法众多但缺少规范与指南。、应用广泛，方法众多但缺少规范与指南。20072007年美国年美国NIHNIH调查有调查有1.4%(3101.4%(310万万)近期接受过近期接受过CAMCAM，7/107/10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。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，但假针作为中国没有接受针刺治疗人数的数据，但假针作为placeboplacebo在国内的在国内的clinic trial clinic trial 中无法使用就是针刺具有深厚背景的中无法使用就是针刺具有深厚背景的证明。证明。全球的针刺治痛方法包括了针刺、灸法、电针、火针、皮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、肤针、放血、腹针、TENsTENs、针刀等针具和各种各样的刺法。、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。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 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、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。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 Overall,it can be very difficult to compare acupuncture research results from study to study and acupuncture research results from study to study and to draw conclusions from the cumulative body of to draw conclusions from the cumulative body of evidence.and outcome measures.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。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说明一、肩周炎一、肩周炎Acupuncture for shoulder pain(Review)Acupuncture for shoulder pain(Review)Sally Green1,Rachelle Buchbinder2,Sarah E Hetrick3 AustraliaSally Green1,Rachelle Buchbinder2,Sarah E Hetrick3 Australia AuthorsAuthors conclusions conclusionsDue to a small number of clinical and methodologically Due to a small number of clinical and methodologically diverse trials,little can be concluded from this review.diverse trials,little can be concluded from this review.There is little evidence to support or refute the use of There is little evidence to support or refute the use of acupuncture for shoulder pain although there may be short-acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function.There is a term benefit with respect to pain and function.There is a need for further well designed clinical trials.need for further well designed clinical trials.What causes shoulder pain诊断问题诊断问题and how can acupuncture help?Shoulder pain can be caused by a number of different Shoulder pain can be caused by a number of different conditions.It can be caused by rotator cuff diseaseconditions.It can be caused by rotator cuff disease（肩袖）（肩袖）,periarthritis,periarthritis（肩周炎）（肩周炎）or adhesive capsulitisor adhesive capsulitis（关节囊粘（关节囊粘连）连）(frozen shoulder).(frozen shoulder).Shoulder pain can sometimes go away on its own but may Shoulder pain can sometimes go away on its own but may last up to 12 to 18 monthslast up to 12 to 18 months（自愈）（自愈）.Drug and non-drug.Drug and non-drug treatments are used to relieve pain and/or swelling.treatments are used to relieve pain and/or swelling.（治疗（治疗目的是减少疼痛和水肿）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?评价评价To answer this question,scientists found and analyzed 9 To answer this question,scientists found and analyzed 9 research studies.The studies tested over 500 people who had research studies.The studies tested over 500 people who had shoulder pain.People had either acupuncture,a placebo(fake shoulder pain.People had either acupuncture,a placebo(fake therapy),ultrasound,gentle movement or exercises usually for therapy),ultrasound,gentle movement or exercises usually for 20-30 minutes,two to three times a week for 3 to 6 weeks.(20-30 minutes,two to three times a week for 3 to 6 weeks.(治治疗时间疗时间)Even though the studies were small and not of the)Even though the studies were small and not of the highest quality,this Cochrane review provides the best highest quality,this Cochrane review provides the best evidence we have today.evidence we have today.How well does acupuncture work?The improvements with acupuncture for pain and function were The improvements with acupuncture for pain and function were about the same as the effects of receiving a fake about the same as the effects of receiving a fake（安慰法）（安慰法）therapy for 2 to 4 weeks.One study showed that therapy for 2 to 4 weeks.One study showed that acupuncture improved shoulder function more than fake therapy acupuncture improved shoulder function more than fake therapy after 4weeks.But after 4months,improvements were about the after 4weeks.But after 4months,improvements were about the same with only an improvement of 4 more points on a scale of same with only an improvement of 4 more points on a scale of 0 to 100 with acupuncture.One small study showed that 0 to 100 with acupuncture.One small study showed that acupuncture plus exercise was better than just exercise for acupuncture plus exercise was better than just exercise for improving pain,range of motion and function for up to 5 improving pain,range of motion and function for up to 5 months.months.中国的研究中国的研究1 1 中国针灸，中国针灸，2008 2008 目的目的:科学评价使用一次性科学评价使用一次性针的有效性及安全性。针的有效性及安全性。方法方法:将将6060例肩周炎患者随机分为例肩周炎患者随机分为针组和常规针组针组和常规针组,针组采针组采用特制的用特制的针针具治疗针针具治疗,常规针组采用直径常规针组采用直径0.38mm0.38mm、长、长40mm40mm的一次的一次性针灸针治疗性针灸针治疗,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节活动中软组织疼痛自评分及肩部压痛自评分,以及以及2 2组患者分别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。况等不适情况。结果结果:活动相关性疼痛、压痛、最受限方位的关节活动程度的活动相关性疼痛、压痛、最受限方位的关节活动程度的改善均为改善均为针组优于常规针组针组优于常规针组,提示提示针组的即刻疗效明显优于常针组的即刻疗效明显优于常规针组规针组;进针过程中的刺痛次数进针过程中的刺痛次数针组少于常规针组针组少于常规针组,留针时的刺留针时的刺痛次数以及出针时出血次数痛次数以及出针时出血次数,2,2组差别无统计学意义。组差别无统计学意义。结论结论:从本试验看从本试验看,在在针疗法中使用一次性针疗法中使用一次性针比常规针灸针针比常规针灸针更为有效、更为安全。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中国的研究2 2 中国针灸，中国针灸，2008目的目的:探寻治疗急性肩关节周围软组织损伤的有效方法。探寻治疗急性肩关节周围软组织损伤的有效方法。方法方法:将将120120例患者随机分为观察组、对照组例患者随机分为观察组、对照组1 1、对照组、对照组2 2。观察组采。观察组采用运动针、电针加用运动针、电针加TDPTDP治疗治疗,穴取肩穴取肩髃髃、肩、肩髎髎、肩贞等穴、肩贞等穴;对照组对照组1 1采用采用电针加电针加TDP,TDP,穴同观察组穴同观察组;对照组对照组2 2口服布洛芬缓释胶囊口服布洛芬缓释胶囊(芬必得芬必得)。通过。通过疼痛视觉模拟评分疼痛视觉模拟评分(VAS)(VAS)对患者首次治疗后、对患者首次治疗后、1 1个疗程后及个疗程后及1 1个月后随访个月后随访情况进行评价及比较。情况进行评价及比较。结果结果:观察组总有效率观察组总有效率100.0%100.0%、愈显率、愈显率95.0%95.0%优于对照组优于对照组1 1的的90.0%90.0%、75.0%75.0%和对照组和对照组2 2的的70.0%70.0%、45.0%(P0.0145.0%(P0.01或或P0.05);P0.05);观察组治疗观察组治疗1 1次后、次后、1 1个疗程后、治疗后个疗程后、治疗后1 1个月随访个月随访VASVAS评分均明显低于评分均明显低于2 2个对照组个对照组(P0.05)(P0.05)。结论结论:运动针、电针加运动针、电针加TDPTDP综合疗法是治疗急性肩关节周围软组织损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。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 Randomized trials of acupuncture(that involves needling)for adults with non-specific(sub)acute or chronic low-back pain,or adults with non-specific(sub)acute or chronic low-back pain,or dry needling for myofascial pain syndrome in the low-back dry needling for myofascial pain syndrome in the low-back region.region.（诊断）（诊断）AuthorsAuthors conclusions conclusionsThe data do not allow firm conclusions about the effectiveness of The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain.For chronic low-back pain,acupuncture for acute low-back pain.For chronic low-back pain,acupuncture is more effective for pain relief and functional acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after improvement than no treatment or sham treatment immediately after treatment and in the short-term only.Acupuncture is not more treatment and in the short-term only.Acupuncture is not more effective than other conventional and effective than other conventional and“alternativealternative”treatments.treatments.The data suggest that acupuncture and dry-needling may be useful The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain.Because adjuncts to other therapies for chronic low-back pain.Because most of the studies were of lower methodological quality,there most of the studies were of lower methodological quality,there certainly is a further need for higher quality trials in this certainly is a further need for higher quality trials in this area.area.Types of outcome measuresRCTs were included that used at least one of the four outcome RCTs were included that used at least one of the four outcome measures considered to be important in the field of low-back measures considered to be important in the field of low-back pain:pain intensity(e.g.,visual analog scale(VAS),a pain:pain intensity(e.g.,visual analog scale(VAS),a global measure(e.g.,overall improvement,proportion of global measure(e.g.,overall improvement,proportion of patients recovered,subjective improvement of symptoms),back patients recovered,subjective improvement of symptoms),back specific functional status(e.g.,Roland Disability Scale,specific functional status(e.g.,Roland Disability Scale,Oswestry Scale)and return to work(e.g.,return to work Oswestry Scale)and return to work(e.g.,return to work status,number of days off work).status,number of days off work).The primary outcomes for this review were pain and functional The primary outcomes for this review were pain and functional status.Physiological outcomes of physical examination(e.g.,status.Physiological outcomes of physical examination(e.g.,range of motion,spinal flexibility,degrees of straight leg range of motion,spinal flexibility,degrees of straight leg raising or muscle strength),generic health status(e.g.,SF-raising or muscle strength),generic health status(e.g.,SF-36,Nottingham Health Profile,Sickness Impact Profile)and 36,Nottingham Health Profile,Sickness Impact Profile)and other symptoms,such as medication use and side effects were other symptoms,such as medication use and side effects were considered secondary outcomes.considered secondary outcomes.中国的研究中国的研究 中国中国康复医学杂志2004目的目的: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。影响。方法方法:将将265265例下腰痛患者随机分为两组例下腰痛患者随机分为两组,组为对照组组为对照组(132(132例例),),采用采用超短波、调制中频电、推拿及功能训练治疗。超短波、调制中频电、推拿及功能训练治疗。组为针刀组组为针刀组(133(133例例),),采用小针刀采用小针刀,辅以封闭和功能训练辅以封闭和功能训练,两组治疗前后均测量腰屈曲活动度两组治疗前后均测量腰屈曲活动度,并采用改良的并采用改良的OswestryOswestry腰痛问卷进行评分腰痛问卷进行评分,以评定生存质量。以评定生存质量。结果结果:针刀组患者治疗后腰屈曲活动度明显改善且针刀组患者治疗后腰屈曲活动度明显改善且OswestryOswestry腰痛问卷腰痛问卷评分分值明显下降评分分值明显下降,与对照组比较与对照组比较,差异均有显著性意义差异均有显著性意义(P0.01)(P0.01)。两。两组患者随访组患者随访6 64848个月个月,平均随访平均随访10.855.7410.855.74个月个月,针刀组疗效稳定针刀组疗效稳定,与对照组比较与对照组比较,差异有显著性意义差异有显著性意义(P0.01)(P0.01)。结论结论: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量,且远期疗效稳定。且远期疗效稳定。国内综述：下腰痛的中西医结合治疗国内综述：下腰痛的中西医结合治疗-中国临床康复中国临床康复20062006 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。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。因其病因复杂因其病因复杂,治疗方法虽多治疗方法虽多,但并无特效方法但并无特效方法,且有治疗显效慢、且有治疗显效慢、易复发的特点易复发的特点,严重影响了患者的生活和工作。目前有关本病的机制、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、治疗方法仍不完善诊断标准、治疗方法仍不完善,尚需进一步研究尚需进一步研究,本文应用计算机检本文应用计算机检索万方数据库索万方数据库2001-06/2006-07 2001-06/2006-07 及及Ovid 2001-06/2006-07 Ovid 2001-06/2006-07 有有关下腰痛临床治疗方面的文献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主要对其临床治疗方法的研究进展进行回顾。行回顾。原发性痛经原发性痛经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 Women needed to meet the following criteria to be included in the review:the review:primary dysmenorrhoea,i.e.no identifiable pelvic pathology primary dysmenorrhoea,i.e.no identifiable pelvic pathology as indicated by pelvic examination,ultrasound scans,or as indicated by pelvic examination,ultrasound scans,or laparoscopy;laparoscopy;primary dysmenorrhoea(self-reported pain)during the primary dysmenorrhoea(self-reported pain)during themajority of the menstrual cycles or for three consecutive majority of the menstrual cycles or for three consecutive menstrual cycles;menstrual cycles;moderate to severe primary dysmenorrhoea(pain that does not moderate to severe primary dysmenorrhoea(pain that does not respond well to analgesics,affects daily activities,or has a respond well to analgesics,affects daily activities,or has a high baseline score on a validated pain scale).high baseline score on a validated pain scale).Authors conclusionsAcupuncture may reduce period pain,however there is a need for Acupuncture may reduce period pain,however there is a need for further well-designed randomised controlled trialsfurther well-designed randomised controlled trialsPrimary outcomes1.Pain relief measured by a visual analogue scale(VAS)or other1.Pain relief measured by a visual analogue scale(VAS)or othervalidated scales,or measured as dichotomous outcomes(i.e.painvalidated scales,or measured as dichotomous outcomes(i.e.painrelief:yes or no).relief:yes or no).Secondary outcomes1.Overall improvement in generic menstrual-related symptoms1.Overall improvement in generic menstrual-related symptoms(e.g.nausea,tiredness)measured by changes in overall dysmenorrhoeic(e.g.nausea,tiredness)measured by changes in overall dysmenorrhoeicsymptoms that were either self reported or investigatorsymptoms that were either self reported or investigatorobserved,or any other similar measures.observed,or any other similar measures.2.Reported use of additional medication measured as the proportion2.Reported use of additional medication measured as the proportionof women requiring analgesics.of women requiring analgesics.3.Restriction of daily life activities measured as the proportion of3.Restriction of daily life act