腕踝针缓解术后疼痛的范围综述

2022-12-02韩欣芮岳微陈善霞刘娜杨明

护理研究 2022年22期

关键词：腕踝针综述置换术

韩欣芮，岳微，陈善霞，刘娜，杨明

·科研论著·

腕踝针缓解术后疼痛的范围综述

韩欣芮，岳微，陈善霞，刘娜，杨明*

广州中医药大学护理学院，广东 510000

:总结腕踝针缓解术后疼痛的研究现状。:采用范围综述方法，检索中国知网、中国生物医学文献服务系统、维普、万方数据库、PubMed、Web of Science、EMbase、the Cochrane Library、EBSCOhost、ClinicalKey数据库，经过文献筛选和数据提取，总结研究结果。:纳入37项研究，从干预效果、评估工具、干预时间等方面进行分析。:腕踝针有利于缓解术后疼痛，减少止痛药的使用，但即使干预对象为同一类术后病人，腕踝针选穴、干预时间等也有较大差别。

腕踝针；术后疼痛；范围综述；护理

已有研究显示，术后疼痛可致免疫抑制等不良后果[1]，且得不到缓解的急性疼痛会形成创伤性记忆[2]。近年来，疼痛管理呈现轻度镇静趋势[3⁃4]。早期镇痛使用最小剂量的镇静药能更好地体现人文关怀[5]，但不同国家和地区药物使用存在差异[6]。非药物干预可具有与阿片类药物相似的镇痛作用，这些干预措施通常具有易实施、安全、低成本的优势[7]，如腕踝针[8]。部分研究者实施腕踝针时会留针30 min[9]，与国家标准《GB/T 21709.19-2009针灸技术操作规范第19部分：腕踝针》[10]要求一致；也有部分研究者选择更长的留针时间[11]。本研究对腕踝针缓解外科手术病人术后疼痛的现状进行范围综述，以期进一步明确腕踝针干预现状及其实施效果。

1 研究方法

范围综述是通过系统检索、选择和总结解决探索性的研究问题，反映与定义领域或领域相关的关键概念、证据类型和研究空白的文献研究方法[12]，多应用Arksey等[12⁃14]建议的框架实施研究。

1.1明确问题、概念本研究提出的主要问题包括：哪些手术的术后疼痛可由腕踝针干预？腕踝针干预是如何实施于术后病人的？干预后病人疼痛缓解疗效如何？调查的人群是术后病人，定义为：因疾病治疗而需要各类外科手术的病人。文献以疼痛为主要结局或者次要结局，干预措施包括单独的腕踝针治疗或者联合其他方式治疗。

1.2文献检索以“手术、术后、疼痛、镇痛、痛、止痛、术后疼痛、术后镇痛、腕踝针”等为中文检索词检索中国知网（CNKI）、中国生物医学文献服务系统（SinoMed）、维普（VIP）、万方数据库；以“pain*、post⁃operative、postoperative、after operation、acupuncture、wrist⁃ankle acupuncture”等为英文检索词检索PubMed、Web of Science（WOS）、EMbase、the Cochrane Library、EBSCOhost、ClinicalKey数据库。检索时间为从数据库建库至2022年2月20日。

1.3文献筛选标准由于范围综述没有文献质量评估方法，为保证文献质量和试验干预实施的规范、可信度，本范围综述对发表刊物的类别进行限制。纳入标准：研究对象为接受手术治疗的病人；干预包含腕踝针治疗；以疼痛强度为主要或次要结局指标；语言为中文或者英文；原始研究；研究发表在中文核心期刊或者SCI收录的期刊。排除标准：重复发表的文献；无法获取全文的文献；动物实验、评论、给编辑的信等。

1.4数据提取与分析2名研究者分别提取以下关键信息：作者、出版年份、国家、研究类型、样本量、手术类型、科室、对照措施、干预措施、腕踝针干预时机、留针时间、选区、评估工具等。使用Pölkki等[15]提出的框架将干预组的干预内容分为3类，即单独的腕踝针干预、附加的腕踝针干预（在常规术后护理或药物治疗基础上添加腕踝针）以及混合其他治疗的腕踝针干预。

2 结果

2.1文献检索结果共检索到488篇文献，剔除重复文献275篇，阅读标题、摘要及全文，根据纳入及排除标准筛选文献，最终纳入37篇文献[9,11,16⁃50]，其中随机对照试验27篇[9,11,16⁃17,19⁃20,22⁃26,28⁃29,32⁃41,43⁃45,47]、类实验8篇[18,21,30⁃31,42,46,48⁃49]、病例对照研究1篇[27]，病例观察1篇[50]。文献筛选流程及结果见图1。

图1　文献筛选流程及结果

2.2纳入研究的基本特征①单独的腕踝针干预：纳入研究中共有11项研究[11,19,29,34,40,42,44,46,48⁃50]实施单独的腕踝针干预，其中1项研究[50]是病例观察研究，10项研究[11,19,29,34,40,42,44,46,48⁃49]是试验或者类实验研究；研究的专科包括妇产科2项[34,49]、普外科3项[42,44,50]、泌尿外科2项[19,40]、骨科3项[11,46,48]、耳鼻喉科1项[29]。②附加的腕踝针干预：纳入研究中共有18项研究[9,16⁃18,20,22⁃23,25⁃26,28,32⁃33,35⁃39,47]实施附加的腕踝针干预，均为试验或者类实验研究；研究的专科包括妇产科4项[22⁃23,32,35]、骨科8项[9,16,18,20,26,33,36,39]、普外科5项[17,28,37⁃38,47]、眼科1项[25]。③混合其他治疗的腕踝针干预：纳入研究中共有8项研究[21,24,27,30⁃31,41,43,45]是混合其他治疗的腕踝针干预，其中1项研究[27]是病例对照研究，其余7项研究[21,24,30⁃31,41,43,45]是试验或者类实验研究；研究的专科包括骨科7项[21,27,30⁃31,41,43,45]、肛肠科1项[24]。纳入研究的基本特征见表1。

表1　纳入研究的基本特征

注：VAS为视觉模拟评分法（Visual Analogue Scale）；PCA为病人自控镇痛（patient controlled analgesia）；PCIA为静脉病人自控镇痛(patient controlled intravenous analgesia)；NRS为疼痛数字评分法（Numerical Rating Scale）；PCEA为硬膜外自控镇痛(patient controlled epidural analgesia)；SF⁃MPQ为简化McGill疼痛问卷（Short Form of McGill Pain Questionnaire）；MPQ为麦吉尔疼痛量表（McGill Pain Questionnaire）；FPS⁃R为修订版Wong Baker面部表情疼痛量表（Wong Baker Faces Pain Scale Revision）；5⁃HT为5⁃羟色胺（5⁃hydroxytryptamine）；NE为去甲肾上腺素（norepinephrine）。干预组数≥2组时，若干预组内容为仅涉及腕踝针和（或）药物，优先归类为单独的腕踝针干预；若干预存在腕踝针联合其他非药物治疗，优先归类为混合其他治疗的腕踝针干预。

3 讨论

本研究共纳入了37篇文献，病人年龄为17～84岁，科室涉及耳鼻喉科、妇产科、肛肠科、骨科、泌尿外科、普外科、眼科，关于腕踝针治疗其他专科病人术后疼痛的高质量证据更少。纳入研究进一步受到方法描述不清、缺乏随机性和干预方案不一致的限制。

3.1干预效果腕踝针干预可有效降低疼痛强度[51⁃52]。部分纳入研究显示，骨科病人治疗后疼痛评分降低[9,11,20⁃21,30,43,48]，但各研究结果间存在一定差异，可能受病人基线疼痛强度、术后疼痛管理模式和手术创伤程度[51]等因素影响，此外，还存在联合干预的影响，而大多数联合干预效果都优于单项的腕踝针干预。

3.2评估工具评估工具的选择和使用也会影响评估结果。本综述纳入的研究涉及的疼痛评估工具包括VAS、NRS、FPS⁃R、MPQ、SF⁃MPQ。但对比专家共识的相关说明[53]，发现纳入的7项研究[16,18,20,24,31,33⁃34]虽表述使用VAS，但其实际应为NRS，部分研究未对评估工具进行详细描述，无法确定使用的正确性，可能影响质量评估。

3.3干预时间本研究发现，即便针对同一类型的术后病人，腕踝针干预的干预时机、留针时间和选区也存在差别，如Cao等[11]与陈巧玲等[48]的选区均为下3区、下4区，留针时间分别为自康复训练前30 min施针直至康复训练完成以及直接留针2 h。针灸治疗的临床疗效受干预频次、留针时间、疗程、病人病情严重程度等多种因素影响[54⁃55]。腕踝针作为缓解术后疼痛的一种针刺方法，其疗效与留针时间也存在一定时效关系[56]。目前，腕踝针留针时间尚无统一标准，鲜见对各类疼痛留针时间规律的探讨和临床循证实践研究。

3.4与以往同类研究的关系以往研究以系统评价、文献综述和Meta分析为主要形式探讨腕踝针缓解疾病或疼痛症状的疗效。目前，关于腕踝针的原始研究集中于疗效的研究，部分研究也探讨了腕踝针联合其他治疗方式（包括药物治疗和非药物治疗）对于疾病或相关症状的效果，部分病人研究较多，如膝关节置换术病人，有利于总结出可靠的临床证据，为临床实践提供参考；但部分病人研究较少，如甲状腺手术的病人，证据有限。

4 小结

本范围综述纳入研究的腕踝针实施细节存在差异，即使是同一类手术人群实际的干预方案也不一致。对于同一类手术病人，由于病人及其疾病相关因素存在聚集和偏倚；加之针灸类疗法本身具有时效相关性和规律性，研究间差异可能影响腕踝针干预的临床决策。因此，需要进一步细化相关研究领域主题，丰富腕踝针以及中医传统疗法和新兴疗法的研究。

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Wrist⁃ankle acupuncture for postoperative pain relief:a scoping review

HANXinrui,YUEWei,CHENShanxia,LIUNa,YANGMing

School of Nursing,Guangzhou University of Chinese Medicine,Guangdong 510000 China

：To summarize literature on relieving postoperative pain with wrist⁃ankle acupuncture.：A scoping review was conducted by searching databases including China National Knowledge Infrastructure，Chinese Biomedical Literature Database，VIP，Wanfang，PubMed，Web of Science，EMbase，the Cochrane Library，EBSCOhost，and ClinicalKey，as well as screening literature to extract data，finally summarizing the findings.：A total of 37 studies were included and analyzed upon intervention effects，assessment tools，duration of intervention，and so on.：Wrist⁃ankle acupuncture is beneficial to relieve postoperative pain and reduce use of painkillers.However，the selection of acupoints and the length of intervention are significantly different even if the participants are the same type of postoperative patients.

wrist⁃ankle acupuncture；postoperative pain；scoping review；nursing

YANG Ming,E⁃mail:hlym@gzucm.edu.cn

10.12102/j.issn.1009-6493.2022.22.017

广东省研究生教育创新计划项目，编号：2022SFKC030

韩欣芮，护士，硕士研究生在读

杨明，E⁃mail:hlym@gzucm.edu.cn

韩欣芮,岳微,陈善霞,等.腕踝针缓解术后疼痛的范围综述[J].护理研究,2022,36(22):4041⁃4048.