韓欣芮，岳微，陳善霞，劉娜，楊明

·科研論著·

腕踝針緩解術(shù)后疼痛的范圍綜述

韓欣芮，岳微，陳善霞，劉娜，楊明*

廣州中醫(yī)藥大學(xué)護(hù)理學(xué)院，廣東 510000

:總結(jié)腕踝針緩解術(shù)后疼痛的研究現(xiàn)狀。:采用范圍綜述方法，檢索中國知網(wǎng)、中國生物醫(yī)學(xué)文獻(xiàn)服務(wù)系統(tǒng)、維普、萬方數(shù)據(jù)庫、PubMed、Web of Science、EMbase、the Cochrane Library、EBSCOhost、ClinicalKey數(shù)據(jù)庫，經(jīng)過文獻(xiàn)篩選和數(shù)據(jù)提取，總結(jié)研究結(jié)果。:納入37項(xiàng)研究，從干預(yù)效果、評(píng)估工具、干預(yù)時(shí)間等方面進(jìn)行分析。:腕踝針有利于緩解術(shù)后疼痛，減少止痛藥的使用，但即使干預(yù)對(duì)象為同一類術(shù)后病人，腕踝針選穴、干預(yù)時(shí)間等也有較大差別。

腕踝針；術(shù)后疼痛；范圍綜述；護(hù)理

已有研究顯示，術(shù)后疼痛可致免疫抑制等不良后果[1]，且得不到緩解的急性疼痛會(huì)形成創(chuàng)傷性記憶[2]。近年來，疼痛管理呈現(xiàn)輕度鎮(zhèn)靜趨勢(shì)[3?4]。早期鎮(zhèn)痛使用最小劑量的鎮(zhèn)靜藥能更好地體現(xiàn)人文關(guān)懷[5]，但不同國家和地區(qū)藥物使用存在差異[6]。非藥物干預(yù)可具有與阿片類藥物相似的鎮(zhèn)痛作用，這些干預(yù)措施通常具有易實(shí)施、安全、低成本的優(yōu)勢(shì)[7]，如腕踝針[8]。部分研究者實(shí)施腕踝針時(shí)會(huì)留針30 min[9]，與國家標(biāo)準(zhǔn)《GB/T 21709.19-2009針灸技術(shù)操作規(guī)范第19部分：腕踝針》[10]要求一致；也有部分研究者選擇更長的留針時(shí)間[11]。本研究對(duì)腕踝針緩解外科手術(shù)病人術(shù)后疼痛的現(xiàn)狀進(jìn)行范圍綜述，以期進(jìn)一步明確腕踝針干預(yù)現(xiàn)狀及其實(shí)施效果。

1 研究方法

范圍綜述是通過系統(tǒng)檢索、選擇和總結(jié)解決探索性的研究問題，反映與定義領(lǐng)域或領(lǐng)域相關(guān)的關(guān)鍵概念、證據(jù)類型和研究空白的文獻(xiàn)研究方法[12]，多應(yīng)用Arksey等[12?14]建議的框架實(shí)施研究。

1.1明確問題、概念本研究提出的主要問題包括：哪些手術(shù)的術(shù)后疼痛可由腕踝針干預(yù)？腕踝針干預(yù)是如何實(shí)施于術(shù)后病人的？干預(yù)后病人疼痛緩解療效如何？調(diào)查的人群是術(shù)后病人，定義為：因疾病治療而需要各類外科手術(shù)的病人。文獻(xiàn)以疼痛為主要結(jié)局或者次要結(jié)局，干預(yù)措施包括單獨(dú)的腕踝針治療或者聯(lián)合其他方式治療。

1.2文獻(xiàn)檢索以“手術(shù)、術(shù)后、疼痛、鎮(zhèn)痛、痛、止痛、術(shù)后疼痛、術(shù)后鎮(zhèn)痛、腕踝針”等為中文檢索詞檢索中國知網(wǎng)（CNKI）、中國生物醫(yī)學(xué)文獻(xiàn)服務(wù)系統(tǒng)（SinoMed）、維普（VIP）、萬方數(shù)據(jù)庫；以“pain*、post?operative、postoperative、after operation、acupuncture、wrist?ankle acupuncture”等為英文檢索詞檢索PubMed、Web of Science（WOS）、EMbase、the Cochrane Library、EBSCOhost、ClinicalKey數(shù)據(jù)庫。檢索時(shí)間為從數(shù)據(jù)庫建庫至2022年2月20日。

1.3文獻(xiàn)篩選標(biāo)準(zhǔn)由于范圍綜述沒有文獻(xiàn)質(zhì)量評(píng)估方法，為保證文獻(xiàn)質(zhì)量和試驗(yàn)干預(yù)實(shí)施的規(guī)范、可信度，本范圍綜述對(duì)發(fā)表刊物的類別進(jìn)行限制。納入標(biāo)準(zhǔn)：研究對(duì)象為接受手術(shù)治療的病人；干預(yù)包含腕踝針治療；以疼痛強(qiáng)度為主要或次要結(jié)局指標(biāo)；語言為中文或者英文；原始研究；研究發(fā)表在中文核心期刊或者SCI收錄的期刊。排除標(biāo)準(zhǔn)：重復(fù)發(fā)表的文獻(xiàn)；無法獲取全文的文獻(xiàn)；動(dòng)物實(shí)驗(yàn)、評(píng)論、給編輯的信等。

1.4數(shù)據(jù)提取與分析2名研究者分別提取以下關(guān)鍵信息：作者、出版年份、國家、研究類型、樣本量、手術(shù)類型、科室、對(duì)照措施、干預(yù)措施、腕踝針干預(yù)時(shí)機(jī)、留針時(shí)間、選區(qū)、評(píng)估工具等。使用P?lkki等[15]提出的框架將干預(yù)組的干預(yù)內(nèi)容分為3類，即單獨(dú)的腕踝針干預(yù)、附加的腕踝針干預(yù)（在常規(guī)術(shù)后護(hù)理或藥物治療基礎(chǔ)上添加腕踝針）以及混合其他治療的腕踝針干預(yù)。

2 結(jié)果

2.1文獻(xiàn)檢索結(jié)果共檢索到488篇文獻(xiàn)，剔除重復(fù)文獻(xiàn)275篇，閱讀標(biāo)題、摘要及全文，根據(jù)納入及排除標(biāo)準(zhǔn)篩選文獻(xiàn)，最終納入37篇文獻(xiàn)[9,11,16?50]，其中隨機(jī)對(duì)照試驗(yàn)27篇[9,11,16?17,19?20,22?26,28?29,32?41,43?45,47]、類實(shí)驗(yàn)8篇[18,21,30?31,42,46,48?49]、病例對(duì)照研究1篇[27]，病例觀察1篇[50]。文獻(xiàn)篩選流程及結(jié)果見圖1。

圖1　文獻(xiàn)篩選流程及結(jié)果

2.2納入研究的基本特征①單獨(dú)的腕踝針干預(yù)：納入研究中共有11項(xiàng)研究[11,19,29,34,40,42,44,46,48?50]實(shí)施單獨(dú)的腕踝針干預(yù)，其中1項(xiàng)研究[50]是病例觀察研究，10項(xiàng)研究[11,19,29,34,40,42,44,46,48?49]是試驗(yàn)或者類實(shí)驗(yàn)研究；研究的?？瓢▼D產(chǎn)科2項(xiàng)[34,49]、普外科3項(xiàng)[42,44,50]、泌尿外科2項(xiàng)[19,40]、骨科3項(xiàng)[11,46,48]、耳鼻喉科1項(xiàng)[29]。②附加的腕踝針干預(yù)：納入研究中共有18項(xiàng)研究[9,16?18,20,22?23,25?26,28,32?33,35?39,47]實(shí)施附加的腕踝針干預(yù)，均為試驗(yàn)或者類實(shí)驗(yàn)研究；研究的?？瓢▼D產(chǎn)科4項(xiàng)[22?23,32,35]、骨科8項(xiàng)[9,16,18,20,26,33,36,39]、普外科5項(xiàng)[17,28,37?38,47]、眼科1項(xiàng)[25]。③混合其他治療的腕踝針干預(yù)：納入研究中共有8項(xiàng)研究[21,24,27,30?31,41,43,45]是混合其他治療的腕踝針干預(yù)，其中1項(xiàng)研究[27]是病例對(duì)照研究，其余7項(xiàng)研究[21,24,30?31,41,43,45]是試驗(yàn)或者類實(shí)驗(yàn)研究；研究的專科包括骨科7項(xiàng)[21,27,30?31,41,43,45]、肛腸科1項(xiàng)[24]。納入研究的基本特征見表1。

表1　納入研究的基本特征

注：VAS為視覺模擬評(píng)分法（Visual Analogue Scale）；PCA為病人自控鎮(zhèn)痛（patient controlled analgesia）；PCIA為靜脈病人自控鎮(zhèn)痛(patient controlled intravenous analgesia)；NRS為疼痛數(shù)字評(píng)分法（Numerical Rating Scale）；PCEA為硬膜外自控鎮(zhèn)痛(patient controlled epidural analgesia)；SF?MPQ為簡化McGill疼痛問卷（Short Form of McGill Pain Questionnaire）；MPQ為麥吉爾疼痛量表（McGill Pain Questionnaire）；FPS?R為修訂版Wong Baker面部表情疼痛量表（Wong Baker Faces Pain Scale Revision）；5?HT為5?羥色胺（5?hydroxytryptamine）；NE為去甲腎上腺素（norepinephrine）。干預(yù)組數(shù)≥2組時(shí)，若干預(yù)組內(nèi)容為僅涉及腕踝針和（或）藥物，優(yōu)先歸類為單獨(dú)的腕踝針干預(yù)；若干預(yù)存在腕踝針聯(lián)合其他非藥物治療，優(yōu)先歸類為混合其他治療的腕踝針干預(yù)。

3 討論

本研究共納入了37篇文獻(xiàn)，病人年齡為17～84歲，科室涉及耳鼻喉科、婦產(chǎn)科、肛腸科、骨科、泌尿外科、普外科、眼科，關(guān)于腕踝針治療其他專科病人術(shù)后疼痛的高質(zhì)量證據(jù)更少。納入研究進(jìn)一步受到方法描述不清、缺乏隨機(jī)性和干預(yù)方案不一致的限制。

3.1干預(yù)效果腕踝針干預(yù)可有效降低疼痛強(qiáng)度[51?52]。部分納入研究顯示，骨科病人治療后疼痛評(píng)分降低[9,11,20?21,30,43,48]，但各研究結(jié)果間存在一定差異，可能受病人基線疼痛強(qiáng)度、術(shù)后疼痛管理模式和手術(shù)創(chuàng)傷程度[51]等因素影響，此外，還存在聯(lián)合干預(yù)的影響，而大多數(shù)聯(lián)合干預(yù)效果都優(yōu)于單項(xiàng)的腕踝針干預(yù)。

3.2評(píng)估工具評(píng)估工具的選擇和使用也會(huì)影響評(píng)估結(jié)果。本綜述納入的研究涉及的疼痛評(píng)估工具包括VAS、NRS、FPS?R、MPQ、SF?MPQ。但對(duì)比專家共識(shí)的相關(guān)說明[53]，發(fā)現(xiàn)納入的7項(xiàng)研究[16,18,20,24,31,33?34]雖表述使用VAS，但其實(shí)際應(yīng)為NRS，部分研究未對(duì)評(píng)估工具進(jìn)行詳細(xì)描述，無法確定使用的正確性，可能影響質(zhì)量評(píng)估。

3.3干預(yù)時(shí)間本研究發(fā)現(xiàn)，即便針對(duì)同一類型的術(shù)后病人，腕踝針干預(yù)的干預(yù)時(shí)機(jī)、留針時(shí)間和選區(qū)也存在差別，如Cao等[11]與陳巧玲等[48]的選區(qū)均為下3區(qū)、下4區(qū)，留針時(shí)間分別為自康復(fù)訓(xùn)練前30 min施針直至康復(fù)訓(xùn)練完成以及直接留針2 h。針灸治療的臨床療效受干預(yù)頻次、留針時(shí)間、療程、病人病情嚴(yán)重程度等多種因素影響[54?55]。腕踝針作為緩解術(shù)后疼痛的一種針刺方法，其療效與留針時(shí)間也存在一定時(shí)效關(guān)系[56]。目前，腕踝針留針時(shí)間尚無統(tǒng)一標(biāo)準(zhǔn)，鮮見對(duì)各類疼痛留針時(shí)間規(guī)律的探討和臨床循證實(shí)踐研究。

3.4與以往同類研究的關(guān)系以往研究以系統(tǒng)評(píng)價(jià)、文獻(xiàn)綜述和Meta分析為主要形式探討腕踝針緩解疾病或疼痛癥狀的療效。目前，關(guān)于腕踝針的原始研究集中于療效的研究，部分研究也探討了腕踝針聯(lián)合其他治療方式（包括藥物治療和非藥物治療）對(duì)于疾病或相關(guān)癥狀的效果，部分病人研究較多，如膝關(guān)節(jié)置換術(shù)病人，有利于總結(jié)出可靠的臨床證據(jù)，為臨床實(shí)踐提供參考；但部分病人研究較少，如甲狀腺手術(shù)的病人，證據(jù)有限。

4 小結(jié)

本范圍綜述納入研究的腕踝針實(shí)施細(xì)節(jié)存在差異，即使是同一類手術(shù)人群實(shí)際的干預(yù)方案也不一致。對(duì)于同一類手術(shù)病人，由于病人及其疾病相關(guān)因素存在聚集和偏倚；加之針灸類療法本身具有時(shí)效相關(guān)性和規(guī)律性，研究間差異可能影響腕踝針干預(yù)的臨床決策。因此，需要進(jìn)一步細(xì)化相關(guān)研究領(lǐng)域主題，豐富腕踝針以及中醫(yī)傳統(tǒng)療法和新興療法的研究。

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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

廣東省研究生教育創(chuàng)新計(jì)劃項(xiàng)目，編號(hào)：2022SFKC030

韓欣芮，護(hù)士，碩士研究生在讀

楊明，E?mail:hlym@gzucm.edu.cn

韓欣芮,岳微,陳善霞,等.腕踝針緩解術(shù)后疼痛的范圍綜述[J].護(hù)理研究,2022,36(22):4041?4048.

（收稿日期：2022-03-08；修回日期：2022-10-29）

（本文編輯 陳瓊）