【作者】 蒋坤融；

【导师】 庄礼兴；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2011， 博士

【摘要】 疼痛是癌症患者常见的伴随症状之一,是癌症病人自觉症状中发生率最高,也最令,患者痛苦的症状。可出现在整个病程的不同时期。目前恶性肿瘤在全球已经成为一类严重威胁人类健康和生命的疾病。世界卫生组织(WHO)公布2000年全球共有恶性肿瘤患者1000万,死于这一疾病的620万,占总死亡人数的12%,在多数发达国家这一数字可达25%。疼痛是癌症患者常见的、令人恐惧的并发症。据统计,新发癌症患者中30%～50%伴有不同程度的疼痛,在非转移患者中15%伴有疼痛,在接受抗癌治疗者中50%有疼痛感,晚期癌症患者中31%～90%有不同程度的疼痛。癌性疼痛主要是指肿瘤细胞浸润、转移、扩散或压迫有关组织引起的疼痛,是癌症患者常见症状,多见于癌症的晚期,是影响患者生存质量的重要因素。疼痛不仅给癌症患者带来躯体的痛苦,也使患者在精神上产生巨大压力。使患者情绪抑郁,甚至产生轻生的念头,严重影响着癌症患者的生存质量。然而对癌痛的控制并不令人满意,根据美国肿瘤护理协会的资料,在一般的医疗条件下,40%～50%的癌痛患者未能达到完全缓解。目前,对于癌痛的治疗尚未圆满解决,癌痛本身是多种因素作用的结果,病因复杂,只有将内治与外治相结合,中医与西医相结合,心理治疗与药物治疗相结合,才可能在临床实践中取得满意的疗效。为了提高癌症患者生存质量,减轻乃至解除疼痛,各国学者都在努力寻找治疗癌性疼痛的新方法,以期将癌症患者从疼痛中解救出来。在姑息治疗中,WHO把疼痛控制提高到“优先解决”的地位。随着WHO癌症三阶梯止痛治疗原则的推广应用,癌痛治疗工作取得了较大的进步,但是由于各国治疗水平参差不齐,在很多国家特别是发展中国家并没有很好的实施,癌痛未得到足够止痛治疗的现象普遍存在,而且长期使用镇痛剂毒副作用大,依赖性强,并受患者耐受性的限制,致使部分患者止痛效果欠佳。WHO癌症三阶梯治疗外,还有辅助用药用于增强止痛效果,治疗疼痛并发症。缓解疼痛,除了药物疗法外,还有放射治疗、手术治疗、化学治疗、放射性同位素治疗、双膦酸盐等治疗方法用于缓解疼痛,提高生活质量。相比西药和相关辅助治疗,中药基本无成瘾性问题,同时能够针对病因认为癌痛主要分为“不通则痛”和“不荣则痛”两类。“不通则痛”是由于痰毒瘀火诸病邪内结,阻滞络脉,气机不畅,脉络瘀阻；“不荣则痛”主要为气血阴阳虚损,正气虚弱,经脉失养。中医中药治疗主要采用辨证论治与辨病相结合、扶正与祛邪相结合、活血化瘀与理气止痛相结合。要以“通”治其标为急,以“补”治其本为缓。近年来相关临床研究报道诸多,证明采用中医药内服、外用、针灸等方法治疗癌性疼痛,毒副作用小、无成瘾性具有现实的临床意义。近十几年来,中医治疗癌痛得到较大的发展,为癌症疼痛的治疗带来新的思路和方法,具有广阔的发展前景。中医对癌性疼痛的治疗手段也是多种多样的,中药止痛疗效确切,但一般作用缓慢,个体差异大,可重复性差。针灸疗法作为传统中医疗法之一,以其安全、无镇痛药物的成瘾性及毒副作用等优势,在癌痛治疗中日益发挥其重要作用。针灸能够疏通经络,调和气血,达到改善肌体因气滞血瘀、经络不通所致的疼痛。采用穴位注射法镇痛,也具有较好的效果。因为穴位药物疗法可起到调整整体功能、激发机体精气、疏导气血、调整神经功能的作用。目前报道的有关针灸止痛方面的文献,所采用的研究方法不一,水平参差不齐,无统一的观察和治疗标准,所以得出的结论也无法进行比较和总结,不利于推广应用,可信度也有待提高。研究目的：本研究按照国际通用的疼痛评价标准,选用针刺结合耳压治疗癌性疼痛,观察在疼痛持续时间、简易疼痛量表、生存质量量表(WHOQOL-BREF)、巴氏量表评分方面的疗效,进行统计分析和综合评估,旨在探求一种简便有效的方法,为临床应用提供思路,并进一步改善患者的生活质量,提高其生活自理能力。研究方法：文献研究综述了中医学、现代医学对癌性疼痛的认识和治疗,以及近年来四关穴在临床上的应用。临床研究共收集到符合纳入标准的病例60例,按首次就诊的先后顺序,用随机数字表法随机分为治疗组和对照组各30例。所有入组者均按照“三阶梯药物止痛法”使用镇痛药物,在此基础上,治疗组采用针刺四关穴结合王不留行籽耳压,依据辨证结果采用捻转补泻手法,依据辨病结果选取耳穴。对照组仅使用基础治疗。观察在疼痛持续时间、简易疼痛量表、生存质量量表(WHOQOL-BREF)、巴氏量表评分方面的疗效,及其安全性。研究结果：在疼痛方面,治疗前两组平均疼痛持续时间差异无统计学意义(P>0.05),具有可比性。治疗后两组患者每天平均疼痛时间较治疗前均有明显下降,差异具有非常显着性意义(P<0.01),提示两种治疗方法均可明显减少疼痛时间；治疗后组间比较,治疗组平均持续时间下降更加明显,差异具有显着性统计学意义(P<0.05)。在WHOQOL-BREF评分方面,治疗前两组疼痛强度评分比较差异无统计学意义(P>0.05),具有可比性。治疗后两组患者的疼痛程度评分较治疗前均有明显下降,差异具有显着性意义(P<0.01,P<0.05),提示两种治疗方法均可明显减轻疼痛程度；治疗后组间比较,治疗组疼痛强度评分下降更加明显,差异具有显着性统计学意义(P<0.05)。在巴氏量表评分方面,治疗前两组疼痛干扰评分比较差异无统计学意义(P>0.05),具有可比性。治疗后两组患者受疼痛的干扰程度评分较治疗前均有明显下降,差异具有显着性意义(P<0.05),提示两种治疗方法均可明显减轻疼痛干扰；治疗后组间比较,差异无显着性意义(P>0.05)。在安全性方面,针刺治疗未出现严重的不良反应。没有患者因不能耐受而停止治疗,或因药物的副作用而退出研究。研究结论：说明针刺四关穴结合王不留行籽耳压治疗癌性疼痛可明显缓解患者的疼痛症状,进一步改善患者的生活质量,提高其生活自理能力。其疗效确切；操作简便,无不良反应,患者易于接受,是值得推广的治疗方法。更多还原

【Abstract】 Objective:Currently malignant tumor in global has become a serious threat to human health and life. The world health organization (WHO) published in 2000, There were totally 10 million patients with malignant tumors,6.2 million died from this disease, accaunted for 12% of the total deaths, in most developed countries the number can reach 25%. Pain is cancer patients’common, frightening complication. According to statistics,30%～50% of new cancer cases have different degree of pain,15% of the untransfer patients have pain and 50% of those who are accepting anti-cancer treatment have aching feeling, among patients with advanced cancer,31%～90% have different levels of pain.In palliative care, WHO has raised the control of pain to the status of "priorities". But when patients use the analgesics for a long time, the dependence and side effects are so strong, and the limit tolerability get poorer. Compared with Opioids, Chinese medicine without addiction, aims at the etiology, actively improve patients’ symptoms, sleep quality and time, and improve the life quality of advanced cancer patients, it can reduce physical and emotional pain, prolong the survival time, all these have extremely vital significance. Nearly ten years, TCM treatment got a greater development in the treatment of cancer pain, which brings new ideas and methods in treating cancer pain, provides a broad development prospects.In Chinese medicine, Cancerous pain belongs to "pain syndrome" category. The traditional Chinese medicine treatments on cancerous pain are also various. As one of the traditional Chinese medicine therapy, acupuncture therapy with its advantages such like safety, no analgesic drug addiction and side effects and so on, now is playing an important role in cancer pain treatment. At present, the methods adopted in relevant acupuncture analgesia reported in literature is different, have no unified observation and treatment standards, so the conclusions cannot be compared and summarized, and can not be widely applied, the credibility needs to be improved as well.This study chose acupuncture and auricular Pressure to treat cancer pain according to international general pain assessment standards, observed the length of pain time, simple pain scale, survival quality scale (WHOQOL-BREF) pasteurella rating scale. And then used statistical analysis to appraise the effect of it and make a comprehensive evaluation, aimed to explore a simple and effective method to provide ideas for clinical application, and further improved the patients’quality of life, improved its self-care ability. Methods:The literature overviewed on the recognitions and treatments of cancer pain in traditional Chinese medicine and modern medicine, and the clinical application of Siguan in recent four yearsClinical study:60 cases who met the inclusion criteria according to the order of diagnosis and random number table were divided into the treatment group and control group,30 cases each group. The patients all took analgesia drugs according to the "three steps drug analgesic method", on this basis, the treatment group were treated with acupuncture point Siguang and auricular Pressure by wangbuliuxing, according the dialectical results to choose reinforcing or reducing method, according disease diagnosing to choose the ear point, observed it’s score in the pain standing time, simple pain scale, survival quality scale (WHOQOL-BREF), Barthel Index scale, and its safety. Results:In pain, average pain time and pain degree were all improved obviously in two groups; the treatment group got better effect. In pain interference, compared with before treatment all patients’pain interference degree declined obviously, compared the treatment group with control group,there were no significant differences.In the WHOQOL-BREF scoring, all patients’subjective feeling markedly reduced in the physiological field, psychological field, social relation field, the environment field and life quality; But compared treatment group with control group in all directions, Treatment group got more scores than control group in physiological field.In Barthel Index rating, two treatments obviously increased Barthel Index score; compared treatment group with control group in this rating, treatment group improved more apparently.In safety, we did not find serious adverse reactions about acupuncture therapy. No patients discontinued the treatment because of they could not tolerate or retreated from the research because of the side effects of the drug Conclusion:Acupuncturing Siguan with auricular pressure treatment can obviously help relieve cancerous patients from Cancerous pain, improve the life quality, improve its self-care ability. Patients are easy to accept it Because this treatment with definite effect and easy to operate and without adverse reaction. It’s a good treatment that worths widely application.更多还原