针刺安全理论探源及框架构建

【作者】 王婧；

【导师】 李晓泓；

【作者基本信息】 北京中医药大学 ， 针灸推拿学， 2012， 博士

【摘要】 1.研究目的针刺疗法具有治疗范围广泛、疗效独特等而日益成为现代医疗中的不可或缺的治疗手段。但是针刺疗法也是一门实践性很强的疗法,在实际操作中,具有一定危险性,不免会产生意外。近些年,针刺意外及其副作用逐渐受到重视,针刺安全的评价方法也日益成为中、西方医学界研究的热点和难点。针刺安全的评价方法一般是通过对针刺意外的研究来进行的。但是,现有研究大多局限于对针刺意外文献报道的分析、讨论,进而探讨针刺疗法安全性的高低,缺乏对导致针刺意外发生的本质原因的分析和总结,更没有系统性、理论性地探讨和总结针刺意外与针刺安全之间的关系。因此,应加强针刺安全的理论研究。2.研究方法本论文的研究方法包括：文献资料的搜集、整理、分析以及模型的建立。其中文献搜集主要通过：人工查阅图书馆、互联网上CNKI、VIP、MEDLINE等数据库。然后采用纵向和横向相结合的方式整理分析文献资料。之后对整理的文献资料运用内容分析法、比较法、实证法等找到针刺安全的构成因素,揭示针刺安全的内在构成因素及因素的普遍联系,归纳概括针刺安全的本质及其运行规律。在此基础上,建立相应的针刺安全理论模型,并对其进行进一步的验证。3.研究结果由于针刺安全与针刺意外之间具有对立统一的关系。因此,本论文的文献综述部分从文献学的角度,整理分析归纳了古今中外关于针刺意外的文献资料。在整理分析的过程中,笔者发现,在古代,《黄帝内经》中已出现针刺安全思想萌芽,但是散见于各篇章中。到现代,随着多种操作规范、诊疗手段、临床经验等的发展,针灸业界开始研究针刺安全。这些研究大都来源于临床经验,缺乏系统的总结和系统的理论指导。在前期的文献资料研究过程中,笔者通过分析针刺临床治疗中的针刺意外,发现导致针刺意外发生的原因很复杂、多样。其中,主要涉及到医生、患者、针具、时间、环境。本论文研究主要针对针刺一次的诊疗过程。一般来说,针刺治疗的时间为30-60分钟,时间较短,并且针刺治疗在室内,环境较为稳定,因此我们认为,在针刺临床治疗中,时间、环境是常量,医生、针具、患者是变量。因此,针刺治疗的简化模型为医生、针具、环境以及之间的相互作用,医生、患者是主体,针具是二者之间的介质。并且医生、患者、针具三者之间的相互作用贯穿于针刺治疗的全过程中。通过分析三者之间的相互作用,提出整个针刺安全的实现,是由医生、患者两个主体与介质针具之间共同作用的结果,而不是某一个因素所实现的。针刺安全的实现是通过医生、患者、针具之间的相互作用实现的,这与三者的属性和行为有关。在医生、患者、针具三者之间的相互作用而构成的针刺安全理论模型的基础之上,我们进而构建了针刺安全理论框架。在针刺安全理论框架中,医生的安全属性为安全意识、安全心态、安全技能。医生的安全意识是指医生对针刺意外危害程度的有全面认识的情况下,主观上形成的自我保护的意识。它是医生学习安全技能、产生安全心态、支配安全行为的思想保证。例如：医生必须具有无菌的意识,在针刺临床治疗中要切实做好消毒的工作,避免出现针刺感染等。医生的安全心态,是指医生在针刺临床治疗中心理状态,它是支配医生安全行为的直接决定因素。医生的安全心态可以反映医生的安全意识、安全技能在针刺临床治疗中安危动态变化中的适应性。例如：医生在发生针刺意外的情况下,务必保持冷静、高度负责的态度等。医生的安全技能,是指医生在针刺临床实践中所掌握的预防、控制针刺意外产生及发展的技术能力。它是医生安全心态、安全行为的技术保障。例如：医生必须掌握解剖学等知识等。医生的安全行为,是指在针刺临床实践中,具有安全意识、安全技能的医生在安全心态支配下的行动表现。具体体现在针刺临床治疗的全过程中,医生对患者以及针具的行为表现。它是产生安全效果的决定因素。由此可见,医生在针刺安全理论框架中,是由具有安全思想、安全技能、安全心态等安全属性的医生,支配其在针刺临床实践中的安全行为,进而产生安全效果的相序组合规律运动构成的。在针刺安全理论框架中,患者具有安全属性和安全行为。患者的安全属性主要是为安全心态这一主观属性,即是患者在针刺临床治疗中的心理状态等。患者的安全行为是指在安全心理支配下的患者的行为举止。具体体现为指在临床治疗中,与医生的配合程度等。由此可见,患者在针刺安全理论框架中,是由具有安全心态等安全属性的患者,支配其在针刺临床治疗中的安全行为,进而产生安全效果的相序组合规律运动构成的。在临床中应用中有很多种针具,毫针是古今临床应用最为广泛的针具,所以本课题主要研究的是针具是毫针。因此,在针刺安全理论框架中,毫针具有安全属性,主要是毫针的安全规格。例如：毫针的质量、粗细、长短等。由此可见,针刺安全理论框架,主要针刺安全理论模型,其中系统描述参与者的属性和相互作用,具有高度概括性和开放性。之后将这一理论分析现有案例,系统总结出临床实践中,医生所应遵循的操作规范。之后,本论文用一章节的篇幅分析了针刺安全理论框架与《黄帝内经》中针刺意外与针刺安全研究的承续关系,此部分内容不仅强化了《黄帝内经》对针刺安全理论框架构建的理论指导意义,而且运用针刺安全理论框架中的构成因素,检验其在《黄帝内经》中的应用,进一步加深针刺安全理论框架的认识和理解。本论文的最后一章节对针刺安全与针刺深度之间的关系的进行了初步探讨。其中,针刺安全深度作为针刺安全理论框架在针刺深度中的应用而提出。针刺安全深度就是在保证针刺安全的情况下,最大的针刺深度。针刺安全深度一般是通过危险深度乘以一个小于1的系数而得到的。为了防止针刺过深,我们应该采用针刺安全深度,即是在保证安全的情况下,实现针刺疗效的深度,这样,医生可以在保证安全的情况下追求针刺疗效。4.研究结论通过古籍和现代医学成果的归纳整理,对针刺安全理论进行文献探源研究。在对古籍和现代医学成果的归纳整理的基础上,我们对针刺意外和针刺安全做了系统研究,发现了导致针刺意外发生的五个相关因素,即医生、针具、患者、时间、环境。通过研究各因素的属性和相互作用,进而构建针刺安全理论框架。之后将并将这一理论应用于实践,提出了针刺安全深度的概念。综上所述,针刺安全理论框架的提出将针刺安全理论框架的提出将在减少针刺意外,建立针刺安全临床规范,改进针具,培养高质量医生等方面提供有益的线索和思路,起到指导作用。更多还原

【Abstract】 (1) Research purposesBecause of its unique and wide-range efficacy, acupuncture therapy is becoming an indispensable means in modern clinical treatments. However, acupuncture is a practical therapy with some risks, and may lead to some accidents. In recent years, acupuncture accidents and its side effects have gradually being paid attention, evaluation methods of acupuncture safety are becoming hot and difficult spots in Chinese and foreign medical research. Nowadays, existing studies are mostly focusing on analyses on acupuncture accidents reported in literatures, and discussion on levels of acupuncture safety. Nevertheless, it lacks analyses and summarization of fundamental reasons of acupuncture accidents, as well as theoretical and systematical investigation on the relationship between accidents and safety in acupuncture therapy. Therefore, theoretical studies of acupuncture safety should be strengthened.(2) Research methodsResearch methods in this paper include collection, organization and analyses of literature as well as modeling. Literature is collected by manual access to libraries, looking up online digital databases, such as CNKI, VIP, MEDLINE and so on. Data from literature are analyzed by using both vertical and horizontal methods. By using content analysis, comparitive methds and positive law, constitutive factors of acupuncture safety and their internal connections are found, so that the essence of acupuncture safety and laws governing the operation are summed up. On this basis, the corresponding theoretical model of acupuncture safety is inferred, and further validated.(3) Results Based on the unity of opposites between the acupuncture safety and accidents, from the philological point of view, the ancient and modern literature on acupuncture accidents from China and foreign countries is collected, analyzed and summed up. As a result, it indicates that in ancient times, the thought about acupuncture safety is originated in "Huangdi Neijing", and, nevertheless, scattered throughout various chapters. Nowadays, with the development of a variety of practice standards, means of diagnosis and treatment and clinical experience, acupuncture practitioners and researchers begin to study acupuncture safety. Most of these studies are derived from clinical experience, and lack of systematic summarization and theoretical guidance.Reasons of accupuncture accidents in clinical treamts are complex and diverse. They mainly involve six factors, i.e., practitioners, patients, needles, time and environment. In this work, we only consider one period of acupuncture treatment, typically, duration of which is 30-60 minutes or shorter, and environment of which is indoor and stable. Therefore, here we assume that time and environment are constant, practitioners, patients and needles are variables. As a result, the origianl model of acupuncture treatment is simplied to interactions among practitioners, patients and needles, in which practitioners and patients are subjects, and needles are the media between subjects. Interactions among the practitioner, the patient and the needles run through the whole process of acupuncture treatment. By analyzing interactions among these three factors, it suggests that realization of acupuncture safety is the result of interactions between the practitioner, the patient and the needles, but not only one factor. These interactions are related to attributes and behaviours of these three factors. Based on the proposed theoretical model of acupuncture safety, we further propose a theoretical framework of acupuncture safety.In the proposed theoretical framework of acupuncture safety, safety attributes of the practitioner involve awareness, state of mind and skills. Safety awareness of a practitioner refers to the subjective self-protection awareness of the practitioner formed under circumstances that he/she comprehensively understands adverse effects of acupucture accidents. It is the premise for a practitioner to learn safety skills, produce safety states of mind, and control safety behaviours. For example, the practitioner must have a sense of sterility so as to disinfect very well in clinical treatments for avoiding infection during the acupuncture treatment. The safety state of mind of a practitioner refers to the psychological status of the practitioner during a clinical treatment. It directly determines safety behaviors of the practitioner, and reilects the adaptability of the practitioner’s safety awareness and skills to the changing safety status during a clinical treatment. For example, in case of accidents, the practitioner should keep calm and high responsibility. Safety skills of a practitioner are the technical capability of the practitioner to prevent and control occurrence and development of acupuncture accidents during a clinical treatment. They are the technical support of a practitioner’s safety awareness and behaviours. For example, the practitioner must master knowledge of anatomy and so on. Safety behavoiours of a practitioner are behaviours of the practitioner with safety awareness, state of mind and skills so as to minimize adverse effects of possible acupuncture accidents during a clinical treatment. These behaviours are applied by the practitioner to the patient and the needles. They are determinants for realizing safe consequence. Therefore, in the proposed theoretical framework, from the practitioner’s point of view, acupuncture safety is realized by a sequence of safety behaviours applied by the practitioner with safety attitudes, such as awareness, state of mind and skills.Similarly, in the proposed framework, a patient has safety attitudes and behaviours. Safety attitudes of a patient usually involve such a subjective attitude as safety state of mind, that is the psychological status of the patient during a clinical treatment. Safety behaviours of a patient are behaviours of the patient with safety state of mind to minimize adverse effects of acupuncture accidents during a clinical treatment. It usually embodies the degree that the patient coordinates with the practitioner. Therefore, from the patient’s point of view, acupuncture safety is realized by a sequence of safety behaviours applied by the patient with safety attitudes.Since the filiform needle is the most widely applied kind of needles in acupuncture clinical treatments, the needles considered in this work are filiform needles. In the proposed framework, needles possess safety attitudes, which mainly refer to the safety requirements, such as quality, thickness and length.In short, in the proposed theoretical framework, especially, the proposed theoretical model of acupuncture safety, attitudes and interactions among various factors are systemactically described. The proposed framework and model have high generality and openness. Thereafer, based on this framework and model, we will analyze existing clinical cases, systematically summarize the operation standards followed by practitioners in their practice. Later, the inheritance relationship between the proposed framework and "Huangdi Neijing" is studied. Some basic ideas about acupuncture accidents and safety derived from the proposed framework are described in "Huangdi Neijing", but scattered in various chapters. By applying factors of acupuncture safety proposed in the framework in cases described in "Huangdi Neijing", the insight and understanding of the proposed framework is deepen further.Next, we discuss the relationship between acupuncture safety and needling depth. Needling safety depth is proposed as an application of the proposed framework to needling depth. Needling safety depth refers to the maximum needling depth ensuring acupuncture safety. Needling safety depth is usually obtained by the dangerous needling depth multiplying a positive coefficient of less than 1. The needling safety depth is applied to prevent from needling too deeply, that is to say, the needling safety depth is the needling depth that keeps both acupuncture efficacy and safety. Hence, the practitioner should achieve efficacy under circumstances that guarantee acupuncture safety.(4) ConclusionBy collecting and summarizing ancient and modern acupuncture research, the literature origin of acupuncture safety theory is studied. Based on the systematic study of acupuncture accidents and safety, five factors leading to acupuncture accidents are proposed. These five factors are practitioners, patients, needles, time and environment. By studying their attitudes and interactions, a theoretical framework of acupuncture safety is proposed. Furthermore, by applying this framework to practice, needling safety depth is proposed. In summary, the theoretical framework of acupuncture safety is proposed to provide guiding clues and ideas for reducing acupuncture accidents, setting up clinical operation standards of acupuncture safety, improving needles, and clutivating high-quality practitioners.更多还原