查看完整版本: 世界各地针灸临床研究的阳性率

世界各地针灸临床研究的阳性率

[font=Arial]履行承诺，我来支持版主了，我会时不时地发一些中医相关的有意思的东西，比如这个：
有人比较了全世界的针灸研究结果

在medline上，来自澳洲、北美、西欧、东欧和东亚五个地区针灸相关RCT中，各地区研究结果统计学差异明显的份额来自东亚、东欧的分别超过了80%，东亚的接近100%。

而发表在英国、中国、日本、俄罗斯和台湾的中医相关研究中，阳性结果份额中国、日本、俄罗斯和台湾几乎均超过90%，而英国的不超过75%。

很有意思……

来自[url=http://www.jr2.ox.ac.uk/bandolier/band71/b71-3.html]http://www.jr2.ox.ac.uk/bandolier/band71/b71-3.html[/url]。

Search and inclusion
There were two searches. The first used MEDLINE to retrieve papers on acupuncture with abstracts available over 30 years. Papers had to have patients receiving acupuncture who were compared with patients receiving placebo, no treatment or a no acupuncture control.

The second search looked for randomised or controlled clinical trials published in China, Taiwan, Japan or Russia/USSR between 1991 and 1995. In addition, 330 most recent randomised or controlled trials published in England were sought. These studies had to have patients receiving a treatment other than acupuncture compared with patients receiving a control intervention.

Outcomes
Reviewers blinded to the country of origin then retrieved and abstracts examined. The outcome was a superiority of treatment over control based on:

[list][*]Author statement[*]At least one statement of statistical superiority[*]At least one outcome described as superior to control[/list]
Results
For acupuncture, there was a wide discrepancy between countries of origin and the proportion of trials showing superiority of acupuncture. Countries in North America, Western Europe and Australasia were positive for acupuncture about half the time, or less. Those from Eastern Europe and especially East Asia were positive nearly all the time (Figure).

Figure: Proportion of controlled trials of acupuncture showing superiority of acupuncture from five regions, with number of studies[table][tr][td=3,1][img=327,238]http://www.jr2.ox.ac.uk/bandolier/band71/b71-31.gif[/img] [/td][/tr][/table][table][tr][td=3,1]
The four countries which had 100% positive rates for acupuncture were compared with England for positive rates for randomised or controlled trials where acupuncture was not being tested. They also had very high rates of positive trials here as well (Table), as high as 97% for Russia/USSR and 99% for China. Rates for England were consistently lower.

Table: Proportion of trials with treatment better than control for randomised or controlled nonacupuncture studies, and from acupuncture studies, from five countries[/td][/tr][/table][table=90%][tr][td]
[/td][td=2,1][b]Randomised or controlled trials[/b] [/td][td=2,1][b]Acupuncture trials[/b] [/td][/tr][tr][td][b]Country[/b] [/td][td][b]Number[/b] [/td][td][b]Positive (%)[/b] [/td][td][b]Number[/b] [/td][td][b]Positive (%)[/b] [/td][/tr][tr][td]England[/td][td]107[/td][td]75[/td][td]20[/td][td]60[/td][/tr][tr][td]China[/td][td]109[/td][td]99[/td][td]36[/td][td]100[/td][/tr][tr][td]Japan[/td][td]120[/td][td]89[/td][td]5[/td][td]100[/td][/tr][tr][td]Russia/USSR[/td][td]29[/td][td]97[/td][td]11[/td][td]91[/td][/tr][tr][td]Taiwan[/td][td]40[/td][td]95[/td][td]6[/td][td]100[/td][/tr][/table][table][tr][td=3,1]
Comment
The authors of this review did a terrific job in trying to eradicate bias from their analysis. They acknowledge that because they included controlled trials, and looked only at abstracts, they will have included studies with known methodological bias. They also acknowledge that authors can and do make misleading or mistaken comments about trial results in abstracts.

That having been said, there remains a gulf between studies reported from different parts of the world. Bias may be institutionalised in some places, or may just be harder to detect in others. The reason randomisation schedules for patients are often described as being enclosed in metallised envelopes is because people have been known to X-ray envelopes to break the code before allocation.

The inference is obvious. Quality is much more important than quantity. No matter how many trials of inadequate or biased design we have, they do not match up to one trial of adequate size and methodological rigor. Quality is first, and everything else is nowhere.

"All was wrong because not all was right" is a useful quotation from George Crabbe that might usefully govern the interpretation of evidence. It applies to all therapies.

Reference:[list=1][*]A Vickers, N Goyal, R Harland, R Rees. Do certain countries produce only positive results? A systematic review of controlled trials. Controlled Clinical Trials 1998 19: 159-166.[/list][/td][/tr][/table][/font]

[[i] 本帖最后由 茯神 于 2008-7-10 19:12 编辑 [/i]]

看不懂，这有什么代表意义吗？

有很多主观因素在里面起作用

相当严重的发表偏倚（publication bias），报告偏倚
当然，也跟针灸本身的文化影响有关系
比如中国的病人，了解针灸，虔诚地来扎针的，安慰剂效应、主观影响是需要考虑的，外国人有的根本不知针灸为何物，迷迷糊糊就来了，所以在国外针灸可以做到针灸的安慰剂，也就是假针刺，给患者蒙上眼睛，用别的什么不入皮肤，象征性点一点，他也认为这就是扎了，从而和治疗组比较，在国内怎么行，患者自己也是半个行家，没有酸麻胀痛，他们才不干呢，所以这个是文化的差异。
意大利有个教授，1998年在中国做了个艾灸至阴穴转胎位的RCT，显著，阳性结果，2005年，又在意大利的白人当中如法炮制了一个，阴性结果。试验设计是相似的，结果却指向相反的方向，如何解释？

中医实在是一个复杂干预。

[[i] 本帖最后由 晚风里的婵娟 于 2008-10-27 12:26 编辑 [/i]]

呵呵，原来如此，茯神老前辈的小背心这回我算是记住了！哈哈~~

    艾灸的例子，您说做一个平行对照试验，我很同意，如果真的有人做，一定会很有意思！
    我个人认为中药对人体的作用和针灸对人体的作用原理，机制恐怕还不一样。的确针灸在西方国家渐渐盛行并且为人所知了，但是我的意思是说接受治疗的老百姓对针灸并不是那么有感性认识。想想中国的老百姓，从小就对中医，针灸耳濡目染，对经络、、穴位、得气这些概念很清楚，大夫要是没有正正规规地扎，一下子就能明白，所以  假针刺在国内实行起来很困难，我想日本，还有相对来说熟悉中国文化的俄罗斯有可能存在类似的情况；
    说到假针刺（sham acupuncture），在西方国家并不罕见。实施的时候，通常可以同时对患者设盲，在患者体表画上穴位点（有时候故意画上不对的），用一块布挡上患者使其看不见医生的操作，运用特制的类似针灸的工具（实际上有很多不同的方法）使得患者感到热感或者感到有东西刺进皮肤（但是实际上刺得很浅，不达到针灸治疗应该到达的深度），总之让患者认为自己接受了针灸治疗，两组比较疗效。

关于针灸安慰剂的问题

还有一个关于针灸安慰剂的问题，上一层楼里说到有时候针刺故意不刺在正确的穴位上，而是刺偏，或者刺在一个不相干的体表位置，有不少临床研究结果显示，这样的“安慰剂对照”，治疗组的正规针刺和对照组这样非穴位的刺激，得出结果没有显著性差异，这让中国针灸着实尴尬了一段时间。然而对于晕症，痛症，针刺的效果是很明显的，所以现在WHO已经正式提出，对于针灸治疗晕症痛症的临床研究，不适宜再设立安慰剂对照组。
    于是就有很多人开始思考，得出结论，其实针灸治疗的效果，有很大一部分恰恰就是安慰剂效应！然后很多人就开始非常不高兴，开始抗议，争论。
    到底是不是安慰剂效应在这里不乱说了，大家怎么看呢，我个人认为，我们应该关注的是患者的结局，是疗效。如果说针灸有效，不管是什么样的效果，难道不值得鼓励和发扬么？

我的意见是具体文献具体分析，针灸的选穴本来就是很大的学问，不要说老外，你我知道选那个穴位效果比较好吗？即使要对针灸下安慰剂效应的结论，也应该有严格的试验来证明，仅仅是想是不可能服众的。
在我看来，针灸最大的贡献并非在于不确切的疗效，而在于为全人类提供了一种中国原创的疗法，区别于药物治疗的疗法，至少现在我们已经证实，对一些疾病，它确实是有效的。那么对什么疾病有效，在什么情况下有效，扎什么位置有效，是不是和经络循行有关，最终或许产生新的理论，都只是学术上的不断完善和进步了。而对于穴位，有效点就是穴位，不见得一定和经络有关（比如经外奇穴）。
那么穴位的问题其实变成了寻找最有效的针刺点的问题了，人的身体本来就不是均质的，所以认为扎哪都一样我觉得是个很天真的想法。
同理，即使找到了穴位，证实了有效点的存在，并不意味着支持了经络的理论，因为经络理论本身是讲气血循行的，在这个问题上，过于复杂。或者加上时间因素类似于子午流注的寻找最佳时点都更有可能出成果。