Zong he shi yong ding liang ji ding xing de yan jiu fang fa ping gu dian zhen zhi zhi liao gong neng xing xiao hua bu liang de qian li

Ph.D.Randomized controlled trials (RCT) evaluating the efficacy of acupuncture often face challenges in design and conduct process when using sham controlled approach. Acupuncture treatment in efficacy trial may not implement clinically relevant elements which are common in day-to-day practice of acupuncture. Taking into account these elements might be critical in evaluation of overall therapeutic outcomes aside from needle insertion per se, that is, the non-specific effects of acupuncture. Overall therapeutic effect of acupuncture might therefore be underestimated if non-specific effects are ignored. To overcome limitations of efficacy approach and focus on value of day-to-day acupuncture practice, it is more appropriate to use the comparative effectiveness research approach. This will allow evaluation of acupuncture against existing treatment options in real world circumstances. To express full therapeutic potential of acupuncture, it is crucial to understand what, why, and how non-specific effects of acupuncture contribute to positive or negative outcomes. This thesis aims to employ mixed method approach in evaluating the effect of acupuncture for managing functional dyspepsia (FD). Methodologies used include network meta-analysis (NMA), qualitative systematic review (SR), and qualitative study, as well as moderation and mediation analyses nested in an RCT. NMA aims to critically appraise and synthesize all clinical evidence on comparative effectiveness of different acupuncture and related therapies on FD treatment. Qualitative SR aims to synthesize existing qualitative evidence among participants who randomized to acupuncture and sham acupuncture in experiencing non-specific effects. Qualitative study aims to explore how and why responders and non-responders to acupuncture experience non-specific effects differently in FD management. Moderation and mediation analyses aim to investigate the mechanisms of electroacupuncture for relieving FD.Results from NMA demonstrated combined manual acupuncture and clebopride treatment has the greatest probability of being the best among eleven treatment choices in alleviating patient reported global FD symptoms. Patients who are contraindicated for prokinetics may utilize manual acupuncture or moxibustion as alternative. Results from qualitative SR indicated non-specific effects of acupuncture could be enhanced by maintaining professional image, applying holistic treatment approach, practicing empathy, and providing patients with appropriate explanation of therapeutic mechanism by acupuncturists. From patients' perspective, lifestyle modification advice provided by acupuncturists, maintaining positive attitude toward treatment, active engagement with acupuncturists during consultation, and making behavioural changes in response to trial experience could collectively contribute to therapeutic effect of acupuncture. Moreover, results from qualitative study showed acupuncture responders have a more trusting relationship with acupuncturist in response to their expression of empathy. Subsequently, responders were more actively engaged and followed dietary adjustment and lifestyle modification advice from acupuncturists. Meanwhile, non-responders were not satisfied with level of reassurance on acupuncture safety. Non-responders were also expecting more peer support from fellow participants as they regarded it as empowerment for initiating and sustaining lifestyle changes. Without these components, they would experience less benefit from acupuncture. Results from moderation analyses cross-validated with the results of the qualitative study quantitatively, showing higher patients' baseline expectation could increase the probability for patients to achieve adequate relief for FD symptoms and improve aggregate symptom score of nutrient drink test who received electroacupuncture. FD patients with lower depression score were more responsive to electroacupuncture. FD patients who had major depressive disorders were shown to be more responsive to electroacupuncture when they maintained a higher patients' baseline expectation. Electroacupuncture could not alleviate FD symptoms via reducing depression or anxiety, as shown in mediation analysis.In conclusion, combined acupuncture and prokinetics demonstrates to be the best among treatment options for FD management. A basis for improving and standardizing components of non-specific effects in acupuncture is generated. Non-specific effects contributing to overall effect of acupuncture should be enhanced in day-to-day practice by emphasizing empathy, trust-building, detailed explanation on safety, and organizing patient self-help groups. To increase the probability for FD patients in responding to electroacupuncture, patients' expectation should be maximized before receiving electroacupuncture. Additional acupoints or conventional treatments targeting depression should be applied among FD patients with major depressive disorders.使用隨機對照試驗評估針灸的效力經常會遇到挑戰, 包括針灸過程和研究設計。針灸的效力試驗可能忽略平常針灸實踐中常見的臨床相關因素。當進行整體針灸治療評估時, 這些因素都可能會帶來針刺以外的治療效果, 名為"非特定效應"。如忽略針灸的非特定效應, 可能會低估針灸整體治療的效果。為了突破效力試驗的局限性, 應使用"比較效果研究"的方法。這樣可將針灸作為現實世界的治療方案來評估。為顯露針灸的全部治療潛力, 應了解為何非特定效應能帶來正面或負面的治療效果。本論文旨在綜合地使用定量及定性的研究方法評估針灸治療功能性消化不良的療效。使用方法包括網絡薈萃分析, 定性系統評價和嵌套在隨機對照試驗中的定性研究, 調節變數及中介變數的定量分析。首先, 網絡薈萃分析旨在評估和綜合所有關於不同針灸和相關療法對功能性消化不良的效果的臨床證據。第二, 定性系統評價旨在綜合病人在隨機對照試驗接受針灸和假針灸時對非特定效應的體會。第三, 定性研究旨在探討為何對針灸有正面反應的病人和對針灸沒有正面反應的病人有不同的非特定效應體會。第四, 調節變數及中介變數的定量分析旨在了解關於電針灸舒緩功能性消化不良的機制。網絡薈萃分析結果顯示，在十一種治療方案中, 針灸聯合氯波必利能最有效改善功能性消化不良的整體症狀。對於不能服用胃腸動力藥的病人,可選擇使用針灸或艾灸。定性系統評價結果表示, 若中醫師能為病人採用整體治療方法，解釋針灸的理論，保持專業形象，並同情病人, 可以提高針灸的非特定效應。從病人的角度來看，若能保持積極的治療態度，主動諮詢中醫師的意見, 接受中醫師建議的生活方式，及根據試驗期間獲得的經驗作出行為的改變, 可以加強針灸的治療效果。此外，定性研究結果顯示，對針灸有反應的病人，中醫師的同情心可以得到他們的信任。因此, 病人會更積極接受針灸師建議的生活方式, 包括飲食調整。相比之下，對針灸沒有反應的病人認為針灸安全的保證需要增強。他們覺得若得到其他一起參加針灸的病人的支持, 能啟發及維持改變了的生活方式。沒有這些因素, 針灸治療帶來的益處就會減少。最後, 調節變數及中介變數的定量分析確認了定性研究的結果, 表明了對電針灸有較高期望的病人有較高機會得到病情的舒緩及改善營養飲料測試的總體症狀評分。抑鬱症狀較輕的病人對電針灸的反應有更佳的反應。電針灸沒有證明到通過減少抑鬱或焦慮而可以舒緩功能性消化不良的症狀。若患有嚴重抑鬱症的功能性消化不良病人對電針灸有較高期望的時候, 他們會對電針灸有更佳的反應。總括而言, 針灸聯合胃腸動力藥在多種治療方案中能最有效地舒緩功能性消化不良。我們亦奠定了改進和標準化針灸非特定效應的基礎。若中醫師能得到病人信任，對病人表達同情及詳細解釋針灸的安全性，而病人之間亦能互相支持，針灸的非特定效應可以進一步增強。接受電針灸治療前, 應加強病人對針灸治療的期望。額外針對舒緩抑鬱的穴位和治療可應用於患有嚴重抑鬱症的功能性消化不良病人。Ho, Sze Tak Robin.Thesis Ph.D. Chinese University of Hong Kong 2019.Includes bibliographical references (leaves 254-276).Abstracts also in Chinese.Title from PDF title page (viewed on 15, December, 2020).Ho, Sze Tak Robin