灸法应用于老年创伤骨科护理：现有证据、风险考量与未来研究框架

Moxibustion in Nursing Care for Older Orthopedic Trauma Patients: Current Evidence, Risk Considerations, and a Framework for Future Research

摘要: 背景：老年创伤骨科患者常合并骨质疏松、衰弱、营养不良、感觉减退及多重用药，疼痛、睡眠障碍、活动受限和围手术期并发症相互影响。灸法可能作为综合护理中的辅助技术，但直接证据匮乏，现有依据主要来自慢性膝骨关节炎及其他非创伤场景；若忽视偏倚风险和临床差异，易将间接证据误用为实践标准。目的：系统梳理灸法相关关键间接证据，批判性评价其偏倚风险及向老年创伤患者外推的适用性，并提出供未来研究验证的护理概念模型。方法：检索中国知网、万方、维普及PubMed中与灸法、老年、骨折、创伤骨科、围手术期护理、疼痛、康复和风险管理相关的文献。对关键临床试验、系统评价和安全性研究提取研究设计、目标人群、干预与对照、主要结局和不良事件；随机对照试验依据随机化、分配隐藏、盲法、缺失数据、结局测量和选择性报告进行简化偏倚风险判断，系统评价优先采用原文报告的RoB、AMSTAR-2、ROBIS或GRADE结果，并进行叙述性综合。结果与结论：共梳理10项关键间接证据，包括4项随机对照试验、4项疗效证据综合和2项安全性系统评价。传统燃艾与常规照护对照试验提示部分疼痛和功能结局改善，但烧伤事件较多；模拟灸、激光灸和电子灸试验的内部效度相对较好，但对象均以慢性膝骨关节炎门诊患者为主，干预形式、共病负担和围手术期风险与老年创伤患者不等同。系统评价普遍受到原始试验偏倚、异质性、选择性报告和不良事件漏报影响。本文据此提出以老年特异性风险、共同治疗、剂量可追溯、停止规则和不良事件监测为核心的概念模型。该模型用于生成和检验研究假设，不是可直接推广的临床实践标准；未来应以安全性和标准镇痛基础上的增量效应为优先结局开展多中心、可信对照试验。

Abstract: Background: Older orthopedic trauma patients commonly present with osteoporosis, frailty, malnutrition, sensory impairment, and polypharmacy. Pain, sleep disturbance, restricted mobility, and perioperative complications may interact and compound one another. Moxibustion may serve as an adjunctive intervention within comprehensive nursing care; however, direct evidence in older orthopedic trauma populations remains scarce. Most available evidence is derived from patients with chronic knee osteoarthritis or from other non-trauma settings. Failure to adequately consider risks of bias and clinical heterogeneity may lead to the inappropriate translation of indirect evidence into clinical practice standards. Objective: To systematically synthesize key indirect evidence regarding moxibustion, critically appraise the risk of bias and its applicability to older orthopedic trauma patients, and propose a conceptual nursing model for validation in future research. Methods: The China National Knowledge Infrastructure, Wanfang Data, VIP Database, and PubMed were searched for literature related to moxibustion, older adults, fractures, orthopedic trauma, perioperative nursing, pain, rehabilitation, and risk management. Data on study design, target population, intervention and comparator, primary outcomes, and adverse events were extracted from key clinical trials, systematic reviews, and safety studies. Randomized controlled trials were subjected to a simplified risk-of-bias assessment covering randomization, allocation concealment, blinding, missing outcome data, outcome measurement, and selective reporting. For systematic reviews, priority was given to the risk-of-bias and certainty assessments reported in the original publications using tools such as RoB, AMSTAR 2, ROBIS, or GRADE. The evidence was synthesized narratively. Results and Conclusions: Ten key sources of indirect evidence were identified, comprising four randomized controlled trials, four evidence syntheses of efficacy, and two systematic reviews of safety. Trials comparing traditional combustion-based moxibustion with usual care suggested improvements in certain pain and functional outcomes but reported a relatively high number of burn events. Trials of sham-controlled moxibustion, laser moxibustion, and electronic moxibustion demonstrated comparatively stronger internal validity; however, their participants were predominantly outpatients with chronic knee osteoarthritis. These populations differed substantially from older orthopedic trauma patients in intervention modality, comorbidity burden, and perioperative risk. Existing systematic reviews were generally limited by biases in the original trials, clinical and methodological heterogeneity, selective reporting, and underreporting of adverse events. On this basis, a conceptual nursing model centered on older-adult-specific risks, concomitant treatments, traceable intervention dosing, predefined stopping rules, and systematic adverse-event monitoring is proposed. This model is intended to generate and test research hypotheses rather than serve as a clinical practice standard for immediate implementation. Future studies should employ multicenter designs and credible control interventions, with safety and the incremental benefit of moxibustion alongside standard analgesic care designated as priority outcomes.