Analgesic effect of acupuncture on herpes zoster
Herpes zoster (abbreviated as HZ) is a viral skin disease, characterized by varicella-zoster virus invading the ganglion and skin, and cluster herpes and neuralgia distributed along the peripheral nerves. It is characterized by invading one or more skin areas on one side, mostly annular or strip lesions on the trunk. The author used the central randomized controlled study method to treat patients with acute herpes zoster with different acupuncture methods, observed the analgesic effect of different acupuncture methods, and analyzed the relationship between patient satisfaction and analgesic effect. The results are reported as follows.
1 data and methods
1. 1 research object
The cases originated from the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou Hospital of Traditional Chinese Medicine and Guangdong Second Hospital of Traditional Chinese Medicine in April 2007? From June 5, 2009 to 10, 2009, inpatients or outpatients in acupuncture department and dermatology department. 10 1 patient with acute herpes zoster were randomly divided into group a (30 cases in electroacupuncture group), group b (23 cases in cotton-separated moxibustion group), group c (25 cases in fire needle group) and group d (23 cases in tapping and cupping group). Excluding 5 cases of mistaken admission and 2 cases of falling off, the results finally met the plan: 27 cases in group A, 23 cases in group B, 24 cases in group C and 20 cases in group D, a total of 94 cases. There were 54 males (57.4%) and 40 females (42.6%). The youngest is 20 years old and the oldest is 70 years old, with an average of (43.38+0? 1.59 years old. There was no significant difference in sex, age, height, weight and vital signs among the four groups (P & gt0.05). Moreover, there was no statistical difference between the two groups (P & gt0.05). Comparability between groups.
1.2 test standard
(1) Diagnostic criteria: Diagnostic criteria of traditional Chinese medicine: refer to the diagnostic criteria of snake string sores in Diagnostic Efficacy Criteria of TCM Diseases and Syndrome [1]. Diagnostic criteria of western medicine: refer to the diagnostic criteria of herpes zoster in Cecil's medical textbook [2]. (2) Inclusion criteria ① Age 18 ~ 70 years old; ② those who did not receive antiviral and analgesic treatment within 1 ~ 7 days after the onset of herpes; (3) sign the informed consent form, agree to accept the various treatment methods of the research group, and obey the personnel arranged by the research group. (3) Exclusion criteria ① belong to special types of herpes zoster, including herpes zoster of eyes and ears, visceral herpes zoster, meningeal herpes zoster, systemic herpes zoster and herpes zoster without rash; ② Pregnant or lactating women; (3) allergic constitution, allergic to various drugs; ④ those with scar constitution; (5) Patients with serious primary diseases such as cardiovascular and cerebrovascular diseases, liver diseases, nephropathy, hematopoietic system or systemic failure, patients with diabetes, malignant tumors, psychosis, connective tissue diseases and hemophilia, and patients with bleeding tendency; ⑥ The patient's condition is critical, so it is difficult to accurately evaluate the effectiveness and safety of treatment; ⑦ 1 month should have used corticosteroids or immunosuppressants.
1.3 processing method
All patients in the four groups kept their skin clean and paid attention to the protection of skin lesions. During the treatment, take the lying position and carry out routine skin disinfection. (1) The acupoints in group A (electroacupuncture group) were Ashi, Jiaji, Zhigou and Houxi. Operation method: All acupoints are selected according to the national standard acupoint position. Ashi point is partially surrounded by a flat needle, Jiaji point obliquely pierces the spine, and directly pierces Zhigou point and Houxi point, all of which are about 0.8 ~ 1.0 inch. After acupuncture became angry, it was connected to Han's acupoint stimulator, with the frequency of 2/ 100Hz and the intensity of 2 ~ 5 mA, depending on the patient's tolerance. 1 time per day, 1 time is 1 course of treatment, a total of1course of treatment. (2) Group B (electroacupuncture+cotton-spreading moxibustion group) Operation method of cotton-spreading moxibustion: the degreased dry cotton is torn as thin as cicada's wings, about 3cm? 3cm cotton pieces, according to the area of skin lesions to determine the number of moxibustion cotton pieces. Apply it to Ashi point, light cotton with a match, and apply moxibustion 3 times each time. Other treatments and courses of treatment are the same as those in group A (3) and group C (electroacupuncture plus fire needle group): the operator holds the lighted alcohol lamp in his left hand, and heats the needle body in the external flame with the medium and thick fire needle in his right hand until the needle tip burns red and white, and then quickly and accurately pierces the center of herpes for about 0.2-0.3 cm. According to the number of herpes, the early-onset herpes is pricked first, 3-5 herpes are selected at a time, each herpes is pricked twice, and the blister fluid is squeezed out after operation. Other treatment methods and courses are the same as those in group A (4) and group D (electroacupuncture+pricking collaterals and cupping group): the performer pricks Ashi point with one-time plum blossom, then selects a glass jar with appropriate size and pulls it quickly at the puncture site and both ends of the lesion. Let the jar stand for 5 ~ 10 minute, and bleed 3 ~ 5 ml. After taking the cupping, disinfect the affected area with active iodine, and determine the type and quantity of cupping according to the size of herpes. Other treatments and courses of treatment were the same as those in group a.
1.4 observation index
(1) pain evaluation index ① pain intensity (VAS evaluation method, unit: mm): record the most painful point within 24 hours before the observation point. With 100mm as the sign, 0 means no pain, and 100mm means the maximum pain intensity that the patient can imagine. ② Degree of pain relief (%): Record the relief of pain intensity relative to the baseline within 24 hours before the observation point. The recording range is 0 ~ 100%, where 0 means no remission at all and 100% means complete remission. ③ Pain relief time (d): the time required from the patient's beginning to feel pain until the degree of pain relief is kept above 30%. ④ Pain duration (d): the time from the patient's feeling of pain to the complete disappearance of pain. Records were made before each treatment and on day 1 ~ 10. ③ If item 4 (pain not relieved or disappeared) cannot be recorded during the treatment, it should be recorded on the 22nd, 30th, 60th and 90th day of follow-up. (2) Patient satisfaction: using the scale method, 0 ~ 100 represents the patient's tolerance to the treatment measures, 100 represents very satisfied, and 0 represents very dissatisfied. Ask the patient to read the position that best represents his tolerance and record the reading (points). Recorded on 1 1 day.
1.5 statistical method
The numerical value is (x? S) means that all data have been tested by K-S normal distribution before comparison. One-way ANOVA was used for normal distribution data, and nonparametric test was used for non-normal distribution data. For non-normal distribution data, Kruskal-Wallis test was used for comparison between groups, Mann-WhitneyU test was used for comparison between groups, and Spearman correlation coefficient was used for correlation analysis. Spss 18.0 was used for statistical analysis.
Two results
2. 1 the relationship between patient satisfaction and VAS pain score
See table 1 and figure 1. The VAS score of patients with herpes zoster in each group decreased significantly after treatment, and there were differences in the VAS score of each group after treatment. The VAS score of group A after treatment was (0.63? 1.62), group b (8.04? 10.95). There was no significant difference between the four groups before and after treatment (P & gt0.05), which indicated that after acupuncture treatment 1 course of treatment, the overall analgesic effect of each acupuncture group was similar. After treatment, the satisfaction of patients with herpes zoster in each group was different (P < 0.05). The satisfaction of patients in group A (electroacupuncture group) and group C (electroacupuncture+fire needle group) was higher than that in group B (electroacupuncture+cotton-spreading moxibustion group) and group D (electroacupuncture+tapping and cupping group) (P < 0.05). The patient satisfaction in electroacupuncture group was similar to that in electroacupuncture+fire needle group (P & gt0.05). The patients' satisfaction in electroacupuncture+cotton-spreading moxibustion group and electroacupuncture+tapping and cupping group was similar (P & gt0.05). From the patient's point of view, compared with electroacupuncture+cotton moxibustion, electroacupuncture+tapping and cupping, patients agree with electroacupuncture or electroacupuncture combined with fire needle. Patient satisfaction refers to the comprehensive evaluation of medical services received by patients with their own understanding of health, weighing their own economic conditions and combining their own medical requirements. [4] It involves every link in the whole process of seeing a doctor, and analyzes the correlation between patient satisfaction and VAS score after treatment and the difference between VAS score before and after treatment. Results As shown in Figure 1, there was no significant correlation between patient satisfaction and the VAS score after treatment and the difference of VAS score before and after treatment (all P & gt0.05).
2.2 Relationship between patient satisfaction and pain relief, pain duration and pain relief degree.
See Table 2 and Figure 2. There was no significant difference in pain relief time and pain duration between the four groups (P & gt0.05), but there was significant difference in pain relief degree (P
3 discussion
Herpes zoster belongs to the category of traditional Chinese medicine? Snake sore? Category, its occurrence is mostly due to the lack of healthy qi in the body, and damp-heat toxin fumigates the skin along the liver, gallbladder and meridians; In the later stage of the disease, the residual poison is not clear, and blood stasis blocks the skin, causing neuralgia. Neuralgia is one of the characteristics of herpes zoster, which can appear before or accompanied by rash. Neuralgia is the main cause of herpes zoster. Analgesia is a major function of acupuncture, which can alleviate the pain of herpes zoster and shorten the pain duration [5-6]. This scheme takes Ashi point, Jiaji point, Zhigou point and Houxi point as the treatment targets. Based on the pathogenesis of snake string sore, this scheme has the functions of clearing away heat and toxic materials, promoting blood circulation to remove blood stasis, eliminating dampness and relieving pain. The patients with herpes zoster were treated by electroacupuncture, electroacupuncture plus cotton moxibustion, electroacupuncture plus fire needle, electroacupuncture plus knocking and cupping. Although there are significant differences in VAS score and pain relief degree between the groups after treatment, there are no significant differences in VAS score, pain duration and pain relief time before and after treatment, and there are no significant differences in patients' satisfaction with pain intensity, VAS score, pain duration, pain relief time and pain relief degree after treatment. Except for the degree of pain relief in group A, there was no significant difference in VAS score, pain duration, pain relief time and pain relief degree between the two groups before and after treatment. Considering that the natural course of herpes zoster is generally 2-3 weeks [7], it is estimated that the natural course of most patients has recovered at the observation point after treatment, so it cannot reflect the difference of analgesic effect of various treatment methods. The electroacupuncture method is acupuncture around Ashi point plus Jiaji point, Zhigou point and Houxi point, and the other three therapies are based on this, namely, cotton-covered moxibustion, fire needle and percussion cupping. After treatment, the VAS score of group A (electroacupuncture group) was significantly lower than that of group B (electroacupuncture+cotton-covered moxibustion group), while the degree of pain relief of group A was better than that of group B. The results showed that acupuncture itself brought some pain to patients, and electroacupuncture and cupping were used.
Patient satisfaction in this study refers to the patient's tolerance to the treatment measures he accepts with a score of 0 ~ 100. The higher the score, the higher the satisfaction, which belongs to the clinical outcome reported by patients. The clinical data reported by patients has become the focus of clinical efficacy evaluation, which can be used to evaluate and choose the best treatment plan. [8] The results of this study show that patients who use different acupuncture methods to treat acute herpes zoster prefer electroacupuncture or electroacupuncture combined with fire acupuncture, but there is no obvious correlation between patient satisfaction and VAS score after treatment, the difference between VAS score before and after treatment, pain duration, pain relief time and pain relief degree.
Model essay II: Analysis of acupuncture evidence in evidence-based medicine
1 Establishment of sources and categories of evidence in acupuncture research
Based on the enlightenment of the evidence evaluation system of evidence-based medicine to acupuncture medicine, according to the development status and characteristics of acupuncture discipline and the scope of evidence sources, the evidence categories of acupuncture research determined in this study mainly include: modern research evidence, ancient books recorded evidence and expert experience evidence, among which modern research evidence includes randomized controlled trial research, non-randomized controlled trial research, case sequence research and case report. The following is a brief explanation of the characteristics and reasons for including all kinds of research evidence.
1. 1 The evidence recorded in ancient books is the accumulation of clinical experience of acupuncture in past dynasties, which not only covers valuable information such as safe and effective successful experience of acupuncture, indications, contraindications and precautions of acupuncture, but also repeatedly proves its authenticity, reliability and applicability through thousands of years of clinical practice. Therefore, the evidence of acupuncture prevention and treatment of diseases recorded in ancient medical books is one of the best evidence that can not be ignored in acupuncture clinical decision-making. The recorded evidence of ancient books included in this study covers all acupuncture treatment documents before the Qing Dynasty, including acupuncture prescription documents and acupuncture medical records focusing on diseases in content and form.
1.2 expert empirical evidence empirical literature is often the most direct experience record of clinical medicine, and it is the result of the combination, breakthrough and innovation of clinical practice and medical theory, which has high theoretical generalization and practical guiding significance. Therefore, the experience summary of acupuncture experts is also one of the best evidences that can not be ignored in acupuncture clinical decision-making. The expert experience summary included in this study is mainly the clinical experience literature of domestic acupuncture experts after 19 19, which is divided into the experience of famous Chinese medicine experts and the experience of general acupuncture experts according to their qualifications.
1.3 evidence of modern clinical research Modern clinical research literature is the main source of evidence of acupuncture clinical research. One of the characteristics of acupuncture and moxibustion is syndrome differentiation and treatment, emphasizing individualized treatment and rich therapies. Therefore, the randomized controlled trial of acupuncture with unified and standardized treatment scheme is not enough to represent the whole picture of acupuncture clinical research. Therefore, this study includes not only randomized controlled trials, but also non-randomized controlled trials, case series studies and case reports, without systematic review or meta-analysis.
(1) Randomized controlled trial: Randomized controlled trial (RCT) is considered as the best research design to evaluate the effectiveness and safety of medical interventions, with the best strength and scientificity of evidence [4]. In this study, RCT is regarded as one of the evidences of acupuncture research, but the evaluation of acupuncture RCT should consider both the quality of experimental design and the clinical practice of acupuncture.
(2) Non-randomized controlled studies: At present, non-randomized clinical controlled trials (CCT) still occupy the majority position in the fields of traditional Chinese medicine and acupuncture [5]. Although this kind of research does not adopt random method, compared with the control group, non-random clinical controlled research can still provide valuable information or clues for acupuncture clinical decision-making. Therefore, non-randomized clinical controlled study is one of the evidence sources of acupuncture research in this study.
(3) Case series study: The value of case series study (Caseseriestri-al) is that it can be used to observe the sick people excluded from clinical controlled trials, give full play to the characteristics of acupuncture and moxibustion treatment based on syndrome differentiation, and its cost is low. Moreover, in the modern clinical research literature published in China, case series research is the most, so this study also included it in the scope of acupuncture research evidence.
(4) Cases: single case study, also known as single case report. Acupuncture medical records often flexibly record excellent treatment schemes or complete treatment change processes, which is the document form that best reflects the characteristics of syndrome differentiation and treatment of traditional Chinese medicine and complex intervention of acupuncture therapy, and has certain value for acupuncture clinical practice. Therefore, individual cases are also included in the scope of acupuncture research evidence. What needs to be added is that systematic evaluation or meta-analysis is one of the best evidences advocated by evidence-based medicine, but the acupuncture treatment scheme is flexible according to the syndrome and emphasizes clinical research? Homogeneity? Systematic review and meta-analysis are not enough to compare and analyze one by one, and it is also difficult to take into account the core characteristics of acupuncture and moxibustion treatment based on syndrome differentiation and comprehensive intervention, so this study did not include them in the research evidence category of clinical decision analysis.
2. Establish the evaluation method of evidence quality in acupuncture clinical research.
Based on the evidence evaluation methods and standards of acupuncture research formed during the formulation of Evidence-based Acupuncture Clinical Practice Guide-Facial Paralysis, this study supplemented and improved the existing evidence evaluation methods and standards in the field of traditional Chinese medicine [6-7], and initially established the scoring standards and grading standards of evidence quality of various acupuncture research.
2. 1 evaluation method of evidence quality recorded in ancient books: the evidence in ancient medical books is explanatory, and it is a record of clinical experience or a description of specific medical processes. Therefore, this study mainly considers the factors such as the quality of medical books, the qualification of doctors, the form of records (medical records, discourses), the intensity of evidence application, the completeness of content and so on, and initially establishes the evaluation table and grading standard of evidence quality of ancient books records. (1) Quality grading standard: quality literature: score? 5 points, and must meet the above 1 in the first three articles, among which those who meet the second article are classic writings and contributions, and those who meet the third article are ancient certificates used in past dynasties. Medium quality literature: scores? 4 points, and must meet more than 2 of the first 4 items (including 2 items). Low-quality documents: those with a score of about 4 points. (2) Description of evaluation index: Precious books: This study refers to 67 kinds of acupuncture medical books included in the large-scale series "Acupuncture Classic Series" edited by Professor Wang Xuetai. Classical works of ancient acupuncture and moxibustion: By combining expert consultation with group discussion, the classical works of ancient acupuncture and moxibustion preliminarily determined in this study refer to Suwen, Lingshu, Difficult Classic and A-B Classic. Famous ancient acupuncturists: According to the literature of traditional Chinese medicine, medical history and the history of acupuncture development [8-9], 33 famous ancient acupuncturists were initially identified, including Huangdi, Bian Que, Hua Tuo, Fu Weng, Guo Yu, Cao Yao, Lu Guang, Huangfu Mi, Xu, Ge Hong. Recorded for past dynasties: refers to the repeated application of this treatment scheme in past dynasties.
2.2 Quality evaluation method of expert experience evidence Expert experience summary is generally summarized by the expert himself or others, and the source scope includes representative monographs and periodical papers of expert experience. On the one hand, the inclusion and exclusion criteria are formulated according to the characteristics of disease diagnosis and treatment, on the other hand, the quality evaluation table and grading criteria of expert experience evidence are preliminarily formulated according to the definitions of expert category, author, carrier form and reliability of experience summary. (1) Quality grading standard: quality literature: score? 5 points, and must meet the first three items above 1. Medium quality literature: scores? 4 points, and must meet more than 2 of the first 4 items (including 2 items). Low-quality documents: those with a score of about 4 points. (2) Description of evaluation index: definition of famous and old Chinese medicine experts in acupuncture field: in the time range, it is defined as famous and old Chinese medicine practitioners in modern acupuncture from the Republic of China to the present; Furthermore, according to the development of philology, medical history and acupuncture [8-9], referring to the list of academic experience integration instructors of the first, second, third and fourth batches of famous old Chinese medicine experts published by state administration of traditional chinese medicine, after expert consultation, discussion and summary, the scope of modern famous old Chinese medicine practitioners was initially determined, with their representative works and the experience summarized by others as the evidence source. Chinese Core Journals: According to the definition of Overview of Chinese Core Journals compiled by Peking University Library from the first edition to the fifth edition.
2.3 quality evaluation method of modern acupuncture research evidence (1) randomized controlled trial: based on CONSORT statement [10] and Jadad evaluation scale [1 1], combined with acupuncture clinical practice and literature characteristics, supplemented the quality control standard, curative effect index and literature carrier index of intervention measures, and initially formulated randomized controlled trial. Quality grading standard: high-quality literature: score? 1 1, what about the first three scores? Three points Article 4 ~ 1 1 meets more than 5 requirements. Medium quality literature: scores? 10, and the top 3? 2 points, item 4 ~ 1 1 satisfies more than 3 items; Or score? Eight points. What about the first three points? 2 points, and must comply with Article 4 ~ 1 1 and meet Article 5 or above. Low quality literature: score -8, top 3? 1 min; Or the observed object has no clear diagnostic criteria. (2) Non-randomized controlled trials: On the basis of RCT evaluation, according to the characteristics of non-randomized clinical controlled trials, the quality evaluation table and grading standard of this kind of evidence were initially formulated. Quality grading standard: high-quality literature: score? 8 points, and the first 8 standards must reach 5 (including 5) or more. Medium quality literature: scores? 8 points, but the first 8 evaluation criteria meet the following 5. Low-quality literature: there is no clear diagnostic standard for the observed object; Or score -8 points. (3) Quality evaluation method of sequence study: Based on RCT evaluation and the characteristics of case sequence study, the quality evaluation table and grading standard of this kind of evidence were established, as shown in Table 5. Quality grading standard: high-quality literature: score? 8 points, and the first 8 standards must reach 5 (including 5) or more. Medium quality literature: scores? 8 points, but the first 8 evaluation criteria only meet the following 5. Low-quality literature: there is no clear diagnostic standard for the observed object; Or score -8 points. (4) Cases: The formulation of the quality evaluation table and grading standard of acupuncture cases takes into account the carrier form, the qualification of the author, the integrity of the patient's diagnosis and treatment information, the treatment measures, the curative effect and other factors. See table 6 for details. Quality grading standard: high-quality literature: score? 5 points, and must comply with articles 4 and 7. Low-quality Literature: Score -5 or Score? If the score is 5 points, it does not meet the standards of Articles 4 and 7.
3. The formation of evidence strength and recommendation grade standard in acupuncture clinical research.
This study follows the principles and methods of evidence-based medicine and combines the characteristics of acupuncture. Through expert meeting discussion and questionnaire consultation, the research evidence strength and recommendation grade standard of acupuncture evidence-based decision-making were preliminarily formulated. The quality of evidence corresponds to the level of recommendation intensity, that is, the recommendation intensity of high-quality evidence is also high.
4 conclusion
Following the best research evidence is the key link to practice evidence-based medicine, and evidence evaluation is the premise to ensure its utilization. Therefore, this study organically integrates the concepts and methods of evidence-based medicine with the principles of acupuncture clinical practice and the characteristics of existing literature, and initially establishes an evidence evaluation system for acupuncture clinical research that conforms to its own characteristics. The system has the following characteristics.
4. 1 refer to the evidence evaluation method of evidence-based medicine and combine the characteristics of acupuncture and moxibustion.
Evidence-based medicine takes objective and true evidence as a reliable source of clinical decision-making, and its ideas, ideas and methods are worthy of in-depth study and reference by acupuncture and moxibustion medicine. There are also a large number of documents used in acupuncture clinical decision-making. Therefore, the purpose of this study is to dig out the real and effective treatment scheme from the literature, refer to the evidence evaluation method of evidence-based medicine and combine the characteristics of acupuncture, and establish a set of evidence evaluation system for evidence-based decision-making in acupuncture clinic. This system not only includes the evaluation methods of research evidence such as RCT, CCT and case sequence, but also emphasizes the position and role of experienced evidence of famous experts and evidence recorded in ancient books, and emphasizes the role of evidence reflecting the actual characteristics of acupuncture and moxibustion in the evaluation system, which can basically reflect the laws and characteristics of acupuncture and moxibustion clinical practice.
4.2 For the purpose of acupuncture clinical decision-making, research evidence should be included as much as possible.
The evidence evaluation system of acupuncture clinical research is a methodological exploration of applying modern evidence-based medicine to study acupuncture clinical decision-making. It spans two different medical systems, but in the final analysis, it is based on acupuncture theory and practice. Therefore, the system must take into account the characteristics of clinical individualization and experience of acupuncture. Randomized, controlled and blind methods are the best methods for clinical reliability evaluation, but due to the completely different theoretical systems of Chinese and Western medicine, there are still many inapplicability in applying these methods to acupuncture clinical practice. Acupuncture clinical literature includes RCT, CCT, case series research, expert experience, case report, evidence recorded in ancient books and so on. There are differences in the reliability of acupuncture methods, clinical applicability, completion quality and acupuncture habits for thousands of years. Therefore, this evidence hierarchy is based on the current situation of acupuncture clinical evidence level, reconciling the influence of various factors on the evaluation of evidence level, and including all kinds of valuable evidence as much as possible.
4.3 Multi-angle consideration of factors affecting the quality of evidence
Clinical decision-making of acupuncture and moxibustion is a very complicated multi-factor influencing process, and it is a new field worthy of in-depth exploration to evaluate all kinds of acupuncture and moxibustion clinical literature from the perspective of evidence. In view of the particularity of acupuncture theory and practice, this study not only considers the existing evaluation indexes of evidence-based medicine, but also explores the evaluation indexes by increasing personal qualifications, grades, units, carriers, academic viewpoints, specific acupuncture schemes, theoretical explanations and many other factors. And put forward a set of strict evaluation methods and quality grading standards for all kinds of research evidence, in order to exclude low-quality or unqualified evidence, screen out high-quality and credible evidence, and provide practical and valuable evidence for clinical application.
To sum up, this study used the methods of literature analysis, expert interview and consensus, combined with the characteristics of acupuncture and moxibustion disciplines and literature, compared the evidence evaluation system of evidence-based medicine, discussed the scope and characteristics of acupuncture research evidence, initially established the evaluation methods and standards of acupuncture research evidence, and initially established the evidence system of acupuncture clinical research. However, in view of the particularity of acupuncture theory and clinical practice, it is still an exploratory study to establish an evidence classification system suitable for the characteristics of acupuncture diagnosis and treatment and the form of literature. Therefore, there are still some shortcomings, such as the determination of evaluation indicators of research evidence may not be perfect, and some evaluation indicators lack authoritative reference standards, which need to be supplemented and improved in future research and practice.
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