疼痛激發(fā)點(diǎn)

1、漫 談肌 筋 膜 疼 痛 癥 候 群與激 發(fā) 點(diǎn),溫永銳醫(yī)師新光吳火獅紀(jì)念醫(yī)院麻醉科,什麼是肌筋膜疼痛？,由骨骼肌肉上某一特定部位的激發(fā)點(diǎn)興奮所引起之疼痛,肌筋膜疼痛癥候群Myofascial Pain Syndrome (MPS),疼痛門診最常見(jiàn)的疼痛種類最容易被誤解的疾病之一病名易被誤用病因、病生理學(xué)、流行病學(xué)諸多疑點(diǎn)診斷及治療方法無(wú)共識(shí),Myofascial Pain Syndrome (MPS),肌筋膜疼痛

2、癥候群的特徵,可觸摸到激發(fā)點(diǎn) (trigger point)包含激發(fā)點(diǎn)的緊束帶 (taut band)觸壓引發(fā)身體遠(yuǎn)端產(chǎn)生相同的疼痛 (referred pain, referred zone)局部抽搐反射 (local twitch response)跳躍反射 (jump sign),臨床癥狀-- 肌筋膜疼痛癥候群之特性 (I),有特定的激發(fā)點(diǎn)激發(fā)點(diǎn)的位置與疼痛位置往往不同(轉(zhuǎn)移痛)疼痛常為鈍痛、酸痛，疼痛位置較深由“

3、輕微不適”至“非常嚴(yán)重”或“痛不欲生”可在休息或運(yùn)動(dòng)時(shí)發(fā)作部位無(wú)對(duì)稱性,臨床癥狀-- 肌筋膜癥候群疼痛之特性 (II),常抱怨疼痛會(huì)轉(zhuǎn)移，或在治療過(guò)程中出現(xiàn)移位代表仍有其它未處理的激發(fā)點(diǎn)或陳舊的激發(fā)點(diǎn)疼痛分布與皮節(jié) (dermatome)、肌節(jié) (myotome)或骨節(jié) (sclerotome) 位置無(wú)關(guān)疼痛的大小及範(fàn)圍和激發(fā)點(diǎn)的可興奮性有關(guān)，而與肌肉的大小無(wú)關(guān)常與其他疼痛合併出現(xiàn)如：癌癥疼痛,肌筋膜癥候群的非疼痛癥狀(1

4、),運(yùn)動(dòng)異常：肌肉無(wú)力、縮短、僵硬、痙攣、關(guān)節(jié)活動(dòng)受限反射異常：膝關(guān)節(jié)反射降低EMG異常：Motor neuron 的 threshold 下降本體感覺(jué)異常：不平衡、昏眩、耳鳴失眠,肌筋膜癥候群的非疼痛癥狀(2),自主神經(jīng)異常局部血管收縮、出汗、流淚、鼻炎、垂涎、豎毛肌運(yùn)動(dòng)感覺(jué)神經(jīng)異常：觸痛感、痛覺(jué)敏感皮膚異常：畫線現(xiàn)象 (dermographia)、 皮下結(jié)節(jié) (panniculosis),激發(fā)點(diǎn)的臨床表現(xiàn),正常的

5、肌肉不會(huì)包含激發(fā)點(diǎn)或緊束帶激發(fā)點(diǎn)隨年齡成長(zhǎng)而增加女性較男性多(3:1)中年女性有較多的激發(fā)點(diǎn)老年人表現(xiàn)為潛伏性激發(fā)點(diǎn)及運(yùn)動(dòng)受限長(zhǎng)期坐著工作者多勞工或經(jīng)常運(yùn)動(dòng)者較不易有激發(fā)點(diǎn),激發(fā)點(diǎn)的形成,激發(fā)點(diǎn)會(huì)因直接或間接因素刺激而形成引起疼痛直接因素：急性重力、反覆使用、疲勞、受寒、外傷間接因素：其它激發(fā)點(diǎn)、內(nèi)臟疾病、關(guān)節(jié)炎、情緒壓力、病毒感染,激發(fā)點(diǎn)--有活動(dòng)性與潛伏性兩種--,以疼痛主訴來(lái)區(qū)別活動(dòng)性激發(fā)點(diǎn)的患者會(huì)抱怨

6、疼痛潛伏性激發(fā)點(diǎn)無(wú)疼痛主訴癥狀只有造成運(yùn)動(dòng)受限及肌肉力量減低壓迫可引發(fā)(轉(zhuǎn)移)疼痛容易受誘發(fā)因子轉(zhuǎn)變成活動(dòng)性,潛伏性激發(fā)點(diǎn),活動(dòng)性激發(fā)點(diǎn),,1. 急性重力2. 長(zhǎng)期或反覆使用3. 過(guò)度疲勞4. 肌肉受寒受冷,激發(fā)點(diǎn)的活化,次級(jí)激發(fā)點(diǎn)(Secondary TrP)因?yàn)槠渌g接因素而引起之疼痛；如骨折、拮抗肌保護(hù)性收縮而引起激發(fā)點(diǎn)衛(wèi)星激發(fā)點(diǎn)(Satellite TrP)：位於由其它激發(fā)點(diǎn)引發(fā)之疼痛肌肉內(nèi)，或由內(nèi)臟疾

7、病之轉(zhuǎn)移痛區(qū)內(nèi)的激發(fā)點(diǎn),Myofascial Pain Syndrome-- Pathogenesis,Acute injury or repetitive microtrauma ? disruption of sarcoplasmic reticulum ? release of calciumActivation of actin-myosin contractile state ? formation of tense ba

8、nd ? sustained contractionIncreased metabolic rate ? accumulation of metabolites (5-HT, histamine, kinins, PGs)Firing of muscle nociceptors ? dorsal horn sensitization ? local and referred painLocal blood flow reducti

9、on ? vicious cycle,BODY CONDOTIONSGenetic factorsPersonalityPhysical conditionPhysiologicalprevious injuryhormone balanceetc.,TRIGGERING STRESSPhysical-disease/fatigueinjurylow level antagonist(scar)Mental-fa

10、tigue/anxiety,Development of Myofascial Pain Syndrome,實(shí)驗(yàn)室診斷--肌筋膜疼痛癥候群,血液檢查無(wú)任何幫助包括：CBC, DC, ESR, biochemistry, thyroid function, muscle enzyme…放射線檢查：大多正常包括：X-ray, MRI, CT, SonoEMG: 有人認(rèn)為有幫助Thermography: “hot spot”仍

11、有爭(zhēng)議Pressure algometer,鑑別診斷 --肌筋膜疼痛癥候群,纖維性肌痛癥候群 (Fibromyalgia)非肌肉性組織 (疤痕、神經(jīng)、骨膜、韌帶、骨骼) 之受傷、發(fā)炎或感染局部發(fā)炎 (肌腱炎、滑液囊炎)內(nèi)臟性疾病肌肉病變(polymyositis, dermatomyositis)關(guān)節(jié)炎 (退化性或類風(fēng)濕性)脊柱病變 (椎盤凸出、骨關(guān)節(jié)炎)精神性疾病,Principles of Treatment--

12、 myofascial pain syndrome,Not “eliminating the pain”but enable the patient “cope with pain”Treat underlying disease or conditionCorrect daily habituate and postureAvoid perpetuating factorsMultidisciplinary approach,

13、Treatment of Myofascial Pain,Trigger point injectionStretch and spray techniqueAdjunctive techniquesSympathetic blockMassage therapyIschemic compressionTranscutaneous electrical nerve stimulationPhysical therapy

14、Pharmacological Agents,Trigger Point Injection-- hypothetical mechanism,Mechnical disruption of muscle fibers and nerve endingsRelease of extracellular potassium ? depolarization of nerve endingInterrupting the posit

15、ive feedback mechanismLocal dilution of nociceptive substances by anesthetics and salineVasodilatation by local anestheticsMembrance stablizating effect of steroidNeurolysis of nerve ending by steroid suspension,Trig

16、ger Point Injection-- Minutiae (I),precise localizationneedles: size (22~27 gauge), lengthtwo-handed techniqueinjectate: dry, saline, local anesthetics, steroidinjection volume: 0.5 - 3 mllow concentration of local

17、 anestheticspost-injection compression and stretch,Trigger Point Injection v.s. Acupuncture,Stretch and Spray -- Technique,Techniques:apply 30°at the skinpassive stretch of muscleexposure to coolant less than 6

18、 sec/sprayspray only 2-3 times for each areapost-stretch warming,Stretch and Spray -- Vaporcoolant agents,Fluori-Methane:non-toxic, non-flammable vaporcoolant spraynot irritating to skin saferdestruction of ozone

19、layerEthyl chloride :flammable and explosivegreater cooling effectlocal anesthetic actionIce,Transcutaneous Electrical Nerve Stimulation (TENS)-- As a therapeutic adjuvant,Gate control theory (Melzack and Wall, 196

20、5)Peripheral low intensity electrical stimulation activates the large-diameter fibers to “close the pain input”mediated by small-diameter fiber in the dorsal horn of spinal cord,避免肌筋膜疼痛之注意事項(xiàng)(1),1. 注意身體正確姿勢(shì)2. 矯正身體左右的不對(duì)

21、稱3. 慎選家俱4. 平時(shí)多運(yùn)動(dòng)5. 避免肌肉受到不正常的束縛,避免肌筋膜疼痛之注意事項(xiàng)(2),6. 注意營(yíng)養(yǎng)均衡，補(bǔ)充維他命及礦物質(zhì)7. 保持愉快的心情8. 避免受寒9. 控制代謝性疾病10.避免感染,臨床診斷-- 肌筋膜疼痛癥候群,激發(fā)點(diǎn)的診斷病史：Pain drawing，疼痛史，個(gè)人及家庭病史、工作或運(yùn)動(dòng)史疼痛：原因、特徵、發(fā)作時(shí)間、加重或減輕因素病人姿勢(shì)、步伐、動(dòng)作、保護(hù)性行為神經(jīng)學(xué)檢查：感覺(jué)、運(yùn)動(dòng)、反

22、射,Oh!,Trigger Point Injection-- Minutiae (II),Contraindications: local or systemic infection, coagulopathy, poor patient compliance, hypoglycemic state, acute phase of muscle traumaComplications of local steroid inje

23、ction:skin depigmentation, tendon atrophy or rupture, depression of plasma cortical levels, insulin-induced hypoglycemia,Stretch and Spray -- Shortcoming and Failure,Shortcomings: lack of reliability Failure: uniden

24、tified etiologic factorsinadequate spraying of all involved fibersincomplete stretching during and after sprayunrelaxed and uncooperative patientnoncompliance by patient after treatment.,激發(fā)點(diǎn)(Trigger Point)的特徵,在肌肉或相關(guān)肌

25、膜內(nèi)高度敏感的病灶存在骨骼肌之緊束帶 (taut band) 內(nèi)壓迫此點(diǎn)會(huì)誘發(fā)疼痛會(huì)引起典型之轉(zhuǎn)移痛或引發(fā)自主神經(jīng)癥狀不同於壓痛點(diǎn) (tender point),臨床診斷-- 肌筋膜疼痛癥候群之檢查(1),主動(dòng)或被動(dòng)地伸展病變的肌肉(含有激發(fā)點(diǎn))，會(huì)增加疼痛伸展病變的肌肉至疼痛程度時(shí)，EMG活動(dòng)增加病變的肌肉對(duì)抗阻力作強(qiáng)力收縮時(shí)，疼痛會(huì)增加肌肉伸展活動(dòng)的範(fàn)圍減小肌肉的最大收縮力量減小,臨床診斷-- 肌筋膜疼痛癥候群

26、之檢查(2),可找到緊束帶、激發(fā)點(diǎn)壓迫此點(diǎn)會(huì)誘發(fā)病患主訴之疼痛觸壓或彈撥激發(fā)點(diǎn)會(huì)引起local twitch response 及 jump sign壓痛點(diǎn)及感覺(jué)異常會(huì)重複出現(xiàn)在轉(zhuǎn)移疼痛區(qū)，而非激發(fā)點(diǎn)部位,臨床診斷-- 肌筋膜疼痛癥候群之檢查(3),自主神經(jīng)異常：血管收縮異常、反射性充血、流淚、鼻炎、豎毛肌收縮皮膚出現(xiàn)畫線現(xiàn)象 (dermographia) 或皮下結(jié)節(jié) (panniculosis),臨床癥狀(1)--激發(fā)點(diǎn)與

27、肌筋膜疼痛癥候群,壓迫或針刺激發(fā)點(diǎn)可引起肌筋膜疼痛或加重疼痛激發(fā)點(diǎn)越敏感，肌筋膜疼痛越厲害，疼痛範(fàn)圍也越大激發(fā)點(diǎn)的敏感性會(huì)隨時(shí)改變，興奮閥值不是一個(gè)定值肌筋膜疼痛可能同時(shí)由多處的激發(fā)點(diǎn)引起,臨床癥狀(2)--激發(fā)點(diǎn)與肌筋膜疼痛癥候群,肌肉能忍受的運(yùn)動(dòng)量越大，激發(fā)點(diǎn)的興奮程度越低激發(fā)點(diǎn)造成的癥狀持續(xù)時(shí)間遠(yuǎn)超過(guò)原先活化它的事件經(jīng)由處理激發(fā)點(diǎn)可以減輕或消除疼痛適當(dāng)?shù)男菹⒓跋罨蛩乜墒够顒?dòng)性激發(fā)點(diǎn)轉(zhuǎn)為潛伏性,臨床癥狀(3)-

28、-激發(fā)點(diǎn)與肌筋膜疼痛癥候群,適當(dāng)?shù)闹委熑詿o(wú)法減輕激發(fā)點(diǎn)活性，表示疾病以由肌肉功能性病變轉(zhuǎn)為神經(jīng)失養(yǎng)癥,斜方肌 (Trapezius m.),脖子僵硬，落枕，膏肓痛，慢性顳側(cè)頭痛，都是因?yàn)樗殖缮现邢氯糠郑饔弥饕獮樘峒缂靶D(zhuǎn)肩關(guān)節(jié)三部分各有不同的激發(fā)點(diǎn)及轉(zhuǎn)移區(qū)支配神經(jīng)：Spinal accessory nerve, 2nd - 4th cervical nerve,Stretch and Spray -- Possi