疼痛激发点

,按一下以編輯母片標題樣式,按一下以編輯母片本文樣式,第二層,第三層,第四層,第五層,2020/11/4,*,漫 談,肌 筋 膜 疼 痛 症 候 群與激 發 點,溫永銳醫師,新光吳火獅紀念醫院麻醉科,2020/11/4,1,什麼是,肌筋膜疼痛,？,由骨骼肌肉上某一特定部位的激發點興奮所引起之疼痛,2020/11/4,2,肌筋膜疼痛症候群,Myofascial Pain Syndrome (MPS),疼痛門診最常見的疼痛種類,最容易被誤解的疾病之一,病名易被誤用,病因、病生理學、流行病學諸多疑點,診斷及治療方法無共識,2020/11/4,3,Fibrositis,Myositis,Fibromyalgia,Myofascitis,Myofibrositis,Muscular,rheumatism,Myelosis,Radiculitis,Myofascial Pain Syndrome (MPS),？,2020/11/4,4,肌筋膜疼痛症候群的特徵,可觸摸到激發點 (,trigger point),包含激發點的緊束帶 (,taut band),觸壓引發身體遠端產生相同的疼痛 (,referred pain, referred zone),局部抽搐反射 (,local twitch response),跳躍反射 (,jump sign),2020/11/4,5,臨床症狀,- 肌筋膜疼痛症候群之特性 (,I),有特定的激發點,激發點的位置與疼痛位置往往不同(轉移痛),疼痛常為鈍痛、酸痛，疼痛位置較深,由“輕微不適”至“非常嚴重”或“痛不欲生”,可在休息或運動時發作,部位無對稱性,2020/11/4,6,臨床症狀,-,肌筋膜症候群疼痛之特性 (,II),常抱怨疼痛會轉移，或在治療過程中出現移位,代表仍有其它未處理的激發點或陳舊的激發點,疼痛分布與皮節 (,dermatome)、,肌節 (,myotome),或骨節 (,sclerotome),位置無關,疼痛的大小及範圍和激發點的可興奮性有關，而與肌肉的大小無關,常與其他疼痛合併出現如：癌症疼痛,2020/11/4,7,肌筋膜症候群的非疼痛症狀(1),運動異常：肌肉無力、縮短、僵硬、痙攣、關節活動受限,反射異常：膝關節反射降低,EMG異常：M,otor neuron,的,threshold,下降,本體感覺異常：不平衡、昏眩、耳鳴,失眠,2020/11/4,8,肌筋膜症候群的非疼痛症狀(2),自主神經異常,局部血管收縮、出汗、流淚、鼻炎、垂涎、豎毛肌運動,感覺神經異常：觸痛感、痛覺敏感,皮膚異常：畫線現象 (,dermographia)、,皮下結節 (,panniculosis),2020/11/4,9,激發點,的臨床表現,正常的肌肉不會包含激發點或緊束帶,激發點隨年齡成長而增加,女性較男性多(3:1),中年女性有較多的激發點,老年人表現為潛伏性激發點及運動受限,長期坐著工作者多,勞工或經常運動者較不易有激發點,2020/11/4,10,激發點的形成,激發點會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,：,其它激發點、內臟疾病、關節炎、情緒壓力、病毒感染,2020/11/4,11,激發點,-有活動性與潛伏性兩種-,以,疼痛主訴,來區別,活動性激發點,的患者會抱怨疼痛,潛伏性激發點,無疼痛主訴症狀,只有造成運動受限及肌肉力量減低,壓迫可引發(轉移)疼痛,容易受誘發因子轉變成活動性,2020/11/4,12,潛伏性,激發點,活動性,激發點,1. 急性重力,2. 長期或反覆使用,3. 過度疲勞,4. 肌肉受寒受冷,2020/11/4,13,激發點的活化,次級激發點(,Secondary TrP),因為其他間接因素而引起之疼痛；如骨折、拮抗肌保護性收縮而引起激發點,衛星激發點(,Satellite TrP)：,位於由其它激發點引發之疼痛肌肉內，或由內臟疾病之轉移痛區內的激發點,2020/11/4,14,Myofascial Pain Syndrome,- Pathogenesis,Acute injury or repetitive microtrauma, disruption of sarcoplasmic reticulum release of,calcium,Activation of actin-myosin contractile state formation of tense band ,sustained contraction,Increased metabolic rate accumulation of metabolites (5-HT, histamine, kinins, PGs),Firing of muscle nociceptors dorsal horn sensitization local and referred pain,Local blood flow reduction vicious cycle,2020/11/4,15,Pain/stress,Recruitment of,additional,trigger point,TrP activation,BODY CONDOTIONS,Genetic factors,Personality,Physical condition,Physiological,previous injury,hormone balance,etc.,TRIGGERING STRESS,Physical-disease/fatigue,injury,low level antagonist,(scar),Mental-fatigue/anxiety,Development of Myofascial Pain Syndrome,2020/11/4,16,實驗室診斷-,肌筋膜疼痛症候群,血液檢查無任何幫助,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, Sono,EMG:,有人認為有幫助,Thermography,: “hot spot”,仍有爭議,Pressure algometer,2020/11/4,17,鑑別診斷,-肌筋膜疼痛症候群,纖維性肌痛症候群 (,Fibromyalgia),非肌肉性組織 (疤痕、神經、骨膜、韌帶、骨骼) 之受傷、發炎或感染,局部發炎 (肌腱炎、滑液囊炎),內臟性疾病,肌肉病變(,polymyositis, dermatomyositis),關節炎 (退化性或類風濕性),脊柱病變 (椎盤凸出、骨關節炎),精神性疾病,2020/11/4,18,Principles of Treatment,- myofascial pain syndrome,Not “,eliminating the pain,”but enable the patient “,cope with pain,”,Treat underlying disease or condition,Correct daily habituate and posture,Avoid perpetuating factors,Multidisciplinary approach,2020/11/4,19,Treatment of Myofascial Pain,Trigger point injection,Stretch and spray technique,Adjunctive techniques,Sympathetic block,Massage therapy,Ischemic compression,Transcutaneous electrical nerve stimulation,Physical therapy,Pharmacological Agents,2020/11/4,20,Trigger Point Injection,- hypothetical mechanism,Mechnical disruption of muscle fibers and nerve endings,Release of extracellular,potassium, depolarization of nerve ending,Interrupting the positive feedback mechanism,Local dilution of nociceptive substances by anesthetics and saline,Vasodilatation by local anesthetics,Membrance stablizating effect of steroid,Neurolysis of nerve ending by steroid suspension,2020/11/4,21,Trigger Point Injection,- Minutiae (I),precise localization,needles: size (2227 gauge), length,two-handed technique,injectate:,dry,saline,local anesthetics,steroid,injection volume:,0.5 - 3 ml,low concentration of local anesthetics,post-injection compression and stretch,2020/11/4,22,Trigger Point Injection,v.s.,Acupuncture,2020/11/4,23,Stretch and Spray,- Technique,Techniques:,apply 30at the skin,passive stretch of muscle,exposure to coolant less than 6 sec/spray,spray only 2-3 times for each area,post-stretch warming,2020/11/4,24,Stretch and Spray,- Vaporcoolant agents,Fluori-Methane:,non-toxic, non-flammable vaporcoolant spray,not irritating to skin,safer,destruction of ozone layer,Ethyl chloride :,flammable and explosive,greater cooling effect,local anesthetic action,Ice,2020/11/4,25,T,ranscutaneous,E,lectrical,N,erve,S,timulation (TENS),- As a therapeutic adjuvant,Gate control theory (Melzack and Wall, 1965),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,2020/11/4,26,避免肌筋膜疼痛之注意事項(1),1. 注意身體正確姿勢,2. 矯正身體左右的不對稱,3. 慎選家俱,4. 平時多運動,5. 避免肌肉受到不正常的束縛,2020/11/4,27,避免肌筋膜疼痛之注意事項(2),6. 注意營養均衡，補充維他命及礦物質,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,2020/11/4,28,臨床診斷,-,肌筋膜疼痛症候群,激發點的診斷,病史：Pain drawing,，,疼痛史，個人及家庭病史、工作或運動史,疼痛：原因、特徵、發作時間、加重或減輕因素,病人姿勢、步伐、動作、保護性行為,神經學檢查：感覺、運動、反射,2020/11/4,29,Oh!,2020/11/4,30,Trigger Point Injection,- Minutiae (II),Contraindications,:,local or systemic infection, coagulopathy, poor patient compliance, hypoglycemic state, acute phase of muscle trauma,Complications of local,steroid,injection,:,skin depigmentation, tendon atrophy or rupture, depression of plasma cortical levels, insulin-induced hypoglycemia,2020/11/4,31,Stretch and Spray,- Shortcoming and Failure,Shortcomings: lack of reliability,Failure:,unidentified etiologic factors,inadequate spraying of all involved fibers,incomplete stretching during and after spray,unrelaxed and uncooperative patient,noncompliance by patient after treatment.,2020/11/4,32,激發點,(,Trigger Point),的特徵,在肌肉或相關肌膜內高度敏感的病灶,存在骨骼肌之緊束帶 (,taut band),內,壓迫此點會誘發疼痛,會引起典型之轉移痛或引發自主神經症狀,不同於壓痛點,(,tender point),2020/11/4,33,臨床診斷,- 肌筋膜疼痛症候群之檢查(1),主動或被動地伸展病變的肌肉(含有激發點)，會增加疼痛,伸展病變的肌肉至疼痛程度時，EMG活動增加,病變的肌肉對抗阻力作強力收縮時，疼痛會增加,肌肉伸展活動的範圍減小,肌肉的最大收縮力量減小,2020/11/4,34,臨床診斷,- 肌筋膜疼痛症候群之檢查(2),可找到緊束帶、激發點,壓迫此點會誘發病患主訴之疼痛,觸壓或彈撥激發點會引起local twitch response 及,jump sign,壓痛點及感覺異常會重複出現在轉移疼痛區，而非激發點部位,2020/11/4,35,臨床診斷,- 肌筋膜疼痛症候群之檢查(3),自主神經異常：血管收縮異常、反射性充血、流淚、鼻炎、豎毛肌收縮,皮膚出現畫線現象 (,dermographia),或皮下結節 (,panniculosis),2020/11/4,36,臨床症狀(1),-激發點與肌筋膜疼痛症候群,壓迫或針刺激發點可引起肌筋膜疼痛或加重疼痛,激發點越敏感，肌筋膜疼痛越厲害，疼痛範圍也越大,激發點的敏感性會隨時改變，興奮閥值不是一個定值,肌筋膜疼痛可能同時由多處的激發點引起,2020/11/4,37,臨床症狀(2),-激發點與肌筋膜疼痛症候群,肌肉能忍受的運動量越大，激發點的興奮程度越低,激發點造成的症狀持續時間遠超過原先活化它的事件,經由處理激發點可以減輕或消除疼痛,適當的休息及消除活化因素可使活動性激發點轉為潛伏性,2020/11/4,38,臨床症狀(3),-激發點與肌筋膜疼痛症候群,適當的治療仍無法減輕激發點活性，表示疾病以由肌肉功能性病變轉為神經失養症,2020/11/4,39,斜方肌 (,Trapezius m.),脖子僵硬，落枕，膏肓痛，慢性顳側頭痛，都是因為它,分成上中下三部分，作用主要為提肩及旋轉肩關節,三部分各有不同的激發點及轉移區,支配神經：,S,pinal accessory nerve,2nd - 4th cervical nerve,2020/11/4,40,Stretch and Spray,- Possible mechanism,2020/11/4,41,