1、漫 談肌 筋 膜 疼 痛 癥 候 群與激 發 點溫永銳醫師新光吳火獅紀念醫院麻醉科漫 談肌 筋 膜 疼 痛 癥 候 群與激 發 點溫什麼是肌筋膜疼痛？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肌筋膜疼痛癥候群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肌筋膜疼痛癥候群Myofascial Pain SyndrFibrositisMyositisFibromyalgiaMyofascitisMyofibro

2、sitisMuscularrheumatismMyelosisRadiculitisMyofascial Pain Syndrome (MPS)？FibrositisFibromyalgiaMyofasci肌筋膜疼痛癥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)肌筋膜疼痛癥候群的特徵可觸摸到激發點 (trigger po臨床癥狀- 肌筋膜疼痛癥候群之特性 (I

3、)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臨床癥狀- 肌筋膜疼痛癥候群之特性 (I)有特定的激發點臨床癥狀- 肌筋膜癥候群疼痛之特性 (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：癌癥疼痛臨床癥狀- 肌筋膜癥候群疼痛之特性 (II)常抱怨疼痛會肌筋膜

4、癥候群的非疼痛癥狀(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：Motor neuron 的 threshold 下降本體感覺異常：不平衡、昏眩、耳鳴失眠肌筋膜癥候群的非疼痛癥狀(1)運動異常：肌肉無力、縮短、僵硬 肌筋膜癥候群的非疼痛癥狀(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) 肌筋膜癥候群的非疼痛癥狀(2)自主神經異常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(

5、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癥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激發點-有活動性與潛伏性兩種-以疼痛主訴來區別潛伏性

6、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. 肌肉受寒受冷潛伏性激發點活動性激發點1. 急性重力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激發點的活化次級激發點(Secondary TrP)Myofascial Pain Syndrome- PathogenesisAcute injury or repetitive microtrauma disruption of sarcoplas

7、mic reticulum release of calciumActivation of actin-myosin contractile state formation of tense band 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

8、reduction vicious cycleMyofascial Pain Syndrome- PaPain/stressRecruitment ofadditionaltrigger pointTrP activationBODY CONDOTIONSGenetic factorsPersonalityPhysical conditionPhysiologicalprevious injuryhormone balanceetc. TRIGGERING STRESSPhysical-disease/fatigueinjurylow level antagonist(scar)Mental-

9、fatigue/anxietyDevelopment of Myofascial Pain SyndromePain/stressRecruitment ofTrP a實驗室診斷-肌筋膜疼痛癥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, SonoEMG: 有人認為有幫助Thermography: “hot spot”仍有爭議Pressure algometer實驗室診斷-肌筋膜疼痛癥候群血液檢查無任何幫助鑑別診斷 -肌筋膜疼痛癥候群纖維性

10、肌痛癥候群 (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)精神性疾病鑑別診斷 -肌筋膜疼痛癥候群纖維性肌痛癥候群 (FibrPrinciples of Treatment- myofascial pain syndromeNot “eliminating the pain”but enable the patient “cope with pain”Treat underlyin

11、g disease or conditionCorrect daily habituate and postureAvoid perpetuating factorsMultidisciplinary approachPrinciples of Treatment- myoTreatment of Myofascial PainTrigger point injectionStretch and spray techniqueAdjunctive techniquesSympathetic blockMassage therapyIschemic compressionTranscutaneo

12、us electrical nerve stimulationPhysical therapyPharmacological AgentsTreatment of Myofascial PainTrigger Point Injection- hypothetical mechanismMechnical disruption of muscle fibers and nerve endingsRelease of extracellular potassium depolarization of nerve endingInterrupting the positive feedback m

13、echanismLocal dilution of nociceptive substances by anesthetics and salineVasodilatation by local anestheticsMembrance stablizating effect of steroidNeurolysis of nerve ending by steroid suspensionTrigger Point Injection- hypTrigger Point Injection- Minutiae (I)precise localizationneedles: size (222

14、7 gauge), lengthtwo-handed techniqueinjectate: dry, saline, local anesthetics, steroidinjection volume: 0.5 - 3 mllow concentration of local anestheticspost-injection compression and stretchTrigger Point Injection- MinTrigger Point Injection v.s. AcupunctureTrigger Point Injection v.s. AStretch and

15、Spray - TechniqueTechniques:apply 30at the skinpassive stretch of muscleexposure to coolant less than 6 sec/sprayspray only 2-3 times for each areapost-stretch warmingStretch and Spray - TechniquStretch and Spray - Vaporcoolant agentsFluori-Methane:non-toxic, non-flammable vaporcoolant spraynot irri

16、tating to skin saferdestruction of ozone layerEthyl chloride :flammable and explosivegreater cooling effectlocal anesthetic actionIce Stretch and Spray - VaporcooTranscutaneous Electrical Nerve Stimulation (TENS)- As a therapeutic adjuvantGate control theory (Melzack and Wall, 1965)Peripheral low in

17、tensity electrical stimulation activates the large-diameter fibers to “close the pain input”mediated by small-diameter fiber in the dorsal horn of spinal cordTranscutaneous Electrical Nerv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避免肌筋膜疼痛之注意事項(1)1. 注意身體正確姿勢避免肌筋膜疼痛之注意事項(2)6.

18、 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，補充維他命臨床診斷- 肌筋膜疼痛癥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、反射臨床診斷- 肌筋膜疼痛癥候群激發點的診斷Oh! Oh! Trigger Point Injection- Minutiae (II)Contraindications: local or systemic infection,

19、coagulopathy, poor patient compliance, hypoglycemic state, acute phase of muscle traumaComplications of local steroid injection:skin depigmentation, tendon atrophy or rupture, depression of plasma cortical levels, insulin-induced hypoglycemia Trigger Point Injection- MinStretch and Spray - Shortcomi

20、ng and FailureShortcomings: lack of reliability Failure: unidentified etiologic factorsinadequate spraying of all involved fibersincomplete stretching during and after sprayunrelaxed and uncooperative patientnoncompliance by patient after treatment.Stretch and Spray - Shortcom激發點(Trigger Point)的特徵在肌

21、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癥狀不同於壓痛點 (tender point)激發點(Trigger Point)的特徵在肌肉或相關肌膜內矯正身體左右的不對稱激發點會因直接或間接因素刺激而形成引起疼痛實驗室診斷-肌筋膜疼痛癥候群Neurolysis of nerve ending by steroid suspensiongreater cooling effectMembrance stablizating effect of steroidEMG異常：Motor neuron 的 threshold

22、 下降不同於壓痛點 (tender point)PhysiologicalTreat underlying disease or conditionhormone balance臨床診斷- 肌筋膜疼痛癥候群之檢查(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矯正身體左右的不對稱臨床診斷- 肌筋膜疼痛癥候群之檢查(壓迫或針刺激發點可引起肌筋膜疼痛或加重疼痛Principles of Treatment- myofascial pain syndrome肌肉的

23、最大收縮力量減小皮膚異常：畫線現象 (dermographia)、 皮下結節 (panniculosis)壓迫可引發(轉移)疼痛Mental-fatigue/anxietyTRIGGERING STRESShormone balance臨床癥狀- 肌筋膜疼痛癥候群之特性 (I)2nd - 4th cervical nerveflammable and explosiveTrigger Point Injection- Minutiae (II)Mental-fatigue/anxiety注意營養均衡，補充維他命及礦物質EMG: 有人認為有幫助病變的肌肉對抗阻力作強力收縮時，疼痛會增加non-toxic, non-flammable vaporcoolant spray肌筋膜疼痛癥候群的特徵臨床診斷- 肌筋膜疼痛癥候群之檢查(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 resp