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肌膜痛症候群  

肌筋膜痛症候群 Myofacial Pain Syndrome
Fibromyalgia:General aches or stiffness with multiple tender's
Myofacial pain syndrome:More localized with tender'pand radiating pattern
物理治療對允膜板機點扮演之角色• 

定義:

 肌膜板機點 ( 或稱引痛點 ) :許多微敏感區聚合成的易興奮點,位於外表可觸摸之緊繃束。

 板機點特色: 1. 引傳痛 Referred Pain 2. 抽慉反應 Local Twitch Response

  • 病理:


  • 肌膜板機點治療原則:
    活性板機點之去活化方法:
    1. 物理治療:伸展 / 按摩 + 冷 / 熱療 + 超音波 + 冷雷射 + 干擾波
    2. 板機點注射
    3. 其它 ( 較無效 ) :藥物、神經阻斷、硬膜外注射、外科處理、心理治療 ( 生物回饋、催眠 ) 、氣功等
    4. 致病因與激發因素的治療
    5. 病患的衛教與居家治療計劃

1、盛行率 30%~93%  占 顱顏痛55% 、腹臀痛21%

2、Nature of Myofacial Trps:

  • Energy Crisis Theory(能量危機診)
  • Muscle Spindle Concept(肌梭論)
  • Motor Endplate Hypothesis (運動終板)

3、Motor Endplate Hypothesis

  • Typ contain vrey minute loci that produce characteristec electrical activity. (SEA)
  • The loci are found among normal endplate.

4、SEA

 abnormal extrafusal endplate activity due to release of grdatly increased numbers of acetylcholine packets.

5、Taut Band

 Continuous abnormal release of calcium from sarcoplasmic reticulum.

6、Twnch response

 Spinal reflex activation of motor units whose endplate have developed active loci and/or a mechanically-elicited axon reflex of those same motor unit.

7、Referred Pain

 Excitation of "sleeping" nociceptors with input from Trp.

8、Spot Tenderness

 Sensitization of nociceptors in the vicinity of the motor endplate.

9、Restricted Range of Motion

 Increased rdlease of acetylcholine in neuromuscular junction of active loci due to mechanical stress wigy related release of sensitizing substances locally. 


1、肌筋膜痛症候群 Myofacial Pain Syndrome

2、定義:

  肌膜板機點 ( 或稱引痛點 ) :許多微敏感區聚合成的易興奮點,位於外表可觸摸之緊繃束。

key:Myofacial trigger point Sensitive loci Taut-band

3、板機點特色:1. 引傳痛 Referred Pain   2. 抽慉反應 Local Twitch Response

4、病理學假說

5、肌膜板機點治療原則 --- 活性板機點之去活化
方法:

  1. 物理治療:伸展 / 按摩 + 冷 / 熱寮 + 超音波 + 冷雷射 + 干擾波
  2. 板機點注射
  3. 其它( 較無效 ) :藥物、神經阻斷、硬膜外注射、外科處理、心理治療
    ( 生物回饋、催眠 ) 、氣功等
  4. 致病因與激發因素的治療
  5. 病患的衛教與居家治療計劃

 

6、 鑑別診斷
Fibromyalgia : General aches or stiffness with multiple tender`p
Myofacial pain syndrome : More localized with trigger`p and refered pain More   identifiable precipitating events
Chronic Fatigue Syndrome : Major debilitating fatigue with minor feature of                 myalgia

   key :Tender point
Trigger point

7、 Fibromyalgia(Fibrositis) : Diffuse Myofacial pain syndrome
[Association for Study of Pain Subcommittee on Taxonomy 1986]
Diffuse aching musculoskeletal pain
Multiple discrete predictable tender points or trigger points Stiffness
PS : Fibrositis : Rheumatology
Myofacial pain syndrome : Physical Medicine and Rehabiliation

8、Fibrositis VS Psychological disturbance

  Ellman1940s : 70%

  1980,1982,1983,1984,1985,1986,1989(MMPI,DSM III) : 40~80%

9、Tender point and Trigger point
VS
1.Muscle/Tendon Junction
2.Skeletal Muscle in Emotion Expression
3.Postural Fixation Muscle

1.limited capillary perfusion---microtrauma eap:                            
eccentric contraction
g:iliac crest
scapula  

  2.Trapezius Muscle,Sternocleidomastoid Muscle
Lumbar Extensor

10、Ultrastural Findings:
EM:fewer mitrochodria per volume of muscle fiber
(Mid-Trapezius)
Blood Flow Study:reduced profusion of exercising muscle
Histochemical Study:decreased level of ATP.Phosphocreatine
(poor aerobic capacity) 

11、Mid-Trapezius muscle:
Angle of neck lateral banding
Postural fixation for movement of arm
---Increased Muscle Tension

12、TCA
improve stage IV sleep paterm at subtherapeutic depression level

13、診斷標準 (Fricton1990)

  1. regional muscle pain complaints
  2. trrigerpoints in taut bands of skeletal that correspondto the pattern of pain and are consistent wuth Travell & Simon's reports(1993)
  3. reproducible altreation of the pain complaints with specific palpation of the responsible trigger points.

14、Findings of Physical Examination 理學檢查發現

15、
一.受害肌肉經被動或主動拉張運動時
疼痛會增加 (Macdonald AR 1980)
Passive or Active Passive
Protective Spasm

16、
二.受害肌肉經拉張運動角度受限
Taut-Band
Increased Muscle Tension

17、
.受害肌肉行抗阻力收縮時疼痛會增加
Trigger Point's Effect is most
marked in a shortened position

18、
四.受害肌肉最大收縮力降低
But not associated with atrophy

19、
五.感覺異常現象常沿特定路線引傳
Dysesthesia
Zone of Referred Pain

20、
六.自主神經障礙
Autonomic Disturbance
Vasomotor Activity :
Pallor
Hyperemia
Lacrimation
Pillomotor Activity
Gooseflsah
EMG activity in refered zone
Increased

21、
七.板機點附近的肌肉張力增加
Fibositic Nodule
Myogeloses
Ropiness
Tense
Effective Tx Trp Tension decrease

22、
八.板機點可存在於觸診時發現之繃緊束
Palpable Taut-Band
Point of Maximal Tenderness

23、
九.指壓活化板機點常導致受檢者劇烈反應
Jump Sign
Cry Out Sign
Withdraw Sign
  A-Shi Sign

24、
十.用力掐壓板機點常引發肌肉之局部抽慉反應
Snapping Palpation
Local Twich Response
EMG show MUAP
Better Therapeutic Effect(Hong1991)

25、
十一.持續適度施壓板機點常誘發或加重引傳痛
Sustained and morderate pressure
Also evoked by Needle penetration
Refered Pain

26、
十二.板機點附近之特殊皮膚反應
Dermographia
Panniculosis
diffuse subcutaneous induration
skin rolling test


人類骨骼肌引痛點 Human trigger pount(Trp)
 敏感小點 Sensitive Locus
局部抽慉反應 Local Twitch Respones
對游離神經末梢的機械性刺激所產生 Free Nerve endings
脊隨反射的一種 Spinal Reflex

兔子骨骼引肌痛點 Rabbit trigger spot(TrS)
反應小點 Responsive Locus
人類骨骼肌引痛點 Human trigger point(Trp)
敏感小點 Sensitive Locus
均可紀錄到
自發性電性活動 Spontaneous electrical activity SEA
且活性越高 SEA 紀錄到之 high amplitude peak MUAP
說越多許多報告指出交感神經阻斷劑 (alfa) 可降低 SEA
臨床上可治療 Causalgia,Reflex sympathetic dystrophy,partial peripheral lesion

Historucal Review :
First Description 1850 German medical literatures
Earlist Report 1975 Dr. Simons
Local injection,Spray and Stretch
”Trigger point”Concept 1983 Travell and Simons
Interrnational Association for the study of Pain(LASP) 1968 Specific Myofacial Pain Syndrome

American Collage of Rheumatology 1990 Criteria for Fibromyalgia

  1. History of widespread pain
  2. Pain in 11 of 18 tender point sites on digital palpation
    Occiput(B) Lower Cervical(B) Trapezius(B) (4kg/cm2)
    Supraspinatus(B) 2nd Rib(B) Lat Epicondyle(B)
    Gluteal(B) Gr. Trochaner(B) Med Knee(B)
  • FMS(fibrositic tender point);MPS(myofscial trigger point)
  • Prevalence:3.7-20%
  • Etiology Unknown

 






 

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