慢性软组织损害的概念与纤维肌痛综合征及肌筋膜疼痛综合征的比较

Concept of chronic soft tissue injury, fibromyalgia syndrome and myofascial pain syndrome

目的:在发病机制、临床表现、诊断、治疗等方面比较慢性软组织损害的学说概念与纤维肌痛综合征、肌筋膜疼痛综合征诸方面的异同。方法:应用计算机检索Medline2001-01/2005-05的纤维肌痛综合征、肌筋膜疼痛综合征相关文献,检索词“fibromyalgiasyndrome,myofascialpainsyndrome”,并限定文献语种为英文。同时计算机检索中国期刊网医学专题全文数据库2000-01/2005-05的与慢性软组织损害、纤维肌痛综合征、肌筋膜疼痛综合征相关文献,检索词“慢性软组织损害、纤维肌痛综合征、肌筋膜疼痛,肌筋膜疼痛综合征”,并限定文献语种为中文。相关主题的书籍3本。对资料进行初审,选取包括上述专题的临床试验文献及所有相关的综述文献,筛除非随机临床试验的研究。对剩余的文献查找全文,以随机对照临床试验及论述相关课题的正反意见的综述作为纳入标准。对文献中有关慢性软组织损害的学说、纤维肌痛综合征、肌筋膜疼痛综合征在发病机理、临床表现、诊断、治疗等方面的资料进行综合。结果:共收集到“纤维肌痛综合征”的英文文献216篇,中文文献57篇,“肌筋膜疼痛综合征”的英文文献67篇,中文文献19篇,慢性软组织损害中文文献6篇,删除内容几近重复的文献,剩余20篇。①发病机制:纤维肌痛综合征的发病因素包括睡眠困扰、生长激素水平下降、心理异常、血清5-HT3受体异常等,但这些发病因素都不一定是病因,而是疾病产生的症状;肌筋膜疼痛综合征可发生于创伤、劳累过度或肌肉长时间维持在收缩状态之后,后者常见于长时间在书桌前从事读写或计算机工作者,同时本病还可见于患有颈或下腰部骨关节炎的患者中;软组织外科学认为,椎管内软组织损害性病变是由于硬膜外和神经根鞘膜外脂肪急性损伤后遗或慢性劳损形成的原发性无菌性炎症病变的化学性刺激,作用于鞘膜外神经末梢,结合椎管外软组织无菌性炎症病变,引起头、颈、背、肩、臂、腰、骶、臀、腿痛。②临床表现:纤维肌痛综合征患者通常表现为躯体、髋部和肩带部位的疼痛和僵硬感,也有患者可出现肌肉疼痛、无力,患者有特殊痛点存在,而在压痛点邻近区正常;肌筋膜疼痛综合征的特征是与触发点相关的局部肌肉、骨骼出现疼痛和压痛,疼痛部位深并可伴有烧灼感;慢性软组织损害病变范围可广可狭,主要取决于病变时间长短和就诊时患者是否存在椎管内炎症反应。③诊断:纤维肌痛综合征的诊断依据是患者具有广泛疼痛的病史,指压检查中18个部位中有11个阳性压痛点;肌筋膜疼痛综合征患者颈后、下腰部、肩和胸部是最常累及部位;慢性软组织损害患者只要有头、颈、背、肩、臂、腰、骶、臀、腿部的疼痛、酸胀、麻木、冷热异常等症状,排除其他系统性疾病、传染性疾病和肿瘤后,均可诊断为某某部位慢性软组织损害。④治疗:纤维肌痛综合征常用水杨酸盐、局部治疗、生物反馈法、行为改善法、催眠疗法、三环类抗抑郁药物、进行规律的有氧锻炼等;肌筋膜疼痛综合征的治疗除镇痛药物外,对受累部位予以按摩和超声有一定的益处;慢性软组织损害的治疗除药物、理疗外,中国特有的推拿按摩、针灸、手法及银质针松解术在治疗慢性软组织损伤中发挥了重要作用。结论:纤维肌痛综合征可基本覆盖肌筋膜疼痛综合征概念,而慢性软组织损害的学说与纤维肌痛综合征、肌筋膜疼痛综合征的概念相比在诊断、治疗方面更完善,更具有临床指导意义,慢性软组织损害的学说是先进而准确的。

AIM： To compare the conception of chronic soft tissue injury,the fibromyalgia syndrome and the myofascial pain syndrome in pathogenesis, clinical manifestation, diagnosis and treatment, etc. METHODS： A computer-based search of Medline was performed using the terms “fibromyalgia syndrome,myofascial pain syndrome” to search the related English articles published from January 2001 to May 2005.Meanwhile, China periodical web medicine special subject full text database was searched using the terms chronic soft tissue injury, fibromyalgia syndrome,myofascial pain syndrome in Chinese for the related Chinese articles publisbed between January 2000 and May 20005. A manual search of three related books was performed. After first trial, articles about clinical trials and reviews were included and articles about non-randomized trial were excluded. The full texts of the rest articles and reviews were consulted for comparing chronic soft tissue injury, the fibromyalgia syndrome and the myofascial pain syndrome in pathogenesis, clinical manifestation, diagnosis and treatment, etc. RESULTS：There were 216 literatures in English and 57 literatures in Chinese about fibromyalgia syndrome,67 literatures in English and 19 literatures in Chinese about myofascial pain syndrome,and 6 about chronic soft tissue injury in Chinese.Repetitive articles were deleted and only 20 literatures remained.①Pathogenesis：Sleeping disorder,decreased growth hormone,mental abnormality,abnormal 5-HT 3 receptor,etc.are the pathogenic factors of fibromyalgia syndrome,which are probably not the etiological factor, but the symptoms of disease. Myofascial pain syndrome can result from trauma, overwork, or long-term contraction of muscle which often occurs in people engaged in reading and writing or computer,and myofascial pain syndrome is often found in patients with osteoarthritis on neck or lumbar part. In soft tissue surgery, it is considered that pain in brain, neck, back, shoulder, upper arm, waist, breech, and leg due to soft tissue injury of vertebral canal is induced by primary aseprtic inflammation caused by sequela of acute injury to epidural fat or chronic strain combined with aseprtic inflammation of soft tissue outside of vertebral canal.②Clinical manifestation： Patients with fibromyalgia syndrome often have pain in body, hip and pectoral girdle and stiffness, and somebody has muscle pain or asthenia. Special pain spot exists in patients, and it is normal near the tenderness spot. Patients with myofascial pain syndrome have pain and tenderness in local muscle and skeleton related to trigger spot accompanied by hurning sensation. The range of chronic soft tissue injury is associated with the duration of lesion and whether inflammation in vertebral canal exists when patients are hospitalized. ③Diagnosis： Fibromyalgia syndrome is diagnosed according to the history of pain, and there are 11 positive tenderness spots out of 18 spots. Myofascial pain syndrome often occurs in neck, inferior lumbar part, shoulder and chest. Chronic soft tissue injury can be diagnosed finally if patients have pain in head, neck, back, shoulder, arm, waist, breech and leg, and soreness, swelling, numbness and abnormal feeling of coldness and heat, excluding other systemic diseases, communicable diseases and tumor.④Treatment： Salicylate, local treatment, biofeedback, behavior improvement, hypnotherapy, antidepressant drugs and regular aerobic exercise are the common therapies for fibromyalgia syndrome. Besides analgesic drugs, massage at involved sites and ultrasound therapy are helpful for myofascial pain syndrome to a certain extent. Drug administration and physiotherapy are the routine therapy for chronic soft tissue injury, and massage, acupuncture, maneuver and release in traditional Chinese medicine play an important role in the treatment of chronic soft tissue injury. CONELUSION： The conception of fibromyalgia syndrome generally ineludes the conception of myofascial pain syndrome. The conception of chronic soft tissue injury, an advanced and accurate theory, is more consummate in diagnosis and treatment than the other two syndromes, and can guide treatment much better.