臺灣博碩士論文加值系統

開胸手術後之慢性疼痛 (chronic post-thoracotomy pain) 是臨床常見的問題，疼痛會沿著手術後留下的傷口區域持續至少兩個月以上，其疼痛嚴重影響患者生活品質、呼吸功能以及清痰能力。原因來自於臨床上開胸手術會使用撐開器 (rib-retractor) 將肋骨撐開，此時肋骨胸腔壁上的肋間神經難以去避免拉扯或壓迫而導致神經受損。在過去人體或動物實驗已發現神經損傷之疼痛也會出現未損傷側，稱之為鏡化現象 (mirror phenomenon)。目前臨床上黃金治療為胸椎硬脊膜外止痛 (thoracic epidural analgesia) 並搭配常見藥物有布比卡因 (bupivacaine) 或氫嗎啡酮 (hydromorphone) 可產生局部性範圍止痛效果，但伴隨嚴重的副作用，包含: 低血壓、尿滯留以及搔癢症。臨床上運動治療是一個比較安全且低風險的治療方式。游泳運動訓練已廣泛運用在各種慢性疼痛以及神經性疼痛上，並且可以產生內源性類阿片物質 (endogenous opioids) 具有調控疼痛的效果。因此本實驗的目的是觀察開胸手術後疼痛情形以及游泳運動訓練有無注射鈉洛酮 (阿片拮抗劑) 對開胸術後大鼠其慢性疼痛的影響。結果發現，手術側與對側的觸覺疼痛閾值 (force threshold) 於開胸手術後第五天顯著下降，且在手術後第十天數值達到最低；手術側與對側的每分鐘搔癢次數於開胸手術後第五天開始明顯增加，手術側與對側分別於在手術第十七天以及第十天次數達到最高。連續游泳運動第14天後，手術側觸覺疼痛閾值明顯提高，對側則是在連續運動的第21天。連續游泳運動第21天手術側與對側的每分鐘搔癢次數明顯減少。單次游泳運動後第30分鐘，手術側與對側觸覺疼痛閾值明顯提高以及每分鐘搔癢次數明顯減少。連續四周或單次游泳運動後注射鈉洛酮並在注射後30分鐘，都能明顯降低觸覺疼痛閾值以及增加每分鐘搔癢次數。根據研究結果顯示，經過胸術手後大鼠動物模式後，手術側與手術對都明顯產生機械性過度敏感 (mechanical allodynia) 以及冷過度敏感 (cold allodynia)。游泳運動訓練可以改善開胸術後慢性疼痛，並由鈉洛酮注射後可部分減緩疼痛產生之鎮痛效果。

Chronic post-thoracotomy pain is quite common clinical problem that affects the patient''s quality of life, respiratory function and cough ability. The pain along a thoracotomy incision can persists after the surgical at least 2 months. The rib- retractors used for the thoracotomy to open the chest, it is difficult to avoid straining or pressing the intercostal nerve. Neuropathic pain also appears in undamaged areas that have been demonstrated in human and animal study, called mirror phenomenon. The current gold standard treatment is thoracic epidural analgesia with drugs such as bupivacaine or hydromorphone that produce localized analgesic effects, but with severe side effects including hypotension, urinary retention, and pruritus. Exercise Therapy is a relatively safe and low-risk treatment. Swimming exercise training has been widely used in a variety of neuropathic pain and chronic pain, and can produce endogenous opioids with the effect of regulating pain. Therefore, the purpose of this study is to observe the pain after thoracotomy and to investigate the effects of swimming exercise training on chronic post-thoracotomy pain in rats with or without injection of naloxone (opioid antagonist). The present study has shown that the force threshold on the operated side and contralateral side decreased significantly at the fifth day after thoracotomy and lowest value at the tenth day after thoracotomy. The number of scratches per min on the operated side and contralateral side was significantly increased on the fifth day after thoracotomy and the highest values of the operated side and the contralateral side were on the 17th and 10th day after thoracotomy, respectively. The force threshold on the operated side was significantly improved after the 14th day of continuous swimming, and the contralateral was on the 21st day of continuous exercise. The number of scratches per min on the operated side and contralateral side was significantly reduced at the 21st consecutive exercise. At the 30th minute after a single swimming exercise, the force threshold on the operated side and contralateral side was significantly increased and the number of scratches per min was significantly reduced. Thirty minutes after injection of naloxone, a significant decrease in the force threshold and an increase in the number of scratches per min. After thoracotomy, rats developed mechanical and cold allodynia in the both side. Swimming exercise training can improve chronic post-thoracotomy pain, and naloxone alleviate the post-exercise analgesic response.

致謝 i
中文摘要 ii
英文摘要 iv
1. 緒論 1
1.1. 文獻回顧 1
1.2. 研究動機 6
2. 材料與方法 7
2.1. 開胸術後疼痛的動物模式 7
2.2. 實驗動物 7
2.3. 動物模式 7
2.4. 實驗分組與流程 9
2.5. 實驗方法 10
2.6. 數據分析 12
3. 結果 13
3.1. 游泳運動訓練對開胸手術後觸覺疼痛閾值比較 13
3.2. 游泳運動訓練對開胸手術後每分鐘搔癢次數數值比較 13
3.3. 不同游泳運動天數對觸覺疼痛閾值的前後比較 13
3.4. 游泳運動訓練注射鈉洛酮後觸覺疼痛閾值的前後比較 13
3.5. 不同游泳運動天數對每分鐘搔癢次數的前後比較 14
3.6. 游泳運動訓練注射鈉洛酮後每分鐘搔癢次數的前後比較 14
4. 討論 15
4.1. 開胸術後造成慢性疼痛 15
4.2. 游泳運動訓練可減緩開胸術後慢性疼痛 16
4.3. 阿片受體抑制劑可降低游泳運動訓練之效果 18
5. 結論 21
參考文獻 22
表1.儀器資料 28
表2.手術器械 29
圖1.游泳運動訓練對開胸手術後的觸覺疼痛閾值比較 30
圖2.游泳運動訓練對開胸手術後每分鐘搔癢次數數值比較 31
圖3.不同游泳運動天數對觸覺疼痛閾值的前後比較 32
圖4.單次游泳運動訓練注射鈉洛酮後觸覺疼痛閾值的前後比較 33
圖5.四周游泳運動訓練注射鈉洛酮後觸覺疼痛閾值的前後比較 34
圖6.不同游泳運動天數對每分鐘搔癢次數的前後比較 35
圖7.單次游泳運動訓練注射鈉洛酮後每分鐘搔癢次數的前後比較 36
圖8.四周游泳運動訓練注射鈉洛酮後每分鐘搔癢次數的前後比較 37

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