臺灣博碩士論文加值系統

背景與研究目的：肌筋膜疼痛症候群 (Myofascial Pain Syndrome; MPS)是指身體局部有慢性或嚴重疼痛，且是由肌肉、肌筋膜或激痛點 (trigger points)所引起的疼痛症候群，在觸摸激痛點時會感覺部分特殊現象，如彈跳反應、轉移痛等。此類病患沒有退化性關節炎、椎間盤突出等其它疾病，但疼痛卻持續出現，甚至影響生活功能。常見治療方式包括藥物、注射 (injection)、乾針 (dry needle)、物理治療等，這些治療具有放鬆肌肉、減輕疼痛、促進循環等效果；事實上，治療目標除了減輕疼痛外，還需找出此問題之相關促成因子(contributing factor)，回復正常肌肉活性(muscle activities)和柔軟度(flexibility)，才能避免復發。按摩及伸展(stretching)是物理治療中直接針對激痛點以放鬆肌肉的處置方式，也以居家運動及自我按摩作為患者衛教的重點，然而相關的療效並未有足夠的研究予以確認其療效；故本研究目的即在探討居家治療及自我按摩療程對於肌筋膜疼痛患者的短期療效。研究方法：本研究設計為隨機分組對照實驗，共招募了63位肌筋膜疼痛病患隨機分為實驗組(32位)以及對照組(31位)兩組，對照組與實驗組均接受共六次的物理治療，內容包括銀椎點電刺激及熱敷；實驗組另外接受由物理治療師教導的居家運動及自我按摩，每次物理治療時，均由治療師確認居家療程執行無誤。兩組患者於療程前後接受基本資料問卷、疼痛分數、頸部失能問卷、病患特殊功能量表、壓力疼痛閾值、心率變異度等測試。統計方式：使用雙因子重複測試變異數分析(Two-way repeated measures ANOVAs)以檢驗兩組患者在療程前後以及兩組之間的差異；顯著差異水準定為?唊###@0.01。研究結果：對照組實際激痛點 (p=0.007)及病患特殊功能量表 (p<0.001)有明顯進步，實驗組在休息時 (p<0.001)、日常活動 (p<0.001)及最劇烈疼痛時 (p<0.001)視覺疼痛指數顯著下降，實際激痛點 (p<0.001)及相關肌群激痛點壓力疼痛閾值皆有提高、且優於對照組 (p<0.001)。頸部失能量表 (p<0.001)及病患特殊功能量表 (p<0.001)也有顯著改善且優於對照組 (p=0.001)。實驗組在心率變異度的高頻有顯著增加 (p=0.003)、高頻百分比提高 (p=0.008)、高低頻比值減少 (p=0.018)，五分鐘心跳速則兩組都有減少 (對照組：p=0.006，實驗組：p=0.001)。討論與結論：居家運動及自我按摩療程配合銀椎點電刺激及熱敷，其短期療效較單純銀椎點電刺激及熱敷顯著，可降低不同程度的主觀疼痛指數、激痛點壓力疼痛閾值，並改善生活功能及心率變異度表現。

Background and purpose: Myofascial pain dysfunction syndrome (MPS) is a condition characterized by chronic or severe pain. It is associated with and caused by "trigger points", which are localized and sometimes extremely painful contractures found in any skeletal muscle of the body. The symptoms can range from referred pain through myofascial trigger points to specific pains in other areas of the body. These patients do not have degenerative arthritis, herniated intervertebral disc or other systemic diseases. However, patients are always in pain thus their functional activities are usually affected. Common treatments for the MPS consist of medication, injection, dry needle, or electrical therapy. However, besides decreasing pain and the intensity of the pain, it is also important to find a way to improve patients’ trigger points conditions, muscle activity and flexibility. Massage and stretch are common methods for treating trigger points and increasing muscle flexibility in physical therapy. The purpose of this study is to investigate the short-term effect of a home exercise and self-massage program for subjects with MPS. Study Design: A randomized controlled trial. Method: Sixty-three patients were randomly assigned into two groups: experimental (n=32) and comparison (n=31). Both groups received six physical therapy sessions, including Silver Spike Point (SSP) and hot pack. In addition, the experimental group also received home exercise programs and self-massage instructed by a physical therapist. Outcome measure data including Neck Disability Index (NDI), pressure pain threshold (PPT) and heart rate variability (HRV) were obtained at beginning and the end of treatment programs. Statistical Analysis: Two-way repeated measures ANOVAs were used to analyze the interaction between group and time as well as the between-group differences (P &lt; 0.01). Results: The experimental group demonstrated significant more improvement of PPT on the truly-trigger points (p&lt;0.001), related muscles than the comparison group. Regarding the effect of pain reduction, only the experimental group demonstrated significantly improvement on the resting pain scale (p&lt;0.001), pain during daily activities (p&lt;0.001) and the maximal pain intensity (p&lt;0.001). Significant functional improvement was also observed in the experimental group with decreasing the NDI score (p&lt;0.001) and increasing the PSFS score (p&lt;0.001). In the HRV, the experimental group demonstrated significant increase in HF (p=0.003) and HF% (p=0.008), as well as decrease in LF/HF (p=0.018) and heart rate (p=0.001). At the end of treatment sessions, the comparison group demonstrated significant improvement of PPT on the truly-trigger points (p=0.007) and PSFS (p=0.003). Discussion and Conclusion: The home exercise and self-massage combined with SSP and hot pack is more effective than SSP with hot pack alone.

中文摘要 i
Abstract iii
目錄 v
表目錄 vii
圖目錄 viii
第一章 簡介 1
第一節 研究背景與動機 1
第二節 研究目的 5
第三節 研究假設 5
第四節 研究重要性 6
第二章 文獻回顧 7
第一節 肌筋膜疼痛與物理治療 7
第二節 肌筋膜疼痛之評估 10
第三節 肌筋膜疼痛與心率變異度 13
第三章 研究方法 17
第一節 研究設計與研究架構 17
第二節 研究材料與流程 17
第三節 資料處理與統計分析 22
第四章 結果 24
第一節 研究對象 24
第二節 疼痛 25
第三節 壓力疼痛閾值 27
第四節 生活功能表現 33
第五節 心率變異度 35
第五章 討論 40
第一節 居家運動與自我按摩對疼痛的影響 40
第二節 居家運動與自我按摩對生活功能的影響 42
第三節 居家運動與自我按摩對心率變異度的影響 44
第四節 臨床意義 44
第五節 研究限制 46
第六節 未來研究 46
第六章 結論 47
參考文獻 48
附錄一：基本資料問卷 99
附錄二：臨床試驗同意書 100

1. Bennett R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2007;21:427-445
2. Yap EC. Myofascial pain--an overview. Ann Acad Med Singapore. 2007;36:43-48
3. Duyur Cakit B, Genc H, Altuntas V, Erdem HR. Disability and related factors in patients with chronic cervical myofascial pain. Clin Rheumatol. 2009
4. Travell J, Rinzler SH. The myofascial genesis of pain. Postgrad Med. 1952;11:425-434
5. Kostopoulos. The manual of trigger point and myofascial therapy. 2004
6. Travell J, Simons D. Myofascial pain and dysfunction: The trigger point manual. Vol.1 1983
7. Hubbard DR, Berkoff GM. Myofascial trigger points show spontaneous needle emg activity. Spine. 1993;18:1803-1807
8. Bennett R. Advances in pain research and therapy: Myofascial pain syndromes and the fibromyalgia syndrome: A comparative analysis. New York: Raven Press 1990;17:43-65
9. Simons D. Travell & simon's myofascial pain and dysgunction: The trigger point manual. Vol. 1,2nd ed. 1999
10. Bron C, Franssen J, Wensing M, Oostendorp RA. Interrater reliability of palpation of myofascial trigger points in three shoulder muscles. J Man Manip Ther. 2007;15:203-215
11. Alvarez DJ, Rockwell PG. Trigger points: Diagnosis and management. Am Fam Physician. 2002;65:653-660
12. Fernandez-de-Las-Penas C, Simons D, Cuadrado ML, Pareja J. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr Pain Headache Rep. 2007;11:365-372
13. McClaflin RR. Myofascial pain syndrome. Primary care strategies for early intervention. Postgrad Med. 1994;96:56-59, 63-56, 69-70 passim
14. Moldofsky HK. Disordered sleep in fibromyalgia and related myofascial facial pain conditions. Dent Clin North Am. 2001;45:701-713
15. Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gevirtz R. Interrater reliability in myofascial trigger point examination. Pain. 1997;69:65-73
16. 林頌凱, 曾愷平,張煥禎. 肌筋膜疼痛症候群. 基層醫學. 2007;22:140-146
17. Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S, Zengin FO, Bayik Y. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005;25:604-611
18. Srbely JZ, Dickey JP, Lowerison M, Edwards AM, Nolet PS, Wong LL. Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: A randomized controlled study. Pain. 2008;139:260-266
19. Majlesi J, Unalan H. High-power pain threshold ultrasound technique in the treatment of active myofascial trigger points: A randomized, double-blind, case-control study. Arch Phys Med Rehabil. 2004;85:833-836
20. Aral. Efficacy of low level laser therapy in myofascial pain syndrome: An algometric and thermographic evaluation. Surgery and Medicine. 2003;33
21. Vernon H, Schneider M. Chiropractic management of myofascial trigger points and myofascial pain syndrome: A systematic review of the literature. J Manipulative Physiol Ther. 2009;32:14-24
22. Hsueh TC, Cheng PT, Kuan TS, Hong CZ. The immediate effectiveness of electrical nerve stimulation and electrical muscle stimulation on myofascial trigger points. Am J Phys Med Rehabil. 1997;76:471-476
23. Füsun Ardiç MS, Oya Topuz. Comparison of two different techniques of electrotherapy on myofascial pain Journal of Back and Musculoskeletal Rehabilitation 2002;16:11-16
24. Itoh K, Okada K, Kawakita K. A proposed experimental model of myofascial trigger points in human muscle after slow eccentric exercise. Acupunct Med. 2004;22:2-12; discussion 12-13
25. Gam AN, Warming S, Larsen LH, Jensen B, Hoydalsmo O, Allon I, Andersen B, Gotzsche NE, Petersen M, Mathiesen B. Treatment of myofascial trigger-points with ultrasound combined with massage and exercise--a randomised controlled trial. Pain. 1998;77:73-79
26. Hanten WP, Olson SL, Butts NL, Nowicki AL. Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Phys Ther. 2000;80:997-1003
27. Esenyel M, Caglar N, Aldemir T. Treatment of myofascial pain. Am J Phys Med Rehabil. 2000;79:48-52
28. 程琡敏. 比較不同物理治療方法對肌筋膜疼痛症候群的療效
行政院國家科學委員會研究計畫. 2000
29. Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. 2002;83:1406-1414
30. Michelotti A, Steenks MH, Farella M, Parisini F, Cimino R, Martina R. The additional value of a home physical therapy regimen versus patient education only for the treatment of myofascial pain of the jaw muscles: Short-term results of a randomized clinical trial. J Orofac Pain. 2004;18:114-125
31. Jensen K, Andersen HO, Olesen J, Lindblom U. Pressure-pain threshold in human temporal region. Evaluation of a new pressure algometer. Pain. 1986;25:313-323
32. Farella M, Michelotti A, Steenks MH, Romeo R, Cimino R, Bosman F. The diagnostic value of pressure algometry in myofascial pain of the jaw muscles. J Oral Rehabil. 2000;27:9-14
33. Gomes MB, Guimaraes JP, Guimaraes FC, Neves AC. Palpation and pressure pain threshold: Reliability and validity in patients with temporomandibular disorders. Cranio. 2008;26:202-210
34. Duyur Cakit B, Genc H, Altuntas V, Erdem HR. Disability and related factors in patients with chronic cervical myofascial pain. Clin Rheumatol. 2009;28:647-654
35. Hsieh LF, Hong CZ, Chern SH, Chen CC. Efficacy and side effects of diclofenac patch in treatment of patients with myofascial pain syndrome of the upper trapezius. J Pain Symptom Manage. 2009
36. Yoon SH, Rah UW, Sheen SS, Cho KH. Comparison of 3 needle sizes for trigger point injection in myofascial pain syndrome of upper- and middle-trapezius muscle: A randomized controlled trial. Arch Phys Med Rehabil. 2009;90:1332-1339
37. Electrophysiology TFotESoCatNASoPa. Heart rate variability: Standards of measurement, physiological interpretation, and clinical use.
. Circulation 1996;93:1043-1065
38. Budgell B, B. P. The effects of thoracic manipulation on heart rate variability: A controlled crossover trial. J manipulative.
. Physiol Ther. 2006;29:603-610
39. Terkelsen AJ, Molgaard H, Hansen J, Andersen OK, Jensen TS. Acute pain increases heart rate: Differential mechanisms during rest and mental stress. Auton Neurosci. 2005;121:101-109
40. Tousignant-Laflamme Y, Marchand S. Sex differences in cardiac and autonomic response to clinical and experimental pain in lbp patients. Eur J Pain. 2006;10:603-614
41. Delaney JP, Leong KS, Watkins A, Brodie D. The short-term effects of myofascial trigger point massage therapy on cardiac autonomic tone in healthy subjects. J Adv Nurs. 2002;37:364-371
42. Takamoto K, Sakai S, Hori E, Urakawa S, Umeno K, Ono T, Nishijo H. Compression on trigger points in the leg muscle increases parasympathetic nervous activity based on heart rate variability. J Physiol Sci. 2009;59:191-197
43. Diego MA, Field T. Moderate pressure massage elicits a parasympathetic nervous system response. Int J Neurosci. 2009;119:630-638
44. Kuo TB, Lin T, Yang CC, Li CL, Chen CF, Chou P. Effect of aging on gender differences in neural control of heart rate. Am J Physiol. 1999;277:H2233-2239
45. Leite FM, Atallah AN, El Dib R, Grossmann E, Januzzi E, Andriolo RB, da Silva EM. Cyclobenzaprine for the treatment of myofascial pain in adults. Cochrane Database Syst Rev. 2009:CD006830
46. Ho KY, Tan KH. Botulinum toxin a for myofascial trigger point injection: A qualitative systematic review. Eur J Pain. 2007;11:519-527
47. 高木榮, 官大紳, 謝悅齡, 楊政峰, 洪章仁. Myofascial low back pain. 臺灣復健醫學雜誌. 2008;36:1-14
48. Hakguder A, Birtane M, Gurcan S, Kokino S, Turan FN. Efficacy of low level laser therapy in myofascial pain syndrome: An algometric and thermographic evaluation. Lasers Surg Med. 2003;33:339-343