超音波彈性造影量化與比較刮痧及缺血性壓迫法對於女性上斜方肌活動性激痛點之影響

Abstract

背景: 肌筋膜疼痛症候群好發於辦公室女性，並易造成肩頸上斜方肌疼痛，臨床上常能在緊帶中發現激痛點的存在，而激痛點的形成與動作終板失常造成肌結節阻擋血液供應進而造成能量危機的惡性循環有關。近日文獻中發現激痛點於超音波彈性造影上呈現一橢圓形低回聲訊號，且活動性激痛點具較大的截面積，然而目前仍尚未有研究使用彈性造影探討治療前後激痛點截面積的型態變化，且也仍尚未發展出最好的治療方式。傳統醫療刮痧已被證實能有效增加局部血液循環，並能改善頸痛患者不適，然而目前仍尚未有研究探討刮痧對於活動性激痛點之影響。 目的: 藉由超音波彈性造影探討並比較傳統醫療-刮痧與常見物理治療介入-缺血性壓迫法對於女性肩頸痠痛上斜方肌具有活動性激痛點之受試者於立即、介入後第二天及第七天的短期影響。 方法: 本實驗招募上斜方肌具有激痛點之女性，並於前測評估後依其疼痛程度隨機分組至刮痧組或缺血性壓迫組，並分別給予五分鐘的介入，介入後立即量測第一次後測，並於介入兩天及七天後再次量測第二次及第三次後測。成效評估包含使用超音波彈性造影量測激痛點之截面積、關節活動度、壓力疼痛閾值、視覺類比量表、二十牛頓力加壓後之疼痛指數及頸椎功能障礙指數問卷。統計方面若有受試者不克前來則使用意圖治療分析法(Intention to treat analysis)進行統計，並使用獨立樣本t檢定比較兩組基本資料，雙因子混和設計變異數分析比較兩組組間在各成效中是否具任何交互作用，若無交互作用但具主效果(main effect)，則再使用單因子變異數分析，分析各組內是否具時間上的變化。 結果: 本實驗共招募四十位女性受試者，每組各二十人，兩組於年齡、使用電腦時間、疼痛強度與症狀持續時間等皆無差異。介入後，刮痧組於立即至七天後的截面積皆較介入前有顯著的減少(28.19 ± 9.8 mm2, 19.48 ± 6.24 mm2, 21.84 ± 6.46 mm2 and 20.63 ± 6.44 mm2)，關節活動度於介入後也有立即的增加(37.67 ± 4.84˚ to 39.97 ± 5.55˚)；缺血性壓迫組則只有在介入後有立即的截面積減少(25.2 ± 11.32 mm2 to 21.06 ± 8.29 mm2)，然而壓力疼痛閾值在介入後第二天及第七天有顯著下降的現象(26.14 ± 10.56 N, 22.23 ± 9.36 N and 21.68 ± 8.37 N)，二十牛頓力加壓後之疼痛指數於第七天也有顯著上升的現象；而兩組之視覺類比量表指數皆於第二天及第七天獲得顯著下降，顯示疼痛皆有改善，且頸椎功能障礙指數問卷也皆於第二天顯示顯著改善其生活功能；但整體而言兩組組間皆不具任何差異。 結論: 對於女性上斜方肌具激痛點者，刮痧較缺血性壓迫法於成效評估上具有較多項目及短期時間上的改善。

Background: Myofascial pain syndrome (MPS) has higher prevalence in female office workers and can find myofascial trigger points (MTrP) in taut bands, especially with their upper trapezius. Formation of MTrP was proposed as motor endplate dysfunction leading to sustained sarcomere contraction that compresses the vessels and causes “energy crisis”. Recent studies showed that MTrPs could be distinguished by sonoelastography as a hypoechoeic ellipsoidal focal area and the active MTrPs also had significant larger cross-sectional area than normal and latent MTrPs. However, no studies to date use MTrPs' cross-sectional areas as an objective outcome measure to investigate treatment effects and there is still no agreement on which treatment is the most effective non-invasive treatment for MTrPs. Besides, traditional Gua-Sha intervention has been proven to be beneficial to chronic neck pain and microcirculation could increase up to four folds after Gua-Sha, but there is still no quantitative study investigating the effect of Gua-Sha intervention on MTrPs. Purposes: To quantify and compare the immediate, two days and one week follow up treatment effects of Gua-Sha and ischemic compression interventions on female upper trapezius active MTrPs. Methods: The study recruited female subjects who had active MTrP on their upper trapezius. After baseline general examination, subjects were divided into Gua Sha group (GSG) and ischemic compression group (ICG) with stratified randomization based on their visual analogue scale (VAS) scores. The outcome measures including: cross-sectional area through sonoelastographic measurement, passive range of motion (PROM), Chinese version neck disability index (NDI), pressure pain threshold (PPT), VAS and pain intensity when apply 20N compression force. All outcomes were recorded at baseline, immediate (IM), 2 days and 7 days after treatment as follow-up. Differences in demographic data at baseline between two groups were assessed with two- tailed independent T tests. Intention to treat analysis and two way mixed ANOVA (2 groups x 4 time points) were used in this study. If there were no interactions but main effect, one way repeated measures ANOVA would be used within each group. Results: Results showed that GSG had significantly reduced MTrP area at IM and sustain to 7 days compared to baseline (28.19 ± 9.8 mm2, 19.48 ± 6.24 mm2, 21.84 ± 6.46 mm2 and 20.63 ± 6.44 mm2). ICG only had significantly reduced MTrP area at IM compared to baseline (25.2 ± 11.32 mm2 to 21.06 ± 8.29 mm2). GSG showed significantly improved PROM at IM (37.67 ± 4.84˚ to 39.97 ± 5.55˚) and ICG showed significantly reduced PPT at 2 days and 7 days after treatments (26.14 ± 10.56 N, 22.23 ± 9.36 N and 21.68 ± 8.37 N, indicating lower force threshold to induce pain). Pain intensity when applying 20N compression force also showed more severe symptom in ICG at 7 days compared to baseline. And both groups showed improvements on NDI at 2 days and VAS at 2 days and 7 days’ time points. But there were no significant differences between two groups on all outcome measures. Conclusion: Gua Sha demonstrated superior short-term effects in more outcome measures than ischemic compression in pain and functional status in female patients with MPS.