心绞痛牵涉痛与穴位敏化的关系
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摘要
目的:观察冠心病稳定型心绞痛牵涉痛分布区域与穴位的关系,并结合动物实验探讨局部敏化出现的规律。方法:临床研究部分,观察1 046例冠心病稳定型心绞痛患者外周压痛敏感部位、局部皮肤形态异常改变,并测量了77位患者疼痛阈值的变化。动物实验部分,以SD大鼠冠状动脉左前降支结扎4h为心肌缺血模型组(n=14),以假手术为对照组(n=4),分别用在自然光下拍摄观察和活体荧光成像的方法,记录大鼠尾静脉注射Evans Blue后体表出现蓝染的部位,并检测痛阈变化。结果:心绞痛患者压痛部位以及皮肤局部组织结构的改变多分布在左侧胸前区、背部、肩部、上肢尺侧部;右侧也有一定数量的分布。压痛点出现在穴位上、穴位附近和穴位以外。心肌缺血的大鼠模型出现类似的变化。结论:心脏发生缺血性病变时,其相应节段(T 1~T 5)神经支配皮节区域发生规律性的牵涉性的"敏化"反应,这些敏感度改变的部位与"穴位"形成有关。
Objective To observe the correlation between the referred pain regions of stable angina pectoris(SAP)and the acupoints in coronary heart disease(CHD)patients and to investigate the rule of regional sensitized point distribution in rats.Methods A total of 1 046 CHD patients with SAP from 8 hospitals in China were recruited in the present study.The tenderness was palpated along the left and right chest,back,shoulder,upper limb,etc.by a specially-assigned researcher in each hospital.Among them,77 patients accepted pain threshold(PT)measurement by using a hand-held esthesiometer.In animal experiments,14 SD rats were subjected to occlusion of the left anterior descending branch of the left coronary artery for 4 hfor establishing myocardial ischemia(MI)model,and other 4 normal rats were used as the sham-operation control group.Four hours after MI,all the rats accepted tail venous injection of 5% Evans blue(50 mg/kg)for examining the distribution of the blue dye exudation spots at the body surface where the mechanical PT was also detected by a von Frey.Results In 1 046 CHD patients,987(94.36%)were found to have at least one tenderness spot.The tenderness spots were found at the left chest(87.47%),right chest(13.67%),left arm(ulnar side,41.30%),right upper limb(4.68%),left shoulder back(30.21%),right shoulder back(7.07%),etc.,accompanied with rash or pigmentation,subcutaneous induration,cord-like tissue contracture,skin sag,etc.The mechanical PT level was significantly lower at the tenderness spots of the left upper limb than at non-tender points of the right upper limb in CHD patients(P<0.001).Tenderness and cutaneous abnormal changes in angor pectoris patients distributed mostly on the left chest,back,shoulder and upper limb,and some also on the right.Tender points scattered on,near or outside acupoints.A similar distribution of the blue exudation spots and lower mechanical PT spots were found in MI rats,but not in shamMI rats.Conclusion In the case of MI,a regular"referred sensitization"response frequently occurs in the dermatomere area innervated by the corresponding segments(T 1-T 5)in both CHD patients and MI rats,which may be closely associated with the formation of acupoints in ancient China.
Objective To observe the correlation between the referred pain regions of stable angina pectoris(SAP)and the acupoints in coronary heart disease(CHD)patients and to investigate the rule of regional sensitized point distribution in rats.Methods A total of 1 046 CHD patients with SAP from 8 hospitals in China were recruited in the present study.The tenderness was palpated along the left and right chest,back,shoulder,upper limb,etc.by a specially-assigned researcher in each hospital.Among them,77 patients accepted pain threshold(PT)measurement by using a hand-held esthesiometer.In animal experiments,14 SD rats were subjected to occlusion of the left anterior descending branch of the left coronary artery for 4 hfor establishing myocardial ischemia(MI)model,and other 4 normal rats were used as the sham-operation control group.Four hours after MI,all the rats accepted tail venous injection of 5% Evans blue(50 mg/kg)for examining the distribution of the blue dye exudation spots at the body surface where the mechanical PT was also detected by a von Frey.Results In 1 046 CHD patients,987(94.36%)were found to have at least one tenderness spot.The tenderness spots were found at the left chest(87.47%),right chest(13.67%),left arm(ulnar side,41.30%),right upper limb(4.68%),left shoulder back(30.21%),right shoulder back(7.07%),etc.,accompanied with rash or pigmentation,subcutaneous induration,cord-like tissue contracture,skin sag,etc.The mechanical PT level was significantly lower at the tenderness spots of the left upper limb than at non-tender points of the right upper limb in CHD patients(P<0.001).Tenderness and cutaneous abnormal changes in angor pectoris patients distributed mostly on the left chest,back,shoulder and upper limb,and some also on the right.Tender points scattered on,near or outside acupoints.A similar distribution of the blue exudation spots and lower mechanical PT spots were found in MI rats,but not in shamMI rats.Conclusion In the case of MI,a regular"referred sensitization"response frequently occurs in the dermatomere area innervated by the corresponding segments(T 1-T 5)in both CHD patients and MI rats,which may be closely associated with the formation of acupoints in ancient China.
引文
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[14]HEAD H.On disturbances of sensation with especial reference to the pain of visceral disease[J].Brain,1893,16(3):1-133.
[15]MACKENZIE J.Heart pain and sensory disorders associated with heart failure[J].Lancet,1895,145(3723):16-22.
[16]SAMPSON J J,CHEITLIN M D.Pathophysiology and differential diagnosis of cardiac pain[J].Prog Cardiovasc Dis,1971,13(6):507-531.
[17]YARUSHKINA N,BOGDANOV A,FILARETOVA L.Somatic pain sensitivity during formation and healing of acetic acid-induced gastric ulcers in conscious rats[J].Auton Neurosci,2006,126-127(4):100-105.
[18]FURUTA A,SUZUKI Y,HONDA M,et al.Time-dependent changes in bladder function and plantar sensitivity in a rat model of fibromyalgia syndrome induced by hydrochloric acid injection into the gluteus[J].BJU Int,2012,109:306-310.
[2]朱兵.穴位可塑性:穴位本态的重要特征[J].中国针灸,2015,35(11):1203-1208.
[3]LUZ L L,FERNANDES E C,SIVADO M,et al.Monosynaptic convergence of somatic and visceral C-fiber afferents on projection and local circuit neurons in lamina I:a substrate for referred pain[J].Pain,2015,156(10):2042-2051.
[4]姜丽华,姜劲峰,戴文君,等.冠心病患者前臂内侧反应点位置和痛觉与手厥阴经穴的一致性探测[J].时珍国医国药,2015,26(8):2037-2040.
[5]陈日新,康明飞.腧穴热敏化艾灸新疗法[M].北京:人民卫生出版社,2006:20-23.
[6]盖国才.穴位压痛诊断法[M].北京:科学技术文献出版社,1978:66-70.
[7]吴秀锦.内脏体表联系的临床观察——136例胃、肝疾病的穴位反应[J].广东医药资料,1979,10(2):46-49.
[8]LI S,MELTON D H,LI S.Tactile,thermal,and electrical thresholds in patients with and without phantom limb pain after traumatic lower limb amputation[J].J Pain Res,2015,8:169-174.
[9]FARMER A D,AZIZ Q.Mechanisms and management of functional abdominal pain[J].J R Soc Med,2014,107(9):347-354.
[10]CHANG L,BERMAN S,MAYER E A,et al.Brain responses to visceral and somatic stimuli in patients with irritable bowel syndrome with and without fibromyalgia[J].Am J Gastroenterol,2003,98(6):1354-1361.
[11]MELZACK R,STILLWELL D M,FOX E J.Trigger points and acupuncture points for pain:correlations and implications[J].Pain,1977,3(1):3-23.
[12]BIRCH S.Trigger point—acupuncture point correlations revisited[J].J Altern Complement Med,2003,9(1):91-103.
[13]DORSHER P T.Can classical acupuncture points and trigger points be compared in the treatment of pain disorders?Birchs analysis revisited[J].J Altern Complement Med,2008,14(4):353-359.
[14]HEAD H.On disturbances of sensation with especial reference to the pain of visceral disease[J].Brain,1893,16(3):1-133.
[15]MACKENZIE J.Heart pain and sensory disorders associated with heart failure[J].Lancet,1895,145(3723):16-22.
[16]SAMPSON J J,CHEITLIN M D.Pathophysiology and differential diagnosis of cardiac pain[J].Prog Cardiovasc Dis,1971,13(6):507-531.
[17]YARUSHKINA N,BOGDANOV A,FILARETOVA L.Somatic pain sensitivity during formation and healing of acetic acid-induced gastric ulcers in conscious rats[J].Auton Neurosci,2006,126-127(4):100-105.
[18]FURUTA A,SUZUKI Y,HONDA M,et al.Time-dependent changes in bladder function and plantar sensitivity in a rat model of fibromyalgia syndrome induced by hydrochloric acid injection into the gluteus[J].BJU Int,2012,109:306-310.