肩的疼痛

ShoulderPain腦卒中后遺癥中約有２１～７２％的患者主訴肩痛。Twenty-one%to72%ofstrokepatientscomplainofshoulderpain.文獻(xiàn)： VanOuwenalleretal.:Painfulshoulderinhemiplegia.Arch

PhysMedRehabil,67:23-25,1986.

BohannonRWetal.:Shoulderpaininhemiplegia:Statistical

relationshipwithfivevariables.ArchPhysMedRehabil,67:

514-516,1986.

ChardMD,HazlemanBL:Shoulderdisordersintheelderly.

AnnRheumDis,46:684-687,1987.

VanIangenbergheHVKetal.:Shoulderpaininhemiplegia: Abookreview.PhysiotherPract,4:155,1988.３種疼痛

(Threekindsofshoulderpain)①活動(dòng)時(shí)疼痛(Mechanicalandlocalpainwhilemovingandbeingmoved)

被動(dòng)活動(dòng)和自主活動(dòng)時(shí)的局部疼痛。②安靜時(shí)自發(fā)疼痛

(Spontaneousandextensivepainatrest)

夜間睡覺時(shí)與長時(shí)間輪椅保持坐位時(shí)，麻痹的上下肢的存在廣泛的疼痛。肩手綜合征的患者多伴有浮腫。

進(jìn)行運(yùn)動(dòng)療法時(shí)該癥狀容易消失，故問診是必不可少的。肩的活動(dòng)時(shí)疼痛多先出現(xiàn)。Thispainisspontaneousandextensivepaininaffectedupperandlowerextremitiesatrestwhenpatientslieonbedsandsitonwheelchairs.Mostofpatientshaveedemaduetoshoulder-handsyndrome.Asthiskindofpaindisappearsinmovementtherapy,therapistsmustaskwhethertheyhavesuchkindofpainornot.Thisextensivepaintendstobeinitiatedbylocalshoulderpain.

BrausDFetal.:Theshoulder-handsyndromeafterstroke:A

prospectiveclinicaltrial.AnnNeurol,36:728-733,1994.３種疼痛

(Threekindsofshoulderpain)③視丘痛(Thalamicpain)

在視床后外側(cè)癥候群中，90%的后外側(cè)損傷病例可見此種疼痛。Thalamicpainisoneofsyndromeinthelesionofposterior-lateralpart.Ninety%ofpatientswiththelesionofthatparthadthalamicpain.

(Miyazaki1997)

宮崎東洋：ペインクリニック.克誠堂、pp40-47?182-193、1997.花岡一雄?橘直矢：わかりやすい神経系の話.メディカルトリビューン、東京、ｐ５２、１９８５.posterioranteriorrightwards(lateral)leftwards(medial)posterolateraln.pulvinarthalamusventralposterolateraln.dorsolateraln.（前外側(cè)腹側(cè)核）ventralanterolateraln.（中間腹側(cè)核）ventrointermedialn.視床Thalamusdorsomedialn.（視床內(nèi)側(cè)核）medialcorpusgeniculatumlatealcorpusgeniculatum(Mori,1995)森於兎（原著）：解剖學(xué)１（改訂１１版）.大內(nèi)弘（改訂）、金原出版、p336、1995.lowerfibresoftrapeziusupperfibresoftrapeziusserratusanteriorlevatorscapulaerhomboidminorrhomboidmajorcentreofrotationcentreofrotation肩胛骨的運(yùn)動(dòng)

ScapularMotion前方後方內(nèi)側(cè)上方下方外側(cè)上方後方下方前方內(nèi)側(cè)外側(cè)後傾posteriortilting前傾anteriortilting上方回旋upwardrotation下方回旋downwardrotation內(nèi)旋int.rot.外旋ext.rot.BramanJP,EngelSC,LaPradeRF,etal.:Invivoassessmentofscapulohumeralrhythmduringunconstrainedoverheadreachinginasymptomaticsubjects.JShoulderElbowSurg,18:960-967,2009.Averagehumerothoracicplaneelevation:63.3±7.0°forwardofcoronalplane,andaveragepeakelevation:132.9±9.9°

①ScapularRot:Int.Rot.until125°ofarmelevation,thenrotatedexternallywithfurtherelevation.②Scapulohumeralrhythm,2.3:1duringelevation.

2.7:1duringlowering.③Maximallytilted11.8±4.9°anteriorlyat15°ofhumerothoracicelevation.

Aminimumposteriortiltof9.8±7.5°at145°.①②③7活動(dòng)時(shí)疼痛(Mechanicalandlocalpain)■初期遲緩期的移乘和臥位翻身時(shí)的細(xì)微損傷（對(duì)于患側(cè)上臂的KP應(yīng)該慎重使用，體干的KP效果較好）Ininitiallyflaccidstage,caregiverssometimegivemicrotraumasandexcessivestretchesofaffectedshoulders.(InearlystagetherapistsandcaregivermustcarefullyuseproximalanddistalKPofaffectedupperextremitiesintransferandturningover.Wehadbetteruseaffectedtrunksandscapulae.)■肌張力的不平衡和肌肉（軟組織）粘彈性低下Imbalanceofposturalmuscletoneanddecreaseofviscoelasticityofmusclesandsofttissues①肩胛骨的不穩(wěn)定

Instabilityofaffectedscapula②容易產(chǎn)生短縮的肌肉：胸小肌、胸大肌尤其是鎖骨枝、肱二頭肌、喙肱肌、菱形肌、背闊肌等。與遲緩肌混合在一起。Shortness:pectminor,pectmajor(especiallyclavicularportion),biceps,coracobrachialis,rhomboids,latissimusdorsiandsoon.Theseexistwithhypotonicmuscles.①②

恢復(fù)肩肱節(jié)律，去除胸大肌的負(fù)荷（de-weight

）

Recoveryofscapulohumeralrhythm&De-weighttoP.Major

BobathK:Shoulderpain.PhysTher,52:444-445,1972.MyersTW:AnatomyTrain.Churchill

Livingstone,London,pp18?163,2006.Pectoralisminorconnectsfasciallytoshortheadofbicepsbrachiiandcoracobrachialisatcoracoidprocess.9粘連(Adhesion)■根據(jù)偏癱患者肩關(guān)節(jié)造影，25%的患者存在粘連變形。特別是肱二頭肌腱鞘達(dá)到了58%。(Fukui1972)

Inarthrography,58%oftendonsheathsofbicepshadadhesion.福井國彥：片麻痺肩の造影レ線像を中心とする所見及び経過について. リハ醫(yī)學(xué)、9:183、1972.■偏癱的患側(cè)肩多少呈現(xiàn)了粘連性癥狀，48個(gè)病例中27個(gè)有此癥狀（56.3%）。(Hakuno1984)Fifty-six%ofaffectedshouldershadadhesion.白野明?他：片麻痺肩の関節(jié)造影上の変化について.総合リハ、12:

47-52、1984.■偏癱患者關(guān)節(jié)造影，根據(jù)與半脫位肩關(guān)節(jié)的比較，在半脫位上產(chǎn)生關(guān)節(jié)的粘連性變化更為常見。而且從肩關(guān)節(jié)整體來看粘連的產(chǎn)生也是在半脫位更容易產(chǎn)生。撞擊的可能性極小。

(Hakuno1986)

Inarthrographyof95shoulderjoints,mostofadhesionwasaccompaniedwithshoulderjointsubuxations.

白野明：片麻痺肩の関節(jié)造影所見.総合リハ、14:203-207、1986.

粘連

(Adhesion)■在實(shí)行肩關(guān)節(jié)造影的50例病例之中，肩肱關(guān)節(jié)處的粘連變化達(dá)80%，腱斷裂存在14%。

(Ono1994)Inarthrographyof50cases,80%hadadhesionofscapurohumeraljoints,and14%hadruptureoftendons.小野幸子?他：片麻痺患者の肩痛.リハ醫(yī)學(xué)、31:928-929、1994.■以發(fā)病未滿1年、主訴肩痛的患者32人進(jìn)行關(guān)節(jié)造影。發(fā)病后2個(gè)月以內(nèi)沒有肩痛癥狀的，50%的病人存在粘連性囊炎(adhesivecapsulitis)。

22%的人旋轉(zhuǎn)肩袖（rotatorcuffs）斷裂，16%存在肩手綜合征、44%存在肩關(guān)節(jié)半脫位。粘連性囊炎為肩關(guān)節(jié)疼痛的誘因。

Fifty%of32caseswhocomplainedofshoulderpainhadadhesivecapsulitis.Twenty-two%hadruptureofrotatorcuffs,16%hadshoulderhandsyndromeandsubluxationsofshoulderjointswerefoundin44%.Adhesivecapsulitisisoneofcausesofshoulderpain.

LoS-Fetal.:Arthrographicandclinicalfindingsinpatientswith

hemiplegicshoulderpain.ArchPhysMedRehabil,84:1786-1791,

2003.粘連

(adhesion)

■由于浮腫導(dǎo)致肱二頭肌、肱三頭肌長頭等起始部位腱鞘和關(guān)節(jié)囊的短縮和粘連。Edemamakesshortnessandadhesionincapsulesandtendonsheathsofbicepsbrachiiandtricepsbrachiietc.

RoyCW:Shoulderpaininhemiplegia:Aliteraturereview. ClinicalRehabilitation,2:35-44,1988.■腱炎?粘連性囊炎

(tendinitisandadhesivecapsulitis)

肱二頭肌長頭的疼痛波及肌腹以及肱二頭肌間溝的腱炎，在前臂內(nèi)側(cè)面出現(xiàn)疼痛，肘部形成二頭肌腱炎。

Someofhepaininoriginofbicepsbrachiilongheadcomesoutinitsbelly,whichistendinitisinintertuberculargroove.Theteniditisintheinsertionofbicepsbrachiiindicatespaininupperandvolarside. DonatelliRA:肩のリハビリテーション.山本龍二?他（監(jiān)訳）、 メディカル葵出版、東京、pp83-101、2002.■臨床觀察(Intheclinicalobservation)

在長期臥床的病例中，在胸廓和背部可見短縮與粘彈性低下，上肢上舉時(shí)肩胛骨和肋骨的分節(jié)運(yùn)動(dòng)困難。

Inthecaseswhohaveexperiencedtolieonbedsinlongterm,shortnessanddecreaseofviscoelasticityofbackmusclesareobserved.Theseproblemsmadesegmentalmovementsofribcagespoor.

CaillietR:肩の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、pp14?51、2004.肱二頭肌長頭的沖突Impingement/stretchofthelongheadofbicepsbrachiiinintertuberculargroove ?PaincapsulelongheadofbicepssynovialmembranelongheadofbicepssynovialfluidsynovialmembranetransverseligamentbicepsScapulohumeralSynovialBursaandJointCapsulecoracoacrominallig.MechanismofBiceps(longhead)伸展二頭肌長頭在結(jié)節(jié)間溝?疼痛Impingement撞擊

(impingementsyndrome,chronicsubacrominalimpingementsyndrome)肩峰、喙肩韌帶、喙突、肩鎖關(guān)節(jié)會(huì)與腱板和肩峰下滑液囊發(fā)生撞擊，發(fā)生慢性的持續(xù)的疼痛時(shí)，稱為impingement綜合癥。Impingementisthephenomenonthattheacromion,coracoacrominallig.,coracoidprocessandacromioclavicularjointcollidetorotatorcuffsandsubacrominalbursa.Whencollisionsarerepeatedandpainoccurs,itiscalledimpingementsyndrome. (Tamai2002)玉井和哉：インピンジメント癥候群.「肩の痛み」 寺山和雄?片岡治（監(jiān)修）、南江堂、pp85-98、2002.■撞擊與夾痛impingement&pinching

上肢水平外展運(yùn)動(dòng)中產(chǎn)生的疼痛，推測(cè)為肩峰下滑液囊和肱三頭肌長頭的夾痛。

Thepainwhilemovinganarmhorizontallyisguessedtobecausedbypinchingacapsuleandalongheadoftricepsbrachii.■根據(jù)運(yùn)動(dòng)方向產(chǎn)生的疼痛

Differentlocalpainindifferentdirectionsofthemovement前方上舉時(shí)的疼痛

(Whatisthelocalpainwhileelevatingaarm?)：水平外展時(shí)的疼痛

(Whatisthelocalpainwhileabductinghorizontally?)：水平內(nèi)收時(shí)的疼痛

(Whatisthelocalpainwhileadductinghorizontally?)：上肢放下時(shí)的疼痛

(Whatisthelocalpainwhiledescendingarm?)：(Mori1995)

森於兎（原著）：解剖學(xué)１（改訂１１版）.大內(nèi)弘（改訂）、金原出版、pp128?341、1995.結(jié)節(jié)間溝Intertuberculargroove肱二頭肌長頭longheadtendonofbicepsbrachii(Mori1995)

森於兎（原著）：解剖學(xué)１（改訂１１版）.大內(nèi)弘（改訂）、金原出版、p207、1995.結(jié)節(jié)間滑液鞘Intertubercularsynovialmembrane(Yazaki2008)

矢崎潔：再び人間の上肢の運(yùn)動(dòng)を考える（１）.ボバースジャーナル、31(1):54-61、2008.肘關(guān)節(jié)屈伸運(yùn)動(dòng)時(shí)（Ｃ）的肱三頭肌和胸大肌的關(guān)系

Relationshipbetweenbicepsandpectoralismajorwhenanelbowextendsandflexes.

（Ａ）肱二頭肌起作用時(shí)長頭腱產(chǎn)生壓力的方向

Thedirectionofpoweronthelongheadofbicepsbrachii（Ｂ）伸展時(shí)，生理上作為協(xié)同肌的胸大肌對(duì)肱骨的牽引方向

Thedirectionofcontractiononthepectoralismajorwhenelevatinganhumerus

、、（Ｄ?Ｅ）肱二頭肌和胸大肌的位置關(guān)系elationshiponalignmentsbetweenlongheadofbicepsandp.major

長頭肌腱處直接加壓，結(jié)節(jié)間溝和周邊疼痛

Pressureisgiventoalongheadofbicepsinintertuberculargroove,andpaintendstooccur.

flexionextension４９歲男性、腦出血（右側(cè)偏癱）、發(fā)病后２月、右肩痛

Age:49Y,Male,Dx.:CerebralHemorrhage(RightHemiandRt.ShoulderPain),2MonthsafteraStroke翻身時(shí)麻痹側(cè)右上肢落在身后，牽張痛會(huì)在肱二頭肌長頭起始部出現(xiàn)。Whenheturnsoverfromsupinetoleftside-lyingwhilesleepingonabed,heoftenleaveshisrightarmandthenhasrightshoulderpain.為了預(yù)防對(duì)于肱二頭肌長頭起始部位過度的伸張和撞擊，調(diào)整肩肱節(jié)律。Inordertopreventstretchandimpingement,scapulohumeralrhythmiscorrectedwithplacing.在患者翻身時(shí),PT要誘導(dǎo)從右側(cè)上肢開始的翻身動(dòng)作。保持肩胛帶的前伸。Atherapistguidestherightscapulaandarmmoveupwardwhenturningover.Thepatient’sawarenessisimportant.Selfcontroltopreventshoulderpain患者自己控制，左手把持麻痹側(cè)上肢，在不引起疼痛下翻身。(Mori1995)森於兎（原著）：解剖學(xué)１（改訂１１版）.大內(nèi)弘（改訂）、金原出版、pp337?344、1995.水平外展時(shí)肱骨三頭肌長頭和關(guān)節(jié)囊的夾痛

Pinchingadpainofalongheadoftricepsbrachiiandajointcapsuleabductinghorizontally.LongheadoftricepsTeresmajorTeresminorLongheadoftricepsTeresmajor(Tamai2002)玉井和哉：インピンジメント癥候群.「肩の痛み」寺山和雄?片岡治（監(jiān)修）、pp85-95、2002.

NeerCS:Cufftears,bicepslesions,andimpingement.ShoulderReconstruction.(Ed.)NeerCS,WBSaunders,Philadelphia,pp41-142,1990.(右図)Impingement撞擊綜合癥ImpingementSyndrome岡上肌出口狹小化NarrowsupraspinatusoutletCaillietR:肩の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、pp27-28?66-68、2004.在損傷部位的壓痛RuptureofSupraspinatus

岡上肌的斷裂Pressurepaininthelesion肩懸吊肩(ShoulderSling)

左側(cè)偏癱Lt.Hemi.活動(dòng)時(shí)疼痛的對(duì)策

(Theapproachtolocalpainwhilemoving)■平衡肌張力和恢復(fù)肌肉粘彈性

Posturalcontrol,modulationofposturalmuscletone,restorationofvscoelsticity.■恢復(fù)肩肱節(jié)律Recoveryofscapulohumeralrhythm?肩胛骨的定勢(shì)Scapulasetting?肩胛帶的穩(wěn)定性與運(yùn)動(dòng)性

Selectivestabilityandmovementof scapula■對(duì)于短縮，在KP控制的部位導(dǎo)入關(guān)節(jié)松動(dòng)術(shù)

Mobilizingtoshortnessofmusclesandsofttissues

肩胛骨的定勢(shì)

Scapulasetting腦梗塞（右側(cè)偏癱）68歲男性Dx.CerebralInfarction(Rt.Hemiplegia)Age:68YScapulasetting偏癱側(cè)肩胛提肌起始部的疼痛Painintheoriginofaffectedlevatorscapulae＊姿勢(shì)性疲勞

PosturalfatigueCaillietR:肩の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、pp275-285、2004.短縮

Shortness疼痛

Pain左側(cè)骨盆后撤

Lt.pelvisretractionCailletR:頚と腕の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、p226、2004.IncreaseofkyphosisDownwardrotationLevatorscapulaeLockedlongmuscles:StrainedLockedshortmuscles:Bunched（一塊）不活動(dòng)的長?。壕o張（＋）MyersTW:AnatomyTrain.Churchill

Livingstone,London,p18,2006.Increaseofthixotropy(觸變性的改變）28肩手綜合癥始于疼痛的肩和上肢Shoulder-handsyndromeisoccurredbylocalpaininaffectedshouldersandupperextremities. DonatelliRA:肩のリハビリテーション.山本龍二?他（監(jiān) 訳）、メディカル葵出版、東京、pp83-101、2002.BrausDFetal.:Theshoulder-handsyndromeafterstroke:Aprospective

clinicaltrial.AnnNeurol,36:728-733,1994.肩手綜合癥由局部損傷引起。Shoulder-handsyndromeisinitiatedbyperipherallesions(localpain).大范圍的麻痹側(cè)上下肢的安靜時(shí)自發(fā)痛Spontaneousandextensivepainatrest

■首先出現(xiàn)麻痹側(cè)運(yùn)動(dòng)時(shí)的局部疼痛。

推測(cè)疼痛是由于炎癥時(shí)產(chǎn)生的緩激肽、復(fù)合胺、組胺、鉀離子等的神經(jīng)激肽廣泛存在于浮腫部位。緩激肽等物質(zhì)促進(jìn)組織產(chǎn)生、游離前列腺素類物質(zhì)。

Thelocalshoulderpainwhilebeingmovedoccursbeforethiskindofpain.Itisguessedthattheneurokininlikebradykinin,serotonin,histamine,Achandpotassiumisaccumulatedalotinedemaandthenproductionofprostaglandinisincreasedandcausesspontaneousandextensivepainofaffectedupperextremitiesatrest.

AwadEA:Interstitialmyofibrositis:hypothesisofthemechanism,

ArchPhysMed,54:449-453,1973.

(Kumazawa1990)

熊澤孝朗：痛覚.「脳の科學(xué)１」中村嘉男?酒田英 夫（編）、朝倉書店、pp187-200、1990.■交感神經(jīng)產(chǎn)生了誘發(fā)疼痛的物質(zhì)-神經(jīng)激肽（neurokinin）。由于不存在皮膚血管擴(kuò)張，疼痛的閾值降低。Sympatheticnervesproducewhichmakespain.Itdilatesskinvesselsandlowersthethresholdofpain.

WattayEG:Reflexsympatheticdystrophysyndrome.Clinical

Management,9(1):28-29,1989.肩手綜合癥ShoulderHandSyndrome?麻痹側(cè)上肢的肌肉活動(dòng)低下

肌肉血流減少

DecreaseofmuscleactivitiesofanaffecttedupperextremityDecreaseofbloodflowinmuscles

?皮膚骨組織的血流增加Increaseofbloodflowinskinsandbones

reversely?局部的代謝障礙

微循環(huán)惡化、神經(jīng)激肽產(chǎn)生

傷害感受器的向心性沖動(dòng)增加

PoorlocalmetabolismInflammationofsofttissuesandalotofproductionofneurokinin

Increaseofafferentimpulsesfromnociceptors?內(nèi)環(huán)境穩(wěn)定，有促使皮膚骨組織增加的血流正?；淖饔肦eactionstonormalizetheincreaseofbloodflowofskinsandbonesbyhomeostasis?但是交感神經(jīng)活動(dòng)亢奮。①細(xì)小動(dòng)脈收縮②交感神經(jīng)和軀體感覺神經(jīng)產(chǎn)生去甲腎上腺素的化學(xué)信號(hào)，增加向心性沖動(dòng)，在脊髓水平，反射性的交感神經(jīng)興奮。

Activitiesofsympatheticnervesbecomeshigher.①Capillariescontract.②Insympatheticnervesandsensorynerves,chemicaltransmissionofnoradrenalinhappens,andthenafferentimpulsesincrease.Inspinalcord,sympatheticnervesreflexivelyexcite. (Ishibashi2002)石橋徹：反射性交感神経性ジストロフィー.「肩の痛み」 寺山和雄?片岡治（監(jiān)修）、pp183-197、2002.

CaillietR:肩の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、p65、2004.traumatraumaserotonincontractionofvesselbloodplateletdilationofvesselhistamineheparinedemaedemamechanicallyP-substancesprostaglandin-Ebradykininspasmsedemaocclusionofbloodflowphospholipidsarachidonicacid浮腫的機(jī)制

MechanismofEdematransmissionCaillietR:肩の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、pp257-260、2004.pumppumparteryveinlimitationofflexionandpumpingactionPumpsforVeinandLymphinUpperExtremity■上肢、手和胸廓全體的肌肉收縮過程中，浮腫也會(huì)減輕。

Intheprocesstorecovernormalcontractionoftheaffectedarmandhandandribcage,edemaisdecreased.大范圍的麻痹側(cè)上下肢安靜時(shí)自發(fā)疼痛的對(duì)策

Approachtospontaneousandextensivepainatrest

■寬動(dòng)作范圍神經(jīng)元（WDR神經(jīng)元）處于過敏狀態(tài)，同時(shí)具有對(duì)麻痹側(cè)肩運(yùn)動(dòng)時(shí)疼痛和局部疼痛的鎮(zhèn)靜效果。Widedynamicrangeneuronishyperreflexive,butmakethelocalpainofanaffectedshouldersedativeatthesamesession.

(Omote&Namiki1995)表圭一?並木昭義：ペインクリニックに おけるRSD.醫(yī)學(xué)の歩み、175:473、1995.■為了減輕浮腫，需恢復(fù)肌泵的作用，改善靜脈回流與淋巴回流。消除不活動(dòng)。

Recoverpumpingactions,andimprovevenousandlymphflowstodecreaseedema.

■麻痹側(cè)肩周圍肌群的持續(xù)收縮，改善遲緩的手部浮腫是重點(diǎn)。改善使腕管變窄的屈肌支持帶、腕關(guān)節(jié)屈肌群的短縮。手內(nèi)在肌收縮對(duì)于手部浮腫改善非常重要。Increasesustainedactivationandstabilityintheaffectedscapulaandarm.Widenandelongateaflexorretinaculumwhichisshortandnarrowsacarpaltunnel.Inordertoalleviateedemaintheaffectedhand,functionalcontractionofintrinsicmusclesisimportant.

CaillietR:肩の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、pp254、2004.外傷、trauma外傷、trauma后根神經(jīng)結(jié)、dorsalrootgangliaC-疼痛纖維、C-nociceptivefiber外側(cè)脊髓丘腦束

lateralspinothalamictract側(cè)束、lateralcolumnA-來自機(jī)械性感受器的纖維、A-fiber交感神經(jīng)

sympatheticnerve交感神經(jīng)信號(hào)、sympatheticsignals?營養(yǎng)障礙、dystrophyWideDynamicRangeNeuron(WDR)

寬動(dòng)作范圍神經(jīng)元肩手綜合癥＋胸廓出口癥候群Shoulderhandsyndromewiththoracicoutletsyndrome

（日常的座位姿勢(shì)

Usualsittingpattern）

（治療中

Treatment）62歲診斷：右側(cè)殼部出血（左側(cè)偏癱）發(fā)病后4個(gè)月26日，左后傾~胸背部，左前胸部~上臂前面、外側(cè)，左腕關(guān)節(jié)掌側(cè)安靜時(shí)自發(fā)疼痛、左手浮腫、裝配肩吊帶。Age:62Y,Dx:Rt.PutamenHemorrhage(Lt.Hemi.)4M26Dfromtheonset.Spontaneousandextensivepaininleftu/eatrest.painpainpain胸廓出口ThoracicOutlet(Sadahiro2002)貞廣哲郎：胸郭出口癥候群.「肩の痛み」寺山和雄?片岡治（監(jiān)修）、南江堂、pp161-171、2002.BrachialplexusPect.Minor1stRibmiddlescalenusClavicleSubclavicularveinSubclaviculararteryAnteriorscalenus安靜時(shí)大范圍的自發(fā)疼痛

(spontaneousandextensivepainatrest)Pain

疼痛端坐位左側(cè)橈動(dòng)脈的脈搏

StrengthofCardiacBeatsinLeftRadialArtery(AdsonTest)治療(Tx)

姿勢(shì)Posture.

CardiacBeats/min.

Strength(AdsonTest)1.(BeforeTx)

頸部軀干過度屈曲６３Alittle

（胸廓狹?。㎞eck&TrunkFlexion↑innaturalposition.

weak2.(BeforeTx)

左側(cè)旋轉(zhuǎn)頸部屈曲６５Weaker（胸廓狹?。㎞eckrotationtotheleftandflexion

innaturalp.

3.(DuringTx15mni.)

頸部、軀干伸展６６Stronger（治療15分，胸廓擴(kuò)張）Neckandtrunkext.withneckrot.toleftDonatelliRA:肩のリハビリテーション.山本龍二?他（監(jiān)訳）、メディカル葵出版、東京、103-128、2002.丘腦性疼痛ThalamicPain世界疼痛學(xué)會(huì)(IASP1986、IntenationalAssociationfortheStudyofPain)１）RSD（反射性交感神經(jīng)萎縮癥、reflexsynpathetic

dystrophies）ＲＳＤ是指在外傷后一個(gè)肢體的特定部分的持續(xù)疼痛。雖然其中包括骨折，但是主要不是神經(jīng)的損傷，是交感神經(jīng)的過度活動(dòng)。RSDisthatcontinuouspaininaportionofanextremityaftertraumawhichmay

includefracturebutdoesnotinvolveamajornerve.Itisassociatedwithsympathetichyperactivity. (Hyodo1989)

兵頭正義：定義と診斷基準(zhǔn).ペインクリニック、10(5):568-574、1989.世界疼痛學(xué)會(huì)(IASP1986、IntenationalAssociationfortheStudyofPain)２）灼性神經(jīng)痛(causalgia)

灼性神經(jīng)痛是指某一神經(jīng)部分受損、或者主要神經(jīng)枝的部分損傷，引起手足的灼熱痛、異常性疼痛、痛覺異常、過敏等癥狀。Causalgiaisthatburningpain,allodyniaandhyperpathia,usuallyinthehandor

foot,afterpartialinjuryofanerveoroeofitsmajorbranches.（＊如果不是神經(jīng)的主枝損傷，則不能稱之為灼性神經(jīng)痛，文獻(xiàn)中多稱之為majornerve、peripheralnervetrunk、peripheralnerve。）

(Hyodo1989) 兵頭正義：定義と診斷基準(zhǔn).ペインクリニック、10(5):568-574、1989.■丘腦痛(thalamicpain)３）傳入神經(jīng)阻滯疼痛綜合征（DPS、deafferentationpainsyndrome）阻斷上行性沖動(dòng)，通常疼痛會(huì)消失。但是有時(shí)會(huì)表現(xiàn)為頑固性疼痛（灼熱痛）、各種的感覺異常（知覺異常hyperthesia、感覺異常dysesthesia）。

Painusuallydisappearsafterinterruptionofascendingimpulses.However,sometimesremarkablepain,hyperthesiaanddysesthesiaoccur.

(MiyazakiandTokuda1989)

宮崎東洋?徳田秀光：考え方および治療法の変遷.ペインクリニック、 10(5):575-580、1989.損傷后(afterlesions)■神經(jīng)損傷（＋）

majornervelesions(＋)

①灼性神經(jīng)痛(causalgia)

②傳入神經(jīng)阻滯疼痛綜合征

(deafferentationpainsyndrome)

幻肢痛

(phamtompain)

丘腦性疼痛(thalamicpain)

皰疹后神經(jīng)痛

(postherpeticneuralgia)■神經(jīng)損傷（－）majornervelesions(ー)

反射性交感神經(jīng)萎縮癥(RSD)

(MiyazakiandTokuda1989)

宮崎東洋?徳田秀光：考え方および治療法の変遷.ペインクリニック、 10(5):575-580、1989.■丘腦性疼痛(thalamicpain)

是一種腦卒中后引起的向心性神經(jīng)傳導(dǎo)阻滯的綜合癥，對(duì)側(cè)出現(xiàn)感覺障礙并伴隨疼痛。

Oneofthedeaferentationpainsyndromecausedbythelesionofthalamusin

strokes.Painisproducedinthecontralateralfieldwhichhassensorydeficits.１）傳導(dǎo)疼痛的脊髓丘腦束的損傷

Thelesionofspinothalamictractwhichisthetractofpain.

２）如果傳導(dǎo)淺感覺、深感覺，抑制疼痛上行性傳導(dǎo)的內(nèi)側(cè)丘系損傷，丘腦性疼痛的發(fā)生率會(huì)變高。

Whenmediallemnicusisinjured,thatcarriestactilesensationsanddeep

sensationswhichinhibitsascendingconductionofpain,theincidenceof

thalamicpainbecomeshigher.

３）

90%的損傷發(fā)生在丘腦后外側(cè)。

Ninety%ofthe