慢性疼痛
慢性疼痛 | |
---|---|
分类和外部资源 | |
医学专科 | 疼痛管理 |
ICD-11 | MG30 |
ICD-10 | G89.4、R52.2 |
ICD-9-CM | 338.4 |
eMedicine | 310834 |
持续时间超过3到6个月的疼痛,会被归类为慢性疼痛(英语:Chronic pain)。[1]在医学上,急性疼痛和慢性疼痛之间的区别经常是以疼痛发作后经历的时间长度而定。两个常用的时间标识是持续3个月,或是6个月,[2]但有些理论家和研究人员把急性疼痛转化为为慢性疼痛的时间拉长到12个月。[3]但又有人描述急性疼痛是持续不到30天的疼痛,而描述慢性疼痛是为期6个月的疼痛,把介于1个月到6个月之间的称为亚急性(subacute)疼痛。[4]有个流行的慢性疼痛替代定义,并不涉及固定的持续时间,而把慢性疼痛描述为“超出预期愈合所需时间的疼痛”。[2]
慢性疼痛可能源自身体,也可能源自大脑,或是脊髓。通常很难治疗。流行病学研究发现,世界各国中有8%到11.2%的人患有慢性全身疼痛。[5]最初被推荐用于治疗慢性疼痛的是各种非鸦片类镇痛药,取决于疼痛是由组织损伤引起,还是周边神经病变所引起。[6][7]对那些有慢性疼痛的人,透过心理治疗(包括认知行为治疗法和接纳与承诺疗法),会在改善生活品质上产生效果。
有些患有慢性疼痛的人可能会受惠于利用鸦片类药物治疗,而另有人则可能反而会因此受到伤害。[8][9]如果患有非癌性疼痛的人,如果他们没有物质使用疾患的病史,也未有精神疾患的问题,而非鸦片类药物无法达到目的时,可建议他们尝试使用鸦片类药物。[10]但如果连鸦片类药物也无法缓解这种疼痛的时候,就该停用。
有慢性疼痛的人有较高罹患抑郁症的几率,[11]但这类共病症之间的确切关联尚未被清楚研究。有项在2017年所做关于神经可塑性的研究发现,“身体疼痛的损伤感觉路径被证明与情绪管理共享相同的大脑区域。“[12]慢性疼痛可能因为患者本人害怕会让情况恶化,而减少体能活动。患者的疼痛强度、疼痛控制、和对疼痛的复原力会受到不同程度和类型的社会支持所影响,也会u受到患者本身的社会经济地位的影响。[13]
有种预测个人慢性疼痛经历的方法叫生物心理社会模型,这种模型认为慢性疼痛的经验是同时受到生物学、心理学和周遭社会环境的复杂混合影响。[14]
分类
[编辑]国际疼痛研究学会把慢性疼痛定义为没有生物学价值的疼痛,在正常组织愈合后仍持续存在。DSM-5(精神疾病诊断与统计手册第五版)承认一种慢性疼痛疾患 - 身心性疾患。其认定标准包括疼痛持续的时间超过6个月。[15]
国际疾病分类第十一修订版 (ICD-11) 把慢性疼痛分为7种。[1]
- 慢性原发性疼痛:定义为身体的一个或多个区域持续3个月的疼痛,无法用别种疼痛状况作描述。
- 慢性癌痛(癌症疼痛):定义为癌症或治疗癌症而产生相关的器官、肌肉骨骼、或骨质变异所造成的疼痛。
- 慢性创伤后疼痛:受伤或手术后发生,持续3个月的疼痛,感染性或既有疾病所产生者不包括在内。
- 慢性神经性疼痛:由体感神经系统损伤所引起的疼痛。
- 慢性头痛和口腔颜面疼痛:源自头部或口腔颜面的疼痛,在3个月内持续发生的时间占有50%,或者更长。
- 慢性内脏性疼痛:源自内脏器官的疼痛。
- 慢性肌肉骨骼疼痛:源自骨骼、肌肉、关节、或是结缔组织的疼痛。
慢性疼痛可分为“伤害性”(由发炎或组织受损,激活称为伤害受器的特殊疼痛感受神经所产生)和“神经性”(由神经系统损伤或故障所引起)两种。[16]
伤害性疼痛可分为“浅层”和“深层”,深层疼痛又分为“躯体深处”和“器官性”。浅层性疼痛是由皮肤或浅层组织中的伤害感受神经受激活所引起。躯体深处疼痛是由韧带、肌腱、骨骼、血管、筋膜和肌肉中的伤害感受神经受到激活的缘故,并且是隐隐、痛苦及难以确定部位的疼痛。器官性疼痛源自内脏(器官)。内脏疼痛可能是明确的局部性,但通常非常不易确定部位,当受损或发炎发生时,几个内脏区域会产生“牵连性”疼痛,而感觉的部位却远离病理或损伤发生的区域。[17]
神经性疼痛[18]分为“周围”(源自周围神经系统)和“中枢”(源自大脑或脊髓)。[19]周围神经病变疼痛常被描述为“灼痛”、“刺痛” 、“电击式”、“受利器刺到”、或“受别针和针刺到”。[20]
原因
[编辑]病理生理学
[编辑]向背角(脊髓后灰柱)传递的疼痛信号受持续激活的时候,会产生疼痛增强现象,从而触发变化,把疼痛信号传递的阈值降低。另外会导致非伤害性疼痛神经纤维去反应、制造以及传输疼痛信号。据信是C类神经纤维产生疼痛信号,这类神经具有缓慢的传导性,并会引起持续长久的疼痛感。[21]当慢性疼痛一旦发生,整个过程就很难被逆转或是停止。[22]在某些情况下,慢性疼痛可能是由会干扰神经元分化(neuronal differentiation)的遗传因素所引起,而导致疼痛阈值永久受到降低。[23]
由不同原因所导致的慢性疼痛已被定性为影响到大脑结构和功能的疾病。透过磁共振成像(MRI)研究,显示涉及与疼痛处理相关的区域在解剖学[24]和功能的连接上都有异常,即使在休息时[25][26]也是如此。已有证据显示持续性的疼痛会导致大脑灰质减少,但一旦疼痛问题获得解决后,这种情况可被逆转。[27][28]
这些结构变化可透过神经可塑性来解释。在慢性疼痛的情况下,身体的体感皮质定位在周围神经和中枢神经致敏后会不适当地重组。而导致轻触疼痛,或是痛觉过敏。有慢性疼痛的人,他们的脑电图会显示大脑活动改变,显示疼痛所引起的神经可塑性变化。更具体地说, 相对的β活动(与大脑的其余部分相比)会增加,相对的α活动减少,θ活动逐渐消失。[29]
大脑中多巴胺管理失调可能会是同时造成慢性疼痛、失眠、和重度抑郁疾患的机制。[30]有慢性疼痛的人,他们的星形胶质细胞、小胶质细胞、和卫星细胞也被发现有功能失调的情况。小胶质细胞的活动增加,小胶质细胞网络的改变,以及小胶质细胞所产生的趋化因子和细胞因子的增加,可能会让慢性疼痛加剧。星形胶质细胞被观察到会失去调节神经元兴奋性的能力,而让疼痛回路中的自发神经活动增加。[31]
管理
[编辑]疼痛管理是种采用科际整合方式的医学分支。结合各种医学专业和医疗相关专业人员的知识,用于缓解疼痛并提高患者的生活品质。[32]典型的疼痛管理团队包括医生(尤其是麻醉师)、复健心理学家、物理治疗师、职能治疗师、助理医生和执业护士。[33]急性疼痛通常只透过一位专家的治疗即可,而对于慢性疼痛,通常需要一个团队的合作才有机会达成。[34][35][36]许多类型的慢性疼痛能达到完全、长期缓解的情况属于罕见。[37]
非鸦片类药物
[编辑]开始治疗时,建议使用非鸦片类镇痛药。[10]这类药物包括对乙酰氨基酚(另称扑热息痛)[38]或是非类固醇抗发炎药(NSAID)。[39]
另有其他非鸦片类镇痛药,根据疼痛是由组织损伤引起,或是神经性疼痛而决定使用类别。少有证据支持对癌痛或由组织损伤引起的慢性疼痛(例如类风湿性关节炎)采用鸦片类药物做治疗。对于神经性疼痛,其他药物可能比鸦片类药物(如三环类抗抑郁药,[40] 5-羟色胺和去甲肾上腺素再摄取抑制剂(SNRI),[41]和抗惊厥药[41])更为有效,[7][42][43]一些非典型抗精神病药,如奥氮平,也可能有效,但支持这一点的证据还处于早期阶段。[44]对于患有慢性疼痛的女性,如口服避孕药(俗称“the pill”)的激素药物可能会有帮助。[45]但没证据显示哪种对某人最为有效时,医生就必须需搜寻,以找出最适合者。[40]医生很难预测谁用鸦片类药物治疗疼痛之后,会发展出成瘾的情况。医生也很难知道哪些患者需要鸦片类药物的真正原因是他们对于这类药物成瘾。对采用鸦片类药物作治疗的人,骤然停止,中断或是撤销治疗,反会造成伤害。[8][46]
介入性疼痛管理或许是合适的治疗方式,包括激痛点注射(参照激痛点英文部分#Trigger point injection)、神经传导阻滞、和放射治疗等技术。虽然没有很强的证据支持治疗性超声波疗法,这种技术对改善非特异性慢性下背痛有小的功效。[47]
心理治疗,如认知行为疗法[48][49]和接纳与承诺疗法[50][51]有助改善患者生活品质和减少疼痛干扰。简短式基于正念的认知治疗法(MBPM)曾被运用,但不建议用作一线治疗。[52]对于基于正念的认知治疗法的有效性,有一系列的研究予以支持 。[53][54][55]
在老年人中,运用心理干预可帮助减轻疼痛,并提高疼痛管理的自我效能。[56]心理治疗也被证明对患有慢性头痛或混合性慢性疼痛的儿童和青少年有效。[57]
虽然运动已被作为减轻慢性疼痛的方法,并且有产生一些功效的证据,但效果并不高,仍有做进一步的研究的需要。[58]对于患有慢性疼痛的人,利用运动以减轻疼痛,几乎不会产生副作用。[58]
鸦片类药物
[编辑]对于从其他治疗措施无法受益,并且没有精神疾病或物质使用疾患病史的人,可尝试使用鸦片类药物做治疗。[10]但如果没出现显著的益处,建议应停止。[10]对长期使用鸦片类药物作治疗的人,停止或减少使用或可对结果有所改善(包括疼痛在内)。[59]
一些患有慢性疼痛的人可从鸦片类药物治疗中受益,而另一些人则不然;有些人反会受到治疗的伤害。[8]可能的害处有性激素分泌减少、性腺机能减退、不孕、免疫系统受损、老年人跌倒和骨折、新生儿戒断症状、心脏问题、睡眠呼吸暂停、鸦片类药物引起的痛觉过敏、身体依赖、成瘾、滥用和药物过量。[60][61]
替代医学
[编辑]替代医学指的是用于治疗疼痛或疾病的手段或是产品,但又通常不被视为属于传统医学的类别。[62]用在处理慢性疼痛的替代医学可分为四类:生物性、心理和身体,身体运作、和治疗能量医学。[62]
改变饮食被认为是生物性的替代医学做法,被证明有助于随着时间演进而把慢性疼痛症状改善。[62]在尝试缓解慢性疼痛时,在饮食中添加补充剂是种常见的做法,受到最多研究的补充剂是:乙酰肉碱、硫辛酸、和维生素E。[63][64][65]在前面所提的三者中,维生素E可能是受到研究最多,有强有力的证据显示它有助于对患有癌症、多发性硬化症、和心血管疾病的人,把他们体内的神经毒素降低。[65]
有初步的证据显示催眠,包括自我催眠有效。[66]催眠,特别是可为大多数人提供疼痛缓解,并且可能是药物治疗的安全替代做法。[67]但有证据不支持运用催眠对因脊髓受伤而引起的慢性疼痛做治疗。[68]
初步研究发现医用大麻对治疗神经性疼痛有益,但对其他类型的长期疼痛无效。[69]截至2018年,其治疗神经性疼痛或与风湿性疾病相关疗效的证据不强,需做进一步的研究。[70][71][72]最近的一项研究结果显示,大麻素对于非癌症慢性疼痛病不会很有效。[73]对大麻或以大麻为基底的药物该做更严格的研究。[72]
太极拳被证明可改善慢性疼痛、身体僵硬(如骨关节炎、下背痛、和骨质疏松症)和生活品质。[74][75]针灸也被发现是种有效且能安全减轻慢性疼痛的方法(包括慢性前列腺炎/慢性骨盆疼痛综合症)而改善生活品质。[76][77]
并没有高品质的证据支持使用穿颅磁刺激仪来缓解慢性疼痛,这类疗法的效果不大,而且为期不长。[78]
Spa疗疗法可能会改善患者的下背慢性疼痛,但需要更多的研究以提供更强而有力的证据。[79]
虽然有些研究对使用贯叶连翘或肉豆蔻治疗神经性疼痛的功效做过调查,但结果是引起对资料准确性的严重关切。[80]
肌筋膜松弛法被用于处理某些纤维肌痛、慢性下背痛、和网球肘的状况,但无足够的证据支持将其当作治疗方法。[82]
流行病学
[编辑]慢性疼痛在不同的国家中影响到8% - 55.2%不等的人口。受到影响的人之中,女性多于男性,慢性疼痛在全球耗用掉大批医疗资源。[83][5]
一项针对欧洲15个国家和以色列所进行的大规模电话调查发现,18岁以上的受访者中,有19%的人曾有过6个月以上的疼痛,包括在上个月,和在上周有2次以上,上次发作的疼痛强度为5或是更高(1代表没疼痛,10则代表可想到最为疼痛的情况)。在受访者中有慢性疼痛的人,其中有4,839人曾接受深入的访谈。在这些人之中,有66%的疼痛强度评分为中度(5-7),34%为重度(8-10);46%有持续性疼痛,56%则为间歇性疼痛;49%疼痛持续的时间在2-15年之间;以及有21%的人被诊断因疼痛患而罹患抑郁症。有61%的人无法或是难以外出工作,19%的人因此失业,13%的人因疼痛而必须更换工作。40%的人有疼痛治疗不足的情况,只有少于2%的人去疼痛管理专家那儿寻求协助。[84]
在美国人口中,估计约有35%的人有慢性疼痛的问题,造成大约有5,000万人因此部分或是完全失能的情况。[85]根据美国国家医学院的数据,大约有1.16亿美国人有慢性疼痛的问题,这表示美国成年人中大约有一半患有某种慢性疼痛。[86][87]而慈善基金会The MAYDAY Fund所提出美国有7,000万人患有慢性疼痛的数字,则是较为保守的估计。[88]在一项透过互联网的研究结果,估计美国慢性疼痛的患病率为30.7%:女性有34.3%,男性有26.7%。[89]
在加拿大,据估计大约五分之一的人患有慢性疼痛,其中一半的人患有慢性疼痛的时间长达10年或更久。[90]加拿大的慢性疼痛患者中,女性以及加拿大原住民较为普遍,以及较为严重。[90]
结果
[编辑]患有慢性疼痛的人经常会因施用药物治疗和疾病症状本身,而导致睡眠障碍和失眠。[91]由于不同药物间的可能药物相互作用,有关睡眠的情况不易治疗,尤其是在患者接受不同医生进行治疗的情况时。
严重的慢性疼痛与10年期间死亡风险的增加有关联,尤其是由心脏病和呼吸系统疾病所造成。[92]有几种机制被提出是造成这种情况的原因,例如身体内分泌系统的压力异常反应。[93]此外,慢性压力似乎透过加快斑块在动脉血管壁上积聚的速度(动脉硬化)而提高心脏和肺脏(循环系统)健康的风险。但仍需要进一步研究来阐明严重慢性疼痛、压力和心血管健康三者间的关系。[92]
最近有项系统综述还发现,慢性疼痛可能会增加开车人员发生碰撞车祸的风险。[94]
心理学
[编辑]个性
[编辑]根据明尼苏达多项人格问卷量表 (MMPI) ,在慢性疼痛患者中发现的两种最常见的人格特征是conversion V以及neurotic triad。conversion V型人格会对身体感觉表达出过度关注,在压力下出现身体症状,但通常不会关注自己的情绪状况(包括忧郁症),而neurotic triad型人格也会对身体感觉表达出过度关注,并在压力下出现身体症状,但会苛求,以及抱怨。[95]
一些研究人员认为,正是这种神经质让急性疼痛变成慢性,但临床证据显示出是慢性疼痛导致神经质。当长期疼痛经过治疗干预而缓解时,neurotic triad型的MMPI评分和焦虑会下降,通常回复正常水准。[96][97][98]通常慢性疼痛患者的自尊会较低,一旦疼痛缓解,这情况也会有所改善。[99]
有人提出疼痛灾难化的心态可能会在疼痛体验中发挥作用。这种心态是倾向用比一般人更夸张的言语来描述疼痛体验,在疼痛发生时给予更多的心思,或是在疼痛发生时更感觉无助。[100]在灾难化测量上得分高的人可能会比得分低的人会给予疼痛经验更高的评价。一般的推理是这种灾难化的倾向导致人会体验更剧烈的疼痛。有种理论认为灾难化通过改变注意力和预期而影响到疼痛感知,把疼痛的情绪反应升高。[101]但至少灾难化的某些部分可能是剧烈疼痛体验后的产物,而非原因。也就是说一个人感受过的疼痛越强烈,他们就越有可能形成符合灾难化定义的想法。[102]
创伤合并症
[编辑]患有创伤后压力症候群(PTSD)的人有很高慢性疼痛的共病率。[103]同时患有PTSD和慢性疼痛的患者,他们报告的疼痛严重程度高于没PTSD共病的患者。[104][105]
对认知的影响
[编辑]对于慢性疼痛在认知上发生影响的领域,研究仍嫌不足,但已有一些初步结论发表。大多数慢性疼痛患者抱怨有认知功能不全的问题,例如健忘、注意力不集中、和难以完成工作。利用客观测试会发现,有慢性疼痛的人往往会在注意力、记忆力、心理灵活性、语言能力、认知事项的反应速度和执行结构化任务的速度方面受到损害。[106]有项在2018年所做的研究评论,把慢性疼痛患者在记忆力、注意力和处理速度的测试发生异常结果,其间的关系提出报告。[107]
对社会和个人影响
[编辑]社会支持
[编辑]社会支持对患有慢性疼痛的人具有重要影响。特别是患者的疼痛强度、疼痛控制和对疼痛的复原力,被认为会受到不同水准和类型的社会支持所影响。这项研究大部分的重点放在情感、工具、和资讯的研究,持续身受慢性疼痛之苦的人倾向依赖社会支持当作应对机制,因此如果这些人身处在一个良好的社会支持环境,就会有较好的结果。根据相当多的研究报告显示,社会活动或社会支持与疼痛之间存在直接显著的关联。较高的疼痛水准与社会活动、社会支持水准、以及社会功能的不足都有关联。[108][109]
种族差异
[编辑]根据一项在2017年发表的评论报告,虽然临床决策未受影响,但对需要疼痛治疗的少数群体所具有的无意识偏见,和负面刻板印象的证据仍然存在。[110]少数群体可能不会得到疼痛的诊断,以及接受药物治疗,并更有可能被认为是有物质滥用的人,而不转诊给疼痛专科医生做治疗。[111]初步研究显示,医疗卫生提供者会对非裔美国人患者缺乏同情心,低估他们的疼痛程度,导致治疗延误。[110][111]少数群体可能因为语言障碍,让患者和医疗卫生提供者之间无法做清楚的沟通,而不能得到适当的治疗。[111]
对不公正的感受
[编辑]类似于疼痛灾难化的破坏性影响,对于不公正的感受被认为是导致慢性疼痛程度加剧和持续时间拉长的原因。[112]与疼痛相关的不公正感受被概念化,成为反映疼痛或伤害的严重性和无法修复的认知评估(例如,“我只想恢复我以往的生活”),以及把怨怼和不公外化(“我因为别人的疏忽而受苦。”)。[113]有建议采用由上而下的处理/认知做评估,以了解问题,而得到更佳的理解以及处理。[114]
慢性疼痛和2019冠状病毒病
[编辑]2019冠状病毒病已把许多人的生活扰乱,导致对一般大众的身体、心理和社会经济产生重大影响。[115]针对这个大流行,所采用的保持社交距离的措施把熟悉的社会互动模式改变,这样的行为创造出被某些心理学家称为进入集体哀伤(collective grief)的时期。[116]患有慢性疼痛的人往往表现出一种模棱两可的态度,有时表示他们所受的痛苦让他们置身于传统医学之间,以及之外。全球大部分的人口因为这场大流行而需忍受社会孤立和痛苦,一项在加拿大所做研究发现,因为这场大流行,那些有慢性疼痛的人在其间遭遇的情况更加恶化。[115]
慢性疼痛对工作场所的影响
[编辑]在工作场所中,这种身体状况对患有慢性疼痛的人,以及他们隶属的组织而言,都是个大问题;由于劳动力趋向高龄化,这种问题在许多国家只会继续恶化。[14]有鉴于此,组织能够顾及其所处的社会环境,以及研究环境如何可舒缓,或是会加剧慢性疼痛的因素,可能会有所帮助[14]一些研究发现社会环境如何影响慢性疼痛的例子,例如高规格的社会[14]完美主义(例如由外部压力(主管)导致的完美主义)可与患有慢性疼痛的人自身的内疚感相互作用,而增加工作上的压力,结果是把工作满意度降低。[14]
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进一步阅读
[编辑]- Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA. April 2016, 315 (15): 1624–45. PMC 6390846
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外部链接
[编辑]- 开放目录项目中的“Chronic Pain Syndromes”
维基共享资源上的相关多媒体资源:pain
- International Association for the Study of Pain (页面存档备份,存于互联网档案馆)
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