《绝地大师疼痛康复专题课程系列1.0》

第二十六讲 手外伤的神经调控康复治疗:病例研究

Case study: upper extremity crush injury

1. Injury mechanism 损伤机制

The patient was getting out of a Taxi when the car door was slammed onto the dorsal side of his left hand. 患者正从出租车里出来时,车门被砰地撞在他的左手背侧上。

There was no fracture but about one month later he began to get terrible pain along his entire arm from hand to shoulder. 没有骨折,但大约一个月后,他开始整个手臂从手到肩部都疼痛难忍。

Patient was not able to get suitable treatment until 3 months post injury. 直到受伤后3个月,患者才得到合适的治疗。

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(1)

2. Motor inhibition 运动抑制

Caused by trauma, pain, and/or changes in the joint 由创伤、疼痛和/或关节内改变引起

It is a failure of the neuromuscular junction to function optimally. 这是神经肌肉接头最佳功能的丧失。

The #1 reason functional mal-adaptation occurs. It is reflected in soft tissue ie, knots, tight bands, trigger points. 发生功能性适应不良的首要原因。它反映在软组织,即,结节、紧绷带、激痛点。

3. Motor dysfunction: the spiraling cycle 运动功能障碍:螺旋式循环

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(2)

4. How neurogenic inflammation works? 神经源性炎症如何起作用?

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(3)

Neuropeptides cause adhesions in muscle and hypersensitivity at sensory nerves 神经肽会引起肌肉内粘连和感觉神经超敏

Large role during nerve compression 神经压迫过程中作用较大

Trophic change accumulation at Spinal segment sites repeately injured ie. Cervico-thoracic junction 营养性改变堆积在重复损伤的脊柱节段,即颈胸椎连接处

Primarily at C7-T2 主要是在C7-T2上(富贵包有先前创伤)

5. Double crush phenomenon 双重挤压现象

Upton and Mccomas (1973):found on NCV tests that a proximal nerve injury in the neck could make that nerve more susceptible to injury distally. 在NCV测试中发现,颈部的近端神经损伤可能会使该神经更容易受到远端损伤。

Hand (1985):legitimized this link as he found that the link between cervical spine arthritis and carpal tunnel syndrome was statistically significant 发现在颈椎关节炎和腕管综合征之间的联系具有统计学意义,使这一联系合理化。

Noxious stimuli releases neurogenic inflammation from spinal or peripheral axons. 有害刺激会从脊髓或外周轴突释放神经源性炎症。

6. Getting our bearings 获得我们的方位

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(4)

臂丛针刺在SCM和锁骨之间的神经干上

腋神经,桡神经

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(5)

7. Reverse double crush 反向双重挤压

Ha et al (2000) in Journal of Korean Neurology Assoc 在韩国神经病学协会杂志上

Found it was just as likely for a CTS injury to cause cervical radiculopathy. 发现CTS损伤引起颈椎神经根病的可能性也一样大。

Injury at either end will cause a maladaptation in the nerve and its branches – if it cannot neuromodulate 任何一端的损伤都会导致神经及其分支的适应不良,如果它无法神经调控

Neurogenic inflammation ensues leading to motor inhibition and spinal sensitization. 神经源性炎症随后导致运动抑制和脊髓敏化。(踝扭伤引起臀中小肌、TFL抑制,共同脊髓通路)

8. Spinal sensitization 脊髓敏化

Motor inhibition causes maladaptations which causes noxious stimuli

运动抑制会导致适应不良,这导致有害刺激

This noxious stimuli finds its way back up the sensory axon

这种有害刺激会返回到感觉轴突上

This causes a sensitization of the nerve(s) at all of the axons which innervate the respective injured tissue. 这导致在所有轴突上的神经敏化,这些轴突支配着各个损伤的组织。(桡神经,C5-T1敏化)

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(6)

9. Up the chain 运动链向上

Spinal sensitization can explain why a hand injury can cause motor inhibition and a progression to pain in the shoulder 脊髓敏化可以解释为什么手部损伤会导致运动抑制和肩部疼痛的进展

All muscles of the shoulder are innervated by C5 segment. So when median or radial nerve areas are injured – this puts spinal sensitization into play and is often the reason for motor inhibition of shoulder girdle. 肩部的所有肌肉都由C5节段支配(颈部问题总是有肩部问题)。因此,当正中神经区或桡神经区域受伤时-这会发挥脊髓敏化作用,往往是肩带运动抑制的原因。

Long thoracic nerve (serratus anterior) is C5-C7. 胸长神经(前锯肌)是C5-C7。(肩带稳定性)

10. 神经支配 nerve innervations

DSN(Dorsal scapular, C5)肩胛背神经:肩胛提肌、菱形肌 Levator scap, rhomboids

SSN(Super scapular, C5, C6)肩胛上神经:冈上肌、冈下肌 Supra/infraspinatus

腋神经 Axillary(C5, C6):三角肌、小圆肌 deltoid, teres minor

桡神经 Radial (C5-T1):三头肌、肘肌、桡侧腕伸长/短肌、肱桡肌、旋后肌(所有伸肌) triceps, anconeus, ECRL/B, brAchinoradialis, supinator (all extensors)

正中神经 Median (C5-T1):旋前圆肌,指浅屈肌、桡侧腕屈肌、掌长肌 pronator teres, FDS, FCR, palmaris longus

尺神经 Ulnar (C8, T1):尺侧腕屈肌、指深屈肌、骨间肌 FCU, FDP, interosei

11. Types of pain 疼痛类型

Nociceptive: occurs without direct trauma or injured tissue. 伤害感受性:无直接创伤或组织损伤发生。(RSI)

Inflammatory: occurs with direct trauma, classic inflammation response trigger neurogenic inflammation cascade. 炎症性:发生于直接创伤,典型炎症反应触发神经源性炎症级联。

Peripheral neuropathic: prolonged injury can cause patients to develop deeper sensitization that interpret non-noxious stimulus as noxious. 外周神经病理性:持久损伤(3月未治疗)会导致患者产生更深的敏化,将无害刺激解释为有害刺激。

Central neuropathic: accelerated by fibromyalgia or any chronic systemic disease. Pain is amplified by “500 times” by non-noxious stimuli and pain is or could be “everywhere” 中枢神经病理性:由纤维肌痛或任何慢性全身性疾病加速。疼痛被无害刺激放大了“500倍”,疼痛现在或可能是“无处不在”。

12. Presentation and assessment 表现和评估

Constant pain, 60 years old, laborer, no reported systemic issues 持续性疼痛,60岁,工人,未报告系统性问题

Began 90 days ago via trauma 从90天前的创伤开始

Pain starts from impact zone up until the back of the shoulder capsule 疼痛从撞击区开始,直到肩关节囊的背面

Muscle testing: inhibited serratus anterior on the left side. 肌力测试:左侧前锯肌抑制。

Palpation revealed signs of peripheral neuropathic pain along the radial nerve. 触诊显示沿桡神经的外周神经病理性疼痛体征(敏化)。

13. Scapular stability 肩胛骨稳定

Trauma to the distal part of an extremity will cause inhibition higher up the chain. Ie, gluteus medius / TFL with an ankle sprain 肢端远端创伤会引起较高运动链上的抑制,即踝扭伤时的臀中肌/TFL

The double / reverse double crush can explain this through the spinal sensitization due to neurogenic inflammation from noxious stimuli 双重/反向双重挤压可以通过脊髓敏化来解释,因为神经源性炎症来自伤害性刺激

Serratus anterior is suppled by C5-C7. 前锯肌由C5-C7支配。(桡神经C5-T1)

Without Restoration Nothing is ever fixed. 没有恢复,就都无法解决。

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(7)

14. The radial nerve 桡神经

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(8)

Superficial radial: sensory only 桡浅神经:仅感觉(手背)(鼻烟壶,沿桡骨,至桡肱关节)

Deep radial: motor only (posterior interosseous N) 桡深神经:(腕伸肌)仅运动(后骨间神经)

Along humerus: lateral intermuscular septum 沿肱骨:外侧肌间隔(肱肌、肱二头肌、肱三头肌之间)

Behind humerus: branches of radial nerve to triceps, capsule. 肱骨后:桡神经分支至肱三头肌、关节囊。(转至肱骨后,上汇入臂丛后索)

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(9)

15. After we restore motor activation 在我们恢复运动激活后(降低脊髓敏化)

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(10)

Sympathetic ganglia via sinovertebral nerve 经窦椎神经的交感神经节

Classic perfusion treatment 经典灌注治疗(自主神经血流效应 局部脊髓节段)

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(11)

16. Sympathetic chain and SSS 交感链和SSS

Spinal sensitization syndrome (SSS) is when noxious stimulus to a region causes the spinal segments from the spinal segments of that region to begin releasing neurogenic inflammation. 脊髓敏化综合征(SSS)是指对一个区域的有害刺激导致该区域的脊髓节段开始释放神经源性炎症。

In this case the entire radial nerve is affected (C5-T1) which would also have a direct influence on the autonomic structures that operate the SNS and provide bloodflow to the head, neck and upper extremity. 在此病例中,整个桡神经受到影响(C5-T1),这也将直接影响自主神经结构,操控SNS,并提供向头部,颈部和上肢的血流。

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(12)

17. Visit 1 第一次就诊

外周神经病理性疼痛

(1)纠正运动抑制:

只有左前锯肌:恢复整个肩带稳定

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(13)

(2)治疗脊髓敏化通路:去敏化,2Hz(每次就诊都可用)

桡神经:C5-T1,神经调控敏化脊髓肌节节段的背侧感觉神经,降低局部神经源性炎症

自主神经:T1-T5,改善头、颈、上肢的血流

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(14)

18. Visit 2: the trajectory of the nerve 第2次就诊:神经轨迹(创伤引起整个桡神经敏化)

Distal to proximal: superficial, trunk, trunk to plexus 远端至近端:浅表、干、干至丛

Superficial: short circuit covers ends of sensory nerve 浅表:覆盖感觉神经末端的短路技术

Nerve: uses in-line needles to cover greatest distance 神经:使用线内针以覆盖最大距离

Trunk to cord: use motor point with 2NT. 干到索:使用运动点和双针。

19. Clinical re-enactment presentation 临床重现

目的:神经调控去敏化,改善肌力和活动性,减轻疼痛

从能量进入点开始

短路技术:沿感觉性桡浅神经

鼻烟壶,桡肱关节

有时邻近肱桡神经运动纤维收缩

非伤害刺激(2Hz)降低局部和脊髓敏化

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(15)

线内技术:沿外侧肌间膈(>3针)

非伤害刺激沿桡神经中心

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(16)

运动点双针技术:桡神经后部

肱三头肌长头

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(17)

20. Reminder: use MP in nerve crush injury that have distal atrophy 提醒:在有远端萎缩(有/无,时程)的神经挤压伤中使用MP

Intro to motor points 运动点介绍

What: neuromuscular junction 什么:神经肌肉接头(运动神经支配运动终板)

Pointer plus: 10Hz, hold 8-10s, 4-5x 电刺激10Hz,8-10秒,4-5次

Needle depth: deep to fascia 针刺深度:深达筋膜

Non-dominant hand: depress tissue, direct electron flow 非优势手:下压组织,引导电流

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(18)

聚集蛋白(agrin)缺乏,Ach与受体无法结合

运动点电针电刺激神经,释放agrin。

21. Visit 3: add manual work 第3次就诊:增加手法治疗

Keys to manual work 手法操作的关键:

Increase ROM creates space 增加ROM和产生空间

To improve hemo/fluid dynamics 改善血液/液体动力学

Releases cutaneous / peripheral nerves 松解皮/外周神经

Address muscle / joint / nerves 处理肌肉/关节/神经

All together better than acupuncture 所有一起优于针刺

22. 演示

(1)桡神经

肱三头肌顶部:桡神经支配

三角肌后部:腋神经支配

1/3人群的桡神经和腋神经之间有交通支

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(19)

从肱三头肌和三角肌之间开始手法松解

拇指内旋肩产生张力:40-50次,不同方向

改善盂肱关节活动,减少粘连

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(20)

(手部外伤的桡神经手法松解)

(2)EPE:手

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(21)

改善手腕关节活动,局部松动

指尖上桡浅神经末端,握拇指轻柔牵引,40-50次。

手指神经修复显微镜手术全过程(手外伤的神经调控康复治疗)(22)

(手部外伤的能量进入点技术)

23. Q&A 问答

-Pointer plus 10Hz

-外周神经病理性疼痛:6-10次治疗

-第一次:病史、功能评估、恢复前锯肌抑制、脊髓敏化(可脊椎矫正)

-增强灌注(高频生骨节):慢性、严重

-前锯肌持续抑制:

慢性系统性(盂唇撕裂持续有害刺激):机械性问题保持激活数周;

治疗不正确。

-肌肉萎缩:《外周神经卡压》,MP EA

-慢性系统性、纤维肌痛、糖尿病性神经病变:

不做运动点,激惹,因为肌梭受交感神经系统支配。

,