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纤维肌痛

Widespread pain and fatigue from an over-sensitised nervous system — what it is, and why movement, sleep and pacing help most.

广泛性疼痛放大的示意图——一个疼痛“旋钮”被调至红色的身体。
在纤维肌痛中,神经系统将“疼痛音量”调高,因此疼痛广泛地遍布全身。 Kieran Hirpara 4.0

本页面由机器翻译,尚未经临床医生审核。英文版本为权威版本。

您的感受

纤维肌痛是一种广泛且长期的疼痛:表现为酸痛、灼痛或压痛,疼痛可在身体各处游走,感觉几乎遍布全身,而非局限于单个关节。除了疼痛,大多数人还会感到极度疲劳,且睡眠无法缓解这种状况:即使整夜卧床,醒来后仍感觉精力未恢复,仿佛从未真正休息过。

许多人还会注意到思维变得模糊:难以集中注意力、寻找合适的词语或记忆事物。这种情况非常普遍,以至于有了专门的名称:“纤维雾”(fibro fog)。此外,身体通常还会变得整体更加敏感:触觉、压力、光线、声音或温度都可能感觉难以承受,而大多数人都不会在意的轻微敲击,却可能带来剧烈的疼痛。这种状况令人精疲力竭,也很容易让人觉得没有人真正理解您所承受的困扰。

实际发生了什么

以下是关键部分:纤维肌痛并非关节或肌肉的损伤,也不是炎症。这就是为什么扫描、X 光和血液检查通常显示正常。并没有任何情况被“漏诊”,正常结果并不意味着疼痛不真实。

问题出在您的神经系统处理疼痛的方式上。在纤维肌痛中,传递疼痛信号的系统被调得过高:音量被设置得比应有的水平更响。正常的感觉被放大为疼痛,而真实的疼痛感觉更加剧烈。医生将此称为中枢敏化。这是神经和大脑处理信号方式的一种真实、生理性的变化:并非“心理作用”,也不是虚弱的表现。纤维肌痛很常见,它是真实的,并且已被医学界认可。

它通常还伴随其他病症(如肠易激综合征、头痛、情绪低落或其他慢性疼痛),并且可能在手术后放大疼痛。最后这一点值得告知您的外科团队,因为了解您患有纤维肌痛有助于他们规划您的疼痛缓解和康复方案,从而让您得到更好的照护。

我们可以采取的措施

目前尚无根治方法,但纤维肌痛是可以管理的,许多患者能够将症状控制在更可承受的水平。最强大、最可靠的帮助并非来自药片,而是来自几项稳定的习惯:

  • 温和、循序渐进的运动。 运动是证据支持最充分的治疗手段。关键在于从非常小的强度开始,并缓慢增加:步行、拉伸或水中运动都是良好的起步方式。过早过度用力会诱发疼痛加剧,因此循序渐进、持之以恒才是关键。
  • 改善睡眠。 由于缺乏恢复性的睡眠会加剧疼痛和脑雾,规律的作息和良好的睡眠习惯能带来切实的改善。
  • 节奏控制(Pacing)。 将活动均匀分配在一天和一周之中(而不是在感觉好的日子里做完所有事情,随后精疲力竭),能让您保持更稳定的状态。
  • 压力管理和心理干预。 压力会进一步放大症状。诸如认知行为疗法(CBT)、放松训练和正念等技术有助于安抚过度敏感的系统。

药物对部分患者有帮助,但有效的药物并非传统意义上的止痛药:它们通过镇静神经系统而非阻断疼痛信号来发挥作用。这些药物包括阿米替林、度洛西汀和普瑞巴林;您可以参阅我们的神经性疼痛药物页面了解更多。相比之下,普通的非甾体抗炎药对纤维肌痛无效(因为不存在需要消除的炎症),且阿片类药物不仅无效,还可能造成实际伤害:它们往往随时间推移使情况恶化,而非改善。我们在术后疼痛管理页面上解释了为何我们避免使用此类药物。

预期情况

纤维肌痛通常是一种长期状况,症状会波动起伏: 有较好的时期和发作期,常由压力、睡眠不佳、疾病或 过度劳累诱发。这可能会让人感到沮丧,但对于坚持运动、 睡眠和节奏管理方法的大多数人来说,前景确实充满希望。 症状会逐渐稳定,发作期更容易度过,生活也会重新展开。

这项工作需要您主导,但您不必独自完成。一个 支持性的团队(您的全科医生,有时还有物理治疗师或疼痛服务) 可以帮助您制定计划,随时间调整,并让您朝着正确的方向前进。 自我管理之所以强大,正是因为您是那个能够 日复一日地降低“音量”的人。

何时就医

  • 出现新症状,或原有症状发生明显变化:不要想当然地认为所有新出现的症状都“只是纤维肌痛”。某一部位的突发或剧烈疼痛、肿胀、发热、不明原因的体重下降,或新出现的无力或麻木,都值得仔细检查,因为它们可能由其他独立问题引起。
  • 情绪低落、焦虑,或对通常喜欢的事物失去兴趣:这些情况常与纤维肌痛相伴发生,且可治疗;获得帮助也有助于更好地控制疼痛。如果您感到绝望或自身安全受到威胁,请立即寻求帮助。
  • 尽管已尽最大努力,症状仍严重影响日常生活:此时应咨询您的全科医生,寻求更多支持,包括转诊至疼痛科或风湿免疫科服务。

深入探讨

Advanced reading: the deeper science (optional)

本节内容超出了您自身治疗决策所需的信息深度。纤维肌痛值得额外阅读,因为关于它最有用且最反直觉的观点是:尽管其表现为肌肉和关节问题,但证据完全指向肌肉和关节之外的因素。

与关节无关的线索

如果纤维肌痛是肌肉或结缔组织疾病,它应当局限于这些组织。事实并非如此。

在一项针对 44,494 人的群体研究中,患有纤维肌痛或其他肌肉骨骼疼痛的人群更有可能报告 听力损失。作者的解读是关键部分:这一发现与纤维肌痛与 中枢神经系统整体失调 相关的观点一致,其他广泛性肌肉骨骼疼痛可能也是如此 [1]。

听力与肩部酸痛之间没有机械联系。当一种以肌肉骨骼疼痛为定义的特征也与耳朵和大脑处理信号的方式相关时,共同因素是处理过程,而非组织。这是中枢敏化模型在一个意想不到的观察中的体现:感觉输入的音量控制被调高了,疼痛是最明显的后果,而非唯一的后果。

为什么您的检查结果正常,以及这并非意味着被忽视

患者经常被告知所有检查结果均正常,并将此解读为对其症状的怀疑。 研究阐明了为何检查结果正常,同时并未暗示疼痛不存在。

一项针对细胞因子的荟萃分析——细胞因子是炎症性关节炎中会出现异常的炎症信号分子——共纳入 1,255 名参与者,并得出结论:其在纤维肌痛中的病理生理作用 仍不明确,需要更优质、规模更大的研究 [2]。对肠道微生物组作为贡献因素的研究也得出了类似结论:这是新兴的“肠道–肌肉骨骼轴”中一个合理的方向,但目前缺乏高质量的研究 [3]。

因此,并不存在某种可发现的血液检测,因为异常在于信号处理,而非组织损伤或炎症。正常的炎症筛查和正常的影像学检查是预期结果,它们用于排除其他疾病,而非排除本病。

已被证实有效的干预措施

基于运动的治疗拥有最有力的数据支持,且其具体形式的重要性远低于运动本身这一事实。一项纳入 936 名患者的荟萃分析发现,传统中式运动——如太极拳、气功及类似的低强度运动与呼吸练习——在 疼痛、睡眠质量 以及 焦虑和抑郁 症状方面均产生了显著改善 [4]。

请注意该试验组所测量的指标。获益涵盖了疼痛、睡眠和情绪的整体改善,这正是当治疗靶点为敏化的神经系统而非疼痛结构时所预期的结果。睡眠在此并非次要问题;睡眠不佳会降低疼痛阈值,且两者相互强化。

与更年期的重叠

纤维肌痛症状常在更年期前后开始,此后往往更为严重,并在子宫切除术(无论是否同时切除卵巢)后加重 [5]。其症状清单与更年期肌肉骨骼综合征存在大量重叠。

该综述的结论是,应谨慎避免将两者混为一谈:纤维肌痛也见于非更年期女性及男性,因此性激素并非其全部机制,且应将两者视为可能共存的独立问题,分别予以识别和治疗 [5]。请参阅我们的更年期肌肉骨骼综合征页面。

如果正在讨论手术,这意味着什么

正是在这里,中枢敏化模型变得具有实际意义。手术旨在纠正结构性问题。如果您的部分疼痛是由中枢处理改变产生的,那么术后这部分疼痛仍会存在,因为手术从未针对它进行处理。

这并不是反对在存在真正需要修复的结构性问题时进行手术的论据。这是一个论据,主张在术前精确明确手术预期消除的疼痛部分,并主张将纤维肌痛作为一种独立疾病进行治疗,而不是寄希望于手术能解决所有问题。在手术前尽可能妥善地管理睡眠、活动和情绪,是对手术结果的实质性工作,而非边缘性的准备工作。

参考文献

[1] Stranden M, Solvin H, Fors EA, Getz L, Helvik A. Are persons with fibromyalgia or other musculoskeletal pain more likely to report hearing loss? A HUNT study. BMC Musculoskelet Disord. 2016;17(1). https://doi.org/10.1186/s12891-016-1331-1

[2] Üçeyler N, Häuser W, Sommer C. Systematic review with meta-analysis: cytokines in fibromyalgia syndrome. BMC Musculoskelet Disord. 2011;12(1). https://doi.org/10.1186/1471-2474-12-245

[3] Erdrich S, Hawrelak JA, Myers SP, Harnett JE. Determining the association between fibromyalgia, the gut microbiome and its biomarkers: a systematic review. BMC Musculoskelet Disord. 2020;21(1). https://doi.org/10.1186/s12891-020-03201-9

[4] Wang X, Luo H. Effects of traditional Chinese exercise therapy on pain scores, sleep quality, and anxiety-depression symptoms in fibromyalgia patients: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2024;25(1). https://doi.org/10.1186/s12891-024-07194-7

[5] Vidal-Neira LF, Neyro JL, Maldonado G, Messina OD, Moreno-Alvarez M, Ríos C. Climacteric and fibromyalgia: a review. Climacteric. 2024;27(5):458-65. https://doi.org/10.1080/13697137.2024.2376190


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d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.


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