【编者的话】
肌筋膜是个很重要的概念，几年前，我们一直使用MTrP的概念。
现在我们提患肌（存在一个或多个MTrP的肌肉，Tightened Muscle），而不提肌筋膜（myofascial）的原因已经在《浮针医学纲要》中写清楚。请大家参看翻阅。
请大家看看，老外的一些研究。
符仲华
膝骨关节炎与肌筋膜疼痛
原作者：Dor A, Kalichman L，译：李康
译文说明：本文源自【 Dor A, Kalichman L. A myofascial component of pain in knee osteoarthritis[J]. Journal of Bodywork and Movement Therapies,2017,21(3):642-647.】的讨论部分（Discussion）。
原文链接：
http://www./science/article/pii/S1360859217300505?via%3Dihub
这篇文章是对骨关节炎（osteoarthritis ,OA）与肌筋膜疼痛（myofascial pain）关系方面的8项研究进行综述分析。其中有2项是骨关节炎患者激痛点（myofascial trigger point，MTrP）发病率的观察性研究；另外6项是针对肌筋膜组织治疗骨关节炎的干预性研究，其中2项的干预性研究也包含了激痛点发病率方面的内容。
对OA激痛点发病率的所有研究都表明肌筋膜疼痛呈现出高发病率。一项最近的病例对照研究发现，膝骨关节炎（knee osteoarthritis，KOA）患者较健康对照组存在明显较多的活性激痛点（active MTrP）。但是另一方面，不同研究对于受累肌肉存在不同结果。Bajaj等人发现单侧膝骨关节炎患者膝周肌肉存在较多的激痛点，而髋骨关节炎则不然；相比较健康对照组，激痛点发病率最高的肌肉是股直肌（64.3%）和腓肠肌（57.1%）。Henry等人发现超过60%的受试者激痛点只存在下肢内侧肌肉，如腓肠肌内侧头和和股内侧肌肉；没有发现MTrP只存在下肢外侧肌肉的受试者；另外大约40%受试者下肢膝内外侧肌肉都会有疼痛。Itoh等人报道MTrPs发病率最高的肌肉为股四头肌，其次为髂腰肌、内收肌和腘绳肌。
从上面列举的研究报告中，我们保守地认为MTrPs应当为KOA患者产生膝痛的部分因素。因为MTrP也可以引起肌力减退、关节活动度减小和KOA相关的症状，所以MTrPs也可能为KOA发病学因素。确定MTrPs和膝或其他部位骨关节炎疼痛的关系，以及想要获得膝痛涉及的肌肉更精确的数据，今后应当开展大样本研究。当然，探究MTrPs在OA发病学上的作用也是非常有意义的。
6项干预性研究也充分支持肌筋膜组织病变参与KOA疼痛的产生。在一项非随机、非盲法临床试验研究中，HEnry等人发现MTrPs注射疗法可显著减轻KOA患者疼痛程度和改善关节活动度。Itoh等人采用随机对照研究方案，对小样本KOA受试者实施了MTrPs干针疗法、传统针灸来和假针刺，结果表明干针疗法较传统标准针刺法治疗KOA更有效，也优于假针刺。
Harish和Kashif比较Maitland释放技术和肌筋膜放松技术在减少KOA患者膝疼痛程度和增加活动度方面的差异。他们发现在这些方法治疗后临床表现都有显著地改善，但这两种方法治疗后临床效果无明显差异；不幸的是，其治疗方案在文章中没有描述，影响到分析实验结果的可能性。Rahbar等人采用单盲随机对照试验方案，研究KOA患者对MTrPs治疗效应。MTrPs的治疗方法为冷喷和拉伸技术，随后予以热敷和按摩，干预组为上述MTrPs治疗方案加上传统物理疗法，而对照组为单纯传统物理疗法，在WOMAC指数和起立行走试验方面，干预组显示出明显的较好结果，但在关节活动度方面，没有明显改善。干预组有较好的临床疗效可能是因为增加了冷喷、拉伸、热敷和按摩，治疗时间延长所导致。
Yentür等人发现激痛点注射利多卡因联合常规关节腔注射玻璃酸钠，较单纯关节腔注射，在增加关节活动度、减少膝痛、改善日常活动方面有着更好的疗效。Gomaa and Zaky发现髂胫束放松技术联合锻炼方案可以改善KOA患者髂胫束灵活性、髌骨排列（patellar alignment）、疼痛压痛阈值（pain pressure threshold，PPT）。干预组之所以疗效好，可能仍然是因为每次治疗持续时间长。当然也应该考虑到他们治疗方案只影响到髂胫束和其他影响膝关节的肌肉没有检查的可能性。
前述的干预性研究提供了从肌筋膜疼痛治疗KOA有效的证据。
MTrPs注射治疗可减轻疼痛程度和改善关节活动度；肌筋膜放松技术可显著改善关节活动度和减少疼痛程度；MTrPs干针可改善疼痛评分和关节功能；MTrPs冷喷和拉伸技术可改善疼痛评分、关节僵硬、关节功能和活动度； MTrPs利多卡因注射改善关节活动度、减轻疼痛、改善关节功能；髂胫束放松技术可改善髂胫束活动性、髌骨排列、压痛阈值。
以上陈述的各个研究样本含量普遍较小，以及治疗方法和评价疗效指标都不一样，因此在探讨OA患者缓解疼痛、功能恢复的MTrPs治疗方案，是需要高质量的研究。
原文：
The current review included two observational studies evaluating the prevalence of MTrPs in OA patients and six intervention studies evaluating the efficacy of treatment, focusing on the myofascial component. Two of the intervention studies also evaluated the prevalence of MTrPs in OA patients.
All studies found a high prevalence of myofascial pain in knee OA patients . A recent case-control study found significantly more active MTrPs in patients with knee OA than in healthy matching subjects. On the other hand, there is some dispute as to the affected muscles. Bajaj et al., (2001)found that unilateral knee joint OA patients had a greater number of MTrPs in muscles surrounding the knee joint compared to the unilateral hip joint OA patients. The knee muscles with the highest prevalence of MTrPs, compared to the healthy controls, were the rectus femoris (prevalence of 64.3%) and the gastrocnemius (prevalence of 57.1%) . Henry et al., (2012) found that more than 60% of the subjects had MTrPs only in the medial muscles (medial head of the gastrocnemius muscle and the vastus medialis); none had MTrPs in the lateral muscles; approximately 40% of the subjects had pain in both medial and lateral muscles . Itoh et al., (2008) reported that the highest prevalence of MTrPs was found in the quadriceps, followed by the iliopsoas, adductors and hamstrings muscles .
As indicated by the aforementioned studies, we can cautiously state that MTrPs can be considered a partial factor in creating pain in knee OA patients. Because MTrPs also cause muscle weakness and decreased ROM , symptoms found to be associated with knee OA, it is possible that MTrPs are also an element of knee OA etiology. Further studies with a larger sample size are warranted in order to confirm the association between the prevalence of MTrPs and OA pain in the knees and other sites (hips, facet joints, etc.). More precise data on involved muscles is needed. It is also potentially important to explore the role of MTrPs in the etiology of OA.
Several intervention studies circumferentially support the assumption of myofascial involvement in knee OA pain. Henry et al., (2012), in a nonrandomized, nonblinded quasi-experimental study found that MTrPs injections significantly reduced pain intensity and pain interference and improve mobility in knee OA patients. Itoh et al., (2008) in a blinded, sham-controlled RCT compared MTrPs dry needling to standard Chinese acupuncture and sham needling in patients with knee OA, suggesting that MTrPs dry needling may be more effective in treating knee OA than standard acupuncture and was superior to non-penetrating sham needling in a small group of elderly patients.
Harish and Kashif (compared the Maitland mobilization and the myofascial release technique in reducing pain level and increasing the ROM in knee OA patients. They observed a significant improvement in the patients’ ROM and pain level after the treatments, but no significant difference between treatment options. Unfortunately, the treatment protocol was not described in the article preventing the possibility of analyzing the results. Rahbar et al., (2013) investigated the impact of MTrPs treatment in patients with knee OA in a single-blinded RCT. The spray and stretching technique, followed by a hot pack and friction massage were used to treat the MTrPs. This treatment was added to the conventional physical therapy received by the control group. The intervention group showed statistically better results in the WOMAC index and in the Timed Up and Go test, but not in the knee ROM. It is possible that the intervention group had a better outcome since their treatment lasted longer due to the additional time required for the spray and stretching technique, the hot pack and friction massage, which was applied on all MTrPs surrounding the knee.
Yentür et al., (2003) found that by adding MTrPs injections with lidocaine to the regular treatment of intra-articular hyaluronic acid injections to patients with knee OA was more effective in increasing ROM, reducing pain and improving daily activities than treatment with only a hyaluronic acid injection. Gomaa and Zaky, (2015) found that adding the ITB myofascial release technique to an exercise program improved ITB flexibility, patellar alignment, and PPT in patients suffering from knee OA. In this study, it is also possible that the intervention group had better outcomes since their treatment lasted longer. It also should be taken into account that their treatment affected only the ITB and that no other muscles impacting the knee were examined.
The aforementioned studies provide initial evidence of the efficacy of myofascial pain treatments in patients with knee OA. Treatment by MTrPs injections reduced pain intensity and improved mobility; the myofascial release technique improved ROM and reduced pain level significantly; MTrPs dry needling improved patients' pain scores and function; the spray and stretching technique for MTrPs improved pain ratings, joint stiffness, function, and ROM; MTrPs lidocaine injections improved ROM, reduced pain and increased patients’ function; and the ITB myofascial release technique improved ITB flexibility, patellar alignment, and PPT.
Considering the small sample size of the above studies and the heterogeneity in treatment types and outcome measures, additional high-quality studies are essential to explore the treatment options of MTrPs to alleviate pain and restore function in OA patients.
