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本次文献选自Oliva V, Gregory R, Brooks JCW, Pickering AE. Pain.2022;163(1):125-136. 本次学习由邱凤主治医师主讲。
Abstract
Fibromyalgia is a prevalent pain condition that is associated with cognitive impairments including in attention, memory, and executive processing. It has been proposed that fibromyalgia may be caused by altered central pain processing characterised by a loss of endogenous pain modulation. We tested whether attentional analgesia, where cognitive engagement diminishes pain percept, was attenuated in patients with fibromyalgia (n = 20) compared with matched healthy controls (n = 20). An individually calibrated, attentional analgesia paradigm with a 2×2 factorial design was used with brain and brainstem-focussed functional magnetic resonance imaging. Patients with fibromyalgia had both lower heat pain thresholds and speeds in a visual attention task. When this was taken into account for both attentional task and thermal stimulation, both groups exhibited an equivalent degree of attentional analgesia. Functional magnetic resonance imaging analysis showed similar patterns of activation in the main effects of pain and attention in the brain and brainstem (with the sole exceptions of increased activation in the control group in the frontopolar cortex and the ipsilateral locus coeruleus). The attentional analgesic effect correlated with activity in the periaqueductal gray and rostral ventromedial medulla. These findings indicate that patients with fibromyalgia can engage the descending pain modulatory system if the attentional task and noxious stimulus intensity are appropriately titrated.
Keywords: Fibromyalgia, Pain, fMRI, Attention, Brainstem, Analgesia
摘要
纤维肌痛是一种常见的疼痛疾病，与包括注意力、记忆和执行加工在内的认知障碍有关。有人提出纤维肌痛可能是由内源性疼痛调节丧失为特征的中枢疼痛处理过程改变。我们测试了患者的注意力镇痛(认知参与减少疼痛感知)，与健康对照组(n= 20)进行比较，是否在纤维肌痛症患者中(n=20) 减弱。一个单独校准的、具有2×2因子设计的注意力镇痛范式被用于大脑和脑干聚焦的功能磁共振成像。纤维肌痛患者的热痛阈值和视觉注意力任务的速度都较低。当注意力任务和热刺激都考虑到这一点时，两组患者都表现出同等程度的注意力镇痛作用。功能性磁共振成像分析显示，在疼痛和注意力的主要影响下，大脑和脑干的激活模式相似（唯一的例外是对照组在额叶皮层和同侧脑室的激活增加）。注意力的镇痛作用与延髓周围灰和喙部外侧延髓的活动有关。这些研究结果表明，如果注意力任务和伤害性刺激强度得到适当的调整，纤维肌痛患者可以参与下行疼痛调节系统。
关键词 纤维肌痛，疼痛，功能MRI，注意力，脑干，镇痛
1.Introduction
Fibromyalgia is a common, chronic condition characterised by widespread pain with hyperalgesia in muscles and joints without any identifiable alternative causative pathology. In addition to widespread pain, fibromyalgia is syndromically linked to fatigue, sleep deficits, and difficulties in concentration, an array of symptoms, which has been referred to as “fibrofog”. A single underlying pathophysiological cause for fibromyalgia is yet to be fully elucidated, and the current diagnostic criteria are based on self-reported measures.
简介
纤维肌痛是一种常见的慢性疾病，其特点是肌肉和关节的广泛疼痛和痛觉减退，但没有任何可识别的替代性病理因素。除了广泛的疼痛外，纤维肌痛还与疲劳、睡眠不足和注意力难以集中等一系列症状有关，这被称为 "纤维雾"。纤维肌痛的单一潜在病理生理原因尚未完全阐明，目前的诊断标准是以根据自我报告的检测为基础。
There are a plethora of studies reporting alterations in nociception and pain processing in patients with fibromyalgia. One intriguing line of investigations has reported a small fibre deficit and altered function of nociceptive primary afferents which may give rise to hyperalgesia. As a counterpoint theory, fibromyalgia has also been proposed to be a “centralised” pain condition characterised by augmented brain responses to noxious stimuli that underlies hyperalgesia. In support of a central aetiology of fibromyalgia, there have been reports of impairments in endogenous pain modulatory mechanisms, such as conditioned pain modulation and exercise-induced analgesia. This has, in part, been the justification for the use of treatments to boost central pain modulatory circuits through the use of monoaminergic reuptake inhibitors (increasing noradrenaline and serotonin), which are among the few medications with any evidence of efficacy in fibromyalgia.
有大量的研究报告称纤维肌痛患者的痛觉和疼痛处理发生了改变。一项有趣的调查报告指出，小纤维缺失和痛觉初级传入的功能改变，可能会引起痛觉减退。作为一种相反的理论，纤维肌痛也被认为是一种 "中枢性 "疼痛状况，其特点是大脑对伤害性刺激的反应增强，是痛觉亢进的基础。为了支持纤维肌痛的中枢病理学，有报道称内源性疼痛调节机制出现了障碍，如条件性疼痛调节和运动诱导镇痛。这在一定程度上成为使用单胺能再摄取抑制剂（增加去甲肾上腺素和5-羟色胺）来促进中枢疼痛调节回路的治疗方法的理由，这些药物是少数有证据表明对纤维肌痛有效的药物之一。
往期回顾：
超声引导下腹横肌平面阻滞与触发点注射治疗慢性腹壁疼痛：一项随机临床试验（八）
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