Prescribing tai chi for fibromyalgia--are we there yet?
Prescribing tai chi for fibromyalgia--are we there yet?
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太极拳治疗纤维肌痛——我们做到了吗？
DOI：
10.1056/nejme1006315
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发表时间：
2010
期刊：
影响因子：
--
通讯作者：
Shmerling,RobertH
中科院分区：
文献类型：
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作者：
Yeh,GloriaY;Kaptchuk,TedJ;Shmerling,RobertH
纤维肌痛是一种常见且知之甚少的疼痛疾病，全球约有2亿或更多人受到影响。1由于缺乏在体格检查和标准血液和影像学检查中检测到的客观异常，许多医生质疑这种疾病的存在。2然而，对于那些经历疼痛和其他相关症状（包括疲劳，僵硬和非恢复性睡眠）的人来说，毫无疑问，这种情况是真实的，因此需要缓解。过去十年的研究表明，纤维肌痛可能是由于，至少部分是由于中枢神经系统疼痛敏感性的改变。3其他潜在的机制性因素包括遗传易感性、情绪或身体压力、睡眠障碍和神经激素功能障碍。我们能为纤维肌痛患者提供什么样的缓解？一旦确诊（这不是一个小壮举，因为这是一个排除诊断，有许多模仿），标准的治疗建议包括锻炼，睡眠卫生和药物。理想的锻炼计划尚不清楚，尽管有氧运动和强化运动的混合可能是最好的。4其他非药物治疗方法包括认知和行为疗法。通常推荐用于纤维肌痛的药物包括阿米替林、环苯扎林、氟西汀和几种现在被食品和药物管理局批准的药物（包括度洛沙汀、普瑞巴林和米那普仑）。然而，即使最佳使用标准措施，临床反应往往令人失望。例如，在一项为期12周的安慰剂对照的度洛沙汀试验中，只有55%的治疗患者的标准疼痛评分至少改善了30%，而安慰剂组的这一比例为33%。标准治疗的其他局限性包括药物治疗的显著副作用和对生活方式改变（特别是运动）的依从性。最后，考虑到这种疾病的慢性性，长期疗效至关重要;不幸的是，迄今为止，大多数研究的持续时间都很短，因此即使是适度的改善，其持久性也是不确定的。
Fibromyalgia is a common and poorly understood pain disorder that afflicts an estimated 200 million or more people worldwide. 1 The lack of objective abnormalities detected on physical examination and standard blood and imaging tests has led many physicians to question the existence of this disorder. 2 However, for those experiencing the pain and other associated symptoms (including fatigue, stiffness, and nonrestorative sleep), there is little doubt that the condition is real—and so is the need for relief. Studies over the past decade suggest that fibromyalgia may be due, at least in part, to an alteration in pain sensitivity in the central nervous system. 3 Other potential mechanistic contributors include a genetic predisposition, emotional or physical stress, disordered sleep, and neurohormonal dysfunction.What relief can we offer persons with fibromyalgia? Once the diagnosis is established with confidence (which is no small feat, since this is a diagnosis of exclusion, with many mimics), standard treatment recommendations include exercise, sleep hygiene, and medications. The ideal exercise program is unclear, although a mix of aerobic and strengthening activities may be best. 4 Other nonmedication approaches include cognitive and behavioral therapies. Pharmacologic agents commonly recommended for fibromyalgia include amitriptyline, cyclobenzaprine, fluoxetine, and several drugs now approved by the Food and Drug Administration (including duloxetine, pregabalin, and milnacipran). Yet even with optimal use of standard measures, the clinical response is often disappointing. For example, in a 12-week, placebo-controlled trial of duloxetine, only 55% of the treated patients, as compared with 33% of those given placebo, had improvement of at least 30% in a standard pain score. 5 Other limitations of standard treatment include significant side effects with pharmacologic approaches and variable compliance with lifestyle changes (especially exercise). Finally, given the chronicity of this disorder, long-term efficacy is of paramount importance; unfortunately, most studies to date have been of short duration, so the durability of even modest improvement is uncertain.