肩的疼痛医学PPT课件.ppt

肩的疼痛ShoulderPain,.,脑卒中后遗症中约有的患者主诉肩痛。Twenty-one%to72%ofstrokepatientscomplainofshoulderpain.文献：VanOuwenalleretal.:Painfulshoulderinhemiplegia.ArchPhysMedRehabil,67:23-25,1986.BohannonRWetal.:Shoulderpaininhemiplegia:Statisticalrelationshipwithfivevariables.ArchPhysMedRehabil,67:514-516,1986.ChardMD,HazlemanBL:Shoulderdisordersintheelderly.AnnRheumDis,46:684-687,1987.VanIangenbergheHVKetal.:Shoulderpaininhemiplegia:Abookreview.PhysiotherPract,4:155,1988.,种疼痛(Threekindsofshoulderpain)活动时疼痛(Mechanicalandlocalpainwhilemovingandbeingmoved)被动活动和自主活动时的局部疼痛。安静时自发疼痛(Spontaneousandextensivepainatrest)夜间睡觉时与长时间轮椅保持坐位时，麻痹的上下肢的存在广泛的疼痛。肩手综合征的患者多伴有浮肿。进行运动疗法时该症状容易消失，故问诊是必不可少的。肩的活动时疼痛多先出现。Thispainisspontaneousandextensivepaininaffectedupperandlowerextremitiesatrestwhenpatientslieonbedsandsitonwheelchairs.Mostofpatientshaveedemaduetoshoulder-handsyndrome.Asthiskindofpaindisappearsinmovementtherapy,therapistsmustaskwhethertheyhavesuchkindofpainornot.Thisextensivepaintendstobeinitiatedbylocalshoulderpain.BrausDFetal.:Theshoulder-handsyndromeafterstroke:Aprospectiveclinicaltrial.AnnNeurol,36:728-733,1994.,种疼痛(Threekindsofshoulderpain)视丘痛(Thalamicpain)在视床后外侧症候群中，90%的后外侧损伤病例可见此种疼痛。Thalamicpainisoneofsyndromeinthelesionofposterior-lateralpart.Ninety%ofpatientswiththelesionofthatparthadthalamicpain.(Miyazaki1997)宮崎東洋：.克誠堂、pp40-47182-193、1997.,花岡一雄橘直矢：神経系話.、東京、.,posterior,anterior,rightwards(lateral),leftwards(medial),posterolateraln.,pulvinarthalamus,ventralposterolateraln.,dorsolateraln.,（前外側腹側核）,ventralanterolateraln.,（中間腹側核）ventrointermedialn.,視床Thalamus,dorsomedialn.（視床内側核）,medialcorpusgeniculatum,latealcorpusgeniculatum,(Mori,1995)森於兎（原著）：解剖学（改訂版）.大内弘（改訂）、金原出版、p336、1995.,lowerfibresoftrapezius,upperfibresoftrapezius,serratusanterior,levatorscapulae,rhomboidminor,rhomboidmajor,centreofrotation,centreofrotation,肩胛骨的运动ScapularMotion,前方,後方,内側,上方,下方,外側,上方,後方,下方,前方,内側,外側,後傾posteriortilting,前傾anteriortilting,上方回旋,upwardrotation,下方回旋downwardrotation,内旋int.rot.,外旋ext.rot.,BramanJP,EngelSC,LaPradeRF,etal.:Invivoassessmentofscapulohumeralrhythmduringunconstrainedoverheadreachinginasymptomaticsubjects.JShoulderElbowSurg,18:960-967,2009.,Averagehumerothoracicplaneelevation:63.37.0forwardofcoronalplane,andaveragepeakelevation:132.99.9ScapularRot:Int.Rot.until125ofarmelevation,thenrotatedexternallywithfurtherelevation.Scapulohumeralrhythm,2.3:1duringelevation.2.7:1duringlowering.Maximallytilted11.84.9anteriorlyat15ofhumerothoracicelevation.Aminimumposteriortiltof9.87.5at145.,7,活动时疼痛(Mechanicalandlocalpain)初期迟缓期的移乘和卧位翻身时的细微损伤（对于患侧上臂的KP应该慎重使用，体干的KP效果较好）Ininitiallyflaccidstage,caregiverssometimegivemicrotraumasandexcessivestretchesofaffectedshoulders.(InearlystagetherapistsandcaregivermustcarefullyuseproximalanddistalKPofaffectedupperextremitiesintransferandturningover.Wehadbetteruseaffectedtrunksandscapulae.)肌张力的不平衡和肌肉（软组织）粘弹性低下Imbalanceofposturalmuscletoneanddecreaseofviscoelasticityofmusclesandsofttissues肩胛骨的不稳定Instabilityofaffectedscapula容易产生短缩的肌肉：胸小肌、胸大肌尤其是锁骨枝、肱二头肌、喙肱肌、菱形肌、背阔肌等。与迟缓肌混合在一起。Shortness:pectminor,pectmajor(especiallyclavicularportion),biceps,coracobrachialis,rhomboids,latissimusdorsiandsoon.Theseexistwithhypotonicmuscles.恢复肩肱节律，去除胸大肌的负荷（de-weight）Recoveryofscapulohumeralrhythm&De-weighttoP.MajorBobathK:Shoulderpain.PhysTher,52:444-445,1972.,MyersTW:AnatomyTrain.ChurchillLivingstone,London,pp18163,2006.,Pectoralisminorconnectsfasciallytoshortheadofbicepsbrachiiandcoracobrachialisatcoracoidprocess.,9,粘连(Adhesion)根据偏瘫患者肩关节造影，25%的患者存在粘连变形。特别是肱二头肌腱鞘达到了58%。(Fukui1972)Inarthrography,58%oftendonsheathsofbicepshadadhesion.福井国彦：片麻痺肩造影線像中心所見及経過.医学、9:183、1972.偏瘫的患侧肩多少呈现了粘连性症状，48个病例中27个有此症状（56.3%）。(Hakuno1984)Fifty-six%ofaffectedshouldershadadhesion.白野明他：片麻痺肩関節造影上変化.総合、12:47-52、1984.偏瘫患者关节造影，根据与半脱位肩关节的比较，在半脱位上产生关节的粘连性变化更为常见。而且从肩关节整体来看粘连的产生也是在半脱位更容易产生。撞击的可能性极小。(Hakuno1986)Inarthrographyof95shoulderjoints,mostofadhesionwasaccompaniedwithshoulderjointsubuxations.白野明：片麻痺肩関節造影所見.総合、14:203-207、1986.,粘连(Adhesion)在实行肩关节造影的50例病例之中，肩肱关节处的粘连变化达80%，腱断裂存在14%。(Ono1994)Inarthrographyof50cases,80%hadadhesionofscapurohumeraljoints,and14%hadruptureoftendons.小野幸子他：片麻痺患者肩痛.医学、31:928-929、1994.以发病未满1年、主诉肩痛的患者32人进行关节造影。发病后2个月以内没有肩痛症状的，50%的病人存在粘连性囊炎(adhesivecapsulitis)。22%的人旋转肩袖（rotatorcuffs）断裂，16%存在肩手综合征、44%存在肩关节半脱位。粘连性囊炎为肩关节疼痛的诱因。Fifty%of32caseswhocomplainedofshoulderpainhadadhesivecapsulitis.Twenty-two%hadruptureofrotatorcuffs,16%hadshoulderhandsyndromeandsubluxationsofshoulderjointswerefoundin44%.Adhesivecapsulitisisoneofcausesofshoulderpain.LoS-Fetal.:Arthrographicandclinicalfindingsinpatientswithhemiplegicshoulderpain.ArchPhysMedRehabil,84:1786-1791,2003.,粘连(adhesion)由于浮肿导致肱二头肌、肱三头肌长头等起始部位腱鞘和关节囊的短缩和粘连。Edemamakesshortnessandadhesionincapsulesandtendonsheathsofbicepsbrachiiandtricepsbrachiietc.RoyCW:Shoulderpaininhemiplegia:Aliteraturereview.ClinicalRehabilitation,2:35-44,1988.腱炎粘连性囊炎(tendinitisandadhesivecapsulitis)肱二头肌长头的疼痛波及肌腹以及肱二头肌间沟的腱炎，在前臂内侧面出现疼痛，肘部形成二头肌腱炎。Someofhepaininoriginofbicepsbrachiilongheadcomesoutinitsbelly,whichistendinitisinintertuberculargroove.Theteniditisintheinsertionofbicepsbrachiiindicatespaininupperandvolarside.DonatelliRA:肩.山本龍二他（監訳）、葵出版、東京、pp83-101、2002.临床观察(Intheclinicalobservation)在长期卧床的病例中，在胸廓和背部可见短缩与粘弹性低下，上肢上举时肩胛骨和肋骨的分节运动困难。Inthecaseswhohaveexperiencedtolieonbedsinlongterm,shortnessanddecreaseofviscoelasticityofbackmusclesareobserved.Theseproblemsmadesegmentalmovementsofribcagespoor.,CaillietR:肩痛（第版）.荻島秀男（訳）、医歯薬出版、pp1451、2004.,肱二头肌长头的冲突Impingement/stretchofthelongheadofbicepsbrachiiinintertuberculargroovePain,capsule,longheadofbiceps,synovialmembrane,longheadofbiceps,synovialfluid,synovialmembrane,transverseligament,biceps,ScapulohumeralSynovialBursaandJointCapsule,coracoacrominallig.,MechanismofBiceps(longhead),伸展二头肌长头在结节间沟疼痛,Impingement撞击(impingementsyndrome,chronicsubacrominalimpingementsyndrome)肩峰、喙肩韧带、喙突、肩锁关节会与腱板和肩峰下滑液囊发生撞击，发生慢性的持续的疼痛时，称为impingement综合症。Impingementisthephenomenonthattheacromion,coracoacrominallig.,coracoidprocessandacromioclavicularjointcollidetorotatorcuffsandsubacrominalbursa.Whencollisionsarerepeatedandpainoccurs,itiscalledimpingementsyndrome.(Tamai2002)玉井和哉：症候群.肩痛寺山和雄片岡治（監修）、南江堂、pp85-98、2002.,撞击与夹痛impingement&pinching上肢水平外展运动中产生的疼痛，推测为肩峰下滑液囊和肱三头肌长头的夹痛。Thepainwhilemovinganarmhorizontallyisguessedtobecausedbypinchingacapsuleandalongheadoftricepsbrachii.根据运动方向产生的疼痛Differentlocalpainindifferentdirectionsofthemovement前方上举时的疼痛(Whatisthelocalpainwhileelevatingaarm?)：水平外展时的疼痛(Whatisthelocalpainwhileabductinghorizontally?)：水平内收时的疼痛(Whatisthelocalpainwhileadductinghorizontally?)：上肢放下时的疼痛(Whatisthelocalpainwhiledescendingarm?)：,(Mori1995)森於兎（原著）：解剖学（改訂版）.大内弘（改訂）、金原出版、pp128341、1995.,结节间沟Intertuberculargroove,肱二头肌长头longheadtendonofbicepsbrachii,(Mori1995)森於兎（原著）：解剖学（改訂版）.大内弘（改訂）、金原出版、p207、1995.,结节间滑液鞘Intertubercularsynovialmembrane,(Yazaki2008)矢崎潔：再人間上肢運動考（）.、31(1):54-61、2008.,肘关节屈伸运动时（）的肱三头肌和胸大肌的关系Relationshipbetweenbicepsandpectoralismajorwhenanelbowextendsandflexes.（）肱二头肌起作用时长头腱产生压力的方向Thedirectionofpoweronthelongheadofbicepsbrachii（）伸展时，生理上作为协同肌的胸大肌对肱骨的牵引方向Thedirectionofcontractiononthepectoralismajorwhenelevatinganhumerus、（）肱二头肌和胸大肌的位置关系elationshiponalignmentsbetweenlongheadofbicepsandp.major长头肌腱处直接加压，结节间沟和周边疼痛Pressureisgiventoalongheadofbicepsinintertuberculargroove,andpaintendstooccur.,flexion,extension,岁男性、脑出血（右侧偏瘫）、发病后月、右肩痛Age:49Y,Male,Dx.:CerebralHemorrhage(RightHemiandRt.ShoulderPain),2MonthsafteraStroke,翻身时麻痹侧右上肢落在身后，牵张痛会在肱二头肌长头起始部出现。Whenheturnsoverfromsupinetoleftside-lyingwhilesleepingonabed,heoftenleaveshisrightarmandthenhasrightshoulderpain.,为了预防对于肱二头肌长头起始部位过度的伸张和撞击，调整肩肱节律。Inordertopreventstretchandimpingement,scapulohumeralrhythmiscorrectedwithplacing.,在患者翻身时,PT要诱导从右侧上肢开始的翻身动作。保持肩胛带的前伸。Atherapistguidestherightscapulaandarmmoveupwardwhenturningover.Thepatientsawarenessisimportant.,Selfcontroltopreventshoulderpain患者自己控制，左手把持麻痹侧上肢，在不引起疼痛下翻身。,(Mori1995)森於兎（原著）：解剖学（改訂版）.大内弘（改訂）、金原出版、pp337344、1995.,水平外展时肱骨三头肌长头和关节囊的夹痛Pinchingadpainofalongheadoftricepsbrachiiandajointcapsuleabductinghorizontally.,Longheadoftriceps,Teresmajor,Teresminor,Longheadoftriceps,Teresmajor,(Tamai2002)玉井和哉：症候群.肩痛寺山和雄片岡治（監修）、pp85-95、2002.NeerCS:Cufftears,bicepslesions,andimpingement.ShoulderReconstruction.(Ed.)NeerCS,WBSaunders,Philadelphia,pp41-142,1990.(右図),Impingement撞击综合症ImpingementSyndrome,冈上肌出口狭小化Narrowsupraspinatusoutlet,CaillietR:肩痛（第版）.荻島秀男（訳）、医歯薬出版、pp27-2866-68、2004.,在损伤部位的压痛,RuptureofSupraspinatus冈上肌的断裂,Pressurepaininthelesion,肩悬吊肩(ShoulderSling),左侧偏瘫Lt.Hemi.,活动时疼痛的对策(Theapproachtolocalpainwhilemoving)平衡肌张力和恢复肌肉粘弹性Posturalcontrol,modulationofposturalmuscletone,restorationofvscoelsticity.恢复肩肱节律Recoveryofscapulohumeralrhythm肩胛骨的定势Scapulasetting肩胛带的稳定性与运动性Selectivestabilityandmovementofscapula对于短缩，在KP控制的部位导入关节松动术Mobilizingtoshortnessofmusclesandsofttissues,肩胛骨的定势Scapulasetting脑梗塞（右侧偏瘫）68岁男性Dx.CerebralInfarction(Rt.Hemiplegia)Age:68Y,Scapulasetting,偏瘫侧肩胛提肌起始部的疼痛Painintheoriginofaffectedlevatorscapulae姿势性疲劳PosturalfatigueCaillietR:肩痛（第版）.荻島秀男（訳）、医歯薬出版、pp275-285、2004.,短缩Shortness,疼痛Pain,左侧骨盆后撤Lt.pelvisretraction,CailletR:頚腕痛（第版）.荻島秀男（訳）、医歯薬出版、p226、2004.,Increaseofkyphosis,Downwardrotation,Levatorscapulae,Lockedlongmuscles:Strained,Lockedshortmuscles:Bunched（一塊）,不活动的长肌：紧张（）,MyersTW:AnatomyTrain.ChurchillLivingstone,London,p18,2006.,Increaseofthixotropy(触变性的改变）,28,肩手综合症始于疼痛的肩和上肢Shoulder-handsyndromeisoccurredbylocalpaininaffectedshouldersandupperextremities.DonatelliRA:肩.山本龍二他（監訳）、葵出版、東京、pp83-101、2002.,BrausDFetal.:Theshoulder-handsyndromeafterstroke:Aprospectiveclinicaltrial.AnnNeurol,36:728-733,1994.,肩手综合症由局部损伤引起。Shoulder-handsyndromeisinitiatedbyperipherallesions(localpain).,大范围的麻痹侧上下肢的安静时自发痛Spontaneousandextensivepainatrest首先出现麻痹侧运动时的局部疼痛。推测疼痛是由于炎症时产生的缓激肽、复合胺、组胺、钾离子等的神经激肽广泛存在于浮肿部位。缓激肽等物质促进组织产生、游离前列腺素类物质。Thelocalshoulderpainwhilebeingmovedoccursbeforethiskindofpain.Itisguessedthattheneurokininlikebradykinin,serotonin,histamine,Achandpotassiumisaccumulatedalotinedemaandthenproductionofprostaglandinisincreasedandcausesspontaneousandextensivepainofaffectedupperextremitiesatrest.AwadEA:Interstitialmyofibrositis:hypothesisofthemechanism,ArchPhysMed,54:449-453,1973.(Kumazawa1990)熊澤孝朗：痛覚.脳科学中村嘉男酒田英夫（編）、朝倉書店、pp187-200、1990.交感神经产生了诱发疼痛的物质-神经激肽（neurokinin）。由于不存在皮肤血管扩张，疼痛的阈值降低。Sympatheticnervesproducewhichmakespain.Itdilatesskinvesselsandlowersthethresholdofpain.WattayEG:Reflexsympatheticdystrophysyndrome.ClinicalManagement,9(1):28-29,1989.,肩手综合症ShoulderHandSyndrome麻痹侧上肢的肌肉活动低下肌肉血流减少DecreaseofmuscleactivitiesofanaffecttedupperextremityDecreaseofbloodflowinmuscles皮肤骨组织的血流增加Increaseofbloodflowinskinsandbonesreversely局部的代谢障碍微循环恶化、神经激肽产生伤害感受器的向心性冲动增加PoorlocalmetabolismInflammationofsofttissuesandalotofproductionofneurokininIncreaseofafferentimpulsesfromnociceptors内环境稳定，有促使皮肤骨组织增加的血流正常化的作用Reactionstonormalizetheincreaseofbloodflowofskinsandbonesbyhomeostasis但是交感神经活动亢奋。细小动脉收缩交感神经和躯体感觉神经产生去甲肾上腺素的化学信号，增加向心性冲动，在脊髓水平，反射性的交感神经兴奋。Activitiesofsympatheticnervesbecomeshigher.Capillariescontract.Insympatheticnervesandsensorynerves,chemicaltransmissionofnoradrenalinhappens,andthenafferentimpulsesincrease.Inspinalcord,sympatheticnervesreflexivelyexcite.(Ishibashi2002)石橋徹：反射性交感神経性.肩痛寺山和雄片岡治（監修）、pp183-197、2002.,CaillietR:肩痛（第版）.荻島秀男（訳）、医歯薬出版、p65、2004.,trauma,trauma,serotonin,contractionofvessel,bloodplatelet,dilationofvessel,histamine,heparin,edema,edema,mechanically,P-substances,prostaglandin-E,bradykinin,spasms,edema,occlusionofbloodflow,phospholipids,arachidonicacid,浮肿的机制MechanismofEdema,transmission,CaillietR:肩痛（第版）.荻島秀男（訳）、医歯薬出版、pp257-260、2004.,pump,pump,artery,vein,limitationofflexionandpumpingaction,PumpsforVeinandLymphinUpperExtremity,上肢、手和胸廓全体的肌肉收缩过程中，浮肿也会减轻。Intheprocesstorecovernormalcontractionoftheaffectedarmandhandandribcage,edemaisdecreased.,大范围的麻痹侧上下肢安静时自发疼痛的对策Approachtospontaneousandextensivepainatrest宽动作范围神经元（WDR神经元）处于过敏状态，同时具有对麻痹侧肩运动时疼痛和局部疼痛的镇静效果。Widedynamicrangeneuronishyperreflexive,butmakethelocalpainofanaffectedshouldersedativeatthesamesession.(Omote&Namiki1995)表圭一並木昭義：RSD.医学歩、175:473、1995.为了减轻浮肿，需恢复肌泵的作用，改善静脉回流与淋巴回流。消除不活动。Recoverpumpingactions,andimprovevenousandlymphflowstodecreaseedema.麻痹侧肩周围肌群的持续收缩，改善迟缓的手部浮肿是重点。改善使腕管变窄的屈肌支持带、腕关节屈肌群的短缩。手内在肌收缩对于手部浮肿改善非常重要。Increasesustainedactivationandstabilityintheaffectedscapulaandarm.Widenandelongateaflexorretinaculumwhichisshortandnarrowsacarpaltunnel.Inordertoalleviateedemaintheaffectedhand,functionalcontractionofintrinsicmusclesisimportant.,CaillietR:肩痛（第版）.荻島秀男（訳）、医歯薬出版、pp254、2004.,外伤、trauma,外伤、trauma,后根神经结、dorsalrootganglia,C-疼痛纤维、C-nociceptivefiber,外侧脊髓丘脑束lateralspinothalamictract,侧束、lateralcolumn,A-来自机械性感受器的纤维、A-fiber,交感神经sympatheticnerve,交感神经信号、sympatheticsignals营养障碍、dystrophy,WideDynamicRangeNeuron(WDR)宽动作范围神经元,肩手综合症胸廓出口症候群Shoulderhandsyndromewiththoracicoutletsyndrome（日常的座位姿势Usualsittingpattern）（治疗中Treatment）,62岁诊断：右侧壳部出血（左侧偏瘫）发病后4个月26日，左后倾胸背部，左前胸部上臂前面、外侧，左腕关节掌侧安静时自发疼痛、左手浮肿、装配肩吊带。Age:62Y,Dx:Rt.PutamenHemorrhage(Lt.Hemi.)4M26Dfromtheonset.Spontaneousandextensivepaininleftu/eatrest.,pain,pain,pain,胸廓出口ThoracicOutlet,(Sadahiro2002)貞廣哲郎：胸郭出口症候群.肩痛寺山和雄片岡治（監修）、南江堂、pp161-171、2002.,Brachialplexus,Pect.Minor1stRib,middlescalenus,Clavicle,Subclavicularvein,Subclavicularartery,Anteriorscalenus,安静时大范围的自发疼痛(spontaneousandextensivepainatrest),Pain疼痛,端坐位左侧桡动脉的脉搏StrengthofCardiacBeatsinLeftRadialArtery(AdsonTest),治疗(Tx)姿势Posture.CardiacBeats/min.Strength(AdsonTest)1.(BeforeTx)颈部躯干过度屈曲Alittle（胸廓狭小）Neck&TrunkFlexioninnaturalposition.weak2.(BeforeTx)左侧旋转颈部屈曲Weaker（胸廓狭小）Neckrotationtotheleftandflexioninnaturalp.3.(DuringTx15mni.)颈部、躯干伸展Stronger（治疗15分，胸廓扩张）Neckandtrunkext.withneckrot.toleft,DonatelliRA:肩.山本龍二他（監訳）、葵出版、東京、103-128、2002.,丘脑性疼痛ThalamicPain,世界疼痛学会(IASP1986、IntenationalAssociationfortheStudyofPain)）RSD（反射性交感神经萎缩症、reflexsynpatheticdystrophies）是指在外伤后一个肢体的特定部分的持续疼痛。虽然其中包括骨折，但是主要不是神经的损伤，是交感神经的过度活动。RSDisthatcontinuouspaininaportionofanextremityaftertraumawhichmayincludefracturebutdoesnotinvolveamajornerve.Itisassociatedwithsympathetichyperactivity.(Hyodo1989)兵頭正義：定義診断基準.、10(5):568-574、1989.,世界疼痛学会(IASP1986、IntenationalAssociationfortheStudyofPain)）灼性神经痛(causalgia)灼性神经痛是指某一神经部分受损、或者主要神经枝的部分损伤，引起手足的灼热痛、异常性疼痛、痛觉异常、过敏等症状。Causalgiaisthatburningpain,allodyniaandhyperpathia,usuallyinthehandorfoot,afterpartialinjuryofanerveoroeofitsmajorbranches.（如果不是神经的主枝损伤，则不能称之为灼性神经痛，文献中多称之为majornerve、peripheralnervetrunk、peripheralnerve。）(Hyodo1989)兵頭正義：定義診断基準.、10(5):568-574、1989.,丘脑痛(thalamicpain)）传入神经阻滞疼痛综合征（DPS、deafferentationpainsyndrome）阻断上行性冲动，通常疼痛会消失。但是有时会表现为顽固性疼痛（灼热痛）、各种的感觉异常（知觉异常hyperthesia、感觉异常dysesthesia）。Painusuallydisappearsafterinterruptionofascendingimpulses.However,sometimesremarkablepain,hyperthesiaanddysesthesiaoccur.(MiyazakiandTokuda1989)宮崎東洋徳田秀光：考方治療法変遷.、10(5):575-580、1989.,损伤后(afterlesions)神经损伤（）majornervelesions()灼性神经痛(causalgia)传入神经阻滞疼痛综合征(deafferentationpainsyndrome)幻肢痛(phamtompain)丘脑性疼痛(thalamicpain)疱疹后神经痛(postherpeticneuralgia)神经损伤（）majornervelesions()反射性交感神经萎缩症(RSD)(MiyazakiandTokuda1989)宮崎東洋徳田秀光：考方治療法変遷.、10(5):575-580、1989.,丘脑性疼痛(thalamicpain)是一种脑卒中后引起的向心性神经传导阻滞的综合症，对侧出现感觉障碍并伴随疼痛。Oneofthedeaferentationpainsyndromecausedbythelesionofthalamusinstrokes.Painisproducedinthecontralateralfieldwhichhassensorydeficits.）传导疼痛的脊髓丘脑束的损伤Thelesionofspinothalamictractwhichisthetractofpain.）如果传导浅感觉、深感觉，抑制疼痛上行性传导的内侧丘系损伤，丘脑性疼痛的发生率会变高。Whenmediallemnicusisinjured,thatcarriestactilesensationsanddeepsensationswhichinhibitsascendingconductionofpain,theincidenceofthalamicpainbecomeshigher.）90%的损伤发生在丘脑后外侧。N