中醫師到底在針蝦密? 談針灸的機轉（by 林冠良中醫師）
針灸是假笑還是真的有效?
越多越多的證據顯示，針灸能夠改善疼痛，幫助病患恢復日常生活功能然而許多第一次針灸的民眾最常問的是中醫師，你到底在針蝦密??是肌肉?是能量?還是…….你在變魔術?
事實上針灸治療疼痛、恢復功能的機轉仍眾說紛紜
有些中醫師以氣血、能量和傳統經絡作解釋有些中醫師則結合現代醫學以解剖生理病理作解釋
關於機轉大家都各有道理
但也都有說不通的地方
唯一共通點是，有效病人才會笑~
為了能夠講清楚說明白，以下以現代醫學的解剖生理病理作跟大家分享嘿~
肌肉怎麼會好痛痛?
我們都知道當身體產生痠痛時，很重要的一個原因就是”肌肉失衡”
著名的物理治療學家弗拉迪米爾·揚達（Vladimir Janda）
曾經提出”肌肉是成對失衡的”的假說
粗略來說就是當主動肌過度緊繃的時候，成對的拮抗肌會薄弱
以膝關節為例，大腿前側的股四頭肌和大腿後側的膕繩肌是成對的
而退化性關節炎的病人通常有
前方股四頭肌受到抑制而薄弱，後方膕繩肌短縮而緊繃的情形
所以對於退化性關節炎的病人，我們經常會衛教坐姿(坐躺姿)抬腿的動作
一方面強化股四頭肌，一方面伸展放鬆膕繩肌
那麼針灸到底是強化肌肉，還是能夠放鬆肌肉呢?
關於肌肉鬆緊的調控，我們要認識兩個接受器
“肌梭(muscle spindle)和高爾基腱受器(Golgi Tendon Organ, GTO)”
1.肌梭
肌梭是肌肉內感受肌肉長度的變化的受器(receptor)，當肌肉(如:股四頭肌)受到牽張而拉長時，肌梭會被活化，透過感覺神經傳入脊髓背角，通過中間神經元後，會走兩條路徑。
(1)第一條是傳出的神經訊號會讓拉長的肌肉收縮，避免肌肉過度的延展而拉傷，也就是說刺激肌梭，會直接增加肌肉的收縮
(2)第二條則是會到對側的拮抗肌(如膕繩肌)去做抑制，導致拮抗肌放鬆，形成交替抑制(reciprocal inhibition)效應。
2.高爾基腱受器
肌腱上有許多高爾肌腱受器分布，它是感受肌肉的張力的受器，當肌肉的張力過大時，會傳入訊號到脊髓的背角，透過中間神經元，發出抑制性訊號，直接造成肌肉放鬆，避免肌肉承受過度的張力而受傷。
高爾基腱受器和肌梭可以說是做相反的工作，針刺肌梭可以活化肌肉，造成肌肉縮短，然而刺激高爾基腱受器，則可以造成肌肉放鬆。
所以當病患罹患退化性膝關節，我們可以用針刺激股四頭肌的肌梭，來激活股四頭肌，使其更有力；此外，因為交替抑制效應，同時也會抑制膕繩肌，導致膕繩肌放鬆。此外，直接針刺膕繩肌的肌腱(有高爾基腱受器)也可以直接造成膕繩肌的放鬆。
針灸怎麼處理受傷的肌肉?
當人體在外傷、手術、勞損等情況下，會導致軟組織局部發炎，造成筋膜出現沾黏、滑動受阻以及影響到筋膜中的感覺受器，最終出現代償(如姿勢異常)、疼痛或是活動受限。其中，主要的機制就是因為筋膜沾黏後，肌肉中的肌梭不能充分感知牽拉，骨骼肌之間的協調性下降，於是關節活動產生失衡與疼痛。
基於這點，我們要知道，關節運動是不同肌纖維在不同時間的依次收縮所產生的結果，那麼在外周，需要一種組織可以負責募集不同肌纖維在不同時間的收縮，這個組織就是筋膜，其中筋膜上有些”張力點”則可以做為骨骼肌運動的募集中心，而這些”張力點”出現的位置，其實大部分都和中醫的穴位雷同。
義大利筋膜學專家Luigi Stecco根據實證研究和臨床經驗，創立了義大利筋膜手法( Fasical manipulation)，深入研究身體張力點以及筋膜鏈治療法。
他們將人體分成不同的運動單元，叫肌筋膜單元(Myofascial unit, MFU)，而同一方向上的運動單元(MFU)連續組成叫做肌筋膜序列(Myofascial sequence, MFS)。每個運動單元有不同的運動向量張力點，叫做協調中心(center of coordination, CC) ，當這些協調中心受損時，經常會有緻密化的情形，因此治療時使用交叉式摩擦按摩來修復緊張點，或用垂直壓力幫助手下的筋膜的透明質酸(HA)流動。
有趣的是，此筋膜學派的研究發現，大部分的協調中心都可以對應到中醫的穴位點，肌筋膜序列(MFS)則與中醫經絡有許多相對應的地方，比如前向運動序列對應到胃經與肺經，後向運動序列則對應到小腸經與膀胱經。
使用針灸，便可以在局部組織造成微創效應(引發輕微發炎，並促進組織修復)，恢復筋膜張力點的受傷(緻密化)。
針灸該如何處理筋膜鏈?
不知道大家有沒有看過有些中醫師在扎針的時候，有的時候扎很深，有的時候扎很淺，甚至是平刺，感覺針只在皮膚下呢?又或者明明我是右邊痛，他扎左邊；我明明是腳踝痛，他扎手腕呢?
在中醫針灸理論裡面，有許多上病下治以及左病右治的治法，這其實與筋膜鏈有關，但由於內容較多，在此僅跟大家分享一個臨床上針刺不同層次筋膜鏈的思維。
肌肉和人一樣，喜歡做肌與肌的連結，以臀大肌為例
- 深層的臀大肌連結:臀大肌的深層附著在股骨的臀肌粗隆以及薦骨、骶結節韌帶；向下和同側的膕繩肌連結，向上和同側的豎脊肌形成連結
- 淺層的臀大肌連結:臀大肌的淺層則透過胸腰筋膜和對側的背闊肌形成淺層筋膜鏈，背闊肌還可連到肱骨結節間溝的內側和肩胛骨下角。
所以當病患主訴有肩膀痛，經測試有臀大肌無力的情形，我們要思考可能是臀大肌失能，造成對側的背闊肌代償，拉到對側的肩膀引起的，在治療上要處理臀大肌的淺層連結。但若病患是抱怨大腿後側緊繃，膝蓋彎曲不能或是腰背痠痛的話，經評估也有臀大肌失能，則要考慮治療深層的臀大肌連結。
針灸並非撲朔迷離
針灸其實還有許多效果，包括止痛、抗發炎等，目前也有許多研究提出了門閥控制理論和腦內啡理論來解釋，而利用針灸或是針刀做去沾黏，在臨床上也經常看見。
以蔡先生的退化性膝關節為例，當他反覆的屈膝活動(如:蹲、跪、爬樓梯)，導致膝關節內側皺襞與股骨內髁互相摩擦，內側皺襞產生發炎、變厚，形成沾黏組織的情形。中醫師就可以利用針灸針(或針刀)幫忙解除沾黏，減少摩擦的機率，避免關節軟骨有更多的磨損。
針灸並非撲朔離迷的玄學，也不是變魔術，很多時候古人留下的經驗，只是缺乏現代醫學實證的統計(欠栽培?)，臨床上的有效性還是擺在眼前。希望透過這篇文章能夠讓大家可以更理解針灸到底在針蝦米碗糕，期望未來中醫可以在運動醫學與疼痛醫學的整合有更多的參與。
- 參考資料:
- 1.Andrew J. Vickers, D.Phil and Klaus Linde, MD. Acupuncture for chronic pain.
- JAMA. 2014 Mar 5; 311(9): 955–956.
- 2. Megha Patel, Ivan Urits, Alan D Kaye, Omar Viswanath. The role of acupuncture in the treatment of chronic pain. Best Pract Res Clin Anaesthesiol. 2020 Sep;34(3):603-616.
- 3.Andrew J Vickers et al. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis J Pain, 2018 May;19(5):455-474
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