特集 : 線維筋痛症 1949 II. 線維筋痛症の基礎 臨床研究 線維筋痛症の痛み定量化 岡 寛 Quantification of pain in patients with fibromyalgia Hiroshi Oka Tokyo Rheumatism Pain Clinic/Hachio
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1 日本臨牀 76 巻月刊号 11 (2018 年 11 月 1 日発行 ) 別刷 特集 : 線維筋痛症 最新の基礎 臨床知見 II. 線維筋痛症の基礎 臨床研究 線維筋痛症の痛み定量化 岡 寛
2 特集 : 線維筋痛症 1949 II. 線維筋痛症の基礎 臨床研究 線維筋痛症の痛み定量化 岡 寛 Quantification of pain in patients with fibromyalgia Hiroshi Oka Tokyo Rheumatism Pain Clinic/Hachiouji Medical Center, Tokyo Medical University Abstract Fibromyalgia (FM) is a common chronic pain disorder characterized by widespread pain. Japanese FM patients are estimated to number more than 2 million based on nationwide monitoring. We usually evaluate the pain by the Visual Analog Scale (VAS) and the Numeric Rating Scale (NRS). But these methods are subjective methods by patients. If we can quantify of pain, it will be one of the cognitive therapy of pain. Therefore quantification of pain is needed for evaluation and treatment of FM patients. A system for quantification of pain (Pain Vision) has been developed in Japan. Using Pain Vision, we can objectively evaluate the patient s pain. We measured the pain in 83 FM patients who met the ACR criteria in 1990 and compared the value between the recent NRS values and Pain Score among these patients. As a result, the average pain threshold of male FM patients is 9.35±2.64 with a pain degree of ±312.94, and the average pain threshold of female FM patients is 7.93±2.30 with a pain degree of ± The average pain degree of FM patients was much higher than seen in rheumatoid arthritis (RA) patients. Also female FM patients have a lower pain threshold and might be related with hyperesthesia. On the other hand, a pain threshold with RA patients is not low. There was no difference in RA and FM for the average of the NRS. However, FM patients who have high NRS scores have a high pain degree. The measurement by Pain Vision is very helpful for us to objectively know the threshold and the pain degree. In conclusion, the pain degree by Pain Vision was able to quantify and evaluate the pain in patients with FM. Key words: fibromyalgia,rheumatoid arthritis,quantification of pain,pain degree 1. 背景と目的 痛みは第 5 のバイタルサインといわれ 1), 患 者の主訴として高頻度かつ重要である. その中 でも, 線維筋痛症 (fibromyalgia: FM) は, 本邦に 200 万人の患者が存在するが, その主訴は全身の痛みである 8, 9, 12). 患者が持つ痛みを理解することは難しく, これまで痛みの強さの評価 東京リウマチ ペインクリニック / 東京医科大学八王子医療センター /18/ 60/ 頁 /JCOPY
3 1950 日本臨牀 76 巻 11 号 ( ) 図 1 Pain Vision による痛みの測定 刺激を感じた時点, あるいは痛みと同じ刺激になった時点で, スイッチを被験者が押す. は,Visual Analog Scale (VAS),Numeric Rating Scale(NRS) などによって行われてきた が 4, 6), これらは患者の主観的評価であり,FM 患者ではスケールアウトすることもある. 患者が持つ痛みの強さを, 痛みを伴わない電 気刺激による感覚の大きさと比較し, 痛みに対 応する大きさを刺激電流値として定量化する, 痛みの定量化システム (Pain Vision) がニプロ社 より 2007 年に発売され, 痛みを客観的に評価 することが可能となった 2, 3, 14, 16). 今回痛みの定量化システム (Pain Vision) で FM 患者と関節リウマチ (RA) 患者の痛み度を 測定し, 客観的な評価と NRS との関係を比較 検討した. 2. 対象 方法 1) 対象 東京医科大学八王子医療センターに通院して いる米国リウマチ学会 (ACR) の 1990 年の分類 基準 5, 15) を満たす外来の FM 患者 83 人 ( 男性 11 人, 女性 72 人平均年齢 45.9 歳 ),RA 持続的有 痛患者 64 人 ( 男性 12 人, 女性 52 人平均年齢 58.4 歳 ) を対象とした. この研究は, 大学の医学研究倫理審査会の承 認 (No.2375) を得ている. 患者には文書にて同 意を得た上で, 痛みの質問アンケートを行い, NRS スコアの記入をしたと同時に,Pain Vision を用いて, 対象患者の閾値である電流知覚閾値 (μa) と患者が感じている同程度の感覚を与え る電気刺激の量である痛み対応電流 (μa) を測 定し, 痛み度を求めた. 2) 測定方法 患者の前腕内側の肘窩中央と手首中央を結ん だ線の中点で, 内側 1 cm のところに遠位側 の電極が位置するように, ディスポーザブ ル電極 EL-BAND( ニプロ社製 ) を装着する ( 図 1). 電流知覚閾値 ( 閾値 ) の測定 スタートボタンにより刺激電流 ( 痛みを伴わ ない電気刺激 ) を 0 から徐々に増大させ, 患者 に電気刺激の存在を初めて感知したとき, 停止 スイッチを押してもらう. これを数回繰り返 し, 電流知覚閾値の平均を得る. 痛み対応電流値 刺激電流を 0 から次第に増大させ, 患者が持 つ痛みと電気刺激の平衡を感知したとき, ある いは患者の注意が自分の痛みから電極部に移動 したときに停止ボタンを押してもらい, 平均値 から痛み対応電流値を得る. これらの値が 式 1 に当てはめられ, 自動的 に痛み度が表示される. 式 1 痛み度 =100 ( 痛み対応電流 - 電流知覚閾値 ) 電流知覚閾値 本研究では, 電流知覚閾値と痛み度について FM 患者と RA 患者の測定値を比較し,NRS ス コアと痛み度の比較検討をした. 得られたデータに対して,JMP10 (SAS Institute. North Carolina USA) を用いて, Student t-test,wilcoxon rank sum test,fisher s exact test を行った. 3) 結果 人数, 年齢, 測定項目について,FM 患者と RA 患者とを比較した結果を表 1 に示す. 男女 の割合は,FM 患者で女性 86.8%,RA 患者 81.3% でいずれの群も女性が多かった. 年齢 は,FM 患者では 45.9±15.8 歳 ( 平均 ±SD),RA 患者では 58.4±14.6 歳で,FM 患者は有意に低
4 Nippon Rinsho Vol 76,No 11, FM RA 表 1 線維筋痛症 (FM) と関節リウマチ (RA) の比較 人数年齢閾値 (μa) 痛み度 NRS 男性女性男性女性男性女性男性女性男性女性 11(13%) 12 (18.7%) ± ± ± ± (86.8%) 38.7± ± ± ± ± ± ± ± ± ± ± ± (81.3%) 56.3± ± ± ± ± ± ± ±2.0 有意差 p=0.3630( 男女比 ) p< p= p< p= * Wilcoxon rank sum test. 男女比は Fisher の正確検定. ( 平均 ± 標準偏差 ) μ 図 2 女性における 1 次性 FM 患者と 2 次性 FM 患者の閾値の比較 1 次性 FM 患者 7.19±1.24,2 次性 FM 患者 8.43±2.73 有意差はないが (p=0.0779), 女性 1 次性 FM 患者の閾値は低い傾向があった. かった (p<0.0001). 電流知覚閾値 ( 以下閾値 ) は,FM 患者は 8.12 ±2.40 μa,ra 患者では 9.13±3.25 μa で FM 患者の方が低いが, 有意差はなかった (p= ). そこで症例数が十分である女性の FM 患者について,1 次性の FM 患者と他の疾患を合併している 2 次性の FM 患者に分けて閾値を比較したところ, 図 2 に示すように 1 次性 FM 患者での閾値低下傾向が明確になった. 痛み度は FM 患者 ±506.79,RA 患者 ± で,FM 患者では有意に高かった (p<0.0001)( 図 3). 痛み度を男女別にみると, 男性では FM 患者 ±312.94,RA 患者 ±307.23(p=0.0193), 女性では FM 患者 ±526.65,RA 患者 ± (p< ) と男女とも FM 患者で有意に高かった. NRS の平均は FM 患者 5.7±2.0,RA 患者 5.5 ±2.2 と有意差はなかった (p=0.4130).
5 1952 日本臨牀 76 巻 11 号 ( ) 図 3 FM 患者と RA 患者の痛み度の比較 痛み度は FM ±506.79,RA ± で FM が有意に高かった (p<0.0001). 図 4 FM 患者と RA 患者の痛み度 FM 患者は RA 患者に比べ痛み度は有意に高かった.FM では痛み度が 1,000 を超える著高例が 22.9% あった (p<0.0001). 他疾患では通常検出されない値痛み度 1,000 を超える例が,FM 患者で 19 人 (22.9%) 存在し, RA 患者では 2 例 (3.1%) であった 7, 11, 16) ( 図 4). FM 患者において,NRS 7~10(34 人 ) と答え た 26 人 (76.5%) が痛み度 500 以上, そのうちの 10 人 (29.4%) が痛み度 1,000 以上であった. NRS スコアが高いほど痛み度が高いことが示された (p=0.0177)( 図 5).
6 Nippon Rinsho Vol 76,No 11, 図 5 FM 患者の痛み度と NRS スコアの分布 FM 患者において,NRS スコアが高いほど痛み度が高かった (p=0.0177). 3. 結語 FM 患者の痛みの評価は, これまで NRS スコアなどの主観的評価で行ってきたが,Pain Vision による痛み度の測定は客観的な痛みの定量化が可能であり,FM 患者の痛みの評価に優れている 13). NRS の平均値は,FM と RA 患者で差がなかったことは,FM 患者は, 痛みの自己評価がむしろ低い可能性がある 10, 17, 18). 今後,FM 患者の治療経過も明らかにしていきたい. この論文の主旨は, 臨床リウマチ 26 巻 (1), 45-50,2014 年に掲載されている 19). 文 献 1) 有田英子, ほか : 痛みの強さの客観的評価知覚 痛覚定量分析装置.Anesthesia 21 Century, 10: 49-53, ) 有田英子, ほか : 痛みの客観的測定法 :Pain Vision. ペインクリニック 29: , ) 有田英子 : 痛みの診療に用いる検査機器と治療機器 Pain Vision TM. Anesthesia 21 Century, 13: 11-15, ) Bigatti SM, et al: A comparison of pain measures used with patients with fibromyalgia. J Nurs Meas 10: 5-14, ) 厚生労働省研究班 ( 編 ): 線維筋痛症診療ガイドライン 日本リウマチ財団, ) López-Pousa S, et al: Development of a multidimensional measure of fibromyalgia symptomatology: the comprehensive rating scale for fibromyalgia symptomatology. J Psychosom Res 74: , ) 前川紀雅, ほか : 知覚 痛覚定量分析装置 Pain Vision による痛みの評価は可能か? 帯状疱疹による痛みでの検討. 日本臨床麻酔学会誌 29: , ) 松本美富士 : 第 3 章疫学 病態 (1) 線維筋痛症の疫学. 線維筋痛症ハンドブック ( 西岡久寿樹編 ), p56-69, 日本医事新報社, ) 岡寛 : リウマチ性疾患と慢性仏痛, 臨床リウマチ 24: 163, ) 岡寛 : 本邦における線維筋痛症の治療の現状. 東京医科大学雑誌 71: 3-6, 2013.
7 1954 日本臨牀 76 巻 11 号 ( ) 11) 太田周平, ほか : ドラッグチャレンジテストに知覚痛覚定量分析装置 (Pain Vision ) を応用した症例の検討. ペインクリニック 30: , ) Staud R: The neurobiology of chronic musculoskeletal pain (including chronic regional pain). In: Fibromyalgia and Other Central Pain Syndromes (ed by Wallace DJ, Clauw DJ), p45-62, Lippincott Williams &Wilkins, Philadelphia, ) 田邉豊, ほか :Pain Vision で得られる値 ( 電流知覚閾値 痛み対応電流値 痛み度 ) の年齢による影響. ペインクリニック 30: , ) 戸田克広 : 繊維筋痛症を含む chronic widespread pain および chronic regional pain 患者における痛み度を含む評価指標の相関 Pain Vision による痛み度の有用性と限界. 整形 災害外科 54: , ) Wolfe F, et al: The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 33: , ) 山田貴志, ほか : 電気的痛み定量計測器を用いて治療評価を行なった繊維筋痛症の症例. 臨床リウマチ 21: , ) 行岡正雄, 三木健司 : 第 3 章疫学 病態 (2) 線維筋痛症の疫学. 線維筋痛症ハンドブック ( 西岡久寿樹編 ),p70-81, 日本医事新報社, ) Yunus MB: Central sensitivity syndromes: a new paradigm and group nosology for fibromyalgia and overlapping conditions, and the related issue of disease versus illness. Semin Arthritis Rheum 37: , ) 岡寛, ほか : 線維筋痛症の痛み定量化. 臨床リウマチ 26: 45-50, 2014.
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