脑影像视角下手法治疗慢性疼痛的中枢机制研究进展

Advances in Understanding the Central Mechanisms of Manual Therapy for Chronic Pain from a Neuroimaging Perspective

摘要:

慢性疼痛是全球高致残性健康问题，其发生发展与中枢敏化及多脑网络可塑性重塑密切相关。近年来，功能核磁共振成像（functional magnetic resonance imaging，fMRI），尤其是静息态 fMRI（resting-state fMRI，rs-fMRI），以及弥散张量成像（diffusion tensor imaging，DTI）和脑电图（electroencephalography，EEG）等技术，为揭示手法治疗镇痛的中枢机制提供了客观证据。本文围绕慢性疼痛的结构—功能重塑，综述脊柱推拿（spinal manipulative therapy，SMT）、整骨手法（osteopathic manipulative treatment，OMT）与推拿在脑区活动、网络连接及下行疼痛调制通路上的影像学改变。现有研究多提示干预可使默认模式网络（Default Mode Network, DMN）、显著性网络（Salience Network, SN）、中央执行网络（Central Executive Network, CEN）及感觉运动网络（Sensorimotor Network, SMN）的异常活动/连接呈一定“正常化”趋势，但结论受样本量有限、手法剂量与对照/盲法不足、随访时间较短及分析管线异质性等因素制约。未来应加强标准化剂量学与假手法对照设计，开展多时间点纵向随访与多模态整合研究，明确不同疼痛表型的可预测脑标志物，推动手法治疗从经验应用走向机制可解释与精准处方。

Abstract:

Chronic pain is a leading cause of disability worldwide, and its onset and persistence are closely linked to central sensitization and plastic remodeling across distributed brain networks. In recent years, functional magnetic resonance imaging (fMRI)—particularly resting-state fMRI (rs-fMRI)—together with diffusion tensor imaging (DTI) and electroencephalography (EEG), has provided objective evidence to interrogate the central mechanisms underlying manual analgesia. Centered on the structural–functional remodeling of chronic pain, this review synthesizes neuroimaging findings on spinal manipulative therapy (SMT), osteopathic manipulative treatment (OMT), and Tuina, focusing on intervention-related changes in regional brain activity, large-scale network connectivity, and descending pain modulatory pathways. Across studies, manual interventions are frequently associated with partial “normalization” of aberrant activity and connectivity within the default mode network (DMN), salience network (SN), central executive network (CEN), and sensorimotor network (SMN). However, conclusions remain constrained by small sample sizes, variability in treatment dose and protocols, insufficient sham controls and blinding, short follow-up intervals, and heterogeneity in analytic pipelines. Future work should prioritize dose standardization and rigorously designed sham-controlled trials, incorporate multi–time-point longitudinal follow-up and multimodal integration, and identify phenotype-specific, predictive neural biomarkers to advance manual therapy from empiricism toward mechanistically interpretable and precision prescribing.