腰背痛营养策略：蛋白酶、维生素、苯丙氨酸

同义索引：背伤发作，背痛，腰椎间盘突出，腰痛，坐骨神经痛，腰椎间盘滑脱

1.简介

2.一览表

3.症状

4.治疗

5.饮食习惯的改变 

6.生活方式的改变

7.补充剂

8.相关草药

9.整体疗法

10.参考文献

腰部支撑了我们身体的绝大部分重量，因此受伤或遇到其它问题时很容易引起疼痛。80%以上的成人都曾经历过这种腰背痛^[1]，半数以上都会反复发作。

尽管肌张力低、关节问题、肌肉或韧带撕裂是常见的病因，但腰背痛的根本原因通常很难确定。突出或滑脱的腰椎间盘也能导致腰背痛，并能引起坐骨神经痛。坐骨神经痛引起的疼痛通常会向单侧或双侧臀部和/或下肢传导。

过久的站立或坐位，以及好穿高跟鞋都会增加发展至腰背痛的几率。肥胖以及抬运过重的物品容易导致的背伤发作也容易增加腰背痛的发生。将近半数的孕妇都会曾经历一定程度的腰背痛。^[2]而且，长时间的开车也会产生影响，^[3]这可能跟坐在车里长时间的颠簸有关。^[4]

很多犯腰背痛的人没有去看医生或者进行任何治疗就能够恢复，这其中将近90%的人恢复时间都在3到4周内，^[5]但是反复发作也是很常见的，^[6,7,8]并且多数会发展成为慢性腰背痛。^[9]一般地，腰背痛是指急性的，或者仅仅持续几天到几周的短时间病程，而慢性腰背痛特指每次疼痛时间超过3个月。虽然腰背痛并不会威胁生命，但是有慢性或者复发性腰背痛时最好还是向健康卫生专家咨询，听取他们的建议。可能隐藏在症状后面的严重疾病包括：脊髓肿瘤、感染、骨折、神经损伤、骨质疏松症、关节炎或者一些内脏器官发生的病变，如肾等，这些病变也可以引起疼痛。

腰背痛的辅助疗法

腰背痛的症状

这种痛可能是一种持续的痛，或者突然的、急性的锐痛，并且会在活动时变得剧烈。

医药治疗

常规的非甾体类抗炎药(NSAIDs)，例如阿司匹林(Bayer^®, Ecotrin^®, Bufferin^®)，布洛芬 (Motrin^®, Advil^®)，以及萘普生(Aleve^®)，都能够帮助缓解轻度的腰背痛。由于肌肉紧张引起要悲痛的患者可以局部应用甲基水杨酸(Ben-Gay®, Icy Hot®, Flexall Ultra Plus^®) 或者三乙醇胺水杨酸(Aspercreme^®, Myoflex^®)。

有时候可能需要属于处方药物的较强的非甾体类抗炎药，诸如布洛芬 (Motrin^®)，萘普生(Naprosyn^®, Anaprox^®)，消炎痛(Indocin^®)，双氯芬酸钾(Voltaren^®)， 以及依托度酸(Lodine^®)。中到重度疼痛可能需要合并使用麻醉药与对乙酰氨基酚，例如可待因(Tylenol^® with Codeine)，重酒石酸氢可酮(Vicodin^®, Lortab^®)，以及 羟考酮(Percocet^®)。

热敷与冷敷，休息，强化训练与适应性训练，物理疗法，以及指导良好的姿势以及机体生理机制，均可以包含到常规治疗方案中。对某些情况，可能要推荐进行背部手术。

可能有益的生活方式

吸烟

初步研究显示，吸烟可能会造成腰背痛。^[10]一项对超过29,000人的调查显示吸烟与腰背痛之间有着很大的联系。^[11] 尤其，“较小”的人（儿童，女性，体重低者）最受影响。一项关于腰椎间盘突出患者的研究发现，与不吸烟者相比，吸烟者或者以前吸烟后来戒烟的人得腰椎间盘疾病的几率更高。^[12]还有一些研究显示，与不吸烟者相比，吸烟的人发生下脊柱腰椎间盘退行性病变时要严重18%。^[13]从原理上看，吸烟会导致椎间盘的营养不良，因此使椎间盘更容易受机械性损伤。^[14]

饮酒

一项调查显示，与不饮酒者相比，饮酒者在经历腰背部的椎间盘手术后恢复更快。^[15]但是，饮酒也会导致肝硬化、癌症、高血压、以及酒精中毒。由此可见，即使中量饮酒对健康有不少好处，许多医生也从不推荐饮酒。但是少量饮酒会不会对腰椎间盘手术后恢复有帮助的问题，最好还是咨询医生。

锻炼

规律的锻炼以及适当的抬举重物的技巧能帮助防止腰背问题的产生。适当抬举，应该保持被抬举的物体靠近身体，以避免抬举时需要向前弯腰、延伸以及扭转。与经常活动的人相比，惯于久坐的人更容易发生腰背痛和椎间盘的退行性变。^[16]然而，另一个极端——长期从事竞技体育也可以造成椎间盘的退行性变。^[17]

治疗性锻炼

治疗性锻炼能帮助腰背痛患者^[18]以及腰背手术患者^[19]恢复。但是具体应该如何做才能获得最大好处目前仍不清楚。也就是说，最适宜的锻炼方式、频率、持续时间以及合适的开展实际仍然有待确定。一项研究表明，与未经专业指导的家庭锻炼相比，治疗性锻炼能够显著改善慢性腰背痛。^[20]另一项实验发现患有慢性腰背痛的妇女中，与在家庭进行持续治疗性锻炼者相比，在健身中心进行指导下的腰背锻炼者更能坚持锻炼。^[21]两组患者的疼痛均获得显著改善。但是，在指导下进行锻炼的患者能够更好的长期改善。

动机训练

尽管抬举重物和其他劳作可以导致腰背痛，一项试验发现，与中或重体力劳动者相比，从事长时间坐位工作的人能从锻炼项目中获得更多的好处。^[22]动机训练可以增加锻炼的持续性，进而减轻疼痛，减少致残的可能。^[23]腰背痛患者如果想进行有计划的锻炼，最好先向物理治疗师或者其他该领域内有经验的医师进行咨询。

对于急性腰背痛患者，医生们经常推荐督导下的卧床休息2到4天，同时行合理的物理治疗以及治疗性锻炼。^[24]但是，对卧床休息的建议进行的综述发现，卧床休息至多是无效的，甚至有可能延长恢复时间。^[25,26]如果能够保持活动，尽可能保持日常的日程安排，则是最有好处的。

对于正在恢复期的腰背痛患者，一般推荐穿着舒适的低跟鞋，座椅应当选择能够对腰部提供良好支持的样式，同时配套的桌面最好是舒适的高度，如果长时间站立的话，应该让一条腿试着踩在矮点的物体上休息，长时间开车的话则应找些东西来支持背部。^[27]

可能有益的营养补充剂

胰岛素与胰乳蛋白酶复合酶制剂

三个双盲试验发现，对伴或不伴有腿痛的腰背痛患者补充7至10天的胰岛素与胰乳蛋白酶复合酶制剂是非常有效果的。起始剂量在所有试验中都是每天8片，但在其中两个试验中，经过2至3天后剂量减为每天4片。其中一个试验报道在一些下脊柱退行性关节炎的患者中发现补充酶复合制剂在某些方面有一些效果，虽然有统计学意义，但是效果是相对比较小的。^[28]另一个试验发现对于坐骨神经痛的患者，酶复合制剂在某些方面有显著的改善。^[29]但是另一项试验发现酶复合制剂并不比安慰剂更加有效。^[30]另外，这些试验中均纳入了慢性腰背痛的患者，因此它们与急性腰背痛单独的相关性受限。

D-苯丙氨酸(DPA)

几个动物实验和人体相关试验表明，人工合成的天然氨基酸苯丙氨酸，也就是D-苯丙氨酸(DPA)，能够通过减少降解endophrin(一种类似吗啡的化学成分，其明显的作用是阻碍我们的身体向大脑总指挥处传达痛苦的讯号)的酶而缓解疼痛。^[31]有少量试验报道了D-苯丙氨酸(DPA)对腰背痛患者有效，^[32]包括一个非对照试验报道了有37名腰背痛患者，其中27名患者都诉说获得了“比较好或非常好的缓解”，^[33]但是目前D-苯丙氨酸(DPA)是否对腰背痛患者有效仍不清楚。在一项双盲试验中，德克萨斯大学的研究者们发现，对于30名各种类型慢性疼痛的患者，给予250毫克D-苯丙氨酸(DPA)每天4次服用4周，并不比安慰剂更有效果，30名受试者中有13名是腰背痛患者。^[34]在日本进行的一项临床研究中，在慢性腰背痛患者接受针灸治疗前给予D-苯丙氨酸每天4克，^[35]尽管结果没有统计学意义，但是结果30名受试者中有18名认为感觉比较好或者非常好。常用的作为营养补充的苯丙氨酸是D,L-苯丙氨酸(DLPA)，医生推荐的典型剂量是1,500到2,500毫克每天。

维生素B1、B6和B12

双盲试验已经证明，维生素B1、B6和B12的联合使用能够有效地用于预防脊柱疾病相关的普通类型的腰背痛，^[36]并且能够有效减少那些用来控制腰背疼痛感的抗炎药物的用量。^[37]常用的剂量是维生素B1和B6各50到100毫克、维生素B12 250到500毫克，均为每天三次。^[38,39]但要注意，使用如此大剂量维生素B6时应该在医生指导下进行。

蛋白水解酶

蛋白水解酶，包括菠萝蛋白酶、木瓜蛋白酶、胰岛素和胰凝乳蛋白酶，在治疗轻微的创伤方面很有经验，因为它们既有抗击炎症的能力又能够从胃肠道很好的吸收。^[40,41,42]有初步研究报道，在各种疾病的患者中，使用菠萝蛋白酶^[43,44,45]或木瓜蛋白酶^[46,47,48]能够减轻疼痛和水肿，或者使他们恢复得更快。

维生素C

1964年报道的一项研究表明，每天500到1,000毫克维生素C能帮助许多腰椎间盘相关性腰背痛的患者避免手术。^[49]但还没有对照试验进一步验证这个结论。

有无副作用及药物之间相互作用呢？

参见各种补充剂的副作用及相互作用。

可能有益的草药

秋水仙碱

从秋番红花中提取的秋水仙碱对椎间盘突出造成腰背痛的患者有一定效果。综述显示，秋水仙碱能够缓解椎间盘疾病引起的疼痛、肌肉痉挛以及虚弱，^[50,51]数个双盲试验也正是了这一点。^[52]这些报道的作者指出，对于椎间盘疾病的患者，给予秋水仙碱每天0.6到1.2毫克的剂量，10名患者中有4名症状能够有显著改善。多数临床试验中，秋水仙碱是经静脉给予的。^[53]但是，口服给药也能获得中等效果。由于有严重副作用，腰背痛患者在使用秋水仙碱之前应该咨询有经验的草药医师。

柳树皮

柳树皮传统用于治疗疼痛和炎症情况。根据一项对照临床研究，使用大剂量柳树皮提取物对腰背痛患者有帮助。一项研究发现，治疗腰背痛加重时，与120毫克从柳树皮中提取的水杨苷或者安慰剂相比，240毫克水杨苷更加有效。^[54]

辣椒粉

局部应用辣椒粉来减轻疼痛已经沿用几个世纪了，近来也被用于治疗多种疾病引起的局部疼痛，^[55]包括慢性的疼痛，^[56]尽管并没有专门研究腰背痛。辣椒乳剂常含有0.025%到0.075%的辣椒素。^[57]刚开始使用时，辣椒乳剂会导致局部烧灼感，但是随着多次使用，这种感觉会减轻。当用药使得能够诱导产生疼痛的P物质耗竭时，也能加强疼痛的缓解。^[58]为了避免污染口腔、鼻腔或眼睛，使用辣椒乳剂时应该佩戴手套或者事后完毕彻底洗手。不可将辣椒乳剂用于破损的皮肤。

钩果草

一项双盲试验发现，钩果草胶囊（含有800毫克浓缩提取物，每天服用三次）对减轻部分急性腰背痛患者的症状有帮助。^[59]另一项关于慢性腰背痛加重患者的双盲研究（200毫克或400毫克钩果草提取物，每天三次）在部分患者中获得了相似的结果。^[60]

生姜

草药学家们常用生姜来减轻炎症以及由炎症引起的疼痛，包括那些能够引起腰背痛的炎症。推荐常用剂量为：1.5到3毫升生姜酊剂每天服用三次，或者2到4克干生姜根粉每天两到三次。有些产品含有姜黄素和生姜。不过，没有研究调查过这些草药对于腰背痛的效果。

桉树油和薄荷油

桉树油和薄荷油的混合制剂直接涂抹于疼痛的部位可能有一定效果。初步研究表明，这些具有反刺激剂（药物，敷于皮肤上引起疼痛感觉，以减轻他处更加强烈的疼痛）性质的精油能够减轻疼痛，并且增加疼痛部位的血液循环。^[61]薄荷油和桉树油稀释后涂抹于患处，一天数次或者按需使用，以控制疼痛。有相似功能的植物油还包括迷迭香、刺柏和鹿蹄草。

姜黄

姜黄是另一种传统使用的、有抗炎作用的草药，可能对腰背痛的患者有一定效果。几个基础研究证实，姜黄素——姜黄中的活性成分——在人体^[62]或动物^[63,64]均能减轻炎症。在一个双盲试验中，一种含有姜黄、其他草药以及锌的配方能够显著减轻骨关节炎患者的疼痛。^[65]标准的提取物每片或胶囊含有400到600毫克姜黄，每天服用三次。姜黄的酊剂常用剂量为0.5到1.5毫升每天。

有无副作用及药物之间相互作用呢？

参见各种草药的副作用及相互作用。

可能有用的整体疗法

针灸

针灸对部分要同患者的治疗有一定帮助。一些个案报道^[66,67]和不少初步研究^{[68,69,70,71,72,73,74]}说明，经过针灸（或针灸加电刺激），急性或慢性腰背痛都有显著改善。一项单对照研究表明，电针灸和药物治疗（对乙酰氨基酚）能够显著减轻疼痛和改善功能。^[75]

一些临床对照研究评价了针灸对于慢性腰背痛的作用。其中一项对照研究发现，对于疼痛和一些物理体征，针灸明显比安慰剂有效四到五倍。^[76]研究电针灸的对照试验则报道对于慢性腰背痛，电针灸有好处^[77]或没有明显好处^[78]。一项双盲试验比较针灸和在非针灸部位皮下注射麻醉剂，结果发现两种疗法效果上没有差异。^[79]对照试验比较针灸和经皮神经刺激(TENS)，结果其中一些^[80,81]，但不是所有的^[82]，证实使用针灸者比使用TENS者疼痛缓解更加显著，其中一项发现使用针灸疗法者脊柱活动功能有改善。^[83]

在一项初步研究中发现，对于腰背痛的孕妇，在减轻疼痛和降低致残方面，针灸比物理疗法更有效。^[84]

最近对一些研究的分析和综述报道，针灸对于腰背痛是有效的，^[85]但是另一项最近的综述得出的结论是，由于研究的质量太低，结论并不可信，因而不推荐针灸疗法。^[86]第三份综述的结论是，对于腰椎间盘脱出或者坐骨神经痛的患者，针灸疗法至少可以作为一种补充疗法。^[87]由于关于针灸疗法的大量对照研究针对的是慢性腰背痛，因此急性腰背痛的患者能否从针灸中获得益处仍不清楚。^[88]

脊柱矫形

联邦政府赞助的卫生健康政策和研究所（Agency for Health Care Policy and Research）认为脊柱矫形对于在发生损伤后一个月以内的急性腰背痛是有效的。^[89]这种观点由一些研究支持，但是其中一些研究没有很好的对照。^[90,91]长期持续疼痛者或慢性腰背痛者可以从脊柱矫形中获得帮助，但是中到重度疼痛或活动受限的患者似乎能从中获得最好效果。^[92,93]一项为期12个月的对照研究发现脊柱矫形与标准的物理治疗效果没有明显差异。^[94] 另一项对照研究发现，由一系列八种疗法组成的脊柱矫形与传统的药物治疗一样有效，但是接受矫形治疗组需要的镇痛治疗和物理治疗更少。^[95]能够进行脊柱矫形治疗的医师包括脊柱指压治疗师，一些整骨治疗师，以及一些理疗师。

一些研究者认为患有椎间盘突出或滑脱的患者不应该进行脊柱矫形治疗，因为这种疗法可能导致脊髓损伤。^[96]尽管如此，其他的一些初步研究表明，脊柱矫形对于椎间盘突出患者有效^{[97,98,99,100]}，一项对照试验比较了脊柱矫形疗法与标准的物理疗法，也得出相同的结论。^[101]一项研究调查了59名椎间盘滑脱的患者，他们接受了包括脊柱矫形疗法在内的脊柱指压疗法，结果报道90%患者有改善。^[102]有腰部手术史的患者预后较差。椎间盘突出的腰背痛患者如果想尝试此种疗法，应该先咨询脊柱指压治疗师或者其他有经验的理疗师。最近一项对照研究比较了脊柱矫形、针灸以及药物治疗对于慢性脊柱疼痛的效果，结果发现只有脊柱矫形显著改善疼痛和残疾评分。^[103]

按摩

有些证据表明按摩能够帮助腰背痛的患者，但是初步研究尚无法确定这种作用是否存在。^[104]许多医师将按摩与其他理疗方法相结合，如脊柱矫形或治疗性锻炼等。腰背痛患者如果想进行按摩治疗，应该先咨询有资质的按摩治疗师。

生物反馈疗法

一些对照研究显示生物反馈疗法对于慢性腰背痛患者有效^[105,106]，但是另一些研究则未能证明其有效性。^[107,108]一个研究发现，与行为疗法或药物保守治疗相比，生物反馈疗法对慢性腰背痛患者更有效。这个研究还发现，随访两年后，生物反馈疗法是唯一的一种能令患者感觉疼痛显著减轻的方法。^[109]想要尝试生物反馈疗法的患者应该咨询一个有资质的医师。

情感压力

情感压力与腰背痛加重是有关联的^[110]，椎间盘突出引起的腰背痛也包括在内。^[111]这种为缓解情感压力进行的社会心理咨询对于腰背痛的效果目前尚不够清楚，但是一些雇用了多专业医师的诊所也偏好采用这种方法治疗慢性腰背痛，说明是有一定临床意义的，不可忽视。

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