脊柱疾病懸吊課件

1、脊柱疾病的康復(fù)治療,江蘇省人民醫(yī)院康復(fù)醫(yī)學(xué)科卞 榮,國(guó)際疼痛研究學(xué)會(huì)的疼痛定義為：,疼痛是一種不愉快的感覺(jué)和情感體驗(yàn)，與真實(shí)的或潛在的組織損傷有關(guān)，疼痛一詞用來(lái)描述這類損傷慢性疼痛的持續(xù)時(shí)間超過(guò)3個(gè)月，伴有日常生活和/或工作活動(dòng)時(shí)的顯著功能障礙,下腰痛（LBP）的明確特異性解剖診斷的意義遠(yuǎn)不如在下腰痛綜合征中那樣重要： 絕大多數(shù)患者的癥狀可在一周內(nèi)緩解，只有少數(shù)患者的癥狀6~8周后仍持續(xù)存在?？紤]到非特異性下腰痛的自然史，即

2、絕大多數(shù)患者的癥狀均可自發(fā)緩解，因此大多無(wú)需明確的解剖診斷,,,下腰痛的流行病學(xué),人類一生中的發(fā)生率為69%~90%下腰痛是造成45歲以下人群功能障礙的主要原因是造成45歲以上人群功能障礙的第三位原因,,,,,脊柱的相關(guān)韌帶,,,,脊柱的韌帶,長(zhǎng)期舉重物可導(dǎo)致脊柱韌帶復(fù)合體（棘上韌帶、棘間韌帶、后縱韌帶、前縱韌帶和黃韌帶）承受應(yīng)力黃韌帶含有神經(jīng)末梢后縱韌帶含有大量受竇椎神經(jīng)（腹腔內(nèi)臟支和自主神經(jīng)灰支交通）支配的游離神經(jīng)末梢前縱

3、韌帶受灰支交通支和腹支的支配,,C:\Documents and Settings\Administrator\桌面\頸腰生物力學(xué)\6.JPG,,,椎間盤(pán),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,脊柱關(guān)節(jié)的運(yùn)動(dòng),,,,,,,,,,,,,,,,,,,,,,脊柱的相關(guān)肌群,,肌力測(cè)量的主要肌肉,L2、L3－髖屈肌L3、L4－膝伸肌L4、L5－踝背屈肌L5－踇背伸肌S1－踝跖屈肌,,,,,,,,,,,,,,,,,,,

4、,,,,,,,,,,,,背深層肌肉,背深層肌（即背固有?。┡c頸后肌延續(xù)，包括深層的橫突棘肌群和較淺層的豎脊肌群。它們的功能是伸脊柱和防止脊柱塌陷。腰方肌、腰大肌、背闊肌、腹內(nèi)斜肌、腹橫肌和胸腰筋膜均輔助上述功能。,枕下肌-夾肌,頭夾肌：起于項(xiàng)韌帶下部及C7、T1-T3椎體的棘突，止于上項(xiàng)線下部及顳骨乳突。頸夾?。浩鹩赥3-T6棘突，止于C1-C3橫突。一側(cè)收縮時(shí)可使頭向同側(cè)屈和回旋，同時(shí)收縮可使頭頸伸直,從內(nèi)側(cè)到外側(cè)分別稱棘肌、最長(zhǎng)

5、肌和髂肋肌 起于骶骨背面、髂嵴后部、腰椎棘突和胸腰筋膜，止點(diǎn)棘肌止于頸胸椎棘突、最長(zhǎng)肌止于頸胸椎橫突和顳骨乳突，髂肋肌止于肋骨的肋角。功能：兩側(cè)的頸豎脊肌收縮使寰枕關(guān)節(jié)和脊柱頸部的后伸，一側(cè)收縮則產(chǎn)生側(cè)屈,,,,,,,前外側(cè)軀干肌,腹直?。呵|干 腹外斜肌 ：為一側(cè)收縮使軀干轉(zhuǎn)向?qū)?cè)，并向同側(cè)屈曲。腹內(nèi)斜肌 ：為一側(cè)收縮軀干屈向同側(cè)，并旋轉(zhuǎn)軀干向?qū)?cè)的肩。腹橫肌 ：增加腹壓 肋間外肌和肋間內(nèi)肌 ：提肋和降肋 膈：吸氣,,,

6、胸腰筋膜,也稱胸背筋膜，是一強(qiáng)健的復(fù)合結(jié)構(gòu)，它像一條巨大的韌帶連結(jié)肋、椎骨、髂骨和骶骨之間，還連結(jié)后椎骨間韌帶系統(tǒng)和三塊軀干肌。這筋膜系統(tǒng)提供提舉重物越過(guò)頭和用高速投擲物體時(shí)穩(wěn)定軀干的特殊能力,,,,,,,,,"核心" （core）,“核心”這個(gè)名詞最早在康復(fù)醫(yī)學(xué)和運(yùn)動(dòng)醫(yī)學(xué)領(lǐng)域廣泛討論有10多年。Behm在2010年提出：解剖的“核心”為中軸骨（包括脊柱、肩帶和骨盆帶）以及與中軸骨相關(guān)的所有的軟組織（韌帶、肌腱和肌

7、肉等）。,3、Behm, D.G.B.D.G., et al., The use of instability to train the core musculature.,何為“核心（core）”,,,,,,核心肌群的分類,,5、Bergmark, A., Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl,

8、 1989. 230: p. 1-54.,近來(lái)很多研究認(rèn)為腹橫肌與多裂肌是脊柱穩(wěn)定的最主要的肌肉[7, 8],7.Cholewicki J, Simons AP, Radebold A. Effects of external trunk loads on lumbar spine stability. J Biomech. 2000; 33(11): 1377.8.Fredericson M, Moore T. Core stabi

9、lization training for middle and long distance runners. New Stud Athl. 2005; 20: 25-37.,核心穩(wěn)定(Core Stability),“核心穩(wěn)定”就是指身體控制中軸骨上各關(guān)節(jié)鏈的機(jī)械穩(wěn)定能力[2, 4]。脊柱受到干擾后幫助恢復(fù)平衡的能力可在運(yùn)動(dòng)中穩(wěn)定和維持人體脊柱、骨盆、髖關(guān)節(jié)牢固性3 核心穩(wěn)定性的優(yōu)劣取決于位于核心部位的肌肉、韌帶和結(jié)締組織的力量

10、以及它們之間的協(xié)作。,2.Hodges, P.W. and C.A. Richardson, Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis.3、楊宇, 馬繼政, 張仁祥, 韓峰. 關(guān)于體育運(yùn)動(dòng)中核心穩(wěn)定性訓(xùn)練

11、之研究. 南京體育學(xué)院學(xué)報(bào): 自然科學(xué)版. 2008; (2): 25.,The beliefs,That certain muscles are more important for stabilisation of the spine, in particular transverses abdominis (TA).That weak abdominal muscles lead to back painThat streng

12、thening abdominal or core muscle can reduce back painThat a strong core will prevent injury.,,,,,,,,,,,,,,,Passive stability,,,,,,,,,,,,,,,Active stability,,,,,,,,,,Serge Gracovetsky’s “controlled instability”,,Serge Gr

13、acovetsky 2005 Stability or controlled instability? Evolution at work. In: Movement, Stability and Lumbo Pelvic Pain 2nd Edition – Ch14,“It was also proposed that the width of the neutral zone was related to the stabilit

14、y of the joint. These conclusions were drawn from cadaver experiments and mathematical models on which an extensive amount of damage had to be inflicted to the joint before an unstable response was obtained. So far, th

15、e neutral zone argument has remained academic.”,,During movement, muscle that are “not working” are just as important as muscles that are working!,Complexity of trunk stabilisation,CONCLUSIONS: No single muscle dominated

16、 in the enhancement of spine stability, and their individual roles were continuously changing across tasks. Clinically, if the goal is to train for stability, enhancing motor patterns that incorporate many muscles rather

17、 than targeting just a few is justifiable. Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 2004 Jun 1;29(11):1254-65.,,Stability is o

18、nly another motor control pattern,,,Skills,Composite abilities,Contraction abilities,Force (static & dynamic), velocity and length,Balance, motor relaxation, coordination, fine control, reaction time, transition rate

19、,reciprocal activation(Movement),,Motor complexity,,Co-contraction (Stability, dynamic / static),,Synergetic abilities,Lederman E 2005 Science and Practice of Manual Therapy, Elsevier.,,,Increase in spinal compression

20、Reduce range of movementIncrease energy expenditure,Increase co-contraction,Increase stability,,,,,,A study proving that you can’t learn to play the piano by practicing on a banjo….Stanton, R., Reaburn, P. R. & H