1、脊柱疾病的康复治疗,江苏省人民医院康复医学科卞 荣,国际疼痛研究学会的疼痛定义为：,疼痛是一种不愉快的感觉和情感体验，与真实的或潜在的组织损伤有关，疼痛一词用来描述这类损伤慢性疼痛的持续时间超过3个月，伴有日常生活和/或工作活动时的显著功能障碍,下腰痛（LBP）的明确特异性解剖诊断的意义远不如在下腰痛综合征中那样重要： 绝大多数患者的症状可在一周内缓解，只有少数患者的症状68周后仍持续存在。考虑到非特异性下腰痛的自然史，即绝大多数患者的症状均可自发缓解，因此大多无需明确的解剖诊断,下腰痛的流行病学,人类一生中的发生率为69%90%下腰痛是造成45岁以下人群功能障碍的主要原因是造成45岁以上人群
2、功能障碍的第三位原因,脊柱的相关韧带,脊柱的韧带,长期举重物可导致脊柱韧带复合体（棘上韧带、棘间韧带、后纵韧带、前纵韧带和黄韧带）承受应力黄韧带含有神经末梢后纵韧带含有大量受窦椎神经（腹腔内脏支和自主神经灰支交通）支配的游离神经末梢前纵韧带受灰支交通支和腹支的支配,C:Documents and SettingsAdministrator桌面颈腰生物力学6.JPG,椎间盘,脊柱关节的运动,脊柱的相关肌群,肌力测量的主要肌肉,L2、L3髋屈肌L3、L4膝伸肌L4、L5踝背屈肌L5踇背伸肌S1踝跖屈肌,背深层肌肉,背深层肌（即背固有肌）与颈后肌延续，包括深层的横突棘肌群和较浅层的竖脊肌群。它们的功
3、能是伸脊柱和防止脊柱塌陷。腰方肌、腰大肌、背阔肌、腹内斜肌、腹横肌和胸腰筋膜均辅助上述功能。,枕下肌-夹肌,头夹肌：起于项韧带下部及C7、T1-T3椎体的棘突，止于上项线下部及颞骨乳突。颈夹肌：起于T3-T6棘突，止于C1-C3横突。一侧收缩时可使头向同侧屈和回旋，同时收缩可使头颈伸直,从内侧到外侧分别称棘肌、最长肌和髂肋肌 起于骶骨背面、髂嵴后部、腰椎棘突和胸腰筋膜，止点棘肌止于颈胸椎棘突、最长肌止于颈胸椎横突和颞骨乳突，髂肋肌止于肋骨的肋角。功能：两侧的颈竖脊肌收缩使寰枕关节和脊柱颈部的后伸，一侧收缩则产生侧屈,前外侧躯干肌,腹直肌：屈躯干 腹外斜肌 ：为一侧收缩使躯干转向对侧，并向同侧屈
4、曲。腹内斜肌 ：为一侧收缩躯干屈向同侧，并旋转躯干向对侧的肩。腹横肌 ：增加腹压 肋间外肌和肋间内肌 ：提肋和降肋 膈：吸气,胸腰筋膜,也称胸背筋膜，是一强健的复合结构，它像一条巨大的韧带连结肋、椎骨、髂骨和骶骨之间，还连结后椎骨间韧带系统和三块躯干肌。这筋膜系统提供提举重物越过头和用高速投掷物体时稳定躯干的特殊能力,核心 （core）,“核心”这个名词最早在康复医学和运动医学领域广泛讨论有10多年。Behm在2010年提出：解剖的“核心”为中轴骨（包括脊柱、肩带和骨盆带）以及与中轴骨相关的所有的软组织（韧带、肌腱和肌肉等）。,3、Behm, D.G.B.D.G., et al., The u
5、se of instability to train the core musculature.,何为“核心（core）”,核心肌群的分类,5、Bergmark, A., Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl, 1989. 230: p. 1-54.,近来很多研究认为腹横肌与多裂肌是脊柱稳定的最主要的肌肉7, 8,7.Cholewicki J, Simons AP, Radebold A. Effects of external trunk loads
6、on lumbar spine stability. J Biomech. 2000; 33(11): 1377.8.Fredericson M, Moore T. Core stabilization training for middle and long distance runners. New Stud Athl. 2005; 20: 25-37.,核心稳定(Core Stability),“核心稳定”就是指身体控制中轴骨上各关节链的机械稳定能力2, 4。脊柱受到干扰后帮助恢复平衡的能力可在运动中稳定和维持人体脊柱、骨盆、髋关节牢固性3 核心稳定性的优劣取决于位于核心部位的肌肉、韧带
7、和结缔组织的力量以及它们之间的协作。,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、杨宇, 马继政, 张仁祥, 韩峰. 关于体育运动中核心稳定性训练之研究. 南京体育学院学报: 自然科学版. 2008; (2): 25.,The beliefs,That certain muscles are
8、 more important for stabilisation of the spine, in particular transverses abdominis (TA).That weak abdominal muscles lead to back painThat strengthening abdominal or core muscle can reduce back painThat a strong core will prevent injury.,Passive stability,Active stability,Serge Gracovetskys “control
9、led instability”,Serge Gracovetsky 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 stability of the joint. These conclusions were drawn from cadaver
10、 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, the neutral zone argument has remained academic.”,During movement, muscle that are “not working” are just as important as muscles that are wo
11、rking!,Complexity of trunk stabilisation,CONCLUSIONS: No single muscle dominated 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
12、 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 only another motor control pattern,Skills,Composite abilities,Contraction abilities,
13、Force (static & dynamic), velocity and length,Balance, motor relaxation, coordination, fine control, reaction time, transition rate,reciprocal activation(Movement),Motor complexity,Co-contraction (Stability, dynamic / static),Synergetic abilities,Lederman E 2005 Science and Practice of Manual Therap
14、y, Elsevier.,Increase in spinal compressionReduce range of movementIncrease energy expenditure,Increase co-contraction,Increase stability,A study proving that you cant learn to play the piano by practicing on a banjo.Stanton, R., Reaburn, P. R. & Humphries, B. (2004). The effect of short-term Swiss ball training on core stability and running economy. J Strength Cond Res 18, 522-528.,上交叉综合症,下交叉综合症,下腰痛的悬吊治疗,核心稳定训练,
