神經(jīng)肌肉重建技術(shù)的基本理論與基本技

1、神經(jīng)肌肉重建技術(shù)的基本理論與基本技術(shù),北京積水潭醫(yī)院康復(fù)科 郭險(xiǎn)峰,一 難題,,局部穩(wěn)定性下降運(yùn)動(dòng)感覺(jué)功能下降肌肉力量下降肌肉萎縮心血管功能下降,慢性運(yùn)動(dòng)系統(tǒng)疾病,,,,在各種原因?qū)е碌碾x職患者中，骨與肌肉損傷/疼痛占40%以上在為期四周的時(shí)間內(nèi)，可能會(huì)有50%的成年人遭受各種疼痛骨與肌肉損傷/疼痛導(dǎo)致巨大經(jīng)濟(jì)損失,術(shù)后疼痛導(dǎo)致肌肉功能抑制,,疼痛可導(dǎo)致肌肉功能和活躍性抑制.,Mosel

2、ey 2004Cheong 2003Hodges 2003Graven-Nielsen 2002Le Pera 2001Sohn 2000,Botti M, Bucknall T, Manias E. The problemof postoperative pain: issues for futureresearch. Int J Nurs Pract. 2004;10(6):257-63.,Neuromuscular

3、 Activation and Training,研究證明疼痛與神經(jīng)肌肉功能的失活關(guān)系密切深部核心穩(wěn)定肌肉和整體穩(wěn)定肌肉的失活實(shí)際發(fā)行疼痛和功能障礙的原因恢復(fù)這些神經(jīng)肌肉功能可以緩解和解除疼痛,,,瑜珈練習(xí),,主動(dòng)運(yùn)動(dòng)裝置（功能訓(xùn)練＋運(yùn)動(dòng)控制訓(xùn)練）,在逐級(jí)遞增負(fù)荷的背伸運(yùn)動(dòng)中，隨著肌肉收縮對(duì)抗負(fù)荷阻力的增大，L5～S1節(jié)段多裂肌的肌電振幅相應(yīng)增加L5～S1節(jié)段多裂肌在逐級(jí)

4、遞增負(fù)荷軀干旋轉(zhuǎn)運(yùn)動(dòng)中，隨著肌肉收縮對(duì)抗負(fù)荷阻力的增大，多裂肌肌電振幅相應(yīng)增加。軀干左旋運(yùn)動(dòng)時(shí)，左側(cè)豎脊肌激活程度大于右側(cè)，而右側(cè)多裂肌激活程度大于左側(cè)；軀干右旋運(yùn)動(dòng)時(shí)，右側(cè)豎脊肌激活程度大于左側(cè)，而左側(cè)多裂肌激活程度大于右側(cè)。,動(dòng)態(tài)平衡練習(xí),CNS控制的改變是肌肉功能改變的原因,Cheong JY, Yoon TS, Lee SJ. Evaluations of inhibitory effect on the motor corte

5、x by cutaneous pain via application of capsaicin. Electromyogr Clin Neurophysiol. 2003;43(4):203-10. Farina S, Valeriani M, Rosso T, Aglioti S, Tamburin S, Fiaschi A, Tinazzi M.. Transient inhibition of the human motor

6、 cortex by capsaicin-induced pain. A study with transcranial magnetic stimulation. Neurosci Lett. 2001;314(1-2):97-101Graven-Nielsen T, Lund H, Arendt-Nielsen L, Danneskiold-Samsoe B, Bliddal H. Inhibition of maximal v

7、oluntary contraction force by experimental muscle pain: a centrally mediated mechanism. Muscle Nerve 2002;26:708-712 Le Pera D, Graven-Nielsen T, Valeriani M, Oliviero A, Di Lazzaro V, Tonali PA, Arendt-Nielsen L. Inh

8、ibition of motor system excitability at cortical and spinal level by tonic muscle pain. Clin. Neurophysiol. 2001;112(9):1633-41.,CNS的雙重運(yùn)動(dòng)控制策略,二 革命性的進(jìn)展,,x,由挪威的醫(yī)生和PT師與其他國(guó)家的康復(fù)工作者共同研究與 開(kāi)發(fā)成功 14年的經(jīng)驗(yàn) 基于科學(xué)理論和具體研究 一種全新的治療

9、和訓(xùn)練體系,S-E-T的背景,局部穩(wěn)定性下降運(yùn)動(dòng)感覺(jué)功能下降肌肉力量下降肌肉萎縮心血管功能下降,慢性運(yùn)動(dòng)系統(tǒng)疾病,,,診斷處理傳統(tǒng)治療專項(xiàng)治療穩(wěn)定性訓(xùn)練運(yùn)動(dòng)感覺(jué)訓(xùn)練力量訓(xùn)練- 閉鏈訓(xùn)練- 開(kāi)鏈訓(xùn)練耐力訓(xùn)練家庭訓(xùn)練/團(tuán)體訓(xùn)練隨訪,,,,功能性運(yùn)動(dòng)中協(xié)同運(yùn)動(dòng)的肌肉群中，某塊肌肉太薄弱以致于不能與其他肌肉一同工作(A muscle that is too weak to do it´s sh

10、are of the work when it is supposed to work along with other muscles in a functional activity),“弱鏈”,定義:,弱鏈測(cè)試,在閉鏈運(yùn)動(dòng)中測(cè)試陽(yáng)性表現(xiàn)為: 疼痛不能正確完成動(dòng)作左右側(cè)表現(xiàn)不一致,Kirkesola 2000,弱鏈測(cè)試,在患者可以完成動(dòng)作的水平上開(kāi)始 緩慢增加負(fù)荷直到患者在完成動(dòng)作時(shí)出現(xiàn)問(wèn)題. 在喪失穩(wěn)定性的測(cè)

11、試水平上作標(biāo)記,,,,杠桿臂,負(fù)荷的調(diào)整,增加力矩：支點(diǎn)的調(diào)整和負(fù)荷的增加增加時(shí)間：改變支撐面的穩(wěn)定性：改變動(dòng)作的對(duì)稱性：增加額外的動(dòng)作：,. 訓(xùn)練內(nèi)容,關(guān)節(jié)活動(dòng)度力量訓(xùn)練肌肉耐力穩(wěn)定性 運(yùn)動(dòng)感覺(jué)訓(xùn)練,放松,Traction of the back,肩關(guān)節(jié)漸進(jìn)訓(xùn)練,髖關(guān)節(jié)漸進(jìn)訓(xùn)練,,S-E-T,老年康復(fù),對(duì)運(yùn)動(dòng)系統(tǒng)疾病的預(yù)防和治療,兒童疾病的早期預(yù)防和治療,,,,針對(duì)公司員工的健康管理,運(yùn)動(dòng)員,,,三 獨(dú)特之處——神

12、經(jīng)肌肉訓(xùn)練技術(shù)的基本原則,,CNS的雙重運(yùn)動(dòng)控制策略,什么是Neurac技術(shù):介助于S-E-T® (Sling Exercise Therapy) 系統(tǒng)，通過(guò)高水平的神經(jīng)肌肉刺激恢復(fù)肌肉功能的技術(shù)體系。,Neuromuscular Activation,Neuromuscular Activation and Training,NEURAC(Neuromuscular

13、Activation),高水平的神經(jīng)肌肉刺激，恢復(fù)中樞神經(jīng)系統(tǒng)對(duì)下位的控制，使失活的深層肌肉恢復(fù)功能,,,,深部穩(wěn)定系統(tǒng)的功能性抑制,頸部深層穩(wěn)定肌的募集,,,疼痛,模式圖,深層的局部穩(wěn)定肌(張力性肌),,,,,,頸部穩(wěn)定機(jī)制的改變,,淺層的整體運(yùn)動(dòng)肌(時(shí)相性肌),,,,模式圖,,頸部深層穩(wěn)定程序,頸部深層穩(wěn)定肌的控制中樞,,Aim of the Neurac method:激活深層穩(wěn)定肌，重新恢復(fù)頸部原有的穩(wěn)定機(jī)制,,,,,模式圖,

14、Video,閉合鏈訓(xùn)練（Closed Kinetic Chain）. 不穩(wěn)定的支撐面（Unsteady base of support）. 逐漸增加的負(fù)荷或持續(xù)時(shí)間（Heavy load / long holding time）. 無(wú)痛（No pain）.,Neuromuscular Activation,使用Neurac技術(shù)強(qiáng)化弱鏈從被確定的弱鏈水平開(kāi)始訓(xùn)練,Approach 1: 負(fù)荷大、次數(shù) 少 (4-5)組間休

15、息30秒. 每組都盡量加大負(fù)荷如果可能，盡量重復(fù)訓(xùn)練 : 1). 負(fù)荷可以不斷增加 2) 無(wú)痛. 3) 動(dòng)作完成正確.反復(fù)、多次的測(cè)試.,Approach 2: 長(zhǎng)時(shí)間保持同一姿勢(shì) 尤其適用于頸腰椎 . 注意調(diào)整脊柱前凸. 患者感覺(jué)疲勞或需要休息時(shí)停止. 記錄時(shí)間重復(fù)治療: 1)不斷增加持續(xù)的時(shí)間. 2) 無(wú)痛3) 動(dòng)作完成正確,（一）閉鏈訓(xùn)練與開(kāi)鏈訓(xùn)練相結(jié)合,,,閉鏈運(yùn)動(dòng),遠(yuǎn)端承重

16、包括兩個(gè)支點(diǎn)（固定點(diǎn)）,,著重于關(guān)節(jié)的功能性訓(xùn)練增加關(guān)節(jié)的軸向壓力增加動(dòng)態(tài)穩(wěn)定性激活主動(dòng)肌、協(xié)同肌和拮抗肌,Harter RA: Clinical rationale for closed kinetic chain activities in functional testing and rehabilitation of ankle pathologies. J Sport Rehab 1:13-24,1996,肢體遠(yuǎn)端不

17、負(fù)重或僅承擔(dān)很少重量,開(kāi)鏈運(yùn)動(dòng),著重于單組肌肉的功能性訓(xùn)練激活主動(dòng)肌和協(xié)同肌,Harter RA: Clinical rationale for closed kinetic chain activities in functional testingand rehabilitation of ankle pathologies. J Sport Rehab 1:13-26,1996,只有一個(gè)支點(diǎn)（固定點(diǎn)）,功能性訓(xùn)練=閉鏈訓(xùn)

18、練,Laskowski 1997Freidhoff 1997Guskiewics 1997Wilk 1996Harter 1996,Voight 1996Lephart 1996Greenberger 1995Dillman 1994 Gray 1989,聯(lián)合使用閉鏈訓(xùn)練和開(kāi)鏈訓(xùn)練可獲得神經(jīng)肌肉控制功能的最大恢復(fù)Lephart SM, Henry TJ: The physiological basis

19、for open and closed kinetic chain rehabilitation for the upper extremity. J Sport Rehab 1:71-87,1996,姿勢(shì)反射與關(guān)節(jié)承重,,緊貼關(guān)節(jié). 大量的張力肌纖維. 大量的肌梭. 前饋機(jī)制 .,張力性局部穩(wěn)定機(jī)制,,,The distal segment is not carrying bodyweight.,Open K

20、inetic Chain,Hip adduction,Focus on isolated training of individual muscles. Activation of agonist/ antagonists.,Harter RA: Clinical rationale for closed kinetic chain activities in functional testingand rehabilitatio

21、n of ankle pathologies. J Sport Rehab 1:13-26,1996,,Open Kinetic Chain,Closed Kinetic Chain,The distal segment is carrying bodyweight, or part of bodyweight.,Hip adduction,Focus on functional training.Increased compres

22、sions within the joints.Increased dynamic stabilization caused by activation of agonist / antagonist / synergist.,Harter RA: Clinical rationale for closed kinetic chainactivities in functional testing and rehabilitati

23、on of anklepathologies. J Sport Rehab 1:13-24,1996,Closed kinetic chain,（二）低負(fù)荷與漸進(jìn)抗阻訓(xùn)練,,,穩(wěn)定肌與運(yùn)動(dòng)肌比較,位于背部深層腱膜狀（aponeurotic）慢肌為主耐力活動(dòng)時(shí)激活選擇性弱化募集較差，可以被抑制在30－40％MVC條件下激活,位于背部淺層梭狀（fusiform）快肌為主爆發(fā)性活動(dòng)時(shí)激活優(yōu)先募集縮短和緊張?jiān)诖笥?0％

24、MVC條件下激活,穩(wěn)定肌,運(yùn)動(dòng)肌,（三）非對(duì)稱、不穩(wěn)定,,（四）振動(dòng)與無(wú)痛,,Brumagne 1999, 2000,Neuromuscular control in lumbal and pelvis,,,Healthy,Back pain,,,Before vibration,During vibration,After vibration,,,,Brumagne 1999, 2000,Results of vibration,（五

25、）離心收縮與姿勢(shì)控制,,穩(wěn)定?。╯tabilisor）與運(yùn)動(dòng)?。╩obilisor）局部肌肉（Local）與全局肌肉（Global）,Rood(1972)根據(jù)功能的不同，將背部肌肉區(qū)分為穩(wěn)定肌和運(yùn)動(dòng)肌兩類穩(wěn)定肌通常位于深部、具有單關(guān)節(jié)或者單一節(jié)段分布、通過(guò)離心收縮控制椎體活動(dòng)和具有靜態(tài)保持能力；運(yùn)動(dòng)肌一般位于表層、具有雙關(guān)節(jié)或者多關(guān)節(jié)分布、通過(guò)向心收縮控制體的運(yùn)動(dòng)和產(chǎn)生功率Bergmark（1989）還根據(jù)肌肉解剖位置的差異，將

26、背部肌肉分為局部肌肉和全局肌肉局部肌肉通常均起源于脊椎，它們的活動(dòng)控制脊柱的彎曲度和維持脊柱的機(jī)械穩(wěn)定性；全局肌肉一般連接胸廓和骨盆，這些肌肉收縮通?？梢援a(chǎn)生較大的力量,（七）弱鏈測(cè)試與整體觀,,Groppel JL. 1992. High tech tennis. 2nd ed. Champaign, IL: Human Kinetics.,Kibler WB. 1994. Clinical biomechanics of the

27、 elbow in tennis: implications for evaluation and diagnosis. Med Sci Sports Exerc 26 (10):1203-1206,,10 %,15 %,21 %,54 %,”What makes a ball go fast in a tennis serve”,Kinetic ChainTransmission of force during a throw,Le

28、g,Truncus,Shoulder,Arm,,,Force,Time,,,,Hilde Fredriksen 1996,Kinetic ChainDecreased activation of a segment during a throw,,,Force,Time,,,,,,Leg,Truncus,Shoulder,Arm,Hilde Fredriksen 1996,Ground reaction force in a jave