孙树椿教授外踝理筋手法治疗陈旧性踝关节扭伤临床观察及机理初探

发布时间：2018-04-26 09:20

本文选题：陈旧性踝关节扭伤 + 肌骨超声　；参考：《中国中医科学院》2016年博士论文

【摘要】：背景：踝关节扭伤临床非常多见。对于不伴有骨折、脱位的单纯踝关节扭伤,则往往被忽视,由此会演变成为陈旧性踝关节扭伤。陈旧性踝关节扭伤会导致踝关节周围的慢性疼痛、踝关节不稳,最后还可能发生严重的踝关节骨性关节炎,不得不进行关节融合或关节置换,从而产生严重的社会和经济负担。清宫正骨派的代表孙树椿教授运用独特的外踝理筋手法治疗陈旧性踝关节扭伤,临床疗效明显。本研究共分四个部分,第一部分为综述,其中包括孙树椿教授小传及清宫正骨学术源流,中医骨伤科对踝关节扭伤的认识和治疗,现代医学当前对踝关节扭伤的认识与治疗。第二部分为孙树椿教授学术思想和临床经验整理与研究。共有7个方面,主要包括孙树椿教授对骨伤科筋伤疾病的认识和治疗疾病首重手法、辨证与辨病结合、手法与用药结合等学术特色以及踝关节外踝理筋手法的渊源与特色。第三、第四部分为运用孙树椿教授清宫外踩理筋手法治疗临床常见病踝关节陈旧性扭伤的临床观察及有关机理初探。目的：1.科学观察、评估清宫正骨外踝理筋手法对陈旧性踝关节扭伤的临床疗效,较为客观地验证、判定中医手法治疗临床常见病的有效性,进一步提高踝关节陈旧性扭伤的临床诊治能力。2.通过肌骨超声技术、足底动态应力分析系统初步探讨清宫正骨外踝理筋手法治疗陈旧性踝关节扭伤的机理。方法：1.临床观察：经过筛选符合纳入标准的病例110例患者,最终有89例符合标准并资料完整,采用随机对照单盲设计方法进行分组,随机分为手法治疗组(简称治疗组)与对照组,其中治疗组52例,对照组37例。治疗组男13例、女39例,对照组男14例、女23例。所有患者踝关节扭伤全部为单侧,且都为内翻损伤,均有不同程度的外踝处疼痛,右侧66例,左侧23例。扭伤到治疗时间最短者3周,最长者11月,平均4.7月。患者年龄最小者18岁,最大者62岁。治疗组进行外踝理筋手法治疗,具体手法要点如下：①手摸心会：在外踝处寻找“筋结”。②手法理筋：轻巧点柔“筋结”,待“筋结”由僵硬变软后以踝关节拔、摇、戳手法理筋。③轻捋收功：最后沿着肌腱韧带走行方向捋顺伤处。对照组进行功能锻炼治疗,具体包括①足背伸锻炼；②足跖屈锻炼；③踝关节内外翻锻炼；④提踵锻炼等。对两组患者治疗前后进行疼痛学VAS评分、AOFAS的Baird-Jackson踝关节评分、距骨倾斜角测量等的对比观察。2.机理初探：上述入组患者中病史6个月以上的陈旧性踝关节扭伤患者共36例,其中男14例,女22例,平均6.3个月随访时对清宫外踝理筋手法治疗前及治疗后进行如下对比研究。研究1：踝关节外侧副韧带肌骨超声检查：对治疗前后的踝关节距腓前韧带、跟腓韧带、距腓后韧带进行高频超声检查,①记录踝关节外侧副韧带的厚度；②观察韧带纤维的连续性；③踝关节运动过程中的韧带张力；④外侧副韧带周围血肿面积;⑤踝关节内积液量等。研究2：观察手法治疗前后患者的足底重心分布及其行走步态变化等。结果：1.临床结果：本组患者随访时间最短者3月,最长者2年,平均13.6月。疼痛学评分：组内比较；两组患者治疗后与末次统计疼痛评分均低于治疗前,差异有统计学意义(P0.05,P0.01)；两组患者末次统计疼痛评分与治疗后相比,治疗组呈升高趋势,对照组呈降低趋势,差异有统计学意义(P0.05)。组间比较：两组患者治疗前疼痛评分差异无统计学意义(P0.05)；治疗后与末次统计,治疗组疼痛评分低于对照组,差异有统计学意义(P0.05,P0.01)。AOFAS评分情况：两组患者治疗后AOFAS评分情况相比治疗前呈升高趋势,差异有统计学意义(P0.05,P0.01)。治疗组治疗前AOFAS评分情况与对照组差异无统计学意义(P0.05)；治疗后治疗组AOFAS评分情况高于对照组,差异有统计学意义(P0.05)。应力位X片距骨倾斜度：两组患者治疗前后,治疗组与对照组在距骨倾斜度情况方面,差异均无统计学意义(P0.05)。2.机理探讨结果：本组患者36例全部得到随访,随访方式均为门诊随访。末次随访到受伤时间平均为6.3个月。手法治疗次数平均为7.8次,每次治疗不超过10分钟。肌骨超声检查：本组病例选择均为踝关节外侧副韧带部分断裂或部分松弛的患者。追踪观察36例踝关节损伤治疗前及治疗后平均6.3个月的情况可见在踝关节各侧副韧带中距腓前韧带是最常损伤、最难恢复的韧带。跟腓韧带、距腓前韧带易同时损伤并损伤程度相仿,但能通过手法保守治疗较快恢复。本组患者损伤可分为挫伤和部分断裂,治疗前所有韧带均连续性好；韧带张力表现为松弛；副韧带周围有面积大小不等的血肿；韧带周围有明显的积液。经手法治疗一段时间后运用业界公认的疗效评价标准-超声进行综合疗效评价。距腓前韧带的有效率为97.2%、跟腓韧带有效率为88.9%,距腓后韧带的有效率为83.3%。并对超声机器所测各韧带厚度值进行统计学分析,清宫外踝手法治疗前后踝关节外侧各副韧带厚度均较治疗前有所恢复,有显著性差异(P0.05)。足底重心分布及其行走步态变化：本组患者的测试结果显示踝关节陈旧性损伤患者明显有对踝关节外侧不信任感,患足足底外侧压力增加,足底压力中心的连线出现明显外移。测量患足较健足压力中心摆动的距离明显变大。经过手法治疗后患者无论足底压力中心还是重心摆动距离均很快恢复到健侧水平。结论：1、运用孙氏“清宫正骨”外踝理筋手法治疗陈旧性踝关节扭伤在缓解疼痛、改善患者踝关节功能方面临床常有立竿见影的明显疗效,优于目前西医常用的踝关节单纯功能疗法锻炼组。2、“清宫正骨”外踝理筋手法和踝关节功能疗法锻炼均不能改善踝关节的解剖关系,所以对于功能性踝关节不稳定疗效明显,对于机械性踝关节不稳定治疗效果一般。3、运用“清宫正骨”外踝理筋手法治疗陈旧性踝关节扭伤经过肌骨超声检查证实可以对踝关节外副韧带张力、厚度、消除周围血肿、积液等方面有所改善,并且通过对全踝关节的手法调整对足底重心位移、足部步态等方面有所改善,从而运用现代技术证实了中医手法的临床疗效和机理。
[Abstract]:Background: ankle sprains are very common. For a single ankle sprain without fracture and dislocation, it tends to be ignored, which will evolve into an old ankle sprain. Old ankle sprains can lead to chronic pain around the ankle, unstable ankle, and severe ankle osteoarthritis at the end of the day. This study is divided into four parts. The first part is a summary of four parts. The first part is a summary of the study, including the biography of Professor Sun Shuchun and the palace of Qing Dynasty. The knowledge and treatment of the ankle sprain in the orthopedics department of orthopedics, the understanding and treatment of the sprain of the ankle joint in modern medicine. The second part is the study and study of Professor Sun Shuchun's academic thought and clinical experience. There are 7 aspects, mainly including Professor Sun Shuchun's understanding of the tendon injury in the bone Department of Traumatology and the first treatment of the disease. The third, the fourth part is the clinical observation and the related mechanism of the treatment of clinical common malleolus sprain with the fourth part of Sun Shuchun's Qing palace. Objective: 1. scientific observation and evaluation. The clinical effect of the external malleolus manipulation on the old ankle sprain, it is more objective to verify the effectiveness of the traditional Chinese medicine manipulation for the clinical common diseases and to further improve the clinical diagnosis and treatment ability of the old sprain of the ankle joint.2. through the musculoskeletal ultrasonic technique and the dynamic stress analysis system of the plantar. The mechanism of manipulative treatment of old ankle sprains. Method: 1. clinical observation: after screening 110 patients who were in accordance with the standard, 89 cases were in conformity with the standard and complete data, and were divided into groups by random control single blind design method, randomly divided into manipulative treatment group (simple treatment group) and control group, of which 52 cases in treatment group and control group were compared. There were 37 cases in the group of 13 men and 39 women in the treatment group, 14 in the control group and 23 in the female. All the ankle sprains were all unilateral, and all were varus. There were different degrees of pain in the outer malleolus, the right 66 cases, the left 23 cases. The longest one was 3 weeks, the oldest was in November, the average age was 18 years and the largest 62 years old. The treatment group carried out the treatment of external malleolus tendon manipulation, and the main points were as follows: (1) hand touch the heart meeting: looking for "tendons" in the outer malleolus. Group for functional exercise treatment, including the foot back and extension exercise; (2) foot and foot flexion exercise; (3) the ankle joint internal and external turnover exercise; (4) heel exercise and so on. The two groups of patients before and after the pain learning VAS score, AOFAS Baird-Jackson ankle score, the talus tilt angle measurement and other comparison observation of the.2. mechanism: the above group of patients There were 36 cases of old ankle sprain with more than 6 months of medical history, including 14 men and 22 women. The average 6.3 months of 6.3 months were compared. 1: ultrasound examination of the lateral collateral ligament of the ankle: the anterior ankle to the anterior peroneal ligament, the peroneal ligament, and the peroneal. The posterior ligament was examined by high frequency ultrasound. (1) the thickness of the lateral collateral ligament of the ankle joint was recorded; secondly, the continuity of the ligament fiber was observed; (3) the ligament tension during the movement of the ankle joint; (4) the area of hematomas around the lateral collateral ligament; (5) the amount of the internal convolution of the ankle joint. Study 2: the distribution of the foot center of gravity of the patients before and after treatment and the walking of the foot before and after treatment. Results: 1. clinical results: 1. clinical results: the shortest follow-up time in this group was in March, the longest was 2 years, an average of 13.6 months. The pain score was compared in group. The pain scores of the two groups were lower than those before the treatment, the difference was statistically significant (P0.05, P0.01); the final statistical pain score of the two group was with the post treatment phase. Ratio, the treatment group showed a trend of increase, the control group showed a decreasing trend, the difference was statistically significant (P0.05). There was no statistical difference between the two groups before treatment (P0.05); the pain score of the treatment group was lower than that of the control group after the treatment and the final statistics, the difference was statistically significant (P0.05, P0.01).AOFAS score: the two groups were affected. After treatment, the AOFAS score was higher than before the treatment (P0.05, P0.01). There was no significant difference between the treatment group and the control group before the treatment (P0.05). The AOFAS score in the treatment group was higher than that of the control group (P0.05). The two groups of the talus inclination of the stress level X tablets: two groups Before and after treatment, there was no significant difference between the treatment group and the control group on the talus inclination of the talus (P0.05).2. mechanism: 36 cases were all followed up and followed up in the outpatient clinic. The average time of the last follow-up was 6.3 months. The average number of hand treatment times was 7.8 times, and the treatment was not more than 10. 36 cases of ankle joint injury before and after treatment averaged 6.3 months after treatment, and the most difficult and most difficult ligaments to recover from the peroneal ligament, peroneal and peroneal, were observed in 36 cases of ankle injury before and after treatment. The anterior ligament was easily damaged and damaged in a similar degree, but it could be recovered quickly by conservative treatment. The injury in this group could be divided into contusion and partial fracture. All ligaments were in good continuity before treatment; the tension of ligaments was relaxed; blood swollen with different size around the collateral ligament; obvious effusion around the ligaments. Hand in hand rule of law After a period of time, the comprehensive curative effect was evaluated using the recognized standard of efficacy evaluation of the industry. The effective rate of the anterior peroneal ligament was 97.2%, the effective rate of the peroneal ligament was 88.9%, the effective rate of the posterior fibula ligament was 83.3%. and the value of the ligament thickness measured by the ultrasonic machine was statistically analyzed, and the ankle joint before and after the treatment of the lateral malleolus in the palace of the Qing palace. There was a significant difference (P0.05). The distribution of the center of gravity of the foot and the walking gait. The test results of the patients in this group showed that the patients with old ankle injuries were obviously distrust of the lateral ankle, increased the lateral pressure of the foot foot, and the connection of the foot pressure center appeared obviously. The distance between the foot pressure center of the foot and the foot pressure center was greatly increased. After the manipulation, the patients recovered to the healthy side quickly regardless of the foot pressure center or the center of gravity. Conclusion: 1, the treatment of the old ankle sprain with sun's "Qing Gong bone" external ankle sprain can relieve the pain and improve the ankle joint work. The clinical curative effect is often immediate. It is superior to the common ankle joint functional therapy exercise group.2, which is commonly used in western medicine. "Qing Gong orthopedics" external malleolus manipulation and ankle joint function exercise can not improve the anatomical relationship of ankle joint, so it has obvious effect on functional ankle joint instability, for mechanical ankle joint. The effect of unstable treatment is generally.3. The treatment of old ankle sprain by means of "Qing Gong orthopedics" external malleolus manipulation can improve the tension, thickness, elimination of surrounding hematoma, effusion, and the adjustment of the foot's center of gravity and foot gait through the manipulation of the ankle joint. And so on, so as to improve the clinical efficacy and mechanism of modern Chinese medicine.

【学位授予单位】：中国中医科学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R249;R274.9

【参考文献】