推拿治疗退行性腰椎滑脱症的规范化探讨

Normalized analysis on tuina manipulation applied in treating degenerative spondylolisthesis

目的:回顾近年来国内外脊柱生物力学基础实验和退行性腰椎滑脱症的推拿临床研究,探讨推拿治疗退行性腰椎滑脱症的手法机制和对腰椎稳定性的影响。方法:应用计算机检索PubMed和OVID数据库1950-01/2006-07脊柱生物力学研究和退行性腰椎滑脱症手法治疗的文献。检索词为“spine,biomechanics,degenerativespondylolisthesis,manipulation”并限定文献语言种类为English,同时计算机检索清华同方CNKI中国期刊全文数据库1992-01/2006-07退行性腰椎滑脱症的推拿临床治疗文献,检索词为“退行性腰椎滑脱,生物力学,推拿”,并限定语言种类为中文;此外,在图书馆手工检索1985-01/2005-12出版的相关专著。纳入标准:①脊柱生物力学研究。②退行性腰椎滑脱症推拿手法治疗。排除标准:①脊柱骨折。②手术治疗。③重复的综述与临床治疗文献。从腰椎生物力学的角度阐述手法的作用途径,评价推拿的临床疗效和对腰椎稳定性的影响。结果:共纳入文献30篇,其中3篇为研究性论著,1篇为普通高等教育“十五”国家级规划教材,将文献进行综合评价。①躯干肌的协调收缩可维持腰椎节段的结构性稳定,调节腰椎活动范围,维持脊柱的动态平衡。退行性腰椎滑脱病变节段椎间盘和关节突关节等退变明显,生物力学性能发生变化,不能发挥其稳定功能,抗剪切力下降,其腰椎旋转中心后移,应力和载荷分布不协调;同时,退行性腰椎滑脱患者腰背肌肌力下降,躯干肌肌力失衡导致腰椎曲度变化,进一步影响腰椎稳定性。②手法的作用机制可能是改善腰肌高张力状态,减小骨盆前倾角及腰椎前凸,降低剪切应力,消除神经根压迫,结合针对性的导引和功能训练可改善腰椎承重力线,改善肌肉收缩的协调性和柔顺性,提高躯干肌群的肌力和腰椎稳定性。结论:推拿是退行性腰椎滑脱症有效的保守方法,手法的筛选、规范以及疗效的客观评估仍需进一步研究。

AIM： To explore the mechanism of tuina manipulation in treating degenerative spo, ndylolisthesis and its effect on lumbar stability on the basis of reviewing the latest researches at home and abroad on the spine biomechanics experiment and clinical treatment of degenerative spondylolisthesis with tuina manipulation. METHODS： The computer-based online search of PubMed and OVID database was undertaken for articles about spine biomechanics and degenerative spondylolisthesis treatment published in English from January 1950 to July 2006 with the key words of “spine, biomechanics, degenerative spondylolisthesis, manipulation”. Meanwhile, we searched Qinghua Tongfang Chinese Journal Full-text Database for articles about tuina treatment for degenerative spondylisthesis published in Chinese from January 1992 to July 2006 with the same key words in Chinese. Additionally, we also manually searched related monographs in library published between January 1985 and December 2005. Inclusive criteria： ① spine biomechanics research; ② papers, manipulation treatment of degenerative spondylolisthesis. Exclusive criteria： ①articles on spine fracture; ②surgery treatment; ③repetitive review and clinical treatment. The literatures elucidated comprehensively the manipulation pathway based on spine biomechanics and evaluated clinical effect of Chinese tuina and its effect on lumbar stability. RESULTS： Thirty literatures were included, in which 3 articles were monographs and 1 was higher education textbook. The literatures were evaluated comprehensively. ①Concordant contraction of trunk muscles could keep structure stability of lumbar and adjust lumbar motion range to maintain spine dynamic balance. There were significantly degenerative changes in the intervertebral disc and zygapophysial joint of degenerative spondylolisthesis, which decreased their stability function of anti-shearlng force. The retroposition of lumbar rotation center produced abnormal distribution of stress and load. Meanwhile, the decrease of back muscles strength and unbalance of body muscles strength in degenerative spondylolisthesis patients induced abnormal lumbar curve to break down lumbar stability. ②The mechanism of manipulation maybe lie in relieving high tension of back muscles and reducing abnormal lumbosacral and sacrohorizontal angle as well as adjusting lumbar gravity curve to eliminate nerve root compression, which could improve the lumbar muscle strength and concordance and enhance the lumbar stability combined with proper exercises. CONCLUSION： Tuina manipulation is an effective controversial method in treating degenerative spondylolisthesis, but its screening, normalization and clinical assessment of curative effect still need further study.