神经松动术的基础及临床康复研究进展

Research Progress of Nerve Mobilization in Basic and Clinical Rehabilitation

旨在综述归纳神经松动术的理论基础、发展演变及其在神经、骨骼肌肉系统疾病临床康复的应用进展,为后续专业领域的基础及临床研究提供重要循证依据。神经松动术是基于解剖学、生物力学和神经动力学理论,针对神经组织施以特定方向和适当力度的牵伸和放松手法治疗。通过改善神经张力、轴浆运输和组织微环境,促进神经组织及其支配结构恢复正常解剖结构和生理功能。临床上,根据手法特点和治疗目的主要分为滑动手法和张力手法,前者指神经相对周围组织较大范围的单向滑动,适用于损伤急性期;后者强调神经内部的张力变化,适用于损伤恢复期及组织粘连等情况。个体化的神经松动术治疗强调神经张力评估,且强调动作时序性。近年来,随着神经松动术临床适应证的范围不断拓展,其在周围神经卡压、周围神经损伤和脑卒中康复等方面的循证学依据不断积累。神经松动术治疗周围神经卡压综合征的机制包括减轻神经水肿、炎症反应和神经根刺激症状,从而缓解因机械嵌顿和异常张力造成的疼痛、神经传导异常和功能受限。神经松动术应用于周围神经损伤术后,有助于减轻肿胀、改善组织粘连,且通过刺激本体感觉受体增加神经内部血流,直接影响手术疗效和功能预后。此外,神经松动术有助于缓解糖尿病周围神经病变患者症状。目前神经松动术的应用领域逐步拓展至脑卒中、颅脑外伤、帕金森病等中枢神经系统疾病,以神经松动术在脑卒中的临床应用最为广泛。通过周围神经组织接受机械负荷刺激的变化,促进肌张力、肌力、重心分布、姿势平衡和其他运动功能障碍改善,增强中枢神经系统可塑性,进而促进神经损伤功能障碍的康复。今后,相关领域研究的重要方向应针对不同疾病和病理状态下的神经松动术的治疗频率、治疗时间和动作时序。目前,尚未有足够的高质量随机对照研究探讨神经松动术的疗效,分子和基因水平的研究证据更加缺乏,包括抗炎、轴浆运输效率和神经组织再生等机制研究有待完善,同时需要大样本、随访时间较长的观察研究验证长期疗效。

The purpose of this paper is to provide a systematic review of the literature concerning the theoretical basis, research advance and clinical status of nerve mobilization (NM) in various neuro-musculoskeletal conditions, which may provide important information for future medical studies. The NM technique is developed based on anatomy, biomechanics, and neurodynamics, and the treatment is applied by stretching and relaxing the specific nerve tissues with appropriate power at the desired direction. By improving the neural tension, axoplasmic transport and the issue microenvironment, the NM helps the anatomical structure and physiological function of nerve tissues restore to normal condition. The two main types of neurodynamic techniques are "sliding technique" and "tensioning technique" respectively. The "sliding technique" results in the relative large longitudinal excursion of nerve with a minimal increase of strain, thus it seems less aggressive than "tensioning technique" and might be more appropriate for acute injuries at the early stage. While the "tensioning technique" usually leads to significant changes in nerve tension to increase the distance between each end of the nerve tract and prevent tissue adhesion during the convalescence period. For the symptomatic patients, the changes of mechanical tension and movement sequence should be identified before the individualized NM treatment. Recent years, the NM technique has been widely used in peripheral nerve entrapment syndromes, periphery nerve injuries, and stroke rehabilitation. The NM technique facilitates to reduce intraneural edema, inflammation response and nerve root irritation. Besides, the NM technique also plays an important role in the postoperative rehabilitation of peripheral nerve injury, since the edema, tissue adhesion and reduced blood flow could influence curative effects and surgical prognosis in negative ways. Preliminary evidences suggest that metabolic and endocrine diseases generally involve the neural disorders and the NM is beneficial for treating the symptomatic diabetic peripheral neuropathy. Despite of insufficient evidence, the NM is proved to be used in the prevention, assessment and treatment of neurological disorders, including stroke, traumatic brain injury and Parkinson's disease. Moreover, previous studies proved that peripheral mechanical loads applied to neural tissues could improve the central neural plasticity, and the improvements were observed in muscular tone, strength, body weight distribution, postural balance and other functional motor performances, which helped to attenuate the motor dysfunction of the upper and lower limbs. Future studies are necessary to validate the treatment frequency, treatment duration and movement sequence for varies diseases and physiopathological conditions. To our knowledge, there are still few qualified clinical randomized controlled trials (RCT) and system reviews about the therapeutic effects of NM techniques, especially the in-depth explorations at the molecular and genetic levels. Up till now, the positive observed effects ofNM technique are mainly based on anecdotal evidences. The curative effects and related mechanisms, including anti-inflammation, increased axonal transport efficiency and nerve tissue regeneration deserve more future investigations. The long-term randomized trials with large samples are needed to observe and identify the therapeutic effects sustained over-time.