昆醫(yī)大康復(fù)治療技術(shù)講座：感覺運動系統(tǒng)理論評估與干預(yù)策略

感覺運動系統(tǒng)理論、評估與干預(yù)策略

THEORIES,EVALUATION,ANDINTERVENTIONSTRATEGIESOFSENSORIMOTORSYSTEM

中山大學(xué)附屬第一醫(yī)院康復(fù)醫(yī)學(xué)科王于領(lǐng)BSc(PT),MPH,PhD

副教授副主任PT2012---浙江麗水省年會---感覺運動系統(tǒng)SENSORIMOTORSYSTEM

人體整個運動控制系統(tǒng)的一部分asubcomponentofthecomprehensivemotorcontrolsystemofthebody描述感覺、運動、中樞整合和處理的部分，包含維持肢體運動（功能性關(guān)節(jié)穩(wěn)定）中關(guān)節(jié)穩(wěn)定狀態(tài)。todescribethesensory,motor,andcentralintegrationandprocessingcomponentsinvolvedinmaintainingjointhomeostasisduringbodilymovements(functionaljointstability)2012---浙江麗水省年會---王于領(lǐng)（Lephartetal.2000）感覺運動系統(tǒng)

SENSORIMOTORSYSTEM2012---浙江麗水省年會---王于領(lǐng)皮層Cortex小腦Cerebellum腦干BrainStem脊髓SpinalCord梭外肌纖維ExtrafusalMuscleFibers梭內(nèi)肌纖維IntrafusalMuscleFibers視覺Vision前庭Vestibular軀體感覺Somatosensory皮膚Cutaneous關(guān)節(jié)Articular肌肉Muscle肌梭MuscleSpindle關(guān)節(jié)功能性穩(wěn)定FUNCTIONALJOINTSTABILITY維持關(guān)節(jié)功能性穩(wěn)定主要由靜態(tài)和動態(tài)部分完成Theprocessofmaintainingfunctionaljointstabilityisaccomplishedthroughacomplementaryrelationshipbetweenstaticanddynamiccomponents.靜態(tài)：韌帶、關(guān)節(jié)囊、軟骨、接觸面和關(guān)節(jié)內(nèi)骨的形態(tài)Ligaments,jointcapsule,cartilage,friction,andthebonygeometrywithinthearticulationcomprisethestatic(passive)components.(Lewetal.1993;Johanssonetal.1993)動態(tài)：作用于關(guān)節(jié)周圍的骨骼肌的神經(jīng)運動控制中的前饋和后饋機制Dynamiccontributionsarisefromfeedforwardandfeedbackneuromotorcontrolovertheskeletalmusclescrossingthejoint.2012---浙江麗水省年會---王于領(lǐng)穩(wěn)定是感覺-運動神經(jīng)統(tǒng)合的結(jié)果

STABILITYISTHERESULTOFSENSORY-MOTORINTEGRATION感覺系統(tǒng)，傳入系統(tǒng)SensorySystem(AfferentSystem)本體感覺Proprioception對位置、姿勢和運動的感覺Sherrington(1906):Thesenseofposition,posture,andmovement傳入神經(jīng)累積輸入到中樞神經(jīng)系統(tǒng)Lephart&Fu(2000):ThecumulativeafferentneuralinputintotheCNS肌肉和關(guān)節(jié)中的特定感受器將信息傳送到中樞神經(jīng)系統(tǒng)SpecializedreceptorsinmusclesandjointssendinformationintoCentralNervousSystem(CNS)2012---浙江麗水省年會---王于領(lǐng)本體感覺PROPRIOCEPTION（Dietz，NatureReviewsNeuroscience3,781-790）本體感覺PROPRIOCEPTION（Dietz，NatureReviewsNeuroscience3,781-790）步態(tài)中神經(jīng)控制機制示意圖Schematicdrawingoftheneuronalmechanismsinvolvedinhumangait本體感覺PROPRIOCEPTION關(guān)節(jié)機械性刺激感受器JointmechanoreceptorsCapsules&ligaments（關(guān)節(jié)囊和韌帶）Muscularreceptors（肌肉感受器）Gammamotorneuron&musclespindle（γ運動神經(jīng)元和肌梭）Cutaneousreceptors（表皮感受器）Pressure,temperature,vibration（壓力，溫度，振動）STABILITYISTHERESULTOFSENSORY-MOTORINTEGRATION

（穩(wěn)定是感覺神經(jīng)-運動整合的結(jié)果）SensorySystem(AfferentSystem)（感覺系統(tǒng),傳入系統(tǒng)）MotorSystem(EfferentSystem)（運動系統(tǒng)，傳出系統(tǒng)）Signalstomuscleasaresultofproprioceptiveinformation&processinginCNS（傳送到肌肉的信號是中樞神經(jīng)系統(tǒng)中本體感覺信息傳輸和處理的結(jié)果）Facilitation:MuscleActivation（促進/易化：肌肉激活）Inhibition:MuscleInhibition（抑制：肌肉抑制）CNSprocessingoccurson3levels（中樞神經(jīng)系統(tǒng)處理發(fā)生在3個層次上）2012---浙江麗水省年會---王于領(lǐng)反饋和前饋FEEDBACK&FEEDFORWARD反饋：通過反射環(huán)調(diào)節(jié)運動控制Feedback:regulatesmotorcontrolthroughreflexloops機械性刺激感受器與肌梭mechanoreceptors&musclespindles前饋：依據(jù)以往的經(jīng)驗計劃運動模式Feedforward:plansmovementpatternbasedonpastexperience二者都依賴于正確的傳入信息Bothrelyonproperafferentinformation（Hodges&Richardson,1998）Zatorreetal.2007.NatureReviewsNeuroscience8,547-558穩(wěn)定是運動和功能的先決條件

STABILITYISAPRE-REQUISITEOFMOVEMENTANDFUNCTION人類出生時中樞神經(jīng)系統(tǒng)有基本的運動模式正常人的成長發(fā)育是以反饋為基礎(chǔ)。人體運動是先保持穩(wěn)定才過渡到活動的。HumansarebornwithbasicmovementpatternsinCNSNormalhumandevelopmentbasedonfeedbackHumanmovementbeginswithstabilitybeforemobility結(jié)構(gòu)與功能穩(wěn)定

STRUCTURALV.FUNCTIONALSTABILITY結(jié)構(gòu)穩(wěn)定：被動機制StructuralStability:passivemechanisms關(guān)節(jié)囊和韌帶Jointcapsules&ligaments關(guān)節(jié)相容性Jointcongruency（）關(guān)節(jié)中心點Jointcentration負荷和穩(wěn)定性最佳optimizeload&stability結(jié)構(gòu)與功能穩(wěn)定

STRUCTURALV.FUNCTIONALSTABILITYFunctionalStability:activemechanisms（功能穩(wěn)定：主動機制）NeuromuscularActivation（神經(jīng)肌肉激活）Local(intrinsic)vs.Global(extrinsic)mechanisms局部（內(nèi)在）與整體（外在）機制Musthavestabilizationgloballytobeeffectivelocally（想要保證局部有效必須先要整體穩(wěn)定）功能穩(wěn)定FUNCTIONALSTABILITY局部穩(wěn)定：肌肉激活，協(xié)同收縮Localstabilization:muscularactivation,co-contraction肩（肩袖和肩胛）Shoulder(rotatorcuff&scapula)膝蓋（股四頭，股二頭）Knee(quads,hams)下背部和頸部（深層穩(wěn)定器）Lowback&neck(deepstabilizers)關(guān)節(jié)功能性穩(wěn)定FUNCTIONALJOINTSTABILIZATION關(guān)節(jié)機械性刺激感受器與肌肉周圍關(guān)節(jié)間的反射環(huán)Reflexloopbetweenjointmechanoreceptors&musclessurroundingjoint

(Anissetal.1992;Guanche,etal.1995;Tsudaetal.2001)肌肉反射性運動來使關(guān)節(jié)穩(wěn)定Musclesactreflexively(fast&automatic)tostabilizejoints

(Buchannan,etal.1996;Kim,etal.1996;Cordovaetal.,1999;Horak&Nashner,1986)無意識反應(yīng)和收縮速度是保持功能穩(wěn)定的最重要因素（而不是肌力）Theunconsciousreactionandspeedofcontractionaremostimportantcomponentsoffunctionalstability(notstrength)

功能穩(wěn)定FUNCTIONALSTABILITYGlobalstabilization:providesproximalstabilizationthroughneuromuscularchains(整體穩(wěn)定：通過神經(jīng)肌肉鏈提供近端穩(wěn)定）“Core”stabilization（“核心”穩(wěn)定）UpperQuarter:scapular&ribstabilization（頭頸上肢：肩胛和肋骨穩(wěn)定）LowerQuarter:pelvic&lumbarstabilization（腰臀下肢：骨盆和腰穩(wěn)定）“ProximalStabilityforDistalMobility”（近端穩(wěn)定以確保遠側(cè)的移動性）WholeBodyBalanceReactions（全身平衡反應(yīng)）2012---浙江麗水省年會---王于領(lǐng)感覺運動系統(tǒng)評測技術(shù)SensorimotorSystemMeasurementTechniques2012---浙江麗水省年會---王于領(lǐng)感覺運動系統(tǒng)評測技術(shù)

SENSORIMOTORSYSTEMMEASUREMENTTECHNIQUES外周傳入的采集和傳輸測量技術(shù)PERIPHERALAFFERENTACQUISITIONANDTRANSMISSIONMEASUREMENTS本體感覺Proprioception體感誘發(fā)電位SomatosensoryEvokedPotentials傳出傳輸測量EFFERENTTRANSMISSIONMEASUREMENTS神經(jīng)傳導(dǎo)測試NerveConductionTesting肌肉激活模式MuscleActivationPatterns肌肉表現(xiàn)特征MusclePerformanceCharacteristics動力學(xué)和運動學(xué)測試KineticandKinematicMeasurements姿勢控制測試PosturalControlMeasures肌肉關(guān)節(jié)僵硬度MuscleandJointStiffness2012---浙江麗水省年會---王于領(lǐng)(Riemannetal.2002)感覺運動系統(tǒng)評測技術(shù)

SENSORIMOTORSYSTEMMEASUREMENTTECHNIQUES外周傳入的采集和傳輸測量技術(shù)PERIPHERALAFFERENTACQUISITIONANDTRANSMISSIONMEASUREMENTS本體感覺Proprioception2012---浙江麗水省年會---王于領(lǐng)(Riemannetal.2002)感覺運動系統(tǒng)評測技術(shù)

SENSORIMOTORSYSTEMMEASUREMENTTECHNIQUES傳出傳輸測量EFFERENTTRANSMISSIONMEASUREMENTS姿勢控制測試PosturalControlMeasures感覺運動系統(tǒng)評測技術(shù)

SENSORIMOTORSYSTEMMEASUREMENTTECHNIQUES外周傳入的采集和傳輸測量技術(shù)PERIPHERALAFFERENTACQUISITIONANDTRANSMISSIONMEASUREMENTS本體感覺Proprioception2012---浙江麗水省年會---王于領(lǐng)PRO-KINisequippedwithsophisticatedsensorsthatallowtheprecisemeasurementandquantificationofthepatient’smotoraction.Prokin系統(tǒng)配備了先進的傳感器，使病人的運動動作能夠精確測量和量化。pressure壓力resistance阻力INCLINATIONS傾斜度MEAN:MANAGEINSTABILITYCONDITIONS用意：控制不穩(wěn)定性條件PRO-KINisabletonoticeappliedLOADSvariablefrom0kgto150kgwiththeresolutionof50g.Prokin系統(tǒng)能夠以50克為最小單位來表示0公斤到150公斤的荷載變量。PRO-KINisabletonoticemedium-lateralandfront-behindINCLINATIONS

of+/-15°withtheresolutionof0,1°.Prokin系統(tǒng)能夠以0,1°為最小單位來表示內(nèi)-外和前-后+/-15°的傾斜度。ThePRO-KINsystemplacesitssurveysandanalysisfunctiononthecountcapacityofthePersonalComputerandtherelativeManageSoftware.Prokin系統(tǒng)將其調(diào)查和分析功能附加于個人電腦和相關(guān)管理軟件的計數(shù)容量中。ProgressiveASSESSMENT逐步評估ANALYSISandREHABILITATION分析和康復(fù)CLINICfolderandREHABILITATIVETRAININGS診斷單和康復(fù)訓(xùn)練RehabilitativeGAMES康復(fù)游戲ScientificTEST科學(xué)測試TheASSESSMENTnoticesthemajorproprioceptiveandarticulardeficit,highlightingthecontrolincapacity.Thecomparisoncanbemadebetweenthehealthlimbandtheilloneorreferringtonormativedata.評估反映了主要本體感受和關(guān)節(jié)的缺失，突出強調(diào)了控制能力的喪失。健康肢體和患病肢體或提到的標準數(shù)據(jù)之間可以進行比較。OBJECTIVE目的MOTORTRAININGoftheARTICULATIONwithaCONTROLLEDLOAD.可控負荷的關(guān)節(jié)運動訓(xùn)練。TheANALYSISoftheRESULTSinstrumentisexhaustiveandcomplete,getsinthesametimeafastandefficiencypollingthroughanintuitivesoftwareinterface.分析結(jié)果詳盡且完整，與此同時，通過直觀的軟件界面可以得到快速有效的圖表。Therehabilitativephasemovesfromtheexecutionofspecificexercisesthatthroughtheacousticandvisualfeedbackgetthearticularscoutingthatthepatientwants康復(fù)階段從做一些特定動作開始，在此期間，可通過聲音和視覺反饋信息獲得病人想要的關(guān)節(jié)反應(yīng)。THEEXERCISESCANBEAUTONOMOUSLYEXECUTEDBYTHEPATIENTBOTHINSINGLEMODALITYANDINPROLONGSEQUENCES.無論該病人是單一的治療方法還是后續(xù)的方案，鍛煉都可以自主執(zhí)行。Duringtherehabilitativephasethevisualfeedbackresultsveryimportantfortherebuildingoftheproprioceptivemechanismsofthemechanoreceptors.在康復(fù)階段的視覺反饋結(jié)果對于重建機械性刺激感受器的本體感受機制非常重要。PRO-KINexploitsthisfunctionpresenting,apartfromtheauditoryfeedback,alsoavisualone,extremelyrealistic,theanatomicvisualizationoftheexecutedmotoraction.Prokin系統(tǒng)利用此項功能，可以對執(zhí)行的動作進行解剖學(xué)可視化展示，除聽覺反饋外，還有視覺反饋，都非常逼真。Therehabilitativephasemovesalsofromtheexecutionofspecificexercisesforbalanceintotalload康復(fù)階段的動作也可以從執(zhí)行總負荷中的特定平衡訓(xùn)練開始。EMGmoduleintegrationinPROKINsoftwareProkin系統(tǒng)軟件中整合肌電圖（EMG）模塊感覺運動系統(tǒng)評測技術(shù)

SENSORIMOTORSYSTEMMEASUREMENTTECHNIQUES傳出傳輸測量EFFERENTTRANSMISSIONMEASUREMENTS肌肉激活模式MuscleActivationPatterns(Riemannetal.2002)姿勢板體型與姿勢的研究功能性障礙的研究肌肉不平衡的研究內(nèi)臟身體姿勢板過度勞累職業(yè)習(xí)慣營養(yǎng)不均衡久坐張力減退運動機能減退感覺運動訓(xùn)練干預(yù)策略

STRATEGIESOFSMTOrangeModule–UpperLimbs橙色模塊-上肢VirtualOccupationalTheraphy虛擬職業(yè)治療VirtualOccupationaltheraphyVSClassicOccupationaltheraphy虛擬職業(yè)治療與經(jīng)典職業(yè)治療比較Theprogressisquantify量化進展Isveryinteractive完全互動Concernemotionalasgame關(guān)注情感如游戲---

Anyquantification任何量化Islittleinteractive互動少Isbusy.Littleinvolving繁忙牽涉少感覺運動訓(xùn)練舉例BluModule–LowLimb藍色模塊-下肢Training訓(xùn)練Feedbackinrealtime實時反饋Posturalpositioncontrol姿勢位置控制Segmentcontrol(pelvis-shoulder-trunk)節(jié)段控制（骨盆、肩部、軀干）姿勢平衡姿勢板作為一個電動鏡子，忠實的告知病人，確保訂購姿勢板能讓他們再一次找到真正的“平衡”。功能穩(wěn)定訓(xùn)練振動VIBRATIONtherapy-conceptsNeuromuscularVascularConnectivetissueTendonsLigamentsFasciaeDermisBoneBloodcirculationPerfusionMetabolismLymphflowHealingMusclemassMusclecoordinationProprioceptionGeneralcoordinationFlexibilityPhysiologicaleffect

ondifferentbiological

systemstherapy-conceptsPhysiologicaleffectsdependentonfrequencyFrequency:2-7HZEffects:

Increasingbalance,coordinationandproprioception,jointmobilisation

Activebalancingmovements臨床推理的實際應(yīng)用：病例分析

CLINICALREASONINGINACTION:CASESTUDY一個職業(yè)網(wǎng)球運動員的髕股關(guān)節(jié)疼痛綜合征

PFPSINPROFESSIONALTENNISPLAYER主觀檢查SubjectiveExamination27歲，職業(yè)網(wǎng)球運動員過去6個月里，左膝痛逐漸加重，膝前與膝外側(cè)疼痛，后者是從6周前更換護具才開始的，膝屈曲位均痛。疼痛已經(jīng)被迫退出巡回賽現(xiàn)在患膝不能負重，需使用步行架才能步行MRI顯示：外側(cè)滑車切跡骨損傷股四頭肌萎縮患者情緒低落，（排名下滑），擔(dān)心就此被迫退役REASONINGDISCUSSIONANDCLINICALREASONINGCOMMENTARY就上述病例信息，請能認識到哪些臨床特點？以上的兩個痛點，有哪些基本推斷？考慮哪些進一步的檢查？PT’sanswer痛髂脛束（ITB）綜合征髕下脂肪墊炎肌肉萎縮MRI軟骨軟化心理變化Clinicalreasoningcommentary推斷--潛在相關(guān)因素痛—髕腱炎、ITB-FS準確的診斷專家/新手臨床經(jīng)驗EBMREASONINGDISCUSSIONANDCLINICALREASONINGCOMMENTARY如何解釋該運動員膝關(guān)節(jié)情況逐漸加重？信息是否能夠更支持對膝痛病因的推斷PT’sanswer快速伸膝--刺激脂肪墊（發(fā)球與高壓球；治療性伸膝動作）屈膝（低位截擊）—抵消治療效用股四頭肌離心收縮—肌腱炎Clinicalreasoningcommentary診斷依據(jù)—推斷理解引致癥狀的病理機制REASONINGDISCUSSIONANDCLINICALREASONINGCOMMENTARY體格檢查望診站立位：股骨內(nèi)旋、膝外翻、腫脹的脂肪墊、后足僵硬和代償性中部足內(nèi)翻、股四頭肌萎縮、臀中肌不夠豐滿。被動檢查程序俯臥位，膝關(guān)節(jié)伸膝時過度受壓引致疼痛屈曲過壓McMurray’