運(yùn)動(dòng)療法治療青少年特發(fā)性脊柱側(cè)彎研究進(jìn)展

田飛，丁桃，閆博，呂沐橋

青少年特發(fā)性脊柱側(cè)彎(Adolescent Idiopathic Scolios，AIS)是一種原因不明的且沒有并發(fā)其他器質(zhì)性病變的脊柱三維方向上發(fā)生彎曲、旋轉(zhuǎn)的疾病，在10～16歲的青少年中患病率為1%～3%[1]。目前國(guó)內(nèi)關(guān)于運(yùn)動(dòng)療法在AIS中的作用幾乎沒有報(bào)道，國(guó)外雖有報(bào)道，但是存在爭(zhēng)議，本文將綜合國(guó)內(nèi)外相關(guān)研究資料，進(jìn)一步探討運(yùn)動(dòng)療法在AIS中的療效。

1 AIS的治療方式

目前，針對(duì)AIS治療方式的選擇，多根據(jù)Risser征和Cobb角情況的不同，采取以下幾種方式。①保守治療：若Risser征<Ⅲ度，同時(shí)局部Cobb角度<25°，或者Risser征為Ⅳ或Ⅴ度，但是未達(dá)到手術(shù)標(biāo)準(zhǔn)時(shí)，則采用以運(yùn)動(dòng)療法為主；如脊柱具備一定的生長(zhǎng)能力(Risser征<Ⅲ度)，局部Cobb角度在25°～40°之間，則采用Milwaukee支具或Boston支具，并配合以運(yùn)動(dòng)療法的治療手段(直到整個(gè)脊柱生長(zhǎng)停止和risser征Ⅳ度以上，方可去掉支具)[2]。②手術(shù)治療：若Cobb>40°，支具治療每年加重6°以上，或胸腰段、腰段側(cè)凸>35°，可以考慮手術(shù)治療[2-3]。

2 AIS的保守治療

常用的保守治療方式有運(yùn)動(dòng)療法、支具治療、物理因子治療等，其中支具治療的療效已得到公認(rèn)，物理因子治療和運(yùn)動(dòng)療法是否有效還存在爭(zhēng)議，但是越來越多的研究報(bào)道了運(yùn)動(dòng)療法在AIS中的有效性。

2.1 運(yùn)動(dòng)療法 運(yùn)動(dòng)療法是為了恢復(fù)正常的肌肉骨骼功能或減少疾病或損傷引起的疼痛，而設(shè)計(jì)和制定的身體活動(dòng)的方案或計(jì)劃[4-5]。在實(shí)施運(yùn)動(dòng)療法的過程中所使用的方法和技術(shù)稱為運(yùn)動(dòng)療法技術(shù)。臨床上對(duì)于AIS與非AIS脊柱側(cè)彎的鑒別很重要，因?yàn)獒槍?duì)兩種疾病所采取的運(yùn)動(dòng)療法技術(shù)與預(yù)后是完全不一樣的。針對(duì)AIS患者，目前國(guó)外報(bào)道的有效的運(yùn)動(dòng)療法技術(shù)有以下4種：SEAS、Schroth改良版的治療性康復(fù)訓(xùn)練技術(shù)、積極自我糾正和任務(wù)導(dǎo)向訓(xùn)練技術(shù)、前傾頭矯正訓(xùn)練技術(shù)。而Mulligan動(dòng)態(tài)關(guān)節(jié)松動(dòng)術(shù)[6]、髂腰肌收縮技[7]、普拉提訓(xùn)練技術(shù)等運(yùn)動(dòng)療法技術(shù)對(duì)非AIS脊柱側(cè)彎患者有效[8]，并且此類患者預(yù)后較AIS脊柱側(cè)彎患者好[5]。

2.1.1 積極自我糾正和任務(wù)導(dǎo)向訓(xùn)練技術(shù) 該項(xiàng)技術(shù)借助鏡子等工具讓患者發(fā)現(xiàn)異常的姿勢(shì)并進(jìn)行自我糾正，或者是通過讓患者在特定的環(huán)境內(nèi)完成明確的任務(wù)從而達(dá)到糾正脊柱側(cè)彎的目的[8]。兩項(xiàng)隨機(jī)對(duì)照實(shí)驗(yàn)表明，積極自我糾正和任務(wù)導(dǎo)向訓(xùn)練能減輕脊柱畸形，提高輕度青少年特發(fā)性脊柱側(cè)彎的生活質(zhì)量[8-9]。Monticone[8]的另一項(xiàng)研究將Cobb<25°的110名AIS患者隨機(jī)分為實(shí)驗(yàn)組(進(jìn)行主動(dòng)自我糾正訓(xùn)練、任務(wù)導(dǎo)向性訓(xùn)練和健康教育)和對(duì)照組(進(jìn)行傳統(tǒng)脊柱訓(xùn)練)，同時(shí)對(duì)所有的患者的影像學(xué)畸形、體表畸形和生活質(zhì)量進(jìn)行干預(yù)前后的評(píng)定，最后發(fā)現(xiàn)實(shí)驗(yàn)組的效果優(yōu)于對(duì)照組，并且自實(shí)驗(yàn)結(jié)束后，這種療效至少持續(xù)了一年[10]。

2.1.2 前傾頭的矯正訓(xùn)練技術(shù) 該技術(shù)認(rèn)為人體許多的姿勢(shì)反射存在于頭頸部，而許多AIS患者存在頭部前傾問題，因此可以通過控制頭頸部的運(yùn)動(dòng)達(dá)到糾正人體異常姿勢(shì)的目的[11]。Diab[12]的一項(xiàng)隨機(jī)對(duì)照研究將76位AIS患者(Cobb角介于10°～30°，顱椎角≥50°)分為實(shí)驗(yàn)組和對(duì)照組，所有患者都進(jìn)行傳統(tǒng)的牽伸和力量訓(xùn)練，實(shí)驗(yàn)組除此之外增加頭部的矯正訓(xùn)練。10周后，實(shí)驗(yàn)組僅在脊柱三維姿態(tài)參數(shù)上改善有統(tǒng)計(jì)學(xué)意義(P=0.8)，12周后，實(shí)驗(yàn)組在脊柱三維姿態(tài)參數(shù)和脊柱功能水平上改善均都有統(tǒng)計(jì)學(xué)意義(P=0.001)[11]。

2.1.3 Schroth改良版的治療性康復(fù)訓(xùn)練技術(shù) 該訓(xùn)練技術(shù)認(rèn)為脊柱周圍肌肉張力不平衡是造成脊柱側(cè)彎的主要原因，因此采用強(qiáng)化過松的肌肉，放松過緊的肌肉的訓(xùn)練方法可以糾正脊柱側(cè)彎[13]。Pugacheva等[13]研究發(fā)現(xiàn)姿勢(shì)矯正訓(xùn)練的確可以提高AIS的治療效果。

2.1.4 脊柱側(cè)凸科學(xué)訓(xùn)練方法(Scientific Exercise Approach to Scoliosis，SEAS) SEAS是意大利脊柱科學(xué)研究所的一種針對(duì)脊柱側(cè)凸患者進(jìn)行矯正的運(yùn)動(dòng)療法技術(shù)。該技術(shù)強(qiáng)調(diào)脊柱側(cè)彎在三維空間上都存在畸形，故通過治療團(tuán)隊(duì)制定個(gè)性化的治療方案，讓患者通過三維自我矯正的方法糾正胸彎、胸腰彎、腰彎、雙凸、駝背等畸形[14]。Zaina等[14]進(jìn)行2組回顧性對(duì)照研究，將一組56位AIS病人分成兩半，一半病人(Cobb角平均22°，Risser 0～3)每天接受SpineCor支具治療20h，另一半病人(Cobb角平均20°，Risser 0～3)每天僅接受SEAS訓(xùn)練，評(píng)估2組患者18個(gè)月前后的Cobb角和臨床癥狀的變化，結(jié)果示訓(xùn)練組Cobb角改善(大于5°)的比例比支具組高14.3%，而病情惡化的比例卻比支具組少7.1%。而另一組針對(duì)103位患者的研究結(jié)果卻顯示SpineCor支具比 SPORT支具在改善Cobb角方面更有效。

針對(duì)AIS的運(yùn)動(dòng)療法技術(shù)，都能改善患者脊柱側(cè)彎的度數(shù)，不僅如此，AIS患者的生活質(zhì)量、心理美感、脊柱活動(dòng)度也有改善。因此，對(duì)于適合運(yùn)動(dòng)療法治療的AIS患者，這些運(yùn)動(dòng)療法技術(shù)都可以選擇。不過，目前并沒有研究將這些有效的運(yùn)動(dòng)療法技術(shù)之間的療效進(jìn)行比較，所以如何選擇最佳的運(yùn)動(dòng)療法技術(shù)還有待進(jìn)一步研究證實(shí)。

2.2 運(yùn)動(dòng)療法結(jié)合支具治療 運(yùn)動(dòng)療法結(jié)合支具治療已有Meta分析表明，單獨(dú)的支具治療在AIS中的治療效果是肯定的。而運(yùn)動(dòng)療法結(jié)合支具治療與單獨(dú)支具治療的效果那個(gè)更好些，相關(guān)證據(jù)并不多。雖然支具并不能減少AIS患者手術(shù)率，但支具結(jié)合運(yùn)動(dòng)療法卻能改善側(cè)彎度數(shù)，提高生活質(zhì)量[12，15-17]。Negrin等[18]對(duì)符合美國(guó)科學(xué)研究學(xué)會(huì)標(biāo)準(zhǔn)的73位AIS患者進(jìn)行前瞻性隊(duì)列研究,結(jié)果示52.3%的患者在Cobb角改善上取得了滿意的效果，他們認(rèn)為使用支具結(jié)合運(yùn)動(dòng)療法比目前的文獻(xiàn)中提到的療效更好。Wnuk[19]等的一項(xiàng)個(gè)案報(bào)道指出，綜合運(yùn)用運(yùn)動(dòng)療法、支具治療和家庭自我訓(xùn)練，患者的呼吸功能、脊柱側(cè)彎和旋轉(zhuǎn)情況得到改善。雖然僅少量證據(jù)表明運(yùn)動(dòng)療法結(jié)合支具治療比單獨(dú)支具治療的效果(脊柱側(cè)彎和旋轉(zhuǎn)改善度、呼吸功能改善情況)更好，但是運(yùn)動(dòng)療法在提高患者生活質(zhì)量和心理美感方面的積極作用，是支具治療無法替代的。

3 小結(jié)

運(yùn)動(dòng)療法和支具治療在AIS的保守治療中起主要作用。AIS會(huì)影響青少年心理健康[20]，運(yùn)動(dòng)療法能提高患者心理的美感，而支具卻給患者帶來心理上的問題[21]。雖然以自我糾正為主要目標(biāo)的SEAS訓(xùn)練方法在減緩整個(gè)青春期脊柱側(cè)彎的進(jìn)程，延遲或避免其他更具有侵略性的治療方法方面存在爭(zhēng)議[22]，但是SEAS訓(xùn)練對(duì)AIS患者有確切的的療效(在減緩青春早期的脊柱側(cè)彎的進(jìn)程和改善Cobb角方面)[11，23-29]。

許多關(guān)于運(yùn)動(dòng)療法技術(shù)在AIS患者中的作用的研究是存在一定問題的。首先，一些研究只是報(bào)道了治療后患者的Cobb 角改變有意義，其實(shí)所謂的有意義只是很小的改變。其次，各種運(yùn)動(dòng)療法之間的療效比較未見報(bào)道。再者，這些研究并沒有指出患者的療效能持續(xù)多久。因此，應(yīng)該設(shè)計(jì)高質(zhì)量的隨機(jī)對(duì)照試驗(yàn)[25]，來進(jìn)一步證實(shí)各種運(yùn)動(dòng)療法技術(shù)在AIS中的治療作用，同時(shí)，哪種或哪幾種運(yùn)動(dòng)療法技術(shù)最有效也應(yīng)該去研究證實(shí)。

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