课件：脊髓损伤患者辅助器械行走的影响.pptx

The influence of walking with an orthosis on bone mineral density by determination of the absolute values of the loads applied on the limb,通过测定下肢的绝对值载荷来探讨配戴矫形器步行对骨密度的影响。,Abstract Spinal cord injury is damage to the spinal cord that results in loss of mobility and sensation below the level of injury. Most patients use various types of orthoses to stand and walk. It has been claimed that walking and standing with orthosis reduces bone osteoporosis, improves joint range of motion and decreases muscle spasm. Unfortunately, there are discrepancies regarding the clinical effects of walking and standing on bone mineral density.,脊髓损伤是指损伤脊髓而导致损伤平面以下活动能力和感觉的丧失。大多数患者借用各类矫形器站立和行走。Y有人认为，配戴矫形器直立和走路可减少骨质疏松，改善关节活动度，并减少肌肉痉挛。然而，关于行走和站立对骨密度的临床效果存在差异。,The aim of this research was to find the absolute values of the loads transmitted by body and orthosis in walking with use of an orthosis. 5 normal subjects were recruited to stand and walk with a new design of reciprocal gait orthosis. The loads transmitted through the orthosis and anatomy was measured by use of strain gauge and motion analysis systems.,目的：得出配戴矫形器步行时通过身体和矫形器传导的载荷绝对值。实验对象：5例健康受试者配戴一种新型的复式步行矫形器（RGO）站立和行走。 方法：通过张力计量器和运动分析系统来得到通过身体解剖结构和矫形器传输的负荷。,结果：通过解剖结构得到的数据比矫形器得到的数据更有意义。此外，该矫形器和身体的力和力矩模式彼此完全不同。在配戴矫形器行走的过程中，携带矫形器行走能够影响骨密度是由于大部分的载荷通过解剖结构进行综合的传递。,It has been shown that the loads applied on the anatomy were significantly more than that transmitted through the orthosis. Moreover, the patterns of the forces and moments of the orthosis and body completely differed from each other. As the most part of the loads applied on the complex transmitted by anatomy in walking with an orthosis, walking with orthosis can influence bone mineral density.,Introduction,Spinal cord injury (SCI) is characterized according to the amount of functional loss, sensational loss and of the inability to stand and walk 1, 2. The incidence of SCI varies amongst countries. For example there are 12.7 and 59 new cases per million in France and the United States of America, respectively 3, 4.,脊髓损伤（SCI）的特点包括功能、感觉的丧失及不能行走和直立。在各个国家，脊髓损伤的发病率各不相同。比如，在法国每年一百万人中有12.7例发病，而美国有59例。,It may be a result of trauma (especially motor vehicle accident), penetrating injuries, or disease. As a result of this type of disability most SCI individuals rely on a wheelchair for their mobility. They can transport themselves from one place to another using a manual wheelchair with the speed and energy expenditure which is similar to normal subjects 5, 6.,它可以由创伤（特别是交通事故） ，穿通伤，或疾病导致。由于这种类型的残疾大多数脊髓损伤的患者靠轮椅移动。他们可以如正常人一样，借助手动轮椅从一个地方到另一个地方。,Although, wheelchair use provides mobility to those patients, it is not without problems. The main problems are the restriction to mobility from architectural features in the landscape, and a number of health issues due to prolonged sitting. Decubitus ulcers, osteoporosis, joint deformities,especially hip joint adduction contracture can result from prolonged wheelchair use 7. SCI individuals often undergo various rehabilitation programmes for walking and exercises. It is claimed that walking is a good exercise for paraplegics in order to maintain good health; decrease urinary tract infections; improve cardiovascular and digestive systems functions and improve psychological health and decreasing bone osteoporosis 7.,虽然，患者可以通过轮椅移动，但也存在些问题。主要问题是活动场所受到建筑特征的限制，及长期坐位所带来的健康问题。如褥疮溃疡，骨质疏松，关节畸形，尤其是长期使用轮椅引起的髋关节内收挛缩。脊髓损伤患者通常进行过各种步行方面的康复训练。据称，步行可以很好的维持截瘫患者的身体健康：降低泌尿道感染，改善心血管系统和消化系统功能，促进心理健康，减少骨质疏松。,Shortly after SCI, the metabolism changes resulting in the body sending a large amount of calcium and other minerals in the urine. This happens independently of the weight, age and sex of the person. The rate of calcium and mineral loss is high during the first 616 months after the injury. Osteoporosis also happens due to the reduction of body weight applied to the bones. Due to SCI these patients cannot stand and apply load to the lower limb bones, the bones become weaker and thus more brittle.,SCI 早期，新陈代谢的改变导致大量的钙和其他的矿物质进入尿中。这种现象与个人的体重，年龄和性别无关。钙和矿物质流失的速率在损伤后的6-16个月最快。骨质疏松症也因施加到骨头上的体重的减少而发生。由于脊髓损伤患者不能通过站立使得下肢骨负重，下肢骨变得越来越脆弱。,In contrast to the lower limbs, more force may be applied on the upper limbs and spine; as a result the percentage of osteoporosis in the upper limb and spine is significantly less than that in the lower limb bones 8. In the research undertook by Biering et al. 9, the bone mineral density (BMD) of lumbar spine and the proximal part of tibia was measured 41 months after injury in a group of paraplegic subjects with complete lesion at C7T1. It was shown that BMD remain unchanged in lumbar spine, however, it decreased to 50 and 70% of normal value at proximal tibia and femoral neck respectively.,与下肢相比，更多的力施加于上肢和脊柱，从而使得上肢和脊柱骨质疏松的百分比比下肢骨低。Biering等人研究了一组C7-T1完全性损伤的患者，测量了腰椎和胫骨近端部分的骨矿物质密度（BMD）。其结果表明， BMD在腰椎没有变化，然而，在胫骨近端和股骨颈分别降至50，即70 的正常值。,Although it was claimed that standing and walking with an orthoisis or a frame had a significant influence on BMD in SCI individuals 7, 10, the results of various research studies has shown that using KAFO (knee ankle foot orthosis) orthosis dose not influence BMD 9, 11,12.Moreover, the duration of the training and using orthosis influence the effects of standing on BMD. Alekna et al.12 showed that BMD of the proximal tibia increased by 10% if the training was done 30 min per day, and 3 days per week, however if the exercise was done 30 min per day and one day per week it did not influence the bone density.,虽然有人声称，利用矫形器或支架站立和行走能够改善SCI患者的BMD，但各研究的结果表明，使用KAFO （膝踝足矫形器）矫形器并不能影响骨密度。此外，持续的训练和使用矫形器能改变站立对BMD的效果。阿列克纳等人实验表明，每天训练30分钟，每周3次能够增加10胫骨近端的骨密度，然而，若每天训练30分钟，每周就一次则对骨密度不起作用。,In the research carried out by Sabo et al. 13, the BMD of the proximal and distal parts of the femur and lumbar spine of 46 male SCI patients, with an average age of 32 years, was monitored regularly. They found a significant difference between the amounts of the BMD of the femur, but not the lumbar spine, between complete and incomplete paraplegic subjects. The level of the BMD of the femur did not show a significant difference between ambulatory and none ambulatory participants. They concluded that the rehabilitation treatment must be for a long time to have a significant impact on the BMD level.,萨博等人定期监测平均年龄在32岁的46名男性脊髓损伤的股骨近侧和远侧端和腰椎的骨密度的研究表明，在完全性和不完全性脊髓损伤的患者中，股骨的BMD的大小有差异性改变，而腰椎没有。股骨骨密度水平在能走动和不能走动的患者中没有差异性改变。他们总结道，只有长时间的康复治疗才能显著影响BMD的水平。,There are only two researches which support the influence of using and standing with orthosis on BMD. Douglas et al. mentioned that using an orthosis increases the bone density, however, they did not present any evidences regarding their claim. In the research undertook by Goemaere et al. 14 it was shown that the use of KAFO had significant effects on BMD at the proximal Femur. The results of this research showed that passive mechanical loading can have a beneficial effect on preservation of bone mass. It has been shown that vertical loads and moments applied on the bone have a significant influence on BMD.,只有两项研究支持使用矫形器站立对骨密度的影响。道格拉斯等人提到使用矫形器能够增加骨密度，但是，他们并没有提出任何证据来证明他们的结论。在Goemaere等人的研究中表明，使用KAFO对股骨近端的骨密度有显著作用。该研究结果显示，被动的机械负载有益于保存骨质量。它已经表明，施加于骨上的垂直载荷和力矩对BMD有显著意义。,The density of long bones such as femur and tibia depends upon the applied loads. However, it was assumed that the loads applied on limb and orthosis complex during paraplegic walking is transmitted by orthosis structure not by body 15. If this assumption is true, walking and standing with an orthosis does not have any significant influence on BMD.,长骨如股骨和胫骨的密度取决于施加的载荷。然而，人们认为在应用过程中截瘫行走肢体矫形器复杂的负载是通过矫形器结构传播的而非身体。如果这个假设是真的，配戴矫形器走路和站立对于骨密度就没有任何影响。,Unfortunately there is no research study which measured the absolute values of the loads applied on the orthosis and leg during walking. Therefore, the aim of this research study was to measure the total values of the loads applied on the orthosis and body complex. Moreover, it was aimed to measure the absolute values of the loads transmitted by orthosis structure. If the percentage of the loads transmitted by orthosis is small, it can be concluded that walking and standing with an orthosis can influence bone osteoporosis.,遗憾的是，目前还没有一项研究是测量行走时施加于矫形器和腿部的绝对负荷值的。因此，这项研究的目的是测量施于矫形器和本体综合的负载总值。此外，它旨在测量通过矫形器结构传播的负荷的绝对值。如果通过矫形器传递的负载百分比较小，可以断定配戴矫形器走路和站立可以影响骨质疏松。,Method Equipment A new RGO (reciprocal gait orthosis) orthosis was designed, based on the hip guidance orthosis, which allows independent donning and doffing by the user. The components of this orthosis were designed to be capable of being aligned with respect to each other. It has an open structure, similar in design to the ARGO (advanced reciprocal gait orthosis) with an improved performance. It allows alignment changes of the orthosis while the user is wearing the orthosis, and the modularity of the orthosis allows easy transportation. The orthosis was made of three main parts, the AFO (ankle foot orthosis), Torso and lateral bars which were connected to each other by using some pins.,一个新型的RGO （复式步态矫形器）的设计，是基于所述髋指导矫形器。患者可以自行的穿戴和脱落。本矫形器的组件能够彼此校对。它有一个开放的结构，在设计上与具有更好的性能的ARGO （高级复式步态矫形器）相似。当用户穿用矫形器时，充许矫形器的排列变化，以及矫形器的模块化使之运输方便。矫形器主要由三部分组成， AFO （踝足矫形器） ，躯干和由螺丝等相连接的侧向金属条。,Kinematic and kinetic assessments were performed in the gait lab using 8 infrared cameras of a 3D gait analysis system (Vicon Motion Analysis System, Ltd., Oxford, UK) and four force plates (Kistler). The data were analysed by using a biomechanical model developed with body builder software (body builder for biomechanics was developed by Vicon motion analysis system, Ltd., Oxford, UK). This software allows calculation of the forces and moments of the different joints from the collected raw data.,在步态实验室进行运动学和动力学评估，使用8个红外摄像机的三维步态分析系统和四个测力板 。运用身体建设者开发的一个生物力学模型软件来分析所得数据。这软件能够计算从不同关节收集到的原始数据的力和力矩。,In order to determine the loads applied on the orthosis during walking, strain gauges, supplied by Showa measuring company (Tokyo, Japan) were attached on the lateral bar of the orthosis near the left side hip joint, using especial glue which was recommended by Vishay measuring group (USA). The adhesive was used according to the procedure recommended by the supplier. It was covered with silicon rubber to protect it during sitting of the participants with the orthosis. The strain gauges consisted of three channels for axial force, flexing/extending and abducting/adducting moments. Three full strain gauge bridges on the orthosis were connected by special 4-wire ribbon cables to a 25-way terminal plug. A length of 25-way cable connected the gauges to amplifiers (developed in Bioengineering Unit of Strathclyde University). The output of the amplifier was connected to a DAQ card which was inserted into a laptop and also to the force plate amplifiers. The outputs of the strain gauges were synchronized with the Vicon system. Figure2shows the location of the strain gauges attached on the lateral bar of the orthosis.,为了确定在行走时施加在矫形器的载荷，由Showa测量公司（东京，日本）提供的应变仪被装在矫正装置的近左侧髋关节的横杆上，使用的是由Vishay测量组（美国）推荐的特殊的胶水。该粘合剂按照供应商推荐的方法使用。为了保护应变仪在携带矫形器的患者坐位过程中不受损害，应变仪的表面覆盖了硅胶。应变仪由轴向力，弯曲/伸展和外展/内收三个力矩渠道组成。矫形器三全应变计桥通过特殊的4线带状电缆连接到一个25路终端插头上。再将长为 25路的电缆连接到仪表放大器上 。放大器的输出端是连接到一台笔记本电脑的数据采集卡和力学模板放大器中。应变计的输出与威康系统进行同步。 图2展示的是附着在矫形器的侧杆的应变计的位置。,Subjects Five normal subjects participated in this study. They had no deformity and contraindication for standing and walking or complicated medical history. The mean values of their age, height and mass were 27.27 years (1831), 1.75 m(1.721.78) and 78 kg (60.589), respectively. The subjects were trained for 4 h to don and doff the orthosis independently and to stand and walk with the orthosis using two crutches. The subjects were asked to walk on a level surface. The tests were repeated 5 times and the force applied on the foot and crutch were collected at the same time.,五个正常人参加了这项研究。他们无站立和行走的畸形和禁忌，或复杂的病史。他们年龄、身高和体重的平均值分别是27.27岁（ 18-31 ） ， 1.75米（ 1.72-1 .78 ）和78kg（ 60.5-89 ）。受试者被训练4小时来独立穿戴和脱下矫形器，并用两根拐杖来配戴矫形器站立和行走。受试者被要求在水平面上行走。该试验重复5次，并同时收集施加在脚和拐杖的力。,Parameters The Spatio-temporal gait parameters, hip joint flexion/extension, abduction/adduction excursions, the moment transmitted through hip joint complex, the loads applied on the lateral bar of the orthosis and crutch were the main parameters selected in this research.,参数 本研究中所选择的主要参数: 时空步态参数，髋关节屈曲/伸，外展/内收偏移，通过髋关节复杂传输的力矩，施加于矫形器和拐杖的横杆的负载。,Procedure The strain gauge bridges were calibrated by applying known loads along the axis when the bar of the orthosis was located horizontally and vertically in specifically manufactured calibration jigs. This procedure is known as static calibration and is used routinely for calibration of strain gauges and transducers. The calibration gave information on coefficients which were used to convert the output into loads. The weights are made to a high degree of accuracy which exceeds the value required for the calibration. The amplifier gain setting was arranged as 10,000 for axial force and 2,000 for bending moments. The output of three channels reset to zero. Then the first load was put on the carrier and this was increased up to 20 and 50 kg insteps of 5 kg for moments and axial force,respectively. The following equations were used to change the output of the strain gage into force and moments 16,当矫形器的横杆位于水平和垂直方向的专门制造的校准夹具时，应用已知的负载的轴来校准应变计桥梁。这个过程被称为静态校正，并常规用于校正应变计和传感器。这个校正把输出的系数信息转变为负荷。权重作出的高度准确性，超过所需的校准值。该放大器增益设置被安排为10,000轴向力和2,000弯矩。三个通道的输出量重置到零。然后第一负载被放于载体上，从而分别为5公斤的脚背力矩和轴向力增加至20和50千克。下面的等式用来把应变器的输出值转换为力和力矩：,其中， Fy：垂直方向的力 A：区域，E：杨氏模量， Vout: 输出电压，Vin 输入电压，k:应变系数， Mz:前后弯曲力矩，Izz:对于前后弯曲力矩的面积二次矩，c:该表面离自然轴的距离，Mx:内外侧的弯曲力矩，Ixx:侧位弯曲力矩在该区域的二次矩。,此图展示的主轴线的方向以及在上述方程式所使用的一些变量的定义。,The markers used in this research were 14 mm spheres covered with a reflective sheet that was recognized by the cameras. The marker placement protocol was the preferred method of marker fixation and subsequent identification used in the Bioengineering Unit of University.Fourteen markers were used for the right and left anterior superior iliac spine (ASIS), right and left posterior superior iliac spine (PSIS), medial and lateral malleolus, first and fifth metatarsal heads and heels. Moreover, four marker clusters comprising four markers attached on rhomboid plates were attached to the anterior surfaces of the legs and thighs using extensible Velcro straps.,在本研究中所用的标志物均为覆盖有反射片能被照相机识别的14毫米球体。本标记放置的协议是用于斯特拉思克莱德大学的生物工程部门固定标记和随后的鉴定使用的首选方法。14个标记物用于右、左髂前上棘（ ASIS ） ，左，右髂后上棘（ PSIS ） ，内外侧踝，第一和第五跖骨头和跟。此外，四个标记集群包括附着在菱形板的四个标记用可扩展的尼龙帶附连到腿和大腿的前表面。,The location of the knee joint epicondyles on the medial and lateral sides was determined using a pointer technique 17. There was no problem in using the markers during walking with the orthosis, because they were attached on the relevant sections of the orthosis. In order to increase the visibility of the camera the clusters were placed equally between the anterior and lateral planes of the subject legs. The marker attachment process was begun from the most distal segment of the lower extremity.,用一个指针技术确定膝关节髁上的内、外侧位置。在配戴矫形器行走过程中使用标记是没有问题的，因为它们被装贴在矫正器的相关截面上。为了增加照相机的可视性，标记簇均匀放置在主体的腿的前部和横向平面之间。标记物附着过程是从下肢的最远侧段开始的。,The subjects were asked to walk at a comfortable speed along the gait lab. The walking tests were repeated to collect 5 successful trials. The data of the force plate,Vicon and strain gauges were collected at the same time and at the same frequency (120 Hz). The collected data were filtered (Woltring filter with frequency as 10) 18, 19 and split into gait cycle intervals using the heel strike data.The moments applied on the hip joint and on the lateral bar of the orthosis and the force transmitted through crutch,foot and orthosis were normalized by body mass (kg) and body weight (N), respectively.,受试者被要求以一个舒适的速度沿步态实验室行走。行走试验重复成功收集5次。在同一时间和同一频率（120赫兹）收集力板、威康和应变仪的数据。所收集的数据进行过滤，并通过脚跟击打数据分为步态周期间隔。施加于髋关节，矫形器的横杆的力矩及通过拐杖，脚和矫形器传输的力通过体重（公斤）和重力（N），分别进行标准化。,Result,上表示施加在矫形器络合物（矫形器和身体）和矫正装横杆力矩和力的平均值。,近50 施加在总的结构的内收力矩是由矫形器传输,施加在矫正装置复杂的垂直力模式,施加在矫正装置的横杆的垂直力模式,施加在髋关节复合结构上的屈曲/伸展力矩,施加在矫正装置横杆上的屈曲/伸展力矩,从两图观察到大部分负荷由体内传输而不是由矫形器。此外，弯曲/伸展力矩的模型各不相同。施加在所述复合物和矫形器的弯曲力矩分别是0.54和0.0366牛顿米/千克体重。相比之下，近半数施加在复合物的伸展力矩是由矫形器传输的。,施加在髋关节复合结构上的内收力矩,施加在矫形器横杆上的内收力矩,施加在矫形器和髋关节复合物的内收力矩的图案的是相似的,The vertical force applied on the crutch is the other parameter collected in this research. The vertical force of the crutch, the complex, and the orthosis were 0.16, 1 and 0.108 N/BW, respectively, which represent that the role of leg to transmit the vertical force is more than that of the orthosis. Moreover, there was a big difference between the type of the force applied on the limb and the orthosis (it can be observed from Figs.4, 5that the main vertical force transmitted by the orthosis and the body were tensile and compression forces, respectively). As the patterns and magnitudes of the loads transmitted by orthosis and the complex, anatomy and orthosis, differed from each others,it can be understood that walking and standing with orthosis can influence BMD.,施加在拐杖的垂直力是这项研究中的另一个参数。施于拐杖、络合物和矫形器的垂直力矩分别为0.16 ， 1和0.108 / BW ，这表明腿对垂直力矩的传输超过矫形器。此外，施加于肢体和矫形器上力的种类有很大的不同（从图4图5得出，垂直力主要通过矫形器传输，而身体主要为拉伸和压缩力）。正如通过矫形器和络合物，解剖学和矫形器传输的载荷的图案和大小的不同，可以理解的是配戴矫形器行走和站立可以影响骨密度。,Discussion Unfortunately, there is lack of information in literature regarding the force and moment transmitted by hip knee ankle foot orthosis (HKAFO). However, some researchers have carried out studies to find out the loads applied on KAFO during walking of normal and handicapped subjects26, 27. The magnitude of the vertical force applied on the lateral bar of a KAFO orthosis varied between 86 and 320 N which is not comparable to the loads transmitted by the orthosis and anatomy complex. The mean values of adducting, flexion and extending moments transmitted by orthosis structure (measured by using a transducer) in walking of handicapped subjects were 1.43, 6.93 and 30 Nm respectively, which represent that most parts of the loads are transmitted through the anatomy. Moreover, the mean values of the loads applied on the orthosis in handicapped subjects were nearly the same