运动控制障碍课件

步行周期支撑相（Stancephase)早期中期末期摆动相(Swingphase)早期中期末期全国康复医学培训班步动力学数据全国康复医学培训班正常人步行时

侧面髋、膝、踝关节角度变化趋势

全国康复医学培训班

膝关节踝关节髋关节

步行动力学特征全国康复医学培训班

膝关节僵直膝关节僵直指步态摆动前相和摆动初期的关节屈曲角度<40度（正常为60度），同时髋关节屈曲程度及时相均延迟。摆动相膝关节屈曲是由髋关节屈曲带动，髋关节屈曲减少将减少膝关节屈曲度，从而减少其摆动相力矩。结果导致拖足。患者往往在摆动相采用患肢划圈步态、尽量抬髋或对侧下肢踮足（过早提踵）来代偿。全国康复医学培训班膝关节僵直动态EMG显示股直肌、股中间肌、股内肌和股外肌过分活跃，髂腰肌活动降低，有时臀大肌活动增加。如果同时存在足内翻，将加重膝关节僵直。全国康复医学培训班膝关节僵直-治疗股四头肌的股神经运动支酚注射，或肉毒毒素注射股四头肌各肌肉。术后应该进行股四头肌牵拉训练，以防止肌肉挛缩。患者可以在硬板床取俯卧位，膝关节屈曲，使髋关节处于牵伸状态。高抬腿步行可以作为屈髋肌肌力训练。全国康复医学培训班股四头肌转移至股薄肌改善屈膝功能改善屈髋功能全国康复医学培训班膝过伸膝过伸很常见，但一般是代偿性改变，多见于支撑相早期。治疗的关键在于纠正原发病因。全国康复医学培训班膝过伸常见诱因：一侧膝关节无力导致对侧代偿膝过伸；蹠屈肌痉挛或挛缩导致膝过伸；膝塌陷步态时采用膝过伸代偿；支撑相伸膝肌痉挛；躯干前屈时重力线落在膝关节中心前方，促使膝关节后伸以保持平衡。全国康复医学培训班膝关节屈曲患者在支撑相和摆动相都保持屈膝姿势。患者在支撑相时必须使用代偿机制以稳定膝关节。由于患者在摆动相末期不能伸膝，致使步长缩短。腘绳肌、股四头肌、腓肠肌、比目鱼肌的动态肌电图常显示腘绳肌内侧头比外侧头活跃，腓肠肌通常过分活跃，特别是在摆动相。全国康复医学培训班膝关节屈曲步态动力学研究常可见伸膝受限伴髋关节屈曲增加。全国康复医学培训班膝关节屈曲-治疗酚注射坐骨神经运动支和腘绳肌运动点。肉毒毒素注射也可以应用，但由于肌肉较大，所以注射的剂量需要较大。腓肠肌运动点酚或肉毒毒素注射比较容易。全国康复医学培训班膝塌陷小腿三头肌（比目鱼肌为主）无力时，胫骨在支撑相中期和后期前向行进过分，导致踝关节不稳或膝塌陷步态。患者膝关节过早屈曲，同时伴有对侧步长缩短，同侧足推进延迟，如果患者采用增加股四头肌收缩的方式避免膝关节过早屈曲，并稳定膝关节，将导致同侧膝关节在支撑相末期屈曲延迟，最终导致伸膝肌过用综合症。全国康复医学培训班膝塌陷患者在不能维持膝关节稳定时，必须使用上肢支持膝关节，以进行代偿。相关肌肉：腓肠肌-比目鱼肌和股四头肌。股四头肌肌电活动可延长和过度活跃。全国康复医学培训班2023/6/10第三届全国骨科康复研讨会2007CompensatoryMechanismofWalkingwithParalyzedQuadricepsFemoris

JiananLi,ShaoqinGu,GuangxuXuDepartmentofRehabilitationMedicineNanjingMedicalUniversityCHINA2023/6/10第三届全国骨科康复研讨会2007Quadricepsisamaincomponentforkneestabilityatstancephaseduringwalking2023/6/10WhattodowhenthequadricepsparalyzedPathologicalconditions:spinalcordinjury,postpoliomyelitis,etc.Theknee-ankle-footorthosis(KAFO)isoftenusedasthestandardprescriptionforpatientswithparalyzedquadriceps.2023/6/10LastepidemiologyofpoliomyelitisPizhou,China987newvictimsin19952023/6/10ClinicalobservationPatientaged16,non-functionalquadriceps,KAFOfor9years2023/6/10CouldshewalkwithoutKAFO?2023/6/10Couldshewalkwithoutcrutch?2023/6/10QuestionIsthereapotentialmechanismtomaintainthekneestabilitywithoutfunctionalquadriceps?Whetherananklefootorthosis(AFO)mayactasthefunctionalsupportforselectedpatientswithparalyzedquadriceps?2023/6/10TheaimofthisstudyToexplorethecompensatorymechanismofkneecontrolforwalkingwithunilateralnon-functionalquadricepsfemoris.2023/6/10PatientselectionPoliogroup:10patientspostpoliomyelitis(age16.7±0.7yrs)withunilateralnon-functionalquadriceps(MMT≤grade2),walkingwithKAFOformorethan8yrs.Normalgroup:10agematchednormalsubjects(age16.2±1.5yrs)Bodyweight,height,bodymassindexwerealsomatched.2023/6/10StudymethodsThe3-DmotionanalysisusingtheMotionAnalysisSystem(MotionAnalysisCo.,USA)Oxygenanalysisusingthegasanalyzer(CosmedK4b)2023/6/10ExperimentalconditionsOn-sitestudyFreewalkingwithKAFOAFOBarefoot2023/6/10AdaptationofAFOwearingAllpoliosubjectsaskedtomakeanAFOadaptationwearingmorethan30min/dayfor3weeks2023/6/10ParametersTime-spatialparametersSteplength,stridelength,stepwidth,stancephase,swingphase,stepwidth,footangleSegmentalparametersJointanglesofFoot,ankle,knee,hip,pelvis,trunkandshouldersOxygencostOC=VO2(ml/kg/min)/walkingdistance(m)2023/6/10Findings:Walkingspeed020406080100KAFOAFOBarefootNormal*#speed（m/min）*##Allconditionsinpolioisslowerthanthenormalgroup(p<0.05)KAFOandbarefootareslowerthanAFO(p<0.05).Polio2023/6/10Findings:OxygenCost00.050.10.150.20.250.30.350.40.450.5KAFOAFOBarefootNormalOxygenCost（ml/m.kg）*#*##Allconditionsinpolioarehigherthanthenormalgroup(p<0.05)KAFOandbarefootarehigherthanAFO(p<0.05).2023/6/10OxygenCost氧价步态异常治疗的金标准正常步态=自然步态要素：省力、安全、有效定量步行时的最低OC=最省力的步行=最安全的步行=最有效的步行2023/6/10Findings:Steplength(cm)withthenormalleg2023/6/10Findings:Singlelegsupport%2023/6/10Findings:Hipextensionatmidstance2023/6/10Findings:Kneeangleatmidstance2023/6/10QuadricepsarenotactivatedduringmidstanceinnormalgaitIfthekneejointalwaysbehindofthecentralgravity,quadricepsmaynotplayaroleinmaintainingkneestabilityatthestancephase.2023/6/10膝关节不稳的代偿机制膝过伸支撑相时间缩短对侧拐杖踝关节稳定（AFO）膝关节固定（KAFO）支撑相中期髋关节屈曲，重心前移股四头肌/膕绳肌收缩2023/6/102023/6/10支撑相早期-儿麻的困难时期2023/6/10代偿性步态全脚掌触地，减少支撑相早期的屈膝角度缩短健侧步长，从而缩短患肢支撑相时间患肢膝过伸，依赖腘韧带稳定膝关节髋过伸或者屈曲（用拐），改变人体重心2023/6/102023/6/102023/6/10Compensation=CompromiseThecompromisedapproachestoadjustthecentralgravityduringwalkingforthispatientgroupare:AFOwearingMinorkneeextensionandhipflexionatthemidstancereductionofsteplength2023/6/10AFO对膝关节稳定的价值人体重心位于膝关节前阻止胫骨前移阻止胫骨后移保证重心稳定2023/6/10Reviewthedemocase2023/6/10ConclusionTheanklestabilitystrengthenedbyAFOleadtoabettergaitpatternandlowerenergyconsumptionforpatientswithunilateralnon-functionalquadriceps.AFOmayplayanimportantcompensatorymechanismforkneecontrolduringwalkingwithparalyzedquadriceps.Therefore,theKAFOmaynotbethesolechoiceinthiscondition.2023/6/10ClinicalsignificanceSelectedpatientswithnon-functionalquadricepsmightuseAFOinsteadofKAFOforabettergaitpatternamoreefficientwalkingcheaperrehabcostmorefunctionaldailyactivities2023/6/10ChallengesLongtermeffect