运动控制障碍课件

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,全国康复医学培训班,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,全国康复医学培训班,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,全国康复医学培训班,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,全国康复医学培训班,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,第三届全国骨科康复研讨会2007,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,第三届全国骨科康复研讨会2007,*,步行周期,支撑相（,Stance phase),早期,中期,末期,摆动相(,Swing phase),早期,中期,末期,全国康复医学培训班,步行周期支撑相（Stance phase)全国康复医学培训班,步动力学数据,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,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,步行动力学特征,全国康复医学培训班,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,膝关节僵直膝关节僵直指步态摆动前相和摆动初期的关节屈曲角度,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,膝关节僵直动态EMG显示股直肌、股中间肌、股内肌和股外肌过分,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,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,股四头肌转移至股薄肌改善屈膝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,膝过伸膝过伸很常见，但一般是代偿性改变，多见于支撑相早期。全,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,膝过伸常见诱因：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,膝关节屈曲患者在支撑相和摆动相都保持屈膝姿势。患者在支撑相时,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,膝关节屈曲步态动力学研究常可见伸膝受限伴髋关节屈曲增加。全国,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,膝关节屈曲-治疗酚注射坐骨神经运动支和腘绳肌运动点。全国康复,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,膝塌陷小腿三头肌（比目鱼肌为主）无力时，胫骨在支撑相中期和后,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,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,2024/8/22,第三届全国骨科康复研讨会2007,Compensatory Mechanism of Walking with Paralyzed Quadriceps Femoris,Jianan Li, Shaoqin Gu, Guangxu Xu,Department of Rehabilitation Medicine,Nanjing Medical University,CHINA,2023/8/31第三届全国骨科康复研讨会2007Compe,2024/8/22,第三届全国骨科康复研讨会2007,Quadriceps is a main component for knee stability at stance phase during walking,2023/8/31第三届全国骨科康复研讨会2007Quadr,2024/8/22,What to do when the quadriceps paralyzed,Pathological conditions: spinal cord injury, post poliomyelitis, etc.,The knee-ankle-foot orthosis (KAFO) is often used as the standard prescription for patients with paralyzed quadriceps.,2023/8/31What to do when the q,2024/8/22,Last epidemiology of poliomyelitis,Pizhou, China,987 new victims in 1995,2023/8/31Last epidemiology of,2024/8/22,Clinical observation,Patient aged 16, non-functional quadriceps, KAFO for 9 years,2023/8/31Clinical observationP,2024/8/22,Could she walk without KAFO?,2023/8/31Could she walk withou,2024/8/22,Could she walk without crutch?,2023/8/31Could she walk withou,2024/8/22,Question,Is there a potential mechanism to maintain the knee stability without functional quadriceps?,Whether an ankle foot orthosis (AFO) may act as the functional support for selected patients with paralyzed quadriceps?,2023/8/31Question Is there a p,2024/8/22,The aim of this study,To explore the compensatory mechanism of knee control for walking with unilateral non-functional quadriceps femoris.,2023/8/31The aim of this study,2024/8/22,Patient selection,Polio group: 10 patients post poliomyelitis (age 16.70.7 yrs) with unilateral non-functional quadriceps (MMT grade 2), walking with KAFO for more than 8 yrs.,Normal group: 10 age matched normal subjects (age 16.21.5 yrs),Body weight, height, body mass index were also matched.,2023/8/31Patient selectionPoli,2024/8/22,Study methods,The 3-D motion analysis using the Motion Analysis System (Motion Analysis Co., USA),Oxygen analysis using the gas analyzer (Cosmed K4b),2023/8/31Study methodsThe 3-D,2024/8/22,Experimental conditions,On-site study,Free walking with,KAFO,AFO,Barefoot,2023/8/31Experimental conditio,2024/8/22,Adaptation of AFO wearing,All polio subjects asked to make an AFO adaptation wearing more than 30 min/day for 3 weeks,2023/8/31Adaptation of AFO wea,2024/8/22,Parameters,Time-spatial parameters,Step length, stride length, step width, stance phase, swing phase, step width, foot angle,Segmental parameters,Joint angles of Foot, ankle, knee, hip, pelvis, trunk and shoulders,Oxygen cost,OC=VO2 (ml/kg/min)/walking distance (m),2023/8/31ParametersTime-spatia,2024/8/22,Findings: Walking speed,0,20,40,60,80,100,KAFO,AFO,Barefoot,Normal,*,#,speed,（,m/min,）,*,#,#,All conditions in p,olio is slower than the normal group (p0.05),KAFO and barefoot are slower than AFO (,p0.05,).,Polio,2023/8/31Findings: Walking spe,2024/8/22,Findings: Oxygen Cost,0,0.05,0.1,0.15,0.2,0.25,0.3,0.35,0.4,0.45,0.5,KAFO,AFO,Barefoot,Normal,Oxygen Cost,（,ml/m.kg,）,*,#,*,#,#,All conditions in polio are higher than the normal group (p0.05),KAFO and barefoot are higher than AFO (,p0.05,).,2023/8/31Findings: Oxygen Cost,2024/8/22,Oxygen Cost,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,2023/8/31Oxygen Cost 氧价步态异常治疗的,2024/8/22,Findings: Step length (cm) with the normal leg,2023/8/31Findings: Step length,2024/8/22,Findings: Single leg support %,2023/8/31Findings: Single leg,2024/8/22,Findings: Hip extension at mid stance,2023/8/31Findings: Hip extensi,2024/8/22,Findings: Knee angle at mid stance,2023/8/31Findings: Knee angle,2024/8/22,Quadriceps are not activated during mid stance in normal gait,If the knee joint always behind of the central gravity, quadriceps may not play a role in maintaining knee stability at the stance phase.,2023/8/31Quadriceps are not ac,2024/8/22,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,2023/8/31膝关节不稳的代偿机制 膝过伸,2024/8/22,2023/8/31,2024/8/22,支撑相早期,-,儿麻的困难时期,2023/8/31支撑相早期-儿麻的困难时期,2024/8/22,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,2023/8/31代偿性步态全脚掌触地，减少支撑相早期的屈膝,2024/8/22,2023/8/31,2024/8/22,2023/8/31,2024/8/22,Compensation=Compromise,The compromised approaches to adjust the central gravity during walking for this patient group are:,AFO wearing,Minor knee extension and hip flexion at the mid stance,reduction of step length,2023/8/31Compensation=Compromi,2024/8/22,AFO,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,2023/8/31AFO对膝关节稳定的价值人体重心位于膝关节,2024/8/22,Review the demo case,2023/8/31Review the demo case,2024/8/22,Conclusion,The ankle stability strengthened by AFO lead to a better gait pattern and lower energy consumption for patients with unilateral non-functional quadriceps.,AFO may play an important compensatory mechanism for knee control during walking with paralyzed quadriceps.,Therefore, the KAFO may not be the sole choice in this condition.,2023/8/31ConclusionThe ankle s,2024/8/22,Clinical significance,Selected patients with non-functional quadriceps might use AFO instead of KAFO for,a better gait pattern,a more efficient walking,cheaper rehab cost,more functional daily activities,2023/8/31Clinical significance,2024/8/22,Challenges,Long term effect of knee extension on stance? Pain? Knee joint injuries? Potential post-polio syndromes?,Whether this mechanism applicable in bilaterally impaired legs?,Muscle behavior during walking?,Kinetic mechanism during walking?,.,Further studies are required,2023/8/31Challenges Long term,2024/8/22,第三届全国骨科康复研讨会2007,thank you,2023/8/31第三届全国骨科康复研讨会2007 than,