身高对腰椎斜扳手法“咔哒”声响时推扳力的影响

目的研究身高对腰椎斜扳手法"咔哒"声响时推扳力的影响,为手法提供定量化依据。方法使用压力检测系统,测量并记录对不同身高两组受试者进行斜扳手法出现"咔哒"声响时的推扳力。结果以出现"咔哒"声响作为腰椎斜扳手法成功的标志,此刻对身材较高和较矮的受试者肩部的平均推扳力分别为(12.814±1.264)kg和(12.414±1.387)kg,臀部的推扳力分别为(13.627±1.351)kg和(13.500±1.094)kg。结论斜扳手法操作时所需推扳力的大小与身高无直接关系。     

腰椎斜扳手法所致“咔哒”声时推扳力的研究

摘要 目的：研究腰椎斜扳手法所致咔哒声响时推扳力的大小，为手法提供定量化依据。方法：使用压力检测系统，测量并记录向左右分别进行斜扳手法出现咔哒声响时作用在肩部和臀部的推扳力。结果：以出现咔哒声响作为腰椎斜扳手法成功的标志，此刻对左右肩部平均推扳力分别为12.552±1.715kg和12.748±1.645kg，对左右臀部平均推扳力分别为13.587±1.631kg和13.274±1.200kg。结论：向左右分别进行斜扳手法时，对左右肩部或臀部的平均推扳力无显著差异（P＞0.05），但对臀部的推扳力大于对肩部的推扳力（P=0.016）。 关键词 斜扳手法；推拿；手法；咔哒声响；推扳力 中图分类号：R244.1,R49 文献标识码：A 文章编号：1001-1242(2008)-03-0202-03     

两种颈椎旋转手法所致咔哒声响的比较

目的:研究两种颈椎旋转手法作用时咔哒声响次数,并进行比较分析。方法:72名健康在校大学生,随机分为两组:实验1组和对照1组,均采用先向左后向右扳动的颈椎旋转手法,其中实验1组施行常规快速颈椎旋转手法,左右各2次;对照1组施行慢速颈椎旋转手法,左右各2次。间隔1周后进行第二轮实验,仍然随机分为两组,实验2组和对照2组,均采用先向右后向左扳动的颈椎旋转手法,其中实验2组仍施行常规快速颈椎旋转手法,左右各2次,对照2组仍施行慢速颈椎旋转手法,左右各2次。运用自行设计的声响采集系统对手法所致的咔哒声响进行采集,分析其发出声响的次数,并进行统计学分析。结果:第一次旋转时,实验1组和对照1组在亚生理区内继续向左旋转出现的咔哒声响次数差异有显著性意义(t=4.077,P=0.009),向右旋转出现的咔哒声响次数差异同样有显著性意义(t=2.017,P=0.047);实验2组和对照2组在亚生理区内继续向左旋转出现的咔哒声响次数差异有显著性意义(t=2.014,P=0.048),向右旋转出现的咔哒声响次数差异同样有显著性意义(t=3.281,P=0.002);实验1组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异有显著性意义(t=1.87,P=0.007),向左产生的声响次数少于向右者;实验2组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异也有显著性意义(t=4.077,P=0.009),向右产生的声响次数少于向左者;对照1组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异无显著性意义(t=0.499,P=0.620),对照2组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异也无显著性意义(t=1.825,P=0.072)。第2次重复实施颈部旋转手法时产生咔哒声响次数的比较结果发现,四组受试者在全部操作过程中出现了极少的咔哒声响,两两比较组间差异无显著性意义(P>0.05)。结论:在颈椎旋转手法时,在亚生理区采用闪动力能引发较多的咔哒声响;使用闪动力向一侧旋转产生咔哒声响后,会影响到向对侧旋转时咔哒声响的产生。     

胸椎掌按法所致“咔哒”声响与最大按压力的量效关系

目的: 研究胸椎掌按法作用时“咔哒”声响与最大按压力的量效关系,为推拿手法的量化提供定量化依据。方法: 利用压力检测系统,检测并记录胸椎掌按法操作时出现“咔哒”声响时术者手掌按压患者胸椎棘突的最大按压力。结果：以“咔哒”声响作为胸椎掌按压法成功的标志,通过出现声响的最大按压力（247.21±8.02 mmHg）和没有出现“咔哒”声响的最大按压力（251.15±2.87mmHg）的比较,两者之间没有显著差异（P>0.05）。结论：胸椎掌按时按压力大小和“咔哒”声响的发生没有直接关系。     

四种不同方式旋转颈椎所致咔哒声响量化的采集与比较

背景:临床上常用以及教科书介绍较多的颈部旋转手法中,端提旋转手法、冯氏定点旋转手法、孙氏旋转手法和龙氏正骨手法比较有代表性.这4种手法旋转颈椎时都可能会产生咔哒声响.但它们的声响有无差别呢?目的:观察不同方式旋转颈椎引发的咔哒声响次数,并进行比较分析.方法;选择96名健康在校大学生,随机分为4组,分别对受试者颈椎实施端提旋转手法、定点旋转手法、孙氏旋转手法和单纯旋转手法.每名受试者均先向左侧旋转,再向右侧旋转.运用自行设计的声响采集系统对手法所致的咔哒声响进行采集,并对声响数量进行统计学分析.结果与结论:在向左侧旋转中,定点旋转手法和孙氏旋转手法产生的咔哒声响次数较少,且单次发声的比例较高,端提旋转手法和单纯旋转手法产生的咔哒声响次数较多,且多次发声的比例较高.向右旋转4组间声响总次数差异和声响次数构成比差异均无显著性意义.说明在颈椎旋转手法时,采用一定的轴向牵引力量能减少咔哒声响次数,增加单次声响比例,在正骨复位中能提高复位的准确性和针对性.     

颈椎旋转（提）手法的在体力学测量

目的：研究颈椎旋转手法操作过程中力学参数的特征及其相互关系。方法：运用生物力学实测方法测量同一操作者对15例患者施行旋转手法过程中的力学参数（作用力、作用时间和加速度）,再通过数学方法,计算出旋转手法扳动过程所产生的位移及冲量。结果：①颈椎旋转手法的力学参数平均值：预加载力15.15±5.11kg,最大作用力27.24±8.81kg,扳动力14.29±5.15kg,扳动时间114.33±16.98ms,最大加速度为-0.35±0.11g,扳动位移为9.34±2.67mm,扳动冲量为22.49±7.11Ns;②左手操作与右手操作的旋转手法力学参数相比较,除最大加速度、扳动时间和扳动冲量以外,余项P值均〉0.05,差异无显著性意义;③预加载力和扳动力相比较,两者间差异无显著性意义（P〉0.05）;④经Pearson相关分析,预加载力、最大作用力和扳动力呈显著的正相关性（R〉0.8,P〈0.001）。结论：左右手施行旋转手法时作用力特征（包括预加载力、最大作用力、扳动力）是相近的;旋转手法从缓慢上牵开始到扳动操作结束整个过程具有一定的规律性：扳动力的大小取决于预加载力的大小。     

颈椎病的手法治疗及其安全性问题

在颈椎病的治疗中,手法治疗有其独特的地位,它具有正骨理筋、舒筋活络、散瘀止痛及通利关节的作用。手法治疗包括纠正紊乱的椎间关节,对错位或脱位椎体的复位及对软组织损伤的按摩治疗。依医者的经验和师传不同,在临床上有各种各样的治疗手法,大多采用综合手法,也有单纯作用于软组织的按摩手法。 一、错位椎体的复位手法 根据生物力学和解剖学的原理,有旋转、侧扳、牵引等方式,而以旋转复位法应用较广。①旋转复位法。坐位:有单人旋转复位法与双人旋转复位法、不定点旋转复位法、顺向旋转复位法(拇指推患椎横突)、按肩旋颈法与侧牵旋颈法、端提旋转复位法等;卧位:患者仰卧位或俯卧位在徒手牵引下旋转复位,如俯卧位旋颈推肩法、二点一面复位法、仰卧位牵拉旋转复位法等(多用于环枢椎的复位)。施行旋转复位法,医者必须熟习局部解剖结构,能够掌握好颈部前屈、侧转、头颈沿矢状轴上旋的角度和力度,还必须依据患椎部位的高低、颈椎生理曲线变化(变直、反张、成角),上下椎间隙大小、颈肌紧张程度而决定     

对中医脊柱推拿所致“咔哒”声响的相关临床思考

"咔哒"声响是中医推拿手法在整复过程中常出现的现象,多将其视为手法整复成功标志,医师在整复关节后都习惯问患者有无听到响声,也习惯告诉患者"复位",但是往往这一声响出现时,有些患者症状好转了,有些患者症状没有缓解,许多医生并不明白这一现象,这一现象的背后存在一系列这样那样的问题,如"咔哒"声响的发生有何意义?脊柱推拿中手法力的大小如何进行有效控制?不同手法所致"咔哒"声是否存在差异?     

颈椎定点旋转手法"点"的数字化解剖

背景:虽然颈椎定点旋转复位手法效果显著,但其机制一直缺乏深入的研究.临床上对所要实施的推拿力和旋转节段无法做到精确控制,有时会造成手法的医源性损伤.目的:从颈椎定点旋转手法旋转中心点的角度分析旋转手法的作用途径.方法:在64排螺旋CT工作平台扫描标本,层距1 mm.在PHILIPS MEDICAL SYSTEMS图像处理功能模块中提取图片中轮廓线数据,进行上颈椎三维结构重建和图像显示.取枢椎棘突顶点(A点)、齿突垂直轴心(B点)以及两者之间连线的中点(C点)为旋转轴心(模拟中的旋转中心点),分别以各点为原点建立球坐标系.观察枢椎棘突顶点与下颌尖旋转前后的连线夹角,以及齿突垂直轴心与下颌尖旋转前后的连线夹角.结果与结论:做定点手法旋转时其中心并非是施术者利手作用的枢椎棘突顶点,而是枢椎齿突垂直轴心;实际轴心旋转角>术者观察角.提示应建立颈椎定轴旋转的新概念,并掌握颈椎定轴旋转手法的原则,以指导临床正确应用脊柱旋转类手法.     

颈椎定点旋转手法“点”的数字化解剖

背景：虽然颈椎定点旋转复位手法效果显著,但其机制一直缺乏深入的研究。临床上对所要实施的推拿力和旋转节段无法做到精确控制,有时会造成手法的医源性损伤。目的：从颈椎定点旋转手法旋转中心点的角度分析旋转手法的作用途径。方法：在64排螺旋CT工作平台扫描标本,层距1mm。在PHILIPSMEDICALSYSTEMS图像处理功能模块中提取图片中轮廓线数据,进行上颈椎三维结构重建和图像显示。取枢椎棘突顶点（A点）、齿突垂直轴心（B点）以及两者之间连线的中点（C点）为旋转轴心（模拟中的旋转中心点）,分别以各点为原点建立球坐标系。观察枢椎棘突顶点与下颌尖旋转前后的连线夹角,以及齿突垂直轴心与下颌尖旋转前后的连线夹角。结果与结论：做定点手法旋转时其中心并非是施术者利手作用的枢椎棘突顶点,而是枢椎齿突垂直轴心;实际轴心旋转角〉术者观察角。提示应建立颈椎定轴旋转的新概念,并掌握颈椎定轴旋转手法的原则,以指导临床正确应用脊柱旋转类手法。     

Spinal manipulative therapy in the management of cervicogenic headache

Patients suffering from cervicogenic headache (CeH) are commonly treated with spinal manipulative therapy. We have analyzed the quality and the outcomes of published, randomized, controlled trials assessing the effectiveness of spinal manipulation in CeH. Among 121 relevant articles, only two met all the inclusion criteria. Methodological quality scores were 8/10 and 7/10 points. Only one of the trials made use of a headache diary. Both the trials reported positive (+) results on headache intensity, headache duration, and medication intake, so that spinal manipulative therapy obtained strong evidence of effectiveness (level 1) with regard to these outcomes. Conversely, spinal manipulation obtained no more than limited evidence (level 3) in reducing headache frequency, as it was analyzed only in one study with positive (+) results. A greater number of well-designed, randomized, controlled trials are required to confirm or refute the effectiveness of spinal manipulation in the management of CeH.     

Vertebral artery dissection and cerebellar infarction following chiropractic manipulation

Vertebral artery dissection (VAD) associated with chiropractic cervical manipulation is a rare but potentially disabling condition. In this report, we present a young patient manifesting with repeated vertigo. Owing to the initial misdiagnosis, the patient later developed cerebellar stroke with inability to stand or walk. Vertigo and disequilibrium are the usual presenting symptoms of this condition, which can result from inner ear or vestibular nerve dysfunction, vertebrobasilar insufficiency, and even lethal cerebellar infarction or haemorrhage; these last two, although rarely seen in young adults, can be caused by traumatic or spontaneous arterial injury, including injury secondary to chiropractic cervical manipulation. A number of cases of VAD associated with chiropractic cervical manipulation have been reported, but rarely in the emergency medicine literature. We present a case of this rare occurrence, and discuss the diagnostic pitfalls.     

Thrust joint manipulation utilization by U.S. physical therapists*

Study Design: Online survey study.

Objective: To determine physical therapists’ utilization of thrust joint manipulation (TJM) and their comfort level in using TJM between the cervical, thoracic, and lumbar regions of the spine. We hypothesized that physical therapists who use TJM would report regular use and comfort providing it to the thoracic and lumbar spines, but not so much for the cervical spine.

Background: Recent surveys of first professional physical therapy degree programs have found that TJM to the cervical spine is not taught to the same degree as to the thoracic and lumbar spines.

Methods: We developed a survey to capture the required information and had a Delphi panel of 15 expert orthopedic physical therapists review it and provide constructive feedback. A revised version of the survey was sent to the same Delphi panel and consensus was obtained on the final survey instrument. The revised survey was made available to any licensed physical therapists in the U.S.A. using an online survey system, from October 2014 through June 2015.

Results: Of 1014 responses collected, 1000 completed surveys were included for analysis. There were 478 (48%) males; the mean age of respondents was 39.7 ± 10.81 years (range 24–92); and mean years of clinical experience was 13.6 ± 10.62. A majority of respondents felt that TJM was safe and effective when applied to lumbar (90.5%) and thoracic (91.1%) spines; however, a smaller percentage (68.9%) felt that about the cervical spine. More therapists reported they would perform additional screening prior to providing TJM to the cervical spine than they would for the lumbar and thoracic spines. Therapists agreed they were less likely to provide and feel comfortable with TJM in the cervical spine compared to the thoracic and lumbar spines. Finally, therapists who are male; practice in orthopedic spine setting; are aware of manipulation clinical prediction rules; and have manual therapy certification, are more likely to use TJM and be comfortable with it in all three regions.

Conclusion: Results indicate that respondents do not believe TJM for the cervical spine to be as safe and efficacious as that for the lumbar and thoracic spines. Further, they are more likely to perform additional screening, abstain from and do not feel comfortable performing TJM for the cervical spine.

Clinical Relevance: Our research reveals there is a discrepancy between utilization of TJM at different spinal levels. This research provides an opportunity to address variability in clinical practice among physical therapists utilizing TJM.     

Short-term effectiveness of the flexion-distraction technique in comparison with high-velocity vertebral manipulation in patients suffering from low-back pain

ObjectivesTo determine the short-term effects of a modified Flexion-Distraction (FD) technique in comparison with a high-velocity low-back spinal manipulation (HVLA-SM) protocol on patients suffering from chronic low-back pain (CLBP).Design and methodsA randomized controlled trial. The sample was composed of 150 patients suffering from CLBP, who were randomly assigned to either a FD (n = 75) or a HVLA-SM (n = 75) group. The variables used to study pain were the scores of the Visual Analogue Scale (VAS) and the Pressure Pain Threshold (PPT) on trigger points (TrPs) of the quadratus lumborum. In addition, the Oswestry Disability Index (ODI) was used to measure disability, and Schober’s test and the Finger Floor Distance test (FFDT) to measure changes in low-back spine motion. An Analysis of Covariance (ANCOVA) was used to measure group effect, and Number Needed to Treat (NNT) for effect size.ResultsGreater improvements occurred in the FD group, with a statistically significant group effect (p < 0.001) for all outcome variables. The ETA² value was larger than 0.100 in the Schober’s and FDD tests, larger than 0.200 in the case of ODI and PPT, and larger than 0.300 for VAS. OR = 0.07 [IC 95% = 0.03 to 0.18] and NNT = 2.08 [IC 95% = 1.64–2.84) yielded improved values for the FD group.ConclusionFor patients suffering from CLBP, greater improvements in pain and function were observed in the group receiving the modified FD treatment than in the HVLA-SM group.     

硬膜外阻滞下手法治疗腰椎间盘突出症的临床观察

目的观察硬膜外阻滞下手法治疗腰椎间盘突出症的临床效果。方法80例患者随机分为两组,康复组(n=40)及对照组(n=40),观察治疗前后两组VSA评分,直腿抬高试验及治愈显效率。结果康复组疗效优于对照组,两组间有显著差异P<0.05。结论硬膜外阻滞下手法治疗腰椎间盘突出症是安全有效的保守治疗方法     

骶髂关节紊乱导致青少年非典型性跟痛及其治疗

目的验证手法调整治疗骶髂关节紊乱所致非典型性跟痛的疗效。方法对23例骶髂关节紊乱所致非典型性跟痛患者,采用腰椎斜扳法、过伸扳法或(和)髋关节摇转法纠正骶髂关节紊乱,必要时配合本体促进法和静力拉伸放松肌肉。结果 21例患者经1次治疗后症状消失;1例治疗3d后复发,再次治疗后症状消失;1例患者10d内经3次治疗后反复发作2个月。结论骶髂关节紊乱所致青少年跟痛是一种典型的脊柱相关疾病,经仔细检查,明确髂骨旋转方向并予以恰当整复,可即刻痊愈。     

The relation between the application angle of spinal manipulative therapy (SMT) and resultant vertebral accelerations in an in situ porcine model

It has been hypothesized that the posterior tissues of the spine are frictionless and therefore allow only the normal force component of spinal manipulative therapy (SMT) to pass to underlying vertebrae. Given this assumption, vertebrae could not be moved in practitioner-defined directions by altering the application angle of SMT. To investigate this possibility, porcine lumbar spines were excised and then SMT applied at 90° to the posterior tissues of the target vertebra. A standard curve was constructed of increasing SMT force versus vertebral acceleration. SMT forces were then applied at 60° and 120° and the resulting accelerations substituted into the standard curve to obtain the transmitted force.Results showed that vertebral accelerations were greatest at a 90° SMT application angle and decreased in all axes at application angles ≠ 90°. The average decrease in transmitted force using application angles of 60° and 120° was within 5% of the predicted absolute value. In this model, SMT applied at a non-normal angle does not increase vertebral acceleration in that same direction, but acts to reduce transmitted force. This work provides justification for future studies in less available human cadavers. It is not yet known if variations in SMT application angle have relevance to clinical outcomes or patient safety.