在核心稳定训练基础上联合呼吸训练对慢性非特异性腰痛患者前馈控制的效果

doi:10.3969/j.issn.1006-9771.2024.06.015

摘要/Abstract

摘要：

目的探讨在核心稳定训练基础上联合呼吸训练对慢性非特异性腰痛(CNLBP)患者前馈控制的效果。

方法选取2022年1月至2023年3月嘉兴市第二医院就诊的CNLBP患者60例，随机分为对照组(n = 30)和试验组(n = 30)。两组均进行健康宣教、物理因子治疗和核心稳定训练，试验组在此基础上增加呼吸训练，共4周。治疗前后，比较两组疼痛视觉模拟量表(VAS)评分、日本骨科协会量表(JOA)评分和Oswestry功能障碍指数(ODI)评分；采用表面肌电图检测腹横肌、多裂肌和肱三头肌(运动肌)的均方根植(RMS)和积分肌电值(iEMG)，并计算腹横肌、多裂肌与肱三头肌之间的激活顺序、相对激活时间。

结果治疗后，两组VAS评分、JOA评分和ODI评分均显著改善(|t| > 8.515, P < 0.001)，试验组优于对照组(|t| > 2.089, P < 0.05)；两组腹横肌RMS、多裂肌RMS、腹横肌iEMG、多裂肌iEMG均显著改善(|t| > 18.831, P < 0.001)，试验组明显优于对照组(|t| > 3.481, P < 0.01)；两组腹横肌和多裂肌均在运动肌之前激活，激活时间负值均显著增加(|t| > 48.115, P < 0.001)，试验组明显优于对照组(|t| > 3.229, P < 0.01)。

结论联合呼吸训练有利于减轻CNLBP患者疼痛程度，降低腰椎功能障碍程度，改善肌肉激活顺序，加强前馈控制。

关键词: 慢性非特异性腰痛, 呼吸训练, 前馈控制, 表面肌电

Abstract:

Objective To investigate the effect of respiratory training based on core stability training on feedforward control in patients with chronic nonspecific low back pain (CNLBP).

Methods A total of 60 patients with CNLBP in Jiaxing Second Hospital from January, 2022 to March, 2023 were randomly divided into control group (n = 30) and experimental group (n = 30). Both groups received health education, physical factor therapy and core stability training, while the experimental group received respiratory training in addition, for four weeks. Visual Analogue Scale (VAS) score, Japanese Orthopaedic Association low back pain (JOA) score and Oswestry Dysfunction Index (ODI) were compared between two groups before and after treatment, while surface electromyography was used to detect the root mean square (RMS) and integrated electromyography (iEMG) of transversus abdominis, multifidus and triceps (movement muscles), and the activation sequence and relative activation time of transversus abdominis, multifidus and triceps were calculated.

Results After treatment, the scores of VAS, JOA and ODI improved significantly in both groups (|t| > 8.515, P < 0.001), and the scores were better in the experimental group than in the control group (|t| > 2.089, P < 0.05). RMS and iEMG of transversus abdominis and multifidus improved significantly after treatment in both groups (|t| > 18.831, P < 0.001), and were significantly better in the experimental group (|t| > 3.481, P < 0.05). The transversus abdominis and multifidus in both groups were activated before the movement muscles, and the relative activation time of transversus abdominis and multifidus increased in negative (|t| > 48.115, P < 0.001), the experimental group being better (|t| > 3.229, P < 0.05).

Conclusion Combination of core stability training and respiratory training is beneficial in reducing the pain of patients with CNLBP, reducing the lumbar dysfunction, improving the order of muscle activation, and strengthening feedforward control.

Key words: chronic nonspecific low back pain, respiratory training, feedforward control, surface electromyography

中图分类号:

R685

陈灵慧, 郑琦, 李岩, 傅建明, 曾明, 金鑫, 陆晶晶. 在核心稳定训练基础上联合呼吸训练对慢性非特异性腰痛患者前馈控制的效果[J]. 《中国康复理论与实践》, 2024, 30(6): 737-744.

CHEN Linghui, ZHENG Qi, LI Yan, FU Jianming, ZENG Ming, JIN Xin, LU Jingjing. Effect of respiratory training based on core stability training on feedforward control in patients with chronic nonspecific low back pain[J]. Chinese Journal of Rehabilitation Theory and Practice, 2024, 30(6): 737-744.

图/表 6

表1

两组治疗前后VAS评分比较"

组别	n	测试	$x - ± s$	t值	P值
对照组	30	前测	4.10±1.49	8.515	< 0.001
		后测	3.10±1.21
试验组	30	前测	4.40±1.57	9.570	< 0.001
		后测	2.40±1.38
治疗前两组均值差			0.30±1.91	0.759	0.451
治疗后两组均值差			-0.70±1.66	2.089	0.041

表1

表2

两组治疗前后JOA评分比较"

组别	n	测试	$x - ± s$	t值	P值
对照组	30	前测	10.23±2.58	14.293	< 0.001
		后测	13.93±2.46
试验组	30	前测	10.03±3.20	12.008	< 0.001
		后测	17.47±1.08
治疗前两组均值差			-0.20±4.17	0.267	0.791
治疗后两组均值差			3.53±2.61	7.217	< 0.001

表2

表3

Comparison of ODI score between two groups pre- and post-treatment 单位：%"

组别	n	测试	$x - ± s$	t值	P值
对照组	30	前测	41.01±5.07	17.929	< 0.001
		后测	24.10±1.01
试验组	30	前测	40.88±4.99	19.941	< 0.001
		后测	20.97±1.68
治疗前两组均值差			-0.13±6.31	0.100	0.921
治疗后两组均值差			-3.12±1.73	8.746	< 0.001

表3

表4

Comparison of RMS of transversus abdominis and multifidus between two groups pre- and post-treatment 单位：μV"

肌肉	组别	n	测试	$x - ± s$	t值	P值
腹横肌	对照组	30	前测	69.49±4.16	19.292	< 0.001
			后测	92.64±4.66
	试验组	30	前测	70.97±4.80	20.848	< 0.001
			后测	98.90±5.61
	治疗前两组均值差			1.48±5.73	1.276	0.207
	治疗后两组均值差			6.27±7.79	4.701	< 0.001
多裂肌	对照组	30	前测	39.95±7.18	18.831	< 0.001
			后测	70.52±4.22
	试验组	30	前测	38.82±6.70	24.895	< 0.001
			后测	80.70±5.77
	治疗前两组均值差			-1.13±11.27	0.630	0.531
	治疗后两组均值差			10.18±6.47	7.800	< 0.001

表4

表5

Comparison of iEMG of transversus abdominis and multifidus between two groups pre- and post-treatment 单位：μV"

肌肉	组别	n	测试	$x - ± s$	t值	P值
腹横肌	对照组	30	前测	183.82±10.78	36.002	< 0.001
			后测	395.28±30.58
	试验组	30	前测	179.90±10.95	29.080	< 0.001
			后测	428.51±42.41
	治疗前两组均值差			-3.93±11.59	1.397	0.168
	治疗后两组均值差			33.23±54.76	3.481	0.001
多裂肌	对照组	30	前测	162.76±11.90	53.746	< 0.001
			后测	354.88±17.73
	试验组	30	前测	162.98±10.44	47.692	< 0.001
			后测	375.41±20.76
	治疗前两组均值差			0.22±14.75	0.076	0.940
	治疗后两组均值差			20.53±29.46	4.119	< 0.001

表5

表6

Comparison of relative activation time of transversus abdominis, multifidus, and triceps between two groups pre- and post-treatment 单位：ms"

肌肉	组别	n	测试	$x - ± s$	t值	P值
腹横肌	对照组	30	前测	46.66±4.14	48.115	< 0.001
			后测	-10.14±5.29
	试验组	30	前测	47.28±3.48	61.026	< 0.001
			后测	-14.89±6.08
	治疗前两组均值差			0.63±5.56	0.628	0.533
	治疗后两组均值差			-4.76±7.32	3.229	0.002
多裂肌	对照组	30	前测	101.79±5.03	108.100	< 0.001
			后测	-19.55±4.61
	试验组	30	前测	100.05±4.61	95.403	< 0.001
			后测	-27.07±3.90
	治疗前两组均值差			-1.74±6.20	1.397	0.168
	治疗后两组均值差			-7.52±6.70	6.821	< 0.001

表6

参考文献 40

[1]	OLIVEIRA C B, MAHER C G, PINTO R Z, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview[J]. Eur Spine J, 2018, 27(11): 2791-2803. doi: 10.1007/s00586-018-5673-2 pmid: 29971708
[2]	FOSTER N E, ANEMA J R, CHERKIN D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions[J]. Lancet, 2018, 391(10137): 2368-2383. doi: S0140-6736(18)30489-6 pmid: 29573872
[3]	HARTVIGSEN J, HANCOCK M J, KONGSTED A, et al. What low back pain is and why we need to pay attention[J]. Lancet, 2018, 391(10137): 2356-2367. doi: S0140-6736(18)30480-X pmid: 29573870
[4]	MIGLIORINI F, VAISHYA R, PAPPALARDO G, et al. Between guidelines and clinical trials: evidence-based advice on the pharmacological management of non-specific chronic low back pain[J]. BMC Musculoskelet Disord, 2023, 24(1): 432.
[5]	FITZE D P, FRANCHI M V, ELLENBERGER L, et al. Lumbar multifidus morphology in youth competitive alpine skiers and associated sex, age, biological maturation, trunk stability, and back complaints[J]. Sports Health, 2023, 15(6): 886-894.
[6]	OSHIKAWA T, ADACHI G, AKUZAWA H, et al. The influence of anticipation of movement starting time on feedforward activation of trunk muscles during rapid shoulder joint movements[J]. J Hum Kinet, 2022, 84: 43-52. doi: 10.2478/hukin-2022-000073 pmid: 36457471
[7]	LI Y, YAN L, HOU L, et al. Exercise intervention for patients with chronic low back pain: a systematic review and network meta-analysis[J]. Front Public Health, 2023, 11: 1155225.
[8]	GROOTEN W, BOSTROM C, DEDERING A, et al. Summarizing the effects of different exercise types in chronic low back pain: a systematic review of systematic reviews[J]. BMC Musculoskelet Disord, 2022, 23(1): 801.
[9]	陈沛, 任超学, 李新通, 等. 呼吸训练在非特异性腰痛防治中的研究进展[J]. 中国康复理论与实践, 2020, 26(8): 913-916. doi: 10.3969/j.issn.1006-9771.2020.08.008
	CHEN P, REN C X, LI X T, et al. Advance in respiratory training for prevention and treatment of nonspecific low back pain (review)[J]. Chin J Rehabil Theory and Pract, 2020, 26(8): 913-916.
[10]	FABERO G R, DEL C T, ANGULO D P S, et al. Respiratory muscle training improves exercise tolerance and respiratory muscle function/structure post-stroke at short term: a systematic review and meta-analysis[J]. Ann Phys Rehabil Med, 2022, 65(5): 101596.
[11]	邱霞, 周晓吉, 景慧云, 等. 腰部核心肌力训练联合呼吸训练对LDH患者术后脊柱功能及生活质量的影响[J]. 河北医药, 2023, 45(3): 361-364.
	QIU X, ZHOU X J, JING H Y, et al. Effect of lumbar core strengthening exercises combined with respiratory training on the postoperative spinal function and quality of life in patients with lumbar disc herniation[J]. Hebei Med J, 2023, 45(3): 361-364.
[12]	JIANG X, SUN W, CHEN Q, et al. Effects of breathing exercises on chronic low back pain: a systematic review and meta-analysis of randomized controlled trials[J]. J Back Musculoskelet Rehabil, 2024, 37(1): 13-23.
[13]	WANG H, FAN Z, LIU X, et al. Effect of progressive postural control exercise versus core stability exercise in young adults with chronic low back pain: a randomized controlled trial[J]. Pain Ther, 2023, 12(1): 293-308.
[14]	郑康勇, 吴进龙, 王雪强. 体力活动对慢性非特异性腰痛患者疼痛和姿势控制的影响[J]. 中国康复医学杂志, 2023, 38(7): 942-948.
	ZHENG K Y, WU J L, WANG X Q. Effects of physical activity on pain and posture control in patients with chronic non-specific low back pain[J]. Chin J Rehabil Med, 2023, 38(7): 942-948.
[15]	李桌瑶, 田子睿, 姚敏, 等. 日本骨科协会腰痛评估量表的汉化与应用[J]. 中国中医基础医学杂志, 2023, 29(2): 269-271.
	LI Z Y, TIAN Z R, YAO M, et al. Sinicization and application of Japanese Orthopedic Association low back pain assessment scale[J]. Chin J Basic Med Tradit Chin Med, 2023, 29(2): 269-271.
[16]	PATEL N P, JAMESON J, JOHNSON C, et al. Durable responses at 24 months with high-frequency spinal cord stimulation for nonsurgical refractory back pain[J]. J Neurosurg Spine, 2024, 40(2): 229-239.
[17]	林慧娟, 王承荣, 王建斌, 等. 悬吊运动训练对非特异性下腰痛患者腰腹肌表面肌电的影响[J]. 中国医药导报, 2021, 18(30): 101-104.
	LIN H J, WANG C R, WANG J B, et al. Effect of sling exercise training on surface electromyography of lumbar and abdominal muscles in patients with nonspecific low back pain[J]. Chin Med Herald, 2021, 18(30): 101-104.
[18]	YANG H C, XIAO W W, GUAN Y X, et al. Effect of cognitive load on anticipatory postural adjustment latency and its relationship with pain-related dysfunction in non-specific chronic low back pain: a cross-sectional study[J]. Pain Ther, 2023, 12(3): 723-735.
[19]	KIM H A, KWON O Y, YI C H, et al. Altered muscle recruitment patterns during isometric shoulder abduction in individuals with chronic upper trapezius pain: a cross sectional study[J]. BMC Musculoskelet Disord, 2022, 23(1): 1131.
[20]	郑依莉, 胡浩宇, 刘晓晨, 等. 非特异性腰痛患者腰背肌群延迟激活的研究[J]. 中国康复理论与实践, 2019, 25(10): 1187-1192. doi: 10.3969/j.issn.1006-9771.2019.10.013
	ZHENG Y L, HU H Y, LIU X C, et al. Activation of multifidus and erector spinae muscles during upper limb flexion and abduction in patients with nonspecific low back pain[J]. Chin J Rehabil Theory Pract, 2019, 25(10): 1187-1192.
[21]	SADEGHI M, TALEBIAN S, OLYAEI G R, et al. Preparatory brain activity and anticipatory postural adjustments accompanied by externally cued weighted-rapid arm rise task in non-specific chronic low back pain patients and healthy subjects[J]. Springerplus, 2016, 5(1): 674.
[22]	SEMBERA M, BUSCH A, KOBESOVA A, et al. The effect of abdominal bracing on respiration during a lifting task: a cross-sectional study[J]. BMC Sports Sci Med Rehabil, 2023, 15(1): 112.
[23]	LARIVIERE C, PREUSS R. The effect of extensible and non-extensible lumbosacral orthoses on anticipatory postural adjustments in participants with low back pain and healthy controls[J]. Musculoskelet Sci Pract, 2021, 55: 102421.
[24]	杨宽女, 李建华, 吴方超, 等. 动态神经肌肉稳定技术治疗慢性腰痛的疗效研究[J]. 华西医学, 2021, 36(8): 1062-1067.
	YANG K N, LI J H, WU F C, et al. Study on the effect of dynamic neuromuscular stabilization technique for chronic low back pain[J]. West Chin Med J, 2021, 36(8): 1062-1067.
[25]	VAN DRUNEN P, MAASWINKEL E, VAN DER HELM F C, et al. Identifying intrinsic and reflexive contributions to low-back stabilization[J]. J Biomech, 2013, 46(8): 1440-1446. doi: 10.1016/j.jbiomech.2013.03.007 pmid: 23578438
[26]	GARCEZ D R, DA SILVA ALMEIDA G C, SILVA C F O, et al. Postural adjustments impairments in elderly people with chronic low back pain[J]. Sci Rep, 2021, 11(1): 4783.
[27]	DAVERGNE T, GRELIER A, OSTERTAG A, et al. Capacity for extra-spinal muscular effort in chronic non-specific low back pain: a cross-sectional case-control study of 192 patients and 335 controls[J]. Joint Bone Spine, 2024, 91(2): 105663.
[28]	VASSELJEN O, UNSGAARD T M, WESTAD C, et al. Effect of core stability exercises on feed-forward activation of deep abdominal muscles in chronic low back pain: a randomized controlled trial[J]. Spine (Phila Pa 1976), 2012, 37(13): 1101-1108. doi: 10.1097/BRS.0b013e318241377c pmid: 22146280
[29]	BROOKS C, KENNEDY S, MARSHALL P W. Specific trunk and general exercise elicit similar changes in anticipatory postural adjustments in patients with chronic low back pain: a randomized controlled trial[J]. Spine (Phila Pa 1976), 2012, 37(25): E1543-E1550.
[30]	RANGER T A, CICUTTINI F M, JENSEN T S, et al. Are the size and composition of the paraspinal muscles associated with low back pain? A systematic review[J]. Spine J, 2017, 17(11): 1729-1748. doi: S1529-9430(17)30320-0 pmid: 28756299
[31]	张珊珊, 王艳君, 赖建洋, 等. 慢性腰痛患者腰部深层多裂肌超声形态特征分析[J]. 中华物理医学与康复杂志, 2020, 42(3): 228-231.
	ZHANG S S, WANG Y J, LAI J Y, et al. The morphology of deep lumbar multifidus in patients with chronic low back pain[J]. Chin J Phys Med and Rehabi, 2020, 42(3): 228-231.
[32]	PEROTTI L, STAMM O, MESLETZKY L, et al. Needs and attitudes of older chronic back pain patients towards a wearable for ultrasound biofeedback during stabilization exercises: a qualitative analysis[J]. Int J Environ Res Public Health, 2023, 20(6): 4927.
[33]	MATHEVE T, HODGES P, DANNEELS L. The role of back muscle dysfunctions in chronic low back pain: state-of-the-art and clinical implications[J]. J Clin Med, 2023, 12(17): 5510.
[34]	AMIRI B, ZEMKOVA E. Diaphragmatic breathing exercises in recovery from fatigue-induced changes in spinal mobility and postural stability: a study protocol[J]. Front Physiol, 2023, 14: 1220464.
[35]	OH Y J, PARK S H, LEE M M. Comparison of effects of abdominal draw-in lumbar stabilization exercises with and without respiratory resistance on women with low back pain: a randomized controlled trial[J]. Med Sci Monit, 2020, 26: e921295.
[36]	JANSSENS L, MCCONNELL A K, PIJNENBURG M, et al. Inspiratory muscle training affects proprioceptive use and low back pain[J]. Med Sci Sports Exerc, 2015, 47(1): 12-19.
[37]	MARUGAN-RUBIO D, CHICHARRO J L, BECERRO D B V R, et al. Effectiveness of ultrasonography visual biofeedback of the diaphragm in conjunction with inspiratory muscle training on muscle thickness, respiratory pressures, pain, disability, quality of life and pulmonary function in athletes with non-specific low back pain: a randomized clinical trial[J]. J Clin Med, 2022, 11(15): 4318.
[38]	YU D, YU Y, PENG Q, et al. Clinical efficacy of breathing training combined with core stability training in chronic nonspecific low back pain[J]. Pak J Med Sci, 2023, 39(4): 1008-1012. doi: 10.12669/pjms.39.4.6918 pmid: 37492324
[39]	GHOLAMI B B, YALFANI A, AHMADNEZHAD L. Eight-week inspiratory muscle training alters electromyography activity of the ankle muscles during overhead and single-leg squats: a randomized controlled trial[J]. J Appl Biomech, 2021, 37(1): 13-20.
[40]	AHMADNEZHAD L, YALFANI A, GHOLAMI B B. Inspiratory muscle training in rehabilitation of low back pain: a randomized controlled trial[J]. J Sport Rehabil, 2020, 29(8): 1151-1158.