物理治疗技术改善慢性踝关节不稳神经肌肉控制障碍的系统综述

doi:10.3969/j.issn.1006-9771.2022.02.002

《中国康复理论与实践》 ›› 2022, Vol. 28 ›› Issue (2): 132-143.doi: 10.3969/j.issn.1006-9771.2022.02.002

物理治疗技术改善慢性踝关节不稳神经肌肉控制障碍的系统综述

施晓剑¹,荣积峰¹,蔡斌²,刘宇³,韩甲³()

1.上海市第一康复医院康复治疗中心,上海市 200090
2.上海交通大学附属第九人民医院康复医学科,上海市 200011
3.上海体育学院运动科学院,上海市 200438

收稿日期:2020-11-26 修回日期:2021-10-25 出版日期:2022-02-25 发布日期:2022-03-09
通讯作者: 韩甲 E-mail:jia.han@canberra.edu.au
作者简介:施晓剑(1992-),男,汉族,江苏盐城市人,硕士研究生,主管康复治疗师,主要研究方向：踝关节损伤与康复。|韩甲,男,博士,教授,博士研究生导师,主要研究方向：运动康复。
基金资助:
1.国家自然科学基金面上项目(31870936);2.上海市海外高层次人才项目(TP2017062)

Effect of physical therapy on neuromuscular control dysfunction for chronic ankle instability: a systematic review

SHI Xiaojian¹,RONG Jifeng¹,CAI Bin²,LIU Yu³,HAN Jia³()

1. Rehabilitation Center, the First Rehabilitation Hospital, Shanghai 200090, China
2. Department of Rehabilitation, Shanghai Ninth People's Hospital, Shanghai Jiaotong University, Shanghai 200011, China
3. School of Kinesiology, Shanghai University of Sport, Shanghai 200438, China

Received:2020-11-26 Revised:2021-10-25 Published:2022-02-25 Online:2022-03-09
Contact: HAN Jia E-mail:jia.han@canberra.edu.au
Supported by:
National Nature Science Foundation of China (General)(31870936);Program for Overseas High-level Talents at Shanghai(TP2017062)

摘要/Abstract

摘要：

目的明确物理治疗技术对慢性踝关节不稳(CAI)所致的神经肌肉控制障碍的干预效应。方法检索2010年10月1日至2020年10月1日PubMed、Web of Science、Cochrane、PEDro、EBSCO和CNKI中CAI物理治疗相关的系统评价、Meta分析、随机对照试验和病例对照研究。对纳入研究进行质量评价后,按牛津循证医学中心(OCEBM)证据水平进行分级。结果共纳入20篇文献。不稳定平面训练为主的运动干预可显著改善CAI患者下肢平衡控制能力(Ⅰ A)和肌力(Ⅱ A);外部设备辅助下可提升干预效率(Ⅱ C),但对肌肉反应(Ⅲ C)和本体感觉(Ⅱ D)效果有限。6次及以上的手法治疗可提高下肢平衡能力(Ⅰ A),而贴扎对踝关节的本体感觉的即刻及短期效应并不显著(Ⅰ A)。结论以不稳定平面为主的运动干预和手法治疗在改善CAI患者的神经肌肉控制能力方面得到高质量的证据支持,应作为物理治疗的主要干预手段。贴扎及其他辅助具的应用可以作为辅助干预手段,有助于提高整体干预的效率;目前缺少研究支持理疗设备在CAI神经肌肉控制干预中的使用。

关键词: 慢性踝关节不稳, 神经肌肉控制, 物理治疗技术, 系统评价再评价

Abstract:

Objective To identify the effectiveness of physical therapy on neuromuscular control dysfunction of chronic ankle instability (CAI). Methods CAI physiotherapy-related systematic reviews, meta-analysis, randomized controlled studies and case-controlled studies were systematically searched in PubMed, Web of Science, Cochrane, PEDro, EBSCO and CNKI from October 1st, 2010 to October 1st, 2020. After quality assessment, the research evidence regarding certain intervention was then graded according to the Oxford Center for Evidence-based Medicine. Results A total of 20 articles were included. Intervention based on unstable plane exercise training could significantly improve lower limb balance control ability (Ⅰ A) and muscle strength (Ⅱ A) for CAI patients. The efficiency of exercise-based intervention could be further raised (Ⅱ C) with the aid of external equipment, but either the benefits in muscle reaction (Ⅲ C) or proprioception (Ⅱ D) was limited. Six sessions or more of manual therapy could be used to enhance the balance ability of the lower limbs (Ⅱ B), while taping failed to provide improvements in ankle proprioception in short period or immediately (Ⅰ A). Conclusion Unstable plane training-based therapeutic exercise and manual therapy could effectively enhance the neuromuscular control with high-quality evidence supporting, which can be primary interventions for CAI patients. Meanwhile, taping and other external devices could be used as adjunct methods to improve the efficiency of physiotherapy program, while there is currently no evidence to support the application of modality treatment in neuromuscular control of CAI.

Key words: chronic ankle instability, neuromuscular control, physiotherapy techniques, overview of systematic review

中图分类号:

R684.7

施晓剑,荣积峰,蔡斌,刘宇,韩甲. 物理治疗技术改善慢性踝关节不稳神经肌肉控制障碍的系统综述[J]. 《中国康复理论与实践》, 2022, 28(2): 132-143.

SHI Xiaojian,RONG Jifeng,CAI Bin,LIU Yu,HAN Jia. Effect of physical therapy on neuromuscular control dysfunction for chronic ankle instability: a systematic review[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2022, 28(2): 132-143.

图/表 9

表1

神经肌肉控制功能的干预内容"

干预内容	定义及对应常用结局指标
静态平衡能力	指受试者有或无干扰下维持身体直立位姿势平衡的能力。常用评估方法包括单腿站立测试(Single Leg Stance Test, SLBT),可在地面上或者测力台上进行测试,此外在测力台上还可以通过稳定极限(limitation of stability, LOS)、压力中心(center of pressure, COP)、触及边界时间(time to boundary, TTB)等指标以反映受试者的静态平衡能力。
动态平衡能力	指受试者在运动过程中维持身体直立位姿势平衡的能力。常用评估方法包括星状平衡偏移测试(Star Excursion Balance Test, SEBT)、Y平衡(Y-Balance)、单腿跳测试(hopping test)、8字跳(Figure-8 hoping)、侧边跳、三级跳等。
踝关节本体感觉	指感知身体部位在静止和运动状态下的踝关节空间位置、运动程度和运动状态的能力,对运动觉和姿势性平衡至关重要。常用评估方法包括关节位置重建(joint position reproduction, JPR)、被动运动阈值检测法(threshold to detect to passive movement, TTDPM)和主动运动程度识别测试(active movement extent discrimination, AMEDA)。
肌反应时	反映肌肉在刺激下激活速率的指标。该指标的测量需要在肌电设备下完成,通过记录踝关节周围肌群在支撑面突然翻动到肌肉产生收缩性电活动的时间间隔,即为肌反应时,常评估CAI腓骨长、短肌处的肌反应时。
肌力	指肌肉收缩产生的力。肌力可以通过等速、等张或等张收缩过程中进行徒手或者利用测力计进行(半)定量化评价。本研究中关注的是CAI踝关节的外翻和背屈肌的肌力,常用的定量评估方式主要是通过测力计以及在等速装置上完成。在等速肌力测试中,指标包括力、峰力矩比值(peak torque ratio, PT ratio)等。

表1

表2

表3

图1

表4

表5

表6

纳入系统评价特征信息"

纳入研究	研究类型	国家	纳入文献数	n	质量评价方法	干预措施		干预周期及剂量	干预内容与证据推荐等级
纳入研究	研究类型	国家	纳入文献数	n	质量评价方法	实验组	对照组	干预周期及剂量	干预内容与证据推荐等级
O'Driscoll等^[15] (2011)	系统评价	爱尔兰	14篇(RCT 13篇、CCT 1篇)	441	Cochrane偏倚风险评价工具	神经肌肉训练	假理疗、空白对照、正常活动	每周3次,共4~6周	动态平衡控制(Ⅰ A推荐),静态平衡控制(Ⅰ C推荐),本体感觉(Ⅰ C推荐),肌力(Ⅰ C推荐)
Raymond等^[16] (2012)	系统评价+Meta分析	澳大利亚	RCT 8篇	152	B&D	刚性贴布、弹性贴布、半刚性贴布	空白对照	即刻	本体感觉(Ⅰ A不推荐)
Gabriner等^[17] (2015)	系统评价	美国	2篇(RCT 1篇,队列研究1篇)	60	PEDro	矫形鞋垫	空白,前后对照	持续2周,或每天4~8 h,共4周	动、静态平衡控制(Ⅱ B~C推荐)
Kosik等^[18] (2018)	系统评价	美国	3篇(RCT 1篇,队列研究2篇)	113	PEDro	动态关节松动、麦氏松动Ⅲ级	空白,前后对照	1~3周内,完成3~6次	动态平衡控制(Ⅰ B~Ⅲ C推荐)
Tsikopoulos等^[19] (2018)	Meta分析	英国	RCT 21篇	789	Cochrane偏倚风险评价工具	监督下平衡、肌力训练	空白对照	4~6周	动态平衡控制(Ⅰ A推荐)
Tsikopoulos等^[20] (2020)	Meta分析	英国	RCT 22篇	469	Cochrane偏倚风险评价工具	(半)弹、刚性、软包扎、Mulligan贴布、运动贴布	空白、假贴扎	0~2周	动态平衡控制(Ⅰ A不推荐)
Shi等^[21] (2019)	系统评价+Meta分析	中国	RCT 4篇	208	PEDro	距上关节(动态)关节松动	正常活动、假手法治疗	2周内完成6次	动、静态平衡控制(Ⅰ A推荐)
Powden等^[22] (2019)	系统评价+Meta分析	美国	RCT 10篇	242	PEDro	动态关节松动,麦氏松动术III、Ⅵ级,关节分离	空白对照、假治疗	2~3周内完成1~6次	动态平衡控制(Ⅰ A推荐)
Jackson等^[23] (2019)	系统评价	美国	4篇(交叉干预1篇,队列研究3篇)	75	B&D	腓骨复位贴扎	空白,前后对照	即刻	动、静态平衡控制(Ⅰ~Ⅲ B不推荐)
王璐等^[24] (2019)	系统评价+Meta分析	中国	RCT 12篇	393	Cochrane偏倚风险评价工具	平衡训练	下肢力量训练、常规、无干预	每周3次,共4~8周	动态平衡控制(Ⅰ A推荐)
Cruz等^[25](2019)	系统评价	葡萄牙	8篇(RCT 6篇, CCT 2篇)	349	Cochrane偏倚风险评价工具	平衡训练,采用晃动板、泡沫垫、Bosu球等;踝周肌群肌力训练	空白对照	每次10~30 min,每周3~5次,共4~6周	平衡控制(Ⅱ B推荐)、肌力(Ⅱ B推荐)、本体感觉(Ⅱ D推荐)
Helly等^[26](2020)	系统评价	美国	3篇(RCT 1篇,交叉对照研究2篇)	115	PEDro	足底按摩	空白、自身对照	每次5 min,每周3~6,共1~2周	静态平衡控制(Ⅱ B推荐)

表6

表7

表8

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证据水平	内容
Ⅰ	RCT的系统评价或Meta分析、高质量前瞻性研究、RCT
Ⅱ	队列研究的系统评价或Meta分析、高质量的前瞻性研究、RCT(如随机选择不当,不设盲法,随访率< 80%)
Ⅲ	CCT或回顾性研究
Ⅳ	单个病例系列研究
Ⅴ	专家观点

推荐等级	证据强度	内容
A	强证据	Ⅰ级研究占优势,和/或Ⅱ级研究支持,至少包括一项Ⅰ级研究
B	中等证据	一项高质量的RCT,或多项Ⅱ级研究支持建议
C	弱证据	一项Ⅱ级研究或者优势Ⅲ级或Ⅳ级研究(包括专家的共识声明)支持建议
D	相互矛盾的证据	针对该主题有不同结论的高质量研究,建议基于这些矛盾的研究
E	理论/基础证据	多项动物或者尸体研究,从概念模型/原理科学研究基础证据,支持该结论
F	专家意见	基于专家共识团队的临床实践总结出的最佳实践意见

纳入研究	条目1	条目2	条目3	条目4	条目6	条目7	条目8	条目9	条目10	条目11	总分
O'Driscoll等^[15](2011)	1	0	1	0	1	1	1	1	0	1	7
Raymond等^[16](2012)	1	1	1	0	1	0	1	1	0	1	7
Gabriner等^[17](2015)	1	0	1	0	1	1	1	1	0	0	6
Kosik等^[18](2018)	1	0	1	0	1	1	1	1	0	0	6
Tsikopoulos^[19]等(2018)	1	1	1	0	1	1	1	1	0	0	7
Tiskapolulos等^[20](2020)	1	1	1	0	1	1	1	1	0	0	7
Shi等^[21](2019)	1	1	1	0	1	1	1	1	0	1	8
Powden等^[22](2019)	1	1	1	1	1	1	1	1	1	0	9
Jackson等^[23](2019)	1	0	1	0	1	1	1	1	0	0	6
王璐等^[24](2019)	1	1	1	0	1	1	1	1	0	0	7
Cruz等^[25](2019)	1	1	1	0	1	1	1	1	0	0	7
Helly等^[26](2020)	1	1	1	0	1	1	1	1	0	0	7

纳入研究	条目1	条目2	条目3	条目4	条目5	条目7	条目8	条目9	条目10	条目11	总分
Cloak等^[27](2013)	√	1	1	1	0	0	0	0	1	1	5
Hall等^[28] (2015)	√	1	0	0	1	0	1	0	1	1	5
Donovan等^[29] (2016)	√	1	1	1	0	1	1	0	0	1	6
Sierra-Guzman等^[30](2017)	√	1	0	1	0	1	1	1	1	1	7
Hall等(2018) ^[31]	√	1	0	1	0	0	1	0	1	1	5
Alves 等^[32](2018)	√	1	0	1	1	1	1	1	0	1	7
Kim等^[33] (2019)	√	1	1	1	0	0	0	0	1	1	5

纳入研究	研究类型	国家	n(男/女)	平均年龄/岁	干预措施		干预周期	随访	干预内容与证据支持(+/-)
纳入研究	研究类型	国家	n(男/女)	平均年龄/岁	实验组(n)	对照组(n)	干预周期	随访	干预内容与证据支持(+/-)
Cloak等^[27](2013)	RCT	英国	33 (33/0)	22.7±1.0	振动+动板训练,每周2次(11);晃动板训练,每周2次(11)	空白对照(11)	6周	无	动、静态平衡控制(++)
Hall等^[28](2015)	RCT	美国	39 (17/22)	19.7±2.0	抗阻训练+等长收缩,每周3次(13);PNF,每周3次(13)	空白对照(13)	6周	无	动、静态平衡控制(--),肌力(++)
Donovan等^[29](2016)	RCT	美国	26 (7/19)	21.3±3.1	佩戴去稳定装置+平衡训练12次(13)	平衡训练12次(13)	4周	无	动静态平衡控制(--)
Taegyu等^[34](2017)	CCT	韩国	21(含12 CAI) (0/21)	25.8±2.3	进阶式方案(活动度+姿势控制+肌力+协调训练),每次60 min,每周5次(12 CAI)	日常专项训练,每次60 min,每周5次(9)	6周	24周	动态平衡控制(++),肌力(--)
Sierra-Guzman等^[30] (2017)	RCT	西班牙	50 (?)	22.6±2.8	全身振动,每周3次(17);Bosu球训练,每周3次(16)	空白对照(17)	6周	无	肌肉反应(+),肌力(-)
Hall等^[31](2018)	RCT	美国	39 (21/18)	20.9±3.8	抗阻+PNF,每次20 min,每周3次(13);平衡训练,每次20 min,每周3次(13)	自行车,每次20 min,每周3次(13)	6周	无	动、静态平衡控制(--),肌力(++)
Alves等^[32](2018)	交叉干预	葡萄牙	16 (0/16)	21.5±2.8	腓骨复位贴扎(16)	空白对照(16)	即刻、跑后20 min	无	动、静态平衡控制 (-),肌肉反应(+)
Kim等^[33](2019)	RCT	韩国	21 (?)	21.0±1.2	VR +抗阻+平衡训练,每次20 min,每周3次(10)	抗阻+平衡训练,每次20 min,每周3次(11)	4周	无	动、静态平衡控制(++)

物理治疗技术改善慢性踝关节不稳神经肌肉控制障碍的系统综述

Effect of physical therapy on neuromuscular control dysfunction for chronic ankle instability: a systematic review

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干预内容	干预方式	ICHI编码(β-2)	结局指标	干预剂量	证据推荐等级
平衡控制	平衡、抗阻训练^[19,24]	MUB.PG.ZZ、MU2.PH.ZZ	SEBT、SLBT	监督下4~6周	强推荐(Ⅰ A)
	足底按摩^[26]	MQS.PS.ZZ	SLBT	每次5 min,共6次	推荐(Ⅰ A)
	关节手法技术^{[18, 21]}	MNJ、PB、ZZ、MNJ.PG.ZZ	SEBT、SLBT	III级,6次	强推荐(Ⅰ A)
	鞋垫、踝足支具^[17]	PNA.DP.AH	SEBT、COP	持续穿戴2~4周	推荐(Ⅱ~Ⅲ C)
	腓骨复位贴扎^[23]	PNA.LC.AH	SEBT	即刻	不推荐(Ⅱ B)
	VR+不稳定平面训练^[34]	AVC.PH.ZZ	COP	10 min	推荐(Ⅱ C)
	振动+不稳定平面训练^[27]	AVC.PH.ZZ	SEBT,三级跳	6周	推荐(Ⅱ C)
本体感觉	不稳定平面训练、抗阻训练^{[15, 25]}	MUB.PG. ZZ	JPR、TTPMD 外翻力觉	4~6周	推荐(Ⅱ D)
本体感觉	贴扎等外部支持^[16]	PNA.LC.AH	JPR TTPMD	即刻	不推荐(Ⅰ B)
肌力	自体平衡扰动练习^[25]	SHD.PG.ZZ	1 RM,内/外翻PT ratio	4~6周	不推荐(Ⅱ B)
	PNF和/或弹力带渐进抗阻+维持收缩方案^{[28,29,30,31,32,33,34,35,36,37,38,39]}	MUB.PG.ZZ、AVC.PH.ZZ	外翻等长肌力测试	每次20 min,每周3次,共6周	推荐(Ⅱ B)
	肌力平衡协调组合干预^[32]	MUB.PG.ZZ、MTC.PG.ZZ	外翻等长肌力测试	每次20 min,每周3次,共6周	推荐(Ⅱ C)
	动静态平衡控制方案^[30]	SHD.PG.ZZ	肌力、肌耐力	6周	推荐(Ⅱ C)
	外部辅具、去稳定装置^[29]	MTC.PG.ZZ、PNA.LC.AH	sEMG	即刻或4周	不推荐(Ⅱ B)
肌反应时	肌力、平衡等运动干预^[15]	MU2.PH.ZZ、MUB.PG.ZZ	腓骨肌肌反应时	每周3次,共6周	推荐(Ⅲ C)
	腓骨复位贴扎^[33]	PNA.LC.AH	腓骨肌肌反应时	即刻	推荐(Ⅱ C)
	振动平台+Bosu球^[31]	SHD.PG.ZZ、AVC.PH.ZZ	腓骨肌肌反应时	每周3次,共6周	推荐(Ⅱ C)

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