Chinese Journal of Tissue Engineering Research ›› 2020, Vol. 24 ›› Issue (2): 289-295.doi: 10.3969/j.issn.2095-4344.1972
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Song Xiaoneng1, 2, Hu Linghui2, Huang Desheng3, Zhou Xuchang2, Wu Wei2
Received:
2019-04-02
Revised:
2019-04-13
Accepted:
2019-05-25
Online:
2020-01-18
Published:
2019-12-25
Contact:
Wu Wei, PhD, Researcher, Shanghai University of Sport, Shanghai 200438, China
About author:
Song Xiaoneng, Lecturer, Jiangnan University Sports Department, Wuxi 214122, Jiangsu Province, China; Shanghai University of Sport, Shanghai 200438, China
Supported by:
CLC Number:
Song Xiaoneng, Hu Linghui, Huang Desheng, Zhou Xuchang, Wu Wei. Exercise in the prevention and treatment of knee osteoarthritis: key factors and cautions [J]. Chinese Journal of Tissue Engineering Research, 2020, 24(2): 289-295.
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2.1 正常与非正常膝关节 正常的膝关节不容易被长期运动所破坏,即使是强度大或者体质量大于自身标准水平,因为软骨表面能够对这些重复的载荷和运动做出适应性反应[17]。但单次冲击载荷超过25 mPa会导致膝关节退变,引起膝骨关节炎的早期症状(如:基质纤维颤动、软骨细胞簇形成、软骨下骨增厚等)[18]。而由于膝关节损伤或关节发育不良导致的非正常膝关节,可以被日常的关节使用水平而破坏。如韧带和半月板损伤后,往往破坏关节的稳定性,阻碍关节表面承受应力的自然分布,这会增加软骨表面某些部位的峰值应力,减少其他部位的峰值应力[19-20]。此外,关节疼痛和受限会导致膝关节肌肉无力,甚至关节松弛。在这种情况下,轻度膝关节损伤甚至可以改变软骨代谢和基质组成,因为软骨表面的峰值应力分布遭到破坏。在一些调查中,膝关节损伤后,经常锻炼的人比不锻炼的人更容易患膝骨关节炎,且这种进展永远不会立即或在短时间内被感觉到或看到[21]。超过80%有膝关节损伤病史的美国橄榄球运动员,他们在退役10-30年后有膝骨关节炎的迹象[22]。 冲击载荷的强度、速度和频率也会影响膝关节软骨[23]。正常的人体软骨可以承受高达25 mPa的冲击载荷而不会出现明显的断裂[18]。正常软骨可能会在以下两种情况下被破坏:一方面,当冲击载荷作用缓慢时,软骨会变形以吸收或减少载荷,但如果冲击力很快,软骨就不能充分发挥作用,此时软骨表面很容易遭到破坏[24];另一方面,重复载荷会破坏组织,损伤程度的通常随着载荷的增加和循环次数的增加而增加,见表1[25-27]。 "
正常膝关节损伤时,关节内存在氧化应激(oxidative stress, OS)和炎症[28]。过剩的活性氧(reactive oxygen species, ROS)和炎症因子(肿瘤坏死因子α、白细胞介素1等)激活了相关信号通路MAPKs,促进环氧合酶2和基质金属蛋白酶13等水平,从而破坏了软骨细胞和关节软骨。MAPKs信号通路中主要的3条通路参与其中,p38、JNK和ERK,具体作用详见表1[29-30]。 2.2 运动疗法对改善膝骨关节炎症状的作用 2.2.1 疼痛 膝骨关节炎的主要症状是疼痛,疼痛机制主要由于周围神经和中枢神经敏感性,膝骨关节炎导致两者传播痛觉过敏,而产生疼痛[31]。运动疗法对膝骨关节炎具有抗炎作用,这种作用有两个方面[32]:单次的运动可以产生局部抗炎作用,例如一次抗阻运动可以减轻局部疼痛的感觉[33];定期或长期的运动则可以使中枢神经适应疼痛,从而降低疼痛敏感性[34]。Marius等[35]通过KOOS评价量表的测试结果得出,运动可以提高疼痛的耐受值。 2.2.2 膝关节功能 运动疗法可以改善膝关节功能,如膝关节屈曲、伸展和步态表现。由于膝关节疼痛、僵硬、肿胀和活动受限等,患者通常不能正常行走。RYO等[36]的系统综述表明,运动锻炼可以增加行走的时间,加快步态速度,甚至可以增加总的步行距离。疼痛、关节僵硬、肿胀和活动受限等常伴随着膝骨关节炎患者,因此,膝骨关节炎患者害怕在走路的时候摔跤[37]。TOPP等[38]也研究得出,运动疗法在增加步行距离、步态速度和步行时间方面具有低到中等质量的疗效。 2.2.3 肌肉萎缩 膝骨关节炎患者肌无力、疼痛与身体功能密切相关,肌肉挛缩可引起膝关节疼痛和残疾,运动对肌肉挛缩有一定的治疗作用[39]。适量冲击载荷是维持关节软骨健康所必不可少的,仅仅是关节的运动并不足以保持关节软骨的完整性,而膝关节肌肉收缩强度是反映关节软骨质量的重要因素,主要包括股四头肌和腘绳肌。股四头肌的肌力是预防膝功能障碍的主要因素,急性关节炎和膝骨关节炎患者发生膝关节不稳时,股四头肌活动往往减少[40-42]。这几乎与关节源性肌肉抑制有关,由炎症、疼痛和肿胀引起的关节源性肌肉抑制,最终损伤相关感受器,使股四头肌活动减少[43]。腘绳肌是另一条重要的肌肉,它可以通过施加胫骨后拉力来稳定膝关节,保护前交叉韧带在高冲击落地时免受高外展张力的影响[44]。此外,腘绳肌的紧张有助于膝关节更加稳定[45]。因此,降低腘绳肌与股四头肌的强度比(腘绳肌与股四头肌共同收缩)可能增加前交叉韧带损伤的风险。相反,RUAN等[46]发现静态拉伸腿筋后,腘绳肌-股四头肌强度比降低,但高冲击落地时膝关节负荷和损伤风险没有增加,甚至膝关节外侧所受负荷降低。静态拉伸腘绳肌肌腱后,急停、跳、变向能力(增加膝损伤风险的动作)得以增强。另外一方面,膝关节肌肉还能吸收冲击,对软骨下骨和半月板作为减震器,保护覆盖软骨,肌肉萎缩则减震保护作用将随之减弱[47]。 2.3 运动疗法在膝骨关节炎中存在不足 膝关节损伤后通常会出现膝部生物力学异常,在步态早期存在“膝关节僵硬步态模式”,包括患侧膝关节伸展和屈曲角减少,即使经过一定的运动疗法,这种模式也能持续较长时间。如髋关节生物力学异常,特别是在动态下肢外翻位置,在康复计划后仍可存在,并增加膝关节损伤的风险。此时,继续使用将增加再次受伤的风险和发展为膝骨关节炎的可能性[48-49]。DEVDATTA等[50]对膝骨关节炎患者进行监督的拉伸、力量训练和短期镇痛治疗,在短期随访中都可改善症状和功能,但在1年后这些结果都略有下降。同样,在一份比较研究中,内侧半月板撕裂的手术治疗组和运动疗法组,两者第一次和最后一次膝关节评价量表评分并无差异,而在修正Lysholm膝关节评分量表中(Modified Lysholm Knee Scoring Scale),手术组的评分要高于运动疗法组[51]。可见,运动疗法在防治膝骨关节炎中,并不具有明显优势,甚至不如其他疗法。 2.4 运动疗法的策略问题 与手术、传统治疗等相比,运动治疗膝关节损伤的疗效存在一定矛盾。因此,如何选择运动疗法,必须知道一些重要的因素。 2.4.1 早期运动疗法中膝关节的角度问题 膝关节屈曲角度是一个关键因素,它会导致不同的膝关节结局,尤其是在膝关节损伤或膝关节手术后。INGRID等[52]发现在恢复训练中肌肉力量需要给予特别的关注,不同类型膝关节损伤之间存在差异。前交叉韧带损伤患者屈膝30°时,股四头肌力量存在最大不足。半月板损伤患者屈膝70°时,股四头肌力量存在最大不足。软骨损伤患者屈膝60°时,股四头肌力量存在最大不足。此外,在股四头肌等长收缩时,前交叉韧带受到最大张力为屈膝15°,在30°时也会受到大量张力,而在30°-50°的时候也会有牵拉感。但是力量训练在屈膝45°-60°时不会造成前交叉韧带拉伤,只会在膝关节全伸时拉伤前交叉韧带[53]。当半月板负重时,受到的最大压力在屈膝30°-60°之间,超过60°,压力随之减小[54]。 前交叉韧带和半月板损伤是膝损伤中较为常见的两种损伤,因此,在刚开始进行运动疗法中,务必要注意前交叉韧带和半月板受到较大张力和压力的角度。在前交叉韧带和半月板受伤的情况下,尽量在开始阶段的治疗中不要去在此角度给膝关节负重。同时也需注意各部损伤股四头肌力量最大不足的角度,在此角度适当减小负重,避免训练过程中失稳失衡造成再次损伤。 2.4.2 运动疗法介入时间 出现膝损伤后,运动疗法介入应尽早。INGRID等[52]发现,如果优于潜在手术的运动疗法得以安全操作,似乎没有必要给膝损伤患者进行早期手术。通常包括8周内损伤严重的前交叉韧带患者,6个月内半月板退行性撕裂的患者,4年内局部软骨磨损的患者。FILBAY等[55]研究中,将符合纳入标准的前交叉韧带患者分为3组,先手术后运动疗法组、先运动疗法后手术组和运动疗法组。最后,他们得到了一个令人惊讶的发现,年轻人出现急性前交叉韧带断裂并伴有半月板损伤,以及那些在早期有严重膝关节症状、疼痛和功能受限的人,在考虑手术前可受益于设计好的运动疗法。这是因为10周内的早期重建可能会增加术后持续困难的可能性,如关节内手术造成的软骨结构创伤,长期的关节炎症,甚至体质量增加,都可能是半月板、韧带和其他关节组织治疗的不理想环境。术前运动疗法可以恢复膝关节功能,改善关节内环境,为膝关节手术做好准备,使康复效果最大化,并降低膝关节进行性退行性变的风险。其平均持续时间为14周,每周2-4次[56]。 如果患者进行过膝关节手术,术后最好同样尽快进行运动疗法。LEE等[57]进行了一个加速运动疗法(accelerated rehabilitation exercise,ARE),仅在术后 2 d开始操作,每次2 h,每周5次,共计12周,训练强度主要根据患者的疼痛级别和运动计划。结果发现,加速运动疗法患者在等长肌力、大腿围、Lysolm评价量表、动平衡等方面均有显著改善。此外,加速运动疗法与普通物理治疗相比,更有效提高30°和60°的等长力量。通常膝关节术后可在3-7 d开始进行康复训练,强度、时间、频率逐渐增加,此过程中需密切关注膝疼痛角度、膝部肌肉力量及患者的主观感受[58-60]。作者的团队之前1例膝关节前交叉韧带重建后1 d开始运动疗法,12周后可回归日常生活。相关运动疗法的操作,可参考图2。"
2.4.3 运动疗法治疗阶段 运动疗法治疗阶段主要分为两个阶段,早期和晚期。 早期以解决膝关节损伤为主,旨在减轻膝关节损伤、手术的疼痛、恐惧和焦虑,恢复关节活动度和膝部肌肉力量,包括关节活动松动、力量训练和神经肌肉训练。关节活动松动是早期运动疗法最为关键的部分,以膝关节屈伸为主[61]。从被动牵伸关节开始,再由患者自行操作。牵伸强度以患者忍受疼痛的酸胀感觉为主,当感觉刺痛时需立即停止。力量训练主要为抗阻训练,强度应该温和和缓慢,通常建议大约60%的最大强度[62]。神经肌肉训练是指包括动态稳定性、体位意识和协调性的运动表现训练。所有的动作都要求在运动时膝关节保持在脚和脚趾上方,同时避免过度的内偏或外偏。该强度的执行依赖于患者的反馈,必须是他们认为最大的安全角度范围内[63-64]。在运动疗法的早期,建议每个疗程在20-30 min之间[65-66]。而晚期阶段集中在准备重返运动场上,增强式训练如跑步、跳跃和敏捷性训练,可以帮助膝关节损伤患者在术后恢复运 动[67]。通常,这种运动产生的垂直地面反作用力是体质量的2-6倍,对膝关节功能恢复有积极影响。但需符合以下条件才能进行增强式训练:①主动膝关节全伸;②与健侧比,屈膝角度差异在5°内;③日常活动的疼痛评分小于2/10;④股四头肌肌力指标>60%(参考平常或健侧值);⑤术后至少12周[68-70]。此外,ERIN等[71]研究发现,负重(体质量50%)步态可以有效缓解运动治疗后和恢复运动前的“膝关节僵硬步态”,负重行走可防止肢体在动态中处于外翻位。而早期负重康复训练对关节软骨的组织学有不良影响[72],非负重运动则可减少膝关节损伤后无组织重建的创伤性骨关节炎[73],BUGBEE等[74]研究发现,非负重跑台可使大鼠膝关节的关节软骨状况更好、糖胺聚糖(增强软骨细胞抗压)水平增加、潮标(软骨发育成熟的重要标志)更具连续性。此外,BARTELS等[75]认为运动疗法中位置特异性方向变化、爆发性加速、协调技能和认知是后期的重要因素,他们展示了一个速度测试系统(Speed Court System, SCS),此系统会发出不可预测的干扰和包含以上重要因素的指令。这种训练更适合晚期的运动疗法,且有助于更科学、客观地计算回归运动的时间。 在整个运动疗法进行过程中,强度需控制在中小强度,因为膝损伤或膝手术后,关节内存在一定炎症和氧化应激。Sun等[76]发现中小强度有氧运动可减少白细胞介素1β,肿瘤坏死因子α和增加抗氧化酶的水平,可以逐渐休眠MAPKs相关信号通路(p38、JNK、ERK),从而抑制环氧合酶2和基质金属蛋白酶13的分泌。如果炎症和氧化应激情况较为严重,可选择被动运动(早期),将有利于减弱炎症和氧化应激情况[77]。一旦关节软骨被破坏,由于关节内无神经、血管和淋巴等使软骨很难被修复。因此,选择合适的运动强度非常重要,避免过度训练,加重膝关节内的炎症和氧化应激水平,而导致损伤加重。有关运动疗法策略见表2。 "
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