Chinese Journal of Tissue Engineering Research ›› 2013, Vol. 17 ›› Issue (20): 3756-3763.doi: 10.3969/j.issn.2095-4344.2013.20.020
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Chen Ke-di1, Chen Na2, Xie Yan-fei1, Li Le2
Received:
2012-11-15
Revised:
2013-01-26
Online:
2013-05-14
Published:
2013-05-14
Contact:
Li Le, M.D., Associate investigator, Department of Rehabilitation Medicine, First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
lile5@mail.sysu.edu.cn
About author:
Chen Ke-di, Zhongshan Medical College, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
chenkedi991@gmail.com
Supported by:
the National Natural Science Foundation of China, No. 31100669; the National Innovation Training Program for College Students, No. 111055853
CLC Number:
Chen Ke-di, Chen Na, Xie Yan-fei, Li Le. Ultrasound assesses muscle morphology and function under different neuropathological conditions[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(20): 3756-3763.
2.1 纳入文献基本情况 初检得到144篇文献,中文14篇,英文130篇。阅读标题和摘要进行初筛,排除因研究目的与此文无关64篇,内容重复性的研究10篇,共保存70篇中英文文献做进一步分析。文献[1-6]回顾了超声测量技术的应用历史,文献[7-18]研究了超声检测到肌肉形态学参数变化及其意义,文献[19-66]研究了在病理情况下超声的应用,文献[67-70]展望了超声测量技术的未来应用前景。 2.2 结果描述 2.2.1 肌肉形态参数的意义 肌纤维长度(fascicle length):有学者指出肌肉的纤维长度是最重要的肌肉形态参数[10],因为肌纤维长度能使特定的肌筋膜产生更大的移动距离,即肌肉收缩时肌纤维缩短,将深筋膜牵拉向运动中心的距离,也就是使肌肉收缩速率,肌纤维每分钟被拉长的长度增加以及更好的收缩策略。肌纤维长度的增加使力量-速率曲线中的最大收缩速率增加,使大部分的骨骼肌肉的力量-长度曲线变得更宽。虽然在力量-长度曲线中对于长的肌纤维和短的肌纤维来说峰值都是一样的,但是长的肌纤维肌肉主动收缩的范围增大了,这与关节的主动活动度直接相关。因此超声对于这一参数的测量在临床的评估中有着非常重要的意义。然而肌肉形态的改变并不会和肌肉张力的变化成正比例关系。比如说肌肉的等长收缩,即肌肉两端固定,由于肌腱的弹性特质肌肉纤维缩短,即使肌肉长度不变,但肌纤维却变短了[11]。肌腱的牵张不是线性的,即在肌腱松弛的阶段只需要较小的力量就可产生较大的形变,而当肌腱被牵张进入平台期,即使很大的力量也只能再使肌腱延长很小的距离。因此在肌肉的等长收缩过程中,超声所探测到的形变和力量大小的关系要分阶段解读,在收缩的初期力量较小,二者相对成线性关系;当肌肉收缩超过最大自主收缩的20%时,肌腱牵张进入平台期,二者不再成线性关系[12]。如果是肌肉进行向心或离心收缩则情况更加复杂,因为不仅要考虑肌腱的弹性特质,还要顾及肌肉长度的变化[13]。 羽状角(pennation angle):羽状角决定了肌腱肌肉中收缩组织启动的数目,角度越大,肌肉肌腱能启动的收缩组织越多,从而增加肌肉的发力能力[14]。同时羽状角对肌纤维收缩力量向筋膜传递的重要因素之一。羽状角在45°以内力量的传递效果较好,随着角度的变大,力量的传递变得较低效,同时也导致了肌纤维长度变小,进而使肌肉收缩的速率及筋膜的移动距离范围变小[15]。 肌肉厚度(muscle thickness):肌肉厚度的大小直接反映了肌肉含量的多少。Shi等[16]用超声成像技术测量肱二头肌进行等长收缩时的肌肉厚度的变化,发现在肌肉处于疲劳状态时肌肉的厚度增加,证明了肌肉厚度的变化可以作为判断肌肉是否处于疲劳状态的重要参数。但Manguhan等[15]在测量胫前肌从放松状态到最大的等长背屈收缩状态中观察到胫前肌的厚度始终保持不变,提示肌肉厚度可能不能很好地反映肌肉功能。 横截面积(cross-section area):横截面分为解剖横截面积和生理横截面积。Manguhan等[15]证明肌肉的生理横断面积越大,肌肉力量就越大。Maganaris 等[17]在测量正常人完整的比目鱼肌和胫前肌的力量-肌纤维长度关系特点时,进一步证实了肌肉力量取决于肌肉的生理横断面积,并发现当肌纤维逐渐增长时,肌肉力量会随之逐渐上升并到达一个最高点,之后即使肌纤维增长,肌肉力量依旧处于平台期。肌肉生理横断面积与肌纤维的角度和长度有关。Narici 等[18]利用超声探测到腓肠肌从放松到完全收缩的状态,肌纤维的角度增加到原来的两倍,肌纤维长度增加了35%,从而导致肌肉生理横断面积增加了35%。 2.2.2 超声在评估疾病对肌肉形态和功能的影响中的应用 超声能有效地观测肌肉形态参数,探寻病理状态下肌肉形态和功能的变化,并指导临床更好地进行对患者的评估和有针对性的康复训练。由于可以发觉不同位置、不同深度下肌肉组织形态改变的信号,因此超声能够用于个体肌肉肌腱活动的检测。肌肉收缩可以产生身体运动,因此肌肉收缩是反映运动功能的重要指标,目前认为最大等长收缩是定量评定肌肉功能的可靠指标[19]。既往文献证实,当肌肉处于放松和收缩状态时,肌纤维长度和羽状角有着显著的差别。同时随着肌肉收缩程度的变化,肌纤维长度和羽状角也跟着产生相应的变化[20]。20世纪90年代已有很多不同的方法测量各种肌肉骨骼组织在二维及三维空间上的平移、旋转和变形[21-22]。有文献报道用超声测量可以检测出深层肌肉在接受物理治疗过程中的肌肉活动。同时应用超声和表面肌电图可以记录下肌肉在准静态下的活动信号[23],可以检测呼吸肌群的活动[24]。刘卫勇等[25]证明超声测量肌肉厚度比超声目测肌肉回声改变对评估先天性马蹄内翻足患儿小腿肌肉萎缩更为敏感。有学者也应用超声测量肌肉生理横截面积来验证稳定性训练对下腰痛的改善作用[26]。近年来随着运动控制训练在下腰痛治疗中的普及,超声因为能明确运动训练效果而被推广开来[27]。 一直以来学者相信针对腹横肌和腰椎多裂肌的训练是治疗下腰痛的关键方法[28]。Hodges应用五导线的肌电图说明了无下腰痛的健康人腹横肌的激活先于腰部任何方向上的运动[29],而下腰痛患者其腹横肌的激活则较健康人慢[30],显示腹横肌在腰部正常活动中起重大作用。因为超声可以探测出肌肉厚度的变化,而厚度变化指示肌肉被激活,因此超声可以应用于各种腰腹部肌肉检查,尤其是深层肌肉的训练中,以明确训练效果。Deydre将超声用于下腰痛患者腹部侧方肌肉[31],Watson等[32]则用于健康人腹横肌,并在其负重和进行功能性任务过程中进行检测,均显示超声结果的可靠性,Mcoherson等[33]则明确了超声所获得的肌肉厚度信号的可重复性。可以预想的是为了满足研究者在腰部稳定训练方案中日渐严格的有关肌肉激活信息的要求,超声被越来越多用于此类检测。然而,国外大部分试验是通过正常人或者运动员来完成的[34-36]。只有在近年来才开始出现利用超声对脑卒中或脑瘫等中枢神经系统损伤所致异常张力的肌肉进行形态结构的观察[37-39]。Li等[39]通过研究发现脑卒中后患者肘关节肌肉肌腱参数的改变,例如肌纤维长度缩短、羽状角变大等,并且这些参数与关节所处位置及发力情况均有关。范宏娟等[40]在超声对股四头肌收缩前后形态测量的研究中观察到在放松状态与处于不同张力的等长收缩状态时,股直肌的厚度有差异,而横截面积却无差异。不同张力之间,股直肌的厚度也没有差异。这就提示在评估存在异常张力的肌肉如脑卒中患者偏瘫侧的股四头肌时,其肌肉横断面积的变化比肌肉厚度的变化更有意义。Gao等[41]通过超声观察到和正常儿童相比,脑瘫儿童小腿肌肉(内侧腓肠肌)有更短的肌纤维长度,更小的肌肉横截面积以及更长的肌腱。Gao等[42]的另一项研究是病程超过1年的脑卒中患者,超声结果表明患侧腓肠肌的肌纤维长度较正常人缩短,羽状角减小和肌肉变薄。 在指导康复训练方面,超声可以应用于偏瘫患者。以盂肱关节为例,它是人体关节活动度最大的滑膜关节,因此其稳定机制格外重要[43]。正常情况下旋袖肌群使肱骨头紧紧压进关节窝内,保持盂肱关节的稳定;偏瘫状态下,因为过度使用或外伤,患侧的旋袖肌群尤其是冈上肌容易受损,并且伴有肌肉萎缩。Lehtinen等[44]报道了冈上肌体积和生理横截面积间存在显著的关系,因此对目标肌肉体积的准确测量有助于评估肌肉萎缩情况及推断其功能水平,从而有利于康复方案的设定及对预后的判断。传统上测量肌肉体积的影像学方法是MRI,但因为其成本高并且不易携带不易操作的缺点,研究者将目光投向超声的应用,尽管锁骨和肩胛冈的存在影响了超声图像的清晰度。在最近的研究中,Yi等[45]认可超声在肩胛切迹获取肌肉图像的可行性,还明确了超声所测量得到的肌肉厚度参数和通过MRI测量得到的肌肉生理横截面积存在很强的正相关关系,超声在肩胛切迹处获得的肌肉厚度参数有助于康复方案的设定和预后的评估。Suetta等[46]发现在进行了12周抗阻训练后,老年术后患者肌肉横截面积增加约32%,肌纤维角度和厚度分别增加了22%和15%,证明抗阻训练对老年术后患者康复的有效性。对于正常老年人而言,横断面研究显示不管是其肌肉厚度,还是肌纤维长度和羽状肌角度,都比年轻状态时减少[47]。为了判断不同模式的抗阻训练对老年人肌肉形态学参数的影响,以确定这种伴随年龄增长所带来的肌肉形态学参数变化能否被训练逆转或者减缓,研究者需要可靠的测量方法。Raj等[48]应用B型超声对21位健康老年人的股外侧肌和内侧腓肠肌进行测量,其结果和Blazevich等[49]对年轻人的测量及Legerlotz等[50]对儿童的测量有很好的吻合,这显示尽管存在年龄影响,从群体角度而言超声对形态学参数的测量依然有很高的可靠性。Raj等[48]也承认对老年人个体来说,超声可能不够敏感。一个有趣的发现是对内侧腓肠肌肌纤维长度测量的可靠性比股外侧肌更高,作者给出的解释是腓肠肌肌肉纤维比较短,因此需要更少的从超声图像外推完整的纤维,意味着更少的误差可能。 最近,有学者利用超声探测健康以及撕裂的冈上肌的不同位置,不仅发现可以定量检测出肌肉纤维长度和羽状肌角度的差异,而且不同位置的肌肉参数参数也具备统计学意义[5]。这些肌肉参数的信息无疑有助于手术施行计划的确定。更进一步,有关处于不同时期的撕裂冈上肌的肌肉参数和不同外展角度、不同收缩模式下的参数变化的研究将对整个冈上肌撕裂手术选择和康复流程有重要意义。香港学者还将超声应用于截肢患者残余肢体的功能评估上,并证明了超声技术具有巨大的应用潜力[51]。他们也提出了利用超声测量残留肢体肌肉厚度这一肌肉参数来控制肌肉变形的方法,并证明了超声技术在这一应用中的灵敏性[52]。大陆学者也应用超声,通过反映局部肌肉厚度变化,为脑瘫患儿的疗效评价提供客观依据,他们指出超声的应用较传统足印法具有更高的准确性和操作性,更易被家长所接受[53]。综合以上可以看出,超声的有效利用在疾病预后的预测,手术方式的评价以及训练有效性的评估方面有很大的潜力。 2.2.3 超声评估疾病影响肌肉形态和功能的优缺点 超声的优点:作为一种可靠的逐步成熟的研究方法,超声与其他骨骼肌评估方法相比亦有着很多的优势。首先超声是一种安全、非侵入性的、较便宜的可以测量肌肉形态学参数的手段,并且二维的超声技术也可以用于三维的肌肉图像重建[54]。和MRI一样,超声测量可以发现肌肉和脂肪的差别,同时避免暴露于电离辐射。超声比MRI更加便宜,使用方便,且可以在肌肉静态和动态的条件下与其他测力设备一起使用[55],并得出良好的肌肉组织图像[56]。超声技术的方便使用不仅有利于测量的快速进行,也不受地点约束,甚至对受试者也有安慰的心理作用,更易被患者接受[54]。超声不仅能测量评估表层的肌肉,而且能实时、无创和便捷地测量评估深层的、小的肌肉[57]。因为躯干稳定肌很多位于深层,超声因此成为核心稳定性训练中测量躯干深层肌肉活动最有效的手段[58]。此外,超声结果的可重复性也很优秀[59]。表面肌电图虽然也是一种实时无创的测量肌肉活动的方法。但是肌电信号受到了很多因素的影响比如电极间的距离,放大器,肌肉类型,邻近的肌肉,环境和噪声[60]。除此之外,由于肌电信号进入深层肌肉后变得越来越弱,同时也会收到表层肌肉肌电信号的干扰,肌电图不能对深层的肌肉进行无创地测量评估[61]。 总而言之,超声具有以下特点:①安全无创性。②重复性高。③良好的成像能力。④操作方便。⑤价格相对低廉。⑥可配合其他测力设备进行测量[62]。基于以上优势,超声在测量骨骼肌形态结构特征上得到了广泛的应用。它可以灵敏、简单、快速、定量地反映肌肉形态结构的变化,并可反复多次检查,前后对比有利于监测疾病的进程,指导临床康复治疗。 超声技术现阶段应用应注意的方面: 超声探头方向的影响:准确测量肌肉形态学参数是研究者开展实验最基本的要求。在羽状肌中,由肌纤维长度和羽状肌角度可以推算出肌肉的长度、肌力以及收缩时的速度潜力。更长的肌纤维可以增加肌肉收缩时的长度,因为募集到更多的肌纤维,其收缩的速度也得到加强。在超声能否胜任准确得到肌肉形态学参数这方面上,尽管很多国外的研究都已经证明超声在动态和静态下进行肌肉参数测量的可行性和有效性[63-64],但超声检查结果易会受探头方向的影响。原因在于超声成像将三维的肌肉转化为二维的图像,故探头角度是影响超声成像准确性的重要因素。Klimstra等[65]实验证明了探头旋转的角度可以影响肌纤维长度、羽状肌角度以及肌肉厚度的测量值,并且这种误差不能通过建立一定的肌肉发力几何模型预测出来。部分原因在于肌肉发力平面和超声成像平面的不吻合。此种不吻合是二维成像不可避免的。一个例子是胫骨前肌并不是只在矢状面上发力,因此要求超声操作者稍微调整探头方向,以完全垂直于肌肉纤维走向的方向进行扫描。周光泉认为现阶段可以利用特殊的物质如轻泡沫将探头固定在身体表面[66],随着技术发展探头影响的问题会得到妥善解决。 操作者的影响:操作者水平的高低会影响误差的大小,这一点适用于其他人体测量技术[55]。操作者水平首先体现在能准确选取肌肉的观察位置,要求操作者对人体解剖有很好的基础,并将探头以合适的角度放置于肌肉上,这个过程不能产生对肌肉的压缩,在超声和肌肉间涂上耦合剂可以较好解决压迫肌肉的问题,然而随着肌肉收缩操作者应该能够同步调整探头方向并时刻保持对肌肉毫无压迫。其次,观察者需要明确骨头与肌肉、肌肉与皮下脂肪之间的分界;运动员或者正常人肌肉与其他组织的分界也许足够清晰,但对于老年人或者肌肉因废用而萎缩的患者,其观测并不容易。 关节角度微动的影响:超声成像一般采用实时测量的方法,除了在测量过程中完全静息,被测者常需要进行肌肉的等长收缩,然而关节经常发生微动,导致测量的不准确。实验证明踝关节进行等长收缩跖屈运动时,关节还是不可避免发生了大约8°的角度旋转,造成了小腿三头肌复合体的位移,这样的影响是不能被忽略的[67]。Karamanielis等[68]也证明了关节角度的变化会影响肌肉形态参数,在最大发力状态下,所测得的内侧腓肠肌肌纤维长度被估大了 1.53 cm,羽状肌肌纤维角度被估大了5.5°,伴随的是肌肉力量不准确的夸大,因而对肌肉功能产生错误的估计。在小腿三头肌负重和不负重两种情况下,踝关节角度的差异会显著影响肌肉纤维长度-肌肉力量二者关系。因此对于羽状肌角度-肌力关系和肌肉纤维长度-肌力关系的研究者而言,踝关节在等长收缩过程中产生的关节旋转变化是不容忽视的。 特定情况下应该与其他设备联合使用:大部分肌肉形态学参数是伴随其收缩而发生变化的,对于其他不在此范畴内的肌肉而言,单独使用超声是成问题的。超声对某些特定肌肉不能提供有意义的信息,如腹外斜肌收缩时肌肉厚度不发生明显变化,因此超声不能用于检测腹外斜肌肌肉活动[57]。上文也提及了肌肉形态学参数变化和肌肉收缩之间的关系,更详细得阐述是肌肉收缩初期形态学参数改变量是相当大的,随着收缩强度不断增大,特别是提高到最大自主收缩水平的20%之后,这些形态学参数变化降低,这是肌肉避免过渡收缩造成肌肉断裂或肌腱拉伤的自我保护机制。因此,超声对于较低强度的肌肉活动探测效果比高强度的肌肉活动而言更准确。特例是内侧腓肠肌,这块肌肉的形态学参数和肌肉收缩之间有很好的线性关系,这意味着超声可以在腓肠肌很宽的收缩强度范围内进行准确有效的探测[12]。这应该是研究者喜欢将腓肠肌作为测试对象的一个原因。"
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