Chinese Journal of Tissue Engineering Research ›› 2019, Vol. 23 ›› Issue (20): 3201-3206.doi: 10.3969/j.issn.2095-4344.1193
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Huang Junneng1, He Yufeng2, Liu Hao1, He Zitong1, Wu Bingjie1, Zhao Xiayun1
Online:
2019-07-18
Published:
2019-07-18
Contact:
He Yufeng, Chief physician, Professor, Master’s supervisor, the First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning 530222, Guangxi Zhuang Autonomous Region, China
About author:
Huang Junneng, Master candidate, Physician, Guangxi University of Chinese Medicine, Nanning 530222, Guangxi Zhuang Autonomous Region, China
Supported by:
the Traditional Chinese Medicine Science and Technology Project of Guangxi Administration of Chinese Medicine, No. GZKZ09-30 (to HYF)| the Graduate Education Innovation Program of Guangxi Zhuang Autonomous Region, No. YCSW2018175 (to HJN)
CLC Number:
Huang Junneng, He Yufeng, Liu Hao, He Zitong, Wu Bingjie, Zhao Xiayun. Diagnosis, treatment and research advances of sacroiliac joint dislocation[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(20): 3201-3206.
2.1 针灸治疗 2.1.1 传统针刺治疗 从文献报道与临床的实际治疗来观察,目前针灸治疗对于骶髂关节错位有显著的疗效。国内学者匡家毅等[11]使用针刺治疗骶髂关节损伤时,将针尖直接朝向症状反应点进行病灶的直接刺激治疗,总有效率90%。《黄帝内经灵枢集注》中记载有“以痛为腧者,随其痛处而即为其所取之俞穴也”。气血堵塞,输布不畅,不通则痛,所以在痛点处直刺,疏通瘀滞是最快最简便,亦能更好的促使局部微循环的改善,并加速炎症吸收,从而改善甚至消除症状。魏文广等[12]也认可针刺能够快速消除炎症,并能恢复功能活动促进错缝复位。而蔡少萍[13]在单纯的局部针刺基础上,加上了灸法,即为温针灸治疗骶髂关节错位疼痛,温针灸增加了温通的功效,不仅能促进局部炎症吸收还能更好疏通经络,还能快速缓解疼痛。袁涛等[14]认为在温针灸的基础上加上矩阵结构的配合,不仅能局部“以痛为腧”,还能起到围刺效果“气至病所”,并能对局部的韧带力量起到增强作用,对于骶髂关节疼痛起到很好的疗效,并促进关节归复。 2.1.2 小针刀及电针治疗 小针刀目前在国内的发展较快,应用也比较广,其应用于骶髂关节错位方面侧重于局部粘连组织的松解,常常能够起到立竿见影的效果。阿力木江•马合木提等[15]采取小针刀对骶髂关节半脱位进行治疗,治疗总效率达到98%,其认为小针刀技术较为成熟,可以提高疗效,降低复发率。同样的,杨永辉等[16]采用针刀治疗骶髂关节错缝也取得了较好疗效,骶髂关节常常因为错位形成高应力导致的局部循环障碍,针刀在骶髂关节的肌肉组织附着点、痛点、挛缩点进行切割等操作,释放能量,减轻压力,并改变软组织结构,有助于骶髂关节复位。除了针刀治疗,临床上亦有医者使用电针来进行复位治疗,陶群等[17]就是利用电针产生的电流刺激,使得筋、肌肉被动收缩,从而促使骶髂关节进行复位,该治疗方式可以满足对于复位有恐惧感的病患人群,同样是值得推广的。 2.2 手法治疗 2.2.1 传统推拿手法整复 手法治疗一般包括推拿松解与整复手法[18]。 国内手法治疗一般先以中医传统的推拿手法松解局部紧张的肌肉组织并运用整复手法将错位的关节恢复到正常的解剖位置。王学习[19]采用骶髂关节反向诊断复位,就是沿着关节面的行径方向来进行错合推动,减小错位的间距使得贴合更紧密而减轻解除症状,总优良率95.33%。其复位是基于错位间距增大,疼痛就会加剧;错位间距减小,疼痛就会减小的原理来评判错位方向再而进反向诊断复位操作,这也是进行前后型错位复位操作的原理基础。 临床上针对于骶髂关节错位,医者普遍会先辨别前后型错位,再施行复位手法,毕竟骶髂关节错位前错型与后错型的复位手法有所不同。正如姜宏凯[20]运用常规按摩手法放松后再进行手法整复医治,前错型错位选用屈膝屈髋复位法,后错位型错位选用单髋过伸扳按压法,总有效率97.56%,这类传统复位手法是运用得较为多见的。当然也有医者认为不需要辨别前后型错位即可手法复位治疗,林勇[21]使用后伸下肢压骶手法来医治骶髂关节错位,总有效率100%,这个复位手法特色就是治疗骶髂关节紊乱不必在意前后型错位的鉴别,主要是通过瞬间分离关节,利用关节韧带组织的弹性来恢复到骶髂关节的正常位置,这与中医骨伤整复的理论“欲合先离”相吻合,临床上亦是可行的。姬明亮[22]运用基础手法以松解粘连、活血通络、温养筋脉,再施行侧卧牵抖复位法进行复位,共治疗110例,有效率为97.3%。其主张应先整复错位,再施以常规推拿手法进行放松,这是较为传统的治疗理念,正如《黄帝内经•素问•举痛论》所言“经脉流行不止……客于脉中则气不通,故卒然而痛”,“通则不痛,痛则不通”,使经络气血通行,疼痛自然就能止。 也有学者会有不同于主流的独特观点,王学昌等[23]认为骶髂关节错位实际就是骶髂关节周围软组织的病变,而并非是关节的稳定性真的破环了,更加不是严重的半脱位或脱位,复位听到“咔”一声后症状随即消失,但这不能证明关节有错位,只能说明了手法的机制在于舒筋、理筋,使筋合其槽、归其位。该学者认为该病的病名应该重新命名定义,可能“骶髂关节筋错缝”会更为准确一点。他采用的治疗是点按拨揉放松腰部,在痛点处缓慢加力点按,俯卧牵拉推按法进行关节的复位。 各家各有特长,应取长补短,方能提高自身能力进而提高临床疗效。作者以自身的临床结合来考虑,对于合并伴有腰椎滑脱、年老体弱及怀孕者,以理筋治疗为主,孕者还应注意不能使用增加腹压的手法,所有的治疗手法都要以安全作为第一前提。 2.2.2 现代外传手法整复 王红锦[24]采用日式骨盆按旋法医治骶髂关节错位,总有效率为98%,该学者认为日式的骨盆压按旋法复位较为可靠安全,复位操作较一般复位手法轻巧,避免了暴力复位,简单实用,这仍然是纯粹手法的治疗。而王平等[25]则应用美式整脊床冲击手法治疗骶髂关节错位,运用整脊床的瞬间顿压的落板效应,将力量渗透到骶髂关节内部而达到复位的效果,器械的协助,能使治疗过程更加简便、快速、安全。同样的,杨杰华等[26]亦是运用器械辅助治疗,矫正枪能够在不同的组织中产生不一样的能量梯度,进而产生一系列物理效应,并能一定程度将错位关节往正常的解剖位置归复,解除疼痛,用在骶髂关节错位的复位亦是可行的。矫正枪的使用也可以提高医师的效率并减轻工作量,器械辅助复位治疗值得大家进一步研究学习。 2.3 国外相关研究 除了上述治疗手段,骶髂关节错位还有其他治疗以及辅助康复手段。Brizzolara等[27]使用镇痛剂和非类固醇抗炎药物进行注射,并安装骶髂关节带或者骨盆压缩带加以辅助恢复,以提供稳定性并减轻疼痛。亦有大量的研究显示骶髂关节内注射类固醇注射后疼痛缓解时间延长,双盲研究显示了关节周围皮质类固醇治疗的有明显效果,苯酚注射相关研究也显示有较好效果[28-29]。 国外有研究人员已经进行了射频去神经化手术以及射频消融术来治疗缓解骶髂关节疼痛[30-34]。所使用的技术包括外周神经场刺激和关节本身粘连组织的剥 离[35]。手术清创术和融合术这2种方法都具有侵入性[36],但对骶髂关节错位疼痛能起到较为显著的疼痛减轻和活动功能的明显改善,不足的是运行成本相对较高。一般患者更倾向于无创治疗,如Moon等[37]使用体外冲击波治疗,这是一种目前较为新型的无创治疗方法,患者接受度较高,亦能促进复位,减轻疼痛。 2.4 多方式结合治疗 往往2种或者多种治疗方式的联合使用,能取得比单方式治疗效果来得显著,疗程更短,因此应用得更广泛。曾金强[38]将用推拿整复骶髂关节后再用微波治疗仪进行局部治疗,当手法将错位的关节归复,但炎症无法跟随消除,微波治疗仪能够温通周围组织,促进周围组织的微循环改善,起到快速消除症状的作用。与曾金强不同的是,卢辉[39]则是采用中药熏蒸来代替微波治疗,总有效率92.9%。中药熏蒸有助于气血运行,温养受损局部,减轻疼痛。朱满华[40]将推拿手法配合针刀治疗骶髂关节损伤,有效率95.24%,针刀可以松解肌紧张并能疏通经络,为手法复位做好松解的基础准备,最后用手法进行复位,使关节更容易复位,二者强强联手,疗效更佳持久。孙珂等[41]将传统针刺和脊柱微调手法很好的结合运用治疗骶髂关节紊乱的远期疗效达到75%,针刺与调脊相辅助,2种治疗方式相结合更能使关节面平整,韧带紧张度恢复,从而起到较为平稳的远期疗效。而魏文广等[12]则更进一步将针灸、整脊及功能锻炼有机结合治疗产后骶髂关节错缝,短期疗效高达100%,且具有较好的远期疗效。针灸和整脊主要是针对短期的疗效,消除症状较为明显,而功能锻炼,尤其是腰臀功能锻炼是远期疗效作用明显,可见锻炼尤其重要。"
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