本文選題：陳舊性踝關(guān)節(jié)扭傷 + 肌骨超聲��； 參考：《中國中醫(yī)科學(xué)院》2016年博士論文

【摘要】：背景：踝關(guān)節(jié)扭傷臨床非常多見。對(duì)于不伴有骨折、脫位的單純踝關(guān)節(jié)扭傷,則往往被忽視,由此會(huì)演變成為陳舊性踝關(guān)節(jié)扭傷。陳舊性踝關(guān)節(jié)扭傷會(huì)導(dǎo)致踝關(guān)節(jié)周圍的慢性疼痛、踝關(guān)節(jié)不穩(wěn),最后還可能發(fā)生嚴(yán)重的踝關(guān)節(jié)骨性關(guān)節(jié)炎,不得不進(jìn)行關(guān)節(jié)融合或關(guān)節(jié)置換,從而產(chǎn)生嚴(yán)重的社會(huì)和經(jīng)濟(jì)負(fù)擔(dān)。清宮正骨派的代表孫樹椿教授運(yùn)用獨(dú)特的外踝理筋手法治療陳舊性踝關(guān)節(jié)扭傷,臨床療效明顯。本研究共分四個(gè)部分,第一部分為綜述,其中包括孫樹椿教授小傳及清宮正骨學(xué)術(shù)源流,中醫(yī)骨傷科對(duì)踝關(guān)節(jié)扭傷的認(rèn)識(shí)和治療,現(xiàn)代醫(yī)學(xué)當(dāng)前對(duì)踝關(guān)節(jié)扭傷的認(rèn)識(shí)與治療。第二部分為孫樹椿教授學(xué)術(shù)思想和臨床經(jīng)驗(yàn)整理與研究。共有7個(gè)方面,主要包括孫樹椿教授對(duì)骨傷科筋傷疾病的認(rèn)識(shí)和治療疾病首重手法、辨證與辨病結(jié)合、手法與用藥結(jié)合等學(xué)術(shù)特色以及踝關(guān)節(jié)外踝理筋手法的淵源與特色。第三、第四部分為運(yùn)用孫樹椿教授清宮外踩理筋手法治療臨床常見病踝關(guān)節(jié)陳舊性扭傷的臨床觀察及有關(guān)機(jī)理初探。目的：1.科學(xué)觀察、評(píng)估清宮正骨外踝理筋手法對(duì)陳舊性踝關(guān)節(jié)扭傷的臨床療效,較為客觀地驗(yàn)證、判定中醫(yī)手法治療臨床常見病的有效性,進(jìn)一步提高踝關(guān)節(jié)陳舊性扭傷的臨床診治能力。2.通過肌骨超聲技術(shù)、足底動(dòng)態(tài)應(yīng)力分析系統(tǒng)初步探討清宮正骨外踝理筋手法治療陳舊性踝關(guān)節(jié)扭傷的機(jī)理。方法：1.臨床觀察：經(jīng)過篩選符合納入標(biāo)準(zhǔn)的病例110例患者,最終有89例符合標(biāo)準(zhǔn)并資料完整,采用隨機(jī)對(duì)照單盲設(shè)計(jì)方法進(jìn)行分組,隨機(jī)分為手法治療組(簡(jiǎn)稱治療組)與對(duì)照組,其中治療組52例,對(duì)照組37例。治療組男13例、女39例,對(duì)照組男14例、女23例。所有患者踝關(guān)節(jié)扭傷全部為單側(cè),且都為內(nèi)翻損傷,均有不同程度的外踝處疼痛,右側(cè)66例,左側(cè)23例。扭傷到治療時(shí)間最短者3周,最長(zhǎng)者11月,平均4.7月�；颊吣挲g最小者18歲,最大者62歲。治療組進(jìn)行外踝理筋手法治療,具體手法要點(diǎn)如下：①手摸心會(huì)：在外踝處尋找“筋結(jié)”。②手法理筋：輕巧點(diǎn)柔“筋結(jié)”,待“筋結(jié)”由僵硬變軟后以踝關(guān)節(jié)拔、搖、戳手法理筋。③輕捋收功：最后沿著肌腱韌帶走行方向捋順傷處。對(duì)照組進(jìn)行功能鍛煉治療,具體包括①足背伸鍛煉；②足跖屈鍛煉；③踝關(guān)節(jié)內(nèi)外翻鍛煉；④提踵鍛煉等。對(duì)兩組患者治療前后進(jìn)行疼痛學(xué)VAS評(píng)分、AOFAS的Baird-Jackson踝關(guān)節(jié)評(píng)分、距骨傾斜角測(cè)量等的對(duì)比觀察。2.機(jī)理初探：上述入組患者中病史6個(gè)月以上的陳舊性踝關(guān)節(jié)扭傷患者共36例,其中男14例,女22例,平均6.3個(gè)月隨訪時(shí)對(duì)清宮外踝理筋手法治療前及治療后進(jìn)行如下對(duì)比研究。研究1：踝關(guān)節(jié)外側(cè)副韌帶肌骨超聲檢查：對(duì)治療前后的踝關(guān)節(jié)距腓前韌帶、跟腓韌帶、距腓后韌帶進(jìn)行高頻超聲檢查,①記錄踝關(guān)節(jié)外側(cè)副韌帶的厚度；②觀察韌帶纖維的連續(xù)性；③踝關(guān)節(jié)運(yùn)動(dòng)過程中的韌帶張力；④外側(cè)副韌帶周圍血腫面積;⑤踝關(guān)節(jié)內(nèi)積液量等。研究2：觀察手法治療前后患者的足底重心分布及其行走步態(tài)變化等。結(jié)果：1.臨床結(jié)果：本組患者隨訪時(shí)間最短者3月,最長(zhǎng)者2年,平均13.6月。疼痛學(xué)評(píng)分：組內(nèi)比較；兩組患者治療后與末次統(tǒng)計(jì)疼痛評(píng)分均低于治療前,差異有統(tǒng)計(jì)學(xué)意義(P0.05,P0.01)；兩組患者末次統(tǒng)計(jì)疼痛評(píng)分與治療后相比,治療組呈升高趨勢(shì),對(duì)照組呈降低趨勢(shì),差異有統(tǒng)計(jì)學(xué)意義(P0.05)。組間比較：兩組患者治療前疼痛評(píng)分差異無統(tǒng)計(jì)學(xué)意義(P0.05)；治療后與末次統(tǒng)計(jì),治療組疼痛評(píng)分低于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P0.05,P0.01)。AOFAS評(píng)分情況：兩組患者治療后AOFAS評(píng)分情況相比治療前呈升高趨勢(shì),差異有統(tǒng)計(jì)學(xué)意義(P0.05,P0.01)。治療組治療前AOFAS評(píng)分情況與對(duì)照組差異無統(tǒng)計(jì)學(xué)意義(P0.05)；治療后治療組AOFAS評(píng)分情況高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。應(yīng)力位X片距骨傾斜度：兩組患者治療前后,治療組與對(duì)照組在距骨傾斜度情況方面,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。2.機(jī)理探討結(jié)果：本組患者36例全部得到隨訪,隨訪方式均為門診隨訪。末次隨訪到受傷時(shí)間平均為6.3個(gè)月。手法治療次數(shù)平均為7.8次,每次治療不超過10分鐘。肌骨超聲檢查：本組病例選擇均為踝關(guān)節(jié)外側(cè)副韌帶部分?jǐn)嗔鸦虿糠炙沙诘幕颊�。追蹤觀察36例踝關(guān)節(jié)損傷治療前及治療后平均6.3個(gè)月的情況可見在踝關(guān)節(jié)各側(cè)副韌帶中距腓前韌帶是最常損傷、最難恢復(fù)的韌帶。跟腓韌帶、距腓前韌帶易同時(shí)損傷并損傷程度相仿,但能通過手法保守治療較快恢復(fù)。本組患者損傷可分為挫傷和部分?jǐn)嗔?治療前所有韌帶均連續(xù)性好；韌帶張力表現(xiàn)為松弛；副韌帶周圍有面積大小不等的血腫；韌帶周圍有明顯的積液。經(jīng)手法治療一段時(shí)間后運(yùn)用業(yè)界公認(rèn)的療效評(píng)價(jià)標(biāo)準(zhǔn)-超聲進(jìn)行綜合療效評(píng)價(jià)。距腓前韌帶的有效率為97.2%、跟腓韌帶有效率為88.9%,距腓后韌帶的有效率為83.3%。并對(duì)超聲機(jī)器所測(cè)各韌帶厚度值進(jìn)行統(tǒng)計(jì)學(xué)分析,清宮外踝手法治療前后踝關(guān)節(jié)外側(cè)各副韌帶厚度均較治療前有所恢復(fù),有顯著性差異(P0.05)。足底重心分布及其行走步態(tài)變化：本組患者的測(cè)試結(jié)果顯示踝關(guān)節(jié)陳舊性損傷患者明顯有對(duì)踝關(guān)節(jié)外側(cè)不信任感,患足足底外側(cè)壓力增加,足底壓力中心的連線出現(xiàn)明顯外移。測(cè)量患足較健足壓力中心擺動(dòng)的距離明顯變大。經(jīng)過手法治療后患者無論足底壓力中心還是重心擺動(dòng)距離均很快恢復(fù)到健側(cè)水平。結(jié)論：1、運(yùn)用孫氏“清宮正骨”外踝理筋手法治療陳舊性踝關(guān)節(jié)扭傷在緩解疼痛、改善患者踝關(guān)節(jié)功能方面臨床常有立竿見影的明顯療效,優(yōu)于目前西醫(yī)常用的踝關(guān)節(jié)單純功能療法鍛煉組。2、“清宮正骨”外踝理筋手法和踝關(guān)節(jié)功能療法鍛煉均不能改善踝關(guān)節(jié)的解剖關(guān)系,所以對(duì)于功能性踝關(guān)節(jié)不穩(wěn)定療效明顯,對(duì)于機(jī)械性踝關(guān)節(jié)不穩(wěn)定治療效果一般。3、運(yùn)用“清宮正骨”外踝理筋手法治療陳舊性踝關(guān)節(jié)扭傷經(jīng)過肌骨超聲檢查證實(shí)可以對(duì)踝關(guān)節(jié)外副韌帶張力、厚度、消除周圍血腫、積液等方面有所改善,并且通過對(duì)全踝關(guān)節(jié)的手法調(diào)整對(duì)足底重心位移、足部步態(tài)等方面有所改善,從而運(yùn)用現(xiàn)代技術(shù)證實(shí)了中醫(yī)手法的臨床療效和機(jī)理。
[Abstract]:Background: ankle sprains are very common. For a single ankle sprain without fracture and dislocation, it tends to be ignored, which will evolve into an old ankle sprain. Old ankle sprains can lead to chronic pain around the ankle, unstable ankle, and severe ankle osteoarthritis at the end of the day. This study is divided into four parts. The first part is a summary of four parts. The first part is a summary of the study, including the biography of Professor Sun Shuchun and the palace of Qing Dynasty. The knowledge and treatment of the ankle sprain in the orthopedics department of orthopedics, the understanding and treatment of the sprain of the ankle joint in modern medicine. The second part is the study and study of Professor Sun Shuchun's academic thought and clinical experience. There are 7 aspects, mainly including Professor Sun Shuchun's understanding of the tendon injury in the bone Department of Traumatology and the first treatment of the disease. The third, the fourth part is the clinical observation and the related mechanism of the treatment of clinical common malleolus sprain with the fourth part of Sun Shuchun's Qing palace. Objective: 1. scientific observation and evaluation. The clinical effect of the external malleolus manipulation on the old ankle sprain, it is more objective to verify the effectiveness of the traditional Chinese medicine manipulation for the clinical common diseases and to further improve the clinical diagnosis and treatment ability of the old sprain of the ankle joint.2. through the musculoskeletal ultrasonic technique and the dynamic stress analysis system of the plantar. The mechanism of manipulative treatment of old ankle sprains. Method: 1. clinical observation: after screening 110 patients who were in accordance with the standard, 89 cases were in conformity with the standard and complete data, and were divided into groups by random control single blind design method, randomly divided into manipulative treatment group (simple treatment group) and control group, of which 52 cases in treatment group and control group were compared. There were 37 cases in the group of 13 men and 39 women in the treatment group, 14 in the control group and 23 in the female. All the ankle sprains were all unilateral, and all were varus. There were different degrees of pain in the outer malleolus, the right 66 cases, the left 23 cases. The longest one was 3 weeks, the oldest was in November, the average age was 18 years and the largest 62 years old. The treatment group carried out the treatment of external malleolus tendon manipulation, and the main points were as follows: (1) hand touch the heart meeting: looking for "tendons" in the outer malleolus. Group for functional exercise treatment, including the foot back and extension exercise; (2) foot and foot flexion exercise; (3) the ankle joint internal and external turnover exercise; (4) heel exercise and so on. The two groups of patients before and after the pain learning VAS score, AOFAS Baird-Jackson ankle score, the talus tilt angle measurement and other comparison observation of the.2. mechanism: the above group of patients There were 36 cases of old ankle sprain with more than 6 months of medical history, including 14 men and 22 women. The average 6.3 months of 6.3 months were compared. 1: ultrasound examination of the lateral collateral ligament of the ankle: the anterior ankle to the anterior peroneal ligament, the peroneal ligament, and the peroneal. The posterior ligament was examined by high frequency ultrasound. (1) the thickness of the lateral collateral ligament of the ankle joint was recorded; secondly, the continuity of the ligament fiber was observed; (3) the ligament tension during the movement of the ankle joint; (4) the area of hematomas around the lateral collateral ligament; (5) the amount of the internal convolution of the ankle joint. Study 2: the distribution of the foot center of gravity of the patients before and after treatment and the walking of the foot before and after treatment. Results: 1. clinical results: 1. clinical results: the shortest follow-up time in this group was in March, the longest was 2 years, an average of 13.6 months. The pain score was compared in group. The pain scores of the two groups were lower than those before the treatment, the difference was statistically significant (P0.05, P0.01); the final statistical pain score of the two group was with the post treatment phase. Ratio, the treatment group showed a trend of increase, the control group showed a decreasing trend, the difference was statistically significant (P0.05). There was no statistical difference between the two groups before treatment (P0.05); the pain score of the treatment group was lower than that of the control group after the treatment and the final statistics, the difference was statistically significant (P0.05, P0.01).AOFAS score: the two groups were affected. After treatment, the AOFAS score was higher than before the treatment (P0.05, P0.01). There was no significant difference between the treatment group and the control group before the treatment (P0.05). The AOFAS score in the treatment group was higher than that of the control group (P0.05). The two groups of the talus inclination of the stress level X tablets: two groups Before and after treatment, there was no significant difference between the treatment group and the control group on the talus inclination of the talus (P0.05).2. mechanism: 36 cases were all followed up and followed up in the outpatient clinic. The average time of the last follow-up was 6.3 months. The average number of hand treatment times was 7.8 times, and the treatment was not more than 10. 36 cases of ankle joint injury before and after treatment averaged 6.3 months after treatment, and the most difficult and most difficult ligaments to recover from the peroneal ligament, peroneal and peroneal, were observed in 36 cases of ankle injury before and after treatment. The anterior ligament was easily damaged and damaged in a similar degree, but it could be recovered quickly by conservative treatment. The injury in this group could be divided into contusion and partial fracture. All ligaments were in good continuity before treatment; the tension of ligaments was relaxed; blood swollen with different size around the collateral ligament; obvious effusion around the ligaments. Hand in hand rule of law After a period of time, the comprehensive curative effect was evaluated using the recognized standard of efficacy evaluation of the industry. The effective rate of the anterior peroneal ligament was 97.2%, the effective rate of the peroneal ligament was 88.9%, the effective rate of the posterior fibula ligament was 83.3%. and the value of the ligament thickness measured by the ultrasonic machine was statistically analyzed, and the ankle joint before and after the treatment of the lateral malleolus in the palace of the Qing palace. There was a significant difference (P0.05). The distribution of the center of gravity of the foot and the walking gait. The test results of the patients in this group showed that the patients with old ankle injuries were obviously distrust of the lateral ankle, increased the lateral pressure of the foot foot, and the connection of the foot pressure center appeared obviously. The distance between the foot pressure center of the foot and the foot pressure center was greatly increased. After the manipulation, the patients recovered to the healthy side quickly regardless of the foot pressure center or the center of gravity. Conclusion: 1, the treatment of the old ankle sprain with sun's "Qing Gong bone" external ankle sprain can relieve the pain and improve the ankle joint work. The clinical curative effect is often immediate. It is superior to the common ankle joint functional therapy exercise group.2, which is commonly used in western medicine. "Qing Gong orthopedics" external malleolus manipulation and ankle joint function exercise can not improve the anatomical relationship of ankle joint, so it has obvious effect on functional ankle joint instability, for mechanical ankle joint. The effect of unstable treatment is generally.3. The treatment of old ankle sprain by means of "Qing Gong orthopedics" external malleolus manipulation can improve the tension, thickness, elimination of surrounding hematoma, effusion, and the adjustment of the foot's center of gravity and foot gait through the manipulation of the ankle joint. And so on, so as to improve the clinical efficacy and mechanism of modern Chinese medicine.

【學(xué)位授予單位】：中國中醫(yī)科學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R249;R274.9

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