葉楓 謝克波 劉洋
摘要:目的? 觀察“豐盛特色手法”結(jié)合關(guān)節(jié)鏡下清理術(shù)治療重度(K-L 4級)膝骨關(guān)節(jié)炎的臨床療效。方法? 采用隨機數(shù)字表法將170例患者分為治療組和對照組各85例。2組均行關(guān)節(jié)鏡下清理術(shù),術(shù)后鍛煉;治療組術(shù)后予“豐盛特色手法”,隔日1次,每次20 min。2組均連續(xù)治療4周。比較2組術(shù)前及術(shù)后2、4、12周日本骨科協(xié)會評估治療分數(shù)(JOA)評分、視覺模擬評分法(VAS)評分、Lysholm膝關(guān)節(jié)功能評分表(Lysholm)評分,評價2組臨床療效。結(jié)果? 與本組術(shù)前比較,2組術(shù)后各時點Lysholm評分明顯升高(P<0.05);2組術(shù)后同一時點比較,治療組Lysholm總分、與術(shù)前差值及疼痛、爬樓梯評分均明顯優(yōu)于對照組(P<0.05,P<0.01,P<0.001)。與本組術(shù)前比較,2組術(shù)后各時點JOA評分明顯升高(P<0.05);2組術(shù)后同一時點比較,治療組JOA總分、與術(shù)前差值及步行、上下樓評分均優(yōu)于對照組(P<0.05,P<0.01,P<0.001)。與本組術(shù)前比較,2組術(shù)后各時點VAS評分明顯降低(P<0.05);2組術(shù)后同一時點比較,治療組VAS評分及差值均明顯優(yōu)于對照組(P<0.05,P<0.001)。術(shù)后4、12周,2組JOA、Lysholm評分系統(tǒng)優(yōu)良率比較差異有統(tǒng)計學意義(P<0.01,P<0.001)。結(jié)論? “豐盛特色手法”結(jié)合關(guān)節(jié)鏡下清理術(shù)治療重度(K-L 4級)膝骨關(guān)節(jié)炎可明顯改善患者骨關(guān)節(jié)炎癥狀,促進膝關(guān)節(jié)功能康復(fù),提高臨床療效。
關(guān)鍵詞:豐盛特色手法;手法治療;關(guān)節(jié)鏡下清理術(shù);膝骨關(guān)節(jié)炎;K-L 4級
中圖分類號:R274.94??? 文獻標識碼:A??? 文章編號:1005-5304(2019)08-0030-05
DOI:10.3969/j.issn.1005-5304.2019.08.007????? 開放科學(資源服務(wù))標識碼(OSID):
Abstract: Objective To observe the clinical efficacy of Fengsheng hospital-specialized manipulation combined with arthroscopic debridement for the treatment of K-L 4 knee osteoarthritis. Methods Totally 170 patients were randomly divided into treatment group and control group, with 85 cases in each group. Both groups have undergone arthroscopic debridement and postoperative function exercise. Base on this, the treatment group was treated with the Fengsheng hospital-specialized manipulation, once every other day, 20 min each time. The treatment for both groups lasted for 4 weeks. JOA, VAS, Lysholm scoring systems were used to quantify the scores in order to understand the symptoms of osteoarthritis and changes in knee joint functions before and after 2, 4, and 12 weeks of surgery. The clinical efficacy of both groups was evaluated. Results Compared with before surgery, the Lysholm scores in each time points of the two groups were significantly increased (P<0.05); Compared in the same time point, the total scores of Lysholm, preoperative difference, pain, and stair climbing scores of the treatment group were significantly better than those of the control group (P<0.05, P<0.01, P<0.001). Compared with before treatment, the JOA scores of the two groups were significantly increased at each time point (P<0.05); Compared in the same time point, the total scores of JOA, preoperative difference, walking, and upper and lower building scores of the treatment group were better than those of the control group (P<0.05, P<0.01, P<0.001). Compared with before treatment, the VAS scores of the two groups were significantly lower (P<0.05); Compared in the same time point, the VAS scores and differences of the treatment group were significantly better than those of the control group (P<0.05, P<0.001). At 4 and 12 weeks after surgery, there was statistical significance in the excellent rates of JOA and Lysholm scoring systems in the two groups (P<0.01, P<0.001). Conclusion Fengsheng hospital-specialized manipulation combined with arthroscopic debridement for the treatment of K-L 4 knee osteoarthritis has obvious advantages in improving symptoms of osteoarthritis and rehabilitation of knee functions, which can enhance clinical efficacy.
Keywords: Fengsheng hospital-specialized manipulation; manual therapy; arthroscopic debridement; knee osteoarthritis; K-L 4
膝骨關(guān)節(jié)炎好發(fā)于老年人群。據(jù)統(tǒng)計,40歲左右人群的膝骨關(guān)節(jié)炎患病率為10%~17%,60歲左右人群患病率為50%,75歲以上人群患病率約80%[1]。重度膝骨關(guān)節(jié)炎患者由于錯過治療最佳時機,單純關(guān)節(jié)鏡下清理術(shù)已很難取得良好療效,故臨床多采取姑息治療或關(guān)節(jié)置換。本研究采用“豐盛特色手法”[2]結(jié)合關(guān)節(jié)鏡下清理術(shù)治療重度膝骨關(guān)節(jié)炎患者,觀察臨床療效及對患者膝關(guān)節(jié)功能的影響,現(xiàn)報道如下。
1? 資料與方法
1.1?? 一般資料
選擇2017年1月-2018年8月本院行膝關(guān)節(jié)鏡下清理術(shù)的重度膝骨關(guān)節(jié)炎患者170例,采用隨機數(shù)字表法分為治療組和對照組各85例。治療組男21例,女64例;對照組男26例,女59例。2組性別、年齡、病程、加重病程、日本骨科協(xié)會評估治療分數(shù)(JOA)、Lysholm膝關(guān)節(jié)功能評分表(Lysholm)、視覺模擬評分法(VAS)評分比較,差異無統(tǒng)計學意義(P>0.05),具有可比性。見表1。本研究經(jīng)本院倫理委員會審查批準(FSLL2016-01)。
1.2? 西醫(yī)診斷標準
參照《骨關(guān)節(jié)炎診治指南(2007年版)》[3]制定膝骨關(guān)節(jié)炎診斷標準。①近1個月內(nèi)反復(fù)膝關(guān)節(jié)疼痛;②X線片(站立或負重位)示關(guān)節(jié)間隙變窄、軟骨下骨硬化和/或囊性變、關(guān)節(jié)緣骨贅形成;③關(guān)節(jié)液(至少2次)清亮、黏稠,WBC<2000個/mL;④年齡≥40歲;⑤晨僵≤3 min;⑥活動時有骨摩擦音/感。綜合臨床、實驗室及X線檢查,符合①②或①③⑤⑥或①④⑤⑥,即可診斷為膝骨關(guān)節(jié)炎。
X線Kellgren-Lawrence(K-L)分級標準[4]。0級:完全正常;1級:關(guān)節(jié)間隙可疑變窄、似有骨贅;2級:關(guān)節(jié)間隙可疑變窄、明顯骨贅;3級:關(guān)節(jié)間隙明確變窄、中量骨贅,硬化改變;4級:關(guān)節(jié)間隙明顯變窄、大量骨贅、硬化和畸形。
1.3? 納入標準
①符合上述西醫(yī)診斷標準,X線分級屬K-L 4級;②患者對治療方案知情并簽署知情同意書。
1.4? 排除標準
①有手術(shù)、手法禁忌者;②合并精神病,不能配合治療者;③合并風濕免疫疾病、感染、腫瘤,出現(xiàn)膝關(guān)節(jié)病變者;④正在或已經(jīng)接受其他相關(guān)治療、可能影響本研究效應(yīng)指標觀察者;⑤診斷為交叉韌帶斷裂需行交叉韌帶重建術(shù)者。
1.5? 剔除標準
①中途發(fā)生嚴重不良事件、退出觀察者;②未完成隨訪者;③自主改變治療方式者。
1.6? 治療方法
2組均行關(guān)節(jié)鏡下清理術(shù)[5],術(shù)后定期換藥;術(shù)后3 d去除加壓包扎,指導(dǎo)患者主動進行“等長收縮”和“踝泵”等肌力鍛煉和膝關(guān)節(jié)活動度鍛煉。不予消炎鎮(zhèn)痛藥及理療。術(shù)后2周拆線。
治療組予“豐盛特色手法”[2,6]。以起止點為主要操作部位,放松膝關(guān)節(jié)周圍肌肉2~3 min,待操作部位發(fā)熱或肌肉松弛則進行提拿和推移髕骨、點按推揉彈撥內(nèi)外側(cè)脛股間隙,每部位約2~3 min。取梁丘、膝陽關(guān)、陽陵泉、血海、陰陵泉、曲泉、膝關(guān)、陰谷、委中、委陽,每穴點按30 s;膝關(guān)節(jié)拔伸牽引及活絡(luò)關(guān)節(jié)手法2~3 min,逐漸增大屈伸和旋轉(zhuǎn)的被動活動度。術(shù)后3 d開始,每次約20 min,隔日1次,連續(xù)4周。
1.7? 觀察指標
分別于術(shù)前及術(shù)后2、4、12周進行VAS評分[7],JOA評分[8](包括步行能力、上下樓功能、膝關(guān)節(jié)活動度、膝關(guān)節(jié)腫脹程度及總分),Lysholm評分[9](包括跛行、負重、交鎖、關(guān)節(jié)不穩(wěn)、疼痛、關(guān)節(jié)腫脹、爬樓梯、下蹲及總分)。
1.8? 療效標準
積分減分率(%)=(治療后分值-治療前分值)÷(100-治療前分值)×100%。JOA評分系統(tǒng):≥75%為優(yōu),≥50%且<75%為良[8]。Lysholm評分系統(tǒng):≥95分為優(yōu),≥85分且<95為良[9]。優(yōu)良率(%)=(優(yōu)例數(shù)+良例數(shù))÷總例數(shù)×100%。
1.9? 統(tǒng)計學方法
采用SPSS20.0統(tǒng)計軟件進行分析。計量資料以
—x±s表示,符合正態(tài)分布采用t檢驗;計數(shù)資料采用卡方檢驗。P<0.05表示差異有統(tǒng)計學意義。
2? 結(jié)果
2.1? 2組不同時點視覺模擬評分法評分比較
與本組治療前比較,2組術(shù)后各時點評分均明顯降低(P<0.05);2組術(shù)后同一時點比較,治療組VAS分值及差值均優(yōu)于對照組(P<0.05,P<0.001)。見表2。
2.2? 2組不同時點Lysholm膝關(guān)節(jié)功能評分表比較
與本組術(shù)前比較,2組術(shù)后不同時點Lysholm各項評分明顯升高(P<0.05);2組術(shù)后同一時點比較,治療組總分、與術(shù)前差值、疼痛、爬樓梯評分均優(yōu)于對照組(P<0.05,P<0.01,P<0.001)。見表3。
2.3? 2組不同時點日本骨科協(xié)會評估治療分數(shù)比較
與本組術(shù)前比較,2組術(shù)后同一時點JOA各項評分均明顯升高(P<0.05);2組術(shù)后同一時點比較,治療組JOA總分、與術(shù)前差值、步行、上下樓評分項在各時點均優(yōu)于對照組(P<0.05,P<0.01,P<0.001)。術(shù)后2周活動度比較2組差異無統(tǒng)計學意義(P=0.602),但2組活動度分值均已接近滿分。見表4。