【作者】 徐海涛；

【导师】 徐达传； 李义凯；

【作者基本信息】 南方医科大学 ， 临床解剖学， 2008， 博士

【摘要】 目的（1）研究常用腰椎手法推拿力的大小以及手法过程中出现“咔哒”声响时对腰椎推扳力的值;（2）研究常用推拿手法的体位和角度,为手法的量化提供依据,并为进一步进行腰椎推拿手法的有限元分析提供生物力学的模拟条件;（3）建立一个可视化的腰椎三维有限元模型,模拟常用腰椎推拿手法作用,对其内在应力、矢量、变形和位移进行研究,为研究推拿手法的作用机理,探讨提高手法疗效的方法,减少手法的意外损伤提供一个直观的、可视化的研究平台;（4）探讨常用推拿手法操作时腰椎间盘、腰椎椎体和后部结构的位移、变形及内在应力分布的特点,以分析手法的机理、安全性与合理性。方法（1）应用压力传感器系统,测量并记录定点旋转手法作用过程中出现“咔哒”声响时术者拇指推顶颈椎和腰椎棘突的最大推扳力;（2）测量直腰旋转扳法操作时对左、右两侧肩部的推力和扳力;（3）测量进行腰椎斜扳手法、腰椎扭转扳法和腰椎侧卧位定位斜扳法出现“咔哒”声响时对肩部和臀部的最大推扳力;（4）测量腰部后伸扳法、腰椎扭转后伸扳法、按腰扳肩法操作时对腰椎的按压力;（5）在进行手法操作时,对腰椎进行X线摄片,与手法操作前的X线片比较,测量出手法作用时腰椎前屈、后伸、侧弯的位移;（6）使用螺旋CT,以1mm的间隔,对1名男性青年的腰椎沿轴向进行断层扫描,以jpg格式将图像输入计算机。使用L_4-5的CT图像,逐层重建L_4-5的含有24990个结点,15652个块单元的三维有限元模型;（7）根据手法原理,将常用腰椎推拿手法进行分解,把各项力学参数代入三维有限元模型,利用Ansys 9.0软件进行计算;（8）显示手法作用时腰椎椎体、后部结构、椎间盘的内在应力、内部变形和位移的变化过程;并将其结果与相应的生物力学测试的结果进行对比。结果（1）定点旋转手法出现“咔哒”声响时术者左、右手拇指对受试者第4腰椎棘突的推扳力分别为5.07±1.30kg和6.64±1.50kg;左、右手拇指对受试者第4颈椎棘突的推扳力分别为4.73±1.04kg和6.42±1.33kg;（2）直腰旋转扳法时术者对受试者肩部的推力为6.22±1.05kg,扳力为7.47±1.02kg;（3）腰椎斜扳手法出现“咔哒”声响时术者对受试者左、右肩部的推扳力分别为12.55±1.72kg和12.75±1.65kg,对左、右臀部的推扳力分别为13.59±1.63kg和13.27±1.20kg;对高、矮受试者肩部的推扳力分别为12.81±1.26kg和12.41±1.39kg,对高、矮受试者臀部的推扳力分别为13.63±1.35kg和13.50±1.09kg;对胖、瘦受试者肩部的推扳力分别为13.27±1.23kg和11.73±1.26kg,对胖、瘦受试者臀部推扳力分别为13.73±1.00kg和12.92±0.23kg;（4）腰椎侧卧位定位斜扳法出现“咔哒”声响时术者对受试者胸部和臀部的推扳力分别为10.72±1.65kg和11.82±1.33kg;（5）后伸30°和45°进行腰部后伸扳法（双测）时术者对受试者腰部的压力分别为4.84±0.56kg和6.34±0.93kg;（6）腰部后伸扳法（单侧）时术者手掌对受试者腰部的压力为8.49±1.31kg,膝部对受试者腰部的压力为10.56±1.12kg;（7）腰椎扭转后伸扳法时术者手掌对受试者腰部压力的大小分布于3.5-9.7kg之间,平均为5.90±1.58kg;（8）按腰扳肩法术者手掌对受试者腰部的压力的大小分布于6.2-9.4kg之间,平均为7.86±0.92kg;（9）腰部后伸扳法（双测）时L₅下缘后部的相对位移为10.05mm,腰部后伸扳法（单侧）时L₅下缘后部的相对位移分别为7.98mm,坐位腰椎定点旋转手法时L₄上缘前缘向前的相对位移为6.10mm,L₄上缘右侧向右的相对位移为5.35mm;（10）腰椎斜扳手法作用时应力集中点位于关节突、椎弓跟,椎板等处,椎间盘的应力小于后部结构,从椎间盘中心到右侧有一个向后的扭转矢量,使椎间盘产生变形;（11）腰部后伸扳法（双测）作用时应力集中点位于双侧椎弓根,椎板和关节突处;整个椎间盘向后突出;（12）腰部后伸扳法（单侧）作用时应力集中点主要位于椎弓根、椎板、关节突和椎体的左侧,椎间盘左侧的位移矢量为向后向下,右侧的矢量为向前向上;（13）按腰扳肩法作用时应力集中点主要位于椎弓根、椎板和关节突;整个椎间盘向后回缩;（14）腰椎侧卧位定位斜扳法作用时椎间盘没有向后的位移和变形;（15）坐位腰椎定点旋转手法作用时椎间盘出现一个向右侧的扭转的变形,椎间盘左侧后部向前回缩。结论（1）在进行定点旋转手法时,术者拇指的推扳力大小与“咔哒”声响的发生无直接关系,对腰椎、颈椎棘突推扳力的大小也无显著性差异（P=0.155）,但利手对左、右拇指的推扳力有显著的影响（P＜0.001）;（2）向左、右分别进行斜扳手法时,对左、右肩部平均推扳力无显著差异（P=0.655）,对臀部的左、右侧的推扳力也一样（P=0.410）,但对臀部的推扳力大于对肩部的推扳力（P=0.016）,斜扳手法操作时所需推扳力的大小与身高无直接关系（P=0.226）,但对身材肥胖者的手法操作比瘦弱者更费力（P=0.002）;（3）腰椎斜扳手法对椎间盘是安全的,但是对于腰椎滑脱、峡部裂和关节突关节损伤的患者有一定危险,并且在椎间盘突出的对侧进行手法操作更为合理;（4）腰椎侧卧位定位斜扳法对于腰椎间盘突出症和腰椎管狭窄患者是安全的;（5）腰部后伸扳法（双测）并不适用于腰椎间盘突出症、峡部裂、腰椎滑脱和关节突关节损伤的治疗,使用腰部后伸扳法（单侧）治疗腰椎间盘突出症时,应该后伸其健侧的下肢;（6）按腰扳肩法能并不适用于有峡部裂、关节突关节损伤、腰椎滑脱、腰椎间盘突出症和腰椎管狭窄的患者的治疗;（7）坐位腰椎定点旋转手法向健侧操作更为合理。更多还原

【Abstract】 Objective （1）To study the manipulative forces of the frequently used lumbar spinal manipulations and the manipulative forces during cracking sounds of manipulations. （2）To study the body postures and angles during lumbar spinal manipulations, in order to provide a quantitative basis for the manipulations, and to provide a basis of biomechanics for analyzing lumbar spinal manipulations with finite element. （3）To Set up a three-dimensional and visible finite element system of lumbar spine, and study the displacement, distortion, vector and intra-stress distribution during the manipulations. And to provide a macroscopic basis for visible study of manipulations, study the mechanism of manipulations, exploring the method of optimizing the manipulations, and reducing the accidental injury of manipulations. （4）To study the trait of distortion, displacement and intra-stress distribution of intervertebral disc, vertebral body and posterior area of lumbar during the frequently used lumbar spinal manipulations, in order to analyze the mechanism, security and rationality of manipulations.Methods （1）The largest forces of thumb on the spinous process of the fourth cervical vertebra and the fourth lumbar vertebra were tested and recorded with a pressure sensor testing system during cracking sounds of the located and rotatory manipulation. （2） The manipulative forces on the left and right side shoulder were tested during the lumbar erected and rotatory manipulation. （3）The manipulative forces on shoulder and hip were tested during cracking sounds of the obligue-pulling manipulation, the lumbar rotatory-pulling manipulation, the lumbar located and obligue-pulling manipulation. （4）The manipulative forces on the lumbar spine were tested during the lumbar troflexed manipulation, the lumbar rotatory and troflexed manipulation and the lumbar-pushing and shoulder-pulling manipulation. （5）The X-ray films were get during manipulations, and were compared with the X-ray films before manipulations, the displacements of anteflected, troflexed, lateral curvature during manipulation were tested. （6）A young man’s lumbar spine was scanned by CT with 1mm interval. Then, the jpg-format data of CT was inputted into computer. Sectional constructed a three-dimensional finite element system of lumbar L4.5 by the CT images. The finite element system contained of 24990 nodes and 15652 elements. （7）The frequently used lumbar spinal manipulations were decomposed by principium of manipulation. The parameters of mechanics were analyzed with the three- dimensional finite element system and computed with software Ansys 9.0. （8）The changes of distortion, displacement and intra-stress distribution in vertebral body, posterior area and intervertebral disc of lumbar spine were displayed during the manipulations. The results were compared with the relevant experimentation of biomechanical.Results （1）As the cracking sound, the forces to the fourth spinous process of lumbar vertebra were 5.07±1.30kg and 6.64±1.50kg respectively in left and right thumbs, the forces to the fourth spinous process of cervical vertebra were 4.73±1.04kg and 6.42±1.33kg respectively in left and right thumbs during the rotatory and localized manipulation. （2）The pushing force was 6.22±1.05kg and the pulling force was 7.47±1.02kg during the lumbar erected and rotatory manipulation. （3）As the cracking sound, the manipulative forces were 12.55±1.72kg and 12.75±1.65kg respectively to the left and right shoulder, and the manipulative forces were 13.59±1.63kg and 13.27±1.20kg respectively to the left and right hip during the lumbar obligue-pulling manipulation. The manipulative forces were 12.81±1.26kg and 12.41±1.39kg respectively to the tail’s and the short’s shoulder, and the manipulative forces were 13.73±1.00kg and 12.92±0.23kg respectively to the tail’s and the short’s hip. The manipulative forces were 13.27±1.23kg and 11.73±1.26kg respectively to the fat’s and the thin’s shoulder, and the manipulative forces were 13.73±1.00kg and 12.92±0.23kg respectively to the fat’s and the thin’s hip. （4）As the cracking sound, the manipulative forces were 10. 72±1. 65kg and 11.82±1.33kg respectively to the thoraces and hip during the lumbar located and obligue-pulling manipulation. （5）The pressures to the lumbar were 4.84±0.56kg and 6.34±0.93kg during the lumbar troflexed manipulation （two sides） respectively with 30°and 45 troflexed body postures. （6）The pressure of palm to lumbar was 8.49±1.31 kg and the pressure of genua to lumbar was 10.56±1.12kg during the lumbar troflexed manipulation （one side）. （7）The pressure of palm to lumbar was in 3.5-9.7kg, and the average pressure was 5.90±1.58kg during the lumbar rotatory and troflexed manipulation. （8）The pressure of palm to lumbar was in 6.2-9.4kg, and the average pressure was 7.86±0.92kg during the lumbar-pushing and shoulder-pulling manipulation. （9） The displacement of inferior of L₅ vertebral body was 10.05mm during the lumbar troflexed manipulation （two sides）. The displacement of inferior of L₅ vertebral body was 7.98mm during the lumbar troflexed manipulation （one side）. The displacement toward anterior of the superior of L₄ vertebral body was 6.1mm and the displacement toward right of the superior of L₄ vertebral body was 5.35mm during lumbar located and rotatory manipulation. （10）The centers of intra-stress were distributed in facet joint, pedicle of vertebral arch and lamina of vertebral arch during the lumbar obligue-pulling manipulation. The intra-stress of posterior area was larger than that of intervertebral disc. There was a palinal vector from center of the intervertebral disc to the right, which distorted the intervertebral disc. （11）The centers of intra-stress were distributed in both side of facet joint, pedicle of vertebral arch and lamina of vertebral arch during the lumbar troflexed manipulation （two sides）. The intervertebral disc protruded posterior. （12）The centers of intra-stress were distributed in left side of facet joint, pedicle of vertebral arch, vertebral body and lamina of vertebral arch during the lumbar troflexed manipulation （one side）. The displacement vector of the left intervertebral disc was toward posterior and inferor. The displacement vector of the right intervertebral disc was toward anterior and superior. （13）The centers of intra-stress were distributed in left side of facet joint, pedicle of vertebral arch and lamina of vertebral arch during the lumbar-pushing and shoulder- pulling manipulation. The intervertebral disc distorted toward posterior. （14）These was not distortion and displacement in intervertebral disc toward posterior during the lumbar located and obligue-pulling manipulation. （15）These was a distortion of rotatory in intervertebral disc toward right during the lumbar rotatory and localized manipulation. The left intervertebral disc distorted toward anterior.Conclusion: （1）There wasn’t directly relationship between the manipulative forces of thumbs and cracking sound during rotatory and localized manipulation, and had much effect of dominant and subdominant hand on the largest manipulative force（P<0.001）. （2）There wasn’t significance difference in manipulative forces to shoulder between the left and right during the lumbar obligue-pulling manipulation （P=0.655）, just as the hip （P=0.410）; but the force to hip was larger than the shoulder（P=0.016）. There wasn’t directly relationship between stature and the manipulative forces of the lumbar obligue-pulling manipulation （P=0. 226）, but it was harder to manipulate the fat than the thin during manipulation （P=0. 002）. （3）The lumbar obligue-pulling manipulation was safe to the intervertebral disc, but it was danger to lumbar vertebrae olisthy, isthmus fracture and facet joint damage, and it was more rational for manipulation in the healthy side. （4）The lumbar located and obligue-pulling manipulation was safe to the lumbar intervertebral disc protrusion and lumbar spinal stenosis. （5）The lumbar troflexed manipulation （two sides） was not suitable for lumbar intervertebral disc protrusion, lumbar vertebrae olisthy, isthmus fracture and facet joint damage. It was more rational for troflexing the healthy side leg in treat lumbar intervertebral disc protrusion during the lumbar troflexed manipulation （one side）. （6）The lumbar-pushing and shoulder-pulling manipulation was not suitable for lumbar vertebrae olisthy, isthmus fracture, facet joint damage, lumbar intervertebral disc protrusion and spinal stenosis. （7）It was more rational for rotatory manipulation toward the healthy side during the lumbar rotatory and localized manipulation.更多还原