非常感谢 非常荣幸 thank you very much i'm honored to be
也非常高兴受邀来参加此次论坛 here and delighted to have been
但是有一点 invited i um the only problem for me is
就是我感觉自己真的很愚笨啊 i feel so dumb compared to you all
因为在座各位可以说四五种语言 you don't need a translator you speak
不需要翻译帮忙 four or five languages
很多人说我需要一个翻译协助 most people think i need a translator
翻译熟悉我的语言 and they speak my language
那么来看看今天我们的内容吧 so um we'll see what we can do from here
关于本次论坛，我发现自己收到的标题 so uh i was actually given the title for
实际上有些难度的 this talk which i found challenging
因为回顾过往30年 to think over the last uh 30 years
事实上我已经在这个领域 uh i actually have been in the
从业55年 profession for 55 years
所以要在40分钟时间内完成自己的陈述 and then to do it in 40 minutes so um
我们需要抓紧时间啊 we're going to have a quick run through
那么 here
我的计划表中 um so there's several things that are
有几项非常重要 really important on my agenda and one of
而其中一项是 them is
物理治疗的转型 this transition in in physiotherapy
30年前 uh so going back 30 years which is about
也就是1980年 1980
当时我所了解的 the identity as i saw it of
物理治疗的身份得以确立 physiotherapy at that time was the
是由于 emergence of
手法治疗开始作为 manual therapy to an important part of
肌骨管理方法的一个重要组成部分 musculoskeletal management
而这件事之所以这么重要 and i think what was so important about
就是因为 it is that
这是首次 really for the first time
物理治疗师开始寻求 physiotherapists were figuring something
弄明白一些问题 out
而在此之前，他们多侧重于 rather than just doing something to
病患治疗 treat patients
另外，手法治疗还有一个重要方面是 and but the the other side of manual
这种治疗起初 therapy was that the time
非常被动 initially it was pretty much passive
并不重视 without any emphasis
身体运动或肌肉功能 on exercise or muscle function and i had
我在其他治疗师之前已经了解到 already learned that that muscles move
肌肉推动关节移动 joints long before therapists knew how
也正是这个工作原理 to move joints because that's the way it
标志着我在这个领域研究的开始 was when i started
除此之外，还有麦肯基疗法 there was also the McKenzie method which
我个人对其疗法的综合理解是 was sort of a self-manipulation i'm
它是一直自我操作的方法 paraphrasing of course all of this and
而我所了解到的 then the only person that i knew of that
对肌肉问题有所论及的 was somewhat talking about muscles was
是Vladimir Yonda vladimir yonda and he had his sort of
他研究的是肌肉协同 muscle synergy things
和肌肉训练 and sort of a little bit of muscle
而我认为 training
从这些研究可以看出我们正处于转型中 where i think we are the big transition
而且关于这个行业 and this has been a
我最感兴趣的方面 major part of my interest for the
也正是形成身份认同 profession is developing an identity
2013年 and in night in 2013 the american
美国物理治疗协会（APTA）宣布 physical therapy association declared
人体运动系统的 the human movement system as the
物理治疗身份 identity of physical therapy
我认为这一点非常重要 and i think this is just really critical
因为对我们来说其重要性 because i think what what's so important
在于它关注的 for us is to be in charge of a body
不仅仅是完成某项活动的人 system not just people that do things
而是整个 but have responsibility for a system of
人体系统 the body
我们已经了解 and what we have is knowledge of its
人体系统的功能 functions and the other part that i
而关于其重要性 think is so important about this and
特别是诸位对运动的理解 particularly you people related to
是 sports
将其视为全生命周期从业者 is that we should be life span
我们要协助 practitioners we should be helping to
提高 shape
身体效能 the performance of a body from the time
从人体开始能活动一直到 people start to move until they
生命不支持任何活动 can't move anymore and my analogy is
我的比喻是牙颌模型 with the dental model people go to the
人们有牙齿的时候会去看牙医 dentist when they get their teeth and
而即使后来牙齿掉光了 then they keep going even after they
还是要去看牙医 don't have teeth
所以生命不支持时 so uh it's much harder to get people to
再让人去动就很难了 move when they can't move but
我们如果早点开始动 if if we start out early then i really
相信就可以降低 believe we can reduce the incidence of
肌骨痛的发病率 musculoskeletal pain or
或者可以推迟发病时间 or put it off for a while and the other
我认为还有一点至关重要 thing that i believe is absolutely
就是我们要 critical is that we have to have
确定症状和诊断类别 defined syndromes and diagnostic
在你贴上标签之前 categories no one will ever think you
人们并不会了解 figure anything out until you put a
你是否弄明白任何问题 label on it
所以我们要 and we've got to get in the habit of
养成归类的习惯 having labels
另外 我认为 so i think the other thing that we're in
我们正处于重大的转型过程中 the major transition of and maybe this
而或许这只是我一厢情愿的看法 is wishful thinking but there's
但诸多迹象表明 many indications of this is that instead
转型并非侧重病理解剖问题 of a big focus on patho anatomical
而是 problems
聚焦在 is a focus on the whether you call it
运动损伤（不知道您是否这样称呼） it's movement impairments and one form
它探讨的是病理运动学 is to talk about pathokinesiology
即某种形式的病理诱发 how some form of pathology induces
运动障碍 movement faults
而我认为我们应该关注的是 but what i think we should be really in
我所谓的 charge of is what i call kinesio
运动病理学 pathology
即运动如何诱发身体问题 which is how movement induces problems
那么这是一份 so this is a diagram developed at
华盛顿大学 washington university
为运动系统制作的图表 uh for the movement system and of course
它比较显著的一点是 what's so wonderful about it it takes in
其囊括的内容非常全面 everything as you all know so well the
包括肌骨系统和神经系统 musculoskeletal and nervous systems
肌骨系统主要负责 musculoskeletal being the primarily
操作执行运动 effector of movement
而神经系统发挥调节功能 and the nervous system the regulator and
当然 of course
还有心肺和内分泌 the cardiopulmonary and endocrine
系统 systems
心肺系统用于 cardiovascular systems which you need to
保持其他系统健康 keep the other systems healthy but
但是这些系统都受到运动影响 they're also affected by movement
在美国我一直说 i kind of keep saying in america we're
我们做这个实验 doing this this experiment
产生的数据非常乐观 the data's coming in good the experiment
实验目的是将运动限定于 is to lift limit our movement to elbow
通常使用勺子或餐叉时 flexion and extension usually with a
肘部的屈曲和外展 spoon or a fork
而且实验结果的确显示变胖 and it does show out that you get obese
罹患心脏疾病 and then you get heart disease and
和糖尿病 diabetes
因此数据真的很有参考价值 so that data is coming in really good
无论如何 anyway
我们面临的一个突出问题 one of our big problems the definition
即华盛顿大学开发的运动系统 of the movement system developed at
是一套 washington university is a system of
生理器官系统 physiological organ systems
这些系统交互产生且支持 that interact to produce and support
机体和其组成部分的 movement of the body and its component
运动 parts
而且我认为 and i believe that the diagnosis that
物理治疗师 physical therapists physiotherapists
应做出的诊断 should make
属于运动系统诊断 are movement system diagnosis they
这些诊断就像是 should be ones of this system just as
神经科医生进行神经学诊断 the neurologist makes neurological
心脏病专家进行心脏诊断 diagnosis the cardiologist makes cardiac
等等 diagnosis etc okay and and i think it
Paula Ludwig的一篇社论里 was explained well in an editorial by
很好地阐释了这一点 paula ludwig
她是一位肩部研究员 who's a investigator on the shoulder
非常优秀 very very good one
关于物理治疗师做出的诊断 and she said regarding diagnosis by
她认为 physical therapists
物理治疗师针对的是运动相关的损伤 that pts treat movement related
而非 impairments rather than structural
结构解剖问题 anatomical problems and using anatomical
使用解剖标签造成 labels creates a disconnect between the
标签和治疗的脱节 label and our treatment
而运动系统标签的好处是 and the advantage of a movement system
它与我们的身份认同 label is it's consistent with our
是一致的 identity
我们的专业知识培训 我们的执照 our expertise training our license and
我们的疗法 our treatment
侧重于动作检查 it prioritizes the movement exam which
而这一点目前是欠缺的 is where i think things are deficient
而对于评估 and evaluation and it uses standard
则采用我们这个领域的 kinesiology terminology within our scope
运动机能学术语 of practice
所以我希望诸位可以认识到 so i i'm hoping you'll see the rest of
接下来的材料与 this material falls in line with that
我们的认知 so what do we know now well i think
或者说我们将要认识到的情况相一致 we're beginning to know
我们逐渐认识到运动的关键性 that movement is really key and can
运动可能引发损伤 become impaired and cause
运动可能造成肌骨痛 musculoskeletal pain this is what i
以上就是我所谓的主要变化和观念 consider the main
这种理解是基于 changes and concepts at least as i've
我在该领域50多年的积累 been around for these 50 odd years
肌骨痛并非 that musculoskeletal pain is not a
短时间内形成的 short-term problem with
通过治疗让相关身体组织 tissues fully restored to normal with
完全恢复正常 treatment
病理结构问题 that the patho anatomical problem is
产生的原因是 induced by progressive
生活方式 micro trauma related to degenerative
和个人特质的 changes in lifestyle
退化病变相关的轻伤 and personal characteristics that
运动损伤是 movement impairments induced are induced
由于 by
神经肌肉骨骼适应性产生的 neuromusculoskeletal adaptations
继而导致 and they result in changes in the
关节内和关节间运动精准度的变化 precision of intra and inter-joint
而这些运动会引发 motions that creates this micro trauma
导致重大创伤的微小创伤 that leads to macro trauma
我想对我来说 and then i guess the really prevailing
非常普遍的一个问题是 question for me and i i hope this is uh
我希望这个理论是合理的 the theory the theory will turn out to
原因是该理论会 be right because it will increase the
增加物理治疗师角色的重要性 importance of your roles
而且这些时间的演化 is that is this really the progression
最终会引发 of events that eventually results in
骨关节炎 osteoarthritis
因此我们创建了这样一个小模型 so we have this little model called a
叫做运动病理模型 kinesio pathological model
这里包含肌骨神经系统 and musculoskeletal nervous system
心肺系统 cardiopulmonary
内分泌系统 等等 endocrine systems etc and i think
我想生物力学 biomechanics is the critical interface
对于这些系统的互相作用非常关键 in the interaction of these systems the
这些问题的诱因 inducers
是重复动作和 of the problem are the repeated
日常活动的持续比对 movements and sustained alignments of
实际上 everyday activities and of course the
修改的是 modifiers are your own personal
个人特征 characteristics
出现肌肉性能的 you get tissue adaptations in muscle
身体组织适应性 performance
肌平衡失调 相对劲度 imbalanced muscle relative stiffness and
和我所谓的相对柔性 what i call relative flexibility
以及由此引发的脊柱附属动作 and then this leads to hypermobility of
运动过度 spinal accessory motions
也很可能引发某种微不稳定性 and probably a form of micro instability
继而导致大的创伤 等等 and then the micro trauma etc so
所以这张图比较宏观 this is
如果我们补充 the big picture and if we fill in a
一些细节的话 little bit of the details
就很显然 just to make it hopefully even more
正是由于 clear that it's
日常活动 everyday activities that give the
引发了 problem
肌骨系统问题 you get the musculoskeletal changes and
和神经系统问题 the nervous system i think
要是还能工作50年 if i had 50 more years i'd be so focused
我会全力 on
研究如何达到训练效果 understanding more about how you get
研究是哪种操作方式 what you train the way you do things you
让你陷入困境 get stuck with
研究哪些地方难以改变 and that's what's hard to change around
这些正是 and of course that's what we have to
我们需要改变的地方 change around
这些个体特点 these individual characteristics
结构变化 性别 structural variations sex
系统性的过度活动 generalized hypermobility how active you
运动量的大小 are inactive you are
这些都能采用运动 all lead to these adoption of movement
和 movement
这些活动的比对模型 and alignment patterns with these
而后将遍及 activities and then it gets generalized
其他所以的活动 across all activities whether you're
不管坐于桌前还是做运动 sitting at a desk or playing a sport
你都拥有一种基本的运动模式 you have a basic pattern of movement
你会固定在这种运动模式中 that you are stuck with
在关节和比对运动中 you get this specific alteration in
你可以获得某些改变 joint and alignment movement
有些身体部位比其他部位更灵活柔韧 some parts become more flexible than
因此 other parts and therefore move too
更容易活动 readily
同时也改变了负荷 and you get altered loading and
积累了压力 accumulation of stress
那么我尝试为大家提供一些 so i'm going to try to give you some of
这些理念背后的 the the research support
研究支持 behind these ideas and i've tried to put
我一直致力于我所谓的 my focus on what i think are the two key
两个关键概念 concepts
即 相对柔性和 which are relative flexibility and
相对劲度 relative stiffness
那么我们对这两者了解有多少呢？ so what do we know about these well we
我们有非常可靠的 have a movement exam
动作检查 with good reliability this is what what
而这是 Linda Van Dillon 的研究 uh linda's van dillon's research has put
为所做的贡献 in place for us
也就是动作检查 so this movement exam and and we i'll
这部分是参考文献 have some references here
这些都非常可靠 is we we have pretty good reliability on
我们可以将 that we can classify patients with low
下背痛患者 back pain
进行分组 into groups based on the direction of
这种分组主要是依据患者症状方向 their symptoms
那么我们有患者通过脊椎活动 so we have patients move their spine as
和四肢活动 well as move their limbs
来看看这些活动是如何引发疼痛 see how that causes pain we let them
我们让患者以患者喜欢的方式活动 move in their preferred way we see that
我们发现患者其动作不对时 they're not doing it right
会帮助纠正 we correct it and look at the effect on
然后看对症状有没有改善 their symptoms
我们根据诊断类别 we've also characterized different
来描述不同的 features according to this diagnostic
特征 category
而后再检查模型的特征 and then examine some features of the
正如我上述提到的 model as i say
相对柔性和 relative flexibility and relative
相对劲度 stiffness
所以物理检查往往 so the physical examination always
始于 starts with
站立 坐下 钩躺 侧卧 standing sitting hook lying side lying
俯卧 prone
四足跪 quadruped and the exam is the same
不管我们是针对背痛 whether you're looking at a back pain
髋痛 hip pain or even hallux valgus of the
还是大拇脚指外翻 big toe
检查都是一样的 you you because these are
因为身体各部分在生物力学上属于相互作用 biomechanically interacting segments and
我们无法在不受其他部分的影响下 you can't take one out
单独考虑其中一部分 without being affected by the others and
而后我也列出了 then i've just listed
一些相关研究 how some of the studies that have put
它们在体格检查和分类方面 reliability behind
都非常重视可靠性 these examinations and the
另外 classifications and again
还有一些参考文献 a a list of references
来支持这一理念 that support the idea that we can
该理念认为 classify people with
我们可以根据引起症状的原因 low back pain according to the direction
来对后背部疼痛进行分类 that causes their symptoms
那么相对灵活和 so what about relative flexibility and
相对劲度是什么呢？ relative stiffness and i think
个人认为，两者非常关键 these are really key and that's why i
所以我曾想要重点研究这一模块 wanted to kind of focus on them
我认为这一理念 i believe that they're generic to
可以广泛应用于理解各个关节的运动损伤 movement impairments at all joints
而非仅仅停留在后背部 not just in the low back but all joints
也要包含如肩 髋 shoulder hip
颈 等关节 相对灵活 neck etc and that relative flexibility
和 and
我们一直在说 as we were saying before we started one
在开始理疗新难题 of our challenges in physiotherapy is
之前 that
很多人会使用不同的术语 so many people use different terminology
来描述同一现象 for the same phenomena
很可能我就是 and i'm probably you know one of the bad
其中个负面案例 ones as well but
但是相信我们可以解决其中的某个问题 hopefully we'll get it all worked out
那么相对柔性 one of these days so relative flex
在我看来指的是 flexibility to me means the intrinsic
关节本身的内在运动 movement of the joint itself
这些是附属运动 these accessory motions and that what
我想说的是我认为 i'll try to show you is that i believe
关节内活动 that intra-joint motion
可能不那么精确 can become imprecise and that one of the
其中一种附属运动 accessory motions
可能比其他运动更容易做到 occurs too readily than the others for
例如滑动 example glide
就比卷起或旋动更容易 rather than roll or spin and that
也可能出现过度运动 that motion also becomes excessive so
有可能是动作幅度的增加 it's increased in its range and it's
也有可能是 increased in the frequency of its
动作发生频率的增加 occurrence
关节内运动指 interjoint movement means when you put
将两个关键放在一起 it together with another joint
如背和髋 如果弯腰 like back and hip if you bend over and
那么背部的屈曲就超过髋部 your back flex is more than your hips
那么 then you got
就呈现出关节内相对灵活 inter-joint relative flexible
即 关节内 inter-joint
相对灵活性 relative flexibility okay and then so
那么这就是一个 that's one
显著的现象 big phenomenon the joint moves too
关节活动太灵活 可以进行附属动作readily using accessory motion
那么其中一个有帮助的因素是 and then one of the contributing factors
我所说的 is what i call relative
相对劲度 而这基本上 stiffness and this is basically the
是肌肉和连接组织的 passive tension of muscle and connective
被动张力 tissue
可以称之为 and it's defined as a change in tension
每单位长度的变化所带来的张力变化 per unit change in length at least this
这部分不是我杜撰 part i didn't make up
而是合情合理 this is legitimate and and i think it's
我想描述这一点最好的方法是 best depicted by having a couple uh
使用一组弹簧 springs and what they never took me when
我在上肌肉生理学课时 i was told me when i was taking muscle
从没听到过这种说法 physiology i
我意识到这些优美的弧线 i got the idea of those nice curves and
并且说这是 said this is the passive tension of a
肌肉的被动张力 muscle
但是他们并没有这么告诉我 but they didn't tell me it changed that
这种认知变迁花费了20年 我动作还是很快的 took 20 years because i'm swift
无论如何 anyway so if you get a muscle that's
你的肌肉是这种大块的 this big
那它就比这种小块的更坚硬 it's a lot stiffer than one that's this
如果把这些都放在一起 big and if you put these in series
刚度最小的弹簧就可以给出 the least stiff spring gives and i
我真的相信 really believe that what we've
我们被打断了那么久 interpreted for so long as muscle
实际上肌肉缩短 shortness is not
并非相对刚度的问题 it's a relative stiffness problem okay
那么这就是基本理念 so that's the underlying idea here
另外还有一些 and it was little things like during
临床检查期间的小问题让我 clinical exams that would always bother
很困扰 me
例如 这位女士 for example this woman is sliding her
将髋关节滑入外展姿势 hip into extension
那么我们可以看到她只活动了 and you can see she's only moved about
30度就出现了 30 degrees before her pelvis is going
骨盆前倾 into an
其指症是 anterior tilt as indicated by the
我的拇指到她髂前上棘时 movement of my thumb on her asis well
并没有出现肌肉缩短 that cannot be muscle shortness because
她的肌肉并没有 you have not come close to the end of a
完全展开 muscle length
她这个姿势做的特别容易 it's happening much too readily so i
所以我想了解 wanted to know why
如果她有肌肉缩短 would her pelvis tilt with such little
那么 movement
为何她髋部这么小幅度的动作就发生了骨盆前倾 of her hip if this was muscle shortness
这完全讲不通啊 it didn't make any sense
那么这就是一个 so i this is an example to me of
相对灵活的典例 relative flexibility
她背部随骨盆活动 her back moved much too easily with her
的移动过于灵活 pelvis and then i would also be confused
那我就是很困惑了 because i would test other people
因为我测试了哪些髋屈肌比较短的人 who actually had a short hip flexor but
而他们并没有 they didn't have an
骨盆前倾 anterior pelvic tilt so it didn't make
所以这讲不通啊 sense
另外我还发现 this kind of person then what i also
这位并没有背痛 realized is this person did not have
但是这位有发生背痛 back pain but this person did
所以背部活动 so it was the back moving that was the
才是关键问题 critical issue not how short a muscle
而不是肌肉缩短 was
后者与之关联不大 that didn't have that much to do with it
这是另一种 okay and this was another way in which i
我用以切换这个问题描述的方法 cut on to trying to depict this this
因此在这种情况下 issue so in this case if someone flexes
如果有人屈膝 their knee
且一切正常 and nothing happens here it's because
那就是因为弹簧 this spring
我们又称之为 we'll call it the rectus femoris tensor
股直肌阔筋膜张肌 fasciae latae
比这三类结构的伸展性更好 is more extensible than these structures
在这个案例李屈膝 well in this case flexing the knee
引发骨盆前倾 causes anterior pelvic tilt because the
是因为其腹部和 support from the abdominals
背部的支撑不如 and the back is not as great it's not as
这个部位的肌肉 stiff
力量更强大 as this muscle right here so
那么这里是一个视频 this is a video if you'll play that
播放视频就可以发现它展示了个体发生 video to just depict this happening in
发生的这种情况 an individual
它为我们所做工作的 and it's formed the basis of some of the
某些实验室分析提供了依据 laboratory analysis that we're doing
那么髋外旋会引发 so hip lateral rotation is causing
腰骨盆旋转 lumbar pelvic rotation
所以只要她做内旋 so as soon as she moves with both medial
和外旋的动作 and lateral rotation
她就会有腰骨盆旋转 she gets lumbo pelvic rotation well and
那么如果我们仔细观察 then if we take a look and play this
请播放视频 video please
我们所能看到的是当她行走时 what do we see is that when she walks
各位猜一下 guess what she gets
是什么原因导致她的腰骨盆旋转 lumbo pelvic rotation so the the fact
实际上她的走路姿势 that she walks that way
导致其腰椎松动 mobilizes her lumbar spine and it's so
从而导致如膝部屈曲或者髋关节旋转这样的 mobile that something as benign as knee
良性现象 flexion
引发同意的活动 or hip rotation causes the same motion
的出现 to occur
那么这对于我们的意义是什么呢 so what does this mean to us it means
要制止她的这种走路姿势 you got to stop the way she walks
严格来讲这并没有任何作用 it won't matter i'm serious so she rides
他随时随地都是这种步态 everywhere now no no no
我们要做的是教她 no no so we had to teach her how to walk
重新学习走路 again
这样就可以预防她恶化为腰骨盆 so that she didn't get lumbo pelvic
旋转 rotation
另外还想之处一点 and and just to point out about personal
个人特征而言 她存在明显的 characteristics she's obviously has very
骨盆宽大 broad pelvis
原因并非仅仅是 well it's not just because she's
她的肥胖 overweight but i'm sure she has
相信还有髋部coccyvera的问题 coccyvera hips
这种步态出现的原因是 and the reason why this plays into it is
她睡觉时采取的是侧卧位 that when she's sleeping on her side
那么由于她骨盆宽大 she goes into a marked side bend because
就导致明显的侧弯 her pelvis is so wide
那么一晚又一晚的重复之后 well you do that night after night and
就诱发腰椎 that mobilizes your lumbar spine into
出现侧屈 side flexion
那么因为持续这样的旋转 so it keeps getting more rotation and
其髋部也变得 her hips keep getting
越来越僵硬 stiffer and stiffer okay
这里显示的是活动的整个流程 so here's the whole flow of activity as
可以看到 we see it
早期的腰骨盆活动 early lumbo pelvic motion increased
频率增加 frequency
组织压力的积累 accumulation of tissue stress low back
后背痛 pain
问题持续或复发 persistence or reoccurrence so all of
那么我们所有的研究 our studies have been done
都是针对慢性腰痛 in people with chronic low back pain not
而非急性腰痛 acute low back pain
实际上也了解 and of course we know everybody that's
急性痛疼终有一天会转化为慢性疼痛 acute will someday become chronic
而且疼痛会复发 we know they'll be back yes okay
那么我们看待这些问题直接关系的方式 so one of the ways we've looked at these
也就是说 relationships is to say well if if
如果因为背部非常灵活， moving the limbs causes the back to move
导致活动四肢引发背部活动 because it's become so flexible
那么要是我们引活动四肢时 what if we just make them not move their
保持背部不动会怎样呢 back when moving their limbs and see
来看看疼痛是否消失 does the pain go away so these are some
那么这些是Linda发表的研究报告 of the studies that linda has published
其结果显示如果我们修改 showing that if we modified how they
其运动方式 move
他们的症状就会减轻 their symptoms decrease so if we look at
那么如果我们来看一下这个测试 uh our tests these are examples of the
他们是一些检查的示例 examination test knee ex they're really
属于非常复杂的 kind of complicated
膝关节外展和髋关节外旋 knee extension and sitting hip abduction
屈膝平躺以及 lateral rotation and hook lying knee
俯卧位膝关节屈曲 flexion and prone
我相信在座诸位如果能说四国语言的话 but i think you're smart enough to get
也一定能够无障碍理解这些 it if you can speak four languages you
可以做这次动作 can do these things
俯卧位髋关节旋转 俯卧位髋关节外展 hip rotation in prone hip extension in
这里显示的症状增加的 prone and these are the numbers of
人数 people that had
可以看到数目大的这个是 increased symptoms as you can see a big
俯卧位髋关节旋转 one is hip rotation in prone and hip
俯卧位髋关节外展 extension in prone
而这一点已经成为我们研究的核心 and this became the focus of our studies
这时如果说 now if we say
让你在进行这些运动的时候 okay let's make you not move your back
保持背部不动 while you perform these motions
就可以看到 you can see the percentages of people
阳性测试结果（即显示症状减轻）的 with positive tests
人数比重的情况 that all showed a decrease in their
在四肢活动时 symptoms so stop the back from moving
保持背部固定不动时 when you're moving your limbs and you
患者症状就会减轻 get a decrease
就是这么简单 in your symptoms it's like that simple
好吧 okay
实际上我们目前进展已经非常深入 so now we've gone on to get more
动作捕捉 sophisticated and do motion capture
咱们来更审慎地 to look at some of these tests more
看看这些测试 critically
这是一位准备好的患者 and so this is a person all dressed up
作为我们动作捕捉 分析的模特 for motion capture
这里我想要强调的是 analysis and what i want to
髋关节运动 stress to you here is what is the timing
和腰椎骨盆运动 differences between
之间的 movement of the hip versus lumbar pelvic
时间差 motion
Linda和其同事 okay so one of the studies that linda
所做的其中一项研究是 and her colleagues did
针对背痛和 was to have people with back pain people
不存在背痛的两组人群 without back pain
指导他们做这些小动作 and they did this little simple two
比如俯卧 simple movements they were prone
膝关节屈曲 they did knee flexion and then they did
而后是髋关节旋转 hip
我们发现 rotation okay and what did we find and
这就是分析所采用的方法 this is the way it was analyzed
我们可以以这个视角来观察 we might looked at this angle to see
他们什么时间开始做髋关节运动 when did they start to move their hip
以及多久后 and then how soon did the pelvis
腰椎骨盆开始随即旋转 start to to rotate lumbo pelvic rotation
这是一份 and this is the diagram of how the data
数据采集方式的图表 was taken
低幅度动作是腰椎骨盆旋转 the low amplitude movement of course is
而高幅度动作是 lumbo pelvic rotation the high amplitude
髋关节外旋 is hip
那么我们观察的 lateral rotation and what we're looking
是 at is the
一个动作开始的时间 time difference between when one started
和另一个动作随之发生的时间差 and the other one followed now the idea
背后的逻辑是 being that
这个时间差越大 the bigger this time difference the less
他们做下肢运动时 likely they are to be
背部损伤的 injuring their back when they move their
可能性就越小 lower extremity
他们的相对灵活性能少 are how much less relative flexibility
多少呢 they have
这就是运作原理 so this is the way it works out that if
如果患者不存在腰痛 you do not have low back pain
此处数据是0.3 it's like 0.3 before your
腰椎骨盆旋转之前 lumbar pelvic rotation starts after your
髋关节开始外旋之后 hip
如果 starts to laterally rotate well if you
存在腰痛 have low back pain
那么腰痛就会提早出现 this starts earlier
另外需要 the the other things that to look to
确认 make sure is how much
存在多大的动作幅度 range of motion there was well actually
实际上 如果患者存在腰痛情况 there was slightly more
那么其髋关节外展的 hip lateral rotation range of motion
动作幅度就会稍大一些 if you didn't if you had back pain than
如果患者不存在腰痛情况 if you did not have back pain
那么相信 and we made sure that they weren't
要想做到这个姿势 moving faster
他们动作就会慢很多 that would cause this so the velocity
所以其速度就受到限制 was controlled and that was similar
此处的腰关节骨盆旋转也是同样的原理 here's lumbo pelvic rotation and again
实际上腰关节骨盆旋转 the maximum lumbo-pelvic rotation
这个动作 was actually a little bit greater in
存在腰痛的患者 people that had low back pain
往往比腰不痛的患者动作幅度更大 than in the other people this is just
而这里是此前跟大家提及的时间维度 the time that i showed you before
那么对于膝关节屈曲这个动作呢？ now what about with knee flexion and
这里展示的是膝关节屈曲做得比较灵活的一个 this was a knee flexion performed
此处比较值得思考的一点是 actively and i think what's interesting
在膝屈曲期间 is there was no difference
骨盆前倾患者并没有表现出 in anterior pelvic tilt during knee
有任何不同 flexion
但是在髋关节旋转这个动作上 but there was a difference in pelvic
却存在差异 rotation
所以我再一次推测 now i think again that points out to me
这就暗示捣乱的动作是 the evil motion
旋转 我相信一定是这个动作 is rotation and i believe the evil
因为 motion is rotation because it's
它与另外一个动作偏离相关 associated with shear
它是最具破坏性的因素 and that's the most destructive force
同时也是最难控制的 and also it's the hardest to control
绝对是最难控制的 absolutely the hardest to control so in
所以 people that
不存在腰痛的患者 did not have back pain they had knee
膝关节屈曲这个动作上 flexion
能够停留的时间会更久一点 for a longer period of time before
而后才发生腰椎骨盆旋转 getting lumbo pelvic rotation
而存在腰痛的患者 than people who had back pain
不存在腰痛的患者 and again the maximum knee flexion was
膝关节屈曲的动作幅度 actually a little bit greater in the non
要比腰痛患者更大一些 back pain people than in the back pain
人群差异巨大 people significantly different but
而动作幅度差异是10度 only 10 degrees the velocity again was
速度没有差异 no different
那么从度数这个维度看，情况如何呢？ so what about degrees well we this is
那么这个显示的是 sort of a
膝屈曲时 during knee flexion the lumbar pelvic
如果存在腰痛，腰椎骨盆旋转动作幅度更大 rotation was greater
如果存在骨盆前倾，幅度则比较小 you had back pain the anterior tilt
关于时间差异 was not and then we've already talked
此前已经谈过 about time differences
所以总结一下 so in summary people with low back pain
腰痛患者下肢运动的动作上 在move the lumbo-pelvic region
停留时间更短 early during lower limb movements
我们认为这可能是由于 that and we consider that this may be an
日常活动期间运动模式的指数 index of the movement pattern during
这些看似很小的 everyday activities these little simple
因素 things
可能就造成了患者做运动是 could be an index of what's really going
很大的差异性 on when you're out there performing
髋关节外旋会迅速带动 hip lateral rotation produces early
腰椎骨盆旋转 lumbar pelvic rotation
膝关节屈曲也会 knee flexion early lumbar pelvic
在肌肉力量到达极限之前 rotation
更快带动 much earlier than reaching the limit of
腰椎骨盆旋转 muscle length that
所以说在开始前一个动作时 后面动作发生的非常非常早 so this occurs very very early when you
而不是非常晚 start to move not late
非常早 very very early now
the maximum knee flexion is less in low
back pain there's no difference in
velocity
maximum lumbo pelvic rotation during
knee flexion
is about and this is what i think
supports the idea
of relative flexibility about one degree
more
the timing is about one second earlier
so we're talking about little little
bitty differences
no difference for anterior pelvic tilt
and
the lateral rotation angle is only about
2.5 degrees
maximum lumbar pelvic rotation during
hip bladder rotation is about 1.5
degrees greater so we're talking about
many aspects of things
not maxi aspects of things okay
so the lumbo pelvic motion occurs very
readily
a limit elicited by lower extremity
movement
and it's not primarily inter it's not
caused by short muscles i think that's
what's so important to realize
stretching a muscle will never
stop these movements stopping these
movements will stretch a muscle
but stretching a muscle will never stop
them
okay and that all this is very minimal
which to me i think is the is sort of
the fun yet the challenging part
all right now another aspect is looking
at
variations in relative flexibility with
the different syndromes
so the syndromes that we're going to
just talk about for a minute
are people classified as rotation that
means they have pain with rotational
type movements
are they have pain with both flexion and
extension
extension rotation patients have pain
when the back is extended
or when rotation is occurring and these
are often people that do
asymmetrical sports that involve
rotation to one side or another
and so again the test is hip rotation
and looking to see
at lumbo pelvic rotation and now we're
going to compare what happens
to the pelvis when you rotate your right
hip
versus your left hip so
these are just to give you an idea of
what we're looking for if you
look at the onset of pelvic motion
with right hip i'm sorry left hip
lateral rotation
and right hip lateral rotation this
would be a late onset
but there would be a high correlation
between left and right
early onset would mean they're really
locked together
but there's would be a correlation
between left and right because
they're both showing the same change
okay
now this is the way it came out also if
it's symmetric
it means that there's a high correlation
the time that the pelvis starts to move
when moving the left is the same as when
you're moving the right
if it's like this and there's no
correlation there's asymmetry
between what happens moving the right
leg and moving the left leg
okay well how did it come out
beautifully
meaning the patients that were
classified as rotation patients
when they moved their left leg and their
right leg
the onset of lumbo-pelvic rotation was
highly correlated
poor 0.94 if they were extension
rotation patients
asymmetric when they moved their right
leg and they moved their left leg they
had very differences
in the timing of their lumbo pelvic
rotation
so the people that we had categorized
clinically according to the
different performances of their symptoms
turned out to have these very high
correlations
okay then the other part that we wanted
to look at was
what about the relative stiffness issue
so we looked at
side bending and we looked at lateral
side bending
in standing and we saw different
patterns
again according to the different
classifications and they paralleled
the hip lateral rotation findings
which which really means that the
problem is in the back
and that asymmetry is from the relative
flexibility
okay so let me just go on to to kind of
show you we had 44 people in this
and with chronic recurrent low back pain
they regularly participated in rotation
related sports
and their symptoms were associated with
these rotation related sports
so again here comes the motion capture
system
they're all dressed up they do side
bending and we look at the change in the
angle
in their lumbar spine
isn't that cute okay
so specifically they we're looking at
what happens
in lumbar motion compared to thoracic uh
and uh and lower thoracic and upper
thoracic
so this is the way the data looked we
looked at the onset of lumbar spine
motion
the movement here at l1 compared to down
here
then the lower thoracic segment and
upper thoracic segment
and compare that to total lateral
bending
and this is again the this uh to give
you an idea of what we're looking for
here's total lateral bending and this is
what's happening in the lumbar region
during different phases so what happened
to 25 percent of the movement
50 percent of the movement 75 percent of
the movement
and 100 percent of the movement
and if the pattern was symmetric it
would look the same whether you're going
to
the right or the left in the lumbar
spine but
how did it turn out it turned out no let
me first see
an asymmetric pattern is that when
you're going to the left
the lumbar motion is not the same as
when you're going to the right
okay so we looked at the percent of
contribution of the lumbar region
at various increments just as i told you
and then set up this little formula
and this is the way it turned out would
you believe that in the rotation
subgroup
that it was the same going to the right
and going to the left
in the rotation extension subgroup there
was much more
lumbar lower lumbar motion in the first
part of the range
and then it became symmetric and this
was asymmetrical
so just like with the hip when you went
to the left you got more motion
in your lumbar spine if you were
extension rotation
if you were rotation that movement was
the same
in both directions okay and what about
stiffness well
the uh we developed a uh
basically like a gravity free table and
people were put on this table
and we measured their passive tension
properties
and this is the way it looked and again
it's the same kind of calculations
and we've looked at the passive elastic
energy
as they were pulled from one side are to
the other side
and this was to their end range and this
area was
calculated and what did we find
is that we looked at looking at group
differences first people with no low
back pain compared to people
with extension low back pain and there
was
asymmetry to a certain extent one side
had more passive elastic energy
than the other side but in no low back
pain people
this was not significant but when we
looked at people with back pain
extension back pain there was an a
significant difference
between the passive elastic energy on
one side compared to the other side
i should have had those fly in okay and
the end range of lumbar motion again
there was a little bit of difference the
side of greater motion
compared to the side of lesser motion in
both people with low back pain
than no low back pain so the range of
motion was not what was important
it was the passive stiffness that was
the most
important factor okay so
the increment of total lumbo
uh total low back pain motion to the
left
total lumbar motion to the left the
condition
at 25 50 75
in a hundred percent so the this is
after treatment
initially they had 75 percent
motion in their lumbar spine at 25 and
then it decreased as you went to the
total motion
after they were treated just taught
not to move that way it went down to 25
so that we could teach people and get a
change in how much their lumbar spine
was moving okay so summaries of these
studies of
relative flexibility that
spinal hypermobility most reasonably
accessory
motion hypermobility and i think we can
start to call it micro instability
though i've been adverse to that for a
long time
is evident in our clinical exam and in
laboratory measures
but what we can do in laboratory
measures is look at the
the amount and and we can look at the
timing
the lumbo pelvic motion occurs earlier
and with greater range of motion
in patients with low back pain compared
to controls
but these differences are in tenths of a
second and just a few degrees
so this suggests that small but frequent
motion is a source of stress
on spinal segments and causes micro
trauma to become macro trauma
and that a contributing factor is the
relative passive stiffness of muscles
about a joint is the is a contributing
factor
now i wanted to tell you one other thing
that this is in the process of being
published and this is a randomized
control trial that
uh linda van dillen uh did
and um it was sort of a good news bad
news thing so she got people with low
back pain
and they were all examined
both clinically and with motion capture
they were then divided up into a
category specific exercise program
and into a generalized exercise program
the uh people were seen once a week for
six weeks now seeing what that means is
treatment is
they were shown exercises to do again
whether category specific or general
and they were also taught to keep their
spine neutral
during functional activities now
functional activities means how do you
roll
how do you go from supine to sitting how
do you walk how do you get up and down
out of a chair
basic keep it neutral things so
what was the good news everybody got
better for six months
they were seen six times once a week and
their pain scores went down for six
months
then there was a little upswing the bad
news was
everybody got better
[Laughter]
meaning how much i wanted the people
that got category specific exercises to
do better than people that got general
exercises but what was the fatal flaw
the fatal flaw is that both groups were
taught to keep their spine
in neutral during all functional
activities the uh other thing that i
think is a really big take-home message
on this
is that linda
has a wonderful case of ocd obsessive
compulsive disorder which i think every
good researcher needs
so what she also did was monitor their
adherence
to their exercise program or to their
functional activities
and what do you think people did longer
modify
continue with their exercises or modify
their their functional activities
functional activities and there was a
very high relationship the longer they
kept
doing their functional activities
correctly the better they did
so now i do believe and i think linda
shares this belief that it's going to
take about four weeks at least
to get people to change their functional
activities in my clinical experience
once people's
pain goes away they don't think they
need to do their exercises anymore
because
that's over with yeah it's like
that's good because then you'll be back
so good keep it up
anyway so i think i think the important
messages are we know people will get
better
if they keep their spines still during
functional activities we know
that people will modify their functional
activities once they've been carefully
instructed
more so than they'll keep up with an
exercise program so
that's what had the greatest effect okay
so spinal stabilization is an
appropriate treatment
and i think because the spine is
basically hypermobile
that's what all these little tests show
and that symptoms are elicited by spinal
motion
when you move your limbs it makes your
spine move which it shouldn't do
and then we decrease their symptoms if
we prevent that motion
and that this imbalance in relative
muscle stiffness
is a big contributing factor and the
bottom line on that is it means you need
to stiffen what
elongates too easily not stretch what
doesn't seem to elongate
well enough and stretching a muscle just
to say
to make this so important will never
stop this motion
it occurs too readily too easily and
that the patient needs to be instructed
in moving the appropriate joint
the hip while not moving in the back
now these are all the people that have
worked with linda on this and
and i thought since i've sped through
this
and i still have five minutes to go uh
right
[Laughter]
i i thought that i would show you a
little bit of of what we're looking at
in other joints so that that
we're not doing with there's some
research in process but we don't have
all the
the data like i've shown you for for the
low back and
for the hip we've put people also into
categories
one category is called anterior glide
with medial rotation
posterior glide and and these again are
the offending motions and they reflect
joint hyper mobility not hypo but
hypermobility
and as you know if you've worked with
people with a frozen shoulder you can
have accessory motion hypermobility when
you have physiological motion
hypo mobility if you didn't you wouldn't
have pain
yeah okay i'll show you
so here's here's the idea
if you did precise hip flexion
you would be able to drive an axle
through the through the head of the
femur and you would just spin
in the joint and that one of the
observations that we made
early is that if you don't flex your hip
precisely
instead of the perfect spinning you get
an anterior glide
and when the head of the femur
anteriorly glides it hits
on the edge of the acetabulum and that
means
you could injure that structure there
now not only i
i'm well aware of the large heads of the
femurs and all the rest of it
but this is another factor oh it's so
scary
anyway uh
you know and halloween is over but we
still put that up there anyway
so video so what i want to show you here
is
is the anterior glide sign that we look
for in people that have hip
joint problems so again
with the idea that i should be my thumb
should be a parallel
axle so that when i flex the hip my
thumb should stay still
if this hip is perfectly spinning but as
you can see
this femur is translating anteriorly
it's kind of a combination of what we
call anterior glide with medial rotation
now this young woman was having hip pain
she's actually a professional
was a professional dancer she's a physio
now
taking care of professional dancers and
and she's also
asian so she's very flexible so there
was absolutely no hamstring resistance
now i'm doing what i call a correction
which just means keep my thumb still
nothing complicated and then i flex her
hip the way it should flex
now i'm going to ask her to take hold of
it and watch what happens when she takes
hold of it
actively contracts her muscles there
goes all that motion
that shouldn't go so it's flexion with
medial rotation
now it tells you the iliopsoas is not
working correctly or would never
immediately rotate
that's what that tells you and the hip
has become
hyper mobile okay
now let me go on another uh
aspect that we that we found too and and
people do these incredible things like
try to posteriorly dislocate their hip
um
i know they're on to the happy life now
they put their chest on their thighs
and then and then they rotate
immediately and they rotate laterally
that is a good way to posteriorly
dislocate their hip
so um we have this posterior glide
problem
so this is the same girl doesn't get any
does not get any better but anyway
you played the video here
she talks and talks it never stops
anyway
so what i want to show you is that with
this hip
that in her right buttock there was
something sticking out that wasn't
sticking out her left buttock
so if i put the stick on there and i put
my fingers behind there
my that's a half an inch of difference
between something prominent in her right
buttock
versus her left buttock okay and then if
i have her rock back
and see if i'm sorry take my hands i i
know my fingers are half an inch thick
there's something going on on the right
side that's not there
on the left side now if i put my hands
on her
sacrum as she rocks back you'll see that
as she rocks back the right side goes
low
compared to the left side so there's
something different
in the way her hip is flexing this is
going low compared to the other side
okay once more
rock back and this goes low now if i put
my thumb
right there on this i think it's the
head of the femur do you see how it's
medially rotating
and what it's also doing is coming out
at me so as she goes back
the head of the femur is going posterior
and medially
rotating it shouldn't do that it should
be like on the left side
where nothing happens as you rock back
now if i put my fingers on either side
of the greater trochanter you can
see the same kind of thing so again i'm
explaining that there's something
prominent on this side
as compared to the other side
so we'll hold on here and then i'll stop
it after this
have her rock back and there goes the
medial rotation on the right
that's not on the left so we call this a
posterior glide with medial rotation
now you can have anterior glide with
medial rotation or you can have both and
then it's hypermobility
accessory motion hypermobility let's
okay
so what and i think the other part
that's interesting is she's already had
an acl
now that's a solid bone that means if
it's rotating up at the top end
it's rotating at the bottom end yeah
five minutes okay
and and then i i'm
not bad not bad i didn't think i'd get
to this so but i did want to show you
because i think observing these movement
impairments is what's what's the
critical issue people can be high
performance
let me show you these shoulder things i
call these the big three of scapular
problems
decrease scapular posterior tilting
decreased scapular upward rotation
and increased scapular internal rotation
and
these are all the studies that have
shown that if you have shoulder pain
this is these are the the faults that
have been identified
okay and the humeral same thing
excessive superior translation
inferior anterior these are all the
things we look for during our exam
and let me just show you this is a video
so when this girl does shoulder flexion
she has it all bad
meaning that's internal rotation not
enough posterior tilt
not not enough external rotation uh
not enough upward rotation and what
happens is she still has
180 degrees of shoulder flexion which
means her glenohumeral joint is hyper
mobile
because her scapula isn't moving enough
and it's not moving in the right place
okay in this fellow this video
you play the one on the left please
okay now most of the most often
you see these faults on return
like that you got it right you got it
that is internal rotation with
insufficient upward rotation
now since it happened on return it's not
a weakness problem
because eccentric is much stronger than
than concentric
so we shouldn't have a problem on return
play the one on the right
now so what we do is teach them how not
to do that
there's a whole lot of don't do that in
this system
did it play already when you saw it that
we cured him
here's here's another one i think this
is so so wonderfully dramatic
look at that
okay here over here on this side oh
she's going to do it once more just to
show that it really does happen
here she goes now this is all in the
same session
see what what does it mean it means that
when she contracts her scapulohumeral
muscles
it causes the scapula to move because
the axial scapular muscles
don't control the scapula they don't
have as much effect on the scapula
as the scapulohumeral muscles so the
tail wags the dog as i see it
instead of enough stiffness and control
from those muscles but it's a training
thing it's not
a strength thing it's a training thing
the staff the
the stiffness has to be changed that's
why they can modify it right away that's
what we try and teach them to do so
i just wanted to show you examples of
these movement faults that can be
categorized we can put people into
syndromes
explain the significant factors and
believe me
our profession will move on so much
better if we put labels on conditions so
people know we figure things out
thank you very much
[Applause]