肌肉不平衡的评估与治疗：JANDA方法

PhilPagePhD,PT,ATC,CSCS,FACSMBatonRouge,Louisiana静态姿势StaticPosture平衡Balance步态Gait肌肉长度MuscleLength运动模式MovementPatterns扳机点TriggerPoints检查感觉运动系统的状态&建立假设Examinestatusofsensorimotorsystem&formulatehypothesis对于感觉运动系统状态来说尤为重要MOSTIMPORTANTviewofthestatusofthemotorsystem这是PDFdo为Add恰Wat当erma的rk试肌用版肉，长注册度后不测会有试此行和力量测试提供线索，以确认在静态姿势中所见Cuestoappropriatemusclelengthorstrengthteststoconfirmwhatisobservedinstaticposture寻求姿势链中系统性适应Lookforsystematicadaptationsinchain优势眼在正中线上Dominanteyeinthemidline使用平衡、阴影&“想象”Usesymmetr这y是,sPhDFaddooAdwdsWa,t&ermark“visualize”过度生长圆隆形，凸起Hypertrophyrounded,convex生长不足平，凹陷Hypotrophyflat,hollow,concave站立位，脱衣拖鞋Standing,clothesoff,noshoes侧面观LATERALVIEW后面观POSTERIORVIEW1234568796234235前面观ANTERIORVIEW811071胸椎后凸增加头前伸颈椎前凸增加圆肩A型（髋）TypeA(hip)B型（背部）TypeB(back)髋轻度屈曲膝轻度屈曲胸腰段后凸骨盆前倾头前伸胸椎后凸膝过伸感觉运动系统功能状态的指标Indicatoroffunctionalstatusofsensorimotorsystem基本原理Rationale观察功能稳定性控制中的骨盆控制Observepelviccontrolforfunctionalstability平衡策略的指标Indicatorofbalancestrategies说明站立中期的单腿站立Single‐legstanceindicativeofmid‐stance臀中肌功能Functionofgluteusmedius观察足部外形和功能Observationoffootformandfunction定量&定性Quantitative&QualitativeDiscriminatesLBPvs.Controls(Byl&Sinnot,1991)测试Test手臂置于体侧；将一足抬离地面Armsatside;raise1legoffthefloor髋屈曲45º这，是膝PDFd屈oAd曲dWa9t0erºmark试用版，注册后不会有此行Hipflexedto45ºandkneeto90º睁眼平衡练习5‐10秒Practicebalancewitheyesopenfor5‐10sec双目直视前方并闭眼Thenfixgazestraightaheadandcloseeyes尝试保持此姿势30秒‐2次机会Trytomaintainfor30seconds–2chances失败出现Failureoccurs若脚碰到这是支P撑DFdo腿Add或Wat地erm面ark试用版，注册后不会有此行ifthefoottouchesthelegonthesupportlegorthefloor出现跳跃动作hoppingoccurs手臂触碰某物以达到支撑目的thearmstouchsomethingforsupport在多平面评估肌肉功能稳定性Evaluatesfunctionalstabilityofmusclesinmultipleplanes将姿势评估和单腿站立测试中得到的信息进行综合考虑Combineinformationfrompostureandsingle‐legstancetest步态模式Gaitpattern病理原因PathologyTrendelenburg臀中肌无力G.Mediusweakness“Lurch”臀大肌无力G.Maximusweakness膝过伸KneeHyperextension股四头肌无力Quadricepsweakness这是PDFdoAddWater足拍地FootSlapmark试用版，注册后不会有此行胫骨肌无力Tibialisweakness跳跃步态VaultingGait腰方肌紧张Quadratustightness运动的质量Qualityofmovement肌肉放电顺序和速度Musclefiringorderandspeed收缩强度Intensityofcontraction大脑中所想为运动，而非肌肉Brainthinksintermsofmovement,notmuscle徒手肌力测试不能给予我们以激活速度、放电模式或关这是节PD稳Fdo定Add性Wat方erma面rk试的用版信，息注册后不会有此行Manualmuscletesting(MMT)doesnotgiveusinformationonspeedofactivation,firingpatternsorjointstabilization在测试中很强壮的肌肉可能会在功能性运动中受到抑制AmusclethattestsstrongmaybeinhibitedwithfunctionalmovementMMT只能用来量化力弱MMTusedonlytoquantifyaweakness1.髋伸展Hipextension主要作用于步态周期的站立相末期essentialinterminalstanceofthegaitcycle2.髋外展Hipabduction主要作用于单腿支撑相维持骨盆侧方稳定性essentialforlateralpelvicstabilityinsinglelimbstance3.屈膝两头起Curl‐up评估髂腰肌&腹肌间的关系estimatestherelationshipbetweentheiliopsoas&abdominals4.头屈曲Headflexion决定了SCM&颈深屈肌群的关系DeterminesrelationshipbetweenSCM&deepneckflexors5.俯卧撑评估前锯肌肌力&肩胛骨稳定性assessesserratusstrength&scapulastability6.肩部外展Shoulderabduction评估肩胛提肌、上斜方肌、三角肌、冈上肌&前锯肌前组间的关系estimatestheinterplaybetweenlevator,uppertraps,deltoid,supraspinatus&serratusanterior这P是usPhDF‐duuopAddWatermark试用版，注册后不会有此行不需要碰触患者。只需触摸局部的肌肉Donottouchthepatient.Touchfacilitateslocalmuscles观察肌肉外形、速度、时序、体积和运动的平滑程度Observecontourofmuscles,speed,timing,amount,andsmoothnessofmovement所有的运动都必须缓慢地进行（重复三次）Allmovementsmustbeperformedslowly(3repetitions)尽量少用语言提示Useasfewverbalcuesaspossible患者无需将这六种运动模式都完成…需要完成的项目将取决于姿势&平衡评估结果Patientsdon’tneedtoperformall6…useposture&balanceassessmenttodecide观察中应重点注意代偿性运动的出现Themostimportantthingtoobserveiscompensatorymovement从临床的观点上看，肌肉放电的顺序并不是非常重要。许多研究都发现个体之间存在放电顺序的差异Firingorderisnotasclinicallyimportant.Severalstudiesshowvariationinfiringbetweenindividuals•俯卧Prone‐lying•足离开桌面这是PDFdoAddWatermark试用版Fe，e注t册o后ff不t会he有此ta行ble•头中立位Headcentered•股骨中立位，双臂置体侧Femurinneutralrotation,armsatside正常顺序Normalsequence1.腘绳肌Hamstrings2.臀大肌GluteusMaximus3.(C)腰伸肌群4.(I)腰伸肌群lumbarextensors5.(C)胸腰部伸肌群thoracolumbarextensors6.(I)胸腰部伸肌群thoracolumbarextensors阳性发现PositiveFindings放电模式改变（早期腰椎PVM）Alteredfiringpattern(early肌肉颤抖Tremblingofmuscles骨盆前倾Anteriorpelvictilt腰椎过伸Hyperextensionoflumbarspine上斜方肌活动显著增加Significantincreaseduppertrapeziusactivitylumbarex这te是nsPoDFrdsoAddWatermark试用lu版m，b注a册r后PV不M会有)此行•患者侧卧Patientsidelying•下方腿取屈膝屈髋位Lowerlegflexedathipandknee•上方腿伸直，骨盆轻微向前Upperlegfullyextended,pelvisslightlyforwardoranterior正常顺序Normalsequence1.臀中肌&臀小肌G.medius&minimus2.阔筋膜张肌TFL3.腰方肌Quadratuslumborum4.髋屈肌群Hipflexors5.腹肌群Abdominals阳性发现PositiveFindings放电顺序改变（TFL&腰方肌提前放电）Alteredfiringpattern(earlyTFLorQuadratus)肌肉颤动Tremblingofmuscles骨盆后旋Posteriorrotationofpelvis髋屈曲/外旋Hipflexion/externalrotation骨盆上提（髋移位）Elevationofpelvis(hiphike)患者屈膝仰卧Patientsupinewithkneesbent医生将手置于患者足部以便这是PDFdoAddWatermark试用施版，加注册压后力不会有此行Clinician’shandunderpatient’sheelstomonitorpressureoftheheelsonthehand出现以下情况时测试结束：Testendswhen:足跟离开手部（髂腰肌）heelsliftfromhands(iliopsoas)肩胛下角离开桌面3秒inferiorangleraised3”offtable正常顺序Normalsequence1.头部Head2.颈部Neck3.肩部Shoulders阳性发现PositiveFindings手部来自足跟压力消失Lossofheelpressurefromhands骨盆前倾Anteriorpelvictilt肌肉颤动Tremblingofmuscles患者仰卧，髋&膝屈曲Patientsupinewithhips这是PDFdoAddWatermark试用版，注册&后k不n会e有es此f行lexed