【摘要】：背景:膝骨關(guān)節(jié)炎是影響人類健康的重要疾病,產(chǎn)生的疼痛及功能障礙嚴(yán)重地影響了人們的生活與工作,特別是絕經(jīng)后女性人群有著很高的發(fā)病率,而此類患者往往伴有不同程度的骨量減低及骨質(zhì)疏松癥,目前仍無(wú)有效的治療方法。體外沖擊波(Extracorporeal Shock Wave,ESW)作為一種有效的力學(xué)刺激可以促進(jìn)骨生成及軟骨下骨重塑越來(lái)越被人們所重視,并應(yīng)用于膝骨關(guān)節(jié)炎的臨床及基礎(chǔ)研究,我們課題組在國(guó)內(nèi)首次將體外沖擊波應(yīng)用于絕經(jīng)后女性膝骨關(guān)節(jié)炎患者的治療。目的:從疼痛,功能角度評(píng)估體外沖擊波療法(Extracorporeal Shock Wave Therapy,ESWT)對(duì)絕經(jīng)后女性膝骨關(guān)節(jié)炎的有效性及安全性,并分析ESWT對(duì)膝骨關(guān)節(jié)炎患者步態(tài)學(xué)的影響,為膝骨關(guān)節(jié)炎防治提供新思路,為臨床體外沖擊波療法治療膝骨關(guān)節(jié)炎患者提供臨床依據(jù)。方法:將2014年8月至2015年6月在我科收治的通過X線檢查為2、3級(jí)(Kellgren-Lawrence分級(jí))的86例絕經(jīng)后女性膝骨關(guān)節(jié)炎患者為研究對(duì)象,詳細(xì)登記患者人口學(xué)資料如受試者的年齡、職業(yè)、婚況、身高、體重。本試驗(yàn)采取隨機(jī)、對(duì)照、單盲、前瞻性臨床研究設(shè)計(jì),在患者簽訂知情同意的前提下通過SAS統(tǒng)計(jì)軟件的PROC PLAN過程編程產(chǎn)生隨機(jī)數(shù)字,根據(jù)數(shù)字的奇偶性隨機(jī)分為兩組:體外沖擊波治療組(ESWT組)44例患者與對(duì)照組(Contral組)42例。沖擊波組患者通過膝關(guān)節(jié)核磁共振來(lái)確定軟骨缺損部位并結(jié)合膝關(guān)節(jié)標(biāo)記疼痛的具體位點(diǎn)來(lái)治療,隨后應(yīng)用氣壓彈道式?jīng)_擊波治療儀,將槍頭對(duì)準(zhǔn)標(biāo)記的痛點(diǎn),接受沖擊頻率為7Hz,能量1~2 bar的發(fā)散式體外沖擊波治療,每個(gè)部位沖擊2000次,1次/周,8次為1療程,沖擊波治療中,未使用任何麻醉藥物和鎮(zhèn)靜劑。對(duì)照組以無(wú)能量的假?zèng)_擊波對(duì)患側(cè)關(guān)節(jié)進(jìn)行治療方法同上。治療過程中患者取坐位,膝關(guān)節(jié)屈曲90°或者伸直180°,治療過程中要主動(dòng)避讓膝關(guān)節(jié)周圍重要神經(jīng)及血管。兩組患者在0月(治療前)及1月(治療中期),2月(療程結(jié)束后),3月(療程結(jié)束后1個(gè)月)、6月(療程結(jié)束后4個(gè)月)通過(VAS)視覺模擬疼痛評(píng)分;(WOMAC)膝關(guān)節(jié)功能評(píng)分;對(duì)治療的滿意程度;50米快速走時(shí)間監(jiān)測(cè)及步態(tài)分析(步速、步長(zhǎng)、站立期及擺動(dòng)期百分比)等指標(biāo)進(jìn)行統(tǒng)計(jì)學(xué)研究分析。結(jié)果:在0月(治療前)及1月(療程中期),2月(療程結(jié)束后),3月(療程結(jié)束后1個(gè)月)、6月(療程結(jié)束后4個(gè)月)對(duì)患者進(jìn)行隨訪,結(jié)果顯示:體外沖擊波治療組(ESWT組)的疼痛及功能相對(duì)與對(duì)照組都明顯改善(P0.01)在治療1月、2月、3月。1 VAS評(píng)分結(jié)果:在3月時(shí),ESWT組的平均VAS評(píng)分(2.5±1.0)相比與治療前VAS評(píng)分(4.3±1.4)及對(duì)照組VAS評(píng)分(4.0±1.3)(P0.01)相比明顯改善。在6月時(shí)(治療結(jié)束后4個(gè)月)ESWT組的平均VAS評(píng)分(3.6±1.3)相比與治療前VAS評(píng)分(4.3±1.4)(P=0.53)及對(duì)照組VAS評(píng)分(4.1±1.2)(P=0.93)沒有統(tǒng)計(jì)學(xué)差異。2 WOMAC評(píng)分結(jié)果:膝關(guān)節(jié)功能評(píng)分(WOMAC評(píng)分)中疼痛評(píng)分在1月,2月,3月與VAS評(píng)分得到相同結(jié)果(P0.01),而在評(píng)分中的僵直評(píng)分在治療及隨訪的時(shí)間里沒有改善(P0.05),而膝關(guān)節(jié)的功能情況在1月,2月,3月都得到很大程度改善(P0.01)。3滿意度評(píng)價(jià):治療前Control組和ESWT組患者治療的滿意程度(差/中/好)為(7/21/11)與(7/21/10)(P0.05)。ESWT組患者在2月和3月時(shí)滿意程度分別為(3/22/14)和(4/23/12),而對(duì)于Control組患者2月和3月時(shí)滿意程度分別為(15/16/7)與(16/15/7),ESWT組患者滿意度明顯高于Control對(duì)照組患者(P0.05)。4 50米快速走時(shí)間:在ESWT組患者只有在2月時(shí)(35.5±7.0s)相對(duì)于Control組(39.8±7.3s)及ESWT組治療前(41.2±7.6s)有統(tǒng)計(jì)學(xué)差異(P0.05)。5步態(tài)分析結(jié)果:步長(zhǎng)Stride Length(cm)在隨訪6個(gè)月時(shí)間內(nèi)ESWT組與Control組及治療前相比無(wú)統(tǒng)計(jì)學(xué)差異P0.05,ESWT組步速Wailing Speed(m/s)只有在2月(1.25±0.18m)相對(duì)與Control組(0.97±0.24m)及治療前(1.12±0.22m)相比具有統(tǒng)計(jì)學(xué)差異P0.001、站立期stance[%gait cycle]、擺動(dòng)期Swing[%gait cycle]的數(shù)據(jù)顯示在2月時(shí)ESWT組與治療前及對(duì)照組相比較都有統(tǒng)計(jì)學(xué)差異P0.05,而其他時(shí)間的隨訪沒有明顯統(tǒng)計(jì)學(xué)差異。6相關(guān)性分析:通過臨床實(shí)踐及統(tǒng)計(jì)學(xué)分析發(fā)現(xiàn)患者的主觀感受與患者的體重指數(shù)成正相關(guān)(BMI),患者體重指數(shù)越大經(jīng)過沖擊波治療后的效果越明顯,疼痛及功能緩解幅度越大。結(jié)論:通過客觀及主觀評(píng)價(jià)的指標(biāo)統(tǒng)計(jì)學(xué)分析得出體外沖擊波療法對(duì)絕經(jīng)后女性特定人群膝骨關(guān)節(jié)炎安全有效,可以有效緩解患者疼痛及改善功能,并發(fā)現(xiàn)體外沖擊波療法的治療效果與患者的體重指數(shù)成正相關(guān)。為該類人群膝骨關(guān)節(jié)炎防治提供新思路和新靶點(diǎn),是治療絕經(jīng)后女性早中期膝骨關(guān)節(jié)炎的有效方法之一。
[Abstract]:BACKGROUND: Osteoarthritis of the knee is an important disease affecting human health. Pain and dysfunction have seriously affected people's life and work. Especially in postmenopausal women, there is a high incidence of osteoarthritis, which is often accompanied by different degrees of osteopenia and osteoporosis. Extracorporeal Shock Wave (ESW), as an effective mechanical stimulus to promote bone formation and subchondral bone remodeling, has been paid more and more attention and applied to the clinical and basic research of knee osteoarthritis. Objective: To evaluate the efficacy and safety of Extracorporeal Shock Wave Therapy (ESWT) in postmenopausal women with knee osteoarthritis from the perspective of pain and function, and to analyze the effect of ESWT on the gait of knee osteoarthritis patients, so as to provide a new idea for the prevention and treatment of knee osteoarthritis, and to provide a new way for clinical application of ESWT in the treatment of knee osteoarthritis. Methods: From August 2014 to June 2015, 86 postmenopausal women with knee osteoarthritis (Kellgren-Lawrence grade) who had undergone X-ray examination in our department were enrolled in this study. The demographic data of the patients, such as age, occupation, marital status, height and weight, were recorded in detail. Contrast, single-blind, prospective clinical study design. Random numbers were generated by PROC PLAN process programming with SAS statistical software on the premise of informed consent. According to the parity of the numbers, the patients were randomly divided into two groups: the extracorporeal shock wave therapy group (ESWT group) 44 patients and the control group (Control group) 42 patients. Magnetic resonance imaging (MRI) was used to determine the location of cartilage defect and to identify the specific site of pain marking in the knee joint. Then, the gun head was pointed at the marking pain point by pneumatic ballistic shock wave therapy instrument. The gun was treated with a 7 Hz, 1-2 bar, diffuse extracorporeal shock wave therapy. Each site was impacted 2000 times, once a week, 8 times as a course of treatment. No anesthetics or sedatives were used during the treatment. The control group received the same treatment as the control group with an energetic pseudoshock wave. During the treatment, the patients were seated, flexed 90 degrees or stretched 180 degrees, and the important nerves and blood vessels around the knee joint were avoided actively. The two groups were treated in October (before treatment) and January (before treatment). In the middle period of treatment, 2 months (after the course), 3 months (one month after the course), 6 months (4 months after the course) through (VAS) visual analogue pain score; (WOMAC) knee joint function score; treatment satisfaction; 50 meters of fast walking time monitoring and gait analysis (pace, step length, standing period and percentage of swing period) and other indicators were statistically studied. Results: The patients were followed up in October (before treatment) and January (middle course), February (after treatment), March (one month after treatment), and June (four months after treatment). The results showed that the pain and function of ESWT group were significantly improved compared with the control group (P 0.01) in January, February and March.1 VAS scores. Results: At March, the average VAS score of ESWT group was significantly improved compared with pre-treatment VAS score (4.3 + 1.4) and control VAS score (4.0 + 1.3) (P = 0.93) and pre-treatment VAS score (3.6 + 1.3) in 6 months (4 months after treatment) compared with pre-treatment VAS score (4.3 + 1.4) (P = 0.53) and control VAS score (4.1 + 1.2) (P = 0.93). There was no significant difference in WOMAC scores. The pain scores in January, February, March and VAS scores were the same (P 0.01), while the stiffness scores in the scores did not improve during treatment and follow-up (P 0.05), while the knee function improved significantly in January, February, and March (P 0.05). Satisfaction evaluation: Before treatment, the degree of satisfaction of the control group and the ESWT group was (7/21/11) and (7/21/10) (P 0.05). The degree of satisfaction of the ESWT group was (3/22/14) and (4/23/12) in February and March, respectively, while that of the control group was (15/16/7) and (16/15/7) in February and March, respectively. Degree was significantly higher than that of control group (P 0.05). 450-meter walking time: In ESWT group, there was significant difference (P 0.05). 5 gait analysis: Stride Length (cm) of step length between ESWT group and Control group at 2 months (35.5 + 7.0s) compared with control group (39.8 + 7.3s) and ESWT group (41.2 + 7.6s) before treatment (P 0.05). There was no significant difference in P 0.05. Wailing Speed (m/s) in ESWT group was only significantly different from that in Control group (0.97 + 0.24m) and pre-treatment (1.12 + 0.22m) in 2 months (1.25 + 0.18m), standing period (stance [% gait cycle], swing period (Swing [% gait cycle] in ESWT group in 2 months (compared with pre-treatment and control group). There was a significant difference between the two groups (P 0.05), but there was no significant difference in other time follow-up. 6 Correlation analysis: Through clinical practice and statistical analysis, it was found that the subjective feelings of patients were positively correlated with body mass index (BMI), the greater the body mass index, the more obvious the effect of shock wave treatment, and the pain and function relief was greater. Conclusion: Extracorporeal shock wave therapy is safe and effective for postmenopausal women with knee osteoarthritis, can effectively relieve pain and improve the function of patients, and the therapeutic effect of extracorporeal shock wave therapy is positively correlated with body mass index. The prevention and treatment of osteoarthritis of the knee provides new ideas and new targets, and is one of the effective methods to treat osteoarthritis of the knee in postmenopausal women.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R684.3

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5 本報(bào)記者 李振輝　通訊員 寧習(xí)源;膝骨關(guān)節(jié)炎康復(fù)要巧用“力”[N];廣東科技報(bào);2008年

6 ;外科治療膝骨關(guān)節(jié)炎應(yīng)嚴(yán)把指征關(guān)[N];中國(guó)醫(yī)藥報(bào);2006年

7 金仲品;非甾體類抗炎藥治膝骨關(guān)節(jié)炎 止痛療效有限[N];大眾衛(wèi)生報(bào);2004年

8 王玉明;中老年女性易患膝骨關(guān)節(jié)炎[N];貴州政協(xié)報(bào);2002年

9 王振嶺;膝骨關(guān)節(jié)炎從肝施治[N];健康報(bào);2007年

10 中國(guó)中醫(yī)科學(xué)院廣安門醫(yī)院 馮興華;蟻參蠲痹膠囊治療膝骨關(guān)節(jié)炎的臨床研究[N];健康報(bào);2010年

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