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摘要: 脊柱侧凸是常见的脊柱三维畸形。利用脊柱侧凸特定性体操治疗特发性脊柱侧凸已被广泛应用。国际上不同类型的脊柱侧凸特定性体操包括意大利脊柱侧凸科学训练法、德国Schroth训练法、西班牙巴塞罗那脊柱侧凸物理治疗法、波兰Dobomed训练法、英国Side Shift训练法、法国里昂训练法、波兰功能性个体化脊柱侧凸治疗7种。本文通过分析以上脊柱侧凸特定性体操的特点和适用范围，以期为临床合理选择及应用提供理论依据。Abstract: Scoliosis is a common three-dimensional deformity of the spine. Physiotherapy scoliosis-specific exercise (PSSE) has been widely used to treat idiopathic scoliosis. There are 7 different schools of PSSE in the world, including scientific exercise approach to scoliosis(SEAS), Schroth, Barcelona scoliosis physical therapy school(BSPTS), Dobomed, Side Shift, Lyon, and functional individual therapy of scoliosis(FITS). By analyzing the characteristics and application scope of all the PSSE above, this paper hoped to provide a theoretical basis for rational clinical selection and application.
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脊柱侧凸是常见的脊柱三维畸形，定义为冠状面上的脊柱侧方弯曲，常伴有不同程度的脊柱旋转。临床上以弯曲≥10°(Cobb角测量法)来界定脊柱侧凸[1]。严重的脊柱侧凸会导致患者自信心下降、心理焦虑、疼痛、肺部并发症和功能受限等问题，给患者自身、家庭及社会带来严重的心理和经济负担[2-7]。治疗脊柱侧凸的方法分为手术治疗和保守治疗。国际脊柱侧凸研究协会(Scoliosis Research Society，SRS)将观察和支具列为脊柱侧凸保守治疗方法，而国际脊柱侧凸矫形与康复治疗协会(Society on Scoliosis Orthopedic and Rehabilitation Treatment，SOSORT)则将物理治疗脊柱侧凸特定性体操(physiotherapy scoliosis-specific exercise，PSSE)也纳入了保守治疗范围。随着人们健康意识的提高，“观察”这一保守治疗方案已经不能满足患者需求，越来越多的患者及其家属选择PSSE进行干预。
1. 国际7种脊柱侧凸特定性体操类型
1.1 意大利脊柱侧凸科学训练法
意大利脊柱侧凸科学训练法(scientific exercise approach to scoliosis，SEAS)主要包括训练前的系统评估和运动训练。系统评估包括影像学评估、大体观评估、功能性评估等。运动训练的核心是三维平面上的自我矫正和基于自我矫正位下的稳定性训练[8]。SEAS十分强调主动自我矫正(active self-correction，ASC)，而非被动矫正。ASC的选择应根据影像学检查和形态学两方面进行判断。冠状面上，Cobb角＞12°或外观明显不对称时，需进行ASC；矢状面上，通过铅垂线测量明显驼背或平背患者需进行ASC；水平面上，椎体旋转度＞15°或外观上剃刀背明显时，需进行ASC。基于自我矫正位下稳定性训练的选择主要取决于患者的评定结果，将评定中存在受损情况的部分编排成训练内容。SEAS的两个目标包括：(1)提高脊柱功能，例如脊柱的稳定性；(2)提高初期评定中受损部分的最终能力，例如肌力、肌肉回缩能力、协调性等。近些年对SEAS的研究报道颇多，大量的前瞻性研究、回顾性研究以及个案报道对SEAS给予了肯定[9-22]。Monticone等[23]也通过随机对照试验证实了SEAS的有效性。
1.2 德国Schroth训练法
德国Schroth训练法是最早的PSSE之一。Katharina Schroth是Schroth训练法的创始人，后被其女儿、外孙及其他保守治疗专家发扬光大[24-25]。目前Schroth训练法被分为以Axel Hennnes为代表的较传统的国际Schroth三维脊柱侧凸治疗和以Weiss为代表的较创新的Schroth最佳训练。Schroth训练法的分型和身体地图是其治疗的基础。根据不同分型为患者绘制身体地图，并设计不同的PSSE动作是Schroth训练法的基本流程。Schroth训练法将人体分为4个区块：肩部、胸部、腰部和髋部。几乎每个区块均有三维上的自我矫正方法和训练动作[26]。与SEAS不同的是，Schroth训练法强调利用辅助器械进行过矫正的自我矫正，并且强调配合不对称的去旋转式呼吸训练法。关于Schroth训练法的研究报道甚多，Yang等[27]、Otman等[28]、Schreiber等[29]、Kim等[30]分别通过试验研究发现，对于轻中度脊柱侧凸患者，通过3~6个月的Schroth训练，不仅可减小Cobb角度和躯干旋转角度，还可增加患者的肺活量。Park等[31]通过Meta分析得出，Schroth训练法是有效干预脊柱侧凸的PSSE，且更适用于Cobb角＜30°的患者。
1.3 西班牙巴塞罗那脊柱侧凸物理治疗法
西班牙巴塞罗那脊柱侧凸物理治疗法(Barcelona scoliosis physical therapy school，BSPTS)是Schroth训练法的衍生版，由Elena Salvá's女士将Schroth的原则和理念带回西班牙后演变发展而来。目前BSPTS的代表人物Manuel Rigo也是Rigo-Chêneau支具的主要创始人之一。BSPTS同样重视侧凸分型，主要分为Group 1(矢状面胸椎生理曲度异常)、Group 2和Group 1-2(仅存在腰椎或胸腰椎侧凸，无胸椎侧凸)，其中Group 2又分为3弧(胸椎和腰椎均为主凸，骨盆与腰椎为一体，无论侧移或旋转均与胸椎相反)、4弧(腰椎为主凸，胸椎为代偿凸，骨盆的侧移或旋转均与腰椎相反)和非3非4(胸椎为主凸，有/无腰椎侧凸，骨盆无侧移或旋转)[32]。BSPTS的训练方法与Schroth类似，其目标包括：(1)矫正脊柱侧凸的姿势，改善外观；(2)稳定脊柱，阻止病变进展；(3)对患者及其家属进行病情及治疗方案的宣教；(4)改善呼吸功能；(5)增加日常生活活动能力；(6)全面提高患者自我意识和自信心；(7)减少疼痛[33]。
1.4 波兰Dobomed训练法
Dobomed训练法是三维自我矫正运动法，在矫正主凸的同时，强调对胸椎后凸不足和腰椎前凸不足进行纠正，同时纠正呼吸功能受损，其最经典的训练体位是手膝跪位[34]。以胸椎右侧凸为例，让患者手膝跪位，右侧“剃刀背”隆起会非常明显。训练过程中要求患者既做增加胸椎后凸的动作又进行去旋转式呼吸，将塌陷的左侧凹侧胸廓充盈起来，使躯干旋转角度降到最小。研究表明，Dobomed训练法能有效阻止或减少非成年脊柱侧凸患者Cobb角的增加，改善患者外观及矢状面上的生理曲度，提高呼吸功能等[35-38]。
1.5 英国的Side Shift训练法
Side Shift以King分型为基础，结合了Schroth训练法和Dobomed训练法，其经典动作是“提踵”和“侧向平移”[39]。对于腰椎侧凸患者，利用提起凸侧足跟，使凸侧髋关节高于凹侧髋关节，迫使腰椎凸侧弯弧趋于中立位甚至过矫正的位置。对于胸椎侧凸患者，胸廓侧向平移至凹侧，有助于打开凹侧塌陷的胸廓，使胸椎侧凸的弯弧趋于中立位。den Boer等[40]研究表明，Side Shift训练法对于Cobb角为20°~32°脊柱侧凸患者的效果与支具效果无显著性差异。其他研究显示，Side Shift训练法对于特发性脊柱侧凸患者来说是有效的[41-42]。
1.6 法国里昂训练法
里昂训练法包括脊柱三维矫正、腰椎侧凸患者腰骶角矫正、患者宣教和日常生活(正确坐姿)活动能力。里昂训练法遵循五大原则：(1)治疗前的评估，包括患者年龄、姿势失衡、Cobb角度；(2)躯干畸形的认知，利用镜子或录像等视觉反馈帮助患者了解侧凸曲度的矫正；(3)适宜的动作，里昂训练法的基础是避免运动中过伸展脊柱，强调在冠状面矫正的同时增加矢状面上的胸椎后凸和腰椎前凸、节段活动度、核心稳定性、本体感觉、平衡等，其中最主要的是强调患者在佩戴支具的同时进行运动训练；(4)不适宜的动作，例如避免矢状面上过度屈伸和引起气短的训练；(5)体育锻炼同样重要，告知患者对脊柱侧凸有益和有害的体育运动[33]。里昂训练法强调佩戴支具时应结合PSSE同时进行[43]。
1.7 波兰功能性个体化脊柱侧凸治疗
功能性个体化脊柱侧凸治疗(functional individual therapy of scoliosis，FITS)起步相对较晚，故综合了上述PSSE中许多经典的理论与动作。根据患者不同情况，FITS也有不同的治疗体系，如接受支具治疗、准备接受手术和术后肩胛带/骨盆带矫正的患者等[44]。FITS包括3个主要矫正阶段：患者评估和宣教、矫正的准备和三维矫正。研究表明，FITS可有效改善脊柱侧凸患者Cobb角度和躯干旋转角度，且可纠正脊柱侧凸引起的姿势异常问题[45-47]。
2. 脊柱侧凸特定性体操临床应用
2.1 我国总体应用情况
由于Dobomed和Side Shift训练法强调二维空间上的矫正，故临床上单独运用的机会较小，一般会采用其经典的方法和理念，再结合患者脊柱侧凸三维情况适当增加治疗内容。里昂训练法和FITS在其本土运用较多，我国尚未开展。目前国内治疗脊柱侧凸应用SEAS、Schroth和BSPTS较多，其中SEAS比较适合日常生活中长期细微姿势调整，不建议过矫正；而Schroth和BSPTS则强调集中训练，对过矫正持积极态度[48-49]。故临床中可将其结合，以求达到最佳治疗效果。
2.2 临床应用情形
PSSE主要被应用于下列5种临床情况[50]：(1)单独应用于Cobb角度数较小的青少年特发性脊柱侧凸，维持或减少目前进展，避免佩戴支具；(2)在佩戴支具前提高脊柱的活动度和弹性，让支具衬垫的压力给予躯干更好的矫正；(3)联合支具使用，减少佩戴支具产生的副作用(肌力下降、僵硬、平背等)，提高支具的效果且避免在佩戴支具过程中三维矫正的丢失；(4)应用于成年脊柱侧凸患者，如果侧凸度数大于一定程度，可能会引起腰痛、呼吸障碍、挛缩、畸形进展等严重问题；(5)术前术后的矫正：术前维持弯弧的活动度有助于术中最大程度地矫正度数，术后增加手术对背部形态、平衡和姿势等的效果，或针对某些个体进行训练。
3. 小结与展望
国际上对PSSE的认可度越来越高，国内虽然也紧跟国际步伐，引入先进的技术，但始终未形成体系。北京协和医院在借鉴国际先进技术的同时，考虑我国国情，研发出了适合我国患者的PUMCH脊柱侧凸保守治疗体系，经过数年临床实践，已取得了一定成果。例如，本团队通过对31例青少年特发性脊柱侧凸患者进行为期6个月的PSSE发现，PSSE能够延缓甚至改善轻度青少年特发性脊柱侧凸，包括Cobb角度和躯干旋转角度[51]；通过对36例少儿型特发性脊柱侧凸患者进行为期6个月的PSSE发现，PSSE亦能改善少儿型特发性脊柱侧凸患者的Cobb角度，并获得了良好的患者满意度[52]。未来，期待更多的脊柱侧凸保守治疗人员能够总结临床经验并进一步进行科技研发，以造福更多的脊柱侧凸患者。
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