核心稳定训练干预慢性腰痛的脑功能网络机制

Chronic low back pain (cLBP) is the most common forms of musculoskeletal pain in rehabilitation medicine, its prevalence rate in Chinese has been 35.6% with a rapidly increasing and younger trend. Previous researches have showed that the development and prognosis of cLBP are closely related to the central nervous system, but the etiology and pathogenesis is still unknown. Recent studies show that cLBP is often associated with impaired control of deep lumbar multifidus and functional changes of the primary motor cortex, suggesting that impaired corticomotor control of core muscles involved in spine stability may be of vital role in patients with cLBP. We had published articles revealed that LBP demonstrated significant regional homogeneity changes in the prefrontal cortex, motor cortex and cingulated cortex. The onsets of the bilateral multifidus were significantly delayed in the cLBP group compared with the healthy group. However, the mechanisms of brain functional networks and its potential relationship with impaired control of core stabilization muscles such as the transversus abdominis and lumbar multifidus. Thus, this project firstly intends to use resting-state functional magnetic resonance imaging and functional connectivity methods to investigate changes in network dynamics and functional activity in cLBP. Then we present a novel method based on surface electromyography (sEMG) system and fine-wire electrodes recording EMG signals to identify the changes in neuromuscular activation of the lumbar multifidus and transversus abdominis during dynamic activities with persistent pain. The muscle thickness, cross-sectional area and contraction activity were also measured by ultrasound imaging to observe potential relationship between EMG activity and structural changes in cLBP. Moreover, two-tailed paired t-test was used to compare the brain functional network differences between two groups before and after the intervention (12 weeks core stability exercise) in cLBP, then find potential association between reorganization of cortical networks and changes of core stability muscles to provide objective basis for clinical rehabilitation.

慢性腰痛（cLBP）是康复医学领域最常见的骨骼肌肉疼痛，患病率约为35.6%，呈逐年增高、年轻化趋势。cLBP发生发展和预后与中枢神经机制密切相关，但其确切机理尚不清楚。最新证据显示cLBP皮质运动区功能改变与腰椎多裂肌协调运动障碍相关，提示核心稳定肌及中枢控制障碍是其关键病因。前期我们发表文章报道：LBP前额叶、运动区、扣带回等局部一致性异常，深层多裂肌激活延迟，但cLBP脑网络模式与腰椎稳定肌的内在联系机制还不明确。本项目拟首先采用静息态fMRI和功能连接等方法，探讨cLBP大脑内在活动及功能网络改变；再通过sEMG结合丝电极测量深层多裂肌、腹横肌电活动和超声检测形态学特征，观察核心稳定肌功能结构变化；最后对cLBP进行核心稳定训练，通过比较干预前后脑功能网络的差异及与肌电超声形态改变的相关性，探讨脑网络与核心稳定肌之间的因果关联性及功能重建机制，为cLBP临床康复与预防提供理论依据。

慢性腰痛（cLBP）是康复医学领域最常见的骨骼肌肉疼痛，患病率约为35.6%，且呈逐年增高、年轻化趋势，已成为世界范围内一个突出的健康问题。cLBP发生发展和预后与中枢神经系统机制密切相关。持续性疼痛与大脑皮层病理痛觉信息编码和加工的神经回路有关，疼痛通过改变大脑区域之间的信息流动和整合而影响大脑的功能和行为。. 本项目首先采用静息态fMRI和功能连接等方法，发现cLBP默认网络环路功能失调，前额叶中部（mPFC）与前扣带回（ACC）功能连接增高，岛叶与额下回、枕叶功能连接减低；局部一致性（ReHo）值增高的脑区包括mPFC、岛叶、海马旁回和小脑，ReHo值降低的脑区包括初级感觉皮层（S1）、ACC及皮质运动区。提示cLBP患者在静息状态下疼痛加工脑区功能关系异常，同时涉及认知和情绪的脑区功能连接发生改变。. 再通过sEMG结合丝电极检测核心稳定肌EMG信号和肌骨超声检测形态学特征，发现cLBP腰部深层多裂肌AEMG、RMS明显小于健康对照组，MF、MPF显著高于对照组，提示长期疼痛刺激下深层多裂肌募集延迟，中枢预激活机制消失； cLBP患者的腰部深层多裂肌静息厚度、收缩厚度、横截面积均显著低于健康对照组，且收缩厚度变化率变小，提示cLBP深层多裂肌收缩幅度减小、自主收缩能力下降。. 最后对cLBP进行12周悬吊式核心稳定训练，发现在不同悬吊姿势下多裂肌AEMG均比整体稳定肌高，且干预后cLBP患者腰背部疼痛明显减轻，多裂肌和竖脊肌的疲劳程度下降，收缩能力增强，提示干预后大脑对躯干运动控制的模式发生了改变，可能是动态不稳定支撑环境增加了对中枢神经系统的刺激，进而提高了中枢神经系统动员肌纤维参与收缩的能力，中枢前馈激活功能恢复，从而在脊柱维持稳定的过程中保证大脑皮质对椎旁肌的精确控制。. 本项目结果为腰痛深层肌肉生理与病理情况、运动模式分析及康复策略制定提供了新的思路，让我们更深入地理解cLBP不同脑区功能改变与核心稳定肌运动障碍之间的关联性，进一步明确了cLBP的病因和发病机制。这对cLBP患者有效完成日常生活工作动作、预测腰痛发生与结局及制定更有针对性、更有效的康复治疗方案具有重要意义。