动作控制临床推理框架

来源:运动康复 日期:2018年10月06日 浏览(28)

临床表现框架

(FRAMING THE CLINICAL PICTURE)

There is increasing awareness of the multifactorial nature of any presentation. Indeed, all clinical presentations are complex; they are the result of the dynamic interactions of multiple factors; for example, the presence of pain, previous injury, fatigue, or changes in morphology. 


近年来,对于临床表现的多因素机制的认知日益提升。确实,所有临床表现是复杂的;他们是多种因素动态的相互作用下的结果,例如,疼痛表现,损伤史,疲劳,或者形态学改变。


However, many presentations possess a ‘movement’ element; something in the person’s movement has changed as a result of their presentations or is contributing to them.


然而,许多临床表现都与“动作”因素相关,因临床症状而导致动作习惯改变,或者动作习惯改变导致症状产生。

The Kinetic Control clinical reasoning framework supplies a systemized process to consider this outcome through the assessment and subsequent retraining of movement, whilst taking into account the other factors influencing the bigger clinical picture.


KC动作控制临床推理框架提供一个系统化过程,通过评估和后期再训练来考量治疗效果,同时也考虑影响更多临床表现的其他因素。

 

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记录临床动作改变

(NOTATING CLINICALLY RELEVANT CHANGES IN MOVEMENT)

In acknowledgment of the need to consider movement with respect to any presentation, the Kinetic Control framework places focus upon specific characteristics of how individuals move; during assessment, during retraining interventions and, ultimately, during the demands of function and sport. The assessment of these characteristics of movement informs on the presence of uncontrolled movement (UCM).


承认有必要考虑与临床表现相关的动作习惯,KC框架重点关注个体的具体动作特点。通常在评估过程中,再训练干预过程中,以及最终,在功能需求和运动需求中。通过评估动作特点可以判断是否出现控制不良动作(UCM)。

Uncontrolled movement (UCM) is defined as “an inability to cognitively control movement at a specific site and direction, while moving elsewhere to benchmark standards (Comerford & Mottram, 2012). Any one UCM can be identified as possessing a site (joint/region at which the movement occurs), a direction (the motion path in which the movement happens) and a threshold (the level of muscle recruitment at which this movement is observed).


非控制性动作(UCM)是指“无法在特定部位和方向上,通过认知功能控制动作完成,同时通过代偿以达到基准”(Comerford & Mottram, 2012)。任何一个UCM都被识别出特定部位(动作发生的关节/部位)、特定方向(动作产生的轨迹)及阈值(观察到动作时的肌肉募集水平)。


为什么非控制性动作很重要?

(WHY DOES UNCONTROLLED MOVEMENT MATTER?)

The notation of the site, direction and threshold  ® of UCM, allows movements the individual cannot observably ‘prevent’ from happening to be profiled;

For example, a person may be unable to prevent the hip from medially rotating as they transition from sitting to standing. If this pattern of movement, cannot be prevented it can be suggested to occur with a high frequency during the day.


记录UCM的部位,方向和阈值,可以描述个体无法预防发生的UCM。

举例说明,从坐位转移至站位时,某人无法控制髋关节内旋。如果无法预防该动作模式的产生,可想而知,一天中该动作模式将会高频发生。

This may lead to stress and strain on tissues local to this region. Uncontrolled movement may then significantly impact quality of life; this may be due to this movement’s association to symptom provocation, risk of recurrence, or injury; all factors potentially leading to activity limitation and participation restriction.

The identification of UCM supplies the clinician with valuable insight on which movement patterns may be contributing to this presentation.


这可能对该部位的局部组织产生压力和张力。非控制性动作可能会对生活质量造成严重影响;起因是该动作可能诱发症状、增加复发风险或者导致损伤;所有因素潜在的导致活动受限和参与受限。

识别UCM可以为临床治疗师提供一种具有价值的治疗角度,从而发现可能导致该临床表现的动作模式。

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However, the identification of UCM represents only the first of the four elements of the Kinetic Control framework identified below.


但是,识别UCM仅仅是以下KC临床框架4个步骤的第1步。


临床推理过程

(THE CLINICAL REASONING PROCESS)

1. Evaluation of Movement Health in terms of Site, Direction and Threshold of UCM ®

2. Evaluation of syndrome, pathology, clinical signs and imaging findings

3. Consideration of pain mechanism

4. Consideration of individual, environmental and task constraints


1. 从UCM的部位,方向和阈值评估动作健康

2. 症状,病理,临床征象和影像学评估

3. 疼痛机制考量

4. 个体因素、环境因素和任务限制考量


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1


从UCM部位,方向和阈值评估动作健康

Evaluation of Movement Health in terms of Site, Direction and Threshold of UCM

As highlighted above, the initial priority is to identify the site and direction of UCM that best correlates with the patient's presentation. It is to be acknowledged that there is often more than one site of UCM. The clinical reasoning process links the UCM to the symptoms, activity limitation and participant restriction, recurrence, risk of injury and performance. This helps guide retraining intervention as a priority as implicated.


和之前强调的一样,首要任务是识别与患者症状相关性最高的UCM部位和方向。众所周知,UCM通常不止出现在一个部位。临床推理过程将UCM与症状、活动受限和参与受限、复发、损伤风险和表现相关联。这有助于引导再训练干预作为优先事项。


2


症状,病理,临床征象和影像学评估

Evaluation of syndrome, pathology, clinical signs and imaging findings

Valuable insight can also be gained from other assessment or imaging techniques. In respect to these findings, there is the need to consider the influence of a variety of pain-sensitive tissues, a knowledge of the mechanism of injury (if there is one), and an understanding of the typical responses of different tissues to stress and strain and injury.


可以通过其他评估方式或影像学技术获得有价值的视角。关于这些发现,有必要考虑不同痛敏组织的影响,了解损伤机制(如果有)和不同组织对于压力、张力和损伤的典型反应。

Contemporary clinical reasoning in patients with chronic pain, suggests it may be more appropriate to explore factors affecting impairment of function and participation than to attempt to diagnose specific structures or tissues as a source of nociception.


现代慢痛患者临床推理建议:研究功能和参与障碍的影响因素比尝试诊断具体致痛结构或组织更为合理。


3


疼痛管理考量  

Consideration of pain management

Cognitive behavioural approaches clearly have a significant role to play for optimal patient outcomes.

The value of patient education, including pain education is crucial for patient outcomes.


认知行为方式对于优化患者结果很关键。

患者教育价值,包括疼痛教育对于患者结果有重要意义。


4


个体,环境和任务受限因素考量

Consideration of individual, environmental and task constraints

Alongside these first three elements, the therapist should also consider the influence of contextual factors – both personal and environmental – on the patient's signs and symptoms and explore how these might relate to UCM. Any one of these factors can classified as belonging to the domain of task, individual or environment (Dingenen et al., 2018). Examples of each are identified:


除前面提到的三项因素,治疗师也应该考虑情境因素-个体和环境-对于患者表征和症状的影响,发现这些因素与UCM之间的联系。这些因素的任何一种可被归类为任务主导、个体主导或者环境主导(Dingenen et al., 2018)。这三种因素的案例如下所示:

Task: speed or distance of walking

Individual: previous injury or age

Environment: footwear, protective equipment  

Only once all elements are considered, can the clinical picture come in full view. 


任务因素:行走速度或距离

个体因素:损伤史或年龄

环境因素:穿的鞋,保护性设备

只有所有因素都被考虑,才能对临床表现有全面观的了解。

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References:

Comerford, M., & Mottram, S. (2012). Kinetic Control: The Management of Uncontrolled Movement. Elsevier Health Sciences.

Dingenen, B., Blandford, L., Comerford, M., Staes, F., & Mottram, S. (2018). The assessment of movement health in clinical practice: A multidimensional perspective. Physical Therapy in Sport.

Keywords: Movement Control, Movement Matters, Kinetic Control

 原文链接:http://www.kineticcontrol.com/kc-buzz/framing-the-clinical-picture

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