腰痛坐骨神經(jīng)痛（腰痛伴隨放射痛）
前言：
脊柱學校源自1970年，第一所腰椎疾病學校在瑞典成立。它是由Danderyl醫(yī)院的Zarichsson-Forsel開發(fā)，后來被稱為瑞典后背學校，旨在幫助嚴重腰椎受傷的工人重返工作崗位。在北美洲盛行，傳承并發(fā)展至今，迄今54年……
在中國北京脊柱學校在2023年開設了第一家，它傳承了傳統(tǒng)的脊柱學校集教育和培訓的項目，并經(jīng)過了不斷更新迭代，脊柱學校包含了運動（包括鍛煉、體力活動和物理治療）、知識教育、瑜伽、動手操作、中醫(yī)等多學科交叉，由醫(yī)生、物理治療師、瑜伽老師、中醫(yī)等為客戶提供服務課程，提供個性化訂制服務，通過自我學習與有效治療干預達到自我管理脊柱健康的目的。
下背痛一年的首次發(fā)病率在6.3%到15.3%之間，一年全部發(fā)病率為1.5%-36%，下腰痛是世界范圍內(nèi)活動受限和工作缺勤的首要原因，并且造成巨大的經(jīng)濟負擔。另外造成活動受限的下腰痛經(jīng)常復發(fā)，復發(fā)率在24%-33%之間，慢性下腰痛發(fā)病率尤其明顯女性較男性發(fā)病趨勢更高，年齡增大與下腰痛發(fā)病率增高相關，下腰痛的的嚴重程度隨年齡的增加而增加，60-65整體發(fā)病率增加，教育水平較低與下腰痛發(fā)病率相關，病程延長和預后不良有關，職業(yè)的不同與發(fā)病率有差異
美國物理治療師協(xié)會骨科物理治療學院與ICF分類發(fā)布的急性與腰痛干預措施：2021年修訂版下腰痛臨床實踐指南（提供診斷、檢查、干預指南）
分類中把下腰痛分為：
急性或亞急性下背痛伴隨活動受限(b7101幾個關節(jié)的活動度)
急性、亞急性或慢性下腰痛伴隨協(xié)調(diào)性運動障礙(b7601控制復雜的自主活動)
急性下腰痛伴發(fā)相關(牽涉痛)下肢疼痛(b28015下肢疼痛)
急性、亞急性或慢性的下腰痛伴隨放射痛(b2804節(jié)段性或區(qū)域性的放射痛)
急性或亞急性下腰痛伴隨相關感覺障礙(b2703對刺激物的敏感度，b1522關節(jié)活動度，b1608思維功能，特指把身體癥狀關聯(lián)到認知/設想方面的原因，b1528情感功能，特指把身體癥狀關聯(lián)到情感方面的原因)
慢性下腰痛伴隨相關的廣泛性疼痛。(b2800廣泛性疼痛，b1520情感適當性，b1602思想內(nèi)容)
本文主要講述的是急性亞急性下腰痛伴放射痛的診斷檢查以及干預
下腰痛伴隨放射痛：
腰椎間盤的髓核向后方移位，壓迫神經(jīng)根，導致腰部和下肢的疼痛。疼痛通常沿坐骨神經(jīng)放射，從臀部經(jīng)過大腿后方，向小腿和足部放射。疼痛可能會加重或緩解，取決于腰椎間盤突出的程度和位置。
急性1個月內(nèi)，亞急性1-3個月
在急性期與亞急性期通常會有一些不同的癥狀
急性下腰痛伴放射痛臨床癥狀：
伴有下肢放射痛的急性下腰痛
下肢可能出現(xiàn)感覺異常、麻木和無力
在腰椎活動度的初始到中段，下肢拉緊/直腿抬高/或slump試驗時可誘發(fā)或加重
可能出現(xiàn)神經(jīng)根受累的癥狀(感覺力量和反射減退)
亞急性下腰痛放射痛臨床癥狀：
亞急性、復發(fā)性的中背部或下腰部疼痛伴放射痛及隱匿性的下肢的感覺、力量或反射的減弱。
中度和重度下肢神經(jīng)壓迫、直腿抬高和/或slump 測試會導致癥狀的出現(xiàn)或加重
影像學：
對于有嚴重的或進行性的神經(jīng)功能缺損的患者，建議及時檢查 CT 與 MRI，因為治療延遲與不良預后相關。另外，如果病人可能行手術或硬膜外注射類固醇治療，MRI(或CT，如無法行 MRI)可能有幫助。在沒有這些檢查時，也沒有證據(jù)表明常規(guī)影像學檢查會影響治療決策或療效。
特殊檢查：
直腿抬高, 35°神經(jīng)拉緊
slump測試
是一種神經(jīng)張力測試，用于檢測改變的神經(jīng)動力學或神經(jīng)組織敏感性
slump測試
直腿抬高及slump測試時可誘發(fā)或加重下肢的根性癥狀
急性下腰痛伴有放射痛的身體功能結構損傷和癥狀同樣可在患有急性下腰痛伴有下肢放射痛（牽涉痛）的患者中出現(xiàn)，在亞急性期在中等范圍下，中背部，下背部，下腰部和背部相關放射痛或感覺異常會出現(xiàn)，在終末范圍運動時會加重，在測試時可能有下肢感覺，力量或反射的減弱伴隨神經(jīng)的異常。
干預
急性期：
手法治療
Ⅰ級證據(jù)脊柱推拿手法對于患者的有些癥狀起到了立竿見影的效果，癥狀持續(xù)時間低于16天，沒有膝關節(jié)以下的癥狀，防止功能障礙加重或者癥狀反復，平均接受10次能有限的減少情況惡化，且多半的可能獲得滿意的手法治療效果。
A級證據(jù)
物理治療師應使用推力或非推力關節(jié)松動來減輕急性腰痛患者的疼痛和殘疾。
B級證據(jù)
物理治療師可以使用按摩或軟組織松動來緩解急性腰痛患者的短期疼痛。
對于急性下腰痛和背部相關的臀或者腿部的疼痛和功能障礙，臨床醫(yī)師可考慮應用推拿手法減輕疼痛和功能障礙，手法治療推拿和松動術也可應用于急性亞急性慢性背部相關的下肢痛的患者上，促進脊柱和髖部的靈活性，減少疼痛和功能障礙
HVLA（高速低振幅）
中心化和定向練習
A級建議
應考慮在確定的方向使用重復運動、訓練及規(guī)程程序，以促進集中反應，改善靈活性，以減少急性下腰痛患者的癥狀與相關的下肢疼痛
麥肯基（McKenzie）療法相關文章：對90%腰痛有效的麥肯基療法
中心化以及邊緣化
牽引：
D級證據(jù)
是否有療效尚未可知，證據(jù)有相互矛盾的地方
有神經(jīng)根受壓的跡象，并伴有外周/末梢（神經(jīng)）癥狀或交叉直腿抬高試驗陽性的患者，它們將受益于俯臥位間歇性腰部牽引。
俯臥位牽引
下肢神經(jīng)松動術：
C級證據(jù)
對于亞急性和慢性下腰痛和放射痛的患者，使用下肢神經(jīng)松動術以減輕疼痛和功能障礙
下肢神經(jīng)松動術
運動訓練：
物理治療師可以使用運動訓練干預措施，包括加強軀干肌肉和耐力以及激活特定的軀干肌肉，以減輕伴有腿部疼痛的急性腰痛患者的疼痛和殘疾。
動態(tài)神經(jīng)肌肉穩(wěn)定
患者教育和咨詢：
B級證據(jù)
不應該利用相關的病人教育和輔導策略直接或間接地增加與下腰疼痛相關的威脅或恐懼感，教育和輔導策略諸如:
(1)提倡延長臥床休息???
(2)提供關于病人的下腰痛具體原因的深入病理解剖方面的解釋。???
下腰痛患者的教育和輔導策略，應強調(diào):
(1)促進了解人體脊柱的解剖/結構強度
(2)應用神經(jīng)系統(tǒng)科學解釋疼痛的感知
(3)下腰痛總體預后良好
(4)使用積極的心理應對策略減少恐懼和疼痛加劇
(5)即使正在經(jīng)歷痛苦，也要盡早恢復正?；蚵殬I(yè)活動(6)活動水平改善的重要性，而不只是疼痛緩解。
脊柱學校
在大多數(shù)情況下單一的治療對于腰痛的管理很難持久，短期緩解，長期療效甚微，脊柱學校對于客戶多方位管理腰痛提供了捷徑，了解它，才能掌控它。
我們是物理治療師，我們拒絕標準化“食譜”式的治療，每個患者情況都是不同的，對于康復的反應也是不同的，每位患者都是獨立的個體，任何康復計劃都應該以患者目標為中心。物理治療師是運動專家，我們會根據(jù)您的身體情況個性化定制診療方案。
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