今日の臨床サポート

跛行

著者: 芳賀信彦 東京大学 リハビリテーション科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2020/06/10
参考ガイドライン:
  1. 日本整形外科学会・日本脊椎脊髄病学会(https://minds.jcqhc.or.jp/n/med/4/med0102/G0000369/0001):腰部脊柱管狭窄症診療ガイドライン 2011
  1. 日本整形外科学会・日本股関節学会(https://minds.jcqhc.or.jp/n/med/4/med0063/G0000859):変形性股関節症診療ガイドライン2016(改訂第2版)
  1. 日本循環器学会・他(https://j-circ.or.jp/old/guideline/pdf/JCS2015_miyata_d.pdf):末梢閉塞性動脈疾患の治療ガイドライン(2015年改訂版)
患者向け説明資料

概要・推奨   

  1. 異なる病態の多くの疾患が跛行の原因となり得る。
  1. 歩行の観察から原因となる疾患を想定し、適切な検査を行う。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
芳賀信彦 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

改訂のポイント:
  1. 関係するガイドラインに基づき、記載を追加した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 跛行とは歩行、歩容の異常であり、「異常歩行」、「歩容異常」との区別は明確でなく、原因や病態も多岐にわたる。
  1. 間欠性跛行は、歩行距離とともに下肢に脱力や疼痛が生じ、休息により回復するもので、腰部脊柱管狭窄症や末梢動脈疾患により生じる。
  1. 軟性墜落性跛行は、股関節外転筋の筋力低下により骨盤の傾斜を生じるもので、変形性股関節症などにより生じる。
  1. 硬性墜落性跛行は、下肢長差による異常歩行で、下肢長差の原因はさまざまである。
  1. 以上のほかに、片側下肢に痛みがある場合の疼痛回避歩行、足関節背屈筋力低下による鶏歩、中枢神経の異常による痙性歩行、失調性歩行などを跛行に含めることがある。
 
  1. 間欠性跛行を示す疾患の有病率
  1. 日本における腰部脊柱管狭窄症の有病率は、60歳以上の成人で12.5%である[1]
  1. 日本における末梢動脈疾患の有病率は、40歳以上の成人で1.71%である[2]
 
  1. 変形性股関節症の有病率
  1. 日本における変形性股関節症の有病率は、60~79歳の女性で2%である[3]
 
跛行の原因の鑑別方法:
  1. 軟性墜落性跛行:片側での立脚相に反対側の骨盤が下降する。股関節の外転筋力が低下している。
  1. 硬性墜落性跛行:片側での立脚相に反対側の骨盤が下降する。反対側の下肢長が短い。
  1. 疼痛回避歩行:痛みのある側の立脚相の時間が反対側に比べて短い。
  1. 足関節背屈筋力低下:患側の遊脚相で股関節・膝関節の屈曲角度が大きく、足部が下垂する。
  1. 中枢神経の異常による痙性歩行:股関節が伸展し、足部は内反尖足を示す。
  1. 失調性歩行:左右の足を広く開いて歩き、足を高く上げて強く床にたたきつけるように歩く。
問診・診察のポイント  
 
  1. 下肢や体幹の疾患の既往を問診する。それら以外にも、高血圧、糖尿病など動脈硬化と関連した疾患、中枢神経系の疾患の既往も確認する。下肢の痙縮や失調を示す疾患のなかには遺伝性の疾患も含まれるため、家族歴の聴取も必要である。

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文献 

著者: Hachiro Ohnishi, Yasunori Sawayama, Norihiro Furusyo, Shinji Maeda, Shoji Tokunaga, Jun Hayashi
雑誌名: J Atheroscler Thromb. 2010 Jul 30;17(7):751-8. Epub 2010 Jun 2.
Abstract/Text AIM: Peripheral arterial disease (PAD) is associated with cerebrovascular disease, ischemic heart disease, and other cardiovascular disease. We investigated the prevalence of and factors related to PAD to clarify the relationship between PAD and carotid atherosclerosis in a cross-sectional population-based study.
METHODS: The study included 2,402 (900 males and 1,502 females; mean+/-SD=64.9+/-10.9 years) of 3,862 residents of two Japanese rural areas who reported for a free health examination in 2005 or 2006. An ankle brachial index value < or =0.9 was considered to be PAD. The carotid artery intima-media thickness (CA-IMT) was measured by carotid ultrasound.
RESULTS: The prevalence of PAD was 1.71% (n=41) of all participants. The risk factors independently associated with a significantly higher risk of PAD, identified by multivariate analysis, are as follows: For males, age, dyslipidemia, and CA-IMT, and for females, age, waist circumference, and dyslipidemia.
CONCLUSION: The prevalence of PAD in Japan was confirmed to be lower than that of similar studies performed in other countries. PAD was strongly correlated with age and dyslipidemia in both sexes, carotid atherosclerosis in males, and abdominal fat in females.

PMID 20523009  J Atheroscler Thromb. 2010 Jul 30;17(7):751-8. Epub 201・・・
著者: N Yoshimura, L Campbell, T Hashimoto, H Kinoshita, T Okayasu, C Wilman, D Coggon, P Croft, C Cooper
雑誌名: Br J Rheumatol. 1998 Nov;37(11):1193-7.
Abstract/Text OBJECTIVE: Geographic differences in the prevalence of hip osteoarthritis (OA) have been ascribed to differences in the frequency of acetabular dysplasia among different ethnic groups. However, there are few data on the shape of the acetabulum in various populations around the world. We examined this issue in samples of pelvic radiographs from Britain and Japan.
METHODS: Measurements were made on the pelvic radiographs of 1303 men and 195 women, aged 60-75 yr, who attended for i.v. urography in two British centres. These were compared with 99 men and 99 women aged 60-79 yr who were included in a population-based study in a rural community in Japan, and who agreed to undergo standardized pelvic radiography. Acetabular dysplasia was assessed by morphometric measurement of the centre-edge (CE) angle and acetabular depth.
RESULTS: The mean CE angle among men was 36 degrees (95% CI 35-37 degrees ) in Britain and 31 degrees (95% CI 29-32 degrees ) in Japan; that in women was 37 degrees (95%, CI 36-38 degrees ) in Britain and 31 degrees (95% CI 29 33 degrees ) in Japan. The mean values of acetabular depth were also significantly (P < 0.001) lower in Japan than in Britain. However, the prevalence of hip OA was lower in Japan (0% in men, 2% in women) than in Britain ( 11% in men, 4.8 / in women). In a random effects model, there were negative relationships between measures of acetabular dysplasia and minimum joint space among individuals.
CONCLUSIONS: We conclude that there are marked differences in pelvic morphometry between Britain and Japan. The acetabular dimensions of Japanese subjects are considerably shallower than those of their British counterparts of similar age and sex. Nevertheless, hip OA is more frequent in Britain than in Japan. Further studies are required on the risk factors for hip OA in Oriental populations, in order that the aetiology of this disorder can be better understood.

PMID 9851268  Br J Rheumatol. 1998 Nov;37(11):1193-7.
著者: De Q H Tran, Silvia Duong, Roderick J Finlayson
雑誌名: Can J Anaesth. 2010 Jul;57(7):694-703. doi: 10.1007/s12630-010-9315-3. Epub 2010 Apr 29.
Abstract/Text PURPOSE: The purpose of this brief narrative review is to summarize the evidence derived from randomized controlled trials pertaining to the nonsurgical treatment of lumbar spinal stenosis (LSS).
SOURCE: The MEDLINE (January 1950 to the fourth week of January 2010) and EMBASE (January 1980 to 2009, week 53) databases, the MESH term "spinal stenosis", and the key words, "vertebral canal stenosis" and "neurogenic claudication", were searched. Results were limited to randomized controlled trials (RCTs) conducted on human subjects, written in English, and published in peer-reviewed journals. Only RCTs pertaining to nonsurgical treatment were considered. Studies comparing conservative and surgical management or different surgical techniques were not included in the review.
PRINCIPAL FINDINGS: The search criteria yielded 13 RCTs. The average enrolment was 54 subjects per study. Blinded assessment and sample size justification were provided in 85% and 39% of RCTs, respectively. The available evidence suggests that parenteral calcitonin, but not intranasal calcitonin, can transiently decrease pain in patients with LSS. In the setting of epidural blocks, local anesthetics can improve pain and function, but the benefits seem short-lived. The available evidence does not support the addition of steroids to local anesthetic agents. Based on the limited evidence, passive physical therapy seems to provide minimal benefits in LSS. The optimal regimen for active physiotherapy remains unknown. Although benefits have been reported with gabapentin, limaprost, methylcobalamin, and epidural adhesiolysis, further trials are required to validate these findings.
CONCLUSIONS: Because of their variable quality, published RCTs can provide only limited evidence to formulate recommendations pertaining to the nonsurgical treatment of LSS. In this narrative review, no study was excluded based on factors such as sample size justification, statistical power, blinding, definition of intervention allocation, or clinical outcomes. This aspect may represent a limitation as it may serve to overemphasize evidence derived from "weaker" trials. Further well-designed RCTs are warranted.

PMID 20428988  Can J Anaesth. 2010 Jul;57(7):694-703. doi: 10.1007/s12・・・
著者: Roberto A Mangiafico, Carmelo E Fiore
雑誌名: Curr Vasc Pharmacol. 2009 Jul;7(3):394-413.
Abstract/Text Lower extremity peripheral arterial disease (PAD) is a manifestation of atherosclerosis, with a prevalence ranging from 4% to 12% in the adult population and increasing up to 20% in older individuals. Intermittent claudication (IC) may markedly impair walking ability, overall functional status and quality of life. PAD is a marker of systemic atherosclerosis and is associated with increased cardiovascular morbidity and mortality. However, leg disease usually runs a rather benign course in claudicant patients, with only about 1% to 3% of them ever requiring a major amputation over a 5-year period. The goals of treatment for claudication are to relieve exertional symptoms, and improve walking capacity and quality of life. Therapeutic strategies aimed at reducing systemic cardiovascular risk burden and prolonging survival, including intensive risk factor modification and antiplatelet therapy, should be implemented in all patients with PAD. Supervised exercise training has proven the most effective conservative treatment for symptomatic relief of IC. Current evidence for drug therapy of IC supports the use of cilostazol as a first-line drug. Other drugs with more limited evidence of benefit for claudication include pentoxifylline and naftidrofuryl. Endovascular or surgical revascularization is indicated for selected patients with vocation- or lifestyle-limiting claudication who are unresponsive to exercise and pharmacotherapy. New drug candidates for managing claudication symptoms include propionyl-L-carnitine and statins. Preliminary studies suggest that therapeutic angiogenesis holds promise for future treatment of IC.

PMID 19601864  Curr Vasc Pharmacol. 2009 Jul;7(3):394-413.
著者: Inge H F Reininga, Martin Stevens, Robert Wagenmakers, Sjoerd K Bulstra, Johan W Groothoff, Wiebren Zijlstra
雑誌名: J Neuroeng Rehabil. 2012 Jan 20;9:3. doi: 10.1186/1743-0003-9-3. Epub 2012 Jan 20.
Abstract/Text BACKGROUND: Compensatory trunk movements during gait, such as a Duchenne limp, are observed frequently in subjects with osteoarthritis of the hip, yet angular trunk movements are seldom included in clinical gait assessments. Hence, the objective of this study was to quantify compensatory trunk movements during gait in subjects with hip osteoarthritis, outside a gait laboratory, using a body-fixed-sensor based gait analysis. Frontal plane angular movements of the pelvis and thorax and spatiotemporal parameters of persons who showed a Duchenne limp during gait were compared to healthy subjects and persons without a Duchenne limp.
METHODS: A Body-fixed-sensor based gait analysis approach was used. Two body-fixed sensors were positioned at the dorsal side of the pelvis and on the upper thorax. Peak-to-peak frontal plane range of motion (ROM) and spatiotemporal parameters (walking speed, step length and cadence) of persons with a Duchenne limp during gait were compared to healthy subjects and persons without a Duchenne limp. Participants were instructed to walk at a self-selected low, preferred and high speed along a hospital corridor. Generalized estimating equations (GEE) analyses were used to assess group differences between persons with a Duchenne limp, without a Duchenne limp and healthy subjects.
RESULTS: Persons with a Duchenne limp showed a significantly larger thoracic ROM during walking compared to healthy subjects and to persons without a Duchenne limp. In both groups of persons with hip osteoarthritis, pelvic ROM was lower than in healthy subjects. This difference however only reached significance in persons without a Duchenne limp. The ratio of thoracic ROM relative to pelvic ROM revealed distinct differences in trunk movement patterns. Persons with hip osteoarthritis walked at a significantly lower speed compared to healthy subjects. No differences in step length and cadence were found between patients and healthy subjects, after correction for differences in walking speed.
CONCLUSIONS: Distinctive patterns of frontal plane angular trunk movements during gait could be objectively quantified in healthy subjects and in persons with hip osteoarthritis using a body-fixed-sensor based gait analysis approach. Therefore, frontal plane angular trunk movements should be included in clinical gait assessments of persons with hip osteoarthritis.

PMID 22264234  J Neuroeng Rehabil. 2012 Jan 20;9:3. doi: 10.1186/1743-・・・

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