研究背景與目的.有關退化性腰椎前位滑脫症之運動治療，屈曲與伸展等治療理論南轅北轍的兩大學派各有人推崇，至今尚無定論。究其原因，可發現雖然脊柱失穩卻是退化性腰椎前位滑脫症最具特色的臨床表徵，然而相關研究缺乏脊椎穩定度、或與穩度控制相關的動作分析、或專屬症狀評估等客觀療效分析。另外，近來放射影像學研究多顯示屈曲動作較易加重腰椎失穩，然而相關療效研究卻頗為支持屈曲運動對於腰椎前位滑脫患者之止痛效果卻是經過驗證的研究成果。因此，本研究目的在比較短期(一個月)與較長時期（三個月）的屈曲運動與伸展運動對退化性腰椎前位滑脫症患者於脊椎穩定度與相關客觀物理檢查之療效，期能藉此提出明確的運動建議。研究方法.本研究共收集29位退化性腰椎前位滑脫症(L4-5)患者，包括屈曲運動組10人、伸展運動組11人、與控制組8人，接受腰椎穩定度與相關物理檢查如：背痛狀態、背部功能、局部肌力、相關柔軟度、腰椎動作控制（活動度、速度）等後，各自進行三個月的居家運動治療或僅服用藥物。期間並於治療一個月時與治療三個月時進行療效評估。結果以克—瓦二氏單因子等級變異數分析法針對相關連續變數檢定不同評估時間點之組間差異。以弗里曼二因子等級變異數分析法檢測個別組內，於治療前後在相關連續變數方面的差異。而背痛型態等類別變數則以卡分檢定分別進行組間差異與組內治療前後之比較。結果.療效分析結果顯示，經短期治療後，屈曲組與伸展組在背部疼痛強度、背部功能、軀伸肌肌力、腰椎活動度與向前彎曲速度方面，均呈現顯著進步(p<0.05)，且療效持續到治療三個月時。而在下肢疼痛強度與腰椎從屈曲姿向後回復之動作速度方面，僅屈曲組於治療一個月後呈現顯著進步(p<0.05)，然而到三個月期滿治療結束時，伸展組已開始呈現顯著進步(p<0.05)，屈曲組卻未能維持其於一個月時之療效，反而退步。在背痛型態與髖伸肌肌力方面，運動組亦於治療三個月後開始呈現顯著進步(p<0.05)，而控制組則不然。在腰椎穩定度方面，經過三個月的治療，屈曲組呈現前位滑脫程度顯著加重的現象 (p<0.05)。就組間差異而言，於治療前各組間並無顯著差異，然而經過三個月後，運動組無論在背痛型態、背部疼痛強度、背部功能與局部肌力（髖伸肌、軀伸肌）方面均顯著優於控制組 (p<0.05)。最後，雖然屈曲組與伸展組間於療後之測量，彼此間均未呈現顯著差異，然而在三個月治療結束時，僅伸展組於下肢疼痛與腰椎向後回復之動作速度呈現顯著進步，而僅屈曲組呈現滑脫顯著加劇的現象。討論與結論.在經過三個月運動治療介入後，運動組在各項物理檢查方面之進步均顯著優於控制組。屈曲與伸展運動兩組間於療後相關物理檢查項目大體上未呈現顯著差異。然而放射學檢查結果卻顯示屈曲組有顯著前位滑脫程度顯著加重，腰椎穩定度降低的現象。另外，屈曲組於短期內即出現下肢疼痛顯著減輕與回復動作速度顯著加快的現象，然而其療效卻無法維持至三個月，反觀伸展組於短期內未能呈現下肢疼痛與回復動作速度方面的顯著進步，然而在治療三個月後卻開始展現明顯的治療效果。可見就短期治療而言，各運動組均可呈現局部肌力與活動度之改善且反映於背部症狀與功能方面之進步，其中尤以屈曲運動組較為明顯，也許與其涵蓋較多柔軟操有關。然而經過較長時間的治療後，局部穩定度之重要性逐漸呈現，因此，偏重穩定度訓練的伸展組逐漸顯現成效。反之，屈曲組於失穩相關症狀與腰部控制能力的表現開始不再看好。甚至於出現前位滑脫程度加重的現象。本研究是首次針對退化性腰椎滑脫症患者之運動療效，提出全方位測量與分析的研究。不但創先使用動作分析系統以分析背部控制能力，而且提出測量放射學檢查證據，實際檢測局部腰椎穩定度。由此力求客觀的療效分析結果期能提供實用與有效的臨床建議。

　　Background and Purpose. Conflicting reports existed concerning the efficacy of trunk flexion and extension exercise in patients with degenerative spondylolisthesis (DS), possibly due to lack of direct evidence on the improvement of lumbar stability and thoroughly objective evaluation for stability related performance. Contrary to the theoretical basis of flexion exercise, the results of functional radiography have further shown significantly larger anterior lumbar translation during trunk flexion in comparison with that during trunk extension in patient with DS The purpose of this study is to compare the effect of flexion with that of extension exercise on lumbar stability and stability related performance in patients with DS for providing better suggestions to effective intervention. Methods. Twenty-one subjects with L4-5 DS randomly assigned to attend flexion (Flex) or extension exercises (Ext) for 3 months. Another 8 subjects with L4-5 DS were recruited as control subjects. Outcome measurements including lumbar stability, pain, back function, flexibility, local muscle strength, and the ability of lumbar control were conducted prior treatment at 1 month (1M), and at 3 months (3M) afterwards. To compare the differences among different treatment groups, several Kruskal-Wallis one-way analysis of variance procedures were conducted for examining all continuous variables and Chi-square tests were conducted for examining all nominal variables. Friedman two-way analysis of variance procedures were used to examine treatment effects at different stages of assessment for each treatment group. Results. Significant improvements in back pain, back function, and muscle strength were found in exercise group but not in control group at 3 months after initial assessment, however no significant differences were found between Flex group and Ext group. However, Flex group was found to exhibit more degree of spondylolisthesis at L4-5 after 3M treatment in lateral radiographs. (p<0.05) In addition, while significant improvements in leg pain and the velocity of lumbar extension movement from forward bended position was soon found at 1M for Flex group (p<0.05).These effects did not last long enough to the end of treatment (3M). In contrast, Ext group showed gradually significant improvements in these aspects especially at the end of treatment (3M) (p<0.05). Discussion and Conclusion. Both Flex and Ext groups showed significantly more improvements than control group in pain, back function, muscle strength, and the ability of lumbar control after 3-month intervention. However, significantly more anterior spondylolisthesis was also found in Flex group after 3-month intervention. Although significant short-term effect on pain status and back function was soon found at 1-month after flexion intervention, extension intervention is the one to be recommended because of better lumbar stability shown in the long round(3M). Further study is needed to follow up the long-term effect of exercise intervention on lumbar stability.

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