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研究生： 林文寶
Lin, Wen-Paw
論文名稱： 腰椎失穩患者緩痛機制之研究 —椎節失穩之靜動態分析與臨床表徵之相關性探討
Pain Avoidance Mechanism in Patients with Lumbar Instability —The Relationship Between Clinical Features and Lumbar Motion
指導教授： 陳文玲
Chen, Wen-Ling
林瑞模
Lin, Ruey-Mo
學位類別： 碩士
Master
系所名稱： 醫學院 - 物理治療學系
Department of Physical Therapy
論文出版年： 2004
畢業學年度： 92
語文別： 中文
論文頁數： 132
中文關鍵詞： 脊椎活動代償機制 、動態分析 、屈曲—伸展影像檢查 、腰椎失穩
外文關鍵詞： Flexion-extension radiograph, motion analysis, Lumbar instability, compensatory mechanism of lumbar control
相關次數： 點閱：80  下載：3 
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    • 研究背景：腰椎失穩是引起下背痛之一大主因，然而目前腰椎失穩之臨床文獻多半著墨於主觀症狀描述。有關腰椎失穩之臨床表徵與其動作控制之相關性方面，至今鮮有報導且缺乏系統性探討。因此腰椎失穩極易被歸類於非特定型下背痛，導致鑑別診斷不易，治療方針難以擬定以致治療成效不彰。目的：利用三度空間超音波定位系統，分析腰椎失穩患者之動作型態，並與其臨床表徵進行比對。同時藉由軀屈曲—伸展影像檢查結果，推導腰椎失穩患者之緩痛機制。方法：本研究徵召70位誘發性腰椎前位滑脫或退化性腰椎前位滑脫患者進行軀屈曲—伸展影像檢查，並取得背痛病史、疼痛強度、及背部失能指數（Revised Oswestry Disability Index）等相關資料。另徵召其中有意願者35人進一步進行直腿抬舉測試以及動作分析，以探討腰椎失穩患者於軀屈曲－伸展過程之動作控制與其影響因子。結果：有關腰椎失穩患者之動作控制與臨床意義方面，伸展初期縮短或伸展末期延長者，其背部功能顯著較差。此外背部功能較差者，其腰薦活動比值顯著偏低（r=-0.41，p<0.05）。有關緩痛機制之探討，腰椎四五節間最大平移量與背部失能指數呈現顯著正相關（r=0.28，p<0.05），而發病時間越長者，腰椎四五節間最大平移量有顯著偏低的現象（p<0.01）。更有趣的是，上腰椎節之節間最大平移量彼此間呈現顯著正相關（L12之於L23，r=0.42，p<0.01），且下腰椎節之節間最大平移量彼此間亦呈現顯著正相關（L45之於L5S1，r=0.35，p<0.01），然而上腰椎與下腰椎之節間最大平移量卻呈現顯著負相關（L23之於L45，r=-0.27，p<0.05）。顯然上下腰椎間存在明顯代償關係，而此現象亦可從上腰椎節間最大平移量（L23）與腰部疼痛強度間之顯著負相關性（r=-0.41，p<0.05）得到佐證。另外，本研究分析誘發失穩傾向結果顯示，退化性前位滑脫患者之失穩傾向（Iit）顯著低於誘發性前位滑脫患者（t=-2.3，p<0.05），其局部椎節穩定度顯然高於誘發性前位滑脫患者，極可能是已進入重新穩定期。結論：本研究不但對腰椎失穩之動作控制提出量化描述，並藉以瞭解動作控制與臨床表徵之相關性。另外提供證據支持腰椎四五節間最大平移現象越明顯者，背部功能越差。下腰椎失穩程度大者，上腰椎平移量出現顯著代償性減少的趨勢。而發病時間越長之患者其腰椎四五節間最大平移量則反而呈現偏低現象。本研究不但藉此相關性分析推導出腰椎失穩之緩痛機制，更為坊間針對失穩椎節需處理鄰近低活動度椎節的治療理論提供明確的佐證。最後，本研究利用動作分析系統所提出之獨創參數（LPR），可以明確呈現患者之背部功能與膕旁肌柔軟度對動作控制能力之影響，而另一參數—誘發失穩傾向（Iit）則有利於早期偵測退化性前位滑脫現象。整體而言，本研究對於臨床上鑑別診斷之執行與治療方針之擬定應有相當程度之貢獻。

    Background：Lumbar instability was frequently cited as an important cause of low back pain. Previous studies mainly focused on the subjective description of clinical symptoms.Little information with respect to motion analysis or symptoms during movement was addressed. In addition, the relationship between clinical features and motor control strategies in lumbar instability has not been thoroughly explored. Lumbar instability was therefore classified as non-specific low back pain, leading to ambiguous diagnosis and inefficient treatment. Purpose：Ultrasound-based motion analysis system was used in patients lumbar instability to clarify their strategies of lumbar control and its relation toclinical features. In addition, dynamic flexion-extension radiography was used to analyze to illustrate the compensatory mechanism of lumbar motion. Method：70 patients diagnosed as induced spondylolisthesis or degenerative spondylolisthesis were recruited to undergo flexion-extension radiographs. The information with respect to the history ofback pain, pain intensity, and Revised Oswestry Disability Index (RODI) was also taken.Besides, 35 volunteers from these subjects were arranged to attend straight leg rasing (SLR) tests and motion analyisis during trunk forward bending. Result：In view of the relationship between lumbar control and clinical features, subjects with poorer motor function exhibited significantly shorter duration in early phase of extension movements,and significantly longer duration in late phase of extension movements. The lumbopelvic ratio (LPR) were also found to be significantly lower with increasing RODI (r=-0.41, p<0.05).Subjects with larger dynamic translation (DT) at L45 exhibited significantly more dysfunction.However, significantly lower DT at L45 was also found in patients with longer history of back pain. Most of all, while significantly positive correlation was found between adjacent intervetebral segments both for upper and lower lumbar spine (DT at L12versus L23, r=0.42, p<0.01; DT at L45 versus L5S1, r=0.35, p<0.01), significantly negative correlation was found between DT at upper lumbar and that at lower lumbar spine (DT atL23 versus L45,r=-0.27, p<0.05). The compensatory phenomenon was also supported by significantly negative correlation found between DT at L23 and the intensity of back pain(r=-0.41, p<0.05). Finally, the index of instability tendency (Iit), proposed in the presentstudy, was found to be significantly lower in patients with degenerative spondylolisthesis to compare with that in patients with induced spondylolisthesis (t=-2.3, p<0.05).Discussion and Conclusion：The results in present study not only proposed a quantitative system for evaluating the motor control strategies to patients with lumbar instability, butalso provided better understanding in the relationship between motor control and clinical features.Furthermore, patients with larger DT at L45 exhibited significantly poorer back function as well as significantly smaller DT at L23, clearly demonstrated a pain-avoidance phenomenon in presence of lumbar instability. The results also provided strong evidence to illustrate the compensatory mechanism found between upper lumbar and lower lumbar spine, and further supported the treatment concepts suggested in chiropractice to reduce excessive motion in compensated joints by correcting the underlying hypomobile segment. Finally, the present study proposed a new parameter, namely lumbopelvic ratio (LPR), that can be used to successfully reflect the effect of back dysfunction and limited SLR on theability of trunk control in patients with lumbar instability. In addition, Iit can be used to determine the tendency of instability facilitation so as to early detect degenerative spondylolisthesis.In aword, current study has shown its clinical significance in assisting differential diagnosis for degenerative spondylolisthesis and clarifying the related clinicalcharacteristics. Side evidence was also provided for proving compensatory mechanism ofspinal control that can be used in the applications of treating spinal instability

    目錄 中文摘要 ------------------------------------------------ 5 英文摘要 ------------------------------------------------ 7 誌謝 ------------------------------------------------ 10 目錄 ------------------------------------------------ 11 表目錄 ------------------------------------------------ 17 圖目錄 ------------------------------------------------ 18 第一章 緒論 前言 ------------------------------------------------ 20 1.1 研究背景與文獻回顧 --------------------------------- 24 1.1.1 腰椎失穩特徵與臨床症狀 1.1.1.1 腰椎失穩之定義 ---------------------------- 24 1.1.1.2 腰椎失穩臨床症狀之表現 -------------------- 25 1.1.2 腰椎失穩發展之過程 --------------------------- 26 1.1.2.1 腰椎失穩形成之原因 ------------------------- 26 1.1.2.2 退化性腰椎前位滑脫之自然發展史 ------------- 30 1.1.3 腰椎失穩之臨床診斷 1.1.3.1 屈曲—伸展放射學檢查 --------------------- 32 1.1.3.2 腰椎失穩之代償機制 ----------------------- 34 1.1.4 軀幹動作分析 --------------------------------- 37 1.1.4.1 超音波定位動作分析系統 -------------------- 37 1.1.4.2 下背痛患者之軀幹動作特色 -------------------- 39 1.1.4.3 腰椎失穩患者之軀幹動作特色 ------------------- 40 1.1.4.4 膕旁肌柔軟度對軀幹動作之影響 ----------------- 42 1.1.5 文獻整合 ------------------------------------ 43 1.2 研究動機 ---------------------------------------- 45 1.3 研究目的 ---------------------------------------- 46 1.4 研究假設 ---------------------------------------- 46 第二章 研究方法 2.1 研究對象 ---------------------------------------- 47 2.2 實驗設備 ---------------------------------------- 47 2.3 測量項目 ---------------------------------------- 49 2.3.1 疼痛狀態評估 -------------------------------- 49 2.3.2 背部功能評估 -------------------------------- 50 2.3.3 靜態腰椎穩定度評估 ------------------------------ 51 2.3.3.1 靜態影像之椎節間滑脫量計算 ---------------- 52 2.3.3.2 F-E影像檢查之椎節間最大前後平移量計算 ------ 53 2.3.3.3 腰椎Cobb’s角度之計算 ----------------------- 54 2.3.4 直腿抬舉測試 -------------------------------- 54 2.3.5 腰椎動作分析 -------------------------------- 56 2.4 實驗步驟與流程 ---------------------------------- 58 2.5 資料處理與分析 2.5.1 誘發性前位滑脫與退化性前位滑脫受試者於F-E影像之分析 59 2.5.1.1 椎節間最大前後平移量 --------------------- 59 2.5.1.2 誘發失穩傾向 -------------------------- 59 2.5.2 軀屈曲—伸展動作時期之分析 2.5.2.1 屈曲—伸展動作時期之定義 ----------------- 60 2.5.2.2 背部功能對屈曲—伸展動作控制之影響 ------- 61 2.5.3 腰薦椎活動型態—腰薦活動比值之分析 ---------- 63 2.5.4 屈曲—伸展動作之活動度與速度分析 2.5.4.1 腰椎最大屈曲角度 ---------------------- 64 2.5.4.2 腰椎屈曲平均速度 ---------------------- 65 2.5.5 誘發性與退化性前位滑脫受試者於腰椎動作之比較 - 66 2.6 統計分析 ---------------------------------------- 66 2.7 超音波感應分析系統之信效度分析 ---------------------- 68 2.7.1 系統之準確度 -------------------------------- 68 2.7.2 系統信度之分析 ------------------------------- 70 2.7.3 皮膚動作干擾於脊椎動作分析之誤差值檢定 ------- 70 2.7.3.1 腰薦椎交角變化 -------------------------- 71 2.7.3.2 腰薦椎水平平移量變化 -------------------- 72 第三章 結果 3.1 受試者基本資料 ---------------------------------- 77 3.2 軀屈曲—伸展放射學檢查檢果 3.2.1 椎節穩定度與臨床症狀之相關性 ---------------- 78 3.2.2 腰薦動作節律之靜態指標 ------------------- 79 3.2.3 腰椎穩定度於發病時間長短之趨勢 ------------- 80 3.2.4 誘發性前位滑脫與退化性前位滑脫患者於腰椎屈曲—伸展 放射檢查之比較 -------------------------- 82 3.2.4.1 最大前後平移量之比較 ------------------- 82 3.2.4.2 誘發失穩傾向之比較 ------------------- 82 3.3 腰椎動作分析 3.3.1 受試者基本資料 ---------------------------- 83 3.3.2 軀屈曲—伸展動作之基本參數分析 ------------- 84 3.3.3 軀屈曲—伸展動作控制之相關因子 ------------- 85 3.3.4 背部功能對軀屈曲—伸展動作控制之影響 -------- 86 3.3.5 腰薦動作節律之動態指標 3.3.5.1 正常腰薦活動節律與薦椎活動比值 -------- 87 3.3.5.2 異常腰薦活動節律與薦椎活動比值 -------- 88 3.3.5.3 影響腰薦活動比值之因子 ---------------- 90 3.3.6 誘發性前位滑脫與退化性前位滑脫受試者於腰椎動作分析 之比較 ---------------- 91 第四章 討論 4.1 腰椎靜態穩定度之緩痛機制 ------------------------ 93 4.1.1 腰椎穩定度與臨床症狀之相關性 ----------------- 94 4.1.2 腰椎穩定度於發病時間長短之趨勢 ----------- 95 4.1.3 上腰椎與下腰椎間之代償機制 ----------------- 96 4.1.4 誘發性前位滑脫與退化性前位滑脫之鑑別—放射影像檢查之 探討 ------------------------- 99 4.1.4.1 最大前後平移量之比較 ------------------- 99 4.1.4.2 誘發失穩傾向之比較 ------------------ 100 4.2 臨床表徵與腰椎動作分析之相關性 ------------------- 101 4.2.1 腰椎失穩之動作控制—屈曲伸展動作時期之探討 4.2.1.1 腰薦動作節律 -------------------------- 102 4.2.1.2 腰椎失穩之屈曲—伸展動作分期 --------- 103 4.2.1.3 影響屈曲—伸展動作時期期間長短之因素 --- 104 4.2.2 腰椎失穩之動作控制—於腰薦活動比值之探討 4.2.2.1 腰椎失穩之姿位控制 ----------------- 105 4.2.2.2 影響腰薦活動比值之因素 ----------------- 106 4.2.3 誘發性前位滑脫與退化性前位滑脫之鑑別—動作相關參數 之探討 ---------------------- 107 4.2.3.1 最大活動度與動作平均速度 ------------------- 108 4.2.3.2 膕旁肌柔軟度 -------------------------- 109 4.2.3.3腰薦活動比值 --------------------------- 109 4.3 研究限制與未來研究方向 -------------------------- 111 4.4 臨床應用與貢獻 -------------------------------------- 112 第五章 討論 --------------------------------------- 113 參考文獻 --------------------------------------- 114 自述 --------------------------------------- 132

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