臺灣博碩士論文加值系統

　　實驗背景及目的 鬆動合併動作是由一位紐西蘭物理治療師Brian Mulligan所發展的治療手法，在肩關節，鬆動合併動作的手法常使用於治療喙凸下夾擠症候群、冰凍肩及旋轉袖肌腱炎、、、等等的病人，在治療夾擠症候群病人方面，其手法是由治療師施予肱骨頭一向後的鬆動術，並請病人做主動手臂抬起的動作，雖然鬆動合併動作的手法在臨床骨科物理治療上已常被使用，卻仍缺乏科學證據來支持它的效果。因此本篇研究即在於分析屍體肩關節樣本在外展動作及鬆動合併動作時，肱骨頭中心的移動情形。實驗方法 在外展及鬆動合併動作程序方面，十位有三年以上骨科物理治療經驗的治療師參與本實驗，他們在肩關節樣本上施行被動外展及鬆動合併動作的手法，本實驗量測施行動作時所施之力量、力矩、關節角度及肱骨頭中心的移動。運動學的資料由VICON 370動作分析系統來擷取，力量及力矩則由AMTI六軸分力儀來量測，至於計算關節轉動中心的方法，則依照Gamage及Lasenby所發展的最小平方法 (least squares method)。在外展及鬆動合併動作程序前後，我們用MTS系統來量測屍體樣本之活動度，包括向後滑動量、向前滑動量、向下滑動量、轉動角度及外展角度，藉由MTS的程序可知道樣本活動度，在外展及鬆動合併動作前後是否改變。資料分析方面，我們比較做外展動作及鬆動合併動作手法時，肱骨頭中心移動之情形，主要針對空間及時間因素：在空間因素，即分析兩者產生肱骨頭中心移動之最大值；時間因素，即分析兩者在肱骨頭中心產生最大移動時之外展角度。本研究使用Wilcoxon signed ranks test來檢定，顯著差異定在0.05，我們使用SPSS 11.0來做統計分析。結果 在做被動外展動作時，肱骨頭中心移動量不大；而在做鬆動合併動作時，相較於外展動作，肱骨頭中心則顯著地在往下、往後及往外移動分別增加7.7 毫米，2.7毫米及0.5毫米。結論 於肩關節施予鬆動合併動作手法，能有效地避免夾擠症候群病人，其肱骨頭過度往上、往前的滑動情形。

　　Background and Purpose. “Mobilization with Movement” (MWM) is a therapeutic technique developed by Brian Mulligan, a New Zealand physiotherapist. In shoulder joints, MWM techniques are commonly performed in patients with subacromial impingement syndrome, frozen shoulder, rotator cuff tendinitis, etc. In treating patients with impingement syndrome, this technique involves the application of a posteriorly directed force by a physical therapist to generate posterior translation of humeral head while the patient is actively elevating his/her arm. Even though MWM technique has became a popular treatment technique in orthopedic practice, there is a lack of scientific evidence to support its efficacy and the underlying mechanisms. The purpose of this study was to analyze the displacement of humeral head center during glenohumeral abduction and the MWM trials. Methods. Ten physical therapists were recruited in this study. They performed passive abduction and the MWM technique on a fresh cadaveric shoulder model. Outcome measures were the applied forces, torques, joint angles, and displacement of the head of the humerus. Kinematical data were collected by VICON motion analysis system; forces and torques were measured by an AMTI 6-axis load cell. We calculated the joint center of rotation by means of the least squares method developed by Gamage and Lasenby. Before and after abduction and MWM procedures, a biaxial material testing system (MTS: 858 MINI Bionix) equipped with an x-y table was used to measure the magnitudes of anterior-posterior gliding, posterior-anterior gliding, inferior gliding, rotation angles and abduction angles of the specimen. We compared spatial and temporal parameters between abduction and the MWM technique. These parameters included the magnitudes of peak linear angular displacements, and temporal parameters were the time and the angle of abduction where peak displacements occurred in abduction trial and MWM trial. The Wilcoxon signed ranks test was used for statistical analysis with an α level of 0.05. Results. In the abduction trial, the humeral head was centered at glenoid fossa with only slight translations (usually less than 0.6 mm). Comparing with abduction trial, there were significant increased in displacements of humeral head posteriorly (7.7 mm), inferiorly (2.7 mm), and laterally (0.5 mm) during MWM trial. Conclusion. The MWM technique can effectively prevent the humeral head from anterior and superior translation.

ABSTRACT --------------------------------------------------------------------I
中文摘要 --------------------------------------------------------------------III
致謝 --------------------------------------------------------------------V
CONTENTS --------------------------------------------------------------------VI
FIGURE LIST -----------------------------------------------------------------IX
TABLE LIST ------------------------------------------------------------------XI
APPENDIX LIST ---------------------------------------------------------------XII

CHAPTER 1 INTRODUCTION 1
1.1 Introduction -------------------------------------------------------------1
1.2 Literature Review --------------------------------------------------------2
1.2.1 Clinical Effect of “Mobilization with Movement” Technique -----------2
1.2.2 Clinical Features and Etiology of Subacromial Impingement Syndrome ----4
1.2.3 Kinematical Features of Glenohumeral Joint ----------------------------5
1.2.3.1 Normal Glenohumeral Joint -------------------------------------------5
1.2.3.2 Kinematics of Subacromial Impingement Syndrome ----------------------6
1.2.4 Method for Estimating the Center of Humeral Head ----------------------8
1.2.5 Purpose -----------------------------------------------------------------10

CHAPTER 2 MATERIALS AND METHOD 12
2.1 Subjects ------------------------------------------------------------------12
2.2 Specimen ------------------------------------------------------------------12
2.3 Instrumentation -----------------------------------------------------------14
2.4 Method of Measuring Rotational Center -------------------------------------17
2.4.1 Derivation of the Coordinate of the Center of the Humeral Head --------18
2.4.2 Accuracy --------------------------------------------------------------21
2.5 Experimental procedures ------------------ --------------------------------22
2.5.1 MTS testing procedures------------- -----------------------------------22
2.5.2 Abduction and MWM procedures-------------------------------------------24
2.6 Data analysis -------------------------------------------------------------26
2.6.1 Data Collected from Abduction and MWM Procedures ----------------------26
2.6.2 Data Collected from MTS Procedures -------------- ---------------------28

CHAPTER 3 RESULTS 30
3.1 Accuracy and Reliability --------------------------------------------------30
3.1.1 Estimation of The Center of Head of Humerus ---------------------------30
3.1.2 Variability -----------------------------------------------------------31
3.2 Joint Angles --------------------------------------------------------------32
3.3 Applied Forces ------------------------------------------------------------36
3.4 Translation of Center of Humeral Head ------------------------------------38
3.5 The MTS Data --------------------------------------------------------------44

CHAPTER 4 DISCUSSION 45
4.1 Intrasession Reliability and Intersession Reliability ---------------------45
4.2 The Patterns of Humeral Head Center Displacement --------------------------45
4.2.1 Comparison with Previous Studies in vitro -----------------------------46
4.2.2 Comparison with Previous Studies in vivo ------------------------------47
4.2.3 Possible Causes Influencing the Displacement of Humeral Head Center ---49
4.2.3.1 The Forces Applied to Rotator Cuff Tendons ------------------------48
4.2.3.2 Flexion and External Rotation Angles ------------------------------50
4.3 The Mobility Data Measured from MTS Procedures ---------------------------51
4.4 Study limitations ---------------------------------------------------------51

CHAPTER 5 CONCLUSION 54

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