臺灣博碩士論文加值系統

背景：彈性扁平足的生物力學作用易在跑步及高度重複性的活動中造成顯著的肌肉骨骼系統傷害。文獻指出增加後足旋前角度會伴隨下肢內轉、骨盆前傾角度增加，而動態過程中可能伴隨著過度膝外翻、髖內收以及骨盆不穩定等連動關係。如此不正常的骨骼排列造成功能性動作中從足部到脊椎的力量傳遞不良，而長期累積的壓力造成下肢傷害如髕骨疼痛症候群、脛骨疼痛、足底筋膜炎以及下背痛的產生，但現今仍無實驗證據指出扁平足患者在功能性動作中是否有這樣的連動關係。另外為了抵制扁平足的不正常排列，重新建立足部到脊椎的動力鏈控制維持關節間的穩定，將其整合至日常生活活動中是非常重要的。然而，尚無研究探討神經肌肉控制運動對於下肢的動力鏈控制以及症狀改善的效果，特別是對於彈性扁平足跑者。目的：本篇探討彈性扁平足跑者下肢生物力學特性，檢視神經肌肉訓練對彈性扁平足合併下肢疼痛跑者的效益。方法：本研究的第一部分是橫斷式探索性研究設計。實驗組徵招20位有跑步相關的下肢疼痛的彈性扁平足跑者以及15位年齡、性別、身體質量指數相符的正常足弓健康跑者做為對照組。在基本身體特徵檢查後，使用動作分析系統以及表面肌電圖偵測受測者在步態過程以及單腳蹲下肢的運動學以及肌肉的活性狀況。本實驗的第二個部分是單組前後測的類實驗型設計。彈性扁平足跑者共17人接受6週的神經肌肉訓練，在介入前、後除了以動作分析系統以及表面肌電圖偵測受測者在步態過程以及單腳蹲下肢的運動學以及肌肉的活性狀況外，並使用視覺疼痛類比量表評估跑步時下肢疼痛的分數，以及下肢功能量表評估失能改善情形。結果：研究第一部份顯示，兩組在平地行走及單腳蹲的下肢運動學無顯著差異，在肌肉活性上，有症狀的彈性扁平足跑者的脛前肌與股二頭肌分別在平地行走與單腳蹲的動作中活性顯著較高 (5%, p<.05; 4.73%, p<.05)，而腓骨長肌在平地行走時則顯著較低 (6.24%, p<.05)。研究第二部分顯示，彈性扁平足跑者在經過六周訓練後疼痛顯著下降 (3.29%, p<.005)，下肢功能量表分數顯著上升 (3.6%, p<.005)。在運動學方面，訓練後單腳下蹲的髖內收角度顯著下降 (2.14°, p<.005)，而肌肉活性方面，脛前肌在平地行走時的活性顯著下降 (4.17%, p<.005)，而在單腳下蹲時顯著上升 (8.74%, p<.005)。結論：彈性扁平足跑者與正常足弓的跑者在足踝與膝關節的肌肉控制情形不相同；神經肌肉訓練可增進彈性扁平足跑者的關節控制能力並改善相關的疼痛及失能情形。
關鍵字：彈性扁平足、下肢運動學、下肢肌電圖學、神經動作訓練

Background and Purpose: Biomechanical stresses in subjects with flexible flatfoot (FFF) during running and other loaded activities with high repetition easily cause significant injuries to the musculoskeletal system. Literature reflects that excessive rearfoot pronation would cause increased lower extremity internal rotation and pelvic anterior tilt, and also lead to excessive knee valgus, hip adduction, pelvic instability in dynamic movements. These abnormal skeletal malalignment causes poor force transfer between the foot and spine in functional movements and accumulated tissue stresses in the lower extremity and lumbar region over time leading to the development of lower extremity injuries such as patellofemoral pain syndrome, shin splints, plantar fasciitis and low back pain. Till now, there have been no empirical evidence focusing on the lower extremity chain reaction in functional movements. To offset the malalignment associated with FFF it is important to reestablish the kinetic control and maintain joint stability from the foot to spine and integrate them into functional activities of daily living. However, no studies have investigated the effects of neuromuscular control exercise on lower extremity kinetic control and symptom improvement; especially in runners with FFF.
Purposes: 1) To investigate the biomechanical characteristics between runners with and without FFF and 2) To examine whether neuromuscular training from the foot to spine is beneficial in runners with FFF and lower extremity or low back pain.
Methods: The first part of this study was a cross sectional, matched-control design. We recruited twenty runners with FFF and associated lower extremity or low back pain, and fifteen age, gender, and BMI matched healthy subjects with normal foot type as the comparison group. After the baseline assessment of physical characteristics, the subjects were tested with a motion capture system and surface electromyography to collect kinematic and muscle activation data of the lower extremity during level walking and single leg squatting. The second part of this study was a one group pretest-posttest quasi-experimental design. 17 Subjects with FFF and running related lower extremity pain in the first part of study received neuromuscular training from the foot to spine. Outcome was evaluated by visual analog scale (VAS) for pain and lower extremity functional scale (LEFS), as well as kinematic and electromyography changes after 6 weeks of training.
Results: There was no significant difference on the kinematics data, but muscle activation of tibialis anterior and biceps femoris was significantly higher during both functional tasks (5%, p<.05; 4.73%, p<.05), and activation of peroneus longus was lower (6.24%, p<.05) during level walking in symptomatic runners with FFF. After 6-week neuromuscular training, runners with FFF showed significantly smaller hip adduction (2.14°, p<.005) and trend of decreased hip internal rotation during single leg squatting. In muscle activity, tibialis anterior were lower during level walking (4.17%, p<.005) and higher during single leg squatting (8.74%, p<.005). These subjects also reported decreased pain (3.29%, p<.005) and increased lower extremity function (3.6%, p<.005) after 6-week training. Conclusion: Knee and ankle muscle activity were different between symptomatic runners with FFF and healthy runners with normal arch. Neuromuscular training can change lower extremity motor control and improve pain and dysfunction in runners with FFF.
Keywords: flexible flatfoot, lower extremity kinematics, lower extremity electromyography, neuromuscular training

謝誌 I
摘要 II
ABSTRACT IV
目錄 VII
表目錄 X
圖目錄 XII
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 2
第三節 研究假設 3
第四節 重要性 3
第五節 操作性名詞定義 4
第二章 文獻回顧 5
第一節 跑步與下肢傷害 5
第二節 扁平足的生物力學 6
第三節 彈性扁平足合併下肢肌骨病症的治療 12
第四節 總結 15
第三章 研究方法 16
第一節 研究設計與研究架構 16
第二節 研究材料與研究方法 16
第三節 資料處理與分析方法 24
第四節 前驅實驗 27
第四章 結果 29
第一節 受試者基本資料 29
第二節 比較足弓正常跑者與扁平足跑者下肢運動學分析 30
第三節 比較足弓正常與扁平足跑者下肢肌肉活性分析 34
第四節 扁平足跑者在神經肌肉運動訓練後運動學及肌肉活性的改變 35
第五節 扁平足跑者在六周神經肌肉運動訓練後疼痛及功能改善情形 36
第五章 討論 37
第一節 受試者特性 37
第二節 下肢運動學 38
第三節 下肢肌肉活性 39
第四節 神經肌肉訓練後運動學及肌肉活性的改變 41
第五節 訓練後疼痛及失能的改善 42
第六節 臨床應用 43
第七節 研究限制與未來方向 44
參考文獻 47
附錄 92
表 1：下肢人體測量項目隔日再測信度 55
表 2：平地步行時下肢關節於三維空間的角度最大值之隔日再測信度 56
表 3：單腳蹲下時下肢關節於三維空間之角度差值隔日再測信度 56
表 4：平地步行時下肢肌肉活性隔日再測信度 58
表 5：單腳蹲下時下肢肌肉活性隔日再測信度 59
表 6：受試者基本資料（第一部分研究） 60
表 7：受試者資料（第二部分研究） 61
表 8：比較彈性扁平足跑者與正常足弓跑者於平地步行時下肢運動學角度 62
表 9：比較彈性扁平足跑者與正常足弓跑者於單腳蹲時下肢運動學角度 63
表 10：比較彈性扁平足跑者與正常足弓跑者於平地步行時下肢肌肉活性 64
表 11：比較彈性扁平足跑者與正常足弓跑者單腳蹲時下肢肌肉活性 65
表 12：比較有症狀之彈性扁平足跑者於六周神經訓練前、後平地步行時下肢運動學角度最大值 66
表 13：比較有症狀之彈性扁平足跑者於六周神經訓練前、後單腳蹲（膝關節屈曲10-60度)時下肢運動學角度差值 67
表 14：比較有症狀之彈性扁平足跑者於六周神經訓練前、後平地步行時下肢肌肉活性 68
表 15：比較有症狀之彈性扁平足跑者於六周神經訓練前、後單腳下蹲時下肢肌肉活性 69
表 16：比較有症狀之彈性扁平足跑者於六周神經訓練前、後的疼痛及功能分數 70
圖 1：單腳蹲測試起始動作 71
圖 2：VICON動作分析系統 72
圖 3：14毫米 (mm) 反光球 73
圖 4：Plug in gait反光球標記肢段點 74
圖 5：氯化銀電極貼片 75
圖 6：脛前肌、腓骨長肌電極貼片黏貼方式 76
圖 7：半腱、半膜肌電極貼片黏貼方式 77
圖 8：臀大肌電極貼片黏貼方式 78
圖 9：Noraxon肌電圖系統，足底壓力開關 (foot switch) 79
圖 10：後足角度量測 80
圖 11：前足角度量測 81
圖 12：足弓高度比量測 82
圖 13：扁平足跑者與足弓正常跑者在步行站立期時骨盆矢狀面的動作 83
圖 14：扁平足跑者與足弓正常跑者在步行站立期時髖關節矢狀面的動作 84
圖 15：扁平足跑者與足弓正常跑者在步行站立期時膝關節矢狀面的動作 85
圖 16：扁平足跑者與足弓正常跑者在步行站立期時骨盆額狀面的動作 86
圖 17：扁平足跑者與足弓正常跑者在步行站立期時髖關節額狀面的動作 87
圖 18：扁平足跑者與足弓正常跑者在步行站立期時膝關節額狀面的動作 88
圖 19：扁平足跑者與足弓正常跑者在步行站立期時骨盆橫狀面的動作 89
圖 20：扁平足跑者與足弓正常跑者在步行站立期時髖關節橫狀面的動作 90
圖 21：扁平足跑者與足弓正常跑者在步行站立期時膝關節橫狀面的動作 91

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