臺灣博碩士論文加值系統

許多肌肉骨骼症狀與腿長不等存在極高的相關性，這可能是因腿長不等造成承重關節受力不均及肌肉骨骼變形所致。過去文獻發現以增高墊來調整腿長可以有效地減輕因腿長不等而產生的症狀，但卻未曾進行力學分析。因此本研究旨在探討以雷射測距計量測腿長的可能性，並探討以增高墊調整腿長後對於臨床症狀與地面反作用力的變化。其具體目標有四：（一）檢測以雷射測距計測量腿長的信、效度、（二）檢測調整腿長後對於下背疼痛之效果、（三）檢測調整腿長後對於長腳過度內旋之變化、（四）檢測調整腿長後對於地面反作用力之影響。

本研究屬於便利抽樣、前瞻性研究、擬試驗分析、前後測研究的設計，共分為兩部分，第一部分為針對健康人以雷射測距計測量腿長的信、效度研究，第二部分為針對腿長不等者以增高墊介入後之下背痛症狀改變、足型改變、地面反作用力的力學分析等。雷射測距計效度測試方面，使 10 名健康成年之男性接受站立骨盆 X 光照射，並以雷射測距計量測腿長 3 次，以皮爾森相關係數來檢測兩種測
量結果的相關性。在信度測試方面，以同一名測試者在同日進行 15 名健康成年人之雷射測距計量測腿長 2 回，每回 3 次，取平均值分析，使用組內相關係數 ICC(3,3)及測量標準誤，用以計算測試者內信度。在增高墊介入研究部分，徵召結構性腿長不等且以長腳內旋代償並有慢性下背痛之受試者 30 名。每名受試者皆接受下背
疼痛情形、足部形態、站立或行走時地面反作用力的力學分析等量測。下背疼痛的評估採用疼痛量表及修訂過之歐式下背痛失能量表檢測受試者的疼痛及日常功能，足部形態量測則包含舟狀骨滑落測試及足部姿態指數等量測，而地面反作用力的力學分析則為靜止站立 60 s 及以自然速度行走 6 m。下背疼痛評估於治療前及治療 1 個月後各測量一次，並以配對 t 檢定檢測治療 1 個月後的改善情形。而其他評估參數都在腿長調整前、調整後立即、及調整後 1 個月等 3 個時間點進行量測，符合常態分佈的連續數資料以重複量測變異數分析，而非常態分佈之連續數資料或序列性資料則以傅來德曼檢定分析，足部姿態測試則以列聯表分析及費雪精確檢定檢測在 3 個時間點之間足型分布的差異。所有統計顯著水準皆訂在α= 0.05，
而檢定力則訂在 0.8。

本研究主要結果為：（一）以雷射測距計測量腿長具有良好的效度及信度；效度方面，皮爾森相關係數於兩腿皆大於 0.96；而信度方面，ICC(3,3)值皆大於 0.99測量標準誤皆小於 0.2 cm；（二）慢性下背痛在腿長調整介入 1 個月之後有顯著改善；（三）於調整結構性腿長不等後，長腳內旋在統計上有顯著的改善，但效應值在低度與中度之間；（四）靜止站立時，治療前長腳受力較多的受試者在治療後兩腳垂直受力量趨於對稱，而治療前短腳受力較多之受試者其在治療後受力情形則無明顯改變。

此結果顯示腿長調整能夠減輕下背疼痛、改善功能，但無法改變足型。在力學參數方面，雖未能完全解釋臨床觀察，但靜止站立時兩腳承重方式可提供評估腿長調整後雙足對稱承重的依據。此外，利用雷射量測計進行腿長測量為具效度及信度之新方法，未來可在臨床上推廣。未來研究方向可進一步探討腿長調整的改變機轉。

Many musculoskeletal symptoms are highly correlated with leg length discrepancy (LLD), which may be related to asymmetric loading on weight-bearing joints and malalignments of the lower extremities. Leg length adjustment has been reported effective on relieving clinical symptoms; however, its mechanism is still unclear. The purpose of this research was to explore the feasibility of measurement of leg length using a laser distance meter, to determine the effect of leg length adjustment on pain relief at low back, pronation control of the long leg, kinematic changes in the feet for people with anatomical LLD. Four study objectives were developed: 1) to examine the validity and reliability of measurement of leg length using a laser distance meter, 2) to examine the effect of leg length adjustment on pain status and daily functions, 3) to examine the effect of leg length adjustment on controlling excessive pronation of the long leg, and 4) to examine the effect of leg length adjustment on the kinetic variables of ground reaction force.

The present research was designed as a convenient sampling, prospective, quasi-experimental, and pretest/posttest design. There were 2 parts in this research: 1) validity and reliability tests of measurement of standing leg length using a laser distance meter and 2) the effect of leg length adjustment on pain relieving, foot pronation
controlling, and related kinetic changes in people with anatomical LLD. For the validity test, standing leg length was obtained through both pelvic radiography and the laser
distance meter in 10 healthy male adults. The results were analyzed using Pearson’s correlation coefficient. For the reliability test, 15 healthy adults received measurements
of standing leg length twice using a laser distance meter by the same rater on the same day. Intraclass correlation coefficient (ICC(3,3)) and standard error of measurement
(SEM) was calculated to present intrarater reliability. Another 30 adults with anatomical LLD were recruited for the second part of the research. The visual analog scale and modified Oswestry Disability Index before and 1-month after intervention were compared using the paired t test, respectively. All participants received the navicular
drop test, Foot Posture Index (FPI), quiet stance for 60s, and level walking for 6 m at pre-, immediate after, and 1-month after leg length adjustment. ANOVA with repeated
measures or Friedman test was calculated to compare the differences among 3 time points. Crosstable analysis with Fisher’s exact test was calculated for FPI. The
significant level was set at α = 0.05 while the power was at 0.8.

The main results of the present research were: 1) using the laser distance meter to measure LLD is valid (r>0.96) and reliable (ICC(3,3) >0.99 and SEM <0.2 cm), 2) the pain status and daily function significantly improved after 1-month intervention, 3) there was a significant decrease in the subtalar pronation of the long leg after 1-month
intervention but the effect size was between small and median level only, and 4) more symmetric force distribution was noted at quiet stance after intervention in the
participants with more weight on the long leg but not for those with more weight on the short leg.

These results concluded that leg length adjustment relieved back pain and improve daily function successfully but failed to alter the foot type. Although the kinetic
variables did not completely explain the effect of intervention, the initial weight bearing pattern at stance affected the results of symmetric wearing bearing pattern after intervention. The laser distance meter was an alternative tool to measure leg length, which presented an excellent validity and reliability, which is a useful clinical tool. All of the above findings give an insight that leg length adjustment can control clinical symptoms which result from anatomical LLD, but the actual mechanism is still further studied.

口試委員審訂書 i
致謝 ii
摘 要 iv
Abstract vi
Table of Contents ix
List of Figures xi
List of Tables xii
Chapter 1. Introduction 1
1.1 Motivation and background 2
1.2 Purposes of present study 4
1.3 Research Questions and Hypotheses 5
1.4 Glossaries 11
Chapter 2. Literature Review 15
2.1 Clinical symptoms resulted from LLD and their managements 16
2.2 Interventions of equalization of leg length 21
2.3 Relationship between leg length discrepancy and pronated foot 28
2.4 Measurements of LLD 32
2.5 Measurements of pronated foot 39
Chapter 3. Methods 44
3.1 Study design 45
3.2 Participants 45
3.3 Equipment 47
3.4 Measurements 49
3.4.1 Measurement of LLD 50
3.4.2 Measurement of low back pain 52
3.4.3 Measurement of foot type 53
3.4.4 Force platform measurement 57
3.5 Procedure 58
3.6 Data reduction and analysis 60
3.7 Statistical analysis 63
Chapter 4. Results 64
4.1 Validity of measurement of standing leg length using laser distance meter 65
4.2 Intrarater reliability of measurement of standing leg length using laser distance meter 67
4.3 Information of participants for main study 69
4.4 Effect of leg length adjustment on low back pain 71
4.5 Changes in foot types before and after leg length adjustment 72
4.6 Kinetic variables of ground reaction force before and after leg length adjustment during quiet stance 73
4.7 Kinetic variables of ground reaction force before and after leg length adjustment during level walking 76
Chapter 5. Discussion 78
5.1 Effect of leg length adjustment on kinetic variables of ground reaction force 79
5.2 Effects of leg length adjustment on low back pain 83
5.3 Effects of leg length adjustment on foot morphology 85
5.4 Validity and reliability of measurement of standing leg length using laser distance meter 88
5.5 Strengths of present research 92
5.6 Limitations of present research and future studies 93
Chapter 6. Conclusions 97
References 99
Appendices 145

Baylis, W., & Rzonca, E. (1988). Functional and structural limb length discrepancies: evaluation and treatment. Clinics in podiatric medicine and surgery, 5(3), 509.
Beattie, P., Isaacson, K., Riddle, D. L., & Rothstein, J. M. (1990). Validity of derived measurements of leg-length differences obtained by use of a tape measure. Phys Ther, 70(3), 150-157.
Beekman, S., Louis, H., Rosich, J. M., & Coppola, N. (1985). A preliminary study on asymmetrical forces at the foot to ground interphase. J Am Podiatr Med Assoc, 75(7), 349-354.
Beurskens, A. J., de Vet, H. C., & Koke, A. J. (1996). Responsiveness of functional status in low back pain: a comparison of different instruments. Pain, 65(1), 71-76.
Bhave, A., Paley, D., & Herzenberg, J. E. (1999). Improvement in gait parameters after lengthening for the treatment of limb-length discrepancy. J Bone Joint Surg Am, 81(4), 529-534.
Blake, R., & Ferguson, H. (1992). Limb length discrepancies. J Am Podiatr Med Assoc, 82(1), 33-38.
Blake, R., & Ferguson, H. (1993). Correlation between limb length discrepancy and asymmetrical rearfoot position. J Am Podiatr Med Assoc, 83(11), 625-633.
Brady, R. J., Dean, J. B., Skinner, T. M., & Gross, M. T. (2003). Limb length inequality: clinical implications for assessment and intervention. J Orthop Sports Phys Ther, 33(5), 221-234.
Brand, R. A., & Yack, H. J. (1996). Effects of leg length discrepancies on the forces at the hip joint. Clin Orthop Relat Res(333), 172-180.
Brody, D. M. (1982). Techniques in the evaluation and treatment of the injured runner. Orthop Clin North Am, 13(3), 541-558.
Chai, H., & Fan, L. C. (1992). Interrater and intrarater reliability of the measurement of leg length. JPTA ROC, 17(2), 123-132.
Chuckpaiwong, B., Nunley, J. A., Mall, N. A., & Queen, R. M. (2008). The effect of foot type on in-shoe plantar pressure during walking and running. Gait Posture, 28(3), 405-411.
Cornwall, M. W., McPoil, T. G., Lebec, M., Vicenzino, B., & Wilson, J. (2008). Reliability of the modified Foot Posture Index. J Am Podiatr Med Assoc, 98(1), 7-13.
Cote, K. P., Brunet, M. E., Gansneder, B. M., & Shultz, S. J. (2005). Effects of Pronated and Supinated Foot Postures on Static and Dynamic Postural Stability. J Athl Train, 40(1), 41-46.
D''Amico, J. C., Dinowitz, H. D., & Polchaninoff, M. (1985). Limb length discrepancy. An electrodynographic analysis. J Am Podiatr Med Assoc, 75(12), 639-643.
De Cock, A., Vanrenterghem, J., Willems, T., Witvrouw, E., & De Clercq, D. (2008). The trajectory of the centre of pressure during barefoot running as a potential measure for foot function. Gait Posture, 27(4), 669-675.
Defrin, R., Ben Benyamin, S., Aldubi, R. D., & Pick, C. G. (2005). Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain. Arch Phys Med Rehabil, 86(11), 2075-2080.
Donatelli, R. A. (1987). Abnormal biomechanics of the foot and ankle. J Orthop Sports Phys Ther, 9(1), 11-16.
Edwards, K. J., & Cummings, R. J. (1992). Fat embolism as a complication of closed femoral shortening. J Pediatr Orthop, 12(4), 542-543.
Fann, A. V., Spencer, H. J., Hammaker, A. F., Kligman, S., & Gray, R. P. (2007). The impact of structural therapy on functioning and pain in chronic pain patients: A pilot study. Journal of Back and Musculoskeletal Rehabilitation, 20(1), 1-9.
Fleiss, J.L.(1986). The design and analysis of clinical experiments. New York, USA: Wiley.
Friberg, O. (1983). Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine, 8(6), 643-651.
Giles, L. G., & Taylor, J. R. (1981). Low-back pain associated with leg length inequality. Spine, 6(5), 510-521.
Golightly, Y. M., Allen, K. D., Helmick, C. G., Renner, J. B., & Jordan, J. M. (2009). Symptoms of the knee and hip in individuals with and without limb length inequality. Osteoarthritis Cartilage, 17(5), 596-600.
Golightly, Y. M., Tate, J. J., Burns, C. B., & Gross, M. T. (2007). Changes in pain and disability secondary to shoe lift intervention in subjects with limb length inequality and chronic low back pain: a preliminary report. J Orthop Sports Phys Ther, 37(7), 380-388.
Gross, M. T. (1995). Lower quarter screening for skeletal malalignment--suggestions for orthotics and shoewear. J Orthop Sports Phys Ther, 21(6), 389-405.
Gross, R. H. (1978). Leg length discrepancy: how much is too much? Orthopedics, 1(4), 307-310.
Gurney, B. (2002). Leg length discrepancy. Gait Posture, 15(2), 195-206.
Hagg, O., Fritzell, P., & Nordwall, A. (2003). The clinical importance of changes in outcome scores after treatment for chronic low back pain. Eur Spine J, 12(1), 12-20.
Hanada, E., Kirby, R. L., Mitchell, M., & Swuste, J. M. (2001). Measuring leg-length discrepancy by the "iliac crest palpation and book correction" method: reliability and validity. Arch Phys Med Rehabil, 82(7), 938-942.
Hargrave, M. D., Carcia, C. R., Gansneder, B. M., & Shultz, S. J. (2003). Subtalar Pronation Does Not Influence Impact Forces or Rate of Loading During a Single-Leg Landing. J Athl Train, 38(1), 18-23.
Hoyle, D. A., Latour, M., & Bohannon, R. W. (1991). Intraexaminer, interexaminer, and interdevice comparability of leg length measurements obtained with measuring tape and metrecom. J Orthop Sports Phys Ther, 14(6), 263-268.
Irving, D. B., Cook, J. L., Young, M. A., & Menz, H. B. (2007). Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study. BMC Musculoskelet Disord, 8, 41.
Irving, D. B., Cook, J. L., Young, M. A., & Menz, H. B. (2008). Impact of chronic plantar heel pain on health-related quality of life. J Am Podiatr Med Assoc, 98(4), 283-289.
Jones, K. B., Sponseller, P. D., Hobbs, W., & Pyeritz, R. E. (2002). Leg-length discrepancy and scoliosis in Marfan syndrome. J Pediatr Orthop, 22(6), 807-812.
Kaufman, K. R., Miller, L. S., & Sutherland, D. H. (1996). Gait asymmetry in patients with limb-length inequality. J Pediatr Orthop, 16(2), 144-150.
Keenan, A. M., Redmond, A. C., Horton, M., Conaghan, P. G., & Tennant, A. (2007). The Foot Posture Index: Rasch analysis of a novel, foot-specific outcome measure. Arch Phys Med Rehabil, 88(1), 88-93.
Ledoux, W. R., & Hillstrom, H. J. (2002). The distributed plantar vertical force of neutrally aligned and pes planus feet. Gait Posture, 15(1), 1-9.
Lee, Y. C., Liao, Z. J., & Chai H. (2009). Interrater reliability of the Foot Posture Index. 中華民國物理治療學會第五十九次學術研討會.
Machen, M. S., & Stevens, P. M. (2005). Should full-length standing anteroposterior radiographs replace the scanogram for measurement of limb length discrepancy? J Pediatr Orthop B, 14(1), 30-37.
Mahar, R. K., Kirby, R. L., & MacLeod, D. A. (1985). Simulated leg-length discrepancy: its effect on mean center-of-pressure position and postural sway. Arch Phys Med Rehabil, 66(12), 822-824.
Mann, M., Glasheen-Wray, M., & Nyberg, R. (1984). Therapist agreement for palpation and observation of iliac crest heights. Physical Therapy, 64(3), 334.
Medved, V. (2000). Measurement of Human Locomotion, Florida, Boca Raton, USA: CRC Press
Menz, H. B., & Munteanu, S. E. (2005). Validity of 3 clinical techniques for the measurement of static foot posture in older people. J Orthop Sports Phys Ther, 35(8), 479-486.
Moseley, C. F. (1977). A straight-line graph for leg-length discrepancies. J Bone Joint Surg Am, 59(2), 174-179.
Mueller, M. J., Host, J. V., & Norton, B. J. (1993). Navicular drop as a composite measure of excessive pronation. J Am Podiatr Med Assoc, 83(4), 198-202.
Neely, F. G. (1998). Biomechanical risk factors for exercise-related lower limb injuries. Sports Med, 26(6), 395-413.
Neumann, D.A. (2010). Kinesiology of the musculoskeletal system: Foundations for rehabilitation, 2nd ed. Philadelphia, PA, USA: Elsevier.
Nester, C. J., van der Linden, M. L., & Bowker, P. (2003). Effect of foot orthoses on the kinematics and kinetics of normal walking gait. Gait Posture, 17(2), 180-187.
Nube, V. L., Molyneaux, L., & Yue, D. K. (2006). Biomechanical risk factors associated with neuropathic ulceration of the hallux in people with diabetes mellitus. J Am Podiatr Med Assoc, 96(3), 189-197.
Paley, D., Bhave, A., Herzenberg, J. E., & Bowen, J. R. (2000). Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am, 82-A(10), 1432-1446.
Pascual Huerta, J., Ropa Moreno, J. M., Kirby, K. A., Garcia Carmona, F. J., & Orejana Garcia, A. M. (2009). Effect of 7-degree rearfoot varus and valgus wedging on rearfoot kinematics and kinetics during the stance phase of walking. J Am Podiatr Med Assoc, 99(5), 415-421.
Perttunen, J. R., Anttila, E., Sodergard, J., Merikanto, J., & Komi, P. V. (2003). Effect of intramedullary gradual elongation of the shorter limb on gait patterns. Pediatr Int, 45(3), 324-332.
Perttunen, J. R., Anttila, E., Sodergard, J., Merikanto, J., & Komi, P. V. (2004). Gait asymmetry in patients with limb length discrepancy. Scand J Med Sci Sports, 14(1), 49-56.
Pfeiffer, M., Kotz, R., Ledl, T., Hauser, G., & Sluga, M. (2006). Prevalence of flat foot in preschool-aged children. Pediatrics, 118(2), 634-639.
Picciano, A. M., Rowlands, M. S., & Worrell, T. (1993). Reliability of open and closed kinetic chain subtalar joint neutral positions and navicular drop test. J Orthop Sports Phys Ther, 18(4), 553-558.
Portney, L.G. (2009). Foundations of clinical research: Application to practice, 3rd ed. Upper Saddle River, New Jersey, USA: Prentice Hall.
Redmond, A. C.(2005). The Foot Posture Index: User guide and manual. Retrieved September 30, 2008, from the World Wide Web: http://www.leeds.ac.uk/medicine/FASTER/FPI/
Redmond, A. C., Crosbie, J., & Ouvrier, R. A. (2006). Development and validation of a novel rating system for scoring standing foot posture: the Foot Posture Index. Clin Biomech (Bristol, Avon), 21(1), 89-98.
Robinson, R. O., Herzog, W., & Nigg, B. M. (1987). Use of force platform variables to quantify the effects of chiropractic manipulation on gait symmetry. J Manipulative Physiol Ther, 10(4), 172-176.
Root, M. L. (1994). Development of the functional orthosis. Clin Podiatr Med Surg, 11(2), 183-210.
Rose, J and Gamble J.G. (2006). Human walking, 3rd ed. Philadelphia, PA, USA: Lippincott Williams & Winkins.
Rothbart, B. A. (2006). Relationship of functional leg-length discrepancy to abnormal pronation. J Am Podiatr Med Assoc, 96(6), 499-504; discussion 505-497.
Sabharwal, S., & Kumar, A. (2008). Methods for assessing leg length discrepancy. Clin Orthop Relat Res, 466(12), 2910-2922.
Sanner, W., Page, J., Tolboe, H., Blake, R., & Bax, C. (1981). A study of ankle joint height changes with subtalar joint motion. Journal of the American Podiatric Medical Association, 71(3), 158-161.
Scharfbillig, R., Evans, A. M., Copper, A. W., Williams, M., Scutter, S., Iasiello, H., et al. (2004). Criterion validation of four criteria of the foot posture index. J Am Podiatr Med Assoc, 94(1), 31-38.
Schmidt, R.A. & Lee, T.D. (2005) Motor control and learning: A Behavioral Emphasis, 4th ed. Champaign, IL, USA: Human Kinetics.
Schuit, D., Adrian, M., & Pidcoe, P. (1989). Effect of heel lifts on ground reaction force patterns in subjects with structural leg-length discrepancies. Phys Ther, 69(8), 663-670.
Sell, K. E., Verity, T. M., Worrell, T. W., Pease, B. J., & Wigglesworth, J. (1994). Two measurement techniques for assessing subtalar joint position: a reliability study. J Orthop Sports Phys Ther, 19(3), 162-167.
Shultz, S. J., Nguyen, A. D., Windley, T. C., Kulas, A. S., Botic, T. L., & Beynnon, B. D. (2006). Intratester and intertester reliability of clinical measures of lower extremity anatomic characteristics: implications for multicenter studies. Clin J Sport Med, 16(2), 155-161.
Subotnick, S. (1981). Limb length discrepancies of the lower extremity (the short leg syndrome). The Journal of orthopaedic and sports physical therapy, 3(1), 11.
Terry, M. A., Winell, J. J., Green, D. W., Schneider, R., Peterson, M., Marx, R. G., et al. (2005). Measurement variance in limb length discrepancy: clinical and radiographic assessment of interobserver and intraobserver variability. J Pediatr Orthop, 25(2), 197-201.
Tiberio, D. (1988). Pathomechanics of structural foot deformities. Phys Ther, 68(12), 1840-1849.
Vinicombe, A., Raspovic, A., & Menz, H. B. (2001). Reliability of navicular displacement measurement as a clinical indicator of foot posture. J Am Podiatr Med Assoc, 91(5), 262-268.
Vitale, M. A., Choe, J. C., Sesko, A. M., Hyman, J. E., Lee, F. Y., Roye, D. P., Jr., et al. (2006). The effect of limb length discrepancy on health-related quality of life: is the ''2 cm rule'' appropriate? J Pediatr Orthop B, 15(1), 1-5.
White, S. C., Gilchrist, L. A., & Wilk, B. E. (2004). Asymmetric limb loading with true or simulated leg-length differences. Clin Orthop Relat Res(421), 287-292.
Woerman, A. L., & Binder-Macleod, S. A. (1984). Leg length discrepancy assessment: accuracv and precision in five clinical methods of evaluation*. J Orthop Sports Phys Ther, 5(5), 230-239.
Wong, L., Hunt, A., Burns, J., & Crosbie, J. (2008). Effect of foot morphology on center-of-pressure excursion during barefoot walking. J Am Podiatr Med Assoc, 98(2), 112-117.
Winter, D.A. (2009). Biomechanics and motor control of human movement, 4th ed. New York, NY, USA: John Wiley & Sons.
Yates, B., & White, S. (2004). The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med, 32(3), 772-780.
胡名霞。動作控制與動作學習(第三版)。台北：金名，2009。