臺灣博碩士論文加值系統

研究背景：在懷孕期間，婦女因為體重的增加、鬆弛素荷爾蒙的分泌的變化，導致身體重心的改變，而產生足弓型態的改變、足底的壓力增加、步態失去平衡，進而影響肌肉骨骼系統和運動功能，造成足部痛、下背痛及日常生活干擾的情形。
研究目的：探討婦女從第一孕期至第三孕期的足型變化、足底壓力變化與步態改變，進而探討不同足型變化、足底壓力對步態平衡、足部與下背痛及日常生活干擾之影響。
研究方法：以長期追蹤研究法，追蹤的時間點分別為懷孕8-12週、20週、24週、28週、32週及36週，於二家醫療院所的婦產科門診進行收案，總計收案樣本數為286人，以生理及生物力學測量及問卷量表收集資料，包括：人口及產科學資料、下背痛、足部痛、日常生活干擾量表，並以熱感測版測量足弓型態，然後進行FOOTPLATE感壓板測量足底壓力分佈與靜態平衡、Pedar®-x足墊足底壓力測試系統測量足底壓力與動態平衡、計時起走測試動態平衡。
研究結果：結果顯示懷孕婦女足弓高度在隨著孕期逐漸降低，亦即隨足型逐漸增大，尤以第三孕期有顯著下降，第三孕期相較於第一孕期平均值增加0.05%。降低的足弓增加地面接觸的面積，導致動態行進時足底壓力變化，第二孕期壓力顯著增加在前足與足跟，第二孕期至第三孕期壓力顯著增加在前足與中足，第三孕期足部整體壓力顯著增加。步態平衡的變化，懷孕婦女於第一、第二和第三孕期的睜眼、閉眼COP前後、內外位移量皆有顯著增加。睜眼的COP前後、內外位移量在第一孕期顯著減少。閉眼的COP在第二和第三孕期，內外位移量顯著增加。睜眼的COP在妊娠晚期相較於妊娠早期的前後位移量顯著增加，而在內外位移上，妊娠期間則沒有顯著差異。在整個孕期觀察到步行速度隨著孕期增加而顯著降低，以第三孕期速度最慢（7.34±1.36/秒），與靜態平衡（COP）搖晃半徑與姿勢穩定度有關，而涵蓋面積則與本體感覺與視覺功能有關。步態動態平衡（TUG）與靜態平衡（COP）表現之搖晃半徑、面積有顯著負相關，意即有較小搖晃半徑、搖晃面積之懷孕婦女有較佳的平衡控制能力而有較佳的行走速度。
在足部痛、下背痛、生活干擾方面，研究顯示足部痛、下背痛、生活干擾皆隨著孕期而增加，且三者之間呈正相關。以廣義估計方程式（GEE）分析足部痛、下背痛及日常生活干擾之預測因子，預測足部痛的因素包括：孕期、水腫價數、運動習慣、足弓型態、足底壓力及靜態平衡。足部痛在第二孕期相較於第一孕期減少1.87分（p=.01），第三孕期相較於第一孕期增加1.22分（p=.01），亦即足部疼痛在第三孕期增加；有運動習慣相較於沒有運動習慣者其足部痛增加1.39分（p=.01），亦即運動增加足部疼痛；右足低足弓相較於正常足弓足部痛減少2.48分（p=.02），低足弓有較少的足部痛；靜態平衡（腳壓中心偏移量）睜眼前後每增加1mm足部痛減少0.11分（p=.01），睜眼內外每增加1mm足部痛增加0.12分（p=.03），亦即腳壓中心內外偏移量增加則足部疼痛增加。
預測下背痛的因素包括：胎兒數、水腫價數、運動習慣、足弓型態、足底壓力及動靜態平衡。在右足弓低足弓相較於正常足弓下背痛減少5.29分（p=.01），亦即低足弓者有較少的下背痛；足底壓力在第一蹠骨每增加1kpa下背痛減少0.02分（p=.04），足跟每增加1kpa下背痛減少0.02分（p=.01）；靜態平衡（腳壓中心偏移量）睜眼前後每增加1mm下背痛增加0.15分（p<.001），睜眼內外每增加1mm下背痛減少0.18分（p=.01），閉眼前後每增加1mm下背痛減少0.09（p=.02），閉眼內外每增加1mm下背痛減少0.09（p=.04）。
預測生活干擾的因素包括：孕期、運動習慣、足弓型態、足底壓力及靜態平衡。第二孕期相較於第一孕期生活干擾增加3.28分（p=.01），第三孕期相較於第一孕期生活干擾增加5.73分（p=.01），亦即生活干擾在第二孕期開始增加，第三孕期更持續增加；有運動習慣相較於沒有運動習慣生活干擾減少3.4分（p=.01），亦即有運動習慣的生活干擾較少；體重每增加1公斤生活干擾增加0.19分（p=.01）；左足弓在低足弓相較於正常足弓生活干擾增加2.48分（p=.01），低足弓有較多的生活干擾；右足弓在低足弓相較於正常足弓生活干擾減少8.46分（p=.01），低足弓有較少的生活干擾；足底壓力在大腳趾每增加1kpa生活干擾減少0.02分（p=.01），在其他蹠骨每增加1kpa生活干擾減少0.04分（p=.01）；靜態平衡（腳壓中心偏移量） 睜眼前後每增加1mm生活干擾增加0.10分（p=.01），閉眼前後每增加1mm生活干擾減少0.31分（p=.02）。
結論：孕期不同足型變化使足底壓力和步態平衡產生變化，進而引起走路型態的異常和足部痛及下背痛，隨著妊娠期的進展，疼痛強度增加，疼痛會干擾孕婦的日常生活，導致她們的身體活動及日常生活活動受到一些限制，並產生負面影響。
臨床應用：本研究之結果對妊娠婦女在妊娠期間，因鬆弛素作用、體重增加的負荷和解剖學上的變化，所造成足弓高度在整個孕期中逐漸降低、足底壓力和步態平衡等變化，及其引起足部痛、下背痛及日常生活干擾之探討結果，有利爾後足底壓力和步態平衡之調整，及足弓支撐墊和鞋具設計與選擇之參考，及妊娠期間足部痛、下背痛衛教介入時機。

Background
The physical center of gravity in women changes during pregnancy because of increasing body weight and changes in the secretion of relaxin hormones, which in turn affects foot arch structure, increases plantar pressure, causes gait instability, and ultimately impacts on the musculoskeletal system and motor functions, leading to lower back pain and disruptions in daily life.
Purpose
The aim of this study was to explore the longitudinal changes in foot type index, plantar pressure, and gait during all three trimesters of pregnancy and to assess the impact of these changes on gait stability, foot pain, lower back pain, and activities of daily life.
Methodology
A longitudinal research method was used to gather data during the 8~12th, 20th, 24 th, 28 th, 32 th, and 36 th weeks of pregnancy from 286 participants, all of whom were attending the gynecology and obstetrics outpatient clinic of two Medical Institution in Taiwan. Data were collected using physiological and biomechanical measures and a questionnaire survey and included demographic and obstetrics information and self-assessed lower back pain, foot pain, and disruption to daily life. In addition, a thermal sensing plate was used to measure arch type, a footplate pressure measurement device was used to measure plantar pressure distribution and static balance, and the Pedar®-x in-shoe pressure measuring system was used to measure plantar pressure and dynamic walking balance.
Results
The findings of this study revealed a progressive decline in the mean arch height and a progressive increase in the mean foot size of participants over time, with the rate of mean arch-height decline most significant during the third trimester, when the average rate of decline was 0.05% greater than the average rate during the first trimester. Lower foot height increases the plantar contact area, which causes changes to plantar pressure distribution during dynamic movement. In this study, plantar pressure increased significantly in the forefoot and hindfoot during the second trimester, in the forefoot and midfoot during the second and third trimesters, and in all three regions of the foot during the third trimester. In terms of walking balance, the participants showed increases in meancenter of pressure (CoP) anteroposterior and mediolateral displacements across all three trimesters under both eyes-open and eyes-closed conditions. CoP anteroposterior and mediolateral displacement with eyes open decreased significantly during the first trimester, while CoP mediolateral displacement with eyes closed increased significantly during both the second and third trimesters. Moreover, CoP anteroposterior displacement with eyes open was significantly higher in late pregnancy than early pregnancy, while no significant change was noted for mediolateral displacement. In terms of observed walking speed, mean observed walking speed decreased steadily over time, with the slowest mean speed of 7.34+1.36 seconds reported during the third trimester. Relationships were found between CoP sway radius and postural stability and between CoP sway area and, respectively, proprioception and visual function. Furthermore, timed up-and-go (TUG) test results were shown to be significantly related to CoP sway radius and area, indicating that participants with smaller CoP sway radiuses and areas had relatively better balance control and walking speeds.
This study further identified longitudinal increases in foot pain, lower back pain, and disruption to daily life as well as positive correlations among these three variables. A general estimating equation (GEE) analysis identified trimester, edema grade, exercise habits, arch type, and static balance as predictors of foot pain. The average score for foot pain decreased by 1.87 points (p=.01) between the first and second trimesters, 1.22 points (p=.01) between the first and third trimesters and increased steadily through pregnancy. The participants who have exercise habits reported an average foot-pain score that was 1.39 points (p=.01) higher than their non-exercising peers, revealing a positive correlation between exercise and foot pain.The participants with a low arches (flat feet) reported a 2.48 point (p=.02) lower foot-pain score than their normally arched peers, low arch has less foot pain. Finally, in terms of static balance (as measured using CoP displacement), the foot-pain score decreased by 0.11 points (p=.01) and increased by 0.12 (p=.03) for each 1mm increase in open-eyed CoP anteroposterior displacement and open-eyed CoP mediolateral displacement, respectively, revealing a positive correlation between mediolateral displacement and foot pain.
The predictors of lower back pain identified in this study were number of fetuses, edema grade, exercise habits, arch type, plantar pressure, and static balance. The participants with a low arches in their right foot reported an average lower-back pain score that was 5.29 points (p=.01) below their peers with normal arches, That is, low arches have less lower back pain.Moreover, each 1kPa increase in pressure on the first metatarsal bone and heel decreased the lower-back pain score by an average 0.02 points (p=.04) and 0.02 points (p=.01). In terms of static balance, the lower-back pain score increased by an average 0.15 points (p<.001) and decreased by an average 0.18 (p = .01) for each 1mm increase in open-eyed CoP anteroposterior displacement and open-eyed CoP mediolateral displacement.the lower-back pain score decreased by an average 0.09 points (p = .02) decreased by an average 0.09 (p = .04) for each 1mm increase in closed-eyed CoP anteroposterior displacement and closed -eyed CoP mediolateral displacement.
The predictors of disruption to daily life identified in this study were trimester, exercise habits, body weight, arch type, plantar pressure, and static balance. The average score for daily-life disruptions rose an average 3.28 points (p=.01) between the first and second trimester and an average 5.73 points (p=.01) between the first and third trimester, revealing that these disruptions increased steadily through the pregnancy period. The participants who have exercise habits reported an average daily-life disruption score that was 3.40 points (p=.01) less than their non-exercising peers.revealing that increased exercise habits less daily-life disruption. In terms of body weight, the average score for daily-life disruptions increased 0.19 points (p=.01) for each 1kg increase in body weight.The participants with low arches in their left and right feet reported average disruption scores that were, respectively,2.48 points (p=.01) higher and 8.45 points (p=.01) lower than their normally arched peers.
Conclusions
Changes in the foot type index during pregnancy cause changes in plantar pressure and walking balance, which subsequently lead to improper walking patterns, foot soreness, and lower back pain. Related pains increase over the course of pregnancy, disrupting the daily life of pregnant women, limiting their interest and ability to engage in normal daily activities, and causing other negative impacts.
Implications for Practice
This study provides important insights into the foot pain, lower back pain, and daily-life disruptions that are caused by the reduced arch height, increased plantar pressure, and altered walking balance associated with the secretion of relaxin hormones, increase in bodyweight burden, and anatomical changes experienced during pregnancy. The findings may be referenced in future efforts to ameliorate the plantar-pressure and walking-balance issues faced by pregnant women as well as in efforts to design arch supports and footwear that fits the unique and currently underserved needs of this population. and Pregnancy foot pain, lower back pain, health education timing of intervention.

致謝 I
中文摘要 II
Abstract V
目錄 X
圖目錄 XII
表目錄 III
第壹章 緒論 1
第一節 研究動機及背景 1
第二節 研究目的 4
第三節 名詞解釋 5
第貳章 文獻查證 7
第一節 足弓構成要素及足弓類型區分的依據 7
第二節 懷孕期婦女的肌肉骨骼的變化 10
第三節 懷孕期婦女足部結構、足底壓力與步態平衡的變化 11
第四節 懷孕期婦女足部腰背酸痛相關因素探討 12
第五節 懷孕期婦女足部腰背酸痛對日常生活干擾 13
第參章 研究方法 15
第一節 研究架構 15
第二節 研究設計 16
第三節 研究對象 16
第四節 資料收集方法 17
第五節 收案流程 22
第六節 倫理考量 22
第七節 資料處理分析 22
第肆章 研究結果 25
第一節 研究對象個人屬性、產科資料之描述性分析 25
第二節 孕期體重、BMI、運動習慣、水腫變化之描述 30
第三節 婦女於三個孕期在足部痛、下背痛、日常生活干擾、足型變化、足底壓力、腳壓中心偏移量、動態平衡之變化 32
第四節 孕期不同足型變化、足底壓力、步態平衡、下背痛、足部痛及日常生活干擾之相關性 39
第五節 不同孕期足部痛、下背痛及日常生活干擾之預測因子 45
第伍章 討論 50
第一節 研究樣本之屬性 50
第二節 探討婦女於三個孕期在足型變化、足底壓力、步態平衡、足部痛、下背痛及日常生活干擾之變化與差異性 52
第三節 探討孕期不同足型變化、足底壓力、步態平衡與足部痛、下背痛及日常生活干擾之相關性
55
第四節 分析不同孕期足部痛、下背痛及日常生活干擾之預測因子 56第陸章 結論與建議 59
第一節 結論 59
第二節 臨床實務的應用 60
第三節 研究限制與建議 61
參考文獻 63
一、 中文部分 63
二、 英文部分 65
附錄 69

一、中文部分
王淑芳（2000）．影響婦女孕期運動行為之相關因素研究．國立臺灣師範大學。
回俊岭、陳樹君、夏鳳歧、路蘭紅、牟兆新、井蘭香（2007）．扁平足X光線測量法與比值法、三線法的比較． 解剖學雜誌，30（2），232-234。
江勁政、江勁彥（2004）．平衡能力檢測在選才時之應用。彰化師大體育學報，4，39-46。
李宏滿、陳五洲、侯耀東（2003）．扁平足的生物力學分析． 國軍桃園總醫院研究發展計畫成果報告書。
李宜庭（2014）．不同孕期婦女之生活品質的比較 ．未發表的碩士論文． 高雄醫學大學護理研究所。.
李靜芳、林淑珊、董政達（2012）．探討懷孕婦女之規律運動行為．亞東學報，（32），189-200。doi:10.30167/JOIT.201212.0007
李靜芳、姜逸群、林淑珊、林顯明、徐菊容（2012）．懷孕婦女於不同孕期之身體活動型態及其相關因素之研究．台灣醫學，16（2），103-111。doi:10.6320/FJM.2012.16（2）.01
阿久津邦男（1992）．步的健康法．日本：女子榮養大學出版社。
林威秀、黃國堂、邱炳坤、黎俊彥（2009）．不同等級大專射箭選手平衡控制能力之差異．大專體育學刊，11（2），85-96。doi:10.5297/ser.200906_11（2）.0006
林信良（2000）．正常足弓與扁平足弓在不同步速下行走對足底壓力影響的探討． 國立體育學院。
邱雅寧（2007） ．懷孕婦女之下背痛．台北市醫師公會會刊，第51卷（第12期）， 33-35。
高美玲等編著（2017）．實用產科護理．台北：華杏出版社。
陳五洲、陳協鴻、王素珍（2006）．我國役齡男子之足弓參數邏輯迴歸分析．大專體育學刊，8，213-228。
陳嘉慧、曾雅玲、應宗和、郭碧照（2017）．第三孕期身體活動、懷孕前身體質量指數和孕期體重增加量對生產結果之影響．護理雜誌，64（1），80-89。doi:10.6224/JN.000011
許夏菁、邱永興、陳祺富、林信良、陳張榮、 張芝綺（2010）．長短腿個案之站姿平衡能力分析．輔仁大學體育學刊，（9）， 35-50。doi:10.29697/jpe.201005.0004
許琬鈞（2016）．不同止痛方式對成人心臟手術之疼痛、生命徵象與焦慮、住院舒適感受度之探討． 國立臺北護理健康大學。
許貞媛、郭碧照（2006）．懷孕婦女孕期運動習慣及影響因素探討．中山醫學雜誌，17（2），187-199。doi:10.30096/CSMJ.200612.0004
郭昊晨（2016）．客製化足弓矯正器矯正扁平足足弓指標與Feiss line角度變化之研究． 國立臺南大學。
黃英哲（1999）．妊娠期婦女足部尺寸及足底壓力之調查研究．大同大學。
張皓媛（2011）．第三妊娠期孕婦下背疼痛強度與疼痛干擾及其相關因素探討之縱貫性研究．臺灣大學護理學研究所學位論文， 1-109。
張皓媛、 賴裕和、 李建南、陳月枝、楊雅玲（2011）．運動對於懷孕相關下背與骨盆疼痛之成效．台灣醫學, 15（2）， 202-216。
張志清（1977） ．足弓墊對扁平足在後足運動與足底壓力影響之研究．國立中央大學。
董政達、李靜芳、林淑珊、林顯明（2014）．婦女於懷孕期間規律運動型態及其相關因素．護理研究, 22（4）， 242-249。doi:10.1097/jnr.0000000000000056
葛魯蘋（2004） ．台灣版簡易疼痛量表之簡介．疼痛通訊， 45， 8-14。,
劉呈寧（2017） ．孕婦足部形態及足底力學特徵的研究． 陝西科技大學。
廖麗君、劉玫舫、郭藍遠、廖健芬、董怡辰、吳依婷（2011）．以超音波測量健康年輕女性腹部肌群不同部位之肌肉厚度及其信度。物理治療，36（2），100-111。
閻秋鳳（2011） ．第二、三孕期孕婦執行生產球運動對孕期不適及下背痛之成效探討．國立臺北護理健康大學。
鍾祥賜、陳五洲、李宏滿 （2011） ．扁平足判定指標相關性之研究．臺灣體育學術研究，（50）， 61-76。
蘇家勳（2015） ．運動功能性足弓墊對網球動作之影響．中國文化大學。
二、英文部分
Alvarez, R., Stokes, I. A. F., E Asprinio, D., Trevino, S., & Braun, T. (1988). Dimensional change of the feet in pregnancy (Vol. 70).
American College of Obstetricians and Gynecologists. (2013). ACOG Committee opinion no. 548: weight gain during pregnancy. Obstetrics and Gynecology, 121(1), 210.
Ashkan, K., Casey, A. T., Powell, M., & Crockard, H. A. (1998). Back pain during pregnancy and after childbirth: an unusual cause not to miss. Journal of the Royal Society of Medicine, 91(2), 88-90.
Bergström, C., Persson, M., & Mogren, I. (2014). Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy - pain status, self-rated health and family situation. BMC Pregnancy and Childbirth, 14, 48-48. doi:10.1186/1471-2393-14-48
Bertuit, J., Leyh, C., Rooze, M., & Feipel, V. (2016). Plantar pressure during gait in pregnant women. Journal of the American Podiatric Medical Association, 106(6), 398-405.
Blaszczyk, J. W., Opala-Berdzik, A., & Plewa, M. (2016). Adaptive changes in spatiotemporal gait characteristics in women during pregnancy. Gait & posture, 43, 160-164.
Branco, M., Santos-Rocha, R., & Vieira, F. (2014). Biomechanics of gait during pregnancy. The Scientific World Journal, Volume 2014, Article ID 527940, 5 pages
Butler, E. E., Colón, I., Druzin, M. L., & Rose, J. (2006). Postural equilibrium during pregnancy: decreased stability with an increased reliance on visual cues. American journal of obstetrics and gynecology, 195(4), 1104-1108.
Cavanagh, P. R., & Rodgers, M. M. (1987). The arch index: A useful measure from footprint. Journal of Biomechanics, 20(5), 547-551.
Chiou, W.-K., Chiu, H.-T., Chao, A.-S., Wang, M.-H., & Chen, Y.-L. (2015). The influence of body mass on foot dimensions during pregnancy. Applied Ergonomics, 46, 212-217. doi:https://doi.org/10.1016/j.apergo.2014.08.004
Cordo, P. J., & Nashner, L. M. (1982). Properties of postural adjustments associated with rapid arm movements. Journal of neurophysiology, 47(2), 287-302.
Dunning, K., LeMasters, G., Levin, L., Bhattacharya, A., Alterman, T., & Lordo, K. (2003). Falls in workers during pregnancy: risk factors, job hazards, and high risk occupations. American journal of industrial medicine, 44(6), 664-672.
Farahpour, N., Jafarnezhad, A., Damavandi, M., Bakhtiari, A., & Allard, P. (2016). Gait ground reaction force characteristics of low back pain patients with pronated foot and able-bodied individuals with and without foot pronation. Journal of Biomechanics, 49(9), 1705-1710. doi:https://doi.org/10.1016/j.jbiomech.2016.03.056
Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175-191.
Forczek, W., & Staszkiewicz, R. (2012). Changes of kinematic gait parameters due to pregnancy. Acta Bioeng Biomech, 14(4), 113-9.
Forczek, W., Ivanenko, Y. P., Bielatowicz, J., Wacławik, K. (2018). Gait assessment of the expectant mothers - Systematic review. Journal of Gait & Posture, 62, 7-19. https://doi.org/10.1016/j.gaitpost.2018.02.024
Gijon-Nogueron, G. A., Gavilan-Diaz, M., Valle-Funes, V., Jimenez-Cebrian, A. M., Cervera-Marin, J. A., & Morales-Asencio, J. M. (2013). Anthropometric foot changes during pregnancy: A pilot study. Journal of the American Podiatric Medical Association, 103(4), 314-321.
George, J. W., Skaggs, C. D., Thompson, P. A., Nelson, D. M., Gavard, J. A., & Gross, G. A. (2013). A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. American Journal of obstetrics and gynecology, 208(4), 295-e1. Goldberg, J., Besser, M. P., & Selby-Silverstein, L. (2001). Changes in foot function throughout pregnancy. Obstetrics & Gynecology, 97(4), S39.
Heckman, J. D., & Sassard, R. (1994). Musculoskeletal considerations in pregnancy. Journal of Bone and Joint Surgery-American Volume, 76(11), 1720-1730.
Hughes, C. M., Liddle, S. D., Sinclair, M., & McCullough, J. E. M. (2018). The use of complementary and alternative medicine (CAM) for pregnancy related low back and/ or pelvic girdle pain: An online survey. Complementary Therapies in Clinical Practice, 31, 379-383. doi:https://doi.org/10.1016/j.ctcp.2018.01.015
Karadag-Saygi, E., unlu ozkan, F., & Basgul, A. (2010). Plantar Pressure and Foot Pain in the Last Trimester of Pregnancy (Vol. 31).
Lima, A. C. D. N., Oliveira, F. B. D., Avolio, G. P., Silva, G. D. D., Silva, P. S. D., & Vale, R. G. D. S. (2017). Prevalence of low back pain and interference with quality of life of pregnant women. Revista Dor, 18(2), 119-123.
López-López, D., Rodríguez-Vila, I., Losa-Iglesias, M. E., Rodríguez-Sanz, D., Calvo-Lobo, C., Romero-Morales, C., & Becerro-de-Bengoa-Vallejo, R. (2017). Impact of the quality of life related to foot health in a sample of pregnant women: A case control study. Medicine, 96(12), e6433. doi:10.1097/MD.0000000000006433
Martínez-Martí, F., Ocón-Hernández, O., Martínez-García, M. S., Torres-Ruiz, F., Martínez-Olmos, A., Carvajal, M. A., ... & Palma, A. J. (2019). Plantar Pressure Changes and Their Relationships with Low Back Pain during Pregnancy Using Instrumented Insoles. Journal of Sensors, 2019, Article ID 1567584, 10 page.
Moccellin, A. S., Nora, F. G., Costa, P. H., & Driusso, P. (2015). Static postural control assessment during pregnancy. Brazilian Journal of Motor Behavior, 9(1),1-9.
Ojukwu, C. P., Anyanwu, E. G., & Nwafor, G. G. (2017). Correlation between Foot Arch Index and the Intensity of Foot, Knee, and Lower Back Pain among Pregnant Women in a South-Eastern Nigerian Community. Medical Principles And Practice: International Journal of The Kuwait University, Health Science Centre, 26(5), 480-484. doi:10.1159/000481622
Oliveira, L. F., Vieira, T. M. M., Macedo, A. R., Simpson, D. M., & Nadal, J. (2009). Postural sway changes during pregnancy: a descriptive study using stabilometry. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 147(1), 25–28. https://doi-org.autorpa.ntunhs.edu.tw/10.1016/j.ejogrb.2009.06.027
Ponnapula, P., & Boberg, J. S. (2010). Lower extremity changes experienced during pregnancy. The Journal of Foot and Ankle Surgery, 49(5), 452-458. doi:https://doi.org/10.1053/j.jfas.2010.06.018
Ramachandra, P., Kumar, P., Kamath, A., & Maiya, A. G. (2017). Do structural changes of the foot influence plantar pressure patterns during various stages of pregnancy and postpartum?. Foot & ankle specialist, 10(6), 513-519. doi:10.1177/1938640016685150
Ribas, S.I., & Guirro, E.C.O. (2007). Análise da pressão plantar e do equilíbrio postural em diferentes fases da gestação. Revista Brasileira de Fisioterapia, 11(5), 391-396.
Ribeiro, A. P., Trombini-Souza, F., de Camargo Neves Sacco, I., Ruano, R., Zugaib, M., & João, S. M. A. (2011). Changes in the plantar pressure distribution during gait throughout gestation. Journal of the American Podiatric Medical Association, 101(5), 415-423.
Ritchie, J. R. (2003). Orthopedic considerations during pregnancy. Clinical Obstetrics and Gynecology, 46(2), 456-466.
Rodrigues, W. F. G., Giani, T. S., de Figueiredo, N. M. A., Porto, F., & Dantas, E. H. M. (2012). Lombalgia na gravidez: impacto nas atividades de vida diárias. Revista de Pesquisa Cuidado é Fundamental Online, 4(2), 2921-2926.
Segal, N. A., Boyer, E. R., Teran-Yengle, P., Glass, N., Hillstrom, H. J., & Yack, H. J. (2013). Pregnancy leads to lasting changes in foot structure. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 92(3), 232-240. doi:10.1097/PHM.0b013e31827443a9
Simkin, A., Leichter, I., Giladi, M., Stein, M., & Milgrom, C. (1989). Combined effect of foot arch structure and an orthotic device on stress fractures. Foot & Ankle, 10(1), 25-29. doi:10.1177/107110078901000105
Smyth, R. M., Aflaifel, N., & Bamigboye, A. A. (2015). Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database of Systematic Reviews, (10).
Tung, C. T., Lee, C. F., Lin, S. S., & Lin, H. M. (2014). The exercise patterns of pregnant women in Taiwan. Journal of Nursing Research, 22(4), 242-249.
Tsai, L. C., Yu, B., Mercer, V. S., & Gross, M. T. (2006). Comparison of different structural foot types for measures of standing postural control. Journal of Orthopaedic & Sports Physical Therapy, 36(12), 942-953.
Varol, T., Göker, A., Cezayirli, E., Özgür, S., & Tuç Yücel, A. (2017). Relation between foot pain and plantar pressure in pregnancy. Turkish Journal of Medical Sciences, 47(4), 1104-1108. doi:10.3906/sag-1601-185
Vullo, V. J., Richardson, J. K., & Hurvitz, E. A. (1996). Hip, knee, and foot pain during pregnancy and the postpartum period. Journal of Family Practice, 43(1), 63-69.
Wang, S. M., Dezinno, P., Maranets, I., Berman, M. R., Caldwell-Andrews, A. A., & Kain, Z. N. (2004). Low back pain during pregnancy: prevalence, risk factors, and outcomes. Obstetrics & Gynecology, 104(1), 65-70..
Wu, W. H., Meijer, O. G., Uegaki, K., Mens, J. M. A., Van Dieen, J. H., Wuisman, P. I. J. M., & Östgaard, H. C. (2004). Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine Journal, 13(7), 575-589.
Yan, C.-F., Hung, Y.-C., Gau, M.-L., & Lin, K.-C. (2014). Effects of a stability ball exercise programme on low back pain and daily life interference during pregnancy. Midwifery, 30(4), 412-419. doi:https://doi.org/10.1016/j.midw.2013.04.011