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研究生:郭芬伶
研究生(外文):Fen-Ling Kuo
論文名稱:退化性膝關節炎患者穿著功能性護膝及外側楔形鞋墊之效益評估
論文名稱(外文):Effect of Functional Knee Brace and Lateral Wedge Insole in Management of Patients with Osteoarthritic Knee
指導教授:楊世偉楊世偉引用關係謝霖芬謝霖芬引用關係
指導教授(外文):SaiWei YangLin-Fen Hsieh
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:復健科技輔具研究所
學門:醫藥衛生學門
學類:復健醫學學類
論文種類:學術論文
論文出版年:2006
畢業學年度:94
語文別:中文
論文頁數:142
中文關鍵詞:內側退化性膝關節炎護膝楔形鞋墊步態分析
外文關鍵詞:OsteoarthritisKnee braceWedged insoleGait
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內側退化性膝關節炎者在台灣有相當高的發生率,且比其他關節炎更容易造成失能的情形,由生物力學的研究瞭解膝關節受力時會產生過大的內翻力矩,造成膝關節的疼痛和變形,加速退化和造成活動的困難,因此臨床上會使用功能型護膝及足跟外側楔型鞋墊改善不當的膝關節受力,這兩種輔具的作用原理分別為:退化性膝關節炎專用護膝是藉由外力的方式減少不適當的內翻力矩、足跟外側楔型鞋墊是減少內翻力矩的力臂,達到減少內翻力矩。國外已有相當的研究,但國內對楔形鞋墊和護膝的使用不普及,且生物力學研究欠缺,因此本研究目的是使用步態分析來瞭解組合式楔形鞋墊(wedged insole)和現有產品Aligner Brace MA對於內側退化性膝關節炎從事功能性活動疼痛控制和動作品質的成效及使用滿意度。
取30名退化性膝關節炎,在Kellgren和Lawrence的分類中之二~四等級,比較使用護膝後之X光片內側空隙、股骨-脛骨角度(femur-tibia angle)、距骨傾斜角度(talar tilt angle)的變化;使用動作分析系統(VICON MX)、力板和壓力板,瞭解使用楔形鞋墊和護膝後之疼痛及功能性活動的變化,包含一般步行、坐到站、蹲、靜態站立等測試,並找出疼痛和不同嚴重程度對於楔形鞋墊和護膝的關係。
結果顯示:使用視覺疼痛量表和膝功能指數量表,顯示有使用護膝、楔形鞋墊或護膝和鞋墊在主觀上的功能性和疼痛都有顯著改善;在放射線檢查,可護膝、護膝加鞋墊可以有效的改善膝關節排列、穿鞋墊、鞋墊加護膝可以有效改看踝關節排列;在一般步行,患測邊雙腳站立和單腳站立的比值有顯著的減少,有效的減少膝內翻力矩;動、靜態平衡方面,在雙腳站立、腳跟接腳尖站、單腳站和蹲姿取物的項目中,壓力中心的穩定度和協調性皆有提高。
因此對於護膝、鞋墊的主觀功能性改善(WOMAC)、步態中內翻力矩的改善、功能性活動和靜態平衡等幾個方面考量,輕微者(第二級)使用護膝或外側楔形鞋墊都可以改善,由滿意度評估發現應增加患者對於護膝的瞭解;嚴重者(第三、四級)使用鞋墊加護膝能有效的改善過大的內翻力矩和疼痛。
The people with medial compartment pain of knee osteoarthritis (OA) suffer from excessive varus torque on the knee joint, which cause pain and deformity on the knee joint. The subjects would had difficities in performing activities of daily life. The Knee brace and wedged insole are often provided knee OA subjects to correct the improper varus deformity. Moreover, there has rarely been any survey to the effect of OA knee brace and wedged insole in OA patients in Taiwan. Therefore, the goal of this study is to investigate the effect of the wedged insole and Aligner Brace MA which is design for people with medial compartment pain of knee osteoarthritis by questionnaires, kinetic and kinematic analysis.

30 subjects with symptomatic medial compartment osteoarthritis of the knee with grade 2 ~4 on Kellgren and Lawrence scale will participate in this study. We compared the changes of the knee joint space, femur-tibia angle, pain score and performing functional activities by X-ray, motion analysis, force plates and footscan with or without wedged insole and knee brace. Besides, we compared the difference of wedged insole and brace effects between different grades of OA patients.

By the questionnaires (VAS and WOMAC), pain and functional ability improved while wearing knee brace and insole. By the X-ray, the femur-tibia angle, talar tilt angle had significant different in wearing brace, insole and brace with insole. At the level walking, the double support time/ single support time ratio of the affect side decreased significantly. At static standing, tandem stance, single standing and squat tasks, the COP acceleration improved while wearing brace and insole.

According to the effect of WOMAC, pain control, varus moment of gait analysis, functional mobility and static balance, the mild subjects with knee OA (K-L scale grade 2) is suitable to wear knee brace or lateral wedged insole to reduce knee varus moment. The severe subjects with knee OA (K-L scale grade 3~4) had well corrected knee force and pain control while wearing functional brace and lateral wedged insole.
目錄
本文
第一章 緒論 …...………………………………………......... 1
1-1 研究動機.............................................................................................1
1-2退化性關節炎的簡介..........................................................................2
1-3文獻回顧..............................................................................................7
1-3-1 退化性膝關節炎之生物力學研究...............................................7
1-3-2 楔形鞋墊在退化性膝關節炎使用成效.....................................11
1-3-3護膝在退化性關節炎的使用成效..............................................15
1-3-4 總結.............................................................................................20
1-4 研究目的..........................................................................................22

第二章 研究方法......................................................................23
2-1 研究對象..............................................................................23
2-2研究設備...............................................................................23
2-3 實驗流程及評估項目.............................................................28
2-3-1 放射線檢查.............................................................................30
2-3-2 問卷評估..................................................................................31
2-3-3 關節活動度..............................................................................32
2-3-4 步態分析..................................................................................34
2-3-5 坐到站分析..............................................................................35
2-3-6 蹲姿取物..................................................................................37
2-3-7靜態平衡測試...........................................................................38
2-4 統計方法........................................................................................39

第三章 結果....................................................................................... 41
3-1 受測者基本資料............................................................................41
3-2 靜態關節活動度............................................................................41
3-3 放射線檢查....................................................................................43
3-4 問卷評估........................................................................................45
3-5 步態分析........................................................................................49
3-5-1 時間空間參數........................................................................ 49
3-5-2 關節角度與力矩......................................................................51
3-5-3 地面反作用力..........................................................................63
3-5-4整體足底壓力壓力中心變化...................................................70
3-5-5足底與鞋墊之足底壓力參數...................................................72
3-6 坐到站分析....................................................................................80
3-7 蹲姿取物........................................................................................86
3-8 靜態平衡測試................................................................................88

第四章 討論.............................................................................96
4-1受測者基本資料..............................................................................96
4-2 靜態關節活動度............................................................................ 96
4-3 放射線檢查.....................................................................................97
4-4 問卷評估......................,..................................................................99
4-5 步態分析.......................................................................................100
4-6 坐到站分析...................................................................................103
4-7 蹲姿取物.......................................................................................104
4-8 靜態平衡測試...............................................................................105
4-9 實驗限制.......................................................................................107

第五章 結論...........................................................................109
參考文獻.................................................................................111
附錄.........................................................................................118

圖目錄
圖1-1 外側楔形鞋墊作用原理..............................................................12
圖1-2 退化性膝關節炎和正常人使用鞋墊關節活動度和力矩變化..14
圖1-3 使用五度和十度外側楔形鞋墊膝關節力矩的變化圖............. 14
圖1-4 護膝的構造..................................................................................15
圖1-5 Aligner Brace MA.........................................................................16
圖1-6 使用護膝的矢狀面關節活動度變化..........................................20 圖1-7 使用護膝的冠狀面關節力矩變化..............................................20
圖2-1 功夫鞋..........................................................................................24
圖2-2 組合式楔形鞋墊..........................................................................24
圖2-3 Aligner Brace MA.........................................................................26
圖2-4 反光球貼法..................................................................................26
圖2-5 Pedar鞋墊式足底壓力量測系統.................................................27
圖2-6 壓力板..........................................................................................28
圖2-7 實驗流程圖..................................................................................29
圖2-8 Δm為內側關節腔空隙大小,Θs為股骨-脛骨角度..................30
圖2-9距骨傾斜角度................................................................................31
圖2-10 地面反作用力與足底壓力量測................................................34
圖2-11髖關節、膝關節、踝關節活動度和力矩分析特定點........... 35
圖2-12 地面反作用力曲線................................................................ 36
圖2-13 壓力中心分析..........................................................................36
圖2-14 腳底與鞋墊之間的足底壓力分區圖.................................... 37
圖2-15 平衡測試項目........................................................................ 39
圖2-16 統計流程................................................................................ 40
圖3-1 膝關節、踝關節X光片.......................................................... 42
圖3-2 步態週期中的關節活動度....................................................... 52
圖3-3 患側矢狀面膝關節角度發生時間和彎曲角度........................53
圖3-4患側冠狀面髖關節角度.............................................................53
圖3-5 患側冠狀面踝關節角度發生時間和內翻角度........................54
圖3-6患側矢狀面踝關節角度蹠屈/背屈角度、時間........................54
圖3-6 步態週期中的關節力矩........................................................... 56
圖3-7患側冠狀面膝關節內翻力矩.....................................................57
圖3-8患側矢狀面膝關節彎曲伸直力矩.............................................58
圖3-9患側冠狀面髖關節內翻力矩.....................................................59
圖3-10患側矢狀面髖關節發生時間和彎曲力矩、伸直力...............60
圖3-11患側矢、橫狀面踝關節發生時間...........................................61
圖3-12患側矢、橫狀面踝關節力矩…………………………...........62
圖3-13 地面反作用力示意圖............................................................. 64
圖3-14 健側與患側垂直地面反作用力的發生時間和力量值........ 64
圖3-15 健側與患側前後剪力的發生時間和力量值........................ 64
圖3-16 健側與患側左右剪力的發生時間和力量值........................ 65
圖3-17 步行時壓力中心的變化........................................................ 71
圖3-18足底壓力示意圖..................................................................... 73
圖3-19 足底各區接觸時間................................................................ 74
圖3-20 足底各區接觸時間百分比......................................................75
圖3-21 各區最大足底壓力................................................................ 76
圖3-22 各區最大受力......................................................................... 77
圖3-23 足底各區壓力-時間積分....................................................... 78
圖3-24 足底各區力-時間積分............................................................ 79
圖3-25 坐到站壓力中心的變化........................................................ 81
圖3-26坐到站壓力中心的變化...........................................................82
圖3-27坐到站壓力中心速度的變化...................................................82
圖3-28 坐到站壓力中心的變化壓力中心晃動加速度……………..83
圖3-29坐到站的時間...........................................................................84
圖3-30 坐到站地面反作用力的變化量..............................................84
圖3-31 坐到站最大地面反作用力結果..............................................85
圖3-32 蹲壓力中心的變化…………………………………………..87
圖3-33蹲壓力中心的變化..................................................................87
圖3-34雙腳站立壓力中心變化..........................................................90
圖3-35雙腳站立壓力中心................................................................. 90
圖3-36單腳站壓力中心變化…..........................................................91
圖3-37健側和患側單腳站壓力中心晃動震幅…..............................91
圖3-38健側和患側單腳站壓力中心晃動橢圓面積的變化........... 91
圖3-39健側和患側單腳站壓力中心晃動速率............................... 91
圖3-40健側和患側單腳站壓力中心晃動加速度........................... 92
圖3-41腳尖接腳跟站壓力中心變化.................................................93
圖3-42腳尖接腳跟站健側在前和患側在前壓力中心晃動震幅... 93
圖3-43腳尖接腳跟站健側在前和患側在前壓力中心晃動橢圓面.93
圖3-44腳尖接腳跟站健側壓力中心晃動速度............................... 94
圖3-45腳尖接腳跟站健側壓力中心晃動加速度........................... 94












表目錄
表1-1 Kellgren-Lawrence X光分級標準............................................. 5
表2-1 鞋墊材料性質........................................................................... 25
表2-2 滿意度問卷............................................................................... 32
表2-3 評估項目與評估參數............................................................... 40
表3-1 受測者基本資料....................................................................... 41
表3-2 健側與患側下肢靜態關節活動度......................................... 42
表3-3 Q angle在四種狀況下的變化............................................... 43
表3-4 使用護膝、鞋墊膝關節股骨-脛骨角度的結果......................44
表3-5 使用護膝、鞋墊膝關節內側空隙的結果...............................44
表3-6 使用護膝、鞋墊膝關節距骨傾斜角度的結果.......................45
表3-7 Lequesne膝功能指數和VAS分別在四種情況下的結果.......46
表3-8 WOMAC、VAS四種情況下的結果..................................... 46
表3- 9 輕微和嚴重者使用護膝或鞋墊後WOMAC的總分........... 47
表3- 10 輕微和嚴重者使用護膝或鞋墊後WOMAC的疼痛分數... 47
表3-11 輕微和嚴重者使用護膝或鞋墊後WOMAC的僵硬分數.... 47
表3-12 輕微和嚴重者使用護膝或鞋墊後WOMAC的功能分數... 48
表3-13 護膝和鞋墊的接受情況.......................................................... 48
表3-14 輕微組護膝和鞋墊的接受情況.............................................. 48
表3-15 嚴重組護膝和鞋墊的接受情況.............................................. 49
表3-16 步頻、走路速度和步長的結果............................................... 50
表3-17腳跟離地百分比和雙腳支撐/單交支撐時間的比例............... 50
表3-18健側(S)與患側(A)垂直地面反作用力的發生時間..........65
表3-19 健側(S)與患側(A)垂直地面反作用力的力量值...........65
表3-20 健側(S)與患側(A)前後剪力的發生時間.......................65
表3-21 健側(S)與患側(A)前後剪力的力量值...........................66
表3-22 健側(S)與患側(A)內外剪力的發生時間.....................66
表3-23 健側(S)與患側(A)內外剪力的力量值...........................66
表3-24 輕微組健側(S)與患側(A)垂直地面反作用力發生時間67
表3-25 輕微組健側(S)與患側(A)垂直地面反作用力的力量值67
表3-26 輕微組健側(S)與患側(A)前後剪力的發生時間............67
表3-27 輕微組健側(S)與患側(A)前後剪力的力量值...............68
表3-28 輕微組健側(S)與患側(A)內外剪力的發生時間............68
表3-29 輕微組健側(S)與患側(A)內外剪力的力量值...............68
表3-30 嚴重組健側(S)與患側(A)垂直地面反作用力發生時間68
表3-31 嚴重組健側(S)與患側(A)垂直地面反作用力的力量值69
表3-32 嚴重組健側(S)與患側(A)前後剪力的發生時間............69
表3-33 嚴重組健側(S)與患側(A)前後剪力的力量值................69
表3-34 嚴重組健側(S)與患側(A)內外剪力的發生時間............70
表3-35 嚴重組健側(S)與患側(A)內外剪力的力量值...............70
表3-36壓力中心速率發生的時間..........................................................71
表3-37 壓力中心速率..........................................................................72
表3-38 壓力中心加速度發生的時間..................................................72
表3-39 壓力中心加速度......................................................................72
表3-40 Up and go、腳跟接腳尖站和單腳站測試完成時間..........…85
表3-41 輕微組和嚴重組壓力晃動的內外、前後最大位移量.............88
表3-42 輕微組和嚴重組壓力晃動的平均速度....................................88
表3-43輕微組和嚴重組健側和患側單腳站壓力中心晃動震幅..........92
表3-44輕微組和嚴重組健側和患側單腳站壓力中心晃動平均速度92
表3-45輕微組和嚴重組腳尖接腳跟站健側在前和患側在前壓力中心晃動震幅..................................................................................................94
表3-46輕微組和嚴重組腳尖接腳跟站健側在前(S)和患側在前(A)壓力中心晃動平均速度..........................................................................95
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