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研究生:魏以斌
研究生(外文):I-Pin Wei
論文名稱:電針刺激對退化性膝關節炎患者步態之立即影響
論文名稱(外文):Immediate Effects of Electroacupuncture on Gait Patterns of Patients with Knee Osteoarthritis
指導教授:林昭庚林昭庚引用關係
學位類別:博士
校院名稱:中國醫藥大學
系所名稱:中國醫學研究所博士班
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
論文頁數:138
中文關鍵詞:退化性關節炎步態分析測力板針灸疼痛評估
外文關鍵詞:AcupunctureOsteoarthritisGait analysis
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骨關節炎(osteoarthritis,OA)俗稱為退化性關節炎,常見於五十歲以上的人,是中老年人最常見的關節炎。關節在長期承受重力及運動下,關節軟骨會退行性病變,連帶引起軟骨下硬骨增厚、關節變形、滑液膜和關節周圍結構相關變化的疾病,並失去彈性,進而發生關節疼痛、腫脹、僵硬、變形的情形,以致活動受限。
退化性膝關節的臨床症狀包括膝關節疼痛(尤其是在上下樓梯時)、關節腫脹、關節僵硬、肌肉無力感(從坐姿要站立困難)、關節雜音、關節運動受限(蹲不下去)及關節變形(以O形腿變形最常見)等。這些症狀常因都會影響病患之步態表現。
根據臨床觀察顯示,針灸方式能直接、快速減緩關節的疼痛與不適,進而改善膝關節活動功能。並且中醫的針灸療效在退化性關節炎部分已被證實有效且副作用極小。因此希望藉由步態分析,可清楚發現病人的動作異常及治療後改善的狀況,可提供作為新的診斷及治療方向。
本研究主要探討退化性膝關節炎患者,接受針灸治療前後之運動學、力動學與腿部勁度之變化。首先,本研究第三章中,徵召30位罹患內側退化性膝關節炎的患者以及15位正常族群相互比較,結果顯示病患組會使用代償步態策略,以因應其患病的膝關節以及周邊肌群。病患組所呈現出較大的髖關節外展肌力矩似乎有益於減少作用於患側膝關節的負重。
同時,本章第四章透過徵召15位罹患雙腿內側退化性膝關節炎患者,以及15位正常族群探討病患步態參數與下肢勁度的改變。結果顯示病患會透過特別的生物力學策略,來改變其腿部及關節勁度以維持正常的時間-距離步態參數。當下肢承重時,病患的腿部勁度會因為膝關節勁度的增加而加大,如此可以減緩患側膝關節的症狀以及改變周邊關節的勁度。當重量釋放時,膝關節炎病患會透過增加膝關節以及踝關節勁度,以調節他們的髖關節以及踝關節的力動學表現,如此可以增加以不增加腿部勁度的方式來維持控制下肢穩定的能力。
此外,本章第五章中,為了客觀的探討針灸治療的療效,特別徵召20位罹患雙腿內側退化性膝關節炎患者,並隨機區分為偽針組與實驗組。結果顯示,偽針組的病患儘管其VAS下降,但是其步態參數並未改變。而實驗組的病患接受治療後,表現出較快的行走速度以及較大的步長,這表示病患透過增加的關節活動度以及關節力矩,能夠有較佳的重量轉移現象。這樣明顯的步態改變相當可能是因為接受針灸治療後,緩解了膝關節疼痛的結果。同時,結合步態分析以及VAS等評估方法,將有助於探討針灸治療對於罹患神經肌肉骨骼系統疾病的療效。
最後,本研究第六章即是以透過客觀的步態分析,探討30位不同嚴重程度雙腿內側退化性膝關節炎患者,在針灸治療後其步態參數與下肢勁度的改變。結果顯示,針灸治療對於輕微病患組造成其運動學與力動學上的改變,而下肢整體勁度也有增加的趨勢。但是嚴重病患組或許是因為其膝關節傷害的情況較為嚴重,因此即使病患在針灸治療後有疼痛的減緩,但對其步態仍未出現顯著的變化。
OA is a slowly progressive degenerative disease in which the joint cartilage gradually wears away, which is associated with hypertrophy of the bone beneath, and deformation of the joint. Pathological changes of the synovoid fluid and structure changes around the joint lead to decrease in elasticity, which is associated with pains, swelling, stiffness and deformation of the joint, thus impaired movement of the joint ensues.
The clinical symptoms of OA of the knee include pains (especially when climbing stairs), swelling, stiffness and muscle weakness (from sitting to standing), cracking noise of the joint, impaired movement of the joint (difficulty bending the knee) and deformation of the joint. The gait pattern would be influenced by these symptoms, especially the pain.
Present study had investigated the kinematics, kinetics and leg stiffness of the OA knee patients via gait analysis. Patients with medial compartment knee OA adopted compensatory strategies for the compromised function of the diseased knee and its surrounding muscles. Increased hip abductor moments in the OA groups seemed to benefit the reduced loading at the diseased knee.
Meanwhile, patients with bilateral medial knee OA modulated their leg and joint stiffness through acquired specific biomechanical strategies in order to maintain normal temporal-spatial patterns of gait. During weight acceptance, the leg stiffness of the OA group was increased mainly through increasing the joint stiffness of the knee, through which effects of the symptoms of the diseased knee were minimized and the stiffness of the adjacent joints were unaltered. During weight release, patients with knee OA modulated their hip and ankle kinetics by increasing knee and ankle stiffness in order to improve the control stability of the limb with unaltered overall leg stiffness. It is suggested that exercise intervention and/or rehabilitation for patients with knee OA should focus on activities that develop and/or maintain functions of the overall lower extremity, not only the knee.
This current study reports for the first time an objective evaluation of gait performance in patients with knee OA following acupuncture treatment. After acupuncture stimulation patients with bilateral medial compartment knee OA walked with greater speed and step length as well as better body weight transfer through increased dynamic joint ranges of motion and increased joint moments. This significantly improved gait performance is likely associated with the relief of pain after treatment. It is suggested that gait analysis combined with the VAS can be useful for the evaluation of the true effect of acupuncture treatment for patients with neuromusculoskeletal diseases and movement disorders.
In the chapter 6, the acupuncture effect of the paitents with different K/L grade was investigated. The results indicated that the mild group showed significantly difference on kinematics, kinetics and leg stiffenss, but the severe group didn’t showed similar changes. These unchanged gait variables might be due to the more damaged knee joint, even through the paitents felt painless after acupuncture treatment and did the compensation.
第一章 導論 1
1.1、前言 1
1.2、退化性關節炎(簡稱OA)的診斷標準 3
1.3、「疼痛」的介紹 5
1.3.1、「疼痛」的機轉 6
1.3.2、「穴位」的特性與經絡傳導 6
1.3.3、痛覺的神經傳導路徑 9
1.3.4、止痛的方法 10
1.3.5、針刺鎮痛的機轉 14
1.4、退化性關節炎疼痛症狀對膝關節的影響 18
1.5、目前中、西醫對OA的療法及穴位介紹 21
1.6、臨床疼痛評估方式 23
1.7、臨床步態分析 24
1.8、退化性膝關節炎患者之腿部勁度改變 25
1.9、研究目的 27
第二章 材料與方法 30
2.1、受試者 30
2.2、實驗設備 32
2.2.1、動作分析系統 32
2.2.2、電針刺激器 33
2.3、實驗流程 34
2.3.1、實驗室硬體系統校正 34
2.3.2、受試者準備與校正 35
2.3.3、受試者步行資料擷取 35
2.3.4、穴位選取 36
2.3.5、電針治療與針刺得氣 37
2.4、生物力學模型 39
2.4.1、剛體定義 39
2.4.2、皮膚標記位置的選定 40
2.4.3、座標系統定義 41
2.4.4、下肢生物力學模型 41
2.4.5、人體量測學資料 43
2.5、逆向動力學 43
2.6、步態週期定義 44
2.6.1、正常步態 45
2.6.2、步態分期 45
2.6.3、正常步態之關節角度 47
2.6.4、正常步態之地面反作用力 49
2.6.5、正常步態之關節力矩 50
第三章 不同嚴重等級之內側退化性膝關節炎患者之步態表現 53
3.1、受試者 54
3.2、資料分析 55
3.3、統計分析 55
3.4、結果 56
3.5、結論 62
第四章 內側退化性膝關節炎患者步行時之下肢及關節勁度 63
4.1、受試者 65
4.2、試驗流程 65
4.3、資料分析 66
4.4、結果 68
4.5、討論 71
4.6、結論 74
第五章 針灸治療對退化性膝關節炎患者步行型態的影響 75
5.1、受試者 76
5.2、試驗流程 77
5.2.1、電針治療 77
5.4、討論 85
5.5、結論 86
第六章 針灸治療對不同嚴重等級退化性膝關節炎患者步行型態與
腿部勁度的影響 87
6.1、受試者 87
6.2、試驗流程 88
6.2.1、電針治療 88
6.2.2、步態分析 89
6.2.3、資料分析 89
6.3、結果 90
6.4、討論 96
6.5、結論 97
第七章 總結 99
7.1、結論 99
7.2、未來研究建議 100
參考文獻 101
附 錄 129
英文摘要 136

圖目錄

圖1. 1、正常人體膝關節之解剖圖 19
圖1. 2、退化性關節炎的病理變化過程 20
圖1. 3、疼痛循環示意圖 21
圖1. 4、下肢質量-彈簧示意圖 26

圖2. 1、標準動作分析系統設備與連接狀態 33
圖2. 2、視覺類比刻度尺(VAS) 34
圖2. 3、針灸治療所選取之五個穴位示意圖 38
圖2. 4、本實驗室所發展模型的皮膚標記位置 42
圖2. 5、步態週期時間示意圖 46
圖2. 6、正常步態中髖關節屈曲(Flexion)、伸直(Extension)活動的角度 48
圖2. 7、正常步態中膝關節屈曲(Flexion)、伸直(Extension)活動的角度 48
圖2. 8、正常步態中踝關節背側屈曲和蹠側屈曲活動的角度 49
圖2. 9、測力板所記錄之步態週期地面反作用力三個分量 50
圖2. 10、地面反作用力(ground reaction force, GRF):從觸地初期(initial contact)到擺盪預備期(preswing) 51
圖2. 11、正常步態中髖關節所產生的屈曲、伸直的力矩 51
圖2. 12、正常步態中膝關節所產生的屈曲、伸直的力矩 52
圖2. 13、正常步態中踝關節所產生的背側屈曲(Dorisflexion)、 蹠側屈曲(Plantarflexion)的力矩 52

圖3. 1、病患組與正常控制組之矢狀面關節作用力矩變化與比較 58
圖3. 2、病患組與正常控制組之額狀面關節作用力矩變化與比較 60

圖4. 1、下肢質量-彈簧示意圖 64
圖4. 2、計算腿部勁度之示意圖 67
圖4. 3、病患組與正常控制組之時間-距離參數比較 68
圖4. 4、病患組與正常控制組之矢狀面關節角度與關節力矩比較圖 69
圖4. 5、病患組與正常控制組之腿部勁度比較圖 70
圖4. 6、病患組與正常控制組之下肢關節勁度比較圖 71

圖5. 1、下肢反光球黏貼之骨標記位置圖 78
圖5. 2、實驗組與偽針組之VAS比較圖 79
圖5. 3、實驗組針灸治療前後之矢狀面關節角度變化圖 83
圖5. 4、實驗組針灸治療前後之矢狀面與額狀面關節力矩變化圖 84


圖6. 1、輕微病患組與嚴重病患組之VAS比較圖 90
圖6. 2、輕微病患組針灸治療前後之關節角度變化圖 94
圖6. 3、輕微病患組針灸治療前後之關節力矩變化圖 95
圖6. 4、輕微病患組針灸治療前後之腿部勁度變化圖 95



表目錄

表2. 1、本實驗室模型的皮膚標記位置 42

表3. 1、病患組與正常控制組之關節角度變化 57

表5. 1、實驗組針灸治療前後之時間-距離參數比較表 80
表5. 2、實驗組針灸治療前後之矢狀面關節角度比較表 81
表5. 3、實驗組針灸治療前後之矢狀面關節力矩比較表 82
表5. 4、實驗組針灸治療前後之額狀面關節力矩比較表 82

表6. 1、輕微病患組針灸治療前後之時間-距離參數比較表 91
表6. 2、嚴重病患組針灸治療前後之時間-距離參數比較表 91
表6. 3、輕微病患組於針灸治療前後之矢狀面關節角度比較表 92
表6. 4、嚴重病患組於針灸治療前後之矢狀面關節角度比較表 92
表6. 5、輕微病患組針灸治療前後之矢狀面關節力矩比較表 93
表6. 6、實驗組針灸治療前後之額狀面關節力矩比較表 93
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