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研究生:許智欽
研究生(外文):Jr-Chin Shiu
論文名稱:機械式腰椎牽引造成下背痛患者立即不良反應之預測因子
論文名稱(外文):Predictors for patients with low back pain with immediate adverse response to mechanical lumbar traction
指導教授:陳文英陳文英引用關係王子娟王子娟引用關係
指導教授(外文):Wen-Yin ChenTzyy-Jiuan Wang
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:物理治療暨輔助科技學系
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:2009
畢業學年度:97
語文別:中文
論文頁數:53
中文關鍵詞:腰椎牽引不良反應預測因子
外文關鍵詞:lumbar tractionadverse responsepresictors
相關次數:
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研究背景和目的:機械式腰椎牽引是常被物理治療師用來治療下背痛的方法之一。在過去只有少部分的文獻中提及腰椎牽引產生的不良反應,但是尚未有針對腰椎牽引之後產生不良反應的預測因子之探討。本篇研究的目的在發展出對於單次腰椎牽引產生不良反應者的預測因子,藉由這些預測因子,希望可以鑑別出某些會因為腰椎牽引產生不良反應的下背痛患者,避免他們因為接受腰椎牽引而產生症狀加劇的情形。
材料和方法:這是一篇回溯性的研究設計,我們將之前一篇研究208位下背痛病人的資料重做分析。這些資料包括受測者的人口學基本資料、健康和疾病相關資料、疼痛和失能的程度、社會心理的狀態和一系列的理學檢查。理學檢查包括了腰椎關節活動度、直膝抬腿測試、反覆動作測試、複合式動作測試、徒手腰椎壓迫和牽引測試、髖關節和髂薦關節區辨測試、神經學檢查、徒手背部張力檢查和關節彈壓測試。在接受完單次腰椎牽引之後,再一次評估受測者自覺疼痛程度、自覺進步程度,以及檢查受測者腰椎在矢狀面的活動度和直膝抬腿測試的角度。單次腰椎牽引產生的不良反應必須同時滿足一項主觀惡化條件(疼痛增加或自覺改善程度變差)和一項客觀惡化條件(腰椎關節在矢狀面的活動度減少4度以上或直膝抬腿測試的角度減少6度以上)。
統計分析:先使用獨立t檢定和卡方檢定來評估牽引不良反應組與非不良反應組在所有變項的異同處。對於具顯著差異的連續變項透過分析接受者操控特色曲線(receiver operation characteristics curve)找出最適當的切點,再利用逐步羅吉斯複回歸分析(stepwise multiple logistics regression)找出具有意義的預測因子;最後再分別計算出各預測因子的正負向概以比(positive and negative likelihood ratios)、預測腰椎牽引惡化機率和累計解釋力以評估其預測力強度。
結果:在預測腰椎牽引產生不良反應模式中,我們辨識出4項顯著預測因子,包括:(1)活動時症狀加劇,(2)腰椎矢狀面前屈角度大於24.5度,(3)背痛症狀發生在背部中間,(4)徒手腰椎牽引測試為陰性反應。此預測模式的解釋力為0.24,當患者符合4項顯著預測因子的其中3項時,對於立即腰椎牽引產生不良反應的機率由5.8%增加到25%。
結論:本回溯性研究所找出之預測因子,可運用於評估患者,做為預測立即腰椎牽引是否可能產生惡化反應參考。當患者具有4項顯著預測因子的其中3項時,會有25%腰椎牽引惡化反應的機率,可能需延緩執行腰椎牽引的治療。
Background and Objectives: Mechanical lumbar traction is a widely accepted treatment methods used by physical therapists in the management of low back pain. However, only a few studies have discussed the adverse effects of mechanical lumbar traction in managing low back problem in the past. There has been no effort to explore predictors for those who might develop adverse effects after mechanical lumbar traction. The purpose of this study was to establish predictors for adverse effects from one-time lumbar traction in patients with low back pain. Using these predictors, we might be able to identify those potentially adverse responders earlier and prevent them from receiving mechanical lumbar traction.
Materials and Methods: This was a retrospective study that re-analyzed the data collected on 208 low back pain patients from a previous study. The data included the subjects’ demographic information, pain and disability level, psychosocial status as well as results from a series of physical examinations, e.g. lumbar range of motion (ROM), straight leg raising (SLR), repeated movements tests, combined movement tests, lumbar compression and distraction tests, hip and sacroiliac joint pain provocation tests, neurological examination, manual muscle tension palpation tests and joint spring tests. After receiving one-time lumbar traction, the subject would rate his/her perceived pain level, global improvement level, and was tested for his/her lumbar sagittal ROM and SLR angles again. Adverse response to lumbar traction was determined by simultaneously fulfilling one subjective criterion (increased pain or negative global rating on improvement) and one objective criterion (decreased lumbar sagittal ROM > 4 degrees or decreased SLR > 6 degrees).
Statistical Analyses: Independent t tests and chi-square testes were used to assess differences between those who did and did not develop adverse responses. Stepwise multiple logistics regression was used to identify significant predictors for classifying the two groups. We then calculated the accuracy and strength for the prediction model; including coefficients of determination (R2) and the positive and negative likelihood ratios.
Result: Four significant factors, including “movement exacerbation”, “flexion ROM >24.5 degrees”, “central back pain“, and “negative response to manual lumbar traction“, have been identified. The cumulative R2 was 0.24. The presence of at least three of these four predictors increased the probability of adverse effects with lumbar traction form 5.8% to 25%.
Conclusion: the predictors for adverse effects from one-time lumbar traction can be used as a reference for managing patients with low back pain. When a patient meets criteria specified by at least three of these four predictors, it may be necessary to withhold the traction treatment for a session and re-evaluate the patient for other treatment options.
摘要 vi
第一章 緒論 1
第一節 研究背景 1
第二節 研究重要性 3
第三節 研究目的 3
第二章 文獻回顧 4
第一節 機械性下背痛 4
第二節 機械性下背痛的病理機轉 4
第三節 機械式腰椎牽引介紹 5
第四節 腰椎牽引的惡化反應 6
第三章 研究方法 10
第一節 研究設計 10
第二節 受測者 10
第三節 牽引前基本資料 11
第四節 腰椎牽引的參數設定 15
第六節 腰椎牽引造成立即惡化反應之定義 16
第七節 統計分析 17
第四章 研究結果 18
第一節 患者治療前的基本資料 18
第二節 與立即牽引惡化反應相關之單因子變項分析 18
第三節 與立即牽引惡化反應相關之逐步羅吉斯複回歸分析 20
第五章 討論 21
第一節 單次腰椎牽引惡化反應之顯著因子 21
第二節 符合惡化反應預測因子的正負向概以比 25
第三節 研究限制與未來研究的建議 26
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