臺灣博碩士論文加值系統

背景：許多久站工作者有肌肉骨骼的症狀，根據研究統計約有77%的員工抱怨有身體疼痛，其中，疼痛部位在下背的比例為34%，雖然位居第二名，但和第一名的足踝部位比例（35%）不相上下。久站工作者的工作除了長時間站立之外，工作需求也可能包括在狹窄處旋轉身體、取出和堆放高處物品、向前彎、提重物、坐下及站起等，這些工作上的身體需求活動也可能是下背痛的危險因子。在工作中反覆出現錯誤的或相同的動作模式，會使局部組織的應力增加，進而導致疼痛。當工作者無法控制身體不出現錯誤的動作模式時，其動作控制能力是降低的，學者將此情況定義為動作控制功能障礙。近年來，陸續有學者提出動作控制測試來測量腰椎的動作控制能力，研究也顯示有下背痛的人和沒有下背痛的人在主動控制腰椎動作的能力存在差異。然而，據我們所知，尚無研究針對久站工作者的動作控制能力進行調查，也沒有研究工作時的動作需求與動作控制能力之間的關係。研究目的：本研究第一部份為比較有下背痛和沒有下背痛問題久站工作者的動作控制能力，第二部分是探討有下背痛之久站工作者的下背痛問題、身體勞動需求與動作控制能力之間的關係。研究方法：本研究為橫斷面及探索性研究，研究第一部分有兩組，分別為有下背痛和無下背痛的久站工作者各36位，第二部分則有65位有下背痛和36位無下背痛之久站工作者參與。詢問受試者的基本資料、身體勞動需求和下背痛相關資料後，由一名物理治療師進行一組包含腰椎伸直、屈曲和旋轉控制的測試，並依每一項測試的通過標準和動作表現給予0至8分，越高分代表動作控制能力越好。數據分析：研究第一部分資料是使用曼惠特尼U檢定和羅吉斯迴歸分析，比較有無下背痛兩組間腰椎動作控制測試的得分，並建立迴歸模式找出較具影響力的測試。研究第二部分之統計分析是使用曼惠特尼U檢定(Mann-Whitney U test)、卡方檢定(Chi-Square test)、單因子變異數分析(Analysis of Variance)、斯皮爾曼等級相關係數(Spearman's ρ test)、羅吉斯迴歸分析(Logistic regression)和Mantel-Haenszel檢定，建立下背痛問題、身體勞動需求與動作控制能力之間的關係。各項檢定的顯著差異水準定為 p < 0.05。結果：第一部份研究結果顯示，有下背痛的久站工作者相較無下背痛的久站工作者，其全部的腰椎動作控制測試、腰椎伸直控制測試、腰椎屈曲控制測試和腰椎旋轉控制測試的分數都顯著較差(p<0.001)，而在羅吉斯迴歸模式中，未通過「站姿鞠躬回到中立姿勢」(p=0.013, OR=11.333)、「站立轉位到坐姿」(p=0.009, OR=18.470)、「四足跪姿向後擺」(p=0.005, OR=14.989)和「站姿胸椎旋轉向非疼痛側」(p=0.002, OR=21.007)等四個測試，與下背痛發生較相關。第二部分的研究結果呈現不同靜態站立姿勢在腰椎伸直控制測試分數中有顯著的組間差異(p=0.006) 且腰椎前凸者之伸直控制測試分數顯著低於理想姿勢的人(p=0.013)。不同的工作姿勢頻率只有和少數幾個腰椎動作控制測試有顯著相關(p=0.017至0.049)，而工作有負重需求者，其大部分的腰椎屈曲、旋轉控制測試分數較低(p<0.001至p=0.048)，但和腰椎伸直控制測試分數則無顯著相關。此外，Mantel-Haenszel檢定結果顯示工作上有負重需求者，若未通過「站姿鞠躬回到中立姿勢」、「站立轉位到坐姿」、「四足跪姿向後擺」或「站姿胸椎旋轉向非疼痛側」等四個測試，與下背痛會有顯著相關(p<0.001至p=0.009)。在羅吉斯迴歸模型中，顯著影響伸直型下背痛的腰椎伸直控制的測試項目包括「站姿鞠躬回到中立姿勢」(p=0.022, OR=5.182)、「仰躺屈膝雙腳降下」(p=0.029, OR=3.989)，同一個模型中，性別(p=0.004, OR=6.624)以及負重身體旋轉需求(p=0.004, OR=9.402)也為顯著影響因子。而針對屈曲型下背痛影響因子的迴歸模型中，顯著的腰椎屈曲控制測試項目以及因子則包括「站姿鞠躬」(p=0.026, OR=4.659)、「站姿胸椎屈曲」(p=0.005, OR=7.287)、「站立轉位到坐姿」(p=0.006, OR=12.854)、「四足跪姿向後擺」(p=0.010, OR=7.992)以及性別(p=0.018, OR=6.330)。結論：本研究發現有下背痛的久站工作者呈現較差的腰椎動作控制能力，且不管在腰椎伸直、屈曲或旋轉方向皆較無下背痛者差，而其中的「站姿鞠躬回到中立姿勢」、「站立轉位到坐姿」、「四足跪姿向後擺」和「站姿胸椎旋轉向非疼痛側」這四項測試較推薦用於臨床測試和訓練。久站工作者腰椎前凸的靜態站立姿勢和腰椎伸直動作控制能力有關，工作上的負重動作需求則和腰椎屈曲和旋轉動作控制能力較有關，所以靜態的工作站姿和動態的負重工作需求，在臨床上對於腰椎動作控制評估或訓練的選擇上十分相關且重要。針對伸直型下背痛的久站工作者，建議可以選用腰椎伸直控制中的「站姿鞠躬回到中立姿勢」和「仰躺屈膝雙腳降下」測試做為臨床使用，針對屈曲型下背痛者，則腰椎屈曲控制的「站姿鞠躬」、「站姿胸椎屈曲」、「站立轉位到坐姿」和「四足跪姿向後擺」等測試皆適合使用。下背痛為一多面向的問題，受到多重因素影響，本研究初步了解久站工作者的下背痛問題和其身體勞動需求與腰椎動作控制能力三者之間的關係，可供臨床工作者在執行下背痛評估時，更完整的應用資訊，也提供未來研究者做後續研究的參考。

Background: Musculoskeletal symptoms are common among prolonged standing workers. According to previous studies, about 70% of employees have musculoskeletal symptoms with a high proportion experiencing in their low back. Besides prolonged standing, these workers’ physical work demands also involve turning a body in a narrow space, pushing or pulling objects placed in high positions, leaning forward, lifting heavy objects, and frequent position changes between different working postures. Ergonomic exposure of work activities has been proven to be a potential risk factor of developing low back pain (LBP). Repetitive movements, especially faulty compensatory movements, have been found associated with increased localized tissue stress which may induce pain and discomfort. Several researchers attribute these movement faults to decreased movement control ability, and name it the movement control dysfunction. A series of movement control tests have been proposed to measure the movement control ability of the lumbar spine. Previous studies have demonstrated a significant difference between subjects with and without LBP regarding their ability to actively control the movements of their lumbar spine. However, to our knowledge, no study has investigated the movement control ability of prolonged standing workers, nor has explored the relationships between the physical work demands and the movement control ability. Purposes: (1) to compare the movement control ability between prolonged standing workers with and without LBP, and (2) to explore the relationships among LBP subgroups, physical work demands and the movement control ability in prolonged standing workers. Methods: This was a cross-sectional and exploratory study. A total of 72 prolonged standing workers (36 with and 36 without LBP) participated in the first part of the study. In the second part, data from 101 prolonged standing workers (65 with and 36 without LBP) were analyzed. After inquiring about the subjects’ basic data, physical work demands and LBP-related information, a physical therapist performed a set of lumbar extension, flexion and rotation control tests on all subjects. Data analysis: The Mann Whitney U tests were used to compare the scores of the lumbar movement control tests between the LBP and non-LBP groups, and logistic regression analyses were used to identify significant movement control tests. For data collected in the second part, we used Mann-Whitney U tests, Chi-square tests, one-way analyses of variance, Spearman's rank correlation coefficients, logistic regressions and Mantel-Haenszel tests for analysis. The significance level was set at 0.05. Results: The first part of our study results showed significant differences existed between workers with and without LBP in the average of all lumbar extension (p<0.001), flexion (p<0.001) and rotation (p<0.001) control tests. The logistic regression analysis identified 4 significant LBP-associated motor control tests including “standing bow back to neutral” (p=0.013, OR=11.333), “stand to sit transfer” (p=0.009, OR=18.470), “all-four backward rocking” (p=0.005, OR=14.989), and “standing thoracic rotation to the non-painful side” (p=0.002, OR=21.007). Results of the second part of the study revealed significant differences among 4 different static standing postures in the lumbar extension control test score (p=0.006), but not in the lumbar flexion control test score (p=0.621) and the lumbar rotation control test score (p= 0.052). In addition, the extension control ability of workers with lumbar lordosis posture were significantly lower than workers with ideal standing posture (p=0.013). The frequency of different working postures was negatively correlated with several lumbar movement control ability (p=0.017 to 0.049). Workers with heavy work demand demonstrated significantly lower lumbar flexion and rotation control ability (p<0.001 to p=0.048), but not their lumbar extension control ability. Mantel-Haenszel tests showed that for workers with heavy work demand, the passing of “standing bow back to neutral”, “stand to sit transfer”, “all-four backward rocking” or “standing thoracic rotation to the non-painful side” significantly correlated with the absence of LBP (p<0.001 to p=0.009). In the regression model, passing of “standing bow back to neutral test” (p=0.022, OR=5.182), “crook-lying bent leg lower test”, (p=0.029, OR=3.989), gender (p=0.004, OR=6.624) and the heavy work demand of trunk rotation (p=0.004, OR=9.402) significantly associated with the extension-type LBP. “Standing bow test” (p=0.026, OR=4.659), “standing thoracic flexion test” (p=0.005, OR=7.287), “stand to sit transfer test” (p=0.006, OR=12.854), “all-four backward rocking test” (p=0.010, OR=7.992), and gender (p=0.018, OR=6.330) were found significantly associated with the flexion-type LBP. Conclusion: Prolonged standing workers with LBP have poorer lumbar movement control ability, regardless of the direction in lumbar extension, flexion, or rotation. Among them, “standing bow back to neutral”, “stand to sit transfer”, “all-four backward rocking”, and “standing thoracic rotation to the non-painful side” were recommended for clinical testing and training. The static standing posture of lumbar lordosis was related to poorer lumbar extension control ability, while the heavy work demand was more related to the lumbar flexion and rotation control ability. Therefore, the static standing posture and information of worker’s dynamic heavy work demand can be clinically relevant and important for the selection of lumbar movement control evaluation or training. For prolonged standing workers with extension-type LBP, it is recommended to choose “standing bowing back to neutral” and “crook-lying bent leg lowering” for clinical use. For testing and training workers with flexion-type LBP, “standing bow”, “standing thoracic flexion”, “stand to sit transfer” and “all-four backward rocking” are recommended. LBP is a multidimensional and multifactorial phenomenon, our study yields a preliminary understanding of the relationships between LBP problems, physical work demands and lumbar movement control ability of the prolonged standing workers. Future study may explore the utility of the motor control tests based on our study findings.

致謝 ........................................................................... i
目錄 ........................................................................... ii
表目錄 ......................................................................... iv
圖目錄 ......................................................................... viii
摘要 ............................................................................1
Abstract ....................................................................... 4
第一章 簡介 .................................................................... 8
第一節 研究背景與動機 .......................................................... 8
第二節 研究目的 .................................................................10
第三節 重要性 .................................................................. 10
第二章 文獻回顧 .................................................................11
第一節 下背痛的危險因子 ........................................................ 11
第二節 久站工作者的下背痛問題 .................................................. 11
第三節 久站工作者的身體勞動需求 ................................................ 13
第四節 下背痛的動作控制障礙 .................................................... 13
第五節 動作控制能力的評估測試 .................................................. 17
第六節 下背痛動作控制的相關研究 ................................................ 19
第七節 綜合結論 ................................................................ 20
第三章 研究方法 ................................................................ 21
第一節 研究設計與研究架構 ...................................................... 21
第二節 研究材料與研究方法 ...................................................... 22
第三節 資料處理與統計分析 ...................................................... 27
第四章 結果 .................................................................... 31
第一節 受試者基本資料 .......................................................... 31
第二節 有無下背痛者腰椎動作控制測試之比較 ...................................... 31
第三節 靜態站立姿勢和腰椎動作控制測試的關係 .................................... 34
第四節 腰椎動作控制測試和工作需求之間的關係 .................................... 36
第五節 工作需求和下背痛及其亞型之間的關係 ...................................... 46
第六節 下背痛亞型和腰椎動作控制能力之間的關係 .................................. 47
第五章 討論 .................................................................... 50
第一節 受試者基本資料 .......................................................... 50
第二節 有無下背痛者腰椎動作控制測試之比較 ...................................... 50
第三節 靜態站立姿勢和腰椎動作控制測試的關係 .................................... 58
第四節 腰椎動作控制測試和工作需求之間的關係 .................................... 63
第五節 工作需求和下背痛及其亞型之間的關係 ...................................... 72
第六節 下背痛亞型和腰椎動作控制能力之間的關係 .................................. 77
第七節 實驗限制 ................................................................ 83
第六章 結論與臨床應用 .......................................................... 85
參考文獻 ....................................................................... 86
附錄一 國立陽明大學人體研究暨倫理委員會審查通過證明 ............................ 186
附錄二 腰椎動作控制測試圖例 .................................................... 191
附錄三 腰椎動作控制測試計分表 .................................................. 195
表 1、前驅實驗結果：腰椎伸直控制測試 ........................................... 97
表 2、前驅實驗結果：腰椎屈曲控制測試 ........................................... 98
表 3、前驅實驗結果：腰椎旋轉控制測試 ........................................... 99
表 4、研究第一部分受試者基本資料之一 ........................................... 100
表 5、研究第一部分受試者基本資料之二 ........................................... 101
表 6、研究第二部分受試者基本資料 ............................................... 102
表 7、有無下背痛者腰椎伸直控制測試之比較 ....................................... 103
表 8、有無下背痛者腰椎屈曲控制測試之比較 ....................................... 104
表 9、有無下背痛者腰椎旋轉控制測試之比較 ....................................... 105
表 10、有無下背痛者腰椎動作控制測試之比較 ...................................... 106
表 11、腰椎伸直控制測試建立的下背痛迴歸模式 .................................... 107
表 12、腰椎屈曲控制測試建立的下背痛迴歸模式 .................................... 108
表 13、腰椎旋轉控制測試建立的下背痛迴歸模式 .................................... 109
表 14、腰椎動作控制測試建立的下背痛向前逐步迴歸模式 ............................ 110
表 15、靜態站立姿勢和有無下背痛的關係之一 ...................................... 112
表 16、靜態站立姿勢和有無下背痛的關係之二 ...................................... 113
表 17、靜態站立姿勢和下背痛亞型的關係 .......................................... 114
表 18、靜態站立姿勢和腰椎伸直控制測試的關係 .................................... 115
表 19、不同靜態站立姿勢的腰椎伸直控制測試分數之比較 ............................ 116
表 20、靜態站立姿勢和腰椎屈曲控制測試的關係 .................................... 118
表 21、靜態站立姿勢和腰椎旋轉控制測試的關係 .................................... 119
表 22、不同靜態站立姿勢的腰椎旋轉控制測試分數之比較 ............................ 121
表 24、靜態站立姿勢和腰椎動作控制測試系列平均分數的關係 ........................ 123
表 25、腰椎伸直控制測試和工作姿勢之間的相關性 .................................. 124
表 26、腰椎屈曲控制測試和工作姿勢之間的相關性 .................................. 125
表 27、腰椎旋轉控制測試和工作姿勢之間的相關性 .................................. 126
表 28、腰椎伸直控制測試和負重動作需求之間的相關性 .............................. 128
表 29、腰椎屈曲控制測試和負重動作需求之間的相關性 .............................. 129
表 30、腰椎旋轉控制測試和負重動作需求之間的相關性 .............................. 130
表 31、腰椎伸直控制測試和是否有抬重物需求之間的關係 ............................ 131
表 32、腰椎屈曲控制測試和是否抬重物需求之間的關係 .............................. 132
表 33、腰椎旋轉控制測試和是否抬重物需求之間的關係 .............................. 133
表 34、有無抬重物需求之下站姿鞠躬回到中立姿勢測試和有無下背痛的關係 ............ 134
表 35、有無抬重物需求之下站立轉位到坐姿測試和有無下背痛的關係 .................. 135
表 36、有無抬重物需求之下四足跪姿向後擺測試和有無下背痛的關係 .................. 136
表 37、有無抬重物需求之下站姿胸椎旋轉向非疼痛側測試和有無下背痛的關係 .......... 137
表 38、腰椎伸直控制測試和是否高處放置或拿取重物需求之間的關係 .................. 138
表 39、腰椎屈曲控制測試和是否高處放置或拿取重物需求之間的關係 .................. 139
表 40、腰椎旋轉控制測試和是否高處放置或拿取重物需求之間的關係 .................. 140
表 41、有無從高處取物需求之下站姿鞠躬回到中立姿勢測試和有無下背痛的關係 ........ 141
表 42、有無從高處取物需求之下站立轉位到坐姿測試和有無下背痛的關係 .............. 142
表 43、有無從高處取物需求之下四足跪姿向後擺測試和有無下背痛的關係 .............. 143
表 44、有無從高處取物需求之下站姿胸椎旋轉向非疼痛側測試和有無下背痛的關係....... 144
表 45、腰椎伸直控制測試和是否搬運重物需求之間的關係 ............................ 145
表 46、腰椎屈曲控制測試和是否搬運重物需求之間的關係 ............................ 146
表 47、腰椎旋轉控制測試和是否搬運重物需求之間的關係 ............................ 147
表 48、有無搬運需求之下站姿鞠躬回到中立姿勢測試和有無下背痛的關係 .............. 148
表 49、有無搬運需求之下站立轉位到坐姿測試和有無下背痛的關係 .................... 149
表 50、有無搬運需求之下四足跪姿向後擺測試和有無下背痛的關係 .................... 150
表 51、有無搬運需求之下站姿胸椎旋轉向非疼痛側測試和有無下背痛的關係 ............ 151
表 52、腰椎伸直控制測試和是否推重物需求之間的關係 .............................. 152
表 53、腰椎屈曲控制測試和是否推重物需求之間的關係 .............................. 153
表 54、腰椎旋轉控制測試和是否推重物需求之間的關係 .............................. 154
表 55、有無推重物需求之下站姿鞠躬回到中立姿勢測試和有無下背痛的關係 ............ 155
表 56、有無推重物需求之下站立轉位到坐姿測試和有無下背痛的關係 .................. 156
表 57、有無推重物需求之下四足跪姿向後擺測試和有無下背痛的關係 .................. 157
表 58、有無推重物需求之下站姿胸椎旋轉向非疼痛側測試和有無下背痛的關係 .......... 158
表 59、腰椎伸直控制測試和是否拉重物需求之間的關係 .............................. 159
表 60、腰椎屈曲控制測試和是否拉重物需求之間的關係 .............................. 160
表 61、腰椎旋轉控制測試和是否拉重物需求之間的關係 .............................. 161
表 62、有無拉重物需求之下站姿鞠躬回到中立姿勢測試和有無下背痛的關係 ............ 162
表 63、有無拉重物需求之下站立轉位到坐姿測試和有無下背痛的關係 .................. 163
表 64、有無拉重物需求之下四足跪姿向後擺測試和有無下背痛的關係 .................. 164
表 65、有無拉重物需求之下站姿胸椎旋轉向非疼痛側測試和有無下背痛的關係 .......... 165
表 66、腰椎伸直控制測試和是否負重身體旋轉需求之間的關係 ........................ 166
表 67、腰椎屈曲控制測試和是否負重身體旋轉需求之間的關係 ........................ 167
表 68、腰椎旋轉控制測試和是否負重身體旋轉需求之間的關係 ........................ 168
表 69、有無負重身體旋轉需求之下站姿鞠躬回到中立姿勢測試和有無下背痛的關係 ...... 169
表 70、有無負重身體旋轉需求之下站立轉位到坐姿測試和有無下背痛的關係 ............ 170
表 71、有無負重身體旋轉需求之下四足跪姿向後擺測試和有無下背痛的關係 ............ 171
表 72、有無負重身體旋轉需求之下站姿胸椎旋轉向非疼痛側測試和有無下背痛的關係 .... 172
表 73、工作姿勢和下背痛的關係 .................................................. 173
表 74、工作姿勢和下背痛亞型之間的關係 .......................................... 174
表 75、負重動作需求和下背痛的關係 .............................................. 175
表 76、負重動作需求和下背痛亞型之間的關係 ...................................... 176
表 77、下背痛亞型和腰椎伸直控制能力的關係 ...................................... 177
表 78、下背痛亞型和腰椎屈曲控制能力的關係 ...................................... 178
表 79、腰椎伸直控制測試和伸直型下背痛的關係 .................................... 179
表 80、腰椎屈曲控制測試預測屈曲型下背痛機率之向前逐步迴歸模式 .................. 180
圖 1、研究流程圖 ............................................................... 181
圖 2、研究第一部份下背痛組的疼痛持續時間之長條圖 ............................... 182
圖 3、研究第一部份下背痛組的疼痛程度之長條圖 ................................... 183
圖 4、研究第二部份下背痛組的疼痛持續時間之長條圖 ............................... 184
圖 5、研究第二部份下背痛組的疼痛程度 ........................................... 185

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