臺灣博碩士論文加值系統

中文摘要
研究背景與目的 髕骨股骨症候群在跑者等活動度高的族群十分常見；患有此症狀的跑者進行下肢承重動作時常會出現動態膝外翻的現象，此現象長期會造成股骨和脛骨、髕骨間的異常排列，若下肢在額狀面及水平面的動作控制能力不佳，經由跑步如此高重複性、高撞擊的活動，便容易出現髕骨股骨症候群。回顧文獻，此症狀的患者之足部整體活動度較正常族群大，並且容易觀察到足部維持旋前的姿勢；對於同時患有第一趾骨列不穩定之跑者，其足部整體活動度更為增加，長期承重後並會合併出現拇趾外翻的現象。由拇趾外翻族群之相關文獻可發現，該族群於行走時足部推進能力受損，並呈現由足部連帶下肢整體動態不穩定的問題。本研究的目的為探討針對同時患有髕骨股骨症候群、第一趾骨列不穩定和拇趾外翻現象的跑者設計的一套下肢神經肌肉控制訓練，並額外提供針對第一趾骨列矯正設計的動態貼紮與足部肌肉訓練，比較其治療效益。
研究方法 本研究為有兩個治療組的實驗型研究。共30位專項為長距離跑步或足球的大學運動員，或是台北地區的業餘跑者參與本研究；他們皆同時患有髕骨股骨症候群、第一趾骨列不穩定和拇趾外翻現象。所有受試者都接受同樣的臨床檢查來排除膝蓋異常結構、病變，或是非和髕骨股骨症候群相關的下肢問題。所有受試者皆接受兩次成效評量，兩次評量中間進行為期6週的物理治療介入。中途退出研究的受試者之後測結果，使用該受試者所屬組別之平均值代入，以進行意向分析 (Intention to treat analysis)。
成效評量 向下踏階測試中支撐腳控制膝部的肌肉之活化程度與時間區間使用表面肌電圖 (TELEmyo DTS, Noraxon Inc., Arizona, USA)收集。下階動作之時間區間則以陀螺儀兼加速規 (myoMOTION™ system, Noraxon Inc., Arizona, USA)記錄；此時間區間以測試中移動腳向下碰觸階梯之時間點決定。主觀評量項目包括髕骨股骨症候群的症狀，使用視覺類比量表劃記；另，由個案回報在膝蓋症狀被誘發之前能連續跑步的最長距離。下肢之排列測量包括脛骨股骨角度、拇趾外翻角度、舟狀骨落下測試、足弓高度指數。
統計分析 本研究所有的實驗數據將使用Statistical Product and Service Solutions, SPSS 20.0做資料分析。費雪精確檢定與獨立樣本t檢定將會用來檢驗兩組基本資料間的差異。前後測的結果則是使用二維重複測量變異數分析是否有組別-時間的交互作用；所有的顯著水準皆設定在 p < 0.05。
實驗結果 儘管兩組受試者之髕骨股骨疼痛程度比較治療前後皆出現顯著下降 (p < 0.001)，但給予額外第一趾骨列矯正之組別在治療過後，相較於控制組，在髕骨股骨疼痛出現之前的連續跑步距離出現顯著增加 (p = 0.039)，並且在股內側肌 (p = 0.003)、股外側肌 (p = 0.038)、臀中肌 (p = 0.022) 三項變項之肌肉活化程度呈現顯著下降，代表實驗組受試者在使用這些肌肉時能以較好的運動單元徵招效率完成向下踏階測試；除此之外，該組別之拇趾外翻角度也經由治療而明顯減少 (p = 0.001)。
結論與臨床意義 本研究結果證實對同時患有髕骨股骨症候群、第一趾骨列不穩定和拇趾外翻的跑者而言，給予下肢閉鎖鍊訓練並額外提供第一趾骨列矯正治療對增進運動表現、提升下肢肌群使用效率等較佳的治療效果。
關鍵字 髕骨股骨症候群，跑者，第一趾骨列不穩定，下肢閉鎖鍊訓練

Abstract
Background and Purpose: Patellofemoral pain syndrome (PFPS) is common in physically active population such as runners. Dynamic knee valgus can often be observed in the PFPS patients. In the long term, such abnormal movement pattern results in patella mal-tracking. If the femur and/or tibia remain uncontrolled in the frontal and transverse planes, the runner will easily develop chronic knee discomfort due to sustaining a high impact and loading activity. For PFPS patients, an increase in foot flexibility and pronated foot posture are reported in literature. Other than rearfoot eversion, first ray instability further increases foot flexibility during foot pronation. As a result, hallux valgus develops. People functioning with abducted hallux represent impaired foot push-off ability, which creates unstable lower extremities in repetitive weight bearing movements. The aim of this study was to investigate the effectiveness of a lower extremity neuromuscular exercises for runners with PFPS, first ray instability, and hallux valgus.
Methods: This was an experimental study with two treatment groups. A total of 30 college athletes majoring in long distance running or soccer, or recreational runners in Taipei metropolitan area were recruited (30 runners with PFPS, first ray instability and hallux valgus). A set of clinical examination would be conducted to rule out abnormal knee structures, pathologies, or injuries apart from PFPS. Subjects received pre- and post-tests, with a 6-week intervention period in between. For those who dropped out, the average data of their allocated group was filled into post-test data based on the principle of intention to treat analysis.
Outcome measures: Muscle activation of the muscles controlling the hip and knee movements during the step down test would be recorded using surface electromyographic sensors (TELEmyo DTS, Noraxon Inc., Arizona, USA.). In order to determine correct timing of each step, the timing when the front leg reached the front step was tracked using 3D inertial accelerators (myoMOTION™ system, Noraxon Inc., Arizona, USA). Knee pain level was rated in a visual analog scale. Pain-free running distance was reported by subjects. Lower extremity alignment included tibiofemoral angle, hallux valgus angle, navicular drop, and arch height index.
Statistical analysis: We analyzed the data with Statistical Product and Service Solutions (SPSS 20.0) for Windows. Fisher-exact and independent t tests were used to examine between-group differences of baseline and demographic data. For difference between pre- and post-test, Two-way repeated measures ANOVA was chosen to examine group-by-time interaction on all the outcome variables. All significance level will be set at p < 0.05.
Results: Patellofemoral pain was improved in both groups after intervention (p < 0.001). However, subjects demonstrated a significant increase in pain-free running distance (p = 0.039) through additional first ray correction. Regarding muscle activities, the experimental group showed a significant decrease in vastus medialis oblique (p = 0.003), vastus lateralis (p = 0.038), and gluteus medius (p = 0.022) muscle groups, which indicated an improvement in motor unit recruitment efficiency. Nevertheless, the severity of hallux valgus (p = 0.001) was significantly improved through a program combining first ray correction and lower extremity neuromuscular retraining.
Conclusions and clinical significance: For runners with PFPS, first ray instability and hallux valgus, it is more effective to provide neuromuscular exercise with first ray correction. After 6-week of exercises, runners may improve exercise performance and neuromuscular efficacy in vastus medialis oblique, vastus lateralis, and gluteus medius muscle groups.
Keywords: patellofemoral pain syndrome, runner, first ray instability, lower extremity closed-chain exercise

Table of Contents

Acknowledgments i
中文摘要 iii
Abstract v
Table of Contents viii
List of tables x
List of figures xi
Chapter I. Introduction 1
PART 1. BACKGROUND AND MOTIVATION 1
PART 2. STUDY PURPOSE 5
PART 3. HYPOTHESIS 5
PART 4. CLINICAL SIGNIFICANCE OF THE STUDY 6
Chapter II. Literature Review 7
PART 1. RUNNERS WITH PATELLOFEMORAL PAIN 7
PART 2. FREQUENTLY USED FUNCTIONAL TASKS FOR PFPS 10
PART 3. CURRENT TREATMENT OF PFPS 11
PART 4. CONSERVATIVE TREATMENT FOCUSED ON THE FOREFOOT 13
PART 5. SUMMARY OF THE LITERATURE REVIEW 14
Chapter III. Method 15
PART 1. RESEARCH DESIGN 15
PART 2. SUBJECTS 15
PART 3. OUTCOME MEASUREMENTS AND INSTRUMENTATION 17
PART 4. PRELIMINARY STUDY 21
PART 5. INTERVENTION 23
PART 6. PROCEDURE 24
PART 7. DATA ANALYSIS OF SEMG 25
PART 8. STATISTICAL ANALYSIS 26
Chapter IV. Results 27
PART 1. SUBJECT RECRUITMENT 27
PART 2. SUBJECT CHARACTERISTICS OF TWO GROUPS 28
PART 3. NEUROMUSCULAR CONTROL PARAMETERS IN STEP DOWN TEST 28
PART 4. LOWER EXTREMITY ALIGNMENT 29
PART 5. CLINICAL OUTCOMES 30
Chapter V. Discussion 31
PART 1. PAIN INTENSITY 31
PART 2. RUNNING DISTANCE 32
PART 3. NEUROMUSCULAR CONTROL PARAMETERS 33
PART 4. LOWER EXTREMITY ALIGNMENT 37
PART 5. STUDY LIMITATION 40
PART 6. FUTURE SUGGESTIONS 42
PART 7. CLINICAL IMPLICATION 42
Chapter VI. Conclusion 44
References 45

List of tables

Table 1. The demographic and baseline measurement of intervention groups 51
Table 2. Comparison of neuromuscular control ability between the two intervention groups at PRE and POST 54
Table 3. Comparison of LE alignment between the two intervention groups at PRE and POST 56
Table 4. Comparison of clinical outcomes between the two intervention groups at PRE and POST 57

List of figures

Figure 1. The flow chart of the study 58
Figure 2. Screenshots and measurement of lower extremity displacement in Adobe Photoshop CS3 59
Figure 4. Placement of 3D inertial accelerometers 61
Figure 5. Visual analog scale 62
Figure 6. Measurement of lower extremity alignment 63
Figure 7. Environment settings of the step down test 64
Figure 8. Equipment used in neuromuscular retraining programs 65
Figure 9. The application of dynamic taping 66
Figure 10. Shift ratio of proximal training group and combined training group at pre- and post-test 67
Figure 11. Vastus medialis oblique (VMO) muscle activity of proximal training group and combined training group at pre- and post-test 68
Figure 12. Vastus lateralis (VL) muscle activity of proximal training group and combined training group at pre- and post-test 69
Figure 13. Medial hamstrings (MH) muscle activity of proximal training group and combined training group at pre- and post-test 70
Figure 14. Gluteus medius (GMed) muscle activity of proximal training group and combined training group at pre- and post-test 71
Figure 15. The ratio of vastus medialis oblique (VMO) and vastus lateralis (VL) of proximal training group and combined training group at pre- and post-test 72
Figure 16. Hallux valgus angle of proximal training group and combined training group at pre- and post-test 73
Figure 17. Arch height index of proximal training group and combined training group at pre- and post-test 74
Figure 18. Pain intensity of proximal training group and combined training group at pre- and post-test 75
Figure 19. Pain-free running distance of proximal training group and combined training group at pre- and post-test 76

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