不同型態軀幹穩定運動時腰部多裂肌厚度變化-動態超音波研究

背景：腰部多裂肌為維持腰部穩定相當重要的肌群，尤其深層多裂肌被認為在持續性收縮及維持關節穩定更為重要，下背痛病人也證實在肌肉控制方面會產生變化，但目前在人體上用來評估深層多裂肌的方法卻仍缺乏，亟需臨床上可行、且可分別量測深層多裂肌功能的評估方法。目的: 1) 建立以超音波影像量測深層多裂肌之方法學；2) 建立以超音波影像量測深層、淺層多裂肌之信度；3) 研究可能會影響深層、淺層多裂肌收縮的因素；4) 比較有無下背痛受試者之間，分別在自主意識收縮及自動收縮這兩大類運動裡，比較深、淺層多裂肌收縮的動作型態有何不同。方法：比較離體豬隻的腰部深層多裂肌形態學與其超音波影像，並注入染料確認多裂肌解剖位置，以建立超音波量測深層多裂肌之方法學。以超音波影像儀器擷取靜態時及收縮時之深層及淺層多裂肌形態學變化以代表收縮程度，並量測兩層肌肉的厚度改變。信度測試及主要測試皆收取下背痛及健康無症狀之受試者，並探討兩層多裂肌之厚度變化與年齡、身高、體重、身體質量指數(Body mass index, BMI)與性別之影響。接著請受試者作兩類常用於臨床治療之多裂肌等長收縮之動作，第一類為自主意識收縮，包含腹部內縮、背肌撐厚、骨盆前傾等；第二類為自動收縮，分為俯臥抬高與測試邊同邊及對邊上肢或下肢，並觀察其厚度變化。信度分析部份將以組內相關係數(Intraclass correlation coefficient, ICC3,3)來分析。研究可能影響因素將用Pearson correlation 計算在休息時及收縮時之肌肉厚度及兩個狀態間之厚度變化，與年齡、身體測量參數的相關性，而以independent t-test來比較性別之間差異。以三尾變異數分析(3-way ANOVA)作在兩組之間同一類型中各動作與深、淺層多裂肌厚度變化之差異比較，α值設在0.05。結果：超音波可以觀測離體豬隻腰部深層多裂肌，實際解剖走向及超音波影像都可與人類相對應。信度測試確立在有無下背痛之兩組受試者中，經由三次量測而得之深、淺層多裂肌在休息、收縮時之厚度或厚度變化平均值，皆可達良好信度(ICC3,3= 0.84~1.00)。在本次收錄之受試者中，年齡、身高、體重、身體質量指數(Pearson correlation= 0.47~0.66)、與性別(p= 0.03~0.05)皆會影響休息及收縮時之淺層多裂肌厚度，厚度變化則不影響，深層多裂肌也都不受影響。在無症狀之受試者中，於自主意識收縮類動作時淺層多裂肌之厚度變化大於深層多裂肌(p< 0.005)，但深層肌之厚度變化與最大收縮時之比例高(0.46~0.95)。檢視不同動作間差異，腹部內縮時之多裂肌厚度變化明顯較背肌撐厚時(p< 0.005)及骨盆前傾時少(p< 0.005)，且淺層肌隨不同動作增加的幅度大於深層肌。自動收縮類動作中，抬高同邊及對邊上肢或抬高同邊及對邊下肢時皆能使淺層多裂肌之標準化厚度變化大於深層多裂肌(p< 0.005)。若是在有無下痛之受試者間比較，在自主意識收縮中，因動作而異之收縮模式在兩組間不相同(p= 0.02)，事後比較發現淺層多裂肌之後度變化較深層多裂肌大(p< 0.005)，且此趨勢隨動作荷重增加而增加。在趴姿抬同側及對側上肢時，病人的多裂肌厚度變化相較於健康人多 (p= 0.05)。在趴姿抬同側及對側上肢或下肢時，淺層多裂肌之厚度變化都較深層多裂大(p< 0.005)。結論：1) 以觀測其解剖走向及超音波影像都可與人類相對應的離體豬隻時實驗，能夠建立觀測腰部深層多裂肌之方法學；2) 經由三次量測而得之深、淺層多裂肌在休息、收縮時之厚度或厚度變化平均值，皆可達良好信度；3) 深、淺層多裂肌之收縮前後厚度變化變化皆不受年齡、身高、體重、身體質量指數與性別影響；4) 自主意識收縮類動作中有高比例之深層肌參與動作，可作為選擇脊椎穩定運動及與下背痛者比較之參考。腹部內縮時前側及背側多裂肌共同收縮，以抬單邊上下肢所引發之兩側腰部多裂肌對稱性的自動收縮，此多裂肌收縮模式支持腰部多裂肌之穩定性功能。復發性下背痛著傾向使用較無症狀者多的多裂肌。可能與代償軀幹深層肌的延遲收縮有關。本篇研究提供治療復發性下背痛患者動作控制的治療方向。

關鍵字

腰部多裂肌；超音波；動作；下背痛

並列摘要

Background: The lumbar multifidus (MF) is an important muscle in maintaining spinal stability. The deep layer of MF (dMF) is considered important in maintaining tonic contraction and joint stability. Motor control impairment is also discovered in patients with low back pain (LBP). However, a non-invasive method to evaluate the morphology of the dMF is lack. Purposes: The purposes of the study are: 1) to establish the methodology of measuring the thickness of the dMF; 2) to establish the reliability of measuring the sMF and the dMF; 3) to investigate the possible factor influencing the contraction of the dMF and the sMF; 4) Compare the contraction pattern of the dMF and the sMF between two groups of subjects with and without LBP during cognitively controlled and automatic controlled movements. Method: We set up the methodology of observing the dMF by comparing the dissection and the ultrasonography (USI) of the porcine specimen and inject the ink to confirm the position of the dMF. An ultrasonographic instrument is used to capture the morphologic change of the dMF and the sMF. The changes of thickness between static and contracted status of the two layers of MF are measured. The subjects with and without LBP will be recruited in the reliability test and the main test and the influence factor such as age, height, weight, body mass index (BMI) and gender would be evaluated. There are two kinds of tasks which are usually performed clinically: the first is cognitively controlled movement, which includes draw-in abdominal maneuver (ADIM), swell-out, pelvis anterior tilt; the second is automatic controlled movement, which include lifting the ipsilateral and contralateral arm or leg to the observing side in prone position. The reliability of measuring the change of thickness is represented by within-subject intraclass correlation coefficient (ICC3,3). We used Pearson correlation to calculate the correlation between age, anthropometric data with the thickness of the MF in resting and contracted status and the change in thickness between two statuses to examining the possible influencing factors. Independent t-test was used to compare the difference between genders. Three-way analysis of variance (3-way ANOVA) was used to analyze the change in thickness of the dMF and the sMF among the tasks within the same kind of movement between two groups of subjects with and without LBP. The α-value is set at 0.05. Results: The USI could be used to observe the dMF of the porcine specimen, the dissection and the USI is compatible with humans. The reliability test showed the measuring the thickness of the dMF or the sMF in static or the contracted status and the change of the thickness are all reliable through averaging three trials of measurement (ICC3,3= 0.84~1.00). In this study, age, anthropometric data (Pearson correlation= 0.47~0.66) and gender (p= 0.03~0.05) are correlated with the thickness of the sMF during static and contracted status. The change of the sMF is not influenced, the dMF is neither influenced. Three-way interaction is significantly revealed in cognitive control tasks (p= 0.02), indicating difference task-specific contraction pattern between groups. Among the asymptomatic subjects, the change of thickness is in the following order: ADIM, swell out, anterior tilt, during lifting upper limbs, and during lifting lower limbs. The change in thickness of the sMF is higher than the dMF in different tasks. However, the proportional change of thickness of dMF in these tasks is high. The change in thickness during the task of ADIM is higher than that during the task of swell out (p< 0.005) and pelvis anterior tilt (p< 0.005). Among the automatic controlled movement, while lifting the ipsilateral and contra-lateral limbs, the changes in thickness of sMF and dMF is no different between sides. The change in thickness of the sMF and the dMF in patients is significant greater than the asymptomatic subjects during the tasks of lifting the ipsi-lateral and contra-lateral arm (p= 0.05). For the tasks of upper and lower extremity lifting, sMF is significantly larger than the dMF (both p< 0.005). Conclusion: 1) The methodology of observing the dMF could be established by observing the porcine specimen that have compatible anatomy and USI of the dMF with human; 2) the measurement of the dMF and the sMF are reliable through averaging three trials of measurement; 3) the change in thickness of the dMF and the sMF is not influenced by age, height, weight, BMI and gender; 4) The activation of the superficial and deep MF is task-specific during cognitively controlled movement. The co-activation of TrA and MF, and the symmetrically activated of deep and superficial MF support the functional role of the MF in trunk stabilization. Patient with recurrent low back pain adapted an activation pattern by increasing the usage of superficial multifidus in mild and moderate tasks, probably due to the compensation for the delay onset of deep trunk muscles. This result provided the base for the intervention of patients with recurrent low back pain with motor control approaches.

並列關鍵字

Lumbar multifidus ； Ultrasonography ； Movement ； Low back pain

參考文獻

87. Hislop HJ, Montgomery J. Daniels and Worthingham's muscle testing. 6th ed. Singapore: Elsevier; 2002.

1. Macintosh JE, Valemcia F, Bogduk N, Munro RR. The morphology of the human lumbar multifidus. Clin Biomech 1986;1:196-204.

2. Rosatelli AL, Ravichandiran K, Agur AM. Three-dimensional study of the musculotendinous architecture of lumbar multifidus and its functional implications. Clin Anat 2008;21(6):539-46.

3. Lonnemann ME, Paris SV, Gorniak GC. A Morphological Comparison of the Human Lumbar Multifidus by Chemical Dissection. J Man Manip Ther 2008;16(4):E84-E92.

4. Moseley GL, Hodges PW, Gandevia SC. Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine 2002;27(2):E29-36.

國際替代計量

不同型態軀幹穩定運動時腰部多裂肌厚度變化-動態超音波研究

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