復發型非特異性下背痛族群之腰部深淺層多裂肌收縮變化與核心穩定和功能的相關性探討

The change of deep and superficial lumbar multifidus during contraction in relation to core stability and function in patients with recurrent non-specific low back pain

蔣昕恬(Shing-Tian Chiang)

指導教授 ： 王淑芬

國立臺灣大學/醫學院/物理治療學研究所/碩士(2021年)

https://doi.org/10.6342/NTU202104340

摘要

研究背景：非特異性下背痛伴隨核心穩定下降的有效治療方式為穩定性運動。病人在執行穩定性運動時需利用生物回饋或姿勢提示的方式幫助誘發多裂肌。深淺層多裂肌為核心肌群，對於脊椎穩定為一重要的主動成分，在慢性下背痛者中有較低的活化，而在復發性下背痛者中則有淺層多裂肌代償性活化的現象。目前沒有文獻探討復發性下背痛者的功能，而慢性下背痛者則因較差的核心穩定使其功能表現下降並失能。在無症狀者或慢性下背痛者中，軀幹肌群活化增加和肌肉質量增加與核心穩定和功能表現增加有關；但對於復發性下背痛者，深層與淺層多裂肌個別與核心穩定和功能的相關性則缺乏探討。近期，利用超音波量測深層與淺層多裂肌的可信方式被建立，需進一步探討復發性下背痛者深淺層多裂肌收縮變化與核心穩定和功能的相關性。
研究目的：1) 比較復發型非特異性下背痛者與無下背痛者深層與淺層多裂肌在動作任務下收縮之差異 2) 比較復發型非特異性下背痛者與無下背痛者核心穩定和功能之差異3) 探討復發型非特異性下背痛者與無下背痛者之深淺層多裂肌收縮變化與核心穩定和功能的相關性差異
研究方法：收錄20至70歲復發型非特異性下背痛成年人健康無下背痛者，請受試者在趴姿下做不同動作任務，分別為抬對側手、抬對側腳和軀幹伸直最大等長收縮，並同時記錄超音波影像，包含L4/5淺層多裂肌的厚度變化率和L4深層多裂肌的變化型態。利用Sahrmann五等級測試評估核心穩定能力，利用旋轉穩定測試評估功能性動作，以及利用五次坐站測試、坐站行走測試和下蹲跳躍進行功能表現測試，並填寫歐氏失能量表(Oswestry Disability Index, ODI)以評估失能程度。以獨立樣本t檢定或Mann-Whitney U Test比較下背痛組和健康組的深層與淺層多裂肌變化和功能性穩定動作之表現，最後再以多元迴歸統計 (Multiple regression analysis)控制年齡、身高和體重，以分析深淺層多裂肌與核心穩定和功能的相關性。
結果：共有14位復發性非特異下背痛者和12位健康成年人納入。兩組族群比較，病人組的淺層多裂肌厚度變化率在抬對側手和腳時顯著較高 (p<0.05)，深層多裂肌在抬對側手、抬對側腳和軀幹伸直時的收縮變化等級顯著較低 (p<0.05)，Sahrmann五等級測試分數顯著較低 (p<0.05)，而旋轉測試、五次坐到站測試和坐站行走測試的差異位在統計邊界值 (p=0.06-0.086)，兩組人下蹲跳躍無顯著差異 (p=0.858)。根據多元回歸分析顯示，控制年齡、身高和體重後，病人深層與淺層多裂肌變化率均與核心穩定和功能無關。在無症狀者中，控制年齡、身高和體重後，旋轉穩定測試與最大等長軀幹伸直時深層多裂肌變化率有正相關 (β=0.669, p=0.024; R2=0.454)；下蹲跳躍與最大等長軀幹伸直時深層多裂肌變化率有正相關 (β=0.634, p=0.004; R2=0.771)。
結論：利用可信的方式量測復發性下背痛者的深淺層多裂肌，首次在超音波影像中證實淺層多裂肌過度活化而深層多裂肌活化下降的現象。並且復發性下背痛者在需要特定脊椎穩定控制之功能中的表現較為下降。復發性下背痛病人的深淺層多裂肌與核心穩定和功能無關，然而深層多裂肌活化較多的無症狀者則有較佳的功能表現。

關鍵字

深層多裂肌 ； 淺層多裂肌 ； 復發型下背痛 ； 動態超音波 ； 核心穩定 ； 功能

並列摘要

Background: When patients having non-specific LBP with decreased core stability use stabilization exercise as an effective treatment, they require biofeedback or postural cueing to assist activation of the multifidus (MF). Local core muscles, superficial and deep multifidus (sMF, dMF), are important active components for maintaining spinal stability. There is decreased activation in patients with chronic low back pain and demonstrated compensatory activation of sMF in patients with recurrent low back pain. There is no previous study discussing the function in patients with rLBP, while patients with chronic LBP have functional deficits due to poor core stability. In patients with chronic LBP and in asymptomatic adults, the activation and muscle mass of trunk are positively correlated to core stability and function. But in patients with rLBP, the relationship of individual sMF and dMF with core stability and function is unknown. Recently, a reliable method to individually measure sMF and dMF with USI was established. Whether the possible compensatory over-activation of sMF and decreased activation of dMF is related to core stability and function in patients with rLBP requires further investigation.
Purpose：1) Compare the activation pattern of dMF and sMF during movement tasks by USI in patients with non-specific rLBP and asymptomatic adults. 2) Compare the core stability and function in patients with non-specific rLBP and asymptomatic adults. 3) Examine whether the relationship of dMF and sMF with core stability and function in patients with non-specific rLBP differs from asymptomatic adults.
Methods：Patients with non-specific rLBP aged 20-70 and asymptomatic adults were recruited. We used USI to measure the percentage of thickness change of sMF (sMF_%△T) on L4/5 and the characteristic change of dMF (△dMF) on L4 during contralateral arm lift (CAL), contralateral leg lift (CLL) and maximal isometric trunk extension (MITE). The Sahrmann five-level core stability test was used for core stability. Rotatory stability test was usd for functional movement. Timed-Up-and-Go (TUG), 5 times Sit-To-Stand (5STS) and Countermovement jump (CMJ) were tested for functional performance. The Oswewtry Disability Index (ODI) evaluated disability of patients. Independent t-test or Mann-Whitney U Test were used to analyze the difference for the sMF_%△T, the △dMF, core stability, and function between asymptomatic adults and patients with rLBP. Multiple regression analysis after controlling for age, height and weight was used to examine the relationship of sMF and dMF with core stability and function.
Results：There were 14 patients with rLBP and 12 asymptomatic adults. Between patients with rLBP and asymptomatic adults, patients had higher value in sMF_%△T during CAL and CLL, and lower value in △dMF during CAL, CLL and MITE (p<0.05). The Sahrmann five-level test scored lower in patients with rLBP than asymptomatic adults (p<0.05). The difference of rotatory stability test, 5STS and TUG were on the borderline of statistical significance (p=0.06-0.086). There was no difference in CMJ between the two groups (p=0.858).
In patients with rLBP, the sMF and dMF were not correlated with core stability or function after adjusting for age, height and weight. In asymptomatic adults, the dMF was correlated to function after adjusting for age, height and weight. The rotatory stability test was positively associated with △dMF during MITE (β=0.669, p=0.024; R2=0.454). The CMJ was positively associated with △dMF during MITE (β=0.634, p=0.004; R2=0.771).
Conclusion：Reliable measurement using USI for sMF and dMF in patients with recurrent low back pain permits the first documentation of the phenomenon of overactivated sMF and less dMF. Additionally, part of the function required for specific control of the spinal stability is first reported to be decreased in patients with recurrent low back pain. Furthermore, the dMF or sMF of patients with recurrent low back pain are not correlated to the core stability and function, whereas asymptomatic participants with more activation of dMF have better function.

並列關鍵字

deep multifidus ； superficial multifidus ； recurrent LBP ； ultrasonography ； core stability ； function

參考文獻

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