Effect of Hip Adduction Combination with Knee Extension Exercise on Morphology of Quadriceps Muscles, Pain and Functional Outcomes in Patients with Patellofemoral Pain Syndrome

背景及目的：髕股關節疼痛症候群為一臨床常見之膝關節疾病，主要原因之一乃股內斜肌失能使髕骨有不正常的外側偏移，造成髕股關節的壓迫。股內斜肌為膝關節動作時髕骨的內側動態穩定者，臨床上常用保守療法即針對股內斜肌作特定性的訓練。由於股內斜肌肌纖維起始於髖內收肌群，學者認為髖內收肌的收縮能誘發股內斜肌的活動，然而文獻除了相關的肌電圖實驗外，至今仍未有臨床試驗之研究。因此，本隨機控制試驗選用超音波儀器量測股內斜肌之肌肉型態，評估在訓練介入前後的變化，探討髖內收合併膝伸直運動訓練對髕股關節疼痛症候群患者的臨床治療效益，並且和傳統末端膝伸直運動，及控制組間作療效比較。方法：本研究徵召62位年齡小於55歲之髕股關節疼痛症候群患者，隨機分配至髖內收合併膝伸直推蹬運動訓練組、傳統末端膝伸直推蹬運動訓練組、及控制組，進行每週3次、為期8週的推蹬運動訓練，然後評估股內斜肌的肌肉型態（包括股內斜肌肌纖維角度、髕骨上緣水平位之股內斜肌截面積、及髕骨上緣水平位以下之股內斜肌體積）、膝關節視評疼痛分數（包括一般疼痛分數、最嚴重疼痛分數、及活動疼痛分數）、以及Lysholm Scale功能量表分數在介入前後之改變。結果：髖內收合併膝伸直推蹬運動及傳統末端膝伸直推蹬運動訓練組患者，經過8週運動訓練後，其髕骨上緣水平位之股內斜肌截面積、髕骨上緣水平位以下之股內斜肌體積皆有顯著進步（p< .005），然進步未較控制組顯著（p= .011~ .042）。而膝關節一般疼痛分數、最嚴重疼痛分數、活動疼痛分數、及Lysholm Scale功能量表分數除了在訓練前後有顯著進步（p< .005）外，進步亦較控制組顯著（p< .005），唯髖內收合併膝伸直推蹬運動組患者之活動疼痛分數之進步，比起控制組仍未達足夠的顯著（p= .016）。此外，兩運動組之間並無組間統計顯著差異。而股內斜肌肌纖維角度則是在訓練前後並無統計顯著差異。控制組患者之股內斜肌肌肉型態、膝關節視評疼痛分數、及Lysholm Scale功能量表分數在8週前後皆無統計顯著差異。結論：閉鎖鏈髖內收合併膝伸直推蹬運動訓練，可使髕股關節疼痛症候群患者的股內斜肌肥厚，疼痛下降，並且增加下肢功能性活動能力。然而其療效與閉鎖鏈末端膝伸直推蹬運動訓練相似。建議臨床上可以任擇一運動訓練計畫，若考量方便及實用性，則可優先選擇閉鎖鏈末端膝伸直推蹬運動。Background and purpose：Patellofemoral pain syndrome（PFPS） is a common knee disorder characterized by anterior or retropatellar pain associated with activities that load the patellofemoral joint. Previous studies reveal that the vastus medialis obliquus（VMO） is an important dynamic medial stabilizer of the patella. Insufficiency of the VMO leads to lateral shift of the patella and the increases of patellofemoral contact pressure. Thus VMO-specific training is a well-accepted clinical treatment conservatively. Hip adduction is thought to enhance VMO contraction because of its anatomic origin from hip adductors. In order to determine its training effect, we used ultrasonography as a measurement tool to examine the VMO morphology changes after hip adduction combination with knee extension exercise training compared with traditional terminal knee extension exercise training and control in patients with PFPS. Methods：62 PFPS patients with age under 55 were recruited for the study and then randomly assigned to either one training or control group. Muscle morphology of VMO（including fiber angle, cross-sectional area on patella-base level, and volume under patella-base level）, 10 cm-visual analog scale of usual pain（VAS-U）,worst pain (VAS-W), activity pain (VAS-activity), and Lysholm Scale scores were measured before and after 8-wk leg press exercise training or control periods. Results：Significant improvements of VMO cross-sectional area, volume, VAS-U, VAS-W, VAS-activity, and Lysholm Scale scores were found after 8-wk training in both exercise groups（p< .005）, but not in the control group. The improvements were also significantly different between the exercise and control groups（p< .005）, except for the VMO cross-sectional area and volume（p= .011~ .042）, and for the VAS-activity between the hip adduction combination with knee extension exercise and control groups（p= .016）. However, no differences were found between two exercise groups. In all three groups, no significant differences were found in VMO fiber angle throughout the experiment. Conclusion：The results suggest that immediate effects of VMO hypertrophy, pain reduction, and functional ability improvement occurred following hip adduction combination with knee extension exercise. Treatment effects did not show significant differences between two exercise groups; therefore, therapists could choose either of these two exercise programs. Moreover, clinical practices may consider the application of leg-press exercise with terminal knee extension alone since additional equipments are not required.目錄................................................................i 表目錄.............................................................iii 圖目錄.............................................................iv 中文摘要............................................................v 英文摘要...........................................................vii 第一章、 前言..............................................1 第一節、研究背景及動機...........................................1 第二節、研究目的.................................................4 第三節、研究問題.................................................4 第四節、實驗假說.................................................4 第二章、文獻回顧...........................................5 第一節、髕股關節疼痛症候群的相關研究.............................5 第二節、股內斜肌的重要角色.......................................6 第三節、運動訓練對髕股關節疼痛症候群患者的治療效益...............7 第四節、股內斜肌與髖內收肌間的連結...............................8 第五節、髖內收運動對股內斜肌活動之影響...........................8 第六節、髕股關節疼痛症候群常用的評估工具........................13 第三章、研究方法..........................................17 第一節、研究設計................................................17 第二節、受試者..................................................17 第三節、研究使用變項定義........................................19 第四節、實驗流程................................................20 第五節、研究使用設備及工具......................................20 第六節、評估項目................................................21 第七節、運動訓練計畫............................................25 第八節、資料分析及統計..........................................28 第四章、結果.............................................29 第一節、收案流程及患者基本資料.................................29 第二節、 結果評量參數之起始組間比較.............................30 第三節、 運動訓練之影響.........................................31 第五章、討論.............................................33 第一節、運動訓練對股內斜肌肌肉型態之影響........................33 第二節、運動訓練對視評疼痛分數之影響............................36 第三節、運動訓練對Lysholm Scale功能量表分數之影響...............38 第四節、髖內收動作對股內斜肌的影響..............................39 第五節、研究限制................................................41 第六節、臨床應用................................................42 第六章、結論.............................................43 參考文獻.................................................44 附表...............................................................51 附圖...............................................................61 附件一：台灣大學醫學院附設醫院倫理委員會公文.......................81 附件二：臨床試驗受試者說明及同意書.................................82 附件三：受試者基本及相關資料評估表.................................8