合併髖外展以及髖外轉肌力訓練於推蹬運動訓練運動治療中對於髕股關節疼痛症候群患者之療效

Abstract

背景：過去針對髕股關節疼痛症候群之治療，不論以何種介入方式皆可有效的降低疼痛、增加股四頭肌肌力以及改善日常生活功能表現，然而，卻無一顯著有效之方式，因此學者提出問題或許不單純只來自於髕股關節本身。依據近年的研究指出，患有髕股關節疼痛症候群的患者相對於未疼痛的受試者，有髖外展肌以及髖外轉肌肌力不足的現象。鑒於髖外展以及髖外轉肌之肌力不足現象之存在，本研究欲比較，對於患有髕股關節疼痛症候群的患者，合併髖外展以及外轉肌群之肌力訓練於推蹬運動訓練中與單純推蹬運動訓練之療效差異。 研究目的：比較以推蹬運動以及推蹬運動伴隨髖外展、外轉肌群之肌力訓練，對於診斷有髕股關節疼痛症候群之患者之肌肉力量、下階梯動作表現、疼痛、日常生活功能表現之療效差異。 研究方法：85位診斷患有髕股關節疼痛症候群之患者，隨機分配至三個組別(推蹬運動(LPE)、推蹬運動加上髖外轉以及髖外展肌力訓練(LPE+HAE)、控制組)。兩組運動組分別接受每週三次，為期八週的運動訓練。療效分析包括以徒手肌力測試儀測得之肌肉力量(膝伸直肌群、髖外展肌群、髖外轉肌群、髖伸直肌群以及髖內轉肌群)、以電磁動作分析儀(FASTRAK)分析下階梯髖關節運動學參數、以髕股關節疼痛症候群疼痛嚴重度量表(PSS)測量患者之疼痛狀況，以及前膝疼痛量表(AKP) 測得患者之功能表現障礙程度。療效分析資料將於運動訓練前以及訓練八週後做蒐集。 結果：推蹬運動或推蹬運動合併髖關節肌力訓練後，髕股關節疼痛症候群之患者之髕股關節疼痛症候群疼痛嚴重度量表(PSS)測量患者之疼痛狀況、前膝疼痛量表(AKP)測得患者之功能表現障礙程度以及髖外展肌群肌力皆有顯著之進步(p＜.005)，同時也較未受治療之控制組有顯著之改善(p＜.008)。兩組運動訓練組於治療前後，其膝伸直肌群肌力以及髖內轉肌群肌力也有顯著之進步(p＜.005)。然而，在下階梯髖關節運動學參數上雖無顯著之改變，但可觀察到於合併髖關節肌力訓練於堆蹬運動組之患者，其治療前後之髖內轉角度有減少較多之趨勢，且於相關性分析中發現經治療後患者之髖外展肌群肌力增加量和其髖內轉角度之減小量有顯著相關(r=-.39. p＜.05)。 結論：經由八週之運動訓練後，不論是單純下肢推蹬運動或是合併髖關節肌力訓練於推蹬運動中，髕股關節疼痛患者之髖外展、內轉及膝伸之直肌群肌力、疼痛情況、日常生活受障礙程度皆可獲得有效改善。增加髖關節肌群運動訓練於傳統推蹬運動中似乎可改善患者於下階梯動作中髖關節過度內轉之現象，尤其在下階梯時髖關節過度內轉之患者，其髖外展肌力之增加量和髖內轉角度減少量具有顯著相關，因此臨床之治療上，必須針對理學檢查後所得到之結果替患者擬定各別之治療計畫。

Background: Quadriceps strength training exercise has been shown to be effective in treating patellofemoral pain syndrome without relevant effective treatment strategies. It is suggested that the problem may not derive just from patellofemoral joint but alterd kinematic from proximal part.(hip and pelvic). According to recent studies, weakness of hip abductors and hip external rotator muscles was discovered in this population while quadriceps weakness was evident. However, if improved hip muscle strength are related to hip kinematics changes difference was interested in current study. Purpose: The first purpose was to compare the difference between leg press exercise(LPE) and additional hip abductor and external rotator muscle strength training to leg press exercise(LPE+HAE) in muscle strength, hip kinematics during step down, pain severity and function for patients diagnosed with patellofemoral pain syndrome. The second one was to discover the relationship between the change in muscle strength performance and the difference of hip joint kinematics post treatment. Methods: 85 individuals diagnosed with PFPS are randomized into 3 groups of intervention (leg press exercise(LPE), additional hip abductor and external rotator strength training to leg press exercise(LPE+HAE) and control). Tow exercise group received 8 weeks of 3 times per week strength training. Outcome measures were muscle strength (quadriceps, hip abductor, hip external rotator, hip internal rotator and hip extensor muscle strength) by hand-held dynamometry, hip joint kinematics during step down by electromagnetic motion tracking system (FASTRAK, Polhemus ), pain severity by PFPS pain severity scale (PSS), functional performance by Anterior Knee Pain Scale(AKP). All the tests mentioned above are measured at the baseline and after 8 weeks of treatment. Results: After 8 weeks of exercise intervention, patients with patellofemoral pain showed significant muscle strength improvements in knee extensors, hip abductors, and hip internal rotators, accompanied with significant reduction in pain(PSS) and functional improvements (Anterior knee pain scale)(p＜.005). Muscle strength performance in hip abductors, PSS and AKP demonstrated with statistical significance between each exercise group and control (p＜.008). There was no significant difference in hip kinematics performance after treatment while the change in hip internal rotation angle seems relevant larger in additional hip muscle strength training group (3°).When pooled the reduction in hip adduction and internal rotation angles and the improvement of every hip muscle strength of both exercise group post treatment, the change in hip abductor muscle group was correlated with change in hip internal rotation angle during stair decent(r=-.39. p＜.05). Conclusion: Both exercise groups demonstrated with significant improvement in muscle strength performance, pain severity and function. Even though there was no statistical significant difference in hip kinematic performance after 8 weeks of treatment, the improvement of hip abductor muscle strength and reduction in hip internal rotation angle were correlated. The relevant reduction in hip internal rotation angle of additional hip muscle strengthening group after treatment might suggest that additional hip muscle strength training may be helpful in reducing excessive hip internal rotation during stair decent.