頸因性頭痛患者於筋膜鬆動術前後之上頸椎活動度量測

Abstract

背景：頸因性頭痛是由上頸椎肌肉骨骼問題所造成的頭痛，佔所有慢性頭痛比率的百分之二十，其特性是上頸椎關節活動度降低與疼痛 。比較頸因性頭痛患者與無症狀健康受試者的之上頸椎關節活動度的研究結果並無一致性。推測是因量測方法的限制。臨床上常採用筋膜鬆動術改善頸因性頭痛患者受限之上頸椎活動度，卻沒有研究採用量化的方法來評估筋膜鬆動術對上頸椎活動度的影響。 研究目的：1)建立以超音波動作分析系統測量上頸椎關節活動度之方法學並測試其信度；2) 建立以超音波影像測量頭顱與第一節頸椎的距離變化之方法學並測試其信度；3) 採用以上兩種方法，比較頸因性頭痛病人之上頸椎活動度與無症狀者之差異；4) 探討筋膜鬆動術對頸因性頭痛患者受限之上頸椎活動度的立即效果。 方法：本實驗使用超音波動作分析系統，以徒手固定的方式測量顱頸關節與寰樞關節的活動度(包含：矢狀面上低頭,抬頭與橫切面上的轉頭動作)。再利用超音波影像觀察頭頸屈曲活動時，頭顱與第一節頸椎間的距離變化（此參數代表其在矢狀面上的活動度）。信度測試收取無頸痛與頭痛症狀之受試者，測試間隔十五分鐘之再測信度。比較十五名頸因性頭痛患者與十五名無症狀受試者上頸椎活動度之表現。再以交叉研究，比較臨床上常使用之筋膜鬆動術，包含：下枕骨肌肉按壓及上頸椎徒手牽引與平躺休息十分鐘後，十位頸因性頭痛患者之上頸椎活動度的立即成效。信度分析以級內相關係數( Intra- class Correlation Coefficient, ICC 3,3)驗證。以independent t test、Mann-Whitney U test來檢驗頸因性頭痛組與無症狀組之差異。以重覆測量變異數分析(ANOVA with repeated measure)檢驗頸因性頭痛患者接受筋膜鬆動術與休息十分鐘前後，上頸椎活動度與與頭顱和第一節頸椎之距離變化。執行上頸椎活動測試時自覺動作僵硬程度在兩種介入前後的結果則以無母數分析中的Wilcoxon signed ranks test來分析。 結果：以超音波動作分析系統測量上頸椎關節活動度與以超音波測量頭顱與第一節頸椎動作變化，皆有良好之再測信度(ICC 3,3=0.85-0.97)。頭痛組與無症狀組之顱頸關節與寰樞關節活動度在四個方向皆無顯著差異；頭頸屈曲活動時，頭顱與第一節頸椎間的距離變化兩組有顯著差異(p<0.001)。予頸因性頭痛患者筋膜鬆動術與休息十分鐘後的結果比較，兩種介入對於上頸椎關節在矢狀面與橫切面上之活動度無顯著影響；但其頭顱與第一節頸椎間的距離變化之影響程度不同，事後分析顯示接受筋膜鬆動術有顯著差異(p<0.001)。執行上頸椎活動測試時，自覺動作僵硬程度在接受筋膜鬆動術後有顯著差異(p =0.008)。 結論：以超音波影像測量頭顱與第一節頸椎的動作變化可偵測出頸因性頭痛病人存在上頸椎活動度下降，以及其接受筋膜鬆動術對於原本下降之活動度的改善。本篇研究提供一個有別於先前採用放射線影像學來評估頭顱與第一節頸椎活動度的方法，可作為鑑別診斷與評估療效的工具；並證實筋膜鬆動術有增加上頸椎活動度的立即效果，可提供未來改善此類病人頭頸部動作型態的參考。

Background: Cervicogenic headache is pain referred from musculoskeletal structure of neck, and the preference is 20% in population of patients with chronic headache. Restricted mobility and pain in upper cervical joints is one of the clinical features of cervicogenic headache. However, the results of previous studies those compared the range of motion within upper cervical segments between patients with cervicogenic headache and asymptomatic subjects were controversial, probably due to methodology limitation. Myofascial release techniques for suboccipital region to increase mobility of upper cervical spine are commonly applied on patients with cervicogenic headache, whether this technique could produced immediately quantitatively increase of cervical mobility is unknown. Purposes: The purposes of this study were 1) to establish the measurements of the range of motions of upper cervical joints by Zebris system, 2) to establish the measurement of the movement of C0-C1 segment in sagittal plane by measuring the distance change between C0 and C1 by ultrasonography 3) to compare the movements of upper cervical region and the mobility of C0-1 segment between population with cervicogenic headache and asymptomatic ones 4) to measure the change of range and mobility of upper cervical spines after myofascial release that applied on this region in subjects with cervicogenic headache and asymptomatic subjects. Methods: The study used two methods: 1) ultrasound-based motion analysis system to measure movements (including: nodding, chin-up and rotation to right and left) which were generated from upper cervical segments by manual fixation below C2; 2) ultrasonography was used to record the distance change between occiput and the first cervical vertebrae during craniocervical flexion, which presenting the mobility derived from C0 and C1 on sagittal plane. Asymptomatic subjects were tested twice with a 15-min rest between two sessions in the same day and the intraday test-retest reliability was examined. Range of motion of upper cervical region was compared between 15 patients with cervicogenic headache and 15 asymptomatic ones. Furthermore, the effects of myofascial release applied to suboccipital muscles and C0-C1 joint in 10 patients with cervicogenic headache were compared with 10 min-rest in a crossover study over 2 separate days. Intra-class correlation coefficients (ICC3,3) were calculated to examine the inter-session reliability of the measures. Differences between headache and asymptomatic groups were examined by independent sample t-test or Mann-Whitney U test. Data of crossover study were analyzed using ANOVA with repeated measure. The scores of subjective tightness during carniocervical test before and after two interventions were examined by Wilcoxon signed ranks test. Results: There were high levels of repeatability of within-day measurements (all ICC3,3 range 0.85 to 0.97) for these two methods. The results revealed that significant difference in the distance change between C0 and C1 (p<0.001). However, no difference was noted between these two groups in ROM of upper cervical segments and total cervical spine. The distance change between C0 and C1 significantly increased after myofascial release (p<0.001), with no significant changes after 10 minutes rest. The scores of subjective tightness during carniocervical test had significant reduced after myofoscial release (p=0.008). Conclusions: Using ultrasonography to measure the distance change between C0 and C1 could detect the restricted upper cervical range of motion in patients with cervicogenic headache and immediate increases of upper cervical range of motion after myofascial release. This study provided a method to evaluate the movement in C0 and C1 segment other than previous method using radiographic images. It is appropriate for differential diagnosis and assessment of treatment outcome. The results also confirmed that myofascial release could have immediate increase of mobility in C0-C1 segment in individuals with restricted upper cervical range of motion and gave us a reference to improve craniocervical movement pattern in patients with cervicogenic headache.