||Effect enhancement by changing intervention sequence of combined therapy in subjects with non-specific neck pain
||Department of Physical Therapy
non-specific neck pain
前言:非特異性頸痛是現今社會常見的疾病，其具備有高度盛行率與再發性。可能伴隨頸部肌力失衡、局部組織緊繃、以及動作控制異常等症狀，並因而與疼痛形成惡性循環導致久痛不癒或容易再發。目前臨床上廣為採用以運動治療、徒手治療或結合兩者之合併式治療，然就執行面而言，有關合併式治療之治療順序，雖有學者Janda呼籲，宜先改善肌肉緊繃及回復正常張力後，再行針對較虛弱或受抑制的肌肉介入運動訓練效果較佳，然至今仍缺乏實證研究針對此類治療順序提出最佳療效建議。目的:針對非特異性頸痛患者檢定於單一治療後(E、M)與合併式治療後(E-M,M-E)在相關臨床徵狀與動作控制方面之立即性療效，並進一步檢定於單一治療(E, M)前後介入前置治療(M-, E-)與後續治療(-M, -E)之治療效應。以釐清合併式治療之最佳治療流程。方法:本研究延攬20名非特異性頸痛患者，隨機分為M-E-E-M(n=10)與E-M-M-E(n=10)採取不同治療順序的兩組，並分別施予不同順序介入之徒手治療與運動治療(E-M,M-E)，在一週後分別交換治療順序再度介入運動治療與徒手治療(M-E,E-M)。所有受測者均在每次治療前接受療前評估，並且於20分鐘之初始治療(E,M)或20分鐘之後續治療(-M,-E)後接受立即性療效評估。結果:(1)就各種治療相關臨床徵狀(疼痛強度、關節活動度與壓痛閾值)之立即性療效而言，徒手治療與兩合併式治療(E-M,M-E)均呈現全面性的顯著療效。反之，運動治療組僅於少部分頸部關節活動度與左側提肩胛肌之壓痛閾值呈現顯著改善。就頸屈曲動作控制之立即性療效而言，運動治療在右側前斜角肌(抬頭高度1.0~1.5公分)呈現顯著的肌電強度減弱之現象與右側前斜角肌亦呈現顯著的延遲徵招。同樣的徒手治療在右側前斜角肌(抬頭高度0~0.5公分與0.5~1公分)呈現顯著的肌電強度減弱之現象。並且發現合併式治療(M-E)於顱頸屈曲瞬間活動度上相較於治療前呈現顯著增加。(2)於初始運動治療結束後再介入之徒手治療(-M)能於臨床徵狀(疼痛強度、關節活動度與壓痛閾值)呈現顯著的後續加成效應，反之若於初始徒手治療結束後再介入運動治療(-E)於臨床徵狀方面則僅能維持療效不衰減，無法呈現進一步的加成效應，但卻發現右側胸鎖乳突肌呈現顯著提前徵招之現象。(3)就是否需要介入另類前置治療而言，運動治療前介入前置徒手治療(M-E)比起直接接受運動治療(E)，在各種臨床徵狀上均呈現顯著提高之療效；反之就徒手治療而言，有無介入前置運動治療(M vs. E-M)並未呈現顯著的額外療效。(4)組間療效比較結果顯示徒手治療及兩種合併式治療(E-M,M-E)於臨床徵狀方面之立即性療效均顯著優於運動治療，惟此三者間卻未呈現顯著的優劣。討論與結論:本研究顯示，徒手治療與兩種合併式治療(E-M,M-E)等三組之立即性療效均顯著優於運動治療組，且三者間未呈現顯著的差異。顯示僅介入20分鐘之徒手治療即可產生與介入40分鐘之合併式治療(E-M,M-E)相當的立即性療效。進一步觀察後續加成效應，僅於運動治療後介入徒手治療才能呈現顯著的加成效應，反之或許是徒手治療已有相當程度的立即性療效之故於其後有無介入後續運動治療對於臨床徵狀上未能產生額外的加成效果。但就頸屈曲動作控制方面，於運動治療前介入前置徒手治療(M-E)比起直接接受運動治療(E)，在各種臨床徵狀上與動作控制方面(動作初期之顱頸屈曲瞬間活動度)均能呈現顯著提高之療效。然而就徒手治療而言，有無介入前置運動治療(M vs. E-M)並未呈現顯著的療效差異，此結果充分顯示出採用正確治療順序的重要性，本研究已提供具體證據支持Janda學者所提出應先進行徒手再進行運動治療之臨床建議。綜上所述，本研究結果具體支持，在臨床上欲尋求短期奏效之道，可優先選擇徒手治療，經濟效益最佳；而欲提高運動治療療效，則需考慮於運動治療前先介入以軟組織操作手法為主的徒手治療。
Background: Nowadays, non-specific neck pain is one of the most common disorders with high prevalence and recurrent rate. It has been reported to closely relate to faulty posture, muscle imbalance or aberrant motor control strategies. The common conservative managements include manual therapies, exercise therapies and the combined therapies. Additionally, several studies have demonstrated the combined therapies as the most effective treatment for non-specific neck pain. On the other hand, Janda proposed the importance of treatment sequence for the combined treatment that restoring normal muscle tone or length for the antagonists must be first addressed before strengthening a weakened or inhibited muscle. However, little has been done to provide evidence for suggesting an optimal intervention sequence of combined therapy in treating patients with non-specific neck pain. Purpose: The study aimed to investigate the immediate effect of manual treatment (M), exercise treatment (E), and combined treatment (E-M,M-E) on common clinical symptoms and motor control strategies. Additional effect after completing the initial treatment (E, M) and the optimal intervention sequence for the application of combined therapy was also determined. Methods: Twenty subjects with non-specific neck pain were randomized into two groups to take different combination of intervention sequence in two treatment sessions (E-M-M-E group: session 1 with E-M and session 2 with M-E; M-E-E-M group: session 1 with M-E and session 2 with E-M). Clinical and biomechanical measurements were arranged for both groups before intervention and immediately after completing initial treatment (E, M), and subsequent treatment (-M, -E) in each session. The measurements included pain intensity for headache and neck pain, cervical range of motion (ROM), pain pressure threshold (PPT) for bilateral upper trapezius, levator scapula, and suboccipital muscles, and motor control strategies for neck flexion pattern test. Several Wilcoxon signed rank tests were conducted for determining the immediate effect after initial treatment(E, M) and combined treatment(E-M,M-E), and several Friendman’s tests were performed to determine additional effect after completing the initial treatment (E, M). In addition, Kruskal wallis tests were used to compare the immediate effects among exercise treatment, manual treatment and combined treatments(E-M,M-E). Results: (1) The results of Wilcoxon signed rank tests showed significantly reduced headache and neck pain, significantly increased cervical ROM in all directions, and significantly raised PPT in all muscles measured after completing manual and the combined treatments. In addition, significantly reduced muscle activities were found in right anterior scalene (AS) (head ascending height: 1~1.5cm) immediately after completing the manual treatments. On the other hand, exercise treatment group only showed significant improvement in some parameters measured such as cervical flexion and side-bending ROM, and the PPT for left AS, however, significantly reduced muscle activities in right AS (head ascending height:0~0.5cm and 0.5~1cm) and significantly delayed onset in AS muscles were also noted after completing the intervention. Moreover, significantly increased neck flexion (head ascending height: 0.5 cm) was found after completing the combined treatment in M-E sequence. (2) Significantly additional effect in all clinical measurements were found after completing the subsequent manual treatment (-M) in performing the combined treatment (E-M), but not after the subsequent exercise treatment (-E) in performing the combined treatment (M-E). (3) In comparison of exercise treatment, significantly greater improvements were found to result from the subsequent manual treatment (-M), and so were the manual treatment and the combined treatment (E-M). However, no significant differences were found among the improvement of manual treatment, and the two combined treatments (M-E, E-M). Discussion and conclusion: The results of group comparisons clearly demonstrated no significant differences among manual treatment, and the two combined treatments (E-M,M-E) in the immediate effect of clinical measures, suggesting a fact of equal effect resulting from 20-minutes manual treatment in comparison to 40-minutes combined treatment including either E-M or M-E treatments. The results have strongly recommended the immediate effect of manual therapy, no matter it is performed alone or by any treatment sequence. On the other hand, the results showing significantly more improvement from the combined treatment (M-E) than exercise treatment alone has provided direct evidence to support Janda’s theory regarding the importance of treatment sequence. For optimal treatment effect, it would better to perform exercise treatment after restoring the normal muscle tone or length for the antagonists. Furthermore, significantly increased craniocervical flexion angle during neck flexion movement pattern test (head ascending height: 0.5 cm) was only found after completing in performing the combined treatment (M-E). These results have further implied M-E treatment sequence as the optimal treatment sequence if time is allowed, and the importance of intervention sequence should not be overlooked. In conclusion, for the sake of immediate effect and time concerns, manual treatment might be the best choice. However, considering the improvement in the motor control strategies, M-E treatment sequence would provide better effect. Finally, to promote the effect of exercise, exercise treatment should be conducted after soft tissue manual treatment.
第一章 文獻回顧 19
1.5 頸痛患者之臨床特色 22
1.7頸痛患者之肌肉失衡(muscle imbalance) 27
1.8異常的頸屈曲模式(aberrant neck flexion pattern) 27
1.9.2頸屈肌耐力測試(neck flexor endurance test) 28
1.9.3頸屈曲動作測試 (neck flexion movement pattern test) 28
第二章 研究方法 38
2.2.1電磁式動作追蹤系統 (electromagnetic notion tracking system) 38
2.2.2肌電圖儀(AMT-8 EMG, Octopus, CA) 39
2.2.3頸部量角器（cervical goniometer） 40
2.2.5充氣式壓力回饋儀(air-filled Pressure feedback) 41
2.4.3頸關節活動度(CROM, cervical range of motion) 44
2.4.4顱頸屈曲測試(CCFT, craniocervical flexion test) 45
2.4.5壓痛閾值(PPT, pain pressure threshold) 46
2.4.6頸屈曲動作測試(neck flexion movement pattern test) 46
2.5參考性自主收縮(RVC, reference voluntary contraction) 49
2.6徒手治療(M) - 軟組織鬆動術 50
2.6.1下枕骨放鬆術(suboccipital release) 50
2.6.2反拉張治療技術(strain-counterstrain technique) 51
2.6.3深層組織摩擦按摩(deep friction massage) 52
2.6.4運動治療(E) - 顱頸屈曲訓練 52
2.7先鋒實驗: 機械性頸痛之風險偵測指標 – 頸屈曲動作測試的量化與資料庫之建立 53
第三章 研究結果 63
3.3後續治療(-M, -E)之加成效應分析 70
3.3.1 相關臨床徵狀 71
3.3.2後續治療(-M, -E)對於顱頸屈曲瞬間活動度之加成效應分析 74
3.3.3後續治療(-M, -E)對於頸部肌肉徵招延遲時間之加成效應分析 75
3.3.4後續治療(-M, -E)對於頸部肌肉平均肌電強度之加成效應分析 76
第四章 研究討論 80
4.1受試者之選擇 - 療前分析 80
4.2前鋒實驗：機械性頸痛之風險偵測指標 – 頸屈曲動作測試的量化與資料庫之建立 82
第五章 結論 103
附錄二: 頸部失能量表 116
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