| 摘要: | 目的：隨著高齡化社會的來臨，膝關節為最常發生退化的關節。退化性膝關節炎的患者常有膝關節疼痛、膝關節僵硬、膝關節活動度減少、下肢肌肉萎縮、走路速度較慢等徵狀發生。這些徵狀明顯的會影響患者在從事一些日常功能性活動，進而造成患者易發生一些潛藏的危險。本研究嘗試解釋退化性膝關節炎患者在水平步行時下肢運動學及動力學的差異。外側楔型鞋墊已被應用在治療退化性膝關節炎，但是其生物力學機轉並未被深入探討，同時是否會產生副作用仍不清楚。本實驗中，外側楔型鞋墊對水平步行所造成的影響及副作用將被探討。最終，期望將外側楔型鞋墊應用於臨床上，以減緩退化性膝關節炎的惡化，維持老年人之生活品質，以及減少醫療成本支出（藥物，復健，手術）。
方法：選擇十二名確定診斷為退化性膝關節炎的門診患者（八名女性，四名男性：平均年齡：70.7 ± 5.9 歲） 給予外側高 12 mm 的外側楔型鞋墊治療十二週。比較受試前和十二週後的自覺疼痛指數和嚴重程度（Lequesne Index）。以站立 X ¬–光評估受試者在受試前裸足，第一次穿外側楔型鞋墊，以及穿外側楔型鞋墊十二週後裸足之間的距骨跟骨夾角，距骨傾斜角以及股骨脛骨夾角是否有明顯改變。接著利用三度空間動作分析和力板系統來計算受試者水平行走時運動學和動力學參數，包括空間時間參數，下肢關節，軀幹和頭部的活動角度變化，下肢各關節受力及承受力矩改變情形，以及身體重心擺動情形。所有參數以相依樣本 T 考驗（paired-t test）檢定。所有資料之 P < 0.05 即達到統計上的顯著意義。
結果：十二名患者全程完成所有十二週之實驗步驟。患者使用外側楔型鞋墊後不論是症狀的改善或是疼痛的減輕都有明顯的差異（P<0.0001），但X-光檢查評估距骨跟骨夾角，距骨傾斜角以及股骨脛骨夾角時都沒有明顯改變。受試者會以較大的步寬來維持平衡，增加穩定度。並透過擺盪期時間增加和站立期佔步態週期百分比減少來減少膝關節承重，以減緩膝關節退化的惡化。外側楔型鞋墊可以直接造成踝關節的內翻外翻角度增加和蹠屈背屈角度減少。而膝關節的屈曲伸展角度在十二週後明顯減少。足踝部的內翻力矩峰值和內旋力矩峰值明顯增加、還有足踝外翻力矩峰值和蹠屈力矩峰值明顯減少。膝部的伸展力矩峰值在立即變化和十二週後追蹤都有增加的趨勢。髖屈曲力矩峰值和外展力矩峰值也有減少的趨勢。
結論：外側楔型鞋墊治療退化性膝關節炎雖然在X-光上並無明顯變化，但從步態分析中確實可以發現一些運動學和動力學參數的變化。更長時間的追蹤以瞭解外側楔型鞋墊的長程效果和避免負面作用是相當重要的。
Objective： The knee joints are most frequently involved degenerative arthritis for the patients in the older society. The patients with knee osteoarthritis (OA) may have the following complaints： knee joint pain, stiffness of the knee joint, limited range of motion (ROM), wasting of the lower limb muscle, and decreased walking speed. These symptoms can decrease the performance of some activities of daily life obviously and followed a potential dangerousness. This research attempts to explain the changes of the kinetics and kinematics of the lower limbs while knee OA patients performing level walking. Lateral-wedge insole has been used to treat knee OA, but the biomechanical nature has not been well studied, and its side effect is unclear. In this study, the influence and the side-effect of the lateral-wedge insole will be investigated. Finally, we expected to apply the insole clinically to slow the degenerative process of the knee joint, to maintain life quality of the elder, and to reduce the medical costs （medicine, physical therapy, and surgery）.
Methods： Twelve outpatients (eight female and four male, mean age, 70.7; standard deviation, 5.9) with knee OA involving the medial compartment were prospectively treated with an inserted wedged insole with lateral elevation of 12 mm for twelve weeks. The visual analog scale (VAS) scores for subjective knee pain and the remission score of the Lequesne index of severity for knee OA were assessed before and 3-months after treatment. Standing radiographs with and without insoles were used to analyze the femorotibial, talocalcaneal and talar tilt angles at baseline, immediate and final assessment. Three-dimensional motion analysis system and force platform were used to calculate kinematic and kinetic gait parameters in level walking, including spatiotemporal parameters, range of motion (in lower limbs, trunk and head), forces and moments in hip, knee and ankle joints and sway range of the center of gravity. Difference in all parameters between baseline assessments and immediate or final assessments were compared using a paired t test.
Results： The 12 patients who completed the 12-weeks study were evaluated. Participants wearing the inserted lateral wedged insole had significantly improved VAS pain score and remission score of the Lequesne index (P<0.0001). No significant differences were found in femorotibial, talocalcaneal and talar tilt angles while comparison among values at baseline, immediate and 3-months after treatment. Patients using a lateral wedged insole had an immediate and significant increase in step width, heel maximum height, and swing phase time, but reduced stance phase of the gait cycle as compared with the baseline data. Beside, increased ROM in ankle inversion-eversion and decreased ankle plantar-dorsiflexion ROM were found. They also generated more ankle invertor moment, internal rotator moment, knee extensor moment, and less ankle plantar flexor moment, ankle evertor moment and hip flexor and abductor moment.
Conclusion： The inserted lateral wedged insole may induce symptomatic relief in patients with medial compartment knee OA, but not make any significant changes in the radiographs taken in the static position. The therapeutic effects were further evaluated during the dynamic phase with motion analysis system and force plates to determine the kinematic & kinetic effects. Longer-term clinical follow up should be addressed in future studies. |
