下背痛診斷分類與手法矯治

Diagnostic Triage and Manipulation for Low Back Pain

下背痛是門診中盛行率僅次於感冒的疾病。絕大多數（至少85%以上）的患者都不需要接受手術，因此保守的物理治療重要性不言而喻。物理物療中的手法矯治能改正異常的異常生物力學，是一種積極的保守治療。而手法矯治的關鍵成功因素在於選擇合適的病人與正確的診斷。因此一套完整的診斷分類系統，是非常必要的。由於造成下背痛的原因眾多，精確診斷不易。若以分類系統觀點，應先區分「非力學相關（non-mechanical）」與「力學相關（mechanical）」疾病兩大類。「非力學相關」疾病，例如腫瘤、感染、膠原病、心理問題、中樞神經敏感化等，通常不適用手法矯治，應轉介至其他相關科別處理。「力學相關」疾病才適用手法矯治。「力學相關」疾病中又可分為「明確性（specific）」疾病與「不明確性（non-specific）」疾病兩大類。所謂「明確性」疾病，是指影像學檢查看得出來的疾病，例如脊椎滑脫、脊椎解離、椎間盤突出等，這類問題的病位比較容易掌握，但多半已有結構性病變，治療難度較高，且有偽陽性的問題要排除。所謂「不明確性」疾病則是指影像學檢查看不出來的疾病，病位較不容易掌握，病因也很多樣化。例如關節動態障礙（小面關節、薦髂關節）、肌筋膜功能障礙、動作控制障礙、周邊神經敏感化等，都須列在鑑別診對的清單上。總之，在特定的診斷分類下找出真正的病因，選擇相應的手法矯治技術改正異常的生物力學，並搭配貼紮、輔具與居家運動，就能有效改善疼痛並顯著縮短病程。 Low back pain (LBP) is a very common complaints seen in daily practice, of which the prevalence is only second to common cold. Most patients with LBP do not need surgery. Therefore, the importance of conservative treatment for LBP cannot be overemphasized. Manipulation has been regarded as an aggressive conservative treatment because of its ability to correct pathomechanics. The key successful factors of manipulation are selecting appropriate patients and making a correct diagnosis. Therefore, a diagnostic triage system is important to accomplish successful manipulations. LBP can be categorized into two major groups: non-mechanical LBP and mechanical LBP. As to ＂non-mechanical＂ LBP, such as LBP caused by tumor, infection, collagen diseases, psychological problems and central sensitization, manipulation is usually not indicated. Manipulation is indicated in ＂mechanical＂ LBP which is further divided into two groups: specific LBP and non-specific LBP. The ＂specific＂ LBP is the LBP of which the cause can be seen on imaging studies, such as spondylolisthesis, spodylolysis, and disc protrusion. These structural changes have the tendency to present with pseudo-positive findings in imaging studies. The ＂non-specific＂ LBP indicates the LBP of which the cause cannot be seen on imaging studies. It is hard to make a precise diagnosis for it because of its variability in etiology. The differential diagnostic list of non-specific LBP includes articular dysfunctions (the facet joint, the sacroiliac joint, etc.), myofascial dysfunctions, motor control dysfunctions and peripheral sensitization. In conclusion, Non-specific LBP can be treated by correcting its pathomechanics through manipulation together with taping, bracing and home exercises under precise diagnosis.