脊髓損傷患者於不同情況下之胸廓三度空間動作分析

Abstract

良好功能的胸廓正常動作，對於日常生活功能及存活是很重要的。許多臨床問題容易造成不正常胸廓動作，這些問題包括：脊髓損傷、中風、頭部外傷、肺部及心臟疾病等。臨床上，物理治療師對於脊髓損傷患者之呼吸訓練，包括：坐姿及躺姿時的呼吸訓練，以及利用上肢活動來增加肺活量，然而，以往的相關研究因為受限於所使用的測量工具，無法提供胸廓活動完整的三度空間的資訊（three dimensional information），且無法探知內部橫膈膜的動作，因此本研究主要目的是:（1）建立三度空間光電動作分析系統（Vicon250,牛津,英國）和超音波攝影（Sonosite Inc., 華盛頓, 美國）之信度與效度，以及胸廓動作三度空間模式；（2）於仰臥姿勢下且無上肢動作時，比較健康人與脊髓損傷患者胸廓三度空間動作; (3) 於仰臥姿勢下且配合上肢動作時，比較健康人與脊髓損傷患者胸廓三度空間動作(4)於坐姿下且無上肢動作時，比較健康人與脊髓損傷患者胸廓三度空間動作。方法：根據實驗目的，本研究分為三個實驗，受試者總共分三組包括健康組、胸髓損傷組、及頸髓損傷組。脊髓損傷患者的收案條件為完全髓損傷患者、男性、年齡在18-65歲、受傷六個月以上、受試期間無感染或發燒症狀、上肢可以在仰臥姿勢下執行肩關節外展的動作。實驗一為建立三度空間胸廓活動推估肺活量與由超音波測得知橫膈膜位移之關係，而部分受試者接受同時螢光攝影(fluoroscopy)及呼吸測量儀（spirometer），並建立超音波測量及螢光攝影測量之橫膈膜位移的關係，建立超音波測得橫膈膜位移之指標；實驗二主要為比較健康受測者與頸椎胸髓損傷患者，於躺姿下無上肢外展動作對胸廓動作之影響；實驗三主要為比較健康受測者與頸椎胸髓損傷患者，於躺姿下有上肢外展動作對胸廓動作之影響；實驗四為比較正常人與頸髓胸椎損傷患者於坐姿及臥姿下對於胸廓動作之影響。本研究方法除臨床量表評估外，要求受測者嘴巴含住呼吸測量儀之吹管做深呼吸，藉此測得肺活量，並同時在身體前側貼47顆反光球，由光電動作分析系統測量胸廓動作，且使用超音波測量右側及左側橫膈膜之移動。呼吸肌用表面肌電圖記錄胸鎖乳突肌、肋間肌與橫膈膜之肌肉活動。分析方法：使用Matlab 7.01及SPSS11.0做不同情況之資料分析。結果：(1) 由超音波測得之橫膈膜位移與螢光攝影測得之橫膈膜位移的相關性達0.914，而且，由超音波測得之橫膈膜位移與腹部變化量有顯著相關。(2) 躺姿下，頸椎脊髓損傷患者主要以腹部移動來完成吸氣及吐氣的動作，對於胸椎脊髓損傷患而言，發現不管在最大吸氣或是吐氣，胸椎患者之下胸廓的移動比正常人少。(3) 上肢外展動作對於頸椎脊髓損傷患者而言，雖然整體的胸廓動作及肺活量並未增加，但增加了上胸廓的動作伴隨著減少腹部的動作，並增加呼吸肌的徵召。(4) 從躺姿改變到坐姿，對於胸椎第四節受傷以上的脊髓損傷患者而言，會讓肺活量降低，使腹部動作變小，但增加呼吸肌的徵召。結論：對於脊髓損傷患者而言，可用腹部動作的大小，來評估橫膈膜位移的程度。在躺姿下執行上肢外展的動作，確實可增加上胸廓的活動度。然而，在坐姿下，易導致脊髓損傷患者腹部及橫膈膜的動作下降，使肺活量低於躺姿。以上結果可提供臨床復健的參考。

Normal chest wall motion is important for good daily function and survival rate. Many clinical problems result in abnormal chest wall motion, including spinal cord injury, stroke, pulmonary diseases, and heart diseases etc. In clinics, a lot of respiratory training methods are used to improve respiratory function of spinal cord injured patients, including respiratory training in sitting and supine posture, with or without arm motion to increase lung volume. However, previous studies about three-dimensional (3D) information of chest wall motion and diaphragmatic excursion are limited, so we will use the optoelectronic plethysmography (OEP) system combining with ultrasonography (USD) to measure chest wall motion in this study. The purposes of these studies are as following: (1) to construct the validity and reliability of chest wall motion by OEP system (Vicon 250, Oxford, UK) and USD system (Sonosite Inc., Washington, USA) and establish 3D chest wall motion model, (2) to compare the chest wall motion between healthy subjects and individuals with spinal cord injury in supine, (3) to compare the chest wall motion with and without arms abduction between healthy subjects and individuals with spinal cord injury in supine, and (4) to compare the chest wall motion between healthy subjects and patients with spinal cord injury in sitting and in supine posture. Methods: According to the purposes of this study, there are there experimental designs. The participants include healthy group, paraplegic group, and tetraplegic group. The inclusion criteria of individuals with spinal cord injury are complete cervical or thoracic cord lesion, male, with age ranging from 18 to 65 years old, at least 6 months since injury, without any infection or inflammatory symptoms during the experimental period, and being able to abduct his arms in supine position. The experiment I is to establish relationship between 3D chest wall motion model and diaphragmatic excursion measured by USD. The index of diaphragmatic excursion is established by evaluation of relation between the diaphragmatic excursion measured by USD and measured by fluoroscopy. The experiment II is to compare chest wall motion in supine posture between healthy able-bodied subjects and individuals with spinal cord injury. The experiment III is to compare chest wall motion in supine posture with and without arms abduction movements between healthy subjects and individuals with spinal cord injury. The experiment IV is to compare chest wall motion between healthy subjects and individuals with spinal cord injury in sitting and supine posture. After the clinical assessments, the subject is asked to breathe via mouth piece of spirometer to measure the vital capacity. Forty-seven passive reflective markers are applied on anterior side of trunk to measure chest wall motion by OEP system. The USD is applied on the right side of the 10th intercostal space in the midclavicular line with slightly upward tilt to subjects’ head to measure diaphragmatic excursion. After the starting signals, all equipments start synchronously while the subject is asked to perform breathing. The surface electromyography (EMG) is used to record the activities of respiratory muscles including Sternocleidomastoid and intercostals combined with diaphragm (costal diaphragm). Data analysis: Matlab 7.01 and SPSS11.0 are used to analyze the data. Results: (1) The relation between diaphragmatic excursion measured by USD and fluoroscopy was good (Pearson correlation coefficient=.914), and the relationship between the diaphragmatic excursion and the abdominal volume changes was good. (2) Comparing to the controls, the individuals with paraplegia had decreased motion of the lower thorax during both maximal inspiration and expiration. (3) Comparing to the arms resting condition, the individuals with tetraplegia had increased movement of the upper thorax and decreased movement of the abdomen with larger recruitment of respiratory muscle activities under arms abduction condition, although the volume change of total chest wall did not change. (4) Comparing to the lying posture, the individuals with lesion level above T4 had decreased lung volume with decreased movement of abdomen and increased recruitment of respiratory muscle activities in seated posture. Conclusion: For individuals with spinal cord injury, the motion of abdomen can be used to assess the excursion of the diaphragm. In addition, the arms abduction during inspiration was a good intervention to increase the movement of the upper thorax. However, the vital capacity would decrease with the reduced the movement of abdomen for individuals with spinal cord injury in seated posture. The above findings would provide the guideline for clinical rehabilitation.