肩胛骨運動異常病患之肩胛骨動態控制訓練:肩胛骨運動學及相關肌肉活動特性

Abstract

背景: 肩胛骨位置及運動方向對肩關節正常功能表現及相關肌肉表現有很大的影響。文獻上也證明肩胛骨動作異常和肩關節病理性疾病相關。因此，肩胛骨動作控制是治療肩關節相關疾病的重要考慮因素之一。肩胛骨動態訓練為訓練肩胛骨運動異常的人主動將肩胛骨擺放在一正確的位置達到矯正肩胛骨的目的。然而，目前研究尚未指出肩胛骨動態訓練在有症狀的肩胛骨運動異常病人是否可行。此外，肩胛骨動態訓練是否能改善相關肌肉表現也無研究支持。目的: 本實驗目的有二: (一) 探討肩胛骨運動異常病人是否能藉由肩胛骨動態訓練將肩胛骨主動擺放在一正確位置。(二) 觀察肩胛骨運動異常病人經由肩胛骨動態訓練後，是否能改善相關肌肉的表現。實驗設計: 以60位肩胛骨動作異常病患為研究對象(肩胛骨下緣翹起組: 16名，肩胛骨內緣翹起組: 16名，肩胛骨下緣及內緣翹起組: 28名)。在肩胛骨動態訓練前後，利用三維動作分析系統及肌電圖分別測量在肩胛骨平面上舉手，側躺舉手及側躺手外轉三個動作的肩胛骨關節動作、肌肉活化程度及肌肉平衡比率。主要測量: 肌肉活化程度(上斜方肌、前鋸肌、中斜方肌及下斜方肌)、肌肉平衡比率(上斜方肌/前鋸肌、上斜方肌/中斜方肌及上斜方肌/下斜方肌)及肩胛骨運動學(肩胛骨上/下轉、外/內轉及前/後傾)。實驗結果: 經由肩胛骨動態訓練後，肌肉活性部分，中斜方肌和下斜方肌在三個運動中的不同量測位置下，三組都有顯著增加肌肉活化程度(平均中斜方肌肌肉活化程度: 由6.57%增加至24.77%; 平均下斜方肌肌肉活化程度: 由17.83%增加至29.03%)。前鋸肌則在側躺手外轉的向心收縮時期的肩胛骨下緣翹起組及肩胛骨下緣及內緣翹起組有顯著增加 (肩胛骨下緣翹起組: 由10.55%增加至12.59%; 肩胛骨下緣及內緣翹起組: 由9.30%增加至12.73%)。肌肉平衡比率部分，三組在肩胛骨平面上舉手的不同量測位置，肌肉平衡比率有顯著下降 (上斜方肌/中斜方肌: 由1.59下降至1.29及上斜方肌/下斜方肌: 由2.27下降至1.61)。在側躺舉手動作則無任何肌肉平衡比率達到統計上顯著差異。在側躺手外轉，肩胛骨下緣翹起組在上斜方肌/下斜方肌比值有顯著下降(向心收縮期: 由 0.25下降至0.19; 離心收縮期: 由0.33下降至0.24)。在肩胛骨運動學部分，肩胛骨外轉角度於三組的肩胛骨平面舉手及側躺舉手有顯著增加 (肩胛骨平面舉手: 由4.82°增加至9.55°; 側躺舉手: 由26.16°增加至33.47°)。討論: 肩胛骨動態訓練可有效改善肩胛骨運動異常病人的肌肉表現(中斜方肌和斜方肌)。前鋸肌只在部分結果有顯著改善可能原因為訓練過程中給予指令問題。在肌肉平衡比率部分，雖然在兩個側躺動作中訓練前後無達到統計上顯著差異，但本實驗訓練後的比值相對過去文獻低，顯示肩胛骨動態訓練可促進良好的肌肉平衡比率。肩胛骨外轉角度增加與肌肉表現改善結果一致。結論: 在這三種運動中，肩胛骨動態訓練能有效改善肩胛骨運動異常病人的肩胛骨運動學及相關肌肉表現。然而，肩胛骨動態訓練之長期療效及運用於不同年齡層、嚴重程度之病人仍有待未來更進一步的研究。

Background: Scapular orientation and movements can affect the function of shoulder joint and associated muscular activity. Scapular dyskinesis is associated with many types of shoulder pathologies. Thus, the scapulothoracic joint may require specific attention during treatment. Conscious control of scapula is a way to train people with scapular dyskinesis actively performing scapula in neutral position. However, evidence is limited whether symptomatic subjects can actively maintain scapula in neutral position in resting position and during arm movements by conscious scapular control training. Besides, whether muscle performance can be improved by conscious scapular control training is unknown. Objective: The purposes of the study are 2-folds: (1) to investigate whether patients with scapular dyskinesis can actively perform corrected scapular orientation by conscious scapular control training; (2) to explore whether correction of scapular dyskinesis can improve muscle performance in subjects with scapular dyskinesis. Design: Sixty patients with scapular dyskinesis were recruited in this study (inferior angle pattern I group: 16, medial border pattern II group: 16 and mixed pattern group: 28). Each patient was asked to perform three selected exercises including arm elevation in scapular plane, side-lying elevation and side-lying external rotation before and after conscious control training. Three-dimensional electromagnetic motion analysis and Electromtography muscle activity were used to record the scapular kinematics, absolute muscle activation and muscular balance ratios during exercises before and after conscious control training. Main outcome measures: The absolute muscle activation upper trapezius (UT), serratus anterior (SA), middle trapezius (MT) and lower trapezius (LT), the muscular balance ratios (UT/SA, UT/MT and UT/LT) and scapular kinematics (scapular upward/downward rotation, external/internal rotation and anterior/posterior tipping) were the outcomes of this study. Result: Significant increased muscle activations (MT and LT) were found after training in most variables in three selected exercises among three groups (MT: from 16.57% to 24.77%; LT: from 17.83% to 29.03%). Increased SA was found only in concentric phase of side-lying external rotation in pattern I and I+II groups (pattern I: from 10.6% to 12.6 %; pattern I+II: from 9.3% to 12.7 %). For arm elevation in scapular plane, UT/MT and UT/LT were found significantly lower after training in high angles of humeral positions among three groups (UT/MT: from 1.59 to 1.29; UT/LT: from 2.27 to 1.61). No significant difference was found in muscular ratios in side-lying elevation. For side-lying external rotation, only UT/LT showed significant decrease after training in both phases in pattern I group (concentric phase: from 0.25 to 0.19; eccentric phase: from 0.33 to 0.24). For scapular kinematics, significant increase in scapular external rotation was found after training in arm elevation in scapular plane (from 4.82° to 9.55°) and side-lying elevation (from 26.16° to 33.47°) in three groups. Discussion: Conscious control training can be used in symptomatic patients (improvement in MT and LT). The reason of lack of improvement in SA might be the correction instruction. Although we did not find the significant changes of muscular ratios (UT/MT and/or UT/LT) in side-lying elevation and side-lying external rotation exercises, low ratios (<0.4) before/after training indicate that these exercises can be an optimal training protocol. The effects of conscious control training in scapular external rotation were also consistent with the associated muscle activation change of MT and LT. Conclusion: Conscious control training improves some of scapular orientation and muscle performance during selected 3 exercises in symptomatic subjects. Most improvements of scapular kinematics and muscle performance are similar across 3 patterns with some muscle performance improvements specific to dyskinesis pattern. Validation of long-term effects of conscious control training on muscle activation and scapular kinematics in wide generation of patients with shoulder symptoms is needed.