前十字韌帶重建術後在上下樓梯時之神經肌肉控制與關節間協調度變化研究

Abstract

背景：前十字韌帶受傷的病人在接受韌帶重建手術後，雖然膝關節之穩定性和功能都得到改善，但其下肢神經肌肉控制仍無法完全回復至術前狀況。神經肌肉控制的改變可能會影響其關節間協調性。此變異會造成病人在上下樓梯時動作表現出現問題而可能提早退化性關節炎的發生。 目的：本研究探討前十字韌帶重建術後病人在上下樓梯時之神經肌肉控制及下肢關節協調度之變化。 假設：前十字韌帶重建術後病人會使用較不協調的神經肌肉控制與關節間協調動作來進行上下樓梯的動作。 設計：橫斷性研究。 受試者：十七位單側前十字韌帶重建術後病人組和十七位年齡性別配對之健康對照組。 方法：受試者會以自選速度上下四階的階梯，(樓梯高度分別為16 及21公分)。動作過程中會同時收取動作學、動力學和肌電圖之訊號。另外會進行膝關節之本體感覺測試。手術側、健側與對照組之關節間協調度、膝關節剛性、協同收縮比率、本體感覺誤差和肌肉力量的數據進行分析。統計分析使用混合型變異數分析(mixed-model ANOVA)進行計算。顯著程度設定在0.05。 結果：本研究發現前十字韌帶重建術後病人會有明顯的肌力下降。上樓梯時，病人患側有較低的肌肉協同收縮比率；患側在髖-膝和膝-踝關節間協調度上也有明顯較高的變異度。而在下樓梯時，患側在控制下降期有較低的膝關節剛性，但在承重期則沒有差異；此外，患側之膝-踝關節間協調度有明顯較高的變異度。 結論：前十字韌帶重建手術後的病人在神經肌肉控制和關節間協調度上與正常人之間仍然有明顯的差異。術後肌力減少可能是造成肌肉協同收縮型態改變之主要原因。 臨床應用：日後對於前十字韌帶重建術後病人，物理治療可能要增加更多的肌力訓練以及強調神經肌肉控制訓練的重要性，以改善術後病人在上下樓梯時關節間協調的變異型態。

Background: After anterior cruciate ligament (ACL) reconstruction surgery, the knee instability decreases, however, the neuromuscular control among the joints of the lower extremity might still not fully recover. Altered neuromuscular control might affect the proper inter-joint coordination. These changes may alter patients’ movement pattern during stair negotiation that could lead to early knee osteoarthritis. Purpose: This study aimed to investigate the neuromuscular control and inter-joint coordination during stair negotiation in patients with ACL reconstruction. Hypothesis: The neuromuscular control and inter-joint coordination of patients would demonstrate a less coordinative pattern during stair negotiation compared to that of healthy control participants. Study design: Cross-sectional study. Subjects: Seventeen unilateral ACL reconstructed patients and seventeen healthy age and gender-matched controls. Methods: Participants were instructed to perform stair ascent and descent on a 4-steps stair (stair height: 16 cm and 21 cm) with their self-selected speed. Kinematic, kinetic and electromyography data was collected during stair negotiation. Proprioception test of knee joint was also evaluated. Inter-joint coordination, knee stiffness, coactivation ratio, proprioceptive error and muscle strength among the surgical side, non-surgical side of patients and controls were analyzed. A mixed-model ANOVA was used to compare the difference of variables among the surgical side, non-surgical side of patients and controls. The significant level was set at 0.05. Results: Muscle strength of affected side in the patient group was significantly decreased compared to the healthy control. During stair ascent, affected side showed a lower knee coactivation ratio compared to the sound side. The variability of hip-knee and knee-ankle inter-joint coordination in the affected side was significantly decreased. During stair descent, significantly lower knee stiffness was observed in the affected side during controlled lowering phase, but not during weight acceptance phase. Higher variability of knee-ankle inter-joint coordination was found in the affected side. Conclusion: Significant alterations of neuromuscular control and inter-joint coordination between the patients and the control during stair negotiation. The varied inter-joint coordination pattern might relate to the altered muscle coactivation pattern and reduced muscle strength in ACL reconstructed patients. Clinical application: In the future, physical therapists should provide adequate muscle strengthening exercise to the patients and focus on importance of neuromuscular training for improving neuromuscular control and inter-joint coordination during stair negotiation.