肩胛骨運動異常:新型分類測試之信度與效度研究

Abstract

背景:肩胛骨運動異常為可觀察之肩胛骨位置與動作模式上之改變。此異常和許多肩關節疾患中常發現肩關節之動作學參數、肩胛骨周圍之肌肉活動之改變有關。文獻指出，過去有許多測試肩胛骨運動異常之評估方法，但並不完備，包括量測肩胛骨與胸廓之距離只能提供靜態量測的資訊，及在臨床環境難以使用複雜精密之儀器，所以針對肩胛骨運動異常以臨床觀察為基礎之評估方法是有需要的。本研究希望發展一新整合之肩胛骨運動異常之臨床評估方法。目的:本實驗目的為探討新型肩胛骨運動異常分類測試方法之信度與效度。實驗設計:本研究欲收錄60位單側肩膀疼痛之受試者。本實驗採用直接肉眼觀察結合觸診之評估法，將受試者之肩胛骨活動分為8種型態【3種單一肩胛骨運動異常型態:肩胛骨下角突起型態(型態I);肩胛骨內緣突起型態(型態II);肩胛骨上緣過高或肩胛肱骨節律異常型態(型態III)、4種合併型態(合併兩種肩胛骨異常之合併型態(型態I及II、型態I及III、型態II及III)、合併所有三種肩胛骨異常之合併型態(型態I及II及III))和正常之肩胛骨運動型態(型態IV)】，探討此評估法之信度與效度。效度部分探討分類出的不同肩胛骨運動異常型態是否有相對應的肩胛骨運動學與肌肉活動性變化。主要測量: (1)肩胛骨運動學(肩胛骨上/下轉、前/後傾、內/外轉、上移/下移)，(2)肌肉活動性(上/中/下斜方肌和前鋸肌)，(3)肌肉力量。結果:新型肩胛骨運動異常分類測試達到中等到高度(κ/κw=0.49~0.64)的測試者間信度。在效度方面相對於正常肩胛骨活動組，在抬手階段時型態III有較少之上轉(7°)與上移(1.7公分)；在放下階段時型態II有較多之內轉(5°~7°)。肌電圖結果只有前距肌肌肉活動有顯著差異(抬手:增加15~19%；放下:減少8%)。結論: 新型肩胛骨運動異常分類測試達到滿意之信度，且效度部分也顯示各類型肩胛骨運動異常組多數有其對應之肩胛骨運動學改變。肌電圖結果顯示只有前距肌肌肉活動有變化，可能與每人有其獨特使用肩胛骨肌肉策略有關。

Background: Scapular dyskinesis are observable alternations in scapular position and the patterns of motion. Shoulder kinematics and scapular muscular activities alternations were found to be correlated with many shoulder disorders. In previous studies, there were several evaluation methods to assess scapular dyskinesis. However, it was not sufficient; for instance, the scapular displacement from the trunk only provides static measurement, and difficulty of using complicated devices in clinical settings. Therefore, visual-based clinical assessment to identify scapular dyskinesis need to be developed. In this study, we want to develop a novel integrated test to evaluate patients with scapular dyskinesis for clinical use. Objective: The purpose of this study was to investigate the reliability and validity of the novel scapular dyskinesis classification test. Study Design: Sixty subjects with unilateral shoulder pain will be recruited in this study. We used visual-based assessment combined palpation to classify the scapular movement of participants as 8 patterns (3 single abnormal scapular patterns: inferior angle of scapula prominence (pattern I), medial border of scapula prominence (pattern II), superior border of scapula prominence or aberrant scapulohumeral rhythm (pattern III); 4 mixed abnormal scapular patterns: 2 patterns combined (pattern I and II, pattern II and III, pattern I and III) and all 3 patterns combined (pattern I, II, and III); normal scapular movement pattern (pattern IV)) to investigate the reliability and validity of this method. In validity part, we analyzed whether different patterns of scapular dyskinesis corresponding to the alternation of the scapular kinematics and muscular activities. Main outcome measures: (1) 8 patterns of scapular movement (2) Scapular kinematics (scapular upward/ downward rotation, anterior/ posterior tipping and internal/ external rotation, elevation/ depression). (3) Scapular muscular activities (upper/ middle/ lower trapezius and serratus anterior). (4) Muscle force. Results: The novel scapular dyskinesis classification test reached moderate to substantial inter-rater reliability. In validity part, there were less scapular upward rotation (7°) and elevation (1.7 cm) in pattern III group in raising phase, and there was more scapular internal rotation (5°~7°) in pattern II group in lowering phase. Results from EMG data only showed significant difference in serratus anterior muscle (raising: increase 15~19%; lowering: decrease 8%). Conclusion: The novel scapular dyskinesis classification test reached satisfactory reliability. The validity of this test has been demonstrated that the alternations of scapular kinematics were found mostly in specific pattern of scapular dyskinesis group compared with normal pattern group in raising and lowering phase of arm elevation. EMG showed that only the alternation of serratus anterior muscle activity was found, which may be consistent with the fact of distinctive strategy of using scapular muscles by each subject.