探討閉鎖式與開放式動力鍊肩胛骨集中運動訓練於肩胛骨動作學及肌肉活化之差異及動作特色

Abstract

背景：肩峰下疼痛症狀佔肩關節患者中百分之四十四至六十五的發生率，會造成疼痛及功能，且症狀可能長期延續。過去針對肩峰下疼痛患者的觀察性研究，可發現常伴有肩胛骨動作控制障礙，推測其可能為造成此症狀的原因，針對此致病機轉，過去研究者提出肩胛骨集中訓練以解決患者疼痛情形，根據過去隨機控制試驗之結果，其可有效舒緩臨床症狀，但於肩胛骨動作控制的效果則無一致結果。過去有學者曾提出閉鎖式動力鍊對於下肢穩定度訓練之益處，近期也有部分研究針對其對於上肢穩定度效果之探討。此外，近期有部分研究使用主成分分析，對肩部之三度空間肌動學及肌電圖數據進行分析，以提供更完整的資訊。目的：本研究目的為探討肩峰下疼痛患者與無症狀受試者，進行閉鎖式動力鍊與開放式動鍊肩胛集中運動時，於肩胛骨運動學及肌肉活化上之差異，並使用主成分分析方式，分析閉鎖式與開放式動力鍊運動之特色。方法：本試驗共收錄24位受試者，肩峰下疼痛症狀患者須符合測試中五項中三項，而健康受試者須符合12個月內無肩關節疼痛或傷害。本試驗共執行二組閉鎖式／開放式動力鍊運動，受試者於第一次訪問熟習此二組運動並量測所需阻力後，間隔至少三天後進行二訪，於運動進行時量測數據，包含三度空間動作學資料及肌電圖訊號。結果：本試驗中肩峰下疼痛症狀患者與健康受試者於進行運動時並無顯著差異。受試者執行開放式水平划船運動時，有較高上斜方肌與前鋸肌活化，進行閉鎖式伏地挺身向上運動離心收縮時，則呈現較高的前鋸肌活化，同時降低上斜方肌活化。於肩胛骨運動學則發現，所有受試者在開放式水平划船運動時，有較多肩胛骨外轉及上轉，此外，進行跪地閉鎖式伏地挺身向上運動向心收縮時有較多上轉。我們亦可藉由主成分分析結果，協助辨認閉鎖式及開放式動力鍊肩胛骨運動之特色，且部分結果與先前開放式及閉鎖式比較相呼應。根據閉鎖式水平划船運動之特色分析，可確認此運動有較低上斜方肌活化之益處。此外，跪地閉鎖式伏地挺身向上運動之前鋸肌優勢與肩胛骨上轉特色亦可被主成分分析結果支持。結論：針對肩峰下疼痛患者，可建議閉鎖式動力鍊運動，因為可促進活化肩胛骨周圍肌肉，進而改善肩胛骨動作控制。然而，在肩胛骨運動學上仍有不確定性，所以須謹慎使用閉鎖式肩胛骨運動。藉由主成分分析動作特色，可使臨床人員了解所選運動之更全面的資訊，協助針對肩峰下疼痛患者進行臨床決策。

Background: Subacromial pain syndrome (SAPS) is a painful and often long-lasting condition that influenced 44-65% of all shoulder pain. Scapular motor control deficit is proposed to be a possible mechanism resulting in SAPS. Scapular-focused exercise has been proved to be effective in clinical symptoms, but effects on scapular motor control is inconclusive. According to advantages of closed-kinetic chain (CKC), there are a few studies emerging to investigate its effects on upper extremities. And also, some studies adopted principal component analysis (PCA) to investigate muscle activity and kinematics in shoulder region. Objectives: To investigate the differences in scapular muscle activity and kinematics between CKC and open-kinetic chain (OKC) when performing scapular-focused exercises in participants with SAPS and asymptomatic subjects. And also, we investigated the characteristics of selected exercises analyzed by PCA. Methods: Twenty-four participants were recruited in this study. Participants with SAPS had to meet 3 of 5 tests and asymptomatic participants had no history of shoulder pain or injury related to upper extremities in recent 12 months. Two pairs of exercise were performed in both CKC and OKC conditions. After familiarization and deciding resistance in the first visit, data collection was performed at least three days after the first visit. Three-dimensional kinematics and surface electromagnetic data were collected during performing exercises. Results: No difference on outcomes was found between SAPS and asymptomatic participants. Averaged across two groups, participants showed higher UT activity in horizontal row open kinetic chain (HRO) exercise (OKC), however, they demonstrated higher SA with less UT activation in eccentric phase of push-up plus (PUP) exercises (CKC). For scapular kinematics, all participants performed more external rotation and upward rotation during HRO in concentric phase. Besides, more upward rotation was found during PUP in concentric phase. We could identify some characteristics by PCA which was corresponding to the differences between CKC and OKC exercises. According to characteristics of horizontal row in CKC (HRC), it partially confirmed the benefits on less UT activation. And also, knee PUP was supported by PCA for dominance of SA activation and scapular upward rotation. Conclusion: For patients with SAPS, exercises in CKC might be recommended to activate scapular muscle for improving scapular motor control. Nevertheless, there was some uncertainty about benefits of kinematics during CKC and OKC, so utilization of scapular-focused exercise in CKC should be considered cautiously. Characteristics analyzed by PCA could provide clinicians more comprehensive information of selected exercises to make decisions for patients with SAPS.