本體神經肌肉誘發伸展術對全膝關節置換者的膝關節活動度之療效

Abstract

研究設計：隨機雙盲臨床試驗、前瞻性研究 背景：本體神經肌肉誘發伸展術（簡稱PNF伸展術）為藉由相同的機轉刺激身體的本體受器產生神經抑制機轉來放鬆痙攣肌肉，得以延展肌肉長度的一種伸展技術。過去文獻發現運用PNF伸展術較被動伸展術更能增加關節活動度，但此類研究多針對健康或肌肉僵硬者，並無針對關節活動受限者研究。在臨床上全膝關節置換者在術後常形成關節活動受限，運用PNF伸展術可有效地增加關節活動度，且治療過程中比較不會疼痛；但缺乏實證研究。因此本研究將針對全膝關節置換者，探討運用PNF伸展術能否改善術後的膝關節屈曲角度、疼痛、膝伸肌肌力、與下肢功能等問題。 研究目的：探討針對全膝關節置換者在住院期間增加施行PNF伸展術對膝關節屈曲角度、疼痛、膝伸肌肌力與下肢功能在介入前後與術後短期的療效。 研究方法：受試者為單側全膝關節置換者，共計64名，隨機分配為實驗組或控制組各32名，所有受試者皆接受術後物理治療。在住院期間，實驗組每天由物理治療師進行5回合的PNF伸展術，一共3天，而控制組則接受相同時間的被動伸展術。療效評量包括治療當天的治療前、治療後、出院前、及出院一個月後執行。量測的變項包括膝關節屈曲角度、膝伸肌最大自主等長收縮肌力、膝關節疼痛分數、計時行走測試時間、患者自行評估膝部傷害及膝關節炎預後量表等，以評量兩組患者術後關節功能恢復情形。 結果：全膝關節置換者在住院期間接受首次介入後，無論是PNF伸展術或被動伸展術都能顯著增加膝屈曲角度，但實驗組較控制組能增加更多屈曲角度（p=0.014），但PNF伸展術可以顯著增加膝伸肌肌力，且在膝屈曲時不會疼痛，優於被動伸展術。而在全膝關節置換者住院期間進行3天的治療介入後，雖然兩組都出現進步情形，但在出院前實驗組較控制組顯著地增加更多的膝屈曲角度（p=0.001），步行功能表現及膝功能分數也較佳。而在術後1個月追蹤時，除計時行走測試外，膝屈曲角度在實驗組（115.7±10.2°）顯著大於控制組（104.3±12.4°）（p<0.0001），且實驗組的膝伸肌肌力也較高、膝屈曲時比較不會疼痛、膝功能較佳。 結論：全膝關節置換者在住院期間運用PNF伸展術可以立即且持續增加膝屈曲角度，在屈曲動作或日常活動時也較不會產生疼痛。同時3天的住院治療即可有效達到出院目標，可以節省治療成本與人力。且在術後一個月即達成過去膝屈曲功能角度的長期目標。本研究為世界首創運用PNF伸展術來增加全膝關節置換者術後療效，研究設計為隨機臨床試驗研究，故其結果可提供臨床應用上有力的實證參考。

Research design： double-blinded randomized control trial, prospective study Background： Proprioceptive neuromuscular facilitation（PNF） stretching technique is a therapeutic technique applying the PNF concept and skills to the related muscles either to increase neuro-inhibition mechanism for releasing muscle spasm and elongating muscle length, or to increase neuro-excitation mechanism for enhancing muscle strength. Improvement in range of motion through PNF stretching technique has been documented superior to other techniques in previous literature, but those studies have only been done in healthy adults. Less is known in the effect of PNF stretching on improvement in joint restriction. Range of motion limitation usually disturbed the patients with total knee arthroplasty. PNF stretching techniques are commonly used in the treatment for patients with total knee arthroplasty to increase range of motion effectively and reduce knee pain during exercises. However, there is no evidence-based research in such a treatment strategy. This research, therefore, explored application of PNF stretch in changes of knee flexion, pain, muscle strength, and function of the lower extremity following total knee arthroplasty. Purposes： To investigate immediate and short-term effects on angle of knee flexion, intensity of pain, strength of the knee extensor, and function of the lower extremity by using PNF stretching technique in patients with total knee arthroplasty as compared to those using passive stretching technique. Method： Sixty-four patients who received total knee arthroplasty in National Taiwan University Hospital were recruited in this study. They were randomly allocated into either experimental or control groups with 32 participants in each. Conventional physical therapy programs were given to all participants. Besides, the experimental group assumed 3-session PNF stretching technique from the third post-operative day to the day of discharge while the control group receiving same-time passive stretching technique, instead. The outcome measures were taken before and after the first session treatment on the same day, on the day of discharge, and one month after the operation. The variables measured included knee flexion angle measured, maximum voluntary isometric strength of the knee extensor, pain score, timed up and go test, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Results： The participants who received PNF stretching technique significantly increased knee flexion angle, enhanced muscle strength of the knee extensor, relieved pain at knee joint, and improved function of the lower extremities as compared to the controls, either immediately after PNF stretching, or on the day of being discharged from the hospital, or at one-month follow-up. Conclusions： Immediate increase in knee flexion angle and decrease in pain during motion were noted for patients receiving unilateral TKA following one-session application of PNF stretch technique. After receiving three-session treatment during hospitalization, the knee flexion angle in patients receiving PNF stretch technique was significantly greater than those receiving passive stretching technique. The fact that PNF stretching technique achieved their goals for discharge earlier in the experimental group might save medical cost and manpower. This effect continuing to improve until one-month follow-up resulted in reaching the condition which was only present one year after operation in previous literature. This is the first study in the world to apply the PNF stretching technique in patients with total knee arthroplasty. The randomized-control-trial nature of this study provides a strong evidence in clinical application of PNF technique.