慢性阻塞性肺疾病患者肩胛骨控制受損

Abstract

背景：疼痛和慢性阻塞性肺病（COPD）共存已被研究指出，但該族群中疼痛的盛行率和影響因素仍不清楚。慢性阻塞性肺病患者的疼痛與姿勢異常、肌肉骨骼問題和肩胛運動障礙之關聯尚未被充分理解。這些問題可能是由於肺部過度充氣和肌肉功能障礙造成的，增加了頸部肩部疾病的風險，凸顯了進一步研究肩胛骨控制障礙的必要性。 研究目的：1) 系統性地評估患有 COPD 和無患病的個體的肩胛控制障礙，2) 評估患有 COPD和未患病的個體的疼痛強度、疼痛干擾或疼痛部位的數量，3) 評估患有COPD個體的疼痛特徵、COPD 評估測試 (CAT)、改良版醫學研究委員會呼吸困難量表 (mMRC)、頸部失能指數問卷 (NDI)、肩部疼痛與失能指數 (ＳＰＡDI) 及改良版動作恐懼量表（mTSK）、肺功能和肩疼痛量表間的關聯性，4) 比較患有和未患有 COPD 的個體在安靜呼吸、完全吸氣和呼氣條件下的肩胛骨/鎖骨運動學和胸腔壁特徵，5) 比較患有和不患有 COPD 的個體在肩胛平面上手臂抬高時的肩胛骨和鎖骨運動學。 方法：針對目標 1，檢索了 7 個資料庫，兩位研究人員篩選研究、擷取資料並評估品質。使用標準化均差 (SMD)、I2 和卡方統計資料的統合分析比較了研究之間的異質性。對於目標 2 和 3，使用卡方檢定疼痛盛行率、獨立 t 檢定或 Mann-Whitney U 檢定進行組別比較以及邏輯回歸對自我報告的問卷和臨床數據進行糾正和分析，以探索與慢性阻塞性肺病患者常見疼痛區域相關的關聯因素。對於目標 4 和 5，所有參與者完成了與研究目標 2 和 3 相同的研究流程，並結合肩部活動範圍和肩胛運動障礙測試。使用基於反光標記的運動分析系統記錄上半身運動學。任務包括三種呼吸條件和手臂抬高。使用雙向重複測量變異數分析分析組和條件比較。 結果：針對目標 1，7項研究被納入回顧，總計287位參與者，其中量性研究包含190位參與者。由於研究之間存在顯著異質性，亞組分析顯示 COPD 患者肩胛骨前傾減少（SMD：0.46；95% CI：0.01 至 0.09）。相反，在 COPD 參與者中觀察到更大的肩胛上抬（SMD：-1.03；95% CI：-1.69 至 -0.73）、內旋（SMD：-1.65；95% CI：-3.19 至 -0.10）和肩部前伸（SMD：-0.73; 95% CI：-1.18 至 -0.32）。對於目標 2 和 3，對 71 名 COPD 患者和 71 名年齡和性別匹配的對照組進行比較，結果顯示疼痛發生率（75.3% 對比 42.4%，p < 0.001）、疼痛嚴重程度（3.9 ± 3.1 對比 2.1 ± 2.8，p < 0.001）、疼痛部位(median 0 [IQR 0.0–2.0] 對比 2 [IQR 0–4.0], p < 0.001) 、疼痛干擾（0 [IQR 0.0–0.9] 與 0.71 [IQR 0–2.6]，p = 0.007）、NDI（1.9 ± 5.3 對比0.3 ± 1.7，p < 0.001）與 SPADI 分數(10.1 ± 17.4 versus 4.4 ± 10.6, p < 0.001)。肩部是最常被回報的疼痛部位，其次是胸椎區域和下肢。 COPD 患者的肩痛與多重疼痛部位相關（調整後 OR：1.82，95% CI：1.25-2.66，p = 0.002）、較高的 SPADI 分數（調整後 OR：1.07，95% CI：1.01-1.13，p = 0.017）和減少的預測FEV1 百分比(調整後 OR: 0.96, 95% CI: 0.92–0.99, p = 0.026)。對於目標 4 和 5，患有 COPD 的個體（n=14，平均年齡 71.8 ± 1.7 歲）表現出顯著較高的鎖骨抬高 (CE)（平均差值 (SE) = 3.292 (1.526)，p = 0.041）和 SUR（組間差值 (SE) = 4.696 (1.633), p = 0.008），但在所有呼吸階段，COPD患者CP均低於(Mean difference (SE) = 3.625 (1.401), p = 0.016)無 COPD 者 (n=12，平均年齡 69.7 ± 2.2 歲)。然而，各組在胸腔壁橫向尺寸或 SIR 和 SPt 方面並沒有統計上顯著差異。兩組均記錄完全吸氣時最寬的胸壁橫向尺寸和完全呼氣時的最窄胸壁橫向尺寸。在非 COPD 組中，數值分別為 322.57 ± 25.92 和 310.71 ± 26.92，p < 0.001。同樣，在 COPD 組中，數值分別為 322.57 ± 25.92 和 310.71 ± 26.92，p = 0.002。與無 COPD 的患者相比，COPD患者在所有肩部運動範圍內也表現出較高的 CE（平均差 (SE) = 4.477 (1.244)，p = 0.001）和 SUR（平均差 (SE) = 4.787 (1.06)，p < 0.001），但較低的CP (Mean difference (SE) = 5.623 (1.359), p < 0.001)。 結論：統合分析顯示，肩胛骨控制障礙在慢性阻塞性肺病患者中更為常見。第二項研究證實，與對照組相比，慢性阻塞性肺病患者的疼痛發生率較高，尤其是在肩部區域。 COPD 患者的肩痛與多個疼痛部位、SPADI 評分和預測 FEV1 百分比有關。在最後一項研究中，完全吸氣會導致最大的胸壁擴張。手臂仰角和呼吸階段會影響 CE、CP 和 SUR。

關鍵字： 慢性阻塞性肺臟疾病;鎖骨運動學；殘疾；運動障礙;薈萃分析；肌肉活動；疼痛;患病率；肩胛;肩部疼痛；肩胛運動學

Background: The coexistence of pain and chronic obstructive pulmonary disease (COPD) has been recognized, but the prevalence and contributing factors of pain in this population remain unclear. Pain in COPD patients, linked to abnormal posture, musculoskeletal issues, and scapular dyskinesis, is not well understood. These problems, likely due to lung hyperinflation and muscle dysfunction, increase the risk of neck and shoulder disorders, highlighting the need for further investigation into scapular control impairments. Aims of the study: 1) to systematically review the scapular control impairments in individuals with and without COPD, 2) to assess the prevalence of pain intensity, pain interference, or the number of pain locations in individuals with and without COPD, 3) to assess the association among pain characteristics, the COPD assessment test (CAT), modified Medical Research Council Dyspnea Scale (mMRC), Neck Disability Index questionnaire (NDI), the Shoulder Pain and Disability Index (SPADI), the modified Tampa Scale for Kinesiophobia (mTSK), pulmonary function, and shoulder pain in individuals with COPD, 4) to compare scapular / clavicle kinematics, and chest wall characteristics in quiet breathing, full inhalation, and exhalation conditions between individuals with and without COPD, and 5) to compare scapular and clavicle kinematics during arm elevations in scapular plane in individuals with and without COPD. Methods: For aim 1, seven databases were searched, and two investigators screened studies, extracted data, and evaluated quality. Meta-analysis with standardized mean difference (SMD), I², and Chi-squared statistics compared heterogeneity across studies. For aims 2 and 3, Self-reported questionnaires and clinical data were corrected and analyzed using Chi-squared tests for pain prevalence, independent t-tests or Mann–Whitney U-tests for group comparisons, and logistic regression to explore association factors related to common pain areas in individuals with COPD. For aims 4 and 5, all participants completed the same methods as study aims 2 and 3 combined with shoulder range of motions and scapular dyskinesis tests. Upper quadrant kinematics were recorded using a reflective marker-based motion analysis system. Tasks included three breathing conditions and arm elevations. Groups and conditions comparisons were analyzed using two-way repeated-measures ANOVA. Results: For aim 1. Seven studies were reviewed with 287 participants, including 190 in the quantitative analysis. Due to significant heterogeneity among studies, subgroup analyses revealed reduced scapular anterior tilting (SMD: 0.46; 95% CI: 0.01 to 0.90) in COPD patients. Conversely, greater scapular elevation (SMD: -1.03; 95% CI: -1.69 to -0. 73), internal rotation (SMD: -1.65; 95% CI: -3.19 to -0.10), and shoulder protraction (SMD: -0.73; 95% CI: -1.18 to -0.32) were observed in COPD participants. For aims 2 and 3, a comparison of 71 individuals with COPD and 71 age- and gender-matched controls revealed significantly higher pain prevalence (75.3% versus 42.4%, p < 0.001), pain severity (3.9 ± 3.1 versus 2.1 ± 2.8, p < 0.001), pain locations (median 0 [IQR 0.0–2.0] versus 2 [IQR 0–4.0], p < 0.001), pain interference (0 [IQR 0–0.9] versus 0.71 [IQR 0–2.6], p = 0.007), NDI (1.9 ± 5.3 versus 0.3 ± 1.7, p < 0.001), and SPADI scores (10.1 ± 17.4 versus 4.4 ± 10.6, p < 0.001) in the COPD group. The shoulder was the most commonly reported pain site, followed by the thoracic region and lower extremities. Shoulder pain in COPD patients was associated with multiple pain locations (adjusted OR: 1.82, 95% CI: 1.25–2.66, p = 0.002), higher SPADI scores (adjusted OR: 1.07, 95% CI: 1.01–1.13, p = 0.017), and reduced % predicted FEV1 (adjusted OR: 0.96, 95% CI: 0.92–0.99, p = 0.026). For aims 4 and 5, individuals with COPD (n=14, mean age 71.8 ± 1.7 years) showed significantly greater clavicle elevation (CE) (Mean difference (SE) = 3.292 (1.526), p = 0.041) and SUR (Mean difference between groups (SE) = 4.696 (1.633), p = 0.008) but lower CP (Mean difference (SE) = 3.625 (1.401), p = 0.016) across all breathing phases than those without COPD (n=12, mean age 69.7 ± 2.2 years). However, the groups had no statistically significant difference in the chest wall lateral dimension or SIR and SPt. The widest chest wall lateral dimension during full inhalation and the narrowest dimension during full exhalation were recorded in both groups. In the non-COPD group, the values were 322.57 ± 25.92 and 310.71 ± 26.92, respectively, with p < 0.001. Similarly, in the COPD group, the values were 322.57 ± 25.92 and 310.71 ± 26.92, respectively, with p = 0.002. They also exhibited greater CE (Mean difference (SE) = 4.477 (1.244), p = 0.001) and SUR (Mean difference (SE) = 4.787 (1.06), p < 0.001) but lower CP (Mean difference (SE) = 5.623 (1.359), p < 0.001) across all shoulder range of motions than those without COPD. Conclusion: The meta-analysis revealed that scapular control impairments were more prevalent among individuals with COPD. The second study confirmed a higher prevalence of pain in individuals with COPD compared to controls, particularly in the shoulder region. Shoulder pain in COPD was associated with multiple pain locations, SPADI scores, and %predicted FEV1. In the last study, full inhalation led to the greatest chest wall expansion. Arm elevation angles and breathing phases can influence CE, CP, and SUR.