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系統識別號 U0026-0812200915374171
論文名稱(中文) 肩峰下注射後施予合併動作式關節鬆動術對於肩峰下夾擠症候群患者之療效追蹤研究
論文名稱(英文) The effect of combined movement therapy for patients with shoulder impingement after subacromial injection
校院名稱 成功大學
系所名稱(中) 物理治療研究所
系所名稱(英) Department of Physical Therapy
學年度 97
學期 2
出版年 98
研究生(中文) 曹百瑾
研究生(英文) Pai-chin Tsao
學號 T6696401
學位類別 碩士
語文別 中文
論文頁數 130頁
口試委員 指導教授-陳文玲
口試委員-徐阿田
指導教授-周一鳴
中文關鍵字 肩峰下夾擠症候群  肩峰下注射  合併動作式關節鬆動術 
英文關鍵字 subacromial injection  mobilization with movement  subacromial impingement syndrome 
學科別分類
中文摘要 研究背景:肩峰下夾擠症候群患者常見疼痛、肩關節活動度不足、肩部肌力減弱等症狀,或伴隨肩胛動作控制異常的現象。有關藉由肩峰下玻尿酸注射治療以消炎止痛,或利用各是物理治療與關節鬆動術以改善肩關節臨床症狀及肩胛控制策略的文獻頗多。然至今仍未有研究檢定接受肩峰下注射治療的夾擠症患者在加入合併動作式關節鬆動術後於疼痛、肩關節臨床症狀或手臂抬舉時肩胛控制策略的療效。目的:針對接受肩峰下玻尿酸注射的肩峰下夾擠症候群患者檢定注射治療後加入合併動作式關節鬆動術治療三週後在物理性檢查與肩胛控制策略方面之療效,期能藉此釐清運動介入的需要性與時機。方法:本研究共收集肩峰下夾擠症候群患者18人,包括治療組10人及對照組8人。所有受試者均分別在注射前及注射隔天進行系列性物理檢查與生物力學測量以評估玻尿酸注射之立即性療效。其中治療組隨在完成注射隔天的評估之後接受一回約20分鐘的合併動作式關節鬆動術治療並再度進行評估以檢定合併動作式關節鬆動術之立即性療效,之後治療組繼續接受每週二回前後共三週之合併動作式關節鬆動術門診治療。所有受試者均於注射後三週接受最後評估。結果:在單回治療之立即性效應方面,顯示注射治療後施予單回合併動作式關節鬆動術可立即於疼痛控制、肩關節活動度(肩屈曲、肩外展、肩內外轉活動度)及肩部肌力(前鉅肌、下斜方肌及肩外轉肌)獲得顯著療效,且肩胛骨向上旋轉活動度及肩胛肌肉(下斜方肌與三角肌)平均活動強度均呈現顯著提升。(n=10,p<0.05)。有關於三週之短期療效方面,治療組於動作時疼痛狀態、肩關節活動度(肩屈曲、肩外展、肩內轉及肩外轉活動度)、肩後側關節囊緊縮程度、肩部肌力(上斜方肌、前鉅肌、肩內轉肌、肩外轉肌及棘上肌)、SPADI肩關節功能量表方面以及肩部功能性動作均呈現顯著進步(p<0.05)。反觀僅接受單次玻尿酸注射的對照組雖於注射後隔天於疼痛狀態、肩關節活動度、肩部肌力方面有呈現改善的現象,然經過三週之追蹤僅於肩部肌力(上斜方肌、三角肌、肩內外轉肌肌力)仍存在持續性的改善(p<0.05),在疼痛狀態(動作時於夜間睡覺時疼痛狀態)、肩關節活動度(肩屈曲與肩內轉活動度)則反而有惡化之趨勢。有關動作分析的短期療效,治療與對照兩組於注射後三週雖均無顯著改善,然治療組在三週治療結束後於肩胛骨向內旋轉活動度減少且肩胛肱骨節律有增加之趨勢。反之,對照組於注射後三週則呈現肩胛骨向內旋轉活動度增加且向上旋轉活動度減少,且肩胛肱骨節律降低之趨勢。同樣的,治療與對照兩組於注射後三週在肩胛肌肉徵召起始時間均未呈現顯著差異,然治療組亦於注射後三週呈現肩胛肌肉相對提早徵召之趨勢。在肩胛肌肉平均活動強度方面,治療組於接受合併動作式關節鬆動術治療三週後,其上斜方肌平均活動強度在手臂放下末期(60°~0°)有顯著降低的現象(p<0.05)。而對照組則於三角肌平均肌肉活動強度呈現顯著降低的現象(手臂抬舉初期20°~40°及放下末期30°~20°,10°~0°,p<0.05)。結論:本研究結果發現肩峰下玻尿酸注射雖於止痛效果、肩關節活動度及肩部肌力有改善的現象,然此現象除上斜方肌、三角肌、肩內外轉肌等部分肌力外均未能持續至注射三週後,且也未能改善注射後三週之肩胛動作控制策略。反之,注射治療外加合併動作式關節鬆動術治療三週後,於疼痛狀態、肩關節活動度即肩部肌力等相關臨床症狀皆有持續性的顯著改善,雖未如預期的顯著改善肩胛骨活動度,但在三週治療結束時已呈現肩胛骨向內旋轉活動度減少之趨勢,且也顯著的降低了上斜方肌之平均活動強度。綜上所述,接受玻尿酸注射治療後施予合併動作式關節鬆動術有助於持續改善肩關節症狀與肩胛動作控制策略,進而降低肩峰下夾擠發生的機率。
英文摘要 Background:Patients with subacromial impingement syndrome (SAIS) have been reported to demonstrate decreased shoulder range of motion, muscle strength and abnormal scapular control strategies during shoulder movement. Sodium hyaluronate (SH) injection has been widely used for the reduction of pain or inflammation, and several studies have provided evidence to support joint mobilization techniques in reducing clinical symptoms or improving scapular control strategies especially for patients with SAIS.
However, no studies have investigated the effects of mobilization with movement (MWM) on clinical symptoms and scapular control strategy for SAIS patients who had SH injection. Purpose:The study aimed to examine the immediate effect as well as the 3-week short term effect of MWM for SAIS patients undertaking SH injection. Methods:Twenty subjects with SAIS were randomly assigned to treatment group (n=10) and control group (n=10), but 2 of control subjects failed to complete the 3-week follow-up evaluation. Pain status, shoulder range of motion (ROM)(flexion, abduction, internal rotation, external rotation), shoulder strength(upper trapezius, UT; serratus anterior, SA; lower trapezius, LT; middle deltoid, MD; shoulder external rotators, ER; shoulder internal rotators, IR; supraspinatus), functional test (hand to scapula test, lift-off test),scapula motion (scapular upward rotation, internal rotation and posterior tipping) and muscle activities(UT, SA, LT MD) during shoulder scaption were measured before SH injection and one day after injection to examine the immediate effect of subacromial injection. The treatment group was then re-evaluated to examine the immediate effect of MWM after receiving the first session of MWM which was performed 20 minutes after post-injection evaluation. Treatment group undertook MWM twice a week for 3 weeks thereafter. At last all subjects in either treatment or control groups were arranged to complete the final assessment. The assessment mainly included pain status, shoulder ROM, shoulder strength, shoulder posterior capsule tightness, shoulder pain and disability index (SPADI), functional test and scapular control strategy. Results:The results of immediate effect of MWM showed significantly reduced pain, significantly increased shoulder ROM (flexion abduction, internal and external rotation), and significantly increments of shoulder strength (SA, LT, ER) right after one-session of MWM (p<0.05). In addition, significantly increased scapular upward rotation during arm lowering process(90°~40°), and significantly increased LT and MD muscle activities during arm lowering process(UT:80°~20°, MD:50°~20°) were also found (p<0.05). The follow-up of short term effect for MWM showed significantly pain reduction, significantly increased shoulder ROM (flexion, abduction, internal rotation), and significantly increments of shoulder strength (MD, SA), and functional test (hand to scapula test, lift-off test) one day after SH injection before MWM was applied, and the effects lasted until 3 weeks after MWM especially in shoulder ROM (flexion, abduction, internal and external rotation), shoulder strength(UT, SA, IR, ER and supraspinatus) , functional test (hand to scapula test, lift-off test) and SPADI scores (p<0.05). In contrast, although significant improvement was also found in pain reduction, shoulder ROM (internal rotation) and shoulder strength(SA) one day after injection in the control group(p<0.05), the effect did not last until 3 weeks after injection except for shoulder strength(UT, DT, IR,ER, p<0.05). No significant difference was found on scapular motion 3 weeks after injection in both groups, but the treatment group has shown a trend toward decreased scapular internal rotation and increased scapulohumeral rhythm after taking 3 week MWM. On the other hand, a trend of increased scapular internal rotation, decreased scapular upward rotation and decreased scapulohumeral rhythm were found in the control group 3-week after injection. The latency of scapular muscle onset during arm scaption also decreased after taking 3 week MWM, although without significant changes. Moreover, significantly decreased UT muscle activities during arm lowering process(60°~0°) were found after taking 3 week MWM in the treatment group and significantly decreased MD muscle activities during arm elevation (20°~40°) and lowering process(30°~20°, 10°~0°) in the control group. Conclusion:Immediate effect of SH injection was found in pain reduction and the improvement of shoulder ROM (internal rotation)and shoulder strength(SA), however the effect did not last until 3 weeks after injection expect for the strength of UT, DT, IR and ER. In contrast, additional MWM after SH injection have provided more significantly immediate effect especially on shoulder ROM (flexion, abduction, external rotation), shoulder strength (LT and ER) and scapular control strategy as well as more lasting effects in shoulder ROM (flexion, abduction, external rotation and internal rotation), shoulder strength (UT, SA, IR and ER), SPADI scores, functional test and scapular control strategy at 3 weeks after injection. In conclusion, MWM treatment was strongly recommended for SAIS patients that just had one shot of SH injection for better outcome or more lasting effects .
論文目次 中文摘要 ------------------------------------------------------------------------------------------------------ 3
英文摘要 ------------------------------------------------------------------------------------------------------ 6
致謝 ----------------------------------------------------------------------------------------------------------- 10
目錄 ----------------------------------------------------------------------------------------------------------- 11
表目錄 -------------------------------------------------------------------------------------------------------- 18
圖目錄 -------------------------------------------------------------------------------------------------------- 19
第一章 文獻回顧
1.1 肩峰下夾擠症候群之盛行率 ------------------------------------------------------------------ 22
1.2 肩峰下夾擠症候群之定義---------------------------------------------------------------------- 22
1.3 致病機轉 ------------------------------------------------------------------------------------------ 22
1.4 臨床症狀 ------------------------------------------------------------------------------------------ 24
1.5 肩旋轉肌之功能----------------------------------------------------------------------------------- 25
1.6 肱骨頭位移量(Translation of humeral head)---------------------------------------------26
1.7 肩胛肌之功能 ------------------------------------------------------------------------------------ 27
1.8 肩峰下夾擠症候群患者之肌肉活動情形 --------------------------------------------------- 28
1.9 肩胛肱骨節律 ------------------------------------------------------------------------------------ 29
1.9.1 肩胛骨之動作學分析 -------------------------------------------------------------------- 29
1.9.2 正常的肩胛肱骨節律 -------------------------------------------------------------------- 30
1.9.3 肩部損傷患者之肩胛肱骨節律 -------------------------------------------------------- 30
1.9.4 影響肩胛肱骨節律之因素 -------------------------------------------------------------- 31
1.9.4.1 胸椎與肩胛姿勢 ----------------------------------------------------------------- 31
1.9.4.2 組織柔軟度 ----------------------------------------------------------------------- 31
1.9.4.3 肩胛肌肉疲勞 -------------------------------------------------------------------- 32
1.9.4.4 肩旋轉肌疲勞 -------------------------------------------------------------------- 32
1.10 肩峰下夾擠症候群之肩胛肱骨節律
1.10.1 肩峰下夾擠症候群患者於手臂抬舉過程之肩胛骨動作學分析 --------------- 33
1.10.1.1 一般性的手臂抬舉控制策略 ------------------------------------------------ 33
1.10.1.2 代償性的手臂抬舉控制策略 ------------------------------------------------ 34
1.10.2 肩峰下夾擠症候群患者於手臂放下過程之肩胛骨動作學分析 --------------- 35
1.10.3 肩峰下注射後之肩胛肱骨節律分析 ------------------------------------------------ 35
1.11 肩峰下夾擠症候群之保守治療 -------------------------------------------------------------- 35
1.11.1 肩部注射治療 --------------------------------------------------------------------------- 36
1.11.1.1 玻尿酸注射之藥物動力學研究 --------------------------------------------- 36
1.11.1.2 單次玻尿酸注射治療之療效研究 ------------------------------------------ 38
1.11.2 物理治療 --------------------------------------------------------------------------------- 38
1.11.3 合併動作式關節鬆動術 --------------------------------------------------------------- 41
1.12 總結 ----------------------------------------------------------------------------------------------- 42
1.13 研究動機 ----------------------------------------------------------------------------------------- 43
1.14 研究目的 ----------------------------------------------------------------------------------------- 44
1.15 研究問題與假說 ------------------------------------------------------------------------------- 44
第二章 研究方法
2.1 研究對象 ------------------------------------------------------------------------------------------ 46
2.2研究儀器與設備
2.2.1電磁式動作追蹤系統(electromagnetic motion tracking system)----------------- 46
2.2.2肌電圖儀(AMT-8 EMG, Octopus, CA)----------------------------------------------- 47
2.2.3量角器(Goniometer)--------------------------------------------------------------------- 48
2.2.4手持式測力器(Handheld dynamometer)---------------------------------------------- 48
2.3 實驗流程 ------------------------------------------------------------------------------------------ 49
2.4 評估項目
2.4.1疼痛狀態評估 ------------------------------------------------------------------------------ 51
2.4.2 肩功能問卷(shoulder pain and disability index, SPADI)------------------------- 52
2.4.3 相關肌力測試 ----------------------------------------------------------------------------- 52
2.4.4 關節活動度量測 -------------------------------------------------------------------------- 57
2.4.4.1 肩屈曲與肩外展 ----------------------------------------------------------------- 57
2.4.4.2 肩外轉與肩內轉 ----------------------------------------------------------------- 57
2.4.4.2 後側肩關節囊緊縮程度 -------------------------------------------------------- 58
2.4.5動作學測量
2.4.5.1 動作測量前的準備工作 ------------------------------------------------------- 58
2.4.5.2 肩胛平面手臂上舉與放下過程中之動作測量 ---------------------------- 60
2.4.5.3 肩部功能性動作測量 ---------------------------------------------------------- 61
2.4.6相關肌肉於肩胛面抬舉時之肌電訊號測量 ------------------------------------------ 62
2.5 合併動作式關節鬆動術
2.5.1 肩關節後外向滑動 ----------------------------------------------------------------------- 63
2.5.2 肩關節內轉 -------------------------------------------------------------------------------- 64
2.6 居家運動
2.6.1 前側肩關節囊牽拉運動 ----------------------------------------------------------------- 65
2.6.2 後側肩關節囊牽拉運動 ----------------------------------------------------------------- 66
2.6.3 肩內轉肌肌力訓練 ----------------------------------------------------------------------- 66
2.6.4 肩外轉肌肌力訓練 ----------------------------------------------------------------------- 67
2.6.5 肩胛內收肌肌力訓練 ------------------------------------------------------------------- 68
2.7 資料處理與分析
2.7.1肩胛面抬舉動作分析 --------------------------------------------------------------------- 68
2.7.2 肩胛面抬舉時肩胛肱骨節律 ----------------------------------------------------------- 70
2.7.3 肩關節肩部功能性動作分析 ----------------------------------------------------------- 70
2.7.4 肌電訊號分析 ----------------------------------------------------------------------------- 71
2.8 研究參數 ------------------------------------------------------------------------------------------ 72
2.9 資料統計與分析 --------------------------------------------------------------------------------- 73
第三章 研究結果
3.1 受試者基本資料 --------------------------------------------------------------------------------- 75
3.2 第一部分合併動作式關節鬆動術治療之立即性療效
3.2.1 物理性檢查 ------------------------------------------------------------------------------- 76
3.2.2 單次合併動作式關節鬆動術對於肩部功能性動作之立即療效------------------ 76
3.2.3 單次合併動作式關節鬆動術於肩關節抬舉策略之療效評估 -------------------- 77
3.2.3.1 手臂向上抬舉與放下過程中肩胛骨活動度分析 -------------------------- 77
3.2.3.2 單次合併動作式關節鬆動術對於肩胛肱骨節律之療效分析 ---------- 79
3.2.3.3 手臂抬舉往上抬舉與放下過程之肩胛肌肉徵召起始時間 ------------- 79
3.2.3.4 手臂往上抬舉與放下過程之肩胛肌肉平均肌肉活動強度 ------------- 80
3.3 第二部分三週後之短期療效:單次玻尿酸注射後合併動作式關節鬆動術治療相對於僅單次玻尿酸注射
3.3.1 物理性檢查
3.3.1.1 疼痛狀態(視覺類比量尺)------------------------------------------------------ 82
3.3.1.2 肩關節活動度 -------------------------------------------------------------------- 86
3.3.1.3 肩部肌力 -------------------------------------------------------------------------- 89
3.3.1.4 肩功能問卷 (SPADI量表) ----------------------------------------------------- 92
3.3.2 肩部功能性動作--------------------------------------------------------------------------- 92
3.3.3 肩關節抬舉策略評估之生物力學分析
3.3.3.1手臂向上抬舉與放下過程中肩胛骨活動度分析 --------------------------- 94
3.3.3.2手臂向上抬舉過程中之肩胛肱骨節律 --------------------------------------- 95
3.3.3.3 手臂抬舉往上抬舉與放下過程之肩胛肌肉徵召起始時間 ------------- 96
3.3.3.4 手臂往上抬舉與放下過程之肩胛肌肉平均活動強度 ------------------- 97
第四章 研究討論
4.1 第一部分合併動作式關節鬆動術治療之立即性療效
4.1.1 物理性檢查 ------------------------------------------------------------------------------ 102
4.1.2 肩部功能性動作 ------------------------------------------------------------------------ 103
4.1.3 肩關節抬舉策略 ------------------------------------------------------------------------ 104
4.1.3.1 手臂向上抬舉與放下過程中肩胛骨活動度與肩胛肱骨節律分析---- 104
4.1.3.2 肩胛肌肉徵召起始時間與肩胛平均肌肉活動強度 --------------------- 105
4.2 第二部分縱向分析注射後三週與治療三週後之療效
4.2.1 疼痛狀態 --------------------------------------------------------------------------------- 106
4.2.2 肩關節活動度與SPADI量表 ---------------------------------------------------------- 107
4.2.3 肩部肌力 --------------------------------------------------------------------------------- 111
4.2.4 肩部功能性動作 ------------------------------------------------------------------------ 112
4.2.5 肩關節抬舉策略
4.2.5.1 手臂向上抬舉與放下過程中肩胛骨活動度分析 ------------------------ 113
4.2.5.2手臂向上抬舉時期之肩胛肱骨節律分析 ----------------------------------- 114
4.2.5.3 肩胛肌肉徵召起始時間 ------------------------------------------------------ 115
4.2.5.4 肩胛平均肌肉活動強度 ------------------------------------------------------ 116
第五章
5.1 臨床應用------------------------------------------------------------------------------------------ 118
5.2 研究限制------------------------------------------------------------------------------------------ 119
參考文獻 ------------------------------------------------------------------------------------- 120
附錄一 人體試驗同意書 -------------------------------------------------- 127
附錄二 肩疼痛與失能指數 ------------------------------------------------ 129
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