離心運動訓練對於阿基里氏肌腱修補後患者之成效

Effects of eccentric exercise training in patients who underwent Achilles tendon repair

廖芃慈(Peng-Tzu Liao)

指導教授 ： 王興國

國立臺灣大學/醫學院/物理治療學研究所/碩士(2019年)

https://doi.org/10.6342/NTU201902968

摘要

研究背景：阿基里氏肌腱斷裂後常進行修補手術，手術後，肌肉肌腱單元型態及肌束行為的變化包括肌肉厚度減少、肌腱延長、肌束縮短，這些型態學上的變化同時與肌力較低、運動功能較差相關，且患側與健側的差異持續存在到傷後數年。文獻指出離心運動訓練於健康人有延長肌束長度、增強肌力、提升運動功能的功效，但尚未有文獻闡明阿基里氏肌腱斷裂修補後進行離心運動訓練的效果。
研究目的：本研究旨在探討阿基里氏肌腱修補後患者進行8周離心運動訓練的效果，比較訓練前後肌肉肌腱單元型態、肌束行為、運動功能表現、肌肉適能等層面的差異，探討各層面的變化趨勢是否相關，並觀察健康受試者與阿基里氏肌腱修補後患者對相同離心運動訓練計畫的反應是否一致，以及訓練效果是否能夠維持到訓練停止後4周。
研究設計：本實驗為準實驗設計中的不等控制組設計。
研究對象：實驗組招募單側阿基里氏肌腱修補術後6個月至5年的患者，健康控制組招募下肢未曾接受過任何手術者，兩組皆符合年齡20至65歲，無系統性疾病，半年內無其他下肢傷害。
研究方法：受試者參加為期8周的離心運動訓練計畫，每周在實驗室訓練2次，執行居家運動1次，在訓練開始前、結束後量測肌肉肌腱單元型態、肌束行為、肌肉活性、運動功能表現、肌肉適能，實驗組額外進行病患自評量表及微循環量測。訓練停止後4周的追蹤量測運動功能表現、肌肉適能及病患自評量表（僅實驗組）。
統計分析：依資料性質使用魏克生符號等級檢定及配對t檢定比較組內訓練前後各參數的變化是否達顯著差異，使用獨立t檢定比較組間的進步量，使用斯皮爾曼等級相關係數分析實驗組各參數變化量之間是否相關。
結果：離心運動訓練之後，實驗組內側腓腸肌肌肉厚度增加（p=0.016），控制組肌束夾角增大（p=0.021），等長收縮過程中兩組皆有肌束夾角增加的變化（p=0.002-0.046），兩組皆有肌肉適能進步及運動功能表現增加（p=0.001-0.047），實驗組患者自評結果進步（p=0.006-0.047），肌肉活性的變化僅有實驗組的比目魚肌肌肉活性在訓練後增加（p=0.016），其他肌肉活性參數及肌腱微循環均無顯著變化。實驗組及控制組離心訓練後多數參數變化的趨勢相似。實驗組單腳向前跳表現與等速向心收縮總功的變化量有統計相關性（r=0.769）。部分訓練成效可維持到訓練停止後4周。
結論：阿基里氏肌腱修補術後6個月之後進行離心運動訓練，有助於改善肌肉萎縮，增加肌肉活性、肌肉適能及運動功能表現，提升患者自覺功能程度，但對肌束長度及肌腱微循環沒有顯著的影響。健康族群進行離心運動訓練也能引起多數如上所述的變化，且與肌腱修補患者的變化量相當。建議阿基里氏肌腱修補術後16周以上的患者，若無關節活動度受限問題，運動功能的下肢對稱指數達到45%以上，可在物理治療計畫中強調離心運動訓練，幫助患者達到更佳的運動能力。

關鍵字

阿基里氏肌腱斷裂 ； 離心運動訓練 ； 肌束型態 ； 肌肉適能 ； 運動功能表現

並列摘要

Background: Ruptured Achilles tendons are often treated through surgical repair. After such repair, the morphology of the muscle-tendon unit and the fascicle behavior change, leading to decreased muscle thickness, a lengthened tendon, and shortened muscle fascicles. These morphological changes are correlated with lower muscle strength and poorer functional performance, and the differences between the injured side and the non-injured side can persist for several years after the injury. Previous studies have reported that eccentric exercise training increases fascicle length, increases muscle strength, and improves functional performance in healthy people. However, there has been no evidence that has clarified the effects of eccentric exercise training for patients who have undergone an Achilles tendon repair.
Purpose: The aim of this study was to investigate the effects of an 8-week eccentric exercise training program for patients who have undergone an Achilles tendon repair. A pre-training and post-training comparison of the morphology of the muscle-tendon unit, fascicle behavior, functional performance, and muscular fitness was performed, so as to investigate any correlations with respect to the trends of change in each parameter, to observe if the effects of this eccentric exercise training were the same for the experimental and control groups, and to determine if the effects could be maintained up to 4 weeks after the exercise training had ended.
Design: This study was a quasi-experimental nonequivalent control group study.
Participants: The experimental group consisted of patients who had undergone a unilateral Achilles tendon repair in the past 6 months to 5 years. The healthy control group consisted of patients with no history of surgery in the lower extremities. The participants in both groups were aged between 20 and 65 years old, had no systemic diseases, and had not experienced any other lower limb injury in the preceding 6 months.
Methods: The participants attended an 8-week eccentric exercise training program that consisted of 2 lab training sessions and 1 home exercise session per week. Data collection was conducted before and after the eccentric exercise training program. The parameters measured included the morphology of the muscle-tendon unit, fascicle behavior, muscle activation, functional performance, and muscular fitness. Patient-reported outcomes and microcirculation were assessed in the experimental group only. At the follow-up conducted 4 weeks after the training had ended, data regarding functional performance, muscular fitness, and patient-reported outcomes (experimental group only) was collected.
Statistical analysis: The Wilcoxon signed-rank test or paired t-test was used, according to the distribution of the data, to compare the within-group differences between the pre-training and post-training states for each parameter. The independent t-test was used to compare the levels of change in the parameters between the two groups. Spearman’s rank correlation coefficient was used to analyze the correlations between the levels of change in each parameter of the experimental group.
Results: After the eccentric exercise training program, the patients with an Achilles tendon repair (experimental group) presented thicker medial gastrocnemius muscle (p=0.016), and those in the control group presented greater fascicle angles (p=0.021). The fascicle angles during isometric contraction became greater in both groups (p=0.002-0.046). The muscular fitness and functional performance levels improved in both groups (p=0.001-0.047), and the patient-reported outcomes improved in the experimental group (p=0.006-0.047). The only change in muscle activation was that the soleus muscles of the experimental group showed increased muscle activation after training (p=0.016). No other change was seen in the muscle activation of other muscles nor in microcirculation. The trends of change were similar in most parameters between the experimental and control groups. In the experimental group, there was a significant correlation (r=0.769) between the levels of change for one-legged hopping performance and the total work as measured via the isokinetic test. Some of the training effects lasted up to 4 weeks after the training had ended.
Conclusions: The investigated eccentric exercise training undertaken at least 6 months after an Achilles tendon repair counteracted muscle atrophy and, in turn, enhanced the muscle activation, muscular fitness, functional performance, and self-reported functional status of the experimental group participants. However, the training had no significant effect on their fascicle lengths and tendon microcirculation. The eccentric exercise training induced changes similar to those mentioned above in the healthy participants, and the levels of change were similar between the two groups. To regain better functional performance, it is recommended that eccentric exercise training be emphasized in the physical therapy programs for patients with an Achilles tendon repair, as long as (1) such training is begun at least 16 weeks after the surgery, (2) the patient presents no range of motion limitation, and (3) the limb symmetry index of functional performance has reached 45%.

並列關鍵字

Achilles tendon rupture ； eccentric exercise training ； fascicle morphology ； muscular fitness ； functional performance

參考文獻

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