以微循環觀點設計阿基里氏肌腱修補後物理治療策略

Design of Physical Intervention Protocol after Achilles Tendon Repair: in the View of Microcirculation

張逸平(Yi-Ping Chang)

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(2015年)

https://doi.org/10.6342/NTU.2015.00180

摘要

研究背景：肌腱微循環與肌腱癒合相關，但目前尚未有前瞻性研究探討斷裂肌腱在手術修補後，微循環之變化情形以及在預測預後的角色；另一方面，許多物理治療因子被認為有利於軟組織之修復，但目前甚少研究從微循環之觀點探討物理治療因子的效果。研究目的：本研究旨在探討肌腱內微循環於肌腱癒合初期（術後第一、二和三個月後）的特徵與後期臨床嚴重程度�結果量測之間的相關性，並探討臨床上常用的物理治療因子於健康肌腱之微循環效益，以作為治療策略之參考。設計：本研究分為兩部分，第一部分為病例世代研究，第二部分為橫斷式研究。實驗對象：第一部分研究徵召接受單側阿基里氏肌腱修補手術之患者，第二部分研究徵召健康成年人，所有受試者年齡皆介於20~65歲。方法：第一部分研究中，受試者在手術後第一、二、三個月後接受阿基里氏肌腱微循環檢測（總血紅素、氧飽和度），並在手術後第三和六個月後接受臨床嚴重程度、肌腱機械特性和運動功能（墊腳尖指數、星狀短距平衡測試和單腳跳）的評估；第二部分研究中，受試者被隨機分為四組，分別接受治療性超音波、低能量雷射、向量干擾波和震動槍的介入，每組受試者的左右腳會接受不同劑量或目標組織（阿基里氏肌腱、小腿肌腹）的介入，並在介入前後接受肌腱微循環的檢測。統計分析：使用魏克森符號等級檢定法以及斯皮爾曼等級相關分析。結果：第一部分結果顯示，修補肌腱之總血紅素含量在術後第一、二和三個月後顯著較健康側高（p<0.05），而氧飽和度則是在術後第三個月後顯著較高（p=0.017），另外，總血紅素含量校正數據（手術側減健康側）在術後初期之變化量與後期之臨床嚴重程度（r=-0.821, -0.929）與墊腳尖指數呈負相關（r=-0.833），和平衡功能與標準化單腳跳距差（健康側減手術側）呈正相關（r=0.786, 0.893/ 0.929, 0.786）；第二部分結果顯示，強度0.8和1.2瓦�平方公分的治療性超音波及針對肌腱的機械性震動介入皆可使肌腱微循環顯著增加（p=0.002~0.006）。結論：阿基里氏肌腱在修補手術後前三個月的微循環變化與第三個月後的臨床嚴重程度和運動功能有關，據此可推論若是在術後初期即改善手術側肌腱微循環的狀況，可能可促進後期的症狀改善及功能恢復，而治療性超音波和震動槍於肌腱微循環效益之結果發現則奠定了後續應用於受傷肌腱或長期介入研究之基礎。

關鍵字

阿基里氏肌腱斷裂 ； 微循環 ； 臨床嚴重度 ； 運動表現 ； 物理治療因子

並列摘要

Background: Tendon microcirculation is considered to be associated with the tendon healing. Few prospective studies investigated neither changes of the tendon microcirculation nor its predicting role after the tendon repair. On the other hand, physical agents are considered to be beneficial for the tissue repair, however, only a few research investigated the effects of the physical agents from the viewpoint of microcirculation. Purpose: The study was aimed to investigate the roles of intratendinous microcirculation in the early phase (1, 2 and 3 months postsurgery) of the tendon repair to clinical severity/ outcome measures afterwards, and to investigate the microcirculatory effects by commonly-used physical agents in clinically setting on the healthy tendon. Design: The study consists of two parts. The first part is a case cohort study, and the second part is a cross-sectional study. Participants: The first part of the study recruited patients who received a unilateral Achilles tendon repair; the second study recruited asymptomatic healthy adults. All the subjects aged between 20~65 years old. Methods: In the first part, the subjects underwent measurements of the tendon microcirculation after 1, 2 and 3 months postsurgery, and assessments of the clinical severity, tendon mechanical property and functional performances (heel raise test index, star excursion balance test and one-leg hopping) after 3 and 6 months postsurgery; in the second part, the subjects were randomly allocated to four groups undergoing one of the intervention of therapeutic ultrasound, low-level laser therapy, interferential current or vibration gun separately. The examinations of tendon microcirculation were performed before and after the intervention. Statistical analysis: Wilcoxon signed-rank test and Spearman's rank correlation analysis were used for the purposes of the study. Results: In the first part of the study, the results showed that the total hemoglobin of the repaired tendon was significantly greater than the one at the healthy side after 1, 2 and 3 months postsurgery (p<0.05); the oxygen saturation of the repaired side was significantly greater than the one at healthy side after 3 month postsurgery (p=0.017). Besides, the changes of the calibrated value (operated side minus healthy side) of the total hemoglobin in the early phase postsurgery showed negative correlations with the clinical severity (r=-0.821, -0.929) and heel raise test index (r=-0.833), and positive correlations with the balance function and differences in normalized one-leg hopping distance (healthy side minus operated side) (r=0.786, 0.893/ 0.929, 0.786) in the late phase. In the second part, the results showed that the tendon microcirculation significantly increased after the intervention of the therapeutic ultrasound with the 0.8 and 1.2 W/cm2 of the intensity as well as the mechanical vibration targeting on the tendon (p=0.002~0.006). Conclusion: The microcirculatory changes of Achilles tendon in the first three months postsurgey were correlated with the clinical severity and functional performances after 3 months postsurgery. It could be speculated to have promoting effects on the improvements of clinical severity and functional performances if improving the tendon microcirculation in the early phase postsurgery. The findings of the microcirculatory effects by the therapeutic ultrasound and mechanical vibration on the tendon built a foundation for the subsequent investigations of the further application to the injured tendon or long-term intervention studies.

並列關鍵字

Achilles tendon ； microcirculation ； clinical severity ； functional performances ； physical agents

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