動作控制訓練對頸部廓清術後之肩胛運動障礙治療效果

Motor-Control Training on Scapular Dyskinesis in Patients with Neck Dissection

陳月霞(Yueh-Hsia Chen)

指導教授 ： 黃正雅

國立臺灣大學/醫學院/物理治療學研究所/博士(2022年)

https://doi.org/10.6342/NTU202200287

摘要

背景：近幾年，我國口腔癌發生率佔世界之冠，且為頭頸癌中最常見之部位。脊副神經肩功能障礙是口腔癌患者接受頸部廓清術後最常見的併發症，會引發肩胛運動障礙並影響生活品質。過去研究指出肩胛訓練運動可改善肩部夾擠症候群患者的肩關節活動度、肩胛肌肉力量、肩胛骨位置。此外，肩胛訓練運動結合動作控制訓練除了提升肩關節活動度與肩胛肌肉力量之外，還可改善肩胛肌肉徵召方式，減輕肩痛和失能。由於脊副神經損傷會造成斜方肌功能障礙，無法正常穩定肩胛骨，有別於肩部夾擠症候群因為上斜方肌與其他肩胛肌肉力量間不平衡所造成的肩胛運動障礙，目前尚無研究將肩胛訓練運動結合動作控制之治療模式應用於口腔癌患者頸部廓清術後，因脊副神經肩功能障礙所造成之肩胛運動障礙。本論文目的在探討肩胛訓練運動結合不同動作控制訓練之技巧，對脊副神經功能障礙之口腔癌患者肩胛功能之訓練效果。本論文包含三個實驗：實驗一目的為探討肩胛訓練運動中給予治療師回饋對肩胛動作控制的短期訓練成效；實驗二目的為探討肩胛訓練運動中患者使用內在意識控制的長期訓練成效；實驗三目的為探討肩胛訓練運動合併表面肌電圖之視覺回饋的長期訓練成效。
方法：實驗一招募38位口腔癌患者，隨機分配至動作控制組與一般運動組，二組皆在頸部廓清術後平均12天，開始為期一個月的治療介入。治療內容包含肩關節一般性物理治療介入(止痛電刺激、肩關節活動)和肩胛訓練運動，而動作控制組於肩胛訓練運動中，治療師會給予肩胛動作控制之回饋。於介入前和介入後，記錄受試者的肩關節疼痛度、肩關節外展活動度、肩胛肌肉最大自主等長收縮與執行肩胛動作時之肌電訊號。實驗二招募36位口腔癌患者，隨機分配至動作控制組與一般運動組，二組在經過頸部廓清術後，立即進行三個月的治療介入。動作控制組於肩胛訓練運動中強調患者本身對肩胛骨的意識控制。於介入前、介入後一個月與介入後三個月進行評估，評估參數包含：肩關節疼痛度、肩關節外展活動度、上肢功能自陳量表、肩胛關節肌肉最大等長收縮肌力與肌電訊號、執行肩胛動作時之肌電訊號。實驗三共徵招24位口腔癌患者，隨機分配至動作控制肌電回饋組與動作控制組，介入時間為三個月。二組都給予肩關節一般性物理治療介入(止痛電刺激、肩關節活動)、肩胛訓練運動和肩胛動作控制訓練，而動作控制肌電回饋組在動作控制訓練時給予斜方肌肌電反應之視覺回饋，而動作控制組則無給予肌電回饋。於介入前、介入後三個月進行評估，評估參數包含：肩關節疼痛度、肩關節外展活動度、肩胛位置、上肢功能自陳量表，以及上斜方肌、中斜方肌和下斜方肌最大等長收縮肌力和肌電訊號，以及肩關節外展向心和離心收縮之肌電訊號。
結果：實驗一，介入一個月後，二組肩關節疼痛皆降低，肩胛肌肉於最大自主等長收縮時，肌電訊號強度皆增加。然肩關節外展活動度僅有動作控制組增加(95% CI 3.80 ~ 20.51, p=0.004)，且在執行負重聳肩動作時(拿1公斤啞鈴)，動作控制組的上斜方肌肌電強度下降(95% CI: -33.06 ~ -1.29, p=0.034)，一般運動組則無改變。此外，執行肩部平行內收與屈曲動作時，動作控制組的前鋸肌肌電強度降低(95% CI: -29.73~ -27.68, p<0.001)，而一般運動組反而增加(95% CI: 28.16 ~ 30.05, p<0.001)。實驗二，介入三個月後，二組除了肩關節疼痛度和上肢功能外，其餘結果皆呈顯著進步。然而，動作控制組的進步程度較一般運動組多，於三個月時，動作控制組之肩關節外展活動度較一般運動組多19度(95% CI: 10 ~ 29, p<0.001)、上斜方肌肌力介入前後共進步11牛頓(95% CI: 2 ~ 20, p=0.021)，生活品質也在介入後有明顯進步(95% CI: 4 ~ 33, p=0.011)。另外，執行肩部平行內收與屈曲動作時，一般運動組之前鋸肌肌電強度較動作控制組高(95% CI 7 to 205, p＝0.037)。實驗三，介入3個月後，動作控制肌電回饋組顯著改善雙側肩胛對稱性，在雙手下垂、插腰及肩外展下，二側對稱性分別比動作控制組增加1.0公分(95% CI：-1.6 ~ -0.4, p=0.001)、0.5公分(95 % CI：-0.9 ~ 0, p=0.040)和1.1公分(95% CI：-1.8 ~ -0.3, p=0.004)。二組肩關節疼痛皆無顯著改變，動作控制肌電回饋組肩關節外展活動度進步23度(95% CI: 14 ~ 31, p<0.001)，而動作控制組進步15度(95 % CI：6 ~ 24, p<0.001)。二組皆增加上斜方肌和中斜方肌之最大等長收縮肌力，然只有動作控制肌電回饋組在介入後顯著增加下斜方肌肌力和上肢功能，且於手臂抬高和放下過程中，上斜方肌和中斜方肌肌電強度降低。
結論：整合實驗一、二、三之結果，於臨床上，建議口腔癌病人在頸部廓清術後，以動作控制加上肩胛訓練運動進行早期動作介入，可有效促進肩關節活動度和減少肩胛肌肉代償之效果。此外，在肩胛訓練運動訓練中，肌電回饋訓練動作控制比單純只有動作控制更能提升雙側肩胛骨對稱性以增加肩胛控制穩定程度，提升肩胛肌肉效能與上肢功能。

關鍵字

動作控制 ； 肩胛訓練運動 ； 口腔癌 ； 頸部廓清術 ； 脊副神經 ； 肩胛骨運動異常 ； 肌電回饋

並列摘要

Background: Oral cancer is the most common type of head and neck cancer. Spinal accessory nerve dysfunction is one complication of neck dissection in patients with oral cancer and affects the quality of life (QoL). It has been proposed that scapular-focused exercises can improve shoulder joint range of motion, muscle strength, scapula position, and scapula kinematics for patients with shoulder impingement syndrome. Moreover, integrating motor-control training (e.g., feedback and conscious control) into scapular-focused exercises could improve muscle recruitment patterns and reduce shoulder pain and disability. However, the evidence of integrating scapular-focused exercises and motor-control training for patients with spinal assessor nerve dysfunction after neck dissection is still lacking. The purpose of Experiment 1 is to investigate the short-term training effects (1 month) of scapular-focused exercises integrating motor-control training of feedback from the therapist. The purpose of Experiment 2 is to explore the long-term training effects (3 months) of scapular-focused exercises integrating motor-control training with inherent feedback by conscious control. The purpose of Experiment 3 is to investigate the long-term training effects (3 months) of scapular-focused exercises integrating motor-control training with online electromyography (EMG) biofeedback.
Methods: Experiment 1. Thirty-eight neck dissection patients with shoulder dysfunction were randomly allocated into the motor-control group and regular-exercise group. Each group received conventional physical therapy and specific scapular muscle strengthening exercises (scapular-focused exercises) for 1 month immediately after neck dissection. Integrated motor control techniques (providing feedback on scapular movement from a physical therapist) with scapular strengthening exercises were only for the motor-control group. Shoulder pain intensity, active range of motion (AROM) of shoulder abduction, and scapular muscle activities including upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) when performing maximal voluntary isometric contraction (MVIC) and scapular muscle exercises were evaluated at baseline and after 1 month of training. Experiment 2. Thirty-six neck dissection patients with shoulder dysfunction were randomly allocated to the motor-control group or the regular-exercise group. Each group received conventional physical therapy and specific scapular muscle strengthening exercises (scapular-focused exercises) for 3 months immediately after neck dissection. Motor-control training (conscious control of scapular orientation) integrated into scapular-focused exercises was only for the motor-control group. Shoulder pain intensity, AROM of shoulder abduction, scapular muscle strength and activity under MVIC, scapular muscle activity when performing scapular movements, and QoL were measured at baseline, one month after the start of the intervention, and the end of the intervention. Experiment 3. Twenty-four neck dissection patients with shoulder dysfunction were randomly allocated to the motor-control with biofeedback group or motor-control group. Each group performed scapular-focused exercises with conscious control of scapular orientation for three months. EMG biofeedback of the trapezius muscle was provided as visual feedback in the motor-control with biofeedback group. Modified lateral scapular slide test (MLSST), shoulder pain, AROM of shoulder abduction, upper extremity function, maximal isometric muscle strength of UT, MT, and LT, and muscle activities during arm elevation/lowering in the scapular plane were evaluated at baseline and the end of the intervention.
Results: Experiment 1. Both groups reduced shoulder pain and increased muscle activity of MVIC of each muscle after the intervention. Increased AROM of shoulder abduction was only observed in the motor-control group (95% CI 3.80 to 20.51, p=0.004). Relative to baseline evaluation, muscle activities of UT decreased in the motor-control group when performing shoulder shrug with 1kg weight (95% CI -33.06 to -1.29, p=0.034). Moreover, the SA activity decreased in the motor-control group (95% CI -29.73 to -27.68, p<0.001) but increased in the regular-exercise group (95% CI 28.16 to 30.05, p<0.001) when performing shoulder horizontal adduction and flexion. Experiment 2. Both groups showed significant improvement in all outcomes except shoulder pain intensity and upper extremity function. After the 3-month intervention, the motor-control group had more significant improvement in AROM of shoulder abduction with a 19-degree difference (95% CI: 10 to 29, p<0.001), muscle strength of upper trapezius with an 11 N difference (95% CI: 2 to 20; p=0.021), and QoL than the regular-exercise group. When performing shoulder horizontal adduction and flexion, the relative value (%MVIC) of SA was smaller in the motor-control group with a 106%MVIC difference (95% CI: 7 to 205, p=0.037). Experiment 3. After the 3-month intervention, MLSST was remarkably improved in the motor-control with biofeedback group than the motor-control group with a 1.0 cm (95% CI: -1.6 to -0.4 cm, p=0.001), 0.5 cm (95% CI: -0.9 to 0 cm, p=0.040), and 1.1 cm difference (95% CI: -1.8 to -0.3 cm, p=0.004) in three testing positions. Although both groups did not show significant improvement in shoulder pain, the AROM of shoulder abduction increased by 23° (95% CI: 14° to 31°, p<0.001) in the motor-control with biofeedback group and by 15° (95% CI: 6° to 24°, p<0.001) in the motor-control group. Increased muscle strength of UT and MT were observed in both groups; however, only the motor-control with biofeedback group had increased LT muscle strength, upper extremity function, and reduced UT and MT muscle activations during arm elevation/lowering.
Conclusions: Based on the findings of Experiments 1, 2, and 3, early intervention with strengthening exercise integrating motor control techniques could be suggested for led to greater benefits for patients with neck dissection-related shoulder dysfunction to improve shoulder AROM and reduce compensatory scapular muscle activities. In addition, adding EMG biofeedback during scapular-focused exercises could improve scapular symmetry and muscle activation patterns for better muscle economy and upper extremity function.

並列關鍵字

motor control ； scapular-focused exercises ； oral cancer ； neck dissection ； accessory nerve ； scapular dyskinesis ； EMG biofeedback

參考文獻

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