平衡與肌力訓練對膝關節單獨後十字韌帶損傷患者之生物力學的影響

背景：膝關節後十字韌帶損傷後的復健訓練與開刀與否至今仍眾說紛紜，單獨後十字韌帶損傷患者運動訓練更沒有如前十字韌帶損傷患者有眾多學者研究相關運動訓練計畫。「平衡訓練」是一種結合活動性和穩定性的動態訓練，普遍被使用在前十字韌帶損傷患者的運動訓練中。本研究將進一步探討針對單獨後十字韌帶損傷患者(GradeⅡ~Ⅲ) 進行平衡加上肌力訓練後在膝關節功能量表、肌力及從事日常生活動作之生物力學分析。目的：本研究目的為探討膝關節單獨後十字韌帶損傷之患者在接受 12 週平衡加上肌力訓練的情況下，透過肌力及下肢(髖、膝、踝關節) 的生物力學參數，了解未手術接受訓練之患者與重建手術後一~二年患者之間日常功能性活動之比較，提供單獨後十字韌帶受傷患者運動訓練之建議，進而藉此針對後十字韌帶患者擬定更完善的訓練計畫。研究方法：本實驗選取單獨後十字韌帶損傷且接受12週肌力加上平衡訓練患者10位(訓練前、後組)及接受單獨後十字韌帶損傷重建手術後一~二年患者(重建組)。進行膝關節功能量表、各項理學檢查、肌力、本體感覺檢測，並利用動作分析系統觀察功能性動作之生物力學分析 (步態、上下階梯、全蹲、向前弓箭步、落地跳及垂直跳)，比較重建組與訓練組(訓練前、後)間各項參數之差異。統計方法使用Wilcoxon signed-rank test比較重建組與訓練後、重建組與訓練前二組受測者的各項數據，包括基本資料、Lysholm量表分數、大腿周徑、關節角度、脛骨位移、本體感覺以及各項功能性動作中的運動學和動力學參數，設p<0.05達統計上顯著差異。針對實驗組使用Mann-Whitney U test比 III 較平衡加肌力訓練前、後受測者患側之差異，設p<0.05達統計上差異。研究結果：膝關節功能量表部分Lysholm量表訓練後與重建組分數皆顯著大於訓練前，訓練後與重建組則無差異；IKDC結果亦同。脛骨位移差值重建組顯著小於訓練前與訓練後組。主動與被動本體感覺皆為訓練後優於訓練前。肌力部分，在膝關節伸直肌肌群120°/s等速肌力重建組顯著優於訓練前，訓練前後相比則在60°, 120°/s等速肌力膝關節伸直肌群與屈曲肌群訓練後皆顯著優於訓練前。功能性動作檢測，運動學部分，全蹲動作髖關節最大屈曲角度訓練後顯著大於訓練前；落地跳動作髖、膝、踝關節皆為訓練前顯著小於重建組與訓練後族群，而重建組與訓練後則無差異；垂直跳部分，髖關節為訓練前顯著小於重建組與訓練後，重建組與訓練後則無統計上差異，膝關節為訓練前顯著小於訓練後。動力學部分，全蹲動作髖關節最大伸直力矩顯示重建組顯著高於訓練前，而重建組與訓練後組皆無差異。垂直跳高度為訓練後顯著高於訓練前。結論：接受12週平衡及肌力訓練之訓練後受試者從各項檢測中顯示，其恢復狀況如同接受重建手術後患者一般，甚至下肢股四頭肌肌力經訓練後更優於重建組，因此，未來建議將平衡訓練納入後十字韌帶傷後訓練計畫中，使後十字韌帶損傷患者可經由平衡及肌力訓練免於手術治療。

關鍵字

後十字韌帶；平衡訓練；功能性動作；動作分析

並列摘要

Background: The exercise training program of posterior cruciate ligament(PCL) injuries remains a controversial issue. Many scholar published about exercise training program for anterior cruciate ligament(ACL) injury more than PCL injury. Balance training is comprised of the activity and stability of the dynamic training that maintain an upright stance and is generally used in patients with anterior cruciate ligament injury training. Purpose: The purpose of this study is to investing the biomechanical differences between training group and post-operative, in order to find out the balance training use in the training program of PCL injuries Method: Ten posterior cruciate ligament injured patients who accept 12 weeks balance with strength training and ten reconstructed-posterior cruciate ligament were recruited in this study. There subjects were separated into three group, post-operate, pre-training and post-training respectively. The Lysholm score, IKDC, physical examinations, proprioception(active and passive), muscle strength were tested. The Qualysis motion capture system was used to collect the biomechanical data during functional tasks. One-way analysis of variance used to compare the data between three groups, and pair t-test was used to compare the differences between pre-training and post-training. Results: The Lysholm score, IKDC score and muscle strength were V significantly greater in post-training and post-operate than pre-training. The proprioception(active and passive) were significantly greater in post-training than pre-training. The hip flexion angle were significantly greater in post-training than post-operate and pre-training, extension moment were significantly greater in post-operate and post-training than pre-training when squatting. During drop landing, the hip, knee, ankle and knee varus joint angle were significantly less in pre-training than post-training and post-operate. The hip extension moment were significantly greater in post-training and post-operate when drop landing. During lung, the hip and knee flexion angle, hip extension moment were significantly greater in post-training than and pre-training . The hip flexion angle in ascending stairways, the knee flexion angle in Squat, and knee joint moment were significantly greater in post-training than pre-training. The hip flexion angle were significantly greater in post-training than post-operate and pre-training when Counter movement jump. The knee flexion angle and varus angle were significantly greater in post-training than and pre-training when Counter movement jump. The jump height was significantly higher in post-training . Conclusion: From the tested of showed that subjects who received 12 weeks balance with strength training as well as reconstructed-posterior cruciate ligament. And quadriceps muscle strength of post-training group was better than post-operate. So we suggest that training program of posterior cruciate ligament include balance training in VI order to help patients with PCL injury.