比較A型肉毒桿菌毒素肌肉注射與經皮
膚脛神經運動分支阻斷兩者降低踝蹠
屈痙攣張力之臨床療效及電生理變化

林傳朝

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比較A型肉毒桿菌毒素肌肉注射與經皮膚脛神經運動分支阻斷兩者降低踝蹠屈痙攣張力之臨床療效及電生理變化

Comparison of intramuscular Botulinum toxin type A injection and percutaneous muscular branch block of the tibial nerve for reducing ankle plantarflexor spasticity: a randomized clinical trial trial

林傳朝 , Ph.D　　Advisor：蔡素如　　

繁體中文

痙攣張力；腓腸肌；肉毒桿菌毒素；酚； spasticity ； gastrocnemius muscle ； botulinum toxin ； phenol

Abstract │ Reference (58) │ Altmetrics

Abstract 〈TOP〉

研究目的：以腓腸肌單一肌肉治療模式處理偏癱患者踝部蹠屈痙攣張力，來比較接受肉毒桿菌毒素肌肉注射及經皮膚脛神經運動分枝酚神經阻斷後病患之臨床療效及電生理變化，以建立更有效的痙攣張力處理模式。
研究方法：收集三十名具有踝部蹠屈痙攣張力的偏癱患者，以隨機方式分派為接受腓腸肌肌肉內肉毒桿菌毒素注射（第一組）或經皮膚脛神經運動分枝酚神經阻斷（第二組），在進入研究時會簽署受試者同意書。兩組病患分別於注射前，注射後二週、四週、八週、及十二週接受理學、電生理及六分鐘行走測試。第二組於注射後當天進行測試以瞭解酚神經阻斷後的立即效果。
研究結果：共有29名病患完成本研究，其中第一組15名，第二組14名。兩組在年齡、身高、體重、性別、診斷以及受影響側都沒有顯著差異。第二組酚神經阻斷後的立即療效結果發現注射後在Modified Ashworth scale (MAS)、Modified Tardieu scale (MTS)、六分鐘行走測試的所有參數都有顯著地改善 (p＜0.05)。以MAS當作痙攣張力的主要測試結果，兩組在注射後所有測量時間點得到的數值與注射前比較都有顯著地下降，而兩組間則沒有統計學上的差異。不管是膝部彎曲或膝部伸直的情形下作踝部蹠屈痙攣張力測試，注射後MTS在兩組的R1(快速動作)角度都有明顯地變大(p<0.0001)。行走步數在兩組治療後第二週、第八週及第十二週比治療前都有明顯改善(p=0.001)。在行走步長以及行走速度上，兩組治療後所有測量時間點得到的數值與注射前比較都有顯著地進步。在電生理檢查測試發現外展拇肌和比目魚肌的複合動作電位、H 潛期、Hmax及HM比率在注射前後及兩組間都沒有明顯差異。外側腓腸肌複合動作電位在注射後所有測量時間點得到的數值與注射前比較都有顯著地下降(p=0.001)。內側腓腸肌複合動作電位在兩組注射後的第二及第四週都有顯著地下降(p=0.026)。副作用方面，第一組有三名(10.3%)患者出現短暫無力現象，第二組則有一名(3.4%)患者在第三週出現膕窩及小腿疼痛，這些狀況都不需要藥物治療處理而隨著時間改善，也完全不影響患者的行走功能。
結論與建議：肌肉內注射A型肉毒桿菌毒素肌肉注射及經皮膚脛神經運動分枝酚神經阻斷兩者都能有效地減少由腓腸肌肌肉引起的踝部蹠屈痙攣張力，包括Modified Ashworth scale、Modified Tardieu scale以及行動能力等，而且副作用少、耐受性及安全性高。然而兩者的藥價成本差距甚大，對於容易精確定位的神經可以妥善地利用酚神經阻斷這種治療方式來達到最佳的治療效果。

Parallel Abstract 〈TOP〉

Objective：We use the single gastrocnemius muscle to treat ankle plantarflexor spasticity in hemiplegic patients. The objective is to compare the efficacy and electrophysiologic changes after intramuscular injection of  botulinum toxin type A and muscular branch block of the tibial nerve with phenol, and to establish the efficient spasticity treatment strategy. 
Methods and Materials：Thirty hemiplegic patients with ankle plantarflexor spasticity were recruited. They were randomly assigned to group 1 which underwent gastrocnemius intramuscular botulinum toxin type A injection and group 2 which underwent percutaneous muscular branch block of the tibial nerve with phenol. Informed consent was signed before the entry to this study. We measured physical, electrophysiological and 6 minute walking test for these two groups before and two, four, eight, and twelve weeks after the time of injection. Group 2 also received post-injection measurements on the same day of injection to understand the immediate phenol nerve blocking effect.  
Results：Twenty nine patients fulfilled this study. There were 15 in group 1and 14 in 
group 2. The immediate phenol blocking effect in group 2 showed significant 
improvement in Modified Ashworth scale (MAS), Modified Tardieu scale (MTS) and 
6 minute walking test (p＜0.05). The outcome measure, MAS and MTS, which were 
significantly reduced in the all time periods after the time of injection but there was no 
difference between these two groups. Significantly larger R1(quick velocity) angle 
was measured in both knee flexion and extension in all post-injection time periods 
(p<0.0001). Walking step counts improved significantly in two, eight and twelve 
weeks after the time of injection (p=0.001). Step length and walking speed also 
increased significantly in these two groups. There was no statistical difference in 
compound muscle action potential (CMAP) of the adductor hallucis and soleus 
muscles, H latency, Hmax and HM ratio before and after injection and in these two 
groups. CMAP of the lateral gastrocnemius muscle reduced significantly at all 
post-injection time periods (p=0.001). In the medial gastrocnemius muscle, the CMAP 
reduced significantly in two and four weeks after the time of injection p=0.026). In 
the adverse effect, there was three patients (10.3%) in group 1complained of transient 
muscle weakness and one patient (3.4%) in group 2 complained of pain over the 
popliteal and calf area. 
Conclusion and Suggestion：Both intramuscular botulinum toxin type A injection and percutaneous muscular branch of the tibial nerve block with phenol can significantly reduce ankle plantarflexor spasticity caused by the gastrocnemius muscle hypertonicity. These two methods improve Modified Ashworth scale, Modified Tardieu scale and walking ability as well. They are both well-tolerated procedures with few adverse effects. We suggest percutaneous muscular branch of the tibial nerve block with phenol is a safe and cost-effective way for the spasticity management.

Reference ( 58 ) 〈TOP〉

Bakheit, A. M., V. A. Maynard, J. Curnow, N. Hudson and S. Kodapala (2003). "The relation between Ashworth scale scores and the excitability of the alpha motor neurones in patients with post-stroke muscle spasticity." J Neurol Neurosurg Psychiatry 74(5): 646-648.
連結：
Baumbach, S. F., M. Brumann, J. Binder, W. Mutschler, M. Regauer and H. Polzer (2014). "The influence of knee position on ankle dorsiflexion - a biometric study." BMC Musculoskelet Disord 15: 246.
連結：
Becker, W. J., C. J. Harris, M. L. Long, D. P. Ablett, G. M. Klein and D. A. DeForge (1995). "Long-term intrathecal baclofen therapy in patients with intractable spasticity." Can J Neurol Sci 22(3): 208-217.
連結：
Bell, K. R. and F. Williams (2003). "Use of botulinum toxin type A and type B for spasticity in upper and lower limbs." Phys Med Rehabil Clin N Am 14(4): 821-835.
連結：
Bodine-Fowler, S. C., S. Allsing and M. J. Botte (1996). "Time course of muscle atrophy and recovery following a phenol-induced nerve block." Muscle Nerve 19(4): 497-504.
連結：

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