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研究生：	廖麗君 Liaw, Lih-Jiun
論文名稱：	乳癌術後立即以橫向腹直肌肌皮瓣進行乳房重建婦女之軀幹功能探討 Trunk Functions in Post-mastectomized Women Underwent Immediate Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous Flap
指導教授：	徐阿田 Hsu, Ar-Tyan
學位類別：	博士 Doctor
系所名稱：	醫學院 - 健康照護科學研究所 Institute of Allied Health Sciences
論文出版年：	2013
畢業學年度：	101
語文別：	英文
論文頁數：	141
中文關鍵詞：	乳癌、橫向腹直肌肌皮瓣乳房重建、軀幹功能、肌肉尺寸
外文關鍵詞：	Breast cancer, Breast reconstruction with transverse rectus abdominis musculocutaneous flap, Trunk muscle functions, Muscle size
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背景與目的：乳癌婦女在乳癌切除後以單側根連橫向腹直肌肌皮瓣進行乳房重建（breast reconstruction with unilateral pedicled transverse rectus abdominis musculocutaneous flap, 簡稱TRAM flap）是目前常使用的自體組織乳房重建手術方式之一。但由於手術方式可能會因為腹直肌的完整性被破壞，因而改變腹斜肌肌群附著位置與鄰近的解剖結構，進而可能因此導致腹部肌群的功能受影響。所以本研究之目的是要探討肌肉保留（muscle sparing）單側根連橫向腹直肌肌皮瓣對於腹部肌群肌肉大小、軀幹肌群的肌力與耐力、核心穩定肌力與耐力的影響，同時也評估這個手術對於這群婦女在執行肢體動作時與當受到一個非預期性的姿勢干擾時其姿勢反應的變化情形。
研究方法：本研究共徵召40位(平均年齡：42.6 ± 6.2歲)接受肌肉保留單側根連橫向腹直肌肌皮瓣乳房重建手術的婦女為實驗組（簡稱TRAM婦女），並徵召30位年齡相仿（平均年齡：41.2 ± 4.9歲）的健康女性自願者為對照組。所有參與女性都接受3個部分的評估：(1) 以超音波造影檢測所有腹部肌群，並測量其肌肉大小（厚度或截面積）；(2) 以測力器、臨床測試方法量測軀幹肌群在執行軀幹伸直、彎曲與旋轉動作時的肌力，也以臨床測試方法測量軀幹彎曲肌群與伸直肌群的耐力、以及核心穩定的肌力（以腹肌測試來測量）與耐力（以雙腳彎曲離地可維持之時間來測量）；(3) 以動作分析系統、測力板與肌電圖儀蒐集受試者在執行肢體上抬動作（自主抬手任務、自主抬腳任務）、以及站在一個會移動的平台上時（非預期性姿勢干擾任務）等三種姿勢調整任務中其姿勢反應的資料，以此評估TRAM婦女在受到預期性與非預期性干擾時之姿勢反應與對照組是否有不同。
結果：(1)在第一部份：共有34位TRAM婦女與25位健康女性完成此部分的評估，結果發現在捐贈側(的腹直肌（Rectus abdominis, 簡稱RA）在收縮時，超音波顯像呈現厚度增加（p<0.05）；TRAM婦女兩側的外側腹部肌群（腹內與腹外斜肌、腹橫肌）厚度一樣，但是TRAM婦女兩側的外側腹部肌群與好側RA的肌肉大小比對照組來得小（p<0.05）。(2)第二部份：共有40位TRAM婦女與30位健康女性參加，結果顯示TRAM婦女腹部肌群的肌力、耐力與核心穩定的肌力與耐力都比健康女性弱（p<0.05）。 (3)第三部份：共有12位TRAM婦女與15位健康女性參加，結果發現在三種姿勢調整任務中，其生物力學參數(身體質量中心與足底壓力中心在前後或左右之最大位移量等)兩組並無統計學上的差異（p>0.05）；兩組最主要的差異是腹部肌群肌肉的活化情形：1)在抬手任務中，TRAM婦女的兩側腹內斜肌（obliquus internus abdominis, 簡稱OI）與抬手側的腹外斜肌（obliquus externus abdominis, 簡稱OE）之活化程度比對照組大(p<0.05)。肩關節在肩胛骨平面上抬90度並拿1.5公斤重量的動作中，TRAM婦女的3組軀幹肌群（兩側OE、兩側OI、兩側多裂肌）之同步程度比對照組高（p=0.015）。2) 但在抬腳任務中，兩組在兩側OE、OI、與多裂肌（multifidus, 簡稱MF）的同步程度則都沒有差異（p>0.05）。兩組有差異的肌肉活化參數主要是發生在活化量上的不同（p<0.05），TRAM婦女兩側OI與抬腳側的OE的活化程度都比對照組相對肌肉的活化程度大（p<0.05）。3)在非預期性姿勢干擾任務中的姿勢反應，兩組主要的差異是在兩側OI的平均活化量，都是TRAM婦女比健康女性大（p<0.05）。但兩側OI同步活化的程度兩組並無差異（p>0.05）。
結論：婦女在乳癌切除後以肌肉保留單側根連橫向腹直肌肌皮瓣進行重建手術約10個月後，腹部肌群之肌力、耐力與核心穩定能力確實有下降、以及腹部肌群肌肉截面積/厚度有變小的情形。這可能是因為術後不動（postoperative immobilization）所導致腹部肌群整體無力的現象。另外，在執行自主抬手或抬腳任務時，TRAM婦女的兩側OI與抬腳側的OE會有較大活化程度；而站在會移動的平面時，TRAM婦女則是兩側OI平均後的活化程度相較於健康女性來得大。
臨床意義：因此，物理治療師必須瞭解接受此手術的婦女可能會有上述這些軀幹功能的變化，執行完整評估並提供適當的物理治療計畫，以減輕此手術對於這些婦女的衝擊，以協助TRAM婦女能獲得最大的軀幹功能恢復與更完整的醫療照護。

Background and purpose: The unilateral transverse rectus abdominis musculocutaneous (TRAM) flap is a major operation widely used for breast reconstruction. It is hypothesized that this surgery has the potential risk of weakening the abdominal wall because it disrupts the integrity of the rectus abdominis muscle (RA), therefore, alters the insertion of the oblique muscles and the biomechanical relationship between the RA muscle and adjacent structures. The purposes of this study were to examine the effects of the muscle-sparing (MS) unilateral TRAM flap surgery on muscle size of abdominal muscles, strength and endurance of trunk muscles, strength and endurance of core stability, as well as the postural responses during the performance of limb lifting movement or after an unexpected postural perturbation.
Methods: Forty women (aged 42.6 ± 6.2 yrs) after MS unilateral TRAM flap surgery and 30 healthy controls (aged 41.2 ± 4.9 yrs) participated. There were 3 experiments involved in this study. (1) Ultrasound imaging measured the thickness of all abdominal wall muscles and the cross-sectional area of the RA muscle at rest and in an isometric contraction. (2) Trunk strength was measured by a dynamometer and clinical tests (prone extension, curl-up and rotational curl-up). Endurance of trunk muscles and strength and endurance of core stability were measured by the clinical tests (abdominal muscle test for strength, unsupported double bend leg lifting for static endurance). (3) We recorded the biomechanical and electromyographic responses during voluntary limb movements and elicited by unexpected support surface translations and tilts in standing. A six-camera Qualisys motion system was used. Ground reaction forces and moments were acquired by a Kisler force plate. Surface electrodes were used to record the muscle activity of selected trunk and limb muscles.
Results: The results of 3 experiments were as follows: (1) 34 patients and 25 controls completed the first experiment. The remnant RA in the relaxed state was thinner and had a smaller cross-sectional area than those of the contracted state. The remnant RA in the relaxed state also was thinner than its contralateral intact counterpart. No differences in the thickness of other abdominal muscles were found between sides. The abdominal muscles in the TRAM group were smaller than those of the control group. (2) In the second experiment, all abdominal strength, endurance, and stabilizing ability measures in the TRAM group were less than those of the control group (p<0.05). (3) 12 patients and 15 controls completed the third experiment. Between these two groups, no significant difference was observed in the maximum displacements of the center of mass and center of pressure in the anterior-posterior (COM A-P max and COP A-P max) and medial-lateral (COM M-L max and COP M-L max) directions. Main significant differences between the TRAM and control groups were observed in electromyographic (EMG) characteristics of abdominal muscles. 1) For arm raising tasks, relative muscle activity levels (percentage of maximal voluntary isometric contraction, normalized EMG) of the ipsilateral OEOP (obliquus externus abdominis on the side of the operated-RA) to the arm-raising side and bilateral OI (obliquus internus abdominis) muscles were higher in the TRAM group than those in the control group during the 4 arm rising tasks (p < 0.05). In addition, The temporal synchronization of bilateral homologous trunk muscle pairs showed a significant group effect in shoulder scaption at 90 degrees while holding a 1.5 kg weight (p=0.015). The TRAM group had higher degree of synchronization in the three trunk muscle pairs. 2) For leg lifting tasks, the TRAM group demonstrated higher muscle activation levels than those of the control group in OI of both sides and OEOP of the side ipsilateral to the leg-lifting in all four tasks. No difference was found in the degree of temporal synchronization between the TRAM and the control group (p>0.05). 3) For unpredictable balance tasks, the EMG data showed no group difference in muscle activation levels of RA nonOP (the contralateral RA to the operation side), mean of bilateral OEs (OEbi-mean), and MFbi-mean (multifidus). However, the TRAM group demonstrated significantly higher levels of muscle activation level in the OIbi-mean than that in the control group. In addition, no group differences in the degree of temporal synchronization were found in all unexpected balance tasks.
Conclusion: The current study demonstrated that TRAM women had impairments in trunk muscle functions. There were decreases in strength and endurance of abdominal muscles, strength and endurance of core stability, and muscle size of the remnant RA and the other abdominal muscle in the women after TRAM surgery. Postoperative immobilization is the most likely cause of generalized weakness of the abdominal musculature. In addition, for limb lifting tasks, the TRAM patients had larger muscle activation levels in bilateral OI muscles and OE ipsilateral to the lifting limb side. Similar results were also observed in response to non-anticipatory postural adjustment tasks by standing a moveable platform.
Clinical Relevance: Based on findings of the current study physical therapists should be aware of the trunk functional deficits experienced by women after breast reconstruction with unilateral TRAM flap surgery. Further research is needed to design and implement appropriate physical therapy interventions.

Table of Contents
中文摘要……i
Abstract………iv
致謝……………vii
Table of Contents…viii
Lists of Tables……xii
Lists of Figures……xiv

CHAPTER 1   INTRODUCTION
1.1	Background… 1
1.2	Hypothesis …4
1.3	Dissertation organization…4
1.4	Definition and abbreviation…5

CHAPTER 2   ULTRASOUND IMAGING EVALUATION OF ABDOMINAL WALL MUSCLES AFTER BREAST RECONSTRUCTION WITH A UMILATERAL PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP……. 8
   2.1    Introduction…8
   2.2    Methods…10
      2.2.1    Participants…10
      2.2.2    Surgical Technique of the Pedicled TRAM Flap Procedure…11
      2.2.3    Instrumentation of Ultrasound Imaging (USI)…12
      2.2.4    Transducer Locations…13
      2.2.5    Imaging Procedures and the Examiner….15
      2.2.6    Measurements of Muscle Size…16
      2.2.7    Tissue Composition Measurements….19
      2.2.8    Data Analysis…19
2.3     Results…21
   2.3.1    Characteristics of Subjects… 21
   2.3.2    Inter-image Reliability…22
   2.3.3    Thickness, Width and CSA of Abdominal Wall Muscles in the Patient Group…24
   2.3.4    Muscle Thickness and CSA During Contraction in the Operated RA…25
   2.3.5    Size of the Abdominal Muscles of the Intact Side in the Patient Group…27
   2.3.6    Tissue Composition…29
2.4     Discussion…31
2.5     Clinical Implications…36
2.6     Conclusion…37

CHAPTER 3   MUSCLE PERFORMANCE AND CORE STABILITY OF TRUNK FOLLOWING BREAST RECONSTRUCTION WITH UNILATERAL PEDICLED TRAM FLAP…38
   3.1     Introduction…38
   3.2     Methods…41
      3.2.1     Research Design…41
      3.2.2     Participants…41
      3.2.3     Testing Procedures…42
      3.2.4     Measurements for Trunk Functions and the Instruments…42
      3.2.5     Statistical Analyses…54
   3.3     Results…56
      3.3.1     Number and Characteristics of Participants…56
      3.3.2     Trunk Muscle Strength in the TRAM Group…57
      3.3.3     Static Trunk Flexion and Extension Endurance…64
3.3.4.     Strength and Endurance of Core Stability…65

   3.4     Discussion…68
      3.4.1     Clinical Tests for Abdominal and Back Muscle Strength…69
      3.4.2     Dynamometry of Trunk Muscle Strength…72
      3.4.3     Endurance Testing…80
      3.4.4     Lumbo-pelvic Stability…81
      3.4.5     Clinical Implication…83
      3.4.6     Limitation…84

CHAPTER 4 ANALYSES OF ANTICIPATORY AND NON-ANTICIPATORY POSTURAL ADJUSTMENTS IN WOMEN FOLLOWING BREAST RECONSTRUCTION WITH UNILATERAL PEDICLED TRAM FLAP…85
   4.1     Introduction…85
   4.2     Methods…88
      4.2.1     Participants …88
      4.2.2     Postural Adjustment Tasks…89
      4.2.3     Kinematic, Kinetic and Surface EMG Data Acquisition…91
      4.2.4     Procedures…94
      4.2.5     Data Processing and Dependent Variables…95
      4.2.6     Statistical Analyses…96
   4.3     Results…98
      4.3.1     Anticipatory Postural Responses during Voluntary Arm Raising 
Tasks…98
      4.3.2    Anticipatory Postural Responses during Voluntary Leg Lifting Tasks…106
      4.3.3    Non-anticipatory Postural Responses during Unpredictable Balance Tasks…112
   4.4     Discussion…122
      4.4.1     Postural Responses in Voluntary Arm Raising and Leg Lifting Tasks…122
      4.4.2     Postural Responses during Unpredictable Balance Tasks…127
      4.4.3     Conclusion…131

CHAPTER 5 CONCLISIONS …132

REFERENCES…134


List of Tables
Table 2.1 Criteria for scoring muscle strength of trunk flexion…14
Table 2.2 Demographics of subjects participated in the present study…21
Table 2.3 The inter-image reliability of muscle size measurements at 3 (upper, middle, and lower) locations of the RA in the TRAM flap group and the healthy control group…23
Table 2.4 Descriptive statistics for averaged measurements of the thickness of all abdominal muscles, width and CSA of RA in women with the unilateral muscle-sparing pedicled TRAM flap procedure…24
Table 2.5 Descriptive statistics for averaged measures of muscle size at rest, during contraction, and contraction ratio data at three locations of the bilateral RA in the women with pedicled TRAM flap…26
Table 2.6 Comparisons of muscle size between women who had breast reconstruction with the unilateral muscle-sparing pedicled TRAM flap and healthy control women…28
Table 2.7 Mean grades of the visibility of muscle contour (grade 0-2) and echogenicity (grade 0-2) of the remnant RA in the donor side at three locations in ultrasound imaging (n=34) …29
Table 3.1 Criteria of clinical tests for scoring muscle strength of trunk flexion, rotation, and extension…43
Table 3.2 Intra-rater reliability of maximum isometric strength test at three muscle group…44
Table 3.3Characteristics of study participants…56
Table 3.4Number of participants completing each test in this study…57
Table 3.5Comparisons of curl-up performance for abdominal muscle strength between the TRAM group and control group…58
Table 3.6Rotational curl-up performance for trunk rotator strength in both groups…58
Table 3.7-1Prone trunk extension performance for trunk extension strength in both groups…60
Table 3.7-2Prone trunk extension performance for trunk extension strength in both groups who were also participated the dynamometer extension strength test…60
Table 3.7-3Prone trunk extension performance for trunk extension strength in each group who were or not participated the dynamometer extension strength test…60
Table 3.8Comparisons of normalized maximum isometric trunk flexion and extension strength values (in peak force/body weight) between the TRAM-flap and control group…61
Table 3.9Comparisons of normalized maximum isometric trunk rotational strength values (in peak force/body weight) between the TRAM and control group…62
Table 3.10Normalized maximum Isometric strength values of rotation to operated-RA and sound-RA sides in the TRAM group…63
Table 3.11Normalized maximum Isometric strength values of rotation to operated-RA and sound-RA sides in control group…64
Table 3.12Comparisons of trunk flexor and extensor endurance between the TRAM and control group…64
Table 3.13Comparisons of strength of stabilizing ability between the unilateral pedicled TRAM flap and control group…65
Table 3.14Comparisons of endurance of core stability between the unilateral pedicled TRAM flap and control group…66
Table 3.15Summary of functional outcomes for abdominal strength measured using a straight of rotational curl-up performance after unilateral pedicled TRAM flap surgery in the literature…71
Table 3.16Summary of functional outcomes for trunk strength measured by using an isokinetic dynamometer after unilateral pedicled TRAM flap surgery in the literature…. 77
Table 4.1Characteristics of study participants…88
Table 4.2Electrode placement for EMG recording of the trunk muscles…. 94
Table 4.3Table 4.3Descriptive statistics (mean, standard deviation) for kinematic and kinetic variables for 4 arm raising tasks and comparisons between the TRAM (n=12) and control (n=15) groups…98
Table 4.3Mean (SD) of NEMG (amplitudes in percentage of MVC) of 7 trunk muscles for 4 arm raising tasks and comparisons between the TRAM (n=12) and control groups (n=15) …99
Table 4.5Descriptive statistics (mean, standard deviation) and comparisons in mean EMG variables (NEMG) for each trunk muscle during all 4 arm raising tasks and for each task between the TRAM group (n=12) and control group (n=15)…103
Table 4.6Mean (SD) cross-correlation values of bilateral trunk muscles during different arm raising tasks in the TRAM group (n=12) and control group (n=15) …105
Table 4.7Dependent variables (mean, standard deviation) of COM and COP displacements during 4 leg lift tasks in the TRAM group (n=12) and control group (n=15) …106
Table 4.8Mean (SD) of NEMG (amplitudes in percentage of MVC) of 7 trunk muscles for 4 leg lifting tasks and comparisons between the TRAM (n=12) and control groups (n=15) …107
Table 4.9Descriptive statics (mean, standard deviation) and comparisons in mean EMG variables (NEMG) for each trunk muscle during all 4 leg lifting tasks, and for each leg lifting task between the TRAM group (n=12) and control group (n=15) …110
Table 4.10Mean (SD) cross-correlation values of bilateral trunk muscles during different leg raising tasks in the TRAM group (n=12) and control group (n=15) …112
Table 4.11Dependent variables (mean, standard deviation) of COM displacements during unpredictable balance tasks in the TRAM (n=12) and control groups (n=15) …113
Table 4.12Mean (SD) of NEMG (amplitudes in percentage of MVC) of 7 trunk muscles for 6 unpredictable balance tasks and comparisons between the TRAM (n=12) and control groups (n=15) …115
Table 4.13Descriptive statics (mean, standard deviation) and comparisons in mean NEMG variables for each trunk muscle during all 6 unpredictable balance tasks, and for each unpredictable balance task between the TRAM group (n=12) and control group (n=15)…118
Table 4.14Mean (SD) cross-correlation values of bilateral trunk muscles during different unpredictable balance tasks in the TRAM group (n=12) and control group (n=15) …120


List of Figures
Figure 2.1Schematic diagram of the abdominal wall…12
Figure 2.2The ultrasound images of the rectus abdominis (RA) during contraction were taken in an isometric head-raised position, with drawing in the lower abdomen first and then the head raised 45° at expiration without moving the trunk…16
Figure 2.3Ultrasound image of the donor (right) side and the intact (left) side of the rectus abdominis muscle (RA) at rest and on contraction in a 45 years old woman with an unilateral muscle-sparing pedicled TRAM flap…17
Figure 2.4Ultrasound image of the lateral abdominal wall muscles at rest in a 45 years old woman with an unilateral muscle-sparing pedicled TRAM flap…17
Figure 2.5Ultrasound images of the intact (left) side of rectus abdominis muscle (RA) at rest and on contraction in a 45 years old woman with an unilateral muscle-sparing pedicled TRAM flap…18
Figure 3.1Trunk flexion strength testing with the isometric dynamometer device)…46
Figure 3.2Trunk extension strength testing with the isometric dynamometer device…46
Figure 3.3Right trunk rotation strength testing with the isometric dynamometer device…46
Figure 3.4Static trunk flexion endurance testing position…47
Figure 3.5Static trunk extension endurance testing position…48
Figure 3.6Picture of the pressure biofeedback unit (PBU)... 49
Figure 3.7Pictures of the end position of each level of abdominal muscle test (AMT)…50
Figure 3.8Starting position for calculating the holding time of static endurance of core stability… 52
Figure 4.1A three-degrees-of-freedom movable platform…90
Figure 4.2Retroreflective marker locations…92
Figure 4.3Normalized mean electrographic signals (%MVC, NEMG) of 7 trunk muscle activation during arm raising tasks in the TRAM and control group…104
Figure 4.4Normalized mean electrographic signals (% of maximal voluntary isometric contraction, MVC) of 7 trunk muscle activation during leg lifting tasks in the TRAM and control group…111
Figure 4.5Normalized mean electrographic signals (NEMG: % of maximal voluntary isometric contraction, MVC) of 4 trunk muscle activation during 6 unpredictable balance tasks in the TRAM and control group…119
                                    

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