研究背景: 肩旋轉肌斷裂是臨床上常見的疾病，而大範圍肩旋轉肌斷裂更是造成老年人肩關節功能失調的主因。大範圍肩旋轉肌斷裂的發生率會隨年齡漸長而大為提高，在五十歲以後發生率可以高達10%。過去文獻指出針對大範圍旋轉肌斷裂進行手術修補，經常可能因為肌肉萎縮及脂肪浸潤而失敗率大增，而導致旋轉肌再斷裂。相反的，有關旋轉肌斷裂之保守治療療效過去也有不少研究支持，然而至今卻鮮有文獻針對大範圍旋轉肌斷裂患者進行肩胛動作分析，並著眼於強化代償機制之訓練計劃以檢定特殊運動設計之需求。
實驗目的:代償性運動治療於大範圍肩旋轉肌斷裂患者之療效檢驗與比較。
研究方法:本研究從國立成功大學附設醫院延攬二十四位大範圍肩旋轉肌斷裂受試者(7位男性、17位女性)進行療前測試，測試項目包括肩疼痛強度與肩關節功能量表、肩關節活動度、肩部與肩胛肌力、與肩胛控制策略評估(肩胛動作分析與肌電訊號分析)。之後將受試者隨機分成兩組，各接受六週代償性運動治療(Compensatory strategy, CS)與六週傳統性運動治療(Traditional exercise, TE)後進行二度評估。之後兩組交換治療方式進行第二階段長治療，為期六週。(CS-TE組，先接受CS治療後接受TE治療； TE-CS組，先接受TE治療後接受CS治療)。最後，於結束十二週後進行三度評估，然三度評估之項目不包含肩胛控制策略分析。
結果:結束第一階段的六週治療後，TE-CS組僅於功能量表分數、肩屈曲活動度和前距肌力量有顯著進步；反之CS-TE組卻呈現出全面性的進步，於疼痛、功能量表分數、肩關節活動度(肩伸展除外)和代償與肩胛肌肉力量(大圓肌、闊背肌、前距肌和下斜方肌)皆呈現顯著進步。另一方面，TE-CS組在改成接受第二階段CS運動治療後，才開始在肩疼痛強度、功能量表分數和代償肌之肌力方面呈現顯著進步。最後，有關肩胛動作控制方面，僅發現CS-TE組經過六週CS運動治療後，在手臂抬舉及放下過程，呈現肩胛骨後傾(GH 500~1200; 1200~600, p<0.05)與外旋(GH 400~1000, p<0.05)活動度顯著增加的現象，此外前距肌、下斜方肌、闊背肌和胸大肌之肌肉活動量亦有顯著提高。
討論:相較於傳統性治療，六週的代償性運動治療確實有發揮代償肌與肩胛肌肌力顯著增加的效果，此外受試者於手臂抬舉過程尤其是在容易產生夾擠現象的角度，呈現肩胛骨後傾與外旋顯著增加的現象，再加上代償肌(闊背肌和胸大肌)與肩胛肌(現前距肌、下斜方肌)的肌肉活動也有顯著的提昇，這些發現也許可以為受試者於肩關節疼痛、關節活動度乃至於肩關節功能方面的顯著進步提供一個合理的解釋。代償肌肌力之強化有助於提供肱骨頭向下拉力以代替原本缺失的旋轉肌來抗衡三角肌；而於抬臂過程增加肩胛骨後傾與外旋活動度則可能提供較大的肩峰下空間，以避免發生夾擠症狀。本研究結果提出明確證據支持，針對大範圍旋轉肌斷裂患者，若能提供特定設計的運動治療，著重於代償肌力的建立與肩胛骨動作控制的掌握，將能達到更顯著的療效。

Purpose: To examine the effect of compensatory strategies training for patients with massive rotator cuff tear (MRCT)
Methods: Twenty-four subjects with MRCT were recruited from the department of Orthopedics in National Cheng Kung University Hospital to participate three times shoulder assessments and the 12 weeks of intervention. After initial assessment, the subjects were assigned randomly into two groups (CS-TE and TE-CS). CS-TE group was provided compensatory strategies (CS) training followed by the 6 weeks of traditional exercise (TE) training. In comparison, TE-CS group took 6 weeks TE training followed by CS. All the participants were arranged to attend the second assessments after completing the first 6 weeks of intervention, and the third assessment at the end of 12 weeks of intervention, including the measurements of visual analogue scale (VAS), the range of motion (ROM) of shoulder, shoulder pain and disability index(SPADI) questionnaire, shoulder and scapular muscle strength. In addition, scapular kinematics and related electromyography (EMG) analysis were performed at initial and 2nd assessments. The two-way repeated measures analysis of variance (ANOVA) was performed to assess the effect of CS training, with significant level of 0.05.
Results: After completing the first 6 weeks training, CS-TE group showed significant improvement in motion pain measurement, SPADI score, AROM (except for extension) and the strength of local muscles at 6th week; however, TE-CS group only showed significant improvement in SPADI score and the flexion of shoulder. Moreover, after completing the 6 weeks of the CS training, TE-CS group showed significant improvement in VAS and the strength of compensatory muscles and scapular muscles. Furthermore, significant improvements in scapular control strategies were only found in CS-TE group after completing the 6 weeks of intervention, showing significantly increasing scapular external rotation (ER) and posterior tipping (PT) with significantly increased EMG activity in serratus anterior (SA)、lower trapezius (LT)、latissimus dorsi (LD) and pectoralis major (PM).
Discussion:
Our results have provided strong evidence for the enhancement of compensatory muscle strength by showing the significant increment of compensatory humeral head depressors (teres major, latissimus dorsi) after CS training for both group (CS-TE at 6th week, TE-CS at 12th week). In addition, our results also showed significant improvements at 6th week in LT and SA for CS-TE group, but only in SA for TE-CS group. It was not until completing additional 6 weeks CS training, the TE-CS group started to show significant improvements in LT strength. The results have again suggested that CS training is more effective in strengthening the compensatory humeral head depressors and scapular stabilizers.
The improvements in compensatory and scapular muscles strength might provide a possible explanation for the preference of improvements found in the CS-TE group, since significant improvements in shoulder pain, and active ROM of shoulder joint (abduction, external rotation, and internal rotation) after completing the first 6 weeks training. In addition, significant improvement in shoulder pain was only found at 12th week for TE-CS group, after completing the final CS training with the significantly increased muscle strength for LT. The results have further supported the importance of compensatory strategy training protocol.
To our knowledge, this study is the first study to report the effect on scapular control strategies for exercise intervention in patients with MRCT. We found that CS-TE group exhibited greater in posterior tipping (500~1200; 1200~600, p<0.05) and lesser in internal rotation (500~1100, p<0.05) during arm elevation and lowering after completing CS training. Also, the improvement of EMG (SA, LT, LD and PM) implied that CS training rebuild the better movement pattern to increase the AHD and depress the humeral head. Our results have supported that CS training is an effective treatment for establishing the compensatory strategies after MRCT and regaining the shoulder function.

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