研究背景：肩旋轉肌斷裂是老年人常見的疾病，有研究指出其中20%的老年人甚至有大範圍肩旋轉肌斷裂的問題，大範圍肩旋轉肌斷裂的定義是指肩旋轉肌斷裂至少斷裂2條以上，或斷裂的大小大於5公分。大範圍肩旋轉肌斷裂的發生率在50歲以後更高達10%。過去有研究指出大範圍肩旋轉肌斷裂的老年人接受手術修補的成功率較低，原因主要是肌肉萎縮和脂肪浸潤，且手術後肩旋轉肌再斷裂比率相當高。因此，臨床上不少人支持針對大範圍的肩旋轉肌斷裂患者給予保守治療，唯相關實證研究極少，僅少數學者指出肩部三角肌的功能性訓練可以減緩大範圍肩旋轉肌斷裂病人的疼痛與改善肩部功能。然而從沒有症狀且功能正常的大範圍的肩旋轉肌斷裂患者身上觀察到，在大範圍肩旋轉肌斷裂後，加強剩餘完整旋轉肌功能、發展肩內收內旋肌群的肱骨頭下壓能力、與強化肩胛上旋與後傾控制，以建立完整肩部代償動作機制應該是更能有效改善功能與減輕疼痛。因此，本研究根據此假說，設計一套加強內收內旋肌群功能與強化肩胛控制的運動計畫，希望能有效提升大範圍的肩旋轉肌斷裂病人的生活功能和降低疼痛。
目的：本研究主要是要探討一個為期六周的肩胛骨動作控制運動治療計畫，目標將發展大範圍的肩旋轉肌斷裂患者之肩部動作代償機制，並檢定其對減緩疼痛與改善功能之效益。
方法：本研究共收集大範圍的肩旋轉肌斷裂病人36人，包括肩胛骨動作控制運動組18 人及傳統運動組18人。肩胛骨動作控制運動組接受六週肩胛骨動作控制之代償性運動治療，而傳統運動組則接受六週傳統性運動治療。所有受試者分別在進行運動介入前與介入後接受一系列測試評估。測試評估項目包括肩疼痛強度、肩關節功能、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)。
結果：結束六週介入後， 肩胛骨動作控制運動組組於疼痛、功能量表分數、內收肌群與肩胛肌肉力量(大圓肌、闊背肌、胸大肌、前距肌和下斜方肌)皆呈現顯著進步，而傳統運動組在疼痛、功能量表分數，以及大部分肌肉力量則無改善，僅三角肌、闊背肌和上斜方肌肌肉力量有增加。另外，肩胛骨動作控制運動組經過六週運動治療後，在手臂抬舉及放下過程，皆呈現顯著肩胛骨後傾與上旋活動度顯著增加的現象，但傳統運動組則無變化。同時，前距肌、下斜方肌、大圓肌、闊背肌和胸大肌之肌電訊號活動量在肩胛骨動作控制運動組中亦有顯著提高。
討論：大範圍的肩旋轉肌斷裂的病人常常會合併肩胛骨作失能的問題，加上失去肩旋轉肌主要穩定肩關節和肱骨頭下拉的角色，患者常常在手臂抬舉的過程出現夾擠的問題，這也是讓他們肩功能下降以及疼痛的主要原因，經過6週肩胛骨動作控制運動治療後， 的確能夠讓大範圍的肩旋轉肌斷裂患者發展出代償機制，我們可以從肩胛骨動作控制運動組發現肩內收肌與肩胛肌肉力量皆呈現顯著增加, 此外這些肌肉手臂抬舉及放下過程之肌電訊號活動量亦有顯著提高，同時發現肩胛骨後傾與上轉顯著增加的現象。內收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上轉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，這些代償的機制可以用來解釋肩胛骨動作控制運動組肩功能的提升以及疼痛降低的原因。
結論：本研究結果支持對於大範圍的肩旋轉肌斷裂病人採用代償的運動治療計劃，對於症狀以及肩功能是能夠有明顯的改善。

Background: Rotator cuff tear (RCT) is a common clinical condition among older adults. Studies have indicated that massive rotator cuff tear (MRCT) accounts for 20% of all RCTs, and that it has a 50% incidence rate for adults over 50 years of age. Other studies have also indicated that muscle atrophy and fatty infiltration are responsible for the low successful repair rate and high re-rupture rate of MRCT after surgery. Thus, a conservative treatment is often suggested for the patients with MRCT clinically. To date, only few previous studies have investigated the effects of functional training of deltoids on improving pain and shoulder functions in patients with MRCT. Based on the observational studies of movements and muscle activities for a group of asymptomatic MRCT adults, it is hypothesized that to emphasize the shoulder adductors/internal rotators as humeral head depressors, and facilitate scapular upward rotation and posterior tipping might develop a better compensatory strategy for increasing subacromion space and reducing impingement, and thereby improve pain and functions in patients with MRCT.
Purpose: To investigate the effects of a 6-week scapular control exercise program focusing on developing compensatory strategies in patient with MRCT.
Methods: 36 subjects with MRCT were assigned to the SCE group (n=18) and TE group (n=18). The SCE group received a 6-week intervention focusing on scapular compensatory training for upward rotation and posterior tipping, while the TE group received a traditional exercise (training. Pain status (Visual Analog Scale, functions (Shoulder Pain and Disability Index), shoulder range of motion, shoulder and scapular strength, scapular kinematics and muscle activities during shoulder scaption were measured before and after completing the 6-week intervention.
Results: After completing the 6-week training, the SCE group showed significant improvement in motion pain and functions, but no changes for the TE group. The SCE group had significant strength increases in all shoulder and scapular muscles except for upper trapezius. The TE group only showed significant improvement in deltoid, latissimus dosi, external rotators and upper trapezius. Furthermore, increased scapular upward rotation and posterior tipping, along with increased muscle activations of shoulder adductors/internal rotators, serratus anterior and lower trapezius, were also observed during arm elevation and lowering in the SCE group, but no differences for the TE group.
Discussion: Patients with MRCT not only lose the functions of humeral head depressors and stabilizers, but also often have the problem of scapular dyskinesia, that may all contribute to pain and disability. The current results demonstrated that the 6-week SCE training could improve shoulder pain and functions in the patients with MRCT. A greater scapular posterior tipping and upward rotation found during arm elevation and lowering may contribute to increasing the acromiohumeral distance and reducing the occurrence of impingement.
Conclusion: The findings of this study support the use of the SCE training is an effective conservative intervention for establishing the compensatory strategies of shoulder movements and regaining functions in the patients with MRCT.

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