臺灣博碩士論文加值系統

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

References:
1.Ahmed S., Snelling A., Bains M., ＆ Whitworth I.H. Breast reconstruction. BMJ, 330(7497),943-948, 2005.
2.Ainscough-Potts, A.M., Morrissey, M.C., Critchley, D. The response of the transverse abdominis and internal oblique muscles to different postures. Man Ther, 11(1),54-60, 2006.
3.Alderman, A. K., Kuzon, W. M., Jr., ＆ Wilkins, E. G. A two-year prospective analysis of trunk function in TRAM breast reconstructions. [Clinical Trial Comparative Study Multicenter Study]. Plast Reconstr Surg, 117(7), 2131-2138, 2006.
4.Al-Ghazal S.K., Fallowfield L., ＆ Blamey R.W. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer,36(15),1938-1943, 2000.
5.Al-Ghazal S.K., Sully L., Fallowfield L. ＆Blamey R.W. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol,26(1),17-19, 2000.
6.Aruin, A.S., Latash, M.L. Directional specificity of postural muscles in feed-forward postural reactions during fast voluntary arm movements. Exp Brain Re, 103(2), 323-332,1995.
7.Ascherman J.A., Seruya M., ＆ Bartsich, S.A. Abdominal wall morbidity following unilateral and bilateral breast reconstruction with pedicled TRAM flaps: an outcomes analysis of 117 consecutive patients. Plast Reconstr Surg,121(1),1-8, 2008.
8.Atisha D., ＆ Alderman A.K. A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction. Ann Plast Surg,63(2),222-230, 2009.
9.Benditte-Klepetko H., Sommer O., Steinbach R., Czembirek H. ＆ Deutinger M. Clinical and ultrasound evaluation of donor site morbidity after tram-flap for breast reconstruction. Microsurgery,24(3),174-181, 2004.
10.Bergmark, A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl, 230:1-54, 1989.
11.Biering-Sorensen, F. Physical measurements as risk indicators for low back trouble over a one year period. Spine, 9, 106-119, 1984.
12.Blondeel, N., Boeckx, W. D., Vanderstraeten, G. G., Lysens, R., Van Landuyt, K., Tonnard, P., . . . Matton, G. The fate of the oblique abdominal muscles after free TRAM flap surgery. Br J Plast Surg, 50(5), 315-321, 1997.
13.Borghuis, J., Hof, A.L., Lemmink, K.A. The importance of sensory-motor control in providing core stability: implications for measurement and training. Sports Med, 38(11):893-916, 2008.
14.Bottero L., Lefaucheur J.P., Fadhul S., Raulo Y., Collins E.D.＆ Lantieri L.
Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg, 113(1),156-161, 2004.
15.Bouisset, S. Zattara, M. Biomechanical study of the programming of anticipatory postural adjustments associated with voluntary movement. J Biomech, 20:735-742, 1987.
16.Bouisset, S., Do, M.C. Posture, dynamic stability, and voluntary movement. Neurophysiol Clin, 38(6):345-362, 2008.
17.Brown S.H. ＆ McGill S.M. An ultrasound investigation into the morphology of the human abdominal wall uncovers complex deformation patterns
during contraction. Eur J Appl Physiol, 104(6),1021-1030, 2008.
18.Bunce, S.M., Moore, A.P., Hough, A.D. M-mode ultrasound: a reliable measure of transverse abdominis thickness? Clin Biomech, 17:315–317, 2002
19.Chanaud, C.M., Macpherson, J.M. Functionally complex muscles of the cat hindlimb. III. Differential activation within biceps femoris during postural perturbation. Exp Brain Res 85:271–280, 1991.
20.Chen, C.L., Lee, J.Y., Horng, R.F., Lou, S.Z., Su, F.C. Development of a three-degrees-of-freedom moveable platform for providing postural perturbations. Proc Inst Mech Eng H, 223(1):87-97, 2009.
21.Chen, L. M., Bih, L. L., Ho, C. C., Hung, M. H., Chen, C. T., ＆ Wei, T. S. Endurance times for trunk-stabilization exercises in healthy women: comparing 3 kinds of trynk-flexor exercises. J Sport Rehabil, 12, 199-207, 2003.
22.Cholewicki, J., ＆ McGill, S.M. Mechanical stability of the in vivo lumbar spine: implications for injury and chronic low back pain. Clin Biomech (Bristol, Avon), 11(1):1-15, 1996.
23.Cairns, M.C., Harrison, K. Wright, C. Pressure biofeedback: a useful tool in the quatification of abdominal muscular dysfunction ? Physiotherapy, 86(3), 127-138, 2000.
24.Comerford, M., ＆ Mottram, S. (eds.). Kinetic Control-The Management of Uncontrolled Movement. London: Churchill Livingstone, 2012.
25.Cram, J.R., Kasman, G.S., ＆ Holtz J. (1998). Introduction to Surface Electromyography. Gaithersburg: Aspen Publishers , Maryland, USA.
26.Cresswell, A. G., Grundstrom, H., ＆ Thorstensson, A. Observations on intra-abdominal pressure and patterns of abdominal intra-muscular activity in man. Acta Physiol. Scand. 144: 409- 418, 1992.
27.Cresswell, A. G., Oddsson, L. ＆Thorstensson, A. The influence of sudden perturbations on trunk muscle activity and intra-abdominal pressure while standing. Exp. Brain Res. 98: 336–341, 1994.
28.Crisco, J.J., ＆ Panjabi, M.M. Euler stability of the human ligamentous lumbar spine. Part I: Theory. Clin Biomech, 7, 19-26,1992.
29.Cyriac, C., Sharma, R. K., ＆ Singh, G. Assessment of the abdominal wall function after pedicled TRAM flap surgery for breast reconstruction: Use of modified mesh repair for the donor defect. Indian J Plast Surg, 43(2), 166-172, 2010.
30.Dean, C.M., ＆ Shepherd, R.B. Task-related training improves performance of seated reaching tasks after stroke. A randomized controlled trial. Stroke, 28(4):722-728, 1997.
31.de Paula Lima, P. O., de Oliveira, R. R., de Moura Filho, A. G., Raposo, M. C., Costa, L. O., ＆ Laurentino, G. E. Reproducibility of the pressure biofeedback unit in measuring transversus abdominis muscle activity in patients with chronic nonspecific low back pain. J Bodyw Mov Ther, 26(2), 251-257, 2012.
32.Demoulin, C., Vanderthommen, M., Duysens, C., ＆ Crielaard, J. M. Spinal muscle evaluation using the Sorensen test: a critical appraisal of the literature. Joint Bone Spine, 73(1), 43-50, 2006.
33.Department of Health. Annual Report of Cancer Registry, Taipei: Department of Health, Executive Yuan 2010 (in Chinese), 2008.
34.Dickstein, R., Shefi, S., Marcovitz, E., ＆ Villa, Y. Electromyographic activity of voluntarily activated trunk flexor and extensor muscles in post-stroke hemiparetic subjects. Clinical Neurophysiology, 115(4), 790-796, 2004.
35.DiGiovine, N., Jobe, F., Pink, P., Perry, J. An electro¬myographic analysis of the upper extremity in pitching. J Shoulder and Elbow Surg. 1,15-25, 1992.
36.Dulin, W. A., Avila, R. A., Verheyden, C. N., ＆ Grossman, L. Evaluation of Abdominal Wall Strength after TRAM Flap Surgery. Plastic and Reconstructive Surgery, 113(6), 1662-1665, 2004.
37.Edsander-Nord, A., Jurell, G., ＆ Wickman, M. Donor-site morbidity after pedicled or free TRAM flap surgery: a prospective and objective study. Plast Reconstr Surg, 102(5), 1508-1516, 1998.
38.Ekstrom, R.A., Donatelli, R.A., Carp, K.C. Electromyo¬graphic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. J Or¬thop Sports Phys Ther, 37:754-762, 2007.
39.Fleckenstein J.L., Watumull D., Conner K.E., Ezaki M., Greenlee R.G. Jr, Bryan
W.W., Chason D.P., Parkey R.W., Peshock R.M. ＆ Purdy P.D. Denervated
human skeletal muscle: MR imaging evaluation. Radiology,187(1),213-218, 1993.
40.Fleiss J.L. Reliability of measurement. In: Fleoss JL, ed. The design and
analysis of clinical experiments. New York: Wiley,1-45, 1986.
41.Friedli, W.G., Cohen, L., Hallett, M., Stanhope, S., Simon, S.R. Postural adjustments associated with rapid voluntary arm movements. II. Biomechanical analysis. J Neurol Neurosurg Psychiatry, 51(2):232-243, 1988.
42.Gardner-Morse, M.G., ＆ Stokes, I.A. The effects of abdominal muscle coactivation on lumbar spine stability. Spine, 23(1):86-91; discussion -2, 1998.
43.Gilleard, W. L., ＆ Brown, J. M. An electromyographic validation of an abdominal muscle test. Arch Phys Med Rehabil, 75(9), 1002-1007, 1994.
44.Gilleard, W. L., ＆ Brown, J. M. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Phys Ther, 76(7), 750-762, 1996.
45.Goel, V.K., Kong, W., Han, J.S., Weinstein, J.N., ＆ Gilbertson, L.G. A combined finite element and optimization investigation of lumbar spine mechanics with and without muscles. Spine, 18(11):1531-1541, 1993.
46.Grotting J.C., Beckenstein M.S., ＆ Arkoulakis N.S. The art and science of autologous breast reconstruction. Breast J,9(5),350-360, 2003.
47.Hagins, M., Adler, K., Cash, M., Daugherty, J., ＆ Mitrani, G. Effects of practice on the ability to perform lumbar stabilization exercises. J Orthop Sports Phys Ther, 29(9), 546-555, 1999.
48.Hartrampf C.R., Scheflan M. ＆ Black P.W. Breast reconstruction with a transverse
abdominal island flap. Plast Reconstr Surg,69(2),216-225, 1982.
49.Hislop H.J. ＆ Montgomery J. Testing the Muscles of the Trunk. Daniels and
Worthingham's Muscle Testing:Techniques of Manual Examination. 8 th ed. St.
Louis: WB Saunders,44-47, 2007.
50.Hodges, P.W., ＆ Richardson, C.A. Relationship between limb movement speed and associated contraction of the trunk muscles. Ergonomics, 40(11):1220-30, 1997a.
51.Hodges, P.W., ＆ Richardson, C.A. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther, 77(2):132-42; discussion 42-44, 1997b.
52.Hodges P.W., Gandevia S.C., Richardson C.A. Contractions of specific abdominal muscles in postural tasks are affected by respiratory maneuvers. J Appl Physiol, 83(3):753-60, 1997c.
53.Hodges, P.W. Is there a role for transversus abdominis in lumbo-pelvic stability? Man Ther, 4(2):74-86, 1999a.
54.Hodges, P.W., Richardson, C.A. Transversus abdominis and the superficial abdominal muscles are controlled independently in a postural task. Neurosci Lett, 16;265(2):91-94, 1999b.
55.Hodges, P., Cresswell, A., ＆ Thorstensson, A. Preparatory trunk motion accompanies
rapid upper limb movement. Exp Brain Res, 124(1),69-79, 1999c.
56.Hodges P., Pengel L., Herbert R. ＆ Gandevia S.C. Measurement of muscle
contraction with ultrasound imaging. Muscle Nerve,27, 682–692, 2003.
57.Hodges, P.W., Pengel, L.H.M., Herbert, R.D., Gandevia, S.C. Measurement
of muscle contraction with ultrasound imaging. Muscle Nerve, 2003;27:682–692, 2003.
58.Hodges, P.W., Cresswell, A.G., Thorstensson, A. Intra-abdominal pressure response to multidirectional support-surface translation. Gait Posture, 20(2):163-170.
59.Horak, F.B., ＆ Nashner, L.M. (1986). Central programming of postural movements: adaptation to altered support-surface configurations. J Neurophysiol, 55(6):1369-1381, 2004.
60.Hsu, A. T., Lorant, J., Baker, L., Brodke, D., Johnson, J., ＆ Woo, F. Trunk function in rectus abdominis myocutaneous flap patients. JPTA ROC, 21(1), 20-32, 1996.
61.Huang C.S., Lin C.H., Lu Y.S. ＆ Shen C.Y. Unique features of breast cancer in
Asian women--breast cancer in Taiwan as an example. J Steroid Biochem Mol
Biol, 118(4-5),300-303, 2010.
62.Hughey, LK., Fung, J. Postural responses triggered by multidirectional leg lifts and surface tilts. Exp Brain Res,165(2):152-166, 2005.
63.Image J. Processing and Anlysis in Java. http:// rsb.info.nih.gov/nih-image/.
Accessed March 1, 2010.
64.Ito, T., Shirado, O., Suzuki, H., Takahashi, M., Kaneda, K., ＆ Strax, T. E. Lumbar trunk muscle endurance testing: an inexpensive alternative to a machine for evaluation. Arch Phys Med Rehabil, 77(1), 75-79, 1996.
65.Jones G. The pedicled TRAM flap in breast reconstruction. Clin Plast Surg., 34(1),
83-104, 2007.
66.Jorgensen, K., ＆ Nicolaisen, T. Trunk extensor endurance: Determination and relation to low-back trouble. Ergonomics, 30, 259-267, 1987.
67.Kamangar, F., Dores, G.M., ＆ Anderson W.F. Patterns of cancer incidence, mortality,
and prevalence across five continents:defining priorities to reduce cancer disparities
in different geographic regions of the world. J Clin Oncol, 24(14), 2137-2150, 2006.
68.Kibler, W.B., Press, J., ＆ Sciascia, A. The role of core stability in athletic function. Sports Med, 36(3):189-198, 2006.
69.Kind, G. M., Rademaker, A. W., ＆ Mustoe, T. A. Abdominal-wall recovery following TRAM flap: a functional outcome study. Plast Reconstr Surg, 99(2), 417-428, 1997.
70.Kroll, S. S., Schusterman, M. A., Reece, G. P., Miller, M. J., Robb, G., ＆ Evans, G. Abdominal wall strength, bulging, and hernia after TRAM flap breast reconstruction. Plast Reconstr Surg, 96(3), 616-619, 1995.
71.Koppenhaver S.L., Hebert J.J., Parent E.C. ＆ Fritz J.M. Rehabilitative ultrasound imaging is a valid measure of trunk muscle size and activation during most isometric sub-maximal contractions: a systematic review. Aust J Physiother,55(3),153-169, 2009.
72.Lee, D. ＆ Hodges, P. The Pelvic Girdle : An Approach to the Examination and Treatment of the Lumbopelvic-Hip Region. 3rd ed. Edinburgh: Churchill Livingstone, 2004.
73.Lejour, M., ＆ Dome, M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg, 87(6), 1054-1068, 1991.
74.Liemohn, W.P., Baumgartner, T.A., ＆ Gagnon, L.H. Measuring core stability. J Strength Cond Res, 19(3):583-586, 2005.
75.Malliou, P., Gioftsidou, A., Beneka, A., ＆ Godolias, G. Measurements and evaluations in low back pain patients. Scand J Med Sci Sports, 16(4), 219-230, 2006.
76.Marshall, P., Murphy, B. The validity and reliability of surface EMG to assess the neuromuscular response of the abdominal muscles to rapid limb movement. J Electromyogr Kinesiol, 13(5):477-489, 2003.
77.McComas A.J. Skeletal Muscle: Form and Function. Champaign: Human Kinetics,
1996.
78.McGill, S.M., Sharratt, M.T. Relationship between intra-abdominal pressure and trunk EMG. Clin Biomech, 5:59–67, 1990.
79.McGill, S.M., Norman, R.W. Low back biomechanics in industry: the prevention of
injury through safer lifting. In: Grabiner MD (ed) Current issues in biomechanics. Human Kinetics Publishers, Champaign, IL, pp 69–120, 1993.
80.McGill, S., Juker, D., ＆ Kropf, P. Appropriately placed surface EMG electrodes reflect deep muscle activity (psoas, quadratus lumborum, abdominal wall) in the lumbar spine. J Biomech, 29(11):1503-7, 1996.
81.McMeeken J., Beith I., Newham D., Milligan P. ＆ Critchley D. The relationship
between EMG and change in thickness of transversus abdominis. Clin Biomech. ,19,
337–342. 2004.
82.Mirka, G.A. The quantification of EMG normalization error. Ergonomics. 34(3), 343-352, 1991.
83.Mizgala, C. L., Hartrampf, C. R., Jr., ＆ Bennett, G. K. Assessment of the abdominal wall after pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecutive patients. Plast Reconstr Surg, 93(5), 988-1002; discussion 1003-1004, 1994.
84.Moffroid, M. T. Endurance of trunk muscles in persons with chronic low back pain: assessment, performance, training. J Rehabil Res Dev, 34(4), 440-447, 1997.
85.Moreland, J., Finch, E., Stratford, P., Balsor, B., ＆ Gill, C. Interrater reliability of six tests of trunk muscle function and endurance. J Orthop Sports Phys Ther, 26(4), 200-208, 1997.
86.Momeni A., Kim R.Y., Heier M., Bannasch H., Stark G.B. Abdominal Wall
Strength: A Matched-Pair Analysis Comparing Muscle-Sparing TRAM Flap
Donor-Site Morbidity with the Effects of Abdominoplasty. Plastic and Reconstructive
Surgery,126(5),1454-1459, 2010.
87.Monteiro M.E. Physical Therapy Implications Following the TRAM Procedure. Phys Ther,77,765-770, 1997.
88.Moseley, G.L., Hodges, P.W., Gandevia, S.C. Deep and superficial fibers of
the lumbar multifidus muscle are differentially active during voluntary arm
movements. Spine, 27, E29–36, 2002.
89.Moseley, G.L., Hodges, P.W., Gandevia, S.C. External perturbation of the trunk in
standing humans differentially activates components of the medial back muscles. J Physiol, 547, 581–7, 2003.
90.Moseley, G.L, Nicholas, M.K., Hodges, P.W. Does anticipation of back pain predispose to back trouble? Brain,127:2339–2347, 2004.
91.Nahabedian M.Y., Dooley W., Singh N., ＆ Manson P.N. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg,109(1),91-101, 2002.
92.Ng, J.K., Kippers, V., ＆ Richardson, C.A. Muscle fibre orientation of abdominal muscles and suggested surface EMG electrode positions. Electromyogr Clin Neurophysiol, 38(1):51-8, 1998.
93.O'Sullivan, P. B., Mitchell, T., Bulich, P., Waller, R., ＆ Holte, J. The relationship beween posture and back muscle endurance in industrial workers with flexion-related low back pain. Man Ther, 11(4), 264-271, 2006.
94.Parnianpour, M., Nordin, M., Kahanovitz, N., ＆ Frankel, V. 1988 Volvo award in biomechanics. The triaxial coupling of torque generation of trunk muscles during isometric exertions and the effect of fatiguing isoinertial movements on the motor output and movement patterns. Spine (Phila Pa 1976), 13(9), 982-992, 1988.
95.Petit, J. Y., Rietjens, M., Ferreira, M. A., Montrucoli, D., Lifrange, E., ＆ Martinelli, P. Abdominal sequelae after pedicled TRAM flap breast reconstruction. Plast Reconstr Surg, 99(3), 723-729, 1997.
96.Preuss, R., Fung, J. Musculature and biomechanics of the trunk in the maintenance of upright posture. J Electromyogr Kinesiol, 18(5):815-828, 2008.
97.Pope M.H., ＆ Panjabi M. Biomechanical definitions of spinal instability. Spine, 10(3),
255-256, 1985.
98.Radebold, A., Cholewicki, J., Panjabi, M.M., ＆ Patel, T.C. Muscle response pattern to sudden trunk loading in healthy individuals and in patients with chronic low back pain. Spine, 15;25(8):947-954, 2000.
99.Ramprasad, M., Shweta, S.D., Jaspal, S.S., Sankara, N., Joseley, S.R.P. The magnitude of pre-programmed reaction dysfunction in back pain patients - experimental pilot electromyography study. Journal of Back and Musculoskeletal Rehabilitation 23 (2), 77-86, 2010.
100.Richardson, C., ＆ Jull, G. Muscle control- pain control. What exercises would you prescribe? Manual Therapy, 1, 2-10, 1995.
101.Richardson, C., Jull, G., Hodges, P., ＆ Hides, J. Back pain and lumbopelvic stabilization: the case for the local muscle system. In C. Richardson, G. Jull, P. Hodges ＆ J. A. Hides (eds.), Therapeutic exercise for spinal segmental stabilization in low back pain: scientific basis and clinical approach (pp. 11-40). London, UK: Churchill Livingstone, 1999.
102.Richardson, C.A., Snijders, C.J., Hides, J.A., Damen, L., Pas, M.S., ＆ Storm, J. The relation between the transversus abdominis muscles, sacro-iliac joint mechanisms,
and low back pain. Spine, 27(4), 399–405, 2002.
103.Reeves, N.P., Everding, V.Q., Cholewicki, J., Morrisette, D.C. The effects of trunk stiffness on postural control during unstable seated balance. Exp Brain Res, 174(4), 694-700, 2006.
104.Richardson, C., Hodges, P.W., ＆ Hides, J. Therapeutic exercise for lumbopelvic stabilization: a motor control approach for the treatment and prevention of low back pain. 2nd ed. Edinburgh ;New York Churchill Livingstone, 2004.
105.SEER (Surveillance Epidemiology and End Results). SEER Stat Fact Sheets.
http://seer.cancer.gov/statfacts/html/breast.html. Accessed November 24, 2011.
106.Serletti J.M. Breast reconstruction with the TRAM flap: Pedicled and free.
Journal of Surgical Oncology,94(6),532-537, 2006.
107.Shen Y.C., Chang C.J., Hsu C., Cheng C.C., Chiu C.F., ＆ Cheng A.L. Significant
difference in the trends of female breast cancer incidence between Taiwanese and Caucasian Americans: implications from age-period-cohort analysis. Cancer Epidemiol Biomarkers Prev,14(8),1986-1990, 2005.
108.Shumway-Cook, A., ＆ Woollacott, M. Motor Control: Theory and practical applications. 3rd ed. Baltimore: Lippincott Williams ＆ Wilkins, 2007.
109.Simon, A. M., Bouwense, C. L., McMillan, S., Lamb, S., ＆ Hammond, D. C. Comparison of unipedicled and bipedicled TRAM flap breast reconstructions: assessment of physical function and patient satisfaction. Plast Reconstr Surg, 113(1), 136-140, 2004.
110.Smidt N, van der Windt DA, Assendelft W.J., Mourits A.J., Devillé W.L., de Winter
A.F. ＆ Bouter L.M. Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis.Arch Phys Med Rehabil,83(8),1145-1150, 2002.
111.Storheim, K., Bø, K., Pederstad, O., ＆ Jahnsen, R. Intra-tester reproducibility of pressure biofeedback in measurement of transversus abdominis function. Physiother Res Int, 7(4), 239-249, 2002.
112.Stokes, I.A., Gardner-Morse, M., Henry, S.M., Badger, G.J. Decrease in trunk uscular response to perturbation with preactivation of lumbar spinal musculature. Spine, 25:1957–1964, 2000.
113.Strobel K., Hodler J., Meyer D.C., Pfirrmann C.W., Pirkl C.＆ Zanetti M. Fatty
atrophy of supraspinatus and infraspinatus muscles: accuracy of US. Radiology,
237(2),584-589, 2005.
114.Suominen S., Asko-Seljavaara S., von Smitten K., Ahovuo J., Sainio P. ＆ Alaranta
H. Sequelae in the abdominal wall after pedicled or free TRAM flap surgery. Ann Plast Surg,36(6),629-636, 1996.
115.Suominen S., Asko-Seljavaara S., Kinnunen J., Sainio P. ＆ Alaranta H. flap harvest:
Abdominal wall competence after free transverse rectus abdominis musculocutaneous a prospective study. Ann Plast Surg,39(3),229-234, 1997.
116.Teyhen D. Rehabilitative Ultrasound Imaging Symposium San Antonio, TX, J Orthop
Sports Phys Ther, 36(8), A1-3, 2006.
117.Teyhen D.S., Gill N.W., Whittaker J.L., Henry S.M., Hides J.A. ＆ Hodges P.
Rehabilitative ultrasound imaging of the abdominal muscles. J Orthop Sports Phys
Ther,37(8),450-466, 2007.
118.Tonseth K.A., Gunther A., Brabrand K., Fogdestam I. ＆ Hokland B.M.
Ultrasonographic evaluation of the rectus abdominis muscle after breast reconstruction with the DIEP flap. Ann Plast Surg, 54(5),483-486, 2005.
119.Urquhart, D.M., Barker, P.J., Hodges, P.W., Story, I.H., Briggs, C.A. Regional morphology of the transversus abdominis and obliquus internus and externus
abdominis muscles. Clin Biomech, 20: 233–241, 2005.
120.Whittaker J.L., Teyhen D.S., Elliott J.M., Cook K., Langevin H.M., Dahl H.H. ＆ Stokes M. Rehabilitative ultrasound imaging: understanding the technology and its applications. J Orthop Sports Phys Ther,37(8),434-449, 2007.
121.Whittaker J.L.＆ Stokes M. Ultrasound imaging and muscle function. J Orthop
Sports Phys Ther,41(8),572-580, 2011.
122.Wohlfahrt, D., Jull, G., ＆ Richardson, C. The relationship between the dyanmic and static function of abdominal muscles. Aust J Physiother, 39, 9-13, 1993.
123.WHO (World Health Organization) 2010. Breast cancer: prevention and control.
http://www.who.int/cancer/detection/breastcancer/en/print.html. Accessed December 1, 2011.
124.Willson J.D., Dougherty C.P., Ireland M.L. ＆ Davis I.M. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg, 13(5),316-325, 2005.
125.Winter, D.A., ＆ Patla, A.E. Signal processing and linear systems for the movement science. University of Waterloo, Canada, Waterloo Biomechanics, pp:45-59, 1997.
126.廖麗君, 吳汶蘭, ＆ 郭藍遠. 以兩個下肢負重測試測量健康女性腹部肌群之穩定能力. 物理治療, 37(4), 297-308, 2012.