臺灣博碩士論文加值系統

背景及目的：中風病人之步態問題長久以來為許多研究所探討。步行能力的缺陷導因於中風後之機能損傷，如：下肢之肌力不足、痙攣、肢體延展性受限與感覺受損等。中風後遠端肢體恢復的程度通常會比近端慢，故於踝關節周圍之肌力不足、蹠屈肌痙攣、蹠屈肌的延展性不足或踝關節的本體感覺及壓覺受損都可能是中風病人形成不良步態之主因。但過去少有研究探討踝關節損傷對中風病患步態的影響。因此本研究之目的即在探討中風病人踝關節之機能損傷對於其步態的影響，並找出影響步行速度及不對稱性之最重要的踝關節機能損傷。
方法：本研究為一截斷式實驗，總計有68位中風病人參與本實驗。步態評估項目包括在「自選速度」及「最快速度」行走下之步行速度、步長不對稱比例、單腳站立時間不對稱比例及其他步態參數。踝關節機能損傷包括：（1）蹠屈肌、背屈肌之最大等長肌力；（2）蹠屈肌於自選速度及最快速度行走下之痙攣指數；（3）蹠屈肌於安靜時之痙攣指數；（4）蹠屈肌被動受限程度；（5）踝關節本體感覺；及（6）踝關節壓力感覺。研究結果以逐步回歸分析找出影響步態表現的最重要因子以及利用皮爾森相關係數（針對連續變項）或史皮爾曼相關係數（針對非連續變項）探討踝關節機能損傷與步態之相關性。
結果：研究結果背屈肌之肌力不足為造成中風病患步行速度變慢及單腳站立時間不對稱之最主要因素。蹠屈肌於行走時之痙攣指數則為中風病患步行長度不對稱之最重要因素。
討論：背屈肌之肌力不足造成中風病患無法有效地將患側腳抬離地面進而延長擺盪週期的時間。擺盪週期時間的延長造成步行速度變慢以及時間上的不對稱步態。患側單腳站立時期所產生的動態痙攣可能造成患肢無法有效地載重，進而影響對側下肢無法跨出足夠長的步伐。
結論：本研究結果指出背屈肌之肌力不足及行走時產生的動態痙攣為影響中風病患步行速度及對稱性之重要因素。這將有助於臨床物理治療師判斷何種踝關節損傷會影響中風病患之步行問題，進而規劃有效的治療計畫。

Background: A common consequence of stroke is impaired gait due to lesions in the central nervous system that affected motor and sensory aspects of movement control. Ankle impairments such as muscle weakness, spasticity, passive stiffness, impaired proprioception and pressure sense have been observed in people with stroke. However, few studies investigated their roles on hemiparetic gait.
Objective: To identify the most important ankle impairments determining gait velocity and asymmetry at both comfortable and fast walking conditions in patients with stroke.
Design: A cross sectional study.
Setting: Patients from outpatient rehabilitation and neurovascular neurology departments in medical centers and municipal hospitals in Taipei area.
Participants: Sixty-eight subjects with hemiparesis post stroke with ability to walk independently.
Measurements: Maximal isometric strength of plantarflexors and dorsiflexors were examined by Hand-held dynamometer. Resting spasticity of plantarflexors was rated by Modified Ashworth scale. Spasticity index, magnitude of relationships between EMG activity and muscle lengthening velocity of gastrocnemius during lengthening period of stance phases, was measured to represent the dynamic spasticity. Passive stiffness of pantarflexors was indicated by the differences of passive range of motion of dorsiflexion between normal and subjects’ value. Joint position sense was assessed as the proprioception of ankle joint. Gait velocity, as well as other gait parameters, were measured by GAIRite system at comfortable and fast walking speed.
Results: Gait velocities were 64.58 cm/s and 89.55 cm/s for comfortable and fast walking conditions in our subjects. Regression analyses revealed that the dorsiflexors strength was the most important factor for gait velocity and temporal asymmetry. Dynamic spasticity was the most important determinant for spatial gait asymmetry.
Discussion: The impaired dorsiflexion control resulted from weakness of dorsiflexors may cause increased swing time of affected side and therefore affected gait velocity and temporal asymmetry in our subjects. Dynamic spasticity of plantarflexors induced at stance phase of affected leg disturbed normal step length of unaffected leg and thus cause a spatial asymmetrical gait.
Conclusion: Gait velocity and temporal asymmetry are mainly affected by the dorsiflexors strength, whereas dynamic spasticity of plantarflexors influences the degree of spatial gait asymmetry in our patients who were able to walk outdoors. Treatment programs aiming to improve different aspects of gait performance should be emphasized on different ankle impairments.

1. 行政院衛生署. 92年 臺 灣 地 區 主 要 死 因 分 析. http://www.doh.gov.tw/statistic . 2004.
2. Fried LP, Ettinger WH, Lind B, Newman AB, Gardin J. Physical disability in older adults: a physiological approach. Cardiovascular Health Study Research Group. J Clin Epidemiol 1994;47:747-60.
3. Hu HH, Sheng WY, Chu FL, Lan CF, Chiang BN. Incidence of stroke in Taiwan. Stroke 1992;23:1237-41.
4. Williams GR. Incidence and characteristics of total stroke in the United States. BMC Neurol 2001;1:2.
5. Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bull LM et al. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004;363:1925-33.
6. Mayo NE. Hospitalization and case-fatality rates for stroke in Canada from 1982 through 1991. The Canadian collaborative study group of stroke hospitalizations. Stroke 1996;27:1215-20.
7. Mayo NE, Wood-Dauphinee S, Ahmed S, Gordon C, Higgins J, McEwen S et al. Disablement following stroke. Disabil Rehabil 1999;21:258-68.
8. Mayo NE, Korner-Bitensky NA, Becker R. Recovery time of independent function post-stroke. Am J Phys Med Rehabil 1991;70:5-12.
9. Lord SE, McPherson K, McNaughton HK, Rochester L, Weatherall M. Community ambulation after stroke: how important and obtainable is it and what measures appear predictive? Arch Phys Med Rehabil 2004;85:234-9.
10. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Recovery of walking function in stroke patients: The Copenhagen Study. Arch Phys Med Rehabil 1995;76:27-32.
11. Wade DT, Wood VA, Heller A, Maggs J, Langton HR. Walking after stroke. Measurement and recovery over the first 3 months. Scand J Rehabil Med 1987;19:25-30.
12. Goldie PA, Matyas TA, Evans OM. Gait after stroke: initial deficit and changes in temporal patterns for each gait phase. Arch Phys Med Rehabil 2001;82:1057-65.
13. Ozgirgin N, Bolukbasi N, Beyazova M, Orkun S. Kinematic gait analysis in hemiplegic patients. Scand J Rehabil Med 1993;25:51-5.
14. Titianova EB, Tarkka IM. Asymmetry in walking performance and postural sway in patients with chronic unilateral cerebral infarction. J Rehabil Res Dev 1995;32:236-44.
15. Dewar ME, Judge G. Temporal asymmetry as a gait quality indicator. Biol Eng Comput 1980;18:689-93.
16. Berger W, Horstmann G, Dietz V. Tension development and muscle activation in the leg during gait in spastic hemiparesis: independence of muscle hypertonia and exaggerated stretch reflexes. J Neurol Neurosurg Psychiatry 1984;47:1029-33.
17. Bohannon RW, Larkin PA, Smith MB, Horton MG. Relationship between static muscle strength deficits and spasticity in stroke patients with hemiparesis. Phys Ther 1987;67:1068-71.
18. Bohannon RW. Gait performance of hemiparetic stroke patients: selected variables. Arch Phys Med Rehabil 1987;68:777-81.
19. Bohannon RW, Horton MG, Wikholm JB. Importance of four variables of walking to patients with stroke. Int J Rehabil Res 1991;14:246-50.
20. Nadeau S, Arsenault AB, Gravel D, Bourbonnais D. Analysis of the clinical factors determining natural and maximal gait speeds in adults with a stroke. Am J Phys Med Rehabil 1999;78:123-30.
21. Knutsson E. Gait control in hemiparesis. Scand J Rehabil Med 1981;13:101-8.
22. Knutsson E, Richards R. Different types of disturbed motor controlin gait of hemiparetic patients. Brain 1979;102:405-30.
23. Keenan MA, Perry J, Jordan C. Factors affecting balance and ambulation following stroke. Clin Orthop Relat Res 1984;165-71.
24. Suzuki K, Nakamura R, Yamada Y, Handa T. Determinants of maximum walking speed in hemiparetic stroke patients. Tohoku J Exp Med 1990;162:337-44.
25. Goldie PA, Matyas TA, Kinsella GJ, Galea MP, Evans OM, Bach TM. Prediction of gait velocity in ambulatory stroke patients during rehabilitation. Arch Phys Med Rehabil 1999;80:415-20.
26. Nadeau S, Gravel D, Arsenault AB, Bourbonnais D. Plantarflexor weakness as a limiting factor of gait speed in stroke subjects and the compensating role of hip flexors. Clin Biomech 1999;14:125-35.
27. Kim CM, Eng JJ. The relationship of lower-extremity muscle torque to locomotor performance in people with stroke. Phys Ther 2003;83:49-57.
28. Olney SJ, Griffin MP, McBride ID. Temporal, kinematic, and kinetic variables related to gait speed in subjects with hemiplegia: a regression approach. Phys Ther 1994;74:872-85.
29. Olney SJ, Griffin MP, Monga TN, McBride ID. Work and power in gait of stroke patients. Arch Phys Med Rehabil 1991;72:309-14.
30. Lamontagne A, Malouin F, Richards CL, Dumas F. Mechanisms of disturbed motor control in ankle weakness during gait after stroke. Gait Posture 2002;15:244-55.
31. Dietz V, Quintern J, Berger W. Electrophysiological studies of gait in spasticity and rigidity. Evidence that altered mechanical properties of muscle contribute to hypertonia. Brain 1981;104:431-49.
32. Richards CL, Malouin F, Dumas F, Wood-Dauphinee S. The relationship of gait speed to clinical measures of function and muscle activations during recovery post-stroke. Proceeding of NACOB 1992;2:299-302.
33. Yang JF, Fung J, Edamura M, Blunt R, Stein RB, Barbeau H. H-reflex modulation during walking in spastic paretic subjects. Can J Neurol Sci 1991;18:443-52.
34. Crenna P. Spasticity and 'spastic' gait in children with cerebral palsy. [Review] [65 refs]. Neurosci Biobehav Rev 1998;22:571-8.
35. Whittle MW. Gait Analysis: an introduction. Oxford: Butterworth-Heinemann, 2003.
36. Lamontagne A, Malouin F, Richards CL. Contribution of passive stiffness to ankle plantarflexor moment during gait after stroke. Arch Phys Med Rehabil 2000;81:351-8.
37. Thilmann AF, Fellows SJ, Ross HF. Biomechanical changes at the ankle joint after stroke. J Neurol Neurosurg Psychiatry 1991;54:134-9.
38. Hsu AL, Tang PF, Jan MH. Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke. Arch Phys Med Rehabil 2003;84:1185-93.
39. Lamontagne A, Malouin F, Richards CL. Locomotor-specific measure of spasticity of plantarflexor muscles after stroke. Arch Phys Med Rehabil 2001;82:1696-704.
40. Richards CL, Olney SJ. Hemiparetic gait following stroke. Part II: Recovery and physical therapy. Gait Posture 1996;4:149-62.
41. Turnbull GI, Charteris J, Wall JC. A comparison of the range of walking speeds between normal and hemiplegic subjects. Scand J Rehabil Med 1995;27:175-82.
42. von Schroeder HP, Coutts RD, Lyden PD, Billings E Jr, Nickel VL. Gait parameters following stroke: a practical assessment. J Rehabil Res Dev 1995;32:25-31.
43. Brandstater ME, de Bruin H, Gowland C, Clark BM. Hemiplegic gait: analysis of temporal variables. Arch Phys Med Rehabil 1983;64:583-7.
44. Brandstater ME, de BH, Gowland C, Clark BM. Hemiplegic gait: analysis of temporal variables. Arch Phys Med Rehabil 1983;64:583-7.
45. Peat M, Dubo HI, Winter DA, Quanbury AO, Steinke T, Grahame R. Electromyographic temporal analysis of gait: hemiplegic locomotion. Arch Phys Med Rehabil 1976;57:421-5.
46. Bohannon RW, Andrews AW. Rehabilitation goals of patients with hemiplegia. Int J Rehabil Res 1988;14:246-50.
47. Rose DJ, Gamble JG. Human Walking. Baltimore: Williamas & Wilkins, 1994.
48. Murray MP. Gait as a total pattern of movement. [Review] [123 refs]. Am J Phys Med Rehabil 1967;46:290-333.
49. Winter DA. Energy generation and absorption at the ankle and knee during fast, natural, and slow cadences. Clin Orthop Relat Res 1983;147-54.
50. Hesse S, Krajnik J, Luecke D, Jahnke MT, Gregoric M, Mauritz KH. Ankle muscle activity before and after botulinum toxin therapy for lower limb extensor spasticity in chronic hemiparetic patients. Stroke 1996;27:455-60.
51. Perry J, Waters RL, Perrin T. Electromyographic analysis of equinovarus following stroke. Clin Orthop Relat Res 1978;47-53.
52. Olney SJ, Richards C. Hemiparetic gait following stroke. Part I: Characteristics. Gait Posture 1996;4:136-48.
53. Dietz V, Berger W. Interlimb coordination of posture in patients with spastic paresis. Impaired function of spinal reflexes. Brain 1984;107:965-78.
54. Bourbonnais D, Vanden NS. Weakness in patients with hemiparesis. Am J Occup Ther 1989;43:313-9.
55. Rosenfalck A, Andreassen S. Impaired regulation of force and firing patter of single motor units in patients with spasticity. J Neurol Neurosurg Psychiatry 1980;43:907-16.
56. McComas AJ. Human neuromuscular adaptations that accompany changes in activity. Med Sci Sports Exerc 1994;26:1498-509.
57. McComas AJ, Sica RE, Upton AR, Aguilera N. Functional changes in motoneurones of hemiparetic patients. J Neurol Neurosurg Psychiatry 1973;36:183-93.
58. Bohannon RW. Strength of lower limb related to gait speed and cadence in stroke patients. Physiotherapy Canada 1986;38:204-6.
59. Nakamura R, Hosokawa T, Tsuji I. Relationship of muscle strength for knee extension to walking capacity in patients with spastic hemiparesis. Tohoku J Exp Med 1985;145:335-40.
60. Adams RW, Gandevia SC, Skuse NF. The distribution of muscle weakness in upper motoneuron lesions affecting the lower limb. Brain 1990;113:1459-76.
61. Nadeau S, Gravel D, Arsenault AB, Bourbonnais D, Goyette M. Dynamometric assessment of the plantarflexors in hemiparetic subjects: relations between muscular, gait and clinical parameters. Scand J Rehabil Med 1997;29:137-46.
62. Ada L, Vattanasilp W, O'Dwyer NJ, Crosbie J. Does spasticity contribute to walking dysfunction after stroke? J Neurol Neurosurg Psychiatry 1998;64:628-35.
63. Knutsson E, Martensson A. Dynamic motor capacity in spastic paresis and itsrelation to prime mover dysfunction, spastic reflexes and antagonist coactivation. Scan J Rehabil Med 1980;12:93-106.
64. Yang JF, Stein RB. Phase-dependent reflex reversal in human leg muscles during walking. J Neurophysiol 1990;63:1109-17.
65. Capaday C, Lavoie BA, Comeau F. Differential effects of a flexor nerve input on the human soleus H-reflex during standing versus walking. Can J Physiol Pharmacol 1995;73:436-49.
66. Lavoie BA, Devanne H, Capaday C. Differential control of reciprocal inhibition during walking versus postural and voluntary motor tasks in humans. J Neurophysiol 1997;78:429-38.
67. Sinkjaer T, Toft E, Hansen HJ. H-reflex modulation during gait in multiple sclerosis patients with spasticity. Acta Neurol Scand 1995;91:239-46.
68. Malouin F, Bonneau C, Pichard L, Corriveau D. Non-reflex mediated changes in plantarflexor muscles early after stroke. Scand J Rehabil Med 1997;29:147-53.
69. Chung SG, Van Rey E, Bai Z, Roth EJ, Zhang LQ. Biomechanic changes in passive properties of hemiplegic ankles with spastic hypertonia. Arch Phys Med Rehabil 2004;85:1638-46.
70. Singer BJ, Jegasothy GM, Singer KP, Allison GT. Evaluation of serial casting to correct equinovarus deformity of the ankle after acquired brain injury in adults. Arch Phys Med Rehabil 2003;84:483-91.
71. Gajdosik RL, Williams AK. Relation of maximal ankle dorsiflexion angle and passive resistive torque to passive-elastic stiffness of ankle dorsiflexion stretch. Percept Mot Skills 2002;95:323-5.
72. Keenan MA, Perry J, Jordan C. Factors affecting balance and ambulation following stroke. Clin Orthop Relat Res 1984;165-71.
73. Dettmann MA, Linder MT, Sepic SB. Relationships among walking performance, postural stability, and functional assessments of the hemiplegic patient. Am J Phys Med 1987;66:77-90.
74. Carey LM. Somatosensory loss after stroke. Crit Rev Phys Rehabil Med 1995;7:51-71.
75. Carey LM, Matyas TA, Oke LE. Sensory loss in stroke patients: effective training of tactile and proprioceptive discrimination. Arch Phys Med Rehabil 1993;74:602-11.
76. Tiderksaar R. Evaluation and management of gait disorders. New York: Marcel Dekker, 1995.
77. Woolley SM, Czaja SJ, Drury CG. An assessment of falls in elderly men and women. J Gerontol A Biol Sci Med Sci 1997;52:M80-M87.
78. Anacker SL, Di Fabio RP. Influence of sensory inputs on standing balance in community-dwelling elders with a recent history of falling. Phys Ther 1992;72:575-81.
79. O'Sullivan SB. Physical rehabilitation: assessment and treatment. Philadelphia: FA Davis, 1994.
80. McDonough AL, Batavia M, Chen FC, Kwon S, Ziai J. The validity and reliability of the GAITRite system's measurements: A preliminary evaluation. Arch Phys Med Rehabil 2001;82:419-25.
81. Bilney B, Morris M, Webster K. Concurrent related validity of the GAITRite walkway system for quantification of the spatial and temporal parameters of gait. Gait Posture 2003;17:68-74.
82. GAITRite operating manual. CIR system, Inc, 2001.
83. Livingston T, Bernardi D, Carroll M. PowerTrackII User's Manual. Salt Lake, USA: J Tech Medical Industries, 1997.
84. Bohannon RW, Andrews AW. Interrater reliability of hand-held dynamometry. Phys Ther 1987;67:931-3.
85. Andrews AW, Thomas MW, Bohannon RW. Normative values for isometric muscle force measurements obtained with hand-held dynamometers. Phys Ther 1996;76:248-59.
86. Perotto AO. Anatomical guide for the electromyographer: the limbs and trunk. New York: Springfield, 1994.
87. Biometrics Ltd goniometer and torsionmeter operating manual. Gwent,UK: Nine Mile Point Ind. Est., 2002.
88. Norkin C.C, White DJ. Measurement of joint motion. A guide to goniometry. Philadelphia: F.A. Davis company, 2003.
89. Winter DA., Scott SH. Technique for interpretation of electromyography for concentric and eccentric contractions in gait. J Electromyogr Kinesiol 1991;1:263-9.
90. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67:206-7.
91. Gregson JM, Leathley M, Moore AP, Sharma AK, Smith TL, Watkins CL. Reliability of the Tone Assessment Scale and the modified Ashworth scale as clinical tools for assessing poststroke spasticity. Arch Phys Med Rehabil 1999;80:1013-6.
92. Gajdosik RL, Vander Linden DW, Williams AK. Influence of age on length and passive elastic stiffness characteristics of the calf muscle-tendon unit of women. Phys Ther 1999;79:827-38.
93. Vandervoort AA, Chesworth BM, Cunningham DA, Paterson DH, Rechnitzer PA, Koval JJ. Age and sex effects on mobility of the human ankle. J Gerontol 1992;47:M17-M21.
94. Deshande N, Connelly DM, Culham EG, Costigan PA. Reliability and validity of ankle proprioceptive measures. Arch Phys Med Rehabil 2003;84:883-9.
95. Leiper CI, Craik RL. Relationships between physical activity and temporal-distance characteristics of walking in elderly women. Phys Ther 1991;71:791-803.
96. Perry J, Garrett M, Gronley JK, Mulroy SJ. Classification of walking handicap in the stroke population. Stroke 1995;26:982-9.
97. Winter DA, Patla AE, Frank JS. Assessment of balance control in humans. [Review] [60 refs]. Med Prog Tech 1990;16:31-51.
98. Wall JC, Turnbull GI. Gait asymmetries in residual hemiplegia. Arch Phys Med Rehabil 1986;67:550-3.
99. Wagenaar RC. Functional Recovery after Stroke. Amsterdam: VU University Press, 1990.
100. Moseley AM, Stark A, Cameron ID, Pollock A. Treadmill training and body weight support for walking after stroke. Stroke 2003;34:3006.
101. Carey LM, Oke LE, Matyas TA. Impaired limb position sense after stroke: a quantitative test for clinical use. [Review] [70 refs]. Arch Phys Med Rehabil 1996;77:1271-8