臺灣博碩士論文加值系統

背景：中風病患傾向增加使用中風後遺留的動作功能以完成動作任務中之活動要求。最常見的情形為在進行伸手取物時，使用過多的軀幹前屈代償動作。然而，代償動作容易造成病患出現疼痛、不適與關節攣縮等情形；更會阻礙正常的動作形式之復原。在中風後的上肢復健方面，目前已有大量的研究證實制動療法（亦稱為侷限誘發治療）能夠有效地改善上肢動作功能。但另有研究指出此療法可能造成病患較易使用代償動作以完成活動。本研究以運動學分析探討分散式侷限誘發治療合併軀幹侷限，對於中風病患上肢動作控制表現之影響。
方法：本研究採取隨機對照試驗之方法，由醫院之復健部門募集共18名慢性中風病患。參與者被隨機分派至分散式侷限誘發治療合併軀幹侷限組與分散式侷限誘發治療組。兩組皆接受由職能治療師所給予的等量治療介入，每天2小時，每週5天，共為期3週。在治療介入前後，利用運動學分析評估患側上肢之動作表現。
結果：合併治療組在治療後相較於分散式侷限誘發治療組有較大的手肘伸直角度，以及較小幅度的軀幹前屈代償動作。在執行雙手伸臂按鈴動作時，合併治療組同時也表現出較佳的上肢關節間協調度。在肩前屈角度與手臂-軀幹間協調的部分，兩組間則無顯著差異。
結論：相較於分散式侷限誘發治療，合併療法較可改善中風病患患側之上肢動作控制策略，使個案表現出較大的主動動作角度，與較少的軀幹前屈幅度。運用此合併療法能夠有效地增加上肢關節間協調，並同時減低中風病患之軀幹代償動作。

Background: After stroke, patients make increased use of the redundancy of motor system to acheive the goals of motor tasks. Trunk anterior displacement is a common compensatory movement used by stroke patients for arm transport during reaching. However, the presence of compensatory movements is associated with pain, discomfort, and joint contractures. It also limits recovery of “normal” motor pattern of the affected arm. Numerous studies have provided strong evidence that constraint-induced therapy (CIT), or distributed/modified CIT can improve the function of the affected hand. A previous study suggested that CIT may encourage patients to generate movement through synergy-dominated compensatory movement. The aim of this present study is to determine whether dCIT combined with trunk restraint lead to better motor control performance as reflected by kinematic variables.
Methods: We employed the randomized controlled design. 18 chronic stroke patients were recruited into this study from the rehabilitation departments of participating hospitals. Patients were individually randomized into the dCIT combined with trunk restraint (dCITRes) or the dCIT groups. Each patient received treatment of equal intensity for 2 hours on weekdays for 3 weeks under direct supervision of the occupational therapists. The kinematic analyses were administered before and after the 3-weeks intervention period.
Results: The dCITRes group showed a greater elbow extension and less trunk flexion than those in the dCIT group. Patients in the dCITRes group also showed a greater increase in
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interjoint coordination of reaching during bimanual task. There was no significant group difference in the normalized shoulder flexion angular change and arm-trunk coordination in this research.
Conclusions: This study provided evidences that there were greater improvements in motor control during reaching movement after dCIT combined with trunk restraint therapy than after dCIT. Patients who received this combined therapy exhibited more active range of motion of UE, less abnormal compensatory movement of trunk and better interjoint coordination than those receiving dCIT. Utilizing this combined therapy may be an effective approach for regaining interjoint coordination of the affected upper extremity and avoiding trunk compensation.

Table of Contents
學位考試審查表……………………………………………………………………………i
誌謝…………………………………………………………………………………………ii
中文摘要……………………………………………………………………………………iii
Abstract...................................................................................................................................v
Table of Contents………………………………………………..……………………..vii
List of Tables………………………...………………………………………………..……xi
List of Figures…………………………………………………………………....……..xii

CHAPTER 1
Literature Review
The Movement Patterns for Reaching in Stroke Survivors………..…………………1-1
The use of the trunk for reaching movement in stroke survivors…………………...1-1
Deficits in interjoint coordination of reaching in stroke population………………...1-2
Summary…………………………………………………………………………….1-2
The Applications of Trunk Restraint on Upper Extremity (UE) Rehabilitation after stroke……………………………………………………………………………….…….1-4
The effects of practice with trunk restraint…………….……………………………1-4
Effects of trunk restraint combined with upper-extremity training protocols…….....1-4
Summary……………………………………………………………………...……..1-6
Introduction of Constraint-Induced Therapy (CIT)………………………………..…1-7
Theory background………………………………………..…………..…………….1-7
Applications of CIT in stroke survivors………………………………………..…1-8
Different forms of constraint-induced therapy (CIT)………………………….…1-10
Summary………………………………………………………………….……..….1-11
References……………………………………………………………………………….....1-12

CHAPTER 2
A Kinematic Study of Distributed Constraint-Induced Therapy Combined with Trunk Restraint in Patients with Stroke
Introduction……..………………………………………………………………...……......2-1
Methods……………………………………..…………………………………………..…..2-4
Design…………………………………………………………………………...……..2-4
Participants……………………………………………………………………….….....2-4
Intervention………………………………………………………………….................2-5
Outcome Measures…………………………………………………………………..…2-6
Data Reduction for Kinematic Variables………………………………………………2-7
Data Analysis………………………………………………………………….…….…2-8
Results…………..………………………………………………………………………...…2-9
Characteristics of Participants……………………………………………………….…2-9
Kinematic Analysis…………………………….………………………………………2-9
Discussion………………….…………………………………………………………...….2-10
Conclusion…………….………………………………………………………………...…2-12
References……………………………………………………………………………….....2-13

CHAPTER 3
Effects of Distributed Constraint-Induced Therapy on Movement kinematics and Clinical Outcome in Patients with Stroke: a Randomized Controlled Trial
Introduction……………...………………………………………………………...……......3-1
Methods…………..……………………………………………………………………..…..3-5
Design…………………………………………………………………………...……..3-5
Participants……………………………………………………………………….….....3-5
Intervention………………………………………………………………….................3-6
Outcome Measures…………………………………………………………………..…3-7
Data Reduction for Kinematic Variables………………………………………………3-9
Data Analysis…………………………………………………………………….……3-11
Results………………………………………………………………………………….…3-12
Characteristics of Participants…………………………………………………..…….3-12
Post hoc analyses…………………………….……………….…………………….…3-13
Discussion…………………..…………………...…………………….………………...…3-15
Conclusion………………………………………………………………….…………...…3-19
References………………………………………………………………………………….3-20

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