臺灣博碩士論文加值系統

背景及目的：中風為一常見的中樞神經受損疾病，而多數中風病人都飽受上肢感覺動作功能受限所苦，進而導致日常生活功能受限。在眾多針對中風病人的療法中，利用機械手臂協助誘發動作，並透過反覆練習來協助個案恢復上肢功能是近年興起的治療手法。目前文獻中並無充足之證據顯示機械手臂療法比起傳統職能治療手法更能將治療成果轉移至一般生活功能表現上，因此本研究主旨為探討新型的機械手臂Armeo®Spring是否能比傳統職能治療手法更有效地改善個案上肢動作功能與動作品質，並能將治療成效轉移至日常生活功能表現中。
研究方法：本研究共招募14位中風個案作為研究對象，利用方便取樣的方法，受測者透過成功大學附設醫院復健部職能治療組轉介，分組方法為隨機分組，個案抽籤後後分配至兩組，其中9人為實驗組(機械手臂Armeo®Spring介入組)、9人為控制組(傳統職能治療介入)，每位個案每次介入一小時，一週二至三次，共計12次，並在介入前、介入後進行評估，評估內容有： Fugl-Meyer Motor Assessment score UE part、Barthel Index、Manual Ability Measure、上肢伸手取物(reaching)動作分析，其中動作分析所使用的參數有動作時間(movement time)、動作單位(movement unit)、運動軌跡平滑度(path ratio)、手臂-軀幹協調性(Arm-Trunk coordination)等，並且共施測九個個位置，水平以身體中線、左右肩峰為水平三個位置，高度則以手平舉、上下30度作為三個高度標準。
研究結果：針對動作能力的Fugl-Meyer Motor Assessment score UE part機械手臂組在介入前後的比較中有出現顯著進步 (p = 0.008)，但在日常生活量表中的Barthel Index、Manual Ability Measure皆沒有出現顯著差異，而機械手臂組與傳統職能治療組在以上三個量表中之間也沒有出現顯著差異。運動學參數中，僅有健側標準化手臂-軀幹協調(Arm-Trunk Coordination normalized through unaffected-side)中在與傳統職能治療組中後測組間比較時多數參數與位置沒有出現顯著差異，僅在ΔNATC的部分出現顯著差異(p = 0.03)、NMTd有出現顯著差異(p = 0.05)。本研究認為機械手臂能夠協助中風病人恢復上肢動作功能，但在12小時四週的治療量中仍無法將進步轉移到日常生活功能中，且在伸手取物的動作品質中，儘管都有小幅進步，但仍無法有顯著的差異，因此本研究認為臨床上透過新型機械手臂Armeo®Spring能夠協助中風個案恢復上肢功能，但仍需要更長的治療時間以及更頻繁的介入次數。

Robot-assisted training (RT) is a new strategy which provides to improve stroke patient’s motor functions in the upper extremity (UE). Although some evidences demonstrate that RT could improve UE motor functions, most RT interventions are designed for training the limb movement abilities only without emphasis on the training for ADL functions. To complement this insufficiency, Armeo®Spring is an innovative design which is combined the robotic mechanism with a visual interaction interface. Moreover, to evaluate more detailed and objective information for movement improvements, kinematic parameters were measured by a motion capture system. In this study, the randomized control trial with blocked design was used to compare the performances between RT group and convention OT group (CT group). Eighteen chronic stroke patients, nine in the RT group and nine in the CT group, were recruited in this study. All subjects received the intervention for one hour in every session, 2~3 sessions per week. A complete intervention lasted 4~6 weeks. Researchers evaluated the subject’s performances two times, pre- and post- intervention, during the studying period. The apparatuses and parameters such as Fugl-Myer motion assessment UE part (FMA), Bathel Index (BI), Manual Ability Measure (MAM) and parameters of kinematics, e.g. movement time, movement unit, path ratio and arm-trunk coordination, were used in the experiment. The results showed the FMA in the RT group had significant improvement but not in the CT group. In addition, the results of the BI and MAM did not find the significant difference between pre- and post-intervention in both groups. Most kinematic parameters did not find the significant improvement after intervention. In conclusions, this study showed that the robot-assisted training helps stroke patients improve their UE motor function after receiving a12-hours intervention. In the future, a larger sample size and longer follow-up study should be considered and carried out for establishing more concrete evidence.

第一章、 緒論.......................................................................................................1
第一節、 研究背景.........................................................................................1
第二節、 研究目的.........................................................................................3
第三節、 研究假設.........................................................................................4
第二章、 文獻回顧................................................................................................5
第一節、 中風個案簡介..................................................................................5
一、 定義、流行病學與症狀……………………………………………..5
二、 針對中風病人之職能治療復健介紹………………………………..6
第二節、 機械手臂之復健成效理論簡介......................................................8
一、 機械手臂之設計與其理論依據……………………………………..8
二、 機械手臂對中風病人療效回顧…………………………………….12
第三節、 文獻回顧總結.................................................................................14
第三章、 研究設計及方法...................................................................................15
第一節、 研究對象.........................................................................................15
第二節、 研究設備及設計.............................................................................16
一、 基本資料及臨床評估工具………………………………………….16
二、 動作分析系統……………………………………………………….19
三、 介入方案…………………………………………………………….22
第三節、 研究流程.........................................................................................24
第四節、 運動學參數.....................................................................................26
第五節、 資料統計分析.................................................................................29
第四章、 研究結果...............................................................................................30
第一節、 描述性統計資料………………………………………………….30
第二節、 上肢動作功能與日常生活功能量表評估……………………….32
一、 組間差異…………………………………………………………….32
二、 兩組前後測分數差比較…………………………………………….33
第三節、 運動學參數…………………………………………………….....35
一、 組間差異…………………………………………………………….36
二、 前測與後測之比較………………………………………………….36
第五章、 討論…………………………………………………………………...43
第一節、 描述性統計資料………………………………………………….44
第二節、 上肢動作功能與日常生活功能量表評估……………………….45
一、 上肢動作功能評估………………………………………………….45
二、 日常生活功能評估………………………………………………….47
第三節、 運動學參數……………………………………………………….50
第六章、 結論……………………………………………………………………54
第一節、 總結…………………………………………………………………54
第二節、 臨床應用與發展……………………………………………………55
第三節、 研究限制級未來研究建議…………………………………………56
參考文獻…………………………………………………………………………..58

表目錄
表3-2-1-1 改良Ashworth量表(Modified Ashworth Scale, MAS)……………17

表 4-1-1 兩組參與者之基本族群描述性統計資料…………………………31

表 4-2-1 上肢動作功能與日常生活能力評估結果…………………………34
表 4-2-2 上肢動作功能與日常生活能力前後測差…………………………34

表4-3-1 距離標準化動作時間………………………………………………37
表4-3-2 路徑-位移軌跡比……………...……………………………………38
表4-3-3 距離標準化動作單位……………………………………………….39
表4-3-4 健側標準化手臂-軀幹協調…………………………………………40
表4-3-5 距離標準化動作時間前後測之差值……………………………….41
表4-3-6 路徑-位移軌跡比前後測之差值…….……………………………...41
表4-3-7 距離標準化動作單位前後測之差值.……………………………....42
表4-3-8 健側標準化手臂-軀幹協調………………………………………....42

圖目錄
圖2-2-1-1. 動作控制學習之封閉環…………………………………………..…..8
圖2-2-1-2. 動作控制學習之開放環……………………………………………....9
圖2-2-1-3. Bi-Manu-Track範例照片……………………………………………..10
圖2-2-1-4. Armeo®Spring 實際操作照片…………………………………….....11

圖3-2-2-1. miniBird 及MotionMonitor System………………………………...21
圖3-2-2-2. 坐姿俯瞰圖與側視圖………………………………………………..21

圖3-2-3-1 介入流程圖………………………………………………………….23

圖3-3-1 研究收案流程圖…………………………………………………….25

圖4-2-2-1. FMA-UE 前後測分數比較圖………………………………………33

附錄目錄
附錄 一 個案基本資料 (詳細)……………………………………………………...67
附錄 二 上肢動作功能與日常生活能力評估結果 (詳細)………………………...68

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