臺灣博碩士論文加值系統

背景及目的：足踝控制是影響平衡與行走功能的重要因素之一。目前較為所知，電刺激可改善動作控制並增加大腦運動皮質的興奮度，有助臨床中風病患之恢復。合併電刺激與動作訓練在正常人可誘發大腦運動皮質的興奮性，且能短時間延續；對中風病患而言，類似的合併治療在上肢部分，有文獻證實效果比單獨運動治療或電刺激更好，且腦部亦有伴隨重組的現象發生。但合併治療對下肢的介入，以及在其動作與功能恢復及腦部運動皮質恢復的影響，目前則較少文獻探討。須進一步的研究及實證。因此，本實驗之目的為探討，給予中風後具痙攣垂足患者合併電刺激與強調踝部控制的站立平衡訓練後，對誘發其脛前肌與降低足蹠屈肌痙攣的療效，並進一步探討，此療效對平衡、步態、功能性行走與大腦運動皮質再塑的影響。研究方法：15位痙攣型垂足之中風患者，以隨機方式分派到實驗組或控制組。所有受測者皆維持常規物理治療，實驗組額外增加電刺激合併站立板輔助訓練足背屈的動作控制30分鐘與強調足踝控制的行走訓練15分鐘。控制組則接受額外一般運動30分鐘與行走訓練15分鐘，共計45分鐘。治療次數為一星期三次，為期四週，並於治療前與治療後一週內接受評估，評估項目包括(1)足背屈肌力評估；(2)動態痙攣指數；(3)動態平衡評估：身體穩定極限(Limit of stability)；(4)步態評估:包含速度、空間與時間對稱性；(5)功能性行走能力：艾默利功能性行走測試 (Emory Functional Ambulation Profile)； (6)穿顱磁刺激器(Transcranial magnetic stimulation)：脛前肌的動作閥值(motor threshold)。研究結果以無母數分析，曼惠氏檢定(Mann-Whitney U-test)和魏氏帶符號等級考驗(Wilcoxon signed-rank test)分別比較組間和組內連續變相的差異，以卡方檢定(chi-square test)比較類別變相的差異。統計上顯著差異水準定α值為0.05。結果：兩組在改變量分析的比較上，實驗組在自選速度下行走時的動態痙攣指數(p=0.049)與空間對稱性(p=0.015)顯著改善；艾默利功能性行走測試中一般地面(p=0.049)，障礙物(p=0.015)，上下樓梯(p=0.005)以及總完成時間(p=0.015)皆達統計差異。而脛前肌的動作閥值則有下降的趨勢(p=0.060)。討論與總結：本研究顯示，合併電刺激與足踝動作訓練可以降低慢性中風患者足蹠屈肌動態痙攣，且伴隨著步態對稱性增加以及功能性行走能力的改善。此外，這方式的合併治療可以誘發更多大腦運動皮質的興奮，而可能進一步促使大腦重組(brain reorganization)的發生。

Background and Purpose: Ankle control is one of the most important factors for balance and gait performance after stroke. Subjects with spastic foot following stroke demonstrate abnormal muscle activation patterns which further affect the gait velocity and symmetry. Previous evidences have demonstrated that electrical stimulation (ES) combining movements can increase the excitability of the motor cortex. However, the benefits of ES combining motor relearning focusing on ankle control to balance, functional activities and motor cortex reorganization are still unclear. The purpose of the study was to investigate the effectiveness of the motor relearning combining ES for spastic foot on dynamic spasticity, balance and gait performances, and cortical activity in subjects with stroke. Methods: 15 subjects with spastic foot after stroke were recruited and randomly assigned to experimental or control group. Subjects in the experimental group received 12 sessions of ES combining ankle movements challenged by a rocker board in standing for 30 minutes followed by 15 minutes ambulation training focusing on the ankle control. Subjects in the control group received general exercises for 30 minutes followed by 15 minutes ambulation training without focusing on the ankle control each session for a total of 12 sessions. All subjects received the baseline and post-treatment assessments. Maximal isometric strength of dorsiflexors was measured by a handheld dynamometer. Dynamic spasticity of plantarflexor during gait was measured to quantify the change of spasticity. Limit of stability (LOS) indicating the balance performance was measured by the Balance Master. Spatial and temporal gait parameters were measured by GAITRite system to document the gait performance. The Emory Functional Ambulation Profile (E-FAP) was used for measuring the functional gait performance. Transcranial magnetic stimulation (TMS) was used to obtain motor threshold of bilateral tibialis anterior (TA) for cortical excitability. Mann-Whitney U-test was used to compare continuous variables between groups, and chi-square test was used to compare categorical variables between groups. Wilcoxon signed-rank test was used to analyze the training effects within group. Significant level was set at 0.05. Results: Based on the change scores for between group comparison, the experimental group demonstrated significantly decrease in dynamic spasticity at self-selected speed (p=0.049), significant improvement in spatial symmetry (p=0.015), significant decrease in time spent of total E-FAP time (p=0.015), and the subtasks, including floor (p=0.049), obstacles (p=0.015), and stairs (p=0.005). The motor threshold of affected TA was also decreased, but not to a significant level (p=0.060). Discussion and conclusion: Our results suggest that electrical stimulation combining ankle movements can decrease the ankle spasticity in subjects with chronic stroke. Furthermore, the improvement concurs with better gait symmetry and functional gait performances. In addition, such combining treatment might facilitate stronger cortical excitability and possibly brain reorganization.

Index……………………………………………………………………...…………………..I
List of tables…………………………………………………………………….………...…V
List of figures………………………………………………………………………………VI
English abstract…………………………………………………………………………. VIII
Chinese abstract……………………………………………………..…………………..….X
List of abbreviations…………………………………………………..…..………………XII

CHAPTER I INTRODUCTION……………………………………………………….…1

CHAPTER II LITERATURE REVIEW……………………………………………..……4
2.1 The influence of the lower limb impairments on balance and gait performances
after stroke……………………………………………….…………………………...4
2.2 Abnormal muscle activation in the ankle joint after stroke………………….…....…5
2.3 Abnormal gait performance after stroke…………………………………….…....….6
2.4 Interventions to improve ankle control in subjects after stroke…………….…..…...7
2.4.1 Electrical stimulation……………………………………………….…...…...7
2.4.2 Motor relearning…………………………………………………………..…8
2.4.3 Electrical stimulation combined with movements……………………......…8
2.4.3.1 The possible mechanisms for spasticity reduction……………...…...10
2.5 Cortical reorganization: TMS………………………………………………………10
2.6 Summary of the literature review……………………………………….…..……..11
2.7 Importance and purpose of the study…………………………………….…..….…11


CHAPTER III METHODS…………………………………………………….………..13
3.1 Study design…………………………………………………………….…….……13
3.2 Subjects…………………………………………………………….…………..…..13
3.3 Protocol…………………………………………………………………….……....14
3.4 Measurements……………………………………………………………….……..14
3.4.1 Demographic data…………………………………………….………….…15
3.4.2 Motor function………………………………………………….…………..15
3.4.2.1 Muscle strength of dorsiflexors……………………………………..15
3.4.2.2 Dynamic spasticity of plantarflexors……………………………..…15
3.4.2.3 Balance performances…………………………………………….....17
3.4.2.4 Gait performances…………………….…………………………..…17
3.4.2.4.1 The GAITRite system………………………………………..17
3.4.2.5 The Emory Functional Ambulation Profile…………….………..….18
3.4.3 Cortical activity……………………………………………….……………19
3.5 Intervention………………………………………………………….…………......19
3.5.1 Instruments………………………………………………………………….19
3.5.2 Training protocols…………………………………………………………..20
3.6 Data analysis……………………………………………………………………….21

CHAPTER IV RESULTS……………………………………………………………….….22
4.1 Demographic and basic data…………………………………………….……….…22
4.2 Muscle strength of dorsiflexors………………………………………….……...…..22
4.3 Dynamic spasticity of plantarflexors………………………………….…………….23
4.4 Dynamic balance performance: limit of stability………………….………...….…..23
4.4.1 Forward direction……………………………………………………..….…..23
4.4.1.1 MXE……………………………………………………………..…. ..23
4.4.2 Non-affected side direction…………………………….……….…………23
4.4.2.1 MXE……………………………………………………..………….23
4.4.3 Backward direction……………………………………………..………….24
4.4.3.1 MXE……………………….………………………….….…………24
4.4.4 Affected side direction…………….………………………….….…….…..24
4.4.4.1 MXE…………………………………………………….….……….24
4.5 Gait parameters…………….………………………………………….….………..24
4.5.1 Self-selected speed…………………………………………….….………..24
4.5.2 Spatial asymmetry ratio………………………………………..….……..…24
4.5.3 Temporal asymmetry ratio……………………………………..….………..25
4.6 Functional gait performances: the E-FAP……………………………..….………..25
4.6.1 Floor……………………………………………………………..….………25
4.6.2 Up & go………………………………………………………….…..……...25
4.6.3 Obstacles…………………………………………………………..….…….26
4.6.4 Stairs……………………………………………………………...…………26
4.6.5 Total…………………………………………………………………..…..…26
4.7 Cortical activity…………………………………………………………….….…...27
4.7.1 Motor threshold of TA in the affected hemisphere………………….….…..27
4.7.2 Asymmetry ratio of motor threshold of TA between both hemispheres……27
4.7.3 Number of subjects whose TA motor threshold can be induced…..…….…..27

CHAPTER V DISCUSSION…………………………………………….………………...28
5.1 Characteristics of subjects with stroke in both groups…………………..…….…..28
5.2 Muscle strength of dorsiflexors………………………………………….……..….28
5.3 Dynamic spasticity of plantarflexors………………………………………..….….29
5.4 Dynamic balance: LOS……………………………………………………….…....30
5.5 Gait performances…………………………………………………………………30
5.5.1 Self-selected speed…………………………………………………………30
5.5.2 Spatial asymmetry ratio…………………………….………………………31
5.5.3 Temporal asymmetry ratio………………………….………………………31
5.6 Functional gait performance: E-FAP……………………….……………………...32
5.7 Cortical activity: motor threshold of TA…………………….……………………..33
5.8 Limitations of the study……………………………………….……….…………..34
5.9 Recommendations for future studies………………………….…………………...34

CHAPTER VI CONCLUSION………………………………………………………….35

REFERENCES……………………………………………………………………………..36

Appendix A…………………………….……………………………….…………..……….69
Appendix B……………………………………………………………….…………………70

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