臺灣博碩士論文加值系統

背景：極低出生體重（出生體重低於1,500公克）早產兒的存活率雖已大幅提昇，但罹患新生兒併發症的比率仍高，對後續的發展有不利的影響。在極低出生體重早產兒早期的發展問題中，以神經動作功能失能最為明顯，例如行走達成遲緩、不協調的步態，以及較低的身體活動量等。雖然跑步機訓練已在臨床廣泛運用來增進極低出生體重早產兒的行走能力和動作能力，但研究證據仍相當缺乏。
研究目的：本研究探討自矯正年齡四個月開始以跑步機介入發展遲緩高風險早產兒到獨立行走達成(或達矯正年齡十八個月大)為止的成效，成效評量包含行走達成前的跑步機跨步動作、達成獨立行走的年齡、以及獨立行走後的步態以及發展情形。
研究設計：本研究為準實驗型研究（qusi-experimental design）、臨床對照試驗 (clinical control trail, CCT)。
研究對象：研究對象的納入標準為：1.早產；2.出生體重低於1,500公克；3.至少罹患下列之一的新生兒疾病：第三度以上之腦室內出血(Grade III or IV intracranial hemorrhage)、腦室周圍白質軟化症(periventricular leukomalacia)、中度以上肺部支氣管發育不全(bronchopulmonary dysplasia)；4.能夠承受於跑步機上執行的行走訓練者。研究對象的排除標準為：1.罹患先天異常或畸形；2.罹患肌肉骨骼系統或心臟血管系統異常不適合進行跑步機訓練者。
研究方法：發展遲緩高風險早產兒分為實驗組和控制組。跑步機介入自矯正年齡四個月大開始到獨立行走達成(或達矯正年齡十八個月大)為止。所有受試早產兒皆接受一般常規的早療介入，研究人員每月進行居家訪視一次，並根據嬰兒的發展及家長的需求給予介入及提供家長居家療育建議，並示範居家療育活動策略或技巧。此外，研究團隊提供了實驗組受試嬰兒一台可攜式嬰兒跑步機，並教導家長在家中執行受試嬰兒之跑步機訓練。實驗組受試嬰兒之跑步機訓練計畫為一天累計訓練時間達十分鐘，一週訓練5天。研究人員在第一次評估及每月居家訪視時會評估實驗組受試嬰兒於跑步機跨步之情形，並依受試嬰兒的表現調整跑步機訓練參數。
成效評量：成效評量包括測量行走達成前的跑步機支撐跨步表現、達成獨立行走的年齡、達成獨立行走後的步態以及整體發展情形。跑步機支撐跨步以及步態皆使用三維動作分析系統(SIMI Reality Motion Systems ,GmbH)進行資料收集。前者於受試嬰兒矯正年齡四個月、八個月、十二個月(或行走達成即停止)進行跨步資料收集，包括交替跨步頻率，以及下肢兩兩關節之間與兩下肢之間的協調情形；後者則是在受試嬰兒達成獨立行走後兩週內及矯正年齡十八個月大時進行步態資料收集，包括步行速度、步幅長度及擺盪期在步態週期的百分比，在速度和步幅長度進一步以身高標準化去比較。行走達成年齡會藉由密集的電話或通訊軟體詢問家長以獲得相關資料，其定義為能放手獨立行走5步，且連續出現3天。此外，發展測試則使用嬰幼兒綜合發展測驗和阿爾伯塔嬰幼兒動作量表。
統計分析：本研究使用描述性統計、卡方檢定和是曼-惠特尼U考驗比較組間差異，另外會使用無母數分析--克-瓦二氏單因子變異數等級分析(Kruskal-Wallis One-Way Analysis of Variance)分析所有受試嬰兒在跑步機支撐跨步表現和發展分數上其隨年齡不同的變化。統計顯著水準訂在α= 0.05。
結果：共計有16位早產兒完成研究收案，其中6位為實驗組，10位為控制組完成矯正年齡四個月，八個月和十二個月大的測試。分析跑步機支撐跨步的結果顯示，兩組受試嬰兒之交替跨步頻率均隨著年齡增加而顯著增加，但無組間差異；在關節間協調參數中，兩組受試嬰兒於矯正年齡12個月時之左側膝-踝關節相關性有顯著差異，實驗組受試嬰兒顯著較控制組受試嬰兒為低。其餘各項跨步表現參數均無顯著之組別或年齡效應。實驗組有四位和控制組有五位受試嬰兒達成獨立行走能力，實驗組受試嬰兒之平均行走達成年齡中位數為54.6週，而控制組受試嬰兒則為60.4週，實驗組受試嬰兒之平均行走達成年齡略早於控制組受試嬰兒。至於在達成獨立行走後的步態表現，在矯正年齡十八個月大時之步態中右腳擺盪期比例實驗組顯著較高，其餘各項步態參數無組間顯著差異，不過實驗組受試嬰兒相較於控制組受試嬰兒有較快的步行速度、較長的步幅及較高的擺盪期時間百分比的趨勢；且將步行速度和步幅對身高標準化後，實驗組相較控制組的數值仍是較較高的。兩組受試嬰兒在矯正年齡十八個月大時之嬰幼兒綜合發展測驗的Z分數和阿爾伯塔動作量表分數亦無組間顯著差異；但在矯正年齡八到十二個月之嬰幼兒綜合發展測驗總分分數的改變量有組間顯著差異，控制組受試嬰兒相較於實驗組受試嬰兒之改變量為高。此外，兩組受試嬰兒之居家療育時間長短無明顯差異，唯多數實驗組受試嬰兒之跑步機訓練量未達建議量，依從度不高。
討論：以跑步機支撐跨步的表現來看，跑步機介入有助於改善發展遲緩高風險早產兒之跨步動作型態，尤其是在關節間協調的表現，可能是給予重複練習的機會和環境任務的挑戰，可以誘發嬰兒採取不同的跨步策略進行調整，而其他參數不顯著；此外，在行走達成年齡和步態上雖然無組間差異，但實驗組受試嬰兒呈現出較早達成獨立行走年齡以及略佳步態的趨勢，由於個案數仍較少，應繼續追蹤以瞭解這部分的療效。在整體發展方面，在矯正年齡四、八、十二個月時兩組受試嬰兒亦無組間差異。探究其無組間差異的原因，由於實驗組腦傷比例偏高，對動作控制和發展較為不利，雖有進步但速度仍較慢，且實驗組其跑步機訓練量不足，可能無法達到預期改善的影響。
結論：本研究發現跑步機訓練有助於改善發展遲緩高風險早產兒支撐跨步的動作型態，並且可能具有促進獨立行走發展的作用。不過本研究的個案數仍少，且實驗組與控制組受試嬰兒在與預後有關的新生兒疾病的分布上有些許差異，以及驗組受試嬰兒跑步機訓練的依從度不高，以上原因均可能弱化跑步機訓練的效果，未來需要招募更多個案、並提升其依從度，以更嚴謹的研究設計來探討跑步機訓練的效果。
關鍵字：早產兒、跑步機訓練、跨步、行走達成年齡、步態和發展。

Background. Very low birth weight (VLBW) infants with severe complications may reveal deviated stepping movements, postponed walking attainment, less-coordinated gait patterns, and delayed development. Although treadmill training has been widely used by therapists to enhance stepping performance, walking ability, and development in VLBW infants; the evidence remains limited.
Purpose. To investigate the effects of treadmill training on stepping, walking and development in high-risk preterm infants.
Design. Clinical control trail.
Subjects. Inclusion criteria (all needed) are: (1) preterm birth, (2) birth weight < 1,500 g, (3) perinatal brain injury or bronchopulmonary dysplasia, (4) able to tolerate treadmill training. Exclusion criteria (either one) are (1) congenital abnormality (2) unable to tolerate treadmill training.
Method: VLBW infants were recruited from TVGH and assigned into experimental group (treadmill training and early intervention, EG) or control group (early intervention only, CG). The intervention commenced from 4 months corrected age to walking attainment or 18 months of corrected age. In addition, infants in the EG, parents were trained to support their infants for practicing stepping on a small, motorized treadmill for 10 minutes a day, 5 days per week in their own home.
Outcome measures. Outcomes examined included treadmill stepping, the age of walking attainment, gait, and development at 4, 8, 12，18 months of corrected age. Stepping data (alternating steps, inter-joint coordination, interlimb coordination) were collected and analyzed using 3-D kinematical analysis. Age of walking attainment was defined as the time when the infant could walk for 5 successive steps without support in 3 consecutive days and was collected and confirmed by parent report and home visit, respectively. Gait data (walking speed, stride length, and percentage of swing time) was collected and analyzed within 2 weeks after the infants had attained walking ability and at 18 months of corrected age. Development was assessed using Comprehensive Developmental Inventory for Infants and Toddlers Diagnosis Test (CDIIT-DT) and Alberta Infants Motor Scale(AIMS).
Statistical analysis. Data were analyzed using descriptive statistics and non-parametric statistics. The significance level was set at α= 0.05.
Results. There were 6 preterm infants in the EG and 10 in the CG. Six preterm infants in the EG and 10 preterm infants in the CG had completed the assessments at 4, 8, and 12 months of corrected age. Four preterm infants in EG and five preterm infants in CG could walk independently and their age of walking attainment was collected. Three preterm infants in EG and four preterm infants completed gait analysis. The groups were comparable among perinatal and demographic data. Preterm infants in the EG tended to have a more severe brain injury (66.7%) than the CG (20%). Both groups exhibited a significant increase in alternating steps frequency with age. Besides, the EG had a significantly lower left knee-ankle correlation at 12 months of corrected age than the CG. The age of walking attainment in the EG (n=4, 54.6 weeks) seemed to be earlier than the CG (n=5, 60.4 weeks). As to the gait at after attaining walking ability and at 18 months of corrected age, the EG tended to have a higher walking speed , a longer stride length, and a higher percentage of swing time than the CG .The percentage of right swing time significantly higher in the EG group. The normalized walking speed and normalized stride length were greater in EG than CG. However, development was comparable between groups. In addition, a low compliance of treadmill program in the EG was noted.
Discussion and Conclusion. Despite a low compliance of treadmill program and a small sample size in this study, the findings indicated that treadmill training was beneficial for enhancing stepping performance, advancing age of walking attainment, and improving gait patterns in high-risk preterm infants. Future study is needed to include a larger sample and design strategies to keep good parental compliance to examine the effect of treadmill training in preterm infants. A longer follow-up for the effects on gait and development is also suggested.
Keywords: Preterm infants, treadmill training, stepping, age of walking attainment, gait and development

目錄
誌謝 I
中文摘要 II
英文摘要 VI
目錄 IX
表目錄 XI
圖目錄 XIII
第一章 簡介 1
第一節 研究背景與動機 1
第二節 研究目的 2
第三節 研究假設 3
第四節 重要性 3
第二章 文獻回顧 4
第一節 極低出生體重早產兒及其發展問題 4
第二節 行走功能的重要性及極低出生體重早產兒的行走表現 6
第三節 跨步動作發展以及其與行走功能的關係 7
第四節 跑步機介入目前的研究 10
第五節 操作型性名詞定義 13
第三章 研究方法 15
第一節 研究設計及研究架構 15
第二節 研究材料及研究方法 15
一、 研究流程： 16
二、 研究對象： 17
三、 研究工具: 18
第三節 資料處理與分析方法 20
一、 跑步機支撐跨步運動學資料處理 20
二、 步態分析資料處理 22
三、 統計分析 23
第四章 結果 24
第一 節 受試嬰兒 24
第二節 跑步機訓練於早產兒矯正年齡四個月、八個月及十二個月時的各項 成效 25
第三節 行走達成年齡及步態分析 28
第四節 居家跑步機訓練、療育活動之執行及接受物理(職能)治療情形 30
第五節 實驗組受試嬰兒跑步機速度調整情形 31
第六節 完成矯正齡十八個月大評估之個別嬰兒的各項表現及變化 33
第五章 討論 52
第一節 受試嬰兒 52
第二節 跑步機訓練於早產兒矯正年齡四個月、八個月及十二個月時的各項成效 52
第三節 行走達成年齡及行走步態分析 58
第四節 完成矯正齡十八個月大評估之個別嬰兒的各項表現及變化 60
第五節 研究貢獻、研究限制及未來研究建議 61
第六章 結論 63
參考文獻 64
表 70
圖 94
附錄一: 同意臨床試驗證明書 104
表目錄
表一 評估進行時程與項目 70
表二 跑步機訓練參數 71
表三 實驗組與控制組週產期資料 72
表四 實驗組與控制組家庭社經背景資料 73
表五 實驗組與控制組個案於矯正年齡四個月、八個月和十二個月之生長測量 74
表六 實驗組與控制組個案於行走達成時及矯正年齡十八個月具行走能力個案之生長測量 75
表七 實驗組與控制組個案於矯正年齡四個月,八個月,十二個月之跑步機支撐跨步之動作表現 76
表八 實驗組與控制組個案於矯正年齡四個月及八個月,十二個月之嬰幼兒綜合發展測驗各發展領域原始分數變化量 77
表九 實驗組與控制組個案於矯正年齡四個月、八個月和十二個月之嬰幼兒綜合發展測驗各發展領域Z分數 78
表十 實驗組與控制組個案於矯正年齡四個月、八個月和十二個月之嬰幼兒綜合發展測驗各發展領域Z分數落於發展遲緩之人數 79
表十一 實驗組與控制組個案於矯正年齡四個月原始分數及八個月,十二個月之阿爾伯他嬰兒動作評量原始分數及其變化量 80
表十二 實驗組與控制組達成獨立行走個案之週產期資料 81
表十三 實驗組與控制組達成獨立行走個案之家庭社經資料 82
表十四 實驗組與控制組個案於行走達成年齡和剛獲得行走能力時的步態表現 83
表十五 實驗組與控制組個案於矯正年齡18個月大時行走能力的步態表現 84
表十六 實驗組個案跑步機訓練速度調整個別計畫執行情形 85
表十七 實驗組與控制組完成矯正年齡十八個月測試個案之週產期資料 86
表十八 實驗組與控制組完成矯正年齡十八個月測試個案之家庭社經資料 87
表十九 實驗組與控制組完成矯正年齡十八個月測試個案之生長測量 88
表二十 完成矯正年齡十八個月之實驗組與控制組個案於矯正年齡四個月,八個月,十二個月之跑步機支撐跨步之動作表現 89
表二十一 實驗組與控制組完成矯正年齡十八個月測試個案之矯正年齡四到八個月、八到十二個月和十二到十八個月其嬰幼兒綜合發展測驗各發展領域原始分數改變量 90
表二十二 實驗組與控制組完成矯正年齡十八個月測試個案之矯正年齡四個月、八個月、十二個月和十八個月其嬰幼兒綜合發展測驗各發展領域Z分數 91
表二十三 實驗組與控制組完成矯正年齡十八個月測試個案之矯正年齡四個月、八個月、十二個月和十八個月阿爾伯他嬰兒動作評量原始分數 92
表二十四 實驗組與控制組完成矯正年齡十八個月測試個案之矯正年齡四個月、八個月、十二個月和十八個月阿爾伯他嬰兒動作評量原始分數改變量 93
圖目錄
圖一 動作分析黏貼反光球解剖位置圖 94
圖二 跑步機支撐跨步測試示意圖 95
圖三 跑步機支撐跨步測試-各測試月齡交替跨步次數 96
圖四 跑步機支撐跨步測試-髖膝關節間相關性 97
圖五 跑步機支撐跨步測試-膝踝關節間相關性 98
圖六 跑步機支撐跨步測試-髖踝關節間相關性 99
圖七 跑步機支撐跨步時間對稱性 100
圖八 實驗組嬰兒居家跑步機練習時間 101
圖九 實驗組與控制組嬰兒居家早療訓練活動練習月平均時間 102
圖十 實驗組與控制組嬰兒接受物理與職能治療月平均次數 103

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