臺灣博碩士論文加值系統

前言：機器輔助療法是一項具備高重複性、高精確性、任務導向及勞力節省等特色之現代療法。然而，先前研究指出：機器輔助療法相較於密集功能性訓練而言，在動作能力恢復有較佳之成效，但在動作功能復原則較為遜色。此外，目前鮮有聚焦於近、遠端機器輔助療法之療效對比研究。因此，透過近、遠端機器輔助療法結合高強度功能性任務訓練之研究，可提供臨床治療人員針對機器輔助療法應用之介入方案與策略。
目的：本個案系列研究主要是比較近、遠端機器輔助療法及常規職能治療結合高強度功能性任務訓練在真實環境上肢功能之療效。此外，也探究近、遠端機器輔助療法在動作能力恢復與習得動作控制策略之成效。
方法：本個案系列研究為叢集隨機分派之研究設計。受試者將被分派至近端機器輔助療法組、遠端機器輔助療法組或常規職能治療組，並接受每日90分鐘、每週五次、為期四週共20次之介入療程。成效評量工具包含：傅格梅爾評估量表(Fugl-Meyer Assessment, FMA-UE)、修訂版艾許沃斯量表(Modified Ashworth Scale, MAS)、醫學研究會議之肌力量表(Medical Research Council Scale, MRC)、渥夫動作功能測驗(Wolf Motor Function Test, WMFT)、動作活動日誌
(Motor Activity Log, MAL)、ABILHAND 問卷(ABILHAND Questionnaire)、功能獨立量表(Functional Independence Measure, FIM)、中風衝擊量表(Stroke Impact Scale, SIS)、運動學分析及腕動計。此外，針對疼痛之不良反應，採用視覺類比量表(Visual Analogue Scale, VAS)來進行監測。
結果：本研究共6位個案分派至近端機器輔助療法組；4位個案分派至遠端機器輔助療法組；3位個案分派至常規職能治療組。臨床評估部分，從FMA-UE得分相對改變量而言，近、遠端機器輔助療法組各有3位個案、常規職能治療組有1位個案達最小臨床重要差異量。從FMA-UE近端次量表而言，近端機器輔助療法組有4位個案、遠端機器輔助療法組有3位個案、常規職能治療組有1位個案達最小臨床重要差異量。從FMA-UE遠端次量表而言，近端機器輔助療法組有2位個案、遠端機器輔助療法組有3位個案、常規職能治療組有1位個案達最小臨床重要差異量。在WMFT動作品質次量表而言，近、遠端機器輔助療法組各有2位個案、常規職能治療組有1位個案達最小臨床重要差異量。在WMFT時間次量表而言，近端機器輔助療法組有3位個案、遠端機器輔助療法組有4位個案達最小臨床重要差異量。在SIS生理功能次量表而言，近端機器輔助療法組有3位個案、遠端機器輔助療法組有2位個案、常規職能治療組有2位個案達最小臨床重要差異量。運動學分析部分，近端機器輔助療法組在食指反應時間、食指動作時間、食指標準化位移、軀幹動作時間、軀幹標準化位移等參數有較佳之表現；遠端機器輔助療法組則在食指反應時間、食指最大速度、食指達到最大速度的時間百分比、軀幹最大速度、關節協調性等參數有較佳之表現。腕動計分析部分，近端與遠端機器輔助療法組在手部使用計次、能量消耗與日常至中等強度活動使用量等參數有較佳之表現。此外，在治療期間並未有任何與研究相關之不良反應發生。
結論：本研究支持合併機器輔助療法及密集功能性訓練於慢性中風病人的動作能力、日常生活功能及生活品質之正向療效。研究結果顯示近端機器輔助療法對於近端與粗大動作有較佳之成效；遠端機器輔助療法對於遠端與精細動作有較佳之成效。另外，轉移效益確實存在於治療中，且遠端機器輔助療法相較於近端機器輔助療法有較高之效益。但是，本研究各組樣本數過小，結果須謹慎解釋，建議未來研究擴大樣本數並更進一步探討療效。

Introduction: Robot-assisted therapy (RT) has become an innovative rehabilitation approach. RT has been known for its high intensity, high accuracy, labor saving, and task-directedness. However, previous studies revealed that RT is more effective on motor abilities, but less on motor functions than intensive functional task practice. Moreover, few studies have studied the effects of proximal- vs. distal-emphasized RT. Comparison of the 2 devices of InMotion interactive therapy system (ie, InMotion Arm 2.0 and InMotion Wrist 3.0) may improve our knowledge about their relative effects and inform clinical practice of motor rehabilitation based on RT.
Objectives: This case series study compared the effects of proximal-emphasized RT (P-IMT), distal-emphasized RT (D-IMT), and control treatment (CT) combined with intensive functional task practice on real-world arm activities and functional outcomes. In addition, this study also examined the effects of these two modes of InMotion on motor impairment, including muscle tone and muscle power, and motor control strategies.
Methods: This case series study was a cluster randomized controlled trial with pretest and posttest assessments. Participants received one of P-IMT, D-IMT, or CT intervention for 20 sessions (90 minutes per day, 5 days per week for 4 weeks). Outcome measures included the upper-extremity subscale of Fugl-Meyer Assessment (FMA-UE), Modified Ashworth Scale (MAS), Medical Research Council Scale (MRC), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), ABILHAND
Questionnaire, Functional Independence Measure (FIM), Stroke Impact Scale (SIS), kinematic variables, and wrist accelerometers. Moreover, self-reported pain was monitored by using the Visual Analogue Scale (VAS) immediately after intervention.
Results: There were 6 participants recruited in P-IMT group; 4 participants recruited in D-IMT group; 3 participants recruited in CT group. In clinical outcomes, from the perspective of relative change in FMA-UE, 3 participants in P-IMT group reached minimal clinically important difference (MCID); 3 participants in D-IMT group reached MCID; 1 participant in CT group reached MCID. In FMA-UE proximal subscale, 4 participants in P-IMT group reached MCID; 3 participants in D-IMT group reached MCID; 1 participant in CT group reached MCID. In FMA-UE distal subscale, 2 participants in P-IMT group reached MCID; 3 participants in D-IMT group reached MCID; 1 participant in CT group reached MCID. In WMFT-QOM, 2 participants in P-IMT group reached MCID; 2 participants in D-IMT group reached MCID; 1 participant in CT group reached MCID. In WMFT-TIME, 3 participants in P-IMT group reached MCID; 4 participants in D-IMT group reached MCID. In SIS physical functions subscale, 3 participants in P-IMT group reached MCID; 2 participants in D-IMT group reached MCID; 2 participants in CT group reached MCID. In kinematic variables, P-IMT group showed favorable outcomes in reaction time, movement time (MT), motor unit (MU), and normalized total displacement (NTD) of endpoint control; MT and NTD of trunk compensation. D-IMT group showed favorable outcomes in reaction time, peak velocity (PV), and percentage of index peak velocity (PPV) of endpoint control; PV of trunk compensation, and joint coordination. In accelerometric measures, both P-IMT and D-IMT groups showed favorable outcomes in vector magnitude counts, energy expenditure and using amount of activity in lifestyle to moderate level. In adverse effects monitoring, no serious adverse effect occurred during the period of intervention.
Conclusion: This study supports the positive effects of P-IMT or D-IMT combined with intensive functional task practice on motor abilities, motor functions, and QOL in patients with chronic stroke. Moreover, P-IMT revealed superiority on proximal and gross movement of upper extremity, while D-IMT revealed superiority on distal and dexterous movement of upper extremity. In addition, generalizing effects emerged during intervention (D-IMT might have more generalizing effects than P-IMT). Due to the small sample size, the conclusion should be interpreted cautiously. Further studies are needed to expand the sample size and further validate the findings of this study.

誌謝 i
摘要 iii
Abstract v
Table of Contents viii
List of Figures xii
List of Tables xiv
Chapter 1 Introduction 1
1.1 Background and motivation 1
1.2 Research Questions, Objectives, and Hypotheses 3
1.2.1 Research Questions 3
1.2.2 Objectives 4
1.2.3 Hypotheses 4
1.3 Literature review 4
1.3.1 Neuroplasticity mechanisms after stroke 4
1.3.2 Motor control mechanisms on proximal and distal segments 5
1.3.3 Effects on InMotion RT in Patients with Stroke 6
Chapter 2 Method 8
2.1 Participants 8
2.2 Study design and procedures 8
2.3 Interventions 9
2.3.1 Proximal-emphasized (P-IMT) and distal-emphasized (D-IMT) RT groups 9
2.3.2 Intensive conventional occupational therapy practices (CT) group 10
2.4 Outcome measures 11
2.4.1 Clinical assessments 11
2.4.2 Kinematic analysis 16
2.4.3 Accelerometric measures 19
2.4.4 Measures for adverse effects - Visual Analogue Scale (VAS) 20
2.5 Data analysis 21
Chapter 3 Results 22
3.1 Baseline characteristics of study participants 22
3.2 Outcome measures: clinical assessments 24
3.2.1 Body functions and structures domain 24
3.2.2 Activities domain 26
3.2.3 Participation domain 26
3.3 Outcome measures: kinematic variables 27
3.4 Outcome measures: accelerometric measures 28
3.5 Adverse effects monitoring 29
3.6 Home programs implementing and supervising 29
Chapter 4 Discussion 30
4.1 Summary of the study findings 30
4.2 The findings of clinical assessments 31
4.2.1 Effects of P-IMT and D-IMT groups (RT groups) relative to CT group 31
4.2.2 Effects of P-IMT group relative to D-IMT group 33
4.3 The findings of kinematic variables 34
4.4 The findings of accelerometric measures 35
4.5 Study limitations and suggestions for further studies 36
4.6 Implication of this study 37
Chapter 5 Conclusions 39
References 40
Figures 47
Tables 71
Appendices 90
Appendix 1. The intervention protocol for the P-IMT group 90
Appendix 2. The intervention protocol for the D-IMT group 90
Appendix 3. The baseline characteristics and evaluation in clinical outcomes. 92

Aisen, M. L., Krebs, H. I., Hogan, N., McDowell, F., & Volpe, B. T. (1997). The effect of robot-assisted therapy and rehabilitative training on motor recovery following stroke. Archives of Neurology, 54(4), 443-446
Benaim, C., Froger, J., Cazottes, C., Gueben, D., Porte, M., Desnuelle, C., & Pelissier, J. Y. (2007). Use of the Faces Pain Scale by left and right hemispheric stroke patients. Pain, 128(1), 52-58.
Bohannon, R. W., & Smith, M. B. (1987). Interrater reliability of a modified Ashworth scale of muscle spasticity. Physical therapy, 67(2), 206-207.
Buma, F., Kwakkel, G., & Ramsey, N. (2013). Understanding upper limb recovery after stroke. Restorative Neurology and Neuroscience, 31(6), 707-722. doi: 10.3233/RNN-130332
Carod-Artal, F. J., Coral, L. F., Trizotto, D. S., & Moreira, C. M. (2008). The stroke impact scale 3.0 - Evaluation of acceptability, reliability, and validity of the Brazilian version. Stroke, 39(9), 2477-2484. doi: 10.1161/STROKEAHA.107.513671
Chen H. M., Chen C. C., Hsueh I. P., Huang S. L., & Hsieh C. L. (2009). Test-retest reproducibility and smallest real difference of 5 hand function tests in patients with stroke. Neurorehabil Neural Repair, 23(5), 435-40. doi: 10.1177/1545968308331146
Chang, W. H., & Kim, Y. H. (2013). Robot-assisted Therapy in Stroke Rehabilitation. Journal of Stroke, 15(3), 174-181. doi:10.5853/jos.2013.15.3.174
Chuang, L. L., Wu, C. Y., Lin, K. C., & Hsieh, C. J. (2014). Relative and Absolute Reliability of a Vertical Numerical Pain Rating Scale Supplemented With a Faces Pain Scale After Stroke. Physical therapy, 94(1), 129-138. doi: 10.2522/ptj.20120422
Edwards, D. F., Lang, C. E., Wagner, J. M., Birkenmeier, R., & Dromerick, A. W. (2012). An Evaluation of the Wolf Motor Function Test in Motor Trials Early After Stroke. Archives of physical medicine and rehabilitation, 93(4), 660-668. doi:10.1016/j.apmr.2011.10.005
Fasoli, S. E., Krebs, H. I., Ferraro, M., Hogan, N., & Volpe, B. T. (2004). Does shorter rehabilitation limit potential recovery poststroke? Neurorehabilitation and Neural Repair, 18(2), 88-94. doi: 10.1177/0888439004267434
French, B, Thomas, L. H., Leathley, M. J., Sutton, C. J., McAdam, J., Forster,
A., … , & Watkins, C. L. (2007). Repetitive task training for improving
functional ability after stroke. Cochrane Database of Systematic Reviews, 4. doi: 10.1002/14651858.CD006073.pub2
Fugl-Meyer, A. R., Jääskö, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scandinavian journal of rehabilitation medicine, 7(1), 13-31.
Gregson, J. M., Leathley, M., Moore, A. P., Sharma, A. K., Smith, T. L., & Watkins, C. L. (2000). Reliability of the Tone Assessment Scale and the modified Ashworth scale as clinical tools for assessing poststroke spasticity. Archives of physical medicine and rehabilitation, 80(9), 1013-1016.
Han, C., Wang, Q., Meng, P. P., & Qi, M. Z. (2013). Effects of intensity of arm training on hemiplegic upper extremity motor recovery in stroke patients: a randomized controlled trial. Clinical Rehabilitation, 27(1), 75-81. doi: 10.1177/0269215512447223
Hsieh, Y. W., Wu, C. Y., Lin, K. C., Chang, Y. F., Chen, C. L., & Liu, J. S. (2009). Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation. Stroke, 40(4), 1386-1391.
Kandel, E., Schwartz, J., & Jessell, T. (2013). Voluntary movement: the primary motor cortex. Principles of Neural Science, Fifth Edition (pp. 835-864). McGraw-Hill Education.
Krebs, H. I., Volpe, B. T., Williams, D., Celestino, J., Charles, S. K., Lynch, D.,
& Hogan, N. (2007). Robot-aided neurorehabilitation: a robot for wrist
rehabilitation. IEEE Transactions on Neural Systems and Rehabilitation-Engineering, 15(3), 327-335. doi: 10.1109/TNSRE.2007.903899
Kwakkel G., Kollen B. J., & Wagenaar R. C. (1999). Therapy impact on functional recovery in stroke rehabilitation. Physiotherapy, 85, 377
Lin, K. C., Hsieh, Y. W., Wu, C. Y., Chen, C. L., Jang, Y., & Liu, J. S (2009). Minimal detectable change and clinically important difference of the Wolf Motor Function Test in stroke patients. Neurorehabilitation Neural Repair, 23(5), 429-34. doi:10.1177/1545968308331144.
Lo, A. C., Guarino, P. D., Richards, L. G., Haselkorn, J. K., Wittenberg, G. F.,
Federman, D. G., … & Peter, P. (2010). Robot-Assisted Therapy for
Long-Term Upper-Limb Impairment after Stroke. New England Journal of Medicine, 362(19), 1772-1783. doi: 10.1056/NEJMoa0911341
Mazzoleni, S., Sale, P., Franceschini, M., Bigazzi, S., Chiar, M., Carrozza, D. P., & Posteraro, F. (2013). Effects of proximal and distal robot-assisted upper limb rehabilitation on chronic stroke recovery. Neurorehabilitation, 33(1), 33-39. doi: 10.3233/NRE-130925
Noorkoiv, M., Rodgers, H., & Price, C. I. (2014). Accelerometer measurement of upper extremity movement after stroke: a systematic review of clinical studies. Journal of Neuroengineering and Rehabilitation, 11. doi: 10.1186/1743-0003-11-144
Norouzi-Gheidari, N., Archambault, P. S., & Fung, J. (2012). Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: Systematic review and meta-analysis of the literature. Journal of Rehabilitation Research and Development, 49(4), 479-496. doi: org/10.1682/JRRD.2010.10.0210
Ottenbacher, K. J., Hsu, Y. W., Granger, C. V., & Fiedler, R. C. (1996). The reliability of the functional independence measure: A quantitative review. Archives of Physical Medicine and Rehabilitation, 77(12), 1226-1232. doi:10.1016/S0003-9993(96)90184-7
Rabadi, M. H., Galgano, M., Lynch, D., Akerman, M., Lesser, M., & Volpe, B. T. (2008). A pilot study of activity-based therapy in the arm motor recovery post stroke: a randomized controlled trial. Clinical Rehabilitation, 22(12), 1071-1082. doi: 10.1177/0269215508095358
Riddle, C. N., Edgley, S. A., & Baker, S. N. (2009). Direct and Indirect Connections with Upper Limb Motoneurons from the Primate Reticulospinal Tract. Journal of Neuroscience, 29(15), 4993-4999. doi: 10.1523/JNEUROSCI.3720-08.2009
Sale, P., Franceschini, M., Mazzoleni, S., Palma, E., Agosti, M., & Posteraro, F. (2014). Effects of upper limb robot-assisted therapy on motor recovery in subacute stroke patients. Journal of Neuroengineering and Rehabilitation, 11. doi: 10.1186/1743-0003-11-104
Taub, E., Miller, N. E., Novack, T. A., Cook, E. W., Fleming, W. C., Nepomuceno, C. S., & Crago, J. E. (1993). Technique to improve chronic motor deficit after stroke. Archives of physical medicine and rehabilitation, 74(4), 347-354.
Timmermans, A. A., Seelen, H. A., Willmann, R. D., & Kingma, H. (2009). Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design. Journal of Neuroengineering and Rehabilitation, 6(1). doi: 10.1186/1743-0003-6-1.
Uswatte, G., Taub. E., Morris, D., Vignolo, M., & McCulloch, K. (2005). Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real-world arm use. Stroke, 36(11), 2493-2496, doi: 10.1161/01.STR.0000185928.90848.2e
Volpe, B. T., Krebs, H. I., Hogan, N., Edelstein, L., Diels, C., & Aisen, M. (2000). A novel approach to stroke rehabilitation - Robot-aided sensorimotor stimulation. Neurology, 54(10), 1938-1944.
Volpe, B.T., Lynch, D., Rykman-Berland, A., Ferraro, M., Galgano, M., Hogan, N., & Krebs, H.I. (2008). Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke. Neurorehabilitation and Neural Repair, 22(3), 305-310. doi: 10.1177/1545968307311102
Wang, T. N., Lin, K. C., Wu, C. Y., Chung, C. Y., Pei, Y. C., & Teng, Y. K. (2011). Validity, Responsiveness, and Clinically Important Difference of the ABILHAND Questionnaire in Patients With Stroke. Archives of Physical Medicine and Rehabilitation, 92(7), 1086-1091. doi:10.1016/j.apmr.2011.01.020
Watson, C., & Harvey. A. R. (2009). Chapter 11: Projections from the Brain to the Spinal Cord. The Spinal Cord (pp. 168-179). San Diego: Academic Press.
Young, P. A., Young, P. H., & Tolbert, D. L. (2008). Basic Clinical Neuroscience. Wolters Kluwer Health/Lippincott Williams & Wilkins.