臺灣博碩士論文加值系統

背景與目的：在日常生活當中時常需要在行走的狀態下同時執行認知性或是動作性的任務(稱為雙重任務)。而巴金森氏症患者在執行行走雙重任務時，患者步態損傷會加劇且會增加跌倒的危險性。過去利用認知性雙重任務步態訓練對於巴金森氏症患者在單獨任務下和雙重任務下步態能力的研究尚未有明確結論。然而利用動作性雙重任務步態訓練對於巴金森氏症患者的效果目前則尚未得知，此外，亦未有研究比較此兩種介入方式之療效。因此本研究之目的為探討認知性及動作性雙重任務步態訓練對於巴金森氏症患者步態表現之成效，以及比較動作性或認知性雙重任務步態訓練對於巴金森氏患者之成效。
方法：本研究為隨機分配單盲試驗。將巴金森氏症患者隨機分配到控制組、動作性雙重任務步態訓練組或認知性雙重任務步態訓練組。控制組的受試者接受傳統步態訓練以及跑步機訓練。動作性雙重任務步態訓練組或認知性雙重任務步態訓練組分別在接受步態訓練的狀態下同時執行另一動作任務或是認知任務。每組每次訓練30分鐘，每周三次，共計四周12次。並分別在接受治療前和治療後進行測量。主要成果測量包括動作性及認知性雙重任務步態表現以及雙重任務效應。次要成果測量包含單獨任務之步態表現、認知能力表現、起身行走測試(timed up and go test, TUG)、步行凍結量表(freezing of gait questionnaire, FOGQ)、自評跌倒關注程度量表(fall efficacy scale-international, FES-I)、以及巴金森氏症生活品質問卷 (Parkinson's disease questionnaire 39, PDQ39)。各項步態表現以步態測試儀(GAITRite®)進行測試。
統計分析：各項測量之前測值以克瓦單因子等級變異數分析(Kruskal-Wallis one-way analysis of variance by ranks)檢測三組受測者是否有差異，並以曼惠特尼U檢定(Mann-Whitney U test)進行事後檢定，而類別變項以卡方檢定(chi-square test)檢測三組間是否有差異。使用魏氏帶符號等級測試(Wilcoxon signed ranks test)比較各組在治療介入前後是否有組內差異。以克瓦單因子等級變異數分析檢測三組之間在各參數之改變量是否有組間差異，再以曼惠特尼U檢定進行事後檢定。統計顯著水準為p<0.05。
結果：共計18位受試者加入本研究，經隨機分配後，每組各6人。經4周，共計12次的訓練後，認知性雙重任務步態訓練組，相較於其他兩組，明顯的減少在認知性雙重任務行走時雙腳支撐的時間(p=0.026, p=0.041分別與動作性雙重任務組及控制組相比)，而動作性雙重任務步態訓練組則是在動作性雙重任務步態表現的跨步時間變異性較其他兩組有明顯的改善(p=0.015, p=0.041分別與認知性雙重任務組及控制組相比)。若以治療前後之變化來看，認知性雙重任務組在認知性及動作性雙重任務步態表現、一般行走步態表現及起身行走測試，都有明顯的進步；而動作性雙重任務組在執行功能測試量表及步行凍結量表有明顯的進步，傳統步態訓練則沒有觀察到較明顯的改善。
結論：本研究顯示，不同雙重任務步態訓練對巴金森氏症患者之雙重任務步態表現，可能有某些特殊性，即利用認知性雙重任務步態訓練，可較有效改善認知性雙重任務步態雙腳支撐的時間。而動作性雙重任務步態訓練，則可改善患者在動作性雙重任務的步態變異性，未來需要更多研究以確認本研究之結果。

Background and purpose: Mobility in daily life requires walking while performing simultaneously cognitive or motor tasks (dual task walking). Patients with Parkinson’s disease (PD) demonstrate gait impairments which are even exacerbated during dual task walking. The cognitive dual task and motor dual task affect gait performance in patients with PD, including step length, gait speed, cadence and stride variability. Especially, the cognitive dual task increased the freezing episodes in patients with PD. Motor dual task gait training can improve the gait performance in stroke patient, but such effect in PD patients is not immediately known. On the other hand, cognitive dual task training has been proposed to improve gait and dual task gait performance in patients with PD, however, these results have not been validated by randomized controlled trials. Furthermore, whether cognitive and motor dual task training exert different effects are not established yet. Therefore, the purpose of this study was to investigate the motor and cognitive dual task gait training on dual task walking performance and to compare the different effects of motor and cognitive dual gait training in individuals with PD.
Methods: This was a randomized controlled trial with pre- and post- measurements. Individuals with PD participated in this study and were randomly assigned to one of three groups, the control, motor dual task and cognitive dual task group. Participants in the control group received the traditional gait training and treadmill training. Participants in the motor and cognitive dual task group practiced the motor and cognitive dual task gait training respectively. The intervention was 30 minutes per session, 3 sessions per week for a total of 4 weeks. The primary outcomes included the dual task gait performance under the motor and cognitive task and the dual task effect. The secondary outcomes included single task gait performance, cognitive performance, functional ability measured by timed up and go test (TUG), freezing of gait measured by freezing of gait questionnaire (FOGQ), fear of fall measured by fall efficacy scale-international (FES-I) and quality of life measured by Parkinson's disease questionnaire 39 (PDQ39). The above mentioned gait performance was measured by GAITRite®system.
Statistic analysis: The Kruskal-Wallis one-way ANOVA by ranks and chi-square test were used for basic data analysis. The Wilcoxon signed ranks test was used for within group comparisons. The Kruskal-Wallis one-way ANOVA by ranks was used for change score between group comparisons with Mann-Whitney U test for post hoc test. The statistical significance was set at p < .05.
Results: A total of 18 participants were included in this study. There were 6 subjects in each group after randomization. After 4 weeks of intervention, participants in the cognitive dual task gait training group decreased significantly more in double support time during cognitive dual task walking as compared with the other two groups (p=0.026, p=0.041vs. motor dual task gait training group and control group respectively). The motor dual task gait training can significantly decrease the stride time variability during the motor dual task walking than the other two groups (p=0.015, p=0.041vs. cognitive dual task gait training group and control group respectively). Regarding the within group comparisons, cognitive dual task gait training can improve the cognitive and motor dual task gait performance, single task gait performance and TUG. The motor dual task gait training can improve the executive function and freezing of gait. The traditional gait training, however, did not result in significant improvement.
Conclusion: According to our results, different dual task gait training may exert different effects in individuals with PD. The cognitive dual task training may improve double support time during cognitive dual task gait performance, and the motor dual task may improve the stride time variability during motor dual task gait performance. Further studies are suggested to validate our results.

目錄
目錄....................................................I
表目錄................................................III
圖目錄.................................................IV
中文摘要.................................................V
英文摘要...............................................VII
第一章 緒論..............................................1
第一節 研究背景與動機.....................................1
第二節 研究目的..........................................1
第三節 研究假設..........................................1
第四節 研究重要性.........................................1
第二章 文獻回顧..........................................3
第一節 雙重任務..........................................3
第二節 巴金森氏症患者雙重任務之表現........................4
第三節 雙重任務步態訓練...................................5
第四節 總結..............................................5
第三章 研究方法..........................................7
第一節 研究設計..........................................7
第二節 研究對象..........................................7
第三節 研究流程..........................................7
第四節 治療介入..........................................7
第五節 結果評估..........................................9
第六節 資料分析與處理....................................11
第四章 結果.............................................12
第一節 受試者基本資料與前測值.............................12
第二節 認知性雙重任務步態表現.............................12
第三節 動作性雙重任務步態表現.............................13
第四節 一般步態表現......................................14
第五節 執行功能測試量表..................................15
第六節 起身行走測試......................................15
第七節 步態凍結量表......................................15
第八節 自評跌倒關注程度量表...............................15
第九節 巴金森氏症生活品質問卷.............................15
第五章 討論.............................................17
第一節 認知性雙重任務步態表現.............................17
第二節 動作性雙重任務步態表現.............................18
第三節 一般行走步態表現..................................18
第四節 執行功能測試量表..................................19
第五節 起身行走測試......................................19
第六節 步態凍結量表......................................20
第七節 自評跌倒關注程度量表...............................20
第八節 巴金森氏症生活品質問卷.............................20
第九節 研究限制與未來建議.................................21
第十節 臨床應用.........................................21
第六章 結論.............................................22
參考文獻...............................................23
附錄...................................................38
附錄一、同意臨床試驗證明書...............................38
附錄二、控制組每周各次步態訓練內容........................40
附錄三、認知性雙重任務組每周各次訓練內容...................41
附錄四、動作性雙重任務組每周各次訓練內容...................43
附錄五、功能執行測試量表..................................45
附錄六、步態凍結問卷.....................................52
附錄七、自評跌倒關注程度量表..............................53
附錄八、巴金森氏症生活品質問卷............................54

表目錄
表一、受試者基本資料....................................30
表二、受試者在各種任務下步態表現之前測值...................31
表三、受試者其他評估項目之前測值..........................32
表四、認知性雙重任務步態表現在治療前後及改變量之比較.........33
表五、動作性雙重任務步態表現在治療前後及改變量之比較.........34
表六、一般行走步態表現在治療前後及改變量之比較..............35
表七、其他評估項目在治療前後及改變量之比較..................36

圖目錄
圖一、研究流程圖.........................................37

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