臺灣博碩士論文加值系統

中文摘要
肌肉張力異常是上運動神經元疾病患者臨床上常見的症狀。其中如痙攣現象經常發生於中風偏癱、腦外傷、腦性麻痺等病患身上，常對肢體功能產生重大影響。臨床上使用持續肌肉牽張的治療方法，對於小腿後肌已證明具有降低肌張力的療效。然而肌肉牽張的治療方式，卻因痙攣程度量化不易及牽張強度無定量描述而無法有標準的治療規範。本研究的目的在於發展一套能隨時偵測長時間伸張治療的力量，且兼具伸張治療及評估的儀器。這套儀器踝關節的腳板可直接產生正弦波的評估模式，伸張治療部分包含固定力量、固定角度與正弦牽張等模式，臨床治療師能方便操作系統並客觀分析各種參數的情況下量化伸張治療的強度與評估治療效果。
在儀器的研發方面，以微電腦控制伺服馬達對患者踝關節作伸張治療及牽張，記錄馬達位置變化及踝關節因伸張治療或牽張反射所引發的扭力。在控制流程方面，以圖形使用介面整合評估與治療模式於自行開發的LabVIEW程式當中，讓臨床人員能以設定相關參數，在安全、方便操作、有效率之情況下評估或治療患者。經過驗證後顯示，在評估及治療方均可達到設計的速度與角度。而在評估固定力量牽張模式對痙攣之治療效果上，二十五位中風患者接受三十分鐘固定力量牽張模式之治療，於治療前、後患者均接受踝關節角度、Modified Ashworth Scale (MAS)及正弦波的評估，其中當正弦波的評估時所記錄到的扭力值，又可區分出彈力與黏滯力。結果發現，患者在接受了三十分鐘固定力量牽張模式之治療後，不論在踝關節角度、MAS及彈力與黏滯力方面，均有明顯的改變。
在臨床應用部份，我們比較固定角度、正弦牽張與固定力量等三種治療模式在抑制痙攣上的效果是否有差異，希望能提供臨床治療師在選擇抑制痙攣方法上的參考。三十三位中風患者以三週的時間，隨機接受固定角度、正弦牽張與固定力量等三種治療模式，於三十分鐘的治療前、後均接受踝關節角度、MAS及正弦波的評估，結果發現，患者不論接受何整治療模式，在三十分鐘之治療後，不論在踝關節角度、MAS及彈力與黏滯力方面，均有明顯的改變；若比較三種治療模式在抑制痙攣上的效果是否有差異時，則發現固定角度的治療模式在踝關節角度、MAS及彈力與黏滯力方面的改變量與接受正弦牽張後所造成之改變量並沒有明顯的差異，而接受固定力量的治療模式在踝關節角度、MAS及彈力與黏滯力方面的改變量均明顯大於比接受固定角度或正弦牽張等治療模式所造成之改變量。顯示本研究所提出之系統與治療模式可提供臨床一個有效量化及治療踝關節痙攣的方法。

Abstract

Spasticity often obstructs the functional performance of patients with upper motor neuron lesion, such as stroke, traumatic brain injury, cerebral palsy etc. Clinical application of prolonged muscle stretch (PMS) for calf muscle has been proven to be an effective approach to reduce excessive muscle tone. However, PMS technique has failed to provide proper treatment criteria due to the incapacity to detect the severity of spasticity and to quantify the stretch force used during PMS. The aims of this study include developing a spasticity treatment/assessment system, quantifying the effectiveness of PMS on inhibition of ankle spasticity in stroke patients, and comparing the treatment effects of varied stretching methods.
A quantitative PMS treatment/assessment system was first designed that was not only used to evaluate the degree of spasticity by determine the reactive torque to a sinusoidal movement of the ankle joint but also applied to treat the spasticity with a constant stretching force. To quantify the effectiveness of PMS, ankle plantarflexors were stretched with constant torque in twenty-five subjects with hemiplegia and calf muscles spasticity. Assessments of ankle plantarflexor performed before and after 30 minutes of PMS treatment that was executed by a spasticity treatment/assessment system. To assess the degrees of spasticity, the torque of the ankle joint was measured with sinusoidal movements by the spasticity treatment/assessment system and the torque was divided to two biomechanical indices, i.e., the elastic (Kei) and viscous (Kv) components. Besides, spasticity at ankle joint measured using the Modified Ashworth Scale (MAS) and passive range of motion (ROM) of ankle joint measured using a goniometer for clinical measures. Differences in clinical measures as well as biomechanical indices before and after PMS were compared.
Our results indicated that the elastic, viscous components and MAS of the ankle joint were reduced significantly (p<0.05) and the ROM of ankle joint was increased significantly (p<0.05) by applying 30 minutes of PMS with varies of stretch force according to the severities of spasticity. The present results suggested that the PMS with constant torque could effect not only on the elasticity but also on the viscosity of the spastic muscles. Further studies were conducted to compare the effectiveness of three stretching mode: PMS with constant angle, cyclic stretching and constant angle treatment modes. Thirty-three subjects underwent constant-angle, cyclic, or constant-torque stretching of the ankle joint in randomly selected order. Those treatments were separated from each other by one week and were completed at the same time of day. The duration of each stretching time was 30 minutes similar to previous PMS studies that exhibited significantly clinical effects.
The results showed that 30 minutes of constant-angle, cyclic and constant-torque stretching of the hypertonic ankle joint resulted in significant ROM increases, MAS, Kei and Kv decreases in our study (p<0.05). Among these three treatment methods, the treatment effect of the constant-torque stretching is significantly greater than those effects of the constant-angle and cyclic stretching (p<0.05). The constant-torque stretching is a new approach method in inhibiting the hypertonia and seems to be more effective than the conventional constant-angle and cyclic PMS methods.

Table of Contents

Chinese Abstract…………………………………………………………………………i
Abstract…………………………………………………………………………………iii
Acknowledgments…………………………………………………………………………vi
Table of Contents……………………………………………………………………………vii
List of Tables……………………………………………………………………………ix
List of Figures…………………………………………………………………………x

Chapter 1 Introduction………………………………………………………………………1
1.1 The Mechanisms of spasticity……………………………………………………1
1.2 Assessments of spasticity………………………………………………………8
1.2.1 Clinical evaluations…………………………………………………………….8
1.2.2 Electrophysiological evaluations…………………………………………….11
1.2.3 Biomechanical measurements…………………………………………………….14
1.3 Treatments of spasticity.………………………………………………………18
1.4 Motivation and specific aims……………………………………………………22

Chapter 2 Material and Methods…………………………………………………………25
2.1 Integration of PMS treatment/asessment system…………………………….25
2.2 Experimental protocal…………………………………………………………….28
2.2.1 Subjects………………………………………………………………………28
2.2.2 Assessment of spasticity……………………………………………………31
2.2.3 Treatment procedure…………………………………………………………32
2.3 Data Analysis………………………………………………………………………34
2.3.1 Treatment effect of constant-torque stretching……………………………35
2.3.2 Treatment effect of three stretching modes…………………………………35

Chapter 3 Results……………………………………………………………………………37
3.1 Validity tests of the PMS treatment/assessment system…………………37
3.2 Treatment effects of constant-torque stretching…………………………43
3.3 Treatment effects of varied stretching modes………………………………50

Chapter 4 Discussion and Conclusion………………………………………………………61
4.1 Discussion…………………………………………………………………………61
4.2 Conclusion…………………………………………………………………………67

Appendix……………………………………………………………………………………68
Appendix A………………………………………………………………………………68
Appendix B………………………………………………………………………………70
Appendix C………………………………………………………………………………72

Reference…………………………………………………………………………………74

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