臺灣博碩士論文加值系統

上運動神經元患者，一側肢體在從事活動時，對側肢體也不自覺的會有一些不自主的動作，這個現象稱為協同反應(associated reaction)，出現在大約80﹪的中風患者。行走時上肢嚴重的協同反應會使痙攣性步態更惡化，影響行走的平衡和安全，而且Bobath的神經發展理論強調不正常的動作型態的抑制，可以促進正常的動作發展，因此過去有許多復健手法來治療協同反應，但都沒有明顯的療效，主要是對肌肉痙攣的處置，未能滿意。肉毒桿毒菌素在這幾年來廣泛應用於肌肉痙攣的治療。在頭部外傷、中風、腦性麻痺等引起的上、下肢肌肉痙攣皆有顯著的療效，協同反應被認為和上肢屈肘肌的肌肉痙攣有關，因此我們假設在使用肉毒桿菌毒素治療腦傷患者，可以降低協同反應的產生，並進而改善步態。
本研究選擇中風三個月後且患側上肢有顯著協同反應的患者，將肉毒桿菌毒素注射至患側的肱二頭肌及其他有明顯痙攣的上肢肌肉，注射前及注射後2，4，6，12週，我們利用modified Ashworth scale，modified Tardieu scale, associated reaction rating scale及步態分析來做療效的評估，統計分析是利用paired t test比較治療前及治療後的評估資料。一共有10位患者參與本研究，平均年齡54.6歲，結果顯示經過肉毒桿菌毒素治療後，患側肱二頭肌的modified Ashworth scale 及modified Tardieu scale皆有顯著改變，療效可維持12週；患側上肢的associated reaction rating scale也有顯著改善；步態分析顯示在注射後受試者的步長變長，步寬變短，患側膝關節的外展，內收角度，肩關節的外展，內收，以及屈曲，伸直角度有顯著增加。根據本研究我們認為肉毒桿菌毒素可以顯著降低中風患者的肌肉痙攣及協同反應，此外也可以改善步態。

In hemiplegic patients, a motor activity, especially if it involves excessive effort, frequently results in involuntary reactions of muscle in the other limbs. The phenomenon is known as associated reaction. Associated movement of the spastic upper limb have been reported in 80% of hemiplegic stroke patients and are characterized by sudden flexion at the elbow and abduction and elevation of the shoulder. It is hypothesized that the treatment of localized muscle spasticity with type A botulinum toxin would abolish the associated reactions and improve balance and mobility. This study is designed to investigate the biomechanical change in associated reaction and spastic gait after botulinum toxin treatment.
Ambulatory hemiplegic stroke patients with significant associated reaction of the upper limb during walking were recruited at least 3 months after stroke. Type A botulinum toxin (BOTOX, Allergan) was injected into the belly of the biceps brachii and other spastic muscle of paretic upper limb. Modified Ashworth scale and modified Tardieu scale were used to evaluate spasticity. Associated reaction was evaluated by associated reaction rating scale. Vicon 460 motion analysis system was used for evaluation of the effect of the botulinum toxin on spastic gait. All the procedures of assessment were performed before and 2, 4, 6, 12 weeks after injection. Paired t test was used to compare the pre-injection and post-injection data, in order to test the effect of clinical treatment.
Ten patients were recruited in this study. The average age was 54.6 year old. Modified Ashworth scale and modified Tardieu scale of biceps brachii showed significant reduction of spasticity after treatment of botulinum toxin. The effect lasted for 12 weeks. Associated reaction during ambulation also improved after botulinum toxin injection. Gait parameters including step length and step width changed significantly after botulinum toxin injection. Joint range of motion of paretic side including shoulder abduction and adduction, shoulder flexion, extension, knee abduction and adduction also increased significantly. In our study, botulinum toxin injections in the paretic upper limb of the stroke patients not only reduce spasticity and associated reaction but also improve gait performance.

學位考試委員審定書……………………………………………….1
中文摘要…………………………………………………………….2
英文摘要…………………………………………………………….4
致謝………………………………………………………………….6
目錄………………………………………………………………….7
圖目錄……………………………………………………………….9
表目錄………………………………………………………………10

第一章 前言…………………………………………………..11
第一節 研究背景………………………………………………11
1.1.1 腦中風……………………………………………….11
1.1.2 協同反應…………………………………………….13
1.1. 3肉毒桿菌毒素………………………………………..16
1.1.4 研究動機…………………………………………….18
第二節 研究目的………………………………………………19
1.2.1 研究目的…………………………………………….19
1.2.2 研究假設…………………………………………….19
第二章 研究方法…………………………………………..…20
第一節 研究材料………………………………………………20
2.1.1 研究對象…………………………………………….20
2.1.2實驗設備……………………………………………..21
第二節 研究設計………………………………………………23
2.2.1 實驗步驟…………………………………………….23
2.2.2 療效評估………………………………………………25
第三節 統計方法………………………………………………..32
第三章 研究結果……………………………………………….34
第一節描述性統計分析………………………………………….34
第二節推論性統計分析………………………………………….38
3.2.1 肌肉痙攣的臨床評估…………………………38
3.2.2 協同反應的評估………………………………………40
3.2.3步態分析的結果…….…………………………………41
第四章 討論……………………………………………………..48
第一節結果討論………………………………………………….48
4.1.1 上肢肌肉痙攣…………………………………………48
4.1.2 協同反應………………………………………………51
4.1.3 偏癱上肢痙攣治療和步態的關係 .………………….54
第二節研究限制……..…………………………………………..57
第五章結論…….…………………………………………………..58
參考文獻……………………………………………………………59

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