臺灣博碩士論文加值系統

背景：姿勢不穩定(postural instability)為巴金森氏症常見的現象，病患容易因此而跌倒，造成不必要的傷害。過去的研究指出，姿勢控制是由感覺、動作與認知系統交互運作所產生的結果。目的：本研究目的在於探討虛擬實境平衡訓練對於巴金森氏症病患姿勢穩定度在感覺、動作與認知三個層面的長短期療效，並與傳統平衡訓練以及無訓練者做比較。方法：本研究為隨機單盲試驗，共徵召42位原發性巴金森氏症病患(平均年齡: 70.6±6.3歲；侯葉分級:2~3)，以分層隨機的方式，將病患隨機分至「虛擬實境」組(n=14)、「傳統訓練」組(n=14)以及控制組(n=14)。訓練組將接受為期6週的訓練(2次/週，30分鐘/次)，控制組則不接受任何物理治療。每位受試者在訓練前、後與結束後4週接受平衡評估。評估項目包含電腦姿勢評估(SMART balance master, Neurocom®)、計時起走與特定活動平衡信心量表。電腦姿勢評估儀測試所採用的項目為：感覺整合測試(SOT)搭配雙項任務以及穩定極限度測試(LOS)。所使用的統計為三因子混合變異數分析( 3 訓練組 x 3 測試時間 x 2 任務)，並使用治療意向分析法(intention to treat)進行分析。結果： (1) 虛擬實境訓練顯著地增加感覺整合測試中「情境六」的平衡分數(單一任務與雙項任務)，而傳統平衡訓練則是顯著地增加「情境五」的平衡分數(單一任務與雙項任務)。此外，在「情境六」中，傳統訓練組在受次要任務的干擾下，其平衡分數顯著低下降，而虛擬實境訓練組則無顯著變化。兩種訓練方式的訓練效果在感覺整合測試中均傾向可維持至少四週；(2) 虛擬實境訓練顯著增加前向重心轉移的速度、後向轉移速度以及後向轉移最大位移，傳統訓練組對於重心轉移則無顯著訓練效果。前項重心轉移速度在四週的追蹤期間仍顯著地增加，而後向重心轉移速度與最大位移則傾向於維持不變；(3) 兩種平衡訓練均無法顯著增加執行特定活動的平衡信心指數；(4) 虛擬實境訓練無法顯著增加行走速度，而傳統平衡訓練除了可以增加行走速度外，亦傾向可維持訓練效果至少四週。結論：虛擬實境訓練有助於改善巴金森氏症患者之動靜態平衡，也使雙項任務的執行不至於退化，所以建議可列為復健訓練項目之一。

Background: Postural instability is common in subjects with Parkinson’s disease (PD), which makes it keen to fall and suffer from unnecessary injury. Previous studies demonstrated that postural stability is the results of interaction of sensory, motor and cognitive system. Purpose: In this study, we tried to investigate short tem and long term effects of virtual reality (VR) balance training on sensory, motor and cognitive domains of postural stability, while compared with conventional balance (CB) training and untrained control group (CG). Method: In this single blind randomized control trial, we recruited 42 PD patients (age: 70.6±6.3y/o；Hoehn and Yahr Stage:2~3)，and allocated them into VR group(n=14), CB group(n=14) and CG group (n=14) by stratified randomization. Both training groups received 6 weeks intervention (2sessions/week, 30 min./session) but the control group did not receive any kind of therapy. Each subject received assessments of postural stability before and after training period and at 4 weeks follow-up, including Sensory Organization test (SOT) with dual task paradigm and Limits of Stability test (LOS) of SMART balance master (Neurocom®), Timed up and go (TUG) and Activities-specific Balance Confidence scale (ABC) assessment. The 3-way mixed ANOVA (3 Groups x 3 Times x 2 Tasks) was used to test our hypotheses with intention to treat analysis. Results: (1) VR training significantly increased equilibrium score (ES) of SOT 6 either in single or dual task condition, and CB training significantly increased equilibrium score (ES) of SOT 5 either in single or dual task condition. Furthermore, secondary task significantly deteriorated ES of SOT 6 in CB group, but not for VR group. The improvements tended to be maintained for at least 4 weeks; (2) VR training significantly enhanced movement velocity (MVL) in forward direction, as well as MVL and maximal excursion (ME) in backward direction. MVL was increased continuously during 4 weeks follow-up, and MVL and ME in backward tended to be maintained; (3) both training programs did not increased ABC scores; (4) VR training did not increase walking speed, but CB training could significantly increase walking speed and tended to maintain the improvement for at least 4 weeks. Conclusion: VR training could improve static and dynamic balance and attenuate deteriorated effect of dual task on postural stability. Therefore, we suggested VR balance training could be added into rehabilitation programs to improve postural stability in PD patients.

誌謝 ii
中文摘要 iii
Abstract v
Chapter 1: Introduction 1
1.1 Background 1
1.2 Purposes and Hypotheses 3
1.3 Operational Definition 7
Chapter 2: Literature review 11
2.1 Mechanisms about normal postural control 11
2.2 Neuroanatomy and Pathways of Basal Ganglia: Relationship with Postural Control 13
2.2.1 Neuroanatomy and Pathways 13
2.2.2 Role of Basal Ganglia in Sensory Processing for Postural Control 15
2.2.3 Role of Basal Ganglia in Self-Initiated Postural Movement 18
2.3 Attention and Postural Control 20
2.4 Motor Learning and Training Effect of postural instability in PD patients 30
2.4.1 Motor Learning in PD Patients 30
2.4.2 Effects of Balance Training on Postural Stability in PD Patients 32
2.5 Applications of virtual reality in motor rehabilitation 33
Chapter 3: Material and Methods 41
3.1 Participants 41
3.2 Study Design 42
3.3 Clinical Assessments 42
3.3.1 Baseline Assessments 42
3.3.2 Outcome Measures 43
3.4 Laboratory Assessments for Postural stability 44
3.4.1. Static Balance with Sensory integration Assessments 44
3.4.2 Dynamic Balance with Voluntary Motor Control Assessments 46
3.4.3 Cognition System (Attention) Assessments 46
3.5 Experimental Equipments 47
3.5.1 Computerized Dynamic Posturography 47
3.5.2 Auditory Stimulator, Sound Level Meter and MP100 System 47
3.5.3 VR System for Balance Training 48
3.6 Experimental Procedure 51
3.6.1 Procedure of LOS Test—Single Task Only 52
3.6.2 Procedure of SOT-- Single and Dual Tasks 52
3.6.3 VR Balance Training Protocol 54
3.6.4 Conventional balance training protocol 56
3.7 Data Analysis 58
3.8 Statistical Analysis 59
Chapter 4：Results 60
4.1 Subjects Recruitment 60
4.2 Pre-Intervention Assessments 61
4.3 Static balance: SOT under Single and Dual Task Condition 61
4.3.1 Equilibrium Score (ES) of Six Conditions with Single and Dual tasks 61
4.3.2 Sensory Ratio 63
4.3.3 Verbal Reaction Time of SOT under Dual Task Condition 64
4.4 Dynamic Balance: LOS test 64
4.4.1 Movement Velocity (MVL) 64
4.4.2 Maximum Excursion (ME) 66
4.4.3 Directional Control 67
4.5 Activities-Specific Balance Confidence (ABC) 67
4.6 Timed up and Go (TUG) 67
Chapter 5：Discussion 69
5.1 Major Findings 69
5.2 Methodologies 71
5.3 Effects of Balance Training on Static Balance under Single and Dual Task Condition 71
5.3.1 Comparison with previous studies 71
5.3.2. Possible Underlying Mechanisms of VR training: Somatosensory vs. Visual vs. Vestibular components 73
5.3.3 Training effect on attention 74
5.4 Effects of Balance Training on Dynamic Balance 75
5.4.1 Comparison with Previous Studies 75
5.4.2. Underlying Mechanisms of VR Training: Voluntary Weight Shifting 76
5.5 Effects of Balance Training on Confidence of Maintaining Balance 78
5.6 Effects of Balance Training on Functional Balance Performance 78
5.7 Clinical Implication 79
5.8 Study Limitations and Further Study 79
5.9 Conclusion 81
Reference 82

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