傾斜床訓練術常用於治療脊髓損傷病患起坐性暈眩的物理治療方法，但目前傾斜床之傾斜角度與變化速度的控制，仍需依賴醫護人員的經驗與手動控制。如何避免脊髓損傷病患在傾斜床訓練中，暈眩時過低的血壓造成生理的傷害，已成為脊髓損傷病患復健上重要的課題。因此，本研究嘗試研究起坐性暈眩程度與生理訊號值之間的關係，設計一生理訊號回饋監控式傾斜床系統以增加傾斜床訓練的安全性與治療效率。生理訊號回饋監控式傾斜床系統設計成三個閉迴路自動控制程序：傾斜角度與時間訓練程序、生理訊號取得監控與病患暈眩程度回饋控制傾斜床面角度。結果顯示，起坐性暈眩程度（level of presyncope symptoms）、損傷程度（ASIA grade）與傾斜角度(tilt angle)會影響脊髓損傷病患的生理訊號值。平均血壓(mean blood pressure)、血氧濃度SpO2(oxygen saturation)與心率變異高低頻比（LF/HF ratio of heart rate variability）為較合適回饋控制傾斜床之生理訊號，其中血氧濃度SpO2 於不同暈眩程度上的差異表現最好。血氧濃度在短時間表現暈眩程度有良好的辨識度，但血氧濃度無法表示病患整體起坐性暈眩的程度或病患起坐性暈眩復原程度。瞭解病患暈眩的復原情況在復健治療中具有相當重要的意義，因此本研究開發一復原指數演算法，利用目前血氧濃度值、復原後血氧濃度值、病患最低血氧濃度值與接受訓練時間等參數，計算每次脊髓損傷病患接受傾斜床訓練之起坐性暈眩狀態。復原指數研究結果顯示，復原指數演算法證實有效可行，本演算法計算之復原指數值與病患真實的臨床訓練表現比較極為相符，而復原指數值的變化趨勢也可提供預估療程與完全復原所需時間的資訊。因此本研究提供血氧濃度與復原指數之參數，能提供物理治療師安全與有效的資訊與標準，協助物理治療師能針對每個病患的生理狀況，設計合適個人的療程。此參數亦為生理訊號回饋監控式傾斜床設計之重要依據。本研究發展生理訊號回饋監控式傾斜床與臨床成果，相信能增加傾斜床之附加價值與提升台灣醫療產業的競爭力。

Tilt-table training is commonly used in clinical physiotherapy to overcome orthostatic syncope in patient with spinal cord injury (SCI), but this also relies on careful manual control of the tilt angle and training time by the experience of therapist. To estimate the symptoms of orthostatic syncope to avoid the physiological damage by excessive hypotension is an important issue in rehabilitation of the patient with SCI. For these reasons, we attempted to investigate the relationship between the levels of orthostatic presyncope symptoms (PS) and the physiological signals, and to develop a physiological signal feedback control tilt table system to increase the safety and efficiency during tilt-table training. The feedback tilt-table was designed with automatic training maneuvers and three closed feedback loops that included controlling the tilting maneuvers, monitoring the acquisition of physiological signals from patients, and monitoring the feedback of presyncope symptoms to regulate the angle of tilt. The results showed that the levels of PS, tilt angle and ASIA grade (level of injury) could affect the physiological signals during head-up tilting in quadriplegic SCI patients, and the mean blood pressure (MBP), Oxygen satureation (SpO2) and ratio of hent rate variability (LF/HF) ratio are the suitable signals to determine the threshold of physiological feedback for the physiological feedback control tilt table system. Although the appears to be the most sensitive factor in the determination of PS, it is necessary to consider the complex effects of tilt angle and severity of the SCI, and it could only provide the transient information of PS. For reason, we developed a mathematical formula for the calculation of the recovery index which was proven workable and capable of estimating the orthostatic syncope status of SCI patients during tilt-table training. The results showed that the recovery index accurately estimated the process of recovery from orthostatic syncope of SCI patients and might provide the information required to forecast the training course that could be required for complete recovery from orthostatic hypotension. The parameters of SpO2 and recovery index should provide safe and efficient normative data for the physiotherapist, and help in the design of the training courses in the feedback-controlled tilt-table system.

Contents
中文摘要.……..…..………………………………………………………….………I
Abstract..…………………………………………………………………...………III
謝誌(Acknowledgment) ………………………………..…...…………...……..V
Contents…………………………………………………………………...……....VI
List of Figures…………………………………………..……………...………....X
List of Tables………………………………..……………...…………………..XIII

Chapter 1 Scope of The Thesis…………….……..…..………….…..……1

Chapter 2 Introduction of Physiological Responses of ......................7
Orthostatic Syncope in Patient with Spinal
Cord Injury
Anatomy of the Spine and Spinal Cord………….…………..…....9
Spinal Cord and Spinal Nerves…………………….………….....10
Spinal Cord Injury…………………………….……………....….10
Complete Spinal Cord Injury……………………………........….12
Incomplete Spinal Cord Injury………………………………...…14
Level of Injury…………………………………………..…….….16
Clinical Effects of Traumatic Spinal Cord Injury………………..17
The Respiratory System in Spinal Injury Pathophysiology…..….18
Arterial Blood Gases…………………………………………..…21
Autonomic Dysfunction in Quadriplegic Patient……………...…22
Characteristics of the Spinal Cord Injury Population ....................30
Orthostatic Hypotension…………………………………….……31
Tilt-Table Testing………………………...…………………..…..33
Normal Responses to Changes in Posture......................................36
Complete Quadriplegia Responses to Changes in Posture……….37
Summary……………………………………………………...….49
References…………………………………………………….….51

Chapter 3 Development of a Biofeedback Tilt Table…………….….61
for Investigating Orthostatic Syncope in
Patients with Spinal Cord Injury
Abstract…………………………………………………………..63
Introduction………………………………………………………64
Methods…………………………………………………………..66
Definition of Presyncope Symptoms……..…..………………...66
Hardware Design………………………………….……………67
Software Design…………………………………….………….69
Clinical Testing……………………………………………...…73
Results……………………………………………………………74
Discussion…………………………………………………….….77
Summary……………………………………………………...….80
References…………………………………………………….….81

Chapter 4 Relationships between Physiological Responses..…...85
and Presyncope Symptoms during Tilting up in
Patients with Spinal Cord Injury
Abstract…………………………………………………………..87
Introduction………………………………………………………88
Methods…………………………………………………………..90
Hardware Design………………………………….……………92
Protocol of Tilt-Table Training……………………...…………93
Statistical analysis………………….……………….………….93
Results……………………………………………………………94
Mean Blood Pressure….………………………….……………94
Oxygen Saturaiton…………………………………...…………95
Heart Rate……….………………….……………….………….96
Heart Rate Variability..…………….……………….………….97
Discussion………………………………………………………102
Summary……………………………………………………..…106
References………………………………………………….…...107

Chapter 5 Using Oxygen Saturation to Estimate the index…...…111
of Recovery from Orthostatic Syncope in
Patients with Spinal Cord Injury
Abstract……………………………………………………...….113
Introduction……………………………………………………..116
Methods…………………………………………………………118
Statistical analysis………………….……………….………...122
Results…………………………………………………………..123
Discussion………………………………………………………129
Summary……………………………………………………......135
References………………………………………………………136

Chapter 6 Conclusion and Perspective Work .….….……………….139

Chapter 7 Appendix .…………………………...……………………...….145

Biographical Sketch…………...…………………………..………...……….155

List of Publications…………………………...……………………...……….157

List of Figures
Fig. 1 The framework of the thesis…………………………………………………….4
Fig. 2.1 Vertebral column…………………………………………………………….11
Fig. 2.2 Typical vertebra……………………………………………………………...11
Fig. 2.3 Dorsal and ventral spinal nerve roots………………………………………..12
Fig. 2.4 The segmental innervation of the major respiratory muscles……………….20
Fig. 2.5 Dual innervation in the autonomic nervous system………………………....28
Fig. 2.6 Autonomic reflex response that controls blood pressure when a person
stands up……………………………………………………....…………....29
Fig. 2.7 Area of the brain that regulate autonomic function………………………....30
Fig. 2.8 Various responses to tilt table testing..............................................................35
Fig. 2.9 Average course of systolic and diastolic blood-pressure and pulse-rate
of a group of patients with high SCI in a single orthostatic tilt-table
exercise at the end of their clinical treatment in comparison with
a group of healthy persons…………………………………………...…….39
Fig. 2.10 Mean arterial pressure (MAP) and heart rate (HR) during head-up
tilting in quadriplegic and control subjects……………………………..….40
Fig. 2.11 Plasma vasopressin concentration (AVP), PRA and plasma ANP
concentration during head-up tilting in quadriplegic and control
subjects……………………………………………………………………..40
Fig. 2.12 Mean velocity of cerebral blood flow in the middle cerebral artery
in tetraplegic patients during tilting expressed as percentage change
from baseline…………………………………………………………...…..43
Fig. 2.13 Heart rate response to changes in posture………………………………….46
Fig. 2.14 Frequency-domain indexes in the three groups of subjects over the
whole experiment and separately in the three conditions………………..…47
Fig. 2.15 Preceived presyncope score (PPS) for subjects with recent and
long-standing injury at increasing angles of tilt…………………………....48
Fig. 2.16 The proportion of subjects reporting presyncopal symptoms at each
angle of tilt in both tilting alone and tilting with functional electric
stimulation……………………………………………………………….....49
Fig. 3.1 Block diagram of the hardware structure of the biofeedback tilt table……...69
Fig. 3.2 The structure of the three closed feedback loops in the biofeedback
tilt-table system.………………………………………………………...….71


Fig. 3.3 Clinical assessments of the biofeedback tilt-table system for (A)
mean blood pressure, and (B) oxygen saturation parameters during
head-up tilt-table training.……………………………………………….…76
Fig. 4.1 Relationship between mean blood pressure(MBP), oxygen saturation
(SpO2), heart rate(HR), and LF/HF of heart rate variability with
ASIA grades: A, B,and C by using the least significant difference(LSD)
test of multivariate analysis of variance for the different title angles
when the presyncope symptoms(PS) is PS 1………………………………99
Fig. 4.2 Relationship between the ASIA grades: A, B, and C with mean
blood pressure(MBP), oxygen saturation(SpO2), heart rate(HR),
and LF/HF of heart rate variability at different tilt nangles:
0 degree, 30 degree, 45 degree, 60 degree, and 75 degree
by using the least significant difference(LSD) test of multivariate
analysis of variance in asymptomatic subjects…………………………..100

Fig. 4.3 Relationship between the levels of presyncope symptoms(PS)
with the tilt angles by using the lest significant difference(LSD)
test of multivariate analysis variance for each physiological
signal of MPB, SpO2, HR and LF/HF in ASIA A………………………101

List of Tables

Table 2.1 ASIA grade functional classification……………………………………....15
Table 2.2 Motor level classification………………………………………………….17
Table 2.3 Lung volumes and spirometry on chronic patients (% normal)…………...21
Table 2.4 Improvement of vital capacity following injury…………………………..21
Table 3.1 The physiological responses of subjects with low and high
symptoms during head-up tilt-table training……………………….………75
Table 4.1 Summary quadriplegic data of SCI subjects……………………..………..91
Table 5.1 The characteristic of the eight spinal-cord-injured subjects………..……119
Table 5.2 Quantitative criteria of presyncope symptoms………………...…………119
Table 5.3 The relationship between the recovery index, the maximum
PS level, and the minimum tilt angle while symptomatic in eight
spinal-cord-injured patients with orthostatic syncope during tilt-table
training……………………………………………………………………126
Table 5.4 Recovery indexes recorded throughout the entire training period
for subjects B, D, and E………………………………………………..….127
Table 5.5 Compare the recovery index between the different periods of
tilt-table training in spinal-cord-injured patients: first, median,
and last training sessions, and at the recovery stage……………...………128
Table 7.1 The database of orthostatic responses of 39 patients with spinal
cord injury in systolic blood pressure (SBP), diastolic blood pressure
(DBP) and mean blood pressure (MBP) ………………………..………..147
Table 7.2 The database of orthostatic responses of 39 patients with spinal
cord injury in heart rate (HR), low frequency (LF) of heart rate
variability (HRV), high frequency (HF) of HRV and LF/HF radio
of HRV………………………………………………………..…..………150
Table 7.3 The database of orthostatic responses of 39 patients with spinal
cord injury in oxygen saturation (SpO2). ……………………..…..………154

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Chapter 4
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6. Gonzalez F, Chang JY, Banovac K, Messina D, Martinez-Arizala A and Kelley RE. Autoregulation of cerebral blood flow in patients with orthostatic hypotension after spinal cord injury. Paraplegia 1991, 29:1-7.
7. Houtman S, Colier WNJM, Oeseburg B and Hopman MTE. Systemic circulation and cerbral oxygenation during head-up tilt in spinal cord injured individuals. Spinal Cord 2000, 38: 158-163.
8. Illman A, Stiller K and Williams M. The prevalence of orthostatic hypotension during physiotherapy treatment in patients with an acute spinal cord injury. Spinal Cord 2000, 38:741-747.
9. Kochiadakis GE, Kanoupakis EM, Igoumenidis NE, Marketou ME, Solomou MC, and Vardas PE. Spectral analysis of heart rate variability in the analysis of autonomic nervous system activity during tilt-table testing in patients with unexplained syncope. IEEE Comput Cardiol 1997, 24:367-369.
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11. Liu DS, Chang WH, Wong AMK, Chen SC, Lin KP and Lai CH. Development of a Biofeedback Tilt Table for Investigating Orthostatic Syncope in Patients with Spinal Cord Injury. Med Biol Eng Comput 2007, 45:1223-1228.
12. Merati G, Di Rienzo M, Parati G, Veicsteinas A and Castiglioni P. Assessment of the autonomic control of heart rate variability in healthy and spinal-cord injured subjects: contribution of different complexity-based estimators. IEEE Trans Biomed Eng 2005, 53:43-52.
13. Mukai S and Hayano J. Heart rate and blood pressure variabilities during graded head-up tilt. J App Physiol 1995, 78:212-216.
14. Onrot J, Goldberg MR and Hollister AS. Management of chronic orthostatic hypotension. Am J Med 1986, 80:454-464.
15. Paul S, Zygmunt D and Haile V. Chronic orthostatic hypotension. Compr Ther 1988, 14:58-65.
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17. Sampson EE, Burnham RS and Andrews BJ. Function electrical stimulation effect on orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2000, 81:139-143.
18. Schatz IJ. Orthostatic hypotension. I. Functional and neurogenic causes. Arch Intern Med 1984, 144:773-777.
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Chapter 5
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2. Engel P and Hildebrandt G. Long-term studies about orthostatic training after high spinal cord injury. Paraplegia 1976, 14:159-64.
3. Gonzalez F, Chang JY, Banovac K, Messina D, Martinez-Arizala A and Kelley RE. Autoregulation of cerebral blood flow in patients with orthostatic hypotension after spinal cord injury. Paraplegia 1991, 29:1-7.
4. Mukai S and Hayano J. Heart rate and blood pressure variabilities during graded head-up tilt. J Appl Physiol 1995, 78:212-6.
5. Wall, BM, Runyan KR, Williams HH, Bobal MA, Crofton JT, Share L and Cooke CR. Characteristics of vasopressin release during controlled reduction in arterial pressure. J Lab Clin Med 1994, 124:554-63.
6. Sampson EE, Burnham RS and Andrews BJ. Function electrical stimulation effect on orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2000, 81:139-43.
7. Liu DS, Chang WH, Wong AMK, Chen SC, Lin KP and Lai CH. Relationships between physiological responses and presyncope symptoms during tilting up in patients with spinal cord injury. Med Biol Eng Comput 2008, 46:681-8.
8. Cariga P, Ahmed S, Mathias CJ and Gardner BP. The prevalence and association of neck (coat-hanger) pain and orthostatic (postural) hypotension in human spinal cord injury. Spinal Cord 2002, 40:77-82.
9. Schatz IJ. Orthostatic hypotension. II. Clinical Diagnosis, Testing, and Treatment. Arch Intern Med. 1984, 144:1037-41.
10. Olaf BP, Svend S and Lars E. Cerebral Autoregulation. Cerebrovascular Brain Metab Rev 1990, 2:161-92.
11. Lipsitz LA. Orthostatic hypotension in the elderly. N Engl J Med 1989, 321:952-7.
12. Paul S, Zygmunt D and Haile V. Chronic orthostatic hypotension. Compr Ther 1988, 14:58-65.
13. Schatz IJ. Orthostatic hypotension. I. Functional and neurogenic causes. Arch Intern Med 1984, 144:773-7.
14. Figoni SF. Cardiovascular and hemodynamic responses to tilting and to standing in tetraplegic patients: a review. Paraplegia 1984, 22:99-109.
15. Illman A, Stiller K and Williams M. The prevalence of orthostatic hypotension during physiotherapy treatment in patients with an acute spinal cord injury. Spinal Cord 2000, 38:741-7.
16. Houtman S, Colier WNJM, Oeseburg B and Hopman MTE. Systemic circulation and cerbral oxygenation during head-up tilt in spinal cord injured individuals. Spinal Cord 2000, 38:158-63.