臺灣博碩士論文加值系統

糖尿病神經病變患者隨著體感覺功能的衰退，進而導致較差的平衡表現及較高的跌倒機率。本篇研究目的在探討足底及踝關節經皮神經電刺激對改善受測者在靜態及動態平衡測試中姿勢控制能力。
19位平均年齡為55.4歲的健康成年人及19位平均年齡為59.1歲的糖尿病周邊神經病變患者首先評估多樣的靜態閉眼平衡站立測試；再以Steward六軸平台探討其在有經皮足底電刺激於非預期性的平台前移動作時，人體對於外在干擾的姿勢控制及反應能力。電刺激隨機地介入於雙側足部的四個位置：第一蹠骨頭、第五蹠骨頭、足後跟及踝關節。平衡表現由測力板(AMTI)及足壓板(RS-scan)所量測的足底壓力中心軌跡之位移相關變數與腿部及軀幹肌肉的活化評估。
結果顯示，經由電刺激介入後，在靜止平衡站立的測試下，前後方向足底壓力中心的最大偏移量及分散情況皆達顯著下降。在靜止站立及Romberg站立的測試下，足底壓力中心的晃動面積分別下降了10.9%及9.2%，但平均晃動速度明顯增加。電刺激介入後，糖尿病神經病變患者在動態平衡表現下有顯著地增進，如包含較短的反應延遲時間、較短的重新回復穩定所需時間及在回復穩定時有較小的足底壓力中心晃動面積。同時我們發現感覺缺失越嚴重的患者，在電刺激介入後的平衡控制能力進步越顯著。因此，經皮足底電刺激確實可增進周邊神經缺失患者的勢穩定能力。

Somatosensory function declines with diabetic neuropathy (DN) resulting in diminished balance performance and higher risk of falling. The purpose of this study was to investigate the effect of plantar transcutaneous electrical nerve stimulation (TENS) on improving the postural control ability for subjects with DN in both static posture and dynamic perturbations.
19 healthy adults (mean age 55.4 years) and 19 subjects with diabetic peripheral neuropathy (mean age 59.1 years) were evaluated in the eye-closed conditions of quiet and Romberg stance trials. A six-axis Steward platform with force plate and pressure platform was used to evaluate the postural control ability in response to an unexpected forward translation with and without the intervention of subthreshold electrical stimulation (ES) randomly applied on the plantar areas (first MTH, fifth MTH, heel and ankle). The measured variables of center of pressure (COP) as well as the EMG activity of the leg and trunk muscles were used as the assessment standard.
After the ES intervention, anteroposterior COP maximal excursion and standard deviation decreased significantly in quiet stance trials (both p< 0.01). Although the average sway velocity increased, the application of ES resulted in 10.9% and 9.2% reductions of sway areas in quiet and Romberg stance trials, respectively. In addition, the DN subjects showed a shorter COP response latency (p< 0.01), a shorter time to re-stabilization (p= 0.04) and a smaller sway area after balance recovery (p< 0.01) in comparison between before and after intervention. The effect on postural stability was profound for subjects with higher level of sensory loss. This study showed the promising effect of using plantar TENS for improving postural stability in people with peripheral sensory loss.

Acknowledgements ---------------------------------------------------------------------------- i
Chinese Abstract ------------------------------------------------------------------------------- ii
English Abstract ------------------------------------------------------------------------------ iii
Table of Contents ----------------------------------------------------------------------------- iv
List of Figures --------------------------------------------------------------------------------- vi
List of Tables ---------------------------------------------------------------------------------- ix
Chapter 1 Introduction --------------------------------------------------------------------- 1
1-1 Motivation -------------------------------------------------------------------------------- 1
1-2 Classification and clinical aspects of diabetic neuropathy ------------------------- 2
1-3 Epidemiology of diabetic neuropathy ------------------------------------------------- 5
1-4 Pathogenic mechanisms of diabetic neuropathy ------------------------------------- 5
1-5 Risk factors, diagnosis and clinical scoring systems of diabetic neuropathy ---- 6
1-6 Postural control and somatosensory system ---------------------------------------- 12
1-7 Diabetes mellitus, falls, and fall-related risk factors ------------------------------ 16
1-8 Postural control and balance performance in subjects with diabetic neuropathy --------------------------------------------------------------------------------------------- 18
1-9 Sensory-enhancing techniques and devices ---------------------------------------- 24
1-10 Physiological effects and possible mechanisms of electrical stimulation ------ 27
1-11 Purpose of this study ------------------------------------------------------------------- 28
1-12 Hypotheses of this study -------------------------------------------------------------- 29
Chapter 2 Material and Method --------------------------------------------------------- 30
2-1 Subjects ---------------------------------------------------------------------------------- 30
2-2 Clinical testing -------------------------------------------------------------------------- 31
2-3 Assessment of motor function -------------------------------------------------------- 32
2-4 Instrumentation and Procedure ------------------------------------------------------- 34
2-5 Data analysis ---------------------------------------------------------------------------- 39
2-6 Statistical analysis ---------------------------------------------------------------------- 47
Chapter 3 Results --------------------------------------------------------------------------- 48
3-1 Basic data and clinical testing -------------------------------------------------------- 48
3-2 Motor function test --------------------------------------------------------------------- 49
3-3 Static balance control ------------------------------------------------------------------ 52
3-4 Reaction time --------------------------------------------------------------------------- 54
3-5 Dynamic balance control -------------------------------------------------------------- 55
3-6 Relationship between improvement of COP measured variables and sensory threshold --------------------------------------------------------------------------------- 67
Chapter 4 Discussion ----------------------------------------------------------------------- 70
4-1 Clinical testing -------------------------------------------------------------------------- 70
4-2 Motor function test --------------------------------------------------------------------- 70
4-3 Static balance control ------------------------------------------------------------------ 71
4-4 Reaction time --------------------------------------------------------------------------- 73
4-5 Dynamic balance control -------------------------------------------------------------- 73
4-6 Relationship between improvement of COP measured variables and sensory threshold --------------------------------------------------------------------------------- 80
4-7 Limitations and perspectives of the study ------------------------------------------ 82
Chapter 5 Conclusion ---------------------------------------------------------------------- 83
References ------------------------------------------------------------------------------------ 84
Appendix A ----------------------------------------------------------------------------------- 90
Appendix B ----------------------------------------------------------------------------------- 91

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