臺灣博碩士論文加值系統

研究背景：在全世界，中風是其中一個導致死亡或失能的疾病，中風後會有感覺及動作功能等的損傷，最常見的動作損傷包含偏癱、肢體不協調等等，導致病患控制平衡困難、能量耗損較高、整體活動能力下降，多有明顯的不對稱異常步態。對許多病患而言改善行走的動作品質是主要的目標。步態的對稱性被證實與動作損傷程度有關，部分學者認為可以作為動作品質的指標。過去文獻證實重複性的感覺輸入刺激及動作訓練能夠誘發中樞神經系統受損後的腦神經迴路重塑及功能恢復，而周邊電刺激及腳踏車訓練作為感覺輸入及動作訓練的工具，證據顯示結合兩者能夠有效改善病人的肌力、行走能力、動作協調能力等等。騎乘腳踏車時下肢的動作模式像是走路，被證實能夠誘發主要感覺及運動皮質、運動輔助區、小腦等腦區對稱性的活化；周邊電刺激可以誘發感覺運動皮質的興奮性及活性，因此合併電療及腳踏車訓練或許能夠誘發病患下肢協調性動作相對應的腦區活化並改善下肢的動作控制能力，進而呈現更對稱的步態動作模式。過去的文獻未曾以腦波觀測電刺激結合腳踏車的訓練對中風後感覺運動皮質區的腦部活性及皮質肌肉功能性連結之變化，針對功能恢復的變化也缺乏步態對稱性變化的觀測，故本研究以結合周邊電刺激及腳踏車的一次性介入觀測其步態及腦部之立即變化並探索腦部與步態表現之間的關聯性。研究目的及假設：觀察周邊電刺激結合腳踏車的一次性介入，對中風病患步態功能進步的立即效應，以及其相關之神經生理變化特徵。本研究假設結合周邊電刺激及腳踏車能立即誘發中風患者腦神經生理的變化、提升大腦感覺運動皮質與患側肌肉的功能性連結，並改善患者下肢神經肌肉控制及步態表現，而且神經生理的變化與行走能力的進步有相關性。研究方法：本篇為隨機單盲研究，徵召26位慢性中風患者，分派至腳踏車加電刺激組及腳踏車組，兩組皆接受一次性30分鐘之電刺激（或偽電刺激）結合腳踏車訓練，電刺激貼在患側腳之股四頭肌及脛前肌，強度達病患可忍受之最大感覺強度並不引起肌肉收縮，腳踏車介入分為兩階段各15分鐘，中間間隔休息5分鐘。在介入前後使用慣性測量單元測量步態參數，包含步速、步長及推進能力並進一步計算步態對稱性，於行走時同步記錄腦電圖及肌電圖。腦電圖蒐集位於Cz腦區的腦電訊號，而肌電圖蒐集雙側下肢的股四頭肌及脛前肌的訊號，腦電訊號及肌電訊號皆經由計算得到腦波譜密度及皮質肌肉共調性。統計分析：使用SPSS 24.0軟體，使用卡方及獨立t檢定檢驗組間基準資料，夏皮羅-威爾克檢驗法(Shapiro–Wilk)檢驗數據的常態性，由於數據不符合常態分佈，故使用無母數之統計分析。曼惠特尼(Mann-Whitney)檢定進行組間前後比較、魏克生符號檢定(Wilcoxon sign rank)進行組內前後比較。使用斯皮爾曼相關係數(Spearman correlation)決定腦部參數與步態參數的關係。顯著水準訂為0.05。研究結果：分析26位受試者的結果顯示腳踏車加電刺激組在一次訓練後無對稱性變化，而腳踏車組在快速速度走路下推進對稱性比率顯著更不對稱(0.78 ± 0.19→1.30 ± 0.79, p = 0.036)，且自選速度走路下患側步長顯著增加(0.44公尺 ± 0.13公尺→0.55公尺 ± 0.24公尺, p = 0.021)的現象。本研究同時觀察到一次介入後腳踏車加電刺激組gamma頻帶腦波譜密度立即增加，且兩組在後側時達顯著差異(腳踏車加電刺激組0.150 ± 0.084→0.167 ± 0.083，腳踏車組0.112 ± 0.039→0.104 ± 0.038, p = 0.024)，且腳踏車組在快速速度下腦波譜密度beta頻帶變化量與步長對稱性比率絕對變化量有中度正相關(r= 0.644, p= 0.026)，隨著PSD beta增加，步長有越不對稱的趨勢。皮質肌肉共調性beta, gamma頻帶在組間或組內皆無顯著差異。皮質肌肉共調性gamma頻帶與步長對稱性比率絕對變化量有中度到高度相關性，二組的結果皆發現隨著gamma上升，步長有越對稱的趨勢(腳踏車加電刺激組r= -0.705, p= 0.034, 腳踏車組r= - 0.618, p= 0.043)。研究結論：一次性電刺激加腳踏車訓練對中風後的步態對稱性表現的沒有額外的效益，卻能立即誘發出更高的腦波譜密度gamma頻帶，一次性腳踏車訓練能立即誘發更長的患側步長，即便推進能力變得更不對稱。觀察腦部神經生理參數在動作介入(感覺輸入)後的步態對稱性的立即性變化，不論是腦波譜密度beta或皮質肌肉共調性gamma頻帶的變化都與步長對稱性的進步有關聯性，反映神經肌肉控制能力在短時間內的改變，證實了動作學習在中風受試者的初步成果。另外，同步的感覺電刺激與動作訓練並無明顯的正面效益，未來研究可進一步探討二者更理想的結合模式。

Background: Stroke is one of the leading death or disability disease in the world. Motor impairments, including hemiparesis, incoordination and spasticity are the most common deficits after stroke. Functional recovery is mediated by neural reorganization, so repetitive motor practice and volitional effort is essential for neuroplasticity to promote functional recovery and quality of life in stroke survivors. It’s indicated that gait symmetry is related to motor impairments, and gait symmetry seems to be indicator of the motor recovery. Previous studies have demonstrated that cycling training and electrical stimulation (ES) are beneficial for promoting neuroplasticity and facilitating post-stroke motor recovery, and combing ES and motor training have potential efficacy on post stroke motor recovery such as strength, walking capacity and coordination. Therefore, ES and motor training could be serve as the tool of amount of sensory inputs to affect the process of motor recovery through neuroplasticity. To our knowledge, previous researches state that effects of combining ES+ motor training on motor function rather than on the quality of walking pattern for stroke patients. However, the assessment of neurophysiological data by EEG-EMG after motor training is still lacking so that we could not built a bridge between the training efficacy and neural activity after stroke. To be more specific, effects of combining ES and cycling on EEG coupled with EMG functional connectivity and functional improvement in stroke patients remains unknown. Research purpose and hypothesis: The first aim of this study is to investigate the immediate effects of single session ES combined cycling on neurophysiological changes and gait improvements in stroke patients. The second aim is to determine the correlation between changes in the neurophysiological data and functional outcomes, specifically to verify whether the combination of ES and cycling as an intervention can induce neurophysiological changes and improve neuromuscular control of lower extremities and gait performance in stroke patients immediately. Also, we dedicate to find out the characteristics of neurophysiological changes soon after the intervention. Methods: 26 stroke patients are recruited and assigned to either ES combined with cycling group or cycling group (sham-ES combined with cycling group). Each group receives either 30 min cycling with consistent ES or sham-ES. 5 min rest in the middle of the intervention. EEG from the LE area of sensorimotor cortex (Cz) and EMG of quadriceps and tibialis anterior muscles are recorded simultaneously during walking tests before and after the intervention. The functional outcomes obtained during walking tests as well by wearable IMU collect self-selected and fast gait speed (m/s), step length (m) of both legs, propulsion of both legs, and gait symmetry ratio determined by step length and propulsion. EEG and EMG signals are calculated and transformed into power spectral density (PSD) and synchronized to indicate the functional connectivity between the cortex and the muscles, namely corticomuscular coherence (CMC). Statistics: The statistical analysis was performed with SPSS version 24.0 software. Chi-square and independent t-test were used to determine the difference of demographic data between groups at baseline. Shapiro–Wilk test was used to assess the normality. We assessed the outcomes of interest by non-parametric statistics because of the non-normality of the data among outcomes. The Mann-Whitney test was used to compare data after the intervention between groups. The Wilcoxon signed-rank test was used to compare data within groups. Spearman correlation test was used to assess pre-post percentage change between neurophysiological data and gait-related outcomes. The significant level is set at 0.05. Data is described in mean ± standard deviation. Results: 26 stroke subjects were analyzed. No significant differences were detected in gait symmetry, both sides of step lengths, and propulsion between groups. However, there was a significant difference in propulsion symmetry ratio under fast speed walking in cycling group (0.78 ± 0.19→1.30 ± 0.79, p = 0.036) and a significant increase in paretic step length under select speed walking in cycling group (0.44 ± 0.13 m → 0.55 ± 0.24 m, p = 0.021). In addition, our results suggested that combined electrical stimulation and cycling significantly increased PSD gamma band under select speed walking in ES group more than that in cycling group (ES combined with cycling group: 0.150 ± 0.084→0.167 ± 0.083, cycling: 0.112 ± 0.039→0.104 ± 0.038, p = 0.024). There were significant moderate correlations between the changes of PSD beta band and the changes of step symmetry ratio in cycling group (r = 0.644, p = 0.026). No significant differences were detected in CMC beta or gamma band between or within groups. But there were significant moderate to high correlations between the changes of CMC gamma band and the changes of step symmetry ratio (ES combined with cycling group: r = - 0.705, p = 0.034；cycling: = - 0.618, p = 0.043) in both groups. Conclusion: Single session of combined electrical stimulation and cycling has neither additional benefits on gait performance determined by gait symmetry, nor step length or propulsion of both legs. But it induced immediately higher PSD gamma band significantly. Single session of cycling could improve paretic step length despite of the worse propulsion symmetry ratio, as PSD beta band increasing and CMC gamma band decreasing, the step length symmetry get worse. Through the changes of PSD and CMC, we could define the degrees of motor recovery with the process of enhancing neuromuscular control after motor intervention. Besides, we couldn’t verify the beneficial effects of combined electrical stimulation and cycling on stroke patients, and future research should further investigate an ideal program and strategy instead.

目錄
誌謝 i
中文摘要 ii
英文摘要 v
目錄 viii
圖目錄 xi
表目錄 xii
第一章 緒論 1
1.1 研究背景與動機 1
1.2 研究目的 3
1.3 研究假設 3
1.4 研究重要性 3
第二章 文獻回顧 5
2.1 中風後動作恢復 5
2.1.1 中風後動作恢復與大腦可塑性 5
2.1.2 中風後步態對稱性及神經肌肉控制 5
2.1.3 腳踏車訓練對大腦可塑性及動作恢復的影響 6
2.1.4 周邊電刺激的中樞調節 7
2.1.5 周邊電刺激合併主動訓練的效果 7
2.2 腦電圖及大腦皮質共調性 8
2.2.1 腦電圖的生理意義及動作學習 8
2.2.2 皮質肌肉共調性的生理定義及臨床重要性 9
2.3 總結 10
第三章 研究方法 12
3.1 研究設計與研究架構 12
3.1.1 研究設計 12
3.2 研究材料與研究方法 12
3.2.1 研究對象及流程 12
3.2.2 研究對象 13
3.2.3 研究流程 14
3.2.4 研究工具 15
3.2.5 量測指標 16
3.3 資料處理與分析方法 16
3.3.1 資料處理 16
3.3.2 統計分析 18
第四章 研究結果 19
4.1 基本資料組間比較結果 19
4.2 神經生理參數組間、變化量及組內比較結果 19
4.2.1 步態參數組間、變化量及組內比較結果 19
4.2.2 皮質肌肉共調性組間、變化量及組內比較結果 19
4.2.3 腦波譜密度組間、變化量及組內比較結果 20
4.3 神經生理參數變化量及步態對稱性變化量的相關性 20
4.3.1 腦波譜密度與步態對稱性 20
4.3.2 皮質肌肉共調性與步態對稱性 20
第五章 討論 22
5.1 中風後步態對稱性及中樞神經系統的控制 22
5.1.1 步態對稱性與動作介入 22
5.1.2 皮質肌肉共調性與步長對稱性的相關性 24
5.2 腦波譜密度變化與動作介入的關聯 25
5.2.1 腦波譜密度與動作的關聯 26
5.2.2 腦波譜密度的生理特徵作為動作恢復的指標 26
5.3 周邊電刺激、皮質肌肉共調性與動作恢復的關聯 27
5.3.1 電刺激與皮質肌肉共調性對動作恢復的效益 28
5.3.2 電刺激使用時機 29
5.4 研究限制 29
第六章 結論 31
參考文獻 32
附錄一 國防醫學院三軍總醫院人體試驗委員會核准函 67
附錄二 受試者同意書 68
附錄三、腦波儀器 75
附錄四、肌電圖儀器 76
附錄五、單顆慣性測量單元、電刺激、腳踏車 77

圖目錄
圖 1研究流程圖 40
圖 2介入流程示意圖 41
圖 3自選速度下步長對稱性及推進對稱性前後變化 42
圖 4快速速度下步長對稱性及推進對稱性前後變化 43
圖 5自選速度下患側步長及好側步長前後變化 44
圖 6快速速度下患側步長及好側步長前後變化 45
圖 7自選速度下皮質肌肉共調性Cz-QC beta, gamma頻帶前後變化 46
圖 8自選速度下皮質肌肉共調性Cz-TA beta, gamma頻帶前後變化 47
圖 9自選速度下腦波譜密度 alpha, beta, gamma頻帶前後變化 48
圖 10快速速度下腦波譜密度 alpha, beta, gamma頻帶前後變化 49
圖 11 步長對稱性變化量與神經生理參數變化量的顯著相關性 50
圖 12自選速度下兩組之進步組與退步組的前測步速 51
圖 13自選速度下兩組以步速區分嚴重度(0.5m/s)之步長對稱性及推進對稱性 52

表目錄
表 1受試者基本資料之組間比較 53
表 2神經生理參數 原始資料及變化量(後測-前測)之組間比較 54
表 3神經生理參數之組內比較 55
表 4步態參數 原始資料及變化量(後測-前測)之組間比較 56
表 5步態參數之組內比較 58
表 6腳踏車加電刺激組 神經生理參數的變化量與步態表現的變化量之相關性 60
表 7腳踏車組 神經生理參數的變化量與步態表現的變化量之相關性 63

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