臺灣博碩士論文加值系統

背景與目的：日常生活行走時常需同時執行另一項任務，即雙重任務行走，在執行雙重任務行走時需要較多的注意力，當任務需求超過可用的注意力資源時任務表現會降低，且會增加跌倒風險。因此雙重任務行走較一般行走更具挑戰，對年長者則更是。根據特定任務之訓練原則，雙重任務訓練能更有效的改善雙重任務之表現。但執行雙重任務時，由於注意力和資訊處理能力有限，因此需要使用雙重任務優先性作為因應策略。有研究發現在雙重任務行走時老年人採取姿勢優先策略，在行走任務有較好的表現，且另一項任務並不會顯著變差。而另一篇研究則指出，老年人採取上姿勢優先策略時，除了可以在不穩定的平面上維持平衡，亦可使另一項任務有較好的表現。但對於將注意力優先性策略，上姿勢優先或姿勢優先，加入雙重任務訓練對於老年人雙重任務行走效果尚不清楚。因此本研究目的為探討在雙重任務訓練加上注意力優先性策略對於老年人之雙重任務行走表現之效果是否優於一般之雙重任務訓練，並比較兩種不同優先策略訓練對於雙重任務行走表現之效果是否有差異。
方法：本研究為單盲隨機對照試驗，招募39位健康老人之受試者，收集基本資料後，會隨機分配到到三組之一：上姿勢優先組、姿勢優先組或不強調優先之對照組(每組各13位)。進行認知性雙重任務訓練，訓練為每次30分鐘，每週2到3次，為期4到6週進行共12次訓練。三組皆執行認知性雙重任務訓練，差異僅在於研究者給予之口語提示，上姿勢優先組會請受試者將注意力放在認知任務上，姿勢優先組放在姿勢控制或行走任務上，對照組則不會給予受試者注意力分配之特別指示。於訓練前後進行量測，主要結果評估項目為認知性及動作性雙重任務行走表現；次要結果評估項目為執行功能、平衡表現、及一般行走表現。基本資料使用卡方檢定分析類別變項，而連續變項則使用克-瓦二氏單因子等級變異數分析。結果評估數據使用廣義估計方程式(Generalized estimating equations, GEE)進行分析，比較各組在介入前後是否有組內顯著差異和三組間結果量測上是否有交互作用，以及使用Bonferroni做事後檢定，檢測三組之間在介入前後是否有組間差異。統計顯著水準為p <0.05。
結果：姿勢優先訓練可改善認知性雙重任務行走之步行速度(p < 0.001)、步長(p = 0.002)、步頻(p < 0.001)、跨步時間變異性(p = 0.003)、速度之雙重任務成本值(p < 0.001)和連續減七正確次數(p < 0.001)，且改善之步行速度(p = 0.004)、步長(p = 0.001)、雙重任務成本值(p = 0.005)和連續減七正確次數(p = 0.001)與對照組有顯著組間差異，而改善之步長(p = 0.009)、步頻(p = 0.049)、雙重任務成本值(p = 0.025)和連續減七正確次數(p = 0.014)與上姿勢優先組有顯著組間差異。姿勢優先訓練亦可改善動作性雙重任務行走之步行速度(p = 0.008)、步頻(p < 0.001)和速度之雙重任務成本值(p < 0.001)，改善之步行速度(p = 0.008)、步頻(p = 0.016)和雙重任務成本值(p = 0.011)則與上姿勢優先組有顯著組間差異。姿勢優先訓練亦可改善一般行走之跨步時間變異性(p < 0.001)及平衡表現(p = 0.027)。不強調優先之對照組可增加動作性雙重任務行走和一般行走之步頻(p = 0.029)及平衡表現(p = 0.018)，且改善之動作性雙重任務行走步頻(p = 0.024)與上姿勢優先組有顯著組間差異。
結論：本研究結果顯示，12次的姿勢優先訓練相較於不強調注意力優先性之雙重任務訓練，更能改善認知性雙重任務行走表現，且此姿勢優先訓練相較於上姿勢優先訓練，亦更能改善認知性和動作性雙重任務行走表現，而經上姿勢優先訓練後並未呈顯著的訓練效果。臨床上可針對老年人給予姿勢優先訓練，能有較佳的雙重任務行走表現。
關鍵字：注意力優先策略、雙重任務訓練、雙重任務行走表現、老年人

Background and purpose: Many daily activities involve performing walking and other tasks simultaneously, the dual task walking. Preforming dual task walking increases the demand on attentional resources, and thus may decrease the dual task performance when one or both tasks’ demands exceed the available resources under dual task especially for older adults. According to task-specific training principle, it is known that dual task training was an effective training to improve dual task performance. However, due to limited attention and information processing capacity when performing dual task, dual task prioritization strategy was adopted. The influence of different task prioritization on dual task performance has not yet settled. Previous study indicated that posture-focus strategy resulted in better gait performance during dual task walking in older people without decreasing the other task performance. On the other hand, another study indicated that supraposture-focus strategy resulted in maintaining posture stability on uneven surface and performing better in the other task in older people. Furthermore, the effects of applying task prioritization during dual task training have not yet been investigated. Therefore, the purpose of this study was to investigate the effects of dual task prioritization training on dual task walking performance in older people. Moreover, whether different task prioritization strategies would result in different dual task walking improvement in older people was also investigated.
Methods: This was a single-blinded, randomized controlled trial. Thirty-nine older people were recruited and randomly assigned to one of the three groups (n=13 for each group): posture-focus group, supraposture-focus group, and control group (no specific focus). The dual task training is 30 min/session, 2-3 sessions/week for 4-6 weeks, with total 12 sessions for each group. All participants received the same cognitive dual task training, and the differences were instructions for task prioritization. Participants were instructed to pay most attention to the cognitive task during training in supraposture-focus group, to the standing or walking task in posture-focus group. No task prioritization was instructed in the control group. The outcomes were measured at baseline and after completing the 12 training sessions. Primary outcomes included cognitive and motor dual task walking performance, and secondary outcomes included cognition, balance, and single task walking performance. Demographic data at baseline were compared between groups using Chi-square test or Kruskal-Wallis test. To compare the interaction of three groups on primary and secondary outcomes and within group difference, a generalized estimating equations (GEE) was used. The post-hoc pairwise comparison was used with Bonferroni correction. The significant level was set at 0.05.
Results: Posture-focus group showed significant improvements in cognitive dual task walking speed (p < 0.001), stride length (p = 0.002), cadence (p < 0.001), stride time variability (p = 0.003), DTC (p < 0.001), and number of accurate subtractions (p < 0.001). The cognitive dual task walking speed (p = 0.004), stride length (p = 0.001), DTC (p = 0.005), and number of accurate subtractions (p = 0.001) were improved more in posture-focus group than control group. Posture-focus group also showed more improvement in stride length (p = 0.009), cadence (p = 0.049), DTC (p = 0.025), and number of accurate subtractions (p = 0.014) than supraposture-focus group. Besides, posture-focus group showed significant improvements in motor dual task walking speed (p = 0.008), cadence (p < 0.001), and DTC (p < 0.001), and the improvements in walking speed (p = 0.008), cadence (p = 0.016), and DTC (p = 0.011) were more than supraposture-focus group. Posture-focus group also demonstrated significant improvements in single walking stride time variability (p < 0.001) and balance (p = 0.027). Control group showed significant improvements in single walking cadence (p = 0.029) and balance (p = 0.018), and the improved cadence was more than supraposture-focus group (p = 0.024).
Conclusions: According to our results, 12 sessions dual task training with posture prioritization led to better cognitive dual task walking performance compared to without prioritization in older people. Moreover, dual task training with posture prioritization led to better dual task walking performance compared to with supraposture prioritization in older people. However, supraposture prioritization during dual task training did not result in significant improvements. Therefore, cognitive dual task training with posture prioritization may be suggested to older people to improve their dual task walking performance.
Key words: Prioritization strategy, Dual task training, Dual task walking performance, Older people

目錄
中文摘要 i
英文摘要 iii
圖目錄 viii
表目錄 ix
第一章 簡介 1
第一節 研究背景與動機 1
第二節 研究目的 1
第三節 研究假設 2
第四節 重要性 2
第二章 文獻回顧 3
第一節 雙重任務 3
第二節 老年人雙重任務行走之表現 3
第三節 雙重任務訓練 4
第四節 注意力優先性策略 4
第五節 總結 5
第三章 研究方法 6
第一節 研究設計與研究架構 6
第二節 研究對象 6
第三節 研究流程 6
第四節 介入內容 7
第五節 結果評估量測 9
第六節 資料處理與分析方法 11
第四章 研究結果 13
第一節 受試者基本資料與前測值 13
第二節 主要評估項目 13
第三節 次要評估項目 14
第五章 討論 16
第一節 姿勢優先策略之雙重任務訓練 16
第二節 上姿勢優先策略之雙重任務訓練 18
第三節 研究限制與未來建議 20
第四節 臨床應用 20
第六章 結論 22
參考文獻 23
附錄 37
附錄一、國立陽明交通大學人體試驗委員會審核通過證明書 37
附錄二、簡易智能量表(Mini-Mental State Examination score, MMSE) 38
附錄三、雙重任務訓練組之認知任務難易度分級表 39
附錄四、雙重任務訓練組各次認知任務合併姿勢控制任務訓練內容 40
附錄五、雙重任務訓練組各次認知任務合併行走任務訓練內容 41
附錄六、中文版路徑描繪測驗(Trail making test, TMT) 42
附錄七、伯格平衡量表(Berg Balance Scale, BBS) 43

圖目錄
圖一、實驗流程圖 28
圖二、三組受試者認知性雙重任務表現前後測之結果 29
圖三、三組受試者動作性雙重任務表現前後測之結果 29

表目錄
表一、三組受試者基本資料 30
表二、三組受試者主要評估項目之前測值 31
表三、三組受試者次要評估項目之前測值 32
表四、三組受試者認知性雙重任務行走表現前後測之結果 33
表五、三組受試者動作性雙重任務行走表現前後測之結果 34
表六、三組受試者執行功能、平衡表現、一般行走表現前後測之結果 35

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