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  • 學位論文

虛擬實境坐姿平衡訓練對巴金森氏症患者坐姿壓力分布與功能表現之影響

Effects of Virtual Reality-Based Sitting Balance Training on Pressure Distribution and Functional Performance in Patients with Parkinson’s Disease

指導教授 : 林光華
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摘要


前言與背景:相較於健康人,巴金森氏症(巴病)患者不良的軀幹柔軟度和肌力可能造成其坐姿控制不佳,尤其在不穩定的坐姿平面上表現出較大的身體晃動以及比較少的軀幹旋轉動作。過去的文獻對神經疾患病人坐姿平衡的治療,支持任務取向模式(task-oriented approach)以及生物回饋(biofeedback)的訓練效果。由於虛擬實境(virtual reality)於互動式的虛擬情境中提供即時回饋,可激發使用者重複練習功能性動作,所以本研究採用新設計之虛擬實境系統包含一互動式坐姿平衡板及模擬日常生活室內、室外活動的虛擬情境,應用於巴金森氏症病患的坐姿平衡訓練。目的:本研究第一個目的是比較六週虛擬實境訓練相較於傳統坐姿平衡訓練於坐姿壓力分佈、功能表現及生活品質之影響,並分析訓練後兩週的維持效果。第二個目的是分析訓練時不同情境下坐姿平衡板合併虛擬實境系統之即時壓力分布與壓心(center of pressure)改變。方法:本研究為施測者單盲的設計,在台大醫院收集侯葉(H-Y)分級3的原發性巴金森氏症病患,以隨機分層方式將病患分至「虛擬實境組」(VR group, n=15)或「傳統訓練組」(CB group, n=14),分別由物理治療師提供6週(2次/週,40分鐘/次)的治療介入。每位個案在介入前、後及兩週後追蹤期接受坐姿壓力分佈測試及臨床評估測試,包含軀幹機能損傷程度、改良式功能性前伸測試、柏格式平衡量表、計時起走測試及巴金森生活品質量表。虛擬實境系統的即時壓力分析則是採用壓力測試板記錄巴病患者在同一虛擬實境軟體情境,以及不同軟體情境的壓力分布與壓心的即時反應。本研究使用的統計為雙項混合變異數分析檢驗兩組的訓練效果,雙項重複及單項重複變異數分析檢驗即時反應;若有差異,則使用事後分析檢定兩組的差異。統計上顯著差異水平定為0.05。結果:(1) 六週虛擬實境及傳統坐姿訓練皆無法增進靜態坐姿穩定性及對稱性;但是兩組在訓練後皆顯著增加最大重心位移量,並維持訓練效果至兩週追蹤期,但兩組組間無差異。(2) 兩組訓練組在軀幹損傷程度、改良式功能性前伸測試、柏格式平衡量表都有顯著的短期及兩週的維持療效;但兩組亦無差異。(3) 在同一虛擬實境軟體,不穩定的坐姿平面需花費更多時間完成任務;而當雙手握球時,前後方向的壓心位移量顯著多於無手部動作情境。(4) 不同的軟體間,步行”walk”在前後方向的最大壓心位移量顯著大於廚房煮菜“cooking”, 洗晾衣服“washing”, 整理書架“book arrangement”,代表軟體間有差異性的設計。結論:六週虛擬實境訓練及傳統坐姿平衡訓練皆可促進巴金森氏症病患在動態平衡的壓力分佈、軀幹控制能力、及功能性平衡的能力。而虛擬實境訓練,病患控制壓心的改變與虛擬情境互動,透過外在操作設計及不同的虛擬情境內容達到訓練的目的,其效果與傳統坐姿平衡訓練無顯著差異。

並列摘要


Introduction and Background: Compared with healthy individuals, patients with Parkinson’s disease (PD) demonstrated greater body sway and less trunk movement to maintain stability when sitting on an unstable surface. The trunk inflexibility and weakness may be involved in poor sitting balance in PD. Previous studies supported the effects of combined training with task-oriented approach and biofeedback in neurological patients. The virtual reality (VR) applications are suggested to provide real-time feedback in interactive virtual environments, and can motivate users to practice the simulated tasks repetitively. Thus, a newly VR-based system, including a interactive balance board and software of simulated daily indoor/outdoor activities, is developed for sitting balance training in patients with PD. Objective: The primary purpose of this study was to compare the short term training effect and retention effect between VR-based sitting balance training group (VR group) and conventional sitting balance training group (CB group). The outcome measures included pressure distribution of sitting balance, functional balance and mobility tests, and quality of life in patients with PD. The secondary purpose was to examine the real-time pressure distribution during sitting balance training with the newly developed VR-based system. Method: In this single-blinded study, patients diagnosed as idiopathic PD (H-Y stage III) were recruited and randomly allocated into VR group (n=15) and CB group (n=14). Both groups received 6-week (2 sessions/week, 40 minutes/session) intervention by different physical therapists for each group. Each participant received assessments before (pre-), after intervention (post-) and at 2-week follow up (FU). The pressure distribution measurement (Zebris, PDM) was used to evaluate symmetry, steadiness, and maximal weight shift in sitting position, and the functional tests included Trunk Impairment Scale (TIS), Modified Functional Reach Test (MFRT), Berg Balance Scale (BBS), Timed Up and Go (TUG) Test and Parkinson’s Disease Questionnaire-39 item version (PDQ-39). Next, to evaluate the characteristics of VR-based training system, the real-time pressure distribution and center of pressure were recorded during VR-based balance training with the same or different VR-software modes. The two-way mixed ANOVA (2 groups x 3 times) was used to test the training effect, and the two-way and one-way repeated ANOVA were used to determine real-time effect of VR-based programs. If any main effect or interaction existed, the post-hoc tests with Bonferroni adjustments were used. An α level of 0.05 was used to determine significance for all statistical tests. Results: (1) Both VR and CB groups didn’t reveal significant differences on pressure distribution in symmetry and steadiness during static sitting. During dynamic maximal weight shift, both groups significantly improved the distances of COP excursion after training and maintained the improvement to follow up. (2) Both training groups showed significantly short term training effect and retention effect on trunk function (TIS) and balance activity (MFRT, BBS), but no significant difference was found between two training groups. (3) In the same VR mode, participants significantly increased the moving time while sitting on the soft surface and significantly increased COP excursion of AP direction with hand manipulation. (4) VR mode of “walking” had significantly larger COP excursions in AP direction than “cooking”, “washing” and “book arrangement”. Conclusion: Both the 6-week VR-based and conventional sitting balance trainings improved dynamic pressure distribution, trunk functions, and clinical balance measures. The newly developed VR-based seated balance system could be controlled by the weight shift with concurrent change of COP to interact with the virtual environment.

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