高功能慢性中風患者因應障礙物之伸臂與取物動作運動學分析

Kinematic Analysis of Obstacle Crossing During Reach- Grasp-Retract Movement in Highly Functioning Patients with Chronic Stroke

陳怡妙(Yi-Miau Chen)

指導教授 ： 毛慧芬

共同指導教授 ： 呂東武

國立臺灣大學/醫學院/職能治療研究所/碩士(2008年)

https://doi.org/10.6342/NTU.2008.02717

摘要

中風患者伸臂取物的動作機轉及有效之復健治療模式常被廣泛研究，然當取物環境中有障礙物存在時，如何影響其動作表現，卻少有相關文獻探討，且大多僅針對伸手及物，而未探討取回的動作。本研究的目的為運用運動學分析來了解中風患者因應障礙物之伸臂與取回物品動作之控制與機轉。
研究方法：有7位高功能慢性中風患者同意參與此研究。受試者採坐姿，將目標物放在一個手臂長距離的桌上，共有兩種情境，一為障礙物置於手臂長65％處，障礙高度設定為上臂長30％及障礙高度為0%的控制情境。受試者執行伸手跨越障礙物，並將目標物拿回近身體桌面上的位置。利用動作分析系統(Vicon 512, Oxford Metrics Group, U. K.)紀錄伸臂取物動作過程。利用配對-t檢定及效應值來比較健側手與患側手伸臂取物及拿回動作，在障礙物高度為上臂長0%與30%情境下之各種運動學參數，包括動作距離、最大速度、達最大瞬間速度所花時間達整個運動時間的比例、手指最大張口角度、手指最大張口角度發生時間比例、動作時間、動作單位、伸臂跨過障礙物時的手腕距障礙物的高度與取回時物品距障礙物的高度等參數。
研究結果：比較健側手與患側手在障礙情境下的表現，發現兩者的運動學參數皆因障礙物存在而改變。患側手在伸臂過程中移動軌跡較短，手指最大張口角度發生的時間點較早與手腕距障礙物的高度較低。在取物回來的過程中，運動時間較長，速度較慢與物品距障礙物的高度較高，顯示兩者在執行因應障礙物取物動作時的動作控制可能不同。可能暗示患側手較缺乏因應障礙調整伸臂動作的彈性，但在將物品取回的過程中，會將手抬的較高，以因應其避免碰觸障礙物以達成取物的目標。另個別分析健側手及患側手在障礙物高度為上臂長0%與30%情境下，運動學參數的變化，結果顯示健側手的動作表現差異性較大，而患側手的動作表現差異較不顯著。
結論：高功能慢性中風患者的患側動作功能障礙，無法從臨床的動作評估中看出。但在障礙物干擾情境下，仍可發現其動作表現比健側手差，且在取回物品的動作差異更加明顯。這可能暗示障礙物與目標物品的存在，都會使動作控制變的較複雜，患側手的動作控制缺失會因而更明顯。在臨床上給予治療建議時，應提供目標導向的活動及提高活動的複雜性以訓練患側手的動作控制。

關鍵字

障礙物 ； 伸臂取物 ； 動作控制 ； 上肢 ； 中風

並列摘要

Objective: The reaching movement of stroke patient has been studied widely in order to understand the mechanism and effective treatment approach. To our knowledge, no prior study has disclosed how the obstacles near the target affect the motor performance of reaching. Besides, most studies explored only the reaching movement without the bring back component. The purposes of this study were to investigate the motor performance of U/E according to the obstacle while reaching for grasping and retracting for placing an object in stroke patients.
Research method: Our study enrolled 7 highly functioning participants with chronic stroke. All participants seated and were asked for reaching the target and then bring it back to put on the table. Obstacle with its height equal to 30% of upper arm length was placed at about 65% of the full arm length. Another condition was to put the obstacle with height of 0 as controlled. Kinematic data were measured using a 6-camera motion analysis system (Vicon 512, Oxford Metrics Group, U. K.). The following parameters were compared between the unaffected and affected upper limb of the stroke participants including reaction time, movement time, transport path, peak velocity (PV), percentage of movement where PV occurs, maximum grip aperture, percentage of reaching time where maximum grip aperture occurs, wrist–obstacle clearance, movement unit, object pick up time, object–obstacle clearance and object placing time in reach to grasp movement and retraction movement in control and obstacle crossing condition, Paired t-test (α=0.05) was used and the effect size was also calculated.
Results: In the obstacle crossing condition, the performances of the kinematic parameters of unaffected and affected upper limbs were both changed by the obstacle. Shorter transport path, smaller percentage of reaching time where maximum grip aperture angle occurs and lower wrist clearance in reach to grasp, whereas longer movement time, slower average speed and higher object clearance in retraction movement were found in affected than in unaffected side. The result might imply that the motor control of affected and unaffected upper limb was different in the obstacle crossing condition. When kinematic parameters of both unaffected and affected upper limb were analyzed in conditions with obstacle height of 0% & 30%, significant differences were found in the unaffected upper limb but not the affected side. The result maybe imply that the affected upper limb lacking the flexibility to adjust the arm movement according to the obstacle height, but when carried an object, it moved higher to prevent hitting the obstacle.

Conclusions: The subjects in this study were with highly motor function and invisible motor deficit observed through clinical evaluation, but when asked them to carry an object crossing an obstacle without hitting it, the motor differences between the unaffected and affected upper limb emerged. The existed of an obstacle as well as an object increased the complexity and demand of the task, the moving body needed to adapt the motor control of reaching hand in order to achieve the task goal, by the way, the motor deficit of the stroke patients would be amplify by the obstacle. When providing the treatment programs to the highly functioning patients with chronic stroke, more complicated and goal directed tasks should be used to treat the motor control of affected upper limb in clinical settings.

並列關鍵字

Obstacle ； reach-grasp-retract ； motor control ； upper limb ； stroke

參考文獻

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