• 期刊

以體外模型探討高糖環境下力學刺激對肌腱細胞轉分化之影響

背景與目的：糖尿病為全球高度盛行的慢性疾病，糖尿病患者肌腱病變的盛行率較健康人高。先前研究指出高糖環境會導致肌腱細胞AMPK(AMP-activated protein kinase)訊息路徑被抑制，使得肌腱相關轉錄因子Egr1 (early growth response protein 1)表現降低，影響基質分子與生長因子的基因表現，暗示高糖環境下肌腱細胞可能產生轉分化的行為。規律的運動型態是目前糖尿病治療的重點之一，根據美國運動醫學會與美國糖尿病學會建議，有氧運動與肌力訓練皆能達到控制糖尿病的效果，然而運動對於糖尿病環境下肌腱細胞恆定的維持，仍有待進一步探討。本研究以體外模型探討高糖環境下肌腱細胞是否發生轉分化行為，並藉由力學刺激模擬體外運動的情形，探討力學刺激對糖尿病肌腱病變可能的保護性分子機轉。方法：利用不同葡萄糖濃度培養大鼠肌腱細胞（正常濃度組：5.5 mM [100 mg/dL]、高糖組：25 mM [450 mg/dL]）。力學刺激以細胞拉伸儀器 (Flexcell FX-5000 Tension System) 對肌腱細胞施予2小時、頻率1 Hz，形變8% 之週期性雙軸拉伸。以聚合酶連鎖反應分析非肌腱標記基因，包含肌纖維母細胞標記SMA (alpha smooth muscle actin)、Fn1-EIIIA (Fibronectin 1 EIIIA)、OB-Cdh (OB-cadherin)；脂肪標記PPARγ (peroxisome proliferator-activated receptor-gamma)、C/EBP-α (CCAAT/enhancerbinding protein, alpha)、C/EBP-β 之表現情形。利用西方墨點法分析AMPK、Akt (protein kinase B)、ERK (extracellular-signal-regulated kinase) 訊息傳遞路徑的活化情形。統計方法以Independent t-test 檢定組間差異。結果：經過1週培養後的高糖組肌腱細胞，脂肪標記PPARγ、C/EBP-α、C/EBP-β 表現較正常組高 (p ＜ 0.05)，肌纖維母細胞標記 SMA基因表現亦較高(p ＜0.05)，Fn1-EIIIA與OB-Cdh則不受影響。施予週期性雙軸拉伸可明顯降低脂肪標記PPARγ、C/EBP-α、C/EBP-β之基因表現(p ＜ 0.05)。以西方墨點法分析訊息路徑，高糖會促進ERK與Akt路徑活化(p ＜ 0.05)，透過Akt調控脂肪標記基因表現； 週期性雙軸拉伸後6小時，ERK路徑會被促進，Akt路徑則明顯抑制(p ＜ 0.05)。結論：肌腱細胞長時間處在高糖環境中，會透過Akt路徑活化，導致脂肪標記上升，力學刺激可有效抑制肌腱細胞的轉分化行為，有助於維持肌腱恆定。臨床意義：本研究結果有助於了解力學刺激對高糖環境下肌腱的保護機制，提供運動有助於維持肌腱恆定的理論證據。

• 期刊

Effectiveness of Joint Mobilization in Addition to Neuromuscular Training on Dynamic Carpal Instability in Athletes with Repetitive Loading on Upper Extremities

Background and Purpose: Dynamic carpal instability is common among athletes, especially in those who repetitively bear weight on their hands. This impairment usually results from ligament laxity and intercarpal positional faults. Yet, there has no established guidelines regarding its clinical management. Neuromuscular training has been recommended for the treatment of joint instabilities and joint mobilization for positional faults in a joint. The aim of this study was to investigate the additional effects of joint mobilization as compared to neuromuscular training for athletes with dynamic carpal instability. Methods: This was a prospective and randomized control trial. Thirty-two student athletes with carpal instability were recruited and randomly allocated into a neuromuscular rehabilitation group (the NMR group) or a combined treatment group with joint mobilization and neuromuscular rehabilitation (the NMR+M group). Both groups received neuromuscular exercise training for their wrist problems, but only subjects in the NMR+M group received carpal mobilization. Wrist active range of motion, pain-free maximal grip strength and pain-free weight-bearing capacity were evaluated before, immediate after the first treatment session, and after the 6-week intervention. Patient specific functional scale (PSFS) was assessed before and after the 6-week intervention, while the global rating of change scores (GROC) was evaluated only after the 6-week intervention. Results: Joint mobilization combined with neuromuscular rehabilitation did demonstrate additional effect on pain intensity (p ＜ 0.001) and weight bearing capacity on the hand (p ＜ 0.001). Similar results were revealed in the participant rated outcomes. The scores of PSFS and GROC were significantly higher in the NMR+M group than those in the NMR group (PSFS: p ＜ 0.006; GROC: p ＜ 0.001). Conclusion: A 6-week neuromuscular rehabilitation combined with joint mobilization was effective on pain intensity and pain-free weight bearing capacity, and these objectively measured functional enhancements did translate to participant-perceived improvements. Clinical Relevance: Neuromuscular training combined with joint mobilization is an effective strategy to treat dynamic carpal instability in athletes with repetitive loading on the upper extremities and allow them to proceed with regular training without delay, and the similarity of the content of neuromuscular rehabilitation could enhance their field performance.

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Physiological Responses to Functional Exercise Test in Patients Referred to Pulmonary Rehabilitation Clinic

Background and Purpose: Pulmonary rehabilitation (PR) is now considered a fundamental component of the integrated disease management of this population. The six-minute walk test (6MWT) is commonly performed to evaluate functional exercise capacity, and few studies have evaluated differences in physiological responses to 6MWT across the case mix of patients receiving PR. The purpose of this study was to compare the physiological responses to the 6MWT in patients referred to the PR program. Methods: A total of 60 patients referred to the out-patient PR program at Physical Therapy Center (National Taiwan University Hospital) were included. The 6MWT was performed according to the American Thoracic Society Statement (ATS) guidelines. Blood pressure (BP) and perceived dyspnea were measured before and after the 6MWT. Heart rate (HR) and arterial oxygen saturation (SpO_2) were continuously monitored by pulse oximetry throughout the test and during the first minute of recovery. The 6-minute walking distance (6MWD) was measured. Results: The case mix was categorized into bronchiectasis (n = 15), and stage I, II, III, and IV chronic obstructive pulmonary disease (COPD) (stage I to IV, n = 9, 17, 13, and 5 respectively). SpO_2 decreased significantly in all groups during the 6MWT (p ＜ 0.0001), with the most prominent reduction in stage III (9%) and IV (8%) COPD, and remained significantly low in stage II, III, and IV COPD one minute after the 6MWT. The percent of 6MWD predicted was significantly lower in stage III, IV, and bronchiectasis compared to stage I and II COPD (all p ＜ 0.05). Maximal HR achieved during the 6MWT was significantly higher in bronchiectasis and stage IV COPD patients compared to other groups (p = 0.03). Recovery HR in one minute remained significantly higher compare to baseline in all groups. Perceived dyspnea increased significantly in all groups during the 6MWT, and the mean increment was 2.6, 2.3, 3.3, 4.0, and 3.4 for stage I, II, III, IV COPD and bronchiectasis, respectively (p ＜ 0.0001). Conclusion: Except for stage I COPD, all patients referred to PR presented with reduced functional exercise capacity. Exercise desaturation and slow heart rate recovery was noted in all patient referred to PR. Clinical Relevance: This result provides evidence that insufficient functional exercise capacity exists in patients with chronic respiratory disease and PR should be provided to these patients if resources, reimbursement; and healthcare professional are sufficient. In addition, O_2 supplementation and careful monitor HR response is recommended during exercise training.

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Physical Therapy for Groin Pain following Pubic Ramus Fracture-A Case Report

Background and Purpose: Non-displaced pubic fracture often spontaneously heals without treatment. Occasionally, inguinal or pubic pain may develop due to irritation of the abundant neurovascular structures in the pelvic area. Scarce literature described conservative management for this condition. Methods: A 58-yearold woman initially visited emergency room for groin pain owing to motor-vehicle accident. Plain radiograph revealed left superior and inferior pubic rami fracture. The orthopedic physician prescribed bedrest and analgesics. However, intractable inguinal pain persisted after two months of rest, resulting in impaired mobility and job performance. She was referred to the physiatrist, who ordered manual therapy, strengthening, and shortwave. Palpation disclosed multiple tender points around the groin and hip. The therapist then applied extra-vaginal soft tissue mobilization to the according areas. Manual techniques incorporated 60 seconds of sustained pressure on each trigger point, as well as myofascial release to lengthen the restricted tissues. Facilitating pelvic and hip stabilizers were also performed. Results: After nine sessions of physical therapy, the subjective pain decreased from 10 to 2 in the 10-point-pain-scale. Walking ability improved from relying on walker to ambulating without device. She could even perform single leg standing and take stairs without symptoms. She was able to return to work by the third months and then discontinued therapy. Conclusion: Manual therapy as an adjunct to other modalities in resolving abnormal tissue tension in the pubic area was promising. Even simple pubic fracture deserves early evaluation and intervention. Clinical Relevance: For cultural concern, careful extra-vaginal manual therapy may serve as an acceptable method to treat myofascial and neuropathic pain.

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The Effect of Age and Physical Activity Level on Motor Skill Learning during both Expected and Unexpected Events

Background and Purpose: The aging process is associated with a reduced capacity to learn new motor skills. Physical activity level has recently emerged as a powerful factor influencing motor skill acquisition and retention. However, none of the previous studies examined if regular physical activity would modulate the capacity to learn to respond to unexpected events at a time prior to the volitional reaction time (transcortical reflex timeframe). Therefore, the purpose of this study was to determine whether age and physical activity level would influence (1) the ability to learn to respond within the transcortical reflex timeframe following unexpected events, and (2) the muscle strategies used to respond to unexpected events that occur before the volitional reaction time. Methods: Twenty less active young, 17 active young, 16 less active old, and 14 active old healthy adults tracked a target using the left wrist before and after motor training over one week (Day 1 pre, Day 1 post, Day 7). Unexpected stretches were imposed to the wrist extensor muscles by releasing the resistance of the device. Surface electromyography (EMG) was recorded from the left wrist extensor and flexor muscles. User rates, the slopes of best-fit lines through wrist displacement during the period before the volitional reaction time, were calculated to measure learning. Repeated measures analysis of variances (ANOVA) were used to compare differences across time points, groups, and physical activity levels. Results: During unexpected events, the less active old group demonstrated poorer motor performance than the active old group. However, motor performance did not differ between the less active young and active young groups. Moreover, four groups showed similar motor acquisition skill with about 20–30 percent decrease in user rates on Day1post as well as similar retention capacity on Day 7. Furthermore, for each age group, the less active and active groups used similar feedforward and feedback strategies to respond to unexpected events during motor learning. Conclusion: This study supported the value of an active lifestyle with age, but also the capacity for less active people to benefit from practice in both expected and unexpected events. Clinical Relevance: These findings assist in designing novel rehabilitation interventions for people with aging or neurological diseases.

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社區老年人害怕跌倒和認知及身體功能之關係

背景與目的：跌倒是老年人意外受傷的主要原因之一。老年人可能在跌倒後產生害怕跌倒心理，進而自我限制活動，使得身體功能退化更加嚴重，而害怕跌倒的心理可能與認知功能的退化及身體功能的下降相關。本研究之目的為探討老年人害怕跌倒的心理和認知及身體功能之關係。方法：研究採便利取樣，針對98 名自願參與本研究的65 歲以上長者進行一次性評估。評估內容包含年齡、簡易心智量表 (mini-mental state exam, MMSE)、老年憂鬱量表 (geriatric depression scale, GDS)、柏格氏平衡量表 (Berg balance scale, BBS)、計時起走測試 (Timed Up and Go Test, TUG)、簡短身體功能量表 (short physical performance battery, SPPB)、行走速度、五次坐椅站立時間、握力、九孔插棒測驗 (ninehole peg test, NHPT) 及畫鐘測驗 (CLOX: an executive clock drawing task developed by Royall, 1998)。在一對一訪談中，老人害怕跌倒的心理以「你是否害怕跌倒？」之答案分為兩組。害怕跌倒組及不害怕跌倒組在認知及身體功能表現之差異以t 檢定和Mann-Whitney test 分析。結果：在 (n = 98) 位受試者中，不害怕跌倒者 (n = 39)之柏格氏平衡量表總分為52.11 ± 3.23、平均計時起走測試時間為13.76 ± 3.36 s、簡短身體功能量表總分8.35 ± 2.31、行走速度平均0.81 ±0.26 m/s、五次坐椅站立時間為16.02 ± 5.4 s、握力為17.68 ± 7.25 kg；相較於害怕跌倒者 (n= 59) 之柏格氏平衡量表總分 (46.00 ± 8.82)、計時起走測試時間 (18.9 ± 7.84 s)、簡短身體功能量表總分 (6.72 ± 2.42)、行走速度 (0.65 ± 0.23m/s)、五次坐椅站立時間 (20.96 ± 11.49 s) 及握力 (14.17 ± 5.95 kg) 顯著較佳 (p ＜ 0.05)；而在年齡、MMSE、GDS、NHPT、畫鐘測試則無顯著差異。結論：害怕跌倒者其伯格氏量表、計時起走測試、五次坐椅站立表現較差。原因推測可能是老年人的身體功能影響其害怕跌倒心理，造成在日常生活活動中不經意降低活動量，進而加速退化，使下肢功能表現日漸下降。臨床意義：下肢身體功能訓練可能可改善社區老年人身體功能，降低其害怕跌倒之心理狀態，進而降低其跌倒風險。

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轉圈走360度和認知及身體功能之關係：以社區老年族群為探討

背景與目的：臨床發現老年族群在轉圈走360 度的表現有極大差異，而過去針對此功能性活動的研究不多，為了瞭解此活動是否與認知和身體功能有關，本研究探討轉圈走360 度與認知以及身體功能之關係。方法：研究採便利取樣，61 名自願參與的65 歲以上老人接受一次評估，內容包含簡易心智量表 (mini-mental state exam, MMSE)、自評跌倒風險量表 (falls efficacy scale, FES)、老年人精神抑鬱量表 (geriatric depression scale, GDS)、畫鐘測驗 (CLOX : an executive clock drawing task developed by Royall, 1998)、斯特魯普效應測試 (Stroop test)、柏格氏平衡量表 (Berg balance scale, BBS)、簡短身體功能量表 (short physical performance battery, SPPB)、行走速度，30 秒坐站及計時起走測試 (Timed Up and Go Test, TUG)。本研究將未能在4 秒內安全地轉圈走360 度及每側皆可在4 秒內完成之人數分為兩組，兩組在認知及身體功能表現之差異以t 檢定和Mann-Whitney 檢定分析。結果：未能在4 秒內安全地轉圈走360 度者 (n = 24) 之MMSE 總分 (23.71 ± 4.54 分 )、未示範之畫鐘測驗CLOX 1 (7.00 ± 3.75 分 )、示範後之畫鐘測驗CLOX 2 (10.18 ± 3.14 分 )、行走速度 (0.49 ±0.16 m/s)、BBS 總分 (42.58 ± 5.88 分 )、SPPB總分 (4.39 ± 2.23 分 ) 及TUG (24.72 ± 8.39 s)比每側皆可在4 秒內安全地轉圈走360 度者 (n= 37; MMSE, 26.36 ± 2.94 分; CLOX 1, 9.71 ±3.80 分; CLOX 2, 12.15 ± 2.08 分; 行走速度,0.74 ± 0.28 m/s; BBS, 51.45 ± 4.18 分; SPPB,7.94 ± 2.37 分; TUG, 15.23 ± 5.07 s) 顯著較差(p ＜ 0.05)； 而在受試者的年齡、FES、GDS、Stroop test、30 秒坐站則無顯著差異。結論：從數據中發現轉圈走360 度表現較差的長者，其簡易心智量表、畫鍾測驗、行走速度、平衡能力以及下肢身體功能表現較差，其原因推測極有可能是能完成此項任務的長者之動態平衡、下肢功能和認知的能力較無法完成的長者好。臨床意義：行走速度、格柏氏平衡量表和簡短身體功能量表表現較差代表平衡與下肢功能較差。MMSE 表現不佳代表認知功能較差，畫鐘測驗表現不佳代表認知功能及計畫執行功能不加。轉圈走360 度可能反應社區老人之動態平衡能力、認知能力與下肢身體功能。

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東臺灣急性心肌梗塞患者糖尿病比例趨勢變化及其影響因子之探討－2000至2011年間

背景與目的：糖尿病為急性心肌梗塞發作主要危險因子，其發生率逐年上升。本研究旨在探討2000 年到2011 年間東臺灣急性心肌梗塞患者，患有糖尿病比例之趨勢變化及其影響因子。方法：以病歷調閱法，調閱2000 年到2011 年間，因首次急性心肌梗塞而住進花蓮慈濟醫學中心且危險因子資料 ( 糖尿病、高血壓、抽菸、身體質量指數以及血清脂質 ) 齊全者為對象。依發作年份分成前期：2000 ~ 2003 (n = 233)、中期：2004 ~ 2007 (n = 516) 以及後期：2008 ~ 2011(n = 828)。再依發作年齡分成年輕組 ( ≤ 50 歲。男：175 名，女：33 名 )、與非年輕組 ( ≥ 51 歲。男：877 名， 女：492 名 )。採邏輯迴歸模型(multivariate logistic regression model)，以糖尿病有無為依變數，計算前期、中期以及後期各自變數之勝算比和95% 信賴區間。結果：2000 至2011 年間，發作年齡、女性比例以及糖尿病比例呈上升趨勢。男性非年輕組，中期與後期，相較於非高血壓者，高血壓者罹患糖尿病之勝算比分別增加0.84 (95% 信賴區間：1.02 ~ 3.33) 與1.59 (95% 信賴區間：1.64 ~ 4.11)。以高血壓有無和年代別交互作用對糖尿病的影響結果顯示，相較於前期，後期之勝算比增加1.36 (95% 信賴區間：1.03 ~ 5.41)。結論：2000 至2011 年間，東臺灣急性心肌梗塞患者糖尿病比例上升現象出現於男性非年輕組，高血壓為其首要影響因子，其顯著差異出現於後期與前期間。臨床意義：經由對急性心肌梗塞患者糖尿病比例上升趨勢及其影響因子之瞭解，有助於急性心肌梗塞發作預防之策略制定。

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創世社會福利基金會復健服務於跨專業團隊之角色建立及成效探討

背景與目的：創世基金會以安養植物人為主要服務宗旨，2011年開始於全臺各院開展復健服務，目前共服務752位院民。在護理與社工專業介入30年中，復健領域目前尚屬起步階段。在服務介入初期，因治療師為兼職角色，介入時間短暫，多依院方要求獨立執行服務，較少能與其他專業共同交流討論個案狀況。本研究目的為回顧統整復健專業融入創世植物人安養院服務團隊的歷程，以創世鳳山分院為執行單位。方法：透過包括定期團隊討論、個案研討、教育訓練、擺位工具運用及輔具介入、擺位照製作等方式建立復健專業於機構的角色，成效評估為個別化服務專業間合作方式轉變及個案關節活動度。結果：創世鳳山分院於2013年治療師由兼職轉為正職，使能更了解服務運作、個案需求及照顧者困難，致力於推動專業整合，積極參與團隊工作，治療師定期每月參與院務會議討論個案服務概況及每年復健主題教育訓練，治療師由原本獨立作業，至可與其他專業共同討論與合作，成功使復健服務融入並落實於照護服務中。透過觀察比較，發現此結果與機構給予空間、主管支持肯定、團隊願意開放及治療師個人特質等有關，也因團隊共同期待服務提昇，促成此合作成效。此外，由治療師規劃，經團隊多次討論，於2015年製作63份個案個別化平躺、側躺、輪椅坐立擺位照，運用不同擺位工具，扣除已結案者(如死亡、轉院等)共評估57位院民兩側肩、肘、腕、指、髖、膝、踝等關節角度，排除變形及攣縮之關節資料，2016年相較2015年有13.8%關節角度進步，81.0%維持：2017年相較2016年有19.7%關節角度進步，74.7%維持，也顯示在擺位觀念推行落實後，達成維持個案關節角度的目標。結論：在長照服務領域中，治療師致力於使復健概念能落實至日常照護流程，提升服務品質、減輕照顧者負擔並改善個案肢體。透過發現問題及找出合適解決方法確實提升個案擺位之合適，並經專業團隊之間的討論，成功建立復健服務於創世安養院的角色並能維持及部分提升長期臥床個案之關節角度。臨床意義：本研究在創世基金會附設清寒植物人安養院之鳳山分院，建立團隊中復健服務的專業角色及合作模式，並在院民關節角度維持及進展上有其成效，可供推廣至其他創世安養院或其他長期照護機構。

• 期刊

悠樂手和彈性繃帶對中風病人上肢運動後體溫和心律變異性的影響

背景與目的：運動後的肢體血循調控反應與自律神經系統有關，交感與副交感的衡定將影響中風病人肢體復健成效與存活率。本研究探討中風病人使用新型手部輔具—悠樂手(Yole hands, YH)和彈繃(elastic bandages, EB)執行信望愛上肢運動後，溫度與心跳變異率(low frequency, LF; high frequency, HF; LF/HF)之變化。方法：徵召18名中風病患(男／女：13/5)，平均62.27 ± 11.16歲。隨機決定參與者以YH或EB固定患側手於信望愛儀器從事上肢被動運動的順序，起始的上肢活動角度為一側肩關節屈曲120度 ± 10度；機器速度設置每10秒4次。以溫度記錄器及Polar心率錶記錄運動後5分鐘(恢復期)的雙手溫度及LF, HF, LF/HF，並填寫1 ~ 4分的不舒適感問卷。隔一天後，再以YH或EB執行相同的測試。將LF, HF, LF/HF值轉換為以10為底的對數值，以皮爾森相關係數分析溫度與LF, HF, LF/HF的相關性；以成對樣本t檢定分析使用YH及EB的雙手溫度及問卷調查。結果：恢復期，EB患側手溫低於YH患側手溫(33.12°C vs. 33.88°C, p ＜ 0.0001)，健側手溫則無差異。YH健側手溫與LF呈現顯著負相關(r = -0.1 9, p = 0.01)，患側雖無顯著仍呈負相關(r = -0.14, p = 0.06)，此為運動促進血循之效益。交感神經活化降低目的為擴張血管，帶走血管內的代謝產物使生理逐漸恢復穩定。以EB固定的患側手，溫度與LF呈正相關(r = 0.03, p= 0.69)；與HF呈負相關 (r = -0.01, p = 0.93)；與LF/HF呈正相關 (r = 0.02, p = 0.79)。健側手溫度與LF/HF呈顯著正相關，在於副交感神經過度活化(r = 0.19, p = 0.01)。YH和EB問卷調查結果，冰冷感達顯著差異(0.17 vs. 0.44, p =0.02)。討論：恢復期，EB患側手對於溫度及血管收放無法做出適當的自律神經調控反應，因彈繃壓迫患側手，周邊血管阻力上升、血流變慢、靜脈血回流減少，進而引起健側手以副交感神經活化代償反應，此異常調控反應對中風病患將造成心血管再次損傷的危險。結論：中風病人患側手以悠樂手固定運動後溫度變化及自律神經調控較和緩，且較無肢體冰冷感。臨床意義：悠樂手可考慮作為中風病人患側手從事上肢運動的固定輔具。