• 期刊

【論文摘要】探討國小高年級學童獨輪車學員的動作能力

背景與目的：獨輪車訓練可以幫助學童身體能力、心智或社交互動上的發展。這其中訓練可以包含從會騎，發展到更有挑戰性的競速及花式展演。過程訓練中，除了需要靈活技巧之外，還需發展出足夠的動作能力等才能勝任。過去的文獻僅比較有無騎乘經驗學童的動作能力，並無探討不同程度騎者的動作能力。同時過去獨輪車研究偏向僅施測下肢肌力及平衡，缺乏探討上下肢體發展。由於騎乘獨輪車的動作模式可能牽涉全身的協調運作，所以有必要評估全身動作能力。本研究使用布魯茵克斯—歐西瑞斯基動作量表第二版（Bruininks-Oseretsky test of motor proficiency, BOT-2）來實施測驗，探討國小高年級生不同程度騎者的全身動作能力（包括精細操作控制、手部協調、身體協調、力量和敏捷度）。方法：本研究對象為高雄市3所國小高年級獨輪車學童共55名，年齡為10～12歲，男生26位，女生29位，平均學習騎乘獨輪車為3.8 ± 1.2年。地點為各國小綜合球場或獨輪車場。本研究發展騎乘動作分級表來分類高階或低階騎乘能力的學童。在簽署同意書之後，開始實施測量，BOT-2為同一人評估及計分，最後進行資料處理與分析。再使用多變量分析比較不同騎乘程度的動作能力。結果：高階學童的手部敏捷、上肢協調、速度及敏捷和肌力皆優於低階的學童（p ＜ 0.05），但在平衡項目無顯著差異。年級與程度的相互作用也無統計上差異。結論：本篇研究發現，高階騎乘的學童在速度與敏捷、肌力及上肢協調優於低階學童，也證實獨輪車是除了運用下肢及軀幹以外，上肢也是極為重要的綜合型運動。臨床意義：獨輪車是一項可以促進全身身體能力的運動，例如敏捷、協調、肌力等，在動作能力上，本研究也提供學童進展獨輪車技術精準的訓練方式。

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【論文摘要】The Effects of Error Augmentation on Upper Extremity Robotic Assisted Training After Stroke: A Systematic Review and Meta-Analysis

Background and Purpose: Error augmentation (EA) is a feedback strategy which artificially increases performance error during practice. Additional information carried by EA is hypothesized to enhance error-based learning. Currently, EA has been adopted by upper extremity robotic assisted training (RAT) to enhance motor performances after stroke. However, the effects of EA on RAT remain to be determined. Therefore, the aim of this study was to investigate the effects of EA on upper extremity RAT in post-stroke subjects with quantitative meta-analyses through a systematic review. Methods: PubMed, Scopus, and Physiotherapy Evidence Database (PEDro) were searched with keywords (error augmentation, robotic assisted training, stroke, upper-extremity, motor recovery, etc.) to locate relevant studies upto November 2018. Two reviewers independently screened abstracts and full-text articles for eligibility of studies. Comprehensive Meta-Analysis software (ver. 3.0, Biostat, Englewood, NJ, USA) was used to analyze standard difference in means (SDM) on two categories of outcome: (1) Arm Motor Fugl-Meyer Assessment (AMFM) and (2) kinematic error (KE) of reaching task. Results: Seven studies (PEDro score = 5.00 ± 1.73) were eligible for systematic review while six studies were available for meta-analysis. RAT with EA significantly improved motor control ability (AMFM: SDM = 0.589, 95% confidence interval [CI] = 0.096-1.083) and motor performance (KE: SDM = 0.985, 95% CI = 0.397-1.573) better than RAT without EA right after training. Conclusion: EA, as a feedback modulation strategy, could be adopted by upper extremity RAT to enhance its training effects on patients with stroke. Clinical Relevance: Therapists may try to adapt EA to their regular training to optimize motor performances of stroke patients.

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【論文摘要】急性中風後6個月內日常生活功能恢復與預測因子

背景與目的：急性中風後的日常生活功能（activity of daily living, ADL）恢復一直是研究人員與臨床工作者關切的議題之一，過去研究對於不同中風類型及性別在功能恢復的影響，呈現不一致的結果。關於共病指數、迷你認知功能（Mini-Cog）、身體質量指數（body mass index, BMI）等變數在預測功能恢復的研究相對較少。本研究探討（1）不同中風類型及性別對中風後第3、6個月功能恢復的影響；（2）預測第3、6個月功能恢復的因子。方法：自2017年9月1日起至2019年1月3日，在某醫學中心急性病房物理治療室收案之急性中風患者，具有完整資料者共99位納入分析。收集住院患者基本資料、臨床相關評估、住院時功能（巴氏量表）與中風後第3個月和第6個月透過電話訪問記錄。資料分析（1）檢驗中風類型（梗塞型與出血型）及性別在3個時間點（住院期間、中風後第3個月和6個月）功能的恢復，使用three-way analysis of variance（ANOVA）mixed design。（2）探討中風後第3個月和6個月功能的預測因子，使用皮爾森相關係數，具有顯著相關的因子再放入羅吉斯迴歸分析。結果：時間主效應（F_(2,190) = 240.8, p ＜ 0.001），時間與中風類型的交叉效應（F_(2,190) = 4.8, p=0.009）皆顯著，而時間與性別（p = 0.232）及3個因子的交叉效應則不顯著（p = 0.626）。梗塞型中風患者，在第3個月功能有顯著進步，但到第6個月間無顯著差異。然而出血型患者的功能則隨著3個時間，呈現顯著的進步（p ＜ 0.001）。與梗塞型中風後第3個月功能相關的因子有年齡（r = -0.42, p ＜ 0.001）、性別（r = -0.28, p ＜ 0.031）、BMI（r = 0.36, p ＜ 0.003）、Mini-Cog（r = 0.25, p ＜ 0.028）、住院時功能（r = 0.66, p ＜ 0.001）；與梗塞型中風後第6個月時功能相關的因子有年齡（r = -0.34, p ＜ 0.004）和住院時功能（r = 0.61, p ＜ 0.001）；與出血型中風第3個月和6個月功能相關的因子只有住院時功能（r = 0.51, p ＜ 0.002; r = 0.46, p ＜ 0.005）。羅吉斯迴歸分析發現住院時功能為預測梗塞型中風第3個月和6個月功能及出血型中風第3個月功能之預測因子。結論：梗塞型中風後到第3個月，功能有顯著的進步，但第3個月到第6個月則不顯著。出血型中風逐次進步。急性住院時的功能分數可以預測中風後第3個月和第6個月的功能表現。臨床意義：住院時的功能可預測後期之功能恢復，有助於規劃急性住院期間治療及出院後的安置。

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【論文摘要】經顱直流電刺激對於中風病患手部功能之療效：系統性回顧

背景與目的：中風是臺灣及西方世界中的第三大死因，其中手部功能缺損對中風患者的日常精細動作影響甚巨。研究顯示在中風病人中有2／3的人仍然無法使用患側手執行日常生活之精細動作與功能性活動。因此，如何加強中風患者手部功能之復健治療效果已成為當前重要的課題之一。過去已有許多研究利用經顱直流電刺激（transcranial direct current stimulation, tDCS）做為一個新的治療方式，本篇系統性文獻回顧旨在探討tDCS針對中風病患的手部功能之療效。方法：本文獻回顧以經顱直流電刺激（tDCS）、中風（stroke）、手部功能（hand function）等關鍵字於PubMed、華藝線上圖書館、Cochrane Library等資料庫進行文獻搜尋。並收錄從2000年迄2018年7月之相關文獻，所有文獻必須符合：受測者均被診斷為中風病患、利用tDCS做為介入來治療、評估項目有針對手部動作評估等條件。本文以英國牛津大學實證醫學中心（Oxford Centre for Evidence-Based Medicine）建議等級及皮卓量表評分（Physiotherapy Evidence Database Scale, PEDro Scale）針對所有欲收錄文獻之研究品質予以評值（appraisal）來檢核文獻品質。結果：經主題或摘要篩選後，總共納入了12篇並進行文獻分析，收取之文獻品質之皮卓分數分別為2篇5分、4篇7分、6篇8分，總平均分數則為7.2分。經過英國牛津大學實證醫學中心建議強度之評等後，共10篇為實證二級，1篇為實證三級，1篇為實證四級。綜觀以上12篇文獻的結果，tDCS在中風患者的手工靈巧度、雙手協調能力、捏力、握力、手部動作平穩度、精細動作、傑森—泰勒手功能測驗（Jebsen-Taylor Hand Function Test）、行為研究手部測驗（Action Research Arm Test），均呈現有顯著差異的療效。結論：根據本篇系統性文獻回顧，tDCS對於中風病患的手部功能療效是一項可實施且有效之介入方式，不僅能夠明顯改善中風患者的捏力、握力、靈巧度等的精細動作，亦能改善許多特定手部功能性動作。臨床意義：中風患者在手部功能障礙上，有很高比例在往後生活中無法透過自主機制完全痊癒，藉由tDCS技術的介入，將可以改善中風患者在日常生活中的手部能力恢復，以做為未來中風病患手部臨床治療的參考。

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【論文摘要】Reliability of Ultrasonography in the Assessment of Thickness of Plantar Soft Tissues: A Systematic Review

Background and Purpose: Plantar soft tissues, including the heel fat pad and plantar fascia, play an important role in shock attenuation for human activities. Shock attenuation capacity deteriorates if dysfunction or any pathological changes was noted in plantar soft tissues. Thickness of the heel pad or plantar fascia to determine shock attenuation capacity is routinely measured using ultrasonography in clinical practice or research purpose to discriminate between healthy and unhealthy conditions and to assess changes in progress over time. Therefore, a reliable measurement tool is essential. The objective of this systematic review was to evaluate current evidences for the intra- and inter-rater reliability of ultrasonographic measurements of thickness of the heel pad or plantar fascia. Methods: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINHAHL), and Excerpta Medica database (Embase) databases were searched using the following key search terms: heel pad, plantar fascia, ultrasonography and reliability. Studies about reliability of 2-dimensional ultrasonographic measurements of thickness of the heel pad or plantar fascia, published from 1990 to November 2018 and limited to literature written in English, were included in this study. One reviewer screened the titles and abstracts of all studies identified by the initial search strategy. Two reviewers filtered the full-text articles with the inclusion criteria and exclusion criteria. The quality appraisal tool for studies of diagnostic reliability (QAREL) was assessed first by 2 reviewers independently, and then a consensus discussion was held by all 3 reviewers. Results: A total of 40 articles were found in the initial search, but only 7 articles met the inclusion criteria in this systematic review. Results showed ultrasonographic measurements of thickness of the heel pad had excellent intra-rater (intraclass correlation coefficient [ICC] = 0.78-0.99) and fair inter-rater reliability (ICC = 0.72). The reliability of ultrasonographic measurements of thickness of plantar fascia was fair to excellent for intra-rater (ICC = 0.50-0.97) and fair to excellent for inter-rater reliability (ICC = 0.59-0.95). Conclusion: The evidences showed that ultrasound imaging had a fair to excellent intra- and inter-rater reliability in measurements of thickness of plantar soft tissues. The detail of the clinical standardized protocol and the evaluator's experience might affect the reliability and need to be verified. Clinical Relevance: The present study provided an important information that ultrasonography is reliable to evaluate the changes in plantar soft tissue dysfunction.

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【論文摘要】Experience of a Workplace Violence Event at Outpatient Department of Rehabilitation

Background and Purpose: Majority of workplace violence in the medical institutions occurs at the emergency department and psychiatric ward. Yet, little literature reported prevention and management of abuse regarding the outpatient setting. We herein share an experience to raise the stakeholders' concern. Methods: A patient had a conflict with others for queue-jump at the musculoskeletal division of physical therapy. The offender shouted at others with verbal violence and intimidation. Medical staffs tried to reconcile the parties, but in vain. The following visit became more aggressive with mobbing the victims. The security guard could not control the situation effectively; hence police authority was immediately called. Results: The police officers took the witness statement to the victims, yet didn't restrain the offender. The person committed the offense had not visited our department since the event. Associated medical personnel and the involved patients continued their routine procedures. Conclusion: Any type of violence could affect the healthcare providers' and patients' health with residual physical and mental stress. Insulting behavior may endanger patient safety or hinder medical practitioners from carrying out services. The employer shall provide training to prevent and cope with misbehavior. Clinical Relevance: Despite the amendment of the Medical Care Act imposes the fine of abuse, strategy to ensure a safe working environment is necessary. We anticipate a robust reporting mechanism and support to against violence in the workplace.

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【論文摘要】The Effect of Gait Training Emphasizing Heel-Strike on Gait Performance in People With Parkinson's Disease: A Preliminary Study

Background and Purpose: Gait disturbance is a debilitating motor symptom in people with Parkinson's disease (PD). The primary gait disorders in PD include lack of heel-strike (HS), short step length and slow walking speed. To ameliorate those gait disorders, clinicians often use verbal cues, such as ＂lift your foot up high＂ or ＂take big steps,＂ to train patients with PD. However, it is uneasy to maintain the required gait patterns because patients often feel tired and embarrassed when walking outdoors with the exaggerated walking pattern. Thus, to identify an effective verbal instruction to train the patients is important. It has often been observed that patients with PD do not have HS at the initial contact. The presence of HS at initial contact is crucial for generating longer step length, faster walking speed and increased foot clearance. Thus, this study aimed to determine whether gait training emphasizing ＂HS at initial contact＂ could improve walking ability in people with PD. Methods: Ten individuals with idiopathic PD have joined the preliminary study. The participants were randomly allocated to the HS group (n = 5) or big-steps (BIG) group (n = 5). All the participants received 12 sessions of 1-h gait training. The verbal instructions of ＂strike your foot with heel＂ and ＂lift your foot high＂ were given to the participants in the HS group and the BIG group, respectively. The participants were assessed before (pre-test), after (post-test), and 1-month after (follow-up test) the interventions. The Physilog®5 system (Gait Up, Renens, Switzerland) was used to evaluate gait parameters including the foot-strike (FS) angle, step length, gait velocity and cadence. Secondary outcomes included the motor subscale of the Unified Parkinson's Disease Rating Scale (UPDRS-III) and the Timed Up and Go test (TUG). Results: Both groups showed an increase in FS angle from pre-test (HS: 15.93 ± 3.87°, BIG: 15.39 ± 3.71°) to post-test (HS: 21.17 ± 4.06°, BIG: 19.79 ± 4.06°), and maintained till follow-up test (HS: 22.02 ± 5.02°, BIG: 19.23 ± 4.47°). As for the step length, both groups showed an increase from pre-test (HS: 0.50 ± 0.05 m, BIG: 0.49 ± 0.05 m) to post-test (HS: 0.56 ± 0.05 m, BIG: 0.53 ± 0.03 m), and maintained till follow-up (HS: 0.56 ± 0.06 m, BIG: 0.51 ± 0.04 m). The HS group seemed to have greater increment in FS angle and step length than the BIG group after the interventions. The HS group showed a decrease in cadence at follow-up test compared with pre-test and post-test, while the BIG group showed an increase in cadence after training. Both groups showed similar amount of improvement on gait velocity. Scores of the UPDRS-III decreased at post-test compared with pre-test for both groups. Only the HS group, but not the BIG group, maintained the improvement of the UPDRS-III at follow-up. Subjects in both groups showed equivalent improvement in TUG at post-test and follow-up. Conclusion: Our preliminary data indicated that gait training emphasizing HS at initial contact could improve walking ability for people with PD. Clinical Relevance: Clinicians may use the verbal instructions of emphasizing HS at initial contact to improve gait performance for people with PD.

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【論文摘要】比較兒童與成人雷特氏症患者的步態表現及生活功能之預測

背景與目的：雷特氏症（Rett syndrome, RTT）是X染色體性聯遺傳的神經發展疾病，患者的臨床 症狀為重度的認知、社會溝通與動作發展障礙，以及手部刻板動作。雖然50～90% RTT患者能夠獨立行走或在輕度協助下行走，異常的步態型態常見於患者的幼兒時期，然而，過去缺乏對RTT患者的步態研究資料，以及並無探討其步行表現與生活功能的關聯，因此，本研究的目的為（1）評估RTT兒童及成人的行走步態之運動學參數，並比較RTT兒童及成人的步態表現；（2）探討步態參數中對於RTT患者生活功能表現的預測因子。方法：此研究共招募25名具行走能力的RTT患者，分為兒童組（＜ 20歲；共14人）及成人組（≥ 20歲；共11人），受試者於10 m走道行走3次， 使用Gait Up®系統（Gait Up, Renens, Switzerland）收集與分析雙腳之步態運動學參數，同時請家長填寫兒童生活功能量表（Chinese Version of Pediatric Evaluation of Disability Inventory, PEDI-C），研究使用獨立樣本t檢定以比較步態資料的組別差異，並以線性回歸模式分析步態參數對PEDI-C分數之預測。結果：研究結果顯示兒童組在行走速度、擺盪期時間比率、站立期之承重時間比率、站立期之腳跟離地時間比率、擺盪初期至中期的最大角加速度、腳趾離地角度，以及擺盪期間腳趾離地高度等參數，皆顯著高於成人組（all p ＜ 0.05），並且，兒童組在整體步態週期時間、站立期時間比率、雙腳支撐時間比率、腳掌著地時間比率，以及腳跟著地時間比率等參數，皆顯著低於成人組（all p ＜ 0.05）。此外，步行速度能預測PEDI-C之功 能性技巧（β = 0.71, p ＜ 0.01）、行動（β = 0.63, p = 0.01）、社會功能（β = 0.55, p = 0.03）及照顧者協助之行動領域分數（β = 0.57, p = 0.02）。結論：研究結果顯示RTT兒童的步態運動學表現優於成人，較高的行走速度能夠預測較佳的生活功能參與能力。臨床意義：此研究結果提供臺灣RTT患者的步態運動學資料，臨床上可將步行速度做為增進RTT生活功能的指標之一，生活中則需要持續維持RTT患者的步行功能以延緩失能。

• 期刊

【論文摘要】雙重任務訓練對於腦性麻痺兒童運動功能之效果：系統性回顧

背景與目的：腦性麻痺為一種多重障礙疾病，並造成肢體運動功能障礙。過去研究顯示腦性麻痺兒童在執行雙重任務時，運動功能較正常兒童更易受到影響。因此，過去有許多研究使用雙重任務做為一種新的訓練方式，來促進腦性痲痺兒童之運動功能表現。本篇研究的目的為系統性回顧雙重任務訓練對於腦性麻痺兒童運動功能恢復的成效。方法：本篇研究搜尋從2009年1月至2017年2月間於PubMed、Semantic Scholar、Bulletin of Faculty of Physical Therapy、International Journal of Physiotherapy and Research（IJPR）等國際資料庫中，針對雙重任務對腦性麻痺治療兒童介入成效之文獻。以腦性麻痺（cerebral palsy）、雙重任務（dual task）、訓練（training）或運動功能（motor function）作為關鍵字進行搜尋。結果：根據上述關鍵字進行搜尋，並依相關主題篩選後，共有4篇文獻納入系統性文獻回顧。其中文獻品質使用皮卓量表（Physiotherapy Evidence Database, PEDro）評分，總分介於3～5分之間。綜觀4篇結果，雙重任務訓練、傳統物理治療與單一任務訓練均能改善腦性麻痺孩童之運動功能，其中2篇文獻顯示雙重任務訓練在行走指數（Ambulation Index）、患側支撐的時間，以及平衡能力比單一任務訓練或傳統物理治療有更顯著的進步。1篇文獻指出在雙重任務訓練後，對於上肢動作的手部抓握能力有進步。最後1篇文獻結果顯示，在雙重任務訓練後，能使腦性麻痺兒童身體搖晃程度減少、步頻下降與步長增加。結論：根據本篇文獻回顧，雖然進行單一任務和傳統物理治療訓練都能明顯改善腦性麻痺兒童的能力，但雙重任務的介入訓練提供了更好的效果，尤其在行走指數、用患側支撐的時間與平衡功能。此外，雙重任務訓練亦能增加步長，降低身體搖晃程度並改善手部抓握能力，在臨床治療上可嘗試設計雙重任務訓練來改善患者的運動功能。另外，由於目前雙重任務訓練應用於腦性麻痺的研究偏少，未來可收取更多文獻來驗證並支持雙重任務訓練之效果。臨床意義：腦性麻痺患者多患有多重障礙，其中主要以肢體障礙為主，藉由雙重任務訓練的介入，可改善腦性麻痺兒童日常生活中執行雙重任務中的運動能力，未來將可做為腦性麻痺患者之治療策略。

• 期刊

【論文摘要】高強度間隔式運動訓練與中等強度持續式運動訓練對紅血球流變特性及氧氣釋放程度的影響

背景與目的：紅血球的流變學特性能動態調節血液黏度與血流阻力；而受損的紅血球流變功能常導致循環功能障礙。運動訓練可能會影響紅血球流變特性，但以何種運動策略為佳，目前仍未臻明瞭。本研究探討高強度間隔式訓練（high-intensity interval training, HIIT）和中度強度持續式訓練（moderate-intensity continuous training, MICT） 如何影響低氧運動（hypoxic exercise, HE）時紅血球的流變特性和釋放氧氣能力。方法：徵召24位19～28歲的靜態生活健康男性，並隨機分為HIIT組與MICT組。兩組訓練前後執行HE測試，並測量紅血球流變特性（凝集、形變與滲透壓耐受性），以及氧氣釋放程度。結果：在介入前，急性HE會增加血中紅血球數目（4.99 ± 0.24 × 10^6 cells/μL至5.33 ± 0.31 × 10^6 cells/μL，p ＜ 0.005）、降低形變能力（shear stress [SS_(1/2)]上升：219 ± 99%至270 ± 115%，p = 0.131）、上升凝集程度（aggregation index [AI%]上升、t_(1/2)下降：62.54 ± 10.07% 至66.91 ± 8.39%， p = 0.015；2.64 ± 1.39 sec至2.20 ± 0.87 sec，p = 0.043），以及提升血中乳酸濃度（1.18 ± 0.51 mmol/L至7.9 ± 2.41 mmol/L，p ＜ 0.005）。而在運動訓練後，兩組在HE引發乳酸上升程度皆下降，但只有HIIT組在HE損害紅血球形變能力（SS_(1/2)上升程度減少）與凝集程度（AI% 上升與t_(1/2)下降程度減少）得到改善。此外，兩組訓練後在HE時紅血球滲透壓耐受性亦獲提升（O hyper上升），且紅血球更易釋放氧氣。結論：急性HE會促使紅血球流變特性變差，可能導致運動表現的限制。然而，HIIT與MICT皆能使紅血球在HE下更易釋放氧氣，且HIIT較MICT能更有效減少HE下紅血球流變特性障礙程度。臨床意義：HIIT可以改善紅血球的流變特性，減少血流阻力；同時增加紅血球氧氣釋放程度，以提供活動組織（如肌肉）使用，進而有效改善運動表現。