• 期刊

【論文摘要】以反應曲面法找出第二期心臟物理治療間歇性訓練最佳參數設定值

背景與目的：缺血性心臟病在全世界是高居十大死因的重要疾病，死亡人數逐年攀升。隨著醫療的進步，許多缺血性心臟病患者可以被早期診斷及治療，因此如何降低缺血性心臟病患者的再發率、死亡率，以及提升術後的生活品質等議題日趨重要。許多研究中已證實第二期心臟物理治療對缺血性心臟病患者術後有許多好處。第二期心臟物理治療訓練常使用的模式有連續型訓練模式（continuous training）和間歇式運動訓練模式（interval training）兩種；過去文獻發現間歇式運動訓練模式在心衰竭病患術後訓練上具有成效，但此模式卻很少使用在其他類型的心血管疾病患者的術後訓練上，究其原因是目前尚無可供調整間歇式運動訓練模式中參數的依據。反應曲面法（response surface methodology, RSM）是工業界常用來找出製程參數之最佳設定值的一種實驗設計方法，此法已廣泛地運用在其他領域。因此，本研究的目的是應用反應曲面法來找出第二期心臟物理治療間歇性訓練模式的最佳參數設定值。方法：本研究利用反應曲面法來規劃實驗，收集臨床13位受測者共36次第二期心臟物理治療訓練前與訓練後之最大攝氧量的變化量，再建構一個反應曲面模型，其中反應變數（response）為最大攝氧量的改變量，此數值越大越好；本實驗的兩個可控因子分別是強度的落差和訓練的循環數。強度的落差設定為3個水準，分別是以訓練期最高強度乘以0.5倍、0.25倍及0倍作為休息期訓練的強度；一個訓練期加上一個休息期定義為一個循環，訓練的循環數也設定為3個水準，分別是10循環、7循環及5循環。10循環的訓練期時間和休息期時間各為1.5 min，7循環的訓練期時間和休息期時間各為2 min，5循環的訓練期時間和休息期時間則各為3 min。本研究藉由反應曲面模型，利用數學規劃法找出一組強度與循環數的最佳設定值，以使最大攝氧量的改變量最大。結果：本研究利用minitab17分析實驗數據，發現當強度設定在0倍及循環數設定在10循環時，會得到最大之最大攝氧量改變量。結論：當訓練參數的強度設定在0倍及循環數設定在10循環時，會得到最佳的治療療效。同時從實驗結果也可以觀察到當強度落差越大且循環數越接近10循環，則訓練成效越好。臨床意義：將本研究所得之第二期心臟物理治療間歇性訓練模式的最佳參數設定值，實際運用到臨床訓練上，預期可以有效提升訓練成效。

• 期刊

【論文摘要】合併病理性肥胖與擴張型心肌病變心臟衰竭病患之運動治療介入成效：個案報告

背景與目的：嚴重肥胖（body mass index，BMI＞40 kg／m^2）會直接導致心臟衰竭，此類患者會有血液動力學、心臟形態學、左心室收縮功能異常與心肌病變。肥胖悖論（obesity paradox）中發現肥胖雖會增加心臟衰竭的風險，但在心臟衰竭患者中，肥胖族群卻相對健康體重的族群死亡率下降33％。文獻回顧中發現BMI與身體組成的差別是造成預後差異的關鍵，文中建議治療目標應放在控制體重、增加淨體重（lean mass）並提升心肺適能。方法：個案為32歲男性，患有病理性肥胖（2018年1月BMI為54.9 kg／m^2），自行運動減重的過程中，發現有呼吸困難的現象。7月5日因休息時嚴重呼吸窘迫送醫，診斷為擴張型心肌病變合併心臟衰竭（左心室射出功率為23.1％），出院後加入急性後期整合照顧心衰竭計畫。7月26日開始1週2次物理治療門診心臟復健。個案主訴體能較差，工作場域須有上下樓梯與搬50～75 kg重物之需求，且無法於戶外騎自行車。8月6日運動測試顯示最大攝氧量為15.0 mL／kg／min，最大運動強度159W，為正常值之44.9％。病人休息心跳為79 bpm，血壓為121／85 mmHg，體重為148.2 kg，腰圍為142 cm，BMI為43.1 kg／m^2，6 min行走測試距離為507 m（正常值之76％）。評估病人屬於高危險群之心臟衰竭病人。治療計畫前18次之訓練強度為目標心跳達106～126 bpm（40～60％heart rate reserve［HRR］），包含各15 min的腳踏車（100W）、跑步機（5.4 kph＋1％）訓練與阻力訓練（seat row, pull down, and knee extension）；後18次之訓練強度定為目標心跳達136～154 bpm（60～80％ HRR），腳踏車阻力增至145W、跑步機增加至6 kph＋2％與阻力訓練，rating of perceived exertion（RPE）均在11～13之間。同時個案也積極配合急性後期整合照顧心衰竭計畫所提供之飲食控制與藥物治療。結果：11月28日，病患6 min行走測試距離增加至607 m（正常值之88％），最大攝氧量達18.9 mL／kg／min。左心室射出功率增為59.3％（10月26日），體重減至138.2 kg，腰圍減為119 cm，BMI為40.5 kg／m^2。病人工作表現提升，日常休閒活動也趨於正常，可連續於戶外騎腳踏車運動1 h。結論：為期5個月之中高等強度（40～80％HRR）心臟復健訓練可提升肥胖心臟衰竭病人之心肺適能。臨床意義：肥胖的心臟衰竭個案在進行飲食、藥物與運動介入之急性後期整合照顧心衰竭計畫後，可以在監控心跳節律下，透過心臟復健，提升其心肺適能，增加工作表現與日常生活功能。

• 期刊

【論文摘要】阻力運動訓練對心臟移植患者骨質密度效果之系統性回顧

背景與目的：心臟移植（heart transplantation）患者因為服用免疫抑制藥物，有2～20％患者第一年會有明顯骨質密度（bone mineral density）流失。阻力訓練（resistance exercise）之機械性負載可以增加健康人肌肉量並改善骨質密度，但臨床缺乏阻力訓練之介入對心臟移植患者骨質密度效果之系統性回顧文章。本篇利用系統性回顧探討阻力訓練介入對心臟移植個案骨質密度之效果。方法：本研究由PubMed、物理治療實證資料庫（Physiotherapy Evidence Database，PEDro）及華藝電子資料庫搜尋至2018年7月發表之所有隨機控制的研究，關鍵字包括多心臟移植（heart transplantation）、阻力訓練（resistance exercise or strengthening exercise）及骨質密度（bone mineral density）。所有文章必須符合的條件為心臟移植病患、接受阻力訓練介入並評估骨質密度的改變。搜尋到符合條件之所有文章，會以物理治療實證資料庫量表（PEDro scale）評定文章等級。結果：共搜尋到3篇符合條件之研究，皆出於同一研究團隊，PEDro分級均為5分。第一篇比較6個月行走訓練與行走訓練加上阻力訓練介入之效果，顯示3個月阻力訓練對全身、腰椎骨質密度即具有明顯效果，但股骨頸骨之骨質密度在6個月才具有明顯改善。第二篇比較6個月alendronate與alendronate加上阻力訓練介入之效果，6個月阻力訓練對全身、腰椎與股骨頸骨之骨質密度具有明顯效果。第三篇比較6個月接受降鈣素與降鈣素加上阻力訓練介入之效果，也顯示6個月阻力訓練可以改善心臟移植患者股骨頸骨與腰椎骨質密度，但是對全身骨質密度沒有改善。結論：在有限的證據裡顯示，6個月上下肢與軀幹之大肌肉群阻力訓練可以有效改善心臟移植患者全身、股骨頸骨與腰椎之骨質密度。臨床意義：為避免心臟移植患者骨質密度過低造成骨質疏鬆或產生骨折之危險，建議心臟移植患者宜積極接受上下肢與軀幹之阻力訓練至少6個月。

• 期刊

【論文摘要】Applying a Computerized Handwriting Assessment Tool to Quantify Handwriting Quality and Evaluate Handwriting Difficulty in Children

Background and Purpose: Handwriting performance develops until the primary school age. Deficits in handwriting performance limit the school activity participation in children with handwriting difficulty. The aim of this study was to examine the feasibility of application of a computerized handwriting assessment tool in quantifying handwriting quality in children aged 7-9 years. Methods: Participating children were divided by children with or without handwriting difficulty based on the subtest of Basic Reading and Writing Test Battery (BRWTB). Five children with handwriting difficulty and 20 children without handwriting difficulty participated in the study. All participants were asked to copy 50 words with a wireless pen as fast as possible on a piece of A4 paper, which was fixed on a digitizer tablet. Five muscles activities (flexor carpi radialis, FCR; flexor carpi ulnaris, FCU; extensor digitorum, ED; flexor pollicis brevis, FPB; first dorsal interossei, FDI) detected with electromyography sensors were recorded. The writing performance and muscle performance included the writing pressure, speed, stroke, legibility and hand activities with wrist and finger. Two-way mixed repeated measures analysis of variance (two way mixed repeated measures ANOVA) was used to analyze the differences between groups of children with or without handwriting difficulty. Results: Children with handwriting difficulty presented greater writing pressure than children without handwriting difficulty. The FDI and FPB muscles activities were also higher in the children with handwriting difficulty than in the children without handwriting difficulty. However, there was no significant difference in other variables between groups. Conclusion: The study showed that the computerized handwriting assessment tool might be able to measure the handwriting performance in children. However, the limited number of children with handwriting difficulty in this study may have affected the generalization value of the study. Clinical Relevance: Applying a computerized handwriting assessment tool to quantify handwriting quality and evaluate handwriting difficulty in children.

• 期刊

【論文摘要】Resting Heart Rate Improvement in Patients Following Acute Myocardial Infarction by Exercise Training

Background and Purpose: Resting heart rate (RHR) is a marker of vagal tone that is a powerful predictor of mortality in patients with coronary artery disease. However, there are limited data discussing the training effect on the RHR in patients with acute myocardial infarction (AMI). The purpose of this study was to evaluate the effect of cardiac rehabilitation (CR) program on RHR recovery and maximum oxygen consumption (VO_2max) in patients with recent AMI. Methods: Forty patients (38 males; 2 females) who were 6 weeks after an AMI attack were enrolled in the study. Each patient underwent the symptom-limited exercise tests before and after the CR intervention. The cardiorespiratory variables including heart rate (HR), VO_2max, HR recovery, resting blood pressure, and maximum HR were measured during the exercise testing. All patients completed 30 min aerobic training under physical therapist's supervision twice a week and home-based exercise once a week for 12 weeks. A paired t-test was applied to compare the differences of all outcome indicators between preand post-intervention. Results: After training, mean RHR significantly decreased by 5% (79.9 to 75.23 beat/ min). Comparable changes were found in duration, VO_2max and double-product at submaximal and maximal workloads. Conclusion: The effect of CR on AMI patient can decrease RHR significantly, and also improve their exercise performance. Clinical Relevance: The findings provide important information to designing proper CR program for AMI patients. Doing aerobic exercise can not only decrease RHR but also improve other exercise parameters.

• 期刊

【論文摘要】頸部淋巴廓清術後物理治療介入之效果：文獻回顧

背景與目的：頸部淋巴廓清術（neck dissection）是治療頭頸癌（如口腔癌、咽喉癌、喉癌、甲狀腺癌等）的頸部淋巴結轉移的重要手術方法。頸部淋巴分為7個區域，進行淋巴結廓清時有可能傷害到脊髓副神經（spinal accessory nerve）而造成暫時或永久的神經麻痺，進而導致肩關節失能（accessory nerve shoulder dysfunction，ANSD）。物理治療介入被建議作為此族群的治療選擇。然而目前對於此類患者運動介入所產生的成效並不明確，也沒有治療準則可依循。因此本篇研究藉由文獻回顧，探討物理治療運動介入對ANSD的效果。方法：本篇研究使用PubMed資料庫，以頸部淋巴廓清術、肩膀（shoulder）、復健（rehabilitation），作關鍵字搜尋，設定搜尋文獻類型為臨床實驗及以英文發表，搜尋至2018年6月所發表的文章。結果：共9篇文章，經由摘要檢視後刪除4篇，保留5篇。其中3篇文獻共招募163位受測者，主要探討術後預防性早期介入（術後2天到8週內開始介入），對肩關節疼痛、關節角度、功能恢復、生活品質的效果，最長進行12個月的追蹤。結果發現，手術1年後，物理治療介入組與衛教單組在生活品質與肩關節功能上皆有顯著進步，兩組之間沒有顯著差異。另外2篇文獻共72位受測者，主要徵召術後慢性ANSD患者（術後2到180個月）給予漸進式阻力訓練與傳統物理治療相比，在疼痛、功能與肌力部分皆有顯著優於傳統物理治療介入。結論：術後預防性物理治療12週早期介入，其對肩關節功能與生活品質的改善並不顯著優於對照組。術前提供衛教單張或術後進行衛教並說明也有同樣的效益。但以術後慢性期發生ANSD的病人而言，物理治療介入是有效的，以漸進式阻力訓練的效果對疼痛改善與肌力增進的效果更加顯著。由於此類病人多有其他合併的癌症治療，配合度不高等等問題，目前缺乏長期的追蹤查看預防性或早期的物理治療是否會降低併發肩關節問題的機率及預後。臨床意義：由於目前手術技術的進步與神經探測器的使用，已經大幅降低手術造成神經永久損傷的機率。術後3個月屬於神經修復的階段，可以在術前或出院前給予病人清楚有圖示的衛教單張，協助病人出院後能順利執行預防關節沾黏的物理治療運動。術後3個月後若發生ANSD疼痛的症狀，接受物理治療對於肌力、功能、肩關節角度與生活品質都會得到顯著改善。

• 期刊

【論文摘要】中間範圍收縮分率心衰竭患者執行間歇性高強度心肺運動介入之效果：個案報告

背景與目的：心臟衰竭（heart failure，HF）主要以藥物控制與運動訓練來減少發病率、減緩症狀，以增加生活品質與功能性活動能力。過去有文獻指出HF病人執行高強度間歇運動訓練其最大攝氧量（maximal oxygen uptake，VO_2max）相較於中等強度連續性運動有顯著較好的結果，但兩種運動模式對於肺換氣效率 （ventilation／carbon dioxide production，VE／VCO_2 slope）與生活品質（quality of life，QoL）的效果無顯著差異。於歐洲心臟醫學會在2016年提出「中間範圍收縮分率心衰竭（heart failure with mid-range ejection fraction，HFmrEF）」族群，其左心室收縮分率在41～49％，約占HF中8～20％，此族群的特徵較分歧，其死亡率介於低收縮分率心衰竭（heart failure with reduced ejection fraction，HFrEF）族群與正常收縮分率心衰竭（heart failure with preserved ejection fraction，HFpEF）族群之間，其共病症與HFpEF族群相似，然而運動能力與訓練方式，HFmrEF族群的結果較為分歧。方法：以美國物理治療學會建議之「個案處理模式（patient／client management model，CMM）」，進行個案評估、介入與成效評量。本文個案為39歲男性診斷為擴張型心肌病變之HF，左心室收縮分率為43.5％，6分鐘行走測試達658 m（正常值的94.8％），VE／VCO_2 slope為24.87，為HFmrEF病人，個案期待能恢復籃球運動，減少跑步時的費力感，能增加社交活動參與，故以HF病人使用的高強度間歇運動訓練原則，來提升其心肺耐力及生活品質。結果：進行為期9週共18次，每次30 min腳踏車與跑步機之高強度間歇運動訓練，強度則依症狀限制最大運動測試結果訂定目標心率分別為低強度40％及高強度80％之心率儲備量，以3 min低強度及3 min高強度為一回，共4回，前後各有3 min的暖身及緩和運動。個案心肺耐力部分之症狀限制最大運動負荷從6.0代謝當量（metabolic equivalent of task，MET）（正常值的67％）進步至7.1MET（正常值的79.5%）；身體質量指數（body mass index，BMI）由26.6 kg／m^2降至25.8 kg／m^2；生活品質量表（Short Form-36，SF-36）中生理分項由62.3分進步至66.5分，心理分項由65.3分增加到74.6分，較有顯著提升的部分為運動耐受度、身體疼痛及社交活動參與。結論：個案於9週心肺運動介入後，在心肺耐力、身體基本測量及生活品質方面皆有成效，且個案主訴在跑步費力感有減少，目前可以從事非競賽型籃球運動。臨床意義：利用CMM分析問題，依實證醫學以高強度間歇運動訓練設定心肺運動介入計畫，可增進HFmrEF病人之心肺耐力並提升生活品質。

• 期刊

【論文摘要】數位學習於實證物理治療之應用

背景與目的：傳統物理治療臨床實習教育大多承襲「專家經驗」，易忽略最新研究證據，而在實證醫學（evidence-based medicine，EBM）的潮流推動下，物理治療職類也將之納入臨床教學中，透過整合現有最佳的研究證據對個案照護上進行臨床決策。然而，由於臨床教學的領域廣泛，EBM臨床實作與討論，需要耗費較多時間，以致於臨床教師在教學與討論的負擔較吃緊；但若透過數位教學的資源與管道，或許能夠有效率地完成教學工作。本課程主要目的如下：（1）透過「eXtended Memory Specification（XMS）平臺」建立數位教學課程，讓實習學生自發性學習「實證物理治療」知識。（2）比較「傳統教學課程」與「數位教學課程」學習效果。方法：傳統課程參與者為105學年度第一學期成大醫院復健部物理治療組之實習生；數位課程參與者為105學年度第二學期國立成功大學醫學院附設醫院復健部物理治療組之實習生。「傳統課程」分為8堂課，其中包含4堂實體講授課程及4堂討論課程，其中第6堂課時，教師會進入各分組與同學互動討論。其中傳統課程將透過powercam錄製為數位課程。「數位課程」分為4堂數位課程及4堂討論課程，其中數位課程內容與傳統課程講述內容一樣。「成效評量」之成效問卷修改自黃靜宜於醫學教育期刊所提出之EBM成效評估問卷。主要分為3部分：對EBM態度（9題）、EBM技能自我評估（8題）、未來EBM臨床運用（9題），計分採五分法。1分為非常不同意，5分為非常同意。於課程第1堂前及最後1堂後填寫成效回饋問卷。統計採用paired-t test檢驗課程前後的問卷差異；組間差異以課程分數前後差異分數做統計分析，採用獨立樣本t檢定。結果：傳統課程共有12名學員（4女8男）參與；數位課程共有18名學員（8女10男）參與。比較傳統課程與數位課程在量表分數前後差異上沒有達顯著差異。數位課程整體量表總分（含態度、技巧自評、未來意願）達顯著（p＜0.05），就個別面向而言，有達到統計上顯著差異為「未來使用意願」（p＜0.05）；傳統課程則在各層面皆未達顯著。結論：數位課程較能提升學生應用實證物理治療的意願。本課程未能改變學生對於實證物理治療的態度，可能因為態度的改變無法於短時間達成，或因為態度的改變涉及更多複雜因素，有待進一步研究探討。臨床意義：數位課程有利於減輕臨床教師之備課負擔，且學生能夠依照自我理解能力調整上課速度，配合案例實際面對面討論，此教學策略相對於傳統課程更有效率。

• 期刊

【論文摘要】Effect of Neuromuscular Electrical Stimulation Combined With Kegel Exercise on Quality of Life and Sphincter Control for Patient With Fecal Incontinence After Lower Anterior Resection of Rectum, Colostomy and Radiotherapy: A Case Report

Background and Purpose: The losing bowl movement is a frequent disorder after lower anterior resection (LAR) of rectum. There are few effective and standard approaches for patient with fecal incontinence. Our patient was a 57-year-old man diagnosed rectal cancer T2 pN1aM0, stage IIIA. After accepting LAR and colostomy, he had done about 5-month postoperative radiotherapy (RT) and one year follow up. We assumed that neuromuscular electrical stimulation (NMES), biofeedback (BF) and Kegel exercise will also be effective for defecation control, strengthening weak sphincter muscles and increase his quality of life (QoL). Methods: Patient accepted NMES with 2 tunnel modes (35 Hz, 500 μs, 25 mA and 50 Hz, 400 μs, 30 mA) 20 min, 1-2 times/week, sphincter endurance and control exercise with BF 20 min and Kegel exercise, 20 min, 1-2 times/week. Outcome measures are sphincter control, endurance and QoL. We recorded sphincter holding timing rate (SHTR), successful control rate and failure rate. Florida Fecal Incontinence Scale (FFIS) was used to represent patient QoL. Results: The SHTR improved from 43.7% to 64% and the successful control rate increased from 42% to 87%. Finally, the FFIS decreased from 7 to 0. Conclusion: Patient performed better sphincter control and endurance also improved his QoL without fecal incontinence after 3 sessions, 18 time treatments. Although we had good outcome, there were still some independent factors for clinical stuff and farther research to consider like patient's motivation, frequency, intensity of electrical stimulation (ES), and timing to start physical therapy after follow up. Clinical Relevance: Our results provided an effective intervention for patient with fecal incontinence after LAR of rectum, colostomy, and RT.

• 期刊

【論文摘要】The Approach of Early Intervention in Postoperation of Oral Cancer by Physical Therapy in Chi Mei Medical Center, Liouying

Background and Purpose: The occurrence of oral cancer in our hospital is within the top 5. Oral cancer most commonly occurs on the lip, gingiva, buccal mucosa, tongue, the floor of the mouth, or palate. In our hospital, stage III, IVA and IVB of the oral cancer staging were found in most cases. These patients usually underwent the excision of the involved area and lymph nodes around the neck, and might be have to receive the flap surgery for reconstruction, if necessary. They also might need to receive a period of radiotherapy, chemotherapy or both of them after surgery. After interventions in the oral cancer, most patients may have uncomfortable symptoms around the neck or the shoulder, and some limitations on their daily living activities, such as eating, speaking or going back to work. This study would reveal how physical therapy could be applied on these patients in the future. Methods: This study included 34 patients, undergoing wide excision of the oral tumor and neck dissection with or without flap reconstruction in our hospital. The physical therapist provided the education on gentle range of motion (ROM) exercise of the neck and upper extremities, and cardiopulmonary exercise at least 3 times within 1 to 2 weeks after surgery. And we would arrange routine rehabilitation program, such as massage and stretch for the stiff tissue, if necessary after 2 weeks. All patients were received evaluation of the distance of mouth opening (mm), function-related tests (FRT) for bilateral shoulders, and the difficulty in the oral activities, such as bite, drinking water, and cleaning within 7 d and 90 d after surgery, respectively. Results: The ages of all the patients were from 32 to 61 years old. Within 1 week after surgery, they could open their mouth less than 20 mm in average. But after 3 months, they could open their mouth to nearly 25 mm in average. The results of FRT showed mild limitations in the shoulder of the surgery side within 7 d after surgery, but improved slightly after 3 months without significant effect. We also found that some patients had more limitations in the shoulder of the surgery site on 1 week than 3 months after surgery, especially the patient with reconstruction by pectoralis major myocutaneous flap. There were significant improvements in all three of the oral activities from 1 week to 3 months after surgery (p ＜ 0.05). Conclusion: The patients of the oral cancer, undergoing surgery intervention in the involved site, mostly had some limitations on both oral activities and the functions of the shoulder near the involved site. It is important that the early rehabilitation program should be selected to fit for different complications of the surgery, radiotherapy or chemotherapy appropriately. Clinical Relevance: Our results revealed the important way to help the design of the early approach of the rehabilitation program for the patient of the oral caner after medical intervention in Taiwan in the future.