- 學位論文
功能性電刺激輔助踩車訓練對於中風患者肌肉張力與站立平衡之影響
The Effects of FES-Cycling Training on Muscle Tone and Standing Balance in Stroke Patients
摘要
研究背景：對腦中風患者而言，痙攣（spasticity）是一種伴隨著上運動神經元損傷出現的常見併發症。此等症狀一直是影響日常生活功能的執行包括平衡、坐、站甚至行走等等。長期而言，由於患者活動量的減少會伴隨肌力降低、肌肉失用性萎縮、關節僵硬攣縮以及心肺功能減弱等，倘若如此成為惡性循環終將導致患者活動能力低下或喪失；也代表病患必須依賴他人的照顧，才能完成日常的生活作息，無論對社會成本、家庭而言，都必須付出龐大的人力、物力及財力，是極大的負擔。現今的物理治療理念，是採用功能導向型的訓練（task-oriented training）模式，即動作學習理論。所以踩車運動是協調性行走的前軀訓練，透過單一重複性方式以訓練下肢踩車的過程，是對中樞神經損傷患者最有效的復健方式，以期能重新學習正確的下肢功能性動作和更進一步的恢復步行功能。近年的文獻更發現，對正常人進行阻力變動型式與維持固定踩車速度的訓練後，其結果發現比目魚肌的Hoffmann反射（H reflex）有明顯下降趨勢，而且此種現象與維持固定踩車車速之技能有顯著的改善和相關；並且進一步認為此種運動模式與活化脊髓神經路徑的塑性調變（plastic changes）有著密切的關係。但是在臨床上對於下肢痙攣的中風患者之實證效果，仍有待進一步探討。研究目的：現今功能性電刺激輔助的踩車動作訓練，可以提供膝伸直肌群與大腿後腱肌群交替、協調性的刺激誘發活動；而此種彼此間短暫刺激與交替抑制（reciprocal inhibition）的效應，有助於降低腦中風患者下肢痙攣的協同表現。因此本研究的目的乃在配合成功大學醫學工程研究所所研發之踩車系統效能，進行臨床研究與評估，以探討中風患者使用此系統作二十分鐘踩車訓練之前、後，下肢痙攣除了包括比目魚肌神經生理上的變化外，其相關膝關節周邊肌肉組織的機械特性以及功能性站立平衡反應等，是否亦會有不同之表現。材料與方法：本研究所使用之儀器包括肌電訊號擷取器、鐘擺力學測試儀、手握肌力測試儀，以及平衡功能測試儀器等，來評估下肢痙攣與功能性站立平衡表現的變化情形。本研究病患來源為台中市立復健醫院之門診與住院病患，所選擇受試者的標準為單一次腦中風、單側偏癱並且需意識清楚之病患，在坐姿下無法自行主控制膝關節彎曲與伸直之協調動作；除此之外，患者並無其他系統疾病與關節角度受限情形。利用隨機分配方式將十八位受測者（男性十五位，女性三位）分為電刺激踩車實驗組（九位）與踩車訓練控制組（九位），在進行踩車運動前，病患均先接受下肢痙攣與功能性站立平衡反應的評估。將踩車訓練機的訓練模式設定為低阻力、定速型式，當每位受測者完成踩車運動二十分鐘後，再評估其下肢痙攣與功能性站立平衡表現的變化。本次研究以SPSS 12.0的統計軟體，採用相依樣本t檢定（paired sample t-test）和重複量數共變數分析（repeated measures ANCOVA），分別來探討每一應變數在組內或者組間是否有變化。研究結果：（1）兩組組內受測者在完成二十分鐘踩車運動後，其患側比目魚肌肌張力如H/Mmax比值皆有改善下降趨勢，而且達到統計的顯著差異（p＜0.05）；膝關節鐘擺力學測試則顯示出，實驗組之受試者其運動後放鬆指數有明顯的增加趨勢（p＜0.02）；而在往前方目標區移動之平衡表現則顯示：其一，實驗組具有顯著的重心最大位移距離改善（p＜0.05）、其二，控制組則具有反應時間、移位動作速度及重心初次位移距離等顯著的變化（p＜0.05）；另外在往患側目標區移動之平衡表現中，分別顯示出兩組組內受試者其初次位移距離、最大位移距離，以及移位方向控制等皆有明顯改善趨勢（p＜0.05）。（2）兩組組間的踩車運動訓練對於下肢偏癱中風患者之比目魚肌的神經生理反射指標、膝關節的鐘擺力學測試指標，以及壓力重心偏移至前方或患側目標區的平衡表現參數等，皆無顯著之差異影響。討論與結論：本次研究藉由實驗組、控制組中可以觀察且證實出，受試者在進行此低阻力、定速型的踩車運動訓練後，皆有助於降低患側足踝關節及小腿後肌群的肌肉張力、增進站立平衡功能之改善。但是，在兩組組間有關於患側下肢肌肉張力與站立平衡功能之差異影響，則無顯著的變化。
並列摘要
Background: For poststroke patients, increasing muscle tone and associated reaction in the paretic limbs sometimes disturb the activities of daily living. Patients with asymmetrical lower limb functions are difficult to perform continuous and smooth reciprocal movements in the lower limb, such as walking. For this reason, decay in cardiopulmonary function and muscle atrophy will also cause them much physical restrictions in the daily life. To enhance residual functions of patients with partial motor disorders, electrical stimulation (ES) combined with cycling exercise has been utilized as a rehabilitation technology recently. Mazzocchio and colleagues were the first investigators who reported on the ability to establish a target speed increased and H-reflex size decreased more after cycling training involving frequent changes in pedal resistance that required calibrated locomotor compensatory action than with training involving constant pedal resistances and lesser compensation. The degree of performance improvement correlated with the reduction in the amplitude of the H-reflex. But there were no detailed report in documents about the effects of muscle tone and functional standing balance with neural plastic changes after the pedaling exercise. Therefore, the purpose of this study was to investigate whether (1) a single bout cycling training with stroke can improve abnormal tone and functional standing balance of paretic leg; (2) ES to the paretic leg during cycling has more effects than cycling without ES. Material and Method: Eighteen stroke patients were recruited, 15 male and 3 female, all subjects gave informed consent as approved by the internal review board of the Chung Shan Medical University School of Medicine and were randomly devided into 2 groups. The experimental group (ES-LCE) performed leg cycling exercise with tolerable ES that evoked muscle contractions during a lower resistance and constant speed cycling training; to evaluate muscle tone and standing balance before and after the training period (20 min). The control group (LCE) received the same study protocol except the ES. In this study, we used the paired sample t-test to assess the changes between the baseline and post-test, and on the other hand the repeated measures ANCOVA was used to analysis the differences between groups. Results: The H/Mmax ratio was significantly decreased in ES-LCE (p= 0.027) and LCE (p= 0.004). The RI was significantly increased in the ES-LCE (p= 0.012), but not in the LCE (p= 0.078). Muscle strength was not significantly changed after training. Scores on the forward limits of stability (LOS) control improved (ie, the MXE increased in the ES-LCE (p= 0.012), and furthermore the significant improvements of RT (p= 0.044), MVL (p= 0.009) and EPE (p= 0.044) were in the LCE). On the other hand scores on the EPE, MXE, and DCL in the affected-ward trial were significantly improved in 2 groups. Training-induced temporal changes of H/Mmax , RI and LOS were no significant difference between the 2 groups. Discussion and Conclusion: This present study showed that a short cycling training program is an useful therapeutic intervention to reduce the muscle tone and to improve the standing balance control of lower paretic limb in patients with stroke. But the use of ES had no additional effects in this specific group of subjects with stroke.