結合虛擬實境之踩車運動復健對中風病人下肢肌肉活動之影響

背景與目的：中風為腦血管疾病造成，在急性期會有半側偏癱的現象，部分患者會遺留慢性肢體偏癱問題，進而造成功能上的限制。踩車運動是一種具功能性、協調性、及安全性之復健項目，而利用虛擬實境可以提供病患接近真實卻相對安全的模擬環境。但目前對於虛擬實境結合踩車運動之訓練方式，研究方向多以功能性步態及雙側表現之對稱性當作評量指標，而對於神經肌肉控制部分上無直接證據研究。因此本研究希望能藉著虛擬實境與踩車系統結合，增加中風患者復健之意願，並提昇踩車復健運動之成效。將使用虛擬實境搭配臨床踩車系統進行復健訓練，配合下肢肌電圖肌電訊號收取，目的為比較有無加入虛擬實境視覺刺激的踩車運動訓練對中風患者兩側下肢肌肉使用情形，以確定中風患者患側邊用力之正確性、及對兩側對稱性之影響。方法：實驗以虛擬實境視覺輔助結合踩車系統，藉著踩車踏板力量及股直肌EMG肌電訊號收集，來分析下肢用力變化情形，本研究納入15位實驗組及10位控制組之中風患者，皆接受6次傳統治療，其中實驗組有加入虛擬實境視覺刺激的踩車運動，每次踩車時間為二十分鐘。一天一次，3次/週，維持兩週。在訓練前及後分別收取兩側由踏板距離地面最高處至踏板距離身體最遠處之區間位置，並量測此區間位置內其下肢踩車踏板力量比值(患側/健側)及肌電表現(mV)。統計分析：使用one-way ANOVA with one repeated measure分析實驗組與控制組之間是否有交互效應，若無交互效應，則以pair t test進行實驗組與控制組組內前、後比較；以one-way ANOVA with one repeated measure分析兩組組間前後改變量。參數包含下肢踩車踏板力量對稱比比值(symmetry ratio)、及用力區間股直肌之全波積分肌電訊號值(Integral electromyography；IEMG)。結果：研究結果顯示中風患者在經由虛擬實境踩車運動訓練兩周後，其兩側踩車踏板力量比值有顯著改善且優於控制組。而股直肌之IEMG顯示患側於訓練後肌肉活動有顯著提升，健側股直肌之肌肉活動亦有減緩趨勢；但其訓練前後的改變量兩組比較並未達顯著差異。結論：本研究顯示經過6次虛擬實境合併踩車運動訓練，可顯著改善踩車運動過程中雙側踏板力量之對稱性且與明顯優於控制組；並可增進其患側股直肌於踩車過程中應用力區間時之肌肉活動情形。臨床意義：供物理治療師於治療中風患者下肢復健之治療策略建議及虛擬實境合併踩車運動之可行性，並期盼本研究之成果能實際應用於中風患者之臨床復健，以探究中風患者功能表現上的改變其可能作用機轉。

關鍵字

虛擬實境；中風；踩車運動；肌電訊號；對稱比比值

並列摘要

Background: Stroke is caused by cerebrovascular diseases, and hemiplegia is the most common in the acute stage and chronic legacy disabling sequela after stroke. Pedaling exercise is an ideal functional, security, and coordination rehabilitation exercise. Virtual reality is a computer-based technology that allows users to receive “real-time” feedback and interact with a safety situation. But the research combine cycling exercise training with virtual reality commonly direct to functional gait performance and bilateral symmetry movements as outcome measures, while no direct evidence of research discuss about the neuromuscular control section. Therefore, this study hopes through combination of virtual reality and cycling system, to improve the stroke patients’ motivation and to enhance the effects of the therapeutic cycling exercise. During the virtual reality cycling training, the EMG data and the pedal force of the lower extremities of subjects wound be detected. The purpose was compare whether the added virtual reality pedaling exercise, the effects of the symmetry of bilateral pedal force and the appropriation of bilateral rectus femoris muscle activities. Methods: Both the experimental group (N=15) and control group (N=10) received 6 times of the traditional treatment. The experimental group was instructed to perform an additional Leg-Cycling with Virtual Reality Training System training for 20min/tume, 3 times/week, for 2 weeks. To collect the symmetry ratio of bilateral pedal force and EMG performance of bilateral rectus femoris muscle during pre- and post- test. And the target region was setting from the top of the pedal place to the most distant from body. Statistical analysis: the interaction effects between the two groups were compared by one way ANOVA with one repeated measure. The results of symmetry ratio of pedal force and the integral electromyography (IEMG) of rectus femoris in the target region between pre and post-training in two groups were compared by pair-t test. The change of pre and post-training between two groups were compared by one way ANOVA with one repeated measure. Result: The symmetry ratio of bilateral pedal force showed significant improvement after the Leg-Cycling with Virtual Reality Training System training, and experimental group was better than the control group(p<.05). The effected side IEMG of rectus femoris showed significant improvement after training (p<.05). The sound side IEMG of rectus femoris showed downward trend, but no significant difference between groups (p>.05). Conclusion: The Leg-Cycling with Virtual Reality Training System training improves the symmetry ratio of bilateral pedal force and the effected side IEMG of rectus femoris in the target region. Suggestion: The Leg-Cycling with Virtual Reality Training System training provide the treatment strategy and feasibility in clinics. And look forward the results of this study can be actually used in clinical stroke rehabilitation; further explored the mechanism of functional performance changing in stroke patients.

並列關鍵字

virtual reality ； stroke ； pedaling exercise ； electromyography ； symmetry ratio

參考文獻

51. 藍依亭 (2012). "虛擬實境踩車訓練系統於中風患者之臨床療效." 中山醫學大學醫學檢驗暨生物技術學系碩士論文.

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2. Brooks, B., McNeil, J. E. et al. (1999). "Route learning in a case of amnesia: a preliminary investigation into the efficacy of training in a virtual environment." Neuropsychological Rehabilitation. 9: 63-76.

3. Brown, D. A. and Kautz, S. A. (1998). "Increased workload enhances force output during pedaling exercise in persons with poststroke hemiplegia." Stroke 29(3): 598-606.

4. Brown, D. A. and Kautz, S. A. (1999). "Speed-dependent reductions of force output in people with poststroke hemiparesis." Phys Ther 79(10): 919-930.

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結合虛擬實境之踩車運動復健對中風病人下肢肌肉活動之影響

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