• 期刊

【論文摘要】跪姿行走訓練對亞急性中風病人於步態站立期之髖關節伸直角度影響：病例報告

背景與目的：可獨立行走的中風病人其走路速度比同齡正常人緩慢。然而，在過去研究中發現中風病人走路速度與下肢肌力、推進力量程度、站立末期的髖關節伸直角度有關。其中，在站立末期時患側髖關節伸直角度10～15°，能提供擺盪期髖關節屈曲的力學優勢，進而提升走路速度。正常人跪姿行走比平地行走會激發更多的髖關節伸直肌收縮，但跪姿行走應用在中風病人促進站立末期髖關節伸直角度增加之研究則較少。本研究目的為探討跪姿行走訓練對亞急性中風病人在站立末期髖關節伸直角度的影響。方法：個案為38歲的男性，診斷為左額頂區阻塞性中風（left frontal-parietal area infarction），處於亞急性期，理學檢查發現個案患側上肢近端、遠端布朗斯壯氏等級為Ⅲ，下肢為Ⅳ，可獨立行走。平地步態評估的部分，在觸地初期，個案無法以腳跟著地，在站立末期髖關節伸直角度不足（屈曲10°）且膝關節過度屈曲（屈曲20°）；在擺盪預備期髖關節伸直角度不足（屈曲5°）。物理治療計畫為地墊上進行跪姿行走訓練，以個案舒適的速度進行，距離為43.2 m。前3週每次10分鐘，後3週由於個案跪姿行走速度變快縮減成每次5分鐘完成相同距離，每週5次。結果：經過6週的跪姿行走訓練，個案在站立末期髖關節從屈曲10°進步到伸直20°，在擺盪預備期髖關節從屈曲5°進步到0°，在步態評估和介入工具（gait assessment and intervention tool）中總分從24/62進步到15/62；平地行走速度（walking speed）從0.59m/s進步到0.84m/s；三公尺起走測試（timed up & go test）從22.40秒進步到13.71秒。結論：個案報告結果顯示跪姿行走訓練能夠增加亞急性中風病人在站立末期髖關節伸直角度和行走速度。臨床意義：跪姿行走訓練可能可作為站立期髖關節伸直角度不足、近端軀幹和髖關節穩定控制不佳及肌力不足的中風病人之治療策略之一，但進一步需要執行隨機對照試驗來作為實證醫學依據。

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【論文摘要】Effect of Weight Bearing Training on Walking Ability in a Patient With Right Basal Ganglia Infarction: A Case Report

Background and Purpose: Patients after a stroke could actively move one's extremities, but he/she could not walk due to unable weight bearing of affected side during stance phase and unable to control leg movement during swing phase, which would influence foot placement at initial contact. Sit-to-stand and single-leg stepping forward exercise could promote weight bearing of the affected leg and weight transfer between two legs. The aim was to investigate the effect of sit-to-stand exercise and stepping forward exercise on walking ability in a patient with right basal ganglia infarction. Methods: This is a 76-year-old woman with left hemiplegia. She could sit to stand with minimal assistance, but her dynamic and static sitting and standing balance are poor. Weight bearing training included sit-to-stand exercise and step forward exercise for total of 15 minutes per day. Initially, sit-to-stand exercise was performed 50 times per day for 3 days. Then, sit-to-stand and stepping forward exercise were performed 25 times per day for another 5 days. The patient treated with sit-to-stand exercise by bearing with both legs under support, and then progressed with a single leg for weight bearing. Stepping forward exercise was also intervened by stepping forward in sound side to increase the weight bearing duration of the affected side under safety support. Distance of assisted walking was recorded as a primary outcome. Results: Totally, the patient completed 8 sessions of sit-to-stand exercise and single leg stepping forward training. After training for two sessions, the patient could ambulate several steps when affected leg worn gaiter and partial support under the therapist's assistance. After training for five sessions, the patient could walk for 30 meters, but the therapist's assistance was still needed during swing phase and initial contact in affected side. Finally, after training for 8 sessions, the walking distance was improved to 60 meters and her affected side could be moved spontaneously under therapist's guidance and adjustment. Conclusion: Weight bearing training could improve the walking ability to facilitate ambulation in the case of hemiplegia caused from right basal ganglia infarction. Clinical Relevance: Sit-to-stand and single leg stepping forward exercise might consider as a possible functional training to increase the independent ambulation in patients with basal ganglia dysfunction.

• 期刊

【論文摘要】The Immediate Effect of Rhythmic Initiation Technique in Affected Pelvis on Stride Length in a Patient With Chronic Stroke: A Case Report

Background and Purpose: The proprioceptive neuromuscular facilitation (PNF) is a method of facilitation, in which rhythmic initiation (RI) is the technique aiding in initiating movement and increasing range of motion. The pelvic mobility plays an important role in gait cycle due to its direct linkage between trunk and lower extremities. The pelvic pattern of PNF includes anterior elevation, anterior depression, posterior elevation and posterior depression. The purpose was to investigate the immediate effect of RI in affected pelvis on stride length in a patient with stroke. Method: This is a 73-year-old female with right hemiplegia. She could walk with moderate assistance three years post stroke. Her Brunnstrom's stage was V in lower extremity of right side, but she had difficulty in initiating walking. She felt hard to lift her right leg and step forward, and was fear of falling. The intervention was specific to pelvic patterns of PNF with RI technique on right side in side-lying. The PT guided the arc movement of right pelvis from anterior elevation to posterior depression back and forth. Following, the arc movement was changed the direction from anterior depression to posterior elevation back and forth. Each movement repeated was performed 3 set each direction, 20 times per set. Outcome measure was stride length. Putting the stickers on the ground that was a point of heel contact measured the length of each stride. Result: She only received one-day treatment. Before intervention, the stride length was 33 cm in right side and was 28.3 cm in left side. Passive range of motion of both sides was within normal limit. After intervention, the stride length was 46 cm (39.3% of improvement) in right side and was 38cm (35.7% of improvement) in left side. The patient could lift the leg of affected side easier and step longer. Conclusion: Application of RI in affected pelvis could increase stride length of the affected side in a patient with stroke. Clinical Relevance: The pelvic pattern of PNF by using RI technique may provide a potential strategy on increasing walking speed and distance in stroke patients.

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【論文摘要】中風患者執行不同足部位置的坐到站活動對空間姿勢之影響：個案報告

背景與目的：坐到站（sit-to-stand）是常見的日常活動，中風患者易以健側代償的方式執行坐到站活動，因不對稱的承重模式（asymmetric weight-bearing pattern）導致完成坐到站的能力降低。文獻指出改變足部位置的坐到站訓練，可改善患者姿勢平衡控制能力與坐到站活動的動作表現。本個案報告為探討中風患者執行坐到站活動，藉由改變足部位置，在不給予任何指令回饋下，對其空間姿勢對稱性之影響。方法：本個案為41歲的男性，在2019年6月9日診斷左側殼核出血性中風（left putaminal hemorrhage），2019年9月4日到桃園長庚復健，評估結果為患側布朗斯壯分級（Brunnstrom stage）上肢為Ⅱ，下肢為Ⅳ；伯格式平衡量表（Berg balance scale）分數為42分，坐姿及站姿明顯承重在健側。本個案報告要求個案執行坐到站活動，使用三種不同足部位置分別為：對稱足位（雙腳並排放置於踝背屈10°）、不對稱足位（健側腳踝背屈10°，並向後放置於患者足長50的距離）及踏階足位（健側腳放在10公分踏階上，患側腳放在地面上，皆踝背屈10°）。在不給予任何指令回饋下請個案各執行三次活動，以攝影方式記錄完整過程，計算空間姿勢的對稱性。結果：坐到站活動期，軀幹偏移比例值在對稱足位平均為1.3，少於踏階足位的1.7及不對稱足位的3.13；骨盆偏移比例值在踏階足位平均0.87，少於對稱足位的2.76及不對稱足位的1.85。重心前移期，軀幹偏移比例值在踏階足位平均為0.55，少於對稱足位的1.24及不對稱足位的0.85。結論：以踏階足位方式執行坐到站活動，在坐到站活動期的骨盆位置與重心前移期的軀幹位置較另二種足位對稱；以對稱足位方式執行，在坐到站活動期的軀幹位置較另二種足位對稱。臨床意義：針對中風患者不對稱的承重模式，可藉由不同足位的坐到站活動來改善，並增進坐到站活動的動作表現。

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【論文摘要】Effect of Combined Functional Training and Nerve Mobilization on the Range of Straight Leg Raising in A Patient With the Second Lumbar Spine Vertebrae Burst Fracture Post-operation: A Case Report

Background and Purpose: Patients with spine-related injuries usually cause muscle guarding or increased muscle tone on extremities. Nerve mobilization can reduce tension and increase mobility. Functional training after nerve mobilization can promote the available range of functional movement. The purpose was to investigate the effect of combined functional training and nerve mobilization on mobility in a patient with L2 burst fracture. Methods: This is a 71-year-old man, who had thoracolumbar (T11-L2) spinal injury with paraplegia post operation. He had a falling accident from a ladder during working. Impression was burst fracture L2 with stenosis, posterior lumbar interbody fusion with Transpedicle Screws at T10-T12, and L1-L3, verteboplasty with spinejack and failed surgery syndrome. Posterior laminectomy decompression of L1-L2 was intervened one month after the first operation. Two months after second operation, he could walk for 60 meters with walker under contact guarding and sit to stand with moderate assistance. It is also difficult to maintain static standing balance independently. The goal of functional training was to enhance independent walking by functional training and nerve mobilization on lower extremities. Functional training of assisted sit-to-stand, stand-to- squat, quadruped rock back, quadruped assisted hip extension, quadruped horizontal hip abduction, standing balance with one leg on the step, and standing balance with one leg heel raising on the step were included in his physical therapy programs for total of 15 minutes per day. Nerve mobilization performing by straight leg raising (SLR) in supine and knee bending in side-lying positions was also applied for 20 times on both legs per day. Both of functional training and nerve mobilization programs were continued for 18 days. Results: Degrees of passive and active SLR were about 30 and 15 degrees respectively for both legs before treatment. After treatment, the degrees of passive and active SLR were changed to 50 and 30 degrees. Moreover, the patient also could stand independently and step forward without walker. Conclusion: Combination of functional training and nerve mobilization could increase the pain-free range of SLR in the case with spine vertebrae burst fracture. Clinical Relevance: Nerve mobilization followed by functional training seems to improve the neuromuscular control in a patient with paraplegia.

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【論文摘要】脊髓損傷之神經肌肉電刺激與傳統復健之成效與追蹤：個案報告

研究背景與目的：現今不完全的脊髓損傷造成下半身癱瘓個案，多以強化現存的上肢與軀幹肌肉力量與肌肉耐力，來增進日常生活功能為訓練目標，然而下半身受損或部分殘留肌肉力量，在復健治療時較容易被忽略，功能性的治療成果，大多以巴氏量表為參考依據。本篇研究探討早期介入一位損傷，造成下半身癱瘓之個案，為期6個月的雙下側肢體功能恢復與活動為目標，以神經肌肉電刺激與傳統物理治療，是否可以促進個案雙側下肢的活動能力，來增進日常生活功能與活動能力。方法：本個案報告對象為一位12歲小女孩，因脊椎海綿狀靜脈畸形引起出血性脊椎損傷，造成下半身癱瘓，S4及S5有殘留部分的感覺與肌肉收縮能力，研究為期6個月的神經肌肉電刺激治療與傳統物理治療，評估感覺與肌力使用American Spinal Injury Association（ASIA）。第一次評估ASIA為B級，感覺階層分數：左邊T6-L3為1分、L4-S3為0分、右邊T6-S3為1分，S4-S5為1分（有輕微自主收縮）；關鍵肌肉分數：左邊L2、L5及S1為0分、L3及L4為1分；右邊L2-S1為0分。功能性活動評估工具使用巴氏量表，第一次評估總分為30分。結果：個案在第6個月時的評估結果：ASIA為C級，感覺階層分數：左邊T6-L3為2分、L4-S3為1分、右邊T6-S3為2，S4-S5為2（可以很好的控制大小便）；關鍵肌肉分數：左邊L2為1分、L3為3分、L4為2分、L5為1分、S1為2分，右邊L2為1分、L3為3分、L4為1分、L5為1分、S1為2分。雙側下肢感覺與肌肉肌力與自主活動有明顯增加，但在巴氏量表中，位移、上下樓梯、如廁等沒有明顯的改善。討論：此病例報告個案之雙側下肢肌肉力量有明顯改善。在神經肌肉電刺激與傳統復健治療中發現，雙側下肢髖關節、膝關節，踝關節的伸直肌群動作是較容易恢復自主動作，而雙側下肢屈曲肌群的自主動作則較難恢復出來。巴氏量表中下肢功能性活動沒有明顯得改善，但大小便控制有顯著的改善，推測可能與加入骨盆底肌的傳統運動復健治療訓練。臨床意義：對於脊椎海綿狀靜脈畸形引起出血性脊椎損傷，造成下半身癱瘓之個案，早期介入受損部位之治療，有明顯的改善下肢動作能力，但無明顯的改善功能性活動，可對於日後的雙側下肢功能性恢復能力是可以期待的。

• 期刊

【論文摘要】應用軀幹任務相關訓練改善急性中風病人之軀幹動作控制與姿勢穩定－個案報告

背景與目的：中風患者除了肢體功能出現動作障礙，軀幹相關的動作機能也會受到損傷，難以配合情境與環境的需求有效地調整姿勢以維持身體的穩定度，進而影響日常生活功能性活動的進行。任務相關訓練（Task-related training）常用於中風患者的動作復健，其中以功能性動作為架構的訓練模式更能增進中風患者的動作控制，並提升偏癱側動作的品質與功能。針對軀幹動作進行任務相關訓練的研究指出，透過該訓練方式可有效提升慢性中風患者的軀幹控制與平衡能力，但應用於改善急性中風患者之成效尚缺乏相關的文獻實證。因此本篇目的為探討軀幹任務相關訓練（Task-related trunk training）用於改善一位急性中風患者軀幹動作控制與姿勢穩定之成效。方法：本個案為60歲的女性，在2020年1月3日診斷右側枕葉急性缺血性中風（right occipital acute ischemic stroke）造成左側偏癱，2020年3月5日到桃園長庚復健，屬急性中風期。患側評估布朗斯壯氏等級（Brunnstrome stage）上、下肢為III；簡易智力測試（Abbreviated Mental Test）為8分；動作評估量表（Motor Assessment Scale）中功能性坐姿活動恢復情形為2分，坐姿明顯承重於健側。治療介入參考文獻提出之軀幹任務相關訓練，共計三週，每週五次，每次約30分鐘。成效量測以軀幹功能障礙量表（Trunk Impaired Scale）、修正式坐姿功能性伸手向前測試（Modified Functional Reach Test）與坐姿功能測試量表（Function in Sitting Test）評估介入前後軀幹動作控制與姿勢穩定之表現。結果：個案經過三週介入後，軀幹功能障礙量表總分由4分進步至11分；修正式坐姿功能性伸手向前測試距離往前由16.25 cm提升至30.5 cm、往健側由10 cm提升至17.5 cm、往患側由6.25 cm提升至15 cm；坐姿功能測試量表總分由23分進步至37分。個案於坐姿活動中軀幹的動作品質明顯提升，可配合姿勢的轉換即時啟動正常的動作模式，經由相互縮短、延長軀幹兩側的肌肉與適當的重心轉移，誘發軀幹的平衡反應，進而改善患者於坐姿功能性活動中的動作表現。結論：軀幹任務相關訓練對於本個案報告中之急性中風患者改善軀幹動作控制與姿勢穩定有正向的效果。臨床意義：軀幹任務相關訓練可經由高重複性的練習經驗可改善軀幹動作控制的能力。針對尚未具備足夠穩定姿勢且認知良好之中風患者，可以先著重於軀幹動作控制的訓練，改善靜、動態情境中軀幹的平衡能力，進而提升急性中風後期復健治療之效益。

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【論文摘要】Changes in Body Sway of Modified Clinical Test for Sensory Interaction in Balance after Noon-sleep

Background and Purpose: The sleepiness hours from 2 to 4 pm are the second peak of accidental falls. Possible mechanisms underlying poorer standing balance after just waking up might include the need to re-calibrate sensory organization system. This study aimed to examine the changes of body sway in modified Clinical Test for Sensory Interaction in Balance (mCTSIB), after just waking up from a noon sleep. Methods: A convenience sample of young adults (7 males and 5 females, 21.0 ± 2.3 yr) was recruited. In four mCTSIB conditions, including factorial combinations of eyes open/close and firm/foam surface in random order, participants stood quietly with barefoot and comfortable stance. Body sway captured by the APDM sensor was recorded before and after noon sleep. The experiment was scheduled at 1:30 pm, and between 2 to 3 pm the participants were put on bed for noon sleep for 50-minutes. Results: In terms of body sway acceleration range in the sagittal plane (m/s^2), main effects of condition (F_(3,33) = 59.828, p ＜ 0.001) and of sleep (F_(1,11) = 8.545, p = 0.014) showed significant larger sway in foam conditions, but less sway after sleep in all four conditions. In terms of body sway centroidal frequency (Hz), no main effects were shown but a significant interaction effect of condition by sleep (F_(3,33) = 5.031, p = 0.006), which increased after sleep in eyes-open conditions but decreased after sleep in eyes-closed conditions. Conclusion: Decreased range of body sway is evident after noon sleep. Inspection of the frequency change of body sway reveals increased changes in directions of body sway after sleep in eyes-open conditions, suggesting that decreased range of body sway after sleep might be caused by deliberate effort to control body sway through muscle stiffness. However, the same mechanism failed in eyes-closed conditions after sleep. Clinical Relevance: This study contributes to the mechanisms underlying changes of balance control after sleep, which might help falls prevention programs.

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【論文摘要】Effect of Progressive Part Practice of Stance Phase in Walking on Walking Ability in A Right Hemiplegic Patient Presented Sensory Selection and Weighting Deficit: A Case Report

Background and Purpose: Sensory selection and weighting deficit, which is one of movement system diagnoses for neuromuscular conditions, is inability to maintain postural orientation due to impair the ability to screen for and attend to appropriate sensory inputs. Dizziness and visual motion sensitivity are commonly complained in these patients. The deficit of motor performance might improve after repetitive practice and instruction. A task can be divided into several parts for practice, which calls part practice. Progressive part practice links one part to another part to practice preparing for a whole task. The aim was to report the effect of progressive part practice of stance phase in walking on walking ability in a right hemiplegic patient presented Sensory Selection and Weighting Deficit. Methods: This is a 63-year-old woman with left temporal tumor status after surgery removal. Four months after surgery, she could maintain static sitting balance, and she felt dizziness while changing positions. Localized light touch sensation of right side was intact except right foot. Proprioception was impaired in right side. She could actively flex her thigh to 30°, and actively assisted flex her knee to 90° in supine, but could not move her foot. She could sit to stand with left hand holding and moderately assisted by the therapist. She felt pain while moving her right extremity. To consider the patient's ability, a gaiter needed to reduce the degrees of freedom for motor control in stepping training and walking training, and initial contact, terminal stance, and preswing would be excluded to part practice. Sit-to-stand training was used to simulate movement in loading response. Stepping training, in which sound leg went onto a step, used to simulate movement in midstance of stance phase. Finally, walking training, in which the therapist brought the affected leg forward, and the patient moved her sound hand and sound leg. Results: Progressive part practice training including 2-day sit-to- stand training 3-day stepping training followed by 5-day walking training were performed in this case. After these training, she could walk 30 meters 5 times within 15 min after she completed 10 times of intervention. Conclusion: Progressive part practice of stance phase in walking could improve walking ability in a right hemiplegic patient presenting sensory selection and weighting deficit. Clinical Relevance: Progressive part practice could be used in patients with sensory selection and weighting deficit for functional training.

• 期刊

【論文摘要】慢性中風患者使用機械外骨骼腰部通用型短期訓練成效：個案報告

背景與目的：根據國內臺灣大學醫學院物理治療學系暨研究所與財團法人工業研究院於102年利用動力外骨骼系統於脊髓損傷患者步態訓練實驗中，結果顯示動力外骨骼系統可讓完全性脊髓損傷患者在坐站轉位以及行走跨步動作上皆較為省力。本研究使用日本進口機械外骨骼HAL®（Hybrid Assistive Limb）腰部通用型（Lumbar Type）HAL1，該系統藉由皮膚表面的感應器讀取人體大腦透過神經向肌肉發出的生理電位訊號（bio-electric signals），再將訊號傳到儀器上的背囊，經整合後傳遞到對應的外骨骼關節產生動作。不同於以往利用外在動力啟動的外骨骼，能藉由穿戴者的意志為中心達到主動式的訓練效果。本研究目的為針對一位慢性中風女性患者進行為期3週的機械外骨骼系統HAL1的訓練，希望能增進腰部、軀幹的穩定性，改善患側下肢控制能力、移位以及步態能力，以提升患者活動能力。方法：個案為59歲有高血壓病史、發病半年的中風女性，右邊患側肢體的Brunnstrom stage為stage III，物理治療訓練的重點放在減少患側肢體的協同動作、提升站姿動態平衡與步態訓練。個案於使用HAL1前、後分別進行兩次Time Up and Go Test（TUG），向右轉與向左轉各一次，記錄其時間與步數。另外再記錄個案的自覺用力係數來比較使用HAL1前後的疲勞程度。訓練過程為期3週、每週6次、每次30分鐘。訓練期間，個案穿戴HAL1時進行三種動作訓練，每個動作各10次、共2個循環；訓練動作分別為坐姿軀幹向前屈曲45度再回到正坐、坐姿到站立、站姿時半蹲再回復站姿。本實驗設備與廠商無相關利益衝突。結果：個案TUG在前、後測中左轉與右轉的步數沒有變化而向右轉與左轉的秒數都有減少。個案表示在HAL1使用過程中感覺患側下肢承重較多而比較累。在HAL1訓練後能走得比訓練前較久且行走速度也變快。觀察個案的動作過程中發現患側下肢的髖、膝關節屈曲角度較大，患側腳離地的困難度降低，下肢的控制能力提升。結論：個案在經過3週總計18次的HAL1訓練後對行走速度以及耐力有提升效果，長期效果則需要進行後續的追蹤才能得知。臨床意義：經過本次試驗顯示HAL1訓練對於該名中風患者的患側下肢的控制力、移位能力與步態都有提升的效果。未來研究需要更多個案參與研究測試，期待能在臨床上應用於神經系統損傷類患者下肢訓練過程中使用，以提升患者的活動能力。