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系統識別號 U0026-0812200912121993
論文名稱(中文) 糖尿病患者之感覺缺失對其多方向伸取測試的影響
論文名稱(英文) Effects of sensory deficits on Multi-Directional Reach Test in diabetic sensory neuropathy
校院名稱 成功大學
系所名稱(中) 物理治療研究所
系所名稱(英) Department of Physical Therapy
學年度 94
學期 2
出版年 95
研究生(中文) 陳怡如
研究生(英文) Yi-Ru Chen
學號 t6693108
學位類別 碩士
語文別 中文
論文頁數 136頁
口試委員 口試委員-官大紳
指導教授-林桑伊
口試委員-林昭宏
中文關鍵字 平衡  多方向伸取測試  體感覺  糖尿病感覺神經病變  糖尿病感覺神經病變 
英文關鍵字 Multi-Directional Reach Test  balance  Diabetic sensory neuropathy  somatosensation 
學科別分類
中文摘要 背景: 糖尿病感覺神經病變所引起的足底感覺缺失是臨床上常見的症狀,過去文獻已證實糖尿病患者的足底感覺缺失對於靜態平衡或是受到外力干擾後的平衡控制能力的影響,然而對於這類患者自主移動身體質量重心的能力較少有文獻提及。多方向伸取是日常生活中經常需要的動作,且此測試在臨床上經常使用來檢測質量重心往前、往兩側移動能力的測試方法,以反映動態平衡的能力。因此本篇研究的目的,是藉由探討糖尿病感覺神經病變所導致的足底感覺缺失對多方向伸取表現的影響,以得知足底表皮感覺對於感知身體質量重心在支撐底面積上移動範圍的貢獻,並且探討其他可能的影響因素。方法: 31位糖尿病受試者參與本實驗,根據足底感覺測試的結果,將受試者分為兩組:感覺缺失組(14位)及正常感覺組(17位)。紀錄受試者的基本資料後,理學檢查包含:足底觸壓覺測試以Semmes-Weinstein單纖維尼龍絲檢查足底不同區域的感覺閥值,並且以測力器檢查下肢、軀幹以及雙手握力,以站起前走測試表示受試者的基本活動力,並且完成一份日常活動量量表。伸取測試包含前伸及側伸測試,請受試者在不移動雙腳或失去平衡的情況下,盡可能的往前、往側伸,以VICON動作分析系統收集空間中身體的運動學資料來計算身體質量重心的位移。使用獨立T檢定比較正常感覺組及感覺缺失組基本資料及理學檢查結果的差異,以多變量共變數分析比較兩組之伸取測試表現的差異,並以皮爾森相關係數分析基本資料、理學檢查及伸取測試參數間的相關,將顯著相關的參數置入多元線性回歸中,探討對伸取表現變異量有顯著貢獻的因子。結果:在控制蹠曲肌肌力的影響後統計分析的結果顯示,前伸距離及質量重心往前及往側移動的範圍,兩組間有顯著的差異,感覺缺失組的移動距離都比正常感覺組小;往前移動質量重心的範圍與第一腳趾(r=-0.645)、第一蹠骨基部(r=-0.59)及第五蹠骨基部(r=-0.581)的觸壓覺閥值、蹠曲肌肌力(r=0.66)及日常活動量(r=0.502)有顯著相關。回歸分析中顯示控制蹠曲肌肌力的貢獻,第一腳趾的感覺閥值及日常活動量還可以多貢獻26.2%質量重心往前移動範圍變異量。往左側伸時,質量重心移動範圍與左腳腳跟(r= -0.562)與第五蹠骨基部(r=-0.581)的感覺閥值及腳踝蹠曲肌肌力(r=0.474)有顯著相關。向左側伸回歸分析結果發現控制年齡、性別、糖尿病發病時間及踝蹠曲肌肌力的貢獻後,左腳腳後跟的感覺閥值可多提供17.4%的變異量。 結論: 糖尿病感覺神經病變患者的動態平衡表現比起沒有神經病變的糖尿病患者來得差。在維持固定的支撐底面時,這些患者可以自主移動身體質量重心的能力與足底感覺、肌力及日常活動量有關。臨床上,糖尿病族群的感覺動作篩檢、平衡訓練以及跌倒預防是非常重要的,除了評估患者的感覺缺失程度,增進下肢肌力及日常活動量是改善這類患者平衡能力的方針。

英文摘要 Background: Impaired somatosensation of the footsole is a common clinical sign of diabetic sensory neuropathy. Somatosensory inputs from the sole of the foot are known to contribute to postural control. Research has shown impaired control in static standing and balance recovery after support surface perturbations in diabetic patients (DP) with sensory deficits at the foot. However, it is unknown if patient’s ability in volitionally moving the body’s center of mass (COM) within a stationary base of support would be associated with the extent of sensory impairment. Reach forward or laterally are functional relevance in daily activities, and usually used as clinical balance tests of volitionally moving COM toward the limit of stability. This study investigated the differences in the ability of moving the COM forward and laterally in DP with and without sensory deficits, and identified its potential contributing factors. Methods:Thirty-one DP participated in the study, and were divided into sensory deficits (DP-SN, N=17) and no sensory deficits (DP-nonSN, N=17) groups based the touch-pressure threshold of the foot. Muscle strength of the lower extremity, trunk and grasp, basic mobility (up-and-go test) and level of physical activity were also examined. Multi-Directional Reach Test (MDRT) that required the subject to reach forward or laterally as far as possible without losing balance or moving the feet was used to measure the ability to control the COM forward and laterally. Body kinematics were recorded by the VICON motion system for offline estimation of the COM location. Independent t test and multivariate analysis of covariance were used to compare the difference of demographic data, physical examinations and reach performances between DP-nonSN and DP-SN. Pearson correlation and Spearman’s test were used for correlation analysis among demographic data, physical examinations and performance in MDRT. Multiple linear regression analysis was used to identify potential contributors (age, gender, duration of diabetes, sensory threshold, strength, basic mobility and physical activity) to COM displacement. Results:After controlling for the strength of the plantarflexors, the COM range during forward and lateral reach was significantly smaller in DP-SN, compared to DP-nonSN. The range of COM forward displacement was significantly correlated with the sensory threshold of the big toe (r=-0.645), the first metatarsal head (r=-0.59), and the fifth metatarsal head (r=-0.581), plantarflexor strength(r=0.66) and physical activity (r=0.502). Stepwise regression analysis showed that sensory threshold of the big toe and physical activity added significant contributions to COM forward displacement (added R2=0.262). The range of COM left lateral displacement was significantly correlated with the sensory threshold of the left heel (r=-0.562) and the fifth metatarsal head (r=-0.435), plantarflexor strength(r=0.474). Sensory threshold of heels added additional 17.4% contribution to COM lateral displacement. Conclusion:Dynamic balance, measured by voluntarily moving the COM within a stationary base of support, was poorer in DP-SN than in DP-nonSN. The ability to move the COM forward and laterally toward the limits of stability was associated with somatosensation of the footsole, strength of the ankle muscles and level of physical activity. Clinically, special attention in sensorimotor screening, balance training and fall preventions should be given to diabetic patients.

論文目次 中文摘要 --------------------------------------------------------------- 4
英文摘要 --------------------------------------------------------------- 6
致謝 ------------------------------------------------------------------- 9
特殊榮耀 -------------------------------------------------------------- 10
表目錄 ---------------------------------------------------------------- 14
圖目錄 ---------------------------------------------------------------- 15
第一章 理論及文獻回顧 ----------------------------------------------- 17
第一節 平衡控制系統 ------------------------------------------------- 17
一、感覺系統簡介 ------------------------------------------------------ 18
二、動作系統簡介 ------------------------------------------------------ 24
三、中樞系統整合 ------------------------------------------------------ 25
第二節 平衡功能檢查 -------------------------------------------------- 27
一、 靜態平衡 --------------------------------------------------------- 27
二、 動態平衡 --------------------------------------------------------- 27
第三節 糖尿病患者的平衡缺失 ------------------------------------------ 30
一、糖尿病簡介 -------------------------------------------------------- 30
二、神經病變的發生與可能的傷害 ---------------------------------------- 30
三、神經病變臨床症狀 -------------------------------------------------- 31
第四節 糖尿病感覺缺失對平衡的影響 ------------------------------------ 32
一、對靜態平衡的影響 -------------------------------------------------- 32
二、對動態平衡的影響 -------------------------------------------------- 35
第二章 研究背景 ------------------------------------------------------ 37
第一節 研究動機 ------------------------------------------------------ 37
第二節 研究目的 ------------------------------------------------------ 38
第三節 研究假設 ------------------------------------------------------ 39
第三章 研究方法 ------------------------------------------------------ 40
第一節 研究設計 ------------------------------------------------------ 40
第二節 受試者 -------------------------------------------------------- 42
第三節 測試工具 ------------------------------------------------------ 43
第四節 測試步驟 ------------------------------------------------------ 47
一、前置研究 ---------------------------------------------------------- 47
二、主要研究 ---------------------------------------------------------- 48
1. 基本資料及活動量表 ------------------------------------------------- 48
2. 理學檢查 ----------------------------------------------------------- 49
3. 多方向伸取測試 ----------------------------------------------------- 55
第五節 重要參數定義與資料處理 ---------------------------------------- 58
第六節 統計分析 ------------------------------------------------------ 63
第四章 實驗結果 ------------------------------------------------------- 66
第一節 受試者基本資料 ------------------------------------------------ 66
第二節 足底壓力分布測試 ---------------------------------------------- 68
第三節 理學檢查結果 -------------------------------------------------- 71
第四節 舉手靜止站立平衡表現 ------------------------------------------ 75
第五節 功能性前伸測試 ------------------------------------------------ 79
第六節 相關及回歸分析: 功能性前伸測試 -------------------------------- 82
第七節 側伸測試 ------------------------------------------------------ 87
第八節 相關及回歸分析: 側伸測試--------------------------------------- 90
第五章 討論 ---------------------------------------------------------- 96
第一節 影響伸取表現的因素 -------------------------------------------- 98
第二節 足底體感覺系統對感知穩定範圍的貢獻 ---------------------------- 101
第三節 動作系統對控制伸取動作的貢獻 ---------------------------------- 106
第四節 其他因素對控制伸取動作的貢獻 ---------------------------------- 109
第五節 前伸及側伸測試檢查穩定範圍的效度 ------------------------------ 111
第六節 實驗限制 ------------------------------------------------------ 112
第七節 臨床應用 ------------------------------------------------------ 113
第六章 結論 ---------------------------------------------------------- 114
第七章 參考文獻 ------------------------------------------------------ 115
附錄 ------------------------------------------------------------------ 126
自述 ------------------------------------------------------------------ 135

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