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系統識別號 U0026-1707201517081700
論文名稱(中文) 中風患者軀幹功能及軀幹動作控制之探討
論文名稱(英文) Trunk Functions and Trunk Motor Control in Stroke Patients
校院名稱 成功大學
系所名稱(中) 健康照護科學研究所
系所名稱(英) Institute of Allied Health Sciences
學年度 103
學期 2
出版年 104
研究生(中文) 廖健芬
研究生(英文) Chien-Fen Liao
學號 TA8951084
學位類別 博士
語文別 英文
論文頁數 126頁
口試委員 指導教授-徐阿田
口試委員-蘇芳慶
口試委員-王瑞瑤
口試委員-林光華
口試委員-林昭宏
口試委員-湯佩芳
中文關鍵字 中風  軀幹穩定  軀幹動作控制  軀幹復位覺  軀幹肌肉力氣 
英文關鍵字 Stroke  Trunk stability  Trunk motor control  Trunk reposition sense  Trunk muscle strength 
學科別分類
中文摘要 背景與目的: 中風是造成老年人長期失能的主要原因之一,其後果往往不只是有肢體功能損傷,軀幹功能也會受到影響。因此本研究欲探討中風患者軀幹肌群功能以及軀幹相關動作的控制,藉此更全面的深入瞭解中風對於軀幹功能損傷的影響。本研究的目的是藉由運動學以及肌電圖分析來探討慢性中風患者和年齡性別配對的健康控制組在軀幹穩定和軀幹動作控制的差異。並探討軀幹穩定和臨床量表之間的關係,軀幹肌群神經肌肉控制與本體感覺之間的關係,以及軀幹動作表現與軀幹肌肉力量之間的關係。
方法: 本研究徵召了15位慢性中風患者以及15位年齡性別與患者配對之健康受試者。(1) 第一部分,每位受試者以最快速度執行軀幹穩定時非偏癱側肩關節上抬至屈曲90度以及非偏癱側髖關節屈曲至抬離地面,並以自選的速度完成軀幹自主彎曲或是伸直的動作。軀幹以及動作肢體的運動學參數以動作分析儀作記錄。(2) 第二部分,以肌電圖分析對稱的軀幹自主彎曲或是伸直的動作,並比較兩組間的軀幹本體感覺。(3)第三部分,受試者以自選的速度執行坐姿前伸動作,越遠越好,但不可失去平衡或是改變支持底面積。研究記錄與分析軀幹和前伸手臂的運動學以及軀幹兩側的肌電訊號。另外,以等長軀幹肌力測試儀量測軀幹屈曲、伸直、側彎以及旋轉的最大力量。
結果:研究結果發現: (1)中風患者在坐姿下肩關節彎曲、髖關節彎曲、軀幹往前彎曲或是往後伸直動作中左右方向的質量中心位移量都比健康受試者要來的大,且質量中心位移速度在髖關節彎曲也較健康受試者大。健康受試者的動作速度在肩關節彎曲、軀幹往前彎曲或是往後伸直動作中都比中風患者要來的大,中風患者的臨床測試結果只和軀幹彎曲或伸直動作有關。(2) 在軀幹往前彎曲動作方面,中風患者表現在兩側腹內斜肌活化的對稱性(symmetry index)較健康受試者低、腹肌在時序上的同步(temporal synchronization)也較低。而在軀幹往後伸直動作方面,中風患者的豎脊肌在對稱性以及交互相關都較低。病人顯示在軀幹本體覺中的伸直復位角度較大。在所有受試者中,軀幹復位角度和兩側軀幹肌肉的交互相關成負相關。(3) 在坐姿前伸動作中,中風患者的質量中心前向位移量、位移速度、上臂和軀幹肢段移動的角速度都較健康受試者小;而在肌電訊號方面,中風患者左右兩側腹內斜肌以及兩側闊背肌肌電訊號在時序上的同步程度較健康受試者低。另外,中風患者的軀幹伸直、側彎、和旋轉肌力也都較健康受試者差。在所有的受試者中,肌肉力量與質量中心的前向位移量,以及兩側闊背肌肌電訊號在時序上的同步程度皆有正相關。
結論: 慢性中風患者軀幹功能仍沒有完全恢復,不論是在軀幹穩定肢體動作(非偏癱側肩關節彎曲、非偏癱側髖關節彎曲)、軀幹自主動作(軀幹往前彎曲與軀幹往後伸直)、或是軀幹結合肢體的動作(坐姿前伸)中。而軀幹的肌肉力量和本體感覺(以關節復位覺表示)也都仍有損傷的情況存在。慢性中風患者的復健治療中,臨床工作者需要多注意患者在軀幹動作控制、軀幹穩定、本體覺以及肌肉力量方面仍存在的損傷,給予患者更全面的治療。
英文摘要 Background and purposes: Residual motor-sensory impairments and disability afflicting patients with stroke are not limited to the limbs, trunk functions are affected as well. There were knowledge gaps regarding trunk performance in patients with stroke. Therefore, the purposes of the current study were to investigate differences between patients with chronic stroke and age-matched healthy controls in trunk stability and trunk control ability by assessing the kinematic parameters during voluntary limb, symmetrical trunk, and trunk combining limb movements, and the bilateral trunk muscle activation during trunk movement and trunk combined limb movements. Additionally, the relationship between trunk stability and clinical measurements, trunk muscle function and trunk proprioception, and the performance of trunk combining limb movement and trunk muscle strength were also examined.
Methods: Fifteen stroke patients and 15 age- and gender-matched healthy subjects participated. (1) Each subject performed flexion of the hip and shoulder of the non-paretic or matched side as fast as possible, as well as trunk flexion and extension at a self-selected speed. A Qualisys motion system was employed to track the kinematics of the trunk and limbs. (2) Bilateral trunk muscle activations were assessed by electromyography during trunk flexion and extension. Trunk re-position errors in trunk flexion and extension directions were recorded by a Qualisys motion system. (3) Each subject performed seated reach as far as possible at a self-selected speed without losing balance or changing the base of support. Kinematics of arm and trunk, and bilateral trunk muscle activation during movement were collected. Maximal trunk muscle strength in flexion, extension, side-bending, and rotation was assessed by an isometric trunk muscle strength dynamometer.
Results: (1) Patients presented larger mediolateral displacement of the center of mass during all limb and trunk movements, and larger velocity of center of mass during hip flexion movement. Healthy subjects showed a greater movement velocity during shoulder flexion, trunk flexion and extension. Patients’ clinical measurements only correlated with movement characteristics during voluntary trunk motions. (2) Patients presented lower symmetrical muscle activation of bilateral internal oblique and lower cross-correlation of abdominal muscles during trunk flexion, and lower symmetry index and cross-correlation of erector spinae in trunk extension. Patients showed larger trunk extension re-position error. Smaller trunk re-position error was associated with higher cross-correlation of bilateral trunk muscles during trunk movements in all subjects. (3) The trunk motor performance in patients during seated reach were compromised in the anterior displacement of COM, reach distance, velocity of the COM / arm/ trunk segment, and cross-correlation of IO and LD muscles. Patients showed less muscle strength on trunk extension, side-bending, and rotation than healthy control subjects. The anterior displacement of COM and the marker on the jugular notch were associated with the trunk muscle strength. Only cross-correlation of LD muscle was correlated with trunk muscle strength.
Conclusion: Trunk motor control in patients with chronic stroke was compromised during voluntary non-paretic limb movement, trunk movement, and trunk combined limb movement. Clinicians should also pay attention to the trunk proprioception, trunk muscle strength as well as trunk movements. Rehabilitation of patients with chronic stroke should include programs to improve trunk functions and trunk motor control.
論文目次 Table of Contents

中文摘要…Ⅰ
Abstract…Ⅲ
致謝…Ⅵ
Table of Contents…Ⅶ
Lists of Tables…XI
Lists of Figures…XⅢ

Chapter 1 General Introduction
1.1. Trunk motor control…1
1.1.1. Trunk motor control in patients with stroke…2
1.2. Trunk movements in patients with stroke…4
1.2.1. Trunk as a prime mover…4
1.2.2. Trunk as a stabilizer…5
1.2.3. Trunk combined limb movement…7
1.3. Main factors related to trunk motor control…9
1.3.1. Trunk muscle strength…10
1.3.2. Trunk proprioception…12
1.4. Motivation and Purposes…14

Chapter 2. Relationship between Trunk Stability during Voluntary Limb and Trunk
Movements and Clinical Measurements of Patients with Chronic Stroke
2.1. Brief introduction…16
2.2. Specific aim…17
2.3. Patients and methods…18
2.3.1. Participants…18
2.3.2. Instrument…18
2.3.3. Procedures…20
2.3.4. Data reduction and analyses…25
2.3.5. Statistical analysis…27
2.4. Results…28
2.4.1. Participants’demographics and clinical measurements…28
2.4.2. Trunk as a stabilizer…31
2.4.3. Trunk as a prime mover…33
2.4.4. Relationship between center of mass variables and clinical measurements…35
2.5. Discussion…37
2.5.1. Trunk as a stabilizer…37
2.5.2. Trunk as a prime mover…40
2.5.3. Correlation between movement variables and clinical measurements…41
2.5.4. Limitations…42
2.5.5. Conclusion…43

Chapter 3. Electromyography of Symmetrical Trunk Movements and Trunk Position Sense
in Chronic Stroke Patients
3.1. Brief introduction…44
3.2. Specific aim…46
3.3. Patients and methods…47
3.3.1. Participants…47
3.3.2. Instruments…48
3.3.3. Procedures…49
3.3.4. Data reduction…51
3.3.5. Statistical analysis…53
3.4. Results…54
3.4.1. Trunk flexion…54
3.4.2. Trunk extension…56
3.4.3. Trunk re-position error…57
3.4.4. Correlations between EMG variables and TRE…58
3.5. Discussion…60
3.5.1. Trunk flexion…60
3.5.2 Trunk extension…62
3.5.3. Trunk re-position error…63
3.5.4. Association between the trunk position sense and EMG variables…64
3.5.5. Limitations…66
3.5.6. Conclusion…66

Chapter 4. Seated Reaching Performance and Muscle Strength in Patients with Chronic
Stroke
4.1. Brief introduction…67
4.2. Specific aim…68
4.3. Patients and methods…69
4.3.1. Participants…69
4.3.2. Instruments…69
4.3.3. Procedures…71
4.3.4. Data reduction…72
4.3.5. Statistical analysis…74
4.4. Results…75
4.4.1. Kinematic variables during seated reach…75
4.4.2. EMG variables during seated reach…77
4.4.3. Trunk muscle strength…79
4.4.4. Relationship between maximal trunk muscle strength and kinematic variables during seated reach…81
4.4.5. Relationship between muscle strength and EMG variables during seated reach…85
4.5. Discussion…89
4.5.1. Kinematic variables during seated reach…89
4.5.2. EMG variables during seated reach…91
4.5.3. Relationship between muscle strength and EMG variables during seated reach…92
4.5.4. Conclusion…93

Chapter 5 Future Work and General Summary…96
References…96

Lists of Tables

Table 1. Characteristics of patients with stroke and health control subjects…29
Table 2. Limb motor function evaluated by Brunnstrom stage of all subjects…30
Table 3. Comparison of movement variables between the two groups during limb movements…32
Table 4. Comparison of movement variables between the two groups during voluntary trunk movement…34
Table 5. Relationship between COM variables and clinical measurements in STROKE…36
Table 6. Comparison of EMG variables between groups during trunk flexion movement…55
Table 7. Comparison of EMG variables between groups during trunk extension movement…56
Table 8. Trunk re-position error (TRE) differences between groups…57
Table 9. Relationship between TRE and EMG data…59
Table 10. Comparison of kinematic variables between the two groups during seated reach…76
Table 11. Comparison of EMG variables between the two groups during seated reach…78
Table 12. Comparison of trunk muscle strength between the two groups during seated reach…79
Table 13. Comparison of trunk muscle strength between paretic side and non-paretic side in stroke patients…80
Table 14. Relationship between muscle strength and kinematics variables: all subjects…82
Table 15. Partial correlation coefficient, controlling age, between muscle strength and kinematics variables…83
Table 16. Relationship between muscle strength and kinematics variables: STROKE and CONTROL…84
Table 17. Relationship between muscle strength and EMG variables: all subjects…86
Table 18. Partial correlation coefficient, controlling age, between muscle strength and EMG variables: all subjects…87
Table 19. Relationship between muscle strength and EMG variables: STROKE and CONTROL…88

Lists of Figures

Figure 1. Motion analysis system (one camera) and Qualisys workstation…19
Figure 2. Shoulder flexion (UE-F) in sitting position…22
Figure 3. Hip flexion (LE-F) in sitting position…22
Figure 4. Trunk flexion (TF) in sitting position…23
Figure 5. Trunk extension (TE) in sitting position…24
Figure 6. COM displacements in vertical, anteroposterior (AP), mediolateral (ML) directions…26
Figure 7. Trunk angles and illustrations of the positions during the trunk position sense tests…50
Figure 8. Cross-correlation (CC) during trunk flexion…52
Figure 9. Cross-correlation during trunk extension…52
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