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中文摘要. 背景與目的：反應性姿勢控制能力(reactive postural control ability) ... 近年研究發現輸入的感覺訊息會經大腦後頂葉皮質區(posterior parietal cortex, ... 篇名 後頂葉皮質區受損之中風病患於側向反應性姿勢控制能力之缺損以及給予提示對其控制能力之影響 並列篇名 ReactivePosturalResponsetoLateralPerturbationinPatientswiththePosteriorParietalCortexLesion: DeficitsandEffectsofPrecues DOI 10.6342/NTU.2008.00085 作者 林盈蕙 關鍵字 中風；動作控制；反應性姿勢控制能力；後頂葉皮質區；提示；stroke；motorcontrol；reactiveposturalresponse；posteriorparietalcortex；cue 出版品名稱 臺灣大學物理治療學研究所學位論文 卷期/出版年月 2008年 學位類別 碩士 指導教授 湯佩芳 內容語文 英文 中文摘要 背景與目的：反應性姿勢控制能力(reactiveposturalcontrolability)取決於感覺訊息的整合以及動作與姿勢的協調。

近年研究發現輸入的感覺訊息會經大腦後頂葉皮質區(posteriorparietalcortex,PPC)整合與注意後轉換為動作訊息，再傳至前動作皮質區(premotorcortex)，以利動作計畫與動作執行。

因此可推測後頂葉皮質區損傷可能導致注意與姿勢控制能力的缺損。

故本研究目的為探討後頂葉皮質區損傷是否造成中風病患站姿平衡能力缺損以及給予事先提示對患者的影響。

方法：9位大腦受損區包含後頂葉皮質區之中風病患(PPC+組,平均年齡=60.8±13.9歲)與9位大腦受損區不包含後頂葉皮質區之中風病患(PPC-組,平均年齡=69.9±10.3歲)參與本研究。

另有9位年齡相符之健康受試者參與，為控制組(Healthy組,平均年齡=67.9±13.7歲)。

所有參與者須在受到由多方向牽拉儀(AdvanceInstrument,Inc.,Taipei,Taiwan)產生之側向牽拉干擾(lateralperturbation)後，於儘量不移動雙腳的情況下，維持站立平衡。

本實驗包含無提示與提示情境各6次牽拉測試(trials)。

在提示情境下，研究者於牽拉干擾前給予聽覺提示，使參與者可事先知道干擾方向。

本實驗中分析反應姿勢肌活化模式、最早活化之反應姿勢肌潛伏時間(onsetlatency)、施力反應時間(reactiontime)、到達施力峰值時間(time-to-peakphaseduration)以及側向衝量(totalforceimpulse)。

結果：在無提示情境下，健康受試者以與牽拉方向同側邊之臀中肌(gluteusmedius)與腓長肌(peroneallongus)為主要反應肌(活化率分別為88.5%與73.1%)，且大多以臀中肌最早反應(反應姿勢肌潛伏時間為129.1毫秒)。

兩組中風受試者受到向健側邊的牽拉干擾時反應模式與健康受試者相似；但受到向患側邊的牽拉干擾時，除患側之臀中肌與腓長肌外，健側臀中肌亦為主要反應姿勢肌之一。

尤其在PPC+組受到向患側邊的牽拉干擾時，健側臀中肌之活化率(40.0%)趨近於患側之臀中肌(56.0%)與腓長肌(48.0%)，且為最早活化之姿勢反應肌(反應姿勢肌潛伏時間為167.0毫秒)。

至於反應姿勢肌潛伏時間分析結果發現，在無提示情境下受到向患側的牽拉干擾，PPC+組(167.0毫秒)的時間顯著長於Healthy(129.1毫秒)與PPC-(136.3毫秒)組(Healthy組與PPC+組:p=.008;PPC-組與PPC+組:p=.039)，但Healthy與PPC-組之間無顯著差異。

此外，PPC+組於受到向患側干擾時之反應姿勢肌潛伏時間較受到向健側干擾時的(124.8毫秒)長(p=.001)。

而無論牽拉方向為何，三組的施力反應時間與到達施力峰值時間皆無差異(p>.05)。

側向衝量分析結果顯示，當受到向患側的牽拉干擾，兩組中風病患產生的衝量(PPC-:1019.4體重百分比*毫秒;PPC+:1152.4體重百分比*毫秒)較健康成人(1504.0體重百分比*毫秒)小(Healthy組與PPC-組:p=.004;Healthy組與PPC+組:p=.028)。

給予提示後，PPC+組於受到向患側邊干擾時患側臀中肌的活化率顯著增加(活化率為80.8%)，且反應姿勢肌活化模式變成與健康成人的相似。

而提示對於三組受試者之反應姿勢肌潛伏時間、到達施力峰值時間與側向衝量並無顯著影響(p>.05)，但可以加快健康成人的施力反應時間(p=.035) 討論與結論：PPC+組的站立反應性姿勢控制能力較Healthy與PPC-組差，可能原因為感覺動作訊息轉換能力(sensory-motortransformation)缺損導致。

此外，本研究中發現聽覺提示可改善後頂葉皮質區受損之中風病患姿勢肌反應策略，但並未改善其反應姿勢肌之潛伏時間及與時間相關之力學上的反應能力。

顯示聽覺提示可能可提高後頂葉皮質區受損病患對輸入之感覺訊息的注意力、改善感覺動作訊息轉換能力或有助於計畫動作輸出之次序或相關姿勢肌，因而改善其反應策略。

反應肌潛伏時間則依賴感覺輸入之快慢與感覺動作訊息轉換之速率，而與時間相關之力學表現除上述兩項外亦取決於反應肌產生力量之速率。

後頂葉皮質區受損之中風病患可能並未因接收聽覺提示而增進其感覺動作整合與反應肌產生力量之速率，所以其姿勢反應上並未較快。

未來研究仍須進一步探討其他感覺提示(如視覺或觸覺)對後頂葉皮質區受損之中風病患反應性姿勢控制能力之影響。

英文摘要 BackgroundandPurpose─Reactiveposturalcontrolabilitydependsupontheintegrationofallsensoryinputsanddescendingmotordrives.Recentstudiessuggestthatallsensoryinputsareintegratedandattended,andthenaretransformedintomotorcommands(sensory-motortransformation)intheposteriorparietalcortex(PPC)forplanningandexecutingmovements.Therefore,itisexpectedthatlesionsoverthePPCwouldcausedeficitsinattentionandmotorcontrol.However,littleempiricalevidencehasbeenprovidedregardingstandingbalancedeficitsandeffectsofprecuesinpatientswiththePPClesion. Methods─Ninepatientswithstroke(meanage=60.8±13.9yrs)withlesionsinvolvingthePPCregion(PPC+group),ninepatientswithstroke(meanage=69.9±10.3yrs)withlesionsnotinvolvingthePPCregion(PPC-group)andninehealthy,age-matchedadults(meanage=67.9±13.7yrs)participatedinthisstudy(healthygroup). Allparticipantswereaskedtomaintainstandingbalancewithoutstepping,ifpossible,afterexperiencinglateralpullingperturbationintheno-cueandcueconditions.Therewere6trialseachintheno-cueandcueconditions.Anauditoryprecueregardingthepullingdirectionwasgiventotheparticipantsinthecuecondition.Posturalmuscleactivationpatterns,theearliestmuscleonsetlatency(OLEarliest),reactiontime(RT)oflateralforce,time-to-peakphaseduration(PDTTP)andtotalforceimpulse(IMPTotal)wereanalyzedtoinvestigatetheperformanceofeachparticipant. Results─Intheno-cuecondition,thegluteusmedius(GM)andperoneallongus(PL)musclesofthelegonthesideipsilateraltothepullingperturbationdirection(GMIpsiandPLIpsi)werethepredominantmusclesgeneratingposturalresponsesinthehealthygroup(firingrate:88.5%and73.1%,respectively).Similarresultswerealsofoundwhenbothstrokegroupsrespondedtoperturbationtowardstheunaffectedside.Whenrespondingtoperturbationtowardstheaffectedside,theGMofthelegcontralateraltotheperturbationdirection(GMContra)becameoneofthepredominantmuscles.HalfsubjectsofthePPC-reliedonco-contractionofGMIpsiandGMContraforreactiveresponses.Andone-thirdofthesubjectsinthePPC+groupsreliedonGMContrainresponsetoperturbation.Comparedtothehealthy(OLEarliest=129.1ms)andPPC-(OLEarliest=136.3ms)groups,thePPC+groupshowedlongerOLEarliest(167.0ms)whilerespondingtoperturbationtowardstheaffectedside(healthyvs.PPC+:p=.008;PPC-vs.PPC+:p=.039),buttherewasnodifferenceinOLEarliestbetweenthehealthyandPPC-groups.Inaddition,thePPC+group,butnotthePPC-group,showedsignificantlylongerOLEarliestwhenrespondingtoperturbationtowardstheaffectedside(167.0ms)thanunaffectedside(124.8ms)(p=.001).FortheRTandPDTTP,therewasnogroup,neitherdirection,maineffect.FortheIMPTotal,bothstrokegroupsgeneratedsmallerIMPTotalthanthehealthygroupafterapulltotheaffectedside(healthyvs.PPC-:p=.004;healthyvs.PPC+:p=.028).Aftercuing,themuscleactivationpatternsofthePPC+groupinresponsetoapulltotheaffectedsidebecamesimilartothoseofthehealthygroup,andthehealthygroupshowedshorterRT(p=.035).TherewerenosignificanteffectsoftheauditorycueonOLEarliest,PDTTPandIMPTotal(p>.05)inthisstudy. DiscussionandConclusions─ThePPC+groupshowedthepoorestreactiveposturalresponsestolateralpullsamongthesethreegroups,whichmaybeduetotheirdeficitsofsensory-motortransformation.Provisionofapriorauditorycueseemstoimprovetheconstructionorselectionofproperposturalstrategy,butnotthetimeneededtogeneratesufficientmuscleorforceresponses,inpatientswiththePPClesion.Thesetemporalparametersmaybedeterminedbyhowfastthepatientscouldprocessandintegrateallsensoryinformation,howfasttheycouldperformthesensory-motortransformationandhowfasttheycouldgenerateforcenecessaryforposturalresponses.Ourauditorycuedidnotseemtoimprovetherateofinformationprocessing,thesensory-motortransformationandforcegenerationofthePPC+subjects.Furtherstudiesarerequiredtoinvestigatewhetherprecueofotherforms,suchasvisualortactilecues,wouldeffectivelyimprovereactiveposturalresponsesofthesepatients. 主題分類 醫藥衛生 > 醫藥總論 醫學院 > 物理治療學研究所 參考文獻 1. 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