2015-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/646013摘要：背景：中風後偏癱側肩痛 (hemiplegic shoulder pain, HSP)之平均發生率超過五成，且嚴重影響個案預後及復健療效。然而目前 HSP的治療成效之實證相當有限，主因之一在於欠缺良好的 HSP評估工具。精確、完整評量 HSP乃臨床復健之關鍵基礎，醫療人員始能充分掌握個案 HSP之特質，以進行臨床推理、擬定治療策略與療效評量。然而目前缺乏精確、完整評量 HSP面向（含強度、位置、頻率、感覺、情感及疼痛之影響等 6大面向），且能快速施測的 HSP評量工具，嚴重影響臨床及研究效能。目前學術界對於中風後 HSP機制的掌握相當有限，且疼痛可分為傷害刺激性 (nociceptive)、神經性 (neuropathic) 二大疼痛類型，然而迄今仍欠缺此二類型於各疼痛層面差異之明確實證。再者，軟組織損傷與上肢動作控制損傷為可能直接 (短期)、間接 (長期) 影響傷害刺激性與神經性疼痛的重要機制，亦為復健治療能積極介入的主要標的。因此軟組織損傷與上肢動作控制損傷於 HSP所扮演之角色亟待釐清。 研究目的：本研究之目的有三：(1)發展「中風病患偏癱側肩痛電腦適性評量系統 (A computerized adaptive testing system for assessing hemiplegic shoulder pain, CAT-HSPAIN) 」 以精確、全面、快速評量中風病患之 HSP。(2)比較中風後不同時期的HSP類型，及不同 HSP類型的疼痛特性差異。(3)探索軟組織與動作控制損傷對於 HSP之影響機制，探究二者與 HSP各疼痛層面的關係，以掌握中風後各時期患者的疼痛來源 (是否/有哪些軟組織損傷)，及其可能影響因子 (如上肢動作控制損傷)。 方法：本計畫預計以 3 年 7 階段完成 CAT-HSPAIN之發展與 HSP機制探索，含(1)建構項目/預試、(2)項目測試（300位個案）、(3)項目分析、(4)模擬分析、(5)建立 CAT施測平台、及(6)驗證 CAT-HSPAIN之心理計量特性及適用性，一年期追蹤測試 130位個案。第 7階段為機制探索，將結合第 6階段 CAT-HSPAIN所得之追蹤資料與超音波影像醫學對軟組織損傷的判讀結果，以結構方程式模型分析中風後各時期 (急性、亞急性、慢性期) HSP (疼痛各面向) 與軟組織損傷、上肢動作控制損傷間之因果關係。 預期結果與貢獻：在創新上，本研究將發展出國際上第一套中風病人偏癱側肩痛電腦適性測驗系統，研究者預期 CAT-HSPAIN為心理計量特性良好，能區辨不同疼痛類型、疼痛特質，且可精確、全面、快速施測之 HSP評量工具。CAT-HSPAIN之預期貢獻/價值有三：一、協助臨床人員掌握個案 HSP之特質與變化，以進行臨床推理、擬定治療策略與療效評量，進而提升治療成效。二、CAT-HSPAIN可達成快速、精準評量，故適用於忙碌的臨床，亦可整合於電子病歷，提升臨床效能。三、CAT-HSPAIN能協助研究人員探索 HSP之機制，包括分類出中風後各時期的 HSP類型與變化、HSP與不同軟組織損傷及動作控制損傷之連結機制。<br> Abstract: Background and purposes: The incidence of hemiplegic shoulder pain (HSP), on average, is higher than 50% of stroke patients. HSP causes poor functional recovery as well as hampers rehabilitation outcomes. The effect of current interventions on HSP, however, is still lack of evidence nowadays. Comprehensive, precise, and efficient measurement of HSP in stroke patients is crucial for clinicians and researchers in treatment planning, clinical reasoning, exploration of HSP mechanism, and outcome measurement. The lack of a comprehensive (including magnitude, spatial, temporal, sensory, affect, effect/interference dimensions), precise, and efficient HSP assessment tool can be overcome by combining both item response theory (e.g., Rasch modeling) and computerized adaptive testing (CAT). Thus, we aim to develop a CAT system for assessing HSP in patients with stroke (CAT-HSPAIN). In addition, we aim to conduct a longitudinal follow-up study to explore the role of soft tissue injury, one of the most important HSP mechanisms potentially leading to both nociceptive and neuropathic pain, in relation to impaired motor control and HSP with different pain dimensions by means of CAT-HSPAIN and sonography. The roles of soft tissue injury and impaired motor control in HSP will be also explored in each of acute, subacute, and chronic stage after stroke. Methods: This project, which will be completed over a period of 3 years, is divided into 7 stages: (1) development of items for the CAT-HSPAIN, (2) item testing, (3) item analysis using Rasch analysis, (4) simulation analysis, (5) development of a web-based testing platform for the CAT-HSPAIN, (6) investigation of psychometric properties and usability of the CAT-HSPAIN, and (7) investigation of HSP mechanisms, including A. the causal-relationship between HSP, soft tissue injury, and impaired motor control using structural equation modeling, B. confirming the type of HSP in different post-stroke stages, and C. pain characteristics between different HSP types. Expected results and contributions: Our CAT-HSPAIN may be the first CAT for measuring HSP of stroke patients in the world. The CAT-HSPAIN can achieve comprehensive, precise, and efficient assessments of HSP post stroke. There are at least three potential contributions of this project. First, the CAT-HSPAIN would help clinicians understand the comprehensive features of HSP, which are critical for clinical reasoning, treatment planning, and outcome measurement. Second, the CAT-HSPAIN can achieve comprehensive and precise assessments of HSP in an efficient fashion and can be integrated into electronic medical records. These benefits will promote the efficiency of clinicians. Third, our results will be helpful to determine the HSP mechanisms, at least, clarifying the roles of soft tissue injury and impaired motor control in HSP.中風肩痛項目反應理論電腦適性測驗strokeshoulder painitem response theorycomputerized adaptive testing.