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研究生：	林宥岑 Lin, Yu-Chen
論文名稱：	書寫力量量測及生理回饋介入訓練系統之開發及應用 Development and applications of a biomechanical assessment and biofeedback-training system for handwriting performances
指導教授：	郭立杰 Kuo, Li-Chieh
學位類別：	博士 Doctor
系所名稱：	醫學院 - 健康照護科學研究所 Institute of Allied Health Sciences
論文出版年：	2019
畢業學年度：	107
語文別：	英文
論文頁數：	103
中文關鍵詞：	孩童、書寫、力量、力學、生物回饋、精細動作
外文關鍵詞：	children, handwriting, force, kinetics, biofeedback, fine motor
相關次數：	點閱：166 下載：2
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書寫在一般人生活中，是不可或缺的能力及表現，特別是對於學齡孩童在學校生活的適應及課業的表現上更顯重要，因此與書寫有關的研究文獻為數眾多，然而現今常見的書寫分析多是量測字跡清晰度、書寫速度及握筆姿勢等因子，針對書寫動力學表現之量化分析仍較缺乏，故本研究將從生物力學及人因的觀點，針對筆桿型態、精細動作表現與書寫表現參數之關係做深入探討，尋找可能與書寫困難相關之因子，開發一書寫評估及生理回饋訓練系統，期盼未來能將研究成果運用於臨床人員評估、治療及書寫教育中。
本研究的第一個目的為開發一書寫力學評估系統，探討書寫內容(描畫內容以及字體大小)及筆桿型態(不同筆桿大小以及筆桿形狀)對運筆力學的影響，同時也將針對此評估系統之相關儀器進行校正及再測信效度分析，第二個目的為探討有書寫困難學童之書寫運動學及動力學表現，並比較有無書寫困難在書寫運動學及動力學方面之差異，以尋找出與書寫困難有關之力學或運動學因子，最後一個目的則為設計一適合學齡孩童之書寫生理回饋訓練系統，並比較所設計之書寫生理回饋訓練以及傳統精細動作訓練對書寫困難孩童之書寫表現影響。
針對第一個研究目的，結果發現書寫內容以及筆桿型態對於不同年齡層的孩童而言確實有不同的影響，針對字體大小的部分，研究結果建議針對寫字過輕畫不出墨跡的學童書寫訓練時，可以使用較大字體的書寫任務，以提升下筆的力量，針對握筆型態的部分，發現使用較粗的圓型筆桿時，學齡兒童在使用時會使用較大的力量握住筆桿，此外，本研究所研發的書寫力學評估系統，針對不同的筆桿型態設計皆有良好的信效度；針對第二個研究目的，結果發現書寫困難兒童和一般書寫表現孩童在書寫力量的表現差異，主要是發生在寫字過程中，筆畫和筆畫之間輪替時的力量控制，書寫困難孩童在筆畫輪替的過程中，力量的施予無法維持，而一般發展孩童則可以維持著力量的輸出，此外在書寫的運動學以及力學相關性的研究也發現到，食指遠端關節角度的變化，確實會與食指施力的大小相關，施力越大，屈曲的角度變越小；針對第三個研究目的，研究結果發現本研究所設計的書寫生理回饋訓練，相較於傳統精細動作訓練，對書寫困難孩童的整體書寫表現在書寫問卷結果的部分有顯著較佳的效果，而在書寫力學部分則是兩種訓練對於寫字表現都有效果，兩者的效果沒有顯著差異。本研究結果將能提供臨床人員及教師在教導孩童書寫之有效且有實證基礎之訓練工具及具體介入策略。

Handwriting is one basic ability and common performance in our daily living activities. Especially, it is crucial for school-aged children to mastering their school-life and academic performance. Numerous methods have been developed for evaluating handwriting performances; however, rare of them was designed to quantify and interpret the handwriting mechanisms thoroughly based on biomechanical perspectives. Most of previous handwriting studies focused on describing writing legibility, writing speed and grip patterns. Hence, the general purpose of this study is to explore the handwriting activity and related factors based on a biomechanical perspective, and then to apply our findings on the daily writing activities of average and people who have handwriting difficulties. We anticipate the research outcomes would contribute to enhancing the quality of clinical evaluations, interventions and handwriting education in the future.
This study consists of three major parts. The purpose of the first study is to establish a novel kinetic assessment system incorporated with Force Acquisition Pens (FAPs) designed with different barrel sizes and shapes for handwriting. Through calibration, the examinations of reliability and validity for this system were presented. The purpose of the second study is to investigate the handwriting mechanisms for the children who have writing difficulties using the kinetic assessment system incorporated with the motion capture system. The purpose of the third part is to integrate the kinetic assessment system and the intervention concept of handwriting difficulties to establish a Biomechanical Assessment and Biofeedback-training System for Handwriting (BABSH). This part also investigated a comparison of the intervention effect between the BABSH and traditional training for children with handwriting difficulties.
The results of the first part study showed that different writing tasks and the designs of the pen did produce distinct effects on writing performances for children with different ages. The findings regarding the effect of the character size indicated that the use of the writing tasks with larger characters might help improve the writing outcomes for the children who usually wrote too lightly to make the ink darker. For the part of the pen design, using the pen with a circular shape in a smaller size, compared to using the pen with a circular shape in a larger size, may help the children with the problem of muscle weakness to grip the pen easily.
In the second part of this dissertation, we explored the differences of handwriting kinematics and kinetics between children with and without handwriting difficulties (HD). The results indicated that the performance while the pen was lifted during handwriting might be crucial for children with HD, and the differences of each digit role should be considered for further handwriting training. In addition, the study also found that the average web angle between thumb and index finger had moderately positive correlation with the factor of average wrist dorsiflexion angle. This may represent that the more the web space opened, the more the wrist may extend to assist the pen manipulation. With this situation, the force applied toward the paper may be output in a more stable way.
In comparison with receiving traditional motor training, the children who undertook the Biofeedback-training System for Handwriting in the third part of this study showed better general handwriting performances that were reported by the children’s parents or teachers. We can also find the better training effect on handwriting construction than the other dimensions via the proposed Biofeedback-training System.
The outcome of this study objectively provides valuable information for clinicians and educators to understand the writing mechanisms of children with writing difficulties based on biomechanical perspectives and then to propose suitable strategies and tools for further interventions to improve their writing qualities.

摘要	I
ABSTRACT	III
致謝	V
LIST OF FIGURES	IX
LIST OF TABLES	X
CHAPTER 1 GENERAL INTRODUCTION	1
1 Research Background	1
2 Our previous works	4
3 Motivations and Specific Aims	5
CHAPTER 2 HANDWRITING KINETICS OF WRITING DIFFERENT SIZES OF CHARACTERS AND CIRCLES FOR CHILDREN.	7
1 Introduction	7
2 Aims and Hypotheses	8
3 Materials and Methods	8
3.1 Participants	8
3.2 Equipment, writing tasks and procedures	8
3.3 Parameters	9
3.4 Data analysis	10
4 Results	11
4.1 Effects of character size, task complexity and age on the AF	11
4.2 Effects of character size, task complexity and age on the CVF	12
4.3 Effects of character size, task complexity and age on the NFFPS	13
4.4 Effects of character size, task complexity and age on the FR	15
4.5 Effects of character size, task complexity and age on the TT	15
5 Discussion	16
6 Summary	19
CHAPTER 3 DEVELOPMENT OF AN INNOVATIVE KINETIC ASSESSMENT SYSTEM AND THE EFFECT OF DIFFERENT PEN DESIGN	19
1 Introduction	20
2 Aims and hypotheses	22
3 Materials and methods	22
3.1 General Design	22
3.2 Participants	24
3.3 Parameters	25
3.4 Validity and Reliability tests	25
3.5 Experimental Protocol	25
3.6 Data Analysis	26
4 Results	26
4.1 The validity and reliability of FAP system	26
4.2 The effect of size difference on handwriting kinetics	28
4.2.1 The effect of size difference on AF	28
4.2.2 The effect of size difference on CVF	30
4.2.3 The effect of size difference on FR	32
4.3 The effect of shape difference on handwriting kinetics	32
4.3.1 The effect of shape difference on AF	32
4.3.2 The effect of shape difference on CVF	33
4.3.3 The effect of shape difference on FR	34
4.4 The difference of handwriting performance between adults and children	35
4.4.1 The difference of AF between adults and children	35
4.4.2 The difference of CVF between adults and children	37
4.4.3 The difference of FR between adults and children	37
4.4.4 The difference of TT between adults and children	38
5 Discussion & Conclusion	38
CHAPTER 4 BIOMECHANICAL ANALYSIS OF HANDWRITING IN CHILDREN WITH AND WITHOUT HANDWRITING DIFFICULTIES	42
1 Handwriting Kinetics in Children with and without Handwriting Difficulties	42
1.1 Introduction	42
1.2 Methods	44
1.2.1 Participants	44
1.2.2 Equipment, writing tasks and procedures	45
1.2.3 Parameters	45
1.2.4 Statistical analysis	46
1.3 Results	46
1.4 Discussion and Conclusion	48
2 The Motion Analysis of Hand in Children with and without Handwriting Difficulties during the Writing	52
2.1 Introduction	52
2.2 Aims and hypotheses	54
2.3 Materials and methods	54
2.3.1 Participants	54
2.3.2 Equipment	54
2.3.3 Experimental Protocol	56
2.3.4 Data Analysis	58
2.4 Results	59
2.4.1 Basic information of participation	59
2.4.2 Effect of handwriting difficulty on handwriting kinetics and kinematics	61
2.4.2.1 Effect of handwriting difficulty on PF	61
2.4.2.2 Effect of handwriting difficulty on AF	62
2.4.2.3 Effect of handwriting difficulty on CVF	62
2.4.2.4 Effect of handwriting difficulty on FR	63
2.4.2.5 Effect of handwriting difficulty on NFFPS	63
2.4.2.6 Effect of handwriting difficulty on TT	64
2.4.2.7 Effect of handwriting difficulty on handwriting kinematics	64
2.4.3 Correlation among fine motor performance and handwriting kinetics and kinematics	65
2.4.4 Correlation between handwriting kinetics and kinematics	67
2.5 Discussion and Conclusion	69
CHAPTER 5 EFFECTIVENESS OF A BIOFEEDBACK-TRAINING SYSTEM FOR HANDWRITING IN CHILDREN WITH HANDWRITING DIFFICULTIES	72
1 Introduction	72
2 Aims and hypotheses	74
3 Materials and methods	74
3.1 Participants	74
3.2 Equipment and training program	75
3.2.1 Biofeedback-training System for Handwriting	75
3.2.2 Traditional fine motor training for handwriting	76
3.3 Experiment Protocol	77
3.3.1 Biomechanical Assessment for Handwriting	77
3.3.2 Fine motor test	77
3.3.3 Chinese Handwriting Evaluation Form	78
3.4 Parameters	78
3.5 Data Analysis	78
4 Results	78
4.1 Basic information of participants	78
4.2 Effects of groups and pre-post tests	79
4.2.1 Effects of groups and pre-post tests on CHEF	79
4.2.2 Effects of groups and pre-post tests on the BOT-2 and the strength	82
4.2.3 Effects of groups and pre-post tests on PF	84
4.2.4 Effects of groups and pre-post tests on AF	86
4.2.5 Effects of groups and pre-post tests on FR	89
4.2.6 Effects of groups and pre-post tests on NFFPS	89
4.2.7 Effects of groups and pre-post tests on CVF	90
4.2.8 Effects of groups and pre-post tests on TT	92
5 Discussion and Conclusion	93
CHAPTER 6 CONCLUSIONS	96
REFERENCE	98

                                    

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