背景及目的：維持姿勢平衡需要前庭、視覺、本體感覺的輸入。老化會造成本體感覺的能力退化，最近的研究顯示老年人和年輕人在靜態站立時，腳踝本體感覺與靜態姿勢平衡呈現正相關，髖本體感覺和靜態姿勢平衡只有在老年人呈現正相關。然而，跌倒通常發生在執行動態平衡任務。另有研究顯示腳踝本體感覺會影響到平衡受損老年人的平衡表現，然而下肢其他關節的本體感覺並沒有在此篇研究中被評估到，所以下肢各關節的本體感覺對於動態平衡的貢獻是未知的。因此本篇研究目的：(1)探討老年人和年輕人的下肢本體感覺(髖、膝、踝)和動態平衡(跨障礙物)之間的關係。

方法：本研究分為兩組，一組為年輕人組，年齡範圍為20-30歲；另一組為老年人組，年齡範圍為65歲以上，受試者在實驗中會執行跨障礙物任務，高度分別為受試者腿長的5%、10%、20%，並以常速和快速的方式行走，接著在受試者的慣用側進行髖、膝、踝本體感覺測試。本研究使用獨立樣本t檢定比較本體感覺在老年人和年輕人是否有顯著差異。皮爾森相關分析比較下肢本體感覺和跨障礙物參數的相關性，進一步使用線性迴歸比較下肢關節的本體感覺對跨障礙物的參數影響程度最高。多因子變異數重複測量分析跨障礙參數和年齡、本體感覺、步行速度、障礙物高度是否有主效果或交互作用。獨立樣本t檢定比較臨床平衡測試是否會反映老人的本體感覺下降。

結果：本研究結果顯示老年人的踝關節本體感覺能力比年輕人差，而膝關節和髖關節沒有顯著差異的。老年人組在跨障礙物時，步態參數和下肢本體感覺並沒有顯著相關。進一步探討年齡、本體感覺能力、步行速度、障礙物高度發現受試者跨障礙物時會受這些因數影響。本體感覺在障礙物抬高至受試者腿長20%高度時，本體感覺差的組別足尖最小高度會顯著高於本體感覺好的組別。老年人相較於年輕人會減少步長、減少慣用腳跨障礙物後的距離、增加足尖最小垂直高度去跨障礙物。至於用速度快的方式去跨障礙物則會增加步長、非慣用腳跨障礙物前的距離、慣用腳跨障礙物後的距離。當障礙物高度增加至20%時，受試者會增加步長和減少足尖最小垂直高度去跨障礙物。臨床平衡測試量表Mini-BESTest在老年人本體感覺好組和壞組有顯著差異。

結論：老化造成踝關節的本體感覺能力比年輕人差。當障礙物高度為受試者腿長的20%時，受試者本體感覺差組與好組相比會增加最小垂直高度去跨障礙物。臨床平衡測試量表Mini-BESTest反映受試者本體感覺能力差組分數比好組低。本研究結果顯示當執行任務有挑戰到平衡能力本體感覺對於維持平衡扮演重要角色。因此本體感覺運動可以加入平衡不好老年人的復健計畫中。

Introduction: Maintaining postural balance requires a multi-sensory process including vestibular, visual, and proprioceptive inputs. Proprioception deteriorates with age. Recent study found that the ankle joint position sense error was positively correlated with posture balance in both young and old adults during bilateral static stance, hip joint position sense error was positively correlated with posture balance in old adults only. However, falls often happen when performing dynamic balance activities. Previous study also investigated the relationship between ankle proprioception and gait pattern in old persons with balance impairment. Other joints of proprioception were not measured so that the relative contribution of each joint in lower limb to dynamic task was unknown. The aim of this study was to investigate the age-related effect of lower-limb joint proprioception on control of dynamic postural balance, including hip, knee, and ankle.

Methods: This study recruited 20 young (20~30 years old) and 20 old subjects (older than 65 years old). For the obstacle crossing task, the height of the obstacle was 5%, 10% and 20% of participants’ leg length. Participants were asked to walk in self-selected speed and fast speed. Lower limb joint position sense including ankle, knee, and hip was assessed respectively on the dominant leg. An independent t-test was calculated to determine if the JPS error of the old subjects was significantly larger than the young subjects. Pearson correlation coefficients was calculated to determine the relationship between JPS error and spatiotemporal variables. Linear regression was conducted to determine the level to which the lower-limb joint JPS errors accounted for each of the spatiotemporal variables. Repeated measure ANOVA was conducted to analyze the main effect and interaction effect of age, JPS error, crossing speed, and obstacle height was significant for the spatiotemporal variables. Independent t-test was calculated to compare the clinical balance test between the 2 JPS error (good and poor) groups.

Results: Ankle JPS error of the old subjects was significantly greater than the young subjects. Hip and knee JPS error showed no significant difference between young and old subjects. For old subjects, ankle, knee and hip JPS did not have significant correlation with the obstacle crossing parameters. The effects of JPS error appeared only when crossing the highest obstacle. The old subjects decreased step length, decreased leading heel obstacle distance, and increased toe clearance to cross the obstacle. As the crossing speed increased, the leading heel obstacle distance, trailing toe obstacle distance and step length were increased. As the obstacle height increased, subjects adopted larger step length and smaller toe clearance. The difference in Mini-BESTest score between the subjects with good and poor JPS error was significant.

Conclusion: Aging caused proprioception of ankle joint was worse in old subjects than young subjects. As the obstacle increased to 20% obstacle height, the toe clearance of the subjects with good and poor JPS error were different between each other. However, old subjects with poor JPS error had lower Mini-BESTest scores than those with good JPS error. Our study provides the evidence that proprioceptive input for maintenance of balance was important while task challenged the posture balance. Therefore, proprioception exercise should be considered as a rehabilitation program for old adults with balance impaired.

Arvin, M., Hoozemans, M. J., Burger, B. J., Verschueren, S. M., van Dieen, J. H., & Pijnappels, M. (2015). Reproducibility of a knee and hip proprioception test in healthy older adults. Aging Clin Exp Res, 27, 171-177.
Begg, R., Best, R., Dell'Oro, L., & Taylor, S. (2007). Minimum foot clearance during walking: strategies for the minimisation of trip-related falls. Gait Posture, 25, 191-198.
Blake, A. J., Morgan, K., Bendall, M. J., Dallosso, H., Ebrahim, S. B., Arie, T. H., Fentem, P. H., & Bassey, E. J. (1988). Falls by elderly people at home: prevalence and associated factors. Age Ageing, 17, 365-372.
Chen, X., & Qu, X. (2018). Age-related differences in the relationships between lower-limb joint proprioception and postural balance. Hum Factors, 61, 702–711.
Chien, J. H., Post, J., & Siu, K. C. (2018). Effects of aging on the obstacle negotiation strategy while stepping over multiple obstacles. Sci Rep, 8, 8576.
Daman, M., Shiravani, F., Hemmati, L., & Taghizadeh, S. (2019). The effect of combined exercise therapy on knee proprioception, pain intensity and quality of life in patients with hypermobility syndrome: A randomized clinical trial. J Bodyw Mov Ther, 23, 202-205.
Damiano, D. L., Wingert, J. R., Stanley, C. J., & Curatalo, L. (2013). Contribution of hip joint proprioception to static and dynamic balance in cerebral palsy: a case control study. J Neuroeng Rehabil, 10, 57.
Deshpande, N., Simonsick, E., Metter, E. J., Ko, S., Ferrucci, L., & Studenski, S. (2016). Ankle proprioceptive acuity is associated with objective as well as self-report measures of balance, mobility, and physical function. Age (Dordr), 38, 53.
Draganich, L. F., & Kuo, C. E. (2004). The effects of walking speed on obstacle crossing in healthy young and healthy older adults. J Biomech, 37, 889-896.
Fan, Y., Li, Z., Han, S., Lv, C., & Zhang, B. (2016). The influence of gait speed on the stability of walking among the elderly. Gait Posture, 47, 31-36.
Franchignoni, F., Horak, F., Godi, M., Nardone, A., & Giordano, A. (2010). Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med, 42, 323-331.
Fujisawa, N., Masuda, T., Inaoka, Y., Fukuoka, H., Ishida, A., & Minamitani, H. (2005). Human standing posture control system depending on adopted strategies. Med Biol Eng Comput, 43, 107-114.
Garman, C. R., Franck, C. T., Nussbaum, M. A., & Madigan, M. L. (2015). A bootstrapping method to assess the influence of age, obesity, gender, and gait speed on probability of tripping as a function of obstacle height. J Biomech, 48, 1229-1232.
Han, J., Waddington, G., Adams, R., Anson, J., & Liu, Y. (2016). Assessing proprioception: A critical review of methods. J Sport Health Sci, 5, 80-90.
Hendershot, B. D., Mahon, C. E., & Pruziner, A. L. (2016). A comparison of kinematic-based gait event detection methods in a self-paced treadmill application. J Biomech, 49, 4146-4149.
Horak, F. B. (2006). Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing, 35 Suppl 2, ii7-ii11.
Ko, S. U., Simonsick, E. M., Deshpande, N., Studenski, S., & Ferrucci, L. (2016). Ankle proprioception-associated gait patterns in older adults: results from the BLSA. Med Sci Sports Exerc, 48, 2190-2194.
Lai, Z., Zhang, Y., Lee, S., & Wang, L. (2018). Effects of strength exercise on the knee and ankle proprioception of individuals with knee osteoarthritis. Res Sports Med, 26, 138-146.
Lu, T. W., Chen, H. L., & Chen, S. C. (2006). Comparisons of the lower limb kinematics between young and older adults when crossing obstacles of different heights. Gait Posture, 23, 471-479.
McChesney, J. W., & Woollacott, M. H. (2000). The effect of age-related declines in proprioception and total knee replacement on postural control. J Gerontol A Biol Sci Med Sci, 55, M658-666.
Menz, H. B., Lord, S. R., & Fitzpatrick, R. C. (2003). Age-related differences in walking stability. Age Ageing, 32, 137-142.
Muir, B. C., Haddad, J. M., Heijnen, M. J., & Rietdyk, S. (2015). Proactive gait strategies to mitigate risk of obstacle contact are more prevalent with advancing age. Gait Posture, 41, 233-239.
O'Connor, C. M., Thorpe, S. K., O'Malley, M. J., & Vaughan, C. L. (2007). Automatic detection of gait events using kinematic data. Gait Posture, 25, 469-474.
Pickard, C. M., Sullivan, P. E., Allison, G. T., & Singer, K. P. (2003). Is there a difference in hip joint position sense between young and older groups? J Gerontol A Biol Sci Med Sci, 58, 631-635.
Powell, L. E., & Myers, A. M. (1995). The activities-specific balance confidence (ABC) scale. J Gerontol A Biol Sci Med Sci, 50, M28-M34.
Priplata, A., Niemi, J., Salen, M., Harry, J., Lipsitz, L. A., & Collins, J. J. (2002). Noise-enhanced human balance control. Phys Rev Lett, 89, 238101.
Proske, U., & Gandevia, S. C. (2012). The proprioceptive senses: their roles in signaling body shape, body position and movement, and muscle force. Physiol Rev, 92, 1651-1697.
Raczkowski, D., Kalat, J. W., & Nebes, R. (1974). Reliability and validity of some handedness questionnaire items. Neuropsychologia, 12, 43-47.
Ribeiro, F., & Oliveira, J. (2007). Aging effects on joint proprioception: The role of physical activity in proprioception preservation. Eur Rev Aging Phys Act, 4, 71-76.
Riemann, B. L., & Lephart, S. M. (2002). The sensorimotor system, part I: the physiologic basis of functional joint stability. J Athl Train, 37, 71-79.
Singh, N., Nussbaum, M., & Madigan, M. (2009). Evaluation of circumferential pressure as an intervention to mitigate postural instability induced by localized muscle fatigue at the ankle. Int. J. Ind. Ergon, 39, 821-827.
Weerdesteyn, V., Nienhuis, B., & Duysens, J. (2005). Advancing age progressively affects obstacle avoidance skills in the elderly. Hum Mov Sci, 24, 865-880.
Wilmut, K., & Barnett, A. L. (2017). When an object appears unexpectedly: foot placement during obstacle circumvention in children and adults with Developmental Coordination Disorder. Exp Brain Res, 235, 2947-2958.
Wingert, J. R., Burton, H., Sinclair, R. J., Brunstrom, J. E., & Damiano, D. L. (2008). Tactile sensory abilities in cerebral palsy: deficits in roughness and object discrimination. Dev Med Child Neurol, 50, 832-838.
Wingert, J. R., Welder, C., & Foo, P. (2014). Age-related hip proprioception declines: effects on postural sway and dynamic balance. Arch Phys Med Rehabil, 95, 253-261.
Yan, T., & Hui-Chan, C. (2000). Ability to detect movement of the knee joint decreases with age. Arch Phys Med Rehabil, 81, 1259-1311.
Yong, M.-S., & Lee, Y.-S. (2017). Effect of ankle proprioceptive exercise on static and dynamic balance in normal adults. J Phys Ther Sci, 29, 242-244.
You, S. H. (2005). Joint position sense in elderly fallers: a preliminary investigation of the validity and reliability of the SENSERite measure. Arch Phys Med Rehabil, 86, 346-352.
吳英, 邱馨儀, 王瑞瑤, & 楊雅如. (2008). 台灣版的特定活動平衡信心量表應用於中風患者之再測信度. [Test-retest Reliability of the Chinese Version of the Activities-specific Balance Confidence Scale in Individuals with Stroke]. 物理治療, 33, 239-245.