遵從性增強技巧對於中風病患居家復健運動遵從性及功能恢復之成效

Abstract

研究背景及目的: 腦中風是造成老年人身心功能障礙的主要原因之一。持續進行居家復健運動，除了能有助於扭轉腦中風後的長期減少活動的不良影響、增進體能、防治腦中風再發以外， 亦是因應保險給付緊縮之重要對策。本研究的目的為探討依據5A’s行為介入諮詢(Five A’s Behavior Intervention Protocol)的遵從性增強策略是否可增進中風患者居家計畫運動之遵從性及動作功能之恢復。方法: 隨機控制雙盲試驗。18位即將出院回家之亞急性單側中風患者，分層隨機分為遵從性增強組及一般居家運動組，於出院前2週開始教導其居家復健運動。遵從性增強組多加了依據5A’s 行為介入諮詢，並使用填寫運動日誌及計步器當成增強物、以及出院後第2週打電話一次討論居家運動執行狀況。出院後第4週結束及第12週時追蹤評估以比較兩組在10公尺行走測試、功能性行走分類、柏格式平衡量表、日常活動日誌、身體失能者身體活動量表、居家復健運動核對清單之間的差異，以評估居家復健運動遵行性之促進介入的效果。並分析遵從性增強組內計步器記錄一日步數隨著時間變化之差異。以SPSS 13.0的電腦軟體做數據分析。結果：兩組受試者除了偏癱側有顯著差異外，其它參數在前測值均無顯著差異。遵從性增強組在出院後第4週時對於日常活動日誌中部分運動項目如柔軟度、平衡運動，具有較佳的遵從度，但無長期的效果。兩組隨著時間變化在10公尺行走測驗、柏格式平衡量表皆有顯著的進步(p<0.001)，且遵從性增強組在10公尺行走測驗表現上顯著優於一般居家運動組(p<0.05)。遵從性增強組在出院後第12週時功能性行走分類平均分數是5，表現顯著優於一般居家運動組(p<0.05)。然而在柏格式平衡量表及身體失能者身體活動量表、居家復健運動核對清單和對運動觀感的表現上，未達組間差異。結論：中風病患於出院前開始接受依據5A''s行為介入諮詢的遵從性增強策略或許仍有些許效益。遵從性增強策略使出院後的中風病患在出院後第4週有部分較佳的居家復健運動的遵從度，尤其是在柔軟運動與平衡運動的執行方面。在功能活動測試方面，有接受遵從性增強策略的中風病患在行走速度及社區行走功能的表現上優於沒有接受此種諮詢的中風病患。雖然在本實驗中，遵從性增強策略的介入無法使遵性增強組的中風病患在平衡及參與度方面的表現和對運動的觀感上，顯著優於沒有接受此種諮詢的中風病患。然而檢討本研究設計發現，一般居家復健運動組有可能也接受了足夠的可增強遵從度的介入，如治療師一對一的教導病患及家屬符合病患個別能力的居家復健運動、預防不良事件發生之方法、給予附有圖片的運動單張以協助記住運動動作、記錄3次評估測試分數的小卡…. 等，因而減少了兩組間的差異。此外，受試者人數不足及評估量表的反應性或許均限制了研究結果。目前有關遵從性增強策略的介入對於中風病人功能性活動的影響，使用物理治療師臨床上常用於評估中風病患功能性表現的評估量表做為功能性預後的研究仍相當有限。未來希望能有更多的相關研究，以瞭解遵從性增強策略的介入對於中風病人功能性活動的影響。

Background and Purpose: Stroke is one of the main leading causes of physical disability in the elderly. The maintenance of home rehabilitation program, i.e., patient adherence, reduces side-effects from declined physical activity, improves fitness, prevents recurrent stroke and is an important strategy in response to gradually limited insurance coverage. The purpose of this study is to investigate the effects of an enhanced intervention program (based on Five A’s Behavior Intervention Protocol) on the adherence of home rehabilitation program in stroke patients. Method: This was a randomized, controlled, double-blind clinical trial. Neither the subjects nor the assessing therapist were informed of the assignment of groups. Sixteen subacute stroke in-patients were recruited. The subjects were randomly assigned into the Adherence Enhancement (AE) group or the Conventional Home Program (CHP) group. Both groups received home exercise instructions before discharge, however, only the AE group instructed based on the 5A’s (address the issue, address the patient, advise the patient, assist the patient, arrange follow-up and assess adherence) Behavior Intervention Protocol. At the baseline test, the subjects evaluated with 10-meter walking test, functional ambulation category, and the Berg Balance Scale. These data were recorded within the last two weeks prior to discharge from the hospital. The AE group subjects used self-reports of daily activity diary and pedometer throughout the 4 weeks after discharge from the hospital as enhancers. One telephone follow up was scheduled on the 2nd week to encourage exercise at home and evaluated the progression of home exercise for each AE group subject. The outcome measurements included the 10-meter walking test, the Functional Ambulation Category, the Berg Balance Scale, the daily activity diary, and the Specific Home Exercise Checklist between the two groups at the end of the 4th week post discharge. Follow up was scheduled during the 12th week post discharge. Results: There were no significant difference on the parameters of basic data, except the hemiplegic side. The AE group subjects exhibited better adherence in some of self-reported of daily activity diary such as flexibility exercise and balance exercise at 4th week, but not at 12th week after discharge. Both groups improved significantly on 10MWT and BBS (p <0.001) at both 4th and 12th weeks after discharge. The AE group subjects exhibited better performance in the 10MWT than the CHP group subjects ( p <0.05) at follow up. All subjects in the AE group reached FAC5 at 12th week, which was significantly better than the CHP group subjects ( p <0.05). However, the groups did not differ significantly on the BBS, PASIPD (Physical Activity Scale for Individuals with Physical Disability, and Specific Home Exercise Cheek list and perceptions of home program exercise. Conclusion: The Five A’s Behavior Intervention Protocol, along with other interventions such as pedometer and telephone follow up possibly reinforced the adherence of some of the home program exercises, particularly in the flexibility exercise and balance exercise. In the functional performance tests, stroke patients who received the adherence enhanced intervention program had better performance in gait speed and community walking ability than the patients who did not receive the intervention program. Though the AE group subjects did not demonstrate better balance performance nor on participation or perceptions of exercise than the CHP group, it is possible that the CHP group subjects might have received enough interventions for enhancing their adherence, thus minizing the between group difference. The CHP group received an exercise booklet with action picture to help remember the movement, one-to-one instructions by the same intervening physiotherapist on how to perform the home program exercise as well as some tips to prevent adverse events, a diary card to record the three test scores, and so on. These were all methods that may help enhancing adherence in the CHP group, thus reducing the differences between the two groups. In addition, the insufficient number of subjects and insufficient responsiveness of evaluating scales might have limited the findings of significance between groups. Thus far, the researches about the effects of the adherence enhanced intervention for functional recovery in stroke patients are limited. It is suggested that further studies in the field of adherence enhancement strategy interventions for functional recovery in stroke patients may help enhance and prolong the effects of physical therapy after the patients are dischaged.