改良式侷限誘發動作治療應用於腦中風患者之運動學研究：腦中風側化性之影響

Abstract

背景 腦中風常遺留下明顯的感覺動作及認知功能缺失，進一步影響生活功能與職能角色的扮演，降低生活品質。改良式侷限誘發動作治療藉由侷限腦傷患者之健側肢體，並提供患肢密集性的功能訓練，來提升患肢動作功能及活動中使用頻率。本研究以單側腦中風患者為對象，探討改良式侷限誘發動作治療是否：(1)改良式侷限誘發動作治療優於傳統的治療方式，而更有助於動作能力及日常生活功能的改善，並提升其生活品質；(2)改良式侷限誘發動作治療的成效是否與腦中風傷側有關；以及(3)對於健側肢體的動作功能有影響。 方法 本研究採用臨床控制的實驗設計，收案28位單側腦中風患者，依腦傷之側化性分至實驗組與控制組。於三週的訓練期間，實驗組患者腦傷同側上肢每日須侷限六小時，患側上肢接受每天兩小時的密集性訓練；控制組則接受傳統訓練。成效評量方面，採用運動學分析的方式來評量治療對患側與腦傷同側上肢伸取動作的運動學特質，並配合臨床量表由動作能力，動作功能，以及生活品質三面向來評估，並且進行一個月的追蹤評量。所得資料以t檢定比較兩組患側上肢各項功能的改善以及腦傷同側手的改變有無達到顯著的差異。再依據腦中風之側化性作次分組，採用曼恩-惠特尼檢定分析此因素對治療療效所造成的可能影響。 結果 伸取動作的運動學特質改善會因活動特性而有差異，整體而言mCIMT組在反應時間、動作時間、標準化路徑和達最大速率時間比方面的改善幅度大於控制組，顯示動作計畫、動作流暢性及效率上的提升，但只有在部分實驗活動中達到顯著的差異。動作能力及活動功能方面，侷限誘發動作治療組的在傅格-梅爾評估量表、動作活動量表以及獨立性功能量表的改善皆顯著大於控制組，而且有趨近於大的效應值；於社會參與度方面，侷限誘發動作治療組患者主要在與生理功能相關的面向改善幅度顯著大於控制組。一個月的追蹤結果顯示侷限誘發動作治療組在動作能力以及患肢活動使用上仍顯著優於控制組，其餘面向則未達顯著之差異。 大腦側化性對治療成效的影響方面，在運動學特質上左腦傷患者的反應時間的改善幅度較大，雖未達顯著差異但有中度的效應存在；右腦傷患者在動作流暢性及執行效率提升方面則有優於左腦傷患者的趨勢。在整體功能獨立性方面，右腦傷患者的改善量顯著優於左腦傷，其餘評量則未達顯著差異。而同側肢體在運動學特質上雖有改善的現象，但是與控制組之間仍未達顯著差異。 結論 改良式侷限誘發動作治療可以改善患者執行伸取動作時的動作計畫能力、執行效率和流暢性，更可改善動作能力，並概化至日常生活中獨立性的增加以及患肢使用頻率和品質的提升。對於右腦傷患者而言，改良式侷限誘發動作治療的治療成效有優於左腦傷患者之趨勢，但仍有待後續研究的探討。

Background and Purpose Stroke is the leading cause of disability and is frequently accompanied by substantial loss of motor function. A possible explanation for the substantial remaining motor deficit might be the occurrence of learned nonuse. Modified constraint-induced movement therapy (mCIMT) is a new rehabilitation approach to improving limb use in stroke patients. The main purposes of this study are: (1) to investigate whether mCIMT is more effective than traditional therapy in restoring motor function, improving activities of daily living functioning and promoting quality of life in stroke patients; (2) the influence of stroke laterality on the mCIMT treatment effects; (3) the impact of treatment on the less-affected arm. Methods Twenty-eight stroke patients were assigned to either the mCIMT group (immobilization of the less-affected arm 6-hour per day combined with intensive training of the affected arm 2-hour per weekday) or the control group of traditional treatment for a period of 3 weeks. The primary outcome measures involve the kinematic system to capture the spatio-temporal characteristics of reaching performance, and clinical measures including Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), Functional Independence Measure (FIM) and Stroke Impact Scale (SIS). Results Patients in the mCIMT group exhibited better reaching performance than control group in some experiemental tasks that was reflected by shorter reaction time, less normalized total displacement and greater percentage of reaching where peak velocity occurs. Results of the FMA, MAL and FIM also showed that mCIMT group had significant improvement of motor function and activity performance in real-life environment. The mCIMT group also showed significant improvement in the physical function domains in the SIS. In the mCIMTgroup, there is a trend that patients with right brain damage (RBD) had better motor efficiency and smoothness in reaching performance than patients with left brain damage (LBD). Patients with RBD also had significant improvement in FIM scores. There was no significant impact on the less-affected arm.

Conclusion The finding of this study supported the therapeutic benefits of mCIMT on improving reaching performance and motor function and overcoming learned nonuse. The mCIMT might have better therapeutic effects for patients with right brain damage. Howerver, further studies are needed to confirm the effects of stroke laterality and the impact of mCIMT on the less-affected arm.