改良性制約誘發運動治療對中風患者療效之運動分析

Abstract

制約－誘發運動治療(constraint-induced movement therapy，CIMT )是一種針對單側腦中風患者，以侷限健側手，並重複、密集地訓練患側上肢約兩至三週，以改善患側上肢動作功能的療法。本研究以運動學分析探討「改良式制約－誘發運動治療」(modified constraint -induced movement therapy，mCIMT)，對亞急性及慢性中風患者患側上肢動作功能的影響。本研究自兩家醫學中心復健病房的住院中風病患選取同意參與此研究且簽署受試者同意書之26位半側偏癱的中風患者，十八位男性，八位女性(平均年齡為51.58歲)隨機分為兩組，其中13位為mCIMT組，每天接受2小時患側手訓練及6小時健側手侷限，持續3週，另外13位為傳統治療組，每天接受1.5小時為期三週的傳統治療療程，且不特別侷限健側手。在治療前後，利用運動學分析評估伸臂及物與伸手取物動作，使用共變量分析來檢測治療後兩組的差異。結果顯示，治療後mCIMT組在伸臂動作(按鈴情境)下比傳統治療組有較快的動作反應(F(1, 23)=4.42，p=0.024)、較佳的動作流暢度 (F(1, 23)= 3.03，p=0.048)及較短的動作路徑(F(1, 23)=5.13，p=0 .017)；在伸手取物(拿飲料罐情境)下，mCIMT組能誘發較多力量(F( 1 , 16)=4.65，p=0.024)。此結果顯示每日治療時間縮短但治療期延長的mCIMT仍具改善某些動作表現的療效。同時也建議運動學分析是一種可偵測動作過程改變的工具，未來的研究可結合運動學分析與腦部顯影技術來探討中風復健後腦功能重組與動作恢復之間的關聯。

Constraint-induced movement therapy (CIMT) refers to repetitive and intensive training of the affected arm and restraint of the unaffected arm for two to three weeks. This study employed a modified CIMT (mCIMT) program and examined the effectiveness of this program in stroke patients at subacute and chronic stages. Twenty-six patients with unilateral stroke (18 males and 8 females, 0.5 to 101 months , mean age 51.58 years), recruited from the rehabilitation wards at two medical centers, signed informed consent forms approved by the Institutional Review Board and participated in this study. These patients were randomly assigned to one of two groups. Thirteen of the patients served as the mCIMT group, received 2 hours training for the affected limb and 6 hours restraint for the unaffected hand per day for three weeks, and the others as the conventional rehabilitation group received one and a half hour traditional occupational training without any restraint for three weeks. Kinematic performance of the reach and reach-to-grasp movements was measured before and immediately after treatments. Analyses of covariance were employed to test the treatment effects. During the desk bell task involving reaching with the affected arm to ring the bell, the mCIMT group showed that initiation of reaching motor acts was earlier (F=4.42, df=1, 23, p=0.024), and the path of the movement was smoother (F= 3.03, df=1, 23,p=0.048) and more direct (F=5.13, df=1, 23, p=0.017) after treatment than the conventional group. During the task involving reaching to grasp a can of coke, the movements made by the patinets in the mCIMT group were more forceful than those by the traditional rehabilitation group( F=4.65, df=1, 16, p=.024). These findings suggested that the mCIMT with shorter intervention and restraint periods per day still improved some aspects of the reach and the reach- to-grasp movements, in comparison with the conventional treatment approach. The findings also suggested that kinematic analysis may help to detect changes in movement process. Further study combining kinematic analysis and brain image technique to identify the relation of movement reorganization patterns and motor recovery after stroke rehabilitation is warranted.