2015-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/646162摘要：上肢功能缺損為腦性麻痺兒童最常見之障礙。於兒童發展時期，上肢動作功能受損會造成日後進階手部技巧缺失，進而影響未來日常生活與學業表現。半側偏癱腦性麻痺兒童常因患側上肢執行動作失敗的經驗，傾向於較少使用患側手，進而出現習得廢用現象或發展性忽略之症狀。單側侷限誘發療法與雙側功能訓練療法為近年來對於半側偏癱患者所提倡具最佳實證基礎之復健治療模式，主要利用動作學習理論及腦部神經的可塑性來改善個案患側的功能，然而兩種復健模式各有優缺，治療成效也不盡相同。單側侷限誘發療法主要強調患側手的大量練習，過去文獻也證實侷限誘發療法較傳統復健更為有效，但臨床上發現孩童較難忍受侷限優勢側上肢所帶來的不適及不自然，加上兒童族群的手功能仍處於發展階段，優勢手的侷限亦會造成發展學習的限制；因此有學者提出雙側功能訓練，希望藉由提供需雙側同時參與的活動，訓練孩童患側上肢的功能，此方案試圖保留單側侷限誘發療法的原則與優點（高密度的治療強度與動作學習理論策略）且彌補其不足，研究顯示雙側功能訓練可提昇個案兩側協調與日常生活功能表現，然而，對於患側手的動作能力的提昇與練習強度，皆不及單側侷限誘發療法；有鑑於此，學者們建議未來應多探討複合療法的可能，希望藉由結合單側侷限誘發療法與雙側功能訓練療法，彼此互補其不足，讓治療成效達到最大。 此議題的研究，目前仍有以下幾點限制與不足處，有待未來研究進行深入討論:第一、單側侷限誘發療法與雙側功能訓練療法為近年最具療效實證的復健模式，然而單一療法與複合療法的相對效應，未有層級較高的研究仔細且全面地探討，使得目前單一療法與複合療法的療效仍停留於理論的推測；第二、過去經驗發現長時間的復健容易讓孩童失去動機，對於孩童執行居家活動的品質亦難以監督，因此，我們將結合現代電腦遊戲輔助方案，藉由電腦遊戲的趣味性與新奇性，提昇孩童執行治療活動時的參與度和動機，同時也能確保個案執行居家活動的練習量與強度，期能利用此經濟、實用、且實務上可行之治療方案，達到傳統復健不易達成之大量且重複練習之成效；最後、單側侷限誘發與雙側功能訓練療法皆屬強度較高的治療，相較於成人個案的認知理解與復健動機，兒童個案較難忍受或配合此治療模式，加上學齡孩童有學業的考量，極需此研究計畫，以發展出適合台灣孩童作息且對於兒童族群來說較為友善（child- friendly）之復健治療策略，並深入探討其療效與影響療效的相關因子。 本研究目的為提供學齡孩童實務上可行且較為友善的復健方案，探究單側侷限誘發療法、雙側功能訓練療法、以及複合療法三種治療模式之成效與可能作用機轉之比較，並了解各種治療方案之進步曲線與相關預測因子，同時探討結合電腦輔助遊戲於上肢復健之策略，對於治療方案參與與居家練習依從性之影響。此三年期的計畫預計募集60位半側偏癱之腦性麻痺兒童參與研究。符合納入標準之兒童將隨機分配至三種治療方案中。所有治療者皆接受相同劑量的治療與練習，包含每天1-1.5小時，每週3次，為期8周的專業介入；搭配與每天至少1-1.5小時（除治療日之外），為期8周的在家練習。治療介入將由專業治療師於醫療院所或個案家中進行。成效評量以國際功能分類-兒童及青少年版架構為依據，評估工具包含墨爾本單側上肢功能評量、拜瑞-布坦尼卡視覺-動作統整發展測驗、協助手評估、孩童動作活動量表、兒童雙側手功能量表、兒童功能獨立測驗、腦性麻痺兒童生活品質問卷、與親職壓力量表；另外每週會讓孩童完成積木與盒子測驗、填寫居家活動內容與活動參度問卷，以記錄孩童之進步曲線與參與情形。受試者將於治療前、治療後、治療後3與6個月各接受一次功能表現評估測驗。療效評量將由同一位不知個案治療組別的評估者負責執行。資料分析將使用多變量共變數分析（MANCOVA），檢驗不同治療組別之成效，並以前測分數做為共變數；另外，將使用廻歸分析檢視各種治療之預測因子。 本研究之結果將可協助從事兒童上肢復健之臨床工作人員與研究人員，了解不同復健治療方案之療效與其優缺點，建立最佳復健治療模式，提供家長或照顧者適當的教育與諮詢。另外，本研究將可掌握各種不同治療相關之預測因子，提供臨床個案選擇之參考，提升復健成效。整體研究預期能提供更具實證基礎的科學資訊，並期能充實與提升國內兒童復健之研究與臨床工作內涵，並期能朝向最佳化與個別化兒童復健效益之目標邁進。 <br> Abstract: Upper limb dysfunction is a common and disabling consequence of children with cerebral palsy (CP). Clinicians dedicate considerable time and resources toward upper limb rehabilitation. Recent evidence suggests that constraint-induced therapy (CIT) and Hand-arm bilateral intensive training (HABIT) are the most effective techniques to improve the use of the affected upper extremity in patients with neuromotor dysfunctions. Findings of previous studies indicated neither intervention was superior. There might be some individual differences governing the effectiveness of one training strategy over another. In summary, CIMT is better at reducing physical impairment, since the trainer has more control over how the involved upper extremity is used. HABIT, in contrast, is better for the achievement of bimanual coordination and goals and enhancing the transfer of unpracticed tasks for the child with a mildly- or severely-affected hand that precludes grasp or who cannot tolerate the restraint method. To achieve the best results in children with unilateral CP, concluding from the aforementioned studies, researchers proposed a combining protocol that including CIMT and HABIT principles. However, to date, the effectiveness and differences of combination therapy (CIMT+HABIT) versus monotherapy (CIMT or HABIT alone) have not been investigated in children with hemiplegia. Whether the cumulative effects of combined unimanual and bimanual training occur and are greater than effects of the individual treatment approach need to be investigated. This 3-year research project aims to investigate and compare the immediate and long-term treatment effectiveness as well as motor improving curve and potential predictors of the CIMT, HABIT, and combined (CIMT+HABIT) child friendly protocols with an equivalent intervention period in children with hemiplegic CP. In addition, based on the ICF-CY model, comprehensive outcome measures including motor functions as well as psychological functions will be included. We will recruit a total of 60 children with hemiplegic CP from the Cerebral Palsy Association, medical centers, and special educational systems (20 participants for each intervention group). Participants will be randomly assigned to the three intervention groups. All treatment groups will receive individualized interventions, 1 to1.5 hours a day, three times a week for 8 weeks. Outside the therapy sessions, the children are encouraged to perform the upper limb exercises or daily activities at home under the supervision of parents, for 1 to 1.5 hours a day for 8 weeks. Parents are asked to document in daily logs the number of restraint hours and their child’s activities during those hours. Outcome measures will be selected based on International Classification of Functioning, Disability and Health - Version of Children & Youth (ICF-CY) including Melbourne Assessment, Beery-Buktenica Developmental Test of Visual-Motor Integration, Assisting Hand Assessment, Pediatric Motor Activity Log-Revised, ABILHAND-kids, Functional Independence Measures for Children, Cerebral Palsy Quality of Life Questionnaire for Children, and Parental Stress Index. All of those functional outcomes will be administered before, immediately after, 3 months and 6 months follow-up after the 8-week intervention by the same rater blinded to group assignment. In addition, Box and Block Test will be collected every week during the entire training period for investigated curve of improvement. Finally, Engagement Questionnaire EQ and number of hours of implementing home practice will be collected every week for investigating a child’s engagement and adherence of the intervention. MANCOVA will be conducted for variables of outcome measures, covariate for pretreatment performance, to evaluate treatment efficacy with group as between-subjects factor and scores of the motor outcomes. Regression analyses will be used to identify the significant predictors for different functional outcomes of each intervention. We believe this project can provide solid scientific evidence and the findings can benefit for the rehabilitative field all over the world.腦性麻痺上肢神經復健實證研究cerebral palsyupper limb neurorehabilitationevidence-based research