2013-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/646021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。侷限誘發療法為近年來對於半側偏癱患者所提倡的一種復健治療模式，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習得廢用的現象，其治療原則為侷限優勢手的活動，加強劣勢手主動使用之動機及訓練。此療法於成人中風個案已具足夠且正向之復健療效證據；然而，在兒童腦傷患者的應用上，仍有以下兩點限制與不足處，有待未來研究深入探討:第一、因侷限誘發療法強調大量且長時間的使用劣勢手，使得過去研究之實驗組與控制組常有治療時數與強度不同的問題，雖然近期已有研究試圖讓兩組兒童有相同的練習時間，但實驗組仍有較多比例的時段由治療師提供訓練，與控制組比較起來，仍有治療強度不同之差異；第二、相較於成人個案的認知理解與復健動機，兒童個案較難忍受侷限優勢側上肢所帶來的不適及不自然，雖然過去文獻多認為侷限誘發療法較傳統復健更為有效，但其對於兒童、家長甚至是整個家庭來說，常伴隨許多負面情緒與社會心理狀態之衝擊，影響家庭功能甚鉅。因此，若能設計一個對於兒童族群來說較為友善（child-friendly）且具最佳療效之復健治療策略，不但能促進兒童功能表現，亦有助於建立正向醫病關係、培養孩童良好情緒與強化家庭功能之效果。 近年來，由於電腦與科技的進步，電腦遊戲方案逐漸受到復健領域的重視，其不但能確保個案執行活動時的練習量與強度，更能藉由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，達到傳統復健不易達成之大量且重複練習之效益。此外過去研究發現電腦輔助軟體較其他療法於兒童視知覺與視覺空間的發展上，更具正面效應。因此，若能將電腦輔助軟體結合於侷限誘發療法中，預期除了可能彌補侷限誘發療法常面臨之負面情緒議題，亦可帶來其他額外的效益（如:視知覺功能提升、動機增強等），成為一個經濟、實用、且實務上可行之治療方案。因此，本研究目的為探究侷限誘發療法結合現代電腦輔助方案、侷限誘發療法與傳統上肢復健三種治療模式之治療成效與可能作用機轉。此一療效對比研究之特定目的包含：（1）三種相同劑量之復健治療方案於動作功能之療效比較；（2）結合電腦輔助軟體於上肢復健之策略，對於視知覺、情緒、社會心理與家庭功能之影響；及（3）了解各種治療方案之相關預測因子。 此三年期的計畫預計募集90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3.5-4小時，每週2次，為期4周的專業介入；與每天至少3.5-4小時（除治療日之外），為期4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。成效評量包含孩童之功能表現與社會心理適應兩部份，功能表現以國際功能分類-兒童及青少年版架構為依據，評估工具包含腕動計、墨爾本單側上肢功能評量（MA2）、視知覺測驗（TVPS-3）、協助手評估（AHA）、孩童動作活動量表（PMAL-R）、兒童雙側手功能量表（ABILHAND-kids）、兒童功能獨立測驗（WeeFIM）以及腦性麻痺兒童生活品質問卷（CPQOL）；社會心理適應與家庭功能評估包含玩性測驗（TOP）、活動參度問卷（EQ）、滿意度問卷(CSQ)、與親職壓力量表(PSI)。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；並於治療前與治療後各接受一次社會心理適應與家庭功能評估。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). Typically, the priminary impairments of motor control, sensation, and endure would further interfere with a child’s daily and academic participation. As children with hemiplegia primarily have one better funcitoning side of their body and one more affected side, they often tend not to use the affected extremity, resulting in a developmentally learned non-use of the involved arm that can be termed developmental disregard. Recent evidence suggests that constraint-induced therapy (CIT) is one of the most effective techniques to improve the use of the affected upper extremity or reduce the developmental disregard phenomenon in patients with neuromotor dysfunctions. Despite the cumulative evidence supporting the effects of pediatric CIT, two concerns prompt us to conduct this current proposal for fulfilling the gaps of existing knowledge. First, previous studies used different treatment duration for the control and CIT groups. In this case, it is not clear whether the improvement of functional outcomes were benefits from the implement of CIT or from the intensity of treatment practice. Second, the negatively emotional side effect have been repeatedly raised regarding the potentially intrusive nature of restraining a child’s unimpaired upper limb and possible distress of limiting upper limb function to the use of a hand with reduced ability. Echoed with Gilmore et al. sugestions that while CIT places demands on a child’s psychological needs, such as combein with play-like atomostphere, the barries were balance. Combining the new technology (low-cost and commercially available game-based approach) with CIT is therefore proposed as a potential solution. This 3-year research project aims to investigate and compare the immediate and long-term treatment effectiveness of CIT combined with game-based materials, CIT and conventional rehabilitation approaches with an equivalent intervention period in children with hemiplegic CP and to identify the potential predictors of each intervention program for more accuracy in patient selection. In addition, the difference of psycho-emotional status among three intervention groups will be compared for investigating the unique outcomes that would be associated with game-based materials. We will recruit a total of 90 children with hemiplegic CP from the Cerebral Palsy Association and medical centers (30 participants for each intervention group). Participants will be randomly assigned to the three intervention groups. All treatment groups will receive individualized interventions, 3.5 to 4 hours a day, twice a week for 4 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 3.5 to 4 hours a day for 4 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) model include functional performance (motor function and skills, motor-related activities, and participation) as well as psychosocial outcomes (engagement, motivation, playfulness, and parental stress level). Functional outcome measures will be administered before, immediately after, 3 months and 6 months follow-up; and psychosocial outcome measures will be administered before and immediately after 4-week intervention period by the same rater blinded to group assignment. 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.