集中式與分散式平衡訓練對輕度創傷性腦傷患者之療效研究

Abstract

頭部外傷可能會造成許多認知、行為或功能上的障礙，近幾年來的流行病學研究指出腦傷病患中約有90%屬於輕度腦傷，本土研究則約為80%。多數輕度腦傷病患傷後會出現腦震盪後症候群的相關症狀與症候，如頭暈、頭痛、走路不穩、注意力不集中、記憶衰退、易怒等，其中以頭暈和走路不穩或平衡不良的症狀經常持續至傷後三個月還未有明顯改善，最為輕度腦傷病患所困擾。平衡不良可能源於感覺整合能力的下降，造成輕度腦傷病患在處理多種感覺訊息衝突時的平衡反應異常，而可能增加跌倒的危險。頭暈的產生可能來自外傷性的前庭病變，持續性的頭暈造成患者在生活有許多限制，亦可能影響整個人或家庭生活品質。過去對輕度腦傷病患的治療方式包含藥物治療、認知復健、病患衛教等等，而較少針專對輕度腦傷病患提供平衡訓練的物理治療研究。 如何依據動作學習理論設計最有效益的治療計畫，是近期臨床物理治療研究的重點之一。若提供相同的練習量，依據練習課程安排的密集程度，可分為集中練習與分散練習。過去文獻對集中式與分散式的練習對於動作學習效果的研究結果，並沒有發現絕對的優劣結果，有些情況下集中練習比較有效、有些情況下分散練習的效果比較好，這可能是因為研究對象族群不同或探討的的動作型態不同所致。由於輕度腦傷患者往往很快的返回工作崗位或學校，因此若能設計最有效益的治療計劃，減少病患往返醫院治療的次數，將對廣大的輕度腦傷患者有相當大的貢獻。本研究探討輕度腦傷病患接受總訓練時數為兩小時的集中式平衡訓練或分散式平衡訓練的兩組訓練組，在動態姿勢平衡儀檢測、動態步態指標以及頭暈障礙量表等面向相較於不接受平衡訓練的控制組之立即與長期的訓練效果。 本研究設計為施測者單盲之隨機分組控制實驗，18位輕度腦傷患者被隨機分配至集中式平衡訓練組、分散式平衡訓練組和控制組，集中式平衡訓練組接受每週一次，每次60分鐘，為期兩週的平衡訓練；分散式平衡訓練組則接受每週兩次，每次30分鐘，為期兩週的平衡訓練，三組受試者皆接受治療前、治療後三天內與治療後兩週共三次評估。評估內容包括動態姿勢平衡測量儀之感覺整合測驗與八方向持續重心轉移測驗、動態步態指標和頭暈障礙量表。平衡訓練內容結合感覺操弄模式，前庭適應運動為輔，內容主要在張眼、閉眼、硬地、軟地等情境下執行與平衡相關之功能性活動以增進平衡能力、步態、協調性與降低減緩頭暈不適的症狀。 本研究結果顯示：一、輕度腦傷病患傷後多有抱怨頭暈、頭痛等典型症狀。二、分散式平衡訓練對輕度腦傷病患感覺整合測試平衡指數的增加有較好的趨勢。三、三組受試者在動態步態指標隨著時間有改善的趨勢。四、分散式與集中式平衡訓練皆使頭暈障礙量表分數在治療後有降低較多的趨勢。 本研究無法證實集中式平衡訓練與分散式平衡訓練對輕度腦傷患者在平衡能力、步態穩定度和頭暈障礙程度在訓練後有明顯改善效應的差異性。這可能是因為受試者人數不足、個案間變異性大、治療的內容不具特異性等原因所致。然而，由結果可以得知無論有無接受平衡訓練，輕度腦傷病患在治療兩週後的平衡能力、步態穩定度、頭暈程度皆與控制組類似有明顯的改善，而分散式平衡訓練組與集中式平衡訓練組在治療後，在感覺整合能力方面，分散式平衡訓練組有改善較多的趨勢。此現象表示給予輕度腦傷病患兩週分散式的平衡訓練，對於平衡能力有較好的效益，而平衡訓練的內容是否需要增加對頭暈或降低前庭敏感度的運動項目以加強治療的效果，值得作為未來研究的參考。

Traumatic brain injury (TBI) may result in a variety of cognitive, behavioral and physical impairments. In recent years, some studies concluded that mild TBI accounts for 90% of TBIs whereas there were about 80% TBIs classified as mild severity group in Taiwan.literature. Mild TBIs often suffered from post-concussion syndrome, and the symptoms included dizziness, headache, unsteadiness, poor mental concentration, memory deficit, and irritability. However, dizziness and unsteadiness recovered slowly and often lasted for three months after injury. The balance deficits following TBI may be due to poor sensory organization and the consequent improper and delayed muscle reactions. The traumatic vestibular lesion may lead to dizziness, which may impose limitations in daily functions. Past studies about mild TBI treatment intervetions were mostly phamacotherapy, cognitive rehabilitation, and patient education. Physical rehabilitation or balance training for the dizziness and balance deficits has not been a routine or common therapy for the mild TBIs. One of the focus of recent clinical physical therapy research is to design an efficient and effective therapeutic program based upon motor learning theory. According to the concentration level of practice, treatment session can be categorized into massed and distributed practice given the same amount of practice. Reviewed literature illustrated no superiority of the above-mentioned categories over each other which could be due to different studied population or motor pattern. Since mild TBI patients go back to work or school shortly after hospitalization, efficient treatment program that reduces their frequency of coming back and forth between these to places will contribute beneficially to this extensive population. The purpose of this study is to compare the immediate and long-term effects of either a two-hour massed or a two-hour distributed balance training relative to control group subjects on dizziness handicap inventory (DHI), dynamic gait index (DGI) and dynamic posturographic measures in mild TBI. This is assessor-blind randomized-control trial study. Eighteen mild TBI patients were randomly assigned to either the control group, massed balance training group or the distributed balance training group. In the massed balance training group, subjects received one 60-minute treatment session per week for two weeks. In the distributed balance training group, subjects received two 30-minute treatment sessions per week for two weeks. The control group received no additional treatment other than the pharmacological threatment as indicated by their clinical symptoms and signs. Every subject was evaluated at pre-training, post-training, and follow-up period (two weeks after training). The measurements included sensory organization test, limits of stability test, DGI and DHI. The balance training program combined functional training related to static and dynamic balance with sensory manipulation and vestibular adaptation exercise in various sensory environments, such as eyes open, eyes closed, soft surface, or firm surface. The results showed that: (1) Our mild TBI subjects demonstrated similar exhibitions of typical symptoms and signs, including dizziness and headache, as the literature. (2) There was a trend toward improvement in the equilibrium score of the sensory organization test in the distributed balance training group from baseline to post-tests. (3) There was significant improvement of dynamic gait index in all three groups from baseline to post-tests. (4) There was a trend toward significant improvement in DHI score in the two balance training groups from baseline to post-tests. Our study failed to demonstrate significant training effect on balance, gait stability and dizziness compared to the control group. This was possibly due to the small sample size, heterogeneity of the subjects, or the nonspecificity of balance training programs. However, there is a trend that the two training groups, and the distributed group more than the massed group, demonstrated more improvements on balance, gait stability, and dizziness after treatment. Furthermore, subjects in the 30-minute treatment group showed less signs of fatigue or inattention than the 60-minute group. Thus a tentative recommendation for clinical implication is that a distributed practice schedule may benefit mild TBI patients for reducing their dizziness and imbalance under sensory changing environment. Further study with more subjects is recommended to clarify the effects of sensory balance training on mild TBI patients.