任務取向雙側上肢運動訓練對中風患者動作功能之療效

Abstract

研究背景及目的：中風是導致成人失能的主要原因，大約有三分之二的中風患者無法使用患側上肢進行功能動作，而影響從事活動的獨立性。物理治療對中風患側上肢以任務導向模式為主流之一，但過去臨床應用多只強調單側運動。受到近十年雙手動作研究在動作行為與神經生理學的啟發，物理治療專家開始嘗試各種基於雙側同步動作的治療方式，並於身體功能與構造、動作策略、功能層面的得到初步的成效。儘管如此，過去研究仍存有一些未解決的問題，包括動作設計與訓練內容變異大、需要使用特製治療器材，而且訓練內容多為機械化重複動作，並非目標導向的任務。本研究之目的為探討任務取向雙側上肢運動訓練對中風患者上肢身體功能與構造、活動表現、日常參與、動作策略之效果。方法：本研究採單盲隨機控制設計，收入38名單側中風受試者，依急慢性進行隨機分層分成兩組，實驗組給予3週(6小時)任務取向雙側上肢運動訓練，控制組則皆受同時數平衡訓練。訓練前、後、訓練後一個月分別進行三次評估(傅格梅爾氏量表上肢部分、上肢動作研究量表、動作活動量表、運動學參數)。本研究使用FASTRAK三維電磁追蹤定位系統蒐集受試者伸臂動作之資料，並以MATLAB程式運算得到動作學參數。所有臨床與動作學參數皆採用治療意向分析法(Intention-to-treat analysis)處理，再以SPSS 15.0軟體進行統計分析。結果：療效並無組間差異，但實驗組內之顯著變化包括傅格梅爾氏量表和上肢動作研究量表在訓練後進步並且維持到追蹤，動作活動量表在訓練後有顯著進步但未維持。動作學方面，實驗組在患側單邊伸臂動作學的結果只有部分參數有進步趨勢但未達顯著，而患側雙邊伸臂動作學的結果則在後測觀察到組內伸臂距離的顯著增加。針對兩組上肢動作受損較嚴重的受試者進行比較，發現實驗組之患側雙邊伸臂動作對稱性相關參數，進步量在追蹤期顯著進步，其中以動作平順度進步量最顯著。相關分析則發現上述動作學參數的進步與傅格梅爾氏量表前測分數有中度相關。分析急慢性的影響，則發現實驗組較嚴重者在傅格梅爾氏量表前測分數以及患側於雙邊動作時間的進步變化主要來自急性期受試者，但在急慢性對於動作學參數的變化沒有顯著影響。結論：中風患者接受三週任務取向雙側上肢運動訓練，可改善身體功能與結構、活動表現並維持到訓練後一個月，並於日常參與的使用量有短期效果；動作學方面主要反應在雙側動作距離的進步，具有任務特定(Task-specific)之效益，其中又以前測較嚴重者進步較為顯著，在訓練後的追蹤期間在雙側伸臂動作更加對稱而平順。本研究之效果是雙側上肢訓練本身還是附加之任務取向設計所造成，還需要往後研究更深入的探討。本研究所觀察到之進步主要為組內進步量以及組間進步量差異而且效益值較小，建議未來研究可以增加訓練時數與樣本數，或針對較嚴重的患者進行研究。

Background and purpose: Upper extremity hemiparesis is a leading cause of functional disability after stroke. Task-oriented approach focuses on affected arm has been a main stream for upper limb rehabilitation in physical therapy for stroke patients. Studies in the past decade have shown that bilateral arm training might promote recovery in impairement, functional activities and movement strategy. Yet most studies reporting positive training effect use new protocols of mechanically repetitive movements, not a goal-directed task. The aim of this study was to investigate the immediate and long term effect of a task-oriented bilateral arm training program on body function and structure, activities, participation and movement strategy for stroke patients. Method: In this single-blind randomized controlled trial, 38 patients with unilateral stroke were recruited and randomly allocated into two groups. Experimental group received task-oriented bilateral arm training (1 hour per session, 2 sessions a week for 3 weeks), and control group received dose-matched balance training. Outcome measures included Fugl-Meyer Assessment- upper extremity part (FMA-UE), Action Research Arm Test (ARAT), Motor Activity Log(MAL) and kinematic performances. Tests were conducted during baseline, immediately after training and at follow-up (one month after trining). Kinematic data were collected by FASTRAK 3D electromagnetic system and calculated by MATLAB sofeware. Statistical analysis were conducted by SPSS 15.0 with signicant level set at 0.05. Results: There were no significant differences between groups, but patients in experimental group showed signigicant intra-group difference including FMA-UE, ARAT and reaching distance of affected arm during bilateral reaching. Considering participants with more severe arm dysfunction, the experimental group improved significantly more during the follow-up period on the kinematic variables related to symmetry of bilateral reaching, especially for the smoothness of reaching. Those improvements moderately correlated with severity of FMA-UE. Among those participants with more severe dysfunction in the experimental group, acute patients only improved more on FMA-UE and the movement time during bilateral reaching, but chronicity did not effect change of other variables. Conclusion: Stroke patients received three weeks of task-oriented bilateral arm training improved more in body function and structure, activity, and also demonstrate task-specific improvement on kinematic variable of bilateral reaching. Patients with more severe upper limb dysfunction benefit more signifigcantly, especially on symmetry and smoothness of bilateral reching. Further studies are needed to optimize treatment dose, increase sample size, and to explore wheather task-oriented design could strengthen the effect of bilateral arm training.