任務導向平衡訓練合併感覺操弄對腦中風患者平衡功能與姿勢控制之療效研究

Abstract

腦中風患者常出現平衡能力不佳的情形，影響日常生活功能。近年來臨床物理治療進行平衡訓練的策略以任務導向手法為主流，研究指出經過任務導向模式訓練之後，中風患者的平衡功能、姿勢控制、平衡信心以及行走速度、耐力等都有明顯的進步。研究指出無法選擇正確的感覺訊息（包括視覺、前庭覺與體感覺）是中風患者無法維持平衡的原因之一，依據國際功能、失能與健康分類系統模式以及系統為基礎的任務導向模式概念，若以任務導向運動訓練加上感覺操弄，由於其產生的交互作用，對於不同感覺情境下的姿勢控制與平衡功能，應能產生正面療效。研究發現中風患者以16小時任務導向訓練加上感覺操弄後，結果顯示受試者的姿勢控制有顯著改善，但平衡功能是否改善則未知。其他學者的研究顯示，低至僅6小時之任務導向肌力訓練即可使平衡功能有顯著改善。為促進臨床效益，本研究欲探討6小時的感覺操弄之任務導向平衡訓練，是否能改善中風病患之姿勢控制與平衡功能等兩個層級的平衡能力。 本研究為施測者單盲隨機分組控制研究設計，在台大醫院復健部、神經部或其他醫院、社區及支持團體收案39名腦中風病患。所有個案完成前測評估後隨機分配到任務導向合併感覺操弄平衡之訓練組與雙側上肢訓練對照組，均接受每次60分鐘、每週2次共三週的訓練。在治療前、後與治療後一個月評估柏格氏平衡量表、計時起走測試、動態步態指標，以及電腦動態姿勢平衡儀之感覺整合測驗與八方向持續重心轉移測驗。本研究使用二維重複變異數分析及事後分析檢定兩組的差異；若前測值有差異，則將前測值作為共變數，進行二維重複共變數分析，並以皮爾森相關係數分析變項間與改變量間相關性。統計上顯著差異水平定為0.05。 本研究結果顯示前測時，兩組受試者除了感覺整合測驗的視覺同步與底板同步情境之平衡分數控制組高於實驗組外，其餘各參數在兩組間均無顯著差異。所有參數在訓練後均無顯著組間差異，但在柏格氏平衡量表、計時起走測試、動態步態指標、感覺整合測驗的平衡總分、底板同步、閉眼及底板同步、視覺同步及底板同步的平衡分數有顯著組內差異，且實驗組較控制組有進步較多的趨勢。 本研究無法證實感覺操弄任務導向平衡訓練對於中風患者在平衡功能與姿勢控制相較控制組的差異性，可能是受到受試者變異性、樣本數、評估工具的適當性和治療劑量與內容的影響。然而由結果可發現實驗組進步的趨勢較控制組明顯，表示感覺操弄平衡訓練對中風患者的平衡功能與姿勢控制改善有良好效益。

Imbalance is a major disability following stroke which contributes to the activity of daily living in these patients. In recent years, task-oriented approach has become a main stream for balance training in physical therapy for the stroke patients. Literature revealed that task-oriented approach may lead to significant improvements in balance function, postural control, balance confidence, walking speed and walking endurance. Impairment of sensory integration for balance is a major contributing factor for imbalance after stroke. Based on the concept of system-based task-oriented approach, a task-oriented approach balance function training combines sensory manipulation may lead to improvement in both balance impairment and balance function more efficiently, hence requiring less training time to result in significant improvement. Previous study showed that after a 16-hour task-oriented balance training with sensory manipulation, stroke patients improved their postural control. The effect on balance function was not investigated in this previous study. The aim of our study was to investigate the immediate and long term treatment effect of a 6-hour task-oriented balance training with sensory manipulation on postural control and balance function in stroke patients. The design of this study was a single-blind randomized controlled trial. The sample size was 39. Patients with stroke were recruited from the Department of Physical Medicine and Rehabilitation, Department of Neurology in National Taiwan University Hospital, other hospitals, community and family support groups. After consent, subjects were randomized to either the balance training group or a control training group. Both groups received 60 minutes/day, 2 days/week for a total of 3 weeks of exercise training. Outcome tests included the Berg Balance Scale, the Timed Up and Go Test, the Dynamic Gait Index and the dynamic posturography (Sensory Organization Test, Limits of Stability of the NeuroCom Smart Balance Master system). These tests were conducted during baseline, immediately after training and at 4 weeks after training. Two-way ANOVA with repeated measure followed by post hoc tests was used for analyzing the differences between two groups. A two-way ANCOVA was used to analyze the Equilibrium Score in the eyes open, sway referenced surround and support condition. The relationships between outcomes and changes were analyzed by Pearson’s correlation coefficient. The results were accepted as statistically significant at p<0.05. There were no significant group differences in baseline data except the equilibrium score in eye open, sway reference surround and support condition derived from the Sensory Organization Test. After the 6-hour balance training, no significant differences were found between experimental and control groups in all variables. Significant within-group improvement was noted in the Berg Balance Scale, the Timed Up and Go Test, the Dynamic Gait Index, the Composite Equilibrium Score, the Equilibrium Score in the eyes open, sway referenced support condition, the eyes closed, sway referenced support condition and the eyes open, sway referenced surround and support condition. Further analysis suggested small differences in favor of the experimental group. No evidence was found for the superiority of the task-oriented balance training with sensory manipulation in stroke patients. This was possibly due to the wide between-group variation, small sample size, appropriateness of outcome measures and the content of balance training program. However, balance function and postural control improved more in the balance training group than in the control group from pre-test to post-test. Therefore, this study showed that a 6-hour task-oriented balance training improved balance function and postural control in stroke patients. Further studies are recommended.