前庭物理治療對梅尼爾氏症患者的療效研究

Abstract

[前言背景]梅尼爾氏症是導致眩暈的原因之一，儘管該疾病僅占耳鼻喉科門診的1- 4 %，但因梅尼爾氏症疾病長時間的症狀造成慢性前庭功能退化，患者的平衡、姿勢控制及生活品質皆較一般健康人差。過去已有少數文獻提出梅尼爾氏症患者可因接受前庭物理治療或姿勢控制訓練而減低頭暈和姿勢不佳的症狀，然而前庭物理治療對梅尼爾氏症患者的最低有效劑量及長期療效仍尚未明瞭。本研究目的在探討前庭物理治療運動訓練對非急性期梅尼爾氏症患者的平衡姿勢控制、步態、活動信心以及自覺頭暈狀況等四方面是否比僅接受藥物治療的控制組個案在前後測以及一個月後的追蹤測驗時有顯著較佳之療效。 [方法]本研究於民國102年於台大醫院耳鼻喉部徵召非急性期梅尼爾氏症患者共10名。以隨機分組控制實驗將個案分為介入組5名與對照組5名。對照組患者接受常規的門診藥物治療。介入組個案除了藥物與衛教外，還接受一週一次，為期一個月，由治療師個別化指導的前庭功能訓練運動，輔以每日30分鐘的居家前庭物理治療運動介入。兩組受試者均於簽署研究同意書後進行初測，再於一個月後接受後測、並於第二個月後接受追蹤測驗。初測蒐集兩組受試者人口學資料及過去病史，前後及追蹤測驗使用動態電腦姿勢平衡儀、動態步態指數、活動平衡信心量表及頭暈障礙問卷等做為評估工具。 [結果] 介入組的平均年齡為51歲，控制組的平均年齡為69歲，控制組的受試者年齡顯著比介入組年長(P =0.032)。介入組3位受試者已被診斷為梅尼爾氏症2至4年，2位則是被診斷為梅尼爾氏症達5年以上；控制組的受試者中2位受試者被診斷為梅尼爾氏症未滿3個月，3位受試者則是已長達五年以上，然兩組受試者平均罹病時間長短無顯著差異。兩組受試者中皆有雙側確診型梅尼爾氏症患者，介入組中有3位(60%)，而控制組中有2位(40%)。在居家運動部分，介入組的所有個案皆有達到百分之九十以上的高遵從度。兩組受試者於實驗前的動態電腦姿勢平衡儀、動態步態指數、頭暈障礙量表成績、及活動平衡信心量表成績皆未達顯著差異。研究結果顯示有頭暈及平衡不佳的非急性發作梅尼爾氏症患者經過一週一次，持續四週的個別化的前庭物理治療，可使感覺整合測驗中閉眼接受地面干擾情境下由36.5分進步至54.5分(P =0.02)，在張眼接受地面及視覺干擾情況下則由31.5分顯著進步至61.1分(P =0.04)；在前後方向的移動速度由每秒2.9度顯著進步至每秒3.6度(P =0.04)，活動平衡信心成績平均由訓練前74.3分進步至88.1分(P =0.04)，並且介入組受試者於一個月及兩個月時皆較控制組受試者服用較少比例的藥物。然而介入組的個案在各方向的初次最大移動距離及最大移動距離僅有微幅上升，動態步態指數則由實驗前平均21.6分進步至22.6分(P =0.17)，頭暈障礙量表測試分數平均由54.3分降至24.4分(P =0.17)，皆未達到統計上的顯著。 [結論] 本研究在梅尼爾氏症患者中證實在有頭暈及平衡不佳的非急性發作梅尼爾氏症患者經過一週一次，持續四週的個別化的前庭物理治療，可增進視覺及體感覺干擾下的站立平衡，前後重心移動的速度和活動平衡信心，至於穩定度極限、動態步態指數及頭暈導致的生活功能障礙則較無顯著改善。相較於過去的研究，本研究僅設計1個月的前庭物理治療介入，同時因施測工具的天花板效應以及受試者中有一位偏頭痛患者，使本研究結果和過去研究結果稍有不同。建議未來研究可拉長物理治療介入時間，並結合前庭物理治療的機制和患者的進步程度探討受試者進步的關鍵時間點，才能以最短的療程給予更有效的治療。

[Background] Meniere’s disease is one of the causes of vertigo and can lead to long term disability in some patients. Although the disease accounted for only 1-4% in patients visiting Department of Otolaryngology, patients with Meniere’s disease suffer from imbalance, poor postural control and poor quality of life due to long term symptoms and deteriorating vestibular function. A few articles had proposed the effect of vestibular physical therapy and postural control training on relieving symptoms and improving quality of life in patients of non-acute onset Meniere’s disease. However, evidence on minimum effective dosage and long term effects of vestibular physical therapy in patients with Meniere’s disease are scarce. This study aimed to investigate in patients with Meniere’s disease whether receiving one month of vestibular physical therapy is better than receiving medication treatment alone in aspects of postural control, gait, balance confidence and dizziness symptoms. [Method] This study included a total of 10 qualified participants referred from the Department of Otolaryngology in National Taiwan University Hospital from July 2013 to October 2013. Five participants were randomized into the intervention group and 5 were randomized into the control group. The control group received medication treatment prescribed by doctors; the intervention group received individualized physical therapy sessions once a week lasting for one month in addition to medication treatment and patient education. After signing the informed consent, the demographic data and past medical history of each participant was collected and baseline assessment was given, and posttest and follow up assessment were performed respectively after one month and two month. Dynamic posturography of the Smart Balance Master system, Dynamic Gait Index (DGI), Activity-specific Balance Confidence scale (ABC scale) and Dizziness Handicapped Inventory (DHI) were chosen to be the assessment tools. [Results] Mean age for the intervention group was 51, and for the control group, 69. There was statistically significant age difference between the two groups (P =0.032). Three participants in the intervention group have been diagnosed of Meniere’s disease 2 to 4 years ago, and the other two have been diagnosed 5 years ago; Two participants in the control group have been diagnosed of Meniere’s disease in past 3 months, and the other three have been diagnosed 5 years ago. There was no statistically significant difference between two groups in symptom duration. There were three patients (60%) with definite bilateral Meniere’s disease in the intervention group and two (40%) in the control group. All patients in the intervention group adhered to 90 percent of prescribed home exercise. There were no statistically significant between two groups in baseline assessment of Dynamic posturography of the Smart Balance Master system, DGI, ABC scale and DHI. After once a week and lasting one month of vestibular physical therapy, the patients with Meniere’s disease improved their performance in sensory organization test condition 5 from a score of 36.5 to 54.5 (P =0.02) and condition 6 from a score of 31.5 to 61.1 (P =0.04), and the velocity of rhythmic weight shift improved from 2.9 deg/sec to 3.6 deg/sec (P =0.04), and in ABC scale from a score of 74.3 to 88.1 (P =0.04). In addition, the intervention group reported decrease medication intake compared to control group during posttest and follow up. However, although the intervention group also improved endpoint excursion and maximum endpoint excursion in weight shift directions, improved DGI from a score of 21.6 to 22.6(P =0.17), and also improved the DHI from a score of 54.3 to 24.4 (P =0.17), no statistically significant difference was found in these three items. [Conclusion] After once a week and a total of 1 month of individualized physical therapy, patients with Meniere’s disease improved their postural control ability which was demonstrated by improved postural stability under visual and sensory interference, increased anterior-posterior center of gravity displacement velocity, and improved balance confidence during daily activities. However, the intervention group did not experience significant improvements in increased displacement of center of gravity, in gait and in self-reported dizziness symptoms. This study was limited to short intervention time and ceiling effect of our measurement tools, and the results were also confounded by a patient with migraine, therefore leading to a slightly different results compared to previous studies. It is recommended that longer therapy duration and combining the mechanism of vestibular physical therapy would be beneficial to find out the critical point of therapy, thus leading to a more effective treatment.