單側與雙側複合療法應用於慢性中風病人在動作功能、日常功能以及動作控制策略上的療效初探：個案系列研究

Abstract

背景與目的：當代神經復健如：侷限誘發療法、雙側肢體訓練以及機器療法已被證實對於慢性中風病人有正向的效益，其中機器療法後續建議輔以功能導向訓練讓習得的動作控制策略得以轉移到日常生活中。單雙肢訓練模式對於中風患者有區辨的訓練效果，另一方面，複合療法為前瞻性的治療方式，已被證實能增強治療效果，根據單雙肢練習模式以及複合療法的概念，複合單側機器療法與局限誘發療法以及複合雙側機器療法與雙側肢體訓練可提供臨床人員針對不同型態之中風病人給予合適的治療方案。 目的：本研究將初探單雙側複合療法對於慢性中風病人在動作功能、日常生活功能以及動作控制策略上的療效 方法：本研究採隨機、單盲之實驗設計，受試者將隨機分派到單側複合組（UHT，將接受單側機器療法與侷限誘發療法）、雙側複合組（BHT，將接受雙側機器療法與雙側肢體訓練）以及機器控制組 （RTG，將接受單、雙側機器療法），進行每週三天，為期治六週之治療，每次治療時間為90分鐘。成效評量分為臨床評估測驗、運動學分析以及加速規資料。臨床評估測驗包含傅格梅爾評估量表 (Fugl-Meyer Assessment, FMA-UE)、修訂版艾許沃斯評量表 (Modified Ashworth Scale, MAS)、醫學研究之肌力量表 (Medical Research Council, MRC)、沃夫動作功能測驗 (Wolf Motor Function Test, WMFT)、動作活動日誌 (Motor Activity Log, MAL)、功能獨立量表 (Functional Independence Measure, FIM)、Chedoke Arm and Hand Activity Inventory (CAHAI)、中風衝擊量表 (Stroke Impact Scale, SIS)。 結果：共七位受試者參與本研究，一位分派到單側複合組；三位分派到雙側複合組；三位分派到機器控制組，雙側複合組其中一位個案因身體不適（練習非本研究指派的訓練使得下肢肌肉拉傷）而退出本研究。臨床評估部分，就FMA-UE的相對改變量而言，一位機器控制組的個案達到最小臨床重要差異。就FMA-UE近端次量表而言，一位雙側複合組與一位機器控制組的個案接近最小臨床重要差異。從FMA遠端次量表而言，兩位機器控制組的個案，一位達到最小臨床重要差異；一位接近最小臨床重要差異。就FMA-UE量表之趨勢圖而言，機器控制組的FMA近端、遠端量表的改變量較大。就MAL的相對改變量而言，單側與雙側複合組的在MAL使用量次量表與MAL動作品質次量表的改變量較機器控制組大；同樣的在FIM量表的改變量上，單側與雙側複合組的改變量較機器控制組高。運動學分析部分，單側複合組在單手125%手長按鈴任務中的食指最大速度與食指運動時間等參數相對雙側複合組別有較佳的表現；雙側複合組在雙手125%手長按鈴任務中的軀幹標準化位移以及標準化動作單位相較於單側複合組有較佳的表現。加速規分析部分，雙側複合組在好患手手部使用次數與能量消耗的比值等參數對比其他組別有較佳的表現。 結論：本研究支持單側與雙側複合療法於慢性中風病人的動作功能、日常生活功能以及動作控制上之正向療效。研究結果顯示單側複合療法可能提升完成單手任務的時間效率；而雙側複合組可能提升近端軀幹的控制。此外，複合療法相較於未複合的純機器訓練對於日常生活功能可能有較佳的成效。

Backgrounds: To date, several therapies are shown to be effective in patients with chronic stroke such as constraint-induced therapy (CIT), bilateral arm training (BAT) and robot-assisted therapy (RT). CIT provides unilateral functional trainings by using a glove to restrict non-affected hand. Bilateral functional training can be offered through BAT by conducting symmetrical tasks with both hands simultaneously. RT provides high intensity, high repetitive and high accuracy motor training. Besides, task-oriented training is recommended after RT to transfer the gains of motor ability from RT to daily life performance. The differential effects between unilateral and bilateral practice modes had been demonstrated. As hybrid therapy is a promising therapy reported to promote additional effects, the combination of unilateral RT with CIT and bilateral RT with BAT may possibly transfer the learned motor control strategies provided by RT to daily life. Objectives: This study aimed to investigate the differential effects between unilateral hybrid therapy (UHT) and bilateral hybrid therapy (BHT). RT group (RTG) was set as control group to examine the additional effects of both hybrid therapies. Methods: Participants were randomly assigned to UHT, BHT or RTG groups. In the UHT group, unilateral RT and CIT were conducted. In the BHT group, participants received bilateral RT and BAT. Participants in the RTG group received only RT. Each participant was provided an intervention of 90minutes/day, 3 days/week for 6 weeks (a total of 18 sessions). Outcomes measures included clinical assessments, kinematic analyses and accelerometric measures. Clinical assessments including Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Medical Research Council (MRC), Motor Activity Log (MAL), Functional Independence Measure (FIM), Chedoke Arm and Hand Activity Inventory (CAHAI) and Stroke Impact Scale (SIS). Results: Total of seven participants were recruited to this study. One participant was allocated to the UHT group; three participants were distributed to the BHT group; three participants were allocated to the RTG group. Finally, six participants completed this study and analyzed. In relative change of FMA-UE total score, one participant in the RTG group reached the minimal clinically important change (MCID). From the prospective of relative change of FMA-UE proximal subscale score, one participant in the BHT group and one participant in the RTG group nearly reached the MCID of the FMA-UE proximal subscale. In relative change of FMA-UE distal subscale score, one participant in the RTG group reached the MCID of FMA-UE distal subscale and one participant nearly reached the MCID of FMA-UE distal subscale. Based on the line chart of FMA-UE score, the RTG group revealed more positive within-group trend than other groups. From the aspect of MAL score, the hybrid group (the UHT and the BHT group) showed relatively greater positive within-group trend than the RTG group in MAL changing scores. Likewise, the hybrid group revealed more positive trend than the RTG group in the FIM changing score. In kinematic analyses, endpoint control variables including index MT and index PV of the UHT group showed more advantageous trend than the BHT group in unilateral beyond reaching task; while, trunk NTD and trunk NMU in trunk control variables of the BHT group revealed more positive tendency than the UHT group. In the accelerometric measures, the ratio of vector magnitude and caloric consumption of the BHT group revealed greater positive trend than other groups. Conclusion: This study supports the potential positive effects of unilateral hybrid therapy and bilateral hybrid therapy on motor functions, activities of daily life (ADL) functions and motor control strategies in patients with chronic stroke. Based on the results of this study, the UHT group might benefit in temporal efficiency of unilateral task; the BHT group might receive progress in enhancing trunk control. Furthermore, the hybrid therapy might have better positive effects than RT in ADL functions.