鏡像治療前導擴增實境於中風復健之隨機控制試驗

Abstract

背景：中風是導致長期失能的重大疾病，亟需有效介入以改善中風後之失能。近年許多研究採納鏡像治療提升復健成效，並可藉其誘導作用，結合其他方案，形成複合療法，可望增益治療成效。藉助輔助科技之快速進展，中風復健援用擴增實境等互動式運動遊戲，提供豐富情境、即時回饋與互動性，可提升使用者參與動機，近年來應用互動性科技之中風復健文獻不斷累積，研究發現顯示擴增實境可望改善中風患者之動作損傷與失能。鏡像治可透過單一療法與複合療法，通過視覺鏡像回饋提升雙側大腦動作皮質活性，從而提高偏癱側上肢的感覺運動功能；而擴增實境遊戲則通過互動遊戲增強動作練習，提升動作控制、軀體平衡及認知功能，兩者具互補結合潛力。據此，本研究探討鏡像治療前導擴增實境遊戲之中風複合療法改善上肢動作、感覺、平衡缺損，提升日常生活照護功能與中風後生活品質之成效，對比複合療法與擴增實境相較於常規復健治療之成效。 方法：本研究為單盲三臂平行隨機控制試驗，共計延攬36位第一次單側腦中風個案參與研究，隨機分派至鏡像治療前導擴增實境組（實驗組）、擴增實境組（對照組）或常規治療組（控制組）。三組受試接受每次90分鐘，每週三次，為期六週的治療介入。實驗組之受試者接受40分鐘的鏡像治療，接著接受40分鐘擴增實境練習，最後進行10分鐘功能練習。對照組則是進行80分鐘之擴增實境練習後，進行10分鐘功能練習。控制組則接受80分鐘的常規治療，之後進行10分鐘之功能練習。每位受試者共計接受三次的評估：前測、後測與追蹤測。主要療效評估工具為傅格梅爾上肢評量及伯格氏平衡量表。根據國際健康功能與身心障礙分類系統之架構，納入修訂版諾丁漢感覺評估量表、柯氏上臂與手部活動評量表與中風衝擊量表第三版作為次要療效指標。另外，將在每次治療前後進行不良反應監測（視覺類比疼痛與疲憊量表以及施力程度自覺量表）。 結果：經過為期六週的治療之後，三組受試者在傅格梅爾上肢評量、伯格氏平衡量表、柯氏上臂與手部活動評量表與中風衝擊量表第三版顯示統計學上的顯著改善。在主要療效評量的組間比較上，鏡像治療前導擴增實境組在傅格梅爾上肢評量上顯著優於控制組（p = 0.043），而擴增實境組則在伯格氏平衡量表上成效達到大的效果量，且顯著優於其他兩組（p = 0.004）。次要療效評量的組間比較上，鏡像治療前導擴增實境組別在觸覺、本體覺以及辨物覺皆有顯著前後測改變，且在觸覺的組間比較上顯著優於其他兩組（p = 0.027）；擴增實境組則在觸覺、本體覺及辨物覺呈現治療後的顯著改善。其他感覺分項雖未達組間顯著差異，但呈現中度以上之效果量，且這些效益大多有延續至三個月追蹤測的趨勢。本研究並無發現任何不良反應。 結論：研究結果發現，鏡像治療前導擴增實境療法與擴增實境療法皆有助於提升中至重度動作損傷中風患者之感覺動作功能、平衡功能表現，促進雙側上肢任務表現與生活品質。此外，兩種療法各有其裨益，鏡像治療前導擴增實境之療法在上肢動作損傷之改善與雙側上肢動作表現、以及觸覺功能的改善優於單一療法；而擴增實境對於平衡功能之改善具優勢。本研究支持鏡像治療前導擴增實境之療法及擴增實境療法的效益，研究結果顯示臨床使用時，應考量患者之優先目標選擇適切的療法，實施精準復健。囿限於有限的樣本數，本研究發現需要謹慎解讀，並依據統計檢定力分析，推估後續研究所需樣本數，進行更進一步的驗證。

Background: Mirror therapy (MT) and augmented reality (AR) are gaining popularity in stroke rehabilitation. MT utilizes mirror visual feedback to promote bilateral brain coupling and increase primary motor cortex excitability. AR offers an interactive context of practice for promoting motor and cognitive recovery. MT and AR may complement each other for hybrid interventions in stroke rehabilitation. The aims of this study were to investigate the differential benefits of AR compared to conventional therapy (CT) and to evaluate the efficacy of MT-primed intervention versus AR alone for individuals with stroke. Method: Thirty-six stroke survivors were randomly assigned to the MT-primed AR group (MT+AR), the AR group (AR), or the CT group. Each treatment session was 90 minutes, 3 times a week, for 6 weeks. All assessments were administered before, immediately after, and 3 months after treatment. Primary outcome measures were Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and the Berg Balance Scale (BBS. Secondary outcome measures were the revised Nottingham Sensory Assessment (rNSA), Chedoke Arm and Hand Activity Inventory (CAHAI), and Stroke Impact Scale Version 3.0 (SIS). Adverse events were monitored before and after each session. Results: After six weeks of treatment, three groups demonstrated significant improvements in the FMA-UE, BBS, CAHAI, and SIS. In the between-group comparisons, MT+AR demonstrated a significant advantage in the FMA-UE (p = 0.043). On the other hand, AR showed greater improvements in the BBS (p = 0.004). Regarding secondary outcome measures, MT + AR exhibited significant changes in rNSA, with a notable advantage in tactile sensation in between-group comparisons (p = 0.027). Despite no significant between-group difference in other assessments, the effect sizes were generally moderate or higher. Most of these changes were retained through the three-month follow-up. No adverse effects were observed. Conclusion: Both MT+AR and AR effectively enhanced sensorimotor functions, balance, task performance, functional independence, and life quality in patients with stroke with moderate to severe motor impairments. Each therapy demonstrated its strength: MT+AR was more beneficial for improving upper limb motor function and sensory function, while AR excelled in balance and functional mobility. Clinical therapists should consider stroke survivors’ goals and select appropriate intervention protocols.