不同劑量感覺操弄平衡訓練對輕度創傷性腦傷患者之療效研究

Abstract

研究背景及目的：輕度創傷性腦傷患者比例約佔所有腦傷患者的90%，其頭暈症狀與姿態不穩定的困擾可延續長達數月甚至更久的時間，影響患者功能與生活品質。有關輕度腦傷的頭暈與平衡不良之研究，目前雖有觀察性或藥物介入等研究，然而尚未見到相關的運動訓練研究結果。本研究目的在探討不同劑量感覺操弄平衡運動訓練對於改善輕度創傷性腦傷患者頭暈症狀及平衡能力的影響，以提供臨床治療師對於訓練此類患者時訓練計畫之參考。方法：本研究徵召15位受試者，隨機分配於低劑量運動組（每次30分鐘，每週二次，為期二週）、高劑量運動組（每次60分鐘，每週二次，為期二週）及控制組（未接受訓練）。所有受試者皆接受前測、後測（前測二週後）及追蹤評估（後測二週後）共三次評估。評估項目包括理學檢查（關節活動度、肌力、感覺功能）、電腦動態姿勢平衡儀平衡測驗（感覺整合測驗、八方向持續重心轉移測驗、規律重心轉移測驗）、動態步態指標及頭暈障礙量表。統計分析採用二維重複變異數分析檢驗三組於三個評估時間點的差異，若有顯著差異則進行事後分析。結果：二維重複變異數分析結果顯示組間無顯著差異，即本研究並未發現顯著訓練效益。但於感覺整合測驗的底板同步情境、閉眼及底板同步情境、視覺同步及底板同步情境的平衡分數及合成平衡分數、動態步態指標、頭暈障礙量表有出現訓練有效的趨勢。另外，統計分析發現顯著時間效應，亦即隨著時間，三組均出現明顯進步。在感覺整合測驗之底板同步情境、閉眼及底板同步情境、視覺同步及底板同步情境的平衡分數、八方向持續重心轉移測驗的後方向動作速度方面，後測比起前測以及追蹤比起前測有顯著的進步；合成平衡分數及動態步態指標總分方面，後測比起前測、追蹤比起後測、追蹤比起前測有顯著的進步；八方向持續重心轉移測驗中的右前方向反應時間方面，追蹤時比起前測有顯著進步；頭暈障礙量表總分則為追蹤比起後測、追蹤比起前測有顯著的進步。結論：本研究發現二小時或四小時的感覺操弄平衡訓練未能有效改善合併有頭暈症狀或姿勢不穩定的輕度創傷性腦傷患者的姿勢平衡、調整步態能力和頭暈主觀症狀。然而由於訓練組感覺整合測驗之底板同步情境、閉眼及底板同步情境、視覺同步及底板同步情境的平衡分數及合成平衡分數、動態步態指標、頭暈障礙量表變項出現較佳表現的趨勢，建議未來可以考慮先對慢性輕度腦傷患者進行不同劑量的感覺平衡訓練研究，以排除較明顯的隨時間而進步的因素並減少個案間的差異性，方能更為清楚回答本研究問題，以了解何種劑量的感覺平衡訓練方能有效促進腦傷患者之姿勢平衡、調整步態能力和頭暈主觀症狀。

Background and purpose: Mild traumatic brain injury (mTBI) patients occupies up to 90% of all TBI patients and their dizziness and unsteadiness symptoms and signs can last more than several months to years, hence limiting the function and welfare of the patients. Even though these symptoms are well documented, but exercise intervention trials attempting to reduce such symptoms have not been found. The purpose of this study was to investigate the immediate and long term effects of varying doses of balance training with sensory manipulation for patients with mTBI. Methods: Fifteen subjects were recruited and randomized into a low-dose exercise group (30 minutes/session, 2 sessions/week, 2 weeks), a high-dose exercise group (60 minutes/session, 2 sessions/week, 2weeks), or a control group (no training). All subjects were assessed three times (pre-treatment evaluation, post-treatment evaluation, and follow-up evaluation) with physical examination (range of motion, muscle strength, sensation), Smart Balance Master balance evaluation including sensory organization test (SOT), limits of stability (LOS), rhythmic weight shifting (RWS), dynamic gait index (DGI), and dizziness handicap inventory (DHI). Two way repeated measures analysis of variance (ANOVA) was performed to identify the effect of time and intervention on differences of dependent variables. If there was any significant result, post hoc analysis was performed. Results: There was no group effect among pre-treatment evaluation, post-treatment evaluation, and follow-up evaluation. It meant no training effect in this study. However, there were effective trends toward SOT (eyes open, sway referenced support condition; eyes closed, sway referenced support condition; eyes open, sway referenced surround and support; composite equilibrium scores), DGI, and DHI. In addition, statistical analysis showed significant time effect. It meant three groups improved significantly as time passed. There were significant improvements between follow-up and post-treatment evaluation, follow-up and pre-treatment evaluation on SOT (eyes open, sway referenced support condition; eyes closed, sway referenced support condition; eyes open, sway referenced surround and support), and LOS (backward movement velocity). There were significant improvements among pre-treatment, post-treatment, and follow-up evaluation on SOT (composite equilibrium scores) and DGI. There were significant improvements between follow-up and pre-treatment evaluation on LOS (right forward direction reaction time). There were significant improvements between follow-up and post-treatment evaluation, follow-up and pre-treatment evaluation on DHI. Conclusion: Patients with mTBI, dizziness and unsteadiness did not improve their postural equilibrium, gait adjustment ability, and subjective symptoms of dizziness by a two-hour or four-hour balance training with sensory manipulation. However, there were effective trends toward SOT (eyes open, sway referenced support condition; eyes closed, sway referenced support condition; eyes open, sway referenced surround and support; composite equilibrium scores), DGI, and DHI. It is proposed we can recruit chronic patients with mTBI in the future to rule out factors in natural recovery and variations among subjects. In this way, the research questions can be answered more clearly.