改良式侷限-誘發動作治療與病人的治療參與度對中風病人功能性結果、空間注意力與腦塑性影響之探討

Abstract

背景與目的： 近年來運用在中風患者身上的改良式侷限—誘發動作治療被認為能夠有效的改善動作功能，然而，此治療在其他方面，包括空間注意力與腦部重組的影響則尚未能確定。此外，個案對於治療的參與度也會是個影響療效的變因之一。本實驗的目的是要與傳統的職能治療做比較，以了解改良式侷限—誘發動作治療對於動作功能、半側忽略、運動學分析與腦部重組的效果。 方法：本研究採取兩組前—後測準實驗設計。共26名來自醫院復健部門，有輕至中度動作缺失的腦中風個案參與。12位個案參與改良式侷限—誘發動作治療，14位個案則是接受傳統職能治療，療程皆為每天兩小時，每週五天，連續三週。成效評量方面，「傅格—梅爾動作復原評估」與「動作活動日誌」用來評估上肢動作功能。上肢伸臂動作則以運動學分析其動作表現。「半測忽略測驗組」與「匹茲堡復健參與量表」則分別評量每一位參與者的空間注意力與參與度。最後，腦部重組的探討則是利用功能性磁振攝影。資料分析採取以下不同的方法: (1) 動作功能結果評估方面(包括「傅格—梅爾動作復原評估」與「動作活動日誌」)，會先計算效應指數之後採用單尾t檢定方式比較兩組間的差異，此外，也計算效應值r和檢定力。「匹茲堡復健參與量表」的分數則是各組平均後利用單尾t檢定比較組間差異。(2) 運動分析學的資料利用共變數分析來檢定研究假設，並計算每個變項的效應值f與檢定力。(3) 功能性磁振攝影的資料則是利用魏克森符號排序檢定來檢定每組前測與後測間的改變。臨床評估與腦部活化間的相關性則是利用皮爾森相關係數來檢定。顯著程度訂在p值小於0.05。 結果： 在相似的參與度下，改良式侷限—誘發動作治療組在上肢動作功能、使用頻率、品質均顯著優於傳統治療組。上肢伸臂動作的運動學分析方面，改良式侷限—誘發動作治療組表現出較有力且節省能量的動作模式。「半測忽略測驗組」部份，兩組沒有顯著差異。有七位個案(三位為改良式侷限—誘發動作治療組)接受功能性磁振攝影，在患側手執行功能性磁振攝影的動作時，兩組在治療後皆有活化移轉向同側腦的現象，但是呈現的模式不盡相同：改良式侷限—誘發動作治療組有整體同側腦的動作區域活化增加的趨勢，而傳統治療組則是對側腦活化(尤其是主感覺動作區)顯著減少。更進一步探討動作功能與腦部活化的關係，結果顯示「傅格—梅爾動作復原評估」與「動作活動日誌」進步量與對側腦的前動作皮質區活化的改變量有顯著的正相關。 結論：改良式侷限—誘發動作治療相較於傳統治療，可以改善上肢的動作功能，增加動作力量與減少能量耗損，並且對腦部重組有所影響。

Background and Purpose: The modified constraint-induced movement therapy (mCIMT) recently applied on patients with stroke was considered to be an efficient treatment to improve motor function. However, the effects of the mCIMT on other dominances including spatial attention and brain reorganization are still uncertain. Besides, the level of participation may also be a variable of efficacy and efficiency of the intervention. This study was to compare the effects of mCIMT with the conventional occupational therapy on motor function, unilateral neglect, kinematics analysis, and brain reorganization. Methods: The present study was a quasi-experimental, two-group pretest-posttest design. Twenty six stroke patients with moderate to mild motor deficit were recruited from rehabilitation department of hospital. 12 participants received mCIMT and 14 participants received conventional occupational therapy and interventions were both 2 hours per day, 5 days per week, and for 3 consecutive weeks. Outcome measures including the Fugl-Meyer Assessment (FMA), the Motor Activity Log (MAL) were used to evaluate the motor function of upper extremity. Movement performances on reaching were measured by kinematics system. The unilateral neglect test battery was used to test the spatial attention and the Pittsburgh Rehabilitation Participation Scale (PRPS) was adopted to determine the level of participation of each participant. Brain reorganization was explored by functional magnetic resonance imaging (fMRI). Data was analyzed by different methods: (1) for outcome measures of motor function (the FMA and the MAL), effectiveness index was calculated and one-tailed t tests were used to compare the differences between group and effect size r and power were also calculated. For the PRPS scores, average of each group is tested by one-tailed t test. (2) For kinematics information, ANCOVA was used to test the study hypothesis and the effect size f and power were calculated for each dependent variable. (3) For fMRI data, the Wilcoxon Signed Ranks test was used to test the changes from pre-test to post-test of each group. The correlation between clinical measures and brain activation characteristic was conducted using Pearson’s coefficient. Significance level was set at p < 0.05 Results: Under similar participation level, the mCIMT group exhibited significant better motor improvement and more powerful and energy efficiency during the reaching tasks than the conventional group. There was no significant different between two groups in the unilateral neglect test battery. 7 participants (3 of mCIMT group) took the session of fMRI. Both groups shifted the brain activation to the ipsilateral hemisphere during more-affected hand performance with different patterns. The mCIMT group exhibited trend on increasing total ipsilateral regions of interest (ROIs) activation and the conventional group significantly decreased contralateral cortex (especially sensorimotor cortex,SMC) activation. Participants were pooled to analyze the correlation between motor improvement and brain activation. More contralateral premotor cortex (PMC) activation voxels positively related to more improvement of the FMA and the MAL. Conclusions: The mCIMT may be an efficient intervention to motor function and brain reorganization.