腦性麻痺孩童單側上肢體感動作訓練系統之發展與療效評估：侷限誘發療法之創新方案

Abstract

背景 腦性麻痺為最常見造成孩童生理失能的原因，而腦性麻痺孩童常有上肢動作功能缺失，這些上肢功能缺失會進而影響孩童的日常生活參與及獨立性。侷限誘發療法是近代備受矚目且有效的上肢介入方式，並已被證實能有效改善腦性麻痺孩童的上肢動作功能及提升日常生活表現，然而此治療方法常會引起孩童的挫折進而缺乏治療參與動機。近年來有許多新興的治療方法，包含使用虛擬實境系統作為治療的媒介，並已被廣泛運用在復健治療中，然而使用虛擬實境之療效研究結果仍不太一致。因此本研究目的為開發一套為腦性麻痺孩童所設計的有趣並具療效之單側上肢體感動作訓練系統，同時驗證其可行性及療效。 方法 本單側上肢體感動作訓練系統之設計重點主要是奠基於侷限誘發療法的原則，同時結合動作學習理論之概念，並以Kinect作為遊戲平台而設計。本研究共分成兩個部分，分別為：驗證所開發的體感動作訓練系統之可行性，以及了解其療效。第一部份的可行性研究，共有10位半側偏癱腦型麻痺孩童參與此研究，所有孩童會接受20分鐘的遊戲測試，在遊戲過程中會同時使用六台紅外線高速攝影機記錄孩童的上肢各關節之活動角度，實驗結束後會經由問卷與訪談的方式探討孩童接受體感動作訓練系統的使用者經驗。除此之外，為瞭解實際介入的可行性，共收了5位腦性麻痺孩童進行36小時的體感復健訓練系統之介入，記錄孩童在治療過程中體感訓練系統記錄每次介入之遊戲參數。第二部分的療效研究，共納入10位年齡介於5~12歲之腦性麻痺孩童，並將孩童隨機分派至一般侷限誘發療法組以及體感侷限誘發療法組。所有孩童皆接受每次2~2.5小時，每周2~3次，為期8周的居家治療。為瞭解治療效果，所有孩童在治療前及八周治療後，皆會接受運動學以及功能性評估工具之評估。 結果 在20分鐘的可行性研究結果顯示，本研究所設計的體感復健訓練系統確實提供腦性麻痺孩童一新型態的復健訓練方式，能提升孩童患側上肢的使用量，綜合問卷與訪談的結果，所有孩童都覺得遊戲過程中的氛圍很快樂且認為此復健訓練方式很有趣並感到很安全。而在36小時的可行性研究結果顯示，所有孩童經由體感復健訓練系統介入後，都能有效提升遊戲中的動作成功率以及平均完成的時間。而將體感復健訓練系統之療效和一般侷限誘發療法相比，孩童接受體感復健訓練系統之介入，能較有效改善患側上肢的動作時間及動作計畫；而孩童接受一般侷限誘發療法之介入，則較能提升患側上肢的最大速度以及雙側協調的表現。 結論 上述結果支持此上肢復健體感訓練系統為可行且具安全性的訓練方案，可提升腦性麻痺孩童的復健參與動機，同時提供密集的動作訓練。所有孩童在八周的介入後，皆能有效提升其上肢動作功能。其中，孩童接受體感復健訓練系統之介入，能較有效的提升其患側手的動作表現；而在一般侷限誘發療法組之孩童，則較能將治療過程中所獲得類化到雙手協調。總結而言，此上肢復健體感系統不僅能提升孩童的動機並能有效提升孩童上肢動作表現，也能減少治療師的負擔，因此是一個較可行的侷限誘發療法之新興方案。

Cerebral Palsy (CP), a common cause of physical disability in children, often impairs upper extremity (UE) function, which limits children’s participation in activities of daily living and independence. Recently, constraint-induced therapy (CIT) is one of the effective approaches to improve UE function. However, children often feel demotivated during this therapy. Virtual reality (VR) has been confirmed to improve this disadvantage and widely been used for rehabilitation. However, the effectiveness of VR system is still controversial. VR system combining with effective rehabilitation approach, such as CIT, may be a feasible approach for designing cost-effective motor rehabilitation program for children with CP. Thus, this study was aim to: (1) develop a Kinect-based CIT and to evaluate its feasibility and safety; (2) evaluate the effectiveness of Kinect-based CIT. Kinect-based CIT was developed by the principle of CIT, which emphasize on restraining the less affect UE and intensive, repetitive training of the more affected UE. Moreover, the components of motor learning would be considered to design the training protocol. In this study, we conducted two experiments. One was to valid the feasibility of Kinect-based CIT and the other was to confirm the effectiveness of this program for children with CP. In feasibility study, 10 children with hemiplegic CP (HCP) were enrolled. Children played the game for 20 minutes and range of motion (ROM) of shoulder, elbow, wrist and trunk were evaluated. After the gameplay, children completed a questionnaire of their gameplay experience. In addition, we examined the game recorded variables to evaluate the gameplay performance of 16-session-intervention. In effectiveness study, 10 children with CP, aged from 5-12 years old, were recruited in this study. Children were randomly assigned to Kinect-based CIT group or home-based CIT group. All the participants received the same treatment duration: 2-2.5 hours/ day, 2-3 days/ week, for 8 weeks. To evaluate the treatment effects, all children underwent kinematic analysis of unimanual and bimanual reaching tasks and functional outcome measures for activities of daily living before and immediately after the intervention. In feasibility study of 20-minutes gameplay, all of the children increased the amount of use of their more affected limb and reported an enjoyable and safe experience during gameplay. Moreover, in feasibility study of 36-hours gameplay, the output data of two games showed that successful rate and average completed time would improve over time. In preliminary effectiveness study, children with CP in both groups had improvements in UE motor functions. Comparing to Home-based CIT group, Kinect-based CIT group had more improvements in movement time of their more affected UE and better motor planning. Home-based CIT group improved more in peak velocity and bilateral coordination. In conclusions, our developed Kinect-based CIT was a feasible motor rehabilitation program for children with CP. Kinect-based CIT group had greater improvements in motor performance of their more affected UE. Home-based CIT group improved more in bilateral coordination. In brief, these two kinds of therapy were both effective to improve motor performance in children with CP. However, the Kinect-based CIT could also enhance motivation of children and decrease load of therapists. Thus, this program was more feasible to apply in clinic or home.