雙側上肢體感動作訓練方案於單側偏癱腦性麻痺孩童之療效

Abstract

前言: 單側偏癱腦性麻痺是常見的生理疾患，其上肢的功能損傷通常較下肢來的嚴重。除了動作能力不足外，亦觀察到其發展性漠視的表現。在上肢動作缺損當中，由於大多數日常生活活動需雙手操作，導致雙手協調問題影響生活獨立性甚鉅。雙側上肢密集訓練不只對於偏癱腦麻孩童的患側上肢功能有助益，更能改善雙手協調以及促進日常生活目標的達成。另一方面，虛擬實境屬於一種新興的療法，可提升治療動機和予以動作上的密集練習。然而，當實務應用於孩童身上，不論是雙側上肢密集訓練或是虛擬實境皆存在部分限制。有鑑於此，本研究團隊結合雙側上肢密集訓練和虛擬實境各自的優勢，研發出雙側上肢體感動作訓練方案。本研究目的藉由對照由治療師活動帶領形式的雙側上肢動作訓練，以驗證雙側上肢體感動作訓練方案於上肢動作控制策略、日常表現的動作功能、活動參與度上的療效。 方法: 本研究屬單盲的隨機控制試驗。招募20位5至12歲的單側偏癱腦性麻痺孩童(平均年齡: 8.05 ± 1.73歲)。受試者被分配至兩組雙側上肢動作訓練方案，體感遊戲形式或是治療師形式，各有10位孩童。體感遊戲形式包含對稱雙手遊戲的「烘焙大師」以及不對稱雙手遊戲的「冰果大師」。為了檢驗成效，本篇將雙側上肢體感動作方案當中的輸出資料納入成效考量。其他比較兩組的成效指標包含如下: (1)動作控制策略，透過執行伸手及物任務量測; (2)動作功能成效指標包含修訂版兒童動作活動量表(Pediatric Motor Activity Log-Revised, PMAL-R)、兒童雙側手功能量表(ABILHAND-Kids); (3)活動參與度方面則有活動參與度問卷(Engagement Questionnaires, EQs)作為衡量依據。本研究使用共變異數分析做為檢驗兩組的組間治療差異，而配對T檢定則用於測量兩組分別於治療前後的組內差異。 結果: 本研究招募之學齡孩童，兩組的基本人口學和臨床變項無顯著差異(p < 0.05)。8週介入後，兩組在單側和雙側上肢動作控制策略皆有正向的變化，如: 患側手的動作品質進步(體感遊戲形式: p = 0.032, d = -0.80; 治療師形式: p = 0.004, d = -1.22)。然而在其他面向兩組仍存有不同的助益，體感遊戲形式方案具有較佳的患側手動作準備效率(即: 反應時間較短: p = 0.108, η2 = 0.15); 另一方面，治療師形式方案在患側手的動作效率和力量控制則有較多的進步(即: 動作時間較短, p = 0.158, η2 = 0.11; 尖峰速度較大, p = 0.208, η2 = 0.09)。至於雙側協調，治療師形式方案有較好表現，包含: 雙手動作重疊時間較多(p = 0.214, η2 = 0.09)和雙手結束動作時間差較少(p = 0.124, η2 = 0.13)。儘管如此，兩組在日常生活的動作功能上具有相當的進步幅度，不論是患側手的使用頻率(p = 0.37, η2 = 0.05)或動作品質 (p = 0.96, η2 < 0.01)，且雙手執行難度有降低(p = 0.83, η2 < 0.01)。此外，從烘焙大師和冰果大師的輸出資料分析中可看出體感遊戲組的孩童在動作表現有所增進(8週內的遊戲成功率提升和平均動作時間降低)。最後，除了動作指標，活動參與度問卷則呈現出兩組的單側偏癱腦性麻痺孩童在介入期間皆維持高度的活動動機。 結論: 雙側上肢體感動作訓練方案是兼具娛樂性與雙側上肢密集訓練原則的介入途徑。在提升患側手動作控制策略和日常生活的動作功能上，具有與治療師形式的雙側上肢密集訓練相當的成效。然而在雙側協調促進的方面，可嘗試將實體媒材融入虛擬實境中，以達到更佳的療效。整體而言，雙側上肢體感動作訓練是可行且有效的方案，可進一步應用於臨床或是居家環境當中。

Introduction: Unilateral cerebral palsy (UCP) is a common pediatric disorder with the affected upper extremity (UE) being more influenced than the lower extremity. Furthermore, the phenomenon of developmental disregard is also being observed. However, among UE motor impairments, problems of bimanual coordination may much impact independence performance in daily life for many activities are bimanual. Bimanual intensive training (BIT) has shown efficacy in improving not only the unilateral hand function of children with UCP but also bimanual coordination and goal attainment. On the other hand, virtual reality (VR) is a novel approach, acknowledged as being beneficial to motivation enhancement and intensive practice. However, both BIT and VR have some difficulties when applying to children with UCP; hence, our research team proposed a program called Kinect-based BIT combining the strengths of BIT and VR. This study aimed to examine the effectiveness of the Kinect-based BIT program, by comparing it with the therapist-based BIT program on UE motor, ADLs performance, and engagement. Methods: This study was a single-blinded and randomized controlled trial. A total of 20 school-aged UCP, aged 5 to 12, were recruited and had completed the BIT programs (mean age: 8.05 ± 1.73 years). Eligible participants received a 36-hour BIT program, either Kinect-based or therapist-based, 10 individuals in each group. The Kinect-based program comprises symmetrical and asymmetrical bimanual games, designed as “Master Baker” and “Master I-Vendor” respectively. To examine the effectiveness, the output data extracted from the Kinect-system is one of the outcome measures of Kinect-based BIT. Besides, other outcome measures which make comparisons between both groups are as follows: (1) motor control strategies, measured by a reach-to-grasp task (RTG); (2) motor function outcomes consist of Pediatric Motor Activity Log-Revised (PMAL-R) and ABILHAND-Kids; (3) Engagement Questionnaires (EQs) is included as engagement outcomes. The ANCOVA will be utilized to perform the between-group analysis, and a paired t-test will be conducted to investigate the within-group changes, pre- and post-test. Results: In each group, the individuals were matched for demographic and clinical characteristics (p < 0.05). After 8-week interventions, both groups demonstrated positive changes in the unilateral and bilateral UE motor control strategies, such as greater movement smoothness of the affected hand during forward-reaching (Kinect-based BIT: p = 0.032, d = -0.80; therapist-based BIT: p = 0.004, d = -1.22). But slightly different benefits also could be seen, that Kinect-based BIT showed better movement preparation efficiency of the affected hand (i.e., less reaction time, p = 0.108, η2 = 0.15); on the contrary, therapist-based BIT gained more improvements on movement efficiency and force control of the affected hand (i.e., less movement time, p = 0.158, η2 = 0.11; higher peak velocity, p = 0.208, η2 = 0.09). Moreover, the results of the bimanual kinematics revealed that therapist-based BIT had better bimanual coordination performance than Kinect-based BIT, such as normalized overlapped-movement time of two hands (p = 0.214, η2 = 0.09), and normalized goal synchronization (p = 0.124, η2 = 0.13). However, two groups had comparable effects on motor functions of the affected hand in daily livings, either on higher amount of use (p = 0.37, η2 = 0.05) or enhanced quality of movements (p = 0.96, η2 < 0.01) assessed by PMAL-R. Furthermore, fewer difficulties while executing bimanual tasks also assessed by ABILHAND-Kids (p = 0.83, η2 < 0.01). Referring to the data recorded from the Master baker and Master I-Vender, higher success rates and less average movement time in 8 weeks were also evidence for the enhanced motor performance of the children in the Kinect-based BIT group. Lastly, except for the motor outcomes, EQs documented that two groups of the children with UCP maintained great and similar motivation responses during the intervention. Conclusion: Kinect-based BIT is an entertaining and BIT-specific intervention, which had comparable treatment effects with therapist-based BIT on aspects of motor control strategies of the affected hand, and enhanced motor function can be observed in daily activities. However, facilitation of the bimanual coordination might be further improved by integrating physical materials into a virtual context. In conclusion, Kinect-based BIT would be a feasible and effective program to apply in clinical settings or home-based environments.