任務導向巡迴訓練對亞急性期中風患者的下肢動作功能以及腦部塑性之療效：統合分析及初探研究

Abstract

動作損傷與行走功能障礙為中風患者常見之失能，而協助中風患者恢復行走功能一直是物理治療主要目標。根據研究顯示，任務導向巡迴訓練可以有效地改善慢性期中風患者的行走速度及行走耐力，但對於亞急性期中風患者的療效證據仍為不足。而下肢動作功能相關之任務導向巡迴訓練對於亞急性期中風患者大腦皮質脊髓徑結構完整性以及大腦主要感覺動作皮質區功能性活化的影響，目前亦尚未有研究探討。因此本研究主要目的為：（1）以統合分析方式探討任務導向治療模式對亞急性期中風患者下肢動作功能之療效；（2）初步探討四週的任務導向巡迴訓練對亞急性期中風患者在下肢動作相關功能（主要療效指標）、大腦皮質脊髓徑結構完整性與大腦主要感覺動作皮質區功能性活化（次要療效指標）之療效，以及一個月追蹤之長期療效。 本研究採統合分析方式探討現有文獻針對任務導向治療模式對亞急性期中風患者的下肢動作功能療效，並採評估者單盲隨機控制臨床試驗，徵召3位輕度至中度的亞急性期中風患者（實驗組：E1；控制組：C1與C2），以抽籤方式隨機分為實驗組與控制組，作為任務導向巡迴訓練對亞急性期中風患者療效的初探研究。兩組受試者皆接受為期四週，每週四次，每次60分鐘的訓練。實驗組的訓練內容為下肢動作功能相關之任務導向巡迴訓練，控制組則接受伸展運動及坐姿下的上肢活動訓練。兩組受試者在訓練前、訓練後、與訓練後一個月接受下肢肌力、下肢動作控制能力、行走能力、平衡能力、失能程度、與生活品質之臨床測試評估、以及擴散頻譜磁振造影與功能性磁振造影掃描。由於個案人數少，本初探研究結果亦加入另1位接受與實驗組訓練內容相同之前驅研究個案（實驗組：E2），實驗採敘述性統計描述個案訓練前後在療效指標上的變化。 統合分析結果顯示，任務導向治療模式能較其他治療模式有效地改善亞急性期中風患者之6分鐘行走距離（平均值差異為82.49公尺；95% 信賴區間：27.59-137.38；P = 0.003）以及舒適行走速度（標準化平均值差異為0.27；95% 信賴區間：0.03-0.52；P = 0.03）；在最快行走速度及柏格氏平衡量表的表現方面則任務導向治療模式組與其他治療模式組效果相當。初探研究之個案皆男性，年齡介於44.2到65.6歲，單側偏癱（左側偏癱3位；右側偏癱1位），中風時間為57-154天，實驗組及控制組各有1位為梗塞型中風診斷（E2和C1）以及1位出血型中風診斷（E1和C2）之亞急性期中風患者。初探研究結果則顯示，任務導向巡迴訓練對亞急性期中風患者在「國際功能、失能與健康分類系統」之活動及參與度層面之改變多為有意義的進步，控制組個案在臨床測試之評估則未看到此有意義的進步；在大腦塑性方面，實驗組個案與控制組個案大腦主要感覺動作皮質區功能性活化強度之改變顯示不同的腦部活化塑性，大腦皮質脊髓徑結構完整性則與訓練前無大幅度的變化。 本研究統合分析結果提供任務導向治療模式對於亞急性期中風患者下肢動作功能之實證醫學證據，而本初探研究則提供任務導向巡迴訓練對亞急性期中風患者下肢動作功能與腦部塑性之治療成效初步結果，可作為未來進行較大型之隨機控制臨床試驗及對亞急性期中風患者設計治療計畫之參考。

Recent studies have shown that task-oriented circuit training is effective in improving walking speed and walking endurance in patients with chronic stroke. However, the training effects of task-oriented approach in patients with sub-acute stroke remain unclear. It also remains to be explored regarding whether task-oriented training has effects on structural integrity of the corticospinal tract (CST) and activation patterns of the sensorimotor cortex (SMC) during ankle movements in patients with sub-acute stroke. Therefore, the purposes of this study were: (1) to investigate the effects of task-oriented training on lower extremity motor functions in patients with sub-acute stroke using meta-analysis; (2) to preliminarily investigate the effects of a 4-week task-oriented circuit training program on lower extremity motor functions (primary outcomes), the structural integrity of the CST of lower extremity motor fibers and brain activation patterns of the SMC (secondary outcomes) in patients with sub-acute stroke. We conducted a meta-analysis to examine the effects of task-oriented approach in patients with sub-acute stroke and a preliminary study of an assessor-blind randomized controlled trial with a total of 3 patients with sub-acute stroke (experimental group: E1; control group: C1 and C2). The participants were randomly assigned to the experimental group or the control group. All participants received 4 weeks of exercise training, which were 4 sessions per week and 60 minutes for each session. The experimental group received task-oriented circuit training to improve lower extremity motor functions. The control group received stretch exercises and upper extremity activities in sitting posture. Both groups received clinical asessments on lower extremity motor functions (primary outcomes), the structural integrity of the CST using diffusion spectrum imaging, and the cortical activation patterns of the SMC using functional magnetic resonance imaging(secondary outcomes) at baseline, post-training (week 4), and 1 month follow-up (week 8). Because of the small number of subjects, we also included one subject (E2) who received the same training programs as experimental group in our pilot study as one subject of the training group result. Training effects were descriptively analyzed for individual subjects. The meta-analysis results showed that task-oriented training led to significantly greater improvement than other training on 6-minute walking distance (mean difference = 82.49 meter; 95% confidence interval: 27.59-137.38) and comfortable gait speed (standardized mean difference = 0.27; 95% confidence interval: 0.03-0.52) in patients with subacute stroke. Our preliminary results showed that the experimental group achieved meaningful improvements in most of the primary outcomes but not for the control group. In addition, different brain reorganization patterns were observed in the two groups. The results of meta-analysis provide relevant clinical evidence for the effects of task-oriented training on lower extremity motor functions, and this preliminary study provides the pilot result for the effects of task-oriented circuit training on lower extremity motor functions, brain structural and functional plasticity in patients with sub-acute stroke.