經顱直流電刺激合併鏡像治療於中風復健之療效與時序效應：前驅研究

Abstract

研究背景：在現代任務導向手法中，鏡像治療相對侷限誘發療法與機器輔助治療節省人力與硬體成本，易於臨床環境中實行，且有許多文獻支持能夠刺激大腦皮質重組並有效提升肢體動作功能。此外，非侵襲性的腦刺激技術可以短暫的改變大腦興奮性與神經塑性，進而促進動作功能恢復。其中，經顱直流電刺激因攜帶方便、造價較低且使用相對簡易而開始被應用於中風復健領域。過去有許多研究將經顱直流電刺激作為前導治療 (priming)融入傳統復健治療與現代任務導向手法中，結果發現有許多因素可能會影響到此種複合療法的療效，包含經顱直流電刺激合併哪種治療以及給予電刺激的時間點 (如：先進行電刺激接續給予動作訓練或者電刺激同時進行動作訓練)。目前，探討經顱直流電刺激合併鏡像療法之療效研究仍然缺乏，此外探討有關經顱直流電刺激給予時間點之文獻存在著不一致的結果，有待進一步驗證。 研究目的：本研究之目的為： (1)探討經顱直流電刺激合併鏡像治療於慢性中風病人之療效； (2)探討經顱直流電刺激合併鏡像治療時，給予不同時間點之電刺激對於療效結果的影響。療效結果評量之面向包含動作功能、日常生活功能、生活品質以及運動學參數。 研究設計：雙盲隨機分派、前後測之安慰劑對照試驗。 研究方法：本研究招募9位受試者並隨機分派至以下三個組別： (1)經顱直流電刺激同時合併鏡像治療組 (n=3)、 (2)經顱直流電刺激接續合併鏡像治療組 (n=3)以及 (3)經顱直流電刺激合併鏡像治療安慰劑組 (n=3)。每組受試者均接受每週五天、每天1.5小時、連續四週共20次的治療。 成效評量：本研究的主要成效評量使用傅格梅爾動作評估量表之上肢次量表 (the upper extremity subscale of Fugl-Meyer Assessment, FMA-UE)、醫學研究會議之肌力量表 (Medical Research Council Scale for Muscle Strength, MRC)、諾丁漢延伸性日常生活功能量表 (Nottingham Extended Activities of Daily Living Scale, NEADL)以及中風影響量表 (Stroke Impact Scale, SIS)。次要成效評量包含沃夫動作功能測驗 (Wolf Motor Function Test)、修正版諾丁漢感覺評估量表 (Revised Nottingham Sensory Assessment, RNSA)、修正版艾許沃斯量表 (Modified Ashworth Scale, MAS)、Chedoke Arm and Hand Activity Inventory (CAHAI)以及運動學參數(Kinematic variables)。本研將使用描述性統計觀察個人以及組別間的進步趨勢。 研究結果：在主要成效評量方面，實驗組 (經顱直流電刺激同時合併以及接續合併鏡像治療組) 相較於控制組於FMA-UE、MRC以及NEADL有較多進步的趨勢。次要成效評量方面，實驗組在WMFT的進步趨勢較控制組明顯。運動學參數方面，實驗組在經過治療後其伸手按鈴的動作表現有進步的趨勢。若比較兩實驗組的時序效應，經顱直流電刺激同時合併鏡像治療組在WMFT的部分較有進步趨勢，而接續合併組則在MRC近端肌肉力量中較有進步趨勢。 結論：本研究的初步結果顯示經顱直流電刺激合併鏡像治療在增進個案的動作功能表現、肌肉力量、日常生活功能以及降低肌肉張力有正向的趨勢，此外，電刺激時序效應造成不同療效的趨勢則顯現在動作速度與品質、肌肉張力以及肌肉力量等面向。本研究為前驅研究，且樣本數不足，未來仍需招募更多受試者深入探討經顱直流電刺激合併鏡像治療的效益以及時序效應。

Background and Study Purpose: To augment the interventional benefits of MT (mirror therapy), one novel approach is to combine MT with tDCS to promote neuroplasticity. However, the differential effects of stimulation timing (concurrent combination vs. sequential combination) of tDCS is still open to question. This study aimed to investigate the benefits and time-dependent effects of tDCS combined with MT in motor rehabilitation after stroke. Methods: A randomized and double-blinded trial design with pretest and posttest assessments was conducted. Each of the eligible participants was randomly assigned to one of the following treatment groups: (1) tDCS combined concurrently with MT group (concurrent tDCS + MT), (2) tDCS combined sequentially with MT group (sequential tDCS + MT) and (3) Sham-tDCS combined with MT group (sham tDCS +MT). The participants received the intervention for 1.5 hours/day, 5 days/week for 4 weeks. Outcome Measures: The main outcome measures were the upper extremity subscale of Fugl-Meyer Assessment (FMA-UE), Medical Research Council (MRC) scale, Nottingham Extended Activities of Daily Living Scale (NEADL) and Stroke Impact Scale (SIS). The secondary outcome measures involved the Wolf Motor Function Test (WMFT), Revised Nottingham Sensory Assessment (RNSA), Modified Ashworth Scale (MAS) and reaching kinematics. Results: A total of 9 participants were enrolled and randomly assigned to the three groups. In the primary outcome measures, a positive trend was observed in the experimental groups (i.e., concurrent tDCS + MT and sequential tDCS + MT) in the FMA-UE, MRC, and NEADL. In the secondary outcome measures, a positive trend was found in the WMFT. The time-dependent effects between two experimental groups were found that the sequential tDCS + MT group could be in favor of the MRC whereas the concurrent tDCS + MT might be in favor of the NEADL and WMFT. Conclusion: The preliminary results showed the promise of tDCS combined with MT in improving motor function, muscle strength, ADL, and decreasing muscle tone. There appears a trend of time-dependent effects in the MRC and WMFT. More participants are needed to support this preliminary finding.