透過您的圖書館登入
IP:3.238.161.165
  • 學位論文

機器輔助療法改善中風病患肌肉功能與日常活動的成效:治療強度效應之研究

Robot-Assisted Therapy for Improving Muscle Functions and Daily Life Activities in Patients with Stroke:The Effects of Treatment Intensity

指導教授 : 林克忠

摘要


背景:機器輔助治療是新興的神經復健療法,提供中風患者高密集重複性且精確控制的治療。近年來臨床試驗產量漸增,但目前尚乏定量適宜的訓練強度、頻率及治療方式。過去文獻回顧顯示機器輔助治療改善中風患者日常生活功能的證據仍有限。 目的:本研究採納不同強度之機器輔助療法,旨在探討訓練強度是否對慢性中風患者的動作功能、肌肉力量及日常活動產生不等療效。本研究合併機器輔助療法及功能性活動,企圖討論此合併療法是 否對中風患者之日常功能有提升的助益。 研究設計:本研究是單盲、多中心的隨機分派試驗。 受試者:20位中風時間超過6個月之慢性患者 治療介入:受試者隨機分派至三組,分別為:高密度機器輔助療法暨功能性活動組、低密度機器輔助療法暨功能性活動組及劑量配對復健治療組。受試者參與每次90至105分鐘、每週5天、持續4周的療程。 評估工具:主要的評估工具有:(1) 傅格梅爾量表(Fugl-Meyer Motor Scale of the upper extremity);(2) 修正式亞許沃夫量表(Modified Ashworth Scale);(3) 上肢肌力量表(Medical Research Council)。次要評估工具包含:(1) 動作活動記錄量表(Motor Activity Log);(2) 諾丁漢延伸性日常活動量表(Nottingham Extended ADL scale);(3) 中風衝擊量表(Stroke Impact scale)及腕動計(Accelerometer)。由未被告知受試組別的職能治療師在受訓後執行評估。 結果:機器輔助療法組在動作功能及肌肉力量改善優於劑量配對復健治療組,並且高密度機器輔助療法組與劑量配對復健治療組達到顯著差異 (p <.05)。高低密度機器輔助療法組於日常生活之患側使用量增加,達到高度效果值。腕動計數值顯示機器輔助療法組患者習得廢用現象呈現降低之趨勢。在生活品質方面,機器輔助療法組於中風衝擊量表(身體功能)改善顯著優於劑量配對復健治療組 ( p <.05)。並且,低密度機器輔助療法組在社交參與層面改善程度最大,達到高度效果值;反之,劑量配對復健治療組較治療前下降。此外,高密度機器輔助療法組及劑量配對復健治療組於治療後疲憊現象上升;反之,低密度組則是下降。 結論:機器輔助療法合併功能性活動相較於劑量配對復健治療可有效改善慢性中風患者之動作功能及肌肉力量,促進偏癱測的使用量,改善動作品質、工具性日常功能及提升生活品質。機器輔助療法的訓練強度為影響療效的重要因子,不同訓練強度的機器輔助療法對中風患者影響層面不一。高訓練強度可顯著提升中風患者的動作功能及肌肉力量,但是卻可能產生疲憊效應。而在日常功能及生活品質等自覺層面,治療強度則未必是同等重要的影響因子。我們認為若治療的目的是在促進功能性恢復及提升生活品質時,低密度的機器輔助療法搭配功能性活動既不造成患者負擔,也能達到預期的效果。

並列摘要


Background: Robot-assisted therapy is a brand-new neuro-rehabilitation technique. Randomized controlled trials that investigated the effects of robot-assisted therapy (RAT) in stroke survivors have accumulated in recent years, but the optimal dose of treatment intensity, treatment frequency and protocol still not be established. Besides, Previous systematic review showed that benefits of RAT for enhancing daily functions were less conclusive. Purpose: To compare the treatment effects of different intensity robot-assisted therapy and dose-matched usual rehabilitation on motor functions, muscle functions, daily functions and quality of life in stroke survivors with moderate to severe paresis. This study also explored changes in daily functions and patient-reported, health-related quality of life associated with robot-assisted therapy combined with functional task training. Design and Setting: A single-blind, multisite, randomized controlled trial was conducted. Participants: Twenty individuals who were six months post-stroke participated. Intervention: Stroke survivors participated in one of the three groups: (1) high intensity robot-assisted therapy; (2) low intensity robot-assisted therapy; (3) dose-matched usual rehabilitation. Both robot-assisted therapy groups combined with 15 to 20 minutes of functional task training in each session. All participants engaged in 90 to 105 minutes of training in each session, 5 times a week for 4 weeks. Measurements: Primary outcome measures were Fugl-Meyer Motor Scale of the upper extremity, Modified Ashworth Scale and Medical Research Council. Secondary outcome measures were Motor Activity Log, Nottingham Extended ADL scale, Stroke Impact scale and Accelerometer. Results: High intensity robot-assisted therapy group not only had significant greater increase in rating of Fugl-Meyer Motor scale than dose-matched usual rehabilitation group, but also in Medical research council. Stroke patients in robot-assisted therapy groups improved affected arm-use and quality of movements in their daily routines. Furthermore, the results of accelerometers showed the declining of learned-use phenomenon in participants of robot-assisted therapy group. However, the dose-matched usual rehabilitation group showed little evidence of increasing affected hand use. Surprisingly, both robot-assisted therapy groups reported improvements in IADL and quality of life, especially in the physical functions of Stroke Impact scale. Stroke survivors in low intensity robot-assisted therapy group enhanced more in social participation than other groups. In order to monitor potential adverse effects, we adopted the Multidimensional Fatigue Symptom Inventory (general). Among the three groups, high intensity robot-assisted therapy and dose-matched usual rehabilitation group demonstrated an increasing tendency in fatigue symptoms after undergone interventions. On the contrary, participants receiving low intensity robot-assisted therapy felt fatigue being relieved and much more energetic than before. Conclusion: Robot-assisted therapy combined with functional task training, in comparison with dose-matched usual rehabilitation, improved more on motor functions, muscle functions, daily functions and quality of life. Training intensity could be an important factor of efficacy, especially in the domains of motor and muscle functions. However, this may not be a crucial factor that related to patient-perceived quality of life. High intensity training may induce muscle fatigue, resulting in decreased self-perceived welling. In contrast, a just enough intensity of robot-assisted therapy not only could improve motor and muscle functions but also quality of life.

參考文獻


World Health Organization. (2001). International Classification of Functioning,
廖建彰、李采娟、林瑞雄、宋鴻樟(2006)。2000年臺灣腦中風發生率與盛行率
Lin, K. C., Wu, C. Y., Liu, J. S., Chen, Y. T., & Hsu, C. J. (2009). Constraint-induced        
Ansari, N. N., Naghdi, S., Hasson, S., Mousakhani, A., Nouriyan, A., & Omidvar, Z. (2009). Inter-rater reliability of the Modified Modified Ashworth Scale as a clinical tool in measurements of post-stroke elbow flexor spasticity. NeuroRehabilitation, 24, 225-229.
Ashford, S., Slade, M., Malaprade, F., & Turner-Stokes, L. (2008). Evaluation of functional outcome measures for the hemiparetic upper limb: a systematic review. Journal of Rehabilitation Medicine, 40, 787-795.

延伸閱讀