任務取向式平衡訓練對急性期中風病患姿勢控制與功能恢復之成效

Effects of Task-Oriented Balance Training on Postural Control and Functional Recovery in Patients with Acute Stroke

陳乃鈺(Nai-Yu Chen)

指導教授 ： 湯佩芳

國立臺灣大學/醫學院/物理治療學研究所/碩士(2009年)

https://doi.org/10.6342/NTU.2009.01208

摘要

背景與目的：急性期中風患者常伴隨有坐姿平衡能力下降及軀幹控制能力缺損的問題。過去針對任務取向式訓練之研究已指出，該種訓練方式可有效提升慢性期中風患者的平衡和行走能力，但關於任務取向式訓練應用於提升中風患者早期軀幹控制和平衡能力方面之療效，則尚缺乏文獻的探討。本篇研究的目的，即在探討為期兩週的外加式任務取向式平衡及軀幹控制訓練，對於急性期的中風病患是否安全、可耐受、且又有助提升其較晚期的姿勢控制和功能恢復。方法：本篇研究徵召十五名於台大醫院住院之中風病患，於中風天數十四天內(含)，依隨機分組為實驗組（8人）和控制組（7人）。實驗組於本研究進行期間除依院內慣例接受一般院內物理治療訓練外，額外接受為期兩週的任務取向式運動訓練；控制組則於本研究進行期間除依院內慣例接受一般院內物理治療訓練外，額外接受兩週之上、下肢被動性關節活動。對兩組皆記錄每位受試者之訓練時間、每次訓練前後之生命徵象變化、及不良反應事件（adverse event）；對實驗組並額外紀錄受試者之柏格自覺用力係數（Borg Rate of Perceived Exertion）。所有受試者於訓練前接受第一次臨床測試；訓練兩週後（訓練不滿兩週即出院者則於出院時）接受第二次臨床測試；並於中風天數滿三個月時再進行追蹤測試。三次的臨床測試內容皆包括肌力測試（Motricity Index, MI）、軀幹控制測試（Trunk Control Test，TCT）、中風病患姿勢控制評估量表（Postural Assessment Scale for Stroke Patients, PASS）、功能性行走分類評量（Functional Ambulation Category，FAC）、巴氏量表（Barthel Index，BI）、與修正版任金量表（modified Rankin Scale，mRS）。結果：實驗組與控制組各別於中風後7.9± 2.6天及9.4± 2.8天起開始接受總共各257± 45分鐘及267± 22分鐘的額外訓練。所有受試者皆完成本研究為期三個月的追蹤。兩組受試者在流行病學方面之特徵相似（p> .05）。實驗組接受較多的任務取向式訓練，而控制組接受較多的關節活動訓練，在特定訓練的時間上達統計上有意義的組間差異（p< .05），符合此研究設計原意。實驗組與控制組相比，並無較多的不良反應事件發生（p> .05）且受試者之生命徵象皆穩定。兩組在訓練後及中風天數滿三個月時的追蹤測試皆呈現進步（p< .05），但同時期各項測試的得分表現不具有組間差異（p> .05）。在訓練前至訓練後期間，實驗組在姿勢控制（PASS）的成效值（effect size, ES）比控制組高；在行走功能（FAC）方面實驗組已呈現統計上有意義的進步（p< .05），但控制組則尚不具有組內顯著差異的進步（p>.05）。在訓練後至追蹤期間，實驗組在肌力（MI）和日常生活自理能力（BI）的成效值比控制組高，但實驗組與控制組在姿勢控制的成效值則不具明顯差異。結論：為期兩週的外加式任務取向式平衡及軀幹控制訓練，對於急性期的中風病患而言是安全可行的。相對於外加式被動關節運動，外加式任務取向式平衡及軀幹控制訓練對於中風患者在姿勢控制能力的提升成效較佳，在訓練期間也較能促進行走能力的恢復。此療效可能與訓練項目的劑量與任務特異性（dose-related, task-specific effects）有關。未來仍需更大型的隨機臨床測試以進一步驗證此一研究結果。

關鍵字

急性期中風 ； 任務取向式 ； 平衡 ； 姿勢控制 ； 功能恢復

並列摘要

Background and Purposes: Impaired sitting balance and trunk control ability is a prevalent problem faced by patients with acute stroke. Task-oriented training has been shown effective in improving balance and ambulation ability of patients with chronic stroke, but effective clinical trials targeting at early trunk control or balance training are still scarce. The purposes of this study were to investigate whether an additional two-week, task-oriented, balance and trunk control training program started in the early phase of stroke during hospitalization would be not only safe and tolerable for patients but also effective on improving their postural control and functional recovery in the later phase. Methods: Fifteen patients admitted to the NTUH due to recent stroke (≦14 days post onset) were randomly assigned to the experimental (EXP, n= 8) or control (CON, n= 7) group. The EXP group received a two-week task-oriented training combined with the conventional physical therapy training, and the CON group received a two-week passive range of motion exercise combined with the conventional physical therapy training. The intensity of additional training in both groups was the same, which was 30 minutes a day, 5 days a week, for 2 weeks. Times spent on conventional and additional exercises and vital sign before and after additional exercise, were documented for each training session during the 2-week study intervention in both groups. For the EXP group, the Borg Rate of Perceived Exertion was documented. In addition, any adverse event during or after additional training in each group was also documented. Outcome measures, including the Motricity Index (MI), Trunk Control Test (TCT), Postural Assessment Scale for Stroke patients (PASS), Functional Ambulatory Category (FAC), Barthel Index (BI), and modified Rankin Scale (mRS) were collected at pre-training, post-training, and at 3 months after stroke. Results: The EXP and CON groups started to receive additional training program 7.9± 2.6 days and 9.4± 2.8 days post stroke onset for a total of 257± 45 minutes and 267± 22 minutes, respectively. Fifteen subjects completed all study phases according to their group assignment. The demographic characteristics at baseline were similar between groups (p> .05). As expected, subjects in the EXP group received more task-oriented training and the CON group received more range of motion exercise, which reached statistically significant differences (p< .05). The EXP group did not present more adverse events or unstable vital sign induced by additional intervention during the 2-week intervention as compared to the CON group (p> .05). There were no statistically significant differences between the groups at post-training and 3 months after stroke with regard to all the outcome measures (p> .05). Subjects in both groups significantly improved in these variables from pre-training to post-training and to the 3-month follow-up (p< .05). However, during the pre-training to post-training period, the EXP group had a larger effect size on the postural control ability (the PASS score); the EXP group also showed significant improvement in ambulation ability (the FAC) (p< .05) but the CON group did not (p> .05). During the post-training to follow-up assessments period, the EXP group had larger effect size on the muscle strength (the MI score) and the activities of daily living ability (the BI score), but the effect size of the PASS became similar between groups. Conclusions: The additional two-week, task-oriented, balance and trunk control training program combined with conventional physical therapy was safe, feasible, and tolerable in the early phase of stroke. Compared to the additional passive range of motion exercise program, this additional task-oriented training program led to more improvement on the postural control ability, and ambulation ability in the training phase. These effects may be due to dose-related, task-specific effects. Larger randomized controlled clinical trials are needed to further test these findings.

並列關鍵字

acute stroke ； task-oriented ； balance ； postural control ； functional recovery

參考文獻

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