結合A型肉毒桿菌毒素注射與改良式侷限誘發動作治療於痙攣型半側偏癱腦性麻痺台灣兒童之療效：病例報告

Combining Botulinum Toxin Type a Injection and Modified Constraint-Induced Movement Therapy in a Taiwanese Patient with Spastic Hemiplegic Cerebral Palsy: A Case Report

曾怡真(Yi-Chen Tseng) ； 蘇瑞雲(Jui-Yun Su) ； 林裕晴(Yu-Ching Lin)

《台灣復健醫學雜誌》 36卷2期 (2008/06) Pp. 119-125

https://doi.org/10.6315/2008.36(2)07

摘要

過高的肌肉張力常會使得痙攣型腦性麻痺兒童在動作上有許多的限制，造成日常活動的表現不佳，目前治療師多以傳統治療手法來處理，但療效有限。近年來的臨床研究顯示注射肉毒桿菌毒素可以降低張力且副作用少，而改良式侷限誘發動作治療主要是限制好手以達到密集訓練患側手的療法。本研究嘗試結合肉毒桿菌素注射及改良式侷限誘發動作治療兩種方法，藉由同時降低痙攣及提昇患手的使用率，以期提升整體療效。
個案爲一名九歲三個月的痙攣型半側偏癱腦性麻痺男童，於左上肢施打A型肉毒桿菌毒素後，每週到醫院兩次進行改良式侷限誘發動作治療，每次一小時；其餘時間由家長每日於家中提供一小時治療訓練，共計兩個月。本研究在注射前一週內、注射後一個月、兩個月、及四個月時進行共四次的評估，評估項目包括修正版阿敘俄斯量表、兒童身心障礙評估量表自我照顧領域、布巴斯歐斯索動作量表第八個次測驗、皮巴迪發展性動作發展量表第二版精細動作領域及上肢動作評分量表。
結果發現修正版阿敘俄斯量表在注射後一個月及兩個月明顯下降，其他評估量表分數在治療後一、二、四個月皆有進步，表示療效可維持到改良式侷限誘發動作治療結束後的兩個月。由此個案治療結果可知結合兩種療法可提升痙攣型半側偏癱腦性麻痺兒童的上肢動作功能，未來可增加研究個案的數量以期了解此療法是否適用於多數痙攣型半側偏癱腦性麻痺患者。

關鍵字

肉毒桿菌毒素 ； 改良式侷限誘發動作治療 ； 痙攣 ； 腦性麻痺

並列摘要

Hypertonia interferes with selective motor control and performance of activities in children with spastic cerebral palsy. At present, most therapists use traditional therapeutic techniques such as neurodevelopmental treatment or other approaches to handle the problems posed by cerebral palsy but the results are not very good. Many studies had shown that botulinum toxin type A (BTX-A) injection can control abnormal muscle tone effectively without major side effects. Constraint-induced movement therapy (CIMT) includes constraint of the sound side upper limb and intensive therapy of the affected limb. In order to reduce spasticity and enhance the use of the affected limb simultaneously, we combined these two therapies and investigated treatment feasibility.
Our patient was a 9 year-old boy with spastic hemiplegic cerebral palsy. He received BTX-A injection once and modified CIMT in left upper limb for two months. Outcome measurements were assessed before injection, and one month, two months, and four months after injection by the same investigator. The evaluation tools included the Modified Ashworth Scale (MAS), the Pediatric Evaluation of Disability Inventory (PEDI) self care domain: functional skills and caregiver assistance, the Peabody Developmental Motor Scale-2 (PDMS-2) fine motor quotient: grasping and visual-motor integration, the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) subtest 8, and the Upper Limb Physician's Rating Scale (ULPRS) modified version.
The results show that MAS scores decreased at one and two months but increased at four months after BTX-A injection. All other outcome measurement scores increased at one month, two months and four months. This means that the treatment effects can be maintained for at least two months after cessation of modified CIMT. We found that combining BTX-A injection and modified CIMT can improve function of the upper extremity. In the future, we plan to enroll more subjects to investigate if this technique is useful for children with spastic hemiplegic cerebral palsy.

並列關鍵字

botulinum toxin ； modified constraint-induced movement therapy ； spasticity ； cerebral palsy