- 學位論文
家庭友善居家侷限誘發療法於腦性麻痺孩童之可行性與療效：一前驅試驗
Feasibility and Efficacy of the Home-based Family-friendly Constraint-induced Therapy on Motor and Psychosocial Outcomes in Children with Unilateral Cerebral Palsy: a Pilot Study
摘要
腦性麻痺為造成孩童生理失能最常見的原因，其中單側痙攣型腦性麻痺佔有相當的比例。單側痙攣型腦性麻痺患者常伴隨上之功能缺失，影響其日常生活參與甚鉅。侷限誘發療法為當今最有效之上肢介入方案之一，然而其治療密集性與侷限孩童患側手可能引發孩童的挫折、排斥侷限、缺乏動機及增加家庭負擔的負面影響。本研究提出家庭友善侷限誘發療法，其為一居家治療方案，採用適合學齡孩童的分散治療時程，並使用較溫和的侷限方式。本研究欲探討此介入方案之可行性與成效，且同時探討動作功能層面與社會心理層面之成效。 本研究為一單組前後測比較試驗。所有受試者皆接受八周的家庭友善侷限誘發療法（每日介入2-2.5小時，每周介入兩日）。動作功能成效指標包含第二版布魯茵克斯-歐西瑞斯基動作能力測驗 (Bruininks-Oseretsky Test of Motor Proficiency, BOT-2) 中的操作靈巧度分測驗、墨爾本測驗 (Melbourne Assessment, MA2)、修訂版兒童動作活動量表 (Revised Pediatric Motor Activity Log, R-PMAL)、兒童雙側手功能量表 (ABILHAND-kid)、兒童障礙評估量表 (Pediatric Evaluation of Disability Inventory, PEDI)、以及積木與盒子測驗 (Box and Block Test, BBT)。社會心理適應成效指標包含親職壓力量表 (Parenting Stress Index-Short Form, PSI-SF)、玩性測驗 (Test of Playfulness, TOP), 活動參與度問卷 (Engagement Questionnaire, EQ)、與滿意度問卷 (Client Satisfactory Questionnaire, CSQ)。本研究使用配對T檢定檢驗治療前後之差異，並以重複量測單變量分析檢定孩童在治療期間，每周動作功能的變化。 本研究共納入10位單側偏癱腦性麻痺孩童（平均年齡: 98.7 ± 27.1 月)，八周介入後，受試者之BOT-2分數（mean = 2.9 ± 2.2, p = 0.02, d = 1.33)、墨爾本測驗量測之關節活動度、動作精確度、靈巧度與流暢度測驗分數(mean ± SD = 0.8 ± 2.5, 0.7 ± 2.3, 0.1 ± 1.7, 1.7 ± 3.4; p = 0.34, 0.36, 0.85, 0.15; d = 0.32, 0.30, 0.06, 0.50) 、 ABILHAND-kid分數 (mean ± SD = 2.3 ± 5.14, p = 0.19, d = 0.45) 與PMAL-R之患側手使用頻率分數 (mean ± SD = 0.53 ± 0.79, p = 0.06, d = 0.68) 及患側手使用品質分數 (mean ± SD = 0.32 ± 0.72, p =0.16, d = 0.45) 皆有進步。此外，受試者之日常生活功能（由PEDI量測），包含功能性技巧 (mean ± SD = 1.00 ± 3.26, p =0.33, d = 0.31) 與照顧者協助程度 (mean ± SD = 2.09 ± 6.28, p =0.30, d = 0.33) 皆有進步趨勢。由BBT 可見，受試者的動作功能呈現每周的進步 ( F(2.476,17.335)=2.346, p = 0.117, η2 = 0.251)。社會心理適應部分，照顧者介入前後之親職壓力並無顯著差異。孩童的玩性（由TOP量測）有顯著進步 (mean= 18.10 ± 8.39, p<0.001)，且孩童在介入中維持高度的參與度。受試者對介入有高度滿意度。 家庭友善侷限誘發療法唯一可行且友善的治療方案，其對孩童上肢功能、表現與日常功能之成效據初步的驗證。本介入方案能提升孩童的玩性與治療參與度，且對照顧者親職壓力無負面影響。本研究結果顯示此方案值得後續研究繼續探討。
並列摘要
Introduction: Cerebral palsy (CP) is the most common cause of physical disability in young children, in which the unilateral spastic CP accounts for a considerable population and has decreased upper limb (UL) function that causes difficulties in participating daily life. Constraint induced therapy (CIT) is one of the most effective intervention aiming UL function in CP; however, it may induce adverse effects such as frustration, negative responses toward restraint, lack of motivation and increased family burden. This study aimed to examine the effect of a family-friendly CIT program, which is provided at home with distributed intervention schedule and gentle restraint method for children at school age. Both motor and psychosocial outcomes were investigated. Methods: The current study is a single group pre-post intervention trial. All participants received eight weeks of family-friendly CIT program (2-2.5 hours per day, twice a week). The motor outcomes included the Manual Dexterity Subtest of Bruininks-Oseretsky Test of Motor Proficiency (BOT-2), Melbourne Assessment (MA2), Revised Pediatric Motor Activity Log (R-PMAL), ABILHAND-kid, Pediatric Evaluation of Disability Inventory (PEDI), and the Box and Block Test (BBT). Psychosocial outcomes were measured by the Parenting Stress Index-Short Form (PSI-SF), Test of Playfulness (TOP), Engagement Questionnaire (EQ), and Client Satisfactory Questionnaire (CSQ). The paired t-test was used to investigate the difference between pre- and post-test. In addition, the repeated measure analyses of covariance (RM-ANOVA) was conducted to analyze the weekly change in motor function. Results: 10 school-aged children (mean age = 98.7 ± 27.1 mo) with hemiplegic CP were recruited. Participants showed improvement on UL function assessed by the BOT-2 (mean = 2.9 ± 2.2, p = 0.02, d = 1.33), the ROM, Accuracy, Dexterity, Fluency Subscale of the MA2 (mean ± SD = 0.8 ± 2.5, 0.7 ± 2.3, 0.1 ± 1.7, 1.7 ± 3.4; p = 0.34, 0.36, 0.85, 0.15; d = 0.32, 0.30, 0.06, 0.50, respectively) and the ABILHAND-kid (mean ± SD = 2.3 ± 5.14, p = 0.19, d = 0.45), and UL performance measured by the How Often (mean ± SD = 0.53 ± 0.79, p = 0.06, d = 0.68) and How Well Scales (mean ± SD = 0.32 ± 0.72, p =0.16, d = 0.45) of the PMAL-R at post-intervention evaluation. In addition, participants’ daily function were facilitated after intervention on the Functional Skills Scale (mean ± SD = 1.00 ± 3.26, p =0.33, d = 0.31) and Caregiver Assistance Scale (mean ± SD = 2.09 ± 6.28, p =0.30, d = 0.33) of the PEDI. The weekly progression of motor function was found in the scores of the BBT ( F(2.476,17.335)=2.346, p = 0.117, η2 = 0.251). On psychosocial outcomes, there was no difference in parenting stress after the intervention. Children’s playfulness evaluated by the TOP were improved (mean=18.10 ± 8.39, p<0.001), and their engagement during intervention remained high. Participants showed high level of satisfactory toward the intervention. Conclusion: Family-friendly CIT is feasible, friendly and preliminary effective in promoting UL function, performance, and daily function in children with CP. The intervention improved children’s playfulness and induced no negative effect on psychosocial outcomes in the children and families. The results were promising and warranted further investigation despite the limited sample size.