住院復健腦中風患者之復健潛能與復健治療成效

背景：腦中風除名列十大死因排行也影響身體功能造成失能，降低日常生活功能及生活品質，為促使日常生活功能恢復和提升生活品質，需接受復健治療，而復健治療的完成度和成效可能受其復健潛能影響。Mosqueda已提出生物心理社會復健潛能模式，但國內外對復健潛能均未量化，且未有研究調查復健病房中腦中風患者的復健潛能和復健治療成效之間的關係。目的：本研究依據Mosqueda生物心理復健潛能模式發展腦中風患者復健潛能測量指標，以及探討復健病房中腦中風患者的復健潛能對復健治療成效之影響。研究方法：本研究採縱貫性研究設計。研究對象為20歲以上因腦中風接受住院復健治療且依賴程度（Modified Rankin Scale，MRS）3-5級之患者，依樣本數計算收案101人。自2020年1月至2021年3月，在北部某醫學中心取得病歷紀錄，並運用結構式問卷和採面訪、電訪或電子郵寄等方式於入住復健病房、出院前1-3天及出院後1個月進行資料收集。復健潛能包含生理、心理和社會面向，分別包含：生理面向：肌力、動作發展評估（布氏動作復原階層）、視（知）覺、吞嚥能力、尿失禁；心理面向：復健動機、心理照護需求、認知功能；社會面向：社會支持。復健治療成效包含日常生活功能和生活品質；日常生活功能以巴氏量表（Barthel Index）測量，分數越高表示日常生活功能越好，生活品質以健康相關生活品質（EuroQoL-5D，EQ-5D）測量，分數越高表示生活品質越好。廣義估計方程式（GEE）檢測復健潛能與日常生活功能和生活品質之間的關係。結果：日常生活功能與生活品質分數自入住復健病房至出院後1個月隨著時間呈現先上升後持平的二次方趨勢。腦中風患者自入住復健病房至出院後一個月的復健潛能之生理面向的「吞嚥能力」和心理面向的「復健動機」與日常生活功能或生活品質具有正相關：吞嚥能力較好（β=3.189，p<0.001）和復健動機較好（β=1.284，p<0.001）之腦中風患者日常生活功能較好；復健動機較好者也有較佳的生活品質（β=1.310，p=0.003）。生理面向的「尿失禁」與心理面向的「認知功能」和「心理照護需求」與日常生活功能或生活品質具有負相關：有尿失禁（β=-15.201，p<0.001）和認知功能缺損（β=-8.516，p=0.013）的腦中風患者日常生活功能較差；認知功能缺損（β=-9.146，p=0.015）和心理照護需求越高（β=-1.427，p<0.001）的腦中風患者生活品質較差。復健潛能心理面向的「復健動機」和社會面向的「社會支持」是生理面向「吞嚥能力」與日常生活功能關係之調節因子。結論：生理面向的「吞嚥能力」和「尿失禁」與心理面向的「復健動機」、「認知功能」和「心理照護需求」皆為復健病房中腦中風患者的重要復健潛能指標，並可預測入住復健病房至出院後一個月日常生活功能或生活品質。未來可針對上述指標作評估以即早檢測出吞嚥能力不佳、有尿失禁、復健動機低、認知功能差，及心理照護需求較高等復健潛能較差者，並制定合適策略以提升日常生活功能和生活品質。再者，復健潛能心理面向的「復健動機」越強或社會面向的「社會支持」越好，則會讓吞嚥能力較好的腦中風患者獲得更明顯的日常生活功能提升，故醫護人員應特別強化復健動機和提供合適支持。未來研究可針對Mosqueda提出的生理、心理和社會面向之復健潛能發展量表；政策制定者可設計合適介入計畫以提升腦中風患者復健潛能，致使有效提升復健治療成效。

關鍵字

腦中風；復健潛能；復健治療成效；日常生活功能；生活品質

並列摘要

Background: Stroke is among the top Ten Leading Causes of Death. It influences not only body function, but also may render disability, reduction in activities of daily living, and quality of life. Rehabilitation is required to promote recovery in activities of daily living and quality of life. However, the effectiveness of rehabilitation is affected by the rehabilitation potential of the patient. Mosqueda proposed a biopsychosocial model of rehabilitation potential that includes biological, psychological, and social domains. Currently, it is yet to be quantitatively studied both domestically and internationally. There are no studies available on the relationship between rehabilitation potential and the effectiveness of rehabilitation therapy among patients with stroke in the rehabilitation ward. Objective: This study aimed to develop indicators of rehabilitation potential based on Mosqueda’s biopsychological rehabilitation potential model and explored the effect of rehabilitation potential on the effectiveness of rehabilitation therapy among patients with stroke in the rehabilitation ward. Methods: We conducted a single hospital-based, longitudinal survey from January 2020 to March 2021 using a questionnaire as a measurement tool in a medical center in Northern Taiwan. A total of 101 patients aged 20 or older, hospitalized for stroke and undertaken rehabilitation therapy with Modified Rankin Scale (MRS) of 3-5 were included for analysis. Structured questionnaires by in-person, phone, or email interviews, were collected at the time of transfer to the rehabilitation ward, 1-3 days before discharge, and one month after discharge. The rehabilitation potential encompasses three domains, including biological domain (muscle power, Brunnstrom’s stage, visuospatial neglect, swallowing ability, and urinary incontinence), psychological domain (motivation, psychological care needs, and cognitive function), and social domain (social support). The outcome of rehabilitation treatment includes activities of daily living using the Barthel Index and quality of life using health-related quality of life (EuroQoL-5D, EQ-5D). The activities of daily living was measured by the Barthel Index; a higher score represents the better function. Quality of life was measured by health-related quality of life (EuroQoL-5D, EQ-5D); a higher score indicates a better quality of life. A generalized estimating equation (GEE) was used to estimate the relationship between rehabilitation potential, activities of daily living, and quality of life. Results: The activities of daily living and quality of life followed a curvilinear trajectory. Both scores were lowest at the time of transfer to the rehabilitation ward, increased sharply until 1-3 days before discharge, then flattened out between 1-3 days before discharge and one month after discharge. The GEE showed that stroke patients who had a better swallowing ability (β=3.189, p<0.001) and a higher rehabilitation motivation (β=1.284, p<0.001) were significantly more likely to have higher activities of daily living; those who had a higher rehabilitation motivation were also significantly more likely to have a higher quality of life (β=1.310, p=0.003). In contrast, those stroke patients who had urinary incontinence (β= -15.201, p<0.001) and who had cognitive impairment (β= -8.516, p=0.013) had the worse ability to perform tasks of activities of daily living. Those who had cognitive impairment (β= -9.146, p=0.015) and who had higher psychological care needs (β=-1.427, p<0.001) had worse quality of life. Rehabilitation motivation and social support interacted with swallowing ability on activities of daily living, respectively. Conclusion: "Swallowing ability" and "urinary incontinence" in the biological domain as well as "habilitation motivation", "cognitive function" and "psychological care needs" in the psychological domain are important indicators of rehabilitation potential among stroke patients in the rehabilitation ward, which can predict activities of daily living and quality of life from admission to the rehabilitation ward to one month after discharge. In the future, the above indicators could be used for the early detections of patients with poor rehabilitation potentials. Appropriate strategies should be developed to improve activities of daily living and quality of life, especially for stroke patients who had poor swallowing ability, urinary incontinence, lower rehabilitation motivation, cognitive impairment, and higher psychological care needs. Stronger "rehabilitation motivation" in the psychological domain or better "social support" in the social domain of the rehabilitation potential could enhance the activities of daily living among stroke patients who had better swallowing ability; therefore, medical and nursing staff should pay more attention to increase rehabilitation motivation and provide appropriate support. Future studies could develop a scale of rehabilitation potential based on Mosqueda’s biopsychosocial model of rehabilitation potential. Policymakers could design appropriate intervention plans to enhance rehabilitation potential, so as to greatly improve the effectiveness of rehabilitation treatment for stroke patients.