任務取向平衡訓練於機構失智症老人之療效研究

Effects of task-oriented balance training in institutionalized older adults with dementia

羅方妤(Fang-Yu Luo)

指導教授 ： 胡名霞

國立臺灣大學/醫學院/物理治療學研究所/碩士(2011年)

https://doi.org/10.6342/NTU.2011.01579

摘要

隨全球人口老化，失智症患者人數漸增，失智症老人成為長期照護機構中主要住民之一。研究顯示失智症老人的平衡及行走功能，較一般老人更常受限，影響日常生活自理及增加跌倒風險。過去研究指出，失智症老人感覺訊息傳入與整合能力較差，影響平衡能力。但失智症老人仍有學習能力，且可接受運動訓練，因概化(generalization)能力較差，訓練應該選用相關性高的任務。過去文獻對失智症患者的運動訓練，以長期訓練為主，不符合台灣長期照護短期介入的原則。
近年來臨床物理治療多以任務取向模式(task-oriented approach)以及感覺操弄技巧(sensory manipulation)為平衡訓練之介入方式，過去研究也指出短期的任務取向平衡訓練及感覺操弄技巧，對神經疾患病人及老年人的平衡功能有正面療效。因此為促進物理治療於失智症患者之臨床應用，本研究欲探討具有平衡及行走功能障礙之機構失智症老人，接受四週任務取向平衡訓練加上感覺操弄技巧，是否可改善平衡及行走能力。
本研究為評估者單盲之隨機分組控制實驗，由台北市三所長期照護機構中，篩檢符合條件的個案。共徵召19位有平衡及行走問題，但具備進步潛力之失智症老年人，隨機分配至兩組，訓練組10位(平均年齡86.27±8.8歲，簡易智能狀態測驗平均11.3±6.9分)，控制組9位(平均年齡84.75±8.21歲，簡易智能狀態測驗平均11.3±6.7分)。訓練組接受一對一的四週任務取向平衡訓練，每次1小時，每週2次，共計8小時；控制組則接收相同頻率和時間的上肢訓練，控制組之訓練皆在坐姿下進行。兩組受試者皆在訓練前、四週訓練後及一個月追蹤評估，接受計時起走測驗(Timed Up and Go Test, TUGT)、柏格氏平衡量表(Berg balance scale, BBS)、行走速度(gait speed)、聖路易大學心智狀態測驗(Saint Louis University mental status examination)、30秒坐到站測驗(30-s chair-stand test)、坐姿直膝前屈測驗(chair sit-and-reach test)及巴氏量表(Barthel index)評估，並記錄跌倒情形和情緒行為表現。本研究使用二維變異數分析(2-way ANOVA)比較兩組在訓練前後以及追蹤評估時的差異，顯著水準定在0.05，並使用意向分析方法(intention-to-treat analysis)處理缺失資料。
結果顯示訓練組在四週任務取向平衡訓練後，柏格氏平衡量表有顯著進步(P=0.001)，但沒有維持到追蹤評估。訓練組在後測時行走速度和計時起走測驗的表現有進步的趨勢，但未達統計上顯著差異。訓練組和控制組後測時，聖路易大學心智狀態測驗(P=0.034)、坐姿直膝前屈測驗(P=0.038)和巴氏量表(P=0.012)皆有改善，時間效果達統計上顯著差異。訓練停止四週後，兩組的行走速度(P=0.001)、坐姿直膝前屈測驗(P=0.034)和巴氏量表(P=0.012)有顯著的去訓練效果(detraining effect)。未來研究可增加樣本數，並針對訓練強度、時間和訓練之間隔進行研究，可進一步瞭解何種劑量之任務取向平衡訓練，能有效的增進失智症患者的平衡和行走功能，且能維持有效的長期效果。

關鍵字

失智症 ； 平衡 ； 行走 ； 任務取向模式 ； 感覺操弄 ； 長期照護 ； 機構

並列摘要

Dementia affects more than 24.3 million individuals, approximately 5~8% of the aged population in the year of 2005. With aging of the world population, this number is expected to continue to increase. Older adults with dementia have become a major category of residents in long-term care facilities in Taiwan. The impaired balance and gait in older adults with dementia is a main concern for health care team members as it affects their activities of daily living and increasing their risk of falls.
Previous studies have revealed that exercise training is feasible for dementia patients. Older adults with dementia can still learn motor and functional skill. However, they have difficulty generalizing the skill to other conditions. Balance problem may be affected by their poor ability of sensory integration and use of sensory strategies. As a result, tasks of the exercise program targeting balance performance should relate closely to the basic activities of daily living, and should combine with sensory manipulations.
Few studies have reported the effectiveness of exercise training in patients with dementia, and their programs are longer than 3 month in duration. Considering the principle of short-term or intermittent intervention, effects of short term intervention must be established for dementia residents in institutions. Balance training based on a task-oriented approach with sensory manipulation has been shown to be effective in patients with neurological disorders and older people.
Based on previous reviews, researches with better designed exercise program are needed. The purpose of this study was to investigate whether older adults with dementia who have balance and gait problems can improve their balance and gait after an individualized 4-week tasks-oriented balance training with sensory manipulation.
This study was a single-blind randomized controlled trial. This project was approved by National Taiwan University Hospital Research Ethics Committee. Participants were recruited from 3 long-term care facilities in Taipei, Taiwan, and screened for eligibility. Older adults with dementia were recruited and randomly assigned to the training group or control group. Training group received 4 weeks balance training, twice a week and 1 hour each session. Control group received 4 weeks upper extremities exercise in sitting position. Both groups were evaluated before training, after training and at one month follow-up. Outcome evaluation included Timed Up and Go Test, Berg Balance Scale, gait speed, 30-s chair-stand test, chair sit-and-reach test, Saint Louis University mental status examination and Barthel index. Two-way ANOVA was used to compare differences between two groups, and significant level was set at 0.05. Intention-to-treat analysis was used for missing data.
Training group showed significant improvement on Berg Balance Scale after 4 weeks task-oriented balance training (P = 0.001), but there was no long-term effect at follow-up evaluation. There were trends of increased walking speed and improvement on Timed Up and Go Test in Training group at post-test. Both groups had significant improvement on Saint Louis University mental status examination (P = 0.034), chair sit-and-reach test (P = 0.038) and Barthel index (P = 0.012) at post-test compared to baseline. After 4 weeks of detraining, both groups had significant decline in walking speed (P = 0.001), chair sit-and-reach test (P = 0.034), and Barthel index (P = 0.012).
A 4 weeks task-oriented balance training program had positive effect on balance in older adults with dementia. Exercises also led to significant improvement on flexibility, cognition and activities of daily living, but long-term effects were not observed. Further studies are needed to optimize the most effective dose of task-oriented balance training on balance and walking ability. Researches with larger sample size and exercise program for dementia patients with different severities are also needed.

並列關鍵字

Dementia ； Balance ； Walking ； Task-oriented approach ； Sensory manipulation ； Long-term care facilities

參考文獻

84. 胡名霞。物理治療與長期照護。中華物療誌 1998；23：52-60。

87. 傅中玲。台灣失智症現況。台灣老年醫學暨老年學雜誌 2008；3：169-81。

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