社區腦中風病人之跌倒預防策略：跌倒預測因子之研究

Fall Prevention Strategies in Community-Dwelling Stroke Patients: An Investigation of Fall Predictors

魏大森(Ta-Sen Wei)

指導教授 ： 章良渭

國立臺灣大學/工學院/醫學工程學研究所/博士(2017年)

https://doi.org/10.6342/NTU201703518

摘要

腦中風為老年人好發疾病之一，為國人十大死因之第四位。隨我國人口快速老年化、醫療照護進步，死亡率明顯下降，腦中風病患逐年增加。腦中風患者發病後常見併發症有肢體痙攣、肢體控制不良、平衡與步態能力障礙、內翻馬蹄足、憂鬱等；這些因素都會導致患者於日常活動中發生跌倒意外，如行走或移位時(坐到站/站到坐），嚴重者可能造成骨折甚至死亡，衍生之家庭負擔與社會問題不容小覷。因此，如何於腦中風發病住院期間篩檢出跌倒高風險因子、提供安全的起身坐站訓練並完整的治療介入策略，實為目前臨床醫護人員迫切亟待解決的議題。
近年來，腦中風病患者的治療介入模式，已由傳統只單純改善個案的生理狀況，轉變成全人的照護模式，如何兼顧個案生理與心理與社會參與，將是擬定腦中風預防跌倒策略的重要面向，也是有效降低個案跌倒或跌倒發生機會之重要因素。
本論文以多面向與客觀化的評估，探討社區腦中風患者跌倒的預測因子，並分析腦中風個案坐到站、站到坐時，不同手與腳擺位姿勢之運動學及動力學表現，來做為日後臨床醫護人員訓練、治療和跌倒預防、介入之重要參考。
研究結果發現兩個預測腦中風出院後發生跌倒之多變項回歸模型，分別為模型一: 步態不對稱性[調整勝算比, adjusted odds ratio, aOR = 2.2, 95% 信賴區間 (1.2–3.8)]、小腿腓腸肌痙攣程度[aOR = 3.2 (1.4–7.3)] 與憂鬱[aOR = 1.4 (1.2–1.8)]，模型準確度 (Area under curve, AUC)為 0.856；模型二: 功能獨立評估量表分數低 [aOR = 0.9 (0.9–1.0)]、步態不對稱性 [aOR = 3.6(1.4–9.2)]與內外側重心晃動程度[aOR = 1.7 (1.0–2.7)]，模型準確度為0.815。
不同手與腳擺位姿勢之動力學結果發現，偏癱腳在後且手成交握狀時，腦中風患者由坐姿起身到站立之預備時間最短，過程中雙腳承重對稱性佳，因此證實臨床治療師訓練患者坐到站時，透過手與腳的姿勢變換，可改善雙腳承重對稱性外，亦可做為訓練偏癱側下肢承重的訓練方法。
而腦中風由站到坐時，腳的擺位顯著影響腳承重策略及坐下時的衝擊力，但手的姿勢並無影響。個案若因前腳（健側）無法代償後腳（偏癱腳）的控制時，將在站到坐過程中產生較大的衝擊力，故為了訓練目的，可將健側腳放置於前方來誘發偏癱腳的肌肉用力與控制能力。
結論:本論文藉由分析腦中風出院前收集之病患臨床資料與功能性評估結果，歸納出兩個跌倒預測模型，並透過坐到站與站到坐的動力學實驗，分析個案對不同姿勢下，肢體動作的調變機制，研究結果提供臨床人員擬訂腦中風個別化防跌介入與治療之重要參考依據。

關鍵字

腦中風 ； 跌倒 ； 步態不對稱性 ； 憂鬱 ； 痙攣 ； 姿勢晃動 ； 功能獨立評估

並列摘要

Cerebrovascular disease is one of common chronic disease in the elderly and is the 4th leading cause of death in Taiwan. The numbers of stroke are gradually increasing annually due to rapid aging of population and excellent healthcare system which decreases the incidence of mortality. The common complications after stroke are limb spasticity, poor coordination, balance & gait impairment, equinus-varus foot, depression and etc. It often results in accidental falls during activity of daily living, such as sit to stand or stand to sit and may causes fractures or even death. It is of no doubt that family and society are also having great impact and challenges. Therefore, it is crucial to predict the risk factors of fall, provide sit-to-stand training and comprehensive interventions for stroke patients during hospitalization.
Recently, the mode of care and intervention is moving from improving the physical functioning toward building a holistic health care in stroke patients. A comprehensive fall prevention strategy, including physical, psychological and biosocial dimensions is essential to meet the unmet needs in clinical practice and reduces the incidence of accidental falls in the stroke patients.
In this dissertation, it will discover the predictors of fall by using objective assessments in the community-dwelling stroke patients. It also analyzes the strategies of leg load discrepancy on bilateral legs during sit to stand and stand to sit tasks according to different postural configuration of foot and hand.
The key findings of this dissertation are as followings:
(1) Two predictive models of fall in the community-dwelling stroke patients are found. Model one: asymmetrical gait pattern [adjusted odds ratio, aOR = 2.2, 95% CI (1.2–3.8)], spasticity of gastrocnemius [aOR = 3.2 (1.4–7.3)], and depression [aOR = 1.4 (1.2–1.8)]; the accuracy of model is 0.856; Model two: low score of functional independent measure [aOR = 0.9 (0.9–1.0)], asymmetrical gait pattern [aOR = 3.6 (1.4–9.2)] and postural sway in mediolateral direction [aOR = 1.7 (1.0–2.7)], the accuracy of model is 0.815.
(2) The paretic foot backward and hand clasped (FabHc) position leads to shorter movement durations before rising up and increased leg load symmetry during SitTS. Using the FabHc position for rising up and releasing clasped hands for more stability after standing is a useful strategy for stroke patients performing the SitTS task. Using this strategy, to train stroke patients according to the purpose of training, clinicians can provide more effective therapeutic interventions for specific underlying impairments.
(3) Altering arm placements does not significantly influence the leg load sharing strategy and sitting impact forces. The leg load sharing strategies are ruled by the preferred use of the non-paretic side and the favored leg position for the biomechanical load. The paretic leg is incapable of modulating the sitting-down process, placing the paretic leg posterior induces notably greater sitting impact forces compared with the counter leg placement. From the strength-training point of view, however, placing the paretic leg posterior would facilitate exertions of the paretic leg.
Conclusions: Patient falls are a major health concern in the care of patients with stroke. Two predictive model of fall risks are defined and the loading strategies during sit to stand and stand to sit are analyzed. The findings of this dissertation may provide an important information for making individualized fall prevention strategies in the stroke patients.

並列關鍵字

stroke ； fall ； gait asymmetry ； depression ； spasticity ； postural sway functional independence measure

參考文獻

[16]M.-R. Lin, S. L. Tsai, S. Y. Chen, and S. J. Tzeng, “Risk factors for elderly falls in a rural community of central Taiwan,” Taiwan J. Public Health, vol. 21, no. 1, pp. 73–82, 2002.

[17]S. C. Huang, T. J. Chen, and P. Chou, “Cumulative incident rate and associated factors of falls among the elderly in Shih-Pai, Taiwan,” Taiwan J Public Health, vol. 24, no. 136, p. e145, 2005.

Chapter 1. Falls and Fall-related injuries in the Elderly and Stroke

[1]P. Lips, “Epidemiology and predictors of fractures associated with osteoporosis,” Am. J. Med., vol. 103, no. 2, pp. S3–S11, 1997.

[4]S. R. Cummings and M. C. Nevitt, “A hypothesis: the causes of hip fractures,” J. Gerontol., vol. 44, no. 5, pp. M107–M111, 1989.