機器輔助治療誘導慢性中風後任務導向或動作導向鏡像治療之對照試驗

Comparative Efficacy Trial of Robot-Assisted Therapy Combined with Task-Specific or Movement-Oriented Mirror Therapy After Chronic Stroke

葉亦平(I-Ping Yeh)

指導教授 ： 林克忠

國立臺灣大學/醫學院/職能治療研究所/碩士(2021年)

https://doi.org/10.6342/NTU202102580

摘要

背景：中風盛行於全球而成為長期失能的一大成因，中風後遺症廣泛並長遠影響健康的各式層面，近年研究指出使用誘導技術有助提升中風復健之效益。誘導技術旨在提升大腦至更具可塑性的狀態，並增益後續治療之果效，其中機器輔助療法具有高密度練習的特性而成為強效的雙側動作誘導策略。鏡像治療是目前極具潛力的雙側途徑療法之一，研究指出機器輔助療法接續鏡像治療用於慢性中風者呈現良好的治療成效。機器輔助療法藉由高密度練習作為重塑腦神經的誘導治療，接續鏡像治療透過鏡像回饋增益動作，此兩種治療之結合可望改善中風個案之復原。鏡像治療尚可依據練習內容進一步劃分為任務型態或動作型態，任務導向型鏡像治療重視動作目標之結果，動作導向型鏡像治療則著眼於降低動作損傷。兩型態之鏡像治療可能各自具有相對優勢，但尚乏足夠對照。本前導研究以機器輔助療法作為誘導治療，接續任務導向型態或動作導向型態鏡像治療，以國際健康功能與身心障礙分類系統為評估架構，旨在對照機器前誘任務導向型態或動作導向型態鏡像治療之相對成效。
方法：本研究為雙盲、多中心、隨機分派臨床試驗，延攬並分析20位慢性中風者隨機分派至上述兩組治療之一，治療劑量為每次90分鐘每周3次為期六周，受試在治療前與治療後接受評估，主要成效評估為傅格-梅爾評估量表(Fugl-Meyer Assessment)、與中風衝擊量表第三版(Stroke Impact Scale 3.0)，次要成效評估包含修訂版諾丁漢感覺評估量表(revised Nottingham Sensation Assessment)、哈馬爾測力計(Jamar dynamometer)、柯氏上臂與手部活動評量表(Chedoke Arm and Hand Activity Inventory)、與諾丁漢延伸性日常生活活動量表(Nottingham Extended Activities of Daily Living)。
結果：本研究顯示兩組經六周治療後皆在傅格-梅爾評估量表、中風衝擊量表第三版，修訂版諾丁漢感覺評估量表、哈馬爾測力計、柯氏上臂與手部活動評量表、與諾丁漢延伸性日常生活活動量表皆呈現顯著進步，機器誘導「任務導向」鏡像組的進步在整體傅格-梅爾量表中同時達到顯著差異與最小臨床重要差異值。組間分析結果顯示機器誘導「任務導向」鏡像組在傅格-梅爾量表遠端分數(F1, 17 = 8.41, p = 0.01, η² = 0.331)、以及諾丁漢延伸性日常生活活動量表-家事分項(F1, 17 = 4.92, p = 0.040, η²= 0.225)顯著優於損傷組；而機器誘導「動作導向」鏡像組則相對任務組在側捏抓握力量(F1, 17 = 4.77, p = 0.043, η²= 0.219)呈現顯著優勢，且在中風衝擊量表-移行分項呈現較大的效果值(F1, 17 = 3.21, p = 0.091, η²= 0.159)。
討論：本研究發現機器誘導鏡像療法有助提升中風個案感覺動作、手部肌肉力量、日常活動、以及生活品質，此外，機器誘導「任務型態」鏡像治療對於動作恢復具有良好效果，尤其在遠端動作效果更勝於「動作型態」組。機器誘導「任務型態」鏡像治療相對在改善上肢遠端動作損傷以及提升家事參與更具優勢；而機器誘導「動作型態」鏡像治療相對在提升手部力量具優勢，且在增進移行相關生活品質呈現更佳療效趨勢。本研究支持機器誘導鏡像治療用於慢性中風個案之成效，研究顯示任務導向與動作導向型態鏡像治療各有所長，建議未來臨床執行鏡像治療時需清楚界定治療活動，且同時兼併任務導向以及動作導向之鏡像治療。依據統計檢定力分析，此研究結果尚需未來樣本數更大的試驗加以佐證，並且納入控制組以對照機器誘導鏡像治療相對單一療法之成效。

關鍵字

中風 ； 機器輔助療法 ； 鏡像治療 ； 動作誘導 ； 上肢

並列摘要

Background: Stroke leads to severe and long-term disability and is becoming the most critical medical issue globally. The sequela of stroke impacts various aspects of health, and a dire need arises for rehabilitation to enhance various aspects of stroke recovery. Priming technique is a notable strategy that can enhance the effect of rehabilitation. The purpose of the priming technique is to stimulate the brain to a more plastic condition, thus enhancing the follow-on effect of the intervention. The characteristic of high intensity makes robot-assisted therapy (RT) a strengthful bilateral robotic priming technique, which is also an effective motor priming technique. Mirror therapy (MT) is a bilateral approach with remarkable efficacy. The combination of RT and MT demonstrated compelling results in patients with chronic stroke in the previous studies. However, MT can be further differentiated into task-specific and movement-oriented according to their activities. Task-specific MT emphasizes the results of activities; in contrast, the movement-oriented MT focuses on motor performance. The two regimes of MT may have a different effects on stroke rehabilitation, and there is limited evidence of differential efficacy between the two regimes of interventions. This pilot study used the RT as a bilateral motor priming technique, combined with task-specific or movement-oriented MT. The evaluation was based on the International Classification of Functioning, Disability, and Health to have a comprehensive evaluation. This pilot study investigated the comparative effectiveness of RT-primed task-specific MT (RTMT) versus RT-primed movement-oriented MT (RMMT). We hypothesized that both the RTMT and the RMMT are effective interventions for patients with stroke, and differential benefits exist between the RTMT and the RMMT intervention.
Methods: This is a double-blinded, multicenter, randomized control trial. Twenty subjects were randomized into the RTMT or the RMMT group and completed the intervention. The interventions frequency was 1.5 hours per session, three sessions per week, last for 6-weeks. Primary outcomes included the Fugl-Meyer Assessment (FMA) and the Stroke Impact Scale 3.0 (SIS); secondary outcomes included the revised Nottingham Sensation Assessment (rNSA), Jamar dynamometer, the Chedoke Arm and Hand Activity Inventory (CAHAI), and the Nottingham Extended Activities of Daily Living (NEADL). Assessments were evaluated at pretest and posttest by the same assessor who was blinded to allocation results.
Results: Both the RTMT and the RMMT significantly improved in FMA, SIS, rNSA, muscle power, CAHAI, and NEADL after treatment. Moreover, the RTMT group achieved both within-group significance and reached FMA-total minimal clinically important difference (MCID) (MCID: FMA =5.2; FMA change: RTMT =8.2, RMMT =4.9). The between-group analysis suggested that the RTMT group had greater improvement compared to the RMMT group in FMA-distal score (F1, 17 = 8.41, p = 0.01, η² = 0.331), and the RTMT gained greater improvement in living affairs subscale of NEADL (F1, 17 = 4.92, p = 0.040, η²= 0.225). In contrast, the RMMT group improved more in lateral pinch strength compared to the RTMT group (F1, 17 = 4.77, p = 0.043, η²= 0.219). There was a large effect size in the SIS-mobility subscale in favor of the RMMT group (F1, 17 = 3.21, p = 0.091, η²= 0.159).
Discussion: This study demonstrated the efficacy of the RTMT and the RMMT in enhancing motor recovery, sensory function, muscle strength, activities and participation of daily life, and life quality in stroke. The results suggested the RTMT was superior to the RMMT in motor recovery of distal arm and life participation. On the contrary, the RMMT was superior to the RTMT in improving muscle strength and seemed to have a greater tendency in improving mobility-related life quality. Our research suggests that activities in MT should be clearly defined and include both the task-specific and the movement-oriented approach in future clinical practice. Based on the statistical power analysis, the current results need to be validated by a larger clinical trial in the future. Moreover, a control group needs to be included to examine the efficacy in the comparisons between the two types of RT primed MT and mono-intervention.

並列關鍵字

stroke ； robot-assisted therapy ； mirror therapy ； motor priming ； upper limb

參考文獻

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