分散式侷限誘發療法於中風後忽略症患者之療效研究：運動學分析與臨床評估

Effects of Distributed Constraint-Induced Therapy in Stroke Survivors with Unilateral Neglect: Kinematic Analysis and Clinical Assessments

李湘婷(Hsiang-Ting Li)

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(2009年)

https://doi.org/10.6342/NTU.2009.01232

摘要

背景: 半側忽略常見於右大腦損傷的中風患者，且會影響患者的日常生活功能與復健成效。患側空間的注意力缺損會導致患者於執行往對側空間之動作時出現障礙，亦會影響患側手(腦傷對側肢體)的動作復原。分散式侷限誘發療法為一新提倡適用於半側忽略症患者之介入方式，但其療效仍缺乏相關研究之探討。分散式侷限誘發療法可迫使患側手產生主動動作，並誘發患者增加對於患側空間的注意力，進而改善忽略症相關的動作缺損並促進動作之復原。本研究的目的為探討中風後忽略症患者接受分散式侷限誘發療法相較於控制療法於功能獨立，動作缺損及動作復原方面的改善程度。
方法: 本研究將11位中風後呈現半側忽略症之患者隨機分派至分散式侷限誘發療法組或控制治療組。分散式侷限誘發療法組患者從事每天2小時、每週5天的密集訓練，並每天侷限健側手6小時，為期3週；控制組則接受等量之傳統治療。成效評量採用運動學分析以探討患者往患側空間執行伸手及物的動作表現；臨床評估工具為功能性獨立測驗、傅格-梅爾動作復原評估量表、手臂動作研究測驗及動作活動日誌以評估患者生活功能及動作方面之改善程度。
結果: 隨機分派後，兩組參與研究之患者的特徵與前測時的動作表現皆無顯著差異。運動學分析結果顯示，分散式侷限誘發療法組相較於控制組於健側手執行跨中線往對側空間的伸手及物動作時，兩組之反應時間 (P=0.020)、動作時間 (P=0.017) 及尖峰速度 (P=0.013)，達統計顯著差異。接受分散式侷限誘發療法之患者呈現較好的動作控制策略，兩組於動作控制策略的表現差異接近顯著水平且達高度效果值(P =0.052; effect size η2=0.334)。兩組患者於患側手執行伸手及物的動作表現上並無顯著差異，但接受分散式侷限誘發療法之患者於動作控制策略的改善仍呈現較好之趨勢，為中度至高度的效果值 (P =0.188; effect size η2=0.113)。在臨床評估結果方面，兩組於功能性獨立測驗 (P=0.017) 及其動作分量表 (P=0.009) 達統計顯著差異。在動作活動日誌之次量表中，患側手使用量 (AOU of MAL, P=0.015) 與患側手使用品質 (QOM of MAL, P=0.023) 結果皆達顯著差異。雖然兩組於傅格-梅爾動作復原評估量表之改善並無顯著差異(P=0.295; effect size η2=0.044)，但分散式侷限誘發療法組的患者於動作復原的改善程度仍呈現較大的進步趨勢。兩組於手臂動作研究測驗的表現中亦未達顯著差異且效果值較小 (P =0.395; effect size η2=0.011)。
結論: 經過為期3週的分散式侷限誘發療法，患者於功能性日常活動之獨立程度獲得顯著提升。健側手往患側空間的動作表現亦呈現顯著的改善，顯示患側手之主動動作可誘發往患側空間的注意力，進而降低其動作障礙。此外，分散式侷限誘發療法同時能促使患者增加對於患側手動作之注意力，使患者於日常生活活動中增加使用患側手的次數並改善動作品質。

關鍵字

半側忽略 ； 功能性獨立 ； 運動學分析 ； 伸手及物動作 ； 中風

並列摘要

Background: Unilateral neglect is a common disorder in right-hemisphere stroke patients and produced impact on reaching performances of both arms and on motor recovery of the more affected arm. Distributed constraint induced therapy (dCIT) has received much attention to become a new treatment of unilateral neglect. However the effects of dCIT in stroke patients with unilateral neglect remained uncertain. We proposed that dCIT could induce reduction of neglect and thus lead improvements in the related motor deficits. The objective of the present study was to investigate whether unilateral neglect patients would benefit more from dCIT, compared with controlled treatment.
Methods: 11 patients with unilateral neglect following stroke were recruited and were allocated randomly to dCIT group (2-hour practice in weekdays for 3 consecutive weeks and constraint of the less affected arm for 6 hours per day) and controlled treatment group (traditional rehabilitation for equivalent intensity and duration). We used kinematic analysis and clinical assessments (the Functional Independence Measure, the Fugl-Meyer Assessment, the Action Research Arm Test, and the Motor Activity Log) to investigate the outcomes of reaching movements towards contralesional space, and functional and motor improvements.
Results: There were no significant differences between the groups at pretreatment. Patients receiving dCIT showed significant improvements of the less affected arm in reaction time (P=0.020), movement time (P=0.017), and peak velocity (P=0.013) and showed greater improvement in preplanned motor control (p=0.052; effect size η2=0.334). For the more affected arm, there were no significant differences in the kinematic variables, though the dCIT produced a moderate to large effect on better motor control strategy (P =0.188; effect size η2=0.113). Patients after dCIT showed significant improvement in independence in daily functional tasks, especially in motor domain (FIM, P=0.017; FIM_motor, P=0.009) and improvement in functional use of the more affected arm (AOU of MAL, P=0.015; QOM of MAL, P=0.023). Though patients in dCIT group showed greater tendency in motor improvement measured by FMA, it failed to reach significant level (P =0.295; effect size η2=0.044). The two groups showed a non significant and small effect of ARAT (P =0.395; effect size η2=0.011).
Conclusions: After three-week dCIT intervention, compared with CT, patients presented much more independence in activities of daily living and had better motor performance while reaching with the less affected arm toward the contralesional space. Additionally, patients were facilitated to spontaneously use the more affected arm and perform better in functional activities.

並列關鍵字

Unilateral neglect ； functional independence ； kinematic analysis ； reaching movement ； stroke

參考文獻

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