腦中風疾病之預防與復健：身體活動量、中風後高血糖和復健治療強度的相關研究

Prevention and Rehabilitation of Stroke: Studies of Physical Activity, Post-stroke Hyperglycemia and Rehabilitation Intensity

胡國琦(Gwo-Chi Hu)

指導教授 ： 簡國龍

國立臺灣大學/公共衛生學院/流行病學與預防醫學研究所/博士(2013年)

https://doi.org/10.6342/NTU.2013.00453

摘要

腦中風是造成死亡或是殘障的重要疾病，會造成醫療體系和社會的沉重負擔。雖然目前對於預防和治療腦中風有明顯的進展，但還是有一些議題尚未完全研究清楚。本論文的主要目的為 (1)探討工作相關身體活動量和休閒相關身體活動量與發生腦中風疾病風險和死亡的關係。(2)了解急性中風時的血糖值和腦中風後三個月的功能殘障及長期死亡風險的關係。(3)探討腦中風病人住院期間接受復健治療的強度和死亡風險的關係。
方法
第一篇次研究為根據金山地區心血管疾病世代研究的資料，共有1,706 位社區居民，平均追蹤16.8年。以前瞻性世代研究設計探討身體活動量與腦中風疾病發生率的關係。第二、三 篇次研究為根據馬偕醫院腦中風登錄資料庫的資料，收集從 2008 年 1 月 1 日到 2009 年 6 月 30 日因為急性缺血性腦中風疾病到馬偕醫院急診求診的所有病人的資料，以回溯性世代研究設計方法探討急性血糖值、復健治療的強度與腦中風功能殘障、死亡的關係。
結果：
第一篇次研究平均追蹤了 16.8 年，研究追蹤期間，研究對象發生腦中風疾病共 118 人；死亡共 438 人，比起最低休閒相關身體活動量的研究對象，最高休閒相關身體活動量的研究對象發生腦中風疾病的相對風險為 0.71 (95%CI, 0.38-0.97)，發生死亡的相對風險為 0.73 (95%CI, 0.58-0.92)。相反的，比起最低工作相關身體活動量的研究對象，最高工作身體活動量的研究對象發生腦中風疾病的相對風險為 1.74 (95%CI, 0.90-2.78)，發生死亡的相對風險為 1.53 (95%CI, 1.06-2.22)。代表休閒相關身體活動量可以降低發生腦中風疾病和死亡的風險；但是工作相關身體活動量反而會增加腦中風疾病和死亡的風險。
第二篇次研究收集 1277 位急性缺血性腦中風病人的資料，急性血糖值愈高會增加病人發生殘障和死亡的風險。比起最低急性血糖值的病人，最高四分位急性血糖的病人發生殘障的相對風險為 2.68 (95%CI, 1.87-3.85)，發生死亡的相對風險為 2.18 (95%CI, 1.36-3.48)。急性血糖值和發生殘障和死亡的關係在非糖尿病病人較為明顯。
第三篇次研究發現缺血性腦中風病人住院期間接受復健治療的強度愈強，發生殘障和死亡的風險愈低。比起接受最低復健治療的病人，接受最高復健治療的病人發生殘障的相對風險為 0.57 (95%, 0.47–0.70)，發生死亡的相對風險為 0.45 (0.30–0.65)。
結論
本論文發現休閒相關身體活動量可以預防腦中風疾病和死亡，但是工作相關身體活動量反而會增加腦中風疾病和死亡。未來需要更多的研究去証實不同面向的身體活動量與腦中風疾病和死亡的關係。另外，本研究確立對於非糖尿病缺血性腦中風病人，急性血糖值與功能預後和死亡的關係，但是，對於糖尿病缺血性腦中風病人，急性血糖值與預後的關係，需要更多的研究去釐清。最後，本研究也發現，對於缺血性腦中風病人，增加住院期間的復健治療強度，可以降低殘障和死亡的風險。

關鍵字

腦中風 ； 身體活動量 ； 高血糖 ； 復健治療強度 ； 殘障 ； 死亡

並列摘要

Background and objectives
Strokes are the third leading cause of death and the leading cause of disabilities among adults. While many advances have been made in stroke prevention and rehabilitation, some issues remain to be resolved. The aims of the thesis were to investigate the associations of occupational physical activity (OPA) and leisure-time physical activity (LTPA) with the risk of stroke and mortality; to investigate the association between acute glucose level and functional outcome after ischemic stroke 3 months later; to evaluate the relationship between acute glucose levels and mortality among patients with acute ischemic stroke; to investigate the relationship between the intensity of inpatient rehabilitation therapy and mortality among patients with acute ischemic stroke.
Materials and Methods
Studies I, were based on data from the Chin-Shan Community Cardiovascular Cohort study with 1,706 participants during a median follow-up period of 16.8 years. Studies II, and III were based on data from a hospital-based database with 1277 consecutive ischemic stroke patients admitted to Mackay Memorial Hospital in Taiwan between January 1, 2008 and June 30, 2009.
Results:
In the first study: During a median follow-up period of 16.8 years, 118 subjects had incident stroke events and 438 deaths were identified. With the lowest tertile as the reference, the relative risks (RRs) for stroke and mortality in the highest tertiles of LTPA were 0.71 (95% confidence interval [CI], 0.38-0.97) and 0.73 (95%CI, 0.58-0.92). In contrast, the RRs for stroke and mortality in the highest tertiles of OPA were 1.74 (95%CI, 0.90-2.78) and 1.53 (95%CI, 1.06-2.22). We found that LTPA decreased the risk of stroke and mortality, while OPA increased the risk of stroke and mortality.
In study II: We collected data from 1277 patients with acute ischemic stroke. Patients within the highest quartile of admission glucose level had a 2.68-fold relative risks (RR) (95% confidence interval [CI], 1.87-3.85) for disability and a 2.18-fold RR (95% CI, 1.36-3.48) for mortality compared with those within the lowest quartile level. Higher acute glucose level was associated with disability and mortality. In addition, the association was relatively modest among non-diabetic patients. In study III, the intensity of inpatient rehabilitation therapy and disability and mortality were significantly inversely related in the ischemic stroke patients. Compared with the lowest tertile, the highest tertile of rehabilitation intensity was associated a 43% lower risk of disability (95% CI, 0.47–0.70), with a 55% lower risk of all-cause mortality (95% CI, 0.30–0.65).
Conclusion:
In the thesis, we found higher levels of OPA are associated with increased risk of stroke and mortality, while LTPA decreased the risk of stroke and mortality. Future studies need to confirm these associations. A significant association between acute glucose level and disability and mortality in non-diabetic ischemic stroke patients were established. Further study regarding the relationship of acute glucose levels and outcomes among ischemic stroke patients with diabetes is warranted. Besides, we found intensive rehabilitation therapy may benefit ischemic stroke patients.

並列關鍵字

stroke ； physical activity ； hyperglycemia ； rehabilitation intensity ； disability ； mortality

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