單側與雙側上肢密集訓練於腦性麻痺孩童之療效比較：隨機控制試驗

Effectiveness of unilateral versus bilateral intensive training in children with cerebral palsy: a randomized controlled study

10.6342/NTU201602342

黃晨維

侷限誘發療法 ； 密集訓練 ； 兒童神經復健 ； 復健 ； 孩童 ； constraint induced therapy ； intensive training ； pediatric neurorehabilitation ； rehabilitation ； children

臺灣大學職能治療研究所學位論文

2016年

碩士

王湉妮

英文

腦性麻痺是造成孩童失能的最主要疾病之一。腦性麻痺孩童經常伴隨著動作與認知上的損傷，導致孩童於國際健康功能與身心障礙分類系統-兒童與青少年版的活動及參與度層級上產生限制。腦性麻痺孩童的動作功能損傷是導致其受限的主要原因之一，其中上肢動作功能的損傷又比下肢動作功能的損傷來得嚴重。此外，腦性麻痺為一異質性高之族群，其中又以一側表現明顯較另一側差的型態最為常見。近年來，兒童復健領域開始使用一種新型態的治療來改善腦性麻痺孩童的動作功能，此療法為密集性治療，其中又以單側密集性治療與雙側密集性治療最為常見。單側密集性治療於訓練過程中會著重於孩童患側手之練習，並且侷限健側手。雙側密集性訓練則在訓練過程中強調孩童自然地雙手使用。 本研究目的為探討在居家環境執行的個別化單側與雙側密集性訓練對腦性麻痺孩童之動作功能與社會情緒之療效與差異。本研究共收錄20位腦性麻痺孩童，每位孩童皆被隨機分配到執行單側密集訓練或雙側密集訓練的組別中。實驗過程中每位孩童都接受相同時數的上肢訓練，總共36個小時（4.5 小時/週，總共8週）。此外，孩童於接受治療前與接受治療後都必須參與評估的過程。在主要結果的評量工具中有墨爾本單側上肢功能評估量表第二版 (Melbourne Assessment-2, MA-2)、兒童動作活動日誌 (Pediatric Motor Activity Log-Revised, PMAL-R)、雙手操作能力問卷兒童版 (ABILHAND-kids)、布魯茵克斯－歐西瑞斯基動作能力測驗第二版 (Bruininks-Oseretsky Test of Motor Proficiency-2, BOT-2)、玩性測驗 (Test of Playfulness, ToP)，以及研究者自行發展的參與度問卷 (Engagement Questionnaire, EQ)。此外，次要結果的評量工具則包含近端與遠端動作表現的墨爾本單側上肢功能評估量表第二版 (Melbourne Assessment-2, MA-2)、研究者自行發展的滿意度問卷 (Satisfaction Questionnaires, SQ)，以及親職壓力量表之短版 (Parental Stress Index-short form, PSI-SF)。最後，在研究結果的分析中本研究使用二因子的變異數分析來檢視兩組是否有產生交互作用，當交互作用產生後，研究者更進一步分析單一組別的改變量，藉此來比較兩種訓練方法之效果。此外，因本研究樣本數較小，研究者以效果值 (eta squared & Cohen’s d) 來呈現效果之大小。 研究結果顯示，接受單側密集訓練的腦性麻痺孩童有較多的動作功能進步。於主要結果中，MA-2 產生時間與訓練的交互作用（關節動作角度，效果值：0.014；動作準確性，效果值：0.069；動作流暢性，效果值：0.030）。PMAL-R中的使用量與動作品質也都達到有意義的時間與訓練交互作用（使用量，效果值：0.241；動作品質，效果值：0.114）。ABILHAND-kids的結果亦呈現有意義的交互作用（效果值：0.021）。BOT-2中的單側與雙側任務表現也皆呈現有意義的交互作用（單側任務，效果值：0.027；雙側任務，效果值：0.053）。除了動作功能的結果外，玩性測驗與參與度問卷也皆產生交乎作用（玩性測驗，效果值：0.029；參與度問卷-孩童，效果值：0.031）。進一步分析後發現，接受單側密集訓練的腦性麻痺孩童於MA-2的關節角度與動作流暢性進步、PMAL-R的使用量與動作品質、ABILHAND-kids以及單側與雙側任務的BOT-2皆較雙側密致訓練組來得多。反之，接受雙側密集訓練的孩童則在MA-2中的動作準確性以及社會心理狀態之反應（ToP & EQ）表現得比單側密集訓練組來得好。接受雙側密集訓練的孩童於訓練過程中呈現出相對於單側密集訓練的孩童較穩定且平均較高的參與度，單側密集訓練組的小朋友於訓練初期則呈現較低的參與度。此外，在次要結果中，我們發現在MA-2的近端與遠端動作表現上以及PSI-SF皆出現交互作用（近端動作，效果值：0.088；遠端動作，效果值：0.039；PSI-SF，效果值：0.018）。進一步分析得知，接受單側密集訓練的孩童呈現較好的近端與遠段動作進步，而兩種訓練方法皆未使得家長壓力指數上升。 研究結果顯示，接受單側密集訓練的孩童呈現較多的動作功能進步，而接受雙側密集訓練的孩童則在訓練過程中呈現較佳的社會心理狀態。此外，本研究也證實孩童接受一週4.5小時的單側密集訓練可達到進步的成效，但對於雙側密集訓練而言則需要更高強度的訓練。最後，本研究結果可提供臨床治療師在選擇治療方案時的考量。

Upper limb dysfunction is a common and disabling consequence of children with cerebral palsy (CP). They usually experience difficulties in daily living routines. Recently, a new contemporary training concept “intensive training” were emerged with evidence. Recent evidence suggests that unilateral intensive training (UIT) and bilateral intensive training (BIT) are two of the most effective intensive techniques to improve the use of the affected hand in children with CP. UIT approach focuses on training a child’s more affected hand with intensive, repetitive practice while restraining the less affected hand. BIT, on the contrary, was developed with the limitations of UIT that emphasizing on spontaneous use the more affected hand in bilateral daily activities. The purpose of this study was to investigate the effectiveness differences between individualized UIT and BIT in a home-based context on motor outcomes and emotional status. We recruited 20 participants. Participants were randomized to either UIT or BIT group, and received individualized training with 4.5 h/wk, lasts for 8 weeks (totaling 36 hours). Outcome measures were conducted at baseline, and after the entire training. Primary assessments included Melbourne Assessment-2 (MA-2), Pediatric Motor Activity Log-Revised (PMAL-R), ABILHAND-kids, Bruininks-Oseretsky Test of Motor Proficiency-2 (BOT-2), Test of Playfulness (ToP) and a self-developed questionnaire: Engagement Questionnaire (EQ). The secondary outcomes included the proximal and distal part of the MA-2, a self-developed questionnaire: Satisfaction Questionnaires (SQ), and Parental Stress Index-short form (PSI-SF). Two-way ANOVA was used to investigate the treatment effects between the two groups for each outcome variable. The values of the effect size (Cohen’s d, η2 ) were also calculated for each outcome variable to present the magnitude of group differences. Results showed that the UIT made more improvements after the entire training than the BIT. For the primary outcomes, the time x training interaction occurred at the MA-2 (ROM, effect size: 0.014; Accuracy, effect size: 0.069; Fluency, effect size: 0.030), PMAL-R: amount of use (effect size: 0.241), PMAL-R: quality of movement (effect size: 0.114), ABILHAND-kids (effect size: 0.021), BOT-2: unilateral (effect size: 0.027), BOT-2:bilateral (effect size: 0.053), ToP (effect size: 0.029) and EQ (children, effect size: 0.031). The UIT made a better gain on the ROM and fluency sub-skills of the MA-2, the usage and quality of movements (as measured by the PMAL-R), the bilateral performance during the daily living environments (as measured by the ABILHAND-kids), and the both unilateral and bilateral performance of BOT-2. The BIT group revealed better improvements on the movement accuracy (as measured by the MA-2) playfulness (as measured by the ToP). In addition, participants in the BIT demonstrated a stable emotional status while the UIT group revealed a relatively low emotional level at the initial stage. As for the secondary outcomes, the time x training interaction occurred at the proximal part of the MA-2 (effect size: 0.088), the distal part of the MA-2 (effect size: 0.039), and PSI-SF (effect size: 0.018). The UIT appeared more gains on the proximal and distal upper limbs movements (as measured by the MA-2). In addition, both of the training did not made participants caregivers more stressful. Results showed the UIT made more gains on the motor function outcomes. While considering the psychosocial issues, the BIT demonstrated a better situation during the training session. In addition, we proved that with 4.5 hours per week training, children received the UIT made their improvements after the training session. However, the BIT might need more training dosage to reach improvement. This study provided a further consideration for applying the UIT and BIT on children with CP to clinical therapists.

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