經顱直流電刺激合併鏡像治療於中風個案之感覺動作及日常生活功能療效探討:偽對照個案系列研究

Effects of Transcranial Direct Current Stimulation Combined With Mirror Therapy on Sensorimotor and Daily Functions in Patients With Stroke: A Sham-Controlled Case Series

林庭安(Ting-An Lin)

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(2016年)

https://doi.org/10.6342/NTU201601365

摘要

背景與目的: 經顱直流電刺激屬於非侵入性腦部電刺激，可用以改變中風後損傷的腦部皮質活性，為神經復健中具有前瞻性的治療技術。鏡像治療於改善中風後上肢感覺動作功能損傷之效益，已被現今中風復健實證研究支持。本研究為探討經顱直流電刺激合併鏡像治療是否能夠增益治療效益，針對此複合療法應用於中風個案進行療效初探。
方法: 本研究採隨機、雙盲且偽對照之實驗設計。10位慢性中風受試者隨機分派至經顱直流電刺激接續合併鏡像治療組或偽經顱直流電刺激合併鏡像治療組，接受每天90分鐘、每週五天、為期四周的治療介入。主要的成效評量工具為傅格梅爾評估量表(Fugl-Meyer Assessment, FMA)、修訂版諾丁漢感覺評估量表(revised Nottingham Sensory Assessment, RNSA)與動作活動日誌(Motor Activities Log, MAL)；次要成效評量工具則包含沃夫動作功能測驗(Wolf Motor Function Test, WMFT)、修訂版艾許沃斯量表(Modified Ashworth Scale, MAS)、握力與指力(Grip and Pinch Strength)、運動學測驗與加速規評估。此外，本研究採問卷記錄監控經顱直流電刺激不良反應。
結果: 於主要成效評量，經顱直流電刺激接續合併鏡像治療組在FMA遠端次量表(P = .048, r = .577)，及MAL之動作品質次量表(P = .028, r = .596)與使用量次量表(P = .048, r = .562)的組間比較中具有顯著成效與高度效果值。偽經顱直流電刺激合併鏡像治療組相較於另一組，在FMA之近端次量表(P = .016, r = .681)的組間比較中達顯著差異。然而，兩組在次要成效評量結果幾乎未達統計上顯著差異，但經顱直流電刺激接續合併鏡像治療組相較於偽經顱直流電刺激合併鏡像治療組，在指力、運動學的角度變化參數及腕動計的熱量消耗與活動量上，有較多改變量的趨勢。偽經顱直流電刺激合併鏡像治療組則在RNSA之觸覺次量表及辨物覺次量表、MAS近端次量表，及WMFT之時間次量表有優勢趨勢。
結論: 本研究支持經顱直流電刺激合併鏡像治療對於中風後動作與日常生活功能有正向療效，因應個案系列之研究設計，研究結論須謹慎推論，建議未來仍須大樣本數或長期追蹤之研究再深入探討治療效益。

關鍵字

經顱直流電刺激 ； 鏡像治療 ； 中風 ； 感覺動作功能 ； 日常生活功能

並列摘要

Background and objectives: Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation for changing the damaged cortical excitability of stroke patients. It is a promising therapeutic technique in neurorehabilitation. Mirror therapy (MT) has been effective for improving sensorimotor functions of the upper extremity in stroke rehabilitation. To verify whether tDCS may be combined with MT for augmented treatment effects, this study was designed to investigate the effects of hybridizing tDCS with MT in patients with stoke.
Methods: A randomized, double-blinded and sham-controlled study was conducted. Ten participants with chronic stroke were randomly assigned to receive tDCS combined sequentially with MT, or sham-tDCS combined with MT. All participants in the two groups received the intervention for 90-min five times a week for 4 weeks. Fugl-Meyer Assessment (FMA), revised Nottingham Sensory Assessment (RNSA), and Motor Activity Log (MAL) were administrated as primary outcomes, moreover; Wolf Motor Function Test (WMFT), Modified Ashworth Scale (MAS), Grip and Pinch Strength, kinematic assessment and actigraphy were secondary outcomes at pre- and post-treatment. Moreover, tDCS adverse effects questionnaire was applied in the study for monitoring the adverse effects.
Results: For primary outcomes, tDCS + MT group had significant changes and large effect on the distal subscale of FMA (P = .048, r = .577); and the quality of movement subscale (P = .028, r = .596) and the amount of use subscale of MAL (P = .048, r = .562) for between-group comparisons. Sham-tDCS + MT group compared to another group were statistically different on the proximal subscale of FMA (P = .016, r = .681).
Although there were few statically significant findings on secondary outcomes in both groups, MT+ tDCS group compared to Sham-tDCS + MT group may have trends of greater changes on lateral pinch strength, angular change of kinematic assessment; and caloric consumption and activity counts for actigraphy. Sham-tDCS + MT group showed a superior trend in tactile sensation and sterognosis of RNSA, the proximal subscale of MAS, and the time subscale of WMFT.
Conclusion: The research supports the positive effects of tDCS combined with MT on motor and daily functions after stroke. With the case series designed in the study, the conclusion should be carefully inferred. Further studies with more sample size or long-term follow-up are needed to examine the present findings.

並列關鍵字

transcranial direct current stimulation ； mirror therapy ； strok ； sensorimotor functions ； daily functions

參考文獻

Boissy, P., Bourbonnais, D., Carlotti, M.M., Gravel, D., Arsenault, B.A. (1999). Maximal grip force in chronic stroke subjects and its relationship to global upper extremity function. Clin Rehabil, 13, 354–362.

Bolognini, N., Vallar, G., Casati, C., Latif, L. A., El-Nazer, R., Williams, J., . . . Fregni, F. (2011). Neurophysiological and behavioral effects of tDCS combined with constraint-induced movement therapy in poststroke patients. Neurorehabilitation and Neural Repair, 25(9), 819-829. doi: 10.1177/1545968311411056

Brunoni, A. R., Amadera, J., Berbel, B., Volz, M. S., Rizzerio, B. G., & Fregni, F. (2011). A systematic review on reporting and assessment of adverse effects associated with transcranial direct current stimulation. International Journal of Neuropsychopharmacology, 14(8), 1133-1145. doi: 10.1017/S1461145710001690

Cha, H. K., Ji, S. G., Kim, M. K., & J.S., C. (2014). Effect of transcranial direct current stimulation of function in patients with stroke. Journal of Physical Therapy, 26, 363–365.

Cho, H.S. & Cha, H.G. (2015). Effect of mirror therapy with tDCS on functional recovery of the upper extremity of stroke patients. Journal of Physical Therapy Science, 27, 1045-1047.