探討以兩種不同重心轉移訓練方式對中風患者功能性表現之影響

背景與目的：伴隨半側偏癱(Hemiplegic)的中風(Stroke)患者，通常會造成平衡、感覺以及動作方面的缺損，而增加跌倒的危險因子以及無法獨力執行日常活動功能(Activities of Daily Living)，因此改善平衡能力、行走能力及減少跌倒的危險因子是中風後患者復健的目標。曾有研究指出視覺生物回饋(Visual Biofeedback)訓練和使用外側楔型鞋墊(Lateral Wedge)來強迫患側的使用(Constraint Induced Movement Technique)，兩種訓練方式在中風後患者於平衡能力、患側承重能力皆有顯著的效果，但在應用於慢性中風患者及後續追蹤的研究尚未被驗證。因此本研究的目的主要為訓練慢性中風患者之動態、靜態平衡功能，以及使用外側楔型鞋墊介入以藉由加強患側下肢載重而增進雙側下肢的重量位移、增進平衡能力，進而改善平衡能力。材料與方法：本實驗分為三組，一組為視覺回饋平衡訓練組(Visual Biofeedback Balance Training Group; BT) 使用生物回饋的站立平衡訓練儀(Biodex Balance System)，來進行視覺回饋的平衡的訓練(重量轉移訓練; Weight Shift Training)，訓練時間為每周3次、每次20分鐘，共6週；一組為外側鞋墊組(Lateral Wedged Group; LW)使用5°的外側楔型鞋墊置於中風患者的健側下肢，可執行一般活動以及接受傳統治療的介入；另一組為只做傳統治療的控制組。三組皆於實驗期間都有做傳統的復健治療。於實驗前(0週)、實驗後(6週)及後續追蹤(10週)皆進行測試。比較治療介入前後差異與療效追蹤。測試項目：臨床功能性平衡活動量表(伯格式平衡量表(Berg Balance Scale, BBS)、中風病人姿勢控制量表(Postural Assessment Scale for Stroke Patients, PASS)、平衡電腦適性測驗(Balance Computerized Adaptive Test, Balance CAT))、平衡儀器測試(姿勢穩定度(posture stability)、穩定限制(limited of stability, LOS)、移行測試(起身行走測試(Timed up and go test, TUG)。使用SPSS第14版軟體進行統計分析；使用描述性統計、費雪精確檢定(Fisher's Exact Test)分析人口特徵相關資料；單因子變異數分析(One Way ANOVA), 重複量數變異數分析(Repeated Measure ANOVA), 雪費(Scheffe)的事後分析(post hoc), 獨立T檢定(Independent T test), 效應值(Effect Size)，分析三組間及三個時間點的差異。結果：共47位受測者完成所有的研究流程(BT組15人、LW組16人、Control組16人)並納入統計分析，所有受測者平均年齡為58.5±9.7歲，平均中風後46.7±33.3個月，36位男性11位女性參與；除了患側邊的分佈在組別分配上有顯著差異之外(P<0.05)，於基本資料皆沒有組別間的顯著差異(P>0.05)。介入前後及後續追蹤結果發現，三組相較於0週皆有組內之顯著差異(P<0.05)；臨床功能性平衡活動量表(BBS, PASS, Balance CAT)於三組間有組間差異，且兩組介入組(BT組和LW組)優於控制組；平衡儀器測試方面(姿勢穩定度三組間無顯著差異、穩定限制(LOS)三組間有顯著差異)；移行能力三組間無顯著差異；心理層面於三組間無顯著差異。結論：透過6週的視覺生物回饋訓練及5°的外側楔型鞋墊介入，可以改善慢性中風患者的平衡能力，且在後續追蹤也有繼續維持其平衡能力，且皆有好的順應性；雖然這兩種介入皆可改善慢性中風患者之平衡能力，但兩組間無顯著差異。

關鍵字

慢性中風；外側楔型鞋墊；視覺生物回饋訓練；平衡訓練；隨機控制分組

並列摘要

Objective: The hemiplegic with stroke patients, who accompanied by balance, motion and sensory ability impaired, and lead to increase the fall risk with decrease the activities of daily living function. Thus improving balance and gait pattern and consequently reduce falls is targets of the stroke rehabilitation. Many studies showed that visual biofeedback training and Constraint Induced Movement Technique to apply a shoe lift or lateral wedge under the sound side for patients with stroke, the balance ability and weight loading on the paretic limb had significant effect by both training, but had not been verified for applied with chronic stroke and without the follow-up studies. Therefore, the purposes of this study were to investigate and compare the effect of weight shift training by the Biodex balance system and 5° lateral wedge on non-paretic limb improving the symmetry of stance and weight bearing for chronic stroke. Material and Method: In this study, which include six-week intervention program, the subjects participated with randomly divided into three groups, the first group was weight shift and static balance training with visual feedback, the frequency of training was 3 times a week, each training session was 20 minutes; the second group was wearing a 5° laterally wedged insole on the non-paretic side for standing and ambulation; and the other group was control group, with traditional therapy of rehabilitation, and all subjects of three groups received traditional therapy of rehabilitation. All subjects should take per-test before training (0-wk), post-test after 6-week training (6-wk) and the follow-up (10-wk). Outcome measures: Clinical balance ability assessment (Berg Balance scale, BBS; Postural Assessment Scale for Stroke Patients, PASS; Balance Computerized Adaptive test, Balance CAT), Equipment of Biodex Balance system (posture stability; Limited of Stability, LOS), mobility (timed up and go test, TUG). Statistical analysis: Using SPSS 14.0 version, Analysis of demographic characteristics by the descriptive statistics, Fisher's exact test; and compared the full measurement parameters differences between before training and after with 3 groups by One way ANOVA, Repeated Measure ANOVA with post hoc test (Scheffe), Independent T test and Effect size. Results: Totally of 47 subjects completed the follow-up study (BT group (n=15), LW group (n=16), Control group (n=16)),and the mean age were 58.5±9.7 years old, onset time after stroke were 46.7±33.3 months. In addition to the grouping for affected side were significantly different (P <0.05), in the baseline information were no significant difference between groups (P>0.05). Before, after the intervention and follow-up compared to 0-week between three groups had significant differences within groups (P <0.05); The clinical balance ability assessment (BBS, PASS, Balance CAT) between groups had significant differences within groups (P <0.05), and both group better then control group; Equipment of Biodex Balance system (posture stability between 3 groups had no significant differences; LOS had significant differences), TUG between 3 groups had no significant differences, GDS between 3 groups had no significant differences. Conclusion: Both group (BT and LW groups) with intervention program could significant improved the balance ability for chronic stroke, and follow-up could maintain the balance ability, both groups also had good compliance. Although LW & BT groups could improved balance ability with chronic stroke, but had non-significant difference between two groups.

並列關鍵字

Chronic stroke ； Lateral Wedge ； Visual biofeedback training ； Balance training ； RCT

參考文獻

行政院衛生署. (2010). 民國九十九年衛生統計系列(一)死因統計

王淳厚, 毛慧芬, 薛漪平, &謝清麟. (2002). 中風病人姿勢控制評估量表之心理計量特性. 臺灣醫學, 6(4), 474-482.

吳英黛, 劉千綺, &鄭建興. (2008). 慢性中風病人的物理治療需求. 腦中風會訊, 15(4), 13-16.

Chen, I.-C., Cheng, P.-T., Chen, C.-L., Chen, S.-C., Chung, C.-Y., & Yeh, T.-H. (2002). Effects of balance training on hemiplegic stroke patients. Chang Gung medical journal, 25(9), 583-590.

Aruin, A. S., Hanke, T., Chaudhuri, G., Harvey, R., & Rao, N. (2000). Compelled weightbearing in persons with hemiparesis following stroke: the effect of a lift insert and goal-directed balance exercise. Journal of rehabilitation research and development, 37(1), 65-72.

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探討以兩種不同重心轉移訓練方式對中風患者功能性表現之影響

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