投擲沙包活動訓練對中風患者動作與認知表現效益

Abstract

中風是全球發生率高的疾病，常伴隨動作與認知失能，進而影響日常生活功能表現。隨著醫療進步，發展出多元保守治療手法來提升病患的能力，降低疾病所帶來的功能性影響。為了有效將病患習得能力類化至日常生活，中風患者在臨床治療手法上強調任務導向功能性訓練。多項研究證實，任務導向模式訓練有助於提升病患的動作表現。其中投擲沙包活動訓練是臨床上常使用的任務導向訓練活動，屬於全身性動態活動，藉由任務的引導，誘發病患全身性感覺、動作協調；而有研究顯示動作訓練過程中，腦部的血流量會跟隨著運動的強度增加，有助於改善、維持及提升認知功能。然而相關效益研究較少，其臨床效益假設需要實證研究的證實。本研究採取短期效果追蹤前-後測實驗設計（Pretest-posttest short-term follow-up study），於臺北地區醫院、復健科診所徵求符合研究條件，且自願參與的中風患者共計21位，分別為實驗組11位；對照組10位。納入條件包括（1）腦中風診斷、病程超過6個月（含6個月）（2）布朗斯壯動作恢復層級（Brunnstrom Stage of Motor Recovery，BSMR）上、下肢動作層級達3以上、（3）改良式艾許沃斯氏量表（Modified Ashworth Scale，MAS）層級上下肢爲2以下、（4）簡易智能量表（Mini-Mental State Examination，MMSE）得分達24分以上、（5）可獨立行走（6）年齡為30~80歲及。符合條件且同意參與研究者會記錄個人基本資料、醫療相關紀錄，並以動作及認知方面能力做為結果參數。 動作能力使用的工具包含傅格梅爾動作評估量表（Fugl-meyer Assessment，FMA）（上肢與下肢動作分數）、積木與盒子測驗（Box and Block Test，BBT）（一分鐘內健側與患側手移動的積木數量）、伯格氏平衡量表（Berg Balance Scale，BBS）（總分56分）、計時起身－行走測驗（Timed-up and Go Test，TUG）（由座椅起立往前走三公尺轉身回到座椅坐下所需秒數）、功能性伸臂測驗（Functional Reach Test，FRT）（健側手臂最大前伸距離公分）、靜態站姿下壓力中心（Center of Pressure，COP）晃動量；認知能力使用工具為褚氏注意力測驗（Chu’s Attention Test，CAT）（10分鐘完成的題數及錯誤數）、刪除測驗（Cancellation Test，CT）（包含形狀刪除測驗CST與數字刪除測驗CNT完成的時間及錯誤數）及彩色路徑描繪測驗（Color Trails Test，CTT）版本1和2（測驗所需時間與干擾值）。 所有的參與者前測完成，讓研究抽籤分為實驗組或對照組。實驗組接受投擲沙包活動訓練30分鐘、患側下肢訓練10分鐘及患側上肢訓練20分鐘；對照組接受站立桌訓練30分鐘、患側下肢訓練10分鐘及患側上肢訓練20分鐘，兩組在患側上下肢訓練皆以肌肉張力正常化、動作協調性與神經肌肉功能整合為主。每位接受每週2次、每次介入60分鐘並持續12週的治療訓練。於研究開始前1週、研究介入第6週及第12週進行成效評量與追蹤。資料分析以 SPSS 23.0套裝統計軟體進行統計分析，以描述性統計呈現兩組個案之特性。以卡方（Chi-square）檢定兩組之性別、教育程度、修正版艾許沃斯氏量表、布朗斯壯動作恢復上下肢層級在兩組是否配對；以t-test檢定兩組之平均年齡、身高、體重、中風時間與簡易智能量表是否配對。兩組訓練之成效差異，以雙因子變異數分析（Two way ANOVA）進行檢定，組間因子是組別、組內因子是測驗時間，同時計算效果值。結果顯示，兩組在人口學特性方面兩組相當，在描述性統計分析結果顯示p值結果皆> 0.05無顯著差異。在訓練成效上，兩組與時間交互檢驗結果得知，兩組在TUG（p = 0.022）、FRT（p = 0.01）及Berg（p = 0.034）達顯著差異（p < 0.05），而在其他變項皆無顯著差異。 效果量顯示FMA-U（ηp2 = 0.066）、BBTNH（ηp2 = 0.09）、TUG（ηp2 = 0.182）、FRT（ηp2 = 0.252）、BBS（ηp2 = 0.206）、CNM（ηp2 = 0.128）、CSM（ηp2 = 0.088）、BFSC（ηp2 = 0.096）、BFTC（ηp2 = 0.109）、HTC（ηp2 = 0.069）、RC（ηp2 = 0.078）皆達到中度以上的效果量。從組內效應檢定結果得知，實驗組（EG）在FMA-L（p = 0.008）、BBTH（p = 0.009）、BBTNH（p = < 0.001）、TUG（p = .007）、FRT（p = < .001）、BBS（p = < .001）、BFTC（p = .04）、CAT（p = 0.007）及CTT1（p = 0.044）皆 < 0.05有顯著差異；對照組（CG）在FMA-L（p = 0.002）、BBTH（p = 0.17）、BBTNH（p = 0.001）、BBS（p = 0.004）及BFTO（p = 0.03）皆< 0.05有顯著差異。兩組於動作能力表現於6週與12週的訓練下，動作能力表現有進步；認知能力結果顯示，為期12週兩組訓練對於認知能力表現有提升的潛能。整體而言，兩組完成12週的訓練效果比參與6週有更多的進步幅度，而實驗組所參與的訓練相較於對照組在動作及認知能力上也有更顯著的提升。 結論為參與投擲沙包活動及站立推拉箱訓練，在為期12週的訓練下，對中風患者在動作與認知能力有所助益，投擲沙包訓練對改善中風患者行走與姿勢控制能力的改善效果優於站立推拉箱訓練。Stroke is one of the diseases with high incidence in Taiwan. It often accompanies movement and cognition disorder , which affects the performance of daily activities. In clinical treatment, therapists use many novel techniques to promote motor function. Lots of studies suggested that task-oriented functional training improved and upgraded patient’s motor、cognition and daily function. Bean-Bag activity is a dynamic task- oriented activity often used in clinics. But there are few studies investigating its training effects. Therefore, this study aims to evaluate the effectiveness of the activity training on motor and daily life functions in patients with stroke.The study design is the Pre-and post-test design with short-term effect follow-up. Twenty one patients who fulfill the inclusion and exclusion criteria was recruited. After the pre-study assessments, participants was assigned into experimental or control group randomly. The treatment program for participants in experimental group is bean-bag activity、lower extremity (L/E) training and ipsilateral upper extremity (U/E) training；the participants in control group participatetr routine occupational therapy program, include standing table training、L/E training and ipsilateral U/E training. Both groups received training twice a week、60 minutes for each session, and the treatment continued for 12 weeks. The demographic data, including the gender、education、MAS、Brunnstrom stage、ages、height、weight、onset time was collected. The outcome measures included Fugl-meyer assessment (FMA)、Box and block test (BBT)、Berg balance scale (BBS)、Timed up and go test (TUG)、Functional reaching test (FRT)、Center of pressure in static standing (COP)、Color trails test (CTT)、Cancellation test (CT) and Chu’s attention test (CAT). All participants will be evaluated one-week before and 6 weeks and 12 weeks after training.SPSS 23.0 software package was used for all statistical analysis. Descriptive analysis was used for comparison of the demographic characteristics of two groups. The gender、education、MAS and the Brunnstrom stage difference between the two groups was determined by Chi-square. T-Test verifiesd whether the ages、height、weight、onset time of the two groups were matched. The difference of between groups in outcome measure was analyzed with two- way analysis of variance (Two-way ANOVA). Between-group factor is Test time is within-group factor，and the effect size was calculated。The results showed that two groups were comparable in terms of demographic characteristics, and the results of the descriptive statistical analysis showed no significant difference( p> 0.05)。The results of group and test time interaction was as follows: the two groups were significantly different (p < 0.05) in TUG (p = 0.022)、FRT (p = 0.01) and BBS (p = 0.034) , and there were no significant differences in other variables. However, the effect size showsd FMA-U (ηp2 = 0.066)、BBTNH (ηp2 = 0.090)、TUG (ηp2 = 0.182)、FRT (ηp2 = 0.252)、BBS (ηp2 = 0.206)、CNM (ηp2 = 0.128)、CSM (ηp2 = 0.088)、BFSC (ηp2 = 0.096)、BFTC (ηp2 = 0.109)、HTC (ηp2 = 0.069)、RC (ηp2 = 0.078) all achieved moderateor high effect size levels. The results of the within-group effect test showed that the experimental group (EG) was significantly different in FMA-L (p = 0.008)、BBTH (p = 0.009)、BBTNH (p =< 0.001)、TUG (p = 0.007)、FRT (p= < 0.001)、BBS (p = < 0.001)、BFTC (p = 0.04)、CAT (p = 0.007) and CTT1 (p = 0.044) ; the control Group were significant different in in FMA-L (p = 0.002)、BBTNH (p = 0.001)、BBS (p = 0.004) and BFTO (p = 0.030). The motor performance of two groups improved after the training of 6 weeks and 12 weeks；the cognitive performance results showed that 12 weeks training in the two groups had the potential to improve cognitive performance. Overall, the training effects of twogroups after 12 weeks of training progressed more than at 6 weeks. The training in experimental group resulted in more significant improvement in motor andcognitive than the training in control group.