臺灣博碩士論文加值系統

目的 探討侷限-誘發動作療法（constraint-induced movement therapy, CIMT）是否優於傳統治療手法是否可以較有效改善中風病患患肢動作功能。在亞急性期與慢性期提供CIMT介入，是否有不同的療效差異。利用運動學動量分析來評估接受CIMT後,是否能有效改善動作控制的策略形成與執行能力，並維持治療效應至一個月後的追蹤期。

方法 分別取樣亞急性與慢性中風病患共28名，含7位亞急性、8位慢性患者，共15名接受CIMT治療。CIMT組個案患肢接受每日兩小時、每週五天，持續三個星期的大量密集性功能性活動訓練，且健側肢體以布質手套每日侷限至少六小時。傳統治療組則接受一般職能治療。於治療前後及一個月後的追蹤期，利用運動學動量分析評估個案在
伸手及物及取物動作上相關動量參數的改變量並配合使用相關臨床行為量表以了解個案在動作損傷、活動失能層級以及個體自我安適感的進步狀況。

結果 CIMT組在動量分析或臨床評量上皆比控制組進步較多，在執行伸手按鈴的活動情境中，反應時間、移動路徑偏移明顯減少較多、達到瞬時速度所佔運動時間比也明顯增加較多而與控制組有顯著差異。臨床評量中的富格麥爾上肢動作評量與上肢動作活動紀錄量表的「患肢使用量」、「動作品質」以及功能獨立測驗皆比控制組進步明顯。而在主觀評定自我安適感的中風量表中，CIMT組明顯呈現較正向的整體復原感受。這些改變量的差異並維持到一個月後的追蹤期。接受CIMT的亞急性患者普遍比慢性病患進步較多，但達到統計上明顯有差異的項目不多，分析結果發現不同發病期對CIMT的療效反應不盡相同。

結論 提供CIMT較一般傳統治療可以有效改善患肢動作功能，不僅改善動作控制策略形成的能力，改善動作執行的品質，更能實際提升個案在日常生活情境中使用患肢的頻率並促進個體安適感。亞急性病患接受CIMT的療效有較佳的趨勢，顯示及早提供足夠強度的治療策略可以有效啟動神經塑性，促進動作恢復。慢性病患藉由CIMT可以有效改善患肢「學習廢用現象」，有效增進患肢使用量。

Objective The purpose of this study was to investigate the effectiveness of constraint-induced movement therapy (CIMT). This study also compared the effects of CIMT applied to subacute and chronic stroke patients. By using more sensitive and objective evaluation tool, 3-D motion analysis, we could get information about how patients improved their motor function by improving motor control strategy after they received CIMT. After one-month follow-up, the long-term effects of CIMT could be evaluated.

Methods Twenty-eight stoke patients were recruited in this study. Fifteen were assigned to receive CIMT (seven were subacute patients, eight were chronic patients), involving 2-hour intensive training for the affected arm and 6-hour constraint of the unaffected arm per day for 3 weeks. The control group received conventional occupation therapy. This study used kinematic motion analysis to assess the changes of the movement performance of reaching and reaching-to-grasping tasks and used other clinical outcome measures to evaluate the improvement of functional performance and well-being perception.

Results The CIMT group improved more in kinematic or clinical assessments than the control group. In pressing desk bell condition in motion analysis, the CIMT group showed significantly more improvement in reaction time, norzTD, and PPV that implicating faster to initiate movement, more direct movement to the target, and more advanced motor planning. CIMT group also showed more significant improvements in FMA, MAL-AOU & QOM, FIM and also perceived more positive well-being of life, especially in physical domains. The subacute patients who received CIMT generally improved more than chronic patients, although the differences were not significant in many dependent variables. Subacute patients and chronic patients might have different responses to CIMT.
Conclusion CIMT was a more effective and efficient method to improve motor function of affected arm in subacute and chronic patients. CIMT applied in subacute patients might have more benefits to help patients to induce brain plasticity and could keep improvements to one-month follow-up.

目錄

中文摘要……………………………………………...…….………………………… i
英文摘要………………………………………………………………………..…… iii
目錄………………………………………………...……….………………………... v
表目錄…………………………………………………..…………………………... vii
圖目錄……………………………………..…………….……………………………ix
第一章 前言………………………………...…………..….………………………. 1
第二章 文獻回顧…………………………………….....….………………………. 3
第一節 侷限-誘發動作療法的理論架構……………………..………………… 3
第二節 侷限-誘發動作療法的臨床實行手法………………..………………… 5
第三節 侷限-誘發動作療法的相關療效驗證………………..………………… 7
第四節 上肢動作運動學分析………………………………….……………… 11
第三章 研究問題…………………………………………………………………. 16
第一節 研究動機………………………………….………………………….... 16
第二節 研究目的…………………………………….……………………….... 18
第三節 研究假設……………………………………………….……...………. 18
第四章 研究方法………………………………………………….…………….... 20
第一節 研究設計……………………………………………….…...…………. 20
第二節 研究對象………………………………………………………………. 20
第三節 治療介入方案…………………………………………………………. 21
第四節 評估工具………………………………………………………………. 21
第五節 研究程序………………………………………………………………. 27
第六節 資料分析………………………………………………………………. 27
第五章 結果…………………………………………..………………………...… 29
第一節 個案基本資料………………………………………………………..... 29
第二節 療效評量結果…………………………………………………….……….….. 29第六章 討論………………………………………………………………………. 37
第一節 侷限-誘發動作療法整體療效的探討………………………………… 37
第二節 中風發病期對侷限-誘發動作療法療效影響之探討………………… 41
第三節 研究侷限與建議……………………………………………………..... 46
第七章 結論……………………………………………………………...……….. 48
參考文獻………………………………………………………………...………….. 49
附錄……………………………………………………………...………………….. 82













表目錄

表1 研究參與者基本人口學資料與臨床特徵……………………...……...…… 55
表2 CIMT組與傳統治療組於三週治療期後及一個月追蹤期後運動學動量分析
相關變項改變值: 患肢伸手撈錢幣………………………..……………… 56
表3 各組研究參與者於三週治療期後及一個月追蹤期後運動學動量分析相關
變項改變值: 患肢伸手撈錢幣………...………………….……………….. 57
表4 各組研究參與者於三週治療期後及一個月追蹤期後運動學動量分析相關
變項改變值之曼惠特尼U檢定結果: 患肢伸手撈錢幣………………….. 58
表5 CIMT組與傳統治療組於三週治療期後及一個月追蹤期後運動學動量分析
相關變項改變值: 患肢伸手按壓按鈴…….…………....….……………… 59
表6 各組研究參與者於三週治療期後及一個月追蹤期後運動學動量分析相關
變項改變值: 患肢伸手按壓按鈴…………..……………..……………….. 60
表7 各組研究參與者於三週治療期後及一個月追蹤期後運動學動量分析相關
變項改變值之曼惠特尼U檢定結果: 患肢伸手按壓按鈴….……..…….. 61
表8 CIMT組與傳統治療組於三週治療期後及一個月追蹤期後運動學動量分析

相關變項改變值: 患肢伸手抓握大飲料罐…..…………...………….…… 62
表9 各組研究參與者於三週治療期後及一個月追蹤期後運動學動量分析相關
變項改變值: 患肢伸手抓握大飲料罐…………..…………………..…….. 63
表10 各組研究參與者於三週治療期後及一個月追蹤期後運動學動量分析相關
變項改變值之曼惠特尼U檢定結果: 患肢伸手抓握大飲料罐……….. 64
表11 CIMT組與傳統治療組於三週治療期後及一個月追蹤期後運動學動量分
析相關變項改變值: 患肢伸手抓握小飲料罐……..…………...……… 65
表12 各組研究參與者於三週治療期後及一個月追蹤期後運動學動量分析相關
變項改變值: 患肢伸手抓握小飲料罐……………...…..…………..……..…….. 66
表13 各組研究參與者於三週治療期後及一個月追蹤期後運動學動量分析相關
變項改變值之曼惠特尼U檢定結果: 患肢伸手抓握小飲料罐………...67
表 14 CIMT組與傳統治療組於三週治療期後及一個月追蹤期後臨床評量分數
進步指數…………………………………………………....………….…68
表15 各組研究參與者於三週治療期後及一個月追蹤期後臨床評量分數進步指
數…………………………….……………………………………..……..69
表16 各組研究參與者於三週治療期後及一個月追蹤期後臨床評量分數進步指
數之曼惠特尼U檢定結果…….………………………..………………..70














圖目錄

圖1 侷限誘發動作療法訓練活動圖……………………………...………………71
圖2 四組個案於三週治療期後及一個月追蹤期後在執行四種活動情境下之RT
變項改變值比較圖………………………………...……………………….. 72
圖3 四組個案於三週治療期後及一個月追蹤期後在執行四種活動情境下之MT
變項改變值比較圖………………………..…..………………………….. 73
圖4 四組個案於三週治療期後及一個月追蹤期後在執行四種活動情境下之
norzTD變項改變值比較圖…………….………...……………………….. 74
圖5 四組個案於三週治療期後及一個月追蹤期後在執行四種活動情境下之PV
變項改變值比較圖…………………………...…………………..……….. 75
圖6 四組個案於三週治療期後及一個月追蹤期後在執行四種活動情境下之PPV變
項改變值比較圖…………………………………….……………………...…….. 76
圖7 四組個案於三週治療期後及一個月追蹤期後在執行四種活動情境下之MU
變項改變值比較圖………………...……………………………..………….. 77
圖8 四組個案於三週治療期後及一個月追蹤期後在執行伸手取物活動情境下
之MGA變項改變值比較圖……………………………………….……….. 78
圖9 四組個案於三週治療期後及一個月追蹤期後在執行伸手取物活動情境下之
PMGA變項改變值比較圖……………………………….…………….. 79
圖10 四組個案於三週治療期後及一個月追蹤期後在臨床動作行為相關評量進
步指數比較圖………………………………………………...………….. 80
圖11 四組個案於三週治療期後及一個月追蹤期後在中風影響量表各向度進步
指數比較圖……………………..……………………...……………...………….. 81

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