急性中風患者之姿勢控制與功能恢復之關係

背景與目的：中風後的動作缺失經常導致病患的長期失能。發掘有效的中風復健，提升日常生活功能的獨立，一直是復健領域的重要目標之一。然而目前研究多集中於亞急性及慢性期的中風患者，在急性階段的研究很少，急性期時神經的自我修復便已經開始，加上復健的介入能提升病患的恢復，所以探討在急性階段的有效復健方式是很重要的議題。本研究目的有二：(1)探討急性中風患者於不同功能等級間的功能活動差異(以中風病患姿勢評估量表評估，Postural Assessment Scale for Stroke，PASS)，(2)找出與三個月後日常生活功能恢復獨立相關的功能活動。方法：本研究使用科技部計畫(MOST106-2314-B-040-019)所蒐集的資料進行二次分析。受試者為住在某醫學中心神經內外科急性病房，符合收案條件且簽署同意書的急性中風病患。蒐集病患年齡、性別、認知功能(Mini-Cog)和嚴重度(美國國家衛生院腦中風評估表，National Institutes of Health Stroke Scale，NIHSS)，並以入院和出院時的PASS一到三項及行走能力進行功能等級分級(臥床、扶持坐、獨立坐、扶持站、獨立站且協助行走、和獨立行走)，最後在三個月時以巴氏量表(Barthel Index，BI)評估病患日常生活獨立性。結果：(一)各功能等級與前一功能等級間呈顯著差異且具有高效果量的PASS項目分別為扶持坐組：「翻到患側」、獨立坐組：「躺到坐」、扶持站組：「站到坐」、獨立站組：「彎腰撿筆」「坐到站」「站在健側」；獨立行走組：「站在患側/健側」。(二)急性缺血性中風病患在入院時能在最小協助下坐到站，或在急性病房出院時獲得最小協助下躺到坐的能力，為三個月後日常生活獨立(BI >60分)的顯著預測因子。結論：(一)不同功能等級之急性中風病患在特定姿勢控制能力呈現顯著差異，能提供急性復健治療計畫的建議。 (二)急性缺血性中風病患在急性入院以及出院時分別以「坐到站」和「躺到坐」的能力為三個月後日常生活獨立與否之預測因子，能作為急性復健目標設定之參考。

Background and purposes: Motor deficits after stroke often leads to long-term disability. Finding effective stroke rehabilitation to help stroke survivors achieving independent activities of daily living (ADL) has always been one of the important goals in the field of rehabilitation. However, studies have been focused mainly on subacute and chronic phases. Study in acute phase is scarce. Rehabilitation in acute phase takes advantage of self-repair process of the nervous system could maximize functional recovery. Thus, to explore effective rehabilitation in acute stage is worthwhile. This study aimed (1) to investigate the functional capability difference (as assessed by the Postural Assessment Scale for Stroke, PASS) between two adjacent functional levels in acute stroke patients and (2) to identify the functional capability that associated with independent ADL after three months. Methods: This study was done by secondary analysis of data collected in a previous research project sponsored by the Ministry of Science and Technology (MOST106-2314-B-040-019). Participants were patients suffered from acute stroke admitted to an acute ward of Neurology and Neuro Surgery in a medical center, met our inclusion criteria and signed the consent. Patient’s age, gender, cognition (Mini-Cog) and severity (National Institutes of Health Stroke Scale, NIHSS) were collected. PASS was assessed at admission and discharging. First three items of PASS and walking ability were used to categorize participants into six levels of function (bed rest, sit with support, independent sit, stand with support, independent stand, and independent walk). Participants’ ADL independence was assessed by Barthel Index (BI) at three months post stroke. Result: (1) The functional capability significantly different between two adjacent levels of function and with big effect sizes were reported as follows. (a) Bed rest vs. sit with support: "turning to the affected side"; (b) sit with support vs. independent sit group: "supine to sitting"; (c) independent sit vs. stand with support: " Stand to sit"; (d) stand with support vs. independent stand: "bend over to pick up a pen", "sit to stand", "stand on the sound side"; (e) stand with support vs. independent walk: "stand on the affected side/ sound side". (2) Patients with acute ischemic stroke could stand up from sitting with minimal assistance at admission or could sit up from supine with minimal assistance at discharge were significant predictors of independent ADL (BI > 60 points) after three months. Conclusion: (1) The revealed functional capability difference between two adjacent levels of function suggest potential intervention for acute rehabilitation. (2) For patients with acute ischemic stroke, their ability to sit-to-stand and supine-to-sit at the time of acute rehabilitation admission and discharge, respectively, significantly predict independent ADL after three months. This could guide goal setting in acute rehabilitation.