醫(yī)院培訓(xùn)課件：《腦卒中康復(fù)治療的循證科研與臨床意義》

1腦卒中康復(fù)治療的循證科研與臨床意義林克忠臺(tái)灣大學(xué)醫(yī)學(xué)院作業(yè)治療學(xué)系教授、博導(dǎo)長庚大學(xué)醫(yī)學(xué)院作業(yè)治療學(xué)系兼任教授2013年8月22日E-mail:

kehchunglin@.twEvidence-BasedStrokeRehabilitationResearchDevelopmentandClinicalApplication中國康復(fù)醫(yī)學(xué)會(huì)第十屆全國康復(fù)治療學(xué)術(shù)年會(huì)循證醫(yī)學(xué)

Evidence-BasedMedicine(EBM)1972年英國臨床流行病學(xué)者

Archi

Cochrane

首先提出循證醫(yī)學(xué)(Evidence-BasedMedicine,EBM)

的概念。循證醫(yī)學(xué)的實(shí)踐原則從資料庫選取主題文獻(xiàn)，經(jīng)由評(píng)讀分析，找出值得信賴的信息，應(yīng)用于臨床工作，使個(gè)案獲得最佳照顧。

ArchiCochrane(1909~1988)DavidSackett(1934~)2循證醫(yī)學(xué)的科學(xué)與藝術(shù)循證醫(yī)學(xué)整合三大要素：BestResearchEvidence（研究新知）ClinicalExpertise（臨床技能）Patients’Values（個(gè)案需求）ResearchEvidencePatients’ValuesClinicalExpertise循證醫(yī)學(xué)以最佳研究證據(jù)為基礎(chǔ)結(jié)合臨床專家意見及個(gè)案價(jià)值→提升臨床教學(xué)、研究、與醫(yī)療服務(wù)質(zhì)量3LevelsofEvidence(證據(jù)層級(jí))LevelDescriptionⅠaMeta-analysisofrandomizedcontrolledtrials（后設(shè)分析）ⅠbAtleastonerandomizedcontrolledtrial（隨機(jī)臨床試驗(yàn)）ⅡaAtleastonecontrolledstudywithoutrandomizationⅡbAtleastoneothertypeofquasi-experimentalstudyⅢNon-experimentaldescriptivestudies(comparative,correlationandcase-controlstudies)ⅣExpertcommitteereportsoropinionsand/orclinicalexperienceofrespectedauthoritiesUSAgencyforHealthCarePolicyandResearchClassification(AHCPR,1992)4腦卒中後的動(dòng)作失能525%

輕度障礙10%

良好復(fù)原40%

重、中度障礙10%

機(jī)構(gòu)照護(hù)需積極治療（如現(xiàn)代神經(jīng)康復(fù)）傳統(tǒng)療法成效受限(NSA,2012;Bonaiutietal.,2007)15%

死亡6腦卒中康復(fù)治療的轉(zhuǎn)變ConventionalApproaches(NeurodevelopmentalTreatments)NDT/BobathBrunnstromContemporaryApproaches(Task-OrientedTherapytoInduceNeuroplasticChanges)BilateralArmTrainingRobot-AssistedTherapyCombinedTherapyMirrorTherapyPNFConstraint-InducedTherapy7

RandomizedControlledTrial(RCT)

(隨機(jī)控制臨床試驗(yàn))Aformofclinicaltrialsincludingexperimentaland

controlgroupsToprovideahigherlevelofevidence

ComparativeEfficacyResearch

(療效對(duì)比試驗(yàn))Atypeofresearchforcomparingdifferentor

alternativetreatments

Toavoidover-generalizedmedicine臨床試驗(yàn)、對(duì)比試驗(yàn)：腦卒中康復(fù)科研重點(diǎn)（林克忠神經(jīng)康復(fù)研究室）8腦卒中康復(fù)治療科研架構(gòu)（林克忠神經(jīng)康復(fù)研究室）NeurorehabilitationinStrokeInnovativeInterventionApproachesRandomizedControlledtrialsComparativeEfficacyResearchAppropriateMeasuresofTreatmentEffectsMetricProperties&Patient-ReportedOutcomePossibleMechanismsBrainPlasticityMotorControlConstraint-InducedTherapyBilateralArmTraining

Robot-AssistedTherapyMirrorTherapyCombinedTherapyMetricStudyfMRIKineticandKinematicAnalysis9Constraint-InducedTherapyForcedUsetoOvercomeLearnedNonuse

「迫用患肢」以克服偏癱者的「習(xí)得廢用」現(xiàn)象ConstrainedUseoftheUnaffectedArmIntensiveTrainingofAffectedArmShapingTechniques局限誘發(fā)療法（強(qiáng)制運(yùn)動(dòng)療法）的治療原則10局限誘發(fā)療法Constraint-InducedTherapyEffectsonMotorandDailyFunctionsBrainReorganizationEvidencedbyfMRIEffectsonMotorControlStrategiesHome-BasedCITinChildrenwithCerebralPalsy11BilateralArmTraining雙肢同步動(dòng)作演練

BilateralCoupling&

InterlimbCoordinationRepetitivePracticeBilateralMovements

雙肢訓(xùn)練療法的治療原則局限誘發(fā)治療與雙肢訓(xùn)練療法的對(duì)比12StudyFindingsandMessages

BATmayuniquelyimproveproximalupper-limbmotorimpairment.

DistributedCITmayproducegreaterfunctionalgains

(eg,theMAL,thesubtestoflocomotionintheFIM).

Thesefindingsemphasizetheneedtotakedomainsofoutcomemeasuresintoconsiderationwhencomparingstrokerehabilitationprograms.MotorandMuscleFunctions13MirrorTherapy

鏡像治療

MirrorVisualFeedback

BilateralSymmetricalMovements鏡像治療法的治療原則14Robot-AssistedTherapy

High-Intensity&Repetitiveness

Feedback&InteractivenessTask-Specificity康復(fù)機(jī)器人治療的治療原則康復(fù)機(jī)器人治療15康復(fù)機(jī)器人治療研究（林克忠研究室）

Robot-AssistedTherapy(RT)RandomizedControlledTrials(RCT)ComparativeEfficacyResearch(CER)MarkersStudy(e.g.,OxidativeMarkers)Unilateralvs.BilateralRTTherapist-Basedvs.Robot-AssistedTherapyCombinedvs.Mono-TherapyFutureStudyEffectsonFunctionalOutcomesandMotionAnalysis例證1NeurorehabilNeuralRepair25:503-511,2011.例證2Stroke43:2729-2734,2012.例證3AmJOccupTher66:198-206,2012.例證4JNeuroengRehabil10:35,2013.例證5PhysTher92:1006-1016,2012.例證6PilotStudyofHybridTherapyDose-ResponseEffectsofRTUnilateralvs.BilateralHybridTherapy16康復(fù)機(jī)器人治療之密集度（劑量）與生物標(biāo)記研究例證1Totestthedose–responserelationsbyusing2groupsreceivinghigherintensityandlowerintensityRT.ToexaminetheeffectsofRTonlevelsofthe8-OHdG,a

biomarkerofoxidativestressassociatedwithintenseexercise.17康復(fù)機(jī)器人的劑量與反應(yīng)關(guān)系研究例證2Patientswithmoderatemotordeficitstendedtohavemoremotorimprovementsafterthehigher-intensityrobot-assistedtherapy.Thepatient’slevelofmotorimpairmentshouldbeconsideredwhenplanningforrobot-assistedstrokerehabilitation.

(Stroke2012;43:2729-2734)

18單肢（患肢）與雙肢康復(fù)機(jī)器人治療之比較

UnilateralRTBilateralRTVS例證3AmJOccup

Ther66(2):198-206,2012

UnilateralRTappearedtobeafavorableapproachtoimprovingmotorimpairment,distalmusclepower,andgripstrength.

BilateralRT

mightbemoreeffectiveinenhancingproximalmusclepower.單肢（患肢）與雙肢康復(fù)機(jī)器人治療之運(yùn)動(dòng)學(xué)比較19JNeuroEng

Rehabil10(1):35,2013例證4

UnilateralRTproducedbetterimprovementsinupperextremitytemporalefficiency.

BilateralRT

mightbemoreeffectiveinreducing

compensatorytrunkatbeginningofreaching.康復(fù)機(jī)器人治療與治療師治療的比較20例證5Therapist-basedandrobot-assistedbilateralarmtrainingmayexhibiteddifferentialeffects.Therapist-basedtreatmentmayimprove

temporalefficiency,smoothness,trunkcontrol,andmotorimpairmentofthedistalupperlimb.Robot-assistedtherapymayimproveshoulderflexion,self-perceivedstrengthandphysicalfunction.Assessedforeligibility(N=250)EnrollmentCTGroup(n=14)TABTGroup(n=14)RABTGroup(n=14)Randomized(n=42)Analyzed(n=14)Excluded(n=280)Didnotmeetinclusioncriteria(n=172)Refusedtoparticipate(n=36)Analyzed(n=14)Analyzed(n=14)康復(fù)機(jī)器人治療與局限誘發(fā)治療：

混合療法的加成效果

21ThepreliminaryfindingssupporttheuseofRTcombinedwiththerapist-basedarmtrainingto

enhancetreatmentefficacy.

RT+CITledtoadditiveeffectsonmotorabilityandfunctionalperformance

relativetomonotherapies.例證6局限誘發(fā)治療與軀干局限的混合療法

22

CITinvolvesmasspracticeoffunctionaltasksandfocusesontheabilitytoaccomplishatask.TR

aimsatreducingcompensatorystrategiesofthetrunkandnormalizingupper-limbmotorcontrol.局限療法(CIT)軀干局限(TR)

局限誘發(fā)治療與視覺遮蔽之混合療法23MonocularEyePatching

（視覺遮蔽:遮蔽健側(cè)視覺輸入）

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