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腦中風患者接受住院復健治療預后功能的研究
【關 鍵 詞】
腦中風Stroke
預后Prognosis
功能結果Functional outcomes
復健治療Rehabilitation therapy
【論文類別】 博士論文
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【中文摘要】
本前瞻性研究目的主要調查與探討民國八十六年一月至十二月期間163位住院高雄醫學大學
附設中和醫院復健科接受復健治療的腦中風患者，其社會人口學及住院期間診斷評估臨床
數據、其復健治療效益性、出院時日常生活功能預后進步情形和相關預測因子、影響住院
天數長短的預測因子、出院至少六個月預后功能獨立自主和使用長期照護機構的影響因素
和生活型態改變的情形。
我們的研究結果顯示：日常生活能力以功能獨立自主量表(Functional Independence
Measure, FIM)分數為指標，在住院期間無論全部項目得分或其六大類別得分的進步量在統
計學上都有顯著的意義。這個結果可以說明復健治療對于中風病人的預后結果扮演重要的
正面角色。影響出院時FIM量表得分的重要預測因子包括年齡、多次中風病史、住院期間多
項并發癥、定向能力異常及神經心理功能異常暨失智癥等；而感覺異常和多次中風病史患
者是影響住院期間功能獨立自主量表進步量的重要預測因子。
住院時FIM量表平均得分57.7 ± 24.5；出院前77.3 ± 26.3。住院期間復健效率平均得分
0.7 ± 0.7和復健效果30.6 ± 24.0%。對于復健治療效率而言，在統計學上有意義的預測
因子包括復健治療住院天數和患側上肢近端肢體運動功能恢復級數，兩項因素可以解釋復
健治療效率21%的變異量；對于復健治療效果而言，在統計學上有意義的預測因子包括年齡
和患側上肢近端肢體運動功能恢復級數，兩項因素可以解釋復健治療效果24%的變異量。
住院初期以福格-米勒平衡量表(Fugl-Meyer Balance Scale, FMBS)評估平衡能力可以解釋
接受復健治療住院天數6%的變異量及復健治療效率3%的變異量；然而，平衡能力無法提供
解釋住院期間FIM得分進步情形的變異量。這些結果說明住院復健初期臨床使用FMBS量表來
評估平衡能力似乎無法有效預測中風病患接受復健治療預后功能結果。
住院時FIM量表得分能力、是否肩關節有半脫位、是否兩側肢體運動功能皆受損和接受教育
年數是為住院天數長短的的重要預測因子。這些重要預測因子可以解釋住院天數長短21.5%
的變異量。這些結果可以做為未來腦中風患者接受住院復健治療健保給付規劃論病例計酬
標準的參考。
出院半年后共完成142位個案日常生活狀態的追蹤訪視，結果發現訪視時日常生活功能完全
獨立者共有23位(16.2%)。住院時加拿大神經量表(Canadian Neurological Scale, CNS)得
分能力和住院時FIM量表得分能力可為中風病患復健治療出院半年后生活功能是否獨立自主
的重要預測因子。
有關使用長期照護機構方面，這部份共完成151位個案的追蹤訪視。結果發現訪視時正住在
長期照護機構者共有23位(15.2%)。邏輯回歸分析結果發現，兩側肢體運動功能是否皆受損
、出院時意識狀況是否正常和平衡量表得分能力是為最佳預測變項。
有關預后生活型態改變的追蹤研究，這部份以出院至少半年后芙蘭切活動量表(Frenchay
Activities Index, FAI)及FIM量表評估結果做為預后全面性日常生活活動分析數據。結果
顯示比較發病前和出院至少半年后訪視時FAI量表及其三大項目(做家務事、戶外活動及休
閑工作)得分的退步量在統計學上都有顯著的差異性。發病前和訪視時FAI量表得分皆與年
齡呈負相關性(Pearson r = - 0.24, p< 0.05; r = -0.34, p< 0.001)；訪視時FAI量表得
分和FIM量表得分呈顯著正相關性(Pearson r = 0.58, p< 0.001)。這些結果說明使用FAI
量表可以量化腦中風患者預后生活型態變化的情形。
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【英文摘要】
The purposes of this prospective study were to investigate the clinical
profile, rehabilitation effectiveness and the functional outcomes at
discharge, to investigate predictive variables of length of rehabilitative
stay, to identify the prognostic factors about functional independence and
long-term care institution utilization, and to investigate the lifestyle
change and analysis of the related factors, at least 6 months after
discharge
for stroke patients following rehabilitation therapy. A total of 163
stroke
patients who were consecutively admitted to the inpatient rehabilitation
department at Kaohsiung Medical University Hospital in 1997 were included
in
this study.
The results indicated that Functional Independence Measure (FIM) score at
discharge and gains were used as the index of prognosis. Statistical
analyses
indicated that significant improvement in each FIM subscale scores was
noted.
Significant predictors of discharge FIM scores include age, previous
attacks
twice or over, medical comorbidities, sensory and orientation impairments,
and
dementia. In addition, previous stroke attacks twice or over and sensory
impairment were significant predictors of FIM gains during rehabilitation
period.
The mean FIM score was 57.7 ± 24.5 at admission versus 77.3 ± 26.3 at
discharge. The mean rehabilitation efficiency (0.7 ± 0.7) and
effectiveness (
30.6 ± 24.0%) of stroke rehabilitation were determined. Rehabilitation
efficiency and rehabilitation effectiveness were significantly predicted
by
length of rehabilitation stay and arm motor recovery stage, and by age and
arm
motor recovery stage, respectively. The variance explained only 21% of the
rehabilitation efficiency and 24% of the achievement of rehabilitation
potential.
The Fugl-Meyer Balance Scale (FMBS) score at admission accounted for 6% of
the
variation in length of stay, once demographic influences were controlled.
The
FIM efficiency score could possibly be predicted by the balance ability at
admission, which accounted for 3% of the variance. However, the balance
score
could not provide predictive information about the FIM gain with
demographic
factors controlled. These findings suggest that the use of FMBS at
admission
to stroke inpatient rehabilitation seemed not to enhance the ability to
predict rehabilitation outcomes.
Admission FIM score, shoulder subluxation, bilateral limbs involvement and
the
level of education significantly predicted length of stay (LOS). But, the
variance of the LOS was explained only 21.5%. The results of this study
suggest that these objective predictors can be used as the basis of
reimbursement for stroke rehabilitation in case payment system in the
future.
Of the 142 subjects surveyed at least 6-month follow-up visit after
discharge,
23 (16.2%) stroke patients had been functional independence outcome at
home.
The results of this study suggest the usefulness of the admission Canadian
Neurological Scale (CNS) and FIM scores in the prediction of functional
independence outcome for stroke survivors following rehabilitation
therapy.
Of the 151 subjects surveyed at least 6-month follow-up visit after
discharge,
23 (15.2%) patients had been living in long-term care institutions.
Whether
they had (1) limbs bilaterally affected, (2) impaired orientation, or (3)
poor
standing ability at discharge were the strongest predictors of long-term
care
institution utilization for stroke patients following rehabilitation
therapy.
FIM instrument and Frenchay Activities Index (FAI) as comprehensive
assessment
of Activities of Daily Living (ADL) were measured at least 6 months
following
the onset of stroke. Significant differences were observed in the FAI
subscore (domestic chores, outdoor activities, and leisure/work
activities)
between prestroke and poststroke status at interview. FAI scores at
prestroke
and poststroke status were negatively correlated (r =- 0.24, p < 0.05;
r=-0.
35, p<0.001) with age; FAI score was positively correlated (r = 0.58, p <
0.
001) with FIM score. The findings indicated that FAI score is useful as a
quantitative index of the lifestyle change on the prognosis for stroke
patients.
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【 目 錄 】
目 錄
博士論文總摘要 1~3
Abstract of Dissertation 4~7
第一章 緒論：前言、文獻探討及本研究目的和規畫 1-1~14
第二章 腦中風患者的臨床數據和功能恢復情況的研究 2-1~16
第三章 腦中風患者復健治療預后的初步研究3-1~24
第四章 初次中風病人復健治療的效率和效果4-1~18
第五章 腦中風患者住院時平衡能力和預后功能的關系 5-1~13
第六章 影響腦中風患者復健治療住院天數長短的因素 6-1~16
第七章 影響腦中風患者預后功能獨立的因素 7-1~16
第八章 影響腦中風患者預后使用長期照護機構的因素 8-1~16
第九章 腦中風患者預后生活型態改變的追蹤研究 9-1~17
第十章 結論：研究成果與未來展望 10-1~13
附錄一：功能獨立自主量表(Functional Independence Measure, FIM)
附錄二：福格-米勒平衡量表(Fugl-Meyer Balance Scale, FMBS)
附錄三：加拿大神經量表(Canadian Neurological Scale, CNS)
附錄四：芙蘭切活動量表(Frenchay Activities Index, FAI)
附錄五：本研究相關論文發表成果
表目錄
INDEX OF TABLE
表2-1. 163位中風病患的基本人口學數據
Demographic data of 163 stroke patients
表2-2. 住院期間臨床診斷檢查和評估數據
Clinical and diagnostic factors of 163 stroke patients
表2-3. 住院期間功能獨立量表主要項目得分和進步量
Functional improvement on subscale and total FIM score during inpatient
rehabilitation
表2-4. 接受復健治療前后步行及生活能力獨立狀況的人數比較
Comparison of number of persons with ambulation and ADL independence
following rehabilitation therapy
表3-1. 147位中風病患的基本人口學數據
Demographic data of 147 stroke patients
表3-2. 住院期間臨床診斷檢查和評估數據
Clinical and diagnostic factors of 147 stroke patients
表3-3. 住院期間功能獨立量表主要項目得分和進步量
Functional improvement on subscale and total FIM score during inpatient
rehabilitation
表3-4. 皮爾森相關系數分析序位/等距變項和預后功能的間的相關性
Pearson correlation for ordinal/interval variables considered in
predicting functional outcome
表3-5. Student's t-test 檢定類別變項和預后功能結果的間的差異性
Student's t-test for nominal variables on functional outcome of stroke
patients
表3-6. 類別變項和預后功能的間的變異數分析
Analysis of variance for nominal variables on functional outcome
表3-7. 復回歸分析預測中風病人出院FIM量表得分的結果
Multiple regression analysis predicting discharge FIM score
表3-8. 復回歸分析預測中風病人FIM量表進步量的結果
Multiple regression analysis predicting FIM improvement
表4-1. 110位初次中風病患的基本人口學和臨床診斷檢查數據
Clinical and demographic data of first 110 stroke patients
表4-2. 住院期間功能獨立量表主要項目得分和進步量
Functional improvement on subscale and total FIM score during inpatient
rehabilitation
表4-3. 皮爾森相關系數分析序位/等距變項和預后功能的間的相關性
Pearson correlation analysis between ordinal/interval
variables and rehabilitation outcome
表4-4. Student's t-test 檢定類別變項和預后功能結果的間的差異性
Difference between nominal variables and rehabilitation outcome as
assessed by Student's t-test
表4-5. 復回歸分析預測110位初次中風病人復健治療的效率和效果
Multiple regression analyses predicting rehabilitation outcome in 110
patients with first stroke
表5-1. 163位中風病患的基本數據
Basic data of 163 stroke patients
表5-2. 皮爾森相關系數分析平衡能力和住院時FIM量表得分及預后 功能間的相
關性
Pearson's correlation analyses between balance score and FIM score and
rehabilitation outcome
表5-3. 復回歸分析剛住院時平衡能力得分和預后功能結果的關系
Multiple regression analyses between admission balance score
and rehabilitation outcomes
表6-1. 中風病患的基本數據 (n=163)
Basic data of 163 stroke patients
表6-2. Pearson 相關系數檢定住院天數長短和等距變項的相關性
Pearson correlation analysis between ordinal/interval variables and
length of rehabilitation stay
表6-3. Student's t-test 檢定住院天數長短和類別變項的差異性
Difference between nominal variables and length of rehabilitation stay
as
assessed by Student's t-test
表6-4. 相關影響因素對住院天數長短的復回歸分析
Multiple regression analyses predicting length of rehabilitation stay
表7-1. 中風病人預后功能獨立與否兩組間相關變項的差異性比較
Comparison of prospective factors between patients with functional
independence or dependence
表7-2. 預后功能獨立與否的影響因素及關聯程度的檢定
Associations between prospective factors and functional independence
表7-3. 影響中風病患預后功能獨立與否的最佳預測因子
Selected predictors influencing functional independence outcome
表8-1. 151位中風病患的基本數據
Basic data of 151 stroke patients
表8-2. 出院后使用長期照護機構的影響因素及關聯程度的檢定
Associations between prospective factors and utilization of long-term
care institution
表8-3. 影響中風病患出院后使用長期照護機構的最佳預測因子
Selected predictors influencing utilization of long-term care
institution
表9-1. 104位首次中風病患的基本數據
Basic data of 104 first stroke patients
表9-2. 中風患者芙蘭切活動量表分數變化情形
FAI change on subscale and total score between prestroke and
post-stroke
表9-3. 類別變項對于中風患者出院至少半年后FAI量表得分退步的 影響
Difference between nominal variables and FAI change as assessed by
Student's t-test
表9-4. 中風病發前和出院至少半年后訪視時FAI量表得分及退步量
與年齡、教育年限及訪視時FIM量表分數的相關性
Pearson's correlation between prestroke FAI score, post-stroke FAI
score
at visit, and FAI change and age, the years of
education, and FIM score at visit
圖目錄
INDEX OF FIGURE
圖 1-1. 研究體系結構：中風病人復健治療預后預測因子和功能結果
Research framework：predictors and functional outcomes for
post-stroke patients following rehabilitation therapy
圖9-1. 中風患者發病前芙蘭切量表得分分布
Histogram with normal curve superimposed over the
distribution of Frenchay Activities Index total score at pre-stroke
圖9-2. 中風患者預后訪視時芙蘭切量表得分分布
Histogram with normal curve superimposed over the
distribution of Frenchay Activities Index total score at post-stroke
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