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脑中风患者接受住院复健治疗预后功能的研究

2013-09-24 01:12

  
　　　　
【关 键 词】
脑中风Stroke
预后Prognosis
功能结果Functional outcomes
复健治疗Rehabilitation therapy

【类别】 博士论文
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【中文摘要】
本前瞻性研究目的主要调查与探讨民国八十六年一月至十二月期间163位住院高雄医学大学
附设中和医院复健科接受复健治疗的脑中风患者，其社会人口学及住院期间诊断评估临床
数据、其复健治疗效益性、出院时日常生活功能预后进步情形和相关预测因子、影响住院
天数长短的预测因子、出院至少六个月预后功能独立自主和使用长期照护机构的影响因素
和生活型态改变的情形。
我们的研究结果显示：日常生活能力以功能独立自主量表(Functional Independence
Measure, FIM)分数为指标，在住院期间无论全部项目得分或其六大类别得分的进步量在统
计学上都有显著的意义。这个结果可以说明复健治疗对于中风病人的预后结果扮演重要的
正面角色。影响出院时FIM量表得分的重要预测因子包括年龄、多次中风病史、住院期间多
项并发症、定向能力异常及神经心理功能异常暨失智症等；而感觉异常和多次中风病史患
者是影响住院期间功能独立自主量表进步量的重要预测因子。
住院时FIM量表平均得分57.7 ± 24.5；出院前77.3 ± 26.3。住院期间复健效率平均得分
0.7 ± 0.7和复健效果30.6 ± 24.0%。对于复健治疗效率而言，在统计学上有意义的预测
因子包括复健治疗住院天数和患侧上肢近端肢体运动功能恢复级数，两项因素可以解释复
健治疗效率21%的变异量；对于复健治疗效果而言，在统计学上有意义的预测因子包括年龄

（科教论文网 lw.nseaC.Com编辑发布）

和患侧上肢近端肢体运动功能恢复级数，两项因素可以解释复健治疗效果24%的变异量。
住院初期以福格-米勒平衡量表(Fugl-Meyer Balance Scale, FMBS)评估平衡能力可以解释
接受复健治疗住院天数6%的变异量及复健治疗效率3%的变异量；然而，平衡能力无法提供
解释住院期间FIM得分进步情形的变异量。这些结果说明住院复健初期临床使用FMBS量表来
评估平衡能力似乎无法有效预测中风病患接受复健治疗预后功能结果。
住院时FIM量表得分能力、是否肩关节有半脱位、是否两侧肢体运动功能皆受损和接受教育
年数是为住院天数长短的的重要预测因子。这些重要预测因子可以解释住院天数长短21.5%
的变异量。这些结果可以做为未来脑中风患者接受住院复健治疗健保给付规划论病例计酬
标准的参考。
出院半年后共完成142位个案日常生活状态的追踪访视，结果发现访视时日常生活功能完全
独立者共有23位(16.2%)。住院时加拿大神经量表(Canadian Neurological Scale, CNS)得
分能力和住院时FIM量表得分能力可为中风病患复健治疗出院半年后生活功能是否独立自主
的重要预测因子。
有关使用长期照护机构方面，这部份共完成151位个案的追踪访视。结果发现访视时正住在
长期照护机构者共有23位(15.2%)。逻辑回归分析结果发现，两侧肢体运动功能是否皆受损
、出院时意识状况是否正常和平衡量表得分能力是为最佳预测变项。
有关预后生活型态改变的追踪研究，这部份以出院至少半年后芙兰切活动量表(Frenchay
Activities Index, FAI)及FIM量表评估结果做为预后全面性日常生活活动分析数据。结果
显示比较发病前和出院至少半年后访视时FAI量表及其三大项目(做家务事、户外活动及休
闲工作)得分的退步量在统计学上都有显著的差异性。发病前和访视时FAI量表得分皆与年
龄呈负相关性(Pearson r = - 0.24, p< 0.05; r = -0.34, p< 0.001)；访视时FAI量表得
分和FIM量表得分呈显著正相关性(Pearson r = 0.58, p< 0.001)。这些结果说明使用FAI
量表可以量化脑中风患者预后生活型态变化的情形。

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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

（科教范文网http://fw.nseac.com）

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 录 】
目　录
博士论文总摘要　1~3
Abstract of Dissertation　　 4~7
第一章 绪论：前言、文献探讨及本研究目的和规画　　　　1-1~14
第二章 脑中风患者的临床数据和功能恢复情况的研究　　　2-1~16
第三章 脑中风患者复健治疗预后的初步研究3-1~24
第四章 初次中风病人复健治疗的效率和效果4-1~18
第五章 脑中风患者住院时平衡能力和预后功能的关系　　　5-1~13
第六章 影响脑中风患者复健治疗住院天数长短的因素　　　6-1~16
第七章 影响脑中风患者预后功能独立的因素 7-1~16
第八章 影响脑中风患者预后使用长期照护机构的因素　　　8-1~16
第九章 脑中风患者预后生活型态改变的追踪研究　　　　　9-1~17
第十章 结论：研究成果与未来展望　　 10-1~13
附录一：功能独立自主量表(Functional Independence Measure, FIM)
附录二：福格-米勒平衡量表(Fugl-Meyer Balance Scale, FMBS)
附录三：加拿大神经量表(Canadian Neurological Scale, CNS) （转载自http://zw.NSEAC.com科教作文网）
附录四：芙兰切活动量表(Frenchay Activities Index, FAI)
附录五：本研究相关论文发表成果
表目录
INDEX OF TABLE
表2-1.　　　 163位中风病患的基本人口学数据
　　 Demographic data of 163 stroke patients
表2-2.　　　 住院期间临床诊断检查和评估数据
　　 Clinical and diagnostic factors of 163 stroke patients
表2-3.　　　 住院期间功能独立量表主要项目得分和进步量
　　 Functional improvement on subscale and total FIM score during inpatient

rehabilitation
表2-4.　　　 接受复健治疗前后步行及生活能力独立状况的人数比较
　　 Comparison of number of persons with ambulation and ADL independence
following rehabilitation therapy
表3-1.　　　 147位中风病患的基本人口学数据
　　 Demographic data of 147 stroke patients
表3-2.　　　 住院期间临床诊断检查和评估数据
　　 Clinical and diagnostic factors of 147 stroke patients
表3-3.　　　 住院期间功能独立量表主要项目得分和进步量
　　 Functional improvement on subscale and total FIM score during inpatient

rehabilitation
表3-4.　　　 皮尔森相关系数分析序位/等距变项和预后功能的间的相关性
　　 Pearson correlation for ordinal/interval variables considered in
predicting functional outcome
表3-5.　　　 Student's t-test 检定类别变项和预后功能结果的间的差异性
　　 Student's t-test for nominal variables on functional outcome of stroke
patients
表3-6.　　　 类别变项和预后功能的间的变异数分析
　　 Analysis of variance for nominal variables on functional outcome
表3-7.　　　 复回归分析预测中风病人出院FIM量表得分的结果
　　 Multiple regression analysis predicting discharge FIM score
表3-8.　　　 复回归分析预测中风病人FIM量表进步量的结果
　　 Multiple regression analysis predicting FIM improvement

表4-1.　　　 110位初次中风病患的基本人口学和临床诊断检查数据
　　 Clinical and demographic data of first 110 stroke patients
表4-2.　　　 住院期间功能独立量表主要项目得分和进步量
　　 Functional improvement on subscale and total FIM score during inpatient

rehabilitation
表4-3.　　　 皮尔森相关系数分析序位/等距变项和预后功能的间的相关性
　　　Pearson correlation analysis between ordinal/interval
variables and rehabilitation outcome
表4-4.　　　 Student's t-test 检定类别变项和预后功能结果的间的差异性
　　 Difference between nominal variables and rehabilitation outcome as
assessed by Student's t-test
表4-5.　　　 复回归分析预测110位初次中风病人复健治疗的效率和效果
　　 Multiple regression analyses predicting rehabilitation outcome in 110
patients with first stroke
表5-1.　　　 163位中风病患的基本数据
　　 Basic data of 163 stroke patients
表5-2.　　　 皮尔森相关系数分析平衡能力和住院时FIM量表得分及预后　　 功能间的相
关性
　　 Pearson's correlation analyses between balance score and FIM score and
rehabilitation outcome
表5-3.　　　 复回归分析刚住院时平衡能力得分和预后功能结果的关系
　　　Multiple regression analyses between admission balance score
and rehabilitation outcomes
表6-1.　　　 中风病患的基本数据 (n=163)
　　 Basic data of 163 stroke patients
表6-2.　　　　Pearson 相关系数检定住院天数长短和等距变项的相关性
　　 Pearson correlation analysis between ordinal/interval variables and
length of rehabilitation stay
表6-3.　　　　Student's t-test 检定住院天数长短和类别变项的差异性
　　 Difference between nominal variables and length of rehabilitation stay
as
assessed by Student's t-test
表6-4.　　　 相关影响因素对住院天数长短的复回归分析 （转载自科教范文网http://fw.nseac.com）
　　 Multiple regression analyses predicting length of rehabilitation stay
表7-1.　　　 中风病人预后功能独立与否两组间相关变项的差异性比较
　　 Comparison of prospective factors between patients with functional
independence or dependence
表7-2.　　　 预后功能独立与否的影响因素及关联程度的检定
　　 Associations between prospective factors and functional independence
表7-3.　　　 影响中风病患预后功能独立与否的最佳预测因子
　　 Selected predictors influencing functional independence outcome
表8-1.　　　 151位中风病患的基本数据
　　 Basic data of 151 stroke patients
表8-2.　　　 出院后使用长期照护机构的影响因素及关联程度的检定
　　 Associations between prospective factors and utilization of long-term
care institution
表8-3.　　　 影响中风病患出院后使用长期照护机构的最佳预测因子
　　 Selected predictors influencing utilization of long-term care
institution
表9-1.　　　 104位首次中风病患的基本数据
　　 Basic data of 104 first stroke patients
表9-2.　　　 中风患者芙兰切活动量表分数变化情形
　　 FAI change on subscale and total score between prestroke and
post-stroke
表9-3.　　　 类别变项对于中风患者出院至少半年后FAI量表得分退步的　　 影响
　　 Difference between nominal variables and FAI change as assessed by
Student's t-test
表9-4.　　　 中风病发前和出院至少半年后访视时FAI量表得分及退步量
　　 与年龄、教育年限及访视时FIM量表分数的相关性
　　 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
图目录
INDEX OF FIGURE
图 1-1.　　　 研究体系结构：中风病人复健治疗预后预测因子和功能结果
　　　 Research framework：predictors and functional outcomes for

post-stroke patients following rehabilitation therapy
图9-1.　　　 中风患者发病前芙兰切量表得分分布
　　　 Histogram with normal curve superimposed over the
distribution of Frenchay Activities Index total score at pre-stroke
图9-2.　　　 中风患者预后访视时芙兰切量表得分分布
　　　 Histogram with normal curve superimposed over the
distribution of Frenchay Activities Index total score at post-stroke

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