臺灣博碩士論文加值系統

研究背景與目的：
遠端橈骨骨折是常見的手部骨折之一，發生機率與年齡及性別有關，特別是在50歲以上停經後婦女及由於車禍、激烈運動或意外的年輕人。骨折後的骨科醫師處理主要以石膏固定為主，但是在固定移除後，常常會導致水腫、上肢各關節僵硬、攣縮、肌力下降、疼痛和變形；如果沒有給予適當治療，甚至會影響日常生活功能獨立及心理調適等職能活動。而目前的實證研究較少去探討早期治療活動對於骨折固定後的影響。本研究設計希望分析早期職能治療介入對遠端橈骨骨折後的手功能恢復之成效。
研究方法：
於南部某區域教學醫院進行，共招募30位遠端橈骨骨折個案，隨機分派為早期介入組（實驗組）和控制組。早期介入組於骨折後約2週開始進行居家運動方案衛教，控制組則以口頭衛教；兩組於固定移除（約骨折4週後）後開始接受職能治療至12週。評估內容包括關節活動度、肌力、肌耐力、疼痛、水腫、手功能表現及生活品質，分別於第2週、第4週第12週進行評估，共3次。以描述性統計方法分析人口學資料。另外，使用混合型重複測量分析設計，以病人首次評估作為共變數檢定各參數組間、組內是否具有顯著性差異。
結果：
早期介入組比控制組在關節活動度、肌力、水腫、疼痛、日常生活功能改善、上肢及手部功能等五項研究問題均有較佳之改善；而雖然在受到石膏固定限制關節的主動總關節活動度、普渡手功能測驗及Quick DASH簡易版上肢功能評估問卷組間未達明顯差異；但是從平均數來看，在第2次及第3次評估中，早期介入組較控制組在各變項中均有較好及較高之恢復。
討論：
本研究發現顯示早期職能治療居家運動方案確實可以改善手部功能表現，幫助在石膏固定期間，減少、減低患側上肢肩、肘、手腕及手指關節的關節活動度受限、減低疼痛、減少水腫、改善循環、避免肌腱沾黏及造成未受傷關節的僵硬與攣縮等併發症；幫助個案更早、更敢且更有效在日常生活中去使用傷手，因而提升受傷後生活品質及改善患側上肢功能，減少生活上的不適及不便，幫助病人盡早在日常生活獨立活動，並返回工作崗位。

Background and Purpose：
The distal radius fracture is one of the common fractures in hand injury. Its occurrence might be related with age and gender, especially, the menopausal women (over 50 years of age), car accident and sport accident. After fracture, orthopedic management would apply plaster to fix the unstable site frequently. But, there are some sequelae complications after removing the plaster, including hand edema, upper extremity joints stiffness or contracture, less strength, pain and deformity. Occupatuonal performance, even activity of daily livings and psychological accommodation might be affected by such complication, if not appropriate treatment. There was few evidence-based study to investigate the effect of early therapeutic treatment after hand fracture. This study was designed to analyze the effect of early occupational therapy for distal radius fracture on hand functional recovery.

Method：
We recruited 30 participants who had distal radius fracture, from southern Taiwan Local-Teaching Hospital. Subjects were randomized assign into early intervention and controlled groups. In early intervention group, we introduced participants to home exercised programs after early injury two weeks, and the controlled group we conducted oral health care introduction. After removing the plaster (about four weeks), both groups would receive occupational therapy for 12 weeks. We evaluated participants’ joint range of motion, muscle strength, endurance, pain, edema, hand function and quality of live during the 2nd week, 4th week and 12th week after onset. Descriptive data and mixed type repeated measure analysis of covariance were utilized for data analysis. Participants first evaluation results was treated as covariant to control the group differences.

Results：
We found the early intervention group had better improvement than controlled group among joint range of motion, muscle strength, edema, pain, activity of daily living and hand function. Although, there were not significant statistic difference between two groups in active R.O.M., Purdue hand function test and Quick DASH. But if we consider the 2nd and 3rd evaluation results that there was better improvement in experiment group by mean difference among each parameter.

Conclusion：
Findings in this study show that the early intervention occupational therapy home program would actually improve in hand functional performance with the effects on decreased R.O.M. limitation in affected side of shoulder, elbow, wrist and fingers, released pain, decreased edema, improved circulation, prevention of tendon adhesion. Moreover, early intervention would benefit the unaffected joints in preventing joint stiffness and contracture, encouraging patients to use their affected limb early. That would promote patients’ quality of live and improved affected side hand function, decreased the unsuitable and inconvenient, consequently helped ADL independence and return to work early.

目錄
第一章　前言
第一節 研究背景與動機 ……………………………………………… P6
第二節 研究目的 ……………………………………………………… P9
第三節 研究假設 ……………………………………………………… P9
第二章　文獻回顧
第一節　遠端橈骨骨折的流行病學、分類及處理方式 ……………… P10
第二節 遠端橈骨骨折的常見後遺症 ………………………………… P15　
第三節　遠端橈骨骨折的復健介入 …………………………………… P16
第三章 研究方法
第一節 研究對象 ……………………………………………………… P20
第二節 研究評估項目及工具 ………………………………………… P20
第三節 研究方法及流程 ……………………………………………… P26
第四節 資料分析 ……………………………………………………… P29
第四章 研究結果…………………………………………………………… P30
第五章 討論………………………………………………………………… P49
第六章 結論………………………………………………………………… P56

參考文獻 ……………………………………………………………………… P57
附錄一 基本資料調查表 …………………………………………………… P59
附錄二 關節活動度測量記錄表 …………………………………………… P60
附錄三 握力及捏力測量記錄表 …………………………………………… P61
附錄四 肌耐力測量記錄表 ………………………………………………… P62
附錄五 水腫測量記錄表 …………………………………………………… P63
附錄六 視覺模擬評分法疼痛量表 ………………………………………… P64
附錄七 Purdue Pegboard評估紀錄表 ……………………………………… P65
附錄八 Quick DASH ……………………………………………………… P66
附錄九 中文版 SF-36 健康量表問卷 …………………………………… P69
附錄十 衛教手冊 …………………………………………………………… P72

張至宏, & 侯勝茂. (2000). 遠端橈骨骨折之治療與預後. 臺灣醫學, 4(3),309-312.
曾旭民, 盧瑞芬, & 蔡益堅. (2003). 國人生活品質評量 (Ⅱ): SF-36 台灣版的常模與效度檢測. 臺灣公共衛生雜誌, 22(6), 512-518.
盧瑞芬, 曾旭民, & 蔡益堅. (2003). 國人生活品質評量 (Ⅰ): SF-36 台灣版的發展及心理計量特質分析. 臺灣公共衛生雜誌, 22(6), 501-511.
Alffram, P. A., & Bauer, G. C. (1962). Epidemiology of fractures of the forearm. A biomechanical investigation of bone strength. The Journal of bone and joint surgery. American, 44-A, 105-114.
Balsky, S., & Goldford, R. J. (2000). Rehabilitation protocol for undisplaced colle''s fractures following cast removal. . The Journal of the Canadian Chiropractic Association, 44(1), , 29.
Bear-Lehman, J., & Flinn-Wagner, S. (1988). Hand rehabilitation and occupational therapy. Occupational Therapy in Health Care, 4(3-4), 7-15. doi: 10.1080/J003v04n03_03
Castanedo, G. M., Sailes, F. C., Dubree, N. J., Nicholas, J. B., Caris, L., Clark, K., . . . Sutherlin, D. P. (2002). Solid-phase synthesis of dual alpha4beta1/alpha4beta7 integrin antagonists: two scaffolds with overlapping pharmacophores. Bioorg Med Chem Lett, 12(20), 2913-2917.
Christensen, O. M., Kunov, A., Hansen, F. F., Christiansen, T. C., & Krasheninnikoff, M. (2001). Occupational therapy and Colles'' fractures. International Orthopaedics 25(1), 43-45.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed). Hillsdale, NJ: Erlbaum.
Collins, D. C. (1993). Management and rehabilitation of distal radius fractures. The Orthopedic clinics of North America, 24(2), 365-378.
Cooney, W. P., 3rd, Dobyns, J. H., & Linscheid, R. L. (1980). Complications of Colles'' fractures. Journal of Bone & Joint Surgery, American 62(4), 613-619.
Dekkers, M., & S??balle, K. . (2004). Activities and impairments in the early stage of rehabilitation after Colles'' fracture.. Disability & Rehabilitation 26(11), 662-668.
Dias, J. J., Wray, C. C., Jones, J. M., & Gregg, P. J. (1987). The value of early mobilisation in the treatment of Colles'' fractures.
. The Journal of bone and joint surgery. British volume., 69(3), 463-467.
Handoll, H. H. G., Madhok, R., & Howe, T. E. (2008). Conservative interventions for treating distal radial fractures in adults.
Hunter JM, Schneider LH, Mackin EJ, et al, eds. (1995).Rehabilitation of the Hand. Surgery and Therapy, 4th ed. St. Louis, Mosby.
Kuo, Li-Chieh, Yang, Tai-Hua, Hsu, Ying-Ya, Wu, Po-Ting, Lin, Cheng-Li, Hsu, Hsiu-Yun, & Jou, I. Ming. (2013). Is progressive early digit mobilization intervention beneficial for patients with external fixation of distal radius fracture? A pilot randomized controlled trial. Clinical Rehabilitation, 27(11), 983-993. doi: 10.1177/0269215513487391
Kurup, H. V. (2006). Kirschner wires for Colles'' fracture. Injury, 37(10), 1027-1028. doi: 10.1016/j.injury.2006.05.022
MacDermid, J. C., Donner, A., Richards, R. S., & Roth, J. H. (2002). Patient versus injury factors as predictors of pain and disability six months after a distal radius fracture. Journal of Clinical Epidemiology, 55(9), 849-854. doi: 10.1016/s0895-4356(02)00445-6
MacDermid, J. C., Richards, R. S., & Roth, J. H. (2001). Distal radius fracture: A prospective outcome study of 275 patients. . Journal of Hand Therapy,, 14(2),, 154.
MacDermid, J. C., Roth, J. H., & McMurtry, R. (2007). Predictors of time lost from work following a distal radius fracture. Journal of Occupational Rehabilitation, 17(1), 47-62. doi: 10.1007/s10926-007-9069-0
Maihafer, G. C., Llewellyn, M. A., Pillar, W. J., Jr., Scott, K. L., Marino, D. M., & Bond, R. M. (2003). A comparison of the figure-of-eight method and water volumetry in measurement of hand and wrist size. Journal of Hand Therapy,, 16(4), 305-310.
Nguyen, T. V., Center, J. R., Sambrook, P. N., & Eisman, J. A. . (2001). Risk Factors for Proximal Humerus, Forearm, and Wrist Fractures in Elderly Men and Women The Dubbo Osteoporosis Epidemiology Study, 153, 587-595.
Nicholas, C. L., Trinder, J., & Colrain, I. M. (2002). Increased production of evoked and spontaneous K-complexes following a night of fragmented sleep. Sleep, 25(8), 882-887.
O''Neill, T. W., Varlow, J., Silman, A. J., Reeve, J., Reid, D. M., Todd, C., et al. (1994). Age and sex influences on fall characteristics British Medical Journal, 53(11), 773-775.
Pellecchia, G. L. (2003). Figure-of-eight method of measuring hand size: reliability and concurrent validity. Journal of Hand Therapy,, 16(4), 300-304.
Tremayne, A., Taylor, N., McBurney, H., & Baskus, K. (2002). Correlation of impairment and activity limitation after wrist fracture. Physiother Res Int, 7(2), 90-99.
Watt, C. F., Taylor, N. F., & Baskus, K. (2000). Do Colles'' fracture patients benefit from routine referral to physiotherapy following cast removal? Archives of Orthopaedic and Trauma Surgery, 120(7-8), 413-415.