臺灣博碩士論文加值系統

糖尿病足為糖尿病病人最常見之合併症，臨床上主要以傳統內科及外科手術為治療方式。高壓氧在糖尿病足的治療上，具有相當大的價值，它可抑制厭氧菌成長及其毒素之活性、增加氧氣擴散到受傷組織、使傷口感染受到控制，達到傷口癒合效果，以降低糖尿病足截肢的需要性，因此可避免糖尿病足的病人身、心受創，進而提高生活品質。本研究目的為探討高壓氧治療介入過程中，個案血液中發炎指數、血糖值、傷口癒合能力、患肢血流量的變化以及傷口細菌培養之菌種的改變與整體生活品質間之功效。本研究採前瞻性、進行一年的臨床研究，採雙組前、後測量，實驗設計方式進行，研究對象取自南部某醫學中心經醫師診斷為糖尿病足且須住院的病患為樣本，收案期間為100年6月至101年5月，實驗組為20人、對照組18人。兩組病人依照病情需要，會給予完整的傳統性治療，唯有實驗組接受高壓氧氣治療介入措施，療程為20次，每次治療時間約120分鐘。兩組評估工具為結構式問卷自填及血液生化檢驗方式收集資料，問卷內容包括病人基本屬性、Grade傷口評分表、The Medical Outcome Study 36-Item Short-Form Health Survey (SF-36)生活品質量表、並以抽血方式測量ESR、CRP、HbA1c及收集傷口細菌培養、以Dopplar血流影像測量患肢血流量；資料收集時間點為:治療前(高壓氧治療第一次前；T1)、治療中(高壓氧治療第十次；T2)、治療後(高壓氧治療第二十次；T3)、治療結束追蹤期(高壓氧二十次治療後之第二週；T4)。所收集到的資料以描述性及推論性的統計方式進行方析與處理，顯著意義定在P<0.05。本研究結果發現「傷口生理指標-傷口等級」方面：實驗組在T3時，傷口明顯得到改善；對照組於T2時，傷口產生惡化；就截肢率而言，實驗組5%、對照組為11%，兩組病人在T4時傷口具有顯著性之差異(P<.001)。實驗組與對照組在「傷口生理指標-血液檢驗-血流測試」當中，由數據證實：實驗組體內ESR、CRP、HbA1C之濃度由T1至T4分別改善54.78%、78.11%及23.05%，且患肢足部血流量增多；對照組病人CRP濃度上升6.54%；故證實高壓氧治療可使病人體內發炎指數及血糖值獲得控制及改善，且穩定性在2周後仍可顯見。「傷口生理指標-細菌培養」當中Proteus.mirabilis與Staph.aureus皆以重複性存在於實驗組與對照組T1至T4之間，此兩株菌種對糖尿病足傷口具有影響力，但實驗組經由高壓氧治療後其長菌個案數由5與7降至2與1；對照組則長菌個案數由7與4變化為8與4。「傷口生理指標-傷口等級」與「生活品質」之相關性兩組皆呈現為正相關性，但唯有實驗組具有顯著性之差異(P<0.001)。於「傷口生理指標-血液檢驗」與「生活品質」之相關性當中發現，兩組病人與生活品質生理健康指標皆呈現負相關；在心理健康指標實驗組為負相關，對照組為正相關；但唯有實驗組與此兩大健康指標具有其相關性之顯著性差異(P<0.001)。高壓氧治療於糖尿病足生活品質之相關性與成效分析當中，兩組病人生活品質於T2時即產生不同之變化，實驗組在生理健康指標與心理健康指標上，得分明顯進步並維持至T4，反之對照組病人於T2時，兩大生活品質指標得分開始呈現下滑之趨勢。就其八大構面逐一分析發現：生理功能、身體健康角色限制、身體疼痛、一般健康狀況4大構面T2時實驗組即有顯著性改善（p <0.05），且於T3、T4時其仍維持顯著水準；活力狀況、社會狀況、心理健康、情緒問題導致角色限制4大構面則T1時實驗組因情緒角色受限與活力構面分數低於對照組（p <0.05），但於T2時得分達到顯著水準（p <0.05），並維持至T3與T4其水準仍具顯著性。另社會功能構面則實驗組T2時，其高壓氧治療成效仍不明顯，（p = .195），於T3之後相較於對照組則進步幅度有明顯增加，並得到了證據支持（p <0.001）。心理健康構面上的成效於T2時，實驗組已達顯著水準（p < 0.05）。本研究證實了高壓氧治療可以改善糖尿病足傷口潰瘍及其生活品質之提升，若以高壓氧治療做為糖尿病足及生活品質之成效評估，於高壓氧治療20次之階段(T3)即是一個重要之分水嶺。因高壓氧在T3時，由證據顯示實驗組傷口等級與發炎指數皆獲得控制與改善，相對的降低了病人生理與心理所受到的創傷和困擾。且本研究也同時發現，對於糖尿病足病人生理面向與心理面向之兩大層面的生活品質上，在T2階段即產生明顯變化，T3時更具有最大之影響成效。故本研究建議在於治療糖尿病足病人傷口潰瘍上，高壓氧輔助治療次數的選擇可以20次做為一個參考指標，其療效較為顯著。

Diabetic foot was the most common complication in diabetic patients. Clinical treatment on diabetic foot was mainly traditional medicine and surgical operation. Hyperbaric oxygen therapy (HBOT) is a complementary medicine, and may be effective for diabetic foot. It can restrain the growing of bacteria and the activation of its toxins, increase oxygen diffusion to wounded tissues, control wound infection, and come to the effect of wound healing to diminish the necessity of diabetic foot amputation. Adequate treatment is essential for patients with diabetic foot, and, may be able to avoid physical and psychological suffering for them and, thus, improves quality of life. The main purpose of this study was to investigate the effects of hyperbaric oxygen therapy on inflammation index, blood glucose, wound healing, change of blood flowing in wounded limb, change of bacterial species cultivated at wound and quality of life among patients with diabetic foot.
This was a quasi-experimental clinical study. The patients enrolled in this study had diagnosed diabetic foot, and were hospitalized in a medical center in Southern Taiwan from June, 2011 to April, 2012. A total of 38 patients were recruited, and then assigned to either the experimental group (n=20) or the control group (n=18). Patients in the experimental group received 20 sessions hyperbaric oxygen therapy. Each session lasted 120 minutes. The control group received routine care. Measurements included structural questionnaire (the Medical Outcome Study 36-Item Short-form Health Survey, SF-36), wound evaluation, blood biochemical indices (ESR, CRP, and HbAlc), bacteria collected from wound site for cultivation, and the testing of blood flowing in wounded limb by Doppler image system. Data were collected at just before the HBOT (T1), the 10th HBOT (T2), the 20th HBOT (T3), and 2 weeks after the final session of HBOT (T4). Descriptive and inferring statistic analyses with a significant difference p< 0.05 were utilized.
The results showed that for the “wound physiological indices-wound grade”, wounds were significantly improved at T3 in experimental group; while wounds were deteriorated at T2 in the control group. The amputation rate was 5% in experimental group, and 11% in the control group. The wounds at T4 had significant difference (p< .001) between two groups. For “wound physiological indices-blood flowing test”, the data proved that the concentrations of ESR, CRP, HbAlc were improved to 54.78 %, 78.11%, 23.05% from T1 to T4 respectively. The blood flow increased for diabetic foot in the experimental group. Contrary, the concentration of CRP raised 6.54% in the control group. Hence it was proved that the inflammation index and blood glucose could be controlled, and improved by HBOT, and its stability could still be noted 2 weeks after therapy. For “wound physiological indices- bacteria culture”, Proteus.mirabilis and Staph. aureus existed repeatedly from T1 to T4 both in experimental group and control group. Therefore, these two bacterial strains were found to have influence on wound at diabetic foot. However, the growing of the two bacterial strains descended from 5 to 2 and 7 to 1 in the experimental group at T4, respectively; while they were from 7 to 8 and 4 to 4 in the control group. The “wound physiological indices- wound grade” and “quality of life” in both two groups presented positive correlation. Yet the noticeable difference (p<.001) was only found in the experimental group. The physical component summary (PCS) showed a negative correlation between “wound physiological indices-blood test” and “quality of life”, in both groups. The mental component summary (MCS) showed a negative correlation in the experimental group, and a positive correlation in the control group. Quality of life in two groups came to different changes from T2. The scoring of PCS and MCS significantly improved and maintained to T4 in the experimental group; while they started to present a tendency of gliding when at T2 in the control group. Furthermore, there were notable improvements in physical function (PF), role limitation due to physical problems(RP), body pain (BP), and general health (GH) from T2 ( p< .05) in the experimental group, and these four dimensions maintained significant level also from T3 to T4. The scores of role limitation due to emotional problems (RE) and vitality (VT) in experimental group were lower than those in control group (p< .05) at T1, but they showed significant differences (p< .05) at T2, and they maintained significant level at T3 and T4. In addition, the effect of HBOT did not show significant difference (p=.195) at T2 in social function (SF) in the experimental group; while it improved remarkably after T3 comparing with the control group (p< .001). The scores at T2 in mental health (MH) had reached significant level (p< .05) in the experimental group. This study proved that HBOT could improve diabetic foot ulcer, and promote quality of life. Twenty sessions HBOT is an important watershed according to our study results. As this study proved that the wound grade and inflammation index were controlled, and improved when undergoing HBOT from T3 in the experimental group, and that relatively reduced patients’ physical and mental wound and persecution. Meanwhile, we found that quality of life for patients with diabetic foot, PCS and MCS presented a remarkable change from T2 and the greatest effect was found at T3. Therefore, 20 sessions of HBOT is recommended for treatment of diabetic foot.

第一章 緒論1
第一節 研究背景與動機1
第二節 問題陳述與研究目的3
第三節 研究重要性4
第二章 文獻查證6
第一節 糖尿病足之相關概念6
第二節 糖尿病足潰瘍傷口菌種及潛在毒性之相關研究14
第三節 高壓氧治療之相關概念16
第四節 高壓氧治療糖尿病足傷口之相關研究22
第五節 生活品質之相關概念29
第六節 糖尿病患生活品質之相關研究31
第三章 研究方法33
第一節 研究設計33
第二節 研究場所及對象33
第三節 研究架構35
第四節 研究假說36
第五節 名詞解釋36
第六節 研究工具37
第七節 資料收集過程42
第八節 資料處理與分析43
第九節 研究倫理考量44
第四章 結果45
第一節 研究對象人口學特性45
第二節 高壓氧治療對糖尿病足傷口生理指標之差異性49
第三節 高壓氧治療於糖尿病足傷口生理指標及生活品質之相關性58
第四節 高壓氧治療於糖尿病足之生活品質成效分析61
第五章 討論71
第六章 結論與建議75
第一節 研究結論75
第二節 理論與實務涵義78
第三節 研究限制79
第四節 後續研究建議80
參考文獻81
一、中文部分81
二、英文部分85
附錄91
附錄A 個人基本資料91
附錄B 生活品質量表（SF-36）93
附錄C 傷口生理指標96
附錄D 人體試驗委員會同意書97
附錄E SF-36授權同意書98
表次
表4-1-1 研究對象之人口學特性分佈••47
表4-2-1 實驗組與對照組在T1、T2、T3、T4時間點上之傷口變化51
表4-2-2 實驗組與對照組在T1、T2、T3、T4時間點上之傷口等級之差異51
表4-2-3 實驗組與對照組在T1、T2、T3、T4及T1與T4血液中ESR、CRP、 HbA1C之變化54
表4-2-4 實驗組與對照組在T1、T2、T3、T4及T1與T4血液中ESR、CRP、HbA1C改善之程度55
表4-2-5 Doppler在實驗組及對照組與T1、T2、T3、T4時間點上之差異55
表4-2-6 實驗組及對照組在T1、T2、T3、T4時間點上細菌生長情形57
表4-3-1 實驗組及對照組「傷口生理指標–傷口等級」與PCS之相關性59
表4-3-2 實驗組及對照組「傷口生理指標–傷口等級」與MCS之相關性59
表4-3-3 實驗組及對照組「傷口生理指標–血液濃度」與PCS之相關性60
表4-3-4 實驗組及對照組「傷口生理指標–血液濃度」與MCS之相關性60
表4-4-1 實驗組及對照組於T1、T2、T3、T4時間點上其生活品質之敘述性統計64
表4-4-2 高壓氧治療介入其生活品質8大構面之成效分析65
圖次
圖2-1 糖尿病足感染的分類與處理流程13
圖3-1 本研究架構圖35
圖4-4-1 高壓氧治療於糖尿病足實驗組與對照組在T1、T2、T3、T4時間點上之生理面向(PCS)分析趨勢圖68
圖4-4-2 高壓氧治療於糖尿病足實驗組與對照組在T1、T2、T3、T4時間點上之心理面向(MCS)分析趨勢圖68
圖4-4-3 高壓氧治療於糖尿病足實驗組與對照組在T1、T2、T3、T4時間點上之生理面向(PCS)的四大構面分析趨勢圖69
圖4-4-4 高壓氧治療於糖尿病足實驗組與對照組在T1、T2、T3、T4時間點上之心理面向(MCS)的四大構面分析趨勢圖70

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