臺灣博碩士論文加值系統

研究背景：下肢肌肉骨骼障礙為常見之臨床問題，臨床上物理治療介入的方式包括水中運動或陸地復健治療；若能找到病患最適合的治療將可使其得到較佳的治療效果，包括增加身體功能的增進、疼痛的降低、進而提升生活水品質。研究目的：1) 比較下肢肌肉骨骼障礙病患接受水中運動和陸地復健治療後的疼痛與功能改善情形，2) 探討接受四週水中運動或陸地復健治療後疼痛與功能改善的相關因子。研究方法：此為前瞻性探索型研究，收取2016/ 3到2017/ 2的下肢肌肉骨骼病個案並在振興醫院接受水中運動或陸地復健治療者。共募集了300位下肢肌肉骨骼障礙的病患，收集病患基本資料以及疼痛（數字量表，numeric rating scale, NRS)、功能（下肢功能量表，lower extremity functional scale, LEFS);在接受治療四週後進行第一次複評（陸地復健組186位、水中運動組90位），並在研究結束前以電訪進行第二次的複評。再將接受四週水中運動或陸地復健治療後的進步情形區分為改善顯著與否兩組。改善顯著者需符合：1)自覺整體進步(global rating score of change, GROC) ≧4分，且2)疼痛下降 ≧2分或是下肢功能進步 (LEFS) ≧9分。統計分析：利用描述性統計呈現受測者的基本資料；單因子共變數分析 (Analysis of covariance, ANCOVA) 探討兩組在不同時間點之間在疼痛、功能、整體進步程度的異同; 並以逐步羅吉斯迴歸分析 (stepwise logistic regression) 探討兩種治療模式對於此族群治療成效顯著改善的相關因子。顯著水準定在0.05。結果：本研究發現不論接受水中運動訓練或陸地復健治療後，疼痛下降以及下肢功能改善都有明顯進步 (p<0.001)。在持續接受二個月的陸地復健治療後，以功能改善的幅度明顯優於水中運動組 (p=0.031)；且在持續接受二至五個月的陸地復健治療後，疼痛的下降的幅度明顯優於水中運動組 (p=0.003)。本研究之下肢肌肉骨骼障礙患者，接受四週復健治療後有顯著改善之預測因子為 「年齡大於五十歲」（勝算比=2.51，95%信賴區間=1.114~5.664）；「受傷狀態為慢性」（勝算比=1.87，95%信賴區間=0.971~3.619）以及「症狀在膝關節」（勝算比=4.66，95%信賴區間= 1.041~20.880）。結論：接受水中運動或陸地復健治療皆能有效地降低下肢肌肉骨骼障礙病患的疼痛以及改善下肢功能了解成效顯著改善的相關因子能強化對於下肢肌肉骨骼障礙病患接受水中運動訓練或陸地復健治療的臨床決策正確性。

Background: Identifying the factors associated with improvement is important for clinicians to decide whether to prescribe land-based or aquatic physical therapy for their patients. However, current literature contains insufficient information addressing the factors associated with outcome improvement in individules with lower extremity musculoskeletal disorders (LE-MSD). Purpose: 1) To compare pain and outcome improvement between the land-based or aquatic physical therapy 2) To explore factors associated with outcome improvement in patients with LE-MSD. Methods: This was a prospective andexploratory study. Patients with LE-MSD referred to physical therapy in Cheng-Hsin General Hospital were recruited from 2016/3 to 2017/3. There were 300 LE-MSD patients with participated. Demographic data of health and illness-related data, pain intensity and duration, and sore of lower extremity functional score (LEFS) 0-80 points, numeric pain rating scale (0-10 points), were obtained through questionnaires. All patients received 4 weeks physical therapy intervention (land-based program, n=186)，(aquatic program, n=90).Participants completed the study all patients were re-assessing by telephone. Outcome improvement was determined by perceived improvement (global rating score) ≧4 and, either pain reduction ≧2 or functional improvement ≧9. Statistical analyses: Univariate analyses were used to compare differences between improvement and non-improvement of subjects participating in land-based and aquatic physical therapy. ANCOVAs were used to compare treatment effect between two physical therapy programs (p<0.05). Then, a multivariate stepwise logistic regression analysis was used to identify significant predictive factors for classifying the outcome improvement and non-improvement (p<0.05). Result: Pain and function were significantly improved 4 weeks after physical therapy (P<0.001). At discharged within 2 months, the land-based group resulted in significantly better functional improvement (p=0.031) as compared to the aquatic group. At discharged within 2~5 months, the land-based group resulted in significantly more pain reduction (p=0.003) as compared to the aquatic group. Patients being older than 50 (OR=2.51, 95% CI =1.114~5.664); with symptom duration more than 3 months (OR=1.87, 95% CI = 0.971~3.619); and with knee impairments (OR=4.66, 95% CI = 1.041~20.880) were more likely to improve 4 weeks of aquatic physical therapy. Conclusion: Both land-based program and aquatic program results in significantly better pain reduction & functional improvement. Using predictors to estimate treatment improvement in administering LE-MSD could significantly achieve of a successful treatment. Clinical relevance: These findings could enhance the efficacy of decision-making in clinical pathway of aquatic or land-based intervention for patients with LE MSD.

目錄
謝誌 i
目錄 iii
表目錄 vi
圖目錄 viii
中文摘要 ix
英文摘要 xi
第一章 簡介 1
第一節 研究背景與動機 1
第二節 研究目的 2
第三節 研究重要性 2
第二章 文獻回顧 3
第一節 下肢肌肉骨骼障礙 3
第二節 下肢肌肉骨骼臨床評估 5
第三節 下肢肌肉骨骼障礙常用的物理治療 8
第四節 總結 14
第五節 相關研究 15
第三章 研究方法 17
第一節 研究設計與研究架構 17
第二節 研究材料與研究方法 17
第三節 成效測量與工具 19
第四節 研究介入項目 20
第五節 資料處理與分析方法 21
第四章 研究結果 24
第一節 受試者基本資料 24
第二節 次族群基本資料分析 25
第三節 療效評估測量結果 29
第四節 兩組治療四週後呈現顯著療效之各變項分析 30
第五節 陸地復健治療四週後療效顯著之多元逐步羅吉斯回歸分析 31
第六節 陸地復健治療四週後療效顯著之多元逐步羅吉斯回歸分析 32
第七節 水中運動治療療效顯著者之多元逐步羅吉斯回歸分析 33
第五章 討論 35
第一節 受試者基本資料探討 35
第二節 自覺疼痛程度之改善 36
第三節 下肢功能之改善 37
第四節 四週治療呈現顯著療效之預測因子 39
第六章 研究限制以及未來方向 43
第七章 臨床應用 44
第八章 結論 45
參考文獻 46

附錄一、人體試驗審查通過證書 65
附錄二、受試者同書 68
附錄三、研究問卷 72

表目錄
表 一、受試者的基本資料 56
表 二、持續治療小於二個月受試者基本資料 60
表 三、持續治療二至五個月受試者基本資料 64
表 四、持續治療大於六個月受試者基本資料 68
表 五、受試者診斷分類 72
表 六、持續治療小於二個月受試者診斷分類 73
表 七、持續治療二至五個月受試者診斷分類 74
表 八、持續治療大於六個月受試者診斷分類 75
表 九、陸地復健和水中復健運動之受試者的疼痛程度與下肢功能改善程度於介入前、介入四週後、持續治療小於二個月之測量數值 76
表 十、陸地復健和水中運動之受試者的疼痛程度與下肢功能改善程度於介入前、介入四週後、持續治療二至五個月之測量數值 77
表 十一、陸地復健和水中運動之受試者的疼痛程度與下肢功能改善程度於介入前、介入四週後、持續治療大於六個月之測量數值 78
表 十二、接受四週治療療效改善者與未改善者之受試者比較 79
表 十三、接受四週陸地復健治療療效改善者與未改善者之受試者比較 80
表 十四、接受四週水中運動治療療效改善者與未改善者之受試者比較 81
表 十五、接受四週復健治療療效改善者之預測因子 82
表 十六、接受四週陸地復健治療療效改善者之預測因子 83
表 十七、接受四週水中運動治療療效改善者之預測因子 84
圖目錄
圖 一：研究流程 85
圖 二：陸地復健和水中運動之受試者的疼痛程度於介入前、介入四週後、持續治療小於二個月之測量數值 86
圖 三：陸地復健和水中運動之受試者的疼痛程度於介入前、介入四週後、持續治療二至五個月之測量數值 87
圖 四：陸地復健和水中運動之受試者的疼痛程度於介入前、介入四週後、持續治療大於六個月之測量數值 88
圖 五：陸地復健和水中運動之受試者的下肢功能改善程度於介入前、介入四週後、持續治療小於二個月之測量數值 89
圖 六：陸地復健和水中運動之受試者的下肢功能改善程度於介入前、介入四週後、持續治療二至五個月之測量數值 90
圖 七：陸地復健和水中運動之受試者的下肢功能改善程度於介入前、介入四週後、持續治療大於六個月之測量數值 91

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