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研究生:黃瓊慧
研究生(外文):Huang,Chiung-Hui
論文名稱:穴位刺激對膝關節置換術病人術後止痛成效探討
論文名稱(外文):Effects of Acupoint Stimulation on Reducing Postoperative Pain in Total Knee Replacement Patients
指導教授:葉美玲葉美玲引用關係
指導教授(外文):Yeh,Mei-Ling
口試委員:葉美玲陳方佩王玉真
口試委員(外文):Yeh,Mei-LingChen,Fang-PeyWang,Yu-Chen
口試日期:2019-06-04
學位類別:碩士
校院名稱:國立臺北護理健康大學
系所名稱:中西醫結合護理研究所
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2019
畢業學年度:107
語文別:中文
論文頁數:59
中文關鍵詞:針灸穴位低能量雷射術後疼痛全膝關節置換術
外文關鍵詞:Acupuncture pointslow-level laserpostoperative paintotal knee arthroplasty
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全膝關節置換術是治療晚期退化性關節炎最常用且有效之治療方式,傷口疼痛仍是病人術後常面臨到的問題。因此,本研究目的是運用低能量雷射刺激,探討膝關節置換術病人手術後疼痛強度、自控式止痛器嗎啡需求劑量、鴉片類相關副作用、膝關節僵硬程度及疼痛干擾日常活動程度。在北部某醫學中心之骨科病房收案,包括82位接受半身麻醉單側全膝關節置換術術後病人,採單盲、隨機對照試驗,將參與者分為低能量雷射處置組(n=41)和對照組(n=41)。所有參與者在全膝關節置換術後,均接受靜脈自控式止痛和周邊神經阻斷術,低能量雷射處置組在術後滿2小時、6小時、10小時、24小時、48小時及72小時予低能量雷射刺激,波長808±10nM,功率密度≦300mW,治療劑量每穴位3焦耳,治療時間每穴位10秒鐘;對照組以相同方式接受穴位處置,但無雷射刺激。研究工具包括數字等級量表(NRS)、簡明疼痛量表(BPI)、西安大略及麥可麥思特大學退化性關節炎量表(WOMAC)。資料收集後使用SPSS 22.0統計軟體,以獨立樣本t檢定、卡方檢定、概似化函數估計式進行資料處理與分析。本研究結果顯示,兩組於基本人口學及手術參數並無顯著差異(p > 0.05);介入措施後,術後72小時兩組平均疼痛強度有顯著差異(p < 0.05),在排除干擾變項年齡及性別,以GEE分析兩組時間與組別交叉作用,顯示低能量雷射處置組於術後48、72小時內自控式止痛器嗎啡需求量低於對照組(p < 0.001);低能量雷射處置組可降低術後10及24小時之噁心嘔吐程度(p < 0.05);降低術後48及72小時之WOMAC關節僵硬分數(p < 0.05),兩組病人膝關節主動彎曲角數皆有增加現象,但未達統計學上顯著差異;低能量雷射措施介入下,術後72小時疼痛干擾生活程度,在日常活動、行走能力、正常工作、與他人交往及生活樂趣等層面, 達統計上顯著差異(P < 0.05)。本研究結果可作為護理人員於膝關節置換術病人術後疼痛照護參考,低能量雷射刺激可減少術後疼痛強度、術後止痛藥需求量、嗎啡副作用及減少疼痛對日常活動之影響,進而提升照護品質。
Total knee arthroplasty (TKA) is a common and effective surgical procedure for patients with end‐stage knee osteoarthritis, and wound pain is still a problem for many of the patients.Therefore, the purpose of this study was to apply low level laser therapy Measured variables included postoperative pain intensity, patient-controlled analgesia requirements, side effects caused by morphine, knee stiffness and wound pain in the daily activities of patients post total knee arthroplasty. Data were collected from the orthopedic wards of a medical center in Taipei, Taiwan. Eighty-two patients who had received TKA under spinal anesthesia for osteoarthritis of the knee were randomly allocated to the low level laser therapy (LLLT) (n=41) or control group (CG) (n=41), and a single-blind randomized controlled trial was used. All participants received intravenous patient-controlled analgesia and peripheral nerve block after TKA. The LLLT group received low level laser 808±10nM wavelength, power density≦300mW/mm2, 3 J per point, 10-second acupoint stimulation at the acupoints at 2, 6, 10, 24, 48, and 72 hours after surgery ; the CG group received acupoint stimulation in the same manner but with a LLLT (0J) . Measurement used in the study included Numerical Rating Scale (NRS), Brief Pain Inventory (BPI), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Data were analyzed using SPSS (version 22.0). Independent t test, Chi square, and generalized estimating equation (GEE) model were used. Results showed that there were no differences among two groups in terms of demographic and intraoperative parameters (p>0.05). After therapy, there was significant differences between two groups in the average pain intensities (p<0.05), and postoperative three days pain intensity showed a decreasing trend over time (p<0.001). After controlling for covariates (age and sex), GEE revealed significant differences on all measured variables between two groups except at 2 and 6 hours after surgery. The analgesic drug usage in low level laser therapy group was significantly lower than control group within 48, 72 hours after surgery (p<0.001). LLLT could reduce the level of nausea and vomiting at 10, and 24 hours after surgery (p<0.05). LA could reduce the level of WOMAC joint stiffness score at 48 and 72 hours after surgery (p<0.05). There was no significant difference in the average initiative knee bending angle between two groups, although the data of two groups showed an increasing trend over time. Brief Pain Inventory (BPI-T) pain analgesia and pain interference in daily activities (general activity, walking ability, normal work, relationships with others, and enjoyment of life) at 72 hours after surgery were significantly different between two the group.In summary, the results of this study could be used as a recommendation for the postoperative pain care of TKA and as a reference for nursing staff to care the postoperative pain of patients undergoing TKA. The LLLT was effective in relieving wound pain, reducing postoperative analgesia consumption and morphine side effects, decreasing influences of pain in daily activities and then improving the quality of care.
中文摘要 …………………………………………………………………………Ⅰ
英文摘要 …………………………………………………………………………Ⅱ
目次 ………………………………………………………………………………Ⅳ
表次 ………………………………………………………………………………Ⅴ
圖次 ………………………………………………………………………………VI
第一章 緒論
第一節 研究動機及重要性 ……………………………………………………1
第二節 研究目的 ………………………………………………………………1
第三節 研究質疑 ………………………………………………………………2
第四節 研究假設 ………………………………………………………………2
第二章 文獻查證
第一節 退化性關節炎之現況及治療 …………………………………………3
第二節 疼痛神經生理學影響………………………………………………… 4
第三節 術後疼痛處置…………………………………………………………4
第四節 手術後疼痛評估 ………………………………………………………7
第五節 中醫止痛輔助療法之相關研究 ………………………………………8
第六節 低能量雷射刺激之相關研究…………………………………………10
第三章 研究架構
第一節 概念架構………………………………………………………………13
第二節 名詞界定………………………………………………………………13
第四章 研究方法
第一節 研究設計………………………………………………………………16
第二節 研究地點及研究對象…………………………………………………17
第三節 研究工具………………………………………………………………18
第四節 研究對象權益維護與倫理考量………………………………………22
第五節 研究步驟及研究流程…………………………………………………23
第六節 資料處理與分析………………………………………………………23
第五章 研究結果
第一節 研究對象之基本屬性…………………………………………………24
第二節 介入措施對疼痛強度之成效…………………………………………28
第三節 介入措施對自我感覺疼痛程度之成效………………………………30
第四節 介入措施對PCA嗎啡需求量之差異 ………………………………31
第五節 介入措施對術後72小時內嗎啡副作用發生率之比較 ……………32
第六節 介入措施對膝關節WOMAC關節僵硬分數狀態 …………………35
第七節 介入措施後膝關節彎曲角度狀態……………………………………36
第八節 介入措施對疼痛干擾生活程度上之成效……………………………37
第六章 討論
第一節 研究對象基本屬性之分析……………………………………………40
第二節 低能量雷射處置後病人自覺在術後疼痛強度之差異………………40
第三節 低能量雷射處置後PCA嗎啡需求量及嗎啡副作用之差異 ………41
第四節 低能量雷射處置後對膝關節僵硬程度之差異………………………42
第五節 低能量雷射處置後對膝關節彎曲程度之差異………………………42
第六節 低能量雷射處置後在疼痛干擾程度上之差異………………………43
第七章 結論與建議
第一節 結論……………………………………………………………………44
第二節 護理上之應用…………………………………………………………44
第三節 建議與限制……………………………………………………………45
參考文獻
中文部分 ………………………………………………………………………46
外文部分 ………………………………………………………………………47
附錄
附錄一 IRB同意臨床試驗研究證明書 ……………………………………58
附錄二 IRB同意執行證明書 ………………………………………………59

表  次
Table 4-1 Pretest and posttest research designs …………………………………………16
Table 4-2 Reliability of the WOMAC……………………………………………………22
Table 5-1-1 Homogeneity of demographic and clinical characteristics for two groups…27
Table 5-2-1 The Average pain intensity before and after surgery in the two groups ……29
Table 5-2-2 Results of Generalized estimating equation in pain intensity………………29
Table 5-3-1 Comparison of pain intensity before and after surgery between groups……30
Table 5-4-1 The PCA morphine requirement after surgery in the two groups……………31
Table 5-4-2 Results of Generalized estimating equation in analgesic dose requirement at
each observation ……………………………………………………………32
Table 5-5-1 Comparison of the incidence of morphine side effects with in 72 hours after
surgery in both groups………………………………………………………32
Table 5-5-2 Comparison of the incidence of morphine side effects between the two
groups at each observation…………………………………………………33
Table 5-6-1 WOMAC joint stiffness score………………………………………………35
Table 5-6-2 Results of GEE analyses of WOMAC joint stiffness score at each observation 36
Table 5-7-1 Knee functional status in the preoperative and postoperative period ………36
Table 5-8-1 Pain-related interference in daily life ………………………………………38
Table 5-8-2 Comparison of pain related interference in daily life between the two groups……39


圖  次
圖3-1 研究架構圖……………………………………………………………………13
圖3-2 量角器…………………………………………………………………………15

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