肩旋轉肌袖破損病患手術決策衝突、決策後悔與術後六個月內生活品質之探討

Abstract

背景：肩旋轉肌袖破損（rotator cuff tear）病患常因疼痛與肩關節功能受限而產生憂鬱情緒，進而影響生活品質。當保守治療成效不佳時，是否接受手術成為一項重要且具挑戰性的醫療決策。由於肩旋轉肌袖修復手術屬擇期性手術，且術後症狀改善與功能恢復通常需要三至六個月，復原期間病患可能持續經歷疼痛、情緒低落及活動與工作能力受限，導致實際復原狀況與術前期待產生落差，進而引發決策衝突與決策後悔，並影響其術後決策後悔與生活品質。然而，現有研究多著重於術後功能恢復與疼痛改善，對於病患在決策歷程中之症狀困擾(疼痛程度與憂鬱情緒)，決策衝突、決策後悔及其與術後生活品質之相關性，仍缺乏探討。 目的：本研究旨在探討肩旋轉肌袖破損病患於手術前、術後三個月及六個月的症狀困擾(疼痛程度與憂鬱情緒)、決策衝突、決策後悔與生活品質的變化。並分析影響術後六個月內生活品質之重要影響因素。 方法：本研究採前瞻性縱貫式調查研究設計，以北部某醫學中心接受肩旋轉肌袖修補術之住院病患為研究對象，採方便取樣。於手術前（T0）、術後三個月（T1）及術後六個月（T2）進行重複資料收集。採結構式問卷蒐集資料，內容包括：(1)自擬之病患屬性與疾病特徵；(2)控制偏好量表(control preferences scale)；(3)症狀困擾，包括以數字等級疼痛量表（Numerical Rating Scale）評估疼痛程度，以及以病患健康問卷（Patient Health Questionnaire-9）評估憂鬱情緒；(4)決策衝突量表(Decisional Conflict Scale)；(5)決策後悔量表(Decision regret scale)及(6)西安大略肩旋轉肌袖指數(Western Ontario Rotator Cuff)。以SPSS 26.0版套裝軟體進行描述性與推論性統計分析，並採用廣義估計方程模型(Generalized Estimating Equations, GEE)分析病患於不同時間點之症狀困擾(疼痛程度與憂鬱情緒)、決策衝突、決策後悔與生活品質之變化情形，以及其相關影響因素。 結果：本研究於2023年1月至2025年4月期間進行，共招募156位病患，其中150位完成研究同意書簽署並填寫術前（T0）資料。術後三個月（T1）共有123位病患完成追蹤評估；至術後六個月（T2），最終完成追蹤者為103位。以術前納入之150位病患為基準，T2之整體完成率為68.7%，流失率為31.3%。結果顯示，術後六個月內病患的疼痛與生活品質均呈持續改善趨勢；憂鬱情緒則在術後三個月短暫上升後，於術後六個月明顯下降。決策後悔於術後六個月略高於術後三個月，但差異不顯著。術前決策衝突整體偏低，但其嚴重程度與術後三個月及術後六個月的決策後悔皆呈顯著相關，且低衝突組的決策後悔顯著較低。GEE與中介分析顯示，疼痛、憂鬱及決策後悔為生活品質的重要預測因子，且決策後悔在症狀困擾與生活品質間具有部分中介效果。 結論與實務應用：肩旋轉肌袖破損病患的生活品質不僅受到疼痛與憂鬱等症狀困擾影響，亦與其術前決策衝突與術後決策後悔密切相關。臨床實務中應強化疼痛與憂鬱之系統性評估，及早辨識高風險病患並提供適切照護，以減輕症狀負荷並提升生活品質。此外，建議發展以病患需求為核心的共享決策模式，協助病患充分理解治療選項並參與決策。同時，將決策衝突與共享決策理念納入醫護人員訓練，以強化臨床溝通與決策支持能力。未來研究則可延長追蹤時間，並結合功能性與質性評估，以更全面理解肩袖破損病患的長期復原與心理調適歷程。

Background: Patients with rotator cuff tears (RCT) frequently experience depressive symptoms due to pain severity and limited shoulder function, both of which substantially affect their quality of life (QoL). When conservative treatment proves ineffective, deciding whether to undergo surgery becomes a critical and challenging medical decision. As rotator cuff repair is an elective surgery and recovery typically spans three to six months, patients may endure persistent pain severity, depressive symptoms, and functional limitations during this period. Discrepancies between actual recovery and preoperative expectations can trigger decisional conflict and decision regret, subsequently affecting postoperative QoL. Purpose: This study aimed to investigate the longitudinal changes in symptom distress (pain severity and depressive symptoms), decisional conflict, decision regret, and QoL among patients with RCT from preoperative stages to six months postoperatively, and to identify key predictors of QoL within the first six months after surgery. Methods: A prospective longitudinal survey design was employed. Patients undergoing rotator cuff repair at a medical center in Northern Taiwan were recruited through convenience sampling. Data were collected at three time points: preoperatively (T0), three months postoperatively (T1), and six months postoperatively (T2). Structured questionnaires included: (1) Participant characteristics and clinical data; (2) Control Preferences Scale (CPS); (3) Symptom distress (Numerical Rating Scale for pain severity and Patient Health Questionnaire-9 for depressive symptoms); (4) Decisional Conflict Scale (DCS); (5) Decision Regret Scale (DRS); and (6) Western Ontario Rotator Cuff (WORC) index. Data were analyzed using SPSS 26.0 for descriptive and inferential statistics, while Generalized Estimating Equations (GEE) were utilized to analyze the changes and predictors of variables across time points. Results: Between January 2023 and April 2025, 156 patients were screened; 150 completed the T0 assessment. Follow-up was completed by 123 patients at T1 and 103 patients at T2, representing a final completion rate of 68.7% and a lateral attrition rate of 31.3%. Results indicated that pain severity and QoL showed continuous improvement over the six-month period. Depressive symptoms rose slightly at T1 before significantly declining at T2. Decision regret was slightly higher at T2 than at T1, though the difference was not statistically significant. Preoperative decisional conflict was generally low but significantly correlated with decision regret at both T1 and T2; patients in the low-conflict group reported significantly lower regret. GEE and mediation analyses revealed that pain severity, depressive symptoms, and decision regret were significant predictors of QoL. Furthermore, decision regret partially mediated the relationship between symptom distress and QoL. Conclusions and Implications for Practice: The QoL of patients with RCT is influenced not only by symptoms distress (pain severity and depressive symptoms) but also by preoperative decisional conflict and postoperative decision regret. Clinical practice should prioritize systematic assessments of pain severity and depressive symptoms to identify high-risk patients early and provide appropriate care to alleviate symptom burden. It is recommended to develop patient-centered Shared Decision-Making (SDM) models to assist patients in understanding treatment options. Additionally, integrating decisional conflict and SDM concepts into healthcare professional training can enhance clinical communication and support. Future research should consider longer follow-up periods and combine functional and qualitative assessments to provide a holistic understanding of long-term recovery and psychological adaptation in RCT patients. Keywords: rotator cuff tear, pain, depressive symptoms, decisional conflict, decisional regret, quality of life