中風患者肩部三種疼痛狀態及對動作、日常活動與生活品質的影響：一年長期追蹤調查研究

Abstract

患側肩部疼痛為中風後最常見的併發症之一，這不僅影響病人的生活品質，也阻礙了患側肢體的活動與上肢復健，病人的功能表現因此受到影響。過去文獻調查中風病人肩部疼痛的研究缺乏長期、密集追蹤、人數充足的特點，各研究調查發生率與盛行率的時間點不一，難以有全面完整的了解。此外與患側肩部疼痛相關的早期預測因子眾多，目前尚未有定論。而患側肩部疼痛的出現，可能對於病人的動作、日常活動及生活品質有負面的影響，減少後期中風病人恢復的程度。 目前調查台灣本土患側肩部疼痛流行病學的研究較少，無法掌握人數比例及變化趨勢。本實驗欲探討中風一年內患側肩部疼痛狀態的人數比例與變化趨勢，以及中風後兩周、一個月時的動作、平衡、感覺、肩關節活動度與年齡是否可以預測患側肩部疼痛一年內的變化趨勢。此外，本實驗探討中風病人發病後六個月及一年時，不同患側肩部疼痛程度與病人在上肢動作、日常生活活動、自覺的上肢功能生活品質、性格生活品質、以及情緒生活品質的相關性。 本研究的樣本採用台灣中風後生活品質研究資料庫的資料，其為一前瞻性研究所收取的資料，收取進入台大醫院1999年12月至2001年11月中風的個案。本研究紀錄個案中風後二周、一個月、三個月、六個月及一年時狀況，包含年齡、傅格—梅爾評量表之患側肩部疼痛、動作、平衡、感覺、肩關節活動角度。 本研究最初徵召了310位個案，最後完整追蹤人數為192人。基本資料記錄了性別、首次中風與否、中風類型與患側，三組間皆沒有統計上差異。依據傅格—梅爾肩部關節疼痛分數，一年內肩部疼痛狀態可分為持續疼痛、疼痛變動、沒有疼痛。人數比例高至低為疼痛變動(113人, 佔58.9%)、持續疼痛(61人, 佔31.8%)、沒有疼痛(18人, 佔9.4%)。中風初期特徵結果顯示，年齡在三類不同患側肩部疼痛變化病人間無統計上顯著差異；傅格—梅爾上肢動作、下肢動作、平衡、感覺方面，沒有疼痛病人顯著優於持續疼痛病人與疼痛變動病人(p<0.001)，疼痛變動與持續疼痛病人間沒有差異；傅格—梅爾肩關節活動更是三者之間皆有差異，沒有疼痛病人優於疼痛變動病人，再優於持續疼痛病人(p≧0.002)。中風後期肩部疼痛嚴重程度與病人的上肢動作、日常生活活動、上肢功能生活品質，有輕度到中度相關(r=0.377-0.494, p≦0.002)，影響較大，而情緒及性格生活品質與肩部疼痛嚴重程度沒有顯著相關。本研究顯示台灣大台北地區有超過90%的中風病人在發病一年內有患側肩部疼痛，其中就屬發病後三個月至一年有較高的盛行率。曾有患側肩部疼痛的病人年齡較高，初期時動作、平衡、感覺、肩關節活動度也較差；此外中風後期病人的日常活動與生活品質也受到肩部疼痛的負面影響。 未來研究可朝向探討患側肩部疼痛的病理機轉，以及臨床介入與家屬照顧對中風病人肩部可能造成的傷害，有助於醫療人員選擇對應且有效的患側肩部疼痛預防方法與治療方式，亦能減少患側肩部疼痛的發生。

Hemiplegic shoulder pain is one of the most common complications after stroke. To the patient, it influences the quality of life and impedes the recovery of upper extremity function during rehabilitation. Previous studies on hemiplegic shoulder pain were mostly short period with few participants. On the other hand, hemiplegic shoulder pain may also influence the recovery of stroke patients’ motor, activities, and quality of life. There is lacking of epidemiology studies for hemiplegic shoulder pain in Taiwan. We have limited information of the number and percentage of hemiplegic shoulder pain patients. The first purpose of this study is to find the trend of hemiplegic shoulder pain development and its percentage of patients. Second, we want to find out the differences of early characteristics between different pain development patients, such as age, motor, balance etc. The last one, we want to figure out whether the pain severity is related to motor of upper extremities, activities, and quality of life in upper limb function, personality of mood. The study sample was recruited from the Registry of the Quality of Life after Stroke Study in Taiwan, a prospective data bank. Data were recorded at 2 weeks, 1 month, 3 months, 6 months, and 1 year after stroke. Basic data, status of hemiplegic shoulder pain, motor, balance, sensation, shoulder range of motion in Fugl-Meyer assessment scale were recorded. Three-hundred-and-ten patients were recruited at the beginning and 192 had completed the follow ups. Hemiplegic shoulder pain was defined by Fugl-Meyer shoulder joint pain subscore. The development of hemiplegic shoulder pain can be categorized into three statuses: persistent pain, transitional pain, and no pain. Basic data between three groups including gender, first stroke or not, stroke type, hemiside were no significantly different. Numbers and percentage of patients of pain development were 113 patients (58.9%) in transitional pain group, 61 patients (31.8%) in persistent pain group, 18 patients (9.4%) in no pain group. Statistical analysis revealed that age was not significantly different between three groups. Fugl-Meyer upper extremity, lower extremity, balance, sensation in no pain group were significantly higher than patients in the transitional pain status and persistent pain status group (p<0.001). Fugl-Meyer shoulder joint motion was largest in the no pain group, then the transitional pain group, and leastly, the persistent pain group (p≧0.002).There were fair to moderate correlation between pain severity and motor of upper extremity, daily activities, upper limb quality of life (r=0.377-0.494, p≦0.002). There was no significant correlation between pain severity and mood and personalityquality of life. The current result is a first report onhemiplegic shoulder pain using the Fugl-Meyer pain subscore in Taiwan. Shoulder range of motion, sensation, balance and motor abilities might influence the development of pain and further research is needed.