全膝關節置換術患者手術前後疾病嚴重性及疾病接受度變化之探討

Abstract

【背景】退化性關節炎是老年人常見的疾病之一，又以膝部為退化性關節炎最好發的部位。膝關節的功能不但要承受體重，還要做屈曲、伸展、旋轉等動作，一旦有了病變，活動能力就受到限制並產生疼痛，常導致老年人不願意外出與人互動，造成社交隔離與依賴，更加深難以接受病情的診斷與了解行為改變的必要，然而目前，全膝關節置換術可有效改善症狀與功能，其餘的治療方式效果有限，因此，了解患者對疾病的接受程度，影響面對未來的治療，手術後膝關節疼痛及身體功能的改善，疾病接受度與疾病嚴重性的變化是個值得探討的議題。 【目的】本研究目的探討退化性膝關節炎患者接受全膝關節置換手術前後其疾病嚴重性與疾病接受度的變化及相關因素。 【研究方法】本篇是屬於相關性研究，採縱貫式及調查性研究設計。於門診進行手術前收案，針對有接受手術的研究對象更進一步分別於術後5-6天、術後第二個月及術後第六個月，此三個時間點再予以面訪，利用結構式問卷進行資料收集；於門診3-4個月後，再針對未來本院手術的研究對象追蹤，進行電訪一次，探究其原因。問卷內容包括基本屬性、疾病相關資料、疾病接受度量表、工具性日常生活能力量表等四大部份。樣本數達210人，分為願意接受手術的患者約108人，而不願接受手術或非在本院手術的患者人數為102人。 【研究結果】研究對象大多為女性佔81.4%，平均年齡為70.04歲，BMI平均為27.13 kg/m2,低教育程度者佔71%，有配偶者65.2%，與家人同住者佔91.9%，無工作者佔75.7%。 在基本屬性方面，女性比男性的術膝屈曲度、未術膝屈曲度、STS-60及IADL有顯著性較差。年齡與BMI、術膝屈曲度、STS-60、IADL皆呈現顯著負相關，低學歷者、無配偶者或無工作者其年齡較大。BMI與未術膝屈曲度呈現顯著負相關。低學歷者比高學歷者未術膝屈曲度及IADL有顯著性較差。無工作者其STS-60、IADL及疾病接受度顯著較差。 在術前方面，術膝屈曲度與疼痛指數呈現顯著負相關；未術膝屈曲度與症狀持續時間呈現顯著負相關，與術膝屈曲度正相關；STS-60與疼痛指數呈現顯著負相關，與術膝屈曲度及未術膝屈曲度皆呈現顯著正相關；IADL與疼痛指數呈現顯著負相關，與術膝屈曲度、未術膝屈曲度及STS-60皆呈現顯著正相關；疾病接受度與疼痛指數呈現顯著負相關，與術膝屈曲度、未術膝屈曲度、STS-60及IADL皆呈現顯著正相關。 手術相關資料與疾病嚴重性及疾病接受度的關係中，綜合術後5-6天、術後第二個月及術後第六個月敘述如下：主要是術後第一次下床時間與術後各階段的疼痛指數呈現顯著正相關；與術後5-6天的術膝屈曲度呈現顯著負相關，其餘時間則無顯著關係；與術後各階段的STS-60呈現顯著負相關；與術後第二個月及術後第六個月的IADL呈現顯著負相關；與術後各階段的疾病接受度呈現顯著負相關。 術後疾病嚴重性及疾病接受度之關係中，綜合術後5-6天、術後第二個月及術後第六個月敘述如下：術膝屈曲度與術後各階段的疼痛指數呈現顯著負相關； STS-60與術後各階段的疼痛指數呈現顯著負相關，與術膝屈曲度呈現顯著正相關；IADL與疼痛指數呈現顯著負相關，除了術後5-6天，與術後各階段的STS-60及術膝屈曲度呈現顯著正相關；疾病接受度與術後各階段的疼痛指數呈現顯著負相關，與術膝屈曲度、STS-60及IADL呈現顯著正相關；術後健術膝屈曲度差距與疾病接受度呈現顯著負相關。 術前及術後疾病嚴重性及疾病接受度之變化中，疼痛指數在術前與術後5-6天是無顯著差異的，術後第二個月疼痛指數開始愈來愈下降，直到術後第六個月已較無明顯的疼痛；術膝屈曲度、STS-60在術後5-6天比術前差，但是在術後第二個月就會比術前好，甚至到第六個月比術前更佳；IADL術後5-6天及術後第二個月比術前差，但是在術後第六個月就會比術前更佳；疾病接受度從術後開始，每個階段都是有顯著逐漸往上升。 根據Mixed model依手術前、術後5-6天、術後第二個月及術後第六個月這四個時間點的整體變化結果分析，疼痛指數愈高對疾病接受度愈低，術膝屈曲度、STS-60及IADL愈高對疾病接受度愈高，整體而言，疾病接受度在術後各個階段對術前是有顯著愈來愈高。 在決定接受手術的相關預測因素中，使用Multiple Logistic regression預測接受手術的意願，未術膝屈曲度的增加會提高6.6%、疾病接受度的增加會降低2.7%及症狀持續時間的增加會提高0.7%接受手術的意願；另外，使用向前逐步迴歸法分析在基本屬性及術前疾病嚴重性對疾病接受度的解釋力，迴歸模式的R2=0.341，調過後的 R2=0.321。 透過本研究結果，可幫助護理人員了解退化性膝關節炎手術後的影響及現況，以作為臨床退化性膝關節炎的衛教宣導參考，此外，可根據患者在術前及術後的每個階段，所可能面臨的問題，給予患者個別性指導及心理支持，以更能發揮護理的獨特性，也能讓患者及家屬對退化性膝關節炎術前的準備及術後因應照護的認知。

[Background] Osteoarthritis (OA) is a common chronic disease in the elderly. It is a degenerating change of knee. When knee joints got a pathological change, they will suffer pain and the daily activities will be limited. It will lead to reduce their social activity and present low self-esteem, social isolation and dependence. The best choice of treatment for severe OA is receiving total knee replacement (TKR). They may get more difficult to accept the necessary of surgery treatment. The patients’ acceptance of disability will influence their willingness of surgery. The issue is worth exploring. Purpose：The study was to explore the acceptance of disability among patients with severe OA of knee and the related factors. [Methods] This was a longitudinal and investigative study design. In outpatient department interviewing 210 patient before surgery, and then for 108 patient undergoing surgery, at postoperative 5-6 days, postoperative two months and postoperative six months interview further. Using structured questionnaire to collect data. In addition, after outpatient department three to four months, the 102 patient did’t undergoing surgery, conducted a telephone interview, explore its causes. The tools include Linkowski’s Acceptance of Disability Scale (score range from 50 to 300), Chinese’s version, Instrumental Activities of Daily Living Scale (IADL), Goniometer to measure the degree of knee flexion, Sit-to-stand cycles in sixty seconds (STS-60) and VAS pain score (0-10). [Result] Participants were more females (81.4%), mean age was 70.04 years, BMI mean was 27.13 kg/m2, there were more low level of education (71%), more spouses (65.2%), more living with family (91.9%), more no woker (75.7%). In demography, women than men had significant poor operative kne flexion, non-operative knee flexion, STS-60 and IADL. Age was negatively correlation with BMI, operative knee flexion, non-operative knee flexion, STS-60 and IADL. The older was lower levels of education, without a spouse or no work. BMI was negatively correlation with non-operative kne flexion. Low levels of education than hign levels of education had significant poor non-operative kne flexion and IADL. No worker had significant poor STS-60, IADL and acceptance of disability. In preoeration, operative knee flexion was negatively correlation with pain score. Non-operative knee flexion was negatively correlation with duration of symptoms, postively correlation with operative knee flexion. STS-60 was negatively correlation with pain score, postively correlation with operative knee flexion and non-operative knee flexion. IADL was negatively correlation with pain score, postively correlation with operative knee flexion, non-operative knee flexion and STS-60. Acceptance of disability was negatively correlation with pain score, postively correlation with operative knee flexion, non-operative knee flexion, STS-60 and IADL. In the surgery-related data, the postoperative ambulation first time was postively correlation with pain score, negatively correlation with operative knee flexion, STS-60, IADL and acceptance of disability. In postoperation, operative knee flexion was negatively correlation with pain score. STS-60 was negatively correlation with pain score, postively correlation with operative knee flexion. IADL was negatively correlation with pain score, except post operative 5-6 days, postively correlation with operative knee flexion and STS-60. Acceptance of disability was negatively correlation with pain score, postively correlation with operative knee flexion, STS-60 and IADL. Between operative knee flexion and non-operative knee flexion distance was negatively correlation with acceptance of disability. For preoperation and postoperation change in pain score, preoperative and postoperative 5-6 days were no significant differences, at postoperative two months began more and more drups, until postoperative six months the pain had relief. In operative knee flexion and STS-60 change, preoperative than postoperative 5-6 days was significantly poor, but at postoperative two months than preoperative was significantly good, even postoperative six months better than preoperative. In IADL change, preoperative than postoperative 5-6 days and postoperative two months were significantly poor, until postoperative six months better than preoperative.In acceptance of disability change, postoperation each stage was significant to rise gradually. According Mixed model to preoperative, postoperative 5-6 days, postoperative two months and postoperative six months four point overall data analysis. Higher pain score lower acceptance of disability. Higher operative knee flexion, STS-60 and IADL higher acceptance of disability. Using the statistical method of Multiple Logistic regression to predicted undergoing surgery probability, the non-operative knee flexion increase wound increase 6.6%. The acceptance of disability score increase wound decrease 2.7%. The duration of symptoms increase wound increase 0.7%. Using the statistical method of Multile linear regression to acceptance of disability explanatory R2=0.341, adjusted R2=0.321. [Conclusion] Resluts revealed this study can help nurses understand osteoarthritis of knee and influence postoperative status, to advocacy reference in clinical health education. In addition, according to pre- and post-operative period, patient may face many problems, given the individual education and psychological suppor. Let nurses play the uniqueness of care, but also let patient and family prepare preoperation and postoperative care konwledge better.