常見腰椎手術後接受早期承重訓練之成效探討：隨機控制試驗

Abstract

背景 : 伴隨著人口老化，許多脊椎退化疾病發生也逐年攀升，尤其以腰椎退化疾病最為常見。許多患者接受手術後，仍有約四成患者症狀仍未完全改善，仍需後續藥物及復健治療。此外，臨床上也有不少腰椎術後的患者，因為傷口疼痛、擔心跌倒或是疼痛復發，術後選擇長期臥床或是減少活動。導致肌力下降、肌肉萎縮、平衡功能及日常生活功能退化，因此如何於術後及早進行安全而有效的復健活動，對於日後肌力恢復和日常生活功能提升有所助益，非常關鍵。

目的 : 探討常見腰椎術後患者，除接受臨床常規治療及教育復健衛教須知外，增加由面對面的指導患者，加強術後早期接受坐到站（sit-to-stand）實地承重訓練，對於術後一個月及三個月在疼痛改善及日常生活功能之成效。

方法 : 本研究為前瞻性隨機對照試驗，收集於2023年12月到2024年11月期間，在新北市兩間區域醫院及地區醫院神經外科中，40到95歲患者因壓迫性骨折、腰椎管狹窄、腰椎滑脫或腰椎退化性疾病，初次接受椎體成形術、腰椎間盤顯微切除術或腰椎間盤切除融合及經椎弓根骨釘固定手術者。實驗組患者術後除接受常見腰椎術後照護及復健須知外（對照組），於出院前接受由研究團隊一對一指導，實際演練從坐到站、站到坐的安全承重訓練，並於每日自行執行此訓練，一天三組，一組來回10次，術後三個月每週以電話鼓勵患者持續。主要成效指標利用數字指數量表（Numerical Rating Scale, NRS）及歐氏失能量表（The Oswestry Disability Index, ODI）來記錄並追蹤患者術前，術後一個月及三個月，疼痛改善和日常生活功能改變的情形。數據利用ANOVA變異數分析（組內及組間）來探討早期承重訓練對於短期及長期疼痛和生活功能上有無助益。此外，追蹤疼痛強度和日常生活功能的縱向變化，分析介入效果和縱向變化趨勢採用廣義估計方程式（generalized estimating equations）中的多變量線性模型（multivariate linear regression model）進行統計分析。

結果: 本研究共招募50位個案，一位個案流失，共完成實驗組25位及對照組24位三個月追蹤。疼痛指數結果顯示，實驗組相對於術前基本分數而言，術後 1個月和3個月的NRS評分分別下降了5.12分（P<0.001）和7.28分（P<0.001），而對照組下降3.19分（P<0.001）和5.81分（P<0.001），表明二組整體上疼痛強度隨時間顯著降低。另外在探討組別與時間的交互作用在1個月（差值=1.74，P=0.005）和3個月（差值=1.27，P=0.001）均達到統計學顯著性，表示實驗組相對對照組在疼痛減輕程度上達顯著差異。在日常生活功能結果分析顯示，相較於術前分數，實驗組1個月和3個月的ODI評分分別下降了18.28分（P<0.001）和25.00分（P<0.001），對照組則是下降11.79分（P<0.001）和20.42分（P<0.001），表示整體上功能障礙隨時間顯著改善。而實驗組相對對照組與時間的交互作用項於1個月（差值=4.70，P=0.053，邊緣顯著）和3個月（差值=2.79，P=0.015）均有明顯差異，顯示實驗組相較對照組在功能改善程度上較佳。此外，本研究追蹤個案皆無術後相關不良反應(傷口癒合不良、跌倒、症狀復發、植入物斷裂或位移)，未發生因實驗操作導致再次手術的情形。

結論: 由本研究發現針對常見腰椎手術患者，術後早期接受簡單、安全又方便的承重訓練指導，於術後一個月及三個月在疼痛控制和日常生活上，相較僅提供衛教有明顯的改善。然樣本數小、追蹤時間較短及評估者知道個案分組，未來仍需調整及更大型試驗，以驗證介入成效。

Background: As the population ages, the incidence of degenerative spinal diseases, particularly lumbar disorders, is rising. Despite surgery, about 40% of patients experience persistent symptoms requiring ongoing medication and rehabilitation. Many post-lumbar surgery patients reduce activity or remain bedridden due to pain, fear of falling, or pain recurrence, leading to muscle weakness, atrophy, balance issues, and decreased daily functioning. Early initiation of safe and effective rehabilitation is crucial for muscle strength recovery and improving daily activities.

Objectives: To investigate the effects of adding face-to-face guided early sit-to-stand weight-bearing training, alongside standard clinical treatment and rehabilitation education (control group), on pain reduction and improvement in activities of daily living at one and three months post-lumbar surgery.

Methods: This study was a prospective, randomized controlled trial conducted between December 2023 and November 2024 in the neurosurgery departments of two regional and local hospitals in New Taipei City. Patients aged 40 to 95 undergoing initial vertebroplasty, lumbar discectomy, lumbar fusion or pedicle screw fixation surgery for conditions such as compression fractures, lumbar spinal stenosis, spondylolisthesis, or degenerative lumbar diseases were recruited. In addition to receiving standard postoperative lumbar care and rehabilitation education (control group), patients in the experimental group received one-on-one, face-to-face guidance from the research team before discharge. This included practical training in safe weight-bearing sit-to-stand and stand-to-sit movements. Patients were instructed to perform this exercise with caregiver’s supervision, three sets per day, with 10 repetitions per set. Weekly phone calls were made for three months postoperatively to encourage continued adherence. Primary outcomes included pain reduction and functional improvement, assessed using the Numerical Rating Scale (NRS) and the Oswestry Disability Index (ODI) at baseline, one month, and three months postoperatively. Data were analyzed using ANOVA to evaluate within-group and between-group differences on outcomes at one and three months post- surgery. Longitudinal changes in pain and daily function were assessed using generalized estimating equations (GEE) with a multivariate linear regression model to analyze intervention effects and trends over time.

Results: A total of 50 participants were recruited, with one lost to follow-up, leaving 25 in the experimental group and 24 in the control group completing the three-month follow-up. The experimental group showed significant reductions in NRS pain scores by 5.12 points at 1 month (P<0.001) and 7.28 points at 3 months (P<0.001), compared to reductions of 3.19 points and 5.81 points in the control group (P<0.001 for both). Group-by-time interaction effects were significant at 1 month (difference = 1.74, P=0.005) and 3 months (difference = 1.27, P=0.001), indicating greater pain relief in the experimental group. For functional outcomes, the experimental group’s ODI scores decreased by 18.28 points at 1 month and 25.00 points at 3 months (P<0.001), while the control group saw reductions of 11.79 and 20.42 points (P<0.001). Group-by-time interactions showed marginal significance at 1 month (difference = 4.70, P=0.053) and significance at 3 months (difference = 2.79, P=0.015), indicating better functional improvement in the experimental group. No postoperative adverse events or reoperations related to the intervention were reported.

Conclusions: This study found that early postoperative guidance on simple, safe, and convenient weight-bearing exercises for common lumbar surgery patients led to significant improvements in pain control and daily functioning at one and three months post-surgery, compared to standard educational care alone. However, due to the small sample size and short follow-up period, and the fact that assessors were aware of group assignments limit the generalizability of the findings. Future studies should involve larger sample sizes, longer follow-up periods, and adjustments to the study design to further validate the intervention's effectiveness.