【作者】 王飞；

【导师】 卢惠娟；

【作者基本信息】 复旦大学 ， 护理学， 2010， 硕士

【摘要】 研究背景腰椎椎间融合术已成为腰椎退变性疾病的重要治疗方法,接受该手术治疗的患者逐年增加。腰椎椎间融合术能为腰椎退变性疾病患者提供腰椎生物力学稳定性。椎间融合器的运用可防止植骨块移位和塌陷等并发症的发生,因而术后可早期下床作适宜的功能锻炼,有利于预防长期卧床所导致的并发症。然而,相对其在临床的快速普及和开展,康复护理发展却相对落后。目前,腰椎椎间融合术后仍有20%-30%的患者出现下腰痛,影响功能恢复和日常活动能力。除具体疾病和手术治疗等因素之外,术后早期康复缺乏严格、系统、有效的指导是其重要原因。同时,持久的慢性疼痛可伴随抑郁等负性情绪,会严重影响患者的生活质量。术后早期积极康复锻炼可预防硬膜外及神经根粘连、增强腰背肌和腹肌肌力、增强脊柱稳定性,同时也是确保手术效果的必要手段。目前,国外对于腰椎椎间融合术患者术后身心的全面康复较为重视,术后康复锻炼全面且分工精细,但主要是由康复机构来承担。由于手术方式的不断改良,对于腰椎椎间融合术患者也未形成系统早期康复护理模式。而国内较多医院还没有专门的康复科,专业康复人员也较少,骨科康复护理缺乏系统性、计划性,普遍存在着手术与早期康复严重脱节的现象。腰椎椎间融合术患者由于行动不便导致术后复诊率低,而社区卫生机构又不能提供康复指导。因此,术后早期康复护理在腰椎椎间融合术的康复中至关重要。国内文献对腰椎椎间融合术的患者所开展的早期康复护理基本上都是经验性的总结,未见对腰椎椎间融合术的患者进行系统护理干预的对照研究报道。因此对腰椎椎间融合术后康复护理的研究具有现实的意义。本课题引用国外腰椎融合术后患者身心全面康复的理念,对行腰椎椎间融合术的腰椎退变性疾病的患者进行对照研究,旨在应用自制腰椎椎间融合术身心康复的视听DV、图文并茂的指导手册和康复计划执行单等载体,通过视听干预、床边个别指导和电话访视,实施结合康复锻炼和心理指导的院内外早期康复护理干预方案,促进患者术后功能恢复,改善生活质量,促进就业,为有关部门制定院内、社区一体化身心康复提供专业参考。目的评价早期康复护理干预对腰椎椎间融合术治疗的腰椎退变性疾病患者术后康复的影响。方法将72名符合纳入标准的腰椎椎间融合术治疗的腰椎退变性疾病患者分为干预组(32名)和对照组(40名)。对照组患者接受腰椎椎间融合术常规护理。干预组患者在接受常规护理的同时,实施早期康复护理干预,包括发放自制腰椎椎间融合术身心康复的视听DV及《腰椎椎间融合术患者健康指导手册》、术前PPT教育、床边个别指导、融合术前的适应性训练和术后早期积极康复训练,围手术期的心理干预,出院后实施电话和门诊随访,随访3个月。以Oswestry功能障碍指数(ODI)、视觉模拟疼痛评分、Barthel指数及抑郁自评量表(SDS)等指标,分别对患者入院后2天内、术后10天、术后1个月、术后3个月的下腰痛功能、疼痛、日常生活能力、心理状况进行评价。结果①干预组与对照组的一般资料、疾病与手术情况差异无统计学意义(P>0.05)。②干预组ODI总评分与对照组的差异有统计学意义(P<0.001),提示干预组术后功能恢复优于对照组；对ODI评分各维度进行比较发现,自理能力、坐、站、社会活动得分明显低于对照组(P<0.05)；干预因素和时间因素上述指标无交互作用(P>0.05)；干预组的疼痛、走路得分显著低于对照组(P<0.05),不同组别和不同时间点之间有交互作用(P<0.05)；③干预组Barthel指数评分明显高于对照组(P<0.001)；干预因素和时间因素有交互作用(P<0.001)。④干预组腰、下肢VAS疼痛评分明显低于对照组(P<0.05)。⑤干预组SDS得分显著低于对照组(P<0.05)；干预因素和时间因素无交互作用(P>0.05)。结论早期康复护理干预可有效改善腰椎退变性疾病腰椎椎间融合术患者术后躯体功能、疼痛、日常生活能力和抑郁水平。早期康复护理干预是促进患者术后身心康复的有效方法。更多还原

【Abstract】 BackgroundLumbar interbody fusion has become an important therapeutic method for lumbar degenerative disease (LDD). There are more and more LDD patients who have had this procedure internationally. Lumbar interbody fusion can provide the LDD patients with biomechanical stable lumber intervertebral segments. The treatment with interbody cage can prevent such complications as migration and collapses due to displacement of the bone graft. As a result, the patients are more likely to have early rehabilitation training and early off bed exercises after operation and reduce the long term sickbed related complications. Compared with the rapid spread and development of posterior lumbar interbody fusion, the postoperative rehabilitation nursing care is legging behind. Usually the process of fusion requires a relatively long period. All these factors raise special requirement on post- lumbar-interbody-fusion-surgery nursing. There are about 20 to 30 per cent patients who still exhibit lower back pain (LBP) after the surgery. Post surgery malfunction also affects their daily activity. Besides such causes as disease and surgery themselves, one important cause is the lack of reasonable rehabilitation nursing after operation. Enduring chronicle pain is usually accompanied with some negative emotions like depression, anxiety, etc.Early rehabilitation exercise is especially important after lumbar interbody fusion surgery, which can prevent nerve sticky and make back and abdominal muscle strong. In mainland China, most hospitals do not have any specialized rehabilitation or physiotherapy staff and early rehabilitation nursing is always inadequate in both depth and breath, and the surgery and rehabilitation are not integrated to provide a comprehensive care. Lumbar interbody fusion patients usually have a low ratio of return visit after operation due to their inconvenience of activity. However, the community health centers cannot provide the required rehabilitation instructions, so postoperation early rehabilitation nursing is especially important after lumbar interbody fusion surgery.In some foreign countries, the hospitals pay great attention to the LDD patients’postoperation rehabilitation, their postoperation exercise is very comprehensive and detailed. However a search of domestic literature shows in recovery nursing study, there is a composite lack of rehabilitation philosophy, rehabilitation technique and educational tools. Most papers on early rehabilitation nursing are empirical conclusion. No report was found to be controlled study for the integrated nursing intervention of LDD patients.This paper is based on the ideology of psychological-physiological comprehensive recovery and tries to study the rehabilitation nursing of patients who have undergone lumbar interbody fusion with a nonrandom controlled manner. We have designed a continuous integrated nursing intervention program in and out of the hospital. Within the program, we have designed a detailed rehabilitation training program with focus on rehabilitation exercise and psychological intervention. To guide the LDD patient’s postoperation recovery, we have composed self-made DV and handbooks with illustrative graphs, and have arranged rehabilitation exercise for the patients.We also arranged audio and visual interventions, individual instruction at bedside and telephone visits. The result shows that early rehabilitation can facilitate patients’ post surgery recovery, improve their life quality, promote employment and also provide the theoretical evidence to reduce the economic loss. It also gives the related department professional reference to design integrated in-hospital and in-community physiological-psychological recovery programs. Objective To evaluate the impact of early rehabilitation nursing intervention on lumbar degenerative disease (LDD) patients undergoing lumbar interbody fusion surgery.Methods 72 LDD patients undergoing operation of lumbar interbody fusion meeting the inclusion criterion were divided into intervention group (n=32) and control group (n=40). Patients in control group received routine care. The patients in intervention group received early rehabilitation nursing intervention. They were provided with audiovisual DV and Handbook for LDD rehabilitation, pre-operative education with PPT, individual instruction, pre-operative adaptive exercise and post-operative early active exercise, psychologic intervention, they also received telephone consultation and outpatients visiting for three months. Their physical functioning and pain were assessed with Oswestry disability index (ODI) and visual analogue scale (VAS) respectively. Activities of daily living were assessed with Barthel Index. Their psychological condition was assessed with self-rating depression scale (SDS). Both groups were assessed upon admission,10 days after operation, 1 month after operation and 3 months after operation.Results①There were no significant differences between the intervention group and the control group in age, gender, educational background, economic status, diagnosis, segment, duration of disease, and complication (P >0.05).②The difference of the total score of ODI score was significant between the intervention group and the control group (P<0.001). The intervention group was much lower than the control group. The results indicated that the intervention group had better physical function than the control group. Through the comparison of different dimensions of ODI score, there were statistical significances between the intervention group and the control group in score of self-care, walk, sit, stand, sleep and social activity (P<0.05). There was no significant interactive effect on total score and each score of the above dimensions between groups or different sampling instants (P<0.05).③The Barthel Index score were significantly higher in the intervention group than the control group (P <0.001). The results indicated that the intervention group has better activities of daily living than the control group. There was significant interactive effect on Barthel Index score between groups or different sampling instants (P<0.001).④Both VAS score of leg pain and VAS score of lumbar pain score were significantly less in the intervention group than the control group, which indicated the intervention group has better improvement in pain intensity. There was no significant interactive effect on VAS scores between groups or different sampling instants (P >0.05).⑤SDS score was significantly lower in the intervention group than the control group (P<0.05).ConclusionThis study shows that early rehabilitation nursing intervention could acquire better improvements in disability score, activities of daily living, pain intensity, and psychological state than the traditional nursing intervention. Therefore early rehabilitation nursing intervention is an effective approach in improving the physiology and psychology of LDD patients undergoing lumbar interbody fusion surgery.更多还原