【作者】 祁俊菊；

【导师】 王仙园；

【作者基本信息】 第三军医大学 ， 护理学， 2013， 博士

【摘要】 慢性腰背痛患者因康复期较长，除了长期疼痛，患者出现各种心身问题，如功能障碍、焦虑、恐惧、过度依赖医疗，此外，对慢性疼痛本身及康复缺乏正确的认识，导致生活能力、活动力低下，延误工作。已被世界疼痛研究协会（IASP）认为是一种疾病，而非急性疼痛的延续。目前慢性腰背痛患者的康复多局限于医院物理治疗和药物治疗，只能缓解暂时疼痛，对于改善患者长期的疼痛程度和改善生理-心理-社会功能并无明显作用。多数患者经过急性治疗后，因缺乏持续管理来巩固临床治疗效果，症状反复发作或加重，使疼痛及其引起的行为和精神不适变得更加复杂。加拿大《腰背痛自我管理指南》提出病人需承担自我护理（管理）的责任，减少对健康服务提供者的依赖。研究表明自我管理能显著降低患者的疼痛和功能障碍，提高自我效能感，改善患者的健康状况，降低医疗费用。许多研究提出疼痛管理方式的多学科性和综合性。目前慢性腰背痛患者的管理方式研究集中在健康教育、认知-行为学干预及各种锻炼方式，但存在几点不足：①自我管理意识缺乏；②管理方式多为单一方式应用，效果改善不全面；③系统的锻炼需在医生指导下，不适合患者自我操作；④自我管理行为的建立需连续护理干预，提高其长期依从性，目前此方面研究多限于随访观察。本课题在目前研究基础上，选择疼痛管理技能和瑜伽锻炼为自我管理方式，后者根据研究目的和人群特点从动作、顺序、时间及安全管理等方面重新设计。构建护理干预策略，包括自我管理认知教育、疼痛管理技能培训、瑜伽锻炼及自我管理依从性干预。并采用随机对照试验对临床常见的2种腰背痛疾病测试该方案的应用效果，包括阶段性结果和最终结果，对研究方案和工具进行评估改进。第一部分提高慢性腰背痛患者自我管理能力的护理干预方案构建一、方法1.复习与慢性腰背痛患者管理相关的文献，系统评价，初步找出有效的、可操作的自我管理方式。2.以相关理论为基础，构建提高患者自我管理认知和技能的护理干预内容。3.分析锻炼方式在慢性腰背痛患者中的应用，选择适合患者自我操作的、安全有效的瑜伽为锻炼干预方式，构建实施方案内容。二、结果1．确定科学、有效的慢性腰背痛患者自我管理方式包括认知-行为干预和瑜伽锻炼。2.构建慢性腰背痛患者的认知-行为护理干预方案，包括认知教育、技能指导及行为依从性干预，后者通过家属参与、团体交流、目标检测、重点对象筛选和指导及自我管理记录等方式实施。3．构建两种慢性腰背痛患者的瑜伽锻炼方案：选择瑜伽体式、改良内容、设计练习顺序、练习时间和安全管理内容，符合锻炼的动作经济原则、循序渐进原理，持续提高患者的身体适应和功能水平。4.建立12周5次系列的连续护理干预活动，包括3次知识、技能和锻炼的培训干预，及2次行为依从性干预。三、结论本研究在文献复习基础上，选择适合患者自我管理的方式，并应用相关理论构建护理干预方案，包括干预方式和内容，形成认知-行为和锻炼结合的一套实施方案。并将两者科学结合，建立12周5次系列的连续护理干预活动，提高自我管理效能和行为的依从性干预。第二部分慢性腰背痛患者护理干预方案的试验研究及效果评价一、方法1.采用试验对照研究验证本研究方案。以常见的2种疾病腰椎间盘突出和慢性腰肌劳损患者为干预对象，按两疾病的纳入、排除标准选择研究对象，腰椎间盘突出患者试验、对照分别为84和63例，腰肌劳损患者分别为36和33例。两类对象的试验组接受本研究系列干预活动；腰椎间盘突出对照组接受3周临床物理、药物治疗和出院自行管理，腰肌劳损对照组实施自行管理。效果评价包括①疼痛和功能障碍评分；②疼痛应对策略评分和疼痛阶段转换；③健康状况；④3个月内（再次）门诊率。突出组于0、3、6、12周采集数据；腰肌劳损组于0、6、12周采集数据。采用SAS8.2专业统计软件进行统计分析，两组计量资料比较采用独立样本T检验，两组计数资料比较采用卡方检验，应用重复测量资料的方差分析对两组病人在不同时间的指标变化，研究结果和一般资料的相关性采用spearman相关性分析法。2.半结构访谈。本研究过程进行了2次访谈，第1次是3周末调查患者自我管理过程的障碍，第2次是12周干预结束对参与此研究的不同人群调查体会和认识。二、结果1．疼痛程度：①腰椎间盘突出试验组在干预12周后最重、大多数及当前疼痛评分较对照组降低显著（P=0.038、0.033、0.032），其中，最重疼痛值在第3周开始降低（P=0.048）。②腰肌劳损试验组在干预12周后最轻、最重、大多数及当前疼痛评分均有显著降低,其中，最重和大多数时间疼痛在第6周较对照组显著降低（P=0.032、0.038）。2．功能障碍：腰椎间盘突出试验组在第3、6、12周的功能障碍评分较对照组显著降低（P=0.041、0.036、0.030），腰肌劳损试验组在第12周功能障碍评分降低显著（P=0.037）。3．疼痛应对：腰椎间盘突出试验组疼痛应对评分在第6、12周有显著提高（P=0.042、0.031），腰肌劳损试验组在第6、12周显著提高（P=0.003、0.002），且两研究对象的疼痛应对评分从0-12周持续升高。4．疼痛阶段：①腰椎间盘突出试验组在3、6、12周思考前期及行动期的分布变化较对照组比均有统计学意义，6周变化最显著（P=0.003、0.005），12周较6周比不显著。维持期的分布在第12周出现统计学差异（P=0.042）。②腰肌劳损试验组第6周思考前期和行动期分布有统计学差异，组间比较6周思考前期与行动期变化最显著（P=0.012、0.002），12周与6周比无明显变化。。5．健康状况：两研究对象健康状况总分均是在第12周出现统计学变化（P=0.015、0.017），因为突出组健康状况较腰肌劳损组差，除了已对疼痛和功能障碍的干预结果分析外，进一步比较干预对突出者精神-社会情况的影响，发现12周后该组患者精力、社会功能、情感职能及精神健康均有显著的统计学差异（P=0.014、0.011、0.012、0.023），此4项分值从0-12周持续升高。6．自我管理情况分析1）试验组自我管理结果：采用频数和百分比分析表示研究对象实施疼痛管理的情况，按方案要求，每2天进行体位练习1次，椎间盘突出组占47.62%，腰肌劳损组占54.54%，两组分别有7.14%和8.33%平均练习次数为0。疼痛管理技能应用：22.22%腰肌劳损组平均应用2次/1天，38.89%人3次/天；38.10%椎间盘突出组患者平均2次/天，13.10%人3次/天。34.52%椎间盘突出对象每周2次得到家人支持，16.66%得不到支持；腰肌劳损组13.88%每周平均得到2次支持，52%以上的得不到家人支持。2）自我管理行为和结果的相关性：选取样本量较大的突出组，应用spearman相关性分析法，比较疼痛应对和功能障碍、疼痛程度的关系，结果显示，疼痛应对和两者均呈负相关，即疼痛应对分值越高，疼痛程度和功能障碍越低。应用spearman相关性分析法分析体位练习、疼痛管理技能应用情况与健康状况的关系，发现呈正相关，尤其是生理职能、一般健康、精力及社会功能相关性较大，说明本方案科学、有效，能提高患者的整体健康状况。3）不同研究对象对自我管理结果的影响应用T检验和方差分析比较腰椎间盘突出试验组一般资料与患者的功能障碍评分、疼痛应对评分及大多数时间疼痛分值的关系，观察患者自我管理结果在不同对象的差异性。结果显示，12周后，女性的功能障碍和大多数时间疼痛减轻程度、疼痛应对分值较男性差异大。不同年龄患者的功能障碍改善都有差异，31-50岁患者的疼痛应对能力比其他年龄段患者更强，31-40岁患者大多数时间的疼痛程度降低较其他年龄人群有差异。无家族史较有家族史的患者功能障碍降低显著，有家族史患者的疼痛应对提高较无家族史者显著。不同文化程度患者的功能障碍干预前后都有显著降低，文化程度越高，疼痛应对能力越高。不同婚姻状况患者功能障碍降低都有差异，已婚患者的功能障碍和大多数时间疼痛程度改善、疼痛应对能力提高较其他组差异更显著（P<0.01）。不同病程患者功能障碍改善都有统计学差异，病程大于5年的患者疼痛应对和疼痛减轻程度更显著。7．研究对象3个月内门诊率比较：调查研究对象在接受干预期间因本病门诊（或再次）率发现，无论何种患者，两试验组共5.83%再次就诊，较对照组低，其中，突出组略高于腰肌劳损组。8.患者的自我管理障碍集中在以下几方面：（1）时间不足；（2）质疑自我管理措施的作用；（3）管理技能不容易掌握；（4）身体不适不愿坚持；（5）错误的认知。9.研究参与者对实施自我管理的认识（1）患者：疼痛减少、精神状态转好；希望得到经常性的指导和鼓励。（2）照顾者：对患者康复态度和行为作用很大，知识能力不足，缺乏足够耐心，但首先需转变意识。（3）医护人员：需建立慢性病的医院-社区-家庭管理体制；改善医患信任度和医护人员综合能力。三、结论1．本研究干预能够减轻慢性腰背痛患者的疼痛和功能障碍程度，瑜伽锻炼方案对腰肌劳损患者的改善更有效。2．本研究护理干预能显著提高两类慢性腰背痛患者的自我管理认知和疼痛应对能力。两组使用较多的疼痛应对技能是瑜伽后伸展练习和转移注意力。3．本研究护理干预能够提高慢性腰背痛患者的健康状况，尤其是腰椎间盘突出者的精神-社会状况。4．实施随访干预能促进慢性腰背痛患者自我管理行为依从，持续改善患者健康状况。5．提高患者自我管理的措施包括：发挥医护人员的专业性，改善其以来医院的康复观念，给予知识信息支持；促进家庭支持、减少其它家庭成员的疼痛史对患者的影响，纠正其不良观念和行为；加强家庭、同伴交流，增强理解和信心支持，提高其自我管理行为依从性。提高男性患者对自我管理的重视。建立医院-社区-家庭-患者的良好沟通途径。6.护理干预结局指标对相关评价工具的敏感性分析：健康状况评分中维度之一“躯体疼痛”不是适合对疼痛测量；“RRMDQ下腰疼痛量表”和“SF-36健康调查量表”中的维度-生理机能（PF）和生理职能（RP）都可以评判患者的功能障碍情况，但SF-36对精神、情绪方面评价更全面。综上所述，本研究制订的认知-行为和瑜伽锻炼结合的护理干预活动，提高了慢性腰背痛患者的自我管理意识和能力，减轻了其疼痛程度和功能障碍，促进了整体健康状况的改善，减少了（再次）门诊率。并分析出影响患者自我管理认知和行为结果的因素，对研究工具的人群和指标的敏感性进行了分析，基本达到研究目的，但需长期应用，观察方案对腰背部组织的病理学改变，进一步提高患者的行为依从性。该研究对我国慢性腰背疼痛患者的护理干预进行了积极的探索，其研究结果为提升慢性病患者的自我管理提供了新的干预思路和实践依据。更多还原

【Abstract】 Because of long rehabilitation period patients with chronic low back pain (CLBP)，inaddition to long-term pain, the patients are associated with various psycho-physicalproblems such as dysfunction, anxiety, fear and over-reliance on medical treatment,moreover, being short of proper understanding of chronic pain itself and rehabilitation,which lead to tardy jobs and low quality of life. It has been defined as a kind of disease bythe International Association for the Study of Pain（IASP）, not a kind of acute paincontinuation. At present, the rehabilitation management of patients with chronic low backpain is limited to physical therapy and drug therapy, only achieving temporary pain relief,which has been proved to have no obvious effect for long-term pain scale relief andphysiological-psychological-social function improvement. Recurrence or aggravation ofpain symptoms appears in most of the patients after acute treatment for the lack of self-management consolidating clinical curative effect, which make the physical and spiritualdiscomfort caused by pain more complex. According to Low Back Pain Self-ManagementHandbook, the patient needs to undertake self-nursing (management) responsibility, reducedependence on health care providers。Studies have shown that self-management cansignificantly reduce the pain and dysfunction, enhance self-efficacy, improve the patient’shealth status and reduce medical costs. Recent years, researches were mainly focused onhealth education, cognitive-behavioral intervention and different exercise methods.However, the self-management for CLBP can be summarized as follows:①self-management consciousness is lacking②management mode is the single mode, effectimproved incompletely③many relaxation training and systematic exercise of painmanagement need the guidance of a doctor, not fit for the patients self-operation④self-management behavior need continuous nursing intervention, to improve the long-termcompliance, the recent research is limited to follow-up observation. Based on the research literature analysis, to improve the patient self-management consciousness and ability,selecting effective nursing intervention methods such as construction of pain managementskills, cognitive education and yoga exercise, and designing exercise prescription,movement, and intervention method and time in accordance with analysis of and applyingyoga in the patients. Directed by nurses, to improve self-management awareness, skills andbehavior compliance for patients. And many randomized controlled trial tests are adoptedto test the application effects.First part Construction of Nursing Intervention Project for Patients with CLBPto Improve Self-Management Ability1. Method(1) Relevant documents about management and nursing intervention CLBP arestudied, systematical evaluation method is found and effective and suitable self-management style for research population is built.(2) With the domestic and international research and application status of each method,the suitable content of nursing intervention for research population is formulated, and thescheme and framework are constructed.(3) Sub schemes are established respectively, including cognitive-behavioral interv-ention scheme and exercise intervention scheme.2. Results(1) Effctive and scientic nursing ways of patients with CLBP are attained fromresearchs,include cognitive-exercise combined intervention projects are selected, such aseducation, training and promoting compliance behavior intervention.(2) The cognitive intervetion includes education, skill instruction and yoga training.compliance behavior intervention includes group communication, target detection, familymembers’ participation, telephone support and records management.(3) Two yoga sketch are designed for patients with prolapsed lumbar intervertebral discand chronic lumbar muscle strain，according to the characteristics of two kinds of diseasesand the difference in the cognitive education and yoga training content, a multidisciplinaryteam, including rehabilitation doctor, physiotherapist, nurse, psychotherapist and senioryogis, is built to support instruction. The design of the yoga exercise is carried on in manyaspects such as exercise content, sequence, time and safety management, to meet the demand of patients self-management.(4)5series continuous nursing interventions are established in12weeks, such as3training and2compliance intervention,to promote self-management efficiency andbehavior.3. ConclusionThe determination of intervention methods and contents is based on sufficientliterature analysis and research, combining with nursing science, cognitive science,management science, yoga theory, motor function and anatomic theory, to ensure scientificcharacter in intervention project, applied to research objects with different disease,improving feedback, squeezing more suitable self-management for research population, toensure the feasibility of intervention project. And the combined training interventionscheme is constructed.5series continuous nursing interventions are established in12weekspromote self-management efficiency and behavior.Second Part Experimental Research and Evaluation on Nursing InterventionProject for Patients with CLBP1. MethodRandom control experiments are adopted to verify the research project. Based on theinclusion and exclusion criteria of two disease groups, research projects are selected.Patients with prolapsed lumbar intervertebral disc are divided into the experiment group (84cases) and the control group (63cases). Patients with lumbar muscle strain are divided intothe experiment group (36cases) and the control group (33cases). The experimental groupreceives the intervention activities. The prolapsed group gets physical and drug therapy andself-management after hospital discharge for three weeks. Self-management is implementedin the control group with lumbar muscle strain. The effect evaluation includes①pain anddysfunction score②pain coping strategies score and pain stage conversion③health status④second outpatient visit rate in three months. The prolapsed group collects data in the0,3,6and12week. The group with lumbar muscle strain collects data in the0,6and12week.Applying the professional statistics software (SAS8.2)to calculate and analyze the data, themeasurement data of two groups are compared with independent sample T-test, thedifference of the count data between two groups was evaluated by chi-square test, varianceanalysis of repeated measurement data is adopted to evaluate the time index change of two group patients at different times, the relationship between research findings and generalinformation was tested by Spearman’s Rank Correlation Analysis method. The studyinclude two interviews, the first is investigating patients’ troubles in self-management atthe third weekend, the second is investigating experience for different participants at theend of12weeks. And improving scheme according this results.2. Results(1) Pain degree：①In the prolapsed experiment group, scores of the slightest, the worst,the majority and the current pain, decrease significantly（P＜0.05）after12weeks,meanwhile, the majority pain intensity have statistical significance as compared with thecontrol group（P=0.046、0.029、0.013）in the3,6and12week, the worst pain intensitybegin to decrease （P=0.044）in the third week, the current pain intensity begin to decrease（P=0.044）in the sixth week.②In the lumbar muscle strain experiment group, scores ofthe slightest, the worst, the majority and the current pain, decrease significantly（P＜0.05）after12weeks, meanwhile, the majority and the worst pain intensity decrease significantlyas compared with the control group（P=0.032、0.038）in the sixth week.(2) Dysfunction：Scores of the prolapsed group decrease significantly as comparedwith the control group（P=0.071、0.026）in the sixth and twelfth week. Scores of the lumbarmuscle strain group decrease significantly（P=0.037）in the twelfth week.(3) Pain coping：Scores of the prolapsed group increase significantly（P＜0.05）in thesixth and twelfth week. Scores of the lumbar muscle strain group increase significantly（P＜0.01）in the sixth and twelfth week. And scores of two groups increase continuously from0-12week.(4) Pain stage：①The distribution variation of the prolapsed group has statisticalsignificance（P＜0.05）during the thinking prophase, thinking metaphase and action stage in3-12week, the difference is most significant（P＜0.01）in the sixth and twelfth week, thedistribution variation of maintenance period have statistical significance（P=0.042）in thetwelfth week.②The distribution variation of the lumbar muscle strain group has statisticalsignificance（P＜0.05）during the thinking prophase and action stage in the sixth week, thedifference（P=0.000、0.034）appears during the thinking metaphase and maintenance periodin the twelfth week.(5) Health Status：The statistical changes is observed in the total scores of two groups in the twelfth week（P=0.015、0.017）. The prolapsed group is associated with poorer physicalhealth as compared with the lumbar muscle strain group. In addition to intervention resultsanalysis of pain and dysfunction, the spirit and social situations effect is further comparedin the prolapsed group, the scores of patients vitality(VT), social functioning(SF),motional role(RE) and mental health(MH) have statistical significance（P＜0.05）after12weeks, the scores of the four indexes increase continuously from0-12week.(6) Pain management：1）To study the implementation of the pain management situation, frequency andpercentage analysis is adopted. According to research requirements, one postural exerciseeach two days must be done.47.62%of the prolapsed can meet this requirement.54.54%ofthe lumbar muscle strain patients can meet this requirement. The Average amount ofexercise is zero for7.14%of the patients with prolapsed and8.33%of the patients withlumbar muscle strain. Application of pain management:22.22%excise two times each day,38.89%excise three times each day, in the prolapsed group.38.10%excise two times eachday,13.10%excise three times each day, in the lumbar muscle strain group.2) The impact of pain coping ability on the pain intensity and Dysfunction: Spearman’sRank Correlation Analysis method is applied to the prolapsed group with larger sample size.There is a negative correlation between the pain coping ability and two Symptoms, thehigher the score of pain coping ability, the lower the pain intensity and Dysfunction. It hasbeen proved that the intervention project is effective to improve the pain copingability.Spearman’s Rank Correlation Analysis method is applied to investigate therelationship among postural exercise, application of pain management, and health status inthe prolapsed group with larger sample size. Positive correlation is observed, especially thegreater relevance for the physiological role, general health, vitality and social functioning.The results show that the project is positive to health status of research project and ishelpful to improve the patient’s overall health status.3）The impact of research project general information on pain coping and pain self-management: Spearman’s Rank Correlation Analysis method is applied to investigate theimpact of research project general information on pain coping and pain self-management.The results show that the patients’ condition affects the implementation of pain management.There is a positive correlation among score of pain coping, usage frequency of pain management skills, disease course, number of pain sites, educational level, family modeland family income. And negative correlation is observed for the family history.（7）Barriers of self-management focus on the following aspects:1) lack of time;2)questioning the role of self-management measures;3)coping skills is maybe too difficult tomaster;4) they do not want to adhere to the physical discomfort;5) cognitive errors.(8) Comparative research on the outpatient rates for research projects within3months:The disease clinic rate (second visiting) for the research project, during the interventionperiod, is surveyed. The investigation discovers that, no matter what kind of patients,5.83%of two experiment groups appears recurrence rate of patients, lower than controlgroups, and that the prolapsed is higher than the lumbar muscle strain group.(9) Thinking about self-management1) Patients think pain decreased and mental improved, but hope getting more guidanceand encouragement.2) Patients’ family thinks their support play important role on patients’ rehabilitation,including their attitudes and behavior. But lacking knowledge, ability and sufficientpatience,3) Health care workers think it is necessary to establish hospital-community-homemanagement system for chronic disease,improve doctor-patient trust and workers’comprehensive ability.3. conclusion(1) cognitive-yoga united intervention can reduce pain and disability levels of CLBPpatients, yoga scheme formulated is more suitable for lumbar muscle strain.(2) Cognitive-yogaUnited intervention can significantly improve self-managementperception and pain coping ability of two CLBP patients. Yoga stretching and distractingare pain coping skills used by two group.(3) Cognitive-yoga United intervention can improve the health status of patients withCLBP, especially for psycho-social status of lumbar disc herniation improve patients’ fullhealth condition,their families play important roles,but more knowelges and skills aredemanded, in addition,a fluent way of hospital-community-family-patient is should beestabilished.(4) Follow-up intervention can promote CLBP patient’self-management behavior compliance and continuous improvement of health status.(5) Promoting factors of self-management include longer disease course, more painpositions, other medical histories, higher cultural level, and more families and main sourceof family income. Pain family history, lack of knowledge, confidence and support are thekey factors influencing the patient self-management. Pessimistic attitude leads to badbehavior compliance.（6）Sensitivity analysis on the related nursing intervention outcome evaluation tool:"one of the dimensions of health status scores in physical pain" is not suitable for painmeasurement;"RRMDQ low back pain scale" and "SF-36health survey scale" in thedimension of physiological function (PF) and physiological functions (RP) can functionevaluation patients, but SF-36evaluation of mental, emotional aspects of a morecomprehensive.In summary, nursing intervention activities of cognition and yoga exercise combinedimprove self-management consciousness and ability of patients with chronic low back pain,alleviate their pain and dysfunction, promote overall health, and reduce the rate ofinpatients. these results prove the research purposes are mainly attained,but long-termapplying is necessary to observe lumbar pathological changes and maintain the complianceof self management behavior. This study explores the nursing intervention of patients withchronic low back pain, the research results provide new ideas and practical basis for chronicdisease patients’ self management.更多还原