||The effectiveness of stage-based rehabilitation program on patients with distal radius fracture
||Department of Physical Therapy
Distal radius fracture
Manual edema mobilization
研究背景: 遠端橈骨骨折為上肢最常見之骨折類型，流行率並隨著社會高齡化日益提升，而其可能衍生之後遺症更是老人慢性疼痛的禍首之一。然有關遠端橈骨骨折術後之復健治療計畫至今仍缺乏明確的建議，且鮮有研究於骨折早期即開始介入術後復健以減少相關後遺症狀。目的: 針對遠端橈骨骨折患者，早期介入階段式復建計畫(stage-based rehabilitation program)，以達到初期降低水腫與預防神經病變，後期鬆弛軟組織緊繃以及增加肌肉力量的目標。方法: 本研究共延攬16名遠端橈骨骨折病患 (早期階段式介入組8人，年齡：57±17歲；傳統居家治療組8人，年齡：64.4±9歲) ，於術後2週開始進行首次評估與居家運動之衛教與諮商。早期介入組並於術後初期(第2至6週)額外接受每週兩次之徒手水腫鬆動術與神經鬆動術，及於後期(第7至9週)接受每週一次的軟組織鬆動術治療計畫。除了首次評估外，所有受試者均於術後4、6以及12週後分別接受3次評估，評估項目包含疼痛、握力、手指活動度、手指腫脹程度、手指溫度及上肢功能評估，此外，並於術後第4週開始進行神經活動度檢測(第4、6、12週)，且於術後第6週開始手掌容積測量(第6、12週)。最後，於術後第12週進行相關後遺症狀況評估，另外，並有部分患者於術後六週時接受健側與患測的肩胛控制策略檢測。結果: 大體上，早期介入組與傳統治療組於術後第6週結束時在握力、手指腫脹程度及手指活動度等方面皆已呈現顯著進步(p<0.05)。其中，不同於傳統治療組，在握力方面，早期介入組在術後4週即開始出現顯著進步，且於術後12週更顯著優於傳統治療組，而其動作疼痛強度與神經活動度亦有所改善，且於第12週結束治療後呈現顯著進步(p<0.05)。另一方面，傳統治療組於動作疼痛強度方面在術後第6週不減反增，到術後第12週才呈現顯著改善，且於神經活動度方面，直到術後12週均未呈現顯著進步。另外，有關後遺症狀的表現，於術後第12週並未呈現顯著組間差異，而就肩胛控制策略而言，術後6週的評估結果顯示兩組均未呈現顯著異常。結論: 本研究結果發現，針對遠端橈骨骨折患者，早期介入階段式治療計畫，相較於傳統居家治療計畫，對於握力表現、疼痛與神經活動度方面能夠提供更顯著的療效。而不論是有無接受階段式治療，自我居家復健計畫仍足以改善遠端橈骨骨折患者術後指力、手指腫脹程度、手指活動度及上肢功能之情形。因此在針對遠端橈骨骨折術後病人的復健計畫給予上，之後可針對病人之需求，來設計所需之復健計畫。此外，本研究也顯示出早期介入於遠端橈骨骨折病人之重要性。
Background: Distal radius fractures (DRF) were the most common upper limb fractures and the prevalence was increased with age. In addition, the complications following DRF might be the cause of chronic pain in elderly. Although there were varies studies that investigated the effect of different rehabilitations on DRF patients, the findings were controversial and no standard rehabilitation protocol has been recommended. In particular, little has been done to investigate the effects of early intervention or complications prevention following DRF. Purpose: The purpose of this study was to examine the effects of a stage-based rehabilitation program that aimed at edema reduction and neuropathy prevention in the immobilization stage and at improving soft tissue tightness and muscle power in the post-immobilization stage for patients with DRF. Methods: 16 DRF participants were included and assigned into the experimental group (n=8, age: 57±17.2 years) and control group (n=8, age: 64.4±8.6 years). All subjects participated in the initial assessment and a general home program at 2 weeks after DRF. An additional stage-based rehabilitation protocol was provided to the experimental group including manual edema mobilization and nerve mobilization program twice a week from week 2 to week 6 after DRF and soft tissue mobilization once a week from week 7 to week 9 after DRF. Re-assessments were arranged for both experimental and control group at the end of week 4, 6, and 12 after DRF, respectively. Pain, grip strength, finger mobility, swelling, finger temperature and functional performance of the upper limb were evaluated regularly and additional measurements for nerve mobility were arranged starting from weeks 4 after DRF (at week 4, 6 and 12 after DRF) and for hand volume starting from week 6 after DRF (at week 6 and 12 after DRF). Finally, complication following DRF was assessed at the end of the study. Results: Significant improvements were found in both groups since 6 weeks after DRF in the measurements of grip strength, finger swelling and finger mobility (p<0.05). On the other hand, an earlier improvement was found in the measurement of grip strength at week 4 after DRF for the experimental group in comparison of the control group and the recovery rate of grip strength was significantly better in the experimental group at week 12 after DRF. In addition, significant improvement in motion pain and nerve mobility were only found in the experimental group at 12 weeks after DRF (p<0.05). On the contrary, the control group demonstrated increased motion pain at week 6 after DRF before the occurrence gradual reduction in the later stage. Finally, no significant group differences were found in the occurrence of complications at 12 weeks after DRF. Conclusion: This study has demonstrated favorable outcomes of the stage-based rehabilitation program in patients with DRF, especially in the grip strength, motion pain and nerve mobility. On the other hand, the general home program provided in this study has also shown significant improvements in the finger swelling, finger mobility and the functional performance of upper limbs. This study has provided evidence to support the early intervention program focusing on the edema control and nerve mobilization followed by a 3-week program of soft tissue mobilization. On the other hand, for the convenience of patients’ needs, a general home exercise program was also recommended starting from week 3 after DRF though with less significant improvements.
誌 謝 VI
Table list XI
Figure list XII
Chapter 1 Literature review 1
1.1 Introduction 1
1.2 Rehabilitation for DRF 3
1.2.1 The effect of ROM exercise and passive mobilization on subjects with DRF 3
1.2.2 The effect of manual edema mobilization (MEM) on subjects with DRF 5
1.2.3 The effect of multiple rehabilitation protocols for DRF 6
1.3 The usage of upper limb neurodynamic technique in peripheral neuropathy 9
1.3.1 Upper limb neurodynamic technique in testing peripheral neuropathy 10
1.3.2 Upper limb neurodynamic technique in treating peripheral neuropathy 11
1.4 Research motivation 13
1.5 Purpose 14
1.6 Hypothesis 15
Chapter 2 Materials and Methods 16
2.1 Subjects 16
2.2 Data collection and Instrument 16
2.3 Procedures 19
2.3.1 Assessments 19
2.3.2 Rehabilitation program 20
2.4 Measurements 20
2.4.1 Pain intensity 21
2.4.2 Grip strength 21
2.4.3 Nerve mobility 22
2.4.4 Finger mobility 22
2.4.5 Hand swelling 24
2.4.6 Hand temperature 25
2.4.7 Functional performance of upper limbs 25
2.4.8 Complications following DRF 26
2.4.9 Shoulder-scapular kinematics 26
2.5 Stage-based rehabilitation program 29
2.5.1 Manual edema mobilization (MEM) 29
2.5.2 Neurodynamic technique 30
2.5.3 Soft tissue mobilization 31
2.6 Home program 31
2.7 Shoulder-scapular kinematics processing 32
2.8 Statistical analysis 34
Chapter 3 Results 36
3.1 Basic characteristics 36
3.2 The effect of stage-based rehabilitation program within group 37
3.2.1 Pain intensity 37
3.2.2 Grip strength 38
3.2.3 Swelling 39
3.2.4 Nerve mobility 41
3.2.5 Hand temperature 41
3.2.6 Finger mobility and functional performance 42
3.2.7 ROM of wrist at 12 weeks after DRF 44
3.2.8 Complications following DRF 45
3.3 The effect of stage-based rehabilitation program between groups 45
3.4 Shoulder-scapular kinematics in patients with DRF 46
Chapter 4 Discussion 49
Appendix Ⅰ 63
Appendix Ⅱ 65
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