2010-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/646009摘要：百分之七十至八十的脊髓損傷（SCI）患者必須乘坐輪椅代償行動限制，以獨立從事日常活動及參與社區生活。使用輪椅雖能達成增進行動功能的正面效果，但文獻均指出SCI 患者因長期使用輪椅產生各種預期外的次發問題：如上肢關節酸麻疼痛、下背痛、脊柱變形、壓瘡、受傷、跌倒等，稱之為「副作用(adverse effects)」，造成患者的痛苦與不便、付出更多醫療代價，影響其生活功能、社會參與及生活品質甚鉅。然目前尚未有完整探討使用輪椅副作用的文獻，大多僅針對單一副作用提出個案報告或調查，產生副作用的成因也未能釐清，但有數篇研究共同指出缺乏專業評估與訓練是導致副作用的重要因子之一。現雖有研究針對副作用的預防介入探討，多限針對特定負作用，且為單一處置方式（如僅針對肩關節運動、輪椅擺位等），可能片面無法顧及各種導致副作用的成因，導致成效受限。故有必要設計全面性考量的副作用預防與輪椅使用訓練方案，提供個案對各類副作用及可能的成因有較完整的概念，透過技巧練習與居家實際情境的教導，使個案能發展出自行判斷與解決問題的能力，才能有效避免生活中使用輪椅時的危害與副作用發生，減低不必要的痛苦、傷害及成本支出，更增進輪椅使用的效益。本三年期研究針對以下問題進行探討：SCI 患者使用手推輪椅會產生哪些副作用？各類副作用的發生率為何？對使用者造成的影響為何？導致副作用發生的原因為何？副作用是可以預防的嗎？若提出預防介入與訓練方案，是否可能降低副作用的發生機率或影響程度？預防介入與訓練方案的成本效益為何？第一年採橫斷式研究設計，旨在瞭解大台北地區長期使用手推輪椅的SCI 患者可能發生的各種副作用類型、徵狀發生率、及其發生的成因，經由焦點團體及專家小組研擬問卷，訪談大台地區脊髓損傷協會所有符合條件之成員，據此結果規劃出副作用預防暨輪椅使用訓練方案。第二、三年為前瞻性隨機控制試驗研究設計，探究「手動輪椅副作用預防暨使用訓練」之成效與成本效益，預計納入新近使用輪椅SCI 患者80 名，隨機分為介入組及控制組各40 名。評量介入方案結束時、介入後六個月、及一年時之成效，主要評量指標為副作用徵狀、意外傷害次數/頻率、輪椅使用技巧、及醫療照護之花費；次要評量指標為健康相關功能狀態、生活品質評量、輔具滿意度等。期待研究結果能驗證藉由全面性考量之副作用預防暨使用訓練，能有效減少SCI 患者使用手推輪椅的副作用，增進健康功能狀態、生活品質，提供未來臨床從業人員進行輪椅處方決策或訓練時的考量，另相關輪椅相關之負作用成因，也可提供輪椅設計或製造業者作為改良產品品質的參考，而成效及成本效益的分析結果，可作為未來輔具政策制訂或給付的依據。<br> Abstract: The use of wheelchair helps about 70-80% patients with spinal cord injury (SCI) toachieve independence through activities of daily and social participation by compensatingfor their mobility limitation. Despite the positive effect of wheelchair using, due to thelong-termed manipulation of manual wheelchairs, patients with SCI do experience severaladverse effects such as pain and discomfort in upper extremities, neck or low back pain,scoliosis, pressure sore, accidental fall or injury, etc. The resulting pain and inconveniencemay lead higher medical expenses, decreased daily functions and social participation, andworsen quality of life.Nevertheless, previous studies on the adverse effects of wheelchair using have been farfrom comprehensive. Most of them were limited to case reports of a single adverse effect,the underlying causes of which were still to be clarified. One of the most commonlyproposed causes was the lack of professional assessment and training for wheelchair users.On the other hand, the lack of positive results of the studies about the effectiveness ofpreventing programs targeting a single adverse effect also reveal the need for a moreextensively planned intervention program that treated several adverse effects simultaneously.Such program should aim at equipping participants with the all-round knowledge of adverseeffects (e.g. their possible causes and necessary protective skills) and problem-solving abilityregarding adverse-effect prevention, making them less vulnerable to the development ofadverse effects, and thus increasing the effectiveness of wheelchair using.The current three-year study aims at the answering of the following questions: What arethe manual wheelchair users’ commonly experienced types of adverse effects, their incidentrates, the effects they may have on the users, and the underlying causes? Are theypreventable or can their negative influence be lessened by preventive intervention? Will it bepossible to develop an effective training protocol, and if so, what will be thecost-effectiveness?During the first year, a cross-sectional study will be conducted among long-term manualusers to explore the types and incidence rate of those adverse effects they have everexperienced. They will be further asked to account for the attributed causes. The collectedinformation further elaborated by a discussion board of related professionals and aquestionnaire is to be developed and used for the subsequent survey among the eligiblemembers of the Association of SCI Patients around Northern Taiwan. The final result willcontribute to the design of an adverse effect preventing and wheelchair skills trainingprogram which will be examined for efficacy and cost effectiveness in the following twoyears through a prospective randomized controlled trial. In this second stage of the study, 80new/recent wheelchair users with SCI will be recruited and then selected randomly into theintervention or control so that each group comprised of 40 participants. Assessments aboutthe developed adverse effects, frequencies and counts of injuries, the skills of wheelchairmanipulation, and the total cost on medical care service, as well as the health-relatedfunctional status, quality of life, and satisfaction with the assistive device will be conductedright after the end of the program and followed up to six months and one year after theprogram.It is expected that an effective and comprehensive preventive training program targetedat decreasing the incidence of the adverse effects related to wheelchair using can provideinformation for the development of clinical intervention and training protocols. The resultsabout the efficacy and cost-effectiveness of the program, on the other hands, may beimportant references for the establishment of related policies and medical insurancecoverage.脊髓損傷輪椅副作用成效成本效益Spinal cord injurywheelchairadverse effecteffectivenesscost effectiveness