人工関節置換術のプレハビリテーション：メタ分析

人工関節置換術前のプレハビリテーションに関するメタ分析の論文を紹介します。

Hoogeboom TJ, Oosting E, Vriezekolk JE, Veenhof C, Siemonsma PC, et al. (2012) Therapeutic Validity and Effectiveness of Preoperative Exercise on Functional Recovery after Joint Replacement: A Systematic Review and Meta-Analysis. PLoS ONE 7(5): e38031. doi:10.1371/journal.pone.0038031

下記のHPで全文見ることができます。

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0038031

リサーチクエスチョンは以下の通りです。

P：人工関節置換術前の患者に
I：運動療法（プレハビリテーション）を行うと
C：運動療法（プレハビリテーション）を行わない場合と比較して
O：①入院中の機能回復が改善する、②手術3か月後の回復が改善する（観察および事故報告）
D：（quasi）RCTのメタ分析

結果ですが、12論文のメタ分析で①、②とも統計学的な有意差を認めませんでした。ただし、研究の妥当性が低いことがこのような結果につながった可能性があると結論付けています。

私はプレハビリテーションを行うべき患者と必要のない患者の選択基準を決めることが重要だと考えています。すべての患者にプレハビリテーションを行っても、有意差は出にくいと思います。おそらくサルコペニア、肥満、サルコペニア肥満の患者に限定して栄養も含めて行えば、有意差がでやすいのではと推測しています。

Background
Our aim was to develop a rating scale to assess the therapeutic validity of therapeutic exercise programmes. By use of this rating scale we investigated the therapeutic validity of therapeutic exercise in patients awaiting primary total joint replacement (TJR). Finally, we studied the association between therapeutic validity of preoperative therapeutic exercise and its effectiveness in terms of postoperative functional recovery.

Methods
(Quasi) randomised clinical trials on preoperative therapeutic exercise in adults awaiting TJR on postoperative recovery of functioning within three months after surgery were identified through database and reference screening. Two reviewers extracted data and assessed the risk of bias and therapeutic validity. Therapeutic validity of the interventions was assessed with a nine-itemed, expert-based rating scale (scores range from 0 to 9; score ≥6 reflecting therapeutic validity), developed in a four-round Delphi study. Effects were pooled using a random-effects model and meta-regression was used to study the influence of therapeutic validity.

Results
Of the 7,492 articles retrieved, 12 studies (737 patients) were included. None of the included studies demonstrated therapeutic validity and two demonstrated low risk of bias. Therapeutic exercise was not associated with 1) observed functional recovery during the hospital stay (Standardised Mean Difference [SMD]: −1.19; 95%-confidence interval [CI], −2.46 to 0.08); 2) observed recovery within three months of surgery (SMD: −0.15; 95%-CI, −0.42 to 0.12); and 3) self-reported recovery within three months of surgery (SMD −0.07; 95%-CI, −0.35 to 0.21) compared with control participants. Meta-regression showed no statistically significant relationship between therapeutic validity and pooled-effects.

Conclusion
Preoperative therapeutic exercise for TJR did not demonstrate beneficial effects on postoperative functional recovery. However, poor therapeutic validity of the therapeutic exercise programmes may have hampered potentially beneficial effects, since none of the studies met the predetermined quality criteria. Future review studies on therapeutic exercise should address therapeutic validity.