運動・栄養・不安軽減のPrehabilitation

大腸がん手術患者に対する、運動・栄養・不安軽減を組み合わせたPrehabilitationの機能回復の効果をみたパイロット研究（前後研究）を紹介します。

Chao Li • Francesco Carli • Lawrence Lee • Patrick Charlebois • Barry Stein • Alexander S. Liberman • Pepa Kaneva • Berson Augustin • Mingkwan Wongyingsinn • Ann Gamsa • Do Jun Kim • Melina C. Vassiliou • Liane S. Feldman: Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surgical Endoscopy, DOI 10.1007/s00464-012-2560-5

リサーチクエスチョンは以下の通りです。

P：大腸がん手術患者に
I：術前に運動療法、栄養指導、不安軽減を行うと（Prehabilitation）
C：これらを行わない場合と比較して
O：術後の身体機能回復が改善する
D：前後研究（介入）

Prehabilitationの内容は、運動療法として週3回30分の有酸素運動と週3回のレジスタンストレーニング、栄養療法として栄養指導とホエイ蛋白の投与（蛋白摂取が1.2g/kg/日）、不安軽減としてリラクゼーションや呼吸運動などを臨床心理士が指導しています。

なお周術期の管理はERASに近いような管理が介入前後で同じように行われています。

結果ですが、図に示すようにPrehabilitation群で6分間歩行距離が術前に有意に改善しています。術後4週間、8週間の時点でも対照群と比較して、有意に6分間歩行距離が長くなっています。以上より運動・栄養・不安軽減を組み合わせたPrehabilitationは有用という結論です。

この研究だけではエビデンスとして不十分ですが、現在RCTも進行中とのことです。RCTでも運動・栄養・不安軽減を組み合わせたPrehabilitationが有用という結論が出ましたら、インパクトは大きいと考えます。術前のリハ栄養のエビデンスと言えますね。

Abstract

Background

Patients undergoing colorectal cancer resections are at risk for delayed recovery. Prehabilitation aims to enhance functional capacity preoperatively for better toleration of surgery and to facilitate recovery. The authors previously demonstrated the limited impact of a prehabilitation program using exercise alone. They propose an expanded trimodal prehabilitation program that adds nutritional counseling, protein supplementation, and anxiety reduction to a moderate exercise program. This study aimed to estimate the impact of this trimodal program on the recovery of functional capacity compared with standard surgical care.

Methods

Consecutive patients were enrolled in this pre- and postintervention study over a 23-month period. The postoperative recovery for 42 consecutive patients enrolled in the prehabilitation program was compared with that of 45 patients assessed before the intervention began. The primary outcome was functional walking capacity (6-min walk test [6MWT]). The secondary outcomes included self-reported physical activity (CHAMPS questionnaire) and health-related quality of life (SF-36). Data are expressed as mean ± standard deviation or median (interquartile range [IQR]) and were analyzed using Chi-square and Student’s t test. All p values lower than 0.05 were considered significant.

Results

The prehabilitation and control groups were comparable in terms of age, gender, body mass index (BMI) and American Society of Anesthesiology (ASA) class. There was no difference in walking capacity at the first assessment (6MWT distance, 422 ± 87 vs 402 ± 57 m; p = 0.21). During the prehabilitation period lasting a median of 33 days (range, 21–46 days), functional walking capacity improved by 40 ± 40 m (p < 0.01). The postoperative complication rates and the hospital length of stay were similar. The patients in the prehabilitation program had better postoperative walking capacity at both 4 weeks (mean difference, 51.5 ± 93 m; p = 0.01) and 8 weeks (mean difference, 84.5 ± 83 m; p < 0.01). At 8 weeks, 81 % of the prehabilitated patients were recovered compared with 40 % of the control group (p < 0.01). The prehabilitation group also reported higher levels of physical activity before and after surgery.

Conclusion

In this pilot study, a 1-month trimodal prehabilitation program improved postoperative functional recovery. A randomized trial is ongoing (NCT01356264).