待機的心臓外科手術のプレハビリテーション

待機的心臓外科手術に対する術前理学療法（プレハビリテーション）のコクランレビューを紹介します。

Hulzebos EH, Smit Y, Helders PP, van Meeteren NL.　Preoperative physical therapy for elective cardiac surgery patients.　Cochrane Database Syst Rev. 2012 Nov 14;11:CD010118. doi: 10.1002/14651858.CD010118.pub2.

8つのRCT論文で856人が対象です。理学療法の内容は、3論文は有酸素運動や呼吸リハの混合介入、5論文は吸気筋トレーニングです。結果ですが、術後の無気肺や肺炎は有意に減少しましたが、気胸と48時間以上の人工呼吸器管理は減少しませんでした。術後死亡率にも有意差を認めませんでした。

介入による合併症は記載のあった3論文では認めませんでした。入院期間は介入群で有意に短かったです。1論文では介入群で6分間歩行距離が低下しました。他の1論文では健康関連QOLが有意に改善しました。呼吸器疾患によ死亡率には有意差がなく、コストに関するデータはありませんでした。

以上より待機的心臓外科手術患者に対するプレハビリテーションは、無気肺や肺炎といった術後合併症を減少させ、入院期間を短縮させるという結論です。一方、気胸、48時間以上の人工呼吸器管理、死亡率には有意差を認めませんでした。

呼吸リハを主としたプレハビリテーションによって、無気肺や肺炎が減少することは納得できる結果です。こちらも対象者を選定して、プログラムを運動のみでなくより包括的なものにすれば、よりよいアウトカムを出せるのではないかと考えます。呼吸リハは待機的心臓外科手術の全患者に行ってもよいと思いますが。

Abstract

BACKGROUND:

After cardiac surgery, physical therapy is a routine procedure delivered with the aim of preventing postoperative pulmonary complications.

OBJECTIVES:

To determine if preoperative physical therapy with an exercise component can prevent postoperative pulmonary complications in cardiac surgery patients, and to evaluate which type of patient benefits and which type of physical therapy is most effective.

SEARCH METHODS:

Searches were run on the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library (2011, Issue 12 ); MEDLINE (1966 to 12 December 2011); EMBASE (1980 to week 49, 2011); the Physical Therapy Evidence Database (PEDro) (to 12 December 2011) and CINAHL (1982 to 12 December 2011).

SELECTION CRITERIA:

Randomised controlled trials or quasi-randomised trials comparing preoperative physical therapy with no preoperative physical therapy or sham therapy in adult patients undergoing elective cardiac surgery.

DATA COLLECTION AND ANALYSIS:

Data were collected on the type of study, participants, treatments used, primary outcomes (postoperative pulmonary complications grade 2 to 4: atelectasis, pneumonia, pneumothorax, mechanical ventilation > 48 hours, all-cause death, adverse events) and secondary outcomes (length of hospital stay, physical function measures, health-related quality of life, respiratory death, costs). Data were extracted by one review author and checked by a second review author. Review Manager 5.1 software was used for the analysis.

MAIN RESULTS:

Eight randomised controlled trials with 856 patients were included. Three studies used a mixed intervention (including either aerobic exercises or breathing exercises); five studies used inspiratory muscle training. Only one study used sham training in the controls. Patients that received preoperative physical therapy had a reduced risk of postoperative atelectasis (four studies including 379 participants, relative risk (RR) 0.52; 95% CI 0.32 to 0.87; P = 0.01) and pneumonia (five studies including 448 participants, RR 0.45; 95% CI 0.24 to 0.83; P = 0.01) but not of pneumothorax (one study with 45 participants, RR 0.12; 95% CI 0.01 to 2.11; P = 0.15) or mechanical ventilation for > 48 hours after surgery (two studies with 306 participants, RR 0.55; 95% CI 0.03 to 9.20; P = 0.68). Postoperative death from all causes did not differ between groups (three studies with 552 participants, RR 0.66; 95% CI 0.02 to 18.48; P = 0.81). Adverse events were not detected in the three studies that reported on them. The length of postoperative hospital stay was significantly shorter in experimental patients versus controls (three studies with 347 participants, mean difference -3.21 days; 95% CI -5.73 to -0.69; P = 0.01). One study reported a reduced physical function measure on the six-minute walking test in experimental patients compared to controls. One other study reported a better health-related quality of life in experimental patients compared to controls. Postoperative death from respiratory causes did not differ between groups (one study with 276 participants, RR 0.14; 95% CI 0.01 to 2.70; P = 0.19). Cost data were not reported on.

AUTHORS' CONCLUSIONS:

Evidence derived from small trials suggests that preoperative physical therapy reduces postoperative pulmonary complications (atelectasis and pneumonia) and length of hospital stay in patients undergoing elective cardiac surgery. There is a lack of evidence that preoperative physical therapy reduces postoperative pneumothorax, prolonged mechanical ventilation or all-cause deaths.

プレハビリテーションと心肺機能と術後回復

術前の運動（プレハビリテーション）による心肺機能と術後回復の効果に関する系統的レビューを紹介します。

Lemanu DP, Singh PP, Maccormick AD, Arroll B, Hill AG. Effect of Preoperative Exercise on Cardiorespiratory Function and Recovery After Surgery: a Systematic Review. World J Surg. 2013 Jan 5. [Epub ahead of print]

アウトカムに心肺機能も含んだプレハビリテーションのRCT8論文の系統的レビューです。手術は心臓外科手術3つ、一般外科手術3つ、整形外科手術2つです。結果ですが、心肺機能と術後回復（呼吸器合併症減少、入院期間短縮）がともに改善したのは1論文のみでした。

Hulzebos EH, Helders PJ, Favie NJ et al (2006) Preoperative
intensive inspiratory muscle training to prevent postoperative
pulmonary complications in high-risk patients undergoing CABG
surgery: a randomized clinical trial. JAMA 296:1851–1857

プレハビリテーションへのアドヒアランスは低く、対象者は高齢者が多く（平均年齢60歳以上）、プレハビリテーションのプログラムは多様でした。以上より、プレハビリテーションによる心肺機能と術後回復の効果に関するエビデンスは少なく、アドヒアランス改善も含めたさらなる研究が必要という結論です。

全患者にプレハビリテーションを行ってもおそらく有意な効果は出ませんので、どのような患者（サルコペニア、虚弱、低栄養など）に行うかの選定が重要です。また、運動のみでなく栄養改善、不安軽減、疼痛管理なども含めた包括的なプレハビリテーションプログラムのほうが望ましいと思います。

Abstract

BACKGROUND:

This systematic review aims to investigate the extent to which preoperative conditioning (PREHAB) improves physiologic function and whether it correlates with improved recovery after major surgery.

METHODS:

An electronic database search identified randomized controlled trials (RCTs) investigating the safety and efficacy of PREHAB. The outcomes studied were changes in cardiorespiratory physiologic function, clinical outcomes (including length of hospital stay and rates of postoperative complications), and measures of changes in functional capacity (physical and psychological).

RESULTS:

Eight low- to medium-quality RCTs were included in the final analysis. The patients were elderly (mean age >60 years), and the exercise programs were significantly varied. Adherence to PREHAB was low. Only one study found that PREHAB led to significant improvement in physiologic function correlating with improved clinical outcomes.

CONCLUSION:

There are only limited data to suggest that PREHAB confers any measured physiologic improvement with subsequent clinical benefit. Further data are required to investigate the efficacy and safety of PREHAB in younger patients and to identify interventions that may help improve adherence to PREHAB.

タイでのサルコペニアの有病割合

タイでのサルコペニアの有病割合と関連要因に関する論文を紹介します。

Pongchaiyakul C, Limpawattana P, Kotruchin P, Rajatanavin R. Prevalence of sarcopenia and associated factors among Thai population. Bone Miner Metab. 2013 Feb 2. [Epub ahead of print]

対象はタイの都市在住の435人と地方在住の397人で、年齢は20-84歳です。サルコペニアの有病割合は骨格筋指数で評価しています（おそらくDEXAで筋肉量を評価）。結果ですが、サルコペニアの有病割合は男性で35.33%、女性で34.74％でした。

多変量解析では男女とも、都市在住、BMI高値、高齢がサルコペニアと関連していました。都市在住が最も強い要因で、地方在住と比較した場合の有病割合の比は男性2.01倍、女性1.69倍でした。サルコペニアの早期発見がサルコペニア関連の障害予防に重要です。

都市在住と地方在住でこれだけサルコペニアの有病割合が異なるというのは、意外な結果です。都市在住のほうが食生活や運動量・活動量に問題があるのかもしれません。BMIが高いほうがサルコペニアが多いというのも意外で、サルコペニア肥満に注意ということでしょうか。

Abstract

The purpose of this study was to determine the prevalence of sarcopenia using the skeletal muscle index (SMI) criteria in the Thai population. The secondary objective was to demonstrate factors influencing low SMI in this population. Femoral neck bone mass density (BMD) was measured by dual-energy X-ray absorptiometry (GE Lunar, Madison, WI, USA) in 435 urban and 397 rural subjects (334 men and 498 women) between 20 and 84 years of age. Body mass index (BMI) was calculated from weight and height. The respective prevalence of sarcopenia among men and women was 35.33 % (95 % CI, 29.91, 40.41) and 34.74 % (95 % CI, 30.56, 39.10). Factors associated with sarcopenia using multiple logistic regression analyses in both sexes were (a) living in the city, (b) higher BMI, and (c) older age. Living in an urban area was the strongest factor, with an odds ratio (OR) of 17.26 ± 7.12 (95 % CI, 7.68, 38.76) in men and 8.62 ± 2.74 (95 % CI, 4.62, 16.05) in women (p < 0.05). The prevalence rate ratio for persons living in urban compared to rural areas was 2.01 (95 % CI, 1.14, 3.53) in men and 1.69 (95 % CI, 1.31, 2.17) in women (p < 0.05). Sarcopenia, as based on SMI, occurs frequently in the Thai population and increases with age. The prevalence of sarcopenia is particularly high among pre-retirement women (50-59 years of age) whereas the number of men with sarcopenia gradually rises with age. An urban environment is the most predictive factor for sarcopenia, followed by high BMI and age. Given the aging population, early recognition of this condition can be beneficial for prevention of an epidemic of sarcopenia-related disability.

入院高齢患者のサルコペニアと予後

入院患者におけるサルコペニアの有病割合と予後的意義に関する論文を紹介します。

Salah Gariballa, Awad Elessa. Sarcopenia: prevalence and prognostic significance in hospitalized patients. Clinical Nutrition, published online 01 February 2013, doi:10.1016/j.clnu.2013.01.010

対象は急性疾患で入院した高齢者432人です。入院72時間後、6週間後、6ヶ月後の3回評価しました。サルコペニアの有無はEWGSOPの診断基準で評価しました。結果ですが、432人中44人（10%）にサルコペニアを認めました。

サルコペニアを認めた患者は、より高齢で、抑うつ症状を認め、血清アルブミンが低値でした。入院期間はサルコペニア患者で有意に長かったです。6ヶ月後の再入院のリスクと死亡率は、サルコペニアを認めない患者で有意に低かったです。

以上より急性疾患で入院した高齢者にサルコペニアを認める場合、臨床的な予後が悪いという結論です。当院でも入院リハを要する高齢者にサルコペニアをしばしば認めますが、リハ期間が長く機能予後が悪い印象ですので、納得できる結果です。次はリハ栄養介入ですね。

Summary

Background

Sarcopenia is prevalent in older populations with many causes and varying outcomes however information for use in clinical practice is still lacking.

Aims

The aim of this report is to identify the clinical determinants and prognostic significance of sarcopenia in a cohort of hospitalized acutely ill older patients.

Methods

Four hundred and thirty two randomly selected patients had their baseline clinical characteristic data assessed within 72 hours of admission, at 6 weeks and at 6 months. Nutritional status was assessed from anthropometric and biochemical data. Sarcopenia was diagnosed from low muscle mass and low muscle strength-hand grip using anthropometric measures based on the European Working Group criteria.

Results

Compared with patients without sarcopenia, those diagnosed with sarcopenia 44 (10%) were more likely to be older, have more depression symptoms and lower serum albumin concentration. The length of hospital stay (LOS) was significantly longer in patients diagnosed with sarcopenia compared with patients without sarcopenia [mean (SD) LOS 13.4 (8.8) versus 9.4 (7) days respectively, p = 0.003]. The risk of non-elective readmission in the 6-months follow up period was significantly lower in patients without sarcopenia compared with those diagnosed with sarcopenia (adjusted hazard ratio 0.53 (95% CI: 0.32 to 0.87, p = 0.013). The death rate was also lower in patients without sarcopenia 38/388 (10%), compared with those with sarcopenia 12/44 (27%), p-value = 0.001

Conclusion

Older people with sarcopenia have poor clinical outcome following acute illness compared with those without sarcopenia.

廃用症候群の急性期入院リハ期間と予後

イスラエルにおける高齢者の廃用症候群の急性期入院リハ期間と予後に関する論文を紹介します。ヘブライ語なので抄録しか読めませんが…。

Guy N, Justo D, Lerman Y, Rabinovich A. [Length and outcome of acute inpatient rehabilitation for hospital-associated deconditioning in the elderly]. [Article in Hebrew] Harefuah. 2012 Sep;151(9):500-4, 558.

対象は廃用症候群と診断された入院高齢患者103人で女性57人、男性46人、平均年齢は83.6歳です。原因疾患として最も多かったのは肺炎、脳出血術後（麻痺なし）、うっ血性心不全の急性増悪でした。退院時の移乗と歩行のFIM点数は5.3点、5.2点でした。

平均リハ期間は20.4日でした。退院時の移乗と歩行のFIM得点、リハ期間はいずれもリハ入院時の移動能力？と有意に関連を認めました。またリハ期間は血清アルブミン値と有意に関連していました。

廃用症候群のアウトカムに関する論文は少ないので貴重です。イスラエルと日本では患者層に大きな違いはなさそうな印象です。アルブミン値とリハ期間に関連があったことより、アルブミン値がリハの予後指標の1つとなる可能性があるといえます。

Abstract

INTRODUCTION:

Acute illness and prolonged bed rest might be associated with loss of muscle mass and significant decline in functional ability and mobility, regardless of a specific neurological or orthopedic insult. This condition is commonly termed hospital-associated deconditioning (HAD). To the best of our knowledge to date, acute inpatient rehabilitation length and outcome for HAD in the elderly have never been studied in Israel.

AIM:

To study which variables are independently associated with the length and mobility outcome of acute inpatient rehabilitation for HAD in the elderly.

METHODS:

A retrospective cross-sectional study was conducted during 2009 at the departments of Geriatric Medicine in the Tel-Aviv Medical Center The medical charts of consecutive elderly (< 65 years) patients admitted for rehabilitation due to HAD were studied for the following measurements: demographics, co-morbidities, causes of HAD, admission albumin serum levels, Mini-Mental Status Examination (MMSE) scores, admission transfer and walking Functional Independence Measure (FIM) scores, discharge transfer and walking FIM scores, and rehabilitation length.

RESULTS:

The cohort included 103 patients: 57 (55.3%) females and 46 (44.7%) males. The mean age for the entire cohort was 83.6 +/- 6.0 years. The three most common causes of HAD were pneumonia, craniotomy due to intracranial bleeding without neurological insults, and congestive heart failure exacerbation. The mean discharge transfer and walking FIM scores were 5.3 +/- 0.9 and 5.2 +/- 0.8, respectively. The mean length of rehabilitation was 20.4 +/- 13.9 days. Linear regression analysis showed that discharge transfer FIM scores, discharge walking FIM scores, and rehabilitation length were all independently associated with mobility upon admission to rehabilitation (p < 0.0001, p < 0.0001, p = 0.024, respectively). Rehabilitation length was also associated with admission albumin serum levels (p = 0.008).

CONCLUSIONS:

The length and mobility outcomes of acute inpatient rehabilitation for HAD in the elderly are associated with mobility upon admission to rehabilitation. Acute inpatient rehabilitation length is also associated with admission albumin serum levels.

重症疾患患者のサルコペニア

重症疾患患者のサルコペニアのレビュー論文を紹介します。

Muscaritoli M, Lucia S, Molfino A. Sarcopenia In Critically Ill Patients: The New Pandemia. Minerva Anestesiol. 2013 Jan 31. [Epub ahead of print]

重症疾患患者では骨格筋の筋肉量と機能の変化を認めることが多く、その原因は多数あります。急性疾患による筋肉以下に加え、ICUに入室していることが骨格筋異常に影響している可能性があります。原発性サルコペニアを重症疾患患者に認めることがあります。

ICUでのサルコペニアは予後に悪影響を与え、ICUサバイバーの長期予後にも影響する可能性があります。ICU入室患者のサルコペニアに関するデータは少ないですが、ICUに関連したサルコペニアICU-related sarcopeniaの予防に注意すべきです。

広義のサルコペニア・リハ栄養的に考えると、高齢者ではもともと加齢によるサルコペニアを有している可能性があり、ICU入室中に侵襲、安静臥床、飢餓を合併することでサルコペニアが悪化して廃用症候群となり、機能予後や生命予後が悪くなる可能性があるといえます。

Abstract

Alteration of muscle mass and function is often observed in critically ill patients and its etiology is multifactorial. Besides the effects of acute disease on muscle metabolism, intensive care stay may per se contribute to muscle derangements. Recently, the concept of sarcopenia has been completely revisited, and indicates the loss of muscle mass and function. Although sarcopenia is generally observed and diagnosed in older adults it may be present in different clinical settings, including critical illness. Sarcopenia in the intensive care unit (ICU) negatively impacts on patients' outcomes and may determine a negative long-term impact on ICU survivors. Additionally, sarcopenia may promote functional disability in the long-term after hospital discharge. Limited data are available on the prevalence of sarcopenia at ICU admission. Considering the growing population of older adults with multiple comorbidities, modern intensive care medicine should pay attention to the prevention of ICU-related sarcopenia and also to the routine screening for sarcopenia at ICU admission.

サルコペニアと悪液質と心不全

高齢者のサルコペニアと悪液質とうっ血性心不全のレビュー論文を紹介します。

Zamboni M, Rossi A, Corzato F, Bambace C, Mazzali G, Fantin F. Sarcopenia, Cachexia and Congestive Heart Failure in the Elderly. Endocr Metab Immune Disord Drug Targets. 2013 Jan 15. [Epub ahead of print]

軽中度の慢性心不全患者に骨格筋異常や骨格筋減少はよく認め、疲労や呼吸困難に影響している可能性があります。骨格筋異常としてサルコペニア（原発性）と心臓悪液質が考えられます。悪液質では筋肉量減少が特徴的ですが、サルコペニアの方の多くは悪液質ではありません。

体重減少、食欲不振、全身炎症反応がない場合には、サルコペニアが疑われます。容易ではありませんが、慢性心不全患者でサルコペニアと悪液質を区別することは治療上、重要です。悪液質の特異的な治療方法はありませんが、サルコペニアなら治療の選択肢があります。

原発性サルコペニアと悪液質を区別することは、リハ栄養的には広義のサルコペニアの原因検索と対応につながりますので、重要だと同感します。ただ、悪液質に対しては決定的な治療方法がないとはいえ、栄養・運動・薬物などの包括的対応はすべきだと考えます。

Abstract

Skeletal muscle abnormalities and loss are frequently present in patients with mild or moderate cardiac heart failure (CHF) and may contribute to fatigue and dyspnea. These muscle abnormalities may be associated with age related body composition changes, such as sarcopenia. Muscle damage has also been observed in subjects with cardiac cahexia, a serious CHF complication, associated with poor prognosis independently of functional disease severity, age, and measures of exercise capacity and cardiac function. Loss of muscle mass is a feature of cachexia, whereas most sarcopenic subjects are not cachectic. Individuals with no weight loss, no anorexia, and no measurable systemic inflammatory response may be sarcopenic. Patients with severe CHF show multiple marked histological abnormalities of skeletal muscle, such as muscle fiber atrophy. These abnormalities are different in sarcopenia and cachexia. The majority of mechanisms involved in sarcopenia play a role even in the determination of cachexia and they are amplified in cachexia where they may induce both muscle damage as well as other abnormalities, such as fat and weight loss, through activation of lypolisis or anorexia. To distinguish cachexia and sarcopenia in CHF patients, even if not easy, should be clinically relevant, because no specific treatment is available for cachectic patients whereas treatment options are possible for sarcopenia.