高齢者の周術期運動療法

高齢者の周術期運動療法のレビュー論文を紹介します。

Jack S, West M, Grocott MP. Perioperative exercise training in elderly subjects. Best Pract Res Clin Anaesthesiol. 2011 Sep;25(3):461-72.

手術患者に対するPrehabilitationについて、現時点ではもっともよいレビュー論文だと思います。

術前はPrehabilitation、術後はRehabilitationとしています。ここでのPrehabilitationは基本的に運動療法しか含んでいません。ただし、実際には栄養療法を含むこともあります。高齢者の周術期運動療法に関する質の高いエビデンスは限られています。

Prehabilitationは、術前の体力を改善させることは検証されていますが、術後の外科的予後を改善させるかどうかは不明です。術前の呼吸筋の筋トレは、無気肺など術後の呼吸器合併症を予防しますが、全体の外科的予後を改善させるかどうかは不明です。

がん患者へのRehabilitationは身体活動、疲労、QOLを改善させることは明らかです。しかし、これらの改善の結果、生存期間の改善し再発時期が遅くなるかどうかは不明です。周術期の運動は有用と思われますが、外科的予後（生存率・期間など）を一次アウトカムとしたRCTが必要としています。

一次アウトカムを外科的予後ではなく身体機能とすれば、Prehabilitationの有用性はある程度検証されているといえます。臨床現場では、どのような患者（例：サルコペニアの高齢者）に、どのような介入（例：歩行訓練＋筋トレ＋BCAA2g以上含む補助栄養剤）をするべきかを検証したいですね。

Abstract
The association between physical fitness and outcome following major surgery is well described - less fit patients having a higher incidence of perioperative morbidity and mortality. This has led to the idea of physical training (exercise training) as a perioperative intervention with the aim of improving postoperative outcome. Studies have started to explore both preoperative training (prehabilitation) and postoperative training (rehabilitation). We have reviewed the current literature regarding the use of prehabilitation and rehabilitation in relation to major surgery in elderly patients. We have focussed particularly on randomised controlled trials, systematic reviews and meta-analyses. There is currently a paucity of high-quality clinical trials in this area, and the evidence base in elderly patients is particularly limited. The review indicated that prehabilitation can improve objectively measured fitness in the short time available prior to major surgery. Furthermore, for several general surgical procedures, prehabilitation using inspiratory muscle training may reduce the risk of some specific complications (e.g., pulmonary complications and predominately atelectasis), but it is unclear whether this translates into an improvement in overall surgical outcome. There is clear evidence that rehabilitation is of benefit to patients following cancer diagnoses, in terms of physical activity, fatigue and health-related quality of life. However, it is uncertain whether this improved physical function translates into increased survival and delayed disease recurrence. Prehabilitation using continuous or interval training has been shown to improve fitness but the impact on surgical outcomes remains ill defined. Taken together, these findings are encouraging and support the notion that pre- and postoperative exercise training may be of benefit to patients. There is an urgent need for adequately powered randomised control studies addressing appropriate clinical outcomes in this field.