人工関節置換術のプレハビリテーション：メタ分析

人工関節置換術のプレハビリテーション（Prehabilitation）のメタ分析を紹介します。

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（膝もしくは股関節）を受ける患者に
I：術前に運動療法を行うと
C：術前に運動療法を行わない場合と比較して
O：術後の機能回復がよい（入院日数など）
D：メタ分析

　
結果ですが、12論文737人の患者のメタ分析で、治療の妥当性が高いものは1つもありませんでした。介入群と対照群で、術後の機能回復に統計学的な有意差を認めませんでした。結論として、プレハビリテーションの有効性は示されませんでしたが、治療の妥当性が低いことが要因かもしれません。

ただ、入院日数は介入群で短縮傾向にありました（95％信頼区間：−2.46 to 0.08）。また、肥満の場合には、減量目的の食事療法＋運動療法（有酸素運動＋レジスタンストレーニング）のプレハビリテーションであれば、より有意差がでやすくなる可能性があると考えます。

Abstract

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.