水中治疗膝盖、髋关节置换术的时机


  【24drs.com】根据在线发表于12月21日身体医学&复健学志的随机控制试验,全膝关节置换术(TKA)后6天开始水中治疗者,与术后14天开始治疗者相比,病患表示可改善结果;相对的,全髋关节置换术(THA)者等到术后14天开始治疗者效果比较好。
  
  德国Schleswig-Holstein大学医学中心骨科Thoralf R. Liebs医师等人写道,虽然治疗差异未达统计上的显著意义,TKA后及早水中治疗的效果与非类固醇抗发炎药物治疗膝骨关节炎的效果相当。
  
  水中治疗对THA和TKA复健有帮助,因为它让病患在一个减轻体重负担的环境运动,而可以逐渐恢复肌肉强度。病患一般会到术后14天才开始水中治疗,主要是等伤口愈合。不过,Liebs医师等人假设,如果病患及早开始治疗可以改善临床结果。
  
  为了评估TKA或THA之后进行水中治疗的时机,研究者随机指派进行THA (n = 280)或TKA (n = 185)的病患在术后6或14天进行水中治疗。
  
  病患包括156名男性和309名女性、各项特征在研究开始时相似,治疗包括每周3次的30分钟课程、直到术后第5周;水池运动目的在改善本体感觉、协调性和强度;在术后第3、6、12和24个月评估体能、疼痛度和僵硬度。
  
  主要结果为自我报告的体能改善程度,根据的是西安大略与麦梅斯特大学骨性关节炎指标(WOMAC),将结果和之前公告的最小临床改善阈值进行比较,次级结果包括Medical Outcomes Study 36-Item Short-Form Health Survey、Lequesne-Hip/Knee-Score、WOMAC疼痛与僵硬分数以及病患满意度。
  
  虽然追踪期间整体研究对象并未达统计上的显著差异,个别分析TKA和THA病患显示,提早治疗对两组产生不同的结果;比较提早治疗之TKA病患和第14天开始治疗之TKA病患的各项WOMAC指标;WOMAC量表的体能效果范围从0.22-0.39。
  
  THA病患中,延后治疗者有比较好的结果,WOMAC效果范围为0.01-0.19,不过,这些差异未达统计上的显著程度。
  
  作者们写道,这篇随机研究显示,对于THA和TKA,术后提早进行水中治疗产生对健康相关生活质量的结果正好相反。
  
  TKA之后,提早水中治疗可改善病患的临床结果。另一方面,研究结果指出,髋关节置换术后,应避免提早水中治疗。
  
  作者们推测,TKA病患提早水中治疗获得较大改善的解释之一是,相较于髋关节病患术后,TKA病患术后的满意度一般较低。
  
  作者们解释,我们假设,THA之后提早水中治疗时机的效果较差,是因为已达最大手术效果,病患满意度比率较高,因THA的健康相关生活质量改善也多,因此,其它介入方式的改善空间自然有限。
  
  另一方面,TKA之后,不满意的病患数显著较多,使得其它介入方式较有改善空间。
  
  他们指出,另一个解释则是膝关节和髋关节的生理差异。
  
  我们假设,除了已知的水中治疗优势之外,水中的流体力学降低了膝关节手术部位的积液。因为关节囊在TKA术后关闭,积液减少会减少疼痛抑制,因而导致功能恢复上的优势,而关节囊在THA并未关闭,这个机转并不适用于THA。
  
  作者们结论指出,需要更多研究来更加了解这个议题。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6691&x_classno=0&x_chkdelpoint=Y
  

Timing of Aquatic Therapy for Knee, Hip Arthroplasty Matters

By Nancy A. Melville
Medscape Medical News

December 22, 2011 — Initiating aquatic therapy just 6 days after total knee arthroplasty (TKA) improved patient-reported outcomes compared with starting therapy 14 days after surgery, according to a randomized controlled study published online December 21 in the Archives of Physical Medicine & Rehabilitation. In contrast, waiting until day 14 to start aquatic therapy was better for patients who had total hip arthroplasty (THA).

"Although the treatment differences did not achieve statistical significance, the effect size for early aquatic therapy after TKA had the same magnitude as the effect size of nonsteroidal anti-inflammatory drugs in the treatment of osteoarthritis of the knee," write study authors Thoralf R. Liebs, MD, from the Department of Orthopaedic Surgery, University of Schleswig-Holstein Medical Center, Kiel, Germany, and colleagues.

Aquatic therapy is useful for THA and TKA rehabilitation because it allows patients to exercise in an environment that relieves body weight while muscular strength is gradually restored. Patients do not usually start aquatic therapy until 14 days after surgery, to allow the wound to heal. However, Dr. Liebs and colleagues and colleagues hypothesized that the clinical outcome could be improved if patients started therapy sooner.

To evaluate the effect of the timing of aquatic therapy after TKA or THA, the researchers randomly assigned patients undergoing primary THA (n = 280) or TKA (n = 185) to begin the therapy either 6 or 14 days after the surgery.

The patients included 156 men and 309 women with similar baseline characteristics. The therapy included 30-minute sessions given 3 times a week, up to the fifth postoperative week, for all patients. Pool exercises were designed to improve proprioception, coordination, and strengthening. Physical function, pain, and stiffness were evaluated 3, 6, 12, and 24 months after the surgery.

The primary outcome was self-reported improvement in physical function according to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the results were compared with previously published thresholds for minimal clinically important improvements. The secondary outcomes included the Medical Outcomes Study 36-Item Short-Form Health Survey, Lequesne-Hip/Knee-Score, WOMAC pain and stiffness scores, and patient satisfaction.

Although there were no statistically significant differences in the total study population at follow-up, separate analyses of the TKA and THA patients showed early therapy had opposite effects in the 2 groups. All WOMAC subscales improved with early therapy in TKA patients compared with in TKA patients who started therapy at day 14. The effect sizes for physical function WOMAC subscales ranged from .22 to .39.

Among the THA patients, the later-therapy group had better outcomes, with WOMAC effects ranging from .01 to .19. However, those differences were not statistically significant.

"This randomized study showed that the use of early aquatic therapy has opposite effects in terms of health-related quality of life after THA when compared with TKA," the authors write.

"After TKA, early aquatic therapy led to clinically important improved patient outcomes when compared with late aquatic therapy. After hip arthroplasty, on the other hand, the results of this study indicate that early aquatic therapy should be avoided."

The authors speculate that one important explanation for the greater improvement with early aquatic therapy for TKA patients is a lower level of satisfaction that TKA patients typically have after the procedure compared with hip patients.

"We hypothesize that the weak effect of the timing of aquatic therapy after THA is due to the ceiling effect of that procedure, with a high rate of patient satisfaction and improvement of health-related quality of life due to THA alone, thereby leaving only a limited space for improvement by additional interventions," the authors explain.

"After TKA, on the other hand, a significant higher number of patients is not satisfied, leaving room for the effect of additional interventions."

Another explanation could involve the physiology of the knee joint vs the hip, they add.

"We assume that, apart from the known advantages of aquatic therapy, the hydrostatic force of water immersion reduces effusion of the operated knee joint. Because the joint capsule is closed after TKA, the reduction of effusion leads to less pain inhibition, and leading to an advantage in functional recovery. As the joint capsule is not closed during THA, this mechanism does not apply to THA."

Additional studies are needed to better understand the issue, the authors conclude.

The authors have disclosed no relevant financial relationships.

Arch Phys Med Rehab. Published online December 21, 2011.

    
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