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Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy

  • Review
  • Intervention

Authors


Abstract

Background

Joint replacements are common procedures and treatment of choice for those with intractable joint pain and disability arising from arthropathy of the hip or knee. Multidisciplinary rehabilitation is considered integral to the outcome of joint replacement.

Objectives

To assess the evidence for effectiveness of multidisciplinary rehabilitation on activity and participation in adults following hip or knee joint replacement for chronic arthropathy.

Search methods

We searched the Cochrane Musculoskeletal Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL up to September 2006.

Selection criteria

Randomised controlled trials (RCTs) that compared organised multidisciplinary rehabilitation with routine services following hip or knee replacement, and included outcome measures of activity and participation in accordance with the International Classification of Functioning, Health and Disability (ICF).

Data collection and analysis

Four authors independently extracted data and assessed methodological quality of included trials.

Main results

Five trials (619 participants) met the inclusion criteria; two addressed inpatient rehabilitation (261 participants) and three (358 participants) home-based settings. There were no trials addressing outpatient centre-based programmes. Pooling of data was not possible due to differences in study design and outcomes used. Methodological assessment showed all trials were of low quality. For inpatient settings early commencement of rehabilitation and clinical pathways led to more rapid attainment of functional milestones (disability) (Functional Independence Measure (FIM) transfer WMD 0.5, 95% CI 0.15, 0.85, number needed to treat to benefit (NNTB) = 6, FIM ambulation WMD 1.55 (95%CI 0.96, 2.14), NNTB = 3), shorter hospital stay, fewer post-operative complications and reduced costs in the first three to four months. Home-based multidisciplinary care improved functional gain (Oxford Hip Score (OHS) WMD at 6 months -7.00 (95%CI -10.36, -3.64), NNT = 2 and quality of life (QoL) and reduced hospital stay in the medium term (six months). No trials addressed longer-term outcomes following hip replacement only.

Authors' conclusions

Based on the heterogeneity and the low quality of the included trials that precluded pooled meta-analysis, there is silver level evidence that following hip or knee joint replacement, early multidisciplinary rehabilitation can improve outcomes at the level of activity and participation. The optimal intensity, frequency and effects of rehabilitation over a longer period and associated social costs need further study. Future research should focus on improving methodological and scientific rigour of clinical trials, and use of standardised outcome measures, so that results can be pooled for statistical analysis.

摘要

針對慢性關節炎經髖部和膝部關節置換手術後的跨領域復健計劃

研究背景

因膝或髖關節炎造成無法以藥物控制的疼痛且生活能力受影響的病患,關節置換是常使用的一種治療方式。跨領域復健療程對關節置換的良好預後是不可或缺的。

研究目的

評估成人關節炎病患在髖部或膝蓋關節置換後,對跨領域復健療程的參與程度及療程對術後活動力的影響。

检索策略

我們搜尋了2006年9月之後的the Cochrane Musculoskeletal Group Trials Register、the Cochrane Central Register of Controlled Trials、MEDLINE、EMBASE及CINAHL。

标准/纳入排除标准

以髖部或膝蓋關節置換後的跨領域復健療程和一般例行復健療程比較的隨機對照試驗,其中必須包含活動力和參與程度的結果,並且是根據the International Classification of Functioning, Health and Disability (ICF)做出的評估。

数据收集与分析

4位作者分別擷取數據並評估收錄的試驗的方法品質。

主要结果

5個試驗(總共619位參與者)符合收錄標準;2個試驗討論住院復健(261位參與者),另外3個試驗討論在家復健(358位參與者)。沒有任何試驗討論院外復健中心的療程。由於各研究在設計及結果的呈現上有所不同,因此無法將數據匯集。方法評估顯示所有的試驗都是低品質的。針對住院復健方面,早期開始復健使病患可以快速恢復行動力(Functional Independence Measure (FIM) transfer WMD 0.5, 95% CI 0.15, 0.85, number needed to treat to benefit (NNTB) = 6, FIM ambulation WMD 1.55 (95%CI 0.96, 2.14), NNTB = 3)、住院時間較短、術後併發症較少,而且可以減少3到4個月的開銷。在家的跨領域復健療程復健可以改善髖關節置換後的功能 (以Oxford Hip Score (OHS)評估, 6個月的WMD為−7.00(95%CI −10.36, −3.64),NNT = 2),以及生活品質(QoL),並可以縮短中期(6個月)的住院時間。沒有試驗針對只有接受髖關節置換手術患者的長期追蹤結果做討論。

作者结论

由於收錄試驗的異質性及低品質,無法進行整合分析,和髖關節和膝蓋置換相關的證據等級並不高,即早進行跨領域復健可以改善病患活動力及參與度。還需要進一步的研究討論長時間而言最佳的復健強度、頻率、復健的效果及相關的社會成本。未來的研究應該著重於方法的改善及臨床試驗的嚴謹度,並且使用標準結果量測,以利結果的統計分析。

Plain language summary

Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy

Joint replacements are common procedures and treatment of choice for those with intractable joint pain and disability arising from arthropathy of the hip or knee. Multidisciplinary rehabilitation is considered integral to the outcome of joint replacement.

Five trials (619 participants) met the inclusion criteria; two addressed inpatient rehabilitation (261 participants) and three (358 participants) home-based settings. There were no trials addressing outpatient centre-based programmes. Pooling of data was not possible due to differences in study design and outcomes used. Methodological assessment showed all trials were of low quality. For inpatient settings early commencement of rehabilitation and clinical pathways led to more rapid attainment of functional milestones (disability) (Functional Independence Measure (FIM) transfer WMD 0.5, 95% CI 0.15, 0.85, number needed to treat to benefit (NNTB) = 6, FIM ambulation WMD 1.55 (95%CI 0.96, 2.14), NNTB = 3), shorter hospital stay, fewer post-operative complications and reduced costs in the first three to four months. Home-based multidisciplinary care improved functional gain (Oxford Hip Score (OHS) WMD at 6 months -7.00 (95%CI -10.36, -3.64), NNT = 2 and quality of life (QoL) and reduced hospital stay in the medium term (six months). No trials addressed longer-term outcomes following hip replacement only.

Based on the heterogeneity and the low quality of the included trials that precluded pooled meta-analysis, there is silver level evidence that following hip or knee joint replacement, early multidisciplinary rehabilitation can improve outcomes at the level of activity and participation. The optimal intensity, frequency and effects of rehabilitation over a longer period and associated social costs need further study. Future research should focus on improving methodological and scientific rigour of clinical trials, and use of standardised outcome measures, so that results can be pooled for statistical analysis.

概要

針對慢性關節炎髖關節和膝部關節置換後的跨領域復健計劃 本篇Cochrane回顧呈現了我們目前所知,和慢性關節炎髖關節和膝部關節置換後的跨領域復健計劃相關的資訊。本篇回顧顯示,在髖關節或膝蓋關節置換手術後:髖關節或膝蓋關節置換後盡快進行跨領域復健:可以改善病患的行動能力。在家的跨領域復健:可以改善病患在髖關節置換後的生活品質及進行日常生活活動的能力;對膝蓋關節置換病患的生活品質及進行日常活動能力並無影響。收錄的研究中,沒有任何一篇發現任何可能由復健療程所引發的不良反應。什麼是關節置換,又什麼是綜合復健計劃呢?關節置換指的是用人工的關節取代原有的髖關節或膝蓋關節。通常會建議病患在手術後進行復健,以幫助病患適應新的關節,恢復原有的生活能力。當復健計劃中涉及一個領域已上的專業時,就被稱為跨領域復健計劃。這些計劃有的較激烈,有的較緩和,可以在手術後即早開始或延後進行,可以在家中進或醫院進行。術後在醫院進行跨領域復健的成效:根據一個1到7分的評量,病患從床走到桌子旁的能力改善了0.5分、爬樓梯的能力改善大約1分。術後在家進行進行跨領域復健的成效:在復健2個月後,根據一個12到60分的量表,病患為自己活動力的評分平均增加了5分,其中有人認為自己進步了10分,有人認為自己只進步0.5分;復健4到6個月後,病患給自己的活動力評分平均增加7分,其中有人給自己11分,有人只給自己3分。這些數據是我們的最佳評估。我們也求出了一個療效範圍,治療的效果有95%的機會落在這個範圍裡。

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