预康复对全膝关节置换术后患者的有效性：系统综述的系统综述

doi:10.3969/j.issn.1006-9771.2023.09.009

摘要/Abstract

摘要：

目的对术前预康复训练对全膝关节置换术患者术后功能影响的系统综述进行系统综述。

方法检索Cochrane Library、Embase、PubMed、Web of Science、万方数据库、中国知网和维普数据库收录关于术前预康复训练应用于全膝关节置换术后功能的系统综述或Meta分析，时间范围为建库至2023年3月10日。采用AMSTAR对文献进行方法学质量评价，采用RevMan 5.3对纳入文献中不重复原始文献中的数据进行更大范围Meta分析。

结果共纳入10项系统综述/Meta分析。与常规康复比较，术前预康复训练能减少术后西安大略和麦克马斯特大学骨关节炎指数(MD = -1.34, 95%CI -1.94~-0.74, P < 0.001)和特种外科医院膝关节评分(MD = -1.04, 95%CI -1.69~-0.40, P = 0.001)，缩短住院时间(MD = -1.01, 95%CI -1.66~-0.36, P = 0.002)，增强术后3个月肌力(SMD = 0.63, 95%CI 0.30~0.97，P < 0.001)。

结论术前预康复训练有助于促进全膝关节置换术患者术后膝关节功能恢复，增强术后3个月的肌力，缩短住院时间。

关键词: 全膝关节置换术, 预康复, 系统综述

Abstract:

Objective To conduct a systematic review of systematic reviews of the effect of preoperative prerehabilitation training on postoperative function of patients after total knee arthroplasty.

Methods The systematic reviews and meta-analysis about the application of preoperative prerehabilitation training after total knee arthroplasty were retrieved from Cochrane Library, Embase, PubMed, Web of Science, Wanfang Data, CNKI and VIP database, from establishment to March 10th, 2023. The methodological quality was evaluated using AMSTAR. The meta-analysis of the reseaches without repetitive content was performed using RevMan 5.3.

Results A total of ten systematic reviews/meta analyses were included. Compared with the routine rehabilitation, preoperative prerehabilitation training might decrease the scores of Western Ontario and McMaster Universities Osteoarthritis Index (MD = -1.34, 95%CI -1.94 to -0.74, P < 0.001), and Hospital for Special Surgery Knee Score (MD = -1.04, 95%CI -1.69 to -0.40, P = 0.001), shorten the length of hospital stay (MD = -1.01, 95%CI -1.66 to -0.36, P = 0.002), and enhance muscle strength three months after operation (SMD = 0.63, 95%CI 0.30 to 0.97, P < 0.001).

Conclusion Preoperative prerehabilitation training can improve postoperative knee function, enhance muscle strength three months after operation, and shorten length of hospital stay for the patients after total knee arthroplasty.

Key words: total knee arthroplasty, prerehabilitation, systematic review

中图分类号:

R687.4

史佳伟, 李凌宇, 杨浩杰, 王琴潞, 邹海欧. 预康复对全膝关节置换术后患者的有效性：系统综述的系统综述[J]. 《中国康复理论与实践》, 2023, 29(9): 1057-1064.

SHI Jiawei, LI Lingyu, YANG Haojie, WANG Qinlu, ZOU Haiou. Effect of preoperative prerehabilitation training on total knee arthroplasty: a systematic review of systematic reviews[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2023, 29(9): 1057-1064.

图/表 5

图1

表1

纳入文献的基本特征"

纳入文献	研究类型	国家	纳入文献数/n	样本量/n	质量评价方法	干预措施		干预周期及剂量	结局指标
纳入文献	研究类型	国家	纳入文献数/n	样本量/n	质量评价方法	实验组	对照组	干预周期及剂量	结局指标
罗欢等^[1](2022)	Meta分析	中国	10	788	Cochrane偏倚风险评估工具	本体感觉训练、躯体和上肢力量训练、抗阻训练、平衡定向训练	常规护理	每周1~3次，共6~12周	①②③④
Wang等^[8](2021)	系统综述+Meta分析	中国	12	889	Cochrane 偏倚风险评估工具	抗阻训练、股四头肌肌力训练、关节活动度训练、平衡训练	常规护理	每周1~3次，共2~6 周	①③④⑤⑥
Kwok等^[9](2015)	系统综述+Meta分析	英国	11	791	PEDro量表	股四头肌肌力训练、平衡训练、本体感觉训练	常规护理	每次20~30 min,每周2~3次，共2~4周	①②③④⑤⑦
Silkman等^[10](2012)	系统综述+Meta分析	美国	7	624	PEDro量表	下肢运动、股四头肌肌力训练、本体感觉训练、躯干和上肢力量训练	常规护理	每周3~4次，共3~6周	①②③④⑦⑧
张慧等^[11](2017)	系统综述+Meta分析	中国	13	745	Cochrane 偏倚风险评估工具	平衡运动、下肢运动、股四头肌肌力训练、关节活动范围训练、平衡训练	常规活动	每周1~3次，共4~8 周	①②③⑤⑥⑦⑨⑩
Chen等^[12](2018)	Meta分析	中国	16	1224	改良版Jadad量表	本体感觉训练、抗阻训练、平衡定向训练	常规护理	共4~8周	①②③④⑥⑦⑨
Wu等^[13](2022)	系统综述+Meta分析	中国	7	306	Cochrane 偏倚风险评估工具	下肢肌力训练、抗阻训练	常规护理	共3~20周	①②③④⑧
Ma等^[14](2018)	系统综述+Meta分析	中国	9	777	Cochrane 偏倚风险评估工具	本体感觉训练、渐进式抗阻训练、关节活动度训练	常规护理正常活动	每次5 min，每周4~6次，共4~8周	①②③④⑤⑥
Su等^[15](2022)	Meta分析	中国	19	1008	Cochrane 偏倚风险评估工具	伸展运动、等长肌力锻炼、活动锻炼、热疗	常规护理	每次10~30 min,每周3~7次，共4~8 周	①②③④⑥⑧⑨
李敏清等^[16](2018)	Meta分析	中国	6	356	Cochrane 偏倚风险评估工具	膝关节被动活动、术前功能锻炼指导、踝泵练习	常规护理	4周内完成	③⑩

表1

表2

表3

表4

参考文献 41

[1]	罗欢, 高静, 柏丁兮, 等. 术前康复训练对老年全膝关节置换术病人术后恢复影响的Meta分析[J]. 循证护理, 2022, 8(18): 2415-2424.
	LUO H, GAO J, BAI D X, et al. Influence of preoperative rehabilitation training on postoperative recovery of elderly patients undergoing total knee arthroplasty: a meta-analysis[J]. Chin Evid Based Nurs, 2022, 8(18): 2415-2424.
[2]	赵改云, 李云, 王凡凡. 预康复训练对全髋关节置换术后关节功能康复效果影响的系统评价[J]. 循证护理, 2020, 6(11): 1170-1178.
	ZHAO G Y, LI Y, WANG F F. Effect of prerehabilitation training on joint function after total hip replacement: a systematic review[J]. Chin Evid Based Nurs, 2020, 6(11): 1170-1178.
[3]	杨延砚, 吴同绚, 张巧云, 等. 个体化术前康复对全膝关节置换术后6周功能转归的影响[J]. 中国康复理论与实践, 2016, 22(6): 701-708. doi: 10.3969/j.issn.1006-9771.2016.06.0017
	YANG Y Y, WU T X, ZHANG Q Y, et al. Effects of individual prehabilitation on functional outcome six weeks after total knee arthroplasty[J]. Chin J Rehabil Theory Pract, 2016, 22(6): 701-708.
[4]	张卫红, 王培霞, 马红娜, 等. 术前预康复在老年膝关节置换合并肌少症患者中的应用[J]. 中华现代护理杂志, 2023, 29(7): 867-872.
	ZHANG W H, WANG P X, MA H N, et al. Application of preoperative pre-rehabilitation in elderly patients with knee arthroplasty combined with sarcopenia[J]. Chin J Mod Nurs, 2023, 29(7): 867-872.
[5]	李秀芳, 周德智, 尹梦星, 等. 全膝关节置换术康复治疗的研究进展[J]. 中国临床新医学, 2022, 15(2): 179-182.
	LI X F, ZHOU D Z, YIN M X, et al. Research progress in rehabilitation therapy of total knee arthroplasty[J]. Chin J New Clin Med, 2022, 15(2): 179-182.
[6]	李琪, 李瑞青, 高静, 等. 远程康复应用于卒中后功能康复有效性的系统评价再评价[J]. 中国全科医学, 2022, 25(13): 1659-1666. doi: 10.12114/j.issn.1007-9572.2022.0156
	LI Q, LI R Q, GAO J, et al. Effectiveness of telerehabilitation applied to functional recovery after stroke: an overview of systematic reviews[J]. Chin Gen Pract, 2022, 25(13): 1659-1666.
[7]	Cochrane Training. Chapter V: Overviews of Reviews \| Cochrane Training[EB/OL]. (2020-03-05)[2023-03-10]. https://training.cochrane.org/handbook/current/chapter-v.
[8]	WANG D, WU T, LI Y, et al. A systematic review and meta-analysis of the effect of preoperative exercise intervention on rehabilitation after total knee arthroplasty[J]. Ann Palliat Med, 2021, 10(10): 10986-10996. doi: 10.21037/apm-21-2670 pmid: 34763461
[9]	KWOK I H, PATON B, HADDAD F S. Does pre-operative physiotherapy improve outcomes in primary total knee arthroplasty? A systematic review[J]. J Arthroplasty, 2015, 30(9): 1657-1663. doi: 10.1016/j.arth.2015.04.013
[10]	SILKMAN B C, MCKEON J M. Does preoperative rehabilitation improve patient-based outcomes in persons who have undergone total knee arthroplasty? A systematic review[J]. PM R, 2012, 4(10): 756-767. doi: 10.1016/j.pmrj.2012.06.005
[11]	张慧, 郝雪云, 帅婷, 等. 全膝关节置换术前康复训练效果的系统评价[J]. 中国循证医学杂志, 2017, 17(9): 1060-1065.
	ZHANG H, HAO X Y, SHUAI T, et al. Efficacy of preoperative rehabilitation for total knee replacement: a systematic review[J]. Chin J Evid Based Med, 2017, 17(9): 1060-1065.
[12]	CHEN H, LI S, RUAN T, et al. Is it necessary to perform prehabilitation exercise for patients undergoing total knee arthroplasty: meta-analysis of randomized controlled trials[J]. Phys Sports Med, 2018, 46(1): 36-43. doi: 10.1080/00913847.2018.1403274
[13]	WU Z, WANG Y, LI C, et al. Preoperative strength training for clinical outcomes before and after total knee arthroplasty: a systematic review and meta-analysis[J]. Front Surg, 2022, 9: 879593. doi: 10.3389/fsurg.2022.879593
[14]	MA J X, ZHANG L K, KUANG M J, et al. The effect of preoperative training on functional recovery in patients undergoing total knee arthroplasty: a systematic review and meta-analysis[J]. Int J Surg, 2018, 51: 205-212. doi: 10.1016/j.ijsu.2018.01.015
[15]	SU W, ZHOU Y, QIU H, et al. The effects of preoperative rehabilitation on pain and functional outcome after total knee arthroplasty: a meta-analysis of randomized controlled trials[J]. J Orthop Surg Res, 2022, 17(1): 175. doi: 10.1186/s13018-022-03066-9 pmid: 35313897
[16]	李敏清, 张广清. 术前功能锻炼对全膝关节置换患者术后康复效果影响的Meta分析[J]. 中国老年学杂志, 2018, 38(15): 3676-3679.
	LI M Q, ZHANG G Q. Effect of preoperative functional exercise on postoperative rehabilitation in patients with total knee replacement:a meta-analysis[J]. Chin J Gerontol, 2018, 38(15): 3676-3679.
[17]	乔玉宁, 谢秋娟, 丁敏华, 等. 早期肌力锻炼对人工全膝关节置换术患者康复的影响[J]. 上海护理, 2014, 14(5): 14-16.
	QIAO Y N, XIE Q J, DING M H, et al. Influence of early muscle training on rehabilitation in patients with total knee arthroplasty[J]. Shanghai Nurs, 2014, 14(5): 14-16.
[18]	AN J, RYU H K, LYU S J, et al. Effects of preoperative telerehabilitation on muscle strength, range of motion, and functional outcomes in candidates for total knee arthroplasty: a single-blind randomized controlled trial[J]. Int J Environ Res Public Health, 2021, 18(11): 6071. doi: 10.3390/ijerph18116071
[19]	BEAUPRE L A, LIER D, DAVIES D M, et al. The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty[J]. J Rheumatol, 2004, 31(6): 1166-1173. pmid: 15170931
[20]	CALATAYUD J, CASANA J, EZZATVAR Y, et al. High-intensity preoperative training improves physical and functional recovery in the early post-operative periods after total knee arthroplasty: a randomized controlled trial[J]. Knee Surg Sports Traumatol Arthrosc, 2017, 25(9): 2864-2872. doi: 10.1007/s00167-016-3985-5
[21]	KIM S, HSU F C, GROBAN L, et al. A pilot study of aquatic prehabilitation in adults with knee osteoarthritis undergoing total knee arthroplasty: short term outcome[J]. BMC Musculoskelet Disord, 2021, 22(1): 388. doi: 10.1186/s12891-021-04253-1
[22]	VAN LEEUWEN D M, DE RUITER C J, NOLTE P A, et al. Preoperative strength training for elderly patients awaiting total knee arthroplasty[J]. Rehabil Res Pract, 2014, 2014: 462750.
[23]	MCKAY C, PRAPAVESSIS H, DOHERTY T. The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study[J]. PM R, 2012, 4(9): 647-656. doi: 10.1016/j.pmrj.2012.04.012
[24]	MITCHELL C, WALKER J, WALTERS S, et al. Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial[J]. J Eval Clin Pract, 2005, 11(3): 283-292. pmid: 15869558
[25]	TUNGTRONGJIT Y, WEINGKUM P, SAUNKOOL P. The effect of preoperative quadriceps exercise on functional outcome after total knee arthroplasty[J]. J Med Assoc Thai, 2012, 95(Suppl 10): S58-S66.
[26]	陈红云, 贾晗, 陈嘉怡, 等. 术前长期功能锻炼对全膝关节置换术后康复效果的影响[J]. 实用医学杂志, 2014(24): 4031-4033.
[27]	CAVILL S, MCKENZIE K, MUNRO A, et al. The effect of prehabilitation on the range of motion and functional outcomes in patients following the total knee or hip arthroplasty: a pilot randomized trial[J]. Physiother Theory Pract, 2016, 32(4): 262-270. doi: 10.3109/09593985.2016.1138174 pmid: 27050325
[28]	DOMINGUEZ-NAVARRO F, SILVESTRE-MUNOZ A, IGUAL-CAMACHO C, et al. A randomized controlled trial assessing the effects of preoperative strengthening plus balance training on balance and functional outcome up to 1 year following total knee replacement[J]. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 838-848. doi: 10.1007/s00167-020-06029-x
[29]	EVGENIADIS G, BENEKA A, MALLIOU P, et al. Effects of pre- or postoperative therapeutic exercise on the quality of life, before and after total knee arthroplasty for osteoarthritis[J]. J Back Musculoskelet Rehabil, 2008, 21: 161-169. doi: 10.3233/BMR-2008-21303
[30]	HUBER E O, ROOS E M, MEICHTRY A, et al. Effect of preoperative neuromuscular training (NEMEX-TJR) on functional outcome after total knee replacement: an assessor-blinded randomized controlled trial[J]. BMC Musculoskelet Disord, 2015, 16: 101. doi: 10.1186/s12891-015-0556-8
[31]	JAKOBSEN T L, KEHLET H, BANDHOLM T. Reliability of the 6-min walk test after total knee arthroplasty[J]. Knee Surg Sports Traumatol Arthrosc, 2013, 21(11): 2625-2628. doi: 10.1007/s00167-012-2054-y
[32]	SKOFFER B, MARIBO T, MECHLENBURG I, et al. Efficacy of preoperative progressive resistance training on postoperative outcomes in patients undergoing total knee arthroplasty[J]. Arthritis Care Res (Hoboken), 2016, 68(9): 1239-1251. doi: 10.1002/acr.22825 pmid: 26713665
[42]	BROWN K, TOPP R, BROSKY J A, et al. Prehabilitation and quality of life three months after total knee arthroplasty: a pilot study[J]. Percept Mot Skills, 2012, 115(3): 765-774. doi: 10.2466/15.06.10.PMS.115.6.765-774
[43]	ROOKS D S, HUANG J, BIERBAUM B E, et al. Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty[J]. Arthritis Rheum, 2006, 55(5): 700-708. doi: 10.1002/(ISSN)1529-0131
[33]	MATASSI F, DUERINCKX J, VANDENNEUCKER H, et al. Range of motion after total knee arthroplasty: the effect of a preoperative home exercise program[J]. Knee Surg Sports Traumatol Arthrosc, 2014, 22(3): 703-709. doi: 10.1007/s00167-012-2349-z
[34]	GSTOETTNER M, RASCHNER C, DIRNBERGER E, et al. Preoperative proprioceptive training in patients with total knee arthroplasty[J]. Knee, 2011, 18(4): 265-270. doi: 10.1016/j.knee.2010.05.012 pmid: 20801047
[35]	WALLS R J, MCHUGH G, O'GORMAN D J, et al. Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study[J]. BMC Musculoskelet Disord, 2010, 11: 119. doi: 10.1186/1471-2474-11-119
[36]	ALGHADIR A, IQBAL Z A, ANWER S. Comparison of the effect of pre- and post-operative physical therapy versus post-operative physical therapy alone on pain and recovery of function after total knee arthroplasty[J]. J Phys Ther Sci, 2016, 28(10): 2754-2758. pmid: 27821929
[37]	AYTEKIN E, SUKUR E, OZ N, et al. The effect of a 12 week prehabilitation program on pain and function for patients undergoing total knee arthroplasty: a prospective controlled study[J]. J Clin Orthop Trauma, 2019, 10(2): 345-349. doi: 10.1016/j.jcot.2018.04.006
[38]	MAT E I M, SHARIFUDIN M A, SHOKRI A A, et al. Preoperative physiotherapy and short-term functional outcomes of primary total knee arthroplasty[J]. Singapore Med J, 2016, 57(3): 138-143. doi: 10.11622/smedj.2016055
[39]	HUANG L, GUO B, XU F, et al. Effects of quadriceps functional exercise with isometric contraction in the treatment of knee osteoarthritis[J]. Int J Rheum Dis, 2018, 21(5): 952-959. doi: 10.1111/1756-185X.13082 pmid: 28544687
[40]	BLASCO J M, ACOSTA-BALLESTER Y, MARTINEZ-GARRIDO I, et al. The effects of preoperative balance training on balance and functional outcome after total knee replacement: a randomized controlled trial[J]. Clin Rehabil, 2020, 34(2): 182-193. doi: 10.1177/0269215519880936
[41]	TOPP R, SWANK A M, QUESADA P M, et al. The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty[J]. PM R, 2009, 1(8): 729-735. doi: 10.1016/j.pmrj.2009.06.003

纳入文献	①	②	③	④	⑤	⑥	⑦	⑧	⑨	⑩	⑪	评分
罗欢等^[1](2022)	否	是	是	否	是	是	是	是	是	不清楚	否	7.5
Wang等^[8](2021)	否	是	是	否	是	是	是	是	是	是	是	9
Kwok等^[9](2015)	否	是	是	否	是	是	是	是	是	否	否	7
Silkman等^[10](2012)	否	是	是	否	是	是	是	是	是	是	否	8
张慧等^[11](2017)	否	是	是	否	是	是	是	是	是	不清楚	否	7.5
Chen等^[12](2018)	否	是	是	否	是	是	是	是	是	是	是	9
Wu等^[13](2022)	是	是	是	否	是	是	是	是	是	是	是	10
Ma等^[14](2018)	否	是	是	否	是	是	是	是	是	是	是	9
Su等^[15](2022)	是	是	是	否	是	是	是	是	是	是	是	10
李敏清等^[16](2018)	否	是	是	是	是	是	是	是	是	不清楚	否	8.5

结局指标	纳入研究数/n	异质性		效应模型	Meta分析
结局指标	纳入研究数/n	P值	I²值	效应模型	MD/SMD	95%CI	P值
膝关节功能
WOMAC	8	< 0.01	87%	随机	-1.34	-1.94~-0.74	< 0.001
HSS	3	< 0.01	76%	随机	-1.04	-1.69~-0.40	0.001
ROM
主动伸展	8	0.16	33%	固定	-0.02	-0.20~-0.16	0.830
主动屈曲	11	< 0.01	85%	随机	2.99	-0.70~6.69	0.110
疼痛
VAS	5	0.06	57%	随机	-0.50	-0.93~-0.17	0.005
KOOS	5	0.20	34%	固定	0.25	-0.07~0.57	0.130
WOMAC	8	< 0.01	81%	随机	-0.29	-0.75~0.17	0.220
住院时间	5	< 0.01	72%	随机	-1.01	-1.66~-0.36	0.002
股四头肌肌力
术后2个月	6	0.15	38%	固定	0.09	-0.21~0.38	0.560
术后3个月	5	0.21	32%	固定	0.63	0.30~0.97	< 0.001
生活质量	5	0.13	44%	固定	-2.36	-7.03~2.32	0.320
运动功能
TUGT	7	< 0.01	82%	随机	-0.61	-1.14~-0.09	0.020
6MWT	3	0.20	38%	固定	-0.22	-0.60~0.16	0.260