英国爱丁堡大学David F Hamilton团队研究了针对性康复治疗对有不良预后风险的全膝关节置换术后患者预后的影响。2020年10月13日，该成果发表在《英国医学杂志》上。

为了针对全膝关节置换术后预后较差的患者，评估门诊理疗的渐进性疗程是否能提供优于单次理疗审查后基于家庭锻炼的干预效果，研究组在英国的13个二级和三级治疗中心进行了一项平行组随机对照试验。

研究组共招募了334名膝骨关节炎参与者，根据牛津膝关节评分，在术后6周被定义为全膝关节置换术后有不良预后的风险。将其随机分组，其中163名患者接受理疗师主导的门诊康复（六周内做18次），171名患者接受单次理疗审查后基于家庭锻炼的方案。主要结局是52周时的牛津大学膝关节评分，若两组间差异超过4分，则被认为具有临床意义。

共有8人失访，干预组依从率超过85%。52周时牛津膝盖评分的组间差异为1.91分，门诊康复组略占优势。分析所有时间点数据后，牛津膝关节评分的组间差异为2.25分，没有临床意义。在52周或更早的时间点，两组间平均疼痛、严重疼痛、对结果满意度或干预后功能等次要结局均无显著差异。

总之，对于全膝关节置换术后有不良预后风险的患者，门诊治疗师主导的康复治疗并不优于单次物理治疗师审查后以家庭锻炼为基础的治疗方案。

附：英文原文

Title: Targeting rehabilitation to improve outcomes after total knee arthroplasty in patients at risk of poor outcomes: randomised controlled trial

Author: David F Hamilton, David J Beard, Karen L Barker, Gary J Macfarlane, Christopher E Tuck, Andrew Stoddart, Timothy Wilton, James D Hutchinson, Gordon D Murray, A Hamish R W Simpson

Issue&Volume: 2020/10/13

Abstract:

Objective To evaluate whether a progressive course of outpatient physiotherapy offers superior outcomes to a single physiotherapy review and home exercise based intervention when targeted at patients with a predicted poor outcome after total knee arthroplasty.

Design Parallel group randomised controlled trial.

Setting 13 secondary and tertiary care centres in the UK providing postoperative physiotherapy.

Participants 334 participants with knee osteoarthritis who were defined as at risk of a poor outcome after total knee arthroplasty, based on the Oxford knee score, at six weeks postoperatively. 163 were allocated to therapist led outpatient rehabilitation and 171 to a home exercise based protocol.

Interventions All participants were reviewed by a physiotherapist and commenced 18 sessions of rehabilitation over six weeks, either as therapist led outpatient rehabilitation (progressive goal oriented functional rehabilitation protocol, modified weekly in one-one contact sessions) or as physiotherapy review followed by a home exercise based regimen (without progressive input from a physiotherapist).

Main outcome measures Primary outcome was Oxford knee score at 52 weeks, with a 4 point difference between groups considered to be clinically meaningful. Secondary outcomes included additional patient reported outcome measures of pain and function at 14, 26, and 52 weeks post-surgery.

Results 334 patients were randomised. Eight were lost to follow-up. Intervention compliance was more than 85%. The between group difference in Oxford knee score at 52 weeks was 1.91 (95% confidence interval 0.18 to 3.99) points, favouring the outpatient rehabilitation arm (P=0.07). When all time point data were analysed, the between group difference in Oxford knee score was a non-clinically meaningful 2.25 points (0.61 to 3.90, P=0.01). No between group differences were found for secondary outcomes of average pain (0.25 points, 0.78 to 0.28, P=0.36) or worst pain (0.22 points, 0.71 to 0.41, P=0.50) at 52 weeks or earlier time points, or of satisfaction with outcome (odds ratio 1.07, 95% confidence interval 0.71 to 1.62, P=0.75) or post-intervention function (4.64 seconds, 95% confidence interval 14.25 to 4.96, P=0.34).

Conclusions Outpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. No clinically relevant differences were observed across primary or secondary outcome measures.

DOI: 10.1136/bmj.m3576

Source: https://www.bmj.com/content/371/bmj.m3576