監督下的運動治療可能對髕股關節疼痛症候群有幫助

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　【24drs.com】October 29, 2009 — 根據一項發表在10月21日英國醫學期刊（BMJ）的隨機分派研究結果，在一般執業中，監督下的運動治療可能對髕股關節疼痛症候群有幫助。
　　
　　來自荷蘭鹿特丹Erasmus大學醫學中心的R. van Linschoten寫到，關於髕股關節疼痛症候群的病因學或是最適當的治療，目前並沒有共識。然
　　
　　而，一般的共識偏向非手術治療。在疼痛期間休息，且建議不要進行可能誘發疼痛的活動；荷蘭國家一般執業指引建議這種「休息以及持續觀察」的策略，且將其視為是常規照護。
　　
　　這項研究的目的在於比較監督下的運動治療與常規照護，對於131位有髕股關節疼痛症候群病患，在恢復、疼痛與功能上的療效。發生新髕股關節疼痛症候群的病患，被一般執業醫師或是運動醫師轉介，而隨機選擇到介入組（共65位）以及一般照護（共66位）組。
　　
　　介入組的病患參加持續6週的標準化運動課程，這些課程是根據個人表現量身訂做，並在物理治療師的監督下進行。除此之外，病患們被教導在家進行練習3個月。常規照護包括「休息與持續觀察」方法，以及在疼痛的時候休息，避免會造成疼痛的活動。這兩組病患都接受有關於髕股關節疼痛症候群的衛教資訊，以及有關於在家運動的一般指引。
　　
　　這項研究的主要試驗終點是在3個月與12個月後續追蹤時以7點李克特量表自我通報的恢復情形，以0~10分數字評量指標評估休息與活動時的疼痛情形、且以0~100分的Kujala髕股關節分數評量其功能。
　　
　　相較於控制組，介入組在3個月時的預後較佳，包括休息時的疼痛（校正後差異為-1.07；95%信賴區間[CI]為-1.92~-0.22；效果差異為0.47）
　　
　　、活動時疼痛（校正後差異為-1.00；95%信賴區間[CI]為-1.91~-0.08；效果差異為0.45）還有功能（校正後差異為4.92；95%信賴區間[CI]為0.14~9.72；效果差異為0.34）。
　　
　　12個月時的預後，介入組同樣比控制組好，包括休息時的疼痛（校正後差異為-1.29；95%信賴區間[CI]為-2.16~-0.42；效果差異為0.56）、活
　　
　　動時疼痛（校正後差異為-1.19；95%信賴區間[CI]為-2.22~-0.16；效果差異為0.54）但功能（校正後差異為4.52；95%信賴區間[CI]為-0.73~9.76）並無顯著差異。
　　
　　相較於控制組，運動組復原比例較高（3個月時，41.9%相較於35.0%，12個月時為62.1%相較於50.8%），但是這些差異並未達到統計上顯著
　　
　　水準。根據事先決定的次組分析，雖然由運動醫師（共30位）收納的病患並未因為運動而受益，由一般執業醫師收納的病患（共101位）在疼
　　
　　痛與功能上達到顯著且臨床上有意義的差異，偏向介入組。
　　
　　研究作者們寫到，在一般執業，監督下的運動治療在短期與長期後續追蹤中，相較於接受常規照護的髕股關節疼痛症候群病患，疼痛比較少且
　　
　　功能也比較好。運動治療在自我通報的恢復上，並沒有顯著差異。
　　
　　這項試驗的限制包括沒有雙盲、運動醫師收納的病患樣本數目太小、接受物理治療的控制組中有8位病患違反試驗計劃。
　　
　　研究作者們的結論是，未來的研究應該釐清運動治療使預後改善的機轉。
　　
　　ZON-MW（荷蘭健康研究與發展組織）贊助這項研究。研究作者們表示已無相關資金上的往來。

Supervised Exercise Therapy May Be Helpful for Patellofemoral Pain Syndrome

By Laurie Barclay, MD
Medscape Medical News

October 29, 2009 — Supervised exercise therapy may be helpful in treatment of patellofemoral pain syndrome in general practice, according to the results of an open-label, randomized controlled trial reported in the October 21 issue of the BMJ.

"There is no agreement concerning the aetiology of patellofemoral pain syndrome or the most appropriate treatment," write R. van Linschoten, from Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues. "There is, however, general consensus that the preferred treatment approach is non-surgical. Rest during periods of pain and refraining from pain-provoking activities are advised; this 'wait and see' approach is advocated in the Dutch national GP [general practice] guidelines and is considered usual care."

The goal of this study was to compare the efficacy of supervised exercise therapy vs usual care for 131 patients with patellofemoral pain syndrome, in recovery, pain, and function. Patients who had a new episode of patellofemoral pain syndrome were recruited by their general practitioner (GP) or sports physician and randomly selected to the intervention group (n = 65) or to usual care (n = 66).

In the intervention group, patients took part in a standardized exercise program for 6 weeks. This was tailored to individual performance and supervised by a physical therapist. In addition, patients were instructed to practice the tailored exercises at home for 3 months. Usual care consisted of a "wait and see" approach, with rest during periods of pain and avoiding activities that caused pain. Patients in both groups received written information about patellofemoral pain syndrome and general instructions regarding home exercises.

The main endpoints of the study at 3-month and 12-month follow-up were self-reported recovery on the 7-point Likert scale, pain at rest and during activity on a 0- to 10-point numeric rating scale, and function measured with a 0- to 100-point Kujala patellofemoral score.

Outcomes at 3 months were better in the intervention group vs the control group in pain at rest (adjusted difference, ?1.07; 95% confidence interval [CI], ?1.92 to ?0.22; effect size, 0.47), pain during activity (adjusted difference, ?1.00; 95% CI, ?1.91 to ?0.08; effect size 0.45), and function (adjusted difference, 4.92; 95% CI, 0.14 - 9.72; effect size, 0.34).

Outcomes at 12 months continued to be better in the intervention group vs the control group in pain at rest (adjusted difference, ?1.29; 95% CI, ?2.16 to ?0.42; effect size, 0.56) and pain during activity (adjusted difference, ?1.19; 95% CI, ?2.22 to ?0.16; effect size 0.54) but not function (adjusted difference, 4.52; 95% CI, ?0.73 to 9.76).

Recovery was reported by more patients in the exercise group vs the control group (41.9% vs 35.0% at 3 months and 62.1% vs 50.8% at 12 months), but these differences were not statistically significant. Although patients recruited by sports physicians (n = 30) did not benefit from the intervention, those recruited by GPs (n = 101) had significant and clinically meaningful differences in pain and function favoring the intervention group, according to predefined subgroup analyses.

"Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice," the study authors write. "Exercise therapy did not produce a significant difference in the rate of self reported recovery."

Limitations of this study include lack of blinding, small numbers of patients recruited by sports physicians, and protocol violation by 8 patients in the control group who received physical therapy.

"Further research should aim to elucidate the mechanisms whereby exercise therapy results in better outcome," the study authors conclude.

ZON-MW (the Netherlands organization for health research and development) supported this study. The study authors have disclosed no relevant financial relationships.

BMJ. 2009;339:b407.