変形性膝関節症に対する足底板の効果

【文献】

Van Raaij TM et al. Medial knee osteoarthritis treated by insoles or braces: a randomized trial. Clin Orthop Relat Res. 2010 Jul;468(7):1926-32. Epub 2010 Feb 23.


【要約】

<BACKGROUND> 

There is controversial evidence regarding whether foot orthoses or knee braces improve pain and function or correct malalignment in selected patients with osteoarthritis (OA) of the medial knee compartment. However, insoles are safe and less costly than knee bracing if they relieve pain or improve function.

<QUESTIONS/PURPOSES>

We therefore asked whether laterally wedged insoles or valgus braces would reduce pain, enhance functional scores, and correct varus malalignment comparable to knee braces.

<PATIENTS AND METHODS>

We prospectively enrolled 91 patients with symptomatic medial compartmental knee OA and randomized to treatment with either a 10-mm laterally wedged insole (index group, n = 45) or a valgus brace (control group, n = 46). All patients were assessed at 6 months. The primary outcome measure was pain severity as measured on a visual analog scale. Secondary outcome measures were knee function score using WOMAC(http://p.tl/nihq) and correction of varus alignment on AP whole-leg radiographs taken with the patient in the standing position. Additionally, we compared the percentage of responders according to the OMERACT-OARSI criteria for both groups.

<RESULTS>

We observed no differences in pain or WOMAC scores between the two groups. Neither device achieved correction of knee varus malalignment in the frontal plane. According to the OMERACT-OARSI criteria, 17% of our patients responded to the allocated intervention. Patients in the insole group complied better with their intervention. Although subgroup analysis results should be translated into practice cautiously, we observed a slightly higher percentage of responders for the insole compared with bracing for patients with mild medial OA.

<CONCLUSIONS>

Our data suggest a laterally wedged insole may be an alternative to valgus bracing for noninvasively treating symptoms of medial knee OA.

【開催日】

2011年5月25日

減量、運動、その両方と、肥満高齢者の身体機能

【文献名】

Villareal DT et al.Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.

The NEW ENGLAND JOURNAL of MEDICINE 2011 364;13 1218-1229


【要約】

<背景>

肥満は年齢による身体機能の低下を助長する。そうなると高齢者では脆弱性の原因となり、QOLは低下し、老人ホームに入所につながる。しかし肥満高齢者に対する減量のエビデンスはない。


<目的>

食事療法と運動療法で、肥満高齢者の身体機能は改善されるのかを知る。


<デザイン>

randomized controlled trial  観察期間は52週間(1年間)


<対象>

志願したBMI30以上の、65歳以上の高齢者107人


<介入>

全ての参加者にカルシウム1500mg/日、ビタミンD1000IU/日を投与。

①コントロール(毎月のフォローの際に健康的な食事の一般的な情報提供のみ)

②食事療法のみ(500?750kcal減。毎週集まり、食事療法、行動療法を受ける。)
③運動療法のみ(PTによる毎週90分のエアロビ、負荷訓練、柔軟、バランス。)

④食事と運動(②+③)


<アウトカム>

・Primary outcome:modified Physical Performance Test(以下PPT)= 9つの作業

・Secondary outcome:VO2peak 、Functional Status Questionnaire、体格(体重、脂肪重量、大腿の筋量、大腿脂肪重量)、骨塩濃度、強度/バランス/歩容specific physical function、QOL(36-item short-form health survey)


<解析>

ITT解析されている(Figure 1. p1222)


<結果>

参加者のcharacteristicsは有意差なし(Table 1 p1223)
追跡率93人/107人=87%
 


○Primary outcome
modified Physical Performance Testの上昇
・PPTでは④>②、③。更に②、③、④>①
○Secondary outcome

・VO2peak ④>②、③
 ・Functional Status Questionnaireでは④>②

・減量:②食事で10%、④で9%、①と③は減らなかった。

・減量と骨塩密度(骨盤)の低下:④<②

・強度/バランス/歩容の改善は④>①②③

・副作用は、運動による筋骨格系の怪我を含め、少数。


<discussion>

・まとめ:肥満高齢者に対し、食事療法、運動療法は単独でも身体機能を改善し、前弱性を改善させる。しかし減量と一般的な運動を組み合わせることで、単独よりもさらに身体機能が改善されるかもしれない。

・副作用:食事療法で骨塩量低下。
運動療法で怪我。事前に評価することで防げる。

・強み :randomized controlled trial、介入期間が長い、主観的/客観的身体機能評価を使用

高い追跡率

・limitation:志願者による研究なので、一般的な肥満高齢者に適応できないかもしれない

サンプルサイズが小さいため、高い教育を受けた白人女性が多いため、一般的な肥満高齢者に適応できないかもしれない。脆弱性が高い高齢者に、今回の介入が安全かは述べていない


【考察とディスカッション】

日本でも65歳以上の肥満者は、ある程度散見される印象である。この論文から、高齢者においても食事療法、運動療法はQOLの改善において有効である可能性がある事がわかった。外来でであう患者をこの論文に適応できるかは、人種が当てはまらない。また患者の身体機能を詳細に評価しなければ今回の研究の参加者と同程度なのかは分からない。
 若年者でも特定健診を行って、肥満患者を中心に食事療法、運動療法にて介入される事がある。若年者では生活習慣病からの脳梗塞、心筋梗塞などの主要臓器の致死的な疾患の予防が目的だが、この論文では高齢者では身体機能、QOLの改善が目的である。

以下、全体でのディスカッション。

日本の保険診療の枠で同様の運動を作り出す(理学療法士)のは難しい。コミュニティの力を利用したい。


【開催日】

2011年5月25日

プライベートで親しい患者さんをみる際に気をつけること

【文献名】

Patients, Friends,and Relationship Boundaries

JAMES T.B. ROURKE, MD, MCLSC(FM) LINDSAY F.P. SMITH, MB, CHB, MRCGP

JUXDITH BELLE BROWNN, PHD

Can Fam Physician 1993;39:2557-2565


【要約】

When patient and physician are close friends, both professional and personal relationships can suffer. Jointly exploring and setting explicit boundaries can help avoid conflict and maintain these valuable relationships.

This is particularly important when the physician practises in a small community where such concurrent relationships are unavoidable.


※※※※※※※※※※※※※※※※※※※※※※※※※※※※※※※※※※


Does being friends with a patient”obscure judgment, and produce timidity and irresolution” in the physician’s practice?
When a patient is also a physician’s personal friend, the physician has obligations within both of these relationships.The obligations that we have to our friends are at two levels’

1) personal social obligations:We should respect the autonomy of others, not harm them, and be just in our dealings with them.
2) we have additional obligations to our personal friends: to do them good, to trust them, and to be loyal to them.

A)the patient-physician professional relationship:
To them we should offer medical beneficence; and for them we should acquire and use expertise appropriately , maintain the standards of the profession and practise accordingly, practise for their benefit (fiduciary relationship), be compassionate, and also, perhaps, be just in distributing health care.

B)Patient’s obligations have social obligations and those of friendship as do physicians.

<Introduction of cases>

1)The patient kept overstepping the boundaries that the physician tried unilaterally to establish
between their professional and personal relationships.
2) This case shows how a patient can set boundaries to a physician’s obligations, presumably to preserve
their friendship and their professional (but now limited) relationship.

3) Physicians in particular need to be aware of possible transference and countertransference
issues activated by life cycle changes.

4) They have developed and continue a mutually satisfactory business relationship and an enjoyable
personal friendship centred on their recreational activities.


<Practical implications for physicians>

1)”Am I too close to probe my friend’s intimate history and physical being and to cope with bearing bad news if need be?” (eg, take a psychiatric history, perform vaginal or rectal examinations,care for a terminal illness).

2) “Can I be objective enough to not give too much, too little, or inappropriate
care?” (eg, overinvestigate due to inappropriate anxiety).

3) “Will my friend comply with my medical care as well as he or she would with the care of a physician who was not a friend?” (eg, familiarity might lead to noncompliance).


<Relationship boundaries>

One of the easiest and most appropriate boundaries to set is that of dealing with patient problems only within the appropriate setting, ie, only at the office or hospital.


【開催日】

2011年5月18日

精神科・行動科学領域での事例の振り返りはレジデントに何をもたらすか

【文献名】
Cheri Bethune , Judith Belle Brown
Residents’ use of case-based reflection exercises.
Can Fam Physician Vol. 53, No. 3, March 2007, pp.470 – 476

【要約】
<OBJECTIVE>
Qualitative exploration of the experience of family practice residents in using semi structured case-based reflection exercises as a learning medium.

<DESIGN>
Qualitative study using in-depth interviews.

<SETTING>
Memorial University’s Family Medicine Residency Program in St John’s, Newfoundland.

<PARTICIPANTS>
Graduates of the residency program who had taken part in a pilot project that involved completion of case-based reflection exercises as a medium for enhancing learning.

<METHOD>
In-depth interviews were conducted with graduates who had used the reflection exercises during their postgraduate training. All participants were in active practice. All of the audiotaped interviews were transcribed verbatim. Thematic analysis continued until saturation was reached.

<MAIN FINDINGS>
Eight interviews were conducted that included 5 women and 3 men. Three themes emerged from the data analysis: effect on the learning process, effect on the patient-doctor relationship, and effect on the learner.

<CONCLUSION>
The experience of using the reflection exercises appeared to affect how family practice residents learned. Three major themes emerged: the reflection exercises as a continuing education process offered participants a strategy for future learning in practice; the exercises offered a different perspective on the patient-doctor interaction that had doctors looking forcues to deeper meaning; and the exercises engaged the learners in a reflective process that revealed qualities about themselves that gave them personal insight. These reflective strategies have relevance for all physicians in their attempts to incorporate new knowledge and understanding into their practices. Similar dimensions are articulated in the educational literature, and this study supports the usefulness of case-based reflection as a catalyst in the education of family physicians.

【開催日】
2011年2月9日

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