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標題: | 運動訓練合併飲食介入對老年下肢退化性關節炎患者之成效 Effects of Exercise Training Combined with Diet Intervention for Older Adults with Lower Extremity Osteoarthritis |
作者: | Chun-De Liao 廖峻德 |
指導教授: | 吳晏慈(Yen-Tzu Wu) |
關鍵字: | 肌少症,退化性關節炎,飲食介入,運動訓練,減重,瘦肉質量,活動功能預後, sarcopenia,osteoarthritis,diet intervention,exercise training,lean mass,physical function, |
出版年 : | 2020 |
學位: | 博士 |
摘要: | 研究背景
下肢退化性關節炎為老年人常見的肌肉骨骼系統病症,其主要病徵為疼痛,進而導致肌肉無力、身體活動功能低下與失能。近年來多數學者認為退化性關節炎之肌肉無力、活動功能低下以及疾病嚴重程度皆與老年肌肉質量減損有密切關聯,因此退化性關節炎老年有潛在發生肌少症(sarcopenia)之危險。此外,肥胖亦為老年退化性關節炎之危險因子。退化性關節炎老年面臨多重風險因子,確認跨專業介入的有效性和效率極為重要,得以使此老年族群達到健康狀態。 過去研究顯示在肌少症或肥胖症老人患者的運動訓練期間,同時給予飲食介入(diet intervention)包括蛋白質營養補給(protein supplement)與減重(weight loss),可以更加提升運動後肌肉質量增長與力量強化。針對老年人下肢膝或髖之退化性關節炎,過去已經有相當多的研究探討其運動訓練療效,包括阻力訓練與複合式運動訓練(multicomponent exercise training),系統性回顧及統合分析的結果顯示,相較於無運動介入之對照組,接受肌力強化訓練的實驗組老人,能夠有效增加身體瘦肉的質量、肌肉厚度與肌肉截面積。然而,結合飲食介入(包括蛋白質營養補給與減重)與運動訓練的治療方式,對於罹患下肢退化性關節炎的老年患者,是否為有效益的介入方法尚未清楚,因此本研究擬應用系統性回顧及統合分析方法,探討飲食介入合併運動訓練對於老年人罹患下肢退化性關節炎的整體效益,並且比較各種飲食介入(白質營養補給與減重)與運動訓練(阻力訓練與複合式運動訓練)合併模式之相對效益。 研究目的 本論文研究目的為(1)應用系統性回顧及統合分析方法,探討飲食介入(diet intervention)合併運動訓練,對下肢退化性關節炎之老年患者的肌肉質量與臨床預後(包括疼痛、肌力、身體活動功能以及日常生活功能等)之介入效益;(2)應用次群組分析(subgroup analysis)檢驗影響介入效益的因子,包括性別、運動訓練型式(阻力訓練與複合式訓練)、飲食介入方式(蛋白質補充與減重)、介入時間週期等;(3)應用統合迴歸分析方法,探討下肢退化性關節炎之老年患者,在接受飲食介入合併運動訓練後,其肌肉質量增加改變量與治療效果量(包括疼痛、肌力、身體活動功能以及日常生活功能等)之間的關聯;(4) 應用網絡統合分析(network meta-analysis)檢定各種飲食介入方式及運動訓練模式之相對治療效益。 研究方法 本研究將以系統性文獻回顧與統合分析方法,分析飲食介入合併運動訓練介入對下肢退化性關節炎老年之成效。研究遵循Preferred Reporting Items for Systematic Reviews and Meta-Analysis的指引,使用多種數位研究資料庫進行線上檢索,檢索時間區段是從該數據庫最早的時間至2020年01月31日。以探討飲食介入合併運動訓練之療效的隨機對照試驗研究為標的,其研究對象為60歲以上且具有退化性膝或髖關節炎之診斷的老年人。主要預後因子為肌肉質量(muscle mass),包括瘦肉質量、瘦肉質量指數、肌肉厚度與肌肉截面積。次要預後因子為疼痛、手握力、下肢肌力、步行速度、下肢活動、日常生活功能、關節炎發炎因子以及生成激素。研究使用PEDro量表評估偏倚風險,使用漏斗圖和視覺評估法驗證出版偏誤,以及使用Q test及I2 index評估異質性。本研究將使用Review Manager 5.3版軟體進行配對統合分析(pairwise meta-analysis),以標準化加權平均差(standard mean difference)呈現連續性預後因子的資料。此外,將建立逆方差加權(inverse-variance weighting)統合回歸模型,以檢驗肌肉質量增加與臨床預後因子治療效果量的關聯。最後,使用R語言統計軟體進行網絡統合分析(network meta-analysis)檢定各種飲食介入方式及運動訓練模式之相對治療效益。此研究結果能夠提供飲食介入合併運動訓練對下肢退化性關節炎之實證療效,將有助於臨床醫療人員擬定適合此疾患之老年患者的治療策略。 研究結果 本研究收納38篇隨機對照試驗研究。 偏倚風險PEDro量表分數之中位數(median)為7/10 (range 3/10 to 9/10)。 配對統合分析結果顯示,與控制組比較,飲食介入合併運動訓練對於肌肉質量增加(SMD = 0.67; 95%CI: 0.41–0.93, P < 0.00001)、疼痛減緩(SMD = 1.07; 95% CI: 0.72−1.41, P < 0.00001)、肌力增加(SMD = 0.58; 95% CI: 0.32−0.83; P < 0.0001)、步行能力增加(SMD = 0.61; 95% CI: 0.26−0.96; P = 0.0007)、整體功能增進(SMD = 1.20; 95% CI: 0.78−1.61; P < 0.00001)、關節炎發炎因子(C-reactive protein reduction; SMD = 0.24; 95% CI: 0.12−0.35; P < 0.0001)以及促進生長激素分泌(SMD = 1.53; 95% CI: 0.42−2.63; P = 0.007)具有顯著效益。統合回歸分析結果顯示,肌肉質量改變量與肌力效果量(β = 0.11, 95% CI: 0.05, 0.17; P = 0.01)以及整體功能效果量(β = 0.06, 95% CI: 0.02, 0.10; P = 0.02)呈現顯著關聯。網絡統合分析結果顯示,與控制組比較,蛋白質補給合併阻力訓練對於肌肉質量增長具有最好之效益(SMD = 1.61, P-score = 0.94),其次依序為蛋白質補給合併複合式運動訓練(SMD = 1.03, P-score = 0.78)、減重合併複合式運動訓練(SMD = 0.87, P-score = 0.70)以及減重合併阻力訓練(SMD = 0.79, P-score = 0.63). 研究討論 針對下肢退化性關節炎老年,飲食介入合併運動訓練介入對肌肉質量增長與臨床預後具有顯著效益。本研究進一步發現,肌肉質量增加量對於肌力以及整體功能之治療效果量具有正面之貢獻。最後,本研究比較各種飲食介入合併運動訓練介入模式,結果顯示蛋白質補給合併複合式運動訓練以及減重合併複合式運動訓練之介入模式分別對人工節置換術患者以及輕中度退化性關節炎老年之肌肉質量增長可以發揮最大治療效益。 Background and Rationale Lower-extremity osteoarthritis (OA) is a prevalent musculoskeletal disease in elder population. The main symptom of OA is pain which leads to muscle weakness and physical disability. Recently, most studies indicated that muscle weakness, function limitation, and severity of disease are closely associated with ageing-related muscle attenuations. Therefore, elder individuals with OA have potential sarcopenia risks. In addition, obesity which exert negative imapcts on disease outcomes has become a burden in OA population. Under multifactor risks of OA, it is important to identify effectiveness and efficiency of multidesplinary management for such elder population to achieve healthy status. Previous studies have indicated that Diet intervention (DI) using protein supplement (PS) or weight loss (WL) enhances exercise efficacy by additionally increasing muscle mass and strength for elder individuals with high sarcopenia and frailty risks who were undergoing exercise training (ET). Previous studies showed that ET facilitates myoprotein synthesis and increases muscle hypertrophy that ultimately result in muscle mass gains and improvement of physical functions in older individuals with lower-extremity OA; results of the latest meta-analysis study showed that the OA patients receiving ET experienced greater increases in muscle mass [standard mean difference (SMD) = 0.49, 95% CI: 0.28, 0.71; P < 0.0001], muscle thickness (SMD = 0.82, 95% CI: 0.20, 1.43; P = 0.009), and muscle cross-sectional area (SMD = 0.80, 95% CI: 0.25, 1.35; P = 0.004), compared with the controls of non-exercise peers. However, it remains unclear whether DI in combination with ET augments benefits in lean mass, strength, and physical function of older adults with lower extremity OA. In addition, few systematic reviews and meta-analysis studies regarding the effects of DI plus ET that have emphasized on elder people with OA. Therefore, this study aimed to investigate whether DI plus ET exert benefial effects on functional outcomes in older individuals with lower-extremity OA by using the methods of systematic reviews and meta-analysis. Purpose The objectives of this thesis included (1) using pairwise meta-analysis to identify the effectiveness of DI plus ET on muscle mass and clinical outcomes including pain, muscle strength, physical mobility, patient-reported global function, inflammation factors, and anabolic hormones for older individules with lower-extremity OA; (2) to identify the potential factors related to the intervention effects on muscle mass, including gender, exercise types, DI type and dosage, and period of intervention; (3) to examine the associations between muscle mass increase and the effect size of several clinical outcome measures; (4) using network meta-analysis to determine the relative effects of various DI and ET interventions on muscle mass. Methods This study followed the guidline of Preferred Reporting Items for Systematic Reviews and Meta-Analysis. A comprehensive searching for RCTs was perfomed using several electronic databases during the periods of the earliest time to December 31st, 2019. The inclusion criteria for the RCTs were: (1) participants aged 60 years or older and received a radiographic diagnosis of hip or knee OA; (2) experimental groups received DI plus ET; (3) control groups received an ET with or without placebo supplement, an DI alone, or regular care. Primary outcome measures will include: (1) muscle mass, including lean body mass, fat free mass, skeletal muscle mass; (2) lean mass index and appendicular lean mass index; (3) muscle volume, muscle cross-sectional area, and muscle thickness. Secondary outcome measures will include pain, hand grip strength, leg strength, walk speed, physical mobility (such as timed up and go and chair rise), patient-reported global function outcome (such as the Western Ontario and McMaster Universities Osteoarthritis index and the Lequesne index), inflammation factors (such as C-reactive protein, interleukin-6), and anabolic hormones (such as growth hormone and testosterone). All pairwise meta-analyses were performed by Review Manager 5.3 (Cochrane collaboration, Oxford, UK). Results of continuous data for each outcome variable were presented as SMD. Risk of bias was assessed using the PEDro scale. Publication bias was assessed using the visual inspection of a funnel plot and the Egger’s regression asymmetry test with the SPSS, Version 17.0, statistical software (IBM, Armonk, NY, USA). Heterogeneity was assessed by Q test and I2 index. An inverse-variance weighted meta-regression model was established to assess the association between muscle mass increase and effect size (i.e., SMD) of clinical outcome measures. A frequentist framework network meta-analysis was performed using the “netmeta” package in R statistics to analyze the direct and indirect comparisons of different DI and ET interventions. Results The final sample consisted of 38 RCTs in this meta-analysis with a median PEDro score of 7/10 (range 3/10 to 9/10). Pairwise meta-analyses results showed that during an overall follow-up duration, the DI plus ET group achieved significant effects on muscle mass gains (SMD = 0.67; 95%CI: 0.41–0.93, P < 0.00001), pain relief (SMD = 1.07; 95% CI: 0.72−1.41, P < 0.00001), muscle strength gain (SMD = 0.58; 95% CI: 0.32−0.83; P < 0.0001), walk capability increase (SMD = 0.61; 95% CI: 0.26−0.96; P = 0.0007), global function recovery (SMD = 1.20; 95% CI: 0.78−1.61; P < 0.00001), C-reactive protein reduction (SMD = 0.24; 95% CI: 0.12−0.35; P < 0.0001), and growth hormone secretion (SMD = 1.53; 95% CI: 0.42−2.63; P = 0.007) compared to the control groups, regardless of methodological design. Meta-regression analyses showed that changes in muscle mass were significantly associated with the effect sizes of pain (β = 0.12; P = 0.001), muscle strength (β = 0.08; P = 0.003) and walking capability (β = 0.17; P = 0.04), respectively. The network meta-analysis demonstrated that PS plus RET was most likely the best option (SMD = 1.61, P-score = 0.94) for muscle mass gain compared to the regular-care control group, followed by PS plus RET (SMD = 1.03, P-score = 0.78), WL plus MET (SMD = 0.87, P-score = 0.70) and WL plus RET (SMD = 0.79, P-score = 0.63). Discussion DI plus ET exhibited significant effects on muscle mass and clinical outcomes for older individuals with OA. Our findings suggest that muscle mass gain after DI plus ET significantly contributes to the efficacy of the intervention on muscle strength and global function outcome. Furthermore, PS plus MET appears to be the optimal treatment strategy for those who were undergoing total joint replacement whereas WL plus MET is most preferred for those who experienced mild to moderate severity of OA disease. Therefore, we concluded that DI additional to ET may have extra effects to prevent or offset muscle loss and function decline for elder individuals with OA who have high sarcopenia risks. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/62406 |
DOI: | 10.6342/NTU202000990 |
全文授權: | 有償授權 |
顯示於系所單位: | 物理治療學系所 |
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