K. Tsikopoulos, 424 Army General Training Hospital and 2nd Orthopaedic Department, Papageorgiou General Hospital, Thessaloniki, Greece D. Mavridis, Department of Primary Education, University of Ioannina, Ioannina, Greece D. Georgiannos, 1st Orthopaedic Department, 424 Army General Training Hospital, Thessaloniki, Greece H. S. Vasiliadis, Kniechirurgie und Sportmedizin, Orthomotion Klinik, Thun, Switzerland.
Clin Orthop Relat Res. 2018 Jun;476(6):1295-1310. doi: 10.1097/01.blo.0000534691.24149.a2.
BACKGROUND: Although there are many nonsurgical treatment options for the primary management of chronic ankle instability, the most effective nonoperative intervention has not been defined. QUESTIONS/PURPOSES: The purpose of this study was to perform a network meta-analysis to compare the results of different standalone and/or combined nonsurgical interventions on chronic ankle instability as measured by (1) the Cumberland Ankle Instability Tool (CAIT) at 0 to 6 months after treatment and (2) treatment-related complications. METHODS: We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus in August 2017 for completed studies published between 2005 and 2016. We conducted random-effects pairwise and network meta-analysis considering randomized trials, which compared the effects of various nonoperative therapies for ankle instability. Studies assessing patients with functional ankle instability and/or mechanical ankle instability and/or recurrent ankle sprains were eligible for inclusion. After combining data from self-administered questionnaires, we analyzed patient self-reported outcomes of function at the end of the rehabilitation period and 1 to 6 months after treatment. We thereafter reexpressed standardized mean differences to mean differences with CAIT. For this instrument, scores vary between 0 and 30, and higher scores indicate better ankle stability. We included 21 trials involving 789 chronically unstable ankles. The rehabilitation interventions included, but were not limited to, balance training, strengthening exercises, a combination of the balance and strengthening exercises, manual therapy, and multimodal treatment. The implemented multistation protocols were targeted at four main areas of rehabilitation (ROM, balance, strength, and overall activity). Control was defined as placebo and/or wait and see. Treatment-related complications were defined as any major or minor adverse event observed after rehabilitation as reported by the source studies. Statistically, we did not detect significant inconsistency in the network meta-analysis. We also assessed the quality of the trials using the Cochrane risk of bias tool and judged 12, eight, and one studies to be at a low, unclear, and high risk of bias, respectively. We also considered the quality of evidence to be of moderate strength utilizing the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We defined the minimum clinically important difference (MCID) in the CAIT to be 3 points. RESULTS: A 4-week supervised rehabilitation program, which included balance training, strengthening, functional tasks, and ROM exercises, was favored over control according to the results of four trials by a clinically important margin (mean difference between multimodal and control groups in the CAIT was -10; 95% confidence interval [CI], -16 to -3; p = 0.001). Among the standalone interventions, only balance training was better than control according to the findings of seven trials (mean difference between balance training and control in the CAIT was -5; 95% CI, -10 to -0.03; p = 0.049); this difference likewise exceeded the MCID and so is believed to be a clinically important difference. Adverse events associated with the enrolled rehabilitation protocols were transient, mild, and uncommon. CONCLUSIONS: Although a supervised impairment-based program after chronic ankle instability was superior to control, we note that followup in the included trials tended to be short and inconsistent, although the effect size exceeded the MCID and so likely would be identified as clinically important by patients. Future randomized trials should determine whether the short-term benefits of these interventions are sustained over time. LEVEL OF EVIDENCE: Level I, therapeutic study.
背景:虽然有许多非手术治疗方法可用于慢性踝关节不稳定的主要治疗,但尚未确定最有效的非手术干预措施。
问题/目的:本研究旨在进行网络荟萃分析,比较不同的单一和/或联合非手术干预措施对慢性踝关节不稳定的治疗效果,通过(1)治疗后 0 至 6 个月的 Cumberland 踝关节不稳定工具(CAIT)和(2)治疗相关并发症进行评估。
方法:我们于 2017 年 8 月在 PubMed、Cochrane 对照试验中心注册(CENTRAL)和 Scopus 中检索了 2005 年至 2016 年期间发表的完成研究。我们进行了随机效应的两两和网络荟萃分析,考虑了比较各种非手术治疗方法对踝关节不稳定效果的随机试验。符合纳入标准的研究评估了具有功能性踝关节不稳定和/或机械性踝关节不稳定和/或复发性踝关节扭伤的患者。在合并自我管理问卷数据后,我们分析了康复治疗结束时和治疗后 1 至 6 个月患者的自我报告功能结果。我们随后将标准化均数差值重新表示为 CAIT 的均数差值。对于该工具,分数在 0 到 30 之间变化,分数越高表示踝关节稳定性越好。我们纳入了 21 项涉及 789 例慢性不稳定踝关节的试验。康复干预措施包括但不限于平衡训练、强化锻炼、平衡和强化锻炼的组合、手法治疗和多模式治疗。实施的多站方案针对康复的四个主要领域(ROM、平衡、力量和整体活动)。对照组定义为安慰剂和/或观察等待。治疗相关并发症定义为根据原始研究报告的康复后观察到的任何重大或轻微不良事件。从网络荟萃分析中我们没有发现统计学上的不一致性。我们还使用 Cochrane 风险偏倚工具评估了试验的质量,并分别判断 12、8 和 1 项研究为低、不确定和高风险偏倚。我们还考虑使用 Grading of Recommendations, Assessment, Development and Evaluations (GRADE) 方法评估证据的质量为中等强度。我们将 CAIT 的最小临床重要差异(MCID)定义为 3 分。
结果:四项试验的结果表明,为期 4 周的监督康复计划,包括平衡训练、强化、功能任务和 ROM 运动,优于对照组,具有临床重要意义(多模式与对照组在 CAIT 中的差值为 -10;95%置信区间,-16 至 -3;p = 0.001)。在单一干预措施中,只有平衡训练根据七项试验的结果优于对照组(CAIT 中平衡训练与对照组的差值为 -5;95%置信区间,-10 至 -0.03;p = 0.049);这种差异也超过了 MCID,因此被认为具有临床重要意义。纳入康复方案的不良事件是短暂的、轻微的和不常见的。
结论:尽管慢性踝关节不稳定后的监督性基于损伤的方案优于对照组,但我们注意到,纳入试验的随访时间往往较短且不一致,尽管效应量超过了 MCID,因此可能被患者认为具有临床意义。未来的随机试验应确定这些干预措施的短期益处是否能持续较长时间。
证据等级:一级,治疗性研究。
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