物理療法のEBM：臨床的推論・医療判断学

(1)

Japanese Physical Therapy Association

NII-Electronic Library Service

Japanese _Physioal _Therapy _Assooiation

理学療法学第

39

巻第

4

号

253 〜

256

頁

（

2012

年）

物理療法

の

EBM 　

臨床的推論

・

医療判断学

＊

GOH

Ah

−

Cheng

i

）

2 ）

要旨

　

Van

　

der

　

Vleuten

らによると

，

臨

床

的推

論

技術は

，

治

療

技

術

と同

様

に重要なものだと述べている

Ou

臨

床

的

推論

プロ

セスは

，

起きている問題の原囚を

特定

し

，

正しい治

_療

目的を設定し

，

さらに

最

適な治療技術を施すために重要なものであり

，

患者に治療を施す前に行われるものである

。

たとえ優れた技術をもった治療者であっても

．

適切な臨床的推論技術なしには効呆的な治療を患者に行うことはできない

。

適切な治療技術に関係する事項について述べることは

，

今回の目的ではない

．

しかし

，

よい臨床的推論技術が

，

治療結果を成功に

導

く前提条件であるということを認識することは重要である

。

理学療法士は

，

専門分野や臨床経験年数の違い

，

バイオメディカルサイエンスについての知識量により

，

様々_{な臨床的推論}プロセスが用いられている。これらの要素については

，

物理療法を例に用いながら述べていく。物理療法の臨床的推論プロセスは

，

図

1

に示した。ステップ

1

では

，

標的組織にどのような生物物理学的変化をもたらしたいかを決定する。たとえば急性損傷の場合

，

炎症過程において

，

熱感

，

発赤

，

疼痛

，

腫脹の

4

つの兆候がみられる。そのため

．

急性炎症の治療では

，

組織を冷やすことが必要となる

。

ステップ

1

で他に必要となるのは

，

生物物理学的変化をもたらすために

．

最適な物理療法介入がなんであるかを判断することである

，

今回の例では

，

寒冷療法

（

アイスパックやアイスマッ_サ

ー

ジ）が

，

損傷組織の温度を下げるためにもっともよく用いられる方法である

。

ステップ

2

では

，

標的組織に対し期待する生理学的効果を決定する

。

たとえば

，

組織湿度が

15

℃ まで減少した時には

．

血管収縮が起こり

，

血流が減少する

．一・

方

，

組織温度が

10

℃ まで減少するか

，

寒冷療法を

15

分以

．

ヒ行うと

，

］

II

［管拡張が起こり

，

結果として血流が増加する

。

このようなことから

，

求める生理学的効果が損傷組織周囲の

1

血流を減少することであれば

，

寒冷療法は

15

分以

．

ドとし

，

組織温度の減少は

15

℃ 程度とする

。

ステップ

1

と

2

で行われた決定により

，

ステップ

3

の臨床効果へ _と続いて行く

。

今回の例では

，

臨床効果は腫脹の減少により得ることができる。今まで述べた臨床的推論と医療判断プロセスは

，

物理療法を用い _たすべての治療法に用いることができる

．

効果的な治療効果を得るために

，

理学療法

．

［tは臨床場面での臨床的推論と医療判断学の重要性を理解することが必要である

。

Introduction

　

Evidence

−

based

_practice

is

defined

　as

‘

the　conscientious

，

explicit

，

　and　

judicious

　use　of　current 　

best

　evidence 玉n 　Inaking

decisions

　_about　

_tbe

　_care　_Qf　_an　

individ

_しlal 　

_palien

匸

．

tt　1）

．

Usually

，

the

focus

　of　evidence

−

based

_practice

has

been

　on

the

forlller

part

　of　

the

definition

，

〔｝n 　

finding

　and 　using 　the

‘

℃urrent 　

best

evidence

”

．

However

，

　equally 　

important

is

　the　

latter

part

　of

the　

definition

　on

“

making 　

decisions

”

about 　what 　

is

the

　most

appropriate 　

treatment

for

the

_patient

．

This

“

making 　

deci

−

sions

”

can　_also　

be

　_caUed

”

_clinical　reasollin9

”

and

」

℃

linieal

deci

一

＊

Clinical

　Reasoning 　and ¢ linical　Decision　

Making

in

ELectrophysicaI

AgentSl

）信州大学医学部保健学科理学療法学専准教授　〔〒

390 −

8621

長野県松本市旭

3 −

1

−

1

）

GOH

Ah

．

Cheng

．

　PhD ：

Department

　of　Physical　

Therapy

，

School

　of

HeaLth

Sciences

Shinshu

University

2

）国際物理療法学会　会長〔2009

．

　

−

2ell ）

GOH

Ah

．

Cheng

．

PhD

：

ISEAPT

【Intcrnati（maL 　

Society

ior

　Elec

−

trophysicat

Agents

in

Physical

　Therapy ）

　キ

ー

ワ

ー

ド：物理療法

，

臨床的推論

，

医療判断学

sion 　making

”

．

’

℃

linicat

Reasoning

”

is

dcfined

　as

‘

Lthe

　application 　of　

knowl

．

edge 　and 　clinica ］experience 　

towards

　a　clinical　

presentation

to

_derive

　_a　_solution

”

2レ

．

_Edwards

　_et _α

₁

．

3，　_also　

defined

　_clinical reasoning 　as　

”

the

th

｛nking 　and　

deciSion

−

rnaking 　

Process

that

are　used 　

in

　clinical　

_practice

’

t

Van

der

Vleuten

　and　

Newbie

　4｝

suggested 　

that

　c且

inical

　reasoning 　skills　are　as　

important

　as

clinical　

treatment

　ski 五

1s

．

Simitarly

，

Barrows

　and　

Feltovich

　5〕

suggested 　

that

　a　therapist

’

s　cHnica 且colnpetency 　

is

dependent

upon 　

the

　effec亡

iveness

　and 　efficiency 　of　clinical　reasoning

skills （

i

．

e

．

thinking

　and 　

decision

−

making 　

process

）as　wcll 　as

practical

　skills（

i

．

e

．

　assessment 　and 　

treatment

techniques

）

．

Be

−

fore

　any　

treatlnent

　can　

be

perforrned

　oll　

thc

patient

，

the

　clini

−

cal　reasoning 　

process

is

important

to

identify

し

be

　cause　of　

the

problem

，

the

　correct 　

treatment

　Qbjcctivcs 　as　well　as　

the

　most

apPropriate 　

treatment

techniqucs

to

　apPly

．

Without

proper

clinical　reasoning 　skills

，

　even 　

the

therapist

　witll　

the

　most

highly

　cornpetent 　

treatment

　skills　will　not　

be

　able　

to

provide

(2)

Japanese Physical Therapy Association

NII-Electronic Library Service

JapanesePhysical

254

TherapyAssociation

Table

l

SackewsG)

tt

tttttt

Grading

Criteria

pm.\debi\

za39tsce4e

level

ofevidence

for

treatmentrecommendation

Level

ofEvidence

Grade

ofRecommendation

la

lb

lc

2a

2b

2c

3a

3b

4

5

effective

treatment

to

the

patient.

to

competent

treatment

skilLsare

paper.

However,

it

is

important

calreasoning skMs are a eutcomes.

Physical

therapists

employ processes

depending

on

their

clinicat experience, and

the

biomedicat

sciences.

Thesa

relation

to

electrophysical agents

The

aim of

this

paper

is

to

dence"

for

seme of

the

discuss

the

clinicalreasoning related

to

EPA.

Current

Best

Evidence

According

to

Sackett's

atic reviews of randomized

the

highest

level

of evidence

for

In

recent

years,

there

have

published

with regards

to

ing

EPA

for

varieus

'

complete

discussien

of all

the

systematic reviews

is

not within

ever, evidence

from

systematic the

following

a.

Pain

control

{impairment)

b.

Increasing

muscle

c.

Increasing

fracture

d.

Improving

upper and

gic

patients

(activity

e.

Improving

swallowing

1. Pain

control

Systematic

review ef

RCTs

including

meta-analysis

Individuat

RCT

with narrow confidence

intervat

All

and none studies

Svstematic

review ofcohort studies

lndividual

cohort study and

low

quality

RCT

C)utcome

research study

Systematic

review of case-control studies

Indivldual

case-control study

Case-series,

poor

quality

cohort and case-colltret studies

Expert

opinTon

AABBBccccD

The

factors

that

contributc not within

the

scepe of

th{s

te

recognize

that

good

pre-requisite

to

successful

treatment

different

clinical reasoning

area of specialty,

their

level

of

extent of

their

knowledge

in

the

factors

wlll

be

diseussed

further

in

(EPA).

present

the

"current

besl

treatment

using

EPA,

as well as

to

process

in

treatment

procedures

level

of evidenee 6)

(Table

1),

contrelled

Lrials

_{RCTs)

represent

treatment

recommendation.

been

many systematic reviews

treatment

recommendation

us-impairments

and activity

limitations.

A

evidence related

to

EPA

from

the

scope of

this

paper.

reviews wiil

be

_presented

for

strcngth

(impairmenO

healing

rate

(disease)

lower

limb

runctien

in

limitatien)

(acrivity

limitution)

Managing

pain

symptorns

in

patients

with

both

acute and chronie

disorders

is

perhaps

one of

the

most common clinical application of

EPA,

In

asystematic review ef

14 RCTs

inves-tigating

]ew

level

laser

therapy

_(LLLT}

in

the

treatment

of

patients

with chrenic

_joint

disorclers,

Bjordat

et al.7) reported

that

LLLT

when applied within asuggested

dose

range can

significantly reduce

the

_pain

and

improve

the

health

status of

patients

with chronic

joint

disorders,

In

a meta-analysis comparing

different

treatments

for

acule

and cbronic

low

back

pain,

Machado

et al.8} reperted that

infrared,

transcutaneous

electrical nerve stimu]ation

_(TENS>,

LLLT

and

traction

were mere effective cempared with a pta-cebo

treatment

for

patients

with

both

acute and chronic

low

back

pain.

However,

shortwave

diathermy

was reperted to

be

ineffective8)

compared with

the

_placebe

treatment.

Converse-ly,

in

a simitar study on

TENS

in

the

treatment or chronic

low

back

pain

patients,

Khadilkar

etal, 9)reperted

that

the

ef

ficacy

ef

TENS

as an

isolated

treatment was

inconsistent

and

larger,

inulticenter

RCTs

were needed.

Graham

et al. 10)also

reported

inconsistent

results

for

mechanicat

traction

for

the

treatment

of

patients

with neck

disorders,

They

concluded

that

whi]e

there

was some evidence that traction was

effec-tive,

other studies

have

shown opposite results iO).

In

another systematic review on

patients

with osteoarthritis of

the

knee,

Bjordal

et al.ii} reported

that

TENS

and

LLLT

in

an

inten-sivc

2 to

4

weeks

treatment

program can resutt

in

clinically

signMcant short-term

pain

retief

for

_patients

with

OA

knees.

2. Increasing

musde strength

Roig

and

Reidi2)

performed

a systematic review

to

deter-mine

the

effect of electrical stimulation on Tnuscle

functiun,

muscle size,

fiber

characteristies and exercise performance

in

patients

with chronic obstructive

_pulmonary

disease

_(COPD).

They

reported

that

electrical stimulation was effeclive

in

(3)

Japanese Physical Therapy Association

NII-Electronic Library Service

JapanesePhysical Therapy Association

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JapanesePhysicalTherapy Association

256 -\utza\

temperature

to

about

15

℃

,

The

clinicalreasoning made

in

step

l

and step

2

will

even-tually

lead

to

step

3,

i.e.

the

clinicaleffect.

In

this

example,

the

clinicaleffeet

that

will

be

achieved

is

areduction

in

swelling.

The

clinical

decision

making

_process

is

the

same as

the

clinical reasoning

_process,

but

in

reverse

(see

Figure

1).

In

other words,

the

clinicat

decisien

making

_process

begins

with step

3,

i.e.

what

is

the

desired

clinical effect

that

the

Physicat

Therapist

would

like

to achieve

in

his

patient.

Usuatly,

this

can atso

be

referred to as the aim of treatment.

From

this

aim, the therapist must

decide

which

_{physiologicat}

effects are related to the aim of treatment

{Le.

step

2)

and what are the

biophysical

changes which will

_produce

this physiological

ef-fect

_(i.e.

step

1).

The

final

decision

would then

be

to select a

treatment modality that will

be

able to

_produce

biophysical

changes at

the

target

tissues,

Conclusion

There

is

good

evidence

from

systematic reviews and meta-analyses

that

many of

t]ie

EPA

treatment

are effective

in

the

treatment

ef

impairrnents

as well as activity

limitations,

Huw-ever, more

higher

_quality

research

is

needed

in

many areas of

EPA.

The

clinical reasoning and

decision

making

_precess

discussed

above can

be

applied

to

all

types

of

treatment

us-ing

EPA.

In

erder

to

achieve effective

treatment

outcomes,

physical

therapists

must understand

the

importance

of

clini-cal reasoning and

dccision

making

in

their

c]inical

practicc,

Reference

1}2)

3)4)5)

Sackett

DL, Rosenberg WM, etal,/Evidence

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iL

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Bacl[

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and mcta-analysis of randomised placebo-controlLed trials.

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function

in

COPD

-

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2009:

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485-495.

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ZB.

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fracture

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by

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current inthe rabbi[

fibula.

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Joint

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MolLon

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Ada

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Foengchomcheay

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HoLLghton

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A meta-analysis.

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Meilink

A. Hemmen

B, et al.:

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20e7;

物理療法のEBM：臨床的推論・医療判断学

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4

253

〜

256

（

2012

物 理 療 法

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