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					常任編集：斉藤秀之（医療法人筑波記念会リハビリテーション事業統括）
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		<div class="headers"><h3 class="current content">内容</h3><h3 class="preface">序文</h3><h3 class="indexes">主要目次</h3></div><section class="current content">PARTⅠでは変形性膝関節症の病態・軟骨代謝障害・痛み・エビデンス・手術療法について解説し，PARTⅡでは膝OAの運動学・運動力学的特徴と体幹・膝・足部・歩行から捉えた評価と治療戦略，慢性疼痛疾患として捉えた評価と治療戦略について解説し，PARTⅢではTKA後における体幹・膝・歩行から捉えた評価と治療戦略，HTO後，運動イメージ・運動観察，術後の筋緊張・動作パターンから捉えた評価と治療戦略を解説している．<br>☆図版72点，表組20点，モノクロ写真38点</section><section class="preface">序<br><br>「臨床思考を究めて，理学療法を極める！」<br>　大規模なコホート研究によると，本邦における変形性膝関節症の患者数は約2,500万人と推定されており，変形性膝関節症で苦しんでいる国民に対して，理学療法という手段を用いて貢献することは，理学療法士に与えられた宿命である．変形性膝関節症に対する治療ガイドラインもいくつか報告されているが，変形性膝関節症という大きなカテゴリーで捉えたガイドラインでは，さまざまな病態や症状を呈する個々の患者に対応することは，現段階では困難である．今後，変形性膝関節症をサブグループ化し，病態や症状で分類した小さなカテゴリーでエビデンスを構築していくことが重要である．<br>　本書では，変形性膝関節症に対する理学療法を保存的理学療法と術後理学療法に分け，さらにさまざまな視点からの治療戦略について述べている．運動器疾患に対する理学療法では，症状を呈している部分のみではなく，全身を評価し，治療していくことが重要であることは周知のことである．変形性膝関節症においても，結果として膝関節に加わるメカニカルストレスが増大したことがさまざまな症状を呈する第1の原因であり，そのメカニズムに関する臨床推論が基本的治療戦略となる．われわれはこれまでの教育の中で，疾患名から評価項目を抽出し，治療を展開すること，すなわち疾患ベースでの理学療法学を学んできた．しかし，変形性膝関節症だからこの評価項目，あるいはこの治療方法という思考過程では，臨床場面で思うような治療効果をあげることができない理学療法士も多いのではないだろうか．今後，疾患ベースから機能障害ベースの理学療法学へパラダイムシフトする必要がある．<br>　本書で書かれているさまざまな治療戦略は，可能な限り最新のエビデンスを用いるよう企画した．しかし，まだ，客観的に証明されていない，いわゆる定性部分（artの部分）も含まれており，今後，科学的に明らかにしていく必要がある．本書が目の前の患者に対して汗をかき，もがき苦しんでいる理学療法士の一助となれば幸いである．<br><br>平成26年5月<br>ゲスト編集　山田英司</section><section class="indexes">PartⅠ 変形性膝関節症とは？<br>1 理学療法的視点からみた変形性膝関節症の病態<br>　変形性関節症（OA）の定義とは？<br>　膝OAの頻度はきわめて高い<br>　なぜ膝OAは痛む？<br>　なぜ膝OAでは関節可動域（ROM）が低下するのか？<br>　膝OAではそれに見合う関節動揺性が存在しない！<br>　関節動揺性の存在が膝OAを悪化させる？<br>　真の関節動揺性の存在の程度は膝OAの進行を予測できる？<br>　動揺性が症状のない安定した膝を作り出す？<br>　膝OAでは歩行時の動的負荷が増大している<br>　関節固有受容感覚の悪化と前十字靱帯（ACL）損傷後の発症と進展<br>　ミニレクチャー 変形性膝関節症と筋力<br>2 変形性膝関節症の軟骨代謝障害<br>　はじめに<br>　関節軟骨の構造<br>　OAにおける蛋白分解酵素の役割<br>　軟骨細胞の変性，アポトーシス<br>　軟骨代謝における炎症の役割と蛋白分解酵素の発現機序<br>　軟骨下骨の構造<br>　終末糖化産物（AGEs）の影響<br>　軟骨下骨の代謝変化<br>　軟骨代謝の評価<br>　軟骨代謝と理学療法<br>3 変形性膝関節症の痛みの捉え方<br>　膝OAの疼痛をどのように捉える？<br>　単純X線による関節変形程度と疼痛は必ずしも比例しない<br>　疼痛の原因となる組織を同定するためには？<br>　鑑別すべき疼痛の評価と理学療法<br>　ミニレクチャー 痛みをとるための物理療法選択のコツ<br>4 変形性膝関節症における理学療法のエビデンスの現状<br>　EBMとエビデンス<br>　保存的理学療法のエビデンス<br>　術後理学療法のエビデンス<br>　エビデンスの臨床応用<br>5 変形性膝関節症に対する手術療法<br>　高位脛骨骨切り術（high tibial osteotomy：HTO）<br>　人工膝単顆置換術（unicompartmental knee arthroplasty：UKA）<br>　人工膝関節全置換術（total knee arthroplasty：TKA）<br>PartII 変形性膝関節症に対する保存的理学療法<br>1 変形性膝関節症の運動学・運動力学的特徴 <br>　初期接地〜荷重応答期にかけて衝撃吸収ができているか<br>　荷重応答期に起こる外側スラストの正体は何か？<br>　荷重応答期〜単脚起立期開始までの間に何が起こっているのか？<br>　立脚中期に何が起こっているだろうか？<br>　立脚中期〜立脚終期の間に何が起こっているのか？<br>　立脚終期〜遊脚期に起こる問題<br>　ミニレクチャー 変形性膝関節症と体力<br>2 体幹から捉えた評価と治療戦略<br>　膝OAの歩行時にみられる特有の問題は？<br>　骨盤帯機能について考えよう<br>　体幹機能について<br>　立脚終期の内転筋活動について<br>　ミニレクチャー 変形性膝関節症と姿勢<br>　膝から捉えた評価と治療戦略<br>　膝OAの理学療法の目的<br>　何が問題か？<br>　問題解決のための情報収集<br>　情報を批判的に吟味する<br>　どのように理学療法を行うか？<br>　膝OAの歩行の特徴<br>　なぜinitial contactが出ないのか？<br>　理学療法<br>　理学療法の効果とその限界<br>4 足部から捉えた評価と治療戦略<br>　膝OAの症状の特徴<br>　膝OAの運動学的特徴<br>　足部から捉えた膝OAの評価<br>　膝OA患者における臨床推論のポイント<br>　ミニレクチャー 変形性膝関節症と運動学習<br>5 歩行から捉えた評価と治療戦略<br>　正常歩行を理解する！<br>　膝OA患者でみられる歩行の特徴は？<br>　歩行時にどのような問題があるか？<br>　問題解決のために情報を集めよう！<br>　情報を批判的に吟味してみる<br>　目の前の患者にどう適用するか？<br>　臨床推論に基づく理学療法の実際<br>　ミニレクチャー 歩行練習のコツ<br>6 慢性疼痛疾患として捉えた評価と治療戦略<br>　何が問題か？<br>　ケース1　身体イメージの変質が痛みを修飾している患者<br>　ケース2　破局的思考や不安回避思考が痛みを修飾している患者<br>　ケース3　下行性疼痛調節系の減弱によって痛みが増強している患者<br>　まとめ<br>Part III 変形性膝関節症に対する術後理学療法<br>1 TKA後における体幹から捉えた評価と治療戦略<br>　何が問題か？<br>　問題解決のための情報収集<br>　情報を批判的に吟味する<br>　どのように理学療法を行うか？<br>　理学療法の効果と限界<br>　おわりに〜腰部変性疾患発症リスクの予測〜<br>　ミニレクチャー 術後のstiff─knee gaitについて<br>　ミニレクチャー スタビリティー向上のための体幹トレーニングのコツ<br>2 TKA後における膝から捉えた評価と治療戦略<br>　人工膝関節の機械特性を理解する<br>　術後経過における治療段階<br>　おわりに<br>　ミニレクチャー TKAにおいて術前から予後予測をするためには？<br>3 TKA後における歩行から捉えた評価と治療戦略<br>　TKA後の歩行に着目する意義とは<br>　TKA後の歩行における問題とは<br>　評価の進め方<br>　仮説の設定とその検証─具体例<br>　理学療法の紹介<br>　効果の判定は？<br>　ミニレクチャー 歩行分析のポイント<br>4 HTO後における評価と治療戦略<br>　はじめに<br>　ステップ1　患者に関する臨床的な問題は何か？<br>　ステップ2　問題を解決するための情報検索<br>　ステップ3　情報の整理<br>　ステップ4　理学療法戦略<br>　ステップ5　理学療法効果の評価<br>　ミニレクチャー 関節可動域運動のコツ<br>5 運動イメージ・運動観察を利用した治療戦略<br>　変形性膝関節症（膝OA）患者の痛みと機能障害について<br>　運動イメージと運動観察の神経機構とは<br>　膝OA理学療法に運動イメージ・運動観察を取り入れるために<br>　膝OAに対する運動イメージ・運動観察の理学療法戦略<br>　まとめ<br>6 術後の筋緊張・動作パターンから捉えた評価と治療戦略<br>　膝OAと筋緊張<br>　何が問題か？<br>　なぜ筋緊張は高まるのか？<br>　どのように理学療法を行うか？<br>　理学療法の効果とその限界<br>　ミニレクチャー 認知機能を利用した理学療法のコツ<br>付録<br>索引</section></article>
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