Hurwitz Eric L, Morgenstern Hal, Kominski Gerald F, Yu Fei, Chiang Lu-May
Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA.
Spine (Phila Pa 1976). 2006 Mar 15;31(6):611-21; discussion 622. doi: 10.1097/01.brs.0000202559.41193.b2.
Randomized clinical trial.
To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care.
Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking.
A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms.
Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80-2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08-2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62-1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months.
Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.
随机临床试验。
比较管理式医疗中医疗护理与整脊疗法对腰痛的长期疗效，并评估接受医疗护理或整脊疗法的患者中物理治疗及相关方式的疗效。
缺乏关于管理式医疗中为腰痛患者提供的常见治疗策略的长期相对疗效的比较证据。
共有681名到管理式医疗机构就诊的腰痛患者被随机分为接受或不接受物理方式的整脊疗法组，以及接受或不接受物理治疗的医疗护理组，并随访18个月。主要结局变量为腰痛强度、功能障碍和完全缓解。次要结局是参与者对腰痛症状改善的感知。
681名患者中，610名（89.6%）完成了18个月的随访。在未被分配接受物理治疗或相关方式的参与者中，整脊疗法组在疼痛和功能障碍方面的估计改善以及18个月时完全缓解的风险略高于医疗护理组（缓解的调整风险比=1.29；95%置信区间=0.80-2.07）。在被分配接受医疗护理的参与者中，接受物理治疗的患者在疼痛和功能障碍方面的平均变化以及缓解风险更大（调整风险比=1.69；95%置信区间=1.08-2.66）。然而，在被分配接受整脊疗法的参与者中，分配的方式与改善或缓解无关（调整风险比=0.98；95%置信区间=0.62-1.55）。与仅接受医疗护理的患者相比，接受整脊疗法和物理治疗的患者更有可能感知到腰痛症状有所改善。然而，所有患者中不到20%在18个月时无疼痛。
在不进行物理治疗或相关方式的情况下，医疗护理与整脊疗法在结局上的差异在临床上并无意义，尽管整脊疗法可能会使患者感觉改善的可能性更大，这可能反映了满意度或缺乏盲法。对于一些患者，物理治疗可能比单纯的医疗护理更有效，而物理方式在整脊疗法中似乎并无益处。
