Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C
Institute for Work & Health, 481 University Avenue, Suite 800, Toronto, Ontario, Canada, M5G 2E9.
Cochrane Database Syst Rev. 2007 Jul 18(2):CD000963. doi: 10.1002/14651858.CD000963.pub2.
Chronic low back pain is, in many countries, the main cause of long term disability in middle age. Patients with chronic low back pain are often referred for multidisciplinary treatment. Previous published systematic reviews on this topic included no randomised controlled trials and pooled together controlled and non-controlled studies.
To assess the effect of multidisciplinary bio-psycho-social rehabilitation on pain, function, employment, quality of life and global assessment outcomes in subjects with chronic disabling low back pain.
We searched MEDLINE, EMBASE, PsychLIT, CINAHL, Health STAR, and The Cochrane Library from the beginning of the database to June 1998 using the comprehensive search strategy recommended by the Back Review Group of the Cochrane Collaboration. INTERVENTION specific key words for this review were: patient care team, patient care management, multidisciplinary, interdisciplinary, multiprofessional, multimodal, pain clinic and functional restoration. We also reviewed reference lists and consulted the editors of the Back Review Group of the Cochrane Collaboration.
randomised controlled trials comparing multidisciplinary bio-psycho-social rehabilitation with a non-multidisciplinary control intervention.
Adults with disabling low back pain of more than three months in duration.
Patients had to be assessed and treated by qualified professionals according to a plan that addresses physical and at least one of psychological, or social/occupational dimensions.
Only trials which reported treatment effect in at least one of pain, function, employment status, quality of life or global improvement.Exclusion: Pure educational interventions (back schools) and pure physical interventions were excluded.
Selection, data extraction and quality grading of studies was done by two independent authors using pre-tested data forms. Study quality was assessed according to the scheme recommended by the Back Review Group of the Cochrane Collaboration. Trials with internal validity scores of five or more in a ten point scale were considered high quality. Discrepancies between authors were resolved by consensus or by a third author. Given the marked heterogeneity in study settings, interventions and control groups we decided not to pool trial results in a meta-analysis. Instead, we summarized findings by strength of evidence and nature of intervention and control treatments. The evidence was judged to be strong when multiple high quality trials produced generally consistent findings. It was judged to be moderate when multiple low quality or one high quality and one or more low quality trials produced generally consistent findings. Evidence was considered to be limited when only one randomised trial existed or if findings of existing trials were inconsistent.
Ten trials (12 randomised comparisons) were included. They randomised a total of 1964 patients with chronic low back pain. There was strong evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved function when compared with inpatient or outpatient non-multidisciplinary treatments. There was moderate evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved pain when compared with outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary bio-psycho-social intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psycho-physical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments.
AUTHORS' CONCLUSIONS: The reviewed trials provide evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves pain and function. Less intensive interventions did not show improvements in clinically relevant outcomes.
在许多国家，慢性下腰痛是中年人群长期残疾的主要原因。慢性下腰痛患者常被转介接受多学科治疗。此前发表的关于该主题的系统评价未纳入随机对照试验，而是将对照研究和非对照研究汇总在一起。
评估多学科生物 - 心理 - 社会康复对慢性致残性下腰痛患者的疼痛、功能、就业、生活质量和整体评估结果的影响。
我们使用Cochrane协作网背部回顾小组推荐的全面检索策略，检索了MEDLINE、EMBASE、PsychLIT、CINAHL、Health STAR和Cochrane图书馆，检索时间从各数据库建库起始至1998年6月。本综述的干预特定关键词为：患者护理团队、患者护理管理、多学科、跨学科、多专业、多模式、疼痛诊所和功能恢复。我们还查阅了参考文献列表，并咨询了Cochrane协作网背部回顾小组的编辑。
比较多学科生物 - 心理 - 社会康复与非多学科对照干预的随机对照试验。
患有持续超过三个月的致残性下腰痛的成年人。
患者必须由合格的专业人员根据涉及身体以及心理或社会/职业维度中至少一个维度的计划进行评估和治疗。
仅纳入那些至少报告了疼痛、功能、就业状况、生活质量或整体改善方面治疗效果的试验。排除标准：纯教育干预（背疼学校）和纯物理干预。
研究的选择、数据提取和质量分级由两位独立作者使用预先测试的数据表格进行。研究质量根据Cochrane协作网背部回顾小组推荐的方案进行评估。在十分制量表中内部效度得分达到五分或更高的试验被视为高质量试验。作者之间的分歧通过协商解决，或由第三位作者裁决。鉴于研究背景、干预措施和对照组存在显著异质性，我们决定不将试验结果汇总进行荟萃分析。相反，我们根据证据强度以及干预和对照治疗的性质总结研究结果。当多个高质量试验得出总体一致的结果时，证据被判定为强。当多个低质量试验或一个高质量试验与一个或多个低质量试验得出总体一致的结果时，证据被判定为中等。当仅存在一项随机试验或现有试验的结果不一致时，证据被认为有限。
纳入了10项试验（12次随机对照比较）。这些试验共随机分配了1964例慢性下腰痛患者。有强有力的证据表明，与住院或门诊非多学科治疗相比，采用功能恢复方法的强化多学科生物 - 心理 - 社会康复可改善功能。有中等证据表明，与门诊非多学科康复或常规护理相比，采用功能恢复方法的强化多学科生物 - 心理 - 社会康复可改善疼痛。关于强化多学科生物 - 心理 - 社会干预的职业结局存在相互矛盾的证据。一些试验报告工作准备情况有所改善，但其他试验显示病假天数没有显著减少。与非多学科门诊治疗或常规护理相比，强度较低的门诊心理 - 身体治疗在疼痛、功能或职业结局方面没有改善。很少有试验报告对生活质量或整体评估的影响。
所综述的试验提供了证据，表明采用功能恢复方法的强化多学科生物 - 心理 - 社会康复可改善疼痛和功能。强度较低的干预措施在临床相关结局方面未显示出改善。
