Long Audrey, May Stephen, Fung Tak
Audrey Long, BSc PT: Bonavista Physical Therapy, Calgary, Alberta.
Physiother Can. 2008 Fall;60(4):307-17. doi: 10.3138/physio.60.4.307. Epub 2008 Nov 12.
To determine whether outcomes could be changed after poor response to non-specific exercise therapy when the prescription was changed to specific, directional-preference exercises (McKenzie method).
Patients who participated in a randomized clinical trial (RCT) and the alternative care phase immediately following formed the cohort for this case series. In an earlier RCT, patients with directional preference were randomized to exercises/advice matched to their individual directional preference or to one of two unmatched protocols. The primary inclusion criterion for our case series was patient reports of being unchanged or worse following 2 weeks' treatment in the RCT. The secondary inclusion criterion was patient requests for "a change to one of the other stretching protocols to see if I can achieve better pain control." Patients meeting either of these criteria were offered matched exercises/advice if they had not previously received this intervention. Two-way repeated-measures ANOVA and McNemar tests compared outcomes during two consecutive time intervals: baseline to 2 weeks and 2 weeks to discharge. Dropouts were included in the intention-to-treat analysis.
Four patients from the matched group met the primary inclusion criterion of "unchanged" (none reported being worse); 10 additional patients requested alternative treatment for better pain control (secondary criterion). Eighty-five patients from the two unmatched treatment groups met all the inclusion criteria, and an additional 22 patients met only the secondary criterion. These patients were offered matched treatment, and 96 consented. Those reporting improvement or resolution of symptoms were 22 % in the first two weeks of unmatched care (during the RCT) compared to 84 % with matched care. Statistically significant and clinically meaningful changes occurred in all outcomes (p < 0.001) after receiving matched care, compared to clinically unimportant changes with previous unmatched care during the RCT.
Poor outcomes from non-specific/unmatched exercise protocols appeared to reverse when patients with directional preference were given sub-group-matched, direction-specific exercises. Because of the limitations of our study design, replication with a control group and longer-term follow-up are required to validate the findings.
确定当非特异性运动疗法效果不佳，转而采用特定的、有方向偏好的运动疗法（麦肯齐方法）时，治疗结果是否会有所改变。
参与随机临床试验（RCT）以及随后立即进入替代护理阶段的患者构成了本病例系列的队列。在早期的RCT中，有方向偏好的患者被随机分配到与其个体方向偏好相匹配的运动/建议组，或两个不匹配方案中的一个。我们病例系列的主要纳入标准是患者报告在RCT治疗2周后病情未改善或恶化。次要纳入标准是患者要求“更换为其他拉伸方案之一，看看是否能更好地控制疼痛”。符合上述任何一项标准的患者，如果之前未接受过这种干预，将被提供匹配的运动/建议。双向重复测量方差分析和麦克尼马尔检验比较了两个连续时间段的结果：基线至2周以及2周至出院。失访者纳入意向性分析。
匹配组中有4名患者符合“无改善”的主要纳入标准（均未报告病情恶化）；另有10名患者要求采用替代治疗以更好地控制疼痛（次要标准）。来自两个不匹配治疗组的85名患者符合所有纳入标准，另有22名患者仅符合次要标准。这些患者被提供匹配治疗，96人同意。在不匹配护理的前两周（RCT期间），报告症状改善或缓解的患者为22%，而匹配护理组为84%。与RCT期间之前不匹配护理时临床上无显著变化相比，接受匹配护理后所有结果均出现了具有统计学意义和临床意义的变化（p < 0.001）。
当给予有方向偏好的患者亚组匹配、方向特定的运动时，非特异性/不匹配运动方案的不良结果似乎得到了逆转。由于我们研究设计存在局限性，需要通过对照组重复研究并进行长期随访来验证这些发现。
