Communication-and Research Unit for Musculoskeletal Disorders, and Orthopaedic Department, Oslo University Hospital and University of Oslo, Norway.
J Physiother. 2012;58(1):57. doi: 10.1016/S1836-9553(12)70073-5.
Does a stratified primary care approach for patients with low back pain result in clinical and economic benefits when compared with current best practice?
A randomised, controlled trial with stratification for three risk groups and a targeted treatment according to the risk profile. Group allocation was carried out by computer-generated block randomisation in a 2:1 ratio.
Ten general practices in England.
Men and women at least 18 years old with low back pain of any duration, with or without associated radiculopathy. Exclusion criteria were potentially serious disorders, serious illness or comorbidity, spinal surgery in the past 6 months, pregnancy, and receiving back treatments (except primary care).
In the intervention group decisions about referral to risk group were made by use of the STarT Back Screening Tool. The 30-min assessment and initial treatment focused on promotion of appropriate levels of activity, including return to work, a pamphlet about local exercise venues and self-help groups, the Back Book, and a 15-min educational video Get Back Active. Low-risk patients were only given this clinic session. Medium-risk patients were referred for standardised physiotherapy to address symptoms and function. High-risk patients were referred for psychologically informed physiotherapy to address physical symptoms and function, and psychosocial obstacles to recovery. In the control group a 30-min physiotherapy assessment and initial treatment including advice and exercises was provided, with the option of onward referral to further physiotherapy, based on the physiotherapist's clinical judgement.
The 12 months score of Roland and Morris Disability Questionnaire (RMDQ). Secondary measures were referral for further physiotherapy, back pain intensity, pain catastrophising, fear-avoidance beliefs, anxiety, depression, health-related quality of life, reduction of risk-subgroup, global change of pain, number of physiotherapy treatment sessions, adverse events, health-care resource use and costs over 12 months, number of days off work because of back pain, and satisfaction with care.
Of 851 patients assigned to the intervention (n=568) and control groups (n=283) a total of 649 completed the 12 months follow-up. Adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4.7 [SD 5.9] vs 3.0 [5.9], between-group difference 1.8 [95% CI 1.6 to 2.6]) and at 12 months (4.3 [6.4] vs 3.3 [6.2], 1.1 [0.6 to 1.9]). At 12 months, stratified care was associated with a mean increase in generic health benefit (0.039 additional QALYs) and cost savings (£240.01 vs £274.40) compared with the control group. There were significant differences in favour of the intervention group in many of the secondary outcomes.
A stratified management approach including a prognostic screening and treatment targeting, showed improved clinical and economic benefits when compared with current best practice.
与当前最佳实践相比，针对低背痛患者采用分层初级保健方法是否会带来临床和经济效益？
一项随机对照试验，针对三个风险组进行分层，并根据风险状况进行针对性治疗。通过计算机生成的块随机化以 2:1 的比例进行分组分配。
英格兰的十家全科诊所。
年龄至少 18 岁的有任何持续时间的背痛的男性和女性，无论是否伴有神经根病变。排除标准为潜在的严重疾病、严重疾病或合并症、过去 6 个月内的脊柱手术、怀孕以及接受背部治疗（除初级保健外）。
在干预组中，通过使用 STarT 后背筛查工具来决定向风险组的转诊。30 分钟的评估和初步治疗侧重于促进适当的活动水平，包括重返工作岗位、有关当地运动场所和自助小组的小册子、《后背书》和 15 分钟的教育视频《重返活跃》。低风险患者仅接受此诊所就诊。中风险患者被转诊接受标准化的物理治疗，以解决症状和功能问题。高风险患者被转诊接受心理知情的物理治疗，以解决身体症状和功能以及康复的心理社会障碍。在对照组中，提供了 30 分钟的物理治疗评估和初步治疗，包括建议和锻炼，并根据物理治疗师的临床判断选择进一步的物理治疗。
在 851 名被分配到干预组（n=568）和对照组（n=283）的患者中，共有 649 名完成了 12 个月的随访。干预组的 Roland 和 Morris 残疾问卷（RMDQ）12 个月评分的调整平均变化明显高于对照组，4 个月时为 4.7（SD 5.9）比 3.0（5.9），组间差异为 1.8（95%CI 1.6 至 2.6），12 个月时为 4.3（6.4）比 3.3（6.2），1.1（0.6 至 1.9）。在 12 个月时，与对照组相比，分层护理与一般健康效益的平均增加（0.039 个额外的 QALY）和成本节约（240.01 英镑与 274.40 英镑）相关。干预组在许多次要结局方面均具有明显优势。
与当前最佳实践相比，包括预后筛查和治疗靶向的分层管理方法显示出了更好的临床和经济效益。
