解释认知行为方法对腰痛的作用：腰背技能训练试验的中介分析。
Explaining How Cognitive Behavioral Approaches Work for Low Back Pain: Mediation Analysis of the Back Skills Training Trial.
机构信息
Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, United Kingdom.
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom.
出版信息
Spine (Phila Pa 1976). 2017 Sep 1;42(17):E1031-E1039. doi: 10.1097/BRS.0000000000002066.
STUDY DESIGN
This is secondary research examining the longitudinal mediation effect within a structural equation model.
OBJECTIVE
To identify possible mechanisms that mediate the effects of a cognitive behavioral approach upon disability and pain in low back pain patients.
SUMMARY OF BACKGROUND DATA
Cognitive behavioral interventions (CBIs) can improve pain and disability in low back pain (LBP) but the mechanisms of action are unclear. We used data from a large randomized controlled trial to investigate mediators of the treatment effect of CBI.
METHODS
Pain self-efficacy, fear avoidance, and physical and mental functioning were selected as candidate mediators based on the theoretical rationale of the intervention. The primary treatment outcomes were the Roland Morris Questionnaire (RMDQ) and the modified Von Korff scale (MVK pain and disability) at 12 months. We used structural equation models to estimate the contribution of mediators. All models were tested for goodness-of-fit using χ , Root Mean Square Error of Approximation, Adjusted Goodness of Fit Index, and Bentler Comparative Fit Index.
RESULTS
We included 701 adults with LBP. The average RMDQ score at baseline for those on the intervention arm was 8.8 (Standard Deviation 5.0). The intervention was effective in reducing disability and pain at 12 months. Change in mental functioning was not a significant mediator. Changes to pain self-efficacy, fear avoidance, and physical functioning were causal mediators of the treatment effect at 12 months (RMDQ b= -0.149, P < 0.001; MVK-pain b = -0.181, P < 0.001 and MVK-disability b = -0.180, P < 0.001). Overall, the SEM model exceeded the threshold for acceptable goodness-of-fit.
CONCLUSION
Fear avoidance and self-efficacy were important causal mediators of the cognitive behavioral treatment effect. Self-assessed change in physical function was a causal mediator but mental functioning was not. This suggests people need to experience meaningful change in physical function and beliefs but not in mental functioning associated with LBP, to achieve a treatment benefit.
LEVEL OF EVIDENCE
研究设计
这是一项二次研究，在结构方程模型中检查纵向中介效应。
目的
确定可能的机制，以调解认知行为方法对腰痛患者的残疾和疼痛的影响。
背景资料概要
认知行为干预（CBIs）可以改善腰痛（LBP）的疼痛和残疾，但作用机制尚不清楚。我们使用来自大型随机对照试验的数据来研究 CBI 治疗效果的中介因素。
方法
根据干预的理论依据，选择疼痛自我效能感、恐惧回避和身心功能作为候选中介因素。主要治疗结果是 12 个月时的 Roland Morris 问卷（RMDQ）和改良 Von Korff 量表（MVK 疼痛和残疾）。我们使用结构方程模型来估计中介因素的贡献。所有模型均使用 χ、均方根误差逼近、调整良好拟合指数和本特勒比较拟合指数进行拟合优度检验。
结果
我们纳入了 701 名腰痛成年人。干预组基线时的平均 RMDQ 评分为 8.8（标准差 5.0）。干预在 12 个月时有效减少了残疾和疼痛。心理功能的变化不是一个显著的中介因素。疼痛自我效能感、恐惧回避和身体功能的变化是 12 个月时治疗效果的因果中介因素（RMDQ b=-0.149，P<0.001；MVK-疼痛 b=-0.181，P<0.001，MVK 残疾 b=-0.180，P<0.001）。总体而言，SEM 模型超过了可接受拟合优度的阈值。
结论
恐惧回避和自我效能感是认知行为治疗效果的重要因果中介因素。身体功能的自我评估变化是一个因果中介因素，但心理功能不是。这表明，人们需要在与腰痛相关的身体功能和信念方面经历有意义的变化，而不是在心理功能方面，才能获得治疗益处。
证据水平
2。
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