Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA.
Department of Medicine, Oregon Health and Science University, Portland, OR, USA.
Eur Spine J. 2018 Sep;27(Suppl 6):851-860. doi: 10.1007/s00586-017-5433-8. Epub 2018 Feb 19.
PURPOSE: The purpose of this review was to develop recommendations for the management of spinal disorders in low-income communities, with a focus on non-invasive pharmacological and non-pharmacological therapies for non-specific low back and neck pain. METHODS: We synthesized two evidence-based clinical practice guidelines for the management of low back and neck pain. Our recommendations considered benefits, harms, quality of evidence, and costs, with attention to feasibility in medically underserved areas and low- and middle-income countries. RESULTS: Clinicians should provide education and reassurance, advise patients to remain active, and provide information about self-care options. For acute low back and neck pain without serious pathology, primary conservative treatment options are exercise, manual therapy, superficial heat, and nonsteroidal anti-inflammatory drugs (NSAIDs). For patients with chronic low back and neck pain without serious pathology, primary treatment options are exercise, yoga, cognitive behavioral therapies, acupuncture, biofeedback, progressive relaxation, massage, manual therapy, interdisciplinary rehabilitation, NSAIDs, acetaminophen, and antidepressants. For patients with spinal pain with radiculopathy, clinicians may consider exercise, spinal manipulation, or NSAIDs; use of other interventions requires extrapolation from evidence regarding effectiveness for non-radicular spinal pain. Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction. CONCLUSION: Guidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences. These slides can be retrieved under Electronic Supplementary Material.
目的:本综述旨在为低收入社区的脊柱疾病管理制定建议,重点关注非特异性下腰痛和颈痛的非侵入性药物和非药物治疗。
方法:我们综合了两项针对下腰痛和颈痛管理的基于证据的临床实践指南。我们的建议考虑了益处、危害、证据质量和成本,同时关注医疗资源匮乏地区和中低收入国家的可行性。
结果:临床医生应提供教育和安慰,建议患者保持活动,并提供自我护理选择的信息。对于无严重病理的急性下腰痛和颈痛,主要的保守治疗选择是运动、手法治疗、浅表热疗和非甾体抗炎药(NSAIDs)。对于无严重病理的慢性下腰痛和颈痛患者,主要的治疗选择是运动、瑜伽、认知行为疗法、针灸、生物反馈、渐进性放松、按摩、手法治疗、跨学科康复、NSAIDs、对乙酰氨基酚和抗抑郁药。对于有根性病变的脊柱疼痛患者,临床医生可以考虑运动、脊柱推拿或 NSAIDs;对于非根性脊柱疼痛有效的其他干预措施需要从证据中推断。临床医生不应提供无效的治疗方法,包括苯二氮䓬类药物、肉毒杆菌毒素注射、全身皮质类固醇、颈托、电肌肉刺激、短波透热疗法、经皮电神经刺激和牵引。
结论:为高收入人群制定的指南通过考虑成本和可行性等因素,以及益处、危害和基础证据质量,被改编为医疗资源匮乏地区和中低收入国家的护理路径和护理模式。推荐的保守治疗方法的选择必须通过与相关社区的讨论,并基于生物心理社会方法来最终确定。选择推荐治疗方法的决策因素包括成本、干预措施的可及性以及文化和患者偏好。这些幻灯片可在电子补充材料中检索。
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