Werneke Mark W, Edmond Susan, Young Michelle, Grigsby David, McClenahan Brian, McGill Troy
Private Practice and Consultation, Waipahu, HI, USA.
Doctoral Programs in Physical Therapy, Rutgers, The State University of New Jersey, Newark, NJ, USA.
Physiother Res Int. 2018 Jul;23(3):e1711. doi: 10.1002/pri.1711. Epub 2018 Mar 14.
Physiotherapy has an important role in managing patients with non-specific low back pain who experience elevated psychosocial distress or risk for chronic disability. In terms of evidence-based physiotherapy practice, cognitive-behavioural approaches for patients at high psychosocial risk are the recommended management to improve patient treatment outcomes. Evidence also suggests that directional preference (DP) is an important treatment effect modifier for prescribing specific exercises for patients to improve outcomes. Little is known about the influence of treatment techniques based on DP on outcomes for patients classified as high psychosocial risk using the Subgroups for Targeted Treatment (STarT) Back Screening Tool. This study aimed to examine the association between functional status (FS) at rehabilitation discharge for patients experiencing low back pain classified at high STarT psychosocial risk and whose symptoms showed a DP versus No-DP.
High STarT risk patients (n = 138) completed intake surveys, that is, the lumbar FS of Focus On Therapeutic Outcomes, Inc., and STarT, and were evaluated for DP by physiotherapists credentialed in McKenzie methods. The FS measure of Focus On Therapeutic Outcomes, Inc., was repeated at discharge. DP and No-DP prevalence rates were calculated. Associations between first-visit DP and No-DP and change in FS were assessed using univariate and multivariate regression models controlling for 11 risk-adjusted variables.
One hundred nine patients classified as high STarT risk had complete intake and discharge FS and DP data. Prevalence rate for DP was 65.1%. A significant and clinically important difference (7.98 FS points; p = .03) in change in function at discharge between DP and No-DP was observed after controlling for all confounding variables in the final model.
Findings suggest that interventions matched to DP are effective for managing high psychological risk patients and may provide physiotherapists with an alternative treatment pathway compared to managing similar patients with cognitive-behavioural approaches. Stricter research designs are required to validate study conclusions.
物理治疗在管理非特异性下腰痛且伴有心理社会困扰加剧或慢性残疾风险的患者中发挥着重要作用。就循证物理治疗实践而言，对于心理社会风险较高的患者，认知行为疗法是推荐的管理方法，以改善患者的治疗效果。证据还表明，方向偏好（DP）是为患者开具特定锻炼处方以改善治疗效果的重要治疗效果调节因素。对于使用针对性治疗亚组（STarT）背部筛查工具被归类为心理社会风险较高的患者，基于DP的治疗技术对其治疗效果的影响知之甚少。本研究旨在探讨使用STarT心理社会风险高分类且症状表现为有DP与无DP的腰痛患者康复出院时的功能状态（FS）之间的关联。
高STarT风险患者（n = 138）完成了入组调查，即聚焦治疗结果公司的腰椎FS和STarT调查，并由具备麦肯齐方法资质的物理治疗师评估DP。聚焦治疗结果公司的FS测量在出院时重复进行。计算DP和无DP的患病率。使用控制11个风险调整变量的单变量和多变量回归模型评估首次就诊时DP和无DP与FS变化之间的关联。
109例被归类为高STarT风险的患者有完整的入组和出院FS及DP数据。DP的患病率为65.1%。在最终模型中控制所有混杂变量后，观察到DP组和无DP组出院时功能变化存在显著且具有临床意义的差异（7.98个FS点；p = 0.03）。
研究结果表明，与DP相匹配的干预措施对管理高心理风险患者有效，并且与采用认知行为疗法管理类似患者相比，可能为物理治疗师提供另一种治疗途径。需要更严格的研究设计来验证研究结论。
