Kolber Michael R, Ton Joey, Thomas Betsy, Kirkwood Jessica, Moe Samantha, Dugré Nicolas, Chan Karenn, Lindblad Adrienne J, McCormack James, Garrison Scott, Allan G Michael, Korownyk Christina S, Craig Rodger, Sept Logan, Rouble Andrew N, Perry Danielle
Family physician and Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
Pharmacist in Edmonton and Clinical Evidence Expert for the College of Family Physicians of Canada.
Can Fam Physician. 2021 Jan;67(1):e20-e30. doi: 10.46747/cfp.6701e20.
To determine the proportion of chronic low back pain patients who achieve a clinically meaningful response from different pharmacologic and nonpharmacologic treatments.
MEDLINE, EMBASE, Cochrane Library, and gray literature search.
Published randomized controlled trials (RCTs) that reported a responder analysis of adults with chronic low back pain treated with any of the following 15 interventions: oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, acupuncture, spinal manipulation therapy, corticosteroid injections, acetaminophen, oral opioids, anticonvulsants, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors, cannabinoids, oral muscle relaxants, or topical rubefacients.
A total of 63 RCTs were included. There was moderate certainty that exercise (risk ratio [RR] of 1.71; 95% CI 1.37 to 2.15; number needed to treat [NNT] of 7), oral NSAIDs (RR = 1.44; 95% CI 1.17 to 1.78; NNT = 6), and SNRIs (duloxetine; RR = 1.25; 95% CI 1.13 to 1.38; NNT = 10) provide clinically meaningful benefits to patients with chronic low back pain. Exercise was the only intervention with sustained benefit (up to 48 weeks). There was low certainty that spinal manipulation therapy and topical rubefacients benefit patients. The benefit of acupuncture disappeared in higher-quality, longer (> 4 weeks) trials. Very low-quality evidence demonstrated that corticosteroid injections are ineffective. Patients treated with opioids had a greater likelihood of discontinuing treatment owing to an adverse event (number needed to harm of 5) than continuing treatment to derive any clinically meaningful benefit (NNT = 16), while those treated with SNRIs (duloxetine) had a similar likelihood of continuing treatment to attain benefit (NNT = 10) as those discontinuing the medication owing to an adverse event (number need to harm of 11). One trial each of anticonvulsants and topical NSAIDs found similar benefit to that of placebo. No RCTs of acetaminophen, cannabinoids, muscle relaxants, selective serotonin reuptake inhibitors, or tricyclic antidepressants met the inclusion criteria.
Exercise, oral NSAIDs, and SNRIs (duloxetine) provide a clinically meaningful reduction in pain, with exercise being the only intervention that demonstrated sustained benefit after the intervention ended. Future high-quality trials that report responder analyses are required to provide a better understanding of the benefits and harms of interventions for patients with chronic low back pain.
确定在接受不同药物和非药物治疗后获得具有临床意义反应的慢性下腰痛患者的比例。
医学索引数据库（MEDLINE）、荷兰医学文摘数据库（EMBASE）、考克兰图书馆以及灰色文献检索。
已发表的随机对照试验（RCT），这些试验报告了对采用以下15种干预措施之一治疗的慢性下腰痛成人进行的反应者分析：口服或外用非甾体抗炎药（NSAIDs）、运动、针灸、脊柱推拿疗法、皮质类固醇注射、对乙酰氨基酚、口服阿片类药物、抗惊厥药、三环类抗抑郁药、5-羟色胺-去甲肾上腺素再摄取抑制剂（SNRIs）、选择性5-羟色胺再摄取抑制剂、大麻素、口服肌肉松弛剂或外用擦剂。
共纳入63项随机对照试验。有中等程度的确定性表明，运动（风险比[RR]为1.71；95%置信区间为1.37至2.15；需治疗人数[NNT]为7）、口服NSAIDs（RR = 1.44；95%置信区间为1.17至1.78；NNT = 6）和SNRIs（度洛西汀；RR = 1.25；95%置信区间为1.13至1.38；NNT = 10）对慢性下腰痛患者具有临床意义上的益处。运动是唯一具有持续益处（长达48周）的干预措施。有低程度的确定性表明脊柱推拿疗法和外用擦剂对患者有益。针灸的益处在质量更高、持续时间更长（> 4周）的试验中消失。极低质量的证据表明皮质类固醇注射无效。接受阿片类药物治疗的患者因不良事件而停药的可能性（伤害需治疗人数为5）高于继续治疗以获得任何临床意义上益处的可能性（NNT = 16），而接受SNRIs（度洛西汀）治疗的患者继续治疗以获得益处的可能性（NNT = 10）与因不良事件停药的可能性（伤害需治疗人数为11）相似。关于抗惊厥药和外用NSAIDs的各一项试验发现其益处与安慰剂相似。没有对乙酰氨基酚、大麻素、肌肉松弛剂、选择性5-羟色胺再摄取抑制剂或三环类抗抑郁药的随机对照试验符合纳入标准。
运动、口服NSAIDs和SNRIs（度洛西汀）能在临床上显著减轻疼痛，并运动是唯一在干预结束后仍显示出持续益处的干预措施。未来需要开展高质量的试验并报告反应者分析，以便更好地了解慢性下腰痛患者干预措施的益处和危害。
