物理治疗师提供的针对急性挥鞭样损伤相关疾病的综合心理与运动干预的作用机制：一项随机对照试验的二次中介分析
The mechanisms of effect of a physiotherapist-delivered integrated psychological and exercise intervention for acute whiplash-associated disorders: secondary mediation analysis of a randomized controlled trial.
作者信息
Elphinston Rachel A, Sterling Michele, Kenardy Justin, Smeets Rob, Armfield Nigel R
机构信息
RECOVER Injury Research Centre, The University of Queensland, Brisbane, Australia.
NHMRC CRE in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Australia.
出版信息
Pain Rep. 2020 Sep 23;5(5):e835. doi: 10.1097/PR9.0000000000000835. eCollection 2020 Sep-Oct.
INTRODUCTION
Integrated psychological and physical treatments can improve recovery for whiplash-associated disorders (WADs). Little is known about how these interventions work.
OBJECTIVE
To examine the mechanisms by which a physiotherapist-delivered integrated intervention for acute WAD improves health outcomes.
METHODS
Secondary analysis using structural equation modelling of a randomized controlled trial comparing integrated stress inoculation training and exercise to exercise alone for acute WAD. Outcomes were disability, pain self-efficacy, pain intensity, and health-related quality of life at 12 months. The intended intervention target and primary mediator, stress was tested in parallel with pain-related coping, an additional cognitive behavioral mediator that significantly improved at posttreatment (Model 1). Stress-related constructs that commonly co-occur with stress and pain were also tested as parallel mediators: depression and pain-related coping (Model 2); and posttraumatic stress and pain-related coping (Model 3).
RESULTS
Reductions in stress mediated the effect of the integrated intervention on disability (β = -0.12, confidence interval [CI] = -0.21 to -0.06), pain self-efficacy (β = 0.09, CI = 0.02-0.18), pain (β = -0.12, CI = -0.21 to -0.06), and health-related quality of life (β = 0.11, CI = 0.04-0.21). There was an additional path to pain self-efficacy through pain-related coping (β = 0.06, CI = 0.01-0.12). Similar patterns were found in Models 2 and 3.
CONCLUSIONS
Improvements in stress and related constructs of depression and posttraumatic stress, and pain-related coping were causal mechanisms of effect in a physiotherapist-delivered integrated intervention. As integrated interventions are growing in popularity, it is important to further personalize interventions for improved benefit.
引言
心理和身体综合治疗可改善挥鞭样相关疾病（WAD）的康复情况。对于这些干预措施的作用机制知之甚少。
目的
探讨物理治疗师提供的针对急性WAD的综合干预改善健康结局的机制。
方法
对一项随机对照试验进行二次分析，采用结构方程模型，比较综合应激接种训练与运动疗法单独用于急性WAD的效果。结局指标为12个月时的残疾程度、疼痛自我效能感、疼痛强度及健康相关生活质量。将预期的干预靶点和主要中介因素应激与疼痛相关应对方式同时进行测试，疼痛相关应对方式是另一种在治疗后有显著改善的认知行为中介因素（模型1）。还将与应激和疼痛共同出现的应激相关结构作为平行中介因素进行测试：抑郁与疼痛相关应对方式（模型2）；创伤后应激与疼痛相关应对方式（模型3）。
结果
应激的降低介导了综合干预对残疾程度（β = -0.12，置信区间[CI] = -0.21至 -0.06）、疼痛自我效能感（β = 0.09，CI = 0.02 - 0.18）、疼痛（β = -0.12，CI = -0.21至 -0.06）及健康相关生活质量（β = 0.11，CI = 0.04 - 0.21）的影响。通过疼痛相关应对方式存在一条通向疼痛自我效能感的额外路径（β = 0.06，CI = 0.01 - 0.12）。在模型2和模型3中发现了类似模式。
结论
应激以及抑郁和创伤后应激等相关结构的改善，以及疼痛相关应对方式是物理治疗师提供的综合干预产生效果的因果机制。随着综合干预越来越受欢迎，进一步个性化干预以提高效益很重要。
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