Department of Psychology, University of Southampton, Southampton, UK
Department of Psychology, University of Southampton, Southampton, UK.
BMJ Open. 2021 May 18;11(5):e044831. doi: 10.1136/bmjopen-2020-044831.
Contextual components of treatment previously associated with patient outcomes include the environment, therapeutic relationship and expectancies. Questions remain about which components are most important, how they influence outcomes and comparative effects across treatment approaches. We aimed to identify significant and strong contextual predictors of patient outcomes, test for psychological mediators and compare effects across three treatment approaches.
Prospective cohort study with patient-reported and practitioner-reported questionnaire data (online or paper) collected at first consultation, 2 weeks and 3 months.
Physiotherapy, osteopathy and acupuncture clinics throughout the UK.
166 practitioners (65 physiotherapists, 46 osteopaths, 55 acupuncturists) were recruited via their professional organisations. Practitioners recruited 960 adult patients seeking treatment for low back pain (LBP).
The primary outcome was back-related disability. Secondary outcomes were pain and well-being. Contextual components measured were: therapeutic alliance; patient satisfaction with appointment systems, access, facilities; patients' treatment beliefs including outcome expectancies; practitioners' attitudes to LBP and practitioners' patient-specific outcome expectancies. The hypothesised mediators measured were: patient self-efficacy for pain management; patient perceptions of LBP and psychosocial distress.
After controlling for baseline and potential confounders, statistically significant predictors of reduced back-related disability were: all three dimensions of stronger therapeutic alliance (goal, task and bond); higher patient satisfaction with appointment systems; reduced patient-perceived treatment credibility and increased practitioner-rated outcome expectancies. Therapeutic alliance over task (η=0.10, 95% CI 0.07 to 0.14) and practitioner-rated outcome expectancies (η=0.08, 95% CI 0.05 to 0.11) demonstrated the largest effect sizes. Patients' self-efficacy, LBP perceptions and psychosocial distress partially mediated these relationships. There were no interactions with treatment approach.
Enhancing contextual components in musculoskeletal healthcare could improve patient outcomes. Interventions should focus on helping practitioners and patients forge effective therapeutic alliances with strong affective bonds and agreement on treatment goals and how to achieve them.
与患者结局相关的治疗情境因素包括环境、治疗关系和期望。目前仍存在一些问题，例如哪些因素最重要、它们如何影响结局以及在不同治疗方法中的比较效果。本研究旨在确定对患者结局有显著和重要影响的情境预测因素，检验心理中介因素，并比较三种治疗方法的效果。
前瞻性队列研究，在首次就诊时、就诊后 2 周和 3 个月，通过患者报告和从业者报告的问卷调查收集数据（在线或纸质）。
英国各地的物理治疗、整骨疗法和针灸诊所。
166 名从业者（65 名物理治疗师、46 名整骨治疗师、55 名针灸师）通过其专业组织招募。从业者招募了 960 名寻求治疗腰痛（LBP）的成年患者。
主要结局是腰痛相关残疾。次要结局为疼痛和幸福感。测量的情境因素包括：治疗联盟；患者对预约系统、就诊机会、设施的满意度；患者对治疗的信念，包括结局期望；从业者对 LBP 的态度和从业者对患者特定结局的期望。测量的假设中介因素包括：患者对疼痛管理的自我效能；患者对腰痛和心理社会困扰的感知。
在控制基线和潜在混杂因素后，腰痛相关残疾减轻的统计学显著预测因素包括：更强治疗联盟的所有三个维度（目标、任务和纽带）；更高的患者对预约系统的满意度；降低患者感知的治疗可信度和增加从业者评定的结局期望。任务上的治疗联盟（η=0.10，95%CI 0.07 至 0.14）和从业者评定的结局期望（η=0.08，95%CI 0.05 至 0.11）的效应量最大。患者的自我效能、腰痛感知和心理社会困扰部分中介了这些关系。治疗方法之间没有交互作用。
增强肌肉骨骼保健中的情境因素可能会改善患者结局。干预措施应侧重于帮助从业者和患者建立有效的治疗联盟，形成强烈的情感纽带，并就治疗目标以及如何实现这些目标达成一致。
