Deyo R A, Phillips W R
Department of Medicine, University of Washington, Seattle, USA.
Spine (Phila Pa 1976). 1996 Dec 15;21(24):2826-32. doi: 10.1097/00007632-199612150-00003.
Back pain is an important problem for primary care physicians; it is common, costly, and controversial. Back pain is the second leading symptom prompting all physician visits in the United States. There are wide geographic variations in medical care for this problem, and surgical rates in the United States are twice those of most developed countries. The treatment of back pain has followed a series of fads and fashions, and work disability resulting from back pain continues to rise. For all these reasons, primary care clinicians have an important role in improving the care of patients with low back pain. Primary care clinicians face unique problems in treating these patients. First, in primary care, most patients have uncomplicated low back pain, and identifying the rare patient with an underlying malignancy or neurologic deficit is like looking for a needle in a haystack. Second, these practitioners face two populations with nonspecific back pain: one that is likely to improve no matter what (who mostly need reassurance), and a smaller group (about 20%) who are prone to development of chronic back pain and who present complex psychosocial and occupational problems. Third, these problems must be dealt with in the typical setting of a 15-minute patient visit. Finally, lifestyle changes in exercise, weight loss, and smoking cessation may be major parts of patient treatment, and improving compliance with such interventions always is a major challenge. Primary care investigators studying back pain face at least three important challenges. One is to identify more efficient diagnostic strategies that will alleviate doctors' and patients' anxieties. Second is to develop a better theory to explain the large majority of episodes of nonspecific low back pain. At present, competing theories generate competing and conflicting treatments, generating frustration among patients and loss of credibility for clinicians. Third, we need better science, with greater methodologic rigor in the evaluation of the many nonsurgical treatments used for back pain in the primary care setting.
背痛是基层医疗医生面临的一个重要问题；它很常见，成本高昂且存在争议。背痛是促使美国人就医的第二大主要症状。针对这个问题的医疗护理存在广泛的地域差异，美国的手术率是大多数发达国家的两倍。背痛的治疗经历了一系列的潮流和时尚，因背痛导致的工作残疾率持续上升。出于所有这些原因，基层医疗临床医生在改善腰痛患者的护理方面发挥着重要作用。基层医疗临床医生在治疗这些患者时面临独特的问题。首先，在基层医疗中，大多数患者患有不复杂的腰痛，识别出罕见的患有潜在恶性肿瘤或神经功能缺损的患者就像大海捞针。其次，这些从业者面对两类非特异性背痛患者：一类无论怎样都可能好转（大多只需要安心），另一类规模较小（约20%），容易发展为慢性背痛，且存在复杂的心理社会和职业问题。第三，这些问题必须在典型的15分钟患者就诊环境中处理。最后，运动、减肥和戒烟等生活方式的改变可能是患者治疗的主要部分，提高对这类干预措施的依从性始终是一项重大挑战。研究背痛的基层医疗研究人员至少面临三个重要挑战。一是确定更有效的诊断策略，以减轻医生和患者的焦虑。二是建立一个更好的理论来解释绝大多数非特异性腰痛发作。目前，相互竞争的理论产生了相互竞争和冲突的治疗方法，给患者带来挫折感，也让临床医生失去公信力。第三，我们需要更好的科学，在评估基层医疗环境中用于背痛的众多非手术治疗方法时要有更高的方法学严谨性。
