澳大利亚悉尼大学Emma Kwan-Yee Ho团队对慢性非特异性腰痛的心理干预进行了网络荟萃分析的系统评价。2022年3月30日出版的《英国医学杂志》发表了这项成果。

为了确定心理干预治疗慢性腰痛的相对有效性和安全性，研究组在MEDLINE、EMPASE、Cochrane控制中心登记册、科学引文索引等大型数据库中检索从建库到2021年1月31日的文献，筛选出对患有慢性非特异性腰痛的成年人进行心理干预与任何对照干预的随机对照试验，采用网络荟萃分析进行系统评价。

由两名评审员独立筛选研究，提取数据，评估偏倚风险和证据的可信度。主要结局是身体功能和疼痛强度。在干预后（从治疗结束到干预后<2个月）、短期内（≥干预后2至<6个月）、中期（≥干预后6至<12个月），以及长期随访（≥干预后12个月）进行随机效应网络荟萃分析。参考比较干预为物理治疗护理。按治疗设计交互模型用于评估整体不一致性，Bucher方法用于评估局部不一致性。

该研究共包括97项随机对照试验，涉及13136名参与者和17个治疗节点。在身体功能的短期和中期随访以及疼痛强度的短期随访中发现了不一致性，并通过敏感性分析加以解决。就身体功能而言，认知行为疗法和疼痛教育与理疗护理一起提供，在干预后（中等质量的证据）取得了临床上重要的改善。

据报道，至少在中期随访之前（低质量证据），通过理疗护理提供的疼痛教育对改善身体功能最具可持续性疗效。尚无研究调查物理治疗护理提供的疼痛教育的长期有效性。

在疼痛强度方面，行为疗法、认知行为疗法和疼痛教育与理疗护理一起提供，在干预后产生了重要的临床效果（低至中等质量的证据）。在中期随访之前（高质量证据），只有在物理治疗护理下进行的行为治疗在降低疼痛强度方面保持了临床上重要的效果。

研究结果表明，对于慢性非特异性腰痛患者，心理干预与理疗护理（主要是结构性运动）结合使用最有效。疼痛教育项目（低到中等质量的证据）和行为治疗（低到高质量的证据）产生了最可持续的治疗效果；然而，它们的长期有效性仍不确定。

附：英文原文

Title: Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis

Author: Emma Kwan-Yee Ho, Lingxiao Chen, Milena Simic, Claire Elizabeth Ashton-James, Josielli Comachio, Daniel Xin Mo Wang, Jill Alison Hayden, Manuela Loureiro Ferreira, Paulo Henrique Ferreira

Issue&Volume: 2022/03/30

Abstract:

Objective To determine the comparative effectiveness and safety of psychological interventions for chronic low back pain.

Design Systematic review with network meta-analysis.

Data sources Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, and CINAHL from database inception to 31 January 2021.

Eligibility criteria for study selection Randomised controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, non-specific low back pain. Two reviewers independently screened studies, extracted data, and assessed risk of bias and confidence in the evidence. Primary outcomes were physical function and pain intensity. A random effects network meta-analysis using a frequentist approach was performed at post-intervention (from the end of treatment to <2 months post-intervention); and at short term (≥2 to <6 months post-intervention), mid-term (≥6 to <12 months post-intervention), and long term follow-up (≥12 months post-intervention). Physiotherapy care was the reference comparison intervention. The design-by-treatment interaction model was used to assess global inconsistency and the Bucher method was used to assess local inconsistency.

Results 97 randomised controlled trials involving 13136 participants and 17 treatment nodes were included. Inconsistency was detected at short term and mid-term follow-up for physical function, and short term follow-up for pain intensity, and were resolved through sensitivity analyses. For physical function, cognitive behavioural therapy (standardised mean difference 1.01, 95% confidence interval 0.58 to 1.44), and pain education (0.62, 0.08 to 1.17), delivered with physiotherapy care, resulted in clinically important improvements at post-intervention (moderate quality evidence). The most sustainable effects of treatment for improving physical function were reported with pain education delivered with physiotherapy care, at least until mid-term follow-up (0.63, 0.25 to 1.00; low quality evidence). No studies investigated the long term effectiveness of pain education delivered with physiotherapy care. For pain intensity, behavioural therapy (1.08, 0.22 to 1.94), cognitive behavioural therapy (0.92, 0.43 to 1.42), and pain education (0.91, 0.37 to 1.45), delivered with physiotherapy care, resulted in clinically important effects at post-intervention (low to moderate quality evidence). Only behavioural therapy delivered with physiotherapy care maintained clinically important effects on reducing pain intensity until mid-term follow-up (1.01, 0.41 to 1.60; high quality evidence).

Conclusions For people with chronic, non-specific low back pain, psychological interventions are most effective when delivered in conjunction with physiotherapy care (mainly structured exercise). Pain education programmes (low to moderate quality evidence) and behavioural therapy (low to high quality evidence) result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness. Although inconsistency was detected, potential sources were identified and resolved.

DOI: 10.1136/bmj-2021-067718

Source: https://www.bmj.com/content/376/bmj-2021-067718