近日，美国华盛顿大学Patrick J. Heagerty团队比较了急性背痛的脊柱手法治疗与临床医生支持的生物心理社会自我管理。2025年12月30日出版的《美国医学会杂志》发表了这项成果。

腰痛（LBP）受生理、心理和社会因素的影响。然而，大多数治疗侧重于减轻症状，而没有解决患者潜在的生物心理社会需求。

为了确定脊柱操作和临床支持的生物心理社会自我管理与医疗护理对慢性致残性腰痛风险增加的成年人的有效性，2018年11月至2023年5月，研究组在美国明尼苏达大学和匹兹堡大学的3个研究诊所进行了2 × 2因子随机临床试验；最后一次随访是在2024年6月。根据STarT - Back工具，急性或亚急性下腰痛中度至重度慢性风险的成人被随机分为4组，干预时间长达8周。统计分析时间为2024年11月至2025年6月。参与者分别接受脊柱推拿疗法（n=201)，支持自我管理(n=305)，或支持自我管理与脊柱推拿相结合(n=193)与基于指南的医疗护理（n = 301）。物理治疗师和脊椎按摩师提供脊椎按摩和自我管理支持。在1年的随访中，平均的2个主要结局是每月腰背部残疾（Roland-Morris残疾问卷）和每周疼痛强度（数值评定量表）。二次分析检查了在主要结局测量中达到50%或更高减少的参与者的比例。

在1000名随机参与者中（平均[SD]年龄为47岁，58%为女性），93%的人完成了试验。综合检验4个治疗组在残疾方面的差异有统计学意义（P = 0.001；支持自我管理，4.7分；脊柱推拿，5.5分；支持自我管理联合脊柱推拿，4.8分；医疗护理，5.9分），但在疼痛强度方面差异无统计学意义（P = 0.16；支持自我管理，2.8分；脊柱推拿，3.0分；支持自我管理联合脊柱推拿，2.8分；医疗护理，3.0分）。平均超过12个月，与支持自我管理的医疗护理（平均差值为1.2）和支持自我管理的脊柱操作（平均差值为1.1）相比，LBP残疾显著降低，而非单独脊柱推拿（平均差值为0.4）。疼痛强度组间差异无统计学意义；点估计范围从- 0.2到0。两个支持自我管理组的患者实现50%或以上残疾减少的比例都较高（支持自我管理，67%；脊柱推拿，54%；支持自我管理与脊柱推拿相结合，65%；医疗护理，54%）。

研究结果表明，对于慢性致残性LBP风险增加的急性或亚急性LBP患者，临床医生支持的生物心理社会自我管理与医疗护理相比，在1年随访中显示有统计学意义，但残疾减少很小，疼痛没有减少，单独脊柱推拿对两种结果都没有显著差异。

附：英文原文

Title: Spinal Manipulation and Clinician-Supported Biopsychosocial Self-Management for Acute Back Pain: The PACBACK Randomized Clinical Trial

Author: Gert Bronfort, Eric N. Meier, Brent Leininger, Michael Schneider, Roni Evans, Carol Greco, Linda Hanson, Christine McFarland, Roger Chou, John Connett, Anthony Delitto, Steven Z. George, Ronald M. Glick, Francis Keefe, John Licciardone, Craig Schulz, Dennis Turk, Patrick J. Heagerty

Issue&Volume: 2025-12-29

Abstract:

Importance  Low back pain (LBP) is influenced by interrelated physical, psychological, and social factors. However, most treatments focus on symptom reduction without addressing the underlying biopsychosocial needs of patients.

Objective  To determine the effectiveness of spinal manipulation and clinician-supported biopsychosocial self-management vs medical care for adults with increased risk of chronic disabling LBP.

Design, Setting, and Participants  This 2×2 factorial randomized clinical trial enrolled participants in 3 research clinics at the Universities of Minnesota and Pittsburgh from November 2018 to May 2023; final follow-up was in June 2024. Adults with acute or subacute LBP at moderate to high risk of chronicity based on the STarT Back tool were randomized to 1 of 4 groups, with interventions lasting up to 8 weeks. Statistical analysis was conducted from November 2024 to June 2025.

Interventions  Spinal manipulation therapy (n=201), supported self-management (n=305), or combined supported self-management with spinal manipulation (n=193) compared with guideline-based medical care (n=301). Physical therapists and chiropractors provided spinal manipulation and supported self-management.

Main Outcomes and Measures  The 2 primary outcomes averaged over a follow-up of 1 year were monthly low back disability (Roland-Morris Disability Questionnaire) and weekly pain intensity (numerical rating scale). Secondary analysis examined the proportion of participants achieving a 50% or higher reduction in the primary outcome measures.

Results  Among the 1000 participants randomized (mean [SD] age, 47 [16] years; 58% female), 93% completed the trial. The omnibus test for differences across the 4 treatment groups was statistically significant for disability (P=.001; supported self-management, 4.7; spinal manipulation, 5.5; combined supported self-management with spinal manipulation, 4.8; medical care, 5.9) but not pain intensity (P=.16; supported self-management, 2.8; spinal manipulation, 3.0; combined supported self-management with spinal manipulation, 2.8; medical care, 3.0). Averaged over 12 months, LBP disability was significantly lower compared with medical care for supported self-management (mean difference, 1.2 [95% CI, 1.9 to 0.5]) and supported self-management with spinal manipulation (mean difference, 1.1 [95% CI, 1.9 to 0.3]) but not spinal manipulation alone (mean difference, 0.4 [95% CI, 1.2 to 0.4]). Group differences in pain intensity were not statistically significant; point estimates ranged from 0.2 to 0. Both supported self-management groups had higher proportions of patients achieving a 50% or greater reduction in disability (supported self-management, 67%; spinal manipulation, 54%; combined supported self-management with spinal manipulation, 65%; medical care, 54%).

Conclusions and Relevance  For patients with acute or subacute LBP at increased risk of chronic disabling LBP, clinician-supported biopsychosocial self-management showed statistically significant but small reductions in disability, but not pain, vs medical care over 1-year follow-up, and spinal manipulation alone showed no significant difference for either outcome.

DOI: 10.1001/jama.2025.21990

Source: https://jamanetwork.com/journals/jama/fullarticle/2843255