Risk-stratified Care Improves Pain-related Knowledge and Reduces Psychological Distress for Low Back Pain: A Secondary Analysis of a Randomized Trial.

IF 4.2 2区 医学 Q1 ORTHOPEDICS
Tina A Greenlee, Steven Z George, Bryan Pickens, Daniel I Rhon
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引用次数: 0

Abstract

Background: A number of efforts have been made to tailor behavioral healthcare treatments to the variable needs of patients with low back pain (LBP). The most common approach involves the STarT Back Screening Tool (SBST) to triage the need for psychologically informed care, which explores concerns about pain and addresses unhelpful beliefs, attitudes, and behaviors. Such beliefs that pain always signifies injury or tissue damage and that exercise should be avoided have been implied as psychosocial mediators of chronic pain and can impede recovery. The ability of physical therapy interventions guided by baseline stratification for risk of persistent LBP or related functional limitations to improve unhelpful pain beliefs has not been well assessed. Because treatments are aimed at addressing these beliefs, understanding a bit more about the nature of beliefs about pain (for example, attitudes and knowledge) might help us understand how to better tailor this care or even our risk-stratification approaches for future treatment of patients with LBP.

Questions/purposes: (1) Did patients assigned to receive risk-stratified care score higher on an assessment of pain science knowledge? (2) Did patients assigned to receive risk-stratified care have fewer unhelpful attitudes related to pain? (3) Did patients assigned to receive risk-stratified care have less pain-associated psychological distress? (4) Regardless of intervention received, is baseline SBST risk category (low, medium, or high) associated with changes in attitudes and knowledge about pain?

Methods: This is a secondary analysis of short-term changes in pain beliefs following the 6-week treatment phase of a randomized controlled trial that examined the effectiveness of a risk-stratified physical therapy intervention on pain-related disability at 1 year. Between April 2017 and February 2020, a total of 290 patients in the Military Health System seeking primary care for LBP were enrolled in a trial comparing a behavioral-based intervention to usual care. The intervention involved psychologically informed physical therapy using cognitive behavioral principles and included tailored education, graded exercise, and graded exposure. Individuals assigned to usual care followed treatment plans set forth by their primary care provider. Thirty-one patients were removed from Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool analyses due to missing assessments at 6 weeks (n = 15 intervention; n = 16 usual care). This resulted in 89% (259 of 290) of participants included for secondary analysis, with no difference in baseline demographic characteristics between groups. The usual-care group comprised 50% of the total study group (129 of 259), with a mean age of 34 ± 9 years; 67% (87 of 129) were men. The risk-stratified care group comprised 50% (130 of 259) of the total study group, with a mean ± SD age of 35 ± 8 years; 64% (83 of 130) were men. Six additional individuals were removed from Survey of Pain Attitudes harm scale (SOPA-h) and revised Neurophysiology of Pain Questionnaire (rNPQ) analyses for missing baseline data (n = 1 intervention) and 6-week data (n = 2 intervention; n = 3 usual care). The rNPQ captured current pain science knowledge, the SOPA-h examined patient attitudes about pain (the extent of beliefs that pain leads to damage and that movement is harmful), and the OSPRO-YF assessed patients for yellow flag clinical markers of pain-related psychological distress across 11 constructs within domains of negative mood, fear avoidance, and positive affect/coping indicative of elevated vulnerability and decreased resilience. Outcomes were assessed at baseline and 6 weeks, and data were analyzed per protocol. We assessed between-group differences at 6 weeks using linear mixed-effects models of pain attitudes and knowledge and related distress, controlling for age, gender, and baseline pain. Regardless of treatment group, we also analyzed differences in rNPQ and SOPA-h scores at 6 weeks based on SBST risk category (low versus medium or high) using generalized linear (Gaussian) regression models.

Results: Risk-stratified treatment was associated with improvements in pain knowledge (rNPQ mean difference 6% [95% confidence interval (CI) 1% to 11%]; p = 0.01) and a reduction in indicators of pain-associated psychological distress (OSPRO-YF mean difference -1 [95% CI -2 to 0]; p = 0.01) at 6 weeks compared with usual care. There was no difference between groups for SOPA-h score at 6 weeks (mean difference -0.2 [95% CI -0.3 to 0.0]; p = 0.09). Patients with medium- or high-risk scores on the SBST, regardless of intervention, improved slightly more on SOPA-h (β = -0.31; p < 0.01) but not rNPQ (β = 0.02; p = 0.95) than those scoring low risk.

Conclusion: Patients receiving risk-stratified care showed small improvements in pain knowledge and reductions in pain-related psychological distress at 6 weeks, immediately after intervention, compared with usual care. Implementation of this risk-stratified care approach for LBP was able to change patients' perceptions about pain and reduce some of their psychological distress beyond what was achieved by usual care in this setting. As these factors are believed to favorably mediate treatment outcomes, future studies should investigate whether these improvements persist over the long term, determine how they influence clinical outcomes, and explore alternatives for risk stratification and treatment to elicit greater improvements.Level of Evidence Level III, therapeutic study.

风险分层护理提高疼痛相关知识,减少腰痛的心理困扰:一项随机试验的二次分析。
背景:针对下腰痛(LBP)患者的不同需求,已经做出了许多努力来定制行为保健治疗。最常见的方法是使用STarT Back Screening Tool (SBST)来对心理知情护理的需求进行分类,该工具探讨了对疼痛的担忧,并解决了无益的信念、态度和行为。疼痛总是意味着损伤或组织损伤,应该避免运动,这种信念被认为是慢性疼痛的社会心理媒介,并可能阻碍康复。对持续腰痛或相关功能限制风险进行基线分层指导的物理治疗干预改善无益疼痛信念的能力尚未得到很好的评估。因为治疗的目的是解决这些信念,更多地了解关于疼痛的信念的本质(例如,态度和知识)可能有助于我们了解如何更好地定制这种护理,甚至我们的风险分层方法,为未来治疗LBP患者。问题/目的:(1)接受风险分层护理的患者是否在疼痛科学知识评估中得分更高?(2)接受风险分层治疗的患者对疼痛的消极态度是否更少?(3)接受风险分层护理的患者是否有更少的疼痛相关心理困扰?(4)无论接受何种干预,基线SBST风险类别(低、中、高)是否与对疼痛的态度和知识的改变有关?方法:这是一项随机对照试验的二次分析,在为期6周的治疗阶段后,疼痛信念的短期变化,该试验检验了风险分层物理治疗干预1年后疼痛相关残疾的有效性。在2017年4月至2020年2月期间,共有290名在军事卫生系统中寻求LBP初级保健的患者参加了一项比较基于行为的干预与常规护理的试验。干预包括使用认知行为原则的心理知情物理治疗,包括量身定制的教育、分级运动和分级暴露。被分配到常规护理组的个体遵循他们的初级保健提供者制定的治疗计划。31名患者因在6周时缺少评估而从预测转诊和结局的最佳筛查黄旗(OSPRO-YF)工具分析中剔除(n = 15干预;N = 16例常规护理)。这导致89%(290人中的259人)的参与者被纳入二次分析,两组之间的基线人口统计学特征没有差异。常规护理组占总研究组的50%(259例中有129例),平均年龄34±9岁;67%(129人中87人)为男性。风险分层护理组占总研究组的50%(259人中有130人),平均±SD年龄为35±8岁;其中64%(130人中83人)为男性。从疼痛态度伤害调查量表(SOPA-h)和修订的疼痛神经生理学问卷(rNPQ)分析中删除另外6名个体,因为缺少基线数据(n = 1干预)和6周数据(n = 2干预;N = 3例常规护理)。rNPQ收集了当前的疼痛科学知识,SOPA-h检查了患者对疼痛的态度(疼痛导致损伤和运动有害的信念程度),OSPRO-YF评估了患者在消极情绪、恐惧回避和积极影响/应对领域的11个结构中与疼痛相关的心理困扰的黄旗临床标志,这些结构表明脆弱性升高和恢复力下降。在基线和6周时评估结果,并按方案分析数据。在控制年龄、性别和基线疼痛的情况下,我们使用疼痛态度、知识和相关痛苦的线性混合效应模型评估6周时组间差异。无论治疗组如何,我们还使用广义线性(高斯)回归模型分析了基于SBST风险类别(低与中或高)的6周rNPQ和SOPA-h评分的差异。结果:风险分层治疗与疼痛知识的改善相关(rNPQ平均差值为6%[95%置信区间(CI) 1%至11%];p = 0.01),疼痛相关心理困扰指标降低(OSPRO-YF平均差值-1 [95% CI -2至0];P = 0.01)。6周时两组间SOPA-h评分无差异(平均差异-0.2 [95% CI -0.3 ~ 0.0];P = 0.09)。不论采取何种干预措施,在SBST中或高风险评分的患者在SOPA-h上的改善略多(β = -0.31;p < 0.01),但rNPQ不存在(β = 0.02;P = 0.95)。 结论:与常规护理相比,接受风险分层护理的患者在干预后6周的疼痛知识和疼痛相关心理困扰方面略有改善。实施这种风险分层治疗LBP的方法能够改变患者对疼痛的看法,并减少他们的一些心理困扰,而不是在这种情况下的常规治疗所达到的。由于这些因素被认为有利于调节治疗结果,未来的研究应调查这些改善是否能长期持续,确定它们如何影响临床结果,并探索风险分层和治疗的替代方案,以获得更大的改善。证据等级:III级,治疗性研究。
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来源期刊
CiteScore
7.00
自引率
11.90%
发文量
722
审稿时长
2.5 months
期刊介绍: Clinical Orthopaedics and Related Research® is a leading peer-reviewed journal devoted to the dissemination of new and important orthopaedic knowledge. CORR® brings readers the latest clinical and basic research, along with columns, commentaries, and interviews with authors.
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