整脊對於下背痛的治療比Sham療法更好


  2003年6月2日--在二篇發表於6月3日Annals of Internal Medicine的系統性回顧文章中,針對人工的下背痛治療方法進行了比較,第一項研究指出,並無證據顯示整脊比其他標準的背部疼痛治療更加有效,第二項研究尋找可以證實按摩和整脊具有臨床優點的證據,但是缺乏針灸的証據,按摩療法可能是唯一可以減少醫療費用的人工治療。
  
  Cochrane背部回顧小組的Willem J. J. Assendelft博士表示,之前的系統性回顧和施行指導方針,針對[整脊]對於下背痛的療效得到不一樣的結果,我們的結論是,整脊治療是幾種只能適度緩解患者下背痛的療法之一。
  
  這項整合性分析從MEDLINE、EMBASE、CINAHL、Cochrane試驗登錄及之前的系統回顧中,針對39項隨機化控制組試驗進行分析。
  
  整脊治療在臨床上和統計上僅勝於Sham療法和其他效率較低或甚至有害的治療方法,如牽引法、束衣、臥床休息、家庭照顧、局部凝膠、未進行治療和最低限度的按摩,和Sham療法相較之下,在一個100毫米的視覺模擬刻度上,其差異為10毫米(95% 信賴區間,2-17毫米)。
  
  並無證據顯示整脊療法比其他建議的方法更好或更差,其他方法包括止痛劑、運動鍛鍊、物理治療和訓練(背部訓練學校)。
  
  作者並未報告資金資助的來源,這項研究並無外來的資金贊助,在第二項回顧中,作者從1995年起的隨機化控制組試驗的系統性回顧,取得所需的研究資料,一共包括20項評估針灸對於持久性下背痛的有效性、安全性和費用的研究,以及3項評估按摩治療持久性下背痛的研究,和26項評估整脊治療持久性下背痛費用的研究。
  
  所有治療似乎都是相對地安全的,而按摩具有一些好處,也是可以減少醫療費用的唯一形式。相較於止痛劑、物理治療或背部運動,整脊療法具有較小的臨床優點。由於這些研究的品質不佳,所以針灸的有效性仍然不清楚。
  
  因為有越來越多的證據顯示,患者的期望會影響結果,所以讓患者選擇他們認為最有效的治療方式,可以改善治療結果。提供患者補充或替代藥物治療時,應該考慮這些治療與傳統治療之有效性、安全性、費用的比較,以及考慮患者的偏好和期望。
  

Spinal Manipulation Better Tha

By Laurie Barclay, MD
Medscape Medical News

June 2, 2003 — Two systematic review articles published in the June 3 issue of the Annals of Internal Medicine look at the use of manual therapy for low back pain. The first shows that there is no evidence that spinal manipulation is superior to other standard treatments for chronic low back pain. The second finds evidence that massage and spinal manipulation may have small clinical benefits, but there is a lack of evidence for acupuncture. Massage therapy may be the only manual therapy that offers a reduction in healthcare costs.

"Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of [spinal manipulative] therapy for low back pain," write Willem J. J. Assendelft, MD, PhD, from the Cochrane Back Review Group, and colleagues. "We conclude that spinal manipulative therapy is one of several options of only modest effectiveness for patients with low back pain."

This meta-analysis identified 39 randomized controlled trials from MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews.

Spinal manipulative therapy was clinically and statistically superior only to sham manipulation or to the group of therapies judged to be ineffective or even harmful, such as traction, corset, bed rest, home care, topical gel, no treatment, and minimal massage. Compared with sham therapy, the difference on a 100-mm visual analogue scale was 10 mm (95% confidence interval, 2 - 17 mm).

There was no evidence that spinal manipulative therapy was either superior or inferior to other recommended therapies, including analgesics, exercises, physical therapy, and education about back injury prevention and ways to deal with back pain (back school).

The authors report no potential financial conflicts of interest, and this study had no external funding.

In the second review, the authors extracted data from systematic reviews of randomized controlled trials published since 1995, including 20 evaluating the effectiveness, safety, and cost of acupuncture, three evaluating massage therapy, and 26 evaluating spinal manipulation for persistent back pain.

All of these treatments appeared to be relatively safe. Massage had some benefit and was the only modality that reduced healthcare costs. Spinal manipulative therapy had small clinical benefits comparable to those of analgesics, physical therapy, or back exercises. Because of the poor quality of the trials, the effectiveness of acupuncture remains unclear.

"Because there is growing evidence that patient expectations affect outcomes, allowing patients to choose the treatment they believe will be most helpful may improve results," the authors write. "The decisions to offer complementary and alternative medicine therapies to patients should consider effectiveness, safety, costs, the relative effectiveness of these therapies compared with conventional treatments, and patient preferences and expectations."

The second author is the former research director of the Northwest Institute of Acupuncture and Oriental Medicine.

Ann Intern Med. 2003;138:871-881, 898-906

Reviewed by Gary D. Vogin, MD

    
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