Kvine 2010-3-16 12:41
CBT顯著改善短期與長期的下背痛
作者：Pam Harrison
出處：WebMD醫學新聞
March 2, 2010 — 新研究認為，相較於只有提供建議，認知行為治療(Cognitive behavioral therapy，CBT)顯著改善了短期與一年之亞急性與慢性下背痛，且有高度成本效益。
研究結果線上發表於2月26日The Lancet期刊，研究者發現，在12個月之後，以Roland Morris問卷這種背痛失能量表測量時，相較於對照組的1.1分，「訂做的」CBT (Back Skills Training [BeST])組的失能分數改善了2.4分。
本研究中使用的CBT介入是特別設計來表達因為背痛導致失能的風險因素，從開始時到12個月時的修改版Von Korff失能分數變化，介入組為13.8%，對照組為5.4%，而同一時間點中，CBT組修改版Von Korff疼痛分數的改變為13.4%，對照組為6.4%。
研究者指出，每一調整品質後存活人年，BeST策略的總計費用為1786英鎊(約新台幣86,000元)，少於針灸等其他介入方式之一半。
研究者指出，可導致下背痛持續改善的有效治療方式是難以捉摸的，本試驗顯示，訂做的認知行為介入計劃－BeST，可於一線照護中有效處置亞急性與慢性下背痛。
【中等病情】
為了本研究，英國Coventry Warwick大學的Sarah Lamb醫師等人，將701名病情中等的亞急性或慢性下背痛病患隨機分組到CBT組或者只有給予建議。
總共有468名病患接受至多6次的CBT療程，另有233名對照組，只有接受15分鐘的主動處置建議而無其他額外治療，建議包括如何維持活動的好處、如何避免臥床休息、適當使用止痛藥物等，所有研究對象都獲得「The Back Book (Spine. 1999;24:2484)」這份資料。
隨機分到CBT組者參與BeST計畫，包括了至多1.5小時的個人評估，以及6次的團體治療、每次1.5小時。研究作者解釋，訓練包括引導發現、瞭解與對抗負面的自動化思考、步態、分級活動、放鬆與其他技能，每一組開始時的人數平均為8人。
對於多數研究對象而言，在隨機分組之後45天之內開始治療，CBT組有75%在隨機分組的3個月內完成介入。
根據自我評比的治療利益，結果顯示，指派到BeST計畫的病患有59%報告指出在12個月時恢復，控制組則有31%(P < .0001)。
研究者指出，治療12個月時，認知行為介入組比對照組有更多病患對治療感到滿意，介入組有65%、對照組有28%。
同樣在CBT組有實質改善而對照組沒有的包括恐懼避免、疼痛之自我效能以及包含12項的簡短版健康調查體能分數。
表、控制組以及建議加CBT組的檢測分數 檢測
控制組
建議加 CBT 組
P 值
12 個月時的 Roland Morris 問卷分數
1.1 points
2/4 points
.0008
12 個月時的 修改版 Von Korff 失能 分數
5.4%
13.8%
.0001
12 個月時的 修改版 Von Korff 疼痛 分數
6.4%
13.4%
<.0001
CBT =認知行為治療
【成本效益】
如研究者所指出的，相對於其他實際用於治療下背痛的介入方式，BeST計畫具有高度成本效益，每個人每年的平均整體健康照護費用，單純建議組為224.65英鎊(約新台幣10,800元)，建議加CBT組為421.52英磅(約新台幣20,300元)，至於每人的平均費用，單純建議組為16.32英鎊(約新台幣787元)，建議加CBT組為187.00英磅(約新台幣9,000元)。
研究者寫道，整體健康照護費用的差異，主要幾乎都可以歸因於認知行為治療的額外費用，再者，他們指出，短期(≦4 個月)效果類似於那些關於一線照護的外科手法、運動、針灸、姿勢方式等之高品質研究以及系統性回顧結果。
再者，與其他多種治療不同的是，CBT的幫助範圍相當廣且可維持到12個月，Lamb醫師向Medscape Psychiatry表示，我們已經知道，增加體能活動是破解「疼痛、無活性、更多疼痛」之循環的關鍵。
另一方面，醫師們承認，當病患感到疼痛時，很難要他們做更多活動，事實上他們可能會感到害怕，而這會使得情況惡化。
Lamb醫師指出，我們教病患如何挑戰這些想法，找到改善他們的活動力的方法，所以，CBT幫助人們改變有關疼痛的想法，因此，改變了他們疼痛時的行為。
【值得注意之處】
肯塔基州Paducah疼痛處置中心的Laxmaiah Manchikanti醫師，對於在一線照護中例行性獲得CBT治療下背痛提出一個值得注意之處，至少在美國，全國性的健康照護系統尚未就緒。
他也在編輯評論中指出，指定到CBT的病患只有63%符合順從性臨界值，其中的11%並未接受任何CBT，開業醫師也需考量CBT的實際成本效益，因為單純建議的平均費用只要16.32英鎊(約新台幣787元)，建議加CBT組為187.00英磅(約新台幣9,000元)，這是很大的差異。
此外，Manchikanti醫師表示，結果令人印象深刻，認為CBT是一線照護醫師尋求特定諮商之前，可以提供給病患的極佳選項，因為在這些病患中，治療在臨床上是有可行性的，但是經濟上並不一定負擔得起。
國家健康研究健康科技評估計畫研究中心資助本試驗，研究作者們皆宣告沒有相關財務關係。
The Lancet. 線上發表於2010年2月26日。
CBT Significantly Improves Low Back Pain in the Short and Long Term
By Pam Harrison
Medscape Medical News
March 2, 2010 — Cognitive behavioral therapy (CBT) significantly improves subacute and chronic low back pain both in the short term and during 1 year compared with advice alone and is highly cost-effective, new research suggests.
Published online February 26 in The Lancet, investigators found that disability scores as measured by the Roland Morris questionnaire — a measure of back pain disability — improved by 2.4 points at the end of 12 months in the "bespoke" CBT (Back Skills Training [BeST]) group compared with 1.1 points among control patients.
The CBT intervention used in this study was specifically designed to address risk factors leading to disability from back pain. Change from baseline to 12 months in the modified Von Korff disability score was 13.8% in the intervention group vs 5.4% in controls, whereas change in the modified Von Korff pain score at the same endpoint was 13.4% in the CBT group and 6.4% in controls.
Per quality-adjusted life-year, the cost of the BeST strategy totaled ￡1786 — less than half that of competing interventions, such as acupuncture, the investigators note.
"Effective treatments that result in sustained improvements in low back pain are elusive," the study authors note, "and this trial shows that a bespoke cognitive behavioral intervention package, BeST, is effective in managing subacute and chronic low back pain in primary care."
Moderately Troublesome
For the study, Sarah Lamb, PhD, University of Warwick, Coventry, United Kingdom, and colleagues randomized 701 patients with moderately troublesome subacute or chronic low back pain to group CBT or to advice alone.
A total of 468 patients were treated with up to 6 sessions of group CBT, whereas 233 controls received no additional treatment other than a 15-minute session of active management advice, including the benefit of how to remain active, how to avoid bed rest, and the appropriate use of pain medication. All participants were also given The Back Book (Spine. 1999;24:2484).
Those randomized to the CBT group attended the BeST program, which consisted of an individual assessment of up to 1.5 hours and 6 sessions of group therapy again lasting 1.5 hours. "Training consisted of guided discovery, identifying and countering negative automatic thoughts, pacing, graded activity, relaxation, and other skills," the study authors explain, "and each group started with a mean of 8 participants."
For most participants, treatment started within 45 days of randomization, and 75% of the CBT group completed the intervention within 3 months of randomization.
According to self-rated benefit from treatment, results showed that 59% of patients assigned to the BeST program reported recovery at 12 months compared with 31% of controls (P < .0001).
"More participants in the cognitive behavioral intervention group than the control group were satisfied with their treatment at 12 months," the study authors add — at 65% of the intervention group vs 28% of controls.
Fear avoidance, pain self-efficacy, and the 12-item Short Form Health Survey physical scores also improved "substantially" in the CBT group but not in the control group.
Table. Test Scores for the Control and Advice Plus CBT Groups
Test Control Group Advice Plus CBT Group P Value
Roland Morris questionnaire score at 12 months 1.1 points 2/4 points .0008
Modified Von Korff disability score at 12 months 5.4% 13.8% .0001
Modified Von Korff pain score at 112 months 6.4% 13.4% <.0001
CBT = cognitive behavioral therapy
Cost-Effective
As the investigators note, the BeST program was highly cost-effective relative to virtually any other intervention used to treat low back pain. Per person, the mean total healthcare costs for 1 year were ￡224.65 for advice alone and ￡421.52 for advice plus CBT, whereas the mean cost per person was ￡16.32 for advice alone and ￡187.00 for advice plus CBT.
"The difference in total healthcare costs was attributable almost entirely to the additional cost of the cognitive behavioral intervention," the investigators write. Further, they note that "the short-term effects (?4 months) are similar to those seen in high-quality studies and systematic reviews of manipulation, exercise, acupuncture, and postural approaches in primary care."
Furthermore, unlike many other treatments, the benefits of CBT were wide-ranging and maintained at 12 months. "We have known for quite some time that increasing physical activity is key to breaking the cycle between pain, inactivity, and more pain," Dr. Lamb told Medscape Psychiatry.
On the other hand, physicians acknowledge that it is difficult for patients to become more active when they have pain and that they can in fact be afraid to move for fear of making things worse.
"We teach people how to challenge these thoughts and to test out ways of improving their activity so CBT helps people to change the way they think about pain and, hence, how they behave when they have it," Dr. Lamb added.
Note of Caution
Laxmaiah Manchikanti, MD, Pain Management Center of Paducah, Kentucky, sounded a note of caution about the routine availability of group CBT for low back pain in primary care — at least in the United States, where there is no national healthcare system in place.
He also points out in an accompanying editorial that only 63% of patients assigned to CBT met the compliance threshold, whereas 11% of them did not receive any CBT. Practitioners must also consider how cost-effective CBT really is, given that the average cost of advice was only ￡16.32 compared with ￡187 for CBT, "a substantial difference," he notes.
Still, Dr. Manchikanti said the results were impressive and suggest that CBT "is an excellent option for primary care physicians before they seek specialty consultations for their patients” because in these individuals the treatment is “feasible clinically and economically [although] not a panacea."
The trial was funded by the National Institute for Health Research Health Technology Assessment Programme. The study authors have disclosed no relevant financial relationships.
The Lancet. Published online February 26, 2010.