以腰痛为表现的未分化疾病的基层临床路径
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摘要
未分化疾病是指医学上无法解释的躯体症状或指疾病早期尚未明确归属于某一系统的疾病,腰痛作为常见的未分化疾病,具有高患病率、高复发率及高医疗支出等特点,且其涉及的相关疾病的种类较多,严重影响人们的生活质量,也给家庭和社会带来巨大的经济负担。本文通过检索中国知网、万方数据知识服务平台、PubMed、Web of Science等数据库中与腰痛相关的国内外文献、临床指南及专家共识等,从全科医生的视角,介绍腰痛的分类、诊断、管理等,探讨并尝试建立适用于全科医生的腰痛临床路径,旨在为全科医生提供清晰的腰痛管理思路,同时优化腰痛患者的管理,促进实现分级诊疗、双向转诊的有效开展。
Medically unexplained physical symptoms(MUPS) are physical symptoms which cannot be explained well or in the early stage of a certain disease. Low back pain is a common MUPS with characteristics of high prevalence,high recurrence rate and high medical expenditure,linking to many diseases. Moreover,it can seriously affect people's quality of life and bring about great burdens on families and society. We did a review of the articles,clinical guidelines and expert consensuses regarding low back pain that were searched from databases of CNKI,WANFANG DATA,PubMed,and Web of Science. And based on this,we detailed the types,diagnosis and management of low back pain from a general practitioner's perspective,and developed a clinical pathway for low back pain suitable for GPs using an experimental approach,aiming to provide a clear thought process of low back pain management for GPs,optimize the procedure of low back pain management,and contributing to the achievement of hierarchical diagnosis and treatment and bidirectional referrals.
Medically unexplained physical symptoms(MUPS) are physical symptoms which cannot be explained well or in the early stage of a certain disease. Low back pain is a common MUPS with characteristics of high prevalence,high recurrence rate and high medical expenditure,linking to many diseases. Moreover,it can seriously affect people's quality of life and bring about great burdens on families and society. We did a review of the articles,clinical guidelines and expert consensuses regarding low back pain that were searched from databases of CNKI,WANFANG DATA,PubMed,and Web of Science. And based on this,we detailed the types,diagnosis and management of low back pain from a general practitioner's perspective,and developed a clinical pathway for low back pain suitable for GPs using an experimental approach,aiming to provide a clear thought process of low back pain management for GPs,optimize the procedure of low back pain management,and contributing to the achievement of hierarchical diagnosis and treatment and bidirectional referrals.
引文
[1]HOY D,BAIN C,WILLIAMS G,et al.A systematic review of the global prevalence of low back pain[J].Arthritis&Rheumatism,2012,64(6):2028-2037.DOI:10.1002/art.34347.
[2]FOSTER N E,THOMPSON K A,BAXTER G D,et al.Management of non-specific low back pain by physiotherapists in Britain and Ireland[J].Spine,1999,24(21):1332-1342.
[3]AIRAKSINEN O,BROX J I,CEDRASCHI C,et al.European guidelines for the management of chronic nonspecific low back pain[J].Eur Spine J,2006,15(suppl 2):s192-300.DOI:10.1007/s00586-006-1072-1.
[4]KOES B W,VAN TULDER M,LIN C W,et al.An updated overview of clinical guidelines for the management of non-specific low back pain in primary care[J].Eur Spine J,2010,19(12):2075-2094.DOI:10.1007/s00586-010-1502-y.
[5]CHOU R,QASEEM A,SNOW V,et al.Diagnosis and treatment of low back pain:a joint clinical practice guideline from the American College of Physicians and the American Pain Society[J].Annals of Internal Medicine,2007,147(7):478-491.
[6]WILLIAMS C M,HENSCHKE N,MAHER C G,et al.Red flags to screen for vertebral fracture in patients presenting with low-back pain[J].Cochrane Database Syst Rev,2013,1:CD008643.DOI:10.1002/14651858.CD008643.pub2.
[7]DOWNIE A,WILLIAMS C M,HENSCHKE N,et al.Red flags to screen for malignancy and fracture in patients with lowback pain:systematic review[J].BMJ,2013,347:f7095.DOI:10.1136/bmj.f7095.
[8]CASSER H R,SEDDIGH S,RAUSCHMANN M.Acute lumbar back pain[J].Deutsches?rzteblatt International,2016,113(13):223-234.DOI:10.3238/arztebl.2016.0223.
[9]CHOU R,QASEEM A,OWENS D K,et al.Diagnostic imaging for low back pain:advice for high-value health care from the American College of Physicians[J].Ann Intern Med,2011,154(3):181-189.DOI:10.7326/0003-4819-154-3-201102010-00008.
[10]DOWNIE A,WILLIAMS C M,HENSCHKE N,et al.Red flags to screen for malignancy and fracture in patients with low back pain[J].Br J Sports Med,2014,48(20):1518.DOI:10.1136/bjsports-2014-f7095rep.
[11]CHOU R,HASHIMOTO R,FRIEDLY J,et al.Epidural corticosteroid injections for radiculopathy and spinal stenosis:a systematic review and meta-analysis[J].Ann Intern Med,2015,163(5):373-381.DOI:10.7326/M15-0934.
[12]RUDWALEIT M,SIEPER J.Referral strategies for early diagnosis of axial spondyloarthritis[J].Nat Rev Rheumatol,2012,8(5):262-268.DOI:10.1038/nrrheum.2012.39.
[13]PENGEL L H,HERBERT R D,MAHER C G,et al.Acute low back pain:systematic review of its prognosis[J].BMJ,2003,327(7410):323.
[14]HENSCHKE N,MAHER C G,REFSHAUGE K M,et al.Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain[J].Arthritis Rheum,2009,60(10):3072-3080.DOI:10.1002/art.24853.
[15]CHOU R,FU R,CARRINO J A,et al.Imaging strategies for low back pain:systematic review and meta-analysis[J].Lancet,2009,373(9662):463-472.DOI:10.1016/S0140-6736(09)60172-0.
[16]BARDIN L D,KING P,MAHER C G.Diagnostic triage for low back pain:a practical approach for primary care[J].Med JAust,2017,206(6):268-273.
[17]LEE J,GUPTA S,PRICE C.Low back and radicular pain:a pathway for care developed by the British Pain Society[J].British Journal of Anaesthesia,2013,111(1):112-120.DOI:10.1093/bja/aet172.
[18]Institute for Clinical Systems Improvement.Adult low back pain[EB/OL].[2018-05-06].http://www.guideline.gov/summary/summary.aspxdoc_id=9863&nbr=005287.
[19]WATERMAN B R,BELMONT P J,SCHOENFELD A J.Low back pain in the United States:incidence and risk factors for presentation in the emergency setting[J].Spine J,2012,12(1):63-70.DOI:10.1016/j.spinee.2011.09.002.
[20]GOLOB A L,WIPF J E.Low back pain[J].Med Clin North Am,2014,98(3):405-428.DOI:10.1016/j.mcna.2014.01.003.
[21]FERREIRA P H,BECKENKAMP P,MAHER C G,et al.Nature or nurture in low back pain?Results of a systematic review of studies based on twin samples[J].Eur J Pain,2013,17(7):957-971.DOI:10.1002/j.1532-2149.2012.00277.x.
[22]BALAGUéF,MANNION A F,PELLISE F,et al.Non-specific low back pain[J].Lancet,2012,379(9814):482-491.DOI:10.1016/S0140-6736(11)60610-7.
[23]NICHOLAS M K,LINTON S J,WATSON P J,et al.Early identification and management of psychological risk factors("yellow flags")in patients with low back pain:a reappraisal[J].Physical Therapy,2011,91(5):737-753.DOI:10.2522/ptj.20100224.
[24]PETIT A,ROZENBERG S,FASSIER J B,et al.Pre-returnto-work medical consultation for low back pain workers.Good practice recommendations based on systematic review and expert consensus[J].Annals of Physical and Rehabilitation Medicine,2015,58(5):298-304.DOI:10.1016/j.rehab.2015.08.001.
[25]Steffens D,MAHER C G,PEREIRA L S,et al.Prevention of low back pain a systematic review and meta-analysis[J].JAMAIntern Med,2016,176(2):199-208.DOI:10.1001/jamainte rnmed.2015.7431.
[26]CHOI B K,VERBEEK J H,TAM W W,et al.Exercises for prevention of recurrences of low-back pain[J].Cochrane Database Syst Rev,2010,1:CD006555.DOI:10.1136/oem.2010.059873.
[27]CHOU R,DEYO R,FRIEDLY J,et al.Nonpharmacologic therapies for low back pain:a systematic review for an American College of Physicians Clinical Practice Guideline[J].Ann Intern Med,2017,166(7):493-505.DOI:10.7326/M16-2459.
[28]KNAGGS R.Low back pain clinical guidelines:similarities and divergent views across the pond[J].British Journal of Pain,2017,11(2):70.DOI:10.1177/2049463717701809.
[29]CHOU R,HUFFMAN L H.Medications for acute and chronic low back pain:a review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline[J].Ann Intern Med,2007,147(7):505-514.
[30]HILL J C,DUNN K M,LEWIS M,et al.A primary care back pain screening tool:identifying patient subgroups for initial treatment[J].Arthritis&Rheumatism,2008,59(5):632-641.DOI:10.1002/art.23563.
[31]HILL J C,WHITEHURST D G,LEWIS M,et al.Comparison of stratified primary care management for low back pain with current best practice(STarT Back):a randomised controlled trial[J].Lancet,2011,378(9802):1560-1571.DOI:10.1016/S0140-6736(11)60937-9.
[32]FOURNEY D R,DETTORI J R,HALL H,et al.A systematic review of clinical pathways for lower back pain and introduction of the Saskatchewan Spine Pathway[J].Spine,2011,36(21):164-171.DOI:10.1097/BRS.0b013e31822ef58f.
[33]CASAZZA B A.Diagnosis and treatment of acute low back pain[J].American Family Physician,2012,85(4):343-350.
[34]SLIPMAN C W,PATEL R K,BOTWIN K,et al.Epidemiology of spine tumors presenting to musculoskeletal physiatrists[J].Arch Phys Med Rehabil,2003,84(4):492-495.
[35]NGUYEN T H,RANDOLPH D C.Nonspecific low back pain and return to work[J].American Academy of Family Physicians,2007,76(10):1497-1502.
[36]阮芝芳,陈辉,杨佳琦,等.杭州市拱墅区“无缝链接”双向转诊模式的实践与探讨[J].中国农村卫生事业管理,2013,33(6):620-622.RUAN Z F,CHEN H,YANG J Q,et al.Practice and discussion on the"seamless link"two-way referral mode in Gongshu District of Hangzhou City[J].Chinese Rural Health Service Administration,2013,33(6):620-622.
[37]朱敏,童晓维,张怡,等.社区眼病分级诊疗与双向转诊模式探索[J].中华全科医师杂志,2018,17(1):10-13.DOI:10.3760/cma.j.issn.1671-7368.2018.01.004.ZHU M,TONG X W,ZHANG Y,et al.Hierarchical system and two-way referral model for eye diseases management in community health service center[J].Chinese Journal of General Practitioners,2018,17(1):10-13.DOI:10.3760/cma.j.issn.1671-7368.2018.01.004.
[38]耿庆山,杜聪.新形势下的“双向转诊”合作[J].现代医院,2008,8(11):90-94.GENG Q S,DU C.Cooperation of two-way referral under new situation[J].Modern Hospital,2008,8(11):90-94.
[39]钟艳宇,陈士爵.我国医联体中双向转诊制度的实施现状及对策[J].中国医药导报,2011,14(16):154-158.ZHONG Y Y,CHEN S J.Current situation and strategy of twoway referral implementation in integrated delivery system of China[J].China Medical Herald,2011,14(16):154-158.
[40]Australian Institute of Health and Welfare.Australia's health2004[EB/OL].[2018-05-06].https://www.aihw.gov.au/.
[41]SPITZER W.Scientific approach to the assessment and management of activity-related spinal disorders[J].Spine,1987,12(7suppl):1-59.
[2]FOSTER N E,THOMPSON K A,BAXTER G D,et al.Management of non-specific low back pain by physiotherapists in Britain and Ireland[J].Spine,1999,24(21):1332-1342.
[3]AIRAKSINEN O,BROX J I,CEDRASCHI C,et al.European guidelines for the management of chronic nonspecific low back pain[J].Eur Spine J,2006,15(suppl 2):s192-300.DOI:10.1007/s00586-006-1072-1.
[4]KOES B W,VAN TULDER M,LIN C W,et al.An updated overview of clinical guidelines for the management of non-specific low back pain in primary care[J].Eur Spine J,2010,19(12):2075-2094.DOI:10.1007/s00586-010-1502-y.
[5]CHOU R,QASEEM A,SNOW V,et al.Diagnosis and treatment of low back pain:a joint clinical practice guideline from the American College of Physicians and the American Pain Society[J].Annals of Internal Medicine,2007,147(7):478-491.
[6]WILLIAMS C M,HENSCHKE N,MAHER C G,et al.Red flags to screen for vertebral fracture in patients presenting with low-back pain[J].Cochrane Database Syst Rev,2013,1:CD008643.DOI:10.1002/14651858.CD008643.pub2.
[7]DOWNIE A,WILLIAMS C M,HENSCHKE N,et al.Red flags to screen for malignancy and fracture in patients with lowback pain:systematic review[J].BMJ,2013,347:f7095.DOI:10.1136/bmj.f7095.
[8]CASSER H R,SEDDIGH S,RAUSCHMANN M.Acute lumbar back pain[J].Deutsches?rzteblatt International,2016,113(13):223-234.DOI:10.3238/arztebl.2016.0223.
[9]CHOU R,QASEEM A,OWENS D K,et al.Diagnostic imaging for low back pain:advice for high-value health care from the American College of Physicians[J].Ann Intern Med,2011,154(3):181-189.DOI:10.7326/0003-4819-154-3-201102010-00008.
[10]DOWNIE A,WILLIAMS C M,HENSCHKE N,et al.Red flags to screen for malignancy and fracture in patients with low back pain[J].Br J Sports Med,2014,48(20):1518.DOI:10.1136/bjsports-2014-f7095rep.
[11]CHOU R,HASHIMOTO R,FRIEDLY J,et al.Epidural corticosteroid injections for radiculopathy and spinal stenosis:a systematic review and meta-analysis[J].Ann Intern Med,2015,163(5):373-381.DOI:10.7326/M15-0934.
[12]RUDWALEIT M,SIEPER J.Referral strategies for early diagnosis of axial spondyloarthritis[J].Nat Rev Rheumatol,2012,8(5):262-268.DOI:10.1038/nrrheum.2012.39.
[13]PENGEL L H,HERBERT R D,MAHER C G,et al.Acute low back pain:systematic review of its prognosis[J].BMJ,2003,327(7410):323.
[14]HENSCHKE N,MAHER C G,REFSHAUGE K M,et al.Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain[J].Arthritis Rheum,2009,60(10):3072-3080.DOI:10.1002/art.24853.
[15]CHOU R,FU R,CARRINO J A,et al.Imaging strategies for low back pain:systematic review and meta-analysis[J].Lancet,2009,373(9662):463-472.DOI:10.1016/S0140-6736(09)60172-0.
[16]BARDIN L D,KING P,MAHER C G.Diagnostic triage for low back pain:a practical approach for primary care[J].Med JAust,2017,206(6):268-273.
[17]LEE J,GUPTA S,PRICE C.Low back and radicular pain:a pathway for care developed by the British Pain Society[J].British Journal of Anaesthesia,2013,111(1):112-120.DOI:10.1093/bja/aet172.
[18]Institute for Clinical Systems Improvement.Adult low back pain[EB/OL].[2018-05-06].http://www.guideline.gov/summary/summary.aspxdoc_id=9863&nbr=005287.
[19]WATERMAN B R,BELMONT P J,SCHOENFELD A J.Low back pain in the United States:incidence and risk factors for presentation in the emergency setting[J].Spine J,2012,12(1):63-70.DOI:10.1016/j.spinee.2011.09.002.
[20]GOLOB A L,WIPF J E.Low back pain[J].Med Clin North Am,2014,98(3):405-428.DOI:10.1016/j.mcna.2014.01.003.
[21]FERREIRA P H,BECKENKAMP P,MAHER C G,et al.Nature or nurture in low back pain?Results of a systematic review of studies based on twin samples[J].Eur J Pain,2013,17(7):957-971.DOI:10.1002/j.1532-2149.2012.00277.x.
[22]BALAGUéF,MANNION A F,PELLISE F,et al.Non-specific low back pain[J].Lancet,2012,379(9814):482-491.DOI:10.1016/S0140-6736(11)60610-7.
[23]NICHOLAS M K,LINTON S J,WATSON P J,et al.Early identification and management of psychological risk factors("yellow flags")in patients with low back pain:a reappraisal[J].Physical Therapy,2011,91(5):737-753.DOI:10.2522/ptj.20100224.
[24]PETIT A,ROZENBERG S,FASSIER J B,et al.Pre-returnto-work medical consultation for low back pain workers.Good practice recommendations based on systematic review and expert consensus[J].Annals of Physical and Rehabilitation Medicine,2015,58(5):298-304.DOI:10.1016/j.rehab.2015.08.001.
[25]Steffens D,MAHER C G,PEREIRA L S,et al.Prevention of low back pain a systematic review and meta-analysis[J].JAMAIntern Med,2016,176(2):199-208.DOI:10.1001/jamainte rnmed.2015.7431.
[26]CHOI B K,VERBEEK J H,TAM W W,et al.Exercises for prevention of recurrences of low-back pain[J].Cochrane Database Syst Rev,2010,1:CD006555.DOI:10.1136/oem.2010.059873.
[27]CHOU R,DEYO R,FRIEDLY J,et al.Nonpharmacologic therapies for low back pain:a systematic review for an American College of Physicians Clinical Practice Guideline[J].Ann Intern Med,2017,166(7):493-505.DOI:10.7326/M16-2459.
[28]KNAGGS R.Low back pain clinical guidelines:similarities and divergent views across the pond[J].British Journal of Pain,2017,11(2):70.DOI:10.1177/2049463717701809.
[29]CHOU R,HUFFMAN L H.Medications for acute and chronic low back pain:a review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline[J].Ann Intern Med,2007,147(7):505-514.
[30]HILL J C,DUNN K M,LEWIS M,et al.A primary care back pain screening tool:identifying patient subgroups for initial treatment[J].Arthritis&Rheumatism,2008,59(5):632-641.DOI:10.1002/art.23563.
[31]HILL J C,WHITEHURST D G,LEWIS M,et al.Comparison of stratified primary care management for low back pain with current best practice(STarT Back):a randomised controlled trial[J].Lancet,2011,378(9802):1560-1571.DOI:10.1016/S0140-6736(11)60937-9.
[32]FOURNEY D R,DETTORI J R,HALL H,et al.A systematic review of clinical pathways for lower back pain and introduction of the Saskatchewan Spine Pathway[J].Spine,2011,36(21):164-171.DOI:10.1097/BRS.0b013e31822ef58f.
[33]CASAZZA B A.Diagnosis and treatment of acute low back pain[J].American Family Physician,2012,85(4):343-350.
[34]SLIPMAN C W,PATEL R K,BOTWIN K,et al.Epidemiology of spine tumors presenting to musculoskeletal physiatrists[J].Arch Phys Med Rehabil,2003,84(4):492-495.
[35]NGUYEN T H,RANDOLPH D C.Nonspecific low back pain and return to work[J].American Academy of Family Physicians,2007,76(10):1497-1502.
[36]阮芝芳,陈辉,杨佳琦,等.杭州市拱墅区“无缝链接”双向转诊模式的实践与探讨[J].中国农村卫生事业管理,2013,33(6):620-622.RUAN Z F,CHEN H,YANG J Q,et al.Practice and discussion on the"seamless link"two-way referral mode in Gongshu District of Hangzhou City[J].Chinese Rural Health Service Administration,2013,33(6):620-622.
[37]朱敏,童晓维,张怡,等.社区眼病分级诊疗与双向转诊模式探索[J].中华全科医师杂志,2018,17(1):10-13.DOI:10.3760/cma.j.issn.1671-7368.2018.01.004.ZHU M,TONG X W,ZHANG Y,et al.Hierarchical system and two-way referral model for eye diseases management in community health service center[J].Chinese Journal of General Practitioners,2018,17(1):10-13.DOI:10.3760/cma.j.issn.1671-7368.2018.01.004.
[38]耿庆山,杜聪.新形势下的“双向转诊”合作[J].现代医院,2008,8(11):90-94.GENG Q S,DU C.Cooperation of two-way referral under new situation[J].Modern Hospital,2008,8(11):90-94.
[39]钟艳宇,陈士爵.我国医联体中双向转诊制度的实施现状及对策[J].中国医药导报,2011,14(16):154-158.ZHONG Y Y,CHEN S J.Current situation and strategy of twoway referral implementation in integrated delivery system of China[J].China Medical Herald,2011,14(16):154-158.
[40]Australian Institute of Health and Welfare.Australia's health2004[EB/OL].[2018-05-06].https://www.aihw.gov.au/.
[41]SPITZER W.Scientific approach to the assessment and management of activity-related spinal disorders[J].Spine,1987,12(7suppl):1-59.