physioscience 2005; 1(2): 59-66
DOI: 10.1055/s-2005-858483
Originalarbeit

© Georg Thieme Verlag KG Stuttgart · New York

Evidenz der Bewegungstherapie und Manuellen Therapie bei chronischen nichtspezifischen Rückenschmerzen - Darstellung der Europäischen Leitlinien - Teil 1

Evidence of the Efficacy of Exercise Therapy and Manual Therapy in the Management of Chronic Non-specific Low Back Pain - Presentation of the European GuidelinesJ. Hildebrandt1 , A. F. Mannion1 , J. I. Brox1 , F. Kovacs1 , J. Klaber-Moffett1 , B. Staal1
  • 1Universitätsklinik Göttingen, Zentrum Anästhesie, Rettungs- und Intensivmedizin
Further Information

Publication History

eingereicht: 21.03.2005

angenommen: 20.04.2005

Publication Date:
08 August 2005 (online)

Zusammenfassung

Hintergrund: Chronische nichtspezifische Rückenschmerzen sind in der Bevölkerung weit verbreitet.

Ziel: Das primäre Ziel europäischer evidenzbasierter Leitlinien für Rückenschmerzen ist es, Vorschläge zu machen, die als Instrument für existierende oder zukünftige nationale und internationale Leitlinien dienen können. Somit soll der Zugang zu einer wirksamen Therapie von chronischen unspezifischen Rückenschmerzen ermöglicht werden. Schwerpunkt dieses Artikels ist die Beschreibung der Effektivität von Bewegungstherapie und Manueller Therapie.

Methode: Die systematische Literatursuche erfolgte in den Datenbanken Medline, Embase, Cochrane Library, CINAHL, HealthStar, Pascal, PEDro, Psyclit, Biosis, Lilacs und IME (Indice Medico Espanol). Die methodische Qualität systematischer Übersichtsarbeiten wurde mit dem Oxman-&-Guyatt-Index geprüft. Randomisierte kontrollierte Studien wurden auf interne Validität begutachtet.

Ergebnisse: Die Suche ergab 54 Studien, von denen 30 als qualitativ hochwertig eingestuft werden konnten. Überwachte Bewegungstherapie ist die wichtigste Maßnahme gegen chronische Rückenschmerzen. Dazu sind keine teuren Maschinen notwendig. Die Anwendung verhaltenstherapeutischer Prinzipien mit schrittweiser Anwendung der Übungen nach „Quoten” scheint das sinnvollste Konzept zu sein. Gruppentherapie ist aus Kostengründen zu bevorzugen. Empfehlungen für spezifische Übungen (z. B. Trainingstherapie, Aerobic, McKenzie, Flexionsübungen) können nicht gegeben werden; sie sind von der Ausbildung der Physiotherapeutinnen und den Bedürfnissen der Patienten abhängig. Wie Bewegungstherapie wirkt, ist unklar: Es gibt keinen Zusammenhang zwischen Verbesserung von Schmerz/Befinden und körperlicher Leistungsfähigkeit. Die Rolle von Manueller Therapie in der Behandlung von chronischen Rückenschmerzen ist nicht eindeutig. Sie ist nur eine Therapieoption als zusätzliche Maßnahme mit geringer Effektivität wie viele andere Behandlungen auch. Manuelle Therapie sollte nur über einen kurzen Zeitraum erfolgen.

Schlussfolgerung: Passive Maßnahmen scheinen keinen Einfluss auf chronische nichtspezifische Rückenschmerzen zu haben. Man sollte ein aktives in der Intensität langsam gesteigertes Bewegungsprogramm bevorzugen. Künftige Studien sollten Kosten-Nutzen- und Risiko-Nutzen-Analysen einschließen.

Abstract

Background: Chronic non-specific low back pain is common in the general population.

Objective: The primary objective of the European evidence-based guidelines on low back pain is to provide a set of recommendations that can support existing and future national and international guidelines, thus allowing an approach to effective treatment of non-specific chronic low back pain. The main focus of this article is to describe the efficacy of exercise therapy and manual therapy.

Methods: A systematic literature review was conducted at the databases of Medline, Embase, Cochrane Library, CINAHL, HealthStar, Pascal, PEDro, Psyclit, Biosis, Lilacs and IME (Indice Medico Espanol). The methodological quality of the systematic review articles was assessed by the Oxman & Guyatt Index. Randomised controlled trials were examined for their internal validity.

Results: 54 articles were identified, 30 of them were of high methodological quality. Supervised exercise therapy is recommended as the most important treatment for chronic non-specific low back pain. Exercise therapy does not require expensive training machines. The application of a cognitive-behavioural approach, in which graded exercises are performed, using exercise quotas, appears to be the most useful concept. Group therapy should be preferred due to lower cost. Recommendations on specific types of exercise (i. e. strengthening/muscle conditioning, aerobic, McKenzie, flexion exercises) can not be given; they depend on the Physiotherapists’ education and the patients’ needs. The effect of exercise therapy is not clear: There is no connection between the improvement of pain/disability and physical performance capacity. The role of manual therapy in the treatment of chronic low back pain is not quite clear. It is only a treatment option as an additional measure with only moderate efficacy, like many other treatments. The course of spinal manipulation/mobilisation should only be short term.

Conclusion: Passive interventions seem to have no effect on chronic non-specific low back pain. An active exercise program with slowly increased intensity should be favoured. Future studies should include cost-benefit and risk-benefit analysis.

Literatur

  • 1 Abenhaim L, Rossignol M, Valat J P. et al . The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain.  Spine. 2000;  25 1S-33S
  • 2 Aure O F, Nilsen J H, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up.  Spine. 2003;  28 525-531; discussion: 531 - 532
  • 3 Bendix A F, Bendix T, Ostenfeld S. et al . Active treatment programs for patients with chronic low back pain: a prospective, randomized, observer-blinded study.  Eur Spine J. 1995;  4 148-152
  • 4 Bendix A E, Bendix T, Haestrup C. et al . A prospective, randomized 5-year follow-up study of functional restoration in chronic low back pain patients.  Eur Spine J. 1998;  7 111-119
  • 5 Bendix T, Bendix A, Labriola M. et al . Functional restoration versus outpatient physical training in chronic low back pain: a randomized comparative study.  Spine. 2000;  25 2494-2500
  • 6 Bentsen H, Lindgarde F, Manthorpe R. The effect of dynamic strength back exercise and/or a home training program in 57-year-old women with chronic low back pain. Results of a prospective randomized study with a 3-year follow-up period.  Spine. 1997;  22 1494-1500
  • 7 Bronfort G, Goldsmith C H, Nelson C F. et al . Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: a randomized, observer-blinded clinical trial.  J Manipulative Physiol Ther. 1996;  19 570-582
  • 8 Brox J I, Hagen K B, Juel N G. et al . Is exercise therapy and manipulation effective in low back pain?.  Tidsskr Nor Laegeforen. 1999;  119 2042-2050
  • 9 Buswell J. Low back pain: a comparison of two treatment programmes.  NZ J Physiotherapy. 1982;  10 13-17
  • 10 Callaghan M. Evaluation of a back rehabilitation group of chronic back pain in an outpatient setting.  Physiotherapy. 1994;  10 677-681
  • 11 Colle F, Poiraudeau S, Revel M. Critical analysis of a systematic review of the literature and a meta-analysis on exercise therapy and chronic low back pain.  Ann Readapt Med Phys. 2001;  44 221-233
  • 12 Daniels K, Denner A. Analysis based medical training therapy for the spine (FPZ concept): quality assurance in the scope of evidence-based medicine.  Z Ärztl Fortbild Qualitätssich. 1999;  93 IV-V
  • 13 Descarreaux M, Normand M C, Laurencelle L. et al . Evaluation of a specific home exercise program for low back pain.  J Manipulative Physiol Ther. 2002;  25 497-503
  • 14 Deyo R A, Walsh N E, Martin D C. et al . A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain.  N Engl J Med. 1990;  322 1627-1634
  • 15 Ebenbichler G R, Oddsson L I, Kollmitzer J. et al . Sensory-motor control of the lower back: implications for rehabilitation.  Med Sci Sports Exerc. 2001;  33 1889-1898
  • 16 Elnaggar I M, Nordin M, Sheikhzadeh A. et al . Effects of spinal flexion and extension exercises on low-back pain and spinal mobility in chronic mechanical low-back pain patients.  Spine. 1991;  16 967-972
  • 17 Evans G, Richards S. Low back pain: an evaluation of therapeutic interventions. Bristol; University of Bristol Health Care Evaluation Unit 1996
  • 18 Faas A. Exercises: which ones are worth trying, for which patients, and when?.  Spine. 1996;  21 2874-2878; discussion: 2878 - 2879
  • 19 Franke A, Gebauer S, Franke K. et al . Acupuncture massage vs. Swedish massage and individual exercise vs. group exercise in low back pain sufferers - a randomized controlled clinical trial in a 2 × 2 factorial design.  Forsch Komplementärmed Klass Naturheilkd. 2000;  7 286-293
  • 20 Friedrich M, Gittler G, Halberstadt Y. et al . Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomized controlled trial.  Arch Phys Med Rehabil. 1998;  79 475-487
  • 21 Frost H, Klaber-Moffett J A, Moser J S. et al . Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain.  BMJ. 1995;  310 151-154
  • 22 Frost H, Lamb S E, Klaber-Moffett J A. et al . A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial.  Pain. 1998;  75 273-279
  • 23 Ghoname E A, Craig W F, White P F. et al . Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study.  JAMA. 1999;  281 818-823
  • 24 Gur A, Karakoc M, Cevik R. et al . Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain.  Lasers Surg Med. 2003;  32 233-238
  • 25 Hagen E M, Eriksen H R, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain?.  Spine. 2000;  25 1973-1976
  • 26 Hansen F R, Bendix T, Skov P. et al . Intensive, dynamic back-muscle exercises, conventional physiotherapy, or placebo-control treatment of low-back pain. A randomized, observer-blind trial.  Spine. 1993;  18 98-108
  • 27 Hemmila H M, Keinanen-Kiukaanniemi S M, Levoska S. et al . Does folk medicine work? A randomized clinical trial on patients with prolonged back pain.  Arch Phys Med Rehabil. 1997;  78 571-577
  • 28 Hemmila H M, Keinanen-Kiukaanniemi S M, Levoska S. et al . Long-term effectiveness of bone-setting, light exercise therapy, and physiotherapy for prolonged back pain: a randomized controlled trial.  J Manipulative Physiol Ther. 2002;  25 99-104
  • 29 Hilde G, Bo K. Effect of exercise in the treatment of chronic back pain: a systematic review, emphasising type and dose of exercise.  Physical Therapy Reviews. 1998;  3 107-117
  • 30 Hildebrandt V H, Proper K I, van den Berg R. et al . Cesar therapy is temporarily more effective in patients with chronic low back pain than the standard treatment by family practitioner: randomized, controlled and blinded clinical trial with 1 year follow-up.  Ned Tijdschr Geneeskd. 2000;  144 2258-2264
  • 31 Horneij E, Hemborg B, Jensen I. et al . No significant differences between intervention programmes on neck, shoulder and low back pain: a prospective randomized study among home-care personnel.  J Rehabil Med. 2001;  33 170-176
  • 32 Hsieh C Y, Adams A H, Tobis J. et al . Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial.  Spine. 2002;  27 1142-1148
  • 33 Hsieh R L, Lee W C. One-shot percutaneous electrical nerve stimulation vs. transcutaneous electrical nerve stimulation for low back pain: comparison of therapeutic effects.  Am J Phys Med Rehabil. 2002;  81 838-843
  • 34 Johannsen F, Remvig L, Kryger P. et al . Exercises for chronic low back pain: a clinical trial.  J Orthop Sports Phys Ther. 1995;  22 52-59
  • 35 Jousset N, Fanello S, Bontoux L. et al . Effects of functional restoration versus 3 hours per week physical therapy: a randomized controlled study.  Spine. 2004;  29 487-493; discussion: 494
  • 36 Kankaanpaa M, Taimela S, Airaksinen O. et al . The efficacy of active rehabilitation in chronic low back pain. Effect on pain intensity, self-experienced disability, and lumbar fatigability.  Spine. 1999;  24 1034-1042
  • 37 Kendall P H, Jenkins J M. Exercises for backache: a double-blind controlled trial.  Physiotherapy. 1968;  54 154-157
  • 38 Klaber-Moffett J, Torgerson D, Bell-Syer S. et al . Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences.  BMJ. 1999;  319 279-283
  • 39 Klein R G, Eek B C. Low-energy laser treatment and exercise for chronic low back pain: double-blind controlled trial.  Arch Phys Med Rehabil. 1990;  71 34-37
  • 40 Koes B W, Bouter L M, Beckerman H. et al . Physiotherapy exercises and back pain: a blinded review.  BMJ. 1991;  302 1572-1576
  • 41 Kool J, de Bie R, Oesch P. et al . Exercise reduces sick leave in patients with non-acute non-specific low back pain: a meta-analysis.  J Rehabil Med. 2004;  36 49-62
  • 42 Kuukkanen T, Malkia E. Effects of a three-month therapeutic exercise programme on flexibility in subjects with low back pain.  Physiother Res Int. 2000;  5 46-61
  • 43 Liddle S D, Baxter G D, Gracey J H. Exercise and chronic low back pain: what works?.  Pain. 2004;  107 176-190
  • 44 Lidstrom A, Zachrisson M. Physical therapy on low back pain and sciatica. An attempt at evaluation.  Scand J Rehabil Med. 1970;  2 37-42
  • 45 Lindström I, Ohlund C, Eek C. et al . The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach.  Phys Ther. 1992;  72 279-290; discussion: 291 - 293
  • 46 Lindström I, Ohlund C, Eek C. et al . Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. A randomized prospective clinical study with a behavioral therapy approach.  Spine. 1992;  17 641-652
  • 47 Lindström I. A successful intervention program for patients with subacute low back pain. Göteborg; Göteborg University 1994
  • 48 Ljunggren A E, Weber H, Kogstad O. et al . Effect of exercise on sick leave due to low back pain. A randomized, comparative, long-term study.  Spine. 1997;  22 1610-1616; discussion: 1617
  • 49 Maher C, Latimer J, Refshauge K. Prescription of activity for low back pain: What works?.  Aust J Physiother. 1999;  45 121-132
  • 50 Manniche C, Hesselsoe G, Bentzen L. et al . Clinical trial of intensive muscle training for chronic low back pain.  Lancet. 1988;  2 1473-1476
  • 51 Manniche C, Lundberg E, Christensen I. et al . Intensive dynamic back exercises for chronic low back pain: a clinical trial.  Pain. 1991;  47 53-63
  • 52 Manniche C, Asmussen K, Lauritsen B. et al . Intensive dynamic back exercises with or without hyperextension in chronic back pain after surgery for lumbar disc protrusion. A clinical trial.  Spine. 1993;  18 560-567
  • 53 Mannion A F, Muntener M, Taimela S. et al . A randomized clinical trial of three active therapies for chronic low back pain.  Spine. 1999;  24 2435-2438
  • 54 Mannion A F, Junge A, Taimela S. et al . Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy.  Spine. 2001;  26 920-929
  • 55 Mannion A F, Muntener M, Taimela S. et al . Comparison of three active therapies for chronic low back pain: results of a randomized clinical trial with one-year follow-up.  Rheumatology (Oxford). 2001;  40 772-778
  • 56 Mannion A F, Taimela S, Muntener M. et al . Active therapy for chronic low back pain part 1. Effects on back muscle activation, fatigability, and strength.  Spine. 2001;  26 897-908
  • 57 Martin P R, Rose M J, Nichols P J. et al . Physiotherapy exercises for low back pain: process and clinical outcome.  Int Rehabil Med. 1986;  8 34-38
  • 58 McIlveen B, Robertson V J. A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain.  Physiotherapy. 1998;  84 17-26
  • 59 Miltner O, Wirtz D C, Siebert C H. Strengthening lumbar extensors - therapy of chronic back pain - an overview and meta-analysis.  Z Orthop ihre Grenzgeb. 2001;  139 287-293
  • 60 Mior S. Exercise in the treatment of chronic pain.  Clin J Pain. 2001;  17 S77-S85
  • 61 Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain.  Aust J Physiother. 2002;  48 297-302
  • 62 Muller K, Schwesig R, Leuchte S. et al . Coordinative treatment and quality of life - a randomised trial of nurses with back pain.  Gesundheitswesen. 2001;  63 609-618
  • 63 Niemisto L, Lahtinen-Suopanki T, Rissanen P. et al . A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain.  Spine. 2003;  28 2185-2191
  • 64 O’Sullivan P B, Phyty G D, Twomey L T. et al . Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis.  Spine. 1997;  22 2959-2967
  • 65 Oxman AD, Guyatt GH. Validation of an index of the quality of reviw articles.  J Clin Epidemiol. 1991;  44 1271-1278
  • 66 Penttinen J, Nevala-Puranen N, Airaksinen O. et al . Randomized controlled trial of back school with and without peer support.  J Occup Rehabil. 2002;  12 21-29
  • 67 Petersen T, Kryger P, Ekdahl C. et al . The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: A randomized controlled trial.  Spine. 2002;  27 1702-1709
  • 68 Preyde M. Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial.  CMAJ. 2000;  162 1815-1820
  • 69 Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I. Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain.  Man Ther. 2003;  8 233-241
  • 70 Reilly K, Lovejoy B, Williams R. et al . Differences between a supervised and independent strength and conditioning program with chronic low back syndromes.  J Occup Med. 1989;  31 547-550
  • 71 Risch S V, Norvell N K, Pollock M L. et al . Lumbar strengthening in chronic low back pain patients. Physiologic and psychological benefits.  Spine. 1993;  18 232-238
  • 72 Rittweger J, Just K, Kautzsch K. et al . Treatment of chronic lower back pain with lumbar extension and whole-body vibration exercise: a randomized controlled trial.  Spine. 2002;  27 1829-1834
  • 73 Snook S H, Webster B S, McGorry R W. et al . The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. A randomized controlled trial.  Spine. 1998;  23 2601-2607
  • 74 Snook S H, Webster B S, McGorry R W. The reduction of chronic, nonspecific low back pain through the control of early morning lumbar flexion: 3-year follow-up.  J Occup Rehabil. 2002;  12 13-19
  • 75 Soukup M G, Glomsrod B, Lonn J H. et al . The effect of a Mensendieck exercise program as secondary prophylaxis for recurrent low back pain. A randomized, controlled trial with 12-month follow-up.  Spine. 1999;  24 1585-1591; discussion: 1592
  • 76 Soukup M G, Lonn J, Glomsrod B. et al . Exercises and education as secondary prevention for recurrent low back pain.  Physiother Res Int. 2001;  6 27-39
  • 77 Staal J B, Hlobil H, Twisk J W. et al . Graded activity for low back pain in occupational health care: a randomized, controlled trial.  Ann Intern Med. 2004;  140 77-84
  • 78 Storheim K, Brox J I, Holm I. et al . Intensive group training versus cognitive intervention in sub-acute low back pain: short-term results of a single-blind randomized controlled trial.  J Rehabil Med. 2003;  35 132-140
  • 79 Sweetman B J, Heinrich I, Anderson J AD. A randomized controlled trial of exercises, short wave diathermy, and traction for low back pain, with evidence of diagnosis-related response to treatment.  Journal of Orthopaedic Rheumatology. 1993;  6 159-166
  • 80 Torstensen T A, Ljunggren A E, Meen H D. et al . Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up.  Spine. 1998;  23 2616-2624
  • 81 Tritilanunt T, Wajanavisit W. The efficacy of an aerobic exercise and health education program for treatment of chronic low back pain.  J Med Assoc Thai. 2001;  84 S528-S533
  • 82 van Tulder M W, Koes B W, Bouter L M. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions.  Spine. 1997;  22 2128-2156
  • 83 van Tulder M W, Koes B. Low back pain and sciatica: chronic.  Clin Evid. 2003;  9
  • 84 van Tulder M W, Malmivaara A, Esmail R. Exercise therapy for low back pain. Oxford; The Cochrane Library 2003
  • 85 Turner J A, Clancy S, McQuade K J. et al . Effectiveness of behavioral therapy for chronic low back pain: a component analysis.  J Consult Clin Psychol. 1990;  58 573-579
  • 86 UK BEAM Trial Team (Brealey S, Coulton S, Farrin A, et al.) . UK Back Pain Exercise and Manipulation (UK BEAM) Randomised Trial: effectiveness of physical treatments for back pain in primary care. BMJ 2004, DOI 10.1136/bmj.38282.669225.AE. 
  • 87 White A W. Low back pain in men receiving workmen’s compensation.  Can Med Assoc J. 1966;  95 50-56
  • 88 White A W. Low back pain in men receiving workmen’s compensation: a follow-up study.  Can Med Assoc J. 1969;  101 61-67

1 Dieses Kapitel wurde primär von A. F. Mannion und J. Klaber-Moffett geschrieben.

Prof. Dr. med. Jan Hildebrandt

Schwerpunkt Algesiologie, Zentrum Anästhesie, Rettungs- und Intensivmedizin, Universitätsklinik Göttingen

Robert-Koch-Str. 40

37075 Göttingen

Email: jhildebr@med.-uni-goettingen.de

    >