Kreuzschmerzen – Abklärung und Behandlung aus rheumatologisch-internistischer Sicht

Zusammenfassung

Kreuzschmerzen sind mit einer Lebensprävalenz zwischen 60–80 % häufig, weisen aber meistens einen gutartigen Verlauf auf. Nur ca. 10–20 % aller Patienten leiden nach 6 Monaten noch weiter an Kreuzschmerzen. Klinisch finden sich häufig muskuläre Befunde im Bereich der paravertebralen Muskulatur und Bewegungseinschränkungen der Wirbelsäule. Diese Befunde sind jedoch meist nicht die Ursache der Schmerzen. Trotz einer ausführlichen klinischen und physiotherapeutischen Untersuchung, inklusive weiterführenden Assessments, lassen sich die schmerzverursachenden Strukturen häufig nicht finden. Der Rückenschmerz ist in 85–90 % unspezifisch. Auch die Röntgenuntersuchungen führen meistens nicht zum Ziel, weil die degenerativen Veränderungen an der Wirbelsäule häufig nachweisbar sind, mit dem Alter zunehmen und in der Regel keine Korrelation mit dem Beschwerdebild zeigen. Die Therapie der Kreuzschmerzen umfasst physikalische und physiotherapeutische Maßnahmen sowie auch medikamentöse Behandlungen und allenfalls interventionelle Verfahren. Während es in der Akutphase sehr wichtig ist, eine Chronifizierung durch das Erkennen von Barrieren für eine vollständige Genesung und durch eine rasche Rückkehr zu den Alltagsaktivitäten zu vermeiden, geht es in der chronischen Phase darum, die allgemeine körperliche Aktivität trotz Schmerzen zu verbessern und dem Patienten das Wiedererreichen der Partizipation im Sozial- und Berufsleben zu ermöglichen. Diese Ziele stehen klar über der Schmerzfreiheit. In der Akutphase stehen somit eher schmerzlindernde medikamentöse Maßnahmen und passive Behandlungen im Vordergrund, während in der chronischen Phase die aktive Übungsbehandlung im Sinne einer ambulanten Physiotherapie oder stationär im Sinne einer multimodalen Rehabilitation zu forcieren ist. Die wissenschaftliche Evidenz ist mittlerweile gut, dass mittels einer Kombinationsbehandlung mit Medikamenten und Physiotherapien die Schmerzen und Behinderungen durch Kreuzschmerzen reduziert und die Rückkehr zur üblichen Aktivität gefördert werden kann.

Abstract

Low back pain (LBP) is frequent with a life time prevalence between 60–80 %. It shows in most cases a benign course. Only 10–20 % of all patients still have problems due to LBP after 6 months. Frequently muscular findings in the area of the musculature of the spine and movement restrictions of the spinal column are clinically found. However, these findings are usually not the cause of the pain. Despite a detailed clinical examination and further assessments, the structures causing pain cannot often be recognised. Therefore, LBP is non-specific in 85–90 % of all cases. Radiographs are not helpful either because the degenerative changes of the spine are frequent, increase with age and, in most cases, do not show any correlation with the complaints of the patient. The therapy of LBP covers physical measures and physiotherapy as well as drug treatments and, if necessary, injection techniques at the spine level. In the acute phase it is important to avoid LBP to get chronic by recognizing barriers for a complete recovery and by a quick return to normal activities. The aims in the chronic phase are to increase physical activity and to promote the participation in the social and work context. Pain relief is therefore only a secondary goal of the treatment in patients with chronic LBP. Pain-relieving measures with drugs and passive treatments are in the foreground during the acute phase of LBP while an active out-patient exercise treatment or an interdisciplinary in-patient rehabilitation program has to be pushed in the chronic phase. By now, the scientific evidence is good that pain and disability can be reduced and that return to usual activities can be promoted by means of a combination of a drug treatment with active exercises and / or rehabilitation programs.

Schlüsselwörter

Kreuzschmerzen - Abklärung - Assessments - Therapie - Rehabilitation

Keywords

low back pain - assessments - therapy - rehabilitation

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Nachtrag bei der Korrektur zu Referenz 88: Die Arbeit ist mittlerweile publiziert. Bachmann S, Wieser S, Oesch P et al. Three-year cost analysis of function-centred versus pain-centred inpatient rehabilitation in patients with chronic non-specific low back pain. J Rehabil Med 2009; 41: 919–923