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

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.

Schlüsselwörter

Rückenschmerz - Leitlinien - Bewegungstherapie - Physiotherapie - Physikalische Therapie - Mobilisation - Manipulation - Manuelle Therapie

Key words

Low back pain - guidelines - exercise - physiotherapy - physical therapy - mobilisation - manipulation - manual therapy

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