Rückenschmerzen: Evidenz, Therapie, Training

Transkript

1 Rückenschmerzen: Evidenz, Therapie, Training Prof. Dr. Hannu Luomajoki PT OMT, ZHAW Leiter MAS MSK PT Fritz Zahnd MPhty, OMTsvomp, GAMT, ACSM certified Rückenschmerzen: Evidenz, Therapie, Training Vorstellung & Thema Hannu Luomajoki Fritz Zahnd

2 NZZ Juli 2014 Entmystifizieren Beispiel strukturelle Befunde in MR-Untersuchungen: Vergleiche zwischen Gesunden und Patienten mit Rückenschmerzen Copyright 2014 by American Society of Neuroradiology.

3 What else? July, 2014 Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial Christopher M Williams, Christopher G Maher, Jane Latimer, Andrew J McLachlan, Mark J Hancock, Richard O Day, Chung-Wei Christine Lin n= ca Patients Three groups: Paracetamol 4 g / day; like neededup tp 4 g / d, Placebo In all groups, after 17 days approximately, pain was gone No differencesbetween groups. NSAIR Main results In total, 65 trials (total number of patients = 11,237) were included in this review. Twenty-eight trials (42%) were considered high quality. Statistically significant effects were found in favour of NSAIDs compared to placebo, but at the cost of statistically significant more side effects. There is moderate evidence that NSAIDs are not more effective than paracetamol for acute low-back pain, but paracetamol had fewer side effects. 2008

4 Beispiel Radikulopathie; ICER Operation verglichen mit konservatiber Therapie und Physiotherapie (Swiss Medical Board 2015) ICER ca CHF Surgery?

5 Erkenntnis Der Befund «Diskushernie» ist bei Gesunden und bei Patienten / Patientinnen mit Rückenschmerzen etwa gleich häufig Ebenso häufig sind andere strukturelle Befunde Röntgenbilder und MRI sagen nicht viel über Rückenschmerzen aus und sie werden deshalb in Leitlinien NICHT empfohlen Evidenz der Effektivität der medizinischen Massnahmen ist bescheiden Leitlinien empfehlen = Seriöse klinische Untersuchung Rückenschmerzen Low Back Pain (LBP) ca. 90% der Menschen haben mindestens 1x im Leben LBP ca. 50% der Bevölkerung hat im letzten Jahr Rückenschmerzen gehabt Bei 90% der Betroffenen heilen akute Rückenschmerzen spontan innert 4 Wochen 70% bekommen allerdings die Rückenschmerzen innerhalb eines Jahres noch einmal Chronische Rückenschmerzen sind die teuerste Krankheit in den westlichen Industrienationen bei 90% der Rückenschmerzen gibt es keine klare medizinische Ursache! = sogenannte unspezifische Rückenschmerzen Airaksinen et al (2006). European guidelines low back pain. Eur Spine J, 10

6 Ist 90% wirklich unspezifisch? Können wir Subgruppieren? Eine mögliche Sub-klassifikation der Rückenschmerzen (O Sullivan 2005) spezifische Rückenschmerzen (10%) nicht mechanisch (30%) Zentraler maladaptiver Schmerz Yellow Flags Psychosoz. Faktoren unspezifische Rückenschmerzen (90%) Klare medizinische Befunde: Frakturen Tumoren Anomalien Nervenwurzelaffektionen Spinalkanalstenose bewegungsabhängig (35%) mechanisch (70%) richtungsspezifisch Hypomobilität haltungsabhängig (35%) richtungsspezifisch

7 O Sullivan s Subgruppierung «classification based cognitive functional therapy» ist zuverlässig und effektiv n=35 Pat. 2 Experts; k= 0.95, 16 weitere Kliniker mean k=0.61 n=121, Groups Man.ther. + Exercise 2. Group CBT At 12 months follow up CBT group was sig. better in pain and function (ODI, NRS). CBT improved by 13.7 points, manual therapy and exercise group by 5.5 points in ODI. CBT NRS 3.2 points, Man ther & Exer.1.5 points.

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9 Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison (2014) Nadine Foster & Jonathan Hill et al on behalf of the IMPaCT Back Study team RESULTS The 922 patients studied had comparable baseline characteristics. At 6 months follow-up, stratified care had a small but significant benefit relative to usual care as seen from a mean difference in Roland-Morris Disability Questionnaire scores of 0.7 (95% CI, ), with a large, clinically important difference in the high risk group of 2.3 (95% CI, ). Dafür Explain Pain und Pat. Edukation Moseley, G. L. (2002). Combined physiotherapy and education is effective for chronic low back pain. A randomised controlled trial. Australian Journal of Physiotherapy, 48, Moseley, G. L. (2003b). Joining forces - combining cognition-targeted motor control training with group or individual pain physiology education: A successful treatment for chronic low back pain. Journal of Manual and Manipulative Therapeutics, 11, Moseley, G. L. (2003a). A pain neuromatrixapproach to rehabilitation of chronic pain patients. Man Ther, 8, Moseley, G. L. (2003). Unravelling the barriers to reconceptualisation of the problem in chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology. J Pain, 4(4), Moseley, G. L. (2004). Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain,

10 Klassifikation der Rückenschmerzen (O Sullivan 2005) spezifische Rückenschmerzen (10%) nicht mechanisch (30%) Zentraler maladaptiver Schmerz Yellow Flags Psychosoz. Faktoren unspezifische Rückenschmerzen (90%) Klare medizinische Befunde: Frakturen Tumoren Anomalien Nervenwurzelaffektionen Spinalkanalstenose bewegungsabhängig (35%) mechanisch (70%) richtungsspezifisch Hypomobilität haltungsabhängig (35%) richtungsspezifisch Patientenbeispiele

11 Oder auch (Luomajoki et al 2007

12 Cross sectional study N= Healthy controls 110 Patients with LBP Odds Ratio by Cut off 2/6 Tests Positive = 8.0 Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls Luomajoki, H., & Moseley, G. L. (2011). Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls. Br J Sports Med, 45(5), Case controls study; N=90 (LBP =44 / healthy =46) Two Point Discrimination (TPD) Low Back Pain (LBP) and Movement Control Tests (MCT)

13 Rückenschmerzen und kortikale Repräsentation geändert Flor 1997 Eine einfache Möglichkeit die Körperwahrnehmung zu messen: Zweipunktdiskriminationstest Two Point Discrimination test (TPD)

14 Resultate

15 Pain Funktion 13 private practices and 28 treating physiotherapists 106 patients Mean 8 9 individual PT treatments Exercise at home over one year Measurements pre- treatment, post-treatment, 6 months and 12 months Primary outcome «Disability» measured with Patient Specific Functional Scale Feb 2015

16 Was hilft Sicher?! Steven Blair in BMJ Editorial 2013 The attributable fraction is an estimate of the number of deaths in a population that would have been avoided if a specific risk factor had been absent. Was hilft Sicher! Patient education

17 Was hilft in Physiotherapie (Meine Meinung an Evidenz angelehnt ) 10 % 20 % 20% 50% Spezifische Effekte Manuelle Therapie, Lösen, Dehnen, Faszien etc. Aktivität / Training Wie was; wie viel? Patient Edukation Was habe ich, was kann man machen? Ist es was schlimmes? Was ich selber machen? Wie lange geht es? Die Entscheidung in Therapie zu gehen Erkenntnis es geht Richtung : Das Gehirn und Rückenschmerzen Kognitive Ebene: Angst, Katastrophisierung, Hypervigilanz= Explain Pain Sensorische Ebene: Körperwahrnehmung, Spüren wo der Rücken ist etc. Motorische Ebene: Bewegungskontrolle, Koordination, Propriozeption etc

18 Results Twenty-eight patients (46% male, mean age 41.5 years (SD 10.6)) were randomized to MMT (n = 14) or UPT (n = 14). Patients adherence to treatment was >80% in both groups. Pain reduction (NRS; [95%CI]) was 2.14 [1.0 to 3.5] in the MMT and 0.69 [-2.0 to 2.5.] in the UPT. The between-group difference was 1.45 [0.0 to 4.0] (p = 0.03), representing a moderate effect size of 0.66 [-0.1 to 1.5]. Reduction in disability on the RMDQ was 6.71 [4.2 to 9.3] in MMT and 4.69 [1.9 to 7.4] in UPT, with a non-significant between-group difference of 2.02 [-1.5 to 5.6] (p = 0.25). The Newer Issues Feel your back Tactile Training? Imagine yourback RecognizeExercises Trick out your back Valedo?

19 Physical Therapy April 2011

20 TPD relates to our sense of self Loss of outline coincides with area of pain and increased TPD Perception of where vertebra are is displaced toward painful side Moseley 2008 PAIN

21 Clinical Journal of Pain * * * 80 Exaktheit (%) 60 Nicht-betroffene Seite Betroffene Seite 40 CTS Gesunde CTS Gesunde CTS Gesunde CTS Gesunde p<0.0001

22 A. Stimulation Probes B. Condition NO ATTENTION Screen mm 11 mm Stimulation sites Affected part ATTENTION Moseley, Zalucki & Wiech PAIN 2008 Photograph of affected part, with stimulation sites marked. 8 Pain NRS TPD mm Screen NO ATTENTIO ATTENTION Task-specific NRS Wait No Attention Review attention Moseley, Zalucki & Wiech PAIN 2008

23 Vielen Dank für die Aufmerksamkeit! Danke auch: Dr. Jan Kool, Klinik Valens MAS & Msc Studierende ZHAW Dr. Ben Wand, Perth AUS Prof. Lorimer Moseley, Adelaide Prof. Peter O Sullivan, Perth Dr. David Butler, Adelaide Und viele andere KollegenInnen! - In der ZHAW - Praxis - Kurse - Etc.