Evidenz für die Diagnose und Therapie von Beckengürtelschmerz - Europäische Leitlinien

Zusammenfassung

Hintergrund: Beckengürtelschmerz (BGS) ist eine häufig auftretende spezifische Form von Rückenschmerz. Schmerz verursachende Strukturen bei Beckengürtelschmerz sind das Iliosakralgelenk (ISG) und in geringerem Maß die Symphysis pubica. Ein Zusammenhang zu nicht optimaler Stabilität des Beckengürtels scheint erwiesen.

Ziel: Dieser Artikel ist eine kommentierte Zusammenfassung des englischen Originaltextes der Europäischen Leitlinien zur Diagnose und Therapie von Beckengürtelschmerz. Er gibt einen Überblick über die Ätiologie, Epidemiologie und Risikofaktoren von BGS, die Anatomie und Biomechanik des Beckengürtels sowie die Evidenz-basierte Diagnostik und Therapie.

Methode: Eine extensive Literaturstudie wurde durchgeführt, um die gegenwärtige Evidenz zur Diagnose und Therapie von BGS zusammenzutragen.

Ergebnisse: Bei der Diagnose von BGS hatten Schmerzprovokationstests die beste Validität und Reliabilität. Empfohlen werden hier zur Untersuchung des ISG der Posterior Pelvic Pain Provocation Test (P4), Patrick-Faber-Test, Palpation des langen, dorsalen ISG-Ligaments und der Gaenslen-Test. Zur Untersuchung der Symphyse werden Palpation und ein modifizierter Trendelenburg-Test befürwortet. Als funktionellen Test empfehlen die Autoren den Active Straight Leg Raise Test (ASLR). Für die Therapie von BGS deutet die vorhandene Evidenz auf die gute Wirksamkeit eines individuellen Trainingsprogramms hin, welches mit der Aktivierung und Kontrolle der lokalen, tiefen lumbalen Muskelsysteme beginnen und darauf folgend auch die oberflächlichen Muskeln in dynamischen Übungen mit einschließen sollte.

Schlussfolgerung: Der Großteil der aufgeführten Evidenz für oder gegen eine bestimmte Form der Therapie oder einen spezifischen diagnostischen Test ist noch unzureichend. Daher empfehlen die Autoren weiterführende Forschung zur Diagnose und Therapie von BGS, um die vorhandene Evidenz zu unterstützen.

Abstract

Background: Pelvic girdle pain is a common special form of back pain. The sacroiliac joint and to a lesser extent the pubic symphysis can cause pelvic girdle pain. Correlation with a suboptimal stability of the pelvic girdle seems to be evident.

Objective: This article is a commented summary of the original English text of the European guidelines for the diagnosis and therapy of pelvic girdle pain. It gives an overview of the etiology, epidemiology and risk factors of pelvic girdle pain, the pelvic girdle’s anatomy and biomechanics as well as the evidence-based diagnosis and therapy.

Method: An extensive literature study was performed in order to round up the existing evidence of the diagnosis and therapy of pelvic girdle pain.

Result: For the diagnosis of pelvic girdle pain pain provocation tests showed the best validity and reliability. For the investigation of the sacroiliac joint the posterior pelvic pain provocation test (P4), Patrick’s faber test, palpation of the long dorsal ligament of the sacroiliac joint and the Gaenslen test are recommended. Concerning the investigation of the symphysis palpation and a modified Trendelenburg test are suggested. As functional test the authors recommend the active straight leg raise test (ASLR). In view of pelvic girdle pain therapy the existing evidence indicates a positive effectiveness of an individual exercise programme which should begin with activation and control of the local lower lumbar muscle system followed by dynamic exercises of the superficial muscles.

Conclusion: Most of the evidence in favour or against a certain intervention or a specific diagnostic test is still insufficient. The authors therefore postulate further research concerning diagnosis and therapy of pelvic girdle pain in order to support the existing evidence.

Schlüsselwörter

Rückenschmerz - Beckengürtel - Iliosakralgelenk - Symphyse - Diagnose - Therapie - Leitlinien

Key words

Back pain - pelvic girdle - sacroiliac joint - symphysis - diagnosis - therapy - guidelines

Literatur

• 1 Abramson D, Roberts S M, Wilson P D. Relation of the pelvic joints in pregnancy.  Surg Gynecol Obstet. 1934;  58 595-613
• 2 Albert H, Godskesen M, Westergaard J. Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain.  Eur Spine J. 2000;  9 161-166
• 3 Arrindell W A, Janssen I CM. Replication of SCL-90-R factors of symptom distress in patients with peripartum pelvic pain syndrome.  2004 [submitted for publication]; 
• 4 Belanger T A, Dall B E. Sacroiliac arthrodesis using a posterior midline fascial splitting approach and pedicle screw instrumentation: a new technique.  J Spinal Disord. 2001;  14 118-124
• 5 Berg G, Hammar M, Möller-Jensen J. et al . Low back pain during pregnancy.  Obstet & Gynecol. 1988;  1 71-75
• 6 Berthelot J M, Gouin F, Glemarec J. et al . Possible use of arthrodesis for intractable sacroiliitis in spondylarthropathy: report of two cases.  Spine. 2001;  26 2297-2299
• 7 Broadhurst, Bond 1998. 
• 8 Brooke et al. 1924 . 
• 9 Cholewicki J, Simons A PD, Radebold A. Effects of external trunk loads on lumbar spine stability.  J Biomech. 2000;  33 1377-1385
• 10 Cibulka M T, Koldehoff R. Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain.  J Orthop Sports Phys Ther. 1999;  29 83-92
• 11 Daly J, Frame P S, Rapoza P A. Sacroiliac subluxation: A common treatable cause of low-back pain in pregnancy.  Fam Practice Res J. 1991;  11 149-159
• 12 Damen L, Buyruk H M, Guler-Uysal F. et al . Pelvic pain during pregnancy is associated with asymmetric laxity of the sacroiliac joints.  Acta Obstet Gynecol Scand. 2001;  80 1019-1024
• 13 Damen L, Buyruk H M, Guler U ysal F. et al . The prognostic value of asymmetric laxity of the sacroiliac joint in pregnancy related pelvic pain.  Spine. 2002;  27 2820-2824
• 14 Damen L, Spoor C W, Snijders C J. et al . Does a pelvic belt influence sacroiliac laxity?.  Clin Biomech. 2002;  17 495-448
• 15 Diakow P R, Gadsby T A, Gadsby J B. et al . Back pain during pregnancy and labor.  J Manip Physiol Ther. 1991;  14 116-118
• 16 Dumas G A, Reid J G, Wolfe L A. et al . Exercise, posture, and back pain during pregnancy. Part 2: Exercise and back pain.  Clinical Biomechanics. 1995;  10 104-109
• 17 Elden H, Ladfors L, Olsèn M F. et al . Effects of acupuncture and stabilizing exercises among women with pregnancy-related pelvic pain: a randomised single blind controlled trial.  2004 [submitted for publication]; 
• 18 Fairbank. et al . 1980. 
• 19 Ferrante F M, King L F, Roche E A. et al . Radiofrequency sacroiliac joint denervation for sacroiliac syndrome.  Reg Anesth Pain Med. 2001;  26 137-142
• 20 Field T, Hernandez-Reif M, Hart S. et al . Pregnant women benefit from massage therapy.  J Psychosom Obstet Gynecol. 1999;  20 31-38
• 21 Gaenslen F J. Sacro-iliac arthrodesis.  J Am Med Assoc. 1927;  89 2031-2035
• 22 Gevargez A, Groenemeyer D, Schirp S. et al . CT-guided percutaneous radiofrequency denervation of the sacroiliac joint.  Eur Radiol. 1992;  12 1360-1365
• 23 Giannikas K A, Khan A M, Karski M T. et al . Sacroiliac joint fusion for chronic pain: a simple technique avoiding the use of metalwork.  Eur Spine J. 2004;  13 253-256
• 24 Hagen R. Pelvic girdle relaxation from an orthopaedic point of view.  Acta Orthop Scand. 1974;  45 550-563
• 25 Hanly J G, Mitchell M, MacMillan L. et al . Efficacy of sacroiliac corticosteroid injections in patients with inflammatory spondyloarthropathy: results of a 6 month controlled study.  J Rheumatol. 2000;  27 719-722
• 26 Hansen A, Jensen D V, Larsen E. et al . Relaxing is not related to symptom-giving pelvic girdle relaxation in pregnant women.  Acta Obstet Gynecol Scand. 1996;  75 245-249
• 27 Hodges P W, Kaigle H olm A, Holm S. et al . Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominus and the diaphragm in in-vivo porcine studies.  Spine. 2003;  28 2594-2601
• 28 Hungerford B, Gilleard W, Hodges P W. Evidence of altered lumbo-pelvic muscle recruitment in the presence of sacroiliac joint pain.  Spine. 2003;  28 1593-1600
• 29 Hungerford B, Gilleard W, Lee D. Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers.  Clin Biomech. 2004;  19 456-464
• 30 Karabacakoglu A, Karakose S, Ozerbil O M. et al . Fluoroscopy-guided intraarticular corticosteroid injection into the sacroiliac joints in patients with ankylosing spondylitis.  Acta Radiol. 2002;  43 425-427
• 31 Keating J G, Avillar M D, Price M. Sacroiliac joint arthrodesis in selected patients with low back pain. Vleeming A, et al Movement, Stability and Low Back Pain Edinburgh; Churchill Livingstone 1997
• 32 Kihlstrand M, Stenman B, Nilsson S. et al . Water-gymnastics reduced the intensity of back/low back pain in pregnant women.  Acta Obstet Gynecol Scand. 1999;  78 180-185
• 33 Koes B W, van Tulder M W, Ostelo R. et al . Clinical guidelines for the management of low back pain in primary care: An international comparison.  Spine. 2001;  26 2504-2513
• 34 Kokmeyer D J, van der Wurff P, Aufdemkampe G. et al . The realibility of multiregimens with sacroiliac pain provocation tests.  J Manip Physiol Ther. 2002;  25 42-48
• 35 Kopec J A, Esdaile J M, Abrahamowicz M. et al . The Quebec Back Pain Disability Scale. Measurement properties.  Spine. 1995;  20 341-352
• 36 Kristiansson P, Svärdsudd K, von Schoultz B. Back pain during pregnancy.  Spine. 1996;  6 702-709
• 37 Kristiansson P, Svärdsudd K. Discriminatory power of tests applied in back pain during pregnancy.  Spine. 1996;  20 2337-2344
• 38 Kvorning N, Holmberg C, Grennert L. et al . Acupuncture relieves pelvic and low-back pain in late pregnancy.  Acta Obstet Gynecol Scand. 2004;  83 246-250
• 39 Larsen. et al . 1991. 
• 40 Laslett M, Williams.
• 41 Laslett M, Young S B, Aprill C N. et al . Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests.  Aust J Physiother. 2003;  49 89-97
• 42 Laslett M, Aprill C N, McDonald B. et al . Diagnosis of sacroiliac joint pain: Validity of individual provocation tests and composites of tests.  Man Ther. 2005;  10 207-218
• 43 Linton S J, Andersson T. Can chronic disability be prevented? A randomized trial of a cognitive-behavior intervention and two forms of information for patients with spinal pain.  Spine. 2000;  25 2824-2831
• 44 Luukkainen R, Nissilä M, Asikainen E. et al . Periarticular corticosteroid treatment of the sacroiliac joint in patients with seronegative spondylarthropaty.  Clin Exp Rheumatol. 1999;  17 88-90
• 45 Luukkainen R K, Wennerstrand P V, Kautiainen H H. et al . Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathic patients with chronic low back pain in the region of the sacroiliac joint.  Clin Exp Rheumatol. 2002;  20 52-54
• 46 Maigne J Y, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain.  Spine. 1996;  21 1889-1892
• 47 Mantle M J, Holmes J, Currey H L. Backache in pregnancy II: prophylactic influence of back care classes.  Rheumatol Rehab. 1981;  20 227-232
• 48 Maugars Y, Mathis C, Berthelot J M. et al . Assessment of the efficacy of sacroiliac corticosteroid injections in spondylarthropathies: a double-blind study.  Br J Rheumatol. 1996;  35 767-770
• 49 McKenzie R A. The lumbar spine: Mechanical diagnosis and therapy.  Waikanae/N.Z.: Spinal Pub. 1981; 
• 50 Mens J M, Vleeming A, Snijders C J. et al . The active straight leg raising test and mobility of the pelvic joints.  Eur Spine J. 1999;  8 468-473
• 51 Mens J M, Snijders C J, Stam H J. Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial.  Phys Ther. 2000;  80 1164-1173
• 52 Mens J M, Vleeming A, Snijders C J. et al . Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy.  Spine. 2001;  26 1167-1171
• 53 Mens J M, Vleeming A, Snijders C H. et al . Responsiveness of outcome measurements in rehabilitation of patients with posterior pelvic pain since pregnancy.  Spine. 2002;  27 1110-1115
• 54 Mens J M, Vleeming A, Snijders C J. et al . Validity of the active straight leg raise test for measuring disease severity with posterior pelvic pain after pregnancy.  Spine. 2002;  27 196-200
• 55 Mooney V, Pozos R, Vleeming A. et al . Exercise treatment for sacroiliac joint pain.  Orthopedics. 2001;  24 29-32
• 56 Moore M R. Surgical treatment of chronic painful sacroiliac joint dysfunction. Vleeming A, et al Movement, Stability and Low Back Pain Edinburgh; Churchill Livingstone 1997
• 57 Moseley G L, Nicholas M K. et al . A randomized controlled trial of intensive neurophysiology education in chronic low back pain.  Clin J Pain. 2004;  20 324-330
• 58 Nilsson-Wikmar L, Holm K, Oijerstedt R. et al .Effect of three different physical therapy treatments on pain and functional activities in pregnant women with pelvic girdle pain: A randomised clinical trial with 3, 6, and 12 months’ follow-up postpartum [PhD Thesis]. Stockholm; Karolinska Institutet 2003
• 59 Njoo K H. Non specific low back pain in general practice: a delicate point [PhD Thesis]. Rotterdam; Erasmus University 1993
• 60 Noren L, Östgaard S, Nielsen T F. et al . Reduction of sick leave for lumbar back and posterior pelvic pain in pregnancy.  Spine. 1997;  22 2157-2160
• 61 Ojala R, Klemola R, Karppinen J. et al . Sacro-iliac joint arthrography in low back pain: feasibility of MRI guidance.  Eur J Radiol. 2001;  40 236-239
• 62 Olerud S, Walheim G G. Symphysiodesis with a new compression plate.  Acta Orthop Scand. 1984;  55 315-313
• 63 Östgaard H C, Andersson G J. Previous back pain and risk of developing back pain in future pregnancy.  Spine. 1991;  16 432-436
• 64 Östgaard H C, Andersson G J, Karlsson K. Prevalence of back pain in pregnancy.  Spine. 1991;  16 549-552
• 65 Östgaard H C, Andersson G BJ, Schultz A B. et al . Influence of biomechanical factors on low back pain in pregnancy.  Spine. 1993;  18 54-58
• 66 Östgaard H C, Zetherström G, Roos-Hansson E. et al . Reduction of back and posterior pelvic pain in pregnancy.  Spine. 1994;  19 894-900
• 67 Östgaard H C, Zetherström G, Roos-Hansen E. et al . The posterior pelvic pain provocation test in pregnant women.  Eur Spine J. 1994;  3 258-260
• 68 Pereira P L, Gunaydin I, Duda S H. et al . Corticosteroid injections of the sacroiliac joint during magnetic resonance: preliminary results.  J Radiol. 2000;  81 223-226
• 69 Petersen T, Olsen S, Laslett M. et al . Inter-tester reliability of a new diagnostic classification system for patients with non-specific low back pain.  Aust J Physiother. 2004;  50 85-94
• 70 Pool-Goudzwaard A. Biomechanics of the sacroiliac joints and the pelvic floor [PhD Thesis]. Rotterdam; Erasmus University 2004
• 71 Richardson C A, Snijders C J, Hides J A. et al . The relationship between the transversus abdominus muscle, sacroiliac joint mechanics and low back pain.  Spine. 2002;  27 399-405
• 72 Riddle D L, Freburger J K. Evaluation of the presence of sacroiliac joint dysfunction using a combination of tests: A multicenter intertester reliability study.  Phys Ther. 2002;  82 772-781
• 73 Salèn. et al . 1994. 
• 74 Schwarzer A C, Aprill C N, Bogduk N. The sacroiliac joint in chronic low back pain.  Spine. 1995;  20 31-37
• 75 Slätis P, Karaharju E O. External fixation of the pelvic girdle with a trapezoid compression frame.  Injury. 1975;  7 53-56
• 76 Slätis P, Eskola A. External fixation of the pelvic girdle as a test for assessing instability of the sacro-iliac joint.  Ann Med. 1989;  21 369-372
• 77 Slipman C W, Lipetz J S, Plastaras C T. et al . Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome.  Am J Phys Med Rehabil. 2001;  80 425-432
• 78 Smith-Petersen M N, Rogers W A. End-result study of arthrodesis of the sacroiliac joint for arthritis - traumatic and nontraumatic.  J Bone Joint Surg. 1926;  8 118-136
• 79 Stuge B, Hilde G, Vollestad N. Physical therapy for pregnancy-related low back and pelvic pain: a systematic review.  Acta Obstetet Gynecol Scand. 2003;  82 983-990
• 80 Stuge B, Lærum E, Kirkesola G. et al . The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy. A randomized controlled trial.  Spine. 2004;  29 351-359
• 81 Suputtitada A, Wacharapreechanont T, Chaisayan P. Effect of the “sitting pelvic tilt exercise” during the third trimester in primigravidas on back pain.  J Med Assoc Thai. 2002;  85 S170-S179
• 82 Svensson H O, Andersson G BJ, Hagstad A. et al . The relationship of low-back pain to pregnancy and gynaecologic factors.  Spine. 1990;  15 371-375
• 83 Thomas I L, Nicklin J, Pollock H. et al . Evaluation of a maternity cushion (Ozzlo Pillow) for backache and insomnia in late pregnancy.  Aust NZ J Obstet Gynaecol. 1989;  29 133-138
• 84 Toussaint R, Gawlik C S, Rehder U. et al . Sacroiliac joint diagnostics in the Hamburg construction workers study.  J Manip Physiol Ther. 1999;  22 139-143
• 85 Tullberg T, Blomberg S, Branth B. et al . Manipulation does not alter the position of the sacroiliac joint. A Roentgen stereophotogrammetric analysis.  Spine. 1998;  23 1124-1128
• 86 Vincent-Smith B, Gibbons S. Inter-examiner and intra-examiner reliability of the standing flexion test.  Man Ther. 1999;  4 87-93
• 87 Vleeming A, Stoeckart R, Volkers A CW. et al . Relation between form and function in the sacroiliac joint. 1. Clinical anatomical aspects.  Spine. 1990;  15 130-132
• 88 Vleeming A, Volkers A CW, Snijders C J. et al . Relation between form and function in the sacroiliac joint. 2. Biomechanical aspects.  Spine. 1990;  15 133-136
• 89 Vleeming A, Buyruk H M, Stoeckart R. et al . An integrated therapy for peripartum pelvic instability: a study of the biomechanical effects of pelvic belts.  Am J Obstet Gynecol. 1992;  166 1243-1247
• 90 Vleeming A, van Wingerden J P, Dijkstra P. et al . Mobility in the SI-joints in old people: a kinematic and radiologic study.  Clin Biomech. 1992;  7 170-176
• 91 Vleeming A, de Vries H J, Mens J M. et al . Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain.  Acta Obstet Gynecol Scand. 2002;  81 430-436
• 92 Wahlheim G G. Stabilization of the pelvis with the Hoffman frame. An aid in diagnosing pelvic instability.  Acta Orthop Scand. 1984;  55 319-324
• 93 Waisbrod H, Krainick J U, Gerbershagen H U. Sacroiliac joint arthrodesis for chronic lower back pain.  Arch Orthop Trauma Surg. 1987;  106 238-240
• 94 Wedenberg K, Moen B, Norling A. A prospective randomized study comparing acupuncture with physiotherapy for low-back and pelvic pain in pregnancy.  Acta Obstet Gynecol Scand. 2000;  79 331-335
• 95 Van Wingerden J P, Vleeming A, Buyruk H M. et al . Stabilization of the sacroiliac joint in vivo: Verification of muscular contribution to force closure of the pelvis.  Eur Spine J. 2004;  13 199-205
• 96 Wormslev M, Juul A M, Marques B. et al . Clinical examination of pelvic insufficiency during pregnancy.  Scand J Rheumatol. 1994;  23 96-102
• 97 Van der Wurff P, Hagmeijer R HM, Meyne W. Clinical tests of the sacroiliac joint. A systematic methodological review. Part 1: Reliability.  Manual Therapy. 2000;  5 30-36
• 98 Van der Wurff P, Hagmeijer R HM, Meyne W. Clinical tests of the sacroiliac joint. A systematic methodological review. Part 2: Validity.  Manual Therapy. 2000;  5 89-96
• 99 Yelland M J, Glasziou P P, Bogduk N. et al . Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial.  Spine. 2004;  29 9-16
• 100 Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain.  Spine. 2003;  3 460-465
• 101 Van Zwienen C M, van den Bosch E W, Snijders C J. et al . Triple pelvic ring fixation in patients with severe pregnancy-related low back and pelvic pain.  Spine. 2004;  29 478-484