Evidenzbasierte Diagnose und Behandlung bei schmerzhaftem Gelenk[1]

Zusammenfassung

SIG-Schmerzen haben ihren Ursprung in Gelenkstrukturen des SIG. Bei SIG-Dysfunktionen handelt es sich um eine anormale Position oder Bewegung von SIG-Strukturen, die Schmerzen auslösen können, aber nicht zwangsläufig müssen.

Diese Arbeit verdeutlicht die Unterschiede zwischen diesen klinischen Konzepten und informiert über die aktuelle Evidenz im Hinblick auf Diagnose und Behandlung von SIG-Störungen. Tests für SIG-Dysfunktionen zeichnen sich im Allgemeinen durch eine geringe Intertester-Reliabilität aus. Da noch kein Referenzstandard für SIG-Dysfunktionen zur Verfügung steht, lässt sich die Validität entsprechender Tests nicht bewerten. Tests, bei denen das SIG belastet wird, um die dem Patienten vertrauten Schmerzen auszulösen, haben eine akzeptable Intertester-Reliabilität und eine klinisch verwendbare Validität gegenüber einem akzeptablen Referenzstandard.

Es lässt sich nicht sagen, ob Provokationstests extraartikuläre SIG-Strukturen verlässlich identifizieren können. 3 oder mehr positive SIG-Schmerzprovokationstests besitzen eine Sensitivität und Spezifizität von 91 % bzw. 78 %. Die Spezifizität von 3 oder mehr positiven Tests erhöht sich auf 87 % der Patienten, deren Symptome nicht dazu gebracht werden können, sich auf die spinale Mittellinie zuzubewegen, d. h. zu zentralisieren.

Bei Populationen mit chronischen Rückenschmerzen besteht für Patienten mit 3 oder mehr positiven SIG-Provokationstests, deren Symptome nicht zur Zentralisierung veranlasst werden können, eine Wahrscheinlichkeit von 77 %, dass sie an SIG-Schmerzen leiden. Für schwangere Frauen mit Rückenschmerzen beträgt die Wahrscheinlichkeit 89 %. Diese Kombination von Testergebnissen könnte in der Forschung zur Evaluierung der Wirksamkeit bestimmter Behandlungsmethoden bei SIG-Schmerzen eingesetzt werden. Den größten Erfolg versprechende Behandlungen sind spezifisches Lenden-Becken-Stabilisationstraining und Kortikosteroid-Injektionen in den intraartikulären Raum.

Abstract

Sacroiliac joint (SIJ) pain refers to the pain arising from the SIJ joint structures. SIJ dysfunction generally refers to aberrant position or movement of SIJ structures that may or may not result in pain.

This paper aims to clarify the difference between these clinical concepts and present current available evidence regarding diagnosis and treatment of SIJ disorders. Tests for SIJ dysfunction generally have poor inter-examiner reliability. A reference standard for SIJ dysfunction is not readily available, so validity of the tests for this disorder is unknown. Tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard. It is unknown if provocation tests can reliably identify extra-articular SIJ sources of pain. 3 or more positive pain provocation SIJ tests have sensitivity and specificity of 91 % and 78 %, respectively. Specificity of 3 or more positive tests increases to 87 % in patients whose symptoms cannot be made to move towards the spinal midline, i. e., centralise. In chronic back pain populations, patients who have 3 or more positive provocation SIJ tests and whose symptoms cannot be made to centralise have a probability of having SIJ pain of 77 %, and in pregnant populations with back pain, a probability of 89 %. This combination of test findings could be used in research to evaluate the efficacy of specific treatments for SIJ pain. Treatments most likely to be effective are specific lumbopelvic stabilisation training and injections of corticosteroid into the intra-articular space.

Schlüsselwörter

Kortikosteroid-Injektion - diagnostische Genauigkeit - intraartikuläre Injektion - Lenden-Becken-Stabilisationstraining - schwangerschaftsbedingte Schmerzen im Beckengürtel - SIG-Dysfunktion - SIG-Schmerzen

Key words

corticosteroid injection - diagnostic accuracy - intra-articular injection - lumbopelvic stabilisation training - pregnancy-related pelvic girdle pain - sacroiliac joint dysfunction - sacroiliac joint pain

1 Der englische Originalartikel ist erschienen in: The Journal of Manual & Manipulative Therapy 2008; 16: 142 – 152.

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1 Der englische Originalartikel ist erschienen in: The Journal of Manual & Manipulative Therapy 2008; 16: 142 – 152.