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これらのガイドラインは、イエローフラッグとして「心理・社会的要因」、レッドフラッグとして「悪性腫瘍、感染症、骨折などの外傷」をあげている。
非特異的な急性腰痛（悪性腫瘍、感染症、骨折以外の腰痛）は安静の排除、構造的診断は無意味という内容か。
いずれもヘルニアによる神経根症状を認めていて、非特異的腰痛に入れていなものが多く、ガイドラインの対象外のようにも思える。
ヨーロッパ
★ EUROPEAN
GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN
PRIMARY CARE （急性腰痛）
http://junk2004.exblog.jp/6482911/
GUIDELINES FOR ACUTE NONSPECIFIC LOW BACK PAIN
Based on systematic reviews and existing clinical guidelines
Summary of recommendations for diagnosis of acute non-specific low back
pain:
-
Case history and brief examination should be carried out
-
If history taking indicates possible serious spinal pathology or nerve root
syndrome, carry out more extensive physical examination including neurological
screening when appropriate
-
Undertake diagnostic triage at the first assessment as basis
for management decisions
-
Be aware of psychosocial factors, and review them in detail if there is no
improvement
-
Diagnostic imaging tests (including X-rays, CT and
MRl) are not routinely indicated for non-specific low back pain
-
Reassess those patients who are not resolving within a few weeks after the first
visit, or those who are following a worsening course
Summary of recommendations for treatment of acute non-specific low back
pain:
-
Give adequate information and reassure the patient
-
Do not prescribe bed rest as a treatment
-
Advise patients to stay active and continue
normal daily activities including work if possible
-
Prescribe medication, if necessary for pain relief; preferably to be taken at regular
intervals; first choice paracetamol, second choice NSAIDs
-
Consider adding a short course of muscle relaxants on its own or added to
NSAIDs, if paracetamol or NSAIDs have failed to reduce pain
-
Consider (referral for) spinal manipulation for patients who are failing to return to
normal activities
-
Multidisciplinary treatment programmes in
occupational settings may be an option for workers with sub-acute low back pain and sick leave for more than 4 - 8 weeks
★ EUROPEAN
GUIDELINES FOR THE MANAGEMENT OF CHRONIC NON-SPECIFIC LOW BACK PAIN （慢性腰痛）
Chapter 11 (G) Surgery
Definition of procedure
The rationale for the use of surgery in
chronic low back pain is the assumption that spinal segments demonstrating degenerative changes on imaging
can lead to mechanical pain.
Usually surgeons tend to reject the global definition of
non-specific chronic low-back pain and attempt to identity subgroups in the CLBP group of patients with presumed,
and in part clinically defined, symptoms elicited by a degenerated segment, often
described as segmental pain, often the sequelae of a disc herniation.
Definitions such as degenerative disc disease, facet joint degeneration,
Spinal instability -which are not universally recognized as diagnostic entities - were therefore
acknowledged in searching for evidence to formulate these recommendations, as
was the term used for the Cochrane review, "degenerative lumbar
spondylosis" (Gibson et al 1999).
Surgery performed for more specific
conditions (tumours, trauma, radicular and myelopathic syndromes) was not taken into
consideration.
The surgical procedures are usually aimed at obtaining a solid fusion between two or
more vertebral segments. This can be performed with a posterior, anterior, or
combined approach.
The surgeon can also use different types of
commercially available instrumentation (spacers, cages, screws, hooks and rods), and
supplemental bone from the same patient or others, or, more recently, synthetic bone
and growth factors, to promote bone formation and the achievement of solid fusion
(arthrodesis).
As in other fields of medicine, in recent years there has been a trend
towards minimally invasive spine surgery, and some of the new
techniques have been considered in other sections of the guidelines; many other variants will no doubt
be presented in the near future, but they will need to firstly undergo the same
rigorous scientific scrutiny as the traditional ones.
Another type of surgery that is potentially indicated in degenerative disc disease, and hence worthy of
consideration in this review on non-specific LBP, is disc replacement surgery.
▲
Australia（オーストラリア）
★Australasian
Faculty of Musculoskeletal Medicine: Acute Low Back Pain Guide
Radicular
pain is a subset of neurogenic pain, in which pain is evoked by
stimulation of the nerve roots or dorsal root ganglion of a spinal
nerve . In neurogenic pain, the pain is perceived in the peripheral
territory of the affected nerve.
神経根性疼痛は神経原性疼痛の一つのサブセットである。そこにおいて痛みは神経根の刺激や脊椎神経の後根神経節の刺激によって起こされる。神経原性疼痛では、刺激をうけた神経の末梢領域で痛みは認められる。
In as much as the pain is perceived
in a region remote from the actual source of pain, neurogenic pain is,
by definition, a form of referred pain. It differs, however, from
somatic and visceral referred pain in that it does not involve the
stimulation of nerve endings, and does not involve convergence.
Rather, it is perceived as arising from the periphery because the
nerves from that region are artificially stimulated proximal to their
peripheral distribution.
痛みは実際の起点から離れた部位で感じられるので、神経原性疼痛は当然ながら関連痛ということになる。しかし、神経末梢の刺激と無関係な点や一ヶ所に集中することがないという点で、体腔や臓器に発生する関連痛とは異なっている。もっと正確に言えば、痛みが末梢部位で発生しているように感じられるのは、その部位から伸びている神経が末梢分布に近いところで人為的に刺激されるからだ。
★http://www.nhmrc.gov.au/publications/synopses/cp94syn.htm
acute
low back pain （急性腰痛） acute
thoracic spinal pain （急性背部痛） acute
neck pain （急性頚痛）
acute
shoulder pain （急性肩痛） acute
knee pain （急性膝痛）
いずれもMAIN MESSAGES（メイン・メッセージ）は
★ Management
of chronic low back pain （慢性腰痛）
▲
Denmark（デンマーク）
Danish
Health Technology Assessment on Low Back Pain: （腰痛）
P.29 DIAGNOSES （診断）
During the years many different diagnostic classification
systems of low-back pain have been devised in order to arrive at a likely diagnosis. Emphasis has either been placed upon the anatomic localisation, causes or symptoms. None of these attempts at classifying patients has been
comprehensive enough to cover the wide spectrum of low-back pain.
長年の間、もっともらしい診断に到達するために、腰痛に対していろいろな違った診断学的分類がなされてきた。原因や症状は局所的解剖学的なことに重点が置かれた。患者をこのような方法で分類する試みは幅広い腰痛をカバーするには十分に包括的とはいえなかった。
It has become accepted in professional circles that it is
impossible to make a specific diagnosis in approximately 70-80% of cases regardless of how thorough the examination procedures have been. Due to a lack of solid biological causes the terms "non-specific
back pain" or "simple back pain" have become widely used.
綿密な検査が行われても、ほぼ７０−８０％が特異的な診断に至らないということは専門家の間では受け入れられている。しっかりとした生物学的原因がないので、「非特異的腰痛」または、「単純腰痛」という言葉が広く用いられるようになった。
Non-specific low-back pain is divided into the following classifications, which are based upon patient symptom description.
These divisions have been shown to be of value regarding the health professionals' need of further examinations and treatment strategy design.
非特異的腰痛は以下の分類に分けられる。そして、それは患者の症状分類に基づく。これらの分類は、医療専門職にとって更なる診察と治療戦略デザインの必要に関して価値があることが示された。
-
Acute low-back pain（急性腰痛）
-
Chronic low-back pain（慢性腰痛）
-
Acute low-back pain with radiating symptoms to the lower extremity （下肢への放散痛をもった急性腰痛）
-
Chronic low-back pain with radiating symptoms to the lower extremity （下肢への放散痛をもった慢性腰痛）
Certain diagnoses can however be based upon a pathoanatomical
basis. This of course depends upon a clear correlation between anatomical findings and patient symptoms. This is possible in
approximately 30% of low-back pain patients.
しかし特定の診断は、病理解剖学的基礎に立って診断が出来る。これはもちろん解剖学的所見と症状のはっきりとした相互関係による。このことは腰痛患者の約３０％に可能である。
P.30 Disc
Herniation : Only one out of four patients require surgery.(椎間板ヘルニア：４人に１人が手術に至る。)
P.78 TREATMENT METHOD
BACK SURGERY
The technology
There are several different operativc methods as well as operation
types for differing conditions in the back. In the text that follows
operation types are grouped into three main categories. This report will
not deal with all of the different operative methods involved for example in treating fractures or different anomalies of the spine such
as scoliosis:
A: Operation or re-operation for a disc herniation.
B: Operation for spinal stenosis (narrowing of the spinal canal).
C: Operation for spinal instability!
There can of course be situations where a combination of the above
mentioned procedures or indeed all of them may be involved. Operations are rarely performed purely on the basis of low-back pain but
more often due to low-back pain with radiations to the leg or legs. Dominant leg pain will more frequently result in surgical intervention
than low-back pain alone. There is a lack of prospective controlled clinical trials for all of the procedures mentioned.
Both neurosurgeons and orthopaedic surgeons perform the
above mentioned operations. Local and regional organisational factors determine which medical departments perform the different
procedures described. The important developments in spinal surgery necessitate that both of the medical specialities involved need to
co-ordinate their activities to a greater degree so that patient selection
and chosen operative techniques in all regions are conducted according to a common consensus.
The total number of surgeries (A, B)
& C) performed in Denmark number approximately 4,000 per year.
Disc herniation（椎間板ヘルニア）
The technique used for performing
first-time or repeat surgery for disc herniations is well known and requires low-tech
equipment. The procedure is carried out by means of a partial laminectomy
(hemilaminectomy). A small amount of bone tissue is removed and the
exposed nuclear and disc tissue is removed. A repeat surgery is
essentially the same procedure but more bone tissue is removed prior to
removing scar tissue.
Indication（適応）
First-time surgeries are not usually performed before conservative
therapy has been attempted for 4-6 weeks. In addition there has to be
a positive correlation between clinical findings and imaging reports.
Subacute operations may be performed if a patient is experiencing progressive weakness in the leg during the course of a few days or if
the pain is extremely severe in spite of medication.
最初の手術は通常、４〜６週間の保存的治療が試みられたあとに行われる。その上、臨床所見とＭＲＩ所見との間にポジティブな関係がなければならない。準緊急手術は、患者が数日の経過の中で下肢に進行性の筋力低下が見られたときや、薬を使用しても耐え難い痛みがあるときに行われる。
Acute operations (within hours or days) are carried out if there
are signs of cauda equina syndrome.
緊急手術（数時間、または１両日）は馬尾症候群の徴候が見られたときに行われる。
Commentary
Three thousand operations of this type are performed per year. In the
counties that have departments of neurosurgery operations are primarily carried out at these departments. However, these procedures
are also carried out at orthopaedic departments particularly in counties in which there are no neurosurgery departments.
In addition to the described operation technique other
techniques such as microsurgery (involving a microscope) may be used.
This type of surgery has not demonstrated shorter post-operative hospitalisation stays. It seems as though microsurgery results m a
greater number of relapses.
Documentation:
- There are many relevant but uncontrolled studies, which
demonstrated a long-term effect on pain after surgery, Only a single
randomised study compared the results of operations to conservative care
(.C).
- Success rates are in the range of
70-90% . The risk of serious complications is rare (A) .
Costs
HlGH COSTS
▲
Netherlands（オランダ）
(Royal Dutch Society for Physical Therapy
Clinical Guidelines:)
Low
Back Pain
(Flowchart) （腰痛） Osteoarthritis
of Hip and Knee
(Flowchart) （股、膝関節痛）
Whiplash
(Flowchart) （鞭打ち） Chronic
Ankle Sprain (Flowchart) （足関節捻挫）
P.1 Definition of low back pain
（腰痛症の定義）
In these guidelines, the term 'low back pain' refers to
'non-specific low back pain', which is defined as low back pain that does not have a specified physical
cause, such as nerve root compression (the radicular syndrome), trauma, infection or the presence of a
tumor. This is the case in about 90% of all low back pain patients.
このガイドラインで"low
back pain"は「非特異的腰痛」を指す。それは、神経根圧迫（神経根症候群）、外傷、感染、腫瘍の存在などの身体的な明らかな原因がない腰痛と定義される。これは腰痛患者の９０％にあたる。
▲
Norwegian（ノルウェー） (Acute Low Back Pain Clinical Guidelines:)
www.ifomt.org/pdf/Norway_Acute_Low_Back.pdf （急性腰痛）
P.5 Diagnostic considerations （診断上、考慮すべきこと）
Further actions are describes on the basis of the division of diagnoses into three categories:
３つのカテゴリに分類して診断が進められる。
1. Non-specific low back pain
(80-90%) 非特異的腰痛
Pain distribution low back, gluteus and thighs （腰、臀部、大腿部の痛み）
Pain intensity varies, often better at rest （痛みの強さが変わる、休むと楽になる）
Patient in general good health （一般状態が良好）
2. Nerve root affection
(5-10%) 神経根障害
-
Radiating pain related to one or several dermatomes. The radiation from the
nerve roots L5 and S1will often be distal to the knee and more intense than the
actual back pain. The L3- and L4- roots give pain radiation
respectively at the front of the thigh and at the medial side of the calf/ medial side
of the foot.
-
放散痛は１つから数個のデルマトーム（皮節）に関係していた。L5とS1の神経根からの痛みはしばしば膝から下で、実際の腰痛より激しい。L3、L4の神経根からはそれぞれ、大腿の前面と下腿の内側、足の内側に放散痛をおこす。
-
Numbness and paraesthesia to a variable degree.
-
種々の程度の知覚麻痺と知覚異常
-
Laègues test reproduces the pain radiation (25%
of the incidents of stenosis).
-
ラセーグテストは放散痛を再現する（脊柱管狭窄症の２５％）
-
Motory, sensory and/or reflex changes accounted for by one or more nerve
roots .
-
運動と（または）知覚反射の変化は１から数個の神経根によって説明される。
-
Coughing/sneezing reproduces the pain radiation (not with
stenosis) .
-
咳やくしゃみで放散痛が再現する（脊柱管狭窄症では起こらない）。
-
Vertebrogic claudication/ spinal
stenosis: Pain (and possibly slight paresis) in one or both legs when walking caused by central and lateral spinal
stenosis.
-
脊椎性跛行/脊柱管狭窄症：歩行時の片側または両側の下肢の痛み（そしてたぶんわずかな麻痺）は中心性や外側性の脊柱管狭窄症による。
-
The pain will not cease by stopping. Numbness and a feeling of heaviness in
the legs, affection of one or more nerve roots, decreased pain by back flexion
for about 60% of patients. Age usually >60.
-
歩行を止めても痛みは収まらない。約６０％の患者で、１から数個の神経根による下肢のしびれや重い感じは、腰を曲げることによって減少した。通常年齢は６０才以上。
-
NB! Cauda equina syndrome
and/or progressive neurological signs. Loss of sensitivity/paresis in the perineum, urine retention, reduced sphincter
tonus, pathological sacral reflexes, progressive paresis, paralysis.
-
馬尾症候群や（または）進行性の神経学的徴候に注意！会陰部の知覚障害や不全麻痺、残尿、括約筋の減弱、仙骨神経の病的反射、進行性の麻痺などに注意。
3. Possible serious underlying pathology (most often fracture/injury, cancer or
inflammation)- suspected by the so-called "red
flags" (1-5%).
可能性のある重大な病理学的異常は（最も多いのは骨折/外傷、癌、感染症）”レッド・フラッグ”と呼ばれている。（１〜５％）
-
Age under 20 or above 55 years.（２０才以下、５５才以上）
-
Constant pain, possibly increasing over time; pain whilst at rest. （持続性疼痛、漸増する痛み、休息時痛）
-
Thoracic pain. （胸部痛）
-
General feeling of illness and /or loss of weight.（全身の病的状態/体重減少）
-
Injury, cancer, use of steroids or immunosuppressant, drug abuse. （外傷、癌、ステロイドや免疫抑制剤の使用、薬物乱用）
-
Widespread neurological signs. （神経学的徴候の多発）
-
Deformity of the spine.（脊椎の変形）
-
High ESR, declared morning stiffness that lasts for more than one hour. （血沈亢進、１時間以上続く朝のこわばり）
▲
New Zealand（ニュージーランド）
★New
Zealand Guidelines Group: Acute Low Back Pain Guide （急性腰痛）
Leg
Pain
Patients
with pain radiating from the back down one leg as far as the ankle,
with or without neurological signs, have a higher chance of a disc
herniation as the cause of their low back problems. Nevertheless, the
natural history of back-related leg pain is benign in most patients
and these patients should be managed as shown in Figure 1 unless there
is unremitting, severe pain or increasing neurological deficit.
Caution should be exercised in advising manipulation if there is any
neurological deficit.
Surgery
Surgery
is not indicated for non-specific low back pain. Where there is no
improvement, some patients with back-related leg pain and a defined
disc lesion may recover more rapidly with surgery. Note that the
long-term results of surgery for back-related leg pain are no better
than conservative management. Patient preferences will be important in
any decision about surgical intervention.
★www.nzgg.org.nz
http://www.nzgg.org.nz/guidelines/0072/acc1038_col.pdf （急性腰痛）
P.4 The natural history of low
back pain（腰痛の自然経過）
This guide deals with the management of acute
low back pain and recurrent episodes-not chronic pain or serious disease and
injury.
このガイドラインは急性腰痛や再発性急性腰痛を取り扱う。慢性痛や重大な病気や外傷を扱わない。
Acute low back pain （急性腰痛）
Acute low back pain is common and episodes by definition
last less than 3 months. in a few cases there is a serious cause, but generally the pain is non-specific and precise diagnosis is not
possible or necessary. If the pain radiates down the leg, below the knee, there is a greater chance that
symptoms are caused by a herniated disc.
急性腰痛はとても一般的なもので、定義上３ヶ月以内のものである。深刻な原因のこともあるだろうが、通常は痛みは非特異的で、正確な診断は可能でないかもしれないし必要がないかもしれない。痛みが下肢、膝下に放散しているのなら、椎間板ヘルニアによる症状の可能性がある。
After an acute episode there may be persistent or
fluctuating pain for a few weeks or months. Even severe pain that significantly limits activity at
first, tends to improve, although there can be recurring episodes and occasional pain afterwards. Acute low back pain does not cause prolonged loss of
function-unlike chronic back pain.
急性の強い症状のあと、数週から数ヶ月、痛みが持続するか、強くなったり弱くなったりする。当初は活動がかなり制限されるような激しい痛みでも改善するものである。しかし、その後もそのようなエピソードと痛みをくり返すかもしれない。急性腰痛は慢性腰痛と違って、長期にわたって機能的なことの損失を起こすことはない。
Chronic back pain （慢性腰痛）
Chronic back pain is defined as pain lasting more than 3 months. It may cause severe disability.
Chronic back pain may be associated with Yellow Flags- psychosocial barriers to recovery. Patients
with symptoms lasting more than 8 weeks have a rapidly reducing rate of return to usual activity.
They are likely to experience difficulties returning to work and suffer work loss.
慢性腰痛は３ヶ月以上続くものと定義される。それは高度な障害を引き起こすかもしれない。慢性腰痛はイエローフラッグ（回復には心理社会的障害がある）と関係しているかもしれない。８週間以上持続する患者は、通常活動に比して急速な減収になる。復職が困難になり、失職に悩む。
Yellow Flags （イエローフラッグ）
Yellow Flags indicate psychosocial barriers to recovery that may increase the risk of
long-term disability and work loss. Identifying any Yellow Flags may help when
improvement is delayed. There is more about identifying Yellow Flags
in Part 2 of this Guide.
イエローフラッグは回復に対して心理・社会的な障害を意味する。それは長期的障害と失職のリスクの増大につながる。改善が遅れるときはイエローフラッグの確認が助けになる。このガイドラインの第２部にはイエローフラッグの確認についてより多く書かれている。
P.14 Symptom Control（症状のコントロール）
Effective interventions to control symptoms of acute low back pain include analgesics and manipulation.
急性腰痛の効果的な対処法は鎮痛剤と徒手療法だ。
Analgesics-regular doses, rather than use 'as required' have been shown to provide effective
pain control. Paracetamol and aspirin are effective first options. All
non-steroidal anti-inflammatory drugs have proven to be equally
effective. An incremental approach to prescribing
analgesics to ensure that pain is adequately controlled whatever the
level will support a return to usual activities.
鎮痛薬は定期的に服用するより”必要に応じて”服用するほうが痛みのコントロールに効果的だということが分かっている。パラセタモールとアスピリンが効果的な最初の選択だ。すべての非ステロイド性消炎鎮痛剤は等しく有効だと証明された。通常の活動に戻れるように、痛みが十分にコントロールされることを確実にするために鎮痛薬が増量される。
Manipulation-manipulation of the spine by trained practitioners using appropriate techniques
is safe and effective in the first 4-6 weeks. Caution is required about using manipulation if there
are neurological signs.
最初の４〜６週間は、徒手療法ー正確な技術をもつよく訓練された徒手療法家による脊椎徒手療法は安全で有効だ。
It is important to combine symptom control with encouraging activity and return to work. Treating symptoms without appropriate emphasis on staying active may lead the patient to fear moving or using their back.
症状をコントロールすることと、活動的であるように励まし復職させることはともに重要だ。活動的を保つように適切なアドバイスなしに症状を治療すると、患者は動くことや腰を使うことに恐怖をもつことになるかもしれない。
Radiating leg pain （下肢への放散痛）
Back pain with radiating leg pain should be managed in the same way recommended for acute low back pain. Manipulation may not be advisable if there are neurological signs -
caution is required.
下肢への放散痛を伴った腰痛も急性腰痛に対する方法と同様に扱われるべきだ。もし注意を要する神経学的徴候があるのなら、徒手整復は勧められない。
Surgery （手術）
Surgery is not indicated for non-specific acute
low back pain unless disc decompression is indicated.
椎間板減圧の適応がないかぎり、非特異的急性腰痛に対して手術の必要はない。
The long-term results of surgery for back-related leg pain are no better than those of
conservative management.
腰下肢痛に対する手術と保存療法の成績は長期的には同じである。
If there is no improvement at 6 weeks, some patients with back-related leg pain and a defined disc lesion may improve more rapidly with surgery. Decisions about operative treatment
should be made on the basis of informed consent in discussion between patient and surgeon.
６週間で改善がないなら、腰下肢痛の患者や明らかな椎間板障害の患者は手術によって早くよくなるかもしれない。手術療法についての決定は、患者と外科医の間で議論において告知に基づく同意に基づいてなされなければならない。
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イギリス
★Royal
College of General Practitioners: Acute Low Back Pain Guide
http://www.emia.com.au/MedicalProviders/EvidenceBasedMedicine/rcgp/figure4.html
★http://www.chiroweb.com/archives/15/02/02.html
Assessment（評価）
- Carry out
diagnostic triage.
- 治療優先順位を診断しなさい。
- X-rays
are not routinely indicated in simple backache.
- 単純な腰痛はレントゲンを必要としない。
- Consider
psychosocial factors.
- 心理、社会的な要因を考慮しなさい。
Drug
Therapy（薬物療法）
- Prescribe
analgesics at regular intervals, not p.r.n.
- 一定間隔で鎮痛剤を処方しなさい。
- Start
with paracetamol. If inadequate, substitute NSAIDs(e.g.,
ibuprofen or diclofenac) and then paracetamol-weak opioid compound
(e.g., codydramol or coproxamol). Finally, consider adding a short
course of muscle relaxant (e.g., diazepam or baclofen).
- パラセタモールから始めなさい。不十分であるならば、NSAID（例えば、イブプロフェンまたはジクロフェナク）に代えなさい。それからパラセタモールー弱いオピオイド合成物（例えばcodydramolまたはcoproxamol）を代えなさい。最後に、筋弛緩薬（例えばジアゼパムまたはバクロフェン）の短いクールを加えることを考えなさい。
- Avoid
narcotics if possible.
- できれば麻薬を避けなさい。
Bed Rest
- Do not
recommend or use bed rest as a treatment for simple back pain.
- Some
patients may be confined to bed for a few days as a consequence of
their pain, but this should not be considered a treatment.
- 単純な腰痛のための処置として、ベッド療養を推薦しないか、使ってはいけない。
- 一部の患者は彼らの痛みの結果として２、３日の間ベッドに閉じこもるかもしれない、しかし、これは処置と考えられてはならない。
Advice on
Staying Active
- Advise
patients to stay as active as possible and to continue normal
daily activities.
- Advise
patients to increase their physical activities progressively over
a few days or weeks.
- If a
patient is working, then advice to stay at work or return to work
as soon as possible is probably beneficial.
- 患者にできるだけ活発なままでいて、通常の毎日の活動を続けるように勧めなさい。
- 患者に２、３日または週にわたって次第に彼らの身体活動を増やすように勧めなさい。
- 患者が働いているならば、仕事中にとどまるか、できるだけ早く職場復帰するアドバイスは多分有益だろう。
Manipulation
- Consider
manipulative treatment within the first 6 weeks for patients who
need additional help with pain relief or who are failing to return
to normal activities.
- 鎮痛でさらなる援助を必要とする、あるいは、通常の活動に戻ることができていない患者のために、最初の6週以内に徒手療法の処置を考慮しなさい。
Back
Exercises
- Patients
who have not returned to ordinary activities and work by 6 weeks
should be referred for reactivation/ rehabilitation.
- 6週たっても普通の活動と働きに戻らなかった患者は、再開/リハビリテーションの対象となる。
The
guidelines additionally assessed psychosocial factors and came to the
following conclusions:
ガイドラインは、さらに社会心理的要因を評価して、以下の結論に達した：
- Psychological,
social and economic factors play an important role in chronic low
back pain and disability.
- Psychosocial
factors are important at a much earlier stage than previously
believed.
- Psychosocial
factors influence a patient's response to treatment and
rehabilitation.
- 精神的、社会的、経済的要因は、慢性腰痛と障害で重要な役割を演ずる。
- 社会心理的要因は、以前信じられているより非常に初期のステージで重要である。
- 社会心理的要因は、処置とリハビリテーションに対する患者の反応に影響する。
★ Cost-effectiveness
and safety of epidural steroids in the management of sciatica
★ Longer
term clinical and economic benefits of offering acupuncture care to
patients with chronic low back pain
▲
United States（アメリカ）
U.S.
Agency for Health Care Policy and Research (1994)
University
of Michigan Health System Guideline for Clinical
Care Acute Low Back Pain
Interventional
techniques in the management of chronic spinal pain: evidence-based
practice guidelines.
Opioid
guidelines in the management of chronic non-cancer pain.
Acupuncture
and electroacupuncture: evidence-based treatment guidelines.
急性腰痛に対する臨床治療ーガイドラインの主な結論
評価
活動の制限と治療
-
苦痛は、一般大衆（ＯＴＣ）薬の投与・脊椎マニピュレーション（manipulation）によって最も安全に緩和できる。
-
急性期の患者において活動性を少し制限することは必要なことであるが、4日以上の臥床は役に立たないばかりか、患者をより弱体化させる可能性がある。
-
低負荷のエアロビック運動は、発症後２週間以内に安全に開始することができ、患者の弱体化を避けられる。一方、体幹筋のコンデイショニング運動は、通常２週間遅らせる。
-
急性腰痛が回復した患者は、できるだけ早く仕事や通常の日常生活に戻ることを奨励する。
症状の持続化
手術の適応
回復の予測
身体以外の因子
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