Konzervativno liječenje bolesnika s križoboljom: smjernice Hrvatskoga vertebrološkog društva

Simeon Grazio, Frane Grubišić, Tea Schnurrer Luke Vrbanić, Tatjana Nikolić, Tonko Vlak, Porin Perić, Branka Aukst Margetić, Arijana Lovrenčić – Huzjan, Dubravka Bobek, Tomislav Nemčić, Dubravka Sajković, Dubravka Šalić Herjavec, Diana Balen, Vedran Brnić, Petra Kovačević Totić, Alemka Krajač-Čupić, Darko Perović

Cilj: Izraditi ažurirane nacionalne smjernice za konzervativno liječenje odraslih bolesnika s križoboljom, kao nastavak prethodno objavljenih smjernica Hrvatskoga vertebrološkog društva o klasifikaciji, dijagnostičkom postupniku i mjerama ishoda. Metode: Proveden je sustavni pregled literature prema prethodno objavljenoj metodologiji Hrvatskoga vertebrološkog društva. Multidisciplinarni panel razmotrio je raspoložive dokaze te formulirao preporuke procesom rasprave, glasanja i konsenzusa prema unaprijed definiranom GRADE-okviru. Snaga preporuke rezultat je konsenzusa panela prema unaprijed definiranom postupku i nije sinonim za kvalitetu/sigurnost dokaza. Kada raspoloživi dokazi nisu bili dostatni za pouzdano usmjeravanje kliničke odluke, preporuka nije formulirana. Rezultati: Formulirano je ukupno 67 preporuka, od kojih je 16 snažnih i 51 uvjetna. Temelj konzervativnog liječenja čine edukacija, održavanje aktivnosti i samoupravljanje, uz izbjegavanje potpunog mirovanja. U akutnoj križobolji farmakološko liječenje treba biti kratkotrajno i individualizirano, pri čemu se nesteroidni antireumatici preporučuju nakon procjene koristi i rizika. Rutinsko rano propisivanje strukturiranog programa medicinskih vježbi ne preporučuje se u akutnoj nespecifičnoj križobolji, ali se bolesnike snažno potiče na održavanje uobičajene aktivnosti. U subakutnoj križobolji preporučuju se individualizirane strukturirane vježbe, a u kroničnoj križobolji medicinske vježbe predstavljaju temelj liječenja, uz izbor programa prema potrebama, mogućnostima i preferencijama bolesnika. Psihološke intervencije i multidisciplinarni biopsihosocijalni programi preporučuju se selektivno, osobito kod psihosocijalnih prepreka oporavku, značajne onesposobljenosti ili nedostatnog odgovora na liječenje prvog reda. Pasivne fizikalne i manualne metode, kada se primjenjuju, trebaju biti dodatak aktivnom programu, a ne njegova zamjena. Za dio intervencija preporučuje se izbjegavanje rutinske primjene zbog nedostatne ili nepovoljne dokazne osnove. Zaključak: Smjernice podupiru individualiziran, aktivan i biopsihosocijalno usmjeren pristup konzervativnom liječenju križobolje. Prioritet imaju edukacija, održavanje aktivnosti, medicinske vježbe u subakutnoj i kroničnoj fazi te ciljane psihološke i multidisciplinarne intervencije u odabranih bolesnika, dok farmakološke i pasivne metode treba primjenjivati racionalno, selektivno i u skladu s očekivanom koristi i rizikom.

Objective: To develop updated national guidelines for the conservative treatment of adults with low back pain, as a continuation of the previously published Croatian Society of Vertebrology guidelines on classification, diagnostic work-up, and outcome measures. Methods: A systematic literature review was conducted according to the previously published methodology of the Croatian Society of Vertebrology. A multidisciplinary panel reviewed the available evidence and formulated recommendations through discussion, voting, and consensus using a predefined GRADE framework. Recommendation strength reflects panel consensus reached through the predefined process and is not synonymous with the quality or certainty of the evidence. When the available evidence was insufficient to reliably guide a clinical decision, no recommendation was formulated. Results: A total of 67 recommendations were formulated, including 16 strong and 51 conditional recommendations. Education, maintenance of activity, and self-management are the foundations of conservative care, while complete bed rest should be avoided. In acute low back pain, pharmacological treatment should be short term and individualized, with non-steroidal anti-inflammatory drugs recommended after assessment of benefits and risks. Routine early prescription of a structured exercise programme is not recommended for acute non-specific low back pain; however, patients should be strongly encouraged to remain active. Individualized structured exercise is recommended in subacute low back pain, while exercise therapy is a cornerstone of chronic low back pain management, with the programme selected according to the patient’s needs, abilities, and preferences. Psychological interventions and multidisciplinary biopsychosocial programmes should be used selectively, particularly in patients with psychosocial barriers to recovery, substantial disability, or an inadequate response to first-line care. Passive physical and manual therapies, when used, should complement rather than replace an active treatment programme. Routine use of several interventions is discouraged because of insufficient or unfavourable evidence. Conclusion: These guidelines support an individualized, active, and biopsychosocially oriented approach to conservative low back pain management. Priority should be given to education, maintenance of activity, exercise therapy in the subacute and chronic stages, and targeted psychological and multidisciplinary interventions in selected patients, while pharmacological and passive treatments should be used rationally and selectively according to their expected benefits and risks.