Bel Ağrısında Fizyoterapi Yöntemlerinin Karşılaştırılması
Özet
Bel ağrısı, dünya genelinde engellilikle geçirilen yılların tek başına en büyük nedenidir; yalnızca 2016 yılında yaklaşık 57,6 milyon engellilikle geçirilen yıldan sorumlu tutulmuştur. Taşıdığı yük ve maruz kaldığı mekanik stres nedeniyle lumbal bölge, omurganın biyomekanik açıdan en fazla talep gören segmentidir. Olguların büyük çoğunluğu, ağrının tek bir anatomik yapıya atfedilemediği spesifik olmayan bel ağrısı grubunda yer alır; kırmızı bayrak bulunmadığında erken dönemde rutin görüntülemeden kaçınılması önerilir. Terapötik egzersiz yaklaşımları (motor kontrol, McKenzie, Pilates, yoga, aerobik egzersiz), manuel terapi, elektroterapi, kinezyolojik bantlama, hasta eğitimi, psikolojik temelli girişimler ve teknoloji destekli uygulamalar etki mekanizmaları ve kanıt düzeyleri bakımından birbirinden ayrışır. Akut dönemde güven verme, aktif kalma ve eğitim; subakut dönemde risk stratifikasyonu ve erken aktif müdahale; kronik dönemde ise egzersiz temelli multimodal yaklaşımlar öne çıkar. Düzey I ağ meta-analizi verileri aktif fizyoterapinin pasif uygulamalara üstünlüğünü göstermekte, psikolojik girişimler en kalıcı etkilerini fizyoterapiyle bütünleştiklerinde vermektedir. Bilişsel fonksiyonel terapi, bir yıla kadar korunan büyük iyileşmeleriyle dikkat çeker. Ağrı mekanizmasına dayalı sınıflama ve risk stratifikasyonunu birleştiren kademeli bir klinik karar algoritması, kanıtla uygulama arasındaki açığı kapatmaya yöneliktir.
Low back pain is the single leading cause of years lived with disability worldwide, accounting for approximately 57.6 million such years in 2016 alone. Because of the load it carries and the mechanical stress it endures, the lumbar region is the most biomechanically demanded segment of the spine. Most cases fall into the non-specific category, in which pain cannot be attributed to a single anatomical structure, and routine early imaging is discouraged in the absence of red flags. Therapeutic exercise approaches (motor control, McKenzie, Pilates, yoga, aerobic exercise), manual therapy, electrotherapy, kinesiology taping, patient education, psychologically informed interventions and technology-assisted applications differ substantially in their mechanisms of action and levels of evidence. Reassurance, staying active and education dominate the acute stage; risk stratification and early active intervention are decisive in the subacute window; exercise-based multimodal care prevails in chronic pain. Level I network meta-analytic data demonstrate the superiority of active over passive physiotherapy, and psychological interventions yield their most durable effects when integrated with physiotherapy. Cognitive functional therapy stands out with large improvements sustained for up to one year. A stepwise clinical decision algorithm combining pain mechanism classification with risk stratification addresses the gap between evidence and practice.
Referanslar
Neumann DA. Kinesiology of the musculoskeletal system: foundations for rehabilitation. 3rd ed. St. Louis: Elsevier; 2017.
Bogduk N. Clinical and radiological anatomy of the lumbar spine. 5th ed. Edinburgh: Churchill Livingstone/Elsevier; 2012.
Adams MA, Bogduk N, Burton K, ve ark. The biomechanics of back pain. 3rd ed. Edinburgh: Churchill Livingstone/Elsevier; 2012.
White AA, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia: J. B. Lippincott; 1990.
Shipton EA. Physical therapy approaches in the treatment of low back pain. Pain and Therapy. 2018;7(2): 127-137. doi:10.1007/s40122-018-0105-x
Foster NE, Anema JR, Cherkin D, ve ark. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391(10137): 2368-2383. doi:10.1016/S0140-6736(18)30489-6
Pergolizzi JV Jr, LeQuang JA. Rehabilitation for low back pain: a narrative review for managing pain and improving function in acute and chronic conditions. Pain and Therapy. 2020;9(1): 83-96. doi:10.1007/s40122-020-00149-5
Nicol V, Verdaguer C, Daste C, ve ark. Chronic low back pain: a narrative review of recent international guidelines for diagnosis and conservative treatment. Journal of Clinical Medicine. 2023;12(4): 1685. doi:10.3390/jcm12041685
George SZ, Fritz JM, Silfies SP, ve ark. Interventions for the management of acute and chronic low back pain: revision 2021. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(11): CPG1-CPG60. doi:10.2519/jospt.2021.0304
Mescouto K, Olson RE, Hodges PW, ve ark. A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disability and Rehabilitation. 2022;44(13): 3270-3284. doi:10.1080/09638288.2020.1851783
Gardner T, Refshauge K, Smith L, ve ark. Physiotherapists’ beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy. 2017;63(3): 132-143. doi:10.1016/j.jphys.2017.05.017
Corp N, Mansell G, Stynes S, ve ark. Evidence-based treatment recommendations for neck and low back pain across Europe: a systematic review of guidelines. European Journal of Pain. 2021;25(2): 275-295. doi:10.1002/ejp.1679
Kühn L, Lindert L, Kuper P, ve ark. Research designs and instruments to detect physiotherapy overuse of low-value care services in low back pain management: a scoping review. BMC Health Services Research. 2023;23: 193. doi:10.1186/s12913-023-09166-4
Malfliet A, Ickmans K, Huysmans E, ve ark. Best evidence rehabilitation for chronic pain part 3: low back pain. Journal of Clinical Medicine. 2019;8(7): 1063. doi:10.3390/jcm8071063
Baroncini A, Maffulli N, Schäfer L, ve ark. Physiotherapeutic and non-conventional approaches in patients with chronic low-back pain: a level I Bayesian network meta-analysis. Scientific Reports. 2024;14: 11546. doi:10.1038/s41598-024-62276-9
Chou R, Deyo R, Friedly J, ve ark. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine. 2017;166(7): 493-505. doi:10.7326/M16-2459
Rubinstein SM, de Zoete A, van Middelkoop M, ve ark. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364: l689. doi:10.1136/bmj.l689
González-Gómez L, Moral-Munoz JA, Rosales-Tristancho A, ve ark. Exercise therapy versus manual therapy for the management of pain intensity, disability, and physical function in people with chronic low back pain: a systematic review with meta-analysis and meta-regression. European Journal of Pain. 2025;29(8): e70090. doi:10.1002/ejp.70090
Ho EKY, Chen L, Simic M, ve ark. Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis. BMJ. 2022;376: e067718. doi:10.1136/bmj-2021-067718
Kent P, Haines T, O’Sullivan P, ve ark. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. The Lancet. 2023;401(10391): 1866-1877. doi:10.1016/S0140-6736(23)00441-5
Sivertsson J, Sernert N, Åhlund K. Exercise-based telerehabilitation in chronic low back pain - a scoping review. BMC Musculoskeletal Disorders. 2024;25: 948. doi:10.1186/s12891-024-07952-7
Cui D, Janela D, Costa F, ve ark. Randomized-controlled trial assessing a digital care program versus conventional physiotherapy for chronic low back pain. npj Digital Medicine. 2023;6: 121. doi:10.1038/s41746-023-00870-3
Kapil D, Wang J, Olawade DB, ve ark. AI-assisted physiotherapy for patients with non-specific low back pain: a systematic review and meta-analysis. Applied Sciences. 2025;15(3): 1532. doi:10.3390/app15031532
Baroncini A, Maffulli N, Manocchio N, ve ark. Active and passive physical therapy in patients with chronic low-back pain: a level I Bayesian network meta-analysis. Journal of Orthopaedics and Traumatology. 2025;26: 66. doi:10.1186/s10195-025-00885-4
Qaseem A, Wilt TJ, McLean RM, ve ark. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2017;166(7): 514-530. doi:10.7326/M16-2367
Baroncini A, Maffulli N, Pilone M, ve ark. Prognostic factors in patients undergoing physiotherapy for chronic low back pain: a level I systematic review. Journal of Clinical Medicine. 2024;13(22): 6864. doi:10.3390/jcm13226864
Tedeschi R, Giorgi F, Platano D, ve ark. Classifying low back pain through pain mechanisms: a scoping review for physiotherapy practice. Journal of Clinical Medicine. 2025;14(2): 412. doi:10.3390/jcm14020412
Ferreira ML, Ferreira PH, Latimer J, ve ark. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain. 2007;131(1-2): 31-37. doi:10.1016/j.pain.2006.12.008
Bronfort G, Maiers MJ, Evans RL, ve ark. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine Journal. 2011;11(7): 585-598. doi:10.1016/j.spinee.2011.01.036
Ulger O, Demirel A, Oz M, ve ark. The effect of manual therapy and exercise in patients with chronic low back pain: double blind randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation. 2017;30(6): 1303-1309. doi:10.3233/BMR-169673
de Oliveira Meirelles F, Oliveira Muniz Cunha JC, da Silva EB. Osteopathic manipulation treatment versus therapeutic exercises in patients with chronic nonspecific low back pain: a randomized, controlled and double-blind study. Journal of Back and Musculoskeletal Rehabilitation. 2020;33(3): 367-377. doi:10.3233/BMR-181294
Zhang Z, Zhang C, Li Y, ve ark. Lipid and metabolic alteration involvement in physiotherapy for chronic nonspecific low back pain. Lipids in Health and Disease. 2022;21: 125. doi:10.1186/s12944-022-01744-5
