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Exercise, education effective in low back pain prevention

Analysis of clinical trials identified that exercise alone or a combination of exercise and education is effective in preventing low back pain, according to findings published in JAMA Internal Medicine.

"Low back pain (LBP) is one of the most burdensome health problems worldwide, generating enormous costs in treatments and time lost from work," Daniel Steffens, PhD, from the musculoskeletal division at The George Institute for Global Health, Sydney Medical School, The University of Sydney, Australia, and colleagues wrote. "The global point prevalence of LBP is 12%; with the aging population, the number of people affected is likely to increase over the coming years."

Noting that approximately half of patients experience another episode of LBP within 1 year of a previous episode, Steffens and colleagues acknowledged the importance of identifying prevention strategies. They searched EMBASE, MEDLINE, Physiotherapy Evidence Database (PEDro) and the Cochrane Central Register of Controlled Trials for randomized controlled trials that assessed the efficacy of interventions for nonspecific LBP prevention. Independent reviewers assessed bias risks and evidence quality using the PEDro scale and the Grading of Recommendations Assessment, Development, and Evaluation system.

Steffens and colleagues reported that their initial search returned 6,133 potential studies. After excluding inappropriate studies, the researchers were left with a final group of 23 reports, encompassing 30,850 unique participants.

Results showed that exercise alone reduced risk for an LBP episode (relative risk = 0.65; 95% CI, 0.5-0.86) and use of sick leave (RR = 0.22; 95% CI, 0.06-0.76). A combination of exercise and education reduced risk for an LBP episode (RR = 0.55, 95% CI; 0.41-0.74) but had no effect on use of sick leave (RR = 0.74; 95% CI, 0.44-1.26).

Additionally, education alone, back belts and shoe insoles had no effect on LBP or use of sick leave, Steffens and colleagues found.

"The results of this systematic review and meta-analysis indicate that exercise in combination with education is likely to reduce the risk of LBP," the researchers wrote. "Exercise alone may reduce the risk of an episode of LBP and sick leave; however, it is uncertain whether the effects persist beyond 1 year. Education alone, back belts, shoe insoles, and ergonomic adjustments probably do not prevent an episode of LBP or sick leave due to LBP. It is uncertain whether education, training, or ergonomic adjustments prevent LBP owing to the very low quality of evidence."

In an accompanying editorial, Timothy S. Carey, MD, MPH, and Janet K. Freburger, PhD, both from the Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, discussed how the results of the study could be implemented in clinical practice.

"The types of exercise instruction across these studies were variable, encompassing core exercises emphasizing the strengthening of back and abdominal muscles, stretching and spine range-of-motion exercises, and more general instruction in aerobic conditioning," they wrote. "Almost all of the education and exercise regimens assessed were substantial regarding the frequency and duration of the sessions."

Carey and Freburger noted that specific exercises instruction is not commonly prescribed to patients with low back pain. They advised that the development of standard exercise treatment protocols, identification of key components of educational programs and efficient delivery models and the improvement of payment policy, as well as addressing patient motivation and instilling prescribing confidence in physicians, would help to address barriers that keep physicians from using exercise instruction.

"To address these barriers, payers, professional societies, consumers and members of health care delivery systems will need to work together," they wrote. "Consensus-development conferences and cross-specialty guidelines can be highly effective in disseminating common polices... The potential benefits to the health system, patients, and employers are substantial." – by Chelsea Frajerman Pardes

Disclosures: The researchers report no relevant financial disclosures.