By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
Summary Points
- This meta-analysis used data from 21 randomized clinical trials with more than 30,000 participants. Studies were graded according to quality of methodology and evidence; outcomes were recurrent episodes and sick-leave days.
- Exercise alone had low-quality evidence of a protective effect against recurrence of low back pain (LBP) in short-term studies (< 12 months) and low-quality evidence of reduced sick leave in long-term studies.
- Exercise combined with education had moderate-quality evidence of a protective effect against recurrence of LBP in short-term studies and low-quality evidence of this same effect in long-term studies; there is low-quality evidence of no protective effect on reduced sick leave.
- Education alone, shoe insoles, and back belts have very low to moderate quality evidence of no effect on recurrence of LBP in short or long term.
- Ergonomic interventions have very low quality evidence of no effect on sick leave in short-term studies, making it difficult to form a conclusion regarding this intervention.
Synopsis: In a meta-analysis of studies on preventing low back pain, researchers found a combination of exercise and education were the most likely interventions to prevent recurrence of this potentially debilitating condition.
Source: Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain. JAMA Intern Med 2016;176:199-208.
Low back pain (LBP) has been making headlines.1 Why? Consider these five facts: 1) LBP exists as a global health problem, affecting at least 12% of the world population.2 2) Although LBP is generally self-limiting, it is quite painful and acute episodes often impair functioning — recovering patients want to know how to prevent recurrences.3 3) Estimated recurrence rates are high, ranging from 24% to 80%.3 4) Recent studies have shown promise in treating LBP via nonpharmacological interventions.4 5) There are no clear guidelines for the prevention of LBP.
Responding to the lack of guidelines for the prevention of LBP, the authors of this study conducted a large-scale literature search to identify evidence-based studies that investigated prevention of LBP. From a base of more than 6,000 published studies, they extracted 21 unique randomized clinical trials that met stringent criteria for inclusion in their meta-analysis. The pooled group included more than 30,000 unique subjects.
Eligible studies had specific criteria required for inclusion in the meta-analysis: active investigation for prevention of LBP, control groups, and participants with either no LBP at baseline or LBP that did not interfere with functioning at baseline. There were no exclusions or inclusions regarding etiology of LBP. From these studies, investigators extracted and analyzed raw data, determined the quality of the trials’ specific methods, and identified the strength of evidence overall. The pooled results were analyzed; quality of the studies was reported along with data generated.
The PEDro scale5 (specific for physiotherapy studies) was used to score methodology; this score was used as part of the determination of the overall quality of evidence. The quality of evidence was determined using the GRADE6 system, a structured method to evaluate quality of evidence and strength of recommendations in healthcare studies. Each group of pooled results was given a quality score: high, moderate, low, or very low.
Three factors primarily influenced the GRADE classification and ultimately determined quality. The factors affecting the scores were: 1) design limitation as noted by the PEDro scale, 2) inconsistent results, and 3) “imprecision” defined as < 400 participants per outcome.
Results. Six different prevention interventions were investigated in the 21 randomized clinical trials meeting inclusion criteria: exercise, education, exercise and education regarding back care, back belts, shoe insoles, and ergonomic program of instruction. In almost all of the studies, participants were of working age; outcome results included workdays missed as well as a recurrent episode of LBP.
All results were reported according to length of study (short- or long-term) and outcome (recurrence of LBP and/or days off work). See Tables 1-6 for study results. In general, the authors concluded that exercise and education combined is the most likely intervention to reduce the risk of recurrence of LBP, with moderate-quality evidence in short-term studies and low-quality evidence in long-term studies. Exercise alone may reduce the likelihood of recurrent LBP in the short term, and there is very-low quality evidence that exercise alone can reduce sick leave in the long term. The other interventions alone (education, shoe insoles, back belts, ergonomic adjustments) are not supported by evidence to prevent recurrence of LBP. The authors noted that there is only very-low quality evidence that ergonomic adjustments do not have an effect on sick leave, making it difficult to draw conclusions about this intervention.
Table 1: Exercise vs. Control |
||||
|
Length of study |
Outcomes Measured |
Number of Participants and Number of Trials |
Quality of Evidence |
Effect |
|
Short-term |
Incidence of LBP |
898: 4 trials |
Low quality |
Protective |
|
Long-term |
Incidence of LBP |
334: 2 trials |
Very low quality |
No effect |
|
Long-term |
Days of missed work/sick leave |
128: 2 trials |
Very low quality |
Protective |
|
Note: There was no standardization of exercise techniques. |
||||
Table 2: Exercise and Education vs. Control |
||||
|
Length of study |
Outcomes Measured |
Number of Participants and Number of Trials |
Quality of Evidence |
Effect |
|
Short-term |
Incidence of LBP |
442: 4 trials |
Moderate quality |
Protective |
|
Short-term |
Days of missed work/sick leave |
228: 3 trials |
Low quality |
No effect |
|
Long-term |
Incidence of LBP |
138: 2 trials |
Low quality |
Protective |
|
Long-term |
Days of missed work/sick leave |
138: 2 trials |
Low quality |
Protective |
|
Note: There was no standardization of exercise techniques. There was no standardization of type of education recommended or implemented. |
||||
Table 3: Education vs. Control |
||||
|
Length of study |
Outcomes Measured |
Number of Participants and Number of Trials |
Quality of Evidence |
Effect |
|
Short-term |
Incidence of LBP |
2,343: 3 trials |
Moderate quality |
No effect |
|
Short-term |
Days of missed work/sick leave |
366: 2 trials |
Very low quality |
No effect |
|
Long-term |
Incidence of LBP |
13,242: 2 trials |
Moderate quality |
No effect |
|
Note: There was no standardization of educational interventions. |
||||
Table 4: Back Belts vs. Control |
||||
|
Length of study |
Outcomes Measured |
Number of Participants and Number of Trials |
Quality of Evidence |
Effect |
|
Short-term |
Incidence of LBP |
329: 2 trials |
Very low quality |
No effect |
|
Short-term |
Days of missed work/sick leave |
282: 1 trial |
Low quality |
No effect |
|
Long-term |
Incidence of LBP |
8,472: 1 trial |
Moderate quality |
No effect |
Table 5: Shoe Insole vs. Control |
||||
|
Length of study |
Outcomes Measured |
Number of Participants and Number of Trials |
Quality of Evidence |
Effect |
|
Short-term |
Incidence of LBP |
1,833: 4 trials |
Low quality |
No effect |
Table 6: Other, Including Ergonomic Training, vs. Control |
||||
|
Length of study |
Outcomes Measured |
Number of Participants and Number of Trials |
Quality of Evidence |
Effect |
|
Short-term |
Incidence of LBP |
3,047: 2 trials |
Moderate quality |
No effect |
|
Short-term |
Days of missed work/sick leave |
360: 1 trial |
Very low quality |
No effect |
Commentary
In March 2016, the Centers for Disease Control and Prevention (CDC) announced new guidelines for the use of opioids, which recommend limiting or eliminating opioids in the treatment of chronic pain outside of specific diagnoses or conditions (such as cancer treatment and palliative care.) The comprehensive CDC document references LBP specifically and frequently, pointing to evidence that non-opioid interventions and nonpharmacological interventions are not only less harmful but also more effective and sustainable than the potentially addicting opioid agents.7 In this meta-analysis, Seffan and his colleagues did not look at interventions for chronic pain. However, their work serves a parallel function and equally essential role in treatment of pain — reviewing interventions that work to prevent pain from becoming recurrent and potentially chronic.
These authors conclude that based on the current body of literature, the most likely effective intervention to reduce the risk of recurrence of LBP is a combination of exercise and education. The lack of standardization of the etiology of LBP as well as the interventions is a weakness and a ripe area for future investigation. For now, it seems useful and medically sound to inform patients that back exercises, along with education regarding back care, may guard against future episodes of LBP in the year following an episode.
This may lead to a question of why the effect was not shown to persist after one year with exercise alone (noting the evidence for effect of exercise on sick leave was very low quality for a protective effect in long-term studies.) The authors speculated that teaching or implementing long-term behavioral changes in the form of exercise and physical activity is key to extending the protective effect of this intervention.
Few of us in medical practice would argue with this conclusion or with the idea that behavioral change that encourages a more active lifestyle and includes exercise for LBP has the potential of protecting against recurrent LBP episodes. However, a 2009 study looking at prescriptions for exercise in chronic back and neck pain found that fewer than one-half of diagnosed patients received exercise instruction or advice, and that of those who did, most of the suggestions or prescriptions came from non-physician healthcare professionals.8
There is hope that this trend is changing. In 2012, the American Board of Internal Medicine (ABIM) launched Choosing Wisely with a goal of “advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.”9 ABIM has partnered with other specialties and Consumer Reports to create patient-friendly handouts and pamphlets explaining current evidence-based interventions. A search of the site reveals straightforward advice regarding the essential role of exercise in the prevention of recurrent LBP.9 The site encourages healthcare professionals to distribute the materials directly to patients.
Together, the CDC recommendations about limiting opioid use and the Choosing Wisely guidelines can support front-line medical providers in prescribing combined exercise and education as treatment for prevention of recurrent LBP. The potential for these interventions to be useful in prevention of recurrent episodes of LBP is clear, but our patients deserve more than potential! With more studies looking for specific exercises and interventions for specific populations, the answers look well within our reach.
References
- Rabin RC. Mind-based Therapies May Ease Lower Back Pain. The New York Times March 22, 2016. Available at: http://well.blogs.nytimes.com/2016/03/22/mind-based-therapies-may-ease-lower-back-pain/?_r=0 Accessed April 5, 2016.
- HoyD, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;64:2028-2037.
- Hoy D, Brooks P, Blyth F, et al. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769-781.
- Morone NE, Greco CM, Moore CG, et al. A mind-body program for older adults with chronic low back pain. JAMA Intern Med 2016;176:329-337.
- Macedo LG, Elkins MR, Maher CG, et al. There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials. J Clin Epidemiol 2010;63:920-925.
- Terracciano L, Brozek J, Compalati E, et al. GRADE system: New paradigm. Curr Opin Allergy Clin Immunol 2010;10:377-383.
- Centers for Disease Control and Prevention. Injury Prevention & Control: Opioid Overdose. CDC Guideline for Prescribing Opioids for Chronic Pain. Available at: http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed April 5, 2016.
- Freburger JK, Carey TS, Holmes GM, et al. Exercise prescription for chronic back or neck pain: Who prescribes it? Who gets it? What is prescribed? Arthritis Rheum 2009;61:192-200.
- The ABIM Foundation. Choosing Wisely. Low Back Pain. Available at: http://www.choosingwisely.org/patient-resources/low-back-pain/. Accessed April 5, 2016.
In a meta-analysis of studies on preventing low back pain, researchers found a combination of exercise and education were the most likely interventions to prevent recurrence of this potentially debilitating condition.
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