Low back pain is the leading cause of global disability and a common reason for absence from work, reduced productivity and seeking care. Prevention strategies are required to reduce the burden associated with this chronic, recurrent condition. This systematic review and meta-analysis aimed to estimate the effect of prevention strategies to reduce the impact of low back pain; as measured by pain intensity and associated disability.
Guided by a prospectively registered protocol, randomised controlled trials were identified through sensitive searches of five databases and citation tracking. Trials evaluating any strategy to reduce the future impact of low back pain, reporting pain intensity or disability at least 3 months after randomisation, and using a no intervention, placebo or minimal intervention control group were included. Prevention strategies could include any approach aiming to prevent or reduce the future impact of low back pain, including workplace interventions targeting risk factors or interventions to make people more fit, healthy or resilient. Trials evaluating the treatment of low back pain were excluded. The primary outcomes were pain intensity and disability (with data converted to a 0-100 point scale) in the short-term (6 months after randomisation) and long-term (12 months after randomisation). Risk of bias was assessed using the Physiotherapy Evidence Database scale and certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Trial selection, data extraction, and appraisal of risk of bias and certainty were independently performed by two reviewers, with any disagreements resolved through discussion. Meta-analyses were used to calculate mean between-group differences and 95% confidence intervals (CI) when trial interventions and populations were considered to be sufficiently similar.
Twenty-seven articles met the criteria to be included in the review. Of those, 21 trials (7,269 participants) published in 23 articles were included in the primary analyses. Prevention strategies were tested in three populations: working aged adults (18 trials, mainly recruited from hospitals or other workplaces, average age 45 years, 76% women), pregnant women (2 trials), and children (1 trial). Six different prevention strategies were evaluated in working aged adults: exercise (3 trials), exercise and education (5 trials), education (8 trials), ergonomics (3 trials), and ergonomics and education (2 trials) [note: some trials had multiple treatment arms so are included in more than one strategy]. Exercise was evaluated in pregnant women. Exercise combined with education was evaluated in children.
For working aged adults, exercise reduced future low back pain intensity (mean difference -5 points on a 100-point scale; 95% CI -7 to -2; 3 trials; 612 participants; moderate certainty) but not disability (-2; -7 to 2; 1 trial; 189 participants; very low certainty) in the short-term when compared to a control intervention. No trials evaluated the long-term outcomes associated with exercise. There was no effect of exercise and education on future low back pain intensity in the short-term (-2; -10 to 6; 3 trials; 184 participants; low certainty) or long-term (-4; -9 to 0; 4 trials; 471 participants; moderate certainty) or on disability in the short-term (-5; -13 to 3; 2 trials; 150 participants; low certainty) when compared to a control group. However, exercise and education did reduce disability in the long-term (-6; -10 to -3; 4 trials; 471 participants; moderate certainty). There was no effect of education alone on either future pain intensity in the short-term (-2; -5 to 1; 3 trials; 777 participants; moderate certainty) or long-term (2; -6 to 10; 2 trials; 126 participants; low certainty) or future disability in the short-term (-3; -6 to 1; 4 trials; 804 participants; moderate certainty) or long-term (0; -5 to 4; 2 trials; 176 participants; low certainty). There was no effect of ergonomics on future pain intensity in the short-term (1; -3 to 6; 1 trial; 552 participants; low certainty) or long-term (2; -3 to 7; 1 trial; 538 participants; low certainty) when compared to control interventions. No trials evaluated disability after ergonomic intervention. Similarly, there was no effect of ergonomics and education on future pain intensity in the short-term (1; 95% CI -7 to 9; 1 trial; 192 participants; very low certainty) or long-term (0; -7 to 7; 2 trials; 266 participants; low certainty) or on disability in the short-term (2; -2 to 6; 1 trial; 192 participants; very low certainty) or long-term (1; -3 to 6; 1 trial; 184 participants; very low certainty).
For pregnant women, exercise did not reduce future low back pain intensity (-3; -7 to 1; 2 trials; 452 participants; moderate certainty) or disability (-3; -7 to 1; 1 trial; 240 participants; low certainty) in the short-term, when compared to control interventions. No trials evaluated long-term outcomes.
For children, when compared to a control intervention, exercise and education did not reduce future low back pain intensity in the short-term (0; -12 to 12; 1 trial; 70 participants; very low certainty). No trials evaluated disability or long-term pain.
This review provides moderate quality evidence that an exercise program, or a program combining exercise and education, may reduce future low back pain intensity (short-term) and associated disability (long-term) in working aged adults. In contrast, interventions focusing on education and ergonomics (separately or in combination) are unlikely to reduce future low back pain intensity or disability in this patient group. Exercise probably doesn’t reduce future low back pain in pregnant women, and exercise and education may not reduce future low back pain in children.
de Campos TF, et al. Prevention strategies to reduce future impact of low back pain: a systematic review and meta-analysis. Brit J Sports Med 2020 Jul 9:Epub ahead of print
