Education combined with exercise linked to reduction of low-back pain episodes

1. In this systematic review and meta-analysis, exercise combined with education had moderate quality evidence for the prevention of future low back pain (LBP) episodes. Low quality evidence suggested exercise alone is linked to short term LBP risk reduction.

2. Education alone, back belts, shoe insoles and other strategies did not correlate with a decreased risk of LBP.

Evidence Rating Level: 1 (Excellent)      

Study Rundown: Low back pain (LBP) is a common condition with high rates of recurrence. Evaluation of evidence for preventative strategies will help guide practice and prevent loss of work-time and improve quality of life. The described meta-analysis evaluated randomized clinical trials for the prevention of LBP. Studies had to be for the prevention of LBP (not therapy), compared to a placebo or no/minimal intervention group, and have outcome measures of either episodes of LBP or work loss due to LBP. From 6133 initially identified articles, a final of 23 randomized controlled trials (RCTs) including 31,112 participants were included, predominantly from a working-age demographic.

Overall evidence for a combination of exercise and education was moderate-quality and demonstrated short-term (<12 months) and long-term (>12 months) risk reduction. Exercise alone had low quality evidence for reducing LBP episodes in the short term, but only had very low quality evidence for reducing sick leave risk in the long term. There was moderate quality evidence that education alone was not linked with reduction in LBP episodes. Back belts, shoe insoles, and other strategies did not correlate with changes in LBP incidence or sick leave risk.

This study is a comprehensive review of available literature for prevention of LBP and associated work absence. The major limitation is in the lack of high quality RCT evidence from which to draw conclusions. Additionally, the precise exercises and educational strategies employed by the trials do differ and provide a heterogeneous collection of examples to draw conclusions from.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Low Back Pain

In-Depth [systematic review and meta-analysis]: This study employed a systematic review of articles from MEDLINE, EMBASE, Physiotherapy Evidence Database (PEDro), and the Cochrane central registry of control trials up to November 22, 2014. A total of 6133 studies were reviewed by two independent reviewers and 23 RCTs were included in final review based on the inclusion crieteria: 1) Participants without LBP at baseline; 2) aimed to prevent further LBP; 3) compared to control group of placebo, minimal or no intervention; 4) reported outcome of episodes of LBP or work loss due to LBP. Evidence was evaluated for quality based on the PEDro and Grading of Recommendations Assessment, Development, and Evaluation System (GRADE).

In final analysis, the combination of exercise and education had moderate-quality evidence for short term (RR=0.55 [0.41-0.74]) and long-term (RR=0.73 [0.55-0.96]) reduction of LBP episodes. The combination approach did not demonstrate reduction of sick leave. Exercise alone demonstrated low quality evidence for short term benefit (RR=0.65 [0.50-0.86]), but not long term benefit [1.04 [0.73-1.49]). Educational interventions had moderate evidence for no effect in the short (RR=1.03 [0.83-1.27]) or long term (RR=0.86 [0.72-1.04]). Back brace, shoe insoles, and other interventions such as ergonomic programs demonstrated no benefit at short and long-term follow up.

Image: PD

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