Elsevier

The Spine Journal

Volume 9, Issue 2, February 2009, Pages 147-168
The Spine Journal

Review Article
High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults

https://doi.org/10.1016/j.spinee.2008.11.001Get rights and content

Abstract

Background context

Back problems (BPs), with their cost and disability, are a substantial burden for individuals, employers, and society.

Purpose

This systematic review of controlled trials evaluates the effectiveness of interventions to prevent BP episodes in working age adults.

Data sources

We searched MEDLINE/EMBASE through May 2007, and COCHRANE/Trials Registry through August 22, 2008 using search terms of back pain, back injuries or sciatica, linked to prevention, control, workplace interventions, or ergonomics and searched article bibliographies.

Study selection

For systematic review inclusion, articles had to describe prospective controlled trials of interventions to prevent BPs in working-age adults, with intervention assignment either to individual participants or preexisting groups. Of 185 articles identified as potentially relevant, 20 trials (11%) met inclusion criteria.

Data extraction

Researchers extracted relevant information from controlled trials and graded methodological quality. Because of heterogeneity of trials, meta-analysis was not performed.

Results

Only exercise was found effective for preventing self-reported BPs in seven of eight trials (effect size 0.39 to >0.69). Other interventions were not found to reduce either incidence or severity of BP episodes compared with controls. Negative trials included five trials of education, four of lumbar supports, two of shoe inserts, and four of reduced lifting programs.

Conclusions

Twenty high-quality controlled trials found strong, consistent evidence to guide prevention of BP episodes in working-age adults. Trials found exercise interventions effective and other interventions not effective, including stress management, shoe inserts, back supports, ergonomic/back education, and reduced lifting programs. The varied successful exercise approaches suggest possible benefits beyond their intended physiologic goals.

Level of evidence

Systematic review Level I evidence.

Introduction

Back problems (BPs) are common and expensive for individuals and society, with wide variations in treatment and prevention approaches [1], [2], [3]. In 1994, the US Department of Health and Human Services, Agency for Health Care Policy and Research (AHCPR) issued a clinical practice guideline on low BPs in adults, using a multidisciplinary panel and based on a systematic review of the literature [3].

The AHCPR back guideline identified over 200 controlled trials of adequate quality for BP interventions, but only three involved preclinical prevention. Shekelle et al. analyzed the validity of the AHCPR back guideline in 2001, recommending only minor updates, including that prevention be expanded [4]. currently, a substantial number of high-quality trials exist to provide a reliable evidentiary basis for the prevention of new BP episodes.

Correctly performed systematic literature reviews can provide a comprehensive and unbiased assessment of the published scientific evidence about specific questions [5], [6]. The Cochrane Collaboration Back Review Group issued widely accepted recommendations for carrying out systematic reviews on interventions for BPs [6], consistent with the AHCPR back guideline methodology.

In the past, systematic reviews of prevention of BPs had relatively few high-quality controlled trials, and typically incorporated lower-quality studies in their analysis [7], [8], [9], [10], [11], [12]. Including lower-quality studies tends to reduce confidence in the validity of systematic review's conclusions. The purpose of this systematic review is to apply rigorous methodology, using high-quality evidence only from prospective controlled trials to evaluate the effectiveness of prevention interventions for BPs in working-age adults.

Section snippets

Basis for the methodology

We sought to use a rigorous methodology to identify high-quality evidence about the effectiveness of interventions to prevent BP episodes. The methodology for this systematic review is consistent with systematic review recommendations of the Cochrane Back Review Group [6],similar to that of the 1994 AHCPR back guideline and National Institute of Occupational Safety and Health (part of the CDC) [3], [13].

Types of trials

The included articles were high-quality, prospective studies which were randomized

Locating primary trials and study selection

Twenty prospective controlled trials (described in 21 articles) met the inclusion criteria for this systematic review on interventions to prevent BP episodes (see Appendix 1) [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38].

Common reasons for excluding studies included retrospective study designs, lack of adequate control groups, substantial differences between groups in baseline factors or assessment protocols, lack of

Comments

Historically, research on prevention of BPs in adults has focused on studies to identify risk factors and on retrospective evaluations of workplace back injury prevention programs [39]. Extensive research and high-quality studies have not consistently identified specific physical or environmental risk factors for BPs. Therefore, basing prevention efforts for BPs on reduction of suspected risk factors requires a degree of speculation, both about the intervention target and intervention

Summary of findings and comparison with prior prevention reviews

Our systematic review found remarkable consistency, as each type of intervention had strong evidence that the intervention either was or was not effective. Because 90% of the included trials were in workplace settings, and half evaluated health-care workers, our findings should be particularly relevant to workplace prevention efforts.

The reasons for the success of only exercise approaches are unclear. The effectiveness of varied exercise approaches suggests that there may be general benefits to

Conclusions

Our systematic review followed a rigorous methodology and included only high-quality prospective controlled trials. Only exercise was found to be an effective intervention for prevention of BPs. All other interventions studied were found ineffective including programs for reducing lifting (no lift policies, ergonomic training, and mechanical lifting aids), ergonomic/back education alone, stress management, lumbar supports and shoe inserts. The consistency in this systematic review, suggests

Summary of conclusions and discussion

In recent years, an increasing number of high-quality prospective controlled trials have evaluated the effectiveness of interventions to prevent BP episodes.

Strong evidence (consistent findings in multiple, high-quality trials) supports the following about preventing episodes of BPs:

  • 1)

    Exercise programs are effective, and

  • 2)

    Other interventions are not effective including:

    • education alone (ergonomic, back school, stress management); back supports (back belts); shoe inserts; and programs for reducing

Acknowledgments

The funding for this project was from the Orthopedic Research and Educational Foundation. The authors thank Orthopedic Research and Educational Foundation, American Academy of Orthopaedic Surgeons-Occupational Health Committee, and American College of Occupational and Environmental Medicine-Guidelines Methodology Committee for support and advisory input. Only the stated authors provided input for the formation and presentation of this article. The authors dedicate this article to the memory of

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