Guidelines on prevention in low back pain

 

Yves Henrotin*

 

* On behalf of the COST B13 Working Group on Guidelines for Prevention in Low Back Pain. Bone and Cartilage Research Unit, Department of Physical Therapy, Institute of pathology, Level +5, CHU Sart-Tilman 4000 Liège, Belgium. yhenrotin@ulg.ac.be; Phone : +32-4-3662467; fax +32-4-3664734.

 

Summary

 

An European group of 14 experts have developed guidelines based on scientific evidence for prevention in low back pain. They have identified three attitudes that have a strong and consistent positive effect in the prevention of back pain consequences (recurrence, care seeking, disability and work loss) : - To do physical exercise - To participate at high intensity back school based on a biopsychosocial model, which comprise both an educational /skills programme and exercises - To organise multidimensional interventions ( including ergonomics component, education and task modification, exercises, pain management) at workplace involving the staff and the workers.

 

Methods

 

The guideline on prevention in low back pain was developed within the framework of the COST ACTION B13 “Low back pain: guidelines for its management’, issued by the European Commission. The evidence underpinning the guideline recommendations was retrieved through systematic searches of the scientific literature up to the end of 2003.

 

Recommendations were formulated for the general population, workers and school age (the latter defined as < 18 years of age).

 

Prevention, in the context of this guidelines, is focused primarily on reduction of the impact and consequences of low back pain.

 

Interventions that are essentially treatments in the clinical environment, focused on management of currents symptoms, are not considered as “ prevention” for the purpose of this guidelines.

 

The strength of recommendation was based on the following fourlevel rating system Level A : Generally consistent findings provided by (a systematic review of) multiple Randomized Controlled Trials (RCTs).

 

Level B : Generally consistent findings provided by (a systematic review of) multiple weaker scientific studies.

 

Level C: One RCT/Weaker scientific study, or inconsistent findings provided by (a systematic review of) multiple weaker scientific studies.

 

Level D : No RCTs or no weaker scientific studies.

 

Overall, there is limited robust evidence for many aspects of prevention in low back pain. The most promising approaches seem to involve physical exercise/activity and education based on a biopsychosocial model for all target groups.

 

Recommendations

 

Recommendations for the general population;

 

- Physical exercise is recommended for prevention of work absenteeism due to low back pain and for the occurrence or duration of further back pain episodes (level A). There is insufficient evidence to formulate recommendations for or against any specific type or intensity of exercise.

 

- Water gymnastics may be recommended during and following pregnancy (level D).

 

- Information and education on back problems can be recommended, if they are based on biopsychosocial model (level C). Information and education based on a biomedical or biomechanical model is not recommended (level C) - Back schools based on traditional biomedical/biomechanical information, advice and instruction are nor recommended for prevention in low back pain (level A). High intensity programs based on a biopsychosocial model, which comprise both an educational/skills programme and exercises, can be recommended for patients with recurrent and persistent back pain (level B).

 

- Lumbar supports or back belts are not recommended (level A) - There is no robust evidence for or against recommending any specific chair or mattress for prevention in low back pain (level C), though persisting symptoms may be reduced with a medium-firm rather than a hard mattress (level C) - There is no evidence to support recommending manipulative treatment for prevention in low back pain (Level D).

 

- Shoes insoles are not recommended in the prevention of back problems (level A). There is insufficient evidence to recommend for or against correction on leg length inequality (level D).

 

Recommendations for workers - Physical exercise is recommended in the prevention of LBP (level A), for prevention of recurrence of LBP (level A) and for prevention of recurrence of sick leave due to LBP (Level C). There is insufficient evidence to recommend for or against any specific type or intensity of exercise (level C).

 

- Back school based on traditional biomedical/biomechanical information, advice, instruction are not recommended (level A). There is insufficient evidence to recommend for or against psychosocial information delivered at the work site (level C), but information oriented toward promoting activity and improving coping, may promote a positive shift in beliefs (level C).

 

- Back belts/lumbar supports are not recommended (level A).

 

- Shoe inserts/orthoses are not recommended (level A). There is insufficient evidence to recommend for or against insoles, soft shoes, soft flooring or antifatigue mats (level D).

 

- Temporary modified work and ergonomic workplace adaptations can be recommended to facilitate earlier return to work for workers sick listed due to low back pain (level B).

 

- There is insufficient consistent evidence to recommend physical ergonomics interventions alone for prevention in low back pain (level C). There is some evidence, that, to be successful, a physical ergonomics programme would need an organisational dimension and involvement of workers (level B).There is insufficient evidence to specify precisely the useful content of such interventions (level C).

 

- There is insufficient evidence to recommend stand-alone work organisational interventions (level C), yet such interventions could, in principle, enhance the effectiveness of physical ergonomics programmes.

 

- Whilst multidimensional interventions at the workplace can be recommended (Level A), it is not possible to recommend which dimensions and in what balance.

 

Recommendations for school age

 

- There is insufficient evidence to recommend for or against a generalised educational intervention for the prevention of LBP or its consequences in schoolchildren (level C).

 

- Despite the intuitive appeal of the idea, there is no evidence that attempts to prevent low back pain in schoolchildren will have any impact on low back pain in adults (level D).