Exercise With or Without Education May Prevent Low Back Pain

EBM Focus - Volume 11, Issue 7

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Reference - JAMA Intern Med 2016 Feb 1;176(2):199 (level 2 [mid-level] evidence)

  • Most people will experience a low back pain episode in their lifetime and recurrence is extremely common within 1 year of the episode.
  • A systematic review of 21 randomized trials assessing measures to prevent low back pain in 30,850 persons currently without low back pain found exercise with or without education significantly reduced episodes of low back pain.
  • Other interventions including education alone, back belt, and shoe insoles were not effective for preventing low back pain episodes or sick leave due to low back pain.

Low back pain is very common, with 49-70% of the population experiencing at least 1 episode of acute low back pain in their lifetime (BMJ 2006 Jun 17;332(7555):1430). Approximately 70% of patients with an acute low back pain episode will have a recurrence within 1 year, and identifying interventions that can effectively prevent low back pain episodes could significantly reduce this healthcare burden (ICSI 2012 Nov PDF, Best Pract Res Clin Rheumatol 2010 Apr;24(2):155). To help identify effective interventions, a recent systematic review analyzed 21 randomized trials assessing interventions to prevent low back pain in 30,850 persons currently without low back pain. Trials examining both primary prevention of back pain and secondary prevention were included in the analysis.

The interventions were categorized as exercise, education, exercise plus education, back belt, shoe insoles, or other. Control groups included no intervention, minimal intervention, or placebo. Low back pain episodes and sick leave due to low back pain were assessed as both short-term (evaluations at ≤ 12 months) and long-term (> 12 month follow-up) outcomes. All trials included in the analysis were of low to moderate quality and the duration of interventions as well as the specifics of each intervention group varied widely. Interventions associated with a significant reduction in low back pain episodes or sick leave are presented in the table below. There were no significant differences in short or long-term outcomes with education alone, back belts, or shoe insoles.

The results of this systematic review suggest that exercise, either alone or in combination with educational interventions, is an effective intervention for preventing low back pain. However, these results are limited by the low quality of evidence and the heterogeneity of exercise interventions included in the trials. The type of exercise, number of sessions, and duration of the intervention varied widely, making it impossible to determine if one type of exercise may be more effective than another. On the other hand, this heterogeneity also suggests that multiple forms of exercise may be beneficial, allowing programs to be tailored more towards individual needs and desires. Though exercise alone significantly reduced short-term episodes of low back pain, the addition of education to exercise further reduced both short and long-term low back pain episodes. These results indicate that education may be important in preventing low back pain episodes, but the small number of trials investigating long-term outcomes limit the ability to determine the magnitude of its role. Equally important to identifying effective preventative measures, this systematic review also identified interventions that are not effective. The results indicate that back belts, shoe insoles, and education alone may not be effective for preventing low back pain.

For more information, see the Acute low back pain topic in DynaMed Plus. DynaMed users click here.