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Preventing low back pain

At a glance:
This article summarises the European Guidelines for Prevention in Low Back Pain, which recommend strategies for preventing the negative consequences of back pain. Strategies currently used have a moderate effect. Those that are most effective use physical activity/exercise, and education that covers psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 and social issues as well as the medical aspects of back pain.
If you have had a back injury, you can reduce its effect on your life by remaining active and learning how to manage your condition. Talk to your treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 about exercise and the ways it might help with your condition. Make sure they are aware of current research in the area.

It's easier to exercise if you set manageable goals and make them a part of your normal routine. This might mean a 20 minute walk before the children get up, playing tennis or golf on the weekends, following an exercise video at home or going to the gym. Swimming is very good for the back, but some people find it difficult to fit into their daily routine. Walking is often very convenient because it requires no equipment or payment, and is easy to fit into most routines. Pick a form of exercise that suits you. It doesn't matter which you choose so long as you are active.
When an employee has back pain, there are a few things employers can do to make the condition more manageable and reduce the chances of recurrent pain.

Employers can:

  • Provide modified duties so the person can work while they recover
  • Encourage a return to normal activities
  • Speak to the employee regularly about their progress and wellbeing
  • Involve the employee in the development of a return to work plan
  • Encourage co-workers to support the person, and to support programs of work modifications
This review finds strong evidence that an increase in physical exercise reduces future episodes of back pain. No specific exercise is indicated, and patients should be encouraged to do whatever suits them best.

Establishing an exercise routine can be difficult. The process is made easier if the person can:

Choose exercise that fits into their routine. Walking is often easiest, since it requires no special equipment and can be done whenever the person chooses.

Recognise that it takes most people a month or two to develop a consistent routine, after which the routine is much easier to follow.

Exercise with a partner or group. This doesn't suit everyone, but if the person finds it helpful then their spouse or partner can help by exercising with them.

Choose exercise they enjoy. This may be running, golf, dancing, or something else. In other cases it is useful to set goals for a return to activity that the person enjoys but currently finds difficult.
There is little evidence to suggest that first onset episodes of back pain can be prevented. There is evidence that people can do a reasonable amount to prevent future episodes of back pain by increasing their fitness level and the amount of exercise they do.

Encourage patients to discuss these issues with their treating practitioners. The strategies involved are simple, but they do require patients to take on a level of personal responsibility and develop routines that are maintained.
Original Article, Authors & Publication Details:
K. Burton (2005)1

How to prevent low back pain. Best Practice and Research Clinical Rheumatology. 19(4): 541-555

1. On behalf of the COST B13 Working Group on European Guidelines for Prevention in Low Back Pain
Background, Study Objectives, How It Was Done:
“Non-specific' low back pain means back pain for which the cause is not known. 85% of low back pain cases are non-specific.

60-70% of people in industrialised countries experience non-specific low back pain at some point in their lives. The condition affects people from all age groups, but is most common between the ages of 35 and 55.

Non-specific low back pain usually gets better over time with little or no treatment. In 2-7% of cases, however, people develop long-term problems. This small minority of cases accounts for 80% of the healthcare and social costs of back pain in general.

Risk factors for low back pain include:

  • A previous history of back pain (the most significant risk factor)
  • Heavy physical work
  • Frequent bending, twisting, lifting, pulling and pushing
  • Repetitive work
  • Remaining in the same position for a long time
  • Exposure to vibrations
  • Distress,
    Severe suffering, pain, anxiety or sorrow
    A symptom of mood disorder characterized by intense feelings of loss, sadness, hopelessness, failure, and rejection. Major depression is likely to interfere significantly with everyday activity, with symptoms including insomnia, irritability, weight loss, and a lack of interest in outside events. The disorder may last several months or longer and may recur, but it is generally reversible in the short run.
     job dissatisfaction and work stress
Most of these risk factors cause only a small elevation of risk, and the evidence for each is limited, making prevention difficult.

The European Guidelines for Prevention in Low Back Pain review the evidence for the effectiveness of some strategies designed to prevent low back pain. The working group that produced the guidelines consisted of 12 low back pain experts from 9 countries, including an orthopaedic surgeon, a biomechanist, a rheumatologist, a physical medicine and rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 specialist, a psychologist, a pathologist, a physiologist and several epidemiologists.

The guidelines were based on an examination of systematic reviews
systematic review
A comprehensive review of research studies in a particular area. The review follows guidelines to ensure the studies included are valid.
 of back pain prevention, and existing evidence based guidelines for back pain management. When neither of these were available, individual scientific studies were used. Studies published as late as 2003 were included, and each was given a rating for scientific quality and reliability.

The working group concluded that preventing the first episode of back pain was not a realistic goal, and instead focused on strategies for preventing the negative consequences of low back pain. This article summarises their findings.
Study Findings:
The working group considered a number of strategies for preventing the negative consequences of low back pain. These strategies and the evidence for their effectiveness are summarised below.

Physical exercise

There is strong evidence that physical exercise is effective in preventing back pain. For people who have already had back pain, there is strong evidence that it prevents reoccurrence. It also prevents absence from work.

Information, education and training (“back school')

Education about the biological, psychological and social aspects of back pain reduces the amount of treatment patients seek, and may improve work and health outcomes. The effect could be quite small however, and there is no evidence to suggest that education covering only biomedical
Applying understanding from the biological and physiological sciences to clinical medicine.
 or biomechanical
Refers to the physical stresses on the body. For example, biomechanical models can calculate physical stresses occurring at the discs
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae.  Disks
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae. Disks have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disc.
  have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disk.
 in the low back joints in the body.
 information has any positive effective. Traditional workplace training on postures, lifting techniques etc has no effect.

Lumbar supports/back belts

relating to the part of the back between the ribs and the hipbones
 supports and back belts are not recommended. There is no evidence that they improve outcomes, and they might even make the problem worse.

Mattresses and chairs

There is no evidence for or against any specific mattress or chair designed to prevent back pain. These cannot be recommended.

Orthotics, insoles, flooring and mats

Shoe inserts and orthotics are not recommended. There has not been enough research into the use of soft shoes, flooring or mats to know whether or not they can prevent low back pain.

Manipulation (e.g. chiropractic treatment)

There is no evidence to support manipulative treatment designed to prevent low back pain.

Workplace ergonomics

There is not enough evidence to conclude that changing the physical work environment will, by itself, reduce back injuries or low back pain. Some evidence suggests that workplace changes are most successful when they involve both management and workers. More research into this area is required.

Multidimensional interventions
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 at work

Multidimensional interventions (programs that combine strategies such as education, ergonomic
Designing activities and the workplace in a way to minimize discomfort. i.e. Adapting work tasks, hours, or workstation to accommodate people. An ergonomic computer workstation allows the person to work in the best position to relieve load on the muscles of the neck and arms.
 workplace changes, physical exercises etc) might reduce some of the consequences of low back pain.

Modified work after sick leave

Employees can return to work more quickly if their work duties can be modified to accommodate restrictions imposed by their illness or injury. The guidelines support the attitude that “work should be comfortable when we are well and accommodating when we are ill.' Programs of modified work are recommended.

Strategies for those under 18

Research focused on those under 18 is limited. There is not enough evidence to recommend school based programs that present information on caring for ones back.

Possible risk-factors for low back pain in those under 18 include:

Being overweight or obese
Low levels of physical activity
Heavy/poorly designed school bags
Poorly designed school furniture
Because the causes of low back are not well known, the prevention of first episodes is not a realistic goal. It is possible, however, to prevent the consequences of low back pain, including recurrence, disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 and time off work.

Current strategies for reducing the effects of low back pain have a moderate effect. Back pain is complex and no single strategy will be effective on its own. The most effective approaches for adults seem to involve a combination of physical activity/exercise, and education that covers psychological and social issues as well as the medical aspects of back pain. More research is needed to determine the effectiveness of other interventions.

Some people might report strategies that work for them, but without scientific evidence these can't be recommended for the general population. There are many misconceptions about low back pain, and these can contribute to long term disability.
PubMed Abstract
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