Exercise, especially when combined with education, was shown to help reduce lower-back pain, but shoe insoles, back belts, ergonomic interventions, or education alone had little effect, researchers reported.
Exercise reduced the risk of lower-back pain episodes by 35% and the risk of sick leave over lower-back pain by 78%, and when combined with education, the risk reduction for the prevention of episodes for up to 1 year was as high as 45%, Daniel Steffens, PhD, of the University of Sydney in Australia, and colleagues, reported in JAMA Internal Medicine.
“The benefits were fairly consistent across studies, and the effect size was large enough to have clinical and policy importance,”Timothy S. Carey, MD, MPH, and Janet K. Freburger, PhD, of the University of North Carolina at Chapel Hill, wrote in an editorial in JAMA Internal Medicine. “Exercise alone or in combination with education is effective for preventing LBP [lower-back pain].”
“If a medication or injection were available that reduced LBP recurrence by such an amount, we would be reading the marketing materials in our journals and viewing them on television,” Carey and Freburger wrote. “However, formal exercise instruction after an episode of LBP is uncommonly prescribed by physicians.”
Steffens’ group of researchers scoured medical databases for all randomized controlled trials (RCTs) involving lower-back pain from inception through November 2014. Out of more than 6,000 potential studies, a total of 23 published reports on 21 separate RCTs, which included 31,112 participants, were incorporated into this investigation.
Participants were asymptomatic at baseline.
Throughout the trials, six different lower-back pain prevention strategies were tested: exercise, education, exercise and education, back belts, shoe insoles, and ergonomic programs. Values were measured by days of sick leave due to lower back pain and lower-back pain episodes.
Among the trials that tested exercise against a control group, results pointed to low-quality evidence of exercise having a protective effect in the short term of less than 12 months (RR 0.65, 95% CI 0.50-0.86). In the long-term (>12 months), very low-quality evidence supported exercise (RR 1.04, 95% CI 0.73-1.49), or that exercise reduces the risk of sick leave for lower-back pain (RR 0.22, 95% CI 0.06-0.76).
In the trials that tested exercise and education versus a control group, moderate-quality evidence supported that exercise and education could reduce the risk of lower-back pain in the short-term (RR 0.55, 95% CI 0.41-0.74). In the long-term, there was low-quality evidence that this combination provided a protective effect (RR 0.73, 95% CI 0.55-0.96). In regard to reducing days of sick leave, the combination provided low-quality evidence of no protective effect for short-term (RR 0.74, 95% CI 0.44-1.26), or long-term (RR 0.72, 95% CI 0.48-1.08).
Education alone compared with a control group showed, with moderate-quality evidence, no protective effect for short-term (RR 1.03, 95% CI 0.83-1.27), or long-term (RR 0.86, 95% 0.72-1.04). As for sick leave, there was low-quality evidence that education alone had no protective effect on lower-back pain in the short-term (RR 0.87, 95% CI 0.47-1.60).
The use of back belts provided low-quality evidence of no effect on lower-back pain, compared with controls, in the short-term (RR 1.01, 95% 0.71-1.44), and in the long-term, moderate-quality evidence also pointed to a lack of effect (RR 0.85, 95% CI 0.64-1.14). And for sick leave, there was low-quality evidence that back belts reduced the number of days in the short-term (RR 1.44, 95% CI 0.73-2.86).
Shoe insoles provided low-quality evidence that they prevented lower-back pain in the short-term, resulting in no overall effect (RR 1.01, 95% 0.74-1.40).
There was moderate-quality evidence that an ergonomic program was no more effective than the control in reducing lower-back pain in the short-term (odds ratio 1.23, 95% CI 0.97-1.57). Low-quality evidence for reductions in sick leave with an ergonomic program, coupled with training and education, showed almost no effect (RR 0.95, 95% 0.51-1.76).
Steffens’ team concluded that exercise in combination with education would likely reduce the risk of lower-back pain. And, at least in the short-term, exercise alone might help a little. However, back belts, shoe insoles, education alone, and ergonomic adjustments would do little to nothing to prevent episodes of lower-back pain or sick leave.
According to Carey and Freburger, the diminished benefit after 12 months may be the result of reduced adherence to the exercise regimen beyond the intervention period.
The authors reported limitations in the designs of the RCTs, including limited ability to blind and conceal allocation, and loss to follow-up.