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,
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).