Nicola M. Parry, DVM
January 14, 2016
Exercise combined with education reduces the risk for a low back pain (LBP) episode, and exercise alone may reduce the risk for a LBP episode and the use of sick leave, a new study suggests.
Daniel Steffens, PhD, from the University of Sydney, New South Wales, Australia, and colleagues published the results of their systematic review and meta-analysis online January 11 in JAMA Internal Medicine.
“To our knowledge, this review is the first to have included a variety of LBP prevention strategies and conducted a meta-analysis of [randomized controlled trials (RCTs)],” the authors write. “In our review, the combination of exercise and education was effective at long-term follow-up ([relative risk (RR)], 0.73 [95% [confidence interval (CI)], 0.55 to 0.96]), while exercise alone was not (RR, 1.04 [95% CI, 0.73 to 1.49]), suggesting that the distinction between exercise alone and exercise combined with education may be important.”
LBP is one of the most common health problems worldwide and creates a substantial financial burden in treatments and work absenteeism. And with aging populations, the number of people with LBP is likely to continue to increase during the coming years. The high recurrence rate of LBP is a key contributor to the burden of the condition, with approximately half of affected individuals experiencing a recurrent LBP episode within 1 year after recovering from a previous episode.
Therefore, the prevention of recurrent LBP episodes is an important component in the management of this patient population, as is the identification of which interventions are most effective.
Although several reviews of interventions to prevent LBP episodes have been published, they are limited in use for various reasons: many are out of date, involved RCTs with participants who were symptomatic at baseline, evaluated a particular intervention or setting, or presented data descriptively. Dr Steffens and colleagues therefore aimed to provide an updated review of the evidence from all available RCTs on the effectiveness of interventions for prevention of LBP episodes and use of sick leave resulting from LBP.
The researchers performed a systematic review of currently available RCTs to assess the effectiveness of prevention strategies for nonspecific LBP. They searched various electronic databases to identify studies for inclusion, and excluded those that used a quasi-randomized design or reported the comparison of two prevention strategies.
A total of 23 studies on 21 different RCTs involving 30,850 participants met their inclusion criteria. These studies evaluated six different prevention strategies: exercise, education, exercise combined with education, back belts, shoe insoles, and other strategies.
Four studies demonstrated moderate-quality evidence that exercise combined with education reduces the risk for a LBP episode at short-term (≤12 months) follow-up (RR, 0.55; 95% CI, 0.41 – 0.74), whereas pooled data from two trials provided low-quality evidence of a protective effect of this combined strategy at long-term (>12 months) follow-up (RR, 0.73; 95% CI, 0.55 – 0.96). Data provided low-quality evidence of no effect of exercise combined with education on sick leave from LBP, after analysis of three studies involving short-term follow-up (RR, 0.74; 95% CI, 0.44 – 1.26) and two studies involving long-term follow-up (RR, 0.72; 95% CI, 0.48 – 1.08).
An analysis of four studies also demonstrated very low quality evidence to suggest that exercise alone may reduce the risk for an LBP episode at short-term follow-up (RR, 0.65; 95% CI, 0.50 – 0.86), although two trials provided very low-quality evidence of no effect at long-term follow-up (RR, 1.04; 95% CI, 0.73 – 1.49). Two studies also provided very low quality evidence that exercise alone reduces the use of sick leave in the long term (RR, 0.22; 95% CI, 0.06 – 0.76).
However, other interventions, including education alone (RR, 1.03 [95% CI, 0.83 – 1.27] at short-term follow-up; RR, 0.86 [95% CI, 0.72 – 1.04] at long-term follow-up), back belts (RR, 1.01; 95% CI, 0.71 – 1.44), and shoe insoles (RR, 1.01; 95% CI, 0.74 – 1.40), did not appear to be associated with the prevention of LBP.
“Although our review found evidence for both exercise alone (35% risk reduction for an LBP episode and 78% risk reduction for sick leave) and for exercise and education (45% risk reduction for an LBP episode) for the prevention of LBP up to 1 year, we also found the effect size reduced (exercise and education) or disappeared (exercise alone) in the longer term (>1 year),” the authors write.
“This finding raises the important issue that, for exercise to remain protective against future LBP, it is likely that ongoing exercise is required. Prevention programs focusing on long-term behavior change in exercise habits seem to be important,” the authors conclude.
“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,” Timothy S. Carey, MD, MPH, and Janet K. Freburger, PhD, from Cecil G. Sheps Center for Health Services Research, the University of North Carolina at Chapel Hill, write in an invited commentary.
“However, formal exercise instruction after an episode of LBP is uncommonly prescribed by physicians. This pattern is, unfortunately, similar to other musculoskeletal problems in which effective but lower-technology and often lower-reimbursed activities are underused,” they continue.
Motivating patients to exercise will require “payers, professional societies, consumers, and members of health care delivery systems…to work together. Consensus-development conferences and cross-specialty guidelines can be highly effective in disseminating common policies,” Dr Carey and Dr Freburger add.
“The discipline of implementation science can provide us with guidance on the readiness of the health care system for such programs. Health care professionals will need simple referral pathways for their patients to receive individual instruction or group classes that are financially attractive to both the health care system and patients.”
The authors and commentators have disclosed no relevant financial relationships.
JAMA Intern Med. Published online January 11, 2016. Full text