ChiroACCESS Article

Preventing Low Back Pain

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ChiroACCESS Editorial Staff



Published on

April 20, 2009

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In a systematic review of high quality clinical trials, exercise was demonstrated to be the most successful strategy for preventing low back pain in working age adults. In addition to exercise, the interventions evaluated included lumbar supports, shoe orthotics, lifting techniques, education programs, back schools and stress management. All prevention strategies, based upon the current level of scientific evidence, were found to be ineffective with the exception of exercise. One must keep in mind that this study is not saying that other interventions are or are not effective, but rather the current evidence is only supportive of the effectiveness of exercise. As more research evidence becomes available it is possible that other strategies alone or in concert with exercise or other interventions may be more effective than exercise. Ninety percent of the research was conducted in the workplace.

The reason for the success of exercise is not well understood and may be partially due to increased strength, flexibility and/ or endurance. A review of the eight high quality clinical studies involving exercise reflects a strong emphasis on trunk or “core” strengthening and flexibility. These “core” exercises are commonly recommended by chiropractors.

On a related topic, an October, 2008 review by the Cochrane Collaboration Back Review Group concluded that there was strong evidence that shoe inserts do not prevent low back pain. This review can be found online at The review was subsequently published in the April 9, 2009 issue of Spine. Please see the second abstract below.

High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults.

Spine J. 2009 Feb;9(2):147-68

Bigos SJ, Holland J, Holland C, Webster JS, Battie M, Malmgren JA.

Department of Orthopedic Surgery, University of Washington, Seattle, WA, USA.

BACKGROUND CONTEXT: Back problems (BPs), with their cost and disability, are a substantial burden for individuals, employers, and society.

PURPOSE: This systematic review of controlled trials evaluates the effectiveness of interventions to prevent BP episodes in working age adults.

DATA SOURCES: We searched MEDLINE/EMBASE through May 2007, and COCHRANE/Trials Registry through August 22, 2008 using search terms of back pain, back injuries or sciatica, linked to prevention, control, workplace interventions, or ergonomics and searched article bibliographies.

STUDY SELECTION: For systematic review inclusion, articles had to describe prospective controlled trials of interventions to prevent BPs in working-age adults, with intervention assignment either to individual participants or preexisting groups. Of 185 articles identified as potentially relevant, 20 trials (11%) met inclusion criteria.

DATA EXTRACTION: Researchers extracted relevant information from controlled trials and graded methodological quality. Because of heterogeneity of trials, meta-analysis was not performed.

RESULTS: Only exercise was found effective for preventing self-reported BPs in seven of eight trials (effect size 0.39 to >0.69). Other interventions were not found to reduce either incidence or severity of BP episodes compared with controls. Negative trials included five trials of education, four of lumbar supports, two of shoe inserts, and four of reduced lifting programs.

CONCLUSIONS: Twenty high-quality controlled trials found strong, consistent evidence to guide prevention of BP episodes in working-age adults. Trials found exercise interventions effective and other interventions not effective, including stress management, shoe inserts, back supports, ergonomic/back education, and reduced lifting programs. The varied successful exercise approaches suggest possible benefits beyond their intended physiologic goals.

LEVEL OF EVIDENCE: Systematic review Level I evidence.

Insoles for Prevention and Treatment of Back Pain: A Systematic Review Within the Framework of the Cochrane Collaboration Back Review Group.

Spine. 2009 Apr 8.

Sahar T, Cohen MJ, Uval-Ne'eman V, Kandel L, Odebiyi DO, Lev I, Brezis M, Lahad A.

From the *Family Medicine Department, Hebrew University, Jerusalem, Israel; daggerCentre for Clinical Quality & Safety, Hadassah University Hospital, Jerusalem, Israel; double daggerDepartment of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; and section signPhysiotherapy Department, College of Medicine, University of Lagos, Nigeria.

STUDY DESIGN.: A systematic review of randomized controlled trials.

OBJECTIVE.: To determine the effectiveness of shoe insoles in the prevention and treatment of nonspecific back pain compared with placebo, no intervention, or other interventions.

SUMMARY OF BACKGROUND DATA.: There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain.

METHODS.: We searched electronic databases from inception to October 2008. We reviewed reference lists in review articles, guidelines, and in the included trials; conducted citation tracking; and contacted individuals with expertise in this domain. One review author conducted the searches and blinded the retrieved references for authors, institution, and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using the criteria recommended by the Cochrane Back Review Group.

RESULTS.: Six randomized controlled trials met inclusion criteria: 3 examined prevention of back pain (2061 participants) and 3 examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities.

CONCLUSION.: There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low back pain does not allow any conclusions.
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