Chapter 2 -: European guidelines for prevention in low back pain

Summary of the concepts of prevention in low back pain (LBP): The general nature and course of commonly experienced LBP means that there is limited scope for preventing its incidence (first-time onset). Prevention, in the context of this guideline, is focused primarily on reduction of the impact and consequences of LBP. Primary causative mechanisms remain largely undetermined: risk factor modification will not necessarily achieve prevention. There is considerable scope, in principle, for prevention of the consequences of LBP - e.g. episodes (recurrence), care seeking, disability, and workloss. Different interventions and outcomes will be appropriate for different target populations (general population, workers, and children) yet inevitably there is overlap. Interventions that are essentially treatments in the clinical environment, focused on management of current symptoms, are not considered as 'prevention' for the purposes of this guideline: they are covered in the accompanying clinical guidelines Overarching comments: Overall, there is limited robust evidence for numerous aspects of prevention in LBP. Nevertheless, there is evidence suggesting that prevention of various consequences of LBP is feasible. However, for those interventions where there is acceptable evidence, the effect sizes are rather modest. The most promising approaches seem to involve physical activity/exercise and appropriate (biopsychosocial) education, at least for adults. But, no single intervention is likely to be effective to prevent the overall problem of LBP, owing to its multidimensional nature. Prevention in LBP is a societal as well as an individual concern. So, optimal progress on prevention in LBP will likely require a cultural shift in the way LBP is viewed, its relationship with activity and work, how it might best be tackled, and just what is reasonable to expect from preventive strategies. It is important to get all the players onside, but innovative studies are required to understand better the mechanisms and delivery of prevention in LBP. Anecdotally, individuals may report that various strategies work for them, but in the absence of scientific evidence that does not mean they can be generally recommended for prevention, it is not known whether some of these strategies have disadvantageous long- term effects. Recommendations: These are based on systematic reviews, existing evidence-based guidelines, and scientific studies. The studies on which these recommendations are based were often variable and imprecise in specifying the interventions and outcomes investigated. Hence, it is not always possible to state exactly which outcomes will be influenced by a given intervention. Summary of recommendations for the general population: Physical exercise is recommended for prevention of sick leave due to LBP and for the occurrence or duration of further episodes (Level A). There is insufficient consistent evidence to recommend for or against any specific type or intensity of exercise (Level C). Information and education about back problems, if based on biopsychosocial principles, should be considered (Level C), but information and education focused principally on a biomedical or biomechanical model cannot be recommended (Level C). Back schools based on traditional biomedical/biomechanical information, advice and instruction are not recommended for prevention in LBP (Level A). High intensity programmes, 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 LBP (Level C), though persisting symptoms may be reduced with a mediurn-firm rather than a hard mattress (Level C). There is no evidence to support recommending manipulative treatment for prevention in LBP (Level D). Shoe insoles are not recommended in the prevention of back problems (Level A). There is insufficient evidence to recommend for or against correction of leg length (Level D). Summary of 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 Q. There is insufficient evidence to recommend for or against any specific type or intensity of exercise (Level C). Back schools based on traditional biomedical/biomechanical information, advice and instruction are not recommended for prevention in LBP (Level A). There is insufficient evidence to recommend for or against psychosocial information delivered at the worksite (Level C), but information oriented toward promoting activity and improving coping may promote a positive shift in beliefs (Level C). Lumbar supports or back belts are not recommended (Level A). Shoe inserts/orthoses are not recommended (Level A). There is insufficient evidence to recommend for or against in-soles, 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 LBP (Level B). There is insufficient consistent evidence to recommended physical ergonomics interventions alone for prevention in LBP (Level C). There is some evidence that, to be successful, a physical ergonomics programme would need an organisational dimension and involvement of the workers (Level B); there is insufficient evidence to specify precisely the useful content of such interventions (Level C). There is insufficient consistent 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. Summary of recommendations for school age: There is insufficient evidence to recommend for or against a generalized 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 LBP in schoolchildren will have any impact on LBP in adults (Level D). Summary of recommendations for further research: It is recommended that the following approaches are considered for further research into prevention in low back pain. Future studies need to be of high quality; where possible that should be in the form of randomised controlled trials. It is also recommended that standards of evidence criteria for efficacy, effectiveness and dissemination should be taken into account (Society for Prevention Research 2004). As a general recommendation, it is considered important that future studies include cost-benefit and risk-benefit analyses. General Studies are needed to determine how and by whom interventions are best delivered to specific target groups. Good quality RCTs are needed to determine the effectiveness of specific interventions aimed at specific risk /target groups. Misconceptions about back pain are shown to be widespread in adults, and they play a role in the development of long-term disability (Goubert et al. 2004). Further study is necessary to explore whether these misconceptions may be prevented by carefully selected and presented health promotion programmes, with the merit of demedicalising LBP. More information is needed to match types of interventions with specific/relevant outcomes. High quality studies are recommended into the effectiveness of specific furniture to justify or refute claims by commercial interests. Workers Good quality RCTs are needed to study the effectiveness of daily physical activity for prevention of LBP and for prevention of recurrence of LBP. In addition, the effectiveness of physical exercise as well as daily physical activity should be studied for prevention of (recurrence of) sick leave due to LBP. It is recommended to perform good quality RCTs on the role of information oriented toward reducing fear avoidance beliefs and improving coping strategies in the prevention of LBP. Good quality RCTs are urgently needed to study the effectiveness of physical, psychosocial and organisational ergonomic interventions on a large variety of outcomes, ranging from prevention of (recurrence of) LBP and prevention of (recurrence of) sick leave due to LBP up to compensable LBP. It is recommended to investigate whether effective interventions can be applied to all workers, irrespective of gender, age, seniority and/or past history of LBP. If the effective interventions have to be more tailor-made, the optimal approach for each relevant subgroup should be examined. School age RCTs evaluating the possible positive effects of preventive programmes and risk factor modifications at young age on adult LBP are advocated. From a physiological point of view, poor life style habits and prolonged static sitting during school age on unadjusted furniture may play a role in the origin of LBP: further study is appropriate to determine any effectiveness of school-based interventions (exercise/sport, desks/seating, backpacks/bags). Further study with a follow-up into adulthood is needed to evaluate whether or not the physical cumulative load experience on the lumbar spine (e.g. from heavy book-bag carrying or sitting on unadjusted furniture) during childhood and adolescence contributes to adult LBP.