Primary Care Interventions to Prevent
Low Back Pain: A Brief Evidence Update
for the U.S. Preventive Services Task Force
Methodology The 1 RCT meeting inclusion criteria found
that neither lumbar supports nor education, alone
The search strategy for this brief update included
or in combination, reduced low back pain incidence
a review of articles published in MEDLINE, the
or sick leave. No new RCTs were found that
Cochrane Library, and the National Guideline demonstrated that exercise or physical activity can
Clearinghouse between 1994 and 2001. The search help prevent low back pain. Two experts reviewed
was limited to the English language and Abridged these findings for comprehensiveness and provided
Index Medicus publications. We searched for no additional evidence.
randomized controlled trials (RCTs), meta-analyses,
systematic reviews, editorials, and commentaries
addressing the key questions.
Key Questions and Results
We used the search term low back pain, then 1. (Overarching) Do exercises aimed
focused on prevention and control and used at strengthening low back muscles
randomized controlled trials as MeSH terms.
prevent low back pain in individuals
Exercise, education, back, school, and risk factors
were also used as free-text search terms. The search compared with no exercise?
yielded 324 articles that were related to low back There is no new RCT-based evidence that exercise
pain prevention and control. Four of these were or physical activity can help strengthen low back
RCTs published in English, 1 of which had been muscles to help prevent low back pain.
evaluated in the previous USPSTF review. Of
the 3 remaining RCTs, only 1 directly addressed 2. Do educational programs (ie, back
injury prevention.
schools) help to prevent low back pain?
Studies were excluded if they did not meet the A recent systematic review assessed the effects
specific inclusion criteria listed or if they were not of back schools for patients with nonspecific low
generalizable to the adult population in the United back pain.3 The authors reviewed 15 RCTs that
States. reported on back schools for the treatment and
Systematic Evidence Reviews serve as the basis for U.S. Preventive Services Task Force (USPSTF) recommendations on clinical
prevention topics. The USPSTF tailors the scope of these reviews to each topic. The USPSTF determined that a brief evidence
update was needed to assist in updating its 1996 recommendations on primary care interventions to prevent low back pain.1 This
brief evidence update was written by Ramesh Krishnaraj.
To assist the USPSTF, the RTI International-University of North Carolina Evidence-based Practice Center, under contract to the
Agency for Healthcare Research and Quality (AHRQ), performed a targeted review of the literature published on this topic from
1994 to 2001. This brief evidence update on primary care interventions to prevent low back pain and the updated
recommendation statement2 are available through the AHRQ Web site (www.preventiveservices.ahrq.gov) and in print through
subscription to the Guide to Clinical Preventive Services, Third Edition: Periodic Updates. The subscription costs $60 and can be
ordered through the AHRQ Publications Clearinghouse (call 1-800-358-9295, or e-mail ahrqpubs@ahrq.gov). The
recommendation is also posted on the Web site of the National Guideline Clearinghouse™ (www.guideline.gov).
The author of this article is responsible for its contents, including any clinical or treatment recommendations. No statement in
this article should be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.
1
Primary Care Interventions to Prevent Low Back Pain: Brief Evidence Update
secondary prevention of nonspecific low back of self-reported back pain. The results showed that
pain. A qualitative review was performed using back belt use did not decrease either the rate of
11 preset internal validity criteria with 6 or more claims or reports of injuries.
positive scores denoting “high quality.”
Using these criteria, only 3 trials were considered 4. Is there new evidence that supports
to be of high quality. Their results showed moderate risk factor modification as a method to
evidence that back schools have better short-term
effects than other interventions for the treatment
help prevent low back pain?
and secondary prevention of low back pain in Smoking has been shown to be associated with
occupational settings. There was only moderate musculoskeletal diseases including low back pain,
evidence that back schools are effective in the but no RCT shows that this risk factor modification
secondary prevention of back pain in occupational helps prevent low back pain.6 Some studies indicate
settings. The review concluded that back schools that low back pain does not seem to be associated
may be effective in preventing further back injury with alcohol consumption.7
for individuals with recurrent and chronic low back
pain, but their cost-effectiveness is not well known.
Summary
3. Is there evidence to show that the Low back pain is a large medical and financial
burden. It is second only to upper respiratory
use of lumbar supports (back belts)
problems as a symptom-related reason for visits to
may increase the risk for low back pain the physician. Interventions in primary care to help
(harm) or help prevent back injuries prevent low back pain would help to reduce this
(benefit)? burden if there were new evidence that such
A study conducted by van Poppel and colleagues interventions are effective. No new evidence was
presented new evidence regarding education and found on the benefits or harms of physical exercise,
lumbar supports.4 This was an RCT with a factorial on the harms of back belts, or on the effectiveness
design conducted with 312 workers in the of risk factor modification, although obesity was not
Netherlands. Subjects were randomized to education considered. However, the review did find new
(lifting instructions) and lumbar support, education, evidence that back schools and back belts (lumbar
lumbar support, or no interventions. Low back pain supports) are ineffective in preventing low back pain.
incidence and sick leave related to low back pain No ongoing research was identified by this review.
were measured during the 6-month intervention
period. The authors found that, overall, neither
lumbar supports nor education, either alone or in Recommendations of
combination, reduced low back pain incidence or Professional Organizations
sick leave. The major limitation of the study was
its lack of blinding of either the subjects or the The American Academy of Orthopaedic
therapists evaluating them. The authors concluded Surgeons recommendations on preventing low back
that further investigation is needed to evaluate the pain can be accessed at http://orthoinfo.org/brochure/
therapeutic effectiveness of lumbar supports for thr_report.cfm?Thread_ID=10&topcategory=Spine
workers with low back pain. &all=all or http://www.aaos.org/.
Another prospective study of back belt use for The National Institute for Occupational Safety
preventing back injury was conducted by Wassell and Health (NIOSH) information on preventing
and colleagues among workers in 30 States.5 The low back pain can be accessed at http://www.cdc.
main outcome measures were rates of worker gov/niosh/homepage.html or http://www.cdc.gov/
compensation claims for back injury and the rate niosh/epstep1.html.
2
Primary Care Interventions to Prevent Low Back Pain: Brief Evidence Update
References 4. van Poppel MN, Koes BW, van der Ploeg T,
Smid T, Bouter LM. Lumbar supports and education
1. U.S. Preventive Services Task Force; Guide to for the prevention of low back pain in industry:
Clinical Preventive Services. 2nd ed. Washington, a randomized controlled trial. JAMA. 1998;
DC: Office of Disease Prevention and Health 279:1789–1794.
Promotion; 1996.
5. Wassell JT, Gardner LI, Landsittel DP, Johnston JJ,
2. U.S. Preventive Services Task Force. Primary care Johnston JM. A prospective study of back belts for
interventions to prevent low back pain in adults: prevention of back pain and injury. JAMA. 2000;
recommendation statement. February 2004. Agency 284:2727–2732.
for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/3rduspstf/lowback/ 6. Porter SE, Hanley EN Jr. The musculoskeletal effects
lowbackrs.htm. of smoking. J Am Acad Orthop Surg. 2001;9:9–17.
3. van Tulder MW, Esmail R, Bombardier C, Koes BW. 7. Leboeuf-Yde C. Alcohol and low-back pain:
Back schools for non-specific low back pain. a systematic literature review. J Manipulative
Cochrane Database Syst Rev. 2000;CD000261. Physiol Ther. 2000;23:343–346.
AHRQ Pub. No. 05-0565-B
November 2004
