Education and Counseling to Prevent Low Back Pain
Recommendation: There is insufficient evidence to recommend for or against counseling patients to exercise to prevent low back pain, but recommendations for regular physical activity can be made based on other proven benefits. There is also insufficient evidence to recommend for or against the routine use of educational interventions, mechanical supports, or risk factor modification to prevent low back pain (see Clinical Intervention).
Burden of Suffering
Low back pain affects 60-80% of U.S. adults at some time during their lives, and up to 50% have back pain within a given year.1-8 Back symptoms are among the 10 leading reasons for patient visits to emergency rooms, hospital outpatient departments, and physicians' offices.9-11 Although symptoms are usually acute and self-limited, low back pain often recurs,12 and in 5-10% of patients low back pain becomes chronic.1-4,13 Back symptoms are the most common cause of disability for persons under age 45.14 Treatment is expensive.2,3,15-18 In 1990, direct medical costs for low back pain exceeded $24 billion. Total annual costs for back pain increase from $35 to $56 billion when disability costs are included.3,8,18
Many back injuries are occupational in nature. Occupational back injury is clearly related to lifting and repeated activities. Persons in occupations that require repetitive lifting, such as nursing19 and heavy industry,20 are especially at risk. Based on national data, occupational groups with the highest estimated prevalence of low back pain (10.1-10.5%) include mechanics and repairers of vehicles, engines and heavy equipment; operators of extractive, mining, and material-moving equipment; and people in construction trades and other construction occupations.20
Efficacy of Risk Reduction
Among the most commonly proposed strategies to prevent low back pain and injury are: (a) back flexion, back extension, and general fitness exercises; (b) improved back mechanic and ergonomic techniques (i.e., maximizing the efficient use of human energy in performing work); (c) mechanical back supports (back belts or corsets); and (d) risk factor modification (such as reducing obesity and smoking).6,7,21 Clinical strategies for preventing low back pain are aimed at asymptomatic subjects both with and without a history of back pain.13,22 The pathophysiology of low back pain and the efficacy of prevention strategies do not differ substantially in these two groups, so prevention studies that enrolled subjects with or without prior acute back pain are included in this review. The Task Force does not specifically address occupational interventions to prevent low back pain such as worker selection, changes in workplace design, or the role of the clinician in the workplace. Studies in occupational settings have been included, however, if they might be generalizable to the primary care setting.
Exercise is typically aimed at strengthening back extensors or flexors and increasing back flexibility to reduce injury risk, improving cardiovascular fitness to minimize injury and enhance recovery should injury occur, and improving mood and pain perception to reduce the impact of injury. Observational studies generally support an association between greater fitness or higher levels of physical activity and reduced prevalence of low back pain or injury, but results are less consistent regarding the effect of greater strength or flexibility on low back pain.23-35