Education and Counseling to Prevent Low Back Pain
Effectiveness of Counseling continued...
None of six nonrandomized trials and one case-control study that evaluated educational interventions found a statistically significant difference between control and intervention subjects in the incidence or duration of low back injuries, pain episodes, or, in one study, absenteeism.41,74-79 One of these, conducted on nursing students, did find that students in the intervention group had significantly better patient handling skills when evaluated by nonblinded observers.75 Nurses observed to have better transfer skills (regardless of study group) while in school had significantly fewer back injuries than did others (2% vs. 24%), but intervention and control groups did not differ in the occurrence of back pain. Thus, educational interventions do increase knowledge and may improve lifting behavior, but there is little evidence that these changes prevent low back pain or injury.
Two studies have evaluated educational interventions for low back pain prevention during pregnancy. In a nonrandomized trial, 85 pregnant women attended two 1-hour sessions in which the causes of back pain, favorable working postures, and lifting strategies were discussed.80 Ninety pregnant women who enrolled in the clinic after the intervention program or enrolled in a nearby clinic served as controls. Baseline rates of low back pain were similar in both groups. Following the educational program, women in the intervention group had significantly less self-reported "troublesome or severe" backache than controls (32% vs. 54%). The benefit continued until delivery, but subjects were not followed further. In another controlled trial, 407 pregnant women were assigned, based on birthday, to no intervention, to two 45-minute back school classes, or to five individualized 30-minute lessons with the same content as the second group.81 Overall, the interventions had no significant effect on the incidence or intensity of back pain. In the subgroup of women who had back or posterior pelvic pain, however, both interventions reduced the pain and the individualized lessons reduced sick leave taken and the intensity of pain reported at 8 weeks postpartum. The study has methodologic weaknesses in both analysis and reporting.
There is currently limited evidence that counseling patients to incorporate regular physical activity into their daily routines will have a positive effect on their behavior. Establishing the effectiveness of counseling about modifiable risk factors to prevent low back pain also requires further study. Multiple studies have shown that clinician counseling can substantially increase the rate of smoking cessation. Similarly, a number of interventions have been proven effective in inducing short-term weight loss. There is also effective treatment for diagnosed depression. There is little evidence, however, specifically addressing the effectiveness of counseling patients about smoking, obesity, or psychological conditions as it relates to the prevention of low back pain.
Recommendations of Other Groups
The American Academy of Family Physicians recommends "back-conditioning exercises" for persons aged 19-64 years who are at increased risk for low back injury because of past history, body configuration, or certain types of activities.82 This policy is currently under review. The Agency for Health Care Policy and Research (AHCPR) recommends patient education about low back symptoms and, in occupational settings, back school. AHCPR has also issued recommendations on the management of acute low back problems.43,83 The American Academy of Orthopaedic Surgeons' "Lift it Safe" program recommends specific lifting techniques to prevent back pain, and exercises to minimize problems with back pain.84 The National Institute for Occupational Safety and Health (NIOSH) does not recommend the use of back belts to prevent injuries among workers who have never been injured. NIOSH recommends that the most effective means of minimizing the likelihood of back injury in the workplace is to develop and implement a comprehensive ergonomics program.85,86