Education and Counseling to Prevent Low Back Pain
With low back pain affecting the majority of adults in the U.S. at some time during their lives, the associated direct and indirect costs make it one of the most expensive ailments in industrialized countries. At present, studies on the prevention of low back pain and its risk factors do not establish a benefit from intervention. Exercise may be mildly protective against back pain, but data are unavailable beyond 18 months. The best results appeared to occur with comprehensive programs that combined exercise training with other educational interventions. Such intensive programs are more typical of work place interventions, but clinicians might expect similar results if resources were available to duplicate the interventions evaluated in published research. Aerobic exercise appears to be at least as effective as exercises aimed at trunk muscles, and can be readily recommended on the basis of other proven benefits. The studies on back education offer minimal support for the use of such strategies in low back pain prevention. Although some educational interventions may have a modest effect, the variability of the interventions and the fact that none of the studies was conducted in typical clinical settings make it difficult to recommend a specific intervention that might be effective in practice. With respect to corsets or back belts, the evidence is contradictory and hence insufficient to make any recommendation at this time. Indeed, the largest studies suggested that mechanical supports may increase the risk of low back pain and the cost of injury in some individuals. Finally, no studies have examined the effect of modifying smoking, obesity, or psychological factors on back pain risk.
Although there is some evidence that exercise (flexion, extension, aerobic, or fitness) protects against the development of low back pain, the effect is modest and of unknown duration, and the interventions have not been demonstrated in typical clinical settings. Thus, there is insufficient evidence to recommend for or against counseling patients to exercise specifically to prevent low back pain ("C" recommendation). Recommendations for regular physical activity can be made on other grounds, including its proven efficacy in preventing coronary heart disease, hypertension, obesity, and diabetes. There is insufficient evidence to recommend for or against educational interventions or the use of mechanical supports in the prevention of low back pain ("C" recommendation). Given some evidence that mechanical supports may increase the risk of low back pain, recommendations can be made against their use except in the context of comprehensive programs where their use can be carefully monitored to avoid injury. There is insufficient evidence to recommend for or against risk factor modification specifically for the prevention of low back pain ("C" recommendation). Screening for obesity and counseling to prevent tobacco use are recommended based on proven benefits unrelated to low back pain.