PREVENTION OF LOW BACK PAIN: A SYSTEMATIC REVIEW AND META-ANALYSIS
 
   

Prevention of Low Back Pain:
A Systematic Review and Meta-analysis

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   JAMA Intern Med. 2016 (Feb);   176 (2):   199–208 ~ FULL TEXT

Daniel Steffens, PhD; Chris G. Maher, PhD; Leani S. M. Pereira, PhD; et al

The George Institute for Global Health,
Sydney Medical School,
The University of Sydney,
Sydney, Australia


IMPORTANCE:   Existing guidelines and systematic reviews lack clear recommendations for prevention of low back pain (LBP).

OBJECTIVE:   To investigate the effectiveness of interventions for prevention of LBP.

DATA SOURCES:   MEDLINE, EMBASE, Physiotherapy Evidence Database Scale, and Cochrane Central Register of Controlled Trials from inception to November 22, 2014.

STUDY SELECTION:   Randomized clinical trials of prevention strategies for nonspecific LBP.

DATA EXTRACTION AND SYNTHESIS:   Two independent reviewers extracted data and assessed the risk of bias. The Physiotherapy Evidence Database Scale was used to evaluate the risk-of-bias. The Grading of Recommendations Assessment, Development, and Evaluation system was used to describe the quality of evidence.

MAIN OUTCOMES AND MEASURES:   The primary outcome measure was an episode of LBP, and the secondary outcome measure was an episode of sick leave associated with LBP. We calculated relative risks (RRs) and 95% CIs using random-effects models.

RESULTS:   The literature search identified 6133 potentially eligible studies; of these, 23 published reports (on 21 different randomized clinical trials including 30,850 unique participants) met the inclusion criteria. With results presented as RRs (95% CIs), there was moderate-quality evidence that exercise combined with education reduces the risk of an episode of LBP (0.55 [0.41–0.74]) and low-quality evidence of no effect on sick leave (0.74 [0.44–1.26]). Low- to very low-quality evidence suggested that exercise alone may reduce the risk of both an LBP episode (0.65 [0.50–0.86]) and use of sick leave (0.22 [0.06–0.76]). For education alone, there was moderate- to very low-quality evidence of no effect on LBP (1.03 [0.83–1.27]) or sick leave (0.87 [0.47–1.60]). There was low- to very low-quality evidence that back belts do not reduce the risk of LBP episodes (1.01 [0.71–1.44]) or sick leave (0.87 [0.47–1.60]). There was low-quality evidence of no protective effect of shoe insoles on LBP (1.01 [0.74–1.40]).

CONCLUSION AND RELEVANCE:   The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. Whether education, training, or ergonomic adjustments prevent sick leave is uncertain because the quality of evidence is low.



From the FULL TEXT Article:

Introduction

Low back pain (LBP) is one of the most burdensome health problems worldwide, [1] generating enormous costs in treatments and time lost from work. [2] The global point prevalence of LBP is 12%; with the aging population, the number of people affected is likely to increase over the coming years. [3] A key contributor to the burden is the high recurrence rate: approximately one-half of patients experience a recurrence of LBP within 1 year after recovering from a previous episode. [4–6] It is therefore important to know whether it is possible to prevent LBP and, if so, which interventions are most effective.

Although there have been several systematic reviews of strategies to prevent LBP, most have major limitations. Many of the existing reviews are out-of-date, [7, 8] report data from randomized clinical trials (RCTs) of symptomatic participants, [9] do not consider the strength of evidence (eg, using the Grading of Recommendations Assessment, Development, and Evaluation [GRADE] system), [8, 10] are restricted to a particular type of intervention [11] or setting, or do not follow a prespecified, publicly accessible protocol. [7, 8]

Therefore, a comprehensive, high-quality review that includes the most recent publications is needed to provide a current overview of the effectiveness of prevention strategies. The aim of this systematic review was to evaluate the evidence on the effectiveness of interventions for prevention of episodes of LBP and use of sick leave due to LBP.



Methods

      Literature Search

The PRISMA Statement was used to guide the conduct and reporting of the study. [12] This study searched the following electronic databases from the earliest record to November 22, 2014: MEDLINE, EMBASE, Physiotherapy Evidence Database (PEDro), and the Cochrane Central Register of Controlled Trials. A sensitive search strategy was used based on the recommendations of the Cochrane Back Review Group [13] for randomized controlled trials and back pain as well as search terms for prevention. [14] The full search strategy is outlined in eTable 1 in the Supplement. The reference lists of relevant reviews and trials were screened for additional studies, and we also used citation tracking of all included trials.

During the first screening, 2 reviewers (D.S. or M.J.H. with V.C.O. or M.C.) evaluated the titles and abstracts of each citation and excluded clearly irrelevant studies. For each potentially eligible study, 2 reviewers (D.S. or M.J.H. with V.C.O. or M.C.) examined the full-text article and assessed whether the study fulfilled the inclusion criteria. In cases of disagreement, a decision was made by consensus or, if necessary, a third reviewer (C.G.M.) was consulted.

      Study Selection

We included RCTs assessing the effectiveness of prevention strategies for nonspecific LBP.

To be eligible, trials needed to meet the following criteria:

(1)   included participants without LBP at study entry or at least 1 outcome was not present at baseline (eg, some participants had mild LBP, but all were working and the study outcome was an episode of work absence due to LBP);

(2)   aimed to prevent future episodes of LBP;

(3)   compared intervention group with groups that received no intervention, placebo, or minimal intervention; and

(4)   reported a measure of a new episode of LBP (eg, episode of LBP or episode of sick leave due to LBP).

Studies that used a quasi-randomized design or reported the comparison of 2 prevention strategies (eg, exercise vs lumbar support) were excluded. No restrictions were placed on the setting or context of the included studies, languages, or date of the RCT report.

      Data Extraction and Synthesis

We assessed the quality of the trials’ methods using the PEDro scale [15, 16] by either downloading the available scores from the PEDro database (http://www.pedro.org.au) or rating the trial ourselves. Scores on the PEDro scale range from 0 (very low methodologic quality) to 10 (high methodological quality); methodologic quality was not an inclusion criterion of this review.

Two independent reviewers (D.S. or M.J.H. with V.C.O. or M.C.) extracted the characteristics and intervention outcomes of each trial using a standardized data extraction form. When possible, we extracted the raw outcomes (number of persons having an episode of LBP) for each group (intervention and control) and calculated the estimates of treatment effect using methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0. [17]

To evaluate the overall quality of the evidence, we used the GRADE system. [18] The GRADE classification was downgraded from high quality by 1 level for each factor that we encountered:

(1)   design limitation (>25% of participants from studies with low methodologic quality: PEDro score <7),

(2)   inconsistency of results (wide variance of point estimates across studies or large heterogeneity between trials: I2>50%), and

(3)   imprecision (<400 participants for each outcome).

We did not consider the indirectness criterion in this review because we included a specific population with relevant outcomes and direct comparisons. A GRADE profile was completed for each pooled estimate and for single trials comparing an LBP prevention strategy with controls. When only single RCTs were available, evidence from studies with fewer than 400 participants was downgraded for inconsistency and imprecision (ie, sparse data) and rated as low-quality evidence.

These trials could be further downgraded to very low–quality evidence if limitations of study design were found (PEDro score <7). Two reviewers (D.S. or M.J.H. with V.C.O. or M.C.) judged whether these factors were present for each outcome. The quality of evidence was defined as

(1)   high (further research is unlikely to change our confidence in the estimate of effect and there are no known or suspected reporting biases: all domains are fulfilled);

(2)   moderate (further research is likely to have an important effect on our confidence in the estimate of effect and might change the estimate: 1 of the domains is not fulfilled);

(3)   low (further research is likely to have an important effect on our confidence in the estimate of effect and is likely to change the estimate: 2 of the domains are not fulfilled); and

(4)   very low (we are uncertain about the estimate: 3 of the domains are not fulfilled). [19]

      Statistical Analysis

Outcome data were extracted for short-term (follow-up evaluations ≤12 months) and long-term (follow-up evaluations >12 months) follow-up. When multiple time points fell into the same category, we used the longest follow-up period.

Trials considered homogeneous were grouped according to the prevention strategy, comparison group, outcome (LBP episode and sick leave), and outcome assessment time points (short-term and long-term). We calculated relative risks (RRs) and 95% CIs and used the random-effects model to pool estimates for each analysis obtained with Comprehensive Meta-analysis, version 2.2.064 (Biostat). For trials that did not report the sample size at the end of the follow-up period, we calculated the RR using the baseline sample size.



Results


Figure 1

The initial electronic database search identified 6,133 potentially eligible studies. After screening citations by title and abstract, we considered 159 potentially eligible studies for inclusion and retrieved full-text articles. Twenty-three published reports (21 different RCTs including 30,850 unique participants) met the inclusion criteria and were included in this review. [20–42] Two RCTs were reported in 4 articles [22, 30, 39, 40] (2 with 12–month data [22, 39] and 2 with 36–month data [30, 40]). Figure 1 outlines the flow of RCTs through the review.

Table 1

The included trials investigated 6 different LBP prevention strategies: exercise, education, exercise and education, back belts, shoe insoles, and other prevention strategies. Most of the trials focused largely or completely on working-age populations. The sample size of the trials ranged from 30 to 4325 participants. A comprehensive description of each trial is provided in Table 1.

Methodologic quality assessment was conducted using the PEDro scale. The mean (SD) score was 5.1 (1.5), with the key problem items being blinding, concealed allocation, and loss to follow-up (eTable 2 in the Supplement).

Table 2

Estimates of the effects of LBP prevention strategies on LBP episode or sick leave due to LBP were calculated for 21 trials. The number of events, sample size, and RRs (95% CIs) for the trials are presented in eTable 3 in the Supplement. Trials were grouped according to the prevention strategy, outcome (episode of LBP or sick leave), and follow-up time point (short- or long-term). Table 2 provides a summary of the findings and GRADE quality ratings.

      Exercise vs Control, Minimal Intervention, or Supplement

Figure 2

Figure 3

Four trials reporting data on 898 participants were included in the meta-analysis to estimate the short-term (ie, ≤12 months) efficacy of exercise on incident cases of LBP (presented as RR [95% CI]). [21, 25, 26, 42] The pooled results provide low-quality evidence of a protective effect of exercise (0.65 [0.50–0.86]). In the long-term (ie, >12 months), the pooled results of 2 trials (334 participants) provide very low–quality evidence of no effect of exercise (1.04 [0.73–1.49]) (Figure 2). [21, 33] Two trials presented data from 128 participants and provide very low–quality evidence that exercise reduces the risk of sick leave due to LBP in the long-term (0.22 [0.06–0.76]) (Figure 3). [30, 42]

      Exercise and Education vs Control, Minimal Intervention, or Supplement

The effect of exercise and education was investigated in 4 trials (442 participants) at short-term follow-up, [22, 35, 39, 42] and in 2 trials (138 participants) at long-term follow-up (LBP episode). [30, 40] The pooled results (presented as RR [95% CI]) of 4 trials provide moderate-quality evidence that exercise and education reduce the risk of an episode of LBP at short-term follow-up (0.55 [0.41–0.74]). The long-term results are based on 2 trials [30, 40] and provide low-quality evidence of a protective effect (0.73 [0.55–0.96]) (Figure 2).

For prevention of sick leave due to LBP, 3 trials (228 participants) [22, 39, 42] presented short-term data and 2 trials (138 participants) [30, 40] presented long-term data. The pooled results (presented as RR [95% CI]) provide low-quality evidence of no protective effect at short-term follow-up (0.74 [0.44–1.26]) or long-term follow-up (0.72 [0.48–1.08]) (Figure 3).

      Education vs Control, Minimal Intervention, or Supplement

The efficacy of education compared with control was investigated in 3 trials (2,343 participants) at short-term follow-up and in 2 trials (13,242 participants) at long-term follow-up (LBP episode). The pooled results (presented as RR [95% CI]) provide moderate-quality evidence of no protective effect of education at either short-term follow-up (1.03 [0.83–1.27]) [37, 41, 42] or long-term follow-up (0.86 [0.72–1.04]) [20, 34] (Figure 2). In addition, a single trial (3,597 participants) not included in the meta-analysis because it did not report raw data provides moderate-quality evidence of no protective effect of education at long-term follow-up (rate ratio, 1.11 [95% CI, 0.90–1.37]) (eTable 3 in the Supplement). [28]

Two trials (366 participants) [41, 42] presented short-term data on sick leave prevention. The pooled results provide very low–quality evidence of no protective effect of education on sick leave due to LBP at short-term follow-up (RR, 0.87 [95% CI, 0.47–1.60]) (Figure 3).

      Back Belts vs Control, Minimal Intervention, or Supplement

The efficacy of back belts over control to prevent LBP episodes (short- and long-term) or sick leave owing to LBP (short-term) was reported in 3 trials. [27, 34, 41] For episodes of LBP, pooling of 2 trials (329 participants) (presented as RR [95% CI]) provides very low–quality evidence of no short-term effect of back belts over controls (1.01 [0.71–1.44]) (Figure 2). [27, 41] At long-term follow-up, a single trial (8,472 participants) provides moderate-quality evidence that back belts do not reduce the risk of LBP episodes when compared with controls (0.85 [0.64–1.14]) (Figure 2). [34] For sick leave owing to LBP, a single trial (282 participants) provides low-quality evidence of no effect of back belts compared with controls at short-term follow-up (RR, 1.44 [95% CI, 0.73–2.86]) (Figure 3). [41]

      Shoe Insole vs Control, Minimal Intervention, or Supplement

Four trials reported data from 1,833 participants on the short-term efficacy of shoe insoles compared with controls. [23, 24, 36, 38] For prevention of episodes of LBP, there is low-quality evidence that shoe insoles are not superior to control at short-term follow-up (RR, 1.01 [95% CI, 0.74–1.40]) (Figure 2). One trial reported the efficacy of semirigid shoe insole vs control and soft shoe insole vs control. [24] Only the group from the semirigid shoe insole was included in the meta-analysis.

      Other LBP Prevention Strategies

Two trials reported the short-term effect of other prevention strategies vs control for LBP episode (3,047 participants), [29] and sick leave due to LBP (360 participants). [32] An ergonomic program (moderate-quality evidence) was not more effective than control in reducing episodes of LBP at short-term follow-up (odds ratio, 1.23 [95% CI, 0.97–1.57]) (Table 2). It is unclear whether sick leave due to LBP can be prevented by education, training, and ergonomic adjustments since there was very low–quality evidence (RR, 0.95 [95% CI, 0.51–1.76]) (Figure 3).



Discussion

      Statement of Principal Findings

The results of this systematic review and meta-analysis indicate that exercise in combination with education is likely to reduce the risk of LBP. Exercise alone may reduce the risk of an episode of LBP and sick leave; however, it is uncertain whether the effects persist beyond 1 year. Education alone, back belts, shoe insoles, and ergonomic adjustments probably do not prevent an episode of LBP or sick leave due to LBP. It is uncertain whether education, training, or ergonomic adjustments prevent LBP owing to the very low quality of evidence.

      Strengths and Weaknesses of the Study

The strengths of this review include the use of a prespecified protocol registered on PROSPERO, inclusion of all prevention strategies from any setting, the use of the GRADE system to evaluate the overall quality of the evidence, and the use of a highly sensitive search strategy to identify LBP prevention trials. We assessed trials’ methodologic quality with the PEDro scale, which has been shown to have acceptable reliability and validity. [15, 16, 44] All scores were available online at the PEDro website. These scores were rated by experienced PEDro researchers, which provided less chance of errors.

This review was designed to be comprehensive with a robust search strategy; however, it is possible that not all studies were identified. Some identified trials did not have the term prevention in either the title or the abstract. [27, 33, 34] For several prevention strategies, we could identify only a small number of trials; this combined with the quality of the trials means the level of evidence for several prevention strategies is very low or low.

      Comparison With Other Studies

To our knowledge, this review is the first to have included a variety of LBP prevention strategies and conducted a meta-analysis of RCTs. Several reviews have investigated the effectiveness of an exercise and/or education program on LBP prevention. All are out-of-date, included at least 1 RCT with symptomatic participants at baseline (ie, the trial evaluated treatment, not prevention), and presented data descriptively. [7–9, 45–49] The most recent review we know of investigating the effectiveness of exercise for preventing a LBP episode, [11] presented data from 3 trials. One was included in the meta-analysis of the current review (ie, exercise vs control), [33] one was excluded because the trial included symptomatic participants at baseline, [50] and one was included in a different LBP prevention strategy (ie, exercise and education vs control). [39] That review by Choi et al [11] reported a 50% (2 RCTs with 130 patients) reduction in future LBP episodes when compared with no intervention, which is a larger effect than our estimate of a 35% reduction (4 RCTs with 898 patients).

Previous reviews investigating the efficacy of exercise on the prevention of LBP episodes have not distinguished between studies that included education with the exercise from those just including exercise. [11, 45, 46] In our review, the combination of exercise and education was effective at long-term follow-up (RR, 0.73 [95%CI, 0.55 to 0.96]), while exercise alone was not (RR, 1.04 [95% CI, 0.73 to 1.49]), suggesting that the distinction between exercise alone and exercise combined with education may be important.

The present review’s finding that back belts do not prevent LBP is consistent with results of a previous systematic review. [51] There are a few previous systematic reviews [10, 45, 52] investigating the use of shoe insoles in the prevention of an LBP episode. Findings from these reviews are in line with the results of our study: shoe insoles are not effective for the prevention of back pain. The most recent review by Chuter et al [10] included 6 trials; our review included 4. We excluded 2 trials because the participants were symptomatic at the time of study entry. [53, 54]

      Meaning of the Study

Although our review found evidence for both exercise alone (35% risk reduction for an LBP episode and 78% risk reduction for sick leave) and for exercise and education (45% risk reduction for an LBP episode) for the prevention of LBP up to 1 year, we also found the effect size reduced (exercise and education) or disappeared (exercise alone) in the longer term (>1 year). This finding raises the important issue that, for exercise to remain protective against future LBP, it is likely that ongoing exercise is required. Prevention programs focusing on long-term behavior change in exercise habits seem to be important.



Conclusions

The results of this systematic review and meta-analysis of RCTs indicate that exercise in combination with education is likely to reduce the risk of LBP and that exercise alone may reduce the risk of an episode of LBP and sick leave due to LBP, at least for the short-term. The available evidence suggests that education alone, back belts, shoe insoles, and ergonomics do not prevent LBP. It is uncertain whether education, training, or ergonomic adjustments prevent sick leave due to LBP because the quality of evidence is very low.


Supplement

eTable 1   Search Strategy

eTable 2   PEDro Scores of Included Randomized Controlled Trials

eTable 3   Low Back Pain Prevention Strategies Estimates for Short- and Long-term
Low Back Pain Episode and Sick Leave Outcome Measures


Authors’ contributions

Drs Steffens and Maher had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design:   Steffens, Maher, Stevens, Teixeira-Salmela, Hancock.

Acquisition, analysis, or interpretation of data:   Steffens, Maher, Pereira, Oliveira, Chapple, Teixeira-Salmela, Hancock.

Drafting of the manuscript:   Steffens, Maher, Teixeira-Salmela, Hancock.

Critical revision of the manuscript for important intellectual content:   All authors.

Statistical analysis:   Steffens, Maher, Chapple.

Administrative, technical, or material support:   Steffens, Oliveira, Teixeira-Salmela, Hancock.

Study supervision:   Steffens, Maher, Pereira, Teixeira-Salmela, Hancock.


Conflict of Interest Disclosures:

None reported.



References:

  1. GBD 2013 Risk Factors Collaborators.
    Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013
    [published online September 10, 2015]. Lancet

  2. Hoy D, March L, Brooks P, et al.
    Measuring the global burden of low back pain.
    Best Pract Res Clin Rheumatol. 2010;24(2):155-165

  3. Hoy D, Bain C, Williams G, et al.
    A systematic review of the global prevalence of low back pain.
    Arthritis Rheum. 2012;64(6):2028-2037

  4. Stanton TR, Henschke N, Maher CG, Refshauge KM, Latimer J, McAuley JH.
    After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought.
    Spine (Phila Pa 1976). 2008;33(26):2923-2928

  5. Carey TS, Garrett JM, Jackman A, Hadler N.
    Recurrence and care seeking after acute back pain: results of a long-term follow-up study: North Carolina Back Pain Project.
    Med Care. 1999;37(2):157-164

  6. Pengel LH, Herbert RD, Maher CG, Refshauge KM.
    Acute low back pain: systematic review of its prognosis.
    BMJ. 2003;327(7410):323

  7. van Poppel MN, Hooftman WE, Koes BW.
    An update of a systematic review of controlled clinical trials on the primary prevention of back pain at the workplace.
    Occup Med (Lond). 2004;54(5):345-352

  8. Maher CG.
    A systematic review of workplace interventions to prevent low back pain.
    Aust J Physiother. 2000;46(4):259-269

  9. Linton SJ, van Tulder MW.
    Preventive interventions for back and neck pain problems: what is the evidence?
    Spine (Phila Pa 1976). 2001;26(7):778-787

  10. Chuter V, Spink M, Searle A, Ho A.
    The effectiveness of shoe insoles for the prevention and treatment of low back pain: a systematic review and meta-analysis of randomised controlled trials.
    BMC Musculoskelet Disord. 2014;15:140

  11. Choi BK, Verbeek JH, Tam WW, Jiang JY.
    Exercises for prevention of recurrences of low-back pain.
    Cochrane Database Syst Rev. 2010;(1):CD006555

  12. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group.
    Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
    BMJ. 2009;339:b2535

  13. Furlan AD, Pennick V, Bombardier C, van Tulder M;
    Editorial Board, Cochrane Back Review Group.
    2009 Updated method guidelines for systematic reviews in the Cochrane Back Review Group.
    Spine (Phila Pa 1976). 2009;34(18):1929-1941

  14. Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Muller G, van der Beek AJ.
    COST B13 Working Group on Guidelines for Prevention in Low Back Pain.
    Chapter 2. European Guidelines for Prevention in Low Back Pain
    European Spine Journal 2006; 15 (suppl 2): S136-S168

  15. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M.
    Reliability of the PEDro scale for rating quality of randomized controlled trials.
    Phys Ther. 2003;83(8):713-721

  16. de Morton NA.
    The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.
    Aust J Physiother. 2009;55(2):129-133

  17. Higgins JPT, Green S, eds.
    Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0.
    Cochrane Collaboration.
    http://www.cochrane-handbook.org
    Updated March 2011. Accessed February 12, 2015.

  18. Atkins D, Best D, Briss PA, et al;
    GRADE Working Group. Grading quality of evidence and strength of recommendations.
    BMJ. 2004;328(7454):1490

  19. Guyatt GH, Oxman AD, Vist GE, et al;
    GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
    BMJ. 2008;336(7650):924-926

  20. George SZ, Childs JD, Teyhen DS, et al.
    Brief Psychosocial Education, Not Core Stabilization, Reduced Incidence of Low Back Pain:
    Results from the Prevention of Low Back Pain in the Military (POLM) Cluster Randomized Trial

    BMC Medicine 2011 (Nov 29);   9:   128

  21. Helewa A, Goldsmith CH, Lee P, Smythe HA, Forwell L.
    Does strengthening the abdominal muscles prevent low back pain—a randomized controlled trial.
    J Rheumatol. 1999;26(8):1808-1815

  22. Lønn JH, Glomsrød B, Soukup MG, Bø K, Larsen S.
    Active back school: prophylactic management for low back pain: a randomized, controlled, 1-year follow-up study.
    Spine (Phila Pa 1976). 1999;24(9):865-871

  23. Mattila VM, Sillanpää P, Salo T, Laine HJ, Mäenpää H, Pihlajamäki H.
    Orthotic insoles do not prevent physical stress-induced low back pain.
    Eur Spine J. 2011;20(1):100-104

  24. Milgrom C, Finestone A, Lubovsky O, Zin D, Lahad A.
    A controlled randomized study of the effect of training with orthoses on the incidence of weight bearing induced back pain among infantry recruits.
    Spine (Phila Pa 1976). 2005;30(3):272-275

  25. Moore C, Holland J, Shaib F, Ceridan E, Schonard C, Marasa M.
    Prevention of low back pain in sedentary healthy workers: a pilot study.
    Am J Med Sci. 2012;344(2):90-95

  26. Sihawong R, Janwantanakul P, Jiamjarasrangsi W.
    A prospective, cluster-randomized controlled trial of exercise program to prevent low back pain in office workers.
    Eur Spine J. 2014;23(4):786-793

  27. Allen SK, Wilder K.
    Back belts pay off for nurses.
    Occup Health Saf. 1996;65(1):59-62

  28. Daltroy LH, Iversen MD, Larson MG, et al.
    A controlled trial of an educational program to prevent low back injuries.
    N Engl J Med. 1997;337(5):322-328

  29. Driessen MT, Proper KI, Anema JR, Knol DL, Bongers PM, van der Beek AJ.
    The effectiveness of participatory ergonomics to prevent low-back and neck pain—results of a cluster randomized controlled trial.
    Scand J Work Environ Health. 2011;37(5):383-393

  30. Glomsrød B, Lønn JH, Soukup MG, Bø K, Larsen S.
    “Active back school”, prophylactic management for low back pain: three-year follow-up of a randomized, controlled trial.
    J Rehabil Med. 2001;33(1):26-30

  31. Gundewall B, Liljeqvist M, Hansson T.
    Primary prevention of back symptoms and absence from work: a prospective randomized study among hospital employees.
    Spine (Phila Pa 1976). 1993;18(5):587-594

  32. IJzelenberg H, Meerding WJ, Burdorf A.
    Effectiveness of a back pain prevention program: a cluster randomized controlled trial in an occupational setting.
    Spine (Phila Pa 1976). 2007;32(7):711-719

  33. Kellett KM, Kellett DA, Nordholm LA.
    Effects of an exercise program on sick leave due to back pain.
    Phys Ther. 1991;71(4):283-291

  34. Kraus JF, Schaffer KB, Rice T, Maroosis J, Harper J.
    A field trial of back belts to reduce the incidence of acute low back injuries in New York City home attendants.
    Int J Occup Environ Health. 2002;8(2):97-104

  35. Larsen K, Weidick F, Leboeuf-Yde C.
    Can passive prone extensions of the back prevent back problems? a randomized, controlled intervention trial of 314 military conscripts.
    Spine (Phila Pa 1976). 2002;27(24):2747-2752

  36. Larsen K, Weidich F, Leboeuf-Yde C.
    Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? a randomized, controlled intervention trial of 146 military conscripts.
    J Manipulative Physiol Ther. 2002;25(5):326-331

  37. Lavender SA, Lorenz EP, Andersson GB.
    Can a new behaviorally oriented training process to improve lifting technique prevent occupationally related back injuries due to lifting?
    Spine (Phila Pa 1976). 2007;32(4):487-494

  38. Schwellnus MP, Jordaan G, Noakes TD.
    Prevention of common overuse injuries by the use of shock absorbing insoles: a prospective study.
    Am J Sports Med. 1990;18(6):636-641

  39. Soukup MG, Glomsröd B, Lönn JH, Bö K, Larsen S.
    The effect of a Mensendieck exercise program as secondary prophylaxis for recurrent low back pain: a randomized, controlled trial with 12-month follow-up.
    Spine (Phila Pa 1976). 1999;24(15):1585-1591

  40. Soukup MG, Lönn J, Glomsröd B, Bö K, Larsen S.
    Exercises and education as secondary prevention for recurrent low back pain.
    Physiother Res Int. 2001;6(1):27-39

  41. van Poppel MN, Koes BW, van der Ploeg T, Smid T, Bouter LM.
    Lumbar supports and education for the prevention of low back pain in industry: a randomized controlled trial.
    JAMA. 1998;279(22):1789-1794

  42. Warming S, Ebbehøj NE, Wiese N, Larsen LH, Duckert J, Tønnesen H.
    Little effect of transfer technique instruction and physical fitness training in reducing low back pain among nurses: a cluster randomised intervention study.
    Ergonomics. 2008;51(10):1530-1548

  43. McKenzie R.
    Treat Your Own Back.
    Waikanae, New Zealand: Spinal Publications; 1987.

  44. Macedo LG, Elkins MR, Maher CG, Moseley AM, Herbert RD, Sherrington C.
    There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials.
    J Clin Epidemiol. 2010;63(8):920-925

  45. Bigos SJ, Holland J, Holland C, Webster JS, Battie M, Malmgren JA.
    High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults.
    Spine J. 2009;9(2):147-168

  46. Bell JA, Burnett A.
    Exercise for the primary, secondary and tertiary prevention of low back pain in the workplace: a systematic review.
    J Occup Rehabil. 2009;19(1):8-24

  47. Dawson AP, McLennan SN, Schiller SD, Jull GA, Hodges PW, Stewart S.
    Interventions to prevent back pain and back injury in nurses: a systematic review.
    Occup Environ Med. 2007;64(10):642-650

  48. Lahad A, Malter AD, Berg AO, Deyo RA.
    The effectiveness of four interventions for the prevention of low back pain.
    JAMA. 1994;272(16):1286-1291

  49. Demoulin C, Marty M, Genevay S, Vanderthommen M, Mahieu G, Henrotin Y.
    Effectiveness of preventive back educational interventions for low back pain: a critical review of randomized controlled clinical trials.
    Eur Spine J. 2012;21(12):2520-2530

  50. . Donchin M, Woolf O, Kaplan L, Floman Y.
    Secondary prevention of low-back pain: a clinical trial.
    Spine (Phila Pa 1976). 1990;15(12):1317-1320

  51. van Duijvenbode IC, Jellema P, van Poppel MN, van Tulder MW.
    Lumbar supports for prevention and treatment of low back pain.
    Cochrane Database Syst Rev. 2008;(2):CD001823

  52. Sahar T, Cohen MJ, Ne’eman V, et al.
    Insoles for prevention and treatment of back pain.
    Cochrane Database Syst Rev. 2007;(4):CD005275

  53. Tooms RE, Griffin JW, Green S, Cagle K.
    Effect of viscoelastic insoles on pain.
    Orthopedics. 1987;10(8):1143-1147

  54. Faunø P, Kålund S, Andreasen I, Jørgensen U.
    Soreness in lower extremities and back is reduced by use of shock absorbing heel inserts.
    Int J Sports Med. 1993;14(5):288-290



Return to the LOW BACK PAIN Section

Since 7-16-2018

                       © 1995–2020 ~ The Chiropractic Resource Organization ~ All Rights Reserved