New research for preventing recurrence of lower back pain: 2 do’s and 5 don’ts

Specific recommendations for how to prevent lower back pain are largely absent from existing clinical guidelines and research literature. Thankfully, newly published data provides some much needed evidence-based insight.

Non-specific low back pain (pain without an identified cause such as degenerative disc disease) is an enormous health problem, causing huge health expenditures and work absences. Lower back pain affects 12% of the global population each year. Approximately half of people will experience a recurrence of symptoms within one year of recovering.

As physiotherapy providers we see a steady stream of patients coming to our clinics with non-specific lower back pain. Since we have a strong focus on patient education and prevention, we have grappled with the lack of published clinical evidence supporting common approaches for preventing the recurrence of lower back pain. Thankfully, a high-quality clinical review has just been published to address this evidence gap.

A systematic review published this month evaluated the combined results of 21 existing clinical trials on lower back pain prevention strategies (with a combined total of over 30 thousand participants). The objective of this study was to determine the effectiveness of various interventions for preventing episodes of lower back pain (ref1). Here are the results:

How to prevent lower back pain:

2 Strategies that prevent recurrence of lower back pain:

1. Exercise combined with education is likely to reduce the risk of recurrence of lower back pain. The analysis suggests a 45% reduction in the risk of having a lower back pain episode in the first year with this strategy. The authors reported the quality of evidence for this conclusion as “moderate” (which in the world of clinical studies is actually pretty good), meaning that this result can most likely be trusted.
2. Exercise alone may reduce the risk of recurrence of lower back pain, but perhaps not beyond the first year. The analysis suggests a 35% reduction in the risk of having a lower back pain episode in the first year with this strategy. The authors reported that the quality of evidence for this conclusion was “low to very low” (which isn’t as good), meaning that the result is only somewhat trustworthy.

Interestingly, the study results suggests that the positive (protective) effect of exercise combined with education for preventing lower back pain decreases after one year, and disappears altogether in the case of exercise alone. The authors conclude that ongoing exercise is likely required in order to protect against future episodes.

Indeed, in another recent study of the factors that predict the effectiveness of physiotherapy for chronic back pain, adherence to the exercise therapy program was found nearly double the likelihood of a good outcome. (See: “Is physiotherapy YOUR cure for chronic low back pain? Researches say that depends…“)

5 Strategies that don’t prevent recurrence of lower back pain:

1. Education alone
2. Back belts
3. Shoe insoles
4. Ergonomic adjustments (for example of the participants’ work environments)
5. Traction alone. Recent data from another clinical study suggested that popular “non-surgical spinal decompression therapy” is not effective at preventing non-specific low back pain, although it can provide temporary relief which may be beneficial. (See: “Traction [‘Spinal Decompression Therapy’] doesn’t help lower back pain“)

A lack of understanding about how to treat non-specific low back pain is pervasive, even among some physicians.

Physician clinical practice guidelines for treating back pain recommend non-opioid pain-killers, avoidance of imaging, and the use of physiotherapy including exercise therapy.

But a recent study of physicians in the United States suggests that physicians are increasingly recommending inappropriate treatment for back pain: narcotics, imaging, and referral to other specialist physicians, to the detriment of their patients. (See: “Incorrect treatment of back pain is on the rise“)

A grain of salt:

A meta-analysis of 21 clinical trials with over 30 thousand participants is strong when publishing a paper, but can be barely passable when dispensing clinical advice to real patients. This is especially true when considering the quality of the individual clinical trials assessed – which are usually performed by different research groups using different protocols – and can thus vary widely.

Accordingly, the authors caution that the “small number of trials… combined with the quality of the trials, means the level of evidence for several prevention strategies is very low or low.”

Take-home message for preventing lower back pain recurrence:

Taking everything into consideration: ongoing targeted exercise combined with low back pain education is the best, evidence-based strategy for preventing lower back pain recurrence. There are no other strategies with as much scientific support, or for that matter, support among knowledgeable clinicians.

Seek out a knowledgeable clinician to develop a personalized lower back exercise routine, with supporting pain prevention education. This is currently the best approach for avoiding lower back pain problems and preventing recurrence.

Keep in mind that there is currently no consensus for what a “standardized” low back pain exercise treatment protocol should look like, or what components should be included in low back pain prevention education.  For this reason, it is wise to choose a clinician with a focus and interest in exercise therapy and patient education.

References:

1. Steffens D., Maher C.G., Pereira L.S., et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016 Feb 1;176(2):199-208.