In an article published in the Journal of Physiotherapy, the authors report that exercise is effective in preventing the recurrence of lower back pain. If you are inclined to do exercises, you can reduce your risk by up to 45%. They are still unsure as to exactly what exercises and how much exercise one has to do, so I usually recommend that the person do the exercises that they like to do because they are more likely to do that than something they don’t like. I have a list of core stabilization exercises that I prescribe as well. They are located on my website at the top of the page HERE. ~ Dr. Broussard
Journal of Physiotherapy
Volume 67, Issue 3, July 2021, Pages 158-159
Tarcisio Fde Camposa
https://doi.org/10.1016/j.jphys.2021.06.012
Journal of Physiotherapy‘s latest article collection relates to the prevention of spinal pain. This collection: facilitates access to recent important findings in the field; highlights trends in the study designs, methodology, populations and interventions addressed by the research; and provides a scoping overview of avenues for further research. An article collection on low back pain was curated in 2018.1 Despite its recency, a remarkable number of papers have addressed prevention of low back pain and neck pain in the interim. Furthermore, prevention of spinal pain has been a particular focus among the more recent papers.
Most people experience low back pain and neck pain at some point in their lives. Spinal pain, including low back pain and neck pain, are among the leading causes of disability, affecting over half a billion people around the world.2,3 It is estimated that the global 1-year mean prevalence of activity-limiting low back pain is around 40%, and neck pain is approximately 11.5%.4,5 Despite much research over the past decades dedicated to understanding spinal pain, the burden associated with this condition has failed to reduce. To reduce the global burden associated with spinal pain, effective strategies to prevent spinal pain are important. Furthermore, given the recurrent nature of spinal pain,4,6 interventions that can reduce the risk of recurrence in those who have previously experienced an episode are also particularly important.
Although most cases of acute low back pain or neck pain improve considerably in the first few weeks, rates of recurrence within 12 months are high.4,6 A recent systematic review of the literature investigating the risk of recurrence of low back pain included eight studies.7 This review reported that only one study8 was considered to have an appropriate estimate for rate of a recurrence of low back pain within one year as the authors used a short inception period. This study conducted by Stanton et al8 reported an estimated recurrence rate of 33%. The authors of that review, however, suggested that it was not yet possible to obtain reliable estimates of recurrence proportions as most included studies have small sample sizes, and low methodological quality.
To overcome this gap in the literature, Da Silva et al4 conducted a high-quality prospective inception cohort study in Australia including 250 participants who had recovered from an episode of low back pain within the previous month.4 This first study in the article collection investigated how commonly low back pain recurrences occur within 1 year of recovering from a previous episode of low back pain, using three different definitions of low back pain recurrence. The study found that by 1 year, 69% (95% CI 62 to 74) of participants experienced a recurrence of any episode of low back pain, 40% (95% CI 33 to 46) of participants had a recurrence of an episode of low back pain leading to at least moderate activity limitation, and 41% (95% CI 34 to 46) of participants had a recurrence of low back pain for which healthcare was sought. Results from this study confirmed the high rates of recurrence and the need for effective strategies to prevent recurrences of spinal pain.
Despite the clear evidence that spinal pain is a long-term problem characterised by recurrent episodes,4,9, 10, 11, 12, 13 there has been minimal attention given to investigating effective strategies for the prevention of spinal pain. Over the last two decades, the number of randomised controlled trials investigating interventions for spinal pain has grown rapidly; however, the vast majority have investigated interventions looking at spinal pain treatment and very few have investigated spinal pain prevention strategies.14,15 Therefore, greater understanding regarding effective strategies to prevent spinal pain represents an important research priority.16, 17, 18, 19
This led to further investigation into ways to prevent episodes of spinal pain. Two recently published high-quality systematic reviews with meta-analysis have investigated interventions aimed at preventing a new episode of low back pain and a new episode of neck pain.14,20 The review of prevention of low back pain found moderate-quality evidence that an exercise program in combination with education reduces the risk of a new episode of low back pain by 45% (RR 0.55, 95% CI 0.41 to 0.74), and low-quality evidence that an exercise program alone may reduce the risk by 35% (RR 0.65, 95% CI 0.50 to 0.86). Most other intervention strategies (eg, education alone, use of back belts, use of shoe insoles, and ergonomic programs) either lacked evidence or appeared to be ineffective.14
The second study in this article collection is a systematic review and meta-analysis by de Campos et al,20 which summarises the results of five trials investigating the evidence for interventions aiming to reduce the risk of a new episode of neck pain.20 It appears that exercise programs are also likely to prevent neck pain episodes. In this review, only two trials were pooled in the meta-analysis for the exercise intervention contrast. The included trials in this literature review investigated different approaches to the exercise. In one trial, Sihawong et al21 investigated an exercise program involving stretching and endurance exercises restricted to the muscles within the neck region, while the trial by Tveito et al22 evaluated an integrated health program including a generalised whole-body exercise program. Consequently, the most effective exercise program to reduce future neck pain episodes remains unclear.
The current evidence on prevention of low back pain demonstrates that exercise alone and exercise in combination with education are effective in reducing the risk of low back pain episodes (35 and 45% risk reduction, respectively, at one year); however, the majority of the exercise programs in these trials are relatively costly, inflexible and time-consuming, potentially making uptake of such programs difficult.14 To overcome these barriers, de Campos et al,23 in the third study in this article collection, investigated the estimated effect of a McKenzie-based self-management exercise and educational approach compared to a minimal intervention control group, in preventing recurrences of low back pain and future care seeking in people recently recovered from an episode of non-specific low back pain. The authors also aimed to investigate if the approach reduces the impact of low back pain over 1 year. The authors in this trial found that the best estimate is that a McKenzie-based self-management exercise and education program does not produce a substantial reduction in the risk of an activity-limiting episode of low back pain (HR 1.11, 95% CI 0.80 to 1.54) but may produce a substantial reduction in recurrence of an episode of low back pain leading to care-seeking (HR 0.69, 95% CI 0.46 to 1.04). The authors also found clear evidence that any effect on the impact of low back pain over 1 year is negligible.
The remaining article in this collection investigates the preferences of people presenting with a recent history of low back pain, for exercise programs to reduce the risk of future episodes of low back pain, using a discrete choice experiment design. This study by Ferreira et al24 explored the influence of program features and participant-level characteristics on their preferences for low back pain exercise prevention programs and determined their willingness to pay for the programs. This study reported data on over 640 participants and showed that people generally preferred brief, low-cost and home-based exercise programs. The results of this study diverged from the current evidence from randomised controlled trials, which indicates that exercise programs that reduce the risk of a new episode of low back pain are typically of long duration and high frequency and have been conducted in settings such as outpatient clinics or the workplace.
This article collection on prevention of spinal pain identifies important implications for future research and helps identify priorities for future studies investigating the prevention of spinal pain. The first research implication is that the best exercise approach and dosage to prevent spinal pain is still unclear. Whilst the majority of existing literature suggests exercise interventions can help reduce spinal pain, some approaches such as that investigated in de Campos et al23 trial are not effective, so future trials investigating head-to-head comparisons of different exercise interventions to prevent spinal pain are required. Moreover, investigation of mediators within these trials may also advance our understanding of the causal mechanisms involved in effective spinal pain prevention programs. Another, research implication is that, despite the promising results in de Campos et al23 trial in terms of preventing future healthcare seeking, the trial was not adequately powered to address that question. This is an important outcome and future prevention studies should investigate whether a prevention program can reduce healthcare seeking related to spinal pain. Furthermore, there is a lack of high-quality studies investigating the impact of prevention strategies for spinal pain on other important outcomes such as quality of life, work ability and days lost from work. Finally, an important research implication is to better define what is meant by prevention of spinal pain and to determine what types of prevention studies are most important. Prevention can include participants who have never experienced spinal pain, those who have had previous episodes, and those with current low levels of pain. Some of the focus of prevention studies can be on preventing future episodes of spinal pain,14,20,23 preventing flare-ups in those with current mild pain or reducing future impact of spinal pain and associated disability.25 It is unclear if prevention interventions are equally effective for these different populations and outcomes. Future studies that include mixed populations such as those with and without a previous history of spinal pain, or those with and without current mild pain, could investigate whether these factors are moderators for the effectiveness of interventions aiming to prevent spinal pain.
In summary, the work presented in this article collection includes important developments in research into the prevention of spinal pain. The study designs address the probability and prognostic factors for a recurrence of low back pain over 1-year period,4 systematic reviews on the evidence of prevention strategies to reduce the risk of low back pain14 and neck pain,20 the effectiveness of a prevention strategy to reduce the risk of low back pain and its impact over a 12-month period,23 and finally the preference of people presenting with a recent history of low back pain, for exercise programs to reduce the risk of future episodes of low back pain, using a discrete choice experiment.24 Importantly, each paper has clear implications for clinical physiotherapists, which are identifiable in the paper’s ‘What this study adds’ summary box and discussion section.