ArticlePDF AvailableLiterature Review

Preventive interventions for back and neck pain. What is the evidence?

Authors:

Abstract and Figures

A review of controlled trials. To determine which interventions are used to prevent back and neck pain problems as well as what the evidence is for their utility. Given the difficulty in successfully treating long-term back and neck pain problems, there has been a call for preventive interventions. Little is known, however, about the value of preventive efforts for nonpatients, e.g., in the general population or workplace. The literature was systematically searched to locate all investigations that were: 1) specifically designed as a preventive intervention; 2) randomized or nonrandomized controlled trials; and, 3) using subjects not seeking treatment. Outcome was evaluated on the key variables of reported pain, report of injury, dysfunction, time off work, health-care utilization, and cost. Conclusions were drawn using a grading system. Twenty-seven investigations meeting the criteria were found for educational efforts, lumbar supports, exercises, ergonomics, and risk factor modification. For back schools, only one of the nine randomized trials reported a significant effect, and there was strong evidence that back schools are not effective in prevention. Because the randomized trials concerning lumbar supports were consistently negative, there is strong evidence that they are not effective in prevention. Exercises, conversely, showed stable positive results in randomized controlled trials, giving consistent evidence of relatively moderate utility in prevention. Because no properly controlled trials were found for ergonomic interventions or risk factor modification, there was not good quality evidence available to draw a conclusion. The results concerning prevention for subjects not seeking medical care are sobering. Only exercises provided sufficient evidence to conclude that they are an effective preventive intervention. There is a dire lack of controlled trials examining broad-based multidimensional programs. The need for high quality outcome studies is underscored.
Content may be subject to copyright.
SPINE Volume 26, Number 7, pp 778–787
©2001, Lippincott Williams & Wilkins, Inc.
Preventive Interventions for Back and Neck
Pain Problems
What is the Evidence?
Steven J. Linton, PhD* and Maurits W. van Tulder, PhD†
Study Design. A review of controlled trials.
Objectives. To determine which interventions are used
to prevent back and neck pain problems as well as what
the evidence is for their utility.
Summary of Background Data. Given the difficulty in
successfully treating long-term back and neck pain prob-
lems, there has been a call for preventive interventions.
Little is known, however, about the value of preventive
efforts for nonpatients,
e.g.
, in the general population or
workplace.
Methods. The literature was systematically searched
to locate all investigations that were: 1) specifically de-
signed as a preventive intervention; 2) randomized or
nonrandomized controlled trials; and, 3) using subjects
not seeking treatment. Outcome was evaluated on the key
variables of reported pain, report of injury, dysfunction,
time off work, health-care utilization, and cost. Conclu-
sions were drawn using a grading system.
Results. Twenty-seven investigations meeting the cri-
teria were found for educational efforts, lumbar supports,
exercises, ergonomics, and risk factor modification. For
back schools, only one of the nine randomized trials re-
ported a significant effect, and there was strong evidence
that back schools are not effective in prevention. Because
the randomized trials concerning lumbar supports were
consistently negative, there is strong evidence that they
are not effective in prevention. Exercises, conversely,
showed stable positive results in randomized controlled
trials, giving consistent evidence of relatively moderate
utility in prevention. Because no properly controlled trials
were found for ergonomic interventions or risk factor
modification, there was not good quality evidence avail-
able to draw a conclusion.
Conclusions. The results concerning prevention for
subjects not seeking medical care are sobering. Only ex-
ercises provided sufficient evidence to conclude that they
are an effective preventive intervention. There is a dire
lack of controlled trials examining broad-based multidi-
mensional programs. The need for high quality outcome
studies is underscored. [Key words: back pain, neck pain,
prevention] Spine 2001;26:778 –787
Prevention offers an alternative to the enormous dis-
comfort and colossal expenditures associated with
back and neck pain problems. The basic idea is to use
the limited resources available at an early point in time
so as to prevent the development of unnecessary dis-
comfort and related costs. Consequently, prevention is
an appealing proposition and an important challenge
for the twenty-first century that already has been rec-
ognized by various agencies and task forces around the
world.
1,12,14,22,27,34,37,42
Several approaches to the prevention of back pain
have been reported in the literature. These range from
unimodal interventions such as back belts to more mul-
tidimensional programs like education. Typically, a pre-
ventive intervention has been put forth, and some em-
piric evidence has been presented indicating benefit. Yet,
many studies may not meet basic scientific standards.
The introduction of evidenced-based medicine has un-
derscored the importance of evaluating well-designed
studies to scientifically determine their value. Moreover,
reviews to date have not been comprehensive, but rather
have tended to focus on a particular type of intervention
or a specific setting. Thus, there is a lack of clarity about
which types of interventions are used as well as their
effectiveness. Consequently, although some reviews are
available in the literature, a wide-ranging review that
includes the latest publications is essential to provide a
current overview of the utility of prevention techniques
to date.
4,8,14,15,18,20,23,25,28,38,46
The purpose of this article was to review empiric stud-
ies investigating the effects of prevention on back and
neck pain problems. Although prevention appears to be
a straightforward term, an important distinction often is
made between primary and secondary prevention. Usu-
ally primary prevention is provided to healthy people
with the aim of preventing the onset of a given disease,
whereas secondary prevention is restricted to attempts to
halt the further development of a disease. Because most
people at some point experience neck or back pain, how-
ever, the difference between primary and secondary pre-
vention becomes hazy. As a result, a distinction is not
made between primary and secondary prevention in this
article. Therefore, studies designed to prevent the devel-
opment of long-term neck or back pain problems deliv-
ered in nonhealth care settings were included. Because
the programs vary greatly in approach as well as in con-
tent, the literature was evaluated systematically in an
attempt to answer the following specific questions:
1. What interventions are used in an attempt to pre-
vent back and neck pain problems?.
2. Which interventions are effective in preventing the
occurrence of back and neck pain problems?
From the *Department of Occupational and Environmental Medicine,
Örebro Medical Center, Örebro, Sweden, and the †Institute for Re-
search in Extramural Medicine, Free University, Amsterdam, The
Netherlands.
Acknowledgment date: June 2, 1999.
First revision date: December 13, 2000.
Second revision date: May 19, 2000.
Acceptance date: September 8, 2000.
Device status category: 1.
Conflict of interest category: 12.
778
3. Which interventions are effective in preventing the
development of long-term back and neck pain
problems?
Methods
Three electronic databases were searched: Medline (1985 to
September 1998), PsychInfo (1967 to September 1998), and
ArbLine. A trained and experienced librarian conducted these
searches. A total of 407 citations were identified in Medline,
138 citations in PsychInfo, and 14 citations in ArbLine. Finally,
articles and reviews were perused and references checked to
identify citations that were not found in the database searches.
Studies were included in this review if they fulfilled three crite-
ria: 1) the study was a randomized controlled trial (RCT) or
nonrandomized controlled trial (CCT), 2) the study reported
on subjects not seeking treatment, 3) the intervention was spe-
cifically designed to prevent some form of back or neck prob-
lem, or the intervention was specifically designed to prevent the
development of long-term back or neck problems. No interven-
tions were excluded. Studies were included that were published
in English, German, Dutch, or Swedish.
Conclusions about the effectiveness of the preventive inter-
ventions are based on the reported outcomes on the key vari-
ables of pain, report of injury, dysfunction, time off work,
health care utilization, and cost. A study was classified as pos-
itive if the preventive intervention was demonstrated to be
more effective (statistically significant) compared with a con-
trol intervention on at least one key variable. If the preventive
intervention was less effective than the control or the preven-
tion was not more effective than no intervention at all, it was
rated as negative. A neutral rating was given to studies where
the preventive intervention and control did not differ on any
key variables. The methodologic quality of the studies was not
assessed because this has been done for most of the trials in
other systematic reviews
25,46,48
Final conclusions were drawn using a grading system con-
sisting of four levels of scientific evidence: Level A was defined
as strong evidence provided by generally consistent findings
from multiple RCTs, Level B was defined as moderate evidence
provided by one RCT or generally consistent findings from
multiple CCTs, Level C was defined as limited evidence from
only one CCT, and Level D was defined as no evidence if there
were no RCTs or CCTs.
Results
Lumbar Supports
The supposed mechanisms by which lumbar supports
may prevent low back pain (LBP) are: 1) they provide
support of the trunk, preventing pain-producing events
caused by overflexion; 2) they remind the wearers to lift
properly; and 3) they increase intra-abdominal pressure
and decrease intradiscal pressure.
Controlled Trials. Four RCTs
2,36,47,50
and two CCTs
3,45
were identified on the preventive effect of lumbar sup-
ports in various types of working populations (Tables 1
and 2). The results of three RCTs showed that there were
no significant differences on any of the outcome mea-
sures when lumbar supports were compared with no in-
tervention.
2,36,47
No effect was shown when compared
with training or anatomy and body mechanics or educa-
tion and lifting instructions.
2,36,47
Similarly, the remain-
ing RCT did not find any differences between lumbar
supports and training on back prevention versus training
only, but the supports did seem to reduce the number of
days lost from work when compared with no interven-
tion.
50
In contrast to the consistently negative findings in
RCTs, the two CCTs showed positive results for lumbar
supports on the incidence of back pain and back inju-
ry.
3,45
It should be noted that several studies reported
problems with participants complying with the recom-
mendation to use lumbar supports. Because RCTs are
methodologically stronger than CCTs and given the
overall results, it was concluded that there is consistent
evidence from RCTs that lumbar supports are not effec-
tive in preventing back pain or back injury. There is
strong and consistent evidence that lumbar supports are
not effective in preventing neck and back pain (Level A).
Back Schools and Education
Back and neck schools make the assumption that people
have higher risk and have more pain than need be be-
cause they lack knowledge about a variety of topics as
diverse as body mechanics and stress. Therefore, the pro-
grams aim to reduce the risk for problems by increasing
the participant’s knowledge, which in turn will alter the
person’s behavior such as lift technique. Back schools
usually contain a series of discussions about anatomy,
biomechanics, lifting, postural changes related to work,
and a program of exercises. They vary from a single
session of less than an hour to several sessions.
32,38
Back
schools are attractive because they use educational prin-
ciples, may be done with groups, and involve no expen-
sive or complicated technology. In addition, the method
appears to have face validity, and patients may enjoy
attending the sessions. Thus, they represent a concrete
and inexpensive preventive intervention.
Controlled Trials. Nine randomized controlled trials
(RCTs)
5,6,9,10,19,29,30,40,41
and five nonrandomized con-
trolled trials (CCTs)
7,11,33,49,51
on back and neck schools
were identified. The characteristics of these studies are
summarized in Tables 1 and 2. Six of the nine RCTs did
not find any significant differences on any of the outcome
variables compared between the back school interven-
tion and usual care or no intervention
6,9,19,29,30
or be-
tween different types of back or neck schools.
6,19,40
One
RCT found a negative effect when back school was com-
pared with a McKenzie-style treatment.
41
Only one RCT
reported a significant positive effect on initial sick leave
and duration of symptoms.
5
Only one study of information that was not a back
school was located. This study specifically examined the
effects of information oriented toward preventing fear–
avoidance and promoting coping and found that the
information was effective compared with no
intervention.
43
In contrast to the consistent negative results found in
RCTs for back schools, three of the five CCTs reported
positive results on at least one variable.
7,49,51
Because
779Preventive Interventions for Back and Neck Pain Problems Linton and van Tulder
Table 1. Randomized Controlled Trials (RCTs) on the Effectiveness of Preventive Interventions for Back Pain
Author Study Population
Interventions
(No. Analyzed) Outcome Measures
Results
(,, 0) Conclusions*
Lumbar support
Alexander, 1995 60 health care workers,
12 men, 48 women.
Excluded were
individuals who had back
surgery, current workers
compensation claims,
pregnant, cardiovascular
problems.
RCT with 3 months
follow-up.
Preventive intervention:
1) Back belts at work for 3
months (n 30).
Control intervention:
2) No intervention
(n 30).
Work-related back
injuries
Perception of physical
pain
0
0
Negative
Reddell, 1992 896 Fleet service clerks
from four international
airports.
RCT with 8 month follow-
up.
Preventive intervention:
1) Back belt (n 145)
2) Back belt plus 1 hour
training session on
spine anatomy and
body mechanics
(n 127)
3) 1 Hour training session
on spine anatomy and
body mechanics
(n 122)
Control intervention:
4) No intervention
(n 248)
Back injury incidence
rate
Lost work days
Worker’s compensation
rates
0
0
0
Negative
(58% stopped using the
belt before the end of
8 months)
Van Poppel, 1998 312 workers at the cargo
department of an airline
company, mean age (SD)
was 35.1 (7.8). Workers
with a work disability
were excluded.
RCT with 12 months
follow-up.
Preventive intervention:
1) Lumbar support during
working hours for 6
months (n 83).
2) Lumbar support plus
education/lifting
instructions (n 70).
Control intervention:
3) Education/lifting
instructions (n 82).
4) No intervention
(n 77).
Back pain incidence
Sick leave due to back
pain
0
0
Neutral; Positive for
subgroup with back
pain at baseline.
(compliance with
wearing lumbar
support more than half
of the time was 43%)
Walsh, 1990 90 male warehouse
workers, aged 20–46
years. Excluded were
individuals currently
treated for back pain.
RCT with 6 months
follow-up.
Preventive intervention:
1) Lumbosacral orthosis
during working hours
plus 1 hour training on
back pain prevention
and body mechanics
(n 27).
2) 1 hour training on back
pain prevention and
body mechanics
(n 27).
Control intervention:
3) No intervention
(n 27).
Abdominal strength
Cognitive data
Work injury incidence
Productivity
Use of health care
services
Days lost from work
0
0
0
0
0
(1
vs.
3)
0(1
vs.
2)
Positive (1
vs.
3)
Neutral (1
vs.
2)
Back school and
education
Berquist-Ullman
& Larsson, 1977
217 autoworkers. 13% F,
mean age 35
back pain 3 mo, pain
free 12 mo prior to
current episode.
Occupational health-care
setting.
RCT
Preventive intervention:
1) Back school: 4
sessions, 45 min
(n 55).
2) Manual physical
therapy (n 61).
Control intervention:
3) Placebo: short-wave
heat (n 66).
Initial sick leave
Pain
Duration of symptoms
Recurrence
0
0
Positive
Berwick, 1989 222 Insurees with 2
wks low back pain, mean
age 33; 60% F. Setting
Health-maintenance
Organization
Preventive intervention:
1) Back school: one
session, 4 hrs (n 72).
2) Back school plus
compliance package
(n 76).
Control intervention:
3) Usual care control
(n 74).
Pain
Function
Health-care utilization
0
0
0
Neutral
780 Spine Volume 26 Number 7 2001
Table 1. Continued
Author Study Population
Interventions
(No. Analyzed) Outcome Measures
Results
(,, 0) Conclusions*
Daltroy, 1997 4000 US postal workers,
34% F, 33 years old.
Preventive intervention:
1) Back school education:
2 sessions, 1
1
2
hrs, plus
4 follow-up sessions
(n 2534).
Control intervention:
2) No intervention control
(n 1894).
Back injuries
Other injuries
Time off work
Cost
0
0
0
0
Negative
Donchin, 1990 142 hospital workers
(clinical, administrative
and technical
professions). Inclusion
criteria: at least 3 annual
episodes of low back
pain.
RCT with 12 mo follow-up.
Preventive intervention:
1) Back school, 90 min, 4
sessions, 2 weeks, plus
a 5th session after 2
months, groups of 10–12
participants, instruction
in body mechanics and
exercises (n 46).
2) Exercise program:
calisthenics, flexion,
pelvic tilt, strengthening
abdominal muscles
(Williams), 45 min.
Biweekly for 3 months,
groups of 10–12
participants (n 46).
Control intervention:
3) Waiting list controls
(n 50).
Low back pain episodes
in the last month
Trunk forward flexion
Isometric strength
Endurance of back
muscles
(1
vs.
2)
(1
vs.
2)
0
0
Negative
Kamwendo &
Linton, 1991
79 women hospital
secretaries, 39 years old.
Inclusion criteria: neck,
shoulder pain, sit 5 hrs
daily, not seeking care.
Preventive intervention:
1) Neck school, 4
sessions, 1 hr (n 25).
2) Neck school
compliance
enhancement, 4
sessions, 1 hr (n 28).
Control intervention:
3) No intervention
(n 26).
Fatigue
Pain
Sick leave
0
0
0
Negative
Leclaire, 1996 168 off work for low back
pain, 42%, F, mean age
32 years old. Quebec
workplace intervention.
Preventive intervention:
1) Back school: 90 min, 3
sessions plus daily
physiotherapy (n 82).
Control intervention:
2) Physiotherapy only
(n 86).
Work loss
Recurrence
Time to return
Pain
Function
0
0
0
0
0
Neutral
Lindequist, 1984 56 primary care patients
seeking care for acute
low back pain. Mean age
38, 57% F. Nonstandard
randomization (birthdate,
unequal group size).
Preventive intervention:
1) Back school plus
physiotherapy (n 24).
Control intervention:
2) Usual treatment control
(n 32).
Recurrences
Health-care utilization
Sick leave
Pain
0
0
0
0
Neutral
Sirles, 1991 74 city employees with
back injury. City fitness
Center. 11% F, 80% 30
years old.
RCT
Preventive intervention:
1) Back school plus
exercise (n 74).
2) Back school plus
exercise plus
counseling (n ?).
Pain
Physical dysfunction
Well being
0
0
0
Neutral (no significant
between-group
differences, within-
group improvements
significant)
Stankovic &
Johnell, 1995
89 (?) Low back pain, 25%
F, mean age 40
Setting ? criteria ?
RCT with 5-year follow-up.
Preventive intervention:
1) Mini back school
(n 49).
Control intervention:
2) McKenzie method of
treatment (n 46).
Recurrence
Need for care
Sick leave
0
Negative
Information
Symonds, 1995 3 light industrial
companies. Responders:
466 group 1 (29%), 105
group 2 (18%).
Randomized companies.
Preventive intervention
1) Informational pamphlet
(n 466).
Control intervention:
2) Nonmedical back pain
pamphlet (n 105).
Work absence
Initial extended work
absence
Positive (NB: not
statistically tested)
781Preventive Interventions for Back and Neck Pain Problems Linton and van Tulder
Table 1. Continued
Author Study Population
Interventions
(No. Analyzed) Outcome Measures
Results
(,, 0) Conclusions*
Exercises
Donchin, 1990 142 hospital workers
(clinical, administrative
and technical
professions), Inclusion
criteria: at least 3 annual
episodes of low back
pain.
RCT with 12 mo follow-
up.
Preventive intervention:
1) Exercise program:
calisthenics, flexion,
pelvic tilt, strengthening
abdominal muscles
(Williams), 45 min
biweekly for 3 mo,
groups of 10–12
participants (n 46).
2) Back school, 90 min, 4
sessions, 2 wks, plus a
5th session after 2 mos,
groups of 10–12
participants, instruction
in body mechanics and
exercises (n 46)
Control intervention:
3) Waiting list controls
(n 50).
Low back pain episodes
in the last month
Trunk forward flexion
Isometric strength
Endurance of back
muscles
(1
vs.
2)
(1
vs.
3)
(1
vs.
2)
(1
vs.
3)
0
0
Positive for calisthenic
exercise program
Gundewall, 1993 69 Nurses and nurse’s
aides at a geriatric
hospital with and without
back pain, 68 women,
aged 18–58 years.
RCT with 13 mos follow-
up.
Preventive intervention:
1) Dynamic endurance,
isometric strength and
functional coordination
exercises during
working hours, 20 min,
average 6 sessions a
month (n 28).
Control intervention:
2) No intervention
(n 32).
Days with low back pain
Work absenteeism (days)
Pain intensity (graphic
rating scale)
Isometric back muscle
strength
Positive (poor
presentation and
analysis of data)
Kellett, 1991 125 employees of a
producer of kitchen units.
Inclusion criteria: self-
reported current or
previous back pain,
willingness to exercise at
least once a week
outside working hours.
Exclusion criteria: sick
leave longer than 50 days
during 1.5 yrs prior to the
study, medical inability to
participate.
RCT, 18 mos follow-up.
Preventive intervention:
1) Exercise program:
warming-up, stretching,
strengthening and
cardiovascular fitness
exercises, relaxation
conducted to music;
40–45 min once a week
during working hours,
plus 30 min weekly at
home; program changed
every 6 months
(n 58).
Control intervention:
2) No intervention
(n 53).
Number of days of sick
leave
Number of episodes
Cardiovascular fitness
0
Positive (drop out rate
36% in exercise group)
Takala et al, 1994 45 women employed in a
printing company with
light sedentary work.
Inclusion criteria were
frequent neck symptoms,
age 20–55. Exclusion
criteria were signs of
nerve root compression
or tendinitis.
Preventive intervention:
1) group gymnastics at
work, 45 min, once per
week for 10 wks.
Sessions contained
aerobic dynamic
exercises, relaxation,
and stretching. (n 22)
Control intervention:
2) No intervention
(n 22)
Crossover design
Pressure pain threshold
Pain rating (VAS)
Handicap
Interference with work
0
0
Positive
Gerdle et al, 1995 97 women employed as
home care service
personnel. Inclusion
criteria: working at least
half-time; employed at
least 6 months; not on
long-term sick leave
Preventive intervention:
1) 1 hr of exercise, 1 per
week during one year.
Exercises included
warmup, muscle
strength, and aerobics
(n 46)
Control intervention:
2) no intervention (n 49)
Pain
Sick leave
Physical fitness
Physical examination
Perceived work situation
0
0
Inconsistent findings.
(However, no between
group differences for
key variables.)
782 Spine Volume 26 Number 7 2001
these studies were not randomized and thus constitute a
lower level of evidence, conclusions from the table are
based mainly on the RCTs. Thus, there is consistent ev-
idence from RCTs that back and neck schools are not
effective interventions in preventing back pain. There is
strong and consistent evidence that back schools are not
effective in preventing neck and back pain (Level A).
Exercises
The mechanisms by which exercises may prevent low
back pain are believed to be: 1) they strengthen the back
muscles and increase trunk flexibility; 2) they increase
blood supply to the spine muscles and joints and inter-
vertebral disks, minimizing injury and enhancing repair;
and 3) they improve mood and thereby alter the percep-
tion of pain.
Controlled Trials. Six RCTs were identified evaluating
the effectiveness of an exercise program for various types
of workers.
10,16,17,21,31,44
The results of four of the five
studies comparing exercises with no intervention showed
that exercises significantly reduced the back pain experi-
ence and reduced work absenteeism.
10,17,21,44
One study
reported inconsistent findings, but the authors of this
study did not perform a proper between-group analy-
sis.
16
Therefore, there is consistent evidence from RCTs
that exercises are effective in the prevention of back pain.
Donchin
10
also reported exercises to be more effective
than a back school. Linton et al,
31
however, found little
support for a preventive effect of exercise on pain when
compared with advice to exercise and a free membership
to a health club. There is inconsistent evidence on the
effectiveness of exercise compared with other interven-
tions. There is consistent evidence that exercise may be
effective in preventing neck and back pain (Level A).
Ergonomics
Ergonomics is the scientific discipline concerned with the
performance of humans at work and how they cope with
the working environment, interact with machines, and
negotiate their work surroundings. Ergonomic interven-
tions are directed toward occupational risk factors such
as lifting, physically heavy work, a static work posture,
frequent bending and twisting, repetitive work, and ex-
posure to vibration. Ergonomic interventions can be di-
vided into job-related interventions and worker-related
interventions and include fitness and stretching exercises,
lumbar supports, education on lifting techniques, pos-
tural instruction, and workplace redesign. Exercises, ed-
ucation, and lumbar supports are separately evaluated in
this review and are not included in the ergonomics
section.
Controlled Trials. No RCTs or CCTs evaluating the ef-
fectiveness of ergonomics were identified. There is no
good quality evidence on the effectiveness of ergonomics
(Level D).
Risk Factor Modification
Certain behavioral factors may predispose to the devel-
opment of low back pain. Potentially modifiable risk
factors are smoking, obesity, and psychological profile.
Three categories of risk factors were evaluated in this
review: 1) individual risk factors (weight, strength,
smoking), 2) biomechanical risk factors (lifting, pos-
ture), and 3) psychosocial risk factors (job control, job
dissatisfaction).
Controlled Trials. No RCTs or CCTs evaluating risk fac-
tor modification were identified. Only one study evalu-
ated the effects of a 1-year back injury prevention pro-
gram after an extensive health risk assessment.
39
This
Table 1. Continued
Author Study Population
Interventions
(No. Analyzed) Outcome Measures
Results
(,, 0) Conclusions*
Exercis
Linton et al, 1996 48 employees (20 women)
working at a company
(tobacco or distributor of
goods). Inclusion criteria
were back pain during
past year, not currently
exercising, no other
illnesses.
Preventive intervention:
1) An individually designed
exercise program using
psychological principles
to enhance compliance.
Graded activity.
(n 25)
Control intervention:
2) advice to exercise,
information,
professional assistance,
and a free membership
to a health club.
(n 23)
Pain 0 Negative
* Positive: if the preventive intervention is more effective (statistically significant difference) than the control intervention on at least one key variable (report of
pain or injury, dysfunction, time off work, health care utilization, cost) and there are no statistically significant differences on the other key variables; Negative: if
the preventive intervention is less effective (statistically significant difference) than a control intervention on at least one key variable and there are no statistically
significant differences on the other key variables or if the preventive intervention is not more effective than no intervention at all; Neutral: if there is no statistically
significant difference between the preventive intervention and control intervention on any of the key variables; Inconsistent findings: if there are statistically
significant positive and negative findings within the same study.
RCT randomized controlled trial; VAS visual analogue score.
783Preventive Interventions for Back and Neck Pain Problems Linton and van Tulder
Table 2. Nonrandomized Controlled Trials on the Effectiveness of Preventive Interventions for Back Pain
Author Study population
Interventions
(No. Analyzed) Outcome Measures
Results
(,, 0) Conclusions*
Lumbar support
Anderson, 1993 266 grocery distribution
warehouse workers.
Nonrandomized
controlled trial with 12
months follow-up.
Preventive intervention:
1) Back belt (1 work site).
Control intervention:
2) No intervention (2 work
sites).
Incidence of back injury Positive (not similar at
baseline)
Thompson, 1994 60 men and women aged
21–65 years, patient
transport personnel in a
hospital.
Nonrandomized
controlled trial with 3
months follow-up.
Preventive intervention:
1) Back belt plus back
school (8 hrs in 1–3
sessions) and
instructions on warming
up exercises (n 41).
Control intervention:
2) Back school (8 hrs in
1–3 sessions) and
instructions on warming
up exercises (n 19).
Incidence of back pain Positive (no data
presented; very small
sample size)
Back school and
education
Brown, 1992 140 (gender age not
stated) municipal
employees with job-
related back pain.
Nonequivalent design.
Controls randomly
selected workers meeting
criteria.
Preventive intervention:
1) Back school 20 min, 5
days, 6 weeks (n 70).
Control intervention:
2) No intervention
(n 70).
Number of injuries
Lost work time
Medical costs
0
Positive
Feldstein, 1993 55 nurses, aides and
orderlies, 79% women,
21% men, aged 19–62
years (mean 42 years).
Nonrandomized
controlled trial with 1-
month follow-up:
Pilot study.
Preventive intervention:
1) 2 hour session on body
mechanics, patient
transfer techniques,
stretching and
strengthening advice,
instructional handouts
plus 8 hr practical time
in 2 weeks (n 30).
Control intervention:
2) No intervention
(n 25).
Composite back pain
score
Composite fatigue score
0
0
Negative (very small
sample size)
Morrison, 1988 120 referrals from a GP,
63% F, 45 years old.
Logically equivalent
design (not randomized).
Preventive intervention:
1) Back school: 6
sessions, 3 hours
(n 60).
Control intervention:
2) Pseudo-control, no
intervention (n 60).
Pain 0 Negative
Versloot, 1992 500 bus drivers.
Nonrandomized
controlled trial with 2
years follow-up.
Preventive intervention:
1) Back school program
on healthy behavior,
information on back
care, physical fitness,
nutrition, stress and
relaxation, 3 sessions
with 6-month intervals
(n 200).
Control intervention:
2) No intervention
(n 300).
Incidence of work
absenteeism
Length of work
absenteeism
0
0
Negative; positive only
for long-term sick
leave of more than 42
days (108 of 200 drivers
attended all three
sessions).
Weber, 1996 865 adults, general
population (53% in pain)
80% F, 70% 40 years.
Matched.
Preventive intervention:
1) Back school: 8
sessions, 90 min
(n 494).
Control intervention:
2) No intervention control
(n 371).
Point prevalence of back
pain
Current pain intensity
Doctor’s visits
Drug intake
Sick leave
0
0
0
0
Positive
* Positive: if the preventive intervention is more effective (statistically significant difference) than the control intervention on at least one key variable (report of
pain or injury, dysfunction, time off work, health care utilization, cost) and there are no statistically significant differences on the other key variables; Negative: if
the preventive intervention is less effective (statistically significant difference) than a control intervention on at least one key variable and there are no statistically
significant differences on the other key variables or if the preventive intervention is not more effective than no intervention at all; Neutral: if there is no statistically
significant difference between the preventive intervention and control intervention on any of the key variables; Inconsistent findings: if there are statistically
significant positive and negative findings within the same study.
784 Spine Volume 26 Number 7 2001
study was excluded from the review, however, because it
did not report results of the comparison group. There is
no good quality evidence on the effectiveness of risk fac-
tor modification (Level D).
Discussion
The evidence for the effectiveness of back and neck pain
prevention programs in workplaces and for the general
population on altering key variables such as the occur-
rence of future pain, disability, and sick leave is some-
what sobering. Despite the application of various tech-
niques, the results thus far have been meager.
Nevertheless, some studies meeting the fairly stringent
criteria used in this review did report positive effects.
Thus, preventive measures may be developed for neck
and back pain.
Several RCTs and CCTs were identified that have at-
tempted to evaluate the effects of quite diverse ap-
proaches to prevention of back and neck pain. These
studies provide a state-of-the art as well as “best evi-
dence” on which to base conclusions. Taken together,
the evidence to date suggests that traditional approaches
to prevention such as back schools, lumbar supports,
and ergonomics have little empirical support. Only exer-
cise has mustered some scientific evidence to support its
use.
The conclusions of the present study about back and
neck schools and education were consistent with those
reported in most other reviews of prevention for back
and neck pain problems, although some reviewers used
more conservative statements, e.g., that there is no clear
evidence or that no conclusion could be
drawn.
8,20,23,28,35,38,46,48
The conclusions made in the
present study about lumbar supports differ somewhat
from previously published reviews, where the authors
often have concluded that there is insufficient or conflict-
ing evidence.
4,18,28,46
Besides the consistent findings, the
reported low compliance for workers to properly use
lumbar supports is another possible reason for a negative
overall conclusion. In one of the trials, 58% of the lum-
bar support group stopped using the supports before the
end of the study. Several reviews of the effect of exercise
as a preventive measure have appeared, and they gener-
ally support the conclusion that exercise may have an
effect.
15,28,46
Similar to the present review of the litera-
ture, other reviewers also have concluded that there are
no controlled studies on ergonomics or risk factor mod-
ification and back and neck pain problems.
14,28,52
It has
been suggested, however, that there is a vast amount of
evidence from laboratory studies indicating that ergo-
nomic interventions may reduce low back pain.
14
In ad-
dition, Frank et al
14
suggested that there is some evidence
from epidemiologic studies that individual, behavioral,
and workplace risk factor modification may be effective.
These conclusions, however, were based on uncontrolled
follow-up studies.
A number of factors may explain the relatively disap-
pointing results found in most of the prevention studies.
Many studies on prevention have small sample sizes and
consequently lack power to detect positive effects. More-
over, almost all studies had, from a prevention view-
point, relatively short follow-up periods so that the full
preventive effect may not yet be visible. Further, the
study populations included in the trials represent a wide
variety of occupations, and the interventions also varied
widely as to exact content, frequency, and duration. An-
other consideration is that the control interventions var-
ied and the definition of outcome differed from back
pain, back injury to sick leave. Although these problems
demonstrate that these are a heterogeneous set of studies,
the authors believe that this review provides “the best
evidence” on the effects of prevention for back and neck
pain problems.
A second possibility is that the preventive effect is
masked by the natural course of spinal pain. Most people
at some time will experience some neck or back pain;
however, this does not necessarily constitute a major
medical problem for the individual. Moreover, the usual
course for acute neck and back pain is that the problem
remits only to reoccur in the future. Thus, the definition
of a “problem case” has considerable influence on judg-
ing results. Most of the studies identified here used the
report of pain or the occurrence of an episode as a mea-
sure of outcome. Because these measures pick up both
cases that are “problematic” and those that are not
“problematic,” it may be difficult to show that a preven-
tive intervention results in better outcome than the usual
base rate. In other words, the natural course of occasion-
ally experiencing pain or having a recurrence that
quickly remits makes up a base rate of comparison that is
difficult to alter. There might be improvements, however,
in the number of cases developing into long-term prob-
lems or problems requiring considerable resources that
are prevented. The research on early interventions for
acute pain seems to suggest that the main benefit of early
intervention is reduced disability and sick leave, but that
other variables e.g., pain reports, are not significantly
better than control conditions. Preventive interventions
may best reduce disability and medical utilization rather
than the number of simple reports of pain.
A third possible explanation of the results is that re-
ports meeting the criteria of the present study have dealt
almost exclusively with single modal programs rather
than with multidimensional ones. A variety of single
modal approaches such as back schools, lumbar sup-
ports, and exercise have been empirically evaluated. Be-
cause many factors may be relevant for the occurrence or
recurrence of back pain or back injury, a multidimen-
sional approach may be needed. A simple example is that
risk factors may be specific to the individual. Thus, a
given risk factor such as poor muscle strength might be
very important for one person, but not another. Exercise,
therefore, may be a powerful preventive measure for
some individuals, but not at all effective for others. A
number of similar examples could be given for other
factors. Multidimensional programs may be more pow-
785Preventive Interventions for Back and Neck Pain Problems Linton and van Tulder
erful because they presumably would cover a wider
range of risk factors. Many workplaces seem to have
embraced this reasoning and have used a program con-
taining several interventions. Although this broader ap-
proach has been suggested,
52
there are no controlled tri-
als at this time that have evaluated their effectiveness.
Because a large portion of any given general or work-
place population will at some point experience neck or
back pain, some have reasoned that all should receive a
preventive intervention. Conducting a risk evaluation
may isolate those aspects of work or individuals most in
need of intervention as well as provide a profile of the
specific risk areas. As a result, the preventive intervention
may be tailored to the needs of the workplace and indi-
viduals. The current literature review, however, pro-
duced no study that used any type of screening or risk
analysis profile. A proper risk analysis, however, has
been identified as one of the basic components of a suc-
cessful program.
26
It has been suggested that for patients
seeking care for acute pain, the recovery curve is so ro-
bust that it may be questionable if early interventions
will improve on the natural rate of recovery.
13
These
authors argue further that for patients with longer dura-
tion problems, early efforts may be quite powerful. Con-
sequently, the effect may depend on the time factor as
well as the profile of the factors contributing to the
problem.
Compliance also may be central to the effectiveness of
preventive interventions. Most of the programs reviewed
were aimed at changing some form of behavior e.g., ex-
ercise, relaxation, wearing supports, attending educa-
tional meetings. Compliance to participate has not al-
ways been high, however, and an underlying question is
how long people continue to practice or use the proce-
dures after the initial intervention is finished. The exer-
cise literature, for example, shows that the majority fails
to continue the recommended exercise program after the
termination of the initial program.
31
Therefore, compli-
ance may be a factor that mediates the effect of the inter-
vention on outcome.
The present review has some limitations. First, even
though every effort has been made to include all relevant
articles and to appraise them in a fair and scientific way,
the search may not have identified all articles. Moreover,
because prevention is not strictly defined, authors may
have used terms not included in the present search strat-
egy. Second, the methodologic quality of the included
studies was not formally assessed. It is well known, how-
ever, that the methodologic quality of many of the back
pain studies in the literature needs to be improved.
24
Low-quality studies are more likely to produce positively
biased results than high-quality studies. The results of
this review suggest that overestimation of the results is
not very likely, but underestimation may have occurred.
Conclusions
A variety of interventions are used to prevent back and
neck pain problems. The most frequently reported inter-
ventions include back schools and other educational ef-
forts, lumbar supports, and exercises. Ergonomic inter-
ventions appear to be used frequently, but they have
never been properly evaluated. The current evidence sug-
gests that exercises seem to be the only effective preven-
tive intervention, although most studies on which this is
based were methodologically flawed, and the effects are
only weak. In consideration of these results, a real need
exists for future studies using the highest methodologic
standards. These studies should focus more on multidi-
mensional programs, should access risk and tailor the
program to the risk profile of the individual or the work-
place, should have longer follow-up periods, and should
include sufficiently large study populations. Further, it is
essential to put efforts into increasing the compliance to
preventive interventions.
Key Points
A variety of interventions have been applied in
an attempt to prevent chronic neck and back pain.
The evidence from controlled trials is sobering
because common methods such as back schools,
lumbar supports, ergonomics, and risk factor mod-
ification have not yet demonstrated their utility.
Exercise, however, did demonstrate a consistent,
but moderate preventive effect.
There is a need for developing preventive inter-
ventions that are tested in rigorous outcome
studies.
Rather than applying prevention to all members
of a given population, selecting those at risk for
developing chronic problems may be more efficient
and effective.
Acknowledgment
The authors thank Mrs. Viveka Alton, librarian of the
Swedish Institute of Technology Assessment in Health
Care (SBU), for conducting the literature searches.
References
1. Agency for Health Care Policy, Research. Clinical practice guidelines num-
ber 14: Acute low back problems in adults. Rockville, Maryland: US Depart-
ment of Health and Human Services, 1994.
2. Alexander MP. Mild traumatic brain injury: Pathophysiology, natural his-
tory, and clinical management. Neurology 1995;45:1253–60.
3. Anderson CK, Morris TL, Vechin DC. The effectiveness of using a lumbar
support belt. Dallas, Texas: Advanced Ergonomics, 1993.
4. Barron BA, Feuerstein M. Industrial back belts and low back pain: Mecha-
nisms and outcomes. J Occup Rehabil 1994;4:125–39.
5. Bergquist-Ullman M, Larsson U. Acute low back pain in industry. Acta
Orthopedics Scandinavia 1977;170:1–117.
6. Berwick DM, Budman S, Feldstein M. No clinical effect of back schools in an
HMO: A randomized prospective trial. Spine 1989;14:33844.
7. Brown KC, Sirles AT, Hilyer JC, et al. Cost-effectiveness of a back school
intervention for municipal employees. Spine 1992;17:12248.
8. Cohen JE, Goel V, Frank JW, et al. Group education interventions for people
with low back pain. An overview of the literature. Spine 1994;19:1214–22.
9. Daltroy LH, Iversen, MD, Larson MG, et al. A controlled trial of an educa-
tional program to prevent low back injuries. N Engl J Med 1997;337:322– 8.
786 Spine Volume 26 Number 7 2001
10. Donchin M, Woolf O, Kaplan L, et al. Secondary prevention of low-back
pain: A clinical trial. Spine 1990;15:1317–20.
11. Feldstein A, Valanis B, Vollmer W, et al. The back injury prevention project
pilot study: Assessing the effectiveness of Back Attack, an injury prevention
program among nurses, aides, and orderlies. J Occup Med 1993;35:114 –20.
12. Fordyce WE. Back pain in the workplace: Management of disability in non-
specific conditions. A report of the Task Force on Pain in the Workplace of
the IASP. Seattle, WA: IASP Press, 1995.
13. Frank JW, Brooker AS, DeMaio SE, et al. Disability resulting from occupa-
tional low back pain: Part II: What do we know about secondary prevention?
A review of the scientific evidence on prevention after disability begins. Spine
1996;21:2918–29.
14. Frank JW, Kerr MS, Brooker AS, et al. Disability resulting from occupational
low back pain. Part I. What do we know about primary prevention? Spine
1996;21:2908–17.
15. Gebhardt WA. Effectiveness of training to prevent job-related back pain: A
meta-analysis. Br J Clin Psychol 1994;33:571–4.
16. Gerdle B, Brulin C, Elert J, et al. Effect of a general fitness program on
musculoskeletal symptoms, clinical status, physiological capacity, and per-
ceived work environment among home care service personnel. J Occup Re-
habil 1995;5:1–16.
17. Gundewall B, Liljeqvist M, Hansson T. Primary prevention of back symp-
toms and absence from work: A prospective randomized study among hos-
pital employees. Spine 1993;18:587–94.
18. Hodgson EA. Occupational back belt use: A literature review. Aaohn J 1996;
44:43843.
19. Kamwendo K, Linton SJ. A controlled study of the effect of neck school in
medical secretaries. Scand J Rehabil Med 1991;23:143–52.
20. Karas BE, Conrad KM. Back injury prevention interventions in the work-
place: An integrative review. Am Assoc Occup Health Nurs J 1996;44:189
96.
21. Kellett KM, Kellett DA, Nordholm LA. Effects of an exercise program on
sick leave due to back pain. Phys Ther 1991;71:283–93.
22. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow
flags in acute low back pain: Risk factors for long-term disability and work
loss. Wellington, New Zealand: Accident Rehabilitation & Compensation
Insurance Corporation of New Zealand and the National Health Commit-
tee, 1997.
23. King PM. Back injury prevention programs: A critical review of the litera-
ture. J Occup Rehabil 1993;3:145–58.
24. Koes BW, Bouter LM, van der Heijden GJMG. Methodological quality of
randomized clinical trials on treatment efficacyin low back pain. Spine 1995;
20:228–35.
25. Koes BW, van Tulder MW, van der Windt D, et al. The efficacy of back
schools: A review of randomized clinical trials. J Clin Epidemiol 1994;47:
851–62.
26. Kompier MAJ, Geurts SAE, Gründemann RWM, et al. Cases in stress pre-
vention: The success of a participative and stepwise approach. Stress Med
1998;14:155–68.
27. Kuorinka I, Jonsson B, Jörgensen K, et al. Arbetsrelaterade sjukdomar i
rörelseorganen: förekomst, orsaker och förebyggande (Work related muscu-
loskeletal disorders: Prevalence, causes and prevention). In: Lundgren N, ed.
Copenhagen: Nordiska Ministerrådet, 1990 (vol 6).
28. Lahad A, Malter AD, Berg AO, et al. The effectiveness of four interventions
for the prevention of low back pain. JAMA 1994;272:1286–91.
29. Leclaire R, Esdaile JM, Suissa S, et al. Back school in a first episode of
compensated acute low back pain: A clinical trial to assess efficacy and
prevent relapse. Arch Phys Med Rehabil 1996;77:673–9.
30. Lindequist S, Lundberg B, Wikmark R, et al. Information and regime at low
back pain. Scand J Rehabil 1984;16:113–6.
31. Linton SJ, Hellsing AL, Bergström G. Exercise for workers with musculo-
skeletal pain: Does enhancing compliance decrease pain? J Occup Rehabil
1996;6:177–90.
32. Linton SJ, Kamwendo K. Low back schools. A critical review. Phys Ther
1987;67:1375–83.
33. Morrison GEC, Chase W, Young V, et al. Back pain. Treatment and preven-
tion in a community hospital. Arch Phys Med Rehabil 1988;69:605–9.
34. National Board of Health, Welfare. Att förebygga sjukdomar i rörelseor-
ganen (Preventing musculoskeletal pain). Stockholm: Socialstyrelsen, 1987.
35. Nordin M, Cedraschi C, Balagu. e F, et al. Back schools in prevention of
chronicity. Baillieres Clin Rheumatol 1992;6:685–703.
36. Reddell CR, Congleton JJ, Huchingson RD, et al. An evaluation of a weight-
lifting belt and back injury prevention training class for airline baggage
handlers. Appl Ergon 1992;23:319–29.
37. Rosen M. Clinical Standards Advisory Group: Back pain report of a com-
mittee on back pain. London: HMSO, 1994.
38. Scheer SJ, Radack KL, O’Brien DRJ. Randomized controlled trials in indus-
trial low back pain relating to return to work. Part 1. Acute interventions.
Arch Phys Med Rehabil 1995;76:966–73.
39. Shi L. A cost–benefit analysis of a California county’s back injury prevention
program. Public Health Rep 1993;108:204–11.
40. Sirles AT, Brown K, Hilyer JC. Effects of back school education and exercise
in back injured municipal workers. AAOH J 1991;39:7–12.
41. Stankovic R, Johnell O. Conservative treatment of acute low back pain. A
5-year follow-up study of two methods of treatment. (see comments) Spine
1995;20:469–72.
42. Swedish Council on Technology Assessment in Health Care S. Back pain:
Causes, diagnostics, and treatment. Stockholm: Swedish Council on Tech-
nology Assessment in Health Care, 1991.
43. Symonds TL, Burton AK, Tillotson KM, et al. Absence resulting from low
back trouble can be reduced by psychosocial intervention at the work place.
Spine 1995;20:273845.
44. Takala EP, Viikari-Juntura E, Tynkkynen EM. Does group gymnastics at the
workplace help in neck pain? A controlled study. Scand J Rehabil Med
1994;26:17–20.
45. Thompson L, Pati AB, Davidson H, et al. Attitudes and back belts in the
workplace. Work 1994;4:22–7.
46. van Poppel MNM, Koes BW, Smid T, et al. A systematic review of controlled
clinical trials on the prevention of back pain in industry. Occup Environ Med
1997;54:841–7.
47. van Poppel MNM, Koes BW, van der Ploeg T, et al. Lumbar supports and
education for the prevention of low back pain in industry: A randomized
controlled trial. JAMA 1998;279:1789–94.
48. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and
chronic nonspecific low back pain. Spine 1997;22:2128–56.
49. Versloot JM, Rozeman MA, van Son AM, et al. The cost-effectiveness of a
back school program in industry. Spine 1992;17:22–7.
50. Walsh NE, Schwartz RK. The influence of prophylactic orthoses on abdom-
inal strength and low back injury in the workplace. Am J Phys Med Rehabil
1990;69:245–50.
51. Weber M, Cedraschi C, Roux E, et al. A prospective controlled study of low
back school in the general population. Br J Rheumatol 1996;35:17883.
52. Westgaard RH, Winkel J. Ergonomic intervention research for improved
musculoskeletal health: A critical review. Int J Indust Ergonom 1997;20:
463–500.
Address reprint requests to
Steven J. Linton, PhD
Department of Occupational and Environmental
Medicine
Örebro Medical Center
701 85 Örebro
Sweden
787Preventive Interventions for Back and Neck Pain Problems Linton and van Tulder
... Many employers use systematic ergonomic improvement processes to remove risk factors that could lead to musculoskeletal injuries with the goal of improving employee performance and productivity. However, except for office environments and computer workstations, evidence supporting the effectiveness of ergonomic interventions is inconclusive [15,16,26,34,48]. Ergonomic assessments are best used in conjunction with job-matching processes. ...
... Education programs attempt to mitigate the risk of work-related back injuries by increasing the participant's knowledge, thereby altering the individual's behaviors to mitigate biomechanical risk. These programs typically cover anatomy, biomechanics, lifting, postural changes, and home exercises [48]. However, a systematic review [48] and metaanalysis [49] presented strong and consistent evidence that education alone does not seem to prevent back pain and comprehensive "back schools" are not effective in preventing neck and back pain. ...
... These programs typically cover anatomy, biomechanics, lifting, postural changes, and home exercises [48]. However, a systematic review [48] and metaanalysis [49] presented strong and consistent evidence that education alone does not seem to prevent back pain and comprehensive "back schools" are not effective in preventing neck and back pain. ...
Article
Full-text available
Context: The direct and indirect costs of work-related musculoskeletal disorders are significant. Prevention is the most effective way to control these costs. To do that, we must understand how these disorders develop. Objectives: To use the five models of osteopathic care to illustrate how cellular processes and neural reflexes interact to create work-related musculoskeletal pathology and to provide evidence-informed musculoskeletal injury and disability prevention recommendations. Methods: A literature review of electronic databases (Google Scholar, PubMed, OVID, Cochrane Central Register of Controlled Trials, PEDro, and OSTMED.DR) from inception to October 16, 2019 and hand-search of publication references was performed for systematic reviews, cohort studies, case-control studies, and randomized controlled trials. The search terms reflected topics related to occupational injury and injury prevention, and included supplementary laboratory studies and narrative reviews related to the biological aspects of musculoskeletal injury. The eligible studies contained the following criteria: (1) the population of working age; (2) exposures to known risk factors, musculoskeletal disorders, and psychosocial factors; (3) written in English; (4) full text papers published in peer-reviewed journals; and (5) systematic review, cohort study, case-control study, and randomized controlled trial methodology. Studies were excluded if they included outcomes of productivity and costs only or outcomes that were assessed through qualitative methods only. Results: The literature search resulted in 1,074 citations; 26 clinical studies and 14 systematic reviews were used in this review. A comprehensive workplace musculoskeletal disorder prevention program should match demands to capacity, correct dysfunctional movement patterns, and limit tissue vulnerability (biomechanical-structural model); restore alpha-gamma balance, tonic-phasic synergistic function, and autonomic balance (neurological model); maximize physiologic reserve (metabolic-energy model) component of a prevention program; optimize respiration and circulation (respiratory-circulatory model); and address cognitive distortions (behavioral-biopsychosocial model). Conclusions: The presented osteopathic model of the development and prevention of work-related musculoskeletal disorders suggests that a combination of preventive interventions will be more effective than any single preventive intervention.
... (1) shows that the majority of (56.7%)were female in the study group and (50%) for each male and female in control group. Most of the study group (30%) from the age group (30)(31)(32)(33)(34)(35) years and (50 years and older), and (33.3%) were the age group (30-35) years for the control group. ...
... The finding of table (4) reveals that a (66.7%) of the study group patients have a high knowledge level and high mean of score after the completion of the instructional program, but a (70%) of the control group patients have no enhancement in their knowledge level and also have a low mean of score in the posttest period.the study ofHanley agreed with this study results and stated that the group which received a teaching sessions getting more enhancement in their knowledge than the other group who not involved in the sessions [30] .Linton disagrees with this study results and reported that there is no effect for improvingthe patients' knowledge related to LDP disease after an implementation of a health program sessions for the study sample [31] . ...
Research
Full-text available
Lumbar disk prolapse (LDP) is a major public health problem and highly percent of the adult population suffers from this disease at some time in their lives. Around 10% of sufferers become chronically disabled patients and may also present with sciatic symptoms. The quality of life hence productivity is reduced due this disease. The Lumbar disk is weakened therefore; causing instability of the spine, which may result in changes and disk displacement, nerve root compression and canal stenosis. This disorder is common among middle-aged individuals, who are at large the working population so an enormous economic burden may be created in the society. Objective: The study aims to determine the effect of the instructional program on knowledge of patients with LDP and to find out the relationship between patients' socio-demographic characteristics of gender, age, educational level, marital status, occupation, monthly income, type of residence and residential area and their knowledge related to LDP. Methodology: A descriptive study was conducted on non-probability (purposive sample) of (60) patients; (30) patients for the study group and (30) for the control group, who had a lumbar disk prolapse in Baghdad teaching hospitals from October 15 th , 2015 to July 20 th , 2016.The same questionnaire form wasused for the study and control groups in the pretest period as a tool of data collection, which these data are introduced through the application of an instructional program.Then after three weeks; the post-test was given to both groups, after the program has been finished with the study group, and with same questionnaires that used in the pretest. Descriptive and inferentialstatistical analyses were used to analyze the data. Results: The results of the LDP study group patients showed there are differences between their knowledge about LDP in pretest and their knowledge in post-test periods. Also, it reveals that there was a statistically no significant association at (P ≤ 0.05) between the study group of LDP patients' knowledge related to (age, gender, marital status, occupation and residential area), but there was a significant association related to the educational level. Conclusion: the results showed that the study group of LDP patients benefited from the implementation of the instructional program, and their knowledge was effectively enhanced and established. Recommendations: The study recommended the importance of increasing awareness among patients about the lumbar disk prolapse distributed through handbooks, explanatory posters, and performing an educational health programs through modern technological means (audio-visual) to follow a healthy back and spine safety during daily life activities at home and at work. Finally, the researchers suggest performing furtherlongitudinal studies that include a larger sample which assists in a more precise investigation of the quality of life of LDP clients.
... 32 a self-reinforcing upward spiral of improvements in selfefficacy beliefs, self-management behaviors, psychosocial functioning and overall well-being. 8,20 however, empirical results on the influence of type and intensity of exercise, as well as the subjective degree of perceived physical exertion (following Borg 21 assessment of physical exertion from any exertion at all up to maximum exertion on a scale from 0 to 10), are inconsistent, 8,[17][18][19][20][21][22] and empirical evidence on the question of whether a movement-induced reduction in back pain affects direct medical costs is rather fragmentary. 7,9,12,[23][24][25] despite the double-digit number of systematic reviews published on the topic, there is no consensus on the relative effectiveness of different exercise patterns, and the question of which elements of an intervention are particularly decisive for the pain-reducing effect remains unanswered. ...
... 32 a self-reinforcing upward spiral of improvements in selfefficacy beliefs, self-management behaviors, psychosocial functioning and overall well-being. 8,20 however, empirical results on the influence of type and intensity of exercise, as well as the subjective degree of perceived physical exertion (following Borg 21 assessment of physical exertion from any exertion at all up to maximum exertion on a scale from 0 to 10), are inconsistent, 8,[17][18][19][20][21][22] and empirical evidence on the question of whether a movement-induced reduction in back pain affects direct medical costs is rather fragmentary. 7,9,12,[23][24][25] despite the double-digit number of systematic reviews published on the topic, there is no consensus on the relative effectiveness of different exercise patterns, and the question of which elements of an intervention are particularly decisive for the pain-reducing effect remains unanswered. ...
Article
Full-text available
Background: Exercise is considered an effective intervention to relieve chronic back pain. However, it is still unknown whether specific exercise patterns vary in terms of their efficiency and effectiveness. Aim: To investigate the differential health and economic effects of intensity, specificity and degree of subjective perceived physical exertion across five exercise patterns (endurance, gymnastics, fitness, back gymnastics, multimodal back exercise) in adults with back pain. Design: Longitudinal observational cohort study over a period of 24 months. Setting: Various non-therapeutic exercise facilities (e.g., outdoor, fitness centres, health insurance programmes, sports clubs) across one federal state of Germany (Baden- Wuerttemberg). Population: Adults with back pain (N = 2,542, Mean = 46.9 years, 66% females, Graded Chronic Back pain GCPS 1= 40.5%, GCPS 2= 27.3 %, GCPS 3= 20.7 %, GCPS 4= 11.5 %). Methods: Self-reported back pain (functional restrictions and pain = Back Pain Function Score, BPFS) and characteristics of exercising behaviour (frequency, duration, type, physical exertion) were assessed at baseline and at 6, 12, 18 and 24 months. Direct medical costs for back disorders (International Classification of Diseases, Dorsopathies: M40 - M54) were compiled from health insurance records. Results: Moderate- to high-intensity exercise patterns were effective in reducing back pain, particularly at lower levels of subjective perceived physical exertion. At these intensity levels, multimodal back exercise (i.e., exercising the spine-stabilizing muscles specifically, ergonomic training) was 14.5 times more effective than non-backspecific fitness exercise in reducing back pain (BPFS). The beneficial effects of both exercise types increased with the initial severity of back pain. However, only multimodal back exercise (moderate- to high-intensity/high back specificity) was associated with a significant decrease in direct medical costs for back pain. Conclusions: Targeted exercise of the spine-stabilizing musculature at moderate to high intensities without maximum perceived exertion is effective and efficient in reducing back pain.
... Tulder showed that exercise was an effective preventive intervention for NP (31). However, it has been shown that exercise therapy is not more cost-effective than other interventions for NP (32)(33)(34). ...
Article
Background: Neck pain (NP) is a common musculoskeletal problem; however, the prevalence and years lived with disability (YLD) of NP in China are still unclear. This study sought to estimate the age-, sex- and province-specific prevalence and YLD of NP in China. Methods: Adopting the methodology framework and analytical strategies used in the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2017), the prevalence and YLD of NP in China were estimated by age, sex, year, and provinces/regions. Results: In China, the age-standardized point prevalence rate of NP was 4,532.6 per 100,000 persons in 1990 and increased slightly to 4,634.4 per 100,000 persons in 2017. The prevalence of NP was 48.0 million in 1990 and rose dramatically to 87.3 million in 2017 (an increase of 82.0%). The age-standardized YLD rate of NP was 454.0 per 100,000 persons in 1990, and there was a slight increase to 465.6 per 100,000 persons in 2017. The all-age YLD of NP was 4.8 million in 1990 and rose to 8.8 million in 2017 (which represents an increase of 81.1%). In 1990, NP was the third leading cause of YLD in China, and in 2017, NP was the leading cause of disability burden. Conclusions: This study estimated the prevalence and disability burden of NP in China. NP is currently the leading cause of disability burden in China; however, it is currently inadequately recognized and should receive further attention and be subject to further research.
... Como método de prevención del DEBI podemos citar varios beneficios aportados por el ejercicio realizado de forma adecuada: incremento de la flexibilidad del tronco, fortalecimiento de la espalda, aumento del riego sanguíneo y una mejora del estado anímico, lo cual tendrá consecuencias sobre su percepción del dolor (Linton & van Tulder, 2001). Los beneficios varían en función del sujeto y de la etapa del dolor en la que se encuentre (aguda, subaguda o crónica), las características sociales, biológicas y psicológicas, y es que estás características hacen variar el impacto del dolor lumbar común. ...
... In response to a lack of research in this area, 6,7 we conducted the first randomised controlled trial (RCT) of a healthy lifestyle intervention for patients with chronic low back pain who are overweight or obese. 8 The intervention involved brief telephone advice, a clinical consultation and referral to a 6-month telephone-based healthy lifestyle coaching service. ...
Preprint
Full-text available
We performed an economic evaluation of a healthy lifestyle intervention targeting weight loss, physical activity and diet for patients with chronic low back pain, who are overweight or obese. Eligible patients with chronic low back pain (n=160) were randomised to an intervention or usual care control group. The intervention included brief advice, a clinical consultation and referral to a 6-month telephone-based healthy lifestyle coaching service. The primary outcome was quality-adjusted life years (QALYs). Secondary outcomes were pain intensity, disability, weight, and body mass index. Costs included intervention costs, healthcare utilisation costs and work absenteeism costs. An economic analysis was performed from the societal perspective. Mean total costs were lower in the intervention group than the control group (-$614; 95%CI: -3133 to 255). The intervention group had significantly lower healthcare costs (-$292; 95%CI: -872 to -33), medication costs (-$30; 95%CI: -65 to -4) and absenteeism costs (-$1000; 95%CI: -3573 to -210). For all outcomes, the intervention was on average less expensive and more effective than usual care, and the probability of the intervention being cost-effective compared to usual care was relatively high (i.e. 0.81) at a willingness-to-pay of $0/unit of effect. However, the probability of cost-effectiveness was not as favourable among sensitivity analyses. The healthy lifestyle intervention seems to be cost-effective from the societal perspective. However, variability in the sensitivity analyses indicates caution is needed when interpreting these findings.
Article
Full-text available
Introduction: Fear of pain is related to disability and chronicity of low back pain. The aim of this study was to investigate the relation between fear avoidance beliefs (FAB) and postural stability and the influence of specific training on postural stability and FAB in individuals with non-specific chronic low back pain (NSCLBP). Materials and Methods: Twenty-seven females with NCLBP were recruited in this quasi-experimental study. Pain intensity, FAB, and disability were recorded using the questionnaires. The force plate was used to measure the postural stability. Abdominal and back muscle endurance was measured respectively by Sit Up and Biering-Sorensen tests. All tests were repeated one week and one month after a short-term specific training for FAB. Repeated measure analysis was used to compare the variables. To evaluate the association between variables Pearson correlation coefficient and mixed model analysis were used. All data were analyzed by SPSS, version16. Results: Pain intensity, FAB, and disability scores showed a significant reduction after intervention (P < 0.010). The time of sit up, Sorensen and single leg stance tests prominently increased (P < 0.010). Center of pressure (COP) excursion and velocity variables faced with a considerable decrease (P < 0.010). Pain intensity was mainly related to cop excursion and velocity during unilateral standing (P < 0.010) but there is no relation between FAB and the parameters of postural stability. However, the trend of changes in FAB was related to the trend of changes in cop excursion and velocity during unilateral standing in the mediolateral plan (P = 0.040). Conclusion: Changes in FAB were related to the changes in COP excursion and velocity during unilateral standing. Specific training for FAB resulted in pain intensity reduction, FAB, and disability scores. It also led to an improvement he postural stability as well as increasing the time of sit up, Biering-Sorensen, and single leg stance tests in subjects with NSCLBP.
Article
ZET Bu çalışma; lomber disk hernili hastaların vücut mekanikleri hakkındaki bilgi düzeylerinin ağrı şiddeti üzerine etkisini belirlemek amacıyla yapıldı. Tanımlayıcı tipteki bu çalışma dokuz aylık süreçte Fizik Tedavi ve Rehabilitasyon servisinde yatan daha önce lomber disk hernisi tanısı alan hastalarla (n=63) yürütüldü. Araştırma verilerinin toplanmasında; sosyo-demografik veri formu ve vücut mekanikleri bilgi formu ile Görsel Anolog Skala kullanıldı. Araştırmada veriler kurum izni ve hastaların yazılı onamları alındıktan sonra araştırmacılar tarafından hastalarla yüz yüze görüşme tekniği ile toplandı. Verilerin değerlendirilmesinde yüzde, ortalama, Kruskal-Wallis varyans analizi ve Mann-Whitney U testi ve pearson korelasyon analizleri kullanıldı. Hastalık süresi ortalamaları 6.2±6.1 yıl olan hastaların, ağrı düzeyi 7.0±2.0 olarak saptandı. Hastaların %79.4'ünün daha önce vücut mekanikleri hakkında eğitim almadığı belirlendi. Hastaların vücut mekanikleriyle ilgili bilgi puan ortalamaları 9.1±2.0 (0-16) bulundu. Hastaların vücut mekanikleri hakkında bilgi düzeyleriyle ağrı düzeyleri arasında negatif yönde orta düzeyde anlamlı bir ilişki saptandı (r:-.324; p=0.009). Bu sonuçlara göre lomber disk hernili hastalarda oluşabilecek komplikasyonları ve buna bağlı ağrıyı önlemek için uygun vücut mekaniklerinin kullanılması konusunda kişilere verilecek eğitim programı ile Fizik Tedavi ve Rehabilitasyon ünitelerinde rutin bakıma eklenilerek bireylerin farkındalıkların arttırılması sağlanabilir.
Article
Full-text available
Study Design. A systematic review of randomized controlled trials. Objectives. To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain. Summary of Background Data. Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy. Methods. A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results. Results. The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100‐point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti‐inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short‐term effects. Conclusions. The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain.
Article
Stress prevention programmes are predominantly reactive and aimed at individuals. Four factors that may contribute to this current status are discussed: the opinions and interests of company management, the nature of psychology, the difficulty of conducting methodologically ‘sound’ intervention studies and the denominational segregation of stress research. To increase the impact of organizational level interventions, the effects need to be demonstrated on matters that appeal to company management, such as quality of products and services, organizational flexibility, productivity and sickness absence rates. The demonstration of examples of good preventive practice is considered as a conditio sine qua non for developing effective stress prevention procedures and for the involvement of both social partners in this field. Therefore, 10 Dutch projects from several branches of industry, aimed at the reduction of work stress, physical workload and sickness absenteeism, were selected, analysed and compared. The results show that in most cases sickness absenteeism was reduced and that the benefits exceeded the costs of the interventions. Five factors seem to be at the heart of a successful approach: (1) its stepwise and systematic nature, (2) an adequate diagnosis or risk analysis, (3) a combination of measures (i.e. both work-directed and person-directed), (4) a participative approach (i.e. worker involvement) and (5) top management support. In conclusion, the projects suggest that stress prevention may be beneficial to both the employee and the organization. © 1998 John Wiley & Sons, Ltd.
Article
This study, conducted on hospital workers, investigated the influence of wearing back belts on employee job attitudes and the experience of back pain. Serial attitude surveys were administered to workers involved in a preventative program of education, exercise, and back belts. Attitudes were found to be significantly improved as a result of the back belt program. Employees perceived back belts as helping them avoid injury and reported a decreased experience of low back pain.
Article
Back schools are increasingly utilized as an injury prevention strategy employed at the worksite. Yet, evidence of the efficacy of back schools is limited and controversial. A review of the literature showed variance in methodologies and consequently, outcomes. Outcome measures used include physical capacity, functional abilities, costs, lost time, absenteeism, perception of pain, lifting performance, attitudes, and job satisfaction. In many studies, lack of randomization and control was found to be a limitation in experimental design. Studies which used the behavioral approach of measuring lifting behavior lacked followup and evidence of long-term effects. The type of education and feedback or reinforcement was an important issue not well-defined in the literature. A variety of hypothetical mechanisms were described as contributing to the outcome of back injury prevention programs. Additional controlled research is necessary to determine the specific mechanisms of change in an effort to further improve outcome in this area.
Article
A low rate of compliance for exercise regimens is a difficult problem for programs aimed at treating or preventing musculoskeletal pain. In fact, the utility of exercise for common pain problems has been debated since poor compliance confounds proper program evaluation. Thus, the purpose of the present study was to evaluate the effects of a compliance enhancement measure and subsequently to assess the effects of physical activity on pain perception. Forty-eight employees (mean age=42, 20 females) currently working at two companies and who reported musculoskeletal pain, but noexercise habit voluntarily served as subjects. The Comparison Group was provided with information and free membership at a health center. The Exercise Compliance Enhancement Group met individually with a behavioral psychologist, who employed cognitive-behavioral techniques, to plan their activity program. Results showed that the Compliance Enhancement Group had a higher rate of adherence and participated in significantly more exercises over the course of 6 months than did the Comparison Group. However, analyses based on pre- and posttest gain scores showed that the differences between the groups for aerobic capacity and pain intensity were not significant. However, when compilers were compared with noncompliers, those complying with the activity program were found to have improved their aerobic capacity more than noncompliers. Yet for overall pain intensity ratings, the difference between compilers and noncompliers was still not significant. Intensity ratings made immediately before and after exercising indicated that exercise activities were related to a significant increase in pain intensity. These results indicate that compliance for exercise may be significantly improved, but the effect of exercise activities on overall pain intensity was not significant relative to the comparison group.
This literature review of ergonomic intervention studies aims to identify effective ergonomic interventions for improved musculoskeletal health in the workplace and to make recommendations for quality criteria in ergonomic intervention research. To avoid ambiguity in terminology a list of definitions of the ergonomic terms used in this paper is provided in an appendix. Models were developed for use in the classification of ergonomic intervention research and to illustrate the problems in interpreting ergonomic intervention data. The relevant literature was identified by a two-step process. First the relevant literature was identified by inclusion criteria, then, quality criteria were applied to identify studies of good quality for effective intervention. These appear to be firstly “organizational culture” and secondly modifier interventions, the former using multiple interventions with high stakeholder commitment to reduce identified risk factors, and the latter especially focusing workers at risk and using measures which actively involve the individual. A list of recommendations is provided.