Get evidence-based right here right now! A study has just been published, this one in the prestigious JAMA, which shows that exercise prevents low back pain recurring in the short term. This is not a groundbreaking idea, but nice to see it backed up with very convincing solid stats.
Prevention of Low Back Pain: A Systematic Review and Meta-analysis, Steffens D, et al. JAMA Intern Med. 2016. Click here for the short version, and here for the full text. There is also a commentary on putting these findings into practice which you can download here.
If you don’t manage to get access, or have time for any of that, the gist of it is:
- Exercise alone (or with education) is effective for preventing recurrence of LBP by 25 to 40% for one year. Yes, that’s quite a large percentage, and it’s moderate quality evidence.
- The long term effect is less clear, but the combination of exercise PLUS education might be more effective than exercise alone after a year. The authors guess that people stopped doing their exercises after the first year, and therefore any exercise programme needs to be ongoing.
- Some other interventions they examined showed barely any effect, maybe none at all, such as
- education alone
- back belts
- orthotic insoles
So once you have put your stock of insoles and back belts on ebay, and sorted out your patient’s episode of back pain with your expert techniques, send them off with the advice to do plenty of exercise if they want to reduce their chances of having a further episode.
- But what sort of exercise? This study has widely been reported as saying that “exercise” reduces the recurrence of LBP. I thought this simply meant people going out and getting fit, in whatever way they liked – fencing, ice skating, line dancing, climbing…but if you look at the detail of the studies they reviewed, I think the better word would be “exercises” – that is, the studies involved specific exercises for the low back rather than generic “exercise”, like swimming or jogging. The exercise programmes were all different but were described as “substantial”. There seems to be quite a lot of strengthening and stretching, particularly the traditional lumbar stretches and abdominal strengthening – and the ubiquitous “core stability” makes an appearance in the table. But because they were all different, the frequency, dose and intensity of the 3 types of exercise – strengthening, stretching and aerobic – were not specifically clarified.
- What sort of eduction is most effective? Having just been dazzled by David Butler’s Explain Pain course, I initially assumed that this is what was meant by education. But no, what they mean here seems to be more about safe lifting techniques and posture. Quite a few of the studies they reviewed seemed to involve people in physically demanding jobs, in sectors such as the military or nursing, and the “education” was probably more about how to avoid injury rather than explaining the neuroscience of pain and how you can affect it. So don’t throw away the proctometer.
- How do you get clinicians to prescribe it, and patients to do it? According to this, fewer than half of clinicians currently prescribe exercise. I tend to suggest and advise exercise of a general sort, and if the patient seems able, keen and willing I demonstrate some stretches and strengthening techniques, but I’d like to see methods of “prescribing” that really work. Because it doesn’t take Sherlock Holmes to spot that a patient needs to lose weight, or sort out their relationship issues, or get moving much more, but it takes some skill to get them to do it.
So, it’s not so hard to get evidence-based in practice. This paper is bang up to date, easy to understand, and in theory not hard to implement. What I need to look at next is a study on the best way to get patients to actually do their exercises.