Low-back pain

Assessment of Therapeutic Effectiveness
Prevention

Family Practice
Internal Medicine
Physical Medicine and Rehabilitation
Preventive Medicine

Occupational Therapists
Physicians

To develop recommendations for the use of back belts to prevent occupational low-back pain

Adults at-risk for occupational low-back pain

Use of back belts

Incidence and/or duration of lost time of reported low-back pain among workers who wore back belts compared to those who did not

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

The published English literature to June 2002 was identified with a computerized search of MEDLINE, CINAHL, EMBASE, and HEALTHSTAR databases using the following keywords: back, lumbar, spine, belts, supports, braces, orthotic devices, prevention, and occupational. Pertinent references from articles obtained from the above search were also reviewed. Studies were included if the study participants were material handlers (i.e., exposed to lifting) and outcome measures included the incidence and/or duration of lost time of reported low-back pain among workers who wore back belts compared to those who did not. No restriction was made on the style of back belt used.

10

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence - Research Design Rating

I Evidence from randomized controlled trial(s)

II-1 Evidence from controlled trial(s) without randomization

II-2 Evidence from cohort or case-control analytic studies, preferably from more than one centre or research group

II-3 Evidence from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments could be included here

III Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert committees

Levels of Evidence - Quality (Internal Validity) Rating

Good A study (including meta-analyses or systematic reviews) that meets all design-specific criteria* well

Fair A study (including meta-analyses or systematic reviews) that does not meet (or it is not clear that it meets) at least one design-specific criterion* but has no known "fatal flaw"

Poor A study (including meta-analyses or systematic reviews) that has at least one design-specific* "fatal flaw," or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendations

*General design-specific criteria are outlined in Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D. Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. Am J Prev Med. 2001;20(suppl 3):21-35.

Systematic Review with Evidence Tables

Not stated

Expert Consensus

Evidence for this topic was presented by the lead author(s) and deliberated upon during 4 task force meetings. Expert panelists addressed critical issues, clarified ambiguous concepts, and analyzed the synthesis of evidence. At the end of this process, the specific clinical recommendations proposed by the lead author were discussed, as were issues related to clarification of the recommendations for clinical application and any gaps in evidence. The results of this process are reflected in the description of the decision criteria presented with the specific recommendations in the technical report companion document (see the "Companion Documents" field).

The Canadian Task Force recognizes that in many cases patient specific factors need to be considered and discussed, such as the value the patient places on the clinical preventive action; its possible positive and negative outcomes; and the context and/or personal circumstances of the patient (medical and other). In certain circumstances where the evidence is complex, conflicting or insufficient, a more detailed discussion may be required.

The Task Force recognizes that in clinical practice, caregivers dealing with individual patients must make binary decisions -- "do it" or "don't do it". It also recognizes, however, that for many preventive interventions, the scientific evidence does not lend itself to such simple two-dimensional alternatives. The particular characteristic that distinguishes the Task Force methodology from traditional approaches to decision-making on prevention issues is that evidence takes precedence over consensus. Refer to the "Companion Document" field for "CTFPHC History/Methodology".

Recommendations Grades for Specific Clinical Preventive Actions

A The CTF concludes that there is good evidence to recommend the clinical preventive action.

B The CTF concludes that there is fair evidence to recommend the clinical preventive action.

C The CTF concludes that the existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action, however other factors may influence decision-making.

D The CTF concludes that there is fair evidence to recommend against the clinical preventive action.

E The CTF concludes that there is good evidence to recommend against the clinical preventive action.

I The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a recommendation, however other factors may influence decision-making.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
External Peer Review

Comparison with Guidelines from Other Groups. Recommendations from the Canadian Centre for Occupational Health and Safety, the United States National Institute for Occupational Safety and Health, and the United States Occupational Safety and Health Administration were reviewed.

External Peer Review. After final revision, the manuscript was sent by the Task Force to 2 experts in the field (identified by Task Force members at the meeting). Feedback from these experts was incorporated into a subsequent draft of the manuscript.

Recommendation grades (A-I) and levels of evidence (I, II-1, II-2, II-3, III; good, fair, poor) are indicated after each recommendation. Definitions for these grades and levels are provided following the recommendations.

The Canadian Task Force on Preventive Health Care concludes that the existing evidence is conflicting and does not allow the task force to make a recommendation for or against the use of back belts to either prevent occupational low-back pain or to reduce lost work time due to occupational low-back pain (grade C recommendation) (Walsh & Schwartz 1990 [I, fair]; van Poppel et al. 1998 [I, fair]; Alexander et al. 1995 [I, fair]; Kraus et al. 2002 [I, fair]; Wassell et al. 2000 [II-2, good]).

Levels of Evidence - Research Design Rating

I Evidence from randomized controlled trial(s)

II-1 Evidence from controlled trial(s) without randomization

II-2 Evidence from cohort or case-control analytic studies, preferably from more than one centre or research group

II-3 Evidence from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments could be included here

III Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert committees

Levels of Evidence - Quality (Internal Validity) Rating

Good A study (including meta-analyses or systematic reviews) that meets all design-specific criteria* well

Fair A study (including meta-analyses or systematic reviews) that does not meet (or it is not clear that it meets) at least one design-specific criterion* but has no known "fatal flaw"

Poor A study (including meta-analyses or systematic reviews) that has at least one design-specific* "fatal flaw," or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendations

*General design-specific criteria are outlined in Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D. Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. Am J Prev Med. 2001;20(suppl 3):21-35.

Recommendations Grades for Specific Clinical Preventive Actions

A The CTF concludes that there is good evidence to recommend the clinical preventive action.

B The CTF concludes that there is fair evidence to recommend the clinical preventive action.

C The CTF concludes that the existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action, however other factors may influence decision-making.

D The CTF concludes that there is fair evidence to recommend against the clinical preventive action.

E The CTF concludes that there is good evidence to recommend against the clinical preventive action.

I The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a recommendation, however other factors may influence decision-making.

None provided

Maneuver: Use of back belts in the workplace to prevent the incidence of occupational low-back pain, or time lost from work due to low-back pain.

Level of Evidence:
I, fair; II-2, good

Refer to the "Major Recommendations" field.

• Reduction in occurrence or recurrence of low-back pain (LBP)
• Reduction in time lost from work owing to low-back pain

• Rubbing, pinching or bruising of ribs; hampered sitting and driving; excessive sweating
• False sense of security
• Laboratory studies show increases in blood and intra-abdominal pressure, back muscle weakening, and abdominal hernia

An implementation strategy was not provided.

Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2003 Aug 5

Canadian Task Force on Preventive Health Care - National Government Agency [Non-U.S.]

The Canadian Task Force on Preventive Health Care (CTFPHC) is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.

Canadian Task Force on Preventive Health Care (CTFPHC)

Not stated

Not stated

None available

This NGC summary was completed by ECRI on March 18, 2004. The information was verified by the guideline developer on March 25, 2004.