NEWS

Advice, Training in Lifting Techniques May Not Improve Prevention of Back Pain
A systematic review published in the February 1 Online First issue of the BMJ shows no evidence to support use of advice or training in lifting techniques in the workplace with or without lifting equipment to prevent back pain or consequent disability.

“Specific techniques have been advocated to reduce the load on the back,” write Kari-Pekka Martimo, from the Finnish Institute of Occupational Health in Helsinki, Finland, and colleagues. “Earlier reviews on occupational interventions have questioned the role of education in the prevention of work related back pain. Even though primary studies have found no effect of training on the incidence of back pain, this could be incidental or caused by small sample size.”

The goal of this systematic review was to determine whether advice and training regarding lifting techniques and use of lifting equipment prevent back pain in jobs that involve heavy lifting. Results of studies comparing similar interventions were summarized and combined in a meta-analysis with use of odds ratios and effect sizes. The review authors compared the conclusions of the primary and secondary analyses.

“There is no evidence to support use of advice or training in working techniques with or without lifting equipment for preventing back pain or consequent disability,” the review authors write. “Either the advocated techniques did not reduce the risk of back injury or training did not lead to adequate change in lifting and handling techniques. . . . The findings challenge current widespread practice of advising workers on correct lifting technique.”

Limitations of this review were varied measurement of the outcomes in the primary studies, inability to extract the data needed from all studies, and the need to adjust the results of most of the studies for the effect of cluster randomization that was not considered by the authors of these studies.

“Many health professionals are involved in training and advising workers on lifting and handling,” the review authors conclude. “Even though there may be other reasons to continue this practice, this review does not provide evidence that it prevents back pain. . . . We need a better understanding of the causal chain between exposure to biomechanical stressors at work and the subsequent development of back pain to enable the development of new and innovative ways to prevent back pain.”

The Commonwealth of Australia as represented by and acting through the Department of Employment and Workplace Relations supported this review. In an accompanying editorial, Niels Wedderkopp, MD, PhD, from Funen Hospital in Funen, Denmark, and Dr. Charlotte Leboeuf-Yde, DC, MPH, PhD, from the University of Southern Denmark in Odense, Denmark, suggest that randomized clinical trials of nonspecific low back pain should be suspended because they include so many different types of back pain that the results are difficult to interpret.

“The commonly given advice to patients to stay at work and be as physically active as possible may not be appropriate for people whose work involves heavy lifting and who have a history of recurrent back pain and several periods of sick leave,” May Not Improve Prevention of Back Pain
Drs. Wedderkopp and Leboeuf-Yde write. “Continuing heavy manual work in their job and increasing leisure time physical activity may not be a good idea as no clearly effective treatment is available. A change of job and (prudently) staying active in daily life may be the best way for these patients to regain command of their back and their occupation.”

BMJ. Published online February 1, 20026

Insoles as Prevention of Back Pain
Tali Safar MD in a new systematic review from the Cochrane Collaboration found no evidence that insoles prevent non-specific low back pain and couldn’t come to a conclusion regarding their role in the treatment of back symptoms. This conclusion stands in contrast to laboratory studies suggesting that insoles may offer some protection against spinal problems by keeping the foot in beneficial alignment and shock absorption. Overall Safar et al found that there is strong evidence that the use of insoles does not prevent back pain among asymptomatic subjects who began wearing these orthotics. One study suggested that insoles might reduce pain while increasing symptoms in the legs. They concluded by stating that there is a need for good studies of the effect of insoles on existing or recurrent back pain, so that recommendations can be made with a greater certainty.

Sahar et al. Insoles for prevention and treatment of back pain. Cochrane Database Systematic Review, 2007; 4;CD005275.

American College of Preventive Medicine Does Not Recommend Prostate Cancer Screening
Information is not adequate to recommend screening men for prostate cancer with digital rectal examination or measurement of prostate-specific antigen (PSA), according to a position statement by the American College of Preventive Medicine (ACPM) published in the February issue of the American Journal of Preventive Medicine.

“Prostate cancer is the leading cancer in U.S. men, and the third leading cause of cancer deaths,” write Lionel S. Lim, MD, MPH, FACP, from the Griffin Hospital (Lim) in Derby, Connecticut, and colleagues from the ACPM Prevention Practice Committee. “Principal screening tests for detection of asymptomatic prostate cancer include digital rectal examination (DRE) and measurement of the serum tumor marker, prostate-specific antigen (PSA). There are risks and benefits associated with prostate cancer screening.”

Although randomized controlled trials (RCTs) of screening for prostate cancer with digital rectal examination and PSA are limited to 2 previously published studies, 2 additional large-scale RCTs are currently ongoing. This review evaluated the efficacy of digital rectal examination and PSA for prostate cancer screening based on medical literature published before July 2007. In clinical practice, applications of PSA screening tests include (1) a PSA cutoff value of 4 ng/mL, (2) age-specific PSA, (3) PSA velocity, (4) PSA density, and (5) percent free PSA.

Although prostate cancer screening can diagnose the disease in its early stages, thereby potentially decreasing morbidity and mortality, the benefits of prostate cancer screening remain unproved, pending findings from RCTs currently in progress. At present, no conclusive data demonstrate that early screening, detection, and treatment reduce mortality.

Other suggested potential benefits of screening include reassurance of being at low risk for prostate cancer and the fact that PSA can be easily obtained with a simple blood test and is widely available. Potential harms of screening for prostate cancer include potential adverse health effects associated with false-positive and negative results and adverse effects of treatment. Other limitations of screening are that a survival benefit from prostate cancer screening has not been proved in rigorous trials.

A false-positive result from prostate cancer screening could lead to increased anxiety, as well as the discomfort and possible complications of biopsy, such as pain, hematospermia, hematuria, or infection. Conversely, false reassurance from a false-negative test could delay the diagnosis of prostate cancer. Even for true-positive screening results, there may be harms because prostate cancer may be slow growing, never advancing, or progress to cause significant disease or death and because of short-term and long-term adverse effects of treatment, such as pain, urinary incontinence, and impotence.

“The American College of Preventive Medicine concludes that there is insufficient evidence to recommend routine population screening with DRE or PSA,” the review authors write. “Clinicians caring for men, especially African-American men and those with positive family histories, should provide information about potential benefits and risks of prostate cancer screening, and the limitations of current evidence for screening, in order to maximize informed decision making.”

“Granted that prostate cancer is more likely to be found in high-risk men, issues pertaining to tumor grade have yet to be resolved (that is, optimal grade of tumor that a screening test should detect to confer a benefit in survival or morbidity), and there is still no evidence establishing effectiveness of screening in high-risk men,” the review authors conclude. “In the meantime, further studies are needed to establish the efficacy and optimal age at which prostate cancer screening should be initiated in these high-risk population groups.” According to the American Cancer Society, no major scientific or medical organization supports routine testing for prostate cancer at this time.

Am J Prev Med. 2008;34:164-170

Sweet Soft Drinks, Fructose Linked to Increased Risk for Gout
Gout is the most common inflammatory arthritis in men. Its prevalence has doubled in the United States within the past few decades and increased 61% from 1977 to 1997, the same period in which sugar-sweetened soft drinks represented the largest single source of calories in the US diet with yearly per capita use increasing from 0 to 29 kg. Fructose administration in humans is associated with a rapid increase in serum levels of uric acid, which are greater in those with gout. The study authors hypothesized that increased intake of sweetened fructosecontaining drinks was linked to the incidence of gout.

This is a prospective evaluation of the association between intake of sugar-sweetened soft drinks, juice, and fruit intake and the incidence of gout in a cohort of healthy men without a previous history of gout.

The goal of this 12-year follow-up study of health professionals was to assess the relationship between consumption of sugarsweetened soft drinks and fructose and the risk for incident gout in a cohort of 46,393 men with no history of gout at enrollment. Validated food frequency questionnaires were used to determine intake of soft drinks and fructose. These associations were independent of dietary and other risk factors for gout, including body mass index, age, hypertension, diuretic use, alcohol intake, and history of chronic renal failure. There was no apparent relationship between diet soft drinks and risk for incident gout (P for trend = 0.99).

The impact of aerobic fitness on functioning in chronic back pain
Despite lack of convincing evidence that reduced aerobic fitness is associated with chronic back pain (CBP), exercise programs are regarded as being effective for persons with non-specific CBP. It is unsure whether gain in aerobic fitness following intervention is associated with functioning improvement in persons with CBP. The objective of this prospective cohort study was to study the impact of aerobic fitness on functioning in persons with CBP, at baseline and following 3-week intensive interdisciplinary intervention. This study included persons who had passed 8 weeks of sick-listing because of back pain (n = 94) and were referred to a 3-week intensive biopsychosocial rehabilitation program. Aerobic fitness was assessed with a sub-maximal bicycle test at baseline, at admission to and discharge from the rehabilitation program, and at 6 months follow-up. Contextual factors, body function, activity and participation were evaluated before and after intervention. In addition, working ability was recorded at 3-years follow-up. At baseline aerobic fitness was reduced in most subjects, but improved significantly following intervention. Baseline measurements and intervention effects did not differ among the diagnostic sub-groups. Neither contextual factors nor functioning at baseline were associated with aerobic fitness. Increase in aerobic fitness was not associated with improvements in functioning and contextual factors and work-return following intervention either. From this study they concluded that improvement of aerobic fitness seems of limited value as goal of treatment outcome for patients with CBP.

Wormgoor MEA, et al. European Spine Journal. April 2008; Vol. 17, No. 4, pp. 475-483

How Common is Back Pain in Women With Gastrointestinal Problems?
This study examined the relationship between back pain and gastrointestinal (GI) symptoms in a large scale population study with consideration of possible confounding factors. The authors employed a cross-sectional analysis of survey data from the Australian Longitudinal Study on Women’s Health was conducted using multinomial logistic regression to model 4 frequencies of back pain in relation to number of GI symptoms (including constipation, hemorrhoids, and other bowel problems). A total of 38,050 women from 3 age cohorts were included in analysis.

Results: After adjustment for confounding factors, the number of GI symptoms was significantly associated with back pain among all age cohorts. The study has identified a strong association between back pain and GI symptoms in women. Possible factors that may account for this relationship include referred pain through viscerosomatic convergence, altered pain perception, increased spinal loading when straining during defecation, or reduced support of the abdominal contents and spine secondary to changes in function of the abdominal muscles.

Smith MD, et al. The Clinical Journal of Pain. March/April 2008; Vol. 24, Iss. 3, pp. 199-203.

NSAID’s are no more effective than other drugs
LBP is a major health problem in western industrialized countries, causing significant disability, morbidity, and healthcare expenditures. Although it usually improves spontaneously, LBP is often treated with NSAIDs, which are the most frequently prescribed medications throughout the world. Despite the underlying rationale for use of NSAIDs based on their analgesic and anti-inflammatory properties, evidence of efficacy in LBP is not clearly established.

Guidelines for the management of LBP in primary care settings recommend NSAIDs as a therapeutic option for symptomatic relief. Compared with nonselective NSAIDs, selective COX-2 inhibitors have a lower risk for gastrointestinal tract adverse effects, but there have been concerns regarding their cardiovascular safety. The present Cochrane review summarizes the available evidence regarding both traditional NSAIDs and selective COX-2 inhibitors in the management of LBP.

The review, published in the January 23 online issue of Cochrane Database of Systematic Reviews, also found that NSAIDs had more adverse effects than placebo and acetaminophen but fewer effects than muscle relaxants and narcotic analgesics. In addition, evidence from the review suggests that no one NSAID is clearly more effective than another.

NSAIDs are the most frequently prescribed medication worldwide, the review authors note. Current guidelines recommend the prescription of an NSAID as an option for symptomatic relief in the management of LBP. Most guidelines recommend NSAIDs as a treatment option after paracetamol has been tried. Goals for NSAID therapy include symptomatic relief and facilitation of early return to normal activities.

The review found moderate evidence that NSAIDs are not much more effective than other drugs for acute LBP and have more adverse effects than paracetamol. “This review suggests that NSAIDs are effective for short term global improvement in patients with acute and chronic LBP without sciatica, although the effects are small,” said Dr. Roelofs ( the study’s lead reviewer).

Cochrane Database Syst Rev. Published online January 23, 2008.

Patterns of sick-leave and health outcomes in injured workers with back pain
Little is known about the sick-leave experiences of workers who make a workers’ compensation claim for back pain. The authors objective was to describe the 1-year patterns of sick-leave and the health outcomes of a cohort of workers who make a workers’ compensation claim for back pain. They studied a cohort of 1,831 workers from five large US firms who made incident workers’ compensation claims for back pain between January 1, 1999 and June 30, 2002. Injured workers were interviewed 1 month (n = 1,321), 6 months (n = 810) and 1 year (n = 462) following the onset of their pain. They described the course of back pain using four patterns of sick-leave: (1) no sick-leave, (2) returned to worked and stayed, (3) multiple episodes of sick-leave and (4) not yet returned to work. They described the health outcomes as back and/or leg pain intensity, functional limitations and health-related quality of life. They analysed data from participants who completed all follow-up interviews (n = 457) to compute the probabilities of transition between patterns of sick-leave. A significant proportion of workers experienced multiple episodes of sick-leave during the 1-year follow-up. The proportion of workers who did not report sick-leave declined from 42.4% at 1 month to 33.6% at 1 year. One year after the injury, 2.9% of workers had not yet returned to work. Workers who did not report sick-leave and those who returned and stayed at work reported better health outcomes than workers who experienced multiple episodes of sick-leave or workers who had not returned to work. Almost a third of workers with an incident episode of back pain experience recurrent spells of work absenteeism during the following year. Their data suggested that stable patterns of sickleave are associated with better health.

Cote P, et al. European Spine Journal. April 2008; Vol. 17, No. 4, pp. 484-493