Public Health Wales / Primary and secondary prevention of
back pain
Healthcare Service Improvement Team
Primary and secondary prevention ofback pain
Author:Norma Prosser, Dr Mary Webb, Public Health Specialists
Date:11 June2010 / Version:1
Publication/ Distribution:
  • Public (Internet)

Review Date:A review of this document is not planned by Public Health Wales NHS Trust.
Purpose and Summary of Document:
The document has been produced to assist local health boards to implement the Commissioning Directive on Arthritis and Chronic Musculoskeletal Conditions, and should be read in conjunction with that publication.
This is an evidence-based summary of effective interventions for primary and secondary prevention of back pain.
No effective interventions have been identified from the available evidence.
Work Plan reference: HS02
Date: 11 June 2010 / Version:1 / Page: 1 of 8
Public Health Wales / Primary and secondary prevention of
back pain

CONTENTS

1Background

2Back pain

2.1Introduction

2.2Search methodology

2.3Prevalence

2.4Hospital admissions

3Primary prevention

4Secondary prevention

5Further information

6References

© 2010 Public Health Wales NHS Trust.

Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context.

Acknowledgement to Public Health Wales NHS Trust to be stated.

1Background

This document has been produced to assist local health boards to implement the Welsh Assembly Government’s, Designed for people with chronic conditions, Service development and commissioning directives, Arthritis and chronic musculoskeletal conditions1, and should be read in conjunction with that publication.

A key action identified in chapter 2, Prevention – reducing the risks (p.9)of the publication, is evidence-based primary and secondary prevention1. From the key categories identified in the commissioning directive (p.2), the aim in this document is the identification of currently available information and evidence-based literature with a focus on back pain.

To supplement the evidence–base, and provide an overview of the topic, information with regard to prevalence (where available); hospital admissions (where information is available from Patient Episode Database Wales - PEDW); and links to additional information resources have been included. The links to further information resources is included to indicate where additional details, or management and treatment guidance can be sought.

The information contained in this document is not exhaustive.

2Back pain

2.1Introduction

Back pain is a common condition and in the UK, it is the largest cause of work-related absence. Whilst it can be very uncomfortable, it is not usually serious2.

Back pain can have numerous causes, from mechanical back pain of uncertain cause, to serious underlying pathologies requiring specific diagnosis and urgent treatment. With information and advice, most back pain can be self managed, but some conditions including tumour, infection, and fracture due to trauma or inflammatory disease as in ankylosing spondylitis will require specific interventions1.

Acute low back pain (LBP) is usually defined as the duration of an episode of low back painpersisting for less than 6 weeks; sub-acute low back pain persisting between 6 and 12 weeks; chronic low back pain persisting for 12 weeks or more. Whilst this categorisation is convenient for clinical purposes, it is less helpful when considering the matter of prevention, where back pain and its consequences tend to occur sporadically3.

Most cases of lower back pain are known as non-specific because they are not caused by serious damage or disease, but by sprains, muscle strains, minor injuries or a pinched or irritated nerve2.

Common causes of back pain include2:

  • pregnancy;
  • gynaecological problems in women, such as pelvic inflammatory disease (PID);
  • different types of arthritis, such as osteoarthritis;
  • osteoporosis (weak and brittle bones);
  • bone disorders;
  • stress-related tension;
  • viral infections;
  • bladder and kidney infections;
  • a trip or fall;
  • a trauma or injury, such as a fracture;
  • lack of exercise;
  • obesity;
  • sleep disorders.

Back pain can also be triggered by everyday activities at home or work, and by poor posture, and may be caused by2:

  • bending awkwardly;
  • lifting, carrying, pushing or pulling incorrectly;
  • slouching in chairs;
  • standing or bending down for long periods;
  • twisting;
  • coughing;
  • sneezing;
  • muscle tension;
  • over-stretching;
  • driving in hunched positions;
  • driving for long periods without taking a break.

2.2Search methodology

Search terms used: primary prevention, secondary prevention, back pain.

Search terms were kept broad to maximise retrieval of literature and search limits set to retrieve papers published between January 2003 to January 2010.

Electronic databases: Medline; Embase; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central Register of Controlled Trials and British Nursing Index.

Meta search engines: Turning Research Into Practice (TRIP); Google Scholar; SUMsearch.

Websites: NHS Evidence; International Network of Agencies for Health Technology Assessment (INAHTA); National Institute for Health and Clinical Excellence (NICE); National Horizon Scanning Centre and Map of Medicine; UpToDate.

2.3Prevalence

Back pain can affect anyone, regardless of age, but it is more common in people who are between 35 and 55 years of age2, 3. During a lifetime 4 out of 5 people will suffer back pain.

2.4Hospital admissions

Figure 1: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of Back Pain (ICD-10, M50 & M54) by Unitary Authority.

Source: PEDW

Figure 2: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of Back Pain (ICD-10, M50 & M54) by Local Health Board.

Source: PEDW

Table 1: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of Back Pain (ICD-10, M50 & M54)

Local Health Board / Unitary Authority / Admissions
BetsiCadwaladrUniversity / Isle of Anglesey / 1172
Gwynedd / 1840
Conwy / 1490
Denbighshire / 1096
Flintshire / 1580
Wrexham / 1313
Powys / Powys / 1369
Hywel Dda / Ceredigion / 799
Pembrokeshire / 2372
Carmarthenshire / 3314
Abertawe Bro Morgannwg / Swansea / 2658
Neath Port Talbot / 1499
Bridgend / 1438
Cardiff and ValeUniversity / Vale of Glamorgan / 1574
Cardiff / 3346
Cwm Taf / Rhondda Cynon Taff / 3111
Merthyr Tydfil / 1003
Aneurin Bevan / Caerphilly / 2417
Blaenau Gwent / 1262
Torfaen / 1328
Monmouthshire / 1321
Newport / 1812
Total / 39114

Source: PEDW

3Primary prevention

Primary causative mechanisms of LBP remain largely undetermined and risk factor modification will not necessarily achieve prevention. The most promising approaches appear to involve physical activity/exercise and appropriate (biopsychosocial) education, at least for adults. National Institute for Health and Clinical Excellence (NICE) guidance4 for early management of persistent non-specific LBPstates that:-

  • no single intervention is likely to be effective to prevent the overall problem of LBP, owing to its multidimensional nature;
  • prevention in LBP is a societal as well as an individual concern;
  • optimal progress on prevention in LBP will likely require a cultural shift in the way LBP is viewed.

A recent systematic review did not find consistent evidence on the role of exercise in prevention of back pain5.

4Secondary prevention

NICE guidance4 recommends that people with non-specific LBP should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.

5Further information

Arthritis and Musculoskeletal Alliance

  • Standards of care for people with back pain.

Clinical Knowledge summaries

  • Back pain

Map of Medicine:

  • Acute low back pain;
  • Chronic low back pain;
  • Low back pain;

NICE

  • Early management of persistent non specific low back pain.CG88.2009.

Welsh Backs

6References

  1. Welsh Assembly Government. Designed for people with chronic conditions. Service development and commissioning directives. Arthritis and chronic musculoskeletal conditions.Cardiff: WAG;2007. Available at: [Accessed 18th Jan 2010]
  1. NHS choices. Your health, your choices. [Website]. Back pain. Available at: 18th Jan 2010]
  1. Cost B13 Working Group on Guidelines for Prevention in Low Back Pain. European guidelines for prevention in low back pain. 2004. Available at: 18th Jan 2010]
  1. National Institute for Health and Clinical Excellence. Low back pain: early management of persistent non-specific low back pain. CG88. London: NICE;2009. Available at: 18th Jan 210]
  1. Bell JA, Burnett A.Exercise for the primary, secondary and tertiary prevention of low back pain in the workplace: a systematic review.J Occup Rehabil2009;19:8-24

Date: 11 June 2010 / Version:1 / Page: 1 of 8