Introduction:
Low back pain (LBP) is one of the most common musculoskeletal disorders in the general population. It is a major cause of disability that affects working performance. (1, 2) About 60-70% of the population will suffer from LBP at least once in their lifetime. (3) LBP prevalence increases and peaks between the ages of 35 to 55 years old. (3) Approximately 20-44% of LBP patients can be found in the working population, and they usually have recurrent episodes within one year. (4) There are various conservative treatments for the management of LBP such as medication, acupuncture, massage and physical therapy. Lumbar support is an additional tool, which is prescribed widely by physicians and physical therapists for treating and preventing LBP.
Lumbar supports are used commonly in the management of LBP and also utilized in the workplace to prevent low-back pain injuries. (5) Lumbar supports affect the restriction of lumbar spinal movement, increase spine stabilization, decrease mechanical load on the trunk and increase intra-abdominal pressure. (6) Lumbar supports are provided as a treatment for people suffering from LBP, with the aim of decreasing impairment and disability.
Previous systematic reviews (7, 8) reported limited evidence of lumbar supports being more effective than no treatment at all, and more high quality researches on the effectiveness of lumbar support are needed. However, more such researches have been published over the past 10 years. Therefore, this study reviewed up-to-date studies on the effectiveness of lumbar support. Furthermore, no information had been found on efficient clinical application (dosage) of lumbar support usage in the management of LBP. Therefore, this review was interested in collecting suitable clinical applications of lumbar support for LBP.
The objectives of this systematic review were to explore the effectiveness and clinical applications of lumbar support in the management of LBP.
Methods
Related studies were searched through electronic databases, including PubMed, Science Direct and Scopus, from January 1995 to December 2017. The keywords used were “lumbar support, lumbar belt, back support, back belt” and “back pain, lumbar pain and backache”. The search was carried out by using individual keywords with a combination of Boolean Logics (AND). In addition, studies that were published in English only were considered for inclusion in this study.
Criteria for considering studies
Both randomized controlled and quasi-experimental trials were included for the review process.
Participants and interventions
The population of all studies consisted of subjects with non-specific LBP, and any type of lumbar support for treating LBP was included in this study. Studies that included subjects with specific LBP such as infection, cancer, scoliosis or fracture were excluded, and special types of lumbar supports for severe scoliosis and post lumbar surgery also were excluded.
Outcome measures
Studies that used related outcome measures for determining progression of LBP symptoms, such as pain intensity (Visual Analog Scale, Numerical Rating Scale), overall improvement (Numerical Rating Scale), quality of life (SF-36, SF-12), specific functional status of back pain (Oswestry disability questionnaire, Roland-Morris disability score, Quebec disability score), etc., were included in this study.
Methodological quality checking
Methodology quality was assessed by two independent assessors (DD and AP). A consensus method, with the agreement of a third independent assessor (PS) was used to resolve disagreements concerning the methodological quality assessment. Methodological quality of the studies was assessed by using the Physiotherapy Evidence Database (PEDro) scales, which are the listed criteria for the quality assessment of randomized controlled trials. Ten checklist items were considered for quality of the studies. The scales assessed randomization, allocation concealment, comparability at baseline, blinding of subjects, blinding of therapists, blinding of assessors, measurement of at least one key outcome obtained from more than 85% of the subjects initially allocated to groups, intention to treat analysis, between-group comparison tested statistically for at least one key outcome measure, and point and variability measures provided for at least one key outcome measure. Each criterion was scored as either positive or negative according to the definitions of the criteria. Validity items were scored as positive when available information regarding that item did not reveal any bias; and negative when no information was provided regarding that item, or the available information revealed bias. The PEDro scores were considered as excellent (9-10), good (6-8), fair (4-5) and poor (<4). (9)
Data extracted and analyzed
Data were extracted on characteristics of the study population (i.e. pathology, and stage of LBP), characteristics of the studied intervention (i.e. types of lumbar support, number of hours per day in which the subjects wore the lumbar support, and duration of the intervention period), adverse effects due to intervention, and final results from measuring the effectiveness of lumbar support in each outcome.
The levels of evidence were analyzed using an updated method of the guideline for systematic reviews proposed by van Tulder and colleagues. (10) The method of assessing accounts consistent of strong findings from multiple high quality studies; consistent multiple low quality studies or one moderately high quality study; and one limited low quality study; and inconsistent and conflicting findings among the studies.
Drawing a conclusion was based on high quality studies that reported the effectiveness of and suggestions for clinical application. Moreover, the details of related studies were clarified in tubular form.
Results
Study selection
The electronic database search resulted in a total of 297 studies; 88 were identified in PubMed, 28 in Science Direct and 181 in Scopus. After excluding duplicated studies, 162 were used to screen titles and abstracts, after which, 11 potentially relevant studies were assessed for the eligibility criteria. Finally, 8 studies were included in the review (Figure 1).
 |
Figure 1: Flow chart of the articles reviewed |
Methodological quality
Methodological quality of the selected studies was assessed by using the PEDro scales. Two reviewers (DD and AP) initially agreed on 77/88 (87.5%) items on the PEDro scales. All differences in the PEDro scales were resolved after discussion and consensus among the reviewers. The results of the quality scores, which ranged from 3/10 to 8/10, are shown in Table 1. Five studies (11-15) demonstrated good quality, two (16, 17) showed fair quality and one (18) had poor quality.
| Table 1: Methodological quality of studies on the effectiveness of lumbar support |
PEDro items |
van Poppel et al., 1998 |
Oleske et al., 2007 |
Roelofs et al., 2007 |
Calmels et al., 2007 |
Roelofs et al., 2010 |
Sato et al., 2012 |
Morrisette et al., 2014 |
Saito et al., 2014 |
1 |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
2 |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
3 |
N |
Y |
N |
N |
Y |
N |
Y |
N |
4 |
Y |
Y |
Y |
Y |
Y |
N |
Y |
Y |
5 |
N |
N |
N |
N |
N |
N |
N |
N |
6 |
N |
N |
N |
N |
Y |
N |
N |
N |
7 |
N |
Y |
Y |
N |
N |
N |
N |
N |
8 |
Y |
Y |
N |
Y |
N |
N |
Y |
N |
9 |
N |
Y |
Y |
Y |
Y |
N |
Y |
N |
10 |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
11 |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
Total |
5/10 |
8/10 |
6/10 |
6/10 |
7/10 |
3/10 |
7/10 |
4/10 |
| Note: Item 1 related to the external validity (as the Pedro criteria did not include the total score) |
Study characteristics
Study characteristics are summarized in Table 2. Of the eight studies, six (11-15, 17) were randomized controlled and two (16, 18) quasi- experimental.
| Table 2: Characteristics of the studies |
Study |
Participants |
Interventions |
Outcomes |
Results |
Note |
van Poppel et al. 1998 |
Workers whose jobs included manual material handling.
Exclusion criteria: subjects who had a permanent partial work disability
172 subjects with previous LBP, 49 subjects with LBP at baseline
N = 312
Female, Male = N/A
Age = 35.1 ± 7.8 yrs |
1) Lumbar support (LS) + education
2) LS *use LS during working hours.
3) Education: lifting instruction
4) Control
*6 months |
LBP incidence, sick leave due to back pain |
No difference in LBP incidence and sick leave between groups after 6 months |
Subjects in the subgroup with LBP at baseline, LS reduced number of days with LBP/month (median; 1.2 vs 6.5 days/month, p = .03)
Compliance with wearing LS for at least half of the time was 43%.
No adverse event
|
Oleske et al. 2007 |
Workers who had non-traumatic work-related low back disorder (within 8 weeks)
Exclusion criteria: subjects who had other work-related conditions
N = 433
Female = 20.1%, Male = 79.9%
Age = 46.1 ± 7.6 yrs |
1) LS + education
*use LS during working hours
2) Education
*12 months |
Pain intensity, disability level, physical health, mental health, recurrence, lost working time, medical care utilization |
Significant decreases in pain, disability and neurogenic symptoms, and increase in physical health in both groups. Over 12 months
LS + education had a lower likelihood of WR-LBD recurrence
No difference between groups in all outcomes
|
Working hours = 47.6 ± 13.7 hrs/wk (6-7 hrs/day)
Compliance in using LS: 78% using LS after 1 month, 51% using LS as instructed at the 12-month study visit
No adverse event
|
Roelofs et al. 2007 |
Home care workers with LBP symptoms at the time of inquiry or had experienced ≥ 2 episodes (≥ 2 consecutive days) of LBP in 12 months
Exclusion criteria: specific LBP (RA, fracture), pregnancy, receiving medical treatment for high back pain
N = 360
Female = 98%, Male = 2%
Age = 41.7 ± 9.7 yrs
|
1) LS + usual care
*use LS during working hours.
2) Usual care
*12 months |
Number of days with LBP, sick leave, severity of LBP, function |
Significant differences in number of days with LBP, pain intensity and function between groups |
Working hours = 25.3 ± 7.9 hrs/wk (5 hrs/day)
Compliance: 78% wore LS for at least one third of the total number of days with LBP, subjects wore LS 5.5 days/mo (90% of the number of days with LBP)
No adverse event
|
Calmels et al, 2009 |
Patients with subacute LBP 20–60 years of age.
Exclusion criteria: used LS during the last 6 months, neurological signs, suffered from LBP for 6 months Preceding inclusion: spinal surgery, pregnancy, unstable chronic cardiac/respiratory complaint, LBP with inflammation/tumor/infection
N = 197
Female = 45.2%, Male = 54.8%
Age = 43 ± 10.7 yrs
|
1) LS
*use LS during the whole day
2) Control
*3 months |
Function (EIFEL), pain intensity, overall cost of associated medical treatment |
LS group had higher decrease in EIFEL (d0, d30 and d90), lower VAS at d30 and d90, decreased medication intake at d90 |
Duration of wearing a belt
D30: 5 days/wk, 8 hrs/day
D60: 4 days/wk, 6 hrs/day
D90: 3 days/wk, 5 hrs/day
No adverse event
|
Roelofs et al. 2010 |
Home care workers with LBP symptoms at the time of inquiry or had experienced ≥ 2 episodes (≥ 2 consecutive days) of LBP in 12 months
Exclusion criteria: specific LBP (RA, fracture), pregnancy, receiving medical treatment for high back pain
N = 360
Female = 98%, Male = 2 %
Age = 41.7 ± 9.7 yrs
|
1) LS + usual care
*use LS during working hours.
2) Usual care
*12 months |
Number of days with LBP, sick leave, quality of life, direct and indirect costs |
LS group reported fewer day with LBP
No difference in sick leave or quality of life
Direct costs were lower in the LS group. |
Working hours = 5 hrs/day
No adverse event
|
Sato et al. 2012 |
Patients with chronic LBP (> 3 months)
Exclusion criteria: infection, osteoporosis, metastasis of malignant tumor, LE symptoms, neurological deficit
N = 50
Female = 50%, Male = 50%
Age = 30 – 78 yrs
|
1) Corset wearing group.
*use LS all day except at bath and bed time
2) Control group – received NSAIDs
*6 months |
Severity of LBP
Muscle endurance
Muscle fatigue |
Corset improved LBP and increased muscle endurance for a short period.
No difference in muscle fatigue |
No report of compliance or duration of wearing LS per day
No adverse event
|
Morrisette et al. 2014 |
Patients with acute, subacute and chronic LBP aged > 18 years
Exclusion criteria: spinal surgery, neurological disease, systematic inflammatory disease, pregnancy, fracture, tumor, infection, LE pain
N = 98
Female = 61%, Male = 39%
Age = 48.4 ± 15.3 yrs
|
1) Standard care – medication and physical therapy
2) Standard care + elastic LS
3) Standard care + inelastic LS
*2 weeks |
Disability, patient specific activity, pain, fear of avoidance questionnaire |
Standard care + inelastic LS showed greater improvement of ODI and specific activity than standard care only.
No difference between 1) & 2) and 2) & 3) |
Chronic LBP 64%
Mean wearing time for eLSO = 4.8 hrs/day, 78% wear daily
For iLSO = 5 hrs/day, 62% wear daily
No adverse event |
Saito et al. 2014 |
Nurses with LBP (NRS ≥ 3) at least once a week for the past 3 months
Exclusion criteria: LE pain, spinal surgery, psychiatric disorders, mental disorders
N = 144
Female = 93.75%, Male = 6.25%
Age = 39.5 ± 11 yrs |
1) Wear-type LS
2) Traditional LS
*use LS all of the time except for bath and bed time in 1st month, then worn when LBP occurs
*3 months |
Quality of life, disability, severity of LBP, number of days with LBP |
Significant decrease in pain severity, number of days with LBP in both groups over time, no difference between groups over time |
Duration of wearing LS
1st month: SW 9 hrs/day
LS 6 hrs/day
2nd mo: SW 7 hrs/day
LS 5 hrs/day
3rd mo: SW 6 hrs/day
LS 4 hrs/day
No adverse event
|
Effects of lumbar support
Lumbar support versus control comparisons
One good quality randomized controlled trial (RCT) (11) compared the effect of lumbar support with no intervention at all. The result showed a significant improvement in LBP and disability in the lumbar support group. There was limited evidence of lumbar support being more effective than no intervention at all. Four studies (12, 14, 15, 18) compared the effect of lumbar support with usual care. Three of them had a good quality RCT (12, 14, 15) and the other one had a poor quality quasi-experimental study.(18) Roelofs et al. (14, 15) demonstrated that lumbar support groups showed greater improvement in the severity of LBP and disability than the usual care group. Lumbar support also significantly reduced the number of days with LBP over a 12-month period and direct costs related health care. There was no difference in sick leave or quality of life. Morrisette et al. (12) found that receiving usual care while wearing an inelastic lumbar support significantly improved disability and patient specific activity when compared with usual care alone. There was no difference between elastic and inelastic lumbar support and usual care. Sato et al. (18) also found that lumbar support can reduce the severity of LBP more effectively than pharmacological consumption. There was strong evidence that lumbar support with usual care was superior to usual care alone. One good (13) and one fair quality RCT (17) compared the effect of lumbar support with education. Oleske et al. (13) found that both lumbar support and education could decrease pain and disability and increase physical health after 12 months of intervention. In addition, van Poppel et al. (17) reported the subgroup analysis of subjects with LBP at baseline. Lumbar support can reduce the number of days with LBP per month when compared to no lumbar support. However, both studies demonstrated no significant difference between groups in all outcomes. There is moderate evidence that lumbar support plus education is no more effective than education alone.
Comparison of different types of lumbar support
One RCT (12) and one quasi-experimental study (16) compared the effects of different types of lumbar support. Morrisette et al. (12) compared the effects of elastic and inelastic lumbar support. They found that using inelastic lumbar support for 2 weeks significantly improved functional ability, while there was no improvement in the elastic lumbar support group. Saito et al. (16) studied a new type of lumbar support (wear-type support) and the traditional one, and both types showed significantly decreased pain severity and number of days with LBP, but there was no significant difference between the two groups. There is limited evidence to show which types of lumbar support are more effective than the others.
Clinical application of lumbar support
Population
Two studies (11, 16) were performed in subacute LBP. Calmels et al. (11) found that wearing lumbar support significantly improved functional status, pain level and pharmacologic consumption. Results from Saito and colleagues (16) reported a decrease in pain intensity and number of days with LBP after wearing lumbar support. There was limited evidence of lumbar support being effective for subacute LBP. One study (18) on chronic LBP showed that wearing lumbar support can decrease its severity, but there is limited evidence of lumbar support being effective for this condition. Four studies (12-15) had mixed duration of LBP, and all of them demonstrated positive effects of wearing lumbar support. There is strong evidence that lumbar support is effective in populations with various durations of LBP. Another study (17) gave no information on the duration of LBP.
Prescriptions for wearing lumbar support
The obvious protocol for wearing lumbar support was not given in any of the selected studies. Four of them (13-15, 17) prescribed lumbar support for their participants to wear during working hours. A study by van Poppel et al. (17) reported that subjects with LBP at baseline had a reduced number of days with LBP per month, while Oleske et al. (13) and Roelofs et al. (14, 15) demonstrated that using lumbar support during working hours can reduce pain intensity and direct costs of health care, and increase functional ability. Three studies (11, 16, 18) prescribed lumbar support for their participants to wear for the whole day except at bath and bed time. LBP symptoms were improved in all of the studies. One study (12) did not give any information on how long to wear lumbar support. However, three studies (11, 12, 16) demonstrated the average hours for wearing lumbar support from records of the participants, which were about 6–8 hours daily. Calmels et al. (11) demonstrated that their participants wore lumbar support for 8, 6 and 5 hours per day in the 1st, 2nd and 3rd month, respectively. That study found an improvement in LBP and disability after the 1st month of follow up. Morrisette et al. (12) showed an average wearing time of 4.8 and 5 hours daily for elastic and inelastic lumbar support, respectively. Saito et al. (16) demonstrated that the average time for wearing lumbar support was 6, 5 and 4 hours per day in the 1st, 2nd and 3rd month, respectively. That study also found an improvement in LBP after the 1st month.
Duration of the intervention period
Three trials (13-15) studied the effects of using lumbar support in workers for 12 months. All of them found that lumbar support reduced pain intensity, disability and costs of health care. In addition, the rate of LBP recurrence also was lower in workers who wore lumbar support. (13) Two trials (17, 18) studied the effects of using lumbar support for 6 months. A study by van Poppel and colleagues (17) reported that subjects who had LBP at baseline and received lumbar support recorded less number of days with LBP per month. Sato and colleagues (18) also found an improvement in LBP after wearing lumbar support for 6 months. Two trials (11, 16) studied the effect of using lumbar support for 3 months, and both demonstrated continual improvement in pain intensity and functional status from the 1st month of follow up and on through each time point. Morrisette and colleagues (12) studied the effects of using lumbar support for 2 weeks, with the inelastic lumbar support group showing significant improvement in disability, but no change was shown in the elastic lumbar support group.
Adverse effects
No adverse events were reported in any of the identified studies.
Discussion
Selection bias
Although there is a well-defined search strategy for identifying studies on the effectiveness of lumbar support, some may have been missed in this study. Missing studies may be in other databases or unpublished sources (e.g., theses) that were inaccessible.
Methodologic quality
The methodologic quality was assessed by the two reviewers, who were not blinded to the authors or journals. Potential bias from the non-blinded assessment was expected to be low because the major reviewers (AP and PS) were professional in the field of LBP and familiar with the literature. The other one (DD) was a layperson in the field of LBP.
Internal validity criteria were used to assess the methodologic quality of the eligible studies by referring to their characteristics, which may be related to bias. The methodologic quality of the studies used seemed to be high. Five of the eight studies, which scored in the range of 6/10 to 8/10, were of good quality, while the other 3 studies scored lower than 6/10, which was considered as poor to fair quality. All of the 8 studies used the proper method of randomization. Among 6 randomized controlled trial studies, only 3 described a method of concealment. Blinding of subjects in the efficacy studies of lumbar support is very difficult. Blinding of assessors, which is an important criterion, was reported in only 2 studies. However, most of the outcome measures in the eligible studies were subjective, and blinding of assessors may not be necessary.
Effectiveness of lumbar support
Overall, this review has conflicting evidence of effective use of lumbar support in the management of LBP, which mostly agrees with previous reviews. (7, 8) However, in comparisons of lumbar support with other treatments, results showed strong evidence that lumbar support with usual care is more effective than usual care alone in the management of LBP. This result was different from a previous review by van Duijvenbode and colleagues (7), which reported conflicting evidence that lumbar support is effective as additional treatment. This difference may be due to recent studies that considered the effectiveness of lumbar support as an additional treatment. There is moderate evidence that lumbar support with education is no more effective than education alone, and limited evidence that lumbar support is more effective than no intervention at all. These conflicting results may be a potential effect of overestimation because of bias from subjective outcomes. Further studies may be needed to evaluate the objective outcomes and confirm the effects of lumbar support. When considering the different types of lumbar support, there is limited evidence. A small number of the studies compared the different types of lumbar support.
Clinical application of lumbar support
The results of this review showed strong evidence that lumbar support is effective for studies with mixed duration of LBP, and this may be convenient for recruiting a large number of participants. A small number of studies researched subacute (11, 16) and chronic LBP,(18) with limited evidence of the effect of lumbar support for the former. There also was limited evidence of effectiveness in chronic LBP, which was from a poor quality study, and there has been no study regarding acute LBP. Therefore, it cannot be concluded that lumbar support is appropriate for a specific stage of LBP.
Three good quality studies (13-15) reported on wearing lumbar support during working hours, which averaged 5–7 hours per day. It may be assumed that wearing lumbar support for 5–7 hours daily affected improvement in pain and function. In addition, it also reduced the rate of LBP recurrence. However, compliance and duration of wearing lumbar support should be recorded by the participants. Of all the identified studies, three (11, 12, 16) demonstrated the duration of using lumbar support per day from records of the participants. After one month, the participants wore lumbar support for an average duration of 5-8 hours daily before the duration was decreased. When considering the results, the 1st month follow up showed the greatest improvement in pain and disability, followed by less change. This reduction of duration after 1-month of intervention may be associated with the improvement of symptoms.
Most of the trials identified (13-15, 17, 18) studied the effects of wearing lumbar support for a long period of time (6, 12 months) without intersection assessment. A suitable duration of wearing lumbar support for the management of LBP is unknown. Previous study (19) demonstrated that core muscle function was reduced after wearing lumbar support for eight weeks. Therefore, it may not be proper to wear lumbar support continuously for a long period of time. However, one good and one fair quality study demonstrated that pain and function can be improved at 1-month follow up.
Conclusion
The results of this study may not point out that lumbar support is superior in management of LBP, when compared to other treatments because the evidence was inconclusive. However, this review suggested that lumbar support seems to be effective as an additional intervention, together with usual care for the management of LBP.
Acknowledgments
The authors are pleased to acknowledge the Thailand Research Fund (TRF) for its funding.
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