High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults.

BACKGROUND CONTEXT: Back problems (BPs), with their cost and disability, are a substantial burden for individuals, employers, and society. PURPOSE: This systematic review of controlled trials evaluates the effectiveness of interventions to prevent BP episodes in working age adults. DATA SOURCES: We searched MEDLINE/EMBASE through May 2007, and COCHRANE/Trials Registry through August 22, 2008 using search terms of back pain, back injuries or sciatica, linked to prevention, control, workplace interventions, or ergonomics and searched article bibliographies. STUDY SELECTION: For systematic review inclusion, articles had to describe prospective controlled trials of interventions to prevent BPs in working-age adults, with intervention assignment either to individual participants or preexisting groups. Of 185 articles identified as potentially relevant, 20 trials (11%) met inclusion criteria. DATA EXTRACTION: Researchers extracted relevant information from controlled trials and graded methodological quality. Because of heterogeneity of trials, meta-analysis was not performed. RESULTS: Only exercise was found effective for preventing self-reported BPs in seven of eight trials (effect size 0.39 to >0.69). Other interventions were not found to reduce either incidence or severity of BP episodes compared with controls. Negative trials included five trials of education, four of lumbar supports, two of shoe inserts, and four of reduced lifting programs. CONCLUSIONS: Twenty high-quality controlled trials found strong, consistent evidence to guide prevention of BP episodes in working-age adults. Trials found exercise interventions effective and other interventions not effective, including stress management, shoe inserts, back supports, ergonomic/back education, and reduced lifting programs. The varied successful exercise approaches suggest possible benefits beyond their intended physiologic goals. LEVEL OF EVIDENCE: Systematic review Level I evidence.

Chronic pain, depression, and the dexamethasone suppression test.

In most healthy individuals, dexamethasone suppresses adrenal cortisol production. However, in patients with major depression, non-suppression frequently occurs and thus may be a marker for depression. The purpose of the present study was to examine the relationship of dexamethasone suppression test (DST) non-suppression to clinical variables such as major depression, site and duration of pain, prior surgery, and medication use in 81 chronic pain patients beginning inpatient pain treatment (Inpt. Pain), and 33 medication-restricted outpatients with chronic back pain and depression (Outpt. Back). In the Inpt. Pain group, the specificity of DST non-suppression for depression was 82% and for sensitivity 24%. In the Outpt. Back group, its sensitivity was 18%. Within the diverse inpatient samples, there was 69% non-suppression in patients with headache pain only, compared to 15% in patients with other sites of pain (P less than 0.01), but there was no significant difference in depression rate between these two groups. In the Inpt. Pain group, non-suppressors also had significantly less prior surgery. In the Outpt. Back group, opioid use was significantly higher in non-suppressors (33%) than in suppressors (11%). In chronic pain populations, the DST appears not to be useful clinically for the detection of depression and may be significantly affected by clinical variables other than depression.