A systematic review of workplace interventions to prevent low back pain. IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): Cluster randomised controlled trial study protocol Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life Individual work support for employed patients with low back pain: a randomized controlled pilot trial A pilot randomised control trial of the effectiveness of a biofeedback mouse in reducing self-reported pain among office workers Effectiveness of an at-work exercise program in the prevention and management of neck and low back complaints in nursery school teachers. Effectiveness of a Back Pain Prevention Program: A Cluster Randomized Controlled Trial in an Occupational Setting A Population‐Based, Randomized Clinical Trial on Back Pain Management Implementation of the Dutch Low Back Pain Guideline for General Practitioners: A Cluster Randomized Controlled Trial Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial Study protocol of effectiveness of a biopsychosocial multidisciplinary intervention in the evolution of non-speficic sub-acute low back pain in the working population: cluster randomised trial A multifaceted workplace intervention for low back pain in nurses' aides: a pragmatic stepped wedge cluster randomised controlled trial Lumbar supports for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Back Review Group. Cost effectiveness of a multi-stage return to work program for workers on sick leave due to low back pain, design of a population based controlled trial [ISRCTN60233560] Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences The effectiveness of participatory ergonomics to prevent low-back and neck pain--results of a cluster randomized controlled trial. Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.
A systematic review of r and omised controlled trials was undertaken to evaluate the effectiveness of  workplace interventions  to prevent low back pain .  Potential trials were located by a computerised search supplemented with citation tracking . The method ological quality of the trials was assessed on 11 criteria and the level of evidence for each intervention was determined , based upon the amount , consistency and quality of evidence from the trials . The review located 13 trials that were generally of moderate quality . The trials suggest that work place exercise is effective , braces and education are ineffective , and workplace modification plus education is of unknown value in preventing low back pain Background Evidence generated from reliable research is not frequently implemented into clinical practice . Evidence -based clinical practice guidelines are a potential vehicle to achieve this . A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines . Recommendations from this review , and other studies , have suggested the use of interventions that are theoretically based because these may be more effective than those that are not . An evidence -based clinical practice guideline for the management of acute low back pain was recently developed in Australia . This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common , has a high burden , and for which there is an evidence - practice gap in the primary care setting . Aim This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria , Australia . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray  , and improving mean level of disability for patients three months post-consultation . Methods / Design This study protocol describes the details of a cluster r and omised controlled trial . Ninety-two general practice s ( clusters ) , which include at least one consenting general practitioner , will be r and omised to an intervention or control arm using restricted r and omisation . Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion . An average of twenty-five patients per general practice will be recruited , providing a total of 2,300 patient participants . General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy . Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory . Investigators ( not involved in the delivery of the intervention ) , patients , outcome assessors and the study statistician will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN012606000098538 ( date registered 14/03/2006 ) Objective To evaluate the effectiveness of an integrated care programme , combining a patient directed and a workplace directed intervention , for patients with chronic low back pain . Design Population based r and omised controlled trial . Setting Primary care ( 10 physiotherapy practice s , one occupational health service , one occupational therapy practice ) and secondary care ( five hospitals ) . Participants 134 adults aged 18 - 65 sick listed for at least 12 weeks owing to low back pain . Intervention Patients were r and omly assigned to usual care ( n=68 ) or integrated care ( n=66 ) . Integrated care consisted of a workplace intervention based on participatory ergonomics , involving a supervisor , and a grade d activity programme based on cognitive behavioural principles . Main outcome measures The primary outcome was the duration of time off work ( work disability ) due to low back pain until full sustainable return to work . Secondary outcome measures were intensity of pain and functional status . Results The median duration until sustainable return to work was 88 days in the integrated care group compared with 208 days in the usual care group ( P=0.003 ) . Integrated care was effective on return to work ( hazard ratio 1.9 , 95 % confidence interval 1.2 to 2.8 , P=0.004 ) . After 12 months , patients in the integrated care group improved significantly more on functional status compared with patients in the usual care group ( P=0.01 ) . Improvement of pain between the groups did not differ significantly . Conclusion The integrated care programme substantially reduced disability due to chronic low back pain in private and working life . Trial registration Current Controlled Trials IS RCT N28478651 Objective : To investigate the feasibility and effectiveness of individual work support for employed patients with low back pain . Design : Pilot r and omized controlled trial of a 16-week vocational intervention with six-month follow-up . Setting : Community/outpatient . Participants : Fifty-one employed participants concerned about their ability to work due to low back pain . Outcome data was obtained for 38 participants at six-month follow-up . Interventions : The intervention group received up to eight individually targeted vocational sessions in conjunction with group rehabilitation for low back pain . The control group received group rehabilitation . Outcome measures : The feasibility of the intervention was assessed by the recruitment rate , drop-out and loss to follow-up of the participants and the content and delivery of the intervention as recorded by the research er . The primary outcome measure was perceived work ability . Results : Seventy-three participants were referred to the study over six months . Eighty-seven individual work support sessions were delivered . Thirty-one participants ( 61 % of those retained in the study ) attended more than half of the group rehabilitation sessions . The intervention was influenced by the uptake of group rehabilitation , the willingness of the participants to involve their workplace and of their workplace to involve the research therapist . The effect of the intervention on work ability was equivocal . Conclusions : Although it was possible to recruit participants and to deliver the intervention , considerable method ological problems were identified . However , even if these were addressed , the impact of such interventions is likely to be limited unless there is an integrated approach between healthcare , employers and employees . Further research is required to evaluate work-focused interventions with this client group A pilot study examined the effectiveness of a biofeedback mouse in reducing  upper extremity pain and discomfort in office workers ; in addition , relative mouse use ( RMU ) , satisfaction and the feasibility of running a r and omised controlled trial ( RCT ) in a workplace setting were evaluated . The mouse would gently vibrate if the h and was idle for more than 12 s. The feedback reminded users to rest the arm in neutral , supported postures . Analysis showed a statistically significant reduction in shoulder pain and discomfort for the intervention group at T2 ( 38.7 % lower than controls ) . Statistically significant differences in RMU time between groups were seen post intervention ( −7 % at T1 and + 15 % at T2 for the intervention group ) . Fifty-five percent of the intervention group was willing to continue using the mouse . It appears feasible to perform an RCT for this type of intervention in a workplace setting . Further study including more participants is suggested . Practitioner Summary : The study findings support the feasibility of conducting r and omised control trials in office setting s to evaluate ergonomics interventions . The intervention result ed in reduced pain and discomfort in the shoulder . The intervention could be a relevant tool in the reduction of upper extremity musculoskeletal disorder . Further research will better explain the study 's preliminary findings The aim of the study was to determine the effectiveness of an extension-oriented exercise program in the prevention and management of low back/neck pain in nursery school teachers . A Cluster R and omized Controlled Trial was utilized . Seventy-one nursery school teachers working in nine school buildings were r and omly divided into two groups , with each school as a unit of r and omization . All the teachers in both groups received an ergonomic brochure ; teachers in the experimental group also received an extension-oriented exercise program , conducted by a physical therapist . Data were collected at baseline and at a two-month follow-up . The primary outcome measure recorded was the level of disability ( Rol and Morris Disability Question naire and Oswestry Disability Index ) , while secondary outcome measure included the evaluation of cervical and lumbar physical discomfort ( Visual Analogue Scale ) . At follow-up , a significant improvement was registered in the experimental group as compared to the control group for all the outcomes evaluated . In conclusion an extension-oriented exercise program may be a useful strategy to prevent low back and neck complaints and to reduce consequent LBP functional disability among nursery school teachers Study Design . A cluster r and omized controlled trial and economic evaluation with a 12-month follow-up and with work department as the unit of r and omization . Objective . To evaluate the effectiveness of a prevention program for  low back pain ( LBP ) in an occupational setting with an economic evaluation . Summary of Background Data . LBP accounts for high economic costs in Western societies . Little is known on the effectiveness and related costs and savings of prevention programs for LBP . Methods . The study population consisted of workers in physically dem and ing jobs from 9 large companies located throughout The Netherl and s. In each company , 2 comparable work units were r and omly allocated , result ing in 18 clusters with 258 workers assigned to the intervention group and 231 workers to the control group . Results . Results in our study did not show significant differences in effects or costs savings of the program . Indirect costs related to work absence and productivity losses accounted for the majority ( 84 % ) of total costs due to LBP . Conclusions . This study provides no evidence for the adoption of this worksite prevention program for LBP Study Design . Population ‐based r and omized clinical trial . Objectives . To develop and test a model of management of subacute back pain , to prevent prolonged disability . Summary of Background Data . The present management of back pain seems inadequate , and development of innovative models has been urged . Methods . A model for the treatment of subacute work‐related back pain has been developed and evaluated in a population ‐based r and omized clinical trial . Workers ( n = 130 ) from eligible workplaces in the Sherbrooke area ( N = 31 ) , who had been absent from work for more than 4 weeks for back pain , were r and omized , based on their workplace , in one of four treatment groups : usual care , clinical intervention , occupational intervention , and full intervention ( a combination of the last two ) . The duration of absence from regular work and from any work was evaluated using survival analysis . Functional status and pain were compared at study entry and after 1 year of follow‐up . Results . The full intervention group returned to regular work 2.41 times faster than the usual care intervention group ( 95 % confidence interval 1.19‐4.89 ; P = 0.01 ) . The specific effect of the occupational intervention accounted for the most important part of this result , with a rate ratio of return to regular work of 1.91 ( 95 % confidence interval = 1.18‐3.10 ; P < 0.01 ) . Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups , compared with the trend in the usual care intervention group . Conclusions . Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practitioners in the intervention group ( n = 21 ) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners , a 2-hour educational and clinical practice workshop ; two scientific articles on low back pain management ; the guideline for occupational physicians ; a tool for patient education ; and a tool for reaching agreement on low back care with physical , exercise , and manual therapists . The control group ( n = 20 ) received no intervention . The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation . General practitioners completed registration forms of each individual consultation with regard to the main outcome measures : advice and information , referral to other health-care providers , and prescription of medication . Results . Forty-one of the 67 r and omized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain . The advice and explanation provided by the general practitioners , the prescription of paracetamol or nonsteroidal anti-inflammatory drugs , and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups . There were also no differences in overall referral rate . However , in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group . Conclusions . The multifaceted intervention strategy modestly improved implementation ( for parts of the recommendations in ) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management . The implementation strategy produced fewer referrals to therapists during follow-up consultations Background Evidence -based clinical practice guidelines may improve treatment quality , but the uptake of guideline recommendations is often incomplete and slow . Recently new low back pain guidelines are being launched in Denmark . The guidelines are considered to reduce personal and public costs . The aim of this study is to evaluate whether a complex , multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy . Methods / design In a two-armed cluster r and omised trial , 100 general practice s ( clusters ) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included . Practice s are r and omly allocated 1:1 to a simple or a complex implementation strategy . Intervention practice s will receive a complex implementation strategy , including guideline facilitator visits , stratification tools , and quality reports on low back pain treatment . Primary outcome is referral to secondary care . Secondary outcomes are pain , physical function , health-related quality of life , patient satisfaction with care and treatment outcome , employment status , and sick leave . Primary and secondary outcomes pertain to the patient level . Assessment s of outcomes are blinded and follow the intention-to-treat principle . Additionally , a process assessment will evaluate the degree to which the intervention elements will be delivered as planned , as well as measure changes in beliefs and behaviours among general practitioners and patients . Discussion This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice , and will provide insight on essential elements to include in future implementation strategies in general practice .Trial registration Registered as NCT01699256 on Clinical Trials.gov Background Non-specific low back pain is a common cause for consultation with the general practitioner , generating increased health and social costs . This study will analyse the effectiveness of a multidisciplinary intervention to reduce disability , severity of pain , anxiety and depression , to improve quality of life and to reduce the incidence of chronic  low back pain in the working population with non-specific low back pain , compared to usual clinical care . Methods / Design A Cluster r and omised clinical trial will be conducted in 38 Primary Health Care Centres located in Barcelona , Spain and its surrounding areas . The centres are r and omly allocated to the multidisciplinary intervention or to usual clinical care .  Patients between 18 and 65 years old ( n = 932 ; 466 per arm ) and with a diagnostic of a non-specific sub-acute low back pain are included .  Patients in the intervention group are receiving the recommendations of clinical practice guidelines , in addition to a biopsychosocial multidisciplinary intervention consisting of group educational sessions lasting a total of 10 hours . The main outcome is change in the score in the Rol and Morris disability question naire at three months after onset of pain . Other outcomes are severity of pain , quality of life , duration of current non-specific low back pain episode , work sick leave and duration , Fear Avoidance Beliefs and Goldberg Question naires . Outcomes will be assessed at baseline , 3 , 6 and 12 months . Analysis will be by intention to treat . The intervention effect will be assessed through the st and ard error of measurement and the effect-size . Responsiveness of each scale will be evaluated by st and ardised response mean and receiver-operating characteristic method . Recovery according to the patient will be used as an external criterion . A multilevel regression will be performed on repeated measures . The time until the current episode of low back pain takes to subside will be analysed by Cox regression . Discussion We hope to provide evidence of the effectiveness of the proposed biopsychosocial multidisciplinary intervention in avoiding the chronification of low back pain , and to reduce the duration of non-specific low back pain episodes . If the intervention is effective , it could be applied to Primary Health Care Centres . Trial Registration IS RCT Abstract This study established the effectiveness of a workplace multifaceted intervention consisting of participatory ergonomics , physical training , and cognitive – behavioural training ( CBT ) for  low back pain ( LBP ) . Between November 2012 and May 2014 , we conducted a pragmatic stepped wedge cluster r and omised controlled trial with 594 workers from eldercare workplaces ( nursing homes and home care ) r and omised to 4 successive time periods , 3 months apart . The intervention lasted 12 weeks and consisted of 19 sessions in total ( physical training [ 12 sessions ] , CBT [ 2 sessions ] , and participatory ergonomics [ 5 sessions ] ) . Low back pain was the outcome and was measured as days , intensity ( worst pain on a 0 - 10 numeric rank scale ) , and bothersomeness ( days ) by monthly text messages . Linear mixed models were used to estimate the intervention effect . Analyses were performed according to intention to treat , including all eligible r and omised participants , and were adjusted for baseline values of the outcome . The linear mixed models yielded significant effects on LBP days of −0.8 ( 95 % confidence interval [ CI ] , −1.19 to −0.38 ) , LBP intensity of −0.4 ( 95 % CI , −0.60 to −0.26 ) , and bothersomeness days of −0.5 ( 95 % CI , −0.85 to −0.13 ) after the intervention compared with the control group . This study shows that a multifaceted intervention consisting of participatory ergonomics , physical training , and CBT can reduce LBP among workers in eldercare . Thus , multifaceted interventions may be relevant for improving LBP in a working population STUDY DESIGN A systematic review of r and omized and nonr and omized controlled trials . SUMMARY OF BACKGROUND DATA Lumbar supports are used in the treatment of low back pain , but also to prevent the onset ( primary prevention ) or recurrences of a low back pain episode ( secondary prevention ) . OBJECTIVES To assess the effects of lumbar sup-ports for prevention and treatment of nonspecific low back pain .  METHODS The Medline , Cinahl , and Current Contents data bases ; the Cochrane Controlled Trials Register up to September 1999 ; and the Embase data base up to September 1998 were all search ed . References of identified trials and systematic review s were review ed and the Science Citation Index used to identify additional trials . Method ologic quality assessment and data extraction were performed by two review ers independently . A quantitative analysis was performed in which the strength of evidence was classified as strong , moderate , limited or conflicting , and no evidence . RESULTS Five r and omized and two nonr and omized preventive trials and six r and omized therapeutic trials were included in the review . Only 4 of the 13 studies were of high quality . There was moderate evidence that lumbar supports are not effective for primary prevention . No evidence was found on the effectiveness of lumbar supports for secondary prevention . The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment , whereas it is still unclear whether lumbar supports are more effective than other interventions for treatment of low back pain . CONCLUSIONS There continues to be a need for high quality r and omized trials on the effectiveness of lumbar supports . One of the most essential issues to tackle in these future trials seems to be the realization of adequate compliance Background To describe the design of a population based r and omized controlled trial ( RCT ) , including a cost-effectiveness analysis , comparing participative ergonomics interventions between 2–8 weeks of sick leave and Grade d Activity after 8 weeks of sick leave with usual care , in occupational back pain management . Methods Design : An RCT and cost-effectiveness evaluation in employees sick-listed for a period of 2 to 6 weeks due to low back pain . Interventions used are 1 . Communication between general practitioner and occupational physician plus Participative Ergonomics protocol performed by an ergonomist . 2 . Grade d Activity based on cognitive behavioural principles by a physiotherapist . 3 . Usual care , provided by an occupational physician according to the Dutch guidelines for the occupational health management of workers with low back pain . The primary outcome measure is return to work . Secondary outcome measures are pain intensity , functional status and general improvement . Intermediate variables are kinesiophobia and pain coping . The cost-effectiveness analysis includes the direct and indirect costs due to low back pain . The outcome measures are assessed before r and omization ( after 2–6 weeks on sick leave ) and 12 weeks , 26 weeks and 52 weeks after first day of sick leave . Discussion The combination of these interventions has been subject of earlier research in Canada . The results of the current RCT will : 1 . crossvali date the Canadian findings in an different sociocultural environment ; 2 . add to the cost-effectiveness on treatment options for workers in the sub acute phase of low back pain . Results might lead to alterations of existing (inter)national guidelines Abstract Objective : To evaluate effectiveness of an exercise programme in a community setting for patients with low back pain to encourage a return to normal activities . Design : R and omised controlled trial of progressive exercise programme compared with usual primary care management . Patients ' preferences for type of management were elicited independently of r and omisation . Participants : 187 patients aged 18 - 60 years with mechanical low back pain of 4 weeks to 6 months ' duration . Interventions : Exercise classes led by a physiotherapist that included strengthening exercises for all main muscle groups , stretching exercises , relaxation session , and brief education on back care . A cognitive-behavioural approach was used . Main outcome measures : Assessment s of debilitating effects of back pain before and after intervention and at 6 months and 1 year later . Measures included Rol and disability question naire , Aberdeen back pain scale , pain diaries , and use of healthcare services . Results : At 6 weeks after r and omisation , the intervention group improved marginally more than the control group on the disability question naire and reported less distressing pain . At 6 months and 1 year , the intervention group showed significantly greater improvement in the disability question naire score ( mean difference in changes 1.35 , 95 % confidence interval 0.13 to 2.57 ) . At 1 year , the intervention group also showed significantly greater improvement in the Aberdeen back pain scale ( 4.44 , 1.01 to 7.87 ) and reported only 378 days off work compared with 607 in the control group . The intervention group used fewer healthcare re sources . Outcome was not influenced by patients ' preferences . Conclusions : The exercise class was more clinical ly effective than traditional general practitioner management , regardless of patient preference , and was cost effective . Key messages Patients with back pain need to return to normal activities as soon as possible but are often afraid that movement or activity may be harmful An exercise programme led by a physiotherapist in the community and based on cognitive-behavioural principles helped patients to cope better with their pain and function better even one year later Patients ' preferences for type of management did not affect outcome Patients in the intervention group tended to use fewer healthcare re sources and took fewer days off work This type of exercise programme should be more widely OBJECTIVE The aim of this r and omized controlled trial ( RCT ) was to investigate the effectiveness of the Stay@Work participatory ergonomics ( PE ) program to prevent low-back and neck pain . METHODS A total of 37 departments were r and omly allocated to either the  intervention ( PE ) or control group ( no PE ) . During a six-hour meeting , working groups followed the PE steps and composed and prioritized ergonomic measures aim ed at preventing low-back and neck pain . Subsequently , working groups were requested to implement the ergonomic measures in the departments . The primary outcomes were low-back and neck pain prevalence and secondary outcomes were pain intensity and duration . Data were collected by question naires at baseline , and after 3- , 6- , 9- , and 12-months follow-up . Additionally , the course of low-back and neck pain ( transitions from no symptoms to symptoms and from symptoms to no symptoms ) was modeled . RESULTS The r and omization procedure result ed in 19 intervention departments ( N=1472 workers ) and 18 control departments ( N=1575 workers ) . After 12 months , the intervention was not more effective than the control group in reducing the prevalence of low-back and neck pain or reducing pain intensity and duration .  PE did not increase the probability of preventing low-back pain [ odds ratio ( OR ) 1.23 , 95 % confidence interval ( 95 % CI ) 0.97 - 1.57 ) or neck pain ( OR 1.01 , 95 % CI 0.74 - 1.40 ) . However , PE increased the probability of recovering from low-back pain ( OR 1.41 , 95 % CI 1.01 - 1.96 ) , but not from neck pain ( OR 0.95 , 95 % CI 0.72 - 1.26 ) . CONCLUSION PE neither reduced low-back and neck pain prevalence nor pain intensity and duration nor was it effective in the prevention of low-back and neck pain or the recovery from neck pain . However , PE was more effective in the recovery from low-back pain BACKGROUND The Royal College of General Practitioners ( RCGP ) has produced guidelines for the management of acute low back pain in primary care . AIM To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners ( GPs ) . DESIGN OF STUDY Group r and omised controlled trial , using the health centre as the unit of r and omisation . SETTING Primary care teams in north-west Engl and . METHOD Twenty-four health centres were r and omly allocated to an intervention or control arm . Practice s in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain , as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms . RESULTS Twenty-four centres were r and omised . Two thous and , one hundred and eighty-seven eligible patients presented with acute low back pain during the study period : 1049 in the intervention group and 1138 in the control group . There were no significant differences between study groups in the proportion of patients who were referred for X-ray , issued with a sickness certificate , prescribed opioids or muscle relaxants , or who were referred to secondary care , but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit ( difference in proportion = 12.2 % , 95 % confidence interval [ CI ] = 2.8 % to 21.6 % ) . CONCLUSION The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs . An increase in referral to physiotherapy or educational programmes followed the provision of a triage service
The trials suggest that work place exercise is effective , braces and education are ineffective , and workplace modification plus education is of unknown value in preventing low back pain
A systematic review of r and omised controlled trials was undertaken to evaluate the effectiveness of  workplace interventions  to prevent low back pain .