Insufficient evidence for load as the primary cause of non-specific (chronic) low back pain. A scoping review

OBJECTIVE: To assess the causal role of the relationship between loading and the onset of nonspecific low back pain (NSLBP) and persistence of NSLBP (chronic low back pain [CLBP]). DESIGN: Scoping review. LITERATURE SEARCH: We searched the literature from 2010 until May 2021 using a combination of terms related to (spinal) load and the Bradford-Hill (BH) criteria. STUDY SELECTION CRITERIA: Operational definitions were developed for every criterion of the BH framework for causality. Study selection was based on the causal role of load in the onset of NSLBP and persistence of chronic low back pain. DATA SYNTHESIS: The BH criteria were operationalized, and causation was considered established when evidence supported the BH criteria strength, temporality, biological gradient, experiment, and biological plausibility. RESULTS: Twenty-two studies were included. There was no consistent support for an association between load and the incidence of NSLBP, or that more load increased the risk of NSLBP/CLBP. Half of the studies did not support specific load exposures to increase incidence of or increase pain in NSLBP/CLBP. Half of studies did not support load preceding NSLBP. No study supported plausible biological explanations to influence the relationship between load and NSLBP/CLBP, or that similar causes have similar effects on NSLBP. Nine of 10 experimental studies did not support that load results in NSLBP or that relieving load reduces NSLBP/CLBP. CONCLUSION: There was insufficient evidence to support a causal relationship between loading and the onset and persistence of NSLBP/CLBP based on the BH criteria. These results question the role of load management as the only/primary strategy to prevent onset and persistence of NSLBP/CLBP. J Orthop Sports Phys Ther 2024;54(3):1-15. Epub 25 January 2024. doi:10.2519/jospt.2024.11314.