Faculty of Health Sciences, School of Physical Therapy, Western University, London, Ontario, Canada.
School of Health Sciences, Nursing and Emergency Services, Cambrian College, Sudbury, Ontario, Canada.
PLoS One. 2024 Aug 13;19(8):e0308625. doi: 10.1371/journal.pone.0308625. eCollection 2024.
Low back pain (LBP) is the leading global cause of years lived with disability. Of the biopsychosocial domains of health, social determinants of LBP remain under-researched. Socioeconomic status (SES) may be associated with the onset of new LBP or outcomes of acute LBP, with educational attainment (EA) being a key component of SES. The association between EA and LBP has yet to be the subject of a dedicated review and meta-analysis.
To review evidence of the association between EA and a) onset or b) outcomes of acute and subacute LBP in the adult general population and to conduct statistical pooling of data where possible.
An electronic search was conducted in MEDLINE, Embase, CINAHL, and ProQuest from inception to 2nd November 2023 including reference lists to identify relevant prospective studies. Risk of bias (RoB) was assessed using the Quality in Prognostic Studies (QUIPS) tool. Where adequate data were available, estimates were pooled using a random-effects meta-analysis. Overall evidence for each outcome was graded using an adapted GRADE.
After screening 8498 studies, 29 were included in the review. Study confounding and attrition were common biases. Data from 19 studies were statistically pooled to explore EA as a predictor of new LBP onset or as prognostic for outcomes of acute or subacute LBP. Pooled results showed no association between EA and the onset of new LBP (OR: 0.927, 95%CI: 0.747 to 1.150; I2 = 0%). For predicting outcomes of acute LBP, compared to those with no more than secondary-level education, post-secondary education or higher was associated with better outcomes of pain (OR: 0.538, 95%CI: 0.432 to 0.671; I2 = 35%) or disability (OR: 0.565, 95%CI: 0.420 to 0.759; I2 = 44%). High heterogeneity (I2>80%) prevented meaningful pooling of estimates for subacute LBP outcomes.
We found no consistent evidence that lower EA increases the risk of LBP onset. Lower EA shows a consistent association with worse LBP outcomes measured at least 3 months later after acute onset with inconclusive findings in subacute LBP. Causation cannot be supported owing to study designs. High-quality research is needed on potential mechanisms to explain these effects.
下背痛（LBP）是全球导致残疾年数最多的主要原因。在健康的心理社会领域中，社会决定因素对 LBP 的研究仍不够充分。社会经济地位（SES）可能与新发 LBP 或急性 LBP 的结局有关，而教育程度（EA）是 SES 的关键组成部分。EA 与 LBP 之间的关联尚未成为专门审查和荟萃分析的主题。
综述 EA 与成人普通人群中 a）新发或 b）急性和亚急性 LBP 结局之间关联的证据，并在可能的情况下对数据进行统计学汇总。
从 MEDLINE、Embase、CINAHL 和 ProQuest 进行电子检索，检索时间从建库到 2023 年 11 月 2 日，包括参考文献列表以确定相关的前瞻性研究。使用预后研究质量（QUIPS）工具评估偏倚风险（RoB）。在有足够数据的情况下，使用随机效应荟萃分析对估计值进行汇总。使用改编的 GRADE 对每个结局的总体证据进行分级。
在筛选了 8498 篇研究后，有 29 篇研究纳入了综述。研究混杂和失访是常见的偏倚。来自 19 项研究的数据进行了统计学汇总，以探讨 EA 作为新发 LBP 发病的预测因子或作为急性或亚急性 LBP 结局的预后因素。汇总结果显示，EA 与新发 LBP 的发病无关（OR：0.927，95%CI：0.747 至 1.150；I2=0%）。对于预测急性 LBP 的结局，与接受的教育程度不超过中学水平相比，接受过中学后教育或更高水平教育与疼痛（OR：0.538，95%CI：0.432 至 0.671；I2=35%）或残疾（OR：0.565，95%CI：0.420 至 0.759；I2=44%）结局的改善有关。高异质性（I2>80%）使得对亚急性 LBP 结局的估计值无法进行有意义的汇总。
我们没有发现一致的证据表明较低的 EA 会增加 LBP 发病的风险。较低的 EA 与急性发病后至少 3 个月时的 LBP 结局较差存在一致关联，但在亚急性 LBP 中结论不明确。由于研究设计，无法支持因果关系。需要高质量的研究来解释这些影响的潜在机制。
