{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,6]],"date-time":"2026-02-06T06:29:18Z","timestamp":1770359358451,"version":"3.49.0"},"reference-count":60,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2025,11,14]],"date-time":"2025-11-14T00:00:00Z","timestamp":1763078400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JFMK"],"abstract":"<jats:p>Background: Firefighters are at elevated risk of low back pain (LBP), yet predictors, mechanisms, and interventions for LBP in this occupation remain poorly defined. The purpose of this study was to systematically review the literature and synthesize the evidence on functional biomarkers associated with the risk of LBP in firefighters. Methods: PubMed, EMBASE, CINAHL, and PEDro were searched for studies evaluating functional biomarkers in firefighters with or without LBP, including aerobic capacity, anthropometric measures, disability\/kinesiophobia, functional work tasks\/capacity, imaging\/structural\/morphological characteristics, kinematics, movement quality\/range of motion, muscular fitness, overall physical fitness, physical activity. Empirical evidence statements were generated for each biomarker domain, under Protocol Registration PROSPERO (CRD420251010061). Results: Eighteen studies (n = 32,977) met inclusion criteria and were predominantly cross-sectional (14\/18) with fair quality (13\/18), which suggests a substantial risk of bias. Higher disability\/kinesiophobia and poorer functional work task performance were linked to increased risk of LBP, although causal relationships cannot be determined. Associations for the eight other biomarkers were inconsistent. Two interventional studies demonstrated benefits from trunk-focused exercise. Conclusions: The literature examining functional biomarkers and LBP in firefighters is fragmented, which precludes making robust and broad clinical recommendations for evidence-based implementation. Findings of future research may ultimately lead to approaches to improve the safety and health of firefighters with LBP through patient-centered and tailored programs addressing integrated functional biomarkers across the continuum of prevention, clinical care, and resilience development.<\/jats:p>","DOI":"10.3390\/jfmk10040441","type":"journal-article","created":{"date-parts":[[2025,11,14]],"date-time":"2025-11-14T16:46:22Z","timestamp":1763138782000},"page":"441","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Functional Biomarkers Associated with Risk of Low Back Pain in Firefighters: A Systematic Review"],"prefix":"10.3390","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0048-2498","authenticated-orcid":false,"given":"John M.","family":"Mayer","sequence":"first","affiliation":[{"name":"The Vert Mooney Research Foundation (dba U.S. Spine & Sport Foundation), San Diego, CA 92074, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mina","family":"Botros","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, Rochester, NY 14642, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elizabeth","family":"Grace","sequence":"additional","affiliation":[{"name":"Edward G. Miner Library, University of Rochester Medical Center, Rochester, NY 14642, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1273-5499","authenticated-orcid":false,"given":"Ram","family":"Haddas","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, Rochester, NY 14642, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,11,14]]},"reference":[{"key":"ref_1","unstructured":"International Association of Fire Fighters (IAFF), and International Association of Fire Chiefs (IAFC) (2018). The Fire Service Joint Labor Management Wellness-Fitness Initiative, IAFF. [4th ed.]."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Guidotti, T.L. (2016). Injury, musculoskeletal disorders, and ergonomics. Health Risks and Fair Compensation in the Fire Service, Springer.","DOI":"10.1007\/978-3-319-23069-6"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1016\/j.shaw.2022.03.009","article-title":"Musculoskeletal model for assessing firefighters\u2019 internal forces and occupational musculoskeletal disorders during self-contained breathing apparatus carriage","volume":"13","author":"Wang","year":"2022","journal-title":"Saf. Health Work"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1002\/ajim.10200","article-title":"Cause, type, and workers\u2019 compensation costs of injury to fire fighters","volume":"43","author":"Walton","year":"2003","journal-title":"Am. J. Ind. Med."},{"key":"ref_5","first-page":"11","article-title":"Firefighters & back injuries: The new study","volume":"4","author":"Verna","year":"2010","journal-title":"Fire Rescue Mag."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e582","DOI":"10.1097\/JOM.0000000000001993","article-title":"Comparison of supervised and telehealth delivery of worksite exercise for prevention of low back pain in firefighters: A cluster randomized trial","volume":"62","author":"Mayer","year":"2020","journal-title":"J. Occup. Environ. Med."},{"key":"ref_7","first-page":"e62189","article-title":"Comparison between disability, physical performance, and other biopsychosocial factors in full-duty career firefighters working with and without current low back pain","volume":"16","author":"Mayer","year":"2024","journal-title":"Cureus"},{"key":"ref_8","first-page":"2057","article-title":"Identification and prevention strategies for musculoskeletal injuries among firefighters: A rapid review","volume":"81","author":"Teegardin","year":"2025","journal-title":"Work"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1249\/JSR.0b013e31821a9fec","article-title":"Firefighter fitness: Improving performance and preventing injuries and fatalities","volume":"10","author":"Smith","year":"2011","journal-title":"Curr. Sports Med. Rep."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1505","DOI":"10.1002\/oby.20436","article-title":"Obesity and incident injury among career firefighters in the central United States","volume":"21","author":"Jahnke","year":"2013","journal-title":"Obesity"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1093\/occmed\/kqs232","article-title":"Economic benefit of the PHLAME wellness programme on firefighter injury","volume":"63","author":"Kuehl","year":"2013","journal-title":"Occup. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/1745-6673-2-3","article-title":"Core strength: A new model for injury prediction and prevention","volume":"2","author":"Peate","year":"2007","journal-title":"J. Occup. Med. Toxicol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e13","DOI":"10.1097\/JOM.0000000000002418","article-title":"Comprehensive assessment of implementation factors related to worksite exercise in firefighters","volume":"64","author":"Lane","year":"2022","journal-title":"J. Occup. Environ. Med."},{"key":"ref_14","first-page":"6","article-title":"Implementation of a regional firefighter wellness initiative during a global pandemic","volume":"2","author":"Mayer","year":"2021","journal-title":"Fire Eng."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2368","DOI":"10.1016\/S0140-6736(18)30489-6","article-title":"Prevention and treatment of low back pain: Evidence, challenges, and promising directions","volume":"391","author":"Foster","year":"2018","journal-title":"Lancet"},{"key":"ref_16","unstructured":"National Research Council (US) and Institute of Medicine (US) Panel on Musculoskeletal Disorders and the Workplace (2001). Chapter 6. Biomechanics. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities, National Academies Press."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1426","DOI":"10.1080\/00140139.2019.1657183","article-title":"Spine loading during laboratory-simulated fireground operations\u2014Inter-individual variation and method of load quantification","volume":"62","author":"Beach","year":"2019","journal-title":"Ergonomics"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"478","DOI":"10.7326\/0003-4819-147-7-200710020-00006","article-title":"Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society","volume":"147","author":"Chou","year":"2007","journal-title":"Ann. Intern. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"CPG1","DOI":"10.2519\/jospt.2021.0304","article-title":"Interventions for the management of acute and chronic low back pain: Revision 2021","volume":"51","author":"George","year":"2021","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"807","DOI":"10.1016\/j.jpain.2015.05.005","article-title":"Fifteen years of explaining pain: The past, present, and future","volume":"16","author":"Moseley","year":"2015","journal-title":"J. Pain"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"402","DOI":"10.2519\/jospt.2019.8489","article-title":"Neuroplasticity of sensorimotor control in low back pain","volume":"49","author":"Brumagne","year":"2019","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"932","DOI":"10.2519\/jospt.2016.0609","article-title":"Unraveling the complexity of low back pain","volume":"46","author":"Caneiro","year":"2016","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Khoshakhlagh, A.H., Al Sulaie, S., Mirzahosseininejad, M., Yazdanirad, S., Orr, R.M., Laal, F., and Bamel, U. (2024). Occupational stress and musculoskeletal disorders in firefighters: The mediating effect of depression and job burnout. Sci. Rep., 14.","DOI":"10.1038\/s41598-024-55468-w"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1016\/j.shaw.2025.04.003","article-title":"Work exposome and related disorders of firefighters: An overview of systematized reviews","volume":"16","author":"Descatha","year":"2025","journal-title":"Saf. Health Work"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"918","DOI":"10.1016\/j.spinee.2010.07.389","article-title":"NASS contemporary concepts in spine care: Spinal manipulation therapy for acute low back pain","volume":"10","author":"Dagenais","year":"2010","journal-title":"Spine J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"552","DOI":"10.1016\/j.spinee.2018.08.011","article-title":"Low back pain in persons with lower extremity amputation: A systematic review of the literature","volume":"19","author":"Highsmith","year":"2019","journal-title":"Spine J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1177\/08901171221112571","article-title":"Relationship of healthy building determinants with back and neck pain: A systematic review","volume":"37","author":"Gherscovici","year":"2023","journal-title":"Am. J. Health Promot."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"929","DOI":"10.1016\/j.spinee.2023.02.020","article-title":"Spine patient care with wearable medical technology: State-of-the-art, opportunities, and challenges: A systematic review","volume":"23","author":"Haddas","year":"2023","journal-title":"Spine J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_30","unstructured":"Bureau of Labor Statistics. U.S. Department of Labor (2025, April 10). Occupational Outlook Handbook: Firefighters, Available online: https:\/\/www.bls.gov\/ooh\/protective-service\/firefighters.htm."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2817","DOI":"10.1097\/01.brs.0000190448.69091.53","article-title":"Incidence and course of low back pain episodes in the general population","volume":"30","author":"Cassidy","year":"2005","journal-title":"Spine"},{"key":"ref_32","unstructured":"Occupational Safety and Health Administration (1999). OSHA Technical Manual TED 01-00-015 [TED 1-0.15A]."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1660","DOI":"10.1097\/BRS.0000000000001061","article-title":"2015 updated method guideline for systematic reviews in the Cochrane Back and Neck Group","volume":"40","author":"Furlan","year":"2015","journal-title":"Spine"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1929","DOI":"10.1097\/BRS.0b013e3181b1c99f","article-title":"2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group","volume":"34","author":"Furlan","year":"2009","journal-title":"Spine"},{"key":"ref_35","unstructured":"U.S. National Heart Lung and Blood Institute (2021, November 18). The National Institutes of Health NIH Quality Assessment Tools, Available online: https:\/\/www.nhlbi.nih.gov\/health-topics\/study-quality-assessment-tools."},{"key":"ref_36","unstructured":"Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence Working Group (2025, April 09). The Oxford 2011 Levels of Evidence. Available online: https:\/\/www.cebm.net\/wp-content\/uploads\/2014\/06\/CEBM-Levels-of-Evidence-2.1.pdf."},{"key":"ref_37","unstructured":"Clinical Information Access Portal (CIAP) (2021, November 11). Introduction to Evidence-Based Practice and CIAP: Grading Levels of Evidence, Available online: https:\/\/www.ciap.health.nsw.gov.au\/training\/ebp-learning-modules\/module1\/grading-levels-of-evidence.html."},{"key":"ref_38","unstructured":"Cochrane Collaboration (2025, October 28). Webinar: Identifying Publication Bias in Meta-Analyses of Continuous Outcomes. Available online: https:\/\/www.cochrane.org\/events\/identifying-publication-bias-meta-analyses-continuous-outcomes."},{"key":"ref_39","unstructured":"Oxford Centre for Evidence-Based Medicine (2025, April 23). Resources: EBM Guides and Practical How to\u2019s for Researchers, Clinicians, Students and Teachers. Available online: https:\/\/www.cebm.ox.ac.uk\/resources."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1016\/j.jclinepi.2010.04.026","article-title":"GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables","volume":"64","author":"Guyatt","year":"2011","journal-title":"J. Clin. Epidemiol."},{"key":"ref_41","first-page":"269","article-title":"Strength and fitness and subsequent back injuries in firefighters","volume":"21","author":"Cady","year":"1979","journal-title":"J. Occup. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1177\/2165079917709020","article-title":"Predictors of back pain in firefighters","volume":"66","author":"Damrongsak","year":"2018","journal-title":"Workplace Health Saf."},{"key":"ref_43","first-page":"365","article-title":"Spine pain in the firefighter profession","volume":"69","author":"Kurkowska","year":"2018","journal-title":"Med. Pr. Work. Health Saf."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Garc\u00eda-Heras, F., Guti\u00e9rrez-Arroyo, J., Le\u00f3n-Guere\u00f1o, P., Carballo-Leyenda, B., and Rodr\u00edguez-Marroyo, J.A. (2022). Chronic pain in Spanish wildland firefighters. J. Clin. Med., 11.","DOI":"10.3390\/jcm11040989"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"e35179","DOI":"10.1097\/MD.0000000000035179","article-title":"Investigation and analysis of training injury and its psychological effects on firefighters in Beijing: A cross-sectional study","volume":"102","author":"Gong","year":"2023","journal-title":"Medicine"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1007\/s11332-013-0167-4","article-title":"Work-related risk factors for low back pain in firefighters. Is exercise helpful?","volume":"10","author":"Katsavouni","year":"2014","journal-title":"Sport Sci. Health"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1080\/10803548.2016.1219149","article-title":"Nationwide firefighter survey: The prevalence of lower back pain and its related psychological factors among Korean firefighters","volume":"23","author":"Kim","year":"2017","journal-title":"Int. J. Occup. Saf. Ergon."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1080\/10803548.2019.1608061","article-title":"Associations between lower back pain and job types in South Korean male firefighters","volume":"27","author":"Kim","year":"2021","journal-title":"Int. J. Occup. Saf. Ergon."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"650","DOI":"10.1080\/00140139.2023.2236821","article-title":"Low back pain and biomechanical characteristics of back muscles in firefighters","volume":"67","author":"Kong","year":"2024","journal-title":"Ergonomics"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1097\/JOM.0b013e318249202d","article-title":"Body mass index as a predictor of firefighter injury and workers\u2019 compensation claims","volume":"54","author":"Kuehl","year":"2012","journal-title":"J. Occup. Environ. Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1093\/oxfordjournals.aje.a116707","article-title":"Work activities and the onset of first-time low back pain among New York City fire fighters","volume":"137","author":"Nuwayhid","year":"1993","journal-title":"Am. J. Epidemiol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"282","DOI":"10.2519\/jospt.1994.19.5.282","article-title":"Injury and proprioception in the lower back","volume":"19","author":"Parkhurst","year":"1994","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Ras, J., Soteriades, E.S., Smith, D.L., Kengne, A.P., and Leach, L. (2023). Association between physical fitness and musculoskeletal health in firefighters. Front. Physiol., 14.","DOI":"10.3389\/fphys.2023.1210107"},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Ras, J., Soteriades, E.S., Smith, D.L., Kengne, A.P., and Leach, L. (2024). Evaluation of the relationship between occupational-specific task performance and measures of physical fitness, cardiovascular and musculoskeletal health in firefighters. BMC Public Health, 24.","DOI":"10.1186\/s12889-023-17487-6"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"18","DOI":"10.3928\/19425864-20190724-01","article-title":"The relationship between fear avoidance beliefs and low back pain in firefighters","volume":"13","author":"Stassin","year":"2021","journal-title":"Athl. Train. Sports Health Care"},{"key":"ref_56","unstructured":"Sackett, D.L., Strauss, S.E., Richarson, W.S., Rosengerg, W., and Haynes, R.B. (2000). Evidence-Based Medicine: How to Practice and Teach EBM, Churchchill Livingstone. [2nd ed.]."},{"key":"ref_57","doi-asserted-by":"crossref","unstructured":"Alsubaie, A.M., Mazaheri, M., Martinez-Valdes, E., and Falla, D. (2023). Is movement variability altered in people with chronic non-specific low back pain? A systematic review. PLoS ONE, 18.","DOI":"10.1371\/journal.pone.0287029"},{"key":"ref_58","doi-asserted-by":"crossref","unstructured":"Schmid, S., Bangerter, C., Schweinhardt, P., and Meier, M.L. (2021). Identifying motor control strategies and their role in low back pain: A cross-disciplinary approach bridging neurosciences with movement biomechanics. Front. Pain Res., 2.","DOI":"10.3389\/fpain.2021.715219"},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Shokouhyan, S.M., Davoudi, M., Hoviattalab, M., Abedi, M., Bervis, S., Parnianpour, M., Brumagne, S., and Khalaf, K. (2020). Linear and non-linear dynamic methods toward investigating proprioception impairment in non-specific low back pain patients. Front. Bioeng. Biotechnol., 8.","DOI":"10.3389\/fbioe.2020.584952"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"1889","DOI":"10.1007\/s00586-022-07253-4","article-title":"Compensatory biomechanics and spinal loading during dynamic maneuvers in patients with chronic low back pain","volume":"31","author":"Nyayapati","year":"2022","journal-title":"Eur. 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