Functional Biomarkers Associated with Risk of Low Back Pain in Firefighters: A Systematic Review

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.