2. Effectiveness Of Back
Schools For Management
of
Chronic Low Back Pain
By: Venus Pagare

3.  Chronic Low back pain (LBP) is currently one of the major public
health problems
 Entails major socioeconomic consequences:
- direct costs caused by increased use of healthcare services
- indirect costs owing to back pain-related production losses
and
work absenteeism
 Changing view that back pain results from an interaction
between
physical, psychological, and social factors : Bio-psychosocial
3

4.  Many therapeutic interventions have been developed for
treatment of Chronic LBP
 Includes: educational programs, cognitive behavioural therapy,
medication, electrotherapy and thermotherapy, manual therapy,
and exercise
 Conservative treatment is gold standard
 To meet demand for treatment in a more effective and
economical way, new methods have been proposed
One such method is “The Low Back School”
4

5.  “Any form of educational program delivered in a group which
aims
to promote among participants : cognitive learning (knowledge
related to spine and back problems) and sensorimotor
learning
(mastery of motor skills) to reduce mechanical forces acting
on
spine”
 It is a class or series of classes designed to provide information
to back pain patients in a cost effective manner
 Prevention and Rehabilitation
Back School
5

6.  Original Swedish back school was introduced in 1969 by
Mariane Zachrisson Forssel
 To reduce pain and prevent recurrence of episodes of CLBP
and get
acutely injured worker back to work
 Consisted of information on anatomy of back, biomechanics,
optimal posture, ergonomic principles and common treatment
modalities
 Patients were taught how to protect spinal structures in daily
activities
HISTORY
6

7.  Later, exercises for maintenance of a “ healthy back” were
included, and back schools were incorporated in comprehensive
multidisciplinary programs
 Scheduled in four 45-minute sessions during a 2-week period
 Since then, content and length of back school programs have
changed and many different models have been proposed
7

8. The Canadian Back Education Units (CBEU)
 In 1974, Hall modified back school concept for chronic LBP
population
 Expanded scope of back school to include psychological
factors
 Class size ranges from 15 to 25
 Program is taught by a health care team:
orthopaedic surgeon,
physical therapist,
psychologist,
&
psychiatrist
8

9. The California Back School
 Developed by White in 1976
 Focuses on acute LBP patients
 Introduced concept of evaluating and training patients in
ergonomic concepts and physical training
 Highly individualized, with class size ranging from 1-4
 A physical therapist provides all instruction and training
 Students were treated individually in three weekly 90-minute
sessions and were observed in work simulation
9

10. The Miami Back School
 Started by Jackson in 1982
 Covers pathology, biomechanics, pain control,
emotional aspects, advice on exercise, practice in
body mechanics
Active Back School (ABS)
 Involves more practical training
 Consists of: 20 sessions over a period of 13 weeks
 2 sessions per week for first 7 weeks and
1 session per week for final 6 weeks
 Each lesson lasted 1 hour, divided into a didactic part
(20 min) and a practical training part (40 min)10
SPINE 1999

11. 11

12. Although various back schools may be different in their
content,
organization, time, they share common goals:
 Prevent occurrence of low back pain or reduce their
risk of recurrence
 Reduce risk of chronicity by addressing patient’s
beliefs and related behaviors
 Reduce anxiety and pain and its impact on everyday
life fear avoidance and kinesiophobia12
GOALS /
OBJECTIVES

13.  Reduce patient dependence on health care system
 Encourage active self-care; increased knowledge
concerning back, better body mechanics (work
techniques), and improved muscle strength
 Facilitate return to work for acute
 Provide group support to decrease anxiety and sense
of isolation
 Few authors cited reduction of amount or frequency of
low back pain as a goal13

14.  Inpatient / outpatient setting
 Can be instituted in a hospital PT department, a private
PT practice or in an industrial setting
 As primary treatment (limited or no cointervention) or
as part of a comprehensive rehabilitation program that
includes work-site visits, general physical conditioning
or work hardening
 Currently increased emphasis on prevention of LBP
Setting up a back
school
14

15.  As a primary preventive measure, persons without
back problems as part of their mandatory education
 As a secondary preventive measure for patients with
acute low back pain
PATIENT CATEGORY:
 Acute, chronic, postsurgical, and nonsurgical patients
can all benefit
 It can be determined who is most likely to benefit from
a back school approach
 Patients with intermittent episodes of pain are good
candidates
 Those with unremitting pain benefit less15

16.  Severity of pain does not correlate with outcome
 Duration of symptoms and prior surgery has no
influence
 Number of doctors consulted prior to back school is
inversely related to success
 Factors which preclude referral to a back school are
limited comprehension skills, drug dependence, and
serious psychiatric disorder
CONTENT
 Depends on target population
 Can be acute, chronic or industrial
16

17.  Acute: program should emphasize information
regarding problem and preventing recurrence via
proper body mechanics and aerobic exercises
 Chronic: emphasis on psychological factors and
coping skills in addition to acute content
 Industrial: program must be specific to job tasks
involved
FORMAT
 Automated slide-tape show to a live team presentation
with groups of patients, or one-on-one functional
training
 Financial resources and staff availability will influence17

18.  Many studies regarding efficacy of back schools have
been published for treatment of patients with LBP
 However, clinical results varied widely in literature and
efficacy of back schools remains controversial
18
LITERATURE
REVIEW

19. 19
 Only a few studies included had proper control and
measurement techniques
 Insufficient data exist recommending use of back
schools for patients with chronic LBP
 With regard to acute pain, reporting is more positive
 Further research is needed to investigate amount of
information participants retain, in addition to amount of
behavioral changes
 Until these two aspects have been studied thoroughly,
it cannot be known whether low back schools have
potential to reach their goals
Low Back Schools: A Critical Re
PHYS THER. 1987; 67:1375-13

20.  Back school can be effective when combined with a
work-site visit, cognitive-behavioral group therapy, or
an intensive physical training regimen
 When back schools are not combined with a
comprehensive program, outcome is no better than
effects of control group
 Efficacy was supported for treatment of pain and
physical impairments and for
education/compliance outcomes
 Work or vocational and disability outcomes did not
improve substantially
20
Efficacy of Comprehensive Rehabilitation
Programs and Back School for Patients With
Low Back Pain: A Meta-analysis
PHYS THER. 1995; 75:865-878.

21.  Moderate evidence that back schools, in an
occupational setting, reduce pain, and improve
function and return-to-work status, in short and
intermediate-term, compared to exercises,
manipulation, myofascial therapy, advice, or placebo
for patients with chronic and recurrent LBP
 However, future trials should improve methodological
quality and clinical relevance and evaluate cost-
effectiveness of back schools
21
Back schools for non-specific low-back pain
Cochrane Database Syst Rev 2011; 2

22.  Traditional reviews may not be adequate to draw
conclusions:
1. Content and length differ
- simple to multiple classes
- “mini” back school: teaches only body mechanics
such as lifting
and carrying
- a multidisciplinary team approach encompassing
many
disciplines, including orthopedic surgeons,
physiatrists,22
NEED FOR RECENT
ADVANCES

23. 2. Different study participants and settings
3. The way outcome efficacy was measured varied in
literature
- Many types of outcome measures: pain, frequency
of analgesic
use, re-turn to work, sick leave, disability, frequency
of
hospitalization and therapeutic exercises, patients’
satisfaction,
and psychologic status
4. Insufficient descriptions of back school interventions23

24. OBJECTIVE
 To review the evidence on effectiveness of Back
Schools in patients with Chronic Low Back Pain
 To identify patient population likely to benefit from back
school programs
 Identify most effective model of back school program
for treating patients with Chronic LBP
24

25. RECENT
STUDIES
25

26.  Databases searched:
PubMed, Cochrane Library,
Google scholar , Sage Pub online ,
Science Direct, PEDro, Free medical journals,
Medline, Proquest, EBSCO
 Searched Terms:
Back schools, Low Back Pain, Patient education,
swedish back school,
SEARCH
STRATEGIES
26

27.  Full text articles from 2007 to 2013
 Studies on any type of back school for low back pain
INCLUSION
CRITERIA
27

28. Total number of articles included = 6
Level of
evidence
Number of
articles
1a 1
1b 3
2b 1
4 1
ARTICLES
INCLUDED
28

29.  1a = Systematic Review of Randomized Controlled
Trials (RCTs)
 1b = RCTs with Narrow Confidence Interval
 1c = All or None Case Series
 2a = Systematic Review Cohort Studies
 2b = Cohort Study/Low Quality RCT
 2c = Outcomes Research
 3a = Systematic Review of Case-Controlled Studies
 3b = Case-controlled Study
 4 = Case Series, Poor Cohort Case Controlled
 5 = Expert Opinion
LEVEL OF EVIDENCE
29

30. 1
J.I. Brox, K. Storheim, M. Grotle, T.H. Tveito
et al.
Spine J
2007; 8 (6)
Systematic review of back schools,
brief education, and fear-avoidance
training for chronic low back pain
1a
30

31. OBJECTIVE:
 To assess effectiveness of back schools, brief
education, and fear-
avoidance training for chronic low back pain (CLBP)
METHODS:
 MEDLINE database of randomized controlled trials
(RCT) until
August 2006 for relevant trials reported in English
 RCTs that reported back schools, or brief education as
main intervention were included
Key Words: Back school; Brief education; Fear-31

32. OUTCOME MEASURES:
 Pain, disability, and sick leave
Results:
 7 systematic reviews were identified
 European Guidelines were included
 Eight RCTs evaluated back schools
32

33. 33
 Cochrane Review concluded that most of trials were of
low methodological quality
 Moderate evidence that back schools conducted in
occupational setting were more effective than other
treatments or controls
 European Guidelines: Conflicting evidence for
effectiveness of back schools compared with controls
 Back schools were more effective than other
treatments with regard to short-term, but not for long-
term effects on pain and disability

34. 34
 3 RCTs were of high quality
 Conflicting evidence for back schools compared with
placebo, usual care, and exercises
CONCLUSION:
 There is lack of consistent evidence regarding use of
back schools
 May be considered in occupational setting
 Back schools may play an important role in
multidisciplinary interventions

35. 2
Meng K et al
Clin J Pain 2011; 27(3)
Intermediate and Long-term Effects of a Standardize
Back School for Inpatient Orthopedic Rehabilitation
Illness Knowledge and Self-management Behavior
A Randomized Controlled Trial 1
b
35

36. OBJECTIVE:
 To evaluate a new back school that was developed
based on theories of health behavior, treatment
evidence, practice guidelines, and quality criteria for
patient education
METHOD:
360 patients were randomized to:
36
Intervention Group
New back school
Control Group
Traditional back school

37. INTERVENTION GROUP
 Biopsychosocial model back school program
 7 sessions of 55 minutes
 <15 participants
 Sessions led by a physiotherapist (5 sessions), an
orthopedist (1 session), and a psychologist (1 session)
 Combination of methods (short lectures, group
discussion, small group work, practice, and individual
work)
 Didactic materials included PowerPoint presentations,
flipcharts, handouts, and work sheets
37

38. 38
Contents:
 Basic knowledge about back pain (eg, epidemiology,
risk factors, therapy)
 Physical, psychological and social aspects
 Spine-related exercises (muscle training and active
stabilization)
 Promoting physical activity (eg, motivation, self-
regulation)

39. 39
TRADITIONAL BACK SCHOOL
 4 sessions of 55 minutes
 Led by a physiotherapist
 Correct back posture and movements as well as back
exercises and trained using a handout
 Knowledge about pain and coping was conveyed
 No limitation of group; about 60 people participated

40. 40
Contents:
 Basic illness information (eg, epidemiology, spine
anatomy, spine disorders, risk factors, diagnostics, and
treatment)
 Epidemiology, acute/chronic pain development and
pain perception, coping strategies
OUTCOME MEASURES:
 Primary : Illness knowledge on back pain and its
treatment
 Secondary: behavioral and health outcomes; physical
activity, back posture and movements, back exercises,
pain beliefs, pain coping strategies, pain intensity

41. 41
 Assessed at admission, discharge, and 6 and 12
months follow-up
RESULTS:
 Participants of IG showed superior knowledge about
chronic back pain and its treatment (primary outcome)
at discharge
 Small-to-medium effect among secondary self-
management behaviors, such as physical activity, back
exercises, back posture habits, and coping with pain,
after 6 and 12 months

42. CONCLUSION:
 A back school based on a biopsychosocial approach is
more
effective than a traditional back school regarding both
short-term and long-term outcomes
 Therefore, program may be recommended for
dissemination within
medical rehabilitation
42

43. 3
Cecchi F et al
Clin Rehab
2010; 24
Spinal manipulation compared with back
school
and with individually delivered
physiotherapy for
the treatment of chronic low back pain:
a randomized trial with one-year follow-up
1
b
43

44. OBJECTIVES:
To compare spinal manipulation, back school and
individual
physiotherapy in treatment of chronic LBP
METHODS:
210 patients with chronic, non-specific low back pain:
Back School
Individual
Physiothera
py
44
Spinal
Manipulatio
n

45. BACK SCHOOL
 All patients received a booklet with evidence-based,
standardized educational information on basic back
anatomy and biomechanics, optimal postures,
ergonomics and advice to stay active
 15 sessions; 1 hour each
 5 days/week, 3 consecutive weeks
 1st 5 : information and group discussions on back
physiology and pathology, with reassurance on benign
character of common low back pain45

46. 46
 Education in ergonomics at home and in different
occupational settings by slides and demonstrations.
 Next 10 sessions included relaxation techniques,
postural and respiratory group exercises, and
individually tailored back exercises
INDIVIDUAL PHYSIOTHERAPY
 Passive mobilization, active exercise,
massage/treatment of soft tissues

47. 47
SPINAL MANIPULATION
 Aim : restoring physiological movement in
dysfunctional vertebral segment(s) and consisted of
vertebral mobilization and manipulation, with
associated soft tissue manipulation, as needed
 4–6 manipulations (as required)
 Weekly sessions of 20 minutes each for a total of 4–6
weeks of treatment

48. OUTCOME MEASURES:
 Roland Morris Disability Questionnaire
 Pain Rating Scale
 Taken at baseline, discharge 3, 6, and 12 months
 Follow-up assessment also included report of low back
pain recurrences, low back pain-related use of drugs
RESULTS:
 Spinal manipulation showed a significantly lower
disability score on
discharge and at 3 follow-ups
48

49. 49
 No significant difference in pain rating scale between
back school and individual physiotherapy on discharge
and at 3 months follow-ups
 1 year later, all three groups maintained improvement
in Roland Morris Disability score and pain rating scale,
reduction in Spinal manipulation group being greater
followed by back school group
 Spinal manipulation group showed better results in low
back pain recurrences, low back pain-related use of
drugs followed by back school group

50. 50
CONCLUSION:
 Spinal manipulation provided better short and long-
term
improvement
 Back school showed superior results to individual
physiotherapy

51. 4
Tavafian SS, Jamshidi AR, Montazeri
A
Spine 2008; 33(15)
A Randomized Study of Back School in
Women With
Chronic Low Back Pain
Quality of Life at Three, Six, and Twelve Months
Follow-up
1
b
51

52. OBJECTIVE:
 To examine effects of back school program on quality
of life in
women with chronic low back pain
METHODS:
102 women were randomly allocated into:Back School Group
N= 50
Back school program +
Medication
Clinic Group
N= 52
Medication Only52

53. 53
BACK SCHOOL PROGRAM
 4-day, 5-session
 Knowledge, awareness, perceptions, skills and needs
of participants were initially assessed by a Focus
Group Discussion
 A PhD level educator assessed knowledge,
perceptions and beliefs of participants concerning
health, contributions of non-healthy behaviors to LBP
and motivated participants to adopt more healthy
behavior
 A clinical psychologist conducted psychological

54. 54
 A rheumatologist obtained health histories and
conducted back school classes, which included
anatomy and physiology of spine, natural history of
spinal conditions, lifestyle factors that accelerate CLBP
process, and techniques for preventing further injury
 Physiotherapist conducted classes to improve
knowledge and skills of participants in respect of
muscle stretching and strengthening and relaxing
exercises for back, abdomen and thighs
 Also educated people to maintain correct position of
back while walking, sitting, standing, sleeping and
bending

55. 55
 Data were collected at baseline and at 3, 6, and 12
months follow-up using SF-36 questionnaire
RESULT:
 Improvement in quality of life score was significantly
better among back school group compared with clinic
group
 Back school program had better short-term effects
 Decreasing quality of life score after 3 months, might
be related to loss of communications
CONCLUSION:
 Back school program might improve quality of life
score in women

56. 5
Maurice M et al.
Ann Phys Rehabil Med
2008; 51 (4)
Efficiency in the short and medium term
program of back school. Retrospective
cohort study of 328 chronic low back pain
conducted from 1997 to 2004
2
b
56

57. OBJECTIVE:
 Assess impact of a school program back to short and
medium
term in chronic low back pain
 Search predictors of effectiveness of back school
METHOD:
 Patients with CLBP were included
 Cohort consisted of 328 patients
 5 days in a department of physical medicine and
rehabilitation
57

58. 58
 Collective learning
 Physical activities : strengthening muscles (trunk and
lower limbs), stretching and initiation in cardio,
introduction to sports (badminton and basketball)
 Presentation of physical exercise
 4 hours of lectures given by a doctor of physical
medicine and rehabilitation on functions and anatomy
of spine, back pain and their causes and treatment
options
 Social worker and psychologist

59. OUTCOME MEASURES:
 Impact of low back pain evaluated by: quality of life
(VAS, 100 mm)
 Spine pain scale: French translation of the Dallas Pain
Questionnaire
 Evaluation of functional impact of LBP by physical
functional disability scale for assessment of low back
pain (EIFEL)
 In five days, only VAS pain, level of pain medication,
physical parameters were taken into account
 At six months, assessment was identical to that carried
out at entrance
 Number of days off work was calculated59

60. RESULTS :
 Results at 6 months showed an efficacy of back school
on pain and functional status
 However, it had little impact on quality of life
 Reduced duration of work stoppages without
decreasing frequency
 Being young and practice regular physical activity was
predictive of efficacy of back school
 Overweight, anxio-depression are disincentives to
program effectiveness
CONCLUSION :
 Back schools are effective in short-and medium-term
reduction in absenteeism, pain and improvement in
functional status.
60

61. 6
Yang EJ, Park WB, Shin HI, Lim JY
Am J Phys Med Rehabil Sept
2010;89(9)
The Effect of Back School Integrated
with Core Strengthening in Patients
with Chronic Low-Back Pain 4
61

62. OBJECTIVE:
 To assess effect of back school integrated with core-
strengthening
exercises on back-specific disability and pain-coping
strategies
 To examine how reactions to pain affect outcomes of
back school in patients with chronic low back pain
METHODS:
 142 participants with chronic low-back pain
 Group of 10 patients
62

63. 63
 Class lasted for 2 hrs/wk for 4 wks
 Intervention was based on a Swedish type of back
school that includes education on epidemiology,
anatomy, function of back, treatment modalities,
positions and ways to decrease physical strain, and
general methods for improving physical conditioning
 Practical guidance on core-stabilization exercises was
provided
 Program was performed by a rehabilitation team
consisting of physiatrists, physiotherapists, and

64. OUTCOME MEASURE:
 Primary: Modified Oswestry Low Back Pain Disability
Questionnaire
 Secondary: pain, coping responses, general health
status, and quantitative functional evaluations of
factors, such as trunk muscle strength,back mobility,
and endurance of core-stabilizing muscles
 Taken at : baseline and immediately after back school
program and at end of long-term follow up (3-6
months)64

65. 65
 28 subjects were used to analyze longitudinal
association between coping strategies and primary
outcome in a long-term follow-up study
 Participants were divided into 3 groups (much
improved, slightly improved, and unimproved) based
on changes in back-specific disability scores
RESULT:
 Participants improved significantly in terms of back-
specific disability, pain, general health, and quantitative
functional tests according to short-term evaluation

66.  More use of relaxation and exercise/stretching
techniques as coping strategies
 Nine patients (32%) were classified as much improved
after back school and this % increased at follow up to
43%
CONCLUSION:
 Back school program may help patients with chronic
low back pain reduce back-specific disability and pain
and develop wellness-focused coping strategies such
as exercise and stretching
66

67. Watch Out For….
Garcia AN et al
BMC Musculoskelet Disord
2011; 12
Effectiveness of the back school and
Mckenzie
techniques in patients with chronic non-
specific
low back pain: a protocol of a Randomised
Controlled Trial
1
b
67

68. 68
OBJECTIVE:
 To compare effects of McKenzie and Back School
techniques in patients with chronic low back pain
METHODS:
148 patients with chronic LBP will be randomly allocated
to
McKenzie
Back
School

69. 69
BACK SCHOOL
 4 treatment sessions, once/week
 1st session will be given individually
 Remaining 3 sessions in a group
 Program is divided based on Theoretical & Practical
information
MCKENZIE GROUP
 4 individual sessions, once per week, lasting 45
minutes – 1 hour
 Treatment will be provided in accordance with the
direction preference of movement

70. 70
OUTCOME MEASURES
 Pain intensity: NPRS
 Disability: Roland Morris Disability Questionnaire
 Quality of life: WHOQOL-Bref
 Trunk flexion ROM: Fleximeter
 Will be taken at 1, 3 and 6 months

71.  Biopsychosocial model back school program
 Didactic materials included PowerPoint presentations,
flipcharts, handouts, and work sheets
 Contents:
Anatomy and spinal biomechanics
Epidemiology
Patho-physiology of most frequent back
disorders
Posture;
IMPLICATIONS FOR
PRACTICE
71

72. Ergonomics
Common treatment modalities
Practical component (exercises esp. core
strengthening)
 Patients who are young and those involved in some
kind of regular physical activity
 Overweight and individuals with anxio-depression are
disincentives to program effectiveness
72

73.  Long-term follow up studies are needed
 Studies on predictors of effectiveness of back school
could be useful. It would define a target population for
which probability of success of this program would be
highest
 Randomized controlled trials and Meta-analysis are
required
 Multi-center studies need to be conducted
IMPLICATIONS FOR
RESEARCH
73