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Back School

A back school is an intervention protocol consisting of an educational program and skills acquisition program, including physical exercises.

All the lessons are given to groups and are supervised by a medical specialist or a Physiotherapist.

The intensity and content of back schools however differ from patient to patient.

Back School was first introduced in 1969, by Zachrisson-Forsell by the name Swedish back school for treating patients with low-back pain (LBP). i.e for reducing pain and preventing recurrent episodes of low back pain

Since then the content of back schools has changed and appears to vary widely today.

Back schools for non-specific low-back pain. (Review)

Heymans et. al

Guidelines have been made and continuously updated to prevent back pain at the healthcare and workplace levels, and such guidelines are termed as ‘‘Back School’’

Back school: A simple way to improve pain and postural behaviour

The target population for back training: 

❑ Patients who have never had low back pain (primary intervention).

❑ Patients who have acute, chronic low back pain or with recurrent back pain

❑ Post-operative patients or patients with a disc prosthesis.

Goals of back school:

1. Functional recovery

2. Protect the spinal structures in daily

activities and in the occupational setting

3. Reduce symptoms (pain)

4. Increasing tissue repair

5. Decrease kinesiophobia 

To achieve these goals, the back school

consists of three parts:

1. Information

2. Systematic training

3. Active exercises

1.Information

➢about the anatomy and function of the spine,

➢spinal biomechanics,

➢pathology physiology back disorders,

➢epidemiology.

Now a days, this part of back school (giving

information) is limited as compared to the back

school in 1969

2. Systematic training in the back school

consist of

❖ proper posture,

❖ standing,

❖ lifting,

❖ bending,

❖ Lying and

❖ Sitting

The back school rules are different for the occupational settings.

Example 1. Sedentary work as a banker. A banker sits the whole day, so it’s

important he’s sitting in a correct way: When he   bends forward while sitting, the

intradiscal pressure is supposed to be twice as high as while standing.

The correct way of sitting: both feet supported on

the ground, situated below the knees

The waist is situated a little higher than the knees

and leaning with a straight back against the backrest.

It’s also important his worksheet is situated at a

correct height.

2. Lifting techniques in the building industry, childcare, healthcare etc

3. Active Exercises

Active protection of the spine by active exercises,

Example

A. Flank breathing versus diaphragmatic breathing: The pressure-changes in the abdomen resulting from diaphragmatic breathing causes some instability in the low back. Flank breathing maintains the tension in the abdominal muscles. (So there is no instability in the lower back).

B. Stretching of the lower limbs muscles

C. Stretching of the erector spinae muscles

D. Kinaesthetic training

(move pelvis making a front and back pelvic

inclination at a comfortable range)

B. S t r e n g t h e n i n g o f t h e a b d o m i n a l

musculature

(stabilizing function)

We teach patients correct posture and

movements, but it’s important that we must

not creating kinesiophobia in patients by

saying that a lot of movements and postures

are ‘dangerous’ for your back.

Without these movements, there is no change in pressure on the nucleus and no influx of water in the nucleus.

The literature shows a strong association between psychosocial and emotional factors and back pain. It even suggests that they have a greater influence on pain than physical factors.

Back and neck pain are related to mental health problems in adolescence. BMC Public Health. 2011;11:382. Rees CS et. al

Acquiring knowledge about the back is the first step towards adopting healthy postural habits to prevent back pain.

Effects of an educational back care program of Brazilian schoolchildren’ knowledge regarding back pain prevention.

Rev Bras Fisioter. 2012;16:128-33.

Foltran.et.al

✓S y s t e m a t i c R e v i e w 1 2011

✓RCT 3

2013

2011

2008

Back schools for non-specific low-back

pain.

Heymans et.al

Systematic Review

The Cochrane Library

Published on 2011

Search methods MEDLINE EMBASE databases and the Cochrane Central Register of Controlled Trials

Trials reported in English, Dutch, French or German.

The literature search : articles updated to November 2004.

O B J E C T I V E S

The objective of this systematic review was to determine if back schools are more effective than other treatments or no treatment for patients with non-specific LBP.

M E T H O D S

Criteria for considering studies for this review Types of studies Only randomized controlled trials (RCTs) were included. Nonrandomized trials were excluded.

Types of participants

Randomized controlled trials that included subjects with ✓nonspecific LBP, ✓aged 18 to 70 years, were included.

Low-back pain was defined as pain localised below the scapulae and above the cleft of the buttocks;

Non-specific indicated that no specific cause was detectable, such as, infection, neoplasm, metastasis, osteoporosis, rheumatoid arthritis, fracture, or inflammatory process.

Types of interventions

Randomized controlled trials in which one of the

treatments consisted of a back school type of

intervention were included.

A back school was defined as consisting of an

educational and skills acquisition program,

including exercises, in which all lessons were

given to groups of patients and supervised by a

therapist or medical specialist.

Types of outcome measures

Randomized controlled trials that measured at

least one of the four primary outcome

measures that are considered to be the most

important

for back pain: .

1. return to work,

2. pain (VAS),

3. a global measure of improvement (overall

improvement, proportion of patients recovered,

subjective improvement of symptoms), and

4. functional status (expressed on a back-specific

index, such as the Roland Disability

Questionnaire or the Oswestry Scale) were

included .

Physiological outcomes of physical examination, such as,

✓range of motion, ✓spinal flexibility, ✓degrees of straight leg raising ✓or muscle strength

were considered secondary outcomes, because these outcome measures may correlate poorly with the clinical status of the patient.

Other symptoms such as medication use and side effects were also considered.

The author did not do meta-analysis, but

summarized the results using a rating system

with four levels of evidence (best evidence

synthesis), based on the quality and the

outcome of the studies :

1. Strong evidence - provided by generally consistent findings in multiple high quality RCTs;

2. Moderate evidence - provided by generally consistent findings in one high quality RCT plus one or more low quality RCTs, or by generally consistent findings in multiple low quality RCTs;

3. Limited or conflicting evidence - only one RCT (either high or low quality) or inconsistent findings in multiple RCTs;

4. No evidence - no RCTs.

Effectiveness of back schools

1a) Back schools versus other treatments for acute/subacute LBP

Four RCTs

One high quality RCT reported positive intermediate and long-term outcomes, and

the other high and low quality studies reported no differences in short, intermediate and long-term out- comes between those receiving back schools and other treatments.

b) Back schools versus other treatments for chronic LBP

Six studies

Other conservative treatments were: ✓exercises, ✓spinal or joint manipulation, ✓myofascial therapy and ✓some kind of instructions or advice.

The high quality study and four low quality showed better short and intermediate- term pain relief and improvement in functional status for the back school group.

Three low quality studies did not find any differences in long-term out- comes.

There is moderate evidence that a back school is more effective than other treatments for patients with chronic LBP for the outcomes pain and functional status (short and intermediate-term follow-up).

There is moderate evidence that there is no difference in long-term pain and functional status between those receiving back school and other treatments, for patients with chronic LBP.

2a) Back schools versus waiting list controls or ’placebo’ interventions for acute/subacute LBP

Only one RCT compared back school with placebo, i.e., short- waves at the lowest intensity, for patients with acute and subacute LBP and showed better short-term recovery and return to work for the back school treatment group

There is limited evidence that back school is more effective than shortwaves at the lowest intensity for patients with acute and subacute LBP

2b) Back schools versus waiting list controls or ’placebo’ interventions for chronic LBP

Eight RCTs were identified for this subgroup analysis

Seven RCTs reported a mix of positive results, with no differences in short and intermediate-term outcomes.

One high quality study found positive long-term outcomes on functional status and return to work and two did not find any long-term differences.

There is conflicting evidence on the effectiveness of back schools compared to waiting list controls or placebo interventions on pain, functional status, and return to work for patients with chronic LBP.

3) Back schools in occupational settings

Nine studies –

three high quality studies and

six low quality studies included patients from an occupational setting.

3a) Back schools in occupational settings versus other treatments for acute/subacute LBP

Three studies, including two high quality studies, examined the effect of a back school compared to other treatments for acute and subacute patients.

One high quality study found positive intermediate and long-term results for the back school .

The other high and low quality RCTs found no short, intermediate or long-term differences between the back school and other treatments.

3b) Back schools in occupational settings versus other treatments for chronic LBP

Four

One RCT studied short and long-term differences

two studied, intermediate and long-term differences and

one study, only long-term differences.

There is moderate evidence that a back school is more effective than other treatments for patients with chronic LBP for pain and functional status (short and intermediate term follow-up).

4a) Back schools in occupational settings versus waiting list controls or ’placebo’ interventions for acute/subacute LBP

There is limited evidence that back school is more effective than placebo for patients with acute and subacute LBP

4b) Back schools in occupational settings versus waiting list controls or ’placebo’ interventions for chronic LBP

Three RCTs

Two s tud ies found pos i t i ve short and intermediate term results and

one did not find any long-term differences.

There is moderate evidence that a back school is more effective than waiting list controls for patients with chronic LBP for pain and return to work (short and intermediate- term follow-up).

CONCLUSIONS

There is moderate evidence that back schools conducted in occupational settings seem to be more effective for patients with recurrent and chronic LBP (as opposed to patients from the general population or primary/secondary care) than other treatments.

The most promising interventions consisted of a modification of the Swedish back school and were quite intensive (a three to five-week stay in a specialized centre).

Implications for research

19 RCTs (3584 patients) were Identified that evaluated the effectiveness of back schools.

Most of the studies included in this review showed methodological deficiencies.

Clearly, there is a need for future high quality RCTs to determine which type of back school is the most effective for LBP patients.

Future RCTs should include :

An evaluation of the cost-effectiveness of

back schools and consider the clinical

relevance of the trial more during study

design and performance.

Effectiveness of Back School Versus McKenzie Exercises in Patients With Chronic Nonspecific Low Back Pain A Randomized Controlled Trial

Alessandra. et .al

Physical Therapy Journal of American Association of Physiotherapy

Published on February 21, 2013doi: 10.2522/ptj.20120414

Objective The purpose of this study was to compare the effectiveness of Back School and McKenzie methods in patients with chronic nonspecific low back pain.

Design The study was a prospectively registered, 2-arm randomized controlled trial with a blinded assessor.

Setting

Outpatient physical therapy clinic of the Universidade Cidade de Sao Paulo, Brazil.

From July 2010 and July 2012.

Inclusion Criteria

✓nonspecific low back pain of at least 3 months’ duration ✓between 18 and 80 years of age.

Exclusion Criteria

✓Patients with any contraindication to physical exercise (American College of Sports Medicine) ✓serious spinal pathology (eg, tumors,fractures, inflammatory diseases) ✓previous spinal surgery ✓nerve root compromise ✓cardiorespiratory illnesses or ✓pregnancy were excluded.

Randomization

✓A total of 148 subjects were enrolled out of which : ✓74 were randomized into the Back School group and ✓remaining 74 were assigned into the McKenzie group

Interventions Participants from both groups received 4, one-hour sessions over 4 weeks, once a week.

All participants received the exercises under the supervision of the physical therapist.

At the end of each treatment session, participants were asked to perform the same exercises at home once a day (3 sets of 10 repetitions that could be performed on the same day or in different times of day depending on the patient’s availability).

Patients in both groups received information in order to maintain lordosis while sitting, including patients with no direction preference for extension, without exacerbating their symptoms.

Patients in the McKenzie group with a direction preference for extension also were instructed to use a back roll while sitting

McKenzie group

Back School group

All participants received the treatments as allocated.

Of these participants, 146 (98.6%) completed the follow-up at 1 month for the primary outcome measures of pain and disability and for the secondary outcome measure of quality of life.

4 participants (5.5%) in the McKenzie group and 8 participants (10.8%) in the Back School group could not be followed up for the secondary outcome measure of trunk flexion range of motion at 1 month due to an inability to attend the clinic.

All participants completed the 3-month follow-up, and only one loss to follow-up in the Back School group occurred for all outcomes at 6 months

Result The author observed a reduction in pain intensity and disability after treatment (1 month) in both groups. Participants allocated to the McKenzie group had greater improvements in disability (treatment effect;2.37 points, 95% CI;0.76 to 3.99) after treatment (at 1-month follow-up).

There was no statistically significant between group difference for pain (treatment effect:0.66 points, 95% CI:0.29 to 1.62).

Most of the improvements in outcomes observed at short-term follow-up were maintained at 3 and 6 months after randomization for both primary and secondary outcomes.

Participants allocated to the McKenzie group had greater improvements in disability, but not pain intensity, at 1-month follow-up compared with participants allocated to the Back School group.

Conclusion Patients allocated to the McKenzie group experienced greater improvements in disability, but not in pain intensity, after treatment compared with patients allocated to the Back School group, but the magnitude of this effect was small and possibly of doubtful clinical importance.

EFFECTIVENESS OF BACK SCHOOL FOR TREATMENT OF PAIN AND FUNCTIONAL DISABILITY IN PATIENTS WITH CHRONIC LOW BACK PAIN

A RANDOMIZED CONTROLLED TRIAL

N. Sahin et al.

Journal of Rehabilitation Medicine Published on 2011;

doi: 10.2340/16501977-0650

Objective: To evaluate the effectiveness of the addition of back school to exercise and physical treatment modalities in relieving pain and improving the functional status of patients with chronic low back pain.

Design: A randomized controlled trial.

Setting

Physical Medicine and Rehabilitation Clinic of Meram Medical Faculty of Selcuk University, Turkey

Inclusion Criteria ✓Patients who had had non-specific low back pain ✓low back pain for longer than 12 weeks without neurological deficits

Exclusion Criteria subjects who had ✓continuous pain with a score above 8 on VAS, ✓age ≤ 18 years, ✓who had already attended the back school programme, ✓who had undergone previous surgery, ✓who had structural anomalies, ✓spinal cord compressions,

✓severe instabilities, ✓severe osteoporosis, ✓acute infections, ✓severe cardiovascular or metabolic diseases, ✓who were pregnant, and ✓ those with a body mass index above 30kg/m2

Evaluation criteria Patients were evaluated

✓at the beginning, ✓after the treatment and ✓at 3 months post-treatment

1. for pain severity by VAS and

1. for functional aspects by Oswestry Low Back Pain Disability Questionnaire (ODQ)

Sample

A total of 160 patients, who were referred or self-referred to our outpatient clinic with CLBP took part in this study.

Interventions 1. Exercise programme. ✓lumbar flexion exercises, ✓lumbar extension and ✓lumbar stretching exercises, and ✓strengthening exercises for the thighs.

The exercise programme was run by the same physiotherapist, who was blinded to which group the patient was allocated to, in patient groups of 5 in an exercise room.

In addition, a written exercise programme was given to the patients.

The exercises were repeated 5 times a week for 2 weeks (total of 10 sessions) in the exercise room and were controlled.

Afterwards, the patients were told to perform the exercises at home 3 times a week for 3 months.

2. Physical therapy

A physical therapy programme, including ✓TENS, ✓ultrasound and ✓ hot pack

once daily, 5 days a week for 2 weeks,

totaling 10 sessions

✓TENS was applied as 100 Hz, 40 µsN in continuous waveform for 30 min/session.

✓Therapeutic ultrasound was applied as a continuous wave with 1 MHz frequency and 1.5 W/cm2 intensity for 5 min.

✓The physical therapy programme was applied once daily for 5 days a week for 2 weeks before the exercise programme was started.

3. Back school programme.

consisted of 2 sessions per week for 2 weeks; a total of 4 sessions.

Each session lasted 1 h and included both didactic and practical training.

The programme was administered by a physiatrist .

The aim of the back school was to teach patients about ✓ the functional anatomy of the low back, ✓the function of the back, pain, ✓the correct use of the lower back in daily life, and ✓skills to enable them to cope with low back problems, ✓increase self-esteem and improve their quality of life, leading to a decrease in recurrence of low back pain.

Patients were given written information by the physician.

A sessions included 4–6 subjects.

In addition, the physiatrist interviewed and assessed each patient’s lifestyle, physical activity, and risk factors.

Each patient who joined the programme explained his or her problems.

Subjects were then explained about the problem-solving skills, and were instructed in how to use low back movements in their daily life during the programme.

Randomization

Samples were randomized in to two groups

Group 1 and Group 2

✓Group 1 (back school group: BSG) received physical treatment modalities, exercise and the back school programme.

✓Group 2 (control group: CG) received physical treatment modalities and exercise.

✓Patients in all groups received 500 mg paracetamol tablets as needed, up to 2 g per day (up to 4 tablets a day) from the beginning of the study.

RESULTS A total of 146 patients completed the study and attended the third-month control visits . The mean age in the BSG was 47.25 years (SD 11.22 years), whereas it was 51.36 years (SD 9.65 years) in the CG.

There was no statistically significant difference between the groups in terms of age, gender, body mass index, occupation or education (p > 0.05).

Within-groups

The decrease in VAS and ODQ values pre- and post-treatment was statistically significant in both study groups

(VAS: 95% CI = 4.68–5.15; 5.12–5.58, ODQ: 95% CI = 39.83–42.18; 43.59–45.94, for BSG-CG, respectively).

These result were statistically significant (p < 0.01).

However, there was no significant difference between post-treatment and third-month controls in both groups

(VAS: 95% CI = 3.29–3.91; 4.00–4.62,ODQ: 95% CI = 34.75–37.51; 38.55–41.31, for BSG-CG, respectively).

These results were not statistically significant (p > 0.05).

Between-groups There was a significant reduction in VAS in the BSG compared with the CG after the treatments and at 3 months post-treatment

(0.665, 95% CI = 0.564–0.767 and 0.205, 95% CI = 0.070– 0.340).

These results were statistically significant (p = 0.010 and p = 0.002, respectively).

Disability (ODQ scores) were significantly lower in the BSG compared with the CG after the treatments and at 3 months post-treatment

(1.011, 95% CI = 0.929–1.093 and 0.844, 95% CI = 0.748–0.941).

These results were statistically significant (p < 0.001).

DISCUSSION

The author observed that a back school programme has an effect on pain and disability when given in addition to physical treatment modalities and exercises.

This effect was observed post-treatment and at 3 months follow-up.

Limiting factors of the present study are ➢the short-term follow-up, ➢lack of cost-analysis and ➢Few assessment criteria.

Effectiveness of a back school program in low back pain

RCT

L.H. Ribeiro.at.el

Clinical and Experimental Rheumatology

Published on 2008

Objectives

To evaluate the effectiveness of a back school program in ✓pain, ✓functional status, ✓quality of life, and in anxiety and ✓depression in patients with non-specific low back pain.

Material and methods

Inclusion criteria

The study included 60 patients aged 18 to 65 years diagnosed with chronic nonspecific low back pain, defined as pain in the back, located between the last rib and the gluteal fold, with mechanical characteristics lasting more than 3 months.

Exclusion criteria

This constituted ✓ previous back surgery, ✓spinal tumor, ✓spinal fracture, ✓ pregnancy, ✓fibromyalgia, ✓ inflammatory or infectious spinal diseases and ✓ litigant patients

Patients were recruited from rheumatology and orthopedic outpatient clinics; Sao Paulo Federal University, Division of Rheumatology, Sao Paulo, Brazil; from October 2002 to November 2003.

Procedures

1. Intervention group: back school program, which consisted of 5 one-hour group sessions

(four consecutive once a week sessions and a fifth reinforcement session after 30 days).

Sessions were instructed by a rheumatologist and a physical therapist for groups of 10 participants.

Orientation was given regarding the anatomy and physiology of the spine, causes and treatment of low back pain, and ergonomic guidelines relevant to back problems, such as standing and sitting postures, reaching, kneeling, twisting,lifting, pushing and pulling.

Abdominal and back strengthening exercises were also performed.

After the exercises, sessions ended with a relaxation posture in bed (semi-Fowler or psoas position).

Control group: patients were seen at 3 medical visits within a four-week period (Week 1; Week 2; Week 4) and at a fourth visit 30 days after Week 4.

Each medical visit was conducted by a rheumatologist (other than the back school instructor).

Patients were asked about their back problems and medications taken to relieve pain.

A general physical examination and an examination of the spine were performed.

No educational orientation was imparted to the control group.

Follow-up assessment

The f i rst assessment (T0) took place immediately after randomization and before initiating the intervention at a maximum interval of seven days.

Other assessment visits took place 30 (T30), 60 (T60) and 120 (T120) days after initiating the intervention.

The following assessment instruments were used: 1. Schober’s Test to assess the level of spine

mobility, 2. Visual Analogical Scale (VAS) for pain with

scores from zero to ten; and 3. the questionnaires SF 36 (Short Health Survey)

for quality of life, 4. Roland-Morris for functional status, 5. Beck Depression Inventory and 6. the State- Anxiety Inventory (STAI).

All questionnaires were translated into the Portuguese language and validated .

Accountability of analgesic medication intake (acetaminophen) supplied at each assessment visit was also conducted.

Patients were instructed to take notes on the number of analgesics they had taken every other day.

The consumption of anti-infl ammatory medication was considered co-intervention

Results There were no significant differences in the baseline characteristics between the two groups.

Fifty-five patients completed the study.

The intervention group showed a significant improvement in the general health domain, assessed by SF-36, and also in the reduction of acetaminophen and NSAID intake.

There was no significant difference between the groups in

✓pain, ✓functional status, ✓anxiety or ✓depression

Conclusion The back school program was more effective than any educational intervention in general health status and in decreasing acetaminophen and NSAID intake.

It was ineffective in the other quality of life domains, in pain, functional status, anxiety and depression.

Take home message

Along with treatment if we educate patient about the pathphysiology of back with respect to the patient activities the improvement will have lasting effect.

Occupation related back pain or disorders are tackled more efficiently through back school, so physiotherapist should actively involve in industrial health programme /ergonomic sound designs.