Recent advances on back school

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Recent advances on back school

  1. 1. Effectiveness Of Back Schools For Management of Chronic Low Back Pain By: Venus Pagare
  2. 2.  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
  3. 3.  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
  4. 4.  “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
  5. 5.  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
  6. 6.  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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 11
  11. 11. 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
  12. 12.  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
  13. 13.  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
  14. 14.  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
  15. 15.  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
  16. 16.  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
  17. 17.  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
  18. 18. 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
  19. 19.  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.
  20. 20.  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
  21. 21.  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
  22. 22. 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
  23. 23. 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
  24. 24. RECENT STUDIES 25
  25. 25.  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
  26. 26.  Full text articles from 2007 to 2013  Studies on any type of back school for low back pain INCLUSION CRITERIA 27
  27. 27. Total number of articles included = 6 Level of evidence Number of articles 1a 1 1b 3 2b 1 4 1 ARTICLES INCLUDED 28
  28. 28.  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
  29. 29. 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
  30. 30. 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
  31. 31. OUTCOME MEASURES:  Pain, disability, and sick leave Results:  7 systematic reviews were identified  European Guidelines were included  Eight RCTs evaluated back schools 32
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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)
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 50 CONCLUSION:  Spinal manipulation provided better short and long- term improvement  Back school showed superior results to individual physiotherapy
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. 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
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. 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
  64. 64. 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
  65. 65.  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
  66. 66. 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
  67. 67. 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
  68. 68. 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
  69. 69. 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
  70. 70.  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
  71. 71. 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
  72. 72.  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

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