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Three Part Question

[In patients with chronic simple low back pain] are [back schools better than standard rehabilitation] at [decreasing pain, improving function and aiding a return to work]

Clinical Scenario

A 43 year old re-presents to her GP with a 3 year history of intermittant back pain. She is rarely without any pain but has regular exacerbations. She is concerned that her sickness record is causing concern amongst her employers and if fearful that she might lose her job. She has heard that she can go to special classes to help her get better and wonder if you know if these "back schools" are any good. You endevour to find out.

Search Strategy

Medline 1966-June 2005 OVID interface via ATHENS
Cochrane database of systematic reviews edition 1 2005.
Medline
back school.mp OR [exp Patient Education/ and exp back pain] LIMIT to 2003-2005 {limited as high quality systematic review published in 2003}
Cochrane
"back-school"

Search Outcome

Medline
43 papers found of which 1 additional randomised controlled trial (not included in the systematic review) was found relevant to the 3 part question.
Cochrane
16 citations of which one was directly relevant to the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
MW Heymans et al 2004 Netherlands	Cochrane systematic review on the use of back schools for back pain. The authors used a wide ranging search to find RCTs of back school therapy.	Systematic review without meta-analysis	Number of relevant papers found	19 papers with a total of 3584 patients. 6 of the studies were concerned with chronic low back pain.	This review was limited in it's conclusions by the quality of the studies found. This fact is accepted byt the authors who make a plea for higher quality research in the future.
			Quality of included papers	Using a preagreed 11 point scale. Only 6 papers were considered high quality (a score of 6/11 or more)
			Back schools versus other (conservative) treatments for chronic LBP	"There is moderate evidence (5 trials; 1095 patients) 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 (3 trials; 822 patients) 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."
			Back schools versus waiting list controls or 'placebo' interventions for chronic LBP	There is conflicting evidence (8 trials; 826 patients) on the effectiveness of back schools compared to waiting list controls or placebo interventions on pain, functional status, and return to work (short, intermediate and long-term follow-up), for patients with chronic LBP.
			Back schools in occupational settings versus other treatments for chronic LBP	There is moderate evidence (3 trials; 764 patients) 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). There is conflicting evidence (4 trials; 906 patients) on the effectiveness of back schools compared to other treatments for chronic LBP on pain and functional status (long-term follow-up).
			Back schools in occupational settings versus waiting list controls or 'placebo' interventions for chronic LBP	There is moderate evidence (2 trials; 186 patients) 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). There is limited evidence (1 trial; 142 patients) that there is no difference in long-term incidence of LBP episodes between back school and waiting list controls for patients with chronic LBP.
Kool JP et al, Switzerland 2005	174 patients with >6weeks of leave abscence due to chronic non-specific back pain. Function-centered treatment (FCT) (4h/d, 6d/wk, for 3 wk) consisted of work simulation, strength, endurance, and cardiovascular training. Pain-centered treatment (PCT) (2.5h/d, 6d/wk, for 3 wk) used a mini back school, individually selected passive and active mobilization, stretching, and low-intensity strength training.	Single Blind RCT	Days at work	25.9 days for FCT vs. 15.8 days for PCT. p=0.029	Abstract only
			Self efficacy	5.9 points for FCT vs. -7.4 points for PCT. p=0.004 (better for PCT)

Comment(s)

Back schools are designed to explain to patients the problems associated with their back pain and to allow the patients to help themselves through understanding and coping with their pain. The concept has been adapted in a number of ways over the years and now encompasses a relatively wide variety of techniques, but the aim remains the same. The back school usually consists of information on the anatomy of the back, biomechanics, optimal posture, ergonomics and back exercises. The studies identified in the Cochrane review suggest that back school appears to be effective at increasing peoples health and does have some effect on function.

Clinical Bottom Line

There is moderate evidence for the efficacy of back schools in the management of chronic low back pain, particularly in the occupational setting.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. MW Heymans, MW van Tulder, R Esmail, C Bombardier, BW Koes Back schools for non-specific low-back pain. The Cochrane Database of Systematic Reviews 2004 Art. No.: CD000261. DOI: 10.1002/14651858.CD000261.pub2
2. Kool JP. Oesch PR. Bachmann S. Knuesel O. Dierkes JG. Russo M. de Bie RA. van den Brandt PA. Increasing days at work using function-centered rehabilitation in nonacute nonspecific low back pain: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 86:857-64