LEC.01. Back School.pptx LEC.01. Back School.pptx

LEC.01. Back School.pptx

1. DR. ABDUL RASHAD Assistant Professor PhD*, MPhil(OPT), DPT, IASTM, SIR. CST, CKPT,  CMT Nazeer Hussain University 1 EFFECTIVENESS OF BACK SCHOOLS FOR MANAGEMENT OF LOW BACK PAIN

2. Chronic Low back pain (LBP) is currently one of the major public health problem. 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 INTRODUCTION 2

3. Many therapeutic interventions have been developed for treatment of Chronic LBP Includes: educational programs, cognitive behavioral 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 ” 3

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 4

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 5

6. Later, exercises for maintenance of a “ healthy back” were included, and back schools were incorporated in comprehensive multidisciplinary programs Scheduled in 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. 6

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: Orthopedic surgeon Physical therapist Psychologist Psychiatrist 7

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. 8

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) 9

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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 kinesiophobia . 11 GOALS / OBJECTIVES

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. Provide group support to decrease anxiety and sense of isolation Few authors cited reduction of amount or frequency of low back pain as a goal. 12

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 co-intervention) 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 13

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 less 14

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 15

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 influence format 16

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. 17 LITERATURE REVIEW

18. 18 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 Review PHYS THER. 1987; 67:1375-1383 .

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 19 Efficacy of Comprehensive Rehabilitation Programs and Back School for Patients With Low Back Pain: A Meta-analysis PHYS THER. 1995; 75:865-878 .

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 20 Back schools for non-specific low-back pain. (Review) Cochrane Database Syst Rev 2011; 2

21. Traditional reviews may not be adequate to draw conclusions: 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, neurologists, psychiatrists, physical therapists, and occupational therapists 21 NEED FOR RECENT ADVANCES

22. Different study participants and settings. 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. Insufficient descriptions of back school interventions. 22

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 23

24. RECENT STUDIES 24

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 25

26. Full text articles from 2007 to 2017 Studies on any type of back school for low back pain INCLUSION CRITERIA 26

27. Total number of articles included = 6 Level of evidence Number of articles 1a 1 1b 3 2b 1 4 1 ARTICLES INCLUDED 27

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 28

29. 1 Natour J, Cazotti Lde A, Ribeiro LH, Baptista AS, Jones A. Clin Rehabil . 2015 Jan;29(1):59-68 Effectiveness of a back school program in low back pain 1a 29

30. OBJECTIVE: To evaluate the efficacy of back school program for low back pain patients. METHODS: Randomized controlled trial with 60 patients randomized to intervention (back school program) and control (medical visits without education). Both groups took acetaminophen. Evaluations at baseline, 30, 60, and 120 days. Key Words: Back school; Brief education; Fear-avoidance training; Systematic review; Chronic low back pain 30

31. OUTCOME MEASURES: SF-36 (quality of life), acetaminophen and NSAID intake, VAS (pain), Roland-Morris (disability), Schober test (flexibility). Results: Intervention group showed significant improvement in SF-36 general health domain and reduction in acetaminophen and NSAID intake. No significant differences in other measures. CONCLUSION: The back school program is effective in improving general health and reducing drug intake in patients with low back pain. 31

32. 2 Straube S et al Pain. 2016 Oct;157(10):2160-2172 Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research—systematic review and meta-analysis 1b 32

33. OBJECTIVE: To systematically review the randomized controlled trial evidence on back schools for the treatment of chronic low back pain. METHOD: Systematic review and meta-analysis of 31 RCTs, searching MEDLINE, Embase, and Cochrane Central. Risk of bias assessed using Cochrane tool. Meta-analyses using random-effects model for pain and functional outcomes. 33

34. OUTCOME MEASURES Pain (VAS), disability (Roland Morris Disability Questionnaire, Oswestry Disability Index), workdays missed, SF-36 scores, adverse events. RESULTS: Statistical superiority of back schools over no intervention for pain and disability at 1-6 months, but heterogeneity prevented firm conclusions. Adverse events poorly reported, no serious events noted. CONCLUSION: No convincing evidence of benefit for back schools in treating chronic low back pain after 47 years of research, though possibility of benefit exists; safety data insufficient. 34

35. 35 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

36. 36 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

37. 37 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

38. 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. 38

39. 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 1b 39

40. 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 Physiotherapy 40 Spinal Manipulation

41. 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 1 st 5 : information and group discussions on back physiology and pathology, with reassurance on benign character of common low back pain 41

42. 42 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.

43. 43 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

44. 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. 44

45. 45 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

46. 46 CONCLUSION: Spinal manipulation provided better short and long-term improvement. Back school showed superior results to individual physiotherapy.

47. 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 1b 47

48. 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 Only 48

49. 49 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 evaluations and assessed individual coping skills, anger management, and relaxation

50. 50 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

51. 51 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 with chronic low back pain.

52. 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 2b 52

53. 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 53

54. 54 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

55. OUTCOME MEASURES: Impact of low back pain evaluated by quality of life. 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 considered. At six months, assessment was identical to that carried out at entrance Number of days off work was calculated 55

56. 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, anxious-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. 56

57. 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 57

58. 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 58

59. 59 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 physician assistants

60. 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) 60

61. 61 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

62. 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 62

63. Watch Out For…. Meng K, Peters S, Faller H Patient Educ Couns. 2017 Jul;100(7):1382-1389 Effectiveness of a standardized back school program for patients with chronic low back pain after implementation in routine rehabilitation care 63

64. 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 64

65. 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 anxious-depression are disincentives to program effectiveness 65

66. 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 Studies including acute LBP population IMPLICATIONS FOR RESEARCH 66

67. 10/24/2025 67