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Transcript of Recent advances on back school
Recent Advances
Effectiveness Of Back Schools For
Management of Chronic Low Back Pain
By: Venus Pagare
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
INTRODUCTI
ON
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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”
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“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
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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
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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
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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
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The California Back School Developed by White in 1976Focuses on acute LBP patientsIntroduced concept of evaluating and training patients
in ergonomic concepts and physical trainingHighly individualized, with class size ranging from 1-4 A physical therapist provides all instruction and trainingStudents were treated individually in three weekly 90-
minute sessions and were observed in work simulation
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The Miami Back School Started by Jackson in 1982Covers pathology, biomechanics, pain control,
emotional aspects, advice on exercise, practice in body mechanics
Active Back School (ABS)Involves more practical trainingConsists of: 20 sessions over a period of 13 weeks2 sessions per week for first 7 weeks and 1 session per week for final 6 weeksEach lesson lasted 1 hour, divided into a didactic
part (20 min) and a practical training part (40 min) 10
SPINE 1999
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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 12
GOALS / OBJECTIVES
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 goal
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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
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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 benefitIt can be determined who is most likely to
benefit from a back school approachPatients with intermittent episodes of pain are
good candidatesThose with unremitting pain benefit less15
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 populationCan be acute, chronic or industrial16
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
FORMATAutomated 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
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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
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LITERATURE REVIEW
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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 goalsLow Back Schools: A Critical Review
PHYS THER. 1987; 67:1375-1383.
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
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Efficacy of Comprehensive Rehabilitation Programs and Back School for Patients With Low Back Pain: A Meta-analysis PHYS THER. 1995; 75:865-878.
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
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Back schools for non-specific low-back pain. (Review) Cochrane Database Syst Rev 2011; 2
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, neurologists, psychiatrists, physical therapists, and
occupational therapists
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NEED FOR RECENT ADVANCES
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 interventions
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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
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RECENT STUDIES
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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
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Full text articles from 2007 to 2013
Studies on any type of back school for low back pain
INCLUSION CRITERIA
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Total number of articles
included = 6
Level of evidence
Number of articles
1a 1
1b 3
2b 1
4 1
ARTICLES INCLUDED
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1a = Systematic Review of Randomized Controlled Trials (RCTs)
1b = RCTs with Narrow Confidence Interval1c = All or None Case Series2a = Systematic Review Cohort Studies2b = Cohort Study/Low Quality RCT2c = Outcomes Research3a = Systematic Review of Case-Controlled
Studies3b = Case-controlled Study4 = Case Series, Poor Cohort Case Controlled5 = Expert Opinion
LEVEL OF EVIDENCE
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
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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 EnglishRCTs that reported back schools, or brief education as
main intervention were included
Key Words: Back school; Brief education; Fear-avoidance training;
Systematic review; Chronic low back pain31
OUTCOME MEASURES:Pain, disability, and sick leave
Results:7 systematic reviews were identifiedEuropean Guidelines were includedEight RCTs evaluated back schools
32
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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
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3 RCTs were of high qualityConflicting evidence for back schools compared
with placebo, usual care, and exercises
CONCLUSION: There is lack of consistent evidence regarding
use of back schoolsMay be considered in occupational settingBack schools may play an important role in
multidisciplinary interventions
2
Meng K et al
Clin J Pain 2011; 27(3)
Intermediate and Long-term Effects of a StandardizedBack School for Inpatient Orthopedic Rehabilitation on
Illness Knowledge and Self-management BehaviorsA Randomized Controlled Trial 1
b
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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:
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Intervention Group New back
school
Control GroupTraditional back
school
INTERVENTION GROUPBiopsychosocial model back school program 7 sessions of 55 minutes<15 participantsSessions 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 sheets37
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Contents:Basic knowledge about back pain (eg,
epidemiology, risk factors, therapy)Physical, psychological and social aspectsSpine-related exercises (muscle training and
active stabilization)Promoting physical activity (eg, motivation, self-
regulation)
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TRADITIONAL BACK SCHOOL
4 sessions of 55 minutesLed by a physiotherapistCorrect back posture and movements as well as
back exercises and trained using a handoutKnowledge about pain and coping was
conveyedNo limitation of group; about 60 people
participated
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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
treatmentSecondary: behavioral and health outcomes;
physical activity, back posture and movements, back exercises, pain beliefs, pain coping strategies, pain intensity
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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
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
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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
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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 Physiother
apy
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Spinal Manipulati
on
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 pain
45
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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
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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
OUTCOME MEASURES:Roland Morris Disability QuestionnairePain Rating ScaleTaken at baseline, discharge 3, 6, and 12
monthsFollow-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-ups48
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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
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CONCLUSION:Spinal manipulation provided better short and
long-term improvementBack school showed superior results to
individual physiotherapy
4
Tavafian SS, Jamshidi AR, Montazeri A
Spine 2008; 33(15)
A Randomized Study of Back School in Women With
Chronic Low Back PainQuality of Life at Three, Six, and Twelve
Months Follow-up1b
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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= 50Back school program +
Medication
Clinic GroupN= 52
Medication Only52
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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
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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
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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 effectsDecreasing 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
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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
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OBJECTIVE:Assess impact of a school program back to short
and medium term in chronic low back painSearch predictors of effectiveness of back
school
METHOD:Patients with CLBP were includedCohort consisted of 328 patients5 days in a department of physical medicine
and rehabilitation57
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Collective learning Physical activities : strengthening muscles
(trunk and lower limbs), stretching and initiation in cardio, introduction to sports (badminton and basketball)
Presentation of physical exercise4 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
OUTCOME MEASURES:Impact of low back pain evaluated by: quality of
life (VAS, 100 mm)Spine pain scale: French translation of
the Dallas Pain QuestionnaireEvaluation 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
RESULTS :Results at 6 months showed an efficacy of back school
on pain and functional statusHowever, it had little impact on quality of lifeReduced duration of work stoppages without
decreasing frequencyBeing young and practice regular physical activity was
predictive of efficacy of back schoolOverweight, 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
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 Patientswith Chronic Low-Back Pain
4
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OBJECTIVE: To assess effect of back school integrated with
core-strengthening exercises on back-specific disability and pain-
coping strategiesTo 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
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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
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
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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
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
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
1b
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
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BACK SCHOOL4 treatment sessions, once/week1st session will be given individuallyRemaining 3 sessions in a groupProgram is divided based on Theoretical &
Practical information
MCKENZIE GROUP4 individual sessions, once per week, lasting 45
minutes – 1 hourTreatment will be provided in accordance with
the direction preference of movement
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OUTCOME MEASURESPain intensity: NPRSDisability: Roland Morris Disability Questionnaire Quality of life: WHOQOL-Bref Trunk flexion ROM: Fleximeter
Will be taken at 1, 3 and 6 months
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
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ErgonomicsCommon treatment modalitiesPractical 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
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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
73