Recent advances on back school

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Recent Advances

Transcript of Recent advances on back school

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Recent Advances

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Effectiveness Of Back Schools For

Management of Chronic Low Back Pain

By: Venus Pagare

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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

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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

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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

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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.

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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.

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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

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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

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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

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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

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OUTCOME MEASURES:Pain, disability, and sick leave

Results:7 systematic reviews were identifiedEuropean Guidelines were includedEight RCTs evaluated back schools

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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

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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

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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

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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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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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)

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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

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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

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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

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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

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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

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