In 1969, the Swedish Back School began with a goal of helping patients learn about spinal anatomy and physiology, as well as ergonomics. These back schools are now used throughout the Western world to help patients cope with chronic lower back pain (CLBP).
There are subtypes to the back schools, including brief education and fear-avoidance training. Researchers have found that the ideal patient for back school education is middle-aged, experiences yearly recurrent episodes of CLBP, has been out of work for short periods, and finds it difficult to sit or stand for periods more than 30 minutes at a time. The ideal patient for brief education is a young, manual laborer who has been out of work for less than eight weeks for the first time. With normal range of motion, he/she tries to avoid pain and has tense and painful muscles. Finally, the ideal patient for fear-avoidance training is a patient who has moderate-to-severe pain and cannot participate in ordinary activities, and has been advised to avoid activities that can aggravate the back pain, such as golf or tennis.
In defining these educational approaches, the authors of this article write that back schools can be defined as group education, training and exercise, that is delivered by a healthcare provider. They often take place in an organized environment. Brief education, on the other hand, is a short-contact type of exchange between the patient and the healthcare provider and can be offered through pamphlets, patient-led groups, even online (Internet) groups. Fear-avoidance training uses exercises and techniques to encourage a return to normal activities.
These educational approaches should be used for patients who have nonspecific, mechanical CLBP, with no serious somatic or psychiatric comorbidity.
In reviewing studies that assessed the efficacy of these educational approaches, the authors found:
- conflicting evidence that back schools are not effective in reducing recurrences of LPB compared with usual care or no intervention
- limited evidence that back schools are less effective than exercise
- moderate evidence that back schools are not better than waiting list, any intervention, placebo, or exercises for reduction of pain
- conflicting evidence that back schools are better than waiting list, no intervention or usual care for return to work
- strong evidence that brief education is not more effective than usual care for return to work
- conflicting evidence that brief education in a clinical setting is more effective than usual care in reducing disability
- limited evidence that brief education provided by a back book is less effective than massage, yoga, and exercise
- conflicting evidence that brief education by back book is more effective than waiting list for pain reduction
- limited evidence that brief education is more effective than massage and no intervention for reduction of disability
- limited evidence that brief education is more effective than massage and no intervention for reduction of disability
- limited evidence that brief education is less effective than yoga and massage for reduction of disability
- no evidence for return to work when brief education is provided by a back book or Internet discussion
- moderate evidence that fear-avoidance training emphasizing exposure is more effective than graded activity with regard to fear avoidance, pain, disability, and return to work
- limited evidence for effectiveness with regard to pain, disability, and return to work compared with usual care
The authors conclude that, although they cannot recommend back schools as management for chronic lower back pain, some positive findings do encourage the need for future studies. They recommend the use of fear-avoidance when warranted.
Jens Ivar Brox, MD, PhD, et al. Evidence-informed management of chronic low back pain with back schools, brief education, and fear avoidance training. In The Spine Journal. January/February 2008. Vol. 8. Issue 1. Pp. 28-39.
