The Role of Education and Back Schools

18 The Role of Education and Back Schools

Gunnar B. J. Andersson

All physicians should be educators. Our patients deserve to know about their health and diseases, diagnosis, treatments, and prevention. Medical school generally does not prepare us well in this respect. Mostly we learn by observing. For time and cost-related reasons the education of patients has changed from a one-to-one approach to other methods such as books, pamphlets, videos, Internet, and group education often provided by nonphysician health care providers. The success of these approaches can be measured by two yardsticks; how much did the patient learn and retain? And what effect did the education have on the individual’s health? Learning and retaining are measured by simple memory tests or by monitoring the intended results of the education. For example, how well treatment advice was followed. The health effect of education is ideally measured in prospective randomized controlled trials.

Educational Environments

For a variety of reasons the education environment in the physician’s office is less than optimal. It is not designed for education. The patient is not in an optimal state for education (nervous, undressed, and often uncomfortable or in pain). The physician is hurried by other waiting patients and the cost of education per patient is high. Many physician offices have a separate room for education purposes often with exhibits, models, videos, and computers. Teaching in that environment is clearly better. Still the patient may not be optimally ready and the one-on-one education is costly even when performed by an allied health care provider.

Group education has several positives. It can be done in a good learning environment, it allows for discussion with and between patients suffering from the same problems and it is cost-effective. Although the home environment (video, DVD, Internet) has the benefit of comfort and individual choice of time as well as the possibility to easily repeat, it is more difficult to ask questions (but not impossible with a computer), and other patients are not there to ask questions and share their experiences.

Back Schools

The first back school was developed in Sweden in 1969 by Zachrisson-Forsell, a physical therapist.1 The intended purposes were to reduce symptoms and prevent chronicity and recurrence of back pain by education. It was formally structured to teach anatomy, biomechanics, body postures, ergonomics, and exercises. It was delivered in the physical therapy setting as four group sessions over a 2-week period. It was widely embraced and adopted worldwide. Although the content and schedule have since changed, many of the features of the early back schools are still used today with great variation.

Effectiveness

A large number of randomized controlled trials have been performed over the years. Some of these involve primarily acute or subacute patients; others are chronic patients. Some of the trials have been specific to an occupational setting. Most published studies compare back schools to other treatments. Some use placebo interventions. Outcomes are typically pain and functional status, but in some instances, return to work is also measured. Because of the significant variation in study populations, content, type of control intervention, and outcome measurements, it is difficult to combine these studies for the purposes of a metaanalysis. Several systematic reviews have been published, including two by the Cochrane Collaboration Back Review Group.^2–5 Generally, it is reported that the methodologic quality of most studies is low. Heyman et al found 19 studies worthy of inclusion in a systematic review.² The conclusions of the reviews are that there is moderate evidence suggesting that back schools have better short- and intermediate-term effects on pain and functional status than other treatments for patients with recurrent and chronic low back pain (LBP). Moderate evidence also suggests that back schools for chronic LBP in an occupational setting are more effective than other treatments, including placebo or waiting list controls, with respect to pain and functional status and return to work in the short- and intermediate-term follow-up.² Although none of the studies in the reviews specifically addresses the issue of the painful intervertebral disc, many patients enrolled likely have pain originating from the disc. A few of the studies warrant closer inspection.

Several studies have tried to determine the efficacy of back schools compared with other treatments (medical, manual therapy, and orthotics) in patients with acute LBP.^6–9 Indahl et al report superior results for the back school group; however, other studies report no differences.^8,9 The efficacy of back schools compared with exercises, manual therapy, myofascial therapy, and medication in patients with chronic LBP (which probably includes most patients with discogenic pain) has also been studied by several groups.9–11 Although there is moderate evidence in support of back schools in the short- and intermediate-term perspective there is no long-term benefit. When compared with no treatment or placebo, one study reports positive outcomes^12,13; two studies found no benefit.^11,14

Cost-effectiveness

Given the methodologic weakness of published RCTs, and the limited evidence suggesting a small effect if any, it is not surprising that few studies have been published on cost-effectiveness. The cost of a back school depends on its curriculum, place of education, and class size—all of which vary significantly. Brown et al¹⁵ and Versloot et al¹⁶ found no significant differences in favor of back schools compared with other treatment approaches.

Discussion

Given the mixed (mostly poor) quality of RCTs comparing back schools to alternatives, it would be compelling to discard this alternative. However, it would be a mistake to equate this with a notion that education is not important. Although we need to improve on the quality of studies to explore the benefits of back schools, it may be even more important to reconsider their content, delivery, and educational settings. Taking advantage of modern teaching delivery systems and the moderate evidence that back schools conducted in the occupational setting is more effective may provide benefits particularly to patients with recurrent and chronic back pain.²

There is general agreement that shared decision making about treatment is beneficial. This requires a well-educated patient with realistic expectations and the ability to engage in discussions about treatment alternatives and outcomes.