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Advance
Back School

A back school is an intervention protocol

consisting of an educational program and skills
acquisition program, including physical
exercises.

All the lessons are given to groups and are

supervised by a medical specialist or a
Physiotherapist.

The intensity and content of back schools

however differ from patient to patient.

Back School was first introduced in 1969, by

Zachrisson-Forsell
by the name Swedish back
school for treating patients with low-back pain
(LBP). i.e
for reducing pain and preventing
recurrent episodes of low back pain
Since then the content of back schools has
changed and appears to vary widely today.
Back schools for non-specific low-back pain. (Review)
Heymans et. al

Guidelines have been made and continuously

updated to prevent back pain at the healthcare
and workplace levels, and such guidelines are
termed as Back School
Back school: A simple way to improve pain and postural behaviour

The target population for back training:

Patients who have never had low back pain
(primary intervention).
Patients who have acute, chronic low back
pain or with recurrent back pain
Post-operative patients or patients with a
disc prosthesis.

Goals of back school:

1. Functional recovery
2. Protect the spinal structures in daily
activities and in the occupational setting
3. Reduce symptoms (pain)
4. Increasing tissue repair
5. Decrease kinesiophobia

To achieve these goals, the back school

consists of three parts:
1. Information
2. Systematic training
3. Active exercises

1.Information
about the anatomy and function of the spine,
spinal biomechanics,
pathology physiology back disorders,
epidemiology.
Now a days, this part of back school (giving
information) is limited as compared to the back
school in 1969

2. Systematic training in the back school

consist of
proper posture,
standing,
lifting,
bending,
Lying and
Sitting

The back school rules are different for the

occupational settings.
Example
1. Sedentary work as a banker.
A banker sits the whole day, so its
important hes sitting in a correct way:
When he bends forward while sitting, the
intradiscal pressure is supposed to be twice
as high as while standing.

The correct way of sitting: both feet

supported on
the ground, situated below the knees
The waist is situated a little higher than the
knees
and leaning with a straight back against the
backrest.
Its also important his worksheet is situated
at a
correct height.

2. Lifting techniques in the building industry,

childcare, healthcare etc

3. Active Exercises
Active protection of the spine by active exercises,
Example
A. Flank breathing versus diaphragmatic breathing:
The pressure-changes in the abdomen resulting from
diaphragmatic breathing causes some instability in the
low back. Flank breathing maintains the tension in the
abdominal muscles. (So there is no instability in the lower
back).

B. Stretching of the lower limbs muscles

C. Stretching of the erector spinae muscles
D. Kinaesthetic training
(move pelvis making a front and back pelvic
inclination at a comfortable range)
B. S t r e n g t h e n i n g o f t h e a b d o m i n a l
musculature
(stabilizing function)

We teach patients

correct posture and

movements, but its important that we must

not creating kinesiophobia in patients by
saying that a lot of movements and postures
are dangerous for your back.

Without these movements, there is no change

in pressure on the nucleus and no influx of
water in the nucleus.

The literature shows a strong association

between psychosocial and emotional factors
and back pain. It even suggests that they have
a greater influence on pain than physical
factors.
Back and neck pain are related to mental health problems in
adolescence. BMC Public Health. 2011;11:382. Rees CS et. al

Acquiring knowledge about the back is the

first step towards adopting healthy
postural habits to prevent back pain.
Effects of an educational back care program of Brazilian
schoolchildren knowledge regarding back pain prevention.
Rev Bras Fisioter. 2012;16:128-33.
Foltran.et.al

S y s t e m a t i c R e v i e w
2011
RCT

3
2013
2011
2008

Back schools for non-specific low-back

pain.
Heymans et.al
Systematic Review
The Cochrane Library
Published on 2011

Search methods
MEDLINE
EMBASE databases and
the Cochrane Central Register of Controlled
Trials
Trials reported in English, Dutch, French or
German.
The literature search :
articles updated to November 2004.

OBJECTIVES
The objective of this systematic review was to
determine if back schools are more effective
than other treatments or no treatment for
patients with non-specific LBP.

METHODS
Criteria for considering studies for this review
Types of studies
Only randomized controlled trials (RCTs) were
included.
Nonrandomized trials were excluded.

Types of participants
Randomized controlled trials that included
subjects with
nonspecific LBP,
aged 18 to 70 years, were included.

Low-back pain was defined as pain localised

below the scapulae and above the cleft of the
buttocks;
Non-specific indicated that no specific cause
was detectable, such as, infection, neoplasm,
metastasis, osteoporosis, rheumatoid
arthritis, fracture, or inflammatory process.

Types of interventions
Randomized controlled trials in which one of the
treatments consisted of a back school type of
intervention were included.

A back school was defined as consisting of an

educational and skills acquisition program,
including exercises, in which all lessons were
given to groups of patients and supervised by a
therapist or medical specialist.

Types of outcome measures

Randomized controlled trials that measured at
least one of the four primary outcome
measures that are considered to be the most
important
for back pain:
.

1. return to work,
2. pain (VAS),
3. a global measure of improvement (overall
improvement, proportion of patients recovered,
subjective improvement of symptoms), and
4. functional status (expressed on a back-specific
index, such as the Roland Disability
Questionnaire or the Oswestry Scale) were
included .

Physiological outcomes of physical examination,

such as,
range of motion,
spinal flexibility,
degrees of straight leg raising
or muscle strength
were considered secondary outcomes, because
these outcome measures may correlate poorly with
the clinical status of the patient.

Other symptoms such as medication use and

side effects were also considered.

The author did not do

meta-analysis, but

summarized the results using a rating system

with four levels of evidence (best evidence
synthesis), based on the quality and the
outcome of the studies :

1. Strong evidence - provided by generally

consistent findings in multiple high quality
RCTs;
2. Moderate evidence - provided by generally
consistent findings in one high quality RCT
plus one or more low quality RCTs, or by
generally consistent findings in multiple low
quality RCTs;

3. Limited or conflicting evidence - only one

RCT (either high or low quality) or
inconsistent findings in multiple RCTs;
4. No evidence - no RCTs.

Effectiveness of back schools

1a) Back schools versus other treatments for
acute/subacute LBP
Four RCTs
One high quality RCT reported positive
intermediate and long-term outcomes, and
the other high and low quality studies reported
no differences in short, intermediate and longterm out- comes between those receiving back
schools and other treatments.

b) Back schools versus other treatments for

chronic LBP
Six studies
Other conservative treatments were:
exercises,
spinal or joint manipulation,
myofascial therapy and
some kind of instructions or advice.

The high quality study and four low quality

showed better short and intermediate- term
pain relief and improvement in functional
status for the back school group.
Three low quality studies did not find any
differences in long-term out- comes.

There is moderate evidence that a back school

is more effective than other treatments for
patients with chronic LBP for the outcomes
pain and functional status (short and
intermediate-term follow-up).

There is moderate evidence that there is no

difference in long-term pain and functional
status between those receiving back school
and other treatments, for patients with
chronic LBP.

2a) Back schools versus waiting list

controls or placebo interventions for
acute/subacute LBP
Only one RCT compared back school with
placebo, i.e., short- waves at the lowest
intensity, for patients with acute and
subacute LBP and showed better short-term
recovery and return to work for the back
school treatment group

There is limited evidence that back

school is more effective than shortwaves
at the lowest intensity for patients with
acute and subacute LBP

2b) Back schools versus waiting list controls

or placebo interventions for chronic LBP
Eight RCTs were identified for this subgroup
analysis
Seven RCTs reported a mix of positive results,
with no differences in short and intermediateterm outcomes.
One high quality study found positive longterm outcomes on functional status and return
to work and two did not find any long-term
differences.

There is conflicting evidence on the

effectiveness of back schools compared to
waiting list controls or placebo interventions
on pain, functional status, and return to work
for patients with chronic LBP.

3) Back schools in occupational settings

Nine studies
three high quality studies and
six low quality studies included patients from an
occupational setting.

3a) Back schools in occupational settings versus

other treatments for acute/subacute LBP
Three studies, including two high quality studies,
examined the effect of a back school compared to
other treatments for acute and subacute patients.
One high quality study found positive intermediate
and long-term results for the back school .
The other high and low quality RCTs found no
short, intermediate or long-term differences
between the back school and other treatments.

3b) Back schools in occupational settings

versus other treatments for chronic LBP
Four
One RCT studied short and long-term
differences
two studied, intermediate and long-term
differences and
one study, only long-term differences.

There is moderate evidence that a back

school is more effective than other
treatments for patients with chronic LBP for
pain and functional status (short and
intermediate term follow-up).

4a) Back schools in occupational settings

versus waiting list controls or placebo
interventions for acute/subacute LBP
There is limited evidence that back school is
more effective than placebo for patients with
acute and subacute LBP

4b) Back schools in occupational settings

versus waiting list controls or placebo
interventions for chronic LBP
Three RCTs
Tw o s t u d i e s f o u n d p o s i t i v e s h o r t a n d
intermediate term results and
one did not find any long-term differences.

There is moderate evidence that a back

school is more effective than waiting list
controls for patients with chronic LBP for pain
and return to work (short and intermediateterm follow-up).

CONCLUSIONS
There is moderate evidence that back schools
conducted in occupational settings seem to be
more effective for patients with recurrent and
chronic LBP (as opposed to patients from the
general population or primary/secondary care)
than other treatments.
The most promising interventions consisted of a
modification of the Swedish back school and
were quite intensive (a three to five-week stay
in a specialized centre).

Implications for research

19 RCTs (3584 patients) were Identified that
evaluated the effectiveness of back schools.
Most of the studies included in this review
showed methodological deficiencies.
Clearly, there is a need for future high quality
RCTs to determine which type of back school is
the most effective for LBP patients.

Future RCTs should include :

An evaluation of the cost-effectiveness of
back schools and consider the clinical
relevance of the trial more during study
design and performance.

Effectiveness of Back School Versus

McKenzie Exercises in Patients With
Chronic Nonspecific Low Back Pain
A Randomized Controlled Trial
Alessandra. et .al
Physical Therapy
Journal of American Association of Physiotherapy
Published on February 21, 2013
doi: 10.2522/ptj.20120414

Objective
The purpose of this study was to compare the
effectiveness of Back School and McKenzie
methods in patients with chronic nonspecific
low back pain.
Design
The study was a prospectively registered,
2-arm randomized controlled trial with a
blinded assessor.

Setting
Outpatient physical therapy clinic of the
Universidade Cidade de Sao Paulo, Brazil.
From July 2010 and July 2012.

Inclusion Criteria
nonspecific low back pain of at least 3
months duration
between 18 and 80 years of age.

Exclusion Criteria
Patients with any contraindication to physical
exercise (American College of Sports Medicine)
serious spinal pathology
(eg, tumors,fractures, inflammatory diseases)
previous spinal surgery
nerve root compromise
cardiorespiratory illnesses or
pregnancy were excluded.

Randomization
A total of 148 subjects were enrolled out
of which :
74 were randomized into the Back School
group and
remaining 74 were assigned into the
McKenzie group

Interventions
Participants from both groups received 4, onehour sessions over 4 weeks, once a week.
All participants received the exercises under the
supervision of the physical therapist.
At the end of each treatment session,
participants were asked to perform the same
exercises at home once a day (3 sets of 10
repetitions that could be performed on the same
day or in different times of day depending on the
patients availability).

Patients in both groups received information in

order to maintain lordosis while sitting,
including patients with no direction preference
for extension, without exacerbating their
symptoms.
Patients in the McKenzie group with a direction
preference for extension also were instructed
to use a back roll while sitting

McKenzie group

Back School group

All participants received the treatments as

allocated.
Of these participants, 146 (98.6%) completed the
follow-up at 1 month
for the primary outcome measures of pain and
disability and
for the secondary outcome measure of quality of
life.

4 participants (5.5%) in the McKenzie group and

8 participants (10.8%) in the Back School group
could not be followed up for the secondary
outcome measure of trunk flexion range of
motion at 1 month due to an inability to attend
the clinic.
All participants completed the 3-month followup, and only one loss to follow-up in the Back
School group occurred for all outcomes at 6
months

Result
The author observed a reduction in pain intensity
and disability after treatment (1 month) in both
groups.
Participants allocated to the McKenzie group had
greater improvements in disability (treatment
effect;2.37 points, 95% CI;0.76 to 3.99) after
treatment (at 1-month follow-up).
There was no statistically significant between
group difference for pain (treatment effect:0.66
points, 95% CI:0.29 to 1.62).

Most of the
observed at
maintained
randomization
outcomes.

improvements in outcomes
short-term follow-up were
at 3 and 6 months after
for both primary and secondary

Participants allocated to the McKenzie group

had greater improvements in disability, but not
pain intensity, at 1-month follow-up compared
with participants allocated to the Back School
group.

Conclusion
Patients allocated to the McKenzie group
experienced greater improvements in disability,
but not in pain intensity, after treatment
compared with patients allocated to the Back
School group, but the magnitude of this effect
was small and possibly of doubtful clinical
importance.

EFFECTIVENESS OF BACK SCHOOL FOR

T R E AT M E N T O F PA I N A N D F U N C T I O N A L
DISABILITY IN PATIENTS WITH CHRONIC LOW
BACK PAIN
A RANDOMIZED CONTROLLED TRIAL
N. Sahin et al.
Journal of Rehabilitation Medicine
Published on 2011;
doi: 10.2340/16501977-0650

Objective:
To evaluate the effectiveness of the addition of
back school to exercise and physical treatment
modalities in relieving pain and improving the
functional status of patients with chronic low
back pain.
Design:
A randomized controlled trial.

Setting
Physical Medicine and Rehabilitation Clinic of
Meram Medical Faculty of Selcuk University,
Turkey
Inclusion Criteria
Patients who had had non-specific low back
pain
low back pain for longer than 12 weeks
without neurological deficits

Exclusion Criteria
subjects who had
continuous pain with a score above 8 on VAS,
age 18 years,
who had already attended the back school
programme,
who had undergone previous surgery,
who had structural anomalies,
spinal cord compressions,

severe instabilities,
severe osteoporosis,
acute infections,
severe cardiovascular or metabolic diseases,
who were pregnant, and
those with a body mass index above 30kg/m2

Evaluation criteria
Patients were evaluated
at the beginning,
after the treatment and
at 3 months post-treatment
1. for pain severity by VAS and
1. for functional aspects by Oswestry Low
Back Pain Disability Questionnaire (ODQ)

Sample
A total of 160 patients, who were referred or
self-referred to our outpatient clinic with
CLBP took part in this study.

Interventions
1. Exercise programme.
lumbar flexion exercises,
lumbar extension and
lumbar stretching exercises, and
strengthening exercises for the thighs.
The exercise programme was run by the same
physiotherapist, who was blinded to which
group the patient was allocated to,
in patient groups of 5 in an exercise room.

In addition, a written exercise programme was

given to the patients.
The exercises were repeated 5 times a week
for 2 weeks (total of 10 sessions) in the
exercise room and were controlled.
Afterwards, the patients were told to perform
the exercises at home 3 times a week for 3
months.

2. Physical therapy
A physical therapy programme, including
TENS,
ultrasound and
hot pack
once daily,
5 days a week
for 2 weeks,
totaling 10 sessions

TENS was applied as 100 Hz, 40 sN in

continuous waveform for 30 min/session.
Therapeutic ultrasound was applied as a
continuous wave with 1 MHz frequency and 1.5
W/cm2 intensity for 5 min.
The physical therapy programme was applied
once daily for 5 days a week for 2 weeks before
the exercise programme was started.

3. Back school programme.

consisted of 2 sessions per week for 2 weeks;
a total of 4 sessions.
Each session lasted 1 h and included both
didactic and practical training.
The programme was administered by a
physiatrist .

The aim of the back school was to teach

patients about
the functional anatomy of the low back,
the function of the back, pain,
the correct use of the lower back in daily life,
and
skills to enable them to cope with low back
problems,
increase self-esteem and improve their quality
of life, leading to a decrease in recurrence of
low back pain.

Patients were given written information by

the physician.
A sessions included 46 subjects.
In addition, the physiatrist interviewed and
assessed each patients lifestyle, physical
activity, and risk factors.

Each patient who joined the programme

explained his or her problems.
Subjects were then explained about the
problem-solving skills, and were instructed
in how to use low back movements in their
daily life during the programme.

Randomization
Samples were randomized in to two groups
Group 1 and Group 2

Group 1 (back school group: BSG) received

physical treatment modalities, exercise and the
back school programme.
Group 2 (control group: CG) received physical
treatment modalities and exercise.
Patients in all groups received 500 mg
paracetamol tablets as needed, up to 2 g per
day (up to 4 tablets a day) from the beginning of
the study.

RESULTS
A total of 146 patients completed the study
and attended the third-month control visits .
The mean age in the BSG
was 47.25 years (SD 11.22 years), whereas it
was 51.36 years (SD 9.65 years) in the CG.
There was no statistically significant
difference between the groups in terms of
age, gender, body mass index, occupation or
education (p > 0.05).

Within-groups
The decrease in VAS and ODQ values preand post-treatment was statistically
significant in both study groups
(VAS: 95% CI = 4.685.15; 5.125.58, ODQ:
95% CI = 39.8342.18; 43.5945.94, for BSGCG, respectively).
These result were statistically significant (p
< 0.01).

However, there was no significant difference

between post-treatment and third-month
controls in both groups
(VAS: 95% CI = 3.293.91; 4.004.62,ODQ: 95% CI
= 34.7537.51; 38.5541.31, for BSG-CG,
respectively).
These results were not statistically significant
(p > 0.05).

Between-groups
There was a significant reduction in VAS in the
BSG compared with the CG after the treatments
and at 3 months post-treatment
(0.665, 95% CI = 0.5640.767 and 0.205,
95% CI = 0.070 0.340).
These results were statistically significant
(p = 0.010 and p = 0.002, respectively).

Disability (ODQ scores) were significantly

lower in the BSG compared with the CG after
the treatments and at 3 months posttreatment
(1.011, 95% CI = 0.9291.093 and 0.844, 95% CI
= 0.7480.941).
These results were statistically significant (p <
0.001).

DISCUSSION
The author
observed that a back school
programme has an effect on pain and disability
when given in addition to physical treatment
modalities and exercises.
This effect was observed post-treatment and
at 3 months follow-up.

Limiting factors of the present study

are
the short-term follow-up,
lack of cost-analysis and
Few assessment criteria.

Effectiveness of a back school program in

low back pain
RCT
L.H. Ribeiro.at.el
Clinical and Experimental Rheumatology
Published on 2008

Objectives
To evaluate the effectiveness of a back school
program in
pain,
functional status,
quality of life, and in anxiety and
depression
in patients with non-specific low back pain.

Material and methods

Inclusion criteria
The study included 60 patients aged 18
to 65 years diagnosed with chronic
nonspecific low back pain, defined as pain
in the back, located between the last rib
and the gluteal fold, with mechanical
characteristics lasting more than 3 months.

Exclusion criteria
This constituted
previous back surgery,
spinal tumor,
spinal fracture,
pregnancy,
fibromyalgia,
inflammatory or infectious spinal diseases
and
litigant patients

Patients were recruited from rheumatology

and orthopedic outpatient clinics;
Sao Paulo Federal University,
Division of Rheumatology, Sao Paulo, Brazil;
from October 2002 to November 2003.

Procedures
1. Intervention group:
back school program,
which consisted of 5 one-hour group sessions
(four
consecutive once a week sessions and a fifth
reinforcement session after 30 days).
Sessions were instructed by a rheumatologist
and a physical therapist for groups of 10
participants.

Orientation was given regarding the anatomy

and physiology of the spine, causes and
treatment of low back pain, and ergonomic
guidelines relevant to back problems, such as
standing and sitting postures, reaching,
kneeling, twisting,lifting, pushing and pulling.

Abdominal and back strengthening exercises

were also performed.
After the exercises, sessions ended with a
relaxation posture in bed (semi-Fowler or psoas
position).

Control group:
patients were seen at 3 medical visits within a
four-week period (Week 1; Week 2; Week 4)
and at a fourth visit 30 days after Week 4.
Each medical visit was conducted by a
rheumatologist (other than the back school
instructor).

Patients were asked about their back problems

and medications taken to relieve pain.
A general physical examination and an
examination of the spine were performed.
No educational orientation was imparted to
the control group.

Follow-up assessment
The first assessment (T0) took place
immediately after randomization and before
initiating the intervention at a maximum
interval of seven days.
Other assessment visits took place 30 (T30), 60
(T60) and 120 (T120) days after initiating the
intervention.

The following assessment instruments were

used:
1. Schobers Test to assess the level of spine
mobility,
2. Visual Analogical Scale (VAS) for pain with
scores from zero to ten; and
3. the questionnaires SF 36 (Short Health Survey)
for quality of life,
4. Roland-Morris for functional status,
5. Beck Depression Inventory and
6. the State- Anxiety Inventory (STAI).

All questionnaires were translated into

the Portuguese language and validated .

Accountability of analgesic medication intake

(acetaminophen) supplied at each assessment
visit was also conducted.
Patients were instructed to take notes on the
number of analgesics they had taken every other
day.
The consumption of anti-infl ammatory
medication was considered co-intervention

Results
There were no significant differences in the
baseline characteristics between the two
groups.
Fifty-five patients completed the study.
The intervention group showed a significant
improvement in the general health domain,
assessed by SF-36, and also in the reduction of
acetaminophen and NSAID intake.

There was no significant difference

between the groups in
pain,
functional status,
anxiety or
depression

Conclusion
The back school program was more effective
than any educational intervention in general
health status and in decreasing acetaminophen
and NSAID intake.
It was ineffective in the other quality of life
domains, in pain, functional status, anxiety and
depression.

Take home message

Along with treatment if we educate patient
about the pathphysiology of back with respect
to the patient activities the improvement will
have lasting effect.
Occupation related back pain or disorders are
tackled more efficiently through back school,
so physiotherapist should actively involve in
industrial health programme /ergonomic sound
designs.