Back schools for acute and subacute non-specific low-back pain

Review question

The aim of the review was to assess the effectiveness of back schools on pain, disability, work status and adverse events compared to another treatment, a placebo (sham treatment) or no treatment for acute and subacute non-specific low-back pain.

Background

Low-back pain is a burden in Western societies and causes high costs in terms of healthcare costs and loss of productivity. It is a common disorder that affects 12% to 30% of the population everyday. Back school is a therapeutic programme which includes both education and exercise, and is given to groups of participants and supervised by a healthcare provider. It was introduced in Sweden in 1969 and the content and length of back schools seem now to vary widely.

The target population of this review were people with acute and subacute (between acute and chronic) non-specific low-back pain. We defined non-specific low-back pain as pain localised below the scapulae (shoulder blade) and above the cleft of the buttocks without any specific cause detectable (e.g. infection, neoplasm, metastasis, osteoporosis, rheumatoid arthritis, fracture or inflammatory process). Acute and subacute pain means that the pain did not last more than six and 12 weeks, respectively. Our primary outcomes were pain and disability, and our secondary outcomes were work status and adverse events.

Study characteristics

We included four studies in this review, which we included in the previous version of this review, which means that we did not identify any new relevant studies for inclusion in this update. The treatment comparisons were too dissimilar to be pooled and half of the studies were at high risk of bias. The quality of the evidence was very low for all outcomes.

One study compared back school with a placebo (sham treatment) and found no difference between groups for pain at short-term follow-up. Concerning work status, people in the back school group had a significantly shorter duration of sick-leave than people in the placebo group at short-term follow-up.

Four studies compared back school with another treatment (physical therapies, myofascial therapy, joint manipulations, advice). Overall, there were no differences between groups for pain, disability, work status and adverse events at any time of follow-up. Only one study showed that back school added to a back care programme was more effective than back school alone for disability at short-term follow-up.

Key results

The included studies are insufficient to clearly answer our question and the inclusion of other well-designed studies is very likely to change the conclusions. However, back schools do not seem to be a treatment widely used nowadays for people with acute and subacute non-specific low-back pain and are not endorsed by guidelines.

Quality of the evidence

The quality of the evidence was very low for all the outcomes according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. This was due to poor study designs and imprecision in the results.

Authors' conclusions: 

It is uncertain if back schools are effective for acute and subacute non-specific LBP as there is only very low quality evidence available. While large well-conducted studies will likely provide more conclusive findings, back schools are not widely used interventions for acute and subacute LBP and further research into this area may not be a priority.

Read the full abstract...
Background: 

Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating people with low-back pain (LBP). However, the content of back schools has changed and appears to vary widely today. In this review we defined back school as a therapeutic programme given to groups of people, which includes both education and exercise. This is an update of a Cochrane review first published in 1999, and updated in 2004. For this review update, we split the review into two distinct reviews which separated acute from chronic LBP.

Objectives: 

To assess the effectiveness of back schools on pain and disability for people with acute or subacute non-specific LBP. We also examined the effect on work status and adverse events.

Search strategy: 

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, PubMed and two clinical trials registers up to 4 August 2015. We also checked the reference lists of articles and contacted experts in the field of research on LBP.

Selection criteria: 

We included randomised controlled trials (RCTs) or quasi-RCTs that reported on back school for acute or subacute non-specific LBP. The primary outcomes were pain and disability. The secondary outcomes were work status and adverse events. Back school had to be compared with another treatment, a placebo (or sham or attention control) or no treatment.

Data collection and analysis: 

We used the 2009 updated method guidelines for this Cochrane review. Two review authors independently screened the references, assessed the quality of the trials and extracted the data. We set the threshold for low risk of bias, a priori, as six or more of 13 internal validity criteria and no serious flaws (e.g. large drop-out rate). We classified the quality of the evidence into one of four levels (high, moderate, low or very low) using the adapted Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We contacted study authors for additional information. We collected adverse effects information from the trials.

Main results: 

The search update identified 273 new references, of which none fulfilled our inclusion criteria. We included four studies (643 participants) in this updated review, which were all included in the previous (2004) update. The quality of the evidence was very low for all outcomes. As data were too clinically heterogeneous to be pooled, we described individual trial results. The results indicate that there is very low quality evidence that back schools are no more effective than a placebo (or sham or attention control) or another treatment (physical therapies, myofascial therapy, joint manipulations, advice) on pain, disability, work status and adverse events at short-term, intermediate-term and long-term follow-up. There is very low quality evidence that shows a statistically significant difference between back schools and a placebo (or sham or attention control) for return to work at short-term follow-up in favour of back school. Very low quality evidence suggests that back school added to a back care programme is more effective than a back care programme alone for disability at short-term follow-up. Very low quality evidence also indicates that there is no difference in terms of adverse events between back school and myofascial therapy, joint manipulation and combined myofascial therapy and joint manipulation.

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