Back schools for non-specific low-back pain.
BACKGROUND
Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating patients with low-back pain (LBP). However, the content of back schools has changed and appears to vary widely today.


OBJECTIVE
To assess the effectiveness of back schools for patients with non-specific LBP.


METHODS
We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials to May 2003 for relevant trials reported in English, Dutch, French or German. We also screened references from relevant reviews and included trials.


METHODS
Randomized controlled trials (RCTs) that reported on any type of back school for non-specific LBP were included.


METHODS
Four reviewers, blinded to authors, institution and journal, independently extracted the data and assessed the quality of the trials. We set the high quality level, a priori, at a trial meeting six or more of 11 internal validity criteria. As data were clinically and statistically too heterogeneous to perform a meta-analysis, we used a qualitative review (best evidence synthesis) to summarize the results. The evidence was classified into four levels (strong, moderate, limited or no evidence), taking into account the methodological quality of the studies. We also evaluated the clinical relevance of the studies.


RESULTS
Nineteen RCTs (3584 patients) were included in this updated review. Overall, the methodological quality was low, with only six trials considered to be high quality. It was not possible to perform relevant subgroup analyses for LBP with radiation versus LBP without radiation. The results indicate 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 LBP. There is moderate evidence suggesting that back schools for chronic LBP in an occupational setting, are more effective than other treatments and placebo or waiting list controls on pain, functional status and return to work during short and intermediate-term follow-up. In general, the clinical relevance of the studies was rated as insufficient.


CONCLUSIONS
There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain, and improve function and return-to-work status, in the short and intermediate-term, compared to exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls, for patients with chronic and recurrent LBP. However, future trials should improve methodological quality and clinical relevance and evaluate the cost-effectiveness of back schools.
Heymans
M W
MW
VUMC/Institute for Research in Extramural Medicine, Van der Boechorststraat 7, Amsterdam, Netherlands, 1081 BT.
van Tulder
M W
MW
Esmail
R
R
Bombardier
C
C
Koes
B W
BW
D015444:Exercise; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D010353:Patient Education as Topic; D016032:Randomized Controlled Trials as Topic; D012574:Schools