Back School

Original Editor - Lien Hennebel

Top Contributors - Sheik Abdul Khadir, Lien Hennebel and Rachael Lowe  

Definition/Description intervention

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 paramedical therapist (a physiotherapist). [1][2]

However this is a common definition, the intensity and content of back schools differ. For example, the existence of high- and low intensity back schools. [3]

The target population for back training: [4]

  • Patients who have never had low back pain (primary intervention).
  • Back school, as a means of secondary prevention, are indicated for patients who have to contend with acute, chronic low back pain or with recurrence a-specific low back pain (but also post-operative patients or patients with a disc prothesis).

Back school is aimed at people with low back pain that can be linked to the clinically relevant anatomy.

Clinically Relevant Anatomy

The intervertebral disc consists of three parts [4] : Lumbosacral Biomechanics

  •  Anulus fibrosus
  •  Nucleus pulposus (surrounded by the anulus fibrosus)
  •  Vertebral end plate

Characteristics/Clinical presentation

The biomechanical principles:

  •  Functional load / compression on the nucleus pulposus results in a deformation without changing the volume of the nucleus.
  • When a persistent compression is applied to the anulus fibrosus, it will release water. The height of the disc decreases, so there is more compression on the nucleus pulposus.
  • The disc needs compression to maintain the metabolic activity of the disc, osmotic system of the disc Lumbosacral Biomechanics. But when the compression is too high, the intradiscular pressure increases and can develop in low back pain.
  • Some body postures and movements increase this intradiscal pressure. The purpose of back school is to teach how these movements and postures can be avoided and to avoid this increasing intradiscal pressure.

For example, the intradiscal pressure by lifting a box. On the graph you can see the intradiscal pressure by two types of lifting. It’s by the principal of the lever. As the load and load arm are smaller, the force required to keep the lever in balance is smaller too.[4]

Biomechanical 2.jpg

Fig. 1: When you lift a box with a rounded back, the intradiscal pressure increases with a sharp peak. It's better you lift a box with a straight back.[4]

The ideal posture for sitting in front of the computer 

                                                  Computer-posture.jpg

Fig. 2: Desk top Ergonomics

Physical Therapy Management (Content of the lessons)

In 1969, the Swedish back school was introduced by Zachrisson-Forsell and was frequently used for reducing pain and preventing recurrent episodes of low back pain. The programs of back schools have evolved over the years... [1] [4]

Goals of patients who attend a back school:

  • Functional recovery: protect the spinal structures in daily activities and in the occupational setting
  • Reduce symptoms (pain)
  •  Increasing tissue repair
  •  Decrease kinesiophobia 
  • .....

To achieve these goals, the back school consists of three parts:

  1.  Information about the anatomy and function of the spine, spinal biomechanics, physiopathology of frequent back disorders, epidemiology… Nowadays, this part of back school (giving information) is limited as compared to the back school in 1969 [4]
  2. Systematic training in the back school rules for posture, standing, lifting, bending, lying, sitting...This back school rules are different for the occupational settings. For example:[4]  
    -  Sedentary work as a banker. A banker sits the whole day, so it’s important he’s 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 at waist level. The waist is situated a little higher than the knees and leaning with a straight back against the backrest. It’s also important his worksheet is situated at a correct height.
    -  Lifting techniques in the building industry, childcare, healthcare (manutention)…
    -  …
  3. Active protection of the spine by active exercises, for example some exercises:[4][5]                                                                   - 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).
    - Stretching of the lower limbs muscles
    - Stretching of the erector spinae muscles
    - Kinaesthetic training (move pelvis making a front and back pelvic inclination at a comfortable range)
    - Strengthening of the abdominal musculature (stabilizing function)
    - …

Comment: The physiotherapist teaches the patients a correct posture and movements, but it’s important that he is 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, diffusion, took place. (biomechanical principles)[4]  

Key Evidence

Moderate evidence* suggests that back schools have better short- and intermediate-term effects on the functional status and pain than other treatments for patients with recurrent and chronic low back pain (LBP) Moderate evidence* suggests that a back school for chronic LBP in an occupational setting are even more effective than the other treatments. [1] [3]

  • Moderate evidence = Provided by findings in multiple low quality RCT’s (level of evidence 2B) or findings in one high quality RCT (level of evidence 1B) plus one or more low quality RCT’s.

Recent Related Research (from Pubmed)

References

  1. 1.0 1.1 1.2 Heymans, M., Van Tulder, M., Esmail, R., Bombardier, C., Koes, B., 'Back schools for nonspecific low back pain', Spine, 2005, Vol. 30, nr. 19, p. 2153-2163 (Level of evidence 1A)
  2. Brox, J.I., Storheim, K., Grotle, M., Tveito, T.H., Indahl, A., Eriksen, H.R., 'Systematic review of back schools, brief education and fear-avoidance training for chronic low back pain', The spine journal, 2008, Vol. 8, p. 948-958 (Level of evidence 1A)
  3. 3.0 3.1 Heymans, M., De Vet, H., Bongers, P., Knol, D., Koes, B., Van Mechelen, W., 'The effectiveness of high-intensity versus low-intensity back schools in an occupational setting', Spine, 2006, Vol. 31, nr. 10, p. 1075-1082 (Level of evidence 1B)
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Kraemer, J., Hasenbring, M., Kraemer, R., Taub, E., Theodoridis T., Wilke, H.J., 'Intervertebral disk diseases: causes, diagnosis, treatment and prophylaxis', Thieme, 2009, p. 321-327
  5. Garcia, A., Gondo, F., Costa, R., Cyrillo, F., Silva, T., Costa, L. CM, Costa, L. OP, 'Effectiveness of the back school and mckenzie techniques in patients with chronic non-specific low back pain: a protocol of a randomised controlled trial', BMC Musculoskeletal Disorders, 2011, nr. 12