Back schools in prevention of chronicity

Multidisciplinary rehabilitation for chronic back pain in an outpatient setting: A controlled randomized trial

Based on existing models for pain chronicity and effective treatment strategies for patients with chronic low back pain, a multidisciplinary rehabilitation programme for an outpatient group setting was developed. The main treatment components address the patient's physical functional capacity (functional restoring), cognitive and affective processes (pain management strategies), and behavioural and ergonomical aspects (back school elements). Short-term (immediately after intervention) and long-term effects (at 6-months follow-up) of the intervention were assessed in a randomized controlled study. Dependent variables were pain measures, functional capacity, disability, muscular strength and endurance, pain and posture-related self-efficacy, attitudes, depression, well-being, behavioural habits and posture assessed by a standardized behavioural observation method. Immediately after the intervention, patients in the treatment group (n=36) showed significant improvement over patients in the control group (n=29) in all variables except depression and muscular strength and endurance. At 6-months follow-up, compared to pretreatment scores, patients continued to show beneficial effects in pain intensity and frequency, posture, posture-related self-efficacy and well-being. In contrast to post-treatment results, there were also significant improvements in strength and endurance. Overall results testify to the effectiveness of the intervention programme. Future studies (with larger sample sizes) should aim at a further improvement of functional capacity and disability perception, an analysis of differential treatment effects, and strategies for an improved long-term maintenance of the changes induced by the programme.

The effect of on-body lift assistive device on the lumbar 3D dynamic moments and EMG during asymmetric freestyle lifting

BACKGROUND

A new on-body personal lift assistive device was developed to reduce force requirements of back muscles during lifting and static holding tasks.

METHODS

Nine male subjects participated in the study. Twelve Fastrak sensors were used to record positions and rotations of the segments. Trunk muscles were normalized to maximum and integrated electromyographic amplitudes of the left and right thoracic erector spinae, lumbar erector spinae, external obliques, and rectus abdominalis were compared in asymmetrical lifting for three different loads (5 kg, 15 kg, 25 kg) using free style under two conditions: with and without a lift assistive device.

FINDINGS

The assistive device significantly reduced the required muscular effort of the lumbar and thoracic erector spinae (P=0.001) with no significant differences in the level of abdominal muscular activity. Average integrated electromyography amplitudes were reduced across all subjects by 23.9% for lumbar erector spinae, 24.4% for thoracic erector spinae, and 34.9% for the contralateral external oblique muscles. The assistive device had its greatest impact on smaller moments with 30% reduction in lateral bending, and 24% reduction in rotational moments, with only 19.5% a reduction in larger flexion-extension moments. To investigate whether the lift assistive device affected lifting kinematics, the device tensions were zeroed mathematically. No kinematic differences in lifting technique would explain this magnitude of moment reduction.

INTERPRETATION

The on-body assistive device reduced the required muscular effort of the lumbar and thoracic erector spinae without adversely affecting the level of abdominal muscle activity. These reductions were mirrored by similar 3D moment reductions.

The INTERMED questionnaire for predicting return to work after a multidisciplinary rehabilitation program for chronic low back pain

OBJECTIVES

To evaluate the performance of the INTERMED questionnaire score, alone or combined with other criteria, in predicting return to work after a multidisciplinary rehabilitation program in patients with non-specific chronic low back pain.

METHODS

The INTERMED questionnaire is a biopsychosocial assessment and clinical classification tool that separates heterogeneous populations into subgroups according to case complexity. We studied 88 patients with chronic low back pain who followed an intensive multidisciplinary rehabilitation program on an outpatient basis. Before the program, we recorded the INTERMED score, radiological abnormalities, subjective pain severity, and sick leave duration. Associations between these variables and return to full-time work within 3 months after the end of the program were evaluated using one-sided Fisher tests and univariate logistic regression followed by multivariate logistic regression.

RESULTS

The univariate analysis showed a significant association between the INTERMED score and return to work (P<0.001; odds ratio, 0.90; 95% confidence interval, 0.86-0.96). In the multivariate analysis, prediction was best when the INTERMED score and sick leave duration were used in combination (P=0.03; odds ratio, 0.48; 95% confidence interval, 0.25-0.93).

CONCLUSION

The INTERMED questionnaire is useful for evaluating patients with chronic low back pain. It could be used to improve the selection of patients for intensive multidisciplinary programs, thereby improving the quality of care, while reducing healthcare costs.

Patients' perspectives on self-management following a back rehabilitation programme

OBJECTIVE

The management of chronic low back pain (CLBP) is becoming increasingly demanding upon health care services and society. Programmes combining exercise, education and a biopsychosocial approach have become a popular way of managing CLBP. Programmes are designed to change behaviour, increase activity levels and encourage self-management. Patients' experiences of attending a back rehabilitation programme were examined.

METHODS

This study used a qualitative approach combining interviews, non-participant observation and evaluation of documentation to establish the patients' perspective of self-management following a back programme.

RESULTS

All the patients (n = 6 ) indicated they were self-managing by continuing to exercise and utilizing the advice given after attendance. Two patients felt they should continue attending the therapy department to exercise in order to gain benefit, demonstrating reliance on continued health care support. Obstacles to continuing with exercise were cited as pain, time, and family constraints. Patients also expressed limitations following attendance regarding the type and level of activity their CLBP would allow them to manage. The data suggested activity limitation was inadvertently reinforced by the therapists during the sessions, in the programme letter and by the patients' existing beliefs regarding the cause of their CLBP.

CONCLUSION

The study demonstrated the importance of understanding patients' beliefs and expectations prior to a back programme and accounting for these during attendance. This study also highlighted that all heath care professionals should be aware of the impact of the language and terminology used when working with CLBP patients.

The weight of schoolbags and the occurrence of neck, shoulder, and back pain in young adolescents

STUDY DESIGN

A cross-sectional study of 745 young adolescents in the area of two Regional Health Centers in the Netherlands.

OBJECTIVES

To assess the occurrence of neck and/or shoulder and back complaints in young adolescents and examine relationships with type and weight of schoolbags and other physical and psychologic risk factors.

SUMMARY OF BACKGROUND DATA

The occurrence of back pain in children and adolescents varies from 8% to 74% in the literature. Age, gender, and certain psychological factors appear to be important risk factors. An association with heavy schoolbags has been presumed but without clear scientific evidence.

METHODS

A questionnaire was used, asking about complaints of back, neck, and/or shoulders and about potential risk factors including psychosomatic factors. Length and weight of the children were determined. Schoolbags were weighed, and the relative weight of the schoolbag was calculated.

RESULTS

Neck and/or shoulder complaints and also back complaints were reported by about 45% of young adolescents. Severe complaints of neck and/or shoulder were reported by 6%, and severe back complaints by 7% of the schoolchildren. The (relative) weight of schoolbags was not related to complaints of neck and/or shoulder and back. Psychosomatic factors showed the strongest association with the occurrence of neck and/or shoulder and back complaints.

CONCLUSION

Psychosomatic factors appear to be more strongly related to the occurrence of neck and/or shoulder and back complaints than the type and weight of the schoolbag and other physical factors. The role of psychosomatic factors should be further explored in future longitudinal research.

Early identification and intervention in the prevention of musculoskeletal pain

BACKGROUND

A large number of people suffer from upper extremity disorders, but a few apparently consume the majority of the resources. Early interventions are badly needed to prevent the development of persistent disability. Since psychological factors are central in the development of a chronic problem these might be utilized in this endeavor.

METHODS

A series of studies are described where a screening procedure based on psychological risk factors was employed to help identify people at risk for developing long-term work disability. The utility of a cognitive-behavioral group intervention that focuses on coping strategies as prevention was assessed in three randomized-controlled studies where participants had low, medium, and high risk, respectively.

RESULTS

The study with low risk showed no significant difference between the groups, while the studies with medium- and high-risk populations demonstrated significantly lower work disability than control groups receiving treatment as usual.

CONCLUSIONS

It appears to be feasible to identify patients with high levels of risk and to subsequently lower the risk for work disability by administering a cognitive-behavioral intervention focusing on psychological aspects of the pain problem.

Early intervention for acute back injury: can we finally develop an evidence-based approach?

OBJECTIVE

Several reviews of the treatment of acute low back pain have been published in the past and have formed the basis of clinical guidelines. However, these lack consistency in some areas and valid data in others. As the literature in this field has continued to expand, the present review was undertaken to establish whether the guidelines in current use are supported by more recently published, scientifically rigorous research, and whether additional consensus regarding treatment of acute low back injury has been forthcoming in recent years.

DESIGN

A review, and critical analysis, of literature relating to the treatment of acute low back pain that has been published since the production of the currently used clinical guidelines. The guidelines have been reviewed to assess whether their recommendations remain supportable.

CONCLUSIONS

Recent research appears to support current clinical guidelines, i.e. exercise may have a positive effect while bed rest is ineffective and may be harmful, simple analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) have short-term benefits, and spinal manipulation may be effective in the first four weeks; no evidence was found for traction or back schools. However, we need more randomized controlled trials of treatments shown to be successful with the chronic population, e.g. focused on understanding psychological determinants, and using a multidisciplinary biopsychosocial approach. In the future this may help us to prevent acute low back progressing to the chronic state.

Postural hygiene program to prevent low back pain

STUDY DESIGN

A quasi-experimental study with 3 x 4 design was performed.

OBJECTIVE

To improve the level of knowledge and motor skills and thereby avert the development of painful symptoms.

SUMMARY OF BACKGROUND DATA

Despite the fact that low back pain affects a high percentage of the population, little research has been carried out to prevent low back pain through health education.

METHODS

The participants in this study were 106 third-grade (9-year-old) students. The program included 11 sessions. The teacher attended the placebo group sessions. No intervention was used with the control group.

RESULTS

The level of knowledge and motor skills in the experimental group showed a significant increase immediately after the intervention finished, and at 6- and 12-month intervals after completion of the postural hygiene program (P = 0.00). Some positive changes were generalized to natural situations (P = 0.00). In an independent health check carried out by the local school health services 4 years after application of the postural hygiene program, the results tended slightly to favor the experimental condition over the control conditions (placebo + no intervention). A greater number of the control subjects required medical treatment for low back pain, although this difference was only marginally significant (P = 0.07).

CONCLUSIONS

The findings from this study support the hypothesis that programs involving practice and motivating strategies impart health knowledge and habits more efficiently than those restricted to the mere transmission of information.

Preventive interventions for back and neck pain problems: what is the evidence?

STUDY DESIGN

A review of controlled trials.

OBJECTIVES

To determine which interventions are used to prevent back and neck pain problems as well as what the evidence is for their utility.

SUMMARY OF BACKGROUND DATA

Given the difficulty in successfully treating long-term back and neck pain problems, there has been a call for preventive interventions. Little is known, however, about the value of preventive efforts for nonpatients, e.g., in the general population or workplace.

METHODS

The literature was systematically searched to locate all investigations that were: 1) specifically designed as a preventive intervention; 2) randomized or nonrandomized controlled trials; and, 3) using subjects not seeking treatment. Outcome was evaluated on the key variables of reported pain, report of injury, dysfunction, time off work, health-care utilization, and cost. Conclusions were drawn using a grading system.

RESULTS

Twenty-seven investigations meeting the criteria were found for educational efforts, lumbar supports, exercises, ergonomics, and risk factor modification. For back schools, only one of the nine randomized trials reported a significant effect, and there was strong evidence that back schools are not effective in prevention. Because the randomized trials concerning lumbar supports were consistently negative, there is strong evidence that they are not effective in prevention. Exercises, conversely, showed stable positive results in randomized controlled trials, giving consistent evidence of relatively moderate utility in prevention. Because no properly controlled trials were found for ergonomic interventions or risk factor modification, there was not good quality evidence available to draw a conclusion.

CONCLUSIONS

The results concerning prevention for subjects not seeking medical care are sobering. Only exercises provided sufficient evidence to conclude that they are an effective preventive intervention. There is a dire lack of controlled trials examining broad-based multidimensional programs. The need for high quality outcome studies is underscored.

Readiness to adopt adequate postural habits: an application of the Transtheoretical Model in the context of back pain prevention

Based on a biomechanical model, an adequate body posture can contribute to the prevention of back pain and back pain chronicity. This study examines the explanatory value of the Transtheoretical Model (TTM) for the adoption of adequate postural habits in a cross-sectional sample of 149 employees of a German administration unit (mean age 40.2 years, 50% female). Using newly developed instruments with satisfactory psychometric properties, basic assumptions of the TTM could be confirmed: self-efficacy and the perceived pros for maintaining a good body posture increased significantly across the stages, while the perceived cons decreased. Additionally, the use of preventive strategies for back pain prevention increased linearly and significantly across the stages of change. The study supports the applicability of the TTM for postural behavior. Considering stages of change as an intervening variable may contribute to clarifying the relationship between participation in low back schools and prevention of back pain chronicity. Longitudinal and intervention study data are needed to support these assumptions.

A systematic review of controlled clinical trials on the prevention of back pain in industry

OBJECTIVE

To assess the effectiveness of lumbar supports, education, and exercise in the prevention of back pain in industry.

METHODS

A computerised search for controlled clinical trials was conducted. A criteria list was used to assess the methodological quality of the studies. The available evidence for the effectiveness of the interventions was graded with a rating system for the level of evidence. Effect sizes of individual studies were combined if the studies were sufficiently similar.

RESULTS

11 studies were identified for the review. The methodological quality of all studies was low, with a maximum score of three out of seven for internal validity. There was no evidence for the effectiveness of lumbar supports due to contradictory outcomes of the studies. Five of the six studies on education reported no effect. Thus there is limited evidence that education does not help to prevent back pain. All three studies on exercise reported a positive result, indicating limited evidence for the effectiveness of exercise. The combined effect size for exercise was 0.53, which is a medium sized effect.

CONCLUSIONS

Although widely used, there is little evaluative research on the preventive measures studied here. The review showed that there is limited evidence that exercise has some effect in the prevention of back pain and that education is not effective. No conclusive evidence was found for or against the effectiveness of lumbar supports. Research of higher methodological quality is needed before firm conclusions on the effectiveness of lumbar supports, education, and exercise in the prevention of back pain in industry can be drawn.

An assessment of lower back pain in young adults: implications for college health education

A convenience sample of 243 undergraduates completed a 36-item questionnaire on their knowledge about back care and exercise patterns before they attended lectures and a workshop on back mechanics. At the workshop, the students were individually evaluated for posture, hamstring flexibility, hip flexor flexibility, back and abdominal strength, and lifting technique. Twenty-nine percent of the students reported that they experienced no back pain; 71% experienced lower back pain 1 to 5 days a week. The majority were neglectful of their posture, lifting and carrying techniques, and scored fair-to-poor on the hamstring flexibility test, possibly foreshadowing back problems in later life. The majority of respondents were unsure of what exercises to do for back care. Within the subgroup of students who claimed they were knowledgeable about exercise, more than 50% were performing ineffective and potentially harmful exercises. The results underscored the potential worth of health education on back care offered through didactic instruction and experiential workshops.

Screening for patients at risk of developing chronic incapacity

Formal investigations of psychiatric disorders and long-term personality characteristics have been relatively unhelpful in the prediction of future incapacity. Clinical studies of pain patients have led to a new range of more specific measurement instruments assessing different aspects of psychological functioning: such as pain behavior, distress, beliefs about pain, and coping strategies. Recent investigations of patients with acute back problems have identified a strong relationship between levels of distress, dysfunctional coping strategies, and future disability. Measurement instruments specifically validated for occupational settings still need to be developed, but preliminary studies suggest that fear of hurting/harming, job stress, and job satisfaction may be important factors. A pilot study into occupationally-oriented back pain management for the unemployed is reported. Results suggest that such clients may have significantly more rehabilitation potential than has previously been believed.

Back injury prevention programs: A critical review of the literature

Back schools are increasingly utilized as an injury prevention strategy employed at the worksite. Yet, evidence of the efficacy of back schools is limited and controversial. A review of the literature showed variance in methodologies and consequently, outcomes. Outcome measures used include physical capacity, functional abilities, costs, lost time, absenteeism, perception of pain, lifting performance, attitudes, and job satisfaction. In many studies, lack of randomization and control was found to be a limitation in experimental design. Studies which used the behavioral approach of measuring lifting behavior lacked followup and evidence of long-term effects. The type of education and feedback or reinforcement was an important issue not well-defined in the literature. A variety of hypothetical mechanisms were described as contributing to the outcome of back injury prevention programs. Additional controlled research is necessary to determine the specific mechanisms of change in an effort to further improve outcome in this area.