Review ArticleSystematic review of back schools, brief education, and fear-avoidance training for chronic low back pain
Introduction
Educational interventions have been given more attention since the Swedish Back School was introduced in 1969 [1]. It was based on current knowledge about the intervertebral disc, spinal anatomy and physiology, and ergonomic principles [2]. Patients were taught how to protect spinal structures in daily activities. Later, exercises were included [3], and back schools were incorporated in comprehensive multidisciplinary programs or functional restoration [4].
Observations of natural history and epidemiology suggest that low back pain usually is a benign, self-limiting condition. Waddell contrasted the traditional medical model of disease with a biopsychosocial model of illness to analyze success and failure in back pain disorders [5]. Inspired by his thoughts, Indahl et al. told patients that a possible crack in the disc might cause reflex muscle activation, but that light activity would not further injure the disc or other structures [6]. The clinical examination was supplemented by a brief education given by a physiatrist, physiotherapist (PT), or nurse, and patients were given guidelines and told to set their own goals. It was emphasized that the worst thing they could do to their back was to be too careful. The link between emotions and chronic low back pain (CLBP) was explained as increased tension in the muscles. Later, brief education has been managed in the physiotherapy setting [7], [8]. The value of pure educational approaches has been challenged [9].
Lethem et al. introduced the fear-avoidance model in 1983, and a questionnaire for measurement of fear-avoidance beliefs was published in 1993 [10], [11]. The central concept of the model is fear of pain. Confrontation and avoidance are postulated as two extreme responses to fear, of which the former leads to reduction of fear over time [12]. Avoidance leads to maintenance and exacerbation of fear, which may generate a phobic state. Physical performance and self-reported disability are associated with cognitive and behavioral aspects of pain, in addition to sensory and biomedical ones [13], [14], [15], [16], [17]. Graded activity programs versus direct exposure to produce disconfirmation of expected consequences of physical activity have been evaluated [18]. Behavior that may be caused by fear of movement is commonly observed. Patients informed or experienced that the “wrong movement” should be avoided, may have an increased the risk of disability [15], [19].
Although there is considerable overlap, back schools, brief education, and fear-avoidance training are different interventions. Back schools are defined as an intervention consisting of an education and skills program, including physical exercises. All lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist. PTs most commonly run back schools. Back schools have been evaluated in an occupational setting and as part of a multidisciplinary program [20]. Brief education includes interventions that involve brief contact with healthcare professionals, self-management patient-led groups, provision of educational booklets, and Internet discussion groups [21]. The degree of clinical involvement may range from zero, in the case of mailing a back booklet to the patient [22], to an intensive course [23]. The aim is to encourage active self-management and to reduce concerns. Fear-avoidance training is defined as an intervention addressing fears and encouraging normal activities and physical exercise. Fear-avoidance beliefs or kinesiophobia can be assessed by validated questionnaires [11], [24], [25].
Communication is a central part of the health care professional/patient relationship.
The impact on patients' fear of lessons about biomechanics to protect the spinal structures has not been addressed. Behavior that derives from pain avoidance is inhibitory and may contribute to chronicity [26]. At present, we do not know whether this inhibition constitutes a learning explanation for gradual development of depression with its low psychomotor level in all dimensions. Automated movements are unconscious, but may be brought to conscious analysis and observation. This conscious analysis occupies more brain capacity and reduces physical performance. Back pain may be viewed as a threatening situation and anxious persons give priority to thoughts and information related to their fear. The cognitive activation theory of stress attempts to explain how pain leads to neurophysiological activation [27]. The stress alarm occurs when there is a discrepancy between what is expected and what is experienced by the individual. This unpleasantness is no health threat, but if sustained, may lead to chronic back pain. The individual outcome expectancies may alter the stress response. A positive response outcome expectancy (coping) may reduce the stress response whereas a negative response (hopelessness) may increase the risk of sustained activation. The challenge in patients with CLBP is to balance information and expectancies regarding spinal structures and the adoption of pain behavior.
The aim of the present study was to systematically assess the effectiveness of back schools, brief education, and fear-avoidance training in patients with nonspecific CLBP excluding nerve root signs and specific pathology.
Section snippets
Methods
We have combined the text words “back school”, “patient education”, “information”, “pain management”, “fear avoidance”, “kinesiophobia”, and “pain-related fear” with the general search strategy outlined in this number of the Spine Journal. We evaluated randomized controlled trials (RCTs) included in the latest Cochrane Review [20] and the European Guidelines [21]. Additional RCTs were identified from the date of inclusion of the latest systemic review (SR) to August 2006 for back schools and
Back schools
We identified seven SRs, two of them were Cochrane Reviews [20], [21], [30], [31], [32], [33], [34]. The latest Cochrane Review included studies until November 2004 and included 21 reports of 12 trials [20]. Both the latest Cochrane Review and the European Guidelines achieved the best quality score according to the Oxman and Guyatt Index [28]. Back schools had been compared with waiting list controls or placebo interventions in eight trials and with other conservative treatments in six trials.
Discussion
Consistent recommendations are given for brief education in the clinical setting for return to work and short-term reduction of disability. Additional physiotherapy with brief intervention is not recommended for return to work (sensitivity analysis). In agreement with the European Guidelines, we found limited and conflicting evidence for the effectiveness of brief education given as a back book or Internet discussion. Consequently, but contrary to the European Guidelines, we conclude that we
Conclusion
Consistent evidence was found only for a recommendation of brief education in the clinical setting. Back schools and fear-avoidance training should be considered in particular settings and in future studies. The discordance between this SR, the Cochrane Review, and the European Guidelines, can mainly be attributed to more strict inclusion criteria and more strict use of evidence and recommendation rules in this SR. The inclusion of recently published studies did not change our conclusions.
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