A couple of years ago, I wrote a column for Dynamic Chiropractic titled "The Back School is Dead" (DC, December 18, 1995). I used the article in part to vent my frustration regarding the lack of participation in this area by chiropractors. I received some rather interesting feedback, but nothing has really happened since that time to alter my mind. If anything, I am more convinced now than ever about the lack of interest in this topic. While the use of back safety programs remains popular in many industrial settings, the back school has not received much in the way of positive press. In fact, in these days of evidenced-based health care, the back school may be on the endangered species list.
It would appear from the literature that preventing future episodes of back pain is extremely difficult. Recently, an article in the New England Journal of Medicine presented evidence to show that even a well-constructed back school was not a very useful tool and did not help in the prevention of back pain (Daltroy, et al.).
A review of the article published in the September, 1997 issue of The Back Letter was titled "Are Ergonomic Programs to Prevent Back Pain and Back Disability a Total Failure?" The authors state that "Fifty years into the back disability epidemic, no single strategy -- ergonomic or otherwise -- has been proven to be effective in the primary prevention of disabling back pain in the workplace." They refer to an editorial by Nortin Hadler in which he states the following:
- The ergonomic approach to the prevention of back pain is a failure.
- Back pain in the workplace rarely has a clear occupational cause.
- While risk factors for back pain have been identified, biomechanical and otherwise, the risk associated with any of these factors appears to be small.
- The concept of workplace "injury" is outmoded.
- Other aspects of workplace organization are more likely to explain compensable back pain than ergonomic considerations.
We must face the fact that there is little evidence that anything, including back school, can prevent future episodes of back pain from occurring. Perhaps it is normal to have back pain and we should focus more attention on coping with it rather than preventing it. Hadler states, "To get through the next year without a single episode of back pain is abnormal. Coping successfully should be the goal."
With so much evidence discounting the value of back school, is it time to throw in the towel? Absolutely not! As I indicated in my earlier column on the subject, back school is important not so much for preventing back pain, but for enabling people to cope. People are not as likely to become disabled by something that they understand. When presented with the realities of back pain, i.e. most people survive and live normal functional lives, much of the fear and stress created by the problem of back pain can be reduced. In my opinion, regardless of the fact that there is little evidence to show that back school can prevent future episodes of back pain, it is a vital part of the care of the back pain patient.
As such, I'd like to propose a somewhat different approach to the classic back school. When I was first in practice (way back in the days before managed care), I attempted a number of different ways to stimulate my practice. One of the most successful, although not the most comfortable, was the spinal care class. The class was held on a weekly basis and was mandatory for new patients. Patients were allowed, in fact they were encouraged, to bring friends and relatives. At the end of the class many of those in attendance who were not already patients were invited to make appointments for a free consultation. A significant number of these became chiropractic patients.
The information provided in the class included some basic anatomy and biomechanics of the spine, a description of the chiropractic model of health, and the role of chiropractic in the maintenance of health. Looking back, I must admit that those patients who attended the classes enjoyed the information provided and had a deeper commitment to chiropractic. The classes seemed to accomplish what they set out to do; i.e., to generate an understanding of chiropractic, to generate enthusiasm in my patients, and to generate new patients for my practice. I have to admit, however, that the focus of the class was more on patient recruitment than on providing any meaningful patient education. I'm not sure my patients came away with any real tools that they could use to improve their own health (other than monthly visits to their chiropractor, that is).
Perhaps it is worth considering combining the type of information provided in a classic back school with the format and enthusiasm of a spinal care class. What if we required our patients to attend a class designed to teach them how to lift, some first aid for back pain, and how to cope with future back problems? It wouldn't hurt to throw in a bit about the role of chiropractic in the maintenance of health. We'd have to be very careful about the promises we make in this area, though. After all, there isn't much evidence that chiropractic can prevent future episodes of back pain.
One of the most common findings in the various studies of back school is that patients are generally satisfied with the information provided. With increasing competition in the health care marketplace, patient satisfaction is becoming more and more important.
I remember a class that I attended nearly 23 years ago. While my wife Debbie was pregnant with our first child, we were required to attend a class on a Saturday afternoon at the obstetrician's office. I wasn't too excited about the idea of giving up a valuable Saturday, but I still remember sitting in his reception room and learning about what would happen when it was time to deliver. He covered such topics as which driveway to use when we got to the hospital, which door to use, which desk to sign in at, etc. To this day, I still appreciate the effort that he took to take some of the fear and uncertainty out of an otherwise stressful time. After the class, I was impressed that he gave up a Saturday afternoon for our benefit. I'd like to think that our patients can appreciate the extra effort that we go to provide them with useful information.
References
- Daltroy LH, et al. A controlled trial of an educational program to prevent low back injuries. New England Journal of Medicine 1997;337:322-8.
- Hadler NM. Workers with disabling back pain. New England Journal of Medicine 1997;337:341-43.
- Hadler NM. Back pain in the workplace: What you lift or how you lift matters far less than whether you lift or when. Spine 1997;22:935-40.
- Hooper PD. The back school is dead. Dynamic Chiropractic December 18, 1995.
- Are ergonomic programs to prevent back pain and back disability a total failure? The Back Letter Vol. 12, No. 9, Sept. 1997.
Paul D. Hooper, DC
Diamond Bar, California
Tel: (909) 598-6344
HoopPD-aol.com
