The Back School Is Dead!

In most of my columns I have attempted to support my comments with facts, figures and references. But not this time. Today, I want to simply offer my opinion.

After years of denial I must grudgingly admit something that I have really known for a long time. The Back School is dead! It is dead at least in the chiropractic profession. While this may not come as a big surprise to many of you, it hurts to admit. After all, I have been one of the strongest supporters of the Back School concept for years.

My interest began in 1979 when, in an effort to develop an education program for my patients, I began to investigate the use of exercises for low back pain. Delving into the current literature concerning what exercises were the most effective, I immediately ran across the term "Back School." Although I considered myself relatively knowledgeable in the area of back pain, I had been completely unaware of the existence of such a program. I was initially surprised to learn that there was so much interest and activity in this topic. At the same time, I was somewhat embarrassed that most of the information came from sources outside my profession. In fact, the Back School concept was the brainchild of a physical therapist (Zachrisson-Forsell, 1972) and the only book written about the subject (at the time) was authored by an orthopedic surgeon (White, 1978). There was, and still is, only limited activity within the chiropractic profession.

Since my initial exposure to the Back School, I have been an avid student of the concept of providing education to patients with back pain. I have read all that I can find that has been published about the topic. I have attended a variety of programs to gain first-hand knowledge of different approaches. I have visited various back school programs and facilities and I have talked to anyone who appears to have an interest in or experience with the back school. I have tried a variety of approaches to teaching individuals how to prevent back pain and, over the years, have personal experience involving methods that work as well as methods that don't. I have developed my own program based on my interpretation of the problems involved (Hooper, 1992 b).

In addition to developing my own Back School program and approach, I have taught dozens of seminars to hundreds of chiropractors and chiropractic students. I took the time to write a book on how to develop a Back School. Unfortunately, it didn't sell very well and, like White's book from 1978, it quickly went out of print. Finally, after all the effort and energy that I have exerted, I am finally willing to admit defeat. I don't think that most chiropractors are interested in this topic!

In contrast to my experience with clinicians, I have found a growing interest in industry. In fact, as the costs for health care continue to rise, the interest in prevention has also increased. As a matter of interest, the Public Service of the United States Department of Health and Human Services has a stated objective of increasing the number of back safety training programs (i.e., Back Schools) in American industry (PHS, 1991). Combined with the escalating costs for back pain, an increasing demand for prevention, and an increasing awareness and respect for chiropractic, things look pretty optimistic. With such a positive outlook it would seem that chiropractors would be standing in line to implement Back School programs. The recent increase in the number of postgraduate rehabilitation programs in the chiropractic profession would tend to lend support to the promotion of Back School, and yet interest in the continued development and implementation of the Back School appears to be declining in chiropractic. For example, none of the rehabilitation programs currently offers the Back School as a singular component. In most, it is simply described as a part of the process with very little emphasis. I have been told that the reason for this is there just isn't enough evidence to justify the use of Back School. A similar comment was made recently by Cohen et al.(1994). After an extensive review of the available literature regarding the effectiveness of the Back School the authors concluded that there is insufficient evidence to recommend group education for people with low back pain. In response, Hall wrote, "After a career in medical and public education, I am convinced that group teaching benefits patients with low back pain. I view the authors' accurate analysis of the current literature, not as a condemnation of my intuition, but as a challenge to prove that education works " (Hall and Hadler, 1995). I must admit, I agree with Hall.

Let's look at some reasons why the evidence is not very supportive of group education for patients with back pain. One of the primary reasons for providing information to patients is the hope that we can reduce the likelihood of future problems. In this regard, I have to agree with Cohen. There is no evidence that the Back School can accomplish this. But then, there isn't much evidence that anything else can produce a reduction in future episodes of back pain. Another reason for educating individuals about their back is to teach them how to use their body more safely and effectively. For example, it is common in a Back School setting to teach individuals safe lifting techniques. Unfortunately, there is little evidence that attending a Back School actually affects the way individuals lift. In fact, there is evidence that it has little effect on the way patients perform their normal activities. It doesn't seem to change things much. So what's the point? If the Back School doesn't reduce the incidence of future episodes of back pain and doesn't appear to affect the way people do things, why bother?

While the reasons cited for using the Back School are probably the most common, it is clear that the Back School has not been successful in these areas. It has long been my contention that the Back School accomplishes something far more important than teaching people how to lift safely. It teaches them not to fear back pain. It gives them some control over their situation and encourages them to become active participants in their own recovery. Like McKenzie's active approach to patient care, the Back School teaches patients with low back pain not to fear pain but to understand it. Since so many patients with back pain are fearful of what the future holds, the information provided in the Back School provides significant reassurance, comfort and encouragement.

I am firmly convinced that the greatest benefit of the Back School is not in its demonstrated inability to change the way patients lift. Nor is it in the reduction of future episodes of back pain. Rather, the greatest strength of the Back School is a result of the positive effects of information on the person with back pain. It has been my experience that patients don't fear that which they understand. It has also been my experience that patients who don't fear movement tend to recover more rapidly.

The most important aspect of the Back School is not addressed in the literature that Cohen reviewed. The Back School affects how patients respond to future episodes of back pain. Since the highest risk factor for developing back pain is a prior history of back pain it may be assumed that patients who suffer with back problems once are, in all probability, going to have problems again. It is, therefore, most important to teach patients how to respond to and how to manage their back problems once an injury occurs. Rather than responding in fear and alarm, patients who have been provided with appropriate first aid information may actually have control over their situation. The correct response to injury can affect the duration and severity of any future episodes of back pain.

So where do we go from here? Do we, as a profession, give up on the concept of Back School as a viable part of chiropractic practice? Do we relegate education of back injured patients and back injured workers to other professions? Do we, as specialists in back pain, ignore the process of educating patients with back pain? Or do we, as White suggested, become "... the largest body of spine care specialists with the most tools with which to treat spinal problems" (White 1992).

References

Cohen JE, Goel V, Frank JW, Bombardier C, Peloso P, Guillemin F. Group education interventions for people with low back pain: An overview of the literature. Spine 1994;19:1214-22

Hall H, Hadler NM. Education or Exercise? Spine 1995; 20(9):1097-1098

Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS Publication No. (PHS) 91-50213, US Dept. of Health and Human Services, Washington, DC, 1991

Hooper PD. Preventing Low Back Pain, Williams and Wilkins, Baltimore, 1992 (a)

Hooper PD. Put Your Back Problems Behind You, Injury Prevention Technologies, Diamond Bar, Ca., 1992 (b)

White AH. The Back School and Other Conservative Approaches to Low Back Pain, C.V. Mosby, St. Louis, 1983

White LA. Back School, Spine: State of the Art Reviews, vol.5(3), Hanley and Belfus, Inc., Philadelphia, 1992

Zachrisson M. The Low Back School, Danderyd, Sweden, Danderyd's Hospital sound and slide program, 1972
Paul Hooper, DC
Diamond Bar, California