Documents Bombardier, Claire 4 results

"Background
Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating patients with low-back pain (LBP). However, the content of back schools has changed and appears to vary widely today.


Objectives
To assess the effectiveness of back schools for patients with non-specific LBP.


Search strategy
We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials to May 2003 for relevant trials reported in English, Dutch, French or German. We also screened references from relevant reviews and included trials. The literature search has now been updated to November 2004. No additional trials were identified.


Selection criteria
Randomized controlled trials (RCTs) that reported on any type of back school for non-specific LBP were included.


Data collection and analysis
Four reviewer authors, blinded to authors, institution and journal, independently extracted the data and assessed the quality of the trials. We set the high quality level, a priori, at a trial meeting six or more of 11 internal validity criteria. As data were clinically and statistically too heterogeneous to perform a meta-analysis, we used a qualitative review (best evidence synthesis) to summarize the results. The evidence was classified into four levels (strong, moderate, limited or no evidence), taking into account the methodological quality of the studies. We also evaluated the clinical relevance of the studies.


Main results
Nineteen RCTs (3584 patients) were included in this updated review. Overall, the methodological quality was low, with only six trials considered to be high quality. It was not possible to perform relevant subgroup analyses for LBP with radiation versus LBP without radiation. The results indicate that there is moderate evidence suggesting that back schools have better short and intermediate-term effects on pain and functional status than other treatments for patients with recurrent and chronic LBP. There is moderate evidence suggesting that back schools for chronic LBP in an occupational setting, are more effective than other treatments and placebo or waiting list controls on pain, functional status and return to work during short and intermediate-term follow-up. In general, the clinical relevance of the studies was rated as insufficient.


Authors' conclusions
There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain, and improve function and return-to-work status, in the short and intermediate-term, compared to exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls, for patients with chronic and recurrent LBP. However, future trials should improve methodological quality and clinical relevance and evaluate the cost-effectiveness of back schools.


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Plain language summary

Back schools for non-specific low-back pain
There is moderate evidence suggesting that back schools are more effective for pain and function than other conservative treatments if the patients with chronic low-back pain (LBP) are from the general public, primary or secondary care. There is conflicting evidence whether back schools are more effective than placebo or waiting list controls for pain, function and return-to-work.

There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain, and improve function and return-to-work status, in the short and intermediate-term, compared to exercises, manipulation, myofascial therapy or advice, placebo or waiting list controls, for patients with chronic LBP."

The measurement properties of five generic discriminative health related quality of life (HRQOL) questionnaires were determined. The study subjects included 127 injured workers receiving wage replacement benefits under the Ontario Workers' Compensation system. Of the 127 workers, 47% had disorders of the upper limb, 12% had disorders of the neck and upper back, and 27% had disorders of the lower back. Each patient completed several profiles including SF-36 (Acute), Nottingham Health Profile (NHP), Duke Health Profile (Duke), Health status section of the Ontario Health Survey (OHS), and the Sickness Impact Profile (SIP). The findings indicated that the use of different tools may give different pictures of health for the same individual. The SF-36 and the Duke were best distributed. The SIP had high ceiling effects and also had practical limitations of being too long to apply in a study with an already heavy respondent burden. The NHP was able to discriminate between respondents with different self rated health, overcoming the high ceiling effects observed. The SF-36 was the next strongest. Except for the OHS mobility subscale, correlations suggest moderate to good convergent validity between tools.

"Objectives Workers' musculoskeletal disorders are often pain-based and elude specific diagnoses; yet diagnosis or classification is the cornerstone to researching and managing these disorders. Clinicians are skilled in pattern recognition and use it in their daily practice. The purpose of this study was to use the clinical reasoning of experienced clinicians to recognize patterns of signs and symptoms and thus create a classification system. Methods Two hundred and forty-two workers consented to a standardized physical assessment and to completing a questionnaire. Each physical assessment finding was dichotomized (normal versus abnormal), and the results were graphically displayed on body diagrams. At two different workshops, groups of experienced researchers or clinicians were led through an exercise of pattern recognition (clustering and naming of clusters) to arrive at a classification system. Interobserver reliability was assessed (8 observers, 40 workers), and the classification system was revised to improve reliability.Results The initial classification system had good face validity but low interobserver reliability (kappa. "