Effects of a back school-based intervention on non-specific low back pain in adults: a randomized controlled trial

Low back pain is a widespread musculoskeletal condition that is considered the primary cause of years lived with disability [1]. It carries a substantial economic burden, resulting from healthcare expenses, reduced productivity, insurance costs, and sick leave [2‐4].

Non-specific low back pain (NSLBP) is the most common type of low back pain and is characterized by the absence of identifiable underlying diseases or anatomical abnormalities [5]. NSLBP typically occurs between the last rib and the iliac crest, although it can also radiate to the gluteus or legs [5]. Patients with chronic NSLBP may experience additional symptoms such as stiffness, muscle weakness, and difficulty with movement [5, 6]. Identifying the primary risk factors associated with NSLBP is crucial to address them effectively and mitigate the significant socio-economic impact it imposes [6]. NSLBP has a multifactorial etiology [7]: involving factors such as sedentary lifestyle [8], obesity [9], smoking [10], inadequate trunk muscle strength [11, 12], poor flexibility [13, 14], psychosocial factors [15, 16] and occupational factors [17, 18].

Prominent clinical practice guidelines recommend a multimodal treatment approach for NSLBP, which combines therapeutic exercise and health education [19‐21]. One widely utilized non-pharmacological method for back pain management is the Back School Programme (BSP), which originated in Sweden in 1969 under the direction of physiotherapist Zachrisson Forssell [22]. The BSP consists of a theoretical and practical program designed to impart skills that promote back health [22]. Contemporary NLBP treatment programs adhere to the biopsychosocial model of pain [7]. In line with this model, the updated BSP incorporates recommendations on healthy lifestyles, provides insights into the neuroscience of pain perception, promotes the use of active pain management strategies to reduce fear and catastrophic thinking, clarifies misconceptions about the causes of low back pain, and emphasizes the inherent anatomical resilience of the human spine in its theoretical component [23]. The practical component of the program focuses on teaching patients back strengthening and stretching exercises [24‐26].

Scientific evidence supports the beneficial effects of the BSP in individuals with low back pain, including pain reduction [27‐35], improved disability [27‐37], enhanced quality of life [27‐29, 37] and pain prevention [26]. A systematic review published in 2017 raised concerns regarding the low methodological quality of existing studies on the BSP and emphasized the need for further research on new variations of the program [38]. Therefore, the primary objective of this study was to evaluate the impact of an original BSP-based intervention on NLBP in adults. Additionally, the study examined other factors associated with pain, such as disability, quality of life, and kinesiophobia. It was hypothesized that the BSP would yield positive effects, including pain reduction, decreased disability, improved quality of life, and reduced kinesiophobia, in adults with NLBP compared to those who did not participate in the BSP.

The sample size for the study initially included 40 participants who met the inclusion and exclusion criteria. However, three participants dropped out during the course of the study, resulting in a final sample size of 37 participants. Among the final participants, there were 23 women and 14 men (Fig. 1). A post-hoc power analysis (1—β err prob) was conducted using the final sample size of 37 participants, yielding a power of 0.9 for a significance level of p < 0.05 [27]. This indicates that the study had a high probability of detecting statistically significant effects if they existed. It is worth noting that none of the participants reported any adverse effects during the study. Baseline values of the study variables are presented in Table 2.

In the analysis per intention to treat of the outcomes, significant differences in change between both groups were found on VAS (U = 305.5; p = 0.004; g = -0.97), RMDQ (U = 357; p < 0.001; g = -2.257), fSF-36 (U = 331; p < 0.001; g = -1.96) and TSK-11 (U = 348; p < 0.001; g = -1.64) while no significant interaction was found on pSF-36 (U = 211; p = 0.779; g = -0.09) (Table 3).

The per-protocol analysis was restricted to 37 patients: 19 in the EG and 18 in the CG. These patients were excluded if they missed more than two BSP sessions in the EG or if they changed their lifestyle in the CG. The results of the per-protocol analysis (Table 4) were similar to the results of the intention-to-treat analysis (Table 3). Both analyses showed significant differences in VAS, RMDQ, SF-36, and TSK-11, while neither showed significant differences in pSF-36.

The aim of this research was to determine the effects of a BSP-based intervention for the treatment of patients with NLBP in an adult population. The results of the study suggest that the effects are positive, including pain reduction, improvement of disability, improvement in the physical components of quality of life, and reduction in kinesiophobia.

Participants in the study demonstrated minimal clinically important differences in pain intensity [47]. This can be attributed to the fact that risk factors influencing NLBP can be addressed through a biopsychosocial approach [48], which aligns with the BSP intervention based on the biopsychosocial model of pain [7]. Consistent with these findings, a systematic review published in 2022 concluded that integrating psychosocial interventions and exercise is more effective in the short-term treatment of NLBP compared to standard medical care. Furthermore, inadequate trunk muscle strength and flexibility have been associated with increased NLBP [11, 12, 14]. Previous studies using the BSP and similar programmes have demonstrated improvements in strength and flexibility [26, 27, 49].

Although the clinically important difference in pain intensity is minimal, it is worth noting that other interventions [27, 49], required a higher frequency of sessions (three sessions per week) to achieve these changes. This distinction can be useful for optimizing the dosage of such programmes to increase their efficacy. Additionally, the observed improvements in disability have been clinically significant according to the definition by Ostelo et al. [47]. These results are consistent with the strong association between pain and disability, given the close relationship between physical and psychosocial factors [50]. Other studies have also reported significant improvements in disability [27, 28, 30‐37, 49], with some noting that these improvements were sustained for several weeks after the programme [31, 34, 36] or even up to two years later [32].

Previous studies have provided evidence for the positive effects of the BSP intervention on the overall quality of life [27‐29, 37]. However, in our study, no significant changes were observed in the psychosocial component of quality of life. It is important to note that the sample size for this particular intervention was smaller compared to the other studies. Nonetheless, even though the results did not reach statistical significance, there was a positive trend observed. This finding is clinically meaningful, as it aligns with the strong relationship between pain, disability, kinesiophobia, and quality of life [51].

A previous study examining the effects of BSP on kinesiophobia also reported positive outcomes [49]. However, it is important to note that the improvements in kinesiophobia observed in our intervention were 62.5% higher than those reported in the study by Martijn et al. [49]. This finding holds significant importance since kinesiophobia is known to be a negative predictor of favourable outcomes in NLBP [52]. Furthermore, individuals with NLBP and higher levels of kinesiophobia tend to experience more pain and have lower quality of life [53]. This is closely linked to their reduced physical activity levels, which is a risk factor for the chronicity of NLBP [8, 53]. The International Association for the Study of Pain recognizes the relationship between fear, pain, and knowledge, as they emphasize that pain is not only a physical sensation but also an emotional experience influenced by other emotions such as anxiety and fear of the unknown [54]. Hence, the biopsychosocial approach aligns with the current paradigm in NLBP treatment [7]. It is also noteworthy that disability is related to kinesiophobia [55], thus confirming the benefits observed in both variables in our study.

Based on the results obtained in this study, it appears that BSP may be beneficial in the treatment of NLBP. This aligns with the findings of a review of Clinical Practice Guidelines, which emphasizes the importance of exercise therapy and health education for favorable outcomes in individuals with NLBP [19].

However, there are several limitations to consider in this study. First, due to the study design, neither the participants nor the evaluators were blinded, which may introduce bias in the results. Additionally, certain physiological factors such as menopause and occupational factors like the type of work or number of hours were not taken into account in the data analysis, potentially influencing the outcomes. It is important to note that our study did not include a post-intervention follow-up, limiting the assessment of long-term effects. Lastly, the limited number of participants hindered the stratification of results by age and gender.

For future research, it would be valuable to incorporate post-intervention follow-ups to evaluate the sustainability of the effects over time. Additionally, larger sample sizes would enable stratified analysis to explore potential age and gender differences in response to the intervention. These improvements would contribute to a more comprehensive understanding of the effectiveness of BSP in treating NLBP.

The BSP-based intervention had beneficial effects on pain in patients with NLBP. In addition, this programme improved disability, physical components of quality of life and kinesiophobia in patients with NLBP. However, the psychosocial components of quality of life did not change after participating in the BSP. This programme could be easily implemented in hospitals, primary care centres and physiotherapy clinics with the aim of reducing the severe socio-economic impact caused by NLBP worldwide.