Back School as an Effective Intervention in Managing Chronic Low Back Pain
Nicole Davis, SPT
UNC PT Outreach 2016
¡Bienvenidos a mi página de Capstone! – Welcome to my Capstone page!
Background
At the end of April, I will travel to Guatemala with a group of UNC PT students and faculty members. During our time there, we will work alongside the Guatemalan physical therapists and students, treating children and adults with physical and cognitive disabilities. We will also be providing educational presentations and sponsoring health fairs in the local communities. After discussing the current needs for the 2016 service-learning trip with a UNC faculty member who has previously participated in these outreach efforts, I decided to develop my Capstone in conjunction with UNC’s PT Outreach program.
Throughout my time in the UNC DPT program, patient-centered care and cultural competence have become reoccurring themes in many of the courses. The importance of these themes are defined in our profession’s Core Values: accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility.1 Though our profession continues to strive for exceptional care for our patients at home, our commitment to society extends beyond American borders.
In Evidence-Based Practice II, I prepared a Critically Appraised Topic (CAT) paper that summarized my systematic search and critical appraisal of research evidence related to the efficacy of stabilization exercise and massage on chronic low back pain (LBP). Current evidence reflects the effectiveness of both interventions in the short-term with questionable efficacy in the long-term. An interesting observation I made during my review of the literature was that patient education further validated significant results and had residual benefits in the long-term. After recognizing this finding, I was interested in investigating the effectiveness of an educational Back School approach on chronic LBP management.
Statement of Need
Chronic LBP is a debilitating condition with a lifetime prevalence of 84%.6 It is the fourth leading musculoskeletal ailment in Guatemala and Central America.5 Chronic LBP accounts for nearly half the cost of treated musculoskeletal conditions.4 The physiological origin of chronic LBP and factors that precipitate recurrence are poorly understood among the research community.2 For this reason, successfully treating individuals with chronic LBP can be challenging.
Current evidence suggests major risk factors for chronic LBP are related to poor lifestyle choices, improper body mechanics and corresponding muscle imbalances. In addition to these factors, inadequate working conditions and occupational hazards may also contribute to chronic LBP.3 The majority of Guatemalans are self-employed and nearly a third work more than 48 hours a week.3 Under these circumstances many workers report that they frequently work on slippery surfaces, carry heavy loads and do a lot of repetitive movements.3 These factors likely influence back pain.
Recent investigations have studied the effect of managing chronic LBP through structured patient education.7 Positive reports have been stated with a Back School approach.7 Given the high lifetime prevalence of chronic LBP and the physical demands that Guatemalans experience daily, implementing a Back School for treating physical therapists in Guatemala would be beneficial to its residents. Guatemalan physical therapists’ lack of time and access to evidence-based interventions further support this need for this program.
Project Overview
To prepare for my Capstone, I performed a review of the current literature and developed an Evidence Table investigating the benefits of Back School for managing chronic LBP. A reference list of the articles used in the table can be accessed HERE. Articles provided in this table reflect a systematic search of the literature but do not include all articles related to Back School for managing chronic LBP, as that was out of scope for this project. The effectiveness of Back School for the management of chronic low back pain was the basis of my presentation materials.
In order to deliver an effective and clinically useful presentation, I utilized materials from the DPT Capstone site and also completed a Health Literacy Assessment to ensure that my presentation materials were appropriate for my audience.8-11 These resources along with the feedback I obtained from my Capstone advisor, Lisa Johnston, guided the final drafts of my presentation handouts. These materials will be translated to Spanish prior to traveling to Guatemala and will be laminated for long-term use in the clinic. Links to the handouts are listed below:
Physical Therapist Handout: A guide that teaches the physical therapist how to educate their patients on managing chronic LBP by addressing the functional anatomy of the spine, LBP etiology and risk factors, proper posture and lifting mechanics. (English/ Spanish)
Patient Handout: A brief handout with visual representations of things to do and things to avoid when managing chronic LBP. (English/Spanish)
The physical therapist and patient handouts will guide my presentation in Guatemala. I will discuss how the physical therapists and students may incorporate this Back School approach in their plan of care for patients with chronic LBP. The presentation will also include short lab sessions where the physical therapists and patients can practice having these conversations and using these materials. Because my target audience for my materials are the patients in rural Guatemala, I will synthesize the information in my evidence table in a brief paper to reflect the effectiveness of the Back School for the management of chronic low back pain.
In order to assess the true benefit and clarity of my presentation, I will provide a Presentation Evaluation Form for my audience members. The feedback form will assess the organization of my presentation, the quality of my content and its usefulness in clinical practice.
Acknowledgements
My genuine thanks goes to my Capstone advisor, Lisa Johnston, for helping me find the direction for my Capstone project, offering her continued guidance and keeping me level-headed throughout this semester. Additionally, I would like to thank my Capstone committee members, Kristel Maes, PT, DPT, Dip MDT and Jennifer Cooke, PT, DPT for their patience and feedback. My sincerest gratitude goes to Sarah van der Horst, PT, DPT for translating all of my presentation materials. Lastly, I would like to recognize the family, friends, classmates and faculty members that have provided their suggestions and support throughout this entire process. You are appreciated!
References
(1) Professionalism in Physical Therapy: Core Values. APTA. [Website] https://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Judicial/ProfessionalisminPT.pdf. Updated December 14, 2009. Accessed April 17, 2016.
(2) Andrusaitis SF, Brech GC, Vitale GF, Greve JM. Trunk stabilization among women with chronic lower back pain: a randomized, controlled, and blinded pilot study. Clinics. 2011;66(9):1645-1650.
(3) Benavides FG, Wesseling C, Delcios GL, Felknor S, Pinilla J, Rodrigo F. Working conditions and health in Central America: a survey of 12,024 workers in six countries. Occup Envrion Med. 2014;71(7):459-65.
(4) Moussouli M, Vlachopoulos SP, Kofotolis ND, Theodarakis Y, Malliou P, Kellis E. Effets of stabilization exercise on health-related quality of life in women with chronic low back pain. Journal of Physical Activity and Health. 2014;11:1295-1303
(5) Obregon-Ponce A, Iraheta I, Garcia-Ferrer H, Mejia B, Garcia-Kutzbach A. Prevalence of musculoskeletal disease in Guatemala, Central America: the COPCORD study of 2 populations. J Clin Rheumatol. 2012;18(4):170-4.
(6) Violante FS, Mattioli S,Bonfigiloli R. Low-back pain. Handb Clin Neurol. 2014;131:397-410.
(7) Sahin N, Albayrak I, Durmus B, et al. Effectiveness of back school for treatment of pain and functional disability in patients with chronic low back pain: a randomized controlled trial. J Rehabil Med. 2011;43(3):224-9.
(8) Integral Family Literacy: Guatemala. United Nations Educational, Scientific and Cultural Organization [Website]. http://www.unesco.org/uil/litbase/?menu=16&programme=94. Updated February 10, 2012. Accessed March 7, 2016.
(9) Jensen GM, Monstrom E. Handbook of Teaching and Learning Physical Therapy. Third Edition. Chapter 12: Patient Education and Health Literacy.
(10) Plack M, Driscoll M. Teaching and Learning in Physical Therapy From Classroom to Clinic. Chapter 4: Systematic Effective Instruction: Keys to Designing Effective Presentations.
(11) Readability Score. Readbility-Score.com [Website] https://readability-score.com/. Accessed March 7, 2016.
5 Responses to “Back School as an Effective Intervention in Managing Chronic LBP”
Abbie Marrale
Hi Nicole!
Great topic, and great job on synthesizing all of this information for use in Guatemala. It’s incredible how widespread back pain is, and how it really affects us all. What makes LBP even worse it that there are so many ways to develop it: sitting too long, moving incorrectly, poor posture, poor body mechanics, poor lifting techniques, etc. What I especially liked about your presentation was how you were really able to focus in on the aspects that are more likely tied to low back pain for this population. You really did your research!
It is interesting to think about the differences between our cultures too, and how this plays a role in educating a ‘back school’. Are there specific aspects of Back School that you will likely address in Guatemala, that would be less useful in the USA? This really ties into the idea of knowing one’s audience.
Nicole Davis
Hi Andrew!
Thanks for your comments! I am happy that you are going to Guatemala – hopefully you will be able to attend my presentation! Though my hand outs are quite simple, I thought it was important to keep them this way as their intended audience are patients in rural Guatemala. Additionally, I will be completing a brief paper synthesizing the effectiveness of Back School for managing chronic LBP so that there is a clear connection between my evidence and my presentation.
Nicole
Nicole Davis
Hi Lexie!
Thanks for your comments! I have not seen a Back School program in the clinic however, when I was at CMC’s inpatient rehab center they held educational classes on different aspects of health for patients with SCIs. The first class provided a general overview of SCI and courses after that focused on nutrition, skin protection, etc. I thought delivery of patient education was engaging so I decided to explore the efficacy of Back School for chronic low back pain.
Yes, the duration and frequency of patient education varied across the studies in my evidence table. With my presentation, I am taking a bit of a different approach. As opposed to group patient education, the PT will discuss only the aspects of the patient handout that pertain to that patient during their treatment session. For example, a PT may only go over Parts 1, 2 and 5 (structure and function, risk factors, lifting mechanics) for a patient with low back pain who works on a farm that require a lot of repetitive, heavy lifting. Hopefully that makes sense!
Nicole
James Foster
Nicole,
I am so glad you focused on LBP and have provided information we can all use with how common this disorder is. In my experience, people from all walks of life are confronted with LBP at some point in time. Therefore, not only will this information benefit individuals in Guatemala, but the public at large here in the US could take advantage of the data and materials you have brought forth and created. I truly look forward to our trip and your presentation in Guatemala. I think you will be doing a wonderful service presenting and providing handout information to the individuals we will be caring for in Guatemala. I thought overall your information is well-organized, the handouts are clear and do not present any confusion, and I really like the animations and how they can easily be understood. I also thought your evidence table was very clear and concise, and I especially like the applicability aspect you incorporated as it encouraged me to look more into the research and read the article.
Eres hermosa y gran trabajo!
Lexie Williams
Nicole,
Great work on your capstone! Though you target is PTs in Guatemala, your research and resources could assist many local therapist as well, since we have learned that nearly one-quarter of adults in the United States experience LBP! Have you been exposed to a Back School program in any of your previous clinical rotations?
The resources you developed are comprehensive and easy to read. I think it is an excellent idea to have the resources laminated so that the education you provide during your presentation can have a long-term impact on the way PT’s approach treating LBP with this quick reference guide.
As I was reviewing your evidence table, I noticed that the length of Back School varied significantly between each study. This may be a question that cannot be answered until our trip to Guatemala, but is it feasible for this model to be reproduced in PT clinics in Guatemala (How frequently are patient’s typically seen?)? Assisting in setting up a structured Back School program may be beyond the focus on your project.
I am looking forward to hearing your presentation in Guatemala!
Lexie