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Medical Factors
The impact of Back Schools on return to work

At a glance:
After an episode of back pain, long-term sick leave is something to be avoided. It is bad for the person's health and well-being, and costly for their employer. This study reviewed the most effective ways to prevent long-term sick leave.

A program of exercises, education about the condition and training in good work techniques are the most common approaches. In most cases, they significantly improve a person's chances of returning to work.
Perspectives:
Employee
The longer you stay off work for back pain, the less likely you are to return. This has financial, social and personal consequences. Research has shown that the quicker you are able to return to work, the better your recovery will be.

When people are educated about their back problem, they are more likely to return to work. This review found that physical exercises and training make no difference to return to work unless people also receive information about their condition and how to stay active.

Talk to your doctor about getting the best advice for back pain – it is essential in helping you return to work.
Employer
People with back pain may be worried about doing damage if they return to certain activities – including work. This review demonstrated significant improvements in return to work rates when people were given thorough information and advice.

Make sure your employees are getting the best advice and have a good understanding about their back problem. People can become worried if they are only told what not to do. They need to understand what activities they can still perform, and feel confident that they can manage their situation.

It is important to realise that many people with back pain are worried. They are dealing with pain and feel limited in their home activities. They may be worried about their job, future abilities and financial situation.
Treater
Interventions that combine exercise and muscle conditioning with education and training in good work techniques appear to be the most effective in reducing sickness absence from back pain.

Traditional management of back pain has revolved around investigations such as a CT
CT
Computed tomography (CT), originally known as computed axial tomography (CAT or CT scan) is a medical imaging method. The images can show soft tissues such as lumbar discs.
 scan or MRI,
MRI
Magnetic resonance imaging (MRI) is used in medical imaging and works by applying a magnetic field to the body and observing how the atoms behave in the field in order to create an image. Whilst an X-ray shows bones, MRI scans can show soft tissues and are used to examine tissues such as discs in the back, cartilage lining a joint, muscles and tendons.
 physiotherapy, and medication. This review of the literature shows that significantly improved return to work rates occur when people are given thorough advice and information about their back problem.

It is likely that this approach gives an individual with back pain confidence and helps them return to everyday function. It demedicalises the issue and removes fear. Referring patients with back pain to practitioners who focus on providing advice and an explanation of the condition is recommended.
Insurer
Ongoing back pain can be a difficult problem for some people. They may be worried about what they are able to do and feel concern that returning to certain activities might cause harm. This study showed that people do better when they are given thorough advice, training in work techniques and physical exercise.

Mini “back schools” are training interventions that usually go for somewhere between one and four hours and give people a thorough understanding of the condition. This approach is used in other medical problems, such as diabetes or heart problems, and consistently helps improve patients' health and their ability to return to work and other activities.
Original Article, Authors & Publication Details:
L. A. Elders1, A. J. van der Beek1 and A. Burdorf1 (2000).

Return to work after sickness absence due to back disorders--a systematic review
systematic review
A comprehensive review of research studies in a particular area. The review follows guidelines to ensure the studies included are valid.
 on intervention
intervention
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 strategies.
International Archives of Occupational & Environmental Health; 73(5):339-348.

1Department of Public Health, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands.
Background, Study Objectives, How It Was Done:
Work-related back pain is a great cost to society through human suffering, health care costs and lost productivity due to sick leave.

In most cases, people recover from back pain without treatment. In some cases, however, an intervention is needed to prevent the pain getting worse or persisting into the long-term.

This study looked at secondary prevention
secondary prevention
Approaches undertaken early in a condition with the aim of preventing worsening of problems that can arise from the condition.
 after sickness absence from back pain. Secondary prevention aims to prevent a person's condition from getting worse or reoccurring. The authors specifically looked at teaching back pain patients to minimise strain
strain
Injury to a muscle in which the muscle fibres tear or become irritated as a result of overstretching or wrenching
 to their back, by exercising and training the muscles, and by practicing good work techniques. The study investigated previous research to assess the effectiveness of these interventions in helping people to return to work.

The authors collected research articles about the effectiveness of interventions on employees' return to work after back pain.

The effectiveness of the intervention was rated by two measures:

1. How quickly people who received the intervention returned to work, compared to those who did not receive it.
2. The fraction of sickness absence that could be prevented if the intervention was used
Study Findings:
The authors found 12 research articles about the effect of interventions on helping people to return to work after sickness absence from back pain. The interventions used were a combination of exercise and muscle training (11 studies), education (9 studies) and training in work and lifting techniques (8 studies).

The effectiveness of an intervention can be influenced by the patients compliance
compliance
Compliance in a medical context refers to a patient adhering to their treatment program as advised by their doctor or other healthcare worker. In the context of return to work this usually means following the return to work plan.
 (how well they follow instructions) and this should be taken into account. In this review, the patients' compliance varied across the studies, however only one study described the patients as following instructions poorly.

The results of the studied interventions were:

Education (“Back school” type interventions)

In these interventions, patients were given advice about the back problem and how to manage it, sometimes along with an exercise program. Encouraging the person to be active and understand their condition is a usual feature of this type of program.

Seven out of eight studies found that “back-school” interventions significantly increased the number of employees that returned to work. The increase was between 22-42%. This meant that between 50 and 70% of sick leave could have been prevented by the intervention.

Physical interventions (Non back-school type interventions)

These interventions focused on increasing the person's fitness and muscle strength. They did not include an education component about how to manage the back problem, such as information about how to lift, why the person should remain active, or advice about return to work.

The non back-school type of interventions had no reliable ongoing effect.
Conclusions:
This study reviewed the effectiveness of certain interventions in reducing sickness absence from back pain.

Previous research had focused on interventions that combined exercise and muscle training with education about good work techniques. This research showed that interventions that included education (“back school” interventions) increased the rate of return to work by 22-42%. In the 3 months after the study began, 50-70% of the sick leave taken by people who did not receive the intervention could have been avoided by “sending them to back school.”

Only one study out of eight with this type of intervention showed no significant effect of treatment. Interventions that involved physical training without education did not have a lasting effect on return to work.
References:
PubMed Abstract
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