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Back School


Back school is a series of educational and training programs with lessons delivered by a therapist to patients or staff with the goal of treating or preventing back pain.

  • They are a common non-pharmaceutical intervention especially in the occupational health setting.
  • Despite the use of back schools since 1969, their effectiveness in preventing or treating back pain has not been clearly established.[1]

Population targeted for background training: [2] .

  • Patients with low back pain (primary intervention).
  • Return to school (secondary prevention) – eg acute or chronic low back pain episodes; recurrence of specific low back pain; post-spine surgery patients.
  • Individuals with low back pain associated with clinically relevant anatomy.

Reserve schools vary in intensity and content.

E.g. Content Swedish Back School (four 45-minute sessions in two weeks)

  1. Anatomy and Causes of LBP and Psoas Position
  2. Muscle function and exercise
  3. Ergonomics
  4. Advice on physical activity
  5. An individual pool session under the supervision of a physiotherapist with an analysis of working conditions [3].
Typical Content

Swedish Back School was developed by Zachrisson Forsell and consists of four 45-minute main audio-visual sessions led by a Physiotherapist.

First Lesson – Discusses the different aspects of back disorders.

  • Provide patients with full details of back anatomy and function.
  • Various treatments are discussed and psoas position taught.
  • The entire procedure is performed with the patient in this position rather than a sitting position.

Section II – Discusses the mechanical strain at different positions and during different movements.

  • Demonstrates the function of the muscles and their effect on the back.
  • Instruct patients to perform isometric abdominal exercises and encourage them to continue these exercises every day.
  • Back muscle exercises are discussed and patients are informed that these exercises place greater stress on the back and risk exacerbation of symptoms.

Section III – includes the practical application of previously acquired theoretical knowledge.

  • Patients are asked to describe their own working situation, and the group works to find an appropriate solution for each individual.

Section 4 – mainly consists of encouraging patients to increase their level of physical activity in their leisure time despite their back problems.

  • Provides a written summary of the main content of Back School.
  • Patients attending the backyard can also enjoy a pool workout under the supervision of a physical therapist. 
Physical Therapy Management

Goals for patients attending fallback schools:

  • Functional restoration: protection of spinal structures during daily activities and occupational settings
  • Reduce symptoms (pain)
  • Increasing tissue repair
  • Decrease kinesiophobia 

To achieve these goals, the school consists of three parts:

  1. Education about the anatomy and function of the spine, spine biomechanics, pathophysiology, epidemiology of recurrent back disorders… Today’s back schools (informative) are limited in this section compared to back schools in 1969 [2]. An example section for an education class is e.g. The Biomechanical principles: Functional loading/compression on the nucleus causes deformation without changing the volume of the nucleus. When sustained pressure is applied to the annulus, it releases water. The height of the disc is reduced, so there is more compression on the nucleus pulposus. Intervertebral discs require pressurization to maintain the metabolic activity of the intervertebral disc osmotic system of the lumbosacral disc biomechanics. But when the pressure is too high, the pressure in the disc can increase and can cause low back pain. some body positions and movements Increased intradiscal pressure. [2]
  2. Train standing, lifting, bending, sitting and more. Varies by occupational setting:[2] eg banker. A banker sits all day, so it’s important that he sits the right way: when he bends forward while sitting, the pressure in the disc should double Same height when standing. Correct sitting posture: feet on the ground, below the knees and waist level. The waist is slightly higher than the knees, and the back is straight against the backrest. It is also important that his sheet is in the correct position Height; Rack Packer – Disc Pressure for Box Lifting See Figure R Disc pressure for both ways of lifting can be seen. This is the principle of leverage. Due to the smaller load and load arm, less force is required to keep the lever balanced. [2]
  3. Actively protect the spine through active exercises [2][4], such as stretching the muscles of the lower extremities; stretching the erector spinae; kinesthetic training (moving the pelvis so that the anteroposterior tilt of the pelvis is within a comfortable range); strengthening the core (stabilizing function). [2][5]
Key Evidence

From the Cochrane review 3.8.2017

It is uncertain whether Back School is effective for chronic low back pain as the quality of evidence for all treatment comparison outcomes and follow-up periods of the survey was low to very low. Results showed no or insignificant differences, although the quality of the evidence was mostly low Good for Back School effects. There are countless potential variations of the Back School method with regards to employing different exercises and teaching methods. While current evidence does not warrant their use at Back School, future variants may have different effects and require to study in future randomized controlled trials and reviews [6]


  1.  Straube S, Harden M, Schröder H, Arendacka B, Fan X, Moore RA, Friede T. Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research—systematic review and meta-analysis. Pain. 2016 Oct;157(10):2160. Available from;https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5028160/ (last accessed 11.9.2020)
  2. ↑ Jump up to:2.0 2.1 2.2 2.3 2.4 2.5 2.6 Kraemer, J., Hasenbring, M., Kraemer, R., Taub, E., Theodoridis T., Wilke, H.J., ‘Intervertebral disk diseases: causes, diagnosis, treatment and prophylaxis’, Thieme, 2009, p. 321-327
  3.  Keijsers JF, Steenbakkers MW, Gerards FM, Meertens RM. The efficacy of the back school: An analysis of the literature. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 1990 Dec;3(4):210-5.Available from:https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1790030409 (last accessed 11.9.2020)
  4.  Garcia, A., Gondo, F., Costa, R., Cyrillo, F., Silva, T., Costa, L. CM, Costa, L. OP, ‘Effectiveness of the back school and mckenzie techniques in patients with chronic non-specific low back pain: a protocol of a randomised controlled trial’, BMC Musculoskeletal Disorders, 2011, nr. 12
  5.  Heymans, M., Van Tulder, M., Esmail, R., Bombardier, C., Koes, B., ‘Back schools for nonspecific low back pain’, Spine, 2005, Vol. 30, nr. 19, p. 2153-2163 (Level of evidence 1A)
  6.  Parreira P, Heymans MW, van Tulder MW, Esmail R, Koes BW, Poquet N, Lin CW, Maher CG. Back Schools for chronic non‐specific low back pain. Cochrane Database of Systematic Reviews. 2017(8).Available from:https://www.cochrane.org/CD011674/BACK_back-school-treatment-chronic-low-back-pain (last accessed 11.9.2020)

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