Thoughts and concerns of patients at hospital discharge after lumbar spine surgery. A qualitative study

PURPOSE

The increased rate of surgical interventions point to the necessity to investigate the patient's experience from a biopsychosocial perspective. The aim of this study was to investigate the thoughts and concerns of patients undergoing spinal surgery for lumbar degenerative disease at the time of their discharge from hospital.

METHODS

Semi-structured interviews were conducted with 28 patients. The questions investigated possible concerns associated to discharging them home. A content analysis was performed by a multidisciplinary group to identify the main themes that emerged from the interviews.

RESULTS

The patients were satisfied with the surgeons' preoperative explanations and description of expected prognosis. However, they were disappointed with the lack of information at hospital discharge, in particular regarding practical and behavioral recommendations. The patients expressed clear concerns about being left alone to deal with possible complications or difficulties they may encounter when returning home.

CONCLUSION

This study underlined the patients' need for a comprehensive psychological guidance and possibly a person of reference during the post-operative process. Discussing discharge with the patient was emphasized as an important issue to improve patients' compliance to the recovery process itself. Putting these elements into practice should help spine surgeons to manage better hospital discharge.IMPLICATIONS FOR REHABILITATIONA comprehensive discussion with the patient at the time of hospital discharge is clearly stressed as an important issue to improve patients' adherence to the recovery process.The patients complained of a lack of information when returning home, in particular regarding practical and behavioral recommendations.The patients expressed clear concerns about possible complications or difficulties they may encounter when returning home and they expressed their need to know whom they can contact for help if needed.A better understanding of the thoughts and concerns of patients undergoing spinal surgery at the time of their discharge from hospital should help spine surgeons to improve the management of hospital discharge and the post-operative recovery.

The impact of low back pain on health-related quality of life in old age: results from a survey of a large sample of Swiss elders living in the community

PURPOSE

The present study aims at investigating the effects of low back pain (LBP), i.e., type of symptoms, activity limitations, frequency, duration, and severity on health-related quality of life (HRQoL) in a sample of 707 community-dwelling men and women aged ≥ 65 years living in Switzerland.

METHODS

The study is part of a larger survey conducted in Switzerland on a sample of older adults selected randomly from population records, stratified by age and sex. The Standardized Back Pain Definition was used to investigate LBP, and HRQoL was assessed by means of the EQ-5D, including Health Utility Index (HUI) measures.

RESULTS

For more than half of the sufferers, pain was chronic, occurred most days or every day and induced activity limitations. One-third of the sufferers reported sciatica symptoms. Individuals reporting every day pain, severe pain and more than 3 years since the last episode without pain lost nearly 10 points of HRQoL. Amongst the dimension of HRQoL, Mobility was the most affected by LBP.

CONCLUSIONS

These results provide further insight into the impact of qualitative aspects of LBP and in particular the importance of radiating leg pain and pain frequency and duration. While LBP-related activity limitations had little impact on both self-rated overall health and HUI, radiating leg pain and pain frequency and duration were associated with significantly decreased scores on both dimensions.

Pain patients' letters: The visit before the visit - A qualitative analysis of letters from patients referred to a tertiary pain center

BACKGROUND

Pain centers manage only selected patients, and have long waiting lists. Some patients spontaneously send letters, before the visit, and these letters represent the first contact between the patients and the pain centers. We report a study of the content and format of these letters, for a patient perspective analysis.

METHODS

During a 3 month-period, all newly referred patients to a tertiary pain center were considered. If a patient letter was provided, it was collected for analysis. Qualitative analyses including semantic and content analyses were performed to identify themes and categories.

RESULTS

Among 138 newly referred patients, 44 had sent a letter before consultation. Content analysis of 42 letters disclosed four themes: I) pain experience; II) impact of the pain problem; III) patient history; and IV) expectations. These themes could be distributed along four pain dimensions: (1) physical; (2) psycho-affective; (3) social; and (4) temporal. This first study on patient letters reveals that a bio-psychosocial model. Patients contribute actively to their trajectory, not only as healthcare seekers but also by constructing their narrative identity.

CONCLUSIONS

Patient letters constitute narrative material to be integrated into clinical analysis, alongside patient interviews, especially in pain management. Pain specialists should take account of this narrative approach to better understand the unvoiced and sometimes silent experience of pain. This may increase quality of medical care by including patient-centered data in an original method. Further studies may be valuable to analyze the possible contributions of such letters to patient management.

SIGNIFICANCE

Patients' letters constitute original narrative material to be integrated into clinical analysis, especially for pain management. Patients' letters analyses may improve the patient physician relationship, by understanding patient's perspectives, beliefs and expectations.

[Postural hygiene and ergonomic advices for low back pain: rethinking our practice]

In recent years, scientific understanding of low back pain has increased considerably, sometimes shoving concepts thought to be unshakable. If we consider postural hygiene,whose techniques were conceptualized in the 70's and are still widely used, not only some axioms were not confirmed but some evidences suggest that it may sometimes have deleterious effects. After reviewing these elements it appears that there is no simple formula applicable to all patients with low back pain. Instead we offer food for thought so that every therapist can adapt his practice on an individual basis.

[Interdisciplinary treatment of chronic low back pain: psychological aspects and personality traits]

Evidence on chronic low back pain treatments stresses the need for a multidimensional approach that aims a biopsychosocial rehabilitation. The caregiver team of the rheumatology division of the University Hospitals of Geneva has successfully applied this approach over the last years and this article emphasizes the value of a close collaboration with the division of liaison psychiatry. The use of cognitive-behavioral and psycho-educational techniques guaranties the definition of patient-centred and measurable treatment objectives. The inclusion of a psychotherapy group promotes free expression and sharing of psychological distress. Assessment of personality traits allows for considering the global nature of the patients rather than merely aiming the normalization of their deviant aspects.

[Chronic pain in elderly people: psychosocial dimension]

Chronic pain in elderly people requires to take into account somatic co-morbidities as well as its psychosocial dimensions. Chronic pain often represents a distress signal addressed to the environment and the care providers. Psychological suffering or mood disorders can be presented in the form of somatic complaints often associated with functional impairments, sometimes severe. Therapeutic care has to address functionality through an image-enhancing approach aiming to summon the patients' resources. The treatment of a concomitant depressive state necessitates a true commitment from the therapist. Its benefits are documented in elderly patients. Analgesic treatment as a whole will seek in particular to restore feelings of self-esteem and help the patient recover a good quality of life.

[Placebo, an underestimated ally]

Patients' views and patient-oriented outcomes are increasingly acknowledged, including beliefs about pain and illness, and expectations of treatment. Indeed, how far patient expectations influence outcomes has developed into an important area of research, and all the more so as the impact of expectations on subjective outcome is related to the placebo effects; indeed, expectations can both mediate and modulate these effects. Surgery has been suggested as conveying a placebo effect related to the ceremony of surgical preparation, the use of sophisticated techniques and the need for hospitalization possibly leading to increased pain management, more active sympathy and disease recognition.

[Chronic pain and depression]

Chronic pain and depression are frequently associated. Links between them are numerous and well documented. It is known for example that depression is associated with a greater number and higher intensity of pain symptoms. Similarly the presence of pain complicates the diagnostic evaluation and aggravates the prognosis of depression. The question of the causality link has no clear answer. Taking care of these patients implies to acknowledge the different aspects of their suffering in a holistic bio-psycho-social model. Treatment or medication, for instance antidepressants, should be a post-scriptum to the construction of a therapeutic relationship.

[Cognitive and behavioral group therapy in chronic pain: expectations and satisfactions]

Twenty-two patients suffering from chronic pain have participated to a behavioural and cognitive group therapy, over 8 weekly sessions, each of 90 minutes. Semi-structured interviews revealed that all of their expectations were satisfied, except for pain decrease. Although they had often negatively anticipated the group situation, all patients evaluated positively the experience: they felt less lonely; they were listen to and understood by the other participants. After 3 months, 80% of the patients had modified some of their daily behaviours. After 12 months, 55% of the patients witnessed a lasting change over the impact that pain had on their life. Even if patients expect a decrease of their pain, disappointment is not an obstacle to the process of change.

Difficulties of residents in training in end-of-life care. A qualitative study

Residents in training are first-line physicians in hospital settings and they are in the process of developing knowledge and mastering clinical skills. They have to confront complex tasks calling upon their personal background, professional identity and relationships with the patients. We conducted a qualitative study investigating the difficulties they perceive in end-of-life care. In all, 24 consecutive residents were presented with a written query asking them to indicate the difficulties they identify in the management of patients hospitalised for end-of-life care. Their responses were submitted to content analysis. Physicians' mean age was 28 +/- 2.2 years, 37% were women, average postgraduate training duration was 2.5 +/- 1.3 years. Content analysis elicited eight categories of difficulties: ability to provide adequate explanations, understand the patients' needs, have sufficient theoretical knowledge, avoid flight, avoid false reassurance, manage provision of time, face one's limits as a physician and be able to help despite everything. Residents' responses showed that they identify the complexity of care in terminally-ill patients early in their training. Their responses pointed to the 'right distance' in-between getting involved and preserving oneself as a dimension of major importance.

[Practical lessons from group treatment in low back pain patients]

Multidisciplinary group therapies for low back pain patients have been devised for more than 30 years. Various models have been developed during this period, resulting in multiple programmes with varying effectiveness. Taking the opportunity of the establishment of a new programme at the Geneva University Hospitals, we reviewed these various models and listed the most prevailing elements in the literature. The summary presented here illustrates the hurdles in the treatment of low back pain patients. It underlines the numerous orientations available to the clinician and offers some indications for improving the treatment in these patients.

[Drugs--of molecules and relationships]

Drugs have always been both medicine and poison. Their function is cure but they can also kill; they have desired but also adverse effects. Drugs can be defined as technical objects which use is inserted within a set of representations, practices and social relationships. Acting as a mediator--and sometimes as an issue--in the relationship, medication and its use are far from the rational management of drugs as defined by public health authorities. The matter at stake can also be the legitimation of illness or pain. As a means of legitimation, psychotropic drugs raise specific questions as there is no objectivation of symptoms, be them mood changes or pain, aside from the patient's account.

Durée d’hospitalisation, programmation de la sortie et politique de raccourcissement des séjours : avis des patients et des soignants

BACKGROUND

In the context of health care cost containment, we interviewed hospitalized patients and their health care teams concerning the length of stay they considered necessary and hospital discharge. Patients were also interviewed on the present tendency to shorten hospital stays.

METHODS

Prospective study conducted in a subacute internal medicine ward with 254 consecutive patients and their health care teams.

RESULTS

The mean evaluation of the length of stay considered as necessary was not significantly different between patients (9.7 days, SD=9.5) and their health care teams (9.6, SD=8.5). However, agreement between the two parties was moderate (r=0.64). Hospital discharge was considered as planned in similar proportions (18% vs 22% respectively), but was reported as more 'assured' by health care teams than by patients (p<0.001). Health care teams and patients approved discharge planning in 200 cases (63.3%), but agreement was only moderate (Kappa 0.43, IC 95%=0.34-0.51). Regarding the tendency to shorten hospital stays, patients'responses were favorable in only 9%, clearly unfavorable in 17% and disclosed explicit fears in 54% of the cases.

CONCLUSIONS

These results show that what patients and health care teams consider the necessary length of stay and the right time for hospital discharge can diverge notably. They highlight the difficulties of medical decisions in the context of cost containment, and the fundamentally asymmetrical character of the relationship between patients and health care teams.

How to identify patients with a poor prognosis in daily clinical practice

Predicting poor outcomes in daily practice is challenging. As well as prior episodes of low back pain and pain intensity, various psychosocial risk factors have been identified, although the independent prognostic value of these is rather low. This supports the necessity for a multidimensional view of the transition from acute to chronic pain and/or the development of disability. Psychological distress has been found to increase the risk of such a transition. Patients' beliefs and expectations about their pain seem to influence the recovery process; pain-related fear and fear avoidance can be influential psychological variables, from pain inception to its chronic stage. The influence of occupational factors such as job satisfaction, low workplace support or physical workload has also been emphasized. Treatment provider factors and the relationship between patients and care providers also contribute to the realistic or unrealistic expectations and meaningful or acceptable outcomes.

Fibromyalgia: a randomised, controlled trial of a treatment programme based on self management

OBJECTIVE

To evaluate the efficacy of a treatment programme for patients with fibromyalgia (FM) based on self management, using pool exercises and education.

METHODS

Randomised controlled trial with a 6 month follow up to evaluate an outpatient multidisciplinary programme; 164 patients with FM were allocated to an immediate 6 week programme (n = 84) or to a waiting list control group (n = 80). The main outcomes were changes in quality of life, functional consequences, patient satisfaction and pain, using a combination of patient questionnaires and clinical examinations. The questionnaires included the Fibromyalgia Impact Questionnaire (FIQ), Psychological General Well-Being (PGWB) index, regional pain score diagrams, and patient satisfaction measures.

RESULTS

61 participants in the treatment group and 68 controls completed the programme and 6 month follow up examinations. Six months after programme completion, significant improvements in quality of life and functional consequences of FM were seen in the treatment group as compared with the controls and as measured by scores on both the FIQ (total score p = 0.025; fatigue p = 0.003; depression p = 0.031) and PGWB (total score p = 0.032; anxiety p = 0.011; vitality p = 0.013,). All four major areas of patient satisfaction showed greater improvement in the treatment than the control groups; between-group differences were statistically significant for "control of symptoms", "psychosocial factors", and "physical therapy" No change in pain was seen.

CONCLUSION

A 6 week self management based programme of pool exercises and education can improve the quality of life of patients with FM and their satisfaction with treatment. These improvements are sustained for at least 6 months after programme completion.

Neurophysiologic evidence for a central sensitization in patients with fibromyalgia

OBJECTIVE

To determine whether abnormalities of peripheral and central nociceptive sensory input processing exist outside areas of spontaneous pain in patients with fibromyalgia (FM) as compared with controls, by using quantitative sensory testing (QST) and a neurophysiologic paradigm independent from subjective reports.

METHODS

A total of 164 outpatients with FM who were attending a self-management program were invited to participate in the study. Data for 85 patients were available and were compared with those for 40 non-FM controls matched for age and sex. QST was performed using thermal, mechanical, and electrical stimuli at locations of nonspontaneous pain. Pain assessment was 2-fold and included use of subjective scales and the spinal nociceptive flexion reflex (NFR), a specific physiologic correlate for the objective evaluation of central nociceptive pathways. Questionnaires regarding quality of life and the impact of FM were available.

RESULTS

Participants were mainly middle-aged women, with a mean disease duration of 8 years. Between-group differences were significant for neurophysiologic, clinical, and quality of life measures. In patients with FM, peripheral QST showed significantly altered cold and heat pain thresholds, and tolerance to cold pain was radically reduced. The median NFR threshold in patients with FM (22.7 mA [range 17.5-31.7]) was significantly decreased compared with that in controls (33 mA [range 28.1-41]). A cutoff value of <27.6 mA for NFR provided sensitivity of 73% and specificity of 80% for detecting central allodynia in the setting of FM.

CONCLUSION

Our results strongly, although indirectly, point to a state of central hyperexcitability of the nociceptive system in patients with FM. The NFR can be used to assess central allodynia in FM. It may also help discriminate patients who may benefit from use of centrally acting analgesics.

A six year prospective study of a cohort of patients with fibromyalgia

OBJECTIVES

To examine the long term prognosis in patients with fibromyalgia (FM).

METHODS

Forty five of 70 patients who had participated in a three week trial six years earlier completed again the same questionnaires used previously.

RESULTS

Most symptoms had remained stable. Pain had increased, but some aspects of quality of life had improved over time.

CONCLUSION

Symptoms of FM persisted over the six years, but patients appeared better able to cope with them.

Advances with analgesics and NSAIDs for the treatment of spinal disorders

One of the major developments with regard to chronic non-malignant pain in these last few years has been a better understanding of the mechanisms that act to maintain pain, while inferences about the pathophysiology have facilitated therapeutic decision-making. This chapter reviews the strength of evidence for the therapeutic effect of pharmacological symptomatic approaches using non-steroidal anti-inflammatory agents, opioids and co-analgesics in acute and chronic back pain with an emphasis on the results of randomized controlled trials as well as on the need for long-term comparative trials of drug efficacy, toxicity and compliance.

The representation of the back in idiomatic expressions--do idioms value the body?

OBJECTIVE

Whilst investigating the influence of patients' representations on the impact of teaching in the back school, we took an interest in 1) the place of the back in the French idioms referring to the body; and 2) the meaning these idioms convey about the back.

METHODS

The idioms including body part terms were sought on the basis of a compilation of French idioms; it has to be noted that such a compilation, however excellent it may be, can only offer a partial view of lay conversation. Occurrence of body parts and of their connotations were assessed. Idioms were classified as positive, negative or neutral, keeping in mind the difficulties of a strict classification in such a field. Drawings were then performed on the basis of the results of the descriptive analysis.

RESULTS

Globally, idiomatic expressions offer a rather negative picture of the body or at least suggest that the body is prominently used to express negative ideas and emotions. This is particularly striking for the idioms associated with the back.

CONCLUSION

The analysis of idioms referring to the body allows us to 'see with our own eyes' another aspect of the representations of the body and the back, as they are conveyed in the French language.

Is chronic non-specific low back pain chronic? Definitions of a problem and problems of a definition

BACKGROUND

Chronic low back pain (LBP) accounts for the majority of the disability and costs for LBP. However, the definition of chronicity is unclear.

AIM

To elicit practitioners' definitions of chronic LBP patients, both in general and in the patients they were treating; to assess the most common characteristics of these practitioners' chronic LBP patients; and to assess the stability of chronicity in a sample of the general population.

METHOD

Semi-structured interviews were conducted with 33 practitioners working in private practice, 71 LBP patients and their therapists, and 252 employees of a chain store who were assessed yearly in a prospective study.

RESULTS

The therapists' definitions of chronic LBP patients generally included psychosocial aspects. Only physical symptoms and signs were stressed in the patients they were treating. These patients displayed common characteristics with reference to pain, functional problems, and contact with health care services. Duration of symptoms was not sufficient to define chronicity. In the employee population, chronicity defined according to pain duration was unstable. However, the same was true when chronicity was measured according to the criteria defined in the patient population.

CONCLUSION

There is a discrepancy between theory and practice regarding the definition of chronic LBP. This discrepancy concerns not only the literature but also clinical practice itself. The term 'chronic' LBP as currently used is therefore equivocal.

[Influence of sex on reporting pain]

In many epidemiological pain studies, women more frequently report more intense, frequent and long-lasting or chronic transient pain than men. In our retrospective study including hospitalised patients referred to a pain centre, prevalence of headaches, musculoskeletal pain and somatoform pain was observed in women, as described in the literature. Generally pain intensity was higher in women and pain was more frequently controlled in men, but when intensity and pain control were compared according to the pain aetiologies, no gender difference was found. Drug treatments were adapted to pain aetiologies, which accounted for the observed differences. In hospitalised patients the significant differences observed in intensity, pain control and treatment reflect the heterogeneity of pain aetiologies rather than gender differences.

Conservative inhospital management of low back pain patients. Factors predicting two-year outcomes

OBJECTIVE

To evaluate the course of symptoms and occupational outcomes in low back pain patients two years after conservative inhospital therapy.

METHODS

Retrospective medical chart study of all patients admitted to a rheumatology department in Geneva in 1993, and telephone interview two years after the admission.

RESULTS

Eighty of the 99 patients (81%) identified by the chart review were interviewed by telephone. The course of symptoms (evaluated based on subjective assessments and on the number of subsequent admissions) was similar in the patients who had acute (n = 33) and chronic (n = 47) low back pain at the index admission. Patients who had not returned to work were significantly more likely to report persistent pain (P < 0.001). As many as 61% of patients had not resumed work. Sick leave duration and symptom duration at admission were the factors that had the largest effects on prognosis. Over 90% of patients who were put on sick leave for more than four weeks did not return to work. Permanent cessation of work was recorded in 82% of manual laborers versus 27% of patients in sedentary jobs (P < 0.001).

CONCLUSION

Our results are ascribable, at least in part, to the fact that our population included large numbers of patients with persistent pain and of blue collar workers with physically-challenging jobs. Sick leave duration and occupation were the best predictors of the course of symptoms and work status.

Patient-health care provider relationship in patients with non-specific low back pain: a review of some problem situations

Problem situations in the patient-health care relationship may relate to the patient or to the health care provider characteristics or to the way they interact; they may also relate to the general social context. Such situations force the clinician dealing with non-specific low back pain patients to look beyond the traditional biomedical model that assumes a linear connection between pathology and symptomatology. The introduction of the biopsychosocial model approximately 10 years ago has improved the understanding of common low back pain. This chapter gives some insight into areas relating to factors that may hamper the patient-therapist relationship and thus complicate treatment and recommendation outcomes. It emphasizes the necessity to involve the patient in the decision-making. Recognizing the patients' psychological, social and cultural background as well as the level of education and employability are important to make successful recommendations. This knowledge is not new but the difficulty is to implement it in today's cost effectiveness driven society. However the benefit at the end may be the decrease of chronicity and/or permanent disability, suffering for the patient and frustration for the clinician. Identifying the underlying cause of non-compliance or of unexpected delayed recovery is an exciting issue. The cause may or may not be biomedical. If a specific cause can be identified, it has to be diagnosed and evaluated. If the clinical examination has ruled out specific or emergency conditions, another perspective may be needed and the course of action could then be determined.

Health care providers should use a common language in relation to low back pain patients

Uncertainty is the rule rather than the exception when it comes to the underlying causes of 'common' or 'non-specific' low back pain. It may be called many names, depending on whether the diagnostic term is descriptive, anatomopathological or physiopathological. Classifications have been devised, including various criteria: symptoms and signs, duration, treatment, consequences of low back pain on the patients' daily life, etc. Because back pain frequently runs a recurrent course, functional and pain outcomes need to be considered separately: chronic disability and chronic pain may not be parallel. Thus, pain duration (e.g. acute, transient, recurrent, chronic) is only one element in the definition of chronicity. These difficulties in defining and classifying non-specific low back pain may lead to communication problems among health professionals as well as between patients and health professionals. These difficulties raise questions such as: what kind of diagnostic term should we use to avoid dramatization of non-specific low back pain? how can we improve the definition of long-term low back pain? and how can we assure and reassure the patient that this condition is benign in the majority of the population?

Evaluating a primary prevention program in a multicultural population: the importance of representations of back pain

OBJECTIVE

This study was carried out during 4 years of longitudinal research assessing back pain problems and the impact of a back pain primary prevention program on the employees of a food and non-food chain store. The impact of the teaching program was reevaluated in a secondary analysis, taking into account subjects' prior representations of back pain.

METHODS

Subjects were grouped according to their cultural origins and socioprofessional levels. Their representations were assessed by means of open questions before and after the teaching program.

RESULTS

The teaching program reinforced pre-existing representations in those participants socioculturally nearest the teachers; it had a weak or even disturbing impact on those furthest removed from the teachers in sociocultural terms.

CONCLUSION

The differential impact of the teaching program in this study indicates that participants' prior representation play a role in the outcome of a Back School teaching program. Thus, the participants' representations should be taken into account when designing the program and when assessing participants' suitability for such programs, their adherence, and the outcome.

The role of congruence between patient and therapist in chronic low back pain patients

OBJECTIVE

To determine the role of congruence in the perception of the evolution of back pain during treatment and in the expectations about the future of back pain problems. Congruence was defined as the agreement between patient and therapist on various aspects of back pain problems and of treatment.

DESIGN

Semistructured interviews at the beginning and the end of treatment.

SUBJECTS

Seventy-one back pain patients and their therapists (6 chiropractors and 6 rheumatologists).

MAIN OUTCOME MEASURES

Synthesized index of congruence based on 24 questions asked of both the patient and his/her therapist.

RESULTS

The distribution of the congruence scores indicated a high level of congruence in 39.4% of the cases, an average level in 35.2% and a low level in 25.4%. The results demonstrated that congruence was significantly associated with the perception of an improvement in back pain. This positive perception was nevertheless associated with the expectation of persistence or recurrence of the back pain problem in the future. Noncongruence was correlated with the patient's estimation of a less favorable evolution of the back pain problem during the treatment and with a major difficulty for both the therapist and the patient to express clear expectations about the future of the patient's back pain problem.

CONCLUSIONS

Congruence mainly reflects an agreement that the treatment is aimed at the management of a long-term condition rather than at the resolution of the back pain problem. Congruent patients seem to accept living with their back problems, a position shared by their therapists, whereas noncongruent patients do not seem to share this conception of back pain.

The gap between back pain patients' prior knowledge and scientific knowledge and its evolution after a back school teaching programme: a quantitative evaluation

This study presents a method for quantitative evaluation of the congruence between patients' representations and teachers' scientific knowledge, which is used as the standard of assessment. First, the patients' knowledge and the teachers' scientific concepts before a back school (BS) programme were compared (T0). Then the evolution of patients' knowledge at 1 month (T1) and 1 year (T2) after the teaching was evaluated. Patients' knowledge was assessed blind by a multidisciplinary panel of nine independent judges. Mean scores were computed for each set of data (T0,T1,T2); these scores were then submitted to an analysis of variance. The results showed an important gap between patients and teachers before BS with an improvement after the teaching. Knowledge referring to know-how and/or attitudes evolved differently when compared to theoretical knowledge.

A prospective controlled study of low back school in the general population

There are no data on the efficacy of a back school in primary prevention of back pain in the general population or on the characteristics of the population who volunteers. After announcement in the local press, 494 healthy adults volunteered and paid for a back school course in Switzerland. A total of 371 controls were matched for sex, age, profession, nationality and back pain. A statistically significant decrease in numbers of doctor's visits was found by the participants during the following 6 months compared with the controls. However, there were no significant between-group difference in the four remaining parameters (presence and intensity of back pain, drug intake and sick leave). Three-quarters of participants changed their attitudes after the back school. Volunteering for a back pain prevention programme was associated with the presence of back pain problems. Reasons for volunteering are further discussed. Overall, the results of this study showed that a back school for the general population may not solve the problem of low back pain, but improves self-help in a subgroup of the population.

Back schools in prevention of chronicity

This chapter has reviewed the role of back school and educational programmes for the common and non-specific acute and subacute low back pain patient. The following seems to come out of this review. Education is an important part of patient care. However, several questions arise about the content of the education, the selection of patients, the patient compliance to instruction given, how the information is retained, and which outcome measures should be used. It is also important to realize that the back school is a modality or a tool that may be used as an adjunct, but as a sole treatment it seems to have less impact than in combination with other structured or goal-oriented programmes. When a back school is instituted in a hospital or in industry, it requires administrative and budgetary support and a multidisciplinary staff to successfully carry out the programme. The information given must be adapted to the needs of the participants and all members of the team must give the same information to the patient. A poorly structured back school where patients are dumped because the physician or other health care provider has nothing else to offer is a poor solution for the patient, a poor solution for the health care provider, and can only increase the patient's discomfort and health care costs.

Psychosocial issues in the prevention of chronic low back pain--a literature review

This chapter has reviewed research on psychological and social factors associated with the onset and progression of low back pain. From this review it can be concluded that psychosocial traits appear to be important contributors to the course of pain and disability though methodologically well-designed longitudinal studies are rare. For this reason it is difficult to assess the relative importance of, for example, psychological distress compared with work stress. Furthermore, the mechanisms by which specific variables effect back pain remain unknown. The answer, no doubt, lies in longitudinal studies which employ multicausal models. It has been noted the psychosocial treatments which have proven effective for chronic pain populations are rarely assessed with acute pain patients. Some problems are the inaccessibility of acute back pain sufferers to psychologists, the difficulty of isolating the effect of one component of a multidisciplinary programme and the lack of uniform practice of psychosocial techniques. None the less, programmes which include psychosocial interventions appear to have superior results to those which do not. Since these techniques are often simple and inexpensive to include they should be incorporated into all treatment programmes where the potential for chronic pain syndrome exists. Gaps and flaws in current research methodologies have been identified and suggestions for future investigations have been proposed. In addition we have attempted to provide some practical guidelines for health care professionals to help them identify salient psychosocial issues which may effect the course of their patient's treatment. Recommendations for assessment and referral are also provided.

The role of prior knowledge on back-pain education

To investigate the effectiveness of the Geneva Back School (BS), we studied certain aspects of the retention of what was taught and the changes it induced in the patients. Thirty-nine BS patients were asked to draw their backs both before and after the BS. They were also asked to define the terms arthrosis and herniated disc once before the BS and twice after the program. Analysis of 78 drawings showed that the representation of the back was far from anatomical reality in both instances. The definitions of terms correlated poorly between patients and health care professional before BS. Teaching increased patient knowledge, but did not delete patients' prior notions. Our findings indicate that teaching strategies need to take into account patients' beliefs and knowledge. Health care professionals involved in BS programs should also be aware of the possible misunderstanding of medical terms. These factors may explain, at least partially, BS failures.