To assess the efficacy of back school programmes for lower-back pain.

MEDLINE was searched from 1966 to 1992 using the MeSH terms 'backache', 'low-back pain', 'lumbago' and 'randomized controlled trials'; references from identified studies were examined. Abstracts and unpublished studies were excluded.

Study designs of evaluations included in the review

Randomised controlled trials were included.

Specific interventions included in the review

Back school programmes consisting of an education and skills programme and including an exercise regimen. All lessons were given to small groups of patients and supervised by a physiotherapist or other (para)medical specialist. Additional interventions were also allowed.

Participants included in the review

People with lower-back pain. No patient characteristics are presented.

Outcomes assessed in the review

Studies were categorised as either 'positive' or 'negative' for the review: those where the authors concluded the back school programme was more effective than the reference treatment were considered to be 'positive', and those with no differences, or better results in the reference treatment, were considered to be 'negative'. Details of the outcome measures used in the individual studies are reported in the table of studies; mainly differing pain scales, but also disability and lower-back pain episodes.

How were decisions on the relevance of primary studies made?

Studies had to meet the following criteria: back school type of intervention, patients with lower-back pain, and a randomised design. It is not stated how the criteria were applied.

All trials were given a methodological score, based on 16 criteria assessing the study population (homogeneity, baseline comparability, randomisation, drop-outs, follow-up, sample size), interventions (standardised and described, adequate control group, avoidance of co-interventions, compliance), effect (patient blinding, relevant outcomes, assessment blinding, follow-up), and data presentation and analysis (intention to treat, frequencies of outcomes). Papers were assessed for validy by two independent reviewers, and any disagreements were resolved by consensus or by a third reviewer.

The authors do not state how the data were extracted for the review, or how many of the authors performed the data extraction.

How were the studies combined?

A narrative synthesis was undertaken. Studies are reported hierarchically by decreasing methodological score.

How were differences between studies investigated?

A sensitivity analysis of the weighting system for the methodological score was undertaken, giving the criteria equal weight, and also giving internal validity criteria twice as much weight as the other criteria.

Sixteen trials (reported in 21 articles) involving 2,232 patients (1,083 in treatment groups and 1,149 in reference groups). Two studies did not report patient numbers.

Only 2 studies scored more than 50 points on methodological scores (maximum 100), and only 5 scored more than 40. Changing the weighting of the scores did not substantially change the ordering of the studies: the 2 best and 2 worst studies remained the same.

Seven studies reported positive results, 7 reported negative ones, and 2 were inconclusive.

The 4 highest methodological scoring studies all reported positive results. Over half of the positive studies had methodological scores of 45 points or more, whilst the highest methodological score for a negative study was 41.

Reported benefits are of short duration only (3 to 6 months), and the 2 best studies reported no difference between groups at 1-year and 2.5-year follow-up.

The most promising results seemed to be obtained by an intensive intervention programme, i.e. a 3 to 5 week stay in a specialised centre.

There are major flaws in the design of most studies. Future studies should be undertaken to account for these methodological shortcomings. The current results indicate that back schools may be effective for patients in occupational settings. Future research should focus on determining which patients would benefit most and the cost-effectiveness of back schools.

This is a methodologically-thorough review. It is unclear whether the MEDLINE search was restricted to English language publications, since only one non-English reference was included. The authors acknowledge the potential for publication bias. The justification for categorising studies as positive, negative or neutral is not given. The use of this outcome measure means there is no estimation of the effect size, or its clinical significance. The authors do not give a definition of what they consider to be 'relevant outcome measures'.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.