Effectiveness of the back school program for the performance of activities of daily living in users of a basic health unit in Porto Alegre, Brazil (2024)

Abstract

[Purpose] Primary care is considered the gateway to the Brazilian public health systemand is responsible for managing the most prevalent problems in the population. In thisstudy, the effects of Back School on pain, functionality, and the performance ofactivities of daily living (ADL) in users with chronic musculoskeletal pain wereevaluated. [Subjects and Methods] Forty-four users (33 females and 11 males) participatedin Back School, with five two-hour theoretical and practical meetings held once a week.The assessment instruments used were as follows: (a) a circuit evaluation of posturedynamics recorded on video, (b) an observational instrument of ADL using video, (c)anamnesis, (d) the visual analogue scale, and (e) the Oswestry Disability Index. [Results]The results showed decreased pain intensity, improved functionality, and the recovery ofADL. [Conclusion] The Back School program is an effective health education strategy forusers with chronic musculoskeletal pain.

Key words: Health evaluation, Primary health care, Chronic pain

INTRODUCTION

The managers of the Brazilian public health system have implemented measures to strengthenprimary health care in all regions of the country, because primary care is considered the“gateway” for Brazilian users^{1, 2)}. The Primary Care Policy mandates that health servicesexpand their activities and improve the quality of life for individuals¹⁾. To achieve this goal, primary care networks should promotehealth, prevent disease and injury, minimize the burdens of disease, and reduce the demandson secondary and tertiary care services^{1, 3)}.

Back pain, and especially lower back pain, has high global prevalence, and some cases maybecome chronic if not treated⁴⁾. This typeof chronic pain can lead to work absenteeism, reduced productivity, and diminished qualityof life and functionality, among other consequences^5,6,7,8). Thus, chronic pain hasbecome a costly public health problem with a negative impact on life, and it is importantfor the Brazilian public health system to include in its Primary Care Policy the means forpreventing and treating chronic pain.

Back School is a program of health education that aims to reduce injury and improve thefunctionality and quality of life for individuals with chronic musculoskeletal pain,especially pain in the spine, through proper implementation of activities of daily living(ADL)^9,10,11). This program iscompatible with the principles of the Brazilian public health system. However, there are fewreports that address Back School in this system¹²⁾, and research has predominantly focused on secondary and tertiarycare services from a biomedical perspective^5,6,7,8). Moreover, current literature¹³⁾ indicates that most research involvingBack School methodology used evaluation questionnaires for pain intensity, quality of life,and functionality to determine the impact of the program¹⁴⁾. Few reports have considered the effects of Back School on theperformance of ADL.

Therefore, this study investigated the effects of Back School on the performance of ADL,pain, and related aspects, as well as functionality in users with chronic musculoskeletalpain in a basic health unit (BHU) in Porto Alegre. With this information, a Back Schoolprogram, as proposed by Forssell⁹⁾, wasimplemented in a BHU in Porto Alegre.

SUBJECTS AND METHODS

This study was approved by the research ethics committee of the Hospital de Clinicas dePorto Alegre (Nº. 100354) and complied with Resolution 196/96 of the National HealthCouncil.

To set the sample size, a calculation was performed based on the estimated populationmean¹⁵⁾. The calculation used aconfidence level of 95%, a maximum average estimated error of 5% (6.47), and a standarddeviation (1.06) of the primary variable (evaluation of dynamic posture in ADL) obtainedfrom the literature¹⁶⁾. Thus, it wasdetermined that a minimum of 41 subjects were required to fulfill the purposes of thepresent study. In anticipation of losses and refusals, eight groups, each with five to sevenmembers, were defined.

The inclusion criteria were the presence of chronic musculoskeletal pain and a referralfrom a doctor in the BHU. The exclusion criterion was attendance at less than three BackSchool meetings. The sample was composed of 44 members: 33 females and 11 males. The agesranged from 35 to 75 years, and the mean age was 57.04 ± 10.38. Most participants (38.6%)were 60–70 years old and had less education; 50% had completed basic education, and 29.5%listed household or custodial services as their occupation. Table 1 lists the characteristics of the subjects.

To evaluate dynamic posture, two instruments were used: the Layout for Assessing DynamicPosture (LADy)¹⁷⁾ and the observationalinstrument for ADL (OI-ADL) through video¹⁸⁾. The LADy was used to assess posture when the participants werelifting objects from the ground, sitting down to write, or sitting on a bench. The OI-ADLwas used to assess seated posture. The evaluation used a script that required the user tomove around the room while performing the ADL requested in their usual manner. The activitywas recorded on a video camera (Sony DCR-DVD201 model) and subsequently recorded on CDs foranalysis.

Each instrument used four to nine predefined criteria for evaluation of each ADL, with ascore of 0 if the task was performed or 1 if it was not. The final score for each ADL wasused for the analysis.

Pre- and posttest assessments were conducted by a researcher in a healthcare field who wasfamiliar with the instruments, and blinded as to whether the evaluation was performed beforeor after testing. The evaluation results were compared with the final score for eachADL.

Anamnesis was used to collect personal data and other relevant information, including theduration of pain, the number of pain-related symptoms, and the main source of pain, whichwas defined in this study as the most intense and frequent pain. The anamnesis also includeda body chart to assist users in correctly identifying the site of pain.

Pain intensity was measured using the visual analogue scale (VAS), which was presented as astraight, horizontal, 10-cm non-numeric line. The left end indicated “no pain,” and theright end indicated “unbearable pain.” Users were asked to score the intensity of painwithin the last week.

Functionality was evaluated with the Oswestry Disability Index (ODI), a questionnairevalidated for Portuguese by Vigatto et al¹⁹⁾. This questionnaire consists of 10 questions designed to identifythe extent to which pain interferes with the performance of certain activities, such aswalking and lifting, without focusing on the psychological consequences of pain. Thequestionnaire scores range from 0, for no pain or disability, to 100, for the worst possiblepain and disability. The ODI divides disability into five categories with a score rangingfrom 20–100 points: minimal (1–20), moderate (21–40), severe (41–60), crippling (61–80), andbed-bound (81–100).

The evaluations were performed in a BHU in Porto Alegre. In each Back School group, thefollowing experimental design was developed for an eight-week program: in the first weekprior to starting Back School, users registered on the waiting list were called for initialassessment (pretest). Users who agreed to participate signed a consent form and wereevaluated by anamnesis, ODI, and ADL filming. From the second to the seventh weeks, the BackSchool intervention was conducted. Finally, in the eighth week, after the conclusion of BackSchool, all users were reassessed (posttest) using the same tools as in the pretest.

Back School consisted of five two-hour theoretical and practical meetings held once a weekin groups of five to seven members. During the first hour, the mostly theoretical aspectsrelated to posture were presented; during each class, theoretical and experiential themesthat addressed specific aspects related to posture and postural care were defined, andproper ways of performing the most common ADL were presented. During the second hour, bodyawareness exercises were performed, including stretching, muscle strengthening, andrelaxation, as well as massage activities and self-massage¹⁴⁾.

Statistical software package SPSS (20.0) for Windows was used for statistical analysis.Data normality was verified with the Shapiro-Wilk test. Descriptive statistics were providedfor absolute and relative frequencies, means, standard deviations, medians, and 25th and75th percentiles; inferential statistics used the paired t-test for parametric data and theWilcoxon test for non-parametric data. These analyses were done to compare the pre- andposttests for performance of ADL, pain intensity, and functionality. The level ofsignificance was p<0.05.

RESULTS

With respect to duration, 76.7% had pain for a year or more, and the remainder (23.3%) hadpain for three months to a year, indicating that the entire sample had chronicmusculoskeletal pain. Most users had two (38.6%) to three pain-related symptoms (36.4%).Lumbar region pain was reported most often (75%) by the study participants, but 90% of thoseusers also complained of pain in another region of the body. The main pain, defined as themost frequent and intense, was also mostly located in the lumbar spine (50%), followed bythe cervical spine (27.3%).

Table 2 shows the medians and 25th and 75th percentile values of the pre- and posttestADL scores. A significant difference was observed for the performance of lifting objectsfrom the ground, sitting down to write, and sitting on a bench. Based on a total of 22points, the user percentile score was 54.5 on the pretest and 68.1 on the posttest, whichwas obtained by summing the scores of the four ADL tasks. The ADL task of sitting down towrite showed the lowest scores (Table 2).

There was also a significant decrease in the intensity of pain in the five body regionsevaluated (Table 3). Furthermore, 30.6% of the sample reported no pain at the posttest.

Table 4 presents the results of the ODI at the pre- and posttest assessments. Therewas less functional disability reported on the ODI questionnaire, and the average disabilityof the group improved from moderate to minimal.

DISCUSSION

The results of this study indicate that the Back School program was effective in teachingthe proper performance of ADL tasks of lifting objects from the ground, sitting down towrite, and sitting on a bench. As described in the program, Back School was only ineffectivein teaching proper sitting posture. Few studies have used instruments that analyzed ADLperformance to examine the impact of the Back School program, and none was conducted inindividuals with chronic musculoskeletal pain, making it difficult to compare studies. Twostudies used the OI-ADL through video¹⁸⁾to verify the effect of Back School in a population of schoolchildren. Candotti et al.²⁰⁾ used the OI-ADL through video to determinethe influence of the Back School program on adolescents, and found significant differencesin all ADL analyzed, including sitting posture. Ritter et al.²¹⁾ conducted a similar study with elementary school students and alsofound a significant difference in sitting posture. However, Back School programs in thesestudies provided 12 and 20 lessons, respectively, and included healthy individuals, orpatients with no chronic pain.

The use of videos to assess dynamic posture is an appropriate strategy for determiningwhether there is improvement in the performance of ADL in an intervention that aims toachieve healthy postural habits. The use of a questionnaire for the assessment of ADL,despite being an important method due to its ability to systematically record subjectiveperceptions, its ease of use, and its low cost²²⁾, may cause bias in the results because the responses are highlydependent on participant perceptions and cognitive levels. Moreover, these questionnairesare not able to verify the incorporation of theoretical knowledge by the individual and howthis knowledge is transferred to movement²³⁾, which is possible by filming the dynamic posture^{24, 25)}.

The posture adopted in the ADL determines the amount and distribution of stress on the bonestructure, muscles, tendons, ligaments, and joints, and can potentiate or ameliorate theburdens imposed on the vertebral column²⁶⁾. For example, Straker²⁷⁾ stated that use of improper posture to lift an object from theground leads to increased shear forces on the spine, and ligament stress is 50% to 75%greater than with proper posture with knees and hips flexed. Improper posture, with flexionof the trunk, tends to accentuate the harm resulting from prolonged and continuous sitting,resulting in pain, fatigue, and even degenerative processes, such as spinal discherniation^{28, 29)}. Thus, the findings of this study are relevant because of thenumerous negative effects caused by incorrect ADL postures.

Good postural habits are important for proper functioning of the musculoskeletalsystem³⁰⁾, and poor postural behaviorsmay be a risk factor for nonspecific chronic back pain¹⁶⁾ and postural changes²⁸⁾. The proper use of body mechanics, simulated in the Back Schoolclasses, allows for better adjustments of the musculoskeletal system through better balanceand distribution of effort required to perform ADL, and can mitigate pain and degenerativeprocesses³¹⁾; however, this mitigationdepends on complex interactions between biomechanical and neuromuscular functions³⁰⁾. Changing habits is not easy. Posturalhabits are deeply embedded in the organization of movements and in the mind, andinterventions that seek to change poor postural habits must create situations that allowreflection, as well as understanding of the postures and movements³²⁾. It is also necessary to consider the psychological andcultural implications involved in acquiring a postural habit.

For a habit to change, individuals must develop the ability to observe the sensationsgenerated by their movements and to interpret them, which is the intent of Back Schoolintervention. This type of methodology allows for greater user autonomy in solving problemsrelated to posture in daily life.

Essential educational activities, such as those in this study, aim to promote properpostures through habit change. These activities are an important means of promoting health,and should be offered in the form of programs that address lifestyles and behaviors thatperpetuate or worsen health problems and can be modified by individuals³²⁾.

The findings of this study corroborate those of others that demonstrate the positiveinfluence of Back School interventions on pain intensity^{5, 7, 8)}. However, these studies only assessed pain in the lumbar spine,probably because this methodology was created as a postural training method used in thetreatment of lumbar pain patients⁹⁾.However, this limitation makes it difficult to compare the results with those for other bodyregions³³⁾.

Chronic low back pain is a frequent complaint, and is the second most frequently reportedchronic disease in Brazil, according to the National Household Survey³⁾. In the present study, the lumbar region was the mostfrequently reported region of pain; however, 90% of users also had pain in other regions ofthe body. Thus, it is important to examine other types of pain, because the Back Schoolmethodology also proved to be effective for reducing pain in regions other than the lumbarspine.

The results also indicate that Back School was effective for improving functionality, whichcorroborates the findings of other literature^{7, 8)}. According to Morone et al.⁷⁾, participants in an educational program suchas Back School can learn to manage different daily tasks without developing pain, which canreduce the severity and recurrence of new episodes.

The National Primary Care Policy in Brazil promotes program development and implementationof activities that focus on the most common health problems, as well as educationalinterventions for various diseases. These activities should focus on groups and behavioralrisk factors, both dietary and environmental, to prevent disease and injury¹⁾. Thus, group programs such as Back School,which can reduce public spending for individual treatment, and are geared toward problemsprevalent in the population, should be encouraged in primary care. Studies evaluating theseprograms are essential to verify their legitimacy in improving the health of users and toidentify strategies that can be effective for chronic problems such as musculoskeletalpain.

Comparing results with a control group is important because it helps to eliminate bias inthe results (i.e., the effectiveness of the program may be related to spontaneousimprovement in the users), which is a limitation of the present study. Another limitationwas the lack of medium- and long-term follow-up. However, we chose to conduct the studywithout a control group because Back School is held in a primary care setting; the staff ofthe unit decided that it was not appropriate to deny the service to a user who was not asubject in the study. Moreover, the entire sample was composed of users with chronicmusculoskeletal pain; the majority of users (76.7%) had experienced pain for a year or moreand had previously sought other treatment. Further research is required to assess theeffects of Back School, both in comparison with usual care, and to assess the medium- andlong-term results.

The Back School program is an effective health education strategy for pain relief. Theprogram improved the performance of ADL and functionality in users with chronicmusculoskeletal pain in a BHU in Porto Alegre. Back School was only ineffective inreeducation for proper sitting posture, and new strategies are needed for this variable.

Programs such as Back School should be developed in primary care, with a focus on solvingproblems prevalent in the population. Group health education using easily applicableassessment instruments is important in reducing public spending on health, and can improvethe health and well-being of the population.

Acknowledgments

We thank the Hospital de Clínicas de Porto Alegre (FIPE/HCPA) for the financial support.

REFERENCES