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The Effectiveness of High-Intensity Versus Low-Intensity Back Schools in an Occupational Setting: A Pragmatic Randomized Controlled Trial

Heymans, Martijn W., PT, PhD*†‡; de Vet, Henrica C. W., PhD; Bongers, Paulien M., PhD*†‡; Knol, Dirk L., PhD; Koes, Bart W., PhD; van Mechelen, Willem, MD, PhD*†‡

doi: 10.1097/01.brs.0000216443.46783.4d
Randomized Trial

Study Design. Randomized controlled trial.

Objectives. To compare high- and low-intensity back schools with usual care in occupational health care.

Summary of Background Data. The content and intensity of back schools vary widely and the methodologic quality of randomized controlled trials is generally weak. Until now, no back school has proven to be superior for workers sick-listed because of subacute nonspecific low back pain.

Methods. Workers (n = 299) sick-listed for a period of 3 to 6 weeks because of nonspecific low back pain were recruited by the occupational physician and randomly assigned to a high-intensity back school, a low-intensity back school, or care as usual. Outcome measures were days until return to work, total days of sick-leave, pain, functional status, kinesiophobia, and perceived recovery and were assessed at baseline and at 3 and 6 months of follow-up. Principal analyses were performed according to the intention-to-treat principle.

Results. We randomly allocated 299 workers. Workers in the low-intensity back school returned to work faster compared with usual care and the high-intensity back school, with hazard ratios of 1.4 (P = 0.06) and 1.3 (P = 0.09), respectively. The comparison between high-intensity back school and usual care resulted in a hazard ratio of 1.0 (P = 0.83). The median number of sick-leave days was 68, 75, and 85 in the low-intensity back school, usual care, and high-intensity back school, respectively. Beneficial effects on functional status and kinesiophobia were found at 3 months in favor of the low-intensity back school. No substantial differences on pain and perceived recovery were found between groups.

Conclusions. The low-intensity back school was most effective in reducing work absence, functional disability, and kinesiophobia, and more workers in this group scored a higher perceived recovery during the 6-month follow-up.

The objective of this randomized controlled trial was to compare a low intensity and high-intensity back school with usual care in an occupational setting. In patients on sick-leave because of subacute low back pain, the low-intensity back school showed more beneficial effects on return to work, functional status, kinesiophobia, and perceived recovery.

From the *Body@Work, Research Center Physical Activity, Work and Health, TNO-VUmc, Amsterdam, The Netherlands; †Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands; ‡Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands; §TNO Quality of Life Hoofddorp, The Netherlands; ∥Clinical Epidemiology and Biostatistics, VU University Medical Center, Amsterdam; and ¶Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands.

This study is granted by The Netherlands Organization for Health Research and Development (Zon/Mw), Dutch Ministries of Health, Welfare and Sports and of Social Affairs and Employment. The funding organizations had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Acknowledgment date: July 1, 2004. First revision date: January 7, 2005. Second revision date: April 26, 2005. Acceptance date: June 23, 2005.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Federal and Foundation funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Willem van Mechelen, MD, PhD, FACSM, Department of Public and Occupational Health and EMGO-Institute, Body@Work TNO Vumc, VU University Medical Center, van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands; E-mail:

© 2006 Lippincott Williams & Wilkins, Inc.