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I. Grundt Larsen et al.
DISCUSSION
This RCT aimed to evaluate the long-term effect of
adding lay-tutors to the educational sessions of a BSP
for SLBPP treated in a primary care setting. Participa-
tion of former back pain patients as lay-tutors in a BSP
was expected to inspire SLBPP to change their health-
related behaviour, thereby improving their physical
function and health status. However, this turned out
not to be the case; no differences were found regarding
any of the outcomes between the 2 groups.
The current study was planned and conducted more
than 10 years ago, but is still a highly relevant concept
used in Denmark and other Western countries. At the
time the study was initiated, the treatment of patients
with low back pain changed to a more individuali-
zed concept. However, the back school concept has
now been reintroduced in the Danish primary sector,
focusing on education and individualized exercise.
This study brings knowledge to the discussion about
whether lay-tutors should be included in BSPs (1).
Poquet et al. (13) have stated that the back school
concept is not efficient for patients with acute and
subacute back pain, in contrast to Sahin et al., who,
among patients with chronic low back pain, found an
effect of adding the back school concept to exercise
and physical treatment (14). This might be the case if
the programme focused on group-based programmes,
but differentiated programmes may be more effective.
This study showed that patients had better outcomes in
long-term follow-up; however, the introduction of lay-
tutors to the educational part of the whole programme
was ineffective.
Whether lay-tutor programmes, by themselves,
might have the same effect as the combination of
education and exercise in the same programme has to
be tested in another setting.
The BSP was planned in collaboration with expe-
rienced physiotherapists and occupational therapists
working in programmes including self-management
strategies for patients with low back pain (Table
I). These programmes were based on the theory of
Bandura (15, 16), and are well described in a compre-
hensive manual. The protocol comprised a structured
programme and theoretical information, as well as
schedules for each exercise session. The manual was
used in the training period by both physiotherapists
and lay-tutors to ensure consistent knowledge
and guidance . As we explored the effect of adding
a lay-tutor to the BSP it was developed by clinicians
for this specific project; therefore, we did not evaluate
the effect of each of the learning sessions. This should
be done if the protocol is used in future projects. The
www.medicaljournals.se/jrm
manual was written in Danish, due to the Danish set-
ting of the study.
Previous studies, including lay-led programmes on
coping and self-help strategies in handling chronic
low back pain in everyday life, describe changes in
coping strategies (5). The current study evaluated to
what extent the participation of a lay-tutor affected
long-term functional outcome and general health sta-
tus, but did not evaluate the effect of the participation
of a lay-tutor on individual competencies to handle
daily activities despite back pain. This focus could be
included as an outcome in future projects. In addition,
including the lay-tutor in the educational programme
and in the assessment of the patient’s ability to cope
is also recommended (17).
Methodological considerations
The RMQ was used as the primary outcome. Mean
RMQ was 10 out of 24, and the pain score was 4 out of
10, which was in accordance with other subacute low
back pain populations treated in primary care (9), but
compared with studies evaluating programmes inclu-
ding chronic back pain patients the score is relatively
low (18). As minimal clinical important change in the
RMQ score we used 4.2, which is higher than recom-
mended by Roland (9). It is stated that a change of 1–2
points in a setting such as the one presented might be
relevant. The relative change could have been used as
an outcome, but it is seldom used in back pain studies
and it was not chosen as an outcome in this study.
Strengths
To strengthen the generalizability of the study, patients
were recruited from general practice and in an outpa-
tient clinic at the university hospital. This strengthened
the recruitment of patients and the external validity of
the findings.
The patients fulfilled the inclusion criteria, repre-
senting a group of patients with subacute low back
pain, of which two-thirds reported previous episodes
of back pain. The mean age was 47 years, and they
were employed, two-thirds as white collar or public
servants. This group of patients were representative of
the patients seen in a private physiotherapy clinic. They
did not represent the group of patients with chronic low
back who are usually the focus of the interventions
described in this study. The eventual effect of including
lay-tutors in the programme including chronic patients
should be tested if it is planned for lay-tutors to be part
of these programmes.
The high compliance with the interventions was
considered another strength of the study, indicating that