Lay-tutors in a back school programme
703
the patients were motivated and participated actively
in most sessions. concept is not tested in this setting. If the dose response
relation is an issue a dose response study will be needed.
Limitations Clinical implications and implications for future
research
The main limitation of this study is that it did not ex-
plore the overall effect of BSPs including lay-tutors
by including a control group not receiving the BSP.
As the BSPs were part of usual practice at the time
of the study, we aimed to explore the effect of adding
lay-tutors to a BSP. Thus, the potential effect of inclu-
ding lay-tutors in the educational part of a BSP as an
intervention in itself was not explored.
Another limitation was that 23 participants (26%)
were lost to follow-up at 24 months. However, with the
inclusion of 87 patients, a loss to follow-up of 26% is
acceptable in accordance with the power calculation.
In the analysis, a mixed model accounting for missing
values was used. In the presence of missing data, the
mixed model is considered an efficient use of the data
at hand (12).
Previous studies on rheumatoid arthritis and on ch-
ronic pain conditions have shown an effect of inclusion
of lay-persons in educational programmes (5). In the
current study it was hypothesized that a similar response
could be obtained in the current study population. Howe-
ver, the previous studies focused on patients with chronic
pain and the patients in the current study were SLBPPs
(17). As such, coping strategies with pain and their ex-
pectations towards functional ability in daily life might
be different, and this might affect how they incorporate
the information provided by lay-tutors. This may have
been a reason for not finding the hypothesized effect of
lay-tutors on our group of SLBPPs. A newly published
study by Mehlsena et al. regarding lay-tutors also repor-
ted no effect of a lay-led group-based self-management
programme for patients with chronic pain (19).
The inclusion of a lay-person in the team perfor-
ming the intervention required that the lay-person
had personal skills and the desire to act as a teacher.
Furthermore, the lay-person needed to be able to
understand the theory behind the programme and the
teaching resources. Finding people who meet these
requirements can be difficult, and requires ongoing
supervision by trained healthcare providers. The cost
of inviting a lay-person as a teacher is expected to be
low, as it represents volunteer work. If lay-tutors need
to be paid, there will be no financial benefit from such
an effort. The specific skills of each of the lay-tutors
have not been tested in this setting, which has to be
done if the programme is conceptualized.
The schedule for the programme, including 1 h of
teaching and 1 h of training every second time, was
decided by the clinicians. Whether this is the strongest
The aim of this study was to specifically evaluate the
effect of adding lay-tutors to the educational sessions
of a BSP for patients with low back pain. Therefore, an
RCT design was used, which was considered to be op-
timal for comparing the effectiveness of 2 interventions.
The programme included both educational and exercise
sessions for all patients. All patients participated in an
individually adjusted exercise programme in accordance
with the protocol. The study focused on the potential
effect of using a lay-person as 1 of 2 teachers in the
educational sessions. It did not focus on the potential
positive effect of the individualized guidance by the
physiotherapist during the exercise programme. Opti-
mally, an extra control group that did not receive any
of the elements of the back school intervention could
have been included; this was not considered as an op-
tion while information is known to be the foundation of
guidance for back pain patients. Another option, which
is recommended for further investigations, would be to
focus on change in coping strategies.
Conclusion
No short- or long-term effects were found of adding
a lay-tutor to the educational sessions of a BSP for
patients with subacute low back pain, with regards
to functional activity, back pain, leg pain or general
health. The main limitations of this study are that: the
potential effect of including lay-tutors in the educa-
tional part of a BSP as an intervention in itself has not
been tested; the programme as a whole protocol should
be tested; and no specific testing was done to secure
the ideal number of sessions in the programme. These
issues should be addressed in another setting.
ACKNOWLEDGEMENTS
The project was supported by the Danish Rheumatism Associa-
tion in collaboration with the Association of Danish Physio
therapists and the Municipality of Aarhus, Denmark.
Funding. This work was financially supported by the Danish
Ministry of Health and conducted as part of the Danish na-
tional health promotion programme: “Healthy Through Life”
[2003-1432-5].
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