Low backache is a symptom and not a disease. The causes are manifold but maybe classified under the following headings:

• PSYCHOGENIC

• VISCEROGENIC

• NEUROGENIC

• VASCULAR

• SPONDYLOGENIC

The average age of the 200 patients was 38.39 years with the range from 18 to 55 years. Majority (50.5%) of the cases lie in the age group of 31 to 40 years. In Group A the average age of the patients was 38.62 whereas in Group B the average age of the patients was 38.17 years. Comparison of age between the groups showed no significant difference (p>0.05).

The study reveals that the prevalence of low backache is slightly more in the males compared to females, male to female ratio being 1.127:1. In Group A there were 52 males compared to 48 females whereas in Group B there were 54 males compared to 46 females. Comparison of gender between the groups showed no significant difference (p>0.05).

Majority of the patients (37.5%) were non-sedentary workers. 31.5% of the patients were housewives, while sedentary workers constituted 31% of the patients.

The duration of low backache ranged between 3 months to 144 months, with the average of 25.895 months (2.158 years). In majority of the cases (58%) it was from 3 months to 1 year. The average duration of low backache in Group A was 26.55 months (2.21 years), whereas the average duration of low backache in Group B was 25.24 months (2.10 years). Comparison of duration of low backache between the groups showed no significant difference (p>0.05).

It was observed that in 60% of the cases, walking; in 50%, bending of the spine; in 46%, prolonged standing and in 25%, coughing and sneezing aggravated pain. It showed that physical activity was an important aggravating factor in majority of the cases.

In 50% of the cases, in the present study, there was no change in the severity of pain by the change in the season. But in 45% of the cases, it got aggravated in the winter months and in 5% of the cases, it got aggravated in the summer months.

The commonest mode of presentation in the present series was low back pain with radiation to lower limbs, which was present in 65% of the cases (Group A- 70%; Group B- 60%). 35% of the cases had low backache only.

Stiffness of the back was present in 43% of the cases (Group A- 45%; Group B- 41%). It was absent in 57% of the cases (Group A- 55%; Group B- 59%).

Tenderness of the spine was the commonest physical sign, being present in 77% of the cases (Group A- 79%; Group B- 75%). It was absent in 23% of the cases (Group A- 21%; Group B- 25%).

Figure 1

Table No: 10 DIAGNOSIS CATEGORIES

Disc degenerative disease was found to be commonest cause of low backache, being present in 72% of the cases.

The average pre-treatment scores were 25.90 and 24.96 in Group A and Group B respectively. There was no significant difference between groups before treatment (p>0.05). Both groups showed significant improvement at 1 month, 3 months and 6 months post treatment when compared to base-line data (p<0.001). Back school patients continued to make an improvement.

The average pre-treatment scores were 6.06 and 6.00 in Group A and Group B respectively. There was no significant difference between groups before treatment (p>0.05). Both groups showed significant improvement at 1 month, 3 months and 6 months post treatment when compared to base-line data (p<0.001). Back school patients continued to make an improvement.

The average pre-treatment scores were 21.44cms and 22.66cms in Group A and Group B respectively. There was no significant difference between groups before treatment (p>0.05). Both groups showed significant improvement at 1 month, 3 months post treatment when compared to base-line data (p<0.001). However, at 6 months post treatment, whereas the patients in Group A continued to show significant improvement (p<0.001), the patients in Group B failed to show any significant improvement when compared to base-line data (p>0.05).

The average pre-treatment scores were 77.02⁰ and 75.85⁰ in Group A and Group B respectively. There was no significant difference between groups before treatment (p>0.05). Both groups showed significant improvement at 1 month, 3 months and 6 months post treatment when compared to base-line data (p<0.001, p<0.05). Back school patients continued to make an improvement.

The average pre-treatment scores were 77.61⁰ and 76.55⁰ in Group A and Group B respectively. There was no significant difference between groups before treatment (p>0.05). Both groups showed significant improvement at 1 month, 3 months post treatment when compared to base-line data (p<0.001). However, at 6 months post treatment, the patients in Group B failed to show any significant improvement when compared to base-line data (p>0.05), whereas patients in Group A continued to show improvement

Figure 2

Table No: 16 Comparison of Results between Group A and Group B

Inter-group comparison at 1 month post treatment showed that the results of Visual analogue Score, Finger to floor distance and Straight leg raising (Left) after Back School Therapy were significantly better than conservative treatment (p<0.001, p<0.05). Inter-group comparison at 3 months and 6 months post treatment showed that the results of all the parameters after Back School Therapy were significantly better than conservative treatment (p<0.001).

MOLBPDQS; MODIFIED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE SCORES

VAS; Visual analogue Score

SLR⁰ (R) Straight leg raising (right)

SLR⁰ (L) Straight leg raising (Left)

Figure 3

FIG 1(A & B): A BACKSCHOOL SESSION IN PROGRESS

Figure 4

FIG 2(A & B): GROUP EDUCATION USING AUDIO VISUAL AIDS

The Back school was first organized in 1970 at Danderyd Hospital, near Stockholm (Zachrisson Forssell M 1980). The purpose of back school is not only to create confidence in the patient to cope with his back troubles but also to avoid excess therapy & to decrease the expenses both for the patient and for the society. For most of the sufferers of low back pain without overwhelming complaints, the ‘Back School’ approach is most useful.

Back school is a kind of patient education to teach him to how to help himself & take active part in the management of the back pain. This is a group therapy of education, flexibility, strength, coordination & endurance training to prevent repetitive micro trauma to the spinal structures responsible for pain & degeneration (Kulkarni GS). In the yesteryears chronic low back pain was treated with analgesics / bed rest or surgery. However, today there is much more emphasis on exercise, psychotherapy, consideration of ergonomics and less so on surgery.

The back school instructions usually begin with description of pertinent anatomy in terms understandable by even the less educated. Various audiovisual aids are used. The initial discussion leads to the information on function of spine & present knowledge of low back pain. The mechanics of spine are explained and patients are taught the postures & positions most beneficial to the back. Various exercises to strengthen the abdominal, back & gluteal muscles are taught. There are wide variations in opinion as to what exercises are the most beneficial; at present no clear cut advantage of one type over the others seems available, no matter what disease process was being treated. The back school can also include an exam to avoid misunderstandings. Physical activities, sports & games are encouraged to improve psychological & physical tolerance of pain.

The back school program can also be applied to a variety of definite conditions such as prolapsed intervertebral disc, stenosis & spondylolisthesis for their effective management & even proper postoperative care.

Thus the back school method emphasizes that back disability is often part of human condition; that everyone bears responsibility for his own health and one cannot place all the blame at the door of other individuals. Back school also removes much of mystique about the back disability. Because the patients are endowed with more responsibility for their cure they are more unlikely to fall prey to various magic cures unless their specific validity is demonstrated.

As of today, ‘Back schools ‘are running successfully in various institutions all over the world. Back school concept is not new in India, however it is not reflected much in practice. There are very few Back schools in India and a study to evaluate the effectiveness of a Back school has not been reported from India so far

Back pain appears to be an inevitable accompaniment of the human lifecycle. Approximately 80% of persons in western society experience back pain at some stage during their life, and this pain is sufficient to cause an alteration in lifestyle for at least a period of time and drives individuals to seek some form of treatment (Nachemson A 1980). Back pain is the single most expensive musculoskeletal ailment in western society (Kelsey J, White AA 1980). Until recently, it was believed that back pain was not a problem in “underdeveloped countries”, but recent evidence clearly shows that its incidence in such countries is similar to that in the “developed” world and that when back pain clinics are made available, local people flock to them for treatment (Frymoyer JW, Cats-Baril WC 1991). Backache is as universal as headache, but it is often impossible to be accurate about the source of the pain (Twomey LT, Taylor JR 1987). Despite improved diagnostic techniques, the difficulties of obtaining an accurate and precise diagnosis still present the greatest obstacle to further well directed research, as well as to effective treatment.

As the patient’s history of back pain extends over a period of months and years, psychosocial factors are likely to intervene and further complicate the problem. Any treatment should therefore be aimed at minimizing the likelihood of the development of a chronic back pain syndrome, with its tendency to passive dependency and learned pain behaviors.

In light of our present knowledge, one of the most effective and economic methods of achieving this would seem to be backcare education administered in a group situation. This method of treatment, often referred to as Back School, is now internationally popular. It is based on available scientific knowledge of the physiology and mechanics of the spinal structures and their relationship to daily activities. Back School, by providing the patient with a better understanding of the problem, aims primarily at helping the patient take responsibility for his or her back pain, while relieving pain and functional disability (Klaber Moffett JA et al. 1986).

Majority (50.5%) of the cases lie in the age group of 31 to 40 years.These observations are comparable with the studies conducted by Grant et al. (1948), O’Connell (1951), Chaterjee (1967), Bulos (1973), Airon et al. (1981) and Sharma and Sankaran (1980), which reported the peak age between 30 to 40 years. These observations are close to the studies conducted by Poppen (1945) and Friberg and Hirsch (1946), where most of the cases were between 30 and 50 years. Klaber Moffett JA et al. (1986) reported average age of 39 years and 6 months in their study. Shirado O et al. (2005) reported average age of 43.8 years in their study. Karkucak M et al. (2006) in their study reported that 45.4% were between 35-44 years of age.

Our figures coincide with the study conducted by Poppen (1945). Nathan (1959) and Clave and Galland (1930) noted higher incidence of degenerative changes and spondylolisthesis in persons engaged in heavy activities, like carrying weights and prolong standing. Troup (1965) stated that there is no absolute distinction between the type of heavy work which causes premature degeneration of the spine; yet it is logical to assume that degeneration is hastened by a series of micro injuries, due to abnormal postures, involving the vertebral bodies and the endplates. Sharma SC et al. (2003) in their series reported that 57% of the patients were heavy manual workers, 26% had to change/leave their profession, and 38% did not enjoy their present job.

However the present study do not confirm to the observations of Levy (1967) who is of the opinion that manual labour strengthens rather than weakens the musculature and the ligamentous support of the back and thereby reduces the likelihood of disc herniation. Sharma and Sankaran (1980) were of the opinion that the majority of the cases having protruded disc belong to well to do families engaged in office work. Karkucak M et al. (2006) in their series reported that 47.7% of the patients were housewives.

In majority of the cases (58%) it was from 3 months to 1 year. These observations are close to the observations of Poppen (1945) (symptoms occurred over a period of 2 years); O’Connell (1951) (less than 6 months in 18.8%, more than 1 year in 63.6% and less than 5 years in 22.8%). However the present study do not confirm to the observations of Klaber Moffett JA et al. (1986) (7 years mean duration of symptoms); Karkucak M et al. (2006) (6.7 years mean duration).

It showed that physical activity was an important aggravating factor in majority of the cases.These observations are close to those of Peyton and Simmons (1947), where in more than 70% of the cases, pain was aggravated by bending and coughing. Friberg (1939) reported coughing and sneezing as the pain aggravating factors. In Poppen’s series (1945), 52% of cases had sciatic radiation of pain on coughing or sneezing and 47% of the cases were constipated.

Commonest mode of presentation in the present series was low back pain with radiation to lower limbs, which was present in 65% of the cases (Group A- 70%; Group B- 60%). It was unilateral in 46% of the cases (Right- 26%; Left- 20%) and bilateral in 19% of the cases. 35% of the cases had low backache only. Stiffness of the back was present in 43% of the cases (Group A- 45%; Group B- 41%).

Poppen (1945) reported that recurrent low back pain was present in 95% of the cases of low back pain and in many cases it preceded the sciatica. Armstrong (1958) reported that backache was the commonest presenting symptom in 69% of the cases with disc lesion. Sharma and Sankaran (1980) in a series of 117 cases of prolapsed intervertebral disc, reported backache with sciatica in 76.1%, backache only in 12.8% and sciatica only in 11.1% of the cases. Hirsch (1965) concluded that analysis of patients’ symptoms in low backache discloses a complex picture with marked variation in the distribution of pain and varying degrees of impaired function.

It was observed that tenderness of the spine was the commonest physical sign, being present in 77% of the cases. Limited motion of lumbar spine was present in 70% of the cases. Decreased lumbar lordosis and muscle spasm were present in 60% and 58% of the cases respectively.

THE FREQUENCY OF THE ABOVE SIGNS VARY FROM 40% TO 70% IN THE STUDIES CONDUCTED BY FRIBERG (1939), PEYTON AND SIMMONS (1947), O’CONNELL (1951) AND ARMSTRONG (1958).