Summary of studies on education and outcomes of interventions among back pain patients
| First author, year, country and reference | Type of study | Subjects (n)/response rate | Definition of education2-150 | Measure of outcome | Association2-151 | Point estimates | Major weaknesses 2-152 | |||||||||
| Major studies | ||||||||||||||||
| Nykvist (1991) Finland93 | Longitudinal (5 years) | Patients admitted to hospital because of severe sciatic pain (n=276 - 179 got some back surgery) / (81%) | No vocational education | →Vocational handicap (ICIDH - at FU) | No | S Z P | ||||||||||
| Vocational course | ||||||||||||||||
| Technical/commercial/high school | ||||||||||||||||
| University | ||||||||||||||||
| Polatin (1989) United States92 | Longitudinal (1 year) | Four groups of patients from the Functional Restoration Program at PRIDE: a success group; a failure group; a drop out group; and a failed to enter group (n=326) / (?) | Years of schooling | →Return to work (at FU) | No | S R P | ||||||||||
| Other studies | ||||||||||||||||
| Keel (1998) Switzerland110 | Longitudinal (1 year) | Patients aged 20–60 years, admitted for inpatient rehabilitation in rural centres of Switzerland for persistent, intractable, low back pain, and who had been on sick leave for at least 6 weeks during the past 2 years (n=254) / (62%) | Elementary school | →Success as defined by work incapacity, physical leisure activities, average pain intensity, general wellbeing, functional limitations and quality of life (at FU) | Inverse | S Z O M P G | ||||||||||
| High school | ||||||||||||||||
| College/university | ||||||||||||||||
| Fishbain (1997) United States109 | Longitudinal (2.5 years) | Chronic low back pain patients aged 19–62 years entering the University of Miami Comprehensive Pain and Rehabilitation Center for a low back problem lasting >6 months (n=128) / (92%) | Not stated | →Return to work (at FU) | Pearson correlation coefficient between education and outcome (statistical significance) | |||||||||||
| Inverse | One month | 0.39 (p<0.001) | S Z E G | |||||||||||||
| 2.5 years | 0.28 (p<0.001) | |||||||||||||||
| Average | 0.41 (p<0.001) | |||||||||||||||
| Vucetic (1997, 1999) Sweden107 108 | Cross sectional and longitudinal (2 years) | Consecutive patients aged 19–68 years undertaking primary surgery for suspected lumbar disc herniation because of severe sciatica, with clinical and radiographic signs of lumbar disc herniation (n=160) / (?) | (2) | High (academics and skilled workers) | →Ruptured v intact annulus as diagnosed during surgery) | OR (95% CI) | ||||||||||
| Direct | (2) 3.2 (1.3, 7.8) | S Z R G | ||||||||||||||
| (1) | Low (no further education or vocational training after elementary school)§ | →Return to work (at FU) | Inverse | (2) 3.3 (1.4, 8.0) | S Z R G | |||||||||||
| Hazard (1991) United States106 | Longitudinal (2 years) | Consecutive back pain patients with ⩾4 months of continuous disability from work entering a functional restoration programme (n=258) / (27–77%) | Years of schooling | →Return to work (at FU) | No | S Z R M P G | ||||||||||
| Lacroix (1990) Canada105 | Longitudinal (mean=13.7 months) | Patients with a work injury involving the low back, with absence from work between 3 and 6 months, referred to the Downsview Rehabilitation Center (n=100) / (?) | Years of schooling | →Return to work (at FU) | Pearson correlation coefficient between education and outcome (statistical significance) | |||||||||||
| No | Sample 1 | 0.50 (NS) | S Z R M G | |||||||||||||
| Sample 2 | 0.40 (NS) | |||||||||||||||
| Doxey (1988) Canada104 | Longitudinal (1 year) | Compensated workers 19–62 years old randomly selected from candidates for first lumbar surgery (n=116 - 74 had surgery) / (?) | Years of schooling | Pearson correlation coefficient between education and outcome (statistical significance) | ||||||||||||
| →Work status (at FU) | No | −0.03 (NS) | S Z R M G | |||||||||||||
| →Orthopaedic outcome (at FU) | Inverse (among non-surgery patients only) | 0.30 (p<0.05) | S Z R M G | |||||||||||||
| Fredrickson (1988) United States103 | Longitudinal (2.5 years) | Patients admitted to a back rehabilitation programme (n=80) / (?) | Not stated | →Pain relief (at FU) | No | S Z E R P G | ||||||||||
| →Return to work (at FU) | No | S Z E R P G | ||||||||||||||
| →Increased activity at home (at FU) | No | S Z E R P G | ||||||||||||||
| Kleinke (1988) United States102 | Longitudinal (28 days) | Chronic back pain patients entering the Spaulding Rehabilitation Hospital in Boston (n=72) / (?) | Years of schooling | →Improvement in pain (at FU) | No | S Z R P G | ||||||||||
| →Improvement in pain behaviors (at FU) | No | S Z R P G | ||||||||||||||
| →Improvement in depression (at FU) | No | S Z R P G | ||||||||||||||
| →Improvement in mood (at FU) | No | S Z R P G | ||||||||||||||
| Hurme (1987) Finland101 | Longitudinal (6 months) | Consecutive patients aged ⩾55 years with suspected lumbar disc herniation, hospitalised in Turkuu University Central Hospital or Turkuu City Hospital (n=215) / (98%) | Not stated | →Patient's evaluation of progress (at FU) | Inverse | p<0.001 | S Z E P G | |||||||||
| →Pain Index (at FU) | Inverse | p<0.001 | S Z E P G | |||||||||||||
| →ADL Index (at FU) | Inverse | p<0.001 | S Z E P G | |||||||||||||
| →Combined Index for pain and disability (at FU) | Inverse | p<0.001 | S Z E P G | |||||||||||||
| Alaranta (1986) Finland100 | Cross sectional | Patients <55 years operated one year earlier for lumbar disc herniation (n=212) / (96%) | (1) No vocational education | →Occupational handicap (ICIDH) | Prevalence of outcome (severe) | |||||||||||
| (2) Vocational course | Inverse (only among men) | Men | (1) 62% | S Z L M | ||||||||||||
| (3) School university | (2) 19% | |||||||||||||||
| (4) High school | (3) 15% | |||||||||||||||
| (4) 4% | p=0.007 | |||||||||||||||
| Women | (1) 38% | |||||||||||||||
| (2) 32% | ||||||||||||||||
| (3) 22% | ||||||||||||||||
| (4) 8% | NS | |||||||||||||||
| Guck (1986) United States99 | Longitudinal (5 years) | Patients from a chronic pain programme (32 with back pain) (Midwestern University Medical Center) (n=77) / (85%) | Years of schooling | →Success/failure (Roberts and Reinhardt criteria - at FU) | Association (direction unclear) | S Z E P G | ||||||||||
| p=0.0002 | ||||||||||||||||
| Oostdam (1983) The Netherlands98 | Longitudinal (6 months) | Patients with low back pain admitted to one of departments of neurosurgery in the 2 hospitals in Zwolle (the Netherlands), who had a back surgery (n=150) / (91.5%) | Not stated | →Patient's and surgeon's rating of improvement (at FU) | Inverse | S Z E P G | ||||||||||
| p<0.05 | ||||||||||||||||
| Tunturi (1980) Finland97 | Longitudinal (mean=4.8 years) | Patients aged 16 to 59 years subject to posterior fusion of the lumbosacral spine in Finland (n=102) / (?) | Years of schooling | →Postoperative working capacity (at FU) | Pearson correlation coefficient between education and outcome (statistical significance) | |||||||||||
| Inverse | 0.28 (statistically significant) | S Z R M G | ||||||||||||||
| Kokan (1974) Canada96 | Longitudinal (2 to 9 years) | Subjects from a veteran population of male patients who had undergone lumbar intervertebral fusion(s) at Shaughnessy Hospital for relief of low back pain (n=28) / (34–36%) | Years of schooling | →Orthopaedist's rating of the success/failure of fusion in restoring each patient to normal functioning (at FU) | Mean years of formal education by outcome category | |||||||||||
| Wilfling (1973) Canada95 | No | Good | 9.4 | S Z R O M G | ||||||||||||
| Fair | 10.1 | |||||||||||||||
| Poor | 8.1 | NS | ||||||||||||||
| Natvig (1970) Norway94 | Longitudinal (1 year) | Consecutive patients with low back pain entering the State Rehabilitation Institute of Oslo (n=185) / (60%) | Unclearly stated | →Return to work or school (at FU) | Pearson correlation coefficient between education and outcome (statistical significance) | |||||||||||
| Inverse | 0.53 (p<0.001) | S Z E R M G | ||||||||||||||
↵2-150 Reference category indicated by §.
↵2-151 No association: there was no statistically significant association. Direct association: statistically significant association where unfavourable outcome increased with increasing educational status. Inverse association: statistically significant association where unfavourable outcome decreased with increasing educational status.
↵2-152 Major weaknesses pertaining to: S: selection of subjects, Z: sample size, E: measure of education, L: length of follow up, R: drop out rate, O: measure of outcome, M: multivariate analysis, P: point estimates, G: consideration of effect modification by gender. FU = follow up.