The Efficacy and Effectiveness of Education for Preventing and Treating Non-Specific Low Back Pain in the Hispanic Cultural Setting: A Systematic Review

A systematic review was conducted to assess the efficacy and effectiveness of education programs to prevent and treat low back pain (LBP) in the Hispanic cultural setting. Electronic and manual searches identified 1148 unique references. Nine randomized clinical trials (RCTs) were included in this review. Methodological quality assessment and data extraction followed the recommendations from the Cochrane Back Pain Review Group. Education programs which were assessed focused on active management (3 studies), postural hygiene (7), exercise (4) and pain neurophysiology (1). Comparators were no intervention, usual care, exercise, other types of education, and different combinations of these procedures. Five RCTs had a low risk of bias. Results show that: (a) education programs in the school setting can transmit potentially useful knowledge for LBP prevention and (b) education programs for patients with LBP improve the outcomes of usual care, especially in terms of disability. Education on pain neurophysiology improves the results of education on exercise, and education on active management is more effective than “sham” education and education on postural hygiene. Future studies should assess the comparative or summatory effects of education on exercise, education on pain neurophysiology and education on active management, as well as explore their efficiency.


Introduction
"Common" or "non-specific" low back pain (LBP) is defined as pain between the costal margins and the inferior gluteal folds, which is usually accompanied by painful limitation of movement, may be associated with pain referred down to the leg ("leg pain"), and is not related to fracture, direct trauma or systemic diseases, such as neoplastic, infectious, vascular, metabolic, or endocrine-related processes [1,2]. It represents a major health and social burden [1][2][3].
Three studies, designed to assess the effectiveness of education as a treatment for LBP, were conducted with adult patients who had been recruited in the clinical setting [18,45,46]. Five studies assessing education for LBP prevention, included school children  Table 1 summarizes the main characteristics of the studies included in the systematic review. Two RCTs had randomized participants at the individual level [45,46], while the rest were cluster RCTs. Five studies were conducted with children, in the school setting [47][48][49][50][51], and four with adults; three in the clinical setting [18,45,46], and one in nursing homes [17].
Three studies, designed to assess the effectiveness of education as a treatment for LBP, were conducted with adult patients who had been recruited in the clinical setting [18,45,46]. Five studies assessing education for LBP prevention, included school children [47][48][49][50][51]. The ninth study assessed the potential effect of education for prevention and treatment, and was conducted with elderly living in nursing homes. This study included subjects both with and without LBP upon recruitment, and analyzed separately results for the whole sample and for participants who reported LBP [17].
Education on "active management" (i.e., primarily focusing on recommending avoiding bed rest and keeping as physically active as pain allowed to) was assessed in three studies [17,18,47], education on "postural hygiene" (i.e., primarily focusing on how to perform daily activities minimizing the load for the spine) in seven [17,18,45,46,48,49,51], education on exercise (i.e., teaching how to perform exercises) in four [18,45,46,50] and education on pain neurophysiology (aiming at altering patients' knowledge about their pain states and conceptualizing pain) [52] in one [46]. Comparators were no intervention, usual care, exercise, other types of education (including short education programs on cardiovascular health and on weight control and healthy nutrition habits, which were considered "sham" educational interventions for LBP), and different combinations of these procedures.
The intensity and duration of the education programs varied widely across studies. In the clinical setting, it varied from a 20 min group talk and the handing out of a leaflet [17,18], to a 11 min video to be seen daily, 5 days a week for 9 months, combined with a face-to-face visit and as many contacts with the researchers as the participants wished during one year [45]. In the school setting, it ranged from handing out a comic book in class [47], to six one-hour sessions [48,51] or two 13 min sessions per week during 32 weeks [50].
In studies conducted with adults, outcomes across studies included LBP-related disability, pain severity (for LBP and referred pain down to the leg), 9 month LBP prevalence, health-related quality of life, fear avoidance beliefs (FABs), catastrophizing, kinesiophobia, finger to floor distance, pressure pain thresholds, and muscle endurance (Shirado-Ito abdominal and lumbar tests [53]). In studies conducted with children, outcomes were knowledge (on active management or postural hygiene), weight of the backpack, pain severity and 1 week LBP prevalence ( Table 2). Table 2 shows the main results of each study. Table 3 shows the risk of bias of the studies included in this review. Five RCTs were categorized as "low risk of bias" [17,18,[45][46][47]. Their results suggest that with regard to education programs designed for adults: (a) the combination of education on postural hygiene and exercise improves on results from usual care [45]; (b) education on pain neurophysiology improves the results of education on exercise [46]; (c) education on "active management" is more effective than education on postural hygiene [17], education on cardiovascular health [17], and on bodyweight control and heathy nutrition habits [18]; (d) adding a combination of education on postural hygiene and exercise does not significantly improve the results of education on active management [18]. With regard to education programs designed for children, the handing out of a comic book in class is effective to transmit knowledge on active management [47].
Four RCTs were categorized as "high risk of bias" [48][49][50][51]. All of them relate to education programs designed for school children, and their results suggest that (a) education in class is effective to transmit knowledge on postural hygiene [48,51], and to reduce the weight of their backpacks [49], and (b) education on exercise reduces the 1 week prevalence of LBP [50]. Usual care + 20 min talk, provided to groups of ≤20 participants, followed by hand out of a booklet (content consistent with the talk) Content: EG1 = Active management EG2 = Postural hygiene Usual care + 20 min talk, provided to groups of ≤20 participants, followed by hand out of a booklet (content consistent with the talk) Content: Cardiovascular health Mixed linear random-effects models The same physician provided the education programs to all groups. He was told that the same effect was expected in both EGs, he had no opinion on their comparative effectiveness (both before and after the study) and was blind to subjects' recruitment and assessment. An independent observer was present at the talks, and reported no differences across groups Usual care + EG1 and EG2: one 15 min talk on active management for low back pain, provided to groups of ≤20 participants, and handing out of a booklet with a consistent content EG2: + One additional 15 min talk, provided to groups of ≤20 participants, and handing out of a booklet on postural hygiene + Four 1 h/week sessions of physical therapy (exercise + stretching), in groups of ≤20 participants, and advice to continue at home Usual care + one 15 min talk on the importance of weight control and healthy nutrition habits for the management of low back pain, provided to groups of ≤20 participants, and handing out of a booklet with a consistent content  [48] Cluster randomized trial Usual care + face-to-face explanation of the program to each participant + As many contacts with researchers as participants wished (they could contact the research team by phone 5 days/week), with at least one face-to-face patient visit once a year + a website-based, educational program, including videos in which explanations were provided using audio and subtitles. Three videos were planned to be seen daily, from Monday to Friday, for 9 months:  1 As per the Spanish law, children are grouped in class based on year of birth (e.g., all the children born between 1 January 2015 and 31 December 2015, are grouped in the same class). Therefore, the age of all the students in a school class is homogenous.  [47] (CG = no intervention, EG = minimal intervention on active management) (see Table 1 [48] (CG = no intervention, EG = intensive program on postural hygiene) (see Table 1 for details) Healthy habits score (1 point given for each of the following items: "correct use of sofa", "stooping correctly", "taking care to sit correctly at home", "taking care to sit correctly at school", "frequent posture change on chair at home" and "frequent posture change on chair at school") Range values: 0 (most "unhealthy" habits) to 6 (healthiest).
Results from a repeated-measures analysis of co-variance (ANCOVA) Comparison of scores before and after the intervention, showed a significant improvement in the EG (p < 0.001), but not in the CG (p > 0.6) Actual scores in each group, are not disclosed (only graphically represented, separately for each of the items scored) Del Pozo-Cruz et al., 2012 [45] (CG = no intervention, EG = intense program on postural hygiene and exercise) (see Table 1  Only results from the "intention to treat" analysis are shown. Results from the "per protocol" analysis were consistent "p" values refer to intra-group differences (baseline values vs. value at the end of the 9 month, follow-up period) Gallardo et al., 2013 [49] (CG = no intervention, EG = one session on use of backpack) (see Table 1  Calculations based on the Number Needed to Treat (NNT) suggest that for every 100 children following the education program, 51 will reduce the weight of their backpacks to <15% of their bodyweight Rodríguez-García et al., 2013 [50] (CG = no intervention, EG = intensive program on exercise) (see Table 1 Table 1 for details) "Healthy backpack use habits score" (1 point given for each of the following items: "try to load the minimum wight possible in the backpack", "carry backpack on two shoulders", "belief that backpack weight does not affect the back", and "use of locker at school"). Range values: 0 (most "unhealthy" habits related to backpack) to 4 (healthiest).
Repeated-measures analysis of co-variance (ANCOVA): EG: the score improved at follow-up (p = 0.001) CG: no significant improvement in the score at follow-up (p = 0.2) Actual scores in each group are not disclosed (only graphically represented, separately for each of the items scored) Bodes Pardo et al., 2018 [46] (CG = intensive program on exercise, supervised and unsupervised at home. EG = same program + education on neurophysiology of pain) (see Table 1 for details) Disability (RMDQ), differences between scores at baseline and at 3 month follow-up pain (NPRS), differences between scores at baseline and at 3 month follow-up Physical quality of life (PCS, SF12), differences between scores at baseline and at 3 month follow-up Kinesiophobia (TSK-11), differences between scores at baseline and at 3 month follow-up Pressure pain thresholds (kg/cm 2 , using an analog Fisher algometer), differences between scores at baseline and at 3 month follow-up: On spinal process L3 On lateral epicondyle Finger to floor distance (cm), differences from baseline to 1 month follow-up Self-perception of improvement (PGIC) Between-group difference in the variation of the score (Pearson chi-square or Student's t test where appropriate) (mean (95%CI) −2.   1 : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. However, Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education program was diffe that other groups were receiving different contents, and patients' expectations were managed to be similar across groups. 2 : Because intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had no preferen different education programs which were implemented in the control and the two experimental groups, either at the beginning and been informed that the same outcome was to be expected across groups, and an independent physician audited that no differences i could be detected during the talks. Key, possible answers: Yes No Unsure . : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progr that other groups were receiving different contents, and patients' expectations were managed to be similar across group intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an Albadalejo 2010, patients in the different groups received the same intervention; only the content of the edu that other groups were receiving different contents, and patients' expectations were managed to be similar a intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave t different education programs which were implemented in the control and the two experimental groups, eith been informed that the same outcome was to be expected across groups, and an independent physician aud could be detected during the talks. Key, possible answers: Yes No Unsure . : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. However, Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education program was diffe that other groups were receiving different contents, and patients' expectations were managed to be similar across groups. 2 : Because intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had no preferen different education programs which were implemented in the control and the two experimental groups, either at the beginning and been informed that the same outcome was to be expected across groups, and an independent physician audited that no differences i could be detected during the talks. Key, possible answers: Yes No Unsure . : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d could be detected during the talks. Key, possible answers: Yes No Unsure . : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an i Albadalejo 2010, patients in the different groups received the same intervention; only the content of the educ that other groups were receiving different contents, and patients' expectations were managed to be similar ac intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave th different education programs which were implemented in the control and the two experimental groups, eithe been informed that the same outcome was to be expected across groups, and an independent physician audit could be detected during the talks. Key, possible answers: Yes No Unsure . : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an i Albadalejo 2010, patients in the different groups received the same intervention; only the content of the educ that other groups were receiving different contents, and patients' expectations were managed to be similar ac intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave th different education programs which were implemented in the control and the two experimental groups, eithe been informed that the same outcome was to be expected across groups, and an independent physician audit could be detected during the talks. Key, possible answers: Yes No Unsure . : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d : Because of the nature of the intervention, pa Albadalejo 2010, patients in the different grou that other groups were receiving different con intervention, the care provider could not be bl different education programs which were imp been informed that the same outcome was to b could be detected during the talks. Key, possib : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d  : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an intervention. Albadalejo 2010, patients in the different groups received the same intervention; only the content of the education progra that other groups were receiving different contents, and patients' expectations were managed to be similar across groups intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave the talks had n different education programs which were implemented in the control and the two experimental groups, either at the beg been informed that the same outcome was to be expected across groups, and an independent physician audited that no d could be detected during the talks. Key, possible answers: Yes No Unsure .
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 1 : Because of the nature of the intervention, patients could not be blinded to whether they were receiving an i Albadalejo 2010, patients in the different groups received the same intervention; only the content of the educ that other groups were receiving different contents, and patients' expectations were managed to be similar ac intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider who gave th different education programs which were implemented in the control and the two experimental groups, eithe been informed that the same outcome was to be expected across groups, and an independent physician audit could be detected during the talks. Key, possible answers: Yes No Unsure .
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 1 : Because of the nature of the intervention, patients could not be blinded to whether they were re Albadalejo 2010, patients in the different groups received the same intervention; only the content that other groups were receiving different contents, and patients' expectations were managed to intervention, the care provider could not be blinded. However, in Kovacs 2007 the care provider different education programs which were implemented in the control and the two experimental been informed that the same outcome was to be expected across groups, and an independent phy could be detected during the talks. Key, possible answers: Yes No Unsure .  In all the RCTs with adults, education led to an improvement in LBP-related disability [17,18,45,46], which was above the cut-off value for clinical relevance [54,55]. Improvements in pain and quality of life were only reported in studies in which intensive programs involving exercise were implemented [45,46].
Several studies conducted with adults assessed the evolution of psychological variables after education (e.g., fear avoidance beliefs (FABs), catastrophizing, and kinesiophobia) [17,18,46]. All showed an improvement in these variables following education. Two studies analyzed the influence of the evolution of FABs and catastrophizing on disability, and showed that these psychological variables had no influence on the effect of education on disability [17,18].

Discussion
According to the results from this systematic review, education programs are effective for treating patients who suffer from LBP in the Hispanic cultural environment. All the studies including patients showed that those receiving any kind of education programs experienced an improvement in disability. Additionally, some studies in which exercise was also promoted reported improvements in pain and health-related quality of life. The effect sizes were generally small, but above the cut-off value for clinical relevance (Table 2) [54,55]. These results are generally consistent with those from studies conducted in other cultural settings [56,57]. In fact, the small size of the effect on disability triggered by education is in line with most medical treatments for LBP [6,7,58] It is impossible to rule out that unspecific effects contributed to the outcomes following education. For instance, some education programs were intense, lasted up to one year and implied a frequent contact with therapists and researchers. All of this may have triggered powerful unspecific effects. Moreover, any education program, irrespective of its content, organization and approach, can have a psychological effect by making patients with LBP feel that they are better prepared to face daily activities, and potentially improve disability.
However, although unspecific effects may have magnified the impact of education in some studies, results from this study suggest that some types of education are likely to have an effect beyond unspecific effects. In fact, a significantly higher improvement in disability after education on active management, vs. postural hygiene, was observed in a study in which patients in both groups had the same interaction with therapists and researchers, received a comparable amount of attention, and all measures were taken to ensure that both patients and therapists were neutral with regard to both types of education (Table 1) [17].
Some studies assessed the evolution of psychological variables, namely FABs, catastrophizing and kinesiophobia, and found improvements after education [17,18,46]. However, those studies in which the influence of these variables on the improvement of pain or disability was explored, showed that such influence was non-existent [17,18]. This suggests that, in the Hispanic cultural environment, education simultaneously improves disability, FABs and catastrophizing, as opposed to the improvement of disability being mediated by the improvement of the latter.
Education programs might lead to deleterious consequences if they promoted misconceptions or inappropriate behavior. However, none of the studies with patients suffering from LBP recorded adverse events from the education programs. This may be because the authors assumed that the contents they were teaching were evidence based, and that the variables their studies gathered (e.g., disability, pain, health-related quality of life, and psychological variables) would have sufficed to capture any adverse events.
Very few medical treatments have been shown to have a clinically significant effect on LBP-related disability [6,7,58], which is the main cause of LBP-related social and economic burden [1][2][3]. Therefore, assuming that education did not lead to any significant adverse events, the fact that education programs improved LBP, and especially LBP-related disability, in the Hispanic environment, would support generalizing their use in clinical practice. This would require firstly defining which specific program or programs should be implemented.
Differences in methods and populations make it inappropriate to compare the effects of different types of education across studies. However, direct comparisons among different education programs within the same study are helpful to assess their comparative effectiveness. Cost, simplicity and amount of resources required by each education program are also likely to be essential for generalization in routine practice.
Therefore, future studies should compare the cost/effectiveness of the different education programs, assess their potential complementarity or summatory effects, and refine their indication criteria or implementation strategy.
Until these studies have been completed, the characteristics and results from the programs already implemented suggest that, among the different types of education which have been shown to be effective for adults suffering from LBP in the Hispanic environment, education on "active management" is the simplest. It requires a standardized 20 min group talk to groups of up to 20 patients, and the handing out of a specific leaflet (Table 1) [17,18]. This program has consistently been shown to be more effective than a program focusing on postural hygiene, both in middle-aged patients and elderly residents in nursing homes [17,18] (Table 2). This suggests that simple programs on active management might be appropriate as a first educational treatment in primary care and, if required, could be complemented at a later stage with more intensive and complex programs, involving prolonged exercise and education on pain neurophysiology [45,46].
In addition to the therapeutic effect of education for patients with LBP, several studies have assessed its potential application for primary prevention of LBP in the Hispanic environment. Due to the high prevalence of low back pain among the general population, and its increase with age [1][2][3], RCTs conducted outside the clinical environment require very large samples, long follow-up periods and low drop-out rates to detect a significant effect on LBP prevention. In fact, among the studies conducted in the school setting, only a low-quality study focused on the 1 week prevalence of LBP [50], while all the others focused on assessing whether the education programs where effective at transmitting the selected knowledge to the children [47][48][49]51]. This implies that these programs are only likely to be effective in practice if the concepts they transmit address proven risk factors or are actually effective at reducing the risk of LBP. Some evidence suggests that this is the case for exercise and active management [58][59][60][61][62][63], but not for backpack weight or form of carry [64,65].

Limitations
This systematic review had some limitations. Despite a comprehensive search, only nine RCTs were identified, some were of low methodological quality and some gathered variables which are not clinically relevant. However, this limitation stemmed from the original studies included in this review, and five studies had a low risk of bias (four of which gathered clinically relevant variables), which made it possible for this review to draw conclusions and recommendations potentially useful for clinical practice.
Education on exercise was heterogeneous in terms of the specific exercises taught and the specific programs implemented. However, this is inherent to exercise in general, and the available evidence suggests that virtually any type of exercise is better than no exercise for both preventing and treating LBP [58][59][60][61]63].
Evidence on the effectiveness of education on pain neurophysiology and exercise, derived from only one study. However, evidence on education on active management is supported by several high-quality RCTs and, although this systematic review included only studies conducted in the Hispanic environment, results from studies conducted in other cultural settings are consistent [58][59][60][61][62][63].
All the RCTs which were identified as having taken place in the Hispanic cultural environment, had been conducted in Spain. Therefore, at this stage, it is unknown whether the conclusions from this review are applicable to the Hispanic populations living in South, Central or North America. This should be assessed in future studies.

Conclusions
In conclusion, this systematic review shows that the available evidence suggests that education on active management, exercise, and pain neurophysiology are effective for treating, and possibly preventing, LBP in the Hispanic cultural environment.

Conflicts of Interest:
The authors declare no conflict of interest.

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Chocrane library low back pain OR back pain OR back OR lumbago OR musculoskeletal pain OR musculoskeletal disorder OR musculoskeletal diseases in Title Abstract Keyword AND education OR health-education OR patient-education OR Therapeutic Patient Education OR physician health education OR educational intervention OR medical community intervention OR health community intervention in Title Abstract Keyword-(Word variations have been searched) SCOPUS
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