Education and Back Pain: The Surprising Discovery

This article is an edited combination of three blogs posted by Donald Higdon on April 15 and September 14, 2016. 

Back Schools

These basic steps for lifting are fairly well known, and they bear repeating:


  •        Face the object and position yourself close to it.
  •        Bend at your knees, not your waist, and squat down as far as you comfortably can.
  •        As you prepare to lift, tighten your stomach and keep your buttocks tucked in.
  •        Lift with your legs, not your back muscles.
  •        Don’t try to lift the object too high—don’t raise a heavy load higher than your waist; keep a light load below shoulder level.
  •        Keep the object close to you as you lift it.
  •        If you need to turn to set something down, don’t twist your upper body. Instead, turn your entire body, moving your shoulders, hips, and feet at the same time.


However, and sad to say, it is possible to follow these instructions and still damage one’s back, either incrementally or even seriously.

Donald Higdon and Caren Bayer

The New England Journal of Medicine1 conducted an exhaustive study of “Back Schools,” educational programs designed by physical therapists for patients with back pain. The programs typically informed patients about back anatomy and physiology, the mechanisms of pain, pain management, good posture, safe methods of lifting and handling, and muscle strengthening and stretching. The high cost of back injuries, the lack of effective treatment, and evidence of the existence of behavioral risk factors led to widespread use of back schools as a form of back injury prevention.

Initial reports of success were based on small samples and were inconclusive. Led by Dr. Lawren Daltroy of Brigham and Women’s Hospital (affiliated with Harvard Medical School), a back school was created for a randomized controlled study of four thousand postal workers over 5½ years.

The study staff was composed of 14 physical therapists (PTs). Groups of 12 workers per class attended two 90-minute sessions composed of lectures, discussions, films, pamphlets, demonstrations, and practice. Content included safe lifting and handling; posture while sitting, standing, and lying down; pain management; stretching and strengthening exercises; and on-site ergonomic analysis. The PTs observed work stations and suggested physical and procedural modifications. Workers’ supervisors were trained to provide reinforcement, which was videotaped for periodic review.

This educational program was provided at the start of the study, again after six months, and again annually thereafter.

Yes, Yes, What Happened?

A survey at the midpoint found “a significant increase in knowledge of safe behaviors in the intervention group as compared to the (unschooled) control group, but no significant im-provements in actual behavior, and  no significant reduction in the proportion of workers with tired backs.” 

Things were no better at the conclusion of the 5½-year trial. Quoting from the report (italics mine):


  1. “Workers’ actually being trained had no significant effect on rates of primary low back injury, on time off from work, on costs associated with injury, or on time elapsed until a further injury.”
  2. “The education program successfully imparted knowledge and skills related to safe lifting and handling, but despite this training and...its regular reinforcement, the  increased practice of desirable be-havior did not take place.
  3. “Back schools are not by themselves an effective intervention for the primary prevention of industrial low back injury.” 

I think that two reasons for the failure of the back school to reduce injury rates are: 1) teaching the wrong way, and 2) teaching the wrong thing.

The failure was not of education per se, but of one particular method of education.

Cognitive Learning

The method in the study was cognitive learning, essentially what is used in public schools: presentation, in various forms, of facts to be absorbed, processed, and used for reasoning. These facts were presented initially, then again at six months, and annually thereafter until the end of the 5½-year trial.

This reservoir of facts was successfully recalled by the workers in a test after 2½ years, but injury rates were unimproved then and throughout the duration of the trial.

Enter the Alexander Technique teacher.

Experiential Learning

The Alexander Technique is a form of experiential learning. The student learns, not by processing abstract facts, but by experiencing the desired behavior and then reflecting on the experience. As children, this is the way we learned to talk, walk, hold a spoon, etc. No mom showed her child a video of how to tie a shoe.

Like the mother or dad teaching the child to tie a shoe, the Alexander Technique teacher guides the student to perform an activity. Spoken words (or pictures, diagrams, etc.) are only an aid to delivering the experience. They are not a substitute for the experience, as they are in cognitive learning.

The Alexander Technique teacher teaches universal principles of thought, to be employed prior to any action, whether it be physical or mental. These principles take the student out of a life-long habit and allow conscious thought to occur, leading to a better method of performance. The new, better experience becomes a stimulus for reflection, i.e., knowledge. In experiential learning, the student applies the newly learned principles to other activities, widening their application, regardless of type. This is why an Alexander Technique lesson may or may not (it makes no difference) involve the activity that is causing the pain.

Regardless of whether workers were presented with and remembered facts of better lifting methods, the stimulus of acquired habit is always stronger than new advice. This meant that even when workers were trying to apply the “better” methods, the study’s instructions were forced through the filter of each worker’s lifetime of habits, preventing them from performing as instructed.

The Alexander Technique is re-education from a distinctly different paradigm. It is neuro-physiological and experiential. The Alexander Technique teacher, teaching experientially, teaches the student how not to be controlled by habit, allowing new knowledge to be applied to a particular activity.

The activity (in this case, lifting) was not the issue. What mattered was the thinking.



1. Lawren Daltroy et al., “A Controlled Trial of an Educational Program to Prevent Low Back Injuries,” The New England Journal of Medicine 337 (1997): 322–8, doi: 10.1056/NEJM 199707313370507.

Original blogs 2016 Donald Higdon. All rights reserved.

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