EFFECTS OF POSTURAL EDUCATION IN ELEMENTARY SCHOOL CHILDREN: A SYSTEMATIC REVIEW

Valenciano, Paola Janeiro; Cibinello, Fabíola Unbehaun; Neves, Jessica Caroliny de Jesus; Fujisawa, Dirce Shizuko

doi:10.1590/1984-0462/2021/39/2020005

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Brasil

Revista Paulista de Pediatria

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Brasil

Español English

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Sumário

ORIGINAL ARTICLE • Rev. paul. pediatr. 39 • 2021 • https://doi.org/10.1590/1984-0462/2021/39/2020005 copy

EFFECTS OF POSTURAL EDUCATION IN ELEMENTARY SCHOOL CHILDREN: A SYSTEMATIC REVIEW

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To determine the effect of postural education on the learning and postural habits of elementary school children without physical intervention.

Methods:

We searched PubMed, Lilacs, SciELO, Cochrane, and Science Direct data bases and reference lists of studies in February 2020. The eligibility criteria were randomized clinical trials related to the effect of postural education in children aged between 6 and 12 years old. Two authors independently assessed trials for inclusion and risk of bias: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Data were extracted in standardized tables including information on author, publication year, country, sample size, age, sex, intervention characteristics, outcome measurements and results.

Results:

We found seven clinical trials (involving 2,568 children) for the review. The studies were conducted between 2000 and 2018: four in Belgium, two in Spain, and one in Germany. All seven included trials underwent evaluation: only one had a clear process of randomization and allocation concealment. All included studies were judged as having high risk of bias in at least one domain or have concerns for multiple domains.

Conclusions:

The positive effects of acquired knowledge and postural habits found in the studies cannot be used to reliably support postural education in elementary school children due to a high risk of bias in the evaluated studies.

Keywords:
Child; Health education; Posture

Study/Country	Participants	Intervention
Cardon et al.¹⁷17. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Effects of back care education in elementary schoolchildren. Acta Pediatr. 2000;89:1010-7. https://doi.org/10.1080/080352500750043521 https://doi.org/https://doi.org/10.1080/... /Belgium	n=78 Age (years)=9.93 in EG and 11.10 in CG Sex=35 M, 43 F	CG=No intervention; EG=Postural education, exercises taught to the children, sessions, and provision of materials for parents and teachers Basis of the educational program: Literature on biomechanics and the German Back School Duration: Six 60-minute sessions, with a one-week interval between sessions; Follow-up: Three months
Cardon et al.¹⁸18. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Back education efficacy in elementary schoolchildren. Spine (Phila Pa 1976). 2002;27:299-305. https://doi.org/10.1097/00007632-200202010-00020 https://doi.org/https://doi.org/10.1097/... /Belgium	n=363 Age (years)=9.8 in EG and 10.3 in CG Sex=171M, 192 F	CG=No intervention; EG=Postural education; information session for parents and teachers, and teachers requested to be present in all sessions Basis of the educational program: Literature on biomechanics and the German Back School Duration: Six 60-minute sessions, with one-week intervals between sessions; Follow-up: One year.
Cardon et al.²¹21. Cardon GM, de Bourdeaudhuij IM, de Clercq DL. Knowledge and perceptions about back education among elementary school students, teachers, and parents in Belgium. J Sch Health. 2002;72:100-6. https://doi.org/10.1111/j.1746-1561.2002.tb06524.x https://doi.org/https://doi.org/10.1111/... /Belgium	n=706 Age (years)=10 (±0.6 in EG and ±0.7 in CG) Sex=401 M, 305 F	CG=No intervention; EG=Postural education, sessions, and provision of materials for parents and teachers, teachers present in all sessions Basis of educational program: Previous studies¹⁷17. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Effects of back care education in elementary schoolchildren. Acta Pediatr. 2000;89:1010-7. https://doi.org/10.1080/080352500750043521 https://doi.org/https://doi.org/10.1080/... Duration: Six 60-minute sessions, with one-week intervals between sessions; Follow-up: Three months and one year
Cardon et al.²²22. Cardon GM, de Clercq DL, Geldhof EJ, Verstraete S, de Bourdeaudhuij IM. Back education in elementary schoolchildren: the effects of adding a physical activity promotion program to a back care program. Eur Spine J. 2007;16:125-33. https://doi.org/10.1007/s00586-006-0095-y https://doi.org/https://doi.org/10.1007/... /Belgium	n=603 Age (years)=9.7±0.7 Sex=289 M, 314 F	CG=No intervention; EG=Postural education; EG+PA=Postural education and physical activity program Basis of the educational program: Previous studies¹⁸18. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Back education efficacy in elementary schoolchildren. Spine (Phila Pa 1976). 2002;27:299-305. https://doi.org/10.1097/00007632-200202010-00020 https://doi.org/https://doi.org/10.1097/... ^,²¹21. Cardon GM, de Bourdeaudhuij IM, de Clercq DL. Knowledge and perceptions about back education among elementary school students, teachers, and parents in Belgium. J Sch Health. 2002;72:100-6. https://doi.org/10.1111/j.1746-1561.2002.tb06524.x https://doi.org/https://doi.org/10.1111/... Duration: Six sessions with one-week intervals between sessions; Follow-up: None
Dullien et al.¹⁹19. Dullien S, Grifka J, Jansen P. Cluster-randomized, controlled evaluation of a teacher led multi factorial school based back education program for 10 to 12-year old children. BMC Pediatr. 2018;18:312. https://doi.org/10.1186/s12887-018-1280-y https://doi.org/https://doi.org/10.1186/... /Germany	n=176 Age (years)=10.5±0.4 Sex=76M, 100 F	CG=No intervention; EG=Five lessons on back care (provided material), posture awareness training and improvement in the classroom, and back and abdominal muscle exercises at the beginning of each lesson Duration: One year; Follow-up: None
Kovacs et al.¹⁶16. Kovacs F, Oliver-Frontera M, Plana MN, Royuela A, Muriel A, Gestoso M, et al. Improving schoolchildren’s knowledge of methods for the prevention and management of low back pain. Spine (Phila Pa 1976). 2011;36:E505-12. https://doi.org/10.1097/BRS.0b013e3181dccebc https://doi.org/https://doi.org/10.1097/... /Spain	n=497 Age (years)=8 Sex=260M, 237 F	CG=No intervention; EG=The professor was advised only to relay the comic story about the spine to each student Basis of the educational program: “Back Book” Duration: One session; Follow-up: Three months
Vidal et al²⁰20. Vidal J, Borras PA, Ortega FB, Cantallops J, Ponseti X, Palou P. Effects of postural education on daily habits in children. Int J Sports Med. 2011;32:303-8. https://doi.org/10.1055/s-0030-1270469 https://doi.org/https://doi.org/10.1055/... /Spain	n=145 Age (years)=10.72±0.672 Sex=52.8% M, 48.2% F	CG=No intervention; EG=Four theoretical educational sessions and two practical ones Basis of the educational program²²22. Cardon GM, de Clercq DL, Geldhof EJ, Verstraete S, de Bourdeaudhuij IM. Back education in elementary schoolchildren: the effects of adding a physical activity promotion program to a back care program. Eur Spine J. 2007;16:125-33. https://doi.org/10.1007/s00586-006-0095-y https://doi.org/https://doi.org/10.1007/... ^,²³23. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 (Suppl 2):S192-300. https://doi.org/10.1007/s00586-006-1072-1 https://doi.org/https://doi.org/10.1007/... ^,²⁴24. Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, et al. Chapter 2. European guidelines for prevention in low back pain: November 2004. Eur Spine J. 2006;15 (Suppl 2):S136-68. https://doi.org/10.1007/s00586-006-1070-3 https://doi.org/https://doi.org/10.1007/... ^,²⁵25. Geldhof E, Cardon GM, de Bourdeaudhuij IM, Danneels L, Coorevits P, Vanderstraeten G, et al. Effects of back posture education on elementary schoolchildren’s back function. Eur Spine J. 2007;16:829-39. https://doi.org/10.1007/s00586-006-0199-4 https://doi.org/https://doi.org/10.1007/... ^,²⁶26. van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 (Suppl 2):S169-91. https://doi.org/10.1007/s00586-006-1071-2 https://doi.org/https://doi.org/10.1007/... Duration: Six sessions; Follow-up: Three months

Study	Measurements of outcome
Cardon et al.¹⁷17. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Effects of back care education in elementary schoolchildren. Acta Pediatr. 2000;89:1010-7. https://doi.org/10.1080/080352500750043521 https://doi.org/https://doi.org/10.1080/...	• Knowledge acquired: -Questionnaire testing knowledge related to the spinal column 13 multiple-choice items • Postural habits: -Individual practical test, filmed: choice of most appropriate furniture, sitting down, standing up from the ground, picking up a pen from the ground, carrying school bag, writing; resources such as the telephone book could be used; score from 0 (very poor) to 4 (excellent)
Cardon et al.¹⁸18. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Back education efficacy in elementary schoolchildren. Spine (Phila Pa 1976). 2002;27:299-305. https://doi.org/10.1097/00007632-200202010-00020 https://doi.org/https://doi.org/10.1097/...	• Postural habits: -Practical test: movement session with different tasks: removing shoes, sitting down, dealing with and moving a box, picking up a small object and using a schoolbag; the better the body biomechanics, the better the score (each test varied the score from 0 to 4) -Evaluation of postural habits with a hidden camera: observation in the classroom and in the movement session with tasks undertaken in groups of two with activities, such as throwing a ball to each other
Cardon et al.²¹21. Cardon GM, de Bourdeaudhuij IM, de Clercq DL. Knowledge and perceptions about back education among elementary school students, teachers, and parents in Belgium. J Sch Health. 2002;72:100-6. https://doi.org/10.1111/j.1746-1561.2002.tb06524.x https://doi.org/https://doi.org/10.1111/...	• Knowledge acquired: -Questionnaire with 12 multiple-choice items on general knowledge about spinal care, 10 items on specific knowledge • Postural habits: -Questionnaire with four items on self-reported behavior
Cardon et al.²²22. Cardon GM, de Clercq DL, Geldhof EJ, Verstraete S, de Bourdeaudhuij IM. Back education in elementary schoolchildren: the effects of adding a physical activity promotion program to a back care program. Eur Spine J. 2007;16:125-33. https://doi.org/10.1007/s00586-006-0095-y https://doi.org/https://doi.org/10.1007/...	• Knowledge acquired: -Questionnaire on knowledge about spinal care with 11 items (based on previous studies)¹⁸18. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Back education efficacy in elementary schoolchildren. Spine (Phila Pa 1976). 2002;27:299-305. https://doi.org/10.1097/00007632-200202010-00020 https://doi.org/https://doi.org/10.1097/... ^,²¹21. Cardon GM, de Bourdeaudhuij IM, de Clercq DL. Knowledge and perceptions about back education among elementary school students, teachers, and parents in Belgium. J Sch Health. 2002;72:100-6. https://doi.org/10.1111/j.1746-1561.2002.tb06524.x https://doi.org/https://doi.org/10.1111/... • Postural habits: -Observation of behaviors in spinal care during the movement session through filming, based on the study by Cardon et al.¹⁸18. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Back education efficacy in elementary schoolchildren. Spine (Phila Pa 1976). 2002;27:299-305. https://doi.org/10.1097/00007632-200202010-00020 https://doi.org/https://doi.org/10.1097/...
Dullien et al.¹⁹19. Dullien S, Grifka J, Jansen P. Cluster-randomized, controlled evaluation of a teacher led multi factorial school based back education program for 10 to 12-year old children. BMC Pediatr. 2018;18:312. https://doi.org/10.1186/s12887-018-1280-y https://doi.org/https://doi.org/10.1186/...	• Knowledge acquired: -Questionnaire with 12 questions related to five back-care lessons (total=24 points) • Postural habits: -Tasks: lifting, carrying, balancing on a marked line, correct turning, and putting down a mineral water crate (0-2 points could be achieved) *Midterm evaluation=After four months
Kovacs et al.¹⁶16. Kovacs F, Oliver-Frontera M, Plana MN, Royuela A, Muriel A, Gestoso M, et al. Improving schoolchildren’s knowledge of methods for the prevention and management of low back pain. Spine (Phila Pa 1976). 2011;36:E505-12. https://doi.org/10.1097/BRS.0b013e3181dccebc https://doi.org/https://doi.org/10.1097/...	• Knowledge acquired: - Questionnaire with10 statements focusing on ways to prevent or manage pain in the back (true or false)
Vidal et al.²⁰20. Vidal J, Borras PA, Ortega FB, Cantallops J, Ponseti X, Palou P. Effects of postural education on daily habits in children. Int J Sports Med. 2011;32:303-8. https://doi.org/10.1055/s-0030-1270469 https://doi.org/https://doi.org/10.1055/...	• Postural habits: -Questionnaire on daily postural habits with seven items (only six items used for analysis) on daily living habits: scored as 0=no and 1=yes

Study	Results
Cardon et al.¹⁷17. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Effects of back care education in elementary schoolchildren. Acta Pediatr. 2000;89:1010-7. https://doi.org/10.1080/080352500750043521 https://doi.org/https://doi.org/10.1080/...	• ↑Knowledge acquired in the immediate post-test and follow-up (p<0.001) • Postural habits: -Better scores in the EG in the immediate post-test period and follow-up (p<0.001)
Cardon et al.¹⁸18. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Back education efficacy in elementary schoolchildren. Spine (Phila Pa 1976). 2002;27:299-305. https://doi.org/10.1097/00007632-200202010-00020 https://doi.org/https://doi.org/10.1097/...	• Postural habits: -EG presented a higher score after the intervention, after three months and one year for all the items and total score -The increase in the total score for the practical test pre intervention evaluation and evaluation after a one-year follow-up was +1.14 for CG and +26.5 for EG -In the evaluation with the hidden camera, the score was significantly greater in EG (p<0.001) one year after the intervention
Cardon et al.²¹21. Cardon GM, de Bourdeaudhuij IM, de Clercq DL. Knowledge and perceptions about back education among elementary school students, teachers, and parents in Belgium. J Sch Health. 2002;72:100-6. https://doi.org/10.1111/j.1746-1561.2002.tb06524.x https://doi.org/https://doi.org/10.1111/...	• Knowledge acquired: -↑Knowledge acquired in the immediate post-test period and follow-up of three months and one year (p<0.001) -The improvement in general knowledge in the immediate post-test at one year was 33% in EG and 12% in CG; for specific knowledge, 21% in EG and 6% in CG • Postural habits: -Self-reporting of checking schoolbag weight: EG scored higher in the pre- and all post-tests (p<0.001). -Posture when taking the shoes off: EG scored significantly higher in the post-test at three months, whereas posture when picking things up and carrying them was significantly higher in the immediate post-test and at three months
Cardon et al²²22. Cardon GM, de Clercq DL, Geldhof EJ, Verstraete S, de Bourdeaudhuij IM. Back education in elementary schoolchildren: the effects of adding a physical activity promotion program to a back care program. Eur Spine J. 2007;16:125-33. https://doi.org/10.1007/s00586-006-0095-y https://doi.org/https://doi.org/10.1007/...	• Knowledge acquired: -↑Knowledge acquired regarding spinal care in EG and EG+PA (p<0.001); No significant difference between EG and EG+PA • Postural habits: -Total score for spinal care behaviors was significantly greater in the EG than in CG (p<0.001) and greater in EG than in EG+PA (p<0.001)
Dullien et al.¹⁹19. Dullien S, Grifka J, Jansen P. Cluster-randomized, controlled evaluation of a teacher led multi factorial school based back education program for 10 to 12-year old children. BMC Pediatr. 2018;18:312. https://doi.org/10.1186/s12887-018-1280-y https://doi.org/https://doi.org/10.1186/...	• Knowledge acquired: -EG significantly improved their knowledge; there was a significant interaction between “group” and “test time” (F (1.123)=11.87, p=0.001) • Postural habits: -EG improved their behavior in the water crate-carrying task; there was a significant interaction between the factors “group” and “test time” (F (1.164)=7.93, p=0.005)
Kovacs et al¹⁶16. Kovacs F, Oliver-Frontera M, Plana MN, Royuela A, Muriel A, Gestoso M, et al. Improving schoolchildren’s knowledge of methods for the prevention and management of low back pain. Spine (Phila Pa 1976). 2011;36:E505-12. https://doi.org/10.1097/BRS.0b013e3181dccebc https://doi.org/https://doi.org/10.1097/...	• Knowledge acquired: -↑Knowledge acquired with the intervention and the effect continued to be significant after three months (p<0.001) -The success in EG, when compared to CG was 1.61 times greater (CI95%: 1.03-2.52, p=0.038)
Vidal et al²⁰20. Vidal J, Borras PA, Ortega FB, Cantallops J, Ponseti X, Palou P. Effects of postural education on daily habits in children. Int J Sports Med. 2011;32:303-8. https://doi.org/10.1055/s-0030-1270469 https://doi.org/https://doi.org/10.1055/...	• Postural habits: -↑in score for healthy habits in the post-test in comparison with the baseline in EG (p<0.001) and maintained after three months of follow-up (p < 0.001) -No significant changes observed in CG (p>0.6)

Study	Professional involved in the postural education	Guided discovery and active methodology	Games, movements and exercises based on daily activities	Ten guidelines on “how to make your disks happy”	Comic book about the spine	Characters: “Fit Fred” and “Lazy Leo”	Additional strategies	Additional interventions
Cardon et al.¹⁷17. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Effects of back care education in elementary schoolchildren. Acta Pediatr. 2000;89:1010-7. https://doi.org/10.1080/080352500750043521 https://doi.org/https://doi.org/10.1080/...	Physiotherapist	Yes	No	Yes	Yes	Yes	Information and materials provided to parents, children, and teachers; teachers present in the sessions	No
Cardon et al.¹⁸18. Cardon GM, de Clercq DL, de Bourdeaudhuij IM. Back education efficacy in elementary schoolchildren. Spine (Phila Pa 1976). 2002;27:299-305. https://doi.org/10.1097/00007632-200202010-00020 https://doi.org/https://doi.org/10.1097/...	Physiotherapist	Yes	No	Yes	Yes	No	Information session for parents and teachers; teachers present in the sessions	No
Cardon et al.²¹21. Cardon GM, de Bourdeaudhuij IM, de Clercq DL. Knowledge and perceptions about back education among elementary school students, teachers, and parents in Belgium. J Sch Health. 2002;72:100-6. https://doi.org/10.1111/j.1746-1561.2002.tb06524.x https://doi.org/https://doi.org/10.1111/...	Physiotherapist	Yes	No	Yes	Yes	No	Information and materials provided to parents and teachers; teachers received extra exercises to be used in the classroom	No
Cardon et al.²²22. Cardon GM, de Clercq DL, Geldhof EJ, Verstraete S, de Bourdeaudhuij IM. Back education in elementary schoolchildren: the effects of adding a physical activity promotion program to a back care program. Eur Spine J. 2007;16:125-33. https://doi.org/10.1007/s00586-006-0095-y https://doi.org/https://doi.org/10.1007/...	Physiotherapist	No	No	No	Yes	Yes	Guidelines provided for teachers to integrate the principles into lessons	Balls, a Dynair, a sitting wedge, and lessons for developing and maintaining an active lifestyle; extracurricular sports session were provided
Dullien et al.¹⁹19. Dullien S, Grifka J, Jansen P. Cluster-randomized, controlled evaluation of a teacher led multi factorial school based back education program for 10 to 12-year old children. BMC Pediatr. 2018;18:312. https://doi.org/10.1186/s12887-018-1280-y https://doi.org/https://doi.org/10.1186/...	Teacher	Yes	Yes	No	No	No	Posture awareness training; healthy lifting and carrying, back-friendly sports, and the importance of reducing sitting behavior were explained	Static exercises to be completed three times (each position held for 15-20s), as well as dynamic exercises (each with 15-20 repetitions)
Kovacs et al.¹⁶16. Kovacs F, Oliver-Frontera M, Plana MN, Royuela A, Muriel A, Gestoso M, et al. Improving schoolchildren’s knowledge of methods for the prevention and management of low back pain. Spine (Phila Pa 1976). 2011;36:E505-12. https://doi.org/10.1097/BRS.0b013e3181dccebc https://doi.org/https://doi.org/10.1097/...	Teacher	No	Yes	No	No	No	No	No
Vidal et al.²⁰20. Vidal J, Borras PA, Ortega FB, Cantallops J, Ponseti X, Palou P. Effects of postural education on daily habits in children. Int J Sports Med. 2011;32:303-8. https://doi.org/10.1055/s-0030-1270469 https://doi.org/https://doi.org/10.1055/...	Not clear	No	No	No	No	No	Two practical sessions: postural analysis, carrying objects, balance, breathing, and relaxation	No

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[1] *Corresponding author. E-mail: paola_jv3@hotmail.com (P.J. Valenciano).