Disability measurement in persons with back pain: a validity study of spinal range of motion and velocity

Finger-Floor Distance Is Not a Valid Parameter for the Assessment of Lumbar Mobility

Low back pain (LBP) could be associated with a reduced lumbar mobility. For the evaluation of lumbar flexibility, parameters such as finger-floor distance (FFD) are historically established. However, the extent of the correlation of FFD to lumbar flexibility or other involved joint kinematics such as pelvic motion, as well as the influence of LBP, is not yet known. We conducted a prospective cross-sectional observation study with 523 participants included (167 with LBP > 12 weeks, 356 asymptomatic). LBP-participants were matched for sex, age, height, and body-mass-index with an asymptomatic control cohort, resulting in two cohorts with 120 participants each. The FFD in maximal trunk flexion was measured. The Epionics-SPINE measurement-system was used to evaluate the pelvic and lumbar Range-of-Flexion (RoF), and the correlation of FFD to pelvic- and lumbar-RoF was evaluated. In an asymptomatic sub-cohort of 12 participants, we examined the individual correlation of FFD to pelvic- and lumbar-RoF under gradual trunk flexion. Participants with LBP showed a significantly reduced pelvic-RoF (p < 0.001) and lumbar-RoF (p < 0.001) as well as an increased FFD (p < 0.001) compared to the asymptomatic control cohort. Asymptomatic participants exhibited a weak correlation of FFD to pelvic-RoF and lumbar-RoF (r < 0.500). LBP patients revealed a moderate correlation of FFD to pelvic-RoF (male: p < 0.001, r = -0.653, female: p < 0.001, r = -0.649) and sex-dependent to lumbar-RoF (male: p < 0.001, r = -0.604, female: p = 0.012, r = -0.256). In the sub-cohort of 12 participants, gradual trunk flexion showed a strong correlation of FFD to pelvic-RoF (p < 0.001, r = -0.895) but a moderate correlation to lumbar-RoF (p < 0.001, r = -0.602). The differences in FFD in an individual patient, assuming consistent hip function, may be attributed partially to the differences in lumbar flexibility. However, the absolute values of FFD do not qualify as a measure for lumbar mobility. Rather, using validated non-invasive measurement devices should be considered.

Quantitative dynamic wearable motion-based metric compared to patient-reported outcomes as indicators of functional recovery after lumbar fusion surgery

BACKGROUND

Low back pain is a debilitating condition with poor patient outcomes despite the use of a wide variety of diagnostic and treatment modalities. A lack of objective metrics to support clinical decision-making may be a reason for these poor outcomes. This study aimed to compare patient recovery following lumbar fusion surgery using an objective motion-based metric (functional performance) and subjective patient-reported outcomes for pain, disability and kinesophobia.

METHODS

A prospective observational study was conducted on 121 patients that received a lumbar fusion surgery. A wearable motion system was used to quantify three-dimensional multi-planar lumbar motion and benchmark each patient's lumbar function prior to surgery and post-operatively at follow-up time points for up to 2 years. Patient recovery profiles after surgery were evaluated using the acquired functional motion data and compared to patient-reported outcomes.

FINDINGS

Our results found significant improvement after surgery in objective functional performance as well as patient-reported pain, disability, and kinesophobia. However, we found a delayed response in the objective metric, with meaningful improvement occurring only 6 months after fusion surgery. In contrast, we found significant improvement in all subjective scores as early as 6 weeks post-surgery.

INTERPRETATION

Objective motion-based metric provides a unique perspective to assessing patient's functional recovery. While it is associated with dimensions of pain, disability and fear avoidance, it is also distinct and assesses a uniquely different dimension of functional health. This information can form the basis for the use of objective metrics to gauge patient recovery after lumbar fusion surgery.

Association of pain-related threat beliefs and disability with postural control and trunk motion in individuals with low back pain: a systematic review and meta-analysis

PURPOSE

Low back pain (LBP) individuals with high levels of fear of pain might display changes in motor behavior, which leads to disability. This study aimed to systematically review the influence of pain-related threat beliefs or disability on trunk kinematic or postural control in LBP.

METHOD

Eight electronic databases were searched from January 1990 to July 1, 2020. Meta-analysis using random-effect model was performed for 18 studies on the association between pain-related threat beliefs or disability and lumbar range of motion. Pearson r correlations were used as the effect size.

RESULT

Negative correlations were observed between lumbar range of motion (ROM) and pain-related threat beliefs (r = - 0.31, p < 0.01, 95% CI: - 0.39, - 0.24) and disability (r =  - 0.24, p < 0.01, 95% CI: - 0.40, - 0.21). Nonsignificant correlations were reported between pain-related threat beliefs and center of pressure parameters during static standing in 75% of the studies. In 33% of the studies, moderate negative correlations between disability and postural control were observed.

CONCLUSION

Motor behaviors are influenced by several factors, and therefore, the relatively weak associations observed between reduced lumbar ROM with higher pain-related threat beliefs and perceived disability, and postural control with disability are to be expected. This could aid clinicians in the assessment and planning rehabilitation interventions.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Does Movement Change When Low Back Pain Changes? A Systematic Review

OBJECTIVE

To investigate the relationship between changes in volitional spinal movement (including muscle activity) and changes in pain or activity limitation at the individual level in people with nonspecific low back pain.

DESIGN

Etiology systematic review.

LITERATURE SEARCH

MEDLINE, Embase, CINAHL, and AMED were searched from inception to January 2020.

STUDY SELECTION CRITERIA

The study included peer-reviewed articles that reported the relationship between changes in volitional spinal movement and changes in pain or activity limitation at the individual level in people with nonspecific low back pain.

DATA SYNTHESIS

The data were descriptively synthesized to identify a relationship between change in movement and improved pain or activity limitation.

RESULTS

We included 27 studies involving 2739 participants. There was low-quality evidence of a relationship between change in movement and change in pain or activity limitation at the individual level 31% of the time (20 of the 65 times investigated within the 27 studies). Increases in spinal range of motion, velocity, and flexion relaxation of the back extensors were consistently related to improved pain or activity limitation (93%, 18.5/20 relationships observed).

CONCLUSION

A relationship between changes in movement and changes in pain or activity limitation was infrequently observed at the individual level; however, a paucity of high-quality evidence precludes a definitive understanding of this relationship. J Orthop Sports Phys Ther 2020;50(12):664-680. Epub 28 Oct 2020. doi:10.2519/jospt.2020.9635.

Manipulation Effect on Lumbar Kinematics in Patients with Unilateral Innominate Rotation and Comparison with Asymptomatic Subjects

Background

Lumbar motion analysis is used as a clinical method in the diagnosis and treatment of low back pain (LBP). So far, no studies have shown if manipulating the sacroiliac joint (SIJ) will change spinal kinematics.

Objective

The main objectives of this study were to investigate the effects of SIJ manipulation on the lumbar kinematics in subjects with innominate rotation and to compare lumbar kinematics among experiment and control groups.

Material and Methods

This study was a quasi-experiment-control trial study. 21 LBP patients with anterior or posterior innominate rotations in experiment group and 22 asymptomatic subjects in control group were evaluated. Lumbar kinematic variables (LKV) include lumbar range of motion (ROM) and speed, lumbar lateral flexion and rotation asymmetry were evaluated using Qualysis Track Manager (QTM) twice within two days in control group, and these parameters with pelvic asymmetry and disability were tested before and after intervention in the experiment group.

Results

While pre-intervention experiment group exhibited significantly lower lumbar lateral flexion (p=0.0001), rotation (p=0.008) ROM and lower lateral flexion speed (p=0.014), post-intervention experiment group exhibited significantly lower lumbar lateral flexion (p=0.01) ROM in comparison with control group. Pelvic asymmetry (p=0.049) and disability (p=0.01) significantly decreased in the experiment group after manipulation, but LKV did not change significantly after the intervention (p˃0.05).

Conclusion

Experiment groups had different lumbar kinematics in comparison with control group before and after SIJ manipulation. Despite the changes in pelvic asymmetry and disability, intervention had no effect on lumbar kinematics.

Longitudinal associations of kinematics and fear-avoidance beliefs with disability, work ability and pain intensity in persons with low back pain

BACKGROUND

Impaired lumbar movement has cross-sectionally been associated with low back pain (LBP); however, the consequence of impaired movement on disability and pain in persons with LBP is poorly understood. Furthermore, fear-avoidance beliefs (FAB) may influence spinal movement, but the relation between fear-avoidance and kinematics is unclear.

OBJECTIVES

To investigate the longitudinal associations of kinematics and FAB with disability, work ability and pain in patients with LBP. Further, to explore associations between FAB and kinematics.

DESIGN

Prospective observational study.

METHOD

Kinematic measures were performed on 44 persons with LBP at baseline, three and nine months. Motion sensors identified range-of-motion and velocity during a spinal flexion/extension. FAB, disability, work ability and pain were reported at all time points using questionnaires.

RESULTS

Increased range-of-motion was weakly associated with less disability (-0.14 points, 95% CI -0.22 to -0.06). Velocity was not associated with disability, work ability or pain. Higher FAB of physical activity were associated with more disability (1.50 points, 95% CI 0.51 to 2.49) and pain (0.37 points, 95% CI 0.11 to 0.62). Higher work-related FAB was associated with lower work ability (-0.37 points, 95% CI -0.68 to -0.05). Moreover, higher FAB showed weak associations with lower velocity in the initial movement phase (-3.3°/s, 95% CI -6.1 to -0.5).

CONCLUSIONS

Of the kinematic measures, only range-of-motion was related to disability. Higher FAB was weakly associated with all self-reported outcomes and with lower velocity only at the initial flexion phase. However, the magnitude of these associations suggest marginal clinical importance.

Does movement matter in people with back pain? Investigating 'atypical' lumbo-pelvic kinematics in people with and without back pain using wireless movement sensors

Background

Interventions for low back pain (LBP) commonly target ‘dysfunctional’ or atypical lumbo-pelvic kinematics in the belief that correcting aberrant movement improves patients’ pain and activity outcomes. If atypical kinematic parameters and postures have a relationship to LBP, they could be expected to more prevalent in people with LBP compared to people without LBP (NoLBP). This exploratory study measured, defined and compared atypical kinematic parameters in people with and without LBP.

Methods

Wireless inertial motion and EMG sensors were used to measure lumbo-pelvic kinematics during standing trunk flexion (range of motion (ROM), timing, sequence coordination, and extensor muscle activation) and in sitting (relative sitting position, pelvic tilt range) in a sample of 126 of adults without LBP and 140 chronic LBP subjects. Atypical movement was defined using the 10th/90th centiles of the NoLBP group. Mean differences and prevalence rates for atypical movement were calculated. Dichotomised pain scores for ‘high-pain-on-bending’ and ‘high-pain-on-sitting’ were tested for their association with atypical kinematic variables.

Results

For standing flexion, significant mean differences, after adjusting for age and gender factors, were seen for the LBP group with (i) reduced ROM (trunk flexion (NoLBP 111^o, LBP 93^o, p < .0001), lumbar flexion (NoLBP 52^o, LBP 46^o, p < .0001), pelvic flexion (NoLBP 59^o, LBP 48^o, p < .0001), (ii) greater extensor muscle activation for the LBP group (NoLBP 0.012, LBP 0.25 p < .0001), (iii) a greater delay in pelvic motion at the onset of flexion (NoLBP − 0.21 s; LBP − 0.36 s, p = 0.023), (iv) and longer movement duration for the LBP group (NoLBP 2.28 s; LBP 3.18 s, p < .0001). Atypical movement was significantly more prevalent in the LBP group for small trunk (× 5.4), lumbar (× 3.0) and pelvic ROM (× 3.9), low FRR (× 4.9), delayed pelvic motion at 20^o flexion (× 2.9), and longer movement duration (× 4.7). No differences between groups were seen for any sitting parameters. High pain intensity was significantly associated with small lumbar ROM and pelvic ROM.

Conclusion

Significant movement differences during flexion were seen in people with LBP, with a higher prevalence of small ROM, slower movement, delayed pelvic movement and greater lumbar extensor muscle activation but without differences for any sitting parameter.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2387-x) contains supplementary material, which is available to authorized users.

Measures of upper limb function for people with neck pain. A systematic review of measurement and practical properties

There is a strong relationship between neck pain (NP) and upper limb disability (ULD). Optimal management of NP should incorporate upper limb rehabilitation and therefore include the use of an ULD measure in the assessment and management process. Clear guidance regarding the suitability of available measures does not exist. The aim of this study was to identify all available measures of ULD for populations with NP, critically evaluate their measurement properties and finally recommend a list of suitable measures. This two-phase systematic review is reported in accordance with the PRISMA statement. Phase one identified clearly reproducible measures of ULD for patients with NP. Phase two identified evidence of their measurement properties. In total, 11 papers evaluating the measurement properties of five instruments were included in this review. The instruments identified were the DASH questionnaire, the QuickDASH questionnaire, the NULI questionnaire, the SFA and the SAMP test. There was limited positive evidence of validity of the DASH, QuickDASH, NULI, SFA and SAMP. There was limited positive evidence of reliability of the NULI, SFA and SAMP. There was unknown evidence of responsiveness of the DASH and QuickDASH. Although all measures are supported by a limited amount of low quality evidence, the DASH, QuickDASH, NULI questionnaires, and the SAMP test are promising measures, but they require further robust evaluation.

Lumbar motion changes in chronic low back pain patients: a secondary analysis of data from a randomized clinical trial

BACKGROUND CONTEXT

Several therapies have been used in the treatment of chronic low back pain (LBP), including various exercise strategies and spinal manipulative therapy (SMT). A common belief is that spinal motion changes in particular ways in direct response to specific interventions, such as exercise or spinal manipulation.

PURPOSE

The purpose of this study was to assess changes in lumbar region motion for more than 12 weeks by evaluating four motion parameters in the sagittal plane and two in the horizontal plane in LBP patients treated with either exercise therapy or spinal manipulation.

STUDY DESIGN/SETTING

Secondary analysis of a subset of participants from a randomized clinical trial.

PATIENT SAMPLE

One hundred ninety-nine study participants with LBP of more than 6 weeks' duration who had spinal motion measures obtained before and after the period of intervention.

OUTCOME MEASURES

Lumbar region spinal kinematics sampled using a six-degree-of-freedom instrumented spatial linkage system.

METHODS

Trained therapists collected regional lumbar spinal motion data at baseline and 12 weeks of follow-up. The lumbar region spinal motion data were analyzed as a total cohort and relative to treatment modality (high dose, supervised low-tech trunk exercise, SMT, and a short course of home exercise and self-care advice). The study was supported by grants from Health Resources and Services Administration, Danish Agency for Science Technology and Innovation, Danish Chiropractors Research Foundation, and the University of Southern Denmark. No conflicts of interest reported.

RESULTS

For the cohort as a whole, lumbar region motion parameters were altered over the 12-week period, except for the jerk index parameter. The group receiving spinal manipulation changed significantly in all, and the exercise groups in half, the motion parameters included in the analysis. The spinal manipulation group changed to a smoother motion pattern (reduced jerk index), whereas the exercise groups did not.

CONCLUSION

This study provides evidence that spinal motion changes can occur in chronic LBP patients over a 12-week period and that these changes are associated with the type of treatment.

Developing functional workspace for the movement of trunk circumduction in healthy young subjects: a reliability study

Background

The lumbar range of motion has traditionally been used to assess disability in patients with low back disorders. Controversy exists about how movement ranges in static positions or in a single straight plane is related to the functional status of the patients. The trunk circumduction, as the result of neuromuscular coordination, is the integrated movements from three dimensions. The functional workspace stands for the volume of movement configuration from the trunk circumduction and represents all possible positions in three dimensions. By using single quantitative value, the functional workspace substitutes the complicated joint linear or angular motions. The aim of this study is to develop the functional workspace of the trunk circumduction (FWTC) considering possible functional positions in three dimensional planes. The reliability of the trunk circumduction is examined.

Methods

Test-retest reliability was performed with 18 healthy young subjects. A three-dimensional (3-D) Motion Analysis System was used to record the trunk circumduction. The FWTC was defined and calculated based on the volume of the cone that was formed as the resultant scanned area of markers, multiplied by the length of the body segment. The statistical analysis of correlation was performed to describe the relation of maximal displacements of trunk circumduction and straight planes: sagittal and coronal.

Results

The results of this study indicate that the movement of trunk circumduction measured by motion analysis instruments is a reliable tool. The ICC value is 0.90-0.96, and the means and standard deviations of the normalized workspace are: C7 0.425 (0.1162); L1 0.843 (0.2965); and knee 0.014 (0.0106). Little correlations between the maximal displacement of trunk circumduction and that of straight planes are shown and therefore suggest different movement patterns exist.

Conclusions

This study demonstrates high statistical reliability for the FWTC, which is important for the potential development as the functional assessment technique. The FWTC provides a single integrated value to represent angular and linear measurements of different joints and planes. Future study is expected to carry out the FWTC to evaluate the amount of workspace for the functional status of patients with low back injuries or patients with spinal surgery.

The validity of spinal mobility for prediction of functional disability in male patients with low back pain

Clinical assessment of functional disability is an integral part of management in patients with low back pain (LBP). The range of spinal motion is one of LBP disability measure. The aim of this study was to investigate the validity of spinal range of motion as a predictable measure of disability and to analyze the intrarater reliability of back range of motion (BROM) instrument for measurement of active lumber spine range of motion. Forty men patients with chronic low back pain over 6 month’s duration were participated in the study. Their ages ranged from 20 to 40 years. Lumber range of motion was measured with BROM device and disability was evaluated by self reported Roland Morris disability questionnaire (RMDQ). Data were analyzed using Spearman’s correlation, multiple regression analysis models and ICC. Statistical analysis revealed that there was a highly significant moderate to good relation between forward trunk flexion and RMDQ score (rho = −0.59, p < 0.001). While there was a weak correlation between trunk extensions, lateral trunk flexion and trunk rotation with the RMDQ scores (p > 0.05). The main predictors of disability were forward and lateral trunk flexion. Furthermore, intrarater reliability for forward trunk flexion was good (ICC, 0.84), for extension was high (ICC, 0.91), for rotation was good (ICC range, 0.86–0.88), and for lateral flexion was good (ICC range, 0.81–0.82). It was suggested that spinal ROM do not appear to be a valid measure for prediction of the functional disability in patients with chronic low back pain.

Spinal manipulative therapy has an immediate effect on thermal pain sensitivity in people with low back pain: a randomized controlled trial

BACKGROUND

Current evidence suggests that spinal manipulative therapy (SMT) is effective in the treatment of people with low back pain (LBP); however, the corresponding mechanisms are unknown. Hypoalgesia is associated with SMT and is suggestive of specific mechanisms.

OBJECTIVE

The primary purpose of this study was to assess the immediate effects of SMT on thermal pain perception in people with LBP. A secondary purpose was to determine whether the resulting hypoalgesia was a local effect and whether psychological influences were associated with changes in pain perception.

DESIGN

This study was a randomized controlled trial.

SETTING

A sample of convenience was recruited from community and outpatient clinics.

PARTICIPANTS

Thirty-six people (10 men, 26 women) currently experiencing LBP participated in the study. The average age of the participants was 32.39 (SD=12.63) years, and the average duration of LBP was 221.79 (SD=365.37) weeks.

INTERVENTION AND MEASUREMENTS

Baseline demographic and psychological measurements were obtained, followed by quantitative sensory testing to assess temporal summation and Adelta fiber-mediated pain perception. Next, participants were randomly assigned to ride a stationary bicycle, perform low back extension exercises, or receive SMT. Finally, the same quantitative sensory testing protocol was reassessed to determine the immediate effects of each intervention on thermal pain sensitivity.

RESULTS

Hypoalgesia to Adelta fiber-mediated pain perception was not observed. Group-dependent hypoalgesia of temporal summation specific to the lumbar innervated region was observed. Pair-wise comparisons indicated significant hypoalgesia in participants who received SMT, but not in those who rode a stationary bicycle or performed low back extension exercises. Psychological factors did not significantly correlate with changes in temporal summation in participants who received SMT.

LIMITATIONS

Only immediate effects of SMT were measured, so the authors are unable to comment on whether the inhibition of temporal summation is a lasting effect. Furthermore, the authors are unable to comment on the relationship between their findings and changes in clinical pain.

CONCLUSIONS

Inhibition of Adelta fiber-mediated pain perception was similar for all groups. However, inhibition of temporal summation was observed only in participants receiving SMT, suggesting a modulation of dorsal horn excitability that was observed primarily in the lumbar innervated area.

The relationship between pain-related fear and lumbar flexion during natural recovery from low back pain

Pain-related fear has been associated with avoidance behavior and increased risk for chronic low back pain; however, few studies have examined how pain-related fear relates specifically to motion of the spine following an acute episode of back pain. Thirty-six participants with a recent episode of low back pain were recruited from the general population using a combination of fliers and radio advertisements. To explore the natural recovery from low back pain we recruited individuals who were not seeking medical care. Participants performed a forward bending task at 3, 6, and 12 weeks following onset of low back pain. Three-dimensional joint motions of the spine and hip were recorded using an electromagnetic tracking device. Initial assessments of low back pain and pain-related fear were then correlated with joint excursions observed during each forward bending. Lumbar motion was inversely related to pain-related fear, but not low back pain, at all three testing sessions. In contrast, hip motion was inversely related to pain at all three testing sessions but was not related to fear. These findings suggest that pain-related fear results in avoidance behavior that specifically limits or restricts motion of the lumbar spine.

Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review

The aim of this systematic review was to survey methods to assess the functional capacity of the musculoskeletal system within the context of work, daily activities, and sport. The following key words and synonyms were used: functional physical assessment, healthy/disabled subjects, and instruments. After applying the inclusion criteria on 697 potential studies and a methodological quality appraisal, 34 studies were included. A level of reliability > 0.80 and of > 0.60 resp 0.75 and 0.90, dependent of type of validity, was considered high. Four questionnaires (the Oswestry Disability Index, the Pain Disability Index, the Roland-Morris Disability Questionnaire, and the Upper Extremity Functional Scale) have high levels on both validity and reliability. None of the functional tests had a high level of both reliability and validity. A combination of a questionnaire and a functional test would seem to be the best instrument to assess functional capacity of the musculoskeletal system, but need further examined.

Low back pain, work absenteeism, chronic back disorders, and clinical findings in the low back as predictors of hospitalization due to low back disorders: a 28-year follow-up of industrial employees

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To study symptoms, chronic disorders, and clinical findings in the low back, and work absenteeism, as predictors of hospitalization.

SUMMARY OF BACKGROUND DATA

Socioeconomic and lifestyle factors are associated with back-related hospitalization, but the significance in the working normal population of low back symptoms and clinical findings are not known.

METHODS

The cohort (n = 902) was drawn in 1973 from among employees in the metal industry (n = 2,653). The data were collected by questionnaire and a structured clinical assessment by a physiotherapist. Weight was measured. A sum score of local and radiating low back symptoms (frequency during the past year on a 4-point Likert scale) was categorized as no/yes and no/infrequent/frequent. Local and radiating symptoms were considered also separately. The data were linked with those from the Finnish Hospital Discharge Register during 1973 to 2000. Logistic regression and the Cox proportional hazard models were used.

RESULTS

As compared with persons without low back pain, those with frequent or radiating low back pain had an increased risk of hospitalization due to low back disorders (hazard rate ratio (HRR), 3.0; 95% confidence interval (CI), 1.4-6.5, and 3.7; 1.8-7.7, respectively) after adjustment for age, gender, and occupational class. Similarly, clinical findings (HRR, 2.4; 95% CI, 1.3-4.7), back-related absenteeism (HRR, 3.3; 95% CI, 1.6-6.7), and chronic low back disorders (HRR, 2.8; 95% CI, 1.5-5.4) predicted hospitalization. The associations persisted when further adjusted for smoking, body mass index, and distress symptoms at baseline.

CONCLUSION

Frequent or radiating low back symptoms, chronic low back disorders, back-related work absenteeism, and having clinical findings in the low back predicted inpatient hospital care for low back disorders.

Comparison of the functional rating index and the 18-item Roland-Morris Disability Questionnaire: responsiveness and reliability

STUDY DESIGN

Retrospective design.

OBJECTIVES

To compare the responsiveness and test-retest reliability of the Functional Rating Index and the 18-item version of the Roland-Morris Disability Questionnaire in detecting change in disability in patients with work-related low back pain.

SUMMARY OF BACKGROUND DATA

Many low back pain-specific disability questionnaires are available, including the Functional Rating Index and the 18-item version of the Roland-Morris Disability Questionnaire. No previous study has compared the responsiveness and reliability of these questionnaires.

METHODS

Files of patients who had been treated for work-related low back pain at a physical therapy clinic were reviewed, and those containing initial and follow-up Functional Rating Index and 18-item Roland-Morris Disability Questionnaires were selected. The responsiveness of both questionnaires was compared using two different methods. First, using the assumption that patients receiving treatment improve over time, various responsiveness coefficients were calculated. Second, using change in work status as an external criterion to identify improved and nonimproved patients, Spearman's rho and receiver operating characteristic curves were calculated. Reliability was estimated from the subset of patients who reported no change in their condition over this period and expressed with the intraclass correlation coefficient and the minimal detectable change.

RESULTS

One hundred and forty-three patient files were retrieved. The responsiveness coefficients for the Functional Rating Index were greater than for the 18-item Roland-Morris Disability Questionnaire. The intraclass correlation coefficient values for both questionnaires calculated from 96 patient files were similar, but the minimal detectable change for the Functional Rating Index was less than for the 18-item Roland-Morris Disability Questionnaire.

CONCLUSION

The Functional Rating Index seems preferable to the 18-item Roland-Morris Disability Questionnaire for use in clinical trials and clinical practice.

Do medical factors predict disability in older adults with persistent low back pain?

Persistent low back pain (LBP) is one of the most common and challenging persistent pain conditions in older adults. Medical comorbidity also is common in these individuals, but its impact on disability has not been examined. The purpose of this study was, using a cross-sectional design, to examine the functional impact of pain-related and general medical comorbidity on 100 community dwelling older adults (mean age 74.3) with persistent mechanical LBP. Subjects received a structured history and physical examination, lumbosacral spine X-rays, and standardized tests of physical function. Pain-related variables included intensity, duration, extent, and lumbar motion-induced pain. General medical variables included age, comorbidity, number of medications, depressive symptoms, back range of motion, body mass index, and severity of radiographic pathology. Function/disability measures included self-reported disability, gait speed, and mean number of static lifts and amount of work performed during a dynamic lifting task. Structural equation modeling was used to evaluate the influence of pain and medical variables on function/disability. The overall regression model indicated pain and medical variables were significantly associated with function/disability measures (R2=0.45, P<0.01). Individual regression coefficients, however, indicated that only pain duration (r=-0.36, P<0.05) and pain severity (r=0.37, P<0.001) were significantly associated with function/disability. Despite the prevalence of medical co-morbidities in older PLBP subjects, they appear to be of limited utility in understanding level of disability. These findings also underscore the need to optimize pain treatment in independent older adults to optimize physical function and delay the onset of dependent living status.

Sagittal range of motion after a spinal fracture: does ROM correlate with functional outcome?

Literature regarding the effect of a spinal fracture and its treatment in terms of resulting spinal range of motion (ROM) is scarce. However, there is need for data regarding sagittal spinal ROM, since many patients who sustain a spinal fracture are concerned about the back mobility they will have after treatment. In addition, the relationship between ROM and impairment is not clear. The literature gives conflicting results. To study spinal ROM after a spinal fracture, we measured thoracolumbar ROM in operatively and non-operatively treated patients (n=76, average 3.7 years follow-up) as well as controls (n=41). In order to study the relation between ROM and subjective back complaints, we calculated the correlation between thoracolumbar ROM and scores derived from the VAS spine score and RMDQ. To assess impairment after a spinal fracture, we compared RMDQ and VAS scores between operatively and non-operatively treated patients and healthy controls. Operatively treated patients were found to have lower thoracolumbar ROM than controls (56.7 degrees vs 70.0 degrees , respectively; p<0.01). There was no difference between operatively treated and non-operatively treated patients (56.7 degrees vs 62.7 degrees , respectively); nor was a difference found between non-operatively treated patients and controls. Correlation between ROM and subjective impairment was very weak and only significant for ROM and RMDQ scores in the whole study group (rho= -0.25; p<0.01). Patients were more impaired than controls, there was no difference between operatively and non-operatively treated patients (VAS score 76.3 vs 72.6; RMDQ score 4.5 vs 4.4, respectively). We conclude that patients treated operatively for a thoracolumbar spinal fracture have a lower thoracolumbar ROM than controls. Spinal ROM, however, does not influence impairment. A spinal fracture results in impairment, no matter what therapy is chosen.

Correlation between pain, disability, and quality of life in patients with common low back pain

STUDY DESIGN

Correlation among previously validated questionnaires.

OBJECTIVES

To determine the correlation between pain, disability, and quality of life in patients with low back pain.

SUMMARY OF BACKGROUND DATA

The Visual Analogue Scale (VAS), and the Roland-Morris (RMQ), Oswestry (OQ), and EuroQol (EQ) Questionnaires are validated instruments to assess pain, low back pain-related disability, and quality of life.

METHODS

The study was done in the primary care setting, in Mallorca, with 195 patients who visited their physician for LBP. Individuals were given the VAS, RMQ, OQ, and EQ on their first visit and 14 days later.

RESULTS

Median duration of pain when entering the study was 10 days (P25,P75: 3, 40). On day 1, simple correlation was r = 0.347 between VAS and RMQ, r = -0.422 between VAS and EQ, and r = -0.442 between RMQ and EQ. On day 15, simple correlation was r = 0.570 between VAS and RMQ, r = -0.672 between VAS and EQ, and r = -0.637 between RMQ and EQ. Multiple linear regression models showed that, on day 1, the VAS score explains 12% of the RMQ score and the VAS and RMQ scores explain 27% of the EQ score. On day 15, the VAS score explains 33% of the RMQ score, and the VAS and RMQ scores explain 58% of the EQ score. On day 1, a 10% increase in VAS worsens disability by 3.3% and quality of life by 2.65%. On day 15, a 10% increase in VAS worsens disability by 4.99% and quality of life by 3.80%. Prestudy duration of pain had no influence on any model. All these correlation coefficients and models are significant at the P < 0.001 level. The OQ had lower correlation values with the other three scales, and only two of them were significant.

CONCLUSION

Clinically relevant improvements in pain may lead to almost unnoticeable changes in disability and quality of life. Therefore, these variables should be assessed separately when evaluating the effect of any form of treatment for low back pain. The influence of pain and disability on quality of life progresses while they last, and doubles in 14 days. In acute and subacute patients, this increase is not dependent on the previous duration of pain.

Biomechanical assessments of lumbar spinal function. how low back pain sufferers differ from normals. implications for outcome measures research. part i: kinematic assessments of lumbar function

OBJECTIVE

To review new and advanced biomechanical assessment techniques for the lumbar spine and illustrate the differences in lumbar function in patients with low back pain and asymtomatic subjects.

DATA SOURCES

The biomedical literature was searched for research and reviews on spinal kinematic differences between low back pain subjects and healthy controls. A data search for articles indexed on MEDLINE until April 2002 was performed.

RESULTS

Kinematic measurements of lumbar function were categorized into 3 areas where low back patients may differ from normals: (1) end range of motion during simple movements; (2) higher order kinematics (displacement, velocity, and acceleration) during complex movement tasks; and (3) spinal proprioception. The assessment of higher order kinematics during complex movement tasks is the most highly researched and the most successful in describing differences between the populations. The use of simple end range of motion appears questionable, while assessing spinal proprioception is the least researched, yet shows potential in highlighting differences between low back sufferers and asymptomatics.

CONCLUSION

Current kinematic biomechanical assessment techniques are capable of identifying functional differences between low back pain populations and controls. The use and validity of the majority of these techniques as outcome measures are currently unknown, yet may be valuable in generating functional diagnoses, evaluating the mechanisms of current therapies, and prescribing specific rehabilitation programs.

The evaluation of the surgical management of nerve root compression in patients with low back pain: Part 1: the assessment of outcome

STUDY DESIGN

This was a prospective study investigating the outcome of decompression surgery using validated measures of outcome.

OBJECTIVES

To investigate the outcome of lumbar decompressive surgery in the initial postoperative year period in terms of function, disability, general health, and psychological well-being.

SUMMARY OF BACKGROUND DATA

The majority of studies investigating the outcome of lumbar decompression surgery have been retrospective and have not used validated measures of outcome. This limits their interpretation and usefulness.

METHODS

Eighty-four patients undergoing lumbar spinal stenosis surgery were recruited into this study. Patients were assessed by use of validated measures of outcome including the Oswestry Disability Index and the Short Form SF-36 General Health Questionnaire before surgery and 6 weeks, 6 months, and 1 year after surgery.

RESULTS

A significant reduction in pain (P < 0.001) was observed at the 6-week postoperative stage; this did not change at the subsequent assessment stages. Only some of the SF-36 categories were sensitive to change. The subcategories that were sensitive to change were physical function (P < 0.05), bodily pain (P < 0.001), and social function (P < 0.05). Improvements were observed in these categories at the 6-week and 6-month reviews. A gradual reduction in the Oswestry Disability Index was observed with time, with changes principally being observed between the 6-week and 6-month review and the 6-week and 1-year review stages (P < 0.05). Minimal changes were observed in the psychological assessments with time. The outcome of surgery could not be predicted reliably from psychological, functional, or pain measures.

CONCLUSIONS

The visual analogue pain scales, the Oswestry Disability Index, and certain categories of the SF-36 Questionnaire, namely bodily pain and physical and social function, appeared to be the most sensitive outcome measures, with significant improvements occurring at the 6-week and 6-month reviews.

The use of Rasch measurement to improve the Oswestry classification scheme

OBJECTIVES

To use Rasch measurement to assess and modify the original classification categories of the Oswestry Low Back Pain Disability Questionnaire (Oswestry), to examine the hypothesis that the items from the Oswestry form a unidimensional construct and a hierarchical representation of low back pain (LBP) disability, and to compare ordinal Likert resultant scores to interval Rasch scaled scores with disability categories serving as a framework.

DESIGN

Rasch analysis model. Existing Oswestry admission data generated by FOTO were analyzed.

SETTING

Statistical analysis of sample database.

PARTICIPANTS

A sample of 942 patients with LBP referred for physical therapy between 1993 and 1994.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Construct validity; disability categories (as assessed by Likert and Rasch models); and fit statistics (infit, outfit as mean squares).

RESULTS

All items from the Oswestry except the pain item fit the Rasch model. Construct validity of the scale using the Rasch model required the structure of the rating scale to be modified from 6 response levels to 4. A hierarchical representation of LBP disability was supported. A comparison of the disability categories based on Likert and Rasch scaling revealed them to be nonequivalent. The new scaling changed the disability categories for 44% of patients.

CONCLUSION

Rasch analysis produced disability categories in the Oswestry that are linear and, therefore, useful for quantitatively assessing self-reported disability levels.