title: Predictive factors for 1-year outcome of low-back and neck pain in patients treated in primary care: comparison between the treatment strategies chiropractic and physiotherapy STATISTICAL METHODS FOR ASSESSING AGREEMENT BETWEEN TWO METHODS OF CLINICAL MEASUREMENT Effectiveness of Harpagophytum procumbens in treatment of acute low back pain. Is Work Status of Low Back Pain Patients Best Described by an Automated Device or by a Questionnaire? Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. Defining the minimum level of detectable change for the Roland-Morris questionnaire. Centralization of low back pain and perceived functional outcome. A Population‐Based, Randomized Clinical Trial on Back Pain Management Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. Measurement Properties of a Self‐Administered Outcome Measure in Lumbar Spinal Stenosis External transpedicular fixation test of the lumbar spine correlates with the outcome of subsequent lumbar fusion. Low Synthesis Rate of Type I Procollagen Is Normalized During Active Back Rehabilitation Assessing change over time in patients with low back pain. Chronic pain and depression: role of perceived impact and perceived control in different age cohorts Return to work following an aquafitness and muscle strengthening program for the low back injured. Relationship of the Pain Disability Index (PDI) and the Oswestry Disability Questionnaire (ODQ) with three dynamic physical tests in a group of patients with chronic low-back and leg pain. Lumbar spinal stenosis: a matched-pair study of operated and non-operated patients. Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain With Radiologic Diagnosis of Spondylolysis or Spondylolisthesis Back school in a first episode of compensated acute low back pain: a clinical trial to assess efficacy and prevent relapse. Function and the patient with chronic low back pain. Disability and functional status in patients with low back pain receiving workers' compensation: a descriptive study with implications for the efficacy of physical therapy. One‐Year Follow‐up Comparison of the Cost and Effectiveness of Chiropractic and Physiotherapy as Primary Management for Back Pain: Subgroup Analysis, Recurrence, and Additional Health Care Utilization Lumbar spinal stenosis: assessment of long-term outcome 12 years after operative and conservative treatment. Efficiency and Costs of Medical Exercise Therapy, Conventional Physiotherapy, and Self‐Exercise in Patients With Chronic Low Back Pain: A Pragmatic, Randomized, Single‐Blinded, Controlled Trial With 1‐Year Follow‐Up Validity of a brief outpatient functional assessment measure. [Active music therapy for chronic pain: a prospective study]. Incorporation of cognitive-behavioral treatment into the medical care of chronic low back patients: a controlled randomized study in German pain treatment centers. Low Back Pain Rating scale: validation of a tool for assessment of low back pain The treatment of acute low back pain--bed rest, exercises, or ordinary activity? Compensation, Work Status, and Disability in Low Back Pain Patients Prospective, Multicenter Study of Spinal Cord Stimulation for Relief of Chronic Back and Extremity Pain A unidimensional pain/disability measure for low-back pain syndromes Comparison of trunk strength measurements between two different isokinetic devices used at clinical settings. Comparison of chiropractic and hospital outpatient management of low back pain: a feasibility study. Report of a working group. Can psychological traits predict the outcome of lumbar disc surgery when anamnestic and physiological risk factors are controlled for? Results of a prospective cohort study. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up Cost and Effectiveness Analysis of Chiropractic and Physiotherapy Treatment for Low Back and Neck Pain: Six‐Month Follow‐Up
abstract: Abstract The inability to predict outcome in patients with low back/neck pain leads to inappropriate or unnecessary treatment . The aims of the study were to identify prognostic factors for disability at 1‐year follow‐up in patients with back pain visiting primary care , and to compare the effect of these in two treatment strategies – chiropractic and physiotherapy . Data were taken from a r and omised trial on patients with back/neck pain visiting the general practitioner , in which patients were allocated to chiropractic and physiotherapy as primary management .  Three hundred and twenty‐three patients , aged 18–60 years , who had no contraindications to manipulation and who had not been treated within the previous month were included in the study . Multiple regression analysis was used to identify prognostic factors . Dependent variables were mean Oswestry score and mean change in Oswestry score at 12‐month follow‐up . The multiple regression analysis revealed five significant ( P<0.001–0.01 ) prognostic factors ; duration of current episode , Oswestry score at entry , expectations of treatment , number of localisations , and well‐being . Besides , the regression coefficients for the significant factors were compared between the two treatment strategies . No significant difference in effect or regression coefficients for the prognostic factors were seen between the two treatment strategies . Twelve per cent of the patients had poor prognostic factors ( duration ≥1 month , more than one localisation , low expectations of treatment and low well‐being ) at entry . These patients had a mean Oswestry score above 20 % at 1‐year follow‐up . Clinical decision models for the management of patients with back pain visiting primary care that consider prognostic factors need to be implemented and prospect ively evaluated In clinical measurement comparison of a new measurement technique with an established one is often needed to see whether they agree sufficiently for the new to replace the old . Such investigations are often analysed inappropriately , notably by using correlation coefficients . The use of correlation is misleading . An alternative approach , based on graphical techniques and simple calculations , is described , together with the relation between this analysis and the assessment of repeatability In a study that indicates more definitive investigation is needed , 118 patients with chronic back problems seeking treatment for acute attacks of pain were included in a 4-week r and omised double-blinded study on the safety and effectiveness of an extract of Harpagophytum procumbens . Both , the treatment and the placebo were administered in the form of two tablets taken three times per day ; the treatment group had a daily consumption equal to 6,000 mg of crude preparation ( 50 mg harpagoside , the putative active ingredient ) . The treatment and placebo groups were well matched in physical characteristics ; in the severity , duration , nature and accompaniments of their pain ; and in laboratory indices of organ system function . 109 patients completed the study . The study was originally design ed to measure Harpagophytum 's effectiveness by measuring the use of supplementary pain-killer Tramadol over its final 3 weeks . However , this did not differ between the Harpagophytum and placebo groups nor was the consumption closely related to the amount of pain . Further analysis , though , revealed that 9 out of 51 patients who received the extract were pain free at the end of treatment compared to only 1 out of 54 patients who received placebo . A modification of the Arhus index was used as an additional measure , covering the more global impact . The percentage change was greater in those patients who received Harpagophytum extract than in those who received placebo , but inferential testing ( Mann Whitney ) allowed only 94 % degree of confidence that this had not arisen by chance . The Arhus index reduction was based on improvement in pain . This indication of effectiveness , and the absence of demonstrable adverse effects show that more definite clinical studies of Harpagophytum extract will be worthwhile Study Design . A prospect i ve cohort study of patients with subacute occupational back pain . Objectives . To study the relation between a marketed opto‐electric device measuring trunk kinematics , a widely used specific functional capacity question naire , and work status in back pain patients , and to assess the responsiveness to change in work status of the opto‐electric device and the question naire . Summary of Background Data . Several instruments have been developed to evaluate the functional capacities of patients with back pain , but the relation between these instruments and work status has rarely been studied . Methods . The relation between the opto‐electric device , the question naire , and work status in patients with back pain was evaluated . The study population was a prospect i ve cohort of patients with subacute back pain who were absent from regular work for more than 4 weeks . All data were compiled blindly on the same day , at study entry ( 4 weeks after work accident ) , and at 12 , 24 , and 52 weeks after the work accident . The validity of the question naire and opto‐electric device scores was assessed with partial correlation analyses , st and ardized response mean , logistic regression analyses , and receiver operating characteristics curves . Results . The correlation between the question naire and opto‐electric device scores was low . The question naire scores were significantly related to work status , but the opto‐electric device scores were not . The question naire was responsive to change in work status , whereas the opto‐electric device was not . Conclusions . The opto‐electric device scores were not related to either functional capacity scores ( question naire ) or work status in patients with low back pain , and the opto‐electric device was not responsive to change in work status . Conversely , the question naire was related to work status and was responsive to change in work status A BSTRACT Background Although epidural corticosteroid injections are commonly used for sciatica , their efficacy has not been established . Methods In a r and omized , double-blind trial , we administered up to three epidural injections of methylprednisolone acetate ( 80 mg in 8 ml of isotonic saline ) or isotonic saline ( 1 ml ) to 158 patients with sciatica due to a herniated nucleus pulposus . All patients had Oswestry disability scores higher than 20 ( on a scale of 1 to 100 , with scores of 20 or less indicating minimal disability , and higher scores greater disability ) . Results At three weeks , the Oswestry score had improved by a mean of 8.0 in the methylprednisolone group and 5.5 in the placebo group ( 95 percent confidence interval for the difference , 7.1 to 2.2 ) . Differences in improvements between the groups were not significant , except for improvements in the finger-to-floor distance ( P 0.006 ) and sensory deficits ( P 0.03 ) , which were greater in the methylprednisolone group . After six weeks , the only significant difference was the improvement in leg pain , which was greater in the methylprednisolone group ( P 0.03 ) . After three months , there were no significant differences between the groups . The Oswestry score had improved by a mean of 17.3 in the methylprednisolone group and 15.4 in the placebo group ( 95 percent confidence interval for the difference , 9.3 to 5.4 ) . At 12 months , the cumulative probability of back surgery was 25.8 percent in the methylprednisolone group and 24.8 percent in the placebo group ( P 0.90 ) . Conclusions Although epidural injections of methylprednisolone may afford short-term improvement in leg pain and sensory deficits in patients with sciatica due to a herniated nucleus pulposus , this treatment offers no significant functional benefit , nor does it reduce the need for surgery . ( N Engl J Med 1997 ; 336:1634 - 40 . BACKGROUND AND PURPOSE The Rol and -Morris Question naire ( RMQ ) is a self-administered disability measure in which greater levels of disability are reflected by higher numbers on a 24-point scale . The RMQ has been shown to yield reliable measurements , which are valid for inferring the level of disability , and to be sensitive to change over time for groups of patients with low back pain . Little is known about the usefulness of this instrument in aiding decision making regarding individual patients . The purpose of this study was to determine the minimum level of detectable change when the RMQ is applied to individual patients . SUBJECTS The study sample consisted of 60 out patients with low back pain . METHODS The RMQ was administered at the subjects ' initial visit and again 4 to 6 weeks later . Conditional st and ard errors of measurement ( CSEMs ) were computed for initial and follow-up RMQ scores , and these values were used to estimate the minimum level of detectable change . Results . Minimum levels of detectable change at the 90 % confidence level varied from 4 to 5 RMQ points . CONCLUSION AND DISCUSSION The magnitude of CSEMs is sufficiently small to detect change in patients with initial scores in the central portion of the scale ( 4 - 20 RMQ points ) ; however , the magnitude is too large to detect improvement in patients with scores of less than 4 and deterioration in patients who have scores greater than 20 McKenzie 's methods for evaluating and treating low back pain are used often but studied little . When using the McKenzie system , it is important to observe signs of symptom movement to a central location ( central ization ) . This study investigated the relationships between central ization of low back pain and /or radiculopathy and the subjects ' rating of functional outcome . Thirty-six subjects with low back pain volunteered to participate and were evaluated and treated by six research ers . Subjects were tested initially and again 14 days after initiation of treatment using the Oswestry Low Back Pain Disability Question naire and the Performance Assessment and Capacity Testing Spinal Function Sort ( SFS ) . Symptoms were monitored for the occurrence of " complete central ization . " Of the 36 subjects , 25 showed complete central ization within 14 days . The SFS score changes were significantly higher for subjects who completely central ized ( p = 0.015 ) . The results supported the hypothesis that subjects who central ize will have improved functional outcome and , thus , quality of life . However , shorter time to occurrence of complete central ization does not necessarily correlate with improved outcome Study Design . Population ‐based r and omized clinical trial . Objectives . To develop and test a model of management of subacute back pain , to prevent prolonged disability . Summary of Background Data . The present management of back pain seems inadequate , and development of innovative models has been urged . Methods . A model for the treatment of subacute work‐related back pain has been developed and evaluated in a population ‐based r and omized clinical trial . Workers ( n = 130 ) from eligible workplaces in the Sherbrooke area ( N = 31 ) , who had been absent from work for more than 4 weeks for back pain , were r and omized , based on their workplace , in one of four treatment groups : usual care , clinical intervention , occupational intervention , and full intervention ( a combination of the last two ) . The duration of absence from regular work and from any work was evaluated using survival analysis . Functional status and pain were compared at study entry and after 1 year of follow‐up . Results . The full intervention group returned to regular work 2.41 times faster than the usual care intervention group ( 95 % confidence interval 1.19‐4.89 ; P = 0.01 ) . The specific effect of the occupational intervention accounted for the most important part of this result , with a rate ratio of return to regular work of 1.91 ( 95 % confidence interval = 1.18‐3.10 ; P < 0.01 ) . Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups , compared with the trend in the usual care intervention group . Conclusions . Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain OBJECTIVE To evaluate a progressive fitness programme for patients with chronic low back pain . DESIGN Single blind r and omised controlled trial . Assessment s were carried out before and after treatment by an observer blinded to the study and included a battery of vali date d measures . All patients were followed up by postal question naire six months after treatment . SETTING Physiotherapy department of orthopaedic hospital . SUBJECTS 81 patients with chronic low back pain referred from orthopaedic consultants for physiotherapy . The patients were r and omly allocated to a fitness programme or control group . INTERVENTION Both groups were taught specific exercises to carry out at home and referred to a back-school for education in back care . Patients allocated to the fitness class attended eight exercise classes over four weeks in addition to the home programme and backschool . RESULTS Significant differences between the groups were shown in the changes before and after treatment in scores on the Oswestry low back pain disability index ( P < 0.005 ) , pain reports ( sensory P < 0.05 and affective P < 0.005 ) , self efficacy reports ( P < 0.05 ) , and walking distance ( P < 0.005 ) . No significant differences between the groups were found by the general health question naire or question naire on pain locus of control . A benefit of about 6 percentage points on the disability index was maintained by patients in the fitness group at six months . CONCLUSION There is a role for supervised fitness programmes in the management of moderately disabled patients with chronic low back pain . Further clinical trials , however , need to be established in other centres to confirm these findings Reprinted with permission from the British Medical Journal 300:1431 - 1437.1990 . Objective - To compare chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin . Design - R and omized controlled trial . Allocation to chiropractic or hospital management by minimization to establish groups for analysis of results according to initial referral clinic , length of current episode , history , and severity of back pain . Patients were followed up for up to two years . Setting - Chiropractic and hospital outpatient clinics in 11 centers . Patients - 741 patients aged 18 - 65 who had no contraindications to manipulation and who had not been treated within the past month . Interventions - Treatment at the discretion of the chiropractors , who used chiropractic manipulation in most patients , or of the hospital staff , who most commonly used Maitl and mobilization or manipulation , or both . Main outcome measures - Changes in the score on the Oswestry pain disability question naire and in the results of tests of straight leg raising and lumbar flexion . Results - Chiropractic treatment was more effective than hospital outpatient management , mainly for patients with chronic or severe back pain . A benefit of about 7 percent points on the Oswestry scale was seen at two years . The benefit of chiropractic treatment became more evident throughout the follow-up period . Secondary outcome measures also showed that chiropractic was more beneficial . Conclusions - For patients with low back pain in whom manipulation is not contraindicated , chiropractic almost certainly confers worthwhile , long-term benefit in comparison with hospital outpatient management . The benefit is seen mainly in those with chronic or severe pain . Introducing chiropractic into NHS practice should be considered . J Orthop Sports Phys Ther 1991;13(6):278 - 287 Study Design The measurement properties and validity of a newly developed patient question naire for the assessment of patients with lumbar spinal stenosis was tested in an ongoing prospect i ve multicenter observational study of patients undergoing decompressive surgery in three teaching hospitals . Objective The goal of the study was to develop a short , self‐administered question naire on symptom severity , physical functional status , and patient satisfaction . Summary of Background Data The measure is intended to complement existing generic measures of spinal‐related disability and health status . The question naire includes three scales with seven questions on symptom severity , five on physical function , and six on satisfaction . Methods The internal consistency of the scales was assessed with Cronbach 's coefficient alpha on crosssectional data from 193 patients before surgery . The test‐retest reliability was assessed on data from a r and om sample of 23 patients using Spearman 's rank correlation coefficient . The responsiveness was assessed on 130 patients with 6‐month follow‐up data using the st and ardized response mean . Results The test‐retest reliability of the scales ranged from 0.82 to 0.96 , the internal consistency from 0.64 to 0.92 , and the responsiveness from 0.96 to 1.07 . The direction , statistical significance , and strength of hypothesized relationships with external criteria were as expected . Conclusions This short self‐administered spinal stenosis measure is reproducible , internally consistent , valid , and highly responsive . It can be used to complement generic instruments in outcome assessment of patients with lumbar spinal stenosis External transpedicular fixation was applied to the lower lumbar spine in a prospect i ve study on 42 patients with chronic low back pain combined with suspected instability of the lumbar segments ; the diagnosis was failed disk surgery , spondylolisthesis , and degenerative disk disease . The aim was to realign the involved segments , to restore disk height , and to record changes in pain and performance during the external fixation test .  Pain was recorded on a visual analog scale , and performance was assessed using the Oswestry disability score . As independent observer assessed the test and treatment results . Twenty-nine patients experienced relief of pain and performed better in the fixator ; they were subjected to anterior interbody fusion , the external frame being kept as a stabilizing device for an additional four months . Twenty-two patients have had follow-up evaluations for two years . One and two years after successful lumbar fusion , significantly ( p < 0.02 ) better pain and performance scores were recorded ; the results of lumbar fusion corresponded to the preoperative fixation test . A temporary external fixation test may be a useful procedure in patients considered for subsequent spondylodesis Study Design . Open , prospect i ve trial with patients participating in an active back restoration program .  Objectives . To compare the concentrations of biochemical indicators of Type I and III collagen synthesis and Type I collagen degradation in the serum of patients with chronic low back pain and healthy control subjects and to evaluate the effect of active back rehabilitation based on vigorous exercise on collagen metabolism . Summary of Background Data . The aim of active back rehabilitation is to restore the physical function of low back pain patients falling into the so-called " deconditioning syndrome . " The changes in functional muscle strength measurements during the restoration rehabilitation program always depend on motivation , learning phenomena , and fear of pain and injury , so that even more objective ways of showing changes in physical activity are needed . Methods . Specific radioimmunoassays for the amino-terminal ( PINP ) and carboxy-terminal ( PICP ) propeptides of Type I procollagen , the amino-terminal propeptide of Type III procollagen ( PIIINP ) , and the cross-linked carboxy-terminal telopeptide of Type I collagen ( ICTP ) were used for serum sample s obtained from 41 patients before , during , and after an active back restoration program and from 16 age- and sex-matched healthy control subjects . Results . The circulating concentrations of PINP and PICP were initially lower in the patients ( [ mean ± SD ] 35.3 ± 12.5 μg/L and 119.0 ± 32.6 μg/L , respectively ) than in the control subjects ( 47.9 ± 18.0 μg/L and 136.7 ± 47.7 μg/L , respectively ; P < 0.05 for PINP ) . Toward the end of the active back rehabilitation program , both PINP and PICP increased in the patients ( P < 0.001 for the increase between the initial level and the end of rehabilitation ) . There was a significant difference in the time courses of these changes , with the circulating PICP concentration increasing earlier than that of PINP . In the intervention group , the PIIINP concentration also increased ( P < 0.01 ) , whereas the ICTP concentration remained unchanged , with a tendency to decrease . No changes occurred in the control subjects . Conclusions . Active back rehabilitation based on vigorous exercise increases Type I collagen synthesis in patients with chronic low back pain ; this may provide a means of objective ly verifying the effects of such rehabilitation BACKGROUND AND PURPOSE This study compared the ability of the Rol and -Morris ( RM ) , Oswestry ( OSW ) , and Jan van Breemen Institute ( JVB ) pain and function question naires to detect change over time . SUBJECTS The sample consisted of 88 patients with mechanical low back pain who were referred by physicians to the outpatient physical therapy department of a teaching hospital . METHODS Question naires were completed by the subjects at their initial visit and 4 to 6 weeks later . Clinical ly important change was estimated by having the subject and the clinician independently complete two rating scales . Sensitivity to change was assessed using receiver operating characteristic ( ROC ) curve analysis . RESULTS The ROC curve areas for the RM ( 0.79 ) , OSW ( 0.78 ) , and JVB pain ( 0.79 ) question naires were significantly greater than for the JVB function question naire ( 0.66 ) . Blank and multiple responses per item were present on approximately 20 % of the OSW question naires and 14 % of the JVB question naires . Words rather than checks were evident on 3 % of the RM question naires . CONCLUSION AND DISCUSSION Based on the latter finding , we believe the RM question naire may be the preferred instrument for assessing change over time in patients with low back pain & NA ; Chronic pain adversely affects individuals ' physical as well as emotional well‐being . A cognitive‐behavioral model has been proposed to explain the role of cognitive appraisal variables in mediating the development of emotional distress following pain of long duration . There is little evidence linking the prevalence of depression in chronic pain patients to life stage , but there are suggestions in the literature that the link between medical illness and depression may be stronger in elderly patients . One purpose of this study was to replicate the efficacy of a previous study of the cognitive‐behavioral mediation model in explaining the association between pain and depressed affect . A second purpose of this study was to extend the cognitive‐behavioral model to evaluate relationships among pain , cognitive appraisal variables , and depressive affect in the elderly chronic pain population . One hundred chronic pain patients were divided into two age groups ( ≤ 69 years and ≥ 70 years ) . A path analysis conducted for the total sample supported the cognitive‐behavioral mediation model of depression in chronic pain , in which cognitive appraisal variables mediate the pain‐depression relationship . Correlations among variables in each of the two age groups , however , revealed different patterns of association . Consistent with the cognitive‐behavioral model , the younger patients demonstrated a low and non‐significant correlation between pain severity and depression ( r = 0.01 ) . Conversely , a strong direct association was observed in the older patients between these variables ( r = 0.51 ) . These results suggest that the relationship between pain and depression varies substantially depending upon age cohort Our purpose , in this prospect i ve clinical study , was to identify the best predictors of 2-month return to work or retraining for a group of low back injured subjects ( n = 40 ) who completed at least 8 weeks of a community-based rehabilitation program that combined aerobic and flexibility exercise conducted in the water ( aquafitness ) with muscle strength and endurance training .  Baseline demographic characteristics and changes in physical fitness , pain , disability , and psychological well-being during the course of program participation were compared between two groups of low back injured subjects : those who returned to work ( RTW ) [ n = 24 ] , and those who did not ( N-RTW ) [ n = 16 ] . Subjects in both groups showed comparable improvement in measures of physical fitness at 8 weeks . However , multivariate analyses showed significant between-group differences in self-report measures . The RTW group showed significant improvement in measures of pain , disability , anxiety , and vigor while self-esteem and affect remained stable . The N-RTW group displayed no change in pain and disability variables and had significant deterioration in mean overall psychological well-being over time . The best predictors of return to work using logistic regression analyses were a first injury rather than a repeat injury to the lower back , and stability in self-esteem . Suggestions are offered for further research to examine the benefits of aquafit exercise for the low back injured , for additional interventions for those with a reinjury , and for maintaining or enhancing self-esteem as a treatment goal OBJECTIVE To determine the relationship between overall disability in daily activities , assessed with the Pain Disability Index ( PDI ) and the Oswestry Disability Question naire ( ODQ ) , and impaired performance on three physical tests in patients with chronic low-back pain . DESIGN AND SUBJECTS The PDI and ODQ were administered in a cross-sectional study , before beginning a back rehabilitation program , to 45 patients with low-back pain of > or = 3 months ' duration , with or without radiation to the legs . All patients also performed repetitive sit-up , arch-up , and squatting tests . SETTING Tertiary care center . RESULTS Modestly significant ( p < 0.05 ) or significant ( p < 0.01 ) inverse correlations ( Pearson 's r = 0.30 - 0.41 ) were noted between the PDI and the ODQ and all three physical performance tests . When normative data were used , the correlation ( Spearman 's rs = -0.45 ) between PDI and the squatting test remained significant ( p < 0.01 ) , whereas it was modestly significant ( rs = -0.33 , p < 0.05 ) between the ODQ and squatting test and between the PDI and arch-up test ( rs = -0.35 , p < 0.05 ) . Compared with patients presently working , those on sick leave had significantly higher scores on the PDI and ODQ ( Wilcoxon 's two- sample test : p < 0.001 ) and also significantly worse performance on all physical tests ( p < 0.001 ) . CONCLUSIONS The PDI and ODQ , as measures of self-perceived disability , and impaired performance on repetitive squatting , arch-up , and sit-up tests , as measures of physical capability , show some overlap in low-back-pain patients . Both types of disability measures are clearly influenced by the patient 's work status The prevailing opinion seems to accept that the natural course of lumbar spinal stenosis is one of progressive worsening , and that only surgery can check this development . In fact , the choice of treatment for lumbar spinal stenosis is still an open question . The aim of this study was to compare in the matched-pair format the outcome of  surgically and non-surgically treated patients with lumbar spinal stenosis . The  surgically treated group consisted of 496 patients who were operated on during the period 1974 - 1987 and 440 of whom were re-examined an average of 4.1 years after surgery . The non-surgically treated group consisted of 57 patients who were treated conservatively during the period 1980 - 1987 and were re-examined an average of 4.3 years after the start of treatment . The matching criteria were sex , age , myelographic findings , major symptom and duration of symptoms . We were able to form 54 similar matched-pairs from the surgically and non-surgically treated patients . Subjective disability was assessed using the Oswestry question naire and functional status was evaluated during the clinical examination . For statistical analysis the McNemar test and the paired Student 's t-test were used . The overall results showed no statistical difference in outcome between the matched-pair groups , but the operated men fared significantly better than the non-operated men . The functional status was very good in both groups and for both sexes . In conclusion , conservative treatment of lumbar spinal stenosis should be considered for the patients with moderate stenosis . Controlled , prospect i ve and r and omized trials are needed to clarify better the choice of treatment in patients with lumbar stenosis Study Design . A r and omized , controlled trial , test‐retest design , with a 3‐ , 6‐ , and 30‐month postal question naire follow‐up . Objective . To determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain and a radiologic diagnosis of spondylolysis or spondylolisthesis . Summary of Background Data . A recent focus in the physiotherapy management of patients with back pain has been the specific training of muscles surrounding the spine ( deep abdominal muscles and lumbar multifidus ) , considered to provide dynamic stability and fine control to the lumbar spine . In no study have research ers evaluated the efficacy of this intervention in a population with chronic low back pain where the anatomic stability of the spine was compromised . Methods . Forty‐four patients with this condition were assigned r and omly to two treatment groups . The first group underwent a 10‐week specific exercise treatment program involving the specific training of the deep abdominal muscles , with co‐activation of the lumbar multifidus proximal to the pars defects . The activation of these muscles was incorporated into previously aggravating static postures and functional tasks . The control group underwent treatment as directed by their treating practitioner . Results . After intervention , the specific exercise group showed a statistically significant reduction in pain intensity and functional disability levels , which was maintained at a 30‐month follow‐up . The control group showed no significant change in these parameters after intervention or at follow‐up . Summary . A " specific exercise " treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis OBJECTIVE To assess the efficacy of a back school program for patients with a first episode of acute work-related low back pain requiring compensation . DESIGN A r and omized single-blind controlled trial . SETTING A private physiatrics outpatient clinic . PATIENTS The mean duration of low back pain was 15 days . INTERVENTION Eligible patients were r and omized to a st and ard treatment program that included daily physiotherapy ( n = 86 ) or the same program with the addition of back school ( n = 82 ) . The back school program consisted of three 90-minute sessions given by a single trained instructor at 0 , 1 , and 8 weeks . MAIN OUTCOME MEASURES The primary outcomes were the time off work for the presenting episode of back pain and the number and duration of recurrences in the year following the study onset . Secondary outcomes included the level of pain , spinal mobility , active straight-leg raising , and functional disability assessed by the Oswestry and Rol and -Morris scales . RESULTS Those r and omized to the back school group gained significantly more knowledge , based on the multiple choice examination ( p = .0001 ) and performed the exercise program significantly better ( p = .0001 ) than the st and ard care group . There were no differences between the two treatment groups for either of the primary outcomes . The median time to return to work from r and omization was 33 days for both the back school and the st and ard care groups ( p = .48 ) . The number of compensated recurrences of low back pain over 1 year was similar ( back school = 14 , st and ard care = 10 , p = .16 ) , as was the median duration of these episodes ( back school = 25 days , st and ard care = 70 days , p = .21 ) . There were no significant differences favoring the back school group for any of the secondary outcomes at the posttreatment , 6-month , or 12-month assessment s. CONCLUSION A back school intervention in addition to st and ard care result ed in no reduction in the time to return to work or the number or duration of recurrences of low back pain requiring compensation over a period of one year OBJECTIVE To undertake a comparative examination of the reliability and validity of two frequently used self-report measures of functional disability , the Pain Disability Index  ( PDI ) and the Oswestry Low Back Pain Disability Question naire  ( OLBPDQ ) . DESIGN A descriptive ex-post facto design was used in the study . SETTING Pain clinics and neurosurgical units at three metropolitan hospitals . SUBJECTS One hundred patients with chronic low back pain of noncancer origin were administered the two question naires as part of a larger question naire battery . RESULTS Acceptable internal consistency values of 0.76 for the PDI and 0.71 for the OLBPDQ were obtained . A correlation of r = 0.63 was found between the PDI and the OLBPDQ , supporting the concurrent validity of the two scales . Both the scales were found to be correlated to the Beck Depression Inventory scores ( PDI , r = 0.42 ; OLBPDQ , r = 0.39 ) , with higher disability associated with greater depression . Only the total PDI score was found to be sensitive to functional status differences within the patient sample . CONCLUSIONS These findings support other recent work in favor of the PDI . The PDI had a slightly higher internal consistency and was more sensitive than the OLBPDQ BACKGROUND AND PURPOSE The efficacy of a physical therapy outpatient program with multiple interventions to treat low back pain in subjects receiving workers ' compensation was examined . The primary purpose of the study was to describe the level of disability , physical impairment , and rate of return to work for compensated patients . SUBJECTS One hundred thirty-eight patients ( 84 male , 54 female ) , aged 17 to 63 years ( mean = 38 , SD = 10 ) , were evaluated prospect ively . METHODS Subjects were assessed initially ( INA ) and were reevaluated 1 month later ( 1MO ) and again at the time of discharge ( DC ) . The Oswestry disability score , fingertip-to-floor distance during forward bending , maximal isometric lift , and work status were described as outcomes . Subjects were grouped based on compliance , chronicity , and leg symptoms . Each disability/impairment outcome was analyzed with paired t tests ( INA versus 1MO and INA versus DC ) . The frequency of subjects returning to work across groups was evaluated with a chi-square analysis corrected for unequal group sizes . RESULTS Overall , there was improvement in each dependent measure at 1MO and DC compared with the INA . Subjects with high compliance had a 10 % reduction in mean disability at 1MO and a 12 % reduction in mean disability at DC compared with the INA . The low-compliance group , in contrast , showed less than a 5 % reduction in mean disability at both the 1MO and DC assessment s compared with the INA . The magnitude of improvement in disability status , forward bending , and maximal lift was approximately two to three times greater for subjects with acute symptoms compared with those with chronic symptoms . The increase in mean forward bending for subjects without leg symptoms was over twice as large as the increase in forward bending for subjects with leg symptoms . Seventy-five percent of the subjects followed at DC ( 30 out of 40 ) were released to work in some capacity . There was no association between compliance or presence of leg symptoms and work status at DC . Eighty percent of the subjects with acute symptoms , however , were working at the time of DC compared with 44 % of those with chronic symptoms . CONCLUSION AND DISCUSSION Compliance , chronicity , and leg symptoms are all factors that can affect the outcome of physical therapy . The positive outcomes for subjects who complied with therapy suggest that a physical therapy program with multiple interventions may decrease disability and impairment Study Design . A r and omized trial was conducted in which patients with back and neck pain , visiting a general practitioner , were allocated to chiropractic or physiotherapy . Objectives . To compare outcome and costs of chiropractic and physiotherapy as primary treatment for patients with back and neck pain , with special reference to subgroups , recurrence rate , and additional health care use at follow‐up evaluation 12 months after treatment . Summary of Background Data . Earlier studies on the effect of spinal manipulation have shown inconsistent results . Mostly they include only short‐term follow‐up periods , and few cost‐effectiveness analyses have been made . Methods . A group of 323 patients aged 18‐60 years who had no contraindications to manipulation and who had not been treated within the previous month were included . Outcome measures were changes in Oswestry scores , pain intensity , and general health ; recurrence rate ; and direct and indirect costs . Results . No differences were detected in health improvement , costs , or recurrence rate between the two groups . According to Oswestry score , chiropractic was more favorable for patients with a current pain episode of less than 1 week ( 5 % ) and physiotherapy for patients with a current pain episode of greater than 1 month ( 6.8 % ) . Nearly 60 % of the patients reported two or more recurrences . More patients in the chiropractic group ( 59 % ) than in the physiotherapy group ( 41 % ) sought additional health care . Costs varied considerably among individuals and subgroups ; the direct costs were lower for physiotherapy in a few subgroups . Conclusions . Effectiveness and costs of chiropractic or physiotherapy as primary treatment were similar for the total population , but some differences were seen according to subgroups . Back problems often recurred , and additional health care was common . Implication s of the result are that treatment policy and clinical decision models must consider subgroups and that the problem often is recurrent . Models must be implemented and tested The present study focuses on the long-term prognosis of radiographically verified stenosis of the lower lumbar spine . The purpose here was to describe the outcome 12 years after radiographic diagnosis of spinal stenosis and to identify factors predicting disability after operative or conservative treatment . Data were compiled on 75 patients ( 43 men and 32 women ) with changes in functional myelography diagnostic for spinal stenosis . Their mean age at the interview 12 years later was 61 years .  The sagittal diameter of the dural sac was measured from baseline myelographs at all intervertebral levels and was corrected for magnification . In the interview , subjective outcome assessment was obtained with a structured question naire , and the low-back disorder was scored using the Oswestry disability index . The sagittal diameter of the dural sac was severely stenotic ( < 7.0 mm ) in 32 patients ( 26 operated ) , and moderately stenotic ( 7.0 - 10.5 mm ) in 43 patients ( 31 operated ) . The severity of the stenosis significantly predicted disability , even when the effects of age , sex , therapy regimen , and body mass index were adjusted for . For moderate and severe stenosis , the adjusted mean Oswestry indices were 28.4 and 39.1 , respectively ( p = 0.01 ) . Therapy as such ( operative versus nonoperative ) did not significantly correlate with later disability . The radiographic severity of lumbar spinal stenosis predicts disability independently of therapy regimen . R and omized clinical trials are needed to establish the indications for surgical and conservative treatment . Radiographic severity of the stenosis should be considered as an effect-modifying or confounding factor in clinical trials and other studies focusing on the outcome of lumbar spinal stenosis Study Design . A multicenter , r and omized , single‐blinded controlled trial with 1‐year follow‐up . Objectives . To evaluate the efficiency of progressively grade d medical exercise therapy , conventional physiotherapy , and self‐exercise by walking in patients with chronic low back pain . Summary and Background Data . Varieties of medical exercise therapy and conventional physiotherapy are considered to reduce symptoms , improve function , and decrease sickness absence , but this opinion is controversial . Methods . Patients with chronic low back pain or radicular pain sick‐listed for more than 8 weeks and less than 52 weeks ( Sickness Certificate II ) were included . The treatment lasted 3 months ( 36 treatments ) . Pain intensity , functional ability , patient satisfaction , return to work , number of days on sick leave , and costs were recorded . Results . Of the 208 patients included in this study , 71 were r and omly assigned to medical exercise therapy , 67 to conventional physiotherapy , and 70 to self‐exercise . Thirty‐three ( 15.8 % ) patients dropped out during the treatment period . No difference was observed between the medical exercise therapy and conventional physiotherapy groups , but both were significantly better than self‐exercise  group . Patient satisfaction was highest for medical exercise therapy . Return to work rates were equal for all 3 intervention groups at assessment 15 months after therapy was started , with 123 patients were back to work . In terms of costs for days on sick leave , the medical exercise therapy group saved 906,732 Norwegian Kroner ( NOK ) ( $ 122,531.00 ) , and the conventional physiotherapy group saved NOK 1,882,560 ( $ 254,200.00 ) , compared with the self‐exercise group . Conclusions . The efficiency of medical exercise therapy and conventional physiotherapy is shown . Leaving patients with chronic low back pain untampered poses a risk of worsening the disability , result ing in longer periods of sick leave Aspects of validity are investigated with a brief functional assessment measure among out patients undergoing rehabilitation for musculoskeletal problems . The Medical Rehabilitation Follow Along measure ( MRFA ) currently has screening , musculoskeletal , neurologic , and multiple sclerosis forms . In this study , the 31-item musculoskeletal form of the MRFA is compared with and contrasted to a measure of general health status , the Medical Outcomes Trust SF-36 . Content , construct , and criterion validity are addressed using scale scores before ( n = 94 ) and after ( n = 48 ) outpatient rehabilitation .  Scale scores are compared with therapists ' ratings of improvement . The results provide support for the validity of inferences made from scale scores of the MRFA for persons with musculoskeletal problems . Applications of the MRFA , including screening , monitoring , and outcome assessment are discussed for clinical management , measuring treatment effectiveness , and program evaluation There are only few publications about the effect of music therapy on pain relief . The intention of this prospect i ve study is to demonstrate the influence of the Nordoff/Robbins method of active music therapy in a group of 12 patients with fibromyalgia , myofascial pain syndromes and polyarthritis on  pain reduction , life quality and coping . The clinical parameters of each patient were related to the observations in the audio- and video-documented music therapy setting s and to the self-reported changes in pain intensity and pain behaviour . There was a significant reduction of pain intensity and pain-related disability in the music group compared to a control group , but no change in the depression and anxiety score . The influence of music therapy could be even better demonstrated in the systematic analysis of the single cases by individual profiles . Active music therapy affects especially the communicative and emotional dimension of chronic pain . Psychophysiological and psychodynamic models are presented to explain the effectiveness of music therapy on pain reduction . Clinical studies on music therapy as well as on other " art therapies " should relate the analysis of clinical parameters to the descriptive-phenomenological documentation of the therapeutic process to demonstrate systematic ally the influence of music and art in the individual case Cognitive behavioral treatment has been incorporated into st and ard medical treatment procedures in German pain centers . Acceptance of the treatment by patients and outcome in terms of pain , coping , and disability was investigated . Components of the psychological treatment are education , relaxation and imagery , modifying thoughts and feelings , enhancement of pleasant activities , and training of good postural habits . The program was conducted in a group setting in accordance with a treatment manual and consists of 12 weekly 2.5-h sessions . A two-factor experiment with repeated measures on one factor was applied . Ninety-four consecutive patients with low-back pain were r and omly assigned to an experimental group having a combined medical and cognitive-behavioral treatment , or to a control group with medical treatment only . Assessment s were taken pre-treatment , post-treatment , and --in the treated group only -- at a 6-months follow-up . At each assessment , patients kept a pain diary over a period of 4 weeks , and filled in self-report question naires . The sample consisted of 36 experimental and 40 control subjects at post-treatment . Experimental subjects reported less pain , better control over pain , more pleasurable activities and feelings , less avoidance and less catastrophizing . In addition , disability was reduced in terms of social roles , physical functions and mental performance . The results were maintained at follow-up . Patients who only received medical treatment showed little improvement . Data indicate that the program meets the needs of the patients and should be continued Low Back Pain Rating scale is an index scale which includes measurements of pain intensity , disability , and physical impairment . The scale was design ed to monitor the outcome of clinical trials of low back pain treatment . It has been vali date d in 58 patients following first-time discectomy .  The scale rating can be rapidly carried out and requires no special aids . With slight modification it can be used in office and telephone interviews , as well as postal question naires . These modifications only slightly reduce the quantity of information gathered . In the study , a high rater agreement ( 97.7 % ) was found without level difference between two observers using the scale . The validation process included : construct validity , criterion-related validity and item bias , relative to Global Assessment s pronounced by the patient and an experienced clinician . Low Back Pain Rating scale hs been shown to be valid and reliable in the assessment of low back pain BACKGROUND Bed rest and back-extension exercises are often prescribed for patients with acute low back pain , but the effectiveness of these two competing treatments remains controversial . METHODS We conducted a controlled trial among employees of the city of Helsinki , Finl and , who presented to an occupational health care center with acute , nonspecific low back pain . The patients were r and omly assigned to one of three treatments : bed rest for two days ( 67 patients ) , back-mobilizing exercises ( 52 patients ) , or the continuation of ordinary activities as tolerated ( the control group ; 67 patients ) . Outcomes and costs were assessed after 3 and 12 weeks . RESULTS After 3 and 12 weeks , the patients in the control group had better recovery than those prescribed either bed rest or exercises . There were statistically significant differences favoring the control group in the duration of pain , pain intensity , lumbar flexion , ability to work as measured subjectively , the Oswestry back-disability index , and number of days absent from work . Recovery was slowest among the patients assigned to bed rest . The overall costs of care did not differ significantly among the three groups . CONCLUSIONS Among patients with acute low back pain , continuing ordinary activities within the limits permitted by the pain leads to more rapid recovery than either bed rest or back-mobilizing exercises Study Design A prospect ively design ed study was performed to assess the influence of employment status and a compensation cl aim on patients experiencing low back pain . Objectives To determine the factor that most influences disability arising from low back pain , unemployment or a compensation cl aim . Summary of Background Data Two hundred sixtynine consecutive patients were assessed from a low back pain clinic . Methods Disability was assessed using the Oswestry Disability Score , and employment , and compensation status were recorded . Results Both unemployment and patients involved in compensation had higher disability scores . However , by controlling the data for employment and assessing only the compensation group it was found that those cl aim ing compensation , but still working had significantly less disability than those cl aim ing compensation who were unemployed . Conclusions Both unemployment and compensation cl aims influence disability , but employment status is the most important factor Study Design This prospect i ve , multicenter study was design ed to investigate the efficacy and outcome of spinal cord stimulation using a variety of clinical and psychosocial outcome measures . Data were collected before implantation and at regular intervals after implantation . This report focuses on 70 patients who had undergone 1 year of follow‐up treatment at the time of data analysis . Objectives To provide a more generalizable assessment of long‐term spinal cord stimulation outcome by comparing a variety of pain and functional/ quality ‐of‐life measures before and after management . This report details results after 1 year of stimulation . Summary of Background Data The historically diverse methods , patient selection criteria , and outcome measures reported in the spinal cord stimulation literature have made interpretation and comparison of results difficult . Although short‐term outcomes are generally consistent , long‐term outcomes of spinal cord stimulation , as determined by prospect i ve studies that assess multidimensional aspects of the pain complaint among a relatively homogeneous population , are not well established . Methods Two hundred nineteen patients were entered at six centers throughout the United States . All patients underwent a trial of stimulation before implant of the permanent system .  Most were psychologically screened . One hundred eighty‐two patients were implanted with a permanent stimulating system .  At the time of this report , complete 1‐year follow‐up data were available on 70 patients , 86 % of whom reported pain in the back or lower extremities . Patient evaluation of pain and functional levels was completed before implantation and 3 , 6 , 12 , and 24 months after implantation . Complications , medication usage , and work status also were monitored . Results All pain and quality ‐of‐life measures showed statistically significant improvement during the treatment year . These included the average pain visual analogue scale , the McGill Pain Question naire , the Oswestry Disability Question naire , the Sickness Impact Profile , and the Beck Depression Inventory . Overall success of the therapy was defined as at least 50 % pain relief and patient assessment of the procedure as fully or partially beneficial and worthwhile . Using this definition , spinal cord stimulation successfully managed pain in 55 % of patients on whom 1‐year follow‐up is available . Complications requiring surgical intervention were reported by 17 % ( 12 of 70 ) of patients . Medication usage and work status were not changed significantly . Conclusions This prospect i ve , multicenter study confirms that spinal cord stimulation can be an effective therapy for management of chronic low back and extremity pain . Significant improvements in many aspects of the pain condition were measured , and complications were minimal Abstract A new measure is presented , suitable for documenting severity and response to treatment in chronic low‐back pain syndromes . It is self‐administered and combines two pain and seven mobility items . These were selected from pre‐existing vali date d instruments on the basis of their sensitivity to change after treatment . Their Italian vali date d translation was adopted . The measure was administered to 32 chronic low‐back pain Italian patients , all refractory to previous conservative treatments . In most cases they presented with herniation or protrusion of 1–3 lumbar discs . Patients were treated with 3–6 sessions of autotraction over a 5‐ to 15‐day period . Scores on the scale were recorded at admission , discharge and follow‐up , 1–3 months after treatment . At discharge and at follow‐up , patients were asked if , overall , they felt improved , the same or worse . At follow‐up , 20 patients out of 32 reported overall improvement . Scalometric properties of the measure were tested using Rasch analysis . For admission and follow‐up , items followed a consistent hierarchical relationship along a unidimensional pain/disability variable , which is being called back illness . The items were not redundant , in that they spread well along a wide range of difficulty/severity . The hierarchy matched well with the expected expression of the conditions of the patients . A study was conducted on 34 chronic back pain patients , showing satisfactory test‐retest reliability . Depending on the various items , Cohen 's unweighted K ranged from 0.27 to 0.78 , with ten of the 11 items above the 0.45 level of acceptability , while intraclass correlation coefficients ranged from 0.42 to 0.89 . At follow‐up , changes in BACKILL of plus 15 % or more , with respect to admission , were consistent with patients ' reports of improvement in 19 out of 20 cases . Changes in BACKILL of less than 15 % were consistent with patients reports of being the same or worse in 11 out of 12 cases Intradevice reliability of isokinetic trunk strength measurements has been studied frequently , but no evidence is available on interdevice reliability . This motivated the present study , in which two isokinetic devices , the Ariel 5000 and Lido Multi-Joint II , were compared in a sample of 41 subjects ( 20 healthy and 21 low back pain subjects ) . The measurements were made in a r and om order with both machines . The results showed that the two isokinetic machines gave quite different results in trunk flexion-extension strength measurements . A statistically significant difference was present in the average peak torques between the two devices , with the exception of flexion at low angular velocity ( 60 degrees/s ) , and the correlations between the two measurements were low . The results were assumed to be more of a reflection of the interdevice variations ( hardware and software , attachment of the subject ) than of learning effects or other phenomena . We conclude that isokinetic trunk-muscle strength test results with the Ariel and Lido are device specific , and one can not automatically compare results obtained from different devices with each other This is the report of a feasibility study of a r and omised controlled trial of chiropractic and hospital outpatient management for low back pain of mechanical origin . Preparations for the study included an approach to the General Medical Council for guidance about the intended collaboration between medically qualified and heterodox practitioners , detailed communication with local general practitioners , and the provision of a Medical Research Council ( MRC ) grant to cover payments to the chiropractors for work carried out in the course of the study . A total of 238 patients were considered , 197 of whom had initially presented to Northwick Park Hospital and the remaining 41 to the chiropractic clinic in Harrow . Only 6 % of the patients presenting to the hospital refused to enter . The single most frequent reason for in eligibility in the hospital patients was freedom from pain at the time of the first hospital visit ( 23 % ) . A variety of medical contraindications accounted for the exclusion of a further 24 % of hospital patients . Patients presenting to the chiropractic group tended to have had shorter current episodes of back pain but to have had more NHS treatment in the past than those presenting to hospital . The commonest reason for exclusion among those presenting to the chiropractic clinic was refusal to enter ( 34 % ) . Only 5 % of the chiropractic patients were ineligible for medical reasons . Overall , 16 % of those presenting to hospital and 44 % of those presenting to the chiropractors were eligible and willing to enter the r and omised treatment phase of the study . Of the 50 patients who entered the treatment phase , all but seven completed treatment and the six weekly self-completed assessment s of progress . Patients whose current episodes had lasted less than a month progressed significantly more rapidly than those with longer current episodes . It is likely that sufficient numbers of patients with low back pain are prepared to take part in a formal r and omized controlled trial . The organization and working methods for such a trial appear to be feasible . A full scale multicentre trial should aim to include about 2000 patients In a prospect i ve study 122 patients with herniated lumbar disc pre-operatively completed psychological question naires .  Surgical outcome was evaluated 12 months post-operatively mainly by a composite clinical overall score ( COS ) , and by its separate elements . Anxiety ( HAD-A scale ) and psychosomatic symptoms ( MSPQ ) had predictive value : fewer symptoms favoured a satisfactory overall outcome , and vice versa . The HAD-A Scale had a predictive power of poor ( ppp ) and satisfactory ( pps ) outcome of 28 and 81 % , respectively . Correspondingly , for the MSPQ , the ppp and pps were 42 and 85 % . Anamnestic and biological variables ( including fibrinolytic variables : ECLT and PAI-1 ) predicted 20 % of the outcome . By adding all psychological variables the prediction increased only to 24 % , but the HAD-A Scale and the MSPQ were still significant . The results suggest that in order to further improve prediction of outcome , future studies should combine biological variables sensitive to the mental state of the patient , with psychometric assessment Abstract Objective : To compare the effectiveness over three years of chiropractic and hospital outpatient management for  low back pain .  Design : R and omised allocation of patients to chiropractic or hospital outpatient management . Setting : Chiropractic clinics and hospital outpatient departments within reasonable travelling distance of each other in 11 centres . Subjects : 741 men and women aged 18 - 64 years with low back pain in whom manipulation was not contraindicated . Outcome measures : Change in total Oswestry question naire score and in score for pain and patient satisfaction with allocated treatment . Results : According to total Oswestry scores improvement in all patients at three years was about 29 % more in those treated by chiropractors than in those treated by the hospitals . The beneficial effect of chiropractic on pain was particularly clear . Those treated by chiropractors had more further treatments for back pain after the completion of trial treatment . Among both those initially referred from chiropractors and from hospitals more rated chiropractic helpful at three years than hospital management . Conclusions : At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals Study Design . A r and omized , clinical trial was conducted in which patients with back/neck problems , visiting a general practitioner , were allocated to chiropractic or physiotherapy as primary management . Objectives . To compare outcome and costs of chiropractic and physiotherapy in managing patients with low back or neck pain . Summary of Background Data . Earlier studies on the treatment of back pain by spinal manipulation have shown inconsistent results . When a " new " strategy ‐chiropractic‐in the treatment of back pain was introduced in public health care in Sweden , there was a need to compare the effects and costs of chiropractic with the established physiotherapy . Methods . Three hundred twenty‐three patients aged 18 to 60 years who had no contraindications to manipulation and who had not been treated within the previous month were included in the study . Treatment was carried out at the discretion of the therapist . Outcome measures were primarily changes in pain intensity and general health , both assessed with visual analog scale and Oswestry pain disability question naire . Direct and indirect costs were measured . Results . For patients with low back or neck pain visiting the general practitioner in primary care , both chiropractic and physiotherapy as primary treatment reduced the symptoms . No difference in outcome or direct or indirect costs between the two groups could be seen , nor in subgroups defined as duration , history , or severity . Conclusions . The effectiveness and total costs of chiropractic or physiotherapy as primary treatment were similar to reach the same result after treatment and after 6 months
target: These data provide both validation and st and ards for other users and indicate the power of the instrument for detecting change in sample population s. CONCLUSIONS The  ODI  remains a valid and vigorous measure and has been a worthwhile outcome measure .
  The behavior of the instrument is incompletely understood , particularly in sensitivity to real change
background: STUDY DESIGN The Oswestry Disability Index ( ODI ) has become one of the principal condition-specific outcome measures used in the management of spinal disorders .
  This review is based on publications using the ODI identified from the authors ' personal data bases , the Science Citation Index , and h and search es of Spine and current textbooks of spinal disorders .
  OBJECTIVES To review the versions of this instrument , document methods by which it has been vali date d , collate data from scores found in normal and back pain population s , provide curves for power calculations in studies using the ODI , and maintain the ODI as a gold st and ard outcome measure .
  SUMMARY OF BACKGROUND DATA It has now been 20 years since its original publication .
  More than 200 citations exist in the Science Citation Index .