Are Measures of Function and Disability Important in

Low Back Care?

Currently, disablement due to low back syndrome (LBS) inflicts a n extremely high Anthony Delltto
cost to society, with yearly direct and indirect costs estimated in the billions of
dollars. Patients with LBS often present a challengefor physical therapists trained
in the evaluation of the physical nature of LBS. The psychosocial nature of a pa-
tient's complaint and the use of measures obtainedfrom evaluation to guide
patient management sometimes require interaction in a multidisciplinary envi-
ronment. In thb article, LBS will be discussed within the frameworks of Nagi's
disablement pathway and a n illness model described by Wadell. Both models
suggest that to adequately treat LBS requires evaluation of the impairment, func-
tional /imitations, and disability using tools with adequate measurement charac-
teristics. This article will focus o n impairments and patient self-reports of quality
of life and will discuss the relationship between impairments,functional limita-
tions, and disability in LBS. Standardized quality of life measures are easily ad-
minbtered in everyday clinical settings and capture the patient's perceptions of the
functional limitations and disability seen with LBS. Comnwn self-reports are re-
viewed, and potential bammersto their use are discussed. Lucking a n identzjiable
disease process in the majority of cases of LBS leaves most clinicians to deal with
the impairments,functional limitations, and resultant disability, Physical therapists
should, therefore, measure and gauge changes in all of these dimensions To
accomplish this, physical therapists must be willing to evaluate the dimensions of
functional limitations and disabilities using tools that allow adherence to the
same nzeasurement standards (eg, reliability and validity) as those used to evalu-
ate physical impairments. [DelittoA. Are measures of function and disability im-
portanf in low back care? Phys Ther. 1994;74:452462.]

Key Words: Backache; Disability evaluation; Tests and measurements,functional.

Low back syndrome (LBS) and the LBS account for the majority of visits Characterizing disablement associated
resulting disablement cost industrial- to orthopedists, neurosurgeons, and with LBS necessitates that the term
ized societies billions of dollars in occupational medicine physicians.5.6 "disability" be used in a consistent
direct and indirect health care,'-3 and With surgery less and less of an op- and defined manner. In the context of
the increased incidence of LBS from tion, the vast majority of patients with this special issue, disability is defined
the 1960s through the 1980s has been LBS are eventually directed toward as a restriction in a person's ability to
characterized as epidemic.4 For the conservative management, and evi- perform socially defined roles. Most
purposes of this article, low back dence suggests that such patients well-established LBS disability ratings,
syndrome is defined as pain, paresthe- comprise a high percentage of the including publications from the Amer-
sia, and related symptoms that are patients seen by physical therapists in ican Medical Association," the Ameri-
believed to emanate from the lumbar typical outpatient facilities.7.8 can Academy of Orthopedic Sur-
spine (this definition includes low geons,1° and the US Social Security
back pain and sciatica). Patients with Administration," rely almost entirely
on diagnoses based on pathology in
determining disability ratings. This is
in spite of the consensus that (1) the
A Delitto, PhD, FT,is Assistant Professor, Depanment of Physical Therapy, School of Health and
Rehabilit.ation Sciences, University of Pittsburgh, 101 Pennsylvania Hall, Pittsburgh, PA 15261 (USA). vast majority of patients with LBS are

Physical Therapy /Volume 74, Number Sway 1994 452 / 83

 DEOENERATNE
DISK DISEASE

ARTHRITIC
CONDITIONS
- ANA TOMICAf.
HERNIATED NUCLEUS
PULPOSUS

PHYSICAL
-
RANOE OF MOTIONIFLEXIBILITY
INABILITY TO PERFORM
ACTNlnES
OF DAILY W I N O
(eg, SITTING, STANDING)
FUNCTIONALCAPACITY
EVALUATION
INABILITY RlMlTAllON
IN PERFORMINO
OCCUPAllONAL
RESPONSIBILITIES

INABIUTYILIMITATDN
IN PERFROMINO
MUSCLE PERFORMANCE DESIRED SOCIAL
OSTEOPOROSIS INTERACTIONS
PSYCHOLOG/CAL DISEASE-SPECIFIC
PSYCHOSOCIALFACTORS QUESTIONNAIRE

0 0
"PARACLINICAL"
EVALUATION (eg, EVALUATION EVALUATION1
LABORATORY, PATIENT SELF- PATIENT SELF-
IMAGING) REPORT REPORT

Flgure 1. Nagi's conceptual scheme for disablement related to low back syndrome, with specifc examples immediately below
each stage of the model. The bottom portion of the figure represents the actual source of data.

without a diagnosis based on patholo-
gyt2and (2), even if present, diag-
noses based on pathology are only a
part of the disablement picture.13
Without a diagnosis to guide treat-
ment, many clinicians encourage
documentation of disablement from
the patient's perspective, relying on
patients' perceptions of their limita-
tions or diminished capacities for
everyday activities.
Clinical tools exist for characterizing
physical impairments, functional limi-
tations, and disability in patients with
LBS. Some of these tools administered
as pan of clinical examinations re-
quire active participation of health
professionals, whereas others are
self-administered (eg, patient self-
reports). In this article, measures of
impairment, functional limitations,
and disabilities specific to patients
with LBS are described. My approach
will be first to characterize disable-
ment due to LBS within the frame-
work of the pathology-driven Nagi
scheme and to offer an alternative
model. The physical therapist's role in
documenting the physical impair-
ments and functional limitations in
patients with LBS will then be dis-
cussed. Next, specific self-repons of
functional limitations and disabilities
will be compared and contrasted with
the outlined advantages and disadvan-
tages. Finally, potential "barriers" in
implementing such indexes will be
reviewed and suggestions to over-
come potential obstacles will be
offered.
Low Back Syndrome and
NaglJsConceptual Scheme
for Disablement
Whether the International Classifica-
tion of Impairments, Disabilities, and
Handicaps (ICIDH) or Nagi's disable-
ment scheme are assessed, both rep-
resent a traditional pathology-oriented
approach to disability, with the path
to handicap o r disability beginning
with disease or active pathology. The
Nagi disablement scheme is illustrated
with specific reference to LBS in Fig-
ure 1. A brief definition of each term
in the scheme follows:
Active pathology: interruption of nor-
mal processes coupled with the orga-
nism's inability to regain a normal
state, examples of which include in-
fection, trauma, metabolic imbalances,
and degenerative processes.
Impaimzent: a loss or abnormality of
an anatomical, physiological, mental,
or emotional nature.
Functional limitations: restrictions in
performance at the level of the indi-
vidual.
Disabilily: restriction in the person's
ability to perform socially defined
roles.

84 / 453 Physical Therapy /Volume 74, Number Sway 1994

Two important issues need to be
considered when placing LBS within
the framework of the Nagi disable-
ment scheme. First, the active disease
process in LBS continues to be ex-
tremely elusive. Second, although
physical findings are an extremely
important consideration, many studies
of LBS support the presence of a
strong nonphysical component (eg,
psychosocial), which, when present, is
indicative of multidisciplinary man-
agement. Each of these issues will be
covered in greater detail with respect
to its impact on the practicing physi-
cal thetapist.
Low Back Syndrome: The
Acthre Pathology
The increasing availability of sophisti-
cated imaging technology has allowed
diagnostic testing to become increas-
ingly se:nsitive to underlying spinal
patholc~gy,presumably leading to eas-
ier identification of the "active patholo-
gy" in Nagi's model. Identlfylng a caus-
ative pathology in LBS, however,
remains elusive. The most commonly
implica.ted structural abnormalities of
the spine involve some pathology of
the intervertebral disk; yet, pathology
of the disk is the cause of symptoms
in only a small percentage of patients
with LI3S.14 Structural abnormalities
may even be quite profound without
symptoms being present. For exam-
ple, Ettinger et all5 assessed the sever-
ity of spinal deformity ("wedge," "end
plate," and "crush) using radio-
graphic findings in 2,992 Caucasian
women 65 to 70 years of age and
found that even severe vertebral de-
formities account for only a small
portion of troublesome back pain.
Similar findings are obtained for pa-
thology related to intervertebral disk
height.l6In addition to a lack of posi-
tive predictive value, structural abnor-
malities of the disk commonly have
an unacceptably high negative predic-
tive value, with several examples of
studies in which unacceptably high
false positive rates of spinal deformi-
ties are documented as a result of
myel~graphy,'~ computer-assisted
tomography scanning,18 magnetic
resonance irnaging,l9f2Oand other
radiological testing meth0ds.21.2~
Physical Therapy/Volume 74, Number
Low Back Syndrome:
Physlcal Impairments
Of particular importance to physical
therapists are physical impairments
that may predispose a person to fu-
ture episodes of LBS or that may have
resulted from a present or previous
incident. In either case, intervention
by the physical therapist for deficits in
muscle performance, spinal mobility,
and other physical impairments could
conceivably have an effect on disable-
ment provided that a strong relation-
ship exists between physical impair-
ment and disablement. Strong
relationships between physical impair-
ment and disablement, however, are
not always the rule when patients
with LBS are evaluated.23 Waddell and
Main23concurrently assessed physical
impairment and disability and demon-
strated convincingly the potential for
disparity between physical impair-
ment and disability in patients with
LBS, especially those patients consid-
ered treatment "failures."
Whether or not psychological factors
are contributing to disablement, it is
generally agreed that measuring phys-
ical impairment in patients with LBS
is irnp0rtant.2~Physical impairments
in LBS have been studied under three
general designs: (1) longitudinal stud-
ies of subjects who are initially asymp-
tomatic in which the predictive ability
of physical impairments is evaluated,
(2) concurrent studies in which re-
sultant physical impairments are com-
pared with findings of other evalua-
tions (eg, disability) in groups who
are symptomatic, and (3) studies in
which the target of the intervention is
the physical impairments of subjects
with LBS.
Biering-Sorensen25measured a variety
of anthropometric, flexibility, and
muscle performance measures in over
900 subjects and followed them for a
1-year period. The author found that
the modified Schober test26 and a
strain-gauge test of isometric back
extensor endurance could be used to
differentiate men with first-time epi-
sodes of "back trouble" from men
who were free of back trouble.
Biering-Sorensen also found that
lower maximal voluntary force levels
in backward extension and longer
endurance times for back extension
could be used to differentiate women
with first-time episodes of back trou-
ble from women who were free of
back trouble. In both cases, however,
the discriminant function based on
the discriminant analysis of these tests
when applied to the groups studied
misclassified from 12.5% to 43% of
the patients.
Searching for possible physical im-
pairments that may predict future
back problems is especially important
in industrial and other work settings,
presumably because preventive mea-
sures can be taken that will decrease
the overall cost of LBS to industry.
Cady et aI2' found that a low fitness
level based on common physical
measures such as muscle perfor-
mance and cardiovascular endurance
could be combined using an elabo-
rate weighting procedure to predict
which fire fighters would experience
future back troubles. Battie and col-
league~~ studied
~ ~ ~ 9flexibility of the
lumbar spine and a maximal isomet-
ric lift test as possible predictors of
low back pain in an industrial setting
and concluded that both measures
have little predictive capability for
future back pain reports.
Waddell et a12*evaluated 23 physical
tests related to lumbar range of mo-
tion (ROM), spinal position (eg, lor-
dosis, kyphosis), and various other
lower-extremity strength and ROM
measures in two groups, one asymp-
tomatic and the other with chronic
LBS. Although their factor analysis
failed to demonstrate the dimension
of physical impairment, they found
that an "empirically" (nonscientifically
or not based on a data analysis) de-
rived combination of total flexion and
extension and lateral flexion (using
an inclinometer), spinal tenderness,
average straight leg raising (in de-
grees of hip flexion), bilateral active
straight leg raising (with the patient
positioned supine, holding both heels
and legs at least 15.2 cm (6 in] off the
table), and a sit-up test could be used
to differentiate between symptomatic
and asymptomatic groups and ex-
plained 25% of the variance of their
disability scores.
Attempts have been made to inter-
vene using treatments targeting physi-
cal impairments in primary and sec-
ondary prevention as well as
rehabilitation of patients with Ll3S.M An only to capture distinctly different
example of the latter was a series of
studies by Mayer and colleag~es,3~~3~ tests36 but also at times to better pre-
who evaluated "functional restoration,"
a treatment that includes "specific
exercises, training in functional tasks, prospective analysis has shown psy-
education, and work simulation and
work hardening" in addition to a psy-
chological intervention that included
pain management techniques, electro-
myographic biofeedback, and other
cognitive-behavioral approaches. They
found improvement in physical mea-
sures of flexibility and muscle perfor-
mance as well as a substantially higher
rate of return to work for persons who
participated in the program as com-
pared with those who did not. Some
investigators have reported similar
benefits with treatment programs
primarily designed to address physical
impairments in patients currently
worlung but with a recent (<6-week)
history of LBS that has caused them to
lose time at workP3 whereas others
have reported less favorable results in
programs with patients with chronic
low back pain (average 8 years'
duration).34
It appears that interventions designed
primarily to focus on physical impair-
ments have a tendency toward im-
proved outcome provided the patients
d o not have a substantial psychosocial
component to their LBS. Psychosocial
issues will be discussed next.
Low Back Syndrome: The
Psychosoclal Component
There is good evidence supporting
the fact that psychosocial and physical
impairments are important consider-
ations when evaluating and treating
the patient with LBS. Deyo and Tsui-
Wu35 found that educational and in-
come levels were better predictors of
"disability days" (days of activity limi- model can explain the various com-
tation, absence from work, confine-
ment to bed, or reduced housework)
than physical findings and prescribed
86 / 455
therapies. A variety of clinically ad-
ministered tests designed to identify
nonphysical components of the clini-
cal examination (eg, magnified illness
behavior, nonorganic factors, disability
exaggeration, psychological distress)
have been developed and shown not
information than traditional physical
dict outcome than physical vari-
ables.37-40 In addition, at least one
chosocial issues (eg, job satisfaction)
to better predict disabling injuries in
the workplace than physical measures
(eg, maximal lift capacity).41
Lack of Pathology and
Psychosoclal Component:
Impact on Nag1 Disablement
Model
The lack of an identifiable disease
process accurately accounting for
functional limitations and disability
has prompted some authors to char-
acterize LBS as "an illness in search of
a disease."" Such findings have led
some researchers to identify the
shortcomings of the traditional pathol-
ogy model and offer alternative mod-
els that are not necessarily pathology
d r i ~ e n . 4 3One
, ~ ~ model, proposed by
Waddell,43 emphasizes treating LBS as
a human illness (the total experience
of disease as perceived by the patient)
rather than as a disease (or active
pathology). He describes illness be-
havior as "the observable and poten-
tially measurable actions and conduct
which express and communicate the
individual's own perception of dis-
turbed health," and he encourages
clinicians treating patients with LBS to
focus on measuring physical severity,
psychological distress, illness behav-
ior, and social interactions.*3
How does an alternative model such
as that proposed by Waddell relate to
the Nagi disablement model? The
answer depends on how the model is
used to guide the management of
patients with LBS. Certainly, the Nagi
ponents of LBS, as Figure 1 depicts,
by offering examples of each compo-
nent of LBS as they relate to each
Physical Therapy/Volume 74, Number 5/May 1994
component of the model. Similarly,
specific examples of components of
Waddell's clinical model based on
illness can also find a place in the
Nagi model.
Attempting to use the Nagi model in
practice by strictly reading from left to
right, however, may on the surface
appear to have shortcomings, because
there are so few cases in which an
identifiable and accountable disease
process is found in patients with LBS.
By not identifying an "active patholo-
gy," those used to working within the
traditional pathology framework are
left with no specific management
guideline at perhaps the most crucial
point-the beginning.
Thus, two issues are brought forth
when active pathology and LBS are
considered: (1) We should not expect
much guidance from a diagnosis of
pathology (if present) with respect to
exactly what impairment, functional
limitation, or disability will result
from LBS, and (2) we should not
expect the lack of a diagnosis of pa-
thology to render a patient free from
an "organic" reason for any impair-
ments or functional limitations the
patient may present. For those work-
ing within the Nagi formulation, lack-
ing identifiable active pathology
leaves clinicians working within the
framework of the impairment, func-
tional limitation, and disability por-
tions of the model. Similarly, the
alternative model proposed by Wad-
dell was an attempt to move the clini-
cian away from concentrating exclu-
sively on disease and focus on the
need to treat the patient and his or
her illness.
The Case for Self-Reports In
Low Back Syndrome
Deyo and Patrick45 outline several
"theoretical advantages" that support
more broad use of patient self-reports
within the health care system, includ-
ing instances in which medical inter-
vention results in improved patient
outcome without concomitant im-
provement in disease status and, alter-
natively, instances in which disease
markers and subsequent changes in
them are not predictive of functional
limitations and patient outcome. Both
examples accurately depict the clinical
situation commonly seen in patients
with LBS, so it would seem that stan-
dardized self-reports could be most
useful and should be an integral part
of clinical settings in which patients
with LBS are examined and treated.
Patrick and D e y distinguish
~ ~ ~ be-
tween generic and disease-specific
indexes of health status. Generic
health status indexes are germane
when a clinician is seeking informa-
tion from a broad spectrum of sub-
scales that make up the construct
"quality of life" and that include infor-
mation from five major categories: (1)
duration of life, (2) impairments, (3)
functiclnal status, (4) perceptions, and
(5) social opportunities. Such sub-
scales include both physical and non-
physicd areas, so such scales would
seem to be applicable to some pa-
tients with LBS, especially those who
develop chronic LBP. Disease-specific
measures of health status are shorter
and tal-get-specific components of
quality of life and are used to assess
specific diagnostic groups. In general,
disease-specific indexes sacrifice com-
prehensiveness for better responsive-
ness (the ability to document clini-
cally important changes) and are most
useful in everyday patient care as well
as clinical trials.
Deyo4" has reviewed a number of
generic and disease-specific (eg, low
back pain specific) health status in-
dexes for potential use in LBS, and
some of the disease-specific indexes
are listed in detail in the Appendix. A
selected group of health status in-
dexes are covered next. My rationale
for the choice of indexes covered was
based on the following two criteria:
(1) that the index have good evidence
of reliability and (2) that the index
have at least some evidence of validity
or has been shown to be responsive
in clinical trials conducted with pa-
tients who have LBS. One generic
index and four disease-specific in-
dexes will be covered, and versions
of all of the disease-specific indexes
are included in the Appendix. Copy-
Physic:al Therapy /Volume 74, Number 5Nay 1994
right limitations prohibit the inclusion
of the generic index in the Appendix.
The Slckness Impact Proflle
Perhaps the most cited generic self-
report for LBS is the Sickness Impact
Profile (SIP). Originally attributed to
Bergner and colleagues,@the SIP has
become a well-established index used
in a number of studies involving pa-
tients with LBS, including studies
examining the treatment efficacy of
bed rest49 and transcutaneous electri-
cal nerve stimulation.50 The SIP is a
comprehensive self-report that in-
cludes information from 12 subscales
(ie, sleep and rest, eating, work,
home management, recreation and
pastimes, ambulation, mobility, body
care and movement, social interac-
tion, alertness behavior, emotional
behavior, and communication). There
is good evidence for the SIP'S validity
in LBS based on the psychosocial and
physical dimensions correlating with
specific scales of the Minnesota Mul-
tiphasic Personality Inventory (MMPI)
and a daily activity diary, respective-
ly.5l On the down side, the SIP in-
cludes over 100 items, takes 20 to 30
minutes to complete, and is some-
what cumbersome to score. By yield-
ing a total score that can be divided
into physical and psychosocial sub-
scores, however, the SIP can be an
extremely effective tool that can be
used both to direct treatment and to
document effectiveness, especially
when the target population includes
patients with a significant psychosocial
component to their LBS.
The Roland and Morrls
Dlsablllty lndex
Recognizing that administering the
entire SIP can be too time-consuming
in everyday clinical settings, Roland
and Morris52 derived a "disability
index" from 24 items on the SIP. By
adding the phrase "because of my
back" to each statement from the SIP,
their resultant index became truly
disease-specific (Appendix). No ratio-
nale for choosing the specific 24
items is offered. In addition, the Ro-
land and Morris Disability Index also
ignores the established scoring scale
of the SIP and instead each answer is
scaled simply 0 or 1, thus leaving a
range of scores of 0 to 24. A subse-
quent study by Deyo,53 however,
revealed that the overall score from
the Roland and Morris Disability In-
dex was comparable to and provided
as meaningful information as the
overall SIP score but failed to capture
a substantial component of the psy-
chosocial dimension of the SIP.
The Oswestry Low Back Paln
Questlonnalre
Another disease-specific index is the
Oswestry Low Back Disability Ques-
tionnaire, originally described by
Fairbanks et a15* and modified by
Hudson-Cook et a155 (Appendix). The
Oswestry questionnaire is an easily
administered self-report that results in
an index of a patient's perceived dis-
ability based on 10 areas of limitation
in performance (ie, pain intensity, the
changing status of pain, personal
hygiene, lifting, walking, sitting, stand-
ing, sleeping, social activity, and trav-
eling). Each section is scored on a
six-point scale (0-3, with 0 represent-
ing no limitation and 5 representing
maximal limitation. The subscales
combined add up to a total maximal
score of 50. The score is then dou-
bled and interpreted as a percentage
of the patient-perceived disability (the
higher the score, the greater the dis-
ability). The Oswestry index has been
used in treatment efficacy studies
involving manipulation and exercise
as well as correlational studies of
physical impairments and functional
limitations.
The Waddell and Maln
Dlsablllty lndex
For the generic and disease-specific
indexes discussed, disability is de-
fined as the inability or difficulty one
has in carrying out functional activi-
ties. A more stringent definition of
disability is used in the Waddell and
Main Disability Index, in which dis-
ability is defined as the inability to
carry out specific tasks without regard
to the degree of difficulty.36 These
tasks include heavy lifting (> 13.6 kg
[>30 Ib], a heavy suitcase, or a 3- to
4-year-old child), sitting for >30 min-
utes, traveling in a car or bus for >30
minutes, standing for >30 minutes,
walking for >30 minutes, sleep dis-
turbances more frequently than three
or four times per week, regularly
missing or curtailing social activities,
diminished frequency of sexual activ-
ity, and requiring help regularly with
donning and doffing footwear. Al-
though not published in self-report
form, a questionnaire was easily com-
posed by Rose et a156 from the cita-
tion and is included in the Appendix.
A positive response is recorded only
if the patient cannot perform the
activity, thus leaving no way to gauge
the difficulty the patient has in per-
forming the task. Only functional
limitations are included, and there is
no attempt to describe any psychoso-
cial dimension of the patient's
problem.
The Dallas Pain
Questionnaire
The Dallas Pain Questionnaire
(DPQ)S7 is a 16-item visual analog
tool that attempts to describe four
areas of disablement: (1) physical
activities of daily living, (2) work and
leisure activities, (3) anxiety and de-
pression, and (4) social interests. A
factor analysis of all components
showed factor loading on two major
components: "functional" and "emo-
tional." Concurrent validity for the
DPQ was established by correlating
the "functional" and "emotional"
scores to functional capacities (eg,
physical demand characteristics of
work) and MMPI scores, respectively.
In both cases, significant correlations
were obtained. The DPQ takes about
3 to 5 minutes to administer and
purportedly takes less than 2 minutes
to score.
Specific Uses for
Self-Reports of Health Status
in Low Back Syndrome
Management
There are two major reasons to use
self-reports in the everyday manage-
ment of patients with LBS: (1) to pro-
vide specific guidance with reference
to how to treat the patient and (2) to
provide a patient-oriented outcome
that should be reflective of important
changes in the patient's health status.
Thus, with regard to Nagi's disable-
ment scheme, self-reports of health
status can be used to provide infor-
mation about the areas of impairment
(both physical and psychosocial) and
functional limitations and to assist in
quantifying disabilities.
Regardless of the index used, the
score from a health status measure
can document the patient's perception
of the severity of the low back inci-
dent. Clearly, we develop treatment
strategies based on severity, with
patients in acute distress treated with
different approaches than those with
less acute low back pain or those with
chronic low back pain. Any high score
on any of the indexes covered within
this report can serve as an excellent
first approximation that the patient
perceives his or her condition to be
acute.
Although self-reports are susceptible
to bias, a biased high score can still
be useful to the clinician. By compar-
ing the score obtained from a self-
report with physical impairment
measures, the clinician can note dis-
parities. In patients whose perceived
disability is "out of proportion" with
their diagnosis, pain, and physical
impairment, Waddell and Main23 sug-
gest either psychological distress o r
voluntary exaggeration is likely the
cause. The physical therapist manag-
ing a patient with evidence of psycho-
logical distress should seek consulta-
tion from health care professionals
trained in managing such conditions.
Individual components of some in-
dexes can guide similar evaluation
and treatment approaches. In the case
of the SIP, for example, a physical
score and a psychosocial score are
obtained. In the case of the patient
with acute low back pain, one could
expect that the physical dimension
score will exceed the psychosocial
score, with the interpretation being
the patient's management strategy can
probably be predominantly physical
in nature (eg, addressing physical
impairments). Another patient, how-
Physical Therapy /Volume 74, Number 5/May 1994
ever, may score highly on the psycho-
social dimension of the SIP, in which
case nonphysical (eg, psychological)
evaluation and intervention may be
indicated.
In both cases described, follow-up
SIP scores can also be used as a
gauge of any therapeutic interven-
tion. Thus, the SIP can serve as a
tool for both guiding specific evalua-
tive treatment strategies and gauging
the outcome of any interventions.
The same uses can be outlined for
the disease-specific DPQ. Because of
its ability to measure both physical
and psychosocial dimensions of the
patient's health status, the DPQ
should be able to detect a psychoso-
cial component to the patient's over-
all pain complaint, and, because of
the precise scoring and documented
reliability, any change in score
should be truly reflective of a
change in the patient's condition.
In reviewing the instruments and
relating items to the Nagi formula-
tion, one can see that there is an
attempt at times to capture different
elements of the model. For exam-
ple, the Oswestry questionnaire,
although labeled a disability ques-
tionnaire, actually includes measures
of impairment (eg, pain), functional
limitations (eg, sitting, lifting, stand-
ing), and disability (eg, personal
care, sex life, traveling). In an at-
tempt to obtain a representative
index, one can make the argument
that mixing different elements of the
Nagi model in one index may con-
found any attempt to explain impair-
ments, functional limitations, and
disability using this particular index.
Impairments and the resultant hnc-
tional limitations provide an initial
approximation of a patient's ability to
manage most everyday situations. In
the final analysis, however, the rela-
tionship between the person's hnc-
tional limitations and his or her dis-
ability wdl be moderated by the i
patient's needs and desires in life (Fig.
2). For example, given a set of hnc-
tional limitations due to a back prob-
lem, a patient whose employment
duties require lifting or heavy material
 psychosocial component to his or her
LBS, the physical therapist has the
obligation to recognize that the psy-
POSITIVE MODERATORS chosocial component exists and to
seek consultation from health care
I INTRINSIC
PATIENT GOALS REQUIRE HlGH PHYSICAL DEMANDS providers who are trained to evaluate

1
and manage this component. The

- U(TRINSIC self-reports discussed can help in this

PREVALENT OCCUPATIONAL RISK FACTORS
JOB CHARACTERISTICS REQUIRE HlGH PHYSICAL
determination.
DEMANDS

I DISABILITY I This is not to say, however, that self-

reports should be used with every

I
I
INTRINSIC
PATIENT GOALS THAT DO NOT REQUIRE HtGH PHYSICAL
DEMANDS

EXTRINSIC
RELATNELY SEDENTARY JOB DEMANDS

NEGATIVE MODERATORS
Flgure 2. Positive and negative moderators of disablement.
handling will likely develop a greater
disability than another patient with
identical functional limitations but
whose job is essentially sedentary. In
both cases, however, quantifyrng the
functional limitations in a meaningful
fashion becomes an important compo-
nent in disability determination, and
health status measures are an excellent
tool for a first approximation.
Barrlers to the Use of Health
Status Indexes
Health status measures appear to be
in only limited use in physical therapy
departments. Deyo and Patrick58 cite
barriers specific to the clinical use of
self-reports, including conceptual/
attitudinal, methodological, and practi-
cal barriers. Of particular concern are
the corlceptual and attitudinal barri-
ers. Lik.e many health care profession-
als, phvsical therapists are not trained
in the methods and philosophy be-
hind the evolution of health status
measures. Such a lack of knowledge
often may lead physical therapists to
perceive information gained from a
health status questionnaire as "subjec-
tive" and not as worthy in the clinical
decision-making process as "hard"
measures related to physical impair-
ments. In our health care system,
physicians are trained to identify and
treat diseases (diagnose); thus, follow-
ing a traditional pathology model and
successfully treating a patient's disease
will eventually lead to return to de-
sired activity (eg, no disablement).
The physician trained and operating
strictly within the traditional pathol-
ogy model is closely paralleled by the
physical therapist trained and operat-
ing with a strong emphasis on using
physical impairments as a predomi-
nant source to guide as well as gauge
the success of treatment. In both
situations, if the disease process or
the physical impairment is closely
associated with patient outcome, then
it is reasonable to assume that im-
provement in the disease or an im-
provement in the physical impairment
should improve patient outcome.
Such is not always the case in LBS. At
times, the patient with LBS who has a
predominant physical component (eg,
acute low back sprain) can most likely
be managed primarily by the physical
therapist, and in most cases indepen-
dent of other health care profession-
als. In other cases, however, there
appears to be no question that the
physical impairment is only one com-
ponent of the resultant illness that
accompanies LBS. For the patient who
is seen by the physical therapist as the
primary caregiver and who has a
patient who has LBS. Some would
argue that too much time and energy
are needed to administer a self-report
to a patient whose clinical course is
likely to be short ( < 6 weeks) and
uncomplicated, with recovery likely to
take place regardless of the particular
intervention. The high cost of the
relatively few failures, however, cer-
tainly argues in favor of characterizing
impairments, functional limitations,
and disability resulting from LBS us-
ing well-established indexes that are
designed to be easily administered
and scored in clinical settings and not
relegating such information to the
meaningless drivel often seen in the
subjective portion of a problem-
oriented medical record (SOAP).
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1989;27:S254-S268.
Appendix. Examples of Disease-Specific Health Status Indexesa
- - - - - - -

WADDELL AND MAIN BACK QUESTIONNAIRE

- -
NAME PHONE
DATE TIME _ SUBJECT CODE
ADMINISTRATION # ORDER

YES NO
1. Do you require help or avoid heavy lifting (ie, 30-40 Ib, a heavy suitcase, or a 3- to 4-year-old child)?
2. Have you limited your sitting to less than 30 minutes?
3. Have! you limited traveling in a bus or car to less than 30 minutes?
4. Have! you limited standing in one place to less than 30 minutes?
5. Do you limit walking to less than 30 minutes?
6. Is your sleep disturbed regularly (ie, more than 2-3 times per week)?
7. Do you regularly miss or curtail social activities (excluding sports)?
8. Has your sexual activity diminished in frequency?
9. Do you regularly require help with footwear (ie, tights, socks, or tying laces)?

Restriction has to be since the onset of and because of low back pain. The common or usual effect is assessed, discounting occasional limitations or
special efforts.
-

RolandIMorris Disability Questionnaire

-
NAME - PHONE
DATE - TIME ~ SUBJECT CODE
ADMINISTRATION # ORDER
When your back hurts, you may find it difficult to do some of the things you normally do.
This list contains some sentences that people have used to describe themselves when they have back pain. When you read them, you may
find that some stand out because they describe you today. As you read the list, think of yourself today. When you read a sentence that
describes you today, put a check beside the number of the sentence. If the sentence does not describe you, then leave the space blank and
go on to the next one. Remember, only check the sentence if you are sure that it describes you today.
1. I stay at home most of the time because of my back.
-- 2. 1 change position frequently to try and get my back comfortable.
-- 3. 1 walk more slowly than usual because of my back.
-- 4. Because of my back, I am not doing any of the jobs that I usually do around the house.
-- 5. Because of my back, I use a handrail to get upstairs.
-- 6. Because of my back, I lie down to rest more often.
7. Because of my back, I have to hold onto something to get out of an easy chair.
8. Because of my back, I try to get other people to do things for me.
-- 9. 1 get dressed more slowly than usual because of my back.
- 10. 1 only stand up for short periods of time because of my back.
11. Because of my back, I try not to bend or kneel down.
-- 12. 1 find it difficult to get out of a chair because of my back.
13. My back is painful almost all the time.
14. 1 find it difficult to turn over in bed because of my back.
15. My appetite is not very good because of my back pain.
16. 1 have trouble putting on my socks (or stockings) because of the pain in my back.
- 17. 1 only walk short distances because of my back pain.
-- 18. 1 sleep less well because of my back.
-- 19. Because of my back pain, I get dressed with help from someone else.
- 20. 1 sit down for most of the day because of my back.
-- 21. 1 avoid heavy jobs around the house because of my back.
- 22. Because of my back pain, I am more irritable and bad tempered with people than usual.
-- 23. Because of my back, I go upstairs more slowly than usual.
24. 1 stay in bed most of the time because of my back.
(continued)

Physical Therapy/Volume 74, Number Sway 1994 460 / 91

Appendix. (Continued)
The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire Department for Spinal Disorders
NAME
DATE TIME .
ADMINISTRATION #
Please read:
This questionnaire has been designed to give the doctor ~nformationas to how your back pain has affected your ability to manage in everyday
life. Please answer every section, and mark in each section only the one box which applies to you. We realize you may consider that two of
the statements in any one section relate to you, but please just mark the box which most closely describes your problem.
Section 1 - Pain Intensity
I can tolerate the pain I have without having to use pain killers.
The pain is bad but I manage without taking pain killers.
Pain killers give complete relief from pain.
Pain killers give moderate relief from pain.
0 Pain killers give very little relief from pain.
Pain killers have no effect on the pain and I do not use them.
Section 2 - Personal Care (Washing, Dressing, etc.)
I can look after myself normally without causing extra pain.
I can look after myself normally but it causes extra pain.
It is painful to look after myself and I am slow and careful.
I need some help but manage most of my personal care.
o I need help every day in most aspects of self care.
I do not get dressed, wash with difficulty and stay in bed.
Section 3 - Lifting
I can lift heavy weights without extra pain.
I can lift heavy weights but it gives extra pain.
Pain prevents me from lifting heavy weights off the floor, but I
can manage if they are conveniently positioned, eg on a table.
I can lift only very light weights.
I cannot lift or carry anything at all.
Section 4 - Walking
Pain does not prevent me walking any distance.
Pain prevents me walking more than 1 mile.
Pain prevents me from walking more than '/2 mile.
Pain prevents me from walking more than l/4 mile.
o I can only walk using a cane or crutches.
o I am in bed most of the time and have to crawl to the toilet
Section 5 - Sitting
I can sit in any chair as long as I like.
I can only sit in my favorite chair as long as I like.
Pain prevents me sitting more than 1 hour.
Pain prevents me from sitting more than VZ hour.
Pain prevents me from sitting more than 10 minutes.
Pain prevents me from sitting at all.
I
PHONE
SUBJECT CODE
ORDER
Section 6 - Standing
I can stand as long as I want without extra pain.
I can stand as long as I want but it gives me extra pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 30 minutes.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.
Section 7 - Sleeping
Pain does not prevent me from sleeping well.
I can sleep well only by using tablets.
Even when I take pills, I have less than six hours sleep.
Even when I take pills, I have less than four hours sleep.
Even when I take pills, I have less than two hours sleep.
Pain prevents me from sleeping at all.
Section 8 - Sex Life
My sex life is normal and causes no extra pain.
My sex life is normal but causes some extra pain
My sex life is nearly normal but is very painful.
My sex life is severely restricted by pain.
My sex life is nearly absent because of pain.
Pain prevents any sex life at all.
Section 9 - Social Life
My social life is normal and gives me no extra pain.
o My social life is normal but increases the degree of pain.
Pain has no significant effect on my social life apart from limiting my
more energetic interests, eg dancing, etc.
Pain has restricted my social life and I do not go out as often.
Pain has restricted my social life to my home.
0 I have no social life because of pain.
Section 10 - Traveling
0 I can travel anywhere without extra pain.
I can travel anywhere but it gives me extra pain.
Pain is bad but I manage journeys over two hours.
Pain restricts me to journeys of less than one hour.
Pain restricts me to short necessary journeys under 30 minutes.
Pain prevents me from traveling except to the doctor or hospital.
(continued)
Physical Therapy /Volume 74, Number 5May 1994
Appendix. (Continued)

DALLAS PAIN QUESTIONNAIRE

Patient #
Name: - Today's Date:
Date of Birth: Examiner

Please read carefully: This questionnaire has been designed to give your doctor information as to how your pain has affected your life. Be sure
that these are your answers. Do not ask someone else to fill out the questionnaire for you. Please mark an "X" in the appropriate box that
expresses your thoughts from 1 to 100 in each section.
Section I: Pain and Intensity Section IX: Traveling
To what degree do you rely on pain medications or pain relieving How much does pain interfere with traveling in a car?
substances for you to be comfortable?
None Some All the time None, same as before Some I cannot travel

Section II: Personal Care Section X: Vocational

How muc:h does pain interfere with your personal care (getting out How much does pain interfere with your job?
of bed, teeth brushing, etc)? None, no interference Some I cannot work

r r I
None (nc pain) Some I cannot get out of bed
0% 100%
0 100%
Section XI: AnxietyIMood
Section Ill: Lifting How much control do you feel that you have over demands made
How much limitation do you notice in lifting? on you?
None (I can lift as I did) Some None (No change) Total Some None

Section I'V: Walking Section XII: Emotional Control

Compared with how far you could walk before your injury or back How much control do you feel that you have over your emotions?
trouble, how much does pain restrict your walking now? Total Some None
I can walk the same Almost the same Very little I cannot walk

0% [I] 100%
100%

Section XIII: De~ression

0%

Section V: Sitting How depressed have you been since the onset of pain?
Back pam limits my sitting in a chair to? Not depressed significantly Overwhelmed by depression
None, pain same as before Some I cannot sit at all
0% 100%

Section XIV: Interpersonal Relationships

Section 'JI: Standing How much do you think you pain had changed your relationships
How much does your pain interfere with your tolerance to stand for with others?
long periods? Not changed Drastically changed
None, same as before Some I cannot stand
0% 100%

Section XV: Social Support

Section VII: Sleeping How much support do you need from others to help you during this
How much does pain interfere with your sleeping? onset of pain (taking over chores, fixing meals, etc)?
None, same as before Some I cannot sleep at all None needed All the time

Section VIII: Social Life Section XVI: Punishing Responses

How much does pain interfere with your social life (dancing, games, How much do you think others express irritation, frustration, or anger
going out, eating with friends, etc)? toward you because of your pain?
None, same as before Some No activities total loss None Some All the time

aThe Roland/Morris Disability Questionnaire is adapted and reprinted with permission from Roland M, Moms R. A study of the natural history of back pain,
part I: the development of a reliable and sensitive measure of disability in low-back pain. Spine. 1983;8:141-144;the Oswestry Low Back Disability Question-
naire is reprinted with permission from Fairbanks JCT, Couper J, Davies JB, et al. The Oswestry Low Back Pain Disability Questionnaire. PhysioIherapy.
1980,66:2!71-273;the Dallas Pain Questionnaire is adapted and reprinted with permission from Lawlis GF, Cuencas R, Selby D, et al. The development of the
Dallas Pah Questionnaire: an assessment of the impact of spinal pain on behavior. Spine. 1989;14:512-515.