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 databases, the Science Citation Index, and hand searches of Spine and current textbooks of spinal disorders. Objectives To review the versions of this instrument, document methods by which it has been validated, collate data from scores found in normal and back pain populations, provide curves for power calculations in studies using the ODI, and maintain the ODI as a gold standard 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. The authors have a large correspondence file relating to the ODI, that is cited in most of the large textbooks related to spinal disorders. Methods All the published versions of the questionnaire were identified. A systematic review of this literature was made. The various reports of validation were collated and related to a version. Results Four versions of the ODI are available in English and nine in other languages. Some published versions contain misprints, and many omit the scoring system. At least 114 studies contain usable data. These data provide both validation and standards for other users and indicate the power of the instrument for detecting change in sample populations. Conclusions The ODI remains a valid and vigorous measure and has been a worthwhile outcome measure. The process of using the ODI is reviewed and should be the subject of further research. The receiver operating characteristics should be explored in a population with higher self-report disabilities. The behavior of the instrument is incompletely understood, particularly in sensitivity to real change.

https://womenshealthapta.org/wp-content/uploads/2013/12/oswestry-fairbanks.pdf

The Oswestry Disability Index.

Non-specific low back pain

Condition-specific health status measures are commonly used as outcome measures in clinical trials and to assess patient progress in routine clinical practice. The expert panel that met to discuss this special issue of Spine recommended that, when possible, a condition-specific measure for back pain should be chosen from two widely used measures, the Roland–Morris Disability Questionnaire (RDQ) or the Oswestry Disability Index (ODI). These two measures have been used in a wide variety of situations over many years, and each is available in a number of languages. In this article, the authors describe these two instruments and provide evidence of their validity and reliability and some comparative results obtained with the use of the two questionnaires. The instruments themselves are included in the appendixes. When used in the forms reproduced in the appendixes, no permission is required from the authors or from Spine. Other back pain–specific health status measures are described by Kopec elsewhere in this edition of Spine.

The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire.

Background
Exercise therapy is widely used as an intervention in low-back pain.

Objectives
To evaluate the effectiveness of exercise therapy in adult non-specific acute, subacute and chronic low-back pain versus no treatment and other conservative treatments.

Search methods
The Cochrane Central Register of Controlled Trials (Issue 3, 2004), MEDLINE, EMBASE, PsychInfo, CINAHL databases to October 2004; citation searches and bibliographic reviews of previous systematic reviews.

Selection criteria
Randomized controlled trials evaluating exercise therapy for adult non-specific low-back pain and measuring pain, function, return-to-work/absenteeism, and/or global improvement outcomes.

Data collection and analysis
Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short, intermediate, and long-term follow-up.

Main results
Sixty-one randomized controlled trials (6390 participants) met inclusion criteria: acute (11), subacute (6) and chronic (43) low-back pain (1 unclear). Evidence was found of effectiveness in chronic populations relative to comparisons at all follow-up periods; pooled mean improvement was 7.3 points (95% CI, 3.7 to 10.9) for pain (out of 100), 2.5 points (1.0 to 3.9) for function (out of 100) at earliest follow-up. In studies investigating patients (i.e. presenting to healthcare providers) mean improvement was 13.3 points (5.5 to 21.1) for pain, 6.9 (2.2 to 11.7) for function, representing significantly greater improvement over studies where participants included those recruited from a general population (e.g. with advertisements). There is some evidence of effectiveness of graded-activity exercise program in subacute low-back pain in occupational settings, though the evidence for other types of exercise therapy in other populations is inconsistent. There was evidence of equal effectiveness relative to comparisons in acute populations [pain: 0.03 points (95% CI, -1.3 to 1.4)].

Limitations: This review largely reflects limitations of the literature, including low quality studies with heterogeneous outcome measures, inconsistent and poor reporting, and possibility of publication bias.

Authors' conclusions
Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

Exercise therapy for treatment of non-specific low back pain.

This systematic review found that 2 features of exercise therapy for chronic nonspecific low back pain seem to be responsible for success: close supervision and an individually designed program.

/pdf/systematic-review-strategies-for-using-exercise-therapy-to-10cpdv9r0w.pdf

Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain

Study design A multicenter, randomized, single-blinded controlled trial with 1-year follow-up. Objectives To evaluate the efficiency of progressively graded 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 randomly 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, resulting in longer periods of sick leave.

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.

STUDY DESIGN In a prospective cohort study 532 patients with rheumatoid arthritis (RA) and subluxations of the cervical spine were consecutively collected during 1974-1999. OBJECTIVE The aims of the study were to assess important factors affecting the mortality rate and the timing of surgical intervention. SUMMARY OF BACKGROUND DATA The average follow-up time from the first visit to death or to the end of the study was 8.5 (SD, 5.7) years. Of the 217 operated patients 144 (66%) died, and of the 315 nonoperated patients 137 (43%) died. METHODS Patients were selected for operative intervention based on anterior, vertical and subaxial subluxations, pain, and/or cervical neurology. Survival analyses were used for comparisons between patients with RA and the normal population, and between the operated and those treated conservatively. RESULTS The survival rate for all RA patients was significantly reduced when compared with average survival in Norway (P < 0.001). The operated group had a significantly lower survival rate than the nonoperated group. In patients with severe instability of the cervical spine, the defined selection criteria for surgical intervention were specific. By comparison of calculated propensity scores, the operated and nonoperated groups were too different to be directly comparable. After surgery only 11 patients (5%) experienced residual pain in the neck or neurologic symptoms. None of these patients were alive at the end of the study, signifying that residual pain or neurologic symptoms are poor prognostic signs (P = 0.015). In the operated group, anterior subluxation and vertical settling greater than the lower indication limits did not have a significant influence on the survival rate, but there was a reduced survival for patients with subaxial subluxations. A clear association was found between increased vertical settling and sudden death. CONCLUSION RA with neck involvement is a progressive and serious condition with reduced lifetime expectancy. Hence, our interpretation is that operative intervention improves local symptoms and most likely changes the condition from worse to better by increasing lifetime expectancy in high risk patients. Since the per- and postoperative complications are few, a changed attitude toward more liberal indications for earlier surgery may reduce the symptoms and the mortality rate even more.

Petter Mowinckel

Papers

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.

High mortality rate in rheumatoid arthritis with subluxation of the cervical spine: a cohort study of operated and nonoperated patients.