Abstract
Recovery is commonly used as an outcome measure in low back pain (LBP) research. There is, however, no accepted definition of what recovery involves or guidance as to how it should be measured. The objective of the study was designed to appraise the LBP literature from the last 10 years to review the methods used to measure recovery. The research design includes electronic searches of Medline, EMBASE, CINAHL, Cochrane database of clinical trials and PEDro from the beginning of 1999 to December 2008. All prospective studies of subjects with non-specific LBP that measured recovery as an outcome were included. The way in which recovery was measured was extracted and categorised according to the domain used to assess recovery. Eighty-two included studies used 66 different measures of recovery. Fifty-nine of the measures did not appear in more than one study. Seventeen measures used pain as a proxy for recovery, seven used disability or function and seventeen were based on a combination of two or more constructs. There were nine single-item recovery rating scales. Eleven studies used a global change scale that included an anchor of ‘completely recovered’. Three measures used return to work as the recovery criterion, two used time to insurance claim closure and six used physical performance. In conclusion, almost every study that measured recovery from LBP in the last 10 years did so differently. This lack of consistency makes interpretation and comparison of the LBP literature problematic. It is likely that the failure to use a standardised measure of recovery is due to the absence of an established definition, and highlights the need for such a definition in back pain research.
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References
Aletaha D, Landewe R, Karonitsch T, Bathon J, Boers M, Bombadier C, Bombadieri S, Choi H, Combe B, Dougados M, Emery P (2008) Reporting disease activity in clinical trials of patients with rheumatoid arthritis: EULAR/ACR collaborative recommendations. Arthritis Care Res 59:1371–1377
Bakhtiar CS, Suneetha S, Vijay R (2002) Conservative approaches benefit occupation-related backaches in milk-vendors and goldsmiths. Indian J Occup Environ Med 6:186–188
Balague F, Nordin M, Sheikhzadeh A, Echegoyen AC, Brisby H, Hoogewoud HM, Fredman P, Skovron ML (1999) Recovery of severe sciatica. Spine 24:2516–2524
Balague F, Nordin M, Sheikhzadeh A, Echegoyen AC, Skovron ML, Bech H, Chassot D, Helsen M (2001) Recovery of impaired muscle function in severe sciatica. Eur Spine J 10:242–249
Beaton DE, Tarasuk V, Katz JN, Wright JG, Bombadier C (2001) Are you better? A qualitative study of the meaning of recovery. Arthritis Care Res 45:270–279
Beauvais C, Wybier M, Chazerain P, Harboun M, Liote F, Roucoules J, Koeger AC, Bellaiche L, Orcel P, Bardin T, Ziza JM, Laredo JD (2003) Prognostic value of early computed tomography in radiculopathy due to lumbar intervertebral disk herniation: a prospective study. Joint Bone Spine 70:134–139
Bekkering G, Hendriks H, van Tulder MW, Knol D, Simmonds M, Oostendorp R, Bouter L (2005) Prognostic factors for low back pain in patients referred for physiotherapy: comparing outcomes and varying modeling techniques. Spine 30:1881–1886
Bernstein E, Carey TS, Garrett JM (2004) The use of muscle relaxant medications in acute low back pain. Spine 29:1346–1351
Beurskens AJ, de Vet HC, Koke AJ, Lindeman E, van der Heijden GJ, Regtop W, Knipschild PG (1999) A patient-specific approach for measuring functional status in low back pain. J Manipulative Physiol Ther 22:144–148
Borman P, Keskin D, Bodur H (2003) The efficacy of lumbar traction in the management of patients with low back pain. Rheumatol Int 23:82–86
Brotz D, Kuker W, Maschke E, Wick W, Dichgans J, Weller M (2003) A prospective trial of mechanical physiotherapy for lumbar disk prolapse. J Neurol 250:746–749
Burton AK, McClune TD, Clarke RD, Main CJ (2004) Long-term follow-up of patients with low back pain attending for manipulative care: Outcomes and predictors. Man Ther 9:30–35
Carey TS, Garrett JM (2003) The relation of race to outcomes and the use of health care services for acute low back pain. Spine 28:390–394
Cassidy JD, Carroll L, Coto P, Berglund A, Nygren A (2003) Low back pain after traffic collisions: a population-based cohort study. Spine 28:1002–1009
Cassidy JD, Cote P, Carroll LJ, Kristman V (2005) Incidence and course of low back pain episodes in the general population. Spine 30:2817–2823
Chen C, Hogg-Johnson S, Smith P (2007) The recovery patterns of back pain among workers with compensated occupational back injuries. Occup Environ Med 64:534–540
Collins DL, Evans JM, Grundy RH (2006) The efficiency of multiple impulse therapy for musculoskeletal complaints. J Manipulative Physiol Ther 29:162e1–162e9
Coste J, Lefrancois G, Guillemin F, Pouchot J (2004) Prognosis and quality of life in patients with acute low back pain: insights from a comprehensive inception cohort study. Arthritis Care Res 51:168–176
Curtis P, Carey TS, Evans P, Rowane MP, Garrett JM, Jackman A (2000) Training primary care physicians to give limited manual therapy for low back pain. Spine 25:2954–2961
Curtis P, Carey TS, Evans P, Rowane MP, Jackman A, Garrett J (2000) Training in back care to improve outcome and patient satisfaction. J Fam Prac 49:786–792
Davidson L, Lawless M, Leary F (2005) Concepts of recovery: competing or complementary. Curr Opin Psychiatr 18:664–667
Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R, Walker BF, Wyatt M, Cassidy JD, Rossignol M, Leboeuf-Yde C, Hartvigsen J, Lein-Arjas P, Latza U (2008) A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine 33:95–103
Dubourg G, Rozenberg S, Fautrel B, Valls-Bellec I, Bissery A, Lang T, Faillot T, Duplan B, Briancon D, Levy-Weil F, Morlock G, Crouzet J, Gatfosse M, Bonnet C, Houvenagel E, Hary S, Brocq O, Poiraudeau S, Beaudreuil J, De Sauverzac C, Durieux S, Levade MH, Esposito P, Maitrot D, Goupille P, Valat JP, Bourgeois P, Lurie JD (2002) A pilot study on the recovery from paresis after lumbar disc herniation. Spine 27:1426–1432
Dunn KM, Jordan K, Croft PR (2006) Characterizing the course of low back pain: a latent class analysis. Am J Epidemiol 163:754–761
Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JS, Jensen MP, Katz NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J, Cowan P (2005) Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 113:9–19
Elders LA, Burdorf A (2004) Prevalence, incidence, and recurrence of low back pain in scaffolders during a 3-year follow-up study. Spine 29:E101–E106
Ferguson SA, Marras WS, Gupta P (2000) Longitudinal quantitative measures of the natural course of low back pain recovery. Spine 25:1950–1956
Ferguson SA, Gupta P, Marras WS, Heaney C (2001) Predicting recovery using continuous low back pain outcome measures. Spine J 1:57–65
Ferguson SA, Marras WS (2004) Revised protocol for the kinematic assessment of impairment. Spine J 4:163–169
Ferreira M, Ferreira P, Latimer J, Herbert R, Hodges P, Jennings M, Maher C, Refshauge K (2007) Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain 131:31–37
Finneran MT, Mazanec D, Marsolais ME, Marsolais EB, Pease WS (2003) Large-array surface electromyography in low back pain: a pilot study. Spine 28:1447–1454
Gheldof ELM, Vinck J, Vlaeyen JWS, Hidding A, Crombez G (2007) Development of and recovery from short- and long-term low back pain in occupational settings: a prospective cohort study. Eur J Pain 11:841–854
Giles LGF, Muller R (2003) Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine 28:1490–1502
Gross DP, Battie MC (2005) Functional capacity evaluation performance does not predict sustained return to work in claimants with chronic back pain. J Occup Rehabil 15:285–294
Gross DP, Battie MC (2005) Work-related recovery expectations and the prognosis of chronic low back pain within a workers’ compensation setting. J Occup Environ Med 47:428–433
Grotle M, Brox JI, Veierod MB, Glomsrod B, Lonn JH, Vollestad NK (2005) Clinical course and prognostic factors in acute low back pain: patients consulting primary care for the first time. Spine 30:976–982
Grotle M, Brox JI, Glomsrod B, Lonn JH, Vollestad NK (2007) Prognostic factors in first-time care seekers due to acute low back pain. Eur J Pain 11:290–298
Guo W, Zhang H-J, Lin W-E (2005) Effect of different acupuncture therapies in improving functional disturbance of waist and limbs in patients with multiple lumbar disc herniation at different stages. 9:184–185
Hancock M, Maher C, Latimer J, McLachlan A, Cooper C, Day R, Spindler M, McAuley J (2007) Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet 370:1638–1643
Hancock MJ, Maher CG, Latimer J, Herbert RD, McAuley JH (2008) Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial. Eur Spine J 17:936–943
Hauer K, Lamb S, Jorstad E, Todd C, Becker C (2006) Systematic review of definitions and methods of measuring falls in randomised controlled fall prevention trials. Age Ageing 35:5–10
Helmhout PH, Harts CC, Viechtbauer W, Staal JB, de Bie RA (2008) Isolated lumbar extensor strengthening versus regular physical therapy in an army working population with nonacute low back pain: a randomized controlled trial. Arch Phys Med Rehabil 89:1675–1685
Heneweer H, Aufdemkampe G, Van Tulder MW, Kiers H, Stappaerts KH, Vanhees L (2007) Psychosocial variables in patients with (sub)acute low back pain: an inception cohort in primary care physical therapy in the Netherlands. Spine 32:586–592
Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH (2008) Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 337:154–157
Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH (2009) Prevalence of and screening for serious spinal pathology in patients presenting to primary care with acute low back pain. Arthritis Rheum 60:3072–3080
Heymans MW, De Vet HCW, Bongers PM, Knol DL, Koes BW, Van Mechelen W (2006) The effectiveness of high-intensity versus low-intensity back schools in an occupational setting: a pragmatic randomized controlled trial. Spine 31:1075–1082
Hides JA, Jull GA, Richardson CA (2001) Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 26:E243–E248
Hildebrandt V, Proper K, van den Berg R, Douwes M, van den Heuvel SG, van Bluren S (2000) Cesar therapy is temporarily more effective than a standard treatment from the general practitioner in patients with chronic aspecific lower back pain; randomized, controlled and blinded study with a I year follow-up. Ned Tidschr Geneesk 144:2258–2264
Hollisaz M (2006) Use of electroacupuncture for treatment of chronic sciatic pain. Internet J Pain Symptom Control Palliative Care 5
Huisstede BMA, Miedema HS, Verhagen AP, Koes BW, Verhaar JAN (2007) Multidisciplinary consensus on the terminology and classification of complaints of the arm, neck and/or shoulder. Occup Environ Med 64:313–319
Hush J, Refshauge K, Sullivan G, de Souza L, Maher C, McAuley J (2009) Recovery: what does this mean to patients with low back pain. Arthritis Care Res 61:124–131
Jans MP, de Korte EM, Heinrich J, Hildebrandt VH (2006) Intermittent follow-up treatment with Cesar exercise therapy in patients with subacute or chronic aspecific low back pain: results of a randomized, controlled trial with a 1.5-year follow-up. Ned Tijdschr Fysiother 116:111–116
Jellema P, van der Windt DAWM, van der Horst HE, Twisk JWR, Stalman WAB, Bouter LM (2005) Should treatment of (sub)acute low back pain be aimed at psychosocial prognostic factors? Cluster randomised clinical trial in general practice. BMJ 331:84
Jellema P, van der Horst HE, Vlaeyen JWS, Stalman WAB, Bouter LM, van der Windt DAW (2006) Predictors of outcome in patients with (sub)acute low back pain differ across treatment groups. Spine 31:1699–1705
Jellema P, Van Der Roer N, Van Der Windt DAWM, Van Tulder MW, Van Der Horst HE, Stalman WAB, Bouter LM (2007) Low back pain in general practice: cost-effectiveness of a minimal psychosocial intervention versus usual care. Eur Spine J 16:1812–1821
Jensen TS, Albert HB, Sorensen JS, Manniche C, Leboeuf-Yde C (2007) Magnetic resonance imaging findings as predictors of clinical outcome in patients with sciatica receiving active conservative treatment. J Manipulative Physiol Ther 30:98–108
Kamper SJ, Rebbeck TJ, Maher CG, McAuley JH, Sterling M (2008) Course and prognostic factors of whiplash: a systematic review and meta-analysis. Pain 138:617–629
Kelly M, Gamble C (2005) Exploring the concept of recovery in schizophrenia. J Psychiatr Mental Health Nurs 12:245–251
Lake JK, Power C, Cole TJ (2000) Back pain and obesity in the 1958 British birth cohort cause or effect? J Clin Epidemiol 53:245–250
Linton SJ, Boersma K (2003) Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Orebro Musculoskeletal Pain Questionnaire. Clin J Pain 19:80–86
Long A, Donelson R, Fung T (2004) Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine 29:2593–2602
Luijsterburg P, Verhagen A, Ostelo R, van den Hoogen HJ, Peul WC, Avezaat CJ, Koes BW (2008) Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur Spine J 17:509–517
Luijsterburg PA, Lamers LM, Verhagen AP, Ostelo RW, van den Hoogen HJ, Peul WC, Avezaat CJ, Koes BW (2007) Cost-effectiveness of physical therapy and general practitioner care for sciatica. Spine 32:1942–1948
Macfarlane GJ, Thomas E, Croft PR, Papageorgiou AC, Jayson MIV, Silman AJ (1999) Predictors of early improvement in low back pain amongst consulters to general practice: the influence of pre-morbid and episode-related factors. Pain 80:113–119
Malhotra S, Pandyan A, Jones P, Hermens H (2009) Spasticity, an impairment that is poorly defined and poorly measured. Clin Rehabil 23:651–658
McGuirk B, King W, Govind J, Lowry J, Bogduk N (2001) Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine 26:2615–2622
Mehling W, Hamel K, Acree M, Byl N, Hecht F (2005) Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Altern Ther Health Med 11:44–52
Mielenz TJ, Garrett JM, Carey TS (2008) Association of psychosocial work characteristics with low back pain outcomes. Spine 33:1270–1275
Mitchell R, Carmen G (1990) Results of a multicenter trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries. Spine 15:514–521
Naguszewski WK, Naguszewski RK, Gose EE (2001) Dermatomal somatosensory evoked potential demonstration of nerve root decompression after VAX-D therapy. Neurol Res 23:706–714
Niemisto L, Sarna S, Lahtinen-Suopanki T, Lindgren K, Hurri H (2004) Predictive factors for 1-year outcome of chronic low back pain following manipulation, stabilizing exercises, and physician consultation or physician consultation alone. J Rehabil Med 36:104–109
Norman GR, Stratford P, Regehr G (1997) Methodological problems in the retrospective computation of responsiveness to change: the lesson of Cronbach. J Clin Epidemiol 50:869–879
Oberg B, Enthoven P, Kjellman G, Skargren E (2003) Back pain in primary care: a prospective cohort study of clinical outcome and healthcare consumption. Adv Physiother 5:98–108
Ozturk B, Gunduz O, Ozoran K, Bostanoglu S (2006) Effect of continuous lumbar traction on the size of herniated disc material in lumbar disc herniation. Rheumatol Int 26:622–626
Papa L, Hoelle R, Idris A (2005) Systematic review of definitions for drowning incidents. Resuscitation 65:255–264
Pengel L, Refshauge K, Maher C, Nicholas M, Herbert R, McNair P (2007) Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial. Ann Intern Med 146:787–796
Peul WC, Brand R, Thomeer RTWM, Koes BW (2008) Influence of gender and other prognostic factors on outcome of sciatica. Pain 138:180–191
Rattanatharn R, Sanjaroensuttikul N, Anadirekkul P, Chaivisate R, Wannasetta W (2004) Effectiveness of lumbar traction with routine conservative treatment in acute herniated disc syndrome. J Med Assoc Thai 87:S272–S277
Reigo T, Tropp H, Timpka T (2000) Clinical findings in a population with back pain. Relation to one-year outcome and long-term sick leave. Scand J Prim Health Care 18:208–214
Roberts G, Wolfson P (2004) The rediscovery of recovery: open to all. Adv Psychiatr Treat 10:37–49
Schattenkirchner M, Milachowski KA (2003) A double-blind, multicentre, randomised clinical trial comparing the efficacy and tolerability of aceclofenac with diclofenac resinate in patients with acute low back pain. Clin Rheumatol 22:127–135
Schiottz-Christensen B, Nielsen GL, Hansen VK, Schodt T, Sorensen HT, Olesen F (1999) Long-term prognosis of acute low back pain in patients seen in general practice: a 1-year prospective follow-up study. Fam Prac 16:223–232
Skillgate E, Vingard E, Alfredsson L (2007) Naprapathic manual therapy or evidence-based care for back and neck pain: a randomized, controlled trial. Clin J Pain 23:431–439
Smeets R, Vlaeyen J, Hidding A, Kester A, van der Heijden GJ, van Geel AC, Knottnerus J (2006) Active rehabilitation for chronic low back pain: cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial. BMC Musculoskel Disorder 7:5
Smeets R, Beelen S, Goossens M, Schouten E, Knottnerus J, Vlaeyen J (2008) Treatment expectancy and credibility are associated with the outcome of both physical and cognitive–behavioral treatment in chronic low back pain. Clin J Pain 24:305–315
Smeets R, Vlaeyen J, Hidding A, Kester AD, van der Heijden GJ, Knottnerus JA (2008) Chronic low back pain: physical training, graded activity with problem solving training, or both? The one-year post-treatment results of a randomized controlled trial. Pain 134:263–276
Smith BH, Elliott AM, Hannaford PC, Chambers WA, Smith WC (2004) Factors related to the onset and persistence of chronic back pain in the community: results from a general population follow-up study. Spine 29:1032–1040
Soer R, van der Schans CP, Groothoff JW, Geertzen JHB, Reneman MF (2008) Towards consensus in operational definitions in functional capacity evaluation: a Delphi survey. J Occup Rehabil 18:389–400
Sonke G, Verbeek A, Kiemeney L (2009) A philosophical perspective supports the need for patient-outcome studies in diagnostic test evaluation. J Clin Epidemiol 62:58–61
Stanton TR, Henschke N, Maher CG, Refshauge KM, Latimer J, McAuley JH (2008) After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought. Spine 33:2923–2928
Steenstra IA, Anema JR, Bongers PM, de Vet HC, Knol DL, van Mechelen W (2006) The effectiveness of graded activity for low back pain in occupational healthcare. Occup Environ Med 63:718–725
Stig L, Nilsson O, Leboeuf-Yde C (2001) Recovery pattern of patients treated with chiropractic spinal manipulative therapy for long-lasting or recurrent low back pain. J Manipulative Physiol Ther 24:288–291
Tubach F, Beaute J, Leclerc A (2004) Natural history and prognostic indicators of sciatica. J Clin Epidemiol 57:174–179
Turk DC, Dworkin RH, Revicki D, Harding G, Burke LB, Cella D, Cleeland CS, Cowan P, Farrar JT, Hertz S, Max MB, Rappaport BA (2008) Identifying important outcome domains for chronic pain clinical trials: an IMMPACT survey or people with pain. Pain 137:276–285
Unlu Z, Tasci S, Tarhan S, Pabuscu Y, Islak S (2008) Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniation measured by clinical evaluation and magnetic resonance imaging. J Manipulative Physiol Ther 31:191–198
van der Roer N, Ostelo RWJ, Bekkering GE, van Tulder MW, de Vet HCW (2006) Minimal clinically important change for pain intensity, functional status, and general health status in patients with nonspecific low back pain. Spine 31:578–582
van der Roer N, van Tulder M, van Mechelen W, de Vet H (2008) Economic evaluation of an intensive group training protocol compared with usual care physiotherapy in patients with chronic low back pain. Spine 33:445–451
Van Der Roer N, Van Tulder M, Barendse J, Knol D, Van Mechelen W, De Vet H (2008) Intensive group training protocol versus guideline physiotherapy for patients with chronic low back pain: a randomised controlled trial. Eur Spine J 17:1193–1200
Vingard E, Mortimer M, Wiktorin C, Pernold G, Fredriksson K, Nemeth G, Alfredsson L (2002) Seeking care for low back pain in the general population. A two-year follow-up study: results from the MUSIC-Norrtalje study. Spine 27:2159–2165
Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA (1999) Lack of effectiveness of bed rest for sciatica. N Engl J Med 340:418–423
Waxman R, Tennant A, Helliwell P (2000) A prospective follow-up study of low back pain in the community. Spine 25:2085–2090
Whitman J, Flynn T, Childs J, Wainner R, Gill H, Ryder M, Garber M, Bennett A, Fritz J (2006) A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 31:2541–2549
Yeomans N, Naesdal J (2008) Systematic review: ulcer definition in NSAID ulcer prevention trials. Aliment Pharmacol Ther 27:465–472
Yip Y, Tse S (2004) The effectiveness of relaxation acupoint stimulation and acupressure with aromatic lavender essential oil for non-specific low back pain in Hong Kong: a randomised controlled trial. Complement Ther Med 12:28–37
Yip Y, Tse H, Wu K (2007) An experimental study comparing the effects of combined transcutaneous acupoint electrical stimulation and electromagnetic millimeter waves for spinal pain in Hong Kong. Complement Ther Clin Prac 13:4–14
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The authors would like to thank those that assisted with translation of the non-English language articles: Prof Rob Smeets, Ms Luciana Macedo, Dr Leo Costa, Dr Christine Lin and Mr Fred Zmudski. SJK’s scholarship and CGM’s fellowship are funded by the National Health and Medical Research Council of Australia, TRS’s scholarship is funded by the University of Sydney.
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Kamper, S.J., Stanton, T.R., Williams, C.M. et al. How is recovery from low back pain measured? A systematic review of the literature. Eur Spine J 20, 9–18 (2011). https://doi.org/10.1007/s00586-010-1477-8
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DOI: https://doi.org/10.1007/s00586-010-1477-8