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Low back pain disability following lumbar intervertebral fusion Wilfling, Francis Joseph 1973

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LOW BACK PAIN D I S A B I L I T Y FOLLOWING LUMBAR INTERVERTEBRAL FUSION by F r a n c i s J o s e p h W i l f l i n g B . A . U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1970 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n t h e Depa r tmen t of PSYCHOLOGY We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA J U L Y , 1973 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C olumbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p urposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f The U n i v e r s i t y o f B r i t i s h Columbia Vancouver 8, Canada Date O u t / 3> , j9 ^ 3 i i A b s t r a c t Low b a c k p a i n (LBP) d i s a b i l i t y i s a n e x t r e m e l y common and i m -m e n s e l y e x p e n s i v e p r o b l e m w h i c h i s o f t e n r e f r a c t o r y t o s u r g i c a l t r e a t m e n t . Though many o r g a n i c , p s y c h o l o g i c a l and d e m o g r a p h i c f a c t o r s have b e e n s u g g e s t e d i n t h e l i t e r a t u r e t o c o n t r i b u t e t o t h i s p r o b l e m , t he c o n t r i b u t i o n s o f few o f t h o s e f a c t o r s have b e e n e s t a b l i s h e d i n a s t a t i s t i c a l l y r i g o r o u s manner . The p r e s e n t s t u d y sough t t o c l a r i f y t h e LBP d i s a b i l i t y p r o b l e m by c o m p r e h e n s i v e l y and r i g o r o u s l y s t u d y i n g 100 p o s t - l u m b a r - s p i n a l - f u s i o n s u b j e c t s w i t h t h e g o a l s o f f i n d i n g new p a t i e n t - m a n a g e m e n t i n s i g h t s and d e v e l o p i n g a f o u n d a t i o n on w h i c h f u t u r e s t u d i e s c o u l d be b a s e d . A d i s a b i l i t y i n d e x was f a c t o r - a n a l y t i c a l l y d e r i v e d f r o m m e a s u r e s o f f u n c t i o n a l . i m p a i r m e n t and was u s e d f o r c o m p a r i s o n w i t h a l a r g e number o f o r t h o p a e d i c , r a d i o l o g i c a l , p s y c h o l o g i c a l and d e m o g r a p h i c v a r i a b l e s documented d u r i n g t h e i n v e s t i g a t i o n . Of a l a r g e r number o f v a r i a b l e s d o c u m e n t e d , 239 we re compared w i t h t h e d i s a b i l i t y i n d e x and 58 s t a t i s t i c a l l y s i g n i f i c a n t (p < . 01 ) c o r r e l a t e s o f LBP d i s a b i l i t y we re f o u n d . I n s p e c t i o n of a c o r r e l a t i o n m a t r i x o f t h e s e 58 c o r r e l a t e s i n d i c a t e d t h a t many o v e r l a p s i n measurement o c c u r be tween what a r e somet imes t h o u g h t o f as " p u r e l y o r g a n i c " and " p u r e l y p s y c h o l o g i c a l " m e a s u r e s . To c l a r i f y what t h e b a s i c d i m e n s i o n s u n d e r l y i n g t he c o r r e l a t e s o f LBP d i s a b i l i t y a r e , t he c o r r e l a t e s we re f a c t o r a n a l y z e d . S e v e n t e e n o r t h o g o n a l f a c t o r s were d e r i v e d i n t h i s f a c t o r a n a l y s i s and t h e c o n t r i -b u t i o n o f e a c h o f them t o LBP d i s a b i l i t y was a s c e r t a i n e d by e x a m i n i n g i i i the square of the c o r r e l a t i o n c o e f f i c i e n t between the f a c t o r scores on each and the d i s a b i l i t y index. I t was found that the 17 f a c t o r s ac-counted f o r n e a r l y 90% of the d i s a b i l i t y v a r i a n c e , and that e i g h t of these 17 f a c t o r s were s i g n i f i c a n t l y r e l a t e d t o , and accounted f o r n e a r l y 80% of the va r i a n c e on, the d i s a b i l i t y index. Three or p o s s i b l y four of the eight s i g n i f i c a n t f a c t o r s , or b a s i c dimensions of LBP d i s a b i l i t y , were found to be p s y c h o l o g i c a l i n nature. The c l a r i f i c a t i o n of the LBP d i s a b i l i t y problem r e s u l t i n g from i d e n t i f i c a t i o n of e i g h t independent b a s i c dimensions of LBP d i s a b i l i t y , and c o n f i r m a t i o n of the s u b s t a n t i a l r o l e played by p s y c h o l o g i c a l f a c t o r s , has many important r a m i f i c a t i o n s . The importance of t r e a t i n g the whole man r a t h e r than j u s t h i s back i s obvious as i s a probable cause f o r the high f a i l u r e r a t e s of surgery when used alone. P a t i e n t p r o f i l e s on the ei g h t b a s i c dimensions of LBP d i s a b i l i t y were s t a t i s t i c a l l y grouped on the b a s i s of p r o f i l e s i m i l a r i t y and four n a t u r a l l y o c c u r r i n g groups of p r o f i l e s , or "Syndrome Complexes," were found. I t was concluded that i n each Syndrome Complex d e f i c i t s occur f o r which a p s y c h o l o g i s t could be of help i n dia g n o s i s and treatment. S u i t a b l e techniques f o r diagno-s i s and treatment, which could be implemented on an orthopaedic ward at minimal a d d i t i o n a l c o s t , are p r e s e n t l y a v a i l a b l e . These techniques are discussed u s i n g the eigh t b a s i c dimensions of LBP d i s a b i l i t y as a frame of reference. D i r e c t i o n s f o r f u t u r e research f o l l o w r a t h e r d i r e c t l y from the c l a r i f i c a t i o n of the LBP d i s a b i l i t y problem by the present study. The s p e c i f i c s of planned f u t u r e s t u d i e s are b r i e f l y o u t l i n e d . iv Table of Contents Page Abstract . i i List of Tables v i i List of Figures . . . . v i i i Acknowledgements ix Introduction 1 Magnitude of the Low Back Pain Problem . . . 1 Medical Aspects of Low Back Pain 5 Introduction 5 Anatomy of the Lumbar Spine 6 Pathology of Low Back Pain 11 Diagnostic Procedures 13 Treatment of Low Back Pain 15 Natural History of Low Back Pain 18 Problems in Management of Low Back Pain 20 Disability Evaluation and Results of Operative Treatment of Low Back Pain 24 Psychological Aspects of Low Back Pain 29 Context and Goals of the Present Study 39 Method . . . . . . 44 Investigators 44 Subjects 44 Measures 45 Materials 48 Procedure . . . 50 Data A n a l y s i s 53 S c o r i n g 53 P r e p a r a t i o n of Data f o r A n a l y s i s 55 D e r i v a t i o n of the D i s a b i l i t y I n dex 56 C o r r e l a t e s of D i s a b i l i t y * 58 O v e r l a p s i n Measurement Among O r t h o p a e d i c and P s y c h o l o g i c a l V a r i a b l e s . . ., 58 D e r i v a t i o n o f t h e B a s i c D i mensions o f D i s a b i l i t y . . 58 Syndrome Complex Groups 61 R e s u l t s , 62 Overview of S u b j e c t C h a r a c t e r i s t i c s 62 D e r i v a t i o n of t h e D i s a b i l i t y I n dex 66 C o r r e l a t e s o f D i s a b i l i t y 68 O v e r l a p s i n Measurement Among P s y c h o l o g i c a l and O r t h o p a e d i c V a r i a b l e s 73 D e r i v a t i o n o f t h e B a s i c D i mensions o f D i s a b i l i t y . . 75 Syndrome Complex Groups 84 D i s c u s s i o n 87 E f f e c t s of S a m p l i n g 87 A p p r o p r i a t e n e s s of t h e Methods of Study 88 A d d i t i o n a l S c o u r c e s of D i s a b i l i t y V a r i a n c e 89 Overview of S u b j e c t C h a r a c t e r i s t i c s 91 D e r i v a t i o n o f t h e D i s a b i l i t y I n dex 92 C o r r e l a t e s of D i s a b i l i t y 93 O v e r l a p s i n Measurement Among O r t h o p a e d i c and P s y c h o l o g i c a l V a r i a b l e s 94 v i Page D e r i v a t i o n o f t h e B a s i c D imensions of D i s a b i l i t y . . . 95 Syndrome Complex Groups 97 C h o i c e o f Measures b e s t used t o Document t h e E i g h t B a s i c D imensions of D i s a b i l i t y 104 D i r e c t i o n s f o r F u r t h e r Study 110 B i b l i o g r a p h y . 118 A p p e n d i c e s 133 A. K i l p a t r i c k C a n t r i l S e l f - A n c h o r i n g S c a l e 134 B. C o l d T o l e r a n c e T e s t 138 C. O r t h o p a e d i c D o c u m e n t a t i o n Forms 141 D. P s y c h o l o g i c a l D o cumentation Forms 177 E. A l l D o c u m e n t a t i o n Forms Showing V a r i a b l e Code-Names, D a t a R e - c o m b i n a t i o n s , and L e v e l s of D a t a A n a l y s e s 186 v i i L i s t of Tables Page Table 1 S t a t i s t i c s Used by the UBC C0RR Computer Program 59 Table 2 Derivation of the D i s a b i l i t y Index 67 Table 3 58 Correlates of D i s a b i l i t y 69 Table 4 Overlaps i n Measurement Among Orthopaedic and Psychological Variables 74 Table 5 Factor Matrix of 55 Correlates of D i s a b i l i t y . . 76 Table 6 Correlations between Success and the Orthogonal Factors Underlying the Correlates of D i s a b i l i t y 78 v i i i L i s t o f F i g u r e s Page F i g u r e 1 S u p e r i o r and L a t e r a l V i e w s o f a Lumbar V e r t e b r a il, F i g u r e 2 A r t i c u l a t i o n of Two Lumbar V e r t e b r a e 8 F i g u r e 3 L a t e r a l V i e w o f Lumbar S p i n e and Sacrum . . . 9 F i g u r e 4 P o s t e r i o r V i e w o f Lumbar S p i n e and Sacrum . . 10 F i g u r e 5 F l o w - C h a r t o f S t e p s t a k e n i n D a t a A n a l y s i s . . 57 F i g u r e 6 Mean P r o f i l e s of Syndrome Comp lexes 85 i x Acknowledgements I am indebted to many i n d i v i d u a l s and i n s t i t u t i o n s f o r assistance, advice and emotional support given during t h i s lengthy and often t r y i n g study. Without that help my work c e r t a i n l y would not have been possible. To a l l that have helped me I express my sincere thanks; the few l i s t e d a l p h a b e t i c a l l y below have made contributions which are of magnitudes beyond my a b i l i t y to f u l l y evaluate or d i f f e r e n t i a t e : Department of Veteran's A f f a i r s : f o r providing f a c i l i t i e s and services at Shaughnessy Hospital so that the i n v e s t i g a t i o n could be conducted. Dr. G.J. Johnson: for a l l that being a thesis advisor e n t a i l s . Dr. H. Klonoff: f o r f i r s t exposing me to the low back pain problem, and for guiding, prodding and supporting me throughout my f i r s t study. Dr. P.J. Kokan: f o r supervision and advice throughout the present study. Dr. C. Marx: f or a l l that being a thesis advisor e n t a i l s . Mrs. J. W i l f l i n g : f o r endless proofreading and for remaining my wife during my countless cyclothymic cycles p r e c i p i t a t e d by t h i s work. Dr. P.C. Wing: for being my f r i e n d and co-investigator and for stimulating a major portion of my i n t e l l e c t u a l and pr o f e s s i o n a l growth. Workmen's Compensation Board of B r i t i s h Columbia and the B r i t i s h Columbia Medical Foundation: f o r subjects and f i n a n c i a l support. I n t r o d u c t i o n M a g n i t u d e o f t h e Low B a c k P a i n P r o b l e m The m a g n i t u d e o f t h e p r o b l e m o f l o w b a c k p a i n ( L B P ) i s s t a g g e r i n g . H u l t (1954) , i n a samp le o f some 1200 w o r k i n g m a l e s b e t w e e n t h e ages o f 2 5 - 5 9 y e a r s , f o u n d t h a t 60% e x p e r i e n c e d o c c a s i o n a l L B P . I n a random samp le o f 692 u r b a n S w e d i s h f e m a l e s , H i r s c h , J o h s s o n and L e w i n (1969) f o u n d t h a t abou t h a l f e x p e r i e n c e d o c c a s i o n a l L B P , t h e i n c i d e n c e b e i n g 70% i n t h e 4 5 - 5 4 age g r o u p . The i n c i d e n c e o f LBP i s p e r h a p s s l i g h t l y l o w e r i n f e m a l e s t h a n i n m a l e s ( H i r s c h e t a l . , 1 9 6 9 ) , and t hough LBP i s common i n a l l o c c u p a t i o n a l g r o u p s , t h e i n c i d e n c e seems t o b e h i g h e r i n h e a v y w o r k e r s ( H u l t , 1 9 5 4 ; L a w r e n c e , 1 9 6 9 ) . The o n s e t o f LBP u s u a l l y o c c u r s d u r i n g t h e t h i r d o r f o u r t h d e c a d e , o f l i f e ( H i r s c h e t a l . , 1 9 6 9 ; H u l t , 1 9 5 4 ) , a f t e r w h i c h l i t t l e i n c r e a s e i n i n c i d e n c e i s u s u a l l y f o u n d . Low b a c k p a i n o f t e m p o r a r i l y i n c a p a c i t a t i n g p r o p o r t i o n s i s a l s o e x t r e m e l y common. H u l t ( 1 9 5 4 ) , i n t h e i n v e s t i g a t i o n q u o t e d a b o v e , f o u n d t h a t 36% o f h i s samp le had e x p e r i e n c e d i n a b i l i t y t o w o r k a t some t i m e b e c a u s e o f L B P . D i l l a n e , F r y and K a l t o n ( 1 9 6 6 ) , i n a s t u d y o f p a t i e n t s r e g i s t e r e d a t a London g e n e r a l p r a c t i c e , f o u n d t h a t d u r i n g a f o u r - y e a r p e r i o d 7.5% o f t h a t p a t i e n t p o p u l a t i o n had c o n s u l t e d t h a t p r a c t i c e abou t L B P . A f t e r d r a w i n g f r o m S w e d e n ' s G e n e r a l S i c k n e s s R e c o r d s a samp le c o n s i s t i n g o f a l l p e o p l e b o r n on t h e f i r s t day o f any m o n t h , W e s t r i n , H i r s c h and L i n d e g a r d (1972) f o u n d t h a t 3.6% o f t h e d e f i n e d p o p u l a t i o n had l o s t e i g h t o r more days f r o m work d u r i n g 2 one y e a r (1964) b e c a u s e o f L B P . I t i s f r om i n d u s t r y , c o n c e r n e d by t h e enormous c o s t s o f L B P , t h a t t h e most awesome s t a t i s t i c s c o n c e r n i n g LBP come. H u l t (1954) e s t i m a t e d t h a t two m i l l i o n w o r k i n g d a y s a r e l o s t y e a r l y by S w e d i s h men b e c a u s e o f b a c k t r o u b l e , and T r o u p , R o a n t r e e and A r c h i b a l d (1970) e s t i m a t e d t i m e l o s s t o be a t l e a s t 20 m i l l i o n man-days p e r y e a r f o r t h e same r e a s o n b y t h o s e c o v e r e d u n d e r G r e a t B r i t a i n ' s H e a l t h I n s u r a n c e . F i g u r e s r e f l e c t i n g t h e i n c i d e n c e o f LBP on a n a t i o n a l b a s i s a r e d i f f i c u l t t o o b t a i n i n N o r t h A m e r i c a b e c a u s e o f t h e d e c e n t r a l i z e d n a t u r e o f h e a l t h c a r e and c o m p e n s a t i o n p r o g r a m s . H o w e v e r , a c o m p e n s a t i o n s t u d y f r o m W a s h i n g t o n S t a t e ( M c G i l l , 1968) n o t e d t h a t LBP p r o b l e m s a c c o u n t f o r 24% o f d a y s l o s t and f i v e p e r c e n t o f i n d u s t r i a l c o m p e n s a t i o n c l a i m s . I n a r e c e n t a r t i c l e B e a l s and H i c k m a n (1972) n o t e d t h a t each y e a r 1 .25 m i l l i o n A m e r i c a n s s u s t a i n i n j u r i e s t o t h e b a c k and s p i n e , 6 5 , 0 0 0 o f whom e x p e r i e n c e some permanent d i s a b i l i t y . A p p r o x i m a t e l y 2 . 5 m i l l i o n A m e r i c a n s p r e s e n t l y h a v e some permanent i m p a i r m e n t o f t h e b a c k as a r e s u l t o f i n j u r y . Many l a r g e compan ies and c i v i l s e r v i c e d e p a r t m e n t s , r e c o g n i z i n g t h e m a g n i t u d e o f t h e LBP p r o b l e m and i t s i n c r e a s i n g i n c i d e n c e ( K o s i a k , A u r e l i u s and H a r t f i e l , 1 9 6 6 ; S c o t t , 1 9 5 5 ) , h a v e a l s o become i n t e r e s t e d i n t h e LBP t o p i c . S . D . S t e i n e r ( 1 9 7 0 ) , m e d i c a l d i r e c t o r o f G e n e r a l M o t o r s , n o t e d t h a t o f t h e 5 , 1 2 4 e m p l o y e e s i n one p l a n t , 737 v i s i t e d t h e m e d i c a l d e p a r t m e n t abou t LBP i n 1 9 6 7 . K o s i a k e t a l . (1966) f o u n d t h a t 20% o f a l l c o m p e n s a t i o n c l a i m s a t a S t . P a u l 3M Company p l a n t i n v o l v e d b a c k p r o b l e m s , and S c h e i n (1968) f o u n d t h a t i n t h e New Y o r k 3 f i r e department 12.5% of a l l i n j u r i e s and 19.5% of major i n j u r i e s i n v o l v e d the spine. Rowe (1969), i n a 10-year study of 1000 Eastman Kodak employees, noted that LBP was second only to upper r e s p i r a t o r y i n f e c t i o n s as a cause of time l o s s . During the 10-year p e r i o d , 35% of sedentary workers and 47% of heavy workers made at l e a s t one v i s i t to the medical department about LBP. Exact f i g u r e s d e a l i n g w i t h the incidence of back problems i n B r i t i s h Columbia are not a v a i l a b l e , but i t i s estimated that of the 30,000 cases seen per year at the Vancouver Workmen's Compensation Board (WCB) , 6000 cases i n v o l v e problems of the low back.''' I n 1971, 35% of a l l patients, admitted to the Vancouver WCB R e h a b i l i t a t i o n 2 C l i n i c had back i n j u r i e s . The cost of back problems has been t r e a t e d only r a r e l y i n the l i t e r a t u r e . M c G i l l (1968) reported that i n the State of Washington compensation claims i n v o l v i n g the low back cost 7.4 m i l l i o n d o l l a r s i n the f i s c a l year 1964-1965 and Hayes (1970) reported that i n the State of Michigan s p i n a l problems cost at l e a s t 53 m i l l i o n d o l l a r s i n 1967. Troup et a l . (1970) estimated that i n Great B r i t a i n the l o s s i n production because of ba c k - r e l a t e d absences amounts to 87.5 m i l l i o n pounds per year. At the i n d i v i d u a l company l e v e l , Rowe (1969) noted that LBP was the s i n g l e most c o s t l y compensation item. For B r i t i s h P e r r e t t , T.S. (Medical D i r e c t o r , WCB), personal communication. 2 M i l b r a n d t , W.E. (Medical D i r e c t o r , WCB R e h a b i l i t a t i o n C l i n i c ) , personal communication. 4 Columbia i t i s known on l y that the WCB pa id " m i l l i o n s " i n compensation and r e h a b i l i t a t i o n cos t s f o r back i n j u r i e s i n 1971 ( B r i t i s h Columbia Automobi le Insurance Board , B r i t i s h Columbia Sa fe ty C o u n c i l , and B r i t i s h Columbia Workmen's Compensation B o a r d , 1971) . On an i n d i v i d u a l - p a t i e n t b a s i s , M c G i l l (1968) noted that the average compensation c l a i m i n v o l v i n g the low back cos t s$1 ,341 .56 . 3 Dr . W. Fordyce of the U n i v e r s i t y of Washington M e d i c a l Schoo l repor ted that insurance c a r r i e r s es t imate the average t o t a l cos t of a f i r s t back f u s i o n case to be $18,000, and tha t c a r r i e r s se t a s i d e more money f o r a ch ron i c back p a t i e n t than f o r a q u a d r i p l e g i c . Fo rdyce , W.E. P e r s o n a l communicat ion. 5 M e d i c a l A s p e c t s o f Low B a c k P a i n I n t r o d u c t i o n I n o r d e r t o u n d e r s t a n d t h e r o l e o f a p s y c h o l o g i s t i n what m i g h t i n i t i a l l y a p p e a r t o be a s o l e l y m e d i c a l f i e l d and t o u n d e r s t a n d t h e g o a l s o f t h e p r e s e n t s t u d y , some k n o w l e d g e o f t h e m e d i c a l a s p e c t s o f LBP i s e s s e n t i a l . Such k n o w l e d g e i s n e c e s s a r y f o r a t l e a s t two r e a s o n s . F i r s . t l y , i f t h e p r o b l e m o f LBP i s a p s y c h o s o m a t i c o n e , as some h a v e s u g -g e s t e d , t h e n i t s s t u d y spans t h e e x p e r t i s e o f two d i s c i p l i n e s . As Mason (1970) h a s n o t e d i n h i s p r e s i d e n t i a l a d d r e s s t o t h e A m e r i c a n P s y c h o s o m a t i c S o c i e t y , an i n t e g r a t i v e r a t h e r t h a n an a n a l y t i c a l a p p r o a c h i s r e q u i r e d i n t h i s t y p e o f r e s e a r c h . C o n s e q u e n t l y , a t l e a s t a m i n i m a l k n o w l e d g e o f t h e d i s c i p l i n e o t h e r t h a n o n e ' s s p e c i a l t y i s r e q u i r e d t o g e n e r a t e h y p o t h e s e s and r e a c h c o n c l u s i o n s w h i c h do j u s t i c e t o t h e p r o b l e m . S e c o n d l y , as R i n g (1957) h a s n o t e d , t h e s h o r t c o m i n g s o f b o t h d i s c i p l i n e s , as w e l l a s t h e p r o b l e m s o f t h e i r i n t e r a c t i o n , a r e assumed i n u n d e r t a k i n g a s t u d y o f p s y c h o s o m a t i c s . O n l y w i t h an u n d e r s t a n d i n g o f t h e o t h e r d i s c i p l i n e ' s s t r e n g t h s and d e f i c i e n c i e s c a n one i n t e g r a t e t h e s t r e n g t h s o f o n e ' s own d i s c i p l i n e i n s u c h a manner t h a t e f f o r t i s n o t u n n e c e s s a r i l y expended and maximum j o i n t p r o d u c t i v i t y r e s u l t s . Members o f t h e two d i s c i p l i n e s b r i n g w i t h them t o t h e d i s c i p l i n e s * i n t e r f a c e , whe re t h e p s y c h o s o m a t i c s i n t e r a c t i o n o c c u r s , t h e i r own m o n i s t i c b i a s e s and t h e i r own l a n g u a g e s . P r o g r e s s i n t h e s t u d y o f p s y c h o s o m a t i c s may h a l t t h e r e u n l e s s e f f o r t i s expended on e a c h s i d e t o l e a r n f r o m and abou t t h e o t h e r . 6 W i t h t h e s e p u r p o s e s i n m i n d , t h e f o l l o w i n g i s a b r i e f o u t l i n e , c o r r e c t i n e s s e n c e i f n o t i n f u l l n e s s o f d e t a i l , o f t h e mos t p e r t i n e n t m e d i c a l a s p e c t s o f L B P . T h i s o u t l i n e i s meant t o s e r v e o n l y as a n i n i t i a l o r i e n t a t i o n f o r t h e p s y c h o l o g i s t new t o t h e a r e a s o f LBP and o r t h o p a e d i c s . A more c o m p r e h e n s i v e r e v i e w o f t h e m e d i c a l l i t e r a t u r e a p p e a r s i n Wing ( 1 9 7 3 ) . Anatomy o f t h e Lumbar S p i n e F i g u r e 1 shows d e t a i l e d l a t e r a l and s u p e r i o r v i e w s o f a l u m b a r v e r t e b r a ( s e c o n d ) . A l l l umbar v e r t e b r a e a r e g r o s s l y s i m i l a r . The a r t i c u l a t i o n ( i n t e r p o s i t i o n i n g ) o f two v e r t e b r a e and t he p l a c e m e n t o f t h e i n t e r v e r t e b r a l d i s c a r e shown i n F i g u r e 2 . The d i s c , w h i c h may be s t r u c t u r a l l y l i k e n e d t o a f l a t t e n e d g o l f b a l l , a c t s as a d i s t e n s i b l e c u s h i o n be tween t h e v e r t e b r a l b o d i e s . The d i s c i s composed o f c a r t i l a -g i n o u s end p l a t e s , a g e l a t i n o u s c e n t e r ( t h e n u c l e u s p u l p o s u s ) and a s p i r a l l y - a r r a n g e d f i b r o u s p e r i p h e r y ( t h e a n n u l u s f i b r o s u s ) . The f u l c r u m o f movement o f t h e j o i n t i s w i t h i n t h e p o s t e r i o r p o r t i o n o f t h e d i s c . The s p i n a l co lumn i s s t a b i l i z e d b y t h e a p o p h y s e a l j o i n t s ^ and .by m u l t i p l e l i g a m e n t s and m u s c l e s l o c a t e d be tween a d j a c e n t v e r t e b r a l b o d i e s and r u n n i n g l o n g i t u d i n a l l y a l o n g t h e e n t i r e s p i n e b o t h a n t e r i o r l y and p o s t e r i o r l y . F i g u r e s 3 and 4 d e p i c t l a t e r a l and p o s t e r i o r v i e w s o f t h e l o w e r p a r t o f t h e human s p i n e f r o m t h e t w e l f t h t h o r a c i c v e r t e b r a ( l y i n g on a h o r i z o n t a l p l a n e a p p r o x i m a t e l y h a l f w a y be tween t h e l o w e r l i m i t o f t h e c h e s t b o n e and t h e n a v e l ) t o t h e c o c c y x ( t h e t a i l b o n e ) . The f i v e l umbar v e r t e b r a e and sac rum f o r m a c u r v e , c o n c a v e p o s t e r i o r l y , r e f e r r e d 7 S p i n o u s P r o c e s s -T r a n s v e r s e P r o c e s s Lam ina V e r t e b r a l Foramen V e r t e b r a l Body P l a n e s f o r Laminec tomy 1 1 I S u p e r i o r V i e w S u p e r i o r N o t c h S u p e r i o r A r t i c u l a r P r o c e s s T r a n s v e r s e P r o c e s s S p i n o u s P r o c e s s I n f e r i o r A r t i c u l a r P r o c e s s L a t e r a l V i e w F i g u r e 1. S u p e r i o r and L a t e r a l V i e w s o f a Lumbar V e r t e b r a 8 Vertebral Body Intervertebral Disc Figure 2 . A r t i c u l a t i o n of Two Lumbar Vertebrae 9 F i g u r e 3 . L a t e r a l V i e w o f Lumbar S p i n e and Sacrum 10 B o u c h e r s c r e w s Sacrum P o s t e r i o r V i e w F i g u r e 4. P o s t e r i o r V i e w o f Lumbar S p i n e and Sacrum 11 t o as t h e l u m b a r l o r d o s i s . The v e r t e b r a l u n i t s a r e i d e n t i f i e d by t h e r e g i o n o f t h e s p i n e and a r e numbered i n d e s c e n d i n g o r d e r ( e . g . , t h e s e c o n d h i g h e s t l umbar (L ) v e r t e b r a i s i d e n t i f i e d a s L 2 ) . The d i s c s a r e i d e n t i f i e d i n t e rms o f t h e i r a d j a c e n t v e r t e b r a l b o d i e s ( e . g . , L 4 -L 5 d i s c ; t h e d i s c be tween L5 and t h e s a c r u m (S) i s i d e n t i f i e d as t h e L 5 - S 1 d i s c ) . B i o m e c h a n i c a l l y , t h e f o c u s o f m a x i m a l f o r c e d u r i n g b e n d i n g , l i f t i n g , e t c . a p p e a r s t o be a t t h e L 4 - L 5 and L 5 - S 1 j o i n t s (DePalma and Ro thman , 1 9 7 0 ) . The s p i n a l c o r d c e a s e s t o b e a c o r d a t a p p r o x i m a t e l y t h e L l l e v e l and becomes a g roup o f i n d i v i d u a l f i l a m e n t s , r e s e m b l i n g i t s L a t i n name c a u d a e q u i n a ( h o r s e ' s t a i l ) , e n c l o s e d i n t h e c e r e b r o s p i n a l - f l u i d f i l l e d d u r a . The d u r a i s l o c a t e d w i t h i n t h e v e r t e b r a l c a n a l , f o rmed b y t h e v e r t e b r a l f o r a m i n a ( s e e F i g u r e 1 ) . N e r v e r o o t s a r i s e b i l a t e r a l l y f r o m t h e d u r a a t e a c h v e r t e b r a l l e v e l , j u s t b e l o w t h e s u p e r i o r v e r t e b r a l n o t c h e s , and e x i t v i a t he i n f e r i o r v e r t e b r a l n o t c h e s . P a t h o l o g y o f t h e Low B a c k P a i n T h e r e a r e many c o n d i t i o n s t h o u g h t t o be p r o d u c t i v e o f L B P . T h e s e i n c l u d e r e f e r r a l o f p a i n f r o m p a t h o l o g y i n o t h e r p a r t s o f t h e b o d y , l o c a l i n f l a m m a t o r y r e a c t i o n s , c o n g e n i t a l o r d e v e l o p m e n t a l d i s o r d e r s , n e o p l a s i a , and d i s o r d e r s o f bone m e t a b o l i s m . I t i s t h e g e n e r a l c o n s e n s u s ( H i r s c h , 1 9 6 6 ) , h o w e v e r , t h a t d e g e n e r a t i o n and c o l l a p s e o f t h e i n t e r v e r t e b r a l d i s c i s o f c e n t r a l i m p o r t a n c e t o t h e p r o d u c t i o n o f a m a j o r p o r t i o n o f t h e c a s e s o f l o n g - t e r m c l i n i c a l L B P . T h i s i s a p r o c e s s whe reby t h e f i b r o u s o u t e r p e r i p h e r y o f t h e d i s c d e g e n e r a t e s and t h e n u c l e u s p u l p o s u s 12 l o s e s i t s g e l a t i n o u s n a t u r e . Why t h i s d e g e n e r a t i o n o c c u r s i s n o t known , b u t t h e e f f e c t s o f age and l o a d b e a r i n g c a u s e d by m a n ' s e r e c t s t a t u r e and p e r h a p s by t e n s i o n o f t h e b a c k m u s c l e s , seem t o be i m p o r t a n t f a c t o r s ( W i l f l i n g and W i n g , 1 9 7 2 ) . C o l l a p s e of t h e d i s c h a s a t l e a s t two i m p o r t a n t c o n s e q u e n c e s . F i r s t , t h e r e i s a d e c r e a s e i n t h e i n t e r v e r t e b r a l d i s t a n c e r e s u l t i n g i n a d i s p l a c e m e n t o f t h e a r t i c u l a r p r o c e s s e s o f t h e a p o p h y s e a l j o i n t s and changes i n t h e b i o m e c h a n i c a l c e n t e r o f r o t a t i o n ( F a r f a n , C o s s e t t e , R o b e r t s o n , W e l l s and K r a u s , 1 9 7 0 ; F r a n k e l , 1 9 6 9 ) . W i t h c o n t i n u e d movement , d e g e n e r a t i v e changes o f t h e a p o p h y s e a l j o i n t s , w h i c h become f o r c e d t o g e t h e r r a t h e r t h a n s l i d i n g , and changes of t h e v e r t e b r a l b o d i e s , r e s u l t . S e c o n d , c o l l a p s e o f t h e d i s c may be a s s o c i a t e d w i t h i t s p r o t r u -s i o n f r o m i t s u s u a l c o n f i n e s . P r o t r u s i o n o f t h e d i s c i n t o t h e v e r t e b r a l c a n a l a n d / o r v e r t e b r a l n o t c h e s and d i s p l a c e m e n t o f t h e v e r t e b r a l b o d i e s may r e s u l t i n t he imp ingement o f t h e c a u d a e q u i n a a n d / o r n e r v e r o o t s . P a i n may o r i g i n a t e f r o m many l o c a t i o n s , b u t n o t f r o m t h e i n t e r i o r o f t h e d i s c i t s e l f , w h i c h c o n t a i n s no n e r v e e n d i n g s . The a n n u l u s f i b r o s u s , t h e c a p s u l e s o f t h e a p o p h y s e a l j o i n t s , t he s u n d r y l i g a m e n t s and t h e b a c k m u s c l e s a l l h a v e n e r v e e n d i n g s , h o w e v e r , and c a n become o r i g i n a t o r s o f LBP f o l l o w i n g d e g e n e r a t i v e changes o f t h e v e r t e b r a l j o i n t . Impingement o f t he c a u d a e q u i n a and n e r v e r o o t s by a p r o t r u d e d lumbar d i s c c a n a l s o r e s u l t i n mo to r a n d / o r s e n s o r y l o s s e s i n t h e a r e a o f i n n e r v a t i o n , o r p r o d u c e p a i n s e n s a t i o n s p e r c e i v e d as o r i g i n a t i n g f r o m t h e a n a t o m i c a l a r e a s e r v e d by t he s p e c i f i c n e r v e t h a t i s i m p i n g e d . The l a t t e r i s one o f t h e mechan isms u n d e r s t o o d t o a c c o u n t f o r t h e 13 " r e f e r r e d p a i n " o f s c i a t i c a ( M i x t e r and B a r r , 1 9 3 4 ) . I t c a n t h u s be s e e n t h a t LBP and s c i a t i c a a r e s e p a r a t e e n t i t i e s w h i c h c a n o c c u r s i n g l y o r i n c o m b i n a t i o n . Movement o f t h e d e g e n e r a t e d j o i n t and a d j a c e n t s t r u c t u r e s c a n be s e e n t o be p o t e n t i a l l y p r o d u c t i v e o f p a i n , t h e l o c a l i z a t i o n o f w h i c h i s o f t e n v e r y d i f f e r e n t f r o m the a c t u a l s i t e o f t h e p a t h o l o g y . A d d i t i o n a l l y , t h e p a t i e n t may r e f l e x i v e l y i m m o b i l i z e t h e p a i n f u l j o i n t by t i g h t e n i n g the m u s c l e s o f t h e b a c k , t h u s p l a c i n g a d d i t i o n a l f o r c e s on t h e p a t h o l o g i c a l j o i n t , p r o d u c i n g more d i s t r e s s and e s t a -b l i s h i n g a v i c i o u s c i r c l e o f p a i n and m u s c l e spasm. D i a g n o s t i c P r o c e d u r e s The d i a g n o s t i c p r o c e d u r e s u s e d w i t h LBP a r e v a r i e d . I n t h e r o u t i n e o r t h o p a e d i c o f f i c e - e x a m i n a t i o n , t h e p h y s i c i a n s e e k s t o l o c a l i z e o r p l o t t h e a n a t o m i c a l d i s t r i b u t i o n s o f p a i n and o f mo to r and s e n s o r y l o s s i n t h e b a c k and l o w e r e x t r e m i t i e s . The p a t i e n t i s q u e s t i o n e d a b o u t a r e a s o f p a i n , a i d e d by s u i t a b l e p a l p a t i o n , and an a t t e m p t i s made t o i d e n t i f y c o n d i t i o n s w h i c h e x a c e r b a t e o r a m e l i o r a t e t h e p a i n . M e c h a n i c a l d e f e c t s a r e a s s e s s e d by n o t i n g t h e movement o f j o i n t s , a t -t e n t i o n b e i n g p a i d t o the p o i n t w i t h i n t h e r a n g e o f n o r m a l movement a t w h i c h p a i n o r o t h e r d i f f i c u l t y o c c u r s . M o t o r l o s s i s a s s e s s e d by v a r i o u s g r o s s t e s t s o f s t r e n g t h and m u s c l e w a s t i n g i s n o t e d as an i n -d i c a t i o n o f l o n g - t e r m moto r l o s s . R e f l e x e s a r e a s s e s s e d t o n o t e i n t e r -r u p t i o n o f r e f l e x a r c s and s e n s o r y changes a r e d e t e r m i n e d by l i g h t t o u c h o r p i n p r i c k s , an a t t e m p t b e i n g made t o d e l i n e a t e t h e a r e a a f f e c t e d . 14 S u b s e q u e n t l y , t h e s e o b s e r v a t i o n s , v i e w e d i n t h e f r a m e w o r k s o f anatomy and p a t h o l o g y , can p r o v i d e c l u e s as t o t h e l o c a l e and n a t u r e o f t he p a t h o l o g y . F o r e x a m p l e , t h e a r e a o f s e n s o r y changes and m o t o r l o s s i n one l e g may be i d e n t i f i e d as t h e a n a t o m i c a l a r e a s e r v e d by a s p e c i f i c n e r v e r o o t and p a i n may be u n i l a t e r a l l y l o c a l i z e d a t t h e v e r t e b r a l l e v e l a t w h i c h t h e c o r r e s p o n d i n g n e r v e r o o t e x i t s ? , t h e i n f e r i o r n o t c h . T h i s i n f o r m a t i o n , t a k e n t o g e t h e r , i m p l i c a t e s imp ingemen t o f t h e n e r v e r o o t a t t he l e v e l a t w h i c h i t e x i s t s s t h e i n f e r i o r n o t c h . I n a l l p r o b a b i l i t y s u c h a p a t i e n t w o u l d a l s o e x p e r i e n c e p a i n on b e n d i n g the s t r a i g h t l e g a t t h e h i p , b e c a u s e t h e n e r v e r o o t w h i c h n o r m a l l y s l i d e s o u t w a r d s d u r i n g t h i s manoeuvre ( F a h r n i , 1966) i s s t r e t c h e d . The d i a g n o s i s o f p r o t r u d e d d i s c , a r r i v e d a t b y s u c h r e a s o n i n g , i s c o n -f i r m e d a t o p e r a t i o n i n a p p r o x i m a t e l y 80% o f c a s e s ( R a a f , 1 9 5 9 ; W h i t e , 1 9 6 9 ) . Roen tgenograms a r e o f l i m i t e d u s e f u l n e s s i n t h e d i a g n o s i s o f b a c k p r o b l e m s b e c a u s e t h e y c a n show d i s p l a c e m e n t o f bony e l e m e n t s o f t he s p i n e , d e c r e a s e d i n t e r v e r t e b r a l d i s t a n c e i n d i c a t i n g a f l a t t e n e d d i s c and p o s -s i b l y p r o t r u s i o n , d e g e n e r a t i v e changes s u c h as s p u r s on t he v e r t e b r a e , d e c r e a s e d d e n s i t y o f b o n e s , and t h e l i k e . Roen tgenograms t a k e n w h i l e t h e p a t i e n t i s i n v a r i o u s b e n d i n g p o s i t i o n s ( B e n d i n g F i l m s ) a l s o may be u s e d t o d e t e c t a b n o r m a l movement o f t h e s p i n a l e l e m e n t s a t some l e v e l s , i n d i c a t i n g t h e p r e s e n c e o f m e c h a n i c a l a b n o r m a l i t i e s . S i m p l e r o e n t g e n o g r a m s , h o w e v e r , w i l l n o t show t h e s t a t u s o f s o f t t i s s u e s , s u c h as w h e t h e r o r n o t t h e a l l - i m p o r t a n t c a u d a e q u i n a and n e r v e r o o t s a r e f r e e . T h i s p r o b l e m i s p a r t l y overcome by m y e l o g r a p h y , 15 a p r o c e d u r e whe reby a r a d i o p a q u e dye i s i n j e c t e d i n t o t h e d u r a and r o e n t g e n o g r a m s a r e t a k e n . T h e s e f i l m s a r e t h e n examined f o r i n d i c a -t i o n s o f r e s t r i c t e d f l o w o f t h e dye and f o r any a b n o r m a l b u l g e s o r i n d e n t a t i o n s o f t he d u r a . The d i a g n o s i s o f p r o t r u d e d d i s c b y m y e l o -g r a p h y i s c o n f i r m e d a t o p e r a t i o n i n 82-84% o f c a s e s ( R a a f , 1 9 5 9 ; W h i t e , 1 9 6 9 ) . O t h e r s o f t t i s s u e a b n o r m a l i t i e s , h o w e v e r , a r e more d i f f i c u l t t o d e t e c t . T r e a t m e n t o f LBP C o n s e r v a t i v e t r e a t m e n t s o f LBP h a v e t h e g o a l o f a l l o w i n g n a t u r a l h e a l i n g t o o c c u r i n t h e a b s e n c e o f t h e a g g r a v a t i o n r e s u l t i n g f r o m m o v e -men t . To t h a t e n d , r e l a t i v e i m m o b i l i z a t i o n and r e m o v a l o f f o r c e f r o m t h e a r e a i s e n c o u r a g e d by bed r e s t , t r a c t i o n , a c t i v i t y r e d u c t i o n , t h e u s e o f c r u t c h e s f o r w a l k i n g , o r t h e w e a r i n g o f v a r i o u s r e s t r a i n i n g d e v i c e s s u c h as c o r s e t s o r body c a s t s . M u s c l e t e n s i o n i s r e l i e v e d b y h e a t , massage and t h e u s e o f c h e m i c a l m u s c l e r e l a x a n t s s u c h a s d i a z e p a m . N a t u r a l r e p a i r o f many o f t h e s o f t t i s s u e s i s no doub t p o s s i b l e , b u t i t i s u n l i k e l y t h a t t h e a v a s c u l a r d i s c i s c a p a b l e o f r e g e n e r a t i o n . H i r s c h (1966) has d e s c r i b e d d i s c d e g e n e r a t i o n a s " . . . a p r o g r e s s i v e and i r r e v e r -s i b l e p r o c e s s e n t a i l i n g a c o n s t a n t d e t e r i o r a t i o n . . . . " ( p . 8 5 9 ) . I n t h e e v e n t o f r e c u r r e n t LBP o f a d i s a b l i n g n a t u r e w h i c h does n o t r e s p o n d t o c o n s e r v a t i v e t r e a t m e n t s , o p e r a t i v e p r o c e d u r e s a r e u s u a l l y u n d e r t a k e n . I n a d d i t i o n t o s i m p l e e x p l o r a t i o n , t h e r e a r e t h r e e g e n e r a l t y p e s o f o p e r a t i o n commonly p e r f o r m e d on t h e l o w b a c k . T h e s e may be u n d e r t a k e n s i n g l y o r i n c o m b i n a t i o n . D i s c e c t o m y . T h i s p r o c e d u r e i s u s e d t o remove p a r t s o f t h e d i s c 16 and i t s nucleus which are impinging on the nerve structures. Access to the d i s c i s gained by placing the patient i n a hyperflexion p o s i t i o n (as i n touching one's toes) and entering between the laminae of adjacent vertebrae. The cauda equina i s pushed aside and parts of the di s c are scooped out. Laminectomy. The goal of t h i s procedure i s to decompress the v e r t e b r a l canal. Pressures r e s u l t i n g from degenerative changes and h o r i z o n t a l movement of the vertebrae are removed from the cauda equina and/or nerve roots by providing more space for them. The laminae and spinous process are generally removed along the planes indicated i n Figure 1. It w i l l be seen that laminectomy creates more space for movement of the nerve structures than would an i n t a c t , c o n s t r i c t i n g v e r t e b r a l foramen. Variations of t h i s procedure include u n i l a t e r a l or b i l a t e r a l (more common) removal of the laminae and removal of varying amounts of the laminae. Fusion. This procedure, f i r s t described independently by Hibbs and Albee i n 1911 (Bick, 1964), i s used to immobilize the pathological j o i n t with the goal of preventing pain caused by movement (Hirsch, 1966) and further degeneration. There are many variants of t h i s procedure, but a l l aim to e s t a b l i s h a bony bridge between adjacent vertebrae. The variants a r i s e from the area i n which the bone g r a f t i s applied, and the type of temporary immobilization used to allow the bony arch to s o l i d i f y . The bone g r a f t i s accomplished with onlaid cancellous bone (soft bone underlying the hard c o r t i c a l surface). A bed i s prepared across 17 a d j a c e n t v e r t e b r a l e l e m e n t s b y r e m o v i n g o r i n t e r r u p t i n g t h e c o r t i c a l l a y e r , and o n t o t h i s bed i s p a c k e d c a n c e l l o u s bone u s u a l l y a c q u i r e d f r o m t h e i l i a c c r e s t . I n t h e s i m p l e s t f u s i o n , beds a r e p r e p a r e d b i l a t e r a l l y on t h e p o s t e r i o r s u r f a c e s o f t h e l a m i n a e . Bone s l i v e r s a r e t u r n e d up i n a p r o c e d u r e w h i c h c o u l d be l i k e n e d t o r a i s i n g s l i v e r s on a b o a r d w i t h a c h i s e l , i n s u c h a way t h a t t h e s l i v e r s ( a t one end) r e m a i n a t t a c h e d t o t he b o a r d . Bone s l i v e r s f r o m t h e two v e r t e b r a l u n i t s a r e i n t e r -l a c e d and t h e a r e a i s o v e r l a i d w i t h c a n c e l l o u s bone f r o m t h e i l i a c d o n o r s i t e . P o s t o p e r a t i v e l y t h e p a t i e n t may o r may no t be i m m o b i l i z e d b y a body c a s t w h i l e t h e f u s i o n s o l i d i f i e s . Tempora ry i m m o b i l i z a t i o n o f t h e j o i n t may a l s o be a c c o m p l i s h e d i n a s e c o n d t y p e o f f u s i o n by h o l d i n g t h e j o i n t t o g e t h e r w i t h s c r e w s , much s i m i l a r t o wood s c r e w s b u t made o f an i n e r t m e t a l s u c h as v i t a l -l i u m . S h o r t 1/2 -3 /4 " s c r e w s may be p l a c e d t h r o u g h t h e a p o p h y s e a l j o i n t s , o r l o n g e r s c r e w s (11V2-2") may be i n s e r t e d a t t h e p o i n t s n o t e d i n F i g u r e 4 , a n g l e d downward and o u t w a r d t o engage t h e v e r t e b r a l body i m m e d i a t e l y b e l o w . T h i s l a t t e r t e c h n i q u e was d e v e l o p e d i n t h e V a n c o u v e r a r e a ( B o u c h e r , 1 9 5 9 ) , and i s w i d e l y u s e d . I n t h e s e " s c r e w f i x a t i o n " f u s i o n s , b o n e p l a c e m e n t i s much s i m i l a r t o t h a t d e s c r i b e d a b o v e . The s c r e w s a r e l e f t i n p l a c e p e r m a n e n t l y , e v e n a f t e r bony f u s i o n h a s b e e n e s t a b l i s h e d . A t h i r d t y p e o f f u s i o n , t h e " H - g r a f t " f u s i o n , i s a c c o m p l i s h e d by p l a c i n g t h e p a t i e n t i n a h y p e r f l e x i o n p o s i t i o n so t h a t m a x i m a l s e p a r a t i o n o f t h e s p i n o u s p r o c e s s e s o c c u r s . A p i e c e o f bone removed 18 f r o m the i l i a c c r e s t i s c a r v e d i n t o an " H " shape and i s i n s e r t e d b e t w e e n t h e s p i n o u s p r o c e s s e s so t h a t t he " H " i s s e e n f r o m t h e p o s t e r i o r v i e w . A f o u r t h t y p e o f f u s i o n , t h e i n t e r b o d y f u s i o n , i s l e s s commonly u s e d . An a n t e r i o r a p p r o a c h t o t h e v e r t e b r a l b o d i e s i s u s e d f o r t h i s p r o c e d u r e and p a r t s o f t h e d i s c a r e removed and a wedge o f bone i s d r i v e n b e t w e e n t h e v e r t e b r a e t o b r i n g a b o u t f u s i o n . N a t u r a l H i s t o r y o f LBP The s e q u e n c e o f t r e a t m e n t s v a r i e s w i t h t h e h y p o t h e s i z e d e t i o l o g y o f t h e LBP i n t he i n d i v i d u a l c a s e . I n a m i n o r i t y o f c a s e s , p r o f o u n d t r a u m a c l o s e l y p r e c e d e s the o n s e t o f LBP s y m p t o m a t o l o g y , and a b n o r -m a l i t i e s o f e l e m e n t s o f t h e l u m b a r s p i n e a r e e a s i l y d e m o n s t r a t e d . I f t h e s e a b n o r m a l i t i e s a r e s i z e a b l e , o p e r a t i v e r e p a i r i s u s u a l l y s o o n u n d e r t a k e n . H o w e v e r , i n t h e v a s t m a j o r i t y o f LBP c a s e s , o n s e t i s i n s i d i o u s and t r auma i s o f u n c e r t a i n m a g n i t u d e . T h e r e i s s u b s t a n t i a l ag reemen t i n m a n y s s t u d i e s ( e . g . , D i l l a n e e t a l . , 1966; H i r s c h , 1966; H u l t , 1954; Rowe, 1969) t h a t a b o u t 20% o f c a s e s o f LBP a r e p r e c e d e d b y i d e n t i f i a b l e t r a u m a , and t h a t i n p e r h a p s a n o t h e r 20% o f c a s e s a p o s s i b l e c o n n e c t i o n t o a l i f t o r s t r a i n c a n be made. M c G i l l (1968) n o t e d t h a t most t r auma h e l d r e s p o n s i b l e f o r t he o n s e t o f LBP w e r e l i f t s o f l e s s t h a n 50 p o u n d s . M o s t c a s e s o f LBP a r e s o o n r e s o l v e d , 82% o f c o m p e n s a t i o n c a s e s b e i n g b a c k t o w o r k w i t h i n t h r e e weeks ( W h i t e , 1966) and 90% o f c a s e s b e i n g b a c k t o w o r k w i t h i n s i x weeks ( W h i t e , 1969). P e r h a p s one p a t i e n t i n 20 19 i s o f f work l o n g enough t o g a i n t he l a b e l " c o m p e n s a t i o n b a c k " ( W h i t e , 1 9 6 6 ) . The m a j o r i t y o f LBP p a t i e n t s r e s p o n d t o c o n s e r v a t i v e t r e a t m e n t , b u t f o r t h e few who f o l l o w a c h r o n i c c o u r s e , t r e a t m e n t by f u s i o n i s u s u a l l y u n d e r t a k e n o n l y a f t e r many y e a r s . C h a r a c t e r i s t i c a l l y , a c h r o n i c p a t i e n t ' s i l l n e s s h i s t o r y i s one o f r e p e a t e d r e l a p s e s , r e -p e a t e d m e d i c a l e x a m i n a t i o n s a s an o u t p a t i e n t o r h o s p i t a l i n p a t i e n t ( f o r d i a g n o s t i c p r o c e d u r e s o r c o n s e r v a t i v e t r e a t m e n t ) , and e x p o s u r e t o t h e w h o l e gamut o f c o n s e r v a t i v e t r e a t m e n t p r o c e d u r e s . I t i s com-mon t o s e e many changes o f s p e c i a l i s t d u r i n g t h i s and s u b s e q u e n t p e r i o d s o f t h e p a t i e n t ' s i l l n e s s . C o n s e r v a t i v e t r e a t m e n t p r o c e d u r e s may c o n t i n u e f o r y e a r s . W i t h an a c c e l e r a t i n g o r h i g h , u n a b a t e d c o m p l a i n t r a t e , and w i t h c o n s i d e r a b l e d i s a b i l i t y i n t h e p a t i e n t ' s d a i l y f u n c t i o n i n g , t h e d e c i s i o n i s o f t e n made t o o p e r a t e . The p u r p o s e o f o p e r a t i o n i s u s u a l l y r e p a i r o f p a t h o l -ogy f o u n d i n t h e l u m b a r s p i n e , b u t o p e r a t i o n i s o c c a s i o n a l l y u n d e r t a k e n f o r e x p l o r a t o r y p u r p o s e s . As w i l l be n o t e d l a t e r , h o w e v e r , s e v e r a l s t u d i e s have f o u n d t h a t p a t h o l o g y o f t h e l u m b a r s p i n e i s o f q u e s t i o n a b l e r e l e v a n c e t o t he p r o d u c t i o n o f L B P . The t y p e o f o p e r a t i o n p e r f o r m e d i s t o a l a r g e d e g r e e dependen t on t h e c l i n i c a l j udgment and p e r s o n a l b i a s e s o f t h e i n d i v i d u a l o r t h o p a e d i s t and on h i s f a m i l i a r i t y w i t h t h e v a r i o u s p r o c e d u r e s . S p i n a l f u s i o n i s gen e r a l l y a c k n o w l e d g e d a s t h e most e x t r e m e o p e r a t i v e p r o c e d u r e , and i s u s u -a l l y u n d e r t a k e n w i t h some r e l u c t a n c e , t hough t he f r e q u e n c y w i t h w h i c h i t 2 0 u s e d v a r i e s by l o c a l e ( H i r s c h , 1966). I n t h e f a c e o f c o n t i n u e d p a t i e n t d i s a b i l i t y , h o w e v e r , r e s o r t i s o f t e n made t o f u s i o n t e c h n i q u e s . Beyond t h i s , l i t t l e o f a r e p a r a t i v e n a t u r e , o t h e r t h a n f u r t h e r f u s i o n s , c a n be a c c o m p l i s h e d . I t i s acknowledged ( W h i t e , 1966) that !a ( d e c i s i o n t o o p e r a t e i s somet imes " . . . b o r n o f f r u s t r a t i o n . . . " and o p e r a t i o n u n d e r t a k e n b e c a u s e i t " . . . m a y p o s s i b l y be h e l p f u l , and a t w o r s t , i t s h o u l d do no h a r m " Cp. 873). T h e r e i s t h e s u g g e s t i o n , h o w e v e r , CWiltberger, 1963) t h a t " s u r g i c a l b a c k c r i p p l e s " may be c r e a t e d b y r e l y i n g on s u r g e r y i n c a s e s w h i c h may be p s y c h o •somat i c? i n a n a t u r e . P r o b l e m s i n Management o f LBP The c o m p l e x i t y o f t h e b a c k , i t s p a t h o l o g y , and s y m p t o m a t o l o g y make LBP p e r h a p s t h e symptom most d i f f i c u l t f o r t h e p h y s i c i a n t o e v a l u a t e ( J o n e s , 1945). T h e r e h a s a l s o b e e n a g r o w i n g r e c o g n i t i o n s i n c e a t l e a s t t h e t i m e o f W o r l d War I I t h a t some p r o p o r t i o n o f LBP s y m p t o m a t o l o g y and d i s a b i l i t y i s due t o f a c t o r s o t h e r t h a n o r g a n i c p a t h o l o g y , p o s s i b l y p s y c h o l o g i c a l f a c t o r s . I t i s t h e a i m o f t h i s s e c t i o n t o show t h a t b e c a u s e o f t h e u n c e r t a i n t i e s i n h e r e n t i n o r g a n i c d i a g n o s i s , p s y c h o l o g i c a l d i a g n o s i s c a n . n o t . be made by t h e e x c l u s i o n o f o r g a n i c f a c t o r s i n some c a s e s o f L B P . A t t h e o f f i c e - e x a m i n a t i o n l e v e l , many a t t e m p t s a r e made t o d i f -f e r e n t i a t e symptoms o f o r g a n i c o r i g i n f r o m t h o s e a r i s i n g f r o m o t h e r s o u r c e s . Beyond s e e k i n g c o n s i s t e n c y i n t h e a n a t o m i c a l d i s t r i b u t i o n o f l o s s e s and p a i n , a c o n s i d e r a b l e l i t e r a t u r e o f a " d e t e c t i v e " n a t u r e has d e v e l o p e d . Symptoms and s i g n s a r e compared ( e . g . , l o n g - t e r m m o t o r l o s s s h o u l d b e a c c o m p a n i e d by m u s c l e w a s t i n g ) , r e d u n d a n t m e a s u r e s a r e u s e d ( e . g . , a b d o m i n a l m u s c l e s t r e n g t h may be a s s e s s e d b y t h e a b i l i t y t o l i f t 21 t h e l e g s o f f t h e e x a m i n i n g t a b l e and by t h e a b i l i t y t o do a " s i t -u p " ) , sh rewd o b s e r v a t i o n i s emp loyed ( e . g . , t h e e a s e o f g e t t i n g o f f t h e e x a m i n i n g t a b l e o r d r e s s i n g a f t e r t he e x a m i n a t i o n may c o n t r a d i c t d i f f i c u l t i e s i n movement shown d u r i n g e x a m i n a t i o n ) , and t h e p a t i e n t ' s p e r s o n a l e f f e c t s a r e examined b e c a u s e t h e y may c o n t r a d i c t h i s d e m o n s t r a t e d d i s a b i l i t i e s ( e . g . , i f t he p a t i e n t h a s a c h r o n i c l i m p , h i s s h o e s s h o u l d show a c h a r a c t e r i s t i c wear p a t t e r n ) . A d e l i g h t f u l compendium o f s u c h t e c h n i q u e s i s p r e s e n t e d b y F r o s t (1972) f o r t h e n e o p h y t e o r t h o p a e d i s t . The r e c e n t l y d e v e l o p e d s p i n a l b l o c k t e c h n i q u e s ( A h l g r e n , S t e p h e n , L l o y d and M c C o l l u m , 1 9 6 6 ; B r o t h e r s and F i n l a y s o n , 1968) a r e p u r p o r t e d t o d i f f e r e n t i a t e " o r g a n i c " p a i n f r o m " p s y c h o g e n i c " p a i n . W i t h t h e s e t e c h n i q u e s , t h e c o n s c i o u s , s y m p t o m a t i c p a t i e n t i s g i v e n f o u r i n j e c t i o n s i n t h e l o w b a c k a t t e n m i n u t e i n t e r v a l s , t h e f i r s t b e i n g an i s o t o n i c s a l i n e p l a c e b o and t h e f o l l o w i n g t h r e e i n j e c t i o n s b e i n g an a n e s t h e t i c g i v e n i n i n c r e a s i n g c o n c e n t r a t i o n s . The t h r e e a n e s t h e t i c i n j e c t i o n s s e -q u e n t i a l l y b r i n g abou t s y m p a t h e t i c b l o c k , s e n s o r y b l o c k and mo to r b l o c k . A f t e r e a c h i n j e c t i o n , t he p a t i e n t i s a s k e d t o e v a l u a t e p a i n a t r e s t , w i t h p a s s i v e movement , p i n p r i c k , e t c . I t i s a p p a r e n t t h a t p a i n o f o r g a n i c o r i g i n s h o u l d n o t s u b s i d e w i t h t h e p l a c e b o i n j e c t i o n , s h o u l d d i s a p p e a r w i t h t h e s y m p a t h e t i c o r s e n s o r y b l o c k s , and most c e r t a i n l y s h o u l d be a b s e n t when mo to r b l o c k i s e s t a b l i s h e d . S e v e r a l p a t i e n t s r e p o r t i n g no dec remen t i n p a i n u n d e r mo to r b l o c k have b e e n o b s e r v e d b y t h e o r t h o p a e d i s t s o f t h e p r e s e n t r e s e a r c h g roup i n t h e c o u r s e o f t h e i r c l i n i c a l a c t i v i t i e s . B r o t h e r s and 22 F i n l a y s o n (1968) n o t e d t h a t o f a s e r i e s o f p a t i e n t s examined w i t h a s p i n a l b l o c k t e c h n i q u e , 45% d i d n o t a p p e a r t o h a v e an o r g a n i c b a s i s f o r t h e i r p a i n . H o w e v e r , i t i s a p p a r e n t t h a t t h e o f f i c e - e x a m i n a t i o n t e c h n i q u e s and t h e s p i n a l b l o c k t e c h n i q u e s a r e p r o n e t o many f a l s e n e g a t i v e s i f t h e y a r e u s e d t o s e e k p s y c h o l o g i c a l f a c t o r s . I t seems r e a s o n a b l e t o s u s p e c t t h a t i n many c a s e s a t l e a s t some m i n o r o r g a n i c p a t h o l o g y and p a i n a r e p r e s e n t , and t h a t t h e p a t i e n t s c a n s i m p l y be cued by t h i s p a i n i n t h e i r r e p o r t s o f w h i c h e x a m i n a t i o n p r o c e d u r e s e x a c e r b a t e o r a m e l i o r a t e t h e p a i n . A d d i t i o n a l l y , i n t h e o f f i c e - e x a m i n a t i o n - p r o c e d u r e s , w h i c h t h e c h r o n i c LBP p a t i e n t h a s no doub t unde rgone a l m o s t i n n u m e r a b l e t i m e s and w h i c h i n v o l v e a f a c e - t o - f a c e i n t e r a c t i o n be tween p h y s i c i a n and p a - 1 t i e n t , a b e h a v i o r a l s h a p i n g p r o c e d u r e i s q u i t e p o s s i b l y o p e r a t i v e ( W i l f l i n g e t a l., 1973). T h u s , o v e r a number o f s e s s i o n s , and p e r h a p s a f t e r a number o f p h y s i c i a n s , t h e p a t i e n t may come t o e x h i b i t t h e symptoms o f a " c l a s s i c a l LBP s y n d r o m e . " Sod ium a m y t a l i n t e r v i e w s h a v e a l s o o c c a s i o n a l l y b e e n u s e d ( F o r d and Lam, 1956; MacNab,. 1969) i n t h e d i f f e r e n t i a l d i a g n o s i s o f L B P . I n one s t u d y ( F o r d and L a m , 1956), i t was c o n c l u d e d t h a t o f 25 p a t i e n t s so e x a m i n e d , 20 had p a i n o f p r e d o m i n a n t l y " p s y c h o l o g i c a l o r i g i n . " U n f o r t u n a t e l y , p a t h o l o g y v i s u a l i z e d by r a d i o l o g i c a l o r o t h e r means i s o f q u e s t i o n a b l e r e l e v a n c e i n t h e p r o d u c t i o n o f L B P . F u r t h e r m o r e , p a t h o l o g y o f t h e l u m b a r s p i n e i s a l s o v e r y common and many " n o r m a l " human s p i n e s , e v e n by t h e m i d - t w e n t i e s , show d e g e n e r a t i v e c h a n g e s . L a w r e n c e (1969) f o u n d d e g e n e r a t e d d i s c s a t a u t o p s y i n 10% o f t h o s e aged 23 20-29, and Moreton (1969) reviewing several studies reports that in a group of healthy 27-year old soldiers only 20% had, no variation in the lumbar spine. After the mid-thirties lumbar disc degeneration ha s been found to be present in 65% of males and 52% of females (Lawrence, 1969), and Hirsch (1966) has noted that after 60 a normal lumbar disc becomes the exception. McGill (1968) presented a table of the findings of 10 other authors, who on pre-employment roentgenographical examination found from 27 to 70% of the backs assessed to Be abnormal in some way. A pathology-free back by middle age then appears to be almost a rarity. Several authors who have compared the incidence of lumbar spine pathology in symptomatic and asymptomatic backs have found l i t t l e evidence to support the notion that any form of pathology is predictive of the occurrence of LBP. Splithoff (1953) studied 100 patients seeking treatment for LBP and 100 subjects who had never sought medical atten-tion for LBP. Though the subjects were not strictly matched by age, Splithoff found no significant differences in the incidence of congenital or degenerative changes between his two groups. Similar conclusions were reached by La Rocca and MacNab (1969), who studied matched groups with, a minimum age of 35 years. /Fullenlove and Williams (1957), in a study of 200 symptomatic and 200 asymptomatic backs, catalogued an impressive l i s t of congenital, traumatic, degenerative, arthritic, neo-plastic and structural pathology. They found l i t t l e difference between their two groups, except for a slightly higher incidence of narrowed discs with spurs and degenerative arthritis in the symptomatic group. 24 They found c o n g e n i t a l defects and s t r u c t u r a l changes to be of h i g h frequency and of approximately equal incidence i n the two groups, and concluded that these defects were not c l i n i c a l l y s i g n i f i c a n t i n and of themselves. F u l l e n l o v e and Williams a l s o c i t e d s e v e r a l other s t u d i e s supporting t h e i r conclusions and quoted A l l e n and Lindem as saying that i t i s "...a moot question as to how great a r o l e anomalies of the lumbosacral spine play i n causation, of back symptoms." There i s even the suggestion (DePalma and Rothman, 1968) that a f t e r attempted i m m o b i l i z a t i o n of s p i n a l elements by f u s i o n o p e r a t i o n , a s o l i d bone g r a f t i s not a necessary c o n d i t i o n f o r symptom r e l i e f . This suggestion has r e c e n t l y been supported by Beals and Hickman (1972), who found that l a c k of a s o l i d f u s i o n d i d not exclude a p a t i e n t ' s r e t u r n to work. The orthopaedist i s thus l e f t i n a d i f f i c u l t p o s i t i o n of having s u b j e c t i v e examination procedures which may be d i s t o r t e d by other than organic causes and some o b j e c t i v e examination procedures (e.g., Roent-genograms) whose f i n d i n g s may be of questionable relevance to the p a t i e n t ' s LBP symptomatology. I t i s evident that concrete r u l e s cannot be a p p l i e d i n determining how much impairment or d i s a b i l i t y some sub-j e c t i v e l y or o b j e c t i v e l y evidenced pathology should have on the p a t i e n t ' s d a i l y a c t i v i t i e s , and c e r t a i n l y i t appears u n l i k e l y t h a t a psychosomatic diagnosis can be reached by e x c l u s i o n i n at l e a s t some cases. Coupled w i t h the above d i f f i c u l t i e s are s t a t i s t i c s i n d i c a t i n g that a l a r g e number of back p a t i e n t s remain d i s a b l e d even f o l l o w i n g operation. D i s a b i l i t y E v a l u a t i o n and Results of Operative Treatment of LBP The benchmark of a l l i n v e s t i g a t i o n s of the LBP problem, before 25 o r a f t e r o p e r a t i o n , i s an i n d e x o f d i s a b i l i t y . A n a l y s i s c a n p r o c e e d o n l y a f t e r t h e d e f i n i n g c r i t e r i a o f d i s a b i l i t y have been c h o s e n and have b e e n u s e d t o a s s i g n s u b j e c t s to g r o u p s . The c r i t e r i a u s e d i n d e v -e lopmen t o f t h e d i s a b i l i t y i n d e x a r e t h e r e f o r e c r u c i a l t o a l l s u b s e -quen t a n a l y s e s and c o n c l u s i o n s o f t h e s t u d y . These c r i t e r i a h a v e v a r i e d e n o r m o u s l y i n p a s t s t u d i e s o f L B P . Some a u t h o r s , ( e . g . , L e v y , L i p s c o m b , McDona ld and D a v i s , 1 9 6 3 ; P r o t h e r o , P a r k e s , and S t i n c h f i e l d , 1 9 6 6 ; Raney and Adams, 1 9 7 0 ; W i l t b e r g e r , 1963) h a v e s i m p l y u s e d t h e p r e s e n c e o f o r g a n i c p a t h o l o g y a n d / o r s o l i d i t y o f t he f u s i o n a s c r i t e r i a . W h i l e t he c h o i c e o f s u c h c r i t e r i a i s a p p r o p r i a t e o r seems d e f e n s i b l e i n a s s e s s i n g t he e f f e c -t i v e n e s s o f v a r i o u s o p e r a t i v e p r o c e d u r e s i n c o r r e c t i n g o r g a n i c d e f e c t s , t h e c h o i c e of s u c h c r i t e r i a t o r e f l e c t f u n c t i o n a l d i s a b i l i t y w o u l d n o t seem d e f e n s i b l e . A s was- shown a b o v e , t h e r e i s l e s s t h a n a p e r f e c t c o r r e s p o n d e n c e b e t w e e n d e g r e e o f o r g a n i c p a t h o l o g y and f u n c t i o n a l i m p a i r -men t . To t h e p a t i e n t and s o c i e t y , i t i s p e r h a p s o f g r e a t e r i m p o r t a n c e t h a t t h e p a t i e n t be f r e e o f d i s c o m f o r t and u n i m p a i r e d i n t h e a c t i v i t i e s o f d a i l y l i v i n g . A f t e r a l l , i t i s f o r f u n c t i o n a l c o m p l a i n t s t h a t h e l p i s s o u g h t ^ and t r e a t m e n t m o n i e s a r e s p e n t . S e v e r a l s t u d i e s have u s e d t h e p a t i e n t ' s w o r k i n g s t a t u s as t h e s o l e c r i t e r i o n o f d i s a b i l i t y . F o r e x a m p l e , B e a l s and H i ckman (1972) h a v e s i m p l y a s s i g n e d two g r o u p s on a b a s i s o f w h e t h e r o r n o t t h e p a t i e n t s we re w o r k i n g a t t h e t i m e o f f o l l o w - u p . W h i t e ( 1 9 6 9 ) , by c o m p a r i s o n , h a s a l s o u s e d w o r k i n g s t a t u s as t he s o l e c r i t e r i o n o f d i s a b i l i t y , b u t h a s g r a d e d h i s p a t i e n t s i n t o f o u r g r o u p s on t h e b a s i s o f w h e t h e r a p h y s i c a l l y l i g h t e r 26 j o b was b e i n g p e r f o r m e d a t f o l l o w - u p t h a n p r e o p e r a t i v e l y and on t h e b a s i s o f t h e t i m e l o s s e x p e r i e n c e d f r o m t h e j o b p e r f o r m e d . T h e r e a r e s e v e r a l d i f f i c u l t i e s , h o w e v e r , i n u s i n g w o r k i n g s t a t u s as t h e s o l e c r i t e r i o n f o r d i s a b i l i t y . As became s u b j e c t i v e l y e v i d e n t i n t he e a r l i e r s t u d y o f t h e p r e s e n t r e s e a r c h g r o u p , t he f a c t t h a t a p a t i e n t i s n o t w o r k i n g i s f r e q u e n t l y n o t r e l a t e d t o L B P , b u t t o o t h e r n o n - b a c k - r e l a t e d f a c t o r s . On t h e o t h e r h a n d , a p a t i e n t i s f r e q u e n t l y s e e n who w o r k s w i t h l i t t l e t i m e l o s s a t a j o b s i m i l a r t o t h e one o f h i s p r e - L B P d a y s , b u t who a p p a r e n t l y manages t o do so o n l y a t t h e e x -p e n s e o f most o t h e r a c t i v i t i e s b e c a u s e h i s p a i n and a c t i v i t y t o l e r a n c e s a r e f u l l y t a x e d by t h e c o m b i n a t i o n o f LBP and w o r k . Thus t h e d e f i c i e n -c i e s o f u s i n g w o r k i n g s t a t u s as t h e s o l e c r i t e r i o n o f d i s a b i l i t y a r e e a s i l y s e e n . O t h e r a u t h o r s h a v e d e r i v e d d i s a b i l i t y i n d i c e s i n more m o l a r t e r m s . B a r r , K u b i k , M o l l o y , M c N e i l l , R i s e b o r o u g h and W h i t e (1967) a s s i g n e d p a t i e n t s t o t h r e e g roups on t h e b a s e s o f t h e p a t i e n t s ' s e l f - r a t i n g s and t h e d e f i c i t s s e e n on e x a m i n a t i o n . G u r d j i a n , O s t r o w s k i , H a r d y , L i n d n e r and Thomas (1961) a l s o a s s i g n e d p a t i e n t s t o t h r e e g r o u p s on a b a s i s o f t h e p a t i e n t s ' s e l f - r e p o r t s . The u s e o f s u c h s e l f - r e p o r t c r i t e r i a i n t h e d e r i v a t i o n o f a d i s a b i l i t y i n d e x w o u l d seem t o be q u i t e d e f e n s i b l e i n t h a t t h e d e g r e e o f d i s a b i l i t y avowed by t he p a t i e n t i s , a f t e r a l l , t h e d i s a b i l i t y t o w h i c h c l i n i c a l p r a c t i c e i s e x p o s e d and t o w h i c h i t must a p p l y i t s e l f . I t i s q u e s t i o n a b l e , h o w e v e r , w h e t h e r most p a t i e n t s w o u l d be c a p a b l e of a c c u r a t e l y mak ing a s i n g l e j udgmen t r e f l e c t i n g t h e e x t e n t o f t h e i r g l o b a l i m p a i r m e n t . C e r t a i n l y t h e u s e o f a b r o a d e r d a t a b a s e i n t he a s s e s s m e n t o f d i s a b i l i t y has been s u g g e s t e d . G a r r a d and B e n n e t t (1971) " . . . d e f i n e d i s a b i l i t y as l i m i t a t i o n o f p e r f o r m a n c e i n one o r more a c t i v i t i e s ( s i c ) 27 w h i c h a r e g e n e r a l l y a c c e p t e d as e s s e n t i a l b a s i c components o f d a i l y l i v i n g . . . " ( p . 9 7 ) . These a u t h o r s s u g g e s t t h a t d a t a f r o m f o u r a r e a s o f e s s e n t i a l a c t i v i t y be i n c l u d e d i n d i s a b i l i t y a s s e s s m e n t : 1) m o b i l i t y , 2) s e l f - c a r e , 3) d o m e s t i c d u t i e s , and 4) o c c u p a t i o n . S i m i l a r a t -t e n t i o n t o t h e e f f e c t s o f i m p a i r m e n t on t h e p a t i e n t s ' a c t i v i t i e s o f d a i l y l i v i n g a r e a l s o s u g g e s t e d by K e s s l e r (1970) and b y t h e A m e r i c a n M e d i c a l A s s o c i a t i o n (1966) i n t h e G u i d e t o t h e E v a l u a t i o n o f Pe rmanen t Impa i rmen t ( o f ) t h e E x t r e m i t i e s and Back . ' : . T h i s r e s e a r c h g r o u p i n t h e i r e x p l o r a t o r y s t u d y ( W i l f l i n g e t a l . , 1973) d e v e l o p e d a c o m p o s i t e d i s a b i l i t y i n d e x u s i n g m e a s u r e s o f o c -c u p a t i o n a l d i f f i c u l t i e s , p a i n e x p e r i e n c e d by t h e s u b j e c t , r e s t r i c t i o n s i n r a n g e s o f m o t i o n s e e n on e x a m i n a t i o n , and o p i n i o n s abou t t h e v a l u e o f p a s t s u r g e r y g i v e n b y b o t h p a t i e n t and o r t h o p a e d i s t . T h i s c o m p o s i t e d i s a b i l i t y i n d e x seemed t o overcome the d e f i c i e n c i e s i n h e r e n t i n t h o s e s t u d i e s u s i n g - a s i n g l e c r i t e r i o n i n t h e d e r i v a t i o n o f a d i s a b i l i t y i n d e x . I t was v e r y u n c l e a r , h o w e v e r , what r e l a t i v e w e i g h t s s h o u l d be a s s i g n e d t o t h e i n d i v i d u a l v a r i a b l e s i n d e r i v i n g t h e d i s a b i l i t y i n d e x . A n o v e l method o f d e r i v i n g a d i s a b i l i t y i n d e x i s e v i d e n t i n t h e w o r k o f N a s h o l d and H r u b e c ( 1 9 7 1 ) . T h e s e a u t h o r s , s o u g h t t o d e r i v e a d i s a b i l i t y i n d e x b y u s i n g a p r i n c i p a l component f a c t o r a n a l y s i s o f 18 v a r i a b l e s r e f l e c t i n g b o t h o r g a n i c and f u n c t i o n a l d e f i c i t s , t h e f i r s t u n r o t a t e d f a c t o r o f w h i c h t h e y u s e d t o s u p p l y t h e d i s a b i l i t y i n d i c e s . T h i s a p p r o a c h w o u l d seem t o be e m i n e n t l y s u i t a b l e t o t h e t a s k o f d e r i v i n g a d i s a b i l i t y i n d e x . A b a s i c d i m e n s i o n i s t h e r e b y f o u n d w h i c h i s _ _ • common t o many c r i t e r i a , w h i c h r e f l e c t s a w i d e r a n g e o f d e f i c i t s , and 28 which is not nearly as open to random error as is an individual criterion. Possibly in large part due to the manner in which disability was defined, studies differ greatly in the percentage of operated patients reported to have achieved a satisfactory result. Using the definition of disability noted above, White (1969) found that less than 40% of the patients in his series achieved a good result, whereas Raney and Adams (1970) reported good or satisfactory results in 77%. Other studies (e.g., Aitken, 1952.; Gurdjian et al. , 1961; Nachlas, 1952; Raaf, 1959) have reported percentages of good results ranging between the two statistics quoted above. Generally, authors who have used organic criteria of success tend to report higher success rates than do authors who have used functional criteria of success. It has been a consistent finding that the multiply-operated patients continue to show very poor results, prompting White (1966) to note that "...damage to their (multiply-operated patients') productive capacity is in proportion to at least the square of the number of procedures." (p. 874). Also there is a suggestion that women may be poorer risks for surgery than men, Aitken (1952), for example, having found that 84% of women in his study had not returned to work. Against this background - tfhat is the difficulties in-orthopaedic diagnosis.-and the discouraging statistics of the success ofoperation in curing LBP disability, there has arisen a literature suggesting that the physician by repeated examinations and medical treatment may re-inforce the neurotic patient's psychopathology by giv.ing authoritative confirmation that something is, or may be, organically wrong (Aitken, 29 1952; A l v a r e z , 1953; L u c k , 1944; S a x e , 1944; Van d e r V a l k , 1965; W e i n s t e i n , 1968; W e i s s , 1969). L u c k (1946) h a s s t a t e d t h a t " . . . . . a t i n y m a r g i n a l o s t e o p h y t e , a s l i g h t m a l a l i g n m e n t o f a j o i n t , o r a m i n o r c o n g e n i t a l anomaly h a s b e e n h e l d up a l l t o o o f t e n a s t h e e t i o l o g y o f p u r e l y n e u r o t i c m u s c u l o s k e l e t a l symptoms" (p.221), and W i l t b e r g e r (1963) h a s s u g g e s t e d t h a t " s u r g i c a l b a c k c r i p p l e s " c a n be c r e a t e d b y r e l y i n g on s u r g e r y f o r t h i s t y p e o f p a t i e n t . T h e r e f o r e i t i s o f g r e a t i m p o r t a n c e t h a t a p s y c h o l o g i c a l d i a g n o s i s must be r e a c h e d on i t s own m e r i t s and n o t by e x c l u s i o n ( B e d b r o o k , 1968; L u c k , 1946). F o r t h e s e r e a s o n s o r t h o p a e d i s t s have i n c r e a s i n g l y t u r n e d t o p s y -c h i a t r i s t s and p s y c h o l o g i s t s f o r a i d i n the d i a g n o s i s o f d i f f i c u l t b a c k p a t i e n t s . The r e a l i z a t i o n s d i s c u s s e d i n t h e above p a r a g r a p h and t h e o r t h o p a e d i s t s ' s e a r c h f o r d i a g n o s t i c a i d a r e q u i t e o l d . The r e s p o n s e s f r o m p s y c h i a t r y and p s y c h o l o g y have however b e e n l e s s t h a n a d e q u a t e , p e r -haps a c c o u n t i n g f o r t h e f a c t t h a t o r t h o p a e d i s t s somet imes s t i l l t u r n t o t h e i r own " d e t e c t i v e " e x a m i n a t i o n p r o c e d u r e s r a t h e r t h a n u s e t h e s e r v i c e s o f t he o t h e r d i s c i p l i n e s i n o v e r a l l e v a l u a t i o n s o f LBP p a t i e n t s . P s y c h o l o g i c a l A s p e c t s o f Low B a c k P a i n A t l e a s t as e a r l y a s 1911 i t was s u g g e s t e d t h a t some c a s e s o f LBP have an " e m o t i o n a l " c a u s e ( C h a b o t , 1911). By W o r l d War I I t h i s theme b e g a n t o a p p e a r f r e q u e n t l y , p r o b a b l y b e c a u s e o f t h e m a g n i t u d e of t h e LBP p r o b l e m i n t h e armed f o r c e s ( e . g . , P a u l , 1950). A c o p i o u s l i t e r a -t u r e h a s s i n c e a c c u m u l a t e d s u g g e s t i n g s u n d r y n o n - o r g a n i c f a c t o r s u n d e r -l y i n g v a r y i n g p r o p o r t i o n s of t he LBP p r o b l e m . Though t h e a s s u m p t i o n i s f r e q u e n t l y made t h a t t h e b a s i s o f some LBP i s p s y c h o l o g i c a l , t h i s a s -s u m p t i o n h a s n o t b e e n a d e q u a t e l y t e s t e d ( W e s t r i n e t a l . , 1972). C e r -t a i n l y a p r o s p e c t i v e s t u d y d o c u m e n t i n g t h e p s y c h o l o g i c a l c h a r a c t e r i s t i c s o f f u t u r e LBP p a t i e n t s h a s n o t been d o n e . 30 The v a s t m a j o r i t y o f a r t i c l e s d i s c u s s i n g t h e p s y c h o l o g i c a l c h a r a c -t e r i s t i c s o f LBP p a t i e n t s a r e of q u e s t i o n a b l e s c i e n t i f i c m e r i t . P s y c h o -m e t r i c d a t a a r e r a r e l y p r e s e n t e d i n t h e s e a r t i c l e s and most o f t h e a r t i c l e s a r e s u b j e c t i v e s t a t e m e n t s o f c l i n i c a l e x p e r i e n c e o r p s y c h o -a n a l y t i c c o n c e p t u a l i z a t i o n s b a s e d on t he s t u d y o f a few c a s e s . E v e n v e r y r e c e n t l y an a r t i c l e has been p u b l i s h e d ( M e y e r s , 1967) s u g g e s t i n g a mechan ism f o r t h e p r o d u c t i o n o f LBP r e m i n i s c e n t of t h e 1 0 t h c e n t u r y c o n c e p t u a l i z a t i o n o f h y s t e r i a as t h e w a n d e r i n g o f t h e u t e r u s t h r o u g h t h e body ( U l l m a n and K r a s n e r , 1 9 6 9 , p . 1 1 5 ) : " . . . B a c k p a i n c a n . . . r e p r e s e n t a s h i f t o f s e x u a l s e n s u o u s n e s s t o t he b a c k i n t he f o r m o f p a i n . . . . W i t h t h e r a p y when t he f o c u s o f s e n s u o u s e x p e r i e n c e c a n be moved ou t o f t h e b a c k t o where i t b e l o n g s , i n t h e p e l v i s , t h e b a c k a c h e d i s a p p e a r s . " ( M e y e r s , 1 9 6 7 , p p . 1 5 6 - 1 5 7 ) . E v e n when l e s s b i z a r r e and more t e s t a b l e e x p l a n a t i o n s of t h e r e l a -t i o n s h i p b e t w e e n LBP and p s y c h o l o g i c a l f a c t o r s a r e o f f e r e d , an i n d i c a t i o n o f t h e methods o f p s y c h o l o g i c a l e v a l u a t i o n i s r a r e l y g i v e n . T h i s o m i s -s i o n may r e s u l t f r o m t h e f a c t t h a t i n t he s e a r c h f o r f a c t o r s t o e x p l a i n LBP t h e a n a l y s i s o f p s y c h o l o g i c a l c h a r a c t e r i s t i c s o f p a t i e n t s i s u s u a l l y s u b o r d i n a t e t o a n a l y s i s of p o s s i b l e o r g a n i c c a u s e s . I n a number o f more a d e q u a t e l y c o n t r o l l e d s t u d i e s , t h e M i n n e s o t a M u l t i p h a s i c P e r s o n a l i t y I n v e n t o r y (EMP'I) has b e e n u s e d t o a s s e s s t h e p s y c h o l o g i c a l c h a r a c t e r i s t i c s of LBP p a t i e n t s ( B e a l s and H i c k m a n , 1 9 7 2 ; H a n v i k , 1 9 4 9 ; P h i l l i p s , 1 9 6 4 ; W i l f l i n g e t a l . , 1 9 7 3 ) . H a n v i k ( 1 9 4 9 ) , i n a P h . D . t h e s i s a t t h e U n i v e r s i t y o f M i n n e s o t a , made u s e o f t h e MMPI i n t he s t u d y o f 60 p a t i e n t s h o s p i t a l i z e d w i t h L B P , 30 o f whom had a 31 c o n f i r m e d p r o t r u d e d i n t e r v e r t e b r a l d i s c ( o r g a n i c g roup ) and 30 o f whom had no c l e a r - c u t o r g a n i c f i n d i n g s ( f u n c t i o n a l g r o u p ) . I n a p a p e r p u b l i s h e d l a t e r , H a n v i k (1951) r e p o r t e d t h a t t he f u n c t i o n a l g roup showed s i g n i f i c a n t l y h i g h e r e l e v a t i o n s t h a n d i d t h e o r g a n i c g roup on t h e H y p o -c h o n d r i a s i s ( H s ) , D e p r e s s i o n ( D ) , H y s t e r i a ( H y ) , P s y c h a s t h e n i a ( P t ) , P s y c h o p a t h i c D e v i a t e (Pd) and S c h i z o p h r e n i a (Sc ) S c a l e s . The mean MMPI p r o f i l e o f t h e f u n c t i o n a l g roup e x h i b i t e d a " c o n v e r s i o n ' V " c o n f i g u r a t i o n on t h e n e u r o t i c t r i a d (D r e l a t i v e l y l o w e r t h a n Hs and H y ) . On a b a s i s o f t he t h e s i s d a t a , H a n v i k a l s o d e v e l o p e d a Low B a c k P a i n S c a l e f o r t h e MMPI d i f f e r e n t i a t i n g t h e s e two g roups o f p a t i e n t s . T h i s s c a l e was n o t p u b l i s h e d u n t i l much l a t e r (Hathaway and B r i g g s , 1957) and a p p a r e n t l y has n o t b e e n w i d e l y u s e d . P h i l l i p s , (1964) u s i n g t h e MMPI , compared 25 f e m a l e 0 and 33 ma le p a t i e n t s h a v i n g " l o w b a c k s y n d r o m e " , 25 f e m a l e s and 47 m a l e s h a v i n g f r a c t u r e s , and a c o n t r o l g r o u p . I t i s u n c l e a r what c r i t e r i a , i f a n y , we re u s e d i n t h e c h o i c e of t h e l o w b a c k syndrome g r o u p , and s t a t i s t i c a l a n a l y s i s was n o t p r e s e n t e d i n t h e p a p e r . H o w e v e r , i t a p p e a r s t h a t b o t h p a t i e n t g r o u p s had h i g h e r e l e v a t i o n s t h a n d i d t h e c o n t r o l s on t h e n e u r o t i c t r i a d ( H s , D and H y ) , t h e l ow b a c k syndrome g roup h a v i n g h i g h e r e l e v a t i o n s t h a n d i d t h e f r a c t u r e g r o u p . B e a l s and H i c k m a n (1972) s t u d i e d a t o t a l o f 180 ma le p a t i e n t s c h o s e n c o n s e c u t i v e l y f r o m p a t i e n t s d i s c h a r g e d d u r i n g 1964 by t he Oregon Workmen 's C o m p e n s a t i o n B o a r d D i s a b i l i t y P r e v e n t i o n D i v i s i o n . A t t h a t c e n t e r a team o f s p e c i a l i s t s make c o n c e r t e d e f f o r t s t o r e t u r n i n j u r e d w o r k e r s t o employment o r t o v o c a t i o n a l r e t r a i n i n g . C o m p a r i s o n s w e r e 32 made among a g roup o f 40 n o r m a l c o n t r o l s emp loyed i n Oregon i n d u s t r y and f i v e p a t i e n t g r o u p s : (A) 35 p a t i e n t s who had a m i n o r i n j u r y t o an e x t r e m i t y . (B) 35 p a t i e n t s who had a m a j o r i n j u r y t o a n e x t r e m i t y f r o m w h i c h r e s i d u a l d i s a b i l i t y was e x p e c t e d . (C) 35 p a t i e n t s who had had LBP f o r t h r e e months o r more w i t h o u t s u r g i c a l t r e a t m e n t . (D) 37 p a t i e n t s who had had one o p e r a t i v e p r o c e d u r e f o r LBP i n c l u d i n g a s p i n a l f u s i o n . (E) 38 p a t i e n t s who had had two o r more b a c k o p e r a t i o n s f o r LBP w i t h o u t r e t u r n i n g t o f u l l - t i m e emp loyment . B e a l s and H i ckman r e p o r t e d a h i g h l y s i g n i f i c a n t e l e v a t i o n o f t h e MMPI n e u r o t i c t r i a d f o r t h e b a c k - i n j u r e d p a t i e n t s ( g roups C , D and E ) , and a l e s s e r b u t s t i l l s i g n i f i c a n t i n c r e a s e f o r t h e e x t r e m i t y -i n j u r e d p a t i e n t s ( g r o u p s A and B) when compared t o t he n o r m a l c o n t r o l s . The d i f f e r e n c e s i n t h e n e u r o t i c t r i a d e l e v a t i o n s be tween t h e b a c k - i n j u r e d and e x t r e m i t y - i n j u r e d p a t i e n t s were s t a t i s t i c a l l y s i g n i f i c a n t and t h e d e g r e e o f n e u r o t i c d i s t u r b a n c e a c r o s s t he b a c k - i n j u r e d g r o u p s was s e e n t o i n c r e a s e w i t h i n c r e a s i n g p h y s i c a l d i s a b i l i t y ( n e u r o t i c symptoms: g roup E > g roup D > g roup C ) . A r e l a t i o n s h i p was a l s o n o t e d be tween t h e c o n f i g u r a t i o n o f t he n e u r o t i c t r i a d and t h e t i m e e l a p s e d s i n c e i n j u r y ; w i t h r e c e n t i n j u r y , t h e D e l e v a t i o n p r e d o m i n a t e d t h e n e u r o t i c t r i a d , w h e r e a s p a t i e n t s w i t h l o n g - t e r m i m p a i r m e n t showed h i g h e r e l e v a t i o n s on t he Hs and Hy S c a l e s w i t h a l o w e r e d D s c o r e ( i . e . , a " c o n v e r s i o n -V " c o n f i g u r a t i o n ) . The T o t a l A d j u s t m e n t S c o r e o f t h e MMPI and t h e P s y c h a s t h e n i a S c a l e a l s o showed the b a c k - i n j u r e d g r o u p s t o be more d i s t u r b e d t h a n t he e x t r e m i t y - i n j u r e d g r o u p s , t h e t r e n d f o r i n c r e a s i n g 33 d i s t u r b a n c e w i t h i n c r e a s i n g d i s a b i l i t y b e i n g shown. S c h i z o p h r e n i c symptoms, as i n d i c a t e d by t h e MMPI , we re a l s o s e e n t o be more p r e v a l e n t i n the b a c k - i n j u r e d a s compared t o t h e e x t r e m i t y - i n j u r e d , b u t t h e s e symptoms d e c r e a s e d a s o r g a n i c LBP d i s a b i l i t y i n c r e a s e d ( s c h i z o p h r e n i c symptoms: g roup C > g roup D > g roup E ) . The a u t h o r s s p e c u l a t e d t h a t t h e s e r e l a t i o n s h i p s " . . . m a y i n d i c a t e t h a t s u r g e r y p o t e n t i a t e s h y p o c h o n -d r i a c a l and h y s t e r i c a l symptoms so t h a t t h e n e u r o t i c d e f e n s e mechan isms p r o t e c t t he p a t i e n t m a k i n g t h e more s e r i o u s p s y c h o t i c f o r m o f a d j u s t m e n t p s y c h o l o g i c a l l y u n n e c e s s a r y " ( p . 1 5 9 9 ) . B e a l s and H i ckman a l s o s u c c e s s f u l l y f o l l o w e d up 151 o f t h e i n i t i a l 180 p a t i e n t s s i x , months a f t e r d i s c h a r g e f r o m t h e D i s a b i l i t y P r e v e n t i o n D i v i s i o n w i t h r e g a r d t o p a t i e n t employment s t a t u s . On d i s c h a r g e f r o m t h e D i s a b i l i t y P r e v e n t i o n D i v i s i o n , t h e p a t i e n t s had b e e n r a t e d by a p -p r o p r i a t e s p e c i a l i s t s i n r e g a r d t o t h e i r p h y s i c a l , v o c a t i o n a l (3ack o f s k i l l s ) and p s y c h o l o g i c a l d e f i c i t s . I t was f o u n d t h a t t h e p h y s i c a l and p s y c h o l o g i c a l r a t i n g s , b u t n o t t h e v o c a t i o n r a t i n g s , h a d p r o g n o s t i c v a l u e i n t e r m s of how many p a t i e n t s w e r e w o r k i n g a t s i x - m o n t h f o l l o w - u p . I t i s u n f o r t u n a t e , h o w e v e r , t h a t t h e p s y c h o l o g i c a l r a t i n g was done on a s u b j e c t i v e b a s i s r a t h e r t h a n by u s i n g a f o r m u l a t r a n s p o s i n g p s y c h o m e -4 t r i e d a t a t o a r a t i n g and t h a t r e g r e s s i o n a n a l y s i s o f p s y c h o m e t r i c d a t a f o r t h e p r e d i c t i o n o f f u t u r e employment was n o t r e p o r t e d i n t h e p u b l i s h e d s t u d y . I n t e r e s t i n g l y , b o t h p h y s i c i a n s and p s y c h o l o g i s t s made r a t i n g s M u n s i e , W. and H . May . P e r s o n a l c o m m u n i c a t i o n . 34 of t h e d e g r e e o f p s y c h o l o g i c a l i m p a i r m e n t l i k e l y t o i n t e r f e r e w i t h t h e p a t i e n t ' s r e t u r n t o w o r k . On s i x - m o n t h f o l l o w - u p , t h e p r o g n o s t i c v a l u e s o f b o t h r a t i n g s we re s e e n t o be s i m i l a r f o r t h e e x t r e m i t y -i n j u r e d p a t i e n t s , w h e r e a s o n l y t he p s y c h o l o g i s t ' s r a t i n g was o f p r o g -g n o s t i c v a l u e f o r b a c k - i n j u r e d p a t i e n t s . W i l f l i n g e t a l . , (1973) a l s o u s e d t h e MMPI i n t he e v a l u a t i o n of 26 ma le v e t e r a n s who had unde rgone l umbar s p i n a l f u s i o n . P a t i e n t s w e r e a s s i g n e d t o t h r e e g r o u p s on a b a s i s o f a c o m p o s i t e r a t i n g s c a l e o f d i s -a b i l i t y i n c o r p o r a t i n g t i m e - l o s s f r o m emp loymen t , p a i n , mo to r s i g n s , t h e p a t i e n t ' s o p i n i o n o f t h e e f f e c t s o f s u r g e r y , and t he o r t h o p a e d i s t ' s o p i n i o n o f t he p a t i e n t ' s d e g r e e of d i s a b i l i t y . I t was f o u n d t h a t t h e "poor , ! ' g :group ( p a t i e n t s s c o r i n g i n t h e h i g h e s t q u a r t i l e on t h e d i s a b i l i t y i n d e x ) showed s i g n i f i c a n t l y h i g h e r e l e v a t i o n s on t he Hs and D S c a l e s of t h e MMPI and s i g n i f i c a n t l y l o w e r e l e v a t i o n s on t h e E g o - S t r e n g t h (Es ) S c a l e t h a n d i d t h e good g roup ( p a t i e n t s s c o r i n g i n t h e l o w e s t q u a r t i l e o f t he d i s a b i l i t y i n d e x ) . The Es S c a l e has n o t b e e n r e p o r t e d i n t he o t h e r MMPI s t u d i e s o f LBP p a t i e n t s , b u t i t s i m p o r t a n c e may be s u p p o r t e d by S t e w a r t ' s f i n d i n g (1966) t h a t l o w e r e g o - s t r e n g t h was c h a r a c t e r i s t i c o f n u r s e s h a v i n g a h i g h f r e q u e n c y o f p h y s i c a l c o m p l a i n t s . The W i l f l i n g e t a l . a n a l y s i s a l s o i n c l u d e d H a n v i k ' s Low B a c k P a i n S c a l e , w h i c h was n o t f o u n d t o d i f f e r e n t i a t e t h e t h r e e g r o u p s . The q u e s t i o n of t h e s p e c i f i c r o l e p l a y e d b y d e p r e s s i o n i n LBP i s a n i n t e r e s t i n g o n e . W i t h o u t r e s t r i c t i n g t h e m s e l v e s t o LBP p a t i e n t s , T i n g l i n g and K l e i n (1966) f o u n d d e p r e s s i o n t o c h a r a c t e r i z e 14 c a s e s w i t h " p s y c h o g e n i c " p a i n , and L e s s e (1967) d e v e l o p e d t h e n o t i o n t h a t 35 hypochondriasis and psychosomatic d i s o r d e r s mask a more primary under-l y i n g depression. S p e c i f i c a l l y i n regard to LBP, Levine (1971) has shown from a review of the l i t e r a t u r e that depression i s as s o c i a t e d w i t h LBP and w i t h an increase i n i n t r a c e l l u l a r sodium. From these f a c t s Levine developed the hypothesis that depression may cause LBP by a pro-cess i n which sodium migrates from the vertebrae to the d i s c and produces d i s c s w e l l i n g . The r e l a t i o n s h i p between LBP and depression has a l s o r e c e n t l y been discussed by F o r r e s t and Wblkind C.1972) . Most t h e o r e t i c a l p o s i t i o n s d e a l i n g w i t h psychosomatics r e q u i r e that some source of chronic s t r e s s be present i n the p a t i e n t ' s l i f e . As the World Health Organization (WHO) Expert Committee (1964) noted i n t h e i r r e p o r t , Psychosomatic D i s o r d e r s , s t r e s s i s a key concept i n the e t i o l o g y of psychosomatic d i s o r d e r s . Although many areas of p o t e n t i a l s t r e s s have been suggested as being common to LBP p a t i e n t s , few have been adequately t e s t e d . With regard to the i n t e l l e c t u a l c a p a c i t i e s of back p a t i e n t s , the evidence i s c o n t r a d i c t o r y . Westrin et a l . (1972) noted that those l o s i n g time from work w i t h LBP have lower i n t e l l e c t u a l c a p a c i t y than do other compensation p a t i e n t s and MacNab (1969) reported that i n a compensation study 25% of those w i t h v a r i o u s i n j u r i e s were found to have i n t e l l i g e n c e quotients (IQs) under 90, whereas 42% of a s e r i e s of f a i l e d f u s i o n p a t i e n t s had IQs under that value. Beals and Hickman (1972) noted that t h e i r b a c k - i n j u r e d groups performed worse on both v e r b a l and non-verbal t e s t s of i n t e l l i g e n c e than d i d t h e i r e x t remity-i n j u r e d groups. Though the method of assessment r e f e r r e d to i s 36 u n c l e a r , Bond (1970) a l s o s u g g e s t e d t h a t p o o r - r e s u l t g roups o f LBP p a t i e n t s o f t e n have IQs b e l o w n o r m a l . P e r s i s t e n t p a i n p a t i e n t s (no t o n l y c h r o n i c LBP p a t i e n t s ) have a l s o been f o u n d t o h a v e l o w e r IQs t h a n t h o s e p a t i e n t s w i t h o u t p e r s i s t e n t p a i n ( M e r s k y , 1 9 6 5 ) . I n c o n t r a s t t o t h e s e f i n d i n g s , h o w e v e r , W i l f l i n g e t a l . , (1973) f o u n d h i g h a v e r a g e I Q s , as a s s e s s e d by t he W e c h s l e r A d u l t I n t e l l i g e n c e S c a l e , to c h a r a c -t e r i z e a l l g r o u p s o f t h e i r p o s t s p i n a l - f u s i o n p a t i e n t s . A c r i t i c a l d i f f e r e n c e may b e t h a t t h e W i l f l i n g e t a l . s t u d y was o f a v e t e r a n p o p u -l a t i o n , w h e r e a s t h e o t h e r LBP s t u d i e s q u o t e d d e a l t w i t h c o m p e n s a t i o n p o p u l a t i o n s . The r e l a t i o n s h i p be tween e d u c a t i o n and LBP i s a l s o v e r y u n c l e a r . W e s t r i n e t a l . (1972) and B e a l s and H i ckman (1972) r e p o r t e d LBP g r o u p s t o have l e s s e d u c a t i o n t h a n o t h e r c o m p e n s a t i o n p a t i e n t g r o u p s . W i l f l i n g e t a l . (1973) h o w e v e r , f o u n d t h a t e d u c a t i o n was n o t r e l a t e d t o t h e d e -g r e e o f d i s a b i l i t y i n p o s t s p i n a l - f u s i o n p a t i e n t s . To c o m p l e t e t h e s p e c t r u m o f c o n f u s i o n , Magora (1970) has r e p o r t e d a h i g h i n c i d e n c e o f LBP t o be a s s o c i a t e d w i t h h i g h l e v e l s o f e d u c a t i o n . H o w e v e r , i t seems t o be f e l t g e n e r a l l y t h a t t h e i l l - e d u c a t e d p a t i e n t i s a h i g h e r d i s a b i l i t y r i s k , p o s s i b l y b e c a u s e common s e n s e w o u l d s u g g e s t t h a t t h i s t y p e o f i n d i v i d u a l w o u l d be more d i f f i c u l t t o r e h a b i l i t a t e i f h i s p h y s i c a l p r o w e s s we re d i m i n i s h e d . Tha t t h e d i s a b l e d LBP p a t i e n t , and i n d e e d mos t p s y c h o s o m a t i c c a s e s , a r e p a r t i c u l a r l y a f f e c t e d by s t r e s s e s o f a s o c i a l n a t u r e due t o s o c i a l m a l a d j u s t m e n t s o r i n a d e q u a c i e s i s a v e r y f r e q u e n t a s s e r t i o n . The WHO E x p e r t Commi t tee (1964) , a f t e r n o t i n g t h a t s t r e s s i s a k e y c o n -c e p t i n e t i o l o g i c a l t h e o r i e s of p s y c h o s o m a t i c d i s o r d e r s , n o t e d t h a t 37 " I n t e r h u m a n r e l a t i o n s c o n s t i t u t e t h e e v e n t s o f g r e a t e s t i m p o r t a n c e " ( p . 8 ) . G a r n e r , W e n a r , Kuhn and Chapman ( 1 9 5 9 ) , i n a R o r s c h a c h i n -v e s t i g a t i o n f o u n d t h a t a p s y c h o s o m a t i c g roup o f c h i l d r e n wase l i m i t e d i n t h e c a p a c i t y f o r s o c i a l p a r t i c i p a t i o n , and W e i n s t e i n ( 1 9 6 8 ) , i n a s u p e r b a r t i c l e d i s c u s s i n g a d i s a b i l i t y a i d p r o g r a m , n o t e d t h a t c h r o n i c i l l n e s s c a n be an a c c e p t a b l e s o l u t i o n t o a p a t i e n t ' s l o n g s t a n d i n g c o n -f l i c t s i n l i v i n g , and t h a t s o c i a l and e m o t i o n a l t e n s i o n s a r e v e r y i m p o r t a n t s o u r c e s o f c o n f l i c t . Ho lmes and W o l f f (1952) i n a w i d e l y c i t e d , and p e r h a p s c l a s s i c a r t i c l e , " L i f e S i t u a t i o n s , E m o t i o n s and B a c k a c h e " d e v e l o p e d t h e t h e s i s t h a t LBP p a t i e n t s , b e c a u s e of d i f f i c u l -t i e s i n s o c i a l and i n t e r p e r s o n a l a d j u s t m e n t s , r e a c t w i t h " f l i g h t o r f i g h t " r e s p o n s e s i n s o c i a l s i t u a t i o n s , e n g e n d e r i n g g e n e r a l i z e d s k e l e t a l m u s c l e h y p e r f u n c t i o n w i t h LBP r e s u l t i n g by p h y s i c a l m e c h a n i s m s . These c o n c l u s i o n s we re drawn on t h e b a s i s o f a s t u d y of 65 LBP p a t i e n t s and 10 c o n t r o l s u s i n g i n t e r v i e w s and e l e c t r o m y o g r a p h i c m e a s u r e s . K r a u s r ( 1 9 7 0 ) , i n a r e c e n t b o o k , has s u g g e s t e d a s i m i l a r mechan ism w h i c h he b e l i e v e s p r o d u c e s 80% o r more o f LBP c a s e s . Ho lmes and W o l f f c o n c l u d e d " . . . i n most o f t h e 65 b a c k a c h e s u b j e c t s s t u d i e d i t was p o s s i b l e t o d e m o n s t r a t e a r e l a t i o n s h i p b e t w e e n e x a c e r b a t i o n o f symptoms and d i f f i -c u l t i e s i n i n t e r p e r s o n a l and s o c i a l a d j u s t m e n t s . . . . " ( p . 2 3 ) . P r o v i d i n g a d d i t i o n a l s u p p o r t f o r t h e n o t i o n t h a t LBP p a t i e n t s a r e d e f i c i e n t i n s o c i a l s k i l l s , W e s t r i h e t a l . (1972) f o u n d t h a t LBP c o m p e n s a t i o n p a t i e n t s d i d n o t e s t a b l i s h r a p p o r t w i t h t he s t u d y i n t e r v i e w e r as w e l l as d i d o t h e r c o m p e n s a t i o n p a t i e n t s . I n t h e l i g h t o f t he s u g g e s t i o n s o f t h e above p a r a g r a p h , i t i s 38 i n t e r e s t i n g t o n o t e t h e wo rk o f G r a c e and Graham (1952) w h i c h a s s o -c i a t e s a c h a r a c t e r i s t i c a t t i t u d e o f r u n n i n g f r o m s o u r c e s o f s t r e s s w i t h the LBP p a t i e n t . T h i s f i n d i n g w o u l d seem t o f a v o r t h e " f l i g h t " t e n d e n c y o f Ho lmes and W o l f f ' s (1952) f l i g h t o r f i g h t s e t . C o n s i s t e n t w i t h t h e f l i g h t r e s p o n s e - t e n d e n c y o f LBP p a t i e n t s i s a l s o t h e f r e q u e n t s u g g e s t i o n t h a t LBP p a t i e n t s a r e v o c a t i o n a l l y u n s t a b l e ( e . g . , C o l l e t e and L u d w i g , 1968; W e s t r i h e t a l . , 1972). H o w e v e r , C o l e t t e and L u d w i g (1968), who s p e c i f i c a l l y i n v e s t i g a t e d t h i s s u g g e s t i o n , d i d no t f i n d s u p p o r t f o r i t . M a r i t a l i n s t a b i l i t y w o u l d a l s o seem t o be c o n s i s t e n t w i t h a h y p o t h e s i s a t t r i b u t i n g i n t e r p e r s o n a l d i f f i c u l t i e s t o LBP p a t i e n t s . W e s t r i n e t a l . (1972) f o u n d t h a t LBP p a t i e n t s had more b r o k e n m a r r i a g e s - t h a n d i d o t h e r c o m p e n s a t i o n c a s e s . M o r e o v e r , B u r n s t e i r - (1965) h a s p r e -s e n t e d c o n v i n c i n g a n a l y s e s o f f a m i l y d y n a m i c s i l l u s t r a t i n g how s i c k n e s s may s e r v e as an a d j u s t i v e mechan ism i n m a r r i a g e . H o w e v e r , W i l f l i n g e t a l . . (1973) f o u n d t h a t a l t h o u g h m a r i t a l a b n o r m a l i t i e s we re v e r y common i n p o s t s p i n a l - f u s i o n p a t i e n t s , t h e s e a b n o r m a l i t i e s d i d n o t d i f f e r e n t i a t e among d i s a b i l i t y g r o u p s . The r o l e o f p a i n t o l e r a n c e h a s been s u g g e s t e d t o be i m p o r t a n t t o LBP d i s a b i l i t y , b u t t h i s s u g g e s t i o n h a s n o t b e e n t e s t e d . MacNab (1969) n o t e d t h a t d i s a b i l i t y c o n s i s t s o f p a i n and t h e p a t i e n t s ' r e a c t i o n s t o i t , b u t o n l y W h i t e (1966) a p p e a r s t o h a v e d i r e c t l y s u g g e s t e d t h a t p a i n t o l e r a n c e may be a n i m p o r t a n t f a c t o r i n t h e p r o g n o s i s o f b a c k s u r g e r y p a t i e n t s . P o s s i b l y r e l a t e d t o p a i n t o l e r a n c e a r e t h e e f f e c t s o f e t h n i c b a c k g r o u n d w h i c h a r e known t o be v e r y i n f l u e n t i a l i n t h e e x -p r e s s i o n o f p a i n ( Z b o r o w s k i , 1969). 39 T h a t " s i c k n e s s b e h a v i o r " may, a t l e a s t i n p a r t , s i m p l y c o n s i s t o f l e a r n e d b e h a v i o r s u s e d i n c o p i n g w i t h some a s p e c t s o f l i f e has b e e n s u g -g e s t e d by a number o f a u t h o r s ( F o r d y c e , F o w l e r , Lehman and D e L a t e u r , 1968; M e r s k y , 1965; Z i e g l e r , Imboden and R o d g e r s , 1963). H o w e v e r , an a s s o c i a t i o n be tween t h e e x p r e s s i o n of s i c k n e s s b e h a v i o r and s i c k n e s s -l e a r n i n g o p p o r t u n i t i e s , s u c h as h a v i n g p a r e n t s w i t h t h e same m a l a d y , does n o t a p p e a r t o have b e e n d e m o n s t r a t e d f o r LBP p a t i e n t s . O t h e r p s y c h o l o g i c a l c h a r a c t e r i s t i c s o f LBP p a t i e n t s h a v e b e e n s u g -g e s t e d l e s s f r e q u e n t l y o r l e s s c o n v i n c i n g l y . H o w e v e r , an e x t e n s i v e s e a r c h o f t he LBP l i t e r a t u r e and t h e l e s s s p e c i f i c p s y c h o s o m a t i c s l i t e r a -t u r e s o o n s u g g e s t s t h a t n e a r l y e v e r y p o s s i b l e human c h a r a c t e r i s t i c m i g h t p o t e n t i a l l y be p e r t i n e n t f o r s t u d y . C o n t e x t and G o a l s o f the P r e s e n t S t u d y The p r e s e n t s t u d y i s t h e s e c o n d i n a p l a n n e d s e r i e s o f s t u d i e s and i t s g o a l s a r e p e r h a p s b e s t u n d e r s t o o d i n t h a t p e r s p e c t i v e . The s e r i e s o f s t u d i e s h o p e f u l l y w i l l a l l o w an u n d e r s t a n d i n g o f t h e mechan ism of LBP and LBP d i s a b i l i t y t o be d e v e l o p e d o v e r t h e l o n g - t e r m . E a c h i n d i v i d u a l s t u d y , i t i s h o p e d , w i l l p r o v i d e some i m m e d i a t e b e n e f i t s f o r p a t i e n t management and add t o a f o u n d a t i o n of k n o w l e d g e on w h i c h f o l -l o w i n g s t u d i e s c a n be b a s e d . Two r e t r o s p e c t i v e s t u d i e s of s p i n a l - f u s i o n p a t i e n t s , t h e e x p l o r a -t o r y s t u d y ( S t u d y I; W i l f l i n g e t a l . , 1973) and t h e p r e s e n t s t u d y ( S t u d y I I ) , f o r s e v e r a l r e a s o n s w e r e t h o u g h t t o be t h e b e s t p o i n t s f o r b e g i n n i n g t h e s e r i e s of s t u d i e s . F i r s t l y , t o e s t a b l i s h w h i c h s u b j e c t c h a r a c t e r i s t i c s 40 a r e a s s o c i a t e d w i t h LBP d i s a b i l i t y , t he s t u d y o f a g roup i n w h i c h d i s -a b i l i t y i s a l r e a d y e s t a b l i s h e d i s most e f f i c i e n t . P r a g m a t i c a l l y , t h e e c o n o m i c s o f s e a r c h i n g f o r and e v a l u a t i n g p e r t i n e n t v a r i a b l e s a r e more f a v o r a b l e i n a r e t r o s p e c t i v e r a t h e r t h a n i n a p r o s p e c t i v e s t u d y . S e c o n d l y , t h e g r e a t e s t c o n t r a s t s i n s u b j e c t c h a r a c t e r i s t i c s we re e x p e c t e d w i t h i n a p o s t - f u s i o n g r o u p . As n o t e d a b o v e , t h e most c h r o n i c LBP p a t i e n t s g r a v i t a t e t o w a r d s and c o l l e c t i n t h e p o s t - f u s i o n g roup w h e r e a s , p e r h a p s f o l l o w i n g t r a u m a , some p a t i e n t s r e c e i v e a s p i n a l f u s i o n and become a s y m p t o m a t i c . The g r e a t e s t c o n t r a s t s i n s u b j e c t c h a r a c t e r i s t i c s r e l a t e d t o LBP d i s a b i l i t y l i k e l y w o u l d a p p e a r be tween t h e s e two s u b g r o u p s o f s u b j e c t s . T h i r d l y , t h e i m m e d i a t e need f o r d i a g n o s i s and t r e a t m e n t i n -s i g h t s i s p e r h a p s g r e a t e s t f o r p o s t - f u s i o n p a t i e n t s who c o n t i n u e t o h a v e c h r o n i c L B P . The p u r p o s e o f S t u d y I was t o e s t a b l i s h t h a t p s y c h o m e t r i c a l l y d o c u m e n t a b l e a b n o r m a l i t i e s a r e i n d e e d r e l a t e d t o t h e d e g r e e o f LBP d i s -a b i l i t y . Tha t a s s o c i a t i o n had n o t b e e n shown b y t h e two p s y c h o m e t r i c s t u d i e s p u b l i s h e d b e f o r e t h a t t i m e ( H a n v i k , 1951; P h i l l i p s , 1964). S t u d y I a l s o a l l o w e d t h e deve lopmen t o f m e t h o d o l o g i c a l p r o c e d u r e s and p r o v i d e d t he i n v e s t i g a t o r s w i t h an e x p o s u r e t o and " f e e l " f o r t h e LBP p r o b l e m . The g e n e r a l p u r p o s e o f S t u d y I I was t o e v a l u a t e a l a r g e number o f v a r i a b l e s i n t he hope o f f i n d i n g many c o r r e l a t e s o f LBP d i s a b i l i t y . These c o r r e l a t e s c o u l d t h e n be u s e d f o r d e r i v i n g s t a t i s t i c a l l y i n d e -p e n d e n t b a s i c d i m e n s i o n s u n d e r l y i n g a l a r g e p r o p o r t i o n o f LBP d i s a b i l i t y , as w e l l a s b e i n g u s e d t o p r o v i d e i n s i g h t s i n t o o t h e r s u b s i d i a r y q u e s t i o n s . 41 A g a i n i t was hoped t h a t i m m e d i a t e b e n e f i t s f o r t h e management o f p o s t -f u s i o n p a t i e n t s as w e l l as a f o u n d a t i o n o f k n o w l e d g e f o r f u r t h e r s t u d i e s w o u l d be p r o v i d e d by S t u d y I I . The s p e c i f i c g o a l s o f t h e p r e s e n t s t u d y w e r e as f o l l o w s : 1. D e r i v a t i o n o f t h e d i s a b i l i t y i n d e x The d i s a b i l i t y i n d e x p r o v i d e s a s t a t e m e n t o f "how bad o f f " t h e i n d i v i d u a l s u b j e c t s a r e and i s u s e d i n a s t a t i s t i c a l c o m p a r i s o n w i t h a l l o t h e r v a r i a b l e s f o r t h e p u r p o s e o f f i n d i n g t h e c o r r e l a t e s o f d i s a b i l i t y . Thus t h e d i s a b i l i t y i n d e x i s one o f t h e most i m p o r t a n t f e a t u r e s o f any d i s a b i l i t y s t u d y b e c a u s e i t i s t h e benchmark t o w h i c h a l l f u r t h e r a n a l y s e s i n t h e s t u d y r e l a t e . F o r r e a s o n s a l r e a d y d i s c u s s e d a b o v e , t h e d e c i s i o n was made t o f a c t o r - a n a l y t i c a l l y d e r i v e a d i s a b i l i t y i n d e x f r o m v a r i a b l e s r e f l e c t i n g s u b j e c t i m p a i r m e n t i n a w i d e r a n g e o f t h e a c t i v i t i e s o f d a i l y l i v i n g . 2 . C o r r e l a t e s o f d i s a b i l i t y S t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t e s o f d i s a b i l i t y w e r e s o u g h t by c o r r e l a t i n g v a r i a b l e s r e f l e c t i n g s u b j e c t c h a r a c t e r i s t i c s w i t h t h e d i s a b i l i t y i n d e x . B e c a u s e t he l i t e r a t u r e c o n t a i n s so many p o o r l y -f o u n d e d s u g g e s t i o n s o f w h i c h o r g a n i c and p s y c h o l o g i c a l v a r i a b l e s m i g h t be p e r t i n e n t t o the LBP d i s a b i l i t y p r o b l e m , and b e c a u s e i t was d e s i r e d t h a t a l a r g e p o r t i o n o f LBP d i s a b i l i t y be c o v e r e d , a " b l u n d e r b u s s " i n -v e s t i g a t i o n t e c h n i q u e seemed a p p r o p r i a t e . T h e r e f o r e , a s many v a r i a b l e s as were s u g g e s t e d by t h e l i t e r a t u r e o r b y s u b j e c t i v e i m p r e s s i o n s g a i n e d d u r i n g S t u d y I were documented and l a t e r c o r r e l a t e d w i t h t h e d i s a b i l i t y i n d e x . T h i s e x p e r i m e n t a l p r o c e d u r e c o u l d be l i k e n e d t o " s e p a r a t i n g 42 t h e g r a i n f r o m the c h a f f . " 3 . O v e r l a p s i n measurement among o r t h o p a e d i c and p s y c h o l o - g i c a l v a r i a b l e s The o r t h o p a e d i c and p s y c h o l o g i c a l v a r i a b l e s we re c o r r e l a t e d i n t h e p r e s e n t s t u d y so t h a t any o v e r l a p s i n measurement among them c o u l d be s e e n . T h a t s u c h o v e r l a p s i n measurement m igh t e x i s t became s u b -j e c t i v e l y a p p a r e n t d u r i n g Study- I. F o r e x a m p l e , t h e r a n g e o f m o t i o n shown i n a t o e - t o u c h i n g a t t e m p t i n t h e o r t h o p a e d i c e x a m i n a t i o n a p p e a r e d i n a l l l i k e l i h o o d t o r e f l e c t t h e s u b j e c t s ' n e u r o t i c s t a t u s whe reas t he n e u r o t i c i s m shown on t he MMPI c o m p l e t e d i n t h e p s y c h o l o g i c a l e x a m i n a t i o n a p p e a r e d i n a l l l i k e l i h o o d t o r e f l e c t t he s u b j e c t s ' o r g a n i c s t a t u s . A w a r e n e s s o f s u c h o v e r l a p s i n measurement i s i m p o r t a n t b e c a u s e a r e d u n -d a n c y w o u l d r e s u l t i n j o i n t o r t h o p a e d i c and p s y c h o l o g i c a l a s s e s s m e n t s o f p a t i e n t s i f s u c h o v e r l a p s e x i s t e d b u t we re no t t a k e n i n t o a c c o u n t . 4 . D e r i v a t i o n of t h e b a s i c d i m e n s i o n s o f LBP d i s a b i l i t y I n o r d e r t o i d e n t i f y o r t h o g o n a l ( i n d e p e n d e n t o r s t a t i s t i c a l l y u n r e l a t e d ) b a s i c d i m e n s i o n s ( f a c t o r s ) o f d i s a b i l i t y , t h e c o r r e l a t e s o f d i s a b i l i t y f o u n d by s t e p 2 above we re f a c t o r - a n a l y z e d . T h i s a n a l y s i s was u n d e r t a k e n b e c a u s e i n d e p e n d e n t c o n t r i b u t i o n t o d i s a b i l i t y c a n n o t ; b e i n f e r r e d f r o m c o r r e l a t e s of d i s a b i l i t y b u t c a n be i n f e r r e d f r o m o r t h o -g o n a l f a c t o r s f o u n d to u n d e r l y s u c h c o r r e l a t e s . The c o n t r i b u t i o n s ' " o f t h e s e b a s i c d i m e n s i o n s t o LBP d i s a b i l i t y w e r e q u a n t i f i e d by c o r r e l a t i n g t he s u b j e c t s c o r e s on e a c h o f t h e d e r i v e d b a s i c d i m e n s i o n s ( f a c t o r s c o r e s ) w i t h t he d i s a b i l i t y i n d e x . 43 5 . Syndrome Complex Groups An i m p o r t a n t q u e s t i o n b o t h i n t e r m s o f t h e l i t e r a t u r e and t he d e -s i g n o f t r e a t m e n t p rog rams i s w h e t h e r o r n o t LBP d i s a b i l i t y p a t i e n t s can be d i v i d e d i n t o p r e d o m i n a n t l y " p s y c h o g e n i c " o r p r e d o m i n a n t l y " o r g a n i c " g r o u p s . A n i n s i g h t i n t o t h i s q u e s t i o n was s o u g h t by g e n e r a t i n g a p r o f i l e f o r e a c h s u b j e c t on t h e b a s i c d i m e n s i o n s o f d i s a b i l i t y and t h e n s t a t i s t i c a l l y s o r t i n g t h e s u b j e c t s ' p r o f i l e s i n t o g r o u p s on t h e b a s i s o f p r o f i l e s i m i l a r i t y . The r e s u l t a n t h o m o g e n e o u s - p r o f i l e g r o u p s c o u l d be t h o u g h t o f as " t y p e s " o f LBP d i s a b i l i t y p a t i e n t s , t h e mean p r o f i l e on t h e b a s i c d i m e n s i o n s o f d i s a b i l i t y f o r e a c h g roup c o n s t i t u t i n g a "Syndrome C o m p l e x . " 44 Method I n v e s t i g a t o r s The p r e s e n t s t u d y i s t h e w o r k o f t h r e e i n v e s t i g a t o r s who a r e r e f e r r e d t o i n t h i s p a p e r as t h e " r e s e a r c h g r o u p . " The o r t h o p a e d i s t s r e f e r r e d t o a r e D r . P . K o k a n , M D . , FRCS ( £ ) t w h o i s t h e Head o f t h e r e s e a r c h g r o u p , and D r . P . W i n g , M B . , C h . B , w h o i s an o r t h o p a e d i c r e s e a r c h f e l l o w . The p r e s e n t a u t h o r i s t h e p s y c h o l o g i s t r e f e r r e d t o . A l l s u b j e c t s e x a m i n a t i o n s we re p e r f o r m e d by t h e l a t t e r two i n d i v i d u a l s . Sub j e c t s The s u b j e c t s o f t h i s s t u d y w e r e 92 men and e i g h t women w i t h a mean age o f 4 4 . 1 y e a r s ( S t a n d a r d D e v i a t i o n (SD) = 8 . 9 y e a r s ; r a n g e 22 -67 y e a r s ) . A l l w e r e C a u c a s i a n s w i t h t h e e x c e p t i o n o f one m a l e N o r t h A m e r i c a n I n d i a n . T h e s e s u b j e c t s we re a l l r e s i d e n t s o f B r i t i s h C o l u m b i a who had u n d e r g o n e t h e i r l a s t l u m b a r s p i n a l f u s i o n a t t h e l i a b i l i t y o f t h e WCB o f B r i t i s h C o l u m b i a i n t h e p e r i o d be tween 1965 and 1 9 6 9 . A l l s u c h s u b j e c t s s t i l l r e s i d i n g i n B r i t i s h C o l u m b i a w e r e c a l l e d . The s u b j e c t s w e r e c h o s e n f r o m t h e f i l e s o f t h e WCB b e g i n n i n g w i t h t h o s e h a v i n g had t h e i r l a s t l umbar s p i n a l f u s i o n two y e a r s p r i o r t o t h e b e g i n n i n g o f t h e p r e s e n t i n v e s t i g a t i o n . A l l names o f p a t i e n t s h a v i n g unde rgone l umbar s p i n a l f u s i o n w e r e t h e n drawn i n a c h r o n o l o g i c a l l y r e t r o g r a d e f a s h i o n u n t i l 100 s u b j e c t s had been s t u d i e d . The WCB. f i l e s w e r e c r o s s - i n d e x e d by t y p e o f o p e r a t i o n f o r t h e p e r i o d f r o m 1969 t o m i d - 1 9 6 6 . B e f o r e m i d - 1 9 6 6 c r o s s - i n d e x i n g had n o t b e e n d o n e , and a p h y s i c a l f i l e - s e a r c h o f a p p r o x i m a t e l y one y e a r ' s r e c o r d s was t h e r e f o r e n e c e s s a r y to c o m p l e t e t h e s u b j e c t q u o t a . I n a l l , t h e names o f 141 45 p o t e n t i a l s u b j e c t s w e r e r e t r i e v e d f r o m t h e WCB f i l e s b e f o r e t h e s t u d y q u o t a o f 100 s u b j e c t s was r e a c h e d . Of t h e 41 p o t e n t i a l s u b j e c t s n o t s t u -d i e d , s i x w e r e f o u n d t o be d e c e a s e d , 20 c o u l d n o t b e c o n t a c t e d , and 14 c o u l d n o t a t t e n d f o r v a r i o u s r e a s o n s . One s u b j e c t was s t u d i e d , b u t a l l h i s d a t a was d i s c a r d e d b e c a u s e o f t h e p o o r q u a l i t y o f h i s r o e n t g e n o g r a m s . M e a s u r e s P s y c h o l o g i c a l and d e m o g r a p h i c c h a r a c t e r i s t i c s o f s u b j e c t s w e r e documented i n t h e p r e s e n t s t u d y by t h e u s e o f f i v e p s y c h o l o g i c a l t e s t s , a p a i n t o l e r a n c e m e a s u r e , and by numerous q u e s t i o n s a s k e d i n s t r u c t u r e d i n t e r v i e w s by b o t h t h e o r t h o p a e d i s t and p s y c h o l o g i s t . The MMPI was u s e d t o document t h e c l i n i c a l c h a r a c t e r i s t i c s o f t h e s u b j e c t s and a number o f e x p e r i m e n t a l MMPI s c a l e s w e r e s c o r e d i n a d d i t i o n t o t h e u s u a l c l i n i c a l and v a l i d i t y s c a l e s . The e x p e r i m e n t a l s c a l e s u s e d w e r e t h e Es S c a l e ( B a r r o n , 1 9 5 3 ) , t h e Low B a c k P a i n S c a l e ( H a n v i k , 1949) and t h e Iowa M a n i f e s t A n x i e t y S c a l e ( T a y l o r , 1 9 5 3 ) . The c r i t i c a l i t e m s f o r t h e s e t h r e e s c a l e s we re f o u n d i n An MMPI Handbook ( D a h l s t r o m and W e l s h , 1960) and w e r e u s e d t o p r o d u c e h a n d s c o r i n g t e m p l a t e s . T - s c o r e c o n v e r s i o n v a l u e s f o r t h e Es S c a l e w e r e f o u n d i n A h MMPI Handbook and t h e T - s c o r e c o n v e r s i o n v a l u e s f o r t h e Low B a c k P a i n S c a l e w e r e f o u n d i n an a r t i c l e by Hathaway and B r i g g s ( 1 9 5 7 ) . The B e c k I n v e n t o r y o f D e p r e s s i o n ( B e c k I . D . ; B e c k , W a r d , M e n d e l s o n , Mock and E r b a u g h , 1961) was u s e d i n t h i s s t u d y i n a d d i t i o n t o t h e MMPI d e p r e s s i o n m e a s u r e . T h i s was done b e c a u s e t h e r e l a t i o n s h i p b e t w e e n d e p r e s s i o n and LBP may be o f s p e c i a l i n t e r e s t and b e c a u s e t h e D S c a l e o f t h e MMPI may be o f q u e s t i o n a b l e v a l u e i n m e a s u r i n g a n y t h i n g t h a t c o u l d 46 j u s t i f i a b l y be t h o u g h t of a s d e p r e s s i o n (Comrey , 1957). The B e c k I . D . was c h o s e n b e c a u s e o f i t s b r e v i t y and b e c a u s e i t h a s been shown t o be v a l i d i n s e v e r a l f a c t o r a n a l y t i c s t u d i e s ( C r o p l e y and w e c k o w i c z , 1966; W e c k o w i c z , M u i r and C r o p l e y , 19 67). A p s y c h o m e t r i c i n s t r u m e n t w h i c h a l l o w s q u a n t i f i c a t i o n o f a s u b -j e c t ' s p h e n o m e n o l o g i c a l w o r l d i n t e rms o f t h e l i f e g o a l s he deems d e s i r a b l e and h i s s u c c e s s i n a t t a i n i n g t h o s e g o a l s was a l s o u s e d i n t h e p r e s e n t s t u d y . T h i s i n s t r u m e n t was u s e d b e c a u s e d u r i n g S t u d y I i t became s u b j e c t i v e l y a p p a r e n t t h a t many LBP d i s a b i l i t y p a t i e n t s we re v e r y f r u s t r a t e d i n a t t a i n i n g s e e m i n g l y u n r e a l i s t i c l i f e g o a l s . The i n s t r u m e n t u s e d i n t h e p r e s e n t s t u d y ( K - C S c a l e ) was w i t h m i n o r m o d i f i c a t i o n s p a t -t e r n e d a f t e r a " S e l f - A n c h o r i n g S c a l e " d e s c r i b e d by K i l p a t r i c k and C a n t r i l (1960). The s u b j e c t s were a s k e d t o d e f i n e t h e ends o f a g r a p h i c t e n -r u n g l a d d e r w i t h what t h e y c o n s i d e r e d t o be t h e i d e a l and v e r y w o r s t l i f e s i t u a t i o n s . They we re t h e n a s k e d t o i n d i c a t e where on t h i s f i g u r a t i v e " l a d d e r of l i f e " t h e y s t o o d i m m e d i a t e l y p r e c e d i n g t h e o n s e t o f t h e i r b a c k p r o b l e m s , where t h e y s t o o d a t t he t i m e o f e x a m i n a t i o n , and where t h e y t h o u g h t t h e y w o u l d s t a n d f i v e y e a r s i n t he f u t u r e . The K - C S c a l e and s t a n d a r d i z e d i n s t r u c t i o n s u s e d i n t h e p r e s e n t s t u d y a r e p r e s e n t e d h e r e i n A p p e n d i x A . The C a l i f o r n i a P s y c h o l o g i c a l I n v e n t o r y ( C P I ; Gough , 1957) was u s e d t o t e s t the r e p e a t e d s u g g e s t i o n s i n t h e l i t e r a t u r e t h a t LBP p a t i e n t s a r e d e f i c i e n t i n s o c i a l and i n t e r p e r s o n a l s k i l l s . The CPI was c h o s e n b e c a u s e t h e l i t e r a t u r e i s v e r y vague r e g a r d i n g t he e x a c t n a t u r e o f t h e s e d e f i c i t s and b e c a u s e the CPI h a s b e e n p u r p o r t e d t o " . . . p r e d i c t . . . j u s t 47 abou t e v e r y t h i n g t h a t happens i n i n t e r p e r s o n a l l i f e . " (Gough , 1 9 7 1 ) . S t a n d a r d s c o r e s on a l l 18 common ly -used CP I s c a l e s w e r e a n a l y z e d . The C u l t u r e F a i r I n t e l l i g e n c e T e s t , S c a l e 2 , Form A ( C a t t e l l and C a t t e l l , 1957) was u s e d t o t e s t t he r e p e a t e d s u g g e s t i o n s i n t h e l i t e r a -t u r e t h a t LBP p a t i e n t s a r e i n t e l l e c t u a l l y d e f i c i e n t . T h i s t e s t was a d o p t e d b e c a u s e o f i t s b r e v i t y , b e c a u s e many s u b j e c t s d e f i c i e n t i n t h e u s e o f t h e E n g l i s h l a n g u a g e were e x p e c t e d , and b e c a u s e i t w o u l d a p p e a r t o be l e s s p r o n e t o t h e e f f e c t s o f e d u c a t i o n . A s t a n d a r d i z e d p a i n t o l e r a n c e m e a s u r e , i n t h e f o r m o f t h e w i d e l y u s e d i c e - c u b e s - i n - w a t e r C o l d P r e s s o r T e s t , was a l s o i n c l u d e d i n t h e p r e s e n t s t u d y . S t a n d a r d i z e d i n s t r u c t i o n s and p r o c e d u r e s f o r t h i s t e s t we re d e v i s e d b e c a u s e t h e y a r e n o t r e a d i l y a v a i l a b l e and y e t a r e o f c r i t i c a l i m p o r t a n c e t o t h e m e a n i n g f u l n e s s o f t h e t e s t r e s u l t s ( K a n f e r and G o l d f o o t , . 1966 ) . These d e t a i l s a r e p r e s e n t e d i n A p p e n d i x B. To p r e v e n t c o n f u s i o n w i t h i n m e d i c a l c i r c l e s , where t he C o l d P r e s s o r T e s t o r i g i n a t e d and i s a s s o c i a t e d w i t h t h e e v a l u a t i o n o f h y p e r t e n s i o n , t h e p a i n t o l e r a n c e measure i n t h e p r e s e n t s t u d y was renamed t h e C o l d T o l e r a n c e T e s t . S t r u c t u r e d p a t i e n t i n t e r v i e w s were d e s i g n e d by b o t h t h e o r t h o -p a e d i s t and p s y c h o l o g i s t as e c o n o m i c a l means o f s e a r c h i n g f o r o t h e r p o s s i b l e c o r r e l a t e s of LBP d i s a b i l i t y . Many o f t he q u e s t i o n s o f p s y c h o l o -g i c a l i n t e r e s t a s k e d i n t h e s e i n t e r v i e w s f o l l o w e d f r o m weak s u g g e s t i o n s i n t h e l i t e r a t u r e , b u t many we re f r a n k l y s p e c u l a t i v e i n o r i g i n o r w e r e i n c l u d e d b e c a u s e t h e y seemed " s t a n d a r d i n t e r v i e w q u e s t i o n s . " The q u e s t i o n s w h i c h were a s k e d may be s e e n i n t h e d o c u m e n t a t i o n f o r m s w h i c h 48 were u s e d i n t h e p r e s e n t s t u d y and a r e i n c l u d e d h e r e i n A p p e n d i c e s C and D. The o r t h o p a e d i c measu res w h i c h w e r e documented i n t h e p r e s e n t s t u d y may be s e e n i n t he o r t h o p a e d i s t s ' d o c u m e n t a t i o n fo rms i n c l u d e d h e r e i n A p p e n d i x C , o r may be f o u n d f u r t h e r e l a b o r a t e d i n Wing ( 1 9 7 3 ) . M a t e r i a l s Forms were n o t a v a i l a b l e f o r d o c u m e n t i n g most o f t h e e x a m i n a t i o n p r o c e d u r e s o f t h e p r e s e n t s t u d y . C o n s e q u e n t l y , f i v e d o c u m e n t a t i o n fo rms we re d e v i s e d by t h e o r t h o p a e d i s t s and p s y c h o l o g i s t t o a i d i n s t r u c t u r i n g s t a n d a r d i z e d e x a m i n a t i o n p r o c e d u r e s , t o a l l o w d a t a r e c o r d i n g c o n c u r r e n t t o t h e s e p r o c e d u r e s , and t o a i d i n s u m m a r i z i n g t he r o e n t g e n o l o g i c a l and p s y c h o m e t r i c d a t a . On t h e b a s i s o f t h e i r c l i n i c a l t r a i n i n g and e x p e r i e n c e , e x p e r i e n c e s f r o m S t u d y I, and s u g g e s t i o n s f r o m the l i t e r a t u r e , t h e o r t h o p a e d i s t s d e v i s e d t h r e e f o r m s : (1) P a t i e n t S e l f - e v a l u a t i o n Form (2) B a c k S u r g e r y Form (3) X - r a y A s s e s s m e n t Form C o p i e s o f t h e s e f o r m s , as u s e d d u r i n g t he s t u d y , , a r e p r e s e n t e d h e r e i n A p p e n d i x C. B r i e f l y , t h e P a t i e n t S e l f - e v a l u a t i o n Form c o n s i s t s o f q u e s t i o n s as t o t h e c h a r a c t e r i s t i c s , l o c a t i o n , and d e g r e e o f p a i n , t h e c o n d i t i o n s w h i c h e x a c e r b a t e o r a m e l i o r a t e p a i n , and t he e f f e c t s o f t h i s p a i n on t he a c t i v i t i e s o f d a i l y l i v i n g . T h i s f o r m , c o m p l e t e d f i r s t i n t h e o r t h o p a e d i s t ' s e x a m i n a t i o n p r o c e d u r e , was a s e l f - a d m i n i s t e r e d f o r m 49 on w h i c h t he s u b j e c t s answered t h e q u e s t i o n s as t h e y a p p l i e d a t t h e t i m e o f e x a m i n a t i o n , and as t h e y w e r e remembered t o have a p p l i e d one month p r i o r t o t he l a s t s p i n a l f u s i o n . The Back S u r g e r y F o r m , c o m p l e t e d by t h e o r t h o p a e d i s t c o n c u r r e n t t o h i s e x a m i n a t i o n o f t h e s u b j e c t s , i n c l u d e d s o c i a l h i s t o r y i t e m s s u c h a s t h o s e w h i c h u s u a l l y accompany an o r t h o p a e d i c e x a m i n a t i o n , a h i s t o r y o f t h e s u b j e c t s ' b a c k p r o b l e m s , and t h e f i n d i n g s o f t h e g e n e r a l m e d i c a l e x a m i n a t i o n s and t h e c o m p r e h e n s i v e o r t h o p a e d i c / n e u r o l o g i c a l e x a m i n a t i o n s o f t h e b a c k and l o w e r e x t r e m i t i e s . I n c l u d e d a t t h e end o f t h i s f o r m w e r e a number o f p s y c h o l o g i c a l p a r a m e t e r s w h i c h t h e o r t h o p a e d i s t r a t e d a f t e r s e e i n g the s u b j e c t s , and s p a c e f o r r e c o r d i n g t h e r e s u l t s o f t h e C o l d T o l e r a n c e T e s t . The X - r a y A s s e s s m e n t Form was d e s i g n e d as an a i d f o r r e c o r d i n g d a t a f r o m a n a l y s i s of t h e n i n e r o e n t g e n o g r a m s t a k e n o f e a c h s u b j e c t . C o n g e n i t a l a n o m a l i e s , p a t h o l o g i c a l s t a t e s , c h a r a c t e r i s t i c s o f t h e f u s i o n , and s i z e s and a n g l e s o f v a r i o u s e l e m e n t s o f t h e lumbar s p i n e w e r e r e c o r d e d . The P s y c h o l o g i c a l I n t e r v i e w F o r m , i n c l u d e d h e r e i n A p p e n d i x D, was d e v i s e d on t h e b a s i s o f i n d i c a t i o n s f r o m t h e l i t e r a t u r e and f r o m s u b -j e c t i v e i m p r e s s i o n s f o rmed i n t he c o u r s e o f S t u d y I. T h i s f o r m , w i t h q u e s t i o n s o c c u r r i n g i n an o r d e r c o n d u c i v e t o a f r e e l y - f l o w i n g i n t e r v i e w , was u s e d t o g u i d e and c o n c u r r e n t l y r e c o r d t h e d a t a f r o m t h e s t r u c t u r e d p a t i e n t i n t e r v i e w . To e x p e d i t e compute r c a r d p u n c h i n g , a D a t a Summary Form was d e v i s e d f o r r e c o r d i n g the a c c u m u l a t e d p s y c h o m e t r i c t e s t r e s u l t s . T h i s f o r m i s a l s o p r e s e n t e d i n A p p e n d i x D. 50 P r o c e d u r e A f t e r t h e names o f p o t e n t i a l s u b j e c t s w e r e r e t r i e v e d f r o m t h e r e c o r d s o f t h e WCB, a r e v i e w o f e a c h i n d i v i d u a l ' s m e d i c a l f i l e was u n d e r -t a k e n t o a s s u r e h i s s u i t a b i l i t y as a s u b j e c t — t h a t i s , t h a t he had i n d e e d had a l u m b a r s p i n e f u s i o n and had n o t had - .ano the r w i t h i n two y e a r s p r i o r t o t h e p r e s e n t s t u d y . A summary o f t h e f i l e was d i c t a t e d f o r f u t u r e r e f e r e n c e i n t h e e v e n t t h a t v a l i d a t i o n o f i n f o r m a t i o n g a t h e r e d i n t h e c o u r s e o f t h e r e s e a r c h i n t e r v i e w s seemed n e c e s s a r y and a l s o b e c a u s e t he o r t h o p a e d i s t was i n t e r e s t e d i n o p e r a t i v e n o t e s and f i n d i n g s . A l e t t e r b e a r i n g t h e l e t t e r h e a d o f t h e D e p a r t m e n t o f Trauma R e s e a r c h , D i v i s i o n o f O r t h o p a e d i c s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , was s e n t t o e a c h p o t e n t i a l s u b j e c t r e q u e s t i n g h i s o r h e r a t t e n d a n c e a t t h e r e s e a r c h p r o g r a m . T h i s l e t t e r s t r e s s e d t h e c o n f i d e n t i a l i t y o f i n f o r m a t i o n g a t h e r e d d u r i n g t he r e s e a r c h and o u t l i n e d t h e d u r a t i o n o f e x a m i n a t i o n and t h e l i m i t s o f r e i m b u r s e m e n t . Re imbursement was l i m i t e d b y t h e g r a n t i n g a g e n c y t o t r a v e l , m e a l , and l o d g i n g e x p e n s e s , and a maximum o f one d a y ' s wage l o s s . An a p p o i n t m e n t d a t e was g i v e n i n t h e l e t t e r and a r e q u e s t was made t h a t t h e r e s e a r c h o f f i c e be t e l e p h o n e d c o l l e c t i f r e - a p p o i n t m e n t was d e s i r e d . I f t h e s u b j e c t d i d n o t r e s p o n d a s e c o n d l e t t e r was s e n t , and i f t h e s u b j e c t s t i l l d i d n o t a p p e a r , a t h i r d , r e g i s t e r e d l e t t e r was s e n t . R e t u r n o f t h e r e g i s t e r e d l e t t e r , i n d i c a t i n g t h a t t he s u b j e c t ' s c u r r e n t a d d r e s s was unknown , was f o l l o w e d b y a t e l e p h o n e s e a r c h o f t h e V a n c o u v e r t o l l - f r e e a r e a . I f c o n t a c t was made w i t h a p o t e n t i a l s u b j e c t and he seemed c o o p e r a t i v e , any number o f p e r s o n a l l e t t e r s o r t e l e p h o n e c a l l s 51 were e x c h a n g e d w i t h h i m i f t h e r e r e m a i n e d hope o f s e e i n g h i m . A f u r t h e r a t t e m p t was m a d e - t o e s t a b l i s h w h e t h e r t h o s e s u b j e c t s w i t h whom c o n t a c t c o u l d n o t be made w e r e l i v i n g o r d e c e a s e d . T h i s a t t e m p t was u n s u c c e s s f u l h o w e v e r , b e c a u s e t h e g o v e r n m e n t a l a g e n c i e s i n v o l v e d w o u l d n o t r e l e a s e t h e n e c e s s a r y i n f o r m a t i o n . The s u b j e c t s p r e s e n t e d t h e m s e l v e s as p e r i n s t r u c t i o n s a t 9 : 0 0 A . M . on t h e a p p o i n t m e n t d a t e a t t h e O u t p a t i e n t ' s Depa r tmen t o f S h a u g h n e s s y V e t e r a n ' s H o s p i t a l . T h i s V e t e r a n ' s h o s p i t a l was t h o u g h t t o be " n e u t r a l g r o u n d " f o r any p a t i e n t s h a r b o u r i n g a n i m o s i t i e s t o w a r d t h e WCB. The s e r i e s o f e x a m i n a t i o n s l a s t e d a f u l l w o r k i n g day f o r e a c h s u b j e c t and f e l l i n t o t h r e e p h a s e s : (1) o r t h o p a e d i c / n e u r o l o g i c a l , (2) r a d i o l o g i c a l , and (3) p s y c h o l o g i c a l . The o r d e r o f t h e s e e x a m i n a t i o n s was o f n e c e s s i t y v a r i e d t o accommodate o t h e r commi tments o f t h e o r t h o p a e d i c and p s y c h o l -o g i c a l e x a m i n e r s , t he r a d i o l o g i c a l e x a m i n a t i o n i n most i n s t a n c e s f a l l i n g i n t he m i d d l e . The o r d e r o f o r t h o p a e d i c / n e u r o l o g i c a l and p s y c h o l o g i c a l e x a m i n a t i o n s was a p p r o x i m a t e l y c o u n t e r - b a l a n c e d and no e f f e c t s o f o r d e r we re d i s c e r n i b l e i n t e rms o f s u b j e c t m o t i v a t i o n o r c o o p e r a t i o n . The o r t h o p a e d i c / n e u r o l o g i c a l e x a m i n a t i o n s w e r e p e r f o r m e d by t h e o r t h o p a e d i c r e s e a r c h . f e l l o w i n t h e e x a m i n i n g rooms o f t h e S h a u g h n e s s y V e t e r a n ' s H o s p i t a l O u t p a t i e n t ' s D e p a r t m e n t . The s u b j e c t s w e r e f i r s t a s k e d t o c o m p l e t e t h e P a t i e n t S e l f - e v a l u a t i o n F o r m , and we re g i v e n any n o n - d i r e c t i v e a s s i s t a n c e n e c e s s a r y f o r i t s c o m p l e t i o n . Then f o l l o w e d a t h o r o u g h g e n e r a l p h y s i c a l e x a m i n a t i o n and a c o m p r e h e n s i v e o r t h o p a e d i c and n e u r o l o g i c a l e v a l u a t i o n of t he b a c k and l o w e r e x t r e m i t i e s a f t e r w h i c h the C o l d T o l e r a n c e T e s t was a d m i n i s t e r e d b y t h e o r t h o p a e d i s t . A l l 52 o b s e r v a t i o n s made d u r i n g t h e s e e x a m i n a t i o n s were c o n c u r r e n t l y e n t e r e d on t he B a c k S u r g e r y F o r m . R a d i o l o g i c a l e x a m i n a t i o n s were p e r f o r m e d b y t h e permanen t s t a f f o f S h a u g h n e s s y V e t e r a n ' s H o s p i t a l R a d i o l o g y D e p a r t m e n t . These e x a m i n a -t i o n s c o n s i s t e d o f n i n e v i e w s and i n c l u d e d B e n d i n g F i l m s . I f s u i t a b l e r o e n t g e n o g r a m s had b e e n t a k e n e l s e w h e r e i n t h e s i x months p r i o r t o a s u b j e c t ' s a t t e n d a n c e a t t h e p r e s e n t i n v e s t i g a t i o n , t h o s e f i l m s w e r e o b t a i n e d so t h a t t he s u b j e c t was n o t e x p o s e d t o u n n e c e s s a r y r a d i a t i o n . The s u b -j e c t s ' r o e n t g e n o g r a m s were l a t e r i n t e r p r e t e d by t h e o r t h o p a e d i c r e s e a r c h f e l l o w and measurements and a b n o r m a l i t i e s we re e n t e r e d on t h e X - r a y A s s e s s m e n t F o r m . P s y c h o l o g i c a l e x a m i n a t i o n s o f t he s u b j e c t s we re c o n d u c t e d by t h e p r e s e n t a u t h o r and t o o k p l a c e i n p r i v a t e o f f i c e s on a r e s e a r c h f l o o r a t S h a u g h n e s s y V e t e r a n ' s H o s p i t a l . The s u b j e c t s we re f i r s t g i v e n a g e n e r a l s t a t e m e n t o f t h e p u r p o s e s o f t h e r e s e a r c h , t h e u s u a l l y s u s p e c t e d r e l a t i o n -s h i p o f t he r e s e a r c h g roup t o t he WCB was e x p l a i n e d , and t h e c o n f i d e n t i a -l i t y and l a c k o f c o m m u n i c a t i o n o f d a t a t o t h e WCB was s t r e s s e d . A p p r o x -i m a t e l y 10 m i n u t e s o f n e u t r a l c o n v e r s a t i o n f o l l o w e d t o e s t a b l i s h r a p p o r t , a f t e r w h i c h t he s u b j e c t s ' e x p e n s e a c c o u n t f o rms we re c o m p l e t e d . The p s y c h o l o g i s t t h e n a d m i n i s t e r e d t h e s t r u c t u r e d i n t e r v i e w , t h e C u l t u r e F a i r I n t e l l i g e n c e T e s t , and t he K - C S c a l e to t h e s u b j e c t s . S t a n d a r d i z e d i n s t r u c -t i o n s w e r e f o l l o w e d t h r o u g h o u t a l l t e s t i n g . S u b s e q u e n t l y , t h e s u b j e c t s com-p l e t e d t he MMPI , B e c k I . D . , and CPI w h i l e s e a t e d a t t h e i r own t a b l e i n t h e p r e s e n c e o f t he p s y c h o l o g i s t . S u b j e c t s w e r e a l l o w e d r e a s o n a b l e " b r e a k s " d u r i n g t h e s e t a s k s , and c o f f e e was s u p p l i e d t o them. 53 The d u r a t i o n o f t h e t h r e e e x a m i n a t i o n p h a s e s was s u c h t h a t o n l y under o p t i m a l c i r c u m s t a n c e s c o u l d a s u b j e c t be f u l l y examined i n t h e c o u r s e o f one w o r k i n g d a y . I f a s u b j e c t was l a t e f o r h i s a p p o i n t m e n t , was a s l o w r e a d e r , o r i f some d e l a y i n t h e s c h e d u l i n g o f e x a m i n a t i o n s o c c u r r e d , t h e t o t a l e x a m i n a t i o n p r o g r a m c o u l d n o t be c o m p l e t e d . I t was n o t p o s s i b l e t o d e t a i n t he s u b j e c t s f o r an e x t r a day b e c a u s e o f t h e g r a n t i n g a g e n c y ' s l i m i t a t i o n o f r e i m b u r s e m e n t t o one d a y ' s l o s s o f w a g e s . A s a r e s u l t one t e s t , t h e C P I , was c h o s e n as t h e " b u f f e r " i n t h i s r i g o r o u s s c h e d u l e . I n i t i a l l y f o u r o f t h e f i r s t 50 s u b j e c t s w e r e e x c u s e d f r o m c o m p l e t i n g t h e C P I , b u t i t was t h e n d e c i d e d t h a t CPI d a t a g a t h e r e d unde r l e s s t h a n o p t i m a l c o n d i t i o n s we re p r e f e r a b l e t o no d a t a * and c o n s e q u e n t l y s i x o f t h e r e m a i n i n g 50 s u b j e c t s w e r e r e q u e s t e d t o c o m p l e t e t h e CP I a t home. S e l f - a d d r e s s e d , p o s t a g e - p a i d e n v e l o p e s we re s u p p l i e d , and t h e s e s u b j e c t s we re r e q u i r e d t o do p a r t o f t he t e s t a t t h e r e s e a r c h o f f i c e s t o make c e r t a i n t h a t t h e y u n d e r s t o o d t h e p r o c e d u r e . They we re a l s o i n s t r u c t e d t o c o m p l e t e t h e CPI by t h e m s e l v e s , removed f r o m o t h e r s and s o u r c e s o f d i s t r a c t i o n . F i v e o f t h e s i x i n v e n t o r i e s were r e t u r n e d . D a t a A n a l y s i s S c o r i n g S c o r i n g o f t h e p s y c h o m e t r i c d a t a w i t h t h e f o l l o w i n g e x c e p t i o n s f o l -l owed t h e s t a n d a r d i z e d p r o c e d u r e s p r e s c r i b e d f o r t h e p s y c h o m e t r i c s u s e d . The C u l t u r e F a i r I n t e l l i g e n c e T e s t , S c a l e 2 , . Form A , y i e l d e d a number o f raw s c o r e s one o r two p o i n t s b e l o w t h e r a n g e o f v a l u e s g i v e n i n t h e 54 c o n v e r s i o n t a b l e ( C a t t e l l and C a t t e l l , 1960) w h i c h y i e l d s i n t e l l i g e n c e q u o t i e n t s ( IQs) w i t h a s t a n d a r d d e v i a t i o n o f 1 6 . The c o n v e r s i o n t a b l e was e x t r a p o l a t e d downward , a raw s c o r e o f 13 (as i n t h e c a s e o f two s u b j e c t s ) b e i n g a s s i g n e d an IQ o f 5 1 , and a raw s c o r e o f 12 (as i n t h e c a s e o f f i v e s u b j e c t s ) b e i n g a s s i g n e d an IQ o f 4 5 . B a r t o n " ' has s t a t e d t h a t s u c h downward e x t r a p o l a t i o n w o u l d seem j u s t i f i a b l e on a t h e o r e t i c a l b a s i s t h o u g h t h e u s e f u l n e s s o f s u c h s c o r e s i n a p r a c t i c a l s e n s e may be q u e s t i o n a b l e . The K - C S c a l e was s c o r e d on a c o n t i n u u m f r o m one t o 1 0 0 , t h e t o p o f t he 1 0 - r u n g l a d d e r b e i n g s c o r e d a s 1 0 0 . The t e n s v a l u e was o b t a i n e d b y n o t i n g w h i c h r u n g o f t h e l a d d e r was i m m e d i a t e l y b e l o w the a r r o w p l a c e d by t he s u b j e c t and t h e d i g i t v a l u e was e s t i m a t e d b e t w e e n a d j a c e n t r u n g s . T h r e e s c o r e s we re d e r i v e d f o r e a c h s u b j e c t c o r r e s p o n d i n g t o t h e t h r e e r a t i n g s e a c h had been r e q u e s t e d t o g i v e o f h i s l i f e s i t u a t i o n i n t h e p a s t , p r e s e n t and f u t u r e . An a t t e m p t was made t o code t h r e e - p o i n t t r e n d s o v e r t h e t i m e s r a t e d , bu t t h i s was abandoned b e c a u s e o f t h e l o w f r e q u e n c i e s o f o b s e r v a t i o n i n e a c h o f t h e l a r g e number o f t r e n d s p o s s i b l e and t h e q u e s t i o n a b l e mean ing o f r e c o m b i n i n g the t r e n d s . Two q u e s t i o n s a s k e d d u r i n g the p s y c h o l o g i c a l i n t e r v i e w — t h o s e d e a l i n g w i t h t h e s u b j e c t ' s h a p p i n e s s d u r i n g c h i l d h o o d and t he compat i^ -b i l i t y o f h i s p a r e n t s — were r a t e d b y t h e s u b j e c t s on g r a p h i c , b i p o l a r s c a l e s d i v i d e d i n t o s e v e n s e c t i o n s . These r a t i n g s we re s c o r e d f r o m z e r o t o 7 0 , a g a i n t h e d i g i t v a l u e b e i n g e s t i m a t e d b e t w e e n s e c t i o n s . B a r t o n , ; K . R e s e a r c h C o n s u l t a n t , H A T . P e r s o n a l c o m m u n i c a t i o n . 55 S c o r i n g c r i t e r i a u s e d by t h e o r t h o p a e d i s t w i l l n o t be d e t a i l e d h e r e ( s e e W i n g , 1 9 7 3 ) . P r e p a r a t i o n o f D a t a f o r A n a l y s i s A l l compu te r wo rk f o r t h e p r e s e n t s t u d y was done b y a q u a l i f i e d compute r programmer f r o m the Depa r tmen t o f S u r g e r y a t V a n c o u v e r G e n e r a l H o s p i t a l . The compu te r f a c i l i t i e s o f t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , i n c l u d i n g an IBM 360 M o d e l 67 c o m p u t e r , we re u s e d f o r t h i s w o r k . To make t he s u b s t a n c e o f p r i n t o u t s e a s i e r t o r e c o g n i z e , t he compu te r p rog rams u s e d i n t h e a n a l y s e s o f t h e d a t a a l l o w e d t h e a s s i g n m e n t o f code names o f e i g h t l e t t e r s o r l e s s t o a l l v a r i a b l e s . A c c o r d i n g l y , a l l v a r i a b l e s we re code-named w i t h common names o r a b b r e v i a t i o n s o f t h e t e s t s u s e d , d e s c r i p t i v e names , o r t h e p r o d u c t s o f t h e i n v e s t i g a t o r s ' s e n s e s o f humor . The code names o f a l l v a r i a b l e s a p p e a r i n t h e l e f t m a r g i n s o f t h e f i v e d o c u m e n t a t i o n fo rms i n c l u d e d h e r e i n A p p e n d i x E . F o l l o w i n g t h e i n p u t o f raw d a t a and code names t o t h e c o m p u t e r , f r e q u e n c y c o u n t s were p r i n t e d o f t h e number o f . o b s e r v a t i o n s f a l l i n g a t each o f t h e p o s s i b l e v a l u e s o f e a c h o f t he v a r i a b l e s . T h i s p r o c e d u r e a l l o -wed a d e t a i l e d o v e r v i e w o f t h e c h a r a c t e r i s t i c s o f t h e s u b j e c t s a m p l e as a w h o l e , t he e v a l u a t i o n of t h e d i s c r i m i n a t o r y a b i l i t y o f e a c h v a r i a b l e ( i . e . , t h e r e m a y h a v e b e e n i n s u f f i c i e n t v a r i a b i l i t y o f o b s e r v a t i o n s f o r a v a r i a b l e t o have d i s c r i m i n a t o r y v a l u e ) , and g u i d a n c e i n t h e r e c o m b i n a -t i o n o f raw d a t a ( d i s c u s s e d b e l o w ) n e c e s s a r y f o r s t a t i s t i c a l a n a l y s i s . Many o f t he o r t h o p a e d i c , r a d i o l o g i c a l and p s y c h o l o g i c a l i n t e r v i e w v a r i a b l e s we re o f a n o m i n a l o r o r d i n a l n a t u r e and we re c o l l e c t e d i n v e r y d e t a i l e d f o r m i n t h e c o u r s e of i n v e s t i g a t i o n . C o n s e q u e n t l y , many o f 56 these nominal and o r d i n a l v a r i a b l e s had numerous ca t e g o r i e s i n which the frequencies of observation were very low. V a l i d s t a t i s t i c a l com-parisons could t h e r e f o r e not be made among these v a r i a b l e s . To overcome t h i s problem, categories w i t h i n many of the i n d i v i d u a l v a r i a b l e s were combined together i n such a manner that the meaningfulness of the v a r i a b l e s was r e t a i n e d and yet the frequencies of observation i n t h e i r new c a t e g o r i e s were r a i s e d . In a few instances two or more measures as documented during the i n v e s t i g a t i o n were combined to form one v a r i a b l e f o r the purposes of a n a l y s i s . For example, observations of the strengths of i n d i v i d u a l l e g muscles c o l l e c t e d during the i n v e s t i g a t i o n were combined to y i e l d one v a r i a b l e r e f l e c t i n g motor stre n g t h of the l e g ( v a r i a b l e LEGPOW) f o r the purposes of a n a l y s i s . A l l data recombinations are i n d i c a t e d on the f i v e documentation forms i n c l u d e d here i n Appendix E. Beyond d e s c r i p t i o n of the p a t i e n t sample as a whole, the recombined v a r i a b l e s form the bases of a l l f u r t h e r analyses presented i n t h i s paper. The steps taken i n s t a t i s t i c a l analyses beyond t h i s point are presented i n flow-chart form i n Figure 5. D e r i v a t i o n of the D i s a b i l i t y Index The r a t i o n a l e f o r the choice of method used to d e r i v e a d i s a b i l i t y index i n the present study has been discussed above. Twenty v a r i a b l e s deemed by the i n v e s t i g a t o r s to r e f l e c t a wide range of the e f f e c t s of subject impairment by LBP were f a c t o r analyzed. The UBC FAN computer program (Halm, 1971) was used to y i e l d a p r i n c i p a l component s o l u t i o n , the f i r s t unrotated f a c t o r being taken as the b a s i c dimension of d i s a b i l i t y . Factor scores were then derived from t h i s f a c t o r to provide d i s a b i l i t y i n d i c e s . f o r the i n d i v i d u a l s u b j e c t s . These f a c t o r scores were standardized 57 Derivation of the D i s a b i l i t y Index Esta b l i s h i n g the components of the LBP d i s a b i l i t y problem Overlap i n measure-cent among ortho-paedic and psychol-o g i c a l v a r i a b l e s 20 variables re-f l e c t i n g subject impairment of function Factor analysis of 20 variables D i s a b i l i t y index (Success) f i r s t unrotated p r i n -c i p a l component factor Factor scores providing d i s -a b i l i t y indices for i n d i v i d u a l subjects 239 Psychological and ortho-paedic v a r i a b l e s documented during the study I n t e r c o r r e l a t i o n of patient scores on 239 v a r i a b l e s and on d i s a b i l i t y index 240x240 c o r r e l a t i o n matrix showing over-lap i n measurement among orthopaedic and psychological va r i a b l e s Correlation of subject scores on 239 va r i a b l e s with subject scores on the d i s a b i l i t y index 58 correlates of d i s a b i l i t y (psychological and orthopaedic) Factor analysis of subject scores on 55 correlates of d i s a b i l i t y 17 orthogonal factors underlying the 55 correlates of d i s a b i l i t y I Correlation of subject scores on each of the 17 orthogonal factors with subject scores on the d i s a b i l i t y index Eight of the 17 orthogonal factor: found to be s i g n i f i c a n t l y related to d i s a b i l i t y ~ basic dimensions of d i s a b i l i t y H i e r a r c h i c a l grouping analysis of subject scores on the basic dimensions of d i s a b i l i t y Four Syndrome Complex groups Derivation of the mean d i s a b i l i t y index score f o r each Syndrome Complex group Relative d i s a b i l i t y of the four Syndrome Complex groups Figure 5. Flow Chart of Steps taken in Data Analysis 58 t o have a mean o f 0.0000 and a s t a n d a r d d e v i a t i o n o f 1.0000. C o r r e l a t e s o f D i s a b i l i t y The c o r r e l a t e s o f d i s a b i l i t y were found by c o r r e l a t i n g t h e s u b j e c t s ' d i s a b i l i t y i n d i c e s w i t h t h e s u b j e c t s ' s c o r e s on a l l s u i t a b l e v a r i a b l e s documented i n t h e c o u r s e of the i n v e s t i g a t i o n . I n t h e f r e q u e n c y c o u n t s d i s c u s s e d above, 239 s u i t a b l e v a r i a b l e s had been f o u n d . . The UBC C0RR computer program ( F l o y d and B j e r r i n g , 1 9 6 9 ) , w h i c h u s e s t h e a p p r o p r i a t e p a r a m e t r i c and n o n - p a r a m e t r i c c o r r e l a t i o n s and t e s t s o f s i g n i f i c a n c e f o r a l l p a i r w i s e c o mparisons o f n o m i n a l , o r d i n a l , and i n t e r v a l v a r i a b l e s , was used t o p e r f o r m t h e s e c o r r e l a t i o n s . The c o r r e l a t i o n s , t e s t s o f s i g -n i f i c a n c e and a n n o t a t i o n s used by th e UBE C0RR program a r e p r e s e n t e d i n T a b l e 1. A s i g n i f i c a n c e l e v e l o f p < .01 was adopted i n the s e a r c h f o r c o r r e l a t e s o f d i s a b i l i t y t o p r e v e n t an e x c e s s i v e e r r o r r a t e . O v e r l a p s i n Measurement Among O r t h o p a e d i c and P s y c h o l o g i c a l V a r i a b l e s The UBC C0RR computer program r e f e r r e d t o above was a l s o used t o d e r i v e a c o r r e l a t i o n m a t r i x showing t h e p a i r w i s e c o m p a r i s o n s between a l l t h e 239 v a r i a b l e s and the d i s a b i l i t y i n d i c e s . To i l l u s t r a t e t h e o v e r -l a p s i n measurement e x i s t i n g among t h e o r t h o p a e d i c and p s y c h o l o g i c a l v a r i a b l e s , o n l y a s m a l l sample of th e 28,800 r e l a t i o n s h i p s w i l l be d i s -c u s s e d i n t h i s paper. The com p l e t e c o r r e l a t i o n m a t r i x i s a v a i l a b l e f r o m t h i s a u t h o r t o any r e a d e r c u r i o u s about r e l a t i o n s h i p s n o t d i s c u s s e d . D e r i v a t i o n o f t h e B a s i c D i m e n s i o n s o f D i s a b i l i t y A g r e a t amount of' o v e r l a p i n measurement was e x p e c t e d (and sub-s e q u e n t l y o b s erved) among o r t h o p a e d i c and p s y c h o l o g i c a l v a r i a b l e s . I n Table 1 S t a t i s t i c s Used by the UBC C0RR Computer Program V a r i a b l e s C o r r e l a t i o n C o e f f i c i e n t Annota t ion . S i g n i f i c a n c e Test Nomina l -Nominal Guttmans Symmetric C o e f f i c i e n t of P r e d i c t a b i l i t y X Chi -squared t e s t (w i th Yates c o r r e c t i o n i f bo th v a r i a b l e s have a l e v e l of 2) Nomina l -O r d i n a l Freeman's C o e f f i c i e n t of De te r -m ina t i on e Mann-Whitney U- tes t i f nominal v a r i a b l e has a l e v e l of 2. Otherwise Ch i -squared t e s t . O r d i n a l -O r d i n a l Goodman's and K r u s k a l ' s C o e f f i c i e n t of Rank A s s o c i a t i o n (G) g G s i g n i f i c a n c e t e s t . Nomina1-I n t e r v a l C o r r e l a t i o n R a t i o n 2 A n a l y s i s of Var iance O r d i n a l -I n t e r v a l J a s p e n ' s C o e f f i c i e n t of M u l t i -s e r i a l C o r r e l a t i o n m F - t e s t . I n t e r v a l -I n t e r v a l P e a r s o n ' s C o e f f i c i e n t of C o r r e l a t i o n r F - t e s t a f t e r F loyd and B j e r r i n g , ' 1969 60 order to gain i n s i g h t into the basic parameters which underly LBP d i s a b i l i t y and contribute independently to i t , further factor analysis was undertaken. The correlates of d i s a b i l i t y , derived i n the manner described above, were fa c t o r analyzed using the UBC FAN computer program (Halm, 1971). A p r i n c i p a l component s o l u t i o n and varimax r o t a t i o n were used to y i e l d highly d i s c r i m i n a t i n g orthogonal f a c t o r s . Not a l l factors derived i n the above manner n e c e s s a r i l y had to be s i g n i f i c a n t l y r e l a t e d to d i s a b i l i t y . A v a r i a b l e s i g n i f i c a n t l y correlated with d i s a b i l i t y could be so because a proportion of the variance on that v a r i a b l e r e f l e c t s a basic dimension (factor) highly r e l a t e d to d i s a b i l i t y ; the remainder of the variance on that v a r i a b l e could r e f l e c t a basic dimension (or dimensions) i n no way r e l a t e d to d i s a b i l i t y . Consequently, the standardized (mean = 0.0000; S.D. = 1.0000) factor scores f o r a l l 100 subjects on each of the orthogonal f a c t o r s were correlated with the subjects' d i s a b i l i t y i n d i c e s . The r e s u l t i n g Pearson Product Moment Cor-r e l a t i o n c o e f f i c i e n t s (Pearson rs) allowed i d e n t i f i c a t i o n of which basic dimensions (orthogonal factors) were indeed s i g n i f i c a n t l y r e l a t e d (p < .05) to d i s a b i l i t y . Also by squaring these Pearson rs the amount of the d i s -a b i l i t y variance accounted f or by each of the basic dimensions could be found. Because the basic dimensions were orthogonal, the amount of d i s -a b i l i t y variance accounted f o r by a l l , or a subset of, the basic dimensions could be obtained by summing the amounts of d i s a b i l i t y variance accounted f o r by the i n d i v i d u a l basic dimensions. The r e l a t i v e "importance" of the basic dimensions and the proportion of the t o t a l d i s a b i l i t y problem accounted for could thus be established. 61 Syndrome Complex Groups As n o t e d e a r l i e r i n t h i s p a p e r , the q u e s t i o n of whether an i n d i v i d u a l s u b j e c t ' s LBP d i s a b i l i t y can be a l l p s y c h o l o g i c a l o r a l l o r g a n i c , o r whether d e f i c i t s i n some or a l l o f the b a s i c d i m e n s i o n s of d i s a b i l i t y a r e n e c e s s a r y f o r or t y p i c a l o f LBP d i s a b i l i t y , i s an i m p o r t a n t one. To g a i n i n s i g h t i n t o t h i s q u e s t i o n , t h e s t a n d a r d i z e d f a c t o r s c o r e s f o r each s u b j e c t on each o f t h e b a s i c d i m e n s i o n s s i g -n i f i c a n t l y r e l a t e d t o d i s a b i l i t y were used t o g e n e r a t e a p r o f i l e and a h i e r a r c h i c a l g r o u p i n g a n a l y s i s computer program (UBC C GROUP; W h i t a k e r and P a t t e r s o n , 1971) was t h e n used t o s o r t the s u b j e c t p r o f i l e s i n t o n a t u r a l l y o c c u r r i n g g r o u p s . I n s p e c t i o n o f t h e r e s u l t i n g group p r o f i l e s and t h e mean d i s a b i l i t y i n d i c e s f o r each group t h e n a l l o w e d i n s i g h t i n t o the c o n f i g u r a t i o n s o f t h e b a s i c d i m e n s i o n s o f d i s a b i l i t y as t h e y t y p i f y n a t u r a l l y o c c u r r i n g LBP gr o u p s . These n a t u r a l l y o c -c u r r i n g c o n f i g u r a t i o n s of d e f i c i t s on t h e b a s i c d i m e n s i o n s o f d i s a b i l i t y may be th o u g h t of as Syndrome Complexes. T e s t s o f s i g n i f i c a n c e between mean p r o f i l e s d e r i v e d by a h i e r a r c h i c a l g r o u p i n g a n a l y s i s a r e n o t a p p r o p r i a t e . 62 Results Overview of Subject C h a r a c t e r i s t i c s The 100 subjects of t h i s study had a mean age of 44.1 years (SD = 8.9; range 22-67). The eight women of the study d i f f e r e d s i g n i f i c a n t l y (p < .01) from the men by being smaller i n s i z e (variables HEIGHT, IPEDMEAN), having weaker abdominal muscles (variable ABDPOWB), having more v e r t e b r a l segments fused (variable LEVELA), having had more diseases of systems other than musculoskeletal (variable DISEASE), having had less abdominal surgery than the men (variable ABDOMEN), having been seen as more passive-aggressive by the orthopaedist (variable OPA), having lower scores on the MMPI Masculinity-Femininity Scale (variable MMPIMF) and by doing more household chores (variable CHORES). The women did not d i f f e r from the men i n any other way, including mean l e v e l of d i s a b i l i t y , and for further analysis the data of both sexes were grouped together. The 100 subjects had had a mean number of 1.98 back operations (range 1-7) and yet the majority of them s t i l l complained of back-related d i f f i c u l t i e s . Though only 11% of these subjects were unemployed, 60% of them had l o s t some time from work because of LBP during the two years p r i o r to the present study. Over one-half (55%) of the subjects avowed that LBP adversely affected t h e i r o v e r a l l enjoyment of l i f e . Inspection of the psychometric data for which norms are a v a i l a b l e characterizes the group studied to be very d i f f e r e n t as a whole from a random sample of the general population. These subjects had a very low mean IQ of 83.18 (t = 7.85, p < .01) as assessed by the Culture F a i r 63 I n t e l l i g e n c e T e s t . The MMPI , on w h i c h one w o u l d e x p e c t on t h e b a s i s o f p r o b a b i l i t y somewhat l e s s t h a n t h r e e p e r c e n t o f r a n d o m l y c h o s e n s u b j e c t s t o have an e l e v a t i o n o f o v e r a T - s c o r e o f 70 on any one o f t h e c l i n i c a l s c a l e s , showed a n e x c e s s i v e amount o f a b n o r m a l i t y ( a b n o r m a l i t y b e i n g d e f i n e d as a T - s c o r e o v e r 70 on any MMPI s c a l e ) . Of t h e 98 MMPI p r o t o c o l s s c o r e d , 60 were f o u n d t o h a v e a n a b n o r m a l e l e v a t i o n on one o r more o f t h e n i n e c l i n i c a l s c a l e s (x 2 = 99.90, p < .001). F o r t y - s i x p r o t o c o l s showed one o r more a b n o r m a l e l e v a t i o n s among t h e n e u r o t i c t r i a d (x 2 = 241.64, p < .001), e i g h t o f t h e s e s h o w i n g s u c h e l e v a t i o n s o n l y on t h e D S c a l e (x 2 = 12.74*, p < .001). N i n e t e e n s u b j e c t s had an a b n o r m a l e l e v a t i o n on t he P s y c h a s t h e n i a S c a l e (x 2 = 121.47*, p < .001). E i g h t e e n p r o t o c o l s showed a b n o r m a l e l e v a t i o n s on t he S c h i z o p h r e n i a S c a l e (x 2 = 107.00*, p < .001) and 19 p r o t o c o l s showed s i m i l a r e l e v a t i o n s on t h e P s y c h o p a t h i c D e v i a t e S c a l e (x 2 = 121.47*, p < .001). Of t h e MMPI e x p e r i m e n t a l s c a l e s s c o r e d , t h e Low B a c k P a i n S c a l e showed 11 p r o t o c o l s t o h a v e a b n o r m a l e l e v a t i o n s (x 2 = 31.38*, p < .001), w i t h a f u r t h e r 12 f a l l i n g on t h e uppe r l i m i t o f what i s u s u a l l y t h o u g h t o f as n o r m a l i t y ( T - s c o r e = 70). Though more d i f f i c u l t t o e v a l u a t e as t o c l i n i c a l s i g n i c a n c e , the E s S c a l e showed 18 p r o t o c o l s w i t h a T - s c o r e o f l e s s t h a n 40, and s i x p r o t o c o l s w i t h a T - s c o r e o f l e s s t h a n 30. The B e c k I . D . w i t h a mean s c o r e o f 8.07 (SD = 6.77; r a n g e 0-37), when a n a l y z e d u s i n g t h e c u t t i n g s c o r e s of M e t c a l f e and Goldman (1965) , K 1 -Y a t e s c o r r e c t i o n f o r c o n t i n u i t y u s e d 64 showed n i n e o f t h e 96 s u b j e c t s o b s e r v e d t o be m o d e r a t e l y d e p r e s s e d , and s i x s u b j e c t s t o be s e v e r e l y d e p r e s s e d . The C P I , o f w h i c h 95 p r o t o c o l s were s c o r e d , showed no s c a l e t o have a s i g n i f i c a n t l y h i g h e r number o f s u b j e c t s f a l l i n g o v e r a s t a n d a r d s c o r e o f 70 t h e n w o u l d be e x p e c t e d . T h e r e w e r e , h o w e v e r , more t h a n t h e e x p e c t e d number o f s u b j e c t s r e c e i v i n g a s t a n d a r d s c o r e o f l e s s t h a n 30 - - f / i t h i i s , a s c o r e two s t a n d a r d d e v i a t i o n s b e l o w t h e p o p u l a t i o n mean — on a number o f t h e CP I s c a l e s . E l e v e n p r o t o c o l s showed s u c h a d e p r e s -s i o n on t h e C a p a c i t y f o r S t a t u s S c a l e (x 2 = 32.81*, p < .001), s i x on t h e S o c i a l P r e s e n c e S c a l e (x 2 = 5.25*, p < .05), 16 on t h e Sense o f W e i l - B e i n g S c a l e (x 2 = 84.00*, p < .001), s i x on t h e R e s p o n s i b i l i t y S c a l e ( x 2 = 5.25*, p < .05) , n i n e on t h e S o c i a l i z a t i o n S c a l e (x 2 = 18.95*, p < .001), 13 on t h e T o l e r a n c e S c a l e (x 2 = 50.45*, p < .001), 13 on t h e A c h i e v e m e n t v i a Con fo rmance S c a l e , (x 2 = 50.45*, p < .001), e i g h t on t h e A c h i e v e m e n t v i a I ndependence S c a l e (x 2 = 13.44*, p < .001) and 13 p r o t o c o l s showed d e p r e s s i o n s b e l o w a s t a n d a r d s c o r e o f 30 on t h e I n t e l l e c t u a l E f -f i c i e n c y S c a l e (X 2 = 50.45*, p < .001). The C o l d T o l e r a n c e T e s t gave a mean t i m e o f i m m e r s i o n o f t h e hand o f 121.52 s e c o n d s ( r a n g e 15-180 s e c o n d s ) . These t i m e s p r e s e n t e d a c u r i o u s d i s t r i b u t i o n ' s w i t h one h a l f (50) o f t he s u b j e c t s l e a v i n g t h e i r hands immersed u n t i l t o l d t o w i t h d r a w them a t t h r e e m i n u t e s (180 s e c o n d s ) . Of t he r e m a i n i n g 50 s u b j e c t s , 26 w i t h d r e w t h e i r hands w i t h i n 60 s e c o n d s o r l e s s , and 43 w i t h d r e w t h e i r hands w i t h i n 90 s e c o n d s o r l e s s . The d a t a g a t h e r e d b y i n t e r v i e w c o n t a i n e d l i t t l e o f a s t a r t l i n g n a t u r e . The 100 s u b j e c t s had a t t e n d e d a mean o f 8.83 y e a r s ( S . D . = 2.55) 65 o f g r a d e s c h o o l . T h i r t y - f i v e s u b j e c t s had some v o c a t i o n a l t r a i n i n g and f i v e s u b j e c t s had some u n i v e r s i t y t r a i n i n g . F i n a n c i a l l y , t he mean g r o s s income ( d a t a g a t h e r e d t o the n e a r e s t $100 p e r month) t o t h e f a m i l i e s i n t h i s g roup was $852 p e r month (med ian $ 8 0 0 ; mode $600 ; r a n g e $ 1 0 0 - 4 0 0 0 ) , and f o r t y - f i v e f a m i l i e s r e c e i v e d a p e n s i o n o f some t y p e . T w e n t y - e i g h t o f t h e s u b j e c t s we re f o r e i g n b o r n , 31 w e r e n a t i v e B r i t i s h C o l u m b i a n s , and t h e r e s t w e r e b o r n i n o t h e r p a r t s o f C a n a d a . Of t h e 96 s u b j e c t s who had a f a t h e r p r e s e n t d u r i n g c h i l d h o o d , 56 s u b -j e c t s had f a t h e r s who were e i t h e r f a r m e r s o r l a b o r e r s . The s u b j e c t s had a mean number o f 4 . 3 5 s i b l i n g s ( r a n g e 0 - 1 8 ) . E i g h t y - t w o of t h e s u b j e c t s we re m a r r i e d and l i v i n g w i t h s p o u s e a t the t i m e o f e x a m i n a t i o n , and 21 r e p o r t e d a d i v o r c e o r s e p a r a t i o n i n t h e p a s t . P r e s e n t m a r i t a l r e l a t i o n s h i p s were s a i d t o be o f l e s s t h a n a v e r a g e q u a l i t y (as d e f i n e d by t h e s u b j e c t s ) by o n l y n i n e s u b j e c t s , bu t o n l y 40 o f t h e 100 s u b j e c t s r e p o r t e d what t h e y c o n s i d e r e d t o be a q u a n t i t a t i v e l y a d e q u a t e s e x l i f e . Twen t y - two o f t h e s u b j e c t s d i r e c t l y i m p l i c a t e d t h e i r b a c k t r o u b l e s i n t h e i m p a i r m e n t o f t h e i r s e x l i v e s . E i g h t e e n of t h e s u b j e c t s had p r e v i o u s l y come t o p s y c h i a t r i c a t -t e n t i o n , b u t o n l y on e v e r y few o c c a s i o n s e a c h (mean = 1 . 4 t i m e s ; S . D . = 1 . 1 7 ; r a n g e 0 - 7 ) , and u s u a l l y f o r r e l a t i v e l y m i n o r m a t t e r s s u c h as m a r i t a l c o u n s e l l i n g o r a s p a r t o f a s t a n d a r d r o u t i n e on r e l e a s e f r o m armed f o r c e s . When a s k e d "Do you t h i n k t h a t p e r s o n a l i t y o r p s y c h o l -o g i c a l s t a t u s c a n have a b e a r i n g on t h e e x i s t e n c e o f , o r t he e x p e r i e n c e o f a b a c k p r o b l e m ? " , 24 s u b j e c t s answered i n t h e n e g a t i v e , 14 were 66 evasive, and 62 answered in the affirmative, 19 using a self-reference. Affirmative answers were explored, and most answers using references to others were of a "malingering" flavor. Derivation of the Disability Index As described previously, 20 variables reflecting a wide range of patient impairment of function were factor analyzed using a principal component solution, the first unrotated factor of which was used to define disability. This factor accounted for 40.097% of the total variance of the 20 variables, with 14 of these variables having their major loadings on this factor. The second factor withdrawn accounted for 8.66% of the total variance of the 20 variables and was unidenti-fiable. The variables, their descriptions, and their loadings on the first factor are presented in Table 2. The first factor withdrawn was oriented in such a manner that negative factor scores corresponded to disability. The factor in ac-cord with convention was named "Success" after the positive end of the continuum. Success has, in the eyes of the present investigators, the inverse connotation to disability. Factor scores on this Success factor, normalized with a mean of 0.0000 and a standard deviation.of 1.0000, were derived for a l l subjects, and are hereafter referred to as "Success scores" or simply "Success." Except for algebraic sign, "Success" as used in the present paper is synonymous with "Disability." In retrospect, these Success scores for the individual subjects seem clinically appropriate, being highly related ,(m = -.9441, p < .0001) 67 T a b l e 2 D e r i v a t i o n o f t he D i s a b i l i t y I n d e x V a r i a b l e code name F a c t o r l o a d i n g * S u b j e c t M a t t e r o f t h e V a r i a b l e INDEPEND - 0 . 5 2 1 7 S e l f c a r e LOSS - 0 . 6 3 4 0 Time l o s s f r o m work i n p a s t two y e a r s WORK - 0 . 6 3 9 8 A b i l i t y t o work n o r m a l l y TENDER - 0 . 6 4 0 4 T e n d e r n e s s s e e n on o r t h o p a e d i c e x a m i n a t i o n SEX - 0 . 6 4 3 5 Impa i rmen t o f s e x l i f e by LBP L I F E - 0 . 7 0 1 8 G e n e r a l q u a l i t y o f l i f e as a f f e c t e d by LBP SLEEP - 0 . 7 0 9 9 D i s t u r b a n c e s o f s l e e p TRANSPOR - 0 . 7 3 4 4 A b i l i t y t o r i d e c a r o r b u s w i t h o u t d i s c o m f o r t MOBILE - 0 . 7 4 0 2 A b i l i t y t o w a l k n o r m a l l y CHAIR - 0 . 7 5 1 6 , A b i l i t y t o s i t w i t h o u t d i s c o m f o r t OPINION - 0 . 7 5 8 9 P a t i e n t ' s o p i n i o n o f t h e v a l u e o f l a s t s u r g e r y SEVERITY - 0 . 8 0 8 1 S e v e r i t y o f LBP FLOOR - 0 . 8 1 2 7 A b i l i t y t o p i c k t h i n g s o f f f l o o r w i t h o u t d i s c o m f o r t SOCIAL - 0 . 8 3 0 3 A b i l i t y t o p a r t a k e o f s o c i a l a c t i v i t i e s NINCOME 0 0 * 4 0 0 0 F a m i l y income p e r month S L I F E 0 0 . 3 0 8 0 Q u a n t i t y o f s e x l i f e COCCYX - 0 . 4 0 9 8 F r e q u e n c y o f p a i n a t t i p o f t a i l b o n e MONEY - 0 . 2 2 2 9 G e n e r a l f i n a n c i a l c i r c u m s t a n c e s AGAIN - 0 . 5 0 1 3 W i l l i n g n e s s of p a t i e n t t o a c c e p t s u r g e r y a g a i n u n d e r c i r c u m s t a n c e s s i m i l a r t o l a s t o p e r a t i o n CHORES 0 . 4 0 0 3 A b i l i t y t o do h o u s e h o l d c h o r e s * B e c a u s e o f t he d i r e c t i o n o f l o a d i n g s on t h i s f a c t o r , a p o s i t i v e f a c t o r s c o r e w o u l d r e f l e c t t h e o p p o s i t e of d i s a b i l i t y . The f a c t o r i s t h u s r e f e r r e d t o as " S u c c e s s . " 68 t o a c l i n i c a l j udgment made b y t h e o r t h o p a e d i s t o f e a c h s u b j e c t ' s d i s -a b i l i t y i m m e d i a t e l y f o l l o w i n g h i s e x a m i n a t i o n s . C o r r e l a t e s of D i s a b i l i t y S i x t y - f o u r s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t e s o f d i s a b i l i t y we re f o u n d by c o r r e l a t i n g t h e 239 v a r i a b l e s documented d u r i n g t h e p r e s e n t s t u d y w i t h t h e S u c c e s s s c o r e s . Of t h e s e 64 c o r r e l a t e s , s i x we re s u b j e c t i v e p s y c h o l o g i c a l r a t i n g s made by t h e o r t h o p a e d i s t w h i c h were r e d u n d a n t t o the p s y c h o m e t r i c d a t a . These s i x c o r r e l a t e s w e r e o m i t t e d f r o m f u r t h e r c o n s i d e r a t i o n . The r e m a i n i n g 58 c o r r e l a t e s a r e d i s c u s s e d b e l o w , and t h e i r code names , d e s c r i p t i o n s and c o r r e l a t i o n s w i t h S u c c e s s a r e i n d i c a t e d i n T a b l e 3 . The 58 v a r i a b l e s s i g n i f i c a n t l y c o r r e l a t e d w i t h S u c c e s s c a n be g rouped i n t o s e v e r a l c a t e g o r i e s . Thus 15 v a r i a b l e s w e r e e x a m i n a t i o n s i g n s s o u g h t by t h e o r t h o p a e d i s t d u r i n g an o f f i c e e x a m i n a t i o n . A t e n d e n c y was s e e n f o r more d i s a b l e d s u b j e c t s t o be weak i n t h e m u s c l e s o f t he abdomen ( v a r i a b l e ABDPOWA, m = - . 6 1 5 8 , p < . 0 0 2 ; v a r i a b l e ABDPOWB, m = - . 7 8 2 9 , p < . 0 0 0 1 ) , t h e b a c k ( v a r i a b l e BACKPOW, m = e . 8 0 4 9 , p < . 0 0 0 1 ) , and t h e l e g s ( v a r i a b l e LEGPOW, m = - . 4 5 9 8 , p < . 0 0 0 5 ) . The more d i s a b l e d s u b j e c t s a l s o t e n d e d t o show a d e c r e a s e i n t h e i r r a n g e s of m o t i o n , a s e v i d e n c e d by s t r a i g h t l e g r a i s i n g ( v a r i a b l e S L R , m = - . 6 8 0 6 , p < . 0 0 0 1 ) , l umbar e x t e n s i o n ( v a r i a b l e LUMEXT, m = - . 4 5 5 5 , p < . 0 0 0 1 ) , a t t e m p t e d t o e - t o u c h i n g ( v a r i a b l e FLEXTWO, m = - . 5 9 1 6 , p < . 0001 ) and l a t e r a l e x -c u r s i o n o f t he hand t o w a r d s t h e knees ( v a r i a b l e R L F L E X , m = - . 4 8 5 1 , p < . 0 0 0 1 ) . «The more d i s a b l e d s u b j e c t s a l s o t e n d e d t o e x p e r i e n c e p a i n Table 3. 58 Correlates of Disability V a r i a b l e code name D e s c r i p t i o n C o r r . Prob. ABDPOWA A b i l i t y to r a i s e s t r a i g h t l e g s 10 cm. o f f exam, t a b l e m = -.6158 < 002 ABDPOWB A b i l i t y to do a " s i t - u p " m = -.7829 < 0001 BACKPOW A b i l i t y to r a i s e b u t t o c k s o f f exam, t a b l e when supine m -.8049 < 0001 LEGPOW Sum of s e v e r a l t e s t s of l e g s t r e n g t h m -.4598 < 0005 SLR P a i n on s t r a i g h t l e g r a i s i n g m - -.6806 < 0001 LUMEXT Range of motion of the lumbar spine on e x t e n s i o n m = -.4555 < 0001 FLEXTWO Range of f l e x i o n ( i n attempt to touch toes) m -.5916 <.0001 RLFLEX Range of motion i n r i g h t / l e f t f l e x i o n m = -.4851 < 0001 PAINEXT P a i n on e x t e n s i o n m = -.5711 0001 HYPEREXT Occurrence of p a i n on p a s s i v e e x t e n s i o n m -.8046 < 0001 GAENSLEN P a i n on s a c r o i l i a c s t r e s s m - -.5794 < 0001 VALSALVA E f f e c t on p a i n of i n c r e a s i n g abdominal p r e s s u r e m -.4794 < 0005 ABDFLEX Presence of the abdominal r e f l e x m = -.4185 < 005 BOW P a i n on t a u t p o p l i t e a l nerve m -.4458 < 005 STANCE A b n o r m a l i t i e s i n p a t i e n t ' s stance m .7764 < 0001 LOWBACK Low back p a i n m - -.6611 < 0001 BUTTOCK P a i n i n the b u t t o c k s or t h i g h s m -.3989 < 0005 LEGS P a i n i n the l e g s or f e e t m = -.4590 < 0001 STIFF S t i f f n e s s of the back or l e g s m -.5308 < 0001 WEAKNESS Weakness of the l e g s m - -.4605 < 0002 SENSAT Change i n s e n s a t i o n s i n the l e g s m - -.2929 < 01 SPASM Spasm of the p a r a v e r t e b r a l muscles m = -.5940 < 0001 WALKING E f f e c t on p a i n of w a l k i n g m -.3666 < 002 BENDING E f f e c t on p a i n of bending forward or sideways m = -.6522 < 0001 LIFTING E f f e c t on p a i n of L i f t i n g m = -.4969 < 0001 CHAIR P a i n on s i t t i n g , g e t t i n g i n t o or out of c h a i r m = -.8676 < 0001 CAR A b i l i t y to d r i v e a c a r without p a i n m = -.7482 < 0001 RETURN Time taken to r e t u r n to work a f t e r l a s t o p e r a t i o n m -.4830 < 0001 RESULT P a t i e n t r a t i n g of how s u c c e s s f u l was l a s t o p e r a t i o n r = -.4503 < 0005 OBJECT Examining o r t h o p a e d i s t ' s o p i n i o n o f p a t i e n t ' s d i s a b i l i t y m - -.9441 < 0001 INTES.CAP P a i n between shoulder b l a d e s m - -.4002 < 001 NECKS P a i n i n the neck r e g i o n m = -.3054 < 01 NECKO A b n o r m a l i t i e s of the c e r v i c a l s p i n e m - -.3718 < 01 OPERATE T o t a l number of back o p e r a t i o n s r = -.4498 < 0001 LAMNO Number of laminectomies r = -.2757 < 01 FUSIONO Number of f u s i o n o p e r a t i o n s r = -.4456 < 0001 HEADACHE M i g r a i n e or headache m = -.3380 < 005 BP Blood p r e s s u r e m -.4324 < 005 TUMMY A b n o r m a l i t i e s of abdomen m = -.4718 < 001 RECTAL A b n o r m a l i t i e s on r e c t a l examination m = -.5382 < 0005 MMPIHS MMPI h y p o c h o n d r i a s i s T - s c o r e r -.5043 < 0001 MMPID MMPI d e p r e s s i o n T - s c o r e r = -.4770 < 0001 BECK Beck Index of D e p r e s s i o n s c o r e r -.5257 < 0001 MMPIHY MMPI h y s t e r i a T - s c o r e r = -.4453 < .0001 MMPIPT MMPI p s y c h a s t h e n i a T - s c o r e r = -.3226 < .002 TAYLOR MMPI T a y l o r Iowa A n x i e t y s c o r e r = -.4439 < .0001 CATIQ C a t t e l l i n t e l l i g e n c e q u o t i e n t (sigma = 16) r - .2841 < 005 MMPIES MMPI e g o - s t r e n g t h T-score r = _.4952 < .0001 KCNOW S e l f - r a t i n g of p r e s e n t l i f e s a t i s f a c t i o n r = .4796 < .0001 KCFUT S e l f - r a t i n g of p r o b a b l e l i f e s a t i s f a c t i o n 5 y e a r s f u t u r e r .4723 < .0001 CPICS CPI C a p a c i t y f o r S t a t u s s t a n d a r d s c o r e r = -.2758 < .01 CPISP CPI S o c i a l Presence stand a r d s c o r e r = .3248 < .002 OBITCH O r t h o p a e d i s t ' s r a t i n g of p a t i e n t ' s eagerness to recount t r o u b l e s r -.3429 < .001 OBLEED O r t h o p a e d i s t ' s r a t i n g of p a t i e n t ' s e m o t i o n a l i t y i n r e c o u n t i n g t r o u b l e s r -.4563 < .0001 CTT Cold T o l e r a n c e T e s t time m .3414 < .005 SIBS Number of s i b l i n g s of p a t i e n t r = -.2671 < .01 PROVINCE P l a c e o f b i r t h — f o r e i g n , B.C., or o t h e r Canada n .3823 < .005 HANDED Handedness of p a t i e n t m = .4973 < .01 70 on e x t e n s i o n o r p a s s i v e h y p e r e x t e n s i o n movement ( v a r i a b l e P A I N E X T , m = - . 5 7 1 1 , p < . 0 0 0 1 ; v a r i a b l e HYPEREXT, m = - . 8 0 4 6 , p < . 0 0 0 1 ) , on s a c r o i l i a c s t r e s s ( v a r i a b l e GAENSLEN, m = - . 5 7 9 4 , p < . 0 0 0 1 ) , o r when i n t r a a b d o m i n a l p r e s s u r e was i n c r e a s e d ( v a r i a b l e V A L S A L V A , m = - . 4 7 9 4 , p < . 0 0 0 5 ) . The a b d o m i n a l r e f l e x a l s o t e n d e d t o be a b s e n t i n t h e more d i s a b l e d ( v a r i a b l e A B D F L E X , m = - . 4 1 8 5 , p < . 0 0 5 ) , and p a i n was more o f t e n r e p o r t e d when p r e s s u r e was p l a c e d on t h e t a u t p o p l i t e a l n e r v e ( v a r i a b l e BOW, m = - . 4 4 5 8 , p < . 0 0 5 ) . The p o s t u r e o f t h e more d i s a b l e d s u b j e c t s was a l s o o f t e n s e e n t o be a b n o r m a l ( v a r i a b l e STANCE, m = . 7 7 6 4 , p < . 0 0 0 1 ) . Seven common b a c k symptoms were more f r e q u e n t l y r e p o r t e d b y t h e most d i s a b l e d s u b j e c t s , i n c l u d i n g l ow b a c k p a i n ( v a r i a b l e LOWBACK, m = - . 6 6 1 1 , p < . 0 0 1 ) , p a i n i n t h e b u t t o c k s o r t h i g h s ( v a r i a b l e BUTTOCKS, m = - . 3 9 8 9 , p < . 0 0 0 5 ) , and p a i n i n t h e l e g s o r f e e t ( v a r i a b l e L E G S , m = - . 4 5 9 0 , p < . 0 0 0 1 ) . The d i s a b l e d s u b j e c t s a l s o more f r e q u e n t l y e x p e r i e n -ced s t i f f n e s s o f t h e b a c k and l e g s ( v a r i a b l e S T I F F , m = - . 5 3 0 8 , p < . 0 0 0 1 ) , weakness i n t h e l e g s ( v a r i a b l e WEAKNESS, m = - . 4 6 0 5 , p < . 0 0 0 2 ) , and changes o f s e n s a t i o n i n t h e l e g s ( v a r i a b l e SENSAT, m = - . 2 9 2 9 , p < . 0 1 ) . Spasm o f t h e p a r a v e r t e b r a l m u s c l e s was a l s o more common i n t h e d i s a b l e d ( v a r i a b l e SPASM, m = - . 5 9 4 0 , p < . 0 0 0 1 ) . E i g h t a p p a r e n t l y b a c k - r e l a t e d p r o b l e m s i n t h e a c t i v i t i e s o f d a i l y l i v i n g w e r e a l s o more commonly s e e n i n t h e more d i s a b l e d . They e x p e r i e n c e d p a i n and i m p a i r m e n t i n w a l k i n g ( v a r i a b l e WALKING, m = - . 3 6 6 6 , p < . 0 0 2 ) , p a i n on b e n d i n g ( v a r i a b l e BENDING, m = - . 6 5 2 2 , p < . 0 0 0 1 ) , p a i n on l i f t i n g ( v a r i a b l e L I F T I N G , m = - . 4 9 6 9 , p < . 0 0 0 1 ) , and p a i n on s i t t i n g o r g e t t i n g 71 i n t o o r ou t o f a c h a i r ( v a r i a b l e CHAIR, m = - . 8 6 7 6 , p < . 0001 ) o r c a r ( v a r i a b l e CAR, m = - . 7 4 8 2 , p < . 0 0 0 1 ) . The more d i s a b l e d s u b j e c t s a l s o had t e n d e d t o t a k e l o n g e r t h a n t he l e s s d i s a b l e d t o r e t u r n t o w o r k a f t e r t h e i r l a s t b a c k o p e r a t i o n s ( v a r i a b l e RETURN, m = - . 4 8 3 0 , p < . 0 0 0 1 ) , t h e y r a t e d t h e v a l u e o f t h e i r l a s t f u s i o n o p e r a t i o n l e s s f a v o r a b l y t h a n t h e l e s s d i s a b l e d ( v a r i a b l e RESULT, r = - . 4 5 0 3 , p < . 0 0 0 5 ) , and t h e o r t h o p a e d i s t r a t e d (on a b a s i s o f c l i n i c a l j udgmen t ) t he more d i s a b l e d a s b e i n g more d i s a b l e d ( v a r i a b l e OBJECT, m = - . 9 4 4 1 , p < . 0 0 0 1 ) . T h r e e i n d i c a t i o n s o f c e r v i c a l s p i n e p r o b l e m s w e r e more commonly s e e n among t h e most d i s a b l e d s u b j e c t s . They more f r e q u e n t l y r e p o r t e d p a i n b e t w e e n t he s h o u l d e r b l a d e s ( v a r i a b l e INTESCAP, m=^-.4Q02-,p^;;001) and p a i n i n t h e n e c k r e g i o n ( v a r i a b l e N E C K S , m = - . 3 0 5 4 , p < . 0 1 ) . The o r t h o p a e d i s t a l s o n o t e d more a b n o r m a l i t i e s o f t he c e r v i c a l s p i n e i n h i s e x a m i n a t i o n o f t h e s e s u b j e c t s ( v a r i a b l e NECKO, m = - . 3 7 1 8 , p < . 0 1 ) . T h r e e v a r i a b l e s showed t h a t t he most d i s a b l e d s u b j e c t s had more b a c k o p e r a t i o n s t h a n l e s s d i s a b l e d p a t i e n t s , i n t e rms o f t he t o t a l number ( v a r i a b l e OPERATE, r = - . 4 4 9 8 , p < . 0 0 0 1 ) , t h e number o f l a m i n e c -t o m i e s ( v a r i a b l e LAMNO, r = - . 2 7 5 7 , p < 0057) and t he number o f f u s i o n s ( v a r i a b l e FUSIONO, r = - . 4 4 5 6 , p < . 0 0 0 1 ' ) , and f o u r v a r i a b l e s showed t h a t the most d i s a b l e d s u b j e c t s more commonly t h a n t h e l e s s d i s a b l e d , gave e v i d e n c e of m e d i c a l p r o b l e m s o t h e r t h a n t h o s e i n v o l v i n g t he b a c k . They more f r e q u e n t l y r e p o r t e d a h i s t o r y o f h e a d a c h e s ( v a r i a b l e HEADACHE, m = - . 3 3 8 0 , p < . 0 0 5 ) , and on e x a m i n a t i o n t h e o r t h o p a e d i s t more o f t e n f o u n d a b n o r m a l i t i e s o f b l o o d p r e s s u r e ( v a r i a b l e , B P , m = - . 4 3 2 4 , p < . 0 0 5 ) , o f t he abdomen ( v a r i a b l e TUMMY, m = - . 4 7 1 8 , p < . 0 0 1 ) , and o f t h e 72 r e c t a l a r e a ( v a r i a b l e RECTAL, m = - . 5 3 8 2 , p < . 0 0 0 5 ) . F i f t e e n p s y c h o l o g i c a l v a r i a b l e s we re f o u n d t o b e a s s o c i a t e d w i t h d i s a b i l i t y , t h e d i s a b l e d s u b j e c t s t e n d i n g t o be more h y p o c h o n d r i a c a l ( v a r i a b l e MMPIHS, r = - . 5 0 4 3 , p < . 0 0 0 1 ) , more d e p r e s s e d ( v a r i a b l e MMPID, r = - . 4 7 7 0 , p < . 0 0 1 ; v a r i a b l e B E C K , r = - . 5 2 5 7 , p < . 0 0 0 1 ) , more h y s t e r i c a l ( v a r i a b l e MMPIHY, r = - . 4 4 5 3 , p < . 0 0 0 1 ) , and more a n x i o u s ( v a r i a b l e MMPIPT, r = - . 3 2 2 6 , p < . 0 0 2 ; ; v a r i a b l e TAYLOR, r = - . 4 4 3 9 , p < .0001) than t h e l e s s d i s a b l e d s u b j e c t s . The more d i s a b l e d a l s o t e n d e d t o be c h a r a c t e r i z e d by b e i n g l e s s i n t e l l i g e n t ( v a r i a b l e CAT IQ , r = . 2 8 4 1 , p < . 0 0 5 ) , and b y h a v i n g l o w e r e g o - s t r e n g t h ( v a r i a b l e MMPIES, r = - . 4 9 5 2 , p < . 0001 ) t h a n t h e l e s s d i s a b l e d . The d i s a b l e d we re more d i s s a t i s f i e d w i t h t h e i r c u r r e n t s u c c e s s i n a t t a i n i n g s e l f - a s c r i b e d l i f e g o a l s ( v a r i a b l e KCNOW, r = . 4 7 9 6 , p < .0001) and more p e s s i m i s t i c abou t r e a c h i n g t h o s e g o a l s i n t he f u t u r e ( v a r i a b l e K C F U T , r = . 4 7 2 3 , p < . 0 0 0 1 ) . As i n d i c a t e d by t h e C P I , t h e most d i s a b l e d t e n d e d t o show a l o w C a p a c i t y f o r S t a t u s ( v a r i a b l e C P I C S , r = - . 2 7 5 8 , p < . 0 1 ) , and l i t t l e S o c i a l P r e s e n c e ( v a r i a b l e C P I S P , r = . 3 2 4 8 , p < . 0 0 2 ) . The o r t h o p a e d i s t a l s o r a t e d t he d i s a b l e d as b e i n g more e a g e r ( v a r i a b l e OBITCH, r = - . 3 4 2 9 , p < . 0 0 1 ) , and more e m o t i o n a l ( v a r i a b l e 0 B L E E D , r = 0 . 4 5 6 3 , p < .0001) i n r e c o u n t i n g t h e i r t r o u b l e s t o h i m . The more d i s -a b l e d a l s o t e n d e d t o have a l ow p a i n t o l e r a n c e ( v a r i a b l e C T T , m = . 3 4 1 4 , p < . 0 0 5 ) , as a s s e s s e d by t h e C o l d T o l e r a n c e T e s t . F i n a l l y , t h r e e l e s s e a s i l y c a t e g o r i z e d c o r r e l a t e s o f d i s a b i l i t y were f o u n d , t h e more d i s a b l e d s u b j e c t s t e n d i n g t o h a v e come f r o m l a r g e r f a m i l i e s , ( v a r i a b l e S I B S , r = - . 2 6 7 1 , p < . 0 1 ) , and t o be f o r e i g n - b o r n 73 ( v a r i a b l e PROVINCE, n 2 = . 3 8 2 3 , p < . 0 0 5 ) . L e f t - h a n d e d s u b j e c t s (n = 8 ) a l s o a p p e a r t o h a v e been l e s s d i s a b l e d ( v a r i a b l e HANDED, m = . 4 9 7 3 , p < . 0 1 ) as a g roup t h a n t h e r i g h t - h a n d e d s u b j e c t s . O v e r l a p s i n Measurement Among P s y c h o l o g i c a l and O r t h o p a e d i c V a r i a b l e s F o l l o w i n g an i n i t i a l p e r u s a l o f t he a n a l y z e d d a t a of t h i s s t u d y , i t became e v i d e n t t h a t a c o m p l e t e e x p o s i t i o n o f the c o r r e l a t i o n s among t h e o r t h o p a e d i c and p s y c h o l o g i c a l measu res w o u l d b e o f l i t t l e v a l u e : t h e c h a o t i c a r r a y o f s u c h r e l a t i o n s h i p s i s beyond human c o g n i t i v e c a p a c i t y t o p r o c e s s , and t h e e x t e n s i v e o v e r l a p p i n g i n measurement c a s t s doub t on what any one of t he v a r i a b l e s i s m e a s u r i n g w i t h o u t t h e b e n e f i t o f f a c t o r a n a l y t i c c l a r i f i c a t i o n . However r e f e r e n c e t o a samp le o f c o r r e l a t i o n s s u c h as t h o s e a p p e a r i n g i n T a b l e 4, b e t w e e n what a r e somet imes t h o u g h t o f as " p u r e l y o r g a n i c " o r " p u r e l y p s y c h o l o g i c a l " i n d i c a t o r s , may have some i l l u s t r a t i v e v a l u e . As i s e a s i l y s e e n i n a g l a n c e a t T a b l e 4, many v e r y h i g h c o r r e l a -t i o n s e x i s t among t h e commonly u s e d o r t h o p a e d i c e x a m i n a t i o n measu res and t h e p s y c h o l o g i c a l measu res w h i c h w e r e c o l l e c t e d i n t h e p r e s e n t s t u d y . F o r e x a m p l e , a measure i n d i c a t i n g t he s u b j e c t ' s e x p e r i e n c e and r e p o r t o f p a i n on p a s s i v e s e x t e n s i o n o f t he b a c k ( v a r i a b l e HYPEREXT) i s h i g h l y r e l a t e d t o many p s y c h o l o g i c a l v a r i a b l e s i ( e . g . , v a r i a b l e s MMPIHS, MMPID, MMPIHY, MMPIPT, MMPIES, TAYLOR, KCNOW, K C F U T ) , as i s a measu re o f t h e s u b j e c t ' s d e m o n s t r a t e d b a c k - m u s c l e . s t r e n g t h ( v a r i a b l e BACKPOW). C o n -v e r s e l y , t h e p s y c h o l o g i c a l measu res a r e o f t e n h i g h l y r e l a t e d t o numerous o r t h o p a e d i c m e a s u r e s . F o r e x a m p l e , t h e h y p o c h o n d r i a s i s measu re ( v a r i a b l e Table 4. Overlaps in Measurement Among Orthopaedic and Psychological Variables W I HS MMPI D MKPI HY MMPI PT MMPI ES TAYLOR CTT KCNOW. KCPUT OPINION AGAIN SUCCESS LUMPLEX _ _ _ _ _ _ _ - m=-.28* - - -FLEXTWO m=.36** m=.28* m=.31* - - m=.28* - - m=-.29* g=.71*** g=.52* m=-.59*** LUHEXT ro=.36** n&.JI** - - n=-.27* m=.32* - - - g^.55** g=.51* m=-.**6*** PAINEXT m=.36* - m=.35* - - - - - - g=.60** - m=-.57*** RLPLEX - - - - - - - - g=.V7** - m=-.k9*** HYPEREXT m=.42*** m=.k7*** m=.36* m=.32* m=-.59*** m=.l*-2** - m=-.if7*** m=-.38* g=.66*** - m=-.80*** GAENSLEN m=. ¥** m=.it4* ra=.37* - - - - - - g=.73*** - m=-.57*** SLR - - - - - m=.30* - - - - m=-.68*** ABDPOWA - - - - - - - - - - - m=-.62* ABDPOWB m=.3^* - - - m=-.30* - - m=-.36* m=-.36* g=.68*** g>=.68*** m=-.78*** BACKPOW m=.50*** m=. **(:** m=.^l** - m=-.37* m=.38* - m=-.i>3** m=-.38* g=.73*** g=.61*** m=-o80*** LEGPOW - - - - - - - - - g=.52** - m=-.**6*~* LOSSRL - - - - - - - - g=.W** - -TENDER - - - - m=-.31* - - - - g=.73*** g=.63* m=-.73*** OPINION m=. 5 ***** m=.k5** m=.51*** m=.37* m=.41** e=-.3*** m=-.42** X g=.89*** X AGAIN - m=.37* - - - s=-.**9* - - X X X SUCCESS r=-.50*** T=-.k8*** r=-.32* r=-.50**« r^-. i jJi .*** m=.3*** ' r=.**S*** m=-.90*** m=-.70*** X * p < . 0 1 ** D < .001 *** p < .0001 75 MMPIHS) i s h i g h l y r e l a t e d t o numerous o r t h o p a e d i c measu res ( e . g . , v a r i a b l e FLEXTWO, LUMEXT, P A I N E X T , HYPEREXT, GAENSLEN, ABDPOW, BACKPOW), as i s t h e d e p r e s s i o n measu re ( v a r i a b l e MMPID) . From t h e e x t e n s i v e o v e r -l a p s i n measurement s e e n t o be p r e s e n t b e t w e e n t h e s e two c l a s s e s o f v a r i a b l e s , t he need f o r f a c t o r a n a l y t i c c l a r i f i c a t i o n i s e v i d e n t . The w a r n i n g may a l s o be d e r i v e d f r o m t h e a b o v e i l l u s t r a t i o n t h a t when an o r t h o p a e d i s t and a p s y c h o l o g i s t e v a l u a t e t h e same p a t i e n t , as i n a j o i n t a p p r a i s a l , n e i t h e r s p e c i a l i s t must assume t h a t h i s e v a l u a t i o n i s i n d e p e n d e n t of t h e o t h e r s p e c i a l i s t ' s . The hope o f " d i s c i p l i n e - p u r e m e a s u r e s , p romoted b y e v i d e n c e s u c h as t h a t o f "LEGPOw" and " C T T " i n T a b l e 4 , i s smashed by t h e f r a g m e n t e d f a c t o r l o a d i n g s w h i c h w i l l be d e s c r i b e d b e l o w . D e r i v a t i o n of t h e B a s i c D i m e n s i o n s o f LBP D i s a b i l i t y A s p o i n t e d ou t a b o v e , t he o v e r l a p s i n measurement among t h e c o r -r e l a t e s o f d i s a b i l i t y l e a d t o m a s s i v e c o n f u s i o n a b o u t what b a s i c p a r a -m e t e r s u n d e r l y d i s a b i l i t y . C o n s e q u e n t l y , 55 v a r i a b l e s s i g n i f i c a n t l y c o r r e l a t e d w i t h S u c c e s s ( t h r e e v a r i a b l e s , PROVINCE, HANDED and RESULT we re o m i t t e d f r o m f u r t h e r a n a l y s i s b e c a u s e the f i r s t two w e r e o f a n o m i n a l n a t u r e and t h e l a t t e r had o n l y 48 o b s e r v a t i o n s ) w e r e f a c t o r a n a l y z e d u s i n g a p r i n c i p a l component s o l u t i o n f o l l o w e d b y v a r i m a x r o t a t i o n . S e v e n t e e n o r t h o g o n a l f a c t o r s we re t h u s d e r i v e d , account ing f o r 74.88% o f t he t o t a l v a r i a n c e o f t h e 55 v a r i a b l e s . The f a c t o r m a t r i x p r e s e n t e d i n T a b l e 5 i n d i c a t e s t h e l o a d i n g s o f e a c h v a r i a b l e on e a c h o f t h e 17 o r t h o g o n a l f a c t o r s . As d i s c u s s e d a b o v e , h o w e v e r , e a c h o f t h e f a c t o r s u n d e r l y i n g t h e 55 76 Table 5. Factor Matrix of 55 Correlates of Disability FACTOR 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 VARIABLE CTT 81 11 -04 01 -02 -12 02 08 07 02 15 -03 05 04 06 07 08 CHAIR -45 -15 -14 -13 -20 19 -05 -32 24 -04 03 16 -18 -41 02 -00 -05 MMPIES 17 74 01 34 16 -02 -14 -01 11 08 01 02 03 18 10 05 -08 TAYLOR -10 -71 -07 -47 -03 09 02 -12 07 02 -10 06 -07 01 08 00 13 MKPIHS -04 -74 -18 05 -24 06 17 -22 06 -02 00 -01 01 01 -16 -12 -12 MKPIHY -02 -76 -18 32 -23 06 19 -13 07 -03 07 -04 -02 -07 -12 -07 -04 BECK -11 -76 -01 -16 -14 14 -01 -21 -11 -07 06 22 -05 04 04 -10 11 MKPID 04 -78 -20 -11 -03 01 10 -13 -07 -06 -04 00 -11 -03 -12 -08 -18 JC-PIPT 03 -81 06 -14 -04 06 -01 -01 00 09 -11 -02 -11 -07 00 -01 02 STIFF -15 -05 -37 -19 -22 35 09 03 06 -04 -24 09 -12 -31 -12 -26 10 LEGS 01 -13 -51 -03 -01 36 13 -07 05 -17 -08 23 -16 -04 -04 -50 -06 TUKIiY -29 01 -57 07 01 -05 08 -38 -13 -06 26 10 15 09 06 -18 -03 WEAKNESS 02 -20 -74 -06 -03 -07 13 -04 -11 03 -00 30 -01 -21 05 -18 04 SEKSAT 13 -15 -78 -02 -03 10 -08 -06 02 08 -20 -17 -03 -18 -20 12 03 CPICS 08 21 -01 79 -05 11 01 16 01 -16 20 -02 01 09 01 01 04 CPISP -07 29 05 75 06 07 -08 07 09 04 -20 07 12 04 15 -01 15 ABDFLEX -30 -02 -38 22 -43 07 -06 -17 05 -04 07 -20 18 -13 07 -09 18 LAMNO 13 -09 -07 -20 -61 06 -07 -16 10 -04 -09 34 15 07 17 -23 00 FUSIONO -07 -32 -03 03 -73. 13 04 -16 -10 07 -07 -06 -17 -02 -07 00 -14 OPERATE -02 -35 02 05 -79 -01 16 -12 -11 -03 -08 03 -20 -07 05 01 -01 NECKO -21 -00 00 l i -09 80 01 -04 -02 05 02 04 03 -11 -11 01 -03 NECKS 05 -26 -07 05 01 76 03 -13 -01 01 -03 -10 -21 05 -06 -10 -03 OBITCH -00 -13 -07 -04 -09 02 85 -18 -01 -07 -09 03 -03 -11 -03 04 -10 OBLEE3) 01 -33 -02 -06 01 05 74 -20 -05 04 -04 08 -09 -26 01 -18 02 HYPERSXT -19 -37 -01 -12 -11 13 17 -42 -12 16 02 27 -10 -21 -38 03 11 ABDPOWA -10 19 -03 -18 -07 -18 28 -45 21 07 17 15 -42 13 -25 00 -13 LTIMEXT 10 -24 -25 -15 -16 28 -03 -47 -13 -27 -24 04 23 -08 -03 22 -11 RLFLEX 05 07 -22 -22 -32 29 13 -49 -25 -21 -01 13 09 -09 08 11 17 SLR -32 -02 -23 -19 -11 -05 16 -51 -04 -08 -29 20 -11 -06 -02 -13 04 OBJECT -17 -32 -28 06 -27 12 15 -54 -06 -03 -09 18 -23 -18 -04 -04 07 SPASM 11 -15 20 00 -11 29 28 -57 -03 -03 -04 -01 -12 -03 -19 02 04 ABDPOWB -15 -08 -05 -02 -03 16 19 -58 -07 -10 28 17 -19 -36 -14 02 05 GAEHSLEW 06 -23 15 02 04 -03 17 -60 -22 04 -04 20 08 03 -28 -26 -15 BACKPOW -21 -31 -16 -04 -05 04 -12 -69 -12 -02 11 11 -12 -17 -05 -08 -15 FLEXTWO -05 -14 -09 -13 -21 -02 06 -76 14 -06 -09 -06 -06 -18 04 -03 16 CATIQ 10 04 02 16 16 -19 -06 15 73 09 05 -04 -17 08 19 10 -02 HEADACHE -03 -42 -01 -08 -10 40 05 -10 52 -09 09 09 08 -10 12 00 -10 BP -02 -18 -14 03 -00 -08 02 -09 -69 02 -06 08 -3<* -04 18 10 -11 PAINEXT 03 -20 -00 09 -13 22 -12 -36 -15 47 02 22 16 -23 -25 -14 -18 STANCE -06 -16 -00 11 -08 04 03 -19 -07 -82 03 07 05 -11 -13 -16 -07 RETURN -36 -28 01 -09 -28 02 22 -08 -24 -01 36 04 -02 -21 -15 02 30 BOW -18 -12 -09 -05 -17 02 15 -07 -15 01 -76 01 08 -05 -06 -17 -04 LEGPOW -06 -02 -07 08 -02 -05 03 -21 -05 -05 01 •78 -10 -18 -08 05 01 WALKING -11 -17 -13 -28 -28 17 12 -05 -04 46 06 49 13 05 11 -07 -22 KCNOW 13 47 -02 02 10 -16 -07 13 07 09 05 -11 61 10 -01 -03 03 KCFUT -00 23 -03 18 19 -21 -04 19 06 -06 -17 -05 59 12 07 27 07 CAR -27 -18 -20 -14 -07 02 25 -36 -11 06 11 - l i -28 -40 -16 01 08 LIFTING 17 -06 -12 -02 03 -01 09 -44 -06 17 -19 11 09 -58 04 -23 -02 LCW3ACK -15 -12 -08 -15 06 06 08 -23 -00 -13 06 -06 02 -60 -11 -32 15 BENDING -06 -03 -23 03 -13 05 23 -09 -06 -10 -05 24 -13 -69 -02 03 -18 RECTAL -03 -09 02 -20 -43 -07 -37 -15 05 -06 -01 14 01 -15 -49 10 -04 INTESCAP -07 -17 -14 -07 18 24 08 -17 -03 -13 -04 01 -07 -03 -75 -08 -03 BUTTOCK -09 -17 -10 03 -08 03 03 -07 -02 -06 -14 -08 -05 -18 -02 -78 02 VALSALVA 14 -10 -11 -07 -08 00 •13 -33 04 14 -16 39 -25 -02 -26 05 46 SIBS -08 -08 05 -32 -16 11 22 00 -01 04 -12 09 -21 -07 -13 06 -59 77 v a r i a b l e s c o r r e l a t e d w i t h S u c c e s s need n o t t h e m s e l v e s be s i g n i f i c a n t l y c o r r e l a t e d w i t h S u c c e s s . F o r t h a t r e a s o n t h e f a c t o r s c o r e s f o r e a c h s u b j e c t on e a c h o f t h e 17 o r t h o g o n a l f a c t o r s we re d e r i v e d , and t h e f a c t o r s c o r e s on e a c h f a c t o r were c o r r e l a t e d w i t h t h e S u c c e s s s c o r e s . The amount o f the S u c c e s s v a r i a n c e a c c o u n t e d f o r by e a c h o r t h o g o n a l f a c t o r was a s c e r t a i n e d b y s q u a r i n g t h e P e a r s o n P r o d u c t Moment c o r r e l a -t i o n , and b e c a u s e t he f a c t o r s w e r e o r t h o g o n a l , t h e t o t a l S u c c e s s v a r i a n c e a c c o u n t e d f o r b y any s u b s e t o f t h e s e f a c t o r s c o u l d be d e t e r m i n e d by s i m p l y summing t h e v a r i a n c e a c c o u n t e d f o r by t h e i n d i v i d u a l f a c t o r s o f t h e s u b s e t . The 17 o r t h o g o n a l f a c t o r s we re f o u n d t o a c c o u n t f o r 87.96% o f t h e t o t a l S u c c e s s v a r i a n c e . E i g h t o f t h e 17 f a c t o r s were f o u n d to be s i g n i f i c a n t l y r e l a t e d t o S u c c e s s (p < . 0 5 ) and t h e s e e i g h t f a c t o r s a c c o u n t e d f o r 78 .81% o f t h e t o t a l S u c c e s s v a r i a n c e . A l l 17 o r t h o g o n a l f a c t o r s , t h e i r c o r r e l a t i o n s w i t h S u c c e s s , t h e amount o f S u c c e s s v a r i a n c e e a c h a c c o u n t s f o r , and t h e c o n c e p t u a l i z a t i o n o f e a c h f a c t o r a r e p r e s e n t e d i n T a b l e 6 . I d e n t i f i c a t i o n o f t h e n a t u r e o f t h e s e 17 f a c t o r s was u n d e r t a k e n j o i n t l y b y t he o r t h o p a e d i s t and p s y c h o l o g i s t . By i n s p e c t i o n o f t h e v a r i a b l e s l o a d i n g mos t h i g h l y on t h e e i g h t f a c t o r s s i g n i f i c a n t l y r e l a t e d t o S u c c e s s , t h e s e e i g h t f a c t o r s we re c o n c e p t u a l i z e d and named; t he o t h e r n i n e f a c t o r s i n some i n s t a n c e s c o u l d n o t be r e a d i l y c o n c e p t u a l i z e d i n t h i s manner . The f o l l o w i n g d e s c r i p t i o n s o f t he f a c t o r c o m p o s i t i o n s a r e b a s e d on T a b l e s 3 , 5 and 6 . F a c t o r One, a c c o u n t i n g f o r 7.69% o f the S u c c e s s v a r i a n c e 78 Table 6 Correlations between Success and the Orthogonal Factors underlying the Correlates of Disability Factor as numbered in Table 5 Correlation with Success (r) Amount Success Variance Accounted for Conceptualization 1 .2821* 7.69% Pain Tolerance 2 .3352* 11.24% Neuroticism 3 .2115* 4.47% Fitness 4 .1438 2.07% -5 .2502* 6.26% Operative History 6 -.1484 2.20% -7 -.1060 1.12% -8 .4851* 23.53% Textbook Back 9 .0657 0.43% -10 .0642 0.41% -11 .0174 0.03% -12 -.2189* 4.79% Nerve Root Deficit 13 .2187* 4.78% Life Goals 14 .3973* 15.78% Mobility of Self 15 .1362 1.86% -16 .1004 1.01% -17 .0149 0.02% I = 87.96% — *asterisked correlations indicate the eight factors showing a sig-nificant (p < .05) relationship to Success. Those eight factors account for a sum total of 78.81% of the Success variance. 79 ( r = . 2 8 2 1 , p < . 0 0 5 ) c l e a r l y r e f l e c t s p a i n t o l e r a n c e , l o w p a i n t o l e r a n c e b e i n g a s s o c i a t e d w i t h d i s a b i l i t y . The C o l d T o l e r a n c e T e s t h a s a v e r y h i g h f a c t o r l o a d i n g (FL ) on t h i s f a c t o r ( v a r i a b l e CTT , FL = . 8 1 ) . T h i s f a c t o r a l s o has l e s s e r l o a d i n g s by v a r i a b l e s i n d i c a t i n g an i n a b i l i t y t o s i t c o m f o r t a b l y f o r e x t e n d e d p e r i o d s ( v a r i a b l e CHAIR, FL = - . 4 5 ; v a r i a b l e CAR, FL = - . 2 7 ) , an a c t w h i c h i n a l l p r o b a b i l i t y w o u l d make any e x i s t i n g LBP more s a l i e n t . The h i g h l o a d i n g on t h i s f a c t o r o f t h e v a r i a b l e i n d i c a t i n g t h e l e n g t h o f t i m e t a k e n t o r e t u r n t o wo rk a f t e r t h e l a s t b a c k s u r g e r y ( v a r i a b l e RETURN, FL = - . 3 6 ) p r o b a b l y r e f l e c t s t h e p r a c t i c e b y p h y s i c i a n s o f r e t u r n i n g t h e p a t i e n t s t o wo rk when t h e y r e p o r t t h a t t h e y a r e r e l a t i v e l y p a i n - f r e e . The v a r i a b l e i n d i c a t i n g a t w h i c h p o i n t p a i n i s f e l t i n t h e c o u r s e o f s t r a i g h t l e g r a i s i n g a l s o l o a d s somewhat on t h i s f a c t o r ( v a r i a b l e S L R , FL = - . 3 2 ) , and p e r h a p s r e f l e c t s e a r l y r e p o r t i n g by t h e s u b j e c t s o f s m a l l amounts of p a i n as s i g n i f i c a n t . F a c t o r Two, a c c o u n t i n g f o r 11.24% o f t he S u c c e s s v a r i a n c e ( r = . 3 3 5 2 , p < .001 ) i s c l e a r l y a f a c t o r r e f l e c t i n g n e u r o t i c i s m , n e u r o t i c i s m b e i n g d i r e c t l y a s s o c i a t e d w i t h d i s a b i l i t y . L o a d i n g h e a v i l y on t h i s f a c t o r a r e t h e MMPI n e u r o t i c t r i a d ( v a r i a b l e MMPIHS, FL = - . 7 4 ; v a r i a b l e MMPID, FL = - . 7 8 ; v a r i a b l e MMPIHY, FL = - . 7 6 ) t h e Beck I . D . s c o r e ( v a r i a b l e B E C K , F L = - . 7 6 ) , and two m e a s u r e s i n d i c a t i n g a n x i e t y ( v a r i a b l e MMPIPT, FL = - . 8 1 ; v a r i a b l e TAYLOR, FL = - . 7 1 ) . E g o - s t r e n g t h l o a d s i n an i n v e r s e f a s h i o n t o t h e n e u r o t i c i s m m e a s u r e s on t h i s f a c t o r ( v a r i a b l e MMPIES, F L = . 7 4 ) . A r a t i n g made by t h e o r t h o p a e d i s t o f t h e s u b j e c t s ' e m o t i o n a l i t y i n r e c o u n t i n g t h e i r p r o b l e m s a l s o l o a d s m o d e s t l y on t h i s f a c t o r ( v a r i a b l e OBLEED, FL = - . 3 3 ) , as does a v a r i a b l e i n d i c a t i n g f r e q u e n t h e a d a c h e s 80 e x p e r i e n c e d by t h e s u b j e c t s ( v a r i a b l e HEADACHE, FL = - . 4 2 ) . F a c t o r T h r e e , a c c o u n t i n g f o r 4.4.7% o f t h e S u c c e s s v a r i a n c e ( r = . 2 1 1 5 , p < . 0 5 ) i s p r e d o m i n a n t l y l o a d e d by p h y s i c a l v a r i a b l e s . T h i s f a c t o r h a s been c o n c e p t u a l i z e d by t h e o r t h o p a e d i s t a s r e f l e c t i n g p h y s i c a l f i t n e s s and good m u s c l e t o n e , w h i c h a r e i n v e r s e l y a s s o c i a t e d w i t h d i s a b i l i t y . F a c t o r F i v e , t he n e x t f a c t o r a c c o u n t i n g f o r a s i g n i f i c a n t p r o p o r -t i o n (6.26%) o f t h e S u c c e s s v a r i a n c e ( r = . 2 5 0 2 , p < . 02 ) c l e a r l y r e f l e c t s o p e r a t i v e h i s t o r y , m u l t i p l e b a c k o p e r a t i o n s b e i n g a s s o c i a t e d w i t h d i s a b i l i t y . V a r i a b l e s l o a d i n g h i g h l y on t h i s f a c t o r i n d i c a t e t h e number o f l a m i n e c t o m i e s ( v a r i a b l e LAMNO, FL = - . 6 1 ) , t h e number o f s p i n a l f u s i o n s ( v a r i a b l e FUSIONO, FL = - . 7 3 ) and t h e t o t a l number o f b a c k o p e r a t i o n s ( v a r i a b l e OPERATE, F L = - . 7 9 ) . A l s o l o a d i n g s u b s t a n t i a l l y on t h i s f a c t o r a r e v a r i a b l e s i n d i c a t i n g l o s s o f t h e a b d o m i n a l r e f l e x ( v a r i a b l e ABDFLEX, F L = - . 4 3 ) , a b n o r m a l i t i e s f e l t on r e c t a l e x a m i n a t i o n ( v a r i a b l e RECTAL , FL = - . 4 3 ) , and d e c r e a s e i n t h e s p i n e ' s l a t e r a l r a n g e o f m o t i o n ( v a r i a b l e R L F L E X , F L = - . 3 2 ) . Of t h e p s y c h o l o g i c a l v a r i a b l e s , o n l y h y p o c h o n d r i a s i s and h y s t e r i a show modest l o a d i n g s on t h i s f a c t o r ( v a r i a b l e MMPIHS, FL = - . 2 4 ; v a r i a b l e MMPIHY, F L = - . 2 3 ) . F a c t o r E i g h t , a c c o u n t i n g f o r a l m o s t one q u a r t e r (23.53%) o f t he S u c c e s s v a r i a n c e ( r = . 4 8 5 1 , p < . 0 0 0 1 ) , i s h e a v i l y l o a d e d by d i a g n o s t i c e x a m i n a t i o n s i g n s commonly sough t i n o r t h o p a e d i c p r a c t i c e . T h i s f a c t o r , as i t a p p e a r s r e l a t e d t o S u c c e s s was named " N o r m a l B a c k O r t h o p a e d i c a l l y " ; a s r e l a t e d t o d i s a b i l i t y t h i s f a c t o r was c a l l e d " T e x t b o o k B a c k " by t h e o r t h o p a e d i s t , so w e l l does i t r e f l e c t t he c l a s s i c a l e x a m i n a t i o n s i g n s . 81 Of t he p s y c h o l o g i c a l v a r i a b l e s , o n l y t he h y p o c h o n d r i a s i s measu re ' has a v e r y modest l o a d i n g on t h i s f a c t o r ( v a r i a b l e MMPIHS, FL = - . 2 2 ) . F a c t o r T w e l v e , a c c o u n t i n g f o r 4 .79% o f t he S u c c e s s v a r i a n c e ( r = - . 2 1 8 9 , p < . 0 5 ) , a p p e a r s t o r e f l e c t n e r v e r o o t d e f i c i t s , t h e p r e s e n c e o f w h i c h i s a s s o c i a t e d w i t h d i s a b i l i t y . T h i s f a c t o r i s l o a d e d h e a v i l y b y e x a m i n a t i o n and s e l f - r e p o r t measu res i n d i c a t i n g mo to r l o s s e s i n t h e l e g s ( v a r i a b l e LEGPOW, FL = . 7 8 ; v a r i a b l e WALKING, F L = . 4 9 ) , a v a r i a b l e i n -d i c a t i n g t h a t p a i n i s f e l t when i n t r a a b d o m i n a l p r e s s u r e i n i n c r e a s e d ( v a r i a b l e VALSALVA, FL = . 39 ) and an o p e r a t i v e h i s t o r y o f l a m i n e c t o m y , ( v a r i a b l e LAMNO, FL = . 3 4 ) . F a c t o r T h i r t e e n , a c c o u n t i n g f o r 4.78% o f t h e S u c c e s s v a r i a n c e ( r = . 2 1 8 7 , p < . 0 5 ) , i s l o a d e d p r e d o m i n a n t l y by two p a t i e n t s e l f - r a t i n g s f r o m t h e K - C S c a l e , l o w r a t i n g s b e i n g a s s o c i a t e d w i t h d i s a b i l i t y . T h i s f a c t o r i s d i f f i c u l t t o c o n c e p t u a l i z e , i n t h a t i t seems p r o b a b l e t h a t t h e s e l f - r a t i n g s c o u l d r e f l e c t a t l e a s t two c o m p o n e n t s . On t h i s s c a l e , t h e s u b j e c t d e f i n e s t h e e n d p o i n t s o f t h e c o n t i n u u m by what f o r h i m w o u l d be t he v e r y b e s t and t h e v e r y w o r s t c i r c u m s t a n c e s i n l i f e , a t w h i c h t i m e he i s a s k e d t o i n d i c a t e whe re be tween t h e s e e x t r e m e s he i s a t p r e s e n t ( v a r i a b l e KCNOW, F L = . 6 1 ) , and whe re he e x p e c t s t o be f i v e y e a r s i n t h e f u t u r e ( v a r i a b l e KCFUT, FL = . 5 9 ) . The s u b j e c t ' s p h e n o m e n o l o g i c a l w o r l d i s t h u s dependen t on t h e g o a l s and e x p e c t a n c i e s u s e d i n d e f i n i n g t h e ends o f t h e r a t i n g c o n t i n u u m , and h i s r a t i n g s w i t h i n t he c o n t i n u u m no doub t r e f l e c t h i s a b i l i t y ( o r d i s a b i l i t y ) t o wo rk t o w a r d s t h e s e g o a l s . H o w e v e r , few v a r i a b l e s a s s o c i a t e d w i t h o t h e r d e m o n s t r a t e d d i m e n s i o n s o f d i s a b i l i t y l o a d e v e n m o d e s t l y on t h i s f a c t o r , s u g g e s t i n g t h a t d e f i n i t i o n o f t h e ends o f t h e r a t i n g c o n t i n u u m by u n r e a l i s t i c l i f e g o a l s i s 82 r e s p o n s i b l e f o r most o f t h e v a r i a n c e r e f l e c t e d i n t h i s f a c t o r . The f a c t o r was t h u s c o n c e p t u a l i z e d as r e f l e c t i n g " L i f e G o a l s . " F a c t o r F o u r t e e n , a c c o u n t i n g f o r 15.78% o f t h e S u c c e s s v a r i a n c e ( r = . 3 9 7 3 , p < .002 ) i s a l s o d i f f i c u l t t o c o n c e p t u a l i z e . L o a d i n g h e a v i l y on t h i s f a c t o r a r e v a r i a b l e s i n d i c a t i n g t h e i n t e r f e r e n c e o f p a i n w i t h b e n d i n g , l i f t i n g o r d r i v i n g ( v a r i a b l e BENDING FL = - . 6 9 ; v a r i a b l e L I F T I N G , FL = - . 5 8 ; v a r i a b l e CAR, FL = - . 4 0 ) , a s w e l l as a v a r i a b l e i n -d i c a t i n g t h e p r e s e n c e o f LBP a t t h e t i m e of e x a m i n a t i o n ( v a r i a b l e LOWBACK', , F L = - . 6 0 ) . A l s o h a v i n g s u b s t a n t i a l l o a d i n g s on t h i s f a c t o r a r e v a r i a b l e s i n d i c a t i n g t h e e x p e r i e n c e o f p a i n on h y p e r e x t e n s i o n ( v a r i a b l e P A I N E X T , F L = - . 2 3 ) , and on s i t t i n g o r g e t t i n g i n t o o r ou t o f a c h a i r ( v a r i a b l e CHAIR, FL = - . 4 1 ) . V a r i a b l e s i n d i c a t i n g t h e a b i l i t y t o do a " s i t - u p ( v a r i a b l e ABDPOWB, FL = - . 3 6 ) and t h e p r e s e n c e o f l e g s t i f f n e s s ( v a r i a b l e S T I F F , F L = - . 3 1 ) a l s o l o a d on t h i s f a c t o r . The n a t u r e o f t h e v a r i a b l e s l o a d i n g t h i s f a c t o r m i g h t i n i t i a l l y s u g g e s t a m e c h a n i c a l a b n o r m a l i t y o f t h e b a c k o r p e r h a p s l o w p a i n t o l e r a n c e . However t h e m a j o r v a r i a b l e s l o a d i n g on F a c t o r F o u r t e e n a l s o l o a d s u b s t a n t i a l l y on F a c t o r E i g h t ( T e x t b o o k B a c k ) and F a c t o r One ( P a i n T o l e r a n c e ) , and y e t F a c t o r F o u r t e e n a c c o u n t s f o r a u n i q u e v a r i a n c e on t h e s e v a r i a b l e s . The n a t u r e o f t h i s u n i q u e n e s s a p p e a r s t o be t h e d e g r e e o f " M o b i l i t y o f S e l f " r e t a i n e d . P e r h a p s t h i s m o b i l i t y i s dependen t on some u n i d e n t i f i e d o r g a n i c c o m p l e x , o r p e r h a p s i t c o r r e s sponds t o a f r e q u e n t l y h e a r d l a y c o n c e p t u a l i z a t i o n t h a t , when i l l , some p e o p l e l i e down w h e r e a s o t h e r s " g e t up and g e t on w i t h i t . " W a l t e r s (1966) has s u g g e s t e d t h a t an i n d i v i d u a l ' s r e a c t i o n t o p a i n may c o n s i s t o f w i t h d r a w a l and c o l l a p s e , o r may c o n s i s t o f a c q u i r e d a c t s o f t o l e r a n c e . 83 S i m i l a r l y F o r d y c e ( s e e F o o t n o t e 3) has n o t e d t h a t some p a t i e n t s r e s p o n d t o p a i n by l y i n g down w h e r e a s o t h e r s r e s p o n d by r e m a i n i n g a c t i v e . The o t h e r n i n e o r t h o g o n a l f a c t o r s f o u n d i n t h e f a c t o r a n a l y s i s o f t h e 55 c o r r e l a t e s o f d i s a b i l i t y we re n o t s i g n i f i c a n t l y r e l a t e d t o d i s -a b i l i t y (p < . 0 5 ) . Mos t o f t h e s e f a c t o r s c o u l d no t be c o n c e p t u a l i z e d , b u t s e v e r a l o f t h o s e t h a t c o u l d be i d e n t i f i e d a r e o f i n t e r e s t . F a c t o r F o u r , a c c o u n t i n g f o r an i n s i g n i f i c a n t 2.07% o f t h e S u c c e s s v a r i a n c e ( r = . 1 4 3 8 , p < . 1 0 ) i s c l e a r l y a s o c i a l compe tence f a c t o r , l o w s o c i a l competence b e i n g a s s o c i a t e d w i t h d i s a b i l i t y . Loaded h i g h l y on t h i s f a c t o r a r e t h e CP I m e a s u r e s , C a p a c i t y f o r S t a t u s ( v a r i a b l e CPAECS, F L = . 79 ) and S o c i a l P r e s e n c e ( v a r i a b l e C P I S P , FL = . 7 5 ) . A l s o h a v i n g s u b s t a n t i a l l o a d i n g s on t h i s f a c t o r a r e v a r i a b l e s i n d i c a t i n g t h e p r e s e n c e o f a n x i e t y ( v a r i a b l e TAYLOR, FL = - . 4 7 ) , and l o w e g o -s t r e n g t h ( v a r i a b l e MMPIES, FL = . 3 4 ) . O n l y v e r y m i n o r l o a d i n g s o f v a r i a b l e s r e f l e c t i n g o r g a n i c c o n d i t i o n s o c c u r on t h i s f a c t o r . F a c t o r S i x , a c c o u n t i n g f o r an i n s i g n i f i c a n t 2.20% o f t h e S u c c e s s v a r i a n c e ( r = - . 1 4 8 4 , p > . 1 0 ) i s h e a v i l y l o a d e d by measu res r e f l e c t i n g n e c k * p a i n s r e p o r t e d by t h e s u b j e c t s ( v a r i a b l e N E C K S , F L = . 86 ) and a b -n o r m a l i t i e s o f t h e c e r v i c a l s p i n e n o t e d on e x a m i n a t i o n o f t h e s u b j e c t s by t h e o r t h o p a e d i s t ( v a r i a b l e NECKO, F L = . 8 0 ) . T h i s f a c t o r w o u l d a p p e a r t o r e f l e c t p a t h o l o g y g e n e r a l i z e d t h r o u g h o u t t h e s p i n a l c o l u m n . F a c t o r Se;ven, a c c o u n t i n g f o r an i n s i g n i f i c a n t 1.12% o f t h e S u c c e s s v a r i a n c e ( r = - . 1 0 6 0 , p >. . 2 5 ) i s h e a v i l y l o a d e d by two b e h a v i o r a l r a t i n g s made b y t h e o r t h o p a e d i s t o f how e a g e r t h e s u b j e c t s seemed i n r e c o u n t i n g t h e i r t r o u b l e s t o h i m ( v a r i a b l e OBITCH, F L = .85 ) and t h e 84 subjects' emotionality in so doing (variance OBLEED), FL = .74). None of the psychometric measures load substantially on this factor, though one might expect the neuroticism measures to do so. This suggests that the orthopaedist was largely responding to something other than neuro-ticism in making his ratings. Syndrome Complex Groups A hierarchical grouping analysis was performed using the stan-dardized factor scores for each subject on each of the eight basic dimensions (factors) significantly related to disability. A "natural grouping" occurred at four groups, indicating that there were four different "profiles" of the basic disability dimensions in the group of patients studied. The deficits shown in these four profiles might be thought of as "Syndrome Complexes" of LBP disability. The mean Success scores for members of each Syndrome Complex group were also derived. Profiles indicating the mean Success scores and the mean factor scores on the eight basic dimensions of disability for each of the four Syndrome Complex groups are plotted in Figure 6. The members of the least disabled group (n = 45; mean Success = +.43 SD) do not show orthopaedic problems (Textbook Back or Nerve Root Deficit), though they may have had a number of back operations (mean Operative History Factor = -.13 SD). They moved freely without pain, had a high Pain Tolerance and were strikingly free of Neuroticism. However these subjects were not very physically f i t (mean Fitness Factor = -.07 SD), and they were somewhat frustrated in attaining the Figure 6. Mean Profiles of Syndrome Complexes 86 l i f e g o a l s t h e y had s e t (mean L i f e G o a l s F a c t o r = - . 1 7 S D ) . The members o f t h e s e c o n d l e a s t d i s a b l e d g roup (n = 2 9 ; mean S u c c e s s = - . 2 1 SD) we re sub jec ts who had marked o r t h o p a e d i c p r o b l e m s (mean N e r v e R o o t D e f i c i t F a c t o r = - . 2 1 S D ; mean T e x t b o o k B a c k F a c t o r = - . 4 0 S D ) , had a l ow p a i n t o l e r a n c e (mean P a i n T o l e r a n c e F a c t o r = - . 2 1 S D ) , were i m m o b i l i z e d b y t h e i r p a i n (mean M o b i l i t y o f S e l f F a c t o r = - . 7 0 S D ) , and a t t h a t t i m e had had few o p e r a t i o n s (mean O p e r a t i v e H i s t o r y F a c t o r = + .28 S D ) . These s u b j e c t s w e r e however s u r p r i s i n g l y s u c c e s s f u l i n t h e p u r s u i t o f L i f e G o a l s t h e y had s e t , we re p h y s i c a l l y f i t , and we re f r e e of N e u r o t i c i s m . The members o f t h e second most d i s a b l e d g roup (n = 1 1 ; mean S u c c e s s = - . 4 6 SD) had had numerous o p e r a t i o n s (mean O p e r a t i v e H i s t o r y F a c t o r = - . 9 2 S D ) , showed n e r v e r o o t d e f i c i t s (mean N e r v e Roo t D e f i c i t F a c t o r = - . 1 . 1 7 S D ) , and were i m m o b i l i z e d by p a i n (mean M o b i l i t y o f S e l f F a c t o r = - . 9 4 S D ) . They w e r e u n f i t (mean F i t n e s s F a c t o r = - . 3 1 S D ) , m o d e r a t e l y n e u r o t i c (mean N e u r o t i c i s m F a c t o r = - . 5 7 S D ) , and u n s u c c e s s f u l i n r e a c h i n g l i f e g o a l s t h e y had s e t (mean L i f e G o a l s F a c t o r = - . 8 0 S D ) . T h e s e s u b j e c t s had a h i g h p a i n t o l e r a n c e h o w e v e r , and showed m i n i m a l T e x t b o o k B a c k d e f i c i t s . The members o f t h e most d i s a b l e d g roup (n = 1 6 ; mean S u c c e s s = - . 5 3 SD) a p p e a r e d t o have had o n l y m i n i m a l o r t h o p a e d i c p r o b l e m s , and t o have r e m a i n e d m o b i l e . They a l s o had had a l o w number o f o p e r a t i o n s . H o w e v e r , t h e s e s u b j e c t s we re e x t r e m e l y n e u r o t i c (mean N e u r o t i c i s m F a c t o r = - . 1 . 3 9 S D ) , t h e y had a l o w p a i n t o l e r a n c e (mean P a i n T o l e r a n c e F a c t o r = - . 3 4 ) and t h e y we re somewhat u n s u c c e s s f u l i n a t t a i n i n g t h e l i f e g o a l s t h e y had s e t (mean L i f e G o a l s F a c t o r = - . 2 9 ) . 87 D i s c u s s i o n E f f e c t s o f S a m p l i n g The p r e s e n t s t u d y i s l i m i t e d by s a m p l i n g d e f i c i e n c i e s b u t n o t s e r i o u s l y s o . The p o p u l a t i o n s t u d i e d was a w o r k m e n ' s c o m p e n s a t i o n g r o u p , and t he g e n e r a l i z a b i l i t y o f t h e s e r e s u l t s may t h e r e f o r e be l i m i t e d t o s i m i l a r s o c i a l and o c c u p a t i o n a l g r o u p s . P r o f e s s i o n a l s and t h e s e l f -e m p l o y e d , f o r i n s t a n c e , a r e u s u a l l y n o t i n s u r e d by t h e WCB and a r e p o s -s i b l y n o t c o m p a r a b l e t o t he i n s u r e d g roup i n t e rms o f s o c i a l p o s i t i o n , a b i l i t i e s , i n t e r e s t s , o r e x p o s u r e t o s i m i l a r v o c a t i o n a l and s o c i a l s t r e s s o r s . However WCB g r o u p s w o u l d a p p e a r t o be t h e f o c u s o f s t u d y i n the LBP l i t e r a t u r e , p e r h a p s b e c a u s e t h e y a c c o u n t f o r t h e l a r g e s t p r o p o r -t i o n and c o s t o f LBP and b e c a u s e i t i s i n t h e s e g r o u p s t h a t d i m i n u t i o n o f p h y s i c a l p r o w e s s i s most d i s r u p t i n g t o t h e i n d i v i d u a l . The r e s u l t s o f t h i s s t u d y t h e n a p p e a r g e n e r a l i z a b l e t o a v e r y l a r g e , and p e r h a p s t h e most i m p o r t a n t , segment o f t h e p o p u l a t i o n . I t i s t h o u g h t t h a t t he d i s a b i l i t y s t a t u s o f the s u b j e c t s s t u d i e d had s t a b i l i z e d by t h e t i m e o f t h e p r e s e n t i n v e s t i g a t i o n , a l l s u b j e c t s h a v i n g b e e n s t u d i e d a t l e a s t two y e a r s a f t e r t h e i r l a s t f u s i o n o p e r a t i o n . Two y e a r s h a s been r e p o r t e d t o be a t i m e a f t e r w h i c h few changes i n d i s -a b i l i t y s t a t u s t a k e o p l a c e ( B e a l s and H i c k m a n , 1972; M c G i l l , 1968; W h i t e , 1969). T h e r e i s p e r h a p s a d i s t o r t i o n i n t h e r e s u l t s of t h e p r e s e n t s t u d y b e c a u s e 40 members c h o s e n f o r s t u d y f r o m t h e p o p u l a t i o n we re n o t i n f a c t s t u d i e d . A t t e m p t s we re made t o l e a r n as much as p o s s i b l e a b o u t t h e s e p o t e n t i a l s u b j e c t s h o w e v e r , so t h a t d i s t o r t i o n o f t h e s t u d y f r o m t h a t 8 8 s o u r c e c o u l d be e v a l u a t e d . The d i s a b i l i t y s t a t u s o f t he s i x s u b j e c t s b e f o r e t h e i r d e a t h i s no t known , e x c e p t t h a t i n one c a s e c o m m u n i c a t i o n w i t h t h e f a m i l y i n d i c a t e d t h a t d e a t h was o s t e n s i b l y due t o s u i c i d e p r e -c i p i t a t e d by p r o f o u n d L B P . I t i s r e a s o n e d t h a t t he 20 s u b j e c t s who c o u l d n o t be c o n t a c t e d w o u l d n o t be v e r y d i s a b l e d b e c a u s e t he a b i l i t y t o c o n t a c t a s u b j e c t was l a r g e l y dependen t on a c u r r e n t a d d r e s s b e i n g a v a i l a b l e a t t h e WCB. The l a c k o f s u c h an a d d r e s s w o u l d i n d i c a t e t h a t t he s u b j e c t was n o t s e e k i n g t r e a t m e n t o r r e c e i v i n g c o m p e n s a t i o n . The 14 s u b j e c t s who we re c o n t a c t e d but c o u l d n o t a t t e n d w o u l d a p p e a r t o have b e e n a m i x e d group w i t h r e g a r d t o d i s a b i l i t y s t a t u s . Some, who w e r e w o r k i n g and t o o b u s y t o a t t e n d we re p r e s u m a b l y n o t s e v e r e l y d i s a -b l e d . O t h e r s , h o w e v e r , c o u l d n o t a t t e n d t h e r e s e a r c h b e c a u s e t h e y c o u l d no t a f f o r d t h e f a r e t o V a n c o u v e r ( t h e g r a n t i n g a g e n c y d i d no t a l l o w a d v a n c e s , o n l y r e m u n e r a t i o n ) , i n d i c a t i n g t h a t t h e y w e r e i n p o o r f i n a n c i a l s t r a i t s p o s s i b l y as a r e s u l t o f LBP d i s a b i l i t y . One s u b j e c t when c o n t a c t e d avowed t h a t he w o u l d be u n a b l e t o c o n t e n d w i t h t h e r i g o r s of the o u t l i n e d e x a m i n a t i o n p r o c e d u r e s b e c a u s e o f s e v e r e L B P . I t i s t h e r e f o r e c o n c l u d e d t h a t t h e p o t e n t i a l s u b j e c t s n o t s t u d i e d we re a t most s l i g h t l y l e s s d i s a b l e d as a g roup t h a n t h e s u b j e c t s who we re s t u d i e d . A p p r o p r i a t e n e s s o f the Me thods of S t u d y A l t h o u g h t he method o f c o l l e c t i n g and c o m p a r i n g a l a r g e number o f measu res may p o t e n t i a l l y p r o d u c e a h i g h e x p e r i m e n t w i s e e r r o r r a t e , t h i s method was t h e o n l y t e n a b l e one i n r e g a r d t o t h e g o a l s o f t h e p r e s e n t s t u d y . T h e r e was e v e r y r e a s o n t o b e l i e v e t h a t t h e p r o b l e m o f LBP d i s -a b i l i t y was a m u l t i f a c t o r i a l o n e , and i t was d e s i r e d t h a t a m a j o r 89 p o r t i o n of the problem be accounted f o r . This task was made more d i f -f i c u l t because a multitude of d i r e c t i o n s but few adequately e s t a b l i s h e d bearings f o r i n v e s t i g a t i o n were suggested i n the l i t e r a t u r e . Therefore, many measures had to be documented and evaluated so that the goal of ac-counting f o r a major p o r t i o n of the LBP d i s a b i l i t y problem could be reached. C l i n i c a l l y needed statements could then be made and a substan-t i a l foundation f o r f u t u r e s t u d i e s would be provided by seeing the LBP d i s a b i l i t y problem as a g e s t a l t . The success of the present study i n i d e n t i f y i n g 5.8 v a r i a b l e s r e l a t e d t o d i s a b i l i t y and eigh t b a s i c dimensions accounting f o r n e a r l y 80% of the LBP d i s a b i l i t y v ariance would seem to j u s t i f y the choice of method. A d d i t i o n a l Sources of D i s a b i l i t y Variance One can only guess about the sources of the 20% of LBP d i s a b i l i t y v a r i a n c e not accounted f o r i n the present study, but s e v e r a l psycholo-g i c a l sources are r e a d i l y suggested. I t may be that the P a i n Tolerance Factor (Factor One) derived i n t h i s study was s l i g h t l y i n a p p r o p r i a t e and underestimated the importance of t h i s f a c t o r i n LBP d i s a b i l i t y . I n s t r u c t i o n s f o r the Cold Tolerance Test i n c l u d e d a t t e n t i o n - d i r e c t i n g i n s t r u c t i o n s whereas the r e s u l t s of a recent study (Kanfer and Seidner, 1972) would seem to i n d i c a t e that i n d i v i d u a l d i f f e r e n c e s i n the use of a t t e n t i o n are very important to pa i n - t o l e r a n c e s e l f - c o n t r o l . D e l e t i o n of the a t t e n t i o n - d i r e c t i n g Cold Tolerance Test i n s t r u c t i o n s i n f u t u r e s t u d i e s might provide a more accurate i n d i c a t i o n of the su b j e c t s ' p a i n tolerance as i t a f f e c t s them i n d a i l y l i f e . 90 A n o t h e r p o s s i b l e s o u r c e o f d i s a b i l i t y v a r i a n c e i s one on w h i c h d o c u m e n t a r y d a t a w e r e u n f o r t u n a t e l y n o t c o l l e c t e d . Much h a s b e e n w r i t t e n abou t t h e i n f l u e n c e o f s e c o n d a r y g a i n s o f a m o n e t a r y n a t u r e on t h e c o u r s e o f LBP d i s a b i l i t y . A number o f a u t h o r s ( e ^ g . , B r o w n , N e m i a h , B a r r and B a r r y , 1 9 5 4 ; R a a f , 1959) have f o u n d t h a t c o m p e n s a t i o n p a t i e n t s show p o o r e r r e s u l t s f o l l o w i n g b a c k s u r g e r y t h a n do uncompen-s a t e d p a t i e n t s , and C y r i a x (1970) has p r o v i d e d an i n s i g h t f u l d i s c u s s i o n o f how the. b a c k p a t i e n t may become i n e s c a p a b l y dependen t on t h e r e s u l t s o f l i t i g a t i o n f o l l o w i n g i n j u r y . M i l l e n (1966) has n o t e d t h a t 93.6% o f p s y c h o n e u r o t i c p a t i e n t s r e c o v e r e d f o l l o w i n g c o m p e n s a b l e i n j u r i e s i n Denmark where " lump sum" c o m p e n s a t i o n s e t t l e m e n t s a r e made, w h e r e a s o n l y 9.3% o f s u c h p a t i e n t s r e c o v e r e d i n Germany whe re m o n t h l y payments s i m i l a r t o t h o s e u s e d i n B r i t i s h C o l u m b i a a r e made. O t h e r a u t h o r s ( e . g . , Behan and H i r s c h f e l d , 1 9 6 3 ; W e i n s t e i n , 1968) have a l s o a n a l y z e d t h e u n f o r t u n a t e p o t e n t i a l o f d i s a b i l i t y p rog rams t o make a c h r o n i c i l l -n e s s l i f e s t y l e f e a s i b l e f o r o t h e r t h a n p h y s i c a l r e a s o n s . I t i s e v i d e n t t h a t t h e c o m p e n s a t i o n s t a t u s , c o m p e n s a t i o n e x p e c t a n c i e s , and l i t i g a t i o n a c t i v i t i e s o f LBP s u b j e c t s s h o u l d be documented i n f u t u r e s t u d i e s . H o w e v e r , i t i s p o s s i b l e t h a t t h e 20% o f LBP d i s a b i l i t y v a r i a n c e n o t a c c o u n t e d f o r i n t he p r e s e n t s t u d y w i l l n o t be f o u n d i n a few s u b -s t a n t i a l f a c t o r s b u t r a t h e r i n a l a r g e number o f s m a l l f a c t o r s . T h i s m igh t be s u g g e s t e d b y the r e s u l t s of t h e p r e s e n t s t u d y w h i c h showed t h a t 10% o f LBP d i s a b i l i t y v a r i a n c e was a c c o u n t e d f o r by n i n e f a c t o r s e a c h o f w h i c h a c c o u n t e d f o r a v e r y s m a l l amount o f LBP d i s a b i l i t y v a r i a n c e . 91 O v e r v i e w o f S u b j e c t C h a r a c t e r i s t i c s An o b v i o u s u s e o f t h e d a t a of a s t u d y s u c h as t h i s one i s d e s -c r i p t i v e , c a t a l o g u i n g t he d e f i c i t s and i m p a i r m e n t s o f the p a t i e n t t y p e . F o r e x a m p l e , i n t h e p r e s e n t s t u d y i t was f o u n d t h a t many d e f i c i t s i n s o c i a l s k i l l s , l o w mean i n t e l l i g e n c e and e v e n an u n e x p e c t e d l y h i g h f r e q u e n c y o f s c h i z o p h r e n i c r e s p o n s e p a t t e r n s (as i n d i c a t e d by t h e M M P I ) , c h a r a c t e r i z e d t h e s u b j e c t p o p u l a t i o n . Though s u c h c h a r a c t e r i z a t i o n s h a v e f o r m e r l y b e e n r e p o r t e d i n t h e LBP l i t e r a t u r e and a r e s u p p o r t e d b y t h e p r e s e n t s t u d y , t h e r e i s a g r e a t d a n g e r i n h e r e n t i n t h e i r u s e . The l o g i c a l l e a p , f r o m t h e u s e of s u c h c h a r a c t e r i z a t i o n s as d e s c r i p t i o n s of t h e p a t i e n t t y p e t o t h e i r u s e i n t h e c l i n i c a l management o f i n d i v i d u a l p a t i e n t s , i s t o o e a s i l y made. F u r t h e r a n a l y s i s o f d a t a i n t h e p r e s e n t s t u d y showed t h a t t h e above p e r s o n a l i t y c h a r a c t e r i s t i c s a r e n o t s i g n i f i c a n t l y r e l a t e d t o p o s t - f u s i o n d i s a b i l i t y . I t a p p e a r s more l i k e l y t h a t s u c h p e r s o n a l i t y c h a r a c t e r i s t i c s r e f l e c t a s a m p l i n g b i a s s i n c e s u c h p e r s o n a l i t y d e f i c i t s a r e more common i n t h e l o w e r s o c i o e c o n o m i c g r o u p s f r o m w h i c h LBP s u b -j e c t s f o r s t u d y a r e u s u a l l y d r a w n . A s e c o n d p o s s i b i l i t y i s t h a t i n d i -v i d u a l s w i t h s u c h p e r s o n a l i t y c h a r a c t e r i s t i c s a r e more l i k e l y t o s u s -t a i n a c c i d e n t a l i n j u r y , b u t s u c h a c a u s a l i n f e r e n c e c a n n o t be made f r o m t h e p r e s e n t s t u d y . What i s shown by t he p r e s e n t s t u d y i s t h a t s u c h p e r s o n a l i t y c h a r a c t e r i s t i c s a r e n o t r e l a t e d t o t h e d e g r e e o f p o s t - f u s i o n d i s a b i l i t y and a r e t h e r e f o r e n o t p e r t i n e n t to p r o g n o s i s once the s u b j e c t has s o u g h t t r e a t m e n t f o r L B P . The f a l l a c y i n s t a t e m e n t s : s u c h as ' a n y -body knows you s h o u l d n ' t o p e r a t e on o d d b a l l s " i s t h e n r e a d i l y a p p a r e n t . 92 The 239 measu res e v a l u a t e d I n t h e p r e s e n t , s t u d y we re c h o s e n f r o m a l a r g e r number o f measu res a v a i l a b l e b e c a u s e t h e o b s e r v a t i o n s on a l l t h o s e 239 measu res showed c o n s i d e r a b l e v a r i a b i l i t y . H o w e v e r , r e l a t i -v e l y few (58) o f t h o s e 239 m e a s u r e s we re f o u n d t o be r e l a t e d t o t h e d e g r e e of p o s t - f u s i o n d i s a b i l i t y . A rgumen ts s i m i l a r t o t h e above c o u l d be g e n e r a t e d f o r a l l t h e v a r i a b l e s n o t f o u n d t o be s i g n i f i c a n t l y r e l a t e d t o d i s a b i l i t y , c a u t i o n i n g a g a i n s t c o n c l u s i o n s b e i n g drawn i n r e g a r d t o p r o g n o s i s o r t r e a t m e n t b a s e d on " a b n o r m a l i t y " s e e n i n t h o s e v a r i a b l e s . The l e n g t h o f s u c h an e x p o s i t i o n w o u l d be p r o h i b i t i v e i n t h e p r e s e n t p a p e r , however , and t h e r e a d e r i s t h e r e f o r e l e f t t o d raw h i s own c o n c l u s i o n s by n o t i n g w h i c h o f t h e 239 v a r i a b l e s s t u d i e d a r e n o t r e p o r t e d h e r e t o be p e r t i n e n t t o t h e LBP d i s a b i l i t y p r o b l e m . D e r i v a t i o n o f t h e D i s a b i l i t y I n d e x The d e r i v a t i o n o f t he d i s a b i l i t y i n d e x o f t h e p r e s e n t s t u d y was s u c c e s s f u l i n t he s e n s e t h a t 40.1% o f t h e v a r i a n c e o f t h e measu res e n t e r i n g i t s d e r i v a t i o n was a c c o u n t e d f o r by t h e f i r s t u n r o t a t e d p r i n -c i p a l component f a c t o r . By c o m p a r i s o n , i n t h e o n l y o t h e r LBP s t u d y u s i n g a s i m i l a r d e r i v a t i o n p r o c e d u r e ( N a s h o l d and H r u b e c , 1971), d i s -a b i l i t y was d e f i n e d on t h e b a s i s o f a f a c t o r a c c o u n t i n g f o r o n l y 23.1% of t he v a r i a n c e o f 18 p r e d o m i n a n t l y o r g a n i c v a r i a b l e s . The d i f f e r e n c e i n t h e amounts o f v a r i a n c e a c c o u n t e d f o r by t h e f i r s t p r i n c i p a l compo-n e n t f a c t o r s o f t h e s e two s t u d i e s may be s e e n t o i n d i c a t e t h a t g r e a t e r h o m o g e n e i t y e x i s t s i n f u n c t i o n a l measu res o f d i s a b i l i t y t h a n i n o r g a n i c measu res o f d i s a b i l i t y . 93 The r e s u l t s o f t he d i s a b i l i t y i n d e x d e r i v a t i o n i n t h e p r e s e n t s t u d y a l s o t h row doub t on t h o s e s t u d i e s w h i c h have u s e d w o r k i n g s t a t u s as t h e s o l e c r i t e r i o n o f d i s a b i l i t y . The m a g n i t u d e s o f t h e f a c t o r l o a d i n g s on t he d i s a b i l i t y f a c t o r o f t h e v a r i a b l e s u s e d i n t h e d i s -a b i l i t y i n d e x d e r i v a t i o n i n d i c a t e t he c o n s i s t e n c y w i t h w h i c h t h o s e v a r i a b l e s r e f l e c t d i s a b i l i t y . I t i s a p p a r e n t ( s e e T a b l e 2) t h a t t h o s e v a r i a b l e s most c o n s i s t e n t l y r e f l e c t i n g d i s a b i l i t y a r e m e a s u r e s i n d i c a -t i n g p a i n e x p e r i e n c e s and t h e a b i l i t y t o p e r f o r m the n e c e s s a r y a c t i v i -t i e s o f l i f e . - D i s p e n s i b l e a c t i v i t i e s s u c h as t h o s e i n v o l v e d i n s o c i a l l i f e a r e a l s o v e r y s e n s i t i v e t o t h e e f f e c t s o f d i s a b i l i t y . Much l e s s c o n s i s t e n t l y , d i s a b i l i t y i s r e f l e c t e d i n t h e w o r k i n g s t a t u s o f t h e i n d i v i d u a l a f f e c t e d . The v a l i d i t y o f t h e d i s a b i l i t y i n d e x f o u n d i n t h i s s t u d y c a n o n l y b e s u b j e c t i v e l y a s s e s s e d b y e x a m i n i n g t h e f a c t o r l o a d i n g s d i s c u s s e d above o r by c i t i n g t h e v e r y h i g h c o r r e l a t i o n b e t w e e n i t and t h e c l i n i c a l j udgment o f t h e o r t h o p a e d i s t . C o r r e l a t e s o f D i s a b i l i t y P e r h a p s u n f o r t u n a t e l y , t h e v a r i a b l e s f o u n d t o be c o r r e l a t e d w i t h a d i s a b i l i t y i n d e x i n i t i a l l y a r o u s e g r e a t i n t e r e s t . F o r e x a m p l e , t he l a r g e number o f n e u r o t i c i s m m e a s u r e s f o u n d t o b e a s s o c i a t e d w i t h LBP i n t h e p r e s e n t and e a r l i e r s t u d i e s ( B e a l s and H i c k m a n , 1972; H a n v i k , 1951; P h i l l i p s , 1964; W i l f l i n g e t a l . , 1973) s u g g e s t t h e n o t i o n t h a t n e u r o t i c i s m i s a c o n t r i b u t i n g f a c t o r t o LBP d i s a b i l i t y . T h i s a s -s u m p t i o n c a n n o t v a l i d l y be made. I t i s known that t h e p r e s e n c e o f a 94 b o d i l y disease process generates p e r s o n a l i t y d i f f i c u l t i e s which are r e f l e c t e d on t e s t s such as the MMPI, (Dahlstrom and Welsh, 1960, p. 353). Thus i t i s u n c e r t a i n that n e u r o t i c i s m c o n t r i b u t e s uniquely to LBP d i s a b i l i t y , because i t may simply be that n e u r o t i c i s m i s a response to o r g a n i c a l l y - b a s e d d i s a b i l i t y . The demonstration i n e a r l i e r s t u d i e s (Beals and Hickman, 1972; W i l f l i n g et a l . , 1973) of i n c r e a s i n g neuro-t i c i s m w i t h i n c r e a s i n g LBP d i s a b i l i t y may simply r e f l e c t a l i n e a r r e l a t i o n s h i p between n e u r o t i c response and degree of or g a n i c a l l y - b a s e d d i s a b i l i t y . The major value i n f i n d i n g c o r r e l a t e s of d i s a b i l i t y i s i n narrowing down the i n v e s t i g a t i o n : The c o r r e l a t e s of LBP d i s a b i l i t y are a l l known to have "something to do w i t h " the LBP d i s a b i l i t y pro-blem, but f u r t h e r steps i n a n a l y s i s must be taken before the i n d i v i -dual c o n t r i b u t i o n s of the c o r r e l a t e s can be assessed. Overlaps i n Measurement Among Orthopaedic and P s y c h o l o g i c a l V a r i a b l e s The i l l u s t r a t i o n of the many very l a r g e c o r r e l a t i o n s which e x i s t between the orthopaedic and p s y c h o l o g i c a l measures gives f u r t h e r weight to the argument of the above paragraph that the p s y c h o l o g i c a l c h a r a c t e r -i s t i c s of the sub j e c t s may be the r e s u l t of t h e i r organic d e f i c i t s . To make sense by i n s p e c t i o n of "what i s r e l a t e d to what and how much i s l e f t over?" i s impossible because of the l a r g e number of c o r r e l a t i o n s which would have to be considered simultaneously. The need f o r f a c t o r a n a l y s i s i s evident. The warning that orthopaedic and p s y c h o l o g i c a l assessments of the same p a t i e n t should not be thought of as independent of one another i s al s o obvious from these c o r r e l a t i o n s . The magnitudes of the overlaps 95 i n measurement a r e , h o w e v e r , more e c o n o m i c a l l y d i s c u s s e d on t h e b a s i s o f d a t a t o b e p r e s e n t e d b e l o w . D e r i v a t i o n o f t h e B a s i c D i m e n s i o n s o f LBP d i s a b i l i t y The l a r g e s t c o n t r i b u t i o n s w h i c h t h e p r e s e n t s t u d y m i g h t make l i e i n t h e r e s u l t s o f t h e f a c t o r a n a l y s i s o f t h e c o r r e l a t e s o f d i s a b i l i t y and the q u a n t i f i c a t i o n o f t h e c o n t r i b u t i o n o f e a c h o f t h e i d e n t i f i e d f a c t o r s t o t h e p r o b l e m o f LBP d i s a b i l i t y . The p r e s e n t s t u d y i s t h e f i r s t , t o t h i s i n v e s t i g a t o r ' s k n o w l e d g e , t o c l a r i f y t h e p r o b l e m o f LBP d i s a b i l i t y by i s o l a t i n g i n d e p e n d e n t f a c t o r s u n d e r l y i n g t h e p r o b l e m and by g i v i n g some e s t i m a t e o f t h e r e l a t i v e i m p o r t a n c e t o t h e p r o b l e m o f t h e s e i n d e -penden t f a c t o r s . The f a c t t h a t t h e s e e i g h t f a c t o r s o r b a s i c d i m e n s i o n s o f d i s a b i l i t y a r e i n d e p e n d e n t o f one a n o t h e r and u n i q u e i n c o n t r i b u t i n g t o t h e LBP d i s a b i l i t y p r o b l e m c a n n o t be t o o s t r o n g l y s t r e s s e d . F o r e x a m p l e , a f r e q u e n t q u e r y f r o m o r t h o p a e d i c c i r c l e s i s w h e t h e r o r n o t t h e n e u r o t i c i s m s e e n i n LBP p a t i e n t s i s m e r e l y a c o n c o m i t a n t o f o r g a n i c p a t h o l o g y , t h e r e a s o n i n g b e h i n d t h e q u e r y b e i n g t h a t i f t h e n e u r o t i c i s m i s a r e a c t i o n t o o r g a n i c a l l y - b a s e d d i s a b i l i t y t h e n o p e r a t i o n s h o u l d r e s o l v e t h e n e u r o t i c i s m a s w e l l a s t h e o r g a n i c p a t h o l o g y . Such r e a -s o n i n g c a n b e s o u n d l y r e f u t e d by t h e r e s u l t s o f t h e p r e s e n t s t u d y . I f n e u r o t i c i s m were m a i n t a i n e d b y o r g a n i c a l l y - b a s e d d i s a b i l i t y , t h e n the v a r i a b l e s r e f l e c t i n g p s y c h o l o g i c a l and o r g a n i c p a t h o l o g y w o u l d c o -v a r y and t h e r e f o r e w o u l d l o a d on t h e same b a s i c d i m e n s i o n s i n t h e f a c -t o r a n a l y s i s . T h i s was s i m p l y n o t f o u n d t o b e so i n t h e p r e s e n t s t u d y , t h e p s y c h o l o g i c a l d i m e n s i o n s b e i n g o r t h o g o n a l t o o r g a n i c d i -m e n s i o n s and u n i q u e i n a c c o u n t i n g f o r p r o p o r t i o n s o f t h e d i s a b i l i t y 96 v a r i a n c e . C e r t a i n l y a small amount of the n e u r o t i c i s m seen i n the raw data measures (e.g., hypochondriasis, v a r i a b l e MMPIHS) i s of an o r g a n i c a l l y - l i n k e d or "secondary" nature, as i s shown by the minor loadings of the n e u r o t i c i s m measures on the organic f a c t o r s (e.g., MMPIHS loads -.22 on the Textbook Back F a c t o r ) , but the major pro-p o r t i o n of the n e u r o t i c i s m measures' vari a n c e i s independent of organic pathology. S i m i l a r l y , of course, a l l eight b a s i c dimensions of d i s -a b i l i t y are independent of one another even though the measures over-l a p them. Knowledge of these b a s i c dimensions of d i s a b i l i t y and of t h e i r independence has important r a m i f i c a t i o n s f o r both the t h e o r e t i c a l understanding of the LBP d i s a b i l i t y problem and f o r the c l i n i c a l management of LBP p a t i e n t s . The present study found three or p o s s i b l y four f a c t o r s of a p s y c h o l o g i c a l nature to be independent c o n t r i b u t o r s to the problem of LBP d i s a b i l i t y as seen i n p o s t - f u s i o n p a t i e n t s . Of the 79% of d i s -a b i l i t y v a r i a n c e accounted f o r by e i g h t major f a c t o r s , three c l e a r l y p s y c h o l o g i c a l f a c t o r s — P a i n Tolerance, Neuroticism, and L i f e Goals — were found to account f o r 24% of the va r i a n c e . I f the f o u r t h f a c t o r , M o b i l i t y of S e l f , i s a l s o p s y c h o l o g i c a l i n nature, the p s y c h o l o g i c a l f a c t o r s would account f o r 39% of the t o t a l d i s a b i l i t y v a r i a n c e and the r e f o r e be equal i n importance to the i d e n t i f i e d p h y s i c a l f a c t o r s . On that b a s i s , the n e c e s s i t y f o r assessment and treatment p r e d i c a t e d on a "whole man" concept (e.g., Dorfman, 1966; Howell and Crown, 1971; White, 1966; White, 1969) becomes r e a d i l y apparent as does a probable 97 c a u s e o f t h e h i g h f a i l u r e r a t e s o f o l d e r LBP t r e a t m e n t a p p r o a c h e s w h i c h t r e a t e d o n l y t h e p h y s i c a l man. The i n s i g h t s f r o m t h e p r e s e n t s t u d y w i l l a l s o a l l o w r i g o r o u s a s s e s s m e n t s o f LBP p a t i e n t s on t h e b a s i s o f t he e i g h t b a s i c d i m e n s i o n s o f d i s a b i l i t y i n l i e u o f t h e p r e s e n t l y u s e d v a g u e , g l o b a l a s s e s s m e n t s b a s e d on many measu res of u n c e r t a i n s i g n i f i c a n c e . S p e c i f i c t r e a t m e n t s may a l s o be t a i l o r e d t o overcome d e f i c i t s i n t h e e i g h t b a s i c d i m e n s i o n s o f d i s a b i l i t y . A s s e s s -ment and t r e a t m e n t w i l l be d i s c u s s e d b e l o w . Syndrome Complex Groups I t i s e v i d e n t t h a t o f t h e f o u r Syndrome Complex g r o u p s o f s u b -j e c t s i d e n t i f i e d b y t h e h i e r a r c h i c a l g r o u p i n g a n a l y s i s i n t h e p r e s e n t s t u d y , o n l y t h r e e g r o u p s w o u l d be of c l i n i c a l i n t e r e s t ; t h e l a r g e s t and m i n i m a l l y s y m p t o m a t i c g roup (n = 45) w o u l d be u n l i k e l y i n t h a t c o n d i t i o n t o s e e k p r o f e s s i o n a l a t t e n t i o n abou t L B P . T h i s g roup s h o w e d , a f t e r p e r h a p s a number o f o p e r a t i o n s , o n l y modest d e f i c i t s i n f i t n e s s and i n t he a t t a i n m e n t o f r e a l i s t i c l i f e g o a l s . The d e s c r i p t i o n o f t h i s g roup by t h e l a t t e r . . . t w o , d e f i c i t s sounds much l i k e t h e s t e r e o t y p e o f t h e a v e r a g e , u n f i t N o r t h A m e r i c a n who i s m o d e r a t e l y f r u s t r a t e d i n h i s p u r s u i t o f t he r a i n b o w . The o t h e r t h r e e g r o u p s (En = 5 5 ) , t h o s e most l i k e l y t o c o n t i n u e s e e k i n g t r e a t m e n t f o r L B P , e a c h e x h i b i t a Syndrome Complex i n w h i c h a p s y c h o l o g i s t m igh t be o f h e l p f o r d i a g n o s i s and t r e a t m e n t . P e r h a p s i t i s b e s t t o d e l i n e a t e t h e s p e c i f i c a r e a s o f d e f i c i t o f e a c h o f t h e t h r e e Syndrome Comp lexes on t h e e i g h t b a s i c d i m e n s i o n s o f d i s a b i l i t y 98 and t h e n t o d i s c u s s t r e a t m e n t s a p p l i c a b l e t o e a c h o f t h e s e e i g h t d e f i c i t s . I f t h e p r o p o r t i o n s o f t h e Syndrome Complexes f o u n d i n t h e p r e s e n t s t u d y a r e r e p r e s e n t a t i v e o f t h e p r o p o r t i o n s l i k e l y t o be s e e n i n p r a c t i c e , a p p r o x i m a t e l y 30% o f p o s t - f u s i o n p a t i e n t s w o u l d show d e f i c i t s c o r r e s p o n d i n g t o t h o s e of t h e most d i s a b l e d g roup o f t h i s s t u d y (n = 1 6 ; 1 6 / 5 5 as 30%). These p a t i e n t s a r e o n l y m i n i m a l l y a f f e c t e d b y o r t h o p a e d i c d e f i c i t s b u t a r e v e r y N e u r o t i c , have a l ow P a i n T o l e r a n c e and a r e m i n i -m a l l y s u c c e s s f u l i n t h e a t t a i n m e n t o f r e a l i s t i c L i f e G o a l s . On f i r s t s i g h t i t w o u l d a p p e a r t h a t t r e a t m e n t i n an o r t h o d o x p s y c h i a t r i c f a c i l i t y w o u l d b e i n d i c a t e d f o r t h e s e p a t i e n t s . H o w e v e r , e x p e r i e n c e w i t h t h e s e p a t i e n t s who p l a c e s u c h e m p h a s i s on t h e i r m i n i m a l o r t h o p a e d i c p r o b l e m s and who so e a s i l y make a "new s t a r t " w i t h a d i f f e r e n t o r t h o p a e d i s t s u g -g e s t s t h a t t h e s e p a t i e n t s w o u l d b e s t be t r e a t e d on an o r t h o p a e d i c w a r d . A n o r t h o p a e d i c ward s t r u c t u r e d a l s o t o t r e a t p s y c h o l o g i c a l p r o b l e m s w i l l be d e s c r i b e d b e l o w . I f t h e p r o p o r t i o n s o f t h e Syndrome Comp lexes f o u n d i n t h e p r e s e n t s t u d y a r e r e p r e s e n t a t i v e o f t he p r o p o r t i o n s l i k e l y t o be s e e n i n p r a c -t i c e , a p p r o x i m a t e l y 20% o f p o s t - f u s i o n p a t i e n t s w o u l d show d e f i c i t s c o r r e s p o n d i n g t o t h o s e o f t h e s e c o n d most d i s a b l e d g roup o f t h i s s t u d y (n = 1 1 ; 1 1 / 5 5 = 20%). These p a t i e n t s show a w i d e r a n g e o f b o t h o r t h o p a e d i c and p s y c h o l o g i c a l d e f i c i t s on t h e N e r v e Roo t D e f i c i t , F i t n e s s , M o b i l i t y o f S e l f , N e u r o t i c i s m and L i f e G o a l s F a c t o r s . These d e f i c i t s a r e a l l s i m u l t a n e o u s l y t r e a t a b l e on t h e o r t h o p a e d i c ward t o be d e s c r i b e d . 99 F i n a l l y , i f t h e p r o p o r t i o n s o f t h e Syndrome Comp lexes f o u n d i n t h e p r e s e n t s t u d y a r e r e p r e s e n t a t i v e o f t h e p r o p o r t i o n s l i k e l y t o be s e e n i n p r a c t i c e , t he r e m a i n i n g 50% o f p o s t - f u s i o n p a t i e n t s w o u l d show d e f i c i t s c o r r e s p o n d i n g t o t h o s e shown by t h e l e a s t d i s a b l e d c l i n i c a l g roup o f t h i s s t u d y (n = 2 8 ; 2 8 / 5 5 £ 50%). These p a t i e n t s h a v e d e f i c i t s on b o t h o r t h o p a e d i c f a c t o r s ( T e x t b o o k B a c k and N e r v e Roo t D e f i c i t ) and a l s o show d e f i c i t s on t h e M o b i l i t y o f S e l f and P a i n T o l e r a n c e F a c t o r s . A g a i n a l l f o u r a r e a s o f d e f i c i t c o u l d be s i m u l t a -n e o u s l y t r e a t e d on t h e o r t h o p a e d i c ward t o be d e s c r i b e d b e l o w . T r e a t m e n t s f o r F a c t o r E i g h t ( T e x t b o o k B a c k ) and F a c t o r Twe l ve (Ne rve Roo t D e f i c i t ) a r e w i t h i n t h e p r o v i n c e o f t h e o r t h o p a e d i s t b e c a u s e t h e s e f a c t o r s a l m o s t c e r t a i n l y r e f l e c t o r g a n i c p a t h o l o g y . I t c o u l d be hoped however t h a t t h e d i a g n o s t i c i n s i g h t s p r o v i d e d by t h e p r e s e n t s t u d y w o u l d a l l o w t r e a t m e n t , p r o b a b l y by o p e r a t i o n , t o be u n d e r t a k e n s o o n e r . The p a t i e n t s ' p r o l o n g e d p h y s i c a l and s o c i a l s u f f e r i n g and t h e c o s t s o f m e d i c a l s e r v i c e s c o u l d t h e r e b y be d e c r e a s e d . P r e s e n t l y i t a p -p e a r s t h a t s u r g i c a l i n t e r v e n t i o n i s o f t e n r e l u c t a n t l y u n d e r t a k e n , p a r t l y b e c a u s e t h e i n d i c a t i o n s f o r s u r g e r y f r o m e x a m i n a t i o n p r o c e d u r e s now u s e d a r e v a g u e , and b e c a u s e p e r i o d s o f c o n s e r v a t i v e t r e a t m e n t may a l l o w f a c t o r s o t h e r t h a n o r g a n i c ones t o s u r f a c e o r r e s o l v e t h e m s e l v e s and t h e L B P . A r e c e n t s u r v e y o f t h e o r t h o p a e d i s t s o f B r i t i s h C o l u m b i a by t h i s r e s e a r c h g roup has shown t h a t t h e i n d i c a t i o n s u s e d i n t he W i n g , P . C . , P . J . K o k a n and F . J . W i l f l i n g . G o a l s o f and I n d i c a t i o n s f o r Lumbar S p i n a l F u s i o n . M a n u s c r i p t i n p r e p a r a t i o n . 100 decision-making to perform surgery are h i g h l y v a r i e d . Perhaps c l a r i -f i c a t i o n of the LBP problem by the present study, and the i d e n t i f i c a t i o n of r e l a t i v e l y unambiguous i n d i c a t o r measures of the eight b a s i c dimen-sions of d i s a b i l i t y may serve to make organic diagnosis more s p e c i f i c . The treatment f o r Factor Two (Neuroticism) might be undertaken by conventional methods of " t a l k " psychotherapy. However these methods are of questionable e f f i c i e n c y (Eysenck, 1952) and would be p r o h i b i t i v e i n terms of cost and probably unmanageable i n terms of t h e r a p i s t time because of the l a r g e number of LBP p a t i e n t s r e q u i r i n g treatment. The low ego-strength found to be a s s o c i a t e d w i t h the Neuroticism Factor would furthermore suggest that these p a t i e n t s would be unresponsive to " t a l k " methods of psychotherapy (Barron, 1953). An a l t e r n a t i v e treatment mode i s suggested by Fordyce and h i s colleagues (Fordyce, Fowler, Lehrman and DeLateur, 1968). These authors see the chronic p a i n p a t i e n t as e x h i b i t i n g operant behaviors. These behaviors have been learned and are maintained by reinforcements con-t i n g e n t on. t h e i r occurrence. The Fordyce "Chronic P a i n Program" con-s i s t s of s t r u c t u r i n g a h o s p i t a l ward on which p a i n responses (complai-n i n g , seeking sympathy, l y i n g down, etc.) are not p o s i t i v e l y r e i n f o r c e d by s o c i a l a t t e n t i o n , r e s t , or the r e c e i p t of medication. A c t i v i t y i n occupational therapy, e x e r c i s e on the ward, and r e p o r t s of w e l l - b e i n g are a l l monitored, g r a p h i c a l l y d i s p l a y e d , and p o s i t i v e l y r e i n f o r c e d . Medication i s given i n a masking medium on a c h r o n o l o g i c a l , r a t h e r than demand, b a s i s and the a c t i v e medication w i t h i n the masking medium i s gr a d u a l l y withdrawn. Tutoring of the p a t i e n t ' s f a m i l y i s a l s o 101 u n d e r t a k e n w i t h t h e p u r p o s e o f r e s t r u c t u r i n g t h e r e i n f o r c e m e n t c o n t i n -g e n c i e s i n t h e p a t i e n t ' s home so t h a t " w e l l b e h a v i o r " w i l l be m a i n t a i n e d a f t e r d i s c h a r g e . Such a b r i e f d e s c r i p t i o n c a n n o t do j u s t i c e t o t h e s c o p e and methods o f t h i s p r o g r a m . The i n t e r e s t e d r e a d e r i s r e f e r r e d t o F o r d y c e ( 1 9 7 0 ) , F o r d y c e e t a l . , ( 1 9 6 8 ) , and F o r d y c e , S a n d , T r i e s c h m a n n and F o w l e r (1971) f o r f u r t h e r d e t a i l s . The " C h r o n i c P a i n P r o g r a m " has b e e n o p e r a t i n g f o r some t i m e on a w a r d a t t h e U n i v e r s i t y o f W a s h i n g t o n M e d i c a l S c h o o l b u t a s t u d y o f i t s e f f i c a c y has n o t y e t b e e n p u b l i s h e d . A p p a r e n t l y , h o w e v e r , t h e m a j o r i t y o f p a t i e n t s t r e a t e d a r e b e i n g r e t u r n e d t o wo rk even t h o u g h t h e y a r e p a t i e n t s who had f o r m e r l y f a i l e d i n a v a r i e t y o f o t h e r r e h a b i l i t a t i v e p rog rams and we re g i v e n up as " h o p e l e s s " ( s e e F o o t n o t e 3 ) . I t i s t h o u g h t - p r o v o k i n g t o n o t e t h a t a l t h o u g h F o r d y c e i s i n t e r e s t e d i n c h r o n i c p a i n p a t i e n t s o f any t y p e , t h e m a j o r i t y o f p a t i e n t s r e f e r r e d t o h i m a r e c h r o n i c LBP c a s e s . The F o r d y c e p r o g r a m i s a v e r y p r o m i s i n g t h e r a p e u t i c r e g i m e f o r s e v e r a l r e a s o n s . F i r s t l y , as w i l l be s e e n i n t h e f o l l o w i n g d i s c u s s i o n , i t w o u l d appea r t o h o l d t h e r a p e u t i c p o t e n t i a l i n r e g a r d t o a t l e a s t f o u r o f t h e b a s i c d i m e n s i o n s o f LBP d i s a b i l i t y i d e n t i f i e d i n t h e p r e s e n t s t u d y . / T h i s m i g h t a c c o u n t f o r t h i s p r o g r a m ' s uncommon t r e a t m e n t s u c c e s s . S e c o n d l y , t h e c o s t o f i m p l e m e n t i n g t h i s p rog ram on an o r t h o p a e d i c ward and u s i n g i t w i t h p a t i e n t s who w o u l d be on t h e ward i n any e v e n t i s m i n i m a l . E x i s t i n g s t a f f a r e t a u g h t t h e p r i n c i p l e s o f t h e o p e r a n t c o n t r o l o f b e h a v i o r and i t i s t h e y who i n t h e c o u r s e o f t h e i r u s u a l a c t i v i t i e s become t h e t h e r a p e u t i c a g e n t s . The p a t i e n t s m o n i t o r t h e i r own b e h a v i o r . The o n l y a d d i t i o n a l p e r s o n n e l r e q u i r e d i s a p s y c h o l o g i s t t o t r a i n t h e 102 s t a f f , m o d i f y and m o n i t o r t h e p rog ram as i t p r o g r e s s e s , and t o c o u n s e l t h e p a t i e n t s and t h e i r f a m i l i e s . T h i r d l y , t h e F o r d y c e p rog ram c o u l d be b e n e f i c i a l l y imp lemen ted on a ward w h i c h t r e a t s f i r s t - o p e r a -t i o n p a t i e n t s i n a d d i t i o n t o c h r o n i c p a t i e n t s b e c a u s e i t w o u l d a p p e a r t o h a v e p r o p h y l a c t i c p o t e n t i a l s i n r e g a r d t o i n i t i a l " s i c k n e s s b e h a v i o r " l e a r n i n g . U n f o r t u n a t e l y , a F o r d y c e " C h r o n i c P a i n P r o g r a m " i s n o t p r e s e n t l y a v a i l a b l e i n B r i t i s h C o l u m b i a . T r e a t m e n t f o r F a c t o r One ( P a i n T o l e r a n c e ) m i g h t come f r o m s e v e r a l s o u r c e s . The p a t i e n t c o u l d be t a u g h t s e l f - c o n t r o l t e c h n i q u e s w h i c h h a v e b e e n f o u n d t o a l t e r a n i n d i v i d u a l ' s p a i n t o l e r a n c e . T h e s e t e c h n i q u e s u s e t h e c o g n i t i v e s e l f - c o n t r o l o f a t t e n t i o n t o p a i n o r t o o t h e r a s p e c t s o f t h e e n v i r o n m e n t ( K a n f e r and G o l d f o o t , 1966) and a r e e s p e c i a l l y e f -f e c t i v e i f t h e s u b j e c t h i m s e l f h a s c o n t r o l o v e r t h e a t t e n t i o n a l t e c h -n i q u e s ( K a n f e r and S e i d n e r , 1 9 7 2 ) . S o c i a l m o d e l s t o l e r a n t t o p a i n have a l s o b e e n f o u n d t o a f f e c t an i n d i v i d u a l ' s t o l e r a n c e ( C r a i g and W e i s s , 1971) and p e r h a p s e v e n . s u b j e c t i v e e x p e r i e n c e ( C r a i g and N e i d e r m a y e r , 1973) o f p a i n . B e n e f i c i a l s o c i a l m o d e l i n g e f f e c t s c o u l d be e x p e c t e d f r o m an i n d i v i d u a l ' s e x p o s u r e t o f e l l o w b a c k p a t i e n t s who e x h i b i t m i n i m a l p a i n b e h a v i o r s on a ward u s i n g t h e F o r d y c e p r o g r a m . T r e a t m e n t f o r F a c t o r T h r e e ( F i t n e s s ) s h o u l d h a v e t h e p u r p o s e o f m a i n t a i n i n g t he LBP p a t i e n t ' s p h y s i c a l f i t n e s s . P h y s i o t h e r a p y i s now w i d e l y p r e s c r i b e d f o r LBP p a t i e n t s and o f t e n e x e r c i s e p rog rams a r e s u g g e s t e d on a l i f e - l o n g b a s i s . The f a i t h f u l p e r f o r m a n c e o f t h e s e e x -e r c i s e s i s however a n o t h e r m a t t e r w h i c h m i g h t be a i d e d by i n c l u s i o n o f t h e F o r d y c e p r o g r a m i n t h e o v e r a l l t r e a t m e n t . F o r d y c e s t r e s s e s 103 a c t i v i t y and a s s u r e s i t s o c c u r r e n c e by u s e o f d i r e c t r e i n f o r c e m e n t -c o n t i n g e n c y management . T r e a t m e n t f o r F a c t o r F o u r t e e n ( M o b i l i t y o f S e l f ) i s d i f f i c u l t t o s p e c i f y b e c a u s e t h e e x a c t n a t u r e o f t h e f a c t o r i s u n c l e a r . I f , however , t h i s f a c t o r i s p s y c h o l o g i c a l i n n a t u r e , as was d i s c u s s e d i n r e g a r d t o t h e c o n c e p t u a l i z a t i o n o f t he f a c t o r s , and r e f l e c t s t h e h a b i t u a l r e s p o n s e p a t t e r n s o f t h e p a t i e n t s t o p a i n , t h e n t h e F o r d y c e p r o g r a m w o u l d be a s u i t a b l e f o r m o f t r e a t m e n t . F o r d y c e m o n i t o r s t h e " u p - t i m e " v e r s u s " d o w n - t i m e " o f h i s p a t i e n t s , b o t h f r o m a b e h a v i o r a l d i a r y k e p t by t h e p a t i e n t s b e f o r e a d m i s s i o n and l a t e r on t h e w a r d , and has shown t h e p r o g r a m t o be v e r y e f f e c t i v e i n i n c r e a s i n g t h e a c t i v i t y l e v e l s o f t h e p a t i e n t s ( s e e F o o t n o t e 3 ) . T r e a t m e n t f o r F a c t o r F i v e ( O p e r a t i v e H i s t o r y ) i s a l s o v e r y d i f -f i c u l t t o s p e c i f y . I t i s e v i d e n t t h a t m u l t i p l e o p e r a t i o n s c o n t r i b u t e t o t he p a t i e n t ' s d i s a b i l i t y , b u t why t h i s s h o u l d be so i s n o t c l e a r . S e v e r a l o r g a n i c e x p l a n a t i o n s , s u c h as o r g a n i c f o c u s s e s o f p a i n b e i n g c r e a t e d by t i s s u e damage and a d h e s i o n s (G reenwood , M c G u i r e and K i m b e l l , 1952) r e s u l t i n g f r o m t h e i n s u l t o f s u r g e r y , come r e a d i l y t o m i n d , b u t p s y c h o l o g i c a l e x p l a n a t i o n s o r t h o g o n a l t o t h e f a c t o r s a l r e a d y i d e n t i f i e d do n o t . T r e a t m e n t f o r F a c t o r T h i r t e e n ( L i f e G o a l s ) w o u l d a p p e a r a p p r o -p r i a t e l y t o be a f o r m o f c o u n s e l l i n g . W h i t e (1966) has d i s c u s s e d a c l i n i c a l i n s i g h t w h i c h seems t o c o r r e s p o n d t o t h e L i f e G o a l s F a c t o r o f t h e p r e s e n t s t u d y . W h i t e n o t e d t h a t t h e r e i s one t y p e o f LBP p a t i e n t who e x p e c t s t o be r e t u r n e d t o 100% o f h i s c a p a b i l i t i e s as t h e y w e r e b e f o r e t h e o n s e t o f h i s LBP and t h a t a n y t h i n g l e s s t h a n a p e r f e c t 104 "cure" i s perceived to be a f a i l u r e by t h i s type of p a t i e n t . The p a t i e n t then does not make adjustments to h i s l i m i t a t i o n s and h i s remaining p o t e n t i a l s are th e r e f o r e not r e a l i z e d . I t would appear that a r e a l i s t i c a p p r a i s a l by the p a t i e n t and a c o u n s e l l o r regarding the tr u e l i m i t a t i o n s of the p a t i e n t ' s s i t u a t i o n would be of p o t e n t i a l b e n e f i t i f i t l e d the p a t i e n t to accept some l i m i t a t i o n s and plan r e a l i s t i c l i f e goals. Choice of Measures Best Used to Document the Eight B a s i c Dimensions of  D i s a b i l i t y I t i s evident that the eigh t b a s i c f a c t o r s found to u n d e r l i e LBP d i s a b i l i t y i n the present study should be documented both i n f u t u r e s t u d i e s of LBP, and i n c l i n i c a l assessments of LBP p a t i e n t s . In the i n t e r e s t s of economy then, i t would be u s e f u l to know which measures best r e f l e c t these v a r i o u s f a c t o r s . The goal of i s o l a t i n g such measures i s complicated, however, by two c o n s i d e r a t i o n s . F i r s t l y , as was seen i n Table 5, no one measure i s an i n d i c a t o r of j u s t one f a c t o r (as would be i n d i c a t e d by a measure loading s o l e l y (1.00) on one f a c t o r ) . Secondly, each f a c t o r i s derived from a number of measures which are themselves i n t e r r e l a t e d and may t h e r e f o r e be somewhat redundant as i n -d i c a t o r s of the f a c t o r parameter. The f i r s t problem — that of the overlap of the measures over two or more f a c t o r s — i s best t r e a t e d i n f u t u r e s t u d i e s by the i n c l u s i o n of another f a c t o r a n a l y s i s . On an i n d i v i d u a l patient-assessment b a s i s however, i n which f a c t o r a n a l y s i s and f a c t o r scores f o r the i n d i v i d u a l p a t i e n t on the b a s i c f a c t o r s are not normally a v a i l a b l e , i t i s evident 105 t h a t some c o m m u n i c a t i o n be tween t he two e x a m i n i n g s p e c i a l i s t s , t h e o r t h o -p a e d i s t and t h e p s y c h o l o g i s t , must t a k e p l a c e . F o r e x a m p l e , t h e p s y c h o l -o g i s t i n i s o l a t i o n , s e e i n g o n l y t he p a t i e n t ' s h y p o c h o n d r i a s i s s c o r e , may o v e r e s t i m a t e i t s c o n t r i b u t i o n t o t h e p a t i e n t ' s d i s a b i l i t y u n l e s s he knows t h e amount o f o r g a n i c p a t h o l o g y f o u n d by t h e o r t h o p a e d i s t and c a n c o r r e s p o n d i n g l y d i s c o u n t an a p p r o p r i a t e p r o p o r t i o n o f t h e h y p o c h o n d r i a -s i s s c o r e as b e i n g o r g a n i c a l l y - l i n k e d . S i m i l a r l y , t h e o r t h o p a e d i s t ' s measu res must be a d j u s t e d i n v i e w o f t h e p s y c h o l o g i s t ' s f i n d i n g s i n o r d e r t o r e f l e c t c o r r e c t l y t h e d e g r e e o f o r g a n i c d e f i c i t s . J o i n t a s s e s s m e n t must t h e n i n c l u d e a v e r b a l c o m p a r i s o n o f f i n d i n g s by t h e two s p e c i a l i s t s , w i t h some " g i v e and t a k e " a d j u s t m e n t s b e i n g made by b o t h t o t h e i r a s s e s s -ments . The m a g n i t u d e s of t h e a l l o w a n c e s t o be made i n t h i s g i v e and t a k e a r e b e s t i n d i c a t e d t o e a c h s p e c i a l i s t b y s t u d y o f t h e f a c t o r l o a d i n g s i n T a b l e 5 . T h u s , f o r e x a m p l e , t h e p s y c h o l o g i s t s h o u l d be p r e p a r e d t o a d -j u s t h i s a s s e s s m e n t o f t h e d i s a b i l i t y c o n t r i b u t i o n o f N e u r o t i c i s m more i f t he o r t h o p a e d i s t i n f o r m s h i m t h a t t h e p a t i e n t shows s i g n s o f a T e x t -book Back t h a n i f t h e p a t i e n t shows a N e r v e Roo t D e f i c i t . S i m i l a r l y t h e o r t h o p a e d i s t s h o u l d a d j u s t h i s a s s e s s m e n t o f a T e x t b o o k B a c k more i f t h e p s y c h o l o g i s t i n f o r m s h im t h a t t h e p a t i e n t i s n e u r o t i c t h a n i f t h e p a t i e n t h a s a low Pa ih ; , T o l e r a n c e . A d m i t t e d l y s u c h a v e r b a l " g i v e and t a k e " b e t w e e n s p e c i a l i s t s i n a j o i n t a p p r a i s a l i s r a t h e r " s l o p p y " , b u t i t i s p r e f e r a b l e t o t h e r e d u n d a n c y w h i c h w o u l d r e s u l t i n t he j o i n t a p p r a i s a l i f t h e s e c o m p a r i s o n s w e r e n o t made. A much more a c c u r a t e a s s e s s m e n t of t h e i n d i v i d u a l p a t i e n t c o u l d o f c o u r s e be made b y t h e u s e o f compu te r d i a g n o s i s w h i c h i s r a p i d l y g a i n i n g i n a c c e p t a n c e 106 i n orthopaedic p r a c t i c e . The computer could be programmed to d e r i v e standardized f a c t o r scores f o r the i n d i v i d u a l p a t i e n t on each of the eight f a c t o r s , by comparing the p a t i e n t ' s assessment data to compiled data such as those r e s u l t i n g from the present, study. The second problem, that of a s c e r t a i n i n g which measures best r e f l e c t the f a c t o r parameters of the i n d i v i d u a l f a c t o r s w i t h a minimal degree of redundancy, i s more d i f f i c u l t to r e s o l v e . As seen i n Table 5, w i t h few exceptions a l l 55 v a r i a b l e s load somewhat on each of the eight b a s i c dimensions of d i s a b i l i t y . D e l e t i o n from considera-t i o n of any v a r i a b l e not loading 0.00 on a given f a c t o r could then p o t e n t i a l l y change the exact i d e n t i t y of that f a c t o r as e s t a b l i s h e d i n t h i s study. The choice of which measures to r e t a i n and monitor i n f u t u r e s t u d i e s or p a t i e n t assessments i s then an a r b i t r a r y one, de-pending on how a c c u r a t e l y i t i s d e s i r e d that the i d e n t i t y of the o r g i n a l b a s i c dimensions be r e f l e c t e d . The choice of which measures to monitor i n a p p r a i s i n g each f a c t o r appears to be best predicated on a pragmatic b a s i s . In i n d i v i d u a l patient-assessment i t would perhaps be l e a s t confusing to use only those measures as i n d i c a t o r s which have t h e i r major f a c t o r loadings on the f a c t o r evaluated, i f those measures are not i n t e r n a l l y redundant as seen from t h e i r r e g r e s s i o n c o e f f i c i e n t s on that f a c t o r . I n f u t u r e s t u d i e s by the present author, another f a c t o r a n a l y s i s w i l l be done Kokan, P.J. Personal communication regarding a course "Computers i n Orthopaedic Research and Education" attended i n A t l a n t a Georgia, March 22-24, 1972. 107 and a l l those measures having a major f a c t o r loading on any one of the eig h t b a s i c dimensions of d i s a b i l i t y found i n the present study w i l l be incl u d e d . This w i l l a l l o w approximation of the f a c t o r i d e n t i t i e s of the present study. A l l except one of the v a r i a b l e s having t h e i r major f a c t o r loadings on the Neuroticism Factor o r i g i n a t e from the MMPI and the r e g r e s s i o n c o e f f i c i e n t s used i n d e r i v i n g the Neuroticism Factor scores suggest that a l l these MMPI v a r i a b l e s make unique c o n t r i b u t i o n s to t h i s f a c t o r ( r e -g r e s s i o n c o e f f i c i e n t s of v a r i a b l e s MMPIHS = -.15; MMPID = -.17; MMPIHY = -.19; MMPIPT = -.20; MMPIES = -.14; TAYLOR = -.14). I f the p a t i e n t com-p l e t e s the MMPI, a l l these measures should be considered i n the assess-ment. The other measure having i t s major f a c t o r l o a d i n g on the Neuro-t i c i s m Factor i s the Beck I.D. and the r e g r e s s i o n c o e f f i c i e n t (-.17) suggests that t h i s measure a l s o makes a unique c o n t r i b u t i o n to the Neuroticism Factor scores. Retention of t h i s measure would appear j u s t i f i e d because t h i s inventory r e q u i r e s only about 10-15 minutes to complete. The P a i n Tolerance Factor i s loaded most h e a v i l y by the Cold T o l -erance Test performance and by a v a r i a b l e r e p o r t i n g the experience of pai n a s s o c i a t e d w i t h s i t t i n g i n a c h a i r . The r e g r e s s i o n c o e f f i c i e n t s of these two v a r i a b l e s on the P a i n Tolerance Factor suggest that both c o n t r i b u t e uniquely to t h i s f a c t o r ( r e g r e s s i o n c o e f f i c i e n t s of v a r i a b l e s CTT = .53; CHAIR = -.21). These two v a r i a b l e s are e a s i l y assessed i n the i n d i v i d u a l p a t i e n t by use of the Cold Tolerance Test, perhaps modified as discussed above, and by the p a t i e n t ' s r e p o r t of p a i n 108 e n c o u n t e r e d i n s i t t i n g . B e h a v i o r a l e v i d e n c e o f i n t o l e r a n c e f o r p a i n e n c o u n t e r e d i n s i t t i n g m i g h t be c o n v e n i e n t l y g a t h e r e d i n t h e f u t u r e d u r i n g t h e p s y c h o l o g i c a l e x a m i n a t i o n , i n w h i c h many p a t i e n t s s p o n t a -n e o u s l y c o m p l a i n o f p a i n , g e t up t o move a b o u t , and somet imes even s t a n d d u r i n g t h e two h o u r s o r more r e q u i r e d f o r c o m p l e t i o n o f t h e i n t e r v i e w and q u e s t i o n n a i r e s . The L i f e G o a l s F a c t o r i s l o a d e d h e a v i l y by two measu res f r o m t h e K - C S c a l e . R e g r e s s i & n c o e f f i c i e n t s o f t h e s e measu res on t h e L i f e G o a l s F a c t o r s u g g e s t t h a t b o t h measu res make a u n i q u e c o n t r i b u t i o n t o t h e f a c t o r ( r e g r e s s i o n c o e f f i c i e n t s o f v a r i a b l e s KCNOW = . 3 6 ; KCFUT = . 3 5 ) . The K - C S c a l e t a k e s l i t t l e t i m e t o a d m i n i s t e r and i s t h e r e f o r e , p r a g m a t i c a l l y , a s u i t a b l e a s s e s s o r o f t h i s f a c t o r . T h i s s c a l e i s d i f f i c u l t t o u s e i n a s s e s s m e n t h o w e v e r , b e c a u s e t h e p a t i e n t ' s d i s a b i l i t y on t h e o t h e r b a s i c d i m e n s i o n s , e s p e c i a l l y t h e T e x t b o o k B a c k F a c t o r , s u b s t a n -t i a l l y i n f l u e n c e the a c t u a l r a t i n g d e r i v e d f r o m t h i s s c a l e ( e . g . , r e g r e s s i o n c o e f f i c i e n t s on t h e L i f e G o a l s F a c t o r o f v a r i a b l e s ABDPOWA = - . 2 1 ; LUMEXT = . 1 7 ; GAENSLEN = . 1 2 ; OBJECT = - . 1 0 ) . The M o b i l i t y o f S e l f F a c t o r has m a j o r l o a d i n g s by f o u r v a r i a b l e s d e r i v e d f r o m t h e P a t i e n t S e l f - e v a l u a t i o n Form ( v a r i a b l e s CAR, L I F T I N G , LOWBACK, and BENDING) and t h e r e g r e s s i o n s c o e f f i c i e n t s o f t h e s e v a r i a -b l e s s u g g e s t t h a t a l l f o u r make u n i q u e c o n t r i b u t i o n s t o t h i s f a c t o r ( r e g r e s s i o n c o e f f i c i e n t s o f v a r i a b l e s CAR = - . 1 3 ; L I F T I N G = - . 3 3 ; LOWBACK = - . 3 1 ; BENDING = - . 4 1 ) . A number o f v a r i a b l e s h a v i n g t h e i r m a j o r f a c t o r l o a d i n g s on o t h e r f a c t o r s a r e a l s o i n d i c a t e d as mak ing s u b s t a n t i a l , u n i q u e c o n t r i b u t i o n s t o t h e M o b i l i t y o f S e l f F a c t o r ( e . g . , 109 r e g r e s s i o n c o e f f i c i e n t s o f v a r i a b l e s ABDPOWA = . 2 1 ; SLR = - . 1 3 ; PAINEXT = - . 1 1 ; NECKS = . 1 0 ) . As p o i n t e d ou t a b o v e , t h e v a r i a b l e s h a v i n g m a j o r l o a d i n g s on t h i s f a c t o r a l s o have s u b s t a n t i a l m i n o r l o a d i n g s on o t h e r f a c t o r s s u c h as t h e T e x t b o o k B a c k and P a i n T o l e r a n c e F a c t o r s , s u g g e s t i n g t h a t t h e v a r i a n c e a c c o u n t e d f o r by t h e M o b i l i t y o f S e l f F a c t o r may r e f l e c t t h e c h a r a c t e r i s t i c b e h a v i o r a l r e s p o n s e o f t h e p a t i e n t t o p a i n , ( i . e . , t o l i e i m m o b i l i z e d v s . t o r e m a i n a c t i v e ) . The f o u r v a r i a b l e s h a v i n g m a j o r l o a d i n g s on t h i s f a c t o r may c o n t i n u e t o be u s e d i n a s s e s s m e n t o f t h i s p a r a m e t e r f o r t h e p r e s e n t , b u t i n f u t u r e s t u d i e s an a t t e m p t s h o u l d be made t o i n c l u d e m e a s u r e s t h a t m i g h t l o a d on t h i s f a c t o r and h e l p t o c l a r i f y i t . What s u c h m e a s u r e s m i g h t b e , o t h e r t h a n p e r h a p s a s k i n g t h e p a t i e n t f o r h i s p r e f e r r e d r e s p o n s e t o p a i n o r p e r h a p s t o t h e " f l u " e s c a p e t h i s i n v e s t i g a t o r a t p r e s e n t . 110 D i r e c t i o n s f o r F u r t h e r S t u d y T h i s s t u d y h a s shown t h a t e i g h t b a s i c d i m e n s i o n s u n d e r l y a p p r o -x i m a t e l y 80% o f LBP d i s a b i l i t y i n p o s t - f u s i o n p a t i e n t s . Though t h e s e f a c t o r s have been shown t o e x i s t i n d e p e n d e n t l y i n t h i s r e t r o s p e c t i v e s t u d y , i t i s p o s s i b l e t h a t c a u s a t i v e r e l a t i o n s h i p s may have e x i s t e d among them i n t he e a r l i e r c o u r s e o f t h e i l l n e s s h i s t o r y . F o r s a k e o f c o n j e c t u r e , i t seems p l a u s i b l e t h a t a l o n g p e r i o d o f o r g a n i c a l l y - b a s e d i l l n e s s gave r i s e t o t h e p s y c h o l o g i c a l d e f i c i t s s e e n h e r e — p s y c h o l o g i c a l d e f i c i t s w h i c h r e m a i n e d a f t e r the o r g a n i c p a t h o l o g y was r e p a i r e d by o p e r a t i o n . C o n v e r s e l y , a p l a u s i b l e a rgument c o u l d be p r e s e n t e d t h a t t h e p s y c h o l o g i c a l c h a r a c t e r i s t i c s e x i s t e d b e f o r e t h e o r g a n i c p a t h o l o g y , g i v i n g r i s e t o i t by some p s y c h o p h y s i o l o g i c a l p r o c e s s . O r g a n i c r e p a i r l e a v i n g t h e p s y c h o l o g i c a l d e f i c i t s and p s y c h o p h y s i o l o g i c a l p r o c e s s i n t a c t , w o u l d a l l o w c o n t i n u e d o r g a n i c d e g e n e r a t i o n t o o c c u r , l e a d i n g t o a c h r o n i c c o u r s e s u c h as i s o f t e n s e e n i n LBP p a t i e n t s ; d e g e n e r a t i o n and r e l a p s e s w o u l d be e x p e c t e d t o o c c u r a f t e r o p e r a t i v e r e p a i r , c u l m i -n a t i n g e v e n t u a l l y i n f u r t h e r o p e r a t i v e t r e a t m e n t o f n e w l y - a p p e a r e d o r g a n i c p a t h o l o g y . H o w e v e r , i n b o t h a rgumen ts i t i s e v i d e n t t h a t a t some a d v a n c e d p e r i o d i n t h e i l l n e s s h i s t o r y p s y c h o l o g i c a l and o r g a n i c f a c t o r s may n o t be s e e n t o g e t h e r , e v e n t h o u g h c o - v a r i a n c e e x i s t e d b e t w e e n them a t some e a r l i e r p o i n t . A number of p r o s p e c t i v e s t u d i e s h a v e t h u s b e e n p l a n n e d w h i c h w i l l c h a r t t h e b a s i c d i m e n s i o n s o f d i s a b i l i t y d u r i n g t h e c o u r s e o f t h e i l l -n e s s h i s t o r y . Two c l i n i c a l l y - b a s e d i n v e s t i g a t i o n s w i l l document t h e e i g h t b a s i c d i m e n s i o n s f o u n d i n t h i s s t u d y , as w e l l as e x p l o r e t h e I l l o t h e r p o s s i b l e s o u r c e s o f d i s a b i l i t y v a r i a n c e w h i c h were d i s c u s s e d a b o v e . E s t a b l i s h m e n t o f t h e t e m p o r a l r e l a t i o n s h i p s among t h e b a s i c f a c t o r s o f d i s a b i l i t y w i l l p r o v i d e i n f o r m a t i o n u s e f u l f o r e a r l y p r o g n o s t i c a t i o n and t r e a t m e n t p l a n n i n g , and may a l l o w e t i o l o g i c a l c l a r i f i c a t i o n o f t he p s y c h o p h y s i o l o g i c a l p r o c e s s e s u n d e r l y i n g L B P . H o w e v e r , e v e n i f t e m p o r a l r e l a t i o n s h i p s a r e e s t a b l i s h e d be tween t h e c l i n i c a l a p p e a r a n c e o f o r g a n i c and p s y c h o l o g i c a l f a c t o r s , c a u s a t i o n may s t i l l n o t b e i n f e r r e d b e c a u s e o n l y t h e t h r e s h o l d o f measurement o f one o r t h e o t h e r s e t o f f a c t o r s may be l o w e r , and t h e r e f o r e one o r t h e o t h e r s e t o f f a c t o r s may a p p e a r t o o c c u r e a r l i e r . F o r t h i s r e a s o n l a b o r a t o r y - b a s e d r e s e a r c h , i s a l s o p l a n n e d t o e s t a b l i s h t h e e t i o l o g i c a l b a s i s o f L B P . P r e c i s o f s t u d i e s p l a n n e d b y t h i s r e s e a r c h g roup a r e p r e s e n t e d b e l o w : S t u d y I. A p r o s p e c t i v e s t u d y o f f i r s t - o p e r a t i o n s p i n a l f u s i o n p a t i e n t s i s p r e s e n t l y b e g i n n i n g . I n t h i s s t u d y , p a t i e n t s who h a v e been deemed c a n d i d a t e s f o r l umbar s p i n a l f u s i o n by t h e i r t r e a t i n g p h y s i c i a n s w i l l be r e f e r r e d t o t h i s r e s e a r c h g r o u p . These p a t i e n t s w i l l be a s s e s s e d as d e s c r i b e d above and w i l l t h e n be r a n d o m l y a s s i g n e d t o f u s i o n and n o n - f u s i o n t r e a t m e n t g r o u p s . These p a t i e n t s w i l l be r e t u r n e d t o t h e i r r e f e r r i n g p h y s i c i a n s f o r t h e t r e a t m e n t s p e c i f i e d by t h i s r e s e a r c h g r o u p , w h i c h w o u l d c o n s i s t o f e i t h e r s p i n a l f u s i o n o r c o n s e r v a t i v e t r e a t m e n t o f t h e r e f e r r i n g p h y s i c i a n ' s c h o i c e . F u r t h e r c o n t r o l o f t r e a t m e n t i s no t p r o f e s s i o n a l l y p o s s i b l e . F o l l o w - u p r e - a s s e s s m e n t on t h e b a s i c d i m e n s i o n s o f d i s a b i l i t y and d e t e r m i n a t i o n by t h i s r e s e a r c h g roup of t he d e g r e e o f d i s a b i l i t y 112 a f t e r one and two y e a r s w i l l p r o v i d e t h e f o l l o w i n g i n s i g h t s : 1) The e f f i c a c y o f s p i n a l f u s i o n as compared w i t h c o n s e r v a t i v e t r e a t m e n t has n o t b e e n r e p o r t e d i n an a d e q u a t e l y c o n t r o l l e d f a s h i o n i n t h e l i t e r a t u r e . The c o m p a r a t i v e e f f i c a c i e s o f t h e s e two t y p e s of t r e a t m e n t may t h u s be e s t a b l i s h e d b y t h i s s t u d y . 2) The p r o g n o s t i c v a l u e s of t h e v a r i o u s a s s e s s m e n t f a c t o r s may a l s o be e s t a b l i s h e d . I n a r e c e n t a r t i c l e B e a l s and H i c k m a n (1972) s u g g e s t e d t h a t p s y c h o l o g i c a l and o r g a n i c f a c t o r s a r e a d d i t i v e i n p r o g n o s t i c v a l u e b u t t h e y d i d n o t d e v e l o p a r i g o r o u s f o r m u l a f o r t r a n s p o s i n g t he v a r i o u s m e a s u r e s i n t o a p r o g n o s t i c i n d e x . The s t u d y h e r e d e s c r i b e d w i l l r e p r e s e n t an a t t e m p t t o e s t a b l i s h s u c h a f o r m u l a w i t h t h e h e l p o f r e g r e s s i o n a n a l y s i s t e c h n i q u e s . 3) I t may be t h a t s p e c i f i c t y p e s o f p a t i e n t s , p e r h a p s c o r r e -s p o n d i n g t o t he Syndrome Complex g r o u p s s e e n i n t he p r e s e n t s t u d y , w i l l be f o u n d t o be d i f f e r e n t i a l l y r e s p o n s i v e t o t h e two t y p e s of t r e a t m e n t . T h i s f i n d i n g w o u l d a l l o w t h e e s t a b l i s h m e n t o f unambiguous i n d i c a t o r s f o r f u s i o n , w h i c h p r e s e n t l y a r e l a c k i n g i n p r a c t i c e . The r e s u l t s o f t h i s s t u d y , even i f t h e y s u p p o r t t h e p r o g n o s t i c v a l u e o f a l l e i g h t b a s i c f a c t o r s o f d i s a b i l i t y , w i l l s t i l l n o t a l l o w s t a t e m e n t s t o be made r e g a r d i n g t h e o c c u r r e n c e o f LBP o f l e s s e r c l i n i c a l p r o p o r t i o n s t h a n t h o s e s e e n i n t h e n e a r l y " e n d - o f - t h e - r o a d " p r e - f u s i o n p a t i e n t s . The p r o c e s s e s u n d e r l y i n g LBP a r e no d o u b t w e l l e s t a b l i s h e d 113 by t h e t i m e s p i n a l f u s i o n i s c o n s i d e r e d f o r most p a t i e n t s . S t u d y I I . I n o r d e r t h a t LBP c a n be p r o s p e c t i v e l y i n v e s t i g a t e d , C a n a d i a n P a c i f i c A i r l i n e s (CPA) o f V a n c o u v e r has been a p p r o a c h e d i n t h e hope t h a t a l a r g e e p i d e m i o l o g i c a l s t u d y may be u n d e r t a k e n t h e r e . From t h e a p p r o x i m a t e l y 3500 CPA emp loyees o f d i v e r s e o c c u p a t i o n a l c l a s s i f i -c a t i o n s w o r k i n g u n d e r one r o o f i n V a n c o u v e r , 1000 s u b j e c t s w o u l d be c h o s e n r a n d o m l y and e v a l u a t e d o r t h o p a e d i c a l l y , r a d i o l o g i c a l l y and p s y c h o l o g i c a l l y . L o n g - t e r m f o l l o w - u p o f t h e s e s u b j e c t s c o u l d t h e n e a s i l y be made, u s i n g c o m p u t e r i z e d m e d i c a l r e c o r d s a l r e a d y m a i n t a i n e d by C P A , and t h e o c c u r r e n c e o f LBP c o u l d t h e n be examined i n r e l a t i o n -s h i p t o t h e f a c t o r s m o n i t o r e d d u r i n g t h e i n i t i a l a s s e s s m e n t . Change i n t h e s e f a c t o r s c o u l d a l s o be d e t e r m i n e d b y r e - a s s e s s m e n t o f t h e s y m p t o m a t i c g roup and an a s y m p t o m a t i c c o n t r o l g roup c h o s e n r a n d o m l y f r o m t h o s e who w e r e i n i t i a l l y a s s e s s e d . A m a j o r l o g i s t i c a l p r o b l e m i n a s t u d y o f t h i s s i z e w o u l d be t h e l e n g t h o f t i m e r e q u i r e d f o r c o m p l e t i o n o f t h e MMPI , u s e d i n a s s e s s m e n t o f t h e N e u r o t i c i s m F a c t o r . H o w e v e r , a v e r y s h o r t q u e s t i o n n a i r e (Crown, and C r i s p , 1 9 6 6 ) , t h e M i d d l e s e x H o s p i t a l Q u e s t i o n n a i r e (MHQ), h a s g i v e n p r o m i s e of b e i n g a v e r y e f f i c i e n t a s s e s s o r o f h e u r o t i c i m , and has a l -r e a d y b e e n shown t o be s u c c e s s f u l i n i d e n t i f y i n g t h o s e w i t h p s y c h o s o -m a t i c i l l s ( H o w e l l and C r o w n , 1 9 7 1 ) . V e r y r e c e n t l y W o l k i n d and F o r r e s t (1972) h a v e a l s o shown t h e MHQ t o h a v e p r o g n o s t i c v a l u e i n r e g a r d t o t he outcome o f c o n s e r v a t i v e t r e a t m e n t f o r L B P . I t i s t h e r e f o r e p l a n n e d t o a d m i n i s t e r b o t h t h e MMPI and MHQ i n i n t h e p r o s p e c t i v e f u s i o n s t u d y ( S t u d y I a b o v e ) , so t h a t t h e p r e s e n t l y 114. unknown r e l a t i o n s h i p o f t h e MMPI and MHQ s c a l e s may be a s c e r t a i n e d , and t h e mean ing o f t h e MHQ s c o r e s i n r e g a r d t o t h e N e u r o t i c i s m F a c t o r o f LBP d i s a b i l i t y may be d e d u c e d . The MHQ may t h e n be u s e d d u r i n g v e r y t i m e - c o n s c i o u s s t u d i e s s u c h as t h e CPA i n v e s t i g a t i o n . S t u d y I I I . S t u d y I I I i s a c t u a l l y a s e r i e s o f p s y c h o p h y s i o l o g i c a l s t u d i e s w h i c h h o p e f u l l y w i l l e s t a b l i s h t h e e t i o l o g y o f i n t e r v e r t e b r a l d i s c d e g e n e r a t i o n . F o r t h e p a s t 30 y e a r s , i t h a s been w i d e l y a c c e p t e d t h a t d e g e n e r a t i o n of t h e i n t e r v e r t e b r a l d i s c l i e s a t t h e b a s e o f LBP and s u b s e q u e n t d e g e n e r a t i v e c h a n g e s o f t h e s p i n a l e l e m e n t s , b u t t h e e t i o l o g y o f t h e d i s c d e g e n e r a t i o n h a s n o t b e e n s a t i s f a c t o r i l y e x -p l a i n e d ( H i r s c h , 1966). T h e . h y p o t h e s i s w h i c h w i l l be t e s t e d i n t h e p r e s e n t l y p r o p o s e d s e r i e s o f s t u d i e s i s t h a t h i g h c h r o n i c f o r c e l o a d i n g s o f t he d i s c b r i n g a b o u t i t s d e g e n e r a t i o n and t h a t , r a t h e r t h a n t h e f o r c e s coming f r o m an e x t e r n a l s o u r c e , t h e c r i t i c a l f o r c e s come f r o m t h e i n d i v i d u a l ' s own c h r o n i c a l l y - t e n s e b a c k ( s a c r o s p i n a l i s ) m u s c l e s . T h a t f o r c e s a id s t r e s s on t h e d i s c b r i n g a b o u t i t s d e g e n e r a t i o n h a s b e e n s u g g e s t e d (Hirsch,1959) and i s c o m p a t i b l e w i t h much o f what i s known a b o u t d i s c d e g e n e r a t i o n ( W i l f l i n g and W i n g , 1972). Though s a c r o s p i n a l i s spasm i s o f t e n s e e n i n LBP p a t i e n t s , i t i s most f r e q u e n t l y d i s m i s s e d as a r e f l e x i v e t i g h t e n i n g w h i c h i s i n s t r u m e n -t a l i n i m m o b i l i z i n g a p a i n f u l j o i n t . Some a u t h o r s ( e . g . , Ho lmes and W o l f f , 1952; K r a u s , 1970; M a l o n e y , 1948; P a u l e t t , 1947) have s u g g e s t e d C r o w n , S . P e r s o n a l c o m m u n i c a t i o n . 115 t h a t m u s c l e t e n s i o n may be d i r e c t l y i n v o l v e d i n t h e p r o d u c t i o n o f L B P , b u t o n l y one a u t h o r ( S o l o m o n , 1949) has s u g g e s t e d i n an " a r m c h a i r " a r t i c l e t h a t s u c h t e n s i o n s m i g h t l e a d t o d e g e n e r a t i o n . R e c e n t b i o -m e c h a n i c a l s t u d i e s ( e . g . , B a r t e l i n k , 1957) h a v e shown t h a t t h e b a c k m u s c l e s a r e c a p a b l e o f e x e r t i n g g i g a n t i c f o r c e s on t h e s p i n e . The h y p o t h e s i s o f t h e p r o p o s e d s t u d i e s w i l l be t e s t e d w i t h i n t h e t h e o r e t i c a l f r amework o f p s y c h o s o m a t i c d i s o r d e r s s u g g e s t e d by S t e r n b a c h ( 1 9 6 5 ) . S t e r n b a c h ' s t h e o r y i s b a s e d on t h e wo rk o f L a c e y who h a s shown t h a t a r e s p o n s e s t e r e o t y p y o f t h e a u t o n o m i c s y s t e m c h a r a c t e r i z e s most i n d i v i d u a l s . S t r e s s i n t h e e n v i r o n m e n t i s a u t o n o -m i c a l l y r e a c t e d t o by a h i e r a r c h i c a l r e s p o n s i v e n e s s o f t h e v a r i o u s a u t o -nomic f u n c t i o n s . S t e r n b a c h h y p o t h e s i z e s t h a t " b r e a k d o w n " w i l l o c c u r i n t h e o r g a n s o f t h e most r e s p o n s i v e f u n c t i o n o f t h i s h i e r a r c h y i f s t i m u l a t i o n o c c u r s o f t e n enough and i f t h e a r o u s a l i n h i b i t i n g m e c h a -n i s m s a l l o w p r o l o n g e d a r o u s a l . I n a p a r a l l e l f a s h i o n and w i t h r e g a r d t o t h e h y p o t h e s i s o f t h e p r e s e n t l y p r o p o s e d s e r i e s o f s t u d i e s , G o l d s t e i n , G r i n k e r , H e a t h , Oken and Sh ipman (1964) h a v e d e m o n s t r a t e d t h a t t h e r e i s a r e s p o n s e s t e r e o t y p y o f t h e m u s c u l o s k e l e t a l s y s t e m and numerous s t u d i e s ( e . g . , G o l d s t e i n , 1 9 6 5 ; M a l m o , S h a g a s s and D a v i s , 1 9 5 0 ; M a r t i n and D a v i s , 1 9 6 6 ; Muecher and H e c k h a u s e n , 1 9 6 2 ; S h i p m a n , O k e n , G o l d s t e i n , G r i n k e r and H e a t h , 1964) have shown t h a t n e u r o t i c and h i g h - g o a l - s e t t i n g i n d i v i d u a l s , s i m i l a r t o t h e LBP s u b j e c t s s e e n i n t h e p r e s e n t s t u d y , have e l e v a t e d and p r o l o n g e d m u s c u l o s k e l e t a l r e s p o n s i v e n e s s t o s t r e s s . H o p e f u l l y i t w i l l be f o u n d i n t h e p r e s e n t l y p r o p o s e d s t u d i e s 116 t h a t c h r o n i c LBP p a t i e n t s a r e i n d i v i d u a l s who r e a c t t o s t r e s s e s f r o m t h e i r e n v i r o n m e n t i n a n a n x i o u s , n e u r o t i c manner and w i t h m a s s i v e and p r o l o n g e d t e n s i o n o f t he b a c k m u s c u l a t u r e b e c a u s e t h e s a c r o s p i n a l i s . m u s c l e s happen t o be t he most r e a c t i v e h i e r a r c h i c a l e l e m e n t i n t h e i r m u s c u l o s k e l e t a l r e s p o n s e s t e r e o t y p y . Tha t t h e i n d i v i d u a l r e s p o n d s t o t h e s t r e s s e s o f l i f e as a p s y c h o b i o l o g i c a l w h o l e as i m p l i e d a b o v e , r a t h e r t h a n i n a d u a l i s t i c f a s h i o n , i s b e c o m i n g w i d e l y a c c e p t e d ( S t e r n b a c h , 1 9 6 8 ; WHO E x p e r t C o m m i t t e e , 1 9 6 4 ) . R e c e n t a d v a n c e s i n p s y c h o p h y s i o l o g y — and i n r e g a r d t o t h e p r e s e n t l y p r o p o s e d s t u d i e s , i n e l e c t r o m y o g r a p h y — have p r o v i d e d b o t h new t o o l s w i t h w h i c h t o e x p l o r e p s y c h o s o m a t i c s and o p p o r t u n i t i e s f o r o b t a i n i n g i n f o r m a t i o n on w h i c h new u n i f y i n g c o n c e p t s c a n be p o s t u l a t e d ( S a r g e n t , G r e e n and W a l t e r s , 1 9 7 2 ) . A d m i t t e d l y t h e above c o n c e p t u a l i z a t i o n i s h i g h l y s p e c u l a t i v e , s u p p o r t e d o n l y by i m p l i c a t i o n s f r o m e x i s t i n g k n o w l e d g e , and p r e d i c a t e d on a new and v i r t u a l l y u n t e s t e d t h e o r y . H o w e v e r , t h e n e c e s s a r y p r i n -c i p l e s f o r t h i s e t i o l o g i c a l c o n c e p t u a l i z a t i o n o f d i s c d e g e n e r a t i o n a r e a l l r i g o r o u s l y t e s t a b l e . A n a t t e m p t t o p r o d u c e l umbar s p i n e p a t h o l o g y i n a n i n f r a - h u m a n s p e c i e s c o u l d be made u s i n g o p e r a n t l y - i n d u c e d c h r o n i c s a c r o s p i n a l i s m u s c l e t e n s i o n , and m u s c u l o s k e l e t a l r e s p o n s e s t e r e o t y p i e s c o u l d be c h a r t e d i n LBP s u b j e c t s b o t h r e t r o s p e c t i v e l y and p r o s p e c t i v e l y . S h o u l d t h i s c o n c e p t u a l i z a t i o n be s u p p o r t e d b y r e s e a r c h e v i d e n c e , w h o l e new v i s t a s w o u l d be opened f o r t h e t r e a t m e n t o f L B P . D e g e n e r a t i o n o f t h e lumbar s p i n e c o u l d b e c u r t a i l e d by u s i n g b i o f e e d b a c k t r a i n i n g t o l o w e r t h e s a c r o s p i n a l i s r e a c t i v i t y t o s t r e s s . T h i s w o u l d be g r e a t l y 117 p r e f e r a b l e t o l i m i t i n g t h e a c t i v i t y o f t h e i n d i v i d u a l o r r e p a i r i n g t h e damage when i t a p p e a r s a s i s p r e s e n t l y d o n e . A l s o , b e c a u s e a n i n d i v i d u a l ' s r e s p o n s e s t e r e o t y p y i s q u i t e s t a b l e o v e r t i m e ( L a c e y and L a c e y , 1962) , e a r l y r e c o g n i t i o n o f h i g h - r i s k LBP i n d i v i d u a l s w o u l d be p o s s i b l e and p r o p h y l a c t i c u s e o f b i o f e e d b a c k c o u l d be made. H a u n t i n g l y , one a l s o wonde rs what b e n e f i t s t o p s y c h o l o g y and t o t h e u n d e r s t a n d i n g o f n e u r o s i s an i n v e s t i g a t i o n c o n c e r n i n g s a c r o s p i n a -l i s m u s c l e t e n s i o n and r e l a x a t i o n m i g h t h a v e . P e r h a p s n o t c o i n c i d e n - . t a l l y , V a l i u m i s w i d e l y u s e d i n t h e t r e a t m e n t o f a n x i e t y and n e u r o s i s as a t r a n q u i l i z e r and a l s o i n t h e c o n s e r v a t i v e t r e a t m e n t o f LBP as a m u s c l e r e l a x a n t . 118 BIBLIOGRAPHY 119 References Ahlgren, E.W., C.R. Stephen, E.A.C. Lloyd, & D.E. McCollum. Diagnosis of Pain with a Graduated Spinal Block Technique. The Journal of  the American Medical Association, 1966, 195 (10), 125-128. Aitken, A.P. Rupture of the Intervertebral Disc i n Industry: Further Observations on the End Results. American Journal of Surgery, 1952, 84, 261-267. Alvarez, W.C. The Neuroses. 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D i s e a s e s o f t h e N e r v o u s S y s t e m , 1967, 28 (3), 155-159. M i l l e n , F . J . P o s t - t r a u m a t i c N e u r o s i s i n I n d u s t r y . I n d u s t r i a l M e d i c i n e  and S u r g e r y . 1966, 35, 929-934. 128 M i x t e r , W . J . & J . S . B a r r . R u p t u r e o f t h e I n t e r v e r t e b r a l D i s c w i t h I n v o l v e m e n t o f t h e S p i n a l C a n a l . New E n g l a n d J o u r n a l o f M e d i c i n e , 1 9 3 4 , 211 ( 5 ) , 2 1 0 - 2 1 4 . M o r e t o n , R . O . S o - c a l l e d N o r m a l B a c k s . I n d u s t r i a l M e d i c i n e and S u r g e r y . 1 9 6 9 , 38 ( 7 ) , 2 1 6 - 2 1 9 . M u e c h e r , H . and H . H e c k h a u s e n . I n f l u e n c e o f M e n t a l A c t i v i t y and A c h i e -vement M o t i v a t i o n on S k e l e t a l M u s c l e T o n u s . P e r c e p t u a l and M o t o r  S k i l l s , 1 9 6 2 , 1 4 , 2 1 4 - 2 1 8 . N a c h l a s , I .W. E n d - r e s u l t S t u d y of t he T r e a t m e n t o f H e r n i a t e d N u c l e u s P u l p o s u s by E x c i s i o n w i t h F u s i o n and w i t h o u t F u s i o n . The J o u r n a l  o f Bone and J o i n t S u r g e r y , 1 9 5 2 , 34A ( 4 ) , 9 8 1 - 9 8 8 . N a s h o l d , B . S . & Z H r u b e c . Lumbar D i s c D i s e a s e : A Twenty Y e a r C l i n i c a l  F o l l o w - u p S t u d y . S t . L o u i s : C . V . Mosby C o . , 1 9 7 1 . P a u l , L . P s y c h o s o m a t i c A s p e c t s o f Low Back P a i n : A R e v i e w o f R e c e n t A r t i c l e s . P s y c h o s o m a t i c M e d i c i n e , 1 9 5 0 , 12 ( 2 ) , 1 1 6 - 1 2 4 . P a u l e t t , J . D . Low B a c k P a i n . L a n c e t , 1 9 4 7 , _2, 2 7 2 - 2 7 6 . P h i l l i p s , E . L . Some P s y c h o l o g i c a l P r o b l e m s A s s o c i a t e d w i t h O r t h o -p a e d i c C o m p l a i n t s . C u r r e n t P r a c t i c e i n O r t h o p a e d i c S u r g e r y , 1 9 6 4 , 2 , 1 6 5 - 1 7 6 . P r o t h e r o , S . R . , J . C . P a r k e s , & F . E . S t i n c h f i e l d . C o m p l i c a t i o n s a f t e r L o w - b a c k F u s i o n i n 1000 P a t i e n t s . The J o u r n a l o f Bone and J o i n t S u r g e r y , 1 9 6 6 , 48A ( 1 ) , 5 7 - 6 5 . R a a f , J . Some O b s e r v a t i o n s R e g a r d i n g 905 P a t i e n t s O p e r a t e d Upon f o r P r o t r u d e d Lumbar I n t e r v e r t e b r a l D i s c . A m e r i c a n J o u r n a l o f S u r g e r y , 1 9 5 9 , 9 7 , 3 8 8 - 3 9 9 . 129 R a n e y , F . L . & J . E . Adams. T r e a t m e n t o f I n t r a c t a b l e L u m b o s a c r a l P a i n and S c i a t i c a by Lumbar A n t e r i o r F u s i o n , i n G u r d j i a n , E . S . & L . M. Thomas ( E d s . ) . N e c k a c h e and B a c k a c h e . S p r i n g f i e l d : C h a r l e s C. Thomas, 1 9 7 0 . R i n g , F . O . T e s t i n g t h e V a l i d i t y o f P e r s o n a l i t y P r o f i l e s i n P s y c h o s o -m a t i c I l l n e s s e s . A m e r i c a n J o u r n a l o f P s y c h i a t r y , 1 9 5 7 , 1 1 3 , 1 0 7 5 - 1 0 8 0 . Rowe, M . L . Low B a c k P a i n i n I n d u s t r y : A P o s i t i o n P a p e r . J o u r n a l o f  O c c u p a t i o n a l M e d i c i n e , 1 9 6 9 , 11. ( 4 ) , 1 6 1 - 1 6 9 . S a r g e n t , J . D . , E . E . G r e e n , & E . D . W a l t e r s . The Use o f A u t o g e n i c F e e d -b a c k T r a i n i n g i n a P i l o t S t u d y o f M i g r a i n e and T e n s i o n H e a d a c h e . H e a d a c h e , 1 9 7 2 , 1 2 , 1 2 0 - 1 2 4 . S a x e , E . F u n c t i o n a l M u s c u l a r D i s a b i l i t i e s : T h e i r R e c o g n i t i o n and T r e a t m e n t . B u l l e t i n of t he M e n n i n g e r C l i n i c , 1 9 4 4 , 8_, 5 9 - 6 2 . S c h e i n , A . J . B a c k and Neck P a i n and A s s o c i a t e d N e r v e Roo t I r r i t a t i o n i n the New Y o r k C i t y F i r e D e p a r t m e n t . C l i n i c a l O r t h o p a e d i c s  and R e l a t e d R e s e a r c h , 1 9 6 8 , 5_9, 1 1 9 - 1 2 4 . S c o t t , J . C . S t r e s s F a c t o r i n t h e D i s c Syndrome. The J o u r n a l o f Bone  and J o i n t S u r g e r y , 1 9 5 5 , 39B ( 1 ) , 1 0 7 - 1 1 1 . S h i p m a n , W . G . , D. O k e n , I . B . G o l d s t e i n , R . R . G r i n k e r and H . A . H e a t h . S t u d y of P s y c h o p h y s i o l o g y o f M u s c l e T e n s i o n : P e r s o n a l i t y F a c t o r s . A r c h i v e s o f G e n e r a l P s y c h i a t r y , 1 9 6 4 , 11 ( 3 ) , 3 3 0 - 3 4 5 . S o l o m o n , A . P . Low B a c k P a i n : The P s y c h o s o m a t i c V i e w p o i n t - A P s y c h o -s o m a t i c s t u d y on I n c r e a s e d M u s c l e T e n s i o n o f t h e V o l u n t a r y M u s c u -l a t u r e as a F a c t o r i n t h e P r o d u c t i o n of Low B a c k P a i n and i n t h e 130 P a t h o g e n e s i s of A t r o p h i c and H y p e r t r o p h i c Arthritis o f t he S p i n e - A P r e l i m i n a r y R e p o r t . I n d u s t r i a l M e d i c i n e , 1949, J.8 (1), 7-12. S p l i t o f f , C A . L u m b o s a c r a l f u n c t i o n : R o e n t g e n o g r a p h i c C o m p a r i s o n o f P a t i e n t s w i t h and w i t h o u t B a c k a c h e s . The J o u r n a l o f t he A m e r i c a n  M e d i c a l A s s o c i a t i o n , 1953, 152 (17), 1160-1163. S t e i n e r , S . D . I n c i d e n c e o f Neck P a i n and B a c k P a i n i n an I n d u s t r i a l Group , i n G u r d j i a n , E . S . , & L . M . Thomas ( E d s . ) . N e c k a c h e and  B a c k a c h e , S p r i n g f i e l d : C h a r l e s C . Thomas, 1970. S t e r n b a c h , R . A . P r i n c i p l e s o f P s y c h o p h y s i o l o g y . W i s c o n s i n : A c a d e m i c P r e s s , 1965. S t e r n b a c h , R . A . P a i n - A P s y c h o p h y s i o l o g i c a l A n a l y s i s . N . Y . : A c a d e m i c P r e s s ,1968. S t e w a r t , H . The R e l a t i o n s h i p o f P h y s i c a l I l l n e s s t o t h e IPAT 16 P e r s o n a l i t y F a c t o r s T e s t . P s y c h o l o g i c a l R e p o r t s , 1966, 18, 264-266. T a y l o r , J . A . A P e r s o n a l i t y S c a l e o f M a n i f e s t A n x i e t y , J o u r n a l o f A b - n o r m a l and S o c i a l P s y c h o l o g y , 1953, 48, 285-290. T i n g l i n g , D . C , & R . F . K l e i n . P s y c h o g e n i c P a i n and A g g r e s s i o n : The Syndrome o f t h e S o l i t a r y H u n t e r . P s y c h o s o m a t i c M e d i c i n e , 1966, 28 (5), 738-748. T r o u p , J . D . C , W . B . R o a n t r e e , & R. A r c h i b a l d . I n d u s t r y and t h e Low-B a c k P r o b l e m . New S c i e n t i s t , 1970, 45, 65-67. U l l m a n , L . P . & L . K r a s n e r . A P s y c h o l o g i c a l A p p r o a c h t o A b n o r m a l B e - h a v i o r . N . J . : P r e n t i c e - H a l l , 1969. 131 Van D e r V a l k , J . M . C l i n i c a l and P h y s i o l o g i c a l A s p e c t s , i n H o p k i n s , P . & H . H . W o l f f . ( E d s . ) . P r i n c i p l e s o f T r e a t m e n t s o f P s y c h o s o m a t i c  D i s o r d e r s . N . Y . : Pergamon P r e s s , 1965 W a l t e r s , A . E m o t i o n and Low B a c k P a i n . A p p l i e d T h e r a p e u t i c s , 1 9 6 6 , 8 ( 1 0 ) , 8 6 8 - 8 7 1 . W e c k o w i c z , T . E . , W. M u i r , & A . J . C r o p l e y . A F a c t o r A n a l y s i s o f t h e Beck I n v e n t o r y o f D e p r e s s i o n . The J o u r n a l o f C o n s u l t i n g P s y c h o l - o g y , 1 9 6 7 , 3 1 , 2 3 - 2 8 . W e i n s t e i n , M . R . 5 T h e I l l n e s s P r o c e s s - P s y c h o s o c i a l H a z a r d s o f D i s a b i l i t y P r o g r a m s . The J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n , 1 9 6 8 , 204 ( 3 ) , 1 1 7 - 1 2 1 . W e i s s , S . M . P s y c h o s o m a t i c A s p e c t s o f Symptom P a t t e r n s among M a j o r S u r g e r y P a t i e n t s . The J o u r n a l o f P s y c h o s o m a t i c R e s e a r c h , 1 9 6 9 , 13 ( 1 ) , 1 0 9 - 1 1 2 . W e s t r i n , C . G . , C . H i r s c h , & B . L i n d e g a r d . The P e r s o n a l i t y o f t h e B a c k P a t i e n t . C l i n i c a l O r t h o p a e d i c s and R e l a t e d R e s e a r c h , 1 9 7 2 , 8 7 , 2 0 9 - 2 1 6 . W h i t a k e r , R . A . , and J . M . P a t t e r s o n . H i e r a r c h i c a l G r o u p i n g A n a l y s i s w i t h  O p t i o n a l C o n t i g u i t y C o n s t r a i n t s . V a n c o u v e r , C a n a d a : U n i v e r s i t y o f B r i t i s h C o l u m b i a Comput ing C e n t e r , 1 9 7 1 . W h i t e , A . W . M . The C o m p e n s a t i o n B a c k . A p p l i e d T h e r a p e u t i c s , 1 9 6 6 , j3 ( 1 0 ) , 8 7 1 - 8 7 4 . W h i t e , A . W . M . Low B a c k P a i n i n Men R e c e i v i n g Workmen 's C o m p e n s a t i o n -A F o l l o w - u p S t u d y . C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l , 1 9 6 9 , 101 ( 2 ) , 6 1 - 6 7 . 132 W i l f l i n g , F . J . , H . K l o n o f f & P . K o k a n . P s y c h o l o g i c a l , Demograph i c and O r t h o p a e d i c F a c t o r s A s s o c i a t e d w i t h P r e d i c t i o n o f Outcome o f S p i n a l F u s i o n . C l i n i c a l O r t h o p a e d i c s and R e l a t e d R e s e a r c h , 1 9 7 3 , 9 0 , 1 5 3 - 1 6 0 . W i l f l i n g , F . J . & P . C . W i n g . The P a t h o g e n e s i s o f Low B a c k P a i n . (MRC r e s e a r c h p r o p o s a l ) . V a n c o u v e r , C a n a d a : O r t h o p a e d i c and Trauma R e s e a r c h U n i t , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1 9 7 2 . W i l l b e r g e r , B . R . S u r g i c a l T r e a t m e n t o f D e g e n e r a t i v e D i s e a s e o f t h e B a c k . The J o u r n a l o f Bone and J o i n t S u r g e r y , 45A ( 7 ) , 1 9 6 3 , 1 5 0 9 - 1 5 1 6 . W i n g , P . C . Lumbar I n t e r v e r t e b r a l F u s i o n - F a c t o r s A s s o c i a t e d w i t h  S u c c e s s o f S u r g e r y . (M. S c . T h e s i s ) V a n c o u v e r , C a n a d a : U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1 9 7 3 . W o l k i n d , S.N. & A . J . F o r r e s t . Low Back P a i n : A P s y c h i a t r i c I n v e s t i -g a t i o n . P o s t G r a d u a t e M e d i c a l J o u r n a l , 1 9 7 2 , 4^3, 7 6 - 7 9 . W o r l d H e a l t h O r g a n i z a t i o n E x p e r t Commi t tee on M e n t a l H e a l t h . T h i r t e e n t h  R e p o r t : P s y c h o s o m a t i c D i s o r d e r s . G e n e v a : W o r l d H e a l t h O r g a n i -z a t i o n , 1964 . Z b o r o w s k i , M. P e o p l e i n P a i n . San F r a n c i s c o * : J o s s e y - B a s s , 1 9 6 9 . Z i e g l e r , F . J . , J . B . Imboden , & D . A . R o d g e r s . C o n t e m p o r a r y C o n v e r s i o n R e a c t i o n s , The J o u r n a l o f t he A m e r i c a n M e d i c a l A s s o c i a t i o n , 1 9 6 3 , 186 ( 4 ) , 9 1 - 9 5 . 133 APPENDICES APPENDIX A Kilpatrick Cantril Self-Anchoring Scale, Standardized Subject Instructions, and Directions for Standardized Administration Procedures 135 K i l p a t r i c k - C a n t r i l Self-Anchoring Scale NAME: S# DATE: As a reminder to the spoken i n s t r u c t i o n s j u s t given, here i s an o u t l i n e of what to do: (1) Think of what f o r you would be the i d e a l l i f e s i t u a t i o n (2) Write a b r i e f d e s c r i p t i o n of t h i s s i t u a t i o n i n the space provided (the upper set of l i n e s to the r i g h t of the ladder's top) (3) Think of what for you would be the very worst l i f e s i t u a t i o n (A) Write a b r i e f d e s c r i p t i o n of t h i s s i t u a t i o n i n the space provided (the lower set of l i n e s to the r i g h t of the ladder's bottom) C5) T e l l the experimenter you're f i n i s h e d so you can do the other things together Ideal l i f e , s i t u a t i o n Give a b r i e f d e s c r i p t i o n of what you would consider the i d e a l l i f e s i t u a t i o n f o r you: Give a b r i e f d e s c r i p t i o n of what you would con-sider the very worst l i f e s i t u a t i o n f o r you: Very worst l i f e s i t u a t i o n 136 I n s t r u c t i o n s f o r K i l p a t r i c k - C a n t r i l A d m i n i s t r a t i o n P u t t h e K - C s c a l e i n f r o n t o f t h e s u b j e c t and g i v e t h e f o l l o w i n g i n s t r u c -t i o n s v e r b a t i m : " T h i s i s a s e l f - p e r c e p t i o n s c a l e . What I w o u l d l i k e y o u t o do i s t o t h i n k f o r a moment what f o r y o u w o u l d b e a n i d e a l l i f e s i t u a t i o n . What I mean b y t h i s i s : what a r e y o u r g o a l s , a s p i r a t i o n s - what w o u l d y o u l i k e t o a t t a i n i n l i f e t h a t w o u l d make y o u happy? A f t e r y o u ' v e t h o u g h t i t o v e r f o r a m i n u t e , w o u l d y o u p l e a s e g i v e me a b r i e f d e s c r i p t i o n o v e r h e r e ? ( i n d i c a t i n g w i t h p e n c i l ) A f t e r t h a t I w o u l d l i k e y o u t o s t o p a n d t h i n k o f what f o r y o u w o u l d b e t h e v e r y w o r s t l i f e s i t u a t i o n . By t h i s I mean a s e t o f c i r c u m s t a n c e s t h a t y o u c o u l d i m a g i n e y o u r s e l f b e i n g i n , b u t t h a t y o u most c e r t a i n l y w o u l d n ' t want to be a p a r t o f . A f t e r y o u ' v e t h o u g h t i t o v e r f o r a m i n u t e , w o u l d y o u p l e a s e g i v e a b r i e f d e s c r i p t i o n o f t h o s e c i r c u m s t a n c e s i n t h e s e s p a c e s ? ( i n d i c a t i n g w i t h p e n c i l ) A f t e r y o u ' v e done t h a t , w e ' l l come o v e r h e r e ( i n d i c a t i n g w i t h p e n c i l ) and l o o k a t t h i s t e n - s t e p l a d d e r . a s b e i n g f i g u r a t i v e l y t h e l a d d e r o f l i f e , w i t h t h e i d e a l l i f e s i t u a t i o n a t t h e t o p and t h e w o r s t l i f e s i t u a t i o n a t t h e b o t t o m . I ' l l a s k y o u t o show me w h e r e o n t h e l a d d e r y o u a r e now, where o n t h e l a d d e r y o u w e r e j u s t b e f o r e y o u r b a c k p r o b l e m s t a r t e d , a n d f i n a l l y where o n t h e l a d d e r y o u t h i n k y o u ' l l be i n 5 y e a r s f r o m now. R i g h t now, t h o u g h , I ' d j u s t l i k e y o u t o t h i n k a b o u t and d e s c r i b e t h e i d e a l l i f e s i t u a t i o n and t h e w o r s t l i f e s i t u a t i o n f o r y o u ( i n d i c a t i n g w i t h p e n c i l ) . T h e n w e ' l l do t h e r e s t t o g e t h e r . " 137 It is a good practice to absent oneself from the room for about 5 minutes at this time, because most subjects try to talk during the task. Before leaving make certain the subject understands the task and as non-directively as possible answer specific questions or overcome objections. Returning after about 5 minutes' absence (the time taken to smoke a cigarette), wait unobtrusively if necessary, for the subject to com-plete the task and then continue: "Okay. Now, if we comeover here to the ladder (indicating with pencil) and regard i t as the ladder of l i f e with this (indicating written description), the ideal l i f e situation at the top, and this (indicating written description) the worst l i f e situation, at the bot-tom, could you show me with an arrow on the (subject's) left of the ladder (making a sweeping motion with the pointer pencil so a point is hot suggested) where you are now." After the arrow is placed by the subject, ask him to write the present year (1972) beside i t . Then continue: "With another arrow, could you show me where on the ladder you were just before your back problem started." After the arrow is placed, ask the subject to label i t with the year his back problem started. And finally, ask: "And finally, could you show me with another arrow where you think you'll be on the ladder in 5 years from now." Label the final arrow with the year 5 years hence (i.e., in 1972, label as 1977). APPENDIX B C o l d T o l e r a n c e T e s t . S t a n d a r d i z e d S u b j e c t I n s t r u c t i o n s , and D i r e c t i o n s f o r S t a n d a r d i z e d A d m i n i s t r a t i o n P r o c e d u r e s 139 C o l d T o l e r a n c e T e s t  P r o c e d u r e . One o r d e r l y a t t h e Shaughnessy H o s p i t a l O u t p a t i e n t D e p a r t -ment was i n s t r u c t e d i n t h e p r e p a r a t i o n o f t h e C o l d T o l e r a n c e T e s t w a t e r -b a t h , and s u b s e q u e n t l y p r e p a r e d i t f o r a l l s u b j e c t s . The s t a n d a r d c o n -t a i n e r , a r e d t w o - g a l l o n p l a s t i c p a i l , was f i l l e d t h r e e q u a r t e r s f u l l w i t h w a t e r , and one s t a n d a r d t r a y o f i c e was a d d e d . The p a i l was c o v e r e d w i t h a c l o t h and a l l o w e d t o come t o t e m p e r a t u r e e q u i l i b r i u m f o r 20 o r 30 m i n u t e s w h i l e t h e o r t h o p a e d i s t c o m p l e t e d h i s o t h e r e x a m i n a t i o n s o f t h e p a t i e n t . T h i s t e s t was a d m i n i s t e r e d a s t h e l a s t o f t h e o r t h o p a e d i s t ' s e x a m i n a t i o n p r o c e d u r e s , and was c o n d u c t e d i n t h e " P l a s t e r Room" (where c a s t s a r e a p p l i e d ) o f t h e O u t p a t i e n t ' s D e p a r t m e n t . The o r t h o p a e d i s t f i r s t s t i r r e d and c h e c k e d t h e t e m p e r a t u r e o f t h e w a t e r w i t h a t h e r m o -m e t e r ( t h e i c e - w a t e r m i x t u r e e q u i l i b r i a t e d i n t h i s c o n t a i n e r a t 4± 1 ° C ) , and t h e n g a v e t h e s t a n d a r d i z e d i n s t r u c t i o n s i n c l u d e d b e l o w ^ i n s t r u c t i n g t h e p a t i e n t t o immerse h i s dom inan t hand i n t h e w a t e r . The o r t h o p a e d i s t d i s c o u r a g e d t a l k i n g d u r i n g t h e t e s t i n g , and r e c o r d e d t h e l e n g t h o f t i m e t h a t t h e pat fent k e p t h i s hand i m m e r s e d . The i m m e r s i o n t i m e was t h e n r e c o r d e d , a s w e r e , f o r t h e s a k e o f i n t e r e s t , any " o d d " p a i n d e s c r i p t i o n s g i v e n . I n i t i a l l y i t was d e c i d e d t o a s k any p a t i e n t s t i l l h a v i n g h i s hand immersed a f t e r f i v e m i n u t e s ( t h e " c u t - o f f t i m e " ) t o remove i t . H o w e v e r , a f t e r 50 p a t i e n t s had been s e e n , i t became a p p a r e n t t h a t no s p o n t a n e o u s hand r e m o v a l s o c c u r r e d be tween t h r e e t o f i v e m i n u t e s . An a n e s t h e t i c -t y p e r e s p o n s e seemed t o be o c c u r r i n g i n t h e s u b j e c t s ' hands p r i o r t o 140 three minutes, a not ion which was s u b j e c t i v e l y supported by personal experience. The c u t - o f f time was therefore changed to three minutes. Ins truc t ions to the Pat ient (memorized and given verbatim to each p a t i e n t ) : "Dif ferent people f e e l d i f f e r e n t amounts of p a i n , and I would l i k e you to t r y a simple tes t of t h i s . Immerse your dominant hand up to the wr i s t i n t h i s bowl of i c e water. Keep your hand . in the water as long as you can reasonably bear i t , but not to the point of s u f f e r i n g unreasonable p a i n . While your hand i s i n the water th ink about the sensations i n your hand and a f ter you have taken i t out you can t e l l me about these. Okay, go ahead and remember to keep your hand i n the water as long as you can ." APPENDIX C Orthopaedic Documentation Forms 1) Patient Self-evaluation Form 2) Back Surgery Form 3) X-ray Assessment Form 142 Low-Back Pain - Patient Self-Evaluation Form Patient Code Number Instructions: In a l l cases, place a ring around the number opposite the one answer that seems most appropriate to you. The column on the left refers to the way you were approximately one month before your fusion operation, the column on the right to the way you are now. If you have difficulty, please ask. for. help. Try and answer. all. the.different parts. Nature of pain One month before fusion Now Severity of Pain 9-10 0 0 No pain 1 1 Mild pain, not a problem 2 2 Pain annoying, but forgotten during activity 3 3 Pain present even during activities 4 4 Moderate pain, interferes with activities or sleep 5 5 Pain prevents activity or sleep 6 6 Severe pain, is immobilizing Location - low back 11-12 0 0 No pain in low back 1 1 Low back, in the centre 2 2 Low back, on the left mostly 3 3 Low back, on the right mostly 4 4 Low back generally Pain between, shoulder blades..- do you have it? 13-14 0 0 No 1 1 Occasionally 2 2 Often 3 3 Most of the time Pain in the neck - do you have it? 15-16 0 0 No 1 1 Occasionally 2 2 Often 3 3 Most of the time 143 One month before fusion Now Location of pain in buttocks or thighs 17-18 0 0 No pain iri" these places 1 1 Left buttock 2 2 Right buttock, 3 3 Both buttocks 4 4 Left thigh 5 5 Right thigh 6 6 Both thighs 7 7 Left buttock and thigh 8 8 Right buttock and thigh 9 9 Both buttocks and thighs Do.you.feel pain in the tip of your tailbone? 19-20 0 0 No 1 1 Occasionally 2 2 Often 3 3 Most of the time Do you get migraine or headaches 21-22 0 0 Seldom or never 1 1 Occasionally 2 2 Frequently Location of pain in legs and feet 23-24 0 0 No pain here 1 1 Left calf 2 2 Right calf 3 3 Both calves 4 4 Left calf and foot 5 5 Right calf and foot 6 6 Both calves and feet 7 7 Left heel and/or foot 8 8 Right heel and/or foot 9 9 Both heels and/or feet Factors Affecting the pain Coughing, sneezing or straining at stool 25-26 0 0 No particular effect on pain 1 1 Improves or lessens pain 2 2 Makes pain worse 3 3 Have not tried i t 4 4 Cannot t e l l Sitting in an upright or firm chair 27-28 0 0 No particular effect on pain 1 1 Improves or lessens pain 2 2 Makes pain worse 3 3 Have not tried i t 4 4 Cannot t e l l 144 One month before fusion Now 29-30 0 0 1 1 2 2 3 3 4 4 31-32 0 0 1 1 2 2 3 3 4 4 33-34 0 0 1 1 2 2 3 3 4 4 35-36 0 0 1 1 2 2 3 3 4 4 37-38 0 0 1 1 2 2 3 3 4 4 39-40 0 0 1 1 2 2 3 3 4 4 41-42 0 0 1 1 2 2 3 3 4 4 Sitting in a comfortable or reclining chair No particular effect on pain Improves or lessens pain Makes pain worse Have not tried i t Cannot t e l l Lying flat No particular effect on pain Improves or lessens pain Makes pain worse Have not tried i t Cannot t e l l Walking No particular effect on pain Improves or lessens pain Makes pain worse Have not tried i t Cannot t e l l Bending forward or sideways No particular effect on pain Improves or lessens pain Makes pain worse Have not tried i t Cannot t e l l Lifting No particular effect on pain Improves or lessens pain Makes pain worse Have not tried i t Cannot t e l l Lying curled up No particular effect on pain Improves or lessens pain Makes pain worse Have not tried i t Cannot te l l Heat or warmth No particular effect on pain Improves or lessens pain Makes pain worse Have not tried i t Cannot t e l l 145 One month b e f o r e f u s i o n Now C o l d 43 -44 0 0 No p a r t i c u l a r e f f e c t on p a i n 1 1 Improves o r l e s s e n s p a i n 2 2 Makes p a i n w o r s e 3 3 Have n o t t r i e d i t 4 4 Canno t t e l l M a n i p u l a t i o n by c h i r o p r a c t o r o r f r i e n d 4 5 - 4 6 0 0 No p a r t i c u l a r e f f e c t on p a i n 1 1 Improves o r l e s s e n s p a i n 2 2 Makes p a i n w o r s e 3 3 Have a n o t t r i e d i t 4 4 Cannot t e l l 4 7--.r_ S i m p l e p a i n p i l l s ( s u c h as a s p i r i n ) 4 7 - 4 8 0 0 No p a r t i c u l a r e f f e c t on p a i n 1 1 Improves o r l e s s e n s p a i n 2 2 Makes p a i n w o r s e 3 3 Have no t t r i e d i t 4 4 Canno t t e l l C o r s e t o r o r t h o p e a d i c t y p e b e l t 4 9 - 5 0 0 0 No p a r t i c u l a r e f f e c t on p a i n 1 1 Improves o r l e s s e n s p a i n 2 2 Makes p a i n w o r s e 3 3 Have no t t r i e d i t 4 4 Canno t t e l l The t i m e of day t h e p a i n i s w o r s t 5 1 - 5 2 0 0 No p a i n 1 1 The p a i n has no r e l a t i o n t o t h e t i m e o f day 2 2 M o r n i n g 3 3 M i d d l e o f day 4 4 E v e n i n g 5 5 E v e n i n g and n i g h t 6 6 M o r n i n g and e v e n i n g 7 7 N i g h t 8 8 A l l day 9 9 Day and n i g h t S t i f f n e s s 5 3 - 5 4 0 0 No s t i f f n e s s o r v e r y l i t t l e 1 1 S t i f f n e s s m o s t l y i n t h e b a c k 2 2 S t i f f n e s s m o s t l y i n t h e l e f t l e g 3 3 S t i f f n e s s m o s t l y i n t h e r i g h t l e g 4 4 S t i f f n e s s m o s t l y i n b o t h l e g s 5 5 S t i f f n e s s i n t h e b a c k and l e f t l e g 6 6 S t i f f n e s s i n t h e b a c k and r i g h t l e g 7 7 S t i f f n e s s i i n t h e b a c k and b o t h l e g s Weakness i n t h e l e g s 5 5 - 5 6 0 0 No l e g weakness 1 1 Weakness i n b o t h l e g s 2 2 Weakness i n l e f t l e g 3 3 Weakness i n r i g h t l e g 146 One month b e f o r e f u s i o n Now Changes i n f e e l i n g i n l e g s 57-58 0 0 No changes 1 1 Change i n f e e l i n g i n r i g h t l e g 2 2 Change i n f e e l i n g i n l e f t l e g 3 3 Change i n f e e l i n g i n b o t h l e g s 4 4 Change i n f e e l i n g i n o t h e r p a r t s A b i l i t y t o manage D a i l y L i f e H o u s e h o l d c h o r e s . Mark t h e one t h a t i n d i c a t e s t h e most d i f f i c u l t o f t h o s e l i s t e d t h a t you manage 59-60 o 0 Cannot manage a n y t h i n g 1 1 Wash ing up 2 2 C o o k i n g 3 3 C l e a n i n g k i t c h e n 4 4 C l e a n i n g and t i d y i n g house 5 5 M a k i n g b e d s 6 6 Washing o r p o l i s h i n g f l o o r s 7 7 C a r r y i n g a h e a v y o b j e c t s u c h as a s u i t c a s e 8 8 M o v i n g h e a v y f u r n i t u r e 9 9 D o i n g h e a v y d i g g i n g i n t h e g a r d e n o r s i m i l a r W a l k i n g 61-62 0 0 No l i m i t t o w a l k i n g 1 I I have t o s t o p a f t e r a b o u t a h a l f m i l e b e c a u s e o f d i s c o m f o r t 2 2 1 c a n o n l y w a l k 2-3 b l o c k s b e f o r e I must r e s t 3 3 1 c a n o n l y w a l k v e r y s h o r t d i s t a n c e s , b u t c a n manage s t a i r s and g e t na round t h e house 4 4 1 c a n n o t manage s t a i r s 5 5 1 need h e l p t o move even i n t h e h o u s e 6 6 1 have t o u s e a w h e e l c h a i r C a r i n g f o r y o u r s e l f — mark t h e most you c a n do 63-64 0 0 U n a b l e t o l o o k a f t e r m y s e l f 1 I I c a n f e e d and wash m y s e l f b u t need h e l p d r e s s i n g 2 2 I am a b l e t o do t h e a b o v e ; I c a n c u t my own t o e n a i l s 3 3 1 c a n d r e s s m y s e l f c o m p l e t e l y b u t need h e l p w i t h some t h i n g s 4 4 I am t o t a l l y i n d e p e n d e n t S i t t i n g , g e t t i n g up 65-66 0 0 N e i t h e r o f t h e s e g i v e s me any d i s c o m f o r t 1 I I c a n s i t down b u t g e t t i n g up f r o m t h e s i t t i n g p o s i t i o n may h u r t 2 2 G e t t i n g up does n o t h u r t b u t a c t u a l l y s i t t i n g may h u r t 3 3 B o t h s i t t i n g down and g e t t i n g up may h u r t 4 4 B e c a u s e o f d i f f i c u l t y I need h e l p w i t h s i t t i n g down and r i s i n g f r o m a c h a i r P i c k i n g t h i n g s up o f f t h e f l o o r 67-68 0 0 1 c a n p i c k t h i n g s up o f f t h e f l o o r w i t h o u t d i f f i c u l t y 1 1 B e n d i n g h u r t s , b u t I c a n s t r a i g h t e n up w i t h o u t d i f f i c u l t y 2 2 1 c a n g e t down t o p i c k s o m e t h i n g up b u t s t r a i g h t e n i n g up h u r t s 3 3 B o t h b e n d i n g and s t r a i g h t e n i n g up h u r t 4 4 B e c a u s e o f d i s c o m f o r t I j u s t c a n ' t p i c k t h i n g s up o f f t h e f l o o r 147 One month b e f o r e f u s i o n Now M a r i t a l s t a t u s 6 9 - 7 0 0 0 S i n g l e M a r r i e d (one m a r r i a g e o n l y ) M a r r i e d ( I have b e e n m a r r i e d more t h a n once) S e p a r a t e d D i v o r c e d Widowed Engaged t o be m a r r i e d 'Common- law ' ( l i v i n g t o g e t h e r , n o t m a r r i e d ) M a r i t a l r e l a t i o n s h i p ( i n c l u d e s common-law p a r t n e r s h i p ) 7 1 - 7 2 0 0 S i n g l e a t p r e s e n t Happy and f a i r l y s e c u r e i n my p r e s e n t r e l a t i o n s h i p F a i r l y h a p p y , b u t q u i t e o b v i o u s u p s and downs Our r e l a t i o n s h i p i s n o t v e r y good We a r e l i k e l y t o s p l i t up s o o n Sp-x-nal 1 i f p - g p n p , r a 1 — Mark t h e one t h a t mos t a p p l i e s t o you 7 3 - 7 4 0 0 N o r m a l — no p r o b l e m a t a l l B a c k p a i n n e c e s s i t a t e s t h e u s e o f c e r t a i n p o s i t i o n s F r e q u e n c y i s g r e a t l y l i m i t e d b y b a c k p a i n B o t h o f t h e above a r e t r u e (1 and 2) I n t e r c o u r s e i s n o t p o s s i b l e b e c a u s e o f some o t h e r i l l n e s s o r d i f f i c u l t y i n e i t h e r p a r t n e r 1 1 2 2 3 3 4 4 5 5 6 6 7 7 1 1 2 2 3 3 4 4 1 1 2 2 3 3 4 4 0 0 1 1 2 2 3 3 4 4 0 0 1 1 2 2 3 3 0 0 1 1 22 2 3 3 4 4 5 5 6 6 7 7 S o c i a l a c t i v i t i e s — g o i n g ou t w i t h f r i e n d s ; t o p a r t i e s o r d a n c e s , e t c . 7 5 - 7 6 No l i m i t a t i o n f o r any r e a s o n No change i n t h e t y p e o f a c t i v i t i e s , b u t l e s s o f t e n b e c a u s e o f p a i n I have had t o change t o e a s i e r a c t i v i t i e s b e c a u s e o f b a c k p a i n I c a n do v e r y l i t t l e b e c a u s e o f p a i n I have had t o change a c t i v i t i e s f o r some o t h e r r e a s o n s F i n a n c i a l 77 -78 I am c o m f o r t a b l y o f f f i n a n c i a l l y I have no d e b t s , b u t w o u l d l i k e t o h a v e more money i n r e s e r v e I have some s m a l l d e b t s I am i n a f a i r l y s e r i o u s f i n a n c i a l p o s i t i o n Work 7 9 - 8 0 0 0 I am n o t w o r k i n g , b u t t h i s i s n o t b e c a u s e o f i l l n e s s I do n o t wo rk b e c a u s e o f i l l n e s s , b u t n o t b e c a u s e o f b a c k t r o u b l e I am a b l e t o c o n t i n u e my u s u a l w o r k w i t h o u t d i f f i c u l t y I f i n d my w o r k q u i t e d i f f i c u l t and u n c o m f o r t a b l e b e c a u s e o f my b a c k t r o u b l e I c a n o n l y wo rk p a r t t i m e b e c a u s e o f my b a c k t r o u b l e I have had t o change to a n e a s i e r j o b b e c a u s e o f t h i s b a c k t r o u b l e I have had t o change t o a n e a s i e r j o b f o r some o t h e r r e a s o n I am u n a b l e t o wo rk b e c a u s e o f my b a c k 148 One month b e f o r e f u s i o n Now , _ . ^ C a r d r i v i n g — mark t he answer most a p p r o p r i a t e t o you 8 1 - 8 2 0 0 I do n o t d r i v e (have n o t l e a r n e d t o ) 1 I I c a n n o t a t t h e moment d r i v e , b u t t h i s i s n o t c o n n e c t e d w i t h my b a c k 2 2 1 have no d i f f i c u l t y d r i v i n g a c a r 3 3 A l o n g c a r j o u r n e y c a u s e s u n r e a s o n a b l e d i s -c o m f o r t 4 4 1 c a n n o t t a k e l o n g c a r j o u r n e y s , and s h o u l d s t o p e v e r y % - l h o u r f o r a r e s t , e v e n s h o r t e r t r i p s a r e u n p l e a s a n t 5 5 1 c a n o n l y d r i v e l o c a l l y b e c a u s e o f d i s c o m f o r t 6 6 1 c a n n o t d r i v e a t a l l b e c a u s e o f d i s c o m f o r t R i d i n g i n a c a r o r b u s 8 3 - 8 4 0 0 1 h a v e no d i f f i c u l t y 1 I I have d i f f i c u l t y g e t t i n g i n o r r i d i n g bu t n o t due t o my b a c k t r o u b l e 2 2 1 f i n d i t h a r d t o g e t i n o r ou t o f a c a r o r b u s , b u t r i d i n g i s f a i r l y c o m f o r t a b l e 3 3 1 f i n d g e t t i n g i n and ou t f a i r l y e a s y , b u t t r a v e l l i n g i s u n c o m f o r t a b l e 4 4 1 f i n d b o t h g e t t i n g i n and ou t d i f f i c u l t and r i d i n g u n c o m f o r t a b l e 5 5 1 a v o i d t r a v e l l i n g i n a c a r o r bus wheneve r p o s s i b l e b e c a u s e of d i f f i c u l t y C h i l d r e n o r g r a n d c h i l d r e n a t home — mark t h a t most a p p r o p r i a t e 8 5 - 8 6 0 0 No c h i l d r e n unde r f i f t e e n a t home 1 1 I am a b l e t o wo rk and p l a y w i t h them and t o h e l p c a r e f o r them 2 2 1 have t o be c a r e f u l t h e y ' r e n o t t o o r o u g h ; I c a n n o t l i f t them 3 3 1 c a n do l i t t l e w i t h them — o n l y t a l k o r r e a d o r p l a y v e r y e a s y games 4 4 1 c a n n o t s h a r e a c t i v i t i e s w i t h them a t a l l S l e e p 8 7 - 8 8 0 0 1 s l e e p n o r m a l l y most n i g h t s 1 I I o f t e n h a v e d i f f i c u l t y g e t t i n g t o s l e e p b e c a u s e of d i s c o m f o r t 2 2 1 o f t e n have d i f f i c u l t y i n g e t t i n g t o s l e e p b u t d o n ' t know why 3 3 1 wake up e a r l y b e c a u s e of d i s c o m f o r t and c a n n o t g e t enough s l e e p 4 4 1 wake up e a r l y and c a n n o t g e t enough s l e e p b u t d o n ' t know why 5 5 A n o t h e r i l l n e s s o f m i n e i n t e r f e r e s withTimy sleep 6 6 1 c a n n o t s l e e p b e c a u s e o f i l l n e s s o r u p s e t o f a n o t h e r p e r s o n i n t h e f a m i l y 7 7 1 have d i f f i c u l t y s l e e p i n g a l l t h r o u g h t h e n i g h t b e c a u s e of my b a c k 149 One month b e f o r e f u s i o n Now I n g e n e r a l 8 9 - 9 0 0 0 1 e n j o y l i f e 1 I I e n j o y l i f e , b u t qu i t e a b i t l e s s t h a n I d i d b e f o r e t h i s b a c k t r o u b l e a r o s e 2 2 T h i s b a c k p r o b l e m i s enough t o s p o i l t h i n g s f o r me most o f t h e t i m e 3 3 L i f e i s o n l y j u s t t o l e r a b l e b e c a u s e o f t h i s b a c k ( o r l e g ) d i s c o m f o r t 4 4 1 have even t h o u g h t o f s u i c i d e b e c a u s e o f t h i s p r o b l e m 5 5 My en joymen t o f l i f e i s more a f f e c t e d by o t h e r p r o b l e m s Some o t h e r q u e s t i o n s  Any m a j o r a b d o m i n a l s u r g e r y 9 1 - 9 2 0 None 1 S u r g e r y f o r u l c e r i n s tomach o r duodenum 2 G a l l b l a d d e r o p e r a t i o n 3 K i d n e y o r b l a d d e r ov ma le o r g a n s 4 F e m a l e o r g a n s 5 B e c a u s e o f i n j u r y 6 B o w e l s u r g e r y 7 Two o f t he above 8 T h r e e o f t h e above 9 F o u r o f t h e above S tomach t r o u b l e — mark o n l y one 93 -94 0 No t r o u b l e 1 O c c a s i o n a l i n d i g e s t i o n o r h e a r t b u r n — no m e d i c a t i o n needed 2 F a i r l y f r e q u e n t i n d i g e s t i o n o r h e a r t b u r n — I t a k e s tomach m e d i c i n e s 3 Q u i t e bad i n d i g e s t i o n o r h e a r t b u r n — I ' v e had t o have t r e a t m e n t f r o m a d o c t o r 4 D i a g n o s i s o f u l c e r made by t h e d o c t o r , and t r e a t m e n t g i v e n 5 I ' v e had t r e a t m e n t i n h o s p i t a l f o r an u l c e r once ( b u t n o t s u r g e r y ) 6 I ' v e had t r e a t m e n t i n h o s p i t a l more t h a n once (bu t n o t s u r g e r y ) 7 I ' v e had a b l e e d i n g u l c e r 8 I ' v e had a p e r f o r a t e d u l c e r 9 I ' v e had s u r g e r y f o r my u l c e r - - S k i n d i s e a s e s 9 5 - 9 6 0 Se ldom o r n e v e r 1 P s o r i a s i s 2 F r e q u e n t r a s h e s o r i t c h i n g now 3 I ' v e had p r o b l e m s w i t h my s k i n s i n c e c h i l d h o o d 150 E s t i m a t i o n o f R e s u l t s R a t e on t h e l i n e b e l o w w i t h a s i n g l e s t r o k e o f y o u r pen t h e s u c c e s s o f y o u r l a s t f u s i o n o p e r a t i o n . E x t r e m e l y p o o r E x t r e m e l y good ( s c o r e d ou t o f 100) 151 Back Surgery Form Dr. Kokan - Wing JDate of examination 2 Hospital . 3-8 Patient's chart number DVA, Pension or WCB number 9-10 Age in years at examination 11-12 Age in years at last fusion 13-14 Age in years at onset of symptoms 15 Sex 1 Male 2 Female 16 Place of birth 0 B.C. 1 Canada other than B.C. 2 United Kingdom 3 Northern or Western Europe 4 South, Central or Eastern Europe 5 Middle East (e.g., Israel, Lebanon, India) 6 Far East (e.g., Chinese, Japanese) 7 British Commonwealth 8 America (U.S.) 9 Other 17 Cultural background (of parents, grandparents or of childhood surroundings) 0 North American - 1 French or French Canadian 2 British (would include Commonwealth) 3 Mediterranean (Italian, Spanish, etc., include S. America) 4 Indian, Pakistani or similar 5 Chinese, Japanese or similar 6 Northern or Western European 7 Central or Eastern European 8 African 9 Other 18 Education 0 Illiterate 1 Incomplete primary 2 Complete primary 3 Incomplete secondary 4 Complete secondary 5 Trade or business training 6 Professional training not included in 5 7 University - bachelor's degree or similar 8 University - further training beyond bachelor's degree 9 Other 152 Occupation 19-20 Professional or equivalent Time of fusion Now 0 0 Not in this category 1 1 Medical, dental, veterinary, osteopathic 2 2 Legal (include jurists) 3 3 Architect 4 4 Engineering (at consultant or design level) 5 5 Teaching 6 6 Government (senior position, department head, etc.) 7 7 Major executive in commerce 8 8 High, rank in military field, police or transport fields 9 9 Other professional or equivalent 21-22 Technical, skilled, clerical 0 1 2 3 4 5 6 7 8 9 23-24 Others 0 1 2 3 4 5 6 7 8 9 0 Not in this category 1 Paramedical - nurses, technicians 2 Banking (management or supervising) 3 Creative writers (authors, journalists, etc.) and performing artists 4 Photographers, artists, sculptors, commercial artists 5 Salesmen (excluding major executives and sales clerks) 6 Clerical 7 Skilled workers, servicing (e.g., electrician, plumber) 8 Agricultural (farmers, forestry, fishing, hunting) 9 Police & military personnel except highest ranks 0 Not in this category 1 Sales clerks 2 Production workers (manufacture or assembly) 3 Transport or vehicle operators and ancil-lary personnel 4 Construction workers 5 Catering and ancillary personnel 6 Housewife 7 Unskilled labour 8 Student 9 Other not categorized - please specify 153 2 5 - 2 6 O c c u p a t i o n changes mos t r e c e n t l y B e f o r e f u s i o n 0 1 2 A f t e r f u s i o n - 0 1 2 None (no change ) P r o m o t i o n i n a s i m i l a r j o b Change t o a d i f f e r e n t j o b , as advancement Change t o a d i f f e r e n t j o b f o r r e a s o n s o t h e r t h a n i l l n e s s Change t o a d i f f e r e n t j o b b e c a u s e o f b a c k d i s a b i l i t y Change t o a d i f f e r e n t j o b b e c a u s e o f o t h e r i l l n e s s C e s s a t i o n o f employment f o r age r e t i r e m e n t C e s s a t i o n o f employment b e c a u s e o f b a c k d i s a b i l i t y C e s s a t i o n o f employment b e c a u s e o f o t h e r r e a s o n s 2 7 - 2 8 Number o f j o b changes 2 9 . T ime l o s s i n l a s t 2 y e a r s 30 B e f o r e A f t e r 0 - None f u s i o n f u s i o n 1 - L e s s t h a n 1 week 0 0 None 2 - L e s s t h a n 1 month 1 1 1 3 L e s s t h a n 2 months 2 2 2 4 L e s s t h a n 4 months 3 3 3 5 L e s s t h a n 6 months 4 4 4 6 L e s s t h a n 1 y e a r 5 5 5 7 L e s s t h a n 18 months 6 6 6 8 L e s s t h a n 2 y e a r s 7 7 7 9 Unemployed 8 8 8 9 9 More t h a n 8 T ime o f f wo rk p r i o r t o l a s t f u s i o n ^ ' (or o p e r a t i o n i f no f u s i o n ) 0 No o p e r a t i o n 1 L e s s t h a n 1 month. 2 L e s s t h a n 2 m o n t h s 3 L e s s t h a n 4 mon ths 4 L e s s t h a n 6 months 5 L e s s t h a n 1 y e a r 6 L e s s t h a n 2 y e a r s 7 L e s s t h a n 4 y e a r s 8 L e s s t h a n 10 y e a r s 9 More t h a n 10 y e a r s 31 T ime o f r e t u r n t o wo rk a f t e r l a s t f u s i o n (or o p e r a t i o n i f no f u s i o n ) 0 1 2 3 4 5 6 7 8 9 No o p e r a t i o n L e s s t h a n L e s s t h a n L e s s t h a n L e s s t h a n L e s s t h a n L e s s t h a n mon th months months mon ths y e a r y e a r s y e a r s L e s s t h a n L e s s t h a n 10 y e a r s More t h a n 10 y e a r s 154 32 Religion 0 No definite views 1 Atheist 2 Jewish 3 Roman Catholic 4 Buddhist 5 Hindu 6 Mohammedan 7 Other Oriental 8 Specific protestant sect or denomination 9 Other 'protestant' (include here Church-of England, etc.) 33 Activity in religious l i f e 0 Never 1 Once-twice yearly 2 'Occasional' 3 Regular attender at a place of religion (twice monthly or more) 4 'Deeply religious' 5 Active in organization of particular church 6 Minister of particular church 7 Considered a religious person but does not take part in an organized church 35 Avocation One month before fusion Now 0 0 1 1 2 2 3 3 5 5 6 6 Family History 36 Number of siblings of father 0 None 1 1 2 2 3 3 '4 4 5' 6 6 6 7 7 8 8 9 More than 8 None Athletics, competitive Athletics, non competitive Major sports (running, skiing, cycling, swimming) Minor sports (walking, jogging, hunting golf, fishing Creative (indoor, lighter work) Domestic maintenance, gardening, house care, etc. 37 Father and siblings of father with back trouble ' 0 None 1 Father 2 1 sibling of father 3 2 siblings of father 4 3 siblings of father 5 4 siblings of father 6 1 + 2 7 1 + 3 8 1 + 4 9 1 + 5 155 38 Number of siblings of mother 0 None 39 Mother and siblings of mother with back trouble 1 1 0 None 2. 2 1 Mother 3 3 2 1 sibling of mother 4 4 3 2 siblings of mother 5 5 4 3 siblings of mother 6 6 5 4 siblings of mother 7 7 6 1 + 2 8 8 7 1 + 3 9 More than 8 8 1 + 4 siblings . . . . 9 1 + 5 40-41 Number of children ^ At time of fusion Now 0 0 None 1 :. 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 9 9 More than 8 Number with back trouble . . Number of children with back trouble or pain Chow) 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More than 8 43 Number of children with leg pain 'rheumatism (now) 0 — 1 2 3 4 5 6 7 8 9 & or growing pains None 1 2 3 4 5 6 7 8 More than 8 44 Smoking habit 0 Non smoker 1 Mainly cigarettes - less than 10 daily 2 Mainly cigarettes - less than 20 daily 3 Mainly cigarettes - less than 40 daily 4 Mainly cigarettes ^ more than 40 daily 5 Mainly pipe - moderate: smoker 6 Mainly pipe - heavy smoker 7 Mainly cigar - moderate smoker 8 Mainly cigar - heavy smoker 9 Combination - fairly heavy 156 45 Alcohol usage 0 Teetotaller (abstainer) 1 Occasional drink - special occasions only 2 Occasional drink at home or social occasions 3 Drinks once or twice most weeks, in moderation 4 Drinks every week at least once as a major part of the evening's entertainment 5 Has an alcohol drink of some sort daily, may or may not drink more at times 6 Probably relies on alcohol beyond normal social use 7 Early alcoholic 8 Unequivocally alcoholic 9 Ex-alcoholic, or member of AA 46 Drug use - mark highest grade 0 None 1 Occasional soft drug user 2 Frequent or habitual soft drug user 3 Has had a conviction related to soft drugs 4 Occasional non-medical user of stimulants or tranquilizers 5 Frequent non-medical user of stimulants or tranquilizers 6 Occasional opiate or similar user 7 /Addict to opiate or similar drug 8 Ex-addict of opiate or similar drug 9 Other - specify 47 Other disease states (requiring major in or outpatient treatment) 0 None 1 C.N.S. (excluding psychiatric care) 2 Respiratory 3 Cardiovascular 4 Gastrointestinal excluding peptic ulcer disease 5 Genitourinary 6 Musculoskeletal 7 Two of above 8 Three of above 9 Four of above 48 Psychiatric care of personality disorder 0 Normal 1 Moderate or frequent tranquilizer use 2 Had psychiatric attention prior to fusion 3 Has had psychiatric attention since fusion 4 1 + 2 5 1 + 3 6 2 + 3 7 1 + 2 + 3 8 Currently in psychiatric ward 9 Other 157 49 H i s t o r y o f t rauma r e l a t e d t o o n s e t o f b a c k t r o u b l e 0 None 1 M i n o r ( l i f t i n g , a t w i s t ) 2 F a l l f r o m a l o w h e i g h t 3 F a l l f r o m a g r e a t e r h e i g h t 4 M a j o r i n j u r y * f r a c t u r e 5 R e p e a t e d s t r e s s o r m i n o r t r auma 6 War i n j u r y o r s i m i l a r ( b l a s t , G . S . W . , e t c . ) 7 A u t o a c c i d e n t 50 H i s t o r y o f o t h e r t r auma p r i o r t o o n s e t o f symptoms b u t u n r e l a t e d 0 None 1 Lower l i m b f r a c t u r e i n s p o r t s o r s i m i l a r a c c i d e n t 2 A u t o a c c i d e n t w i t h o u t f r a c t u r e o r m a j o r i n j u r y -3 A u t o a c c i d e n t w i t h f r a c t u r e o r m a j o r i n j u r y 4 B l a s t , G . S . W . , ' o r ' s i m i l a r 5 F a l l f r o m a l o w h e i g h t 6 M a j o r f a l l 7 Two o f above 8 T h r e e o f above 51 R e s i d u a l d i s a b i l i t y f r o m o t h e r t rauma (50) 0 No r e s i d u a l 1 M i l d r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y 2 M o d e r a t e r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y - u n p e n s i o n e d 3 S e v e r e r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y - u n p e n s i o n e d 4 M o d e r a t e r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y - p e n s i o n e d 5 S e v e r e r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y - p e n s i o n e d 52 T o t a l number o f h o s p i t a l a d m i s s i o n s f o r b a c k  0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 53 T o t a l number o f o p e r a t i o n s on b a c k 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 M o r e t h a n 8 158 54 T o t a l number o f f u s i o n o p e r a t i o n s 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 56 Number o f r e f u s i o n s o f any l e v e l 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 55 T o t a l number o f l a m i n e c t o m i e s 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 57 C o m p l i c a t i o n s o f any and a l l b a c k o p e r a t i o n s 0 None 1 Wound i n f e c t i o n (deep) 2 Wound i n f e c t i o n ( s u p e r -f i c i a l ) 3 Hematoma 4 R o o t damage o r i r r i t a t i o n 5 P s e u d a r t h r o s i s 6 Shock 7 C h e s t o r a b d o m i n a l p r o b l e m s 8 More t h a n 1 o f t h e above ( s p e c i f y ) 9 O t h e r 58 C o m p l i c a t i o n s o f l a s t f u s i o n o p e r a t i o n 0 None 1 - Wound i n f e c t i o n (deep) 2 Wound i n f e c t i o n ( s u p e r f i c i a l ) 3 Hematoma 4 R o o t damage o r i r r i t a t i o n 5 P s e u d a r t h r o s i s 6 Shock 7 C h e s t o r a b d o m i n a l p r o b l e m s 8 More t h a n 1 o f t h e above ( s p e c i f y ) 9 O t h e r 59 G e n e r a l a p p e a r a n c e - most p r e d o m i n a n t f e a t u r e 0 N o r m a l , h e a l t h y 1 V e r y m u s c u l a r , n o t o v e r w e i g h t 2 O v e r w e i g h t f o r h e i g h t 3 A p p e a r s v e r y t h i n 4 P a l e , u n h e a l t h y l o o k i n g 9 O t h e r 159 60 B l o o d P r e s s u r e 0 N o r m a l 1 Low ( s y s t o l i c l e s s t h a n 100 mm) 2 H i g h ( d i a s t o l i c o v e r 90 mm) 3 V e r y h i g h ( d i a s t o l i c o v e r 120 mm) 6.2 H a i g h t i n icent j - f f ie ters 1 L e s s t h a n 120 2 121-130 3 131-140 4 141-150 5 151-160 6 161-170 7 171—180"J 8 181-190 9 M o r e t h a n 190 63 ENT 0 1 2 (4'0" - 4'3") (4'3%" - 4 '7") (4'7%" - 4'11") C 4 ' l l ¥ * - 5*3") (5*33* ~ 5*7") C5'7ig" - 5*11") C 5 ' l l % - 6'3") 64 C h e s t 61. W e i g h t i n k i l o s 1 L e s s t h a n 40 ( unde r 88 l b s ) 2 41-50 ( 89-110 l b s ) 3 51-60 (111-132 l b s ) 4 61-70 (133-154 l b s ) 5 71-80 (155-176 l b s ) 6 81-90 (177-198 l b s ) 7 91-100 (199-220 l b s ) 8 101-110 (221-242 l b s ) 9 More t h a n 110 (mare than 243) n o r m a l a b n o r m a l ( s p e c i f y ) n o t done 65 H e a r t 0 n o r m a l 1 a b n o r m a l ( s p e c i f y ) 2 n o t done 0 n o r m a l 1 a b n o r m a l ( s p e c i f y ) 2 n o t done 66 Abdomen 0 n o r m a l 1 o b e s e 2 2 o r more s c a r s 3 h e r n i a o f any t y p e 4 1 + 2 5 1 + 3 6 2 + 3 7 1 + 2 + 3 8 O t h e r more s e r i o u s a b n o r m a l i t y r e q u i r i n g r e f e r r a l 9 n o t done 67 R e c t a l 0 n o r m a l 1 f i s s u r e a n d / h e m o r r h o i d s 2 c o c c y g e a l t e n d e r n e s s 3 a b n o r m a l i t y o f p r o s t a t e , s a c r o t u b e r o u s l i g a m e n t o r o t h e r deep s t r u c t u r e ( s p e c i f y ) 4 1 + 2 5 1 + 3 6 2 + 3 7 1 + 2 + 3 8 O t h e r more s e r i o u s a b n o r m a l i t y r e q u i r i n g r e f e r r a l 9 No t done ( t h i s s h o u l d n o t be m a r k e d ' ) 160 68 Pelvic 69 0 normal 1 abnormal (specify) 2 not done 70 Stance 71 0 normal 1 l i s t to right 2 l i s t to left 3 l i s t forward 4 l i s t backward 9 other (specify) 72 Lumbar curve 0 normal lordosis 1 exaggerated lordosis 2 flattened lordosis 3 kyphosis 4 scoliosis convex to right 5 scoliosis convex to left 6 1 + 4 7 1 + 5 8 2 + 4 9 2 + 5 74 Abdominal muscle tone 0 normal 1 obese, fair tone 2 not obese, but poor tone 3 obese, poor tone Gait 0 normal 1 limping R. leg 2 limping L. leg 3 difficulty in both legs 4 unable to walk 5 unable to stand 9 other (specify) Pelvic t i l t 0 normal 1 right side up 2 left side up 73 Paravertebral muscle tone 0 normal 1 right paravertebral muscle spasm 2 left paravertebral muscle spasm 3 . 1 + 2 9 other (specify) 75 Cervical spine range of motion 0 normal for age 1 limited flexion 2 limited extension 3 limited t i l t and/or rotation to right 4 limited t i l t and/or rotation to left 5 1 + 3 6 1 + 4 7 2 + 3 8 2 + 4 9 virtually or completely ankylosed 161 76 Cervical spine - other 0 1 2 4 5 6 7 9 normal posterior muscle abnormal tone tenderness on axial compression (over vertex) localized tenderness over cervical spine 1 + 2 1 + 3 2 + 3 1 + 2 + 3 other Cspecify) 77 Upper limbs (either) 0 normal 1 limitation of shoulder movement 2 crepitus in shoulder region on motion 3 neurological impair-ment of some type in limb 4 1 + 2 5 1 + 3 6 2 + 3 7 1 + 2 + 3 9 other (specify) 78 Thoracic spine 0 normal 1 abnormal curve (specify type) 2 limited rotation 3 marked tenderness (specify where) 4 1 + 2 5 1 + 3 6 2 + 3 7 1 + 2 + 3 9 other (specify) 79 Lumbar spine ROM flexion measure C-j ference in CMS to S1 dif-0 More than 8 1 7-1 - 8 cms 2 6-1 - 7 cms 3 5-1 - 6 cms 4 4-1 - 5 cms 5 3-1 - 4 cms 6 2-1 - 3 cms 7 1-1 - 2 cms 8 less than 1 80 Flexion expressed differently 0 touch toes 1 below mid tibia 2 mid tibia 3 touches knees 4 mid thigh 5 0° 81 Spasm on flexion (of paravertebral muscles) 0 none 1 moderate 2 marked 82 Lumbar spine ROM extension 0 normal 1 20 - 30° 2 10 - 20° 3 less than 10° 4 0° 83 Pain on extension 0 1 no yes 162 84 ROM R i g h t f l e x i o n 0 n o r m a l 1 3 0 - 4 5 ° - k n e e j o i n t 2 1 5 - 3 0 ° - l o w e r t h i g h 3 l e s s t h a n 1 5 ° - m i d t h i g h 4 0 ° 85 ROM L e f t f l e x i o n 0 n o r m a l 1 3 0 - 4 5 ° - knee j o i n t 2 1 5 - 3 0 ° - l o w e r t h i g h 3 l e s s t h a n 1 5 ° - m i d t h i g h 4 QO 87 P a s s i v e H y p e r t e n s i o n t e s t 88 0 f u l l p a s s i v e h y p e r t e n s i o n p a i n f r e e 1 g i v e s s l i g h t p a i n a t n o r m a l l i m i t 2 m i l d p a i n on h y p e r e x t e n s i o n 3 m o d e r a t e p a i n 4 s e v e r e p a i n - r e l i e v e d b y f l e x i o n 5 g i v e s p a i n n o t e a s e d on f l e x i o n 89 P e r i p h e r a l p u l s e s - l o w e r l i m b s 90 0 n o r m a l 1 m i l d d e c r e a s e r i g h t 2 marked d e c r e a s e r i g h t 3 m i l d d e c r e a s e l e f t 4 marked d e c r e a s e l e f t 5 m i l d b i l a t e r a l d e c r e a s e 6 more marked b i l a t e r a l d e c r e a s e L e g l e n g t h 0 e q u a l 1 r i g h t s h o r t e r by 1-5 cms 2 r i g h t s h o r t e r by 5 -10 cms 3 r i g h t s h o r t e r by o v e r 10 cms 4 l e f t s h o r t e r by 1-5 cms 5 l e f t s h o r t e r b y 5 - 1 0 cms 6 l e f t s h o r t e r by o v e r 10 cms. I n d i c a t e c a u s e 0 n o r m a l 1 r i g h t a b n o r m a l ( s p e c i f y ) 2 l e f t a b n o r m a l ( s p e c i f y ) 3 1 + 2 ( s p e c i f y ) 91 Knees 0 n o r m a l 1 r i g h t a b n o r m a l ( s p e c i f y ) 2 l e f t a b n o r m a l ( s p e c i f y ) 3 1 + 2 ( s p e c i f y ) 92 A n k l e s 0 n o r m a l 1 r i g h t a b n o r m a l ( s p e c i f y ) 2 l e f t a b n o r m a l ( s p e c i f y ) 3 1 + 2 ( s p e c i f y ) 93 R i g h t f o o t 94 L e f t f o o t 0 n o r m a l 0 n o r m a l 1 a b n o r m a l i t y o f a r c h 1 a b n o r m a l i t y o f a r c h 2 h a l l u x v a l g u s 2 h a l l u x v a l g u s 3 c l a w o r hammer t o e s ± 3 c l a w o r hammer t o e s c a l l u s e s + c a l l u s e s 4 1 + 2 4 1 + 2 5 1 + 3 5 1 + 3 6 2 + 3 6 2 + 3 7 1 + 2 + 3 7 1 + 2 + 3 9 o t h e r ( s p e c i f y ) 9 o t h e r ( s p e c i f y ) 163 96 Straight leg raising pain 0 none (normal) 1 right 0-30 degrees 2 right 30-60 " 3 right 60-90 " 4 left 0-30 5 left 30-60 6 left 60-90 7 both legs - 0-30 degrees 8 both legs 30-60 " 9 both legs 60-90 97 Bowstring sign Cpressure over 98 Musele wasting more than taut popliteal nerve) 2 cms 0 negative bilaterally 0 none 1 positive left 1 right thigh 2 positive right 2 left thigh 3 bilaterally positive 3 right calf 4 left calf 5 1 + 3 6 2 + 3 7 1 + 4 8 2 + 4 9 other (specify) 99 Muscle wasting-continued 0 none 1 right extensor digitorum brevis 2 left 3 right anterior calf muscles 4 left anterior calf muscles 5 1 + 3 6 2 + 3 7 1 + 4 8 2 + 4 9 other (specify) 101 Ability to l i f t upper body off table - legs secured 0 normal - fairly easily 1 with difficulty - a l l the way 2 moderate difficulty - only part way 3 marked difficulty - only just able to move 4 unable to rise off table 95 Sacroiliac stress (Gaenslen's test) 0 normal 1 right positive 2 left positive 3 1 + 2 100 Abdominal - able to l i f t straight legs 10 cm off table? 0 yes 1 no 164 102 B a c k a b l e t o l i f t b u t t o c k s o f f t a b l e when s u p i n e 0 y e s - n o r m a l l y and e a s i l y 1 w i t h some d i f f i c u l t y r e m a i n s e x t e n d e d 2 m o d e r a t e d i f f i c u l t y - c a n n o t s u s t a i n i t 3 marked d i f f i c u l t y - u n a b l e t o r a i s e b u t t o c k s f r o m t a b l e 103 H i p f l e x o r s 104 H i p e x t e n s o r s 105 H i p a b d u c t o r s 109 112 L R L R L R 0 0 g r a d e 5 0 0 g r a d e 5 0 0 g r a d e 5 1 1 ti 4 1 1 " 4 1 1 " 4 2 2 II 3 2 2 „ 3 2 2 " 3 3 3 II 2 3 3 " 2 3 3 „ 2 4 4 it 1 4 4 " 1 4 4 " 1 5 5 no f u n c t i o n 5 5 no f u n c t i o n 5 5 no f u n c t i o n H i p a d d u c t o r s 107 Knee e x t e n s o r s 108 Knee f l e x o r s L R L R L R 0 0 g r a d e 5 0 0 g r a d e 5 0 0 g r a d e 5 1 1 II 4 1 1 " 4 1 1 " 4 2 2 it 3 2 2 „ 3 2 2 " 3 3 3 II 2 3 3 2 3 3 2 4 4 II 1 4 4 " 1 4 4 " 1 5 5 no f u n c t i o n 5 5 no f u n c t i o n 5 5 no f u n c t i o n F o o t d o r s i f l e x o r s 110 F o o t p l a n t a r f l e x o r s 111 F o o t e v e r t o r s L R L R L R 0 0 g r a d e 5 0 0 g r a d e 5 0 0 g r a d e 5 1 1 II 4 1 1 " 4 1 1 " 4 2 2 II 3 2 2 " 3 2 2 " 3 3 3 it 2 3 3 " • 2 3 3 " 2 4 4 II 1 4 4 " 1 4 4 " 1 5 ' 5 no f u n c t i o n 5 5 no f u n c t i o n 5 5 no f u n c t i o n G r e a t t o e e x t e n s i o n 113 G r e a t t o e f l e x i o n L R L R 0 0 g r a d e 5 0 0 g r a d e 5 1 1 II 4 1 1 " 4 2 2 it 3 2 2 " 3 3 3 II 2 3 3 " 2 4 4 II 1 4 4 " 1 5 5 no f u n c t i o n 5 5 no f u n c t i o n 165 114 Deep t e n d o n r e f l e x - knee 0 n o r m a l 1 r i g h t i n c r e a s e d 2 r i g h t d e c r e a s e d 3 r i g h t a b s e n t 4 l e f t i n c r e a s e d 5 l e f t d e c r e a s e d 6 l e f t a b s e n t 7 b o t h i n c r e a s e d 8 b o t h d e c r e a s e d 9 b o t h a b s e n t 115 Deep t e n d o n r e f l e x - a n k l e 0 n o r m a l 1 r i g h t i n c r e a s e d 2 r i g h t d e c r e a s e d 3 r i g h t a b s e n t 4 l e f t i n c r e a s e d 5 l e f t d e c r e a s e d 6 l e f t a b s e n t 7 b o t h i n c r e a s e d 8 b o t h d e c r e a s e d 9 b o t h a b s e n t 116 P l a n t a r r e f l e x 0 n o r m a l 1 r i g h t u p g o i n g 2 l e f t u p g o i n g 3 b o t h u p g o i n g 117 A b d o m i n a l r e f l e x 0 ' n o r m a l 1 a b s e n t r i g h t 2 a b s e n t l e f t 3 a b s e n t b o t h s i d e s 4 a b n o r m a l b e c a u s e o f l o c a l d i s e a s e 118 C r e m a s t e r r e f l e x 0 n o r m a l 1 a b s e n t r i g h t 2 a b s e n t l e f t 3 a b s e n t b o t h s i d e s 4 a b n o r m a l b e c a u s e of l o c a l d i s e a s e 120 Type o f l o s s ( r i g h t ) 0 no l o s s 2 c o n f o r m s w e l l t o dermatome i n d i c a t e d 2 does n o t c o n f o r m t o e x p e c t e d dermatome 3 h y p e r e s t h e s i a 4 hypo o r a n e s t h e s i a 5 1 + 3 6 1 + 4 • 7 2 + 3 8 2 + 4 9 o t h e r ( s p e c i f y ) 119 S e n s a t i o n r i g h t - l e v e l o f i m p a i r m e n t  0 none 1 L 3 2 L4 3 L5 4 S I 5 S2 6 More t h a n 1 r o o t ( s p e c i f y ) 7 P e r i p h e r a l n e r v e l o s s ( s p e c i f y ) 121 S e n s a t i o n s l e f t t i l e v e l o f i m p a i r m e n t  0 none 1 L3 2 L4 3 L5 4 S I 5 S2 6 more t h a n 1 r o o t ( s p e c i f y ) 7 p e r i p h e r a l n e r v e l o s s ( s p e c i f y ) 166 122 Type of loss.(left) 0 no loss 1 conforms well to dermatome'indicated 2 does not conform to expected dermatome 3 hyperesthesia 4 hypo or anesthesia 5 1 + 3 6 1 + 4 7 2 + 3 8 2 + 4 • 9 other (specify) 123 Most prominent site of•tenderness 0 none 1 spinous process 2 S. 1. joint right 3 S. 1. joint left 4 right buttock 5 left buttock 6 right paravertebral muscles (specify level) 7 left paravertebral muscles (specify level) 8 greater trochanter (specify side) 124 Secondary site of tenderness 0 none 1 spinous process 2 S. 1. joint right 3 S. 1. joint left 4 right buttock 5 left buttock 6 right paravertebral muscles (specify level) 7 left paravertebral muscles (.specify level) 8 . greater trochanter (specify side) 9 other (specify) 125 Spinous process tenderness level (if not localized, give central level) 0 no spinous process tenderness 1 LI 2 L2 3 L3 4 L4 5 L5 6 SI 7 over a spinous process but obviously more superficial in scar 9 other (specify) 167 126 M o t i v a t i o n f o r s u r g e r y 0 no s u r g e r y 1 p a t i e n t demanded i t 2 p a t i e n t i n i t i a l l y r e f u s e d i t 3 s u r g e o n s u g g e s t e d i t , a f t e r f a i l u r e o f c o n s i d e r a b l e c o n -s e r v a t i v e t h e r a p y 4 s u r g e o n s t r o n g l y s u g g e s t e d i t , a f t e r l i t t l e c o n s e r v a t i v e t h e r a p y 9 o t h e r ( s p e c i f y ) 127 P a t i e n t ' s o p i n i o n o f s u r g e r y 0 no s u r g e r y 1 pe rmanen t d e f i n i t e improvement 2 pe rmanen t p a r t i a l improvement 3 no improvement 4 t e m p o r a r y improvement f o r l e s s t h a n 2 y e a r s 5 t e m p o r a r y improvement f o r a l o n g e r p e r i o d o f t i m e 6 some w o r s e n i n g 7 d e f i n i t e l y w o r s e 9 o t h e r ( s p e c i f y ) 128 Under t h e same c i r c u m s t a n c e s , t h e p a t i e n t w o u l d now: 0 no s u r g e r y 1 a c c e p t s u r g e r y a g a i n 2 r e f u s e s u r g e r y a g a i n 3 u n d e c i d e d 129 P a t i e n t ' s u n d e r s t a n d i n g o f m a i n r e a s o n s f o r s u r g e r y 0 no s u r g e r y 1 does n o t know - p u r e l y on s u r g e o n ' s r ecommenda t i on 2 t o r e l i e v e p a i n 3 t o p r e v e n t f u r t h e r t r o u b l e 4 t o i m p r o v e weakness 5 t o i m p r o v e b a c k f u n c t i o n 9 o t h e r ( s p e c i f y ) 130 E x a m i n e r ' s o p i n i o n 0 no s u r g e r y 1 p a t i e n t d e f i n i t e l y i m p r o v e d 2 p a t i e n t p a r t i a l l y i m p r o v e d 3 w o r s e n i n g as a ; r e s u l t o f s u r g e r y 4 w o r s e n i n g as a r e s u l t o f p r o g r e s s i v e d i s c d i s e a s e 5 w o r s e n i n g a s a r e s u l t o f e m o t i o n a l d i s e a s e 7 t e m p o r a r y i m p r o v e m e n t , now w o r s e n i n g 9 o t h e r ( s p e c i f y ) S u r g e o n ' s p r e o p e r a t i v e d i a g n o s i s : 131 P a t h o l o g y f o u n d a t s u r g e r y ( l a s t o p e r a t i o n ) 0 no o p e r a t i o n 1 no a b n o r m a l i t y s e e n 2 b u l g i n g d i s c 3 h e r n i a t e d d i s c 4 p s e u d a r t h r o s i s 5 f i b r o s i s and s c a r r i n g i n c a n a l 6 c o n g e n i t a l anomaly ( i n c l u d e s p o n d y l o l y s i s ) 7 c o m b i n a t i o n o f more t h a n one o f above 8 s u r g e o n ' s r e p o r t n o t a v a i l a b l e 9 o t h e r ( s p e c i f y ) 168 132 Kissing vertebrae or instability 133 Pathological examination 0 neither 0 no surgery 1" kissing spines (specify level) 1 normal disc tissue 2 vertebral instability 2 degenerative disc 3 both of above 3 not available 4 no discectomy 5 no tissue examined 9 other (specify) Orthopaedists' Rating of Psychological Factors: All ratings are done on a 7-point continuum from.least to most 134 Ih your relationship Introvert 12 3 4 5 6 7 Extravert Introvert = shy, withdrawing, socially uncomfortable 135 Dependent 12 3 4 5 6 7 Independent Dependent = subject seems to get some sort of emotional gratification and clings to you like a child might 136 Passive - Agressive not at a l l 12 3 4 5 6 7 very much so P.A. (very much so) = patient complies with your requests that apparently displease him, but you get the impression he's "getting back at you" by not complying fully 137 Submissive 12 3 4 5 6 7 Dominant Submissive = patient acceptingly goes along with a l l your requests, allows you to initiate topics Dominant = patient tries to 'steer' parts of the discussion and/or examination 138 Eagerness in recounting his troubles l i t t l e 12 3 4 5 6 7 very 139 Emotionality in recounting troubles (is he like a bleeding-heart) l i t t l e 12 3 4 5 6 7 very 140 Anxiety in approaching you as authority or father figure l i t t l e 12 3 4 5 6 7 very much 141 Anxiety in the stage or course of his pathology l i t t l e 12 3 4 5 6 7 very much l i t t l e = indifference 142 Estimatelof-verbal ability low 12 3 4 5 6 7 high 169 143 Estimate of I.Q. IQ has a mean of 100, standard deviation of 15 low C70) 12 3 4 5 6 7 high 130 'normal average' Cold tolerance time seconds State right or left hand Comment on patient's reaction 170 •Back S u r g e r y S t u d y - X - r a y A s s e s s m e n t Form D r . P e t e r Wing P a t i e n t I . D . Coumn C a r d 1 2 H o s p i t a l 3 -8 R e c o r d Number 9 -13 D,V,A,M W , C . B . o r o t h e r number 9 -13 X - r a y Number 14 Number o f v e r t e b r a e 1 - 4 d i s t i n c t l umbar v e r t e b r a e 2 - 5 3 - 6 4 - i n c o m p l e t e t r a n s i t i o n of a s i x t h l umbar v e r t e b r a 5 - h e m i v e r t e b r a D e s c r i b e a n o m a l i e s : 15 S a c r a l a n o m a l i e s 0 - none 1 - c o n g e n i t a l D e s c r i b e : 2 - a c q u i r e d 16 S e p a r a t e f a c e t e p i p h y s e s 0 - none 4 - L4 1 - L I 5 - L5 2 - L2 6 - S I 3 - L3 7 - a c o m b i n a t i o n ( s p e c i f y ) S t a t e s i d e , w h e t h e r s u p e r i o r o r i n f e r i o r f a c e t : 171 Column 17 18 19 20 Scoliosis 0 - none Describe and measure: 1 - 10-20° 2 - over 20° Spondylolysis (specify side) 0 - none 4 - L4 1 - LI 5 - L5 2 - L2 6 - SI 3 - L3 7 - other Spondylolisthesis (specify type by cause if possible) 0 - none seen 1 - grade 1 2 - grade 2 3 - grade 3 4 - grade 4 Osteoporosis 0 - none seen 1 - grade 1 2 - grade 2 3 - grade 3 4 - grade 4 5 - grade 5 6 - localized osteopenia (specify) 172 Column 21 Fracture 0 - none Describe type and level 1 - probably old 2 - probably new 22 Myelogram dye 0 T- none seen 1 - few drops 2 - moderate amount 23 Evidence of laminectomy (posterior with bone removal - describe) 0 - none seen 1 - LI 2 - L2 3 - L3 24 Evidence of fusion 0 - none seen 1 - posterior bone block 2 - Boucher's type 3 - posterolateral 4 - apophyseal screws 25 Level of fusion 0 - no fusion 1 - L5S1 2 - L4S1 3 - L3S1 4 - L2S1 4 - L4 5 - L5 6 - SI 7 - combination (specify) 5 - anterior interbody 6-1 + 2 .7.-1 + 4 8 - other combinations (specify) 9 - other types (specify) 5 - L4-5 6 - L3-5 7 - L3-4 9 - other (specify) 173 Column 26 Solidity of fusion 0 - no fusion 1 - solid fusion 2 - pseudarthrosis (specify level(s) and criteria) 27 Screws number present 0 - none 4 - 4 1- 1 5 - 5 2- ^2 6-6 3- 3 7 - more than 6 28 Screws abnormalities 0 - none 1 - normal 2 - bent 3 - broken 29 Schmorl's nodes 0 - none (specify level and describe) 1 - one site 2 - -more than one site 30 Knutsson's sign 0 - not seen 1 - L5S1 only 2 - other sites (specify) 174 Column 31 Posterior joint degeneration 0 - none (specify site(s) and side) 1- 1 level, 1 side 2- 1 level, bilateral 3 - more than 1 level 32 Traction spurs of anterior longitudinal ligament 0 - none 1 - present at 1 site 2 - present at more than 1 site Specify levels and position 33 Osteophytes 0 - none 1 - localized 1 site 2 - more than 1 site Detail sites 34 Ligamentous calcification 0 - none 1 - localized 1 level 2 - more than 1 level Specify position and site 35 Kissing vertebral spines (Baastrup's phonemenon) 0 - none (specify levels) 1- 1 level 2- 2 levels 175 Column 35 ( c o n t i n u e d ) 3 - 3 l e v e l s 4- 4 l e v e l s 36 O t h e r s k e l e t a l p a t h o l o g y , e . g . , P a g e t ' s , C a . 0 - a b s e n t 1 - p r e s e n t 37-39 L u m b o s a c r a l a n g l e - d e g r e e s D i s c h e i g h t f r o n t b a c k 40-43 L12 44-47 L 2 3 4 8 - 5 1 L34 5 2 - 5 5 L45 5 6 - 5 9 L 5 S 1 P o s t e r i o r j o i n t s u b l u x a t i o n i n mm. a b o v e j o i n t - b o d y l i n e 6 0 - 6 1 L12 62-63 L23 64-65 L34 66-67 L45 R e t r o s p o n d y l o l i s t h e s i s ( i n mm, m e a s u r e d p o s t e r i o r l y ) 68 L12 69 L23 70 L34 7 1 L 4 5 72 L 5 S 1 Column Interpedicular distance in mm. 73-74 LI 75-76 L2 77-78 L3 79-80 L4 9-10 L5 Sagittal diameter of canal in mm. 11-12 LI 13-14 L2 15-16 L3 17-18 L4 19-20 L5 21-22 SI Body height Front Back LI L2 L3 L4 L5 APPENDIX D P s y c h o l o g i c a l D o c u m e n t a t i o n Forms 1) P s y c h o l o g i c a l I n t e r v i e w Form 2) D a t a Summary Form 178 "PSYCHOLOGICAL INTERVIEW FORM" Datum Name •- Date of examination Subj ect # Sex Male 1 Female 2 Date of birth / _ _ _ _ / / Blank Age in years Position in birth order, from oldest Position in birth order, i f : 1 oldest 2 intermediate 3 youngest 4 only child Province of birth 0 not Canada 6 Quebec 1 B.C. 7 N.B. 2 Alberta 8 N.S. 3 Sask. 9 P.E.I. 4 Manitoba 10 Nfld. 5 Ontario 11 - NVWTT. Size of community S_grew up in (use estimate of size i f several moves - most important between 10 and.leaving home) ; 1 <500 - 6 10,000 - 25,000 2 500 - 1,000 7 25,000 - 100,000 3 1,000 - 2,500' 8 >100,000 4 2,500 - 5,000 9 can't estimate, many moves 5 5,000 - 10,000 Occupation of father: 0 no father 1 farmer (owner) 2 own small business (like corner store) 3 own large business 4 professional (lawyer, doctor, engineer, etc.) 379 Datum 5 semi-professional (teacher, accountant) 6 clergy 7 salesman 8 blue-collar (clerk, agent, etc.) 9 minor supervisor (working) 10 service employee 11 laborer 12 unemployed 13 other 14 major supervisor Parents religious? 0 no 1 very 2 moderately 3 a l i t t l e 4 one parent no, other 1 or 2 5 very moral, but not religious (only i f given spontaneously) How did parents get along? 1-70 scale How happy was childhood? 1-70 scale Any member of family "sickly"? Indicate in separate columns up to 3 of: 0 none 5 grandparent 1 father 6 uncle, aunt 2 mother 7 cousin 3 same sexed sib. 8 unrelated member of household 4 opp. sexed sib. At what age did j3 leave home permanently? (years) Number of years of grade school completed 1 Number of years University 2 Months of vocational school 3 Years of apprenticeship In the three above, indicate completeness: 0 didn't do any of 1-3 1 completed 2 incomplete, withdrew (quit with l i t t l e reason) 3 incomplete, was ejected 4 moved down in order above and completed 180 Spaces Code Datum 5 moved down i n o r d e r above and d i d n ' t c o m p l e t e 6 moved up i n o r d e r above and c o m p l e t e d 7 moved up i n o r d e r above and d i d n ' t c o m p l e t e 8 w i t h d r e w due t o w a r , l a c k o f f u n d s 9 w i t h d r e w due t o h e a l t h , e m o t i o n a l r e a s o n s (1) What was f a v o r i t e s u b j e c t i n s c h o o l ? (code b e l o w ) (1) • What was mos t d i s l i k e d s u b j e c t i n s c h o o l ? 0 c a n ' t answer 1 m a t h 2 s c i e n c e 3 E n g l i s h o r a l a n g u a g e 4 h i s t o r y / g e o g r a p h y 5 c l e r i c a l 6 shop w o r k , a g r i c u l t u r e , home e c o n o m i c s 7 s p o r t s 8 a r t - p a i n t i n g , m u s i c , drama 9 o t h e r (1) R e l i g i o u s n e s s 0 n e v e r h a v e b e e n r e l i g i o u s 1 I a l w a y s h a v e b e e n r e l i g i o u s 2 h a v e changed t o more r e l i g i o u s 3 h a v e changed t o l e s s r e l i g i o u s 4 r e m a i n e d r e l i g i o u s , b u t changed f a i t h s (1) CU S e r v i c e 0 none 1 WW2 d i d n ' t s e e b a t t l e 2 WW2 d i d s e e b a t t l e 3 K o r e a d i d n ' t s e e b a t t l e 4 K o r e a d i d s e e b a t t l e 5 b o t h , d i d n ' t s e e b a t t l e 6 b o t h , d i d s e e b a t t l e 7 p e a c e t i m e f o r c e s o n l y (1) P r e s e n t m a r i t a l s t a t u s : 0 s ingle 3 separated l married 4 divorced 2 widowed 5 common-law CD P a s t m a r i t a l record Cexcluding the above) ( l ) 0 nothing to add 6 three or more separations CD 1 one divorce 7 one past common-law wife 2 two divorces 8 two or more past common-law wives 3 widowed once or more 4 one separation 9 refuses to t a l k 5 two separations 181 Spaces Code Datum (1) ' Status of present marital relationship: 0 there isn't one 1 ready to break up 2 would break up if not for children 3 stormy but will remain intact 4 Jindifferent 5 about average 6 above average 7 superb 9 refuses to discuss (2) • Sex l i f e 0 not exposed to one 1 l i t t l e interest, mutual 2 l i t t l e interest, spouse frigid or impotent 3 l i t t l e - spouse has other difficulty 4 l i t t l e — j3 not interested (frigid or impotent) 5 l i t t l e - because of S/s back 6 l i t t l e - because of S/s other troubles 7 moderate - mutual 8 moderate - spouse's lack of interest 9 moderate - spouse's other troubles 10 moderate - j3/s lack of interest 11 moderate - j3' s back 12 moderate - _S' s other troubles 13 all's well 14.4 rrevfuses to discuss (1) Number of children at home now 0-9 (9=9 or more) (1) Does S^  support anyone else? (1) 0 no (1) 1 pparent or grandparent' 2 parent or grandparent of spouse 3 sib. 4 sib. of spouse 5 removed relative 6 removed.relative of spouse 7 child of relative 8 child of spouse's relative 9 unrelated child or adult (1) Does j>' own home or apartment? 0 no 1 yes, large mortgage .$?.$10v000 2 yes, moderate mortgage 5-10,000 3 yes, small mortgage Ysi?5y000 4 yes, clear t i t l e 182 Spaces Code Datum (1) ' Has _S ever owned a home? 0 no 1 yes - had to give i t up for financial reasons 2 -yes = gave i t up because of other difficulties 3 yes - gave i t up for sake of convenience (2) ____ • Income to S/s family per month in $ 100s (Gross) (1) Source of income Cl) ____ 0 no income (for sources 2,3) d) l business ownership 2 investments 3 _S works 4 spouse works 5 pension 6 parents 7 children 8 welfare 9 S^  won't say (1) Does j3 think that personality or psychological status can have a bearing on the existence of or the experience of a back problem? 0 no •1 yes, a l i t t l e self^ I 2 yes, a moderate amount reference ) 3 yes, quite a bit 4 not now, but used to have a bit 5 not now, but used to have a moderate amount •6 not now, but used to have a lot to do with i t 7 not for self, but for others a bit 8 not for self, but for others a lot 9 j> will not give a direct answer Elaborate on back if thinks psych, status affects him (1) Has ^  ever had psychiatric attention? 0 no 1- 8 9= 9 or more times DSM-2 codes for major disorders (let 000 = no disorder) (3) (3) C2) When first psych, attention? (years ago) 183 Spaces Code Datum (2) When last psych, attention? (years ago; 0= < 1 yr. or none) (1) Has anyone in _S's family had psychiatric attention? (1) 0 no (1) ' 1 grandparent 2 parent 3 sib. 4 spouse 5 offspring 6 removed blood relative 7 in-law 8 unrelated "family" member (3) DSM-2 codes for the immediately above, in order given (3) (3) (1) How does S_ feel about taking part in this study? 0 no response 1 great dislike 2 minor dislike 3 indifferent 4 glad to help 184 " D a t a Summary F o r m " S u b j e c t #: C a t t e l l F o r m A : Raw S c o r e C a t t e l l Form A : IQ. s i g m a = 16 K i l p a t r i c k - C a n t r i l D a t a P a s t S t a n d i n g P r e s e n t S t a n d i n g '.(.00 - 100) F u t u r e S t a n d i n g T r e n d o v e r t i m e ( i f o n l y 2 p o i n t s , c o d e 1, 2 o r 3) = i A = 7 / = 2 V = 8 \ = 3 V = 9 A = 4 10 A = 5 V = 11 ~\ = 6 V_ - 12 / " - 13 B e c k I . D . S c o r e MMPI D a t a T - S c o r e s L F K Hs D Hy Pd P t Sc Ma Si Es Lb Mf Pa Taylor M.A. S. raw score CPI Data Standard Scores Do Cs Sy Sp Sa Wb Re So Sc To Gi Cm Ac Ai Ie Py Fx Fe 186 APPENDIX E O r t h o p a e d i c and P s y c h o l o g i c a l D o c u m e n t a t i o n Forms s h o w i n g : 1) The Code-Names o f a l l v a r i a b l e s , i n c a p i t a l l e t t e r s s u r r o u n d e d by q u o t a t i o n m a r k s , i n t h e l e f t m a r g i n s 2) D a t a r e - c o m b i n a t i o n s , i n d i c a t e d by t h e same number b e i n g a s s i g n e d t o s e v e r a l c a t e g o r i e s w i t h i n a v a r i a b l e 3) The l e v e l o f a n a l y s i s r e c e i v e d by e a c h v a r i a b l e , i n d i c a t e d by s u p e r s c r i p t numbers f o l l o w i n g t he Code-Names 1 t h e v a r i a b l e was c o r r e l a t e d w i t h t h e d i s a b i l i t y i n d e x 2 t h e v a r i a b l e was u s e d t o d e r i v e t h e d i s a b i l i t y i n d e x 3 t h e v a r i a b l e was f o u n d t o be a s i g n i f i c a n t c o r r e l a t e o f d i s a b i l i t y ^ t h e v a r i a b l e was f o u n d t o be a s i g n i f i c a n t c o r r e l a t e o f d i s a b i l i t y and e n t e r e d t h e f a c t o r a n a l y s i s w h i c h r e s u l t e d i n t h e b a s i c d i m e n s i o n s o f d i s a b i l i t y 187 Low B a c k P a i n - P a t i e n t S e l f - e v a l u a t i o n Form P a t i e n t Code Number I n s t r u c t i o n s : I n a l l c a s e s , p l a c e a r i n g r o u n d t h e number o p p o s i t e t h e one answer t h a t seems most a p p r o p r i a t e t o y o u . The co l umn on t h e l e f t r e f e r s t o t h e way you w e r e a p p r o x i m a t e l y one month b e f o r e y o u r f u s i o n o p e r a t i o n , t h e co lumn on t he r i g h t t o t h e way you a r e now. I f you have d i f f i c u l t y , p l e a s e a s k f o r h e l p . T r y and answer a l l t h e d i f -f e r e n t p a r t s . N a t u r e o f P a i n Now S e v e r i t y o f p a i n No p a i n M i l d p a i n , n o t a p r o b l e m P a i n a n n o y i n g , b u t f o r g o t t e n d u r i n g a c t i v i t y P a i n p r e s e n t , e v e n d u r i n g a c t i v i t i e s M o d e r a t e p a i n , i n t e r f e r e s w i t h a c t i v i e s o r s l e e p P a i n p r e v e n t s a c t i v i t y o r s l e e p S e v e r e p a i n , i s i m m o b i l i z i n g L o c a t i o n — l o w b a c k No p a i n i n l o w b a c k Low b a c k , i n t h e c e n t e r Low b a c k , on t h e l e f t m o s t l y Low b a c k , on t h e r i g h t m o s t l y Low b a c k g e n e r a l l y P a i n be tween s h o u l d e r b l a d e s — dp you have i t ? No O c c a s i o n a l l y O f t e n M o s t o f t h e t i m e P a i n i n t h e n e c k — do you have i t ? No O c c a s i o n a l l y O f t e n Most o f t h e t i m e 0 1 2 " S E V E R I T Y " 2 3 4 5 6 1 2 'LOWBACK" 4 2 " N E C K S " 4 1 " I N T E S C A P " 4 ^ 2 1 2 2 2 188 Location of p a i n i n buttocks or thighs No p a i n i n these places L e f t buttock Right buttock Both buttocks L e f t t h i g h Right t h i g h Both thighs L e f t buttock and t h i g h Right buttock and t h i g h Both buttocks and thighs Do you f e e l p a i n i n the t i p of your t a i l b o n e ? No O c c a s i o n a l l y Often Most of the time Do you get migraine or headaches? Seldom or never O c c a s i o n a l l y Frequently Location of p a i n i n legs and f e e t No pain here L e f t c a l f Right c a l f Both calves L e f t c a l f and foot Right c a l f and f o o t Both calves and f e e t L e f t h e e l and/or foot Right h e e l and/or fo o t Both heels and/or f e e t Factors A f f e c t i n g the P a i n Coughing, sneezing or s t r a i n i n g at s t o o l No p a r t i c u l a r e f f e c t on p a i n Improves or lessens p a i n Makes p a i n worse Have not t r i e d i t Cannot t e l l S i t t i n g i n an u p r i g h t or f i r m c h a i r No p a r t i c u l a r e f f e c t on p a i n Improves or lessens p a i n Makes p a i n worse Have not t r i e d i t Cannot t e l l 189 Now S i t t i n g i n a c o m f o r t a b l e o r r e c l i n i n g c h a i r 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n " R E C L I N E " 1 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Cannot t e l l L y i n g f l a t 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n " L Y I N G " 1 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Canno t t e l l W a l k i n g 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n "WALKING" 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Canno t t e l l B e n d i n g f o r w a r d o r s i d e w a y s 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n " B E N D I N G " 4 3 Makes p a i n w o r s e 2 Have no t t r i e d i t 2 Canno t t e l l L i f t i n g 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n " L I F T I N G " 4 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Cannot t e l l L y i n g c u r l e d up 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n " C U R L E D " 1 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Cannot t e l l H e a t o r warmth 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n " H E A T " 1 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Cannot t e l l 190 Now C o l d "COLD"^ " M A N I P " 1 " A N A L G E S " 1 "CORSET ,,1 " T I M E " " S T I F F " 4 " W E A K N E S S " 4 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Cannot t e l l M a n i p u l a t i o n by c h i r o p r a c t o r o r f r i e n d 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n 3 Makes p a i n w o r s e 2 Have no t t r i e d i t 2 Canno t t e l l S i m p l e p a i n p i l l s ( s u c h as a s p i r i n ) 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Canno t t e l l C o r s e t o r o r t h o p a e d i c t y p e b e l t 2 No p a r t i c u l a r e f f e c t on p a i n 1 Improves o r l e s s e n s p a i n 3 Makes p a i n w o r s e 2 Have n o t t r i e d i t 2 Cannot t e l l The t i m e o f day t h e p a i n i s w o r s t 1 No p a i n 2 The p a i n h a s no r e l a t i o n t o t h e t i m e of day 3 M o r n i n g 3 M i d d l e o f day 3 E v e n i n g 3 E v e n i n g and n i g h t 3 M o r n i n g and e v e n i n g 3 N i g h t 3 A l l day 2 Day and n i g h t S t i f f n e s s 1 No s t i f f n e s s o r v e r y l i t t l e 2 S t i f f n e s s m o s t l y i n t h e b a c k 2 S t i f f n e s s m o s t l y i n t h e l e f t l e g 2 S t i f f n e s s m o s t l y i n t h e r i g h t l e g 3 S t i f f n e s s m o s t l y i n b o t h l e g s 2 S t i f f n e s s i n t h e b a c k and l e f t l e g 2 S t i f f n e s s i n t h e b a c k and r i g h t l e g 3 S t i f f n e s s i n t h e b a c k and b o t h l e g s Weakness 1 No l e g weakness 3 Weakness i n b o t h l e g s 2 Weakness i n l e f t l e g 2 Weakness i n r i g h t l e g 191 Now Changes i n f e e l i n g i n l e g s "SENSAT"1* "CHORES" 2 "MOBILE" 2 "INDEPEND ,,2 "CHAIR" 2 "FLOOR" 2 1 2 2 3 2 I 1 1 1 2 2 2 3 3 3 0 1 2 3 4 5 0 1 2 3 1 2 2 3 4 1 2 2 3 4 No changes Change i n f e e l i n g i n r i g h t l e g Change i n f e e l i n g i n l e f t l e g Change i n f e e l i n g i n b o t h l e g s Change i n f e e l i n g i n o t h e r p a r t s A b i l i t y t o manage D a i l y L i f e H o usehold c h o r e s . Mark the one t h a t i n d i c a t e s t h e most d i f f i c u l t o f t h o s e l i s t e d t h a t you manage Cannot manage a n y t h i n g Washing up Co o k i n g C l e a n i n g k i t c h e n C l e a n i n g and t i d y i n g house Making beds Washing o r p o l i s h i n g f l o o r s C a r r y i n g a heavy o b j e c t s u c h as a s u i t c a s e Moving heavy f u r n i t u r e D oing heavy d i g g i n g i n t h e garden o r s i m i l a r W a l k i n g No l i m i t t o w a l k i n g I have t o s t o p a f t e r about a h a l f m i l e because of d i s c o m f o r t I can o n l y w a l k 2-3 b l o c k s b e f o r e I must r e s t I can o n l y w a l k v e r y s h o r t d i s t a n c e s , b u t c a n manage s t a i r s and get around t h e house I c a n n o t manage s t a i r s I need h e l p t o move even i n t h e house I have t o use a w h e e l c h a i r C a r i n g f o r y o u r s e l f — mark t h e most you can do Unable t o l o o k a f t e r m y s e l f I c a n f e e d and wash m y s e l f b u t need h e l p d r e s s i n g I am a b l e t o do the above; I can c u t my own t o e n a i l s I can d r e s s m y s e l f c o m p l e t e l y b u t need h e l p w i t h some t h i n g s I am t o t a l l y i n d e p e n d e n t S i t t i n g , g e t t i n g up N e i t h e r of t h e s e g i v e s me any d i s c o m f o r t I c a n s i t down b u t g e t t i n g up f r o m t h e s i t t i n g p o s i t i o n may h u r t G e t t i n g up does n o t h u r t b u t a c t u a l l y s i t t i n g may h u r t B o t h s i t t i n g down and g e t t i n g up may h u r t Because of d i f f i c u l t y I need h e l p w i t h s i t t i n g down and r i s i n g f r o m a c h a i r P i c k i n g t h i n g s up o f f t h e f l o o r I can p i c k t h i n g s up o f f the f l o o r w i t h o u t d i f f i c u l t y B e n d i n g h u r t s , b u t I can s t r a i g h t e n up w i t h o u t difficulty I can g e t down t o p i c k something up b u t s t r a i g h t e n i n g h u r t s B o t h b e n d i n g and s t r a i g h t e n i n g up h u r t Because of d i s c o m f o r t I j u s t c a n ' t p i c k t h i n g s up o f f t h e f l o o r 192 Now M a r i t a l s t a t u s 1 S i n g l e 2 M a r r i e d (one m a r r i a g e o n l y ) 3 M a r r i e d ( I have b e e n m a r r i e d more t h a n once) " M A R I T A L " 1 I S e p a r a t e d 3 D i v o r c e d 3 Widowed 2 Engaged t o be m a r r i e d 3 'Common- law ' ( l i v i n g t o g e t h e r , n o t m a r r i e d ) M a r i t a l r e l a t i o n s h i p ( i n c l u d e s common-law p a r t n e r s h i p ) 0 S i n g l e a t p r e s e n t M i 1 Happy and f a i r l y s e c u r e i n my p r e s e n t r e l a t i o n s h i p BL ISS 2 F a i r l y h a p p y , b u t q u i t e o b v i o u s ups and downs 3 Our r e l a t i o n s h i p i s n o t v e r y good 4 We a r e l i k e l y t o s p l i t up soon S e x u a l l i f e - g e n e r a l — Mark t h e one t h a t most a p p l i e s t o you 1 N o r m a l — no p r o b l e m a t a l l 2 B a c k p a i n n e c e s s i t a t e s t h e u s e o f c e r t a i n p o s i t i o n s " S E X " 2 ^ F r e q u e n c y i s g r e a t l y l i m i t e d b y b a c k p a i n 3 B o t h o f t he above a r e t r u e (1 and 2) 1 I n t e r c o u r s e i s n o t p o s s i b l e b e c a u s e o f some o t h e r i l l n e s s o r d i f f i c u l t y i n e i t h e r p a r t n e r S o c i a l A c t i v i t i e s — g o i n g ou t w i t h f r i e n d s ; t o p a r t i e s o r d a n c e s , e t c . 1 No l i m i t a t i o n f o r any r e a s o n 2 No change i n t h e t y p e o f a c t i v i t i e s , b u t l e s s o f t e n 2 b e c a u s e o f p a i n SOCIAL 2 I have had t o change t o e a s i e r a c t i v i t i e s b e c a u s e o f b a c k p a i n 3 I c a n do v e r y l i t t l e b e c a u s e o f p a i n 1 I have had t o change a c t i v i t i e s f o r some o t h e r r e a s o n F i n a n c i a l 0 I am c o m f o r t a b l y o f f f i n a n c i a l l y ? I I have no d e b t s , b u t w o u l d l i k e t o have more money "MONEY" i n r e s e r v e 2 I have some s m a l l d e b t s 3 I am i n a f a i r l y s e r i o u s f i n a n c i a l p o s i t i o n Work 2 I am n o t w o r k i n g , b u t t h i s i s n o t b e c a u s e o f i l l n e s s 2 I do n o t wo rk b e c a u s e o f i l l n e s s , b u t n o t b e c a u s e o f b a c k t r o u b l e 1 I am a b l e t o c o n t i n u e my u s u a l wo rk w i t h o u t d i f f i c u l t y M i f 2 2 I f i n d my work q u i t e d i f f i c u l t and u n c o m f o r t a b l e WORK b e c a u s e o f my b a c k t r o u b l e 2 I c a n o n l y wo rk p a r t t i m e b e c a u s e o f my b a c k t r o u b l e 2 I have had t o change t o an e a s i e r j o b b e c a u s e o f t h i s b a c k t r o u b l e 2 I have had t o change t o an e a s i e r j o b f o r some o t h e r r e a s o n 3 I am u n a b l e to wo rk b e c a u s e o f my b a c k 193 "CAR' I I 1 * " T R A N S P O R " 2 Now 1 1 1 2 1 1 2 2 3 3 " C H I L D R E N " " S L E E P " 2 1 1 2 2 2 1 2 2 2 2 1 1 C a r d r i v i n g - - 'mark the answer most a p p r o p r i a t e t o y o u I do n o t d r i v e (have n o t l e a r n e d t o ) I c a n n o t a t t he moment d r i v e , b u t t h i s i s n o t c o n n e c t e d w i t h my b a c k I have no d i f f i c u l t y d r i v i n g a c a r A l o n g c a r j o u r n e y c a u s e s u n r e a s o n a b l e d i s c o m f o r t , b u t s h o r t e r t r i p s a r e n o t p a r t i c u l a r l y u n c o m f o r t a b l e I c a n n o t t a k e l o n g c a r j o u r n e y s , and s h o u l d s t o p e v e r y h-1 hou r f o r a r e s t , even s h o r t e r t r i p s a r e u n p l e a s a n t I c a n o n l y d r i v e l o c a l l y b e c a u s e o f d i s c o m f o r t I c a n n o t d r i v e a t a l l b e c a u s e o f d i s c o m f o r t R i d i n g i n a c a r o r b u s I h a v e no d i f f i c u l t y I h a v e d i f f i c u l t y g e t t i n g i n o r r i d i n g b u t n o t due t o my b a c k t r o u b l e I f i n d i t h a r d t o g e t i n o r ou t o f a c a r o r b u s , b u t r i d i n g i s f a i r l y c o m f o r t a b l e I f i n d g e t t i n g i n and ou t f a i r l y e a s y , b u t t r a v e l i n g i s u n c o m f o r t a b l e I a v o i d t r a v e l i n g i n a c a r o r bus whenever p o s s i b l e b e c a u s e o f d i f f i c u l t y I a v o i d t r a v e l i n g i n a c a r o r bus wheneve r p o s s i b l e b e c a u s e o f d i f f i c u l t y C h i l d r e n o r g r a n d c h i l d r e n a t home — mark t h a t most a p p r o p r i a t e No c h i l d r e n under f i f t e e n a t home I am a b l e t o wo rk and p l a y w i t h them and t o h e l p c a r e f o r them I have t o be c a r e f u l t h e y ' r e no t t o o r o u g h ; I c a n n o t l i f t them I can do l i t t l e w i t h them — o n l y t a l k o r r e a d o r p l a y v e r y e a s y games I c a n n o t s h a r e a c t i v i t i e s w i t h them a t a l l S l e e p I s l e e p n o r m a l l y most n i g h t s I o f t e n h a v e d i f f i c u l t y i n g e t t i n g t o s l e e p b e c a u s e o f d i s c o m f o r t I o f t e n h a v e d i f f i c u l t y i n g e t t i n g t o s l e e p b u t d o n ' t know why I wake up e a r l y b e c a u s e o f d i s c o m f o r t and c a n n o t g e t enough s l e e p I wake up e a r l y and c a n n o t g e t enough s l e e p b u t d o n ' t know why A n o t h e r i l l n e s s o f m ine i n t e r f e r e s w i t h my s l e e p I c a n n o t s l e e p b e c a u s e o f i l l n e s s o r u p s e t o f a n o t h e r p e r s o n i n t h e f a m i l y I have d i f f i c u l t y s l e e p i n g a l l t h r o u g h t h e n i g h t b e c a u s e o f my b a c k 194 Now I n G e n e r a l 1 I e n j o y l i f e 2 I e n j o y l i f e , b u t q u i t e a b i t l e s s t h a n I d i d b e f o r e t h i s b a c k t r o u b l e a r o s e 3 T h i s b a c k p r o b l e m i s enough t o s p o i l t h i n g s f o r me " L I F E " most o f t h e t i m e 4 L i f e i s o n l y j u s t t o l e r a b l e b e c a u s e o f t h i s b a c k ( o r l e g ) d i s c o m f o r t 5 I h a v e even t h o u g h t o f s u i c i d e b e c a u s e o f t h i s p r o b l e m 1 My en joymen t o f l i f e i s more a f f e c t e d by o t h e r p r o b l e m s Some o t h e r q u e s t i o n s  Any maj o r a b d o m i n a l s u r g e r y 1 None 2 S u r g e r y f o r u l c e r i n s t omach o r duodenum 2 G a l l b l a d d e r o p e r a t i o n 2 K i d n e y o r b l a d d e r o r m a l e o r g a n s "ABDOMEN" 1 ; * ^ e m a l e ° r f n S . 2 B e c a u s e o f i n j u r y 2 B o w e l s u r g e r y 3 Two o f t h e above 3 T h r e e of t h e above 3 F o u r i o f t he above Stomach t r o u b l e — mark o n l y one 0 No t r o u b l e 1 O c c a s i o n a l i n d i g e s t i o n o r h e a r t b u r n — no m e d i c a t i o n needed 2 F a i r l y f r e q u e n t i n d i g e s t i o n o r h e a r t b u r n — I t a k e s tomach m e d i c i n e s 3 Q u i t e bad i n d i g e s t i o n o r h e a r t b u r n — I ' v e had t o h a v e n ui t r e a t m e n t f r o m a d o c t o r DYSPEP ^ D i a g n o s i s o f u l c e r made b y t h e d o c t o r , and t r e a t m e n t g i v e n 5 I ' v e had t r e a t m e n t i n h o s p i t a l f o r ah u l c e r once (bu t n o t s u r g e r y ) 6 I ' v e had t r e a t m e n t i n h o s p i t a l more t h a n once (bu t n o t s u r g e r y ) 7 I ' v e had a b l e e d i n g u l c e r 8 I ' v e had a p e r f o r a t e d u l c e r 9 I ' v e had s u r g e r y f o r my u l c e r S k i n d i s e a s e s 1 Se ldom o r n e v e r " S K I N " 2 P s o r i a s i s 2 F r e q u e n t r a s h e s o r i t c h i n g now 2 I ' v e had p r o b l e m s w i t h my s k i n s i n c e c h i l d h o o d 195 E s t i m a t i o n o f R e s u l t s .Ra te on t h e l i n e b e l o w w i t h a s i n g l e s t r o k e o f y o u r pen t h e s u c c e s s o f y o u r l a s t f u s i o n o p e r a t i o n . " R E S U L T " 3 E x t r e m e l y poo r \ E x t r e m e l y good ( s c o r e d ou t o f 100) 196 B a c k S u r g e r y Form D r . P . J . K o k a n - D r . P e t e r C . Wing D a t e o f e x a m i n a t i o n . H o s p i t a l P a t i e n t ' s c h a r t number DVA, P e n s i o n o r WCB number * 1 Age i n y e a r s o f e x a m i n a t i o n " A E X A M " Age i n y e a r s a t l a s t f u s i o n " A F U S I O N " 1 Age i n y e a r s a t o n s e t o f symptoms "ASYMPTOM" 1 Time l a p s e o n s e t F u s i o n i n mon ths " L A P S E " 1 SEX 1 M a l e 2 Fema le P l a c e o f b i r t h 1 B . C . 1 Canada o t h e r t h a n B . C . 2 U n i t e d K ingdom 2 N o r t h e r n o r W e s t e r n E u r o p e " B I R T H P L " 1 2 S o u t h , C e n t r a l o r E a s t e r n E u r o p e 2 M i d d l e E a s t ( e . g . , I s r a e l , L e b a n o n , I n d i a ) 2 F a r E a s t ( e . g . , C h i n e s e , J a p a n e s e ) 2 B r i t i s h Commonwealth 1 A m e r i c a ( U . S . ) 2 O t h e r C u l t u r a l b a c k g r o u n d (o f p a r e n t s , g r a n d p a r e n t s o r o f c h i l d h o o d s u r r o u n d i n g s ) 0 N o r t h A m e r i c a n 1 F r e n c h o f F r e n c h C a n a d i a n 2 B r i t i s h (wou ld i n c l u d e Commonwealth) 3 M e d i t e r r a n e a n ( I t a l i a n , S p a n i s h , e t c . , i n c l u d e S . A m e r i c a ) " E T H N I C " 1 4 I n d i a n , P a k i s t a n i o r s i m i l a r 5 C h i n e s e , J a p a n e s e o r s i m i l a r 6 N o r t h e r n o r W e s t e r n E u r o p e a n 7 C e n t r a l o r E a s t e r n E u r o p e a n 8 A f r i c a n 9 O t h e r E d u c a t i o n 0 I l l i t e r a t e 1 I n c o m p l e t e p r i m a r y 2 C o m p l e t e p r i m a r y "EDUCAT" 3 I n c o m P l e t e s e c o n d a r y 4 C o m p l e t e s e c o n d a r y 5 T r a d e o r b u s i n e s s t r a i n i n g 6 P r o f e s s i o n a l t r a i n i n g n o t i n c l u d e d i n 5 7 U n i v e r s i t y - b a c h e l o r ' s d e g r e e o r s i m i l a r 8 U n i v e r s i t y - f u r t h e r t r a i n i n g beyond b a c h e l o r ' s d e g r e e 197 Occupation Professional or equivalent Now 0 1 2 3 4 "OCCUPA" 5 6 7 8 Not in this category Medical, dental, veterinary, osteopathic Legal (include jurists) Architect Engineering (at consultant or design level) Teaching Government (senior position, department head, etc.) Major executive in commerce High rank in military field, police or transport fields Other professional or equivalent Technical, skilled, clerical "OCCUPB" 0 Not in this category 1 Paramedical - nurses, technicians 2 Banking (management or supervising) 3 Creative writers (authors, journalists, etc.) and performing artists 1 4 Photographers, artists, sculptors, commercial artists 5 Salesmen (excluding major executives and sales clerks) 6 Clerical 7 Skilled workers, servicing (e.g., electrician, plumber) 8 Agricultural (farmers, forestry, fishing, hunting) 9 Police and military personnel except highest ranks Others "OCCUPC" "CHANGOC" 0 Not in this category 1 Sales clerks 2 Production workers (manufacture or assembly) 3 Transport or vehicle operators and ancillary personnel Construction workers Catering and ancillary personnel Housewife Unskilled labour Student Other not categorized - specify Occupation changes most recently After fusion 0 None (no change) Promotion in a similar job Change to a different job, Change to a different than illness Change to a different disability Change to a different 4 5 6 7 8 9 1 2 3 as advancement job for reasons other job because of back 5 job because of other illness 6 Cessation of employment for age retirement 7 Cessation of employment because of back disability 8 Cessation of employment because of other reasons 198 Number o f j o b c h a n g e s A f t e r f u s i o n 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 T ime l o s s i n l a s t 2 y e a r s " L O S S " 2 " JOBNO" 8 8 9 More t h a n 8 T ime o f f work p r i o r t o l a s t f u s i o n 1 None 2 L e s s t h a n 1 week 2 L e s s t h a n 1 mon th 3 L e s s t h a n 2 months 3 L e s s t h a n 4 months 4 L e s s t h a n 6 months 4 L e s s t h a n 1 y e a r 4 L e s s t h a n 18 months 4 L e s s t h a n 2 y e a r s 5 Unemployed " P R I O R " 1 ( o r o p e r a t i o n i f no f u s i o n ) 0 No o p e r a t i o n 1 L e s s t h a n 1 month 2 L e s s t h a n 2 months 3 L e s s t h a n 4 months 4 L e s s t h a n 6 months 5 L e s s t h a n 1 y e a r 6 L e s s t h a n 2 y e a r s 7 L e s s t h a n 4 y e a r s 8 L e s s t h a n 10 y e a r s 9 More t h a n 10 y e a r s T ime of r e t u r n t o work a f t e r l a s t f u s i o n ( o r o p e r a t i o n i f no f u s i o n )  " R E T U R N " ^ " F A I T H " 1 R e l i g i o n 0 No d e f i n i t e v i e w s 1 A t h e i s t 2 J e w i s h 3 Roman C a t h o l i c 4 B u d d h i s t 5 H i n d u 6 Mohammedan 7 O t h e r O r i e n t a l 8 S p e c i f i c p r o t e s t a n t ; 9 O t h e r ' p r o t e s t a n t ' 0 No o p e r a t i o n 1 L e s s t h a n 1 month 2 L e s s t h a n 2 months 3 L e s s t h a n 4 months 4 L e s s t h a n 6 months 5 L e s s t h a n 1 y e a r 6 L e s s t h a n 2 y e a r s 7 L e s s t h a n 4 y e a r s 8 L e s s t h a n 10 y e a r s 9 More t h a n 10 y e a r s s e c t o r d e n o m i n a t i o n ( i n c l u d e h e r e C h u r c h o f E n g l a n d , e t c . ) " A C T I V E " 1 A c t i v i t y i n r e l i g i o u s l i f e 1\ N e v e r 2 O n c e - t w i c e y e a r l y 3 ' O c c a s i o n a l ' 4 R e g u l a r a t t e n d e r a t a p l a c e o f r e l i g i o n ( t w i c e m o n t h l y o r more) 5 ' D e e p l y r e l i g i o u s ' 6 A c t i v e i n o r g a n i z a t i o n o f p a r t i c u l a r c h u r c h 7 M i n i s t e r o f p a r t i c u l a r c h u r c h 5 C o n s i d e r e d a r e l i g i o u s p e r s o n , b u t d o e s n o t t a k e p a r t i n an o r g a n i z e d c h u r c h 199 Avocation Now 1 None 2 A t h l e t i c s , competitive 2 A t h l e t i c s , non-competitive 2 Major sports (running, s k i i n g , c y c l i n g , swimming) 2 Minor sports (walking, jogging, hunting, g o l f , f i s h i n g ) 2 Creative (indoor, l i g h t e r work) 2 Domestic maintenance, gardening, house care, etc. Family History Number of s i b l i n g s of father 0 None 1 1 2 2 3 3 4 4 5 5 "EXUNCLE" 6 6 7 7 8 8 9 More than 8 Father and s i b l i n g s of father with back trouble 0 None 1 Father 2 1 s i b l i n g of father 3 2 s i b l i n g s of father 4 3 s i b l i n g s of father 5 4 s i b l i n g s of father 6 1 + 2 7 1 + 3 8 1 + 4 9 1 + 5 Number of s i b l i n g s of mother 0 None 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 Mother and s i b l i n g s of mother with back trouble '^ EXAUNT'1 More than 8 Patient's s i b l i n g s Number of s i b l i n g s with back trouble Number of ch i l d r e n 0 None 1 < Mother 2 1 s i b l i n g of mother 3 2 s i b l i n g s of mother 4 3 s i b l i n g s of mother 5 4 s i b l i n g s of mother 6 1 + 2 7 1 + 3 8 1 + 4 9 1 + 5 At time of fusion Now 0 0 None 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 9 9 More Number of c h i l d r e n with back trouble or pain (now)  0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More than 8 "OFFBACK"1 200 Number o f c h i l d r e n w i t h l e g p a i n , ' r h e u m a t i s m & o r ' g r o w i n g p a i n s ' (now) 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 Smok ing h a b i t 1 Non smoker 2 M a i n l y c i g a r e t t e s 2 M a i n l y c i g a r e t t e s 3 M a i n l y c i g a r e t t e s 4 M a i n l y c i g a r e t t e s 3 M a i n l y p i p e 4 M a i n l y p i p e 3 M a i n l y c i g a r 4 M a i n l y c i g a r 4 C o m b i n a t i o n l e s s t h a n 10 d a i l y l e s s t h a n 20 d a i l y l e s s t h a n 40 d a i l y more t h a n 40 d a i l y - m o d e r a t e smoker - heavy smoker - m o d e r a t e smoker - h e a v y smoker f a i r l y heavy A l c o h o l u s a g e T e e t o t a l e r ( a b s t a i n e r ) O c c a s i o n a l d r i n k - s p e c i a l o c c a s i o n s o n l y O c c a s i o n a l d r i n k a t home o r s o c i a l o c c a s i o n s D r i n k s o n c e o r t w i c e mos t w e e k s , i n m o d e r a t i o n D r i n k s e v e r y week a t l e a s t once a s a m a j o r p a r t o f t h e e v e n i n g ' s e n t e r t a i n m e n t Has an a l c o h o l d r i n k o f some s o r t d a i l y , may o r ma} n o t d r i n k more a t t i m e s P r o b a b l y r e l i e s on a l c o h o l beyond n o r m a l s o c i a l u s e E a r l y a l c o h o l i c U n e q u i v o c a l l y a l c o h o l i c E x - a l c o h o l i c , o r member o f AA 1 2 3 4 6 7 8 9 Drug u s e - mark h i g h e s t g r a d e 1 None 2 O c c a s i o n a l s o f t d r u g u s e r 2 F r e q u e n t o r h a b i t u a l s o f t d r u g u s e r 2 Has had a c o n v i c t i o n r e l a t e d t o s o f t d r u g s 2 O c c a s i o n a l n o n - m e d i c a l u s e r o f s t i m u l a n t s o r t r a n -q u i l i z e r s 2 F r e q u e n t n o n - m e d i c a l u s e r o f s t i m u l a n t s o r t r a n q u i l i z e r s 2 O c c a s i o n a l o p i a t e o r s i m i l a r u s e r 2 A d d i c t t o o p i a t e o r s i m i l a r d r u g 2 E x - a d d i c t t o o p i a t e o r s i m i l a r d r u g 2 O t h e r - s p e c i f y 201 O t h e r d i s e a s e s t a t e s ( r e q u i r i n g m a j o r i n o r o u t p a t i e n t t r e a t m e n t ) 1 None 2 C . N . S . ( e x c l u d i n g p s y c h i a t r i c c a r e ) 2 R e s p i r a t o r y 2 C a r d i o v a s c u l a r 2 G a s t r o i n t e s t i n a l e x c l u d i n g p e p t i c u l c e r d i s e a s e 2 G e n i t o u r i n a r y 2 M u s c u l o s k e l e t a l 3 Two o f above 3 T h r e e o f above 3 F o u r o f above P s y c h i a t r i c c a r e o r p e r s o n a l i t y d i s o r d e r 1 N o r m a l 2 M o d e r a t e o r f r e q u e n t t r a n q u i l i z e r u s e 2 Had p s y c h i a t r i c a t t e n t i o n p r i o r t o f u s i o n 2 Has had p s y c h i a t r i c a t t e n t i o n s i n c e f u s i o n 2 1 + 2 2 1 + 3 2 2 + 3 2 1 + 2 + 3 2 C u r r e n t l y i n p s y c h i a t r i c ward 2 O t h e r H i s t o r y o f t rauma r e l a t e d t o o n s e t o f b a c k t r o u b l e .. 1' None 1 M i n o r ( l i f t i n g , a t w i s t ) 2 F a l l f r o m a l o w h e i g h t 2 F a l l f r om a g r e a t e r h e i g h t 2 M a j o r i n j u r y -± f r a c t u r e 2 R e p e a t e d s t r e s s o r m i n o r t r a u m a 1 War i n j u r y o r s i m i l a r ( b l a s t , G . S . W . , e t c . ) 1 A u t o a c c i d e n t H i s t o r y o f o t h e r t rauma p r i o r t o o n s e t o f symptoms b u t u n r e l a t e d I None 1 Lower l i m b f r a c t u r e i n s p o r t s o r s i m i l a r a c c i d e n t 2 A u t o a c c i d e n t w i t h o u t f r a c t u r e o r m a j o r i n j u r y 2 A u t o a c c i d e n t w i t h f r a c t u r e o r m a j o r i n j u r y " 2 B l a s t , G . S . W . , o r s i m i l a r 2 F a l l f r o m a l o w h e i g h t 2 M a j o r f a l l 2 Two o f above 2 T h r e e o f above R e s i d u a l d i s a b i l i t y f r o m o t h e r t rauma 0 No r e s i d u a l 1 M i l d r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y 2 M o d e r a t e r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y - u n p e n s i o n e d 3 S e v e r e r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y - u n p e n s i o n e d 4 M o d e r a t e r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y - p e n s i o n e d 5 S e v e r e r e s i d u a l d i s c o m f o r t o r d i s a b i l i t y - p e n s i o n e d 202 ' A D M I S S 1 ' 1 T o t a l number o f h o s p i t a l a d m i s s i o n s f o r b a c k 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 " R E F U S I O N " " O P E R A T E " 4 T o t a l number o f o p e r a t i o n s on b a c k  0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 T o t a l number o f f u s i o n O p e r a t i o n s T o t a l number o f l a m i n e c t o m i e s " F U S I O N O " 4 ' L A M N O " 4 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 Number o f r e f u s i o n s o f any l e v e l 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 " C O M P L I C A " 1 0 None 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 More t h a n 8 C o m p l i c a t i o n s o f any and a l l b a c k o p e r a t i o n s  1 None 2 Wound i n f e c t i o n (deep) 2 Wound i n f e c t i o n ( s u p e r f i c i a l ) 2 Hematoma 2 Roo t damage o r i r r i t a t i o n 2 P s e u d a r t h r o s i s 2 Shock 2 C h e s t o r a b d o m i n a l p r o b l e m s 2 More t h a n 1 o f t h e above ( s p e c i f y ) 2 O t h e r " C O M P L I C B " 1 C o m p l i c a t i o n s o f l a s t f u s i o n o p e r a t i o n 1 None 2 Wound i n f e c t i o n (deep) 2 Wound i n f e c t i o n ( s u p e r f i c i a l ) 2 Hematoma 2 Roo t damage o r i r r i t a t i o n 2 P s e u d a r t h r o s i s 2 Shock 2 C h e s t o r a b d o m i n a l p r o b l e m s 2 More t h a n 1 o f t h e above ( s p e c i f y ) 2 O t h e r 203 "GENERAL" 1 " B P I I 1 * " W E I G H T " 1 "HEIGHT II 1 " F A T F A C T " " E N T " 1 1 G e n e r a l a p p e a r a n c e - most p r e d o m i n a n t f e a t u r e 1 N o r m a l , h e a l t h y 1 V e r y m u s c u l a r , n o t o v e r w e i g h t 2 O v e r w e i g h t f o r h e i g h t 2 A p p e a r s v e r y t h i n 2 P a l e , u n h e a l t h y - l o o k i n g 2 O t h e r B l o o d p r e s s u r e 1 N o r m a l 2 Low ( s y s t o l i c l e s s t h a n 100 mm) 2 H i g h ( d i a s t o l i c o v e r 90 mm) 2 V e r y h i g h ( d i a s t o l i c o v e r 120 mm) Weig ;ht i n k i l o s 1 L e s s t h a n 40 ( unde r 88 l b s . ) 2 4 1 - 5 0 ( 8 9 - 1 1 0 l b s . ) 3 5 1 - 6 0 ( 1 1 1 - 1 3 2 l b s . ) 4 6 1 - 7 0 (133 -154 l b s . ) 5 7 1 - 8 0 (155 -176 l b s . ) 6 8 1 - 9 0 ( 177 -198 l b s . ) 7 9 1 - 1 0 0 ( 1 9 9 - 2 2 0 l b s . ) 8 1 0 1 - 1 1 0 ( 2 2 1 - 2 4 2 l b s . ) 9 More t h a n 110 (more t h a n 243 l b s . ) H e i g h t i n c e n t i m e t e r s 1 L e s s t h a n 120 ( u n d e r 4 ' ) 2 1 2 1 - 1 3 0 ( 4 ' 0 " - 4 ' 3 " ) 3 1 3 1 - 1 4 0 ( 4 ' 3 y - 4 ' 7 " ) 4 1 4 1 - 1 5 0 - ( 4 ' 7 V - 4 ' 1 1 " ) 5 1 5 1 - 1 6 0 ( 4 ' l l i g " - 5 ' 3 " ) 6 1 6 1 - 1 7 0 ( 5 ' 3 % " - 5 * 7 " ) 7 1 7 1 - 1 8 0 ( 5 * 7 V - 5 * 1 1 " ) 8 1 8 1 - 1 9 0 ( 5 ' 1 1 % - 6 ' 3 " ) 9 More t h a n 190 (more t h a n 6 ' 3 " ) i s w e i g h t code v 10 h e i g h t code ENT 0 N o r m a l 1 A b n o r m a l ( s p e c i f y ) 2 n o t done " C H E S T " 1 C h e s t 0 1 2 N o r m a l A b n o r m a l ( s p e c i f y ) No t done "HEART" H e a r t 0 N o r m a l 1 A b n o r m a l ( s p e c i f y ) 2 No t done Abdomen 1 N o r m a l 2 1 Obese 2 'TUMMY 1" 4 2 2 o r more s c a r s 2 2 H e r n i a o f any t y p e 2 2 1 + 2 1 + 3 2 + 3 1 + 2 + 3 O t h e r more s e r i o u s a b n o r m a l i t y r e q u i r i n g r e f e r r a l N o t e done 204 " R E C T A L " ^ - o m i t t e d " STANCE" •* " C U R V E " 1 " A B T O N E " 1 R e c t a l 1 N o r m a l 2 F i s s u r e a n d / o r h e m o r r h o i d s 2 C o c c y g e a l t e n d e r n e s s 2 A b n o r m a l i t y o f p r o s t a t e , s a c r o t u b e r o u s l i g a m e n t o r o t h e r deep s t r u c t u r e ( s p e c i f y ) 2 1 + 3 2 1 + 3 2 2 +.3 • 2 1 + 2 + 3 2 O t h e r more s e r i o u s a b n o r m a l i t y r e q u i r i n g r e f e r r a l 1 No t done ( t h i s s h o u l d n o t be m a r k e d ! ) P e l v i c O m i t t e d 0 N o r m a l 1 A b n o r m a l ( s p e c i f y ) 2 N o t done S t a n c e 1 N o r m a l 2 L i s t t o r i g h t 2 L i s t t o l e f t 2 L i s t f o r w a r d 2 L i s t b a c k w a r d 2 O t h e r ( s p e c i f y ) Lumbar c u r v e 1 N o r m a l l o r d o s i s 1 E x a g g e r a t e d l o r d o s i s 2 F l a t t e n e d l o r d o s i s 2 K y p h o s i s 2 S c o l i o s i s c o n v e x t o r i g h t 2 S c o l i o s i s c o n v e x t o l e f t 2 1 + 4 2 1 + 5 2 2 + 4 2 2 + 5 " G A I T " J G a i t 1 2 2 L 2 2 2 2 N o r m a l L i m p i n g R. l e g L i m p i n g L . l e g D i f f i c u l t y i n b o t h l e g s U n a b l e t o w a l k U n a b l e t o s t a n d O t h e r ( s p e c i f y ) P e l v i c T i l t 1 N o r m a l " T I L T " 1 2 R i g h t s i d e up 2 L e f t s i d e up P a r a v e r t e b r a l musc le tone 1 2 " P V T O N E " 1 2 N o r m a l R i g h t p a r a v e r -t e b r a l m u s c l e spasm L e f t p a r a v e r -t e b r a l m u s c l e spasm 1 + 2 O t h e r ( s p e c i f y ) A b d o m i n a l m u s c l e t o n e 1 N o r m a l 2 O b e s e , f a i r t o n e 3 No t o b e s e , b u t poo r t o n e 3 O b e s e , p o o r t o n e 205 " C E R V I C A " " C E R V I C B " "NECKO" " A R M S " 1 C e r v i c a l s p i n e r a n g e o f m o t i o n 1 N o r m a l f o r age 1 L i m i t e d f l e x i o n 2 L i m i t e d e x t e n s i o n 2 L i m i t e d t i l t a n d / o r r o t a t i o n t o r i g h t 2 L i m i t e d t i l t a n d / o r r o t a t i o n t o l e f t 2 1 + 3 2 1 + 4 2 2 + 3 2 2 + 4 2 V i r t u a l l y o r c o m p l e t e l y a n k y l o s e d C e r v i c a l s p i n e - o t h e r 1 N o r m a l 1 P o s t e r i o r m u s c l e a b n o r m a l t o n e 2 . T e n d e r n e s s on a x i a l c o m p r e s s i o n Cover v e r t e x ) 2 L o c a l i z e d t e n d e r n e s s o v e r c e r v i c a l s p i n e 2 1 + 2 2 1 + 3 2 2 + 3 2 . 1 + 2 + 3 2 O t h e r Cspecify) Combined " C E R V I C A " and " C E R V I C B " 1 on e i t h e r = 1 2 on e i t h e r = 2 Upper l i m b s ( e i t h e r ) 1 N o r m a l L i m i t a t i o n of s h o u l d e r movement C r e p i t u s i n s h o u l d e r r e g i o n on m o t i o n N e u r o l o g i c a l i m p a i r m e n t o f some t y p e i n l i m b 1 + 2 Lumbar s p i n e - ROM f l e x i o n M e a s u r e C 7 t o S 1 d i f f e r e n c e i n cms. " F L E X T W O " 4 1 2 2 2 2 2 2 2 1 + 3 2 + 3 1 + 2 + 3 O t h e r ( s p e c i f y ) T h o r a c i c s p i n e " T H O R A C I C " 1 Loraclc spj 1 N o r m a l 1 A b n o r m a l curve Cspecify type) ( | M 2 L i m i t e d ro ta t ion LUMFLEX 2 Marked tenderness Cspecify where) 2 . 1 + 2 2 . 1 + 3 2 2 + 3 2 1 + 2 + 3 2 O t h e r (specify) 0 More t h a n 8 cms. 1 7 -1 - 8 cms. 2 6 -1 - 7 cms 3 ' •5-1 — 6 cms. 1 4 4 - 1 — 5 cms. 5 3 -1 - 4 cms. 6 2 - 1 - 3 cms . 7 1-1 - 2 cms. 8 L e s s - 1 cm. F l e x i o n e x p r e s s e d d i f f e r e n t l y 0 Touch t o e s 1 B e l o w m id t i b i a 2 M i d t i b i a 3 Touches knees 4 M i d t h i g h 5 0 ° " S P A S M " 4 Spasm on F l e x i o n Cof p a r a v e r t e b r a l m u s c l e s ) 0 None 1 M o d e r a t e 2 Ma rked 206 " L U M E X T " 4 Lumbar s p i n e ROM e x t e n s i o n 0 N o r m a l 20 - 30° 10 - 20° L e s s t h a n 1 0 ° 0 ° 1 2 3 4 " P A I N E X T " 4 P a i n on e x t e n s i o n 1 No 2 Y e s ROM R i g h t f l e x i o n " R F L E X " 0 1 2 3 4 N o r m a l 30 - 4 5 ° - Knee j o i n t 15 - 3 0 ° - Lower t h i g h " L F L E X " L e s s t h a n 15° - M i d t h i g h 0 ° ROM L e f t f l e x i o n 0 N o r m a l 1 30 - 4 5 ° Knee j o i n t 2 15 - 3 0 ° Lower t h i g h 3 Less t h a n 1 5 ° - mid thigh 4 0 ° " R E E L E X e q u a l s sum o f r a t i n g s of " R F L E X " and " L F L E X " " H Y P E R E X T " 4 P a s s i v e E y p e f e x t e n s i o n • t e s t  0 F u l l p a s s i v e h y p e r e x t e n s i o n p a i n f r e e 1 G i v e s s l i g h t p a i n a t n o r m a l l i m i t M i l d p a i n on h y p e r e x t e n s i o n M o d e r a t e p a i n S e v e r e p a i n - r e l i e v e d b y f l e x i o n G i v e s p a i n no t e a s e d on f l e x i o n LENGTH" 1 Leg l e n g t h 0 E q u a l 1 R i g h t s h o r t e r by 1-5 cms . 2 R i g h t s h o r t e r by 5 -10 cms. 2 R i g h t s h o r t e r by o v e r 10 cms. 2 L e f t s h o r t e r 1-5 cms. 2 L e f t s h o r t e r 5 - 1 0 cms. 2 L e f t s h o r t e r o v e r 10 cms. I n d i c a t e c a u s e by by by P e r i p h e r a l p u l s e s - l o w e r l i m b s " P U L S E S " 1 N o r m a l 2 M i l d d e c r e a s e r i g h t 2 Marked d e c r e a s e r i g h t " H I P S " 2 M i l d d e c r e a s e l e f t 2 Marked d e c r e a s e ILefltt 2 M i l d b i l a t e r a l d e c r e a s e 2 More marked b i l a t e r a l d e c r e a s e H i P s 1 2 N o r m a l R i g h t a b n o r m a l ( s p e c i f y ) L e f t a b n o r m a l ( s p e c i f y ) 1 + 2 ( s p e c i f y ) K n e e s " K N E E S " " L I M B " 1 1 N o r m a l 2 R i g h t a b n o r m a l ( s p e c i f y ) 2 L e f t a b n o r m a l ( s p e c i f y ) 2 1 + 2 ( s p e c i f y ) A n k l e s 1 2 " A N K L E S " Combined p e r i p h e r a l p u l s e s i n l o w e r l i m b s 1 on a l l = 1 2 on any = 2 N o r m a l R i g h t a b n o r m a l ( s p e c i f y ) L e f t a b n o r m a l ( s p e c i f y ) 1 + 2 ( s p e c i f y ) 207 R i g h t f o o t "RFOOT" 1 1 2 2 2 2 2 2 2 N o r m a l A b n o r m a l i t y o f a r c h H a l l u x v a l g u s C l a w o r hammer t o e s ± c a l l u s e s 1 + 2 1 + 3 2 + 3 1 + 2 + 3 O t h e r ( s p e c i f y ) "LFOOT" " G A E N S L E N " 4 S a c r o i l i a c s t r e s s ( G a e n s l e n ' s t e s t ) 1 N o r m a l 2 R i g h t p o s i t i v e 2 L e f t p o s i t i v e 3 1 + 2 " S L R " 4 L e f t f o o t 1 N o r m a l 2 A b n o r m a l i t y o f a r c h 2 H a l l u x v a l g u s 2 C law o r hammer t o e s ± c a l l u s e s 2 1 + 2 2 1 + 3 2 2 + 3 2 1 + 2 + 3 2 O t h e r ( s p e c i f y ) . S t r a i g h t l e g r a i s i n g p a i n 1 None ( n o r m a l ) 2 R i g h t - 0 -30 d e g r e e s 3 R i g h t - 3 0 - 6 0 4 R i g h t - 6 0 - 9 0 2 L e f t - 0 - 3 0 3 L e f t - 3 0 - 6 0 4 L e f t - 6 0 - 9 0 2 B o t h l e g s 0 - 3 0 3 B o t h l e g s 3 0 - 6 0 4 B o t h l e g s - 6 0 - 9 0 d e g r e e s " B O W " 4 B o w s t r i n g s i g n ( p r e s s u r e o v e r t a u t p o p l i t e a l n e r v e ) 1 N e g a t i v e b i l a t e r a l l y 2 P o s i t i v e l e f t 2 P o s i t i v e r i g h t 3 B i l a t e r a l l y p o s i t i v e "WASTA" M u s c l e w a s t i n g more t h a n 2 cms. 1 None 1 R i g h t t h i g h 2 L e f t t h i g h 2 R i g h t c a l f 2 L e f t c a l f 2 1 + 3 2 2 + 3 2 1 + 4 2 2 + 4 2 O t h e r ( s p e c i f y ) "WASTB" O t h e r m u s c l e w a s t i n g 1 None i n t h i s g roup 1 R i g h t e x t e n s o r d i g i t o r u m b r e v i s 2 L e f t e x t e n s o r d i g i t o r u m b r e v i s 2 R i g h t a n t e r i o r c a l f m u s c l e s 2 L e f t a n t e r i o r c a l f m u s c l e s 2 1 + 3 2 2 + 3 2 1 + 4 2 2 + 4 2 O t h e r ( s p e c i f y ) "ABDPOWA" 4 A b d o m i n a l - able to l i f t s t ra igh t legs 10 cm. o f f t a b l e ? 0 Y e s 1 No " W A S T E " 1 i s t o t a l o f p o s i t i v e e n t r i e s on "WASTA" and WASTB" "ABDPOWB" 4 A b i l i t y t o l i f t uppe r body o f f t a b l e - l e g s s e c u r e d 0 N o r m a l - f a i r l y e a s i l y 1 W i t h d i f f i c u l t y - a l l t h e way 2 M o d e r a t e d i f f i c u l t y - o n l y p a r t way 3 Marked d i f f i c u l t y - o n l y j u s t a b l e t o move 4 U n a b l e t o r i s e o f f t a b l e 208 Back a b l e to l i f t b u t t o c k s o f f t a b l e when s u p i n e 1 Y e s - n o r m a l l y and e a s i l y 'BACKPOW" 4 ^ W i t h some d i f f i c u l t y - r e m a i n s e x t e n d e d 3 M o d e r a t e d i f f i c u l t y - c a n n o t s u s t a i n i t 3 Ma rked d i f f i c u l t y - u n a b l e t o r a i s e b u t t o c k s f r o m t a b l e L imb M u s c l e S t r e n g t h H i p E x t e n s o r s " L E G P O W " 4 (= sum o f p o s i t i v e e n t r i e s o f l i m b s t r e n g t h measu res ) " D T R K N E E " 1 L R L R L R 0 0 Grade 5 0 0 Grade 5 0 0 G rade 5 1 1 Grade 4 1 1 Grade 4 1 1 Grade 4 2 2 Grade 3 . 2 2 Grade 3 2 2 Grade 3 3 3 Grade 2 3 3 Grade 2 3 3 Grade 2 4 4 Grade 1 4 4 Grade 1 4 4 Grade 1 5 5 No f u n c t i o n 5 5 No f u n c t i o n 5 5 No f u n c t i o n H i p A ' d d u c t o r s Knee E x t e n s o r s Knee F l e x o r s L R L R L R 0 0 Grade 5 0 0 Grade 5 0 0 Grade 5 1 1 Grade 4 1 1 Grade 4 1 1 Grade 4 2 2 G rade 3 2 2 Grade 3 2 2 Grade 3 3 3 Grade 2 3 3 Grade 2 3 3 Grade 2 4 4 Grade 1 4 4 Grade 1 4 4 Grade 1 5 5 No f u n c t i o n 5 5 No f u n c t i o n 5 5 No f u n c t i o n FoOt D O r s i f l e x o r s F o o t P l a n t a r F l e x o r s F o o t E v e r t o r s L R L R L R 0 0 Grade 5 0 0 Grade 5 0 0 G rade 5 1 1 Grade 4 1 1 Grade 4 1 1 Grade 4 2 2 Grade 3 2 2 Grade 3 2 2 Grade 3 3 3 Grade 2 3 3 Grade 2 3 3 Grade 2 4 4 Grade 1 4 4 Grade 1 .4 .4 Grade 1 5 5 No f u n c t i o n 5 5 No f u n c t i o n 5 5 No f u n c t i o n G r e a t Toe E x t e n s i o n G r e a t Toe F l e x i o n L R L R 0 0 Grade 5 0 0 Grade 5 1 1 Grade 4 1 1 Grade 4 2 2 Grade 3 2 2 Grade 3 3 3 Grade 2 3 3 Grade 2 4 4 Grade 1 4 4 Grade 1 5 5 No f u n c t i o n 5 5 No f u n c t i o n Deep Tendon R e f l e x - Knee 1 N o r m a l 2 R i g h t i n c r e a s e d 2 R i g h t d e c r e a s e d 2 R i g h t a b s e n t 2 L e f t i n c r e a s e d 2 L e f t d e c r e a s e d 2 L e f t a b s e n t 3 B o t h i n c r e a s e d 3 B o t h d e c r e a s e d 3 B o t h a b s e n t " D T R A N K " 1 Deep TendOn R e f l e x - A n k l e 1 N o r m a l 2 R i g h t i n c r e a s e d 2 R i g h t d e c r e a s e d 2 R i g h t a b s e n t 2 L e f t i n c r e a s e d 2 L e f t d e c r e a s e d 2 L e f t a b s e n t 3 B o t h i n c r e a s e d 3 B o t h d e c r e a s e d 3 B o t h a b s e n t "DTRKA" i s comb ined v a r i a b l e o f t h e s e two - a s s i g n h i g h e s t v a l u e on e i t h e r one 209 "PLANTAR" P l a n t a r r e f l e x 1 N o r m a l 2 R i g h t u p g o i n g 2 L e f t u p g o i n g 2 B o t h u p g o i n g C r e m a s t e r r e f l e x " C R E M A S T " 1 A b d o m i n a l r e f l e x 1 N o r m a l 2 A b s e n t r i g h t " A B D F L E X " 4 2 A b s e n t l e f t 2 A b s e n t b o t h s i d e s 2 A b n o r m a l b e c a u s e o f l o c a l disease 1 N o r m a l 2 A b s e n t r i g h t 2 A b s e n t l e f t 2 A b s e n t b o t h s i d e s 2 A b n o r m a l b e c a u s e o f l o c a l d i s e a s e " S E N S R " S e n s a t i o n r i g h t - l e v e l o f i m p a i r m e n t 1 None 2 L3 3 L4 4 L 5 5 S I 6 S2 7 More t h a n 1 r o o t ( s p e c i f y ) 8 P e r i p h e r a l n e r v e l o s s ( s p e c i f y ) " L O S S R " " L O S S L " " L O S S R L " Type o f l o s s ( r i g h t ) 0 No l o s s 1 Con fo rms w e l l t o dermatome i n d i c a t e d 2 Does n o t c o n f o r m 2 3 " S E N S L " 4 t o e x p e c t e d dermatome 3 H y p e r e s t h e s i a 4 Hypo o r a n e s t h e s i a 5 1 + 3 6 1 + 4 7 2 + 3 8 2 + 4 9 O t h e r ( s p e c i f y ) Type of l o s s ( l e f t ) S e n s a t i o n l e f t - l e v e l o f i m p a i r m e n t 1 None L3 L4 L 5 S I S2 More t h a n 1 r o o t ( s p e c i f y ) P e r i p h e r a l n e r v e l o s s ( s p e c i f y ) 5 6 7 8 ' T E N D E R 1 " 1 0 No l o s s 1 Con fo rms w e l l t o dermatome i n d i c a t e d 2 Does n o t c o n f o r m t o e x p e c t e d dermatome 3 H y p e r e s t h e s i a 4 Hypo o r a n e s t h e s i a 5 1 + 3 6 1 + 4 7 2 + 3 8 2 + 4 9 O t h e r ( s p e c i f y ) i s c o m b i n a t i o n o f LOSSL and LOSSR coded as n o r m a l = 1 a b n o r m a l = 2 Most p r o m i n e n t s i t e o f . t ende rness 0 None 1 S p i n o u s p r o c e s s 2 S . 1 j o i n t r i g h t 3 S . 1 j o i n t l e f t .4 R i g h t b u t t o c k 5 L e f t b u t t o c k 6 R i g h t p a r a v e r t e b r a l m u s c l e s ( s p e c i f y l e v e l ) 7 L e f t p a r a v e r t e b r a l m u s c l e s ( s p e c i f y l e v e l ) 8 G r e a t e r t r o c h a n t e r 210 " T E N D E R " 2 S e c o n d a r y s i t e o f t e n d e r n e s s 0 None 1 S p i n o u s p r o c e s s 2 S . l . j o i n t r i g h t 3 S . l j o i n t l e f t " T E N D E R 2 " 1 4 R i g h t b u t t o c k 5 L e f t b u t t o c k 6 R i g h t p a r a v e r t e b r a l m u s c l e s ( s p e c i f y l e v e l ) 7 L e f t p a r a v e r t e b r a l m u s c l e s ( s p e c i f y l e v e l ) 8 G r e a t e r t r o c h a n t e r ( s p e c i f y s i d e ) 9 O t h e r , s p e c i f y i s c o m b i n a t i o n o f TENDER1 and TENDER2 c o d e d a s 1 N o r m a l 2 1 p l a c e t e n d e r 3 2 p l a c e s t e n d e r S p i n o u s p r o c e s s t e n d e r n e s s l e v e l ( i f n o t l o c a l i z e d , g i v e c e n t r a l l e v e l ) 0 No s p i n o u s p r o c e s s t e n d e r n e s s 1 L I 2 L 2 3 L 3 4 L4 5 L5 6 S I 7 Over a s p i n o u s p r o c e s s b u t o b v i o u s l y more s u p e r f i c i a l i n s c a r M o t i v a t i o n f o r s u r g e r y 0 No s u r g e r y 1 P a t i e n t demanded i t 2 P a t i e n t i n i t i a l l y r e f u s e d i t 3 S u r g e o n s u g g e s t e d i t , a f t e r f a i l u r e o f c o n s i d e r a b l e c o n s e r v a t i v e t h e r a p y 4 S u r g e o n s t r o n g l y s u g g e s t e d i t , a f t e r l i t t l e c o n s e r v a t i v e t h e r a p y 9 O t h e r ( s p e c i f y "TENDLOC" " M O T I V " 1 " O P I N I O N " " A G A I N " 2 P a t i e n t ' s ' o p i n i o n o f s u r g e r y - ( l a s t o p e r a t i o n o n l y ) 1 Pe rmanen t d e f i n i t e improvement 2 Pe rmanen t p a r t i a l improvement No improvement I 3 Tempora ry improvement f o r l e s s t h a n 2 y e a r s 3 Tempora ry improvement f o r a l o n g e r p e r i o d o f t i m e Some w o r s e n i n g 3 D e f i n i t e l y w o r s e 3 O t h e r ( s p e c i f y ) Under t h e same c i r c u m s t a n c e s , t h e p a t i e n t w o u l d now: 1 A c c e p t s u r g e r y a g a i n 3 R e f u s e s u r g e r y a g a i n 2 U n d e c i d e d 211 "WHY u l " O B J E C T " 4 " P A T H " P a t i e n t ' s u n d e r s t a n d i n g o f m a i n r e a s o n s f o r s u r g e r y 1 Does n o t know - p u r e l y on s u r g e o n ' s r e c o m m e n d a t i o n 2 To r e l i e v e p a i n 2 To p r e v e n t f u r t h e r t r o u b l e 2 To i m p r o v e weakness 2 To i m p r o v e b a c k f u n c t i o n 2 O t h e r ( s p e c i f y ) E x a m i n e r ' s o p i n i o n 1 P a t i e n t d e f i n i t e l y i m p r o v e d 2 P a t i e n t p a r t i a l l y i m p r o v e d 3 W o r s e n i n g a s a r e s u l t o f s u r g e r y 3 W o r s e n i n g a s a r e s u l t o f p r o g r e s s i v e d i s c ' d i s e a s e 3 W o r s e n i n g a s a r e s u l t o f e m o t i o n a l d i s e a s e 3 W o r s e n i n g a s a r e s u l t o f some o t h e r d i s e a s e 3 Tempora ry i m p r o v e m e n t , now w o r s e n i n g 3 O t h e r ( s p e c i f y ) S u r g e o n ' s p r e o p e r a t i v e d i a g n o s i s : P a t h o l o g y f o u n d a t s u r g e r y ( l a s t o p e r a t i o n ) 1 No a b n o r m a l i t y s e e n 2 B u l g i n g d i s c 2 H e r n i a t e d d i s c 2 P s e u d a r t h r o s i s 2 F i b r o s i s and s c a r r i n g i n c a n a l 2 C o n g e n i t a l anoma ly ( i n c l u d e s p o n d y l o l y s i s ) 2 C o m b i n a t i o n of more t h a n one of above 1 S u r g e o n ' s r e p o r t n o t a v a i l a b l e 2 O t h e r ( s p e c i f y ) " K I S S " K i s s i n g v e r t e b r a e o r i n s t a b i l i t y 1 N e i t h e r 2 K i s s i n g s p i n e s ( s p e c i f y l e v e l ) 2 V e r t e b r a l i n s t a b i l i t y "MICRO" 2 B o t h o f above P a t h o l o g i c a l e x a m i n a t i o n 2 N o r m a l d i s c t i s s u e D e g e n e r a t i v e d i s c No t a v a i l a b l e No d i s c e c t o m y No t i s s u e examined O t h e r ( s p e c i f y ) " O V E R T " 1 O r t h o p a e d i s t ' s R a t i n g o f P s y c h o l o g i c a l f a c t o r s : A l l r a t i n g s a r e done on a 7 - p o i n t c o n t i n u u m f r o m l e a s t t o m o s t . R a t e p a t i e n t i n t e rms o f y o u r r e l a t i o n s h i p ' : I n t r o v e r t 1 2 3 4 5 6 7 E x t r a v e r t I n t r o v e r t = s h y , w i t h d r a w i n g , s o c i a l l y u n c o m f o r t a b l e Dependen t 1 2 3 4 5 6 7 I n d e p e n d e n t " O P E N D " 1 Dependen t = s u b j e c t seems t o g e t some s o r t o f e m o t i o n a l g r a t i f i c a t i o n and c l i n g s t o you l i k e a c h i l d m i g h t 212 ' O P A , , J •OPOWER"1 'OBITCH"1* 'OBLEED"'4 'OANXIETY P a s s i v e - A g g r e s s i v e n o t a t a l l 1 2 3 4 5 6 7 v e r y much so P . A . = ( v e r y much so) - p a t i e n t c o m p l i e s w i t h y o u r r e q u e s t t h a t a p p a r e n t l y d i s p l e a s e h i m , b u t y o u g e t t he i m p r e s s i o n h e ' s " g e t t i n g b a c k a t y o u " by n o t c o m p l y i n g f u l l y S u b m i s s i v e 1 2 3 4 5 6 7 Dominan t S u b m i s s i v e = p a t i e n t a c c e p t i n g l y goes a l o n g w i t h a l l y o u r r e q u e s t s , a l l o w s you t o i n i t i a t e t o p i c s Dominant = p a t i e n t t r i e s t o " s t e e r " p a r t s o f t he d i s c u s s i o n a n d / o r e x a m i n a t i o n E a g e r n e s s i n r e c o u n t i n g h i s t r o u b l e s l i t t l e 1 2 3 4 5 6 v e r y E m o t i o n a l i t y i n r e c o u n t i n g t r o u b l e s ( i s he l i k e a b l e e d i n g - h e a r t ) l i t t l e 1 2 3 4 5 6 7 v e r y ( j A n x i e t y i n a p p r o a c h i n g you as an a u t h o r i t y o r f a t h e r f i g u r e l i t t l e 1 2 3 4 5 6 7 v e r y much A n x i e t y i n t he s t a g e o r c o u r s e o f h i s p a t h o l o g y ' S A N X I E T Y " J 'OwORD."1 •OTRUTH"! ' C T T " 4 'HANDED" 3 l i t t l e 1 2 3 4 5 6 7 v e r y much l i t t l e = i n d i f f e r e n c e E s t i m a t e o f v e r b a l a b i l i t y l o w 1 2 3 4 5 6 7 h i g h E s t i m a t e o f I . Q . IQ h a s a mean o f 1 0 0 , s t a n d a r d d e v i a t i o n o f 15 l o w (70) 1 2 3 4 5 ' n o r m a l 6 7 h i g h 130 a v e r a g e C o l d T o l e r a n c e T e s t = s e c o n d s S t a t e r i g h t o r l e f t hand . . . Comment on p a t i e n t ' s r e a c t i o n R 213 "NUMBER" " S A C R A L " 1 ' F A C E T S " B a c k S u r g e r y S t u d y - X - r a y A s s e s s m e n t . D r . P e t e r Wing P a t i e n t I . D . C a r d 1 H o s p i t a l R e c o r d Number • D . V . A . , W . C . B . o r o t h e r number X - r a y number Number o f v e r t e b r a e 1 4 - d i s t i n c t l umbar v e r t e b r a e 2 5 - " 1 6 - " 1 i n c o m p l e t e t r a n s i t i o n o f a s i x t h l u m b a r v e r t e b r a h e m i v e r t e b r a D e s c r i b e a n o m a l i e s : S a c r a l a n o m a l i e s 1 2 2 none c o n g e n i t a l a c q u i r e d D e s c r i b e : S e p a r a t e f a c e t e p i p h y s e s 1 2 2 2 none L I L2 L 3 2 2 2 2 L4 L5 S I a c o m b i n a t i o n s p e c i f y S t a t e s i d e , w h e t h e r s u p e r i o r o r i n f e r i o r f a c e t : 214 S c o l i o s i s " S C O L I O S " " L Y S I S " 1 " L I S T H E S " 1 " P O R O S I S " 1 " F R A C T U R E " 1 1 - none. ' . ; . ' . / D e s c r i b e and m e a s u r e ; 2 - 10 t o 20° 2 - o v e r 2 0 ° S p o n d y l o l y s i s - s p e c i f y s i d e 1 - none 2 - L4 2 - L I 2 - L 5 2 - L2 2 - S I 2 - L3 2 - o t h e r S p o n d y l o l i s t h e s i s - s p e c i f y t y p e by c a u s e i f p o s s i b l e 1 - none s e e n 2 - g r a d e 1 2 - g r a d e 2 2 - g r a d e 3 2 - g r a d e 4 O s t e o p o r o s i s 1 - none s e e n 2 - g r a d e 1 2 - g r a d e 2 2 - g r a d e 3 F r a c t u r e - d e s c r i b e t y p e and l e v e l 1 - none 2 - p r o b a b l y o l d 2 - p r o b a b l y new 2 - g r a d e 4 2 - g r a d e 5 2 - l o c a l i z e d o s t e o p e n i a - s p e c i f y 215 Myelogram dye 1 - none seen 2 - few drops 3 - moderate amount Evidence of laminectomy (posterior with bone removal - describe) 0 - none seen 1 - LI 1 - L2 1 - L3 Evidence of fusion 1 - L4 1 - L5 1 - Combination - specify 1 - posterior bone block 5 -- anterior interbody 2 - Boucher's type 6 -• 1 + 2 3 - posterolateral 7 -• 1 + 4 4 - apophyseal screws 8 - other combinations - specify 9 - other types - specify Split up into 1 - no 2 - yes for each type of fusion Level of fusion 0 - no fusion 5 -• L4 5 1 - L5 SI 6 -• L3 5 2 - L4 SI 7 -- L3 4 3 - L3 SI 9 - other - specify 4 - L2 SI Number of segments fused No recombination Solidity of fusion 0 - no fusion 1 - solid fusion 2 - pseudarthrosis Specify level(s) and criteria 216 Screws number present 0 none 4 4 1 1 5 5 2 2 6 6 3 3 7 more than 6 Screws abnormalities 1 - none 2 - normal 3 - bent 3 - broken Schmorl's nodes 1 - none Specify level and describe 2 - one site 2 - more than one site Knutsson's sign 1 - not seen 2 - L-5 SI only 2 - other sites - specify Posterior .joint degeneration 1 - none Specify site(s) and side 2 - 1 level, 1 side 2 - 1 level, bilateral 2 - more than 1 level 217 " S P U R S " 1 " O S T E O P H Y " 1 " L I G C A L C " 1 " B A A S T R U P " 1 " S K E L E X " T r a c t i o n s p u r s o f a n t e r i o r l o n g i t u d i n a l l i g a m e n t 1 - none 2 - p r e s e n t a t 1 s i t e 2 - p r e s e n t a t more t h a n 1 s i t e S p e c i f y l e v e l s and p o s i t i o n O s t e o p h y t e s 1 - none 2 - l o c a l i z e d 1 s i t e 2 - more t h a n 1 s i t e D e t a i l s i t e s L i g a m e n t o u s c a l c i f i c a t i o n 1 - none 2 - l o c a l i z e d 1 l e v e l 2 - more t h a n 1 l e v e l S p e c i f y p o s i t i o n and s i t e K i s s i n g v e r t e b r a l s p i n e s ( B a a s t r u p ' s phenomenon) 0 - none S p e c i f y l e v e l s 1 - 1 l e v e l 2 - 2 l e v e l s 3 - 3 l e v e l s 4 - 4 l e v e l s O t h e r s k e l e t a l p a t h o l o g y e . g . , P a g e t ' s , C a . 0 - a b s e n t 1 - p r e s e n t 218 " L A N G L E " 1 " D I S C M E A N " 1 "LUXMEAN"' "RETROAVG" " I P E D A V G " 1 L u m b o s a c r a l a n g l e i n d e g r e e s D i s c h e i g h t f r o n t b a c k L 1 2 L 2 3 L 3 4 L 4 5 L 5 S 1 P o s t e r i o r j o i n t s u b l u x a t i o n i n mm. a b o v e j o i n t - b o d y l i n e mean o f a l l p a i r e d measuremen ts L 1 2 L 2 3 L 3 4 L 4 5 R e t r o s p o n d y l o l i s t h e s i s ( i n mm. measured p o s t e r i o r l y ) mean o f a l l l e v e l s L 1 2 L 2 3 L 3 4 L 4 5 L 5 S 1 I n t e r p e d i c u l a r d i s t a n c e i n mm. mean o f a l l l e v e l s L 1 L 2 L 3 L 4 L. 5 219 " S A G M E A N " 1 S a g i t t a l d i a m e t e r o f c a n a l i n mm. mean o f a l l l e v e l s L 1 L 2 L 3 L 4 L 5 S I Body H e i g h t F r o n t B a c k mean o f a l l p a i r e d measurements L 1 L 2 "BODYMEAN" 1 L 3 L 4 L 5 " D I S C N E X T " 1 - D i s c h e i g h t a t t h e l e v e l i m m e d i a t e l y a b o v e t h e f u s i o n " L U M N E X T " 1 - P o s t e r i o r j o i n t s u b l u x a t i o n a t t h e l e v e l i m m e d i a t e l y above t h e f u s i o n " R E T R O N E X " 1 - R e t r o s p o n d y l o l i s t h e s i s a t t h e l e v e l i m m e d i a t e l y above t h e f u s i o n Psychological Interview Form 220 Datum Name Date of Exam. Subject # Sex Male 1 Female 2 Date of Birth / _ _ _ _ _ _ / Blank Age in years Position in birth order, from oldest Position in birth order, i f : 1 oldest 2 intermediate 3 youngest 1 only child Province of birth 1 not Canada 3 Quebec 2 B.C. 3 N.B. 3 Alberta 3 N.S. 3 Sask. 3 P.E.I. 3 Manitoba 3 Nfld. 3 Ontario 3 N.W.T. Size of community j> grew up in (use estimate of size i f several moves - most important betweel 10 and leaving home) 1 < 500 2 1 500 - 1,000 2 1 1,000 - 2,500 3 1 2,500 - 5,000 -2 5,000 -10,000 10,000 - 25,000 25,000 -100,000 > 100,000 can t estimate, many moves Occupation of father: 0 no father 1 farmer (owner) 2 own small business (like corner store) 3 own large business 4 professional (lawyer, doctor, engineer, etc.) 5 semi-professional (teacher, accountant) 6 clergy 7 salesman 8 blue-collar (clerk, agent, etc.) 9 minor supervisor (working) 10 service employee 11 laborer 12 unemployed 13 other 14 major supervisor 221 'PRELIG ,.1 MPCOMAT"J "CHILDHOD "FAMSICKA" "FAMSICKB" "FAMSICKC" "FAMSICK"1 (scored as total # entries) "INDEPEND"1 "EDUCAT"1 "UNIV"1 "VOCASCH"1 "APPRENT"1 "COMPLETE" Datum Parents religious? 1 no 4 very 3 moderately 2 a l i t t l e 3 one parent no, other 1 or 2 1 very moral, but not religious (only i f given spontaneously) How did parents get along? 1-70 scale 1-70 scale Indicate in separate "FAVSUBJ" IIHATESUBJ' grandparent uncle, aunt cousin unrelated member of household How happy was childhood? Any member of family "sickly"? columns up to 3 of: 0 none 5 1 father 6 2 mother 7 3 same sexed sib. 8 4 opp. sexed sib. At what age did j3 leave home permanently? (years) Number of years of grade school completed 1) Number of years University 2) Months of vocational school 3) Years of apprenticeship In the three above, indicate completeness: 0 didn't do any of 1-3 1 completed incomplete, withdrew (quit with l i t t l e reason) incomplete, was ejected moved down in order above and completed " " " " " didn't complete moved up in order above and completed " " " " " didn't complete 2 3 4 5 6 7 8 9 withdrew due war, lack of funds withdrew due health, emotional reasons What was favorite subject in school? (code below) What was most disliked subject in school? 0 can't answer 1 math 2 a science 3 English, or a language 4 history/geography 5 clerical 6 shop work, agriculture, home economics 7 sports 8 art - painting, music, drama 9 other 222 Datum "CFAITH"1 Religiousness 0 never have been religious 2 I always have been religious 3 have changed to more religious 1 have changed to less religious 2 remained religious, but changed faiths "SERVICE"1 Service "MSTATUS"1 " M A B N " 1 0 none 1 W.W. 2 didn't see battle 2 W.W. 2 did see battle 3 Korea.didn't see battle 4 Korea did see battle 5 both., didn't see Battle 6 both,, did see battle 7 peacetime forces only Present marital status: 0 single 3 separated 1 married 4 divorced 2 widowed 5 common-law Past marital record (excluding the above): 0 nothing to add 6 three or more separations 1 one divorce 7 one past common-law wife 2 two divorces 8 two or more past common-law 3 widowed once or more wives 4 one separation 9 refuses to talk 5 two separations "MARRIAGE"1 Status of present marital relationship: "SLIFE"2 1 2 2 2 3 4 5 Sex 1 2 2 2 2 , 2 2 3 3 3 3 3 3 4 1 there isn't one ready to break up would break up if not for children stormy but will remain intact indifferent about average above average superb refuses to discuss l i f e not exposed to one l i t t l e interest, mutual l i t t l e interest, spouse frigid or impotent l i t t l e - .spouse has other difficulty l i t t l e - S not interested (frigid or impotent) l i t t l e - "Because of j5's back because of ^ 's other troubles - mutual l i t t l e -moderate moderate -moderate -moderate -moderate -moderate -all's well refuses to spouse's lack of interest spouse's other troubles _S's lack of interest S/s back £>/s other troubles discuss 223 "KIDS"1 "MOOCHERA" "MOOCHERB" "MOOCHERC" "MOOCHERS"1 (Scored as total # entries) "MORTGAGE"1 Datum Number of children at home not 0-9 9=9 or more "HOWNER" "NINCOME"2 "SOURCEA" "SOURCEB" "SOURCEC" "INSITE"1 Does support anyone else? 0 no parent or grandparent f' of spouse sib. sib. of spouse removed relative " " of spouse child of relative child of spouse's relative unrelated child or adult 1 2 3 4 5 6 7 8 9 Does j> own home or apartment? 0 no 1 yes, large mortgage > $10,000 2 yes, moderate mortgage 5—10,000 . 3 yes, small mortgage < 5,000 4 yes, clear t i t l e Has j[ ever owned a home? 0 no 1 yes, had to give it up for financial reasons 2 yes, gave i t up because of other difficulties 3 yes, gave i t up for sake of convenience Income to jS"s family per month in $100s (gross) Source of income 0 no income (for sources 2,3) 1 business ownership 2 investments 3 S^  works 4 spouse works 5 pension 6 parents 7 children 8 welfare 9 jS won't say Does j5 think that personality or psychological status can have a bearing on the existence of or the exper-ience, of a back problem? 0 4 4 4 no yes, a l i t t l e yes, a moderate amount yes, quite a bit not now, but used to have a bit not now, but used to have a lot to do with i t not now, but used to have a moderate amount not for self, but for others a bit not for self, but for others a lot S^  will not give a direct answer Elaborate on back if thinks psych, status affects him 224 Datum " S H R I N K " 1 Has j> e v e r had p s y c h i a t r i c a t t e n t i o n ? . 0 no 1 - 8 9= 9 o r m o r e t i m e s o m i t DSM-2 codes f o r m a j o r d i s o r d e r s ( l e t 000 = no d i s o r d e r ) " S T I M E A " " S T I M E B " "RELSHRA" " R E L S H R B " " R E L S H R C " " R E L S H R " 1 ( S c o r e d a s t o t a l # e n t r i e s ) Wheri f i r s t p s y c h , a t t e n t i o n ? ( y e a r s ago) When l a s t p s y c h , a t t e n t i o n ? ( y e a r s a g o ; 0 = < 1 y r . o r none) Has anyone i n _S's f a m i l y had p s y c h i a t r i c a t t e n t i o n ' ? 0 no 1 g r a n d p a r e n t 2 p a r e n t 3 s i b . 4 s p o u s e 5 o f f s p r i n g 6 removed b l o o d r e l a t i v e 7 i n - l a w 8 u n r e l a t e d " f a m i l y " member '  o m i t DSM-2 c o d e s f o r t h e i m m e d i a t e l y a b o v e , i n o r d e r g i v e n How does ^ f e e l abou t t a k i n g p a r t i n t h i s s t u d y ? o m i t 0 no r e s p o n s e 1 g r e a t d i s l i k e 2 m i n o r d i s l i k e 3 i n d i f f e r e n t 4 g l a d t o h e l p 225 "CATRAW" "CATIQ"4 "KCPAST"1 "KCNOW"4 "KCFUT"4 "KCTREND" Subject #: Data Summary Form Cattell Form A Raw Score Cattell Form A IQ (sigma = 16) Kilpatrick-Cantril Data Past Standing (00-100) Present Standing (00-100) Future Standing (00-100) Trend over time (if only 2 points, code 1, 2 or 3) "BECK"4 "MMP.IL"1 "MMPIF"1 "MMPIK"1 "MMPIHS"4 "MMEID"4 "MMPIHY"4 — = i A = 7 / = 2 V = 8 \ = 3 v/ = 9 A - 4 10 /\- 5 \y = 11 ~ \ = 6 V_ = 12 r-13 Beck D.I. Score MMPI T-score Data L F K Hs D Hy "MMPIPD' .1 "MMPIPT "MMPISC"1 "MMPIMA"1 "MMPISI"1 "MMPIES"4 "MMPILB"1 "MMPIMF"1 "MMPIPA"1 "TAYLOR"4 "CPIDO"1 "CPICS"4 "CPISY i l "CPISP"4 "CPISA"1 "CPIWB"1 "CPIRE"1 "CPISO"1 "CPISC"1 "CPITO"1 "CPIGI"1 "CPICM"1 "CPIAC"1 "CPIAI"1 "CPIIE"1 "CPIPY"1 "CPIFX"1 "CPIFE"1 Pd Pt Sc Ma Si Es Lb Mf Pa Taylor M.A.S. raw score CPI Data. Standard Scores Do Cs sy Sp Sa Wb Re So Sc To Gi Cm Ac Ai Ie Py Fx Fe 

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