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PURPOSE: To measure the cerebrospinal fluid (CSF) velocity in the cervical spinal canal both above and below a stenotic segment in patients with cervical spinal stenosis. The cord velocity was also measured at the level of C2. MATERIAL AND METHODS: Thirteen patients with chronic neck pain were examined with MR imaging. The degree of cervical spinal stenosis was assessed and measured on MR images and CSF velocity in the cervical spinal canal was measured using the phase MR flow quantification method at the level of C2 and below the stenotic segment. The cord motion was measured at the level of C2. RESULTS: The peak velocities of CSF in front of the cord at the level of C2 were, on average, a little higher than behind the cord, but the interindividual variation was high. The caudal or rostral velocities of CSF above and below the stenotic segment could be measured in most cases and they were not dependent on the degree of stenosis when assessed visually. When the stenosis was assessed by relating the cord area to the dural sac area, a statistical correlation between narrow spinal canal and high velocities in the anterior CSF space below the stenotic segment was found. CONCLUSION: Spinal stenosis does not alter the cord or CSF velocities at the C2 level, but increases the velocity of CSF in the anterior CSF space below the stenotic segment when the stenosis is assessed by cord and dural sac area measurements.

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The theoretical assumptions concerning the assessment of some physical disease consequences according to the Biopsychosocial Dimensional Classification (BPSDC) model were tested in patients with chronic low back pain. Factor analyses showed that the mutual relations of selected measures for biodisabilities, as well as their relationship to some measures of bioimpairments, and bio- and psycho-handicaps supported many of the original assumptions of the BPSDC model. For instance, several dynamometer and non-dynamometer measures of physical capacity and performance associated themselves with the factor of 'physical fitness' interpreted to represent disabilities. A very interesting observation was that the subjective experiences of pain intensity, pain interference and management in various physical activities assessed by self-reports, represented the psycho-axis instead of the bio-axis. Another interesting notion was that the measures for organic pathology, i.e. 'neuromuscular findings' and 'spinal findings', separated themselves from other factors, and were interpreted to represent bio-impairments. Additionally, the range of motion measures in active movements and body positions were related to organic pathology, and were thus interpreted to bio-impairments, not disabilities as previously thought. It is emphasized that in order to know about the clinical meaningfulness of the dimensions found, further studies about the predictive value of the factors should be performed.

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To compare the effectiveness of diverse rehabilitation programmes, comparable data about their effects on maintaining or improving the residual function of the rehabilitation patients should be gathered. Current rehabilitation theories and assessment procedures for functioning are not consistent enough for valid comparisons. The rehabilitation theory should be developed to produce coherence and generalizability to the rehabilitation process. The biopsychosocial disease consequence (BPSDC) model for functioning is presented for this purpose. The model describes the rehabilitation process of patients with chronic pain as a three-axial (biopsychosocial) and three-dimensional (disease consequences) assessment and intervention grid for functioning. It emphasizes the strict mutual relationship between the assessment procedures and intervention plans. Application of the BPSDC model in the Finnish AKSELI project studying the effects of two different programmes on patients with chronic low-back pain is described. Although the AKSELI studies indicated that in addition to the assessment procedures other factors also contributed to valid evaluation of outcomes, and it is hoped that the BPSDC model will encourage researchers to look for definitions of functioning, to assess functioning according to theoretical assumptions about the sub-areas of functioning, and to provide comparable outcome data for the evaluation of various programmes.

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The purpose of this study is to emphasize the meaningfulness of a global, functional rather than a narrow medical view in the efficacy evaluation of chronic pain treatment. Therefore, the 'Biopsychosocial Disease Consequence (BPSDC) model' to assess function more globally than before, is presented in this article. The model is based on two theories: (1) the biopsychosocial approach and (2) WHO's classification of impairments, disabilities and handicaps. In addition to the presentation of the conceptual model, the development of the hypothetical criteria and assessment models for psychological impairments, disabilities and handicaps, and the validity testing of the psychological assessment axis are described. Within each of the three classes, i.e. psychological impairments, disabilities and handicaps, the results supported the independence of the hypothetical criteria from each other. On the other hand, results suggested that some changes to the hypothetical assessment models for some of the criteria might be valuable. It was concluded that although the most adequate psychological assessment models for function, found in this study, can be considered as robust and recommendable as one set of tools for functional assessment, the main aim of this article is to encourage multidisciplinary team efforts to develop and systematize the assessment procedures of function in patients suffering from chronic diseases.

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STUDY DESIGN: The authors conducted a controlled clinical trial with 1-year follow-up to define the effectiveness of an intensive physical and psychosocial training program on patients with low back pain. SUMMARY OF BACKGROUND DATA: The intervention group included 152 patients (mean age 40.5 yr, Million index 45.1/100), and the reference group included 141 patients (mean age 40.4 yr, Million-index 44.5/100). METHODS: The progressive intervention program consisted of intensive physical training and psychosocial activation. The outcomes were physical and psychosocial measures, the pain and disability index (Million), sick leaves, and occupational handicap. RESULTS: The intervention was more efficient with respect to physical measures and pain and disability index. There were only mild or no differences in changes between the study groups in psychologic variables, sick leaves, or retirement. CONCLUSIONS: The intervention program could improve physical disability, but to improve occupational handicap, activities of the whole society (social legislation, labor market policy) are needed.

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OBJECTIVE: To search for generalizable, psychological predictors of chronic pain treatment outcome. DESIGN: The prognostic power of the psychological predictors, classified into subareas of function, i.e., impairments, disabilities, and handicaps, was compared in predictive situations varying with the quality of patient samples, programs, and outcome measures. SETTING: Four rehabilitation centers in Finland providing "functioning activation" or more passive "spa resort" treatment programs for low back pain patients. PATIENTS: 173 low back pain patients for whom the inpatient rehabilitation program was funded by the Finnish Social Insurance Institution. OUTCOME MEASURES: The measures were panel assessment of global functioning (DSM III Axis V), self-report of handicap (Million), panel assessment of handicap (WHO index), panel assessment of adherence (four rating scales), and self-report of well-being (Faces scale). RESULTS: Multivariate, stepwise regression analyses suggested that the disability and handicap measures of functioning may be more effective predictors than impairment measures, which, however, add to the variance explained by the former. However, the predictive power of psychological impairments, disabilities, and handicaps varied with differences in patient group, outcome measure, and program. CONCLUSION: The "general predictors" of chronic pain treatment outcome may be difficult to find. Therefore, planning treatment for the individual patient may always have to be based on accurate multiaxial and multidimensional assessment of patient functioning.

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The reproducibility of measurements with the triaxial lumbar dynamometer Isostation B-200 was measured in 61 volunteers with or without low back problems. Both for the intra- and interrater measurements the reproducibility was good (r = 0.76-0.89) for lateral flexions and almost as good (r = 0.76-0.87) for the sum of all ranges of motion (SROM). The corresponding reproducibilities were excellent (r = 0.82-0.99) for the isometric strength and good (r = 0.60-0.90) for isoinertial flexion-extension repetition test parameters in the main (primary axis) direction. A number of parameters were combined into three functional indices: the reproducibility for "power" and "work" index was good (r = 0.76-0.94) in both intra- and interrater conditions, whereas for "movement" index it was somewhat weaker (r = 0.53-0.87). It is concluded that parameters: lateral flexions, SROM, isometric strength, and functional indices (power and work) are reproducible enough to use in further studies.

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This study aimed to evaluate the lumbar intervertebral discs and the maximum isometric strength and size of the trunk muscles of middle-aged healthy volunteers (60 persons) and low back pain patients (48 persons). Disc degeneration was more frequently seen in the patients than in the healthy volunteers. The psoas and back muscles (erector spinae and multifidus) of the patients were smaller than those of the volunteers. Patients had also more fat deposits in the back muscles than controls. The maximum isometric strength of trunk muscles of the patients was on average weaker than that of the volunteers. However, the size of the back muscles was not related to the maximum isometric extension strength of the trunk.

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Fifty-six chronic low back pain (CLBP) patients participated in a controlled, prospective 5-yr follow-up study evaluating the long-term effects of five-session couple therapy. Twenty-eight patients were included both in the treatment group and in the control group. Outcome measures were self-reported psychological distress, marital satisfaction, health locus of control, pain and disability as well as clinical examinations. The reliability of the outcome measures was statistically analysed and found acceptable. At the 5-yr follow-up assessments, psychological distress was found to be decreased in the treatment group and increased in controls. The difference between the groups was significant. No difference was found in the other self-reported or clinical outcome measures. We conclude that couple therapy has a prolonged beneficial effect on the mental well-being of CLBP patients.

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It has been proposed that pain treatment evaluation is hindered by heterogeneous properties of patient samples. Therefore, to facilitate pain treatment evaluation in this psychological study, a heterogeneous group of chronic low back pain patients was classified into more homogeneous subgroups. Two designs were used to compare the outcome by the "functioning activation" and the "spa resort" type of rehabilitation. In the first design, the outcome was compared in groups, clinically homogenized by sociodemographic variables and in respect to contraindications for heavy physical training. In the second design, the pain patient subgroups, homogenized by cluster analysis technique in accordance with the psychological profiles of functioning, were compared in their response to treatments. The results indicated that the outcome evaluation was facilitated by the latter design releasing more specific information about the effects of the program quality, the patient characteristics, and their interaction on the improvement by rehabilitation. It was concluded that in treatment outcome analysis, the subgroup's homogeneity must be considered.

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This study addresses the psychological assessment of functioning in chronic pain patients. First, a model of functional assessment is proposed, which is based on the biopsychosocial view of chronic disease (Engel) and on the consequences of diseases (WHO). Second, a set of psychological criteria for impairments, disabilities, and handicaps, described by WHO as the consequences of diseases, are determined. Third, the psychological criteria selected are operationalized and the utility of the psychological assessment instruments tested in a clinical rehabilitation study. The results indicate that prediction of post-treatment functioning in the rehabilitation patient, by psychological procedures, may improve if the concept of functioning is determined as three sub-areas of impairments, disabilities, and handicaps.

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A group of 12 sedentary medical students (1 man and 11 women aged 21-27 years) participated in a strength training programme for the trunk muscles lasting 18 weeks. The maximal isometric flexion and extension forces of the trunk muscles were measured before the training and at 18 weeks by dynamometer. The cross-sectional area of the back muscles, i.e. erector spinae, multifidus and psoas muscles, was measured from magnetic resonance images (spin echo sequence TR/TE 1500/80, slice thickness 10 mm) obtained at the L4-L5 disc level before the training, at 11 and 18 weeks. During training, no significant change in the body mass or body fat content was found. Muscle forces or muscle cross-sectional area were not related to body mass. There was a significant increase in both trunk muscle cross-sectional area (psoas muscle P < 0.001 and back muscles P < 0.01) and trunk muscle forces (flexion and extension forces P < 0.01) during the training but no direct association between the muscle cross-sectional area and strength of the flexors and extensors was detected before or after the training.

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Family-oriented approaches and consequent conjoint marital sessions have been widely accepted as ingredients of comprehensive treatment and rehabilitation of chronic pain patients. However, no controlled trials have been conducted to confirm the effectiveness of couple therapy in these patients. We examined 63 chronic low back pain (CLBP) patients identified in primary health care centres. They were randomly allocated to a couple therapy group (n = 33) and to a control group without couple therapy (n = 30). The therapy consisted of five monthly sessions and was attended by two family therapists. All patients attended an initial examination and a 12-month follow-up examination. Effects on self-reported pain, disability, and some clinical measures, as well as on the use of medical services were evaluated. The study groups did not differ significantly in any of the outcome measures. Hence, we conclude that couple therapy has no significant effect on disability in CLBP patients.

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This study examined the relation between marital satisfaction, psychological distress, self-reported pain, disability, and clinical findings in 63 chronic low-back pain (CLBP) patients from primary health care centers. The relation between marital satisfaction and psychological distress in their spouses was also studied. Marital dissatisfaction in female CLBP patients was significantly associated with psychological distress, as well as with patient self-reported pain and disability. Marital dissatisfaction in their male spouses was also strongly related to psychological distress. In male CLBP patient couples, marital dissatisfaction and psychological distress were much less significantly related. This gender difference should be taken into account in the treatment of CLBP couples.

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