Chapter II

Review of related literature

According to Emine Aslan Telci from the year 2013, Chronic low back pain (CLBP) is
one of the most important health problems in adults.

Patients with CLBP often report a

decreased level of mobility due to pain.

Mobility is a vital factor in order to be able to perform the activities of daily living. Ones
state of mobility affects his/her medical condition and state of well-being. Self-report measures
for related physical functions assess the perceived physical status in subjects with low back pain.
Some studies show a mismatch between self-reported measurements and observed disability. It
was stated that the tests such as muscle strength and range of motion, which are used to measure
the functional level in patients with low back pain, remain incapable of determining disability in
daily life as they measure determining physical impairment. The majority of the tests used to
assess functional level have aimed to measure trunk mobility and the coordination of speed and
movement, in the last few decades in particular. Some tests such as progressive isoinertial lifting
test, which evaluate the functional level for patients with low back pain require suitable space,
time and equipment. Therefore, it is important to choose the most suitable tests among various
functional tests in order to determine performance level of people with CLBP.
The assessment of trunk mobility in different activities better reveals the difference
between subjects with and without CLBP. The Back Performance Scale (BPS) is a useful
instrument for determining the performance of the individuals with CLBP.

The relationship between the psychological status and spinal pain has not been fully explained.
One study found the incidence of depressive symptoms to be higher in community-dwelling
elderly people with low back and neck pain compared to elderly people not experiencing without
pain. Our main goal in this study, which was planned as a home-based study, was to determine
the degree of mobility difficulty faced by older adults with CLBP during activities of daily living
and to describe the impact of CLBP. We preferred to use performance-based measurements
imitating the activities of daily living for this purpose.
Another one from Robert Froud, Whilst back pain is not itself life-threatening, it does
threaten quality of life. In the absence of diagnosis and effective treatment, complex enmeshment
and interactions can ensue between chronic LBP, identity, and social roles, having a diverse and
pervasive impact of the condition with life-changing psychological and social consequences.
There is little in the data to suggest that individual characteristics, country, or study setting are
associated with differences in described impact of LBP. There is some suggestion that age is a
factor in determining the impact of perceived threat to career, and one setting in which a back
pain sufferer and his wife were interviewed together, described a more supportive relationship
than was otherwise typical.
The back-specific core sets of outcome measures recommended by Deyo et al. in 1998,
and later updated by Bombardier et al. in 2000, recommend measurement in the domains of pain,
function, well-being, disability, and work disability. WHO made back-specific recommendations
to measure pain, disability, and depression, in 1999. International Classifications of functioning
(ICF) categories were later proposed, with a core-set of 78 (comprehensive) or 35 (brief)
categories being recommended for LBP in 2004. The brief set, intended in particular for use in

clinical studies, has been criticised for incomplete coverage. Accepting that both the aetiology
and management of LBP fits a biopsychosocial model, and if it follows that outcome
measurement coverage should be associated with this trinity, then the recommended coverage
may be incomplete. Whilst the bio- component is well-represented within recommendations,
psychological factors are less well represented, and the social factors identified by this review
are not represented at all in recommendations; excluding the comprehensive ICF core-set, which
is likely to be too large to be of practical use in clinical studies. Deyo originally suggested that
disability (in parentheses social role) be measured using the number of days off-work, reduced
activities, or bed rest. The domain was later renamed work disability in the Bombardier update,
which with a shifted focus, it was suggested should be measured using the number of days off
work, the number of days of cut-down work, and the time for return-to-work.

A study from Kose G. from the year 2012, it states that this study was performed to
assess disability on daily living activities, which developed secondary to low back pain, in
patients with lumbar disc herniation and treated either conservatively or surgically. The study
was performed between November 2008 and June 2009. Visual analogue scale (VAS) was used
to measure the intensity of pain, and the Oswestry Disability Index (ODI) was used to assess the
disability of the patients on daily living activities. Of the 112 patients, 55 were women and 57
were men. The mean age was 39.68 years for the conservative treatment group and 46.46 years
the for surgical treatment group. In the pretreatment period, the patients who were selected for
surgical treatment had higher VAS score and ODI than did the patients who were selected for
conservative treatment.

The disability areas that were reported in the pretreatment period were walking, sleeping,
standing, and traveling for the surgical treatment group and self-care, sitting, and social life areas
for the conservative treatment group. When the ODI and VAS score of the patients were
statistically compared at the third month of posttreatment period, the scores were significantly
low in the surgical treatment group. The disability areas that were reported at the third month of
posttreatment period were weight lifting, self-care, and walking for the surgical treatment group
and social life, sleeping, sitting, and standing for the conservative treatment group. This study
found that patients with low back pain experience physical disabilities due to pain. Their daily
living activities are affected by these disabilities and the intensity of pain affects the level of
disability. Knowledge of the disability areas caused by low back pain plays an important role in
the determination of nursing care and content of the education which will be offered to the
patients. The use of scale on the patient's care is important to form a common language in
nursing and to obtain evidence-based data related to the patients.
According to Michael Vianin in his study from the year 2008, Clinical decision making
relies on valid and reliable outcome measures. Outcome measures determine clients' disability
and impairment, choice of therapy, and degree of change over time. To be clinically meaningful,
an outcome measure must be easy to complete and score, valid, reliable, and responsive.
The Oswestry Disability Index (ODI) is one of the most commonly used outcome
measures for individuals with low back pain (LBP). The ODI is a self-administered questionnaire
that requires 5 minutes to complete and 1 minute to score. Scores are associated with degree of
disability ranging from minimal to bedbound. The ease of administering, scoring, and
interpreting renders the ODI a potentially meaningful tool in clinical practice. Psychometric
characteristics (validity, reliability, and responsiveness) of the ODI are the final determinants of

the questionnaire's suitability as a clinically useful measure. Validity expresses the ability of a
tool to measure what it intends to measure, whereas reliability describes a tool's ability to be
consistent, to have small errors of measurement, and to differentiate among clients. A valid and
reliable outcome measure is clinically relevant only if it possesses the ability to assess change
over time (sensitivity to change). Even more clinically meaningful is the measurement of change
over time that is important to clients (responsiveness).
The determination of the appropriateness of the ODI as an outcome measure used to
direct clinical decision making requires a critical review of its psychometric properties,
interpretability, and burden of administration. His method in his study, A literature search of
relevant databases on psychometric evaluation of the ODI was performed. The search was done
using the key words disability evaluation, and low back pain, and questionnaires, and
reproducibility of results, and the term Oswestry. Inclusion criterion was direct reference
regarding psychometric property, interpretability, and burden being included in the abstract. The
results: The ODI's psychometric properties have been well established. The ODI correlates with
other outcome measures aiming at measuring disability due to LBP. Validation of the Pain
Disability Index, the Low Back Outcome Score, the Manniche Scale, the Aberdeen Score, the
Curtin Scale, and a functional capacity evaluation was performed with the ODI. Therefore, the
ODI shows good construct validity because it is consistent with some and was used as the
standard of comparison for other outcome measures assessing LBP-induced disability.