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Difference in evaluation of patients with low back pain using the Japanese Orthopaedic Association Score for Back Pain and the Japanese Version of the Roland-Morris Disability Questionnaire
J Orthop Sci (2009) 14:367–373 DOI 10.1007/s00776-009-1348-5
Original article Difference in evaluation of patients with low back pain using the Japanese Orthopaedic Association Score for Back Pain and the Japanese Version of the Roland-Morris Disability Questionnaire MASAO NAKAMURA1, KEI MIYAMOTO2, and KATSUJI SHIMIZU3 1
Department of Orthopaedic Surgery, Mino Municipal Hospital, Mino, Gifu, Japan Department of Reconstructive Surgery for Spine, Bone, and Joint, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 5011194, Japan 3 Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan 2
Abstract Background. The number of patients suffering from degenerative diseases in the lumbar spine is increasing in Japan. Although various scales to measure disability or quality of life in patients with low back pain and/or lumbar diseases are currently available, it has been shown that one questionnaire is not always compatible with another. Our purpose is to evaluate the association and differences between the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese Orthopaedic Association score for low back pain. Methods. These two scales were examined and compared using data from 602 patients with low back pain and/or lumbar disease. The associations between the Japanese version of the Roland-Morris Disability Questionnaire and each subscale in the Japanese Orthopaedic Association score in back pain dominant group and leg pain dominant group, and with respect to six pathological conditions (i.e., sciatica, spondylosis, spondylolisthesis, lumbar spinal canal stenosis, muscular pain, traumatic pain) were analyzed. Results. While the Japanese version of the Roland-Morris Disability Questionnaire and the Subjective and Activities of daily living (ADL) subscale of the Japanese Orthopaedic Association score showed a good correlation (r > 0.60), the Japanese version of the Roland-Morris Disability Questionnaire and the Clinical subscale showed a weak correlation (r = 0.35). Among the six pathological conditions, the correlation between the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese Orthopaedic Association score was the lowest (r = 0.66) in the lumbar spinal canal stenosis category. Conclusions. The clinical signs in patients with low back pain and/or lumbar diseases are not associated closely with the Japanese version of the Roland-Morris Disability Questionnaire. Therefore, a combination of the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese
Offprint requests to: K. Miyamoto Received: May 7, 2008 / Accepted: March 2, 2009 M. Nakamura and K. Miyamoto made equal contributions to this study
Orthopaedic Association score can provide wide-ranging assessment of the level of impairment in patients with low back pain and/or lumbar diseases.
Introduction With the increase of the aged population, the incidence of degenerative diseases in the lumbar spine is increasing in Japan.1 Low back pain (LBP), one of the major symptoms of this type of disease, causes deterioration of the patients’ activities of daily living (ADL) and quality of life (QOL) levels.2,3 In the Japanese population, whether young or aged, the prevalence rate of LBP is rather high, at more than 25%.4 Therefore, it is essential for clinicians to evaluate the LBP in patients accurately. The Japanese Orthopaedic Association score for back pain (JOA score) was established and validated in 1986 for evaluating LBP and/or lumbar spinal diseases (LD)5,6 (see the Appendix) and has been used by Japanese clinicians in the field of orthopedic medicine to estimate the severity of LBP or clinical outcomes most frequently.5,6 The JOA score consists of three subscales: Subjective symptoms, Clinical signs, and ADL, providing clinicians with significant information.7 The score is unique in that it is obtained by the examiners noting patients’ replies to questions plus clinical findings by examination. In 1986, the Roland-Morris Disability Questionnaire (RMDQ), consisting of 24 questions, was published as a measure to assess disability and QOL level of patients with LBP and/or LD.8,9 This questionnaire is simple and easy to read.10,11 In 2003, the Japanese version of the RMDQ (JRDQ) was introduced, and its validity and reliability were confirmed.4,12–14 Although some scales to measure disability or QOL in patients with LBP/LD are currently available,15–20 they are not always compatible with one another. Taking
8.1 (3.2) [range 0–14] 8.0 (3.2) [range 0–14] 8.3 (3.0) [range 0–14] 4.9 (1.4) [range 0–6] 5.1 (1.2) [range 0–6] 4.3 (1.6) [range 0–6] 5.1 (2.0) [range 0–9] 5.4 (1.9) [range 0–9] 4.4 (2.0) [range 0–8] 18.1 (5.7) [range 0–23] 18.4 (5.2) [range 1–28] 17.1 (5.4) [range 0–28]
ADL subscale (range 0–14) Clin.subscale (range 0–6) Subj.subscale (range 0–9) Total score (range 0–29)
into consideration that the JOA score consists of three subscales and thus can evaluate patients from multiple aspects, it might be important to know the association between the JRDQ and each subscale of the JOA score. The purpose of this study was to elucidate the association and difference between the JRDQ and the JOA score, the three subscales of the JOA score (Subjective, Clinical, ADL) in two groups divided according to the visual analogue scale (VAS) scores21–24 and diagnoses of LBP/LD.
Methods Participants A total of 602 patients (male/female ratio 260:342; age 64.6 ± 17.3 years) with back and/or leg pain participated in this cross-sectional study. The subjects consulted our university hospital and four other affiliated hospitals between November 2001 and June 2004, and all were examined by one orthopedic surgeon. The subjects were asked to check the VAS for back pain (VAS-back) and the VAS for leg pain (VAS-leg). According to the VAS marks, the population was then divided into two groups. The patients with VAS-back marks equal to or higher than those of the VAS-leg were classified as the Back-dominant group (456 cases) (VAS-back mean 50.0 ± 24.6, VAS-leg mean 10.0 ± 21.0), and the other patients were included in the Legdominant group (146 cases) (VAS-back mean 23.2 ± 25.5, VAS-leg mean 60.6 ± 25.3) (Table 1).
JRDQ (range 0–24)
8.5 (5.7) [range 0–23] 8.3 (5.7) [range 0–23] 9.0 (5.5) [range 0–23] Total (n = 602) Back-dominant group (n = 456) Leg-dominant group (n = 146)
Methods
Group
JOA score for low back pain
M. Nakamura et al.: Difference between JOA score and JRDQ Table 1. Clinical data [average (SD)] of the Japanese version of the Roland-Morris Disability Questionnaire (JRDQ) and the Japanese Orthopaedic Asociation (JOA) score for low back pain
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The participants were asked to fill out the JRDQ by themselves. The previously published version of the JRDQ by the present authors12 was used. The JOA score was marked by the orthopedic surgeon. The JOA score has a maximum of 29 points, with three subscales: Subjective symptoms (maximum score 9 points), Clinical signs (6 points), and ADL (14 points). We tested for a significant correlation between the JRDQ and the JOA score in each group using regression analysis in which the JOA score served as a standard and the JRDQ as a parameter. The JRDQ and the JOA score had a negative correlation. To understand their relation better, the JOA score was modified to make the correlation positive. The acquired marks were subtracted from the maximum mark of each scale; that is, the total JOA score, the Subjective, Clinical, and ADL subscales, and the subtracted values were renamed as the JOA minus (29 — JOA total score), the Subjective minus (9 — Subjective subscale), the Clinical minus (6 — Clinical sub-
M. Nakamura et al.: Difference between JOA score and JRDQ
369
Table 2. Descriptive statistics of the JRDQ, the JOA score for low back pain, VAS-Back, and VAS-Leg
Group Total Sciatica Spondylosis Spondylolisthesis LSCS Muscular pain Traumatic
JRDQ
JOA score
VAS-back
VAS-leg
No. of subjects (male : female)
Age (years)
mean (S.D.)
max min
mean (S.D.)
max min
mean (S.D.)
max min
mean (S.D.)
max min
602 (260–342) 198 (109 : 89) 126 (38 : 88) 105 (34 : 71) 93 (46 : 47) 57 (30 : 27) 23 (7 : 16)
64.6 (11–93) 54.2 (13–91) 74.2 (45–93) 67.6 (23–86) 75.3 (52–90) 53.7 (11–83) 70.7 (27–81)
8.5 (5.7) 8.5 (5.6) 8.3 (5.5) 7.3 (5.2) 9.8 (5.1) 7.3 (5.8) 13.3 (7.6)
23 0 22 0 22 0 20 0 23 0 22 0 23 2
18.1 (5.3) 17.2 (5.7) 19.0 (4.7) 19.6 (4.7) 16.3 (4.6) 20.6 (4.7) 16.0 (6.1)
28 1 28 1 28 5 27 3 26 2 27 9 27 8
43.5 (27.4) 43.4 (28.6) 44.4 (24.8) 42.5 (25.7) 34.9 (28.9) 54.8 (25.5) 48.8 (26.3)
100 0 100 0 100 0 100 0 100 0 100 3 92 0
22.4 (31.1) 26.9 (32.0) 23.7 (11.0) 24.0 (30.4) 42.9 (34.7) 3.7 (13.3) 3.1 (14.3)
100 0 100 0 100 0 100 0 100 0 80 3 67 0
scale), and the ADL minus (14 — ADL subscale). The relations between the JRDQ and the modified scores were then evaluated. Urinary function, one of the subscales for the JOA score, was not used in the present study. To estimate the difference between the JRDQ and the JOA scores among lumbar spine-related diseases, the population was divided into six categories according to diagnosis based on the physical examination and image findings, including plain radiography, computed tomography, and magnetic resonance imaging. The six categories were sciatica, spondylosis, spondylolisthesis, lumbar spinal canal stenosis (LSCS), muscular pain, and traumatic pain. We categorized spondylosis and spondylolisthesis with intermittent claudication and/or equina symptoms as LSCS. Sciatica was diagnosed when the nerve root tension sign was positive using the straight-leg-raising test (SLRT). The traumatic pain group included patients with fresh compression fractures within a week of injury. The correlations between the JOA score and the JRDQ in these categories were then calculated (Table 2). Statistical analyses All data were collected by one examiner. Statistical analysis with Spearman’s correlation analysis was performed between the JRDQ and the JOA score, the three subscales of the JOA score, and the three branches of the Clinical subscale of the JOA score. Regression analysis was used to test the relations among these scales, subscales, and branches as metrics. StatView version 5 software (Abacus Concepts, Berkeley, CA, USA) running on Microsoft Windows XP (Microsoft, Redmond, WA, USA) was used.
Ethical considerations This study was approved by our institution’s ethics committee. The patients and/or their families were informed that data from the case would be submitted for publication and gave their consent.
Results Table 1 shows the averages of raw marks of the JRDQ, the JOA total score, Subjective subscore, Clinical subscore, and ADL subscore for the total population, the Back-dominant group, and the Leg-dominant group. The correlation coefficient between the JRDQ and the JOA minus was 0.75 (P < 0.0001) in the total population, 0.75 in the Back-dominant group, and 0.76 in the Leg-dominant group (Table 3). The coefficient of determination between the JRDQ and the JOA minus was >0.50 (0.58). These observations indicate that there is little dispersion between these two scales. In addition, the JRDQ and the JOA minus had an excellent correlation. As shown in Table 3 and Fig. 1 for each group, the correlation coefficients between the JRDQ and the Clinical minus and the three branches of the Clinical minus (SLR minus, Sensation minus, Muscle Power minus) were <0.40; however, all those between the JRDQ and the JOA minus, the Subjective minus, the ADL minus were >0.60. Especially, SLR minus showed a much lower correlation coefficient (0.10) with the JRDQ in the Leg-dominant group. Similarly, the Muscle Power minus showed a lower correlation coefficient (0.12) with the JRDQ in the Back-dominant group (Table 4).
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M. Nakamura et al.: Difference between JOA score and JRDQ
Table 3. Correlation coefficients between the JRDQ and the JOA score for back pain JOA score for back pain JRDQ Total (n = 602) Back-dominant group (n = 456) Leg-dominant group (n = 146)
JOA minus
Subjective minus
Clinical minus
ADL minus
0.75*** 0.75*** 0.76***
0.63*** 0.61*** 0.68***
0.35*** 0.27*** 0.37***
0.73*** 0.74*** 0.73***
*** P < 0.001
Table 4. Correlation coefficients for the JRDQ and the JOA score for back pain JOA score for back pain Clinical minus
Subjective JOA minus minus Clinical total
JRDQ Total (n = 602) Back-dominant group (n = 456) Leg-dominant group (n = 146)
0.75*** 0.75*** 0.76***
0.63*** 0.61*** 0.68***
SLR
0.35*** 0.27*** 0.37***
0.39*** 0.39*** 0.10
Sensation Muscle Power ADL minus 0.37*** 0.39** 0.34***
0.36*** 0.12* 0.33***
0.73*** 0.74*** 0.73***
*** P < 0.001, ** P < 0.01, * P < 0.05
(B)
(A) r=0.61, P<0.0001
r=0.30, P<0.0001
30
10
20
10
0
0 0
2
4
6
8
10
Subjective minus
r=0.73, P<0.0001
30
JRDQ
20
JRDQ
JRDQ
30
(C)
20
10
0 0
2
4
6
8
Clinical minus
Regardless of the diagnosis of LBP/LD of patients, the correlation coefficient between the JRDQ and the Clinical minus was, at most, 0.50. In contrast, the correlation coefficients between the JRDQ and the JOA minus, the Subjective minus, and the ADL minus were >0.50, with most of these scores being >0.7 (Table 5). The correlation coefficient between the JRDQ and the total JOA minus was lowest in the LSCS category (0.66), compared to other five categories. The same tendency was observed between the JRDQ and the Subjective minus (0.55 in LSCS) and ADL minus (0.63 in LSCS). In all categories, the correlation coefficients between the JRDQ and the Clinical minus were relatively low. The VAS-leg scores were very low in both the Muscular Pain category (3.7) and the Traumatic category (3.1) (Table 2). Whereas the maximum scores of the other four categories were 100, the maximum scores in these two categories reached only 80 and 67, respectively.
0
4
8
12
ADL minus
16
Fig. 1. Regression analysis between the JRDQ and the subjective minus (A), between the JRDQ and the Clinical minus (B), between the JRDQ and the ADL minus (C). The ellipses in each figure indicate the tolerance limits. Subjective minus: 9 — Subjective subscale. Clinical minus: 6 — Clinical subscale. ADL minus: 14 — ADL subscale
Discussion Regression analysis between the JRDQ and the JOA score had no significant outliers in the present study. The results showed the coefficient of determination to be >0.5, indicating that the JRDQ and the JOA score have a relatively strong relation (r = 0.74, r2 = 0.56) (Table 3, Fig. 2). However, the Clinical minus and the JRDQ showed a relatively weak association with the JRDQ, and the JRDQ showed a strong association with the Subjective minus and the ADL minus. This weak association may be due to the fact that the Clinical subscale does not pick up the patient’s pain itself, but neurological disturbance including motor and sensory functions.5,6 These clinical findings, including reduced muscular strength or decreased sensing ability, were demonstrated when determining the treatment plan for each patient.
M. Nakamura et al.: Difference between JOA score and JRDQ
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Table 5. Correlation coefficient between the JRDQ and the JOA minus, Subjective minus, Clinical minus, and ADL minus using Spearman’s correlation coefficient by rank in the validity test JOA score for back pain
JRDQ Sciatica Spondylosis Spondylolisthesis LSCS Muscular Pain Traumatic
Clinical minus
JOA minus
Subjective minus
Clinical total
SLR
Sensation
Muscle Power
ADL minus
0.79*** 0.72*** 0.73*** 0.66*** 0.72*** 0.83***
0.66*** 0.57*** 0.62*** 0.55*** 0.63*** 0.70**
0.44*** 0.41*** 0.31** 0.26* 0.50** 0.18
0.41*** 0.43*** 0.37*** 0.57*** 0.49*** 0.31
0.35*** 0.44*** 0.35*** 0.31*** (see foot notes†) 0.40
0.38*** 0.40*** 0.35*** 0.23 0.52*** 0.12
0.77*** 0.69*** 0.73*** 0.63*** 0.68*** 0.86***
*** P < 0.001, ** P < 0.01, * P < 0.05 † All scores were 2 in the “sensation”
30 r=0.74, p<0.0001
JRDQ
20
10
0
0
10
20
30
JOA minus Fig. 2. Regression analysis between the JRDQ and the JOA score minus (=29 — JOA total score). The dispersion between the JRDQ and the JOA scores had few outliers. There was a linear relation between these two scales, and the distribution of each outside area of the regression line makes an almost normal distribution
The correlation coefficients between the JRDQ and the Clinical subscale in the VAS-leg group differs from the one in the VAS-back group, which may be due to the broader distribution of the Clinical subscale in the VAS-leg group (Table 3). On the other hand, the JRDQ showed similar correlation coefficients with the total JOA minus and the ADL subscale in the two groups in the present study. These results may be due
to the fact that the JRDQ and the ADL subscale have several similar questions associated with posture and walking ability. LSCS has been well characterized25 by “greater age,” “severe lower-extremity pain,” and “absence of pain when seated.” In the LSCS category, the correlation coefficient between the JRDQ and the JOA score was lower (0.66) than the average in the total population. The correlation coefficients were 0.55 (JRDQ vs. Subjective), 0.26 (JRDQ vs. Clinical), and 0.63 (JRDQ vs. ADL) (Table 5). These values in patients with LSCS were the lowest among all six categories, which implies that the disability in patients with LSCS cannot be assessed by the JOA score alone, especially not by the Clinical subscale of the JOA score. These difficulties may be explained by the absence of any standard protocol for treating LSCS.2,15,21 Thus, combining the JRDQ and the JOA score may help clinicians evaluate the status of the patients with LSCS and develop strategies for treating the disease. The responses to questions associated with gait disturbance and posture in the JRDQ together with respective physical findings of the JOA score may facilitate examiners’ better understanding of QOL based on the notion that when more information is available it is more likely that the practitioner can devise an ideal therapeutic plan. On the other hand, in the Traumatic category, the correlation coefficient between the JRDQ and the ADL minus in the traumatic category was higher (0.86, P < 0.001) than in the other five categories (Table 5). Fresh compression fractures led to sudden severe back pain, so these patients felt more irritation than the patients with chronic LBP, who had become accustomed to the pain and known how to manage it. These characteristics of the Traumatic category are assumed to be the reasons for the apparent low scores of the JOA score, the apparent high scores of the JRDQ, and the relatively low correlation between them.
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Also in the Traumatic category, the correlation coefficient between the JRDQ and the Clinical minus is much lower (0.18) than in the other five categories (0.26–0.50), and the total JOA minus and the JRDQ were closely correlated (r = 0.83, P < 0.001). Between the JRDQ and the SLR minus (0.31) and the Muscle power minus (0.12) (Table 5) it was lowest among all the categories. These facts may be explained by the fact that the chief complaint of patients in the Traumatic category is likely to be centered on severe back pain. Although use of the JOA score and the JRDQ for those traumatic lumbar conditions might not be appropriate, the comparison between the scores of acute and chronic lumbar pathological conditions suggested the magnitude of disability in patients with chronic low back pain. The JRDQ sometimes leads to overestimating patients’ subjective feelings and underestimating the objective findings. In contrast, the JOA score can lead to underestimating patients’ subjective feelings. Therefore, it can be concluded that the QOL of patients with LBP/LD can be better estimated multilaterally by combining the JRDQ and the JOA score. Because the JRDQ does not contain any objective subscale, each case may be overestimated or underestimated with the JRDQ. In clinical practice, this combination would be beneficial for both clinicians and patients, especially patients with LSCS. Furthermore, an ideal scale specific to LBP/LD that is capable of evaluating patients from multiple directions must be established to provide a better understanding of the QOL of patients. The QOL of patients with LBP/LD has rarely been studied using a combination of JRDQ and the JOA score. It can be assumed that the two instruments are complementary in evaluating patients with LBP and are thus important. In 2008, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEC) was established as a new, reliable measure to describe QOL in patients with LBP/LD.26,27 The JOABPEC is patientoriented and measures symptoms and self-reported functional status in multiple dimensions.26 Therefore, an examination of the correlation between the JRDQ, JOA score, and the JOABPEC is of interest. There were several limitations in the present study. First, this study was conducted in a cross-sectional design where each patient was processed by physical examination and image diagnoses on the first visit only. Follow-up studies of these patients may be able to reveal confirmed diagnoses and show the relation between the JRDQ and the JOA score more clearly. Second, as the same examiner diagnosed each case, interobserver reliability was not an issue, and second opinions were not sought. However, in future studies employing multiple observers, interrater reliability will
M. Nakamura et al.: Difference between JOA score and JRDQ
need to be determined when categorizing patients into various pathological condition groups. Acknowledgments. The authors express their appreciation to Dr. Yasumichi Sakaguchi (Department of Orthopaedic Surgery, Mino Municipal Hospital) for his generous support for this study. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
References 1. Muramatsu N, Liang J, Sugisawa H. Transitions in chronic low back pain in Japanese older adults: a sociomedical perspective. J Gerontol B Psychol Sci Soc Sci 1997;52:S222–34. 2. Tsuji T, Matsuyama Y, Sato K, Hasegawa Y, Yimin Y, Iwata H. Epidemiology of low back pain in the elderly: correlation with lumbar lordosis. J Orthop Sci 2001;6:307–11. 3. Statistics and Information Department, Minister’s Secretariat, Ministry of Health, Labour and Welfare, Japan. Comprehensive survey of living conditions of people on health and welfare; 2001 (in Japanese). 4. Fukuhara S. User’s manual of Japanese version of Roland-Morris Disability Questionnaire. Tokyo: Iryoubunkasya; 2004 (in Japanese). 5. Mimatsu K, Yoshida T, Kasai T. The relations between visual analogue scale (VAS) and assessment chart of low back pain according to Japanese Orthopaedic Association (lumbar JOA). J Lumbar Disord 2000;6:13–6 (in Japanese). 6. Takahashi Y, Hirayama J, Takahashi K. Correlation between the pain intensity measured by the JOA score and visual analogue scale in low back pain syndrome. Orthop Surg 2000;1:21–6 (in Japanese). 7. Fujii K, Henmi T, Kanematsu Y, Mishiro T, Sakai T. Surgical treatment of lumbar disc herniation in elderly patients. J Bone Joint Surg Br 2003;85:1146–50. 8. Roland M, Morris R. A study of the natural history of low-back pain. Part I. Development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8:141–4. 9. Roland M, Morris R. A study of the natural history of low-back pain. Part II. Development of guidelines for trials of treatment in primary care. Spine1983;8:145–50. 10. Roland MO, Morrell DC, Morris RW. Can general practitioners predict the outcome of episodes of back pain? BMJ (Clin Res Ed) 1983;286:523–5. 11. Roland M, Morris R. Are referrals by general practitioners influenced by the availability of consultants? BMJ 1988;297:599–600. 12. Nakamura M, Miyamoto K, Shimizu K. Validation of the Japanese version of the Roland-Morris Disability Questionnaire for Japanese patients with lumbar spinal diseases. Spine 2003; 28:2414–8. 13. Suzukamo Y, Fukuhara S, Kikuchi S, Konno S, Roland M, Iwamoto Y, et al. Validation of the Japanese version of the Roland-Morris Disability Questionnaire. J Orthop Sci 2003; 8:543–8. 14. Fujiwara A, Kobayashi N, Saiki K, Kitagawa T, Tamai K, Saotome K. Association of the Japanese Orthopaedic Association score with the Oswestry Disability Index, Roland-Morris Disability Questionnaire, and Short-Form 36. Spine 2003;28:1601–7. 15. Wind H, Gouttebarge V, Kuijer PP, Frings-Dresen MH. Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review. J Occup Rehabil 2005;15:253–72.
M. Nakamura et al.: Difference between JOA score and JRDQ 16. Grotle M, Brox JI, Vøllestad NK. Concurrent comparison of responsiveness in pain and functional status measurements used for patients with low back pain. Spine 2004;29:E492–501. 17. Ganzer D, Giese K, Völker L, Pietzner U, Follak N, Merk H. Two-year results after lumbar microdiscectomy with and without prophylaxis of a peridural fibrosis using Adcon-L. Arch Orthop Trauma Surg 2003;123:17–21. 18. Davidson M, Keating JL. A comparison of five low back disability questionnaires: reliability and responsiveness. Phys Ther 2002;82: 8–24. 19. Davidson M, Keating JL, Eyres S. A low back-specific version of the SF-36 Physical Functioning scale. Spine 2004;29:586–94. 20. Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine 2000;25:3100–3. 21. Anagnostis C, Gatchel RJ, Mayer TG. The pain disability questionnaire: a new psychometrically sound measure for chronic musculoskeletal disorders. Spine 2004;29:2290–302. 22. Zanoli G, Strömqvist B, Jönsson B. Visual analog scales for interpretation of back and leg pain intensity in patients operated for degenerative lumbar spine disorders. Spine 2001;26:2375–80. 23. Matsui H, Maeda A, Tsuji H, Naruse Y. Risk indicators of low back pain among workers in Japan: association of familial
373
24.
25.
26.
27.
and physical factors with low back pain. Spine 1997;22:1242– 8. Ng L, Chaundhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine 2005;30:857–62. Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, et al. Degenerative lumbar spinal stenosis: diagnostic value of the history and physical examination. Arthritis Rheum 1995;38: 1236–41. Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S , Miyamoto M, et al. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 2. Verification of its reliability: the Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association. J Orthop Sci 2007;12:526–32. Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S , Miyamoto M, et al. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 3. Validity study and establishment of the measurement scale: Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association, Japan. J Orthop Sci 2008;13:173–9.
Appendix. Japanese Orthopaedic Association Score for Low Back Pain Parameter I. Subjective symptoms Lower back pain
Leg pain and/or tingling
Gait
II. Clinical signs Straight-leg-raising test Sensory disturbance Motor disturbance
III. Restriction of ADL Turn over while lying Standing Washing Leaning forward Sitting (about 1 h) Lifting or holding heavy objective Walking IV. Urinary bladder function
Evaluation
Score
None Occasional mild pain Occasional severe pain Continuous severe pain None Occasional slight symptoms Occasional severe symptoms Continuous severe symptoms Normal Able to walk farther than 500 m although it results in symptoms Unable to walk farther than 500 m Unable to walk farther than 100 m
3 2 1 0 3 2 1 0 3 2 1 0
Normal 30°–70° <30° None Slight disturbance (not subjective) Marked disturbance Normal Slight weakness (MMT 4) Marked weakness (MMT 3 to 0) Severe Moderate 0 1 0 1 0 1 0 1 0 1 0 1 0 1 Normal Mild dysuria Severe dysuria
2 1 0 2 1 0 2 1 0 None 2 2 2 2 2 2 2 0 −3 −6 Total 29
Original article Difference in evaluation of patients with low back pain using the Japanese Orthopaedic Association Score for Back Pain and the Japanese Version of the Roland-Morris Disability Questionnaire MASAO NAKAMURA1, KEI MIYAMOTO2, and KATSUJI SHIMIZU3 1
Department of Orthopaedic Surgery, Mino Municipal Hospital, Mino, Gifu, Japan Department of Reconstructive Surgery for Spine, Bone, and Joint, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 5011194, Japan 3 Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan 2
Abstract Background. The number of patients suffering from degenerative diseases in the lumbar spine is increasing in Japan. Although various scales to measure disability or quality of life in patients with low back pain and/or lumbar diseases are currently available, it has been shown that one questionnaire is not always compatible with another. Our purpose is to evaluate the association and differences between the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese Orthopaedic Association score for low back pain. Methods. These two scales were examined and compared using data from 602 patients with low back pain and/or lumbar disease. The associations between the Japanese version of the Roland-Morris Disability Questionnaire and each subscale in the Japanese Orthopaedic Association score in back pain dominant group and leg pain dominant group, and with respect to six pathological conditions (i.e., sciatica, spondylosis, spondylolisthesis, lumbar spinal canal stenosis, muscular pain, traumatic pain) were analyzed. Results. While the Japanese version of the Roland-Morris Disability Questionnaire and the Subjective and Activities of daily living (ADL) subscale of the Japanese Orthopaedic Association score showed a good correlation (r > 0.60), the Japanese version of the Roland-Morris Disability Questionnaire and the Clinical subscale showed a weak correlation (r = 0.35). Among the six pathological conditions, the correlation between the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese Orthopaedic Association score was the lowest (r = 0.66) in the lumbar spinal canal stenosis category. Conclusions. The clinical signs in patients with low back pain and/or lumbar diseases are not associated closely with the Japanese version of the Roland-Morris Disability Questionnaire. Therefore, a combination of the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese
Offprint requests to: K. Miyamoto Received: May 7, 2008 / Accepted: March 2, 2009 M. Nakamura and K. Miyamoto made equal contributions to this study
Orthopaedic Association score can provide wide-ranging assessment of the level of impairment in patients with low back pain and/or lumbar diseases.
Introduction With the increase of the aged population, the incidence of degenerative diseases in the lumbar spine is increasing in Japan.1 Low back pain (LBP), one of the major symptoms of this type of disease, causes deterioration of the patients’ activities of daily living (ADL) and quality of life (QOL) levels.2,3 In the Japanese population, whether young or aged, the prevalence rate of LBP is rather high, at more than 25%.4 Therefore, it is essential for clinicians to evaluate the LBP in patients accurately. The Japanese Orthopaedic Association score for back pain (JOA score) was established and validated in 1986 for evaluating LBP and/or lumbar spinal diseases (LD)5,6 (see the Appendix) and has been used by Japanese clinicians in the field of orthopedic medicine to estimate the severity of LBP or clinical outcomes most frequently.5,6 The JOA score consists of three subscales: Subjective symptoms, Clinical signs, and ADL, providing clinicians with significant information.7 The score is unique in that it is obtained by the examiners noting patients’ replies to questions plus clinical findings by examination. In 1986, the Roland-Morris Disability Questionnaire (RMDQ), consisting of 24 questions, was published as a measure to assess disability and QOL level of patients with LBP and/or LD.8,9 This questionnaire is simple and easy to read.10,11 In 2003, the Japanese version of the RMDQ (JRDQ) was introduced, and its validity and reliability were confirmed.4,12–14 Although some scales to measure disability or QOL in patients with LBP/LD are currently available,15–20 they are not always compatible with one another. Taking
8.1 (3.2) [range 0–14] 8.0 (3.2) [range 0–14] 8.3 (3.0) [range 0–14] 4.9 (1.4) [range 0–6] 5.1 (1.2) [range 0–6] 4.3 (1.6) [range 0–6] 5.1 (2.0) [range 0–9] 5.4 (1.9) [range 0–9] 4.4 (2.0) [range 0–8] 18.1 (5.7) [range 0–23] 18.4 (5.2) [range 1–28] 17.1 (5.4) [range 0–28]
ADL subscale (range 0–14) Clin.subscale (range 0–6) Subj.subscale (range 0–9) Total score (range 0–29)
into consideration that the JOA score consists of three subscales and thus can evaluate patients from multiple aspects, it might be important to know the association between the JRDQ and each subscale of the JOA score. The purpose of this study was to elucidate the association and difference between the JRDQ and the JOA score, the three subscales of the JOA score (Subjective, Clinical, ADL) in two groups divided according to the visual analogue scale (VAS) scores21–24 and diagnoses of LBP/LD.
Methods Participants A total of 602 patients (male/female ratio 260:342; age 64.6 ± 17.3 years) with back and/or leg pain participated in this cross-sectional study. The subjects consulted our university hospital and four other affiliated hospitals between November 2001 and June 2004, and all were examined by one orthopedic surgeon. The subjects were asked to check the VAS for back pain (VAS-back) and the VAS for leg pain (VAS-leg). According to the VAS marks, the population was then divided into two groups. The patients with VAS-back marks equal to or higher than those of the VAS-leg were classified as the Back-dominant group (456 cases) (VAS-back mean 50.0 ± 24.6, VAS-leg mean 10.0 ± 21.0), and the other patients were included in the Legdominant group (146 cases) (VAS-back mean 23.2 ± 25.5, VAS-leg mean 60.6 ± 25.3) (Table 1).
JRDQ (range 0–24)
8.5 (5.7) [range 0–23] 8.3 (5.7) [range 0–23] 9.0 (5.5) [range 0–23] Total (n = 602) Back-dominant group (n = 456) Leg-dominant group (n = 146)
Methods
Group
JOA score for low back pain
M. Nakamura et al.: Difference between JOA score and JRDQ Table 1. Clinical data [average (SD)] of the Japanese version of the Roland-Morris Disability Questionnaire (JRDQ) and the Japanese Orthopaedic Asociation (JOA) score for low back pain
368
The participants were asked to fill out the JRDQ by themselves. The previously published version of the JRDQ by the present authors12 was used. The JOA score was marked by the orthopedic surgeon. The JOA score has a maximum of 29 points, with three subscales: Subjective symptoms (maximum score 9 points), Clinical signs (6 points), and ADL (14 points). We tested for a significant correlation between the JRDQ and the JOA score in each group using regression analysis in which the JOA score served as a standard and the JRDQ as a parameter. The JRDQ and the JOA score had a negative correlation. To understand their relation better, the JOA score was modified to make the correlation positive. The acquired marks were subtracted from the maximum mark of each scale; that is, the total JOA score, the Subjective, Clinical, and ADL subscales, and the subtracted values were renamed as the JOA minus (29 — JOA total score), the Subjective minus (9 — Subjective subscale), the Clinical minus (6 — Clinical sub-
M. Nakamura et al.: Difference between JOA score and JRDQ
369
Table 2. Descriptive statistics of the JRDQ, the JOA score for low back pain, VAS-Back, and VAS-Leg
Group Total Sciatica Spondylosis Spondylolisthesis LSCS Muscular pain Traumatic
JRDQ
JOA score
VAS-back
VAS-leg
No. of subjects (male : female)
Age (years)
mean (S.D.)
max min
mean (S.D.)
max min
mean (S.D.)
max min
mean (S.D.)
max min
602 (260–342) 198 (109 : 89) 126 (38 : 88) 105 (34 : 71) 93 (46 : 47) 57 (30 : 27) 23 (7 : 16)
64.6 (11–93) 54.2 (13–91) 74.2 (45–93) 67.6 (23–86) 75.3 (52–90) 53.7 (11–83) 70.7 (27–81)
8.5 (5.7) 8.5 (5.6) 8.3 (5.5) 7.3 (5.2) 9.8 (5.1) 7.3 (5.8) 13.3 (7.6)
23 0 22 0 22 0 20 0 23 0 22 0 23 2
18.1 (5.3) 17.2 (5.7) 19.0 (4.7) 19.6 (4.7) 16.3 (4.6) 20.6 (4.7) 16.0 (6.1)
28 1 28 1 28 5 27 3 26 2 27 9 27 8
43.5 (27.4) 43.4 (28.6) 44.4 (24.8) 42.5 (25.7) 34.9 (28.9) 54.8 (25.5) 48.8 (26.3)
100 0 100 0 100 0 100 0 100 0 100 3 92 0
22.4 (31.1) 26.9 (32.0) 23.7 (11.0) 24.0 (30.4) 42.9 (34.7) 3.7 (13.3) 3.1 (14.3)
100 0 100 0 100 0 100 0 100 0 80 3 67 0
scale), and the ADL minus (14 — ADL subscale). The relations between the JRDQ and the modified scores were then evaluated. Urinary function, one of the subscales for the JOA score, was not used in the present study. To estimate the difference between the JRDQ and the JOA scores among lumbar spine-related diseases, the population was divided into six categories according to diagnosis based on the physical examination and image findings, including plain radiography, computed tomography, and magnetic resonance imaging. The six categories were sciatica, spondylosis, spondylolisthesis, lumbar spinal canal stenosis (LSCS), muscular pain, and traumatic pain. We categorized spondylosis and spondylolisthesis with intermittent claudication and/or equina symptoms as LSCS. Sciatica was diagnosed when the nerve root tension sign was positive using the straight-leg-raising test (SLRT). The traumatic pain group included patients with fresh compression fractures within a week of injury. The correlations between the JOA score and the JRDQ in these categories were then calculated (Table 2). Statistical analyses All data were collected by one examiner. Statistical analysis with Spearman’s correlation analysis was performed between the JRDQ and the JOA score, the three subscales of the JOA score, and the three branches of the Clinical subscale of the JOA score. Regression analysis was used to test the relations among these scales, subscales, and branches as metrics. StatView version 5 software (Abacus Concepts, Berkeley, CA, USA) running on Microsoft Windows XP (Microsoft, Redmond, WA, USA) was used.
Ethical considerations This study was approved by our institution’s ethics committee. The patients and/or their families were informed that data from the case would be submitted for publication and gave their consent.
Results Table 1 shows the averages of raw marks of the JRDQ, the JOA total score, Subjective subscore, Clinical subscore, and ADL subscore for the total population, the Back-dominant group, and the Leg-dominant group. The correlation coefficient between the JRDQ and the JOA minus was 0.75 (P < 0.0001) in the total population, 0.75 in the Back-dominant group, and 0.76 in the Leg-dominant group (Table 3). The coefficient of determination between the JRDQ and the JOA minus was >0.50 (0.58). These observations indicate that there is little dispersion between these two scales. In addition, the JRDQ and the JOA minus had an excellent correlation. As shown in Table 3 and Fig. 1 for each group, the correlation coefficients between the JRDQ and the Clinical minus and the three branches of the Clinical minus (SLR minus, Sensation minus, Muscle Power minus) were <0.40; however, all those between the JRDQ and the JOA minus, the Subjective minus, the ADL minus were >0.60. Especially, SLR minus showed a much lower correlation coefficient (0.10) with the JRDQ in the Leg-dominant group. Similarly, the Muscle Power minus showed a lower correlation coefficient (0.12) with the JRDQ in the Back-dominant group (Table 4).
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M. Nakamura et al.: Difference between JOA score and JRDQ
Table 3. Correlation coefficients between the JRDQ and the JOA score for back pain JOA score for back pain JRDQ Total (n = 602) Back-dominant group (n = 456) Leg-dominant group (n = 146)
JOA minus
Subjective minus
Clinical minus
ADL minus
0.75*** 0.75*** 0.76***
0.63*** 0.61*** 0.68***
0.35*** 0.27*** 0.37***
0.73*** 0.74*** 0.73***
*** P < 0.001
Table 4. Correlation coefficients for the JRDQ and the JOA score for back pain JOA score for back pain Clinical minus
Subjective JOA minus minus Clinical total
JRDQ Total (n = 602) Back-dominant group (n = 456) Leg-dominant group (n = 146)
0.75*** 0.75*** 0.76***
0.63*** 0.61*** 0.68***
SLR
0.35*** 0.27*** 0.37***
0.39*** 0.39*** 0.10
Sensation Muscle Power ADL minus 0.37*** 0.39** 0.34***
0.36*** 0.12* 0.33***
0.73*** 0.74*** 0.73***
*** P < 0.001, ** P < 0.01, * P < 0.05
(B)
(A) r=0.61, P<0.0001
r=0.30, P<0.0001
30
10
20
10
0
0 0
2
4
6
8
10
Subjective minus
r=0.73, P<0.0001
30
JRDQ
20
JRDQ
JRDQ
30
(C)
20
10
0 0
2
4
6
8
Clinical minus
Regardless of the diagnosis of LBP/LD of patients, the correlation coefficient between the JRDQ and the Clinical minus was, at most, 0.50. In contrast, the correlation coefficients between the JRDQ and the JOA minus, the Subjective minus, and the ADL minus were >0.50, with most of these scores being >0.7 (Table 5). The correlation coefficient between the JRDQ and the total JOA minus was lowest in the LSCS category (0.66), compared to other five categories. The same tendency was observed between the JRDQ and the Subjective minus (0.55 in LSCS) and ADL minus (0.63 in LSCS). In all categories, the correlation coefficients between the JRDQ and the Clinical minus were relatively low. The VAS-leg scores were very low in both the Muscular Pain category (3.7) and the Traumatic category (3.1) (Table 2). Whereas the maximum scores of the other four categories were 100, the maximum scores in these two categories reached only 80 and 67, respectively.
0
4
8
12
ADL minus
16
Fig. 1. Regression analysis between the JRDQ and the subjective minus (A), between the JRDQ and the Clinical minus (B), between the JRDQ and the ADL minus (C). The ellipses in each figure indicate the tolerance limits. Subjective minus: 9 — Subjective subscale. Clinical minus: 6 — Clinical subscale. ADL minus: 14 — ADL subscale
Discussion Regression analysis between the JRDQ and the JOA score had no significant outliers in the present study. The results showed the coefficient of determination to be >0.5, indicating that the JRDQ and the JOA score have a relatively strong relation (r = 0.74, r2 = 0.56) (Table 3, Fig. 2). However, the Clinical minus and the JRDQ showed a relatively weak association with the JRDQ, and the JRDQ showed a strong association with the Subjective minus and the ADL minus. This weak association may be due to the fact that the Clinical subscale does not pick up the patient’s pain itself, but neurological disturbance including motor and sensory functions.5,6 These clinical findings, including reduced muscular strength or decreased sensing ability, were demonstrated when determining the treatment plan for each patient.
M. Nakamura et al.: Difference between JOA score and JRDQ
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Table 5. Correlation coefficient between the JRDQ and the JOA minus, Subjective minus, Clinical minus, and ADL minus using Spearman’s correlation coefficient by rank in the validity test JOA score for back pain
JRDQ Sciatica Spondylosis Spondylolisthesis LSCS Muscular Pain Traumatic
Clinical minus
JOA minus
Subjective minus
Clinical total
SLR
Sensation
Muscle Power
ADL minus
0.79*** 0.72*** 0.73*** 0.66*** 0.72*** 0.83***
0.66*** 0.57*** 0.62*** 0.55*** 0.63*** 0.70**
0.44*** 0.41*** 0.31** 0.26* 0.50** 0.18
0.41*** 0.43*** 0.37*** 0.57*** 0.49*** 0.31
0.35*** 0.44*** 0.35*** 0.31*** (see foot notes†) 0.40
0.38*** 0.40*** 0.35*** 0.23 0.52*** 0.12
0.77*** 0.69*** 0.73*** 0.63*** 0.68*** 0.86***
*** P < 0.001, ** P < 0.01, * P < 0.05 † All scores were 2 in the “sensation”
30 r=0.74, p<0.0001
JRDQ
20
10
0
0
10
20
30
JOA minus Fig. 2. Regression analysis between the JRDQ and the JOA score minus (=29 — JOA total score). The dispersion between the JRDQ and the JOA scores had few outliers. There was a linear relation between these two scales, and the distribution of each outside area of the regression line makes an almost normal distribution
The correlation coefficients between the JRDQ and the Clinical subscale in the VAS-leg group differs from the one in the VAS-back group, which may be due to the broader distribution of the Clinical subscale in the VAS-leg group (Table 3). On the other hand, the JRDQ showed similar correlation coefficients with the total JOA minus and the ADL subscale in the two groups in the present study. These results may be due
to the fact that the JRDQ and the ADL subscale have several similar questions associated with posture and walking ability. LSCS has been well characterized25 by “greater age,” “severe lower-extremity pain,” and “absence of pain when seated.” In the LSCS category, the correlation coefficient between the JRDQ and the JOA score was lower (0.66) than the average in the total population. The correlation coefficients were 0.55 (JRDQ vs. Subjective), 0.26 (JRDQ vs. Clinical), and 0.63 (JRDQ vs. ADL) (Table 5). These values in patients with LSCS were the lowest among all six categories, which implies that the disability in patients with LSCS cannot be assessed by the JOA score alone, especially not by the Clinical subscale of the JOA score. These difficulties may be explained by the absence of any standard protocol for treating LSCS.2,15,21 Thus, combining the JRDQ and the JOA score may help clinicians evaluate the status of the patients with LSCS and develop strategies for treating the disease. The responses to questions associated with gait disturbance and posture in the JRDQ together with respective physical findings of the JOA score may facilitate examiners’ better understanding of QOL based on the notion that when more information is available it is more likely that the practitioner can devise an ideal therapeutic plan. On the other hand, in the Traumatic category, the correlation coefficient between the JRDQ and the ADL minus in the traumatic category was higher (0.86, P < 0.001) than in the other five categories (Table 5). Fresh compression fractures led to sudden severe back pain, so these patients felt more irritation than the patients with chronic LBP, who had become accustomed to the pain and known how to manage it. These characteristics of the Traumatic category are assumed to be the reasons for the apparent low scores of the JOA score, the apparent high scores of the JRDQ, and the relatively low correlation between them.
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Also in the Traumatic category, the correlation coefficient between the JRDQ and the Clinical minus is much lower (0.18) than in the other five categories (0.26–0.50), and the total JOA minus and the JRDQ were closely correlated (r = 0.83, P < 0.001). Between the JRDQ and the SLR minus (0.31) and the Muscle power minus (0.12) (Table 5) it was lowest among all the categories. These facts may be explained by the fact that the chief complaint of patients in the Traumatic category is likely to be centered on severe back pain. Although use of the JOA score and the JRDQ for those traumatic lumbar conditions might not be appropriate, the comparison between the scores of acute and chronic lumbar pathological conditions suggested the magnitude of disability in patients with chronic low back pain. The JRDQ sometimes leads to overestimating patients’ subjective feelings and underestimating the objective findings. In contrast, the JOA score can lead to underestimating patients’ subjective feelings. Therefore, it can be concluded that the QOL of patients with LBP/LD can be better estimated multilaterally by combining the JRDQ and the JOA score. Because the JRDQ does not contain any objective subscale, each case may be overestimated or underestimated with the JRDQ. In clinical practice, this combination would be beneficial for both clinicians and patients, especially patients with LSCS. Furthermore, an ideal scale specific to LBP/LD that is capable of evaluating patients from multiple directions must be established to provide a better understanding of the QOL of patients. The QOL of patients with LBP/LD has rarely been studied using a combination of JRDQ and the JOA score. It can be assumed that the two instruments are complementary in evaluating patients with LBP and are thus important. In 2008, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEC) was established as a new, reliable measure to describe QOL in patients with LBP/LD.26,27 The JOABPEC is patientoriented and measures symptoms and self-reported functional status in multiple dimensions.26 Therefore, an examination of the correlation between the JRDQ, JOA score, and the JOABPEC is of interest. There were several limitations in the present study. First, this study was conducted in a cross-sectional design where each patient was processed by physical examination and image diagnoses on the first visit only. Follow-up studies of these patients may be able to reveal confirmed diagnoses and show the relation between the JRDQ and the JOA score more clearly. Second, as the same examiner diagnosed each case, interobserver reliability was not an issue, and second opinions were not sought. However, in future studies employing multiple observers, interrater reliability will
M. Nakamura et al.: Difference between JOA score and JRDQ
need to be determined when categorizing patients into various pathological condition groups. Acknowledgments. The authors express their appreciation to Dr. Yasumichi Sakaguchi (Department of Orthopaedic Surgery, Mino Municipal Hospital) for his generous support for this study. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
References 1. Muramatsu N, Liang J, Sugisawa H. Transitions in chronic low back pain in Japanese older adults: a sociomedical perspective. J Gerontol B Psychol Sci Soc Sci 1997;52:S222–34. 2. Tsuji T, Matsuyama Y, Sato K, Hasegawa Y, Yimin Y, Iwata H. Epidemiology of low back pain in the elderly: correlation with lumbar lordosis. J Orthop Sci 2001;6:307–11. 3. Statistics and Information Department, Minister’s Secretariat, Ministry of Health, Labour and Welfare, Japan. Comprehensive survey of living conditions of people on health and welfare; 2001 (in Japanese). 4. Fukuhara S. User’s manual of Japanese version of Roland-Morris Disability Questionnaire. Tokyo: Iryoubunkasya; 2004 (in Japanese). 5. Mimatsu K, Yoshida T, Kasai T. The relations between visual analogue scale (VAS) and assessment chart of low back pain according to Japanese Orthopaedic Association (lumbar JOA). J Lumbar Disord 2000;6:13–6 (in Japanese). 6. Takahashi Y, Hirayama J, Takahashi K. Correlation between the pain intensity measured by the JOA score and visual analogue scale in low back pain syndrome. Orthop Surg 2000;1:21–6 (in Japanese). 7. Fujii K, Henmi T, Kanematsu Y, Mishiro T, Sakai T. Surgical treatment of lumbar disc herniation in elderly patients. J Bone Joint Surg Br 2003;85:1146–50. 8. Roland M, Morris R. A study of the natural history of low-back pain. Part I. Development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8:141–4. 9. Roland M, Morris R. A study of the natural history of low-back pain. Part II. Development of guidelines for trials of treatment in primary care. Spine1983;8:145–50. 10. Roland MO, Morrell DC, Morris RW. Can general practitioners predict the outcome of episodes of back pain? BMJ (Clin Res Ed) 1983;286:523–5. 11. Roland M, Morris R. Are referrals by general practitioners influenced by the availability of consultants? BMJ 1988;297:599–600. 12. Nakamura M, Miyamoto K, Shimizu K. Validation of the Japanese version of the Roland-Morris Disability Questionnaire for Japanese patients with lumbar spinal diseases. Spine 2003; 28:2414–8. 13. Suzukamo Y, Fukuhara S, Kikuchi S, Konno S, Roland M, Iwamoto Y, et al. Validation of the Japanese version of the Roland-Morris Disability Questionnaire. J Orthop Sci 2003; 8:543–8. 14. Fujiwara A, Kobayashi N, Saiki K, Kitagawa T, Tamai K, Saotome K. Association of the Japanese Orthopaedic Association score with the Oswestry Disability Index, Roland-Morris Disability Questionnaire, and Short-Form 36. Spine 2003;28:1601–7. 15. Wind H, Gouttebarge V, Kuijer PP, Frings-Dresen MH. Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review. J Occup Rehabil 2005;15:253–72.
M. Nakamura et al.: Difference between JOA score and JRDQ 16. Grotle M, Brox JI, Vøllestad NK. Concurrent comparison of responsiveness in pain and functional status measurements used for patients with low back pain. Spine 2004;29:E492–501. 17. Ganzer D, Giese K, Völker L, Pietzner U, Follak N, Merk H. Two-year results after lumbar microdiscectomy with and without prophylaxis of a peridural fibrosis using Adcon-L. Arch Orthop Trauma Surg 2003;123:17–21. 18. Davidson M, Keating JL. A comparison of five low back disability questionnaires: reliability and responsiveness. Phys Ther 2002;82: 8–24. 19. Davidson M, Keating JL, Eyres S. A low back-specific version of the SF-36 Physical Functioning scale. Spine 2004;29:586–94. 20. Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine 2000;25:3100–3. 21. Anagnostis C, Gatchel RJ, Mayer TG. The pain disability questionnaire: a new psychometrically sound measure for chronic musculoskeletal disorders. Spine 2004;29:2290–302. 22. Zanoli G, Strömqvist B, Jönsson B. Visual analog scales for interpretation of back and leg pain intensity in patients operated for degenerative lumbar spine disorders. Spine 2001;26:2375–80. 23. Matsui H, Maeda A, Tsuji H, Naruse Y. Risk indicators of low back pain among workers in Japan: association of familial
373
24.
25.
26.
27.
and physical factors with low back pain. Spine 1997;22:1242– 8. Ng L, Chaundhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine 2005;30:857–62. Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, et al. Degenerative lumbar spinal stenosis: diagnostic value of the history and physical examination. Arthritis Rheum 1995;38: 1236–41. Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S , Miyamoto M, et al. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 2. Verification of its reliability: the Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association. J Orthop Sci 2007;12:526–32. Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S , Miyamoto M, et al. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 3. Validity study and establishment of the measurement scale: Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association, Japan. J Orthop Sci 2008;13:173–9.
Appendix. Japanese Orthopaedic Association Score for Low Back Pain Parameter I. Subjective symptoms Lower back pain
Leg pain and/or tingling
Gait
II. Clinical signs Straight-leg-raising test Sensory disturbance Motor disturbance
III. Restriction of ADL Turn over while lying Standing Washing Leaning forward Sitting (about 1 h) Lifting or holding heavy objective Walking IV. Urinary bladder function
Evaluation
Score
None Occasional mild pain Occasional severe pain Continuous severe pain None Occasional slight symptoms Occasional severe symptoms Continuous severe symptoms Normal Able to walk farther than 500 m although it results in symptoms Unable to walk farther than 500 m Unable to walk farther than 100 m
3 2 1 0 3 2 1 0 3 2 1 0
Normal 30°–70° <30° None Slight disturbance (not subjective) Marked disturbance Normal Slight weakness (MMT 4) Marked weakness (MMT 3 to 0) Severe Moderate 0 1 0 1 0 1 0 1 0 1 0 1 0 1 Normal Mild dysuria Severe dysuria
2 1 0 2 1 0 2 1 0 None 2 2 2 2 2 2 2 0 −3 −6 Total 29