Upsala J Med Sci: 81: 103-108, 1976 Rehabilitation of Patients with Low Back Disorders in the County of Uppsala SOREN HILDING, HERMAN HEDQVIST, BRITA ARBMAN and ANDERS WIGREN From the Department of Orthopaedic Surgery, University Hospital, Uppsala and the Rehabilitation Centre of Uppsala County Council, Sweden ABSTRACT Low back pain is a common cause of inability to work. At the Rehabilitation Centre of the Uppsala County Council an annual number of more than 100 patients with this condition undergo an investigation aimed at evaluating their capacity for work and their need for rehabilitation. By compiling and analysing the informa- tion recorded in the case journals of the patients with low back disorders during the years 1969 to 1971, it was hoped that more knowledge would be gained about the factors constituting a hindrance to rehabilitation. The present paper is a preliminary report on an analysis of 47 case journals unsystematically selected from the entire ma- terial. The study verifies a number of previously reported observations, e.g. the low frequency of roentgenological changes. It is also noted that in a remarkably large number of patients no or only slight abnormalities were found on physical examination. Compared with the results of other investigations, there was a very low frequency of concurrent psychiatric disorders and abuse of alcohol. It was considered from this analysis that the information in the case journal material in question is adequate for elucidating the relevant problems in the planned larger investigation; further, it provides motivation for a future follow-up study. INTRODUCTION AND BACKGROUND A large number of people of occupational age suffer from low back pain, which in many cases causes inability to work. This problem has long been a subject of research efforts, and numerous investi- gations have been made, especially in the indus- trialized countries, with the aim of shedding light not only on its orthopaedic and general medical aspects but also on its psycho-social effects. In Scandinavia, studies have been reported by Hult (1954), Gogstad (1962), Magnusson (1968), Sparup (1969), Horal (1969), Natvig (1970), Tufvesson and co-workers (1970) and Westrin (1970), among others. In Sweden those people who because of illness or disablement are unable to carry out their ordi- nary work generally undergo both medical and occupational rehabilitation. With respect to the latter, in order t o make a more accurate evalua- tion of the patient’s capacity for work and need for rehabilitation, a relatively extensive investiga- tion is undertaken. At the Rehabilitation Centre of the Uppsala County Council, about 350 patients are investi- gated each year. About 35% of these are cate- gorized as patients with low back disorders. Despite considerable efforts at medical and oc- cupational rehabilitation, the impression is ob- tained that many of these patients, because of their low back pain, have great difficulty in readjusting to working life. By compiling and analysing the in- formation recorded in the case journals of the Rehabilitation Centre concerning patients pre- dominantly disabled by a low back disorder, and by examining the patients 4 to 5 years later, it was hoped that more knowledge would be gained about the factors constituting a hindrance to rehabilita- tion. The present paper concerns the first part of the investigation, i.e. an analysis of case journals from the Rehabilitation Centre. An attempt was made to find out whether any correlations existed between particular symptoms, in combination with objective findings, and the outcome of the rehabilitation. The patients’ physi- cal and intellectual capacities and their social situa- tion also seemed worthy of investigation in this context. It was considered that some type or types of patients with low back pain in whom the rehabili- tational measures had a particularly good or poor effect might be distinguishable. Further, it was hoped that the results of this investigation would Upsala J Med Sci 81 \ 104 S . ffilding et al. have practical benefits such as: ( 1 ) improvement of the routine rehabilitational investigation; (2) es- tablishment of appropriate methods of medical treatment; ( 3 ) improvement of prognostic evalua- tion; (4) establishment of measures to prevent re- currence. MATERIAL, METHODS AND DEFINITIONS During the years 1969 to 1971, 977 patients were investi- gated at the Rehabilitation Centre in Uppsala. Of these, about 35 9% (340 patients) were considered to have a low back disorder as their main diagnosis. 1971 was chosen as the last year in order to have at least 4 years between the investigation and the planned follow-up examination or, to use a mare modern term, the product control. From the relevant case journal material, 47 were se- lected unsystematically. The patients were divided into age groups of 5 years, with 15 years as the lower limit and 49 years as the upper. Patients with low back disorders get in contact with Rehabilitation Centre mainly in two ways, either through the County Employment Board, or by referral from the Department of Orthopaedics a t the University Hospital of Uppsala. Orthopaedic examination The examination was performed at the Dept. of Ortho- paedics and with a few exceptions, by the same doctor. This latter was considered an advantage and is a reason- able guarantee of relatively good uniformity in the evalu- ation of the signs and symptoms. The patients were clas- sified essentially according to the same principles as were used by Lennart Hult in the Munkfors investigation in 1954. Lumbar spine insufficiency By lumbar spine insufficiency is meant a condition with a more or less intermittent sensation of fatigue or pain located in the form of a band over the lumbar spine. The symptoms are often provoked by physical work in the forward bending position. Recurrent lumbago This is defined as repeated attacks of aching, pain on movement, and stiffness in the lumbar spine. Between attacks the patient is relatively free from symptoms. Chronic lumbago These patients have the same symptoms as the fore- going, but the symptoms are more persistent and there are no completely free intervals. Sciatica This group have not only symptoms from the lumbar spine but also radiating pain in the lower extremities, usually unilateral. The patient often has a concomitant sensation of numbness or paresthesia in the foot and toes. By concurrent symptoms from the cervical and thoracic spine is meant aching, pain and stiffness in these spinal areas, in some cases combined with radiating pain in the upper extremities. The objective findings in the orthopaedic examina- tion were also classified in accordance with the defini- tions in the above-mentioned investigation by Hult: Static spinal deformity By this is meant deviations from the normal configuration of the spinal column, e.g. kyphosis, lordosis or scolio- sis. Restricted mobiliiy Extension, forward flexion and lateral flexion of the spine were evaluated. From the findings at the ortho- paedic examination the patients were divided into two groups, one with restricted mobility and one with pro- nounced restricted mobility. This was only a rough classification but seemed to be the only one practicable at this stage of the investigation. Lasegue's sign This sign was tested in all patients, and for the purpose of this investigation it was considered sufficient to note only a positive finding. Neurological deficit By this is meant here the occurrence of sensory impair- ments, paresthesia, paresis, muscular atrophy and ab- sence of the patellar or Achilles reflexes. The patients with lumbo-sacral rhizopathy were also divided into two groups according to whether or not the level of the lesion could be determined. General medical evaluation A detailed history was first taken, including both previous illnesses and the present condition. Any psychological disorders or abuse of alcohol were noted, and patients with such symptoms were always examined by a psychi- atrist. A thorough physical examination was carried out and laboratory tests included blood analyses for haemo- globin concentration (expressed in grams per cent), red and white blood counts and sedimentation rate, and uri- nary analysis for protein and glucose. It was considered sufficient to record only the occurrence of disease in the respective organic systems. Additional examinations Roentgenological examination of the lumbar spine was performed in most patients, with special regard to disc degeneration, spondylosis and spondylolisthesis. If lum- bar myelography with contrast medium was carried out, this was also noted. Examination of isometric muscle strength was per- formed in all patients at the Department of Clinical Physiology of the University Hospital. This included tests of the muscle power and function in the upper and lower extremities and lumbar spine. Any pain in connec- tion with the examination was noted. For the present Upsala J Med Sci 81 Rehabilitation of patients with low back disorders 105 Table I. A g e distribution of the patient material Age patients No. of 15-19 4 20-24 7 30-34 4 35-39 10 40-44 6 45-49 2 Total 47 25-29 14 study a recording was made only of whether the muscle strength was considered normal or reduced. A physicul work test was also usually included in the investigation. This also was performed at the Dept. of Clinical Physiology, using a bicycle ergometer with in- creasing work loads. The heart rate, respiratory fre- quency and blood pressure were recorded continuously. The patients were classified according to whether their physical work capacity was good, ordinary, somewhat low, low or very low. A psychological examination was carried out in most cases. This was undertaken by a psychologist attached to the Rehabilitation Centre, with the aim of assessing the patient’s intellectual and practical abilities. The patients were graded according to the scale: sub-normal, normal and above normal. An extensive social investigation was performed, comprising school and vocational education, the occupa- tional situation, absence from work, periods on the sick- list, family conditions, housing and financial situation, hobbies and any criminal record. It was considered im- portant to get an idea, if possible, of the patients’ annual incomes prior to the rehabilitational investiga- tion and to compare them with those of the rest of the population in the years in question. Useful information on incomes was obtained from about half of the patients, but it should be pointed out that even these are only rough estimates and that the figures are therefore uncer- tain. The definitions of low and high incomes used by Holmberg & Strom (3) were applied in the present anal- yses. The income data of the low-income investigation are based on an analysis of Swedish people in 1966. In the investigation of low-income groups the income limits were listed in relation to the wages development from 1966 to 1970. The following income groups were thus defined: A low income meant an annual income of less than 20000 Sw. kr, an average income an annual income of 20000 to 40000 kr, and a high income an annual income of more than 40000 kr. A rehabilitational investigation always results in a rec- ommendation, and a t present there are more than 50 different alternatives. The alternatives most relevant for patients with low back disorders may be summarized as follows: Return to previous work; change to different occupation; vocational training (patients who have not previously had such training); re-training (patients with previous vocational training who are trained for another occupation); higher education (junior secondary school, upper secondary school, university or equivalent); con- tribution towards a business; and retirement pension. RESULTS Of the 47 patients, 34 were men and 13 women. Four of them were of foreign nationality. Thirty-three of the patients were referred for the investigation by the County Employment Board, and the rest by the Department of Orthopaedics at the University Hospital. The age distribution is presented in Table I. All age groups are represented, though somewhat unevenly. The general medical examination revealed that one patient had concurrent cardiopulmonary dis- ease, 3 patients gastrointestinal diseases, 3 patients urogenital diseases and one patient contact allergy. Four of the patients were suffering from psychiatric disorders and 3 were heavy drinkers. The results of the orthopaedic examination are given in Tables I1 and 111. In 31 patients, i.e. the majority, lumbar spine insufficiency was the domi- nant symptom. Sixteen suffered from lumbago or sciatica. A few patients also had concurrent symp- toms from the cervico-thoracic spine. In 19 of the patients no abnormal findings were made at the orthopaedic examination, and in the remaining 28 the main finding was restricted mobility of the lumbar spine, but in no case was this restriction pronounced. Thirty-one patients had a roentgenological ex- amination of the lumbar spine. In 8 patients, one or several discs in the lumbar spine were lower than normal, indicating degeneration. 10 patients also exhibited osteophytes on the margins of the vertebrae (spondylosis deformans). In one patient Table 11. S y m p t o m s a t the orthopaedic examina- tion Lumbar spine insufficiency 31 Lumbago recurrent 2 Lumbago chronic 4 Sciatica, back symptoms predominating 4 Sciatica, leg pain 0 Sciatica, equally troubled by both Concurrent symptoms from cervico- thoracic spine 4 Concurrent lesion or disease of lower extremities 3 6 Upsala J Med Sci81 106 S . Hilding et al. Table 111. Findings at orthopaedic examination No abnormalities 19 Restricted mobility 20 Unqualified gainful employment 32 Greatly restricted mobility 1 Qualified gainful employment 14 Laskgue's sign positive 12 Light gainful employment 16 Table V. Occupational situation prior to the re- habilitational investigation Static spinal deformity 10 Housewife 1 Neurological deficit with established Heavy gainful employment 30 Neurological deficit with level uncertain level of lesion 2 3 with sciatica and with neurological deficit, lumbar myelography with contrast medium was per- formed, with no evidence of herniation of the discs. Examination of the isometric muscle strength revealed reduced muscle strength in 15 of the pa- tients and normal strength in the remainder. A physical work test was performed in 38 patients. In 9 of them the physical work capacity was above normal, in 24 normal and in 5 subnormal. The results of the psychological examination, which was carried out on 40 of the patients, can be seen in Table IV. The social investigation showed that 32 of the patients had only completed the compulsory school education, one patient higher school education and 15 patients vocational training. Table V shows the occupational situation of the patients prior to the rehabilitational investigation. It is seen that the majority-about 30 of the pa- tients-had heavy, unqualified work. Fairly reliable information concerning annual incomes was obtained for 23 patients and are di- vided into low, average, and high incomes in Table VI. About half the patients whose incomes could be ascertained lay within the average income group, a few had a high income and the rest, mostly wom- en, were in the low income group. During the 3 years immediately preceding the in- vestigation, 25 of the patients had been o n the sick- list for more than 6 consecutive months or for short, frequent periods. Four patients were unemployed at the time of Table IV. Psychological examination the investigation. The family situation can be seen in Table VII. The majority of the patients (36) were married or cohabiting, and 20 of these had a gain- fully employed husband/partner. The housing situa- tion could be regarded as unsatisfactory in 6 cases. Twenty-two of the patients stated that they had ac- tive hobbies, and in 10 of them these involved physical activity. Two of the patients had criminal records. The recommendations resulting from the rehabil- itational measures are listed in Table VIII. The two predominant recommendations were change of occupation and vocational training. DISCUSSION As it was the intention to analyse the entire case journal material, it was considered necessary when selecting patients for the present pilot study only to take into account the completeness of the jour- nals, and not the exact distribution of the total ma- terial with regard to sex, etc. For the same reason it was not considered to satisfy statistical demands of randomness. The results reported here are derived from a small portion of a series of patients who underwent rehabilitational investigation during 3 consecutive years. As mentioned previously, the present study is to be regarded as a preliminary report for the planning of a broader investigation including the whole series of patients. N o definite conclusions can therefore be drawn concerning the patients T o h l P wT Distribution of incomes prior to rehabi- Subnormal intellectual ability 4 Normal intellectual ability 26 Above normal intellectual ability 10 l a " l C "I. litation Subnormal practical ability 3 Low income 7 ( 1 man, 6 women) Normal practical ability 24 Average income 13 (12 men, 1 woman) Above normal practical ability 13 High income 3 (men) Examination not performed 7 No evaluable information 24 Wpsala J Med Sci 81 Rehabilitation of patients with low back disorders 107 Table VII. Family conditions Married or cohabiting 36 20 2 3 Husband or wife gainfully employed Sole family supporter 3 Single without duty to support family Separated or divorced at time of investigation Family problems 3 with low back disorders undergoing rehabilitational measures. In choosing the lower age limit consideration was taken of the fact that an increasing number of people undergo rehabilitational measures at a very young age and often at the end of the compulsory school period. The upper limit of 49 years may seem rather low, but this limit was chosen for practical reasons, so that all patients in the ma- terial should have a true possibility of utilizing the recommendations following the rehabilitational investigation. The total rehabilitation of a patient is often a long procedure and in practice covers several years. This material was somewhat un- evenly distributed between the age groups. Thus there were two peaks, the 25-29 year group and the group of 35-39 years. This age distribution will cer- tainly not reflect that of the total material, which could only be roughly estimated but which probably has a peak at 3 5 4 9 years. For this pilot study it was considered most important, however, t o in- clude patients from every age group. Most of the patients had symptoms of lumbar spine insufficiency and only a few had more severe conditions such as lumbago and sciatica. In 19 of the patients, normal conditions were found on ex- amination, and in the rest only mild disorders were observed. Other investigations on similar materials (e.g. Natvig, 1970) have revealed a considerably higher frequency of both mild and severe symp- toms and signs. This may be explained by the fact that the age distribution of the present small se- ries of patients probably deviates somewhat from that of the total material, in which it is expected that higher ages will predominate. Among the 31 patients who underwent roent- genological examination, pathological changes were found to only a very small extent. L a Rocca & Macnab (1970), and previously other authors, have demonstrated the limited value of roentgenological examination of patients with low back pain. Even from a prognostic aspect the roentgenological ex- amination is not reliable, especially in young work- ing people. In the younger age groups it is prob- ably realistic, therefore, to assume that a correct evaluation can be made without roentgenological examination. Other somatic diseases were present t o a strik- ingly small extent, and it is of even greater interest that only 4 patients had a history of psychiatric disorder and only 3 were heavy drinkers. Other investigations of this category of patients have revealed psychiatric disorders in about 40% and alcoholism or abuse of alcohol in 18% (Natvig, 1970). This may be explained by a non-representa- tive age distribution, but the low figures are inter- esting. The majority of the patients were tested for muscle strength, physical work capacity and intel- lectual capability. On the whole it may be said that the patients appeared to be normal in these respects. It is evident from the social investigation that the education of most of the patients ended with the compulsory school period, after which they had unqualified, heavy work. As mentioned previously, it was difficult to ob- tain reliable information from the case journals concerning the patients’ incomes prior to the re- habilitational investigation. Information on income was available for only about half of the patients. In a few cases this information concerned hour- ly wages, in others weekly or monthly wages and in a few, the annual income. Thus it must be pointed out again that the income figures are un- certain. Nevertheless the patients were placed in their respective income groups with respect to annual income. It may also be mentioned that the income distribution showed similarities to the statistics for all gainfully employed persons re- ported in the 1966 state investigation of low-income groups. The well known sex+difference with re- Table VIII. Recommendations of rehabilitation centre following investigation Return to previous work 2 Re- training 4 Higher education 7 Contribution towards a business 2 Pension 1 Change of occupation 16 Vocational training 15 Upsala J Med Sci 81 108 S . Hilding et al. spect to income is also evident in this small ma- terial. It was found that half of the patients had been on the sick-list for long periods prior to the reha- bilitational investigation. This is an unexpectedly low figure in view of the fact that low back pain is one of the main causes of absence from work on account of illness, and that there was a waiting period of several months €or investigation at the Rehabilitation Centre. The housing situation could be regarded as un- satisfactory for only 6 of the patients. As this is a very important factor socially, which is certainly of considerable importance for adjustment to em- ployment, it should be of interest to find out whether this low figure is representative for the total material. The recommendations of the Rehabilitation Centre for this group of patients comprise seven alternatives. The two predominant recommenda- tions were change of occupation and vocational training. In only one case was an early retirement pension suggested. Since there is reason to expect that in the total material from the years in question there will be a greater number of patients in the age group 4 0 4 9 years, the latter alternative, an early pension, will probably have a higher frequency in the planned, broader investigation. The recom- mendations will probably have their greatest inte- rest, however, when related to the occupational situation of the patients 4-5 years after the reha- bilitational investigation. It is planned to elucidate this question in a future follow-up study. REFERENCES 1 . 2. 3 . 4. 5 . Gogstad, A. C.: Psykiatriske klienter i attforings- institutt. Nord Psykiatr Tidskr 1: 1962. Gogstad, A. C.: Etterundersokelse av rehabilite- ringsforanstaltninger. Nord Med 8, XI, 1962,68: no. 45, 1962. Holmberg, P. & Strom, H.: Lgginkomstutredningens forsta betiinkande i sammandrag. Allmanna Forlaget, Stockholm, 1970. Horal, 1.: The clinical appearance of low back dis- orders in the city of Gothenburg. Acta Orthop Scand, Suppl. 118, 1969. Hult, L.: The Munkfors Investigation. A study of the frequency and causes of the stiff neck brachialgia and lumbago-sciatica syndromes, as well as observations on certain signs and symptoms from the dorsal spine and the joint of the extremities in industrial and forest workers. Acta Orthop Scand, Suppl. 16, 1954. 6. 7. 8. 9. 10. 11. Hult, L.: Cervical, dorsal and lumbar-spinal syn- dromes. A field investigation of a non-selected ma- terial of 1200 workers in different occupations with special reference to disc degeneration and so-called muscular rheumatism. Acta Orthop Scand, Suppl. X V I I , 17, 1954. L a Rocca, H . & Macnab, I.: Value of pre-employ- ment radiographic assessment of the lumbar spine. Canad Med Ass J 4: 49, 1969. Magnusson, R.: Rehabilitering av skogsarbetare med ryggbesvar. Lakartidn No. 5 , 1968. Natvig, H.: Sociomedical aspects of low back pain causing prolonged sick leave. Acta Socio-Med Scand Sparup, K . H.: A sociomedical evaluation of back insufficiency. Scand J Rehab Med I : 74, 1969. Tufvesson, B . , Cardell, H. & Martelius, E.: Reha- bilitering av 240 ryggpatienter. Lakartidningen, No. 2-3: 117, 1970. . __. 46, 1970 12. Westrin, C. G.: Low back sick-listing. A nosological and medical insurance investigation. Acta Socio- Med Scand2-3: 127, 1970. Received October 29, 1975 Address for reprints: Soren Hilding, M.D. Dept. of Orthopaedic Surgery University Hospital S-750 14 Uppsala Sweden Upsala J Med Sci 81