Physical Therapy and Health

Outcomes in Patients With Spinal

Impairments

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Background and Purpose. Little is known concerning the effects of
physical therapy on health outcomes in patients with spinal impair-
ments. This research examined the pattern of health outcomes in
patients with spinal impairments and the relationship of outcomes to
the physical therapy provided. Subiects. Data were obtained from 1,097
patients with spinal impairments who completed an episode of care in
any of 68 physical therapy practices across the United States. Methods.
Data were derived from the Focus on Therapeutic Outcomes database
during 1993 and 1994. Multivariate analyses were used to determine
which of the treatment variables, controlled for baseline health status
and relevant patient characteristics, were related to outcomes. Results.
Improvement occurred in nearly all health scales. Inclusion of endur-
ance exercise was most consistently associated with better outcomes.
Inclusion of heat or cold modalities was associated with poorer
outcomes. Conclusion and Discussion. This study suggests that physical
therapists take a broader view of patient-related goals and documen-
tation of outcomes. It also provides evidence that the type of interven-
tion is related to outcomes. uette DU, Jette AM. Physical therapy and
health outcomes in patients with spinal impairments. Phys Ther.
1996;76:930-945.1

Key Words: Back pain, Neck pain, Outcome and process assessment.

Diane UJette

Alan M Jette

Physical Therapy . Volume 76 . Number 9 . September 1996


usculoskeletal impairments account for a
large percentage of conditions for which
medical care is sought in the United
States,] and a large proportion of the cost
t low back pain identified from NHANES I1 had used
associated with this care is related to the disability caused
by these impairments. In 1984, Cunningham and Kelsey2
reported the overall prevalence of musculoskeletal
impairments using data from the National Health and
Nutrition Examination Survey (NHANES) I. In the
United States, 32.6% of persons between the ages of 25
and 74 years were affected by some type of physician-
observed musculoskeletal impairment, and 29.7% of the
population had self-reported musculoskeletal impair-
ments. Impairments related to the spine had the highest
prevalence. In the National Medical Care Utilization and
Expenditure Survey (NMCUES), about 20% of the 1980
noninstitutionalized population reported having a mus-
culoskeletal problem involving the back or joints that
resulted in some type of disability or use of the health
care system."
Conservative treatment of musculoskeletal impairments
often includes physical therapy, and there may be a
trend toward an increase in the use of physical therapy
service^.^ Of all patients discharged from outpatient
physical therapy practices in the United States, 25% were
patients jbr whom low back pain was the primary prob-
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lem, and a large majority of the remaining patients
sought care for other musculoskeletal impairments."
Deyo and Tsui-Wu"eported that 40.5% of subjects with
"exercises or physical therapy" for treatment. Other
common interventions provided by physical therapists
were traction, which had been used by 20.7% of the
subjects, and diathermy or paraffin, which had been
used by 16.7% of the subjects. The NMCUES indicated
that 13.3% of total charges for treatment of musculoskel-
etal conditions was attributed to care given by health
care professionals other than physicians, including phys-
ical therapists.The cost of health care related to the
treatment of musculoskeletal impairments accounted
for 8% of total health care expenditures in 1980, ranking
third among health problems in terms of costs for
civilian noninstitutionalized individual^.^
Little is known concerning the relationship of specific
health care interventions to disability. Deyo and Diehlv
found that demographic, psychosocial, and baseline
health status, rather than impairment status or interven-
tion, had an effect on functional outcomes in patients
with low back pain. Although physical therapy is a
common intervention and is often initiated with the
belief that disability can be reduced or prevented, there
is little evidence that suggests any particular treatment

DU Jette, DSc, PT, is Associate Professor and Program Director, Graduate Program in Physical Therapy, Graduate School for Health Studies,
Simmons College, 300 The Fenway, Boston, MA 02115 (USA) (djette@vmsvax.simmons.edu),and Physical Therapist, Beth Israel Healthcare,
330 Brookline Ave, Boston, MA 02215. Address all correspondence to Dr Jette at the first address.

AM Jette, PhD, PT, is Professor and Dean, Sargent College of Allied Health Professions, Boston University, 635 Commonwealth Ave, Boston, MA
02215. He was Chief Research Scientist, New England Research Institutes Inc, 9 Galen St, Watertown, MA 02172, and Professor of Social and
Behavioral Sciences, Boston University School of Public Health, 80 E Concord St, Boston, MA 02118, at the time of this study.

This study was approved by the Human Subjects Review Board of New England Research Institutes Inc.

This work was supported by a Mary Switzer Rehabilitation Research Fellowship awarded to DU Jette from the National lnstitute of Disability and
Rehabilitation Research, US Department of Education (#H133F50022).

This article was submitt~dOctober 2, 1995, and was accqted March 27, 1996.

Physical Therapy. Volume 76 . Number 9 . September 1996 Jette and Jette . 93 1

approach produces better outcomes than another. The
recently published Acute Low Back Pain Problems in Adults:
Clinical Practice Guideline No. 14," developed by the
federal Agency for Health Care Policy and Research
(AHCPR), cites as "not recommended" several interven-
tions commonly administered by physical therapists,
including heat and cold modalities and stretching exer-
cises for the low back. Other physical therapy interven-
tions such as "low-stress aerobics" were recommended,
noting, however, the limited research-based evidence for
their inclusion.
The general goal of this study was to improve under-
standing of the pattern and magnitude of treatment
outcomes following physical therapy for patients with
spinal impairments. The specific purpose of the study
was to examine the relationship of patient outcomes
over a physical therapy episode of care to the character-
istics of that episode of care in terms of the type and
duration of treatment selected by the physical therapist,
controlling for characteristics of the patient.
Method
Subjects
The data for the study were derived from a large
database generated by the Focus on Therapeutic Out-
comes (FOTO) network.* The FOTO network was a
privately funded consortium of five outpatient rehabili-
tation companies. The FOTO network was developed for
the purpose of generating an outcome-oriented, stan-
dardized information management system for use in
outpatient physical therapy settings. Companies were
required to maintain an agreed-on data quality standard
and record completion rate to remain in the FOTO
network. The database contained information from
3,994 patients admitted for physical therapy care for
lumbar and cervical impairments during a 1-year period
beginning in July 1993. The sample for this study was
1,097 patients who filled out the requisite initial and
discharge health status questionnaires and had a com-
pleted episode of care. The remaining patients either
failed to make a final visit to allow for follow-up data
collection or did not complete follow-up questionnaires
at the final visit. These patients were treated in any of 68
physical therapy practices by 141 physical therapists. The
project was approved by the Human Subjects Review
Board of New England Research Institute, which was
responsible for the design and administration of the
database in 1993 and 1994.
Practices. The practices were located across the United
States: 2% from the middle Atlantic states, 20% from the
south Atlantic states, 9% from the south central states,
FOTO. PO Box 11441, Knoxville, TN 37939.
932 . Jette and Jette
62% from the north central states, 7% from the moun-
tain states, and less than 1% from the Pacific states. The
practices ranged in size, with 24% having one full-time
physical therapist, 38% having two full-time physical
therapists, 15% having three full-time physical thera-
pists, and 23% having more than three full-time physical
therapists.
Physical therapists. The average age of the physical
therapists was 32.6 years (SD= 7.8, range=22-60). Sev-
enty percent of the physical therapists were women. The
highest credential of 84% of the physical therapists was a
bachelor's degree. Nine percent of the physical thera-
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pists had an entry-level master's degree, and 7% of the
therapists had an advanced master's degree. The average
years of practice was 8.4 (SD=7.4, range= 1-33). Eighty-
three percent of the therapists worked full time, treating
an average of 50 patients per week.
Patients. Sixty-seven percent of the patients had impair-
ments of the lumbar spine, and 33% of the patients had
impairments of the cervical spine. Differences between
patients with complete follow-up data and those with
incomplete data were determined using analysis of vari-
ance. Patients with complete follow-up data were slightly
older (41.1 years versus 40.0 years, F=5.12, P=.024) than
those without follow-up data. Patients with incomplete
data had lower initial health status in six health out-
comes scales (energy/fatigue: 43.4 versus 46.1, F= 11.45,
P=.0007; general health perceptions: 67.4 versus 69.0,
F=4.56, P . 0 3 3 ; mental health: 66.3 versus 69.3,
F=17.55, P.OOO1; physical function: 52.3 versus 55.4,
F=9.97, P=.002; role limitation-emotional: 61.5 versus
65.8, 1;=7.78, P . 0 0 5 ; and social function: 54.1 versus
57.5, F=10.43, P=.001). Table 1 shows the characteris-
tics of the patients by primary impairment.
Treatments. Table 2 shows the percentages of patients
receiving various physical therapy treatments over the
episode of care. Ninety-six percent of the episodes
included various combinations of these treatments. The
most frequent combination was flexibility exercise,
strength exercise, and heat.
Data Collection
Data for each patient in the database were obtained by
the primary practitioner caring for the patient and from
the patient and included age, gender, ethnicity, height,
weight, educational level, income, employment status,
comorbidity, duration of the spinal problem, surgical
history, duration of the episode of care, and type of
treatments provided. In addition, each patient com-
pleted the standard form of the Medical Outcome Study
36Item Short Form Health Survey (SF-36)9 and
a disease-specific health outcomes questionnaire
(Oswestry Low Back Pain Disability Index1() or Neck
Physical Therapy. Volume 76 . Number 9 . September 1996
Table 1. Table 2.
Demographic and Financial Characteristics of Patients With Vertebral Characteristics of Treatments" and Episode of Care for Patients With
Impairments Spinal Impairments

Lumbar Cervical Lumbar Cervical

Impairment lmpairment lmpairment lmpairment
Characteristic (n=739) (n=358) Characteristic (n=739) (n=358)

Ag_e (Y) Manipulation/mobilization 39% 61%

X 41.2 42.0 Flexibility exercises 84% 8 1%
SD 13.9 13.4
Strengthening exercises 81% 60%
Gender
Female 46% 67% Endurance exercises 52% 36%
Male 53% 33% Massage techniques 3 9% 65%
Ethnicity Heat modalities 81% 91%

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White 87% 83%
10% 11% Cold modalities 19% 12%
Black
Native American <1% < 1Yo Episode length (d)
Asian < 1% 1% X 28.1 29.7
Hispanic 2% 4% SD 21.7 23.5
Employment Range 1-1 82 1-1 5 4
a
Full time 34% 49% "Percentage of patients receiving this type of treatment.
Light duty 13% 10%
Off because of health 35% 16%
Retired 8% 11%
Unemployed 10% 13% Oswestry Low Back Pain Disability Index is used to assess
Income the status of patients with lumbar spine impairments.1°
<$15,000 1 0% 8% The reliability and validity of measurements obtained
$15,000-$25,000 18% 17% with this instrument have been reported.1° Ten areas are
$26,000-$35,000 16% 22% assessed: pain, personal care, lifting, walking, sitting,
$36,000-$45,000 15% 14%
26% 25%
standing, sleeping, sex life, social life, and traveling. The
>$45,000
Refused to answer 15% 14% Neck Disability Index is used to assess the status of
patients with impairment of the cervical spine." Ten
Acuity
Acute 21% 19% areas are assessed: pain, personal care, lifting, reading,
Subacute 49% 53% headaches, concentration, work, driving, sleeping, and
Chronic: 30% 28% recreation. Vernon and Moirn have reported on the
Surgery reliability and validity of scores obtained with the instru-
Yes 15% 7% ment. For each of the SF-36 scales, responses to the
No 85% 93% questions were summarized and then transformed to
Depressed provide scores ranging from 0 to 100, with 100 being the
Yes 3 1% 3 1% best possible score. The SF-36 provides a profile of
No 69% 69%
health, with a score for each of the eight health dimen-
Comorbidities sions. Each impairment scale provides one comprehen-
None 58% 55%
1 category 27% 30%
sive score, with 0 being the best score and 100 being the
2 categories 13% 13% worst score.
More than 2 categories 2% 2%
Data Analyses
The pattern of health status for patients with spinal
Disability Index") at initiation and completion of phys- impairments beginning physical therapy care was exam-
ical therapy. These questionnaires provided the major ined by comparing gender- and age-controlled SF-36
indicators of health outcome. scores of patients at the time of their initial visit with the
population norms. Norms were derived from a sample of
The SF-36 queries the patient concerning health over 2,474 noninstitutionalized adults residing in the United
the past 4 weeks in eight different health outcome States who responded to the National Survey of Func-
dimensions: energy/fatigue, general health perception, tional Health Status in 1990.1The comparisons were
mental health, bodily pain, physical functioning, role made by computing standard scores, which were derived
limitation due to emotional problems, role limitation by subtracting scores for patients on each of the scales
due to physical problems, and social functioning." from the mean general population scores and dividing
Acceptable reliability and validity of the SF-36 have been the results by the standard deviations of the general
reported for its use in aggregate analyses.lZ-l5 The population scores.14Comparing scores in this way allows

Physical Therapy . Volume 7 6 . Number 9 . September 1996 Jette and Jette . 933
Table 3.
Independent Variables

Variable Type Measurement

Patient demographic
Age Continuous Years
Gender Categorical Male, female
Income Categorical <$lS,OOO, $15,000-$25,000, $26,000-$35,000,
$36,000-$45,000, >$45,000, refused to answer
Education Categorical No high-school diploma, high-school diploma or some college,
college diploma or some graduate work, graduate degree
Employment Categorical Full time, light duty, off because of health, retired, unemployed
Ethnicity Categorical White, Black, Hispanic, Asian, Native American
Patient clinical
Body mass index Continuous Weight/height2 x 100

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Comorbidity Categorical Disease(s)in 0 categories, 1 category, 2 categories, >2 categories
Depression Categorical Depressed within the past year, not depressed within past year
Surgery Categorical Surgery related to current vertebral problem, no surgery
Acuity Categorical <2 wk duration, 2 wk to 6 mo, >6 mo
Treatment
Manipulation/mobilization Categorical Having manipulation/mobilization as part of treatment, not having
manipulation/mobilization as part of treatment
Flexibility exercise Categorical Having flexibility exercise as part of treatment, not having flexibility
exercise as part of treatment
Strength exercise Categorical Having strengthening exercise as part of treatment, not having
strengthening exercise as part of treatment
Endurance exercise Categorical Having endurance exercise as part of treatment, not having
endurance exercise as part of treatment
Massage techniques Categorical Having massage as part of treatment, not having massage as part
of treatment
Cold modalities Categorical Having cold modality as part of treatment, not having cold modality
as part of treatment
Heat modalities Categorical Having heat modality as part of treatment, not having heat modality
as part of treatment
Episode
Length Continuous Total days from admission to discharge

comparisons regarding the patterns of health status
across groups with various demographic characteristics
and health conditions.
The pattern and magnitude of outcomes for patients
with spinal impairments were estimated by computing
effect sizes for each of the SF-36 scales and the disease-
specific scales. Effect size represents change in a scale as
it relates to the standard deviation of scores for that
scale, and it is computed by subtracting the initial score
from the final score and dividing the result by the
standard deviation for the initial score.l7J* Demonstrat-
ing change in this way provides a standardized measure-
ment of change to aid interpretation. The magnitude of
change is described and, because it is standardized, can
be compared with changes in other scales, with bench-
marks that signify clinically meaningful changes, or with
changes obtained with another treatment regimen or in
another group of patients. Cohen18suggested the follow-
ing interpretation of effect size: 0.2 to 0.4 is small, 0.5 to
0.7 is moderate, and 0.8 or greater is large.
To examine the relationship of the characteristics of the
physical therapy episode of care to health outcomes,
nine sets of multivariate analyses were conducted for
each type of impairment, with follow-up scores on the
SF-36 and disease-specific scales as the dependent vari-
ables and baseline scores as covariates. The major inde-
pendent variables of interest consisted of treatment
characteristics. In addition, relevant characteristics of
the patient were included to control for potential con-
founding. Table 3 describes the variables in detail.
Initially, univariate analyses were used to determine
possible confounding variables among the patient char-
acteristics. Then, using general linear models and a
backward deletion process, treatment variables were
determined for models that included baseline scores
and those patient variables that had a significant univar-
iate correlation to the outcomes of interest. This is an
interative process that begins with a regression model
containing all independent variables. Subsequent steps
involve decisions to retain or delete variables based on
their contribution to the model and comparison of the

934 . Jette and Jette Physical Therapy . Volume 76 . Number 9 . September 1996

Figure 1.
Comparison of SF-36 scores for the general population and for patients with spinal impairments. The US population norms are represented by the
straight line c~tzero on the y axis. Points for patients with spinal impairments represent the magnitude of difference relative to the population norms.
partial F e:tatistic with a preselected critical value. This
multivariate analysis allows variation in the dependent
variable to be attributed to a combination of indepen-
dent variables, both continuous and categorical, and
allows coritrol for the baseline value of the dependent
variable in a "pre-post measurement" design. An alpha
level of .OA was used to determine the patient variables to
include as possible confounders. An alpha level of .05
was used as the criterion for other variables to remain in
a model controlled for baseline health status and the
potentially confounding variables. Only data of patients
with complete data for the independent variables of
interest were included in the analyses. Due to some
missing data for some variables, the number included in
each model varied. All analyses were performed using
SAS software.+
+ SAS Institute Inc, SAS Campus Dr, Cary, NC 27513.
Physical Therapy . Volume 7 6 . Number 9 . September 1996
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Results
The SF-36 can be seen as measuring two basic compo-
nents of health: physical and emotional.lVatients with
lumbar and cervical impairments during an initial phys-
ical therapy visit reported poorer physical and emotional
health than did the general population (Fig. 1). The
areas most notably affected were bodily pain and role
limitation due to physical problems. In each scale, scores
were nearly 2 standard deviations below scores for the
general population. Patients with lumbar impairment
also demonstrated striking problems with physical func-
tion (1.5 standard deviations below the norm). The
pattern of loss of health was similar for patients with
cervical and lumbar impairments except in the area of
physical function, where lumbar impairment appeared
to have a greater effect. The patient's age, gender,
education, employment status, income, problem acuity,
comorbid status, body mass index (BMI), surgical his-
Jette and Jette . 935
 +LUMBAR IMPAIRMENT +CERVICAL IMPAIRMENT

energylfatigue
0.9 -
0.8 -.
health perceptions

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Figure 2.
roleemotional / Y physical function

Outcomes over an episode of physical therapy care for patients with spinal impairments. Magnitude of change is represented by a point on an arm
of the radar graph. The center of the graph represents no change. Each hatch mark represents a change of 1/10 of a standard deviation.

tory, and depression were de~erminantsof outcome in
both physical and psychological health domains.
Health improved in the disease-specific scales and in all
other areas except general health perceptions over a
course of physical therapy care, which lasted, on average,
28 days (Fig. 2). Changes occurred most notably in the
physical dimension of health as measured by bodily pain
(approximately 0.8 standard deviation) and the disease-
specific scales (approximately 0.7 standard deviation)
for both lumbar and cervical impairments. Patients with
lumbar impairments also demonstrated important
changes in physical functioning (approximately 0.7 stan-
dard deviation). Patients with lumbar and cervical
impairments demonstrated similar patterns of improve-
ment except in physical functioning.
Controlling for relevant patient characteristics and base-
line health, characteristics of the physical therapy epi-
sode of care were associated with outcome in six of the
nine outcomes for patients with lumbar impairment and
in four of the nine outcomes for patients with cervical
impairments. Of all the treatments examined (Tab. 2),
the use of treatments that included endurance exercise
predicted better outcome most often in scales measuring
both the physical and emotional aspects of health. Better
outcome was associated with endurance exercise in
energy/fatigue for patients with each type of spinal
impairment, in physical function and social function for
patients with lumbar impairments, and in general health
perceptions for patients with cervical impairments.
Treatment with mobilization or manipulation was
related to better outcomes in general health perceptions

936 . Jette and Jete Physical Therapy . Volume 76 . Number 9 . September 1996
Table 4.
Factors Related to Better Outcomes in Patients With Lumbar Impairmentso

Model
Patient Clinical Treatments Episode Nb

Physical health dimension

Bodily pain Not off work because of health Not depressed N o heat modalities .26 663
Having high-school diploma Less comorbidity N o cold modalities
IncomeC BMIc
Physical function Younger Lower BMI Having endurance .37 711
Having high-school diploma N o previous surgery exercise
Employmentc Less chronic
Comorbidityc
Rol*pt~ysical Not off work because of health Problem acuityc N o cold modalities .24 71 1
Younger

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IncomeC
Educationc
Emotional health dimension
Mental health Female Not depressed .47 679
Income not $15,000-$25,000
Educationc
Role-ernotional Income not $15,000-$25,000 Not depressed .32 667
Not African-American Less comorbidity
Not off work because of health
Having high-school diploma
Social I'unction Not off work because of health Not depressed Having endurance .34 669
Having high-school diploma Lower BMI exercises
Female N o heat modalities
N o cold modalities
Physical c~ndemotional
health dimensions
Energy,/fatigue Not off work because of health Not depressed Having endurance Shorter length .37 679
Salary not $15,000-$25,000 exercises
No heat modalities
N o cold modalities
Health perception Younger Less comorbidity .56 684
Not depressed
Disease-specific
Oswestry Index Having high-school diploma Less chronic N o heat modalities .38 676
Agec N o previous surgery
Not depressed
Less cormorbidity

"All ~notlrlsare statistically controlled for baseline health outcome score. (BMI=body mass index.)
" N varies due to missing data.
' Variable significant in univariate analysis, but not significant in final model.

and in the Neck Disability Index for patients with
cenical i:mpairments. Patients with cervical impairments
also showed improved outcome in physical functioning
with the i.nclusion of flexibility exercises and in the Neck
Disability Index with inclusion of strength exercises as
part of the treatment. For those patients with lumbar
impairments, the inclusion of heat or cold modalities
was associated with poorer outcomes in five scales.
The factors explaining better outcomes in the various
health scales are presented in Tables 4 and 5. Significant
models were generated for all scales ( ~ * = . 2 4 - . 5 6and
.23-.60 for lumbar and cervical impairments, respective-
ly). In all cases, most of the variability in outcome was
accounted for by baseline scores.
Discussion
This study adds to our knowledge concerning the health
effects of problems involving the spine and demonstrates
the pattern and magnitude of outcomes achieved over a
course of physical therapy. We believe that this is the first
study to comprehensively examine whether the types of
treatments provided by physical therapists are associated
with outcomes of patients undergoing physical therapy.
Although the majority of patients in our study had
treatment that involved multiple approaches, we were

Physical Therapy . Volume 7 6 . Number 9 . September 1996 Jette and Jette . 937
Table 5.
Factors Related to Better Outcomes in Patients With Cervical Impairmentsa

Model
Patient Clinical Treatments Episode R2 N~

Physical Health Dimension

Bodily pain Not off work because of health .23 349
Physical function Younger Not depressed Having flexibility exercises .52 315
Employmentc Comorbidityc
BMIc
Role-physical Not off work because of health Less comorbidity .25 349
Emotional health dimension
Mental health Not off work because of health Not depressed .44 319
Income not $35,000-$45,000

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Role-emotional Not depressed .29 322
Less comorbidity
Social function Not off work because of health Not depressed .40 32 1
Less comorbidity
Physical and emotional
health dimensions
Energy/fatigue Not depressed Having endurance exercises .39 323
Less comorbidity
Health perception Less comorbidity Having manipulation/ .60 323
Not depressed mobilization
Having endurance exercises
Disease-specific
Neck Index Younger Less chronic Having manipulation/ .38 676
Not depressed mobilization
Having strength exercises

"All models are statistically controlled for baseline health outcome scores. (BMI=body m a s index.)
% varies due to missing data.
' Variahle significant In univariate analysis, but not significant in final model.

able to show that outcomes were associated with the use
of some types of treatments.
Use of endurance exercises was the most consistent
predictor of better outcome. The effect seemed to be in
both the physical and emotional health dimensions.
These results are supported by the findings of Lindstrom
et al,?Owho found that a group of workers with low back
pain who participated in an individualized exercise
program that included some form of endurance exercise
returned to work more quickly and had less long-term
sick leave than a control group who did not have
exercise instruction. Our findings also provide support
for the AHCPR guideline for acute low back pain, which
recommends endurance programs and low-stress aero-
b i c ~ Inclusion
.~ of endurance exercises in a physical
therapy regimen may convince patients to try physical
activities that they have avoided and may improve their
aerobic capacity, allowing them to perform activities with
less perceived exertion. Endurance exercise may also
reduce sensitivity to pain, increase blood flow to painful
muscles, and increase endorphin levels. In addition to
endurance exercise, other treatments, including manip-
ulation or mobilization, strengthening exercises, and
flexibility exercises, are related to better outcomes for
patients with cervical impairments. These findings sug-
gest a multimodal approach to physical therapy care for
patients with cervical impairments.
The inclusion of heat and cold modalities in a treatment
episode was associated with poorer outcomes and may
reflect less time during treatment spent on more active
therapies such as exercise. This finding serves as support
of the AHCPR guideline, which does not recommend
physical agents provided by health care practitioners for
the treatment of low back pain.8
This study confirms reports of the detrimental effects of
low back pain on health.1?,?"-" Health profiles for
patients with low back pain similar to those for our
sample were reported by Stewart et al'"sing the SF-20
and by Lansky et a1z2 and Garratt et all4 using the SF-36.
Deyo and DiehlZ1 also showed similar disabilities as
measured by the Sickness Impact Profile. In all cases,
patients with back pain demonstrated the greatest dis-
ability in role functioning. The physical functioning and
pain scales for the SF-36 and SF-20 in these studies were
also considerably lower than for the general population.

938 . Jette and Jette Physical Therapy . Volume 7 6 . Number 9 . September 1996
Our findings show that cervical problems also affect role
function related to physical health and that pain is a
major prr~blem.Unlike patients with lumbar impair-
ment, however, patients with cervical impairment d o not
experience the same degree of loss of physical function-
ing. Interestingly, both lumbar and cel-cical problems
appear to affect social functioning.
Over a course of physical therapy care, improvements in
health occur in nearly all areas for patients with either
type of vertebral problem. The design of the study
precludes attributing these changes to the inte~vention,
and reported changes may well be due to the natural
history OF the problem or some characteristic of the
patient (eg, patients receiving endurance exercises may
be different from those receiving thermal modalities).
.4 comparison of the changes found in our study with
those documented by Garratt et alN over a 1-year period
'ind by Lansky et a122 over a 90-day period provides some
insight into the possible effects of history on low back
pain problems. Whereas Garratt et alZ4and Lansky et a122
showed the greatest amount of change in the bodily pain
and phys~calrole limitation scales, changes in our study
werc grea~testin the bodily pain and physical functioning
scales fbr patients with lumbar impairments. This dis-
crepancy may suggest that early changes in health occur
in physic;al functioning, with improvement in role func-
tioning occurring later. Improvement in pain may occur
early and be sustained. Physical therapists' understand-
ing of pain as a major problem area can be inferred by
the Fact that reduction of pain was reported as a treat-
ment goal for 90% of the patients treated by physical
therapists for low back pain.' Goals related to physical
function, role function, and social function, however,
were not identified in that study. In spite of this lack of
reported physical therapy goals for improved physical
role and social functioning, such improvement appears
to occur over a physical therapy episode of care. The
improvernent in function may be a reflection of implicit,
rather ~ h : a nexplicit, goals set with the physical therapist.
Our stl~clysuggests a need for physical therapists to
reconceptualize the scope of the goals set with the
patient and to make functional goals more explicit.
O u r findings also show that the degree of change in
disease-specific scale scores is similar to the degree of
change in pain scores of the SF-36 over the course of
treatment. The degree of change in the Oswestry Low
Back Pain Disability Index is also similar to that found in
the physical functioning scale of the SF-36 and reflects
their me.asurement of similar functions. The Neck Dis-
ability Index is not quite so clearly a measure of one
aspect of health. These findings argue for the use of a
generic health instrument, as it provides a more com-
prehensivc measure of health than the disease-specific
Physical Therapy . Volume 76 . Number 9 . September 1996
scales, with apparently similar responsiveness to change
in some of its scales.
Outcomes for patients with vertebral impairments are
only minimally to moderately predicted by an array of
factors commonly noted during a physical therapy epi-
sode of care in spite of the fact that changes are
moderate or better in most scales. Harada et a12Vound
that they could explain 52% of the variability in func-
tional change for patients with low back injury. These
authors, however, forced all predictor variables into the
model in a predetermined order. Our approach to the
analyses used an elimination process that resulted in
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models that included only significant variables and,
therefore, explained less variance. Deyo and Dieh17
found that 17% of the variability in pain improvement in
patients with low back pain could be accounted for by a
model that included three patient-related factors.
According to our results, patients who might be
expected to have better outcomes over an episode of
physical therapy care for the treatment of either lumbar
or cenical spine impairments are young, are not off
work because of their health, have less comorbidity, and
are not depressed. For patients treated for lumbar
impairment, having a high-school diploma is an addi-
tional factor associated with better outcomes. Income in
the range of $15,000 to $25,000 per year is associated
with poorer outcomes in patients with lumbar
impairments.
Yor~nger age has been found to be associated with
improvement in low back pain outcomes following sur-
gery in at least one previor~sstudy.'Wur finding that
better outcome was associated with being younger held
true in spite of controlling for comordities. This finding
suggests reasons other than the increased rate of comor-
bidity with aging for older people not faring as well.
Research reports consistently suggest that lower educa-
tional level has a negative effect o n 0utcomes.7.~7This
finding may be a result of problems understanding and
complying with iristructions from health care providers
or it may be due to the fact that lower education levels
are generally associated with employment that requires
physical labor that is difficult to resume with a low back
impairment. The finding that women had better out-
comes than did men is contrary to the reports of others
who have found that women fare less ell.'^,'^ Interest-
ingly, the scales in which women fared better repre-
sented the emotional domain of health.
Poor outcomes in both the physical and psychological
domains of health were found to be related to being
depressed at initiation of treatment. Previous investiga-
tions have not directly included a measure of depression
in multivariate examinations of changes in health in
Jette and Jette . 939
patients with spinal impairments. Deyo and Diehl,7 how-
ever, found that a report by patients of "always feeling
sick was a consistent predictor of poor outcome in
patients with low back pain. They speculated that this
variable was a marker for psychological state. In another
study, the same authors found that patients with back
pain who had psychiatric problems or were worried
about serious illness had greater disability.z1
The relationship of income to outcome in patients with
lumbar impairments is most consistent in the emotional
domain of health. This relationship may reflect prob-
lems associated with coverage for payment of care.
Patients in this income bracket are likely to have low-
paying employment that does not provide health insur-
ance, yet too much income to qualify for government
programs.
Limitations
This study was observational in nature and precludes
conclusions about the effectiveness of physical therapy
treatments. Patients were not randomized to treatments,
and illness behavior may have influenced treatment
choices made by the physical therapists. In addition,
individual physical therapists indicated whether they had
used particular treatment approaches. These
approaches, for example, endurance exercise, were
broadly defined, and no attempt was made to assess the
reliability of therapists' entries into the database. The
data also do not account for the subtle changes in
patients' conditions over time and the treatment adjust-
ments that occur in response to these changes.
The database used for this study lacked data concerning
specific impairments of the musculoskeletal system that
might be found in patients with vertebral impairments,
for example, pain pattern, flexibility, and muscle
strength. In addition, patients' problems were only
grossly classified as lumbar or cervical. There is some
evidence in the literature that specific impairments are
related to di~ability.2~-2qet, other studies have not
found any effects of physical examination findings when
they were included with other psychosocial variables in
multivariate analy~es.~,2"
The findings reported here are based on analysis of a
clinical database. These data were generated for the
major purposes of quality assurance and business deci-
sion making, and using them for predicting outcomes
presents limitations. Because of these limitations, this
study should be viewed as hypothesis generating rather
than hypothesis testing.
The issues related to the use of clinical databases have
been clearly outlined by Pryor and LeeN and include the
use of data to answer questions not determined a priori,
940 . Jette and Jette
missing observations, and other biases that limit the
external validity. These biases include selection bias and
referral bias. In our database, only approximately 28% of
the patients had completed episodes with complete data.
Patients failing to complete data collection had poorer
initial health status than those completing data collec-
tion in six of the outcome scales. If those patients did not
complete an episode of care because of failure to
improve or worsening, the inclysion of their data in the
analysis would result in lower effect sizes and possibly
different models showing the association of treatment to
outcomes. This example demonstrates the problem that
can occur when physical therapists fail to obtain or
document data relevant to their practice and treatment
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of patients. The example also illustrates the necessity of
quality control and rigorous auditing practices in design-
ing, implementing, and maintaining databases that are
used for any type of research.
In addition, this database included large numbers of
variables that needed to be reduced in some way to
facilitate interpretation of the predictive models. Such
reduction results in the loss of some information and the
increased chance of misclassification. Despite reducing
variables to a manageable number and selecting vari-
ables that measured unique attributes, many predictor
variables were examined. The large number of variables,
defined in unique ways by the investigators, is likely to
result in idiosyncratic models. Further studies are
required to test the validity of the predictions.
In spite of these limitations, this study provides informa-
tion not previously reported concerning the relationship
of physical therapy to comprehensive health-related
outcomes. It also adds to the body of knowledge con-
cerning prognosis for patients with lumbar and vertebral
impairments. Although observational studies using clin-
ical databases cannot provide the same rigorous results
as clinical trials concerning the effectiveness of treat-
ments, they can provide valuable information for con-
ceptualizing efficient and effective future trials.
Conclusion
Individuals with vertebral impairments demonstrate dec-
rements in health status in both the physical and emo-
tional dimensions of health. Both lumbar and cervical
impairments substantially affect role function related to
physical health, and pain is a major problem. Persons
with cervical impairments, unlike those with lumbar
impairments, do not experience a substantial loss of
physical function. Over a course of physical therapy care,
improvements in health occur in nearly all areas for
those with either type of spinal problem. Physical thera-
pists may, therefore, wish to expand the scope of the
goals for treatment set with each patient. Inclusion of
endurance exercise and the exclusion of heat or cold
Physical Therapy . Volume 76 . Number 9 . September 1996
modalities in the treatment regimen were associated
with better outcomes. Future studies are needed to
validate the models reported here and to further exam-
ine the effect of physical examination findings and
physical therapy interventions on outcomes in patients
with spinal impairments.
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Physical Therapy. Volume 76 . Number 9 . September 1996 Jette and Jette . 941