This is an enhanced PDF from The Journal of Bone and Joint Surgery The PDF of the article you

requested follows this cover page.

Risk factors in low-back pain. An epidemiological survey

JW Frymoyer, MH Pope, JH Clements, DG Wilder, B MacPherson and T Ashikaga J Bone Joint Surg Am. 1983;65:213-218.

This information is current as of July 14, 2010 Reprints and Permissions Click here to order reprints or request permission to use material from this article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org

Publisher Information

(opyri@ht I 953 by I/,

Journal if 8'ne aiiii Joipit Surgery. imorporated

Risk Factors in Low-Back

AN EPIDEMIOLOGICAL
BY J. W@. FRYMOYER, M.D.t, M. H. POPE, PI-I.D.t, JANICE

Pain
BAt, DAVID G. WILDER, M.S.M.E.t,

SURVEY
El. CLEMENTS,

BRIAN MA'PHERSON,

M.S4,

AND TAKAMARU

ASHIKAGA,

PH.D4,

BURLINGTON, Facility,

VERMONT

I. rout tist De/)art?tlent o/ Ort/:ojatu-tlies atul ReI,abilitatio,,

(liii tcF.sit\ (.1/ Vermont. College ()/ Medicine

(iFl(lthe Bio,netts
, Burlingtoii

ABSTRACT:

A survey

was

done

on

1221

men

be

tween the ages of eighteen and fifty-five years who had been seen in a family-practice facility between 1975 and
1978 Each patient completed a questionnaire concern

verity, and resultant disability of low-back pain. In an attempt to elucidate the contributions of some of
these
ported women

and other

potential

risk factors,
analysis of the family

we previously
incidence practice of

re
how

a retrospective who were seen

ing any history of low-back pain, associated symptoms in the lower limbs, resultant disability, types of health care utilized, certain occupational characteristics, ex posure to vehicular vibration, and sports activities. We found that 368 patients (30. 1 per cent) had never exper ienced low-back pain, 565 (46.3 per cent) had or were having moderate low-back pain, and 288 (23.6 per cent) had or were having severe low-back pain. Pa tients with severe low-back pain had significantly more complaints in the lower limbs, sought more medical care and treatment for the low-back pain, and had lost more time from work for this reason. Risk factors as sociated with severe low-back pain included jobs re quiring repetitive heavy lifting, the use of jackham mers or machine tools, and the operation of motor ye hides. Patients with severe pain were more likely to be cigarette-smokers and had a greater tobacco consump tion as measured by both the number of cigarettes smoked per day and the number of years of exposure. Patients with moderate low-back pain were more often joggers and cross-country skiers when compared with the asymptomatic men and the men with severe low back pain. Otherwise, there were no identifiable differ ences related to sports activity. Although low-back pain is the most common dis abhing musculoskeletal symptom, there is little under standing regarding the risk factors with which it has been
reported to be associated. Spine geometry'2 , increased

back pain from the medical

records

of 3920 men and

between

in a rural

1975 and l978'@. In that study, we found that patients who reported low-back pain to the physician had occupations
that required and more more repetitive stressful lifting, pulling, and twisting, women and

as well as having more episodes of anxiety and depression

life events. Multiparous

cigarette-smokers pain.

were more likely to report low-back

the results of a questionnaire

We are now reporting

survey of the men in the same population; to our knowl edge, this is the first such study conducted in the United
States. certain This paper describes the socioeconomic and and medi risk

cal impact of how-back pain in this population and explores

occupational. recreational, environmental

factors. Methods and Materials

Population

The population for this study was derived from a model family-practice facility that was opened in 1975. The facility serves as the only local medical facility for a
population of approximately 8000 people and consists of

rural and commuting who were patients

suburban of the practice

populations. from 1975 to 1978 were

All men between the ages of eighteen and fifty-five sent a questionnaire. Patients who were older than fifty five were excluded, because retirement makes accurate oc
cupational analysis difficult and because the probability of

lumbar lordosis certain mechanical stresses 0.12 repeti , tive heavy lifting'78'26,a sedentary life-style6', poor ab dominal tone2, obesity2. certain personality profiles, and psychological stress@72@27''4424' have all been cited as important risk factors associated with the frequency, Se
Supported in part by Grant PHS ROl 00745-01 . Department of

other chronic medical conditions in these patients would have made some of the planned tests difficult to accom plish. The questionnaire survey was carried out between
l979and multiple 1980.

A self-administered
items related

questionnaire
to present

was designed, with

com

and past low-back

Health,

Educat,on

and Welfare,

Public Health Service.

National Insti
University of

tutes of Occupational Safety and Health. -y Department of Orthopaedics and Rehabilitation,

phaints; it included a Likert-type scale of severity based on the McGill pain questionnaire27. In that scale, subjects
rate pain as mild, discomforting, moderate distressing, horrible, discomfort
213

Vermont, (.ollege of Medicine, Burlington. dress reprint requests to Dr. Frymoyer.

:@ Biometry Facility. University Burlington. Vermont 05405.

Vermont 05405. Please ad

College of Medicine.

or

of Vermont.

excruciating.
questionnaire

We categorized
as no pain,

the
pain

responses
(mild,

to our

VOL. 65-A, NO. 2, FEBRUARY 983

214

J. W.

FRYMOYER

ET AL. TABLE I

ing, or distressing), and high pain (horrible or excruciat ing). Patients rated the severity of current or past low-back pain, or both. Patients were classified as having had no pain, moderate pain, or severe pain based on their rating of past pain. Specific items in the questionnaire dealt with syrup toms associated with low-back pain, such as pain, numb
ness, or weakness in the lower limbs; medical care, includ

MEN REPORTINGSYMPTOMSIN THE LOWER LIMBS

ASSOCIATED WITH LOW-BACK PAIN

with Low-B
Symptoms in the Moderate Lower Limbs*Men (n = 565)ack 288)Pain28.954.5tNumbness14.037.4tWeakness17.944.Ot

Pain (Per cent) Severe (n =

ing that of physicians and other health-care practitioners; occupational requirements , including job classification and lifting activities; the use of heavy equipment and machine tools; the use of motor vehicles (automobiles, trucks, buses, or motorcycles, expressed in hours per week of use); current recreational activities as well as those pur sued during late adolescence (between the ages of sixteen and twenty-one); and disability and time lost from work because of low-back pain. The collection of data began in January 1979 and was completed in June 1980. The protocol for the acquisition of data included the following hierarchy of steps, listed in the order in which they were attempted: ( 1) we mailed a written request to the subject, asking him to complete an enclosed questionnaire; (2) we attempted telephone con tact; (3) we sent two Mail-Gram requests; and (4) personal contact was made by trained and experienced interviewers. As many as three follow-ups were conducted in cases in which the respondent was not at home. To locate a respon dent, interviewers first went to the last known address. If the respondent no longer lived at that location, the present occupants, neighbors, friends, or relatives were queried. It was standard practice to check with town clerks and post offices. Public documents, city directories, and telephone books were also used. At all steps in the contact process, the confidential nature of the desired information was stressed to the respondent.
Statistical A nalyses

subject

may

have

reported

one

or

more

of

these

symptoms.

t p < 0.001,

chi-square

analysis.

1221 ofthe total of 1816 men, representing a response rate of 67 per cent. Nineteen per cent could not be located, 6 per cent refused to respond, 3 per cent had moved out of the area and did not reply when contacted by mail at a for warding address, 2 per cent failed to reply despite having indicated that they would respond, and 1 per cent were never at home when contact was attempted or had another medical illness that prevented their participation. An additional thirty-five respondents (2 per cent) failed to adequately indicate their history of back pain on the questionnaire. A comparison of the medical records of questionnaire respondents and non-respondents demon strated no significant differences between the two groups with respect to age, symptoms, disability, or utilization of health care as determined from the previous retrospective
study'4.

Of the 1221 subjects who responded to the questionnaire, 368 (30. 1 per cent) had never experienced low-back pain, 565 (46.3 per cent) had experienced moderate pain, and 288 (23.6 per cent) had had severe symptoms. Thus, 853 respondents (69.9 per cent) had ex penenced either severe or moderate low-back pain. The mean age was thirty-two years old for patients with no low-back pain, 32.6 years for those with moderate pain,
TABLE
TYPE OF HEALTH-CARE SERVICES

Categorical data were analyzed by using chi-square contingency-table techniques . The relationship between the severity of low-back pain and other variables was ex

II
AND TREATMENT UTILIZED BY

MEN WITH LOW-BACK PAIN

amined using Spearman's rank correlation procedure.

@ @

Comparison of specific (cohort) subgroups was accom plished by means of analysis with variance techniques, with subsequent tests for multiple comparisons. The as sociation of levels of severity of low-back pain in groups of patients with multiple risk factors was examined using multiple regression and linear discriminant analysis. Using these multivariate statistical techniques, it was possible to estimate the effects of each potential risk factor on the severity of how-back pain by controlling for other relevant factors that may also be related to low-back pain. Analyses were conducted using a DEC 2060 computer using Statis tical Packages for the Social Sciences (SPSS)29 and Biomedical Computer Programs (BMDP)8. Results Fully completed questionnaires were obtained from

Men with Low-Back Pain (Per cent)

Moderate

(n@@ 565)

(n=288)

Severe

Health-care practitionerFamily physician30.566.7Orthopaedic surgeon8.832.3Neurosurgeon2.79.5Osteopath7.023.8ChiropractorI

2.727.5Physiotherapist3.816. 1Other5.012.1TreatmentBest

172.8Muscle rest35. relaxant17.752.6Prescription I58.0Physiotherapy9.523.9Back pain medication21 .337.4Other support1

. 1

treatment12.627.4Lumbar non-surgical spine surgery2.010.5

THE JOURNAL OF BONE AND JOINT SURGERY

RISK FACTORS

IN LOW-BACK

PAIN TABLE IV

215

and 33.2 years for those with severe pain. The age range for all three groups was eighteen to fifty-five years. Symptoms in the lower limbs, which might indicate nerve-root involvement, were reported by the men with moderate and severe back pain (Table I). A significantly greater incidence (p < 0.001 , chi-square test) of symp toms in the lower limbs was reported by patients with se vere back pain than by those with moderate back pain. Table II expresses the percentage of each group seek ing consultation or treatment for low-back pain at any time previous to the time of the study. Patients with severe back pain utilized a great variety of health practitioners and treatments . Forty-one patients (3 .4 per cent) had had sur gical treatment. Of these, eleven (26.8 per cent) had moderate pain and thirty (73 .2 per cent) had severe pain. Table III shows the frequency with which the patients sought treatment. The socioeconomic impact of the low-back corn plaints was measured by the number of days that the pa tient had been unable to work during the previous year. Of the patients with severe or moderate low-back pain, 181 had an average loss of 30.3 days of work due to low-back pain. Sixty-nine (12.2 per cent) of the patients with mild pain and 107 (37. 1 per cent) of the patients with severe pain had lost days of work during the preceding year. The mean number of days lost in the preceding year was 21.7
6 1 .9 (standard deviation) for the group with moderate

AssociATIoN OF PREVIOUSANDCURRENT CIGARETTE-SMOKING WITH LOW-BACK PAIN

Men with Low-Back Pain (Per cent)

None (n = 368) Had smoked before the67.068.379.6time study*Was of the39.643.853.0time smoking at of study*
* These are not mutually exclusive categories because those who

Moderate (n = 565)

Severe (n = 288)

were smoking at the time of the study also had smoked before the time of the study.

cent) of the asymptomatic patients, 269 (47.7 per cent) of the moderately symptomatic patients, and 155 (53.8 per
cent) of the patients with severe low-back pain did work

that required repetitive lifting of twenty kilograms or more. Differences were also identified in patients who
used jackhamrners, chainsaws, or rotary cultivators. The

pain and 34.7 78.4 for the group with severe pain. Nine patients with moderate pain and seven with severe two pain ost more than 180 days from work. Excluding l these individuals did not alter the relative number of days lost. The means for the two groups were 11.5 16.3 for those with moderate pain and 17. 1 28.6 for those with severe pain (t test, p = 0.10). The most striking finding was the relationship of low-back complaints to cigarette-smoking. Table IV shows significant differences between the three groups of patients with respect to current and previous smoking, and Table V shows the relationship between low-back pain and total exposure to cigarettes. In analyzing the patients' occupations, the most im portant prognostic variable was identified as repetitive weight-lifting. One hundred and sixty-three (44.4 per
TABLE
TREATMENTS UTILIZED

over-all cumulative exposure to these types of common vibrational equipment was higher in both groups with low-back pain than in the asymptomatic group. The driving of automobiles , motorcycles , buses , trac tors, trucks, and heavy construction equipment was more frequent in the patients with low-back pain (Table VI). These findings suggest the existence of a complex occupa tional relationship involving lifting, the use of motor ye hides, and vibrational insults in patients with low-back pain. The effect of current and adolescent sports activity was also examined. Current participation in football, ten
nis, golf, snowrnobiling, ice hockey, baseball, and other

III
WITH LOW-BACK PAIN

NUMBEROF HEALTH-CAREPRACTITIONERS SEEN AND

FOR MEN

Men with Low-Back Pain (Per cent)

Moderate Severe

(n = 565) seenNone53.313.91-240.959.83-75.926.3No. No. of practitioners

(n = 288)

utilizedNone50.88.71-234.838.93-614.452.5 of treatments

athletic activities was similar in the asymptomatic patients and in those with moderate or severe how-back pain, although there was a trend for subjects with moderate pain to have a greater level of sports activity than the asymptomatic patients or those who were severely af fected. At the time of the survey, sixty-four (17.4 per cent) of the asymptomatic subjects, 123 (21 .7 per cent) of those with moderate pain, and thirty-eight (13.2 per cent) of those with severe low-back pain were joggers, while thirty-nine (10.7 per cent) of the asymptomatic subjects, eighty-four (14.9 per cent) of those with moderate pain, and thirty-two ( 11. 1 per cent) of those with severe pain were cross-country skiers. When a comparison was made between current participation in sports activities and par ticipation during adolescence, it appeared that subjects with moderate low-back pain tended to maintain a higher level of sports activity than subjects with severe low-back pain, but this finding was not statistically significant. Sub jects with severe pain had participated in sports activities during adolescence to the same degree as asymptomatic patients and those with mild pain, but had become rela lively less active in later years. Stepwise linear discriminant analysis was conducted with the three groups (those with no pain, those with moderate pain, and those with severe pain) being used as

VOL. 65-A, NO. 2, FEBRUARY 1983

216
AssociATIoN

J. W.

FRYMOYER

ET AL.

TABLE

OF TOTAL EXPOSURE TO CIGARETTES WITH LOW-BACK PAIN

Low-BackPainNone Patients with 288)MeanS.D.MeanS.D.MeanS.D:@Yearssmokcd9.2610.198.59.5412.0010.11No. (n= 368)Moderate

(n =565)Severe

(n =

I0.86Pack-years14.0918.9012.9917.4318.7420.24 of packs per day0.930.860.980.861

.2

S.D.

standard

deviation.

the classification variable. This method of analysis allowed examination of the joint influence of several var iables simultaneously. The variables that were found to have the best predictive value, in order of importance. were: the number of years of cigarette-smoking. a history
TABLE VI
EXPSURE TO VEHICULARVIBRATIONOF
MEN WITH LOW-BAK PAIN

younger.
those with

We found that the asymptomatic

mild low-back pain were younger

patients and
than the pa

with Li@

Pa

(Per cent)
Severe

Type of 288)Automobile85.688.189.5Motorcycle Motor VehicleM

None
= (nen 368)nv-Back

Moderate

(n = 565)in (n =

tients with severe complaints, although the age differences were not striking. Hult'8, Horal'7, Lawrence24, and Kehhgren and Lawrence2 speculated that the more se verely affected subjects had degenerative diseases of the spine, including degenerative disc disease with or without nerve-root involvement and degeneration of the facets. The increased incidence of symptoms in the lower limbs in our group with severe low-back pain might lead to a simi lar interpretation. Recently Porter et al . , in a survey of a
large population, showed an canal, age-related as determined disc association be

tween low-back pain, symptoms

4.9Light Bus15.5

in the lower limbs, and

by ultrasonic disease with or

3.516.8 14.7 I3 . I39.8

2.55.0

narrowing scanning. 15.7

of the spinal In addition

truck Heavy truck 15.4Heavy Tractor39.0 equipment7.97.68.0

. A subject may have operated

to degenerative

14.2 I2.344.8

without
facets,

nerve-root
spinal stenosis

involvement

and arthropathy

of the

might also account

for this observed

association between symptoms in the lower limbs and in

@iore than one motor vehicle.

of cross-country
twenty-one, use, twice the daily. the lifting

skiing
frequency of at

between
least twenty

the ages of sixteen

and jackhammer more kilograms sports between

and
than

the how back. Our studies confirm the significance of a number of previously described risk factors as well as identifying
previously was dents identified to our unknown as being questionnaire, risk factors for severely associated were between symptomatic

of chainsaw in other

low-back disease. In our retrospective

significantly who

analysisi4.

smoking
with mcdi of

participation

the ages

of sixteen and twenty-one.

and the patient's

present age.

cally reported episodes of low-back pain. Of the respon

the ages

Discussion The incidence of low-back pain in the population of the United States is similar to that reported in other indus trialized societies. HuIt'TM, HoraP7, Lawrence24, and Kellgren and Lawrence2 reported that 60 to 80 per cent of men in their study populations had experienced low-back pain. The incidence has been reported to be less in non industrialized societies , suggesting possible environmental
or occupational influences6. In our study. attempts were

eighteen
tion study

and fifty-five years,

showed

44 per cent were current

a study of the popula
of men than older than

cigarette-smokers.
of Vermont showed

In comparison,

that 40 per cent of men

twenty

years were cigarette-smokers , and a national

that 42 per cent older the age of

made to quantify

the severity

of low-back

complaints

twenty were smokers'7. In view of these data, our finding that 39.6 per cent of asymptomatic men and 53.0 per cent of those with severe low-back pain smoked cigarettes is striking. Svenssont4 identified a similar association in Swedish industrial workers. He speculated that coughing
leading to increased intradiscal pressure was the mediary

using a modification of the McGill pain questionnaire27.

This scale appears to differentiate
lations of patients with

between two subpopu

pain (those with

low-back

moderate and those with severe complaints), as defined by significant differences in associated symptoms in the lower limbs, utilization of health-care professionals and treat ment, and the disability resulting from the back pain. Hult1TM and Horal'7 also classified patients with low-back pain, referring to their patients with moderate pain as hay ing symptoms of muscular insufficiency' . They found that patients with mild low-back pain tended to be

in this relationship. This conclusion was supported by a Danish study@, which identified coughing and chronic bronchitis, but not smoking, as important in the etiology of low-back complaints. Our previous study'4 indicated that
smoking and coughing were related to low-back pain, but

that coughing alone was insufficient to account for the ob

served differences in back complaints in subjects who smoked. It might be that smokers have emotional. recre

ational , or occupational differences , although multivariate analysis of our retrospective and epidemiological survey
THE JOURNAL OF BONE AND JOINT SURGERY

RISK FACTORS

IN LOW-BACK

PAIN

217

data did not confirm that speculation. The most intriguing conjecture is that cigarette smoke, or one of its con
stituents, spine. has a direct adverse physiological laboratory effect have on the shown Preliminary studies in our

health problem. However, the incidence of how-back complaints in this population is comparable to the mci dence in Swedish and English populations47'8'34. In all of these studies, the lack of a specific dependent variable

that an amount of nicotine equivalent to that contained in other than the subjective complaint of intensity of how one cigarette, when injected into dogs, may cause a reduc back pain is problematic. The relationship between low tion in vertebral-body blood flow. In view of the depen back pain and the risk factors that are studied might be dency of the disc on the diffusion of nutrients through the more apparent if a precise and accurate measure of out adjacent vertebral end-plates and the precarious metabolic come were available. This shortcoming in epidemiological status of the intervertebral disc, it is at least conceivable studies of the general problem of low-back pain is not eas that such alterations in blood flow could adversely affect ily overcome. Clinical studies have shown that the precise discal metabolism, rendering the disc more susceptible to cause of low-back pain is unclear in at least 50 per cent of mechanical deformities38. patients who have undergone extensive radiographic and The occupational risk factors in how-back pain are laboratory evaluations. The other inherent problem in complex. The physical demands of the work-place envi epidemiological studies such as this one is that the ob ronment, particularly lifting, are relevant to low-back served associations between low-back pain and the studied complaints'78'26. Others have suggested that this associ variables may not be causal. For example, it is possible ation should be viewed with caution, as workers with that chronic smokers have a psychological profile that both low-back pain whose jobs require heavy lifting tend to relates to the smoking habit and places them at greater risk both aggravate their symptoms and complain more fre for symptomatic low-back pain. quently because of the potential for worker's compen Finally, this study focuses attention on some of the sation3. have also identified a complex, age We important socioeconomic and medical consequences of related interaction between low-back pain and exposure to low-back complaints. In our population the general medi industrial, vehicular, and certain recreational vibrations. It cal practitioner, orthopaedist, and chiropractor were most was perhaps for this reason that Kelsey and Hardy iden commonly seen by individuals who had low-back corn tified a striking relationship between the driving of motor plaints. Bed rest and medication were most commonly
vehicles posus21'22. and the occurrence is no doubt of that herniated vibration nucleus pul prescribed patients as treatment, were treated although by physiotherapy a significant and back number supports. of There is a significant

factor in certain low-back disorders'4'22'31'35'4' . Labora tory investigations of vibration have demonstrated a typi cal behavior of seated human subjects when subjected to vibrational inputs of zero to twenty hertz4' . Amplification of the imparted motion (resonance) occurs in the range of 5.0 hertz, which is within the dominant frequency range of many vehicles and industrial devices. Under these cir
cumstances high energy transfers occur, with increased

It was striking that 3.4 per cent of this population had un dergone surgical treatment for how-back complaints at some time prior to the study. It is nearly impossible to de termine if this represents a true incidence of lumbar surgery, because in our subjects the operations were per formed over a significant time-interval, and some patients may have had multiple procedures. It has been calculated
that I 13,000 laminectomies 34,000 other lumbar-spine and disc excisions as well as operations are performed on

risk for mechanical

damage

to the resonating

structures.

Recreational activities appeared to have a minimum relationship to low-back complaints, although patients with mild pain tended to participate in more sports activi ties, particularly jogging and cross-country skiing, when compared with both asymptomatic subjects and those with
severe low-back pain. Whether this relationship is the

men annually in the United States'6. There is no question that low-back pain is an ex tremely significant cause of disability and has a major
socioeconomic P3,4,21.23.40 In our population , nine

cause or the result of low-back pain is unknown. It has also

been observed that patients with severe low-back pain tend to stop participation in sports between the adolescent and later years, whereas those with moderate back pain con tinue their sports activities largely uninterrupted. Whether
this change in activity is the cause or the result of low-back

subjects (0.7 per cent) were disabled by low-back pain for more than six months, and 176 ( 14.4 per cent) lost a mean of 30.3 days from work in the preceding year, the great
est loss being sustained by those with severe pain. If these

figures

are

extrapolated

to the

fifty

million

working

pain is uncertain. It is known that certain sports (football and gymnastics) are associated with low-back pain be cause of a fourfold increase in isthrnic spondylolis thesis
These data characterize only one population,
climate. Our

American years, it would be American

men in the age group of eighteen to fifty-five can be calculated that 217 million workdays lost annually in this largest single group of the work-force. Based on the reported annual in
men36 , this translates into host wages

come for American

and may
population

not be representative
urbanized society

of the situation occurring in a highly

of $1 1,000,000,000 per year. Most importantly, these figures indicate the need for ongoing systematic investiga tion of the multiple risk factors that may be causally re lated to low-back pain and may possibly be preventable.
Noir: The authors wish to acknowledge the competent cooperation of the staff of the Villemaire Health Care Center and its Director. David Little. M.D. . and of the Department of Family Practice and its Chairman. Edward Freidman. M.D. . as well as Sandra Tower of the Biometry Facility for programming assistance.

or in a different

sample may be biased, insofar as these individuals had

been seen at some time during a four-year interval for a

218

J. W. FRYMOYER AL. ET References

I. ANDERSSON,G. B. J.: Epidemiologic

2. ASMUSSEN. ERLING. and KI.AUSEN.

Aspects on Low-Back
KLAUS: Form

Pain in Industry.
of the Erect

Spine. 6: 53-60,
Human Spine. Clin.

1981.
Orthop. , 25: 55-63. 1962.

and Function

3. BEAtS, R. K.. and HICKMAN, N. W.: Industrial Injuries of the Back and Extremities. Comprehensive Evaluation n Aid in Prognosis and A Management: A Study of One Hundred and Eighty Patients. J. Bone and Joint Surg.. 54-A: 1593-1611, Dec. 1972. 4. BENN, R. T., and WOOD. P. H. N.: Pain in the Back. An Attemptto Estimate the Size ofthe Problem. Rheumat. and Rehab., 14: 121-128, 1975. 5. BERKOW. ROBERT: Psychological Aspects of Back Pain. In Orthopedic Surgery. edited by Walter Mercer and R. B. Duthie. Ed. 6, pp. 760-768. Baltimore. Williams and Wilkins, 1964. 6. BREMNER. J. M.; LAWRENCE. J. S.; and MIAL.L. W. E.: Degenerative Joint Disease in a Jamaican Rural Population. Ann. Rheumat. Dis., 27: 326-332. 1968.
7. CALDWEI.L, A. B., and CHAsE, CHRISTOPHER: Diagnosis and Treatment of Personality Factors in Chronic Low Back Pain. Clin. Orthop. . 129:

8. 9. 10. 11. 12. 13. 14. 15.

141-149, 1977. DIxoN, W. J., and BROWN. M. B.: BMDP-79: Biomedical Computer Programs. P-Series. Berkeley. University of California Press, 1979. FAHRNI, W. H., and TRUEMAN, G. E.: Comparative Radiological Study of the Spines of a Primitive Population with North Americans and Northern Europeans. J. Bone and Joint Surg. . 47-B(3): 552-555. 1965. FARFAN. H. F.; COSSETTE, J. W.; ROBERTSON,G. H.; WELLS, R. V.; and KRAUS. H.: The Effects of Torsion on the Lumbar Intervertebral Joints: The Role of Torsion in the Production of Disc Degeneration. J. Bone and Joint Surg. . 52-A: 468-497, April 1970. FERGUSON.R. J.: Low Back Pain in College Football Linemen. In Proceedings ofThe American Academy ofOrthopaedic Surgeons. J. Bone and Joint Surg. . 56-A: 1300. Sept. 1974. FRYMOYER,J. W., and POPE, M. H.: The Role of Trauma in Low Back Pain: A Review. J. Trauma, 18: 628-634, 1978. FRYMOYER,J.; KRISTIANSEN.T.; DONNERMEYER.D.; CLEMENTS. J. E.; MACPHERSON, BRIAN; and POPE, M. H.: Cigarette Smoking in Low Back Pain. Read by title at the Annual Meeting of the International Society for the Study of the Lumbar Spine, Toronto, Ontario, Canada, June 6-10. 1982. FRYMOYER.J. W.; POPE, M. H.; COSTANZA. M. C.; ROSEN, J. C.; GOGGIN, J. E.; and WILDER, D. G.: Epidemiologic Studies of Low-Back Pain. Spine. 5: 419-423. 1980. GYNTELBERG. F.: One Year Incidence of Low Back Pain Among Male Residents of Copenhagen Aged 40-59. Danish Med. Bull., 21: 30-36, 1974.

16. HAUPT.B. J.: Detailed Diagnoses and Surgical Procedures for Patients Discharged from Short-Stay Hospitals. DHHS Publication No. (PHS)
80- 1274. Hyattsville. Maryland. United States Department of Health and Human Services, Public Health Service. 1980. 17. HORAL, J.: The Clinical Appearance ofLow Back Disorders in the City ofGothenburg Sweden. Acta Orthop. Scandinavica, Supplementum 118, 1969. 18. HULT, L.: Cervical, Dorsal and Lumbar Spinal Syndromes. Acta Orthop. Scandinavica, 24: 174-175. 1954. 19. JAKSON, D. W.: WILTSE. L. L.; and CIR1NCIONE, R. J.: Spondylolysis in the Female Gymnast. Clin. Orthop.. 117: 68-73, 1976. 20. KELLGREN, J. H., and LAWRENCE, J. S.: Osteo-Arthrosis and Disk Degeneration in an Urban Population. Ann. Rheumat. Dis., 17: 388-397, 1958.
21. 22. 23. KELSEY. J. L.: An Epidemiological Study of Acute Herniated Lumbar Intervertebral KELSEY. J. L., and HARDY. R. J.: Driving of Motor Vehicles as a Risk Factor Discs. Rheumat. and Rehab.. 14: 144-159, 1975. for Acute Herniated Lumbar Intervertebral Disc. Am. Disorderson the Population of the J.

Epidemiol. . 102: 63-73.

1975.
E.. JR.: ThelmpactofMusculoskeletal

KELSEY. J. L.; WHITE, A. A.. III; PASTIDES. HARRIS: and BISBEE,G.

United States. J. Bone and Joint Surg. , 61-A: 959-964, Oct. 1979. 24. LAWRENCE, J. S.: Disc Degeneration. Its Frequency and Relationship
25.

to Symptoms.

Ann. Rheumat.
of Response

Dis., 28: 121-138,

to Conservative

1969.
for Low Back

MCCREARY, CHARLES; TURNER. JUDITH; and DAWSON. EDGAR: The MMPI

as a Predictor

Treatment

Pain. J. Clin. Psychol. . 35: 278-284. 1979. 26. MAGORA. ALEXANDER:Investigation of the Relation Between Low Back Pain and Occupation.
27. 28.
.

Indust. Med. and Surg. . 39: 465-471 . 1970.

1975. Disc. Rheumat. and Rehabil..

MELZACK. RONALD: The McGill Pain Questionnaire: Major Properties and Scoring Methods. Pain. 1: 277-299, NACHEMSON, ALF: Towards a Better Understanding ofLow-Back Pain: A Review ofthe Mechanics ofthe Lumbar
14: 29-143, 1975.

29. NIL, N. H.; HULL. C. H.; JENKINS. J. G.; STEINBRENNER, K.; and BENT, D. H.: Statistical Package for the Social Sciences. Ed. 2. New York, McGraw-Hill, 1975. 30. PHILI.u's, E. L.: Some Psychological Characteristics Associated with Orthopaedic Complaints. Curr. Pract. Orthop. Surg.. 2: 165-176, 1964. 31. POPE. M. H.; WILDER, D. G.: and FRYMOYER.J. W.: Vibration as an Aetiologic Factor in Low Back Pain. In Engineering Aspects ofthe Spine.

Joint Meeting of the British Orthopaedic Association and the Institute of Mechanical Engineers. St. Edmonds, Suffolk, Mechanical Engineering,
1980.
32. PORTER. R. W.; HIBBERT. C.; and WELLMAN, P.: Backache and the Lumbar Spinal Canal. Spine. 5: 99-lOS. 1980.

33. ROSEN. J. C.; FRYMOYER.J. W.; andCLEMENTS. J. H.: A Further Look at Validity ofthe MMPI with Low Back Patients. J. Clin. Psychol., 36: 994-1000, 1980. 34. SvENSs0N, H . 0.: Low Back Pain in Relation to Other Diseases and Cardiovascular Risk Factors. Thesis. Gteborg. Sweden, 1981. 35. TROUP. J. D. G.: Driver's Back Pain and Its Prevention. A Review ofthe Postural. Vibratory and Muscular Factors, Together with the Problem of Transmitted Road-Shock. AppI. Ergonom.. 9: 207-214. 1978. 36. UNITED STATES BUREAU OF THE CENSUS: Current Population Reports. Series P.60. No. 123. Washington. D.C. . United States Department of Commerce, June 1980.
37. UNITED STATES SURGEON GENERAL: Report on the Health Consequences of Smoking in Women. Hyattsville, Maryland, United States Depart

ment of Health and Human Services, 1981. 38. URBAN, J. P. G.; HOLM, S.; MAROUDAS,A.; and NMIHEMSON, A.: Nutrition ofthe Intervertebral Disk. Anin Viva Study ofSolute Transport. Clin.Orthop., 129: 101-114.1977. 39. VERMONT LUNG CENTER: Unpublished data. 1975-1976. 40. WHITE, A. W. M.: Low Back Pain in Men Receiving Workmen's Compensation. A Follow-up Study. Canadian Med. Assn. J., 101: 6 1-67,

1969.
41. WILDER, D. G.; WOODWORTH. B. B.; FRYMOYER.J. W.; and POPE, M. H.: Vibration and the Human Spine. Spine, 7: 243-254, 1982. 42. WILFLiNG. F. J.; KLONOFF, H.: and KOKAN, P.: Psychological, Demographic and Orthopaedic Factors Associated with Prediction of Outcome ofSpinal Fusion. Clin. Orthop., 90: 153-160, 1973. 43. WILT5E, L. L., and RocCHIo, P. D.: Preoperative Psychological Tests as Predictors of Success of Chemonucleolysis in the Treatment of the Low-Back Syndrome. J. Bone and Joint Surg. , 57-A: 478-483, June 1975. 44. WILTSE, L. L.; WIDELI., E. H., JR.; and JACKSON,D. W.: Fatigue Fracture: The Basic Lesion in lsthmic Spondylolisthesis. J. Bone and Joint Surg. . 57-A: 17-22, Jan. 1975.

THE JOURNAL

OF BONE

AND

JOINT

SURGERY