See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/262001223

Factors Influencing Disability due to Low Back Pain Using the Oswestry
Disability Questionnaire and the Quebec Back Pain Disability Scale

Article  in  Physiotherapy Research International · May 2014

DOI: 10.1002/pri.1591

CITATIONS READS

5 171

3 authors:

gyoung-mo Kim Chung-Hwi Yi

Daejeon Health Sciences College Yonsei University
22 PUBLICATIONS   71 CITATIONS    157 PUBLICATIONS   1,033 CITATIONS   

SEE PROFILE SEE PROFILE

Heon-Seock Cynn
Yonsei University
144 PUBLICATIONS   842 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Clinical Physical Therapy View project

Therapeutic Exercise View project

All content following this page was uploaded by gyoung-mo Kim on 06 September 2018.

The user has requested enhancement of the downloaded file.

RESEARCH ARTICLE
Factors Influencing Disability due to Low Back Pain
Using the Oswestry Disability Questionnaire and the
Quebec Back Pain Disability Scale
Gyoung-mo Kim1, Chung-hwi Yi2* & Heon-seock Cynn2
1
Department of Physical Therapy, Division of Health Science, Baekseok University, Korea
2
Department of Physical Therapy, College of Health Science, Yonsei University, Korea

Abstract
Objectives. The aim of this research was to compare the difference in disability caused by back pain using scores
from the Oswestry Disability Questionnaire (ODQ) and the Quebec Back Pain Disability Scale (QUE) according
to gender, acute and chronic low back pain (LBP) groups, specific and nonspecific LBP groups and to identify
the factors influencing the degree of LBP disability. Methods. One hundred and thirty-three patients with LBP par-
ticipated in this study. The Visual Analogue Scale (VAS) of ODQ and QUE were used to compare the differences
between men and women, acute and chronic and specific and nonspecific LBP groups. We identified the factors
influencing the disability of LBP using a stepwise multiple regression. Results. In comparison with the nonspecific
LBP group, the VAS, ODQ and QUE scores were significantly higher and the pain duration was significantly longer
in the specific LBP group (P < 0.05). A multiple regression equation with VAS and LBP classification explained the
45.4% variance in ODQ and an equation with VAS, LBP classification, pain duration and gender explained 31.1% of
the variance in QUE. Conclusions. The degree of disability from back pain assessed using the ODQ score was
influenced by a pain severity and LBP type. Also, QUE score was influenced by a pain severity, LBP type, pain du-
ration and gender. To assess the disability caused by back pain accurately using the ODQ and QUE, various factors
affecting the scores of the questionnaire must be considered. Copyright © 2014 John Wiley & Sons, Ltd.

Received 25 September 2013; Revised 13 February 2014; Accepted 11 March 2014

Keywords
disability; low back pain; Oswestry disability questionnaire; Quebec back pain disability scale

*Correspondence
Chung-hwi Yi, PT, PhD, Department of Physical Therapy, College of Health Science, Yonsei University, 1 Yonseidae-gil, Wonju,
Kangwondo, 220-710, Korea.
Email: pteagle@yonsei.ac.kr

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1591

Introduction 90 workdays (Murphy and Volinn, 1999; Lee et al.,

In industrialized countries, low back pain (LBP) is a ma-
jor public health problem and a leading cause of disabil-
ity. It also imposes an enormous social and economic
burden on the community (Mounce, 2002; Lis et al.,
2007). Each year, more than one-quarter of the working
population is affected by LBP, with the loss of more than
2001). Most acute LBP patients improve over the short-
term, but some patients will proceed to chronic or recur-
rent LBP with a disability resulting in high costs and
reduced quality of life (Hill and Fritz, 2011).
The goal of patients with LBP is the restoration of
function and a return to the workplace as quickly and

Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Factors Influencing Back Pain Disability
safely as possible (Nguyen and Randolph, 2007).
General recommendations to prevent long-term
disability for patients with LBP are early activation and
restoration of function (Waddell, 1996). Especially,
the evaluation of functional ability with LBP patients
is essential for confirming treatment effects and
predicting prognosis (Dallmeijer et al., 2005). Standard-
ized self-reported questionnaires are used to evaluate
patients with LBP before and after treatment and to de-
tect short-term or long-term clinical changes of symp-
toms and disabilities (Grotle et al., 2004). Although
many questionnaires evaluating disability caused by
LBP have been developed, not all questionnaires assess
same aspect of disability associated with LBP because
there are different items in each questionnaire. The
most commonly recommended disability question-
naires for patients with LBP are the Oswestry Disability
Questionnaire (ODQ) and Quebec Back Pain Disability
Scale (QUE). These are easy to use, reliable and valid
assessment tools (Davidson and Keating, 2002). ODQ
assesses the level of pain interference with physical ac-
tivities, whereas QUE describes the perceived difficulty
of performing simple physical activities (Bombardier,
2000; Rocchi et al., 2005).
Usually, LBP and disability are influenced by physi-
cal activities and posture, but the etiological factors as-
sociated with LBP are difficult to identify. The risk
factors of LBP are divided into individual (age, gender,
body mass index and general health), psychosocial
(stress, distress, emotional state and pain behaviour),
occupational (work load, work environment and job
dissatisfaction) and biomechanical categories (Manek
and MacGregor, 2005). The prevalence and incidence
of LBP and functional level can be affected by age, gen-
der, obesity and socioeconomic level (Andersson et al.,
1993; Fillingim et al., 2009). Also, prognosis of LBP and
clinical features can be affected by the degree and
Table 1. Demographic characteristics of the participants (mean ± SD)
Parameters Male (N = 90)
Age (year) 39.86(12.55)
Height (cm) 173.98(0.05)
Weight (kg) 72.54(8.92)
2
Body mass index (kg m ) 23.99(2.72)
Pain duration (mo) 43.24 ± 49.53
VAS score 5.24 ± 2.25
ODQ score 29.83 ± 12.49
QUE score 19.48 ± 17.87
SD, standard deviation; VAS, visual analogue scale; ODQ, Oswestry disability questionnaire; QUE, Quebec back pain disability scale.
G.-m. Kim et al.
duration of pain, the level of disability and experience
of back pain (Coste et al., 1994; van den Hoogen
et al., 1997; Thomas et al., 1999). The selection of
appropriate questionnaire is another critical factor be-
cause contents of the questionnaire may influence
scores of the LBP and disability (Davidson and Keating,
2002). Although LBP and disability are influenced by
many risk factors, it is unclear which factors have the
greatest influence on LBP disability (Pincus et al.,
2002).
The aim of this study was to identify the factors that
affect LBP disability. Specifically, we had the following
aims: 1) to compare the ODQ and QUE scores
according to gender, acute and chronic LBP and spe-
cific and nonspecific LBP; and 2) to identify factors
influencing the degree of disability from LBP using
the ODQ and QUE scores.
Subjects and methods
In total, 133 patients with LBP (male = 90, female = 43)
who received physical therapy as outpatients at seven
hospitals were investigated in this study. The general
characteristics of the participants are presented in
Table 1. The participants were sufficiently informed
of the study procedure and submitted written consent
forms. The participants completed a general character-
istics questionnaire to provide information regarding
their gender, age, height, weight, LBP type (specific or
nonspecific LBP), pain duration and Visual Analogue
Scale (VAS) score. We classified LBP pain lasting less
than 3 months as acute, and pain lasting more than
3 months was chronic (Koes et al., 2010). Also, we used
the classification that a specific LBP was that attri-
butable to any diagnosis, including injury, trauma, in-
fection or structural deformity, whereas nonspecific
LBP included diagnoses such as lumbago, myofascial
Female (N = 43) Total (N = 133)
41.74 ± 11.65 40.47 ± 12.26
160.00 ± 0.05 169.47 ± 0.08
55.56 ± 9.37 67.05 ± 12.05
21.71 ± 3.65 23.25 ± 3.22
55.58 ± 63.80 47.23 ± 54.62
4.86 ± 2.13 5.12 ± 2.21
31.81 ± 15.54 30.47 ± 13.52
24.21 ± 19.61 21.01 ± 18.51
Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
G.-m. Kim et al. Factors Influencing Back Pain Disability

syndromes, muscle spasm or back sprain (Cherkin the VAS (male = 5.24 ± 2.25, female = 4.86 ± 2.13), ODQ
et al., 1992). (male = 29.83 ± 12.49, female = 31.81 ± 15.54) or QUE
After completing a general questionnaire, each sub- scores (male = 19.48 ± 17.87, female = 24.21 ± 19.61) be-
ject completed the ODQ and QUE to determine his tween male and female patients (P > 0.05), (Table 2).
or her degree of disability. The ODQ consisted of 10
items describing the impact of pain on different activi-
ties of daily living. It has good test–retest reliability Comparison of VAS, ODQ and QUE scores
(ICC = 0.94), internal consistency (Cronbach’s alpha = between the acute and chronic LBP groups
0.93) and criterion-related validity with Roland Morris No statistically significant differences were observed in
Disability Questionnaire (r = 0.70) (Fairbank et al., the VAS (acute = 5.25 ± 2.17, chronic = 5.09 ± 2.23),
1980; Rocchi et al., 2005). The QUE was composed of ODQ (acute = 31.21 ± 13.82, chronic = 30.28 ± 13.50)
20 items that describe the perceived difficulty of or QUE scores (acute = 25.07 ± 21.05, chronic = 19.92
performing simple physical activities. Its reliability ± 17.73) between the acute and chronic LBP patient
was verified by test–retest (ICC = 0.92) and internal groups (P > 0.05), (Table 3).
consistency (Cronbach’s alpha = 0.96). It has good va-
lidity with Roland Morris Disability Questionnaire
(r = 0.80) (Kopec et al., 1995; Rocchi et al., 2005). Each Comparison of the duration of pain and
item in both ODQ and QUE is scaled on a six-point the VAS, ODQ and QUE scores between the
Likert scale (range 0–5). The ODQ total scores range specific and nonspecific LBP groups
from 0 to 50, and the QUE total scores range from 0 to The duration of pain was significantly increased in the
100. The total score can be interpreted as the percentage specific LBP group (60.79 ± 65.07) compared with the
of perceived disability; in both ODQ and QUE, a higher nonspecific group (35.03 ± 39.73), (P < 0.05). In addi-
score indicates greater disability (Rocchi et al., 2005). tion, the VAS (nonspecific = 4.37 ± 1.82, specific = 5.95
We conducted an independent t-test to compare the ± 2.31), ODQ (nonspecific = 23.49 ± 8.77, specific =
total ODQ and QUE scores, the VAS score and the pain 38.24 ± 13.68) and QUE scores (nonspecific = 14.51 ±
duration between male and female patients. Also, we 14.59, specific = 28.22 ± 19.81) differed significantly
conducted an independent t-test to compare the total
ODQ and QUE scores and VAS score between acute
and chronic LBP groups. In addition, an independent Table 2. Comparison of the pain duration, VAS, ODQ and QUE
scores of male and female patients (mean ± SD)
t-test was used to compare the total ODQ and QUE
scores and the VAS score and pain duration between Male (N = 90) Female (N = 43) P value
specific and nonspecific LBP groups. Finally, multiple
Pain duration(mo) 43.24 ± 49.53 55.58 ± 63.80 0.224
regression analysis using a stepwise method was
VAS score 5.24 ± 2.25 4.86 ± 2.13 0.351
conducted to identify the factors that influence the ODQ score 29.83 ± 12.49 31.81 ± 15.54 0.468
ODQ and QUE scores. Gender and acute and chronic QUE score 19.48 ± 17.87 24.21 ± 19.61 0.169
LBP and LBP type (specific or nonspecific) were used VAS, visual analogue scale; ODQ, Oswestry disability questionnaire;
as dummy variables. The level of statistical significance QUE, Quebec back pain disability scale; SD, standard deviation.
was set at P < 0.05. Statistical analyses were performed
using the SPSS 12.0 software (SPSS Inc., Chicago, IL,
Table 3. Comparison of VAS, ODQ and QUE scores between the
USA). This study was approved by Yonsei University
acute and chronic LBP groups (mean ± SD)
Wonju Institutional Review Board.
Acute group Chronic group
(N = 28) (N = 105) P value
Results
VAS score 5.25 ± 2.17 5.09 ± 2.23 0.728
Comparison of pain duration, VAS, ODQ
ODQ score 31.21 ± 13.82 30.28 ± 13.50 0.938
and QUE scores between male and female QUE score 25.07 ± 21.05 19.92 ± 17.73 0.192
patients
VAS, visual analogue scale; ODQ, Oswestry disability questionnaire;
No statistically significant differences were observed in pain QUE, Quebec back pain disability scale; LBP, low back pain; SD,
duration (male = 43.24 ± 49.53, female = 55.58 ± 63.80) or standard deviation.

Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Factors Influencing Back Pain Disability G.-m. Kim et al.

between the specific and nonspecific LBP groups Discussion

(P < 0.05), (Table 4).
The perceived severity of pain, pain duration and ODQ
scores were higher in female patients compared with
Multiple regression outcomes from the male patients (Kopec et al., 1996; Unruh, 1996). The
ODQ and QUE scores findings of our study show that the VAS score was higher
The VAS score and the LBP type were significantly in male patients compared with female patients, whereas
correlated and explained the 45.4% variance in ODQ pain duration and ODQ and QUE scores were higher in
(P < 0.05), (Table 5). Also, the VAS score, LBP type, pain female patients compared with male patients. However,
duration and gender were significantly correlated and these differences were not statistically significant.
explained the 31.1% variance in QUE (P < 0.05), (Table 6). Chronic LBP was defined as pain persisting for
more than 3 months (Koes et al., 2010). Chronic LBP
patients tend to have an increased risk of functional
Table 4. Comparison of pain duration, VAS, ODQ and QUE scores limitation and pain severity and a decrease in activity
between the specific and nonspecific LBP groups (mean ± SD)
of daily living and work activity (Brox et al., 2005).
LBP type Our results show that the ODQ and QUE scores of
the acute LBP group were higher than those of the
Specific group Nonspecific group P
chronic LBP group, but there was no significant differ-
(N = 63) (N = 70) value
ence in the degree of pain or ODQ and the QUE scores
Pain duration 60.79 ± 65.07 35.03 ± 39.79 0.008
between the acute and chronic LBP groups.
VAS score 5.95 ± 2.31 4.37 ± 1.82 0.000
ODQ score 38.24 ± 13.68 23.49 ± 8.77 0.000
Low back pain is usually classified as ‘specific’ or
QUE score 28.22 ± 19.81 14.51 ± 14.59 0.000 ‘nonspecific’. A specific LBP refers to a diagnosis
resulting from a trauma, injury, infection or structural
VAS, visual analogue scale; ODQ, Oswestry disability questionnaire;
QUE, Quebec back pain disability scale; LBP, low back pain; SD,
pathology, whereas nonspecific LBP indicates no
standard deviation. known structural problem causing the pain (Cherkin
et al., 1992). Approximately 35–40% of patients with
a specific LBP progress to chronic LBP compared with
10% or less of patients with a nonspecific LBP
Table 5. Multiple regression model for ODQ score
(Abenhaim et al., 1995). Our results demonstrated that
Independent the specific LBP group VAS, ODQ and QUE scores and
2
variable B t P value Adjusted R pain duration were significantly higher than the nonspecific
ODQ score VAS score 2.649 6.294 0.000 0.324 group scores. Therefore, the specific LBP group had a higher
LBP type 10.564 5.685 0.000 0.454 risk of disability, a longer duration and a higher sensitivity
ODQ, Oswestry disability questionnaire; VAS, visual analogue scale; to pain compared with the nonspecific LBP group.
LBP, low back pain. Disability was defined as ‘any restriction or lack of
LBP type (0 = nonspecific LBP group, 1 = specific LBP group). ability resulting from impairment to perform an
activity in the manner of within the range considered
normal for a human being’ ((WHO), 1980). Disability
Table 6. Multiple regression model for QUE score due to LBP was influenced by many factors, including
age, gender, obesity, impairment, pain, general
Independent
variable B t P value Adjusted R
2 health status and psychological problems (Nisha and
MacGregor, 2005). To understand the impact of LBP
QUE score VAS score 3.504 5.358 0.000 0.210
on the patient’s function and monitor the progress over
LBP type 10.325 3.554 0.001 0.253
Pain duration -0.072 -2.807 0.006 0.280 time, evaluation of disability caused by LBP is an im-
Gender 7.448 2.582 0.011 0.311 perative process (Grotle et al., 2004). Questionnaires
QUE, Quebec back pain disability scale; VAS, visual analogue scale;
have been used to provide a reliable and convenient
LBP, low back pain. method of collecting a large amount of information
LBP type (0 = nonspecific LBP group, 1 = specific LBP group). on functional limitation (Delitto, 1994). It is viable to
Gender (0 = male, 1 = female). recognize the unique features of each questionnaire,

Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
G.-m. Kim et al.
so that clinician can choose each questionnaire for the
individual who has disability caused by LBP (Davidson
and Keating, 200).
Our study indicates that the VAS score and the LBP
type were significantly predictive of the ODQ score;
whereas the VAS score, LBP type, duration of pain
and gender were significantly predictive of the QUE
score. Because ODQ was developed by describing the
impact of pain on different daily living activities
(Rocchi et al., 2005), the VAS score is likely a signi-
ficant predictive variable. QUE is a more useful ques-
tionnaire for monitoring progress and is sensitive to
change over time. In addition, QUE has more content
relating to upper-limb activities compared with ODQ
(Davidson and Keating, 2002). For example, ‘reach up
to high shelves’, ‘take food out of the refrigerator’ and
‘carry two bags of groceries’. We considered these com-
ponents to be more familiar to female patients than
male patients. We speculate that this explains why pain
duration and gender were determined as significant
predictive variables in QUE. These results suggest that
to assess the disability of back pain accurately using
self-reported questionnaires such as ODQ and QUE,
the factors that affect the scoring of the questionnaire
should be considered and understood.
Our study had some limitations. First, because our
findings were analysed using data collected by self-
questionnaire responses in a small sample size, pain
and disability are both highly variable depending the per-
ception of individual participant. Second, because our
study was cross-sectional, we cannot determine the cause
and effect relationship of clinical changes in pain and
disability over time. Third, we did not consider psycho-
logical factors, for example, fear-avoidance behaviour,
depression, stress and job satisfaction, that may affect dis-
ability in patients with LBP. Further study should incor-
porate other factors that can affect disability in patients
with LBP, and the data should be collected using the
performance-based quantitative disability assessment tool.
Conclusion
Our study showed that the VAS, ODQ and QUE scores
were significantly higher and the pain duration was sig-
nificantly longer in the specific LBP group compared
with the nonspecific LBP group. Additionally, the de-
gree of disability caused by LBP assessed using the
ODQ score was influenced by a pain severity and LBP
type, and the QUE score was influenced by a pain
Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Factors Influencing Back Pain Disability
severity, LBP type, pain duration and gender. To pre-
vent the progression of disability caused by back pain,
effective management, including pain control and accu-
rate evaluation, should be implemented for patients with
LBP, particularly specific LBP. To assess the disability asso-
ciated with back pain using self-reported questionnaires,
the factors that affect the scoring of the questionnaires
must be identified and examined thoroughly.
REFERENCES
Abenhaim L, Rossignol M, Gobeille D, Bonvalot Y, Fines P,
Scott S. The prognostic consequences in the making of
the initial medical diagnosis of work-related back injuries.
Spine 1995; 20: 791–795.
Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic
pain in a geographically defined general population: studies
of differences in age, gender, social class, and pain locali-
zation. The Clinical Journal of Pain 1993; 9: 174–182.
Bombardier C. Outcome assessments in the evaluation of
treatment of spinal disorders: summary and general rec-
ommendations. Spine 2000; 25: 3100–3103.
Brox JI, Storheim K, Holm I, Reikerås O. Disability, pain,
psychological factors and physical performance in
healthy controls, patient with sub-acute and chronic
low back pain: a case-control study. Journal of Rehabil-
itation Medicine 2005; 37: 95–99.
Cherkin DC, Deyo RA, Volinn E, Loeser JD. Use of the
International Classification of Diseases (ICD-9-CM) to
identify hospitalizations for mechanical low back problems
in administrative databases. Spine 1992; 17: 817–825.
Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM,
Paolaggi JB. Clinical course and prognostic factors in
acute low back pain: an inception cohort study in primary
care practice. BMJ 1994; 308: 577–580.
Dallmeijer AJ, Dekker J, Roorda LD, Knol DL, van Baalen B,
de Groot V, Schepers VP, Lankhorst GJ. Differential item
functioning of the functional independence measure in
higher performing neurological patients. Journal of
Rehabilitation Medicine 2005; 37: 346–352.
Davidson M, Keating JL. A comparison of five low back
disability questionnaires: reliability and responsiveness.
Physical Therapy 2002; 82: 8–24.
Delitto A. Are measures of function and disability important
in low back care? Physical Therapy 1994; 74: 452–462.
Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry
low back pain disability questionnaire. Physiotherapy
1980; 66: 271–273.
Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B,
Riley JL 3rd. Sex, gender and pain: a review of recent
clinical and experimental findings. The Journal of Pain
2009; 10: 447–485.
 Factors Influencing Back Pain Disability
Grotle M, Brox JI, Vøllestad NK. Functional status and
disability questionnaires: what do they assess? A system-
atic review of back-specific outcome questionnaires.
Spine 2004; 30: 130–140.
Hill JC, Fritz JM. Psychosocial influences on low-back
pain, disability and response to treatment. Physical
Therapy 2011; 91: 712–721.
Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J,
Maher C. An updated overview of clinical guidelines
for the management of non-specific low-back pain
in primary care. European Spine Journal 2010; 19:
2075–2094.
Kopec JA, Esdaile JM, Abrahamowicz M, Abenhaim L,
Wood-Dauphinee S, Lamping DL, Williams JI. The
Quebec Back Pain Disability Scale. Measurement prop-
erties. Spine 1995; 20: 341–352.
Kopec JA, Esdaile JM, Abrahamowicz M, Abenhaim L,
Wood-Dauphinee S, Lamping DL, Williams JI. The
Quebec Back Pain Disability Scale: conceptualization
and development. Journal of Clinical Epidemiology
1996; 49: 151–161.
Lee P, Helewa A, Goldsmith CH, Smythe HA, Stitt LW.
Low back pain: prevalence and risk factors in an industrial
setting. Journal of Rheumatology 2001; 28: 346–351.
Lis AM, Black KM, Korn H, Nordin M. Association
between sitting and occupational LBP. European Spine
Journal 2007; 16: 283–298.
Manek NJ, MacGregor AJ. Epidemiology of back disor-
ders: prevalence, risk factors, and prognosis. Current
Opinion in Rheumatology 2005; 17: 134–140.
Mounce K. Back pain. Rheumatology 2002; 41: 1–5.
View publication stats
G.-m. Kim et al.
Murphy PL, Volinn E. Is occupational low-back pain on
the rise? Spine 1999; 24: 691–697.
Nguyen TH, Randolph DC. Nonspecific low-back pain
and return to work. American Family Physician 2007;
76: 1497–1502.
Nisha JM, MacGregor AJ. Epidemiology of back disorders:
prevalence, risk factors and prognosis. Current Opinion
in Rheumatology 2005; 17: 134–140.
Pincus T, Burton AK, Vogel S, Field AP. A systematic review
of psychological factors as predictors of chronicity/
disability in prospective cohorts of low-back pain. Spine
2002; 27: 109–120.
Rocchi MB, Sisti D, Benedetti P, Valentini M, Bellagamba
S, Federici A. A. Critical comparison of nine different
self-administered questionnaires for the evaluation of
disability caused by low-back pain. European Medical
Physics 2005; 41: 275–281.
Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson
MI, Macfarlane GJ. Predicting who develops chronic
low back pain in primary care: a prospective study.
BMJ 1999: 318: 1662–1667.
Unruh AM. Gender variations in clinical pain experience.
Pain 1996; 65: 123–167.
van den Hoogen HJ, Koes BW, Devillé W, van Eijk JT,
Bouter LM. The prognosis of low back pain in general
practice. Spine 1997; 22: 1515–1521.
Waddell G. Low back pain: a twentieth century health care
enigma. Spine 1996; 21: 2820–2825.
World Health Organization (WHO). International
Classification of Impairment, Disability and Handicaps.
Geneva: WHO, 1980.
Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.