Long-Term Effects of Individually Tailored Physical Training and Activity on Physical Function, Well-Being and Cognition in Scandinavian Nursing Home Residents: A Randomized Controlled Trial.

BACKGROUND: The preservation of physical functions such as muscle strength, balance and mobility is fundamental to maintaining independence in activities of daily living (ADL). The physical activity level of most nursing home residents is very low, which implies that they are often subject to a decline in health, mobility, autonomy and social contacts and are also at risk of suffering a decline in mental well-being. In a previous study, we demonstrated that transfers, balance and physical activity level improved after 3 months of individually tailored intervention in nursing home residents. OBJECTIVE: To evaluate the long-term effects on ADL, balance function, physical activity level, physical performance, falls-related self-efficacy, well-being and cognitive function 3 months after the completion of our intervention in nursing home residents. METHODS: The study was a multicenter randomized, controlled clinical trial with a parallel-group design. It was conducted in nursing homes in Sweden, Norway and Denmark, with an intervention period lasting 3 months and a follow-up at 6 months. Initially, 322 nursing home residents with a mean age of 85 years were included; 85 from Sweden, 171 from Norway and 66 from Denmark. Of these, 241 [129 intervention group (IG), 112 control group (CG)] were eligible for the 6-month follow-up tests. The level of dependence in ADL, physical activity level, several dimensions of physical function, well-being, falls-related self-efficacy and cognitive function were assessed with reliable and valid instruments at baseline, immediately after 3 months of intervention and 3 months later at the 6-month follow-up. RESULTS: After 3 months of intervention and an additional period of 3 months without intervention, only the following 2 variables demonstrated significant group differences: social and cognitive function, measured by the Functional Independence Measure n-r, where the IG deteriorated while the CG was almost stable. However, regarding transfers, the IG deteriorated significantly less than the CG. CONCLUSION: Without supervised physical exercise that challenged the individuals' capability, gains in ADL function, balance and transfer ability deteriorated during the 3 months following the intervention period. Thus, continuous, individually adjusted and supported physical activity seems crucial for the maintenance of physical functions in these vulnerable elderly persons.

Individual risk factors associated with premature discharge from military service.

Research on military populations indicates that failure to complete training is a significant problem for armed forces around the world. The present study estimated the prevalence of musculoskeletal complaints or injuries and potential individual risk factors leading to premature discharge from Swedish military service. Male conscripts, n=469 answered a questionnaire and performed physical tests at the start of their military service. A high prevalence of complaints or injuries in lower back and knee was shown. Logistic regression analyses showed an increased risk of discharge (odds ratio, OR) when reporting current complaints or injuries in any part of the body (OR 4.6), being physically inactive (OR 2.0), cigarette smoking (OR 2.7), or poor mental health (OR 3.6). The findings highlight the need for improved preenlistment examination and/or early preventive strategies addressing both physical and psychological interventions.

Screening tests detect knee pain and predict discharge from military service.

This study evaluated the capacity of a screening test to predict discharge from military training. When starting their training, 590 artillery and 258 ranger conscripts were tested in step-up, step-down, rising from a 0.40-m-high bench, and bilateral squat tests, with pain intensity ratings. Ranger conscripts who did not complete their training were noted. The rising test identified 82% and the step-down test 81% of artillery conscripts who reported pain at any level during any of the screening tests. Receiver operating characteristic curve analysis revealed that both the step-down test and the rising test were good in predicting discharge from military ranger training because of knee problems. The step-down test identified 80% of ranger conscripts who did not complete training because of knee disorders. The tests constitute a simple, time-saving, cost-effective tool in a systematic process for screening knee pain to identify high-risk groups, for prioritization of interventions.

Inter-rater and test-retest reliability of movement control tests for the neck, shoulder, thoracic, lumbar, and hip regions in military personnel.

Strategies are needed to mitigate the high rates and related risks of musculoskeletal complaints and injuries (MSCI) in the military aviator community. Previous work on Swedish Armed Forces (SwAF) soldiers have shown that proper screening methods have been successful in reducing early discharge from military training. Research has pointed at the importance of optimal spinal movement control in military aviators. The aim of this work was to investigate the inter-rater and test-retest reliability of a battery of clinical tests for evaluating movement control in the neck, shoulders, thoracic, lumbar, and hip regions in a population of SwAF military personnel. Inter-rater and test-retest reliability of 15 movement control tests were assessed by crude and prevalence-adjusted kappa coefficient. The study included 37 (inter-rater) and 45 (test-retest) SwAF personnel and was performed with two physiotherapists simultaneously observing and rating the movements on the first occasion and repeated with one physiotherapist on the second occasion. For inter-rater reliability, the kappa coefficient ranged from .19 to .95. Seven tests showed substantial to almost perfect agreement (kappa > .60). With the adjusted kappa, three more tests reached the level of substantial agreement. The corresponding values for test-retest reliability ranged from .26 to .65. Substantial agreement was attained for two tests, three with adjusted kappa. The following tests can reliably be used when screening for biomechanically less advantageous movement patters in military aviators: Shoulder flexion, and rotation, Neck flexion in sitting and supine, Neck extension and rotation in sitting, Pelvic tilt, Forward lean and Single and Double knee extension tests. Grading criteria for tests in supine and quadruped positions need to be further elaborated.

How does exercise dose affect patients with long-term osteoarthritis of the knee? A study protocol of a randomised controlled trial in Sweden and Norway: the SWENOR Study.

INTRODUCTION: Osteoarthritis (OA) of the knee is characterised by knee pain, disability and degenerative changes, and places a burden on societies all over the world. Exercise therapy is an often-used modality, but there is little evidence of what type of exercise dose is the most effective, indicating a need for controlled studies of the effect of different dosages. Thus, the aim of the study described in this protocol is to evaluate the effects of high-dose versus low-dose medical exercise therapy (MET) in patients with knee OA. METHODS AND ANALYSIS: This is a multicentre prospective randomised two-arm trial with blinded assessment and data analysis. We are planning to include 200 patients aged 45-85 years with symptomatic (pain and decreased functioning) and X-ray verified diagnosis of knee OA. Those eligible for participation will be randomly allocated to either high-dose (n=100) or low-dose (n=100) MET. All patients receive three supervised treatments each week for 12 weeks, giving a total of 36 MET sessions. The high-dose group exercises for 70-90 min compared with 20-30 min for the low-dose group. The high-dose group exercises for a longer time, and receives a greater number of exercises with more repetitions and sets. Background and outcome variables are recorded at inclusion, and outcome measures are collected after every sixth treatment, at the end of treatment, and at 6-month and 12-month follow-ups. Primary outcome is self-rated knee functioning and pain using the Knee Injury and Osteoarthritis Outcome Score (KOOS). The primary end point is at the end of treatment after 3 months, and secondary end points are at 6 months and 12 months after the end of treatment. ETHICS AND DISSEMINATION: This project has been approved by the Regional Research Ethics Committees in Stockholm, Sweden, and in Norway. Our results will be submitted to peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT02024126; Pre-results.

Strategies for prevention and management of musculoskeletal conditions. Neck pain.

The aim of this article was to summarise the existing evidence concerning interventions for non-specific neck pain. Neck-and-shoulder pain is commonly experienced by both adolescents and adults. Although the prevalence appears to vary among different nations, the situation is essentially the same, at least in the industrialised nations. Explanations for the wide variation in incidence and prevalence include various methodological issues. Back and neck disorders represent one of the most common causes for both short- and long-term sick leave and disability pension. Evidenced risk factors for the onset and maintenance of non-specific neck and back pain include both individual and work-related psychosocial factors. Based on the existing evidence different forms of exercise can be strongly recommended for at-risk populations, as well as for the acute and chronic non-specific neck pain patient. Furthermore, for symptom relief this condition can be treated with transcutaneous electric nerve stimulation, low level laser therapy, pulse electromagnetic treatment or radiofrequency denervation.

A structural equation model of the relation between socioeconomic status, physical activity level, independence and health status in older Iranian people.

BACKGROUND AND AIM: Health status is an independent predictor of mortality, morbidity and functioning in older people. The present study was designed to evaluate the link between socioeconomic status (SES), physical activity (PA), independence (I) and the health status (HS) of older people in Iran, using structural equation modelling. METHODS: Using computerized randomly selection, a representative sample of 851 75-year-olds living in Tehran (2007-2008), Iran, was included. Participants answered questions regarding indicators of HS, SES and also PA and I through interviews. Both measurement and conceptual models of our hypotheses were tested using Mplus 5. Maximum-likelihood estimation with robust standard errors (MLR estimator), chi-square tests, the goodness of fit index (and degrees of freedom), as well as the Comparative Fit Index (CFI), and the Root Mean Square Error of Approximation (RSMEA) were used to evaluate the model fit. RESULTS: The measurement model yielded a reasonable fit to the data, χ2=110.93, df=38; CFI=0.97; RMSEA=0.047, with 90% C.I.=0.037-0.058. The model fit for the conceptual model was acceptable; χ2=271.64, df=39; CFI=0.91; RMSEA=0.084, with 90% C.I.=0.074-0.093. SES itself was not a direct predictor of HS (ß=0.13, p=0.059) but it was a predictor of HS either through affecting PA (ß=0.31, p<0.001) or I (ß=0.57, p<0.001). CONCLUSION: Socioeconomic status appeared to influence health status, not directly but through mediating some behavioral and self-confidence aspects including physical activity and independence in ADL.

Sickness absence and sickness attendance--what people with neck or back pain think.

This study explores the decision of 33 men and women to be sick-listed from work for neck pain or low-back pain. Qualitative interviews with the subjects, who lived in a city or a sparsely populated area of Sweden, were tape-recorded, transcribed and analysed in the interpretive tradition by the three authors. New, intense and threatening pain quickly made persons report sick. For other pain, sickness absence, its timing and duration, were negotiated on the basis of the subjects' self-image, work-duty norms, organisational and extra-organisational work factors. Thirty-one people aimed to return to work, but spine-related pain was a hindrance. Five strategies to avoid, delay or shorten sickness absence were identified. Concepts of the illness flexibility model well described how the workers balanced the factors driving them from work and those forcing them or attracting them to remain. The conclusion is that reporting sick is neither undertaken lightly nor for short-term reasons only. Instead, personal history and anticipated future, spine-related pain, workplace and labour market factors are also important considerations.

Neck pain and related disability in helicopter pilots: A survey of prevalence and risk factors.

INTRODUCTION: Today's demands on helicopter missions-often using helmet-mounted visual technology-place much physical stress on the cervical spine. The objective of the present analytical survey was to estimate the prevalence of, and associated risk factors for, helicopter pilots' neck pain and related disability. METHODS: There were 127 Swedish helicopter pilots consecutively enrolled for the study who completed a structured questionnaire during their regular medical health checkups. The questionnaire concerned flight-related and individual risk indicators, frequency of neck pain episodes, and disability. Multivariate regressions, with the potential to control for confounding factors, were used to estimate relative risks (RR). RESULTS: The 3-mo prevalence of neck pain was 57%, with 32% reporting frequent pain. A history of previous neck pain (RR = 1.8, 95% CI = 1.2-2.7) and recent shoulder pain (RR = 1.6, 95% CI = 1.1-2.4) were significant risk factors, while the use of night-vision goggles and muscle strength-training showed a non-significant associated trend, the latter toward a decreased risk. In neck pain cases, 58% and 55% reported that their pain interfered with their flying and leisure, respectively, and those with frequent pain risked pain interfering with flying duty (RR = 1.6, 95% CI = 1.1-2.5). However, only 25% of the cases had ever been on sick leave due to neck pain. CONCLUSIONS: Neck pain is common among helicopter pilots, and certain factors are identified for use in risk reduction. The link between cases with frequent pain and reported interference with flying duty highlights the need for early prevention of neck pain when planning and implementing helicopter pilots' health care. More clinical trials of good design are required.

A lower-limb functional capacity test for enlistment into Swedish Armed Forces ranger units.

The present work validated minimal performance standards for a lower-limb functional capacity test used at enrollment to predict the risk of discharge from strenuous military ranger training in the Swedish Armed Forces. To set a relevant level of performance, trained conscripts in a ranger unit (n = 38) performed a maximal physical fitness test, including the newly developed ranger test, during the last week of their 1-year basic training. The following year, basic training started with an initial strength test performed by all conscripts (n = 285). They performed the ranger test as a submaximal one. The relative risk was high (risk ratio, 48.5) for discharge attributable to knee problems for conscripts who failed the submaximal ranger test during the initial strength test. The area under the receiver operating characteristic curve was 0.91 (SE, 0.09) for failing the test. The submaximal ranger test had a high discriminating ability and predictive value for discharge caused by knee problems.

Short- and long-term effects of exercise on neck muscle function in cervical radiculopathy: A randomized clinical trial.

OBJECTIVE: To compare short- and long-term changes in neck muscle endurance, electromyography measures of neck muscle activation and fatigue and ratings of fatigue and pain after neck-specific training or physical activity in people with cervical radiculopathy. DESIGN: Randomized clinical trial. SUBJECTS/PATIENTS: Seventy-five patients with cervical radiculopathy. METHODS: Patients underwent neck-specific training in combination with a cognitive behavioural approach or prescribed physical activity over a period of 14 weeks. Immediately after the intervention and 12 months later, surface electromyography was recorded from neck flexor and extensor muscles during neck endurance tests. Time to task failure, amplitude and median frequency of the electromyography signal, and subjective fatigue and pain ratings were analysed in 50 patients who completed at least one follow-up. RESULTS: A significant increase in neck flexor endurance time was observed for both groups at 14 weeks compared with baseline and this was maintained at the 12-month follow-up (p < 0.005). No change was identified for the slope of the median frequency. For the neck-specific training group, splenius capitis was less active during neck flexion at both follow-ups (p < 0.01), indicating reduced muscle co-activation. CONCLUSION: Both specific and general exercise increased neck flexor endurance, but neck-specific training only reduced co-activation of antagonist muscles during sustained neck flexion.

Intra-rater reliability of electromyographic recordings and subjective evaluation of neck muscle fatigue among helicopter pilots.

UNLABELLED: The aim was to evaluate the reliability of a method of measuring neck muscle fatigue among helicopter pilots. METHOD: Surface EMG from three areas in the neck region, bilaterally, was recorded among 10 male helicopter pilots while they were performing isometric contractions in flexion and extension for 45 s, sustaining a force representing 75% of maximum strength in a seated position. Perceived fatigue was rated using the Borg CR-10 scale. The test was repeated twice the first day and then two additional times with one-week intervals. Variables analyzed were the slope of the median frequency change, the normalized slope, and the ratings after 15, 30 and 45 s; and also the initial median frequency (IMDF). The intra-class correlation (ICC) and the measurement error (S(w)), intra- and inter-day were calculated statistically. RESULTS: The best reliability for the slope was found for the 45 s intra-day analysis taking all measurements into account (ICC 0.65-0.83). The reliability after 30 s was poorer but still acceptable (ICC 0.52-0.71). For the subjective ratings, the highest reliability was found after 30 s inter-day (ICC 0.86-0.88). IMDF showed generally high reliability for the intra-day analyses (ICC 0.63-0.80). CONCLUSION: The method is reliable for use in further research. Since performing a contraction of 75% of maximum was quite strenuous, we recommend that the protocol be shortened to 30 s.

Neck strength and myoelectric fatigue in fighter and helicopter pilots with a history of neck pain.

INTRODUCTION: Flight-induced neck pain at high Gz loads or during sustained rotary-wing missions may be caused by limitations in neck muscle function. A better understanding of the contributing factors of excessive external load and internal neck-stabilizing mechanisms would improve the ability to prevent and treat such pain. The aim of this single-blinded cross-sectional study was to evaluate neck neuromuscular function in fighter and helicopter pilots who suffered from frequent neck pain. METHODS: Subjects with pain were 16 fighter pilots (FP-P) and 15 helicopter pilots (HP-P) with frequent neck pain episodes who were compared with pain-free controls (FP-C and HP-C). In all groups, neck extensor and flexor muscles were studied by measuring 1) the strength of maximum voluntary contraction (MVC), and 2) fatigue due to a submaximal isometric contraction. The decline (slope) of the electromyogram (EMG) median frequency power spectra was used as an index of fatigue, while initial median frequency (fi) was taken from the intercept of the regression line. RESULTS: Two-way analysis of variance (ANOVA) revealed interaction effects for extensor MVC. Post hoc testing showed that FP-P had significantly lower extensor MVC (p = 0.03) than FP-C, while there was no such difference for the HP-P vs. HP-C or between the two control groups. There were no significant effects for MVC-balance (flexors/extensors); nor were there any fi or extensor EMG-slope effects. However, there were interaction effects for flexor EMG-slopes: HP-P showed lower slopes than did HP-C (p = 0.02). CONCLUSIONS: To protect and stabilize the head and neck in high Gz environments, higher neck muscle strength is needed; less muscle strength in FP-P may cause further pain and perhaps reduced mission effectiveness. Less localized steep slopes for HP-P might reflect impaired muscle functioning. Specific preventive and clinical attention may be warranted for different types of pilot.

Dimensions Underlying Measures of Disability, Personal Factors, and Health Status in Cervical Radiculopathy: A Cross-Sectional Study.

This cross-sectional study sought to identify dimensions underlying measures of impairment, disability, personal factors, and health status in patients with cervical radiculopathy. One hundred twenty-four patients with magnetic resonance imaging-verified cervical radiculopathy, attending a neurosurgery clinic in Sweden, participated. Data from clinical tests and questionnaires on disability, personal factors, and health status were used in a principal-component analysis (PCA) with oblique rotation. The PCA supported a 3-component model including 14 variables from clinical tests and questionnaires, accounting for 73% of the cumulative percentage. The first component, pain and disability, explained 56%. The second component, health, fear-avoidance beliefs, kinesiophobia, and self-efficacy, explained 9.2%. The third component including anxiety, depression, and catastrophizing explained 7.6%. The strongest-loading variables of each dimension were "present neck pain intensity," "fear avoidance," and "anxiety." The three underlying dimensions identified and labeled Pain and functioning, Health, beliefs, and kinesiophobia, and Mood state and catastrophizing captured aspects of importance for cervical radiculopathy. Since the variables "present neck pain intensity," "fear avoidance," and "anxiety" had the strongest loading in each of the three dimensions; it may be important to include them in a reduced multidimensional measurement set in cervical radiculopathy.

Pain assessment with different intensity scales in response to loading of joint structures.

The purpose of the present study was to compare intensity levels assessed on Borg's Category Scale for Ratings of Perceived Pain (BRPP) (1982) (a verbal scale using adjectives and adverbs combined with the numbers 0-10), with assessments on the Visual Analogue Scale (VAS) (a 10 cm horizontal line). Eight healthy subjects volunteered in an experimental study, where pain was provoked by load on passive soft tissue elbow joint structures. Each subject participated 4 times on different occasions in the same experimental set-up, which was divided into six 2 min periods; 3 periods with load induced by applied external weights causing load moments of 3.4 Nm, 4.5 Nm and 6.8 Nm plus that induced by the weight of the lower arm and hand (average 2.9 Nm), followed by 3 periods without external weights. Each series consisted of 12 assessments given during the last 10 sec period of each minute on either the BRPP or the VAS. No significant difference was found between the first and second time a scale was used by the same subject, and none between the assessments on the VAS and the BRPP. Intensity levels of pain increased with load and time and decreased after reduction of the load moments. It is concluded that both scales can be used to reliably assess intensity levels of perceived pain elicited by loading joint structures. Intensity levels, as assessed on both scales, are associated with applied external load and time for exposure.

Movement-provoked muscle torque and EMG activity in longstanding motor complete spinal cord injured individuals.

Muscle resistance was evaluated by measurement of movement-provoked torque performed during simultaneous thigh muscle EMG recordings in individuals with a motor complete spinal cord injury (SCI). Fifteen men with a motor complete (ASIA grade A or B) cervical injury participated in the study. The activity started at an average of 0.11 seconds after the start of the provoking movement as evidenced by EMG recordings. However, no activity at all was found before the end of the movement provocation for 0.3 seconds in >60% of the test situations, whereas muscle torque was recorded in all cases. Significantly higher resistive muscle torque (p = 0.049) was provoked during extension movement compared with that of flexion. On the contrary, the maximum muscle activity was significantly higher (p = 0.009) during flexion movement compared with that during extension, with no differences between muscle groups. The resistive muscle torque seems to measure the passive viscoelastic component rather then the active spastic component of the movement-provoked muscle resistance in our group of motor complete SCI individuals.

Physical performance tests for people with long-term spinal pain: aspects of construct validity.

OBJECTIVE: The aim of this study was to investigate the construct validity of 6 physical performance tests that had already been shown to have acceptable repeatability. DESIGN: Data were collected in a randomized controlled multi-centre study. SUBJECTS: 126 women and 105 men sick-listed for spinal pain carried out the tests and provided personal and background data at inclusion in the study. METHODS: One test measured stepping up onto and down from a stool, 2 measured lifting ability and 3 walking speed. Construct validity was examined by analysing the influence of some variables on test performance. RESULTS: High-rated pain behaviour and perceived high pain intensity during testing or during the previous 4 weeks were connected with low test performance. Exercise twice a week was connected with high test performance. The test with the highest ability to detect disability in the women with lumbar pain was a lumbar lifting test, while for the men, it was a cervical lifting test. The test with the highest ability to detect disability in the participants with neck pain was the cervical lifting test in addition to a gait test with burden for the women. CONCLUSION: Back pain hampered the test performance more than neck pain. Impairments and activity limitations expressed by the patient should guide the choice of test.

Effects of functional electrical stimulation training for six months on body composition and spasticity in motor complete tetraplegic spinal cord-injured individuals.

The effect of functional electrical stimulation (FES) training on body composition, assessed by computed tomography, and the effect of spasticity, assessed by both objective and subjective measures, are evaluated. Fifteen motor-complete spinal-cord-injured men participated in the study. Eight of the 15 subjects undertook FES cycling 3 times weekly for 6 months. Whole body computed tomography scans evaluated changes in body composition. Simultaneous Modified Ashworth Scale and electromyography (EMG) measurements, resistive torque (Kin-Com) and EMG measurements, and self-ratings with Visual Analogue Scale during four consecutive days were used to evaluate changes in spasticity. Lower extremity muscle volume increased by an average of 1300 cm3 (p < 0.001) in the training group compared to the control group, who experienced no change. Otherwise no changes in body composition were seen. Significant correlations (Spearman) were found between individual EMG activity recordings and movement-provoked Modified Ashworth Scale ratings in 26% of the test situations, irrespective of group and time. The objective and subjective evaluation of movement-provoked passive (viscoelastic) and active (spasticity-related) resistance remained unchanged.

Electromyography and ratings of lumbar muscle fatigue using a four-level staircase protocol.

OBJECTIVE: The purpose of the study was to explore whether a relationship existed between subject's experience and objective measurements of back-muscle fatigue in healthy subjects. This may be used as reference material later. DESIGN: Muscle fatigue in the lower back was measured in healthy subjects using a staircase protocol. BACKGROUND: Muscle fatigue measurement in the lower back is of importance when assessing patients with low-back pain. The subject's experience of muscle fatigue needs to be explored further. METHODS: Twenty healthy subjects with informed consent participated. Borg CR-10 scale responses and electromyography measurements were obtained from low-back muscles of the subjects following a staircase protocol with sustained contractions at 20%, 40%, 60%, and 80% of maximum voluntary contraction. RESULTS: A strong correlation was found between Borg ratings and force (r=0.83) and between slope and force (r= -0.72) but not between Borg ratings and slopes which was at best 0.43 (/r/< or =0.43). CONCLUSIONS: Although subjective ratings and slopes showed a low correlation; increases in force with a concomitant increase in fatigue was reflected both by the subjective ratings and the slope. One cannot use subjective ratings for prediction of the slope for this type of protocol. However, a more complete description of muscle fatigue needs both the slope and the Borg ratings. RELEVANCE: In clinical testing, both subjective and objective measures of muscle fatigue must be considered since they measure different aspects of muscle fatigue. The median frequency slope probably reflects "physical discomfort" but the Borg ratings add a factor of "lack of energy".

Physical performance tests for people with spinal pain--sensitivity to change.

OBJECTIVE: The sensitivity to change for six physical performance tests for assessing impairments and activity limitations in persons with spinal pain was examined. METHOD: Eighty men and 106 women with long-term spinal pain participating in a randomized controlled study went through the tests on inclusion in the study, and were then invited to follow-up tests after 5 weeks and 6 months. The tests were a 'step-on-stool test', three gait tests and two lifting tests (PILE tests). Sensitivity to change was examined by relating changes in physical performance to self-rated concepts assumed to reflect a real change in the individual. Effect sizes were calculated. RESULT: Sensitivity to change in absolute values was revealed for the gait test with burden, the stair-climbing test and the PILE cervical test for women. Only the PILE cervical test showed responsiveness to clinically important change according to our criteria. Moderate to high effect sizes were found for all tests. Relatively few subjects improved to an extent considered clinically important. Improvement was greater in subjects whom inclusion measurements showed to be less fit. CONCLUSIONS: The sensitivity to change was moderate over a 6-month period for the physical performance tests. The gait test with burden, the stair-climbing test and the PILE tests were most sensitive to change. It is suggested that these tests be incorporated in an 'assessment instrument bank' for physiotherapists, supplemented with other reliable and valid tests relevant to the problems for the individual with spinal pain.