The aim of the study was to assess the effectiveness of surgical treatment for degenerative lumbar spinal stenosis (LSS) as compared with non-operative measures. Four university hospitals contributed, after agreement on study protocol, surgical rationale and non-operative procedures (For details, see Spine2007;32:1–8). Ninety-four patients were randomized into a surgical or nonoperative treatment group, 50 and 44 patients, respectively. Surgery comprised undercutting laminectomy of the stenotic segments, in 10 patients augmented with transpedicular instrumented fusion. The primary outcome was based on assessment of functional disability using the Oswestry Disability Index (ODI, scale 0–100). Intensity of leg and back pain (scales 0–10), as well as self-reported walking ability, were recorded at randomization and at follow-ups at 6, 12, 24 months and on average 6 years after the randomization. At the 2-year follow-up, back and leg pain scales and ODI had improved more in the surgical than the nonoperative group (p-values for global difference < 0,01). At the 6-year follow-up the mean difference in ODI in favor of surgery was 9.5 (95% confidence interval 0.9–18.1). However, the intensity of pains did not any-more differ between the two treatment groups at the 6-year follow-up. Walking ability did not differ between the treatment groups at any time point. Of the 44 patients in the nonoperative group, 4 had been subjected to surgery within two years after randomization because of persistent symptoms.

We conclude that surgical treatment improves functional ability in lumbar spinal stenosis. We emphasize that improvement also occurs after nonoperative measures. We recommend starting treatment with non-operative measures during a 2-year surveillance period, as during this period only 10 per cent of the patients will need surgical intervention.

Since neurological claudication is a major symptom in lumbar spinal stenosis (LSS), walking distance is commonly used as a measure of the severity and surgical outcome in LSS. The aim of this study was to compare self-reported and treadmill-measured walking distances in a trial, in which 94 patients with moderate LSS had been randomized into conservative and surgical treatment. Among the 44 patients in conservative treatment, the treadmill-measured walking distance was more reproducible after 6 months than the self-reported distance; the intraclass correlation coefficients were 0.75 and 0.41, respectively. Among all the patients at baseline, the agreement between self-reported and measured walking distance was satisfactory (intraclass correlation 0.57), although male patients overwhelmed their performance by 200 meters. Such a shift was not found in women. For walking distance categorized as < 400, 400–1249 and ≥ 1250 meters, there was a fair agreement between self-report and treadmill (weighed kappa 0.42). However, when the analysis was restricted to those whose walking distance was restricted to < 1250 meters, the corresponding agreement was poor (intraclass correlation 0.26). The self-reported walking distance was closely correlated with Oswestry index at baseline (r = 0.26), and changes in these outcomes from randomization to the follow-up of 6 months showed a strong correlation with each other (r = 0.37). We conclude that walking distance is a fundamental element of disability in LSS. Self-reported walking distance seems to be an appropriate clinical tool, but its limited precision in relation to treadmill-measured distance must be considered, when walking ability is severely restricted.

Purpose of the study: There are no previous studies for psychometric properties of Finnish version of Tampa Scale of Kinesiophobia questionnaire (TSK-FIN). The aim of this study was to examine test-retest reliability and comparability of two different methods (paper and computer) for the completion of the TSK-FIN among chronic pain patients.

Material and methods: Reliability was tested by 94 subjects who participated in the in-patient rehabilitation program. Mean age was 46.8 yrs(SD 7.5). The mean Oswestry index was 34.4% (SD 15.2). All subjects completed both versions at the interval of eight hours in two consecutive days. Test-retest reliability of TSK-FIN for the paper and computer sum scores were tested by Intra-class Correlation Coefficient (ICC). Internal consistency was measured by Chronbach’s alfa.

Results: Mean (SD) scores of the paper version were 35.3 (7.8) and 35.6 (7.8). Mean (SD) scores of computer version were 37.1 (8.2) and 36.3 (8.5). Test-retest reliability (ICC) for the paper and computer versions were 0.887 and 0.877 respectively which are both excellent. Intertest reliability (ICC) between paper and computer versions was 0.773 which is acceptable. Both versions demonstrated good internal consistency, Cronbach’s alpha was 0.797 for the paper version and 0.815 for the computer version.

Conclusion: Reliability and internal consistency found in this study were consistent with previous studies. Both versions of TSK-FIN demonstrated acceptable test-retest and intertest reliability and internal consistency suggesting suitability for clinical use. However there was tendency that subjects scored higher (t= 3.564, p=0.001) when using computer version. Further research is required to detect clinical importance of the difference.

Aims: To evaluate the efþcacy and safety of inßiximab, a monoclonal chimeric antibody against TNFα, for the treatment of severe sciatica. Background: Evidence from animal studies indicates that tumour necrosis factor (TNF)α plays a role in the pathophysiology of sciatica. Anti-TNFα therapy has not been previously evaluated in sciatic patients. Methods: 10 patients with disc herniation-induced severe sciatica received inßiximab (Remi-cade¨; 3mg/weight-kg) intravenously over 2 hours. The outcome was assessed at 1 hour, 1 week, 2 weeks, 1 month and 3 months after the infusion, and was compared to historical controls consisting of 62 patients who received saline in a trial of periradicular inþltration for sciatica. Leg pain was the primary outcome, with over 75% decrease from baseline score constituting a painless state. Fisherñs exact test and repeated measures analysis of variance were used for statistical analysis. Results: One hour after the infusion, leg pain had decreased by 50%. At 2 weeks, 60% of patients in the inßiximab group were painless vs. 16% of control patients (P = 0.006). The difference was sustained at 3-months (90% vs. 46%; P = 0.014). Inßiximab was superior over the whole follow-up period in leg pain (P=0.003) and back-related disability (P=0.004). At 1 month, every patient in the inßiximab group had returned to work whereas 38% of controls were still on sick leave (P=0.02). None of the patients treated with inßiximab underwent surgery during the follow-up. No immediate or delayed adverse drug reactions, or any adverse effects due to medication were observed. Conclusions: Anti-TNFα therapy is a promising treatment option for sciatica. There is an urgent need for a ran-domised controlled trial to evaluate if these promising early results can be conþrmed.

Introduction: Infliximab, a monoclonal antibody against tumour necrosis factor alfa (TNFα) has been used succesfully in the treatment of rheumatoid arthritis and Crohn’s disease. Recent animal studies suggest that TNFα also has an important role in the pathogenesis of sciatica. The purpose of this study was to evaluate the efficacy and safety of infliximab in the treatment of sciatic patients.

Methods: 10 patients with acute or subacute severe sciatica (duration of symptoms from 2 to 12 weeks) were included. A disc herniation corresponding to symptoms was confirmed by MRI in each case. Patients with previous back operation or with contraindications for infliximab were excluded. A dose of 3 mg/kg body weight of infliximab in saline was infused intravenously over 2 hours. Leg pain (100-mm Visual Analog Scale) was recorded before and one hour after the infusion, and later at 1 week, 2 weeks, 1 month, 3 months and 6 months. Changes in leg pain were compared statistically with 62 historical controls (saline group in a study of periradicular infiltration) using repeated measures analysis of variance. Changes in back pain, back-related disability on Oswestry Index and clinical status were also assessed.

Results: Mean (SD) leg pain before the infusion was 80 (18) mm in the infliximab group. One hour after the infusion, there was a decrease of 49% in leg pain. At 1 week mean leg pain was 26 (21), at 2 weeks 19 (20), at 1 month 18 (19), at 3 months 10 (16) and at 6 months 13 (8). When compared with the historical controls, the difference was in favour of infliximab for leg pain (19 mm; 95% CI, 6 to 32, P=0.005) and for back-related disability on Oswestry (12%; 95%CI, 4 to 20, P=0.003) over the 6 month follow-up period. At the one-month follow-up every patient in the infliximab group had returned to work compared to 38% of control patients (P=0.02). None of the patients treated with infliximab underwent surgery during the follow-up compared to 14 (23%) in the control group (P=0.09). No immediate or delayed adverse drug reactions were observed.

Conclusions: According to this study, a single infusion of infliximab seems to provide immediate, highly effective and safe treatment of sciatica through 6 months. Rapid return to work appears to be fascilitated, and surgery may possibly be avoided in some patients. There is an urgent need for a randomized trial to verify these results.

Rehabilitation as a concept, and the practice of rehabilitation, have changed remarkably during the preceding years. Modern rehabilitation is multidisciplinary and multi-professional. The development and research of rehabilitation has also grown international. The contents of modern rehabilitation include medical, social and psychological aspects, and in vocational rehabilitation, the working conditions and organisational questions are dealt with as well (Jager 1999).

Traditional methods in vocational rehabilitation and guidance include medical and psychological assessment, and work clinics assessment (which includes practical work assessment in the work place). Presently, the methods, have advanced and rehabilitation is not seen merely as a specific method for handicapped people. Various rehabilitation measures are flexibly applied, and rehabilitation includes elements of adult education, training of working skills, and ideas of on-the-job training and career advancement. The concepts, targets and contexts of rehabilitation and prevention can be described as follows:

Primary Prevention: health education and ergonomic advice for general, non-disabled population.

Secondary Prevention: early rehabilitation for groups at risk with early signs of disability.

Tertiary Prevention: rehabilitation and habilitation of severely disabled to secure social integration.

The outcome of rehabilitation has been studied extensively, but the number of randomised controlled trials (RCT) is not large in any of the major target groups of rehabilitation. Among musculoskeletal disorders, the best evidence for the efficacy of multidisciplinary rehabilitation is for sub-acute and chronic low back pain disorders. Systematic reviews have been performed in various other musculoskeletal disorders as well, e.g. in fibromyalgia and multilocational pain syndromes, where no clear evidence has yet been demonstrated. It should be noted though that RCT’s are not the only way to get information about the outcome, efficacy or effectiveness of rehabilitation, and vocational rehabilitation in particular. The outcome of vocational rehabilitation, i.e. the success of occupational integration, depends a great deal on the general employment outlook. This is generally known but often ignored.

Various forms of supported employments have become more important than earlier. The European Social Fund’s Employment Horizon initiative has launched many projects in Europe. As a result, new training and employment approaches have been developed for disabled persons, including co-operatives, social enterprises and distance work. In practice, supported employment takes the form of individual training at the workplace and consists of finding suitable supported work, redesigning job requirements in co-operation with both employer and employee to fit the employee’s abilities, and ongoing support as long as it is needed.

These programmes reflect the important values of the society. It is a valuable goal to help disabled people to integrate into society, which involves participation into working life. This makes it possible for them to preserve their dignity as well. In fact, how Society deals with its disabled people enables it to discover most clearly its basic values.