normative database for lumbar ROM by Qualified Physio

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Manual Therapy 10 (2005) 198–206 www.elsevier.com/locate/math

Original article

A normative database of lumbar spine ranges of motion Michael Trokea, , Ann P Moored, Frederick J Maillardetb, Elizabeth Cheekc a

Head of Research & Enterprise, York St John College, Lord Mayor’s Walk, York, YO31 7EX, UK b Clinical Research Centre for Health Professions, University of Brighton, UK c University of Brighton, UK d Faculty of Management & Information Sciences, University of Brighton, UK Received 4 June 2003; received in revised form 17 September 2004; accepted 25 October 2004

Abstract The overall aim of the work was to develop a comprehensive normative database of indices for ranges of motion in the lumbar spine, in an asymptomatic sample of the general population. This was a repeated measures prospective study utilizing a reliable and valid instrument, the modified CA6000 Spine Motion Analyzer (Orthopedic Systems Inc. Union City CA & Troke/University of Brighton). The portable equipment was used to collect data in a variety of community settings (e.g. schools, GP surgeries, offices, leisure centres, emergency services stations). A total of 405 asymptomatic subjects (196 female, 209 male) aged 16–90 yr from sedentary, mixed and physically demanding occupations participated in the study and data were collected in standing, at different times of the day, following a standardized methodology for lumbar spine motion in the sagittal, coronal and horizontal planes. Age-related centile graphs were derived separately for male and female subjects in flexion, extension, left and right lateral flexion and left and right axial rotation. All 12 graphs are presented as an appendix located on the Manual Therapy website (www.elsevierscience.com/journals/math). Overall, flexion (73–401) and lateral flexion (28–141, L&R) declined 45% and 48%, respectively, across the age range. Extension (29–61) declined the greatest at 79%. By contrast, no overall decline in axial rotational RoMs was recorded, and the median RoM remained at 71 each way across the age spectrum examined. A comprehensive database of indices of lumbar spine ranges of motion has thus been developed which is gender specific, age related, drawn from a wide age range and presents data for all three planes of motion. It is considered that the new database has a number of potential clinical and research applications. r 2004 Elsevier Ltd. All rights reserved. Keywords: Normative; Database; Lumbar; Spine

1. Introduction An introductory paper has been published in Clinical Rehabilitation (Troke et al., 2001b), in which the methodology developed for this work, along with a new approach to the analysis of lumbar spine normative data were discussed. Summary results were also presented along with an example of the database graphs. The principal purpose of this current paper is to publish the new, comprehensive, normative database of lumbar Corresponding author.

spinal motion in full, and make the complete database available to interested clinicians and researchers. The clinical relevance of this work is considered in Section 5. Many papers and publications offering normative data for lumbar spine movement have used different types of equipment, a variety of methodologies and different methods of analysis. Some only offer data across a limited spectrum of age ranges, do not encompass all three planes of movement, or are not gender speciﬁc. This present work is an attempt to address these limitations, following the development of the modiﬁed CA6000 Spine Motion Analyzer (Troke and Moore, 1995).

Table 1 Selected comparative ranges of lumbar spinal motion including this current normative database 1978

1979

1985

1993

1994

1995

2000

2001

Author(s)

Kapandji

Twomey

Pearcy

Russell et al. Dopf et al.

Reliability reported Validity reported Total subjects No. (Female No.) (Male No.) Ages (Yr) Spinal RegionReported Gender speciﬁc Age related Measurement Methods Results Flexion Extension R Lat Flex L Lat Flex R Ax Rotn L Ax Rotn

White and Panjabi No

Dvorak et al. Yes

McGregor et al. Yes

Van Herp et al. No

Ng et al.

Troke et al.

Yes

Greene and Heckman No

Yes

Not stated

Composite

144

245

120

(a)

104

203

100

405

Not stated Not stated Not stated T12-sacrum

72 72 20–60+ T12-sacrum

0 31 21–37 L1-sacrum

118 127 20–69 L1-sacrum

60 60 20–35 T12-sacrum

(a) (a) (b) T12/L1-sacrum

42 62 20–70 T12-sacrum

100 103 20–70 T12-sacrum

50 50 20–77 T12-sacrum

0 35 Mean 29 T12-sacrum

196 209 16–90 T12-sacrum

Yes

No Not stated

Yes Mechanical with cadavers Note: Where a range of values is reported, 60 115–70 39–24 35 Combined 14–9 20 47–23 20–14 20 Combined 20–13 5 18–17 16–12 5 Combined 16–12

1994

No Yes No No Yes Yes Yes StereoIsotrak CA6000 with Radiographic CA6000 CA6000 Isotrak radiographic straps+others with straps with straps they are shown here in descending order according to ascending age. All values are shown in degrees 51 75–58 81 76–70 75–55 64–45 59–51 16 28–15 35 Combined 31–17 30–13 37–15 17 57–35 45 50–40 36–23 35–25 26–15 18 Combined 46 Combined 35–20 36–25 26–15 4 36–26 42 12 48–32 30–23 19–13 5 Combined 43 Combined 48–33 31–23 19–11

No Yes Inclinometer+ CA6000 rotameter with Pads 52 19 31 30 32 33

72–40 29–6 28–15 29–16 7 7

Key: T12-sacrum: Whole lumbar spine region; L1-sacrum: Excluded T/Lumbar junction. (a) Given in cited studies—Dvorak: 41(23 Male, 18 Female), Pearcy: 11 (all Male). (b) Given in cited studies—Dvorak: 22–50 yr, Pearcy: 25–36 yr.

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Increasingly more sophisticated methods have been developed including the use of stereo X-ray equipment (Pearcy, 1985) and different electronic methods (Hindle et al., 1990; Gomez et al., 1991; Russell et al., 1993; Dopf et al., 1994; Dvorak et al., 1995; McGregor et al., 1995; Van Herp et al., 2000). Of these, the Dopf, Dvorak and McGregor studies utilized the unmodified CA6000 Spine Motion Analyzer with strap fixation. A modified version of that instrument utilising a new skin pad fixation system was used for this current work. Selected publications which offered normative data of lumbar spine motion are summarized in Table 1 and reviewed below. Kapandji (1974) provided maximal figures for ranges of motion which bear comparison with this current work. It is not clear what methodologies were drawn upon to establish the maximal RoMs quoted, although work by Tanz (1953) is cited, but not specifically referenced. The data were not gender specific but age-related segmental ranges by Tanz were reproduced, and these have also been cited by White and Panjabi (1990). Normative data reported by White and Panjabi (1978a) were originally published in a journal paper and also in the first edition of their book (White and Panjabi, 1978b). Their figures for individual segments of the lumbar spine were drawn from comprehensive references and the ‘‘authors’ own best opinion’’, based upon a review of the literature at the time, as well as their own analysis. Neither the number of subjects from which the data were drawn, nor their gender and ages were reported and nor the methods by which the representative values offered by these authors were derived. In 1979, Twomey published a paper on the effects of age on the RoMs of the lumbar spine. Results were reported on 200 cadaveric specimens, secured in a mechanical test vice, of which 144 were in the adult age ranges from 20 years to over 60 years, with an equal number of male and female subjects. Measurements were taken from T12 to S2, as in this current work. The ranges of motion were categorized according to age and gender, flexion, extension, left and right lateral flexion and left and right axial rotation. The work of Pearcy (1985), described extensive studies utilizing stereo radiography. The author reported on work with 31 male subjects who were exposed to stereo-radiographic X-rays in a specially constructed framework. Eleven subjects were measured for flexion/ extension and had a mean age of 29 yrs (SDs not given). A further 10 subjects carried out lateral flexion movements (mean age 28 yrs) and another 10 subjects carried out axial rotation movements (mean age 24 yrs). Measures (in degrees) were reported for each segment from L1 to the sacrum, but excluded the thoraco-lumbar junction (T12/L1). Russell et al. (1993) utilized the Isotrak electromagnetic equipment (Polhemus Navigation, Inc.) to

investigate normal ranges of motion for groups of males and females aged from 20 to 69 years. The authors chose to combine left and right lateral flexion and axial rotation figures to give total ranges and like Pearcy (1985) this work reports motion of the lumbar spine taken from L1. In 1994, the American Academy of Orthopedic Surgeons (AAOS) published a revised and updated edition of their earlier book (AAOS, 1965) on joint motion (Greene and Heckman, 1994). The latter book drew on two papers (Pearcy et al., 1984; Dvorak et al., 1991) to tabulate radiographic segmental RoMs for the lumbar spine from L1 to S1. Additionally, when discussing clinical measurements of the lumbar spine, the authors compared earlier results using the Schober (1937) method with the later work which utilized inclinometers and goniometers (Loebl, 1967; Fitzgerald et al., 1983). A study by Van Herp et al. (2000) utilized the 3-Space Isotrak electro-magnetic system (as did Russell et al., 1993) to produce a normative database involving 50 male and 50 female subjects aged from 20 to 77 years. The data reported by Van Herp and colleagues involved the whole of the lumbar region (as in this current work), the instrument having been applied from the T12 vertebra to the sacrum. The data were arranged in 10year age bands, were gender specific and demonstrated changes in RoMs with advancing age. In their reliability and normative study, Ng et al. (2001) utilized double inclinometers and rotameter techniques. Like Pearcy (1985), Ng et al. involved a small sample (31 and 35, respectively) of young male subjects.

1.1. Normative work with the CA6000 Spine Motion Analyzer The first study to be published which offered normative values for lumbar spinal motion utilising the unmodified CA6000 was published by Dopf et al. (1994). In 1995, Dvorak et al. reported on data from a substantial number of subjects across a wide age range (20–70 yr), and the data were age related and gender specific. McGregor et al. (1995) discussed normative data for RoMs as well as for velocity of movement. Like Dvorak et al.’s (1995) work, McGregor and colleagues’ data were gender specific and age related in 10-year age bands. The diversity of methods used to establish lumbar spine normative RoMs and summarized in Table 1, illustrate the significant lack of agreement and very wide variation in reported RoMs for substantially the same region of the spine. The values reported demonstrate the need for a comprehensive normative database, and the

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work highlighted in Table 1 is considered further in the discussion section of this paper. Developmental work on the CA6000 spinal motion analysis system has been described in a series of conference presentations and journal papers. In the light of difficulties encountered with the manufacturers’ strap fixation, and the exaggerated results obtained with the un-modified instrument, the programme of work began with the development of a new skin fixation system (Troke and Moore, 1995). The system comprises semi-flexible self-adhesive pads with balance weights and squared alloy mounting hooks. The linkage consists of six potentiometers connected by light alloy tubular rods. The instrument is thereby secured directly onto the skin, typically over the spinous processes of T12 and S2 vertebrae. This work was followed by a series of reliability studies (Troke et al., 1996, 1998) and a study of validity (Troke et al., 2001a), all directed towards the development of a credible clinical tool.

2. Aim and objectives for the normative database study The aim of the study was to develop a comprehensive normative database of indices for ranges of lumbar spinal motion in an asymptomatic sample of the general population, utilizing a reliable and valid instrument. The principal objectives were to generate these data utilizing the modiﬁed CA6000 Spine Motion Analyzer (Orthopedic Systems Inc. Union City CA and Troke / University of Brighton), and to analyse and present gender-speciﬁc and age-related results for all planes of movement which clinicians and researchers interested in spinal dysfunction could readily utilize.

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movements intended to overcome any initial stiffness were carried out. Four successive lumbar spine movements in each plane (sagittal, coronal and horizontal) were then recorded from a standing start position. In order to encompass diurnal variations, two complete data sets of lumbar spine movement data were recorded at different times of the day. Over the course of two separate days, a total of 24 observations were taken with each of the 405 subjects. The methodology used for this study has been described in detail in an introductory paper published in the journal Clinical Rehabilitation (Troke et al., 2001b). The statistical analysis of the data produced agerelated centiles as a continuum across all the subject ages, in each gender, and for each plane of movement. This is in accordance with the epidemiological and statistical advice received, plus reference to Altman (1993), and is thought to be an innovative approach to the presentation of spinal motion data. Prior to the construction of the centile graphs, analyses of variance (2-way) were conducted, leading to the calculation of Type 2,1 Intra-class Correlation Coefficients (Shrout and Fleiss, 1979) in order to test the reliability of the data. Initial trends emerged, some of which appeared to confirm established knowledge about the effect of age on lumbar spine ranges of motion, and some of which appeared to shed new light on this area. Using regression analysis techniques, age-related centiles were constructed from the data collected. The graphs are gender specific, illustrate the age-related variations in lumbar ranges of motion as a continuum across the age spectrum, and relate to each plane of movement (sagittal flexion–extension, coronal lateral flexion to the right and to the left, and horizontal axial rotation, with the shoulders rotating clockwise towards the right and anti-clockwise to the left).

3. Method Ethical approval for the work was granted by the University of Brighton Research Ethics Committee. Data collection was carried out in a variety of community locations (e.g. schools, GP surgeries, ofﬁces, leisure centres, emergency services stations, etc.). A portable system linked to a laptop computer was utilized with the CA6000 instrument and the skin pad ﬁxation system as described in previous papers (Troke and Moore, 1995; Troke et al., 1996, 1998). Over 400 participants were recruited for the study with ages ranging from 16 to 90 years, 209 of whom were male, and 196 of whom were female. In excess of 20 companies, institutions or groups were involved, from a variety of sedentary, mixed and physically demanding occupations. Data collection was carried out according to the standardized protocol developed during the reliability studies (Troke et al., 1996). The instrument was secured over T12 and S2 vertebrae, and preliminary

4. Results As examples from the complete website database (www.elsevierscience.com/journals/math), graphs for female ﬂexion, extension, lateral ﬂexion and axial rotation are illustrated in Figs. 1–4. The graphs show the centiles as a continuum for all subjects, according to gender, with individual data points shown as a scatter plot. The 50th centile (median), the 97th, 90th, 10th and 3rd centiles are superimposed. The 50th centile represents the values such that half of the subjects will have RoM values greater, and half will have RoM values less than the median. The values found between the 90th and 10th centiles represent RoMs which it might be expected that 80% of the population would achieve. The values beyond these centiles are either in the upper 10% or lower 10% of the general population distribution. The values found below

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Degrees

202

100 90 80 70 60 50 40 30 20 10 0 10

50 60 Age (years)

Fig. 1. Flexion-females 3rd, 10th, 50th, 90th and 97th Centiles. r Copyright M. Troke.

Degrees

40 30 20 10 0 10

50 Age (years)

Fig. 2. Extension-females 3rd, 10th, 50th, 90th and 97th Centiles. r Copyright M. Troke.

Degrees

40 30 20 10 0 10

50 Age (years)

Fig. 3. Right lateral ﬂexion-females 3rd, 10th, 50th, 90th and 97th Centiles. r Copyright M. Troke.

the 3rd or above the 97th centiles could be regarded as at the extremes of RoMs to be expected in the general population. The median ﬂexion RoM value for male subjects declined from 731 to 401 across the age spectrum of 16–90 yr. The median value for females was similar, from 681 to 401. In extension, the male median RoM declined with age from 291 to 71 and the female median

RoM similarly declined from 281 to 61. These overall ranges of motion are summarized in Table 2. In lateral ﬂexion both male and female median values were very similar, ranging from 281 to 141, left or right. In axial rotation, the median RoM value, both for male and female subjects, to both the left and the right remained at approximately 71 in each direction, across the whole age spectrum studied.

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Degrees

25 20 15 10 5 0 10

50 Age (years)

Fig. 4. Left axial rotation-females 3rd, 10th, 50th, 90th and 97th Centiles. r Copyright M. Troke.

Table 2 Maximum and minimum median ranges of lumbar spinal motion across all subjects (overall age range of subjects 16–90 yr) Movement

Flexion Extension Right lateral ﬂexion Left lateral ﬂexion Right axial rotation Left axial rotation

Male

Female

Max (median of values) (deg)

Min

Max (median of values) (deg)

Min

73 29 28 28 7 7

40 7 15 16 7 7

68 28 27 28 8 6

40 6 14 18 8 6

Whilst the apparent effect on RoMs of increasing age is self-evident, it will be noted that this change (where it occurs) is generally linear. Nevertheless, it is also noteworthy that extension appears to decline as a slight curve and that all the axial rotation RoMs remain substantially constant across the age spectrum. On comparing Fig. 1 with the male equivalent, there appears to be slightly greater variability in RoMs, and therefore the centiles are more closely spaced with male subjects. Female subjects have lower RoMs at 16 yr, but appear to equal male subjects in the ﬁnal decade. The decline in RoMs is linear, and between ages 16 and 90 yr the reduction is 45%. In extension, the male and female values and centile patterns are almost identical. The slightly curved changes suggest a steeper decline in earlier years, which levels out somewhat in later life. Overall, the reduction across the age ranges is 79%, and is the greatest decline of any of the primary movements. In lateral ﬂexion, the decline in RoMs is linear at 48% overall. There appears to be less variability with male subjects than with females. Overall patterns between movement to the left and right are very similar. In axial rotation, no overall decline is apparent in RoMs across the age spectrum. The 50th centile value is very similar for both men and women, and overall variability is also comparable.

The presentation of the results of this study as centile graphs has been designed to make direct reading of ranges immediately accessible, if comparison needed to be made with other subjects or patients of a given gender and age, in a given plane of motion. It can be seen that the centiles offer a comprehensive reference for ranges of motion of the lumbar spine for each sex and in all three planes of motion, in either a clinical or research arena.

5. Discussion 5.1. Current work with the modified CA6000 There was considerable agreement between the overall maximum and minimum RoMs achieved by the male and female participants in this study. This is in contrast to many previous studies which have found differences between overall mobility in spinal motion between the sexes. Results from this database suggest that there was no discernable difference in RoMs between males and females. A possible exception was that the median value for the youngest of the female subjects was approximately 51 less in ﬂexion than the equivalent male ﬁgure. This difference is less than 10% and may therefore be considered by some clinicians as within the bounds of normal variation.

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The use of centile graphs to present the complete normative data sets is thought to be an innovative way of presenting spinal motion data whilst making the overall results readily accessible and easy to use. The age-related data can be related directly to the individual research subject or clinical patient RoM values achieved, and used as part of a broader clinical assessment of possible spinal pathology or dysfunction. Centiles were also used in order to avoid artificial age bands and in order to present the individual’s results as a continuous correlation between range of motion and age. The centiles were calculated using regression techniques with the 50th centile (median value) being the line of best fit. The reference intervals are consequential upon this approach. Utilization of age-related centiles also enabled the use of reference intervals (e.g. 80% of the population between the 10th and 90th centiles) to determine the location of an individual’s results as within the reference interval, or not, as the case may be. Use of the term ‘reference interval’ can be as an alternative to describe ‘normal’ or ‘normative’ data in the context of range of motion (Bland and Altman, 1995). In this study, reference interval is defined as a range of values obtained from a majority of normal subjects. Extensive speculation as to the possible reasons for the substantially similar RoMs achieved by male and female subjects in this study, and for the age-related changes, or lack of change, in the lumbar spinal RoMs shown in the new database, is perhaps more suited to a future paper. However, given the availability of the new database, further research may now be able to offer greater insight into lumbar spinal motion, and offer substantiated propositions for these similarities, and for the age-related changes found in this work. 5.2. Earlier work with the unmodified CA6000 Dopf et al. (1994) made comparisons with other methods of measuring spinal motion including the Schober (1937) method for measuring flexion, and inclinometers for measurements in other planes. The RoMs reported for horizontal axial rotation were clearly exaggerated when compared to the Kapandji (1974) data, White and Panjabi (1978a, b), Twomey’s (1979) paper and Pearcy’s (1985) data. It is perhaps unfortunate that Dopf et al. (1994) did not acknowledge the limitations of the early versions of the CA6000 when reporting their findings. In a subsequent study, Dvorak et al. (1995) used a much more constrictive method when measuring subjects in lateral flexion than this current work or any other studies which utilised the CA6000. Unlike Dopf et al. (1994) however, Dvorak et al. acknowledged that the results obtained for axial rotation were exaggerated and that the strap fixation supplied by the manufacturer was

a likely source of error. Insofar as the paper provided an interesting insight into various aspects of lumbar spinal movement, comparison of results with the new normative database reported here requires caution in the light of Dvorak and colleagues’ own reservations. A similar criticism to that which could be applied to the RoMs reported by Dopf et al. (1994) in axial rotation could also be applied to McGregor et al.’s (1995) results. In comparison to earlier work (e.g. Panjabi et al., 1994) the axial rotation RoMs again appeared exaggerated. 5.3. Clinical applicability of the new database The modified CA6000 instrument is a safe, noninvasive means of establishing reliable and valid indices of regional lumbar spine motion. The new normative database offers complementary data on lumbar ranges of motion which might be expected amongst an asymptomatic population. It has been established as easy to use in different clinical and community locations, economic of operator’s time and readily portable. The new database is intended to be quick and easy to interpret by clinicians, and where appropriate to be used in explanations to patients as a means of offering feedback following treatment intervention. In considering the possible clinical applicability of the instrument and the new database, it should be acknowledged immediately, that RoM indices and patterns of movement graphs can only be part of the whole clinical picture and the clinical relevance of such data is still a matter for debate. The graphical representations provided by the instrument combined with the new normative database could, however, be seen as useful adjuncts in initial assessment in the context of specific spinal conditions, monitoring the progress of rehabilitation and the efficacy of treatment regimes. It has been suggested anecdotally that research colleagues investigating low back pain (LBP) syndromes in general, as well as more specific conditions, have possibly been reluctant to utilize objective measures of lumbar spinal RoMs in their studies. This has been in some measure due to the lack of confidence in the results produced by some instruments purporting to quantify lumbar spine motion. Long-term monitoring of the progress (or otherwise) of rheumatic diseases such as ankylosing spondylitis also suggest themselves as examples where reliable and valid RoMs data on lumbar spinal motion would be advantageous. Additionally, studies are already progressing on assessing risks associated with specific manual handling tasks, applications in the field of occupational health, and post-surgical outcomes—all areas of current research seen as of high priority. It is expected that future use of the data will itself promote further opportunities to evaluate treatment

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efficacy, monitor diseases and quantify outcomes in clinical and research settings—and relate findings to the age-related data illustrated in the new normative database. 5.4. Further developments with the instrument and the database It might be desirable to replicate this study in a number of diverse locations nationally, with the aim of reflecting differing living environments. Statistical (actuarial) advice would, however, be advisable in this respect to avoid expanding the database to an unnecessary extent without the benefit of clear advantages in terms of statistical power and the generalizablity of the results. All the subjects for this study were of caucasian background, although people from other backgrounds were not specifically excluded from volunteering for the studies. It might therefore be argued that to be truly representative of the overall diversity of cultural and ethnic backgrounds to be found in the UK, people with a variety of ethnic backgrounds should be included in an expanded database. This might appear to be a counsel of perfection, which would be theoretically desirable but logistically impractical. It might therefore be more feasible to carry out small-scale studies involving participants from specific ethnic backgrounds (e.g. the Indian sub-continent, Africa, the Far East), and compare their results with the existing database to establish if any significant difference exists. In considering the possible influence of coupled motion characteristics on primary movement a detailed analysis of the three-dimensional data collected was beyond the scope of this work. However, the raw data were recorded in three dimensions as part of the normal collection process. Given recent developments in calibration and computer modelling of the instrument’s measures of coupled motion (Higgison, 2004, pers. comm.), subsequent analysis could focus on the coupled motion characteristics displayed by this group of subjects. The coupled RoMs and patterns of movement could be directly related to the individual participants, and also analysed as centile graphs. The results could also be presented as parallel data to the primary movement centiles illustrated in Figs. 1–12 in the website appendix (www.elsevierscience.com/journals/math).

6. Conclusions As has been previously noted, there has been considerable diversity in approach to the collection of normative data for motion of the lumbar spine. Similarly, there has been considerable variation in the

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analysis or presentation of results, making the comparison of different studies very difﬁcult. The innovative, clear, consistent and uniform presentation of the normative values for spinal motion data in all three planes of movement has been achieved in this work. It is anticipated that the results may be of particular value to clinicians who are involved in research with, or the management of, patients with low back pain syndromes. The database offers comprehensive indices of spinal RoMs, and may also be of interest to clinicians utilizing other forms of spinal measurement equipment. Additionally, the database may be of interest to clinicians and researchers working in occupational health, primary, secondary or intermediate care settings. In due course the database may be used in the monitoring of rehabilitation programmes, the evaluation of treatment regimes and as an outcome measure for interventions.

Acknowledgement The authors gratefully acknowledge the support of South Thames Regional Health Authority for this work.

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