Association of maximum back and leg pain severity with objective functional impairment as assessed by five-repetition sit-to-stand testing: analysis of two prospective studies


The five-repetition sit-to-stand (5R-STS) test was designed to capture objective functional impairment (OFI), and provides a new adjunctive dimension in patient assessment. Its interpretability and confounders remain poorly understood. We quantify the association among maximum patient-reported back (MBP) or leg pain (MLP) and OFI as measured by the 5R-STS using data from two prospective studies. Patients performed the 5R-STS test and completed visual analogue scales (VAS) for back and leg pain severity. Maximum pain severity was defined as VAS scores of 9 or 10. The association of MBP and MLP with 5R-STS test times as well as with the presence of OFI (> 10.5 s) and severe OFI (> 22.0 s) as determined by the 5R-STS baseline severity stratification was quantified by use of crude and adjusted regression models. A total of 258 patients were included. MBP and MLP were reported by 27 (10.5%) and 76 (29.5%) patients, respectively. Rates of OFI differed among patients with (92.6%) and without (55.0%) MBP (p < 0.001), while presence of MLP did not influence OFI (61.8% vs. 57.7%, p = 0.632). Similarly, severe OFI was more common among patients with MBP (33.3% vs. 9.1%, p < 0.001), but not among patients with MLP (17.1% vs. 9.3%, p = 0.119). In the adjusted logistic analysis, the influence of MBP on OFI persisted (odds ratio [OR] 10.08, confidence interval [CI] 2.73–65.74, p = 0.003), while MLP demonstrated no association (OR 0.91, CI 0.49–1.72, p = 0.780). These associations were consistent with findings pertaining to raw 5R-STS test times and in discectomy patients alone. There is a strong association of maximum back pain severity on VAS with the degree of OFI determined by 5R-STS testing. Radiculopathy with maximally strong back pain, however, does not seem to relevantly influence 5R-STS performance.

Trial registration NCT03321357 & NCT03303300

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  1. 1.

    Stienen MN, Ho AL, Staartjes VE, Maldaner N, Veeravagu A, Desai A, Gautschi OP, Bellut D, Regli L, Ratliff JK, Park J (2019) Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature. Spine J 19:1276–1293.

    Article  PubMed  Google Scholar 

  2. 2.

    Jakobsson M, Gutke A, Mokkink LB, Smeets R, Lundberg M (2018) Level of evidence for reliability, validity, and responsiveness of physical capacity tasks designed to assess functioning in patients with low Back pain: a systematic review using the COSMIN standards. Phys Ther 99:457–477.

    Article  PubMed Central  Google Scholar 

  3. 3.

    Deyo RAM, Battie M, Beurskens AJHM et al (1998) Outcome measures for low back pain research: a proposal for standardized use. [miscellaneous article]. Spine 23(18):2003–2013

    CAS  Article  Google Scholar 

  4. 4.

    Staartjes VE, Schröder ML (2018) The five-repetition sit-to-stand test: evaluation of a simple and objective tool for the assessment of degenerative pathologies of the lumbar spine. J Neurosurg Spine 29(4):380–387.

    Article  PubMed  Google Scholar 

  5. 5.

    Gautschi OP, Smoll NR, Corniola MV, Joswig H, Chau I, Hildebrandt G, Schaller K, Stienen MN (2016) Validity and reliability of a measurement of objective functional impairment in lumbar degenerative disc disease: the timed up and go (TUG) test. Neurosurgery 79(2):270–278.

    Article  PubMed  Google Scholar 

  6. 6.

    Staartjes VE, Beusekamp F, Schröder ML (2019) Can objective functional impairment in lumbar degenerative disease be reliably assessed at home using the five-repetition sit-to-stand test? A prospective study. Eur Spine J 28:665–673.

    Article  PubMed  Google Scholar 

  7. 7.

    Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO, Taylor DW, Berman LB (1985) The 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J 132(8):919–923

    CAS  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, Bouter LM, de Vet HCW (2010) The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. J Clin Epidemiol 63(7):737–745.

    Article  PubMed  Google Scholar 

  9. 9.

    Von Elm E, Altman DG, Egger M et al (2007) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 335(7624):806–808.

    Article  Google Scholar 

  10. 10.

    Jones SE, Kon SSC, Canavan JL, Patel MS, Clark AL, Nolan CM, Polkey MI, Man WDC (2013) The five-repetition sit-to-stand test as a functional outcome measure in COPD. Thorax. 68(11):1015–1020.

    Article  PubMed  Google Scholar 

  11. 11.

    Streitberg B, Röhmel J (1986) Exact distributions for permutation and rank tests: an introduction to some recently published algorithms. Stat Softw Newsl 12(1):10–17

    Google Scholar 

  12. 12.

    Chiarotto A, Boers M, Deyo RA, Buchbinder R, Corbin TP, Costa LOP, Foster NE, Grotle M, Koes BW, Kovacs FM, Lin CWC, Maher CG, Pearson AM, Peul WC, Schoene ML, Turk DC, van Tulder MW, Terwee CB, Ostelo RW (2018) Core outcome measurement instruments for clinical trials in nonspecific low back pain. Pain 159(3):481–495.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Kane RL, Bershadsky B, Rockwood T, Saleh K, Islam NC (2005) Visual analog scale pain reporting was standardized. J Clin Epidemiol 58(6):618–623.

    Article  PubMed  Google Scholar 

  14. 14.

    Rucker KS, Metzler HM, Kregel J (1996) Standardization of chronic pain assessment: a multiperspective approach. Clin J Pain 12(2):94–110

    CAS  Article  Google Scholar 

  15. 15.

    Porchet F, Lattig F, Grob D, Kleinstueck FS, Jeszenszky D, Paus C, O'Riordan D, Mannion AF (2010) Comparison of patient and surgeon ratings of outcome 12 months after spine surgery: presented at the 2009 Joint Spine Section Meeting. J Neurosurg Spine 12(5):447–455.

    Article  PubMed  Google Scholar 

  16. 16.

    Gvozdyev BV, Carreon LY, Graves CM, Riley SA, McGraw KE, Head RJ, Dimar JR, Glassman SD (2017) Patient-reported outcome scores underestimate the impact of major complications in patients undergoing spine surgery for degenerative conditions. J Neurosurg Spine 27(4):397–402.

    Article  PubMed  Google Scholar 

  17. 17.

    Joswig H, Stienen MN, Smoll NR, Corniola MV, Chau I, Schaller K, Hildebrandt G, Gautschi OP (2017) Patients’ preference of the timed up and go test or patient-reported outcome measures before and after surgery for lumbar degenerative disk disease. World Neurosurg 99:26–30.

    Article  PubMed  Google Scholar 

  18. 18.

    Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M, Buchbinder R, Hartvigsen J, Cherkin D, Foster NE, Maher CG, Underwood M, van Tulder M, Anema JR, Chou R, Cohen SP, Menezes Costa L, Croft P, Ferreira M, Ferreira PH, Fritz JM, Genevay S, Gross DP, Hancock MJ, Hoy D, Karppinen J, Koes BW, Kongsted A, Louw Q, Öberg B, Peul WC, Pransky G, Schoene M, Sieper J, Smeets RJ, Turner JA, Woolf A (2018) What low back pain is and why we need to pay attention. Lancet 391(10137):2356–2367.

    Article  PubMed  Google Scholar 

  19. 19.

    Wertli MM, Held U, Lis A, Campello M, Weiser S (2018) Both positive and negative beliefs are important in patients with spine pain: findings from the Occupational and Industrial Orthopaedic Center registry. Spine J 18(8):1463–1474.

    Article  PubMed  Google Scholar 

  20. 20.

    Burgstaller JM, Wertli MM, Steurer J, Kessels AGH, Held U, Gramke HF (2017) The influence of pre- and postoperative fear avoidance beliefs on postoperative pain and disability in patients with lumbar spinal stenosis: analysis of the Lumbar Spinal Outcome Study (LSOS) data. Spine 42(7):E425–E432.

    Article  PubMed  Google Scholar 

  21. 21.

    Pinheiro MB, Ferreira ML, Refshauge K, Ordoñana JR, Machado GC, Prado LR, Maher CG, Ferreira PH (2015) Symptoms of depression and risk of new episodes of low back pain: a systematic review and meta-analysis. Arthritis Care Res (Hoboken) 67(11):1591–1603.

    Article  Google Scholar 

  22. 22.

    Stienen MN, Smoll NR, Joswig H, Snagowski J, Corniola MV, Schaller K, Hildebrandt G, Gautschi OP (2017) Influence of the mental health status on a new measure of objective functional impairment in lumbar degenerative disc disease. Spine J 17(6):807–813.

    Article  PubMed  Google Scholar 

  23. 23.

    Shum GLK, Crosbie J, Lee RYW (2007) Three-dimensional kinetics of the lumbar spine and hips in low back pain patients during sit-to-stand and stand-to-sit. Spine 32(7):E211–E219.

    Article  PubMed  Google Scholar 

  24. 24.

    Shum GLK, Crosbie J, Lee RYW (2005) Effect of low back pain on the kinematics and joint coordination of the lumbar spine and hip during sit-to-stand and stand-to-sit. Spine 30(17):1998–2004

    Article  Google Scholar 

  25. 25.

    Vergroesen P-PA, Kingma I, Emanuel KS, Hoogendoorn RJW, Welting TJ, van Royen BJ, van Dieën JH, Smit TH (2015) Mechanics and biology in intervertebral disc degeneration: a vicious circle. Osteoarthr Cartil 23(7):1057–1070.

    Article  PubMed  Google Scholar 

  26. 26.

    Aono H, Iwasaki M, Ohwada T, Okuda S, Hosono N, Fuji T, Yoshikawa H (2007) Surgical outcome of drop foot caused by degenerative lumbar diseases. Spine 32(8):E262–E266.

    Article  PubMed  Google Scholar 

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The authors are grateful to all participating patients, and to Marlies P. de Wispelaere, MSc for her efforts in clinical informatics.

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Correspondence to Victor E. Staartjes.

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Ethical approval

The prospective studies ( Identifiers: NCT03321357 & NCT03303300) were approved by the local institutional review board (Medical Research Ethics Committees United, Registration Number: W17.107 and W17.134), and were conducted according to the Declaration of Helsinki.

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Supplementary Methods 1

1 R Code for the statistical analysis figure rendering. The code was executed in R Version 3.5.2 (The R Foundation for Statistical Computing, Vienna, Austria) on a machine running Windows 10 (Microsoft Corp., Redmond, WA, USA). The raw data will be made available by the authors on request. (R 10 kb)


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Staartjes, V.E., Klukowska, A.M. & Schröder, M.L. Association of maximum back and leg pain severity with objective functional impairment as assessed by five-repetition sit-to-stand testing: analysis of two prospective studies. Neurosurg Rev 43, 1331–1338 (2020).

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  • Objective functional testing
  • Functional impairment
  • Degenerative disc disease
  • Lumbar spinal stenosis
  • Lumbar disc herniation
  • Pain