Evolving evidence has shown increased clinical outcomes, when low back pain (LBP) patients are classified and receive matched physical treatment. The present study aimed to examine the inter-examiner reliability of a proposed new decision-making classification system for non-specific LBP patients, using a mixed simultaneous and independent examiner design. With minimal familiarization, two pairs of experienced physiotherapists trained in Orthopedic Manual Therapy (OMT) at two different out-patient clinics in primary care, examined and classified 64 consenting consecutive patients. Further, inter-examiner reliability on five examination items was examined. The agreement between examiners was expressed by percentage of agreement (%) and by the un-weighted (κ) or weighted (κ(w)) kappa coefficient. The overall % agreement, categorizing patients into one of four classifications was 80% and κ = 0.72. For each classification, pain modulation, stabilization exercise, mobilization and training, agreement was 90%, 83%, 58% and 89% (κ = 0.77, 0.67, 0.11 and 0.75), respectively. Agreement on five individual examination items was; irritability 82% (κ(w) = 0.41), specific movement pattern 68% (κ = 0.38), specific segmental signs 67% (κ = 0.28), uni- or bilateral signs 62% (κ = 0.42), and neurological signs and symptoms 92% (κ = 0.84). This study demonstrated that this new classification system had substantial inter-examiner reliability when used by clinically experienced OMT-trained physiotherapists. Agreement within classification was substantial, except for mobilization which was poor. Inter-examiner reliability for the individual examination items varied from fair to almost perfect. Further studies are needed to investigate utility and validity of this new classification system.

Method. aEuro integral A nominated sample of 18 obese adolescents (12 girls, 14--16 years, body mass index (BMI) 25--47.4 kg center dot center dot m<SU--2</SU), recruited from a paediatric obesity clinic, participated in semi-structured interviews. These were analysed using a phenomenographic research approach. Purposeful sampling reflected variations in age, gender, degree of obesity, weight loss achievement, ethnicity, time of registration and socioeconomic status.Results. aEuro integral The adolescents expressed numerous physical, psychological and social disabilities as a consequence of their obesity. Qualitatively different ways of perceiving and responding to obesity treatment were identified and could be described in six categories of descriptions and a two-dimensional construct for interpreting these categories; (a) personal empowerment, (b) despair and disappointment, (c) safety and relief, (d) ambivalence and uncertainty, (e) acceptance and realisation and (f) shame and guilt. The distinguishing structures to be found between the categories were as follows: focus on the individual and focus on body weight.Conclusions. aEuro integral Treatment strategies must consider the large impact obesity has on adolescents'' lives. It is necessary to engage the obese adolescent personally in the treatment process and to focus on the adolescents'' personal needs, goals and motive for weight reduction.

BACKGROUND AND PURPOSE The six-minute walk test (6MWT) is increasingly used in clinical practice. The aims of this study were to determine the reproducibility of the 6MWT in obese children and adolescents, to describe walking capacity in this population and compare the results with values from normal-weight children (known group validity), and, finally, to describe the correlation between distance walked and estimated maximum oxygen uptake (VO(2)max). METHODS Reproducibility was determined by a test-retest design and known group validity by a comparative design. The 6MWT was first test-retested in 49 obese children (30 boys, 19 girls, 8-16 years, body mass index [BMI] 24.9-52.1 kg?m(-2)). Then, for validation, 250 obese children (126 boys, 124 girls, 8-16 years, BMI 23.2-57 kg/m(2)) and 97 normal-weight children (48 boys, 49 girls, 8-16 years, BMI 13.3-23.2 kg.m(-2)) performed the 6MWT. The obese children also performed a sub-maximal bicycle ergometry test. RESULTS In the test-retest, the obese children walked 571 m the first test and 57 m the second (p = 0.578). The measurement error (S(w)) was 24 m, coefficient of variation (CV): 4.3% and the intraclass correlation (ICC1:1): 0.84. Repeatability was 68 m, and limits of agreement were +71 and -65 m. In comparison mean (standard deviation), six-minute walk distance (6MWD) in the obese children was 571 m (65.5), and in the normal-weight children, 663 m (61.1) (p < 0.001). The correlation between 6MWD and estimated VO(2)max (r = 0.34) was low. CONCLUSIONS The 6MWT showed good reproducibility and known group validity, and can be recommended for use in clinical practice in the studied population. To evaluate individual outcomes after intervention, the 6MWD needs to change by >68 m to be statistically significant. The 6MWD performed by obese children averaged 86% of the distance normal-weight children walked. In obese children, the correlation between 6MWD and estimated VO(2)max was low, hence the 6MWT cannot substitute a bicycle ergometry test.

AIM:The aim of this study was to identify relationships between insulin sensitivity (SI), cardiorespiratory fitness and body composition in severely obese Swedish children and adolescents.METHODS:Two hundred and twenty-eight obese children (119 girls, 8-16 years, body mass index (BMI) 23.2-57.0 kg/m(2)) performed a frequently sampled intravenous glucose tolerance test (FSIVGTT), a submaximal bicycle ergometry test and a dual-energy X-ray absorptiometry (DEXA).RESULTS:Mean SI (SD) was 0.38 (0.32) (x10(-5)/min/pM). SI correlated positively with relative body mass (BM) VO(2)max (r = 0.42) (p < 0.001), relative fat-free mass (FFM) VO(2)max (r = 0.36) (p < 0.001) and negatively with body mass index standard deviation score (BMI SDS) (r =-0.22) (p = 0.001). SI did not correlate with percent body fat (r =-0.01) and absolute VO(2)max (r = 0.01). In multiple regression analyses with SI as dependent variable, VO(2)max and body composition, together with gender, age and Tanner stage, explained 20-26% of the variance.CONCLUSION:Relative (BM) VO(2)max and relative (FFM) VO(2)max were stronger predictors of SI than percent body fat in severely obese children and adolescents. The study confirms that cardiorespiratory fitness is of importance for the metabolic syndrome in the studied population. Efforts to improve SI should include physical activity targeting cardiorespiratory fitness also in severely obese children and adolescents.

BACKGROUND AND PURPOSETo assess the reproducibility and validity of the six-minute walk test (6MWT) in men and women with obesity in order to facilitate evaluation of treatment outcome.METHODA test--retest design was used to test reproducibility and a comparative design to test known group validity. Forty-three obese outpatients (16 male), mean age 47 (21-62) years, mean body mass index (BMI) 40 (3-62)kg-m(-2) performed the 6MWT twice within one week. Intraclass correlation (ICC1.1) and measurement error (S(w)) were calculated from the mean square values derived from a one-way repeated-measures ANOVA (fixed effect model). The reproducibility was also analysed by means of coefficient of variation (CV) and the Bland Altman method including 95% limits of agreement. The variance of the distance walked was analysed by means of regressions. The known group validity of the 6MWT (distance walked and the work of walking) in obese participants was shown by comparisons with 41 lean participants (18 male), mean age 47 (24-65) years, mean BMI 22.7 kg-m(-2) (19-25).RESULTSThe obese group walked 534 m (confidence interval [CI] 508-560 the first and 552 m (CI 523-580) the second walk (p < 0.001). S(w) was 25 m, CV 4.7%, ICC1.1 was 0.96. The limits of agreement were -46 m+80 m. The validity tests showed that they walked 162 m shorter (p < 0.001) and performed much heavier work (p < 0.001) than the lean group. In the obese group, BMI alone explained 38% of the variance of the distance walked.CONCLUSIONSThe 6MWT showed good reproducibility and known group validity and can be recommended for evaluating walking ability in subjects with obesity. For individual evaluation, however, an improved walking distance of at least 80 m was required to make the difference clinically significant. Despite shorter walking distance the obese participants performed heavier work than the lean.

Aim: To describe age and gender differences in estimated maximum oxygen uptake (VO(2)max) and participation in organized physical activity in Swedish obese children and adolescents, and compare the results with an age-matched reference group representative of the general population.Methods: Two hundred and nineteen obese children (102 boys, 117 girls, aged 8-16 years, Body Mass Index (BMI) 24.3-57.0 kg.m(-2)) performed a submaximal bicycle ergometry test and an interview concerning participation in organized physical activity.Results: The obese children had lower relative VO(2)max (p < 0.001) than the reference group. In contrast to the reference group no age or gender differences were detected in the obese children aged 11-13 years and 14-16 years. With increased age (after 11 years) the obese children participated less in organized physical activity than the reference group (p < 0.001). In obese adolescents, participation in organized physical activity in leisure time explained 7% and BMI 45% of the variance in relative VO(2)max.Conclusion: The obese children had lower relative VO(2)max, and participated less in organized physical activity than the reference group. The variance in relative VO(2)max was primarily explained by BMI. Obese adolescents, especially boys, were found to be at risk of physical inactivity.

OBJECTIVE The objective was to investigate effects of dieted weight reduction on walking ability in obese women. METHODS Fifty-seven obese women 44.1 +/- 10.7 years, body mass index 37.1 +/- 3.4 kg x m(-2) performed an indoor walking test. Speed, oxygen consumption and heart rate were measured, perceived exertion and pain graded and oxygen cost calculated. Maximum oxygen uptake (VO2max/kg) was predicted from a submaximum bicycle ergometry test. All tests were measured at baseline, after 12 weeks' weight reduction and after 52 weeks' maintenance. RESULTS Despite a partial weight relapse, improvements were seen in body mass index, self-selected walking speed, VO2max/kg, heart rate, perceived exertion and relative oxygen cost of walking (% VO2max). CONCLUSION A modest weight reduction of 10% in moderately-to-severely obese women significantly improved their walking ability, perceived exertion and %VO2max. When dealing with obese women, attention should be drawn to these positive effects, instead of focusing only on the magnitude of the weight loss.

OBJECTIVES: To evaluate the effects of weight reduction by dieting on musculoskeletal pain, perceived disability and observed functional limitations in everyday life. SUBJECTS: Female outpatients in weight-loss programmes at the Karolinska Hospital, who met the criteria for participating in this study: age 20–65 y and body mass index (BMI) ⩾30 kg/m 2 . In all, 57 entered the programme studied and 43 completed it. INTERVENTIONS: Diet programmes for 8–12 weeks and thereafter 6688 kJ/day for >52 weeks. MAIN OUTCOME MEASURES: Questionnaires on musculoskeletal symptoms and obesity-specific questions on basic activities of daily living (ADL), mobility, housework, occupational disability and activities outside home. Test protocol developed for observation of functional limitations in obese women. Assessments at baseline, after 12 and after 64 weeks of dieting. RESULTS: In all, 75% completed the study. Weight loss was 14% (14.7±6.1 kg) at 12 weeks and, due to a weight relapse, 10% (10.1±8.1 kg) at 64 weeks. At the end of the study period, the proportion of current pain from lower backs and feet had normalised. Important perceived improvements were ability to rise from having fallen over, to walk up stairs and to lift heavy things. Most functional limitations improved, such as climbing onto high stools, walking up stairs with grocery bags, doing pedicure, rising from floor or low furniture. The questionnaire results partly followed the weight development, but the observed improvements were long-lasting. CONCLUSIONS: Weight reduction had positive short-term effects on musculoskeletal pain, perceived disability and observed functional limitations. A partial weight relapse had some impact on perceived pain and disability, but not on observed limitations. The maintained improvements may be due to weight loss, but also less pain and increased physical activity.

OBJECTIVE: To describe functional limitations in obese women. DESIGN: Comparisons of functional limitations in obese women and in a normal-weight reference group regarding mobility, balance and housework transport. SETTING: A large room with a corridor and staircase nearby. SUBJECTS: Fifty-seven consecutively selected obese female outpatients, mean age 44 y, body mass index (BMI) 37 kg·m−2, and 22 voluntary references, mean age 49 y, BMI 22 kg·m−2. MAIN OUTCOME MEASURES: Pain questionnaire (for background data); a new valid and reliable test protocol measuring activities of daily life (ADL), pain and exertion, heart rate, balance and speed. RESULTS: The patients had problems in performing 13 of 16 actions compared with the references (P-values between 0.05 and 0.001). They moved more slowly and had difficulties and /or pain and exertion in flexibility tasks, balancing, activities at floor level (bending and kneeling), climbing stairs and carrying groceries. BMI (P=0.002), age (P=0.02) and current pain (P=0.02) from the lower body predicted functional limitation. CONCLUSIONS: The functional test reflected functional limitations in obese women, revealing difficulties and perceived pain in ADL. The test protocol can be used to evaluate the effects of training or dieting. For clinical use we recommend considering BMI, age and current pain for use when individualizing advice on training.

OBJECTIVE: To describe perceived disability in obese women. DESIGN: Comparisons of perceived disability in obese women and in a normal-weight reference group regarding activities of daily life (ADL), mobility, housework and professional work as well as comparisons of perceived disability and observed functional limitations reported in a previous study. SUBJECTS: Fifty-seven consecutively selected obese female outpatients, mean age 44 y (body mass index (BMI) 37 kg/m2) and 22 voluntary referents, mean age 49 y (BMI 22 kg/m2). MAIN OUTCOME MEASURES: A pain questionnaire (for background data) and a disability questionnaire, which is new, detailed and specific with test–retest stability and content- and criterion-referenced validity. Comparisons of results from the questionnaire and a functional test regarding observations of similar functional limitations. RESULTS: The obese women perceived disability to a much higher extent (P<0.003) than did the normal-weight women. The main problems concerned occupational work in strenuous positions, strain and pain, sports, walking outdoors or on stairs, and moderate housework requiring squatting, stooping or lifting. Rising from sofas, pedicure and stress incontinence were problematic. The correlation between perceived disability and functional limitations was fairly good (rs=0.56) but ranged widely (rs=0.14–0.61). Within the group of obese women the disability neither correlated to BMI nor age, rather to lower-body pain. CONCLUSION: The disability questionnaire conveyed new and detailed information of disability problems in everyday life in obese women. It highlighted the difference between the disability these women may perceive and the functional limitations we can observe and measure. This result is of great clinical relevance in the care of obese women.

OBJECTIVES: As exhaustion and pain during walking seem to be common problems among obese women, we decided to analyse the relative oxygen cost (%V . O 2 max) in obese women during level walking. SUBJECTS: Fifty-seven obese female outpatients, 44.1±10.7 y, BMI 37.1±3.4 kg · m −2 . METHODS: Walking tests at a self-selected, comfortable speed were performed indoors. Speed was measured with a speedometer, oxygen consumption (V . O 2 ) with the argon-dilution method and oxygen cost was estimated. Heart rate was measured; perceived exertion and pain were assessed with Borg's Category Ratio scale, CR10. Maximum oxygen uptake (V . O 2 max/kg) was predicted from a submaximum bicycle ergometry test. RESULTS: The women walked more slowly, 70.9±5.6 m · min −1 ( P <0.0001), and had higher V . O 2 , 1.2±0.2 l · min −1 ( P <0.001), than normals. A majority experienced exertion and some experienced pain. Their V . O 2 max/kg, 21.2±5.0 ml · kg −1 · min −1 , was less than for normals ( P <0.0001). The mean % V . O 2 max during walking was 56%, which was higher than in normal subjects 36% ( P <0.0001). Significant correlations between %V . O 2 max and V . O 2 max/kg ( P <0.0001), heart rate during walking ( P =0.0009) and age ( P =0.0081), respectively, were found. CONCLUSION: Very low V . O 2 max/kg in obese women, rather than severe obesity per se, seems the most important factor to cause high %V . O 2 max during walking. This might explain why many obese women perceive the exertion to be excessive and cannot follow the advice of their clinicians to exercise through long and brisk walks.