Published Online January 10, 2010

Rating scales for low back pain

Umile Giuseppe Longo†, Mattia Loppini†, Luca Denaro‡, Nicola Maffulli*§, and
Vincenzo Denaro†
†
Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Via Alvaro del
Portillo, 200 00128 Trigoria, Rome, Italy; ‡Department of Neurosurgery, Catholic University School
of Medicine, Rome, Italy, and §Centre for Sports and Exercise Medicine, Barts and The London
School of Medicine and Dentistry Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK

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Introduction: During the past decades several rating scales have been developed
to assess the functional status of patients with low back pain.

Methods: We performed a search using the keywords ‘spine’ in combination

with ‘scoring system’, ‘scale’, ‘scores’, ‘outcome assessment’, ‘low back pain’ and
‘clinical evaluation’.

Results: Twenty-eight scoring systems are currently available for the evaluation
of low back pain. Each of them evaluates low back pain using specific variables.
All these scoring systems are presented.

Discussion: Although many scoring systems have been used to evaluate the back
function, we are still far from a single outcome evaluation system that is
reliable, valid and sensitive to clinically relevant changes, taken into account
both patients’ and physicians’ perspective and is short and practical to use.
Conclusion: Further studies are required to evaluate the reliability, validity and
sensitivity of the low back pain scoring systems used in the common clinical
practice.

Keywords: low back pain/rating scores/assessment

Introduction
Low back pain (LBP) is a common symptom, affecting more than 80%
Accepted: November 24,
2009
of the general population in the industrialized world.1 It is the most fre-
*Correspondence to: quent cause of disability in people under 45 years of age.2 It represents
Nicola Maffulli, Centre a relevant social and economic problem in developed countries, being
for Sports and Exercise
Medicine, Barts and The
the first reason for orthopaedic consultations.3
London School of The development of instruments to measure the outcome of patient
Medicine and Dentistry with LBP has been the subject of increasing interest. During the past
Mile End Hospital, 275
decades, several score systems have been developed to assess the func-
Bancroft Road, London
E1 4DG, UK. E-mail: tional status of patients with LBP.4 – 7 Many generic and disease-specific
[email protected] measures are available for orthopaedic clinical and research practice.8

British Medical Bulletin 2010; 94: 81–144 & The Author 2010. Published by Oxford University Press. All rights reserved.
DOI:10.1093/bmb/ldp052 For permissions, please e-mail: [email protected]
U. G. Longo et al.

Self-report questionnaires of pain and functional status allow one to

evaluate patients before and after a given treatment, and they can be
used to detect short-term or long-term clinical changes of symptoms
and disabilities.9
The aim of this review is to report all the available score systems for
the evaluation of LBP and their use in the current orthopaedic practice.

Materials and methods

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We performed a search using the keywords ‘spine’ in combination with
‘scoring system’, ‘scale’, ‘scores’, ‘outcome assessment’, ‘low back pain’
and ‘clinical evaluation’, with no limit regarding the year of publi-
cation. The following databases were accessed on 20 February 2009:
PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez/); Ovid (http://www.
ovid.com); Cochrane Reviews (http://www.cochrane.org/reviews/).
Given the linguistic capabilities of the research team, we considered
publications in English, Spanish and Italian. Two authors (U.G.L. and
M.L.) independently read the abstract of each publication identified (if
an abstract was available). If no abstract was available, the publication
was excluded. In addition, the references section of all the publications
identified were studied to ascertain whether other relevant material
could be found. The personal collection of scientific material of the
senior authors (N.M. and V.D.) was consulted for the same purpose. If
deemed relevant, all relevant publications were retrieved. The most rel-
evant material was drawn between the years 1990 and 2007. A large
number of publications focusing on surgical techniques of the lumbar
spine, not including outcome scores, were not included. The publi-
cations thus selected were examined by all authors. After this further
selection, 94 publications relevant to the topic at hand were included
(Fig. 1).

Analytical description of LBP scoring systems

Roland–Morris disability questionnaire
The Roland –Morris disability questionnaire10 is constructed by choos-
ing statements from the sickness impact profile (SIP), which is a
136-item health status measure covering a range of aspects of daily
living about physical and mental function.11,12 The scale consists of 24
yes/no items related specifically to physical functions to specifically
assess the disability from LBP (Table 1). The physical functions con-
sidered include walking, bending over, sitting, lying down, dressing,

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 Rating scales for low back pain

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Fig. 1 Details of the investigations excluded and included in the study.

sleeping, self-care and daily activities. Patients are asked whether the
statements apply to them that day (i.e. the last 24 h). In the scale, one
point is given for each item. The RDQ score can be obtained by adding
up the number of items checked. The final score ranges from 0 (no dis-
ability) to 24 (severe disability). The questionnaire is self-administered
by the patient, it can be completed in a maximum of 5 min, and an
un-weighted score can be calculated in less than 1 min.
The original RDQ also contains a six-point pain rating scale in the
form of a pain thermometer.10 However, the authors prefer to use the
pain scale of SF-36 instead of scale described in the original article.13

Variants of Roland –Morris disability questionnaire

The RDQ-237 (Table 2) is a modified 23-item version of Roland–
Morris disability scale. In this instrument five original items are deleted
and replaced with other four items which the authors selected from the
SIP. The five deleted items are ‘Because of my back, I lie down to rest
more often’, ‘Because of my back, I try to get other people to do things
for me’, ‘My appetite is not very good because of my back’, ‘Because
of my back pain, I get dressed with help from someone else’ and ‘I sit
down for most of the day because of my back’. Each item is scored
with 0 or 1 point and the final score is obtained by adding up item
scores, ranging from 0 to 23.
The RDQ-1814 (Table 3) is a shorter modified version of Roland–
Morris disability scale, in which items 2, 15, 17, 19, 20 and 24 are

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U. G. Longo et al.

Table 1 The Roland–Morris disability questionnaire.

Roland –Morris disability questionnaire

When your back hurts, you may find it difficult to do some things you normally do. This list contains
sentences that people have used to describe themselves when they have back pain. When you read
them, you may find that some stand out because they describe you today. As you read the list, think of
yourself today. When you read a sentence that describes you today, put a tick against it. If the sentence
does not describe you, then leave the space blank and go on to the next one. Remember, only tick the
sentence if you are sure it describes you today.
Yes No
1. I stay at home most of the time because of my back.

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2. I change position frequently to try and get my back comfortable.
3. I walk more slowly than usual because of my back.
4. Because of my back I am not doing any of the jobs that I usually do around the
house.
5. Because of my back, I use a handrail to get upstairs.
6. Because of my back, I lie down to rest more often.
7. Because of my back, I have to hold on to something to get out of an easy chair.
8. Because of my back, I try to get other people to do things for me.
9. I get dressed more slowly than usual because of my back.
10. I only stand for short periods of time because of my back.
11. Because of my back, I try not to bend or kneel down.
12. I find it difficult to get out of a chair because of my back.
13. My back is painful almost all the time.
14. I find it difficult to turn over in bed because of my back.
15. My appetite is not very good because of my back pain.
16. I have trouble putting on my socks (or stockings) because of the pain in my back.
17. I only walk short distances because of my back.
18. I sleep less well on my back.
19. Because of my back pain, I get dressed with help from someone else.
20. I sit down for most of the day because of my back.
21. I avoid heavy jobs around the house because of my back.
22. Because of my back pain, I am more irritable and bad tempered with people than
usual.
23. Because of my back, I go upstairs more slowly than usual.
24. I stay in bed most of the time because of my back.

deleted. The other questions are the same of original questions. Item
reduction is obtained by measuring the frequency of item endorsement,
calculating the inter-item correlations and determining the internal con-
sistency of the questionnaire. The original version scoring scheme is
maintained.
The RDQ-1615,16 (Table 4) is a modified 16-item Roland– Morris
disability scale designed to measure the limitations in daily living in the
past 2 weeks due to back pain. Each item can be answered as follows:
‘yes’, ‘no’, ‘don’t know’ or ‘not applicable’. For scoring, the number of
affirmative answers is divided by the number of questions answered.
The final score is expressed by the percentage of items checked with
higher scores representing greater limitations.
The RDQ-two time version (RDQ-two)17 (Table 5) is a modified
version of Roland– Morris disability scale produced to assess the LBP

84 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 2 The Roland–Morris disability questionnaire 23-item version.

Roland –Morris disability questionnaire 23-item version

When your back or leg hurts, you may find it difficult to do some things you normally do. This list
contains sentences that people have used to describe themselves when they have back pain or sciatica.
When you read them, you may find that some stand out because they describe you today. As you read
the list, think of yourself today. When you read a sentence that describes you today, put a check in the
‘yes’ column. If the sentence does not describe you today, you check the ‘no’ column.
Yes No
1. I stay at home most of the time because of my back problem or leg pain (sciatica).
2. I change position frequently to try to get my back or leg comfortable.

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3. I walk more slowly than usual because of my back problem or leg pain (sciatica).
4. Because of my back problem, I am not doing any of the jobs that I usually do around the
house.
5. Because of my back problem, I use a handrail to get upstairs.
6. Because of my back problem, I have to hold on to something to get out of an easy chair.
7. I get dressed more slowly than usual because of my back problem or leg pain (sciatica).
8. I only stand for short periods of time because of my back problem or leg pain (sciatica).
9. Because of my back problem, I try not to bend or kneel down.
10. I find it difficult to get out of a chair because of my back problem or leg pain (sciatica).
11. My back or leg is painful almost all the time.
12. I find it difficult to turn over in bed because of my back problem or leg pain (sciatica).
13. I have trouble putting on my socks (or stockings) because of the pain in my back or leg.
14. I only walk short distances because of my back problem or leg pain (sciatica).
15. I sleep less well because of my back problem.
16. I avoid heavy jobs around the house because of my back problem.
17. Because of my back problem, I am more irritable and bad tempered with people than
usual.
18. Because of my back problem, I go upstairs more slowly than usual.
19. I stay in bed most of the time because of my back or leg pain (sciatica).
20. Because of my back problem, my sexual activity is decreased.
21. I keep rubbing or holding areas of my body that hurt or are uncomfortable.
22. Because of my back problem, I am doing less of the daily work around the house than I
would usually do.
23. I often express concern to other people over what might be happening to my health.

over the preceding 4 weeks. Patients have to mark how many days in
the previous 4 weeks they had been affected by LBP. Each question has
different possible answers and is scored with a 4-week time scale,
ranging from 0 to 1 and according to how many days patient is
affected: ‘not at all’ or ‘not applicable’ are scored with 0 points; ‘1– 7
days’ is scored with 0.2 points; ‘8–14 days’ is scored with 0.4 points;
‘15– 21 days’ is scored with 0.6 points; ‘21–27 days’ is scored with 0.8
points and ‘every day’ is scored with 1 point. The number of questions
and the domains investigated are the same of the original version. The
final score is calculated by dividing the patient total score by the
maximum possible score (24) to express the result as a percentage.
The RDQ-7p18 (Table 6) is a modified version of Roland– Morris
disability scale in which a seven point Likert scale is used. This version
consists of original wording and original scheme. For scoring, yes/no
responses are replaced with a seven-point scale, ranging from 0

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U. G. Longo et al.

Table 3 The Roland–Morris disability questionnaire 18-item version.

Roland –Morris disability questionnaire 18-item version

When your back hurts, you may find it difficult to do some things you normally do. This list contains
sentences that people have used to describe themselves when they have back pain. When you read
them, you may find that some stand out because they describe you today. As you read the list, think of
yourself today. When you read a sentence that describes you today, put a tick against it. If the sentence
does not describe you, then leave the space blank and go on to the next one. Remember, only tick the
sentence if you are sure it describes you today.
Yes No
1. I stay at home most of the time because of my back.

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2. I walk more slowly than usual because of my back.
3. Because of my back I am not doing any of the jobs that I usually do around the house.
4. Because of my back, I use a handrail to get upstairs.
5. Because of my back, I lie down to rest more often.
6. Because of my back, I have to hold on to something to get out of an easy chair.
7. Because of my back, I try to get other people to do things for me.
8. I get dressed more slowly than usual because of my back.
9. I only stand for short periods of time because of my back.
10. Because of my back, I try not to bend or kneel down.
11. I find it difficult to get out of a chair because of my back.
12. My back is painful almost all the time.
13. I find it difficult to turn over in bed because of my back.
14. I have trouble putting on my socks (or stockings) because of the pain in my back.
15. I sleep less well on my back.
16. I avoid heavy jobs around the house because of my back.
17. Because of my back pain, I am more irritable and bad tempered with people than usual.
18. Because of my back, I go upstairs more slowly than usual.

Table 4 The modified 16-item Roland–Morris scale.

Modified 16-Item Roland –Morris scale

In the past 2 weeks, because of past or present back pain have you . . .
Yes No DK NA
1. Stayed in bed more?
2. Done less of the jobs you usually do around the house?
3. Avoided heavy jobs around the house?
4. Laid down to rest more often?
5. Kept rubbing or holding areas of your body that hurt or are
uncomfortable?
6. Shown less affection?
7. Been more irritable and bad tempered with people than usual?
8. Done fewer social activities with groups of people?
9. Talked less with those around you?
10. Asked people to do things for you?
11. Not kept your attention on any activity for long?
12. Not finished things you start?
13. Had difficulty eating?
14. Accomplished less than usual at work? (if NA, skip to item 16)
15. Taken frequent rest when you work?
16. Gone out for entertainment less often?

DK: don’t know; NA: not applicable.

Note: When less than six answers are missing, the number of ‘yes’ answers is divided by the number of
answered items.

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 Rating scales for low back pain

Table 5 The Roland–Morris disability questionnaire two.

Roland –Morris disability questionnaire two

Not at 1–7 8 – 14 15 –21 22 –27 Every NA

all days days days days day

I have stayed at home because of my back.

When sitting for long periods I have needed to

change position frequently to try and get of
my back confortable.

I have had to walk more slowly than usual

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because of my back.

My back has prevented me doing any of my

usual jobs around the house.

Because of my back, I have needed to use the

handrail to go up stairs.

Because of my back, I have needed to lie down

to rest more than usual.

Because of my back, I have needed to hold on

to something to get out of an easy chair.

Because of my back, I had to try to get other

people to do things for me.

Because of my back, I have needed to get

dressed more slowly than usual.

Because of my back, I have only been able to

stand for short periods.

Because of my back, I have tried not to bend or

kneel down.

I have found it difficult to get out of a chair

because of my back.

My back has been painful.

I have found it difficult to turn over in bed

because of my back.

My appetite has not been very good because

of my back pain.

I have had trouble putting on my socks, tights

or stockings because of pain in my back.

I have only been able to walk short distances

because of my back pain.

I have slept less well because of my back.

Because of my back pain, I have needed help

to get dressed.

I have needed to sit down most of the day

because of my back.

Continued

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U. G. Longo et al.

Table 5 Continued

Roland –Morris disability questionnaire two

Not at 1– 7 8 – 14 15 –21 22 –27 Every NA

all days days days days day

I avoided heavy jobs around the house because

of my back.

Because of my back pain, I have been more

irritable and bad tempered with people than

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usual.

Because of my back, I have gone up stairs more

slowly than usual.

I have stayed in bed most of the day because of

my back.

NA, not applicable.

to 6. The scale is labelled as follows: 0 points means ‘disagree totally’,

3 points means ‘not sure’ and 6 means ‘agree totally’. The final ques-
tionnaire score is expressed as percentages of the total possible score
with higher scores representing greater disability.
The RDQ-12 (Table 7), also named the Maine-Seattle back question-
naire, is a 12-item version of Roland –Morris disability scale derived
from the RDQ-23.19 It is a short self-administered back-specific ques-
tionnaire. Like the original scale, the final score is obtained with an
unweighted sum of each item score. Thus, the RDQ-12 score can range
from 0 (no impairment) to 12 (severe impairment).

Oswestry disability index

The original Oswestry disability index (ODI) (version 1.0)20 (Table 8)
includes 10 sections of questions that evaluate the activities of daily
living, which can be drastically influenced by LBP. The sections have
been selected from experimental questionnaires that aimed to assess
several aspects of daily living. The ODI domains are the following: pain
intensity, personal care, lifting, walking, sitting, standing, sleeping, sex
life, social life and travelling. Each section contains six statements that
are scored from 0 (minimum degree of difficulty in that activity) to 5
(maximum degree of difficulty). If more than one statement is marked in
each section, the highest score should be taken. The total score is
obtained by summing up the scores of all sections, giving a maximum of
50 points. The final score is expressed as a percentage with the following
formula: (total score/(5  number of questions answered)  100%. For
example, if all 10 sections are completed the score is calculated as

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Table 6 The Roland– Morris disability questionnaire 7p.

Roland –Morris disability questionnaire 7p

When your back hurts, you may find it difficult to do some things you normally do. This list contains sentences that people have used to describe themselves when they
have back pain. When you read them, you may find that some stand out because they describe you today. As you read the list, think of yourself today. When you read a
sentence that describes you today, put a tick against it. If the sentence does not describe you, then leave the space blank and go on to the next one. Remember, only tick
the sentence if you are sure it describes you today.
0 1 2 3 4 5 6
1. I stay at home most of the time because of my back.
2. I change position frequently to try and get my back comfortable.
3. I walk more slowly than usual because of my back.
4. Because of my back I am not doing any of the jobs that I usually do around the house.
5. Because of my back, I use a handrail to get upstairs.
6. Because of my back, I lie down to rest more often.
7. Because of my back, I have to hold on to something to get out of an easy chair.
8. Because of my back, I try to get other people to do things for me.
9. I get dressed more slowly than usual because of my back.
10. I only stand for short periods of time because of my back.
11. Because of my back, I try not to bend or kneel down.
12. I find it difficult to get out of a chair because of my back.
13. My back is painful almost all the time.
14. I find it difficult to turn over in bed because of my back.
15. My appetite is not very good because of my back pain.
16. I have trouble putting on my socks (or stockings) because of the pain in my back.
17. I only walk short distances because of my back.
18. I sleep less well on my back.

Rating scales for low back pain

19. Because of my back pain, I get dressed with help from someone else.
20. I sit down for most of the day because of my back.
21. I avoid heavy jobs around the house because of my back.
22. Because of my back pain, I am more irritable and bad tempered with people than usual.
23. Because of my back, I go upstairs more slowly than usual.
24. I stay in bed most of the time because of my back.
89
U. G. Longo et al.

Table 7 The Roland–Morris disability questionnaire 12-item version.

Roland –Morris disability questionnaire 12-item version

When your back or leg hurts, you may find it difficult to do some things you normally do. This list
contains sentences that people have used to describe themselves when they have back pain or sciatica.
When you read them, you may find that some stand out because they describe you today. As you read
the list, think of yourself today. When you read a sentence that describes you today, put a check in the
‘yes’ column. If the sentence does not describe you today, you check the ‘no’ column.
Yes No
1. I change position frequently to try to get my back or leg comfortable.
2. Because of my back problem, I use a handrail to get upstairs.

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3. I get dressed more slowly than usual because of my back problem or leg pain
(sciatica).
4. I only stand for short periods of time because of my back problem or leg pain
(sciatica).
5. Because of my back problem, I try not to bend or kneel down.
6. I find it difficult to get out of a chair because of my back problem or leg pain
(sciatica).
7. My back or leg is painful almost all the time.
8. I sleep less well because of my back problem.
9. I stay in bed most of the time because of my back or leg pain (sciatica).
10. Because of my back problem, my sexual activity is decreased.
11. I keep rubbing or holding areas of my body that hurt or are uncomfortable.
12. Because of my back problem, I am doing less of the daily work around the house than
I would usually do.

Table 8 The Oswestry disability index (version 1.0).

Oswestry disability index (version 1.0)

The questionnaire has been designed to give the doctor information as to how your back pain has
affected your ability to manage in every day life. Please answer every section, and mark in each section
only the one box which applies to you. We realize you may consider that two of the statements in any
one section relate to you, but please just mark the box which most closely describes your problem.

Section 1: Pain intensity

1. I can tolerate the pain I have without having to use painkillers.
2. The pain is bad but I manage without taking painkillers.
3. Painkillers give complete relief from pain.
4. Painkillers give moderate relief from pain.
5. Painkillers give very little relief from pain.
6. Painkillers have no effect on the pain and I do not use them.

Section 2: Personal care (washing, dressing, etc.)

1. I can look after myself normally without causing extra pain.
2. I can look after myself normally but it causes extra pain.
3. It is painful to look after myself and I am slow and careful.
4. I need some help but I manage most of my personal care.
5. I need help every day in most aspects of self-care.
6. I do not get dressed, wash with difficulty and stay in bed.

Section 3: Lifting
1. I can lift heavy weights without extra pain.
2. I can lift heavy weights but it gives extra pain.
3. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are
conveniently positionated (e.g. on a table).

Continued

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 Rating scales for low back pain

Table 8 Continued

Oswestry disability index (version 1.0)

4. Pain prevents me from lifting heavy weights, but I can manage light-to-medium weights if they are
conveniently positionated.
5. I can lift only very light weights.
6. I cannot lift or carry anything at all.

Section 4: Walking
1. Pain does not prevent my walking any distance.
2. Pain prevents me walking more than 1 mile.

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3. Pain prevents me walking more than 1/2 mile.
4. Pain prevents me walking more than 1/4 mile.
5. I can only walk using a stick or crutches.
6. I am in bed most of the time and have to crawl to the toilet.

Section 5: Sitting
1. I can sit in any chair as long as I like.
2. I can sit in my favourite chair as long as I like.
3. Pain prevents me sitting more than 1 h.
4. Pain prevents me from sitting more than 1/2 an hour.
5. Pain prevents me from sitting more than 10 min.
6. Pain prevents me from sitting at all.

Section 6: Standing
1. I can stand as long as I want without extra pain.
2. I can stand as long as I want but it gives me extra pain.
3. Pain prevents me from standing for more than 1 h.
4. Pain prevents me from standing for more than 30 min.
5. Pain prevents me from standing for more than 10 min.
6. Pain prevents me from standing at all.

Section 7: Sleeping
1. Pain does not prevent me from sleeping well.
2. I can sleep well only by using tablets.
3. Even when I take tablets I have less than 6 h sleep.
4. Even when I take tablets I have less than 4 h sleep.
5. Even when I take tablets I have less than 2 h sleep.
6. Pain prevents me from sleeping at all.

Section 8: Sex life

1. My sex life is normal and causes no extra pain.
2. My sex life is normal but causes some extra pain.
3. My sex life is nearly normal but is very painful.
4. My sex life is severely restricted by pain.
5. My sex life is nearly absent because of pain.
6. Pain prevents any sex life at all.

Section 9: Social life

1. My social life is normal and gives me no extra pain.
2. My social life is normal but increases the degree of pain.
3. Pain has no significant effect on my social life apart from limiting my more energetic interests (e.g.
dancing, etc.).
4. Pain has restricted my social life and I do not go out as often.
5. Pain has restricted social life to my home.
6. I have no social life because of pain.

Continued

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Table 8 Continued

Oswestry disability index (version 1.0)

Section 10: Travelling

1. I can travel anywhere without extra pain.
2. I can travel anywhere but it gives me extra pain.
3. Pain is bad but I manage journeys over 2 h.
4. Pain restricts me to journeys of less than 1 h.
5. Pain restricts me to short necessary journeys under 30 min.
6. Pain prevents travel except to the doctor or hospital.

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follows: 16 (total scored)/50 (total possible score)  100 ¼ 32%. If one
section is missed (or not applicable) the score is calculated as follows:
16 (total scored)/45 (total possible score)  100 ¼ 35.5%.21
The authors suggest rounding the percentage to a whole number for
convenience. The higher the percentage, the greater the perceived level
of disability by the patient. The total score ranges from 0 to 100%,
with 0 representing no disability and 100 representing maximum dis-
ability. A total score between 0 and 20% means minimal disability;
between 20 and 40%, moderate disability; between 40 and 60%,
severe disability; between 60 and 80%, crippled; between 80 and
100%, bed bound or symptom magnifier.20
The questionnaire is self-administered by the patient, it is usually
completed in less than 5 min and scored in less than 1 min.

Versions of the ODI

Several versions of the ODI are available.21 The original version 1.020
was published without section 8 (sex life) or section 9 (social life).22
Moreover, there are two studies, in which the administration of the
ODI by telephone has been reported.23,24
The Medical Research Council group produced a modified version of
the ODI (version 2.0)25 (Table 9), which has been proposed for general
use.26 – 28 It has been distributed by correspondence and is available as
part of a computer interview in the UK (slightly modified)25,29 or in
the USA through MODEMS (PO Box 2354, Des Plaines, IL
60017-2354). In this version the following domains are included: pain
intensity, personal care, lifting, walking, sitting, standing, sleeping, sex
life (if applicable), social life and travelling. Each section contains six
statements, ranging from 0 to 5, and patients should answer the ques-
tions in relation to that day (‘today’). The standard scoring method can
be used to obtain the final disability score.20,21
A revised Oswestry Disability Questionnaire (Table 10) was pub-
lished by a chiropractic study group in the UK.30 This version consists

92 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 9 The Oswestry disability index (version 2.0).

Oswestry disability index (version 2.0)

Could you please complete this questionnaire. It is designed to give us information as to how your back
(or leg) trouble has affected your ability to manage in everyday life. Please answer every section. Mark
one box only in each section that most closely describes you today.

Section 1: Pain intensity

1. I have no pain at the moment.
2. The pain is very mild at the moment.
3. The pain is moderate at the moment.
4. The pain is fairly severe at the moment.

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5. The pain is very severe at the moment.
6. The pain is the worst imaginable at the moment.

Section 2: Personal care (washing, dressing, etc.)

1. I can look after myself normally without causing extra pain.
2. I can look after myself normally but it is very painful.
3. It is painful to look after myself and I am slow and careful.
4. I need some help but I manage most of my personal care.
5. I need help every day in most aspects of self-care.
6. I do not get dressed, wash with difficulty and stay in bed.

Section 3: Lifting
1. I can lift heavy weights without extra pain.
2. I can lift heavy weights but it gives extra pain.
3. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are
conveniently positionated (e.g. on a table).
4. Pain prevents me from lifting heavy weights, but I can manage light-to-medium weights if they are
conveniently positionated.
5. I can lift only very light weights.
6. I cannot lift or carry anything at all.

Section 4: Walking
1. Pain does not prevent me walking any distance.
2. Pain prevents me walking more than 1 mile.
3. Pain prevents me walking more than a quarter of a mile.
4. Pain prevents me walking more than 100 yards.
5. I can only walk using a stick or crutches.
6. I am in bed most of the time and have to crawl to the toilet.

Section 5: Sitting
1. I can sit in any chair as long as I like.
2. I can sit in my favourite chair as long as I like.
3. Pain prevents me sitting more than 1 h.
4. Pain prevents me from sitting more than half an hour.
5. Pain prevents me from sitting more than 10 min.
6. Pain prevents me from sitting at all.

Section 6: Standing
1. I can stand as long as I want without extra pain.
2. I can stand as long as I want but it gives me extra pain.
3. Pain prevents me from standing for more than 1 h.
4. Pain prevents me from standing for more than half an hour.
5. Pain prevents me from standing for more than 10 min.
6. Pain prevents me from standing at all.

Continued

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U. G. Longo et al.

Table 9 Continued

Oswestry disability index (version 2.0)

Section 7: Sleeping
1. My sleep is never disturbed by pain.
2. My sleep is occasionally disturbed by pain.
3. Because of pain I have less than 6 h sleep.
4. Because of pain I have less than 4 h sleep.
5. Because of pain I have less than 2 h sleep.
6. Pain prevents me from sleeping at all.

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Section 8: Sex life (if applicable)
1. My sex life is normal and causes no extra pain.
2. My sex life is normal but causes some extra pain.
3. My sex life is nearly normal but is very painful.
4. My sex life is severely restricted by pain.
5. My sex life is nearly absent because of pain.
6. Pain prevents any sex life at all.

Section 9: Social life

1. My social life is normal and causes me no extra pain.
2. My social life is normal but increases the degree of pain.
3. Pain has no significant effect on my social life apart from limiting my more energetic interests (e.g.
sport, etc.).
4. Pain has restricted my social life and I do not go out as often.
5. Pain has restricted social life to my home.
6. I have no social life because of pain.

Section 10: Travelling

1. I can travel anywhere without pain.
2. I can travel anywhere but it gives me extra pain.
3. Pain is bad but I manage journeys over 2 h.
4. Pain restricts me to journeys of less than 1 h.
5. Pain restricts me to short necessary journeys under 30 min.
6. Pain prevents me from travelling except to receive treatment.

of 10 sections: pain intensity, personal care, lifting, walking, sitting,

standing, sleeping, social life, travelling and changing degree of pain.
Also in this version each section contains six statements, ranging from
0 to 5, and the final score is calculated with standard scoring method.
A modified ODI published by Fritz and Irrgang31 (Table 11) is similar
to the modified ODI used by Hudson-Cook et al.30 The questionnaire
consists of 10 domains: pain intensity, personal care, lifting, walking,
sitting, standing, sleeping, social life, travelling and employment/home-
making. A section regarding employment and home-making ability is
substituted for the section related to sex life. Each domain contains six
statements, scored from 0 to 5, with higher values representing greater
disability. The final score is obtained with standard scoring method.
The American Academy of Orthopaedic Surgeons (AAOS) and other
spine societies have modified version 1.0 to use it like their spine
outcome instrument32 (Table 12). This version includes seven sections:
personal care, lifting, walking, sitting, standing, sleeping and travelling.

94 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 10 The revised Oswestry disability index.

Revised Oswestry disability index

This questionnaire is designed to enable us to understand how much your low back pain has affected
your ability to manage your everyday activities. Mark one box only in each section that most closely
describes you today.

Section 1: Pain intensity

1. The pain comes and goes and is very mild.
2. The pain is mild and does not very much.
3. The pain comes and goes and is moderate.
4. The pain is moderate and does not very much.

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5. The pain comes and goes and is severe.
6. The pain is severe and does not very much.

Section 2: Personal care

1. I would not have to change my way of washing or dressing in order to avoid pain.
2. I do not normally change my way of washing or dressing even though it causes some pain.
3. Washing and dressing increase the pain but I manage not to change my way of doing it.
4. Washing and dressing increase the pain and I find it necessary to change my way of doing it.
5. Because of the pain I am unable to do some washing and dressing without help.
6. Because of the pain I am unable to do any washing and dressing without help.

Section 3: Lifting
1. I can lift heavy weights without extra pain.
2. I can lift heavy weights but it gives extra pain.
3. Pain prevents me from lifting heavy weights off the floor.
4. Pain prevents me from lifting heavy weights off the floor but I can manage if they are
conveniently positioned, e.g. on a table.
5. Pain prevents me from lifting heavy weights but I can manage light-to-medium weights if they are
conveniently positioned
6. I can only lift very light weights at the most.

Section 4: Walking
1. I have no pain on walking.
2. I have some pain with walking but it does not increase with distance.
3. I cannot walk more than 1 mile without increasing pain.
4. I cannot walk more than 1/2 mile without increasing pain.
5. I cannot walk more than 1/4 mile without increasing pain.
6. I cannot walk at all without increasing pain.

Section 5: Sitting
1. I can sit in any chair as long as I like.
2. I can sit only in my favourite chair as long as I like.
3. Pain prevents me from sitting more than 1 h.
4. Pain prevents me from sitting more than half an hour.
5. Pain prevents me from sitting more than 10 min.
6. I avoid sitting because it increases pain straight away.

Section 6: Standing
1. I can stand as long as I want without pain.
2. I have some pain on standing but it does not increase with time.
3. I cannot stand for longer than 1 h without increasing pain.
4. I cannot stand for longer than half an hour without increasing pain.
5. I cannot stand for longer than 10 min without increasing pain.
6. I avoid standing because it increases pain straight away.

Continued

British Medical Bulletin 2010;94 95

U. G. Longo et al.

Table 10 Continued

Revised Oswestry disability index

Section 7: Sleeping
1. I get no pain in bed.
2. I get pain in bed but it does not prevent me from sleeping well.
3. Because of pain my normal nights sleep is reduced by less than 1/4.
4. Because of pain my normal nights sleep is reduced by less than 1/2.
5. Because of pain my normal nights sleep is reduced by less than 3/4.
6. Pain prevents (me) from sleeping at all.

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Section 8: Social life
1. My social life is normal and gives me no pain.
2. My social life is normal but increases the degree of pain.
3. Pain has no significant effect on my social life apart from limiting my more energetic interests (e.g.
dancing, etc.).
4. Pain has restricted my social life and I do not go out very often.
5. Pain has restricted social life to my home.
6. I have hardly any social life because of pain.

Section 9: Travelling
1. I get no pain whilst travelling.
2. I get some pain whilst travelling but none of my usual sorts of travel make it any worse.
3. I get extra pain whilst travelling but it does not compel me to seek alternative forms of travel.
4. I get extra pain whilst travelling which compels me to seek alternative forms of travel.
5. Pain restricts all forms of travel.
6. Pain prevents all forms of travel except that done lying down.

Section 10: Changing degree of pain

1. My pain is rapidly getting better.
2. My pain fluctuates but overall is definitely getting better.
3. My pain seems to be getting better but improvement is slow at present.
4. My pain is neither getting better or worse.
5. My pain is gradually worsening.
6. My pain is rapidly worsening.

The sections 1, 8 and 9 are omitted. Each section contains six state-
ments, ranging from 0 to 5, and patients should answer the questions
in relation to ‘the past week’.13 The standard scoring method can be
also used for this versions of the ODI, but because it has only seven
sections, corrections should be made to obtain the final score.21
Another version of the ODI has been published by the North
American Spine Society (NASS).33 This version includes a pain diagram,
questions from the SF-36 health questionnaire, questions on neurological
symptoms and on the LBP, and a modification of the original ODI.13

The Quebec back pain disability scale

The Quebec back pain disability scale (QBPDS) (Table 13) is a 20-item
condition-specific questionnaire to assess the degree of disability in
patient with back pain.34 Item selection was performed from 46

96 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 11 The modified Oswestry disability index.

Modified Oswestry disability index

This questionnaire has been designed to give your therapist information as to how your back pain has
affected your ability to manage in everyday life. Please answer every question by placing a mark in the
one box that best describes your condition today. We realize you may feel that two of the statements
may describe your condition, but please mark only the box that most closely describes your current
condition.

Section 1: Pain intensity

1. I can tolerate the pain I have without having to use pain medication.
2. The pain is bad, but I can manage without having to take pain medication.

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3. Pain medication provides me with complete relief from pain.
4. Pain medication provides me with moderate relief from pain.
5. Pain medication provides me with little relief from pain.
6. Pain medication has no effect on my pain.

Section 2: Personal care (e.g. washing, dressing)

1. I can take care of myself normally without causing increased pain.
2. I can take care of myself normally, but it increases my pain.
3. It is painful to take care of myself, and I am slow and careful.
4. I need help, but I am able to manage most of my personal care.
5. I need help every day in most aspects of my care.
6. I do not get dressed, wash with difficulty, and stay in bed. I can sleep well only by using pain
medication.

Section 3: Lifting
1. I can lift heavy weights without increased pain.
2. I can lift heavy weights, but it causes increased pain.
3. Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are
conveniently positioned (e.g. on a table).
4. Pain prevents me from lifting heavy weights, but I can manage light-to-medium weights if they are
conveniently positioned.
5. I can lift only very light weights.
6. I cannot lift or carry anything at all. My social life is normal and does not increase my pain.

Section 4: Walking
1. Pain does not prevent me from walking any distance.
2. Pain prevents me from walking more than 1 mile.
3. Pain prevents me from walking more than 1/2 mile.
4. Pain prevents me from walking more than 1/4 mile.
5. I can only walk with crutches or a cane.
6. I am in bed most of the time and have to crawl to the toilet.

Section 5: Sitting
1. I can sit in any chair as long as I like.
2. I can sit only in my favourite chair as long as I like.
3. Pain prevents me from sitting more than 1 h.
4. Pain prevents me from sitting more than 1/2 h.
5. Pain prevents me from sitting more than 10 min.
6. Pain prevents me from sitting at all.

Section 6: Standing
1. I can stand as long as I want without increased pain.
2. I can stand as long as I want, but it increases my pain.
3. Pain prevents me from standing more than 1 h.
4. Pain prevents me from standing more than 1/2 h.
5. Pain prevents me from standing more than 10 min.
6. Pain prevents me from standing at all.

Continued

British Medical Bulletin 2010;94 97

U. G. Longo et al.

Table 11 Continued

Modified Oswestry disability index

Section 7: Sleeping
1. Pain does not prevent me from sleeping well.
2. I can sleep well only by using pain medication.
3. Even when I take pain medication, I sleep less than 6 h.
4. Even when I take pain medication, I sleep less than 4 h.
5. Even when I take pain medication, I sleep less than 2 h.
6. Pain prevents me from sleeping at all.

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Section 8: Social life
1. My social life is normal and does not increase my pain.
2. My social life is normal, but it increases my level of pain.
3. Pain prevents me from participating in more energetic activities (e.g. sports, dancing).
4. Pain prevents me from going out very often.
5. Pain has restricted social life to my home.
6. I have hardly any social life because of my pain.

Section 9: Travelling
1. I can travel anywhere without increased pain.
2. I can travel anywhere, but it increases my pain.
3. My pain restricts my travel over 2 h.
4. My pain restricts my travel over 1 h.
5. My pain restricts my travel to short necessary journeys under 1/2 h.
6. My pain prevents all travel except for visits to the physician/therapist or hospital.

Section 10: Employment/Homemaking

1. My normal homemaking/job activities do not cause pain.
2. My normal homemaking/job activities increase my pain, but I can still perform all that is required
of me.
3. I can perform most of my homemaking/job duties, but pain prevents me from performing more
physically stressful activities (e.g. lifting, vacuuming).
4. Pain prevents me from doing anything but light duties.
5. Pain prevents me from doing even light duties.
6. Pain prevents me from performing any job or homemaking chores.

Table 12 AAOS/MODEMS.

AAOS/MODEMS

In the past week, please tell us how pain has affected your ability to perform the following activities.
Mark any one statement that best describes your average ability.

Section 1: Getting dressed (in the past week)

1. I can dress myself without pain.
2. I can dress myself without increasing pain.
3. I can dress myself but pain increases.
4. I can dress myself but with significant pain.
5. I can dress myself but with very severe pain.
6. I cannot dress myself.

Section 2: Lifting (in the past week)

1. I can lift heavy objects without pain.
2. I can lift heavy objects but it is painful.
3. Pain prevents me from lifting heavy objects off the floor, but I can lift heavy objects if they are on
a table.

Continued

98 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 12 Continued

AAOS/MODEMS

4. Pain prevents me from lifting heavy object, but I can lift light-to-medium objects if they are on a
table
5. I can only lift light objects.
6. I cannot lift anything.

Section 3: Walking (in the past week)

1. I can run or walk without pain.
2. I can walk comfortably, but running is painful.

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3. Pain prevents me from walking more than 1 h.
4. Pain prevents me from walking more than 30 min.
5. Pain prevents me from walking more than 10 min.
6. I am unable to walk or can walk only a few steps at a time.

Section 4: Sitting (in the past week)

1. I can sit in any chair as long as I like.
2. I can only sit in a special chair as long as I like.
3. Pain prevents me from sitting for more than 1 h.
4. Pain prevents me from sitting for more than 30 min.
5. Pain prevents me from sitting for more than 10 min.
6. Pain prevents me from sitting at all.

Section 5: Standing (in the past week)

1. I can stand as long as I want.
2. I can stand as long as I want, but it increases my pain.
3. Pain prevents me from standing more than 1 h.
4. Pain prevents me from standing more than 30 min.
5. Pain prevents me from standing more than 10 min.
6. Pain prevents me from standing at all.

Section 6: Sleeping (in the past week)

1. I sleep well.
2. Pain occasionally interrupts my sleep.
3. Pain interrupts my sleep half of the time.
4. Pain often interrupts my sleep.
5. Pain always interrupts my sleep.
6. I never sleep well.

Section 7: Travelling (in the past week)

1. I can travel anywhere.
2. I can travel anywhere but it gives me pain.
3. Pain is bad but I can manage to travel over 2 h.
4. Pain restricts me to journeys of less than 1 h.
5. Pain restricts me to trips less than 30 min.
6. Pain prevents me from travelling.

disability items by examining the test–retest reliability and responsive-

ness of individual items, by using techniques of factor analysis and by
application of item response theory.35 The QBPDS assess disability by
evaluating the following daily tasks: self-care, sleeping, walking, climb-
ing stairs, sitting, standing, lifting large or heavy objects, bending and
stooping, physical activities and houseworks. Social life, sex life and
pain intensity are omitted; so pain should be evaluated with other

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100

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Table 13 The Quebec back pain disability scale.

Quebec back pain disability scale

This questionnaire is about the way your back pain affects your daily life. People with back problems may find it difficult to perform some of their daily activities. We would
like to know if you find it difficult, because of your back, to perform any of the activities listed below. For each activity there is a scale that ranges from 0 (not difficult at all)
to 5 (unable to do). Please choose the one response for each activity that best describes your current condition and place a check mark in the appropriate box. Please answer
all of the questions.

Because of your back problems, how difficult do you find it Not difficult at Minimally Somewhat Fairly Very Unable to
today to. all difficult difficult difficult difficult do
1. Get out of bed?
2. Sleep through the night?
3. Turn over in bed?
4. Ride in a car?
5. Stand up for 20 –30 min?
6. Sit in a chair for several hours?
7. Climb one flight of stairs?
8. Walk a few blocks (300 –400 m)?
9. Walk several miles?
10. Reach up to high shelves?
11. Throw a ball?
12. Run one block (about 100 m)?
13. Take food out of the refrigerator?
14. Make your bed?
15. Put on socks (pantyhose)?
16. Bend over to clean the bathtub?
17. Move a chair?
18. Pull or push heavy doors?
British Medical Bulletin 2010;94

19. Carry two bags of groceries?

20. Lift and carry a heavy suitcase?
 Rating scales for low back pain

scoring system. Each one of 20 daily activities is scored with a six-point

difficult scale ranging from 0 (‘not difficult at all’) to 5 (‘unable to
do’). The item scores are added up in order to obtain the disability
score, which ranges between 0 and 100. The higher values represent
greater disability, and sub-scores are not reported.34
The questionnaire is self-administered by the patient, it can be easily
completed in about 5 –10 min, and scored in less than 2 min.

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The Waddell disability index
The Waddell disability index (WDI) (Table 14)36 is nine-item scale
which assesses disability by evaluating daily living activities commonly
restricted by LBP. The items included are: lifting, sitting, standing, tra-
velling, walking, sleeping, social life, sex life and putting on footwear.
Items about work, self-care and sports are not included. Questions are
not related to a specific time period and are selected from a previous
questionnaire37 and pilot interviews. Patients answer to questions only
with positive or negative statement (yes/no). The final score is calcu-
lated by adding up positive items, and ranges from 0 to 9.36
The questionnaire is easy to administer; it can be filled out in about
5 min and scored in less than 1 min. It was validated on a chronic LBP
population.

The Million visual analogue scale

The Million visual analogue scale (MVAS) (Table 15) is a 15-item
questionnaire about disability and pain intensity in patients with
LBP.38 The 15 questions investigate the body functions ( pain, sleep,
stiffness and twisting), daily activities (walking, sitting, standing and
work) and social life. Information about item selection process is not

Table 14 The Waddell disability index.

Waddell disability index

Because of your back pain, which following limits do you have? Yes No
1. Help required or avoid heavy lifting, i.e. 30 –40 lbs, a heavy suitcase, or a 3 –4-year-old
child.
2. Sitting limited to less than 1.5 h.
3. Travelling in a car or bus limited to less than 1.5 h.
4. Standing limited to less than 1.5 h.
5. Walking limited to less than 1.5 h.
6. Sleep disturbed regularly by low back pain, i.e. 2 –3 times per week.
7. Regularly miss or curtail social activities (excluding sports).
8. Diminished frequency of sexual activity.
9. Help regularly required with footwear (tights, socks or tying laces).

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Table 15 The Million visual analogue scale.

Million visual analogue scale

1. Do you have any pain in the back? How severe is it?

No pain – Intolerable
2. Do you have any pain in the night? How severe is it?

No pain – Intolerable
3. Is there anything that you do or are there any circumstances in your lifestyle which make your pain
worse? If so, how stressful has this to be to give you pain?

Very stressful –Not stressfull at all

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4. Do you get relief from pain killers?

Complete relief –No relief

5. Do you have any stifness in the back?

No stiffness– Intolerable stiffness

6. Does your back pain interfere with your freedom to walk?

Complete freedom to walk–Completely unable to walk because of pain

7. Do you have discomfort when walking?

None at all –Intolerable

8. Does your pain interfere with your ability to stand still?

Stand still for a long time, that is an hour–Not able to stand still at all
9. Does your pain prevent you from turning and twisting?

Complete freedom to twist –Completely incapable of twisting

10. Does your back pain allow you to sit on an upright hard chair?

Complete freedom to sit on a hard chair– So much pain that cannot sit on such a chair at all
11. Does your back pain prevent you from sitting in a soft armchair?

Complete comfort–Such discomfort that cannot sit in a soft chair at all

12. Do you have back pain when lying down in bed?

Complete comfort–No comfort at all

13. What is your overall handicap in your complete lifestyle because of back pain?

Completely free to perform any task –Totally handicapped

14. To what extent does your pain interfere with your work?

No interference at all –Totally incapable of work

15. To what extent does your work have to be modified so that you are able to do your job?

No adjustment to work –So much adjustment that you have had to change your job

available. Score is given on a 100 mm visual analogue scale(VAS). For

example, if patients are asked to quantify the severity of his pain (like
the first question), they mark a point on a 100-mm line in which the
end points are labelled as ‘no pain’ and ‘intolerable’. In each question,
it is possible to obtain an index of severity of symptoms in a patient-
specific fashion measuring the distance of the marked point from the
origin of the line. The final score is calculated by adding up the equally
weighted scores.
The questionnaire can be completed in about 5 –10 min, and scored
in about 2 –3 min.

102 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 16 The low back outcome score.

Low back outcome score

Item Answers Scores

Factors scoring 9 points

1. Current pain (VAS) 7– 10 0
5– 6 3
3– 4 6
0– 2 9

2. Employment (housewives related to previous abilities) Unemployed 0

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Part-time 3
Full time, lighter 6
Full time, original 9

3. Domestic chores None 0

A few but not many 3
Most, or all but more slowly 6
Normally 9

4. Sport/active social (dancing) None 0

Some-much less than before 3
Back to previous level 9

Factors scoring 6 points

1. Resting Resting more than half the day 0
Little rest needed, occasionally 4
No need to rest 6

2. Treatment or consultation More than once per month 0

About once per month 2
Rarely 4
Never 6

3. Analgesia Several times each day 0

Almost every day 2
Occasionally 4
Never 6

4. Sex life Severely affected (impossible) 0

Moderately affected (difficult) 2
Mild affected 4
Unaffected 6

Factors scoring 3 points

Sleeping, walking, sitting, travelling, dressing Severely affected (impossible) 0
Moderately affected (difficult) 1
Mild affected 2
Unaffected 3

The low back outcome score

The low back outcome score (LBOS)39 (Table 16) is designed as a self-
reported measure to assess the patients with LBP. It is a 13-item ques-
tionnaire, and it includes weighted questions about current pain,
employment, domestic chores, sport activities, resting, medical

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U. G. Longo et al.

treatments or consultations, drug use, sex life and daily activities (such
as sleeping, walking, sitting, travelling, dressing).
The pain question is answered with an 11-point VAS ranging from ‘no
pain’ to ‘maximum pain possible’. However, for scoring, the 11 answer
possibilities are reduced to four categories (0–2, 3–4, 5–6, 7–10). All the
other questions offer an answer for different possibilities, except the sport
activities and resting questions, which provide three different answers.
The answering possibilities of each item are scored with a four-point
scale, but questions are differently weighted. Three different groups of

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questions can be identified. Items with a nine-point scoring system
( pain, employment, domestic and sport activities) in which the score
can be 0, 3, 6 or 9 points. Items with a six-points scoring system
(resting, treatment or consultation, analgesia and sex life) in which the
score can be 0, 2, 4 or 6 points. Items with a three-points scoring
system (sleeping, walking, sitting, travelling, dressing) in which the
score can be 0, 1, 2 or 3 points. The final score is obtained by
summing the score of each item and it ranges from 0 to 75, with lower
values representing greater disability.
The questionnaire can be completed in about 5 min and scored in
less than 1 min.

The low back pain rating scale

The low back pain rating scale (LBPRS)40 (Table 17) is a rating system
designed to evaluate the clinical outcome of LBP patients. This instru-
ment includes three different components: pain, disability and physical
impairment. The pain component consists of six questions divided into
two groups: three questions about back pain and three questions about
leg pain. Each item is scored with the VAS. Items are the following: LBP/
leg pain at the time of examination (0–10 points), the worst LBP/leg
pain within the last 2 weeks (0–10 points) and the average level of the
back pain/leg pain during the same period (0–10 points). The final score
ranges from 0 to 30 for both low back/leg pain. Therefore, the pain com-
ponent in total gives 0–60 points. The disability component consists of
15 questions evaluating the patient’s ability to perform daily activities,
such as sleeping, ability to perform houseworks, walking, sitting, lifting,
working, dressing, driving, running, getting up from a chair, climbing
stairs, contact with people and expectations of future pain. Each ques-
tion can be answered with three different possible answers and is scored
with a three-point Likert scale. Answers are the following: ‘yes’ (0
points), ‘can be a problem’ (1 point) or ‘no’ (2 points). The disability
component gives a total score of 0–30 points. The physical impairment
component is evaluated by measuring the back muscle endurance, spinal

104 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 17 The Low back pain rating scale.

Low back pain rating scale

Back and leg pain

Items Scores

1. Back pain at the time of the examination VAS: no pain (0 points) –worst imaginable
pain (10 points)

2. Leg pain at the time of the examination VAS: no pain (0 points) –worst imaginable
pain (10 points)

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3. The worst back pain within the last 2 weeks VAS: no pain (0 points) –worst imaginable
pain (10 points)

4. The worst leg pain within the last 2 weeks VAS: no pain (0 points) –worst imaginable
pain (10 points)

5. Average level of back pain during the last 2 weeks VAS: no pain (0 points) –worst imaginable
pain (10 points)

6. Average level of leg pain during the past 2 weeks VAS: no pain (0 points) –worst imaginable
pain (10 points)
Disability index
Items Answers Score
1. Can you sleep at night without low back pain Yes 0
interfering?
Can be problem 1
No 2

2. Can you do your daily work without low back pain Yes 0
reducing your activities?
Can be problem 1
No 2

3. Can you do the easy chores at home such as watering Yes 0

flowers or cleaning the table?
Can be problem 1
No 2
4. Can you put on shoes and stockings by yourself? Yes 0
Can be problem 1
No 2

5. Can you carry two full shopping bags (10 kilograms Yes 0
total)?
Can be problem 1
No 2

6. Can you get up from a low armchair without difficulty? Yes 0

Can be problem 1
No 2

7. Can you bend over the wash basin to brush your teeth? Yes 0
Can be problem 1
No 2

8. Can you climb stairs from one floor to another without Yes 0
resting because of low back pain?
Can be problem 1

Continued

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U. G. Longo et al.

Table 17 Continued

Low back pain rating scale

Back and leg pain

Items Scores

No 2

9. Can you walk 400 meters without resting because of Yes 0

low back pain?

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Can be problem 1
No 2

10. Can you run 100 meters without resting because of Yes 0
low back pain?
Can be problem 1
No 2

11. Can you ride a bike or drive a car without feeling any Yes 0
low back pain?
Can be problem 1
No 2

12. Does low back pain influence your emotional Yes 0

relationship to your nearest family?
Can be problem 1
No 2

13. Did you have to give up contact with other people Yes 0
within the last 2 weeks because of low back pain?
Can be problem 1
No 2

14. If it was a present interest do you think that there are Yes 0
certain jobs which you would not be able to manage
because of your back trouble?
Can be problem 1
No 2

15. Do you think that the low back pain will influence Yes 0
your future?
Can be problem 1
No 2

Physical impairment
Measure Finding Points

1. Back muscle endurance (s) 270 0

240 –269 1
210 –239 2
180 –209 3
150 –179 4
120 –149 5
90 – 119 6
60 – 89 7
30 – 59 8
1 –29 9
0 10

Continued

106 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 17 Continued

Low back pain rating scale

Back and leg pain

Items Scores

2. Back mobility (modified Schober’s test) (mm) 14 0

50 – 59 2
40 – 49 4
30 – 39 6

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20 – 29 8
0 –19 10

3. Overall mobility test(s) ,10 0

10 – 19 2
20 – 29 4
30 – 39 6
40 – 49 8
50 10

4. Analgesic use None during past week 0

Use NSAID or non-narcotic 2
analgesic 1 –4 times a week
Use of NSAID or non-narcotic 4
analgesic 5þ times a week
Use NSAID or non-narcotic 2
analgesic 1 –4 times a week
Use of NSAID or non-narcotic 4
analgesic 5þ times a week

mobility, patient mobility and use of analgesics. Muscle endurance and

spinal/patient mobility are recorded with specific physical test, and each
is scored on a scale ranging from 0 to 10. Use of analgesics/NSAID is
scored as follows: ‘no use during a week’ (0 points); ‘use of NSAID/non-
narcotic analgesics up to 4 times a week’ (2 points); ‘use of NSAID/non-
narcotic analgesics more than 4 times a week’ (4 points); ‘use of morphine/
analogues up to 4 times a week’ (8 points) and ‘use of morphine/analogues
more than 4 times a week’ (10 points). The physical impairment com-
ponent in total gives 0–40 points.
The three different components are weighted: 60 points for pain
scoring, 30 points for disability and 40 points for physical impairment.
Therefore, combining them, the final LBPRS score ranges from 0 (in
patient without back problems) to 130 (in disabled patient). The ques-
tionnaire can be filled out in about 15 min and scored in about 3–5 min.

The NASS lumbar spine outcome assessment instrument

The NASS lumbar spine outcome assessment instrument (NASS LSO)
was first published by Daltroy et al.,33 and is derived from a consensus

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U. G. Longo et al.

of the NASS. It consists of 62 main question obtained from three

different existing questionnaires: the SF36, a modified ODI and a
modified employment assessment published by Bigos.41
The NASS data are grouped into five categories. The first group con-
sists of demographic data (age, sex, race, education and insurance
information). The second group consists of the medical history (diagno-
sis, past surgeries, comorbidities, etc.). The third group includes: pain,
neurogenic symptoms and function. These domains are measured by a
modified ODI version. The fourth group is represented by employment

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history, evaluated by a score system published by Bigos et al. 41 The
fifth group consists of data about outcomes of treatment, but it is
included only in the follow-up module.
The scoring is complex and subscores are extractable (modified ODI,
SF36, pain and disability scale, neurogenic symptoms scale, job exer-
tion scale, expectation and satisfaction scale).42 The questionnaire is
long and it takes 20 min to be filled out.

The clinical back pain questionnaire

The clinical back pain questionnaire (CBPQ) (Table 18), also known as
the Aberdeen LBP scale, is a 19-items questionnaire, consisting of ques-
tions commonly used in the clinical assessment of patients with LBP.43
It includes questions about body functions (pain, sleep, bending, loss
of feeling and leg weakness) and questions about daily activities (self-
care, walking, sitting, standing, sport, housework and resting). There
are 6 multiple choice questions and 13 single choice questions.
Answering possibilities for each question can vary between three and
six items. The answer categories to each single choice question are
scored in an ordinal manner (e.g. 0, 1, 2, 3 points, etc.), while multiple
choice questions’ responses are assigned a score of one point. The
‘back pain severity score’ is calculated by summing the score of the
responses’ to each question, and then it is converted to percentages.
The final score ranges between 0 and 100 with the higher values repre-
senting greater disability.
The questionnaire is easy to administer, can be completed within
5– 10 min, and scored within 3 min.

The resumption of activities of daily living scale

The resumption of activities of daily living scale (RADL) (Table 19)
scale is designed to assess broad areas often affected by back injury.44
The scale measures the extent of resumption of a person’s ‘usual’

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 Rating scales for low back pain

Table 18 The clinical back pain questionnaire.

Clinical back pain questionnaire

1. In the last two weeks, for how many days did you suffer pain in the back or leg(s)?
(please mark one answer)
None at all
Between 1 and 5 days
Between 6 and 10 days
For more than 10 days

2. On the worst day during the last two weeks, how many painkilling tablets did you take?
(please mark one answer)

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None at all
Less than 4 tablets
Between 4 and 8 tablets
Between 9 and 12 tablets
More than 12 tablets

3. Is the pain made worse by any of the following? (please mark all answers that apply to you)
Coughing
Sneezing
Sitting
Standing
Bending
Walking

4. Do any of the following movements ease the pain? (please mark all answers that apply to you)
Lying down
Sitting down
Standing
Walking

5. In your right leg, do you have any pain in the following areas? (please mark all answers that apply to
you)
Pain in the buttock
Pain in the high
Pain in the shin/calf
Pain in the foot/ankle

6. In your left leg, do you have any pain in the following areas? (please mark all answers that apply to
you)
Pain in the buttock
Pain in the high
Pain in the shin/calf
Pain in the foot/ankle

7. Do you have any loss of feeling in your legs? (please mark one answer)
No
Yes, just one leg
Yes, both legs

8. In your right leg, do you have any weakness of loss of power in the following areas? (please mark all
answers that apply to you)
The hip
The knee
The ankle
The foot

Continued

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U. G. Longo et al.

Table 18 Continued

Clinical back pain questionnaire

9. In your left leg, do you have any weakness of loss of power in the following areas? (please mark all
answers that apply to you)
The hip
The knee
The ankle
The foot

10. If you were to try and bend forwards without bending your knees, how far down do you think you

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could bend before the pain stopped you? (please mark one answer)
I could touch the floor
I could touch my ankles with the tips of my fingers
I could touch my mild-thighs with the tips of my fingers
I could touch my knees with the tips of my fingers
I could not bend forward at all

11. On the worst night during the last 2 weeks, how badly was your sleep affected by the pain?
(please mark one answer)
Not affected at all
I didn’t lose any sleep but needed tablets
It prevented me from sleeping but I slept for more than 4 h
I only had 2– 4 h sleep
I had less than 2 h sleep

12. On the worst day during the last 2 weeks, did the pain interfere with your ability to sit down?
(please mark one answer)
I was able to sit in any chair as long as I liked
I could only sit in my favourite chair as long as I liked
Pain prevented me from sitting more than 1 h
Pain prevented me from sitting more than 30 min
Pain prevented me from sitting more than 15 min
Pain prevented me from sitting at all

13. On the worst day during the last 2 weeks, did the pain interfere with your ability to stand?
(please mark one answer)
I could stand as long as I wanted without extra pain
I could stand as long as I wanted but it gave me extra pain
Pain prevented me from standing more than 1 h
Pain prevented me from standing more than 30 min
Pain prevented me from standing more than 15 min
Pain prevented me from standing at all

14. On the worst day during the last 2 weeks, did the pain interfere with your ability to walk?
(please mark one answer)
Pain did not prevent me walking any distance
Pain prevented me walking more than 1 mile
Pain prevented me walking more than 1/2 mile
Pain prevented me walking more than 1/4 mile
I can walk but less than 1/4 mile
I was unable to walk at all

15. In the last 2 weeks, did the pain prevent you from carring out your work/housework and other daily
activities? (please mark one answer)
No, not at all
I could continue with my work, but my work suffered

Continued

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 Rating scales for low back pain

Table 18 Continued

Clinical back pain questionnaire

Yes, for 1 day

Yes, for 2 –6 days
Yes, for more than 7 days
16. In the last 2 weeks, for how many days have you had to stay in bed because of the pain? (please
mark one answer)
None at all
Between 1 and 5 days
Between 6 and 10 days

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For more than 10 days

17. In the last 2 weeks, has your sex life been affected by your pain? (please mark one answer)
Not affected by the pain
Mildly affected by the pain
Moderately affected by the pain
Severely affected by the pain
Does not apply

18. In the last 2 weeks, have your leisure activities been affected by your pain (including sports, hobbies
and social life)? (please mark one answer)
Not affected by the pain
Mildly affected by the pain
Moderately affected by the pain
Severely affected by the pain
Pain prevents any social life at all

19. In the last 2 weeks, has the pain interfered with your ability to look after yourself, e.g. washing,
dressing, etc.? (please mark one answer)
Not at all
Because of the pain, I needed some help looking after myself
Because of the pain, I needed a lot of help looking after myself
Because of the pain, I could not look after myself at all

activities since the time of injury. The final 12-item RADL includes the
following areas: sleeping patterns, sexual activity, self-care, light and
heavy household chores, shopping, socializing inside and outside
home, travelling, recreational activities and paid employment. Each
item is scored with a graphic scale ranging from 0 (not at all) to 100%
(complete resumption). The total RADL score can vary from 0 to 100;
it is obtained by summing across the items and dividing by the number
of items. At least 9 items of the 12 questions have to be completed to
calculate a total score for each patient.

The functional rating index

The functional rating index (FRI) (Table 20) is a 10-item scoring
system designed to measure both patient’s perception of function and
pain of the spinal musculoskeletal system.45 The instrument includes:

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U. G. Longo et al.

Table 19 The resumption of activities of daily living scale.

Resumption of activities of daily living scale

Since your injury, to what extent have you resumed your usual activities in each of the following areas?
If you do not do an activity, put N/A (nonapplicable) beside the scale. As you rate each activity, think of
how you are today. Mark the box on the scale for each question.

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

1. Sleeping patterns
2. Sexual activity
3. Self-care (e.g.

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washlng, dressing)
4. Light household
chores (e.g. doing
dishes, making beds,
preparing meals)
5. Heavy household
chores (e.g. yardwork,
cleaning windows,
doing laundry)
6. Shopping
7. Socializing with
family and friends
inside your home
8. Socializing with
family and friends
outside your home
9. Travelling (in cars,
buses, etc.) for less than
30 min
10. Travelling (in cars,
buses, etc.) for longer
than 1 h
11. Engaging in your
usual recreational
activities
12. Engaging in your
usual paid employment

eight items focus on daily activities (sleeping, self-care, travel, work,

recreation, lifting, walking and standing) that can be affected by a
spinal disease and two items focus on two different aspects of pain
(intensity and frequency). Each item is scored with a five-point scale
ranging from 0 (no pain or full ability to function) to 4 (worst possible
pain or unable to perform a specific function at all). The index score is
achieved by adding up the equally weighted scores, dividing by the
maximum possible score, and multiplying by 100%. When all 10 items
are answered, the formula is the following: (total score/40)  100%.
The final score ranges from 0 (representing absence of disability) to
100% (representing severe disability). Therefore, the higher the score
the higher the perception of dysfunction and pain.

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Table 20 The functional rating index.

Functional rating index

In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each
item below, please mark the box which most closely describes your condition right now.
0 1 2 3 4
1. Pain intensity No pain Mild pain Moderate pain Severe pain Worst possible pain
2. Sleeping Perfect sleep Mildly disturbed sleep Moderately disturbed Greatly disturbed sleep Totally disturbed sleep
sleep
3. Personal care (washing, No pain; no restrictions Mild pain; no Moderate pain; need to Moderate pain; need Severe pain; need 100%
dressing, etc.) restrictions go slowly some assistance assistance
4. Travel (driving, etc.) No pain on long trips Mild pain on long trips Moderate pain on long Moderate pain on short Severe pain on short
trips trips trips
5. Work Can do usual work plus Can do usual work; no Can do 50% of usual work Can do 25% of usual Cannot work
unlimited extra work extra work work
6. Recreation Can do all activities Can do most activities Can do some activities Can do a few activities Cannot do any activities
7. Frequency of pain No pain Occasional pain; 25% of Intermittent pain; 50% of Frequent pain; 75% of Constant pain; 100% of
the day the day the day the day
8. Lifting No pain with heavy weight Increased pain with Increased pain with Increased pain with light Increased pain with any
heavy weight moderate weight weight weight
9. Walking No pain; any distance Increased pain after 1 Increased pain after 1/2 Increased pain after 1/4 Increased pain with all
mile mile mile walking

Rating scales for low back pain

10. Standing No pain after several hours Increased pain after Increased pain after 1 h Increased pain after 1.5 h Increased pain with any
several hours standing
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U. G. Longo et al.

The back pain functional scale

The back pain functional scale (BPFS) (Table 21) is a self-report
measure evaluating patient’s functional status in clinical and research-
ing settings.46 Item selection was from existing questionnaires (such as
SIP,47 OLBPD,20 QBPD,34 Dallas pain questionnaire(DPQ),48 RMQ,10
MOS-36,49 PSFS50) and interviews with physical therapists. Items
reduction was performed by examining the test–retest reliability,
internal consistency, content and construct validity. The final version
of the BPFS consists of 12 items, investigating work, hobbies, home

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activities, bending or stooping, dressing shoes or socks, lifting, sleeping,
standing, walking, climbing stairs, sitting and driving. Each item is
scored with a six-point scale, in which 0 means unable to perform
activity, 1 extreme difficulty, 2 quite a bit of difficulty, 3 moderate dif-
ficulty, 4 a little bit of difficulty and 5 no difficulty. The total BPFS
score can vary from 0, representing the lowest functional level, to 60,
representing the highest functional level.
The questionnaire takes less than 5 min to complete and about 30 s
to score.

The general function score

The general function score (GFS) (Table 22) is a disease-specific instru-
ment consisting of nine items, created to measure physical disability in
patients with LBP.51 The original version consists of 17 items concerning
physical activities of daily living. The final GFS includes just 9 of the 17
original items, showing high individual correlations, validity, reliability,
responsiveness and feasibility. The final items are walking a flight of
stairs; sitting more than 30 min; standing more than 30 min; walking
more than 30 min; lifting more than 10 kg; lean over a basin; carry a
bag of groceries; make the bed and dressing. Each item can be answered
with three possible response alternatives: ‘can perform’, ‘can perform
with difficulty’ or ‘cannot perform’. These responses are respectively
scored as 0, 1 and 2 points. The total score is obtained by summing
each item’s score, but it is represented as a percentage: 0% means no
physical disability and 100% means maximal physical disability.
The questionnaire is filled out in about 2 min and scored in less than
1 min.

The patient-specific functional scale

The patient-specific functional scale (PSFS) (Table 23)50 is a patient
self-defined instrument, designed to record and measure a list of

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Table 21 The back pain functional scale.

Back pain functional scale

On the questions listed below we are interested in knowing whether you are having ANY DIFFICULTY at all with the activities because of your back problem for which you
are currently seeking attention. Please provide an answer for each activity (marking one box for each question). Today, do you or would you have any DIFFICULTY at all with
the following activities BECAUSE OF YOUR BACK PROBLEM?
Unable to perform Extreme difficulty Quite a bit of Moderate difficulty A little bit of No difficulty
activity (0 points) (1 points) difficulty (2 points) (3 points) difficulty (4 points) (5 points)
1. Any of your usual work,
housework, or school activities
2. Your usual hobbies, recreational,
or sporting activities
3. Performing heavy activities
around your home
4. Bending or stooping
5. Putting on your shoes or socks
(pantyhose)
6. Lifting a box of groceries from
the floor
7. Sleeping
8. Standing for 1 h
9. Walking a mile
10. Going up or down 2 flights of

Rating scales for low back pain

stairs (about 20 stairs)
11. Sitting for 1 h
12. Driving for 1 h
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U. G. Longo et al.

Table 22 The general function score.

General function score

Can perform Can perform with difficulty, Cannot perform, due to

(0 points) due to low back pain (1 point) low back pain (2 points)

1. Walk a staircase
2. Sit .30 min
3. Stand .30 min
4. Walk .30 min
5. Lift .10 kg
6. Lean over a basin

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7. Carry a bag of
groceries
8. Dress
9. Make the bed

Table 23 The patient-specific functional scale.

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 Rating scales for low back pain

disabilities specific for each patient. The questionnaire has three separ-
ate sections: pain question set, pain limitation section and pain inten-
sity section. The first section includes a list of activities chosen by the
patient. Patients are asked to identify the five most affected activities in
their daily living, because of the low back pain. A slightly different
version has been also described in a population with neck dysfunc-
tion,52 in which the list of activities includes only three items plus the
space for additional activities. To quantify the level of disability, each
item is scored with an 11-point scale, ranging from 0 (‘unable to

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perform activity’) to 10 (‘able to perform activity at pre-injury status
level’). The second section assesses the functional limitation from pain
during the previous 24 h. Pain limitation is also scored with an
11-point scale, ranging from 0 (‘activities have been severely limited’)
to 10 (‘activities have not been limited’). The third section measures
pain intensity during the previous 24 h. Scoring is performed using an
11-point scale, in which the orientation is reversed, because 0 means
‘no pain’ and 10 means ‘pain as bad as it can be’.
The PSFS can be administered and recorded in about 4 min. It should
be administered during history taking and prior to physical examin-
ation. The clinician should read the instructions to the patient and
record the activities, the corresponding score and the assessment date.
At subsequent reassessments, the clinician reads the follow-up instruc-
tions, and records the score of the previously identified activities and
the date.53

The outcome measure in lumbar spinal stenosis

The outcome measure in lumbar spinal stenosis (OMLSS) (Table 24) is
a short self-administered questionnaire for the assessment of patients
with lumbar spinal stenosis.54 The questionnaire includes three sec-
tions: symptom severity, physical function and patient satisfaction. The
items for each section were selected from a literature consultation and
interviews with rheumatologists and orthopaedic surgeons specialized
in spine surgery.
The symptom severity scale includes seven items: pain severity, pain
frequency, pain in the back, pain in the leg, weakness, numbness and
balance disturbance. Questions 1, 3, 4, 5 and 6 can be answered as
follows: none, mild, moderate, severe and very severe. These responses
are respectively scored with 1, 2, 3, 4 and 5 points. Also, question 2
has five possible responses scored with a five-point scale: less than once
a week (1 point); at least once a week (2 points); everyday, for at least
a few minutes (3 points); everyday, for most of the day (4 points) and
every minute of the day (5 points). However, balance disturbance has

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Table 24 The outcome measure in lumbar spinal stenosis.

Outcome measure in lumbar spinal stenosis

Item Answers Scores

In the last month, how would you describe

The pain you have had on average including pain in None 1
your back, buttocks and pain that goes down the
legs?
Mild 2
Moderate 3
Severe 4

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Very severe 5

How often have you had back, buttock or leg pain? Less than once a week 1
At least once a week 2
Everyday, for at least a few min 3
Everyday, for most of the day 4
Every minute of the day 5

The pain in your back or buttocks? None 1

Mild 2
Moderate 3
Severe 4
Very severe 5

The pain in your legs or feet? None 1

Mild 2
Moderate 3
Severe 4
Very severe 5

Numbness or tingling in your legs or feet? None 1

Mild 2
Moderate 3
Severe 4
Very severe 5

Weakness in your legs or feet? None 1

Mild 2
Moderate 3
Severe 4
Very severe 5

Problems with your balance? No, I’ve had no problems with 1

balance
Yes, sometimes I feel my balance is 3
off, or that I am not sure-footed
Yes, often I feel my balance is off, or 5
that I am not sure-footed

In the last month, on a typical day

How far have you been able to walk? Over 2 miles 1
Over 2 blocks, but less than 2 miles 2
Over 50 feet, but less than 2 blocks 3
Less than 50 feet 4

Continued

118 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 24 Continued

Outcome measure in lumbar spinal stenosis

Item Answers Scores

Have you taken walks outdoors or in malls for Yes, comfortably 1

pleasure?
Yes, but sometimes with pain 2
Yes, but always with pain 3
No 4

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Have you been shopping for groceries or other items? Yes, comfortably 1
Yes, but sometimes with pain 2
Yes, but always with pain 3
No 4

Have you walked around the different rooms in your Yes, comfortably 1
house or apartment?
Yes, but sometimes with pain 2
Yes, but always with pain 3
No 4

Have you walked from your bedroom to the Yes, comfortably 1

bathroom
Yes, but sometimes with pain 2
Yes, but always with pain 3
No 4

How satisfied are you with

The overall result of back operation? Very satisfied 1
Somewhat satisfied 2
Somewhat dissatisfied 3
Very dissatisfied 4

Relief of pain following the operation? Very satisfied 1

Somewhat satisfied 2
Somewhat dissatisfied 3
Very dissatisfied 4

Your ability to walk following the operation? Very satisfied 1

Somewhat satisfied 2
Somewhat dissatisfied 3
Very dissatisfied 4

Your ability to do housework, yard work or job Very satisfied 1

following the operation?
Somewhat satisfied 2
Somewhat dissatisfied 3
Very dissatisfied 4

Your strength in the thighs, legs and feet? Very satisfied 1

Somewhat satisfied 2
Somewhat dissatisfied 3
Very dissatisfied 4

Your balance or steadiness on your feet? Very satisfied 1

Somewhat satisfied 2
Somewhat dissatisfied 3
Very dissatisfied 4

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U. G. Longo et al.

only three answers: none (1 point), sometimes (3 points) and often

(5 points). The symptom severity scale score is calculated by summing
score of each answered item and dividing for the number of answered
questions. The score can range from 1 to 5. If more than two items are
missing, the scale score cannot be obtained.
The physical function scale consists of five questions about walking
distance, ability to walk for pleasure, for shopping, for getting around
the house and from bathroom to bedroom. All questions are scored
with a four-point scale. Questions 2, 3, 4 and 5 can be answered as

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follows: yes, comfortably (1 point); yes, but sometimes with pain
(2 points); yes, but always with pain (3 points) and no, could not
perform (4 points). Question 1 can be answered as follows: more than
2 miles (1 point), more than 2 blocks but less than 2 miles (2 points),
more than 50 feet but less than 2 blocks (3 points) and less than 50
feet (4 points). The physical function scale score is obtained by adding
up score of each answered item and dividing by the number of
answered questions. The score can range from 1 to 4. If more than two
items are missing, the scale score cannot be calculated.
The patient satisfaction scale includes six questions about satisfaction
with the overall result of the back operation, pain relief after the oper-
ation, walking ability after the operation, ability to do housework or
job after the operation, strength in the thighs, legs or feet and balance
or steadiness on feet. All questions are scored with a four-point scale
and can be answered as follows: very satisfied (1 point), somewhat sat-
isfied (2 points), somewhat dissatisfied (3 points) and very dissatisfied
(4 points). The satisfaction scale score is obtained by summing the
score of each answered item and dividing for the number of answered
questions. The score can range from 1 to 4. If the number of responses
exceed fours, the scale score can be calculated. The questionnaire is
very easy to compile and to score.

The back illness pain and disability nine-item scale

The back illness pain and disability nine-item scale (BACKILL)55
(Table 25) aims to detect disability and response to treatment in
chronic low-back pain affected patients. Items are selected from three
pre-existing validated instruments: the PAIN-FREE8, which is an
8-item version of McGill Pain Questionnaire;56 the Functional
Assessment Screening Questionnaire with five items,57,58 which is
derived from the original 15-item FASQ;59 the Oswestry low back pain
disability questionnaire with eight items, which is a shorter version of
the original OSW.20 The BACKILL includes two items for pain (aching
and tiring), and seven items for mobility (lifting, sitting for 30 min,

120 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 25 The back illness pain and disability nine-item scale.

Back illness pain and disability nine-item scale

Item Answers Scores

How is your pain?

1. Aching None 4
Mild 3
Moderate 2
Severe 1

2. Tiring None 4

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Mild 3
Moderate 2
Severe 1

Do you find
3. Sitting for 30 min Easy 4
A little difficulty 3
A lot of difficulty 2
Cannot do without help 1

4. Standing for 30 min Easy 4

A little difficulty 3
A lot of difficulty 2
Cannot do without help 1

5. Getting up from a low Easy 4

seat
A little difficulty 3
A lot of difficulty 2
Cannot do without help 1

6. Lifting I can lift heavy weights without having extra discomfort. 6

I can lift heavy weights but I get extra discomfort. 5
I can lift heavy weights only if they are conveniently positioned. 4
I can only lift light-to-medium weights if they are conveniently 3
positioned.
I can lift only very light weights. 2
I cannot lift or carry anything at all. 1

7. Walking I am able to walk any distance. 6

Discomfort prevents me from walking more than 1 mile. 5
Discomfort prevents me from walking more than 1/2 mile. 4
Discomfort prevents me from walking more than 1/4 mile. 3
I walk only a limited distance or use a cane, crutches, or a walker. 2
I am in bed most of the time or I use a wheelchair. 1

8. Travelling I can travel anywhere without extra discomfort. 6

I can travel anywhere but it gives me extra discomfort. 5
I manage trips over 2 h but with some discomfort. 4
My discomfort limits me to trips of less than 1 h duration. 3
My discomfort limits me to short, necessary trips under 30 min. 2
My discomfort prevents me from travelling except to the doctor 1
or hospital.
9. Personal care I can look after myself normally without having extra discomfort. 6
I can look after myself normally but have extra discomfort. 5
It is uncomfortable to look after myself and I am slow and 4
careful.

Continued

British Medical Bulletin 2010;94 121

U. G. Longo et al.

Table 25 Continued

Back illness pain and disability nine-item scale

Item Answers Scores

I need some help but I manage most of my personal care. 3

I need help every day in most aspects of self-care. 2
I do not get dressed, I wash with difficulty and I stay in bed. 1

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standing for 30 min, travelling, getting up from a low seat, walking
and personal care). Items about pain are scored with a four-point scale:
none (4 points), mild (3 points), moderate (2 points) and severe (1
points). Three items about mobility (standing, sitting and getting up
from a low seat) are also scored with a four-point scale: easy (4
points), a little difficulty (3 points), a lot of difficulty (2 points) and
unable to do without help (1 points). Resting mobility items are scored
with a six-point scale in which possible answers are specific for each
question. Moreover two additional items can be included (fearful and
punishing-cruel). They are scored separately from BACKILL items,
with a four-point scale. The questionnaire is self-administered and it is
easy to complete and to score.

The Bournemouth questionnaire

The Bournemouth questionnaire (BQ)60 (Table 26) is a short-form
multidimensional questionnaire designed to measure the outcomes in
back pain patients. The items included in the questionnaire were
obtained by reviewing the literature. Seven aspects of the back pain
experience were selected. These aspects were the most commonly
measured, and showed significant responsiveness to clinical change.
Domains are the following: pain intensity; ability to perform daily
activities and social activities; anxiety status; depression status; pain
interference with work activities and pain locus control. Each item
is scored with an 11-point numerical rating scale from 0 to 10. A
total score can be obtained by summing result of each item,
although the authors recommend to express the total score of
the BQ as a percentage. The questionnaire can be completed and
scored quickly.

The Dallas pain questionnaire

The DPQ48 (Table 27) is a 16-item instrument to assess the four
aspects of daily living affected by chronic back pain: day-to-day

122 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 26 The Bournemouth questionnaire.

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activities, such as pain and intensity, personal care, lifting, standing,
sitting, walking and sleeping; work and leisure activities, such as social
life, travelling and vocational; anxiety-depression status, including
anxiety and mood, emotional control and depression; and social inter-
est, such as interpersonal relationship, social support and punishing
responses. Each item is scored with a VAS, divided into five, six, seven
or eight small segments (it depends on the question). Scale extremities
are labelled with specific words (e.g. ‘no pain’/’all the time’) and with
percentage (0%/100%). For every specific question, the patient marks
the point on the scale which represents his/her condition.
For scoring, 0 points are assigned to the left-hand segment, 1 point
to the next segment, 2 points to the next segment and so on to the last
segment. Item scores are added and multiplied by a constant to obtain
the percentage of pain interference with each of four daily living
aspects evaluated by DPQ. The constant used for daily activities
section is 3, while the constant used for work/leisure activities, anxiety/
depression and social interest section is 5. The DPQ can be answered
in 3– 5 min and scored in less than 1 min.

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U. G. Longo et al.

Table 27 The Dallas pain questionnaire.

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Continued

124 British Medical Bulletin 2010;94

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Rating scales for low back pain

125
Table 27 Continued

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U. G. Longo et al.

The disability rating index

The disability rating index (DRI)61 (Table 28) is a 12-item question-
naire that allows to evaluate the physical function. The DRI includes
the following activities: dressing; outdoor walks; climbing stairs;
sitting for a longer time; standing bent over a sink; carrying a bag;
making a bed; running; light work; heavy work; lifting heavy
objects; participating in exercise/sports. The 12 items are divided
into three categories: basic daily life activities (questions 1– 4); phys-
ical activities (questions 5-8); work-related/vigorous activities (ques-

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tions 9– 12).
Each item is scored with a 100 mm VAS. Extremities of the scale are
labelled with ‘without difficulty’ (0 points) and ‘not at all’ (100
points). Patients mark a point on the line, representing their ability to
perform the daily activities included in the question list. For scoring, in
each item the distance in mm on the VAS between the zero points and
the point marked from the patient is measured. The mean of these
measurements is calculated, and the DRI score is expressed as percen-
tage. The DRI is a very quick self-administered questionnaire, and can
be scored in less than 2 min.

Jan van Breemen functional scale

Jan van Breemen functional scale (JVB)62 (Table 29) quantifies back
pain. It consists of three different domains: pain, functional capacity
and spinal mobility. The pain component includes six questions about
back pain in the past week: ‘in general’, ‘at night’, ‘during the first
hour in the morning’, ‘during sitting’, ‘during walking’ and ‘during

Table 28 The disability rating index.

Disability rating index

How do you manage the following activities? For each question, please mark one point on the line
1. Dressing (without help) Without difficulty– –Not at all
2. Out-door walks Without difficulty– –Not at all
3. Climbing stairs Without difficulty– –Not at all
4. Sitting longer time Without difficulty– –Not at all
5. Standing bent over a sink Without difficulty– –Not at all
6. Carrying a bag Without difficulty– –Not at all
7. Making a bed Without difficulty– –Not at all
8. Running Without difficulty– –Not at all
9. Light work Without difficulty– –Not at all
10. Heavy work Without difficulty– –Not at all
11. Lifting heavy objects Without difficulty– –Not at all
12. Participating in exercise/sports Without difficulty– –Not at all

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 Rating scales for low back pain

Table 29 The Jan van Breemen functional scale.

Jan van Breemen functional scale

Pain scores
How much backache did you suffer . . .. . .. . . during the last week?
1. In general 0: no pain 1 2 3 4 5 6 7 8 9 10: worst pain possible
2. At night 0: no pain 1 2 3 4 5 6 7 8 9 10: worst pain possible
3. During the first hour 0: no pain 1 2 3 4 5 6 7 8 9 10: worst pain possible
in the morning
4. During sitting 0: no pain 1 2 3 4 5 6 7 8 9 10: worst pain possible
5. During Walking 0: no pain 1 2 3 4 5 6 7 8 9 10: worst pain possible

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6. During standing 0: no pain 1 2 3 4 5 6 7 8 9 10: worst pain possible
Functional capacity scores
How well were you able to . . .. . .. . . during the last week (in relation to your back problem)?
1. Carry 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10: very good/ normal
2. Walk 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10: very good/ normal
3. Sit 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10: very good/ normal
4. Stand 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10: very good/ normal
5. Lift 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10: very good/ normal
6. Go outdoors 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10: very good/ normal
7. Sleep 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10; very good/ normal
8. Perform household 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10: very good/ normal
and hobby activities
9. Perform 0: very bad/ impossible 1 2 3 4 5 6 7 8 9 10: very good/ normal
occupational activities
Spinal mobility tests
1. Lumbar flexion index . . .. . .. . . cm
2. Lumbar flexion/extension index . . .. . .. . . cm
3. Lateral bending, fingertips to fibular head; right . . .. . .. . . cm
4. Lateral bending, fingertips to fibular head; left . . .. . .. . . cm
5. Lateral bending to the right; contraction . . .. . .. . . cm
6. Lateral bending to the right; distraction . . .. . .. . . cm
7. Lateral bending to the left; contraction . . .. . .. . . cm
8. Lateral bending to the left; distraction . . .. . .. . . cm
9. Active straight leg raising; right . . .. . .. . . 8
10. Active straight leg raising; left . . .. . .. . . 8

standing’. Each item is scored with an 11-point scale, ranging from 0

to 10. The functional capacity component includes eight questions
about the ability to perform the following tasks during the past week:
carrying, walking, standing, sitting, lifting, going outdoors, sleeping
and performing household/hobby activities. Each item is also scored
with a 0 –10 scale. The lumbar spine mobility component is measured
with the following tests: lumbar flexion index; lumbar flexion/exten-
sion index; lateral bending, fingertips to fibular head (right/left); lateral
bending to the right/left, contraction; lateral bending to the right/left,
distraction; active straight leg raising (right/left).
The complete JVB (questionnaire and physical test) requires about
20 min.

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U. G. Longo et al.

Table 30 The occupational role questionnaire.

The occupational role questionnaire

The following questions ask about the way your back pain may interfere with your job. To answer each
question, please mark one box.

Would you say that, because of back pain, A lot Somewhat A little Not at all
(3) (2) (1) (0)
1. You cut down on the amount of extra work or
overtime?
2. You work more slowly?
3. You take more frequent or longer breaks?

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4. You are less able to concentrate on your work?
5. You have fewer opportunities to upgrade your
skills?
6. You are more likely to lose your job?
7. You have less satisfaction with your job?
8. You need more help from your co-workers?

The occupational role questionnaire

The occupational role questionnaire63 (Table 30) is a short eight-item
instrument to assess the impact of back pain in workers. It consists of
two sections: productivity and satisfaction. The productivity com-
ponent includes four questions about extra work, ability to work
quickly, productivity/efficiency and quality of work. The satisfaction
component includes four questions about opportunities to improve
one’s skills, job security, job satisfaction and relations with co-workers.
Each of eight item is answered with four possible responses: ‘a lot’
(scored with 3 points); ‘somewhat’ (scored with 2 points); ‘a little’
(scored with 1 point) or ‘not at all’ (scored with 0 points). The final
score is calculated adding up item scores and it is converted to a 0–
100 scale. It is also possible to obtain two subscores, one for pro-
ductivity section and one for satisfaction section. Each of them is calcu-
lated with the same format of the final ODQ score.

The spinal pain independence measure

The spinal pain independence measure64 (Table 31) is designed to
assess the chronic LBP. It consists of three sections: activities related to
mobility, activities performed in sitting and standing and activities per-
formed in the room and bathroom. The mobility section includes five
items: mobility for short distances, mobility for moderate distances,
mobility for long distances, stair management and maximal walking
speed. The activity in sitting and standing section includes three items:
carrying loads, activity in the sitting position and activity in the

128 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 31 The spinal pain independence measure.

Spinal pain independence measure

Item Answer Score

Mobility
1. Mobility for short distances (indoors) Lies constantly in bed 0
Moves independently in a wheelchair 1
Moves with a forearm frame 2
Walks with a walking frame 3
Walks with crutches 4
Walks with two canes 5

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Walks with one cane or a leg orthosis 6
Walks without aids 7

2. Mobility for moderate distances (10 –100 m) Unable to walk 0

Walks with a walking frame 1
Walks with crutches or canes on a paved 2
and flat at surface
Walks with leg orthosis or without aids on 3
a paved surface
Walks with canes or crutches on an uneven 4
surface
Walks with one cane or orthosis on an 5
uneven surface
Walks without aids on a paved surface and/ 6
or needs short breaks
Walks without aids on an uneven surface 7

3. Mobility for long distances (more than 100 m) Unable to walk 0

Walks with a walking frame 1
Walks with crutches or canes on a paved 2
and flat at surface
Walks with leg orthosis or without aids on 3
a paved surface
Walks with canes or crutches on an uneven 4
surface
Walks with one cane or orthosis on an 5
uneven surface
Walks without aids on a paved surface and/ 6
or needs short breaks
Walks without aids on an uneven surface 7

4. Stair management 0. Unable to climb or descend stairs 0

1. Climbs one or two steps in treatment 1
session only
2. Climbs and descends three steps with 2
support or supervision of another person
3. Climbs and descends three steps with 3
support of handrail and/or crutch/cane
4. Climbs and descends a staircase with 4
support of handrail and/or crutch/cane
Climbs and descends a staircase without 5
support

Continued

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U. G. Longo et al.

Table 31 Continued

Spinal pain independence measure

Item Answer Score

5. Maximal walking speed (in the maximal Unable to walk 0

distance subject reached)
Walks slowly 2
Walks at a moderate speed 4
Walks fast 6

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Activity in the sitting and standing positions
6. Carrying loads (lifting load from a chair, mark Unable to carry loads 0
if preferred carrying with one or both hands)
Carries 1 kg for 1 min continuously 1
Carries 2 kg for 1 min continuously 2
Carries 2 kg for 5 min continuously 3
Carries 4 kg for 1 min continuously 4
Carries 4 kg for 5 min continuously 5
Carries 6 kg for 1 min continuously 6
Carries 6 kg for 5 min continuously 7
Carries 8 kg for 1 min continuously 8
Carries 8 kg for 5 min continuously 9
Carries 10 kg for 1 min continuously 10
Carries 10 kg for 5 min continuously 11
Carries 10 kg for 10 min continuously 12

7. Activity in the sitting position Incapable of activity in sitting for at least 0

5 min continuously
Active in sitting on an adapted chair for at 2
least 5 min continuously
Active in sitting on a common chair for at 5
least 5 min continuously
Active in sitting on an adapted chair for at 8
least 15 min continuously
Active in sitting on a common chair for at 10
least 15 min continuously
Active in sitting on an adapted chair for at 13
least 30 min continuously
Active in sitting on a common chair for at 15
least 30 min continuously
Active in sitting on a common chair for at 20
least 1 h continuously

8. Activity in the standing position Incapable of activity in standing for at least 0

5 min continuously
Active in standing for at least 5 min 2
continuously
Active in standing for at least 10 min 4
continuously
Active in standing for at least 20 min 6
continuously
Active in standing for at least 30 min 8
continuously

Continued

130 British Medical Bulletin 2010;94

 Rating scales for low back pain

Table 31 Continued

Spinal pain independence measure

Item Answer Score

Active in standing for at least 1 h 12

continuously

Activity indoors
9. Mobility in bed (turning in bed, raising up to Requires total assistance 0
sitting)

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Requires partial assistance 2
Independent with adaptive devices and/or 4
specific setting
Completely independent 6

10. Transfers (from bed to chair to standing) Requires total assistance 0

Requires partial assistance 2
Independent with adaptive devices and/or 4
specific setting (external support)
Completely independent 6

11. Washing lower body Requires total assistance 0

Requires partial assistance 2
Independent with adaptive devices and/or 4
specific setting (a chair, a handrail)
Completely independent 6

12. Dressing lower body Requires total assistance 0

Requires partial assistance 2
Independent with adaptive devices and/or 4
specific setting (external support)
Completely independent 6

standing position. The activity indoors section includes four items:

mobility in bed, transfers, washing lower body and dressing lower body.

The physical impairment scale

The physical impairment scale (PIS)65 (Table 32) is designed to
measure the physical impairment in patients with LBP. It includes
seven item selected from a pool of 27 physical tests by investigating
reliability, ability to discriminate patients and normal subjects, and
ability to express the disability. Physical tests included in the final
version of PIS are the following: total flexion, total extension, average
lateral flexion, average straight leg raising (SLR), spinal tenderness,
bilateral active SLR and sit-up. For each item a cut-off value is estab-
lished to differentiate illness subjects from normal subjects. Each item
is scored with 0 points if the test value is normal, or with 1 point if the
test value is pathologic. The final score of PIS ranges from 0 to 7 and it
can be expressed as percentage.

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U. G. Longo et al.

Table 32 The physical impairment scale.

The physical impairment scale

Scores

Physical test 0 1

Total flexion .878 ,878

Total extension .188 ,188
Average lateral flexion .248 ,248
Average SLR

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Female .718 ,718
Male .668 ,668
Spinal tenderness Negative Positive
Bilateral active SLR .5 s ,5 s
Sit-up .5 s ,5 s

The functional outcomes questionnaire for spinal disorders

The functional outcomes questionnaire for spinal disorders (FOQSD)66
includes the following items: ability to perform heavy activities (such
as active sports, heavy housecleaning, gardening, etc.), ability to
perform light/moderate activities (such as washing, cooking, light
cleaning, etc.), ability to perform activities (such as visiting friends,
eating out, etc.), sitting, walking, sleeping, duration of symptoms,
depression, level of pain, pain medication usage and overall satisfaction
with results.

The pain response to activity and position questionnaire

The pain response to activity and position questionnaire (PRAP)67 is a
30-item questionnaire consisting of two sections of 15 questions. One
section is related to LBP and the other section is related to leg pain. In
both groups of questions, for each item the patient describes his/her
pain as follows: ‘no pain’, ‘better’, ‘same’ or ‘worse’. The PRAP is a
patient self-report instrument.

The back pain interference scale

The back pain interference scale68 is an 18-item questionnaire to
measure the restrictions in daily activities due to the back pain. Each
question is scored with a 10-cm line scale ranging from 0 (no pain/
symptoms at all) to 10 (the worst pain/symptoms). Final score vary
from 0 to 180.
An analytic description for every score is presented in Table 33.

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British Medical Bulletin 2010;94
Table 33 Analytic description for every score.

Scale Authors Sample Domains (items)

Roland –Morris disability Roland and Morris10 Patients with low back pain aged 16 – 64 years from all Physical functions (walking, bending over, sitting, lying
questionnaire social classes down, dressing, sleeping, self-care and daily activities);

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RDQ-23 Patrick et al.7 Patients with sciatica due to lumbar disc herniation Physical functions

RDQ-18 Stratford and Binkley14 Patients with low back pain of musculoskeletal origin Physical functions
16
RDQ-16 Dionne et al. Patients with low back pain aged 18 – 75 years Physical functions
17
RDQ-two Underwood et al. Individuals with chronic back pain Physical functions
18
RDQ-7p Walsh and Radcliffe Patients with chronic low back pain Physical functions

RDQ-12 Atlas et al., 200319 Patients 18 years of age or older with sciatica due to Physical functions
intervertebral disc herniation or lumbar spinal stenosis

Oswestry disability index Fairbank et al.20 Patients with low back pain Pain intensity; personal care; lifting; walking; sitting;
standing; sleeping; sex life; social life and travelling

ODI version 2.0 Baker et al.25 Patients with chronic low back pain Pain intensity; personal care; lifting; walking; sitting;
standing; sleeping; sex life (if applicable); social life and
travelling

Revised Oswestry Hudson-Cook et al.30 Patients with acute or chronic low back pain Pain intensity; personal care; lifting; walking; sitting;
disability questionnaire standing; sleeping; social life; travelling and changing
degree of pain
modified ODI Fritz and Irrgang31 Patients with work-related acute low back pain due to Pain intensity; personal care; lifting; walking; sitting;
injury of the lumbosacral spine standing; sleeping; social life; travelling and
employment/homemaking

AAOS/MODEMS Fairbank, 199532 Patients with low back pain Personal care; lifting; walking; sitting; standing; sleeping
and travelling

Quebec back pain Kopec et al.34 Patients with back pain Daily tasks (self-care, sleeping, walking, climbing stairs,
disability scale sitting, standing, lifting large or heavy objects, bending

Rating scales for low back pain

and stooping, physical activities and houseworks)

Waddell disability index Waddell and Main36 Patients aged 20 –55 years with low back pain or sciatica Daily living activities (lifting, sitting, standing, travelling,
walking, sleeping, social life, sex life and putting on
footwear)

Million visual analogue Million et al., 198138 Patients with chronic back pain Body functions (pain, sleep, stiffness and twisting); daily
scale activities (walking, sitting, standing and work) and social
life

Continued
133
 Table 33 Continued
134

U. G. Longo et al.
Scale Authors Sample Domains (items)
39
Low back outcome score Greenough and Fraser Patients with low back pain Current pain; employment; domestic chores; sport

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activities; resting; medical treatments or consultations;
drug use; sex life and daily activities (such as sleeping,
walking, sitting, travelling, dressing)

Low back pain rating Manniche et al.40 Patients undergone first-time lumbar surgery for disc Pain (low back pain/leg pain); disability (sleeping, ability
scale prolapse, without re-operation to perform houseworks, walking, sitting, lifting,
working, dressing, driving, running, getting up from a
chair, climbing stairs, contact with people and
expectations of future pain) and physical impairment
(back muscle endurance, spinal mobility, patient mobility
and use of analgesics)

NASS lumbar spine Daltroy et al., 199633 Patients with central low back pain without radiation or Demographic data (age, sex, race, education and
outcome assessment compression of a spinal nerve root (herniated disc insurance information); medical history (diagnosis, past
instrument syndrome) or lumbar spinal stenosis or chronic low back surgeries, comorbidities, etc.); pain, neurogenic
pain syndrome or patients undergone discectomy or symptoms and function; employment history; outcomes
decompression for spinal stenosis of treatment

Clinical back pain Ruta et al.43 Patients with low back pain Body functions (pain, sleep, bending, loss of feeling and
questionnaire leg weakness) and daily activities (self-care, walking,
sitting, standing, sport, housework and resting)
Resumption of activities Williams and Myers44 Injured workers with acute low back pain Sleeping patterns; sexual activity; self-care; light and
of daily living scale heavy household chores; shopping; socializing inside and
outside home; travelling; recreational activities and paid
employment

Functional rating index Feise and Menke45 Patients seeking professional care for spinal pain and Daily activities (sleeping, self-care, travel, work,
dysfunction (cervical, thoracic, lumbar) at chiropractic recreation, lifting, walking and standing) and pain
practices (intensity and frequency)

Back pain functional Stratford et al.46 Patients of ages 18 –79 years affected by LBP of Functional status of patient (work, hobbies, home
scale suspected musculoskeletal origin activities, bending or stooping, dressing shoes or socks,
lifting, sleeping, standing, walking, climbing stairs,
British Medical Bulletin 2010;94

sitting and driving)

General Function Score Hägg et al.51 Patients with chronic low back pain; patients with Physical activities of daily living (walking a flight of
different low back disorders admitted for surgery; stairs; sitting more than 30 min; standing more than
patients operated for lumbar disc herniation and 30 min; walking more than 30 min; lifting more than
patients undergone posterolateral fusion for isthmic 10 kg; lean over a basin; carry a bag of groceries; make
lumbosacral spondylolisthesis; outpatients with spinal the bed and dressing)
disorders
British Medical Bulletin 2010;94
Patient-specific Stratford et al.50 Patients of ages 12 – 80 years with neck pain of Pain question set; pain limitation section and pain
functional scale suspected musculoskeletal origin intensity section

Outcome measure in Stucki et al., 199654 Patients with low back pain and/or leg pain undergone Symptom severity (pain severity, pain frequency, pain in
lumbar spinal stenosis surgery for lumbar spinal stenosis the back, pain in the leg, weakness, numbness and
balance disturbance); physical function (walking

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distance, ability to walk for pleasure, for shopping, for
getting around the house and from bathroom to
bedroom) and patient satisfaction (overall result of the
back operation, pain relief after the operation, walking
ability after the operation, ability to do housework or
job after the operation, strength in the thighs, legs, or
feet, and balance or steadiness on feet)

Back illness pain and Tesio et al.55 Chronic low-back pain patients with herniation or Pain (aching and tiring) and mobility (lifting, sitting for
disability 9-item scale protrusion of at least one lumbar disc 30 min, standing for 30 min, travelling, getting up from a
low seat, walking and personal care)

Bournemouth Jennifer et al.60 Patients with back pain Pain intensity; ability to perform daily activities and
questionnaire social activities; anxiety status; depression status; pain
interference with work activities and pain locus control

Dallas pain Lawlis et al., 198948 Chronic low-back pain patients of ages 21 –61 years Day-to-day activities (pain and intensity, personal care,
questionnaire lifting, standing, sitting, walking and sleeping); work
and leisure activities (social life, travelling and
vocational); anxiety-depression status (anxiety and mood,
emotional control and depression) and social interest
(interpersonal relationship, social support and punishing
responses)

Disability Rating Index Salén et al. Patients with neck/shoulder/low-back pain Basic daily life activities (dressing, outdoor walks,
climbing stairs and sitting for a longer time); physical
activities (standing bent over a sink, carrying a bag,
making a bed and running) and work-related/vigorous
activities (light work, heavy work, lifting heavy objects

Rating scales for low back pain

and participating in exercise/sports)

Continued
135
 Table 33 Continued
136

U. G. Longo et al.
Scale Authors Sample Domains (items)
62
Jan van Breemen Lankhorst et al., 1982 Patients affected by idiopathic low back pain Pain (back pain ‘in general’, ‘at night’, ‘during the first

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functional scale hour in the morning’, ‘during sitting’, ‘during walking’
and ‘during standing’); functional capacity (carrying,
walking, standing, sitting, lifting, going outdoors,
sleeping and performing household/hobby activities) and
lumbar spine mobility (lumbar flexion/extension; lateral
bending, fingertips to fibular head (right/left); lateral
bending to the right/left, contraction; lateral bending to
the right/left, distraction and active straight leg raising)

Occupational role Kopec and Esdaile63 Individuals employed and worked with chronic back Productivity (extra work, ability to work quikly,
questionnaire pain productivity/efficiency and quality of work) and
satisfaction (opportunities to improve one’s skills, job
security, job satisfaction and relations with co-workers)

Spinal pain Itzkovich et al., 200164 Patients with chronic low back pain Mobility (mobility for short distances, mobility for
independence measure moderate distances, mobility for long distances, stair
management and maximal walking speed); activity in
sitting and standing (carrying loads, activity in the sitting
position and activity in the standing position) and
activity indoors (mobility in bed, transfers, washing lower
body and dressing lower body)

Physical impairment Waddell et al.65 Patients with chronic low back pain with or without Physical impairment (total flexion, total extension,
scale referred pain into the buttock(s) or thigh(s) average lateral flexion, average straight leg raising (SLR),
spinal tenderness, bilateral active SLR and sit-up)

Functional outcomes Nork et al.66 Patients with low back pain with or without leg pain Ability to perform heavy activities; ability to perform
questionnaire for spinal due to degenerative spondylolisthesis with or without light/moderate activities; ability to perform activities
disorders multilevel spinal stenosis (such as visiting friends, eating out, etc.); sitting;
walking; sleeping; duration of symptoms; depression;
level of pain; pain medication usage and overall
satisfaction with results
British Medical Bulletin 2010;94

Pain response to activity Roach et al.67 Patients with low back pain Low back pain and leg pain
and position
questionnaire

Back pain interference Rytokoski et al.68 Patients with chronic low back Activities of daily living
scale
 Rating scales for low back pain

Discussion
A wide variety of rating systems to measure functional outcomes in
patients with LBP have been described in the past decades. Each of
them evaluates low back performance using specific variables, includ-
ing both objective and subjective criteria. Also, when the same vari-
ables are evaluated, different weight is attributed to the single domain.
Interpreting these domains becomes difficult, because, even though
they can be common to more than one scoring system, each stresses

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them in a different way. Functional status measures are usually classi-
fied as generic or disease specific.69 Generic measures allow one to
evaluate symptoms, functions or organ systems, which are not necess-
arily spine related; moreover they can be used in all kind of patients.
Disease-specific measures assess symptoms and functional limitations
related to a specific disease/condition, so in the back pain patient back-
related problems are focused.5 Usually, physicians and researchers use
both functional status measures.
Although many back pain score systems are available, the most used
in clinical and research settings are: RDQ, ODI, QBPDS, WDI, MVAS,
LBOS, LBPRS, NASS and CBPQ.
The RDQ is a health status measure created to assess physical disabil-
ity from LBP and it is one of the most used in research or clinical set-
tings for monitoring patients.
The RDQ is validated in English,10 French,70 German,71 Greek,72
Portuguese,73 Spanish,74 Swedish,75 Turkish,76 Norwegian,77 Iranian,78
Moroccan.79
The questionnaire is simple to complete and easily understood by
patients. Patients completing the RDQ have to mark statements which
describe themselves that day. The RDQ score correlate well with the
data obtained from other physical function score systems, such as the
QBPDS34 and the ODI.20 The RDQ has good construct validity,
internal consistency, responsiveness and reliability.13 The test–retest
reliability when the test– retest interval is short (24 h) is better than
when the test– retest interval is long.
On the basis of the validation study conducted by Roland and
Morris, the RDQ should be applied for disability assessment when
there is the need to detect short-term changes in back pain or short-
term changes in response to treatment. On the contrary, because of the
absence of specific domains in the scale, the RDQ is inadequate when
the clinicians want to assess the psychological or social problems
related to the patient’s LBP.10 For these reason, the RDQ should be
integrated with other appropriate outcome measures when this kind of
evaluation is required.

British Medical Bulletin 2010;94 137

U. G. Longo et al.

The ODI is a functional status outcome measure widely used in the

clinical management of spinal disorders. It is validated in English,20
Finnish,80,81 French,82 German,83 Greek,72 Norwegian,77 Iranian.78
The questionnaire is quick to complete and has good construct validity,
pointed out by internal consistency, responsiveness and reliability. The
ODI and RDQ scores are highly correlated, with similar test–retest
reliability and internal consistency.25
In a recent review by Fairbank and Pynsent21, the authors rec-
ommend the use of ODI version 2.0 to detect meaningful changes in

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disability status in every day life, as when using the RDQ. However,
the RDQ is recommended in patients with mild/moderate disability,
whereas the ODI is recommended in patients with persistent severe dis-
ability.13 Moreover, unlike the RDQ, the ODI allows one to investigate
the patient’s social problems and sexual life.
The QBPDS is a condition-specific instrument,34 which assesses only
functional disability and sleep, while it does not evaluate pain. The
QBPDS is validated in English, Dutch,84 French35 and Iranian.78
Because of a few validated translations to other languages, it is not as
often used as the RDQ or the ODI. Internal consistency, test–retest
reliability and responsiveness are satisfactory.34
In the validation study by Kopec et al.,34 the QBPDS is recommended
both as outcome measurement in clinical trials and as a monitor for
the patients’ progresses during treatment and rehabilitation programs.
Furthermore, it resulted more reliable and at least as sensitive to
change when compared with the ODI and RDQ, although some
authors found that the test– retest reliability and responsiveness are
better for the modified ODI than the QBPDS.31 However, in the assess-
ment of patients affected by LBP, the QBPDS needs to be associated
with an independent pain assessment tool.85 Moreover, it does not
allow to investigate patient’s social and sex life, as these items are not
included in the score.
The WDI is a short nine-item score system consisting of questions
about daily activities. It is validated in English,36 Spanish and is also
available in an unvalidated French version.86 Internal consistency is
higher in the WDI than in the RDQ, but it is lower than in the ODI.87
Responsiveness is good: the questionnaire is sensible for clinical change
4 weeks after surgery.43 Following the indications given in the vali-
dation study by Waddell and Main36, in clinical settings, the WDI
should be associated with other functional scoring systems to obtain a
more complete assessment of disability by evaluating daily living activi-
ties commonly restricted by LBP.
The MVAS is a 15-item questionnaire evaluating disability and pain
intensity in patients affected by LBP. The main advantage of MVAS
scale is that it is easy to use. Despite its good reliability and internal

138 British Medical Bulletin 2010;94

 Rating scales for low back pain

consistency, it should be applied only when previous score are not

available because it has received limited validation, and some of its
questions could lead to inaccurate answers. As reported in the vali-
dation study by Million et al.,38 the correlation between results by
different observers is not always satisfactory.
The LBOS is a self-reporting measure for both assessment and
outcome in patients with LBP. The LBOS should be applied when
physicians need a short general assessment of current or previous back
pain, medical treatments, employment, daily activities, sport activities,

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sex life, etc. Moreover, it is helpful in clinical settings because it is easy
to administer and clearly discriminates between pain and disability.88
Test–retest reliability is high, the internal consistency is good89 and it
correlates well with the ODI and the WDI.90 Nevertheless, in the
LBOS score pain is assessed independently and other items are scored
with different scale.5 In this way, there is an item-weighting bias,
because the total score gives different weight to questions.84 Moreover,
the LBOS is validated in English.39
The LBPRS is a rating system evaluating the clinical outcome of
LBP patients in clinical settings. It assesses pain, disability and
physical impairment with a good internal consistency.42 It is avail-
able in English and validated in Danish.40 The score is influenced
by a weighting bias due to the difference in the scoring of pain
(obtained with 11-point VAS scale) and scoring of all other items
(obtained with a three-point Likert scale).88 Despite its limitations,
including the small number of patients recruited for the validation
study, the LBPRS score is recommended in the evaluation of func-
tional pain.42
The NASS LSO is another questionnaire designed for the assess-
ment and outcome measurements of patients with LBP. It is vali-
dated in English,33 German91 and Italian.92 It represents a complete
outcome assessment in which pain is a very dominant factor
assessed with several measurements. In contrast to the ODI and
other LBP assessment scales, pain can be indicated clearly by using
a pain locator (picture where patient has to mark the location of
pain).84 In the validation study, the authors clearly pointed out
how the NASS LSO does not claim to contain the best scales at all
but, given its good reliability, validity and easiness in the adminis-
tration, it should be taken in consideration whenever the clinicians
need to monitor patients’ progress during treatment. Moreover, it
allows pooling of data and it could result useful in clinical trials on
LBP treatments.33
The CBPQ, also known as the Aberdeen LBP scale, is a clinical
assessment questionnaire consisting of questions about body functions
and questions about daily activities. It is validated in English43 and

British Medical Bulletin 2010;94 139

U. G. Longo et al.

Chinese.93 Internal consistency, test–retest correlation and responsive-

ness are acceptable.43 However, the CBPQ gives different weights to
the questions, pointed out by the various answering scales. In the vali-
dation study by Ruta et al.88, the CBPQ scale is meant to be used in
association with a general evaluation of the patient (such as the one
given by SF-36) to identify health gain that enable those who treat
back pain to justify their claims on scarce resources. Nevertheless,
given the structural problems previously reported, the questionnaire is
of limited value.

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Grotle et al.,9 according to the three ICF perspectives of health
(bodily, personal and social perspective), proposed a division of LBP
rating systems into four group: (i) questionnaires mainly assessing
activity limitations; (ii) questionnaires mainly assessing activity limit-
ations and few social functions; (iii) questionnaires assessing a mix of
activity limitations and impairments; and (iv) questionnaires assessing
items derived from all domain of functioning.
Most scores do not appear to have been constructed in a systematic
fashion using recommended methodology. There is an increasing need
for orthopaedic surgeons both to be familiar with and to routinely use
objective measures of outcome for their procedures.94 There is a trend
towards the increased use of validated patient-based scores, but many
have not been properly tested for validity, repeatability and sensitivity
to change. Scores are not valid when used in a modified form and their
use should be discouraged. One of the further areas of study is to
compare and contrast two or more scoring scale, to ascertain whether
they address the same category of low back function. In conclusion,
although many scoring systems have been used to evaluate the low
back function, we are still far from a single outcome evaluation system,
which is reliable, valid and sensitive to clinically relevant changes,
which takes into account both patients’ and physicians perspective, and
which is short and practical to use.

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