"Modified Oswestry Low Back Pain Disability Questionnaire Form"

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Modified Oswestry Low Back Pain Disability Questionnaire
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.
Pain Intensity
Sitting
I can tolerate the pain I have without having to use
I can sit in any chair as long as I like.
pain medication.
I can only sit in my favorite chair as long as I like.
The pain is bad, but I can manage without having
Pain prevents me from sitting for more than 1 hour.
to take pain medication.
Pain prevents me from sitting for more than
Pain medication provides me with complete relief
1/2 hour.
Pain prevents me from sitting for more than
from pain.
Pain medication provides me with moderate relief
10 minutes.
from pain.
Pain prevents me from sitting at all.
Pain medication provides me with little relief
from pain.
Standing
Pain medication has no effect on my pain.
I can stand as long as I want without increased pain.
I can stand as long as I want, but it increases
Personal Care (e.g., Washing, Dressing)
my pain.
I can take care of myself normally without causing
Pain prevents me from standing for more than
increased pain.
1 hour.
I can take care of myself normally, but it increases
Pain prevents me from standing for more than
my pain.
1/2 hour.
It is painful to take care of myself, and I am slow
Pain prevents me from standing for more than
and careful.
10 minutes.
I need help, but I am able to manage most of my
Pain prevents me from standing at all.
personal care.
I need help every day in most aspects of my care.
Sleeping
I do not get dressed, I wash with difficulty, and I
Pain does not prevent me from sleeping well.
stay in bed.
I can sleep well only by using pain medication.
Even when I take medication, I sleep less than
Lifting
6 hours.
I can lift heavy weights without increased pain.
Even when I take medication, I sleep less than
I can lift heavy weights, but it causes increased pain.
4 hours.
Pain prevents me from lifting heavy weights off
Even when I take medication, I sleep less than
the floor, but I can manage if the weights are
2 hours.
conveniently positioned (e.g., on a table).
Pain prevents me from sleeping at all.
Pain prevents me from lifting heavy weights, but
I can manage light to medium weights if they are
Social Life
conveniently positioned.
My social life is normal and does not increase
I can lift only very light weights.
my pain.
I cannot lift or carry anything at all.
My social life is normal, but it increases my level
of pain.
Walking
Pain prevents me from participating in more
Pain does not prevent me from walking any distance.
energetic activities (e.g., sports, dancing).
Pain prevents me from walking more than 1 mile.
Pain prevents me from going out very often.
(1 mile = 1.6 km).
Pain has restricted my social life to my home.
Pain prevents me from walking more than 1/2 mile.
I have hardly any social life because of my pain.
Pain prevents me from walking more than 1/4 mile.
I can walk only with crutches or a cane.
I am in bed most of the time and have to crawl to
the toilet.
Please complete questionnaire on other side.
a
Modified Oswestry Low Back Pain Disability Questionnaire
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.
Pain Intensity
Sitting
I can tolerate the pain I have without having to use
I can sit in any chair as long as I like.
pain medication.
I can only sit in my favorite chair as long as I like.
The pain is bad, but I can manage without having
Pain prevents me from sitting for more than 1 hour.
to take pain medication.
Pain prevents me from sitting for more than
Pain medication provides me with complete relief
1/2 hour.
Pain prevents me from sitting for more than
from pain.
Pain medication provides me with moderate relief
10 minutes.
from pain.
Pain prevents me from sitting at all.
Pain medication provides me with little relief
from pain.
Standing
Pain medication has no effect on my pain.
I can stand as long as I want without increased pain.
I can stand as long as I want, but it increases
Personal Care (e.g., Washing, Dressing)
my pain.
I can take care of myself normally without causing
Pain prevents me from standing for more than
increased pain.
1 hour.
I can take care of myself normally, but it increases
Pain prevents me from standing for more than
my pain.
1/2 hour.
It is painful to take care of myself, and I am slow
Pain prevents me from standing for more than
and careful.
10 minutes.
I need help, but I am able to manage most of my
Pain prevents me from standing at all.
personal care.
I need help every day in most aspects of my care.
Sleeping
I do not get dressed, I wash with difficulty, and I
Pain does not prevent me from sleeping well.
stay in bed.
I can sleep well only by using pain medication.
Even when I take medication, I sleep less than
Lifting
6 hours.
I can lift heavy weights without increased pain.
Even when I take medication, I sleep less than
I can lift heavy weights, but it causes increased pain.
4 hours.
Pain prevents me from lifting heavy weights off
Even when I take medication, I sleep less than
the floor, but I can manage if the weights are
2 hours.
conveniently positioned (e.g., on a table).
Pain prevents me from sleeping at all.
Pain prevents me from lifting heavy weights, but
I can manage light to medium weights if they are
Social Life
conveniently positioned.
My social life is normal and does not increase
I can lift only very light weights.
my pain.
I cannot lift or carry anything at all.
My social life is normal, but it increases my level
of pain.
Walking
Pain prevents me from participating in more
Pain does not prevent me from walking any distance.
energetic activities (e.g., sports, dancing).
Pain prevents me from walking more than 1 mile.
Pain prevents me from going out very often.
(1 mile = 1.6 km).
Pain has restricted my social life to my home.
Pain prevents me from walking more than 1/2 mile.
I have hardly any social life because of my pain.
Pain prevents me from walking more than 1/4 mile.
I can walk only with crutches or a cane.
I am in bed most of the time and have to crawl to
the toilet.
Please complete questionnaire on other side.
2
Traveling
Employment / Homemaking
I can travel anywhere without increased pain.
My normal homemaking / job activities do not
I can travel anywhere, but it increases my pain.
cause pain.
My pain restricts my travel over 2 hours.
My normal homemaking / job activities increase
My pain restricts my travel over 1 hour.
my pain, but I can still perform all that is required
My pain restricts my travel to short necessary
of me.
journeys under 1/2 hour.
I can perform most of my homemaking / job
My pain prevents all travel except for visits to the
duties, but pain prevents me from performing
physician / therapist or hospital.
more physically stressful activities (e.g., lifting,
vacuuming).
Pain prevents me from doing anything but
light duties.
Pain prevents me from doing even light duties.
Pain prevents me from performing any job or
homemaking chores.
FOR OFFICE USE ONLY
Score: /50 x 100 = ____% points
Scoring: For each section the total possible score is 5: if the first statement is marked the section score = 0, if the last
statement is marked it = 5. If all ten sections are completed the score is calculated as follows:
Example:
16 (total scored)
50 (total possible score) x 100 = 32%
If one section is missed or not applicable the score is calculated:
16 (total scored)
45 (total possible score) x 100 = 35.5%
Minimum Detectable Change (90% confidence): 10%points (Change of less than this amount may be attributed to
error in the measurement.)
Name: _________________________________________________________________
Date: ______________________
Source: Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability
Questionnaire and the Quebec Back Pain Disability Scale. Physical Therapy. 2001;81:776-788.
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Modified by Fritz & Irrgang with permission of The Chartered Society of Physiotherapy, from
Fairbanks JCT, Couper J, Davies JB, et al. The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy.
1980;66:271-273.
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