Score : 1

Instructions: Please answer the below questions.

Back and Leg Pain

1. Back pain at the time of the examination

2. Leg pain at the time of the examination

3. The worst back pain within the last 2 weeks

4. The worst back pain within the last 2 weeks

5. Average level of back pain during the last 2 weeks

6. Answer the door or telephone

Disability Index

7. Can you sleep at night without low back pain interfereing?

8. Can you do your daily work without low back pain reducing your activities?

9. Can you do the easy chores at home such as watering flowers or cleaning the table?

10. Can you put on shoes and stockings by yourself?

11. Can you carry two full shopping bags (10 kilograms total)?

12. Can you get up from a low armchair without difficulty?

13. Can you bend over the wash basin to brush your teeth?

14. Can you climb stairs from one floor to another without resting because of low back pain?

15. Can you walk 400 meters without resting because of low back pain?

16. Can you run 100 meters without resting because of low back pain?

17. Can you ride a bike or drive a car without feeling any low back pain?

18. Does low back pain influence your emotional relationship to your nearest family?

19. Did you have to give up contact with other people within the last 2 weeks because of low back pain?

20. If it was a present interest do you think that there are certain jobs which you would not be able to manage because of your back trouble?

21. Do you think that the low back pain will influence your future?

Physical Impairment

22. Endurance of back muscles:length of time that the patient can lie horizontal above the floor with the legs strapped to a bench and the trunk unsupported from the level of the iliac crest


23. Back mobility: Modified Schober's test

  1. draw a line between the posterior iliac spines then
  2. identify a point 10 cm above the midpoint of the line then
  3. with the person bending forward measure the distance from that point to the midpoint of the line connecting the posterior iliac spines and
  4. determine the distraction = increase in measuremnt while bending forward.

24. Overall mobility: Fastest time taken to go from

  1. lying supine on a flat couch 80 cm above the floor to
  2. standing beside the couch then
  3. walking to the end of the couch where
  4. a deep knee bend is done and then
  5. return to the starting position.

25. Use of analgesics: Based on the frequency of use for non-narcotic and narcotic analgesics


Bibliographic References (copyright belongs to the author/s of this instrument):

  1. Christensen, T. H., Bliddal, H., Hansen, S. E., Jensen, E. M., Jensen, H., Jensen, R., & Bay, H. (1993). Severe low-back pain. I: Clinical assessment of two weeks conservative therapy.
  2. Kalidindi, K. K. V., Patro, D. K., & Sharma, D. (2016). Significance of sub grouping patients with chronic low back pain in management decisions: A prospective study.
  3. Lauridsen, H. H., Hartvigsen, J., Manniche, C., Korsholm, L., & Grunnet-Nilsson, N. (2006). Responsiveness and minimal clinically important difference for pain and disability instruments in low back pain patients.
  4. Manniche, C., Asmussen, K., Lauritsen, B., Vinterberg, H., Kreiner, S., & Jordan, A. (1994). Low Back Pain Rating Scale: Validation of a tool for assessment of low back pain.
  5. Muller, U., Duetz, M. S., Roeder, C., & Greenough, C. G. (2004). Condition-specific outcome measures for low back pain. Part I: Validation.