The Revised Oswestry Disability Index Form (For Low Back Pain Dysfunction)

The   R evised   O swestry   D isability   I ndex   ( for   l ow   b ack   p ain/dysfunction)  

 

Name:  ____________________________________   File   #   _____________     Date:     ____   /   _ ___   /   _ ___    

 

mm  

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This   q uestionnaire   h as   b een   d esigned   t o   g ive   y our   t herapist   i nformation   a s   t o   h ow   y our   b ack   p ain   h as   a ffected  

your   a bility   t o   m anage   i n   e veryday   l ife.   P lease   a nswer   e very   q uestion   b y   p lacing   a   m ark   i n   t he   o ne   b ox   t hat  

best   d escribes   y our   c ondition   t oday.   W e   r ealize   y ou   m ay   f eel   t hat   t wo   o f   t he   s tatements   m ay   d escribe   y our  

condition,   b ut   p lease   m ark   o nly   t he   b ox,   w hich   m ost   c losely   d escribes   y our   c urrent   c ondition.  

 

Section   1 :   P ain   I ntensity  

Section   6 :   S tanding  

☐   The   p ain   c omes   a nd   g oes   a nd   i s   v ery   m ild.  

☐   I   c an   s tand   a s   l ong   a s   I   w ant   w ithout   p ain.  

☐   The   p ain   i s   m ild   a nd   d oes   n ot   v ary   m uch.  

☐   I   h ave   s ome   p ain   w hen   s tanding,   b ut   i t   d oes   n ot   i ncrease  

☐   The   p ain   c omes   a nd   g oes   a nd   i s   m oderate.  

with   t ime.  

☐   The   p ain   i s   m oderate   a nd   d oes   n ot   v ary   m uch.    

☐   Pain   p revents   m e   f rom   s tanding   m ore   t han   1   h our.  

☐   The   p ain   c omes   a nd   g oes   a nd   i s   v ery   s evere.  

☐   Pain   p revents   m e   f rom   s tanding   m ore   t han   1 /2   h our.  

☐   The   p ain   i s   s evere   a nd   d oes   n ot   v ary   m uch.  

☐   Pain   p revents   m e   f rom   s tanding   m ore   t han   1 0   m inutes.  

 

☐   Pain   p revents   m e   f rom   s tanding   a t   a ll.  

Section   2 :   P ersonal   C are  

 

☐   I   d o   n ot   h ave   t o   c hange   m y   w ay   o f   w ashing   o r   d ressing   t o  

Section   7 :   S leeping  

avoid   p ain.  

☐   I   h ave   n o   p ain   i n   b ed.  

☐   I   d o   n ot   n ormally   c hange   m y   w ay   o f   w ashing   o r   d ressing,   e ven  

☐   I   h ave   p ain   i n   b ed,   b ut   i t   d oes   n ot   p revent   m e   f rom  

though   i t   c auses   s ome   p ain.  

sleeping   w ell.  

☐   Washing   a nd   d ressing   i ncrease   t he   p ain,   b ut   I   m anage   n ot   t o  

☐   Because   o f   p ain,   m y   s leep   i s   r educed   b y   l ess   t han   1 /4.  

change   m y   w ay   o f   d oing   i t.  

☐   Because   o f   p ain,   m y   s leep   i s   r educed   b y   l ess   t han   1 /2.  

☐   Washing   a nd   d ressing   i ncrease   t he   p ain   a nd   I   f ind   i t   n ecessary   t o  

☐   Because   o f   p ain,   m y   s leep   i s   r educed   b y   l ess   t han   3 /4.  

change   m y   w ay   o f   d oing   i t.  

☐   Pain   p revents   m e   f rom   s leeping   a t   a ll.  

☐   Because   o f   t he   p ain,   I   a m   u nable   t o   d o   s ome   w ashing   a nd  

 

dressing   w ithout   h elp.    

Section   8 :   S ocial   L ife  

☐   Because   o f   t he   p ain,   I   a m   u nable   t o   d o   a ny   w ashing   a nd   d ressing  

☐   My   s ocial   l ife   i s   n ormal   a nd   c auses   n o   p ain.  

without   h elp.  

☐   My   s ocial   l ife   i s   n ormal,   b ut   i t   i ncreases   t he   d egree   o f   p ain.  

 

☐   Pain   h as   n o   s ignificant   e ffect   o n   m y   s ocial   l ife   a part   f rom   l imiting   m y  

 

more   e nergetic   i nterests   ( e.g.,   d ancing,   e tc.)  

Section   3 :   L ifting  

☐   Pain   h as   r estricted   m y   s ocial   l ife   a nd   I   d o   n ot   g o   o ut   v ery   o ften.  

☐   I   c an   l ift   h eavy   w eights   w ithout   i ncreased   p ain.  

☐   Pain   h as   r estricted   m y   s ocial   l ife   t o   m y   h ome.  

☐   I   c an   l ift   h eavy   w eights,   b ut   i t   c auses   i ncreased   p ain.  

☐   I   h ave   h ardly   a ny   s ocial   l ife   b ecause   o f   m y   p ain.  

☐   Pain   p revents   m e   f rom   l ifting   h eavy   w eights   o ff   t he   f loor,   b ut   I  

 

can   m anage   i f   t he   w eights   a re   c onveniently   p ositioned   ( e.g.,   o n  

Section   9 :   T raveling  

a   t able).    

☐   I   h ave   n o   p ain   w hile   t raveling.  

☐   Pain   p revents   m e   f rom   l ifting   h eavy   w eights   o ff   t he   f loor.  

☐   I   h ave   s ome   p ain   w hile   t raveling,   b ut   n one   o f   m y   u sual   f orms   o f   t ravel  

☐   Pain   p revents   m e   f rom   l ifting   h eavy   w eights,   b ut   I   c an   m anage  

make   i t   a ny   w orse.  

light   t o   m edium   w eights,   i f   t hey   a re   c onveniently   p ositioned.  

☐   I   h ave   e xtra   p ain   w hile   t raveling,   b ut   i t   d oes   n ot   c ompel   m e   t o   s eek  

☐   I   c an   o nly   l ift   v ery   l ight   w eights   a t   t he   m ost.  

alternate   f orms   o f   t ravel.  

 

☐   I   h ave   e xtra   p ain   w hile   t raveling,   w hich   c ompels   m e   t o   s eek   a lternate  

Section   4 :   W alking  

forms   o f   t ravel.  

☐   I   h ave   n o   p ain   w hen   w alking.    

☐   Pain   r estricts   a ll   f orm   o f   t ravel.  

☐   I   h ave   s ome   p ain   w ith   w alking,   b ut   i t   d oes   n ot   i ncrease  

☐   Pain   p revents   a ll   f orm   o f   t ravel   e xcept   t hat   d one   l ying   d own.  

with   d istance.  

 

☐   Pain   p revents   m e   f rom   w alking   m ore   t han   1   m ile.  

Section   1 0:   C hanging   D egree   o f   P ain  

☐   Pain   p revents   m e   f rom   w alking   m ore   t han   1 /2   m ile.  

☐   My   p ain   i s   r apidly   g etting   b etter.  

☐   Pain   p revents   m e   f rom   w alking   m ore   t han   1 /4   m ile.  

☐   My   p ain   f luctuates,   b ut   i s   d efinitely   g etting   b etter.  

☐   I   c annot   w alk   a t   a ll   w ithout   i ncreasing   p ain.  

☐   My   p ain   s eems   t o   b e   g etting   b etter,   b ut   i mprovement   i s   s low   a t  

 

present.  

Section   5 :   S itting  

☐   My   p ain   i s   n either   g etting   b etter   n or   w orse.    

☐   I   c an   s it   i n   m y   c hair   a s   l ong   a s   I   l ike.  

☐   My   p ain   i s   g radually   w orsening.    

☐   I   c an   o nly   s it   i n   m y   f avorite   c hair   a s   l ong   a s   I   l ike.  

☐   My   p ain   i s   r apidly   w orsening.  

☐   Pain   p revents   m e   f rom   s itting   f or   m ore   t han   1   h our.  

☐   Pain   p revents   m e   f rom   s itting   f or   m ore   t han   1 /2   h our.  

☐   Pain   p revents   m e   f rom   s itting   f or   m ore   t han   1 0   m inutes.  

☐   I   a void   s itting   b ecause   i t   i ncreases   p ain   r ight   a way.