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| Oswestry Disability Index | Neck Disability Index | Roland-Morris Disability Questionnaire | Stanford Score | Disability & Anxiety |

As a health-care provider, it is imperative that we have a standard method to assess a patient's level of pain and disability. Or, to put that in 'plain English', us doctors need to have a way to measure peoples level of pain, suffering and the inability to work and play. To help us achieve this, there are some classic tools that are utilized and accepted:

FUNCTIONAL PAIN ASSESSMENT: How is the patient disabled from everyday work & life?

The Oswestry Disability Index (2) and the Roland-Morris Disability Questionnaire (22) are hands-down the most commonly used and recommened outcome measure tools used for assessing the disabling effects of lumbar spinal disorders. (28,34,53) The Stanford Score is an attempt to combine the level of the patients functional disability and subjective disability. It's a good idea but has really never caught on; however, I really like this scale and maybe can give it a 'push' into the lime light.

For the cervical spine, we have a tool called the Neck Disability Index that is hands down the most frequently used functional outcome tool for cervical related disabilities. This outcome assessement tool was created by modifing the Oswestry Disability Index and is extremely relialbe. (26)

The MacNab Criteria:

Each patient’s clinical data, which included chart notes; MRI images; discography results; surgery noted & video; and any follow-up assessment notes, were reviewed independently by doctor Tsou. The patient outcome results were graded as either excellent, good, fair, or poor based on the MacNab criteria (51) and a modification: if the patient answered yes or true to any of the following questions, an automatic ‘poor’ results was assigned: 1) Since my arthroscopic back surgery, my back/leg pain is no better or worse than before surgery; 2) I had a reoperation at the arthroscopic back surgery level; 3) My arthroscopic back surgery was not satisfactory; and 4) I will not select arthroscopic back surgery again if I encounter similar back problems in the future.   IF none of the latter four statements applied to the patient, than the patients were placed into one of the following categories based on the MacNab Criteria: 1) No pain and no functional resthistrictions = Excellent Rating; 2) Occasional back/leg pain, brief functional restrictions = Good Rating; and 3) Improved overall function, permanent work and activities of daily living modification = Fair. (poor was not defined). 

The Prolo Scale (Prolo Economic Scale, Prolo Score) [23]: This is a 10-point scale consisting of only two questions evaluating the functional and economic status of the patient. Score of 9 and 10 are considered excellent; however, scores less then 4 are considered poor. It can be described as an outcome disability tool (originally designed for use as an outcome measurement for patients in whom underwent posterior lumbar interbody fusions) measures economic and functional status of the patient before and after treatment. It is well known in the neurosurgical community [24]. It is relatively easy to use but is not used that often [93]–VAS and Oswestry score are probably the two most common. Also because of the simplicity of the scale, it may not tell the full story because there is no pain scale or analgesic usage incorporated into the scale. There is also a modified Prolo scale frequently for use in patients in whom underwent cervical operative procedures.

Medical Outcomes Study Short-Form 36 (SF-36 or MOS): Another old faithful is a test called, for short, the SF-36. This is a 36-item survey that can be administered via direct interview, telephone interview, or even by the patient alone. This outcome tool assesses the patient's concept of their own health in eight categories: physical functioning, limitations due to their physical problems, limitations due to there emotional problems, social ability to function, body pain, general mental health, vitality, and general health perceptions [19]. The SF-36 has been validated in investigations [26, 27] and is widely accepted as a general outcome measure. (you can take it here SF-36 or here for licensing).

Euro quality of Life: Another one that was reported by a group of Harvard researchers in the nucleoplasty meta-analysis is the EQ5D (Euro Quality of Life 5 D).

Another functional test that I've seen thrown around is called the "North American Spine Society Lumbar Spine Outcome Assessment Instrument." This assessment tool was developed as a disease-specific, comprehensive, self reporting instrument for the assessment of patients with low back pain [Daltroy LH, et al – Spine – 1996]. It is made up of 17 questions which cover the topics of pain, patient function, and neurogenic symptomatology. It is in part based upon the Oswestry disability index. The cool thing about it is that there are "normal values" available from the general population. These can be used to compare back pain patient’s scores against. The other cool thing is that there are computerized versions available. The not so cool thing about it is that I rarely seen it used in spinal research that I read (That's probably because you can't even find it! Try googling it and see if you can download a copy).

Another assessment tool you will see in the literature is called the Dallas Pain Questionnaire (DPQ).

Another one is called the Low Back Pain Rating Scale (LBPR). And yet another: SWISSDISC-questionnaire. and the Japanese Orthopedic Association Scoring System.

Another one (Nachemson likes) is the Short-Form of the McGill Pain Questionnaire (SF-MPQ) [3]. This tests the experience of clinical pain. It has been described as a short and he easily executed assessment of sensory and affective pain.

Singh Functional Scale (dg): this was another good idea: Singh et al came up with the scale to rate functional improvement following nucleoplasty. They simply asked patients, before and after, about there ability to sit, stand, and walk in these categories: <15 min.; 15-30 min.; 31-45 min.; 1-2 hr; >2 hr. Then they made three separate graphs demonstrating improvement prior to and after [16]

General Function Score (GFS) [this was used in a Volvo award-winning paper in 2001 – Fritzell]:this disease-specific instrument consists of nine items which focus strictly on physical activities of daily living. It is intended to be used as an alternative to the more complex scores of disability (such as the ODI) and serves as a complement to the quality-of-life instruments in the study of low back pain. This test has demonstrated construct validity, reliability, feasibility and responsiveness in six different cohorts.



SUBJECTIVE PAIN ASSESSMENT: How much pain is the patient experiencing?

A patients level of subjective 'PAIN' (what the patient feels) is best measured with a device called the 'Visual Analog Scale' (VAS). There are a few different versions of the VAS, but I prefer a simple '0 to 10' scale. Here's how it works: Simply ask the patient the following question regarding their pain: "Mrs. Smith, on a scale of 0 to 10, where 0 is no pain and 10 is the worst imaginable pain, where does your current level of pain fall." VAS does an nice neat job of assessing your patients pain levels and allows you to document their subjective improvement or lack of improvement.

Another one is the verbal analog scale


From Nachemson's 2004 free paper:



| Oswestry Disability Index | Roland-Morris Disability Questionnaire | Stanford Score


1) Fairbank JC, Pynsent PB, "The Oswestry Disability Index." Spine 2000; 25(22):2940-2952

2) Fairbank JCT, Couper J, Davies JB. "The Oswestry low Back Pain Questionnaire." Physiotherapy 1980; 66: 271-273.

3) Melzack R: The short-form McGill Pain Questionnaire. Pain 1987; 30:191-197

16) Singh V, et al "Percutaneous Disc Decompression using coblation (Nucleoplasty) In the Treatment of Chronic Discogenic Pain." 2002 Pain Physician, Volume 5, Number 3, pp 250-259 ASIPP.

26) Vernon H, Mior S. "The Neck Disability Index: a study of reliability and validity." J Manipulative Physiol Ther. 1991 Sep;14(7):409-15.

28) Deyo RA, Battie M, et al. "Outcome measures for low back pain research: a proposal for standardized use." Spine 1998;23:2003-13

34)Doleys DM et al. "Psychological evaluation in spinal cord stimulation therapy." Pain Rev 1997; 4:189-207

22) Roland M, Morris R. "A study of the natural history of low back pain. Part 1: Development of a reliable and sensitive measure of disability in low-back pain." Spine 1983;8:141-4

24) Prolo DJ, Oklund SA, Butcher M: Toward uniformity in evaluating results of lumbar spine operations: a paradigm applied to posterior lumbar interbody fusions. Spine 1986; 11:601-606

26) Jenkinson C, Coulter A, Wright L: Short form 36 (SF36) health survey questionnaire: normative data for adults of working age. BMJ 1993; 306:1437-1440

27) Garratt AM, Ruta DA, Abdalla MI, et al: The SF36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? BMJ 1993; 306:1440-1444


29) Ware JE Jr, Sherbourne CD: The MOS 36-Item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30:473-483

51) MacNab I. “negative disc exploration: an analysis of the cause of nerve root involvement in sixty-eight patients.” J Bone Joint Surg (Am) 1971 ;53:891-903

53) Turk DC, Marcus DA. "Assessment of chronic pain patients." Semin Neurol 1994; 14:206-12

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