| ROLAND MORRIS LOW BACK PAIN QUESTIONNAIRE
The
Roland-Morris Questionnaire (RMQ) is a self-administered disability
measure in which greater levels of disability are reflected by higher
numbers on a 24-point scale. The RMQ has been shown to yield reliable
measurements, which are valid for inferring the level of disability,
and to be sensitive to change over time for groups of patients with
low back pain. Little is known about the usefulness of this instrument
in aiding decision making regarding individual patients. [Stratford
PW, Binkley J, Solomon P, et al. Defining the minimum level of detectable
change for the Roland-Morris Questionnaire. Phys Ther. 1996;76:359-365.]
N.B.
This questionnaire has been adapted to limit confusion by the patient
with nerve root pain, who may have little back pain.
Name:
Dr. Douglas M. Gillard Dob: 02/26/
Date: 10/18/03
When your back
or leg hurts, you may find if difficult to do some of the things you
normally do. Please mark with a cross only the sentences that
describe you TODAY.
01. [ ] I stay
at home most of the time because of my back and/or leg pain.
02. [x ] I walk more slowly
than usual because of my back and/or leg pain.
03. [x ] Because of my back
and/or leg pain, I am not doing any jobs that I usually do around
the house.
04. [ ] Because
of my back and/or leg pain pain, I use a
handrail to get upstairs.
05. [x ] Because of my back
and/or leg pain, I lie down to rest more often.
06. [ ] Because
of my back and/or leg pain, I have to hold onto something to get out
of an easy chair.
07. [ x] Because of my back
and/or leg pain, I try to get other people to do things for me.
08. [ ] I get
dressed more slowly than usual because of my back and/or leg pain.
09. [ ] I stand
up only for short periods of time because of my back and/or leg pain.
10. [ ] Because
of my back and/or leg pain, I try not to bend or kneel down.
11. [ ] I find
it difficult to get out of a chair because of my back and/or leg pain.
12. [ ] My back
is painful almost all of the time.
13. [ ] I find
it difficult to turn over in bed because of my back and/or leg pain.
14. [ ] I have
trouble putting on my socks (or stockings) because of pain in my back
and/or leg pain.
15. [ ] I sleep
less well because of my back and/or leg pain.
16. [x ] I avoid heavy jobs
around the house because of my back and/or leg pain.
17. [x ] Because of back and/or
leg pain, I am more irritable and bad tempered with people than usual.
18. [x ] Because of my back
and/or leg pain, I go upstairs more slowly than usual.
19. [ ] I change
positions frequently to try to get my back and /or leg comfortable.
20. [ ] My appetite
is not very good because of my back and/or leg pain.
21. [ ] I can
only walk short distances because of my back and/or leg pain.
22. [ ] Because
of my back and/or leg pain, I get dressed with the help of someone
else.
23. [ ] I sit
down for most of the day because of my back and/or leg pain.
24. [ ] I stay
in bed most of the time because of my back and/or leg pain.
Office
Use Only Score: 7 of 24 Improvement: 60%
GUIDE
Simply
count the scores for a result betwen
0 and 24. Scores under 4 and over 20 may not show significant
change over time in patients with scores of less than 4 and
deterioration in patients who have scores greater than 20. [Stratford
PW, Binkley J, Solomon P, et al. Defining the minimum level
of detectable change for the Roland-Morris Questionnaire. Phys
Ther. 1996;76:359-365.]
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