THERAPIESDIRECTORATE

ClinicStaffPleaseTickAssessment 6/1212/1224/12 Other ...

LowBackAssessmentForm
TodaysDate

Surname FirstName DateofBirth

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Label

Thisassessmentformwillhelpustocreateawiderpictureofyourparticularbackproblem.Duringyour careinNorthCheshireHospitalsSpinalUnitDepartmentstheseassessmentswillbeusedtomonitoryour progressduringyoursurgeryandfollowup.Ifyouwouldlikeassistanceinfillinginthisformpleaseask. Thefollowingdiagramwillhelpustomeasurethelevelandwhereaboutsofyourpain.Pleaseshadethe areawhereyoufeelpain.Markanyareasofpinsandneedleswithadottedarea.

Pleasemarkonthelinebelow,withacross(X),howmuchpainyouhavehadonaverageduringthepast week.Thisistoassessyouroveralllevelofpain.
Nopainatall Worstpain

OswestryLowBackDisabilityIndex
Pleaseanswerall10sections.Ineachcategory,tickonlyonethatbestappliestoyourcurrentcondition.
6. STANDING 1. PAININTENSITY Ihavenopaincurrently. Thepainisverymildatthemoment. Thepainismoderateatthemoment. Thepainisfairlysevereatthemoment. Thepainisverysevereatthemoment. Thepainistheworstimaginableatthemoment. 2. PERSONALCARE (Washing,Dressing,etc.) Icanlookaftermyselfnormally,withoutcausing extrapain. Icanlookaftermyselfnormally,butitisverypainful. ItispainfultolookaftermyselfandIamslowand careful. Ineedsomehelp,butmanagemostofmypersonal care. Ineedhelpeverydayinmostaspectsofselfcare. IdonotgetdressedIwashwithdifficultyandstayin bed. 3. LIFTING Icanliftheavyobjectswithoutextrapain. Icanliftheavyweights,butitgivesextrapain. Painpreventsmefromliftingheavyweightsoffthe floor,butIcanmanageiftheyareconveniently positioned,forexample,onatable. Painpreventsmefromliftingheavyweights,butI canmanagelighttomediumweightsiftheyare convenientlypositioned. Icanliftonlyverylightweights. Icannotliftorcarryanythingatall. IcanstandaslongasIwantwithoutextrapain. IcanstandaslongasIwantbutitgivesmeextra pain. Painpreventsmefromstandingformorethan1 hour. Painpreventsmefromstandingformorethanan hour. Painpreventsmefromstandingformorethan10 minutes. Painpreventsmefromstandingatall.

7. SLEEPING Mysleepisneverdisturbedbypain. Mysleepisoccasionallydisturbedbypain. BecauseofpainIhavelessthan6hourssleep. BecauseofpainIhavelessthan4hourssleep. BecauseofpainIhavelessthan2hourssleep. Painpreventsmefromsleepingatall.

8. SEXLIFE(ifapplicable) Mysexlifeisnormalandcausesnoextrapain. Mysexlifeisnormalbutcausessomeextrapain. Mysexlifeisnearlynormalbutisverypainful. Mysexlifeisseverelyrestrictedbypain. Mysexlifeisnearlyabsentbecauseofpain. Painpreventsanysexlifeatall.

9. SOCIALLIFE Mysociallifeisnormalandcausesnoextrapain. Mysociallifeisnormalbutincreasesthedegreeof pain. Painhasnosignificanteffectonmysociallifeapart fromlimitingmymoreenergeticinterestsegsport. PainhasrestrictedmysociallifeandIdonotgo outasoften. Painhasrestrictedsociallifetomyhome. Ihavenosociallifebecauseofpain.

4. WALKING Paindoesnotpreventmewalkinganydistance. Painpreventsmewalkingmorethan1mile. Painpreventsmewalkingmorethanofamile. Painpreventsmewalkingmorethan100yards. Icanonlywalkusingastickorcrutches. Iaminbedmostofthetimeandhavetocrawltothe toilet.

10. TRAVELLING Icantravelanywherewithoutpain. Icantravelanywherebutitgivesmeextrapain. PainisbadbutImanagejourneysofover2hours. Painrestrictsmetojourneysoflessthan1hour. Painrestrictsmetoshortnecessaryjourneysunder 30minutes. Painpreventsmefromtravellingexcepttoreceive treatment.

5. SITTING IcansitinanychairaslongasIlike. IcansitinmyfavouritechairaslongasIlike. Painpreventsmefromsittingformorethan1hour. Painpreventsmefromsittingformorethanan hour. Painpreventsmefromsittingformorethan10 minutes. Painpreventsmefromsittingatall.

TheOswestryLowBackPainDisabilityQuestionnaire

RolandMorrisDisabilityQuestionnaire
Whenyourbackhurtsyoumayfinditdifficulttodosomeofthethingsyounormallydo.Thislist containssomesentencesthatpeoplehaveusedtodescribethemselveswhentheyhaveback pain.Whenyoureadasentencethatdescribesyoutoday,putatickagainstit.Ifthesentence doesnotdescribeyou,thenleavethespaceblankandgotothenextone.Remember,onlytick thesentenceifyouaresureitdescribesyoutoday.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

Istayathomemostofthetimebecauseofmyback. Ichangepositionfrequentlytotryandgetmybackcomfortable. Iwalkmoreslowlythanusualbecauseofmyback. Becauseofmyback,IamnotdoinganyofthejobsthatIusuallydoaroundthehouse. Becauseofmyback,Iuseahandrailtogetupstairs. Becauseofmyback,Iliedowntorestmoreoften. Becauseofmyback,Ihavetoholdontosomethingtogetoutofaneasychair. Becauseofmyback,Itrytogetotherpeopletodothingsforme. Igetdressedmoreslowlythanusualbecauseofmyback. Ionlystandforshortperiodsoftimebecauseofmyback. Becauseofmyback,Itrynottobendorkneeldown. Ifinditdifficulttogetoutofachairbecauseofmyback. Mybackispainfulalmostallofthetime. Ifinditdifficulttoturnoverinbedbecauseofmyback. Myappetiteisnotverygoodbecauseofmybackpain. Ihavetroubleputtingonmysocks/stockingsbecauseofmybackpain. Ionlywalkshortdistancesbecauseofmybackpain. Isleeplesswellbecauseofmybackpain. Becauseofmybackpain,Igetdressedwithhelpfromsomeoneelse. Isitdownformostofthedaybecauseofmyback. Iavoidheavyjobsaroundthehousebecauseofmyback. Becauseofmybackpain,Iammoreirritable/badtemperedthanusual. Becauseofmyback,Iclimbthestairsmoreslowlythanusual. Istayinbedmostofthetimebecauseofmyback. Yes/No

Haveyoureturnedtowork? Areyouretired? Yes/No

LowBackOutcomeScore
____________________________________________________________________________________________ Pleaseticktheanswerthatmostclearlydescribesyouoneachofthefollowingquestions. 1. Doyouhavetorestduringthedaybecauseofpain? Notatall Alittle Halftheday Overhalftheday 2. Howoftendoyouhaveaconsultationwithadoctororhaveanytreatment(e.g.physiotherapy)foryour pain? Never Rarely Aboutonceamonth Morethanonceamonth 3. Howoftendoyouhavetotakepainkillersforyourpain? Never Occasionally Almosteveryday Severaltimesaday 4. Atpresentareyouworking? Fulltimeatyourusualjob Fulltimeatalighterjob Parttime Notworking 5. Atpresentcanyouundertakesportsoractivepursuits? Asmuchasusual Almostasmuchasusual Some,muchlessthanusual Notatall 6. Atpresentcanyouundertakehouseholdchoresorjobs? Normally Asmuchasusualbutslowly Afew,notasmanyasusual Notatall 7. Howmuchdoesyourbackpainaffectthefollowingactivities? Tickoneboxforeachrow. Severely, Impossible SexLife Sleeping Walking Travelling Dressing Moderately difficult Mildly,notmuch Notatall

CESD
Circle the number for each statement, which best describes how often you felt or behaved duringthepastweek. Duringthepastweek.. Rarelyor Someor noneofthe alittleof time thetime (lessthan 1day) 1.Iwasbotheredbythingsthat dontusuallybotherme. 2.Ididnotfeellikeeatingmy appetitewaspoor. 3.IfeltthatIcouldnotshakeoff thebluesevenwithhelpfrom myfamilyorfriends. 4.IfeltthatIwasjustasgoodas otherpeople. 5.Ihadtroublekeepingmymind onwhatIwasdoing. 6.Ifeltdepressed. 7.IfeltthateverythingIdidwas aneffort. 8.Ifelthopefulaboutthefuture. 9.Ithoughtmylifehadbeena failure. 10.Ifelttearful. 11.Mysleepwasrestless. 12.Iwashappy. 13.Italkedlessthanusual. 14.Ifeltlonely. 15.Peoplewereunfriendly. 16.Ienjoyedlife. 17.Ihadcryingspells. 18.Ifeltsad. 19.Ifeltthatpeopledislikedme. 20.Icouldnotgetgoing. 0 0 0 (1to2 days) 1 1 1 Occasionally oramoderate amountof time (3to4days) 2 2 2 Mostorallof thetime

(5to7days) 3 3 3

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3