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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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