problem of not taking into account functionality
and physical activity. In some situations, only
a minority of patients receive simple positive
messages to stay active and exercise, while
inappropriate use of analgesia and imaging
persists. 19
Nevertheless, none of the currently available
measures are sufficiently comprehensive in covering
all of the key domains of physical functioning. Some
questionnaires focus only on physical functioning,
whereas others include multiple domains in which
physical functioning is only one component of the
assessment tool. Furthermore, some of the
challenges that are encountered are not given
adequate importance including: 12,14
1 Instruments developed for use in adults aged above
18 and under a certain age might not be appropriate
for older adults, children and adolescents
2 Measures might not be transferrable to second
language samples
3 Measures of work outcomes must be included,
because different kinds of work will have different
levels of functionality (any measures should not only
look at work loss but also take into account
absenteeism and productivity)
4 Cultural and ethnic factors can play a major role,
and outcome measures might differ in certain
cultural or ethnic groups
5 There is a possibility that functionality tests
might have differences in patients whose pain has
a neuropathic component and this must be
accounted for.
This was shown in a recent study in which the
intensity, impairment of QoL and functionality
were not necessarily reported in association: some
patients’ QoL and functionality were highly
impaired despite a moderate-to-low pain intensity,
whereas others suffered from severe pain but their
QoL or functionality were impaired to a lesser
degree. 11
Which questionnaires should be used?
From a practical point of view, which questionnaires
can be used? There is no clear agreement on which
instrument should be used, although an expert
consensus reached the conclusion that physical
functioning, pain intensity, and HRQoL should be
core outcome domains. The use of the Oswestry
Disability Index version 2.1a or 24-item Roland-
Morris Disability Questionnaire for physical
functioning and the Numeric Rating Scale (NRS)
for pain intensity have been recommended. No
consensus was achieved on any measure of HRQoL,
although the Short Form 12 (SF12) or 10-item
PROMIS Global Health form for HRQoL are the main
options. 20
The six main questionnaires that can be used in
clinical practice are discussed here.
The first two questionnaires measure the quality
of life globally with subsections for functionality:
these are the 36-item Short Form Health Survey
(SF-36) and the 12-item Short Form Survey (SF-12).
Both can be used in clinical practice and they are
described briefly below. The four remaining
questionnaires measure functionality specifically
in LBP.
SF-36
First published in 1992, the SF-36 is a measure of
HRQoL. It is a subset of questions from longer
instruments that were used in the Medical Outcomes
Study. 21 It is a patient-reported questionnaire with 36
items based on scores in eight subdomains: physical
functioning (10 items), role-physical (4 items), bodily
pain (2 items), general health (5 items), vitality
(4 items), social functioning (2 items), role-emotional
(3 items), and mental health (5 items); scored by
patients on a scale from 0 to 100 (0 = “poor health”
to 100 = “good health”) and two summary scales of
physical and mental component summaries. 21 It is
perhaps the most widely used instrument to assess
perceived health status. 22
In a study carried out on more than 900 patients
evaluating different outcomes in low back disease,
regardless of the aetiology, the conclusion was that
the general SF-36 may be a sufficient measure of
health status and patient function, without the need
for additional condition-specific instruments. Pain
scales appear to be the most responsive measures in
patients with LBP. 23
SF-12
This is a general health questionnaire that was first
published in 1995 as part of the Medical Outcomes
Study. The SF-12 was constructed using questions
drawn from each of the eight dimensions of SF-36.
It is designed to have similar performance to the
SF-36, while taking less time to complete. Two
summary scores are reported from the SF-12 –
a mental component score (MCS-12) and a physical
component score (PCS-12). The scores may be
reported as Z-scores (difference compared with the
population average, measured in standard
deviations). 24,25 The SF-12 has the advantage of being
easier and quicker to complete, thus minimising the
costs for data collection and management. SF-12 was
developed as an alternative to the SF-36 for use in
large-scale studies to assess overall physical and
mental health outcomes. 22
The Oswestry Disability Index
This comprises 12 assessment items covering ten
domains including pain intensity, personal care,
lifting, walking, sitting, standing, sleeping, sex life,
social life, and travelling. The scoring conventions
allow the clinician to assess the level of associated
disability or pain interference. It has been
recommended for use in primary care, but clinician
preference and ease of administration should guide
tool selection. 26
The Roland-Morris Disability Questionnaire (RMQ)
This is a 24-point, self-administered disability
measure in which greater levels of disability are
reflected by ascending numbers on the scale. The
RMQ yields reliable measurements that are valid for
inferring the level of disability, and which are
sensitive to change over time for groups of patients
with LBP. The score of the RMQ is the total number
of items checked – that is, a minimum of 0 to
a maximum of 24. The authors did not provide
descriptions of the varying degrees of disability
(for example, 40%–60% is severe disability). Clinical
improvement over time can be graded based on the
analysis of serial questionnaire scores. If, for
example, at the beginning of treatment, a patient’s
score was 12 and at the conclusion of treatment,
their score was 2 (10 points of improvement), this
represents an 83% (10/12 x 100) improvement.
The questionnaire can be adapted for use online
or by telephone. 27
The Hannover Functional Ability Questionnaire
(FFbH-R)
This is the least known of the three but has
equivalent functionality. The FFbH-R comprises
12 questions about ability to perform activities such
as lifting a heavy object, putting on socks,
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