Outcome Assessment
Questionnaires

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

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Dear Readers:   The Outcome Forms actually stored on our server have been approved for your use by the owners (or copyright holders). If you plan to use them for commercial use, research, or publication, please Google those owners, and ask them for permission. I can not do that for you. The QAs that we “link to” (that are located on other websites) are ones we couldn't get permission for. I have provided scoring/grading methods with the questionnaires whenever they have been available. If you utilize these QAs in patient care, you will need those scoring methodologies. I strongly recommend that you purchase Yeoman's The Clinical Application of Outcomes Assessment from Amazon, to get all that information. The best way to copy a Word or Adobe Acrobat (PDF) file from this page is to follow this procedure: “Right-click” the URL (or link), and then select “Save Target As”, then choose the “directory” (in your computer) where you want to save it. When the item is saved, then select “open file”. Adobe Acrobat files open and print much more reliably when they already reside within your own computer, especially the larger documents.

Outcome Assessment Questionnaires need to be sensitive to 3 criteria:

1. Validity:   The degree to which an instrument measures what it is supposed to measure.
   

2. Reliability:   The degree to which an instrument can produce consistent results, and consistent results on different occasions, even when there is no evidence of change.

3. Responsiveness:   An instrument's ability to detect change over time.

The following questionnaires have been tested for accurately measuring all 3 criteria.

Articles about Outcome Questionnaires

	The Outcome Assessment Guidelines Page A Chiro.Org article collection These National Guidelines come from a variety of sources.
	The Outcome Assessment Book Shelf A Chiro.Org book collection Please browse our Outcome Assessment book shelf. Any books you purchase will help to support our non-commercial website.
	Outcome Assessment Reference Articles, Compiled by Category A Chiro.Org article collection This collection of primary citations covers Questionnaires, Measuring Instruments, and other assessment methods.
	View a Powerpoint Presentation About Outcome Assessment Thanks to Dr. Steve Yeomans and the ACRB for the use of this file! Download the FREE Powerpoint Viewer
	Outcome Assessment in Routine Clinical Practice in Psychosocial Services   PDF British Psychological Society’s Centre for Outcomes, Research and Effectiveness It is fundamental to the relationship between a user of a service and a clinician that the user should derive some benefit from that relationship. But how can it be determined whether benefit has occurred and how might one go about trying to define or measure such benefits? These are key challenges facing psychosocial services that want to develop systems for the routine monitoring of outcomes.
	Development and Validation of the EXPECT Questionnaire: Assessing Patient Expectations of Outcomes of Complementary and Alternative Medicine Treatments for Chronic Pain J Altern Complement Med. 2016 (Nov);   22 (11):   936–946 ~ FULL TEXT The EXPECT questionnaire can be used in research to assess individuals’ expectations of treatments for chronic pain. Several directions for future research are indicated. Further research is needed to assess the psychometric characteristics of the EXPECT questionnaire and short form in samples with different sociodemographic and clinical characteristics. Examination of the association of EXPECT scores with outcomes after CAM treatments may help increase knowledge about the role of individuals’ expectations in their outcomes after CAM treatments. Finally, although the questionnaire can be used with individuals beginning CAM treatments for CLBP, the questionnaire might be adapted for use with individuals with other pain problems and for use with non-CAM treatments.
	Outcomes and Outcomes Measurements Used in Intervention Studies of Pelvic Girdle Pain and Lumbopelvic Pain: A Systematic Review Chiropractic & Manual Therapies 2019 (Nov 5);   27:   62 ~ FULL TEXT Studies and systematic reviews examining the effectiveness of interventions for PGP and LPP assess a range of outcomes, predominantly pain intensity and disability/function, and use a large variety of outcome measurement instruments. Few studies examine adverse events and economic outcomes. Not only do different studies often measure different outcomes, authors also rarely define outcomes and terminology for outcomes varies, making comparison of study findings very difficult.
	Chiropractors' Views on the Use of Patient-reported Outcome Measures in Clinical Practice: A Qualitative Study Chiropractic & Manual Therapies 2018 (Dec 18);   26:   50 ~ FULL TEXT Chiropractors are increasingly using PROMs in their clinical practice. The aim of this qualitative study was to examine the views of chiropractors on using PROMs. Exploring chiropractors’ experience of using PROMs, this study identified how clinician knowledge and engagement and organisational barriers and facilitators affect implementing PROMs in chiropractic care, such as choosing the appropriate PROMs and systems to use in their practice. Chiropractors also identified possible training needs of chiropractors regarding PROMs, with training including the process and benefits of using PROMs in clinical practice. The results from the study also demonstrated the necessity of ensuring PROMs are meaningful to patients and chiropractors. It is clear there are differing views and engagement with PROMs within clinical practice; in addition, future research must consider patients’ views on completing PROMs and how it affects the process of clinical practice and outcomes.
	Brief Screening Questions for Depression in Chiropractic Patients with Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity Chiropractic & Manual Therapies 2014 (Jan 17); 22: 4 ~ FULL TEXT Pain and depression often co-exist [1–3] , and although the causal relation between the two is not clear, [4, 5] evidence suggests that pain negatively affects outcome in depression as well as vice versa [6]. Low back pain (LBP) is a highly frequent pain condition with a substantial impact on global health [7] for which the risk of a poor prognosis is increased in the presence of depression [8, 9] . It is a condition for which there is no generally effective treatment, but non-pharmacological treatment addressing psychological symptoms in addition to the physical symptoms has been demonstrated to improve outcome in LBP patients with high scores on psychological questions [10].
	Symptomatic Reactions, Clinical Outcomes and Patient Satisfaction Associated with Upper Cervical Chiropractic Care: A Prospective, Multicenter, Cohort Study BMC Musculoskelet Disord. 2011 (Oct 5);   12:   219 ~ FULL TEXT A total of 1,090 patients completed the study having 4,920 (4.5 per patient) office visits requiring 2,653 (2.4 per patient) upper cervical adjustments over 17 days. Three hundred thirty- eight (31.0%) patients had symptomatic reactions (SRs) meeting the accepted definition. Intense SR (NRS ≥8) occurred in 56 patients (5.1%). Outcome assessments were significantly improved for neck pain and disability, headache, mid-back pain, as well as lower back pain and disability (p <0.001) following care with a high level (mean = 9.1/10) of patient satisfaction. The 83 chiropractors administered >5 million career upper cervical adjustments without a reported incidence of serious adverse event.
	Psychosocial Risk Factors For Chronic Low Back Pain in Primary Care — A Systematic Review Fam Pract. 2011 (Feb);   28 (1):   12–21 ~ FULL TEXT Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome.
	A Critical Piece of Quality Documentation: Outcomes Assessment American Chiropractor 2011 (May):   33 (5):   28–34 ~ FULL TEXT Outcomes assessment tool availability is not a new concept. Back in the 1970’s, long, impractical outcomes tools surfaced that were too cumbersome for routine use in a primary care setting, but shortly thereafter, in 1980, Fairbank introduced the Oswestry (Low Back) Disability Index (ODI). An interesting point is that the original purpose of the ODI was to identify patients that may require “…positive intervention” in the form of psychological care when scores exceeded 60% (defined as “crippled”).
	Assessment of Patients With Neck Pain: A Review of Definitions, Selection Criteria, and Measurement Tools Journal of Chiropractic Medicine 2010 (Jun);   9 (2):   49–59 ~ FULL TEXT The introduction of evidence-based practice in the last years of the 20th century stimulated the development and research of an enormous number of instruments to assess many types of patient variables. [1] Now, more rehabilitation professionals are familiarizing themselves with the use of outcome measures in clinical practice and for research purposes. [2, 3] Outcomes assessment is primarily designed to establish baselines, to evaluate the effect of an intervention, to assist in goal setting, and to motivate patients to evaluate their treatment. [4, 5] When used in a clinical setting, it can enhance clinical decision making and improve quality of care. [6] Many patients with neck pain visit health care clinics seeking treatment of their problem, and health professionals aim to use the best available evidence for making decisions about therapy. The best evidence comes from randomized clinical trials, systematic reviews, and evidence-based clinical practice guidelines. [7]
	Expectations for Recovery Important in the Prognosis of Whiplash Injuries PLoS Med. 2008 (May 13);   5 (5):   e105 ~ FULL TEXT In conclusion, we suggest early assessment of expectations for recovery to be made, in order to identify people at risk for poor prognosis after WAD. Furthermore, controlled studies on interventions aimed at modifying expectations are warranted. Such studies could be conducted on the population level, similar to the successful media campaign on back pain beliefs, which decreased disability claims, both in terms of incidence and time on benefits. [31, 32] Alternatively interventions targeting persons in the acute phase of an injury should be evaluated. Finally, it is not inconceivable that our findings can be extended to persons with pain conditions other than WAD.
	Implementation of Outcome Measures in a Complementary and Alternative Medicine Clinic: Evidence of Decreased Pain and Improved Quality of Life J Altern Complement Med 2004 (Jul);   10 (3):   506–513 This study established that a practical data collection system could be implemented in a CAM clinic utilizing several treatment modalities. In addition, outcome measures demonstrated both a significant reduction in pain and improvement in quality of life for subjects who utilized acupuncture, chiropractic, or naturopathy treatments.
	The Possibility to Use Simple Validated Questionnaires to Predict Long-term Health Problems After Whiplash Injury Spine 2004 (Feb 1);   29 (3):   E47–51 The subjective experience of a notably decreased level of activity because of the neck pain when supplemented by the enhanced score of Neck Disability Index questionnaire predicts well poor outcome in long-term follow-up and can be used as a tool to identify persons who are at risk to suffer long-term health problems after whiplash injury.
	Assessing the Clinical Significance of Change Scores Recorded on Subjective Outcome Measures J Manipulative Physiol Ther 2004 (Jan);   27 (1):   26–35 ~ FULL TEXT To date, clinical trials have relied almost exclusively on the statistical significance of changes in scores from outcome measures in interpreting the effectiveness of treatment interventions. It is becoming increasingly important, however, to determine the clinical rather than statistical significance of these change scores.
	Subjective and Objective Numerical Outcome Measure Assessment (SONOMA). A Combined Outcome Measure Tool: Findings on a Study of Reliability J Manipulative Physiol Ther 2003 (Oct);   26 (8):   481–492 ~ FULL TEXT Function-based evaluation and treatment is the wave of the future for physical medicine and particularly for chiropractic for several reasons. First, function is quantifiable. Quantification of the patient-clinical picture promotes better evaluation. This leads to better application of diagnostic procedures and more specifically tailored treatment protocol. Quantification of function also allows us to more appropriately, adequately, and clearly communicate the patient-clinical picture to ourselves, to our patients, and to third parties.
	A Comparison of Five Low Back Disability Questionnaires: Reliability and Responsiveness Physical Therapy 2002 (Jan);   82 (1):   8–24 ~ FULL TEXT Our data indicate that the Oswestry Disability Questionnaire, the SF-36 Physical Functioning scale, and the Quebec Back Pain Disability Scale have sufficient reliability and scale width to be applied in an ambulatory clinical population with low back problems. The Waddell Disability Index has insufficient scale width for clinical utility. The Roland-Morris Disability Questionnaire and the SF-36 Role Limitations–Physical and Bodily Pain scales did not have sufficient reliability to be recommended as clinical outcome measures for individual patients. This study showed that the responsiveness of the questionnaires was similar, and we conclude that one questionnaire cannot be preferred over another based on the magnitude of the absolute values of responsiveness indexes.
	The Relationship of Disability (Oswestry) and Pain Drawings to Functional Testing European Spine Journal 2000 (Jun);   9 (3):   208–212 ~ FULL TEXT The results of this study indicate that isokinetic test values are significantly influenced by a patient's self-reported disability and pain expression, which can be evaluated using simple tools such as pain drawings and the Oswestry questionnaire. This study supports the supposition that dynamometry testing is related to factors other than muscle performance.
	Behavioral Responses to Examination: A Reappraisal of the Interpretation of "Nonorganic Signs" Spine (Phila Pa 1976) 1998 (Nov 1):   23 (21);   2367–2371 Waddell et al in 1980 developed a standardized assessment of behavioral responses to examination. The signs were associated with other clinical measures of illness behavior and distress, and are not simply a feature of medicolegal presentations. Despite clear caveats about the interpretation of the signs, they have been misinterpreted and misused both clinically and medico-legally.
	The SCL–90–R in Clinical Application The SCL-90-R is a 90-item self-report system inventory developed in the 1980s by Derogatis and designed to reflect the psychological symptom patterns of community, medical and psychiatric respondents. In the special application of CAD trauma and its aftermath, the SCL-90-R is particularly useful. It can validate or challenge the veracity of the patient's claims; it can be used to follow the patient's progress; and it can also be used as an outcome variable in clinical research.
	Outcomes: The Key to the Future Outcomes measurement will be a critical factor if the profession is to establish itself in the managed care market. This was echoed in a recent article in Topics, Clinical Chiropractic titled "Chiropractic Health Care: The Second Century Begins": " ... chiropractic will be pushed by insurers, employers, workers' compensation programs, and managed care plans to demonstrate successful clinical outcomes using cost-efficient care methods."
	Spinal Algometry in Clinical Practice One drawback with palpation is that the examiner is unable to determine how much pressure is being applied. Terms like "mild," "moderate," or "strong" mean different things to different practicioners and patients. An instrument which is very useful in quantifying pressure is the algometer, also known as the pain threshold meter. This is a hand-held force gauge, fitted with a stylus and covered by a 1cm2 rubber tip. An analogue gauge is calibrated in kilograms/cm2, with a minimum reading of 1kg/cm2, and a maximum reading of 10kgs/cm2. Return to:   The Outcomes Documentation Section

Functional Outcome Questionnaires

The RAND 36-Item Short Form Health Survey   (SF-36)

	Rand SF-36 ~   in Word    or    as Adobe Acrobat As part of the Medical Outcomes Study (MOS) — a multi-year, multi-site study to explain variations in patient outcomes — RAND developed the 36-Item Short Form Health Survey (SF-36).   SF-36 is a set of generic, coherent, and easily administered quality-of-life measures.   These measures rely upon patient self-reporting and are now widely utilized by managed care organizations and by Medicare for routine monitoring and assessment of care outcomes in adult patients.   Before downloading the SF-36 you must read Rand's Disclaimer.   This document is formatted to print on both sides of a page, with a larger border on the left-hand side for binding into a file. How to score the SF-36 ~   in Word    or    as Adobe Acrobat    or    as a Web Page Document (HTML) These pages takes you on a step–by–step method for scoring the Rand–36. Scoring Page for SF-36 ~   in Word    or    as Adobe Acrobat    or as a Web Page Document (HTML) This page is for tallying the score from the Rand–36 and can be stored in the patient file.
	Measuring Functional Health Status in the Chiropractic Office Using Self-Report Questionnaires Topics in Clinical Chiropractic 1994:   1 (1):   51–59 ~ FULL TEXT Patient self-perception of the health care experience is becoming an important component of clinical outcomes assessment. In light of impending change toward more closely managed health care purchasing, chiropractors are being expected to document and quantify clinical progress. Functional health status instruments are an economic and efficient way of accomplishing the task. Two such instruments are presented in detail: the Dartmouth COOP charts and the RAND 36-Item Health Survey 1.0, the latter of which is included in its entirety for use in the office setting. Several other instruments are briefly summarized. The questionnaire is located on page 81-83.
	Responsiveness of the Cervical Northern American Spine Society Questionnaire (NASS) and the Short Form 36 (SF-36) in Chronic Whiplash Clin Rehabil. 2012 (Feb);   26 (2):   142–151 The NASS was consistently less responsive in function than the SF-36 and cannot be recommended as a specific instrument to measure pain and function more responsively than the SF-36 in chronic whiplash disorder.   The SF-36 seems to be a powerful, responsive instrument in chronic pain.
	Development of an Index of Physical Functional Health Status in Rehabilitation Arch Phys Med Rehabil 2002 (May);   83 (5):   655–665 Results support the reliability and validity of FHS-36 measures in the present sample. Analyses show the potential for a dynamic, computer-controlled, adaptive survey for FHS assessment applicable for group analysis and clinical decision making for individual patients.

The Neck Disability Index   (NDI)

	Neck Disability Index (NDI) ~   in Word   or    as Adobe Acrobat (PDF) This modified Oswestry questionnaire is a 2 sided form....with a pain diagram on the second side.   The borders are alligned so you can make it into a two-sided sheet, which can be side-punched (on the 11" side) and put into the patient file. Scoring Methodology and comments by author Howard Vernon, D.C. The scoring method also available in  Adobe Acrobat (PDF).
	The Neck Disability Index: State-of-the-Art, 1991-2008 J Manipulative Physiol Ther 2008 (Sep);   31 (7):   491–502 ~ FULL TEXT The NDI has been translated into 22 languages, with 6 published reports and 1 large Web-based resource with 18 readily available versions. It has been used in 52 surgical clinical trials and 3 trials of injection therapies as well as RCTs of numerous conservative therapies, chiefly manipulation and exercise. In this regard, it has served to expand the range of outcome measurements of neck pain patients beyond the limited use of pain scales and has enriched the yield of these clinical trials.
	Comparison of the Neck Disability Index and the Neck Bournemouth Questionnaire in a Sample of Patients with Chronic Uncomplicated Neck Pain J Manipulative Physiol Ther 2007 (May);   30 (4):   259–262 ~ FULL TEXT The NDI and the NBQ performed comparably in this group of patients with chronic uncomplicated neck pain. Both are sensitive to change and would be efficient outcome tools in studies of chronic neck pain. Both had acceptable internal consistency and are appropriate for use as single-outcome scales.
	The Reliability of the Vernon and Mior Neck Disability Index, and its Validity Compared With the Short Form-36 Health Survey Questionnaire European Spine Journal 2007 (Dec);   16 (12):   2111–2117 ~ FULL TEXT The correlations between each item of the NDI scores and the total NDI score ranged from 0.447 to 0.659, (all with P < 0.001). The test-retest reliability of the NDI was high (intra-class correlation 0.93, 95% confidence limits 0.86-0.97) and comparable with the best values found for SF36. The correlations between NDI and SF36 domains ranged from -0.45 to -0.74 (all with P < 0.001). We have shown that the NDI has good reliability and validity and that it compares well with the SF36 in the spinal surgery out patient setting.
	Psychometric Properties of the Neck Disability Index J Manipulative Physiol Ther 1998 (Feb);   21 (2):   75–80 Results from 237 neck pain patients show that the responses given on the eight versions of the NDI are a function of the content and not of the format in which the items are presented.   The NDI has stable psychometric characteristics, evidenced by high internal consistency (alpha = .92).   In both factor analyses, one factor was extracted.   The NDI possesses stable psychometric properties and provides an objective means of assessing the disability of patients suffering from neck pain.
	The Neck Disability Index: A Study of Reliability and Validity J Manipulative Physiol Ther 1991 (Sep);   14 (7):   409–415 Injuries to the cervical spine, especially those involving the soft tissues, represent a significant source of chronic disability. Methods of assessment for such disability, especially those targeted at activities of daily living which are most affected by neck pain, are few in number. A modification of the Oswestry Low Back Pain Index was conducted producing a 10-item scaled questionnaire entitled the Neck Disability Index (NDI).While the sample size of some of the analyses is somewhat small, this study demonstrated that the NDI achieved a high degree of reliability and internal consistency.

The Oswestry Low Back Pain Questionnaire   (OLB)

Oswestry Low Back Pain Questionnaire ~   in Word    or    in Adobe Acrobat (PDF) This questionnaire is the J. Fairbanks QA from the journal Physiotherapy 1980; 66: 271, and comes with a second page, containing a pain drawing. Please note that the scoring methodology is the same as with the NDI. Scoring Methodology (HTML) The scoring method also available in  Adobe Acrobat (PDF).

The Oswestry Disability Index Spine (Phila Pa 1976) 2000 (Nov 15);   25 (22):   2940–2952 The ODI remains a valid and vigorous measure and has been a worthwhile outcome measure. The process of using the ODI is reviewed and should be the subject of further research. The receiver operating characteristics should be explored in a population with higher self-report disabilities. The behavior of the instrument is incompletely understood, particularly in sensitivity to real change.

The Bournemouth Back and Neck Questionnaires

Bournemouth Back Adobe Acrobat (PDF) version. No scoring method is available on our website

The Bournemouth Questionnaire: A Short-form Comprehensive Outcome Measure. I. Psychometric Properties in Back Pain Patients J Manipulative Physiol Ther 1999 (Oct);   22 (8):   503–510 ~ FULL TEXT Seven dimensions of the back pain model were included in the questionnaire. Having established face validity, the instrument was shown to demonstrate high internal consistency (Cronbach's ALPHA = 0.9) and good test-retest reliability (ICC = 0.95). All items were retained on the basis that they contributed to the overall score (item-corrected total score correlations) and to the instrument's responsiveness to clinical change (item change-corrected total change score correlations). The instrument demonstrated acceptable construct and longitudinal construct validity with established external measures. The effect size of the instrument was high (1.29) and comparable with established measures.

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	Bournemouth Neck   PDF No scoring method is available on our website
	Sensitivity And Specificity Of Outcome Measures In Patients With Neck Pain: Detecting Clinically Significant Improvement Spine (Phila Pa 1976). 2004 (Nov 1);   29 (21):   2410–2417 The best cutoffs with a balance between the highest sensitivity and highest specificity in detecting clinical improvement were a score of 2 or less on the Patients' Global Impression of Change (11-point Numerical Rating Scale: 0 = much better, 5 = no change, and 10 = much worse) and a raw change score of three or more points on each of the seven 11-point Numerical Rating Scale subscales of the Bournemouth Questionnaire. For the total score of the Bournemouth Questionnaire, raw change scores of 13 or more points, percentage change scores of 36% or more, and individual effect sizes of 1.0 or more were all associated with clinically significant improvement. The sensitivity of the Bournemouth Questionnaire in terms of its effect size was comparable with that of pain intensity scales and the Neck Disability Index.
	The Bournemouth Questionnaire: A Short-form Comprehensive Outcome Measure. II. Psychometric Properties in Neck Pain Patients J Manipulative Physiol Ther 2002 (Mar);   25 (3):   141–148 ~ FULL TEXT The neck BQ covers the salient dimensions of the biopsychosocial model of pain, is quick and easy to complete, and has been shown to be reliable, valid, and responsive to clinically significant change in patients with nonspecific neck pain. Its use as an outcome measure in clinical trials and outcomes research is recommended.

The Functional Rating Index   (FRI)

	The Functional Rating Index (FRI)   PDF Patient-centered outcome instruments are now widely recognized as valuable assessment tools for researchers, doctors, patients and payors. The need to measure the function of the neck and back and to demonstrate clinical effectiveness has resulted in many reliable and valid patient report instruments being produced. Yet, existing self-report instruments measuring spinal pain and dysfunction require too much time for patients to answer (5 to 10 minutes per instrument) and health care workers to score (1 to 5 minutes per instrument) and, therefore, are underutilized in daily practice. A new instrument, the Functional Rating Index, reduces the administrative burden. Functional Rating Index has been tested, and the initial results have been published in Spine. Medical Science Monitor has published a scientific review of 10 independent studies on the Functional Rating Index. The researchers found that the Functional Rating Index demonstrates favorable measurement properties of reliability, validity and responsiveness, and it significantly reduces administrative burden. On average, Functional Rating Index requires only about one minute for a patient to complete and about 20 seconds for a health care worker to score. Additionally, this instrument can be used with cervical, thoracic or lumbar conditions, which reduces the need for multiple instruments for spine-related conditions.
	The Functional Rating Index Scoring Protocol You will need to e-mail them at chiroevidence.com to ask for their "complimentary copy of the Functional Rating Index scoring protocols"
	Functional Rating Index: A New Valid and Reliable Instrument to Measure the Magnitude of Clinical Change in Spinal Conditions Spine (Phila Pa 1976). 2001 (Jan 1);   26 (1):   78–86 The Functional Rating Index correlated with the Disability Rating Index (0.76), the Short Form-12 Physical Component Score (0.76), and the Short Form-12 Mental Component Score (0.36). Responsiveness: Overall, the size effect was 1.24, which is commendable. Clinical utility: Time required by the patient and staff averaged 78 seconds per administration, which is noteworthy. Effect of Sociodemographics: Total scores were not affected by education, gender, nor age, suggesting minimal external validity bias. nbsp; The Functional Rating Index appears to be psychometrically sound with regard to reliability, validity, and responsiveness and is clearly superior to other instruments with regard to clinical utility. The Functional Rating Index is a promising useful instrument in the assessment of spinal conditions.

The Quadruple Visual Analogue Scale   (VAS)

	The Quadruple Visual Analogue Scale   PDF This Adobe Acrobat file covers 4 characteristics of the Patient Complaint: Present Pain, Typical or Average Pain, and Pain Range at it's least and worst.
	Responsiveness of Visual Analogue Scale and McGill Pain Scale Measures J Manipulative Physiol Ther 2001 (Oct);   24 (8):   501–504 ~ FULL TEXT The results of this study suggest that the VAS may be a better tool than the McGill Pain Questionnaire for measuring pain in clinical trials and clinical practice.

Patient Global Impression of Change

Patient Global Impression of Change   PDF No scoring method is available on our website The Patient Global Impression of Change (PGIC) is a self-reported 7-point Likert scale where a patient assesses his or her degree of change since starting treatment, ranging from very much better to very much worse. The PGIC has been well validated and has been commonly used by pain researchers as a standard outcome instrument.

Clinical Importance of Changes in Chronic Pain Intensity Measured on an 11-point Numerical Pain Rating Scale Pain 2001 (Nov);   94 (2):   149–158 To date, there are no data driven estimates for clinically important differences in pain intensity scales used for chronic pain studies. We have estimated a clinically important difference on this scale by relating it to global assessments of change in multiple studies of chronic pain. Data on 2724 subjects from 10 recently completed placebo-controlled clinical trials of pregabalin in diabetic neuropathy, postherpetic neuralgia, chronic low back pain, fibromyalgia, and osteoarthritis were used. The studies had similar designs and measurement instruments, including the PI-NRS, collected in a daily diary, and the standard seven-point Patient Global Impression of Change (PGIC), collected at the endpoint. The changes in the PI-NRS from baseline to the endpoint were compared to the PGIC for each subject. Categories of "much improved" and "very much improved" were used as determinants of a clinically important difference and the relationship to the PI-NRS was explored using graphs, box plots, and sensitivity/specificity analyses. A consistent relationship between the change in PI-NRS and the PGIC was demonstrated regardless of study, disease type, age, sex, study result, or treatment group.

The McGill Pain Questionnaire

	McGill Pain Questionnaire (20 Question Version)   PDF No scoring method is available on our website
	McGill Pain Questionnaire (Short Form)   PDF No scoring method is available on our website
	The McGill Pain Questionnaire: Major Properties and Scoring Methods Pain 1975 (Sep);   1 (3):   277–299 The McGill Pain Questionnaire consists primarily of 3 major classes of word descriptors--sensory, affective and evaluative--that are used by patients to specify subjective pain experience. It also contains an intensity scale and other items to determine the properties of pain experience. The questionnaire was designed to provide quantitative measures of clinical pain that can be treated statistically.
	The Short-form McGill Pain Questionnaire Pain 1987 (Aug);   30 (2):   191–197 A short form of the McGill Pain Questionnaire (SF-MPQ) has been developed. The main component of the SF-MPQ consists of 15 descriptors (11 sensory; 4 affective) which are rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate or 3 = severe. Three pain scores are derived from the sum of the intensity rank values of the words chosen for sensory, affective and total descriptors.

The Copenhagen Neck Disability Scale

Copenhagen Neck Disability Scale   PDF No scoring method is available on our website

The Copenhagen Neck Functional Disability Scale: A Study of Reliability and Validity J Manipulative Physiol Ther 1998 (Oct);   21 (8):   520–527 The disability scale demonstrated excellent practicality and reliability. The scale accurately reflects patient perceptions regarding functional status and pain as well as doctor's global assessment and is responsive to change over long periods of time. We feel that this scale can be a valuable tool for the assessment of patients in future clinical trials and quality of care studies.

The Roland–Morris Questionnaire

	Roland–Morris ~ in Word    or    as Adobe Acrobat The Roland-Morris instrument was developed as an abbreviated SIP (sickness index profile) and is specific for low back pain, like the Revised Oswestry Disability Index. This questionnaire of 24 items can be administered in five minutes and has been validated in randomized trials of spinal manipulation. It was shown to be at least as reliable as the full SIP in cases of acute low back pain. It was found to be slightly more responsive to changes over time than the complete SIP. Compared to the Revised Oswestry Disability Index, the Roland-Morris instrument is also slightly more responsive to changes in acute to subacute low back pain. Thanks to the Illinois Chiropractic Society for putting this Adobe PDF file on line! How to score the Roland–Morris Questionnaire A simple, step-by-step analysis, courtesy of the Illinois Chiropractic Society.
	The Roland–Morris Questionnaire There is an abbreviated 18 question low back QA here in this article by Craig Liebenson...check it out!
	A Cross-sectional Study Comparing the Oswestry and Roland-Morris Functional Disability Scales in Two Populations of Patients with Low Back Pain of Different Levels of Severity Spine 1997 (Jan 1);   22 (1):   68–71 Patients diagnosed with low back pain who exhibited signs of radiculopathy on electromyography had a mean score of 49.1 +/- 17.1 on the Oswestry disability questionnaire; a mean score of 33.0 +/- 14.7 was found for patients who experienced "simple" low back sprain (with no radiculopathy). This difference was statistically significant (P < 0.0001). On the Roland-Morris questionnaire, the mean score obtained by the group of patients with radiculopathy was 59.1 +/- 21.8 compared with 45.4 +/- 19.4 for those with no radiculopathy. This difference was also statistically significant (P < 0.0001). Moreover, there exists a moderate correlation between both functional scales within each group of patients: 0.72 (P < 0.0001) in the group with radiculopathy and 0.66 (P < 0.0001) among those without radiculopathy.

Measure Yourself Medical Outcome Profile   (MYMOP)

	Measure Yourself Medical Outcome Profile Questionnaire   PDF This is the Initial Form. The Follup-up Form   PDF is also available.
	Measure Yourself Medical Outcome Profile Scoring Methodology   PDF
	Use of the Measure Your Medical Outcome Profile (MYMOP2) and W-BQ12 (Well-Being) Outcomes Measures to Evaluate Chiropractic Treatment: An Observational Study Chiropractic & Manual Therapies 2011 (Mar 20);   19 (1):   7 ~ FULL TEXT This study assesses the use of the MYMOP2 and W-BQ12 questionnaires as outcome measures to monitor changes following chiropractic therapy. Within the limitations of this study, it was shown that both questionnaires were responsive to change. The MYMOP2 also correlated well with the W-BQ12 questionnaire. It thus appears to be a useful instrument for assessing change among chiropractic patients and in the assessment of patient perceived wellbeing for chiropractic patients who present with a variety of symptoms and clinical conditions.

Functional Rating Index

	Functional Rating Index   PDF You may request a complimentary copy of the FRI scoring protocols from the Institute of Evidence-Based Chiropractic (owners).
	Functional Rating Index: Literature Review Med Sci Monit. 2010 (Feb);   16:   RA25–36 In 1999, a new self-report outcome measure, the Functional Rating Index (FRI), was developed and tested. This measure demonstrated reasonable reliability, validity and responsiveness. Since the publication of the original testing, numerous independent research teams have examined the psychometric qualities of the FRI and published their findings. The aim of this study is to review the psychometric properties of the FRI as reported by published studies.
	Functional Rating Index: A New Valid and Reliable Instrument to Measure the Magnitude of Clinical Change in Spinal Conditions Spine (Phila Pa 1976). 2001 (Jan 1);   26 (1):   78–86 The Functional Rating Index appears to be psychometrically sound with regard to reliability, validity, and responsiveness and is clearly superior to other instruments with regard to clinical utility. The Functional Rating Index is a promising useful instrument in the assessment of spinal conditions.

The Patient-Specific Functional Scale

	The Patient-Specific Functional Scale   PDF In a recent study, the Patient Specific Functional Scale was the most responsive disability measure in a trail comparing a variety of OA tools. Adobe Acrobat version.   No scoring method is available on our website
	The Patient-Specific Functional Scale: Psychometrics, Clinimetrics, and Application as a Clinical Outcome Measure J Orthop Sports Phys Ther. 2012 (Jan);   42 (1):   30–42 There has been a shift in current health practices toward patient-focused outcome measures in rehabilitation. [43] In response to this shift, the need for individualized outcome measures has become more apparent. [20, 43] Stratford et al [69] describe this in more detail as being a change from impairment-based to function-based measurement. This view is supported by Pengel et al, [58] who found that disability and function measures were more responsive than impairment measures in a population with subacute low back pain. A move away from practitioner-based measures to a more holistic approach, centering on the patient and the patient's quality of life, has been described by several authors. [20, 48]
	Responsiveness of Pain and Disability Measures for Chronic Whiplash Spine (Phila Pa 1976) 2007 (Mar 1);   32 (5):   580–585 Pain (pain intensity, bothersomeness, and SF-36 bodily pain score) and disability (Patient Specific Functional Scale, Neck Disability Index, Functional Rating Index, Copenhagen Scale, and SF-36 physical summary) measures were completed by 132 patients with chronic whiplash at baseline and then again after 6 weeks together with an 11-point global perceived effect scale. Internal responsiveness was evaluated by calculating effect sizes and standardized response means, and external responsiveness by correlating change scores with global perceived effect scores and by ROC curves. The ranking of responsiveness was consistent across the different analyses. Pain bothersomeness was more responsive than pain intensity, which was more responsive than the SF-36 pain measure. The Patient Specific Functional Scale was the most responsive disability measure, followed by the spine-specific measures, with the SF-36 physical summary measure the least responsive.

The Headache Disability Inventory

	Headache Disability Inventory   PDF Self-completed disability scale measuring the impact of headache on a patients ability to function normally in daily life. It contains 25 items and measures change over time. The responses of *yes*, *sometimes* or *no* are scored 4, 2 and 0 respectively. It is simple to administer and interpret.
	The Henry Ford Hospital Headache Disability Inventory (HDI) Neurology. 1994 (May);   44 (5):   837–842 To quantify the impact of headache of daily living, we developed a 25-item headache disability inventory (HDI). The alpha version of the HDI (alpha-HDI) consisted of 40 items, each requiring a "yes" (four points), "sometimes" (two points), or "no" (zero points) response based on items derived empirically from case history responses of subjects with headache. From the alpha-HDI, we derived a 25-item beta version (beta-HDI) with the items subgrouped into functional and emotional subscales. The internal consistency/reliability was strong, as was construct validity. The test-retest reliability for the beta-HDI was acceptable for the total score and functional and emotional subscale scores.
	Headache Disability Inventory (HDI): Short-term Test-retest Reliability and Spouse Perceptions Headache. 1995 (Oct);   35 (9):   534–539 We have reported previously that the 25-item Headache Disability Inventory has good internal consistency reliability, robust long-term (2 month) test-retest stability, and good construct validity. We conducted further investigations to evaluate the short-term (1 week) test-retest reliability and spouse perceptions of patients' self-perceived headache disability. The short-term test-retest reliability of the Headache Disability Inventory was excellent. Additionally, the spouse and patients' perceptions of the patient's headache disability generally were congruent, although we observed instances where the differences were marked.

Psychosocial Outcome Questionnaires

Major Depression Inventory (MDI)

Major Depression Inventory (MDI)   PDF This document contains the questionnaire, scoring methodology and other scoring instructions.

The Internal and External Validity of the Major Depression Inventory in Measuring Severity of Depressive Dtates Psychol Med. 2003 (Feb);   33 (2):   351–35–539 In total, 91 patients were included. The results showed that the MDI had an adequate internal validity in being a unidimensional scale (the total score an appropriate or sufficient statistic). The external validity of the MDI was also confirmed as the total score of the MDI correlated significantly with the HAM-D (Pearson's coefficient 0.86, P < or = 0.01, Spearman 0.80, P < or = 0.01). When used in a sample of patients with different states of depression the MDI has an adequate internal and external validity.

The Questionnaire for Assessing Psychosocial Yellow Flags

Questionnaire for Assessing Psychosocial Yellow Flags This is the QA designed by Linton & Hallden 1996. Return to the:   Documentation Section Refer also to the:   New Zealand Acute Low Back Pain Guide   PDF

The NeckPix(©) Tool for Assessing Kinesiophobia

	The NeckPix(©) Questionnaire   PDF Thanks to Dr. Marco Monticone for releasing the NeckPix QA to the profession!
	Responsiveness and Minimal Important Change of the NeckPix(©) in Subjects with Chronic Neck Pain Undergoing Rehabilitation European Spine Journal 2018 (Jun);   27 (6):   1324–1331 The NeckPix was sensitive in detecting clinical changes in subjects with chronic neck pain undergoing rehabilitation. We recommend taking the minimal important changes (MICs) provided into account when assessing subjects' improvement or planning studies in this clinical context.
	The NeckPix(©): Development of an Evaluation Tool for Assessing Kinesiophobia in Subjects with Chronic Neck Pain European Spine Journal 2015 (Jan);   24 (1):   72-79 NeckPix(©), which was successfully developed following international recommendations, proved to have a good factorial structure and satisfactory psychometric properties. Its use is recommended for research purposes.

The STarT Back Screening Tool

	The STarT Back Screening Tool   PDF Researchers have developed and validated a simple, brief, and practical way to subgroup patients with nonspecific low back pain in primary care. The new STarT Back Screening Tool identifies potentially modifiable prognostic indicators that may be appropriate targets for primary care interventions.
	The STarT Back Clinical Measurement Tool   PDF Can be used to track progress during care.
	What is the STarT Back Screening Tool? Keele University Website The Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability The resulting score stratifies patients into low, medium or high risk categories For each category there is a matched treatment package. This approach has been shown to reduce back pain related disability and be cost-effective.
	Prediction of Outcome in Patients with Low Back Pain -- A Prospective Cohort Study Comparing Clinicians' Predictions with those of the Start Back Tool Manual Therapy 2016 (Feb);   21:   120–127 ~ FULL TEXT The accuracies of predictions made by clinicians (AUC .58-.63) and the STarT Back Screening Tool (SBT) (AUC .50-.61) were comparable and low. No substantial increase in the predictive capability was achieved by combining clinicians' expectations and the SBT. In conclusion, chiropractors' predictions were associated with well-established prognostic factors but not simply a product of these. Chiropractors were able to predict differences in outcome on a group level, but prediction of individual patients' outcomes were inaccurate and not substantially improved by the SBT.
	Comparison of Stratified Primary Care Management For Low Back Pain wth Current Best Practice (STarT Back): A Randomised Controlled Trial Lancet. 2011 (Oct 29);   378 (9802):   1560–1571 ~ FULL TEXT A stratified management approach in which prognostic screening and treatment targeting were combined resulted in improved primary care efficiency, leading to higher health gains for patients with back pain than did existing non-stratified best care. Significant improvements were not only noted in the primary outcome measure (disability) at both 4-month and 12-month follow-ups, but also for a range of secondary outcome measures, including physical and emotional functioning, pain intensity, quality of life, days off work, global improvement ratings, and treatment satisfaction.
	Feasibility of the STarT Back Screening Tool in Chiropractic Clinics: A Cross-sectional Study of Patients With Low Back Pain Chiropractic & Manual Therapies 2011 (Apr 28);   19:   10 ~ FULL TEXT The STarT back screening tool (SBT) allocates low back pain (LBP) patients into three risk groups and is intended to assist clinicians in their decisions about choice of treatment. The tool consists of domains from larger questionnaires that previously have been shown to be predictive of non-recovery from LBP.
	A Primary Care Back Pain Screening Tool: Identifying Patient Subgroups For Initial Treatment (The STarT Back Screening Tool) Arthritis Rheum. 2008 (May 15);   59 (5):   632–641 ~ FULL TEXT We have developed and validated a simple, brief, and practical way to subgroup patients with nonspecific low back pain in primary care. The new STarT Back Screening Tool identifies potentially modifiable prognostic indicators that may be appropriate targets for primary care interventions. The tool included 9 items: referred leg pain, comorbid pain, disability (2 items), bothersomeness, catastrophizing, fear, anxiety, and depression. The latter 5 items were identified as a psychosocial subscale. The tool demonstrated good reliability and validity and was acceptable to patients and clinicians. Patients scoring 0–3 were classified as low risk, and those scoring 4 or 5 on a psychosocial subscale were classified as high risk. The remainder were classified as medium risk.

Fear Avoidance Beliefs Questionnaire (FABQ)

	Fear Avoidance Beliefs Questionnaire (FABQ) The FABQ was developed by Waddell to investigate fear-avoidance beliefs among LBP patients in the clinical setting. [3] This survey can help predict those that have a high pain avoidance behavior. Clinically, these people may need to be supervised more than those that confront their pain. Questionnaire AND the Scoring Methodology are included.
	The Predictive Effect of Fear-avoidance Beliefs on Low Back Pain Among Newly Qualified Health Care Workers With and Without Previous Low Back Pain: A Prospective Cohort Study BMC Musculoskelet Disord. 2009 (Sep 24);   10:   117 ~ FULL TEXT Health care workers have a high prevalence of low back pain (LBP). Although physical exposures in the working environment are linked to an increased risk of LBP, it has been suggested that individual coping strategies, for example fear-avoidance beliefs, could also be important in the development and maintenance of LBP. Accordingly, the main objective of this study was to examine (1) the association between physical work load and LBP, (2) the predictive effect of fear-avoidance beliefs on the development of LBP, and (3) the moderating effect of fear-avoidance beliefs on the association between physical work load and LBP among cases with and without previous LBP.
	A Fear-Avoidance Beliefs Questionnaire (FABQ) and the Role of Fear-avoidance Beliefs in Chronic Low Back Pain and Disability Pain. 1993 (Feb);   52 (2):   157–168 Test-retest reproducibility in 26 patients was high. Principal-components analysis of the questionnaire in 210 patients identified 2 factors: fear-avoidance beliefs about work and fear-avoidance beliefs about physical activity with internal consistency (alpha) of 0.88 and 0.77 and accounting for 43.7% and 16.5% of the total variance, respectively. Regression analysis in 184 patients showed that fear-avoidance beliefs about work accounted for 23% of the variance of disability in activities of daily living and 26% of the variance of work loss, even after allowing for severity of pain; fear-avoidance beliefs about physical activity explained an additional 9% of the variance of disability. These results confirm the importance of fear-avoidance beliefs and demonstrate that specific fear-avoidance beliefs about work are strongly related to work loss due to low back pain. These findings are incorporated into a biopsychosocial model of the cognitive, affective and behavioural influences in low back pain and disability. It is recommended that fear-avoidance beliefs should be considered in the medical management of low back pain and disability.

The Tampa Scale of Kinesiophobia   (TSK)

	Tampa Scale of Kinesiophobia   PDF The Tampa Scale of Kinesiophobia (TSK) that was developed in 1990 is a 17 item scale originally developed to measure the fear of movement related to chronic lower back pain.
	The Tampa Scale of Kinesiophobia and Neck Pain, Disability and Range of Motion: A Narrative Review of the Literature J Can Chiropr Assoc. 2011 (Sep);   55 (3):   222–232 ~ FULL TEXT The fear avoidance model can be applied to neck pain sufferers and there is value from a psychometric perspective in using the TSK to assess kinesiophobia. Future research should investigate if, and to what extent, other measureable factors commonly associated with neck pain, such as decreased range of motion, correlate with kinesiophobia.
	Norming of the Tampa Scale for Kinesiophobia Across Pain Diagnoses and Various Countries Pain. 2011 (May);   152 (5):   1090–1095 The present study aimed to develop norms for the Tampa Scale for Kinesiophobia (TSK), a frequently used measure of fear of movement/(re)injury. Norms were assessed for the TSK total score as well as for scores on the previously proposed TSK activity avoidance and TSK somatic focus scales. Data from Dutch, Canadian, and Swedish pain samples were used (N=3082). Norms were established using multiple regression to obtain more valid and reliable norms than can be obtained by subgroup analyses based on age or gender.

Patient Satisfaction Questionnaires

Visit-Specific Satisfaction Instrument (VSQ-9)

Visit-Specific Satisfaction Instrument (VSQ-9)   PDF The VSQ-9 is a visit-specific satisfaction instrument adapted by the American Medical Group Association from the Visit Rating Questionnaire used in the Medical Outcomes Study, a two-year study of patients with chronic conditions. Scoring Methodology

Patient Satisfaction Survey as a Tool Towards Quality Improvement Oman Med J. 2014 (Jan);   29 (1):   3–7 Over the past 20 years, patient satisfaction surveys have gained increasing attention as meaningful and essential sources of information for identifying gaps and developing an effective action plan for quality improvement in healthcare organizations. However, there are very few published studies reporting of the improvements resulting from feedback information of patient satisfaction surveys, and in most cases, these studies are contradictory in their findings. This article investigates in-depth a number of research studies that critically discuss the relationship of dependent and independent influential attributes towards overall patient satisfaction in addition to its impact on the quality improvement process of healthcare organizations.

Quality of Life Questionnaires

Patient Reported Outcomes Measurement Information System (PROMIS)

	PROMIS Pediatric Profile v2.0   PDF PROMIS® (Patient-Reported Outcomes Measurement Information System) is a set of person-centered measures that evaluates and monitors physical, mental, and social health in adults and children. It can be used with the general population and with individuals living with chronic conditions.
	Visit the PROMIS® website for other related questionnaires HealthMeasures @ Northwestern University PROMIS developed self-report measures for adults for the functions, symptoms, behaviors, and feelings shown here. Measures are applicable to the general population and to those with chronic conditions.

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Updated 5-06-2021