Outcome Measures

Functional Measurement Tools
Tinetti Performance Oriented Mobility Assessment

(POMA)*
Description:
The Tinetti assessment tool is an easily administered task-oriented test that measures an older adults
gait and balance abilities.
Equipment needed: Hard armless chair
Stopwatch or wristwatch
15 ft walkway
Completion:
Time:
10-15 minutes
A three-point ordinal scale, ranging from 0-2. 0 indicates the
Scoring:
highest level of impairment and 2 the individuals independence.
Total Balance Score = 16
Total Gait Score = 12
Total Test Score = 28
Interpretation:
25-28 = low fall risk

19-24 = medium fall risk
< 19 = high fall risk
* Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. JAGS 1986;
34: 119-126. (Scoring description: PT Bulletin Feb. 10, 1993)
Tinetti Performance Oriented Mobility Assessment (POMA)

- Balance Tests Initial instructions: Subject is seated in hard, armless chair. The following maneuvers are tested.
1.
Leans or slides in chair

Steady, safe
=0
=1
_____
Unable without help

Able, uses arms to help
Able without using arms
=0
=1
=2
_____
Unable without help

Able, requires > 1 attempt
Able to rise, 1 attempt
4.
Immediate Standing Balance (first 5 seconds)
Unsteady (swaggers, moves feet, trunk sway)
=0
Steady but uses walker or other support
=1
Steady without walker or other support
=2
_____
5.
Standing Balance
Unsteady
=0
Steady but wide stance( medial heals > 4 inches
apart) and uses cane or other support
=1
Narrow stance without support
=2
_____
6.
Nudged (subject at maximum position with feet as close
together as possible, examiner pushes lightly on subjects
sternum with palm of hand 3 times)
Begins to fall
=0
Staggers, grabs, catches self =1
Steady
=2
7.
Eyes Closed (at maximum position of item 6)
Unsteady
=0
Steady
=1
_____
=0
=1
=2
_____
8.
=0
=1
=0
=1
2.
3.
Sitting Balance
Arises
Attempts to Arise
Turing 360 Degrees
Discontinuous steps
Continuous steps
Unsteady (grabs, staggers)
Steady
9.
Sitting Down
Unsafe (misjudged distance, falls into chair)
Uses arms or not a smooth motion
Safe, smooth motion
=0
=1
=2
BALANCE SCORE:
_____
_____/16
_____
_____
_____

- Gait Tests -
Initial Instructions: Subject stands with examiner, walks down hallway or across room, first at usual
pace, then back at rapid, but safe pace (using usual walking aids)
10.
Initiation of Gait (immediately after told to go
Any hesitancy or multiple attempts to start
=0
No hesitancy
=1
_____
11.
Step Length and Height
Right swing foot
Does not pass left stance foot with step
=0
Passes left stance foot
=1
Right foot does not clear floor completely
With step
=0
Right foot completely clears floor
=1
Left swing foot
Does not pass right stance foot with step
=0
Passes right stance foot
=1
_____
Left foot does not clear floor completely
With step
=0
Left foot completely clears floor
=1
_____
12.
Step Symmetry
Right and left step length not equal (estimate)
=0
Right and left step length appear equal
=1
_____
13.
Step Continuity
Stopping or discontinuity between steps
Steps appear continuous
14.
Path (estimated in relation to floor tiles, 12-inch diameter;
observe excursion of 1 foot over about 10 ft. of the course)
Marked deviation
=0
Mild/moderate deviation or uses walking aid
Straight without walking aid
15.
Trunk
Marked sway or uses walking aid
No sway but flexion of knees or back or
Spreads arms out while walking
No sway, no flexion, no use of arms, and no
Use of walking aid
16.
Walking Stance
Heels apart
Heels almost touching while walking
GAIT SCORE =
_____
_____
=0
=1
_____
=1
=2
_____
=0
=1
=2
_____
=0
=1
_____
_____/12
BALANCE SCORE = _____/16

TOTAL SCORE (Gait + Balance ) =
_____/28
{< 19 high fall risk, 19-24 medium fall risk, 25-28 low fall risk}

Balance Tests: Subject is seated on hard, armless chair
Date
Date
Date
Date
/16
/16
/16
/16
/12
/12
/12
/12
/28
/28
/28
/28
SITTING BALANCE
Leans or slides in chair =0, Steady, safe =1
ARISES
Unable without help =0; Able, uses arms =1, Able without using arms = 2
ATTEMPTS TO RISE:
Unable w/o help=0; Able, requires > 1 attempt =1; Able in 1 attempt =2
IMMEDIATE STANDING BALANCE (first 5 seconds)
Unsteady (sway/stagger/feet move)=0; Steady, w/ support =1;Steady w/o support =2
STANDING BALANCE
Unsteady =0; Steady, stance > 4 inch BOS & requires support =1;
Narrow stance, w/o support =2
STERNAL NUDGE (feet close together)
Begins to fall =0; Staggers, grabs, catches self =1; Steady =2
EYES CLOSED (feet close together)
Unsteady =0; Steady =1
TURNING 360 DEGREES
Discontinuous steps =0; Continuous steps =1
TURNING 360 DEGREES
Unsteady (staggers, grabs) =0;Steady =1
SITTING DOWN
Unsafe (misjudges distance, falls) =0;Uses arms, or not a smooth motion

=1;
Safe, smooth motion =2
BALANCE SCORE TOTAL
GAIT INITATION (immediate after told go)
Any hesitancy, multiple attempts to start =0; No hesitancy =1
STEP LENGTH
R swing foot passes L stance leg =1; L swing foot passes R =1
FOOT CLEARANCE
R foot completely clears floor =1; L foot completely clears floor =1
STEP SYMMETRY
R and L step length unequal =0; R and L step length equal=1
STEP CONTINUITY
Stop/discontinuity between steps =0; Steps appear continuous =1
PATH (excursion)
Marked deviation =0; Mild/moderate deviation or use of aid =1; Straight without
device=2
TRUNK
Marked sway or uses device =0; No sway but knee or trunk flexion or spread arms while
walking =1; None of the above deviations=2
BASE OF SUPPORT
Heels apart =0; Heels close while walking =1
GAIT SCORE TOTAL
ASSISTIVE DEVICE
TOTAL SCORE (BALANCE + GAIT)
FALL RISK
(minimal >23, Mod. 19-23, High < 19)
Therapist initials
Berg Balance Scale

Name: __________________________________
Date: ___________________
Location: ________________________________ Rater: ___________________

ITEM DESCRIPTION
SCORE (0-4)
Sitting to standing
Standing unsupported
Sitting unsupported
Standing to sitting
Transfers
Standing with eyes closed
Standing with feet together
Reaching forward with outstretched arm
Retrieving object from floor
Turning to look behind
Turning 360 degrees
Placing alternate foot on stool
Standing with one foot in front
Standing on one foot
Total
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
GENERAL INSTRUCTIONS
Please document each task and/or give instructions as written. When scoring, please record
the lowest response category that applies for each item.
In most items, the subject is asked to maintain a given position for a specific time.
Progressively more points are deducted if:
x the time or distance requirements are not met
x the subjects performance warrants supervision
x the subject touches an external support or receives assistance from the examiner
Subject should understand that they must maintain their balance while attempting the tasks.
The choices of which leg to stand on or how far to reach are left to the subject. Poor
judgment will adversely influence the performance and the scoring.
Equipment required for testing is a stopwatch or watch with a second hand, and a ruler or
other indicator of 2, 5, and 10 inches. Chairs used during testing should be a reasonable
height. Either a step or a stool of average step height may be used for item # 12.
Berg Balance Scale

SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hand for support.
( )4
able to stand without using hands and stabilize independently
( )3
able to stand independently using hands
( )2
able to stand using hands after several tries
( )1
needs minimal aid to stand or stabilize
( )0
needs moderate or maximal assist to stand
STANDING UNSUPPORTED
INSTRUCTIONS: Please stand for two minutes without holding on.
( )4
able to stand safely for 2 minutes
( )3
able to stand 2 minutes with supervision
( )2
able to stand 30 seconds unsupported
( )1
needs several tries to stand 30 seconds unsupported
( )0
unable to stand 30 seconds unsupported
If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4.
SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL
INSTRUCTIONS: Please sit with arms folded for 2 minutes.
( )4
able to sit safely and securely for 2 minutes
( )3
able to sit 2 minutes under supervision
( )2
able to able to sit 30 seconds
( )1
able to sit 10 seconds
( )0
unable to sit without support 10 seconds
STANDING TO SITTING
INSTRUCTIONS: Please sit down.
( )4
sits safely with minimal use of hands
( )3
controls descent by using hands
( )2
uses back of legs against chair to control descent
( )1
sits independently but has uncontrolled descent
( )0
needs assist to sit
TRANSFERS
INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a
seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a chair.
( )4
able to transfer safely with minor use of hands
( )3
able to transfer safely definite need of hands
( )2
able to transfer with verbal cuing and/or supervision
( )1
needs one person to assist
( )0
needs two people to assist or supervise to be safe
STANDING UNSUPPORTED WITH EYES CLOSED
INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.
( )4
able to stand 10 seconds safely
( )3
able to stand 10 seconds with supervision
( )2
able to stand 3 seconds
( )1
unable to keep eyes closed 3 seconds but stays safely
( )0
needs help to keep from falling
STANDING UNSUPPORTED WITH FEET TOGETHER
INSTRUCTIONS: Place your feet together and stand without holding on.
( )4
able to place feet together independently and stand 1 minute safely
( )3
able to place feet together independently and stand 1 minute with supervision
( )2
able to place feet together independently but unable to hold for 30 seconds
( )1
needs help to attain position but able to stand 15 seconds feet together
( )0
needs help to attain position and unable to hold for 15 seconds
Berg Balance Scale continued..

REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING
INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the
end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the
distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use both
arms when reaching to avoid rotation of the trunk.)
( )4
can reach forward confidently 25 cm (10 inches)
( )3
can reach forward 12 cm (5 inches)
( )2
can reach forward 5 cm (2 inches)
( )1
reaches forward but needs supervision
( )0
loses balance while trying/requires external support
PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION
INSTRUCTIONS: Pick up the shoe/slipper, which is place in front of your feet.
( )4
able to pick up slipper safely and easily
( )3
able to pick up slipper but needs supervision
( )2
unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance
independently
( )1
unable to pick up and needs supervision while trying
( )0
unable to try/needs assist to keep from losing balance or falling
TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING
INSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat to the right. Examiner may pick an object to
look at directly behind the subject to encourage a better twist turn.
( )4
looks behind from both sides and weight shifts well
( )3
looks behind one side only other side shows less weight shift
( )2
turns sideways only but maintains balance
( )1
needs supervision when turning
( )0
needs assist to keep from losing balance or falling
TURN 360 DEGREES
INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.
( )4
able to turn 360 degrees safely in 4 seconds or less
( )3
able to turn 360 degrees safely one side only 4 seconds or less
( )2
able to turn 360 degrees safely but slowly
( )1
needs close supervision or verbal cuing
( )0
needs assistance while turning
PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED
INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touch the step/stool four times.
( )4
able to stand independently and safely and complete 8 steps in 20 seconds
( )3
able to stand independently and complete 8 steps in > 20 seconds
( )2
able to complete 4 steps without aid with supervision
( )1
able to complete > 2 steps needs minimal assist
( )0
needs assistance to keep from falling/unable to try
STANDING UNSUPPORTED ONE FOOT IN FRONT
INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of the other. If you feel that you cannot place your
foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To score 3
points, the length of the step should exceed the length of the other foot and the width of the stance should approximate the subjects
normal stride width.)
( )4
able to place foot tandem independently and hold 30 seconds
( )3
able to foot ahead independently and hold 30 seconds
( )2
able to take small step independently and hold 30 seconds
( )1
needs help to step but can hold 15 seconds
( )0
loses balance while stepping or standing
STANDING ON ONE LEG
INSTRUCTIONS: Stand on one leg as long as you can without holding on.
( )4
able to lift leg independently and hold > 10 seconds
( )3
able to lift leg independently and hold 5-10 seconds
( )2
able to lift leg independently and hold 3 seconds
( )1
tries to lift leg unable to hold 3 seconds but remains standing independently.
( )0
unable to try of needs assist to prevent fall
( ) TOTAL SCORE (Maximum = 56)
Timed Up & Go Test (TUG)

Research Report
Author: Anne Shumway-Cook, Sandy Brauer, and Marjorie Woollacott
Description of the Instrument
Patients are timed (in seconds) when performing the TUG3 conditions
1. TUG alone-from sitting in a chair, stand up, walk 3 meters, turn around, walk back, and sit
down..
2. TUG Cognitive-complete the task while counting backwards from a randomly selected number
between 20 and 100.
3. TUG manual-complete the task while carrying a full cup of water.
The time taken to complete the task is strongly correlated to level of functional mobility, (i.e.
the more time taken, the more dependent in activities of daily living).
The cutoff levels for TUG is 13.5 seconds or longer with an overall correct prediction rate
of 90%; for TUG manual is 14.5 seconds or longer with a 90% correct prediction rate; and Tug
cognitive is 15 seconds or longer with an overall correct prediction rate of 87%.
Form of instrument:
Hazard/Risk Assessment Tools
To identify/screen elderly individuals who are prone to falls
Interrater reliability was very high, with r=.98, .99, and .99 for the TUG, TUGmanual, and
TUGcognitive respectively
The TUG alone correctly classified 13/15 fallers (87% sensitivity) and 13/15 nonfallers (87%
specficity).
Validity Measures
Older adults who take longer than 14 seconds to complete the TUG have a high risk
for falls. This cutoff is different from Podsiadlo and Richardson, which is 30 seconds.
Reference
Lundlin-Olsson, L., Nyberg, L., & Gustafson, Y. (1998). Attention, frailty, and falls: the
effect of a manual task on basic mobilty. Journal of the American Geriatrics Society, 46,
758-761.
Podsiadlo, D., & Richardson, S. (1991). The timed up & go: A test of basic functional
mobility for frail elderly persons. Journal of the American Geriatrics Society, 39, 142148.
Shumway-Cook, A., Brauer, S., & Woollacott, M. (2000). Predicting the probability for
falls in community-dwelling older adults using the timed up & go test. Physical Therapy,
80(9), 896-903.
Timed Up and Go*

Directions:
The timed Up and Go test measures, in seconds, the time taken by an individual to stand
up from a standard arm chair (approximate seat height of 46 cm [18in], arm height 65 cm
[25.6 in]), walk a distance of 3 meters (118 inches, approximately 10 feet), turn, walk back
to the chair, and sit down. The subject wears their regular footwear and uses their
customary walking aid (none, cane, walker). No physical assistance is given. They start
with their back against the chair, their arms resting on the armrests, and their walking aid at
hand. They are instructed that, on the word go they are to get up and walk at a
comfortable and safe pace to a line on the floor 3 meters away, turn, return to the chair and
sit down again. The subject walks through the test once before being timed in order to
become familiar with the test. Either a stopwatch or a wristwatch with a second hand can
be used to time the trial.
Instructions to the patient:
When I say go I want you to stand up and walk to the line, turn and then walk back to
the chair and sit down again. Walk at your normal pace.
Variations:
You may have the patient walk at a fast pace to see how quickly they can ambulate. Also
you could have them turn to the left and to the right to test any differences.
*Podsiadlo D, Richardson S. The timed up and go: a test of basic functional mobility for
frail elderly persons. JAGS 1991; 39: 142-148.
Scoring:
Time for Up and Go test _________sec.
Unstable on turning?
Walking aid used? Type of aid: ___________
Functional Reach
Directions:
Using a yardstick mounted on the wall at shoulder height, ask the subject to position
themselves close to, but not touching the wall with their arm outstretched and hand fisted.
Take note of the starting position by determining what number the MCP joints line up with
on the yardstick. Have the subject reach as far forward as possible in a plane parallel with
the measuring device. Instruct them to Reach as far forward as you can without taking a
step. They are free to use various reaching strategies. Take note of the end position of the
MCP joints against the ruler, and record the difference between the starting and ending
position numbers. If they move their feet, that trial must be discarded and the trial repeated.
Guard the subject as the task is performed to prevent a fall. Subjects are given two practice
trials, and then their performance on an additional three trials is recorded and averaged.
Scores less than 6 or 7 inches indicate limited functional balance. Most

healthy individuals with adequate functional balance can reach 10 inches or
more.
Instructions to the patient:
Please reach as far forward as you can without losing your balance. Keep your feet on the
floor. You are not allowed to touch the wall or the ruler as you reach. You will have two
practice trials and then I will record the distance that you reach forward.
Criteria to stop the test:
The patients feet lifted up from the floor or they fell forward. Most patients fall forward
with this test. The therapist should guard from the front as that is the direction that you
reach forward.
*Duncan P, Weiner D, Chandler J, et al. Functional reach: a new clinical measure of

balance. J of Gerontol 1990; 45: M192-197.
10
FICSIT-4
(Frailty and Injuries: Cooperative Studies of Intervention Techniques)
Tests of Static Balance:

parallel, semi-tandem, tandem, and one-legged stance tests
Journals of Gerontology Series A: Biological Sciences and Medical Sciences, Vol 50, Issue 6 M291-M297,
Copyright 1995 by The Gerontological Society of America
MULTICENTER STUDY
A cross-sectional validation study of the FICSIT common data base static balance measures. Frailty and
Injuries: Cooperative Studies of Intervention Techniques
JE Rossiter-Fornoff, SL Wolf, LI Wolfson and DM Buchner
Division of Biostatistics, Washington University School of Medicine, St. Louis, USA.
BACKGROUND. Two simple balance scales comprising three or four familiar tests of static balance were
developed, and their validity and reliability are described. The scales were such that the relative difficulties of
the basic tests were taken into consideration. METHODS. Using FICSIT data, Fisher's method was used to
construct scales combining ability to maintain balance in parallel, semi-tandem, tandem, and one-legged
stances. Reliability was inferred from the stability of the measure over 3-4 months. Construct validity was
assessed by cross- sectional correlations. RESULTS. Test-retest reliability (over 3-4 months) was good (r = .66).
Validity of the FICSIT-3 scale was suggested by its low correlation with age, its moderate to high correlations
with physical function measures, and three balance assessment systems. The FICSIT-4 scale discriminated
balance over a wide range of health status; the three-test scale had a substantial ceiling effect in community
samples. CONCLUSION. A balance scale was developed that appears to have acceptable reliability, validity,
and discriminant ability.
INSTRUCTIONS: Demonstrate each position to the subject, then ask them to perform and time.
F-1. FEET CLOSELY TOGETHER, UNSUPPORTED, eyes open (ROMBERG POSITION)

INSTRUCTIONS: Stand still with your feet together as demonstrated for 10 seconds. [Berg #7 = 60 seconds]
4 able to stand 10 seconds safely
3 able to stand 10 seconds with supervision
2 able to stand 3 seconds
1 unable to stand 3 seconds but stays steady
0 needs help to keep from falling
If subject is able to do this, proceed to the next position, if not, stop.
F-2. FEET CLOSELY TOGETHER, UNSUPPORTED, eyes closed (ROMBERG POSITION)
INSTRUCTIONS: Please close your eyes and stand still with your feet together as demonstrated for 10 seconds.
1 unable to keep eyes closed 3 seconds but stays steady
11
F-3. SEMI-TANDEM: eyes open HEEL OF 1 FOOT PLACED TO THE SIDE OF THE 1ST TOE OF THE
OPPOSITE FOOT (SUBJECT CHOOSES WHICH FOOT GOES FORWARD)
INSTRUCTIONS: Please stand still with your feet together as demonstrated for 10 seconds.
F-4. SEMI-TANDEM: eyes closed HEEL OF 1 FOOT PLACED TO THE SIDE OF THE 1ST TOE OF THE
OPPOSITE FOOT (SUBJECT CHOOSES WHICH FOOT GOES FORWARD)
INSTRUCTIONS: Please close your eyes and stand still with your feet together as demonstrated for 10 seconds.
1 unable to keep eyes closed 3 seconds but stays steady
F-5. FULL TANDEM: eyes open HEEL OF 1 FOOT DIRECTLY IN FRONT OF THE OTHER FOOT
(SUBJECT CHOOSES WHICH FOOT GOES FORWARD) [Berg #14 = 30 seconds]
F-6. FULL TANDEM: eyes closed HEEL OF 1 FOOT DIRECTLY IN FRONT OF THE OTHER FOOT
(SUBJECT CHOOSES WHICH FOOT GOES FORWARD)
If subject is able to do this, proceed to the next position, if not, stop
F-7. STANDING ON ONE LEG: eyes open [Same as Berg #13]
INSTRUCTIONS: Stand on one leg as long as you can without holding.
4 able to lift leg independently and hold >10 seconds
3 able to lift leg independently and hold 5-10 seconds
2 able to lift leg independently and hold = or >3 seconds
1 tries to lift leg unable to hold 3 seconds but remains standing independently
0 unable to try or needs assist to prevent fall
Total FICSIT-4 Static Balance score = ____ / 28
12
13
14
Patient
Date
Dizziness Handicap Inventory
INSTRUCTIONS: The purpose of this questionnaire is to identify difficulties that you may be experiencing because of
your dizziness. Please answer every question. Please do not skip any questions.
1. Does looking up increase your problem?
Yes
Sometimes
No
2. Because of your problem, do you feel frustrated?
Yes
Sometimes
No
3. Because of your problem, do you restrict your travel for business or recreation? Yes
Sometimes
No
4. Does walking down the aisle of a supermarket increase your problem?
Yes
Sometimes
No
5. Because of your problem, do you have difficulty getting into or out of bed?
Yes
Sometimes
No
6. Does your problem significantly restrict your participation in social activities

such as going out to dinner, going to movies, dancing, or to parties?
Yes
Sometimes
No
7. Because of your problem, do you have difficulty reading?
Yes
Sometimes
No
8. Does performing more ambitious activities like sports, dancing, household

chores such as sweeping or putting dishes away increase your problem?
Yes
Sometimes
No
9. Because of your problem, are you afraid to leave home without having
someone with you?
Yes
Sometimes
No
10. Because of your problem, have you been embarrassed in front of others?
Yes
Sometimes
No
11. Do quick movements of your head increase your problem?
Yes
Sometimes
No
12. Because of your problem, do you avoid heights?
Yes
Sometimes
No
13. Does turning over in bed increase your problem?
Yes
Sometimes
No
14. Because of your problem, is it difficult for you to do strenuous housework or

yard work?
Yes
Sometimes
No
15. Because of your problem, are you afraid people may think you are intoxicated? Yes
Sometimes
No
16. Because of your problem, is it difficult for you to go for a walk by yourself?
Yes
Sometimes
No
17. Does walking down a sidewalk increase your problem?
Yes
Sometimes
No
18. Because of your problem, is it difficult for you to concentrate?
Yes
Sometimes
No
19. Because of your problem, is it difficult for you to go for a walk around your
house in the dark?
Yes
Sometimes
No
20. Because of your problem, are you afraid to stay home alone?
Yes
Sometimes
No
21. Because of your problem, do you feel handicapped?
Yes
Sometimes
No
22. Has your problem placed stress on your relationship with members of your
family or friends?
Yes
Sometimes
No
23. Because of your problem, are you depressed?
Yes
Sometimes
No
24. Does your problem interfere with your job or household responsibilities?
Yes
Sometimes
No
25. Does bending over increase your problem?
Yes
Sometimes
No
15
FOUR SQUARE STEP TEST (FSST)
Test Description
The equipment required for the FSST includes
a stopwatch
4 canes.
The square is formed by using 4 canes resting flat on the floor. Canes were 90cm long, and the
direction and type of handle used is not important (fig 1).
The subject stands in square number 1 facing square number 2.
The aim is to step as Square number 2, 3, 4, 1, 4, 3, 2, and 1.
This sequence requires the subject to step forward, backward, and sideway to the right and left.
The score is recorded as the time taken to complete the sequence.
The stopwatch starts when the first foot contacts the floor in square 2 and finishes when the last
foot comes back to touch the floor in square 1.
The following instructions are given to the subject, Try to complete the sequence as fast as
possible without touching the sticks. Both feet must make contact with the floor in each square.
If possible, face forward during the entire sequence.
The sequence is then shown to the subject. One practice trial is completed to ensure the subject
knows the sequence.
Two FSST are completed with the best time taken as the score.
A trial is repeated if the subject fails to complete the sequence successfully, loses balance, or
makes contact with a cane during the sequence.
Time required to perform: _____seconds
Start
Finish
1 2
3 4
From: Dite W, Temple VA. A clinical test of stepping and change of direction to identify
multiple falling older adults. Archives of physical medicine and rehabilitation 2002;83(11):156671.
16
6-Minute Walk Test

Description: The 6-Minute Walk test is a measure of endurance.
Equipment: stopwatch, rolling tape measure, track/loop walkway
Instructions: Monitor vital signs before and after each test. Assure patient safety throughout the test. Give the
same verbal instructions each time. When I say go, I want you to walk around this [track]. Keep walking until
I say stop or until you are too tired to go any further. If you need to rest, you can stop until you feel ready to go
again. I am interested in measuring how far you can walk. You can begin when I say go. Time the subject for
6 minutes, then say stop. Inform the patient of the time elapsed at each minute. Measure the distance walked.
Stop testing based on the following criteria:
C/o angina symptoms (chest pain or tightness)
Any of the following symptoms:
Light-headedness
Confusion
Ataxia, staggering unsteadiness
Pallor
Cyanosis
Nausea
Marked dyspnea
Unusual fatigue
Signs of peripheral circulatory insufficiency
Claudication or other significant pain
Facial expressions signifying distress
Abnormal cardiac responses
Systolic blood pressure drops > 10 mmHg
Systolic blood pressure rises < 250 mmHg
Diastolic blood pressure rises to > 120 mmHg
Heart rate drops more than 15 beats per minute (given the subject was walking the last minutes of the test versus
resting)
Notify physician if test is terminated for any of the above reasons
6-Minute Walk Test Distances: Means and Standard Deviations by Age and Gender (Meters)
Age
Gender
Mean
SD
Normal Range
(N)
(2SD)
60-69
Male (15)
572
92
388-756
Female (22)
538
92
354-722
70-79
Male (14)
527
85
357-697
Female (22)
471
75
321-621
80-89
Male (8)
417
73
271-563
Female (15)
392
85
222-562
Steffen, T.M. (2000) Functional assessment: A literature review of four tools. Focus: Geriatric Physical
Therapy: An Independent Home Study Course for Individual Continuing Education.
6 minute walk
Resting
Post
5 minutes Post
HR
Resp
BP
Borg
17
Distance
#Rests
Assitive Device?
Type:
Gait deviation:
Dynamic Gait Index*

Description:
Developed to assess the likelihood of falling in older adults.
This scale was designed to test eight facets of gait.
Equipment needed: Box (Shoebox)
Cones (2)
Stairs
Completion:
Time:
15 minutes
Scoring:
A four-point ordinal scale, ranging from 0-3. 0 indicates the
lowest level of function and 3 the highest level of function.
Total Score = 24
Interpretation:
< 19 = predictive of falls in the elderly

> 22 = safe ambulators
*Shumway-Cook A, Woollacott M. Motor Control Theory and Applications, Williams and Wilkins
Baltimore, 1995: 323-324
18
Dynamic Gait Index

Gait level surface _____
Instructions: Walk at your normal speed from here to the next mark (20)
Grading: Mark the lowest category that applies.
(3)
Normal: Walks 20, no assistive devices, good sped, no evidence for imbalance, normal gait pattern
(2)
Mild Impairment: Walks 20, uses assistive devices, slower speed, mild gait deviations.
Moderate Impairment: Walks 20, slow speed, abnormal gait pattern, evidence for imbalance.
Severe Impairment: Cannot walk 20 without assistance, severe gait deviations or imbalance.
Change in gait speed _____
Instructions: Begin walking at your normal pace (for 5), when I tell you go, walk as fast as you can (for 5). When I tell
you slow, walk as slowly as you can (for 5).
(3)
Normal: Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant
difference in walking speeds between normal, fast and slow speeds.
(2)
Mild Impairment: Is able to change speed but demonstrates mild gait deviations, or not gait deviations but unable
to achieve a significant change in velocity, or uses an assistive device.
Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant
gait deviations, or changes speed but has significant gait deviations, or changes speed but loses balance but is able to
recover and continue walking.
Severe Impairment: Cannot change speeds, or loses balance and has to reach for wall or be caught.
Gait with horizontal head turns _____
Instructions: Begin walking at your normal pace. When I tell you to look right, keep walking straight, but turn your head
to the right. Keep looking to the right until I tell you, look left, then keep walking straight and turn your head to the left.
Keep your head to the left until I tell you look straight, then keep walking straight, but return your head to the center.
(3)
Normal: Performs head turns smoothly with no change in gait.
(2)
Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to
smooth gait path or uses walking aid.
Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can
continue to walk.
Severe Impairment: Performs task with severe disruption of gait, i.e., staggers
outside 15 path, loses balance, stops, reaches for wall.
Gait with vertical head turns _____
Instructions: Begin walking at your normal pace. When I tell you to look up, keep walking straight, but tip your head up.
Keep looking up until I tell you, look down, then keep walking straight and tip your head down. Keep your head down
until I tell you look straight, then keep walking straight, but return your head to the center.
(3)
Normal: Performs head turns smoothly with no change in gait.
Mild Impairment: Performs head turns smoothly with slight change in gait
velocity, i.e., minor disruption to smooth gait path or uses walking aid.
(1)
Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but
recovers, can continue to walk.
(0)
Severe Impairment: Performs task with severe disruption of gait, i.e., staggers
outside 15 path, loses balance, stops, reaches for wall.
19
Dynamic Gait Index continued.

Gait and pivot turn _____
Instructions: Begin walking at your normal pace. When I tell you, turn and stop, turn as quickly as you can to face the
opposite direction and stop.
(3) Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance.
(2) Mild Impairment: Pivot turns safely in > 3 seconds and stops with no loss of balance.
Moderate Impairment: Turns slowly, requires verbal cueing, requires several small steps to catch balance following turn
and stop.
Severe Impairment: Cannot turn safely, requires assistance to turn and stop.
Step over obstacle ____
Instructions: Begin walking at your normal speed. When you come to the shoebox, step over it, not around it, and keep
walking.
(3) Normal: Is able to step over the box without changing gait speed, no evidence of imbalance.
Mild Impairment: Is able to step over box, but must slow down and adjust steps to clear box
safely.
Moderate Impairment: Is able to step over box but must stop, then step over. May require verbal cueing.
Severe Impairment: Cannot perform without assistance.
Step around obstacles _____
Instructions: Begin walking at normal speed. When you come to the first cone (about 6 away), walk around the right side
of it. When you come to the second cone (6 past first cone), walk around it to the left.
Normal: Is able to walk around cones safely without changing gait speed; no evidence of
imbalance.
Mild Impairment: Is able to step around both cones, but must slow down and
adjust steps to clear cones.
Moderate Impairment: Is able to clear cones but must significantly slow, speed to accomplish task, or requires verbal
cueing.
Severe Impairment: Unable to clear cones, walks into one or both cones, or requires physical assistance.
Steps _____
Instructions: Walk up these stairs as you would at home, i.e., using the railing if necessary. At the top, turn around and
walk down.
(3)
Normal: Alternating feet, no rail.
(2)
Mild Impairment: Alternating feet, must use rail.
Moderate Impairment: Two feet to a stair, must use rail.
(0)
Severe Impairment: Cannot do safely.
TOTAL SCORE: ___ / 24
20
TIMED 10 REPETITION CHAIR RISE: AGE RELATED NORMS

Women
Age Mean (sec)
Men
Upper limit (sec)
Mean (sec)
Upper limit (sec)
60
16.6
22.6
16.6
20.1
65
18.4
23.5
17.6
21.1
70
19.2
24.3
18.5
22.0
75
20.1
25.2
19.5
23.0
80
20.9
26.1
20.5
24.0
85
21.8
27.0
21.5
25.0
NORMS FOR GAIT SPEED

Steffen TM et al, 2002; Bohannon RW, 1997
Age
Gender
60-69
Male
70-79
80-89
Mean
Comfortable Gait Speed
1.59m/s (Steffen et al)
1.36m/s (Bohannon)
Mean
Fast Gait Speed
2.05m/s
1.93m/s
Female
1.44m/s
1.29m/s
1.87m/s
1.77m/s
Male
1.38m/s
1.33m/s
1.83m/s
2.07 m/s
Female
Male
1.33m/s
1.27m/s
1.21m/s
1.71m/s
1.75 m/s
1.65m/s
Female
1.15m/s
1.59m/s
21

Rivermead Mobility Index
Overview: The Rivermead Mobility Index is a measure of disability related to bodily mobility. It demonstrates
the patient's ability to move her or his own body. It does not measure the effective use of a wheelchair or the
mobility when aided by someone else. It was developed for patients who had suffered a head injury or stroke
at the Rivermead Rehabilitation Centre in Oxford England.
Rivermead Motor Index
No
Parameter
Question
Turning over in bed
Do you turn over from your back to side without help?
Lying to sitting
From lying in bed do you get up to sit on the edge of the

bed on your own?
Sitting balance
Do you sit on the edge of the bed without holding on for

10 seconds?
Sitting to standing
Do you stand up (from any chair) in less than 15

seconds and stand there for 15 seconds (using hands
and with an aid if necessary)?
Standing unsupported
Observe standing for 10 seconds without any aid or

support.
Transfer
Do you manage to move from bed to chair and back

without any help?
Walking inside with an aid if

needed
Do you walk 10 meters with an aid or furniture if

necessary but with no standby help?
Stairs
Do you manage a flight of stairs without help?
Walking outside (even

ground)
Do you walk around outside on pavements without

help?
10
Walking inside with no aid
Do you walk 10 meters inside with no caliper splint aid

or use of furniture and no standby help?
11
Picking off floor
If you drop something on the floor do you manage to

walk 5 meters pick it up and then walk back?
12
Walking outside (uneven

ground)
Do you walk over uneven ground (grass gravel dirt

snow ice etc.) without help?
13
Bathing
Do you get in and out of bath or shower unsupervised

and wash self?
14
Up and down 4 steps
Do you manage to go up and down 4 steps with no rail

and without help but using an aid if necessary?
15
Running
Do you run 10 meters without limping in 4 seconds (a

fast walk is acceptable)?
22
Response
Points
Yes
No
Rivermead motor index = SUM(points for all 15 questions)

Interpretation:
minimum score = 0
maximum score =1
The higher the score the better the mobility.
References:
Collen FM Wade DT et al. The Rivermead Mobility Index: a further development of the Rivermead Motor
Assessment. Int Disabil Studies. 1991; 13: 50-54.
23
The Patient-Specific Functional Scale

This useful questionnaire can be used to quantify activity limitation and measure functional outcome for patients
with any orthopaedic condition.
Clinician to read and fill in below: Complete at the end of the history and prior to physical examination.
Initial Assessment:
I am going to ask you to identify up to three important activities that you are unable to do or are having difficulty
with as a result of your _________________ problem. Today, are there any activities that you are unable to do
or having difficulty with because of your _________________ problem? (Clinician: show scale to patient and
have the patient rate each activity).
Follow-up Assessments:
When I assessed you on (state previous assessment date), you told me that you had difficulty with (read all
activities from list at a time). Today, do you still have difficulty with: (read and have patient score each item in
the list)?
Patient-specific activity scoring scheme (Point to one number):

0
Unable to
perform
activity
10
Able to perform
activity at the same
level as before
injury or problem
(Date and Score)

Activity
Initial
1.
2.
3.
4.
5.
Additional
Additional
Total score = sum of the activity scores/number of activities

Minimum detectable change (90%CI) for average score = 2 points
Minimum detectable change (90%CI) for single activity score = 3 points
PSFS developed by: Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual
patients: a report of a patient specific measure. Physiotherapy Canada, 47, 258-263.
Reproduced with the permission of the authors.
24
OPTIMAL INSTRUMENT
Demographic Information
1. Date of Birth _____________
mm / dd / yyyy
2. Sex
1) ____Male
2) ____Female
3. Race
1) ____Aleut/Eskimo
2) ____American Indian
3) ____Asian/Pacific Islander
4) ____Black
5) ____White
6) ____Other
4. Ethnicity
1) ____Hispanic or Latino
2) ____Not Hispanic or Latino
5. Insurance (Please check all that apply)

1) ____Workers compensation
2) ____Self-pay
3) ____HMO/PPO/private insurance
4) ____Medicare
5) ____Medicaid
6) ____Auto
7) ____Other
6. Education (Please check one)

1) ____Less than high school
2) ____Some high school
3) ____High school graduate
4) ____Attended or graduated from technical school
5) ____Attended college, did not graduate
6) ____College graduate
7) ____Completed graduate school/advanced degree
7. Please check the combined annual income of everyone

in your house:
1) ____Less than $10,000
2) ____$10,000$14,999
3) ____$15,000$24,999
4) ____$25,000$34,999
5) ____$35,000$49,999
6) ____$50,000$74,999
7) ____$75,000$99,999
8) ____$100,000$149,999
9) ____$150,000 or more
8. Employment/Work (Check all that apply)

1) ____Working full-time outside of home
2) ____Working part-time outside of home
3) ____Working full-time from home
4) ____Working part-time from home
5) ____Working with modification in job
because of current illness/injury
6) ____Not working because of current illness/
injury
7) ____Homemaker
8) ____Student
9) ____Retired
10) ____Unemployed
Occupation:__________________________
9. Do you use a: (Check all that apply)

1) ____Cane?
2) ____Walker, rolling walker, or rollator?
3) ____Manual wheelchair?
4) ____Motorized wheelchair?
5) ____Other:__________
10. With whom do you live? (Check all that apply)

1) ____Alone
2) ____Spouse/significant other
3) ____Child/children
4) ____Other relative(s)
5) ____Group setting
6) ____Personal care attendant
7) ____Other:______________
11. Where do you live?

1) ____Private home
2) ____Private apartment
3) ____Rented room
4) ____Board and care/assisted living/group home
5) ____Homeless (with or without shelter)
6) ____Long-term care facility (nursing home)
7) ____Hospice
8) ____Other
Adapted/revised in July 2005 and August 2006 with permission of

APTA from Guccione AA, Mielenz TJ, De Vellis RF, et al.
Development and testing of a self-report instrument to measure
actions: Outpatient Physical Therapy Improvement in Movement
Assessment Log (OPTIMAL). Phys Ther. 2005;85:515530.
2005, 2006 American Physical Therapy Association. All rights reserved. No part of this instrument may be reproduced, stored in
a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise without prior
permission of the American Physical Therapy Association. Contact permissions@apta.org or visit www.apta.org/publications.
OPTIMAL INSTRUMENT
DifficultyBaseline
Able to do
Instructions: Please circle the without
any
level of difficulty you have for
difficulty
each activity today.
1. Lying flat
2. Rolling over
3. Movinglying to sitting
4. Sitting
5. Squatting
6. Bending/stooping
7. Balancing
8. Kneeling
9. Walkingshort distance
10. Walkinglong distance
11. Walkingoutdoors
12. Climbing stairs
13. Hopping
14. Jumping
15. Running
16. Pushing
17. Pulling
18. Reaching
19. Grasping
20. Lifting
21. Carrying
Able to do
Able to do
Able to do
with little with moderate with much Unable to
do
difficulty
difficulty
difficulty
Not applicable
22. Thinking about all of the activities you would like to do, please mark an X at the point on the line
that best describes your overall level of difficulty with these activities today.
I have extreme difficulty

doing any of the activities
that I would like to do.
I have no difficulty doing any

of the activities that I would
like to do.
23. From the above list, choose the 3 activities you would most like to be able to do without any difficulty
(for example, if you would most like to be able to climb stairs, kneel, and hop without any difficulty, you
would choose: 1. 12
2. 8
3. 13 )
1.____ 2.____ 3.____
Adapted/revised in July 2005 and August 2006 with permission of APTA from Guccione AA, Mielenz TJ, De Vellis RF, et al.
Development and testing of a self-report instrument to measure actions: Outpatient Physical Therapy Improvement in Movement
Assessment Log (OPTIMAL). Phys Ther. 2005;85:515-530.
ConfidenceBaseline
Instructions: Please circle the
level of confidence you have for
doing each activity today.
1. Lying flat
2. Rolling over
3. Movinglying to sitting
4. Sitting
5. Squatting
6. Bending/stooping
7. Balancing
8. Kneeling
9. Walkingshort distance
10. Walkinglong distance
11. Walkingoutdoors
12. Climbing stairs
13. Hopping
14. Jumping
15. Running
16. Pushing
17. Pulling
18. Reaching
19. Grasping
20. Lifting
21. Carrying
Fully confident
in my ability to
perform
Not
confident in
Very
Moderate
Some my ability to Not applicable
confident confidence confidence perform
22. Thinking about all the activities you like to do, please mark an X at the point on the line that
best describes your overall level of confidence in performing these activities today:
I have no confidence that I

can do activities that I
would want to do.
I have complete confidence

that I can do activities that I
would want to do.
Adapted/revised in July 2005 and August 2006 with permission of APTA from Guccione AA, Mielenz TJ, De Vellis RF, et al.
Development and testing of a self-report instrument to measure actions: Outpatient Physical Therapy Improvement in Movement
Assessment Log (OPTIMAL). Phys Ther. 2005;85:515-530.
Modified - Physical Performance Test

Testing Protocol:
Administer the test as outlined below. Subjects are given up to two chances to complete each item.
Assistive devices are permitted for tasks 6 9.
Feet together: Stand still with your feet together as demonstrated for 10 seconds.
Semi Tandem: Stand with the heel of one foot placed to the side of the 1st toe of the opposite foot for
10 seconds. Subject chooses which foot goes forward.
Tandem: Stand with the heel of one foot directly in front of the other foot, for 10 seconds. Subject
chooses which foot goes forward.
Chair Rise: Use a straight back chair with a solid seat that is 16 high. Ask participant to sit on the
chair with arms folded across their chest. Stand up and sit down as quickly as possible 5 times,
keeping your arms folded across your chest.
Book Lift: Place a Physicians Desk Reference Book (1988 PDR: 5.5 lbs) or other heavy book on a table
in front of the patient. Ask the patient, when given the command go to place the book on a shelf
above shoulder level. Time from the command go to the time the book is resting on the shelf.
Put on and remove a jacket: If the subject has a jacket or cardigan sweater, ask them to remove it. If
not, give the subject a lab coat. Ask the subject, on the command go to put the coat on completely
such that it is straight on their shoulders and then remove the garment completely. Time from the
command go until the garment has been completely removed.
Pick up a penny from floor: Place a penny approximately 12 inches from the patients foot on the
dominant side. Ask the patient, on the command go to pick up the penny from the floor and stand up.
Time from the command go until the subject is standing erect with a penny in hand.
Turn 360 degrees: With subject in a corridor or in an open room, ask the subject to turn 360 degrees.
Evaluate using the scale on PPT scoring sheet.
50-foot walk test: Bring subject to start on a 50 foot walk test course (25 feet out and 25 feet back)
and ask the subject, on the command go to walk to the 25-foot mark and back. Time from the
command go until the starting line is crossed on the way back.
Stairs: Bring subject to foot of stairs (nine to 12 steps) and ask subject, on the command go to begin
climbing stairs until they feel tired and wishes to stop. Before beginning this task, alert the subject to
the possibility of developing chest pain or shortness of breath and inform the subject to tell you if any
of these symptoms occur. Escort the subject up the stairs. Time from the command go until the
subjects first foot reaches the top of the first flight of stairs. Record the number of flights (maximum
is four) completed (up and down is one flight).
25

Modified - Physical Performance Test
1.
Standing Static Balance
Feet Together:
________ sec.
10s.
10s.
10s.
10s.
0-9s.
Semi Tandem:
________ sec.
10s.
10s.
10s.
0-9s.
Unable
Time
2.
Chair rise
3.
Lift a book and put it on a shelf
4.
Put on and remove a jacket
5.
Pick up a penny from floor.
6.
Turn 360 degrees
7.
50-foot walk test.

.
8.
Climb one flight of stairs.
9.
Climb stairs.
Tandem: ________
sec.
10s.
3-9.9s.
0-2.9s.
Unable
Unable
Score
Scoring values
Score
11 sec
11.1--14 sec
14.1--17 sec
>17 sec
unable
2 sec
2.1--4 sec
4.1-- 6 sec
> 6 sec
unable
10 sec
10.1 --15 sec
15.1 20 sec
>20 sec
unable
2 sec
2.1--4 sec
4.1-- 6 sec
> 6 sec
unable
Discontinuous steps
=0
Continuous steps
=2
4
3
2
1
0
=4
=3
=2
=1
= 0
=4
=3
=2
=1
= 0
=4
=3
=2
=1
= 0
=4
=3
=2
=1
= 0
Unsteady (grabs, staggers) = 0

Steady
=2
15 sec
=4
15.1--20 sec = 3
20.1--25 sec = 2
>25 sec
=1
unable
= 0
5 sec
=4
5.1--10 sec = 3
10.1 15 sec = 2
>15 sec
=1
unable
= 0
Number of flights of stairs up and down
(maximum 4)
TOTAL SCORE
9-item score
26
/36
ARTHRITIS IMPACT MEASUREMENT SCALES 2
AIMS
Please check (X) the most appropriate answer for each question.
These questions refer to MOBILITY LEVEL.
DURING THE PAST MONTH...
All
Days
(1)
Most
Days
(2)
Some
Days
(3)
Few
Days
(4)
No
Days
(5)
1.
How often were you physically able

to drive a car or use public transportation?
_____
_____
_____
_____
_____
8/
2.
How often were you out of the house

for at least part of the day?
_____
_____
_____
_____
_____
9/
3.
How often were you able to do errands

in the neighborhood?
_____
_____
_____
_____
_____
10/
4.
How often did someone have to assist

you to get around outside your home?
_____
_____
_____
_____
_____
11/
5.
How often were you in a bed or chair

for most or all of the day?
_____
_____
_____
_____
_____
12/
..........................................................................
AIMS
These questions refer to WALKING AND BENDING.
All
Days
(1)
Most
Days
(2)
Some
Days
(3)
Few
Days
(4)
No
Days
(5)
Did you have trouble doing vigorous

activities such as running, lifting
heavy objects, or participating in
strenuous sports?
_____
_____
_____
_____
_____
13/
Did you have trouble either walking

several blocks or climbing a few flights
of stairs?
_____
_____
_____
_____
_____
14/
8.
Did you have trouble bending, lifting

or stooping?
_____
_____
_____
_____
_____
15/
9.
Did you have trouble either walking

one block or climbing one flight of stairs?
_____
_____
_____
_____
_____
16/
10.
Were you unable to walk unless assisted

by another person or by a cane, crutches,
or walker?
_____
_____
_____
_____
_____
17/

6.
7.
28

AIMS
These questions refer to HAND AND FINGER FUNCTION.
All
Days
(1)
Most
Days
(2)
Some
Days
(3)
Few
Days
(4)
No
Days
(5)
11.
Could you easily write with a pen or pencil? _____
_____
_____
_____
_____
18/
12.
Could you easily button a shirt or blouse?
_____
_____
_____
_____
_____
19/
13.
Could you easily turn a key in a lock?
_____
_____
_____
_____
_____
20/
14.
Could you easily tie a knot or a bow?
_____
_____
_____
_____
_____
21/
15.
Could you easily open a new jar of food?
_____
_____
_____
_____
_____
22/
..........................................................................
AIMS
These questions refer to ARM FUNCTION.
All
Days
(1)
Most
Days
(2)
Some
Days
(3)
Few
Days
(4)
No
Days
(5)
16.
Could you easily wipe your mouth with

a napkin?
_____
_____
_____
_____
_____
23/
17.
Could you easily put on a pullover

sweater?
_____
_____
_____
_____
_____
24/
18.
Could you easily comb or brush your

hair?
_____
_____
_____
_____
_____
25/
19.
Could you easily scratch your low back

with your hand?
_____
_____
_____
_____
_____
26/
20.
Could you easily reach shelves that were

above your head?
_____
_____
_____
_____
_____
27/
29

AIMS
These questions refer to SELF-CARE TASKS.
Always
(1)
Very
Almost
Often Sometimes Never
(2)
(3)
(4)
Never
(5)
21.
Did you need help to take a bath or shower? _____
_____
_____
_____
_____ 28/
22.
Did you need help to get dressed?
_____
_____
_____
_____
_____ 29/
23.
Did you need help to use the toilet?
_____
_____
_____
_____
_____ 30/
24.
Did you need help to get in or out of bed?
_____
_____
_____
_____
_____ 31/
..........................................................................
AIMS
These questions refer to HOUSEHOLD TASKS.
25.
Always
(1)
Very
Almost
Often Sometimes Never
(2)
(3)
(4)
Never
(5)
If you had the necessary transportation,

could you go shopping for groceries
without help?
_____
_____
_____
_____
_____ 32/
26.
If you had kitchen facilities, could you

prepare your own meals without help?
_____
_____
_____
_____
_____ 33/
27.
If you had household tools and appliances,

could you do your own housework without
help?
_____
_____
_____
_____
_____ 34/
If you had laundry facilities, could you do

your own laundry without help?
_____
_____
_____
_____
_____ 35/
28.
30

AIMS
These questions refer to SOCIAL ACTIVITY.
All
Days
(1)
Most
Days
(2)
Some
Days
(3)
Few
Days
(4)
No
Days
(5)
29.
How often did you get together

with friends or relatives?
_____
_____
_____
_____
_____
36/
30.
How often did you have friends

or relatives over to your home?
_____
_____
_____
_____
_____
37/
31.
How often did you visit friends

or relatives at their homes?
_____
_____
_____
_____
_____
38/
32.
How often were you on the telephone

with close friends or relatives?
_____
_____
_____
_____
_____
39/
33.
How often did you go to a meeting of a

church, club, team or other group?
_____
_____
_____
_____
_____
40/
..........................................................................
AIMS
These questions refer to SUPPORT FROM FAMILY AND FRIENDS.
Very
Almost
Always
Often Sometimes Never Never
(1)
(2)
(3)
(4)
(5)
34.
35.
36.
37.
Did you feel that your family or

friends would be around if you
needed assistance?
_____
_____
_____
_____
_____
41/

friends were sensitive to your
personal needs?
_____
_____
_____
_____
_____
42/

friends were interested in helping
you solve problems?
_____
_____
_____
_____
_____
43/

friends understood the effects of
your arthritis?
_____
_____
_____
_____
_____
44/
31

AIMS
These questions refer to ARTHRITIS PAIN.
38.
How would you describe the arthritis

pain you usually had?
Severe
(1)
Moderate Mild Very Mild None

(2)
(3)
(4)
(5)
_____
_____
_____
_____
_____ 45/
All
Days
(1)
Most
Days
(2)
Some
Days
(3)
Few
Days
(4)
No
Days
(5)
39.
How often did you have severe

pain from your arthritis?
_____
_____
_____
_____
_____ 46/
40.
How often did you have pain in

two or more joints at the same time?
_____
_____
_____
_____
_____ 47/
41.
How often did your morning stiffness

last more than one hour from the time
you woke up?
_____
_____
_____
_____
_____ 48/
How often did your pain make it difficult

for you to sleep?
_____
_____
_____
_____
_____ 49/
42.
..........................................................................
AIMS
These questions refer to WORK.
Paid House School
work work work Unemployed Disabled Retired
(1)
(2)
(3)
(4)
(5)
(6)
43.
What has been your

main form of work?
_____
_____
_____
_____
_____
_____ 50/
If you answered unemployed, disabled or retired, please skip the next four questions and go to the next page.
All
Days
(1)
Most
Days
(2)
Some
Days
(3)
Few
Days
(4)
No
Days
(5)
How often were you unable to

do any paid work, housework
or school work?
_____
_____
_____
_____
_____ 51/
On the days that you did work,

how often did you have to work
a shorter day?
_____
_____
_____
_____
_____ 52/

how often were you unable to do
your work as carefully and accurately
as you would like?
_____
_____
_____
_____
_____ 53/

how often did you have to change
the way your paid work, housework
or school work is usually done?
_____
_____
_____
_____
_____ 54/

44.
45.
46.
47.
32

AIMS
These questions refer to LEVEL OF TENSION.
Always
(1)
Very
Almost
(2)
(3)
(4)
(5)
48.
How often have you felt tense

or high strung?
_____
_____
_____
_____
_____
55/
49.
How often have you been bothered

by nervousness or your nerves?
_____
_____
_____
_____
_____
56/
50.
How often were you able to relax

without difficulty?
_____
_____
_____
_____
_____
57/
51.
How often have you felt relaxed

and free of tension?
_____
_____
_____
_____
_____
58/
52.
How often have you felt calm and

peaceful?
_____
_____
_____
_____ _____
59/
..........................................................................
AIMS
These questions refer to MOOD.
Always
(1)
Very
Almost
(2)
(3)
(4)
(5)
53.
How often have you enjoyed the

things you do?
____
_____
_____
_____
_____
60/
54.
How often have you been in low

or very low spirits?
_____
_____
_____
_____
_____
61/
55.
How often did you feel that nothing

turned out the way you wanted it to?
_____
_____
_____
_____
_____
62/
56.
How often did you feel that others

would be better off if you were dead?
_____
_____
_____
_____
_____
63/
57.
How often did you feel so down in

the dumps that nothing would cheer you up? _____
_____
_____
_____
_____
64/
33

AIMS
These questions refer to SATISFACTION WITH EACH HEALTH AREA.
Very
Satisfied
(1)
58.
Neither
Satisfied
Somewhat Nor Dis- Somewhat Very DisSatisfied
satisfied Dissatisfied satisfied
(2)
(3)
(4)
(5)
How satisfied have you been

with each of these areas of your
health?
MOBILITY LEVEL
(example: do errands)
_____
_____
_____
_____
_____
65/
WALKING AND BENDING

(example: climb stairs)
_____
____
_____
_____
_____
66/
HAND AND FINGER FUNCTION

(example: tie a bow)
_____
_____
_____
_____
_____
67/
ARM FUNCTION
(example: comb hair)
_____
_____
_____
_____
_____
68/
SELF-CARE
(example: take bath)
_____
_____
_____
_____
_____
69/
HOUSEHOLD TASKS
(example: housework)
_____
_____
_____
_____
_____
70/
SOCIAL ACTIVITY
(example: visit friends)
_____
_____
_____
_____
_____
71/
SUPPORT FROM FAMILY

(example: help with problems) _____
_____
_____
_____
_____
72/
ARTHRITIS PAIN
(example: joint pain)
_____
_____
_____
_____
_____
73/
WORK
(example: reduce hours)
_____
_____
_____
_____
_____
74/
LEVEL OF TENSION
(example: felt tense)
_____
_____
_____
_____
_____
75/
MOOD
(example: down in dumps)
_____
_____
_____
_____
_____
76/
34
AIMS
These questions refer to ARTHRITIS IMPACT ON EACH AREA OF HEALTH.
Due Partly
Due
To Arthritis
Due
Due
Largely And Partly Largely Entirely
To Other To Other
To My To My
Causes
Causes
Arthritis Arthritis
(2)
(3)
(4)
(5)
Not A
Problem
For Me
(0)
Due
Entirely
To Other
Causes
(1)
MOBILITY LEVEL
_____
_____
_____
_____
_____
_____
8/
WALKING AND BENDING

_____
_____
_____
_____
____
_____
9/

_____
_____
_____
_____
_____
_____
10/
ARM FUNCTION
_____
_____
_____
_____
_____
_____
11/
SELF-CARE
_____
_____
_____
_____
_____
_____
12/
HOUSEHOLD TASKS
_____
_____
_____
_____
_____
_____
13/
SOCIAL ACTIVITY
_____
_____
_____
_____
_____
_____
14/
SUPPORT FROM FAMILY

(example: help with problems)
_____
_____
_____
_____
_____
_____
15/
ARTHRITIS PAIN
_____
_____
_____
_____
_____
_____
16/
WORK
_____
_____
_____
_____
_____
_____
17/
LEVEL OF TENSION
_____
_____
_____
_____
_____
_____
18/
MOOD
_____
_____
_____
_____
_____
_____
19/

59.
How much of your problem in

each area of health was due to
your arthritis?
35

AIMS
You have now answered questions about different AREAS OF YOUR HEALTH. These areas are listed
below. Please check (X) UP to THREE AREAS in which you would MOST LIKE TO SEE
IMPROVEMENT. Please read all 12 areas of health choices before making your decision:
check = 1
blank = 0
60.
AREAS OF HEALTH
THREE AREAS FOR IMPROVEMENT
MOBILITY LEVEL
______________
20/
WALKING AND BENDING

______________
21/

______________
22/
ARM FUNCTION
______________
23/
SELF-CARE
______________
24/
HOUSEHOLD TASKS
______________
25/
SOCIAL ACTIVITY
______________
26/
SUPPORT FROM FAMILY

(example: help with problems)
______________
27/
ARTHRITIS PAIN
______________
28/
WORK
______________
29/
LEVEL OF TENSION
______________
30/
MOOD
______________
31/
Please make sure that you have checked no more than THREE AREAS for improvement.
36

AIMS
These questions refer to your CURRENT and FUTURE HEALTH.
61.
In general would you say that

your HEALTH NOW is excellent,
good, fair or poor?
Excellent
(1)
Good
(2)
Fair
(3)
Poor
(4)
_____
_____
_____
_____
64/
..........................................................................
62.
Neither
Satisfied
Very Somewhat Nor Dis- Somewhat Very DisSatisfied Satisfied satisfied Dissatisfied satisfied
(1)
(2)
(3)
(4)
(5)
How satisfied are you

with your HEALTH NOW?
_____
_____
_____
_____
Due Partly
Due
Due To Arthritis Due
Not A
Entirely Largely And Partly Largely
Problem To Other To Other To Other To My
For Me
Causes
Causes
Causes Arthritis
(0)
(1)
(2)
(3)
(4)
63.
How much of your problem

with your HEALTH NOW
is due to your arthritis?
_____
_____
_____
_____
_____
_____
32/
Due
Entirely
To My
Arthritis
(5)
_____
34/
..........................................................................
64.
In general do you expect that

your HEALTH 10 YEARS
FROM NOW will be excellent,
good, fair or poor?
Excellent
(1)
Good
(2)
Fair
(3)
Poor
(4)
_____
_____
_____
_____
35/
No Problem Minor Moderate Major

At All
Problem Problem Problem
(1)
(2)
(3)
(4)
65.
How big a problem do you expect

your arthritis to be
10 YEARS FROM NOW?
_____
37
_____
_____
_____
36/

AIMS
This question refers to OVERALL ARTHRITIS IMPACT.
66.
67.
CONSIDERING ALL THE WAYS

THAT YOUR ARTHRITIS AFFECTS
YOU, how well are you doing compared
to other people your age?
Very Well
(1)
Well
(2)
Fair
(3)
Poor Very Poorly

(4)
(5)
_____
_____
_____
_____
What is the main kind of arthritis that you have?
_____
37/
check = 1
blank = 0
Rheumatoid Arthritis
_______
38/
Osteoarthritis/Degenerative Arthritis
_______
39/
Systemic Lupus Erythematosis
_______
40/
Fibromyalgia
_______
41/
Scleroderma
_______
42/
Psoriatic Arthritis
_______
43/
Reiter's Syndrome
_______
44/
Gout
_______
45/
Low Back Pain
_______
46/
Tendonitis/Bursitis
_______
47/
Osteoporosis
_______
48/
Other
_______
49/
68.
_______
5051/
How many years have you had arthritis?
..........................................................................

69.
How often have you had to take

MEDICATION for your arthritis?
38
All
Days
(1)
Most
Days
(2)
Some
Days
(3)
Few
Days
(4)
No
Days
(5)
_____
_____
_____
_____
_____
52/

AIMS
Please check (X) yes or no for each question.
70.
Is your health currently affected by any of the following medical problems?

Yes
(1)
No
(2)
High blood pressure _______________________________
_______
_______ 53/
Heart disease _____________________________________
_______
_______ 54/
Mental illness _____________________________________
_______
_______ 55/
Diabetes _________________________________________
_______
_______ 56/
Cancer ___________________________________________
_______
_______ 57/
Alcohol or drug use ________________________________
_______
_______ 58/
Lung disease ______________________________________
_______
_______ 59/
Kidney disease _____________________________________
_______
_______ 60/
Liver disease _______________________________________
_______
_______ 61/
Ulcer or other stomach disease ______________________
_______
_______ 62/
Anaemia or other blood disease ______________________
_______
_______ 63/
Yes
(1)
No
(2)
71.
Do you take medicine every day for any problem

other than your arthritis?
_______
_______ 64/
72.
Did you see a doctor more than three times last

year for any problem other than arthritis?
_______
_______ 65/
39

AIMS
Please provide the following information about yourself:
73.
What is your age at this time?
74.
What is your sex?
Male (1)
Female (2)
75.
68/
_______
_______
_______
_______
_______
_______
69/
_______
_______
_______
_______
_______
70/
What is the highest level of education you received?
Less than seven years of school (1)

Grades seven through nine (2)
Grades ten through eleven (3)
High school graduate (4)
One to four years of college (5)
College graduate (6)
Professional or graduate school (7)
78.
_______
_______
What is your current marital status?
Married (1)
Separate (2)
Divorced (3)
Widowed (4)
Never married (5)
77.
6667/
What is your racial background?
White (1)
Black (2)
Hispanic (3)
Asian or Pacific Islander (4)
American Indian or Alaskan Native (5)
Other (6)
76.
_______
71/
_______
_______
_______
_______
_______
_______
_______
What is your approximate family income including wages,

disability payment, retirement income and welfare?
Less than $10,000 (1)

$10,000$19,999 (2)
$20,000$29,999 (3)
$30,000$39,999 (4)
$40,000$49,999 (5)
$50,000$59,999 (6)
$60,000$69,999 (7)
More than $70,000 (8)
72/
_______
_______
_______
_______
_______
_______
_______
_______
Thank you for completing this questionnaire.
40
Katz Index of Independence in Activities of Daily Living
ACTIVITIES
INDEPENDENCE:
POINTS (1 OR 0)
(1 POINT)
DEPENDENCE:
(0 POINTS)
NO supervision, direction or personal
WITH supervision, direction, personal
assistance
assistance or total care
POINTS:___________
(1 POINT) Bathes self completely or

needs help in bathing only a single
part of the body such as the back,
genital area or disabled extremity.
POINTS:___________
(1 POINT) Gets clothes from closets

(0 POINTS) Needs help with dressing
and drawers and puts on clothes and self or needs to be completely
outer garments complete with
dressed.
fasteners. May have help tying shoes.
POINTS:___________
(1 POINT) Goes to toilet, gets on and

off, arranges clothes, cleans genital
area without help.
BATHING
DRESSING
TOILETING
TRANSFERRING
POINTS:___________
CONTINENCE
(0 POINTS) Needs help with bathing

more than one part of the body,
getting in or out of the tub or shower.
Requires total bathing.
(0 POINTS) Needs help transferring

to the toilet, cleaning self or uses
bedpan or commode.
(1 POINT) Moves in and out of bed or (0 POINTS) Needs help in moving

chair unassisted. Mechanical
from bed to chair or requires a
transferring aides are acceptable.
complete transfer.
(1 POINT) Exercises complete self
control over urination and defecation.
(0 POINTS) Is partially or totally

incontinent of bowel or bladder.
(1 POINT) Gets food from plate into

mouth without help. Preparation of
food may be done by another person.
(0 POINTS) Needs partial or total help

with feeding or requires parenteral
feeding.
POINTS:___________
FEEDING
POINTS:___________
TOTAL POINTS = ______ 6 = High (patient independent ) 0 = Low (patient very dependent )
Slightly adapted from Katz, S., Down, T.D., Cash, H.R., & Grotz, R.C. (1970) Progress in the development of the index of ADL. The Gerontologist, 10(1), 20-30.
Copyright The Gerontological Society of America. Reproduced [Adapted] by permission of the publisher.
42
Rheumatoid and Arthritis Outcome Score (RAOS), English version LK 1.0
Rheumatoid and Arthritis Outcome Score

RAOS
Todays date: _____/______/______ Date of birth: _____/______/______
Name: ____________________________________________________
INSTRUCTIONS: This survey asks for your view about problems related to
your hips, knees and/or feet. This information will help us keep track of how you
feel about your hip, knee and/or foot problems and how well you are able to do
your usual activities.
Answer every question by ticking the appropriate box, only one box for each
question. If you are unsure about how to answer a question, please give the
best answer you can.
Symptoms
These questions should be answered thinking of your hip, knee and foot
symptoms during the last week.
S1. Do you have swelling in your hip, knee or foot?

Never
Rarely
Sometimes
Often
Always
S2. Do you feel grinding, hear clicking or any other type of noise when your hip, knee
or foot moves?
Never
Rarely
Sometimes
Often
Always
S3. Does your hip, knee or foot catch or hang up when moving?
Never
Rarely
Sometimes
Often
Always
Rarely
Never
Rarely
Never
S4. Can you straighten your hip, knee or foot fully?

Always
Often
Sometimes
S5. Can you bend your hip, knee or foot fully?

Always
Often
Sometimes
Stiffness
The following questions concern the amount of joint stiffness you have
experienced in your hip/knee/foot during the last week. Stiffness is a sensation
of restriction or slowness in the ease with which you move your hip, knee or
foot joint.
S6. How severe is your hip, knee or foot joint stiffness after first wakening in the
morning?
None
Mild
Moderate
Severe
Extreme
S7. How severe is your hip, knee or foot stiffness after sitting, lying or resting later in
the day?
None
Mild
Moderate
43
Severe
Extreme
Pain
P1. How often do you experience hip, knee or foot pain?
Never
Monthly
Weekly
Daily
Always
How much hip, knee or foot pain have you experienced the last week during
the following activities?
P2. Twisting/pivoting on your hip, knee or foot (dancing, ball games, etc.)
None
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
P3. Straightening hip, knee or foot fully

None
Mild
P4. Bending hip, knee or foot fully

None
Mild
P5. Walking on flat surface

None
Mild
P6. Going up or down stairs

None
Mild
P7. At night while in bed

None
P8. Sitting or lying

None
P9. Standing upright

None
Function, daily living

The following questions concern your physical function. By this we mean your
ability to move around and to look after yourself. For each of the following
activities please indicate the degree of difficulty you have experienced in the
last week due to your hip, knee or foot.
A1. Descending stairs
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
A2. Ascending stairs

None
44
For each of the following activities please indicate the degree of difficulty you
have experienced in the last week due to your hip, knee or foot.
A3. Rising from sitting
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
A4. Standing
None
A5. Bending to floor/pick up an object

None
Mild
A6. Walking on flat surface

None
Mild
A7. Getting in/out of car

None
A8. Going shopping

None
A9. Putting on socks/stockings

None
A10. Rising from bed

None
A11. Taking off socks/stockings

None
Mild
A12. Lying in bed (turning over, maintaining leg position)

None
Mild
A13. Getting in/out of bath

None
A14. Sitting
None
A15. Getting on/off toilet

None
Mild
45
A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)
None
Mild
Moderate
Severe
Extreme
Severe
Extreme
A17. Light domestic duties (cooking, dusting, etc)

None
Mild
Moderate
Function, sports and recreational activities

The following questions concern your physical function when being active on a
higher level. The questions should be answered thinking of what degree of
difficulty you have experienced during the last week due to your hip, knee or
foot.
SP1. Squatting
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
SP2. Running
None
SP3. Jumping
None
SP4. Twisting/pivoting on your affected leg (dancing, ball games, etc)

None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
SP5. Kneeling
None
Quality of Life
Q1. How often are you aware of your hip, knee or foot problem?
Never
Monthly
Weekly
Daily
Constantly
Q2. Have you modified your life style to avoid potentially damaging activities
to your legs?
Not at all
Mildly
Moderately
Severely
Totally
Q3. How much are you troubled with lack of confidence in your hip/knee/foot?
Not at all
Mildly
Moderately
Severely
Extremely
Q4. In general, how much difficulty do you have with your hip/ knee/foot?
None
Mild
Moderate
Severe
Thank you very much for completing all the questions in this
questionnaire.
46
Extreme
The Roland Morris Low Back Pain and Disability Questionnaire

Patient name: ____________________________________ File # __________ Date: __________
Please read instructions: when your back hurts, you may find it difficult to do some of the things you
normally do. Mark only the sentences that describe you today.
[ ]
I stay at home most of the time because of my back.
[ ]
I change position frequently to try to get my back comfortable.
[ ]
I walk more slowly than usual because of my back.
[ ]
Because of my back, I am not doing any jobs that I usually do around the house.
[ ]
Because of my back, I use a handrail to get upstairs.
[ ]
Because of my back, I lie down to rest more often.
[ ]
Because of my back, I have to hold on to something to get out of an easy chair.
[ ]
Because of my back, I try to get other people to do things for me.
[ ]
I get dressed more slowly than usual because of my back.
[ ]
I only stand up for short periods of time because of my back.
[ ]
Because of my back, I try not to bend or kneel down.
[ ]
I find it difficult to get out of a chair because of my back.
[ ]
My back is painful almost all of the time.
[ ]
I find it difficult to turn over in bed because of my back.
[ ]
My appetite is not very good because of my back.
[ ]
I have trouble putting on my sock (or stockings) because of the pain in my back.
[ ]
I can only walk short distances because of my back pain.
[ ]
I sleep less well because of my back.
[ ]
Because of my back pain, I get dressed with the help of someone else.
[ ]
I sit down for most of the day because of my back.
[ ]
I avoid heavy jobs around the house because of my back.
[ ]
Because of back pain, I am more irritable and bad tempered with people than usual.
[ ]
Because of my back, I go upstairs more slowly than usual.
[ ]
I stay in bed most of the time because of my back.
Score: __________
Improvement: __________ %
47

The Quebec Back Pain Disability Scale
This questionnaire is about the way your back pain is affecting your daily life. People with back problems may find it
difficult to perform some of their daily activities. We would like to know if you find it difficult to perform any of the
activities listed below, because of your back. For each activity there is a scale of 0 to 5. Please choose one response
option for each activity (do not skip any activities) and circle the corresponding number.
Today, do you find it difficult to perform the following activities because of your back?
0
Not difficult
at all
0
1
Minimally
difficult
1
2
Somewhat
difficult
2
3
Fairly
difficult
3
4
Very
difficult
4
5
Unable
to do
5
Get out of bed
Sleep through the night
Turn over in bed
Ride in a car
Stand up for 20-30 minutes
Sit in a chair for several hours
Climb one flight of stairs
Walk a few blocks (300-400 m)
Walk several kilometres
10
Reach up to high shelves
11
Throw a ball
12
Run one block (about 100m)
13
Take food out of the refrigerator
14
Make your bed
15
Put on socks (pantyhose)
16
Bend over to clean the bathtub
17
Move a chair
18
Pull or push heavy doors
19
Carry two bags of groceries
20
Lift and carry a heavy suitcase
Add the numbers for a total score: ___________

Minimum detectable change (90% confidence) 15 points
Source: Kopec, JA, Esdaile, JM, Abrahamowicz, M., Abenhaim, L, Wood-Dauphinee, S, Lamping, DL & Williams JI.
(1995). The Quebec Back Pain Disability Scale. Spine, 20 (3), 341-352. Reproduced with permission of the publisher.
MDC90: Davidson, M. & Keating, J.L. (2002). A comparison of five low back disability questionnaires: Reliability and
responsiveness. Physical Therapy, 82 (1), 8- 24.
48
Activity rating scale for disorders of the knee
49
Copenhagen Neck Disability Scale

Yes
1.
Can you sleep at night without neck pain interfering?
2.
Can you manage daily activities without neck pain reducing

activity levels?
3.
Can you manage daily activities without help from others?
4.
Can you manage putting on your clothes in the morning without

taking more time than usual.
5.
Can you bend over the washing basin in order to brush your
teeth without getting neck pain?
6.
Do you spend more time than usual at home because of neck

pain?
7.
Are you prevented from lifting objects weighing from 2-4kg due
to neck pain?
8.
Have you reduced your reading activity due to neck pain?
9.
Have you been bothered by headaches during the time that you
have had neck pain?
10.
Do you feel that your ability to concentrate is reduced due to

neck pain?
11.
Are you prevented from participating in your usual leisure time

activities due to neck pain?
12.
Do you remain in bed longer than usual due to neck pain?
13.
Do you feel that neck pain has influenced your emotional

relationship with your nearest family?
14.
Have you had to give up social contact with other people during
the past two weeks due to neck pain?
15.
Do you feel that neck pain will influence your future?
50
Occasionally
No

D ISABILITIES OF THE A RM , S HOULDER AND
THE
DA SH
INSTRUCTIONS
This questionnaire asks about your
symptoms as well as your ability to
perform certain activities.
Please answer every question, based
on your condition in the last week,
by circling the appropriate number.
If you did not have the opportunity
to perform an activity in the past
week, please make your best estimate
on which response would be the most
accurate.
It doesnt matter which hand or arm
you use to perform the activity; please
answer based on your ability regardless
of how you perform the task.
52
H AND

H AND
D.A.S.H.
Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.
NO
DIFFICULTY
MILD
DIFFICULTY
MODERATE
DIFFICULTY
SEVERE
DIFFICULTY
UNABLE
1. Open a tight or new jar.
2. Write.
3. Turn a key.
4. Prepare a meal.
5. Push open a heavy door.
6. Place an object on a shelf above your head.
7. Do heavy household chores (e.g., wash walls, wash floors).
8. Garden or do yard work.
9. Make a bed.
10. Carry a shopping bag or briefcase.
11. Carry a heavy object (over 10 lbs).
12. Change a lightbulb overhead.
13. Wash or blow dry your hair.
14. Wash your back.
15. Put on a pullover sweater.
16. Use a knife to cut food.
17. Recreational activities which require little effort

(e.g., cardplaying, knitting, etc.).
18. Recreational activities in which you take some force

or impact through your arm, shoulder or hand
(e.g., golf, hammering, tennis, etc.).
19. Recreational activities in which you move your

arm freely (e.g., playing frisbee, badminton, etc.).
20. Manage transportation needs

(getting from one place to another).
21. Sexual activities.
53

H AND
D.A.S.H.
NOT AT ALL
SLIGHTLY
MODERATELY
QUITE
A BIT
EXTREMELY
NOT LIMITED
AT ALL
SLIGHTLY
LIMITED
MODERATELY
LIMITED
VERY
LIMITED
UNABLE
NONE
MILD
MODERATE
SEVERE
EXTREME
24. Arm, shoulder or hand pain.
25. Arm, shoulder or hand pain when you

performed any specific activity.
26. Tingling (pins and needles) in your arm, shoulder or hand.
27. Weakness in your arm, shoulder or hand.
28. Stiffness in your arm, shoulder or hand.
NO
DIFFICULTY
MILD
DIFFICULTY
MODERATE
DIFFICULTY
SEVERE
DIFFICULTY
SO MUCH
DIFFICULTY
THAT I
CANT SLEEP
AGREE
STRONGLY
AGREE
22. During the past week, to what extent has your arm,
shoulder or hand problem interfered with your normal
social activities with family, friends, neighbours or groups?
(circle number)
23. During the past week, were you limited in your work
or other regular daily activities as a result of your arm,
shoulder or hand problem? (circle number)
Please rate the severity of the following symptoms in the last week. (circle number)
29. During the past week, how much difficulty have you had
sleeping because of the pain in your arm, shoulder or hand?
(circle number)
STRONGLY
DISAGREE
30. I feel less capable, less confident or less useful

because of my arm, shoulder or hand problem.
(circle number)
DISAGREE NEITHER AGREE

NOR DISAGREE
DASH DISABILITY/SYMPTOM SCORE = [(sum of n responses) - 1] x 25, where n is equal to the number of completed responses.
n
A DASH score may not be calculated if there are greater than 3 missing items.
54

D ISABILITIES OF THE A
RM , S HOULDER AND
D.A.S.H.
H AND
WORK MODULE (OPTIONAL)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking
if that is your main work role).
Please indicate what your job/work is:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
p I do not work. (You may skip this section.)
Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:
NO
DIFFICULTY
MILD
DIFFICULTY
MODERATE
DIFFICULTY
SEVERE
DIFFICULTY
UNABLE
1.
using your usual technique for your work?
2.
doing your usual work because of arm,

shoulder or hand pain?
3.
doing your work as well as you would like?
4.
spending your usual amount of time doing your work?
SPORTS/PERFORMING ARTS MODULE (OPTIONAL)

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or
both.
If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to
you.
Please indicate the sport or instrument which is most important to you:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I do not play a sport or an instrument. (You may skip this section.)
Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:
1.
2.
3.
4.
NO
DIFFICULTY
MILD
DIFFICULTY
MODERATE
DIFFICULTY
SEVERE
DIFFICULTY
UNABLE
using your usual technique for playing your

instrument or sport?
playing your musical instrument or sport because

of arm, shoulder or hand pain?
playing your musical instrument or sport

as well as you would like?
spending your usual amount of time

practising or playing your instrument or sport?
SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by
4 (number of items); subtract 1; multiply by 25.
An optional module score may not be calculated if there are any missing items.
51
IWH 2006
Hip dysfunction and Osteoarthritis Outcome Score (HOOS), English version LK 2.0
HOOS HIP SURVEY

Name: ____________________________________________________
INSTRUCTIONS: This survey asks for your view about your hip. This
information will help us keep track of how you feel about your hip and how well
you are able to do your usual activities.
question. If you are uncertain about how to answer a question, please give the
Symptoms
These questions should be answered thinking of your hip symptoms and
difficulties during the last week.
S1. Do you feel grinding, hear clicking or any other type of noise from your hip?
Never
Rarely
Sometimes
Often
Always
Severe
Extreme
Severe
Extreme
S2. Difficulties spreading legs wide apart

None
Mild
Moderate
S3. Difficulties to stride out when walking

None
Mild
Moderate
Stiffness
experienced during the last week in your hip. Stiffness is a sensation of
restriction or slowness in the ease with which you move your hip joint.
S4. How severe is your hip joint stiffness after first wakening in the morning?
None
Mild
Moderate
Severe
Extreme
S5. How severe is your hip stiffness after sitting, lying or resting later in the day?
None
Mild
Moderate
Severe
Extreme
Weekly
Daily
Always
Pain
P1. How often is your hip painful?
Never
Monthly
What amount of hip pain have you experienced the last week during the
following activities?
P2. Straightening your hip fully
None
Mild
Moderate
55
Severe
Extreme
What amount of hip pain have you experienced the last week during the
P3. Bending your hip fully
None
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
P4. Walking on a flat surface

None
Mild

None
Mild

None

None

None
P9. Walking on a hard surface (asphalt, concrete, etc.)

None
Mild
P10. Walking on an uneven surface

None
Mild

last week due to your hip.
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme

None

None
A4. Standing
None
56
have experienced in the last week due to your hip.
A5. Bending to the floor/pick up an object
None
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
A6. Walking on a flat surface

None
Mild

None
A8. Going shopping

None

None

None

None
Mild
A12. Lying in bed (turning over, maintaining hip position)

None
Mild

None
A14. Sitting
None

None
Mild
None
Mild
Moderate
Severe
Extreme
Severe
Extreme

None
Mild
Moderate
57

difficulty you have experienced during the last week due to your hip.
SP1. Squatting
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Daily
Constantly
SP2. Running
None
SP3. Twisting/pivoting on loaded leg

None
Mild
SP4. Walking on uneven surface

None
Mild
Quality of Life
Q1. How often are you aware of your hip problem?
Never
Monthly
Weekly
Q2. Have you modified your life style to avoid activities potentially damaging
to your hip?
Not at all
Mildly
Moderatly
Severely
Totally
Q3. How much are you troubled with lack of confidence in your hip?
Not at all
Mildly
Moderately
Severely
Extremely
Q4. In general, how much difficulty do you have with your hip?
None
Mild
Moderate
Severe
Thank you very much for completing all the questions

in this questionnaire.
58
Extreme
Foot and Ankle Outcome Score (FAOS), English version LK1.0
FAOS FOOT & ANKLE SURVEY

Name: ____________________________________________________
INSTRUCTIONS: This survey asks for your view about your foot/ankle. This
information will help us keep track of how you feel about your foot/ankle and
how well you are able to do your usual activities.
Symptoms
These questions should be answered thinking of your foot/ankle symptoms
during the last week.
S1. Do you have swelling in your foot/ankle?
Never
Rarely
Sometimes
Often
Always
S2. Do you feel grinding, hear clicking or any other type of noise when your foot/ankle
moves?
Never
Rarely
Sometimes
Often
Always
Often
Always
Rarely
Never
Rarely
Never
S3. Does your foot/ankle catch or hang up when moving?

Never
Rarely
Sometimes
S4. Can you straighten your foot/ankle fully?

Always
Often
Sometimes
S5. Can you bend your foot/ankle fully?

Always
Often
Sometimes
Stiffness
experienced during the last week in your foot/ankle. Stiffness is a sensation of
restriction or slowness in the ease with which you move your joints.
S6. How severe is your foot/ankle stiffness after first wakening in the morning?
None
Mild
Moderate
Severe
Extreme
S7. How severe is your foot/ankle stiffness after sitting, lying or resting later in the
day?
None
Mild
Moderate
59
Severe
Extreme
Pain
P1. How often do you experience foot/ankle pain?
Never
Monthly
Weekly
Daily
Always
What amount of foot/ankle pain have you experienced the last week during the
P2. Twisting/pivoting on your foot/ankle
None
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
P3. Straightening foot/ankle fully

None
Mild
P4. Bending foot/ankle fully

None
Mild

None
Mild

None
Mild

None

None

None

last week due to your foot/ankle.
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme

None
60
have experienced in the last week due to your foot/ankle.
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
A4. Standing
None

None
Mild

None
Mild

None
A8. Going shopping

None

None

None

None
Mild
A12. Lying in bed (turning over, maintaining foot/ankle position)

None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme

None
A14. Sitting
None

None
Mild
61
have experienced in the last week due to your foot/ankle.
None
Mild
Moderate
Severe
Extreme
Severe
Extreme

None
Mild
Moderate

difficulty you have experienced during the last week due to your foot/ankle.
SP1. Squatting
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
SP2. Running
None
SP3. Jumping
None
SP4. Twisting/pivoting on your injured foot/ankle

None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Daily
Constantly
SP5. Kneeling
None
Quality of Life
Q1. How often are you aware of your foot/ankle problem?
Never
Monthly
Weekly
to your foot/ankle?
Not at all
Mildly
Moderatly
Severely
Totally
Q3. How much are you troubled with lack of confidence in your foot/ankle?
Not at all
Mildly
Moderately
Severely
Extremely
Q4. In general, how much difficulty do you have with your foot/ankle?
None
Mild
Moderate
Severe
questionnaire.
62
Questionnaire and User's Guide can be downloaded from: www.koos.nu
Extreme

Knee and Osteoarthritis Outcome Score (KOOS), English version LK1.0
KOOS KNEE SURVEY

Name: ____________________________________________________
INSTRUCTIONS: This survey asks for your view about your knee. This
information will help us keep track of how you feel about your knee and how
well you are able to do your usual activities.
Symptoms
These questions should be answered thinking of your knee symptoms during
the last week.
S1. Do you have swelling in your knee?
Never
Rarely
Sometimes
Often
Always
S2. Do you feel grinding, hear clicking or any other type of noise when your knee
moves?
Never
Rarely
Sometimes
Often
Always
Sometimes
Often
Always
Sometimes
Rarely
Never
Sometimes
Rarely
Never
S3. Does your knee catch or hang up when moving?

Never
Rarely
S4. Can you straighten your knee fully?

Always
Often
S5. Can you bend your knee fully?

Always
Often
Stiffness
experienced during the last week in your knee. Stiffness is a sensation of
restriction or slowness in the ease with which you move your knee joint.
S6. How severe is your knee joint stiffness after first wakening in the morning?
None
Mild
Moderate
Severe
Extreme
S7. How severe is your knee stiffness after sitting, lying or resting later in the day?
None
Mild
Moderate
63
Severe
Extreme

Pain
P1. How often do you experience knee pain?
Never
Monthly
Weekly
Daily
Always
What amount of knee pain have you experienced the last week during the
following ativities?
P2. Twisting/pivoting on your knee
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
P3. Straightening knee fully

None
P4. Bending knee fully

None

None
Mild

None
Mild

None

None

None

last week due to your knee.
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme

None
64

have experienced in the last week due to your knee.
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
A4. Standing
None

None
Mild

None

None
A8. Going shopping

None

None

None

None
Mild
A12. Lying in bed (turning over, maintaining knee position)

None
Mild

None
A14. Sitting
None

None
Mild
65

have experienced in the last week due to your knee.
None
Mild
Moderate
Severe
Extreme
Severe
Extreme

None
Mild
Moderate

The following questions concern your physical function when being active on
a higher level. The questions should be answered thinking of what degree of
difficulty you have experienced during the last week due to your knee.
SP1. Squatting
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
SP2. Running
None
SP3. Jumping
None
SP4. Twisting/pivoting on your injured knee

None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Daily
Constantly
SP5. Kneeling
None
Quality of Life
Q1. How often are you aware of your knee problem?
Never
Monthly
Weekly
to your knee?
Not at all
Mildly
Moderatly
Severely
Totally
Q3. How much are you troubled with lack of confidence in your knee?
Not at all
Mildly
Moderately
Severely
Extremely
Q4. In general, how much difficulty do you have with your knee?
None
Mild
Moderate
Severe
Extreme
Thank you very much for completing all the questions in this questionnaire.
66
67

.
68
69

THE NECK DISABILITY INDEX QUESTIONNAIRE
NAME
DATE
How long have you had neck pain
years
months
weeks
On the diagram below, please indicate where you are experiencing pain or other symptoms, right
now. Please complete both sides of this form.
A = ACHE
P = PINS & NEEDLES
B = BURNING
S = STABBING
N = NUMBNESS
O = OTHER
OVER PLEASE
70

Please Read: This questionnaire is designed to enable us to understand how much your neck pain has affected your
ability to manage everyday activities. Please answer each Section by circling the ONE CHOICE that most applies to you.
We realize that you may feel that more than one statement may relate to you, but Please just circle the one choice
which closely describes your problem right now.
SECTION 1--Pain Intensity
A. I have no pain at the moment
B. The pain is mild at the moment.
C. The pain comes and goes and is moderate.
D. The pain is moderate and does not vary much.
E. The pain is severe but comes and goes.
F. The pain is severe and does not vary much.
SECTION 2--Personal Care (Washing, Dressing etc.)
A. I can look after myself without causing extra pain.
B. I can look after myself normally but it causes extra pain.
C. It is painful to look after myself and I am slow and careful.
D. I need some help, but manage most of my personal care.
E. I need help every day in most aspects of self-care.
F. I do not get dressed, I wash with difficulty and stay in bed.
SECTION 3--Lifting
A. I can lift heavy weights without extra pain.
B. I can lift heavy weights, but it causes extra pain.
C. Pain prevents me from lifting heavy weights off the floor but
I can if they are conveniently positioned, for example on a
table.
D. Pain prevents me from lifting heavy weights, but I can
manage light to medium weights if they are conveniently
positioned.
E. I can lift very light weights.
F. I cannot lift or carry anything at all.
SECTION 4 --Reading
A. I can read as much as I want to with no pain in my neck.
B. I can read as much as I want with slight pain in my neck.
C. I can read as much as I want with moderate pain in my neck.
D. I cannot read as much as I want because of moderate pain in
my neck.
E. I cannot read as much as I want because of severe pain in my
neck.
F. I cannot read at all.
SECTION 5--Headache
A. I have no headaches at all.
B. I have slight headaches which come infrequently.
C. I have moderate headaches which come in-frequently.
D. I have moderate headaches which come frequently.
E. I have severe headaches which come frequently.
F. I have headaches almost all the time.
SIGNATURE:
SECTION 6 -- Concentration
A. I can concentrate fully when I want to with no difficulty.
B. I can concentrate fully when I want to with slight difficulty.
C. I have a fair degree of difficulty in concentrating when I
want to.
D. I have a lot of difficulty in concentrating when I want to.
E. I have a great deal of difficulty in concentrating when I want
to.
F. I cannot concentrate at all.
SECTION 7--Work
A. I can do as much work as I want to.
B. I can only do my usual work, but no more.
C. I can do most of my usual work, but no more.
D. I cannot do my usual work.
E. I can hardly do any work at all.
F. I cannot do any work at all.
SECTION 8--Driving
A. I can drive my car without neck pain.
B. I can drive my car as long as I want with slight pain in my
neck.
C. I can drive my car as long as I want with moderate pain in
my neck.
D. I cannot drive my car as long as I want because of moderate
pain in my neck.
E. I can hardly drive my car at all because of severe pain in my
neck.
F. I cannot drive my car at all.
SECTION 9--Sleeping
A. I have no trouble sleeping
B. My sleep is slightly disturbed (less than 1 hour sleepless).
C. My sleep is mildly disturbed (1-2 hours sleepless).
D. My sleep is moderately disturbed (2-3 hours sleepless).
E. My sleep is greatly disturbed (3-5 hours sleepless).
F. My sleep is completely disturbed (5-7 hours sleepless).
SECTION 10--Recreation
A. I am able engage in all recreational activities with no pain in
my neck at all.
B. I am able engage in all recreational activities with some pain
in my neck.
C. I am able engage in most, but not all recreational activities
because of pain in my neck.
D. I am able engage in a few of my usual recreational activities
because of pain in my neck.
E. I can hardly do any recreational activities because of pain in
my neck.
F. I cannot do any recreational activities all all.
DATE:
Vernon H and Hagino C, 1991

(with permission from Fairbank J)
DISABILITY INDEX SCORE:
71
MICHIGAN HAND OUTCOMES

QUESTIONNAIRE (MHQ)
Today's date:
Month
Day
72
Year
MICHIGAN HAND OUTCOMES QUESTIONNAIRE (MHQ)

Instructions:
This survey asks for your views about your hands and your health. This information will help keep
track of how you feel and how well you are able to do your usual activities.
Answer EVERY question by marking the answer as indicated. If you are unsure about how to
answer a question, please give the best answer you can.
I.
The following questions refer to the function of your hand(s)/wrist(s) during the past week. (Please circle one
answer for each question). Please answer EVERY question, even if you do not experience any problems with
the hand and/or wrist.
A. The following questions refer to your right hand/wrist.
Very
Good
Good
Fair
Poor
Very Poor
1. Overall, how well did your right

hand work?
2. How well did your right fingers

move?
3. How well did your right wrist

move?
4. How was the strength in your right

hand?
5. How was the sensation (feeling) in

your right hand?
B. The following questions refer to your left hand/wrist.

Very
Good
Good
Fair
Poor
Very Poor
1. Overall, how well did your left

hand work?
2. How well did your left fingers

move?
3. How well did your left wrist

move?
4. How was the strength in your left

hand?
5. How was the sensation (feeling) in

your left hand?
73
II. The following questions refer to the ability of your hand(s) to do certain tasks during the past week.
(Please circle one answer for each question). If you do not do a certain task, please estimate the difficulty with
which you would have in performing it.
A. How difficult was it for you to perform the following activities using your right hand ?
Not at All
Difficult
A Little
Difficult
Somewhat
Difficult
Moderately
Difficult
Very
Difficult
1. Turn a door knob
2. Pick up a coin
3. Hold a glass of water
4. Turn a key in a lock
5. Hold a frying pan
B. How difficult was it for you to perform the following activities using your left hand ?
Not at All
Difficult
A Little
Difficult
Somewhat
Difficult
Moderately
Difficult
Very
Difficult
1. Turn a door knob
2. Pick up a coin
3. Hold a glass of water
4. Turn a key in a lock
5. Hold a frying pan
74
C. How difficult was it for you to perform the following activities using both of your hands?
Not at All
Difficult
A Little
Difficult
Somewhat
Difficult
Moderately
Difficult
Very
Difficult
1. Open a jar
2. Button a shirt/blouse
3. Eat with a knife/fork
4. Carry a grocery bag
5. Wash dishes
6. Wash your hair
7. Tie shoelaces/knots
75
III. The following questions refer to how you did in your normal work (including both housework and school
work) during the past four weeks. (Please circle one answer for each question).
1. How often were you unable to do

your work because of problems
with your hand(s)/wrist(s)?
2. How often did you have to shorten
your work day because of
problems with your hand(s)/
wrist(s)?
3. How often did you have to take
it easy at your work because of
problems with your hand(s)/
wrist(s)?
4. How often did you accomplish less
in your work because of problems
with your hand(s)/
wrist(s)?
5. How often did you take longer to
do the tasks in your work because
of problems with your hand(s)/
wrist(s)?
Always
Often
Sometimes
Rarely
Never
76
IV.
The following questions refer to how much pain you had in your hand(s)/wrist(s) during the past week.
(Please circle one answer for each question).
A. The following questions refer to pain in your right hand/wrist.
1.
How often did you have pain in your right hand/wrist?

1. Always
2. Often
3. Sometimes
4. Rarely
5. Never
If you answered Never to question IV-A1 above, please skip the following questions and go to the next page.
2.
Please describe the pain you had in your right hand/wrist.

1. Very mild
2. Mild
3. Moderate
4. Severe
5. Very severe
3. How often did the pain in your

right hand/wrist interfere with
your sleep?
right hand/wrist interfere with
your daily activities (such as
eating or bathing)?
right hand/wrist make you
unhappy?
Always
Often
Sometimes
Rarely
Never
77
B. The following questions refer to pain in your left hand/wrist.

1.
How often did you have pain in your left hand/wrist?

1. Always
2. Often
3. Sometimes
4. Rarely
5. Never
If you answered Never to question IV-B1 above, please skip the following questions and go to the next page.
2.
Please describe the pain you had in your left hand/wrist.

1. Very mild
2. Mild
3. Moderate
4. Severe
5. Very severe

left hand/wrist interfere with
your sleep?
left hand/wrist interfere with
your daily activities (such as
eating or bathing)?
left hand/wrist make you
unhappy?
Always
Often
Sometimes
Rarely
Never
78
V. A. The following questions refer to the appearance (look) of your right hand during the past week.
1. I am satisfied with the appearance

(look) of my right hand.
2. The appearance (look) of my
right hand sometimes made me
uncomfortable in public.
right hand made me depressed.
4. The appearance (look) of my right
hand interfered with my normal
social activities.
Strongly
Agree
Agree
Neither Agree
nor Disagree
Disagree
Strongly
Disagree
B. The following questions refer to the appearance (look) of your left hand during the past week.
1. I am satisfied with the appearance

(look) of my left hand.
left hand sometimes made me
uncomfortable in public.
left hand made me depressed.
4. The appearance (look) of my left
hand interfered with my normal
social activities.
Strongly
Agree
Agree
Neither Agree
nor Disagree
Disagree
Strongly
Disagree
79
VI. A. The following questions refer to your satisfaction with your right hand/wrist during the past week.
Very
Satisfied
Somewhat
Satisfied
Neither
Satisfied
nor
Dissatisfied
Somewhat
Dissatisfied
Very
Dissatisfied
1. Overall function of your

right hand
2. Motion of the fingers in your

right hand
3. Motion of your right wrist
4. Strength of your right hand
5. Pain level of your right hand
6. Sensation (feeling) of your

right hand
B. The following questions refer to your satisfaction with your left hand/wrist during the past week.
Very
Satisfied
Somewhat
Satisfied
Neither
Satisfied
nor
Dissatisfied
Somewhat
Dissatisfied
Very
Dissatisfied
1. Overall function of your left

hand
2. Motion of the fingers in your

left hand
3. Motion of your left wrist
4. Strength of your left hand
5. Pain level of your left hand
6. Sensation (feeling) of your

left hand
80
Please provide the following information about yourself. (Please circle one answer for each question.)
1.
2.
3.
Are you right-handed or left-handed?

a.
Right-handed
b.
Left-handed
c.
Both
Which hand gives you the most problem?

a.
Right hand
b.
Left hand
c.
Both
Have you changed your job since you had problem with your hand(s)?
a.
Yes
b.
No
Please describe the type of job you did before you had problem with your hand(s).
Please describe the type of job you are doing now.
4.
5.
6.
What is your gender?

a.
Male
b.
Female
What is your ethnic background?

a.
White
b.
Black
c.
Hispanic
d.
Asian or Pacific Islander
e.
American Indian or Alaskan Native
f.
Other (Please specify.)
What is the highest level of education you received?

a.
Less than high school graduate
b.
High school graduate
c.
Some college
d.
College graduate
e.
Professional or graduate school
81
10
7.
8.
What is your approximate family income including wages, disability payment, retirement income and welfare?
a.
Less than $10,000
b.
$10,000 - $19,999
c.
$20,000 - $29,999
d.
$30,000 - $39,999
e.
$40,000 - $49,999
f.
$50,000 - $59,999
g.
$60,000 - $69,999
h.
More than $70,000
Is your injury covered by Workers' Compensation?

a.
Yes
b.
No
Thank you very much for completing this questionnaire.
82
11
Name:
Date:
PATIENT RATED WRIST EVALUATION

The que stions b elow will help us und erstan d ho w m uch difficulty you have ha d with your w rist in the pa st week.
You will be d escribing your average wrist symptom s over the past week on a scale of 0-10. Please provide an
answer for ALL questions. If you did not perform an activity, please ESTIMATE the pain or difficu lty you wou ld
expect. If you have never performed the activity, you may leave it blank.
1. PA IN
Rate the average amount of pain in your wrist over the past week by circling the number that best
describes your pain on a scale from 0-10. A zero (0) means that you did not have any pain and a ten (10)
means that you had the worst pain you have ever experienced or that you could not do the activity because
of pain.
RATE YOUR PAIN: Sample Scale L
No Pain
9 10
Worst Ever
At rest
10
When doing a task with a repeated wrist movement
10
When lifting a heavy object
10
When it is at its worst
10
0 1
Never
How often do you have pain?
10
Always
2. FUNCTION
A. SPECIFIC ACTIVITIES
Rate the amount of difficulty you experienced performing each of the items listed below - over the past
week, by circling the number that describes your difficulty on a scale of 0-10. A zero (0) means you did not
experience any difficulty and a ten (10) means it was so difficult you were unable to do it at all.
Sample scale
0 1
No Difficulty
10
Unable
To Do
Turn a door knob using my affected hand
10
Cut meat using a knife in my affected hand
10
Fasten buttons on my shirt
10
Use my affected hand to push up from a chair
10
Carry a 10lb object in my affected hand
10
Use bathroom tissue with my affected hand
10
B. USUAL ACTIVITIES
Rate the amount of difficulty you experienced performing your usual activities in each of the areas listed
below, over the past week, by circling the number that best describes your difficulty on a scale of 0-10. By usual
activities, we mean the activities you performed before you started having a problem with your wrist. A zero (0)
means that you did not experience any difficulty and a ten (10) means it was so difficult you were unable to do
any of your usual activities.
Personal care activities (dressing, washing)
10
Household work (cleaning, maintenance)
10
Work (your job or usual everyday work)
10
10
Recreational activities
JC MacDermid
83
Please Read: This questionnaire is designed to enable us to understand how much your low back has affected your ability
to manage everyday activities. Please answer each Section by circling the ONE CHOICE that most applies to you. We
realize that you may feel that more than one statement may relate to you, but Please just circle the one choice which
closely describes your problem right now.
SECTION 1--Pain Intensity
A. The pain comes and goes and is very mild.
B. The pain is mild and does not vary much.
C. The pain comes and goes and is moderate.
D. The pain is moderate and does not vary much.
E. The pain is severe but comes and goes.
F. The pain is severe and does not vary much.
SECTION 2--Personal Care
A. I would not have to change my way of washing or dressing in
order to avoid pain.
B. I do not normally change my way of washing or dressing even
though it causes some pain.
C. Washing and dressing increase the pain, but I manage not to
change my way of doing it.
D. Washing and dressing increase the pain and I it necessary to
change my way of doing it.
E. Because of the pain, I am unable to do any washing and
dressing without help.
F. Because of the pain, I am unable to do any washing or
dressing without help.
SECTION 3--Lifting
A. I can lift heavy weights without extra pain.
B. I can lift heavy weights, but it causes extra pain.
C. Pain prevents me from lifting heavy weights off the floor.
D. Pain prevents me from lifting heavy weights off the floor, but
I can manage if they are conveniently positioned, e.g. on the
table.
E. Pain prevents me from lifting heavy weights , but I can
manage light to medium weights if they are conveniently
positioned.
F. I can only lift very light weights, at the most.
SECTION 4 --Walking
A. Pain does not prevent me from walking any distance.
B. Pain prevents me from walking more than one mile.
C. Pain prevents me from walking more than one mile.
D. Pain prevents me from walking more than 1/2 mile.
E. I can only walk while using a cane or on crutches.
F. I am in bed most of the time and have to crawl to the toilet.
SECTION 5--Sitting
A. I can sit in any chair as long as I like without pain.
B. I can only sit in my favorite chair as long as I like.
C. Pain prevents me from sitting more than one hour.
D. Pain prevents me from sitting more than 1/2 hour.
E. Pain prevents me from sitting more than ten minutes.
F. Pain prevents me from sitting at all.
SECTION 6 -- Standing
A. I can stand as long as I want without pain
B. I have some pain while standing, but it does not increase with
time.
C. I cannot stand for longer than one hour without increasing
pain.
D. I cannot stand for longer than hour without increasing pain.
E. I cant stand for more than 10 minutes without increasing
pain.
F. I avoid standing because it increases pain right away.
SECTION 7--Sleeping
A. I get no pain in bed.
B. I get pain in bed, but it does not prevent me from sleeping.
C. Because of pain , my normal nights sleep is reduced by less
than one-quarter.
D. Because of pain, my normal nights sleep is reduced by less
than one-half.
E. Because of pain, my normal nights sleep is reduced by less
than three-quarters.
F. Pain prevents me from sleeping at all.
SECTION 8--Social Life
A. My social life is normal and gives me no pain.
B. My social life is normal, but increases the degree of my pain.
C. Pain has no significant effect on my social life apart from
limiting my more energetic interests, e.g., dancing, etc.
D. Pain has restricted my social life and I do not go out very
often.
E. Pain has restricted my social life to my home.
F. Pain prevents me from sleeping at all.
SECTION 9--Traveling
A. I get no pain while traveling.
B. I get some pain while traveling, but none of my usual forms of
travel make it any worse.
C. I get extra pain while traveling, but it does not compel me to
seek alternative forms of travel.
D. I get extra pain while traveling which compels me to seek
alternative forms of travel.
E. Pain restricts all forms off travel.
F. Pain prevents all forms of travel except that done lying down.
SECTION 10--Changing Degree of Pain
A. My pain is rapidly getting better.
B. My pain fluctuates, but overall is definitely getting better.
C. My pain seems to be getting better, but improvement is slow
at present.
D. My pain is neither getting better nor worse.
E. My pain is gradually worsening.
F. My pain is rapidly worsening.
DISABILITY INDEX SCORE: %
84

THE REVISED OSWESTRY PAIN QUESTIONNAIRE
NAME
DATE
How long have you had back pain
years
months
weeks
On the diagram below, please indicate where you are experiencing pain, right now. Please
complete both sides of this form.
A = ACHE
B = BURNING
P = PINS & NEEDLES S = STABBING
85
N = NUMBNESS
O = OTHER
Shoulder Pain and disability Index (SPADI)

Name__________________________ Date____________ Patient # _____________
Disability scale: How much difficulty do you have.

0 = no difficulty
10 = unable to do NA = not applicable
1. Washing your hair?
2. Washing your back?
3. Putting on an undershirt or pullover sweater?
4. Putting on a shirt that buttons down the front?
5. Putting on your pants?
6. Placing an object on a high shelf?
7. Carrying a heavy object of 10 pounds?
8. Removing something from your back pocket?
Scoring: Add the scores for each question and divide by the total possible
number possible. If the patient marks two or more items not applicable, no
score is calculated.
References:
Williams, J.W., Holleman, D.R., Simel, D.L. (1995). Measuring shoulder
function with the shoulder pain and disability index. Journal of Rheumatology,
22, 727-32.
Roach, K.E., Budiman-mak E, Songsirideg, N., Yongsuk, L., (1001).
Development of a shoulder pain and disability index. Arthritis and Research, 4,
143-149.
86
Name: ____________________________________________
Date: _____________________
Here are some of the things which other patients have told us about their pain. For each statement please circle any
number from 0 to 6 to say how much physical activities such as bending, lifting, walking or driving affect or would
affect your back pain.
COMPLETELY
DISAGREE
UNSURE
COMPLETELY
AGREE
1. My pain was caused by physical activity
2. Physical activity makes my pain worse
3. Physical activity might harm my back
4. I should not do physical activities

which (might) make my pain worse
5. I cannot do physical activities which

(might) make my pain worse
The following statements are about how your normal work affects or would affect your back pain.
COMPLETELY
DISAGREE
UNSURE
COMPLETELY
AGREE
6. My pain was caused by my work or by

an accident at work
7. My work aggravated my pain
8. I have a claim for compensation for my pain
9. My work is too heavy for me
10. My work makes or would make my pain worse 0
11. My work might harm my back
12. I should not do my normal work with my

present pain
13. I cannot do my normal work with my

present pain
14. I cannot do my normal work until my pain

is treated
15. I do not think that I will be back to my

normal work within 3 months
16. I do not think that I will ever be able to go

back to that work
87
FEAR AVOIDANCE BELIEFS QUESTIONNAIRE (FABQ)

Purpose: 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.
Scoring: The FABQ consists of 2 subscales, which are reflected in the division
of the outcome form into 2 separate sections. The first subscale (items 1-5) is the
Physical Activity subscale (FABQPA), and the second subscale (items 6-16) is
the Work subscale (FABQW). Interestingly, not all items contribute to the score
for each subscale; however the patient should still complete all items as these
items were included when the reliability and validity of the scale was initially
established. A low FABQW score (less than 19) was one of 5 variables in a
clinical prediction rule that increased the probability of success from SI region
manipulation in individuals with low back pain.1 Each subscale is graded
separately by summing the responses respective scale items (0 6 for each
item); for scoring purposes, only 4 of the physical activity scale items are scored
(24 possible points) and only 7 of the work items (42 possible points). The
method to score each subscale is outlined below. (Note: It is extremely important
to ensure all items are completed, as there is no procedure to adjust for
incomplete items.)
Scoring the Physical Activity subscale (FABQPA)
Sum items 2, 3, 4, and 5 (the score circled by the patient for these items).
Scoring the Work subscale (FABQW)
Sum items 6, 7, 9, 10, 11, 12, and 15.

Measurement Characteristics: The FABQ has been demonstrated to be valid
and reliable in a chronic LBP population3 and appears to be a useful screening
tool for identifying acute LBP patients who will not return to work by 4wks.2
References:
1. Flynn T, Fritz J, Whitman J, Wainner R, et al. Clinical Prediction Rule for
Classifying Patients with Low Back Pain Likely to Respond to a Manipulation
Technique. Spine (In Press) 2002.
2. Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low
back pain: relationships with current and future disability and work status. Pain
2001; 94:7-15.
3. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance
Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic
low back pain and disability. Pain 1993; 52:157-168
88
89

HEADACHE DISABILITY INDEX
Patient Name ________________________________________________
INSTRUCTIONS: Please CIRCLE the correct response:
1. I have headache: (1) 1 per month (2) more than 1 but less than 4 per month
2. My headache is: (1) mild
(2) moderate
Date ___________________________
(3) more than one per week
(3) severe
Please read carefully: The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please
check off YES, SOMETIMES, or NO to each item. Answer each question as it pertains to your headache only.
YES SOMETIMES NO
_____
______
_____
E1.
Because of my headaches I feel handicapped.
_____
______
_____
F2.
Because of my headaches I feel restricted in performing my routine daily activities.
_____
______
_____
E3.
No one understands the effect my headaches have on my life.
_____
______
_____
F4.
I restrict my recreational activities (eg, sports, hobbies) because of my headaches.
_____
______
_____
E5.
My headaches make me angry.
_____
______
_____
E6.
Sometimes I feel that I am going to lose control because of my headaches.
_____
______
_____
F7.
Because of my headaches I am less likely to socialize.
_____
______
_____
E8.
_____
______
_____
E9.
My spouse (significant other), or family and friends have no idea what I am going through
because of my headaches.
My headaches are so bad that I feel that I am going to go insane.
_____
______
_____
E10.
My outlook on the world is affected by my headaches.
_____
______
_____
E11.
I am afraid to go outside when I feel that a headaches is starting.
_____
______
_____
E12.
I feel desperate because of my headaches.
_____
______
_____
F13.
I am concerned that I am paying penalties at work or at home because of my headaches.
_____
______
_____
E14.
My headaches place stress on my relationships with family or friends.
_____
______
_____
F15.
I avoid being around people when I have a headache.
_____
______
_____
F16.
I believe my headaches are making it difficult for me to achieve my goals in life.
_____
______
_____
F17.
I am unable to think clearly because of my headaches.
_____
______
_____
F18.
I get tense (eg, muscle tension) because of my headaches.
_____
______
_____
F19.
I do not enjoy social gatherings because of my headaches.
_____
______
_____
E20.
I feel irritable because of my headaches.
_____
______
_____
F21.
I avoid traveling because of my headaches.
_____
______
_____
E22.
My headaches make me feel confused.
_____
______
_____
E23.
My headaches make me feel frustrated.
_____
______
_____
F24.
I find it difficult to read because of my headaches.
_____
______
_____
F25.
I find it difficult to focus my attention away from my headaches and on other things.
OTHER COMMENTS:__________________________________________________________________________________________________________
__________________________________
Examiner
With permission from: Jacobson GP, Ramadan NM, et al. The Henry Ford Hospital headache disability inventory (HDI). Neurology 1994;44:837-842.
90
Date:
Short-Form McGill Pain Questionnaire:

I. Pain Rating Index (PRI):
The words below describe average pain. Place a check mark () in the column
that represents the degree to which you feel that type of pain. Please limit
yourself to a description of the pain in your pelvic area only:
None
Throbbing
Shooting
Stabbing
Sharp
Cramping
Gnawing
Hot-Burning
Aching
Heavy
Tender
Splitting
Tiring-Exhausting
Sickening
Fearful
Punishing-Cruel
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Mild
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Moderate
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Severe
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
II. Present Pain Intensity (PPI)Visual Analog Scale (VAS). Tick along scale below for
pelvic pain:
Worst
No
possible
pain
pain
III. Evaluative overall intensity of total pain experience. Please limit yourself to a
description of the pain in your pelvic area only. Place a check mark () in the
appropriate column:
Evaluative
0 No pain
1 Mild
2 Discomforting
3 Distressing
4 Horrible
5 Excruciating
IV. Scoring:
Score
I-a
I-b
I-a+b
II
III
S-PRI (Sensory Pain Rating Index)

A-PRI (Affective Pain Rating Index
T-PRI (Total Pain Rating Index)
PPI-VAS (Present Pain Intensity-Visual Analog Scale)
Evaluative overall intensity of total pain experience
91
92
93

QUADRUPLE VISUAL ANALOGUE SCALE
Patient Name ________________________________________________
Date ___________________________
Please read carefully:

Instructions: Please circle the number that best describes the question being asked.
Note:
If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each
complaint. Please indicate your pain level right now, average pain, and pain at its best and worst.
Example:
No pain
Headache
Neck
Low Back
________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
worst possible pain
1 What is your pain RIGHT NOW?
No pain
0
________________________________________________________________________________
1
2
3
4
5
6
7
8
9
10
worst possible pain
2 What is your TYPICAL or AVERAGE pain?
No pain
0
________________________________________________________________________________
1
2
3
4
5
6
7
8
9
10
worst possible pain
3 What is your pain level AT ITS BEST (How close to 0 does your pain get at its best)?
No pain
0
________________________________________________________________________________
1
2
3
4
5
6
7
8
9
10
worst possible pain
4 What is your pain level AT ITS WORST (How close to 10 does your pain get at its worst)?
No pain
0
________________________________________________________________________________
1
2
3
4
5
6
7
8
9
10
worst possible pain
OTHER COMMENTS:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
______________________________________________
Examiner
94
Rheumatoid and Arthritis Outcome Score

RAOS
Name: ____________________________________________________
INSTRUCTIONS: This survey asks for your view about problems related to
your hips, knees and/or feet. This information will help us keep track of how you
feel about your hip, knee and/or foot problems and how well you are able to do
your usual activities.
Symptoms
These questions should be answered thinking of your hip, knee and foot
symptoms during the last week.
S1. Do you have swelling in your hip, knee or foot?

Never
Rarely
Sometimes
Often
Always
S2. Do you feel grinding, hear clicking or any other type of noise when your hip, knee
or foot moves?
Never
Rarely
Sometimes
Often
Always
S3. Does your hip, knee or foot catch or hang up when moving?
Never
Rarely
Sometimes
Often
Always
Rarely
Never
Rarely
Never
S4. Can you straighten your hip, knee or foot fully?

Always
Often
Sometimes
S5. Can you bend your hip, knee or foot fully?

Always
Often
Sometimes
Stiffness
experienced in your hip/knee/foot during the last week. Stiffness is a sensation
of restriction or slowness in the ease with which you move your hip, knee or
foot joint.
S6. How severe is your hip, knee or foot joint stiffness after first wakening in the
morning?
None
Mild
Moderate
Severe
Extreme
S7. How severe is your hip, knee or foot stiffness after sitting, lying or resting later in
the day?
None
Mild
Moderate
95
Severe
Extreme
Pain
P1. How often do you experience hip, knee or foot pain?
Never
Monthly
Weekly
Daily
Always
How much hip, knee or foot pain have you experienced the last week during
the following activities?
P2. Twisting/pivoting on your hip, knee or foot (dancing, ball games, etc.)
None
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
P3. Straightening hip, knee or foot fully

None
Mild
P4. Bending hip, knee or foot fully

None
Mild

None
Mild

None
Mild

None

None

None

last week due to your hip, knee or foot.
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme

None
96
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Moderate
Severe
Extreme
A4. Standing
None

None
Mild

None
Mild

None
A8. Going shopping

None

None

None

None
Mild
A12. Lying in bed (turning over, maintaining leg position)

None
Mild

None
A14. Sitting
None

None
Mild
97
None
Mild
Moderate
Severe
Extreme
Severe
Extreme

None
Mild
Moderate

difficulty you have experienced during the last week due to your hip, knee or
foot.
SP1. Squatting
None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
SP2. Running
None
SP3. Jumping
None
SP4. Twisting/pivoting on your affected leg (dancing, ball games, etc)

None
Mild
Moderate
Severe
Extreme
Mild
Moderate
Severe
Extreme
SP5. Kneeling
None
Quality of Life
Q1. How often are you aware of your hip, knee or foot problem?
Never
Monthly
Weekly
Daily
Constantly
to your legs?
Not at all
Mildly
Moderately
Severely
Totally
Q3. How much are you troubled with lack of confidence in your hip/knee/foot?
Not at all
Mildly
Moderately
Severely
Extremely
Q4. In general, how much difficulty do you have with your hip/ knee/foot?
None
Mild
Moderate
Severe
questionnaire.
98
Extreme
Short Osteoporosis Quality of Life Questionnaire

ECOS-16 QUESTIONNAIRE
During the last week and because of your back problems due to osteoporosis,
1. How often have you had back pain in the last week?
1. I have not had back pain
2. 1 day
3. 2-3 days
4. 4-6 days
5. Every day
2. How severe is your back pain?

1. I have not had back pain
2. Mild
3. Moderate
4. Severe
5. Intolerable
3. How much distress or discomfort have you had because it has been painful to stand for a long
time?
1. No discomfort or suffering
2. Slight discomfort or suffering
3. Moderate discomfort or suffering
4. Severe discomfort or suffering
5. Very severe discomfort or suffering
4. How much distress or discomfort have you had due to pain from bending?
1. No discomfort or suffering
2. Slight discomfort or suffering
3. Moderate discomfort or suffering
4. Severe discomfort or suffering
5. Very severe discomfort or suffering
99
5. Has the back pain disturbed your sleep in the last week?
1. On no occasion
2. One night
3. Two nights
4. Three or four nights
5. Every night
6. How difficult has it been for you to carry out the household activities?
1. No difficulty
2. Slight difficulty
3. Moderate difficulty
4. Great difficulty
5. I was unable to do anything
7. Can you climb stairs to the next floor of a house?

1. No difficulty
3. I had to rest at least once
4. I could only climb the stairs with help
5. I was unable to climb the stairs
8. Do you have problems with dressing?

1. No difficulty
2. I can dress myself with slight difficulty
3. I can dress myself with moderate difficulty
4. I sometimes need help to dress myself
5. I cannot dress myself unaided
9. How difficult has it been for you to bend?

1. No difficulty
4. Great difficulty
5. I am unable to bend down
100
10. How much has your walking been limited?

1. Not limited
2. Slightly limited
3. Moderately limited
4. Very limited
5. I am unable to walk
11. How difficult has it been for you to visit friends or relatives?
1. No difficulty
4. Great difficulty
5. I have been unable to visit family or friends
12. Do you feel downhearted?

1. No
2. Rarely
3. Sometimes
4. Often
5. Always
13. Are you hopeful about your future?

1. Always
2. Often
3. Sometimes
4. Rarely
5. No
14. Do you feel frustrated?

1. No
2. Rarely
3. Sometimes
4. Often
5. Always
101
15. Are you afraid of falling?

1. No
2. Rarely
3. Sometimes
4. Often
5. Always
16. Are you afraid of getting a fracture?

1. No
2. Rarely
3. Sometimes
4. Often
5. Always
102
The Activities-specific Balance Confidence (ABC)

Scale
Administration:
The ABC can be self-administered or administered via personal or telephone interview.
Larger typeset should be used for self-administration, while an enlarged version of the
rating scale on an index card will facilitate in-person interviews. Regardless of method of
administration, each respondent should be queried concerning their understanding of
instructions, and probed regarding difficulty answering specific items.
Instructions to Participants:
For each of the following, please indicate your level of confidence in doing the activity
without losing your balance or becoming unsteady from choosing one of the percentage
points on the scale form 0% to 100%. If you do not currently do the activity in question,
try and imagine how confident you would be if you had to do the activity. If you normally
use a walking aid to do the activity or hold onto someone, rate your confidence as it you
were using these supports. If you have any questions about answering any of these items,
please ask the administrator.
Instructions for Scoring:
The ABC is an 11-point scale and ratings should consist of whole numbers (0-100) for
each item. Total the ratings (possible range = 0 1600) and divide by 16 to
get each subjects ABC score. If a subject qualifies his/her response to items #2, #9,
#11, #14 or #15 (different ratings for up vs. down or onto vs. off), solicit separate
ratings and use the lowest confidence of the two (as this will limit the entire activity, for
instance the likelihood of using the stairs.)
*Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J
Gerontol Med Sci 1995; 50(1): M28-34
103
The Activities-specific Balance Confidence (ABC) Scale*

For each of the following activities, please indicate your level of
self-confidence by choosing a corresponding number from the
following rating scale:
0% 10 20
no confidence
30
40
50
60
70 80 90 100%
completely confident
How confident are you that you will not lose your balance or become
unsteady when you
walk around the house? ____%
walk up or down stairs? ____%
bend over and pick up a slipper from the front of a closet floor ____%
reach for a small can off a shelf at eye level? ____%
stand on your tiptoes and reach for something above your head?
____%
stand on a chair and reach for something? ____%
sweep the floor? ____%
walk outside the house to a car parked in the driveway? ____%
get into or out of a car? ____%
walk across a parking lot to the mall? ____%
walk up or down a ramp? ____%
walk in a crowded mall where people rapidly walk past you? ____%
are bumped into by people as you walk through the mall?____%
step onto or off an escalator while you are holding onto a railing?
____%
step onto or off an escalator while holding onto parcels such that you
cannot hold onto the railing? ____%
walk outside on icy sidewalks? ____%
*Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J
Gerontol Med Sci 1995; 50(1): M28-34
104
Mini Mental Status Examination

The "Mini" Mental Status Exam is a quick way to evaluate cognitive function. It is often used to
screen for dementia or monitor its progression. [See Page 120 in Bates A Guide to Physical
Examination, 7th Ed ]
Folstein Mini Mental Status Examination
Task
Instructions
Scoring
Date
Orientation
"Tell me the date?" Ask for omitted items.
One point each for year,

season, date, day of week, 5
and month
Place
Orientation
"Where are you?" Ask for omitted items.
One point each for state,

county, town, building,
and floor or room
Register 3
Objects
Name three objects slowly and clearly. Ask

the patient to repeat them.
One point for each item

correctly repeated
Ask the patient to count backwards from 100

One point for each correct
Serial Sevens by 7. Stop after five answers. (Or ask them to
5
answer (or letter)
spell "world" backwards.)
Recall 3
Objects
Ask the patient to recall the objects

mentioned above.
Naming
Point to your watch and ask the patient "what One point for each correct
2
is this?" Repeat with a pencil.
answer
Repeating a
Phrase
Ask the patient to say "no ifs, ands, or buts."
One point if successful on

1
first try
Verbal
Commands
Give the patient a plain piece of paper and

say "Take this paper in your right hand, fold
it in half, and put it on the floor."
One point for each correct

3
action
Written
Commands
Show the patient a piece of paper with

"CLOSE YOUR EYES" printed on it.
One point if the patient's

eyes close
Writing
Ask the patient to write a sentence.
One point if sentence has a

subject, a verb, and makes 1
sense
Drawing
Scoring
Ask the patient to copy a

pair of intersecting
pentagons onto a piece of
paper.
One point for each item

correctly remembered
One point if the figure has

ten corners and two
1
intersecting lines
A score of 24 or above is considered normal.
Adapted from Folstein et al, Mini Mental State, J PSYCH RES 12:196-198 (1975)
105
30

Pressure Ulcer Scale for Healing (PUSH)
PUSH Tool 3.0

Patient Name________________________________________________ Patient ID# _____________________
Ulcer Location ____________________________________________________ Date _____________________
Directions:
Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudate, and type of
wound tissue. Record a sub-score for each of these ulcer characteristics. Add the sub-scores to obtain the total
score. A comparison of total scores measured over time provides an indication of the improvement or deterioration
in pressure ulcer healing.
LENGTH
X
WIDTH
(in
< 0.3
0.3 0.6
0.7 1.0
1.1 2.0
2.1 3.0
10
3.1 4.0
4.1 8.0
8.1 12.0
12.1 24.0
> 24.0
None
Light
Moderate
Heavy
Slough
Necrotic
Tissue
Sub-score
cm2)
EXUDATE
AMOUNT
TISSUE
TYPE
Closed
Epithelial
Tissue
Granulation
Tissue
Sub-score
Sub-score
TOTAL SCORE
Length x Width: Measure the greatest length (head to toe) and the greatest width (side to side) using a
centimeter ruler. Multiply these two measurements (length x width) to obtain an estimate of surface area in square
centimeters (cm2). Caveat: Do not guess! Always use a centimeter ruler and always use the same method each
time the ulcer is measured.
Exudate Amount: Estimate the amount of exudate (drainage) present after removal of the dressing and before
applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy.
Tissue Type: This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a 4 if there
is any necrotic tissue present. Score as a 3 if there is any amount of slough present and necrotic tissue is absent.
Score as a 2 if the wound is clean and contains granulation tissue. A superficial wound that is reepithelializing is
scored as a 1. When the wound is closed, score as a 0.
4 Necrotic Tissue (Eschar): black, brown, or tan tissue that adheres firmly to the wound bed or ulcer
edges and may be either firmer or softer than surrounding skin.
3 Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous.
2 Granulation Tissue: pink or beefy red tissue with a shiny, moist, granular appearance.
1 Epithelial Tissue: for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or
as islands on the ulcer surface.
0 Closed/Resurfaced: the wound is completely covered with epithelium (new skin).
www.npuap.org
11F
106
PUSH Tool Version 3.0: 9/15/98
Pressure Ulcer Healing Chart

To monitor trends in PUSH Scores over time
(Use a separate page for each pressure ulcer)
Patient Name________________________________________________ Patient ID# _____________________
Ulcer Location ____________________________________________________ Date _____________________
Directions:
Observe and measure pressure ulcers at regular intervals using the PUSH Tool.
Date and record PUSH Sub-scores and Total Scores on the Pressure Ulcer Healing Record below.
Pressure Ulcer Healing Record

Date
Length x Width
Exudate Amount
Tissue Type
PUSH Total Score
Graph the PUSH Total Scores on the Pressure Ulcer Healing Graph below.
PUSH Total Score
Pressure Ulcer Healing Graph
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Healed = 0
Date
www.npuap.org
11F
107
PUSH Tool Version 3.0: 9/15/98

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Outcome Measures

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Functional Measurement Tools

Tinetti Performance Oriented Mobility Assessment

25-28 = low fall risk

Functional Measurement Tools

Tinetti Performance Oriented Mobility Assessment (POMA)

Leans or slides in chair

Unable without help

Unable without help

Turing 360 Degrees

Functional Measurement Tools

Tinetti Performance Oriented Mobility Assessment (POMA)

BALANCE SCORE = _____/16

Functional Measurement Tools

Unsafe (misjudges distance, falls) =0;Uses arms, or not a smooth motion

Functional Measurement Tools

Berg Balance Scale

Location: ________________________________ Rater: ___________________

Functional Measurement Tools

Berg Balance Scale

Functional Measurement Tools

Berg Balance Scale continued..

( ) TOTAL SCORE (Maximum = 56)

Functional Measurement Tools

Timed Up & Go Test (TUG)

Functional Measurement Tools

Timed Up and Go*

Functional Measurement Tools

Scores less than 6 or 7 inches indicate limited functional balance. Most

*Duncan P, Weiner D, Chandler J, et al. Functional reach: a new clinical measure of

Functional Measurement Tools

Tests of Static Balance:

F-1. FEET CLOSELY TOGETHER, UNSUPPORTED, eyes open (ROMBERG POSITION)

Functional Measurement Tools

Total FICSIT-4 Static Balance score = ____ / 28

Functional Measurement Tools

Functional Measurement Tools

Functional Measurement Tools

2. Because of your problem, do you feel frustrated?

4. Does walking down the aisle of a supermarket increase your problem?

6. Does your problem significantly restrict your participation in social activities

7. Because of your problem, do you have difficulty reading?

8. Does performing more ambitious activities like sports, dancing, household

11. Do quick movements of your head increase your problem?

12. Because of your problem, do you avoid heights?

13. Does turning over in bed increase your problem?

14. Because of your problem, is it difficult for you to do strenuous housework or

17. Does walking down a sidewalk increase your problem?

18. Because of your problem, is it difficult for you to concentrate?

21. Because of your problem, do you feel handicapped?

23. Because of your problem, are you depressed?

25. Does bending over increase your problem?

Functional Measurement Tools

FOUR SQUARE STEP TEST (FSST)

Functional Measurement Tools

6-Minute Walk Test

Functional Measurement Tools

Dynamic Gait Index*

< 19 = predictive of falls in the elderly

Functional Measurement Tools

Dynamic Gait Index

Functional Measurement Tools

Dynamic Gait Index continued.

TOTAL SCORE: ___ / 24

Functional Measurement Tools

Location: ______________ Rater: _