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Oswestry Disability Index

Oswestry Disability Index - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related


SPINE Volume 25, Number 22, pp 2940–2953
©2000, Lippincott Williams & Wilkins, Inc.
The Oswestry Disability Index
Jeremy C. T. Fairbank, MD, FRCS,* and Paul B. Pynsent, PhD†
Study Design. The Oswestry Disability Index (ODI) has
become one of the principal condition-specific outcome
measures used in the management of spinal disorders.
This review is based on publications using the ODI iden-
tified from the authors’ personal databases, the Science
Citation Index, and hand searches of Spine and current
textbooks of spinal disorders.
Objectives. To review the versions of this instrument,
document methods by which it has been validated, col-
late data from scores found in normal and back pain
populations, provide curves for power calculations in
studies using the ODI, and maintain the ODI as a gold
standard outcome measure.
Summary of Background Data. It has now been 20
years since its original publication. More than 200 cita-
tions exist in the Science Citation Index. The authors have
a large correspondence file relating to the ODI, that is
cited in most of the large textbooks related to spinal
disorders.
Methods. All the published versions of the question-
naire were identified. A systematic review of this litera-
ture was made. The various reports of validation were
collated and related to a version.
Results. Four versions of the ODI are available in En-
glish and nine in other languages. Some published ver-
sions contain misprints, and many omit the scoring sys-
tem. At least 114 studies contain usable data. These data
provide both validation and standards for other users and
indicate the power of the instrument for detecting change
in sample populations.
Conclusions. The ODI remains a valid and vigorous
measure and has been a worthwhile outcome measure.
The process of using the ODI is reviewed and should be
the subject of further research. The receiver operating
characteristics should be explored in a population with
higher self-report disabilities. The behavior of the instru-
ment is incompletely understood, particularly in sensitiv-
ity to real change. [Key words: back pain, Oswestry Dis-
ability Index, outcome measures, validity] Spine 2000;25:
2940–2953
The Oswestry Disability Index
38
(ODI) and the Roland–
Morris disability questionnaire
122
(R-M) have emerged
as the most commonly recommended condition specific
outcome measures for spinal disorders.
28,34,153
The development of the Oswestry Disability Index
was initiated by John O’Brien in 1976. Patients with
back pain were interviewed by an orthopedic surgeon
(Stephen Eisenstein), and an occupational therapist (Ju-
dith Couper). Various drafts of the questionnaire were
tried. The questionnaire had been published in 1980
38
and widely disseminated from the 1981 meeting of the
International Society for the Study of the Lumbar Spine
(ISSLS) in Paris.
The objects of this article are:
● To present the various versions of the ODI instru-
ment for comparison
● To review the various efforts that have been made to
validate this questionnaire
● To compare the scores obtained in studies of differ-
ent patient population both before and after treat-
ment
● To review the methodology of outcome measure-
ment
● To consider what is actually measured by this and
similar instruments
Search Methodology
Citations were identified from the authors’ personal da-
tabases, the Science Citation Index (searching for the
original reference
38
), and hand searches of Spine and
current textbooks of spinal disorders. There are well
over 200 citations of the ODI in the Science Citation
Index alone.
Versions of the ODI
Table 1 shows four versions of the ODI. Version 1.0 is
the original,
38
reproduced by Hupli et al
66
(with a scor-
ing system) and Boden
6
without one. It has also been
published omitting a single item from both section 8 (sex
life) and section 9 (social life).
8
The American Academy
of Orthopedic Surgeons (AAOS) and other spine societ-
ies have adapted version 1.0 into their spine outcome
instruments. This version reflects American rather than
British usage. It omits sections 1, 8, and 9. It scores the
remaining sections from 1 to 6 (rather than 0–5), which
leads to confusion when comparing scores obtained with
other versions.
37,28
Version 2.0 was a modification of the ODI made by a
Medical Research Council group in the United King-
dom.
1,104,105,116
It has been widely distributed by corre-
spondence and is available as part of a computer inter-
view in the United Kingdom (slightly modified)
1,117
or in
the United States (through MODEMS; available at PO
Box 2354, Des Plaines, IL 60017-2354).
A revised Oswestry Disability Questionnaire was
published by a chiropractic study group in the United
Kingdom in 1989.
62
Its objective was to increase the
sensitivity of the scale for less disabled patients, but it
confuses impairment with disability. The sex question is
omitted.
62,91,168
In the authors’ view, this version is not
From the *Nuffield Orthopaedic Centre, Oxford, United Kingdom,
and the †Research and Teaching Centre, Royal Orthopaedic Hospital,
Birmingham, United Kingdom.
Acknowledgment date: August 3, 1999.
Acceptance date: February 8, 2000.
Device status category: 1.
Conflict of interest category: 12.
2940

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3

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2941The Oswestry Disability Index

Fairbank and Pynsent

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7

S
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7

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3
/
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P
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p
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(
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)
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.
2942 Spine

Volume 25

Number 22

2000

T
a
b
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1
.
C
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1
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8

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.
2943The Oswestry Disability Index

Fairbank and Pynsent

acceptable, because it confuses impairment questions
with disability questions. Its wording is often complex,
and some sections do not allow for no symptoms. It
allows a measurement of changing symptoms, however.
The sex question (Section 8) is unacceptable in some
cultures and has been omitted in certain studies—
notably in those involving teenagers with spondylolisthe-
sis
114
and in patients with multiple metastases.
19,115,162
The cancer studies have also omitted Section 1 (Pain),
which they measured by other means.
In at least two studies, the administration of the ODI
by telephone has been reported.
66,103
Versions in Languages Other Than English
Although much of the medical literature quoted in this
article is published in English (a reflection of the Science
Citation Index), instruments have to be translated for
local use (Table 2). In theory, all these versions should be
validated independently, although this is probably not
always the case. Ideally, there should be a single version
in each language.
Scoring
The standard scoring method (Table 3) can be used for
all versions of the ODI shown in Table 1, but because the
AAOS version has only eight sections, corrections would
have to be made for this. MODEMS now includes both
versions 1.0 and 2.0, as well as the AAOS instruments.
Some researchers have used versions of the instrument
scoring each section from 1 to 6 (notably the Ste. Justine
Group
44
and the AAOS and North American Spine So-
ciety [NASS]). This can make hand scoring more difficult
and unreliable (Table 3).
37,103
If the first answer of each
section is scored zero, then it can be ignored when sum-
ming the score. If it is scored 1 then it must be counted
and subtracted from the total to calculate the final score.
This can and does lead to errors: Orr et al.
112
reported to
NASS in 1998 a series of 25 spinal fusion patients with a
preoperative ODI score of 18.7 6 5.5 (SD). This is in-
consistent with all other publications in Table 4 and Fig-
ure 1.
Definitions of Disability
The World Health Organization (WHO) definitions of
impairment, disability, and handicap are now widely ac-
cepted.
167
Discussion groups in 1991
146
and 1992
61
re-
viewed the available outcome measures for patients with
back pain. Both groups concluded that the ODI was rea-
sonably confined to disability according to the WHO
definition. Many of the alternatives also attempted to
measure impairment (pain) and some ranged into the
areas of handicap as well. Handicap has been extremely
difficult to measure by questionnaire.
118
The ODI was
deliberately focused on physical activities and not the
psychological consequences of acute or chronic pain.
Validity and Reliability
In the 20 years since the ODI was published, there have
been considerable advances in the understanding of in-
strument validation.
140
Face and Content Validity. This means that the scale ap-
pears to be assessing the desired qualities. In the author’s
original study, a group of 25 patients was reported in the
first episode of low back pain who might be reasonably
expected to improve with passing time.
38
The ODI
tracked this process. Beuerskins et al
4
performed a more
sophisticated analysis of 81 patients during a 5-week
period confirming an expected improvement in ODI
scores. Their study design allows calculation of an effect
size of 0.8.
18
However, Kopec et al
75
reported an effect
size of only 0.07. Fisher and Johnson
40
conducted one of
the most detailed validations of the questionnaire (ver-
sion 2.0). They related patient behavior while they were
completing this and other questionnaires to their re-
sponses within the questionnaires. Two sections of the
questionnaires (sitting and walking) correlated with pa-
tient response, but correlation was less satisfactory for a
third (lifting).
Test–Retest. In the original study patients with chronic
low back pain were tested twice at a 24-hour interval
(n 5 22, r 5 0.99).
38
This may include a memory effect.
If the test–retest interval is extended to 4 days, the cor-
relation of scores decreases to n5 22, r 5 0.91
75
and, if
retested after a week, n 5 22, r 5 0.83.
51
The disadvan-
Table 2.
Language Citation(s)
Danish 15, 100, 99, 162
Dutch 162
Finnish 67, 69, 52, 51, 81, 54, 77, 82, 78, 58–60,
65, 85, 95, 96, 147–149, 53, 63, 64, 66,
79, 80, 68, 76, 83
133–135, 169, 98, 73, 72, 163
French 35, 162
86, 101
German 3, 108, 165
9, 16, 164
Greek 7
Norwegian 36, 48, 47, 132, 150
Spanish 84
Swedish 130, 128, 129
Table 3. Scoring System for Oswetry Disability
Index (ODI)
Oswetry Disability Index Version 1.0 and 2.0, and the chiropractic
revised questionnaire are scored in the same way. An ODI can be
scored from the eight sections of the AAOS instrument, although it
would be more valid to use a complete version of the instrument.
For each section of six statements the total score is 5; if the first
statement is marked the score 5 0; if the last statement is marked
it 5 5. Intervening statements are scored according to rank. If more
than one box is marked in each section, take the highest score. If all
10 sections are completed the score is calculated as follows:
Example: if 16 (total scored) out of 50 (total possible score) 3 100 5
32%.
If one section is missed (or not applicable) the score is calculated:
Example: 16 (total scored)/45 (total possible score) 3 100 5 35.6%.
So the final score may be summarized as:
(total score/(5 3 number of questions answered)) 3 100%.
It is suggested rounding the percentage to a whole number for
convenience.
2944 Spine

Volume 25

Number 22

2000

tage of increasing the time interval is that natural symp-
tom fluctuation may also be an influence. Grevitt (per-
sonal communication May, 1997) found a poorer test–
retest correlation in a study in which he mailed versions
of the questionnaire to patients to complete and then
asked them to complete the questionnaire again in a dif-
ferent format when they attended as outpatients. The
authors compared a hard copy version 2.0 with a com-
puter version of the questionnaire and found a high cor-
relation (n 5 183, r 5 0.89).
1
Table 4.
Category Total No. No. of Groups
Wt Mean
ODI Score S.D. Range F Sources Used
Sources Not
Used
“Normal” populations 461 4 10.19 2.2–12 0.37 103, 65, 63, 66, 73, 72 24
Pelvic fractures 31 1 13.26 15.4 – 56
Idiopathic scoliosis 1264 5 13.81 9.2–13 0.03 44, 103
Neck pain 56 1 21 9.7 – 169
Spondylolisthesis 120 5 26.63 6.1–16 1.76 111, 133–135, 147
Primary back pain 2166 21 27 5.8–23.6 0.33 45, 106, 151, 105, 65, 7
4, 63, 66, 73, 93, 130, 72, 94,
128, 129
98
Psychiatric patients 75 1 30.8 21.5 – 166
Neurogenic claudication 82 2 36.65 17–18 0.14 58–60 24
Chronic back pain 1530 25 43.3 10–21 0.02 131, 30, 52, 54, 90, 31–33, 53
119, 14, 152, 81, 134, 77, 82,
135, 137, 153, 154, 11, 78,
97, 158, 8, 10, 147–149, 155,
159, 161, 79, 80, 157, 156,
12, 76, 83, 160
PID/Sciatica 663 9 44.65 10.5–30.1 0.16 31, 32, 48, 33, 47, 13, 50, 150 81, 77, 82, 78–80,
132, 145, 76, 83
Fibromyalgia 192 4 44.83 14.2–18.9 0.07 152–154, 158, 155, 159, 161,
157, 156, 160
Metastases 100 2 48.04 18.1–23 0.04 115, 162
Figure 1. Weighted means (95%
confidence intervals) for the Os-
westry Disability Index calcu-
lated from pooled data for vari-
ous categories of patients. The
number of patients for each cat-
egory is also marked. See Table
4 for more information.
2945The Oswestry Disability Index

Fairbank and Pynsent

Time Frame. The original questionnaire did not specify
the time frame in which the subject should answer the
questionnaire, although it is implicit that it means
“now.” Version 2.0 specifically asks about “now.” The
NASS modification emphasizes a review of symptoms in
the past week. Recently, the authors’ work on outcomes
in neurogenic claudication has included the use of ver-
sion 2.0 of the ODI and the instrument described by Stucki
et al
142
using a time frame of a week. Patients prefer the
format in which they are asked for symptoms “now.”
24
Internal Consistency. Cronbach’s a is a measure of all the
various components of a questionnaire moving together.
Strong et al
141
(using version 1.0) found Cronbach’s a to
be 0.71, Fisher and Johnson
40
(using version 2.0) 0.76,
and Kopec et al
75
0.87. All these investigations show an
acceptable degree of internal consistency. In the original
study
38
and the 1989 study
1
the current authors found
that all the sections tended to move with Section 1 (pain
scale) although Fisher and Johnson
40
did not confirm
this in patients who had chronic pain.
Validation by Comparison With Other Tests
The ODI shows moderate correlation with pain mea-
sures such as a visual analogue scale (n5 94, r5 0.62)
51
and the McGill Pain Questionnaire.
55,107
The ODI has been used to validate the Pain Disability
Index,
51,51,124,141
the Low Back Outcome Score,
49
Man-
niche,
99,100
the Aberdeen score,
123
a new German lan-
guage scale,
3
the Curtin Scale,
57
and a functional capac-
ity evaluation.
74
The ODI correlates with the Short Form (SF)36.
50
ODI is a better predictor of return to work than two
different mechanical methods of lumbar spine assess-
ment.
94,109
It predicts isokinetic performance,
71
isomet-
ric endurance,
85
and pain with sitting and standing (but
not lifting) in a secret observation study.
40
In the Mack-
enzie system of evaluation, “centralizers” show improv-
ing ODI scores.
143
Physical tests correlate with the
ODI
54
but range of movement does not.
53
The ODI has been mined for questions by the design-
ers of other instruments.
2,20,21,39,46,49,87,100
The ODI has
been used in at least one study of neck pain patients.
169
Identification of Patient Populations
The ODI has been used to identify populations of pa-
tients for research projects
17,23,43,55,59–61,65,102
but is un-
likely that this approach has much clinical application.
Categoric Versus Dimensional Scales
The data gathered in the ODI is in a categoric format, but
each category is ordinal. This is converted to discrete
quantitative data by summing (a dimensional scale). This
assumes that disability can be viewed as a continuum
from “not disabled” to “severely disabled.” Many view
the ODI as having a linear correlation with disability,
and thus a person with a score of 40 is twice as disabled
as one with a score of 20. This is unlikely to be true,
because the structure of some sections are not linear (e.g.,
Section 5: 1 hour, 30 minutes, and 10 minutes). Similar
arguments and assumptions apply to change in score.
Most users readily apply statistical tests to before and
after treatment value with no regard to the starting point
of the first value. Little and MacDonald
92
have expressed
this change as a percentage of the original score, arguing
that it is better to shift a patient from 20% to 10% than
to go from 60% to 50%. No other investigator has used
this scheme.
An alternative is to aggregate the index into several
categories. In the original paper five levels of the score
were suggested (0–20%, 21–40%, 41–60%, 61–80%,
and 81–100%). Some investigators have used this system
to categorize their patients.
9,95,96
Others have divided
their patient population into two groups above and be-
low a criterion, such as 40%.
125
A further possibility is
to disaggregate the ODI.
7
The issues of disaggregation
are discussed by Scott et al.
127
Clinically Significant Change
Meade
107
chose 4 points as the minimum difference in
mean scores between groups that carried clinical signifi-
cance. The U. S. Food and Drug Administration (FDA)
has chosen a minimum 15-point change in patients who
undergo spinal fusion before surgery and at follow-up
(Lipscombe, personal communication, May, 1999). Fig-
ure 2 and Table 5 show change in weighted means cal-
culated from publications reporting ODI before and af-
ter treatment in various subgroups of patients. Large
changes in score are seen in patients with primary back
pain and the least in those with spinal metastases. Table
4 and Figure 1 demonstrate the large standard deviations
seen in clinically homogenous populations with various
back pain syndromes. More work is needed in this area.
Analysis of Changing Scores
The change in the total score and change in components
of the ODI have been investigated.
110,120,121,136,139
Sources of error include inconsistencies in the answering
of a questionnaire, the natural fluctuations of symptoms
as well as clinical improvements (Figure 2 and Table 5).
The Oswestry Disability Index and Roland–Morris
Scores
The ODI has been directly compared with R-M in several
studies.
1,88,89
The two scales correlate (n 5 500, r 5
0.77).
7
The scatter chart from Baker et al
1
(Figure 3A) was
obtained when both questionnaires were simultaneously
presented in a computer questionnaire. The results reflect
the imprecision of these scales. The ODI tends to score
higher than the R-M score (Figure 3). Thus it is likely that
the ODI is better at detecting change in the more seriously
disabled patients, whereas the R-M score may well have an
advantage in patients with minor disability.
Receiver Operating Characteristic
This is a concept used to explore the diagnostic test per-
formance of an instrument or the ability of the instru-
ment to detect change,
25
where its sensitivity is plotted
against 1 minus specificity. This allows the ability of the
instrument to detect change to be investigated. The ROC
2946 Spine

Volume 25

Number 22

2000

index (D9) for the ODI was found to be 0.76, a score that
is acceptable but not as good as the R-M scale. This is
perhaps not surprising in a population of patients who
are not severely affected (mean ODI 5 26.2 6 13.5
[SD]).
4,94
The ROC index has not been calculated for the
ODI in a group of more severely affected patients. Be-
cause the ROC curve depends on sensitivity and specific-
ity, there is an inherent assumption that a “true disabil-
ity” is known. This may be difficult to justify.
25
Male–Female Differences
Some researchers have reported consistently higher ODI
scores in women than men, but others have not con-
firmed this.
75,119
Normal Subjects
There are few published reports of ODI scores in the
“normal population.” Two small biomechanical studies
used back pain–free control subjects.
72,73
The Ste. Jus-
tine study of idiopathic scoliosis includes a telephone
survey of normal subjects published separately from the
parent studies in subsequent correspondence in Spine.
103
The current authors have used the ODI in control sub-
jects age-matched to a patient population with neuro-
genic claudication.
24
Together the results in these studies
yield a mean score of 10.19 (range, 2.2–12; Table 4).
Citations and Mbaot
It is always frustrating for a reader to find that articles
are inaccurately cited. Sometimes the inaccuracies are
such that the reference is impossible to find. In the cur-
rent investigation, approximately half the papers con-
tained minor spelling errors in their reference to the orig-
inal work, such as Deyo and Centor in 1986.
25
A number
of authors substituted Judith Couper’s Occupational
Therapy qualification (MBAOT) Mbaot or even Mboat
for her surname. The order of the authors’ names has
been altered frequently. One reason for this is the poor
typographical layout in the original journal. Another is
the copying of unread references from one paper to an-
other. An incomplete list of these papers is cit-
ed.
6,20,21,24–33,70,93,94,113,152–161
Discussion
The ODI has proved to be a versatile questionnaire, al-
though unfortunately a single version no longer exists. It
is also unfortunate that the time frame for symptoms has
been varied by others outside versions 1.0 and 2.0. Ulti-
Figure 2. Weighted means with
95% confidence intervals for
measured change of the ODI cal-
culated from pooled data for var-
ious categories of patients. The
number of patients for each cat-
egory is also marked. See Table
5 for more information.
Table 5.
Group
Weighted Mean
Difference Presample Postsample
Sample
S.D. Range F
Number of
Groups Sources
Spinal metastases 9 34 34 17.4–18.1 – 1 115
Sciatica with p.i.d. 15.1 330 330 10.5–17.2 0.58 4 48, 47, 150
Chronic back pain 15.4 793 702 10.0–26.0 0.02 12 131, 31, 126, 32, 50, 80,
138, 14, 97, 149, 147, 148,
12, 11, 10
Spondylolisthesis 14.4 51 51 14.0–20.1 – 1 133
Primary back pain 25.5 168 168 9.6–14.8 0.004 2 89
2947The Oswestry Disability Index

Fairbank and Pynsent

mately, there can be no absolute measure of disability
and the score of this or similar instruments takes on a life
of its own. The results published by the diversity of in-
vestigators gives an indication of the likely responses that
can be expected in a particular patient subgroup. If the
ODI is to be used an as outcome measure, this can assist
in power calculations for a planned trial (Figure 4).
The choice of which condition-specific disability ques-
tionnaire to use must be an individual one. The ODI has
found favor in studies of patients with more severe symp-
toms, although it also appears to provide a robust indi-
cation of those with minor symptoms. The R-M has been
used more frequently in the primary care environment
and in the elderly. There is no questionnaire that can be
used to measure handicap.
The time scale of the ODI and the R-M questionnaire
is “now.” The authors believe that this is more robust
than asking subjects to average their symptoms over the
previous week, as is the choice of the AAOS.
The measurement of disability is an important com-
ponent of the management of patients with back pain.
Figure 3. A comparison of the
Oswestry Disability Index (ODI)
and Roland-Morris (R-M) ques-
tionnaire. Note the R-M ques-
tionnaire has been adjusted to a
percentage so that it can be di-
rectly compared; normally it
scores between 0 and 24.
122
A, A
scatterplot adapted from Baker
et al.
1
for 183 patients. The mean
ODI score is 34.9 whereas the
mean for the R-M questionnaire
is 52.45. Thus, on average the
R-M scores higher. The mean
difference of 17.5 is significant
(P , 0.001) using a paired t test.
The dotted line shows the line of
identity where the ODI and R-M
scores would take the same val-
ues. B, The use of a Bland and
Altman plot to exemplify differ-
ences.
5
The solid line marks the
mean difference, and the two
dashed lines mark two standard
deviations on either side of the
mean (the upper and lower limits
of agreement). The trend, in
which the greater the mean val-
ues the more negative the differ-
ences, is clear.
2948 Spine

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Self-report questionnaires have been better than so-
called “objective” measures, such as range of movement
and various measures of functional capacity, in achieving
this. This has meant that some of self-report disability
scores have become, in their own right, a dimension of
disability, in the same way that the Glasgow Coma Scale
has become a measure of head injury status in its own
right.
144
It is not possible to define the mathematical
behavior of these scales, although many investigators
have used them as if they behave in a linear fashion. The
collation of scores from different diagnostic groups re-
corded in different cultures speaks for the robustness of
this concept.
In spite of the inadequacies of physical measures, the
authors do not believe that such measures should be
abandoned as outcome measures, because they may well
be measuring a dimension different from that measured
by the questionnaires. The current authors have used the
Shuttle Walking Test as an outcome measure in a phys-
iotherapy study,
42
in patients with neurogenic claudica-
tion,
24
and, currently, in the Spine Stabilization Trial.
41
Further work is needed to optimize physical measures
and the correlation of responses with the questionnaires.
Because so many researchers have recommended the
use of the ODI, it is important that the structure and the
scoring systems be adhered to. This opens the possibili-
ties of aggregating the results of studies and comparing
outcomes. Doubtless, scales will evolve in the future, and
new ones will be presented. However, the authors believe
that until a method is developed that is clearly superior,
the ODI, the R-M, or both should be used as condition-
specific outcome measures in studies of patients with
back pain.
Conclusions
The ODI remains a valid and vigorous measure of con-
dition-specific disability. The authors recommend the
use of version 2.0. The data presented are a guide to the
power of the instrument to detect meaningful changes in
disability status. More work is needed in this area. The
ROCs of the curve should be explored in populations
with higher self-report disabilities. More studies are
needed to explore the response to change in an individ-
ual. The work started by the Ste. Justine group in extract-
ing more information from disability instruments should
be developed in more disabled populations than those
with idiopathic scoliosis. The statisticians of the Ste. Jus-
tine Group have argued that additional information can
be obtained by disaggregating the score and using so-
phisticated statistical techniques.
103,127
Key Points
● The ODI has been published in at least four for-
mats in English and in nine other languages. The
four versions in English are presented in full.
● The authors recommend the use of version 2.0.
● The ODI has stood the test of time and many
reviews. It is usable in a wide variety of applica-
tions as a condition-specific outcome measure of
spine-related disability.
● Results of a meta-analysis show variations in es-
timated population means of ODI scores for differ-
ent spinal diseases and changes after treatment
consistent with clinical experience.
Figure 4. Power calculations for
a study to show the difference in
means between two groups of
patients. The family of curves
uses standard deviations com-
monly found in Oswestry Disabil-
ity Index studies using a planned
probability for significance of
a 5 0.05 at two different power
settings. The y-axis shows the
number of patients necessary for
each group, assuming the num-
bers are equal. For example, to
show a difference of 4 between
the means of the ODI score (x-
axis) with standard deviation of
10 and a power of 80%, 100 pa-
tients would be needed in each
group.
2949The Oswestry Disability Index

Fairbank and Pynsent

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Address reprint requests to
Jeremy Fairbank
Nuffield Orthopaedic Centre
Oxford OX3 7LD, UK
jeremy.fairbank@ndos.ox.ac.uk
2952 Spine

Volume 25

Number 22

2000

Point of View
Thom Walsh, MS, PT, OCS, Dip MDT
The Spine Center at Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
The 1980 publication of the Oswestry Disability Index
(ODI) in the journal Physiotherapy foreshadowed an ex-
plosion in the field of pain and disability scales for pa-
tients with back pain by nearly a decade. The authors’
opening comments point out an unfortunate situation
that can arise from early development of a useful tool,
namely, multiple versions and idiosyncratic scoring
methods.
1
The recommended version from the authors is
their ODI 2.0 and the scoring method is outlined. This is
not a trivial concern when one considers that both a score
of 0 and a score of 100 have been used to define normal.
A stated objective of this review was to “maintain a
gold-standard” in the field. Dr. Fairbank’s seminal piece
from 1980
2
concluded that the ODI was a reliable instru-
ment based on the high test-retest correlation in 22 pa-
tients over a 24-hour period. The validation portion con-
sisted of following 25 patients with their first episode of
LBP over a 3-week period. As the patients reported im-
provement in their backache (as was expected), their
ODI scores improved also.
Dr. Fairbank proposes in this piece, “The wide use of
the ODI is part of the validation process.” The thought
that wide use and reasonable performance as expected
on a small sample are synonymous with validation and a
rigorous review is one that falls short of current capabil-
ities in the field.
It should no longer be enough to simply report find-
ings that turned out as expected, or that a gold-standard
measure is crowned as a result of widespread use. Good
validation studies should state a clear hypothesis and test
it using a rigorous design and statistical analysis.
3,4
This
review article nicely compiles a wide range of work uti-
lizing the ODI over the past 20 years. While the breadth
of this compilation is notable, and the validation steps
taken at various times have raised interesting questions,
it has not, in my opinion, established a gold-standard
measure. In conclusion, a fitting statement from Mc-
Dowell and Newell
5
: “It is possible to use statistically
correct procedures to refine an instrument whose content
is based on clinical wisdom and common sense.”
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2953The Oswestry Disability Index

Fairbank and Pynsent