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Rehab Measures: Oswestry Disability Index

Rehabilitation Measures Database

Oswestry Disability Index

Title of Assessment
Access to the Oswestry Disability Index

Link to instrument
Purpose

To assess symptoms and severity of low back pain in terms of

disablement and the degree to which back or leg pain impacts
functional activities
ODI

Acronym
Instrument Reviewer(s)

Initially reviewed by Spencer Cole, SPT, Sarah Dickey, SPT, Jess

Godfrey, SPT, Noemi Gomez, SPT, Laura Grabowski, SPT, Haley
Harrell. SPT, Laura Henderson, SPT, Jenn Hilmer. SPT, Kerry
Mclaughlin, SPT, Charles Miller, SPT, Carter Norbo, SPT, and YenYen Gee, MMus, in July 2013.

27 11 2013

Summary Date
Description

ODI Version 1.0, 2.0, Chiropractic Revised

Questionnaire consisting of 10 items: pain intensity, personal care,
lifting, walking, sitting, standing, sleeping, sex (if applicable), social,
and travel. Each item consists of six statements correlating to
scores of 0 through 5, with the patient choosing the statement that
matches his or her ability. The statement correlating with a score of
0 indicates the least disability, and the statement correlating to 5
represents the greatest disability.
Scores are calculated as follows: [total score/(5 x number of
questions answered)] x 100%, falling within a range of 0 through 50
ODI AAOS/MODEMS Instrument
Questionnaire consisting of 8 items: pain intensity, personal care,
walking/running, sitting, standing, sleeping, and traveling. Each item
consists of six statements correlating to scores of 1 through 6, with
the patient choosing the statement that matches his or her ability.
The statement correlating with a score of 1 indicates the least
disability, and the statement correlating to 6 represents the greatest
disability.

Scores are calculated as follows: [total score/(5 x number of

questions answered)] x 100%, falling within a range of 8 through 48
The instrument is recommended as a more valid, complete version
of the test and may be administered directly via paper or over the
phone.
Body Structure, Body Function, Activity, Participation, Environment

ICF Domain
3.5-5 minutes to complete, 1 minute to score

Time to Administer
Number of Items
Equipment Required
Training Required

ODI Version 1.0, 2.0, Chiropractic Revised: 60 Total Questions, 10

Sections with 6 Questions each

Survey
Writing utensil
Telephone (if administered by phone)
No training required; however training the staff improves
accuracy of the results
No cost

Actual Cost
Populations Tested

Subacute low back pain

Chronic low back pain

Pelvic fractures

Neck pain

Sciatica

Fibromyalgia

Matastases

Spinal surgeries

Standard Error of
Measurement (SEM)

Lumbar spinal fusion

Laminectomy

Pelvic girdle pain

Arthritis

Low back pain:

(Copay et al, 2008; n = 457, mean age = 54.4 years, average BMI =
29.9 kg/m2, 59.1% female; patients were selected from a Lumbar
Spine Study Group with scores at baseline and at 1 year; most
frequent diagnoses were spinal stenosis (28.5%), lumbar disc
pathology/degeneration (15.8%), spondylolisthesis (14.7%);
patients either went under decompression surgery (11.5%) or fusion
surgery (88.5%); study is to determine the clinically and statistically
appropriate MCID value for patients who underwent lumbar spinal
surgery when utilizing anchor-based and distribution-based
methods)

When using the Health Transition Item (HTI) as an anchor,

SEM = 4.62

When using the Satisfaction with Results Scale as an

anchor, SEM = 4.21

(Dawson et al, 2010; Cohort 1: n = 214, age = 25.9 (9.0), weight

(kg) = 68.1 (14.6), 88.3% female, 49.5% with annual upper back
pain, 92.1% with annual lower pain; Cohort 2: n = 33, age = 23.2
(6.5), weight = 68.0 (12.2), 90.9% female, 52.3% with annual upper
back pain, 94.0% with annual lower back pain; patients were
enrolled as Bachelor of Nursing students in Australia; Cohort 2 is a
subsection of Cohort 1, having completed the ODI Version 2.0 on
two separate occasions instead of one)

For students reporting back pain (BP) in the previous year

(n = 214), SEM = 2.56% (90% CI)

For students reporting BP on the day of the study (n = 82):

SEM = 2.77% (90% CI)

(Grotle et al, 2012; n = 87 for control group and n = 42 for test retest
group, mean age = 35 (5.0); patients recruited from primary care
clinics in Norway using the following inclusion criteria: pelvic girdle
pain located distal, lateral, or both in relation to the L5 - S1 area, in
the buttocks, symphsis or both, with pain onset during pregnancy or
within 3 weeks after delivery; diagnostic criteria determined by the

following tests: Posterior Pelvic Pain Provocation Test, Active

Straight Leg Raising Test, pain provocation of the long dorsal
sacroiliac ligament, and pain provocation of the symphysis by
palpation and by a modified Tredelenburg test)

SEM = 4.02

(Johnsen et al, 2013; n = 113, age = 25 - 55, mean age = 41, 52.6%
female, mean duration of low back pain = 5.74 years; inclusion
criteria: age between 25 - 55, lower back pain for over a year,
degenerative changes in the intervertebral disc in one of the two
lowest levels of the lumbar spine and an Oswestry Disability Index
of equal to or greater than 30%; exclusion criteria: generalized
chronic pain syndrome and degeneration established in more than
two levels; patients randomized to surgery with insertion of artificial
disc or non-surgical, multidisciplinary back rehabilitation program;
only those outcomes of patients who completed the SF6D, EG5D
and ODI at baseline and at 2 year follow up were included)

SEM = 4.24 for patients stable for a period of 3 months

(Miekisiak et al, 2013; n = 164 with 70 men and 94 women, age =

49.7 (11.8); n = 84 (52%) provided retest questionnaires within 2 14 days of baseline data; patients were recruited as surgical
candidates and inclusion crtiteria included chronic LBP with or
without radiation to the leg, 18 years or older, and good
comprehension of the Polish language; a culturally, translated
version of the ODI was used, after review by a committee including
one neurosurgeon, one psychologist, one physical therapist, and a
translator)

Minimal Detectable
Change (MDC)

SEM = 3.54 (2.62 - 4.79)

Low back pain:

(Copay et al, 2008)

Using the Health Transition Item (HTI) as an anchor, MDC =

12.81 (CI = 95%)

Using the Satisfaction with Results Scale as an anchor,

MDC = 11.67 (CI = 95%)

(Dawson et al, 2010)

For students reporting back pain (BP) in the previous year

(n = 214), MDC90 = 5.94%

For students reporting back pain (BP) in the previous year

(n = 82), MDC90 = 6.43%

(Grotle et al, 2012)

Individual MDC = 11.1

Group MDC = 1.7

(Johnsen et al, 2013)

MDC = 11.74, CI = 95%

(Miekisiak et al, 2013)

For the total sample population (MDC95 = 10)

(Monticone et al, 2012; n = 179, 62.6% female; patients recruited

from rehabilitation centers between 2009 - 2010; inclusion criteria
included diagnosis of sub-acute or chronic common lower back
pain, age 18 - 70 years, and the ability to read and speak fluent
Italian; exclusion criteria were acute common lower back pain and
specific causes of lower back pain including disc herniation, canal
stenosis, and with recent myocardial infarctions, cerebrovascular
events)

Minimally Clinically
Important Difference
(MCID)

For the total sample population (MDC = 13.67)

For the population with subacute lower back pain (MDC =

15.35)

For the population with chronic lower back pain (MDC =

12.72)

Low back pain:

(Copay et al, 2008)

MCID = 12.8 (2.92 - 15.36), based on different calculation

methods yielding widely different threshold values

(Johnsen et al, 2013)

MIC = 12.88 with 88% sensitivity and 85% specificity

(Glassman et al, 2006; n = 497, with 270 females and 227 males,

age = 47 years (17 - 86); inclusion criteria included one (65%) or

two (35%) level lumbar spinal fusions with preoperative baseline
data and at least 1 year post-operative data with many contributing
also 2 year post-operative data; 131 patients also had a prior
decompressive surgical procedure)

FDA standards for good to excellent operative outcomes

include a 15 point improvement in ODI, plus maintenance or
improvement in SF - 36 score. Older studies indicate that a
4 or 10 point decrease might identify a significant
improvement

(Monticone et al, 2012)

With the MCID taken as the point on the ROC curve closest
to the upper left corner of the figure, the MCID is 9.5 (AUC
= 0.71, sensitivity = 76%, specificity = 63%)

Not established

Cut-Off Scores
Normative Data

Lower back pain:

(Cho et al, 2012; n = 166; age = 53.8 years with follow up 3.5 years
(2 - 7 years); patients underwent multilevel revision surgery for
spinal deformity with a minimum 2 year follow up; primary diagnosis
included de novo scoliosis, degenerative, trauma, neuromuscular
scoliosis, congenital deformity, ankylosing spondylitis, tumor,
Scheuerman kyphosis, and rheumatoid arthritis)

Comparison of ODI scores at ultimate follow-up: follow-up

complication, mean ODI = 37.2; no complication, mean ODI
= 26.6

Assessing the difference between final and preoperative

ODI scores: no or perioperative major complication groups,
mean ODI = 17.9; follow up complication group, mean ODI
= 9.5

(Copay et al, 2008)

ODI at baseline = 52.50 (14.06)

ODI after 1 year = 37.60 (21.50)

(Dawson et al, 2010)

Total Sample (n = Test-retest sample (n

214)
= 33)
Age

25.9 (9.0)

23.2 (6.5)

Weight (kg)

68.1 (14.6)

68.0 (12.2)

Height (cm)

167.1 (8.6)

166.6 (8.7)

Female (%)

88.3

90.9

Annual upper back

pain (%)

49.5

52.3

Annual lower back

pain (%)

92.1

94.0

ODI score

8.8 (7.4, 0 - 38)

1.15 (0.36)

Additionally, Cohort 1:

For students with non-serious back pain (n = 80), as

defined by not requiring sick leave and/or treatment, ODI =
7.3% (6.2), range (0 - 24)%

For students with serious back pain (n = 134), as defined by

requiring sick leave and/or reatment, ODI = 9.7% (7.9),
range (0 - 38)%

(Frost et al, 2008; n = 201, age = 42.5; patients were invited to take
part if they were 18 years old and over with at least a 6 week history
of low back pain or without leg pain or neurologic signs; patients
were excluded if they present with serious pathologies (ie. systemic
rheumatological, gynecological problems, ankylosing), were unable
or unwilling to complete the questionnaires independently, had
received physical therapies, or were referred for intensive functional
restoration programs, data assessed at baseline and 12 months)
Sample data
n

201 (90 male, 111 female)

Mean age (years)

42.5 (14.4)

After 2 months, back pain:

Improved

109 (54.3%)

Changed

76 (37.7%)

Worse

16 (8%)

(Glassman et al, 2006; n = 497; mean age = 47 (17 - 86)

1-year post-op (n = 413): mean 22.2 pt improvement

2-year post-op (n = 141): mean 22.1 pt improvement

Prior decompression surgery (n = 131): baseline, mean

54.4; 1-year post-op, mean 17.5 pt improvement; 2-year
post-op: mean 16.6 pt improvement

No prior decompression surgery (n = 366): baseline, mean

49.8; 1-year post-op, mean 21.7 pt improvement; 2-year
post-op, mean 24.4 pt improvement

(Grotle et al, 2012)

Total sample (n Test-retest sample
= 87)
(n = 42)
Age (years)

34.4 (5.3)

34.6 (5.3)

Pain duration (months)

31.6 (53.0)

34.6 (60.8)

7, 26, 29, 11

3, 12, 13, 6

43

21

At 1 or 2 pelvic joints

61

27

All 3 pelvic joints

26

15

No

15

Sometimes

54

26

Often

17

35.3 (12.3)

36.6 (12.1)

Number of children: 0, 1,
2, 3+
Pregnant at time
Pain localization:

Pain-free periods:

ODI score (0-100)

Mean scores for ODI
subsections:
Pain intensity

2.13 (0.79)

Personal hygiene

0.71 (0.91)

Lifting

2.31 (1.08)

Walking

1.44 (0.94)

Sitting

2.14 (0.89)

Standing

2.71 (1.07)

Sleeping

1.18 (0.69)

Sexual activity

1.61 (1.30)

Social activity

1.95 (1.00)

Traveling

1.48 (0.98)

(Monticone et al, 2012; n = 179, age = 47.7 (12.3)

Baseline ODI mean score: 26.8 (16.6)

ODI mean score (after 8 week exercise program): 17.9

(16.0)

(Wittink et al, 2004)

Mean ODI score = 45.16 (19.56)

(Miekisiak et al, 2013)

Mean ODI score = 48.45 (18.94), range = 9 - 24

Surgical
candidates

Test-retest Reliability

Conservatively
treated

59

75

11

19

Age (years)

49.3 (12.5)

49.6
(12.7)

52.5 (9.45)

49.5
(6.95)

ODI

44.3 (18.4)

51.6
(20.2)

51.7 (13.2)

47.0
(16.5)

Visual analogue
scale (VAS) of
back

5.15 (2.16)

5.93
(2.65)

7.91 (1.87)

6.32
(2.63)

VAS leg

5.24 (2.94)

6.37
(2.94)

6.55 (3.59)

5.53
(2.95)

Low back pain:

(Dawson et al, 2010)

Excellent test retest reliability (n = 33) for ODI subsections

of walking (ICC = 0.78 (0.60 - 0.88)), sleep (ICC = 0.82
(0.67 - 0.91)), and total ODI score (ICC = 0.88 (0.77 0.94)), all with CI 95%

Adequate test retest reliability (n = 33) for ODI subsections

of pain intensity (ICC = 0.65 (0.40 - 0.81)), lifting (ICC =
0.74 (0.53 - 0.87)), sitting (ICC = 0.71 (0.48 - 0.85)),
standing (ICC = 0.59 (0.31 - 0.78)), social life (ICC = 0.52
(0.22 - 0.73), and travel (ICC = 0.51 (0.21 - 0.73))

Poor test retest reliability (n = 33) for ODI subsection of sex

(ICC = 0.25 (-0.11 - 0.55))

Test retest reliability not established for personal care

(Gronbald et al, 1993; n = 94, age = 42.7 (10.3) years, range 18 79; inclusion criteria including low back pain with or without
radiation to the legs for at least 2 months, indicating a chronic back
pain state; exclusion criteria including major disease, back pain > 3
months)

Excellent test retest reliability when test-retest interval is 1

week (ICC = 0.83)

(Grotle et al, 2012)

Excellent test retest reliability (ICC= 0.94 (0.89 - 0.97);

95% CI)

(Miekisiak et al, 2013)

Excellent test retest reliability (ICC = 0.97 (0.94 - 0.98);

95% CI)

Not established

Interrater/Intrarater
Reliability
Internal Consistency

Low Back Pain:

(Grotle et al, 2012)

Excellent internal consistency for overall ODI score

(Cronbachs alpha = 0.83)

Adequate internal consistency for ODI traveling sectiontotal score correlation (Cronbachs alpha = 0.72)

Poor internal consistency for ODI subsections-total score

correlation: pain (Cronbachs alpha = 0.50), personal
hygiene (0.61), lifting (0.58), walking (0.61), sitting (0.34),
standing (0.51), sleeping (0.42), sexual activity (0.53),
social activity (0.44)

(Miekisiak et al, 2013)

Excellent internal consistency (Cronbachs alpha = 0.90)

(Wittink et al, 2004; n = 87 and age = 46.9 years; included patients

classified according to six most common ICD9 diagnostic groups by
anatomic site (head and neck, upper or lower abdominal, low back)
and/or pathophysiology (complex regional pain syndrome of
myofascial pain)

Excellent internal reliability (Cronbachs alpha = 0.86); this

figure is better than previously reported in the literature

Criterion Validity

Low back pain:

(Predictive/Concurrent)

(Copay et al, 2008)

Poor correlation between baseline and change scores on

ODI (r = 0.11)

Adequate correlation between HTI anchor and ODI change

(rho = 0.35) and between Satisfaction with results anchor
and ODI change (rho = 0.46)

(Frost et al, 2008)

Excellent correlation between improved vs nonimproved

patients (ROC = 0.75 (0.68-0.82), 95% CI)

(Johnsen et al, 2013)

Adequate correlation between ODI and EQ5D baseline

scores (r = 0.58) and between ODI and SF6D baseline
scores (r = 0.38)

(Wittink et al, 2004)

Overlap of Multidimensional Personality Inventory (MPI) with the
ODI Instruments in R2 values

MPI

ODI

Pain severity

0.43

Interference

0.43

Life control

0.15

Affective distress

0.17

Support

0.005

Negative responses

0.03

Solicitous responses

0.03

Distracting responses

0.02

Household chores

0.11

Outdoor work

0.09

Activities away from home

0.22

Social activities

0.11

General activities

0.22

Overlap of SF36 Domains with the ODI Instruments in R2

values
SF-36 Domain

ODI

Physical functioning

0.51

Role physical

0.18

Bodily pain

0.37

General health

0.09

Vitality

0.16

Social functioning

0.32

Role emotional

0.10

Mental health

0.14

Construct Validity

Low Back Pain:

(Convergent/Discriminant)

(Frost et al, 2008)

Adequate correlation between transition rating index and

the ODI (version 2.1) (r = 0.47)

(Grotle et al, 2012)

Excellent correlation with: Pelvic Girdle Questionnaire

(PGQ) total (r = 0.75), PGQ Activity subscale (r = 0.72),
PGQ Symptom subscale (r = 0.71), Disability Rating Index
(r = 0.71), SF2 - Physical Functioning (r = 0.66)

Adequate correlation with: Fear-avoidance beliefs

questionnaire (r = 0.33), SF1 - General Health (r = 0.51),
SF3 - Role-physical (r = 0.54), SF4 - Bodily pain (r = 0.56),
SF6 - Social functioning (r = 0.52)

Poor correlation with: Pain catastrophizing scale (r = 0.26),

SF5 - Vitality (r = 0.07), SF7 - Mental Health (r = 0.12), SF8

- Role-emotional (r = 0.17)

Adequate discriminant validity between ODI and pain

localization (ROC = 0.726, 95% CI, 0.621 - 0.830, p =
0.015)

Poor discriminant validity between ODI and pregnancy

(ROC = 0.63, 95% CI, 0.535 - 0.769, p = 0.001)

(Haro et al, 2008; n = 42, age 66.8 (10.9); patients were surgical
patients followed for more than 2 years; surgical indications
included no response to conservative treatment and neurological
deterioration; neurological symptoms were classified as nerve root
type, cauda equine type or combined type; surgical interventions
included decompression at the location of the dural or root
indentation by myelography)

Excellent correlation between the visual analogue scale

(VAS) of low back pain with ODI V2, preoperation and
postoperation respectively (r = -0.71 and r = -0.75)

(Little and MacDonald et al, 1994; n = 144; patients had all received
lumbar spinal surgery to operatively manage various diagnosis such
as spinal canal stenosis, prolapsed intervertebral discs, low back
pain)

Excellent correlation between patients subjective

assessment of improvement postoperatively and change in
ODI (r = 0.61)

(Miekisiak et al, 2013)

Content Validity

Excellent correlation between the Polish ODI and RMDQ (r

= 0.607, p < 0.001)

Adequate correlation between VAS score for leg pain and

ODI (r = 0.56, p < 0.001)

Low back pain:

(Copay et al, 2008)

MDC was selected as the most appropriate MCID threshold

value by comparing potential MCID value calculations and
verifying with two different anchors (global health
assessment, the Health Transition Item, and rating of
satisfaction with the results of the surgery, the Satisfaction

Results Scale)

Not established

Face Validity
Floor/Ceiling Effects

Low back pain:

(Dawson et al, 2010)

Adequate floor effects (13% scored ODI = 0)

36% of student nurses scored less than MDC90, which is

outside of the recommended 15% maximum

(Frost et al, 2008)

Adequate floor effect with baseline data, with 16 (6%)

subjects scoring less than 8%, including 2 subjects who
scored 0

(Grotle et al, 2012)

Excellent, no floor or ceiling effects reported

(Little & MacDonald et al,1994)

Possible floor effect as researchers assumed that

participants that were worse did not feel comfortable to
admit it

(Miekisiak et al, 2013)

Responsiveness

Excellent, no floor or ceiling effects reported

Low back pain:

(Copay et al, 2008)

Small effect size (r = 0.11)

(Frost et al, 2008)

Large effect size for improved patients using the ODI scale,

-0.88 to -1.00, and worse patients, 0.77

Small effect size for unchanged patients using the ODI

scale, 0.007

Low Back Pain: SF-36 effect size to the ODI comparing

each domain, analyzing 81 patients during a 5-week period:

Physical functioning

0.27

Role physical

0.02

Bodily pain

0.44

General health

-0.05

Vitality

0.20

Social functioning

0.25

Role emotional

0.02

Mental health

0.09

(Johnsen et al, 2013)

Professional Association
Recommendations

Excellent correlation between change scores of ODI and

EQ5D (r = 0.64) and between changes scores of ODI and
SF6D (r = 0.77)

Excellent correlation between change scores of ODI and

global score categories (rho = 0.84) and between change
scores of SF6D and global score categories (rho = 0.76)

Adequate correlation between change scores of EQ5D and

global score categories (rho = 0.55)

Excellent discrimination between improved and nonimproved patients for ODI (ROC = 94% (87.5 - 97.6), CI =
95%) and for SF6D (ROC = 90% (82.1 - 94.6), CI = 95%)

Adequate discrimination between improved and nonimproved patients for EQ5D (ROC = 83% (75 - 90), CI =
95%)

Considerations

Lower back pain:

(Copay et al, 2008)

Patients with higher pain/disability and lower health at

baseline will demonstrate greater improvement in ODI score
after spine surgery

Patients who showed greater changes in ODI score after

spine surgery had lower disability and pain

(Dawson et al, 2010)

The ODI is not appropriate for studies of back pain in the

population of nursing students as ODI scores in nursing
populations cluster around the low range of the scale

ODI is limited in its ability to detect longitudinal reduction in

disability due to back pain in nurses with back injuries
because the scores are too low at baseline

(Fairbank and Pyrsent et al, 2000)

The American Academy of Orthoperdic Surgeons (AAOS)

and other spine societies adapted version 1.0 into their
spine outcome instruments, reflecting the American rather
than British usage. It omits sections 1, 8, and 9, and scores
the remaining sections from 1 - 6 instead of 0 - 5, which
leads to confusion when comparing scores obtained with
other versions

The revised ODI published in the UK in 1989 confuses

impairment with disability. 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.

Cancer studies have omitted Section 1 (Pain), which is

measured by other means

There exists versions of the measure in Danish, Dutch,

Finnish, French, German, Greek, Norwegian, Spanish and
Swedich, though these versions have not all been validated
individually

As handicap is extremely difficult to measure by

questionnaire, the ODI deliberately focuses on physical

activities and not the psychological consequences of acute
or chronic pain as determined by ODI discussion groups in
1991 and 1992
(Johnsen et al, 2013)

In comparison with the SF6d and the EQ5d, the ODI has
the highest sensitivity/specificity, and was the most accurate
at detecting change

(Little & MacDonald et al, 1994)

The change in DI can be utilized as an outcomes measure

for patients having lumbar spinal surgery (diagnostic and
surgical)

The percentage of change in the DI reliable, independent of

surgeon bias, and correlates with the patients subjective
assessment of improvement following lumbar spinal surgery

(Wittink et al, 2004)

Bibliography

ODI has lowest burden, is comprehensive in scope, and

easy to score, but more detailed information may be
obtained when using the Multidimensional Personality
Inventory (MPI) or the SF36

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Access to the Oswestry Disability Index

Link to instrument

The contents of this database were developed under a grant from the Department of Education, NIDRR
grant number H133B090024 (PI: Allen Heinemann, PhD). However, the content does not necessarily
represent the policy of the Department of Education, and you should not assume endorsement by the
Federal Government.
Developed by Rehabilitation Institute of Chicago, Center for Rehabilitation Outcomes Research, Northwestern
University Feinberg School of Medicine Department of Medical Social Sciences Informatics group.

2010 Rehabilitation Institute of Chicago

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