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 Index38 (ODI) and the Roland
Morris disability questionnaire122 (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 OBrien 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
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
tried. The questionnaire had been published in 198038
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 reference38), 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 al66 (with a scor-
ing system) and Boden6 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
Table 1.
ODI Version 1.0
This questionnaire has been designed to give the doctor
information as to how your back pain has affected
your ability to manage in every day life. Please
answer every section, and mark in each section only
the one box which applies to you. We realize you may
consider that two of the statements in any one
section relate to you, but please just mark the box
which most closely describes your problem.
Section 1Pain intensity
I can tolerate the pain I have without having to use
painkillers.
The pain is bad but I manage without taking painkillers.
Painkillers give complete relief from pain.
Painkillers give moderate relief from pain.
Painkillers give very little relief from pain.
Painkillers have no effect on the pain and I do not use
them.
Section 2Personal care (washing, dressing, etc.)
I can look after myself normally without causing extra
pain.
I can look after myself normally but it causes extra pain.
It is painful to look after myself and I am slow and
careful.
I need some help but manage most of my personal care.
I need help every day in most aspects of self-care.
I do not get dressed, wash with difficulty and stay in
bed.
Section 3Lifting
I can lift heavy weights without extra pain.
I can lift heavy weights but it gives extra pain.
Pain prevents me from lifting heavy weights off the floor,
but I can manage if they are conveniently positioned,
e.g. on a table.
Pain prevents me from lifting heavy weights but I can
manage light to medium weights if they are
conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.
ODI Version 2.0
Could you please complete this questionnaire
It is designed to give us information as to
how your back (or leg) trouble has affected
your ability to manage in everyday life.
Please answer every section. Mark one box
only in each section that most closely
describes you today.
Section 1Pain intensity
I have no pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the
moment.
Section 2Personal care (washing, dressing,
etc.)
I can look after myself normally without
causing extra pain.
I can look after myself normally but it is very
painful.
It is painful to look after myself and I am
slow and careful.
I need some help but manage most of my
personal care.
I need help every day in most aspects of self
care.
I do not get dressed, wash with difficulty and
stay in bed.
Section 3Lifting
I can lift heavy weights without extra pain.
I can lift heavy weights but it gives extra
pain.
Pain prevents me from lifting heavy weights
off the floor but I can manage if they are
conveniently positioned, e.g. on a table.
Pain prevents me from lifting heavy weights
but I can manage light to medium weights
if they are conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.
AAOS/MODEMS
In the past week, please tell us how pain has
affected your ability to perform the
following activities.
(Circle the one statement that best describes
your average ability.)
46. Getting dressed (in the past week).
I can dress myself without pain.
I can dress myself without increasing pain.
I can dress myself but pain increases.
I can dress myself but with significant pain.
I can dress myself but with very severe pain.
I cannot dress myself.
47. Lifting (in the past week).
I can lift heavy objects without pain.
I can lift heavy objects but it is painful.
Pain prevents me from lifting heavy objects
off the floor, but I can lift heavy objects if
they are on a table.
Pain prevents me from lifting heavy objects,
but I can lift light to medium objects if they
are on a table.
I can only lift light objects.
I cannot lift anything.
Chiropractic Revised Oswestry pain
questionnaire
Please read: This Questionnaire It is designed
to enable us to understand how much your
low back pain has affected your ability to
manage your everyday activities.
Section 1Pain intensity
The pain comes and goes and is very mild.
The pain is mild and does not vary much.
The pain comes and goes and is moderate.
The pain is moderate and does not vary
much.
The pain comes and goes and is severe.
The pain is severe and does not vary much.
Section 2Personal care
I would not have to change my way of
washing or dressing in order to avoid pain.
I do not normally change my way of washing
or dressing even though it causes some
pain.
Washing and dressing increase the pain but I
manage not to change my way of doing it.
Washing and dressing increase the pain and
I find it necessary to change my way of
doing it.
Because of the pain I am unable to do some
washing and dressing without help.
Because of the pain I am unable to do any
washing and dressing without help.
Section 3Lifting
I can lift heavy weights without extra pain.
I can lift heavy weights but it gives extra
pain.
Pain prevents me from lifting heavy weights
off the floor.
Pain prevents me from lifting heavy weights
off the floor but I can manage if they are
conveniently positioned, e.g. on a table.
Pain prevents me from lifting heavy weights
but I can manage light to medium weights
if they are conveniently positioned.
I can only lift very light weights at the most.
The Oswestry Disability Index Fairbank and Pynsent 2941
Table 1. Continued
ODI Version 1.0
Section 4Walking
Pain does not prevent my walking any distance.
Pain prevents me walking more than 1 mile.
Pain prevents me walking more than 1/2 mile.
Pain prevents me walking more than 1/4 mile.
I can only walk using a stick or crutches.
I am in bed most of the time and have to crawl to the
toilet.
Section 5Sitting
I can sit in any chair as long as I like.
I can sit in my favourite chair as long as I like.
Pain prevents me sitting more than 1 hour.
Pain prevents me from sitting more than 1/2 an hour.
Pain prevents me from sitting more than 10 minutes.
Pain prevents me from sitting at all.
Section 6Standing
I can stand as long as I want without extra pain.
I can stand as long as I want but it gives me extra pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 30
minutes.
Pain prevents me from standing for more than 10
minutes.
Pain prevents me from standing at all.
Section 7Sleeping
Pain does not prevent me from sleeping well.
I can sleep well only by using tablets.
Even when I take tablets I have less than 6 hours sleep.
Even when I take tablets I have less than 4 hours sleep.
Even when I take tablets I have less than 2 hours sleep.
Pain prevents me from sleeping at all.
ODI Version 2.0
Section 4Walking
Pain does not prevent me walking any
distance.
Pain prevents me walking more than 1 mile.
Pain prevents me walking more than than 1/2
of a mile.
Pain prevents me walking more than 100
yards.
I can only walk using a stick or crutches.
I am in bed most of the time and have to
crawl to the toilet.
Section 5Sitting
I can sit in any chair as long as I like.
I can sit in my favourite chair as long as I
like.
Pain prevents me from sitting for more than 1
hour.
Pain prevents me from sitting for more than
1/2 an hour.
Pain prevents me from sitting for more than
10 minutes.
Pain prevents me from sitting at all.
Section 6Standing
I can stand as long as I want without extra
pain.
I can stand as long as I want but it gives me
extra pain.
Pain prevents me from standing for more
than 1 hour.
Pain prevents me from standing for more
than 1/2 an hour.
Pain prevents me from standing for more
than 10 minutes.
Pain prevents me from standing at all.
Section 7Sleeping
My sleep is never disturbed by pain.
My sleep is occasionally disturbed by pain.
Because of pain I have less than 6 hours
sleep.
Because of pain I have less than 4 hours
sleep.
Because of pain I have less than 2 hours
sleep.
Pain prevents me from sleeping at all.
AAOS/MODEMS
48. Walking and Running (in the past week).
I can run or walk without pain.
I can walk comfortably, but running is painful.
Pain prevents me from walking more than 1
hour.
Pain prevents me from walking more than 30
minutes.
Pain prevents me from walking more than 10
minutes.
I am unable to walk or can walk only a few
steps at a time.
49. Sitting (in the past week).
I can sit in any chair as long as I like.
I can only sit in a special chair as long as I
like.
Pain prevents me from sitting more than 1
hour.
Pain prevents me from sitting more than 30
minutes.
Pain prevents me from sitting more than 10
minutes.
Pain prevents me from sitting at all.
50. Standing (in the past week).
I can stand as long as I want.
I can stand as long as I want but it gives me
pain.
Pain prevents me from standing more than 1
hour.
Pain prevents me from standing for more
than 30 minutes.
Pain prevents me from standing for more
than 10 minutes.
Pain prevents me from standing at all.
51. Sleeping (in the past week).
I sleep well.
Pain occasionally interrupts my sleep.
Pain interrupts my sleep half of the time.
Pain often interrupts my sleep.
Pain always interrupts my sleep.
I never sleep well.
Chiropractic Revised Oswestry pain
questionnaire
Section 4Walking
I have no pain on walking.
I have some pain with walking but it does not
increase with distance.
I cannot walk more than One Mile without
increasing pain.
I cannot walk more than 1/2 Mile without
increasing pain.
I cannot walk more than 1/4 Mile without
increasing pain.
I cannot walk at all without increasing pain.
Section 5Sitting
I can sit in any chair as long as I like.
I can sit only in my favourite chair as long as
I like.
2942 Spine Volume 25 Number 22 2000
Pain prevents me from sitting for more than
one hour.
Pain prevents me from sitting for more than
1/2 hour.
Pain prevents me from sitting for more than
10 minutes.
I avoid sitting because it increases pain
straight away.
Section 6Standing
I can stand as long as I want without pain.
I have some pain on standing but it does not
increase with time.
I cannot stand for longer than one hour
without increasing pain.
I cannot stand for longer than 1/2 hour
without increasing pain.
I cannot stand for longer than 10 minutes
without increasing pain.
I avoid standing because it increases pain
straight away.
Section 7Sleeping
I get no pain in bed.
I get pain in bed but it does not prevent me
from sleeping well.
Because of pain my normal nights sleep is
reduced by less than 1/4.
Because of pain my normal nights sleep is
reduced by less than 1/2.
Because of pain my normal nights sleep is
reduced by less than 3/4.
Pain prevents (me) from sleeping at all.
Table 1. Continued
ODI Version 1.0
Section 8Sex life
My sex life is normal and causes no extra pain.
My sex life is normal but causes some extra pain.
My sex life is nearly normal but is very painful.
My sex life is severely restricted by pain.
My sex life is nearly absent because of pain.
Pain prevents any sex life at all.
Section 9Social life
My social life is normal and gives me no extra pain.
My social life is normal but increases the degree of
pain.
Pain has no significant effect on my social life apart
from limiting my more energetic interests, e.g.
dancing, etc.
Pain has restricted my social life and I do not go out as
often.
Pain has restricted social life to my home.
I have no social life because of pain.
Section 10Travelling
I can travel anywhere without extra pain.
I can travel anywhere but it gives me extra pain.
Pain is bad but I manage journeys over two hours.
Pain restricts me to journeys of less than one hour.
Pain restricts me to short necessary journeys under 30
minutes.
Pain prevents travel except to the doctor or hospital.
ODI Version 2.0
Section 8Sex life (if applicable)
My sex life is normal and causes no extra
pain.
My sex life is normal but causes some extra
pain.
My sex life is nearly normal but is very
painful.
My sex life is severely restricted by pain.
My sex life is nearly absent because of pain.
Pain prevents any sex life at all.
Section 9Social life
My social life is normal and causes me no
extra pain.
My social life is normal but increases the
degree of pain.
Pain has no significant effect on my social
life apart from limiting my more energetic
interests, e.g. sport, etc.
Pain has restricted my social life and I do not
go out as often.
Pain has restricted social life to my home.
I have no social life because of pain.
Section 10Travelling
I can travel anywhere without pain.
I can travel anywhere but it gives extra pain.
Pain is bad but I manage journeys over two
hours.
Pain restricts me to journeys of less than one
hour.
Pain restricts me to short necessary journeys
under 30 minutes.
Pain prevents me from travelling except to
receive treatment.
AAOS/MODEMS
52. Travelling (in the past week):
I can travel anywhere.
I can travel anywhere but it gives me pain.
Pain is bad but I can manage to travel over
two hours.
Pain restricts me to journeys of less than one
hour.
Pain restricts me to trips less than 30
minutes.
Pain prevents me from travelling.
Chiropractic Revised Oswestry pain
questionnaire
Section 8Social life
My social life is normal and gives me no
pain.
My social life is normal but increases the
degree of my pain.
Pain has no significant effect on my social
life apart from limiting my more energetic
interests, e.g. dancing, etc.
Pain has restricted my social life and I do not
go out very often.
Pain has restricted social life to my home.
I have hardly any social life because of the
pain.
Section 9Travelling
I get no pain whilst travelling.
I get some pain whilst travelling but none of
my usual sorts of travel make it any worse.
I get extra pain whilst travelling but it does
not compel me to seek alternative forms of
travel.
I get extra pain whilst travelling which
compels me to seek alternative forms of
travel.
Pain restricts all forms of travel.
Pain prevents all forms of travel except that
done lying down.
Section 10Changing degree of pain
My pain is rapidly getting better.
My pain fluctuates but overall is definitely
getting better.
My pain seems to be getting better but
improvement is slow at present.
My pain is neither getting better or worse.
My pain is gradually worsening.
My pain is rapidly worsening.
The Oswestry Disability Index Fairbank and Pynsent 2943
2944 Spine Volume 25 Number 22 2000
Table 2.
Language Citation(s)
Danish 15, 100, 99, 162
Dutch 162
Finnish 67, 69, 52, 51, 81, 54, 77, 82, 78, 5860,
65, 85, 95, 96, 147149, 53, 63, 64, 66,
79, 80, 68, 76, 83
133135, 169, 98, 73, 72, 163
French 35, 162
86, 101
German 3, 108, 165
9, 16, 164
Greek 7 NASS in 1998 a series of 25 spinal fusion patients with a
Norwegian 36, 48, 47, 132, 150
Spanish 84
Swedish 130, 128, 129
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-
sis114 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
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 0; if the last statement is marked
it 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) 100
32%.
If one section is missed (or not applicable) the score is calculated:
Example: 16 (total scored)/45 (total possible score) 100 35.6%.
So the final score may be summarized as:
(total score/(5 number of questions answered)) 100%.
It is suggested rounding the percentage to a whole number for
convenience.
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
Group44 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
preoperative ODI score of 18.7 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 1991146 and 199261 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 authors
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 al4 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 al75 reported an effect
size of only 0.07. Fisher and Johnson40 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).
TestRetest. In the original study patients with chronic
low back pain were tested twice at a 24-hour interval
(n 22, r 0.99).38 This may include a memory effect.
If the testretest interval is extended to 4 days, the cor-
relation of scores decreases to n 22, r 0.9175 and, if
retested after a week, n 22, r 0.83.51 The disadvan-
 The Oswestry Disability Index Fairbank and Pynsent 2945

Table 4.
Wt Mean Sources Not
Category Total No. No. of Groups ODI Score S.D. Range F Sources Used Used

Normal populations 461 4 10.19 2.212 0.37 103, 65, 63, 66, 73, 72 24

Pelvic fractures 31 1 13.26 15.4 56

Idiopathic scoliosis 1264 5 13.81 9.213 0.03 44, 103

Neck pain 56 1 21 9.7 169

Spondylolisthesis 120 5 26.63 6.116 1.76 111, 133135, 147

Primary back pain 2166 21 27 5.823.6 0.33 45, 106, 151, 105, 65, 7 98
4, 63, 66, 73, 93, 130, 72, 94,
128, 129

Psychiatric patients 75 1 30.8 21.5 166

Neurogenic claudication 82 2 36.65 1718 0.14 5860 24

Chronic back pain 1530 25 43.3 1021 0.02 131, 30, 52, 54, 90, 3133, 53
119, 14, 152, 81, 134, 77, 82,
135, 137, 153, 154, 11, 78,
97, 158, 8, 10, 147149, 155,
159, 161, 79, 80, 157, 156,
12, 76, 83, 160

PID/Sciatica 663 9 44.65 10.530.1 0.16 31, 32, 48, 33, 47, 13, 50, 150 81, 77, 82, 7880,
132, 145, 76, 83

Fibromyalgia 192 4 44.83 14.218.9 0.07 152154, 158, 155, 159, 161,
157, 156, 160

Metastases 100 2 48.04 18.123 0.04 115, 162

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 183, r 0.89).1

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.
2946 Spine Volume 25 Number 22 2000
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 al142 using a time frame of a week. Patients prefer the
format in which they are asked for symptoms now.24
Internal Consistency. Cronbachs is a measure of all the
various components of a questionnaire moving together.
Strong et al141 (using version 1.0) found Cronbachs to
be 0.71, Fisher and Johnson40 (using version 2.0) 0.76,
and Kopec et al75 0.87. All these investigations show an
acceptable degree of internal consistency. In the original
study38 and the 1989 study1 the current authors found
that all the sections tended to move with Section 1 (pain
scale) although Fisher and Johnson40 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 (n 94, r 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
ODI54 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 projects17,23,43,55,59 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 MacDonald92 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 81100%). 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
Meade107 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 RolandMorris
Scores
The ODI has been directly compared with R-M in several
studies.1,88,89 The two scales correlate (n 500,
0.77).7 The scatter chart from Baker et al1 (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
 The Oswestry Disability Index Fairbank and Pynsent 2947

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.

index (D) 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 26.2 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
MaleFemale 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 painfree 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, 2.212; 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 Coupers 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 33,70,93,94,113,152161
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-

Table 5.
Weighted Mean Sample Number of
Group Difference Presample Postsample S.D. Range F Groups Sources

Spinal metastases 9 34 34 17.418.1 1 115

Sciatica with p.i.d. 15.1 330 330 10.517.2 0.58 4 48, 47, 150
Chronic back pain 15.4 793 702 10.026.0 0.02 12 131, 31, 126, 32, 50, 80,
138, 14, 97, 149, 147, 148,
12, 11, 10
Spondylolisthesis 14.4 51 51 14.020.1 1 133
Primary back pain 25.5 168 168 9.614.8 0.004 2 89
2948 Spine Volume 25 Number 22 2000

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.

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.
 The Oswestry Disability Index Fairbank and Pynsent 2949

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
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.

Self-report questionnaires have been better than so- Conclusions

called objective measures, such as range of movement
The ODI remains a valid and vigorous measure of con-
and various measures of functional capacity, in achieving
dition-specific disability. The authors recommend the
this. This has meant that some of self-report disability
use of version 2.0. The data presented are a guide to the
scores have become, in their own right, a dimension of
power of the instrument to detect meaningful changes in
disability, in the same way that the Glasgow Coma Scale
disability status. More work is needed in this area. The
has become a measure of head injury status in its own
ROCs of the curve should be explored in populations
right.144 It is not possible to define the mathematical
with higher self-report disabilities. More studies are
behavior of these scales, although many investigators
needed to explore the response to change in an individ-
have used them as if they behave in a linear fashion. The
ual. The work started by the Ste. Justine group in extract-
collation of scores from different diagnostic groups re-
ing more information from disability instruments should
corded in different cultures speaks for the robustness of
be developed in more disabled populations than those
this concept.
with idiopathic scoliosis. The statisticians of the Ste. Jus-
In spite of the inadequacies of physical measures, the
tine Group have argued that additional information can
authors do not believe that such measures should be
be obtained by disaggregating the score and using so-
abandoned as outcome measures, because they may well
phisticated statistical techniques.103,127
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- Key Points
iotherapy study,42 in patients with neurogenic claudica-
The ODI has been published in at least four for-
tion,24 and, currently, in the Spine Stabilization Trial.41
Further work is needed to optimize physical measures mats in English and in nine other languages. The
and the correlation of responses with the questionnaires. four versions in English are presented in full.
The authors recommend the use of version 2.0.
Because so many researchers have recommended the
The ODI has stood the test of time and many
use of the ODI, it is important that the structure and the
reviews. It is usable in a wide variety of applica-
scoring systems be adhered to. This opens the possibili-
tions as a condition-specific outcome measure of
ties of aggregating the results of studies and comparing
spine-related disability.
outcomes. Doubtless, scales will evolve in the future, and
Results of a meta-analysis show variations in es-
new ones will be presented. However, the authors believe
timated population means of ODI scores for differ-
that until a method is developed that is clearly superior,
ent spinal diseases and changes after treatment
the ODI, the R-M, or both should be used as condition-
consistent with clinical experience.
specific outcome measures in studies of patients with
back pain.
2950 Spine Volume 25 Number 22 2000
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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. Fairbanks seminal piece
from 19802 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.
The Oswestry Disability Index Fairbank and Pynsent 2953
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 Newell5: 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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