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 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 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 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

Table 1. ODI Version 1.0 ODI Version 2.0 AAOS/MODEMS Chiropractic ���Revised Oswestry pain questionnaire��� 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. 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 . 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.) 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 1 ���Pain 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 1 ���Pain 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 1 ���Pain 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 2 ���Personal 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 2 ���Personal 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. 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. Section 2 ���Personal 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 3 ���Lifting 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. Section 3 ���Lifting 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. 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. Section 3 ���Lifting 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. 2941 The Oswestry Disability Index ��� Fairbank and Pynsent