SPINE Volume 30, Number 5, pp E123E127

2005, Lippincott Williams & Wilkins, Inc.

Validation of the Korean Version of the Oswestry

Disability Index
Dong-Yun Kim, MD,* Sang-Ho Lee, MD, PhD,* Ho-Yeon Lee, MD, PhD,*
Hyun-Ju Lee, RN,* Sang-Beom Chang, MD, Sang-Ki Chung, MD, and
Hyun-Jib Kim, MD, PhD

Study Design. Validation of a translated, culturally

adapted questionnaire.
Objectives. To translate and culturally adapt a Korean
version of the Oswestry Disability Index (ODI) and to validate its use in Korean patients.
Summary of Background Data. The ODI is one of the
most widely used and validated instruments for measuring disability in spinal disorders. However, no validated
Korean version of the index was available at the time our
study was initiated.
Methods. The study was carried out in three phases:
the first was translation into Korean and cultural adaptation of the questionnaire; the second was a pilot study to
assess the comprehensibility of the prefinal version and
modification; the third was a reliability and validity study of
the final version. The Korean version was tested on 206
patients with lumbar spinal disorders who had undergone
operations at the authors institute. Test-retest reliability,
internal consistency, concurrent validity, and construct validity were investigated. Follow-up questionnaires were obtained from 39 patients at the 3-month postoperative follow-up meeting. Differences in the ODI, visual analog scale
(VAS), and World Health Organization (WHO) quality of life
assessment (WHOQOL-BREF) between preoperative and
follow-up questionnaires were evaluated. The correlation of
the postoperative ODI with the pain rating on a visual analog scale and WHOQOL-BREF was also analyzed.
Results. Test-retest reliability was assessed with 88
patients in a time interval of 48 hours. The intraclass
correlation coefficient of test-retest reliability was 0.9167.
Reliability estimated by the internal consistency reached
a Cronbachs alpha of 0.84. The correlation of the preoperative ODI with the pain rating on a visual analog scale
(100 mm) was r 0.425 (P 0.0001). The correlation
between three of the WHOQOL-BREF domains (physical
health, psychological health, and environment) and the
ODI was statistically significant. The correlation coefficient between the ODI and physical health domain of the
WHOQOL-BREF was r 0.48 (P 0.05). The correlations with psychological health and environment do-

From the *Department of Neurosurgery and Department of Orthopedic Surgery, Wooridul Spine Hospital, Seoul, Korea, and the Department of Neurosurgery, Seoul National University Bundang Hospital,
Acknowledgment date: December 8, 2003. First revision date: June 21,
2004. Acceptance date: July 20, 2004.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Hyun-Jib Kim, MD,
PhD, Department of Neurosurgery Seoul National University, Bundang Hospital 300 Gumi-Dong Bundang-Gu, Seongnam, Gyeonggi,
Korea; E-mail: jibkim@snu.ac.kr

mains were low with r 0.192 and 0.160, respectively,

even though statistically significant (P 0.05). The correlation of the postoperative ODI with the pain rating on a visual
analog scale (100 mm) was r 0.626 (P 0.0001). The
correlation between all four domains of the WHOQOL-BREF
and the postoperative ODI was statistically significant.
Conclusions. The results of this study indicate that the
Korean version of the ODI is a reliable and valid instrument
for the measurement of disability in Korean patients with
lower back problems. The authors recommend this Korean
version of the ODI for use in future clinical studies in Korea.
Key words: Oswestry Disability Index, reliability, validity. Spine 2005;30:E123E127

Condition-specific health status measures are commonly

used as outcome measures in clinical trials and to assess
patient progress in routine clinical practice. The Oswestry Disability Index (ODI) has emerged as one of the
most commonly recommended condition-specific outcome measures for spinal disorders.13 The ODI, developed
by Fairbank et al, consists of 10 items that assess the level of
pain and interference with several physical activities.2 The
index was designed as a measure for assessment of the baseline disability and its change over time. Various drafts of the
questionnaire have been conceived. Version 1.0 of the questionnaire was published in 1980, while the subsequently
released Version 2.0 improved on the original concept and
was validated in a study by a Medical Research Council
group in the United Kingdom.4 Version 2.0 is recommended for general use by the authors.4
With the increase in the number of multinational and
multicultural research projects, the need to adapt health
status measures for use in other than the source language
has grown rapidly. ODI has been translated into a number
of languages, such as Danish, Dutch, French, German,
Spanish, and Swedish.3,4 However, before our efforts, no
Korean version of the ODI had been validated. It has been
established that a scale or questionnaire cannot be transposed directly from one social environment to another
without being revalidated for new, culture-specific conditions.5 Thus, the objectives of this study were twofold: to
translate into the Korean language a culturally adapted version of the ODI, and to then validate it in Korean patients.
Methods
The study was carried out in three phases: the first was translation into Korean and cultural adaptation of the questionnaire; the second was a pilot study to assess the comprehensibility of the prefinal version and modification; the third was a
reliability and validity study of the final version.
E123

E124 Spine Volume 30 Number 5 2005

Translation and Cultural Adaptation. The authors translated
and validated the ODI version 2.0. Two translations were obtained; one performed by a professional translator and one by
a physician. The translators were bilingual native speakers of
Korean. The professional translator was not informed of the
purpose of the interpretation, nor of the cross-cultural concepts
involved in the index. The two translators were instructed to
aim for conceptual rather than literal translation. Synthesis of
the translations was conducted by an expert committee, which
consisted of two translators, a neurosurgeon, an orthopedic
surgeon, and a methodologist. Consensus regarding the Korean wording was reached by discussion.
The committee agreed on numerous initial modifications of
the translations. For example, with regard to Section 4 (walking) of the ODI, walking distances described in terms of miles
or yards would be unfamiliar to the majority of Koreans. Distances quoted in miles or yards (e.g., 1 mile, 1/2 mile,
100 yards) were converted to kilometers or meters, which
are the familiar method of distance measurement to Koreans
(respectively: 1 km, 500 m, 100 m). Further, the term social
life in Section 9 (social life), when loosely translated, has a few
quite different meanings in Korean, so this word required supplementary wording such as get-together, social gathering.
Moreover, in Section 10 (traveling), the term traveling usually strictly means a tour for pleasure or business trip in
Korean. Therefore, the supplementary term transportation
was added for clarity.
Pilot Study and Modification of the Prefinal Version. Prefinal
translation was tested by 50 subjects with low back pain to
establish that this version could be understood and that the
questions measured what they were intended to measure. The
50 patients included 25 men and 25 women with a mean age of
42 years (range: 22 67 years). The interviewer was asked to
document any problems that occurred during administration of
the questionnaire. Each patient was asked to provide comments about the questionnaire and identify any words that
were difficult to understand at the end of the interview. On the
basis of their comments, the final version was developed by the
committee (see Appendix). Most of the 50 patients correctly
understood the questionnaire. However, only 21 patients
(42%) answered Section 8 (pertaining to details of their sex life)
of the ODI. In addition, some patients complained they were
embarrassed by this section, especially when they were given
the questionnaire in front of family members. The committee
decided to omit Section 8 (sex life) from the final version of the
Korean version of ODI to make questionnaire administration
smoother and less compounded by the lower response rate of this
section. Six patients expressed concern about the exact meaning of
the question in Section 9 (pertaining to social life). Supplementary
terms hobby and leisure activity were thus added.
Reliability and Validity Study. The study was carried out with
the final version of the questionnaire, on 206 patients with
lumbar spinal disorders who had undergone operations at the
authors institute. The patients were given the Korean version
of the ODI on the day they consulted their physician. Eightyeight patients, who were available with 48 hours time interval,
were asked to complete a second questionnaire to assess test-retest
reliability before surgery. Each time, they were also given the Korean versions of the visual analog scale (100 mm) for pain, and a
short form of the World Health Organization (WHO) quality of
life assessment (WHOQOL-BREF). At the time of the 3-month

Table 1. WHOQOL-BREF Domains (From World Health

Organization, with permission)
Domain
1. Physical health

2. Psychological

3. Social relationships
4. Environment

Facets Incorporated Within Domains

Activities of daily living
Dependence on medicinal substances and
medical aids
Energy and fatigue
Mobility
Pain and discomfort
Sleep and rest
Work Capacity
Bodily image and appearance
Negative feelings
Positive feelings
Self-esteem
Spirituality/Religion/Personal beliefs
Thinking, learning, memory and
concentration
Personal relationships
Social support
Sexual activity
Financial resources
Freedom, physical safety and security
Health and social care: accessibility and
quality
Home environment
Opportunities for acquiring new
information and skills
Participation in and opportunities for
recreation/leisure activities
Physical environment
(pollution/noise/traffic/climate)
Transport

postoperative follow-up, the patients were given the same questionnaire that they had been given before surgery.
WHOQOL-BREF is a quality of life assessment tool developed by WHOQOL group and available in 19 different languages, including Korean. It consists of 26 questions and yields
four domain scores that denote an individuals perception of
quality of life in each particular domain (Table 1).6,7 The four
domains include physical health, psychological health, social
relationships, and environment. Higher scores denote a higher
quality of life.
Test-retest reliability was measured by comparing the results of the first and second administration of ODI. Reliability
was assessed with intraclass correlation coefficient. Cronbachs
alpha was used to evaluate internal consistency. Concurrent
validity is the comparison of two measures done at the same
time. Concurrent validity was measured by comparing the responses to the ODI with the results of the visual analog scale
(VAS). Construct validity is the extent to which the measurement corresponds to theoretical concepts concerning the phenomenon under study. To test the construct validity, a strong
correlation between the ODI and the quality of life measured
by the WHOQOL-BREF was hypothesized.
Follow-up questionnaires were obtained from 39 patients at
the 3-month postoperative follow-up meeting. Differences in
the ODI, VAS, and WHOQOL-BREF between preoperative
and follow-up questionnaires were evaluated. The correlation
of the postoperative ODI with the pain rating on a visual analog scale and WHOQOL-BREF was also analyzed.

Results
Table 2 contains sex, age, educational, and occupational
level of the study subjects. The study enrolled 206 pa-

Korean Version of the Oswestry Disability Index Kim et al E125

Table 2. Demographic Data

N
Age*
Sex
Male
Female
Education
None
Elementary school
Middle school
High school
University
Profession
Blue collar
Intermediary level
White collar
Retired
Housewife
Others
NA

Table 3. Pearsons Correlation Coefficients of the ODI

with 4 domains of the WHOQOL-BREF

Pilot Study Group

Validation Study Group

50
42 (14.5)

206
46 (14.8)

25 (50)
25 (50)

131 (64)
75 (36)

2 (4)
8 (16)
9 (18)
15 (30)
16 (32)

5 (2)
48 (23)
31 (15)
64 (31)
58 (28)

9 (18)
8 (16)
9 (18)
3 (6)
9 (18)
10 (20)
2 (4)

34 (17)
31 (15)
25 (12)
11 (5)
32 (16)
25 (12)
48 (23)

* Mean (Standard deviation).

Others includes: students, those on disability, and unemployed.
Not available.
Values in parentheses are percentages.

tients with lumbar spinal disorders who had undergone

operations at the authors institute. The mean age of the
patients was 46 years (standard deviation 15), and the
study group comprised 131 men and 75 women. Their
diagnoses were lumbar disc herniation (146 patients),
lumbar stenosis (28 patients), degenerative spondylolisthesis (9 patients), isthmic spondylolisthesis (13 patients), and discogenic back pain (10 patients). The performed operations were microscopic discectomy in 90
patients (43.7%), percutaneous endoscopic discectomy
in 56 patients (27.2%), transforaminal lumbar interbody
fusion with pedicle screw fixation in 16 patients (7.8%),
anterior lumbar interbody fusion with pedicle screw fixation in 11 patients (5.3%), artificial disc replacement in
4 patients (1.9%), intradiscal electrothermal therapy in 6
patients (2.9%), and decompressive laminectomy in 23
patients (11.2%).
Reliability estimated by the internal consistency
reached a Cronbachs alpha of 0.84. Test-retest reliability was assessed with 88 patients on two occasions separated by a time interval of 48 hours. There was no
statistically significant difference in sex, education, occupation, diagnosis, and operation method between the
group completing the retest (88 patients) and those who did
not (118 patients). Mean age was 42 years (SD 14.5) in
the retest group and 48.8 years (SD 14.4) in the group
without retest. Difference in age was statistically significant
(P 0.001, Students t test). The intraclass correlation coefficient of test-retest reliability was 0.9167.
Concurrent validity was measured by comparing the
responses to the ODI with the results of the visual analog
scale. The correlation of the preoperative ODI with the
pain rating on a visual analog scale (100 mm) was r
0.425 (P 0.0001).
In determining construct validity, a correlation between the ODI and WHOQOL-BREF was hypothesized.

Preoperative ODI
(n 206)
Domains
Physical health
Psychological
Social relationships
Environment

Postoperative ODI
(n 39)

Correlation

Correlation

0.480
0.192
0.090
0.160

0.0001
0.006
0.199
0.022

0.510
0.569
0.366
0.364

0.001
0.0001
0.028
0.025

Table 3 summarizes the correlation between four domains of the WHOQOL-BREF and ODI. The correlation between three of the WHOQOL-BREF domains
(physical health, psychological health, and environment)
and the ODI was statistically significant. The correlation
coefficient between the ODI and physical health domain
of the WHOQOL-BREF was r 0.48 (P 0.05). The
correlations with psychological health and environment
domains were low with r 0.192 and 0.160, respectively, even though statistically significant (P 0.05).
Follow-up questionnaires were obtained from 39 patients at the 3-month postoperative follow-up meeting.
Statistically significant improvement was observed in the
ODI, VAS, and physical health domain of the WHOQOL-BREF (Table 4). The ODI score was improved
from 41.7 (SD 17.5) to 18.4 (SD 13.3). The visual
analog scale showed a decrease from 7.2 (SD 2.1) to
2.4 (SD 1.9). The physical health domain of the WHOQOL-BREF showed improvement, increasing from 10.3
(SD 2.7) to 13.2 (SD 2.4). The correlation of the
postoperative ODI with the pain rating on a visual analog scale (100 mm) was r 0.626 (P 0.0001). The
correlation between all four domains of the WHOQOLBREF and the postoperative ODI was statistically significant (Table 3).
Discussion
The results of this study indicate that the Korean version
of the ODI is a reliable and valid instrument for the
measurement of disability in Korean patients with lower
back problems. The Korean version of the ODI showed
similar results to those presented in the original ODI
English version with test-retest reliability,2,8,9 internal
Table 4. Descriptive Data of ODI, VAS, and
WHOQOL-BREF

ODI
VAS
WHOQOL-BREF
Physical health
Psychological
Social relationships
Environment
*Paired t test.
Not significant.

Preoperative

Postoperative

41.7 ( 17.5)
7.2 ( 2.1)

18.4 ( 13.3)
2.4 ( 1.9)

0.0001*
0.0001*

10.3 ( 2.7)
12.7 ( 2.0)
13.4 ( 2.2)
11.4 ( 2.1)

13.2 ( 2.4)
12.8 ( 2.7)
13.5 ( 2.4)
11.9 ( 2.6)

0.0001*
NS
NS
NS

E126 Spine Volume 30 Number 5 2005

consistency,2,9 11 and correlation with a visual analog

scale.8 Although there has not been any comparable
study, significant correlation was found between the
WHOQOL-BREF, especially in the physical health domain, and the Korean version of the ODI. Correlation
between the Korean version of the ODI and VAS and
WHOQOL-BREF was also significant in postoperative
follow-up questionnaires.
The sex life question in Section 8 was omitted in this
Korean version of the ODI. This question is unacceptable in some cultures, and has been omitted in certain
studies.1215 Fujiwara et al reported low response rate
(60%) to the sex life question in Japan in their validation
study of Japanese version of the ODI, although they did
not omit the sex question from the Japanese version of
the ODI.16 We omitted Section 8 (sex life) from the final
version of the Korean version of ODI to make questionnaire administration smoother and less compounded by
the lower response rate of this section. Although the ODI
was developed originally as a self-administered questionnaire, the administration of the ODI by telephone interview has been reported.17,18 Regardless, in Korean culture it remains quite difficult to ask questions related to
the sex life of the interviewee.
To the authors knowledge, this Korean version of the
ODI is the first condition specific outcome instrument for
spinal disorders to have been validated in Korean. Development and validation of multiple-language versions
of existing validated questionnaires plays a key role in
standardizing the outcome measurement and increasing
the statistical power of clinical studies. The results of this
study demonstrated that the ODI was successfully crossculturally translated into Korean without losing the psychometric properties of the original versions. Therefore,
this Korean version of the ODI seems to be a reliable and
valid outcome measure for assessing functional status of
patients with spinal disorders. The use of this Korean
version of the ODI can be recommended in future clinical
studies in Korea.
Key Points:
The Oswestry Disability Index was crossculturally translated into Korean and validated.
The Korean version of the Oswestry Disability
Index had acceptable reproducibility, concurrent
validity, and construct validity.
The results of this study indicate that the Korean
version of the ODI is a reliable, valid instrument for
the measurement of disability in Korean patients
with lower back problems.

Acknowledgments
The documentation of translation, back translation, and
the results of the reliability and validity study were reported to the original developer, Dr. Jeremy Fairbank.
The authors thank Dr. Jeremy Fairbank for granting permission to translate the Oswestry Disability Index into
Korean and appraisal of this Korean version of the ODI.
The authors are also grateful to In-Kyung Cho, Hye-Ran
Lee, In-Sook Cho, and Jihee Hwang for their invaluable
assistance on this project.

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Korean Version of the Oswestry Disability Index Kim et al E127

Appendix