Measurement Properties of the Neck
Disability Index: A Systematic Review
Downloaded from www.jospt.org at University of Washington on December 1, 2014. For personal use only. No other uses without permission.

t is estimated that a third of all adults will experience neck pain However, the episodic, fluctuating nature

I during the course of 1 year,12 and 70% is the approximate lifetime
prevalence.6,28 About 19% of the population may suffer from chronic
neck pain at any given time,6 creating a substantial societal burden.
Monitoring outcomes is a key component of monitoring the effects of
evidence-based care, in justifying services, and in program evaluation.
of neck pain and the lack of clear and con-
sistent physiological findings complicate
this process. A fundamental component
of monitoring outcomes is having reliable
and valid tools with known measurement
properties.27 In the case of neck disorders,
self-reported pain and disability are usu-
TIJK:O:;I?=D0 Systematic review of clinical group differences or absolute reliability (standard ally the primary focus.
measurement. error of measurement [SEM] or minimum detect- Isolated studies on outcomes mea-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

TE8@;9J?L;0 To find and synthesize evidence
able change [MDC]). Most studies suggest that the sures provide a context and method-
NDI has acceptable reliability, although intraclass specific view of the measure’s ability to
on the psychometric properties and usefulness of
correlation coefficients (ICCs) range from 0.50 to
the neck disability index (NDI). provide useful clinical information. It is
0.98. Longer test intervals and the definition of sta-
T879A=HEKD:0 The NDI is the most commonly ble can influence reliability estimates. A number
only by synthesizing information from
used outcome measure for neck pain, and a of high-quality published (Korean, Dutch, Spanish, multiple studies that we can understand
synthesis of knowledge should provide a deeper French, Brazilian Portuguese) and commercially how a measurement tool performs across
understanding of its use and limitations. supported translations are available. The NDI is different contexts and applications. The
TC;J>E:I7D:C;7IKH;I0 Using a standard considered a 1-dimensional measure that can be synthesis of larger pools of data is a mech-
search strategy (1966 to September 2008) and interpreted as an interval scale. Some studies
anism to provide more stable estimates of
question these assumptions. The MDC is around
Journal of Orthopaedic & Sports Physical Therapy®

4 databases (Medline, CINAHL, Embase, and
5/50 for uncomplicated neck pain and up to 10/50 measurement errors and benchmarks for
PsychInfo), a structured search was conducted
and supplemented by web and hand searching. In for cervical radiculopathy. The reported clinically change/outcomes. In fact, 2 systematic
total, 37 published primary studies, 3 reviews, and important difference (CID) is inconsistent across reviews have been conducted that ad-
1 in-press paper were analyzed. Pairs of raters con- different studies ranging from 5/50 to 19/50. The dress self-report measures for neck pain.
ducted data extraction and critical appraisal using NDI is strongly correlated (0.70) to a number
Both compared different outcome mea-
structured tools. Ranking of quality and descriptive of similar indices and moderately related to both
physical and mental aspects of general health. sures using a semistructured process and
synthesis were performed.
concluded that the Neck Disability Index
TH;IKBJI0 Horizon estimation suggested the T9ED9BKI?ED0 The NDI has sufficient support
and usefulness to retain its current status as the (NDI) was the most commonly used self-
potential for 1 missed paper. The agreement
most commonly used self-report measure for report instrument for evaluating status
between raters on quality assessments was high
(kappa = 0.82). Half of the studies reached a qual- neck pain. More studies of CID in different clinical in neck pain clinical research.34,37 Both
ity level greater than 70%. Failures to report clear populations and the relationship to subjective/ reviews alluded to the psychometric and
work/function categories are required. J Orthop
psychometric objectives/hypotheses or to rational- clinical properties of the tools, but neither
ize the sample size were the most common design Sports Phys Ther 2009;39(5):400-417. doi:10.2519/
jospt.2009.2930 attempted to deal with specific properties
flaws. Studies often focused on less clinically
or to synthesize this knowledge. The de-
applicable properties, like construct validity or TA;OMEH:I0 cervical spine, outcome measure,
group reliability, than transferable data, like known reliability, validity veloper of the NDI published a summary
paper in 2008 summarizing a 17-year his-

Co-director, Hand and Upper Limb Centre Clinical Research Laboratory, St Joseph’s Health Centre, London, ON, Canada; Associate Professor, School of Rehabilitation Science,
McMaster University, Hamilton, ON, Canada; Funded by a New Investigator Award, Canadian Institutes of Health Research. 2 Lecturer and PhD Candidate, School of Physical
Therapy, The University of Western Ontario, London, ON, Canada; Funded by a Doctoral Fellowship, Canadian Institutes of Health Research. 3 Physiotherapy Student, School of
Physical Therapy, The University of Western Ontario, London, ON, Canada. 4 Emeritus Professor, Department of Clinical Epidemiology and Biostatistics, McMaster University,
Hamilton, ON, Canada. Address correspondence to Dr Joy MacDermid, Co-director, Hand and Upper Limb Centre Clinical Research Lab, Monsignor Roney Ambulatory Care
Centre, 930 Richmond Street, London, ON, N6A 3J4 Canada. E-mail: jmacderm@uwo.ca

400 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy

tory with the NDI.46 The author stated
that “The Neck Disability Index has been Search Strategy
used in over 300 publications, translated Key words: (NDI OR Neck Disability Index) AND (reliability OR validity OR
responsiveness OR clinically important difference OR MCID OR Rasch OR
into 22 languages…and endorsed for use factor analysis OR translation OR validation).
by a number of clinical practice guideline Dates: January 1966 to September 2008
committees…making it the most widely Other: Google searches and hand searches of retrieved study references lists
used and most strongly validated instru-
ment for assessing suffering disability in
patients with neck pain.” Located citations (n = 189):
Downloaded from www.jospt.org at University of Washington on December 1, 2014. For personal use only. No other uses without permission.

While previous reviews have claimed D mbase (n = 66)
D "edline (n = 63)
to be systematic, none have included a
D INAHL (n = 66)
key element of systematic review, criti- D %sycInfo (n = 1)
cal appraisal of the quality of individual D and searching (n = 2)
studies. This may reflect inherent dif- D ontact author (n = 1)
ficulties in performing the critical ap-
praisal due to lack of instrumentation.
(3=5/ +,<=;+-=;/?3/@7 
The lead author of this current review
has published a scale and interpretation
guide25,26 for this purpose. Psychometric Unique articles accepted for full A-5>./.+=+,<=;+-=;/?3/@
studies are important to establish mea- review (n =  ): D #8.+=+8;78=;/5/?+7= unique)
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

surement properties like the relative dif- D mbase (n = 30) D tudy design criteria (n = 0)
ficulty of items, appropriate grouping of D "edline (n = 28)
D #!7

items into subscales, reliability, validity, D and searching (n = 2)
and responsiveness. In addition to psy- Horizon estimation of database
D $ther (n = 1) </+;-2;/=;3/?+5
chometric properties, clinicians are con-
cerned with issues on feasibility, floor/
ceiling effects, availability of different Included: A-5>./.+0=/;0>55=/A=;/?3/@7 = 2):
language/cultural adaptations, and ad- D tructured reviews (data No data on NDI (n = 2)
ministration burden for themselves and extraction) (n = 3) !+71>+1/

D >55=/A=-.<=.+3<+5736) kept for data extraction plicability.  7  the psychometric issues but also need in. 88. “usefulness” have been used in reference to these practical considerations.” or “clinical utility/ap. Terms like “clinician/pa- D ata extraction (n = 38) excluded from critical appraisal tient friendliness.  7   formation on usefulness.3=3-+5+99.  7 .  7   clinical practice.” or. they are concerned with +3.B188.+-=7877153<2=/<= their patients.@3=27153<2 D %rimary studies Journal of Orthopaedic & Sports Physical Therapy® +. as we prefer. When thera- pists try to integrate the NDI into their Quality summary of appraised primary papers (n = 36): %88. The purpose of */.

particularly as a strategy to deal with questions left metric. resulting in the 10-item scale. each item is summed for a score varying L the NDI using the Oswestry Low Back Pain Index (OLBPI) as a tem- plate for identifying items and a scoring These 10 items were modified for clarity and relevance based on feedback from 5 individuals with a history of whiplash in- from 0 to 50. concentration. lifting. from the original scale: pain intensity.The systematic review evidence flowchart. The consulting team added 4 a 6-point scale from 0 (no disability) to 5 :[l[befc[dje\j^[D:? items: headache. A-/55/7=( 7  view that would summarize the quality and content of current research regard. journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 401 . personal care. items. ing the psychometric properties and use- fulness of the NDI.47 The questions are measured on ing team.D:?N7). reading. the unanswered (7FF. NDI contained 5 items from the OLBPI.47 Some evaluators choose to provide a score out of 100%. In the end. The numeric response for ernon and Mior47 developed and work. and 5 new C. (full disability). and 2 of which were modified. sleep. <?=KH. driving.J>E:I sex life. and submitted this to a consult. They initially selected 6 items jury and the review team. this study was to conduct a systematic re.

er did not include formal critical appraisal pendently reviewed by at least 2 of the 2. We used the following consensus process mation after these 3 databases.M. but few were comprehensive. if the raters continued to size calculations/justification. we conducted Google searches and hand searches of retrieved associated ratings for individual studies.43 to 1.46 The primary authors. The data extraction form was de. Factual content/oversights (the although neither included formal critical Charlie Goldsmith). At this point. gible studies: (NDI OR Neck Disability interpretation guide used to assess indi- Downloaded from www.). Due to the reviewed 1 paper then met and discussed 2 points.34. studies provided specific conclusions or 402 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . the study. For personal use only.'). The number of scores of rater pairs. their disagreement. We A database search was performed us.) for studies crossed different populations. with 37% of papers reaching or exceeding Dutch.25. original manuscript."J78B. (). and 1 unpublished documented in the manuscript it was reporting specific psychometric hypoth- in press manuscript proceeded to a full treated as “not done”). veloped by adaptation of categories used rank ordered studies on quality and con- ing Medline. PsychInfo. no meta-analyses terpretation of critical appraisal items. Index) AND (reliability OR validity OR vidual study quality were developed by H. 0-2. first.IKBJI responsiveness OR clinically important the lead author. A descriptive synthesis ments and a predetermined consensus signing the lesser of the 2 scores. 2014. leaving unequal ?Z[dj_ÓYWj_ed tools. stract data extraction but not full critical manuscript complied with item re.EDB?D.13 with additions from clusions and recommendations. Quality of the individual studies written in French or English (2 with Eng.82. although this was not required during properties evaluated. then CINAHL.37 Similarly.25. 4. 37 primary studies. Pairs of raters consulted the first au. An article was accepted if it met thor/instrument developer (J. raters were not comfortable with this ties across all identified studies is sum- tion review. In total. Raters then discussed their percep.). based on the quality of the were used to search all databases for eli. Most studies addressed Following this. interventions. Few articles using previously developed data follow-up and some psychometric stud. Interrater reliability on quality ratings was calculated based on preconsensus J a possibility that our search strategy missed 1 article (95% confidence interval. esis/objectives. ware (full details available from author item. disagree on an item by 1 point. raters clarified if the disagree. 97% yield). or the extent of compliance with the ity instrument reviews were identified. 1 Spanish] were included for ab. and then Medline. quality tool are listed in J78B. pairs of raters indepen. appraisal. All rights reserved. tions of the extent to which the study a score of 75% on the quality rating (J78B. the overall estimated search strategy would have been Embase studies retrieved and the net results of kappa was 0. CINAHL. 78B. who also developed an there was no formal mechanism to weight 2008 (<?=KH. conclusions. No other uses without permission.14 most common source of disagree. denominators for different studies. surement (SEM). Journal of Orthopaedic & Sports Physical Therapy® the following inclusion criteria: reported clarification of the meaning or inter.26 The items from the difference OR MCID OR Rasch OR fac. which included papers written Euchaute et al. Two neck disabil- by Foster and Goldsmith for SAS soft. and in a previous psychometric review by sidered this ranking when making con- Embase. although between January 1966 and September the first author.D:?N 8" 7L7?B. and time intervals.. were performed.00. and on at least 1 psychometric property of the pretation of specific items of the scale addressed different psychometric prop- NDI in patients with neck pain and was if they felt this was contributing to erties. quirements (if something was not the psychometric articles were (1) not 3 structured reviews. lish abstracts and non-English full text [1 3.(. Critical appraisal forms and associated source document. PsychInfo did not contribute any infor- the <?=KH. addressed at least 1 psychometric proper- our search using a procedure developed ment was based on factual content ty of the NDI (J78B.org at University of Washington on December 1. with agreement on indi. Each paper’s score was converted into a spectrum of psychometric proper- dently evaluated an assigned subset of a percentage because 1 item was based on ties. [ LITERATURE REVIEW ] B_j[hWjkh[I[WhY^WdZIjkZo extraction forms and quality appraisal ies are cross-sectional. with the default compromise of as. If the of the findings for psychometric proper- process. 41 studies were identified that Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. and (3) The data extraction and review pro. articles were missed and the efficiency of 1. ranging from 21% to 96%. an adjudicator was required. abstract/title and full review are noted in vidual items varying from 0. (2) inadequate sample review (<?=KH. absence of error estimates such as confi- cess was conducted by pairs of raters and ers decided if they were comfortable dence intervals or standard error of mea- was based on the use of structured instru. with the he Horizon analysis14 indicated tor analysis OR translation OR valida- tion). which were inde. a recent compre- The first stage of study identification ment) were resolved by recheck of the hensive review of the NDI by the develop- was of title/abstracts. in which they independently resolution or continued to disagree by marized in J78B.I) through 5. An optimal study references lists. of individual studies. In addition.'). heterogeneity of study populations and each item to clarify the meaning and in. First. was variable.jospt. the rat. The most common flaws observed in appraisal).26 All authors met for a calibra. We conducted a Horizon esti. mation to evaluate the potential that any when independent assessments differed: In total. The following keywords accompanying guide (7FF.

neck trauma Chok et al 20008 Patients: NP 46 Reliability. Intervention: ND Site: midsize hospital in southern Brazil validity. 60% F. Unknown validity Hoving et al 200319 Patients: mean age. symptom duration. 22 tested twice for reliability and 24 discharge that completed baseline and discharge assessments Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. plus heat. responsiveness Retest interval: 10 subjects retested randomly at 24 h and a separate 10 subjects retested at 7 d Gay et al 200715 Patients: 7 M. many occupations. Intervention: manual therapy duration. 59% of patients were M.' Summary of Studies Addressing Psychometrics of the NDI IjkZo FefkbWj_ed n Fhef[hj_[i. 18-89 y (mean. mean age. validity. rheumatoid arthritis. and 20 had no NP but had other within 48 hours. 21 F. and chronic NP Retest interval: unknown Site: chiropractic college clinics in Vancouver and Toronto Included: English speaking. chronic NP 33 Responsiveness Intervention: group 1. responsiveness Intervention: PT 14 wk Retest interval: baseline evaluation and Site: PT Clinics after 5-7 visits Cleland et al 20089 Patients: stable. symptom 138 Reliability (SEM and ICC). responsiveness exercise program Retest interval: 4 wk Goolkasian et al 200216 Patients: 12 M. No other uses without permission. 42% II. fied version) Retest interval: 5 occasions. PT. reliability. Intervention: ND Downloaded from www. reliability. chronic 23 Primary purpose to evaluate Intervention: 1 of 3 manual therapy uncomplicated NP another scale. and community rheumatology clinic into private PT practice journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 403 . 2014. Reliability. responsiveness Retest interval: after 1 session symptom duration. mean age. NP. 31 F). mean age. For personal use only. validity Intervention: PT Site: an outpatient setting Retest interval: admission and Included: 2 cohorts. 43 y. Cleland et al 200610 Patients: 47% F.lWbkWj[Z ?dj[hl[dj_ed%H[j[ij?dj[hlWb 1 Ackelman et al 2002 Patients: 59 Swedish patients (28 M. 40 y. central nervous system involvement. NP with or without referral of symptoms to the upper extremity or extremities. 42 y. mean age. 51 y. prior surgery to the cervical or thoracic spine. 16 F. improved. 43 y. and 6% III). 71 Validity Intervention: none all patients were less than 24 mo since MVA. ankylosing spondylitis. aged. retest 19 had chronic NP. GPs.org at University of Washington on December 1. NDI score greater than 10%. home consistency. 237 Validity Intervention: unknown acute. responsiveness Intervention: PT patients were in the acute phase after a neck sprain. n = 71 Site: patients recruited from PT clinics. Site: PT clinics involved in a study of botulin toxin Included: received PT that they considered inadequate for NP Excluded: surgical candidates Retest interval: within 1 wk Hains et al 199817 Patients: 62% F. J78B. 17 y or older Heijmans et al 200218 Patients: chronic WAD 61 Dutch translation. construct validity Intervention: PT Included: patients with at least 3 mo of NP Retest interval: 7 d Bolton 20045 Patients: nonspecific NP 125 Responsiveness Intervention: chiropractic Site: 8 chiropractic clinics and 1 teaching clinic Retest interval: pre-Rx and 4-6 wk postinitial Rx Chan et al 20087 Included: patients with chronic nontraumatic NP with a 20 Construct validity Intervention: ND duration of greater than 3 mo Retest interval: Cross-sectional Excluded: cervical radiculopathy. WAD within the past 6 wk. 39 y. validity. 25% F. mean age. varying severity and duration of WAD (level of WAD: 23% I. mean age. at 3 w and 3 mo musculoskeletal symptoms Andrade et al 20082 Patients: nonspecific or posttraumatic NP 48 Spanish translation. 46 d (SRM and MDC) Included: age 18-60 y. 83 d.jospt. construct validity. 50 y. All rights reserved. Site: Spain responsiveness Aslan et al 20083 Patients: NP 88 Reliability. subacute. 43 y) 203 Brazilian Portuguese translation. 38 Reliability. or pending legal action regarding their NP Cook et al 200611 Patients: 62% M. group 2. twenty 59 (38 for modi. Excluded: any signs or symptoms consistent with a nonmusculoskeletal etiology. NDI: internal approaches. 2 or more Journal of Orthopaedic & Sports Physical Therapy® signs consistent with nerve root compression.

146 (69 for retest) Validity. subacute. pain. 183 CID Intervention: random allocation to PT. 48%. and chronic who visited their 221 (54 from pilot. responsiveness Retest interval: 1-d retest and Site: 9 primary care and 12 specialty services from 9 re-evaluation at 14 d regions in Spain Excluded: functional illiteracy. 26%. 66%. 6/10 Rebbeck et al 200736 Patients: 3 cohorts primary care insurance (early and (99. employed: 80%. tion 2-6 wk. include a content analysis at item level Riddle et al 199838 Patients: 64% F. mean age. 46 y. prior history of chronic pain. NR. No other uses without permission. NDI score.' Summary of Studies Addressing Psychometrics of the NDI (continued) IjkZo FefkbWj_ed n Fhef[hj_[i. 68%. 1 year 33%. For personal use only. 54% F. neurological injury. Retest interval: 1-3 d without therapy Downloaded from www. F: 80%. manual therapy. 7-12 wk. responsiveness Intervention: chiropractic Site: 8 chiropractic clinics and 1 teaching clinic Retest interval: postinitial Rx. neck trauma. with a primary 180 Reliability. age. 6 wk of NP 102 Reliability.lWbkWj[Z ?dj[hl[dj_ed%H[j[ij?dj[hlWb 20 Humphreys et al 2002 Patients: NA 125 Reliability. ness 67%. baseline VAS. 55/100 reliability.org at University of Washington on December 1. 31 F. 18-69 y. validity. Spanish translation. responsiveness Intervention: PT Ontario Canada who had grade II WAD. 250) Convergent validity. age. convergent validity. aged 18-65 y Excluded: fracture dislocation. translation Intervention: routine Rx than 3 mo following whiplash injury from 10 different practices. 70%. 18 Resnick 200537 An overview of instruments in a structured review by NA Validity NA a single author and evaluator. second 160 controls) Retest interval: follow-up varied group subjects from a convenience sample who did between 4-12 w not have NP and who were not being treated Site: tertiary outpatient clinic Lee et al 200624 Patients: 17 M. All rights reserved. reliability. most common neck strain Retest interval: admission and or NP discharge Site: 1 of 4 clinics in Richmond. Intervention: ND physician for NP plus 167) validity. responsiveness Intervention: unknown variety of neck disorders. 26%. 13 wk. validity Intervention: various Site: spinal clinic Retest interval: 1-2 wk Miettinen et al 200430 Patients: NP who had been involved in an MVA 144 Validity. responsiveness Intervention: PT 5/wk for 3 wk Excluded: inflammatory arthritis. responsiveness Intervention: ND Site: Finland Retest interval: 1 and 3 y post-MVA Mousavi et al 200731 Patients: NP 3 mo 30%. validity. interpretability Journal of Orthopaedic & Sports Physical Therapy® Nieto et al 200833 Patients: Catalan-speaking. systemic disease. adequate mental capacity within 4 wk of surgery decompression and fusion Sites: 23 clinics Excluded: revisions/tumors 404 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . internal consistency. relative Intervention: ND 78%. 88% of patients 50 years or younger. bidity. 534 Convergent validity Intervention: anterior cervical thy. 23. responsiveness Intervention: ND diagnosis of NP Retest interval: first and last visit or Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. ND late). 2 or more missing items on NDI Pietrobon et al 200234 Structured review of different neck disability scales NA Validity NA Pool et al 200735 Patients: 61% F. 2014. responsive. surgery. 18-55 y. Reliability. 4-6 d post-Rx Kose et al 200721 Patients: 83% F. central nervous system Kumbhare et al 200523 Patients: the first group comprised of 81 patients from 241 (81 patients. 134. with subacute pain of less 150 Factor validity. Site: patients were chosen from 3 hospitals and 7 7th or 8th Rx clinics in 5 Korean cities McCarthy et al 200729 Patients: NP 160 (34 retest) Reliability. nonspecific NP. dura. infection Kovacs et al 200822 Patients: acute. Retest interval: none Site: primary care or PT clinics floor/ceiling. VA Excluded: under treatment for problems other than c-spine Scolasky et al 200739 Patients: NP cohort cervical radiculopathy or myelopa. [ LITERATURE REVIEW ] J78B. gradual onset 185 Iranian translation.jospt. NDI. GP care 14. spine injury. comor. validity.

2014. systemic or other major disorder Wlodyka-Demaille et al Patients: mean age. neck pain. 28 M. validity Intervention: none 200253 Site: patients recruited from outpatient clinics. VA. responsiveness Intervention: PT Site: 5 PT clinics in North America Retest interval: 1-3 wk Trouli et al 200844 Patients: NP 65 (43 classified Factor validity. minimal detectable change. MVA. severe or greater depressive symptoms. Numeric Pain Rat- ing Scale. GP. Site: referred by physician to PT 72 h. 2 sessions week 3. within 1 mo of MVA.' Summary of Studies Addressing Psychometrics of the NDI (continued) IjkZo FefkbWj_ed n Fhef[hj_[i. For personal use only. 70% WAD in past 4-6 wk. vascular or neurological disorders. with pain-free interval of at least 3 mo Retest interval: 1-wk follow-up Site: referred by GPs in Rotterdam and region Inclusion criteria: aged 18 and sufficient Dutch Exclusion criteria: specific cause of NP (ie. numeric rating. NP 101 Reliability. 68 M. 12-80 y.jospt. rheumatology department (ie. to exercise. PT. not described. known or suspected 1. nonchronic NP of musculoskel. and tion of reduced 8-item scale and total NDI of 13-14 differential item functioning of Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. validity. chronic WAD (>3 mo). Intervention: routine Rx Site: primary care in 3 rural centers as stable) internal consistency. Downloaded from www. recurrent acute NP lasting no 187 Reliability. NA NA NA oper) that includes psychometrics. contraindicated session weeks 5. 31 F. current PT neck Rx. Intervention: ND studies of n = 188 and the other n = 333 Rasch modeling of item. etc) Westaway et al 199850 Patients: Age. males. PSFS Retest interval: 3 sessions in week Excluded: previous neck surgery. ICC. 6 cases removed because of 2 missing items on NDI van der Velde et al45 Patients: 55% or more F in 2 cohorts from previous 521 Factor analysis. MDC. responsiveness Intervention: 6-wk individualized disabled preinjury and presented for medical care submaximal exercise program. intraclass correlation coefficient. tertiary care teaching hospital and outpatient clinic) Abbreviations: CID. VAS. All rights reserved. 49 y 71 Validity.org at University of Washington on December 1. 49 y. motor vehicle accident. NDI. SEM. content validity. Virginia. 30% 48 Reliability. RCT. SRM. poor English Stratford et al 199943 Patients: NP 50 Reliability. females. positive upper limb tension test. standardized response mean. pain bother-someness. low blood pressure. no formal critical appraisal of studies Vernon et al 199147 Patients: 17 M. F. Pain-Specific Functional Scale. randomized controlled trial. prediction and effect sizes across treatment RCTs that used the NDI. LBP. at at 2 hospitals in UK 1 wk and 8 wk Excluded: undergoing litigation. responsiveness Intervention: none longer than 6 wk. physiotherapy. UK. M. evalua- Included: pain for 5-6 wk. baseline pain of 5-6/10. 4. WAD. rehab Retest interval: 11 2 mo department. item consistency. mean age. journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 405 . 31 Reliability. general practitioner. validity. clinically important difference. neurological ability. a score of at least 20% on primary supervised by PT outcome measures: NPRS. PSFS. United Kingdom. treatment. tertiary care teaching hospital and outpatient clinic) Wlodyka-Demaille et al Patients: 43 F. 6. “mildly” 134 Reliability. rheumatology department (ie. validity Intervention: none chronic nontraumatic Retest interval: 2 d Site: Clinic of Canadian Memorial Chiropractic College Journal of Orthopaedic & Sports Physical Therapy® Vos et al 200649 Patients: 119 F. 31 F. reha. NPRS.lWbkWj[Z ?dj[hl[dj_ed%H[j[ij?dj[hlWb 42 Stewart et al 2007 Patients: 17 M. Rx. ND. Site: different clinics items Vernon 200048 Combination of instrument review (NDI and other). 1 red flags. responsiveness Intervention: routine Rx etal origin “cervical dysfunction” Retest interval: initial assessment. No other uses without permission. and following 1-4 w of Rx by 1 certified Canadian orthopae- dic manipulative PT White et al 200451 Patients: chronic mechanical NP 133 Validity Intervention: in treatment RCT Site: recruited from PT and rheumatology waiting lists Retest interval: before Rx initiated. retest reli- Excluded: symptoms below the elbow. NR. J78B. whiplash-associated disorder. 2 follow-up phone calls no neck radiograph since MVA. plus NA Content validity (comparison of NA some impairment sincerity of effort testing items) Vernon 200846 A structured review by a single author (the NDI devel. standard error of measurement. Neck Disability Index. 2. responsiveness Intervention: ND 200452 Site: patients recruited from outpatient clinics. nerve root compromise. NP. visual analog scale. Retest interval: 24 h bilitation department. translation signs.

No other uses without permission. 5. 0 0 1 1 1 0 36 Chok et al 20058 1 1 0 1 0 0 1 1 1 0 1 1 33 Miettenen et al 200430 0 2 0 0 0 0 0 0 1 0 1 1 21 Abbreviations: NA. comprised of less clinically useful data.2. † Papers where NDI evaluations were performed while evaluating a different measure as the primary purpose. because they were in non-English text.37. 3. The authors referenced specific procedures for administration. * Evaluation criteria: 1.46 406 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . All rights reserved. Appropriate statistics-point estimates. and interpretation of procedures. Ap- propriate statistical error estimates. Follow-up.34. Appropri- ate scope of psychometric properties. rather. Riddle et al 199838 2 2 2 2 0 0 2 1 2 2 1 2 75 Lee et al24 2 1 2 2 0 0 2 2 1 2 2 2 75 42 Stewart et al 2007 1 2 2 1 0 NA 2 2 2 2 1 1 73 Pool 200735 2 2 1 0 1 1 1 1 2 2 2 2 71 Kose et al 200721 1 2 1 2 1 2 1 1 2 2 1 1 71 Kovacs et al 200822 1 2 1 2 1 1 1 2 1 2 2 1 71 Hains et al 199817 2 1 2 1 0 NA 2 1 2 1 1 2 68 Ackelman et al 20021 1 2 1 2 0 2 1 2 2 2 0 1 67 Vos et al 200649 2 2 1 1 0 0 2 2 1 2 2 1 66 Journal of Orthopaedic & Sports Physical Therapy® Vernon et al 199147 2 1 1 2 0 2 1 1 2 2 0 2 66 52 Wlododycka et al 2 2 0 0 0 1 1 1 2 2 2 2 63 White et al51 1 2 1 1 0 1 1 1 2 2 1 2 63 Goolkasian et al 200216 1 1 2 1 0 1 1 1 2 1 2 2 63 Gay et al 200715 2 2 1 2 0 1 1 0 1 2 2 1 63 Nieto et al 200833 2 2 1 1 1 NA 1 1 2 2 0 1 61 Pietrobon et al 200234 2 0 1 2 1 0 2 NA 2 1 0 2 59 Mousavi et al 200731 2 1 1 2 1 0 1 0 1 2 1 1 59 Scolasky 200739 1 2 0 0 2 . 2 2 1 1 0 0 50 Bolton 20045 1 1 0 1 0 0 2 1 2 1 1 2 50 7 Chan et al 2008 1 2 0 0 0 NA 1 1 2 2 0 1 43 Humphreys et al 200220 1 1 1 1 0 0 0 0 2 2 0 2 42 Rebbeck 200736 0 1 1 1 2 . 2. 7. 10. Valid conclusions and clinical recommendations. Cleland et a 20089 2 2 1 2 2 2 2 2 2 2 2 2 96 Van der Velde et al45 2 2 2 1 2 2 2 2 2 2 2 2 96 Kumbhare et al 200523 2 2 2 2 2 2 2 2 1 2 2 2 96 Westway et al 199850 2 2 2 2 0 2 2 1 2 2 2 2 88 Cook et al 200611 2 2 2 2 0 2 1 2 2 2 2 2 88 10 Cleland et al 2006 2 2 2 2 0 2 1 2 2 2 2 2 88 Trouli et al 2008 1 2 1 2 1 2 2 1 2 2 2 2 83 Hoving et al 200319 2 2 1 2 0 NA 2 2 2 2 1 2 82 Aslan et al 20083 2 2 1 2 0 1 2 2 2 2 1 2 79 Stratford et al 199943 2 1 1 1 1 2 2 1 2 2 2 2 79 McCarthy et al 200729 2 1 1 2 1 1 2 2 1 2 2 2 79 Wlodyka-Demaille et al 200253 1 2 1 2 1 2 1 1 2 2 1 2 75 Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. 8. 9. scoring. tended clusions. The type of data collected dur. - . Specific inclusion/exclusion criteria.46 Two papers had data extraction from the English abstract and study tables but no critical appraisal. J78B.( Quality of Studies on the Psychometric of the Neck Disability Index ?j[c. For personal use only. ing NDI validation studies was typically into clinical practice but.jospt. Quality scores were rated in content for the NDI-related methods. Thorough literature review to define the research question.lWbkWj_ed9h_j[h_W IjkZo† ' ( ) * + . Specific hypotheses. 11. Three structured reviews underwent data extraction but no critical appraisal. / '& '' '( JejWb Downloaded from www. 12.18 One paper had item comparison but no NDI data. Sample size. so no full critical appraisal. not applicable to paper. 4. 6. Data were presented for each hypothesis.org at University of Washington on December 1. 2014. [ LITERATURE REVIEW ] numbers that could readily be integrated to rely on generalities when making con. Measurement techniques were standardized.

7 d. where reliability is assessed as mean difference be- group reliability. ICC = 0. 7-14 d.8621 view was based on a formal search of 2 3-7 d. 8. These included til 2004 suggested that instrument de. No 7-14 d.2 in patients with cervical radiculopathy10 MDC. All rights reserved. No other uses without permission. –0. was reported SEM Patients classified as stable. These authors concluded that 0.90 in first cohort8 tional Disability Scale.66 in WAD49 authors performed a comprehensive structured review with use of a formal Test-retest reliability 1 d. 3 to –3/7). 7 d.6. tant because it established the relative 2 d. but com.97 (n = 30/185)31 structure and psychometric properties: Patients classified as stable on GRC. the NDI had the strength of being most studied amongst these 3 and was at that time the only instrument revalidated in The results of a subsequent systematic vidual studies. 3 to –3/7). It was suggested that ficient. using GRC scores of 3 to –3/7.48 (chronic) to 0. in patients with 6 wk of neck pain 0. 0.9 mean retest differences.7350 when compared to other scales.9329 Five standardized neck pain scales were 7-21 d.99 (chronic) to 0. 7 d.96 Journal of Orthopaedic & Sports Physical Therapy® formal quality evaluation was performed. patients in acute condition. The authors review of studies on outcome measures thesize results. like known group differ- ences that could be used as comparative H[b_WX_b_jo :WjW.90 (acute)11 tation tracking using the citation index. but without use of coefficients 1 d. 0. intraclass correlation coef- wick Park Scale. 1-3 d. or minimal de- MDC. Again. reviewed in a qualitative manner. 5 with 90% CI in patients with neck pain48 IkccWhoe\Fh[l_eki MDC. MDC. The first review34 is impor. tween retests and the 2 standard deviation brackets around that difference.5  344 relation coefficients (ICCs). or a formal process to syn- different study populations.) Summary of Reliability Properties information.982. The psy- Patient-Specific Functional Scale was total of 11 scales). 10.9443 identified and compared qualitatively 21 d..9353 praisal. the content of instruments was compared parisons between patients are virtually formed.89 (acute)1 Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. whiplash- associated disorder. 0. 0.5 in patients with neck pain35 tectable change [MDC]). SEM. impossible. r = 0. 0. MEDLINE and CINAHL.jospt.971 strengths and weaknesses of the NDI 3 d.941 properties. minimal detectable change. versus more useful J78B.”34 data extractors. This re. k = 0. like correlations indicating construct convergent validity.22 3 of the scales were similar in terms of 0. 0.94-0. MDC. while changes in individual patients. including use of multiple raters/ more quantitatively in a summary table. Eight English-language of this review suggested other scales had for the cervical spine published up un. r = 0.9049 hand searching of relevant journals.509 the NDI. 0. 1. r = 0. Mean retest difference As per Altman and Bland technique. 4. SEM..983 ditional papers (up to year 2000). r = 0. This item analysis indicated that the most journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 407 . –1. WAD. 0. global rating of change. Similarly. 0. cific validated for the neck) scales were that the Neck Pain and Disability Scale velopment is ongoing as it identified an reviewed.93 (acute)11 search for articles. standard error of the measurement. (specific-to-neck) scales and 3 (nonspe- important limitations. Downloaded from www. For personal use only. 0. 0.njhWYj[Z data for clinical comparisons. The instruments (and year must be read to the patient and the increased number of neck pain scales (a published) are listed in J78B. the Copenhagen Neck Func. ICC. other ele.49 absolute measurement error (like SEMs. 2014. 19. Abbreviations: CI. confidence interval. such as intraclass cor. and 7 d. SEM. ments of systematic review were not per.951 in terms of content and measurement 90 d. while databases chometric properties of each scale were considered “very sensitive to functional were used to identify papers. 2 d.7 with 90% CI43 IjhkYjkh[ZH[l_[mi Patients classified as stable over 1 wk (GRC. and the North. quality ratings for indi. GRC.9211 multiple raters or formal critical ap. ci.9024 databases. MDC Patients classified as stable (GRC 3 to –3/7). 1 d.92 (chronic) to 0. in healthy controls.81-0.6444 more often than more useful indicators of Patients classified as stable over 1 wk (GRC. 10. MDC. r = 0.org at University of Washington on December 1. 1. MDC.93 correspondence with experts to find ad.7844 Three papers were identified where the MDC.

53 š L7IZ_iWX_b_jo"F9II"C9II"DFGXWi[b_d["9IGXWi[b_d[ š L7IZ_iWX_b_jo"f^oi_YWbhWj_d]"ckiYb[ifWic"d[YaHEC"d[Yai[di_j_l_jo21 š =[d[hWb^[Wbj^"l_jWb_jo"ieY_Wb\kdYj_ed"f^oi_YWb\kdYj_ed31 š 9EI0fW_d_dd[Ya"Whci"f^oi_YWbiocfjeci"\kdYj_ed$FioY^ebe]_YWbZ_ijh[ii"^[Wbj^YWh[ki["39 a Patient-Specific Problem Elicitation Technique7.21L7IfW_d"9IG"DFG22 š L7IXeZ_bofW_d31 Correlation with other scales reported as moderate (0. 6 were included on the NDI. known Detected differences between group differences š :_iWX_b_job[l[bi0deZ_iWX_b_jo"'. and symptoms.30-0. reading. sleep disturbance. The second factor on functional disability included the items personal care. concentration.F9I"I<#).1i[l[h[".7 š D:?mWideji[di_j_l[jej^[_j[ciYedY[djhWj_ed'$*"'$'ehf[hiedWbYWh[&$-"&$.and 2-factor solutions. personal care.$11.70): š I<#). It was determined that 75% of patients identify problems with sleep.53 VAS pain. Of the 11 problems identified by most subjects.*lWh_WdY[edÓhij\WYjeh11. work. appropriate. lifting. convergent Correlations with other scales reported 0.19. A scree plot confirmed a 2-factor solution as optimal. š 7kj^ehiki[ZWfWj_[dj_dj[hl_[mje[b_Y_jfheXb[ciYWbb[Zj^[fheXb[c[b_Y_jWj_edj[Y^d_gk[je_Z[dj_\o\kdYj_edWbfheXb[ci_dfWj_[djim_j^Y^hed_YdedjhWk# ness. All rights reserved. No other uses without permission.51 and 0. emotion.jospt. Construct. and sitting upright. driving.43.* Summary of Validity Properties LWb_Z_jo :WjW.1c_bZ"(-1ceZ[hWj["*&1i[l[h["**WdZl[hoi[l[h["-&$ š FW_d0defW_d"((1c_bZ")&1ceZ[hWj["). mobility.66.1ib_]^jbo_cfhel[Z")$-1deY^Wd]["&$(. r for VAS test and retest groups of 0.623 Construct. gardening.1_cfehjWdjY^Wd]["/35 š H[Yel[h[Z". the latter being significantly better.0)53 š <WYjeh'"\kdYj_edWdZZ_iWX_b_jo_j[ci0(".29.C9I">7:I"DF7:"L7IfW_d"Y^hed_Y1. lifting.'22 š 7cekdje\Y^Wd][0'&$+"Yecfb[j[boh[Yel[h[Z1ckY^_cfhel[Z".24.17 Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. work.org at University of Washington on December 1.50.e\_j[cic_ii_d]"Zh_l_d]ceije\j[db[\jc_ii_d]Zk[jedejWffb_YWXb[$21 š ?d?hWd"*(Z_ZdejWdim[hZh_l_d]"/h[WZ_d]$31 š Beea[Z\ehY[_b_d][÷[YjiXkjdejZ[j[Yj[Z$31 š . analyses were completed to deter- mine differences between the 1. The highest mean severity scores were found Downloaded from www. headaches.$+e\fWj_[dji^WZ_d_j_WbiYeh[im_j^_d'C:9Z_ijWdY[\hecj^[X[ijfeii_Xb[Wdim[h&h[l[Wb_d]deY[_b_d][÷[YjiWYYehZ_d]jeW'+Yh_j[h_ed$44 š '&%+&Wia[Z\ehYbWh_ÓYWj_edZkh_d]IfWd_i^WZWfjWj_ed$22 š CeijYeccedboc_ii_d]_j[ciedXWi[b_d[Wii[iic[djWdZ'mabWj[h_dYbkZ[Zb_\j_d]''"h[WZ_d]/"Zh_l_d]*+"h[Yh[Wj_ed'44 Internal consistency š 9edi_ij[djbo^_]^9hedXWY^Wbf^W0&$-&#&$/. missing matic neck pain.16. in depression. headaches. and sleeping. role activity. Because of previous reports of a 1-factor solution.$19 š D:?Z_Zdej_dYbkZ[j^[[njh[c[ie\l[ho[Wioehl[hoZ_øYkbj_j[ci"cWdom[h[i_c_bWh_dZ_øYkbjoWdZj^[h[\eh[fej[dj_Wbboh[ZkdZWdj$24 š IeY_WbYedi[gk[dY[iWh[Wd_cfehjWdjfWhje\ikX`[YjÊii_jkWj_edj^Wj_idejc[dj_ed[Z_dD:?$1 š LWb_ZWj[Z\ehckbj_fb[eh_]_die\d[YafW_d"\kdYj_ed"WdZYb_d_YWbi_]diWdZiocfjeci$34 š .WdZl[hoi[l[h[". Less common but mentioned by more than 30% of effects) patients were looking into cupboards. The correlation between these factors was 0. and frustration. Individual problems ranked most important by subjects were driving. Sleep disturbance had items. cooking. and general exercise.njhWYj[Z Content (including š 9ecfWh_iede\_j[ciWYheiiD:?"DFG"WdZj^[9ef[d^W][dD[Ya<kdYj_edWb:_iWX_b_jo?dZ[n1_j[ciedWbb)0ib[[f_d]WdZh[WZ_d]1_j[cied(iYWb[i0fW_d" analyses of ques.15. and recreation."'&53 š <WYjeh("d[YafW_d_j[ci0'"*"+"/53 š <WYjeh'"fW_dWdZ_dj[h\[h[dY[m_j^Ye]d_j_l[\kdYj_ed_d]33 š <WYjeh("\kdYj_edWbZ_iWX_b_jo š Ki_d]WdeXb_gk[hejWj_edj[Y^d_gk["'\WYjehÇfW_dWdZ_dj[h\[h[dY[e\Ye]d_j_l[\kdYj_ed_d]"È[nfbW_d[Z*(e\j^[lWh_WdY[WdZYedjW_d[Zj^[\ebbem_d]_j[ci0 pain intensity. working overhead. concentration. [ LITERATURE REVIEW ] J78B. š '\WYjeh2 Support for 2 factors š <WYjehWdWboi_i0(\WYjehi[njhWYj[Z[_][dlWbk[i"1. driving. recreation48 tion. For personal use only.#.38.19. 2014. More than half of subjects identified difficulties with frustration. ceiling/floor the highest prevalence. housework.47 Factor validity Support for 1 factor š '\WYjehYedÓhc[Z. driving. and lifting.70 Journal of Orthopaedic & Sports Physical Therapy® š FI<I"50DFG"DF:I":H?"L7IWYj_l_jo#Y^hed_Y"L7IfW_dWdZWYj_l_jo"WYkj[$1.17.

Neck Pain and Disability Score. Multi- country Survey Study. common content items on neck disability ed a historical perspective. This publication provided the Most recently. PCSS. range of motion. acupuncture.37 from the MAPI website. exercise. ROM.32. standing/running. Patient-specific Functional Scale. Short-Form 36 mental component scale. MCSS. a list of translations available cervical pillow. HADS. NPQ.8. pain ent studies. Cervical Spine Outcomes Questionnaire. VAS. Short-Form 36 physical component scale. mobilization.46 This review includ. and relaxation intensity. scores in effect sizes with different treat.46 Abbreviations: CSQ. psychometric properties from 22 differ. work. Pain Coping Strategy Scale. DRI. 408 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . laser. medication. a summary of therapy. moderate/severe disability. scales were self-care/activities of daily liv. PSFS. ing (ADL). the developer of the results from prognostic studies that use most extensive review of the NDI to date NDI published a comprehensive 17-year the NDI. 10-28. visual analogue scale. mild disability. appraisal. NPAD. a summary of ments. Neck Pain and Disability Scale. NPDS. and driving. and tables listing mean change but did not include independent critical review of the NDI. including manipulation. SF-36 PCS. Hospital Anxiety and Depression Scale. Northwick Park Neck Pain Questionnaire. SF-36 MCS. 3041 š 7j(*ma"h[Yel[h[Z"'*1f[hi_ij[djfW_d"(. Disability Rating Index.

in a number of studies. (). a committee who reviewed the translator be measurable. In of missing items. however. is considered “complete disability. where 0 is over the spectrum of possible NDI scores. that it takes 8-10 minutes to complete and cutoff of 20/50 at 3 years. made by the developers on the handling al49 reported a floor-ceiling effect on the ability due to neck pain was of interest. Polish. Danish. :_÷[h[dj_WbEkjYec[i specifically analyzed how the MDC varies tic equivalence. 2014.1.46 the extreme ends of the scale.org) to produce additional rived and no validation of these categories large high-quality studies indicated lower translations through standardized was performed. but these did has been suggested that if 3 or more items is difficult to observe change in scores at not appear to be related to educational are missing. 16% of patients had items required for validity.53 Through a series of utes (range. it may be difficult to deemed to be acceptable. All rights reserved. including seman. if a subject population. Cook et al11 questionnaire could be completed in the as they represent patients for whom ensured good readability of the Brazilian/ waiting room and thus did not add any pain and disability estimates may be Portuguese version of the NDI through additional time to the patient’s visit.18 Floor-Ceiling Effect Floor and ceiling properties of the original English ver. cess retained the sound measurement 5 minutes to analyze the (Dutch) NDI. However. Miettinen30 used a recovery al24 concluded that their translation pro. recent proqolid.90 have been reported with an independent organization (www. Finnish. However. se.2 Oth. cutoff. for level and reliability was excellent. they provided complete the NDI was about 3 minutes.9 for scores that fall in the “severe disabil- a high rate of nonresponse in an Iranian provide a percentage score as a strategy to ity” interval. 25 to 34. mon for task items like driving and. More recently. They reached consensus on dis. No other uses without permission. There was only as having persistent pain had a score of translating and back translating. In the same study. One group of authors set reliability9.jospt.4 (6. where reliability co- The developer reported that he worked plete disability. The majority of authors report the NDI out both “low” or “normal” scores. as well as ers identified that the driving item had of a total of 50.1 if more than 2 items were left objectively distinguish further decline in patients require support to understand unscored. 1-60 minutes). that is. and nonresponse is more com. ?dj[hfh[jWX_b_jo%IkX]hekf_d]e\ cally addressed this issue.30 Again. and definitions of “stable. reading. IkccWhoe\Fh_cWhoIjkZ_[i French (Canadian/Switzerland/ validated. recovered as having NDI scores of less addressed issues around readability. com. the subjects were not included. amount of time is required.” journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 409 . clinical studies to define patients who had Translation A number of papers have Spanish (Spain/US). Administration Burden Few authors than 4 (8%). sure” and “social activities” had differ. Italian. although some Lindgren. Vernon and Mior47 offered the follow. and this cutoff has not been study process. Lee et a single report of therapist burden stating 28 or greater.11 In the Swedish version. For personal use only. no explicit recommendations were the NDI.10 In the study by Ackelman and of 50 on the NDI. Stratford et al43 commented that the effects have practical clinical relevance. Wlodyka-Demaille measured the time taken to complete the those with moderate to severe disability et al53 reported that the concepts of “lei. the score may not be valid. whereas Hains et al17 and Vos et item of the tool to specify that only dis. (Australian/UK/US). cultures. patients defined this population. demonstrated a ceiling effect when using Ackelman and Lindgren1 changed each inally. moderate disability.34. and none have crepancies in 4 areas. with a severe pathology scored 48 out English and all translated versions is swered. those with mild disability as usually in the context of language and specifically address or state how they having scores of 5 to 14 (10%-28%). and conceptual considered “no activity limitation” and 50 Riddle et al38 reported that 6% of patients equivalence. no process was efficients above 0. Sterling et al40 used data from Readability/Language and Cultural Germany). all agree that only a short as having scores of greater than 15 (30%).” Some authors report that it comprehension difficulties. and subsequently examples in these areas to make the while Wlodyka-Demaille et al53 reported defined a score of less than 15 as a recovery questionnaire more understandable for that it took a mean (SD) of 7. Nederland32 found that pa- ent meanings in French and American al43 reported that the time for patients to tients defined as recovered at 24 weeks Downloaded from www. to a ing interpretation of NDI scores: 0 to 4. ac- These translations included English behind setting this benchmark was not tual difference in clinical subpopulations. some authors1. described for how these ratings were de. and 20 points. and greater than 35. their status. 15 dence to support appropriate retest re- Not all translations have been to 24. Norwegian. NDI scores vary from 0 to 50.10 (J78B. NDI. Few studies have specifi- reports. sion in the Korean version.31 Overall readability in the account for questions that are left unan. as they may have attained a the items.org at University of Washington on December 1. no disability. and cultural translations. the methodology ies are random differences in samples. had a score of 14 or less. liability of the NDI in both acute and published in peer-reviewed literature. it centration. chronic populations. Reliability There is considerable evi- lesser extent. near maximum score. 5 to 14.”47 Orig. Possible reasons translation methodology (although the “normal limit” of the NDI between 0 for variation in reliability between stud- psychometric testing was not performed). described. mild disability. In contrast. idiomatic equivalence.8) min. vere disability. For that reason. invalid and for whom changes may not Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. experiential equivalence.38 For example. Stratford et Conversely. or minimum number of items regarding “personal care” and “con- Journal of Orthopaedic & Sports Physical Therapy® the Spanish version.

67 –0.47. weaker correla. Although dices. convergent validity status.46.50 or 0.53 which is consistent with the similarity in their tions were observed with less similar in. 0.50.njhWYj[Z information on acuity and found test-re. ES: 1.90).04 0. SRM (improved cohort): 1.20.53 The Patient- Manipulation 1.I IHC comes from Cleland et al.38.83.51.+ Cultural Adaptation.11.04 1.60/0. and Disabil- Medication 5 ity Rating Index have the strongest cor- relation with the NDI.92 Long term 1. ES or SRM ES: 0.93.55 0. the Neck Mobilization 7 Acupuncture 0.53 Lower was reli.38.04. 84% CI42 terval was 72 hours from initial adminis.77. J78B.25 –0.13 0.1-1. Summary of Responsiveness.03 1.24/–0. These Mean change –4.24. high-quality ES (total cohort): 0. making it difficult to deter. which included stable pa.50. analogue scale (VAS) pain ratings. the Northwick Exercise 0. No other uses without permission. CID: 19 (sensitivity.99 in patients Downloaded from www. respec.5.19. Change24 ES SRM spite a range of 2 to 10.jospt.5/4. For personal use only.10. reported when the retest was based on a 7Ykj[ ?dikhWdY[BWj[ single occasion but administered in dif- ferent languages31 or presented questions .91. The 410 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy .50.73 0.4 8-10 Park Neck Pain Questionnaire. Improved 0. ES (improved cohort): 0. mine why variations in reliability exist. Deteriorated –0. For example.30. and an r of 0. 84% CI24 SRM: 1.98 on NDI versus 1.805 studies by Cleland et al9.50 Two well-powered.44 for patient and physician GRC16 has been established between the NDI and a variety of other questionnaires In a review of randomized controlled trials using the NDI46 that can be used for patients with neck .16 tients with recurrent neck pain.87-1.72)9 with acute and chronic neck pain.88 at 4-6 wk5 tively. All rights reserved.77 0.49 who Change42 ES SRM reported an MDC of 1. many studies did not sepa.1.95. ICCs Change in 2 cohorts36 (similar to CWOM or FRS) Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. [ LITERATURE REVIEW ] Some studies did not define these impor- tant factors.80/ 9-10 Specific Functional Scale.93 0.47.0 12.40 and 0.org at University of Washington on December 1. Short term 0. Response Burden. Administrative rate patients with acute or chronic neck pain. tients’ perceived pain and psychological purported constructs (J78B. The highest estimate .17 estimate for MDC is around 5/50 (10%).49 De.67 a –3 to +3 global rating of change.85-0. Only a few studies presented the SEM Change in group after 11 mo (no standardized Rx during gap) (compared   DF:?"DFG"L7IfW_d"L7I^WdZ_YWf"ceh[i_]d_ÓYWdjP value than all but or the MDC.77 the lowest comes from Voss et al.10 suggested that Mehi[ KdY^Wd][Z ?cfhel[Z reliability may be lower than generally    FW_d%:_iWX_b_jo FW_d%:_iWX_b_jo FW_d%:_iWX_b_jo reported (ICCs of 0.3/–4.2/12.1 2.48.91 study sample. In a study of the Neck Pain and Disability Index response to botulin toxin Validity Construct convergent validity measured by Cohen d was 0.53 Others provided some FioY^ec[j_YFhef[hj_[i :WjW. score of the NDI both predicted visual with related constructs.95 1.25 0. 84% CI42 SRM (total cohort): 0.11. 84% CI42 tration. 0.93 Journal of Orthopaedic & Sports Physical Therapy® an MDC of 10.17. 2014. specificity. 84% CI24 ability reported for individuals with an ES (total cohort): 0.66 points for their Overall 0.0 studies based their definition of stable on ES –0.15/0.I 9^Wd][_dD:?IYeh[i%+& pain (J78B.49. the more common Overall 1.2 points for their patient Stable –0.40 for former and 0. cates that there is a link between the pa.34 population with cervical radiculopathy.77 0.53 It was also reported by Hains et adequate convergent validity has been detected between the Hospital Anxiety al17 that the single pain item or the total demonstrated for a variety of measures and Depression Scale and the NDI indi. The developer suggests that   DFG3 MDC be 5 points.89 to 0. For example.1.92 7 Pain and Disability Score.16.43.)). *).68).24. Responsiveness test reliability varied from an r of 0.10 who reported Improved 0.73 to CID CID: 5 points43 CID: 7 points10 0.I IHC in a different order have been exception.66 ally high (0. 84% CI42 acute condition when the test-retest in.I IHC .

0. 70% Nieto et al33 conducted a factor analysis With COM.5.proqoulid. total score (0. MID 10.5 (pooled).84).5450 Correlation to PSFS. Norwe- gian. French.21 4 min. Spanish for the United States and samples. 2014. Translated into Greek. r = 0.95. not clear how/if for appraisal. Response Burden.839 function) in some subgroups. ICC = 0. ROC. rate concepts across different pathologies German. –0.+ Cultural Adaptation. All rights reserved. Wlodyka-  m_j^ej^[hY^Wd][iYeh[i š =F. 90%.” suggesting that the   š 9ehh[bWj_edD:?Y^Wd][jeD8G&$.38. tent to which pain and disability are sepa- Dutch. 0. SF-36 physical.21 Spanish.344 and interference with cognitive function- Correlation to clinicians prediction of change.88 tions about pain and disability treated as Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. 0. 0.$49 ity” and “Neck pain.WdZL7I&$+ scale may have 2 dimensions (pain and AUC. Similarly. VAS in 150 patients with whiplash injury and activity.66 and A highly powered Rasch analysis of 0. Correlation of English and Turkish NDI the r for test and retest was 0. and items of “personal FioY^ec[j_Yfhef[hj_[i :WjW. the items Administrative (continued) of “work” and “driving” had the strongest correlation (0.   š F[Whiedr.jospt.54-0. English for the United States. sensitivity. 0.31 Portugese-Brazilian. “Functional Disabil- Downloaded from www. Danish.83 change scores50 ing” and “functional disability. and in 7 min 59 s (1 min 26 s) by those with low one (p .49   š HE9Ykhl["&$-.601 found 2 factors that they termed “pain Correlation of NDI change to GRC change. English for the UK."&$*&"/+9?53 Demaille et al53 extracted 2 domains in   š 7K9"&$-/"/+9?53 the French version.org at University of Washington on December 1. lations perform similarly well.njhWYj[Z care” and “headaches” had the weakest Longitudinal validity correlation Comparisons: correlation (0.22 5 min (stated.com: English for Australia.45 “fulfilled in 6 min 08 s (54 s) by those with middle-high cultural level. 3. Portuguese. French Canadian. based on a manuscript now measured)29 in press that was shared by the authors. French for Switzerland. 0.77). Italian.36 0. specificity. VAS pain. Interitem corre- J78B.76 Correlation to Disability Rating Index. items are positively correlated with the Summary of Responsiveness.73-0.17 Conversely.11 French53 brief disability scales which include ques- Agreement between translated version 69% identical answers. No other uses without permission.33). German for Switzerland. For personal use only.88.” This 1. with input from the developer44 one-dimensional and may reflect the ex- Translations available on the MAPI website www. Polish. 0. Italian for Switzerland.733 the NDI (n = 521 patients) was available Response burden Time to complete: 9 min. Finnish.or 2-factor effect has been observed on other Cultural adaptation Language/cultural translation/validation Turkish.86.22 Iranian. Spanish for Spain.

core surement by examining fit with a Rasch outcome measure. model. scales. GPE. Overall. GRC. treatment. 0. NPDI. this approach is Northwick Park Neck Pain Questionnaire. Structural the same meaning across subgroups. relation between the VAS and items on vides a relatively weak indication of struc. effect size. NDI to the model and that 4 items had sions of the NDI. Ackel. and values reported for other unidimensional demonstrated disordered thresholds.85. Unidimensionality tests showed that dif- of the NDI has demonstrated validity in tor analysis in a small number of studies ferent subsets of items gave significantly evaluation of pain and disability in acute with inconsistent findings. which is consistent with on lifting. deviation from model expectations. operating characteristic curve. tions are ordered and might be reason- standardized response mean. and work also with acute and chronic conditions. Hains et al17 observed that all on headaches did not fit with the trait journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 411 . or nontraumatic injury. neck disability index. This study determined that there was a lack of fit of same study administered 7 different ver. CID. whether have supported the NDI as a 1-dimen. SRM. Some studies different person estimates. indicating that some items did not have the NDI pertaining to pain and activity in tural validity or dimensionality. clinically important difference. Items on changing the order of the questions does sional disability instrument for patients headaches and recreation had significant not change the validity of the tool. COM. the content validity has also been evaluated using fac. ROC. Neck Pain Disability Index. with neck pain. NPQ. Short-Form 36 physical component scale. and concluded that The NDI was developed as a unidimen. In particular. personal care. global rating of change. core whiplash outcome measure. visual analog scale ably interpreted as numbers. while others suggest it has a single underlying construct. global perceived effect. this statistic alone pro. CWOM.001)”2 An advantage of this approach is that it Journal of Orthopaedic & Sports Physical Therapy® formally assesses whether an instrument Adminstrative burden 5 min to analyze18 satisfies rules for interval scale mea- Abbreviations: AUC. The item and whether stemming from a traumatic 2 factors. able to determine whether response op- ing characteristic. that the NDI items did not contribute to from a musculoskeletal or neural source. VAS. suggesting and chronic neck conditions. PSFS. ferential item functioning was detected. ES. Dif- demonstrated that there is a higher cor. Pain-Specific Functional Scale. Rx. SF-36 physical. Items man and Lindgren1 included individuals ally exceeded . disordered response thresholds. Cronbach’s B has gener. NDI. However. sional scale. an acute population. receiver operat.

org at University of Washington on December 1. by to their situation and use. The reliability data cur- treated patients remain relatively stable rently published in the literature provide :?I9KII?ED over 1 to 3 days. when using ty is a plausible explanation for lower es- abling chronic whiplash-associated dis. Some studies have used as much as Extended Aberdeen Spine Pain Scale 2001 a 5-week interval in patients defined as 8ekhd[cekj^D[YaGk[ij_eddW_h[(&&( stable to determine test-retest reliability. changes in Responsiveness The NDI appears to properties will vary according to pur.90). However. that a revised 8-item NDI would satisfy to strong evidence for a spectrum of psy. Patient-Specific Functional Scale 1998 Copenhagen Neck Functional Disability Scale 1998 neck pain. it is impor- the improved cohort (J78B. Only a few studies presented more cal recommendations regarding its use. Conversely. For example. affect scores as test-retest intervals are that the NDI is not unidimensional. self-efficacy. ate self-reported changes are defined as clinically relevant indicators of measure- 412 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . to 0. They concluded within the limits prescribed by the avail. Conversely. pain or task difficulty remains consis- these requirements and provide interval. the patient has remained stable.43 have stable scores in longer test-retest in. estimates that reflect different definitions tervals it is more necessary to establish of stable. Thus.5. be appropriate for consideration when compared to a 7-point change in patients tervals. tant to consider that these variables do indicates that the NDI has good ability to ences between known subgroups. In short-term test-retest intervals estimating error across shorter clinical with neck pain of neural origin.23. [ LITERATURE REVIEW ] stable in this analysis. but able evidence. In longer test-retest in. importance of different psychometric external references.. For personal use only. Thus.43. patients with small to moder. All rights reserved.+).60 when measured in the and responsiveness should be considered in the absence of changes in pain intensi- total cohort of subjects with “mildly” dis. a form of test-retest intervals.42 This discriminative validation that tests differ. factors like coping. in different clinical subgroups.jospt. re-evaluations. (Nonspecific Validated for the Neck) Scales on a single occasion. have been ex- Neck Disability Index 1991 ceptionally high (0. +). the level measurement of neck disability. most relevant. No other uses without permission. it should be appreciated that an increasing number of factors may captured by other items. would contribute to measurement error in clini- detect change over time. This suggests Dehj^m_YaFWhaD[YaFW_dGk[ij_eddW_h['//* that lower test-retest reliability across Disability Rating Index 1994 longer test intervals may reflect changes in scores due to the episodic nature of Downloaded from www. be more important.10. whereas shorter intervals may is a change of greater than 5 points.47 When neck NDI is stable over short test-retest time important to consider when designing pain is of musculoskeletal origin. Even if a patient’s severity of Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. or social have good responsiveness when consid. pose. patients. There is adequate evidence that the with longer test-retest intervals may be ference (CID) (J78B. the NDI to differentiate different levels of timates of reliability in studies with larger orders. mediated by psychosocial influences and item version and had similar correlations eletal or neurogenic origin. Only a few stud. NDI and was able to provide some clini. and how “sta- Neck Pain and Disability Visual Analog Scale 1999 ble” is defined within a given time win- Functional Rating Index 2001 dow. reliability studies ies calculated the clinically important dif. neck pain with symptoms of musculosk.95 when measured in only disability. the absolute measurement error Recalibration of the disability experience varying from 0. Overall. ICCs English Language (Specific-to-Neck) and 3 reported when the test-retest was based J78B. This is with different test-retest intervals allow- J his study synthesized current research in 37 studies addressing often based on a –3 to +3 score on global ing users to select estimates most similar the psychometric properties of the rating of change instrument. there is moderate extended. 9[hl_YWbIf_d[EkjYec[iGk[ij_eddW_h[(&&( While it is important to understand short- M^_fbWi^:_iWX_b_joGk[ij_eddW_h[(&&* term and long-term stability of clinical measurements. The the NDI in patients with acute or chronic experience of pain and disability will be 8-item NDI was consistent with the 10. definition. known group validity.10 researchers often assume that most un. Therefore. Journal of Orthopaedic & Sports Physical Therapy® standardized response mean (SRM). early recovery. 2014. chometric properties supporting use of tent over the course of several weeks. although it is less clinical research studies and reliability can be said to have occurred when there likely that patients defined as stable will studies. a CID intervals (0-3 days). with the NDI ad- Reviewed in a Previous Systematic Review 37 ministered in different languages31 or different question order. when using the NDI support may contribute to alterations in ering the typical reported effect sizes or to evaluate clinical change in individual perceived disability over a 5-week period. cal studies. The relative calibrated against multiple internal and to measurements of neck pain intensity.

If full-text papers written in only English or an MDC of 1.50 which is able to sample ness to detection of clinical change. we rank ordered studies by cal practice and research requires tre- that another instrument was superior to quality to allow the reader and ourselves mendous efforts in translation/cultural the NDI in terms of responsiveness. none of the studies that per. Despite a range of 2 to 10. was not an outcome measure. Across the different studies. Evidence suggests that smaller abstracts in non-English text. Neither previous systematic these variations are reflected on the NDI responsive. like the Patient-Specific Func. individual studies by developing a tool velopment or validation to replace the length of follow-up. as objective as possible. suggesting that a num. so it these ranges. For personal use only. there are no levels of evidence that It is an important consideration that formed head-to-head comparisons of create clear categories for study quality. This reviews only high-quality studies are research and practice. in both its original English format. making it difficult to synthesize re- points. We don’t expect this limitation to included stable patients with recurrent points (and up to 10 points). clinicians should consider cal utility. estimates come from studies with lower struments. For these reasons. there are inher- being expressed in unit of the original dures for valid translation and demon. teria for synthesis process for psychomet. therefore. different contexts and purposes.66 for their study. it is important to patients who score at the extremes may designed to comment on whether the see how the instrument performs across benefit from supplemental scales. we were able to extract data from English large range of MDC values are largely tively. this cross-validation is well under way. These include its brevity and is not surprising that the larger MDC supplementing the NDI with other in. tion articles were printed in English. ment error. The de. MDC tional Scale.org at University of Washington on December 1. There was agreement across studies on the findings from high-quality studies. a mechanism to place greater emphasis adaptation and knowledge translation. more. like NDI is the most responsive neck scale. both least some of the recommended proce.10. The most recent sug- general.4 Due to the brief must be taken within the context of the cient and the sample variability. estimates are highly variable review incorporated critical appraisal. introducing new instruments into clini- different neck disability scales indicated Therefore. tine evaluation of neck disability. tural or language subgroups. respec. All rights reserved. making the scale more amenable to that can be applied across different cul- reliability estimates. In some systematic instrument is suitable for both clinical in different clinical circumstances. The highest estimate comes from scoring variations can create potential sults from individual studies into global Cleland et al. We would also suggest that within tures that suggest that it has good clini- can increase the value of the MDC. the NDI has a number of fea- deviations or lower reliability coefficients scale. Ceiling/floor effects have recommendations. this consideration. is important to have outcome measures interval and the definition of stability on thus.2 points for their patient population been suggested as a potential problem. of 40 or higher and 10 or lower might as the majority of translation and valida- the more common estimate for MDC is be considered problematic for detect. published translations used at ers. although pose. Despite variability. method to synthesize the extracted psy. unclear. It variations reflect the effects of test-retest items that are of high or low difficulty. However.26 there is no clear NDI as the instrument of choice in rou- nature of the neck condition will be re.49 who reported of what constitutes a ceiling or floor. Although the first author of this review It is certainly true that no other in- ber of fully powered studies that vary on has addressed the critical appraisal of strument has undergone sufficient de- factors such as the type of intervention. 2014. change to different instruments or in stand.10 who reported an MDC of for confusion. although there is no consistent definition that the scope of our search retrieved Downloaded from www. In and expanding a framework used by oth. However. neck pain. the NDI has study population. any suggestions of that the NDI is easy to read and under. varies across the subgroups and how Journal of Orthopaedic & Sports Physical Therapy® While the NDI has been shown to be ric studies. Further. the Patient-Specific Functional Scale. when evaluating and measurement principles suggest that ent instruments and. A second limitation in our review is with cervical radiculopathy.jospt. One limitation of our review stems future studies may focus on whether the priate for most clinical comparisons that from the lack of agreed upon quality cri. While we tried to make the process gestion is that an 8-item version of the journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 413 . interventions. and the for this purpose. No other uses without permission. chometrics and usefulness by adapting the NDI itself should be balanced with as well as in subsequent translations. and pur- veloper of the NDI suggests that MDC is 5 minimal administrative burden. Although the value of 5/50 or 10% commonly used cal presentation. which one assumes that the MDC is usually at 5 French. the fact that it has been translated into a Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. The reasons for this ing worsening or improvement. nature of the questionnaire. although either larger standard changes are relevant at these ends of the Overall. among studies. and the low. although evidence review did not attempt to evaluate differ. ently subjective elements. the SEM or the MDC. and around 5/50 (10%). est was from Voss et al. in clinical situations appears to be appro. responses. comorbidity. then scores have a substantial impact on our results. strated equivalence. number of languages and its responsive- ICCs. The quired to provide more precise estimates chometric evidence. pain/disability experience in neck pain tend to occur over 2 weeks or less. synthesized.25. 10. change for patients with this type of clini. We summarized the information on psy. as study results score and based on the reliability coeffi.

Finnish. veloped using a clinimetric process and by interested users when publishing and Spanish for the United States. Swedish. languages: English.43 ative data and benchmarks. valid.9ECC. including the specific psycho. clinical subgroups and the impact of dif. are warranted and should specifically 3. Others have return to work. and respon. [ LITERATURE REVIEW ] NDI performs as well as the original NDI H. 3.1. mechanisms for these to be obtained ish. However. most importantly. and up to 10 points might enhance performance. and Portu- script. goals should require a minimum of 5 their relative priority. Qualitative studies and cognitive be set for a minimum 7-point reduc- Perhaps. French. to the subjective categories reported current benchmarks set for normality whiplash-associated disorders. Korean. as well as those Scale should be considered. so or comparing scores as to whether scores need for this revision. When the allow clinicians to provide more accurate 1. literature and provide more accurate Dutch.49 tion should be exercised when presenting studies are required to determine the 5. English for the United the accessibility of translations would needed to resolve confusion in the States. Iranian. The CID is approximately 7 points. “gold standard” among outcome measures. Defining detectable change on the NDI. Studies that determine NDI bench. Spanish for Spain.10. For example.jospt. The NDI is reliable. like disorder I and II.45 Currently. published with the validation manu. and in the literature.53 In addition. French Cana- While the NDI may be considered the prognostication/outcome evaluation. Italian. Ital- this review suggests further investigation ity of their translations and provide ian for Switzerland. Because these are not ated. this should be re-evaluated within a Journal of Orthopaedic & Sports Physical Therapy® prove performance. and to communicate more suffering from neck pain associated 7.1. German for Switzerland.24.11. ies and may be up to 10 for cervical concepts for patients with neck pain or marks that clinicians could use with radiculopathy. commercial cian to seek out these tools by contacting 2. it is not clear whether translation process.45 <KJKH. German. moves to improve and CID in different subgroups are for Australia.43 a statement reflecting that these dis- and specific data analyses are needed to 2. there are interviewing that evaluate how pa. Studies that compare the proposed re. term goals. For personal use only. supplementation of the NDI would be important in assisting clinicians including patients with acute and with a Patient-Specific Functional in using the NDI to set short. the with musculoskeletal dysfunction.23. performed for the NDI in the following validation studies. All rights reserved. Short-term therapy weighs pain and disability according to confidence to indicate “normal” ver. cau. as Dutch. ficulty of obtaining official translations.10. Downloaded from www. MDC. a ficiently validated nor occupational 414 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . Pol- is needed. properties in different clinical groups ric was used. clinical contexts and in longitudinal be anticipated (2 weeks).48. Clinicians may relate an NDI score effectively with payers. it is the responsibility of the clini. Published cultural validation has been as these are not usually published with state hypotheses that are to be evalu. Patients who score in the range of ei- the work on MDC and CID is sparse and self-reported disability as reflected ther 40 to 50 or 0 to 10 on the NDI inconsistent. for whiplash-associated disorder III. but should include and for levels of disability are arbitrary.D:? by 2 to restore the expected metric. English for the UK.:. well as the expected outcome. Finally. Studies that determine SEM. baseline score is outside of the 10-to- prognosis and outcome evaluation. 40 range. suggested that removal of items might im. would inform our understanding of 6. variations visions to the 8-item NDI in different timeframe where this change could in scoring exist in the literature. Importantly.OFE?DJI making it difficult to detect subsequent ferent prognostic variables on these would worsening or improvement. and points change for whiplash-associated the possibility that the addition of items targets for important milestones. French. longer-term treatment goals should are out of 50 points or 100%. tion in score to demonstrate treatment gaps in defining clinically useful compar. original pilot testing was conducted on a official manuscripts related to the 4. it is easier to change to a reduced-item Caution should be used when reading instrument than a different one. 9ED9BKI?ED%A. very small sample. The NDI should be scored out of 50 ability benchmarks have not been suf- establish valid benchmarks. Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. are needed. sites provide translations in English developers. tients respond to items of the NDI benefits. dian.DJ answered questions must be divided An advantage of this suggestion is that E<J>.BEFC. should be considered as approaching a and important difference for different ceiling/floor effect (45/5. These sive in numerous patient populations. respectively). Authors should consider the availabil. metric property being analyzed. but varies considerably across stud- the NDI captures all of the important 4.D:7J?EDI<EH percentage score used to adjust for un- and can be considered as interval data.1. This leaves open sus different levels of disability. Because the NDI was not de. 5. Norwegian.and long. No other uses without permission.org at University of Washington on December 1. thus. 6. The MDC is accepted as 5 points. Future studies on the psychometric clinical reports to ascertain what met- a practical issue for clinicians is the dif. Danish. Portuguese. guese. as recommended by the developer. cervical radiculopathy. benefit clinical practice.49. 2014.L. chronic conditions. 1. French for Switzerland.

org/10. Heliovaara M. ). Psycho. http://dx. interpretation and 24 moderate disability. A ment of functional outcome for cervical pain of the Neck Disability Index and Neck Pain and comparison of four disability scales for or dysfunction: a systematic review.org/10. Spine. Critical appraisal of study quality disability. for psychometric articles. Measurement of cervical flexor whiplash.16 quality for psychometric articles. 2008. et  )$ Aslan E. Validity ('$ Kose G.08. Silcocks P. Minimal clinically important change of math. J Manipulative al. Cieslak KR. of a modified version of the neck disability in- Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. Northwick Park neck pain questionnaire. dx.doi. 15 brs. WJ.33:E630-635. Spine. Childs JD. Oostendorp RAB. Adams RD. http://dx.30:259-262. of the Neck Disability Index in physiotherapy. discussion 2418.0000257595. chbinder R.35035.2007.I '+$ Gay RE. 2005. Development and psycho. Coeytaux RR. Applying evidence that individuals who have recovered have Duquet W. 2007. those with mild assessed instruments for measuring chronic J Hand Ther. Refshauge KM.doi. J Reha. the Neck Disability Index and the Numerical  . Waalen J.1097/ 2008.89:69-74. Validity of the neck disability index.2340/16501977-0060 Vet HC. NJ: Slack Inc.8:6. Clair DA. '($ Croft PR. Spine. (-$ MacDermid JC.0b013e31815cf75b  /$ Cleland JA. of instruments to measure neck pain disability. http:// 2004.1016/j. Whitman JM.4:113-134. consequences for clinical decision making. Sterling et al41 suggest ')$ Eechaute C. http://dx. Lindgren KA. disability have a score of 10 to 28. 2006. Disability Scale for measuring disability associ. Turkish patients with neck pain. 2007.0000201241. Karaduwman A.” has been suggested by Miet.31:1621-1627. Prevalence.  ($ Andrade Ortega JA.doi.39:358-362. Hermens HJ. '$ Ackelman BH. Thorofare.009 )&$ Miettinen T.org/10. J '&$ Cleland JA.2007. Pain. Zilvold G.1097/01.doi. Psychometric proper. Yakut Y. http://dx. J Manipulative Physiol Ther. Ijzerman MJ. 2007.org/10. Spine. Miro J.0b013e31817eb836  .brs.005 Musculoskelet Disord. et al. 2001.18:245-250. Green S. BMC org/10. Standard scales for measure-  -$ Chan Ci En M.2004.1007/s00586-007-0503-y dex. Wheeler AH. )-$ Resnick DN.org/10. plete disability. Carey TS. Neck pain in the comes in neck pain patients. In: Law M. dx. mechanical neck pain. Aras B. 2004. bil Med. (/$ McCarthy MJ.1080/09638280400020615 for cervical spine pathology: a narrative review.32:E825-831.3:16-19. have a score greater than 30. Med Clin (Barc).22 org/10. Fritz JM. Lewis M. 2002. Validity and reliability patients with chronic uncomplicated neck pain. Predictive value of fear avoid- MB. Arch 2000. Asman S. Stratford PW.D9.2008. MacDermid JC. Papageorgiou AC. Critical appraisal of study no disability.130:85-89. Sievers K. Maher CG. Nicholson LL. Schipholt HJA.<. et al. Iranian versions of the Neck Disability Index and validity of neck disability index in patients '. )'$ Mousavi SJ.1186/1471-2474-9-42 ). 2008. Bouter LM. Impivaara O.1097/01. (. M. Hepguler S. )+$ Pool JJ. reliability Physiol Ther.doi.$ Makela M. Spine. The reliability of the Vernon and Mior neck of the Neck Disability Index and the Neck disability index. 1994. Gomez E.53069. Arch Phys Med Rehabil. Disability in subacute measures in patients with neck pain: detect. Hobbs H. Pain.org/10. A “normal” score of between 0 to 20 org/10. Nederlands Tijd. Spine. de Man Ther.1097/01. Comparison G. and Phys Med Rehabil. The neck The possibility to use simple validated question- mecija Ruiz R. Spine. Stratford P. 1998. Spine. Al- '. Hoving JL. (+$ MacDermid JC. 2002.doi. 2004.0000221989. Thorofare. Van Aerschot L.27:801-807. Braga L.005 (($ Kovacs FM. Royuela A. Spine. Montazeri A. Bolton JE.0b013e31817144e1 patients with chronic whiplash. BMC Musculoskelet Disord. and greater than 35 com. Niere KR. Bu. 2003. 5. 2007. T '*$ Foster GA. Parkinson WL. 2006.doi.$ MacDermid JC. Delgado Martinez AD. Guillemin F. Am J Epidemiol. Palmer JA.30 Vernon and Mior48 suggest ian Portuguese version of the Neck Disability M. http://dx. determinants.H. In: Law tinen et al. with neck pain: a Turkish version study.1186/1471-2474-8-6 Knekt P.112:94-99. Psycho. factors for neck pain: a longitudinal study in the Based Rehabilitation. Huguet A. Sand T. Elvers JWH. Evaluation of the core outcome measure in and Numeric Pain Rating Scale in patients with et al.doi. Edmondston SJ.doi.http://dx.jospt. Leino E. org/10. Turk Journal of Orthopaedic & Sports Physical Therapy®  *$ Beaton DE.02.1097/BRS.jht.29:2410-2417. of 4 neck pain and disability questionnaires. ability index. on outcome measures to hand therapy practice.doi. Evidence- vere disability.a5 points.$ Heijmans WPG. Sensitivity and specificity of outcome problem elicitation technique for measuring ))$ Nieto R. (*$ Lee H. No other uses without permission.85:496-501. Goldsmith CH.doi. construct validity.1:5-22.doi. 2008. 5 and 14 mild disability. 2008:387-388.25:3186-3191. 2002. Documenting out. disability associated with whiplash-associated whiplash patients: usefulness of the neck dis- ing clinically significant improvement.21:75-80. http://dx.1097/01. 2007. and the Neck Pain and Disability Scale. Evidence-Based Rehabili- Index and Neck Pain and Disability Scale.doi. Ostelo RW. Cross. endurance following whiplash. cultural adaptation and validation of the Brazil.93:317-325. Disorders. 2002. Rehabil. http://dx. 2005.07.17:165-173. Bombardier C. and ankle instability: a systematic review. Disabil org/10.1197/j. Simsek ties of the neck disability index. Horizon Estimation and consequences of chronic neck pain in Fin- Using SAS Software.1097/ Physiotherapy Singapore. Stewart metric properties of the Neck Disability Index ()$ Kumbhare DA. Aromaa A. thy. TX: 2008. http:// BRS. SAS Global Forum 2008. Spine. Atamaz F.$ Rebbeck TJ. DC. Spine. 1991. 2004. Madson TJ. Whitman JM.126 org/10. Schrader H. Subjective outcome assessments apmr.16:2111-2117. DeVellis RF.03. general population.brs. 2007. 25 and 34 se. Clin J Pain. Gretz SS. scale in patients with cervical radiculopa.31:1841-1845. http://dx. http://dx. Bae SS. Balsor B. non-traumatic neck pain. The clinimetric qualities of patient. )($ Nederhand MJ. those with moderate to severe disability org/10.$ Bovim G. Richardson JK.$ Riddle DL. after whiplash injury. O’Leary EF. San Antonio.doi. The reliability and application metric characteristics of the Spanish version Rating Scale for patients with neck pain.$ Goolkasian P. a NDI score of 8 or less.org/10. 2008. Mior S. Eur Spine J. The cultural adaptation. Translation and validation study of the IE. land.102:273-281. All rights reserved.org/10. http://dx.9:42.org/10. 2014.31:598-602. Oder G.134:1356-1367. Spine.1016/j. which represents “none to mild ''$ Cook C.brs.52 2008. Downloaded from www. Bolton JE. http://dx. 2000.27:515-522. Risk guide.doi.doi.33:E362-365. Chiro Med. Grevitt MP. Guidelines for the process of cross-cultural '/$ Hoving JL.$ Chok B.doi. tation. The reliability and construct validity of the Neck Halaki M.org/10.75367.0b013e31815ce6dd BRS. Richardson general population. http://dx. (&$ Humphreys H.19:1307-1309.1016/j. 2002.org at University of Washington on December 1. Lindgren U. Parnianpour M. J Rehabil Med.90914.0000227268. and its validity compared with 8ekhd[cekj^Gk[ij_eddW_h[_dWiWcfb[e\ the short form-36 health survey questionnaire.32:3047-3051. http://dx. ance in developing chronic neck pain disability: adaptation of self-report measures. 2008:389-392. MacDermid JC.jmpt. disorders. Neck disability index Dutch 2007. ated with chronic. J Whiplash Rel )*$ Pietrobon R. (. that a score between 0 and 4 represents 2006. eds.29:E47-51. NJ: Slack Inc. Spine.  '-$ Hains F. Yagly N. Vaes P. eds. For personal use only.32:696-702. http://dx. Maher CG.1097/ version (NDI-DV): investigation of reliability in BRS.34:284-287. Use of generic versus Disability Index and patient specific functional metric testing of Korean language versions region-specific functional status measures on journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 415 . [Validation of a Spanish version pain and disability scale: test-retest reliability and naires to predict long-term health problems of the Neck Disability Index]. Airaksinen O. et al. Bago J. demands considered. Ferraz schrift Voor Fysiotherpie. evaluation form.

To participate in the program: 1. http://dx. Arch Phys Med Rehabil. Assessment of self-rated dis. and the Journal website maintains a history of the quizzes you have taken and the credits and certificates you have been awarded in the “My CEUs” section of your “My JOSPT” account. 1998.$ Vernon H. Login and pay for the quiz by credit card. 1991-2008.doi. Responsiveness of pain and dis.1016/j.org/10. patient-specific functional scale: validation of its EkjYec[iGk[ij_eddW_h[WdZ_jih[bWj_edi^_f BMC Musculoskelet Disord.doi. pain.2008. Padfield B. Antono. 2004. of the Neck Disability Index and validation of the +&$ Westaway MD. *)$ Stratford PW.07.?D<EHC7J?ED Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®.1097/01. brs. 2002.BRS. Tennant A. Albert TJ. Arthritis Rheum.doi. Spadoni 2000.doi.12598. 416 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . Physiol Ther.01.32:580-585.org/10. http://dx.71:317-326. responsiveness of the Dutch version of the Neck CEH. Fermanian J. Westaway MD. Kenardy J. 3rd.9:106. Joint Bone Spine. The Neck Disability Index: state-of.doi.1016/j. Physiother Canada. 2014.71056. 1998. Sports Phys Ther.org/10. http://dx.005 Hurwitz E. +($ Wlodyka-Demaille S. Binkley JM. http://dx. Kakavelakis KN. 2007.78:951-963. Jull G. Prescott P. The Neck Disability Index: a +)$ Wlodyka-Demaille S. Vernon HT.14:409-415. Poiraudeau S. Rannou F. Spine J. Riddle DL. G. http://dx. Eur Spine J. For personal use only. Disability Index in patients with acute neck pain 1999.29:182-188. 2006. Reliability and @ Disability Index to make decisions concern. ability measures for chronic whiplash. Catanzariti 2006. Mior S. Paganas AN. org/10.51:107-112. 5.1097/01. JF. click “Take Exam” for that article. Bogduk study of reliability and validity. http:// orders.jospt.org/10.doi.2006. http://dx.doi.doi. Verhagen AP. Binkley JM. J Orthop research. art. Psy.org/10. 2004.org at University of Washington on December 1. Rannou F. 2. predictive capacity post-whiplash injury. Phys **$ Trouli MN. Riley LH. Hogg-Johnston S.2006. 3. 2008.1007/s00586-006- Ther. 1736. http://dx. Spine.31:491-502. 2004.7:174-179. poulou MD.83:376-382. Nicholas M. The core outcomes *&$ Sterling M. Spine. Spine.24399 pain.1016/j.0000105535.61:544-551. jmpt.AE *-$ Vernon H. Go to www. Physical and new insights into the measurement properties for neck pain: validation of a new outcome mea- psychological factors maintain long-term of the neck disability index.04.JOSPT.08. *+$ van der Velde G. Vicenzino B.1016/j.1186/1471-2474-9-106 use in persons with neck dysfunction. 2009. Poiraudeau S. Koes BW. translation and validation of 3 functional disabil- 2007.27:331-338. Using the Neck */$ Vos CJ. French N.004 org/10. The RFC program offers you 2 opportunities to pass the quiz. Revel M.6d whiplash-associated disorder. WWW.006 dx. the-art. Pain. impairment and sincerity of effort in ity scales for neck pain. Translation 0119-7 )/$ Skolasky RL. Beaton D. Maher CG. No other uses without permission.014 *. Kenardy J.org/10. Lionis CD. Stratford PW. You may review all of your answers—including the questions you missed. 1991. The chometric properties of the Cervical Spine Greek version in a sample of neck pain patients. [ LITERATURE REVIEW ] patients with cervical spine disorders. in general practice. Take the quiz. *.0000256380. ability.122:102-108. http:// to standard assessment tools used in spine dx.jospt.15:1729. Revel M.2003. J Manipulative Physiol Ther. ity to change of three questionnaires for neck acterization of acute whiplash-associated dis.org/10.doi.2 CEUs for each quiz passed. Char. Rasch analysis provides +'$ White P.8:155-167. sure. Fermanian J. ing individual patients.29:1923-1930. Catanzariti *($ Stewart M.jbspin.ORG EARN CEUs With JOSPT’s Read for Credit Program Journal of Orthopaedic & Sports Physical Therapy® JOSPT’s Read for Credit (RFC) program invites Journal readers to study and analyze selected JOSPT articles and successfully complete online quizzes about them for continuing education credit. Choose an article to study and when ready. 4.1002/ Downloaded from www. J Muscskel Pain. All rights reserved.$ Vernon HT. Lewith G. 2008. Jull G. J Manipulative JF.spinee.org and click the link in the “Read for Credit” box in the right-hand column of the home page. The abil- *'$ Sterling M. You receive 0. Evaluate the RFC experience and receive a personalized certificate of continuing education credits. Refshauge KM.

APPENDIX A NECK DISABILITY INDEX This questionnaire is designed to help us better understand how your neck pain af. Section 8: Driving Q It is painful to look after myself. 1991. but no more. Q I do not get dressed.ca Q I have severe headaches that come frequently. Score __________ [50] Q I have slight headaches that come infrequently. Q The pain is the worst imaginable at the moment. Section 5: Headaches Patient Name _______________________________________ Date _____________ Q I have no headaches at all. Q I can only do my usual work. Q I have moderate headaches that come infrequently. Section 1: Pain Intensity Q I can’t concentrate at all. Q I have some neck pain with all recreational activities. present-day situation. Dr. Q I can hardly drive at all because of severe neck pain. Q I can hardly do any work at all. Q I have no neck pain during all recreational activities. but it causes extra neck pain. Q I can drive as long as I want with moderate neck pain. Q I need some help but manage most of my personal care. any one section relate to you. Q I can lift heavy weights. Please mark the box that most closely describes your Q I have a fair degree of difficulty concentrating. Downloaded from www. Section 9: Reading Q Neck pain prevents me from lifting heavy weights off the floor but I can manage if items Q I can read as much as I want with no neck pain. For permission to use the NDI. Q I can hardly do recreational activities due to neck pain. Q My sleep is mildly disturbed for up to 1-2 hours. Q Neck pain prevents me from lifting heavy weights. Q I can’t drive as long as I want because of moderate neck pain. Q I can’t do my usual work. Howard Vernon at hvernon@cmcc. Q I need help every day in most aspects of self -care. but it gives me extra neck pain. although you may consider that two of the statements in Q I can concentrate fully with slight difficulty. Q I have neck pain with most recreational activities. are conveniently positioned. Q I cannot lift or carry anything at all. Q I can look after myself normally without causing extra neck pain. Q I can read as much as I want with slight neck pain. Section 3: Lifting Q I can’t drive my car at all because of neck pain. one box that applies to you. For personal use only. Q The pain is very severe at the moment. Please mark in each section the Q I can concentrate fully without difficulty. Q I can lift heavy weights without causing extra neck pain. Q I can lift only very light weights. Journal of Orthopaedic & Sports Physical Therapy® they are conveniently positioned Q I can’t read as much as I want because of moderate neck pain. Section 2: Personal Care Q My sleep is completely disturbed for up to 5-7 hours. 2014. Q I have a great deal of difficulty concentrating. journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 417 . please contact Q I have moderate headaches that come frequently.org at University of Washington on December 1. Q My sleep is greatly disturbed for up to 3-5 hours. Q I have no trouble sleeping. I wash with difficulty and stay in bed. Q I can’t do any recreational activities due to neck pain. Q I have some neck pain with a few recreational activities. Q My sleep is moderately disturbed for up to 2-3 hours. Q I have headaches almost all the time. Q I have a lot of difficulty concentrating. but no more. Q I have no neck pain at the moment. Section 7: Sleeping Q The pain is moderate at the moment. ie. Copyright: Vernon H & Hagino C. Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. Q My sleep is slightly disturbed for less than 1 hour. and I am slow and careful Q I can drive my car without neck pain. No other uses without permission. All rights reserved. Q The pain is fairly severe at the moment. on a table. Section 4: Work Section 10: Recreation Q I can do as much work as I want. Q I can look after myself normally. Q The pain is very mild at the moment. Q I can do most of my usual work. Section 6: Concentration fects your ability to manage everyday-life activities. Q I can’t read as much as I want because of severe neck pain. Q I can’t do any work at all. Q I can drive my car with only slight neck pain. but I can manage light weights if Q I can read as much as I want with moderate neck pain.jospt. Q I can’t read at all.

it is important to realize that the purpose of data extraction is to remove or extract the specific information reported by authors within a study. Data Extracted Population studied Population Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. To make data extraction as useful as possible and to avoid the need for repeated data extractions.jospt. Intervention Reliability Reliability (relative) Journal of Orthopaedic & Sports Physical Therapy® Reliability (absolute) Minimum detectable change (MDC) Content/structural validity Internal consistency Content validity Floor/ceiling effects Factorial validity Item response/Rasch analyses C1 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . Instructions When using the data extraction form. not to evaluate the validity or value of that piece of information. read the accompanying guide and be as specific as possible when extracting information. [ LITERATURE REVIEW ] APPENDIX B DATA EXTRACTION FORM FOR STUDIES EVALUATING THE PSYCHOMETRICS OF OUTCOME MEASURES Authors: _______________________ Year: ____________ Rater: ___________ Downloaded from www. For personal use only.org at University of Washington on December 1. No other uses without permission. All rights reserved. 2014.

No other uses without permission. Construct/criterion validity Known groups Convergent Downloaded from www.jospt. Responsiveness Minimally clinical important difference (MCID) Usefulness/practicality Journal of Orthopaedic & Sports Physical Therapy® Readability Interpretability Time to administer Administration burden Cultural applicability © JC MacDermid 2008 journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | C2 . Divergent Longitudinal validity Concurrent criterion Predictive criterion Responsiveness/clinical change Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. For personal use only. All rights reserved. 2014.org at University of Washington on December 1.

Repeated testing (agreement). Studies will not address every aspect. If you find some studies with similar designs. or different raters (interrater) if a individuals. different test instruments (inter-instrument) are evaluated. Based on the findings of extraction. To this end. or standard error of measurement (SEM). In some cases. clinically important difference (CID). not to evaluate the validity or value of that information. how and where subjects were chosen. Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. and how it might be measured within a study. Evaluation of the quality of articles (also called critical appraisal) is performed in a separate step. you may be able to conduct a meta-analysis of some properties such as minimal detectable change (MDC). it is useful to collect information within standardized domains so that this information might be more easily synthesized to provide a summary of our collective knowledge about psychometrics and the utility of any given outcome measure. Listed here are an explanation of each property Downloaded from www. setting. acute versus chron- ic. Intervention Interventions (if applicable) applied for longitudinal Description of the nature. server-based scale is used. [ LITERATURE REVIEW ] DATA EXTRACTION GUIDE FOR STUDIES EVALUATING THE PSYCHOMETRICS OF OUTCOME MEASURES Instructions Psychometric studies may evaluate a wide spectrum of potential psychometric properties and aspects that relate to the utility or usability of outcome measures. Methods That Might Be Used to Collect This Property Information/Relevant Statistics Population studied Population A description of the study population Report meaningful demographics and indicators of the population studied: sample size. SEM is used to pres- ent a quantitative estimate of the reliability in the original units of measure. Some consider that sufficient time between tests is within 48 hours for acute conditions. Report the type of reliability evaluated and coefficients obtained. you may elect to present the synthesized data in a descriptive way by creating a summary table in each category. frequency. When using the data extraction form. In summarizing what is known about the psychometrics and utility of outcome measures. and 4–14 days for chronic conditions. OR by the same individual compare to the variability between rater (intrarater). demographics. There is no clear or easy method to synthesize this information. Relative reliability evaluates the extent to may be performed on different occasions (test- which variations on repeated assessment of the same retest) for self-report measures. pathology/ disorder. and the follow-up interval Reliability Reliability description The extent to which the same results are obtained Test procedures or measures are typically reapplied on repeated administrations of the same measure when on repeated occasions in individuals considered to no change in status has occurred (reliability) or how have a stable condition during that timeframe in precise the scores are on repeated measurements which repeated testing occurs. the following guide has been devised to describe the separate properties that might be evaluated in a psychometric study. The accompanying extraction form can then be used to collect specific information about these psychometric or utility properties from particular studies.jospt. 2014. To make data extraction as useful as possible and to avoid the need for repeated data extractions. Reliability (relative) The extent to which variability in test scores on repeated ICCs and their associated confidence intervals tests of the same person are related to variability overall (including between people) C3 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . No other uses without permission. it is important to realize that the purpose of data extraction is to remove or extract the specific information reported by authors within a study. it is best to be as specific as possible when extracting information. For personal use only. All rights reserved. The most common statistic used is the intraclass correlation coefficient (ICC) for quantitative data and Kappa for nominal data. and intensity Journal of Orthopaedic & Sports Physical Therapy® studies of the intervention.org at University of Washington on December 1.

5. Specific quantitative estimates of reli. Report the percentage of patients who sustained a floor or ceiling effect.org at University of Washington on December 1. 2014. Factorial validity The extent to which factor analysis supports assump. MDC Based on the reliability and defined level of confidence. the content’s relevance. and limits of 2 standard deviations are shown) Downloaded from www. Report the number of factors derived and the extent to which these findings agree with the instrument structure or original factor structure. Patients were consulted for reading and comprehension. Cognitive interviews were done with patients to determine the meaning of items.jospt. 2. content. it is important to consider the population the necessary content to capture the concept of to which the measure applies. extent to which items on a given measure reflect tent validity. journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | C4 . Reliability (absolute) The extent to which the same results are obtained on This may be reported as repeated administrations of the same measure when 1. Content validity The extent to which the domain of interest is adequately A variety of techniques can be used to assess the sampled by the items in the measure. specific study of the meaning of the questions to another cultural or language group was studied. and emphasis. No other uses without permission. In assessing con. Extract what was done and what was found.Factor analysis is conducted and compared to the tions surrounding constructs measured as defined by inherent structure of the instrument or factor analy- the measure or as indicated by subscale structure sis on which its construction is based. 2. Some of the techniques typically found are Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. 3. For personal use only. Content/structural validity Internal consistency The extent to which items on a test or subscale are Cronbach’s alpha is the inter-item correlation usu- related (an indication of the consistency of the concept ally reported. Expert panels or Delphi procedures were used Journal of Orthopaedic & Sports Physical Therapy® to select items or evaluate the validity of the instrument. Altman and Bland graphical technique where the ability in individual units portray the actual amount of difference on repeated tests for each individual is variation expected between repeated applications— plotted versus their mean score (and the overall reported in the original units of measure. the completeness of the interest. Note that different studies may define floor/ceiling differently. 1. Patients and experts were involved during item selection/reduction. Floor-ceiling effects When the measure fails to demonstrate a worse score in Descriptive statistics of the distribution of scores patients who clinically deteriorated and/or an improved were presented graphically or numerically and score in patients who clinically improved indicate this. During translation. 4. All rights reserved. so extract how these attributes were determined as well as the percentage. Extract the number and level of confidence this measure reflects the amount required to change before achieving a level of confidence that exceeds the random error that occurs in stable patients. Report alpha and whether it relates to measured) the entire instrument or specific subscales. SEM (possibly expressed as coefficient of varia- no change in status has occurred (reliability) or how tion in older articles) precise the scores are on repeated measurements (agreement). listed.

In other cases. Rasch analysis can be used to evaluate Downloaded from www. pared against a specific instrument and report the For subjective constructs such as pain and disability. Extract the test names and correlations. Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. In thought to represent similar constructs or divergent each case. their mean scores. and comparison of ability estimation. Construct validity is the extent to sures in a manner consistent with theoretically which measures perform according to a priori defined derived hypothesis concerning the domains that are constructs. 2014. Concurrent criterion Comparing a scale and its criterion at a single point in Extract the test names and correlations time assesses concurrent validity. Analyses might address item difficulty. Report whether these analyses were conducted and if they determined that items crossed a range of difficulty. For personal use only. No other uses without permission. C5 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . [ LITERATURE REVIEW ] Item response/ Rasch The extent to which items cross a range of difficulty. or Items can be placed along a spectrum using item analyses a spectrum of the concept measured response theory or Rasch analysis.Extract the groups. correlation or agreement between the measures. therefore. Known groups Known groups are constructed on theoretical assump. Convergent Relationship between similar scales/tests Extract test names and correlations. hypotheses are formulated. Constructed hypotheses “known groups” OR in relation to other indices that can assess convergent validity where measures are are similar (convergent) or different (divergent). individual ability curves.org at University of Washington on December 1. when summa- rizing. in accordance with the hypotheses. the term comparability is used when scales measure the same subjective construct. Construct validity can be cross-sectional measured OR the expected differences between or longitudinal (predictive). it is sometimes argued that there is no criterion and. All rights reserved. Predictive validity is evaluated by determining the extent to which the results of administering an outcome measure at one point in time is associated with a future status or outcome.70) and moderate (0. and level of tions that they should be different. validation focuses on construct validity. Concurrent validity is assessed by comparing a scale and its criterion at a single point in time. Predictive criterion Predictive validity is evaluated by determining the Extract the test names and correlations and time extent to which the results of administering an outcome interval measure at 1 point in time is associated with a future status or outcome. differential item functioning (DIF)—report if done and whether items demonstrated DIF. consider grouping into strong (>0.jospt. and the difference significance is assessed. the order of item placement in a test and/or the discriminative ability of specific items are defined. Construct/criterion validity Construct validity Constructs are artificial frameworks that are not The extent to which scores relate to other mea- description directly observable.70) correlations Divergent Relationship to scales/tests assumed unrelated Extract test names and correlations Longitudinal validity Relationship between change scores among similar Extract test names and correlations Journal of Orthopaedic & Sports Physical Therapy® scales/tests measured on different time points where change is expected Criterion validity description Criterion validation is determined by comparing a given Authors will state that their measure is being com- outcome measure to an accepted standard of measure. Results are validity where it is assumed they measure different evaluated to determine whether they are acceptable constructs. Most commonly. particularly if one is considered more accepted or rigorous.40–0.

Subjects are evaluated at size. standard response mean. Hypotheses are formulated and results are in agreement. If this is not specifically reported in the text of the study. patients perceive to be beneficial mandates a change minimally clinical important difference (MCID). compare scoring algorithms and administrative burden and report this. to extract the specific scoring algorithm for an instrument and compare it to others. multiple raters should evaluate the relative com- plexity of these scoring algorithms. Information is provided about or CID and the method/cut-off used to define impor- what difference in score would be clinically meaningful. For personal use only. However. This must be done in a systematic way and the method should be documented. CID The difference in scores in the domain of interests that Extract the minimally important difference (MID). 2014. Validation of subjective categories of outcome: excellent/ good/fair. the method used to validate/ quantitative scores or define subgroups by scores. during a systematic review. MID. For example. if appropriate. No other uses without permission. grade level can be assigned in some software Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. it cannot be extracted.org at University of Washington on December 1. Extract study data on scoring method burden Authors provide specific information on the ease of scoring. journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | C6 . Responsiveness/clinical change Responsiveness The ability to detect important change over time in the Extract indicators of responsiveness.jospt. etc) 2. Extract time Administration burden Ease of method used to calculate the questionnaire’s score. stable. and the method for 2 points in time and change in patients who had assessing whether patients were improved. All rights reserved. Authors analyze subgroup differences provide information on the interpretation of scores: 1. compared across different measures (and/or to patients who have not improved). improved (or have improved an important amount) is or worse. packages) Interpretability State the type of categorization and relevant scores The degree to which one can assign qualitative meaning to and. including effect concept being measured. Downloaded from www. Usefulness/practicality Readability The questionnaire is understandable by all patients. tance. in patients’ management. and CID are 3 different terms for How clinically meaningful is defined may vary (global the same concept. normal/abnormal Journal of Orthopaedic & Sports Physical Therapy® Time to administer Authors provide specific information on time to administer. rating of change with different methods of rating or establishing cutoffs for importance are often used). Authors State method and results obtained provide specific information on readability as evaluated by the target population or specific tools are applied to evaluate readability (eg. MCID. Comparative data for relevant subgroups (acute versus chronic.

2014. © JC MacDermid 2008 Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. Cross- cultural adaptation may be used to translate measures into different languages and to convert any items having specific meaning to culturally relevant items. Journal of Orthopaedic & Sports Physical Therapy® C7 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . All rights reserved. a number of analyses may be performed. including a structured translation process that includes forward and backward translation and retesting Downloaded from www. Highlight the results of cross-cultural adaptation as well as any languages/cultural adaptations that have been reported. reliability of the translated version. For personal use only. however. and a formal evalua- tion of the meaning of items in different cultures. If specific reliability and validity values are reported. No other uses without permission.jospt. an annotation should be made to note that the psychometric property applies to an adapted version. they can be documented in the appropriate data collection boxes above. [ LITERATURE REVIEW ] Cultural applicability The extent to which an instrument contains items that will Extract language/cultural translation performed be meaningful across different cultural groups or subgroups (and relevant findings) for which the measure is relevant or may be applied.org at University of Washington on December 1. In cross-cultural adaptation.

Was appropriate retention/follow-up obtained? (Studies involving retesting or follow-up only) Journal of Orthopaedic & Sports Physical Therapy® Measurements 7.jospt. standard error of measurement [SEM]. and did they consider potential sources of error/misinterpretation? Analyses 9. All rights reserved. Were appropriate inclusion/exclusion criteria defined? Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. benchmark comparisons. Were analyses conducted for each specific hypothesis or purpose? 10. Study question 2 1 0 1. 2014. CRITICAL APPRAISAL OF STUDY DESIGN FOR PSYCHOMETRIC ARTICLES: EVALUATION FORM Authors: _______________________ Year: ____________ Rater: ___________ Evaluation Criteria Score Downloaded from www. 3. Documentation: Were specific descriptions provided or referenced that explain the measures and their correct application/interpretation (to a standard that would allow replication)? 8. For personal use only. Were specific psychometric hypotheses identified? 4. Was an appropriate sample size used? 6.Were appropriate ancillary analyses done to describe properties beyond the point estimates (confidence intervals [CI].org at University of Washington on December 1. Was an appropriate scope of psychometric properties considered? 5. No other uses without permission. Standardized methods: Were administration and application of measurement techniques within the study standardized. Were appropriate statistical tests conducted to obtain point estimates of the psychometric property? 11. minimally important difference [MID])? journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | C8 . Was the relevant background research cited to define what is currently known about the psychometric properties of the measures under study and the need or potential contributions of the current research question? Study design 2.

© JC MacDermid 2008 Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. and multiply by 100 to get the percentage score. No other uses without permission. Journal of Orthopaedic & Sports Physical Therapy® C9 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . 2014. Total score % (sum of subtotals/24 × 100). if for a specific paper an item is deemed inappropriate. divide by 2 times the number of items. or. and results? Subtotals (of columns 1 and 2) Downloaded from www. [ LITERATURE REVIEW ] Recommendations 12. Were the conclusions/clinical recommendations supported by the study objectives.org at University of Washington on December 1.jospt. then sum items. For personal use only. analysis. All rights reserved.

0 No information on the type of clinical settings or study participants is provided. 1 Some. A detailed focus on validity that includes multiple forms of validity (content) judgmental (structured. Presented a critical and unbiased view of the current state of knowledge. but a clear rationale was provided for the research question. Pick the descriptor that sounds most like the study being evaluated with respect to a given item. A detailed focus on reliability that includes multiple forms of reliability (at least 2 of intrarater. read the following descriptors. factor analyses). and specific hypotheses on reli- ability and validity were not stated. Indicated how the current research question evolves from a gap in the current knowledge base. convergent/divergent associations). longitudinal/concurrent. as well as both relative and absolute reliability [eg. 4. but not clearly defined in terms of specific hypotheses. 1 Types of reliability and validity being tested were stated. For personal use only. but without additional information. which included the specific type of reliability (intra/interrater or test- retest) or validity (construct/criterion/content. however. 0 A foundation for the current research question was not clear. Question Score Descriptors Study question 1 2 The authors: Downloaded from www. 2014. All rights reserved. interrater. No other uses without permission. A priori hypothesis definitions are provided of level of reliability and for validity. responsiveness. the practice setting was described. as well as expected relationships (strength Journal of Orthopaedic & Sports Physical Therapy® of associations) or constructs. 1 All of the above criteria were not fulfilled (little reference to previous research and present gaps in knowledge). internal consistency and 1 test/form of validity). If there is no documentation of an action. Study design 2 2 Specific inclusion/exclusion criteria for the study were defined. and established predictive.jospt. Information on the type of patients is briefly defined. evaluative or discriminative properties 3. age/sex/diagnosis and the name or type of the practice is given. 0 Specific types of reliability or validity under evaluation were not clearly defined. and appropriate Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. 3. Established a research question based on the above. but is insufficient to allow the reader to generalize the study to a specific population. and the rationale was not founded on previous literature. convergent/divergent) being tested. (“The purpose of this study was to investigate the reliability and validity of…” can be rated as zero if no further detail on the types of reliability and validity or the nature of specific hypotheses is provided. eg. criterion (concurrent/predictive).org at University of Washington on December 1. and minimally important difference (MID)] 2. indicating what is currently known about the psychometric properties of the instruments or tests under study from previous research studies. 3 2 Authors identified specific hypotheses. 1 Two or more psychometric properties were evaluated. intraclass correlation coefficients (ICC). 0 The scope of psychometric properties was narrow as indicated by evaluation of only 1 form of reliability or validity.) 4 2 An appropriate scope of psychometric properties would be indicated by: 1. treat it as not done. Performed a thorough literature review. expert review/survey or qualitative interviews) or statistical (eg. journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | C10 . demographic information was presented. but not all information on participants and place is provided. standard error of measurement (SEM). For example. 2. 1. yielding a study group generalizable to a clinical situation. scope was narrow and did not meet the above criteria (eg. Some aspects of both reliability and validity were examined concurrently. test- retest). CRITICAL APPRAISAL OF STUDY DESIGN FOR PSYCHOMETRIC ARTICLES Interpretation Guide To decide which score to provide for each item on a quality checklist. construct (known group differences.

cost. Journal of Orthopaedic & Sports Physical Therapy® 1 No obvious sources of bias in how tests were performed/administered.jospt. 0 Data were not presented for each hypothesis or psychometric property outlined in the purposes or methods. For simple reliability/validity statistics if sample is greater than 100 but without justification for sample size. 0 Less than 70% of the patients eligible for study were reevaluated. training required. too many missing items] or individuals [language. use of consistent measurement tools and scoring. any special equipment required. Measurements 7 2 The authors provided or referenced a published manual/article that outlines specific procedures for administration. this includes calibration of any equipment. but authors did not clearly link analyses to hypotheses. but did not present specific sample size calculations or post-hoc power analyses. and examiner procedures/actions. 1 Procedures are referenced without any details. [ LITERATURE REVIEW ] 5 2 Authors performed a sample size calculation and obtained their recruitment targets. 1 More than 70% of the patients eligible for study were reevaluated. a priori exclusion of any participants likely to give invalid results or unable to complete testing (not exclusion after enrollment). but minimal attention or description of the extent to which the above standards were maintained. For self-report. or a limited description of procedures is included in the text. 2014. then the text describes the procedures in sufficient detail so they can be replicated. For personal use only. All rights reserved. 1 The authors provided a rationale for the number of subjects included in the study. Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. 0 Size of the sample was not rationalized or is clearly underpowered. and interpretation of test procedures that includes any necessary information about positioning/active participation of the subject. calibration of equipment if necessary. If no manual is referenced. were performed in a standardized way. 0 Minimal description of procedures is provided and without appropriate references. use of standardized instructions. 6 2 Ninety percent or more of the patients enrolled for study were reevaluated. No other uses without permission. or by demarcat- ing which analyses addressed specific psychometric properties. Downloaded from www. this is characterized by a statement of who administered the forms and by what process (definition of rules for exclusion of forms [eg. C11 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy . scoring (including how scoring algorithms handle missing data). including test administration and scoring.org at University of Washington on December 1. 8 2 All of the measurements. Post-hoc power analyses and/or confidence intervals (CI) confirm that the sample size was sufficient to define relatively precise estimates of reliability or validity. Analyses 9 2 Authors clearly defined which specific analyses were conducted for each of the stated specific hypotheses of the study. Data were presented for each hypothesis/research question. etc]). and test procedures. 0 No description of the extent to which the above standards were maintained or an obvious source of bias in data collection methods. For impairment measures. 1 Data were presented for each hypothesis. This may be accomplished through organization of the results under specific subheadings. comprehension.

however. Recommendations 12 2 Authors made specific conclusions and clinical recommendations that were clearly related to the specific hypotheses stated at the beginning of the study and supported by the data presented. 2014. but suboptimal choices were made in other analyses. 0 Inappropriate use of statistical tests 11 2 For key indicators such as reliability coefficients indices. Validity a. or other correlations if appropriate b. absolute .jospt. Appropriate confidence intervals (CI) 2. SEM or plot of score differences versus average score showing mean and 2 standard deviation (SD) limit—Altman and Bland) 2. Spearman rank correlations for ordinal Downloaded from www. with post-hoc tests that adjusted for multiple testing 4. OR authors made conclusions and clinical recommendations for only some of the study hypotheses. MID 3. Journal of Orthopaedic & Sports Physical Therapy® 0 Authors made vague conclusions without any clinical recommendations. For personal use only. CIs and benchmarks should be used according to standards for this type of analysis. data. 1 Authors made conclusions and clinical recommendations that were general. SEM Correlation matrices for validity analysis may not require that each individual correlation be presented with its Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. at least 2 of the following were presented: 1.org at University of Washington on December 1. but basically supported by the study data. ICCs for quantitative data. 1 Either CIs or appropriate benchmarks were used. Reliability (Relative. © JC MacDermid 2008 journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | C12 . Comparison to appropriate benchmarks or standards 3. 0 Benchmarks or CIs were either used inappropriately or not included. Kappa for nominal data). 10 2 Appropriate statistical tests were conducted: 1. All rights reserved. Clinical relevance—minimal detectable change (MDC). but not both. Validity associations—Pearson correlations for normally distributed data. Validity tests of significant difference—an appropriate global test such as analysis of variance was used where indicated. No other uses without permission. associated CI. Responsiveness—standardized response means or effect sizes or other recognized responsiveness indices were used 1 Appropriate statistical tests were used in some instances. and conclusions OR recommendations contradicted the actual data presented.