State-of-the-Art Papers
The Neck Disability Index: State-of-the-Art, 1991-2008

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Abstract

Background

Published in 1991, the Neck Disability Index (NDI) was the first instrument designed to assess self-rated disability in patients with neck pain. This article reviews the history of the NDI and the current state of the research into its psychometric properties—reliability, validity, and responsiveness—as well as its translations. Focused reviews are presented into its use in studies of the prognosis of whiplash-injured patients as well as its use in clinical trials of conservative therapies for neck pain.

Special Features

The NDI is a relatively short, paper-pencil instrument that is easy to apply in both clinical and research settings. It has strong psychometric characteristics and has proven to be highly responsive in clinical trials. As of late 2007, it has been used in approximately 300 publications; it has been translated into 22 languages, and it is endorsed for use by a number of clinical guidelines.

Summary

The NDI is the most widely used and most strongly validated instrument for assessing self-rated disability in patients with neck pain. It has been used effectively in both clinical and research settings in the treatment of this very common problem.

Section snippets

History of the Neck Disability Index

Before 1991, no instrument was available to assess the self-rated disability of patients with neck pain. In the previous decade, a few of such instruments for patients with low back pain had been developed, chiefly, the Oswestry Low Back Pain Index (OI)1 and the Roland-Morris Low Back Pain Questionnaire.2 Recognizing the deficiency with respect to neck pain, Vernon undertook to develop a similar instrument suitable for patients with neck pain. It was decided to model this instrument on the OI,

Scoring and Interpretation

Each item is scored out of 5 for a maximum total score of 50. Care should be taken in reporting the score as either out of 50 or as a percentage out of 100. Most studies have reported the scores out of 50. Several strategies for dealing with missing data or noncompliance with an item have been developed. When only 1 item is missing, some authors have scored the NDI out of 45 and converted the score to a percentage. When several items are missing, some authors have used the mean value of the

The Original 1991 Report

The original study reported on test-retest reliability over a 2-day period, obtaining a value of 0.89 (P < .05). Internal consistency was measured using Cronbach α, with a total index value of .80. The highest scoring items (average out of 5) were the following: headaches = 2.6; lifting = 2.2; recreation = 2.2; reading = 2.1; and driving = 2.0. The total index scores of the study sample were normally distributed, as follows: 0 to 4 (none) = 2%; 5 to 14 (mild) = 35%; 15 to 24 (moderate) = 48%;

Methods

The search strategy for the current report for articles using or referring to the NDI was conducted as a citation search of the 1991 publication using Science Citation Index, through the Scholar's Portal Web of Science. Articles were retrieved from 1991 to December 2007. Articles were reviewed to insure that the instrument used in assessing the self-rating of disability by patients with neck pain was actually the NDI. This resulted in 287 qualified citations. These articles were then classified

Psychometric Properties

Since 1991, 22 additional publications have reported on the psychometric properties of the NDI.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 Eight of these were published before 20025, 6, 7, 8, 9, 10, 11, 12 and most of these were included in the only systematic review to date.27 In that review, it was acknowledged that (1) the NDI was the most widely used of the several scales for self-rating disability in patients with neck pain, which had been developed

Conclusion

The current “state-of-the-art” of the NDI has been reviewed here. The NDI is the oldest and most widely used instrument for self-reporting of disability due to neck pain. Its internal psychometric properties have been well established in numerous cultural groups with neck pain: it is highly reliable, strongly internally consistent, and with a 1-factor structure for “physical disability.” It has strong and well-documented convergent and divergent validity with other instruments used in the

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