Abstract
Introduction
Chronic pain causes suffering for affected individuals and incurs costs to society through work disability. Interventions based on early screening of psychological risk factors for chronic pain using screening tools such as the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) have been found to reduce work absenteeism and health care visits and increase perceived health. The aim of the current study was to translate the ÖMPSQ into Finnish and test its validity and reliability in a patient sample.
Methods
The ÖMPSQ was forward–backward translated and cross-culturally adapted, and applied to our study population (n = 69), the members of which had been referred to the Department of Physical and Rehabilitation Medicine of Oulu University Hospital from primary health care centres in Northern Finland due to chronic low back pain. The patients answered the ÖMPSQ two weeks before the hospital visit, and the follow-up questionnaire either during the hospital visit, or after by mail. The reliability of the ÖMPSQ was evaluated using intraclass correlation coefficients (ICC). Factor analysis was used to group items of the ÖMPSQ, and internal consistency between the items was determined by calculating Cronbach’s alphas.
Results
The cross-cultural adaptation revealed only minor semantic and cultural differences. Measurements showed reliability as moderate to nearly perfect for all of the ÖMPSQ items (ICC values ranged from 0.59 to 0.96). Items loaded into five different factors: disability, psychological symptoms, pain, fear avoidance, and work. All except one (work) showed acceptable internal consistency. The ÖMPSQ score was positively associated with both intensity of pain and the Oswestry Disability Index.
Conclusions and implications
The reliability and construct validity of the Finnish version of the ÖMPSQ were good. The predictive ability of the ÖMPSQ in the Finnish population should be evaluated in further studies.
1 Introduction
Chronic pain has significant effects on individuals’ health and quality of life, and globally affects societal costs through work absenteeism [1,2,3]. By detecting and treating individuals at high risk of developing early stage chronic pain, the negative effects may be minimized [4,5].
Psychological risk factors, such as fear avoidance behaviours, negative affect and catastrophizing all contribute to the development and maintenance of chronic pain [6]. Early identification of these factors with appropriate interventions may lead to a better healing process and a reduction of prolonged sick leaves [5]. In clinical practice, screening can be carried out using simple, fast screening tools such as the Örebro Musculosceletal Pain Screening Questionnaire (ÖMPSQ). These tools help clinicians detect individuals who would not otherwise be noticed as having psychological risk factors.
The ÖMPSQ was developed to identify patients at risk of developing work disability due to pain [7]. The ÖMPSQ is a valid instrument for predicting chronic pain, work disability, perceived mental health, and functional disability [7,8,9].
The reliability and validity of the ÖMPSQ has been tested in several languages, including English [7,10], Norwegian [11], French [12], Chinese [13], Spanish [14], Portuguese [15], Turkish [16], and German [17]. The aim of the present study was to evaluate the reliability and construct validity of its Finnish translation.
2 Methods
2.1 Study population
The study population consisted of chronic low back pain (LBP) patients who had been referred to the Department of Physical and Rehabilitation Medicine in Oulu University Hospital from primary health care centres in Northern Finland. The patients were recruited between May 2010 and June 2011. Inclusion criteria were an age of 18 years or over, current LBP with or without radicular symptoms, and the ability to communicate in written Finnish. The patients responded to the baseline ÖMPSQ and the Oswestry Disability Index (ODI) [18], which measures disability due to LBP, approximately two weeks before the scheduled hospital visit. The follow-up questionnaire was filled in either during the hospital visit or returned after by mail. Those who answered all items in both the baseline and follow-up ÖMPSQs were selected, resulting in a sample of 69 patients.
2.2 Örebro Musculoskeletal Pain Screening Questionnaire
The ÖMPSQ is used to identify subjects at risk of developing chronic musculoskeletal pain, by measuring the psychological risk factors [19]. The version of the ÖMPSQ we used contains 25 items, in which 21 (items 5–25) are included in a sum score. The questionnaire includes items about pain, sick leave, anxiety and depression, activity limitations, coping, work satisfaction, fear avoidance beliefs, and expectations of the future (Supplementary material). The items are scored from 0 to 10, where 0 refers to the absence of impairment and 10 to severe impairment. Items are summed to obtain a total score, of which the maximum is 210. Cut-off scores for patients in primary care have been defined as: being at high risk (>105), medium risk (90–105) and low risk (<90) of work disability due to pain [7,10], although criticism regarding the specific cut-off scores has been expressed [3].
2.3 Translation process
The translation and cross-cultural adaptation adhered to the International Society of Pharmacoeconomics and Outcome Research (ISPOR) guidelines [20]. The ÖMPSQ was translated into Finnish using a forward–backward method, to ensure proper translation. Two non-professional native Finnish speaker translators made independent Finnish translations of the original ÖMPSQ. These two independent translations were compared, and discrepancies concerning mainly vocabulary and cultural adaptations were resolved in a discussion between the translators and a physiotherapy specialist. Thereafter, a back-translation was made by the bilingual native English translator with no medical background or awareness of the concepts being explored in order to verify that the translated Finnish version reflects the same item content as the original version. An expert committee, consisting of the project manager, one specialist in medicine and the translators, compared the forward and backward translations with each other and with the original questionnaire and reviewed the translation reports. When a consensus was reached regarding the translated Finnish version and the original English version, the Finnish version was proofread by a Finnish language expert of the Finnish medical association (Duodecim). This version was pilot-tested with 10 Finnish-speaking subacute or acute low back pain patients to discover any offending content, or anything that complicate answering or understandings the questions. The testing demonstrated no concerns or reasons for any changes. Supplementary materialshows the final translated version.
2.4 Statistical methods
The characteristics of the study population are shown as frequencies with proportions and means with standard deviations (SD). In order to evaluate the reliability of the questionnaire, the intraclass correlation coefficients (ICC), as well as the floor and ceiling values representing the percentages of the participants who obtained the lowest or highest scores, were calculated per each item separately. The ICC can be interpreted as follows: 0.0–0.20, slight; 0.21–0.40, fair; 0.41–0.60, moderate; 0.61–0.80, substantial; 0.81–1.0, almost perfect [21]. The construct validity of the ÖMPSQ items at baseline were tested using principal axis factor analysis with varimax rotation. The internal consistency of the factors was determined using Cronbach’s alphas. Linear regression analysis was used to evaluate the association between the ÖMPSQ score and pain intensity and ODI. IBM SPSS Statistics, version 22.0, was used for the statistical analyses.
3 Results
The cross-cultural adaptation revealed only minor cultural differences. Some semantic issues in the translation process, concerning mainly word choices (items 11, 20 and 21–24) and cultural differences, were debated: Item 5 (the word “leg” may be misleading as it refers to lower extremity without foot) and Item 13 (the word “anxious” in Finnish may have either a physical or psychological meaning).
The mean age of the participants was 46 years (SD = 11) (Table 1). There were 40 (58%) females and 29 (42%) males. At the time of the baseline questionnaire, 59% of the patients had had LBP for longer than 12 months, but 48% had been on sick leave for a maximum of two weeks during the past 12 months. In the repeated questionnaires, the intensity of pain during the past week worsened among 32%, remained the same among 39%, and improved among 29% of the participants at the time of the follow-up questionnaire. The characteristics of the study population, stratified by gender, are presented in Table 1.
Characteristics of study population (n = 69).
| Variables | Females (n = 40) | Males (n = 29) |
|---|---|---|
| Age, years, mean (SD)[a] | 47.3(11.6) | 44.8(10.7) |
| [b]BMI, n (%) | ||
| Normal (BMI<25.0kg/m2) | 16(40.0) | 8(27.6) |
| Overweight (BMI 25.0–29.9kg/m2) | 11(27.5) | 11(37.9) |
| Obesity (BMI ≥ 30.0 kg/m2) | 6(15.) | 4(13.8) |
| Sick leave during 12 months, n (%) | ||
| <2 weeks | 19(47.5) | 14(48.3) |
| 2 weeks to 3 months | 7(17.5) | 2(6.9) |
| >3 months | 14(35.0) | 13(44.8) |
| Work situation, n (%) | ||
| Working or studying | 23(57.5) | 14(48.3) |
| On sick leave | 10(25.0) | 9(31.0) |
| Retired | 2(5.0) | 1(3.4) |
| Other | 5(12.5) | 5(17.2) |
| Duration of pain, n (%) | ||
| <24 weeks | 4(10.0) | 5(17.2) |
| 24 weeks to 12months | 13(32.5) | 6(20.7) |
| >12 months | 23(57.5) | 18(62.1) |
| Pain location, n (%) | ||
| Neck | 18(45.0) | 14(48.3) |
| Shoulder | 17(42.5) | 9(31.0) |
| Upperback | 13(32.5) | 4(13.8) |
| Lower back | 34(85.0) | 26(89.7) |
| Leg | 26(65.0) | 17(58.6) |
At baseline, the mean (SD) ÖMPSQ score was 109.2 (30.7) and at follow-up 107.8 (31.1). According to the ÖMPSQ, at baseline 49% of the patients were classified as being in the high, 22% in the medium and 29% on the low risk group. The corresponding percentages in the follow-up questionnaire were 54%, 13% and 33%, respectively. The ÖMPSQ score deteriorated between the baseline and followup questionnaires among 44%, and improved among 52% of the patients.
The highest mean scores of a single item were observed in item 7, which concerned the duration of the current pain (How many weeks have you suffered from your current pain problem?), with values of 8.9 in the baseline and 8.6 in the follow-up questionnaire (Table 2). The lowest mean scores were in items 24 (I can do weekly shopping.), 17 (If you take into consideration your work routines management, salary, promotion possibilities, and work mates, how satisfied are you with your job?) and 21 (I can do light work for an hour.).
Characteristics of Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) items and their reliability.
| Item | Baseline | Follow-up | ICC (95% CI)[c] | ||||
|---|---|---|---|---|---|---|---|
|
|
|
||||||
| Mean (SD)[b] | Floor (%) | Ceiling (%) | Mean (SD) | Floor (%) | Ceiling, % | ||
| 5. Where do you have your pain problem? | 5.2 (2.5) | 24.6 | 5.8 | 4.7 (2.2) | 23.2 | 2.9 | 0.66 (0.50–0.77) |
| 6. How many days of work have you missed (sick leave) because of pain duringthe past 12 months? | 5.4 (3.6) | 26.1 | 20.3 | 5.2 (3.5) | 27.5 | 15.9 | 0.96 (0.94–0.98) |
| 7. How many weeks have you suffered from your current pain problem? | 8.9 (2.0) | 1.4 | 59.4 | 8.6 (2.2) | 2.9 | 50.7 | 0.68 (0.53–0.79) |
| 8. Is yourwork heavy or monotonous?[a] | 6.9 (3.2) | 2.9 | 4.3 | 7.4 (3.1) | 0.0 | 2.9 | 0.73 (0.60–0.83) |
| 9. How would you rate the pain you have had during past week? | 5.9 (2.3) | 1.4 | 0.0 | 6.0 (2.3) | 2.9 | 0.0 | 0.77 (0.65–0.85) |
| 10. In the past 3 months, on average, how intense was your pain? | 6.5 (2.1) | 1.4 | 1.4 | 6.5 (1.9) | 0.0 | 1.4 | 0.64 (0.48–0.76) |
| 11. How often would you say that you have experienced pain episodes, on average, during the past 3 months? | 7.5 (2.5) | 0.0 | 27.5 | 7.5 (2.4) | 0.0 | 26.1 | 0.82 (0.72–0.88) |
| 12. Based on all things you do to cope or deal with your pain, on an average day, how much are you able to decrease it? | 4.7 (2.3) | 2.9 | 2.9 | 4.6 (2.2) | 1.4 | 1.4 | 0.59 (0.41–0.73) |
| 13. How tense or anxious have you felt in the past week? | 4.8 (2.3) | 4.3 | 0.0 | 4.8 (2.4) | 1.4 | 1.4 | 0.61 (0.43–0.74) |
| 14. How much have you been bothered by feeling depressed in the past week? | 3.8 (3.2) | 20.3 | 1.4 | 3.8 (2.9) | 14.5 | 1.4 | 0.78 (0.66–0.85) |
| 15. In your view, how large is the risk that your current pain may become persistent (may not go away)? | 8.2 (1.9) | 0.0 | 33.3 | 7.7 (2.5) | 1.4 | 30.4 | 0.68 (0.53–0.79) |
| 16. Inyourestimation, what are the chances that you will be working in 6 months? | 4.2 (3.4) | 17.4 | 11.6 | 4.1 (3.3) | 20.3 | 7.2 | 0.89 (0.82–0.93) |
| 17. If you take into consideration your work routines management, salary, promotion possibilities, and work mates, how satisfied are you with your job?[a] | 2.5 (3.1) | 26.1 | 4.3 | 2.4 (3.0) | 27.5 | 2.9 | 0.75 (0.62–0.84) |
| 18. Physical activity makes my pain worse. | 7.4 (2.6) | 1.4 | 26.1 | 7.5 (2.1) | 0.0 | 18.8 | 0.68 (0.53–0.79) |
| 19. An increase in pain is an indication that I should stop what I am doing until the pain decreases. | 8.2 (2.2) | 0.0 | 42.0 | 8.0 (2.3) | 0.0 | 40.6 | 0.59 (0.41–0.72) |
| 20. I should not do my normal work with my present pain. | 5.4 (3.1) | 5.8 | 11.6 | 4.9 (3.2) | 10.1 | 8.7 | 0.78 (0.67–0.86) |
| 21. I can do light work for an hour. | 2.5 (2.9) | 40.6 | 2.9 | 2.9 (2.9) | 30.4 | 0.0 | 0.86 (0.78–0.91) |
| 22. I can walk for an hour. | 3.7 (3.3) | 27.5 | 4.3 | 4.0 (3.5) | 20.3 | 7.2 | 0.80 (0.69–0.87) |
| 23. I can do ordinary household chores. | 3.1 (2.6) | 20.3 | 1.4 | 3.2 (2.6) | 20.3 | 1.4 | 0.85 (0.77–0.91) |
| 24. I can do weekly shopping. | 2.4 (2.7) | 36.2 | 1.4 | 2.6 (2.5) | 26.1 | 1.4 | 0.83 (0.73–0.89) |
| 25. I can sleep at night. | 4.2 (2.9) | 8.7 | 0.0 | 4.2 (2.8) | 14.5 | 1.4 | 0.83 (0.74–0.89) |
The item with the highest percentage of patients scoring a ceiling value was Item 7 (duration of current pain), in both baseline and follow-up questionnaires, with scores of 59.4% and 50.7%, respectively. In addition, Item 15 (self-perceived risk of pain becoming persistent) and Item 19 (an increase in pain is an indication that I should stop what I am doing until the pain decreases) showed high ceiling percentages (42% and 33% at baseline, respectively). The highest floor value at baseline, 40.6%, was observed in Item 21 (I can do light work for an hour).
Overall, the ICC values ranged from 0.59 to 0.96, showing moderate to almost perfect reliability of the baseline and follow-up questionnaires (Table 2). Item 6, about sick leave, had the highest reliability with ICC = 0.96 (almost perfect). Items 19 and 12, about fear avoidance behaviour and coping, had the lowest (ICC = 0.59; moderate; for both) reliability. The items regarding disability and pain duration had the highest reliabilities.
In the final factor analysis, the items loaded into five different factors: disability, psychological symptoms, pain, fear avoidance, and work, and all except one (work) showed acceptable internal consistency (Table 3). Two items were removed (5 and 7), because they did not sufficiently load into any of the five factors. Table 3 describes the factor loadings and Cronbach’s alphas within the factors.
Final principal axis factor analysis with varimax rotated factor loadings of the ÖMPSQ items at the baseline (n = 56).
| Item[a] | Factor loadings | ||||
|---|---|---|---|---|---|
|
|
|||||
| Disability | Psychological symptoms | Pain | Fear avoidance | Work | |
| Cronbach’s alpha[b] | 0.901 | 0.660 | 0.821 | 0.599 | 0.469 |
| 24. I can do weekly shopping. | 0.832 | ||||
| 21. I can do light work for an hour. | 0.796 | ||||
| 22. I can walk for an hour. | 0.792 | ||||
| 23. I can do ordinary household chores. | 0.777 | ||||
| 25. I can sleep at night. | 0.643 | ||||
| 15. In your view, how large is the risk that your current pain may become persistent (may not go away)? | 0.563 | ||||
| 18. Physical activity makes my pain worse. | 0.558 | ||||
| 16. In your estimation, what are the chances that you will be working in 6 months? | 0.554 | ||||
| 14. How much have you been bothered by feeling depressed in the past week? | 0.904 | ||||
| 13. How tense or anxious have you felt in the past week? | 0.650 | ||||
| 6. How many days of work have you missed (sick leave) because of pain during the past 12 months? | 0.508 | ||||
| 9. How would you rate the pain you have had during past week? | 0.819 | ||||
| 10. In the past 3 months, on average, how intense was your pain? | 0.653 | ||||
| 11. How often would you say that you have experienced pain episodes, on average, during the past 3 months? | 0.586 | ||||
| 20. I should not do my normal work with my present pain. | 0.725 | ||||
| 19. An increase in pain is an indication that I should stop what I am doing until the pain decreases. | 0.674 | ||||
| 12. Based on all things you do to cope or deal with your pain, on an average day, how much are you able to decrease it? | 0.369 | ||||
| 8. Is your work heavy or monotonous?[c] | 0.639 | ||||
| 17. If you take into consideration your work routines management, salary, promotion possibilities, and work mates, how satisfied are you with your job?[c] | 0.540 | ||||
The ÖMPSQ score was positively associated with both intensity of pain and ODI (standardized regression coefficient beta 0.58 and 0.69, respectively) (Table 4). The strength of associations remained when adjusted for age and sex.
Associations between ÖMPSQ at the baseline and pain intensity during last week and Oswestry Disability Index, both unadjusted and adjusted with age and sex.
| Unadjusted | Adjusted | |||||
|---|---|---|---|---|---|---|
|
|
|
|||||
| B (SE)[a] | Beta[b] | P | B (SE) | Beta | P | |
| Pain intensity, n = 69 | 7.8(13) | 0.58 | <0.001 | 8.1 (1.3) | 0.61 | <0.001 |
| Oswestry Disability Index, n = 56 | 31.8 (4.5) | 0.69 | <0.001 | 32.5 (4.8) | 0.71 | <0.001 |
4 Discussion
The reliability, as well as construct validity, of the Finnish version of the ÖMPSQ was good, and in line with earlier studies [14,15,17]. This study provided information about the usability of the ÖMPSQ in clinical practice, even though the predictive validity of the Finnish version still needs to be tested.
The ICC values showed good reliability for all the ÖMPSQ items, ranging from 0.59 to 0.96. This supports the results of recent studies, [14,15] which show good reliability of the ÖMPSQ regardless of language. For example, in the study of Fagundes et al. [15], the ICC of the whole ÖMPSQ was 0.76 (substantial). In the Spanish version of the ÖMPSQ [14], the ICCs of the items varied from 0.22 to 0.85, showing mainly substantial reliability, as all except one item had an ICC of over 0.70.
The results of our factor analysis and linear regression analysis showed the construct validity of the ÖMPSQ to be good, which is also in line with previous studies [16,17]. Yet caution may be needed in evaluating the relevance of some of the items (5 and 7), as they did not load sufficiently into any factor. The overall internal consistencies of all the factors were acceptable, except for the ‘work’ factor. The weak internal consistency of this factor may have been caused by a proportion of participants who were retired or did report their work status as “other” (n = 13), and whose answers were not included in these items. The higher ÖMPSQ total score also associated well with both the higher ODI and higher pain intensity.
The same kind of factor loadings have been seen before. For example, Schmidt et al. [17] divided the ÖMPSQ’s items into three different factors; depression, fear avoidance beliefs and disability. The present study also had factors for work and pain. Furthermore, they also somewhat correlated with the variables for which the ÖMPSQ was originally created to predict future sick leave: fear avoidance work beliefs, perceived improvement, problems with work function, stress, and previous sick leave [10]. In addition, the factor loadings were similar to those in a study conducted by Westman et al. [8], with the difference of the ‘coping’ factor, which was not included in the model of the present study.
According to previous research on the validation of the ÖMPSQ [7,17], screening instruments such as the ÖMPSQ should be considered for use in normal clinical practice. They could be used among, for example, LBP patients, since screening instruments’ ability to identify individuals at a high risk of prolonged disability due to pain is good, and therefore both the negative effects of the pain problem for the individual and the health care costs to society might be minimized. Our results indicate that the Finnish translation of the ÖMPSQ is a reliable and valid screening tool, and can hence be used among Finnish pain patients to screen for psychological risk factors for developing chronic pain.
The translation and cross-cultural adaptation followed best practice guidelines [21]. Cultural differences were encountered in the adaptation process. The results of the present study regarding the cross-cultural translation and adaptation of the Finnish version of the ÖMPSQ indicate that the cross-cultural adaptation was successful.
The main weakness of the present study was the small number of included patients, partly due to incompletely filled questionnaires. Almost all the participants had chronic LBP already, and therefore the use of the ÖMPSQ may not have been entirely suitable in this patient sample. This might also have had an impact on the results, via higher total ÖMPSQ scores and stronger associations between ÖMPSQ, ODI and pain intensity. Nevertheless, the results replicate other studies of the psychometrics of translating the ÖMPSQ.
5 Conclusions and implications
The reliability and construct validity of the Finnish version of ÖMPSQ was good. The predictive ability of the ÖMPSQ in the general Finnish population however, needs to be evaluated by further studies.
Highlights
The reliability and construct validity of the Finnish version of the ÖMPSQ is good.
ÖMPSQ should be considered for use in normal clinical practice.
The cross-cultural adaptation of ÖMPSQ was successful.
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Conflict of interest: None declared.
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Ethical issues: The study was approved by the ethics committee of the Northern Ostrobothnia Hospital District and was conducted following the principles of the declaration of Helsinki. All the participants took part voluntarily and signed a written informed consent form.
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Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.sjpain.2016.06.002.
© 2016 Scandinavian Association for the Study of Pain
