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Original article
The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified
primary care musculoskeletal screening tool in an acute work injured population
Charles Philip Gabel
a
,
b
,
*
, Markus Melloh
c
, Brendan Burkett
a
, Jason Osborne
d
, Michael Yelland
b
a
Faculty of Science, Centre for Healthy Activities, Sport and Exercise, University of the Sunshine Coast, Sippy Downs, Sunshine Coast, Queensland 4556, Australia
b
Primary Health Care Section, School of Medicine, Griffith University, Queensland, Australia
c
Western Australian Institute for Medical Research (WAIMR), University of Western Australia, Nedlands, Western Australia, Australia
d
Educational Foundations and Leadership, Darden College of Education, Old Dominion University, Norfolk, VA, USA
article info
Article history:
Received 9 January 2012
Received in revised form
24 May 2012
Accepted 29 May 2012
Keywords:
Screening
Absenteeism
Injury
Musculoskeletal
abstract
The original Örebro Musculoskeletal Pain Questionnaire (original-ÖMPQ) was developed to identify
patients at risk of developing persistent back pain problems and is also advocated for musculoskeletal
work injured populations. It is critiqued for its informal non-clinimetric development process and
narrow focus. A modified version, the Örebro Musculoskeletal Screening Questionnaire (ÖMSQ), evolved
and progressed the original-ÖMPQ to broaden application and improve practicality. This study evaluated
and validated the ÖMSQ clinimetric characteristics and predictive ability through a single-stage
prospective observational cohort of 143 acute musculoskeletal injured workers from ten Australian
physiotherapy clinics. Baseline-ÖMSQ scores were concurrently recorded with functional status and
problem severity outcomes, then compared at six months along with absenteeism, costs and recovery
time to 80% of pre-injury functional status. The ÖMSQ demonstrated face and content validity with high
reliability (ICC
2.1
¼0.978, p<0.001). The score range was broad (40e174 ÖMSQ-points) with normalised
distribution. Factor analysis revealed a six-factor model with internal consistency
a
¼0.82 (construct
range
a
¼0.26e0.83). Practical characteristics included completion and scoring times (7.5 min), missing
responses (5.6%) and FlescheKincaid readability (sixth-grade and 70% reading-ease). Predictive ability
ÖMSQ-points cut-off scores were: 114 for absenteeism, functional impairment, problem severity and
high cost; 83 for no-absenteeism; and 95 for low cost. Baseline-ÖMSQ scores correlated strongly with
recovery time to 80% functional status (r¼0.73, p<0.01). The ÖMSQ was validated prospectively in an
acute work-injured musculoskeletal population. The ÖMSQ cut-off scores retain the predictive capacity
intent of the original-ÖMPQ and provide clinicians and insurers with identification of patients with
potentially high and low risks of unfavourable outcomes.
Ó2012 Elsevier Ltd. All rights reserved.
1. Introduction
The early identification of patients at risk of developing
disability from chronic musculoskeletal conditions is essential
(Melloh et al., 2012). Despite the small percentage of injuries that
transition from acute to chronic (Melloh et al., 2011), this subgroup
accounts for the majority of financial (Driessen et al., 2008), indi-
vidual and societal costs (Ekman et al., 2005). This subgroup is
generally identified through their subjective history and the clini-
cians’experience and expertise (Bell and Burnett, 2009). However,
the human judgement process can be flawed, particularly in
identifying fear-avoidance (Calley et al., 2010), catastrophizing
(Sullivan et al., 2011) and disability (Maher and Grotle, 2009).
Screening questionnaires can supplement this judgement process,
particularly for musculoskeletal conditions (Liebenson and
Yeomans, 2007). The ‘Örebro Musculoskeletal Screening Question-
naire’(ÖMSQ)(Gabel et al., 2011) is a recently developed instru-
ment designed for this purpose and is a modified version of the
original Örebro Musculoskeletal Pain Questionnaire (original-
ÖMPQ) (Linton, 1999).
The original-ÖMPQ was developed to identify patients at risk of
persistent pain. It is widely used and adapted from the Acute Low
Back Pain Screening Questionnaire (ALBPSQ) (Linton and Hallden,
1998). It is advocated in clinical guidelines (van Tulder et al.,
2006) and workers compensation guidelines (ACC-New Zealand,
2004;Workers Compensation Authority NSW, 2006;WorkCover
SA, 2007;WorkSafe-TAC Victoria, 2007). Two systematic reviews
of the original-ÖMPQ (Hockings et al., 2008;Sattelmayer et al.,
*Corresponding author. Faculty of Science, Centre for Healthy Activities, Sport
and Exercise, University of the Sunshine Coast, Sippy Downs, Sunshine Coast,
Queensland 4556, Australia. Tel.: þ61 (0)408 48 1125; fax: þ61 5471 7022.
E-mail addresses: cp.gabel@bigpond.com (C.P. Gabel), markus.melloh@
uwa.edu.au (M. Melloh), bburkett@usc.edu.au (B. Burkett), jxosborn@odu.edu
(J. Osborne), m.yelland@griffith.edu.au (M. Yelland).
Contents lists available at SciVerse ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
1356-689X/$ esee front matter Ó2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2012.05.014
Manual Therapy xxx (2012) 1e12
Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
2011) raised several critiques. These included the informal non-
clinimetric development process and the use of total cut-off
scores. Additional concerns have included the face and content
validity, and that general musculoskeletal injuries and non-
working individuals are not specifically included (Hurley et al.,
2000;Margison and French, 2007). Consequently, to address
these concerns the original-ÖMPQ was modified and progressed
through rigorous clinimetric methodology to broaden its applica-
tion and improve both practicality and suitability, resulting in the
ÖMSQ.
The ÖMSQ incorporated the original-ÖMPQ’s‘generalised
musculoskeletal’application and ‘screening’objectives and
retained the item format, score range, and concept of cut-off score
recommendations (Brown, 2008;Johnston, 2009). Simultaneously,
the ÖMSQ simplified the questions, improved the psychometric
characteristics (factor structure, face and content validity), practical
characteristics (33% reduction in missing responses), and predictive
ability. This revised instrument broadened the focus to general
musculoskeletal problems, rather than the original emphasis on
‘back’,‘pain’and ‘work’(Gabel et al., 2011). To continue this
development the aims of this study were to: examine the ÖMSQ
format for an acute musculoskeletal work-injured population; and
further develop the clinimetric properties and predictive validity
for the outcomes of function, problem severity, absenteeism,
insurer costs and recovery time at six months.
2. Material and methods
2.1. Study design
A single phase prospective, observational cohort study was
conducted in an independent work-related musculoskeletal injury
population (Fig. 1).
2.2. Patients and setting
An inception cohort (n¼143, 42.6% female, age 38.9 10.5,
range 18e65 years) was formed from consecutive outpatients,
recruited from a convenience sample referred by medical
practitioners’to 10 Australian physiotherapy centres. Each referrer
was interviewed where study goals and protocols were discussed.
This facilitated referrals and minimised potential confounding
through non-referral of suitable participants. The affected body
areas included the back (50%), neck (16%), upper limbs (22%) and
lower limbs (12%) with 5% of participants being multi-area injury.
This was proportionally representative of the work-related injury
population in the sampled geographical region (WorkCover
Queensland, 2005). All participants were entitled to wage related
compensation under the governing legislation. Consistency in
entitlement was anticipated to minimise any confounding influ-
ence of financial compensation on individual recovery. The sample
size required for each subgroup was estimated using the primary
variable of the score and calculated from the original ÖMSQ LBP
validation study (Gabel et al., 2011) with an 80% chance of detecting
difference between baseline and repeated measures (p<0.05) and
allowing an additional 15% attrition. This gave sample estimates for
test-retest reliability of n>42, for predictive validity of n>126,
and for factor analysis of n>120 (Field, 2005).
2.3. Inclusion and exclusion criteria
Participants included in the study had an acute musculoskel-
etal injury to the spine, upper limb or lower limb, sustained at
work within the previous five weeks (NHMRC, 2003). The ‘date of
injury’was defined as the date the current injury commenced and
included ‘provocation or worsening of a pre-existing injury’. This
classification accounted for 20% (n¼29) of participants. Exclusion
criteria were pregnancy, red flags for serious spinal pathology,
difficulty with English comprehension and <18 years. No upper
age limit was specified in order to comply with equal opportunity
and discrimination laws and maximise full workforce represen-
tation. The insurer outcome data were provided independently
and the outcome assessors were blinded to the baseline ÖMSQ
scores. All results were compiled at the study’s completion. This
facilitated the blinding process as the time between screening and
compilation of the outcome results was maximized and compliant
with recent methodology recommendations (Hockings et al.,
2008).
n denotes number of participants
Fig. 1. Flow chart of ÖMSQ testing process in a general working musculoskeletal population.
C.P. Gabel et al. / Manual Therapy xxx (2012) 1e122
Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
Fig. 2. Örebro Musculoskeletal Screening Questionnaire (ÖMSQ).
C.P. Gabel et al. / Manual Therapy xxx (2012) 1e12 3
Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
Fig. 2. (Continued)
C.P. Gabel et al. / Manual Therapy xxx (2012) 1e124
Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
2.4. Assessments
Measurement and data collection were performed by self-report
questionnaires that included the ÖMSQ and patient reported
outcomes (PROs) for functional impairment and problem severity.
These PROs were completed at baseline then repeated at two-week
then four-week intervals until discharge or study completion at six
months. Absenteeism and cost data were provided by the partici-
pants’insurer. Predictive ability was estimated from dichotomized
patient responses of ‘less affected’and ‘more affected’(Field, 2005)
for six specific outcome traits.
1. Functional status was assessed by region specific PROs with
continuity of format and scale. This enabled direct comparison
and pooling of PRO scores: the Spine Functional Index (Gabel
et al., submitted for publication), the Upper Limb Functional
Index (Gabel et al., 2010) and the Lower Limb Functional Index
(Gabel et al., 2012). Each questionnaire had 25, three-point
scale questions with a minimal detectable change <8%. Status
was divided into ‘recovered’at 10% or ‘non-recovered’at
>10% (Ostelo et al., 2008).
2. Problem severity was assessed from an eleven-point global
numerical rating scale (NRS-global) where 0 ¼No problem and
10 ¼Maximum (Farrar, 2000) with a >10% cut-off for ‘non-
recovered’.
3. Absenteeism was assessed by ‘paid-days-off’(PDO) recorded by
the participants’insurer and divided into PDO ¼0 (none)
versus PDO >0 (absenteeism).
4. Long term absenteeism was assessed by a cut-off of PDO >28
(Australia’s longest permitted continuous work period) (AIRC,
1999).
5. Total cost was assessed in Australian dollars from insurer
incurred expenses. This included all consultations, treatments,
investigations, wages and travel as calculated from the date of
original injury. For 20% of participants this was different from
their date of provocation or exacerbation. This cost was
dichotomized into high-cost $10,000 and low-cost <$1000.
The interim group was not evaluated to minimise the effect of
those with exacerbation, 85% of who were classified within the
high-cost group and the remainder who were within the
interim group.
6. Recovery time was the number of days required to reach 80%
recovery on the PRO measure (t
80
)(Gabel et al., 2006). This
functional status was lower than the ‘recovered’classification
of 10%, but was selected to maximise statistical correlation
(Gabel et al., 2011) and allow for symptom fluctuation within
a chronic state (Young et al., 2011). This 80% level was defined
as a PRO score 20% (Ostelo et al., 2008). An a-priori minimum
correlation was required with the ÖMSQ baseline score of
r>0.70 (p<0.01) (Field, 2005).
Sensitivity and specificity were calculated at the different ÖMSQ
cut-off scores to determine the optimum threshold for each
outcome. The subsequent positive likelihood ratios (LRs) were
determined from: sensitivity/(1specificity). Negative LRs were not
calculated as only cut-off scores for trait presence were required.
2.5. Face and content validity
Two focus groups provided feedback and determined the
ÖMSQ’sface and content validity. A 12-person participants group
that contained four sets of three participants with symptoms from
the same region, the back, neck, upper limb and lower limb; and
a three-person therapists group. A two thirds majority consensus
opinion was required (nine participants and two therapists). The
recommended changes (detailed in the results) were implemented
(Fig. 2).
2.6. Psychometric characteristics
To determine the psychometric characteristics, validity and
reliability sub-groups were used. The full data sample was used for
all remaining characteristics (Fig. 1).
Construct validity (n¼143): criterion-related validity as
demonstrated by predictive validity calculated from the positive
LRs; divergent validity as demonstrated by a statistically significant
t-test comparing ÖMSQ scores between groups with known posi-
tive and negative traits for each outcome excluding ‘Recovery time’;
Testeretest reliability (n¼60): used the ICC
2.1
at three days
(Shrout and Fleiss, 1979). Proportional representation by body
region reflected the general compensation population (WorkCover-
Queensland, 2005) for the back (n¼24), neck, upper limb and
lower limb (n¼12 for each).
2.7. Practical characteristics
The original development study methodology was employed to
determine missing responses, completion time and scoring time.The
readability was determined from the FlescheKincaid scales of
‘Reading G rade’and ‘FleschReading Ease’ascalculated through word-
processing software (Kincaid et al.,1975;Paasche-Orlow et al., 2003).
2.8. Statistical analysis
The SPSS version 14.0 (Inc, Chicago, IL) was used with signifi-
cance level set at p<0.01. Factor analysis used maximum likelihood
extraction with varimax rotation and coefficient suppression at
0.30 (Costello and Osborne, 2005).
3. Results
3.1. Focus group
The focus group consensus supported face and content validity.
Recommendations to improve the ÖMSQ format to facilitate accep-
tance and use in the clinical and research settings included: simpli-
fying the boxed format; shortening the introduction; use of single-
line summary statements for introductory sentences; clarification
of scale range through modification of descriptive anchors for
minimums and maximums; substitute ‘days’for ‘weeks’; and minor
wording changes to improve clarity for questions4, 11 and 13 (Fig. 2).
3.2. Psychometric characteristics
The ÖMSQ baseline responses are provided in Table 1. Normality
for these scores was examined through a normalised histogram,
ShapiroeWilk test (0.987,df ¼143, significance <0.190), and
examination of Skewness and Kurtosis. These indicated ÖMSQ
baseline scores were distributed normally. Testeretest reliability was
high (r¼0.978, p<0.001) and comparable for each body region
where respective rvalues were: full spine ¼0.967, back ¼0.954,
neck ¼0.981, both limbs ¼0.978, upper limb ¼0.942 and lower
limb ¼0.984.
Predictive validity using the full sample of n¼143 was shown
through positive LRs (Table 2). The critical cut-off score was 114 ÖMSQ-
points for absenteeism, long term absenteeism, functional impair-
ment, severity and high cost. Other cut-offs were 83 ÖMSQ-points for
‘no absenteeism’and 95 ÖMSQ-points for low cost. At three months,
the transition from subacute to chronic, 15.4% of participants were
‘non-recovered’(spine ¼13.4%, c ervical ¼19.9% an d back ¼11.7% ;
C.P. Gabel et al. / Manual Therapy xxx (2012) 1e12 5
Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
extremities ¼16.9 %, arm ¼17.2%, le g ¼16.7%). At si x months 7.7% of
participants were ‘non-recovered’(spine ¼8.2%, cervical ¼6.6% and
back ¼8.8%; extremities ¼7.3 %, a rm ¼8.5%, leg ¼5.9%).
Discriminant validity was demonstrated by significant t-tests
between outcome/non-outcome groups (Table 3). This was sup-
ported by a high Pearson’s correlation between the ÖMSQ and t
80
(r¼0.73 p<0.01). Internal consistency of the total score was good
(Cronbach’s
a
¼0.83), although individual constructs varied
(
a
¼0.26e0.83, Table 4).
The factor analysis correlation matrix was determined as suit-
able from the KaisereMeyereOklin value of 0.73 and highly
significant Barlett Test of Sphericity (p<0.001). The ÖMSQ gener-
ated six factors based on the Scree plot (Cattell, 1966), eigenvalues
>1.0 ( Kaiser, 1960) and item-variance >5% (Field, 2005). The total
cumulative variance was 63.6%. The rotated six-component solu-
tion showed consistent loading within the designated constructs
(Table 4) with failure to load for two ÖMSQ-items (#1 and #12) and
cross-loading for two items (#15 and #16).
Table 1
Baseline ÖMSQ responses in a musculoskeletal working population.
Qu Response
format
Construct by
factor (#)
Variable name n(%) Mean
(SD)
Missing
items
1 Categories Other (5) Region
Back 77
(54%)
Neck 23
(17%)
Arm 35
(24%)
Leg 22
(12%)
Both sides 31
(22%)
Several areas 30
(21%)
2 Categories Personal (4) Absenteeism 1
0 days 3
(2%)
1e28 days 103
(72%)
>28 days 37
(26%)
30e10 Personal (4) Duration 4.1 (2.9)
40e10 Other (5) Burdensome 5.5 (2.9)
50e10 Other (5) Intensity acute 6.3 (2.0)
60e10 Problem (3) Severity chronic 6.0 (2.9) 2
70e10 Problem (3) Frequency 6.3 (3.2) 4
80e10 Psyche (2) Coping 4.8 (2.2)
90e10 Psyche (2) Anxiety 5.8 (2.9)
10 0e10 Psyche (2) Depression 4.5 (3.3)
11 0e10 Psyche (2) Recovery
expectation
problem
5.2 (2.9) 1
12 0e10 Personal (4) Recovery
expectation
work
1.6 (2.5)
13 0e10 Physical (1) Job satisfaction 3.7 (3.0) 1
14 0e10 Physical (1) Fear-avoidance:
activity
7.4 (2.4)
15 0e10 Fear-avoidance
(6)
Fear-avoidance:
stop
8.0 (2.5)
16 0e10 Fear-avoidance
(6)
Fear-avoidance:
not
work
6.8 (3.2)
17 0e10 Physical (1) Light work/chores 5.2 (3.2)
18 0e10 Physical (1) Walk/recreation 4.8 (3.3) 1
19 0e10 Physical (1) Home activity 4.6 (2.7)
20 0e10 Physical (1) ADL and social 5.1 (2.7)
21 0e10 Physical (1) Sleep/move in
bed
5.1 (2.9)
Total score 10 or 7.0%
Low risk 83 41
(29%)
Moderate risk
83e114
35
(24%)
High risk >114 67
(47%)
n¼143, ÖMSQ score range ¼40e174 points, mean ¼106.4 29.0. The six constructs are identified by name and number. Continuous variables are presented as means with
SD in parentheses and categorical variables as frequencies with percentages (%) in parentheses. Questions are rated 0e10 points where higher scores indicate increased risk.
Questions 8, 12, 13 and 17e21 were reversed and calculated as (10 escore).
C.P. Gabel et al. / Manual Therapy xxx (2012) 1e126
Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
3.3. Practical characteristics
Readability for the ÖMSQ was confirmed with ‘Flesch Reading
Ease’at 70% and ‘FlescheKincaid grade’at 6.0. Missing responses
were at 5.6% (n¼10 in eight questionnaires, Table 1). Completion
time was 5.57 3.03 min and scoring time 1.28 0.10 min.
4. Discussion
4.1. Main findings
The ÖMSQ was validated in an independent acute musculo-
skeletal work injured population. The psychometric and practical
characteristics were equivalent to those calibrated in the LBP
population (Gabel et al., 2011). The predictive ability for outcome
status at six months post-injury, as determined by the positive
LRs, was comparable to the LBP population. This reinforced the
development and validation study conclusions that the ÖMSQ
may be substituted for the original-ÖMPQ. This study conse-
quently provides the required research on the ÖMSQ, as a modi-
fication of the original-ÖMPQ, that has assessed and verified its
applicability in a broader general musculoskeletal population.
The ÖMSQ score predicted important outcomes related to
financial costs, an important consideration for insurers (Westman
et al., 2008), and the time required to achieve 80% functional
status, an important consideration for predicting recovery (Young
et al., 2011). The optimal ÖMSQ cut-off score was 114 ÖMSQ-
points with sensitivity levels around 80%. This cut-off score was
comparable to the 110 ÖMSQ-points determined for LBP (Gabel
et al., 2011) and 109 ÖMSQ-points for whiplash (Gabel et al.,
2008). It marginally exceeded the 105e112 ÖMPQ-points cut-off
range found in several LBP studies (Linton and Hallden, 1998;
Grotle et al., 2007) but was markedly higher than the 90 ÖMPQ-
points from the Swedish spinal study (Linton and Boersma, 2003),
81 ÖMPQ-points from the Dutch LBP study (Heneweer et al., 2007)
and 72 ÖMPQ-points from the Dutch neck study (Vos et al., 2009).
However, it is lower than the 119e141 found in three musculo-
skeletal studies (Dunstan et al., 2005;Margison and French, 2007;
Westman et al., 2008). The established 109e114 ÖMSQ-points cut-
off range is midway between these original-ÖMPQ spine and
generalised populations findings. This supports the use of the
ÖMSQ as an evolved version of the original-ÖMPQ and demon-
strates its improved consistency. These differences could be
attributed both geographical and cultural differences in the patient
population. However, they may also be a consequence of the
improved relevance of the individual ÖMSQ questions. The scores
may also be affected by ‘therapist influences’such as treatment,
management and practitioners that catastrophize for their patients.
The ÖMSQ language changes were developed and tested in
Australia as a representative multicultural English-speaking
society. Consequently they should improve patient responses and
provide greater consistency between different population groups.
This potential explanation was supported by patient focus group
feedback and by the lower missing responses, 5.6%e6.6%,
compared to the original-ÖMPQ at 11.8% (Gabel et al., 2011)or
16%e25% (Grotle et al., 2006).
The results reported similar chronicity levels for the different
body regions. This implies that screening for long-term complica-
tions in both the extremities and the spine seem equally worth-
while. The ÖMSQ successfully identified a high proportion of ‘non-
recovered’at six months through both constructs and specific
contributing items with higher means (Sattelmayer et al., 2011).
These findings are consistent with previous original-ÖMPQ and
ALBPSQ studies where fear avoidance and pain that is widespread,
of a high level, or chronic, were prognostic for LBP at 12 months
(Grotle et al., 2010). This acute/chronic timeline was also identified
by Foster et al. (2010) who used the six month time frame to select
patients for targeted treatments. Foster also included coping
through perceived personal control and pain self-efficacy as deter-
mined in this study. By contrast, they found depression and fear
avoidance as not significant. The ÖMSQ was specifically designed to
broaden and evolve the original-ÖMPQ. This should increase its’
suitability for general musculoskeletal populations including the
spine. However, it cannot account for all identified potential risk
factors such as illness (Foster et al., 2008), perceived injustice
(Sullivan et al., 2008), catastrophizing (Sullivan et al., 2001), beliefs
(Symonds et al., 1996) and expectations (Hilfiker et al., 2007).
4.2. Validation considerations
The prospective validation of a prognostic instrument is consid-
ered essential (Altman et al., 2009). To date, no published study has
assessed the psychometric and practical characteristics of the orig-
inal-ÖMPQ in an acute general musculoskeletal population, the
defined target population for which it is advocated by clinical
guidelines. These characteristics have only been investigated in LBP
populations in four separate data sets (Linton and Hallden, 1998;
Linton and Boersma, 2003;Grotleet al., 2005;Gabel et al., 2011). The
ÖMSQ modificationprocess broadened the application capacity to all
body regions (Margison and French, 2007), anticipated those in non-
working situations (Hurley et al., 2000) and would be eligible for
consideration by guidelines committees. This process also addresses
critiques concerning the development and validation methodology
used to produce the ALBPSQ and subsequently the original-ÖMPQ.
4.3. Sample size considerations
Sample sizes for one of our primary statistical analyses,
compared favourably with previous research. Only three original-
ÖMPQ studies considered multiple body regions of the spine, upper
and lower extremities. Only two had comparable sample sizes (to
Table 2
Predictive validity as determined from sensitivity and specificity cut-off scores.
Outcome ÖMSQ cut-off Sensitivity Specificity LRs
Absenteeism
(>0 paid days off)
114 60.5% 92.3% 7.9
Long term absenteeism
(28 paid days off)
114 78.3% 80.4% 4.0
Functional Status
(not recovered >10%)
114 79.1% 69.0% 2.5
Problem severity
(not recovered >10%)
114 79.1% 67.2% 2.4
High cost ($10,000) 114 85.3% 73.5% 3.2
No absenteeism (no days off) 83 53.8% 88.2% 4.5
Low cost (<$1000) 95 75.9% 76.6% 3.2
Risk categories Low Medium High
Absenteeism <83 8e114 >114
Cost <95 95e114 >114
Where: LR ¼Sensitivity/(1Specificity).
Table 3
Independent t-tests between outcome groups of known difference (n¼143).
Group defined by Positive trait ÖMSQ
score mean 95% CI
Negative trait
ÖMSQ score mean
95% CI
t-Statistic
a
Absenteeism (>0 PDO) 116.2 114e18.4 84.8 82.8e86.8 5.40
Long term (28 PDO)
absenteeism
126.4 124.7e128.1 93.3 91.1e95.5 6.96
Function (10%) 128 126.2e129.8 95.6 93.4e97.8 6.48
Severity (10%) 130.2 128.6e131.8 95.8 93.5e98.1 6.90
Cost ($10,000) 126.9 125.1e128.7 98.8 96.5e101.1 5.17
a
All tests were significant (p<0.001).
C.P. Gabel et al. / Manual Therapy xxx (2012) 1e12 7
Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
our n¼143) at both baseline and follow-up with n¼211 (Margison
and French, 2007) and n¼158 (Westman et al., 2008). The third
had n¼55 at final follow-up (Dunstan et al., 2005). Of the
remaining 13 discrete data sets, where only LBP or spine with
referral pain to the limbs was considered, six studies had compa-
rable or larger sample sizes exceeding n¼140 (Appendix 1).
4.4. Psychometric properties
The high reliability (r¼0.978) in this study was comparable to
the original-ÖMPQ (r¼0.975) and the ÖMSQ (r¼0.982) devel-
opment study (Gabel et al., 2011). Consequently, wording modifi-
cations alone were unlikely to have improved reliability which was
higher than previous original-ÖMPQ and ALBPSQ studies. A more
likely explanation was this study’s use of the recommended ICC
2.1
method with a three-day interval in the target acute patient pop-
ulation (Shrout and Fleiss, 1979). The four previous reliability
studies found r¼0.90, ICC
1.1
at two days with chronic patients
(Grotle et al., 2006), r¼0.85, ICC
2.1
at one week with acute patients
(Vos et al., 2009), r¼0.83, Pearson’s product-moment at one week
in chronic patients (Linton and Hallden, 1998), and r¼0.80, Pear-
son’s product-moment at 2e4 weeks in sub-acute to chronic
patients (Linton and Boersma, 2003).
This study’s demographic details were comparable with
previous findings (Hockings et al., 2008) as were the baseline
percentage of ‘non-recovered’patients (Heneweer et al., 2007) and
absenteeism levels (Grotle et al., 2007). However, those ‘non-
recovered’at six months (7.7%) were considerably lower than
previously reported at 15%e70% and likely to be due to different
definitions of ‘non-recovered’and the outcome criteria used.
Factor analysis with maximum likelihood extraction showed
a six-factor model aligned to the theoretical constructs (Linton and
Hallden, 1998). Previous studies showed poorer fit to this proposed
model, including less factors (Grotle et al., 2006), and items
(Westman et al., 2008), specifically for ‘Distress’and ‘Fear-avoid-
ance’. This may be attributed to principal component analysis,
which is inappropriate for normally distributed populations
(Fabrigar et al., 1999), and use of chronic LBP participants (Westman
et al., 2008). This study’s six factors explained 63% of variance, an
acceptable statistical level (Henson and Roberts, 2006). This was
higher than the 49% reported by Grotle et al. (2006) but comparable
to the 59.8% found by Heneweer (2010) and marginally lower than
the 69% found by Westman et al. (2008) on 17 items. Our analysis
showed some support for a four construct model which suggests
a shorter more practical tool, perhaps with 12-items, could be
developed and investigated. This would facilitate early recognition
of the critical underlying constructs that lead to delayed recovery.
Such recognition can optimize referral to specific targeted inter-
ventions that facilitate improved outcomes (Foster et al., 2010).
4.5. Limitations
The findings cannot be extrapolated beyond the time frame of
the six month follow-up. The study included participants with
provocation or exacerbation of a previous injury. This was a con-
founding factor for cost calculations for the interim group and high-
cost groups as it included participants with insurer calculated costs
that were incurred prior to the study’sdefined date of inclusion.
Entitlement to wage-related compensation may also be a potential
confounder for individual recovery however its influence was
beyond the scope of this study.
4.6. Strengths
The ÖMSQ sought to improve upon the original-ÖMPQ for use in
a broader musculoskeletal population. It provided greater diversity
in work status, body regions and symptoms. The ÖMSQ psycho-
metric and practical characteristics were consistent with the orig-
inal development study in an LBP population (Gabel et al., 2011).
There was comparable reliability but at a value higher than repor-
ted in previous original-ÖMPQ studies.
4.7. Implications for practice
The ÖMSQ provided reference cut-off scores that supplement
clinical judgement. These are conducive to everyday primary care as
they complement and facilitate standard clinical examination. This
includes a clinicians’decision to ‘wait and see’or refer to specialists,
psychologists, counsellors or rehabilitation. This referral decision
could be assisted by total construct scores and individual profiles
Table 4
ÖMSQ factor analysis loading in a working musculoskeletal population.
1 Physical function 2 Psychological 3 Problem 4 Personal 5 Other 6 Fear-avoidance
Q20 ADL and social 0.944
Q18 Walk or light recreational activity 0.775
Q21 Home activity 0.720
Q17 Light work e1 h 0.719
Q19 Sleep or movement in bed 0.510
Q14 Fear-avoidance: activity makes worse 0.426
Q13 Job satisfaction 0.333
Q10 Depression 0.843
Q9 Anxiety 0.757
Q11 Recovery expectation: of problem 0.470
Q12 Recovery expectation: of work <0.300
Q1 Region <0.300
Q7 Problem severity echronic 0.890
Q6 Problem frequency 0.665
Q3 Problem duration 0.807
Q2 Absenteeism 0.729
Q5 Problem intensity eacute 0.954
Q4 Burdensome 0.392
Q16 Fear-avoidance: stop work/ADL if worse 0.387 0.595
Q15 Fear-avoidance: stop if activity if worse 0.384 0.427
Q8 Cope with problem 0.415
a
Internal consistency by construct
a
¼0.83 0.69 0.77 0.72 0.55 0.26
Total tool
a
¼0.82
Factor analysis used maximum likelihood extraction and varimax rotation; 21 items (n¼143), suppression at 0.300.
a
Q8 loading has been reversed by multiplying by 1.
C.P. Gabel et al. / Manual Therapy xxx (2012) 1e128
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musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
determined by the response to specific questions and constructs
(Sattelmayer et al., 2011). The determined cut-off scores could assist
in minimising incorrect prognosis classification (Hill et al., 2010).
This would enable at-risk patients to be identified and appropriately
referred at an earlier stage. The ÖMSQ scores are interchangeable
with the original-ÖMPQ due to the systematic modification process
used in the ÖMSQ development. This is supported by the excellent
criterion validity (r¼0.97) previously demonstrated (Gabel et al.,
2011). These considerations should facilitate acceptance of the
ÖMSQ in clinical, research and insurance settings which minimize
potential data loss for existing systems that use the original-ÖMPQ.
4.8. Implications for research
Further research should seek to validate these findings in both
general and specific subgroup populations, including the limbs, the
elderly and sports injury populations. This may lead to a more
accurate prediction of chronicity (Hockings et al., 2008) and indi-
vidual recovery time (Gabel et al., 2006). Furthermore, systematic
reviews of predictive validity (Hockings et al., 2008) and meta-
analysis of screening and outcome scores, including individual
profiles and item construct scores (Sattelmayer et al., 2011), should
be extended from the original-ÖMPQ’s spinal populations to
general musculoskeletal populations. In addition, investigation of
the effectiveness of specific interventions targeting screening
questionnaire constructs should be considered. A shortened 12-
item instrument could be considered in order to improve clinical
practicality through reduced patient and clinician burden yet retain
representation of the six constructs determined by the focus group
and factor analysis. This concept is supported by a recent LBP
version (Linton et al., 2011) and potential item redundancy shown
through factor analysis and loading inconsistencies between the
ÖMSQ and original-ÖMPQ.
5. Conclusions
The ÖMSQ is a valid and reliable instrument that can assist in
identifying acute musculoskeletal work injured patients in
a primary care setting that are at risk of unfavourable outcome at
six months. This may facilitate early specialist referral and optimize
outcomes from targeted intervention strategies.
Competing interests
None.
Acknowledgements
This research was supported by an Australian Commonwealth
Government’s Department of Aging, PHC-RED program Grant.
Research support and ethics approval was provided by the
University of the Sunshine Coast. We thank all participating
patients, general practitioners, and therapists.
Appendix 1
Comparison of data between ÖMSQ and previous original-ÖMPQ studies, modified ÖMPQ versions and the ALBPSQ.
Author Journal Questionnaire Country Patient type Region nat
baseline
nat
follow-up
Mean/Median Score range Cut-off
Linton and
Hallden, 1998
Clin J Pain ALBPSQ Sweden Acuteesubacute Spine and
shoulders
147 137 (93.2%) 104 45e176 105
Kendall, 1999 IASP 9th Cong ALBPSQ New
Zealand
Acute LBP Not stated Not stated Not stated Not stated 105
Hurley
et al., 2000
Clin J Pain ALBPSQ Northern
Ireland
Acute LBP 118 90 (76.3%) Median 113.5 49e208 112
Hurley
et al., 2001
Clin J Pain ALBPSQ Northern
Ireland
1 year review LBP 118 90 (76.3%) Median 113.5 49e208 112
Linton and
Boersma, 2003
Clin J Pain ÖMPQ Sweden Acuteesubacute Spine and
shoulder
122 107 (87.7%) 95 32e166 90
Dunstan
et al., 2005
Int J
Rehabil Res
Mod-ÖMPQ Australia
(NSW)
Chronic General 196 55 (28.1%) 99.6 Not stated 119
Nordeman
et al., 2006
Clin J Pain ÖMPQ Sweden Subacute LBP 60 53 (88.3%) 97.5 80e115 105
Grotle
et al., 2005
Spine ALBPSQ Norway 1 year review LBP 123 112 (91%) Acute ¼78.9
Chronic ¼115
45e125 105
Grotle
et al., 2006
Clin J Pain ALBPSQ Norway Mixed LBP 123 112 (91%) Acute ¼78.9
Chronic ¼115
45e125 105
Grotle
et al., 2007
Eur J P ALBPSQ Norway 1 year review LBP 123 112 (91%) Acute ¼78.9
Chronic ¼115
45e125 105
Margison and
French, 2007
J Occup
Environ Med
Mod-ÖMPQ Canada Chronic General 211 211 (100%) 123/220 Not stated 147/220
Jellema
et al., 2007
Br J Gen Pract ÖMPQ Holland Acuteesubacute LBP 314 298 (94.9%) Not stated Not stated Low ¼90
High ¼105
Heneweer
et al., 2007
Spine ÖMPQ Holland Acuteesubacute LBP 66 56 (84.8%) Recovered ¼67
Not ¼81
41e106 81
Gabel
et al., 2008
Int J Rehab Res ÖMSQ Australia
(Qld)
Acuteesubacute WAD 33 30 (90%) 95 46e179 109
Grimmer-Somers
et al., 2008
J Pain Res ALBPSQ New Zealand Acute LBP 328 328 (100%) Not Stated 10e146 Low ¼50,
High >105
Med ¼50e89
Westman
et al., 2008
Eur J Pain Mod-ÖMPQ Sweden Chronic General 158 149 (94.3%) 121 Not stated >117 and <139
(continued on next page)
C.P. Gabel et al. / Manual Therapy xxx (2012) 1e12 9
Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
Appendix 2. Glossary of terms.
(continued )
Author Journal Questionnaire Country Patient type Region nat
baseline
nat
follow-up
Mean/Median Score range Cut-off
Hill et al., 2009 Eur J Pain ÖMPQ UK Not stated LBP 131 130 (99.2%) Not noted Not stated Low ¼90
High ¼112
Vos et al., 2009 J Manip
Physiol Ther
ALBPSQ Holland Acuteesubacute Neck 187 180 (96.3%) 71.3 14e151 72/200
Maher and
Grotle, 2009
Clin J Pain ÖMPQ Norway
/Australia
(NSW)
Mixed LBP 259 230 (88.9%) 75.2 and 84.6 Not stated Not stated
Heneweer
et al., 2010
Spine ÖMPQ Holland Acuteesubacute LBP 66 56 (84.8%) Recovered ¼67 Not ¼85 41e106
Gabel et al., 2011 Eur Spine J ÖMSQ Australia (Qld) Acuteesubacute LBP 106 106 (100%) 112.5 40e174 110
This article Man Ther ÖMSQ Australia (Qld) Acuteesubacute General 143 143 (100%) 106.4 40e174 114
Barlett Test of Sphericity: preliminary test conducted to determine if three or more independent samples are homogenous or
variant before proceeding.
Cronbachi’s alpha coefficient: test for a model or survey’s internal consistency.
Clinimetric properties: assessment or description of symptoms, signs and findings by means of scales, indices and other
quantitative instruments ee.g. psychometric and practical characteristics of an outcome measure.
Concurrent validity: method of determining validity as the correlation of the test with scores from known valid measures.
Pearson’s Correlation Coefficient r value most commonly used
Construct validity: degree to which an instrument accurately measures the underlying theoretical or hypothetical constructs of
concern including the normality of baseline. Distribution patterns, the presence of floor and ceiling effects and how well the tool
performs in comparison to instruments of a similar (convergent validity) and/or dissimilar (divergent validity) purpose and
dimension.
Content validity: method of establishing validity based on expert judgement that the content of the measure is consistent with
what is to be measured.
Convergent validity: type of validity determined by hypothesizing and examining the overlap between two or more tests that
presumably measure the same construct
Criterion validity: degree to which a measure or test correlates with other measures or tests of the same construct assessed
concurrently or in future; ability of a test to predict a criterion.
Discriminant validity: degree to which an operation is not similar to or diverges from other operations that it theoretically should
not be similar to.
Divergent validity: hypothesizing and examining differential relations between a test and measures of similar or different
constructs; the ability of a scale to discriminate between patients with maximal and minimal functional deficits.
Effect size: mean change scores divided by the standard deviation of the baseline scores.
Eigenvalue: value such that a given square matrix minus that number times the identity matrix has a zero determinant. A cut-off
value of 1.0 is often considered critical (in factor analysis).
Face/logical validity: overall appearance of the test; extent to which a test appeals to test takers.
Factor structure: mathematical procedure to reduce large amounts of data into a structure that can be more easily studied
Flesch-Kincaid scale: ‘Reading Ease’ and ‘Grade Level’ use word length and sentence length to indicate the comprehension
difficulty when reading text, the scales are invesely related
Intention-to-treat-analysis: analysis based on the initial treatment intent, not on that eventually administered, withdrawal from
treatment or deviation from the protocol
Intraclass correlation coefficient (ICC): descriptive statistic for quantitative measurements to indicate how strongly units in the
same group resemble each other.
KaisereMeyereOklin value: measure of ‘Sampling Adequacy’ should exceed the recommended minimum value such as 0.6 or 0.8
depending on the sample size and requirements.
KolmogoroveSmirnov (KeS) test for normality: statistical nonparametric method for comparing the empirical distribution
functions of two samples, i.e. to quantify distances between the sample and the reference distribution.
Likelihood Ratio (LR): Sensitivity/(1 eSpecificity).
Maximum likelihood extraction: method of extracting common variables to make multivariate data simpler and easier to
understand through correlations between factors, but requires the assumption of multivariate normality.
Measurement of outcome measures: 25-item dichotomous tool to assist quantification of the quality of a patient reported
outcome (PRO) measurement questionnaire.
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musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
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Please cite this article in press as: Gabel CP, et al., The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care
musculoskeletal screening tool in an acute work injured population, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.05.014
