Accepted Manuscript

Association between the 10 item Örebro musculoskeletal pain screening

questionnaire and physiotherapists’ perception of the contribution of biopsychosocial
factors in patients with musculoskeletal pain

D. Beales, M. Kendell, R.P. Chang, M. Håmsø, L. Gregory, K. Richardson, P.

O’Sullivan
PII: S1356-689X(16)00041-2
DOI: 10.1016/j.math.2016.03.010
Reference: YMATH 1841

To appear in: Manual Therapy

Received Date: 6 June 2015

Revised Date: 28 February 2016
Accepted Date: 18 March 2016

Please cite this article as: Beales D, Kendell M, Chang RP, Håmsø M, Gregory L, Richardson K,
O’Sullivan P, Association between the 10 item Örebro musculoskeletal pain screening questionnaire
and physiotherapists’ perception of the contribution of biopsychosocial factors in patients with
musculoskeletal pain, Manual Therapy (2016), doi: 10.1016/j.math.2016.03.010.

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 ACCEPTED MANUSCRIPT
TITLE PAGE

Association between the 10 item Örebro musculoskeletal pain screening

questionnaire and physiotherapists’ perception of the contribution of
biopsychosocial factors in patients with musculoskeletal pain

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D. Beales a* (D.Beales@curtin.edu.au)

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M. Kendell a (M.Kendell@curtin.edu.au)

R. P. Chang a (ruth@iinet.net.au)

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M. Håmsø a (magnushamso@gmail.com)

L. Gregory a (luke_gregory4@hotmail.com)

K. Richardson a
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(kanda.richardson@gmail.com)
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P. O’Sullivan a (P.OSullivan@curtin.edu.au)
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a
School of Physiotherapy and Exercise Science, Curtin University. GPO Box U1987, Perth,
Western Australia 6845. Tel.: +61 89266 4644
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*Corresponding author. School of Physiotherapy and Exercise Science, Curtin University.

GPO Box U1987, Perth, Western Australia 6845. Tel.: +61 89266 4644
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E-mail address: D.Beales@curtin.edu.au

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Keywords
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musculoskeletal pain, short-form Örebro, screening, psychosocial factors

 Correlation Short Form Örebro (SFO) And Clinicians
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ABSTRACT

Background: Contrasting evidence exists on the ability of clinicians to identify

biopsychosocial factors in patients with musculoskeletal pain compared to questionnaires.
Objective: Evaluate associations between two aspects of clinical practice used to assess
biopsychosocial factor contribution in patient presentations (physiotherapist perceptions

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versus shortened 10-item Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ-
10)). Potential influence of physiotherapists’ training, experience and confidence level were

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assessed.
Study Design: Observational.

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Methods: 90 musculoskeletal pain patients completed the ÖMPSQ-10 prior to their initial
assessment. Independently, 19 treating physiotherapists provided their perception of

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contribution of biopsychosocial factors to the patient presentation. Pragmatic comparison of
physiotherapist perceptions and the ÖMPSQ-10 was made with Spearman’s correlations.
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Results: Fair correlation existed between physiotherapists’ perception of overall contribution
of biopsychosocial factors to the patients’ presentation and the ÖMPSQ-10 (0.39). There
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where moderate correlations for the domains of recovery expectancy (0.53), self-perceived
ability to work (0.52) and ability to sleep (0.54). There where fair correlations for anxiety
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(0.33) and depression (0.32), and a poor correlation for fear (0.10). Correlations were
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influenced by therapist training in psychosocial aspects of pain, experience and confidence.

Conclusions: Physiotherapists perceptions on biopsychosocial contributing factors to overall
presentation of patients with musculoskeletal pain were reasonably correlated with a number
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of the domains in the ÖMPSQ-10. However, correlations for anxiety, depression and fear
were not as good. This may reflect a lack of adequate training and/or the inadequacy of single
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questionnaire items to capture complex issues such as pain-related fear. Screening

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questionnaires are recommended as an adjunct to clinician perceptions.

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INTRODUCTION

Disabling musculoskeletal pain conditions are widespread in many countries (Global Burden
of Disease Study, 2015). There is increasing understanding of the importance of considering
musculoskeletal pain disorders from a multidimensional, biopsychosocial perspective, with

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complex interactions of multiple factors influencing an individual’s experience of pain
(Gatchel et al. , 2007, Vranceanu et al. , 2009). There is evidence indicating that psychosocial
factors (yellow flags) can have a larger impact on persistent pain, disability and work

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absenteeism than biomechanical or biomedical factors, as well as being strongly linked to the
transition from acute to chronic pain (Chou et al. , 2007, Mallen et al. , 2007, Overmeer et al.

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, 2004, Ramond et al. , 2011).

However, it has been reported that some clinicians find it difficult to comprehend the

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multidimensional nature of pain disorders. Often this relates to difficulty understanding the
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role of psychosocial factors in musculoskeletal pain presentations or uncertainty on how to
best assess these factors (Singla et al. , 2015). While many clinicians are turning to screening
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tools in their clinical assessment to identify psychosocial factors, many do not despite such
tools being readily available (Crawford et al. , 2007, Daubs et al. , 2010, Kent et al. , 2009,
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Linton and Shaw, 2011). Furthermore, clinicians may focus on physical impairments and
pain rather than routinely considering the contribution of psychosocial factors (Beales et al. ,
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2015, Crawford et al. , 2007, Kent et al. , 2009). Clinicians’ identification and management of
psychosocial factors in patients with musculoskeletal pain can be influenced by an
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individual’s beliefs, culture of practice, experience using formulated guidelines, sufficiency

of training, knowledge and skills, confidence levels and time constraints (Crawford et al. ,
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2007, Kent et al. , 2009).

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Evidenced based guidelines for the management of both acute and chronic musculoskeletal
pain disorders recommend clinicians screen for psychosocial factors to assist in
understanding the multidimensional nature of a patients presentation (Airaksinen et al. , 2006,
Chou et al. , 2007, Kendall et al. , 2004, Koes et al. , 2010, van Tulder et al. , 2006). Of the
available screening tools, the STarT Back Screening Tool (Hill et al. , 2008) and Örebro
Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) (Linton and Hallden, 1998) are two
that have been widely researched and implemented in clinical practice due to ease of

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application. More recently, a short form of the ÖMPSQ (ÖMPSQ-10) has been developed,
improving its clinical utility due to its shorter length (Linton et al. , 2011).

Despite their recommended use, there appears to be differing opinions in the literature with
regards to the value and validity of formal screening tools compared to clinician judgement
and intuition in the identification of biopsychosocial factors and assessment of risk of poor
prognosis. Some studies report that clinicians make inconsistent risk estimations using

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clinical intuition alone when compared to formal screening tools (Bishop and Foster, 2005,
Hill et al. , 2010). Furthermore, clinician ability to identify individual psychosocial factors

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such as depression (Haggman et al. , 2004), fear-avoidance beliefs (Calley et al. , 2010) and
psychological distress (Daubs et al. , 2010, Grevitt et al. , 1998) has been reported to be poor

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in comparison to formal screening tools. In contrast, other authors have suggested that
clinicians’ prognostic assessment is similar or even preferable to that of formal screening

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tools (Dagfinrud et al. , 2013, Jellema et al. , 2007, Vibe Fersum et al. , 2009). Interestingly,
the studies that have shown favourable results for clinician risk assessment and/or identifying
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psychosocial factors over that of screening questionnaires have tended to use ‘real patients’
presenting with spinal pain rather than videos or vignettes. Further, the potential influence of
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clinician attributes such as training, experience and level of confidence in identifying and
managing biopsychosocial factors does not appear to have previously been considered in
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studies evaluating the association between clinician perspective and formal questionnaires.
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Understanding how clinician attributes influence the association between clinicians’

perspective or judgment and screening tool results may assist in developing education
strategies for clinicians and/or refining recommendations regarding the use of screening tools.
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The aim of this study was to evaluate the association between the short-form ÖMPSQ-10 and
physiotherapists’ perception of the contribution of multidimensional, biopsychosocial factors
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in patients with musculoskeletal pain. This was performed pragmatically in clinical settings
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in an attempt to reflect current day physiotherapy practice. The influence of physiotherapists’

training, experience and level of confidence in identifying and managing psychosocial factors
were also evaluated given the potential of these clinician attributes to influence these
associations. A secondary aim of this study was to determine the test-retest reliability of the
ÖMPSQ-10 in subjects with musculoskeletal pain as this has not been previously reported.

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METHODS

Study design

This study was a pragmatic, observational study with ethical approval obtained from Curtin
University’s Human Research Ethics Committee (Approval Number PT0199).

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Participants

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Physiotherapists were recruited by invitation from private and public outpatient
physiotherapy centres throughout Perth, Western Australia. A total of 19 physiotherapists

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participated (female n=9, male n=10) based upon convenience sampling. New patients (n=90)
seeking treatment from these physiotherapists (who had not previously been seen by the
physiotherapist) were invited to participate by the treating physiotherapist. Data was not

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collected on the number of patients invited to participate who declined. Inclusion criteria
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included musculoskeletal pain of any duration or body region. This inclusion criterion was
decided pragmatically as the best reflection of current clinical practice. Participants were
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excluded if they had inadequate English language skills to complete the questionnaire. Both
physiotherapists and the patients provided written informed consent.
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To determine the test-retest reliability of an online version of the ÖMPSQ-10, a convenience

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sample of 39 participants were recruited by invitation. For this, the ÖMPSQ-10 was
completed on two separate occasions within one week (mean was 1.7 days with a range of 1
to 6 days).
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Shortened 10 item Örebro Musculoskeletal Pain Screening Questionnaire

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The ÖMPSQ-10 was chosen as the screening tool of interest in this study because it is
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multidimensional, is not worded to be body region specific and is increasingly being utilised
in clinical practice as an alternative to the full length version.

The ÖMPSQ-10 was developed from the ÖMPSQ to reduce the tool to one page with 10
items (Linton et al. , 2011). Two items were selected from each of the five factors (self-
perceived function, pain experience, distress, fear avoidance beliefs and return to work
expectancy) shown to have the greatest predictive power (Linton et al. , 2011). The ÖMPSQ-
10 has been validated against its original version and has been recommended for clinical

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purposes (Linton et al. , 2011), taking less time to complete and score than the original
version. Debate exists regarding this process of development (Linton et al. , 2015), with a 12
item version of the Örebro available with potentially enhanced psychometric properties
(Gabel et al. , 2013). The test-retest reliability for the original ÖMPSQ has been reported
between 0.80 to 0.98 (Grotle et al. , 2006, Linton and Boersma, 2003, Linton and Halldén,
1998, Vos et al. , 2009), with intervals ranging from two days (Grotle et al. , 2006) up to two

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to four weeks (Linton and Boersma, 2003). The test-retest reliability has not been evaluated
for the ÖMPSQ-10.

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Measurements completed by physiotherapists

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Background demographic data about the physiotherapists including number of years of
experience and specific post-graduate training in psychosocial aspects of pain were collected
via a questionnaire. Physiotherapists also rated on a 0 to 10 numerical rating scale (NRS)

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their perception of the role of psychosocial factors in musculoskeletal pain disorders (0=No
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role, 10=The dominant role), the importance of consideration of psychosocial factors by
physiotherapists in musculoskeletal pain, (0=Not important at all, 10= Critically important)
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and their perceived confidence in identifying and managing psychosocial factors contributing
to musculoskeletal pain disorders (0=Not confident at all, 10=Completely confident) (for full
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details see Table 1).

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A second questionnaire was created in order to identify physiotherapists’ perception of the

contribution of biopsychosocial factors to the patients’ musculoskeletal pain. It was based on
the ÖMPSQ-10 domains (self-perceived function, anxiety, depression, recovery expectation
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and fear avoidance beliefs) and also allowed clinicians to rate their perception of the overall
influence of psychosocial factors on the patients’ musculoskeletal pain. Each item was rated
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using a 0 to10 NRS (for full details see Table 2).

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Procedure

Patients completed the ÖMPSQ-10 before their initial physiotherapy consultation. The
physiotherapist, while blinded to the results of the ÖMPSQ-10, also completed the clinician
questionnaire following the initial consultation. The completed physiotherapist questionnaire,
ÖMPSQ-10 and signed consent form were placed into separate sealed envelopes and returned
to the primary investigator.

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In order to investigate the test-retest reliability of the ÖMPSQ-10, an online version was
created using Qualtrics Online Survey Software (http://qualtrics.com). Patients were given an
information sheet that included the purpose of the study and a link to the ÖMPSQ-10. The
patients were asked to complete the online ÖMPSQ-10 on two occasions within one week of
each other.

Statistical analyses

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Analyses were performed in ‘R’ statistics package for Mac OS X (www.r-project.org),

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utilising the graphical user interface ‘JGR’ extension (www.rosuda.org/software/). The level
of significance was set at p<0.05. Descriptive statistics were used to present physiotherapist

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demographics.

Spread of physiotherapists’ data for each patient assessed was graphically analysed to assess

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for potential within therapist bias (mean number of patients seen by each physiotherapist was
4.7 with a range of 1 to 10). Shapiro-Wilk tests revealed the majority of data had a non-
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normal distribution and subsequently Spearman’s correlations were performed. The
association between physiotherapists’ assessment of the contribution of biopsychosocial
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factors to the patient presentation and the ÖMPSQ-10 results were analysed using
Spearman’s correlation coefficient and p values. These results were interpreted according to
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correlation coefficient interpretation guidelines (Colton, 1974).

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Separate Spearman’s correlations were calculated based on physiotherapist confidence,

experience and if the physiotherapist had specific post-graduate training on psychosocial
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aspects of musculoskeletal pain. Physiotherapist confidence in identifying and managing

psychosocial factors was dichotomised at ≤6 (n=10), or ≥7 (n=9) on the NRS rating.
Physiotherapist experience was determined by years treating musculoskeletal pain disorders,
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split at ≤2 years of experience (n=10), or ≥3 years (n=9). These cut-offs were based on the
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judgment of the authors while allowing for a relatively even group distribution for sub-
analysis. Those with specific post-graduate training in psychosocial aspects of
musculoskeletal pain was n=6 and those without was n=13. The correlations of each group
were compared with independent correlation comparisons performed with SISA: Simple
Interactive Statistical Analysis online software
(www.quantitativeskills.com/sisa/statistics/corrhlp.htm, accessed 21 November 2014).

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The test-retest reliability of the online ÖMPSQ-10 was analysed with two-way mixed effects
model for single measures intra-class correlation coefficients (ICC) with 95% confidence
intervals using IBM SPSS Version 19 for Windows.

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RESULTS

Physiotherapist demographics and self-report measures are presented in Table 1. A wide

spread of individual responses was demonstrated ensuring there was no within therapist bias

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affecting correlations (Appendix 1). For the 90 patients, the median ÖMPSQ-10 score was 45
(inter quartile range = 37 to 54). The median pain rating for the previous week (from the

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ÖMPSQ-10 for pain intensity) was 6 (inter quartile range = 4 to 8). From the ÖMPSQ-10 for
symptom duration, 35 subjects had experienced their pain for 4 weeks or less, 28 for 4 weeks

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to 1 year and 27 for greater than 1 year.

Correlations between physiotherapist questions and the corresponding ÖMPSQ-10 questions

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are presented in Table 2. There was a fair correlation (rho(ρ)=0.39) between the ÖMPSQ-10
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and the physiotherapists overall perception of the contribution of psychosocial factors to the
individual patients’ presentation. There were moderate correlations between the domains of
light work (ρ=0.52), sleep (ρ=0.54) and recovery expectations (ρ=0.53). Fair correlations
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existed for physiotherapists’ perception of the presence of tension or anxiety (ρ=0.33),

depression (ρ=0.32) and recovery expectation in regard to return to work (ρ=0.28) compared
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to the ÖMPSQ-10.
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The effect of stratification (base upon confidence, experience or training) on the association
between physiotherapist perspective and ÖMPSQ-10 are presented in Table 3. Significant
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differences in the correlations existed for physiotherapists with ≥7/10 confidence in the
domains of sleep (p=0.003) and depression (p=0.03); for physiotherapists with ≥3yrs
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experience in the domains of sleep (p=0.002) and anxiety (p=0.03), and also in those with
specific training related to psychosocial aspects of pain in the domain of anxiety (p<0.001).
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The test-retest reliability of the ÖMPSQ-10 was strong with an ICC of 0.90 (95% confidence
interval: 0.82 to 0.94).

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DISCUSSION

The results of this study indicate a broad association between the ability of physiotherapists
to identify biopsychosocial factors following clinical examination of patients with

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musculoskeletal pain and the results of the ÖMPSQ-10. Associations were stronger in
specific domains such as perceived ability to do light work, sleep ability and patient’s

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perceived recovery expectations, but poorer in other domains such as fear avoidance beliefs.

Other research has suggested that clinician intuition is adequate when identifying

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psychosocial factors or risk profiling patients with spinal pain (Jellema et al. , 2007, Vibe
Fersum et al. , 2009). However, these findings are in contrast to other studies that suggest

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clinicians make inconsistent risk estimates compared to formal screening tools (Bishop and
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Foster, 2005, Hill et al. , 2010). This conflict in findings may be explained in part by the
methodology of these studies. For example, Bishop et al 2005 used written patient vignettes
and Hill et al 2010 video recorded patient assessments to elicit judgment from participating
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clinicians, both of which may not represent a true clinical situation. In contrast Jellema et al
2007, whose results are most analogous with the present study, also used clinician assessment
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of actual patients. A strength of the present study was that it was performed in clinical
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settings with ‘real patients’, and thus is a close reflection of current day physiotherapy
practice. Also, differences in wording of questions asked of clinicians (compared to the
questionnaires completed by patients) may underlie differences in the results between studies.
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Findings related to specific questionnaire domains

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While the ÖMPSQ-10 does provide an overall score for general risk assessment (Linton et al.
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, 2011), investigation of individual domains within the ÖMPSQ-10 can be insightful. In this
study, correlation between the ÖMPSQ-10 and physiotherapists’ perceptions were stronger in
specific domains including light work, sleep and recovery expectations and weaker in
domains such as anxiety, depression and fear. This is consistent with previous studies that
have assessed the ability of clinicians to detect these constructs in individual patients versus
structured questionnaire profiling (Calley et al. , 2010, Daubs et al. , 2010, Grevitt et al. ,
1998, Haggman et al. , 2004). A potential reason for higher agreement between
physiotherapists’ perceptions and questionnaire domains more related to physical

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impairments is that these domains represent the traditional focus of physiotherapy training
and practice (Beales et al. , 2015), which may also be the case for other non-psychological
health care professionals. In contrast, integration of psychosocial aspects of musculoskeletal
pain disorders may be lacking in education and clinical practice (Foster and Delitto, 2011,
Pincus et al. , 2013), leading to reduced ability to recognise these domains in the clinical
interaction.

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This study found a moderate correlation between the physiotherapists' judgement of the
patients’ perception of their own recovery versus the ÖMPSQ-10 question related to the risk

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of their problem becoming persistent (Table 2). However, there was a weaker correlation
between the physiotherapists’ judgement of the patients’ self-perceived recovery and the

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ÖMPSQ-10 question related to expectation of return to work (Table 2). This second finding
is consistent with a previous report of a weak correlation between clinician and patient

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expectations of return to work (Kapoor et al. , 2006). Despite this weak correlation, both
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clinician and patient expectation for return to work can be predictive of this actual outcome
(Kapoor et al. , 2006). Those authors also noted that clinicians tended to place greater
emphasis on the physical factors than psychosocial factors. The results of the question
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relating to return to work may be influenced by whether the patients were actually working or
not. However, generally physiotherapists will consider broader definitions of work that
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include home duties and other non-traditional work activities. Nevertheless, clarification of
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this would be useful in future research.

Only fair associations were identified between physiotherapist judgement related to

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psychological distress (depression and anxiety) and the distress domain questions of the
ÖMPSQ-10. Previous research has reported similar findings (Daubs et al. , 2010, Grevitt et
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al. , 1998, Haggman et al. , 2004). Physiotherapist ability to detect the fear domain was
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especially poor. This finding has previously been reported, with the physiotherapists view of
fear avoidance showing stronger correlation with pain catastrophising and disability rather
than fear avoidance beliefs and kinesiophobia (Calley et al. , 2010). It is suggested that skills
in identifying physical impairments may confound the ability to make isolated determinations
about fear avoidance (Calley et al. , 2010). Alternatively, the poor detection of fear may be a
reflection that the questions in the ÖMPSQ-10 do not comprehensively address the construct
of fear. A comprehensive review of fear related questionnaires found weak construct validity
which implies no measure can currently identify who is fearful in relation to pain (Lundberg

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et al. , 2011). Bunzli et al 2015, identified from a qualitative study of people with chronic low
back pain and high levels of kinesiophobia, that fear avoidance was associated with beliefs
that painful activity will result in damage, and/or that painful activity will increase suffering
and/or functional loss. In contrast, both ÖMPSQ-10 fear avoidance questions are based
largely on stopping activity or work if pain is worse (Bunzli et al. , 2015) which may not
necessarily relate to fear, rather a pain exacerbation response to repeated movement tasks

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(Sullivan et al. , 2009). Responses to fear constructs may further be complicated by
differences in related coping strategies (Hasenbring et al. , 2012) and might be another

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challenge for clinicians to integrate into their conceptualisation of fear responses.

Clinician confidence, experience and training

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In terms of overall impression of the contribution of biopsychosocial factors to patient
presentation and ÖMPSQ-10 score, physiotherapist confidence and experience did not result

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in significantly better correlations. However, specific post-graduate training in psychosocial
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aspects of pain did improve the correlation, though short of statistical significance. Consistent
with this trend, Vibe Fersum et al 2009 reported that four physiotherapists, with specific
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training in a cognitive function approach to low back pain, reached fair to excellent
agreement between the perception that significant psychosocial factors were present in a
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group of patients with non-specific low back pain compared to the ÖMPSQ (Vibe Fersum et
al. , 2009). Specific training related to psychosocial influences on pain, apparently lacking
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generally in clinician education (Foster and Delitto, 2011, Pincus et al. , 2013, Singla et al. ,
2015), appears to be an important strategy in improving overall recognition of these factors
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by clinicians. Additionally the elements of physiotherapist confidence, experience and

training were variably associated with significantly stronger correlations in the ÖMPSQ-10
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domain of psychological distress (confidence with depression; experience and training with
anxiety) (Table 3). This was not the case for the fear domain, (Table 3) which either reflects
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the need for greater focus in training programs, or greater clarity in the questioning of fear in
screening questionnaires to determine the basis of avoidance (Bunzli et al. , 2015).

Interestingly, confident and experienced physiotherapists demonstrated significantly stronger

correlations in the area of sleep impairment. There is growing evidence for the important role
that sleep plays in pain disorders (Finan et al. , 2013). The results of this study support the
targeting of education regarding the sleep-pain relationship in less experienced and less
confident physiotherapists.

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Potential limitations

In interpreting the results of this study, a number of limitations should be considered. First,
the total number of patients assessed by individual physiotherapists varied. The potential of
this to create within therapist bias was assessed as part of the data preparation and analysis
procedure. A wide spread of physiotherapist responses confirmed individual therapist bias did
not significantly influence the results (Appendix 1). Another potential weakness of this study

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was that there was some limited patient demographic data available. While we have been able
to report ÖMPSQ-10 score, pain intensity and symptom duration, we do not have data on the

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age and gender of the patients, the body area they consulted the physiotherapist for or
compensation/occupational status. We do not present the ÖMPSQ-10 as a reference standard,

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but as an example of a screening tool commonly used in clinical practice. Some consideration
of this tool itself is warranted in relation to the patient sample in this study. In terms of pain

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location, the authors acknowledge that the validity of the ÖMPSQ-10 has been assessed in
subjects with spinal pain (Linton et al. , 2011)) and this study may have included patients
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with non-spinal musculoskeletal pain. While the ÖMPSQ-10 is worded to not be body region
specific, and this is most certainly the way it is used in clinical practice, it’s suitability for the
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patient cohort in this investigation warrants further investigation. Moreover, the aim of this
study was not to use the ÖMPSQ-10 as a reference standard, nor was it the intention to
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further validate this questionnaire. The authors also acknowledge that the area of pain may
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influence prognostic assessment. For example, Dagfinrud et al 2013 found that both the
ÖMPSQ and clinicians prognostic assessment had similar ability in predicting outcome eight
weeks after assessment in patients with low back pain but not patients with neck pain
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(Dagfinrud et al. , 2013). Also patient behaviours observed during clinical assessment may
inherently differ from self-reported behaviours reported on a questionnaire (Calley et al. ,
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2010). Finally, the arbitrary cut-off scores used for physiotherapist experience and level of
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confidence were made based on the judgment of the authors and were grouped to allow
meaningful analysis therefore potentially influencing the results. While the aforementioned
limitations need consideration, the study is a true reflection of day-to-day clinical practice
and some limitations represent inherent factors within the pragmatic study design.

Test-retest reliability of the ÖMPSQ-10

This appears to be the first time test-retest reliability of the ÖMPSQ-10 has been reported in
the literature. The ICC value demonstrated a strong test-retest repeatability over an average

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period 1.7 days, and is consistent with results of reliability testing for the original version of
the ÖMPSQ (Grotle et al. , 2006, Linton and Boersma, 2003, Linton and Halldén, 1998, Vos
et al. , 2009). This lends some credence to the use of an electronic version of the
questionnaire, but further research may be needed to assess the test-retest reliability of the
paper version of the questionnaire. This provides some support to the stability of the
ÖMPSQ-10 results provided by patients in this study, though recent research indicates

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consideration of fluctuations in biopsychosocial profiles over time might be necessary
(Bergbom et al. , 2015). Further research evaluating the stability of the physiotherapists’

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perspective on the patient presentation over a short period of time would be of value.

Clinical implications

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Use of screening questionnaires, such as the ÖMPSQ-10, to supplement clinician intuition
and judgement is recommended in clinical practice. The results of this study support that this

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should extend beyond the use of total scores (Sattelmayer et al. , 2012). Considering scores
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on individual domains within the ÖMPSQ-10 may provide additional information to the
clinician and should be used to guide the clinician-patient interaction to inform patient
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centred care. Just as importantly, management should not be dictated by the questionnaire
results alone due to the possibility of non-disclosure in some individuals. Careful
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interpretation and reasoning of questionnaire results can potentially direct clinicians to the
need for additional questioning and assessment of contributing factors to musculoskeletal
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pain across multiple domains. Research to produce improved screening tools (Linton et al. ,
2015) may benefit from insight into how clinicians utilise these tools.
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Previous studies have suggested clinicians’ identification and management of

biopsychosocial factors in patients can change depending on their experience of using
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formulated guidelines, the sufficiency of their training, knowledge and skills (Chou et al. ,
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2007, Ramond et al. , 2011). In an effort to integrate psychosocial perspectives within clinical
management it is proposed that appropriate education at a tertiary level (in balance with
biomedical models of pathology) is an important strategy (Beales and O'Sullivan, 2014,
Foster and Delitto, 2011, O'Sullivan, 2012, Singla et al. , 2015). This should include
utilisation of biopsychosocial based screening tools. Given the results of this study and
similar findings identified in the literature, education specifically in the domains of distress
(depression and anxiety), and fear avoidance should be priorities.

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Conclusion

The results of this study show some association between biopsychosocial factors as
determined by physiotherapist perceptions and the ÖMPSQ-10 in patients with
musculoskeletal pain. There were stronger correlations in perceived function, sleep and
expectation of recovery than in the domains of distress and fear. There was some influence of
physiotherapist experience, confidence and training on these associations. The authors

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recommend integration of biopsychosocial orientated screening tools into clinical practice to
assist the clinician in the assessment of contributing factors to musculoskeletal pain disorders.

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Table 1: Clinician demographics and self-report measures of ability to identify and manage
psychosocial factors in patients with musculoskeletal pain.

Values*

Age 28.5 (7.6)

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Female clinicians 9/19 (47%)

Years treating musculoskeletal pain disorders 4.9 (6.4)

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Previous training related to psychosocial aspects of 6/19 (32%)
pain

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What role do you think psychosocial issues play in 6.4 (1.2)
musculoskeletal pain disorders? (0=No role, 10=The

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Do you think psychosocial factors are important for a 9.0 (1.0)
physiotherapist to consider in musculoskeletal pain
disorders? (0=Not important at all, 10= Critically
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important)

Confidence rating in self-ability to identify 6.3 (1.7)

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psychosocial factors contributing to musculoskeletal

pain (0=Not confident at all, 10=Completely
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confident)

Confidence rating in self-ability to manage 5.5 (1.7)

psychosocial factors in patients with musculoskeletal
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pain (0=Not confident at all, 10=Completely

confident)
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*Values are reported as mean (standard deviation), or n/total sample (percentage)

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Table 2. Correlations of clinician opinion with the 10 item Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ-10).

Clinician Questions ÖMPSQ-10 Spearman's

Rank

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Correlation

(p)

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Overall

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What is the overall contribution of psychosocial Total score 0.39
factors to this patient’s presentation? (0=No (<0.001)

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contribution, 10=Dominant Contribution)

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Perceived Function and Sleep

To what extent has your patient been able to Please circle the one number which describes your current

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participate in these activities: ability to participate in each of these activities:

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- They can do light work for an hour (0=Can’t - I can do light work for an hour (0=Can’t do it because of the 0.52
do it because of pain, 10=Can do it without pain problem, 10=Can do it without pain being a problem) (<0.001)

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pain)

- They can sleep at night (0=Can’t do it because - I can sleep at night (0=Can’t do it because of the pain 0.54
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of pain, 10=Can do it without pain) problem, 10=Can do it without pain being a problem) (<0.001)

Distress
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To what extent do you feel tension or anxiety is How tense or anxious have you felt in the past week? 0.33
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contributing to this patient’s presentation? (0=Absolutely calm and relaxed, 10=As tense and anxious as (0.002)
(0=Not at all, 10=Extremely) I’ve ever felt)

To what extent do you think depression is How much have you been bothered by feeling depressed in the
contributing to this patient’s presentation? past week? (0=Not at all, 10=Extremely) 0.32
(0.002)

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Correlation Short Form ÖMPSQ And Clinicians

(0=Not at all, 10=Extremely)

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Expectations

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How do you feel this patient perceives their In your view, how large is the risk that your current pain may 0.53
prognosis for recovery? (0=Extremely negative, become persistent? (0=No risk, 10=Very large risk) (<0.001)

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10=Extremely positive)
In your estimation, what are the chances you will be working 0.28

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your normal duties in 3 months? (0=No chance, 10=Very large (0.009)
chance)

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Fear

To what extent do you feel fear avoidance is An increase in pain is an indication that I should stop what I’m 0.10

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contributing to this patient’s presentation? doing until the pain decreases. (0=Completely disagree, (0.368)
(0=Not at all, 10=Extremely) 10=Completely agree)

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I should not do my normal work with my present pain.
(0=Completely disagree, 10=Completely agree) 0.06
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(0.578)
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Table 3. Correlations of clinician opinion and 10 item Örebro Musculoskeletal Pain Screening
Questionnaire (ÖMPSQ-10) stratified by level of self-reported confidence in identifying
psychosocial factors, experience as a physiotherapist or having received specific training
related to psychosocial aspects of pain.

Domain Confidence Experience Training

z z No Yes z

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≤6/10 ≥7/10 ≤2yrs ≥3yrs
(n=11) (n=8) (p) (n=10) (n=9) (p) (n=13) (n=6) (p)

Total 0.37 0.44 -0.38 0.29 0.53 -1.37 0.28 0.64 -1.75

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ÖMPSQ-10 (.70) (.17) (.08)

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Light Work 0.43 0.65 -1.43 0.42 0.64 -1.43 0.52 0.54 -0.14
(.15) (.15) (.89)

Sleep 0.31 0.75 -2.95 0.30 0.76 -3.09 0.45 0.71 -1.45

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(.003)
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Anxiety 0.16 0.43 -1.35 0.08 0.52 -2.24 0.17 0.86 -4.17
(.18) (.03) (<.001)

Depression 0.15 0.55 -2.11 0.21 0.49 -1.47 0.23 0.55 -1.34
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(.03) (.14) (.17)

Recovery 0.37 0.64 -1.67 0.39 0.63 -1.52 0.43 0.71 -1.55
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Pain (.09) (.13) (.12)

Recovery 0.14 0.37 -1.12 0.10 0.42 -1.56 0.29 0.24 0.19
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Work (.26) (.12) (.85)

Fear Pain 0.05 0.12 -0.32 0.06 0.14 -0.33 0.03 0.26 -0.86
(.75) (.74) (.39)
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Fear Work -0.12 0.27 -0.71 -0.10 0.24 -0.63 0.01 0.25 -0.93
(.48) (.53) (.35)
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ACKNOWLEDGEMENTS

Dr Darren Beales is supported by an Australian National Health and Medical Research

Council Fellowship (APP1036778).

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Highlights

• Association between clinician perception of contributing factors and the OMPSQ-10

were mixed
• Associations for anxiety, depression and fear were not as good as some other domains
• Higher levels of therapist confidence and experience improved some associations
•

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Training in psychosocial aspects of pain improved some associations
• Use of screening tools as an adjunct to clinician perception is recommended

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Appendix 1:

Spread of Clinician Responses

Contribution of Psychosocial Factors

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Clinicians (n=19)
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Wide spread of clinician responses is strongly suggestive that individual clinician

bias did not influence the results of the study.
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