Applied Ergonomics 1987, 18.3,233-237 Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms I. Kuorinka*, B. Jonsson t, A. Kilbom**, H. Vinterberg t t , F. Biering-S6rensen~, G. Andersson §§ and K. J6rgensen 7r *Institute of Occupational Health, Department of Physiology, Helsinki, Finland; tNational Board of Occupational Safety and Health, Work Physiology Unit, Ume/l, Sweden; **National Board of Occupational Safety and Health, Work Physiology Unit, ResearchDepartment, Solna, Sweden; ttDepartment of Rheumatology, County Hospital, Hiller6d, Denmark; §Rigshospitalet, University of Copenhagen, Denmark; ~Department of Orthopaedic Surgery, Rush-Presbyterian- St. Luke's Medical Center, Chicago, USA; rrAugust Krogh Institute, University of Copenhagen, Denmark Standardised questionnaires for the analysis of musculoskeletal symptoms in an ergonomic or occupational health context are presented. The questions are forced choice variants and may be either self-administered or used in interviews. They concentrate on symptoms most often encountered in an occupational setting. The reliability of the questionnaires has been shown to be acceptable. Specific characteristics of work strain are reflected in the frequency of responses to the questionnaires. Keywords: Questionnaires, musculoskeletal disorders, occupational health Background Musculoskeletal disorders and symptoms in a working population are common, occurring predominantly in the low back (see review by Troup and Edwards, 1985), neck and upper limbs (e g, Armstrong et al, 1982; Waris, 1979; Oxenburgh etal, 1985). Mechanical factors contribute to the development of these problems and in general influence symptoms (Kilbom et al, 1986; Maeda et al, 1979; Pope et al, 1984). To help define the problem and its relationship to work factors, increasing interest has been directed in many countries to the development of methods to estimate and record musculoskeletal symptoms. Questionnaires have proved to be the most obvious means of collecting the necessary data. Standardisation is needed in the analysis and recording of the musculoskeletal symptoms. Otherwise it is difficult to compare the results from different studies. This consideration was the main motive for a Nordic group to start developing standardised questionnaires for the analysis of musculoskeletal symptoms. Even a modest degree of standardisation was regarded as useful. We found that the major part of most questionnaires used in previous studies could have been easily comparable, but that the individual questions often differed in trivial details from study to study and thus impeded the comparison of the results. It was evident that the knowledge about the musculoskeletal symptoms was not sufficient to allow an advanced degree of standardisation. Consequently, we faced a trade-off between the banality of the questionnaire and the depth of the approach. The questionnaires presented here are a compromise between the extremes. We are well aware, however, that use of identical questionnaires is not the only prerequisite for comparison of data from different studies. The questionnaires follow the tradition of some earlier medical questionnaires - e g, for cardiovascular (Rose and Blackburn, 1968) or pulmonary surveys (British Medical Research Council's questionnaire for chronic bronchitis (Anon, 1960a, 1960b)). The nature of the musculoskeletal symptoms dictates a different structure, however. Supported by the Nordic Council of Ministers, a project was undertaken to develop and test standardised questionnaires on general, low back and neck/shoulder complaints. The text has been translated into four Nordic languages, using a multiple to-and-from technique from the source languages which were Swedish and Danish. Translation into English has been guided by native speakers of English, but might require further revision. If comparability with the Nordic languages is desired, a further check-and.cross translation is recommended. 0003-6870/87/03 0233-05 $03.00 ~) 1987 Butterworth & Co (Publishers) Ltd Applied Ergonomics Sept~ml~r 1987 233 . it is evident that this type of questionnaire is most applicable for cross-sectional studies with all the concomitant limitations. . . 1975). 2 and 3) concentrate on anatomical areas in which the musculoskeletal symptoms are most common. . . Subjects have filled and refilled questionnaires . These regions were selected on the basis of two criteria: regions where symptoms tend to accumulate. . Anatomical areas and questionnaire layout General questionnaire The general questionnaire was designed to answer the tbllowing question: "Do musculoskeletal troubles occur in a given population. .~. 1 shows the anatomical areas and the layout of the questionnaire.~t ~e~r . i r. The incompatibility of the user and the task or the tool have been shown to relate to the musculoskeletal symptoms (van Wely. . Norway and Sweden. and specific ones focusing on the low back and neck/shoulders. . Limitations of the questionnaires The general limitations of questionnaire techniques also apply to these standardised questionnaires.. .r. k " ~. neck and shoulder symptoms The two specific questionnaires (Figs. . . The two main purposes of the questionnaires are to serve as instruments (1) in the screening of musculoskeletal disorders in an ergonomics context. The main broadening in these questionnaires is that they analyse more thoroughly the severity of the symptoms in terms of their effect on activities at work and during leisure time. ~ : . The intentional choice of the back aspect of the body leaves gaps when disorders are located in the frontal part of the shoulder or on the flexor side of the upper limbs. The occupational health service may use the questionnaire for multiple purposes e g. . . 1978). ~. . . . .ea~ = ITI .t~ ¸ ~ a ~ . right f~arlae(l ( r . . . workstation and tool design. .t . . The localisation of symptoms may reveal the cause of loading.. Screening of the musculoskeletal disorders may serve as a diagnostic tool for analysing the work environment. This choice has been made because numerous possible causes of pain in the front part of the body (abdominal and thoracical pains. . . . while the specific ones permit a somewhat more profound analysis. and regions which are distinguishable from each other both by the respondent and a health surveyor. The questionnaires may provide means to measure the outcome of epidemiological studies on musculoskeletal disorders. . . .n~'~ r{uR ~Qurs a ~eqk tall a ' e . The verbal questions deal with each anatomical area in turn. . . . Preliminary observations seem to point out that this choice does not significantly modify the response rates. . . 1970. . . . . l~. . Fig. . 1 -2~-L . . There are two types of questionnaires: a general questionnaire. 1975. . . .. . . have been used in more than 100 different projects. .Structure of the questionnaires The questionnaires consist of structured. . as well as in routine work in occupational health care services. ' A r e ¢ o .1. forced. .i e. . L. . . . . . or has had. From an epidemiological viewpoint. . . The purpose of the general questionnaire is simple surveying. and (2) for occupational health care service. . The experience of the person who fills out the questionnaire may affect the results. .. . . Reliability and validity of the results The reliability and validity of the questionnaires has been investigated. and if so. binary or multiple choice variants and can be used as selfadministered questionnaires or in interviews. Fig. whether this pain is disabling and whether it is ongoing. . . . Questionnaire about trouble with the locomotive organs . . a questionnaire was constructed in which the human body (viewed from the back) is divided into nine anatomical regions. and in terms of total duration of symptoms and sick-leave during the preceding 12 months.. . The questionnaires are not meant to provide a basis for clinical diagnosis. The questionnaires. Special questionnaires for low back. for follow-up of the effects of improvements of the work environment. . .. . .. . troubles in the respective area during the preceding 12 months. . . . .I eq~ h a q d e a > 2~ rlghl handed left h a n d e d i ii . . ' . . ' . mainly the general questionnaire. ' . . : r ¸¸ d c n q {()Jr p r e s e n t t. and inquire whether the respondent has.'ar~ a w e e k 3o y o u w o .:. etc) might intermingle with the musculoskeletal pain in the upper thorax. Experience from the use of the questionnaires The standardised questionnaires have been in extensive use in Denmark. . The environment and filling out situation at the time of the questioning may also affect the results (Brigham. for diagnosis of the work strain.~. . and so on. More than 50 000 persons have responded to one or more of the questionnaires. Recent and more serious musculosketetal disorders are prone to be remembered better than older and less serious ones. entire life. 234 AppliedErgonomics September1987 and previous 7 days. . .1. . . Finland.. . in what parts of the body are they localised?" With this consideration in mind.. . last 12 months. These questionnaires probe more deeply into the analysis of the respective symptoms and contain questions on the duration of the symptoms over past time .~pe OT ~ O f ~ o On average how . Sinclair. Corlett and Bishop. . one on 1 ? medical secretaries and ! 1 One or beth ankleS/feet No 2 Yes Sex year 1 1 one on 22 railway maintenance workers) showed that the number of non-identical answers varied from 0 to 23%.me that you have had low back trouble during the lest 12 monthl~ w 1 2 3 4 5.JIM ? diyll? ted from do~ng J normal ~ o r k (at h o m e .one cross for each quest~n You may be in dOubt as to how to answer.o n e c r o s s for e a c h q u e s t i o n . pain or discomfort)? 1 On average. phy~mtherapist. If yOU ins/tared NO to Question 1 dO nol answer questions 2--8 6~ Whal is the to/hi kJngth of time that low back trouble has p ~ r l t 4 K I yOU from doing your normal work (at home or away from home) during the l i l t 12 months? right-handed leh handed Have you ~ been hospitalized because of low back trouble? 1 I No 2 Yes 2 3 4 Have you ever had to change j o b l or duties because of lOW back trouble? 1 No 2 Yes 7 Haw you ~ INmn by a doctor. . z 47 O days 1--7 days 8--30 days More than 30 days.HOw tO Trouble with the locomotive organs answer the queetlonnaire: P l e a s e a n s w e r b y p u t t i n g a c r o s s in t h e a p p r o p r i a t e b o x . or away from home) be. P l e a s e a n s w e r e v e r y q u e s t i o n . LOWBACK Questionnaire about low back trouble The date of inquiry i HOWto anlmer the q u u t l o n n l b t : In this picture you can see the approximate portion of the pert of the body referred to in the questionnaire By low back trouble is meanl ache. but not every day E~ry day 1 L~ No 2 [] Yes 8. Reliability tests with the test-retest method of preliminary versions of the general questionnaire (one study on 29 safety engineers. pain or discomfort in the shaded area whether or not it extends from there Io one or bOth legs (sciatica) Please answer by butt~ng a cross ~n the apbroP~ate Cox . and the subjects' responses to the questionnaires have been compared with their clinical history. chiropractor or other such person because of lOW back trouble during the felt 12 men/hi? What is the total length of I. do nol a n s ~ r the questi~s 5--8 Fig. . e v e n if y o u h a v e n e v e r h a d t r o u b l e in a n y p a r t of y o u r body.n the right shoulder 3 Yes. a n d c e r t a i n p a r t s overlap. Have you had low ~ack trouble a( any time during the last 7 days? If you angered O daya to question 4.~No 2 [ ] Yes b Leisure activity? 1 :No 2 ~] Yes J ~ .stlhand Yes m the left wrist/hand Yes . Yes in the right elbow Yes in 1he left elbow Yes in both elbows [ 1 i NO 2 Yes T Wrists/hands NO 2 3 4 HIPS/THIGHS Yes m 1he r. l Haveyouat a n y t i m e d u r i n g t h e l a l t 12 months had trouble (ache..ght w~. Validity tests against clinical history (one study on 19 medical secretaries and one on 20 railway maintenance workers) showed that the number of non-identical answers varied between 0 and 20%.] cause of the trouble? I your 1 // ii ¸ Neck No 2 No Yes ehoulders 2 Yes. how many hours a week do you work ~ No 5 Has tow baCk treubk3 caused you to your activity during the lest 12 men/ha? 2 f: Yes a Work activity (at home or away from home)? 1. irl the tel/ shoulder 4 Yes in both shoulders NO ~ •' ~"iow ~c~ Yes NO 2 Yes NO 2 Yes 1 WRISTS/HANDS 2 3 4 No 2 [ Yes I! 1 Elbows NO ~ 2 . [ . 2 0 days ~--7 days 8--30 days More Ihan 30 days 1L NO 2 Yes E Low back trouble questionnaire Applied Ergonomics September 1987 235 . You s h o u l d d e c i d e for y o u r s e l f in w h i c h part you h a v e or h a v e h a d y o u r t r o u b l e (if any). ] = = i ANKLES/FEET * i = i In this p i c t u r e you c a n see t h e a p p r o x i m a t e p o s i t i o n of t h e p a r t s of the bOdy r e f e r r e d to in the q u e s t i o n n a i r e • L i m i t s are not s h a r p l y d e f i n e d . palm discomfort) in: To be i m l ~ l l t l d onlyby t h o l e who ~ had trou4ofe Have you at any lime Have you had trouble during the l i l t 12 i at any time during the months been pnr*l~l. but p4ease do your best anyway month day Female 2 Male ~] What year were you born? H ~ many years and months have you been doing your present type el ~ r k ? years + months hours a weak H ~ much de you weigh ~ kg How tall are you? Ate you right-handed or leti-handed ~ L i _ cm 1 2 reduce HaM you ever had low back trouble (ache. b u t p l e a s e d o y o u r b e s t anyway. You m a y b e in d o u b t a s to h o w to answer.. Yes iI ij 1 NO 2 Yes 1 NO 2 Yes One or both hips/thighs No 2 Yes [ I 1 No 2 Yes 1 No 2 Yes One or both knees NO 2 Yes i ] 1 NO 2 Yes 1 NO 2 Yes No 2 Yes 1 No 2 Yes Low back (small of the beck) NO 2 Yes .n both wrists/hands i 2 Yes 1 1I Upper back No 2 Yes KNEES No i No 2 Yes 1 NO 2 . E. The questionnaire has been structured for computer analysis. B. Arbete och Hhlsa. 9 0 . 37-47. 1985 Musculoskeletal trouble among Swedish railway workers (in Swedish). 2. B. Persson.D. Armstrong. S.. B. F. 18.. varying from 0 to 4%.J. ~/hat y e a r were ~'ou born HOW m a n y years and m o n t h s have you been doing your presen~ type of work ~ yea. Karlehagen.9 6 . 3 . 1665. 3 Neck and shoulder trouble questionnaire Andersson. except for one question where it was 25%. The validity was tested on 82 women in electronics manufacturing.. Jonsson. 3)where it was 30 and 22%.S. John Wiley & Sons. Acknowledgement The study was supported by the Nordic Council of Ministers. 424-426. Anon 1960 (b) British Medical Journal. R.2 3 2 . t987 Applied Ergonomics. References 1973 Statistical methods for rates and proportions. The dichotomy of the response alternatives may require special consideration (see. Fleiss. and Bishop. 2 2 9 . Disorders of the cervicobrachial region among female workers in electronics industry.lt Sex mor.A. S. Medical Research Council's Committee on the Aetiology of Chronic Bronchitis: Instructions for the use of the questionnaire on respiratory symptoms. k~} HOw tall are yoL Are you . Various studies have shown that response distributions are different for different occupational groups (Jonsson and Ydreborg. respectively. Medical Research Council's Committee on the Aetiology of Chronic Bronchitis: Standardised questionnaires on respiratory symptoms. . 1975 Applied Ergonomics. Brulin et al. Proceedings of the 9th Congress of the International Ergonomics Association. Some quantitative considerations in questionnaire design and analysis. and Karlehagen.. and Jonsson. The percentage of disagreement between the subjects' own responses and the physiotherapist's estimates varied from 0 to 13%. 1985) and that the differences are related to the estimated workload. Brown eta/). In the opinion of the project group the questionnaires provide useful and reliable information on musculoskeletal symptoms.. 1987). The importance of variations in questionnaire administration. C.. B. 1986 International Journal of Industrial Ergonomics. 236 AppliedErgonomics September1987 Kilbom. Fig. T. except for questions 4 and 13 (Fig. who answered the questionnaire twice with a 3-week interval. Joseph. Stockholm. and Ydreborg. Anon Jonsson.. and Goldstein.. 1985 Identification of ergonomic problems by means of questionnaires for musculoskeletal troubles. In some studies the questionnaires have revealed a high prevalence of symptoms and disorders in certain anatomical regions which clearly correlate to the local physical demands (e g.~ ~ O n average hOW m a n y h o u ~ a week do you work ? month~ rl0urs a wee~ HOW muct~ dc ytJu we~gh'~ The reliability of a preliminary version of the low back questionnaire was tested on 25 nursing staff members who answered the questionnaire twice with a 15-day interval The percentage of disagreeing answers was on average 4-4.gh~ hanOed ~r ~e~ handed ~ cm t 2 r~ght-handed left. As a consequence. 1. B. 103-116. This information either gives rise to further indepth investigation or gives hints for decision-making on preventive measures.. New York. The usage of the questionnaire A critical question that arises is whether the questionnaires can provide useful information which can be used in decisionmaking in occupational health practice. S. Fleiss. The percentage of disagreeing responses varied from 0 to 15%.P.. 43. The ergonomics of spot welders.. 1973).L.The reliability of the neck-shoulder questionnaire was tested on 27 women in clerical work. Brulin. this question was reformulated in the final version. 1982 American Industrial Hygiene Association Journal.th oar Femste I 2 Mal.R.A. The questionnaire responses were compared with those obtained when a physiotherapist filled out the questionnaire after a thorough interview about medical history. Brigham. for example.N. and Jonsson. (Ed" I. 1960 (a) British Medical Journal. J. B. 23-32. Bournemouth. Investigation of cumulative trauma disorders in a poultry processing plant.handed The method of administration of the questionnaire has an effect on the response rates (Andersson et al. 6. 9.. A. J. 1978 Applied Ergonomies. (in press) Arbetarskyddsstyrelsen. Questionnaire about neck and shoulder trouble ~. Routine analysis of various statistical epidemiological programmes can be applied. J. Corlett. 1985). Foulke. Oslo. K. . Philadelphia. beJn or dmcomfoM in the shaded area. in both shoulders 8 Have you had neck trouble at any time during the l i l t 7 1 No 2 Yes I [ B Maeda. and Takamatsu. in both shoulUers ~. G. phySlofherapist.S. ignorthg any trouble you may have in a d ~ pans of the hody There is a separate questionnade for shoofder trouble How to m the q w l t k m m l m : 8y shoulder troubte m mear~ acda. Hirayama. 1984 Occupational low back pain. Occupational cervicobrachial syndromes: A review.one cross for eaCh queshon. M.¢ble you may dave in adtacem pare of the ho(~/ There is a separste queslionnawe for neCk trouble.A.J Sinclair. in my left shoulder Yes. K. Environment & Health. but not every day 5 : E~l~y day If you a n ~ m d 0 ~ answer the q u e ~ n s Io Question 4.. but please do your past anyway I 1 NO E: 2 :: Yes If you answered NO fo Quest!on 1.A. 258-261. Troup. Design and disease. 2. J..8 Have you ~ 1L NO 1 No 2 :: Yes or E What ts the ~ lingth of time that you bawl had neck trouble during the l i l t 12 momhl? 1 E. my r~ght should~ 3 Yes. Please answer by putting a cross in the appropriate box . Prager Press. 6.G. 5. 106-112. O deys 2 r[[ 1--7 days 3 ~ 8--30 days 4 E~ More then 30 days. Rose. Pleaseanswer by putting a Cross m the a~or Oys~ste be= . 1975 Applied Ergonomics. 1979 Japanese Journal of Industrial Health. my ~efl shoulder 4 ~ . chirowactor or other such person because of neck trouble during the l a i r 12 montho? [] 14 Has shoulder trouble caused you to fldl. Please c~lceof tale on thin area.. Health and Safety Executive.. Van Wely. physioIhefaplst. 1985 Journal of Occupational Health and Safety. 1985 Manual Handling. Questionnaire design.B. Chang. H.D. M. 1970 Applied Ergonomics. in my right shoulda¢ Yes. pain or discomfort)? 1--7 days 8 ..J. F.. Studies on the progress of occupational cervicobrachial disorder by analysing the subjective symptoms of workmen in assembly lines of a cigarette factory. do not 5--8 2 Yes ~ : NO 2 a Work acUvdy (at home or away from Yes 10 Have you ~ hurt your shoulder in an Iceklent't 1 No 2 Yes. PUt pJesse do your best anyway. Wads. 3-14. and Douglas. 21. M. P. pain of d~comfoll fo me shadad area Pfelme concemrale o~ thts area. pain OF discomfort)? Has neck trouble caused you 113reduce your activity during the l i l d 12 monlh$? 1 Have you ever hzv3 neck trouble (ache.. You may be in doubt as to how to answer. M.. in my lef~ shoulder 4 Yes.H. and Edwards. 1979 Scandinavian Journal of Work. Frymoyer. 73-80.~ What is the troll4 length of brae that shoulder trouble ~ ~ you Item doing your normal work (at home or away from hcfne) during the ~ 12 I ~ l ~ l h l ? 3 4 tf you answered NO to Question 12.C.. A review paper. de not answer the questions 1~--17 13 What is the total length of l i ~ thai you have had shoulder trouble during the k i l t 12 mo~tho? t 1--7 days 2 : 8--30 days 3 : More than 30 days. S. 1. 188.~ 1 12 Have you had shoulder trouble during the l u 1 1 2 mOllfhl? 1 NO 2 Yes in my ngbl shoulder 3 Yes.... J. 1968 Cardiovascular survey methods..one cross for each questkm Yeu may be m douof as to how to anst. ~nonng any ~. 2 Yes L~_ NO 2 r i Yes 1. Supplement 3. do not answer the questions 2 . P. WHO. Work activity (at home or away from home)? 1 No 2 Yes 1 acck~r~ 9 HaVe you ~ r had shoulder trouble (ache. both shou.. C-P.A. Applied Ergonomics September 1987 237 .398-407. and Blackburn. but not every day 4 E ' ~ y day No b L e i ~ m activity ") 11 Ha~e you e w f had to chonge jall~4Lor duties dacause of shoulder trouble? 1 No 2 Yes 1 0 days 2 ~ 1--7 days 3 8--30 days 4 More than 30 days 7 Have you been m e n by a dector. Oxenburgh. Rowe.B.3 0 days More than 30 days 16 Have you been l i e n by a doctor. G.. Geneva.NECK SHOULDER to ~ the q~eallonnaim: By neck trouble is meant ache..~. Repetition strain injury in keyboard operators Australia and New Zealand. and Andersson. H. D. Pope.~r. do not answer l i e questions 10--17 What is the total ter~jth of time thai neck troubli has prevented you from doing your normal wOrk (at home of away ttom home) during the ~ 12 nlonlhll? 2 :: Yes NO b Leisure activity? hurt your neck in an Have you i ~ l r had to change ~ dl~tlel because of neck trouble? 1 a. chiropractor or o~her suCh person because of stlouk:ler trouble during the l i l t 12 m o l l l h l ? 1 NO 2 Yes [1 17 Have you had shoulder trouble at any time during the l i l t 7 days? 1 No 2 3 i 4 i Yes.lce your activity Ounng the l i l t 12 momhl? If Y° u e n s u r e d N ° to Ouest~n 9.