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 evident that the knowledge about the musculoskeletal

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
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 question-
naires 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
 Structure of the questionnaires
The questionnaires consist of structured, forced, binary Questionnaire about
or multiple choice variants and can be used as self- trouble with the
administered questionnaires or in interviews. There are two locomotive organs
types of questionnaires: a general questionnaire, and specific
ones focusing on the low back and neck/shoulders. The
. . . . . . . . . . . . . . . . . . . . . . . . . i
purpose of the general questionnaire is simple surveying, l~, ,1.1,., r,,:,,,
., ~.t , L,r,t~ ¸ ~ a ~
while the specific ones permit a somewhat more profound
analysis. ; ' , ' ,~t ~e~r ..,,~,~. ~ : . , ' , , : r ¸¸

The two main purposes of the questionnaires are to d c n q {()Jr p r e s e n t t.~pe OT ~ O f ~ o .ea~ = ITI .n~'~

serve as instruments (1) in the screening of musculoskeletal On average how ,'ar~ r{uR
a w e e k 3o y o u w o , k " ~Qurs a ~eqk
disorders in an ergonomics context, and (2) for occupational
health care service. The questionnaires may provide means
~. tall a ' e , , , ' ,I

to measure the outcome of epidemiological studies on A r e ¢ o , right f~arlae(l ( r eq~ h a q d e a > rlghl handed
musculoskeletal disorders. The questionnaires are not meant 2~ left h a n d e d

to provide a basis for clinical diagnosis. Screening of the

musculoskeletal disorders may serve as a diagnostic tool for
analysing the work environment, workstation and tool
design. The incompatibility of the user and the task or the
tool have been shown to relate to the musculoskeletal
i
symptoms (van Wely, 1970; Corlett and Bishop, 1978).
The localisation of symptoms may reveal the cause of
loading. The occupational health service may use the
questionnaire for multiple purposes e g, for diagnosis of
the work strain, for follow-up of the effects of improvements
of the work environment, and so on.
ii
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -2~-L . . . . . . . . . . . . . . .

Fig. 1 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, and if so, in what parts of the body are
they localised?" With this consideration in mind, a
questionnaire was constructed in which the human body
(viewed from the back) is divided into nine anatomical
regions. These regions were selected on the basis of two
criteria: regions where symptoms tend to accumulate, and
regions which are distinguishable from each other both by
the respondent and a health surveyor. 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. This choice has been made
because numerous possible causes of pain in the front part
of the body (abdominal and thoracical pains, etc) might
intermingle with the musculoskeletal pain in the upper
thorax. Preliminary observations seem to point out that
this choice does not significantly modify the response rates.
The verbal questions deal with each anatomical area in turn,
and inquire whether the respondent has, or has had, troubles
in the respective area during the preceding 12 months,
whether this pain is disabling and whether it is ongoing.
Fig. 1 shows the anatomical areas and the layout of the
questionnaire.
Special questionnaires for low back, neck and
shoulder symptoms
The two specific questionnaires (Figs. 2 and 3)
concentrate on anatomical areas in which the musculo-
skeletal symptoms are most common. These questionnaires
probe more deeply into the analysis of the respective
symptoms and contain questions on the duration of the
symptoms over past time - i e, entire life, last 12 months,
and previous 7 days. 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, and in terms of total
duration of symptoms and sick-leave during the preceding
12 months.
Limitations of the questionnaires
The general limitations of questionnaire techniques also
apply to these standardised questionnaires. The experience
of the person who fills out the questionnaire may affect the
results. Recent and more serious musculosketetal disorders
are prone to be remembered better than older and less
serious ones. The environment and filling out situation at
the time of the questioning may also affect the results
(Brigham, 1975; Sinclair, 1975). From an epidemiological
viewpoint, it is evident that this type of questionnaire is
most applicable for cross-sectional studies with all the
concomitant limitations.
Experience from the use of the questionnaires
The standardised questionnaires have been in extensive
use in Denmark, Finland, Norway and Sweden. The
questionnaires, mainly the general questionnaire, have been
used in more than 100 different projects, as well as in routine
work in occupational health care services. More than 50 000
persons have responded to one or more of the questionnaires.
Reliability and validity of the results
The reliability and validity of the questionnaires has been
investigated. Subjects have filled and refilled questionnaires

234 AppliedErgonomics September1987

 HOw tO answer the queetlonnaire: Trouble with the locomotive organs
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 - - o n e c r o s s for l To be i m l ~ l l t l d onlyby t h o l e
e a c h q u e s t i o n . You m a y b e in d o u b t a s to h o w to answer, b u t p l e a s e d o who ~ had trou4ofe
y o u r b e s t anyway. 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 , 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, Haveyouat a n y t i m e d u r i n g t h e l a l t 12 months had Have you at any lime Have you had trouble
trouble (ache, palm discomfort) in: during the l i l t 12 i at any time during the
months been pnr*l~l- JIM ? diyll?
ted from do~ng your
J normal ~ o r k (at h o m e ,
or away from home) be- ]
cause of the trouble? I

Neck
1 No 2 Yes No 2 Yes 1 No 2 Yes [ ,

ehoulders

// I
NO 2 Yes, ,n the right shoulder [
3 Yes, irl the tel/ shoulder NO 2 Yes ! 1
ii ¸ ~ •' 4 Yes in both shoulders

~"iow ~c~ Elbows

NO 2 Yes in the right elbow ;
3 Yes in 1he left elbow NO 2 Yes [ 1 NO 2 Yes
~ WRISTS/HANDS 4 Yes in both elbows i

T
Wrists/hands
HIPS/THIGHS NO 2 Yes m 1he r,ght w~,stlhand
3 Yes m the left wrist/hand i No 2 Yes 1
4 Yes ,n both wrists/hands
i
Upper back
1I
KNEES No 2 Yes No 2 Yes 1 NO 2 ; Yes

Low back (small of the beck)

iI
ji 1
, ]
NO 2 Yes NO 2 Yes 1 NO 2 Yes = =
i

ANKLES/FEET One or both hips/thighs [ *

No 2 Yes I 1 No 2 Yes 1 No 2 Yes

One or both knees i

NO 2 Yes ] 1 NO 2 Yes 1 NO 2 Yes 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 , a n d One or beth ankleS/feet i

c e r t a i n p a r t s overlap. 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 1 No 2 Yes 1 No 2 Yes 1 No 2 Yes
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).

and the subjects' responses to the questionnaires have been one on 22 railway maintenance workers) showed that the
compared with their clinical history. number of non-identical answers varied from 0 to 23%.
Validity tests against clinical history (one study on 19
Reliability tests with the test-retest method of medical secretaries and one on 20 railway maintenance
preliminary versions of the general questionnaire (one study workers) showed that the number of non-identical answers
on 29 safety engineers, one on 1 ? medical secretaries and varied between 0 and 20%.

Questionnaire about low LOWBACK

HOWto anlmer the q u u t l o n n l b t :
In this picture you can see the
back trouble approximate portion of the pert of the body referred to in the question-
naire By low back trouble is meanl ache, 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 - - one cross
for each quest~n You may be in dOubt as to how to answer, but p4ease
do your best anyway

The date of inquiry

year month day

Sex 1 Female 2 Male ~]

What year were you born?

H ~ many years and months have you been HaM you ever had low back trouble (ache. 5 Has tow baCk treubk3 caused you to reduce
doing your present type el ~ r k ? years + months L i _ pain or discomfort)? your activity during the lest 12 men/ha?
1 No 2 f: Yes a Work activity (at home or away from
On average, how many hours
a week do you work ~ hours a weak J home)?
1;~No 2 [ ] Yes
H ~ much de you weigh ~ kg ~ b Leisure activity?
If yOU ins/tared NO to Question 1 dO nol answer 1 :No 2 ~] Yes
How tall are you? cm . . questions 2--8

Ate you right-handed or leti-handed ~ 1 right-handed 6~ Whal is the to/hi kJngth of time that low
2 leh handed back trouble has p ~ r l t 4 K I yOU from doing
your normal work (at home or away from
Have you ~ been hospitalized because of home) during the l i l t 12 months?
low back trouble?
0 days
1 I No 2 Yes
2 ~--7 days
Have you ever had to change j o b l or 3 8--30 days
duties because of lOW back trouble? 4 More Ihan 30 days
1 No 2 Yes

7 Haw you ~ INmn by a doctor, phy~m-

What is the total length of I,me that you therapist, chiropractor or other such person
have had low back trouble during the lest because of lOW back trouble during the felt
12 monthl~ 12 men/hi?
w
1 O days
z 2 1--7 days
1 No 2 [] Yes
3 8--30 days
47 4
5,
More than 30 days, but not every day
E~ry day L~ 8. Have you had low ~ack trouble a( any time
during the last 7 days?

If you angered O daya to question 4, do nol

1L NO 2 Yes E
a n s ~ r the questi~s 5--8

Fig. 2 Low back trouble questionnaire

Applied Ergonomics September 1987 235

 The reliability of the neck-shoulder questionnaire was
tested on 27 women in clerical work, who answered the Questionnaire about neck
questionnaire twice with a 3-week interval. The percentage
and shoulder trouble
of disagreeing responses varied from 0 to 15%, except for
questions 4 and 13 (Fig. 3)where it was 30 and 22%,
respectively. The validity was tested on 82 women in
electronics manufacturing. The questionnaire responses
~.lt mor,th oar
were compared with those obtained when a physiotherapist
Sex I Femste 2 Mal,
filled out the questionnaire after a thorough interview
~/hat y e a r were ~'ou born
about medical history. The percentage of disagreement
HOW m a n y years and m o n t h s have you been
between the subjects' own responses and the physiotherapist's doing your presen~ type of work ~ yea,~ ~ month~

estimates varied from 0 to 13%. O n average hOW m a n y h o u ~

a week do you work ? rl0urs a wee~

HOW muct~ dc ytJu we~gh'~ k~}

The reliability of a preliminary version of the low back
HOw tall are yoL cm
questionnaire was tested on 25 nursing staff members who
Are you ,,gh~ hanOed ~r ~e~ handed ~ t r~ght-handed
answered the questionnaire twice with a 15-day interval 2 left.handed

The percentage of disagreeing answers was on average 4-4,

varying from 0 to 4%, except for one question where it was
25%. As a consequence, this question was reformulated in
the final version.
The method of administration of the questionnaire has
an effect on the response rates (Andersson et al, 1987).

The usage of the questionnaire

A critical question that arises is whether the questionnaires
can provide useful information which can be used in decision-
making in occupational health practice. Various studies have
shown that response distributions are different for different
occupational groups (Jonsson and Ydreborg, 1985) and that
the differences are related to the estimated workload. 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, Brulin
et al, 1985).
The questionnaire has been structured for computer
analysis. Routine analysis of various statistical epidemio-
logical programmes can be applied. The dichotomy of the
response alternatives may require special consideration (see,
for example, Fleiss, 1973).
In the opinion of the project group the questionnaires
provide useful and reliable information on musculoskeletal
symptoms. This information either gives rise to further in-
depth investigation or gives hints for decision-making on
preventive measures.
Acknowledgement
The study was supported by the Nordic Council of
Ministers, Oslo.
References
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Anon
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Committee on the Aetiology of Chronic Bronchitis:
Instructions for the use of the questionnaire on
respiratory symptoms.
Fig. 3 Neck and shoulder trouble questionnaire
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Brigham, F.R.
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Fleiss, J.L.
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female workers in electronics industry.

236 AppliedErgonomics September1987

 NECK SHOULDER
to ~ the q~eallonnaim: By neck trouble is meant ache, How to m the q w l t k m m l m : 8y shoulder troubte m mear~ acda,
beJn or dmcomfoM in the shaded area. Please c~lceof tale on thin area. pain of d~comfoll fo me shadad area Pfelme concemrale o~ thts area.
ignorthg any trouble you may have in a d ~ pans of the hody There ~nonng any ~.¢ble you may dave in adtacem pare of the ho(~/ There
is a separate questionnade for shoofder trouble is a separste queslionnawe for neCk trouble.
Please answer by putting a cross in the appropriate box - - one cross Pleaseanswer by putting a Cross m the a~or Oys~ste be= - - one cross
for eaCh queshon. You may be in doubt as to how to answer, but please for each questkm Yeu may be m douof as to how to anst,~r, PUt pJesse
do your past anyway do your best anyway,

9 HaVe you ~ r had shoulder trouble (ache.

I
1 Have you ever hzv3 neck trouble (ache, pain Has neck trouble caused you 113reduce pain OF discomfort)? 14 Has shoulder trouble caused you to
or discomfort)? your activity during the l i l d 12 monlh$? fldl,lce your activity Ounng the l i l t 12
1 NO 2 Yes ~ : momhl?
1 NO 2 :: Yes E: a. Work activity (at home or away from
a Work acUvdy (at home or away from
home)?
If Y° u e n s u r e d N ° to Ouest~n 9, do not answer
1 No 2 Yes l i e questions 10--17
If you answered NO fo Quest!on 1, do not answer 1 No 2 Yes
the questions 2 - - 8 b Leisure activity?
b L e i ~ m activity ") r i
1 NO 2 Yes 10 Have you ~ hurt your shoulder in an I NO 2 Yes
Iceklent't
1 No 2 Yes, my r~ght should~
Have you ~ hurt your neck in an What is the total ter~jth of time thai neck 3 Yes, my ~efl shoulder 1,~ What is the troll4 length of brae that
acck~r~ troubli has prevented you from doing your 4 ~ . both shou,,~,,,.~ [ shoulder trouble ~ ~ you Item
normal wOrk (at home of away ttom home) doing your normal work (at home or away
1L NO 2 :: Yes during the ~ 12 nlonlhll? from hcfne) during the ~ 12 I ~ l ~ l h l ?
11 Ha~e you e w f had to chonge jall~4Lor
1 0 days duties dacause of shoulder trouble? 1--7 days
Have you i ~ l r had to change ~ or 2 ~ 1--7 days 1 No 2 Yes 3 8 - - 3 0 days
dl~tlel because of neck trouble? 3 8--30 days 4 More than 30 days
12 Have you had shoulder trouble during the
1 No 2 :: Yes E 4 More than 30 days
l u 1 1 2 mOllfhl?
1 NO 2 Yes in my ngbl shoulder 16 Have you been l i e n by a doctor, physio-
Ihefaplst, chiropractor or o~her suCh person
What ts the ~ lingth of time that you 3 Yes, in my lef~ shoulder because of stlouk:ler trouble during the
bawl had neck trouble during the l i l t 12 7 Have you been m e n by a dector. 4 Yes, in both shoulders L~_
phySlofherapist, chirowactor or other such l i l t 12 m o l l l h l ?
momhl?
person because of neck trouble during the 1 NO 2 Yes [1
1 E; O deys l a i r 12 montho? tf you answered NO to Question 12. de not
2 r[[ 1--7 days answer the questions 1~--17
3 ~ 8--30 days 17 Have you had shoulder trouble at any time
during the l i l t 7 days?
4 E~ More then 30 days, but not every day 13 What is the total length of l i ~ thai you
5 : E~l~y day
[] have had shoulder trouble during the k i l t 1 No 2 Yes, in my right shoulda¢
8 Have you had neck trouble at any time 12 mo~tho?
during the l i l t 7 t 1--7 days 3 i Yes, in my left shoulder
If you a n ~ m d 0 ~ Io Question 4, do not 2 : 8--30 days 4 i Yes, in both shoulUers
answer the q u e ~ n s 5--8 1 No 2 Yes B 3 : More than 30 days, but not every day
4 E ' ~ y day ~.J

Maeda, K., Hirayama, H., Chang, C-P., and Takamatsu, M. Sinclair, M.A.
1979 Japanese Journal of Industrial Health, 21,398-407. 1975 Applied Ergonomics, 6, 73-80. Questionnaire design.
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disorder by analysing the subjective symptoms of Troup, J.D.G., and Edwards, F.C.
workmen in assembly lines of a cigarette factory. 1985 Manual Handling. A review paper. Health and Safety
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Oxenburgh, M.S., Rowe, S.A., and Douglas, D.B.
1985 Journal of Occupational Health and Safety, 2, 106-112. Van Wely, P.
Repetition strain injury in keyboard operators - 1970 Applied Ergonomics, 1, 258-261. Design and
Australia and New Zealand. disease.
Pope, M.H., Frymoyer, J., and Andersson, G.B.J.
Wads, P.
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Rose, G.A., and Blackburn, H. 5, Supplement 3, 3-14. Occupational cervicobrachial
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Applied Ergonomics September 1987 237