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Manual Therapy 16 (2011) 531e543

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Manual Therapy

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Systematic review

A systematic review of instruments for the assessment of work-relatedpsychosocial factors (Blue Flags) in individuals with non-specific low back pain

Heather Gray a,*, Abiodun T. Adefolarin b, Tracey E. Howe a

aGlasgow Caledonian University, Glasgow G4 0BA, Scotland, UKb South Tipperary Primary Community & Continuing Care, HSE-South, Clonmel, Tipperary, Ireland

a r t i c l e i n f o

Article history:Received 4 January 2011Received in revised form27 March 2011Accepted 11 April 2011

Keywords:Back painPsychosocialPsychometricBlue Flags

* Corresponding author. Tel.: þ44 (0) 141 331 8115E-mail address: h.gray@gcu.ac.uk (H. Gray).

1356-689X/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.math.2011.04.001

a b s t r a c t

In individuals with low back pain (LBP) psychosocial factors can act as obstacles to return to work. Acoloured Flags Framework has been conceptualised, in which Blue Flags represent work-relatedpsychosocial issues. This systematic review was conducted to appraise available instruments for theassessment of Blue Flags in working age adults with non-specific LBP.

The Ovid versions of MEDLINE, EMBASE, PsycINFO, AMED and CINAHL databases were searched frominception until the first week of March 2010; additionally, experts and study authors were contacted.Two authors independently selected studies, extracted data and assessed methodological quality.

Eight studies (recruiting 5630 participants) met the review inclusion criteria, reporting six instru-ments: the Back Disability Risk Questionnaire (BDRQ); Occupational Role Questionnaire (ORQ); Obstaclesto Return to Work Questionnaire (ORTWQ); Psychosocial Aspects of Work Questionnaire (PAWQ); Ver-mont Disability Prediction Questionnaire (VDPQ); and Modified Work Adaptation, Partnership, Growth,Affection and Resolve. Limited psychometric testing had been performed on the instruments, and solelyby the original developers.

None of the instruments, in their current stage of development, can be recommended as Blue Flagsassessment instruments. The ORTWQ was the only instrument that showed adequate psychometricproperties but was not considered clinically feasible in its present format. Future research should focuson further psychometric development of the ORTWQ.

� 2011 Elsevier Ltd. All rights reserved.

1. Introduction

1.1. Background

Back pain is a global phenomenon, with significant socio-economic consequences. The vast majority of cases of back painaffect the lower back, have no specific diagnosis and are categorisedas non-specific low back pain (NSLBP) (Airaksinen et al., 2006;Bevan et al., 2009).

Recent systematic reviews provide convincing evidence thatpsychosocial factors can play an important role in NSLBP in per-sisting disability and delaying return towork (Iles et al., 2008; Heitzet al., 2009; Chou and Shekelle, 2010). Consequently, internationalguidelines for the management of LBP stress the importance of

; fax: þ44 (0) 141 331 8112.

All rights reserved.

addressing psychosocial factors during clinical assessments (Staalet al., 2003; Australian Acute Musculoskeletal Pain GuidelinesGroup, 2003; Burton et al., 2006; Chou et al., 2007).

In order to assist clinicians’ assessment of psychosocial factors,a colour-coded Flags Framework has been conceptualised (Kendallet al., 1997; Main et al., 2008); within which Blue Flags are definedas the individual’s perceptions about work, whether accurate orinaccurate, that can affect disability (Shaw et al., 2009a). Blue Flagsconstructs include, for example: negative expectations of return towork (RTW); job dissatisfaction; stress at work; work-related fearavoidance beliefs (i.e. belief that work is harmful or fear of re-injury); perceptions of physical job demands; and poor colleagueor supervisor relationships.

With respect to these different Blue Flags constructs as predic-tors of outcome, the strength of their supporting evidence is notidentical. The construct that appears to have the strongest evidencebase is recovery expectations. Several systematic reviews haveconcluded consistently that there is strong predictive evidence thatworkers’ low expectations about their recovery or ability to returnto work are particularly important in prognosis (Turner et al., 2006;

H. Gray et al. / Manual Therapy 16 (2011) 531e543532

Fadyl and McPherson, 2008; Iles et al., 2008). Iles et al. (2009), intheir systematic review of 10 studies, found that recovery expec-tations measured within 3 weeks of NSLBP onset provide a strongprediction of work outcome. The increased risk of activity limita-tion due to lower recovery expectations ranged from around 10% upto 300%.

The evidence for other work-related psychosocial factors,however, is less equivocal. For example, Burton et al. (2003) in theirsystematic review of 28 review papers found strong evidence thatjob dissatisfaction was a strong predictor of chronic pain anddisability. Likewise, the review of six reviews by Macfarlane et al.(2009) found that there was moderate to strong evidence that jobdissatisfactionwas associated with LBP. Further, a recent systematicreview with meta-analysis conducted by Chou and Shekelle (2010)found that higher job dissatisfaction was a predictor of chronicdisability at one year (median [range] positive likelihood ratio: 1.5[1.3e1.8]).

However, Hartvigsen et al. (2004) in their systematic review of40 prospective cohort studies asserted that no conclusions couldbe drawn regarding job dissatisfaction and the consequences ofLBP, such as, sick leave or RTW. Although this review was robustlyconducted, the authors grouped 36 psychosocial constructs intoone of four categories for analysis, which may have affected theirfindings. Additionally, their reviewed studies included a mixtureof general and working populations.

In relation to the construct of job stress, Hartvigsen et al. (2004)concluded that there was moderate evidence for no associationbetween stress at work and consequences of LBP. Additionally,Iles et al. (2008), in their review of 24 studies, found moderateevidence that stress was not a predictor of work outcome.However, several reviews have found evidence that personal stressis a risk factor for LBP disability (Shaw et al., 2001, 2009a; Burtonet al., 2003).

Iles et al. (2008), additionally, found that there was moderateevidence that fear avoidance beliefs were predictive of workoutcome, and Turner et al. (2006) found that high work fearavoidance was a significant predictor of work disability at sixmonths (odds ratio, 4.6; 95% confidence interval, 1.6e13.7).However, the systematic review of nine studies by Pincus et al.(2006) found little evidence to link fear of pain with pooroutcome. It should be noted, however, that work-specific outcomeswere not the main focus of the review by Pincus et al. (2006) whichmay explain their difference in findings.

The construct of physical job demands is generally supported byseveral systematic reviews. Shaw et al. (2001) found that workerself reports of greater physical job demands were predictive ofchronic occupational LBP disability. The review by Burton et al.(2003) concluded that there was strong evidence that physicaldemands of the job was a relevant construct; however, in thereviewers’ subjective judgements, it was a weak predictor of longerterm incapacity. In the meta-analysis conducted by Chou andShekelle (2010), the construct of higher physical job demandswas not found to predict worse outcomes at three months, but itdid at one year (median [range] positive likelihood ratio: 1.4[1.2e1.7]).

With regards to the construct of low social support at work,Macfarlane et al. (2009), found that there was moderate to strongevidence for low work support being associated with LBP. Addi-tionally, a Norwegian study conducted to examine the effect offormalised peer support in the workplace as an intervention foundthat it resulted in a 49% reduction in LBP-related sickness absence(Werner et al., 2007). However, Hoogendoorn et al. (2000), in theirsystematic review of 13 studies, found that there was insufficientevidence that this was a predictor of the occurrence of LBP.Similarly, Hartvigsen et al. (2004) found that there was moderate

evidence for no association between social support at work andthe consequences of LBP, such as, sick leave or RTW.

Due to the conflicting findings of the systematic reviews con-ducted to date, several of the review authors stress the need for thedevelopment of standardised operational definitions and psycho-metrically robust instruments that will enable reproduciblemeasurements of psychosocial factors for use in future studiesinternationally (Hartvigsen et al., 2004; Shaw et al., 2009a; Chouand Shekelle, 2010). However, it is acknowledged that work-related psychosocial constructs (Blue Flags) are often difficult toisolate using questionnaires as many constructs have some overlap(Hayden et al., 2006).

Kendall et al. (2009) provide a very practical ‘how-to’ guide forclinicians on Flags assessment, based on the Flags Framework;however, they do not provide any recommendations as to assess-ment instruments.

1.2. Review objectives

The objectives of this systematic review were to evaluate thecontent, psychometric properties and clinical feasibility of instru-ments available for the assessment of work-related psychosocialfactors (Blue Flags) in working age adults with NSLBP. This willprovide clinicians with evidence based information upon which toguide their decision making.

2. Methods

2.1. Types of studies

Full text articles in peer-reviewed journals or conferenceproceedings that examined the psychometric properties of instru-ments suitable for Blue Flags assessment for NSLBP were includedfor review. No exclusion criteria were set for type of study design;however, prospective cohort studies were preferred, as these bestcapture the criterion of predictive validity, a crucial property in thedevelopment and validation of a screening instrument.

2.2. Types of participants and study settings

Studies were included that recruited working age adults(between 18 and 65 years), with NSLBP in either the (sub)acute orchronic stages, and who presented in community based, occupa-tional or workers’ compensation settings. Studies were excluded ifthe study population had the following conditions: a specific causeof back pain; degenerative arthritis; acute trauma; post surgicalinterventions; or other causes, such as cancer or pregnancy.

2.3. Types of instruments

Instruments included any outcome measure, questionnaire,interview, test or tool that met the following criteria: at least 50% ofthe instrument’s items, excluding demographic related items,measured Blue Flags constructs; it could be used as a ‘stand alone’instrument, rather than being part of a multi-method protocol; itwas designed for clinical use for individual patients or workers, butnot an organisational level assessment tool; it was published inEnglish; and its respondent and administrative burdens wereminimal, i.e. completed/administered in 20 min or less.

2.3.1. Blue Flags constructsIn assessing whether or not the instrument met the criterion

that at least 50% of its content measured Blue Flags constructs, thefollowing items, based on the recommendations by the Decade ofFlags Working Group (Shaw et al., 2009a), primarily, were sought:

Fig. 1. Preferred reporting items for systematic reviews and META-analyses [PRISMA]flowchart (Moher et al., 2009; Liberati et al., 2009).

H. Gray et al. / Manual Therapy 16 (2011) 531e543 533

expectations of RTW; stress at work; job dissatisfaction; supportfrom colleagues or supervisors; perceptions of job demands; beliefsthat work is harmful; fear of re-injury; and availability of modifiedwork. Secondary to these, the following were also considered:a work history that includes patterns of frequent job changes andlack of vocational direction.

2.4. Information sources

The following five Ovid databases were searched from inceptiontill the first week of March 2010: MEDLINE; EMBASE; PsycINFO;AMED and CINAHL. Searches were also conducted in ISI’s Web ofScience database, Google and Google Scholar.

The Cochrane Register of Systematic Reviews was searched inaddition to the reference lists of relevant systematic reviews andeligible studies. Names of instruments that were retrieved weresubsequently used as terms for further searches of the databasesin combination with search terms on psychometric testing.Experts in the field were contacted as well as authors of includedstudies.

2.5. Search strategy

As the topic area of Blue Flags is an evolving area the reviewerssought to ensure that as many as possible of the necessary andrelevant studies were included in the review. Therefore, thereviewers chose to conduct as sensitive (comprehensive) a searchstrategy as possible with the knowledge that this would reduce itsprecision, i.e. yield studies that did not meet the a priori inclusioncriteria (Higgins and Green, 2011).

A search strategy, conducted by one of the reviewers (AA),in conjunction with an information scientist, was employed inEMBASE, MEDLINE and AMED, which was altered for PsycINFO andCINAHL. The following search terms were used and mapped tosubject or MeSH headings, wherever possible: ‘valid$’, ‘reliab$’,‘reproducib$’, ‘psychometric’, and ‘low back pain’, limited toEnglish and human subjects (Appendix 1 provides details of searchstrategies).

2.6. Study selection and data collection

Two reviewers (HG and AA) independently conducteda screening strategy for citation identification and study selection.Full texts of included articles were evaluated independently againstthe inclusion/exclusion criteria, with a third investigator (TEH)available had there been any cases of disagreement between thereviewers.

A standardised template was used to extract data regardingstudy design and population, instruments, study quality, dataanalysis and results. Information extracted was summarised intable format to highlight methodological quality, similarities anddifferences between the studies, and narrative summaries of resultswere provided.

2.7. Psychometric properties

Each instrument was graded independently using the levels ofreliability, validity and responsiveness for methodological qualityassessment described by Wind et al. (2005). Furthermore,psychometric testing results were summarised using the ratingscales for thoroughness of testing and testing results described byMcDowell (2006, p. 7); who categorises levels of validity and reli-ability as weak, adequate or excellent (details of these are providedwith Table 5).

3. Results

3.1. Study selection

The electronic search strategy yielded 3059 citations, with 22from other sources (Fig. 1). After adjusting for duplicates andapplying the inclusion/exclusion criteria to titles and abstracts, 41studies had their full text assessed. A further 33 were excluded,representing 21 instruments (Appendix 2), which left eightstudies reporting six instruments that were included in thereview.

3.2. Characteristics of included studies

Seven of the included studies were cohort design, six of whichwere prospective and one retrospective, and the remaining studywas a randomised controlled trial. The studies involved 5630participants, with sample sizes ranging from 154 to 3020. Allparticipants, except one (Shaw et al., 2005), were of workingage, i.e. between 18 and 67 years. There was a slight predomi-nance of male participants across the studies. Five of the studiesrecruited acute (�14 days) back pain sufferers; one recruiteda sample with chronic musculoskeletal pain, of which 25% hadNSLBP; and the remaining two studies did not define their backpain samples.

Participants were recruited from a range of countries andsettings, including occupational health clinics, an aircraftmanufacturing factory and database of workers’ compensation fileclaimants in the US; rehabilitation clinics and practices in Canada;

Table 1Summary of included studies.

Study Study Objective PrimaryOutcome ofInterest

Country and Setting Study Design and Population Study Size

Shaw et al.(2005)

To evaluate the 1-monthpredictive ability of the BackDisability Risk Questionnaire(BDRQ)

Pain, functionallimitation(s) andreturn to work

USAOccupational Healthclinic

Prospective cohort study of workers seekingtreatment for acute onset (�14 days) orexacerbation of non-specific, occupationalsacral, lumbar or thoracic back pain, aged18e80 years, 68% male: 32% female. Fluentin English or Spanish.

N ¼ 568(recruited)N ¼ 522(completed)

Shaw et al.(2009a,b,c)

To evaluate the 3-monthpredictive validity of the BDRQ.

Pain, functionallimitation(s) andreturn to work

USAOccupational Healthclinic

Prospective cohort study of workers seekingtreatment for acute onset (�14 days) orexacerbation of non-specific, occupationalsacral, lumbar or thoracic back pain, aged18e80years, 66% male: 34% female. Fluentin English or Spanish.

N ¼ 573(recruited)N ¼ 519(completed)

Kopec andEsdaile(1998)

To develop and validate theOccupational Role Questionnaire(ORQ)

Work satisfactionand productivity

CanadaPrivate and hospital basedphysiotherapy clinics,physiatrist centre, familygroup practice andorthopaedic clinic

Prospective cohort study of workers seekingtreatment for back pain (no definition provided)who were aged >18 years, able to communicatein English or French and who had worked at least5 days in the last 2 weeks. 50% male: 50% female.

N ¼ 242(recruited)N ¼ 137(completed)

Marhold et al.(2002)

To develop and determine thepsychometric properties of theObstacles to Return to WorkQuestionnaire (ORTWQ)

Duration of sickleave

SwedenRehabilitation clinics in 3Swedish cities andpatients ona register at the nationalinsurance authority

Prospective cohort study of workers with chronic(no definition) musculoskeletal pain (averagepain duration of 35 months) and on sick leave.Mean age 45years � 9 years, 19% male: 81%female, 73% in permanent employment, 4% hadtime limited employment, 23% were unemployed.

N ¼ 154(recruited)N ¼ 121(completed)

Symonds et al.(1996)

To develop a new instrumentPsychosocial Aspects of WorkQuestionnaire (PAWQ) and tomeasure attitudes related to LBP.

Length of sicknessabsence

UKIndustrial (biscuitfactory) andhospital settings

Retrospective cohort study of workers with lowback trouble (no definition provided), 120industrial workers and 483 nurses. 27% male:63% female. 70% aged <45 years.

N ¼ 603(completed)

Hazard et al.(1996)

To develop the Vermont DisabilityPrediction Questionnaire (VDPQ)and test its ability to predict chronicdisability after occupational low backinjury. (Derivation study)

Development ofchronic disabilityand return to work

USAWorkers’ CompensationFile Claimants

Prospective cohort study of injured workerswith acute LBP (�14 days) reporting injuries tothe Dept. of Labour & Industry, aged 18e60 years,mean age 37 � 9.4, male: female not described.

N ¼ 166(recruited)N ¼ 163(completed)

Hazard et al.(1997)

To test the 3-month predictivevalidity of the VDPQ.(Validation study)

Development ofchronic disabilityand return to work

USAWorkers’ CompensationFile Claimants

Randomised controlled trial of injured workerswith acute LBP (�14 days) reporting injuries tothe Dept. of Labour & Industry, aged 18e60 years,mean age 38 � 0.53 years, 62% male: 38% female.

N ¼ 304(recruited)N ¼ 268(completed)

Bigos et al.(1991)

To evaluate the factors associatedwith work-related back injurycomplaints using the ModifiedWork Adaptation, Partnership,Growth, Affection and Resolve(Modified WAPGAR)

Reporting of acuteback pain

USAAircraft manufacturingfactory (BoeingCompany)

Prospective cohort study of workers with acuteLBP, aged 21e67 years, 78% male: 22% female

N ¼ 3020(recruited)N ¼ 1569(completed)

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rehabilitation clinics in Sweden; and UK hospital and factory worksettings (Table 1 provides study details).

3.3. Characteristics of included instruments

The six included instruments, which were self report ques-tionnaires, were: the Back Disability Risk Questionnaire (BDRQ)(Shaw et al., 2005, 2009b); Occupational Role Questionnaire (ORQ)(Kopec and Esdaile, 1998); Obstacles to Return to Work Question-naire (ORTWQ), (Marhold and Linton, 2002); Psychosocial Aspectsof Work Questionnaire (PAWQ) (Symonds et al., 1996); VermontDisability Prediction Questionnaire (VDPQ) (Hazard et al., 1996,1997); and Modified Work APGAR (Modified WAPGAR) (Bigoset al., 1991). The instruments are described in further detail inTable 2.

In relation to Kirshner and Guyatt’s (1985) three stated purposesfor health measures, one of the instruments appeared to bedeveloped for discrimination (PAWQ); four were developed forpredictive purposes with potential for evaluation (BDRQ, ORTWQ,VDPQ, Modified WAPGAR); and the ORQ was designed forevaluation.

3.3.1. Instrument contentAll six instruments address the body structure, participation

and contextual (environmental) components of the ICF; of which,three (BDRQ, ORTWQ, VDPQ) also, include questions that relate tothe body function component. Additionally, the BDRQ and VDPQaddress some aspects of activity limitations.

The Blue Flags constructs that were most frequently includedin the instruments were: expectations for return to work (RTW);job dissatisfaction; poor supervisor and colleague relations;and heavy physical job demands. The BDRQ and ORTWQincluded the widest range of Blue Flags constructs, seven andnine, respectively (Table 3 summarises the instruments’content).

3.3.2. Psychometric propertiesTable 4 describes in detail the psychometric testing numer-

ical results that were reported for the six instruments. Addi-tionally, in testing face validity, only the developers of the ORQand ORTWQ sought the views of their target population in thedesign phase of the instruments. However, with regards tocontent validity, all six instruments were developed using

Table 2Characteristics of included instruments.

Instrument ICF Component(s) InstrumentPurpose

Summary of Instrument/Scored Scales(no. of items)

Scoring Method Cut-off Scores InstrumentAccessibility/Cost

Respondent‘Burden’/Administrative‘Burden’

Back DisabilityRiskQuestionnaire(BDRQ)

Structure/Function;ActivityLimitation;Participationand Contextual

Predictive 16 item paper, self report questionnaireassessing potential occupational backpain disability risk factors which include:work factors (3); physical health risks(2); physical work demands (2);supervisor response (1); pain (2); mood(2); wellness/job satisfaction (3) andexpectations for recovery (1).Mixture of nominal, ordinal andinterval scale response options.

‘Flag’ related itemsare summed and levelof risk categorized aslow, medium or high.

0-1 Flag items ¼ lowrisk; 2e3 items ¼ mediumrisk; 4e9 items ¼ high risk

Available in thepublic domainor from theauthors at nocost.

10 min/10 min

OccupationalRoleQuestionnaire(ORQ)(Translatedinto French)

Structure/Function;Participationand Contextual

Evaluative 8 item paper, self report questionnairefor assessing occupational role performancein individuals with back pain. It has 2 scales(4 items each), namely: ‘productivity’ (worksmore slowly, cuts down on extra work, takesmore frequent and longer rest breaks, is lessable to concentrate) and ‘satisfaction withwork’(has less opportunity to upgrade skills,is more likely to lose job, is less satisfied,needs more help from co-workers) 4 Likertresponse options for each item, ’no’, ’a little’,’somewhat’ and ’a lot’.

Scores for all items inboth scales are summedfor an aggregate &converted to a 0e100range

Scores of 75/100 or less indicatenegative effects on worksatisfaction/productivity

Available in thepublic domain.No permissionrequired fromauthors to use ormodify thisinstrument(source to beacknowledged).

5 min/5 min

Obstacles toReturn to WorkQuestionnaire

Structure/Function;Participation &

Predictive 55 item paper, self report questionnaire in3 parts/9 scales to identify and measurepsychosocial factors related to

Adding the scores of thenine sub-scales,

A cut-off of 150 will correctly Available in thepublic domainor from theauthors

20 min/15 min

(ORTWQ)(Developed inSwedish,translated intoEnglish)

Contextual Work which could be barriers for a RTW.Part 1: pain intensity (4) and depression (4);Part 2: difficulties at work return (9); physicalworkload and harmfulness (8); social supportat work (6); worry due to sick leave (3); worksatisfaction (9); family situation and support (7)Part 3: perceived prognosis of work return (6).Each item is assessed on a 7 point Likert scale(0e6) with text at both ends.Items from three of the scales on the ORTWQwere taken from the Orebro MusculoskeletalPain Screening Questionnaire (Linton andHalld�en, 1998)

However, 13 items haveto be inverted beforeadding to the otheritems. Total scoreranges from 0e330

Classify equal percentage of thepopulation with a good or apoorer prognosis. Cut-off scoresprovided for different purposes.

At no cost.

PsychosocialAspectsof WorkQuestionnaire(PAWQ)

Structure/Function;Participationand Contextual

Discriminative 15 item paper, self report questionnaire forjob satisfaction in 3 parts/3 scales. It reflectsthe worker’s with LBP attitude towards threespecific aspects of work: Part 1: general jobsatisfaction (7); Part 2: social support fromcolleagues/managers (4); Part 3: mentalstress of work (4).All items are assessed on a 5 point Likertscale ranging from 1 (strongly disagree)through 5 (strongly agree).Based on the Modified WAPGAR.

Each subscale is calculatedby summing the item scores.The scores are arranged sothat negative attitudes andbeliefs are represented bylow scores.

Not explicitly reported,low scores are worse

Available in thepublic domainor from theauthors at nocost.

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Table 2 (continued )

Instrument ICF Component(s) InstrumentPurpose

Summary of Instrument/Scored Scales(no. of items)

Scoring Method Cut-off Scores InstrumentAccessibility/Cost

Respondent‘Burden’/Administrative‘Burden’

VermontDisabilityPredictionQuestionnaire(VDPQ)

Structure/Function;ActivityLimitation;Participationand Contextual

Predictive 11 item paper, self-report questionnairedesigned to predict chronic disabilityafter occupational low back injury.Assesses: workers’ perceptions of whoblame for the injury (self, work factor,someone/something else, no one) (1);coworker relationships (0 ¼ don’t getalong well at all, 10 ¼ get along extremelywell) (1); confidence that he/she will beworking in 6 months (0 ¼ not at all certain,10 ¼ extremely certain) (1); physicaldemands of work (0 ¼ not at alldemanding, 10 ¼ very demanding)(1); and ability to do job expectations(0 ¼ no trouble at all, 10 ¼ won’t beable to do job) (1).Other questions assess marriage,previous back problems, surgery,hospitalization, medical visits, andcurrent pain (1 item each with ordinalscales).Derived from the VermontRehabilitation Engineering CentrePredictive Risk Model (Cats-Bariland Frymoyer, 1991)

Item scored dichotomouslyand summed and expressedas the proportion (percentage),scoring template provided,higher the score, the higherthe risk of chronic disability

A cut-off score of0.48 (0e1 scale)indicates risk ofdisability. 5 cut-offscores provided fordifferent purposes.

Available in theoriginal article andfrom the authors.

5 min/5 min

ModifiedWAPGAR

Participationand Contextual

Predictive 7 item paper, self report questionnaireassessing work perceptions andpsychosocial factors affecting the reportof back injury. 3 scales: fellow workerrelationships (5); job satisfaction (1);relationship with supervisor (1) 3 Likertresponse options: almost always; someof the time and hardly ever. Based on theFamily APGAR (Smilkstein, 1978): a measureof the family support system, whichcomprises a brief, five-item, familyfunction questionnaire.

The 7 response scores aresummed resulting in ascore ranging from 0e14,with higher scoresrepresenting greaterdissatisfaction withworkplace relations.

Low scores arebetter e nocut-off scoresdescribed

Available in thepublic domain orfrom the authorsat no cost.

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Table 3Blue Flags constructs contained in included instruments.

Number of Blue Flags Related Items per Construct

Blue Flags Constructs BDRQ ORQ ORTWQ PAWQ VDPQ Modified WAPGAR

Negative expectation for RTW 1 6 1Job dissatisfaction 1 1 3 7 1Belief work is harmful 4Fears of re-injury 1Heavy physical demands 1 4 1Poor colleague relations 1 2 4 1 1Poor supervisor relations 2 1 5Lack of ability to modify work 1Mental stress 1 4Worries about work absence 1 3Difficulties at RTW 8Negative employer response 1Short job tenure 1Lack of vocational direction 1Blame work/workers for injury 1Monotonous work 3Percentage of instrument items 50% 50% 64% 100% 50% 100%

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theoretical frameworks, such as the ICF (BDRQ, ORQ, ORTWQ);reviews of the literature (ORQ, BDRQ, VDPQ); and expertopinion via the Delphi consensus method (VDPQ). An overallsummary of the findings using the McDowell ratings is outlinedin Table 5.

3.3.3. Clinical feasibilityAll of the instruments had short, simply worded questions

that could be completed by respondents in 20 min or less;additionally, all had fewer than 17 questions, except for theORTWQ, which had 55 questions. Each of the instruments can bescored manually, requiring no more than 15 min of the clinician’stime; in addition, three of the instruments require some reversescoring (ORTWQ) or other arithmetical calculation (ORQ, VDPQ).The VDPQ has a useful scoring template and is able to beadministered by telephone. In relation to risk stratification, fourof the instruments (BDRQ, ORQ, ORTWQ, VDPQ) have publishedcut-off scores to aid clinicians.

Four of the instruments are freely available in the publicdomain (BDRQ, ORQ, ORTWQ, PAWQ) if the instrument isbeing used for clinical or research purposes. The authorswere unsuccessful in obtaining a response from the developersof the VDPQ or Modified WAPGAR regarding cost and avail-ability; although instrument copies are available in the originalpapers.

4. Discussion

4.1. Summary of main results

This systematic review examined the content, psychometricproperties and clinical feasibility of published instruments avail-able for the assessment of Blue Flags in working age adults withNSLBP.

Overall, only eight studies (recruiting 5630 participants),describing six instruments were identified; the majority of whichhad weak or adequate reliability and validity reported solely by theoriginal developers. No reliability data were available for three ofthe instruments (BDRQ, VDPR, Modified WAPGAR), despite suchinformation normally being considered a pre-requisite to validity(Streiner and Norman, 2003, p. 6).

The following sections provide summary discussions of theincluded instruments.

4.2. Back Disability Risk Questionnaire

The BDRQ has several strengths: its content was developed froma literature review of predictors of back disability (Shaw et al.,2001); it assesses seven Blue Flags constructs; its construct val-idity has been tested; it has low respondent and administrativeburdens; and demonstrates predictive properties. However, thescoring systems for the BDRQ are different between the two vali-dation studies (Shaw et al., 2005, 2009b) and a later study (Shawet al., 2009c). The developers recommend that users adopt thelater scoring system, which stratifies patients as low, medium orhigh risk (Shaw et al., 2009c); however, this arbitrarily designedscoring system assumes that each of the Blue Flags is equallyweighted in terms of predictive ability.

The BDRQ, in common with the VDPQ and Modified WAPGAR,consists of a range of single-item measures, rather than scales,which has the advantage of keeping the questionnaire shorter.However, single-itemmeasures are least preferable as it is doubtfulthat one question can effectively ‘tap into’ a given construct, and itis also difficult to assess their adequacy (Bowling and Ebrahim,2005, p. 15).

4.3. Occupational Role Questionnaire

The ORQ has adequate reliability but weak validity testingresults and appears clinically feasible. However, it only addressesthe constructs of ‘work productivity’ and ‘job satisfaction’, and itstesting was carried out on a relatively small sample of 137 LBPsufferers, of which only 56 were used for test-retest reliability.Furthermore, despite being designed as an instrument for evalua-tive purposes, it has not undergone testing in relation to itsresponsiveness.

In their review of health-related work outcome measures,Amick et al. (2000) assert that there are three potential problemswith the ORQ: the meaningfulness of its role constructs; therequirements of questionnaire respondents for extensive recall andcognitive comparisons; and the lack of generalisability of theinstrument.

Fadyl et al. (2010) also included the ORQ in their review ofwork ability instruments and described it as an example of aninstrument that could be used for estimating the costs of health-related productivity loss. In contrast, Nieuwenhuijsen et al.(2010), who included the ORQ in their review of work

Table 4Psychometric testing results for included instruments.

BDRQ (2 studies) ORQ ORTWQ PAWQ VDPQ (2 studies) Modified WAPGAR

Internal consistency No Productivity ¼ 0.82 Part 1 ¼ 0.81, 0.75 Job satisfaction ¼ 0.88 No NoSatisfaction ¼ 0.86 Part 2 ¼ 0.66, 0.83,

0.80, 0.52, 0.76, 0.73Social support ¼ 0.77

Summary ¼ 0.88 Part 3 0.72 Mental stress ¼ 0.76Cronbach’s a Cronbach’s a Cronbach’s a

Test-Retest Reliability(time interval for testing)

No Productivity ¼ 0.89 Part 1 ¼ 0.80, 0.77 No No NoSatisfaction ¼ 0.80 Part 2 ¼ 0.90, 0.96,

0.86, 0.85, 0.93, 0.90Summary ¼ 0.91 Part 3 ¼ 0.91Pearson’s (r) Pearson’s (r)(56 participants e 2week interval)

(30 participants e 1week interval)

Face Validity No Yes Yes No Yes NoContent Validity Yes Yes Yes Yes Yes YesConstruct Validity Yes e 5 factors with

eigen valuesa � 1(Principal componentanalysis with varimaxrotation)

Yes e all items witheigen values � 1 (Principalcomponent analysis usedto reduce 16 items to 8)

Yes - all items witheigen values � 1(Principal componentsanalysis with varimaxrotation to reduce 87items to 55)

Yes e no numeric valuesreported (Principalcomponents analysisused to reduce 25items to 15)

Yes e all items withKappa >0.1 (Kappaanalysis and stepwise,logistic regression analysisto reduce 33items to 11)

No

Concurrent Validity No Yes Pain (TyPE LBP Form)(�0.31,�0.36, �0.37) andfunctional disability (RMDQ)(�0.46, �0.45, e 0.51)Pearson’s (r)

Yes (BDI, CSQ, MPI,DRI) Part 1 ¼ moderatebut significant correlationswith MPI (0.56, 0.54), BDI(0.68), CSQ (0.63) Part 2 ¼moderate but significantcorrelations with MPI 0.51,DRI 0.48) Part 3 ¼ low butsignificant correlations(BDI 0.20), CSQ (0.21), MPI(0.33, 0.21), DRI (0.26)

No No No

Pearson’s (r)Predictive Validity (time

interval for testing)Yes e RTWPPV ¼ 44%/NPV ¼ 90%(1 month) Classificationaccuracy 75% (3 months)

No Yes e sick leave Five of thescales significantly predictedsick leave with 79% classificationaccuracy e ‘perceived prognosisof work return’; ‘social support atwork’; ‘physical workload andharmfulness’; ‘pain intensity’; and‘depression’ Forward stepwisediscriminant analysis (9 months)

No Yes e RTW Kappa 0.48 and0.36, (both at 3 months)

Yes e Cox proportionalhazards regression model.‘can communicate withpeers’ and ‘enjoy job tasks’were predictive of futureback pain reporting(p < 0.0001)

Sensitivity (time intervalfor testing)

Yes e 74.3% (1 month)b

and 44.8% (3 months)Logistic regression

No Yes e 90% (9 months) No Yes e 0.94 and 0.75 (bothat 3 months)

No

Specificity (time intervalfor testing)

Yes - 70.1% (1 month)and 88.5% (3 months)Logistic regression

No 44% (9 months) No Yes - 0.84 and 0.73(both at 3 months)

No

Responsiveness (timeinterval for testing)

No No No No AUROC ¼ 0.92c AUROC ¼ 0.78)(both at 3 months)

No

Floor/ceiling effects No Unclear No No No No

Abbreviations: AUROC e area under receiver operating curve; BDI e Beck Depression Inventory; BDRQ e Back Disability Risk Questionnaire; CSQ e Coping Strategies Questionnaire; DRI e Disability Rating Index; ModifiedWAPGAR eWork Adaptation, Partnership, Growth, Affection and Resolve; MPI eMultidimensional Pain Inventory; NPV ¼ negative predictive value (the number of true negatives divided by the number who tested negative);ORQ e Occupational Role Questionnaire; ORTWQ e Obstacles to Return toWork Questionnaire; PAWQe Psychosocial Aspects of Work Questionnaire; PPV - positive predictive value (the number of true positives divided by thenumber who tested positive); RMDQ e Roland and Morris Disability Questionnaire; RTW ¼ return to work; VDPQ e Vermont Disability Prediction Questionnaire.

a Eigen values �1 are desirable for construct validity.b Sensitivity and specificity results are a combination of participant responses from the BDRQ and a brief clinician questionnaire.c If area under the curve (AUROC) is near 1 it has higher chance of correct classification.

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al./Manual

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(2011)531

e543

538

Table 5Summary ratings for instruments (adapted from McDowell, 2006, p. 7).

Instrument Reliability Thoroughness Reliability Results Validity Thoroughness Validity Results

BDRQ 0 0 * **

ORQ * ** * *

ORTWQ * ** * **

PAWQ * * * 0VDPQ 0 0 * **

Modified WAPGAR 0 0 * 0

Ratings for the thoroughness of reliability & validity testing Ratings for the results of the reliability and validity testing

Rating Meaning Rating Meaning

0 No reported evidence of reliability or validity 0 No numerical results reported* Basic information only; information only by the original authors of the scale. * The evidence suggests weak reliability or validity** Several types of test, and several studies by different authors have reported

reliability or validity** Adequate reliability or validity

*** All major forms of reliability or validity testing reported in numerous studies *** Excellent reliability or validity: higher coefficientsthan those normally seen in other instruments.

? Results were not stated or are un-interpretable

H. Gray et al. / Manual Therapy 16 (2011) 531e543 539

functioning instruments, stated that it was not suitable as a lostproductivity instrument for economic perspectives as it did nothave the possibility of monetary valuation. These conflicting viewsgive the impression that there appears to be confusion as to theactual purpose of this instrument.

Lastly, due to the fact that a range of psychometric tests havebeen reported for the ORQ, it was highly recommended in a reviewof assessment instruments for persistent pain for use in primaryand secondary healthcare settings to assess RTW prognosis(Grimmer-Somers et al., 2009a,b). The current reviewers do notconcur with this recommendation, as the ORQ has not had itspredictive validity tested.

4.4. Obstacles to return to Work Questionnaire

The ORTWQ was the instrument that had the greatest coverageof Blue Flags constructs and was categorised as having adequatevalidity and reliability; however, it performed the least favourablyin relation to its clinical feasibility, due to its length and scoringmethod.

The ORTWQ also was included in two reviews by Grimmer-Somers et al. (2009a, b), who highly recommended it for use insecondary healthcare settings to assess ‘multiple occupationalissues’, but did not consider it suitable for primary care settings dueto its length.

Although the ORTWQ’s psychometric testing results lookpromising, there is the possibility of them being overestimated, fortwo reasons. Firstly, several of its scales had seven or more ques-tions, which can make them appear more ‘homogeneous’ thanperhaps they are (Streiner and Norman, 2003, p. 73). Secondly, inrelation to its factor analysis, its 55 questions were tested ona sample of 121 individuals; whereas, in order to maximise stabilityand generalisability, a sample size of at least 300 has been rec-ommended (DeVellis, 2003, p. 137).

4.5. Psychosocial aspects of Work Questionnaire

In terms of its psychometric robustness, the PAWQ has weakreliability with no numerical results reported for validity testing. Itwas based on the Modified WAPGAR, and only has had its internalconsistency and construct validity tested. Furthermore, later testingthat was conducted found that its scale ‘mental stress’was not ableto distinguish between workers who did or did not have LBP(Bartys, 2003), and, therefore, was removed in a subsequent study(Bartys et al., 2005).

The developmental purpose of the PAWQ is rather ambig-uous. It was developed initially in a retrospective study(Symonds et al., 1996), and has been used in other retrospectivecohort studies (Burton et al., 1996, 1997). It subsequently wasused in a prospective cohort study to screen for duration of workabsence (Bartys et al., 2005); however, the cut-offs scores werenot referenced in this study but in a PhD thesis, in which theauthor states that she was not attempting to develop a screeningtool (Bartys, 2003).

Pincus et al. (2008), on behalf of the Multinational Musculo-skeletal Inception Cohort Study Collaboration, developed a list ofrecommended measurement instruments for prospective cohortstudies in LBP based on their clinimetric properties. They consid-ered the PAWQ as a measure for work-related factors, but, ulti-mately, did not select it in their final recommendations.

4.6. Vermont Disability Prediction Questionnaire

The commendations for the VDPQ are that it was preceded byconsiderable developmental work (Cats-Baril and Frymoyer, 1991;Reid et al., 1997); it was the only instrument reviewed that fol-lowed up the initial derivation cohort with a separate validationcohort study (Hazard et al., 1996, 1997); has adequate validity; andit has been used in several research studies (Turner et al., 2006;Newcomer et al., 2008; Fulton-Kehoe et al., 2008). Despite this, ithas no published reliability testing.

In a recent review of risk assessment instruments, Chou andShekelle (2010) criticised the fact that some questions in theVDPQ are not predictive of outcomes, for example, ‘previous backproblems’ and ‘physician visits for back pain’. Pengel et al. (2003)further critique the VDPQ’s developers for selecting their cut-offscores following data inspection, which is known to inflatepredictive accuracy (Altman et al., 1994).

4.7. Modified WAPGAR

Of all the instruments in this review, the Modified WAPGAR hasbeen the most extensively used (for example, Friedrich et al., 2000;Reigo et al., 2001; Durand et al., 2002; LeRoux et al., 2004; Fransenet al., 2002). This is probably due to the facts that the ModifiedWAPGAR has been in existence for 20 years and was testedprospectively on a large cohort (n ¼ 3020) over four years.However, questionnaire validity does not increase merely withfrequency of use (Grotle et al., 2006).

H. Gray et al. / Manual Therapy 16 (2011) 531e543540

Three other studies have tested the internal consistency of theModified WAPGAR and reported Cronbach’s alpha ranging from0.78 to 0.86 (Williams et al., 1998; Van Vuuren et al., 2005; vanVuuren et al., 2007). Additionally, high test-retest reliability wasrecorded (frequency of differences was less than 20%) in the twostudies by van Vuuren et al. (2005, 2007).

Further, a second study by the instrument’s developers reportedthat individuals who rated highly on the Modified WAPGAR’squestion on ‘job dissatisfaction’were 3.3 timesmore likely to reporta back injury (Bigos et al., 1992).

The Modified WAPGAR was developed from a re-wording of theFamily APGAR (Smilkstein, 1978; Good, 1979), based on the slightlysuspect rationale that the components of interpersonal relation-ships at the workplace are similar to those of the family. In fact, thedevelopers of the Modified WAPGAR described their own instru-ment as a ‘psychometrically simple-minded device’ and fullyanticipated that future studies would use more sophisticatedmeasures than theirs.

4.8. Generalisability

The results of psychometric testing of instruments aresituation-specific and depend highly on the study population andmeasurement circumstances (de Vet et al., 2003). Each instru-ment in this review had only been tested in one country, there-fore, limiting generalisability to other study populations indifferent cultures. Furthermore, although the ORTWQ has beenpublished in English, only the Swedish version of the question-naire has been tested, and it has not been tested in a (sub)acuteLBP population.

Four of the instruments (BDRQ, ORQ, ORTWQ, VDPQ) areaccompanied with cut-off scores to guide clinicians as to thepatient’s risk of sick leave, RTWor work productivity. However, anycut-offs have to be applied carefully with reference to the patientpopulations in which they were tested; as it cannot be assumedthat patients from different cultural backgrounds all will respond inthe same manner during an episode of LBP.

Although the reviewers were unsuccessful in contacting theauthors of the VDPQ or Modified WAPGAR to verify instrumentenquiries, this review has several strengths. Namely, it is the firstreview of its kind, it included a wide range of sources and infor-mation was sought from experts in the field and article authors.One review limitation is that only articles that had been publishedin the English language were included.

4.9. Recommendations for clinical practice and research

For the reasons discussed, none of the reviewed instruments canbe recommended in their current format for routine clinical prac-tice. Although the ORTWQ was the instrument that underwent themost thorough psychometric testing with promising results, itsrespondent and administrative burdens make it less clinicallyfeasible. That said, clinicians may find the questions in thefollowing three scales of the ORTWQ helpful when conductingwork-focussed patient assessments: ‘perceptions of physicalworkload’; ‘social support at work’; and ‘perceived prognosis ofreturn to work’. These scales were predictive of sick leave andrepresent Blue Flags constructs that are supported by researchevidence.

Future research should focus on further psychometric devel-opment of the ORTWQ, which should include: testing it in othertypes of and larger populations; assessing its ability to predictreturn to work as well as sick leave duration; reducing the numberof sub-scales to the ones that demonstrate predictive validity; and

developing a range of interpretable cut-off scores that will aidclinical decision making and link to treatment interventions.

4.10. The ‘ideal’ Blue Flags instrument

In addition to the pre-requisites of possessing high levels ofinternal consistency, test-retest reliability and predictive validitythe following additional features would conceptualise the ‘ideal’Blue Flags instrument.

Firstly, the instrument would only include Blue Flags constructsthat have been confirmed through systematic reviews of prospec-tive cohort studies to be prognostic indicators of specificoutcomes of interest for individuals with NSLBP. Additionally, theseconstructs would be supported by standardised operationaldefinitions.

Secondly, the inclusion of evidence based constructs in the BlueFlags assessment instrument should facilitate the screening andtargeting of potentially modifiable obstacles to recovery. In thisregard instrument usage could aid clinical decision makingprocesses and inform rehabilitation strategies, work-focusedinterventions or case management. Further, if the instrument wasdesigned with item response sets that had sufficient gradations toregister change, then it may have the potential to be used for bothpredictive and evaluative purposes, i.e. screening and outcomemeasurement (Kirshner and Guyatt, 1985).

Thirdly, any ideal Blue Flags instrument should be as short as isfeasible, concisely worded in layperson’s language, and have highface validity. This will reduce the burden to patients and increasetheir likelihood of completing it appropriately.

Finally, an instrument that is simple and quick to score witheasily interpretable results, for both clinician and patient, would betremendously beneficial for busy healthcare providers, and wouldincrease the chance of it being adopted into routine practice inclinical or occupational settings.

5. Conclusions

This systematic review provides an evaluation of the content,psychometric properties and clinical feasibility of six instrumentsavailable for the assessment of Blue Flags for NSLBP. Despite thewidespread use of some of these instruments in clinical practiceand primary research, the lack of evidence of psychometrictesting in the populations of interest precludes recommendationfor their use at this time. The ORTWQ was the instrument thatunderwent the most thorough psychometric testing with themost promising results; however, due to its length, it would notbe considered by most clinicians to be feasible for routinepractice.

Further development of ORTWQ is needed urgently, and todo this real collaboration between clinicians, patients andresearchers is required; particularly in facilitating the develop-ment of accompanying guidance for clinicians as to how to linkthe instrument’s results to evidence based patient managementinterventions.

Acknowledgements

The Scottish Government Health Department is acknowledgedfor the funding of its project on the development of a minimum setof outcome measures for musculoskeletal conditions in a commu-nity based setting, of which this current review was a part. LesleyDawson is acknowledged for her contribution in the design of thedata extraction form, as is Dr Kerri McPherson for her valuablecomments on drafts of the article.

Appendix 1. Search strategies for ovid databases

Database Period/Duration Search terms

MEDLINE 1950 e 1st wk March 2010 1.(valid$ or $ reliab$).mp [mp ¼ title, original title,abstract, name of substance word, subject heading word, unique identifier]2.(reproducib$ or psychometric).mp3. 1 or 24. Exp low back pain5. Low back pain6. 4 or 57. 3 and 68. Limit to humans

EMBASE 1980 e 1st wk March 2010 As aboveAMED 1985 e 1st wk March 2010 As abovePsycINFO 1806 e 1st wk March 2010 Exp test reliability/or exp test validity/or exp psychometrics

Exp back pain1 and 2Exp rating scales/or exp questionnaires/or exp interviews/orexp measurement/or exp perceptual measures1 and 2 and 4Limit 6 to human

CINAHL 1982 e 1st wk March 2010 TI (valid$ or reliab$) or TI (reproducib$) or psychometric) (MH “low back pain”)

Appendix 2. Instruments excluded from the review at full text stage with reason(s) for exclusion

Author(s) Instrument Main Reason(s) for Exclusion

De Zwart et al. (2002) The Work Ability Index (WAI) Questionnaire <50% of items assess Blue Flags constructsNot tested in NSLBP population

Durand et al. (2002) The Work Disability Diagnosis Interview (WODDI) A multi-method, multi dimensional assessment>20 min administrative burden

Edwards et al. (2008) Health and safety Executive Stress Indicator Tool (HSE SIT) Organisational level stress tool for psychosocialrisk assessment at work

Gaines and Hegmann (1999);Fritz et al. (2000)

Non Organic Signs & Symptoms Screening Test No Blue Flags constructs assessed

Hill et al. (2008); Hill et al. (2010) The StarT Back Tool (SBT): A screening questionnaire No Blue Flags constructs assessedHuyse et al. (1999); Stiefel et al.

(1999a,b); Scerri et al. (2006)Instrument to Assess HealthCare Needs of Patients with aPhysical Illness (INTERMED): A Screening Questionnaire

<50% of items assess Blue Flags constructsNot tested in NSLBP population

Karasek et al. (1998) Job Content Questionnaire (JCQ) Not tested specifically in LBP populationKielhofner et al. (1999) Work Environment Impact Scale (WEIS) Not tested in NSLBP population, only patients

with psychiatric problemsLerner et al. (2001); Beaton and

Kennedy (2005)Work Limitations Questionnaire (WLQ-25 & WLQ-16) <50% of items assess Blue Flags constructs

Not tested in LBP populationLinton and Halld�en (1998); Linton

and Boersma (2003); Hockingset al. (2008)

The Acute Low Back Pain Screening Questionnaire (ALBPSQ) <50% of items assess Blue Flags constructs

Loisel et al. (2001) Participatory Ergonomics (PE) An intervention programme not a psychometricevaluation

Neubauer et al. (2006) Heidelberger Short Early Risk Assessment Questionnaire for thePrediction of Chronicity in LBP (HKF-R 10)

No Blue Flags constructs assessed

New Zealand Accident CompensationCorporation and Linton andHalldén (1997)

Guide to Assessing Psychosocial Yellow Flags Screening Instrument <50% of items assess Blue Flags constructs

Reis et al. (2007) The Low Back Pain Patient Perception Scale (LBP PPS) No Blue Flags constructs assessedSchultz et al. (2002, 2004, 2005) Psychosocial Risk for Occupational Disability Instrument (PRODI) Multi-method, model of assessment

>20 min administrative burdenTruchon and Côté (2005) Chronic Pain Coping Inventory (CPCI) <50% of items assess Blue Flags constructsVelozo et al. (1999); Forsyth et al.

(2006); Fenger and Kramer (2007)Worker Role Interview (WRI) (version 9.0) <50% of items assess Blue Flags constructs

>20 min administrative burdenWaddell et al. (1993); Grotle et al. (2006) Fear Avoidance Beliefs Questionnaire (FABQ) <50% of items assess Blue Flags constructsWännström et al. (2009) General Nordic Questionnaire for Psychological and Social Factors

at Work (QPSnordic)>20 min administrative burden

Wynne-Jones et al. (2009) Work Organisation Assessment Questionnaire (WOAQ) Organisational level stress tool forpsychosocial risk assessment at workNot tested in NSLBP population

H. Gray et al. / Manual Therapy 16 (2011) 531e543 541

H. Gray et al. / Manual Therapy 16 (2011) 531e543542

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