Neck Solutions

Agreement between a self-administered questionnaire on musculoskeletal disorders of the neck and shoulder region and a physical examination

From: BMC Musculoskelet Disord. 2008 Mar 17;9:34

In epidemiological studies on neck and shoulder disorders, physical examination by health professionals, although more expensive, is usually considered a better method of data collection than self-administered questionnaires on symptoms. However, little is known on the comparison of these two methods of data collection. The agreement between self-administered questionnaires and the physical examination on the presence of neck and shoulder disorders was assessed in the present study.

These results suggest a fair to good agreement between the presence of musculoskeletal disorders ascertained by self-administered questionnaire and physical examination that may reflect differences in the constructs measured. Shorter time lags result in better agreement. Investigators should consider these results before choosing a method to measure the presence of musculoskeletal disorders in the neck and shoulder region.

In epidemiological studies, data on neck-shoulder disorders are often collected by physical examination, by questionnaire or with both instruments. Physical examination by health professionals is usually recognized as more objective than questionnaires. However, questionnaires permit data collection on many participants for a fraction of the cost and time of a physical examination. Few epidemiological studies on neck and upper extremity musculoskeletal disorders have systematically compared the findings of questionnaires with those obtained by physical examination. Only four studies published in English have reported the sensitivity and specificity of a questionnaire compared to clinical examination of the neck and shoulder region to identify individuals with neck and shoulder disorders.

In this study of VDU users, the agreement between a self-administered questionnaire on musculoskeletal disorders of the neck and shoulder region and a physical examination of the same region was examined in a sample of university clerical workers. Prevalence figures observed with questionnaire definitions were lower than those obtained from physical examination definitions. Results show an overall Kappa of 0.44 and a global agreement of 72% between the two instruments. The agreement was not substantially improved by the addition of questionnaire criteria related to functional limitations. The agreement diminished when the physical examination definition excluded the manifestation of pain. The percent agreement tended to be higher among cases than among non-cases. Higher agreement was observed with shorter time lapses between the administrations of the tests.

The questionnaire used here was adapted from questionnaires used in previous studies. Some items were taken from the Standardized Nordic Questionnaire, which showed an acceptable degree of reliability for the neck and shoulder region. Furthermore, previous studies suggested that questions related to the presence, duration and intensity of symptoms provide reliable information on musculoskeletal symptoms. Thus, it is reasonable to consider that the questionnaire used in the present study had an acceptable level of reliability.

Previous studies also provide evidence of construct validity of subjective symptoms reported in questionnaires. Also, VAS are considered among the best instruments to measure pain. To reduce the impact of potential error in recall in this study, only symptoms in the last seven days were considered. Furthermore, the fact that the questionnaire prevalence of musculoskeletal disorders in the neck and shoulder region was comparable (17%) to what was observed in previous studies on VDU workers provides further support for the validity of outcome measures obtained from the questionnaire.

The results of the current study suggest a fair to good agreement between the presence of neck and shoulder disorders ascertained by self-administered questionnaire and physical examination. This finding is in accordance with those obtained in previous studies comparing data from questionnaire with clinical examination to identify cases of neck and shoulder disorders. These earlier studies have concluded that self-reported neck and shoulder symptoms by questionnaire gave fairly good to good picture of the neck and shoulders disorders prevalence.

According to previous studies, tests used in physical examination, especially measurement of range of motion and manual muscle testing, have poor to good reliability. However, the use of a rigorous standardized protocol, pretested by the examiner at the beginning of the current study, and the fact that only one person examined all the workers favored reliability. In their literature review, Gajdosik and Bohannon (1987) concluded that there was acceptable content validity for the measurement of range of motion. Nevertheless, the comparisons in the present study might have been compromised at least in part by measurement error which could explain some lack of association with symptoms.

The different questionnaire definitions permitted the assessment of the influence of functional limitations on the agreement. The definition that included limitations in ADL gave similar agreement values when compared to the primary definition. On the other hand, definitions that included limitations in work, household and leisure activities resulted in poorer agreement. The lack of improvement in the agreement observed with the addition of functional limitations criterion may be explained by the fact that the questionnaire definition was already somewhat restrictive (pain reported in the neck and shoulder region for at least three days during the last seven days, with the worst pain intensity greater than 50 millimeters on the 100-millimeter VAS). Under these circumstances, the addition of the ADL limitations may not have contributed more information than the primary definition. Alternatively, the physical examination findings may not correspond closely enough to the domains that limit ADL. Furthermore, limitations measured in a dichotomous format (yes/no items) may not have been sufficiently sensitive in comparison to the more refined ADL limitations question.

According to our results, the measure of pain intensity provoked by specific maneuvers during the physical examination offered the best agreement when compared with the self-administered questionnaire. A low agreement was obtained with the physical examination definition based solely on decrease in range of motion or muscular strength. These results are consistent with the hypothesis that musculoskeletal disorders are progressive and that patients may have symptoms before objective physical findings appear. Also, cases defined by physical examination of range of motion and muscular strength may have been overlooked by the questionnaire; this would be consistent with previous studies that showed a low correlation between pain intensity and extent of tissue damaged.

The definition based on questionnaire may not measure the same concept than the physical examination. While the physical examination measures the integrity and the absolute performance of the structures and tissues, self-reported symptoms are based on actual performance and sensation, much affected by pain perception. This distinction is supported by the large impact that pain has on the agreement. The results of this study suggest that pain intensity is an important feature in the agreement between a questionnaire on musculoskeletal disorders and a physical examination and support the construct validity of a case definition based on symptoms.

The present study was part of a larger investigation on the prevalence of musculoskeletal disorders among video display unit (VDU) users. The main objective of the present study was to assess the agreement between a self-administered questionnaire and the physical examination made by a health professional on the presence of musculoskeletal disorders of the neck and shoulder region. Secondary objectives were to assess the effects on the agreement of different questionnaire and physical examination definitions and the importance of the time interval elapsed between the administrations of the tests.

Results of this study show that the agreement between a questionnaire on musculoskeletal disorders for the neck and shoulder region and a physical examination is fair to good. Inclusion of items related to functional limitations in questionnaires appears to be of limited value to improve the agreement. It is the physical examination definition that included pain manifestations that offered the best agreement with the questionnaire. A shorter time interval between the administrations of the two tests also yields a better agreement. Investigators should consider these results before choosing a method to measure the presence of musculoskeletal disorders of the neck and shoulder region.