Physiotherapy Theory and Practice, 28(7):515–528, 2012

Copyright © Informa Healthcare USA, Inc.

ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593985.2011.642068

DESCRIPTIVE REPORT

Body Awareness Rating Questionnaire: Measurement

properties
Tove Dragesund, Research Fellow, MSc, Målfrid Råheim, Associate Professor, PhD, and
Liv Inger Strand, Professor, PhD
Physiotherapy Research Group, Department of Public Health and Primary Health Care, University of Bergen, Norway
Physiother Theory Pract Downloaded from informahealthcare.com by University of Connecticut on 10/28/14

ABSTRACT
The purpose of present study was to investigate important measurement properties of the Body Awareness
Rating Questionnaire (BARQ) subscales: Function; Mood; Feelings; and Awareness. Samples of 50 patients
with prolonged musculoskeletal pain and psychosomatic disorders, and 50 gender and age-matched healthy per-
sons participated in the study. Relative (ICC 2,1) and absolute reliability (Sw) were calculated. Construct validity
was examined by testing hypothesis using Pearson (r) or Spearman rank (rs) correlation. Discriminate ability was
examined using a receiver operating characteristic (ROC) curve, the area under the curve (aROC) being the
measure of discriminative validity. All patients reported more or less improvement after treatment, using the
Patient Global Impression of Change (PGIC) as an external indicator of important change. Responsiveness to
For personal use only.

important change was therefore examined by one-way repeated measures analysis of variance (ANOVA), relat-
ing change scores of BARQ subscales to the PGIC categories. Relative and absolute reliability values were within
recommended limits for all four subscales. Construct and discriminate validity was indicated for Function,
Feelings and Awareness, but not for Mood. Responsiveness was indicated for the subscales Function and
Awareness, but not for Feelings and Mood. Further research is needed to complement the subscales of
BARQ, found with appropriate measurement properties.

INTRODUCTION related to emotions. In relation to trauma treatment,

Body awareness has emerged as a focus of scientific
research across a wide range of health topics. However,
the phenomenon is described somewhat differently in
different fields and there has been no definitive defi-
nition of the term (Mehling et al, 2009). In line with
this, there is uncertainty of how the phenomenon
should be assessed, for instance in physiotherapy.
The term body awareness can have various focuses
within different medical fields. In neurophysiology,
body awareness is primarily related to proprioception
and interoception (Brodal, 2001). While propriocep-
tion is understood as the conscious perception of pos-
itions and movements of joints without use of vision,
interoception is the perception of sensation from
organs and the autonomic nervous system activity
Accepted for publication 3 November 2011
Address correspondence to: Tove Dragesund, Research Fellow, Phy-
siotherapy Research Group, Department of Public Health and Primary
Health Care, University of Bergen, Norway. E-mail: tove.dragesund@
isf.uib.no
Rothschild (2000) defined body awareness as “the
precise, subjective consciousness of body sensations
arising from stimuli that originate from both inside
(interoceptors) and outside (exteroceptors) of the
body, the latter being the processing input from
vision, taste, smell and touch. Body image and body
awareness are terms often used interchangeably.
However, body image reflects a preferential reliance
on visual appearance over perceptions from inside
the body, and is explored in fields like psychiatry
(Skrzypek, Wehmeier, and Remschmidt, 2001) and
neuroscience (Giummarra, Gibson, Georgiou-
Karistianis and Bradshaw, 2007).
Body awareness is considered an important aspect in
different body-oriented physiotherapeutic approaches
like the Norwegian Psychomotor Physiotherapy
(NPMP) and Basic Body Awareness Therapy (BBAT)
(Kvåle and Ljunggren, 2007). In BBAT, body awareness
is seen as an overall concept for experience and use of the
body, representing body consciousness, body manage-
ment and deepened body experience (Roxendal,
1985). In NPMP body awareness has not been

515
 516 Tove et al.
defined, but Mølstad et al. (1989) points to the impor-
tance of contact with one’s own body, that a positive
feeling for your own body includes both accepting and
being confidential with its reactions. They emphasize
that the patients’ ability to sense body movements and
their emotional aspects, reflect how they experience
and relate to their own body. Working on body aware-
ness is considered essential in musculoskeletal and psy-
chosomatic conditions in order to relieve pain and
tension and to improve respiration and bodily function
in general (Dragesund and Råheim, 2008; Mølstad
et al, 1989; Thornquist and Bunkan, 1991; Øien,
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Råheim, Iversen, and Steihaug, 2009).
An appropriate self-reported assessment tool for
body awareness as understood in physiotherapy has
not been available, and we decided to initiate a
process of developing such a tool. To derive descrip-
tive terms of body awareness for a self-report question-
naire, patients with long-lasting musculoskeletal
conditions and/or psychosomatic disorders contribu-
ted by participating in focus groups, discussing how
they experienced the phenomenon (Dragesund and
Råheim, 2008). Also specialists in NPMP contribu-
ted, by providing descriptors of the phenomenon
For personal use only.
(Dragesund, Ljunggren, Kvåle, and Strand, 2010).
Initially, a pool of 66 test items was collected. Then
300 patients scored each of the items on a Likert
scale. The underlying factor structure and internal
consistency was examined, excluding items that did
not contribute to increased internal consistency.
Four dimensions (factors) were identified and
the six items with highest loadings within each sub-
dimension were retained, resulting in a 24-item
questionnaire, called the Body Awareness Rating
Questionnaire (BARQ).
When developing a new assessment tool, evidence
must be provided that it has satisfactory measurement
properties. Terwee et al. (2007) has presented quality
criteria for health measurement questionnaires pro-
posed by the Scientific Advisory Committee of the
Medical Outcomes Trust (2002), and these criteria
were taken into consideration in the present study.
The content validity and internal consistency of
BARQ have recently been demonstrated (Dragesund,
Ljunggren, Kvåle, and Strand, 2010). It is realized
that each measurement property may not be equally
important. The intended use of the questionnaire
decides which measurement properties that should
be examined. The four subscales of BARQ were
aimed to be both discriminative and evaluative
(i.e. being able to discriminate between healthy indi-
viduals and patients with long-lasting musculoskeletal
pain and/or psychosomatic disorders, and be able to
capture change in body awareness). The four
subscales of BARQ were shown to reflect somewhat
different aspects of the phenomenon of body aware-
ness (Dragesund, Ljunggren, Kvåle, and Strand,
2010) and should thus be examined separately in
further clinometric analysis. The purpose of the
present study was to examine test-retest reliability,
construct and discriminative validity and responsive-
ness to important change of the BARQ subscales.
Internal consistency was also re-examined in the new
sample of patients.
MATERIALS AND METHODS
Design
A longitudinal design was used to examine test-retest
reliability and responsiveness to important change,
while a cross-sectional design was used to examine
construct and discriminative validity.
Subjects
The inclusion criteria of patients were: a diagnosis of
musculoskeletal pain (ICPC-2-2004, L-codes) and/
or psychosomatic disorders (ICD-10-2005, codes:
F45.0-F45.4); a condition that had lasted for more
than 3 months; and not earlier being treated with
NPMP. Exclusion criterion was severe psychiatric dis-
orders. In Norway, physicians and manual therapists
diagnose and refer patients with the above conditions
to NPMP. Fifty patients who were asked to participate
in the present study were recruited consecutively from
the waiting- lists of six physiotherapists during a period
of 15 months (October 2008 to December 2009). The
physiotherapists had been specialists in NPMP for
more than 6 years, and all worked in primary health
care.
To evaluate the BARQ’s discriminative validity, a
convenience sample of 50 persons who considered
themselves as healthy were asked to participate. They
were recruited among part and full time workers in
six different private companies during the same
period of time as the patients (October 2008 to
December 2009). They should not have been on sick
leave due to musculoskeletal pain or psychosomatic
disorders during the preceding year and not be familiar
with BARQ prior to the study. To match the patient
group, the healthy persons were stratified according
to age groups (20-35, >35-50, >50) and gender.
Both samples were given written and oral infor-
mation about the study, and the participants signed a
consent form. The study was approved by the Regional
Committee for Medical Research Ethics in Western
Norway and the Norwegian Data Inspectorate.
Copyright © Informa Healthcare USA, Inc.
 Body Awareness Rating Questionnaire: Measurement properties 517
Measurement
Body Awareness Rating Questionnaire (BARQ)
The BARQ is a self-report questionnaire including
four subscales that aim to reflect different aspects of
body awareness. The subscales are: 1) Function; 2)
Mood; 3) Feelings; and 4) Awareness. Examples of
items regarding Function are: ‘I never sit comforta-
bly’; Mood: ‘I breath more easily when I’m in a
good mood’; Feelings: ‘I dislike my body’; and Aware-
ness: ‘I am not aware of how I move’. The items are
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scored on a seven-point Likert scale. Subscale scores
range from 6 to 42, and high scores reflect better
body awareness (Dragesund, Ljunggren, Kvåle, and
Strand, 2010). The BARQ is presented with subscales
and single items in the Appendix.
To examine construct validity, two other question-
naires were filled in by the patients. These question-
naires were the Short Form-36 Health Survey
(SF-36) and the Toronto Alexithymia Scale (TAS-
20). The SF-36 is designed to measure perceived
health related quality of life, and body awareness as
captured by BARQ was hypothesized to be related to
For personal use only.
this construct. However, the constructs assessed by
the different subscales were expected to be more or
less related, as reflected in the purpose statement.
Since patients with long-lasting musculoskeletal pain
and/or psychosomatic disorders often have problems
describing their feelings and bodily function
(Braatøy, 1947), the TAS-20 was also chosen for con-
struct validation.
After treatment the patients filled in the Patients
Global Impression of Change as an external anchor
of important change.
Short Form-36 Health Survey (SF-36)
SF-36 is a 36-item self-report questionnaire used to
measure health-related quality of life (Ware, 2000).
The questionnaire includes eight subscales: 1) Phys-
ical Functioning (PF); 2) Role function - Physical
aspects (RP),;3) Bodily Pain (BP); 4) General
Health (GH); 5) Vitality (V); 6) Social Functioning
(SF); 7) Role function - Emotional aspects (RE);
and 8) Mental Health (MH). The score for each of
the eight subscales ranges from 0 to 100. A higher
score indicates better health (Ware, 2000). SF-36
has been used in several studies on musculoskeletal
disorders and has been found to be reliable, valid
and responsive to change (Kvien, Kaasa, and Smed-
stad, 1998; Schlenk et al, 1998; Tuttleman et al,
1997). Good psychometric properties have also been
demonstrated in the Norwegian version (Loge,
Kaasa, Hjermstad, and Kvien, 1998).
Physiotherapy Theory and Practice
Toronto Alexithymia Scale (TAS-20)
Alexithymia is a multidimensional construct character-
ised by an impoverished fantasy life, difficulty in
expressing or naming feelings, difficulty distinguishing
between bodily sensations and feelings, and a preoccu-
pation with external events (Taylor and Bagby, 2000).
TAS-20 (Bagby, Parker, and Taylor, 1994) is the
most widely used and studied measure of alexithymia.
Factor analyses have supported a three-factor solution,
representing: 1) Difficulty identifying feelings; 2) Diffi-
culty describing feelings; and 3) External thinking
(Bagby, Parker, and Taylor, 1994; Loas et al, 1996).
A higher score indicates alexithymia. The Norwegian
version has demonstrated good psychometric proper-
ties (Graeme, Taylor, Bagby, and Parker, 2002;
Taylor, Bagby, and Parker, 2003).
Patient Global Impression of Change (PGIC)
PGIC is a 7-point ordinal scale, used as an external
criterion to measure clinical important change after
treatment (Farrar et al, 2001). Scores <4 denote
improvement (1 = very much improved, 2 = much
improved, 3 = slightly improved), and scores >4 a
worsening (5= minimal worse, 6= much worse, 7 =
very much worse). Studies indicate that the PGIC is
valid as a measure of important change in patients
with low back pain (Grotle, Brox, and Vollestad,
2004; Ostelo, de Vet, Knol, and van den Brandt,
2004). In the present study the questionnaire was
used to report change in body awareness.
Treatment
Norwegian Psychomotor Physiotherapy (NPMP) is a
body-oriented physiotherapeutic approach, taking
into consideration the association between body and
mind. The whole body is examined and treated as a
functional unit. Respiration, muscle tension and
emotions are considered to be intertwined, and the
patients’ respiration pattern is particularly a focus of
attention in examination as well as in treatment. The
aim of NPMP is to address dysfunction by facilitating
change through massage and movements, closely
linked to respiration. Movements include grounding,
balancing, stretching and relaxation. Verbal reflection
on embodied experiences is part of the therapy. Body
awareness is considered essential to improve function,
and is stimulated by encouraging the patient to sense
bodily reactions during treatment (Thornquist and
Bunkan, 1991; Øien, Råheim, Iversen, and Steihaug,
2009; Øvreberg and Andersen, 1986). Each treatment
session lasts one hour and usually the patients receive
treatment once a week or once every second week.
 518 Tove et al.
Procedure
The patients were asked to fill in the BARQ in the
waiting room after the first examination. They were
also asked to fill in a questionnaire booklet containing
the BARQ, SF-36 and TAS-20 at home after a couple
of days, but before the next treatment session seven
days later (2-7 days). The patients received NPMP
for six months, and after the last treatment they
answered the BARQ and the PGIC at the waiting
room. On all occasions the therapists collected the
forms, and made sure that all questions were
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answered. The questionnaires were coded and regis-
tered on a data sheet.
Statistical Analysis
SPSS Version 15.0 was used for all statistical analysis.
Demographic data were examined using descriptive
statistics. All variables were examined for normality
using a Kolmogorov-Smirnov test (normal distri-
bution, p > 0.05) and by inspecting Q-Q plots. Level
For personal use only.
of significance was p ≤ 0.05.
Reliability
The internal consistency of each subscale was examined
and reported as Cronbach’s alpha. Test-retest reliability
was quantified as both relative and absolute reliability.
Relative reliability was assessed by calculating interclass
correlation coefficients (ICC), using two-way random,
absolute agreement (2,1) (McGraw and Wrong,
1996). An ICC of at least 0.70 is recommended as a
minimum standard for relative reliability (Terwee
et al, 2007). However, since a large ICC value is poss-
ible even with large between-subject differences, it is
recommended to also examine absolute reliability, or
measurement error (Terwee et al, 2007). Within-
subject standard deviation (Sw) denotes measurement
error, and the variability is expressed in the unit of the
measurement tool (Domholdt, 2005). The percentage
Sw related to the total score was calculated. According
to Ostelo, de Vet, Knol, and van den Brandt (2004),
the results of this calculation can be interpreted as
follows: ≤5% very good; >5% and ≤10% good; >10 %
and ≤20% doubtful; and >20% negative. The difference
between two measurements of the same subject is
expected to be <2.77 Sw for 95% pairs of observations
(Bland and Altman, 1996). This is called the smallest
detectable change (SDC). A change in a measure
must exceed the SDC value to claim treatment effect
in individual patients.
To visualise test-retest reliability, an Altman plot
was constructed for each subscale (Bland and
Altman, 1986). The mean of the test and retest
scores was calculated to check for a drift in scores (sys-
tematic error), and the SD of the differences between
test and retest scores was calculated as a measure of
random error. Drift in scores was taken into consider-
ation before adding and subtracting the limits of
agreement: ±1.96 × SD difference.
Construct Validity
Construct validity refers to ‘the extent to which scores
on a particular instrument relate to other measures in
a manner that is consistent with theoretically derived
hypotheses concerning the concepts that are being
measured’ (Streiner and Norman, 2008). Based on
what the four subscales of BARQ and the subscales
of SF-36 and TAS-20 intend to measure, 11 hypoth-
eses regarding the expected correlation between each
BARQ subscale and the other subscales were formu-
lated. We expected at least medium correlation
between Function in BARQ and the three SF-36 sub-
scales: 1) Physical Functioning; 2) Role function-
Physical aspects; and 3) Bodily Pain, but only a
small or no correlation with the other SF-36 subscales.
Furthermore, at least medium correlation was
expected between Mood and Feelings in the BARQ
and the three SF-36 subscales: 1) Social Functioning;
2) Role function-Emotional aspects; and 3) Mental
Health, but only a small or no correlation with the
other SF-36 subscales. The BARQ’s Awareness sub-
scale was expected to show a small or no correlation
overall with the SF-36 subscales. In regards to the
TAS-20, the BARQ Mood and Feelings subscales
were expected to show at least a negative medium cor-
relation with the two TAS-20 subscales: 1) Difficulty
identifying feelings; and 2) Difficulty describing
feelings, but a small or no correlation with the other
subscales. The correlations were calculated by
Pearson (r) or Spearman rank correlation coefficient
(rs), depending on the scale and normality of scores.
According to Cohen (1998), a value of r = 0.10 −
0.29 is interpreted as small; while r = 0.30 − 0.49 is
medium; and r = 0.50 − 1.0 is a strong correlation.
Discriminative Validity
Discriminative validity is defined as an instrument’s
ability to discriminate between extreme groups of
persons (Streiner and Norman, 2008). The BARQ
subscale scores of healthy persons and patients with
musculoskeletal pain and/or psychosomatic disorders
were calculated, and a receiver operating characteristic
curve (ROC) was constructed for each subscale, con-
trasting scores of the two groups. The area under the
curve (aROC) was examined. The area should be at
least 0.70 (Terwee et al, 2003), and the greater the
Copyright © Informa Healthcare USA, Inc.
 Body Awareness Rating Questionnaire: Measurement properties 519

area, the greater the measure’s discriminate ability. If RESULTS

the aROC was adequate, a cut-off value was calculated
for each subscale, where the percentages of false posi-
tives and false negatives were minimal.
Responsiveness to Important Change
Responsiveness concerns “the ability of a question-
naire to detect clinically important change over time,
even if these changes are small” as defined by Guyatt
et al. (1989). The change in scores of the four
BARQ subscales from baseline to after 6 months of
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In the group of patients there were 38 women and 12
men, with a mean age of 42.2 years (± 13.2) (range
17-66 years). The average duration of pain problems
was 6.6 years (± 6.6), and 14 were on full-time sick-
leave. The healthy participants consisted of 38 women
and 12 men with a mean age of 40.3 years (± 12.8)
(range 18-63 years). All the healthy participants were
employed, and some of the part time employed individ-
uals were also students. There were no significant differ-
ences in age, gender and work (white or blue collar)

NPMP treatment was calculated by paired samples

t-test. The PGIC was used as an external anchor of
meaningful change. Change in BARQ scores were to
be dichotomized in ROC curve analysis, contrasting
patients who reported very much, much and slightly
improved body awareness on the PGIC, versus those
who reported to be unchanged or worse after the treat-
ment. The area under the curve (aROC) was used as
an indication of responsiveness. According to
Terwee et al. (2003) an area should at least be 0.70.
A linear trend of decreasing improvement in each of
the BARQ subscales was further expected, in line
For personal use only.
between patients and healthy participants, but only
patients were more or less on sick leave. Descriptive
information of the 100 participants is given in Table 1.
Reliability
Internal consistency was demonstrated, with high
values of Cronbach’s α for all subscales (0.88-0.93)
(Table 2). Relative reliability measured by ICC (2,1)
was: 0.85 for the subscale Function; 0.83 for Mood;
0.87 for Feelings; and 0.79 for Awareness (Table 1).
Absolute reliability (Sw) was: 2.9 for the subscale

with less improvement of body awareness reported Function; 3.2 for Mood; 2.7 for Feelings; and 3.1
on PGIC. This trend was examined by a one-way for Awareness. The percentage of Sw related to the
repeated measures analysis of variance (ANOVA). total score ranged between 7.5% and 8.9%
(Table 2). The smallest detectable change (SDC)
TABLE 1 Background characteristics of the participants values are also presented in Table 2. A tendency
(n = 100) towards higher scores from test to retest was seen,
and when drafting the Bland-Altman plot (Figure 1),
Patients Healthy this drift must be taken into consideration to arrive
Variables N = 50 N = 50 at the 95% limits of agreement, which indicate the
limit an individual has to exceed to demonstrate a
Age, years: mean, (SD) 42.2 (13.2) 40.3 (12.8)
change above measurement error.
17–35 years, men, women 2/15 2/15
36–50 years, men, women 7/13 7/13
>51 years men, women 4/10 4/10 Construct Validity
Gender: men, women, % 12/38 12/38
The Kolmogorov-Smirnov test for normality of
(23.5/75.5 %) (23.5/75.5 %)
Duration of pain problems, 6.6 (6.6) 0
subscale data showed p-values ranging between
years: mean (SD) p < 0.001 and 0.200, thus deciding the use of
Work: blue collar, white 10/35/5 5/37/8 Pearson or Spearman rank correlation. All 11 hypoth-
collar, students eses regarding a correlation between the Function
Sick listed: yes, no, % 22/17 0/50 subscale and the subscales of the other measures
(43.1/33.3 %) (0/100%) (Table 3) were confirmed, with medium correlations

TABLE 2 Cronbach’s α values and reliability of the BARQ subscales by ICC(2,1), Sw, also in per cent of the maximum score and the
smallest detectable change (SDC).

Subscales (6-42) Cronbach’s α values ICC (95% CI) Sw Sw in per cent (%) of max. scale score SDC

Function 0.92 0.85 (0.75−0.91) 2.86 7.9 7.9

Mood 0.90 0.83 (0.71−0.90) 3.20 8.9 8.9
Feelings 0.93 0.87 (0.79−0.93) 2.70 7.5 7.5
Awareness 0.88 0.79 (0.67−0.88) 3.10 8.6 8.6

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 520 Tove et al.
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For personal use only.

FIGURE 1 Intra-individual differences between test and retest plotted against the mean of the two tests for the four subscales, Func-
tion, Mood, Feelings and Awareness. The central horizontal line represents the mean of the intra-individual differences, and the flank-
ing lines the mean difference + /- 1.96 × SDdifference, which are the limits of agreement (see inserted values).

with the three SF-36 subscales: 1) Physical Function-

ing (r = 0.468); 2) Role function-Physical aspects (r =
0.538); and 3) Bodily Pain (r = 0.437) (Table 3).
Mood demonstrated a medium correlation with the
SF-36 subscale Role function-Emotional aspects (r
= 0.422), but a negative correlation with Mental
Health (r = -0.508) and Social Functioning (r =
−0.261), and no correlation with the TAS-20 sub-
scales Difficulty identifying feelings and Difficulty
describing feelings. Feelings in BARQ demonstrated
a medium correlation with the SF-36 subscales
Social Functioning (r = 0.369) and Mental Health
(r = 0.390), but no correlation with the Role func-
tion-Emotional aspects of SF-36, and a negative
medium correlation with the TAS-20 subscales Diffi-
culty identifying feelings (r = -0.304) and Difficulty
describing feelings (r = -0.355), as hypothesised.
Awareness of BARQ demonstrated no correlation
with any of the subscales of SF-36 and TAS-20.
Discriminative Validity
The aROC for discriminative validity was: 0.97 for
Function; 0.46 for Mood; 0.73 for Feelings; and
0.80 for Awareness as shown in Figure 2 and
presented in Table 4 as 95% CI, which also shows
the cut-off values for best discrimination between
the patients and healthy participants.
Responsiveness to Important Change
The patients received between 12 and 20 treatment
sessions. All the patients completed the treatment
period of six months and filled in the questionnaires.
There was a positive mean change on all the BARQ
subscales from baseline to 6 months after NPMP
treatment, but the change was only statistically signifi-
cant for the subscales Function and Awareness
(Table 5). All patients reported more or less

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 Body Awareness Rating Questionnaire: Measurement properties 521

TABLE 3 Correlation between the subscale scores of BARQ and the subscale scores of SF-36 and of TAS-20.

BARQ subscales

Questionnaires Function Mood Feelings Awareness

SF-36
Physical Functioning (PF) 0.468∗ 0.285∗ 0.029 −0.068
Role function-Physical aspects (RP) 0.538∗ 0.268 0.101 0.154
Bodily Pain (BP) 0.437∗ 0.085 −0.026 −0.089
General Health (GH) 0.119 0.277 0.042 −0.130
Vitality 0.279 −0.074 0.253 −0.079
Social Functioning (SF) 0.205 −0.261 0.369∗ 0.154
Role function-Emotional aspects (RE) 0.089 0.422∗ 0.222 −0.105
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Mental Health (MH) 0.181 −0.508∗ 0.390∗ 0.248

TAS-20
Difficulty identifying feelings 0.088 0.269 −0.304∗ −0.239
Difficulty describing feelings −0.098 0.062 −0.355∗ −0.179
External thinking −0.167 0.074 −0.254 −0.177

p ≤ 0.05∗ . Predefined hypotheses of at least moderate correlations (r > 0.30) should be seen in relation to the bold face values, most
confirming the hypothesis, others rejecting the hypothesis.
For personal use only.

FIGURE 2 Area under the Receiver Operating Characteristic (ROC) curves demonstrating discriminate ability of the BARQ sub-
scales Function, Mood, Feelings and Awareness, contrasting test scores of patients with prolonged musculoskeletal pain and psycho-
somatic disorders and gender and age-matched healthy participants.

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 522 Tove et al.

TABLE 4 Discriminate ability of the four subscales of BARQ, contrasting test scores of healthy persons and patients with prolonged
musculoskeletal pain and psychosomatic disorders using ROC curve analysis, reporting the area under the curve (aROC) with a 95%
confidence interval (CI).

BARQ Healthy, n = 50 Mean Patients, n = 50 Mean 95% CI, Cut-off

subscales (SD) (SD) aROC aROC value Sensitivity Specificity

Function 36.74 (4.71) 17.76 (7.13) 0.97 0.95,1.00 21.5 1.00 0.76
Mood 30.22 (8.14) 31.40 (7.58) 0.46 0.35,0.58 30.5 0.50 0.42
Feelings 37.04 (5.48) 31.82 (7.60) 0.73 0.63,0.83 33.5 0.84 0.50
Awareness 30.06 (6.32) 21.68 (7.19) 0.80 0.71,0.88 21.5 0.94 0.52
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TABLE 5 Scores on the four subscales of BARQ at baseline and after 6 months NPMP treatment and change in scores, with p-values,
after 6 months treatment.

Items Baseline Scores Mean (SD) After Treatment Mean (SD) Change Mean (SD), p-values

Function 17.76 (7.13) 22.76 (7.91) 5.00 (6.78), p < 0.001

Mood 31.40 (7.58) 32.38 (6.92) 0.98 (6.15), p = 0.265
Feelings 31.82 (7.60) 32.34 (6.59) 0.52 (3.96), p = 0.357
Awareness 21.68 (7.19) 27.22 (6.57) 5.54 (7.49), p < 0.001

TABLE 6 Change in scores on the four subscales of BARQ according to categories of self-reported change on the Patient Global
Impression of Change (PGIC) after rehabilitation, examined for linear trend by One way ANOVA. N = 50.
For personal use only.

BARQ Very much Improved Mean Much Improved Mean Slightly Improved Mean Linear trend, Contrast and
subscales (SD) n = 11 (SD) n= 33 (SD) n= 6 p-values

Function 7.55 (9.34) 4.33 (6.03) 4.00 (4.94) -35.73, p = 0.001

Mood -1.09 (9.38) 1.45 (5.24) 2.17 (2.48) 6.54, p = 0.489
Feelings 1.18 (2.75) 0.91 (4.30) -2.83 (2.14) -7.33, p = 0.215
Awareness 8.00 (8.38) 5.06 (6.65) 3.67 (10.39) -38.17, p = 0.002

improvement on the PGIC (Table 6), therefore ROC
curve analysis could not be performed discriminating
improved from not improved. There was a significant
linear trend of decreasing change scores according to
decreasing improvement on the PGIC, for the sub-
scales Function and Awareness, but not for Mood.
DISCUSSION
The aim of this study was to examine important
measurement properties of BARQ which includes
four subscales intended to assess different aspects of
body awareness. Test-retest reliability was found to
be satisfactory for all four subscales, since both relative
and absolute reliability were within recommended
limits. Construct validity was acceptable for Function,
Feelings and Awareness, with moderate associations
with other related scales, while Mood demonstrated
inconsistent results. The Function subscale demon-
strated very high discriminate ability, and this property
was also satisfactory for Feelings and Awareness, but
not for Mood. Positive improvement after therapy
was indicated by all the four subscales, but responsive-
ness to important change was only demonstrated by
Function and Awareness.
The internal consistency of all BARQ subscales was
highly satisfactory, and even better than found in a pre-
vious study (Dragesund, Ljunggren, Kvåle, and
Strand, 2010) of a similar patient group (n = 300).
Relative reliability was satisfactory for each subscale,
with ICC (2,1) values between 0.79 (Awareness) and
0.87 (Feelings). One prerequisite when examining the
test-retest reliability of a measure is that the patients’
condition does not change between tests. Because
phenomena and conditions tend to change over time,
the time period between test and retest should be
short enough to ensure that a clinical change has not oc-
curred, but long enough to prevent recall of the pre-
vious scoring (Terwee et al, 2007). In the present
study, three to six days elapsed between test and
retest. The first test was performed in the waiting
room shortly after examination by an NPMP specialist.
Since the patients filled in a form with demographic

Copyright © Informa Healthcare USA, Inc.

 Body Awareness Rating Questionnaire: Measurement properties 523
data and two other questionnaires on the same
occasion, they probably did not recall their previous
scoring on the retest, which was performed at home.
There was a tendency, however, of drift in data, with
patients scoring somewhat better the second time.
This drift could have been caused by the different test
situations and/or by a possible treatment effect. Some-
what better scores on the second test may reflect a more
relaxed state of mind and less dysfunction due to the
initiation of NPMP after several months on a waiting
list. Another explanation may be familiarity with the
questionnaire from the first test.
Physiother Theory Pract Downloaded from informahealthcare.com by University of Connecticut on 10/28/14
Absolute reliability indicates how much error we can
expect (Domholdt, 2005). Absolute agreement for the
subscales was satisfactory, since the Sw values related
to the total score were less than 10% for all subscales
(Ostelo, de Vet, Knol, and van den Brandt, 2004).
The Bland-Altman plots show the limits of agreement,
including the systematic drift that should be taken
into consideration when judging changed scores for
individual patients. To be 95% confident that the
change is not simply a measurement error, a change
should be above the limits of agreement.
The construct validity of a measure should be
For personal use only.
examined if the construct in question cannot be
observed objectively or directly and no gold standard
is available (Streiner and Norman, 2008).
The Function subscale mainly captures awareness
of bodily pain and tension during daily functioning.
It seems to assess a somewhat similar phenomenon
as captured by the SF-36 subscales Physical Function-
ing, Role function-Physical aspects and Bodily pain.
We hypothesised at least a medium correlation with
these subscales, but a low or no correlation with the
other subscales of SF-36 and TAS-20, which appar-
ently assess different phenomena. All these hypotheses
were confirmed.
The Mood subscale measures awareness of the
mood’s influence on the body in items such as: ‘My
body feels different when I am happy and when I am
sad’, and ‘I breathe more easily when I am in a good
mood’. We expected at least a moderate correlation
between this scale and the three SF-36 subscales: 1)
Social Functioning; 2) Role function-Emotional
aspects; and 3) Mental Health, and the two TAS-2-
subscales: 1) Difficulty identifying feelings; and 2)
Difficulty describing feelings. However, Mood corre-
lated only moderately with Role function-Emotional
aspects and negatively and moderately with Mental
Health of SF-36. There is, accordingly, no evidence
for construct validity of this scale.
The Feelings subscale largely consists of items
relating to respondents’ feelings about their own
bodies, such as: ‘I am ashamed of my body’ and ‘I
dislike my body’. We therefore expected this scale to
Physiotherapy Theory and Practice
be at least moderately associated with the three SF-
36 subscales: 1) Social Functioning; 2) Role func-
tion-Emotional aspects; and 3) Mental Health and
the two TAS-20 items: 1) Difficulty identifying feel-
ings; and 2) Difficulty describing feelings, but not
with the other (six) subscales. All the hypotheses
were confirmed except the hypothesis of a moderate
association between Feelings and Role function-
Emotional aspects. There is, accordingly, evidence
for construct validity of Feelings.
The Awareness subscale reflects awareness of body
movements and actions in items such as: ‘I am not
aware of how I breathe’, and ‘I always push myself to
my limits’. It appears to assess a different construct
than the SF-36 and TAS-20 subscales. We therefore
did not expect a correlation with these subscales, as
was in fact demonstrated. As we lack a validated
measure of body awareness, it is difficult to find
evidence for construct validity by showing moderate
or high associations with other measures.
Regarding discriminative validity, the ability of the
BARQ subscales to discriminate between patients
with prolonged musculoskeletal pain and/or psychoso-
matic disorders and healthy participants was satisfac-
tory (aROC > 0.70) in all subscales except Mood.
The Function subscale demonstrated an almost
perfect ability to discriminate between patients and
healthy participants (aROC = 0.97). The statements
included in this scale seem to characterise very well
functional problems of patients referred to NPMP,
for instance in the items ‘My muscles are often
tense’ and ‘I never sit comfortably’. Work on body
awareness in NPMP aims to harmonise muscle
tension, breathing, movement and daily functioning.
These aspects are addressed in treatment, for instance
by repeatedly asking the patient what he/she senses
and/or feels in different positions and movements
(Dragesund and Råheim, 2008; Øien, Råheim,
Iversen, and Steihaug, 2009).
The discriminative ability of the Awareness subscale
was very satisfactory (aROC of 0.80). A lack of aware-
ness of how they move, breathe and expend effort on
daily activities seems common in patients referred to
NPMP, and the subscale appears to capture a differ-
ence in this phenomenon between patients and
healthy participants. The Feelings subscale had also
sufficient discriminative ability (aROC = 0.73), but
negative perceptions of the body (dislike and shame)
as captured by this scale may not just characterise
NPMP patients, but also healthy persons, as suggested
when comparing scores on this scale (Table 4). The
Mood subscale lacks evidence for construct validity.
The scale seems to reflect a general awareness of how
being happy, sad etc. influences the body, and may
explain why it does not discriminate between healthy
 524 Tove et al.
persons and patients with prolonged musculoskeletal
pain and/or psychosomatic disorders.
A recommended method of examining responsive-
ness is the ROC curve analysis, distinguishing patients
who have and have not improved according to an
external criterion. In the present study 44 patients
reported much or very much improvement of body
awareness on the PGIC after treatment and six
patients reported to be slightly improved making it
impossible to contrast patients who had improved
versus those that had not improved. The subscales
Function and Awareness demonstrated, however, a
Physiother Theory Pract Downloaded from informahealthcare.com by University of Connecticut on 10/28/14
positive change after NPMP treatment, and a linear
trend of decreasing change scores according to
decreasing improvement on the PGIC was demon-
strated. There is, accordingly, indication that the sub-
scales Function and Awareness can be used as
outcome measures of clinically important change
after body awareness therapy.
The subscale Feelings lack evidence for responsive-
ness in this study. The scale concerns feelings about
one’s own body, an aspect of body awareness that is
addressed more indirectly during the treatment. It
might be that a treatment period of six months is too
For personal use only.
short to improve this aspect, or that this aspect
should be addressed more in therapy. NPMP is a read-
justing treatment process, and the treatment period
can vary from a few months to several years (Øvreberg
and Andersen, 1986). Since the subscale has shown
discriminative properties, we could assume that the
scale can detect changes. Further examination of this
scale’s responsiveness is needed.
The Mood subscale lacks evidence for both con-
struct and discriminative validity and responsiveness
to important change. Based on our results, it is con-
cluded that Mood should be excluded from BARQ.
We argue, however, that what we have intended to
capture in the Mood subscale is an important aspect
that is also addressed in therapy. Further efforts
should therefore be made to develop a better subscale
of this phenomenon.
Limitations of the Study
Although we have demonstrated satisfactory reliability,
construct validity and discriminate ability, for three
subscales, and responsiveness to important change
for two subscales the question remains whether they
are able to fully reflect the essential aspects of body
awareness addressed in NPMP. We realize that we
lack a scale assessing the patients’ perception of how
mood influences their bodies, which we consider an
important aspect. Whether it is possible to capture
this phenomenon using a quantitative assessment
tool remains to be seen.
Our results are based on a rather small sample, and
we cannot be sure that they apply to the whole popu-
lation of patients with long-lasting musculoskeletal
pain and/or psychosomatic disorders although demo-
graphic characteristics were similar to a broader
sample including 300 patients in a previous study
(Dragesund, Ljunggren, Kvåle, and Strand, 2010).
The sampling procedure used in the study secured a
high compliance, preventing missing data, but the in-
volvement of the therapists might have influenced the
scoring of the questionnaires.
CONCLUSION
The three subscales: 1) Function; 2) Feelings; and 3)
Awareness, were found to have very satisfactory
measurement properties showing test-retest reliability,
construct and discriminative validity, while Function,
and Awareness also demonstrated responsiveness,
implying evaluative ability. It is a challenge to sup-
plement the BARQ with a subscale that validly
assesses Mood as an aspect of body awareness. We
think the present study is an important contribution
in the process of developing a self-report assessment
tool of body awareness to be used by physiotherapists
focusing on this phenomenon in therapy.
Acknowledgments
The authors are very grateful to the physiotherapists at
Strandgaten and Fortunen Physioterapy, and give
special thanks to Heidi Ann Fiske, Lars Sætre and
Solveig H Iversen for their assistance in recruiting
patients.
Declaration of interest: The authors report no
declarations of interest.
The study was supported by the Norwegian Fund
for Postgraduate training in Physiotherapy.
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