Blackwell Science, LtdOxford, UKINRInternational Nursing Review0020-8132International Council of Nurses, 2003June 2003502101108Original ArticleNordic musculoskeletal questionnaire adaptationE. N. C.
de Barros & N. M. C. Alexandre
Keywords
Cross-Cultural
Adaptation,
Ergonomics,
Musculoskeletal
Symptoms, Research
Instrument
Correspondence address:
Prof. Neusa M. C. Alexandre,
Department of Nursing, College
of Medical Sciences, State
University of Campinas
(UNICAMP), Cidade
Universitatria ‘Zeferino Vaz’,
Dist. Barao Geraldo, Cep.
13083-970, Campinas, SP, Brazil
Tel.: 55 19 37888820
Fax: 55 19 37888822
E-mail:
neusalex@fcm.unicamp.br or
lili@fcm.unicamp.br
Original Article
Cross-cultural adaptation of the Nordic
musculoskeletal questionnaire
E. N. C. de Barros1 RN & N. M. C. Alexandre2 RN, PhD
1 Nurse, Department of Nursing, College of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Sao Paulo,
Brazil
2 Nurse, Department of Nursing, College of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Sao Paulo,
Brazil
Abstract
Background: Reports in the literature have identified a need for internationally
standardized and reliable measurements to analyse musculoskeletal symptoms.
Screening of musculoskeletal disorders may serve as a diagnostic tool to evaluate the
work environment. The Nordic general questionnaire is a standardized instrument
used to analyse musculoskeletal symptoms in an ergonomic or occupational health
context. Purpose: To translate and adapt a version of the Nordic general
questionnaire into Brazilian Portuguese and evaluate its reliability. Method: The
cross-cultural adaptation was performed according to internationally recommended
methodology, using the following guidelines: translation; back-translation;
committee review; and pretesting. First, the questionnaire was independently
translated into Portuguese by two teachers and one doctor, and a consensus version
was generated. Second, two other translators performed a back-translation
independently from one another. This version was then submitted to a committee,
consisting of six specialists in the area of knowledge of the instrument, to evaluate its
equivalence to the original instrument. The final version was pretested on 20 subjects
randomly selected in an outpatient clinic. Reliability was assessed by a test–retest
procedure at 1-day intervals using the Kappa coefficient in a group of 40 subjects.
The Kappa agreement values were calculated for each one of the four questions of the
questionnaire. The agreement among the same observers was substantial, varying
from 0.88 to 1, according to the Kappa values. Results: these demonstrated strong
agreement of the instrument, suggesting that the Brazilian version of the
‘Standardized Nordic Questionnaire’ offers substantial reliability.
causes of disability and absenteeism in workers, as
Introduction
well as having various personal, social and eco-
Musculoskeletal disorders represent a serious pub- nomic impacts (Courtney & Webster 1999; Lidgren
lic health problem, being one of the most important 1998; Santos Filho & Barreto 2001; Yelin & Calahan
© 2003 International Council of Nurses 101
102 E. N. C. de Barros & N. M. C.Alexandre
1995). Included among these musculoskeletal dis-
orders is low back pain, the most frequent cause of
activity limitation in workers of productive age
(Alexandre & Benatti 1998; Alexandre et al. 1996;
2001; Guo et al. 1999; Hagen & Thune 1998; Lee
et al. 2001; Nordin et al. 1997).
It is currently known that the occurrence of mus-
culoskeletal disorders encompasses several inter-
related variables; for this reason, new approaches to
identify and cope with the problem are increasingly
being sought. The international literature describes
questionnaires and specific scales for using to evalu-
ate various aspects of musculoskeletal disorders,
including: frequency, location and intensity of
symptoms; functional capability and quality of life
of the patients; and social and emotional aspects
(Alonso et al. 1990; Deyo et al. 1998; Macdowell &
Newell 1996; Nusbaum et al. 2001). These instru-
ments are very important as they provide standard-
ized data, which can be used in clinical practice,
research and public health programmes. Some
authors have recommended the adaptation of scales
and questionnaires already validated in another lan-
guage, defending the idea that this will facilitate the
exchange of information in the scientific commu-
nity (Hutchinson et al. 1996).
Several researchers have directed their studies to
the development of methods for assessing muscu-
loskeletal disorders, particularly to help define the
relationship of the symptoms with the type of work
and the areas of the body most affected. The ‘Stan-
dardized Nordic Questionnaire’ is an internation-
ally respected instrument designed to standardize
studies on evaluation of musculoskeletal com-
plaints (Kuorinka et al. 1987). Its objective is to
evaluate musculoskeletal problems in an ergonomic
approach. The first part of this instrument consists
of questions regarding parts of the human body that
correspond to nine anatomical areas (three on the
upper limbs, three on the lower limbs and three on
the torso), marked on an illustration of the human
body seen from behind. The instrument utilized in
this study was adapted to the English language and
the questions arranged in the following order:
annual and weekly prevalence; functional incapac-
ity; and search for medical assistance in the last 12
months (Bork et al. 1996; Dichinson et al. 1992;
© 2003 International Council of Nurses, International Nursing Review, 50, 101–108
Rosecrance et al. 1996). This instrument may be
applied through an interview or answered by the
person being evaluated.
Purpose of the study
The present study had the objective of culturally
adapting the general content of the ‘Standardized
Nordic Questionnaire’ to the Portuguese language
and assessing the reliability of its Brazilian version.
Methodology
In order to ensure the quality of adapted instru-
ments, international norms should be followed
when carrying out the adaptation. The employment
of a methodology accepted by the scientific litera-
ture permits the comparison of data obtained in dif-
ferent services (Riberto et al. 2001). This study
aimed to follow the essential steps that should be
taken in the adaptation of instruments, based on
specialized literature (Alexandre & Guirardello
2002; Guillemin 1995; Hutchinson et al. 1996). The
phases carried out were: first, translation into the
Portuguese language from the English version and
back translation into English; second, analysis by a
committee of specialists; and third, pretest and reli-
ability testing (test–retest).
Initial translation into the Portuguese language
Translation of the general questionnaire that is part
of the ‘Standardized Nordic Questionnaire’, was car-
ried out by three Brazilian individuals who worked
independently; two were English teachers and the
third was a physician in the residency programme of
Yale University (USA). The three translation ver-
sions were compared by the author and analysed
until there was a consensus regarding the initial
translation.
English version
The initial translation into Portuguese was back
translated into English by two different bilingual
independent translators, whose mother tongue was
English and who did not participate in the previous
phase. This phase had the purpose of checking for
Nordic musculoskeletal questionnaire adaptation
discrepancies between content and meaning of the
original version and the translated instrument. All
the versions were analysed and compared by the
author, and a final version was obtained.
Reviewers’ committee
The final translated version was submitted to a com-
mittee consisting of six specialists in the area of
knowledge of the instrument, who were informed
of the measures and concepts involved. This multi-
disciplinary team comprised an orthopaedist, a
rheumatologist, a neurologist, an occupational
health nurse, an undergraduate nursing student and
a physician. Each of the committee members was
asked to evaluate the equivalency of the original
instrument to the final translated version of the
‘Standardized Nordic Questionnaire’. This evalua-
tion was directed by the use of an instrument specif-
ically developed for this study with the theoretical
support of another study about cultural adaptation
(Kimura 1999). This instrument consisted of nine
items divided into two parts – A and B – with part A
corresponding to the original version of the instru-
ment being studied and part B being the version
translated into Portuguese. Each of the profession-
als on this committee was instructed to evaluate
each item regarding the equivalency of the transla-
tions presented, following the scale: ‘+1’ when
equivalent and ‘-1’ when not. On the basis of other
research (Kimura 1999), the authors decided that in
the event of obtaining three ‘-1’ answers it would be
necessary to re-evaluate the translation for its
alteration.
Pretest
The questionnaire was applied to 20 randomly
selected individuals, while they were waiting to be
examined at the Health Unit of the University where
the study was carried out. This group included
employees, students and professors of the
institution.
In order to simplify recording of doubts and sug-
gestions concerning the questionnaire being stud-
ied, an instrument was specifically prepared for this
research phase. This instrument at first contained
© 2003 International Council of Nurses, International Nursing Review, 50, 101–108
103
general information on the interviewee, such as
gender, age, civil status and occupation. It was
divided in three main parts: ‘instructions to fill out
questionnaire’, ‘questions’ and ‘body areas’. A place
to write down doubts and suggestions was provided
for each one of these three parts. All of the partici-
pants were informed of the purpose of the research
study and the need to advise whenever a doubt
about the written information and structure of the
instrument emerged.
Evaluation of the reliability of
the questionnaire
The reliability was assessed by using the test–retest
method. This test consists of the application of the
questionnaire to the same subjects, under a similar
condition, in two or more situations (LoBiondo-
Wood & Haber 1998; Polit & Hungler 1995).
The questionnaire was applied to 40 individuals
from the university staff, chosen at random by the
systematic choice method. These individuals com-
prised four distinct groups, as follows: 10 under-
graduate nursing students; 10 professors from the
Nursing Department; 10 administrative employees
from the Medical Sciences School of the institution;
and 10 patients assisted by the physiotherapy service
at the Health Unit of the University. In order to be
part of the sample, certain criteria had to be met, such
as being adult, being literate, and being able to
understand verbal expressions and answers by mark-
ing the chosen answers. The selected subjects were
informed of the purpose of the research. Each
received two copies of the instrument, and they were
orientated to answer the first copy on the day when
the questionnaire was handed in and the second copy
on the next day, at the same time and under similar
conditions, without referring to the previous ques-
tionnaire. General data on the interviewee were also
collected, such as age, gender and educational status.
The data were entered and analysed by means of a
database (Microsoft Excel 2000 Professional; Pro-
gram Microsoft Map” 1995–98. MapInfo Cor-
poration, Troy, NY). The participants were
characterized by descriptive analysis. The Kappa
coefficient (k) was utilized for evaluation of test–
retest reliability. This coefficient has values ranging
104 E. N. C. de Barros & N. M. C.Alexandre
from -1 to +1. Values close to +1 indicate total
agreement between the two moments, while values
close to -1 indicate total discrepancy. Values higher
than 0.75 represent strong agreement and those
below 0.40 indicate poor agreement. Kappa coeffi-
cient values of 0.40–0.75 represent moderate agree-
ment (Fleiss 1981).
At first, agreement of all the answers of partici-
pants was evaluated according to the nine body
areas affected. Kappa coefficients concerning the
answers to the four questions were also evaluated,
without considering pain location.
Ethical aspects
The protocol received the approval of the Ethics
Committee for Research of the Medical Sciences
School of UNICAMP with the number 073/2001.
All the individuals who agreed to participate in each
phase of this study signed the informed consent
form.
Results
Reviewers’ committee
Analysis of the judges’ evaluations regarding equiv-
alency of the instrument demonstrated that there
was no need to modify its form and content. There-
fore, the instrument was maintained in the form
presented to this committee.
Pretest
After analysing the records of participants’ doubts
and suggestions, it was observed that there were
two ways of making it easier to understand how to
fill out the instrument. The first was to move the
question about weekly prevalence of the problem
to the end of the questionnaire, to facilitate the
temporal situation, so that the first three questions
refer to the last 12 months and the fourth question
refers to the last 7 days. The second was that the
word ‘doctor’ should be replaced by ‘health care
professional (doctor, physician)’, increasing the
options of the kind of assistance searched for in
© 2003 International Council of Nurses, International Nursing Review, 50, 101–108
view of the problem presented. These suggestions
were carefully analysed, and there was consensus
that they were viable and would make it easier to
understand the instrument. The final version is
shown in Fig. 1.
Analysis of instrument reliability
As regards the demographic characteristics of the
general group participating in this phase of the
study, it was verified that 75% (n = 30) were female
and 25% (n = 10) were male (mean age 36 years;
range 20–68 years). As for educational status, 10%
(n = 4) were at elementary school level (complete
and incomplete), 25% (n = 10) were at high school
or technical school level and 65% (n = 26) were at
college level (complete and incomplete).
It was also observed that 97.5% (n = 39) of the
participants had reported pain in some part of their
body during the last 12 months. The most common
region where pain occurred was the neck, as
reported by 67.5% (n = 27) of the participants. The
second most frequent complaint of pain was in the
shoulder region, reported by 55% (n = 22) of the
individuals. A total of 72.5% (n = 29) of the partici-
pants reported experiencing pain in the previous
7 days. The place where the symptoms occurred
most frequently was the shoulders, reported by 30%
(n = 12) of the subjects, followed by the low back, in
27.5% (n = 11).
Agreement among all the answers of participants
calculated by the Kappa coefficient, according to the
region of the body involved, is shown in Table 1.
According to Kappa values, 32 of the 36 items that
comprise the instrument obtained a value of at least
0.75, with seven items obtaining a score equal to 1.
The other four items reached a Kappa value of
between 0.48 and 0.72. This result demonstrates a
good reliability of the instrument being studied.
The level of agreement between the two temporal
moments was also calculated for each answer of the
four questions, independently of pain location. The
question on annual prevalence obtained a Kappa
value of 1 and the one on weekly prevalence, a
Kappa coefficient value of 0.88. The question on
interference on normal activities had a Kappa coef-
ficient value of 0.93 and the one on search for assis-
Nordic musculoskeletal questionnaire adaptation 105

Fig. 1 Standardized Nordic Questionnaire. (a) version in English; (b) translated version in Portugese.

tance from a health professional, a Kappa coefficient
value of 1.
Discussion
Because musculoskeletal symptoms represent an
acknowledged public health problem, researchers
have developed scales and questionnaires to evalu-
ate the functional capability, location and intensity
of pain, quality of life and social aspects of patients
with such symptoms. However, most of these
instruments have been developed and validated in
the English language. Several Brazilian researchers
(Ciconelli et al. 1999; Ferraz et al. 1990; Kimura

© 2003 International Council of Nurses, International Nursing Review, 50, 101–108

106 E. N. C. de Barros & N. M. C.Alexandre

Table 1 The Kappa agreement coefficient for each answer in the questionnaire

Location of Question
the pain
Have you at any During the last 12 During the last 12 Have you had
time during the months have you months have you trouble during the
last 12 months been prevented seen a physician last 7 days?
had trouble from carrying out for this condition?
(such as ache, normal activities
pain, discomfort, (e.g. job, housework,
numbness)? hobbies) because
of this trouble?

Neck 0.83 0.91 1 0.78

Shoulders 0.85 0.89 0.83 0.76
Upper back 0.89 1 1 0.63
Elbows 1 0.84 0.89 0.48
Wrists/hands 0.78 0.89 0.89 0.80
Lower back 0.75 0.88 0.72 0.82
Hips/thighs 0.83 0.79 0.64 1
Knees 0.84 0.91 0.93 0.78
Ankles/feet 0.90 1 0.84 1

1999; Pimenta & Teixeira 1997; Riberto 2001;
Sawada et al. 1998) have carried out adaptations of
important instruments.
The current study presents a cultural adaptation
of the general portion of a version of the ‘Stan-
dardized Nordic Questionnaire’ instrument, fol-
lowing internationally respected methodological
procedures. This questionnaire is internationally
validated and respected, having been used in the
assessment of musculoskeletal symptoms world-
wide, as well as for evaluating these symptoms
with an ergonomic approach in different occupa-
tional groups (Anderson et al. 1987; Björkstén
et al. 1999; Josephson et al. 1997; Ramel & Moritz
1994). The method conducted permitted the
acquisition of an easily understood version in
Brazilian Portuguese.
As a result of the pilot study it was possible to
effect an alteration in the order of questions related
to the annual and weekly prevalence of pain. With
this alteration, the questionnaire returned to its
original construct (Kuorinka et al. 1987).
In order to evaluate reliability, agreement among
the answers of participants was verified on two dif-
ferent occasions. Initially, the Kappa coefficient was
calculated separately, according to the body area
affected and the four questions that comprise this
questionnaire. The question on the annual preva-
lence of pain presented Kappa coefficients that
varied (according to the body area) between 0.83
and 1, which was considered an excellent result.
As regards the incidence of pain in the last 7 days,
the results were also very good (0.63–1). Only in
the elbow area did the Kappa coefficient present
moderate agreement (0.49). This result can be
explained by the variables that may have an influ-
ence when procedures of the reliability test–retest
kind are used. The problems that may occur, inde-
pendently of the stability of the instrument, are
that some aspects change with time. Furthermore,
the participants may object to being approached
twice, answering carelessly in the second instance,
resulting in a misleadingly low estimate of stability
(Polit & Hungler 1995). The question that evalu-
ates interference of musculoskeletal symptoms in
performing daily activities presented strong agree-
ment, which varied from Kappa = 0.78 to Kappa =
1. Agreement among the answers with reference to
the search for assistance from a health professional
was also very good (0.64–1).

© 2003 International Council of Nurses, International Nursing Review, 50, 101–108

Nordic musculoskeletal questionnaire adaptation
The analysis of each question separately, without
considering pain location, demonstrated that all the
questions obtained very good agreement (0.88–1).
In the original version of the questionnaire, when
evaluating its reproducibility Kuorinka et al. (1987)
found a rate of non-identical answers that varied
between 0 and 23%. Dickinson et al. (1992), when
applying the questionnaire to cashiers of a super-
market, on two occasions and with an interval of
1 week, found different answers that varied from 7
to 26% for the annual prevalence of pain, and from
6 to 19% for the weekly prevalence of pain. In the
case of the present study, we attempted to apply the
questionnaire at two points separated by a suffi-
ciently short interval so that the variable studied
would not undergo alteration. However, one must
remember that other factors may interfere when a
questionnaire is used.
It is important to emphasize that most of the par-
ticipants in the reliability assessment had a high
level of education (65% had a complete or incom-
plete college level education) and the questionnaire
was answered by the interviewee. New research
should be carried out using the instrument in inter-
views with illiterate individuals to evaluate its reli-
ability under these circumstances, extending the use
of this questionnaire for evaluation of musculoskel-
etal disorders to different populations.
Conclusion
The development of scales and questionnaires is a
complex procedure that involves high costs. The
international literature describes questionnaires
and specific scales used to evaluate musculoskeletal
disorders. These instruments are very important as
they provide standardized data. In order to ensure
the quality of adapted instruments it is recom-
mended that international norms are followed
when carrying out this process. The employment of
a methodology accepted by the scientific literature
permits comparison of the data obtained in differ-
ent languages.
The Brazilian Portuguese version of the Stan-
dardized Nordic Questionnaire, presented here, will
enable identification of musculoskeletal symptoms
© 2003 International Council of Nurses, International Nursing Review, 50, 101–108
107
in epidemiological studies. It may also be used as an
ergonomic instrument to analyse the work environ-
ment and equipment. The occupational health area
may evaluate large work environments in a reliable,
fast and economical manner. We believe that this
research study will not end here. It is recommended
that this questionnaire should be re-evaluated in
different occupational health settings (e.g. hospital,
industries), by a variety of populations (e.g. nurses,
workers).
Our conclusion is that the Brazilian Portuguese
version of the Standardized Nordic Questionnaire is
easily understood and quickly applied, offering sub-
stantial reliability.
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