Cross-Cultural Adaptation, Reliability, and Validity of Urdu Version of Örebro Musculoskeletal Pain Screening Questionnaire in Non-Specific Low Back Pain Patients
1Faculty of Rehabilitation and Allied Health Sciences, Riphah International University, Islamabad, Pakistan
2Department of Physiotherapy, Kulsum Institute of Health Sciences, Islamabad, Pakistan
3Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand
4Rehabilitation Sciences, Institute of Allied Health Sciences, Rawalpindi Medical University, Rawalpindi, Pakistan
5Biomedical Engineering and Sciences, Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand
Correspondence to: Imran Amjad Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland 1060, New Zealand. Tel: +64-2108906707 E-mail: imran.amjad@riphah.edu.pk
• Received: October 13, 2025 • Revised: December 12, 2025 • Accepted: January 5, 2026
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To translate the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) into Urdu and to determine the psychometric properties of its Urdu version.
Methods
This cross-sectional study recruited 300 participants (18–60 years) with non-specific low back pain (NSLBP), who were able to read Urdu. Test-retest reliability was assessed using intra-class correlation coefficient (ICC), and reproducibility through Cronbach’s α. Face and content validity were examined via individual interviews, and construct validity by correlating with relevant reference standards. Exploratory factor analysis (EFA) & confirmatory factor analysis (CFA) was also carried out
Results
ÖMPSQ was successfully translated into Urdu version with acceptable face and content validity. ÖMPSQ Urdu version showed acceptable internal consistency (α=0.789) & good test-retest reliability (ICC=0.784, 95% confidence interval, p<0.001) while good correlation was demonstrated between ÖMPSQ and Chronic Pain Grade Scale (pain and disability subscales i.e., r=0.809 and 0.807, respectively). However, Roland-Morris Disability Questionnaire showed moderate correlation (r=0.513). Additionally, no significant floor or ceiling effects were observed in the ÖMPSQ Urdu version. EFA revealed a five-factor solution using twenty items, 89.21% was the total item variance in the database, while CFA demonstrated good model fit with strong factor loadings and acceptable fit indices
Conclusion
The ÖMPSQ Urdu version is valid and reliable for assessing the risk of long-term disability & workplace absence in NSLBP patients.
Low back pain (LBP) is a frequent cause of discomfort and disability among adults. Although often perceived as a minor issue, it is, in fact, one of the leading causes of long-term disability worldwide [1]. In 2019, around 223.5 million people were affected from LBP with 63.7 million living with disability [2-4]. Although LBP is a global condition, the likelihood of experiencing it is high in individuals residing in low and middle income countries (LMICs). The increased burden in these regions may be attributed to limited health related resources, which are often insufficient to meet rising population needs. Additional contributing factors include high unemployment with low paying job, physically demanding work with associated psychological stresses, poor living conditions, and widespread myths and misperceptions about LBP. Furthermore, limited access to evidence based treatments, self-management without awareness of multidisciplinary rehabilitation approaches, and the interaction between overall health, workplace environment and social factors exacerbate the impact of LBP in these populations [3,5].
There is a growing emphasis on identifying specific causes of back pain through different pain trajectories, which enables targeted treatment and may help reduce the overall burden of the condition. In general, most people who experience back pain for the first time can recover quickly; however, recurrent episodes are common and can progress to chronic pain, resulting in prolonged disability, especially among the working population [6]. LMICs face more challenges regarding back pain, making its transition to chronicity especially devastating. This can create a vicious cycle of poverty, unemployment, loss of social identity, strained family and social relationships, psychological stress, and overall reduced quality of life [7].
LBP is a complex condition with multiple contributing factors, including psychosocial and psychological influences. Although pain and psychological problems are often associated, the precise nature of this relationship remains unclear. LBP carries significant medical, social, and financial implications [8]. Psychological distress can trigger physiological stress responses, and according to the cognitive activation theory of stress, feelings of helplessness or hopelessness, may produce prolonged stress responses that can ultimately lead to illness [9]. Regardless of the specific pathway, it is important to identify these psychological symptoms, commonly referred to as “yellow flags” in medical terminology. If left unrecognized and untreated, these yellow flags can cause significant disability, hinder effective treatment, and negatively impact the patients’ overall well-being [8,10].
To assess yellow flags associated with back pain, various assessment tools have been used, among which the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) is widely employed. The ÖMPSQ is a self-administered questionnaire designed to measure psychosocial risk factors [11]. A maximum score of 210 indicates high disability; scores below 105 indicate low disability [12]. The ÖMPSQ can assess most psychological factors that contribute to the development of chronic back pain, including depression, fear-avoidance behavior, coping strategies, pain-related disability, job satisfaction, and perceived risk of developing a chronic condition. Its format and concision make the ÖMPSQ a feasible tool for use in interventional studies [13].
Although the ÖMPSQ has been translated in multiple languages for cross-cultural adaptation, an Urdu version has not yet been developed. Therefore, the current study aimed to translate ÖMPSQ into Urdu language and evaluate the psychometric properties of the translated version for use in the Pakistani population. This adaptation will assist local physiotherapists and consultants in developing more individualized treatment plans and support research on back pain in this population.
METHODS
Ethical considerations
This study was approved by the Institutional Review Board Faculty of Rehabilitation & Allied Health Sciences, Riphah International University (approval number: RIPHAH/RCRS/REC/PhD/Letter-02384) and Clinical Trial Number (Clinicaltrials.gov) is NCT05111782. Written informed consent was taken individually from all participants keeping confidentiality of participants. All ethical principles were observed by not revealing personal information and identity was kept undisclosed. Each participant willingly participated in the research.
Design
In this study, a descriptive-analytical design was employed, in which the ÖMPSQ was first translated and then its reliability and validity were evaluated. Data were collected from clinical settings in Islamabad & Rawalpindi. A non-probability purposive sampling technique was used, and 300 participants were recruited. Inclusion criteria comprised male and female patients aged 18 years or older, diagnosed with non-specific low back pain for more than three months, and able to read and understand Urdu. Patients with neurological disorders, infections, tumours, prior spinal surgery, cognitive impairments, or rheumatologic diseases were excluded.
Phase I: translation and cross-cultural adaptation
The ÖMPSQ was translated into Urdu according to the guidelines of Beaton et al. [14]. In the first step, forward translation was performed by two translators whose native language was Urdu and who were highly proficient in English. These two translations were then merged into a single version. In the second step, backward translation was carried out by two translators whose native language was English and who were also proficient in Urdu; the Urdu version was translated back into English. In the third step, an expert committee reviewed all translations from the previous steps and developed a pre-final Urdu version of the ÖMPSQ. The committee included two researchers and three clinicians familiar with Pakistani culture to ensure cultural appropriateness. This pre-final version was tested on 10 patients with LBP across the study settings to evaluate comprehension and interpretation of each item. No issues were identified, and the expert committee finalized the version for use in the target population.
Phase II: psychometric testing
In this phase, the COSMIN Guidelines were followed [15] to evaluate the psychometric properties of the Urdu-translated version ÖMPSQ in the targeted population. The questionnaire was assessed across the following parameters:
Reliability/reproducibility
Test-retest reliability was determined by the administering the questionnaire to patients with LBP at baseline and again after 2 days. The intra-class correlation coefficient (ICC) was used to assess response stability. A total of 80 participants were included with an expected ICC of 0.95, and a 95% confidence interval (CI).
Internal consistency/homogeneity
Cronbach’s α value was used to determine the interrelation among different items within each domain. Values range from 0 to 1, with values greater than 0.75 being considered good [16].
Face/content validity
Face and content validity was evaluated by both the targeted population and subject matter experts through deep evaluation of the questionnaire’s content and structure [17]. The final Urdu version of the ÖMPSQ was reviewed to ensure clarity, relevance and comprehensibility for use by clinicians and physical therapists.
Construct validity
To assess construct validity, participants completed two additional questionnaires: Roland-Morris Disability Questionnaire (RMDQ) and pain and disability subscales of the Chronic Pain Grade Scale (CPGS). Associations between constructs were assessed using the Pearson correlation coefficient, interpreted as follows: minimal to mild (r=0.00–<0.30), low (r=0.30–<0.49), moderate (r=0.50–<0.69), high (r=0.70–<0.89), and excellent correlation (r=0.90–1.00) [18].
Floor/ceiling effects
Participants with the highest and lowest ÖMPSQ scores were assessed for floor and ceiling effects, & they were considered present if more than 15% of responses fell at the extremes.
Factor analysis
To clarify the underlying dimensions of the ÖMPSQ, exploratory factor analysis (EFA) using principal component analysis (PCA) was conducted. Items with factor loadings ≥0.50 were considered satisfactory. Confirmatory factor analysis (CFA) was then performed to validate the factor structure using chi-square/degrees of freedom ratio (CMIN/DF, χ2/df), goodness of fit index (GFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA) with 90% CIs to evaluate model fit for construct validity.
Assessment tools used in the study
ÖMPSQ
The ÖMPSQ is a self-administered questionnaire consisting of 25 items designed to measure psychosocial risk factors associated with musculoskeletal pain. Four items collect demographic information, while the remaining 21 items are scored to yield a total ranging from 4 to 210 [11]. This tool demonstrates high sensitivity (0.89), low specificity (0.46) and a moderate area under the curve (AUC=0.81) [13].
RMDQ
The RMDQ assesses perceived physical disability in patients with LBP [19]. Scoring varies depending on the version used; in general, scores of 0–11 indicate minimal to no disability, while scores of 18–24 reflect greater disability [20]. The 24-item version has shown variable test-retest reliability, with ICC ranging from 0.42 to 0.91, supporting its construct validity [21,22].
CPGS
The CPGS is a 7-item instrument designed to evaluate multiple dimensions of pain, including intensity (CPGS-I) and disability (CPGS-Ds). Using a recall period of 3–6 months, it categorizes patients into five grades: grade 0 (no pain) through grade IV (high disability with severe pain). All items are scored on an 11-point Likert scale from 0 to 10 [23].
Data collection procedure
At the first visit, participants completed the ÖMPSQ, RMDQ, and CPGS after providing informed consent. Patients continued to receive standard treatment for LBP during this interval.
Data analysis procedure
Data analysis was performed using IBM SPSS Statistics 20 (IBM Corp.). Statistical significance was set at p<0.05. Construct validity of the Urdu ÖMPSQ was assessed by examining correlations with the RMDQ and CPGS. Test-retest reliability was evaluated using ICC. Internal consistency and homogeneity of the instrument were determined using Cronbach’s α.
RESULTS
Descriptive statistics
Data was collected from 300 participants to evaluate the psychometric properties of the Urdu version of ÖMPSQ. The mean age of the participants was 49.34±14.47 years, comprising 148 males and 152 females.
Floor/ceiling effects
No significant floor or ceiling effects were observed.
Test-retest reliability
A randomly selected subset of 80 patients completed the questionnaire on two occasions. The ICC value was 0.784 (95% CI, p<0.001), exhibiting good test-retest reliability.
Internal consistency
Data was collected from 80 low back patients & consistent results were produced by Cronbach’s alpha. The Cronbach’s alpha was 0.789 (95% CI, p<0.001), demonstrating satisfactory internal consistency.
Face validity testing
No cultural ambiguity was identified. The Urdu version was accepted without objections by both patients and subject experts.
Construct validity
Pearson correlation was used to assess construct validity by correlating the score of the ÖMPSQ with the RMDQ, CPGS-I and CPGS-Ds. Results were r=0.513 (ÖMPSQ and RMDQ), r=0.809 (ÖMPSQ and CPGS-I), and r=0.807 (ÖMPSQ and CPGS-Ds), all with 95% CI and p<0.001.
Data analyses
Factor analysis was carried out using IBM SPSS (version 25) and AMOS (version 23) (IBM Corp.).
EFA
EFA was conducted to evaluate item performance within subscales and to determine the dimensionality of the scale. The process included:
1. Assessing dataset suitability.
2. Examining item loadings, with items removed if factor loadings were below 0.40 (early analysis) or 0.50 (final analysis).
3. Identifying and defining the factor structure.
Sampling adequacy was confirmed by a Kaiser–Meyer–Olkin coefficient of 0.887 and a significant Bartlett’s test of sphericity (χ2(231)=559.58, p<0.001). PCA was used to reduce dimensionality while maintaining variance. For the ÖMPSQ-Urdu, a five-factor solution was identified, explaining 89.21% of the variance. Factor extraction used Varimax rotation, with 0.50 as the criterion for cross-loadings and item retention
CFA
To obtain the simple structure item loadings (Pattern Matrix), multiple iterations of EFA were performed on the data, with each execution focusing on specific variables. CFA was then employed to validate the factor structure identified earlier. The values from the Pattern Matrix were used to construct a model in AMOS (Fig. 1).
In the CFA path model (Fig. 1), all observed variables demonstrated strong factor loadings, with values exceeding 0.50. However, the factor loading for Q24 (an observed variable) exceeded 1.00, so it was excluded from the model to improve the model fit.
Several fit indices were examined to assess the model’s goodness-of-fit. The indices included standardized root mean square residual, CFI, RMSEA, Tucker-Lewis index (TLI), and normed fit index (NFI) explained in Table 1. These fit indices confirmed that the CFA model exhibits a good fit to the data, with the exception of a few values that are considered acceptable. The indices suggest that the model’s structure is robust, supporting the validity of the factor structure.
In order to assess the model’s fit, several baseline comparison indices were examined, including the NFI, relative fit index, incremental fit index, TLI, and CFI. The goodnessof-fit indices root mean square residual and GFI were also assessed to evaluate the model fit. The results are shown in Table 2.
DISCUSSION
This study is the first to translate ÖMPSQ into Urdu language and evaluate its psychometric properties. This Urdu version demonstrated appropriate face and content validity, with no unnecessary items identified. The internal consistency of the Urdu translated version of ÖMPSQ is highly satisfactory (Cronbach’s α=0.789, 95% CI). Test–retest reliability was also good, with an ICC of 0.784 (95% CI, p<0.001).
In the current study, it was found that there is sufficient intra rater reliability of ÖMPSQ Urdu version (0.784 with 95% CI). These results align with other translated versions such as Arabic (ICC=0.92, 95% CI 0.83 to 0.96) [24], Chinese (ICC=0.814, 95% CI 0.627 to 0.913) [25], Greek (ICC=0.964, 95% CI 0.91 to 0.985) [26] and Persian version (ICC=0.89, 95% CI 0.70 to 0.93) [27].
The internal consistency of the ÖMPSQ was found to be 0.789 (95% CI) for Urdu Version. This aligns closely with findings from other translated versions, including the Chinese version (0.843, 95% CI) [25], the Greek version (0.76, 95% CI) [26] and the Persian version (0.71, 95% CI) [27], supporting its suitability as a culturally adapted tool for assessing back pain.
A moderate correlation was observed between the ÖMPSQ and RMDQ while the ÖMPSQ and the CPGS indicated satisfactory construct validity. Pearson correlation coefficients showed values of r=0.513 for the ÖMPSQ and RMDQ, r=0.809 for the ÖMPSQ and CPGS-I, and r=0.807 for the ÖMPSQ and CPGS-Ds. These results demonstrated moderate to high correlations (r≥0.5) with measures of pain, disability, and fear avoidance. These findings are consistent with those of the Persian version which demonstrated high correlations with other pain assessment tools such as the Pain Disability Questionnaire (r=0.72) [27]. Similarly, the Chinese version of the ÖMPSQ showed good correlations with the numeric pain rating scale, RMDQ, and Tampa Scale of Kinesiophobia-HK. The highest correlation coefficients in the Chinese version were found between the ÖMPSQ-HK and RMDQ-HK (r=0.525) and between the ÖMPSQ-HK and Neck Pain Questionnaire-HK (r=0.697) supporting results of the current study [25].
Likewise, in the Finnish version, strong associations were reported between the ÖMPSQ and both pain intensity and the Oswestry Disability Index, with regression coefficients of β=0.58 and β=0.69, respectively [28]. In line with these findings, the current study also found strong correlations when comparing the Urdu-translated ÖMPSQ with the pain and disability subscales of the CPGS (r=0.809 for ÖMPSQ and CPGS-I; r=0.807 for ÖMPSQ and CPGS-Ds).
In the CFA path model, all observed variables showed good factor loadings above 0.50, confirming their contribution to the construct. The Default Model demonstrated an acceptable fit (CMIN/DF=3.793, RMR=0.138, GFI=0.878), while the Saturated Model achieved perfect fit indices. Overall, these findings indicate that the proposed model provides a satisfactory representation of the Urdu ÖMPSQ.
These results align with earlier validation studies. For example, in the Finnish version, two items (Q5 and Q7) were removed as they did not load onto any factor [28], while another study also reported similar outcomes with their EFA (RMSEA=0.05), where Q7 was excluded, leaving four meaningful factors. These factors were related to pain, fear-avoidance behavior, and limitations in daily activities. The consistency of findings across different cultural adaptations strengthens the validity of the Urdu ÖMPSQ and supports its structural reliability for assessing psychosocial aspects of LBP [29].
Similarly, in the Hausa version of the ÖMPSQ, all items demonstrated sufficient factor loadings, with analyses showing that this version achieved some of the best fitting values compared with other translated versions, although the variance was higher than that of the English version [30]. The findings of the current study also confirm that the Urdu version is effective for assessing psychosocial risk factors and identifying yellow flags in populations where Urdu is the primary language. However, since psychosocial responses can vary across cultural contexts, further studies are needed to confirm its applicability in other Urdu-speaking populations. Overall, the validity and reliability results of the Urdu ÖMPSQ align closely with the original tool, supporting its use as a psychometrically sound instrument for the Urdu-speaking population.
Strengths and limitations
A key strength of this study is that it is the first to translate and validate the ÖMPSQ in Urdu, with data collected from multiple clinical sites to enhance generalizability. A key limitation of this study is that both EFA and CFA were conducted on the same sample, which reduces the confirmatory strength of the CFA. Thus, future research should validate the factor structure using an independent sample. Another limitation is that the study was conducted on a single population, without accounting for broader variations in psychosocial stressors that may influence patient responses across different settings. It is therefore recommended that future research test the Urdu ÖMPSQ in diverse Urdu-speaking populations globally to further confirm its reliability and validity.
Conclusion
The Urdu version of the ÖMPSQ demonstrated good face, content, and constructs validity, as well as strong test–retest reliability and internal consistency. This culturally adapted version is suitable for clinical practice and research in assessing non-specific LBP in Urdu-speaking populations. Further studies are recommended to explore its psychometric properties in varied healthcare environments and confirm its utility through additional exploratory and confirmatory factor analyses.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
None.
AUTHOR CONTRIBUTION
Conceptualization: Naeem A, Amjad I. Methodology: Naeem A, Amjad I. Formal analysis: Umar M, Niazi IK. Project administration: Naeem A. Visualization: Naeem A, Amjad I. Writing – original draft: Naeem A. Writing – review and editing: Glucina T, Niazi IK. Approval of final manuscript: all authors.
ACKNOWLEDGMENTS
Author is thankful to everyone who helped in the completion of the study.
The study is a part of PhD dissertation project & received no support in the form of grants, equipment, drugs, or all of these.
Fig. 1.
Confirmatory factor analysis pathway model.
Table 1.
Goodness-of-fit model measures
Measure
Estimate
Threshold
Interpretation
CMIN
356.507
--
--
DF
94
--
--
CMIN/DF
3.793
Between 1 and 3
Acceptable
CFI
0.949
>0.95
Acceptable
SRMR
0.049
<0.08
Excellent
RMSEA
0.067
<0.06
Acceptable
TLI
0.935
>0.95
Acceptable
NFI
0.932
>0.95
Acceptable
CMIN, chi-square; DF, degrees of freedom ratio; CFI, comparative fit index; SRMR, standardized root mean square residual; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis index; NFI, normed fit index.
Table 2.
Baseline comparison of different indices for model’s fit
Model name
Value
Root mean square residual (RMR)
0.138
Goodness of fit index (GFI)
0.878
Normed Fit Index (NFI)
0.932
Relative fit index (RFI)
0.913
Incremental fit index (IFI)
0.949
Tucker-Lewis index (TLI)
0.935
Comparative fit index (CFI)
0.949
Root mean square error of approximation (RMSEA)
0.067
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Cross-Cultural Adaptation, Reliability, and Validity of Urdu Version of Örebro Musculoskeletal Pain Screening Questionnaire in Non-Specific Low Back Pain Patients
Cross-Cultural Adaptation, Reliability, and Validity of Urdu Version of Örebro Musculoskeletal Pain Screening Questionnaire in Non-Specific Low Back Pain Patients
Measure
Estimate
Threshold
Interpretation
CMIN
356.507
--
--
DF
94
--
--
CMIN/DF
3.793
Between 1 and 3
Acceptable
CFI
0.949
>0.95
Acceptable
SRMR
0.049
<0.08
Excellent
RMSEA
0.067
<0.06
Acceptable
TLI
0.935
>0.95
Acceptable
NFI
0.932
>0.95
Acceptable
Model name
Value
Root mean square residual (RMR)
0.138
Goodness of fit index (GFI)
0.878
Normed Fit Index (NFI)
0.932
Relative fit index (RFI)
0.913
Incremental fit index (IFI)
0.949
Tucker-Lewis index (TLI)
0.935
Comparative fit index (CFI)
0.949
Root mean square error of approximation (RMSEA)
0.067
Table 1. Goodness-of-fit model measures
CMIN, chi-square; DF, degrees of freedom ratio; CFI, comparative fit index; SRMR, standardized root mean square residual; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis index; NFI, normed fit index.
Table 2. Baseline comparison of different indices for model’s fit
, Tanja Glucina, PhD3
