Disability & Rehabilitation, 2012; 34(11): 934942

2012 Informa UK, Ltd.

ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2011.628436

Research Paper

An initial factor analysis of prominent aspects of health experiences for

women with neck-shoulder pain
Birgitta Wiitavaara1, Martin Bjrklund13 & Annika Nilsson4,5
1

Centre for Musculoskeletal Research, Department of Occupational and Public Health Sciences, Faculty of Health and
Occupational Studies, University of Gvle, Gvle, Sweden, 2Alfta Research Foundation, Alfta, Sweden, 3Department of
Community Medicine and Rehabilitation, Physiotherapy, Ume University, Ume, Sweden, 4Department of Health and Caring
Sciences, Faculty of Health and Occupational Studies, University of Gvle, Gvle, Sweden, and 5Department of Public Health
and Caring Sciences, Uppsala University, Uppsala, Sweden

Implications for Rehabilitation

Purpose: The prospect of adequate comparisons is essential to

decide on the effectiveness of different treatments. As there is a
lack of unity in choice of questionnaires and included measures
concerning musculoskeletal disorders, further investigations
based on international recommendations are of interest. The
intention of present study was to initiate the development of
a clinically useful short-form questionnaire. The aim was to
select items that capture prominent health aspects for women
with neck-shoulder pain and thereby reduce the number of
items to a clinically more convenient amount, and to determine
the underlying structure of included items. Method: Data were
collected in a randomised controlled trial including women
with non-specific neck-shoulder pain >3 months (n=117). Data
collection included three core domains: pain intensity, physical
and emotional functioning, and analysis was performed using
Principal component analysis, and Varimax rotation. Results:
The resulting 9-factor solution included interference, solicitous/
distracting responses, mood and feelings about self and
relations, pain intensity, punishing responses, personal growth,
life control, sleep, and appetite (29 items). Conclusions: The
results will contribute to the development of a reduced battery
of questions representing core dimensions. Such questionnaire
would lighten the assessment load in the clinic as well as in
research.

Despite the call for multidimensional evaluation of

MSDs, measurement is often reduced to pain and
disability.
A lack of unity in choice of outcome measures limits the possibilities for comparisons and hinders the
development of effective treatment methods.
International recommendations regarding outcome
measures can serve to unify evaluation.
This study presents the first step in the development
of a short-form questionnaire for evaluation of neckshoulder pain, based on international recommendations for clinical evaluation of pain conditions
perspectives. As a bio-psycho-social direction [1] in rehabilitation is recommended [2], multidimensional evaluations
are to prefer. However, regarding neck-shoulder symptoms,
measurement is often reduced to pain and disability, which
have low correspondence to the spectrum of symptoms experienced by those affected [3]. There are several reliable and
valid questionnaires available for measurement of symptoms
related to MSDs, but there is no consensus regarding which
of them to use and in what combinations. This lack of unity
in choice of outcome measures limits the possibility for comparisons between individuals, as well as groups, which in turn
hinders the development of effective treatment methods [2].
Four core domains has been presented as relevant to
include in clinical pain trials; pain intensity, physical functioning, emotional functioning, and general improvement
[47]. Valid and reliable questionnaires for measurement
of the different domains have also been recommended [7].

Keywords: Factor analysis, health experiences, neck,

outcome measures, pain, questionnaires, shoulder,
women

Background
Musculoskeletal disorders (MSDs) are complex phenomena
that, to be fully understood, require knowledge from different

Correspondence: Birgitta Wiitavaara, Centre for Musculoskeletal Research, Department of Occupational and Public Health Sciences, Faculty of Health
and Occupational Studies, University of Gvle, SE-801 76 Gvle, Sweden. Tel: +46 (0) 26 648405. Fax: +46 (0) 26 648686. E-mail: biawia@hig.se
(Accepted September 2011)

934

Analysis of prominent aspects with neck-shoulder pain 935

However, to answer several questionnaires is time-consuming
and the large number of questions increases the burden on
patients and may also increase the risk of omission of answers.
A reduced assessment battery that corresponds to the aspects
of health of importance for different musculoskeletal disorders would lighten the assessment load in the clinic, as well
as in research.
Hence, the intention of present study was to take the first
step in the development of a clinically useful short-form
questionnaire, based on valid and reliable outcome measures that have been recommended for treatment evaluation.
Specifically, the aim of the study was to select items from the
outcome measures that capture prominent health aspects for
women with neck-shoulder pain and thereby reduce the number of items to a clinically more convenient amount, and to
determine the underlying structure of included items.

Methods
Design
This cross-sectional study is based on data from a baseline
measurement, collected in a randomised controlled study
(RCT: ISRCTN trial registration number 92199001) of neckshoulder treatment among women during 2008 in Sweden.
The study was approved by the regional ethical review board
in Uppsala (D-nr. 2007-206).
Sample
The sample consisted of 117 participants, all female, (mean
age 51.3; range 2565; SD 8.8), with non-specific neckshoulder pain. We define non-specific neck-shoulder pain
as pain in the neck and surrounding tissues. This includes
pain from the neck/shoulder muscles, but not complaints
related to the gleno-humeral joints. The sample constituted
a convenience sample for an initial factor analysis, as they
were recruited for a RCT-study with specific aims focusing
women with neck-shoulder pain. The participants reported
pain durations of at least 3 months (mean duration 139
months; range 6456; SD 95.5). Women with fibromyalgia,
whiplash or other concurrent chronic disease were excluded
(for further information on criteria for inclusion/exclusion,
turn to the study protocol http://www.controlled-trials.com/
ISRCTN92199001).
Measures
The starting point for the selection of outcome measures was
the recommended four core domains [7]: (1) pain intensity,
(2) physical functioning, (3) emotional functioning and (4)
general improvement. However, the recommended measure
for the domain general improvement, the Patient Global
Impression of Change Scale [8] is only administered after
treatment and was therefore excluded. The recommended
outcome measures for the remaining three domains are (1)
a numeric rating scale (NRS), (2) the Brief Pain Inventory
[9] or the Multidimensional Pain Inventory; MPI [10] (3)
the Beck Depression Inventory (BDI) [11,12] or the Profile
of Mood States (POMS) [13]. For details on selected outcome
measures, see below.
2012 Informa UK, Ltd.

Pain intensity and physical functioning

The MPI Swedish version (MPI-S [14]) was developed from
the West Haven-Yale Multidimensional Pain Inventory [10].
MPI-S includes two sections and a total of 34 questions.
Section one (22 items) consists of five subscales: pain severity, interference, life control, affective distress, and support.
Section 2 (12 items) consists of three subscales regarding
responses from significant others: punishing, solicitous and
distracting responses. Each item has a seven-point response
scale between 0 (no, not at all) and 6 (yes, very much). One
question (no 6 in part 1) has to be recoded in reverse to correspond to the scaling of all other questions. We chose to use
MPI-S also for measurement of pain intensity, as it includes a
NRS to measure pain intensity in two time perspectives.
Emotional functioning
For measurement of negative aspects of emotional functioning an alternative questionnaire, compared to those recommended by the Initiative on Methods and Measurement in
Clinical Pain Trials (IMMPACT [7]), was chosen. Comparing
the content of BDI and POMS, BDI was judged to be the most
suitable for this sample. However, the final, alternative choice
fell on the Montgomery-sberg Depression Scale (MADRS-S
[15]). It has the same qualities as the BDI with respect to its
ability to differentiate between different diagnoses and sensitivity to change [16], and we considered MADRS-S a favourable
choice since it can be used free of charge. MADRS-S request
people to rate their last 3 days core symptoms of depression in
nine items (mood, anxiety, sleep, appetite, ability to concentrate, ability of initiative, emotional commitment, pessimism
and vitality). Each item is scored from 0 (none at all) to 6
(maximum), with a maximum total score of 54. Reduction in
score reflects symptom improvement.
Normally, depression scales are used for measurement
of emotional functioning. However, positive aspects of
psychological health has been actualised and also linked to
biological processes and biomarkers [1720]. Enjoyment of
life and emotional well-being have, in addition to pain reduction, been appraised as the most important aspects of health
among people with chronic pain [6]. Psychological wellbeing, rather than specific somatic symptoms, has also been
found to influence peoples care-seeking for neck-shoulder
pain [21]. Efforts to balance illness and wellness have been
described as significant for the overall experience of health
among people with MSDs [22,23]. Thus, the inclusion of a
well-being questionnaire may give information about health
promoting aspects by capturing positive aspects of emotional
functioning. Hence, in order to make the assessment of the
emotional functioning domain more thorough we decided
to complement this domain with the short form of the Ryff
Psychological Well-being Scale (RPWS [17,18,2427]). The
questionnaire consists of 18 items, six subscales with three
items each: self-acceptance, positive relations with others,
autonomy, environmental mastery, purpose in life and personal growth [25]. The items are phrased as statements, such
as I like most aspects of my personality and The past had
its ups and downs, but in general, I wouldnt want to change
it. The answers are given on a response scale between 1 (very

936 B. Wiitavaara etal.

strongly disagree) and 6 (very strongly agree). The answers
for some questions (no. 7, 9, 11, 32, 42, 55, 65, 76) have to be
recoded so that high scores correspond to high well-being for
all items.

Statistical analyses
All analyses were performed using PASW statistics for
Windows 18.0 (SPSS). Initially Cronbachs was calculated
to determine the internal consistency of the instruments total
and subscale scores (Table I).
Thereafter a factor analysis was performed in two steps,
using principal component analysis (PCA) for extraction and
orthogonal Varimax rotation with Kaiser normalisation to
clarify factor structure. The two step procedure was chosen
to get an acceptable subject-to-variable ratio in the analysis.
Kaiser-Meyer-Olkin measure of sampling adequacy (KMO)
and Bartletts test were used to determine the adequacy of
performing a factor analysis on the selected data (Table II).
The KMOs were satisfactorily above 0.70 [28], and Bartletts
test showed significant results for all three questionnaires
(p <0.05).
Table I. Reliability of the questionnaires (n=117).

Questionnaire
MPI-S overall score
MPI-S pain intensity
MPI-S interference
MPI-S life control
MPI-S affective distress
MPI-S support
MPI-S responses
from significant others:
punishing
MPI-S responses
from significant others:
solicitous
MPI-S responses
from significant others:
distracting
MADRS-S overall
score
RPWS overall score
RPWS environmental
mastery
RPWS self-acceptance
RPWS positive
relations
RPWS purpose in life
RPWS personal growth
RPWS autonomy

Valid cases Cronbachs Item means Range

99
117
102
117
117
117
112

0.86
0.87
0.95
0.77
0.79
0.86
0.82

2.37
3.08
2.03
3.71
2.19
3.21
0.86

3.84
0.36
1.67
1.29
0.37
0.27
0.47

112

0.85

2.36

1.72

112

0.75

2.53

0.82

115

0.77

1.05

1.85

116
117

0.79
0.57

4.46
4.61

1.39
0.10

116
116

0.74
0.61

4.47
4.62

1.02
0.84

117
117
116

0.35
0.61
0.58

4.46
4.49
4.12

1.33
1.10
0.42

MADRS-S, Montgomery sberg Depression Rating Scale; MPI-S, Multidimensional

Pain Inventory; RPWS, Ryff s Psychological Well-being Scale.

Table II. Sampling adequacy (n=117).

Questionnaire
MPI-S
MADRS-S
RPWS

Kaiser-Meyer-Olkin (KMO) Bartletta

0.813
0.797
0.742

0.000
0.000
0.000

MPI-S: Multidimensional Pain Inventory- Swedish version: MADRS-S: Montgomery sberg Depression Rating Scale, RPWS: Ryff s Psychological Well-being Scale.
(ap<0.05).

During factor analysis, an Eigenvalue >1 and Scree plot

were used to determine the number of factors to extract, as
recommended for PCA [29]. Three possible levels of factor
loadings were considered throughout the analysis, alternatively 0.70, 0.60 or 0.50. The logic of the factor structure and
coverage regarding included items in each factor were also
judged when selecting level of factor loadings.
Initially, PCAs using an orthogonal Varimax rotation were
performed on each questionnaire separately. Thereafter, items
with a factor load 0.70 in the separate factor analysis of the
three questionnaires were selected for a joint factor analysis,
also using an orthogonal Varimax rotation. The factor load
level was set high, compared to the recommended cut point
of 0.30 or 0.40 [30], as a reduction of items was intended. In
the results of the joint factor analysis, a comparison between
a selection of items with factor loads over 0.50, 0.60 and 0.70
was made, where the 0.60 selection was judged as the most
appropriate. The resulting factors were labelled according to
content. When only items from one subscale of the original
questionnaire were included in the factor, the original subscale name was used. A descriptive label was used when items
from several subscales and/or questionnaires were included in
the same factor [30].

Results
Factor analysis
In the separate PCA of MPI-S seven factors were extracted
that explained 70.8% of the variance. The PCA of MADRS-S
resulted in a 3-factor solution, which explained 63.2% of the
variance, whereas the PCA of RPWS suggested a 5-factor
solution explaining 61.2% of the variance. The 36 items that
had a factor loading of 0.70 or more in the separate PCAs
were thereafter included in a joint PCA with Varimax rotation. The results suggested a 9-factor solution including items
that explained 68.9% of the variance. The component matrix
before rotation is presented in Table III, the rotated component matrix and communalities are presented in Table IV and
the total variance explained in Table V.
Items and factor structure of the 9-factor solution including 29 items loading 0.60 are shown in table VI. The resulting factors were; interference (of pain) (1), solicitous and
distracting responses from significant others (2), mood and
feelings about self and relations (3), pain intensity (4), punishing responses from significant others (5), personal growth
(6), life control (7), sleep (8) and appetite (9) (for details see
Table VI).

Discussion
The intention of the study was to take the first step in the
development of a clinically useful short-form questionnaire
for measurement of musculoskeletal symptoms, based on
recommendations on valid and reliable outcome measures.
According to the final factor analysis, the short-form questionnaire should constitute of nine factors (in all 29 items)
measuring four domains; pain intensity, physical functioning,
Disability & Rehabilitation

Analysis of prominent aspects with neck-shoulder pain 937

Table III. Component matrix before rotationa.

1
mpiP1Q4b
mpiP1Q10
mpiP1Q21
mpiP1Q8
mpiP1Q12
mpiP1Q3
mpiP1Q2
mpiP1Q19
mpiP1Q17
mpiP1Q9
mpiP1Q20
mpiP1Q7
mpiP1Q15
rpwsFinalf55
rpwsFinalf7
madrsQ8
mpiFinalP1Q6
mpiP2Q1
mpiP2Q11
mpiP2Q6
mpiP2Q10
mpiP2Q4
mpiP2Q12
madrsQ7
madrsQ9
rpwsFinalQ65
rpwsFinalQ76
rpwsQ28
mpiP1Q1
mpiP2Q5
mpiP2Q8
mpiP1Q16
rpwsQ80
rpwsFinalQ11
madrsQ4
madrsQ3

0.859
0.836
0.810
0.790
0.763
0.756
0.750
0.741
0.687
0.665
0.630
0.594
0.500
0.487
0.481
0.472
0.435
0.102
0.148
0.061
0.053
0.171
0.179
0.429
0.374
0.155
0.128
0.140
0.501
0.306
0.154
0.282
0.101
0.075
0.189
0.235

2
0.032
0.193
0.070
0.130
0.080
0.132
0.132
0.133
0.114
0.173
0.333
0.010
0.212
0.300
0.360
0.188
0.417
0.795
0.747
0.741
0.734
0.723
0.681
0.084
0.296
0.211
0.300
0.316
0.012
0.318
0.144
0.131
0.167
0.268
0.012
0.036

3
0.253
0.098
0.142
0.177
0.075
0.185
0.256
0.215
0.229
0.186
0.035
0.290
0.220
0.329
0.371
0.358
0.174
0.207
0.345
0.185
0.278
0.322
0.375
0.585
0.497
0.477
0.421
0.076
0.241
0.321
0.413
0.079
0.058
0.095
0.168
0.076

4
0.013
0.167
0.077
0.290
0.003
0.090
0.024
0.217
0.190
0.268
0.208
0.314
0.179
0.264
0.198
0.245
0.336
0.021
0.056
0.129
0.112
0.008
0.023
0.012
0.010
0.024
0.340
0.508
0.397
0.214
0.331
0.086
0.440
0.041
0.131
0.091

Component
5
0.013
0.102
0.132
0.009
0.122
0.106
0.197
0.089
0.230
0.081
0.120
0.483
0.064
0.242
0.064
0.356
0.218
0.048
0.045
0.127
0.032
0.025
0.019
0.087
0.159
0.270
0.225
0.092
0.561
0.483
0.452
0.211
0.024
0.089
0.104
0.127

6
0.048
0.117
0.174
0.073
0.167
0.052
0.187
0.061
0.009
0.004
0.120
0.086
0.348
0.029
0.129
0.069
0.078
0.061
0.019
0.060
0.074
0.073
0.212
0.074
0.054
0.160
0.086
0.253
0.045
0.324
0.360
0.602
0.494
0.316
0.361
0.070

7
0.018
0.026
0.085
0.031
0.135
0.114
0.057
0.148
0.243
0.005
0.196
0.123
0.070
0.077
0.189
0.175
0.315
0.145
0.102
0.086
0.199
0.132
0.075
0.076
0.159
0.125
0.349
0.419
0.016
0.273
0.098
0.054
0.059
0.612
0.025
0.323

8
0.048
0.022
0.038
0.019
0.164
0.024
0.106
0.126
0.032
0.073
0.017
0.017
0.088
0.063
0.023
0.095
0.071
0.131
0.034
0.048
0.124
0.023
0.017
0.191
0.241
0.353
0.329
0.171
0.041
0.063
0.398
0.103
0.002
0.101
0.690
0.307

9
0.002
0.122
0.152
0.116
0.089
0.011
0.040
0.013
-0.080
0.324
0.313
0.073
0.137
0.182
0.016
0.123
0.132
0.117
0.015
0.130
0.256
0.073
0.036
0.118
0.013
0.069
0.037
0.332
0.241
0.007
0.046
0.175
0.167
0.279
0.293
0.463

Extraction method: principal component analysis.

a9 components extracted.
bmadrs, Montgomery sberg Depression Rating Scale; mpi, Multidimensional Pain Inventory- Swedish version; P, part of questionnaire; Q, question number; rpws, Ryff s Psychological Well-being Scale.

emotional functioning and an additional domain which

we have labelled support. The support domain (regarding
responses from significant others) can be beneficial to complement measurement with, as it is a relevant aspect of life in
all long-term illnesses [31].
The data were analysed by means of a PCA analysis, with
varimax rotation. No assumption about any underlying structure was made before analysis, nor was it embedded in the
analysis [32]. Nevertheless, the results show a factor structure
that was quite consistent with the original subscales of the
included questionnaires. For example, factor 4 includes MPIs
two items about pain intensity and factor 1 constitutes of ten
items from MPIs interference scale. In total, six of the nine
factors included only items corresponding to one original
questionnaire subscale. Regarding the remaining three factors,
2012 Informa UK, Ltd.

(2, 3 and 8) each included items from two or three different

questionnaire subscales (Table VI).
Which are the prominent health aspects that can be captured with the selected items?
Two items, addressing different temporal aspects of pain,
were selected for the domain pain intensity. To estimate pain
at present as well as in the near past increases the possibility to
depict the variability of pain, which appears to be an important characteristic of chronic neck-shoulder problems [33].
Ten items regarding interference of pain corresponds to
physical functioning. A point to consider is whether interference of pain measure physical function per se, or if it is a
measure of consequences of physical dysfunction. Not that the
consequences of physical dysfunction are unimportant, but in
some cases, for example when evaluating physical therapy, it

938 B. Wiitavaara etal.

Table IV. Rotated component matrixa.

1
mpiP1Q10b
mpiP1Q8
mpiP1Q4
mpiP1Q9
mpiP1Q19
mpiP1Q17
mpiP1Q21
mpiP1Q12
mpiP1Q2
mpiP1Q3
mpiP2Q10
mpiP2Q1
mpiP2Q11
mpiP2Q4
mpiP2Q12
mpiP2Q6
mpiFinalP1Q6
rpwsFinalQ55
rpwsFinalQ7
madrsQ8
madrsQ9
mpiP1Q20
madrsQ7
mpiP1Q1
mpiP1Q7
mpiP2Q8
mpiP2Q5
rpwsFinalQ65
rpwsQ28
rpwsQ80
rpwsFinalQ76
mpiP1Q16
mpiP1Q15
rpwsFinalQ11
madrsQ3
madrsQ4

0.858
0.853
0.800
0.798
0.794
0.786
0.762
0.729
0.695
0.678
0.023
0.120
0.147
0.122
0.104
0.013
0.125
0.222
0.165
0.188
0.128
0.380
0.152
0.267
0.412
0.023
0.139
0.055
0.081
0.072
0.048
0.095
0.233
0.041
0.175
0.037

2
0.169
0.075
0.059
0.066
0.087
0.020
0.090
0.068
0.096
0.107
0.818
0.810
0.805
0.802
0.789
0.772
0.193
0.086
0.092
0.065
0.008
0.177
0.203
0.025
0.028
0.028
0.149
0.024
0.155
0.062
0.029
0.022
0.028
0.154
0.005
0.071

3
0.200
0.063
0.252
0.008
0.118
0.078
0.296
0.276
0.020
0.142
0.024
0.130
0.051
0.011
0.008
0.118
0.735
0.708
0.696
0.681
0.578
0.574
0.544
0.043
0.067
0.040
0.124
0.284
0.111
0.080
0.230
0.119
0.415
0.083
0.044
0.130

Component
5

0.048
0.075
0.304
0.087
0.112
0.068
0.201
0.074
0.404
0.344
0.087
0.045
0.156
0.004
0.059
0.162
0.214
0.036
0.110
0.046
0.163
0.371
0.151
0.852
0.761
0.021
0.125
0.007
0.054
0.070
0.020
0.219
0.167
0.047
0.098
0.048

0.070
0.125
0.004
0.018
0.036
0.037
0.008
0.104
0.001
0.024
0.075
0.077
0.058
0.050
0.005
0.068
0.075
0.057
0.211
0.022
0.293
0.034
0.319
0.109
0.044
0.839
0.822
0.523
0.021
0.013
0.364
0.061
0.066
0.073
0.018
0.061

6
0.020
0.115
0.021
0.008
0.163
0.054
0.106
0.132
0.063
0.093
0.024
0.143
0.111
0.018
0.047
0.069
0.123
0.071
0.071
0.055
0.030
0.165
0.062
0.118
0.047
0.144
0.010
0.059
0.843
0.597
0.522
0.185
0.031
0.008
0.145
0.037

7
0.011
0.046
0.003
0.175
0.005
0.030
0.157
0.074
0.248
0.149
0.259
0.039
0.054
0.094
0.194
0.000
0.112
0.122
0.027
0.132
0.207
0.182
0.195
0.113
0.164
0.206
0.027
0.269
0.088
0.298
0.275
0.652
0.501
0.282
0.228
0.196

Communalities

0.038
0.042
0.059
0.122
0.073
0.240
0.061
0.113
0.117
0.121
0.057
0.130
0.038
0.117
0.059
0.061
0.076
0.056
0.106
0.317
0.164
0.090
0.098
0.073
0.083
0.012
0.100
0.056
0.032
0.210
0.259
0.001
0.097
0.724
0.608
0.003

0.013
0.012
0.071
0.038
0.110
0.048
0.097
0.161
0.009
0.051
0.066
0.101
0.011
0.028
0.099
0.008
0.050
0.147
0.036
0.072
0.227
0.068
0.258
0.002
0.076
0.242
0.029
0.321
0.074
0.041
0.292
0.164
0.107
0.116
0.141
0.847

0.814
0.776
0.808
0.696
0.694
0.711
0.766
0.690
0.659
0.735
0.744
0.716
0.758
0.650
0.690
0.685
0.532
0.562
0.844
0.798
0.681
0.718
0.829
0.761
0.585
0.633
0.602
0.786
0.505
0.606
0.595
0.512
0.772
0.540
0.688
0.658

Extraction method: principal component analysis. Rotation method: Varimax with Kaiser Normalization.
aRotation converged in 11 iterations.
Bold numbers=selected items.
bmadrs, Montgomery sberg Depression Rating Scale; mpi, Multidimensional Pain Inventory-Swedish version; P, part of questionnaire; Q, question number; rpws, Ryff s Psychological Well-being Scale.

may be advantageous to use direct questions regarding physical functioning (e.g. ability to bend the neck). This notion
is corroborated by studies on sensorimotor dysfunctions of
women with neck pain, showing that self-rated difficulties of
neck movement were associated with reduced head- and arm
movement performance [34,35].
Nine items encompassing mood and feelings about self
and relations, sleep, appetite, personal growth, and life control were attributed to emotional functioning. These items are
related to important aspects affected by pain, disclosed in an
extensive survey by IMMPACT on chronic pain conditions
including MSDs; enjoyment of life in general, emotional
well-being, fatigue, weakness and sleep related problems
[6]. Relations with family, relatives or significant others were

also considered as highly important [6]. The factor support

in our study included solicitous and distracting responses
from significant others, as well as punishing responses (lack
of support).
The resulting factor structure of this study comprised a
wider spectrum of symptoms than is usually the case for neck
pain questionnaires. Yet, there may still be relevant aspects to
add, for example mental/cognitive symptoms like fatigue and
difficulties in concentrating [3,6], and possibly also nuances
of bodily symptoms other than just pain [3].
The joint PCA of parts of MPI-S, MADRS-S, and RPWS
resulted in factor solutions that had a total variance explained
of 68.8%. Streiner [36] recommends a level of 50% for the
total variance explained, while Floyd and Widaman [32] call
Disability & Rehabilitation

Analysis of prominent aspects with neck-shoulder pain 939

Table V. Total variance explained.

Component

Total

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

8.815
4.581
2.803
1.687
1.669
1.539
1.371
1.242
1.092
0.998
0.981
0.935
0.808
0.753
0.704
0.671
0.565
0.543
0.453
0.417
0.398
0.384
0.326
0.289
0.270
0.253
0.217
0.207
0.184
0.165
0.150
0.143
0.132
0.102
0.091
0.062

Initial Eigenvalues
% of variance Cumulative %
24.485
12.725
7.785
4.685
4.635
4.276
3.807
3.449
3.032
2.773
2.726
2.598
2.243
2.091
1.954
1.864
1.571
1.509
1.258
1.158
1.104
1.066
0.905
0.802
0.750
0.703
0.602
0.576
0.511
0.460
0.418
0.399
0.367
0.282
0.254
0.173

24.485
37.210
44.995
49.681
54.316
58.592
62.400
65.849
68.881
71.654
74.380
76.979
79.222
81.313
83.267
85.131
86.702
88.211
89.469
90.628
91.732
92.798
93.702
94.504
95.254
95.957
96.560
97.136
97.647
98.107
98.525
98.923
99.290
99.573
99.827
100.000

Extraction sums of squared loadings

Total
% of variance Cumulative %

Rotation sums of squared loadings

Total
% of Variance Cumulative %

8.815
4.581
2.803
1.687
1.669
1.539
1.371
1.242
1.092

6.793
4.131
3.684
2.185
2.117
1.624
1.598
1.379
1.287

24.485
12.725
7.785
4.685
4.635
4.276
3.807
3.449
3.032

24.485
37.210
44.995
49.681
54.316
58.592
62.400
65.849
68.881

18.871
11.474
10.233
6.068
5.882
4.510
4.438
3.830
3.575

18.871
30.345
40.578
46.646
52.528
57.038
61.476
65.306
68.881

Extraction method: principal component analysis.

for a level of at least 80%; otherwise, a reduction of low-loading factors is necessary. In the present study, the level of total
variance explained was judged as satisfactory with a factor
loading over 0.60. Henson and Roberts [29] discussed levels
of total variance explained in a review article on the use of
exploratory factor analysis. They presented substantially lower
levels of variance explained (on average 52%) and questioned
whether levels of 75% or higher are reasonable expectations in
for example psychological research.
In the present study we made some alternative choices
regarding questionnaires compared to those recommended by
IMMPACT. Regarding pain intensity, the use of a NRS (010)
is recommended. In this study pain intensity was measured
using the two items that are included in MPI-S. The advantage
in doing so is that these two items make it possible to measure
variability in pain intensity, as they ask for pain at the moment
and during the last week. A single NRS only measures pain at
2012 Informa UK, Ltd.

one occasion. The disadvantage is that it makes comparisons

a bit harder with respect to that MPI-S uses a seven-point
scale while NRS is an eleven-point scale. Including two 010
NRS measuring pain at the moment and previously could
solve this problem. Regarding MPI-S, we also made the
decision to include both section one and section two, while
IMMPACT only recommends section one. The reasoning was
that if section two included items that were significant to
the study participants, they should have high factor loadings
and make a complement or else they would automatically be
excluded. According to the results, this was probably a wise
decision considering that six items from these subscales had a
factor loading over 0.80, and the remaining two had loadings
over 0.70.
The analysis of internal consistency resulted in one negative Cronbachs , for the RPWS subscale purpose in life
(Table I). Streiner [37] suggests that a negative value is caused

940 B. Wiitavaara etal.

Table VI. Factor structure and items after reduction.

Factor Label

Item

MPI P1Q10a

0.858

MPI P1Q8

0.853

MPI P1Q4

0.800

MPI P1Q9
MPI P1Q17
MPI P1Q19
MPI P1Q21

0.789
0.786
0.794
0.762

MPI P1Q12

0.729

MPI P1Q2
MPI P1Q3
Solicitous and
MPI P2Q1
distracting responses MPI P2Q11
from significant others
MPI P2Q12
MPI P2Q6
MPI P2Q10
MPI P2Q4
Mood and feelings
MPI P1Q6
about self and
RPWS Q 55
relations
RPWS Q 7
MADRS Q8

0.695
0.678
0.810
0.805
0.789
0.772
0.818
0.802
0.735
0.708
0.696
0.681

Interference of pain

MPI P1Q1
MPI P1Q7
Punishing responses
MPI P2Q8
from significant others MPI P2Q5
Personal growth
RPWS Q28

0.852
0.761
0.839
0.822
0.843

7
8

Life control
Sleep

MPI P1Q16
RPWS Q 11
MADRS Q3

0.652
0.724
0.608

Appetite

MADRS Q4

0.847

Pain intensity

Loading Wording of items

How much has your pain changed the amount of satisfaction or enjoyment you get from
family-related activities?
How much has your pain changed your ability to participate in recreational and other
social activities?
How much has your pain changed the amount of satisfaction or enjoyment you get from
taking part in social and recreational activities?
How much do you limit your activities in order to keep your pain from getting worse?
How much has your pain changed your ability to do household chores?
How much has your pain interfered with your ability to plan activities?
How much has your pain changed or interfered your friendships with people other than
your family?
How much has your pain changed your relationship with your spouse, family or
significant other?
In general, how much does your pain interfere with your day-to-day activities?
Since the time your pain began, how much has your pain changed your ability to work?
Asks me what he/she can do to help.
Gets me something to eat or drink.
Turns on the TV to take my mind off my pain.
Tries to get me to rest.
Encourages me to work on a hobby.
Talks to me about something else to take my mind off the pain.
Rate your overall mood during the past week.
I have not experienced many warm and trusting relationships with others.
Maintaining close relationships has been difficult and frustrating for me.
Here you should consider how you view your future, and how you feel about yourself.
Consider to what extent you may feel self-critical, whether you are plagued with guilty
feelings and whether you have been worrying more than usual about your finances or
your health.
Rate the level of your pain at the present moment.
On average, how severe has your pain been during the last week?
Gets angry with me.
Gets frustrated with me.
I think it is important to have new experiences that challenge how you think about the
world
How much control do you feel that you have over your pain?
I live life one day at a time and dont really think about the future.
Here you should indicate how well you sleep how long you sleep, and how good your
sleep has been for the past three nights. Your assessment should reflect how you have
actually slept, regardless of whether you have used sleeping pills. If you have slept more
than usual, you should mark the scale at zero (0).
Here you should indicate how your appetite has been, and try to recall whether it has
differed in any way from normal. If your appetite has been better than usual, you should
mark the scale at zero (0).

aMADRS,

Montgomery sberg Depression Rating Scale; MPI- S, Multidimensional Pain Inventory- Swedish version; P, part of questionnaire, Q, question number; RPWS, Ryff s
Psychological Well-being Scale.

by problems with the original construction of the scale, for

example, that the items are tapping different constructs. We
have not found any reports on negative Cronbachs in studies using the 18-item RPWS in other samples. The internal
consistency has been reported to be low for the subscale
purpose in life, using the 18-item version on Swedish samples
(Cronbachs 0.240.34 [20,27,38]), as well as on samples in
other countries (Cronbachs 0.260.37 [3941]).
Regarding sample size, several rules of thumb are presented for factor analyses, among those, subject-to-variable
ratios of 4:1 or 5:1, or a sample size of 100 or 200 people
[36]. However, another approach to sample size is the use
of component saturation (mainly size of factor loadings;
secondly number of items) together with total sample

size in determining the stability of a factor solution [32].

According to this approach stable factor solutions can be
attained using samples as small as 50 with factor loadings
at 0.80 [32]. Stable factor solutions were also found with
sample sizes of 150 and factor loading of 0.60, and if four or
more items had a factor loading of 0.60 on each component
the sample size could be even smaller [32]. In the present
study a factor loading of 0.80 on at least one item and several
above 0.70 was found in all but three factors (no 3, 7 and 8).
In those, the items with the highest factor loadings reached
0.74, 0.66 and 0.72, respectively (Table VI). Moreover, the
result showed predominantly high communalities 0.60
[29]. This led us to conclude that stable factor solutions
were attained with this rather small sample. Worth noting
Disability & Rehabilitation

Analysis of prominent aspects with neck-shoulder pain 941

is that the sample in this study, 117 women with long-term
neck-shoulder pain, was well defined due to the strict inclusion criteria of the randomised controlled study from which
the data was acquired. Nevertheless, further studies, using
larger samples of women and men with neck-shoulder problems are needed to corroborate our findings. One question
rendering answer is whether one short-form questionnaire
is useful for all sorts of MSDs or if there is a need to develop
specific questionnaires for different MSDs such as neck pain
and low back pain.

7.

8.
9.
10.
11.
12.

Conclusions
From the starting point with three questionnaires including
61 items the factor analyses resulted in a stable 9-factor solution including 29 items. The result constitutes the first step in
the development of a short-form questionnaire that contains
core dimensions of symptoms and functioning for people
with neck-shoulder disorders. Further studies with samples of
both men and women and of other musculoskeletal disorders
would additionally contribute to the development of valid
outcome measures.

Acknowledgements
The authors would like to thank Hans Hgberg, statistician at the Centre for Research and Development, County
Council of Gvleborg/Uppsala University, for statistical
advice and discussions regarding the outline, computation
and results of analysis. The authors also would like to thank
Maria Frykman for excellent administrative work. And
finally, thanks to Marina Heiden, researcher at the Centre
for Musculoskeletal Research, University of Gvle, for proof
reading.
Declaration of Interest: The authors declare that they have
no competing interests. The study was funded by Alfta
Research Foundation and by grants from the Swedish Council
for Working Life and Social Research (20061162) and
Lnsfrskringar Forskning och Framtid (511010/06).

13.
14.

15.
16.
17.
18.

19.
20.
21.
22.

23.
24.
25.
26.

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