Skip to main content

The Fremantle Back Awareness Questionnaire: cross-cultural adaptation, reliability, and validity of the Italian version in people with chronic low back pain


Background and aim

There is evidence to suggest that assessing back-specific altered self-perception may be useful when seeking to understand and manage low back pain (LBP). The Fremantle Back Awareness Questionnaire (FreBAQ) is a patient-reported measure of back-specific body perception that has never been adapted and psychometrically analysed in Italian. Hence, the objectives of this research were to cross-culturally adapt and validate the Italian version of this outcome measure (namely, the FreBAQ-I), to make it available for use with Italians suffering from chronic LBP.


The FreBAQ-I was developed by forward and backward translation, review by a committee skilled in patient-reported measures and test of the pre-final version to assess its clarity, acceptability, and relevance. The statistical analyses examined: structural validity based on Rasch analysis; hypotheses testing by investigating correlations of the FreBAQ-I with the Roland Morris Disability Questionnaire (RMDQ), a pain intensity numerical rating scale (PI-NRS), the Pain Catastrophising Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK) (Pearson’s correlations); reliability by internal consistency (Cronbach’s alpha) and test–retest repeatability (intraclass correlation coefficient, ICC (2,1)); and measurement error by determining the minimum detectable change (MDC). After the development of a consensus-based translation of the FreBAQ-I, the new outcome measure was delivered to 100 people with chronic LBP.


Rasch analysis confirmed the substantial unidimensionality and the structural validity of the FreBAQ-I. Hypothesis testing was considered good as at least 75% of the hypotheses were confirmed; correlations: RMDQ (r = 0.35), PI-NRS (r = 0.25), PCS (r = 0.41) and TSK (r = 0.38). Internal consistency was acceptable (alpha = 0.82) and test–retest repeatability was excellent (ICC (2,1) = 0.88, 95% CI: 0.83, 0.92). The MDC95 corresponded to 6.7 scale points.


The FreBAQ-I was found to be a unidimensional, valid, and reliable outcome measure in Italians with chronic LBP. Its application is advised for clinical and research use within the Italian speaking community.

Peer Review reports


Low back pain (LBP) is a very common condition with a highly variable course[1]. Most episodes improve considerably within 6 weeks [2]; however, about two-thirds of persons still report some pain at 3 and 12 months, leading to chronic ill health[3, 4]. Chronic LBP has a wide range of deleterious effects on the individual, limiting functional capacity, work participation, and social engagement, as well as negatively impacting personal relationships, and mental and physical health [2].

An extensive research effort over many years has suggested multiple factors that might impact the chronic LBP experience, including changes in the way the back is perceived or experienced by the individual. Previous studies have reported that people with chronic LBP represent the back differently when asked to draw how it feels to them [5], have reduced tactile acuity [6], deficits in proprioception [7], reduced motor-imagery ability [8], and changes in tactile processing similar to the spatial neglect seen following cerebrovascular accidents [9].

Based on these premises, the Fremantle Back Awareness Questionnaire (FreBAQ) –a self-report questionnaire designed to assess back-specific body perception– was specifically developed for persons with chronic LBP [10]. The questionnaire was shown to be feasible, reliable, and valid, by means of associations with measures of pain duration, pain intensity, disability, and pain catastrophising [10]. Further, a later study on chronic LBP demonstrated the FreBAQ’s unidimensionality and acceptable internal consistency, as well as offering further support for the relationship between FreBAQ scores and clinical status, including measures of fear-avoidance and psychological distress [11].

The FreBAQ represents a helpful tool for assessing warning signs of compromised self-perception of the lower back in people with chronic LBP [10, 11] and in women with lumbopelvic pain during pregnancy and postpartum [12]. This questionnaire seems a promising instrument for identifying additional factors involved in the persistence of back problems, and could serve to guide targeted treatment strategies [10, 11, 13]. Indeed, preliminary studies suggest that treatment programs aimed at improving disturbed body perception (through sensorimotor retraining) may have positive effects on pain and function in individuals with non-specific LBP [14, 15].

However, the quality of a patient-reported outcome measure (PROM) may differ noticeably when cross-culturally adapted and used in a country different to where it was initially developed [16]. Well-established methodological criteria are recommended when validation studies are performed [17]. Application of these criteria are designed to ensure the quality of the new measurement tool and permit more confident comparison of findings across populations.

The FreBAQ has previously been adapted and psychometrically examined in Japanese, Dutch, German, Turkish, Chinese, Indian, Spanish and Persian populations [13, 18,19,20,21,22,23,24], but an Italian version (FreBAQ-I) has not yet been cross-culturally adapted and psychometrically analysed in a similar population. Therefore, the purpose of this research was to develop a FreBAQ-I and examine its psychometric properties in Italians suffering from chronic LBP.


The COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines were adopted [16].

The Institutional Review Board endorsed this cross-sectional study (no. 7/16, April 5th 2016). The research was carried out in accordance with the ethical and humane principles of research specified in the Declaration of Helsinki.


This research engaged people attending an outpatient Hospital Rehabilitation Unit, meeting the following inclusion criteria: diagnosis of chronic non-specific LBP (i.e. a pain localised below the costal margin and above the inferior gluteal folds lasting for more than three months, without a distinguishable, specific, patho-anatomical cause or disease [25]); people speaking Italian as their first language (as well as those who had an adequate knowledge of Italian) and aged over 18. Exclusion criteria: acute (lasting up to one month) and subacute non-specific LBP (lasting up to three months); specific LBP (i.e. fracture, spinal deformity, disc herniation, canal stenosis, spondylolisthesis, or infections); peripheral or central neurological disorders assessed by means of imaging (e.g. radiographs, CT scans, or MRI) and/or anamnesis; systemic illness (including rheumatologic diseases); cognitive disorders (Mini Mental State Examination of < 24); recent myocardial infarctions; any past cerebrovascular accidents; and not capable or reluctant to give informed consent.

Participants were assessed by two physical and rehabilitation medicine physicians, who were under the supervision of the principal investigator (MM). Both physicians had at least a fifteen years’ experience, were involved in the assessments of the participants during the research process but not in the treatment procedure. Those who satisfied the criteria for inclusion were provided with information about the research aims and procedures and invited to sign a written informed consent form. After that, demographic and clinical characteristics were collected, and all participants completed the outcome measures listed below. Participants were invited to fill in the FreBAQ-I a second time, 7–10 days after their initial assessment to side-step variations in symptoms associated with possible memory effects [26].

Cross-cultural adaptation

The Italian translation and adaptation of the FreBAQ was performed following the American Association of Orthopaedic Surgeon Outcomes Committee’s recommended protocol and according to the standards for good practice used in the translation and cultural adaptation procedure for PROM [27, 28].

Step 1: Italian translation

The original FreBAQ [10] was independently translated into Italian by two bilingual professionals with distinct backgrounds and some experience in the PROM field. They strove to select terms capturing the connotative meanings of the source text and –at the same time– reflecting everyday-spoken language. Conflicts between translations were examined by the principal investigator and then settled by consensus, in order to consolidate a preliminary Italian version.

Step 2: Back-translation Into English

Two native English-speaking bilingual professional translators, separately back-translated the preliminary adaptation. Then, the principal investigator and the translators checked and clarified potential inconsistencies between the different versions and agreed an advanced Italian version of the questionnaire.

Step 3: Expert Committee

This advanced version was submitted to a team of six bilingual clinicians, methodologists, and translators. They investigated the idiomatic, semantic, and theoretical similarity of items and response categories. This phase finished when a consensus was reached on a prefinal version.

Step 4: Test of the prefinal version

A pilot test was then performed to explore intelligibility, appropriateness, cultural relevance, and potential ambiguity of the prefinal version. Cognitive interviews were performed by a qualified psychologist after administering the tool to 10 persons with chronic LBP, representatives of the target population. The team of experts examined the findings of this test in order to detect any useful refinement and then agreed the final version of FreBAQ-I. These deliberations are available from the corresponding author on request.

Acceptability and feasibility

Participants were interviewed about the comprehensibility of each part of the questionnaire, and the data were verified for missing or multiple answers. The time to compile each questionnaire was gathered (Fig. 1).

Fig. 1
figure 1

The study procedure

Psychometric properties

Construct validity

It represents the degree to which the scores of a measurement instrument are consistent with hypotheses, with regard to internal relationships, or relationships with scores of other instruments or differences between relevant groups [29] and was assessed by structural validity and hypothesis testing.

1. Structural validity (i.e. the degree to which the scores of a measurement instrument are an adequate reflection of the dimensionality of the construct to be measured [29]). Rasch analysis (Winsteps software v. 4.8.0) examined the FreBAQ-I using the rating scale model (because all items shared the same rating scale structure). Our detailed iterative procedure has been reported in previous studies [30, 31]. In short, the following psychometric issues were investigated:

a) diagnostic assessment of the rating categories, by investigating whether each response category was being used consistently and effectively; for that, the transition thresholds between categories (i.e. the points where two adjacent categories have an equal probability to be endorsed) and average category measures should be ordered from less to more on the underlying latent continuum [32];

b) internal construct validity, assessed checking how well the observed responses to the items align with the responses predicted by the Rasch model, using chi-square fit statistics (infit and outfit mean-square statistics, MnSq). Based on the sample size, values from 0.75 to 1.30 [33] were considered as indicating an acceptable fit;

c) reliability, in terms of both person reliability index and item reliability index [32], providing an estimate of the degree of replicability (across different samples) of person and item placements along the trait continuum (range 0–1; coefficients > 0.80 are considered as good, > 0.90 as excellent). High reliability levels (of persons or items) mean that there is a high probability that persons (or items) estimated with high Rasch measures actually do have higher measures than persons (or items) estimated with low measures [33].

d) unidimensionality of the scale, examining the unexplained variance after the Rasch dimension is extracted, as obtained by a Principal Component Analysis of the residuals (PCAr). Additional factors are not likely to be present in the residuals if the eigenvalue of the first residual component is < 2 [33];

e) local item dependence. For any pair of items, no residual correlation > 0.20 (above the average observed residual correlation) should be detected once the variable under measurement (Rasch factor) has been filtered out [34].

2. Hypothesis testing, which takes place when hypotheses are formulated a priori on the relationships of scores on the instrument under investigation with scores deriving from other measures evaluating related or dissimilar constructs, by also describing the expected direction (i.e. positive or negative) and magnitude (i.e. low, moderate, large) [29]. Based on what previously assumed in a previous study on the same matter [11], it was hypothesized a priori the FreBAQ-I would achieve positive moderate correlations (from 0.30 to 0.60) with measures of disability, and catastrophizing, and low correlations (< 0.30) with measures of pain intensity and kinesiophobia. Pearson’s correlation coefficients were calculated, and construct validity was considered as satisfactory if at least 75% of the hypotheses was reached [26].


It represents the degree to which the measurement is free from measurement error [29] and was calculated as detailed below.

  • 1. Internal consistency is the degree of interrelatedness among the items [29]) and was evaluated by calculating Cronbach’s alpha (values of > 0.70 being considered acceptable).

  • 2. Test–retest repeatability is the degree to which the measurement is free from measurement error over time [29]) and was examined 7–10 days later without treatment using the intraclass correlation coefficient, ICC (2,1) (values of 0.70–0.85 were considered good and > 0.85 excellent) [26].

  • 3. The standard error of measurement (SEM) is the difference between an amount that can be measured and its true value [29]) and was assessed using the formula:


where SD represents the standard deviation of the measurements at baseline.


It represents the degree to which one can assign qualitative meaning to an instrument’s quantitative scores or change in scores [29] and was calculated by the minimum detectable change (MDC) (i.e. the change beyond measurement error [29]) by using the following equation:

$$MDC=SEM* z value*\sqrt{2}$$

A z value of 1.96 was used to derive a 95% confidence level MDC (MDC95).

Descriptive statistics were further calculated to identify floor/ceiling effects, which were present if > 15% of the scores achieve their lowest or highest potential value, respectively [26].



This questionnaire quantifies distorted perception of the back. It is self-administered and includes 9 items. Each item is scored by a five-point response scale (range: 0 = ‘never’ up to 4 = ‘always’); the final score is obtained by summing the responses from each of the items and ranges from 0 to 36, with higher scores corresponding to greater levels of back-perception distortion [10].

Roland Morris Disability Questionnaire

This questionnaire assesses LBP related disability. It comprises 24 items, with a total score ranging from 0 (no disability) to 24 (highest level of disability) [35].

Pain Numerical Rating Scale (PI-NRS)

An 11-point pain numerical rating scale ranging from 0 (no pain at all) to 10 (the worst imaginable pain) was used [36], asking participants to rate their current pain intensity.

Pain Catastrophising Scale (PCS)

This is a 13-item self-administered questionnaire. People are asked to classify the frequency with which they experience the thoughts listed in the tool, based on a five-point scale, which ranges from 0 (never) to 4 (always). The total score is obtained summing up the scores of the individual items and can vary from 0 to 52 [37]. Higher scores denote greater levels of pain catastrophising.

Tampa Scale of Kinesiophobia (TSK)

This questionnaire is self-administered and composed of 13 items [38]. Each item is scored using a four-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree), and the total score is calculated by adding the scores of the individual items (range 13–52). Higher values correspond to greater fear of movement [38].

All outcome measures were administered in their validated Italian versions [35, 37,38,39,40,41]. The FreBAQ-I was systematically distributed first, then the RMDQ, the NRS, the TSK and the PCS during the first assessment, respectively; only the FreBAQ-I was delivered during the second assessment. Statistical analyses were performed with STATA 13.1 software (StataCorp LP, College Station, TX, USA).

The sample size of 100 was determined to provide adequate statistical power for test–retest reliability, expecting to obtain, with 90% probability, an ICC of about 0.85, with the lower limit of the 95% CI not less than 0.75 [42]. Moreover, a sample size of 100 participants is able to ensure stability in Rasch item calibrations within ± 0.5 logits with 95% confidence [43].



One hundred and thirty-five persons with chronic non-specific LBP were consecutively assessed, of whom 25 were excluded. The reasons for exclusion were: cognitive impairment (n = 5); systemic illness (n = 4); recent cerebrovascular event (n = 2); recent myocardial infarction (n = 7); and reluctance to take part (n = 7). Of the remaining people, 10 dropped out before starting the study because of: logistic issues (n = 4); economic constraints (n = 3); or personal problems (n = 3). Hence, our final sample was comprised of 100 subjects. All participants returned to the hospital for a second assessment within a period of 7 to 10 days, facilitated by a telephonic follow-up conducted by a research assistant. Average pain duration was 49 months (SD 80). Socio-demographic and clinical characteristics of the participants are described in Tables 1 and 2 (Fig. 2).

Table 1 Socio-demographic characteristics of the study population (n = 100)
Table 2 Scores (mean and standard deviation, SD) of the examined questionnaires: Fremantle Back Awareness Questionnaire (FreBAQ), Roland Morris Disability Questionnaire (RMDQ), Pain Intensity Numerical Rating Scale (PI-NRS), Tampa Scale of Kinesiophobia (TSK) and Pain Catastrophising Scale (PCS). Minimum–maximum possible scores for each tool are given between brackets
Fig. 2
figure 2

Flow chart of participants inclusion

Translation and cross-cultural adaptation

The adaptation process took four weeks to settle upon a culturally appropriate version. All the terms were easily forward and back translated and there was no need of any major local adjustment. The term “occasionally” of one rating category was translated in Italian with “qualche volta” because it was judged as more suitable for a middle response category, while the translation “occasionalmente” would have been hardly discernible in Italian from the adjacent category “rarely/raramente”.

The appropriateness of the whole procedure and related results was endorsed by the team of experts, who also reviewed the findings from the cognitive interviews and made only minor changes based on concerns raised by some participants, to enhance the questionnaire’s comprehensibility. After that, the principal investigator and experts confirmed the final version of the FreBAQ-I, in agreement with the developer (BMW).


The questionnaire took 1.97 ± 1.13 min to complete. The questions were well received. No missing responses or multiple responses were observed, nor were any comprehension difficulties raised during the instrument completion.

Scale psychometric properties

Construct validity

Structural validity

The 5-level rating scale of the FreBAQ-I showed a monotonical advance of both the transition thresholds between categories and the average category measure. According to the mean-square goodness-of-fit statistics, all items fitted the Rasch model (Table 3).

Table 3 Item calibrations (measure with standard error, SE), and fit statistics (infit and outfit mean-square statistics, MnSq) for the FreBAQ-I

The mean person ability was -0.97 logits (ability range from -3.06 to 3.34). The item reliability was 0.96, while person reliability was 0.75. The PCAr showed that FreBAQ was essentially unidimensional: the measured variable explained 50.3% of the variance in the data, while the secondary component explained only 9.9% of the variance (corresponding to an eigenvalue of 1.8). No local item dependence was detected, (i.e., no strong > 0.20 residual correlation between items was found).

Hypothesis testing

It was considered good as 3 out of 4 a priori hypotheses were confirmed (i.e., ≥ 75%). Related results are shown in Table 4.

Table 4 Hypothesis testing. Pearson’s correlation (r) between the Fremantle Back Awareness Questionnaire, Italian version (FreBAQ-I) and the other clinical measures (for all, p < 0.01)


Cronbach’s α was 0.82. Test–retest reliability was found to be high: ICC (2,1) = 0.88 (95% CI: 0.83—0.92). The SEM was 2.44.


The MDC95 was 6.7 points.

The mean score for the FreBAQ-I was 9.68 points (SD 6.98). No ceiling or floor effects were detected in any of the used scales, including the FreBAQ-I.


This research describes the cross-cultural adaptation of the FreBAQ and the assessment of its validity, reliability, and measurement error, in Italian-speaking people with chronic non-specific LBP. The FreBAQ-I demonstrated unidimensionality, good validity, and adequate reliability. International recommendations were followed in the current study and all the steps suggested that the process of translation and cross-cultural adaptation was accurate and efficient. Our methodological approach comprised forward and backward translation, minor amendments by a team of experts, cognitive debriefing, and discussion and resolution through consensus among the committee members. The procedure established the initial conceptual, semantic, and content equivalence between source and target language. The final version was well accepted, and easily understood and self-administered. The respondent burden was minimal as the questionnaire needs only a few minutes to complete. Overall, the FreBAQ-I appears to be appropriate for everyday clinical practice.

Construct validity

Structural validity

Our results corroborated the findings of the previous structural validations of this outcome measure [11, 13, 44]. The tool proved to be unidimensional (a key measurement requirement), with items acceptably fitting the mathematical model, and a rating scale functioning as expected. No local item dependence was found. In our sample the average difficulty of the items (endorsability) was about 1 logit lower than the mean sample ability (agreeability): in that condition the scale better assesses persons with moderate to high levels of disturbed body perception. These findings indicate that the item selection was appropriate and able to correctly measure the variable of interest. A minor deviation from unidimensionality was found in a sample of Indian people with chronic LBP but no issue was expected as for the clinical application of the FreBAQ in this population [22].

Hypothesis testing

The correlation with disability (RMDQ) was as expected (Table 3), indicating that higher levels of back pain related disability are associated with enhanced levels of body perception disruption relating specifically to the back. This is in line with the findings of the developers, where a moderate correlation with disability was observed (0.32)[11]. As predicted, we also noted a positive correlation between pain intensity and disrupted perception of the back, though this relationship was weaker than that noted for disability, also consistent with previous research [11]. Taken together, these results suggest that disrupted body perception is more strongly related to disability than pain in people with chronic LBP [11]. This issue was also seen in most other adapted studies of the FreBAQ (i.e. Japanese, Dutch, German, Turkish and Persian) [13, 18,19,20, 24], probably indicating disrupted body perception impacts more on the functional consequences of pain, rather than the experience of pain itself. A higher correlation with disability than pain was otherwise found in the Spanish sample (0.48 vs 0.38) [23]. Very low correlations with disability and pain were found in the Indian study [22].

With respect to catastrophizing, we noted a similar correlation to what was reported in the original English version (0.36) [11]. Our results are also consistent with results obtained from the Japanese (0.38) [13], Turkish (0.41) [20], Spanish (0.46) [23] and Persian (0.60) [24] cross-cultural adaptation studies. These findings support the idea of a relationship between high levels of pain catastrophizing and disrupted body perception. For kinesiophobia, our estimates are slightly higher than those reported by the original developers (0.26) [11], however this study utilized a different measure of kinesiophobia (i.e. the Fear Avoidance Beliefs Questionnaire, physical activity subscale), which makes direct comparison difficult. Our results are somewhat in line with the Turkish and Spanish estimates (0.60 and 0.37) [20, 23], while divergent from what was found in Japanese, Dutch and Persian samples (0.22, 0.10, and 0.17 respectively) [13, 18, 24], and, therefore, more analyses are recommended before firm conclusions can be drawn about the relationship between kinesiophobia and altered body perception.


The internal consistency of the FreBAQ-I was good (0.82) and quite similar to that reported by the developers (0.80) [11]. Similar results were found in other versions of the questionnaires: Japanese 0.80 [13]; Dutch 0.82 [18]; German 0.91 [19]; Turkish 0.87 [20]; Chinese 0.83 [21], Indian 0.91 [22], Spanish 0.82 [23] and Persian 0.74 [24].

Test–retest repeatability demonstrated an excellent level of agreement between the results on days 1 and 8 (ICC (2,1) = 0.88), a value higher than those reported in the original study (0.65) [10], while in the other validations, values were of 0.69 [18], 0.78 [23] and 0.90 [21]. The better reliability noted in this investigation may reflect the fact that no treatment was provided to participants between the two testing occasions, a control not enacted in the original study [10]. The measurement error of the FreBAQ-I was acceptable. Due to the high repeatability of the test–retest the SEM and MDC were rather low.


The MDC95 demonstrated that a change of more than 7 points after a given intervention (~ 19% of the FreBAQ score range of 36 points) would not be the result of an error in measurement. Slightly different findings were achieved by the Dutch study (where the MDC was estimated at 10.8 points) [18] and the Persian study (2.52 points) [24], while the validation of the Chinese and the Spanish version of the FreBAQ reported an MDC95 of 5.99 and 5.12 points, respectively [21].

This study should acknowledge some limitations. First, the study design is cross-sectional and thus responsiveness and minimal important change could not be assessed. Second, no external anchor such as a global rating of change was used to assess clinical stability during the assessment of reliability and participants may have improved or worsened between the first and second assessment of the FreBAQ-I. Third, the association between back-related perceptual dysfunction and physical performance measures was not investigated as only questionnaires were employed. Fourth, relationships with other psychological characteristics (e.g. Pain Self-Efficacy Questionnaire or the Coping Strategies Questionnaire-27 revised) [45,46,47], or quality of life (e.g. the Short-Form Health Survey 36-items) [48], as well as with clinical tests that might have the ability to detect alterations in the sensorimotor system [49], were not examined. Fifth, our research was limited to people with chronic non-specific LBP and it is doubtful if these results can be expanded to individuals with other causes of lumbar pain (e.g. canal stenosis, fracture, or disk herniation) or pain of another duration. Therefore, studies in these populations are advised.


The FreBAQ-I displays a one-factor structure, it is valid and reliable, and has an adequate measurement error. This Italian version can be recommended for use in clinical and research settings for the assessment of Italian-speaking people with chronic LBP.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the first author under a reasonable request.



Confidence Interval


Computed Tomography


Fremantle Back Awareness Questionnaire


Fremantle Back Awareness Questionnaire-Italian


Intraclass correlation coefficient


International Society for Pharmacoeconomics and Outcomes Research


Low back pain


Minimum detectable change


Mean-square statistics


Magnetic Resonance Imaging


Principal Component Analysis of the residuals


Pain Catastrophising Scale


Pain intensity numerical rating scale


Patient-reported outcomes measures


Standard error


Standard error of measurement


Tampa Scale of Kinesiophobia


  1. Dunn KM, Hestbaek L, Cassidy JD. Low back pain across the life course. Best Prac Res Clin Rheumatol. 2013;27:591–600.

    Article  Google Scholar 

  2. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391:2356–67.

    Article  Google Scholar 

  3. Menezes Costa LDC, Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LOP. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012;184:E613–24.

    Article  PubMed Central  Google Scholar 

  4. Itz CJ, Geurts JW, Van Kleef M, Nelemans P. Clinical course of non-specific low back pain: A systematic review of prospective cohort studies set in primary care: Clinical course of non-specific low back pain. EJP. 2013;17:5–15.

    Article  CAS  PubMed  Google Scholar 

  5. Moseley LG. I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008;140:239–43.

    Article  PubMed  Google Scholar 

  6. Wand BM, Di Pietro F, George P, O’Connell NE. Tactile thresholds are preserved yet complex sensory function is impaired over the lumbar spine of chronic non-specific low back pain patients: a preliminary investigation. Physiotherapy. 2010;96:317–23.

    Article  PubMed  Google Scholar 

  7. Sheeran L, Sparkes V, Caterson B, Busse-Morris M, Van Deursen R. Spinal Position Sense and Trunk Muscle Activity During Sitting and Standing in Nonspecific Chronic Low Back Pain: Classification Analysis. Spine. 2012;37:E486–95.

    Article  PubMed  Google Scholar 

  8. Bray H, Moseley GL. Disrupted working body schema of the trunk in people with back pain. Br J Sports Med. 2011;45:168–73.

    Article  CAS  PubMed  Google Scholar 

  9. Moseley GL, Gallagher L, Gallace A. Neglect-like tactile dysfunction in chronic back pain. Neurology. 2012;79:327–32.

    Article  PubMed  Google Scholar 

  10. Wand BM, James M, Abbaszadeh S, George PJ, Formby PM, Smith AJ, et al. Assessing self-perception in patients with chronic low back pain: Development of a back-specific body-perception questionnaire. BMR. 2014;27:463–73.

    Article  Google Scholar 

  11. Wand BM, Catley MJ, Rabey MI, O’Sullivan PB, O’Connell NE, Smith AJ. Disrupted Self-Perception in People With Chronic Low Back Pain. Further Evaluation of the Fremantle Back Awareness Questionnaire. J Pain. 2016;17:1001–12.

    Article  PubMed  Google Scholar 

  12. Goossens N, Geraerts I, Vandenplas L, Van Veldhoven Z, Asnong A, Janssens L. Body perception disturbances in women with pregnancy-related lumbopelvic pain and their role in the persistence of pain postpartum. BMC Pregnancy Childbirth. 2021;21:219.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Nishigami T, Mibu A, Tanaka K, Yamashita Y, Shimizu ME, Wand BM, et al. Validation of the Japanese Version of the Fremantle Back Awareness Questionnaire in Patients with Low Back Pain. Pain Pract. 2018;18:170–9.

    Article  PubMed  Google Scholar 

  14. Wälti P, Kool J, Luomajoki H. Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial. BMC Musculoskelet Disord. 2015;16:83.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Wand BM, O’Connell NE, Di Pietro F, Bulsara M. Managing Chronic Nonspecific Low Back Pain With a Sensorimotor Retraining Approach: Exploratory Multiple-Baseline Study of 3 Participants. Phys Ther. 2011;91:535–46.

    Article  PubMed  Google Scholar 

  16. Prinsen CAC, Mokkink LB, Bouter LM, Alonso J, Patrick DL, De Vet HCW, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res. 2018;27:1147–57.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Mokkink LB, De Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures. Qual Life Res. 2018;27:1171–9.

    Article  CAS  PubMed  Google Scholar 

  18. Janssens L, Goossens N, Wand BM, Pijnenburg M, Thys T, Brumagne S. The development of the Dutch version of the Fremantle Back Awareness Questionnaire. Musculoskeletal Science and Practice. 2017;32:84–91.

    Article  PubMed  Google Scholar 

  19. Ehrenbrusthoff K, Ryan CG, Grüneberg C, Wand BM, Martin DJ. The translation, validity and reliability of the German version of the Fremantle Back Awareness Questionnaire. PLoS ONE. 2018;13:e0205244.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Erol E, Yildiz A, Yildiz R, Apaydin U, Gokmen D, Elbasan B. Reliability and Validity of the Turkish Version of the Fremantle Back Awareness Questionnaire. Spine. 2019;44:E549–54.

    Article  PubMed  Google Scholar 

  21. Hu F, Liu C, Cao S, Wang X, Liu W, Li T, et al. Cross-cultural adaptation and validation of the simplified chinese version of the fremantle back awareness questionnaire in patients with low back Pain. Eur Spine J. 2022;31:935–42.

    Article  PubMed  Google Scholar 

  22. Rao P, Jain M, Barman A, Bansal S, Sahu R, Singh N. Fremantle Back awareness questionnaire in chronic low Back pain (Frebaq-I): translation and validation in the Indian population. Asian J Neurosurg. 2021;16:113–8.

    Article  PubMed  PubMed Central  Google Scholar 

  23. García-Dopico N, La Torre-Luque D, Wand BM, Velasco-Roldán O, Sitges C. The cross-cultural adaptation, validity, and reliability of the Spanish version of the Fremantle Back Awareness Questionnaire. Front Psychol. 2023;14:1070411.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Mahmoudzadeh A, Abbaszadeh S, Baharlouei H, Karimi A. Translation and Cross-cultural Adaptation of the Fremantle Back Awareness Questionnaire into Persian language and the assessment of reliability and validity in patients with chronic low back pain. J Res Med Sci. 2020;25:74.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Negrini S, Bonaiuti D, Monticone M, Trevisan C. Medical causes of low back pain. In: Interventional Spine. Elsevier; 2008. p. 803–11.

    Chapter  Google Scholar 

  26. Monticone M, Galeoto G, Berardi A, Tofani M. Psychometric properties of assessment tools. Measuring Spinal Cord Injury: A Practical Guide of Outcome Measures; 2021. p. 7–15.

    Google Scholar 

  27. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures: Spine. 2000;25:3186–91.

    CAS  PubMed  Google Scholar 

  28. Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, et al. Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes (PRO) Measures: Report of the ISPOR Task Force for Translation and Cultural Adaptation. Value in Health. 2005;8:94–104.

    Article  PubMed  Google Scholar 

  29. De Vet HC, Terwee CB, Mokkink LB, Knol DL. Measurement in medicine: a practical guide. Cambridge university press; 2011.

    Book  Google Scholar 

  30. Franchignoni F, Monticone M, Giordano A, Rocca B. Rasch validation of the Prosthetic Mobility Questionnaire: A new outcome measure for assessing mobility in people with lower limb amputation. J Rehabil Med. 2015;47:460–5.

    Article  PubMed  Google Scholar 

  31. Franchignoni F, Giordano A, Vercelli S, Bravini E, Stissi V, Ferriero G. Rasch Analysis of the Patient and Observer Scar Assessment Scale in Linear Scars: Suggestions for a Patient and Observer Scar Assessment Scale v21 Plastic  Recons Surg. 2019;144:1073E-9E.

    CAS  Google Scholar 

  32. Bond T, Yan Z, Heene M. Applying the Rasch model: Fundamental measurement in the human sciences. Routledge; 2020.

    Book  Google Scholar 

  33. Linacre JM, Wright BD. Winsteps. 2000.Accessed 27–06–2013

  34. Christensen KB, Makransky G, Horton M. Critical values for Yen’s Q 3: Identification of local dependence in the Rasch model using residual correlations. Appl Psychol Meas. 2017;41:178–94.

    Article  PubMed  Google Scholar 

  35. Padua R, Padua L, Ceccarelli E, Romanini E, Zanoli G, Bondì R, et al. Italian version of the Roland Disability Questionnaire, specific for low back pain: cross-cultural adaptation and validation. Eur Spine J. 2002;11:126–9.

    Article  CAS  PubMed  Google Scholar 

  36. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–58.

    Article  PubMed  Google Scholar 

  37. Monticone M, Baiardi P, Ferrari S, Foti C, Mugnai R, Pillastrini P, et al. Development of the Italian version of the Pain Catastrophising Scale (PCS-I): cross-cultural adaptation, factor analysis, reliability, validity and sensitivity to change. Qual Life Res. 2012;21:1045–50.

    Article  PubMed  Google Scholar 

  38. Monticone M, Giorgi I, Baiardi P, Barbieri M, Rocca B, Bonezzi C. Development of the Italian Version of the Tampa Scale of Kinesiophobia (TSK-I): Cross-Cultural Adaptation. Factor Analysis, Reliability, and Validity: Spine. 2010;35:1241–6.

    PubMed  Google Scholar 

  39. Monticone M, Baiardi P, Vanti C, Ferrari S, Pillastrini P, Mugnai R, et al. Responsiveness of the Oswestry Disability Index and the Roland Morris Disability Questionnaire in Italian subjects with sub-acute and chronic low back pain. Eur Spine J. 2012;21:122–9.

    Article  PubMed  Google Scholar 

  40. Monticone M, Ambrosini E, Rocca B, Foti C, Ferrante S. Responsiveness of the Tampa Scale of Kinesiophobia in Italian subjects with chronic low back pain undergoing motor and cognitive rehabilitation. European Spine J. 2016;25:2882–8.

    Article  Google Scholar 

  41. Monticone M, Portoghese I, Rocca B, Giordano A, Campagna M, Franchignoni F. Responsiveness and minimal important change of the Pain Catastrophizing Scale in people with chronic low back pain undergoing multidisciplinary rehabilitation. Eur J Phys Rehab Med. 2022;58:68.

    Google Scholar 

  42. Zou GY. Sample size formulas for estimating intraclass correlation coefficients with precision and assurance. Stat Med. 2012;31:3972–81.

    Article  CAS  PubMed  Google Scholar 

  43. Linacre JM. Sample size and item calibration stability. Rasch measurement transactions. 1994;7:328.

    Google Scholar 

  44. Schäfer A, Wand BM, Lüdtke K, Ehrenbrusthoff K, Schöttker-Königer T. Validation and investigation of cross cultural equivalence of the Fremantle back awareness questionnaire-German version (FreBAQ-G). BMC Musculoskelet Disord. 2021;22:1–14.

    Article  Google Scholar 

  45. Chiarotto A, Vanti C, Ostelo RW, Ferrari S, Tedesco G, Rocca B, et al. The pain self-efficacy questionnaire: cross-cultural adaptation into Italian and assessment of its measurement properties. Pain Pract. 2015;15:738–47.

    Article  PubMed  Google Scholar 

  46. Monticone M, Giordano A, Franchignoni F. Scale shortening and decrease in measurement precision: Analysis of the Pain Self-Efficacy Questionnaire and its short forms in an Italian-speaking population with neck pain disorders. Physical Therapy. 2021;101:pzab039.

    Article  PubMed  Google Scholar 

  47. Monticone M, Ferrante S, Giorgi I, Galandra C, Rocca B, Foti C. The 27-item coping strategies questionnaire—revised: confirmatory factor analysis, reliability and validity in italian-speaking subjects with chronic pain. Pain Res Manage. 2014;19:153–8.

    Article  Google Scholar 

  48. Apolone G, Mosconi P. The Italian SF-36 Health Survey: translation, validation and norming. J Clin Epidemiol. 1998;51:1025–36.

    Article  CAS  PubMed  Google Scholar 

  49. Meier R, Emch C, Gross-Wolf C, Pfeiffer F, Meichtry A, Schmid A, et al. Sensorimotor and body perception assessments of nonspecific chronic low back pain: a cross-sectional study. BMC Musculoskelet Disord. 2021;22:1–10.

    Article  Google Scholar 

Download references


The authors would like to thank all the people who got involved into the study, along with Dr Franco Franchignoni and Dr Andrea Giordano, which gave important suggestions and support for the data analysis.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations



MM initiated study conception and design. CM, GC and EP performed the data collection and acquisition of data. FA performed the data analysis. MM interpreted the data. MM wrote the manuscript. MM, EP and FA edited the manuscript. BMW had a role in critical revision of different parts of the work. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Federico Arippa.

Ethics declarations

Ethics approval and consent to participate

This cross-sectional study was approved by our Local Ethical Committee (Salvatore Maugeri Foundation, Scientific Institute of Lissone, Monza Brianza, Italy) on the 05/04/2016 (committee’s reference number: no. 7/16), and conducted in accordance with ethical and humane principles of research of the Declaration of Helsinki. Informed consent, written and verbal, was obtained from all participants. Before inclusion, all participants signed a written informed consent that detailed the study’s aims, attendance modalities in the trial, and that asked for permission to use their clinical and socio-demographic data for the purpose of the present research.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Monticone, M., Maurandi, C., Porcu, E. et al. The Fremantle Back Awareness Questionnaire: cross-cultural adaptation, reliability, and validity of the Italian version in people with chronic low back pain. BMC Musculoskelet Disord 25, 279 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: