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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

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Volume 13, Issue 1


Rasch analysis resulted in an improved Norwegian version of the Pain Attitudes and Beliefs Scale(PABS)

Nicolaas D. Eland / Alice Kvåle
  • Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
  • Occupational Therapy, Physiotherapy and Radiography, Department of Health and Social Sciences, Bergen University College, Inndalsveien 28, 5020 Bergen, Norway
  • Email
  • Other articles by this author:
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/ Raymond W.J.G. Ostelo
  • Department of Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research, VU Medical Centre, de Boelelaan 1081, 1081 HV Amsterdam, The Netherlands
  • Department of Health Sciences, Faculty of Earth and Life Sciences, EMGO+ Institute for Health and Care Research, VU University, Amsterdam, The Netherlands
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  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Liv Inger Strand
  • Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
  • Department of Physiotherapy, Haukeland University Hospital, Haukelandsveien 22, 5021 Bergen, Norway
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Published Online: 2016-10-01 | DOI: https://doi.org/10.1016/j.sjpain.2016.06.009


Background and aim

There is evidence that clinicians’ pain attitudes and beliefs are associated with the pain beliefs and illness perceptions of their patients and furthermore influence their recommendations for activity and work to patients with back pain. The Pain Attitudes and Beliefs Scale (PABS) is a questionnaire designed to differentiate between biomedical and biopsychosocial pain attitudes among health care providers regarding common low back pain. The original version had 36 items, and several shorter versions have been developed. Concern has been raised over the PABS’ internal construct validity because of low internal consistency and low explained variance. The aim of this study was to examine and improve the scale’s measurement properties and item performance.


A convenience sample of 667 Norwegian physiotherapists provided data for Rasch analysis. The biomedical and biopsychosocial subscales of the PABS were examined for unidimensionality, local response independency, invariance, response category function and targeting of persons and items. Reliability was measured with the person separation index (PSI). Items originally excluded by the developers of the scale because of skewness were re-introduced in a second analysis.


Our analysis suggested that both subscales required removal of several psychometrically redundant and misfitting items to satisfy the requirements of the Rasch measurement model. Most biopsychosocial items needed revision of their scoring structure. Furthermore, we identified two items originally excluded because of skewness that improved the reliability of the subscales after reintroduction. The ultimate result was two strictly unidimensional subscales, each consisting of seven items, with invariant item ordering and free from any form of misfit. The unidimensionality implies that summation of items to valid total scores is justified. Transformation tables are provided to convert raw ordinal scores to unbiased interval-level scores. Both subscales were adequately targeted at the ability level of our physiotherapist population. Reliability of the biomedical subscale as measured with the PSI was 0.69. A low PSI of 0.64 for the biopsychosocial subscale indicated limitations with regard to its discriminative ability.


Rasch analysis produced an improved Norwegian version of the PABS which represents true (fundamental) measurement of clinicians’ biomedical and biopsychosocial treatment orientation. However, researchers should be aware of the low discriminative ability of the biopsychosocial subscale when analyzing differences and effect changes.


The study presents a revised PABS that provides interval-level measurement of clinicians’ pain beliefs. The revision allows for confident use of parametric statistical analysis. Further examination of discriminative validity is required.

This article offers supplementary material which is provided at the end of the article.

Keywords: Pain Attitudes and Beliefs Scale; Attitudes of health care professionals; Psychometrics; Low backpain; Rasch analysis


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About the article

Tel.: +47 909 83 795.

Received: 2016-01-16

Revised: 2016-06-20

Accepted: 2016-06-27

Published Online: 2016-10-01

Published in Print: 2016-10-01

Ethical issues: The study was accepted by the Norwegian Centre for Research Data (project nr. 28806). Consent of responders was assumed if they completed the questionnaire. Written information was provided to responders regarding the purpose of our study.

Conflict of interest: Nicolaas Eland was supported by the Norwegian Fund for Post Graduate Training in Physiotherapy in writing the manuscript. The authors report no conflict of interests in relation to this paper.

Citation Information: Scandinavian Journal of Pain, Volume 13, Issue 1, Pages 98–108, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2016.06.009.

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