Physiotherapists ’ knowledge of pain : A cross-sectional correlational study of members of the South African Sports and Orthopaedic Manipulative Special Interest Groups

SAJSM VOL. 25 NO. 4 2013 95 Background. Pain is the most common complaint for which patients seek the help of a physiotherapist. Furthermore, pain has been identified as the fifth vital sign, indicating the attention with which physiotherapists should be assessing pain. Previous studies have found deficits in pain knowledge among healthcare providers. Poor knowledge about pain is recognised to lead to poor assessment ability, and subsequently, to poor pain management. Objective. To investigate the pain knowledge of sports and orthopaedic manipulative physiotherapists in South Africa (SA). Methods. Data were collected online by means of a demographic questionnaire and Unruh’s Revised Pain Knowledge and Attitudes Questionnaire (RPKAQ). Participants were members of the Sports Physiotherapy Group and Orthopaedic Manipulative Physiotherapy Group of the South African Society of Physiotherapy. Results. The mean score for the RPKAQ was 65.5% (standard deviation (SD) ±8.6). Only 14.45% of the physiotherapists scored ≥75%. Lowest scores were obtained for the ‘assessment and measurement of pain’ (47.6%; SD ±15.6) and ‘developmental changes in pain perception’ (58.7%; SD ±20.8) sections of the RPKAQ, while the highest mean score was obtained for the ‘physiological basis of pain’ section (76.8%; SD±14.6). Gender, ethnicity (defined by home language), academic training and clinical experience did not contribute significantly to overall pain knowledge. Conclusion. There is an inadequate level of pain knowledge among members of the sports and orthopaedic manipulative physiotherapy groups in SA, particularly in the areas of the assessment and measurement of pain, and developmental changes in pain perception.

Pain is defined by the International Association for the Study of Pain (IASP) as '... an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage; pain is always subjective ... ' . [1]Pain is recognised as the most common complaint for which individuals seek the help of a physiotherapist; [2] however, the most commonly cited reasons for mismanagement of pain are healthcare practitioners' negative attitudes and lack of knowledge about pain. [3]ain has been identified as the fifth vital sign, [4,5] indicating the attention with which physiotherapists should be assessing pain.Vital signs are measures used to assess basic body functions.The four primary functions include temperature, blood pressure, heart rate and respiratory rate. [5]Pain as the fifth vital sign was initially promoted by the American Pain Society to elevate awareness of pain treatment among healthcare professionals.Vital signs are critical; therefore, if pain was to be assessed as seriously as other vital signs, this may lead to an improved chance of adequate and optimal treatment. [6]Physio therapists are accepted and involved members of the pain-management team [7] concerned with identifying possible causes of pain.All physiotherapists registered with the Health Professions Council of South Africa are considered first-line practitioners. [8]derstanding the science behind nociceptive and pain neurophysiology during the clinical assessment of patients with musculoskeletal pain is crucial in determining appropriate treatment parameters. [9]Physiotherapists' clinical reasoning of pain may in fluence reasoning associated with other aspects of clinical practice, such as the planning of physical examinations, treatment and prognostication. [10]urther, central sensitisation plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how physiotherapists can recognise this condition. [9]here is a paucity of evidence relating to pain knowledge and assessment ability among healthcare professionals.The implications for physiotherapy practice are that such poor knowledge is recognised to lead to poor assessment ability, and subsequently, to poor pain management. [4]A greater understanding of pain mechanisms may enable more effective treatment and management of clinical presentations of pain. [10]In South Africa (SA), there is a lack of research on healthcare professionals' knowledge of pain, particularly such knowledge among physiotherapists.
The principle aim of this study was to provide baseline descriptive information regarding pain knowledge among SA sports and orthopaedic manipulative physiotherapists, particularly those treating athletes, and to explore factors which contribute to level of knowledge.

Table 1. RPKAQ reliability* α -if deleted
There is a predictable relationship between the extent of an injury and a person's perception of pain 0.61 Pain is a physiological sensation 0.62 The sensation of pain varies from individual to individual 0.62 Nociception is experienced at the site of tissue damage 0.64 † The physiological basis of pain is well understood 0.62 The intensity of pain is its most important quality 0.62

Ethical approval
The study was performed in accordance with the principles of the

Participants
Participants were recruited by electronic correspondence using the South African Society of Physiotherapy Special Interest Group database.Members of the Sports Physiotherapy Group (SPG) and/ or Orthopaedic Manipulative Physiotherapy Group (OMPTG) of the South African Society of Physiotherapy (N=1 562) were invited to participate.Using the pain knowledge scores obtained by SA physiotherapy students in a previous study (68.9%) [4] with a 4% precision interval (score range 63.9 -73.9%), a sample size of 272 (17.4% response rate) with a 95% confidence interval, was calculated to be adequate and targeted accordingly.

Instrumentation
A demographic questionnaire was used to survey the characteristics of the sample.The Revised Pain Knowledge and Attitudes Question naire (RPKAQ) -which covers a wide base of knowledge that is appropriate for healthcare professionals, including sections on physiological, psychological, developmental, assessment/measurement, pharmacological and cognitive/behavioural aspects of pain knowledge -was adapted for the study.The section on pharmacological management of pain was excluded, as pharmacology is outside the scope of practice of SA physiotherapists.
The content validity of the original Pain Knowledge and Attitudes Questionnaire (PKAQ) was established by consultation with five internationally recognised experts in pain research, and a Cronbach's α of 0.65 was reported. [11]Internal consistency of the adapted RPKAQ used in this study was established post hoc by calculating reliability; it was shown to have an acceptable Cronbach's α of 0.62.As summarised in Table 1, α-values were determined for each question and recalculated with individal items deleted to explore the contribution that each item made to the underlying construct of the subscale.The omission of items did not significantly affect the underlying construct of the questionnaire.Four questions caused a slight increase in α-value when omitted, suggesting that there may have been an associated interpretation issue.However, as the increase in α-value was <0.1 in each case, the items were retained.

Procedure
All members of the SPG and OMPTG were informed of the purpose of the study via e-mail.The e-mail included a link to the questionnaire on Survey Monkey.Electronic informed consent was obtained prior to providing access to the questionnaire.All data were anonymous.

Statistical analysis
Data were analysed for those who completed the full questionnaire.Respondents who completed only the demographic data or did not complete the full questionnaire were excluded from the analysis.The score selected to represent an appropriate level of knowledge for the RPKAQ was 75%, as this represents a first-class pass at SA universities.Pain has been identified as the fifth vital sign, [4] indicating the attention with which physiotherapists should be assessing pain.Vital signs are critical; therefore, 75% was regarded as a necessary score of adequate knowledge if pain is to be assessed as seriously as other vital signs.Correlations between pain knowledge and gender, ethnicity, academic training and clinical experience were analysed.Th e demographic data and knowledge of the whole sample group were presented using descriptive statistics in the form of means ± standard deviations (SDs).Diff erences in levels of knowledge between two independent groups, those with adequate v. inadequate pain knowledge, were analysed using the Mann-Whitney U-test for numerical data and the χ 2 test for categorical data.Relation ships between levels of knowledge and factors that may influence knowledge were illustrated using Spearman's correlation coefficients.
Signifi cance was accepted at p<0.05.

Results
A total of 207 respondents completed the full questionnaire, representing a response rate of 13.25%.

Descriptive characteristics
The sociodemographic and professional character istics of the participants are presented in Table 2.The participants were predominantly female, English-speaking, with a mean 14 years of experience as physiotherapists.The majority had experience in treating athletes and had been doing so for a mean of 12 years.

Pain knowledge and attitudes questionnaire
Th e mean RPKAQ score was 66% (SD ±9).The lowest scores were obtained for the 'assess ment and measurement' (48%; SD ±16) and 'developmental' (59%; SD ±21) sections of the RPKAQ.The highest scores were obtained for the 'physiology' (77%; SD ±15) and 'psychology' (73%; SD±11) sections.Th e mean score for the 'cognitive/behavioural' section of the RPKAQ was 68% (SD ±12).No signifi cant correlations were found between the total RPKAQ scores and gender, home language, postgraduate qualification or experience in treating athletes.

Adequate pain knowledge scores
Only 15% of the participants had adequate scores on the RPKAQ (i.e.score ≥75%).A comparison of the percentage of participants obtaining adequate scores in each of the RPKAQ subsections is illustrated in Fig. 1.Th e only subsection in which the majority of participants obtained adequate scores was 'physiology' , with 57% of participants receiving an adequate score (≥75%).Only 4% of the participants had adequate knowledge in the 'assessment and measurement' section.

Factors contributing to pain knowledge
The analysis of variables according to adequate or inadequate pain knowledge (RPKAQ ≥75%) revealed no differences in terms of gender for the total score or for any of the subsections.There were no significant differences between those with adequate v. inadequate in terms of home language.In addition, there was no difference in the pain knowledge scores between those who completed their undergraduate degree in their home language and those who completed their undergraduate degree in a second language.Those who studied in their first or home language scored significantly higher (77%; SD ±14) in the 'physiology' section of the RPKAQ than those who studied in their second language (68%; SD ±15) (U=677.00;p=0.04).Furthermore, no significant differences were found between those with adequate pain knowledge and those with inadequate pain knowledge in terms of years of clinical experience or experience in treating athletes.
There was a weak but significant positive correlation between the number of years since graduation and the 'psychology' section of the RPKAQ (r=0.20;p<0.05), as well as the 'cognitive/behavioural' section of the RPKAQ (r=0.17;p<0.05).This correlation showed that increased time since graduation corresponded with better knowledge scores for the psychological and cognitive/behavioural aspects of pain.
Similarly, there was a weak positive correlation between the number of years in clinical practice and the pain knowledge scores in the psychological (r=0.19;p<0.05) and cognitive/behavioural aspects of pain (r=0.17;p<0.05).

Discussion
Physiotherapists have a central role in all aspects of pain assessment and management, particularly in the management of musculoskeletal injuries.The mean score for the RPKAQ in the study sample was 65%.This is well below the score regarded as indicating adequate knowledge (≥75%).These results are concurrent with a previous SA study which also identified poor pain knowledge scores in final-year health sciences students. [4]The spread of scores across the different knowledge areas in the present study reaffirms the findings of Parker et al. [4] and Strong et al., [11] who identified the areas of most knowledge to be in the physiological aspects of pain, while assessment and measurement knowledge was found to be least understood.This is one of only a few studies where attempts have been made to quantify adequate pain knowledge, classified as a minimum RPKAQ score of 75%.It is of concern that 86% of the physiotherapists had inadequate scores on the RPKAQ; thus indicating a poor level of pain knowledge among members of the sports and orthopaedic manipulative physiotherapy groups in SA.The significance of this is highlighted by the fact that poor knowledge of current best evidence about pain may limit efficacy of intervention, [12] leading to poor assessment and management of patients with musculoskeletal pain. [4,9]These factors represent barriers to the reconceptualisation of the problem of chronic pain. [12]Despite IASP guidelines aiming to improve and standardise pain education, there is a paucity of research on the pain curriculum content in healthcare courses in an SA context.The results of the present study indicate the need for improved education in pain, with particular focus on the 'assessment and measurement' and 'developmental' aspects of pain.It is unclear whether the deficit in pain education lies at an undergraduate or postgraduate level.Considering the results of the present study, where postgraduate qualification was not associated with improved scores, targeting undergraduate training may be most beneficial.
The literature highlights the importance of pain education for accurate pain assessment and management, as well as the correlation between pain education and improved knowledge. [14,15]Well-designed pain curricula can significantly improve pain knowledge and the associated beliefs of health professional students. [14]n this study, academic training made no significant contribution to overall pain knowledge, possibly since the majority of the physiotherapists graduated over 10 years ago.Perhaps adequate education may not be associated directly with effective use of knowledge; which leads one to question the influence of other factors in healthcare professionals' pain-management strategies.Moseley [12] reported that health professionals underestimate their patients' ability to understand the neurophysiology of pain; therefore, it is reasonable to assume that this may not form part of the theoretical basis of treatment or be included in the management approach. [12]Further, clinical reasoning of pain appears to influence reasoning associated with other aspects of clinical practice such as the planning of physical examinations, treatment and prognostication. [10]revious studies have found that clinical experience influences knowledge of pain. [16,17]However, in the present study there was no significant relationship between overall pain knowledge and clinical experience.Other studies concurrently show no significant correlation between postgraduate years of experience and pain knowledge. [12]Interestingly, in the present study, there was a weak but significantly positive correlation between the number of years since graduation and pain knowledge related to the psychological and cognitive behavioural aspects of pain.This correlation showed that increased time since graduation was positively associated with better knowledge scores.Considering that the pain education curriculum has become more salient in the past decade, one may expect to find the opposite result, i.e. for physiotherapists who trained more recently to have higher scores.This association between experience and better scores may be as a consequence of increased exposure to the psychosocial elements involved in treating athletes and/or patients with chronic pain.Furthermore, perhaps with maturity and clinical experience, physiotherapists acknowledge the relevance of the psychosocial aspects of pain management.In addition, there may be better multidisciplinary interaction between older physiotherapists and psychologists.One could argue that older physiotherapists may be more flexible in accepting a biopsychosocial framework and have a wider understanding of pain beliefs and coping strategies.

Study limitations
It is recognised that the sample size was insufficient to ensure the 95% confidence level targeted.A larger sample size may have allowed a better representation of gender, ethnicity, academic training and clinical experience of the SA physiotherapy population, and may have influenced the results differently.In addition, uneven distribution of characteristics within the sample may have obscured the outcomes.However, despite the low response rate (13.25%) and the sample size being smaller than the targeted 272 required for a 95% confidence level, a sample of 207 gave a 90% confidence level, which is regarded as acceptable in surveys of the type described here. [16]The participants were all physiotherapists registered to practise in SA with a special interest in sports and/or orthopaedic manipulative physiotherapy.This study provides valuable information on a population group in which there is a paucity of evidence regarding pain knowledge.
Further limitations are found by virtue of the study design.Selfadministered questionnaires are common measurement tools used to assess descriptive characteristics and obtain information from large populations.However, questionnaires are also associated with low response rates. [18]To minimise the limitations of self-administered questionnaires, a pilot study was conducted on the online demographic questionnaire and RPKAQ used in the present study to assess the feasibility, accessibility, comprehension and ease of completion.However, the present study was unable to control for the disadvantages associated with self-administered questionnaires, including accuracy of mailing lists; literacy and language issues (such as dyslexia and translation); interpretation of the questions; and technical problems (possible online faults or limited access to the internet). [19]here may be sample bias in the results due to the differences in motivation between those individuals who chose to respond and those who did not respond.Respondents may not have been motivated to give accurate answers, but rather to give answers that presented themselves in a favourable light.Furthermore, it is identified that people who feel more confident in their knowledge are more likely to respond to questionnaires than those who feel they have insufficient knowledge. [4]If this is the case and physiotherapists with poor knowledge about pain were not motivated to respond, then the results were effectively inflated by a selection bias.
The content validity of the original PKAQ was established by consultation with five internationally recognised experts in pain research. [11]Although the questionnaire was originally utilised over 10 years ago, the questions still hold true today.The adapted RPKAQ had an acceptable Cronbach's α of 0.62.There is, however, room for revision and improvement, with the objective to develop a more recent and reliable outcome measure for pain knowledge.It is noted that cross-cultural adaptation of the questionnaire for the SA population may enhance applicability of the findings and that test-retest reliability could have been included in the pilot study to strengthen the dependability of the questionnaire.

Conclusion
Despite its limitations, the present study demonstrated that members of the sports and orthopaedic manipulative physiotherapy groups in SA may have inadequate pain knowledge.Based on a minimum score of 75%, indicating adequate knowledge to assess and treat a vital sign, the physiotherapists in our sample had insufficient knowledge to ensure optimal pain assessment and management.In particular, there was a lack of knowledge in the assessment and measurement of pain as well as in the developmental aspects of pain.There was no significant contribution by academic training, clinical experience, gender or ethnicity to overall pain knowledge.The content of pain education in both undergraduate and postgraduate curricula for physiotherapists should be explored to identify the specific areas of pain education that are lacking, and to optimise the efficacy of pain education for physiotherapists treating athletes in SA.

Table 2 . Sociodemographic characteristics of the sample (N=207)
*Athlete is defi ned as any person who is profi cient in sports and/or any other form of exercise, at any level of participation.Fig. 1. Percentage of participants obtaining adequate and inadequate scores on the RPKAQ.