Prevention and RehabilitationPain knowledge, attitudes and beliefs of Australian osteopaths drawn from a nationally representative sample of the profession
Introduction
Pain has been identified as a global health issue with substantial effects on individual quality of life and broadly on healthcare and social care systems (Thompson et al., 2018). The burden of chronic pain is high with 19% of Australians afflicted (Henderson et al., 2013). An individual's pain experience is shown to include multidimensional subjective phenomena influenced by varying degrees of biological, psychological and social factors. Concerning musculoskeletal pain, 10% of those who experience acute low back pain are estimated to progress to chronic low back pain (cLBP) with modest treatment results (Linton et al., 2018).
Current Australian and international guidelines for primary care of chronic low back pain (cLBP) recommend a multidisciplinary biopsychosocial approach ((NICE), 2016; Almeida et al., 2018; Foster et al., 2018; Qaseem et al., 2017). In a recent systematic review of clinical practice guidelines for cLBP, Oliviera and colleagues summarised the recommended use of multiple interventions such as NSAIDs and antidepressants, exercise therapy, and psychosocial interventions” (Oliveira et al., 2018).
The International Association for the Study of Pain (IASP) states it is essential health professionals undertake comprehensive pain education to ensure they develop the capability to utilise a patient-centred, biopsychosocial management approach (International Association for the Study of Pain (IASP), 2018a).
Australian osteopaths are primary contact health professionals who chiefly manage musculoskeletal pain complaints. A study undertaken in 2004 investigated the types of complaints seen by Australian osteopaths (Orrock, 2009). The research identified osteopaths predominantly manage lumbar (27.3%) or neck (24.5%) pain and immobility, and headaches (10%), with 51.2% of presenting complaints reported as chronic in duration. Similarly, a further study exploring the profile of Australian osteopathic practice identified the most common anatomical regions presenting were symptoms in the cervical spine (16%) and lumbar spine (15%) (Burke et al., 2013). Given the prevalence of pain presentations in osteopathic practice, it is imperative that osteopaths have a sound education in pain neurophysiology. Additionally, they must also show attitudes and beliefs that facilitate a biopsychosocial management approach to pain through provision of effective, ethical pain management (International Association for the Study of Pain (IASP), 2018b; Moseley, 2003).
The need for such education is highlighted by Darlow, who identified practitioners' beliefs about back pain are often consistent with their patients (Darlow et al., 2012). Further, Darlow suggest professionals “with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities” (p. 15). A contemporary understanding of pain neurophysiology is suggested to facilitate the ability of practitioners to adequately explain the basis of a patient's pain (International Association for the Study of Pain (IASP), 2018a). Pain education, including its biological, psychological and social components, is taught in Australian osteopathy pre-professional programs. That said, contemporary pain education addressing these three components is a relatively recent inclusion (over the last 5 years) in Australian teaching programs with Fitzgerald et al. (2018) providing a description of the approach taken by one institution. Therefore, more experienced practitioners are unlikely to have received this education unless they have undertaken professional development in this area. The experience of those osteopaths trained overseas may also be different with respect to volume and coverage of pain education in their program.
Evaluation of pain neurobiology knowledge offers the opportunity to measure practitioners' knowledge at a point in time, or before and after an educational intervention. The Neurophysiology of Pain Questionnaire (NPQ) was developed to evaluate understanding of pain neurophysiology and has previously been used to evaluate neurophysiology of pain knowledge in patients, practitioners (Moseley, 2003) and students (Adillón et al., 2015; Cox et al., 2017; Fitzgerald et al., 2018; Springer et al., 2018).
Attitudes and beliefs towards back pain of musculoskeletal practitioners and students including physiotherapists (Bishop et al., 2008; Daykin and Richardson, 2004; Ferreira et al., 2004; Gardner et al., 2017; Houben et al., 2005; Latimer et al., 2004; Mackey and Hurley, 2014; Ostelo et al., 2003b), osteopaths (Moran et al., 2017; Pincus et al., 2006) and chiropractors (Pincus et al., 2007) have previously been evaluated. These studies have generally described practitioners as having a biomedical bias in their attitudes towards low back pain, which likely impacts patient management as this approach is not consistent with current guideline recommendation to utilise a biopsychosocial approach (Foster et al., 2018).
Research evaluating attitudes towards back pain have typically used self-report questionnaires published specifically for this purpose (Bishop et al., 2007). One of the more commonly utilised measures is the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), a 19-item questionnaire developed to assess the attitudes of physiotherapists regarding back pain (26). It is postulated that having a predominantly biomedical treatment orientation rather than behavioural orientation may affect patient management (Mutsaers et al., 2012; Ostelo et al., 2003b).
Another questionnaire that evaluates beliefs specifically in musculoskeletal practitioners is the Attitudes to Back Pain Scale in Musculoskeletal Practitioners (ABS-mp) (Pincus et al., 2006, 2007). This 19-item questionnaire assesses six factors, namely psychological influences on low back pain, the influence of muscular and skeletal structures, and beliefs about movement, exercise and work capacity. This questionnaire may offer additional insights into osteopathic practice, as osteopaths participated in the development and testing of the ABS-mp. Together these questionnaires capture a range of beliefs and attitudes albeit they are exploring these in relation to low back pain only.
To our knowledge there is no literature investigating knowledge of the neurophysiology of pain or the influence of attitudes or beliefs towards CLBP in Australian osteopaths. Thus, given the drive towards biopsychosocial treatment approaches, the aim was to determine the current levels of knowledge and attitudes of practicing Australian osteopaths. This data can be used to inform curricula development at teaching institutions, guide professional development activities, and contribute to the development of guidelines and policies for the management of musculoskeletal pain.
The objective of the current study was to evaluate the current level of knowledge of the neurophysiology of pain and the beliefs and attitudes towards pain in the Australian osteopathy profession. A secondary objective was to assess whether knowledge, attitudes or beliefs are associated with demographic variables in this population.
Section snippets
Methods
The study was approved by the Victoria University Human Research Ethics Committee (HRE17-020) and the Osteopathy Research and Innovation Network (ORION) Steering Committee.
Results
Two-hundred and sixty osteopaths consented to participate in the study. Data were removed from 49 participants as the data were either substantially incomplete or missing, leaving 211 datasets for analysis. The response rate represents 21.3% of the ORION cohort (n = 992) and 8.8% of Australian osteopathy profession (n = 2388). Most respondents were female (60.2%) and the largest age group represented was 35–44 years (38.4%). Sixty three percent were educated at one of two Australian
Discussion
Findings from this study show for the first time that Australian osteopaths demonstrate a range of pain neurophysiology knowledge, and beliefs and attitudes towards pain.
Conclusion
Australian osteopaths demonstrate a range of pain neurophysiology knowledge, and beliefs and attitudes towards pain. These results are somewhat consistent with other osteopathy populations where the same measures have been utilised. The findings provide initial support for the positive impact of professional development for developing pain knowledge in this population. There is also an opportunity to develop pain beliefs and knowledge that is consistent with evidence-based practice approaches
Funding sources
Not applicable.
CRediT authorship contribution statement
Kylie Fitzgerald: Conceptualization, Methodology, Investigation, Resources, Writing - original draft, Project administration. Brett Vaughan: Methodology, Formal analysis, Investigation, Writing - review & editing. Michael Fleischmann: Methodology, Formal analysis, Investigation, Writing - review & editing. Philip Austin: Methodology, Investigation, Resources, Writing - review & editing.
Declaration of competing interest
There are no known conflicts of interest to declare.
Acknowledgments
The research reported in this paper was facilitated and made possible by the Osteopathy Research and Innovation Network (ORION) practice-based research network. ORION was supported by the Osteopathy Australia and independently designed and conducted by the ORION Project team. We thank all the osteopaths who consented to participate in the ORION PBRN cohort. The arguments and approaches outlined in this manuscript reflect those of the named authors only.
References (39)
- et al.
The attitudes and beliefs of UK osteopaths towards the management of low back pain: a cross-sectional study
Int. J. Osteopath. Med.
(2018) - et al.
Health care practitioners' attitudes and beliefs about low back pain: a systematic search and critical review of available measurement tools
Pain
(2007) - et al.
How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners?
(2008) - et al.
Physiotherapists' beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies
J. Physiother.
(2017) - et al.
Prevention and treatment of low back pain: evidence, challenges, and promising directions.
Lancet
(2018) - et al.
Health care providers' orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity
Eur. J. Pain
(2005) - et al.
Complementing or conflicting? A qualitative study of osteopaths’ perceptions of NICE low back pain and sciatica guidelines in the UK
Int. J. Osteopath. Med.
(2019) - et al.
Revisiting gender differences: what we know and what lies ahead
J. Consum. Psychol.
(2015) - et al.
Investigation of four self-report instruments (FABT, TSK-HC, Back-PAQ, HC-PAIRS) to measure healthcare practitioners' attitudes and beliefs toward low back pain: reliability, convergent validity and survey of New Zealand osteopaths and manipulative physiotherapists
Musculoskeletal Sci. Prac.
(2017) Unraveling the barriers to reconceptualization of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology
J. Pain
(2003)
Psychometric properties of the pain attitudes and beliefs scale for physiotherapists: a systematic review
Man. Ther.
Profile of members of the Australian osteopathic association: Part 2 – the patients
Int. J. Osteopath. Med.
Health care provider's attitudes and beliefs towards chronic low back pain: the development of a questionnaire
Man. Ther.
Health care provider's attitudes and beliefs towards chronic low back pain: the development of a questionnaire
Man. Ther.
Attitudes to back pain amongst musculoskeletal practitioners: a comparison of professional groups and practice settings using the ABS-mp
Man. Ther.
A workforce survey of Australian osteopathy: analysis of a nationally-representative sample of osteopaths from the Osteopathy Research and Innovation Network (ORION) project
BMC Health Serv. Res.
Comparison of pain neurophysiology knowledge among health sciences students: a cross-sectional study
BMC Res. Notes
Primary care management of non-specific low back pain: key messages from recent clinical guidelines
Med. J. Aust.
A profile of osteopathic practice in Australia 2010–2011: a cross sectional survey
BMC Muscoskel. Disord.
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