Evaluation of Musculoskeletal Medicine Knowledge Among Physicians and Physical Therapists in Saudi Arabia: A Cross-Sectional Study

Evaluation of Musculoskeletal Medicine Knowledge Among Physicians and Physical Therapists in Saudi Arabia: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Musculoskeletal Medicine Knowledge Among Physicians and Physical Therapists in Saudi Arabia: A Cross-Sectional Study Muhammad Alrwaily, Fahad Alanazi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-909940/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Musculoskeletal (MSK) conditions are rapidly rising in Saudi Arabia and considered the 3 rd reason for hospital visits across the country. Despite their prevalence, the adequacy of knowledge in MSK medicine has not been assessed. The purpose of this study is to assess MSK medicine knowledge amongst healthcare providers (orthopedists, primary care physicians, and physical therapists) and medical and physical therapy students and interns. Method: In this cross-sectional study, a web-based 25-question MSK test was given to licensed physical therapists and physicians; as well as final year physical therapy and medical students and interns in Saudi Arabia. One-way analysis of variance was used to determine MSK test scores differences amongst orthopedists, primary care physicians, and physical therapists; and amongst medical and physical therapy students and interns. Results : A total of 680 participants were included (response rate is 86.7%.) The overall MSK test score was 48.2%; and the passing rate was 14%. There was a significant score difference amongst orthopedists (88.8%), primary care physicians (53.6%), and physical therapists (46.7%); F (2,431) = 38.1, p < .001). There was significant score difference amongst physical therapy students (45.3%), physical therapy interns (42.6%), medical students (52.3%) and medical interns (67.4%); F (3,242) = 10.7, p < .001). Conclusion: Except for orthopedists, the MSK medicine knowledge appears inadequate amongst healthcare providers, medical and physical therapy students and interns in Saudi Arabia. To improve knowledge in MSK medicine, increasing contents of MSK medicine in undergraduate education and postgraduate training is necessary. Educational Philosophy and Theory Internal Medicine musculoskeletal medicine competency education Saudi Arabia primary care providers physical therapists students interns Figures Figure 1 Lessons For The Practice Except for orthopedists, musculoskeletal (MSK) medicine knowledge appears inadequate amongst physicians and physical therapists. Inadequate MSK medicine knowledge may be explained by lack of exposure to skills of history taking, orthopedic physical examination, radiographic evaluation, proper MSK intervention, and overall minimal time devoted to education of MSK medicine at under- and postgraduate levels. National plans to improve MSK medicine knowledge are necessary to bridge the gap between the inadequate knowledge of how to manage MSK conditions and the increasing volume of patients suffering from MSK conditions. Introduction Musculoskeletal (MSK) conditions are rapidly rising in Saudi Arabia reaching levels similar to that of the western world. 1 , 2 MSK conditions are the 3rd reason to visit a hospital in Saudi Arabia, 3 and account for 38% of visits in family practice. 4 Despite the prevalence of MSK conditions, physicians in Saudi Arabia reported low level of confidence in MSK physical examination and had self-perception of incompetency in managing MSK conditions appropriately. 5 This can partly be explained by inadequate preparation of physicians to deal with MSK conditions in both undergraduate and postgraduate medical training. 6 Medical schools, worldwide, spend less than 3% of their curricula on MSK system compared to other body systems. 7 In Canada, only 2.26% of the medical school curriculum is devoted to MSK education. 8 In the United Kingdom, 2% of the clinical years is devoted to orthopedics. 9 Recently, the Association of American Medical Colleges recognized MSK education as one area of deficiency in medical schools and called for strategies to increase MSK contents. 10 Knowledge in MSK medicine among medical practitioners was first assessed using a standardized MSK test developed by Freedman and Bernstein. 11 Eighty-five physicians underwent the test during the first week following graduation. The physicians had a mean score of 59.6%, with only 18% achieving the passing score. Following Freedman and Bernstein study, 11 several medical schools and residencies used the MSK test to evaluate students and physicians. 12 – 15 Except for orthopedists, most of these studies found that students or physicians from various specialties had less than adequate knowledge in MSK medicine. MSK conditions are not only managed by physicians but also by other healthcare practitioners including physical therapists. Early use of physical therapy for management of MSK conditions is supported by consistent recommendations from various clinical practice guidelines, including the American College of Physicians. 16 , 17 Physical therapy has evolved in the past two decades to become an autonomous practice where physical therapists can see patients without a physician referral (i.e. direct access). 18 However, assessment of physical therapists’ knowledge in managing MSK conditions was done in very few studies. 13 , 14 , 19 Childs et al. showed that physical therapists with orthopedic or sports board certification had higher scores on the MSK test than medical students, interns, residents and most medical specialties except orthopedists. 13 , 19 These studies have implications to for health and public policy to utilize physical therapists to provide direct care for patients with MSK conditions. In Saudi Arabia, however, physical therapy has not fully evolved into autonomous practice, and is still a secondary care that requires physician referral to manage patients with MSK conditions. 20 Physical therapy programs in Saudi Arabia grant bachelor’s degrees (except for two universities), and their curricula do not adequately emphasize contents of medical screening or differential diagnosis. 21 Physical therapy services are highly demanded in Saudi Arabia with more than 1.5 million visits a year. 22 Visits related to MSK conditions in Saudi Arabia are just under 1.1 million. 23 Despite the high demand, the competency of physical therapists in managing MSK conditions in Saudi Arabia is unknown. Therefore, the purpose of this study is to assess the physical therapists’ and physicians’ knowledge in managing MSK conditions using a standardized MSK test. Based on previous studies, 13 we hypothesized that orthopedists would have the highest mean score on the MSK test compared to primary care physicians and physical therapists. Also, we hypothesized that physical therapists will have similar mean scores on the test compared primary care physicians on the MSK test. This study will additionally assess knowledge of medical and physical therapy students and interns in managing MSK condition. We hypothesize that knowledge amongst medical and physical therapy students and interns is similar across groups. Method Research Design and Participants This was a cross-sectional study conducted from 4th of March 2019 to 30th of April 2019. We included licensed physical therapists and physicians; as well as final year physical therapy and medical students and interns in Saudi Arabia. We excluded physical therapists and physicians who are not licensed to practice in Saudi Arabia and students who are not in their final year. This study was approved by the Research Ethics Committee at XXXX XXXXXXXX XXXXXXX (XXXXXXXX). Sample Size At the time of data collection, the Saudi Ministry of Health had 2645 orthopedists, 9531 primary care physicians, and 4466 rehabilitation providers. 22 We used calculator.net to obtain a sample that represent the targeted population of 16,642 with a margin of error of ± 5 and 95% confidence interval. The needed sample was approximately 376 practitioners (orthopedists, primary care physicians, and physical therapists). 24 Response rate amongst healthcare practitioners were estimated to be between 10–17%, 25,26 thus we planned to send invitations to 3000 or more potential participants. Musculoskeletal Knowledge Test We used a standardized MSK test developed by Freedman and Bernstein. 11 The test contains 25 questions that assessed MSK knowledge (Appendix 1). The questions include commonly encountered MSK conditions in primary care setting such as fractures, dislocations, arthritis, spinal pain, or conditions that warrant emergency referrals. The passing score was determined to be 70% (at least 18 correct answers out of 25). The test was used to assess the MSK knowledge of physical therapy and medical practitioners; and was validated in previous studies. 11 , 12 The original format of the test was paper-based that required short-answers. However, for practicality purposes, we modified the test to a web-based multiple-choice-question format that included 1 correct answer as determined in the original answer key of the test and 3 distractors that we developed. To ensure that the distractors were appropriate, an expert item writer with an orthopedic physical therapy specialty certificate reviewed the questions and the multiple choice answers and made changes as necessary. Data Collection The data were collected using onlineexambuilder.com platform. 27 This platform had many test-taking features necessary for our study. It had a front page where participant could be informed and consented to take the test as part of this research study, and allowed for requesting participants information, timing the test, restricting the number of attempts to 1 per participant, knowing how much time each participant spent taking the test, and exporting the data into a spreadsheet for analysis. An electronic link to the test was sent to email lists of specialized groups of physical therapy and medical students and practitioners. Also, invitations to take the test were posted on several social media channels. Additionally, physical therapy and medical educational programs and hospitals in the northern, southern, central and western regions of Saudi Arabia were invited to participate via phone or direct visits. A reminder to take the MSK test was sent 6 times over the period of the study. After the participant consented, they were asked for demographics and specialty information. The test was in English and limited to 20 minutes. The test was not proctored but questions and answers were presented in random order. Only one correct answer per question was allowed. As soon as the participant finished and submitted the test, they were not allowed to take it again. The results of the test were automatically saved in the platform, which was protected with a password for subsequent analysis. Statistical Analysis Data were analyzed using SPSS 26 (Armonk, NY). Descriptive statistics were used with sample demographics and characteristics. For our primary hypothesis, we conducted a one-way between-subject analysis of variance (ANOVA) to determine if there was a significant difference on the MSK test scores amongst orthopedists, primary care physicians, and physical therapists. For our secondary hypothesis, we also used one-way between-subject ANOVA to determine if there was a difference between physical therapy and medical students and interns (i.e. four groups). If one-way ANOVA was significant for either analyses, subsequent pairwise comparison was done using Tukey’s test to determine where the difference lies. For all analyses, assumptions were tested, and alpha level of significance was set at p < .05. Results A total of 784 potential participants were approached. Of those, 35 were excluded because they did not answer any question; another 51 appeared to have dropped out of the study after answering 2–3 questions and no time was recorded for them; and another 18 did not specify their specialty. We included 680 participants, and the response rate was 86.7%. The participants demographics and specialty information are listed in Table 1 . Table 1 Participants demographics and specialty characteristics Group Age (y) Mean ± SD Sex Females Experience (y) Students and Interns PT students (n = 109) 21.4 ± 3.8 44 na PT interns (n = 77) 21.9 ± 4.6 50 na MD students (n = 40) 23.0 ± 3.1 15 na MD interns (n = 20) 25.3 ± 4.4 4 na Total (n = 246) 22.1 ± 4.1 113 na Physical Therapists Bachelor (n = 329) 26.15 ± 5.6 163 3.3 ± 4.4 Master (n = 34) 31.7 ± 5.4 6 8.6 ± 4.3 DPT (n = 20) 25.2 ± 6.7 15 2.4 ± 3.3 PhD (n = 6) 30.8 ± 6.9 1 7.4 ± 5.1 Total (n = 388) 26.4 ± 5.9 185 3.8 ± 4.6 Primary Care Physicians Family physicians (n = 8) 31.1 ± 14.3 1 8.8 ± 8.1 General practitioners (n = 7) 27.6 ± 3.7 4 3.6 ± General surgery (n = 2) 31 ± 2.8 0 6 ± 2.8 Internal medicine (n = 4) 32.5 ± 4.2 2 7 ± 2.6 Neurologists (n = 1) 27 0 1 Obstetrics & Gynecology (n = 1) 39 0 10 Physiatrists (n = 5) 26.2 ± 3.5 0 2 ± 1.6 Psychiatric (n = 1) 28 0 4 Rheumatologists (n = 1) 22 1 3 Total (n = 30) 29.4 ± 8.1 8 5.4 ± 5.2 Orthopedists (n = 16) 33.8 ± 6.5 1 7.5 ± 3.8 MD: medical doctor na: not applicable PT: physical therapy y: years SD: standard deviation The mean scores for each group of participants are shown in Fig. 1 . The overall passing rate was 14% (Table 2 ). The passing rate was 93.8% for orthopedists, 20% for primary care physicians, and 11.3% for physical therapists. Table 2 Scores and passing rate in the musculoskeletal test for each group of participants Group n MSK Score mean% (SD) Passed (Score ≥ 70%) n Pass Rate % PT student 109 45.3 (19.9) 12 11 PT intern 77 42.6 (16.2) 2 2.6 PT 388 46.7(19.1) 44 11.3 MD student 40 52.3 (19.7) 8 20 MD intern 20 67.4 (19.1) 8 40 Primary Care Physicians 30 53.6 (21.8) 6 20 Orthopedists 16 88.8 (14.1) 15 93.8 Total 680 48.2 (20.4) 95 14 MD: medical doctor MSK: musculoskeletal PT: physical therapy SD: standard deviation For our primary hypothesis, the assumption of normality was not met (Shapiro-Wilk p .05). One way ANOVA showed that there was a significant difference on the MSK test scores amongst orthopedists, primary care physicians and physical therapists F (2,431) = 38.1, p < .001). Subsequent pairwise comparison, shown in Table 3 , revealed a significant difference between orthopedists and physical therapists and orthopedists and primary care physicians. However, there was no significant difference between primary care physicians and physical therapists on MSK test scores. Table 3 Mean differences in MSK test scores among healthcare providers, interns and students MSK Score mean difference % P value 95% Confidence interval Physicians and Physical Therapists Orthopedists vs primary care physicians* 35.15 < .001 21.2–49.1 Orthopedists vs physical therapists* 42 < .001 30.6–53.5 Primary care physicians vs physical therapists 6.9 .141 -1.6–15.4 Students and Interns Medical interns vs medical students* 15.1 .02 1.8–28.4 Medical interns vs physical therapy interns* 24.8 < .001 12.6–37 Medial interns vs physical therapy students* 22.2 < .001 10.4–33.9 Medical students vs physical therapy interns* 9.7 .04 0.3–19.1 Medical students vs physical therapy students 7.1 .18 -1.9–16 Physical therapy interns vs physical therapy students -2.6 .78 -9.9–4.6 *: significant difference ( p .05) except for physical therapy students. The homogeneity assumption of variance was met (Levene statistics > .05) for groups. One way ANOVA showed a significant difference on the MSK test scores amongst the four groups of physical therapy students, physical therapy interns, medical students and medical interns F (3,242) = 10.7, p < .001). Subsequent pairwise comparison, shown in Table 3 , revealed that medical interns had significantly higher scores than medical students, physical therapy students and physical therapy interns. Also, medical students had significantly higher scores than physical therapy interns but not physical therapy students. There was no significant difference between physical therapy inters and students. Discussion Orthopedists, Physicians and Physical Therapists This study highlights the inadequacy of MSK medicine knowledge among various health specialties in Saudi Arabia. As we hypothesized, orthopedists in Saudi Arabia achieved the highest scores and passing rates on the MSK test compared to primary care physicians and physical therapists (Fig. 1 ; Table 2 ). Also, our findings showed that primary care physicians scores averaged 53.6% with a passing rate of 20%, which is similar to Matzkin et al. study showing MSK test scores for physicians in the United States of 50% with a passing rate of 21%. 12 However, our finding showed that physical therapists achieved the lowest scores of 46.72% with a passing rate of 11.3%, which is in sharp contrast to previous studies from the United States showing that physical therapists come next to orthopedists on the MSK test with scores between 74% − 81% and a passing rate of 58% − 88%. 13 These low scores among physicians and physical therapists is quite disturbing provided that MSK complaints are the 3rd reason to visit primary care clinics in Saudi Arabia and up to 83% of rehabilitation visits require physical therapy. 22 , 23 This discrepancy between the volume of MSK conditions and inadequate knowledge in management of MSK conditions might be a factor that contribute to the rising health care expenditure and the MSK-related disability in Saudi Arabia. 1 National plans to improve musculoskeletal knowledge are necessary. Even though there was no significant difference between primary care physicians and physical therapists on the MSK test score, both professions exhibited inadequate level of knowledge in managing MSK conditions and several reasons may explain such low performance. For primary care physicians, multiple studies suggested that lack of exposure to essential elements of MSK medicine such as orthopedic physical examination skills, radiographic evaluation, and overall time devoted to training MSK clinical skill was minimal or nonexistent. 6 In Saudi Arabia, one study showed management of MSK spinal disorders by primary care physician was improper. 28 Fifty percent of primary care physicians indicated they would prescribe lumbar support, 62% would recommend bed rest 57% would not refer a patient when they suspected a spinal fracture, and up to 72% underestimated neurological risks post spinal surgery. 28 Spinal disorders are the 4th major cause of disability in Saudi Arabia and represent a large portion of MSK complaints, 1 yet primary care physicians seem inadequately prepared to manage such conditions. While we recognize that further research is needed to identify reasons underpinning such practice patterns, we believe MSK training can help bridge the gap in knowledge of how to manage MSK conditions. For physical therapists, the lower performance on the MSK test score may be explained partly by lack of postgraduate clinical training in Saudi Arabia. 20 , 29 Once physical therapists graduate, there are no residency or fellowship opportunities they can pursue to improve their clinical experiences. 29 It appears that graduate education in Saudi Arabia is associated with improved MSK medicine knowledge amongst physical therapists with master or doctor of philosophy degrees as shown in Fig. 1 . However, these degrees are research-oriented more so than clinically-oriented, and the achieved scores among physical therapists with graduate degrees is still suboptimal. Previous research in the United States showed that physical therapists with clinical orthopedic or sports board certification or fellowship achieved highest scores and passing rates on the MSK test compared to other specialties (except orthopedists). 13 , 14 Also, Jette et al. showed that physical therapists with orthopedic board specialization were twice as likely to make correct clinical decision when presented with MSK conditions than those without. 30 Further, physical therapists with orthopedic board specialization were more efficient in MSK conditions management using fewer visits, lower cost, and utilization of treatment procedures. 31 Thus, establishing orthopedic and sport residency and fellowship programs in Saudi Arabia has the potential to improve MSK medicine knowledge amongst physical therapists in Saudi Arabia. The other reason, we believe, for the low performance of physical therapists in Saudi Arabia is the professional legislation. In Saudi Arabia, physical therapy is a secondary care service that relies on physician referral that sometimes involve directions on what intervention should be used. Because of this, physical therapists in Saudi Arabia might be continuously under the impression that patients with MSK conditions had already been screened and diagnosed by the physician, which leave them less prepared to conduct their own screening and examination, and only ready to conduct interventions. This lack of opportunity for physical therapists to practice autonomously as primary care providers may have its impact on their clinical skills to practice proper management of MSK conditions. Nonetheless, the poor performance on the MSK test implies that physical therapists in Saudi Arabia might not be ready to see patients in direct access settings. Before such privilege is legislated, adequate training in MSK medicine must be instated. Medical and Physical Therapy Students and Interns At the level of students and interns, medical interns and students in Saudi Arabia showed higher MSK test scores than physical therapy students and interns (Fig. 1 ). Medical interns in Saudi Arabia, noticeably, achieved higher scores and passing rate (40%) than the whole sample of participants in this study, except orthopedists. This performance is better than we anticipated and may be explained by that medical interns are actively involved in preparing for the licensure examination, which may have provided them an advantage in exam-taking skills over other participants. Nevertheless, the overall average scores of medical interns and student were suboptimal (67% and 52% respectively), and comparable to the scores reported by Freedman and Bernstein for medical interns (60%) and students (54%) in the United States. 11 The lower scores of medical interns and students reinforce the finding from one survey that reported that medical undergraduates perceived that MSK medicine was not emphasized, nor competency in MSK medicine was required. 5 Similar findings were reported in many parts of the world, and we join the Bulletin of World Health Organization call to increase the contents of MSK medicine in medical curricula. 6 Also, this finding begs the question whether future physicians are being adequately prepared to deal with the increasing volume of MSK conditions once they enter the workforce. Physical therapy students and interns were amongst the lower scores on the MSK test (Fig. 1 ). Interestingly, the students and interns scores did not differ largely from the scores of those with bachelor or doctor of physical therapy degrees. This finding concurs with our prior survey that examined the entry-level competency of 149 graduating physical therapists in Saudi Arabia using a 70-question multiple choice exam and found that the average score in various clinical skills to be 34%. 32 Also, Bindawas et al. evaluated the competency of graduating physical therapists in Saudi Arabia from the perspective of clinicians and academicians and found that skills of evaluation, examination, and treatment were all rated less than 3 out 5 on the Clinical Internship Evaluation Tool. 33 These suboptimal scores from the current study and previous ones are likely due to the variability in physical therapy curricula and lack of emphasis on MSK medicine education. 21 One study showed that physical therapy students and interns uniformly agree there is a need to increase manual therapy contents and establish orthopedic residencies. 21 We believe that there is a critical need to reform physical therapy education and training in Saudi Arabia, not only in MSK medicine contents but in all other subjects. Recommendations Musculoskeletal medicine education in under- and postgraduate levels can be improved by adopting the recommendations of the World Health Organization Bulletin and the Association of American Medical Colleges. 6 , 10 In undergraduate MSK education of physicians and physical therapists, teaching should include basic sciences needed for understanding the MSK system such as anatomy, pathophysiology of MSK system, kinesiology and biomechanics of the locomotor system. Clinical MSK education should develop students’ skills in history taking, physical examination, treatment options, decision-making algorithms, 34 extend into disease prevention, and communication and attitude skills. 6 , 35 MSK teaching method should focus on problem-based learning that utilize case studies to further develop deep learning and analytical skills. For postgraduate MSK education, programs for primary care physicians and physical therapists should include rotations in orthopedic and rheumatology or any specialty that deal with MSK conditions. Specialized training such as residencies and fellowships should be developed to increase knowledge in specific MSK area such sports, rehabilitation, or pain management. Elaborated details of MSK education contents have been published in the literature. 35 Limitations Our study included many limitations. The study included a convenience sample so we cannot exclude the possibility of selection bias. Despite our multiple attempts to increase the representation of primary care physicians and orthopedists, the number of participants in these groups was lower and we cannot be sure that our findings were representative of these populations. Our sample was composed of volunteers who may have chosen to complete the MSK test due to desire for professional self-development and personal growth in practice, which may limit the generalizability to other practitioners. Also, the content of the MSK test may have been more inclined towards physicians more than physical therapists, however, previous studies used the test for physical therapists too. Some authors expressed concerns that the MSK test by Freedman and Bernstein did not capture the competency skills for primary care physicians and suggested a modified version that was still under validity investigation. 36 Conclusion Except for orthopedists, the current study showed that MSK medicine knowledge is suboptimal amongst primary care physicians and physical therapists in Saudi Arabia. Even though not significantly different, primary care physicians achieved higher scores than physical therapists. Also, the study identified deficiency in knowledge among medical and physical therapy students and interns. Medical interns had the highest score of all the groups except orthopedist. Our study highlights the need to improve musculoskeletal education in Saudi Arabia for various specialties. Abbreviations ANOVA Analysis of Variance MSK Musculoskeletal Declarations Ethical Approval and Consent of Participants This study was approved by the Office of Research Integrity and Compliance at XXXXXXXX School of Medicine # XXXXXXXX Consent of Publication Not Applicable Availability of Data and Materail The datasets used during the current study are available from the corresponding author upon request. Competing Interest The authors declare that they have no competing interests. Funding The authors received no funding for this study. Author’s Contributions MA and FA equally participated in designing the study, collecting, analyzing, and interpreting the patient data, as well as writing the manuscript. All authors read and approved the final manuscript. Acknowledgement Not Applicable References References : Mokdad AH, Jaber S, Aziz MI, et al. The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet. 2014;383(9914):309–320. Moradi-Lakeh M, Forouzanfar MH, Vollset SE, et al. Burden of musculoskeletal disorders in the Eastern Mediterranean Region, 1990–2013: findings from the Global Burden of Disease Study 2013. Annals of the rheumatic diseases. 2017;76(8):1365–1373. Health Mo. Health Statistics Annual Book. https://www.moh.gov.sa/en/Ministry/Statistics/book/Documents/Statistics-Book-1434.pdf . Published 2013. AccessedApril 9, 2020. al-Shammari SA, Nass M, al-Maatouq MA, al-Quaiz JM. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-909940","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":54439420,"identity":"a3bc4044-6200-4aa9-b47a-fe2bc801f96b","order_by":0,"name":"Muhammad Alrwaily","email":"data:image/png;base64,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","orcid":"","institution":"West Virginia University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Alrwaily","suffix":""},{"id":54439421,"identity":"f23d63c4-81ec-4642-ba68-26a0159b3fce","order_by":1,"name":"Fahad Alanazi","email":"","orcid":"","institution":"Aljouf University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fahad","middleName":"","lastName":"Alanazi","suffix":""}],"badges":[],"createdAt":"2021-09-16 03:44:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-909940/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-909940/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":14068271,"identity":"c7463a65-446a-463d-b9c5-22b45be6232d","added_by":"auto","created_at":"2021-09-28 15:50:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34914,"visible":true,"origin":"","legend":"Scores of the musculoskeletal test for each specialty of participants.\nPT: physical therapy\nDPT: doctor of physical therapy\nPhD: philosophy degree\n","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-909940/v1/0e840adf226538924bafe2ec.png"},{"id":17686036,"identity":"d19368c8-6227-463e-bbda-d2690518a92c","added_by":"auto","created_at":"2022-01-27 05:59:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":431700,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-909940/v1/06c0bc20-15f1-47ef-b8be-92fba47b3d7d.pdf"},{"id":14068272,"identity":"0937f56d-c200-451e-9d18-19062d28b97f","added_by":"auto","created_at":"2021-09-28 15:50:03","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":178855,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-909940/v1/905a70eb3d208f364fb81065.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Musculoskeletal Medicine Knowledge Among Physicians and Physical Therapists in Saudi Arabia: A Cross-Sectional Study","fulltext":[{"header":"Lessons For The Practice","content":"\u003cul\u003e\n \u003cli\u003eExcept for orthopedists, musculoskeletal (MSK) medicine knowledge appears inadequate amongst physicians and physical therapists.\u003c/li\u003e\n \u003cli\u003eInadequate MSK medicine knowledge may be explained by lack of exposure to skills of history taking, orthopedic physical examination, radiographic evaluation, proper MSK intervention, and overall minimal time devoted to education of MSK medicine at under- and postgraduate levels.\u003c/li\u003e\n \u003cli\u003eNational plans to improve MSK medicine knowledge are necessary to bridge the gap between the inadequate knowledge of how to manage MSK conditions and the increasing volume of patients suffering from MSK conditions.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eMusculoskeletal (MSK) conditions are rapidly rising in Saudi Arabia reaching levels similar to that of the western world.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e MSK conditions are the 3rd reason to visit a hospital in Saudi Arabia,\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e and account for 38% of visits in family practice.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Despite the prevalence of MSK conditions, physicians in Saudi Arabia reported low level of confidence in MSK physical examination and had self-perception of incompetency in managing MSK conditions appropriately.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e This can partly be explained by inadequate preparation of physicians to deal with MSK conditions in both undergraduate and postgraduate medical training.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Medical schools, worldwide, spend less than 3% of their curricula on MSK system compared to other body systems.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In Canada, only 2.26% of the medical school curriculum is devoted to MSK education.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In the United Kingdom, 2% of the clinical years is devoted to orthopedics.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Recently, the Association of American Medical Colleges recognized MSK education as one area of deficiency in medical schools and called for strategies to increase MSK contents.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eKnowledge in MSK medicine among medical practitioners was first assessed using a standardized MSK test developed by Freedman and Bernstein.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Eighty-five physicians underwent the test during the first week following graduation. The physicians had a mean score of 59.6%, with only 18% achieving the passing score. Following Freedman and Bernstein study,\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e several medical schools and residencies used the MSK test to evaluate students and physicians.\u003csup\u003e\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Except for orthopedists, most of these studies found that students or physicians from various specialties had less than adequate knowledge in MSK medicine.\u003c/p\u003e \u003cp\u003eMSK conditions are not only managed by physicians but also by other healthcare practitioners including physical therapists. Early use of physical therapy for management of MSK conditions is supported by consistent recommendations from various clinical practice guidelines, including the American College of Physicians.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Physical therapy has evolved in the past two decades to become an autonomous practice where physical therapists can see patients without a physician referral (i.e. direct access).\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e However, assessment of physical therapists\u0026rsquo; knowledge in managing MSK conditions was done in very few studies.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Childs et al. showed that physical therapists with orthopedic or sports board certification had higher scores on the MSK test than medical students, interns, residents and most medical specialties except orthopedists.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e These studies have implications to for health and public policy to utilize physical therapists to provide direct care for patients with MSK conditions.\u003c/p\u003e \u003cp\u003eIn Saudi Arabia, however, physical therapy has not fully evolved into autonomous practice, and is still a secondary care that requires physician referral to manage patients with MSK conditions.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Physical therapy programs in Saudi Arabia grant bachelor\u0026rsquo;s degrees (except for two universities), and their curricula do not adequately emphasize contents of medical screening or differential diagnosis.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Physical therapy services are highly demanded in Saudi Arabia with more than 1.5\u0026nbsp;million visits a year.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Visits related to MSK conditions in Saudi Arabia are just under 1.1\u0026nbsp;million.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Despite the high demand, the competency of physical therapists in managing MSK conditions in Saudi Arabia is unknown. Therefore, the purpose of this study is to assess the physical therapists\u0026rsquo; and physicians\u0026rsquo; knowledge in managing MSK conditions using a standardized MSK test. Based on previous studies,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e we hypothesized that orthopedists would have the highest mean score on the MSK test compared to primary care physicians and physical therapists. Also, we hypothesized that physical therapists will have similar mean scores on the test compared primary care physicians on the MSK test. This study will additionally assess knowledge of medical and physical therapy students and interns in managing MSK condition. We hypothesize that knowledge amongst medical and physical therapy students and interns is similar across groups.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Design and Participants\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional study conducted from 4th of March 2019 to 30th of April 2019. We included licensed physical therapists and physicians; as well as final year physical therapy and medical students and interns in Saudi Arabia. We excluded physical therapists and physicians who are not licensed to practice in Saudi Arabia and students who are not in their final year. This study was approved by the Research Ethics Committee at XXXX XXXXXXXX XXXXXXX (XXXXXXXX).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSample Size\u003c/h2\u003e \u003cp\u003eAt the time of data collection, the Saudi Ministry of Health had 2645 orthopedists, 9531 primary care physicians, and 4466 rehabilitation providers.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e We used calculator.net to obtain a sample that represent the targeted population of 16,642 with a margin of error of \u0026plusmn;\u0026thinsp;5 and 95% confidence interval. The needed sample was approximately 376 practitioners (orthopedists, primary care physicians, and physical therapists).\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Response rate amongst healthcare practitioners were estimated to be between 10\u0026ndash;17%,\u003csup\u003e25,26\u003c/sup\u003e thus we planned to send invitations to 3000 or more potential participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMusculoskeletal Knowledge Test\u003c/h2\u003e \u003cp\u003eWe used a standardized MSK test developed by Freedman and Bernstein.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The test contains 25 questions that assessed MSK knowledge (Appendix 1). The questions include commonly encountered MSK conditions in primary care setting such as fractures, dislocations, arthritis, spinal pain, or conditions that warrant emergency referrals. The passing score was determined to be 70% (at least 18 correct answers out of 25). The test was used to assess the MSK knowledge of physical therapy and medical practitioners; and was validated in previous studies.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe original format of the test was paper-based that required short-answers. However, for practicality purposes, we modified the test to a web-based multiple-choice-question format that included 1 correct answer as determined in the original answer key of the test and 3 distractors that we developed. To ensure that the distractors were appropriate, an expert item writer with an orthopedic physical therapy specialty certificate reviewed the questions and the multiple choice answers and made changes as necessary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eThe data were collected using onlineexambuilder.com platform.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e This platform had many test-taking features necessary for our study. It had a front page where participant could be informed and consented to take the test as part of this research study, and allowed for requesting participants information, timing the test, restricting the number of attempts to 1 per participant, knowing how much time each participant spent taking the test, and exporting the data into a spreadsheet for analysis.\u003c/p\u003e \u003cp\u003eAn electronic link to the test was sent to email lists of specialized groups of physical therapy and medical students and practitioners. Also, invitations to take the test were posted on several social media channels. Additionally, physical therapy and medical educational programs and hospitals in the northern, southern, central and western regions of Saudi Arabia were invited to participate via phone or direct visits. A reminder to take the MSK test was sent 6 times over the period of the study.\u003c/p\u003e \u003cp\u003eAfter the participant consented, they were asked for demographics and specialty information. The test was in English and limited to 20 minutes. The test was not proctored but questions and answers were presented in random order. Only one correct answer per question was allowed. As soon as the participant finished and submitted the test, they were not allowed to take it again. The results of the test were automatically saved in the platform, which was protected with a password for subsequent analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS 26 (Armonk, NY). Descriptive statistics were used with sample demographics and characteristics. For our primary hypothesis, we conducted a one-way between-subject analysis of variance (ANOVA) to determine if there was a significant difference on the MSK test scores amongst orthopedists, primary care physicians, and physical therapists. For our secondary hypothesis, we also used one-way between-subject ANOVA to determine if there was a difference between physical therapy and medical students and interns (i.e. four groups). If one-way ANOVA was significant for either analyses, subsequent pairwise comparison was done using Tukey\u0026rsquo;s test to determine where the difference lies. For all analyses, assumptions were tested, and alpha level of significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 784 potential participants were approached. Of those, 35 were excluded because they did not answer any question; another 51 appeared to have dropped out of the study after answering 2\u0026ndash;3 questions and no time was recorded for them; and another 18 did not specify their specialty. We included 680 participants, and the response rate was 86.7%. The participants demographics and specialty information are listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eParticipants demographics and specialty characteristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAge (y)\u003c/p\u003e\n\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSex\u003c/p\u003e\n\u003cp\u003eFemales\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eExperience (y)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eStudents and Interns\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePT students (n\u0026thinsp;=\u0026thinsp;109)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePT interns (n\u0026thinsp;=\u0026thinsp;77)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMD students (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMD interns (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;246)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e113\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical Therapists\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBachelor (n\u0026thinsp;=\u0026thinsp;329)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.15\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e163\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaster (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDPT (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhD (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;388)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e185\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Care Physicians\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFamily physicians (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral practitioners (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.6 \u0026plusmn;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral surgery (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInternal medicine (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeurologists (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eObstetrics \u0026amp; Gynecology (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysiatrists (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePsychiatric (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRheumatologists (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOrthopedists (n\u0026thinsp;=\u0026thinsp;16)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eMD: medical doctor\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003ena: not applicable\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003ePT: physical therapy\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003ey: years\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eSD: standard deviation\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe mean scores for each group of participants are shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The overall passing rate was 14% (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The passing rate was 93.8% for orthopedists, 20% for primary care physicians, and 11.3% for physical therapists.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eScores and passing rate in the musculoskeletal test for each group of participants\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMSK Score mean% (SD)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePassed\u003c/p\u003e\n\u003cp\u003e(Score\u0026thinsp;\u0026ge;\u0026thinsp;70%)\u003c/p\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePass Rate %\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePT student\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e109\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e45.3 (19.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePT intern\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e42.6 (16.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e388\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e46.7(19.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMD student\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e52.3 (19.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMD intern\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e67.4 (19.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrimary Care Physicians\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e53.6 (21.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOrthopedists\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e88.8 (14.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e680\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e48.2 (20.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eMD: medical doctor\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eMSK: musculoskeletal\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003ePT: physical therapy\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eSD: standard deviation\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFor our primary hypothesis, the assumption of normality was not met (Shapiro-Wilk \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) but the assumption of homogeneity of variance was met for all the levels (Levene statistic \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05). One way ANOVA showed that there was a significant difference on the MSK test scores amongst orthopedists, primary care physicians and physical therapists \u003cem\u003eF\u003c/em\u003e(2,431)\u0026thinsp;=\u0026thinsp;38.1, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Subsequent pairwise comparison, shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, revealed a significant difference between orthopedists and physical therapists and orthopedists and primary care physicians. However, there was no significant difference between primary care physicians and physical therapists on MSK test scores.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMean differences in MSK test scores among healthcare providers, interns and students\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMSK Score mean difference %\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e95% Confidence interval\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePhysicians and Physical Therapists\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOrthopedists vs primary care physicians*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35.15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.2\u0026ndash;49.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOrthopedists vs physical therapists*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.6\u0026ndash;53.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrimary care physicians vs physical therapists\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.141\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-1.6\u0026ndash;15.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eStudents and Interns\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical interns vs medical students*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.8\u0026ndash;28.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical interns vs physical therapy interns*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.6\u0026ndash;37\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedial interns vs physical therapy students*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.4\u0026ndash;33.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical students vs physical therapy interns*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.3\u0026ndash;19.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical students vs physical therapy students\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-1.9\u0026ndash;16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical therapy interns vs physical therapy students\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-2.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-9.9\u0026ndash;4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003e*: significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05)\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eMSK: musculoskeletal\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFor our secondary hypothesis, the assumption of normality was met for all groups (Shapiro-Wilk \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05) except for physical therapy students. The homogeneity assumption of variance was met (Levene statistics\u0026thinsp;\u0026gt;\u0026thinsp;.05) for groups. One way ANOVA showed a significant difference on the MSK test scores amongst the four groups of physical therapy students, physical therapy interns, medical students and medical interns \u003cem\u003eF\u003c/em\u003e(3,242)\u0026thinsp;=\u0026thinsp;10.7, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Subsequent pairwise comparison, shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, revealed that medical interns had significantly higher scores than medical students, physical therapy students and physical therapy interns. Also, medical students had significantly higher scores than physical therapy interns but not physical therapy students. There was no significant difference between physical therapy inters and students.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eOrthopedists, Physicians and Physical Therapists\u003c/h2\u003e \u003cp\u003eThis study highlights the inadequacy of MSK medicine knowledge among various health specialties in Saudi Arabia. As we hypothesized, orthopedists in Saudi Arabia achieved the highest scores and passing rates on the MSK test compared to primary care physicians and physical therapists (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Also, our findings showed that primary care physicians scores averaged 53.6% with a passing rate of 20%, which is similar to Matzkin et al. study showing MSK test scores for physicians in the United States of 50% with a passing rate of 21%.\u003csup\u003e12\u003c/sup\u003e However, our finding showed that physical therapists achieved the lowest scores of 46.72% with a passing rate of 11.3%, which is in sharp contrast to previous studies from the United States showing that physical therapists come next to orthopedists on the MSK test with scores between 74% \u0026minus;\u0026thinsp;81% and a passing rate of 58% \u0026minus;\u0026thinsp;88%.\u003csup\u003e13\u003c/sup\u003e These low scores among physicians and physical therapists is quite disturbing provided that MSK complaints are the 3rd reason to visit primary care clinics in Saudi Arabia and up to 83% of rehabilitation visits require physical therapy.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e This discrepancy between the volume of MSK conditions and inadequate knowledge in management of MSK conditions might be a factor that contribute to the rising health care expenditure and the MSK-related disability in Saudi Arabia.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e National plans to improve musculoskeletal knowledge are necessary.\u003c/p\u003e \u003cp\u003eEven though there was no significant difference between primary care physicians and physical therapists on the MSK test score, both professions exhibited inadequate level of knowledge in managing MSK conditions and several reasons may explain such low performance. For primary care physicians, multiple studies suggested that lack of exposure to essential elements of MSK medicine such as orthopedic physical examination skills, radiographic evaluation, and overall time devoted to training MSK clinical skill was minimal or nonexistent.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In Saudi Arabia, one study showed management of MSK spinal disorders by primary care physician was improper.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Fifty percent of primary care physicians indicated they would prescribe lumbar support, 62% would recommend bed rest 57% would not refer a patient when they suspected a spinal fracture, and up to 72% underestimated neurological risks post spinal surgery.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Spinal disorders are the 4th major cause of disability in Saudi Arabia and represent a large portion of MSK complaints,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e yet primary care physicians seem inadequately prepared to manage such conditions. While we recognize that further research is needed to identify reasons underpinning such practice patterns, we believe MSK training can help bridge the gap in knowledge of how to manage MSK conditions.\u003c/p\u003e \u003cp\u003eFor physical therapists, the lower performance on the MSK test score may be explained partly by lack of postgraduate clinical training in Saudi Arabia.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Once physical therapists graduate, there are no residency or fellowship opportunities they can pursue to improve their clinical experiences.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e It appears that graduate education in Saudi Arabia is associated with improved MSK medicine knowledge amongst physical therapists with master or doctor of philosophy degrees as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. However, these degrees are research-oriented more so than clinically-oriented, and the achieved scores among physical therapists with graduate degrees is still suboptimal. Previous research in the United States showed that physical therapists with clinical orthopedic or sports board certification or fellowship achieved highest scores and passing rates on the MSK test compared to other specialties (except orthopedists).\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Also, Jette et al. showed that physical therapists with orthopedic board specialization were twice as likely to make correct clinical decision when presented with MSK conditions than those without.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Further, physical therapists with orthopedic board specialization were more efficient in MSK conditions management using fewer visits, lower cost, and utilization of treatment procedures.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Thus, establishing orthopedic and sport residency and fellowship programs in Saudi Arabia has the potential to improve MSK medicine knowledge amongst physical therapists in Saudi Arabia.\u003c/p\u003e \u003cp\u003eThe other reason, we believe, for the low performance of physical therapists in Saudi Arabia is the professional legislation. In Saudi Arabia, physical therapy is a secondary care service that relies on physician referral that sometimes involve directions on what intervention should be used. Because of this, physical therapists in Saudi Arabia might be continuously under the impression that patients with MSK conditions had already been screened and diagnosed by the physician, which leave them less prepared to conduct their own screening and examination, and only ready to conduct interventions. This lack of opportunity for physical therapists to practice autonomously as primary care providers may have its impact on their clinical skills to practice proper management of MSK conditions. Nonetheless, the poor performance on the MSK test implies that physical therapists in Saudi Arabia might not be ready to see patients in direct access settings. Before such privilege is legislated, adequate training in MSK medicine must be instated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMedical and Physical Therapy Students and Interns\u003c/h2\u003e \u003cp\u003eAt the level of students and interns, medical interns and students in Saudi Arabia showed higher MSK test scores than physical therapy students and interns (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Medical interns in Saudi Arabia, noticeably, achieved higher scores and passing rate (40%) than the whole sample of participants in this study, except orthopedists. This performance is better than we anticipated and may be explained by that medical interns are actively involved in preparing for the licensure examination, which may have provided them an advantage in exam-taking skills over other participants. Nevertheless, the overall average scores of medical interns and student were suboptimal (67% and 52% respectively), and comparable to the scores reported by Freedman and Bernstein for medical interns (60%) and students (54%) in the United States.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The lower scores of medical interns and students reinforce the finding from one survey that reported that medical undergraduates perceived that MSK medicine was not emphasized, nor competency in MSK medicine was required.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Similar findings were reported in many parts of the world, and we join the Bulletin of World Health Organization call to increase the contents of MSK medicine in medical curricula.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Also, this finding begs the question whether future physicians are being adequately prepared to deal with the increasing volume of MSK conditions once they enter the workforce.\u003c/p\u003e \u003cp\u003ePhysical therapy students and interns were amongst the lower scores on the MSK test (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Interestingly, the students and interns scores did not differ largely from the scores of those with bachelor or doctor of physical therapy degrees. This finding concurs with our prior survey that examined the entry-level competency of 149 graduating physical therapists in Saudi Arabia using a 70-question multiple choice exam and found that the average score in various clinical skills to be 34%.\u003csup\u003e32\u003c/sup\u003e Also, Bindawas et al. evaluated the competency of graduating physical therapists in Saudi Arabia from the perspective of clinicians and academicians and found that skills of evaluation, examination, and treatment were all rated less than 3 out 5 on the Clinical Internship Evaluation Tool.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e These suboptimal scores from the current study and previous ones are likely due to the variability in physical therapy curricula and lack of emphasis on MSK medicine education.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e One study showed that physical therapy students and interns uniformly agree there is a need to increase manual therapy contents and establish orthopedic residencies.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e We believe that there is a critical need to reform physical therapy education and training in Saudi Arabia, not only in MSK medicine contents but in all other subjects.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eMusculoskeletal medicine education in under- and postgraduate levels can be improved by adopting the recommendations of the World Health Organization Bulletin and the Association of American Medical Colleges.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In undergraduate MSK education of physicians and physical therapists, teaching should include basic sciences needed for understanding the MSK system such as anatomy, pathophysiology of MSK system, kinesiology and biomechanics of the locomotor system. Clinical MSK education should develop students\u0026rsquo; skills in history taking, physical examination, treatment options, decision-making algorithms,\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e extend into disease prevention, and communication and attitude skills.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e MSK teaching method should focus on problem-based learning that utilize case studies to further develop deep learning and analytical skills. For postgraduate MSK education, programs for primary care physicians and physical therapists should include rotations in orthopedic and rheumatology or any specialty that deal with MSK conditions. Specialized training such as residencies and fellowships should be developed to increase knowledge in specific MSK area such sports, rehabilitation, or pain management. Elaborated details of MSK education contents have been published in the literature.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e "},{"header":"Limitations","content":"\u003cp\u003eOur study included many limitations. The study included a convenience sample so we cannot exclude the possibility of selection bias. Despite our multiple attempts to increase the representation of primary care physicians and orthopedists, the number of participants in these groups was lower and we cannot be sure that our findings were representative of these populations. Our sample was composed of volunteers who may have chosen to complete the MSK test due to desire for professional self-development and personal growth in practice, which may limit the generalizability to other practitioners. Also, the content of the MSK test may have been more inclined towards physicians more than physical therapists, however, previous studies used the test for physical therapists too. Some authors expressed concerns that the MSK test by Freedman and Bernstein did not capture the competency skills for primary care physicians and suggested a modified version that was still under validity investigation.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e Except for orthopedists, the current study showed that MSK medicine knowledge is suboptimal amongst primary care physicians and physical therapists in Saudi Arabia. Even though not significantly different, primary care physicians achieved higher scores than physical therapists. Also, the study identified deficiency in knowledge among medical and physical therapy students and interns. Medical interns had the highest score of all the groups except orthopedist. Our study highlights the need to improve musculoskeletal education in Saudi Arabia for various specialties.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANOVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnalysis of Variance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMSK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMusculoskeletal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent of Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Office of Research Integrity and Compliance at XXXXXXXX School of Medicine #\u0026nbsp;XXXXXXXX\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent of Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materail\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe datasets used during the current study are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMA and FA equally participated in designing the study, collecting, analyzing, and interpreting the patient data, as well as writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cdiv class=\"Heading\"\u003e\u003cb\u003eReferences\u003c/b\u003e:\u003c/div\u003e \u003cli\u003e\u003cspan\u003eMokdad AH, Jaber S, Aziz MI, et al. The state of health in the Arab world, 1990\u0026ndash;2010: an analysis of the burden of diseases, injuries, and risk factors. \u003cem\u003eLancet.\u003c/em\u003e 2014;383(9914):309\u0026ndash;320.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoradi-Lakeh M, Forouzanfar MH, Vollset SE, et al. 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Assessment of the views of clinical and academic physical therapists. \u003cem\u003eJ Phys Ther Sci.\u003c/em\u003e 2013;25(5):649\u0026ndash;655.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlrwaily M, Timko M, Schneider M, et al. Treatment-Based Classification System for Low Back Pain: Revision and Update. \u003cem\u003ePhysical therapy.\u003c/em\u003e 2016;96(7):1057\u0026ndash;1066.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoolf AD, Walsh NE, Akesson K. Global core recommendations for a musculoskeletal undergraduate curriculum. \u003cem\u003eAnnals of the rheumatic diseases.\u003c/em\u003e 2004;63(5):517\u0026ndash;524.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCummings DL, Smith M, Merrigan B, Leggit J. MSK30: a validated tool to assess clinical musculoskeletal knowledge. \u003cem\u003eBMJ Open Sport Exerc Med.\u003c/em\u003e 2019;5(1):e000495.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"musculoskeletal medicine, competency, education, Saudi Arabia, primary care providers, physical therapists, students, interns","lastPublishedDoi":"10.21203/rs.3.rs-909940/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-909940/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Musculoskeletal (MSK) conditions are rapidly rising in Saudi Arabia and considered the 3\u003csup\u003erd\u003c/sup\u003e reason for hospital visits across the country.\u0026nbsp;Despite their prevalence, the adequacy of knowledge in MSK medicine has not been assessed.\u0026nbsp;The purpose of this study is to assess MSK medicine knowledge amongst healthcare providers (orthopedists, primary care physicians, and physical therapists) and medical and physical therapy students and interns.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eIn this cross-sectional study, a web-based 25-question MSK test was given to licensed physical therapists and physicians; as well as final year physical therapy and medical students and interns in Saudi Arabia. One-way analysis of variance was used to determine MSK test scores differences amongst orthopedists, primary care physicians, and physical therapists; and amongst medical and physical therapy students and interns.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 680 participants were included (response rate is 86.7%.)\u0026nbsp;The overall MSK test score was 48.2%; and the passing rate was 14%.\u0026nbsp;There was a significant score difference amongst orthopedists (88.8%), primary care physicians (53.6%), and physical therapists (46.7%); \u003cem\u003eF\u003c/em\u003e(2,431) = 38.1, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001).\u0026nbsp;There was significant score difference amongst physical therapy students (45.3%), physical therapy interns (42.6%), medical students (52.3%) and medical interns (67.4%); \u003cem\u003eF\u003c/em\u003e(3,242) = 10.7, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Except for orthopedists, the MSK medicine knowledge appears inadequate amongst healthcare providers, medical and physical therapy students and interns in Saudi Arabia.\u0026nbsp;To improve knowledge in MSK medicine, increasing contents of MSK medicine in undergraduate education and postgraduate training is necessary.\u003c/p\u003e","manuscriptTitle":"Evaluation of Musculoskeletal Medicine Knowledge Among Physicians and Physical Therapists in Saudi Arabia: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-28 15:50:01","doi":"10.21203/rs.3.rs-909940/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"04c2eb64-cb8f-4fb3-aa49-c9c5dd0e9898","owner":[],"postedDate":"September 28th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":7504560,"name":"Educational Philosophy and Theory"},{"id":7504561,"name":"Internal Medicine"}],"tags":[],"updatedAt":"2022-01-27T05:59:12+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-28 15:50:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-909940","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-909940","identity":"rs-909940","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}