Knowledge of physiotherapists on the use of Muscle Energy Technique in the management of Non-Specic Low Back Pain

Objective: The relevance and use of Muscle Energy Technique (MET) as a mode of treatment for Non-specic low back pain (NSLBP) over the last two decades has increased among physiotherapists and other health professionals. This supports the clinical relevance and ecacy of this technique. However, there are no studies to determine the level of MET knowledge among Nigerian physiotherapists. This study was designed to determine the MET knowledge among Nigerian physiotherapists. Method: A total of one hundred and twenty physiotherapists were recruited from the database of the Nigerian Society of Physiotherapy and participated in the study. They completed a semi-structured questionnaire containing 46-items. This was divided into four sections which sourced information on sociodemographic characteristics, work-prole, treatment activities and the knowledge of MET for the management of NSLBP. Data were analyzed using descriptive statistics for mean, frequency and percentages. Inferential statistics of Chi-square, Pearson Correlation, independent t-test and ANOVA were used to determine the signicant difference with signicance set at p<0.05. Result: The study revealed that 16.7% of the participants had knowledge of the application of MET in the management for NSLBP. Age, educational level, practice setting, area of specialization such as musculoskeletal therapy, ergonomics and additional training of low back pain (LBP) were factors that inuenced respondents’ MET knowledge (p<0.05). However, gender, university of training, number of years of experience and the practice of managing of LBP in the physiotherapy department did not inuence knowledge of MET for the management of NSLBP (p >0.05). Conclusion: This study showed that a small number of participants had knowledge of MET application in the management of NSLBP and certain factors inuenced this knowledge.


Aim
The main aim of the study is to determine the knowledge of Nigerian physiotherapists on the use of MET for the management of NSLBP and to identify factors that in uence the knowledge of the physiotherapists on the use of MET. However, the following are the speci c objectives of the study;

1.
To test the validity of the questionnaire section that measures the knowledge of MET use among Nigerian Physiotherapists. 2.
To determine if some selected sociodemographic characteristics of physiotherapists have any relation with the knowledge of MET use for the management of NSLBP (e.g. age, sex, educational level, university of graduation, year of induction into physiotherapy and location of practice). 3.
To determine if physiotherapists work-related pro le have any association with knowledge of MET use for the management of NSLBP.

4.
To pro le the treatment activities/strategies of Nigerian physiotherapists in the management of NSLBP. 5.
To determine the proportion of Nigerian physiotherapists that use MET alone or in combination with other therapeutic technique in the management of NSLBP 6.
To determine if physiotherapists' area of specialization has an association with choice of MET in the management of chronic NSLBP.

Research Design
The research design for this study was a cross-sectional survey.

Questionnaire design
This questionnaire titled 'Knowledge of physiotherapists on Muscle Energy Technique use for the management of NSLBP' was adopted from the previous study that is related to the present study (19). A ve-man focus group that consisted of expert researchers and clinicians use the adopted questionnaire as a working document to develop the version of the present structured questionnaire for this study. The nal version was subjected to a validity test for reliability and acceptability. The questionnaire consisted of 46 items divided into four sections. Section A (item 1-6) which sought information on sociodemographic data of the participants, section B (item 7-15) collected information on pro le of work experience, section C (item [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] collected information on physiotherapists treatment activities/strategies for the management of NSLBP, while section D (item 32-46) collected information on physiotherapists knowledge of the use of MET in the management of NSLBP.

Administration of Questionnaire
Ethical approval was sought and obtained prior to the administration of the questionnaire from the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal, Durban, South Africa. Copies of the questionnaire were then distributed online to practising physiotherapists across the 36 states of Nigeria. Participants for this study were selected from the database of Nigerian Society of Physiotherapy based on their current nancial standing with the association and registration with physiotherapy practice regulatory agency i.e. Medical Rehabilitation Therapists Board of Nigeria (MRTB). The aims and objectives of the study were clearly explained in a cover note attached to each copy of the questionnaire, in order to seek their consent. The copies of the questionnaire were distributed to a total of 200 participants aged 20 years and above recruited for this study.

Data Analysis
Data collected were analyzed using SPSS version 24.0. The statistical analyses used for this study were descriptive and inferential statistics. The descriptive statistics focused mainly on frequency, percentages, mean and standard deviation while the inferential statistics focused on Chi-square/Fisher exact test, Pearson correlation, independent t-test and ANOVA (one-way analysis of variance) to determine signi cant difference at p < 0.05. However, to test the internal consistency for section D of the questionnaire, Cronbach's alpha was determined.

Normality test
The normality distribution of age score and MET knowledge score were assessed using a Kolmogorov-Smirnov test of normality, and the p-values were greater than 0.05 (Table 3). Therefore, one-way Anova was used to evaluate the mean difference of age between MET knowledge category (i.e. excellent, very good, good, poor, very poor), and independent t-test was used to evaluate the mean difference of MET knowledge score between the choice of MET category (i.e. yes and no) ( Table 7).

Sociodemographic characteristics
The demographic data of the respondents are shown in table 1. Two-hundred questionnaires were distributed and 140 questionnaires were returned, but only 120 were valid for analysis giving a response of 60.0%. The mean age of the respondents was 36.04 ± 7.51 with range of 33-67 years, 93 (77.5%) are males while the females were 27 (27%), the highest, 57 (47.5%) educational attainment for most of the respondents was Master's degree, followed by rst degree 40 (33.3%). Most of the respondents to this study graduated from Bayero University Kano 76(64.4%), and with regards to respondents year of graduation, graduates from 2001 to 2010 have the highest percentage54 (45.0%) and those from 1970 to 1980 have the least 1 (0.8%). Most of the respondents to this study practice at teaching hospital 35 (29.2%), also 53 (44.2%) of the respondents are musculoskeletal specialists with 52 (43.3%) presently practising at the musculoskeletal unit of their respective hospitals (      (Table 4).   respondents reported that availability of the modalities is the major reasons for the choice of the treatment modalities (Table 5). On average, therapists spend about 20-30 minutes for the management of NSLBP for both initial and follow-up visits (Fig. 3), additionally, 10 to 12 treatment sessions are the most frequent sessions spent 97(80.8%) followed by 7 to 9 sessions 85(70.8%) (Fig. 4), however, the study showed that the respondents spend more time and sessions for the management of chronic NSLBP patients. The major determinant for the choice of the treatment sessions is prognosis followed by a diagnosis of the condition (Fig. 5).
Seventy-three (60.8%) of the study respondents re-evaluate their NSLBP patients over a period of time (Fig. 6), especially after about four to six sessions of treatment (Fig. 7). This study showed that more than 50% of the respondents used one to several outcome measures for the assessment of the NSLBP, however, most common outcome measures reported in the study are stated in Table 6, this includes visual analogue scale (VAS), Oswestry Disability Index  (Table 6).  Chi-square analysis revealed that there was a statistically signi cant association (X 2 = 16.37, P = 0.04) between respondents area of specialization and the choice of MET intervention in the management of NSLBP (Table 6). Additionally, independent t-test analysis further showed that there was a signi cant mean difference in knowledge score between therapists that use MET (mean = 5.15 ± 2.68) and those who do not use MET (mean = 2.86 ± 1.84) in the management of NSLBP, p-value = 0.001, t(df)= -3.65(22.7).

Discussion
The main aim of the study is to determine the knowledge of Nigerian physiotherapists on the use of MET for the management of NSLBP and to identify factors that in uence the knowledge of physiotherapists on the use of MET for the management of NSLBP. The nding of section D of the questionnaire which evaluates the physiotherapists' knowledge on MET use for the management of NSLBP was a valid tool with good internal consistency, this implies that the data collected was valid and it re ects the accurate level of respondents' knowledge.
An important nding from this study is that NSLBP is one of the most common musculoskeletal conditions seen by many physiotherapists in Nigeria, 90% of the respondents reported that they currently manage patients with LBP. This support the current literature estimates that about 50% of patients treated by physiotherapists suffer from LBP [1,2,21,22,23].
This survey also intended to determine if some selected sociodemographic characteristics of the respondents (age, gender, educational level and university of graduation) would have any in uence on the knowledge level of MET use in the management of patients with NSLBP. The ndings from this study revealed that age and educational level have a signi cant in uence on respondents' knowledge of MET, while gender and university of graduation do not in uence the knowledge of the use MET. This implies that the knowledge of the respondents is dependent on his/her years of experience which is directly linked to opportunity for educational advancement in form of postgraduate or in-service training by the respondents in the course of their practice. Additionally, the study showed that majority of the respondents possesses postgraduate quali cations (i.e. masters, PhD or DPT). This nding is in agreement with the report of Swinkels et al [24] and Odebiyi et al [24], who in their studies on low back pain management, reported that older physiotherapists have more knowledge and skills than their younger counterparts, and this could be attributed to experience acquired over the years and more so the acquisition of additional quali cations. Additional post-quali cation training by physiotherapists has been found by this study to have a signi cant relationship with the knowledge of MET use in the management of NSLBP. Therefore, this nding goes in line with the ndings of the above mentioned studies.
The ndings from this study on the relationship between knowledge of MET use and some work-related variables ( i.e. setting of practice, area of specialization, the present unit of practice, certi ed orthopaedic manual therapist, worked in musculoskeletal unit, the cadre of practice and additional training in LBP management) shows that there was a signi cant relationship between the setting of practice and level of knowledge of MET use for the management of NSLBP, this implies that setting of practice could have a tremendous in uence on physiotherapists' MET knowledge. Further analysis of the respondents setting of practice shows that majority of the respondents' practice in teaching hospitals and most of them specialized in musculoskeletal therapy. Teaching hospitals in Nigeria like in most countries are linked to universities for the purpose of research and advanced care to patients, therefore, the institutions provide opportunity to physiotherapists practising at the facility for postgraduate and post-quali cation training, therefore, those in musculoskeletal unit will have the advantage to acquire more quali cations in their speciality and also to regularly attend post-quali cation training and workshops on LBP management. This could be the reason why they are more knowledgeable than their counterparts in other practice settings. The nding is in line with the report from the study by Akodu et al [19] that reported a signi cant association between the setting of practice and knowledge of clinical practice among Nigerian physiotherapist.
The nding that there was a signi cant association between respondents MET use knowledge level and area of specialization suggests that the area of specialization of respondents contributed to their MET knowledge. The study further reveals that those who specialized in musculoskeletal physiotherapy are more knowledgeable about MET application in the management of NSLBP than their counterparts in other specialization of physiotherapy. This nding conforms with the ndings of Akodu et al [19], who reported that physiotherapists who specialize in Orthopedic/musculoskeletal physiotherapy are more knowledgeable about techniques used in the management of LBP as recommended in clinical practice guidelines. However, on the contrary, it was observed from the result of this study that there was no signi cant relationship between MET use knowledge and whether the respondent has ever worked in musculoskeletal unit of his/her department as it would have been presumed that those who have worked in musculoskeletal unit would have a much broader knowledge on LBP management techniques. This implies that only physiotherapists who acquired additional training or quali cations particularly in the management of LBP are knowledgeable about MET application. However, it was observed that there are very few Nigerian physiotherapists, who are certi ed OMT specialists. Although generally, they have a good MET knowledge level score, when compared to other respondents who are not OMT specialists, it was found that presently in Nigeria certi cation in OMT does not have any signi cant in uence on knowledge of MET use among physiotherapists. This might be as a result of the fact that the OMT is relatively a new sub-speciality of physiotherapy in the country with relatively few experts. The program is not yet integrated into the already established postgraduate program and post-quali cation training of musculoskeletal physiotherapy and also, there might be a possibility that MET is not well captured in the current OMT curriculum offered in Nigeria as compared to musculoskeletal postgraduate program or postquali cation training on LBP management.
The respondents' professional cadre of practice was observed to have a signi cant relationship with the MET use knowledge, and the result showed there is a relatively high level of MET knowledge among respondents on the senior cadre of practice than their junior colleagues. This also could be attributed to more skills and additional knowledge acquired as one advance on the professional cadre.
It is evident from this study that majority of Nigerian physiotherapists manage patients with NSLBP, and that chronic NSLBP is the most common type of the ailment attended to followed by recurrent NSLBP while acute on chronic is the least type of NSLBP managed by the respondents. However, the pattern of patient referral is a challenge as many physiotherapists reported the rst contact with NSLBP patients when the condition was at the chronic stage. This is contrary to the recommendation of the principle of evidence-based practice and the majority of clinical practice guidelines for NSLBP management [26,27,28,29].
This study reveals that there was a signi cant relationship between the respondents' area of specialization and choice of MET intervention in the management of NSLBP and also there was a signi cant difference in the knowledge of MET use between respondents that used MET and those who do not use MET for the management of NSLBP. This showed that those who specialized in musculoskeletal therapy and ergonomics are more knowledgeable than their counterparts in other specialities of physiotherapy, and thus they have demonstrated a better preference to employ MET approach for the treatment of NSLBP.
It is obvious from the ndings of this study that physiotherapists use a variety of treatment modalities for the management of NSLBP. The respondents of this study generally involve the use of exercise therapy approach for the treatment of NSLBP; the most common preferred exercises involved include McKenzie, spinal stabilization, abdominal strengthening, spinal extensor strengthening, hip muscles strengthening and exibility exercises. Although, majority of the respondents believe exercise therapy in combination with other forms of therapeutic intervention is the best approach for the management of NSLBP, this belief could be attributed to the fact that previous study reported Nigerian physiotherapists to believe spinal disc diseases and muscle strain were the reason for the greatest proportion of back pain symptoms [23]. Thus, exercises therapy alone may not resolve the symptoms as desired, but its combination with other therapeutic modalities particularly manual therapy techniques will restore spinal stability, trunk exibility and consequently relieve pain and improve lost functions. TENS is the most common electrotherapy modality involved followed by therapeutic ultrasound and cold packs for the management of NSLBP. The study also showed that postural re-education, ergonomic advice and counselling regarding proper body mechanics in daily activity are highly involved in the management of NSLBP. The selection and combination of therapeutic modalities are in agreement with the report from the work of [19,21,23,30]. Some physiotherapists also favour a combination of MET with other forms of intervention particularly stabilization exercises and perceive it as an appropriate intervention approach for the management of NSLBP especially chronic type of the condition. However, physiotherapists involved in this study were less inclined to the involvement of some treatment approaches like iontophoresis, laser therapy, mulligan approach, Myo-facial trigger point therapy, acupuncture, dry needling and Tai Chi.
This study tried to identify the reasons for the respondents' choice of treatment modalities for the management of NSLBP, the ndings reveal that availability of modalities is the major reason that in uences the choice of the modalities followed by respondents' skills, patients' prognosis and diagnosis. This is in line with the nding from the study of Akodu et al [19] that also reported skills, diagnosis and availability of treatment modalities to be the most common factors that in uenced Nigerian physiotherapists' choice of treatment modalities. However, the respondents reported that power supply, personal preference, treatment time and the number of patients are the least factors that in uence their choice of modalities for the management of NSLBP.
On treatment duration, this study reveals that the majority of physiotherapists participating in this study spend about 20 to 30 minutes on the treatment of NSLBP for both initial and follow-up visits, although on the initial visit there is a substantial number of respondents who spend 30 to 40 minutes on the treatment of patients with NSLBP. Additionally, this survey showed that majority of the respondents prefer 9-11 treatment sessions for the management of patients with NSLBP, but the study also reveals that a good number of respondents employ 7-9 treatment sessions, however, it is obvious from the result that physiotherapists that are more experienced in practice with additional quali cations, especially in the management of LBP, prefer fewer number of sessions than their younger counterparts. This nding is in agreement with the trend in the literature, Wheeler [30]reported 11 treatment sessions(visits) for the management of patients with NSLBP, Swinkels et al [24] reported 9.9 sessions as a mean number of treatment sessions for NSLBP. Odebiyi et al [25] suggested that most of the Nigerian physiotherapists employ 10 treatment sessions for NSLBP patients. Thus, it is observed that the patient's prognosis is the major factor that in uences the respondents' choice of treatment sessions; this is followed by the availability of modalities and then the patient's diagnosis. This implies that patients characteristics are the major factor that determines the number of treatment sessions for the management of NSLBP, this is in line with nding from the study of Swinkels et al [24] that reported the number of physical therapy treatment sessions in patients with LBP mainly depends on patientlevel (characteristics) instead of practice level.
It is observed that the majority of respondents in this study always re-evaluate patients with NSLBP before, during and after treatment sessions, and they usually re-evaluate the patients after four to six treatment sessions. The nding that all the respondents employ the use of one to several outcome measures for the assessment of patients with NSLBP is consistent with the above nding, and it implies that it is a common practice in Nigeria. The most common outcome measures employed by the respondents are those for the assessment of pain, functional disability, body functions and quality of life. This may be for the reason that pain, functional disability and limitation in body functions are usually the main reason for hospital visit by the patients. The assessment of these variables is possibly used as the basis for objectively determining the patient's improvement before and after sessions of treatment. This practice is widely practised in developed nations [31,25] and is in line with recommendations of clinical practice guidelines linked to the international classi cation of functioning, disability and health for the management of LBP [32].
The nding that the majority of the respondents discharge their patients after successful patient recovery is a positive development in the management of patients with NSLBP. This implies that the physiotherapists in Nigeria have good skills for the management of NSLBP and that they try to minimize the rate of transition from acute/subacute to the chronic stage of the condition. The study further reveals that prognosis is the major factor that in uences the respondents to this study to discharge their patients with NSLBP.

Conclusion
Based on the nding of this study, it can be concluded that the outcome tool (section D of the questionnaire) for the assessment of physiotherapists MET knowledge level is valid and reliable. The study reveals despite the decades' existence of postgraduate and post-quali cation training in Nigeria, the knowledge of MET use for the management of NSLBP among Nigerian physiotherapists is still low. Although, the study showed that many physiotherapists believed MET in combination with other therapeutic intervention will be an appropriate management procedure for patients with NSLBP.
It is however revealed that physiotherapists' knowledge for MET use in the management of NSLBP was in uenced by age, educational level, the setting of practice, area of specialization, the professional cadre of practice and additional training in LBP management.
Although, this study did not intend to assess the knowledge of Nigerian physiotherapists on the use of clinical practice guidelines for the management of LBP, however, the study pro led the treatment strategies of the Nigerian physiotherapists for the management of NSLBP. This demonstrated that to a large extent Nigerian physiotherapists complied with the recommendation of many clinical practice guidelines for the management of LBP, thus, they take the importance of patients evaluation/re-evaluation using standard outcome measures, the treatment time and number of treatment sessions are adequate, the treatment modalities are selected based on patients characteristics (patient-centred-approach) and discharge of patients is based on informed decision from evaluation of patient's prognosis. However, the pattern of patient referral is quite worrisome as many physiotherapists reported the rst contact with NSLBP patients when the condition was at the chronic stage; this is quite contrary to the recommendation of the principle of evidence-based practice and majority of clinical practice guidelines for NSLBP. The problem may be attributed to the fact that physiotherapists in Nigeria do not have rst contact access to patients, but with the recent upgrade of physiotherapy curriculum and institutionalization of postgraduate/post-quali cation training, it is hoped that the trend will change for better patient care.
Therefore, from the ndings of this study, it can be recommended that there is a need for the Nigerian physiotherapists to develop a clinical practice guideline Please, it is of importance to note that this study is part of the objectives of the main study I am presently carrying out for my PhD; therefore the title of the main study is the one on the ethical approval letter.
A written and signed informed consent was obtained from all recruited participants for the study by attaching the consent form to the copy of the questionnaire distributed. The consent form is designed by the Biomedical Research Ethics Committee of University of KwaZulu-Natal (BREC) according to the WMA Helsinki declaration. The aims and objectives of the study were clearly explained in the form attached.

Competing interests
The authors declare that they have no competing interests.