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

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 nal 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 signicant 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 signicant 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.


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 con dence 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 de ciency in medical schools and called for strategies to increase MSK contents. 10 Knowledge in MSK medicine among medical practitioners was rst assessed using a standardized MSK test developed by Freedman and Bernstein. 11 Eighty-ve physicians underwent the test during the rst 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][13][14][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 certi cation 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.

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 nal 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 nal 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% con dence 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 modi ed 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 certi cate 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 nished 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 signi cant 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 signi cant 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 signi cance 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. 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 3, revealed that medical interns had signi cantly higher scores than medical students, physical therapy students and physical therapy interns. Also, medical students had signi cantly higher scores than physical therapy interns but not physical therapy students. There was no signi cant difference between physical therapy inters and students.

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 ndings showed that primary care physicians scores averaged 53.6% with a passing rate of 20%, which is similar to Matzkin 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 certi cation 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 e cient 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 nding from one survey that reported that medical undergraduates perceived that MSK medicine was not emphasized, nor competency in MSK medicine was required. 5 Similar ndings 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 nding 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 nding concurs with our prior survey that examined the entrylevel 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

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 signi cantly different, primary care physicians achieved higher scores than physical therapists. Also, the study identi ed 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.

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 ndings 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 modi ed version that was still under validity investigation. 36 de ciency 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. Availability of Data and Materail The datasets used during the current study are available from the corresponding author upon request.