Many countries have started adopting musculoskeletal imaging as part of physiotherapy practice and their educational programmes are expected to bridge the gaps in training.
To develop an instrument that can be used to explore the level and nature of training, attitude, competence and utilisation of musculoskeletal imaging among physiotherapists.
An exploratory sequential mixed methods design was used. An in-depth international literature search was conducted, followed by a focus group discussion (FGD). The FGD informants were recruited through maximum variation sampling. The results of the FGD and the information from relevant literature were used to draft the physiotherapist’s musculoskeletal imaging profile questionnaire (PMIPQ). The PMIPQ was then subjected to face, content and criterion validity and pilot testing. The final version of the PMIPQ consists of six domains: (A) demographic details, (B) nature of training in musculoskeletal imaging, (C) level of training, (D) attitude towards musculoskeletal imaging, (E) utilisation and (F) competence. Data were analysed using means, standard deviation, Spearman’s correlation (
The results showed that the PMIPQ has good psychometric properties: validity and internal consistency. The test–retest reliability (
Physiotherapist’s musculoskeletal imaging profile questionnaire is a relevant instrument for assessing the musculoskeletal imaging profile of physiotherapists in Nigeria and in other countries with a similar scope of training and practice.
Musculoskeletal system imaging is a potentially useful adjunct to physiotherapists in clinical practice.
Physiotherapy is a health care profession that addresses the issues of human movement, functionality and quality of life (Melnick
Musculoskeletal system imaging is indispensable to physiotherapists and has always been a component of their clinical decision-making (Domholdt et al.
The inadequacy in education and training of some referral sources in musculoskeletal disorders and incomplete evaluation of patients for serious pathologies prior to referral for physiotherapy have contributed to the need for physiotherapists to become better at assessment prior to managing patients (Boissonnault et al.
Physiotherapists’ competency in the utilisation of musculoskeletal imaging for clinical examination purposes was established among the US military physiotherapists 44 years ago (James & Stutart
Although this level of competency was mostly demonstrated within the military model of practice, examples also exist in civilian settings in the USA and abroad (Moore et al.
The current practice model in Nigeria is tailored towards autonomous practice, which includes unrestricted direct patient access, the ability to refer to other providers and the ability to refer for diagnostic tests (APTA
Various countries have legislation and regulations over diagnostic imaging (Kam
However, the use of diagnostic imaging by physiotherapists has a sound foundation for expansion in future practice and commensurate emphasis in physiotherapy education (Boyles et al.
Accordingly, there is a need to explore the level and nature of training, attitude, competence and utilisation of musculoskeletal imaging among physiotherapists in Nigeria. Following a search of the international literature using keywords to search databases, the authors could not identify any appropriate survey instrument, which could be used for a study such as this. Therefore, a new survey instrument, which can be used to collect comprehensive data on the musculoskeletal imaging profile of physiotherapists in Nigeria, was developed.
An exploratory sequential mixed methods design was undertaken among registered physiotherapists in Nigeria.
A qualitative approach was used to develop the contents of the survey instrument, while a quantitative design was used to validate and pilot test the draft instrument (Dizon, Grimmer-Somers & Kumar
The literature was reviewed by searching the following databases: PEDro, MEDLINE, Embase and Google Scholar, with the keywords (physical therapy, physiotherapy, musculoskeletal imaging, diagnostic imaging, profile and questionnaire) that made up the title of our study. We did not find any comprehensive instrument that could be used to explore the nature of training, attitude, competence and utilisation of musculoskeletal imaging among physiotherapists. However, the following bodies of literature were found relevant in drafting the initial version of the instrument: physiotherapists’ perceptions and use of medical imaging information in practice (Little & Lazaro
Maximum variation sampling was used to set up a focus group discussion (FGD). Ten key informants (three women and seven men) were recruited across all the possible demographic variables of the population of the study. These key informants were identified and contacted through the network of the Association of Clinical and Academic Physiotherapists of Nigeria (ACAPN). The inclusion criterion was as follows: participant must be a registered physiotherapist, who is currently licensed and practising in Nigeria for at least 2 years. Potential participants were informed of the study objectives and the mode of the meetings. They granted their individual informed consent and they were added to a social media (WhatsApp) forum created for that purpose. This technological innovation of social media meeting reduces the challenges of a traditional focus discussion such as geographical barriers, mandatory physical presence, convenient timing, meeting logistics and cost, the burden of transcribing the audio recording and loss of man-hours. One of the key informants facilitated the sessions, while one of the authors tracked and highlighted all the points raised. Another author and a software developer who later designed the online version of the instrument were also added to the forum as observers.
Open-ended questions were asked to explore the informants’ perspectives of survey content. The core questions were: (1) what are the important demographic characteristics of physiotherapists in Nigeria, relevant to the present study?, (2) what is the nature, content and amount of musculoskeletal imaging training received by physiotherapist in Nigeria during undergraduate, internship, postgraduate and workshops?, (3) what factors drive the attitude of physiotherapists in Nigeria towards musculoskeletal imaging?, (4) what factors influence Nigerian physiotherapists’ utilisation of musculoskeletal imaging? and (5) what are the imaging modalities a physiotherapist needs to be competent in to optimise his or her clinical practice?
Afterwards, all the comments from the FGD were collated and reposted in the forum until all the key informants confirmed that the issues raised during the discussions had been captured. The outcome of the FGD was given to a panel of two independent reviewers (university senior lecturers) to harmonise (Dizon et al.
Information from the reviewed literature and FGD were used to draft the physiotherapists’ musculoskeletal imaging profiling questionnaire (PMIPQ). The initial draft of the instrument was sent to the members of the focus group to check for congruence with their recall of the FGDs. The comments from the participants were integrated into the draft before sending it for expert validation; this approach ensured the completion of the triangulation processes. Dizon et al. (
The draft questionnaire was subjected to face and content validity. A six-man validation panel of experts was selected based on the Hoffmann expertise proficiency scale (Chi
Their areas of expertise were physiotherapy education, musculoskeletal physiotherapy and questionnaire development. The experts had at least 15 years post-qualification experience in (academic or clinical) practice and with publications in related fields of physiotherapy. The panellists were sent an anonymous blind carbon copy email, seeking their individual informed consent to participate in the validation process.
Following their permission, they received the objectives of the study and a copy of the draft questionnaire, through an email. Then, a Delphi method of information exchanges (facilitated through the anonymous email address: pmipqresearcher18@yahoo.com) was employed until the validation panellists reached consensus that the questionnaire was appropriate for the study (Dizon et al.
The panellists were required to check the relevance of the questions in line with the questionnaire domains (content validity) and to comment on the orderliness of the questions and response options (face validity). The experts were asked to comment on and rate the questionnaire’s length, whether it was easy to comprehend (language and terms), adequacy of content, chronology and clarity of instructions, questions and answer options, using a three-point scale (1 – not appropriate, 2 – neutral and 3 – appropriate).
The responses from the panellists were collated and the appropriate correction was made. The revised instrument was returned to the panel of experts for further review, feedback and consensus. Exchanges were done twice before consensus was reached. The validated instrument covered six main domains labelled as parts A–F (
Contents of the draft survey instrument.
Themes | Description |
---|---|
Part A. Demographic details and general Information | Intended to obtain demographic details, licence renewal history, years of practice, region of practice, practice setting, employment cadre, specialty of interest, continuous professional development and educational background. |
Part B. Nature of training in musculoskeletal imaging | Intended to obtain entry points, methods, duration, personnel employed and hands-on experiences for undergraduate, internship, workshop and postgraduate trainings. |
Part C. Level of training of respondents in utilisation of musculoskeletal imaging | Intended to obtain the level of training of respondents on interpretation and utilisation of results from the following musculoskeletal imaging modalities (X-ray, MRI, CT scan, ultrasound, bone scan and DEXA). |
Part D. Attitude of respondents to musculoskeletal imaging | Intended to obtain the attitude of respondents towards the use of musculoskeletal imaging in clinical practice. |
Part E. Level of utilisation of musculoskeletal imaging results in clinical practice | Intended to obtain the level of utilisation of musculoskeletal imaging results in clinical practice (utilisation of X-ray, MRI, CT scan and bone scan results, ordering DEXA before manipulation in geriatrics, performing musculoskeletal ultrasonography), referral rights and others. |
Part F. Level of competence in interpretation of musculoskeletal imaging results | Intended to obtain the level of competence of physiotherapists in interpretation of musculoskeletal imaging results, specifically X-ray, MRI, CT scan, ultrasound, bone scan and DEXA. |
MRI, magnetic resonance imaging; CT, computed tomography; DEXA, dual-energy X-ray absorptiometry.
During pilot testing, the instrument was further tested for criterion validity. Criterion validity is defined as the correlation of a scale with an accepted instrument or measure (Dizon et al.
A mixed method of conducting pilot testing by using both paper and online questionnaires was adapted from Dizon et al. (
Moreover, the online survey tracked and recorded the time it took each respondent to complete the questionnaire. The paper version contained a checklist (
Checklist for physiotherapist’s musculoskeletal imaging profiling questionnaire: Summary of the respondents’ opinion on the characteristics of the instrument.
S/N | Questionnaire characteristic | Not appropriate | Neutral | Appropriate | Remarks |
---|---|---|---|---|---|
1 | Relevancy | - | - | X | - |
2 | Length | - | X | - | - |
3 | Simplicity or easy to comprehend language and terms | - | - | X | - |
4 | All-inclusive | - | - | X | - |
5 | Adequacy of content | - | X | - | - |
6 | Chronology or systematic arrangement | - | - | X | - |
7 | Self-explanatory | - | - | X | - |
8 | Clarity of instructions, questions and answer options | - | - | X | - |
9 | Easy to fill | - | - | X | - |
10 | (Other comments on areas you seek clarification or changes) | - | - | - | - |
The responses to the paper version of the instrument were manually collated in a Microsoft Excel spreadsheet, while the online version was self-collated in a database and was downloaded in the same file format. Computer-based analysis of the data was performed using SPSS 20 software (SPSS, Chicago, IL, USA). The time spent in completion of the online version of the instrument was analysed with a mean ± standard deviation. Criterion validity (convergence) and reliability of the instrument (test–retest; paper scores vs. online scores) were analysed with Spearman’s correlation coefficient (
Ethical approval was obtained from the Health Research and Ethics Committee of the Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nnewi campus, Nigeria, prior to the commencement of the study (reference number: ERC/FHST/NAU/2018/193). The objectives of the study were clearly explained on the informed consent form attached to the questionnaire and endorsed by each participant.
The first draft of the instrument consisted of the major themes that were raised from the FGD (
The face and content validated instrument was divided into (parts A–F) six domains as follows: (A) 17 questions on demographic details which include age, gender, marital status, licence renewal history, years of practice, the region of practice, practice setting, employment cadre, the specialty of interest, continuous professional development and educational background; (B) 25 questions on nature of training in musculoskeletal imaging which includes entry points, methods, duration, personnel employed and hands-on experiences for undergraduates, internship, workshop and postgraduate training; (C) seven questions on the level of training in the interpretation of musculoskeletal imaging results; (D) eight questions on the attitude of physiotherapists towards musculoskeletal imaging; (E) seven questions on the utilisation of musculoskeletal imaging results in clinical practice and (F) six questions on the level of competence of physiotherapists in the interpretation of musculoskeletal imaging results.
In total, the questionnaire was made up of 70 items. Parts A and B are multiple choices or dichotomous questions (yes or no). This aspect was designed for descriptive purposes and did not have a specific scoring system. The remaining domains (parts C–F) were designed as a five-point Likert scale (1 – lowest to 5 – highest score). Specifically, the range of score for the domains was: part C (6–30), part D (8–40), part E (7–35) and part F (6–30).
Another essential component of the methodology was piloting the PMIPQ on representatives of the study population (Dizon et al.
Information from the checklists showed that a few respondents requested a revision of the language structure of part B for clarity. Nonetheless, the summary of the checklist (
Psychometric properties of the physiotherapist’s musculoskeletal imaging profiling questionnaire.
Psychometrics | Part A Demographics | Part B Nature of training | Part C Level of training | Part D Attitude | Part E Utilisation | Part F Competence |
---|---|---|---|---|---|---|
Face validity | Appropriate | Appropriate | Appropriate | Appropriate | Appropriate | Appropriate |
Content validity | Appropriate | Appropriate | Appropriate | Appropriate | Appropriate | Appropriate |
Criterion validity ( |
Not applicable | Not applicable | 0.151 | 0.371 | 0.515* | 0.481* |
Internal consistency ( |
Not applicable | Not applicable | 0.731* | 0.737* | 0.446 | 0.796* |
Reliability ( |
Not applicable | Not applicable | 0.973* | 0.979* | 0.842* | 0.716* |
Our study explored the current musculoskeletal imaging practice among physiotherapists in Nigeria. We could not find any instrument in the literature that could address the objectives of our proposed study. Therefore, the development of the PMIPQ was undertaken. The questionnaire was designed, validated and piloted in adherence with the general guidelines for development and implementation of (face-to-face and online) dual administration mode surveys (Adje
The scope of practice and span of physiotherapy training vary from one country to another (Moffat
All the domains (parts) of the online version of the instrument were programmed as compulsory fields except for part B where a respondent can choose the ‘not applicable’ option and move on to the next subsection. The software ensures that incomplete questionnaires cannot be submitted; rather, the missing fields will be highlighted for the respondent to complete them before submission. There is no question that this innovation reduces the problem of incomplete data – a major challenge in questionnaire-based surveys (Andrews et al.
The results of our study showed a positive correlation between the criterion and all the tested domains of the PMIPQ. However, part E (
Nonetheless, all the domains of the online version of the PMIPQ showed an acceptable level of internal consistency except part E, which obtained responses on the level of utilisation of imaging studies. The value
The emphasis PMIPQ laid on ultrasonography as content in physiotherapy training and practice is noteworthy.
This is because ultrasound is a promising area for future practice. It has the comparative advantage of being portable, inexpensive and safe, as well as being a non-ionising-radiation-based musculoskeletal imaging modality (Boyles et al.
This study combined a qualitative and quantitative approach in analysing the outcome of the pilot testing; a similar study that reported the processes of development of a new instrument relied only on a qualitative approach (Dizon et al.
After merging all comments from the developmental steps (
Practical applications in designing profile questionnaires.
Steps | Purpose | Who are involved? |
---|---|---|
Initial scoping | To check the availability of an appropriate instrument which matches the objectives of an intended study |
Authors |
Focus group interviews | To explore key areas of concern in designing the instrument | Key informants and researchers |
Validation using the Delphi technique | To ensure that the instrument measures what it intends to measure |
Experts in relevant areas of the study |
Pilot testing | To ‘trial’ the survey and identify possible problems to be encountered and allow troubleshooting to address the problems | Participants representative of the sample population |
This study has provided a relevant instrument for assessing the musculoskeletal imaging profile of physiotherapist in Nigeria and abroad. The PMIPQ has acceptable psychometric properties, the design is comprehensive and mode of administration is innovative and appealing to respondents.
The authors acknowledge the following colleagues for their contributions to this study: Profs. J.O. Balogun, R.A. Adedoyin and G. Sokunbi; Drs D.O. Odebiyi and A.O. Ezeukwu; and Mr B.B. Rotibi – validation panellists. Others are Drs O. Dada and C. Eze; Messrs M. Olumayowa, Y. Abubakar, E. Uduonu, I. Akinola, B. Omisore and U. Wanda; Ms I. Brendan and C. Namirhyel – FGD key informants. Drs F.A. Maruf and C.O. Akosile – FGD reviewers. Dr J.C. Eze (diagnostic imaging expert) served as an independent reviewer.
The authors declare that they have no competing interests.
O.K.K.O., J.O.U., P.O.I., A.C.O., C.C.A., C.I.E. and M.J.N. contributed to the conceptualisation, conduct and writing of this manuscript. All authors read and approved the final manuscript.
No funding was received from any individual, institution or organisation.
Data are available on request.
The views expressed in this article are the authors’ own and not an official position of the institution or funder.
Physiotherapists Musculoskeletal Imaging Profiling Questionnaire (Nigerian Online Version)