RESEARCH ARTICLE
Physiotherapists’ Beliefs About Whiplash-associated Disorder: A Comparison Between Singapore and Queensland, Australia Tze Siong Ng1,2, Ashley Pedler3, Bill Vicenzino2 & Michele Sterling4* 1
National University Hospital, Physiotherapy Section, Department of Rehabilitation, Singapore, Singapore
2
The University of Queensland, School of Health and Rehabilitation Sciences St Lucia, Brisbane, Queensland, Australia
3
The University of Queensland, Centre of National Research on Disability and Rehabilitation Medicine (CONROD), Herston, Brisbane, QLD
Australia 4
Griffith Health Institute, Griffith University, Parklands, Queensland, Australia
Abstract Background and purpose. Healthcare providers’ beliefs may play a role in the outcome of whiplash-associated disorders (WAD), a condition which is proposed to be culturally dependent. Clinical practice guidelines recommend an active approach for the management of WAD, which is often delivered by physiotherapists. However, there is no data on physiotherapists’ whiplash beliefs. Our primary objective was to determine physiotherapists’ beliefs from Queensland (Australia) and Singapore, two cultures with differing prevalence of chronic musculoskeletal pain and chronic WAD. Methods. A pen and paper survey of musculoskeletal physiotherapists practicing in Queensland and Singapore was conducted. Participants completed questionnaires consisting of patient vignettes and statements inquiring knowledge and attitudes towards WAD. Chi-square tests of significance were used to compare the responses of physiotherapists from both samples. Results. Ninety-one (response rate 45%) Queensland-based and 94 (response rate 98%) Singapore-based physiotherapists participated in the study. The beliefs in the management strategies for the patient vignettes were generally consistent with practice guidelines. A higher proportion of Queensland-based physiotherapists expected permanent disabilities for the patient vignette depicting chronic WAD (Queensland: 55% Singapore: 28% Pearson chi-sq 18.76, p < 0.005).Up to 99% of the physiotherapists from both samples believed in encouragement of physical activity, the effectiveness of exercise and multimodal physiotherapy for WAD. Significantly higher proportions of Singapore-based physiotherapists believed in ordering radiographs for acute WAD (Pearson chi-sq 41.98, p < 0.001) and also believed in a psychogenic origin of chronic WAD (Pearson chi-sq 22.57, p < 0.001). Conclusion. The majority of beliefs between physiotherapists in Queensland and Singapore were similar but there were specific differences. Physiotherapists’ whiplash beliefs in Queensland and Singapore did not clearly reflect the difference in prevalence of chronic musculoskeletal pain or chronic WAD in Queensland and Singapore. Copyright © 2014 John Wiley & Sons, Ltd. Received 21 January 2014; Revised 4 April 2014; Accepted 1 June 2014 Keywords pain; physiotherapy; practice/service settings *Correspondence Michele Sterling, Griffith University, Parklands, Queensland 4222, Australia. E-mail: m.sterling@griffith.edu.au
Published online 23 July 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1598
Physiother. Res. Int. 20 (2015) 77–86 © 2014 John Wiley & Sons, Ltd.
77
T. S. Ng et al.
Physiotherapists’ Whiplash Beliefs
Introduction In western countries such as Australia and Canada, up to 50% of people with whiplash injury following a motor vehicle collision develop chronic pain and disability (Rebbeck et al., 2006; Carroll et al., 2008). The prevalence of chronic whiplash-associated disorders (WAD) has been proposed to be culturally dependent with lower prevalence reported in countries such as Lithuania (Obelieniene et al., 1999).There has been little research in Asian countries but an early study reported the prevalence of WAD as being low (Balla, 1982). Whilst there is no more recent data available for WAD, the prevalence of chronic pain in general seems to be lower (9%) in Singapore (Yeo, 2009) compared to nearly 20% in Australia (Henderson et al., 2013). There is strong evidence that patients’ beliefs are associated with healthcare providers’ beliefs. Healthcare providers’ beliefs influence their clinical management and patient education, which in turn influence their patients’ beliefs (Darlow et al., 2012). It has been suggested that healthcare providers with a strong biomedical belief system tend to advise patients with low back pain to limit work and physical activities, advice which is inconsistent with treatment guidelines (Houben et al., 2005; Bishop et al., 2008).Certainly with respect to WAD, the beliefs and expectations of the injured person have been shown to influence health outcomes and patients with acute WAD who report more pessimistic expectations of recovery have slower recovery (Carroll et al., 2009; Ozegovic et al., 2009). Furthermore, there is some evidence indicating that a greater amount of treatment for acute WAD may be detrimental and slow recovery (Côté and Soklaridis, 2011). Healthcare providers play a role in both influencing patient’s beliefs and expectations as well as the amount and nature of treatments provided and thus could affect outcomes for patients with WAD. Beliefs are shaped by culture, learning and experience (Burnett et al., 2009). There is data indicating that healthcare students from different cultural backgrounds have different beliefs about various musculoskeletal conditions. When compared with Australian physiotherapy students, Brazilian, Taiwanese and Chinese Singaporean physiotherapy students displayed more negative back pain beliefs and more fear avoidant beliefs towards physical activity (Ferreira et al., 2004; Burnett et al., 2009). Physiotherapists are arguably the healthcare providers most commonly involved in the management of WAD, and their beliefs could influence 78
their patients’ beliefs. As such, it is important to investigate their beliefs about a condition that incurs such a large health burden. The primary aim of this study was to determine the whiplash beliefs of physiotherapists in Queensland (Australia) and Singapore, two culturally different countries with differing prevalence of musculoskeletal pain and chronic WAD. The secondary aim was to assess the association between physiotherapists’ whiplash beliefs and demographic factors.
Methods Design The pen and paper survey in Queensland and Singapore took place concurrently. The survey instrument was personally handed and collected from the participants in Singapore. A package containing the survey questionnaire, cover letter and a pre-paid, selfaddressed envelope was mailed to the participants in Queensland as hand delivery of the questionnaires was impractical in Queensland with a land area more than two thousand times that of Singapore. An e-mail with the soft copy of the questionnaire was sent to all non-respondents 3 months after the mailed survey. Participants The participants in Queensland were recruited from the 203 physiotherapists listed as members of the Musculoskeletal Physiotherapy Australia, a special interest group of the Australian Physiotherapy Association (Australian Physiotherapy Association, 2011). Members of this special interest group are not required to have additional training or caseloads that are different from musculoskeletal physiotherapists who are not members. Eighty-eight percent of the listed physiotherapists were practicing in Brisbane, the capital city of Queensland. Ninety-seven percent of the 203 listed physiotherapists were in private practice (Australian Physiotherapy Association, 2011). Insurance companies in Singapore commonly informed injured people to consult health professionals in public hospitals; hence, we limited this survey to musculoskeletal physiotherapists practicing in all the six general public hospitals in Singapore. Physiotherapists who did not actively manage adult patients with whiplash injury were excluded. No incentive for completing the questionnaire was offered. Ethics approval for this study was obtained from the Physiother. Res. Int. 20 (2015) 77–86 © 2014 John Wiley & Sons, Ltd.
T. S. Ng et al.
Physiotherapists’ Whiplash Beliefs
National Healthcare Group (Singapore) and the University of Queensland’s medical research ethics committees. Informed consent was implied when participants completed and returned the questionnaires.
Survey instrument Participants were requested to complete a questionnaire. The first section of the questionnaire inquired about demographic and practice characteristics (e.g. postregistration master’s degree) (Table 1). As WAD is a heterogeneous condition with variable prognosis depending on the complexity of clinical presentation (Sterling et al., 2006; Sterling et al., 2010), the second section was designed to assess physiotherapists’ beliefs in the appropriate management and prognosis of patients with WAD based on two patient vignettes depicting heterogeneity in WAD. The vignettes were produced in consultation with a panel comprising physiotherapists with expertise in both clinical management of WAD and research of the condition. Vignette I was a case of acute WAD with mild to moderate pain and disability (pain visual analogue scale VAS 5/10, neck disability index 28%), no signs of psychological distress nor central nervous system hyper-excitability, hence low risk of developing longterm symptoms (Sterling, 2009; Sterling et al., 2011). Vignette II was a case of chronic WAD with a complex Table 1. Demographic and practice characteristics of participants
Sex
Queensland (n = 91) 51% female
Years of practice post-registration qualification Median (range) 20 (1–47) years 1. 1–10 years 29% 2. 11–20 years 22% 3. >20 years 50% Post-registration qualification Master’s and above No. of whiplash cases 1–5/year 6–10/year 1–2/month 3–5/month >6/month Attended neck pain management course in the past 2 years (Continuing Professional Development CPD)
Singapore (n = 94) 65% female
6 (1–20) years 81% 19% 0
53%
42%
19% 9% 39% 26% 8% 58%
38% 11% 32% 19% 0 43%
Physiother. Res. Int. 20 (2015) 77–86 © 2014 John Wiley & Sons, Ltd.
presentation of high pain intensity (VAS 8/10), indicators of central nervous system hyper-excitability and post-traumatic stress symptoms indicating that an interdisciplinary management approach may be warranted (Sterling, 2009; Sterling et al., 2011). The questions and answering cues given were the same for both vignettes. The first question was ‘What treatment and advice would you give to this patient?’ Participants can select all appropriate answering cues given (bed rest, advice on staying active, work modification, psychosocial evaluation, manipulation/mobilization, heat/ ice pack, exercises, transcutaneous electrical stimulation, cervical traction, therapeutic ultrasound, cervical collar, no further referral, further referral to specialist, psychology and multidisciplinary rehabilitation program) (Table 2). The second question was ‘What is the probability that this patient will a) recover within
Table 2. Beliefs in management strategies for patient vignettes I and II Management strategies recommended for Vignette I Exercises Bed rest Advice on staying active Manipulation/mobilization Heat/ice pack TENS/interferential Ultrasound Psychosocial evaluation Cervical collar No further referral Referral to specialist Referral to psychologist
Proportion of Proportion of respondents respondents from SG from QLD (%) n = 94 (%) n = 91 99 0 88 86 71 12 11 7 1 81 1 2
98 0 78 66 65 13 7 28 2 56 37 10
Management strategies recommended for Vignette II Advice on staying active 82 76 Bed rest 0 0 Exercises 98 93 Psychosocial evaluation 87 94 Work modification 68 68 Manipulation/mobilization 53 46 Heat/ice pack 58 49 Transcutaneous electrical 24 34 stimulation Therapeutic ultrasound 8 2 Cervical collar 2 2 Referral to specialist 100 99 Multidisciplinary rehabilitation 64 56 programme Psychology referral 75 68
p value NS NS NS 0.002 NS NS NS
Physiotherapists’ Beliefs About Whiplash-associated Disorder: A Comparison Between Singapore and Queensland, Australia Tze Siong Ng1,2, Ashley Pedler3, Bill Vicenzino2 & Michele Sterling4* 1
National University Hospital, Physiotherapy Section, Department of Rehabilitation, Singapore, Singapore
2
The University of Queensland, School of Health and Rehabilitation Sciences St Lucia, Brisbane, Queensland, Australia
3
The University of Queensland, Centre of National Research on Disability and Rehabilitation Medicine (CONROD), Herston, Brisbane, QLD
Australia 4
Griffith Health Institute, Griffith University, Parklands, Queensland, Australia
Abstract Background and purpose. Healthcare providers’ beliefs may play a role in the outcome of whiplash-associated disorders (WAD), a condition which is proposed to be culturally dependent. Clinical practice guidelines recommend an active approach for the management of WAD, which is often delivered by physiotherapists. However, there is no data on physiotherapists’ whiplash beliefs. Our primary objective was to determine physiotherapists’ beliefs from Queensland (Australia) and Singapore, two cultures with differing prevalence of chronic musculoskeletal pain and chronic WAD. Methods. A pen and paper survey of musculoskeletal physiotherapists practicing in Queensland and Singapore was conducted. Participants completed questionnaires consisting of patient vignettes and statements inquiring knowledge and attitudes towards WAD. Chi-square tests of significance were used to compare the responses of physiotherapists from both samples. Results. Ninety-one (response rate 45%) Queensland-based and 94 (response rate 98%) Singapore-based physiotherapists participated in the study. The beliefs in the management strategies for the patient vignettes were generally consistent with practice guidelines. A higher proportion of Queensland-based physiotherapists expected permanent disabilities for the patient vignette depicting chronic WAD (Queensland: 55% Singapore: 28% Pearson chi-sq 18.76, p < 0.005).Up to 99% of the physiotherapists from both samples believed in encouragement of physical activity, the effectiveness of exercise and multimodal physiotherapy for WAD. Significantly higher proportions of Singapore-based physiotherapists believed in ordering radiographs for acute WAD (Pearson chi-sq 41.98, p < 0.001) and also believed in a psychogenic origin of chronic WAD (Pearson chi-sq 22.57, p < 0.001). Conclusion. The majority of beliefs between physiotherapists in Queensland and Singapore were similar but there were specific differences. Physiotherapists’ whiplash beliefs in Queensland and Singapore did not clearly reflect the difference in prevalence of chronic musculoskeletal pain or chronic WAD in Queensland and Singapore. Copyright © 2014 John Wiley & Sons, Ltd. Received 21 January 2014; Revised 4 April 2014; Accepted 1 June 2014 Keywords pain; physiotherapy; practice/service settings *Correspondence Michele Sterling, Griffith University, Parklands, Queensland 4222, Australia. E-mail: m.sterling@griffith.edu.au
Published online 23 July 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1598
Physiother. Res. Int. 20 (2015) 77–86 © 2014 John Wiley & Sons, Ltd.
77
T. S. Ng et al.
Physiotherapists’ Whiplash Beliefs
Introduction In western countries such as Australia and Canada, up to 50% of people with whiplash injury following a motor vehicle collision develop chronic pain and disability (Rebbeck et al., 2006; Carroll et al., 2008). The prevalence of chronic whiplash-associated disorders (WAD) has been proposed to be culturally dependent with lower prevalence reported in countries such as Lithuania (Obelieniene et al., 1999).There has been little research in Asian countries but an early study reported the prevalence of WAD as being low (Balla, 1982). Whilst there is no more recent data available for WAD, the prevalence of chronic pain in general seems to be lower (9%) in Singapore (Yeo, 2009) compared to nearly 20% in Australia (Henderson et al., 2013). There is strong evidence that patients’ beliefs are associated with healthcare providers’ beliefs. Healthcare providers’ beliefs influence their clinical management and patient education, which in turn influence their patients’ beliefs (Darlow et al., 2012). It has been suggested that healthcare providers with a strong biomedical belief system tend to advise patients with low back pain to limit work and physical activities, advice which is inconsistent with treatment guidelines (Houben et al., 2005; Bishop et al., 2008).Certainly with respect to WAD, the beliefs and expectations of the injured person have been shown to influence health outcomes and patients with acute WAD who report more pessimistic expectations of recovery have slower recovery (Carroll et al., 2009; Ozegovic et al., 2009). Furthermore, there is some evidence indicating that a greater amount of treatment for acute WAD may be detrimental and slow recovery (Côté and Soklaridis, 2011). Healthcare providers play a role in both influencing patient’s beliefs and expectations as well as the amount and nature of treatments provided and thus could affect outcomes for patients with WAD. Beliefs are shaped by culture, learning and experience (Burnett et al., 2009). There is data indicating that healthcare students from different cultural backgrounds have different beliefs about various musculoskeletal conditions. When compared with Australian physiotherapy students, Brazilian, Taiwanese and Chinese Singaporean physiotherapy students displayed more negative back pain beliefs and more fear avoidant beliefs towards physical activity (Ferreira et al., 2004; Burnett et al., 2009). Physiotherapists are arguably the healthcare providers most commonly involved in the management of WAD, and their beliefs could influence 78
their patients’ beliefs. As such, it is important to investigate their beliefs about a condition that incurs such a large health burden. The primary aim of this study was to determine the whiplash beliefs of physiotherapists in Queensland (Australia) and Singapore, two culturally different countries with differing prevalence of musculoskeletal pain and chronic WAD. The secondary aim was to assess the association between physiotherapists’ whiplash beliefs and demographic factors.
Methods Design The pen and paper survey in Queensland and Singapore took place concurrently. The survey instrument was personally handed and collected from the participants in Singapore. A package containing the survey questionnaire, cover letter and a pre-paid, selfaddressed envelope was mailed to the participants in Queensland as hand delivery of the questionnaires was impractical in Queensland with a land area more than two thousand times that of Singapore. An e-mail with the soft copy of the questionnaire was sent to all non-respondents 3 months after the mailed survey. Participants The participants in Queensland were recruited from the 203 physiotherapists listed as members of the Musculoskeletal Physiotherapy Australia, a special interest group of the Australian Physiotherapy Association (Australian Physiotherapy Association, 2011). Members of this special interest group are not required to have additional training or caseloads that are different from musculoskeletal physiotherapists who are not members. Eighty-eight percent of the listed physiotherapists were practicing in Brisbane, the capital city of Queensland. Ninety-seven percent of the 203 listed physiotherapists were in private practice (Australian Physiotherapy Association, 2011). Insurance companies in Singapore commonly informed injured people to consult health professionals in public hospitals; hence, we limited this survey to musculoskeletal physiotherapists practicing in all the six general public hospitals in Singapore. Physiotherapists who did not actively manage adult patients with whiplash injury were excluded. No incentive for completing the questionnaire was offered. Ethics approval for this study was obtained from the Physiother. Res. Int. 20 (2015) 77–86 © 2014 John Wiley & Sons, Ltd.
T. S. Ng et al.
Physiotherapists’ Whiplash Beliefs
National Healthcare Group (Singapore) and the University of Queensland’s medical research ethics committees. Informed consent was implied when participants completed and returned the questionnaires.
Survey instrument Participants were requested to complete a questionnaire. The first section of the questionnaire inquired about demographic and practice characteristics (e.g. postregistration master’s degree) (Table 1). As WAD is a heterogeneous condition with variable prognosis depending on the complexity of clinical presentation (Sterling et al., 2006; Sterling et al., 2010), the second section was designed to assess physiotherapists’ beliefs in the appropriate management and prognosis of patients with WAD based on two patient vignettes depicting heterogeneity in WAD. The vignettes were produced in consultation with a panel comprising physiotherapists with expertise in both clinical management of WAD and research of the condition. Vignette I was a case of acute WAD with mild to moderate pain and disability (pain visual analogue scale VAS 5/10, neck disability index 28%), no signs of psychological distress nor central nervous system hyper-excitability, hence low risk of developing longterm symptoms (Sterling, 2009; Sterling et al., 2011). Vignette II was a case of chronic WAD with a complex Table 1. Demographic and practice characteristics of participants
Sex
Queensland (n = 91) 51% female
Years of practice post-registration qualification Median (range) 20 (1–47) years 1. 1–10 years 29% 2. 11–20 years 22% 3. >20 years 50% Post-registration qualification Master’s and above No. of whiplash cases 1–5/year 6–10/year 1–2/month 3–5/month >6/month Attended neck pain management course in the past 2 years (Continuing Professional Development CPD)
Singapore (n = 94) 65% female
6 (1–20) years 81% 19% 0
53%
42%
19% 9% 39% 26% 8% 58%
38% 11% 32% 19% 0 43%
Physiother. Res. Int. 20 (2015) 77–86 © 2014 John Wiley & Sons, Ltd.
presentation of high pain intensity (VAS 8/10), indicators of central nervous system hyper-excitability and post-traumatic stress symptoms indicating that an interdisciplinary management approach may be warranted (Sterling, 2009; Sterling et al., 2011). The questions and answering cues given were the same for both vignettes. The first question was ‘What treatment and advice would you give to this patient?’ Participants can select all appropriate answering cues given (bed rest, advice on staying active, work modification, psychosocial evaluation, manipulation/mobilization, heat/ ice pack, exercises, transcutaneous electrical stimulation, cervical traction, therapeutic ultrasound, cervical collar, no further referral, further referral to specialist, psychology and multidisciplinary rehabilitation program) (Table 2). The second question was ‘What is the probability that this patient will a) recover within
Table 2. Beliefs in management strategies for patient vignettes I and II Management strategies recommended for Vignette I Exercises Bed rest Advice on staying active Manipulation/mobilization Heat/ice pack TENS/interferential Ultrasound Psychosocial evaluation Cervical collar No further referral Referral to specialist Referral to psychologist
Proportion of Proportion of respondents respondents from SG from QLD (%) n = 94 (%) n = 91 99 0 88 86 71 12 11 7 1 81 1 2
98 0 78 66 65 13 7 28 2 56 37 10
Management strategies recommended for Vignette II Advice on staying active 82 76 Bed rest 0 0 Exercises 98 93 Psychosocial evaluation 87 94 Work modification 68 68 Manipulation/mobilization 53 46 Heat/ice pack 58 49 Transcutaneous electrical 24 34 stimulation Therapeutic ultrasound 8 2 Cervical collar 2 2 Referral to specialist 100 99 Multidisciplinary rehabilitation 64 56 programme Psychology referral 75 68
p value NS NS NS 0.002 NS NS NS
