Wisdom of Musculoskeletal Issues | JMDH

Wisdom of Musculoskeletal Issues | JMDH


Musculoskeletal problems (MSDs) are unexpectedly emerging in Saudi Arabia, achieving ranges very similar to the ones of the western global.1,2 MSDs are the third explanation why to discuss with a medical institution in Saudi Arabia3 and account for 38% of visits in circle of relatives follow.4 Regardless of the superiority of MSDs, physicians in Saudi Arabia reported low point of self assurance in MSD bodily exam and had self-perception of incompetency in managing MSDs as it should be.5 This will partially be defined via insufficient preparation of physicians to take care of MSDs in each undergraduate and postgraduate scientific coaching.6 Clinical faculties, international, spend not up to 3% in their curricula on MSDs device in comparison to different frame techniques.7 In Canada, handiest 2.26% of the scientific faculty curriculum is dedicated to MSD training.8 In the UK, 2% of the scientific years is dedicated to orthopedics.9 Lately, the Affiliation of American Clinical Schools identified MSD training as one space of deficiency in scientific faculties and known as for methods to extend MSD contents.10

Wisdom in MSDs amongst scientific practitioners was once first assessed the usage of a standardized MSDs check evolved via Freedman and Bernstein.11 80-five physicians underwent the check throughout the primary week following commencement. The physicians had an average ranking of 59.6%, with handiest 18% attaining the passing ranking. Following Freedman and Bernstein learn about,11 a number of scientific faculties and residencies used the MSD check to judge scholars and physicians.12–15 Apart from for orthopedists, a lot of these research discovered that scholars or physicians from quite a lot of specialties had not up to good enough wisdom in MSDs.

MSDs aren’t handiest controlled via physicians but additionally via different healthcare practitioners together with bodily therapists. Early use of bodily remedy for the control of MSDs is supported via constant suggestions from quite a lot of scientific follow tips, together with the American Faculty of Physicians.16,17 Bodily remedy has developed prior to now twenty years to transform an self sufficient follow the place bodily therapists can see sufferers and not using a doctor referral (ie, direct get entry to).18 On the other hand, evaluate of bodily therapists’ wisdom in managing MSDs was once carried out in only a few research.13,14,19 Childs et al confirmed that bodily therapists with orthopedic or sports activities board certification had upper rankings at the MSD check than scientific scholars, interns, citizens and maximum scientific specialties excluding orthopedists.13,19

In Saudi Arabia, alternatively, bodily remedy has now not absolutely developed into an self sufficient follow and continues to be a secondary care that calls for doctor referral to regulate sufferers with MSDs.20 Bodily remedy techniques in Saudi Arabia grant bachelor’s levels (excluding for 2 universities), and their curricula don’t adequately emphasize the contents of scientific screening or differential analysis.21 Bodily remedy products and services are extremely demanded in Saudi Arabia, with greater than 1.5 million visits a yr.22 Visits to number one care physicians and consultants associated with MSDs in Saudi Arabia are slightly below 1.1 million.23 Regardless of the top call for for bodily remedy products and services to regard MSDs, the competency of bodily therapists in managing MSDs in Saudi Arabia is unknown. Subsequently, the aim of this learn about was once to evaluate wisdom of MSDs amongst healthcare suppliers in Saudi Arabia. We aimed to judge MSD wisdom amongst (1) orthopedists, number one care physicians and bodily therapists, in addition to (2) bodily remedy and scientific scholars and interns.


Analysis Design and Atmosphere

This was once a cross-sectional learn about that integrated a unmarried on-line consultation that was once performed from 4th of March 2019 to thirtieth of April 2019.

Individuals and Pattern Measurement

We integrated authorized bodily therapists, physicians (together with citizens) and orthopedists, in addition to final-year bodily remedy and scientific scholars and interns in Saudi Arabia. We excluded bodily therapists, physicians and orthopedists who aren’t authorized to follow in Saudi Arabia and scholars who aren’t of their last yr.

On the time of the knowledge assortment, the Saudi Ministry of Well being had 2645 orthopedists, 9531 number one care physicians, and 4466 bodily therapists.22 We used calculator.web to acquire a pattern that represents the focused inhabitants of 16,642 with a margin of error of ±5 and 95% self assurance period.24 The wanted pattern was once roughly 376 practitioners (orthopedists, number one care physicians, and bodily therapists). Reaction fee among healthcare practitioners was once estimated to be between 10% and 17%;25,26 thus, we deliberate to ship invites to 3000 or extra possible members.

Musculoskeletal Wisdom Check

We used a standardized MSDs check evolved via Freedman and Bernstein.11 The check accommodates 25 questions that assessed MSDs wisdom (Appendix 1). The questions come with usually encountered MSDs in number one care atmosphere comparable to fractures, dislocations, arthritis, spinal ache, or prerequisites that warrant emergency referrals. The passing ranking was once made up our minds to be 70% (no less than 18 proper solutions out of 25). The check was once used to evaluate the MSD wisdom of bodily remedy and scientific practitioners and was once validated in earlier research.11,12

The unique structure of the check was once paper founded and required short-answers. On the other hand, for practicality functions, we changed the check to an online multiple-choice-question structure that integrated 1 proper solution as made up our minds within the unique solution key of the check and three distractors that we evolved. To be sure that the distractors have been suitable, a professional merchandise creator with an orthopedic bodily remedy uniqueness certificates with 10 years’ enjoy reviewed the distractors and made adjustments most commonly associated with phrase variety or grammar.

Information Assortment

The information have been accumulated the usage of onlineexambuilder.com platform.27 This platform had many test-taking options essential for our learn about. It had a entrance web page the place members might be knowledgeable and consented to take the check as a part of this examine learn about and allowed for inquiring for members’ data, timing the check, proscribing the selection of makes an attempt to at least one in keeping with player, figuring out how a lot time each and every player spent taking the check, and exporting the knowledge right into a spreadsheet for research.

An digital hyperlink to the check was once despatched to electronic mail lists of specialised teams of bodily remedy and scientific scholars and practitioners. Additionally, invites to take the check have been posted on a number of social media channels. Moreover, bodily remedy and scientific instructional techniques and hospitals within the northern, southern, central and western areas of Saudi Arabia have been invited to take part by way of telephone or direct visits. A reminder to take the MSDs check was once despatched 6 occasions over the duration of the learn about.

After the members consented, they have been requested for demographics and uniqueness data. The check was once in English and restricted to twenty mins. The check was once now not proctored, however questions and solutions have been offered in random order. Just one proper solution in keeping with query was once allowed. As quickly because the player completed and submitted the check, they weren’t allowed to take it once more. The result of the check have been mechanically stored at the platform, which was once safe with a password for next research.

This learn about was once authorized via the Analysis Ethics Committee at West Virginia College (1903492338).

Statistical Research

Information have been analyzed the usage of SPSS 26 (Armonk, NY). Descriptive statistics have been used with pattern demographics and traits. For goal 1, multivariable linear regression research was once carried out between MSD check ranking as dependent variable and age, gender, years of enjoy and uniqueness as impartial variables. Area of expertise variable concerned orthopedists, number one care physicians, and bodily therapists because the reference staff. Age was once targeted across the imply to permit interpretation of the consistent. For goal 2, multivariable linear regression was once additionally carried out between MSD check ranking as dependent variable and age, gender and uniqueness as impartial variables. Area of expertise variable concerned bodily remedy scholars as a reference staff, bodily remedy interns, scientific scholars and scientific interns. For all analyses, assumptions have been examined, and alpha point of importance was once set at p < 0.05.


Out of 3000 invites, we have been ready to manner 784 practitioners. Of the 784 possible respondents, 35 have been excluded as a result of they didn’t solution any query; every other 51 looked as if it would have dropped out of the learn about after answering 2–3 questions and no time was once recorded for them; and every other 18 didn’t specify their uniqueness. We integrated 680 members, and the reaction fee was once 22.7%. The members’ demographics and uniqueness data are indexed in Determine 1 and Desk 1.

Wisdom of Musculoskeletal Issues | JMDH

Desk 1 Demographics, Ratings and Passing Charges for Individuals within the Musculoskeletal Check

Determine 1 Ratings of the musculoskeletal check for each and every uniqueness of members.

The total passing fee was once 14% (Desk 1). The passing fee was once 93.8% for orthopedists, 20% for number one care physicians, and 11.3% for bodily therapists.

For each regression fashions, the assumptions have been met. There was once a vital prediction of MSD check ranking via age, gender, years of enjoy and uniqueness for style 1, F(5482)=15.57, p<0.001, R2=0.154. There was once additionally a vital prediction of MSD check ranking via age, gender, and uniqueness for style 2, F (5240) = 6.71, p < 0.001, R2 = 0.123.

Desk 2 items the unstandardized regression coefficients (B), usual mistakes (SEB), t-test and importance point for style 1. Age, gender and years of enjoy didn’t considerably are expecting MSDs check ranking (P > 0.05). The t-test for each and every regression coefficient of the uniqueness predictors examined whether or not there was once a vital distinction between the indicator coded teams (ie, number one care physicians, and orthopedists) and the reference staff (bodily therapists). The outcome signifies that orthopedist’s staff had considerably upper imply ranking on MSD check than bodily therapists (t482= 8.12, p < 0.001) and number one care doctor (t482= 6.00, p < 0.05). On the other hand, the end result signifies that number one care doctor rankings didn’t considerably fluctuate from bodily remedy staff (t482= 6.47, p = 0.07).

Desk 2 Regression Research Abstract for Musculoskeletal Dysfunction Check on More than a few Healthcare Suppliers

Desk 3 items the unstandardized regression coefficients (B), usual mistakes (SEB), t-test and importance point for style 2. Age and gender didn’t considerably are expecting MSDs check rankings (P > 0.05). The t-test for each and every regression coefficient of the uniqueness predictors examined whether or not there was once a vital distinction between the indicator coded teams (ie, bodily remedy interns, scientific scholars, and scientific interns) and the reference staff (ie, bodily remedy scholars). The outcome signifies that scientific interns had considerably upper imply ranking on MSD check than bodily remedy scholars (t240=4.46, p<0.001), bodily remedy interns (t240=4.7, p<0.05), and scientific scholars (t240=2.79, p<0.05). There was once additionally a vital distinction between scientific scholars and bodily remedy interns (t240=2.5, p<0.05). On the other hand, there was once no vital distinction between scientific scholars and bodily remedy scholars (Desk 3).

Desk 3 Regression Research Abstract for Musculoskeletal Dysfunction Check Ranking The usage of More than a few Pupil Teams


Orthopedists, Physicians and Bodily Therapists

This learn about highlights the inadequacy of MSD wisdom amongst quite a lot of well being specialties in Saudi Arabia. Orthopedists in Saudi Arabia completed the very best rankings and passing charges at the MSD check in comparison to number one care physicians and bodily therapists (Tables 1 and a pair of). Additionally, our findings confirmed that number one care doctor rankings averaged 53.6% with a passing fee of 20%, which is analogous to Matzkin et al learn about appearing MSDs check rankings for physicians in the US of fifty% with a passing fee of 21%.12 On the other hand, our discovering confirmed that bodily therapists completed the bottom rankings of 46.72% with a passing fee of eleven.3%, which is in sharp distinction to earlier research from the US appearing that bodily therapists come subsequent to orthopedists at the MSD check with rankings between 74% and 81% and a passing fee of 58%–88%.13 Those low rankings amongst physicians and bodily therapists are slightly annoying only if MSD lawsuits are the third explanation why to discuss with number one care clinics in Saudi Arabia and as much as 83% of rehabilitation visits require bodily remedy.22,23 This discrepancy between the amount of MSDs and insufficient wisdom in control of MSDs may well be an element that contributes to the emerging well being care expenditure and the MSDs-related incapacity in Saudi Arabia.1 Nationwide plans to beef up musculoskeletal wisdom are essential.

Even supposing there was once no vital distinction between number one care physicians and bodily therapists at the MSD check ranking, each professions exhibited insufficient point of data in managing MSDs and a number of other causes might provide an explanation for such low efficiency. For number one care physicians, a number of research advised that loss of publicity to very important parts of MSDs comparable to orthopedic bodily exam abilities, radiographic analysis, and total time dedicated to coaching MSDs scientific abilities was once minimum or nonexistent.6 In Saudi Arabia, one learn about confirmed control of spinal MSDs via number one care doctor was once fallacious.28 Fifty p.c of number one care physicians indicated they’d prescribe lumbar give a boost to, 62% would counsel mattress leisure, 57% would now not refer a affected person after they suspected a spinal fracture, and as much as 72% underestimated neurological dangers publish spinal surgical operation.28 Spinal MSDs are the 4th main reason behind incapacity in Saudi Arabia and constitute a big portion of MSD lawsuits,1 but number one care physicians appear inadequately ready to regulate such prerequisites. Whilst we acknowledge that additional examine is had to determine the explanations underpinning such follow patterns, we consider MSD coaching can lend a hand bridge the space in wisdom of the way to organize MSDs.

For bodily therapists, the decrease efficiency at the MSD check ranking is also partially defined via the loss of postgraduate scientific coaching in Saudi Arabia.20,21 As soon as bodily therapists graduate, there are not any residency or fellowship alternatives they may be able to pursue to beef up their scientific stories.21 Graduate training in Saudi Arabia comes to grasp or physician of philosophy levels; alternatively, those levels are research-oriented extra so than clinically orientated and might not be related to advanced scientific wisdom. Earlier examine in the US confirmed that bodily therapists with scientific orthopedic or sports activities board certification or fellowship completed the very best rankings and passing charges at the MSD check in comparison to different specialties (excluding orthopedists).13,14 Additionally, Jette et al confirmed that bodily therapists with orthopedic board specialization have been two times as prone to make proper scientific resolution when offered with MSDs than the ones with out.29 Additional, bodily therapists with orthopedic board specialization have been extra environment friendly in MSDs control the usage of fewer visits, lower price, and usage of remedy procedures.30 Thus, organising orthopedic and game residency and fellowship techniques in Saudi Arabia has the prospective to beef up MSD wisdom among bodily therapists in Saudi Arabia.

The opposite causes, we consider, for the low efficiency of bodily therapists in Saudi Arabia are the pro regulation. In Saudi Arabia, bodily remedy is a secondary care carrier that will depend on doctor referral that every now and then contain instructions on what intervention must be used. As a result of this, bodily therapists in Saudi Arabia may well be incessantly beneath the influence that sufferers with MSDs had already been screened and identified via the doctor, which go away them much less ready to habits their very own screening and exam, and handiest in a position to habits interventions. This loss of alternative for bodily therapists to follow autonomously as number one care suppliers could have its affect on their scientific abilities to follow correct control of MSDs. However, the deficient efficiency at the MSD check signifies that bodily therapists in Saudi Arabia will not be in a position to look sufferers in direct get entry to settings. Earlier than such privilege is legislated, good enough coaching in MSDs should be instated.

Clinical and Bodily Remedy Scholars and Interns

On the point of scholars and interns, scientific interns and scholars in Saudi Arabia confirmed upper MSDs check rankings than bodily remedy scholars and interns (Tables 1 and three). Clinical interns in Saudi Arabia, noticeably, completed upper rankings and passing fee (40%) than the entire pattern of members on this learn about, excluding orthopedists. This efficiency is healthier than we expected and is also defined via that scientific interns are actively excited about making ready for the licensure exam, which could have equipped them a bonus in exam-taking abilities over different members. Nonetheless, the total reasonable rankings of scientific interns and scholars have been suboptimal (67% and 52% respectively), and related to the rankings reported via Freedman and Bernstein for scientific interns (60%) and scholars (54%) in the US.11 The decrease rankings of scientific interns and scholars support the discovering from one survey that reported that scientific undergraduates perceived that MSDs weren’t emphasised, nor competency in MSDs was once required.5 Identical findings have been reported in lots of portions of the sector, and we sign up for the Bulletin of the International Well being Group name to extend the contents of MSDs in scientific curricula.6 Additionally, this discovering begs the query whether or not long run physicians are being adequately ready to take care of the expanding quantity of MSDs when they input the personnel.

Bodily remedy scholars and interns have been among the decrease rankings at the MSD check (Desk 1). This discovering sees eye to eye with our prior survey that tested the entry-level competency of 149 graduating bodily therapists in Saudi Arabia the usage of a 70-question multiple-choice examination and located that the common ranking in quite a lot of scientific abilities to be 34%.31 Additionally, Bindawas et al evaluated the competency of graduating bodily therapists in Saudi Arabia from the standpoint of clinicians and academicians and located that abilities of analysis, exam, and remedy have been all rated not up to 3 out 5 at the Scientific Internship Analysis Instrument.32 Those suboptimal rankings from the present learn about and former ones are most likely because of the variety in bodily remedy curricula and loss of emphasis on MSD training.21 One learn about confirmed that bodily remedy scholars and interns uniformly agree there’s a want to build up handbook remedy contents and determine orthopedic residencies.21 We consider that there’s a crucial want to reform bodily remedy training and coaching in Saudi Arabia, now not handiest in MSD contents however in all different topics.


Musculoskeletal dysfunction training in under- and postgraduate ranges will also be advanced via adopting the suggestions of the International Well being Group Bulletin and the Affiliation of American Clinical Schools.6,10 In undergraduate MSD training of physicians and bodily therapists, instructing must come with fundamental sciences wanted for working out the MSD device comparable to anatomy, pathophysiology of MSDs device, kinesiology and biomechanics of the locomotor device. Scientific MSD training must expand scholars’ abilities in historical past taking, bodily exam, remedy choices, decision-making algorithms,33 lengthen into illness prevention, and verbal exchange and perspective abilities.6,34 MSD instructing means must focal point on problem-based studying that makes use of case research to additional expand deep studying and analytical abilities. For postgraduate MSD training, techniques for number one care physicians and bodily therapists must come with rotations in orthopedic and rheumatology or any uniqueness that offers with MSDs. Specialised coaching comparable to residencies and fellowships must be evolved to extend wisdom in explicit MSDs space such sports activities, rehabilitation, or ache control. Elaborated main points of MSD training contents were printed within the literature.34


Our learn about integrated many obstacles. The learn about integrated a comfort pattern, so we can’t exclude the potential for variety bias. Regardless of our a number of makes an attempt to extend the illustration of number one care physicians and orthopedists, the selection of members in those teams was once decrease, and we can’t make certain that our findings have been consultant of those populations. Our pattern was once composed of volunteers who could have selected to finish the MSD check because of want for pro self-development and private enlargement in follow, which might restrict the generalizability to different practitioners. Additionally, the content material of the MSD check could have been extra prone against physicians greater than bodily therapists; alternatively, earlier research used the check for bodily therapists too.13,14 It’s value noting that our amendment of the check to multiple-choice questions didn’t go through a means of validation very similar to that of the unique check.11 Some authors expressed considerations that the MSD check via Freedman and Bernstein didn’t seize the competency abilities for number one care physicians and advised a changed model that was once nonetheless beneath validity investigation.35


Apart from for orthopedists, the present learn about confirmed that MSD wisdom is suboptimal among number one care physicians and bodily therapists in Saudi Arabia. Even supposing now not considerably other, number one care physicians completed upper rankings than bodily therapists. Additionally, the learn about recognized deficiency in wisdom amongst scientific and bodily remedy scholars and interns. Clinical interns had the very best ranking of all of the teams excluding orthopedists. Our learn about highlights the want to beef up musculoskeletal training in Saudi Arabia for quite a lot of specialties.

Implications of the Learn about

Apart from for orthopedists, MSD wisdom seems insufficient among physicians and bodily therapists.

Insufficient MSD wisdom is also defined via loss of publicity to abilities of historical past taking, orthopedic bodily exam, radiographic analysis, correct MSD intervention, and total minimum time dedicated to training of MSDs at under- and postgraduate ranges.

Nationwide plans to beef up MSDs wisdom are essential to bridge the space between the insufficient wisdom of the way to organize MSDs and the expanding quantity of sufferers affected by MSDs.

Information Sharing Commentary

The datasets used throughout the present learn about are to be had from the corresponding creator upon request.

Moral Approval and Consent of Individuals

This learn about was once authorized via the Place of job of Analysis Integrity and Compliance at West Virginia College, College of Drugs # 1903492338.

Writer Contributions

All authors made a vital contribution to the paintings reported, whether or not this is within the conception, learn about design, execution, acquisition of knowledge, research and interpretation, or in these kind of spaces; took section in drafting, revising or seriously reviewing the item; gave last approval of the model to be printed; have agreed at the magazine to which the item has been submitted; and conform to be in command of all facets of the paintings.


The authors gained no investment for this learn about.


The authors claim that they have got no competing pursuits.


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