The psychometric properties of the PABS-PT in neck pain patients: a validation study

Translation, validity and reliability of the pain attitudes and beliefs scale for physiotherapists in French

BACKGROUND

The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) questionnaire evaluates manual therapists' biomedical and biopsychosocial beliefs regarding the management of chronic low back pain. Its usage in clinical settings is an important step in the implementation of national guidelines and policies to improve patient management.

OBJECTIVES

The objective of this study was to translate the PABS-PT questionnaire into French, to adapt it culturally, and to conduct a psychometric analysis.

DESIGN

Qualitative and cross-sectional study.

METHOD

The translation process followed published guidelines with cross-cultural validation by an expert committee. We followed a forward and backward translation procedure and an expert committee, including the original author of the questionnaire and a linguistics expert ensuring good cultural adaptation, issued a finalised version. Psychometric analysis of the French version of the questionnaire was conducted among 390 French manual therapists in two phases. The first phase evaluated structural validity as well as external validity compared with the TSK and BBQ questionnaires. Then, reliability and scalability were analysed. The second phase evaluated test-retest reproducibility by sending the same questionnaire 3 months later.

RESULTS

The validity study revealed three subscales: the classic biomedical subscale and two subscales for biopsychosocial beliefs (aetiology of pain and physical activity). With 21 items in total for the PABS-PT-FR, the structural validity scores were good (BM: alpha = 0.82, H = 0.38; Physical Activity: alpha = 0.62, H = 0.32; Aetiology of Pain: alpha = 0.55, H = 0.29).

CONCLUSIONS

This study provides a validated tool to assess French physiotherapists' and, more generally, healthcare providers' beliefs about chronic low back pain, with a new insight into the BPS subscale internal construct.

Transcultural Adaptation and Psychometric Validation of the Spanish Version of the Pain Attitudes and Beliefs Scale for Physiotherapists

Low back pain (LBP) is one of the main musculoskeletal pain conditions, and it affects 23-28% of the global population. Strong evidence supports the absence of a direct relationship between the intensity of pain and tissue damage, with psychosocial factors also playing a crucial role. In this context, the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) is a useful tool for evaluating physiotherapists' treatment orientations and beliefs regarding the management of low back pain (LBP). It helps identify practitioners who may benefit from additional education in modern pain neuroscience. However, there is not a Spanish validation of this scale for physiotherapists. Thus, the aims of this study were to translate and culturally adapt the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) into Spanish and to evaluate its psychometric properties. This validation study used three convenience samples of physiotherapists (PTs) (n = 22 for the pilot study, n = 529 for the validity study and n = 53 for assessing the instrument's responsiveness). The process of translating and adapting the PABS-PT into Spanish followed international guidelines and produced a satisfactory pre-final version of the questionnaire. Factor analysis confirmed the two-factor structure of the original version, with the biomedical (BM) factor explaining 39.4% of the variance and the biopsychosocial (BPS) factor explaining 13.8% of the variance. Cronbach's alpha values were excellent for the BM factor (0.86) and good for the BPS factor (0.77), indicating good internal consistency. Test-retest reliability was excellent for both factors, with intraclass correlation coefficients (ICCs) of 0.84 for BM and 0.82 for BPS. The standard error of measurement (SEM) was acceptable for both factors (3.9 points for BM and 2.4 points for BPS). Concurrent validity was moderate and in the expected direction and had significant correlations with the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and Revised Neurophysiology Pain Questionnaire (R-NPQ). Sensitivity to change was demonstrated by significant improvements in both factors after an educational intervention, with medium-to-large effect sizes. The PABS-PT also showed good discriminative ability, as it was able to distinguish between physiotherapists with and without pain education. Cut-off values for the BM and BPS factors were determined. In conclusion, the translated and adapted Spanish version of the PABS-PT demonstrated good psychometric properties and can be reliably used to assess the attitudes and beliefs of Spanish-speaking physiotherapists regarding LBP. The questionnaire is recommended for use in clinical and educational research in the Spanish language context.

The pain attitudes and beliefs scale for physiotherapists: development and psychometric assessment of the Spanish version among physiotherapy students

INTRODUCTION

Pain might be approached from a biomedical or biopsychosocial perspective. There is a lack of research on the attitudes and beliefs about pain among physiotherapy students. In this context, the Pain Attitudes and Belief Scale for Physiotherapists (PABS-PT) is an instrument widely used from a clinical and educational perspective, but its psychometric properties have not yet been tested in a student-based population.

OBJECTIVE

To develop the Spanish version of the PABS-PT scale and to assess its psychometric properties among students in physiotherapy.

METHODS

The study was carried out among 103 students in their final years of academic studies in the Degree in Physiotherapy in the University of Murcia (Spain). Sociodemographic and PABS-PT related variables were collected. The instrument was translated into Spanish and tested through factor analysis, internal consistency, test-retest reliability, and known-groups validity. The 95% minimal detectable change of the instrument was also calculated.

RESULTS

The factor analysis revealed two factors within the instrument: Biomedical (9 items) and Biopsychosocial (7 items) factors, with Cronbach's alpha values of 0.730 and 0.708, respectively. The Intraclass Correlation Coefficient (3,2) was 0.851 for the Biomedical factor and 0.699 for the Biopsychosocial factor. The minimal detectable changes (95% CI) for the Biomedical and Biopsychosocial factors were 6.01 and 5.56, respectively. The pre-specified hypothesis for the known-groups validity test was met and revealed large effect sizes (d = 1.24).

CONCLUSION

The Spanish version of the instrument PABS-PT-SP covers two factors. It shows satisfactory psychometric properties and it is therefore an effective framework to discriminate between the biomedical and/or biopsychosocial thoughts and attitudes toward pain in physiotherapy.

Physiotherapists' knowledge, attitude and practice behavior to prevent chronification in patients with non-specific, non-traumatic, acute- and subacute neck pain: A qualitative study

BACKGROUND

The purpose of this study was to explore physiotherapists' knowledge, attitude, and practice behavior in assessing and managing patients with non-specific, non-traumatic, acute- and subacute neck pain, with a focus on prognostic factors for chronification.

METHOD

A qualitative study using in-depth semi-structured interviews was conducted with 13 physiotherapists working in primary care. A purposive sampling method served to seek the broadest perspectives. The knowledge-attitude and practice framework was used as an analytic lens throughout the process. Textual data were analyzed using qualitative content analysis with an inductive approach and constant comparison.

RESULTS

Seven main themes emerged from the data; physiotherapists self-estimated knowledge and attitude, role clarity, therapeutic relationship, internal- and external barriers to practice behavior, physiotherapists' practice behaviors, and self-reflection. These findings are presented in an adjusted knowledge-attitude and practice behavior framework.

CONCLUSION

A complex relationship was found between a physiotherapist's knowledge about, attitude, and practice behavior concerning the diagnostic process and interventions for non-specific, non-traumatic, acute, and subacute neck pain. Overall, physiotherapists used a biopsychosocial view of patients with non-specific neck pain. Physiotherapists' practice behaviors was influenced by individual attitudes towards their professional role and therapeutic relationship with the patient, and individual knowledge and skills, personal routines and habits, the feeling of powerlessness to modify patients' external factors, and patients' lack of willingness to a biopsychosocial approach influenced physiotherapists' clinical decisions. In addition, we found self-reflection to have an essential role in developing self-estimated knowledge and change in attitude towards their therapeutic role and therapist-patient relationship.

Pain knowledge, attitudes and beliefs of doctor of physical therapy students: changes across the curriculum and the role of an elective pain science course

Introduction: Entry-level physical therapist education on pain has been described as lacking. Calls have been made to include pain science courses to address this knowledge gap.Methods: Physical therapist students' pain knowledge and attitudes were measured using the revised Neurophysiology of Pain Questionnaire (rNPQ) and Pain Attitudes and Beliefs Scale for Physical Therapists (PABS-PT), respectively. Univariate ANOVAs, with post hoc pairwise comparison and effect sizes, were used to measure these aspects over time.Results: Pain knowledge and clinician beliefs were significantly different (p < 0.001) at various curricular timepoints. rNPQ scores increased from 1^st to 2^nd year (effect size: 1.10), remained similar between years 2 and 3, and improved following the pain course (effect size: 1.25). Biomedical beliefs were similar during years 1, 2 and 3, and declined following the pain course (effect size: 1.56). Conversely, psychosocial belief scores increased from 1^st to 2^nd year (effect size: 0.82), remained similar between years 2 and 3, and increased following the pain course (effect size: 1.08).Discussion/Conclusions: Physical therapist education, without a dedicated pain science course, may be insufficiently preparing students to treat patients in pain. Educators should consider adopting a dedicated pain science course or substantially bolstering embedded curricular pain content to promote best practice in pain treatment.

The (cost-)effectiveness and cost-utility of a novel integrative care initiative for patients with chronic musculoskeletal pain: the pragmatic trial protocol of Network Pain Rehabilitation Limburg

BACKGROUND

Rehabilitation care for patients with chronic musculoskeletal pain (CMP) is not optimally organized. The Network Pain Rehabilitation Limburg 2.0 (NPRL2.0) provides integrated care with a biopsychosocial approach and strives to improve the Quadruple Aim outcomes: pain-related disability of patients with CMP; experiences of care of patients with CMP; meaning in the work of healthcare professionals; and healthcare costs. Firstly, in this study, the effectiveness (with regard to the functioning and participation of patients) of primary care for patients with CMP will be assessed, comparing care organized following the NPRL2.0 procedure with usual care. Secondly, the cost-effectiveness and cost-utility with regard to health-related quality of life and healthcare costs will be assessed. And thirdly, the effect of duration of participation in a local network in primary care will be studied.

METHODS

In this pragmatic study, it is expected that two local networks with 105 patients will participate in the prospective cohort study and six local networks with 184 patients in the stepped-wedge based design. Healthcare professionals in the local networks will recruit patients.

INCLUSION CRITERIA

age ≥ 18 years; having CMP; willing to improve functioning despite pain; and adequate Dutch literacy.

EXCLUSION CRITERIA

pregnancy; and having a treatable medical or psychiatric disease. Patients will complete questionnaires at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4). Questionnaires at T1 and T4 will include the Pain Disability Index and Short Form Health Survey. Questionnaires at T1, T2, T3, and T4 will include the EQ-5D-5L, and iMTA Medical Consumption and Productivity Cost Questionnaires. Outcomes will be compared using linear mixed-model analysis and costs will be compared using bootstrapping methods.

DISCUSSION

NPRL2.0 is a multidimensional, complex intervention, executed in daily practice, and therefore needing a pragmatic study design. The current study will assess NPRL2.0 with respect to the Quadruple Aim outcomes: patient health and costs. This will provide more information on the (cost-) effectiveness of the organization of care in a network structure regarding patients with CMP. The other two Quadruple Aim outcomes will be examined alongside this study. Trial registration Netherlands Trial Register: NL7643. https://www.trialregister.nl/trial/7643 .

Can the Pain Attitudes and Beliefs Scales be adapted for use in the context of osteoarthritis with general practitioners and physiotherapists?

BACKGROUND

Conservative, first-line treatments (exercise, education and weight-loss if appropriate) for hip and knee joint osteoarthritis are underused despite the known benefits. Clinicians' beliefs can affect the advice and education given to patients, in turn, this can influence the uptake of treatment. In New Zealand, most conservative OA management is prescribed by general practitioners (GPs; primary care physicians) and physiotherapists. Few questionnaires have been designed to measure GPs' and physiotherapists' osteoarthritis-related health, illness and treatment beliefs. This study aimed to identify if a questionnaire about low back pain beliefs, the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), can be adapted to assess GP and physiotherapists' beliefs about osteoarthritis.

METHODS

This study used a cross-sectional observational design. Data were collected anonymously from GPs and physiotherapists using an online survey. The survey included a study-specific demographic and occupational characteristics questionnaire and the PABS-PT questionnaire adapted for osteoarthritis. All data were analysed using descriptive statistics, and the PABS-PT data underwent principal factor analysis.

RESULTS

In total, 295 clinicians (87 GPs, 208 physiotherapists) participated in this study. The principal factor analysis identified two factors or subscales (categorised as biomedical and behavioural), with a Cronbach's alpha of 0.84 and 0.44, respectively.

CONCLUSIONS

The biomedical subscale of the PABS-PT appears appropriate for adaptation for use in the context of osteoarthritis, but the low internal consistency of the behavioural subscale suggests this subscale is not currently suitable. Future research should consider the inclusion of additional items to the behavioural subscale to improve internal consistency or look to develop a new, osteoarthritis-specific questionnaire.

TRIAL REGISTRATION

This trial was part of the primary author's PhD, which began in 2012 and therefore this study was not registered.

Translation and psychometric evaluation of the Hebrew version of the Health Care Providers' Pain and Impairment Relationship Scale

BACKGROUND AND PURPOSE

Physiotherapists' different attitudes towards low back pain (LBP) are associated with patients' attitudes towards pain and with patients' disability. The Health Care Providers' Pain and Impairment Relationship Scale (HC-Pairs) is a self-administered instrument that assesses the attitudes and beliefs of health care professionals regarding LBP and the patient's daily function. The aims of this study are to translate, culturally adapt, and asses the psychometric properties of the Hebrew version of the HC-Pairs.

METHODS

The English version of the HC-Pairs was forward-backward translated, pretested, and reviewed by a panel of experts. Reliability was determined by computing Cronbach's α, and validity by exploring the correlations between the HC-Pairs' scores and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) scores. Confirmatory factor analysis was performed. A convenience sample of 277 physiotherapists was invited to fill the HC-Pairs and PABS-PT questionnaires and a sociodemographic questionnaire.

RESULTS

The forward-backward translation process revealed minor discrepancies between the texts. After the pretest, the expert panel agreed on a final version. A sample of 241 physiotherapists completed the questionnaires (response rate of 87%; 241/277); 213 met the inclusion criteria. Factor analysis suggests that the Hebrew version of the scale fits the one-factor model. Cronbach's α was 0.81 after deletion of two items and indicated good internal consistency. The scores produced by the instrument showed a substantial correlation with those of the biomedical dimension of the PABS-PT, and poor correlation with the behavioural dimension, in the expected directions.

CONCLUSION

The findings of the present study on the psychometric properties of the HC-Pairs are positive. Nevertheless, the Hebrew version of the HC-Pairs is still in a developmental stage. Further psychometric research is needed to assess the attitudes and beliefs of Hebrew-speaking physiotherapists, which have been shown to be associated with treatment orientations and work recommendations.

Item response theory evaluation of the biomedical scale of the Pain Attitudes and Beliefs Scale

OBJECTIVES

The assessment of health care professionals' attitudes and beliefs towards musculoskeletal pain is essential because they are key determinants of their clinical practice behaviour. The Pain Attitudes and Beliefs Scale (PABS) biomedical scale evaluates the degree of health professionals' biomedical orientation towards musculoskeletal pain and was never assessed using item response theory (IRT). This study aimed at assessing the psychometric performance of the 10-item biomedical scale of the PABS scale using IRT.

METHODS

Two cross-sectional samples (BeBack, n = 1016; DABS; n = 958) of health care professionals working in the UK were analysed. Mokken scale analysis (nonparametric IRT) and common factor analysis were used to assess dimensionality of the instrument. Parametric IRT was used to assess model fit, item parameters, and local reliability (measurement precision).

RESULTS

Results were largely similar in the two samples and the scale was found to be unidimensional. The graded response model showed adequate fit, covering a broad range of the measured construct in terms of item difficulty. Item 3 showed some misfit but only in the DABS sample. Some items (i.e. 7, 8 and 9) displayed remarkably higher discrimination parameters than others (4, 5 and 10). The scale showed satisfactory measurement precision (reliability > 0.70) between theta values -2 and +3.

DISCUSSION

The 10-item biomedical scale of the PABS displayed adequate psychometric performance in two large samples of health care professionals, and it is suggested to assess group-level professionals degree of biomedical orientation towards musculoskeletal pain.

Factor structure of the German version of the pain attitudes and beliefs scale for physiotherapists

The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) is a questionnaire that is frequently used to measure the treatment orientation of physiotherapists and other healthcare providers toward low back pain (LBP). Previous validation studies of the PABS-PT have reported consistently that exploratory factor analysis (EFA) yielded a two-factor model with the factors "biomedical" and "biopsychosocial." However, there remain concerns regarding the composition of these two factors and the internal consistency of the "biopsychosocial" factor. The objective of this study was to replicate the previous validation study on the German PABS-PT. EFA was implemented to reexamine the underlying structure of the scale, and confirmatory factor analysis (CFA) was used to test the fit of the hypothesized two-factor model. Results of the initial validation study were not replicated. EFA indicated that a two-factor solution is an inadequate representation of the PABS-PT data, and CFA showed insufficient fit of the hypothesized two-factor model to the PABS-PT data. Our results indicate a need for caution when using the PABS-PT to measure physiotherapists' orientation toward LBP, particularly in measuring the magnitude of a biopsychosocial orientation.

Rasch analysis resulted in an improved Norwegian version of the Pain Attitudes and Beliefs Scale(PABS)

Background and aim

There is evidence that clinicians’ pain attitudes and beliefs are associated with the pain beliefs and illness perceptions of their patients and furthermore influence their recommendations for activity and work to patients with back pain. The Pain Attitudes and Beliefs Scale (PABS) is a questionnaire designed to differentiate between biomedical and biopsychosocial pain attitudes among health care providers regarding common low back pain. The original version had 36 items, and several shorter versions have been developed. Concern has been raised over the PABS’ internal construct validity because of low internal consistency and low explained variance. The aim of this study was to examine and improve the scale’s measurement properties and item performance.

Methods

A convenience sample of 667 Norwegian physiotherapists provided data for Rasch analysis. The biomedical and biopsychosocial subscales of the PABS were examined for unidimensionality, local response independency, invariance, response category function and targeting of persons and items. Reliability was measured with the person separation index (PSI). Items originally excluded by the developers of the scale because of skewness were re-introduced in a second analysis.

Results

Our analysis suggested that both subscales required removal of several psychometrically redundant and misfitting items to satisfy the requirements of the Rasch measurement model. Most biopsychosocial items needed revision of their scoring structure. Furthermore, we identified two items originally excluded because of skewness that improved the reliability of the subscales after reintroduction. The ultimate result was two strictly unidimensional subscales, each consisting of seven items, with invariant item ordering and free from any form of misfit. The unidimensionality implies that summation of items to valid total scores is justified. Transformation tables are provided to convert raw ordinal scores to unbiased interval-level scores. Both subscales were adequately targeted at the ability level of our physiotherapist population. Reliability of the biomedical subscale as measured with the PSI was 0.69. A low PSI of 0.64 for the biopsychosocial subscale indicated limitations with regard to its discriminative ability.

Conclusions

Rasch analysis produced an improved Norwegian version of the PABS which represents true (fundamental) measurement of clinicians’ biomedical and biopsychosocial treatment orientation. However, researchers should be aware of the low discriminative ability of the biopsychosocial subscale when analyzing differences and effect changes.

Implications

The study presents a revised PABS that provides interval-level measurement of clinicians’ pain beliefs. The revision allows for confident use of parametric statistical analysis. Further examination of discriminative validity is required.