PAIRS - Pain and Impairment Relationship Scale. Looking for abbreviations of PAIRS? It is Pain and Impairment Relationship Scale. Pain and Impairment. Health Care ProfessionalsL Pain and Impairment Relationship Scale (HC-PAIRS ) questionnaire. This measures attitudes of clinicians towards. Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS).  and the Pain Attitudes and Beliefs Scale for physiotherapists. (PABS-PT) .
PT scales would demonstrate an acceptable level of internal consistency; 2. PT would demonstrate an acceptable reproducibility in a test-retest design with seven-day interval; 4. PT would demonstrate low levels of ceiling and floor effects. Translation and cross-cultural adaptation The translation and cross-cultural adaptation procedures followed the Guidelines for the process of cross-cultural adaptation of self report measures21, as described below: PT scale was translated into the Brazilian-Portuguese by two independent bilingual translators who were unaware of the instrument; 2.
Synthesis of the translations: PT into Brazilian-Portuguese; 3. PT was then back translated into English by two independent bilingual translators, who did not have previous knowledge of the original version of the questionnaire; 4.
An expert committee composed by the four translators and the authors of this study revised all the previous procedures, compared all translations and corrected possible discrepancies so that the final version of PABS. PT could be tested in Brazil.
Pre-tests were not performed to check the understanding of items of the instruments as suggested by the guidelines The participants of the study were asked about the comprehensibility of the items of these instruments and they reported no major problems when answering the instruments. PT scales were tested in a sample of physical therapists who routinely treat patients with low back pain in their clinical practice.
To participate in the study, the physical therapists should be registered in any Brazilian registration board, have experience in the treatment of patients with low back pain this information was obtained through the question: How many patients with low back pain on average do you treat per week? The sample size of physical therapists was defined following the recommendations of the Quality criteria for measurement properties of health status questionnaires22 which suggest that, at least, 50 participants would be necessary for the reproducibility, validity and ceiling and floor effects analyses, and at least participants would be needed for the internal consistency analysis.
The following clinimetric properties were tested: The internal consistency of the instruments was tested through the Cronbach's alpha statistics Cronbach's alpha values ranging from 0. Reproducibility is an umbrella term that covers two properties: In other words, the reliability is the relative measurement error22, ICCs lower than 0.
The statistical procedure of agreement is able to determine how close two scores measured in different time points are from each other. Agreement is always expresses in the same measurement units of the instrument through the Standard Error of the Measurement SEM.
The construct validity is evaluated by testing a priori hypotheses. The statistical test used in our study was the Pearson Correlation Coefficient r Ceiling and floor effects: One of the consequences of the ceiling and floor effects is the inability to distinguish patients who answered very low or very high scores, which influences the reliability of the instrument.
The ceiling and floor effects were calculated through frequency analyses starting from summing the number of participants who answered the questionnaires with maximum ceiling and minimum floor scores and through the subsequent conversion of these values into percentages. PT scales twice through interviews, being the first interview at baseline day 0 and the second one seven days later day 7.
The seven-day interval was chosen to avoid the recall from the first interview, but also to ensure that there was not enough time that the beliefs with regards to low back pain could be changed for example due to continuous education courses.
The baseline interview and the one seven days later were previously scheduled with the participants, and there were no drop outs between the first and the second interview. Demographic data, such as age, gender, workplace and professional experience were also collected at baseline.
Results A total of physical therapists of both genders, being most young adults, with professional experience lower than 5 years, following different treatment approaches for low back pain and attending in different types of clinical environment participated in the study Table 1. The final version of the PABS. PT scale translated and cross- culturally adapted into Brazilian-Portuguese is described in appendix 1. Tables 2 and 3 present the results for the internal consistency, reproducibility and construct validity of the instruments as well as their respective subscales.
The internal consistency estimates ranged from 0. These results reflect appropriate estimates of internal consistency and reproducibility.
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The correlation matrix with the results of the construct validity analysis shows correlation estimates that ranged from weak to moderate in most of the cases, except for the correlation between the subscale PABS.
Moreover the participants were physical therapists with different levels of academic degrees and professional experience, who worked in different clinical environments. These factors together are relevant with regards to the external validity of the study.
An acceptable Cronbach's alpha value was observed 0. Two studies presented similar estimates. The first study15 analyzed attitudes and beliefs of health care providers in relation to patients with chronic low back pain. This study recruited American health care providers i. The second study7 recruited a sample of Dutch therapists i.
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PT scale is interpreted according to a two-dimensional model. In this study, the analyses of the internal consistency of the PABS.
PTBiomedical factor subscale 0. PTBiopsychosocial factor subscale 0. These results are also similar to the results of clinimetric studies performed previously. PTBiomedical factor subscale and 0.
The same pattern of results was observed in Ostelo's et al. PTBiomedical factor subscale and of 0. In all studies which the internal consistency of PABS. Studies are necessary in order to revise and retest the items of this subscale. Reproducibility refers to the ability of a measurement instrument to obtain similar answers under stable conditions24 and it is evaluated through the relative reliability and absolute agreement error of the instrument.
In the present study, reliability estimates ranged from moderate to substantial. Similarly the study of Rainville et al. With regards to the PABS. PT scale, we observed an ICC of 0.
The agreement values observed in this study were 4. PTBiomedical factor and 3. The percentage of the SEM in relation to the total score of the questionnaires ranged from 4. PTBiopsychosocial factor subscalerepresenting a good agreement. We are unaware of previous studies that measured the agreement of these instruments.
Construct validity is tested when the score of a certain measurement instrument is correlated with the score of another instrument that measures the same construct or a similar construct.
The correlation matrix in Table 3 demonstrates correlations that range from weak to moderate in all cases, except for the correlations between the PABS. It is important to highlight that the PABS. Therefore, moderate correlation coefficients can be considerate acceptable given that our results support our a priori hypothesis that these scales would be positively correlated.
PT evaluates the attitudes and beliefs of health care providers regarding the development and maintenance of the chronic low back pain, the HC-PAIRS evaluates the belief of health care providers in the relationship between intensity pain and disability in patients with chronic low back pain.
So, high correlation values between these instruments are not expected. On the other hand, the study of Houben et al. The differences in terms of construct validity in different countries may be explained by a combination of cultural aspects, sample differences or still by differences in the educational context of the curricular structure of the educational programs of physical therapy worldwide.
Our study has some limitations that should be considered on the interpretation of the results. First, the pre-tests were not performed to analyze the comprehensibility of the scales' items before starting the data collection. The cross-cultural adaptation guidelines21 suggest that the pre-test should be carry out in a small sample of patients to test if the final version is easy to understand. Although the participants of this study have considered the instruments as easy to complete, the possibility that the pre-test would have identified the need of a review of some PABS.
PTbiomedical subscale represents a belief in the relationship between low back pain and tissue damage, while a high score on the PABS. PTbiopsychosocial subscale indicates a belief in the influence of psychological and social as well as biological factors PT, which has also been previously translated and cross-culturally adapted, and presents acceptable clinimetric properties Data normality was verified through the visual inspection of histograms, with all variables being normally distributed.
Univariate and multivariate linear regression analyses were used to investigate sociodemographic characteristics that could be associated with the beliefs and attitudes measured by the two scales.
PT subscales were used as dependent variables. The following independent variables were selected a priori: Although we considered the variables "main work location" and "highest academic degree" for possible inclusion in the regression models, these variables do not satisfy the assumption of linearity with the dependent variables.
We used the SPSS Results A total of physical therapists were invited to participate in the study and All participants were young adults with an average of six years of professional experience. Table 1 lists the main characteristics of the participants. Table 2 shows the results of the evaluation of participants' beliefs and attitudes about chronic low back pain.
This result indicates that male and less experienced physical therapists with regards to years of professional experience were more likely to follow a biomedical approach to the treatment of patients with chronic low back pain. Discussion The scores on the two scales used in the present study were very close to their midpoint values. This result may indicate an uncertainty among physical therapists regarding their treatment orientation i.
Three previous studies reported similar scores for PABS. Finally, the study by Fullen et al. The difference between the scores on PABS. PTbiopsychosocial of these previous studies and the present study may be explained by a combination of sampling differences, including cultural aspects, type of academic training and professional experience, or by differences in the curricular structure of university programs in different countries.
The attitudes and beliefs of healthcare providers are intimately associated with their clinical decision-making. For example, healthcare professionals with a stronger biomedical profile tend to prescribe more imaging exams to search for specific causes of chronic low back pain and to encourage patients to rest and take time away from work in an attempt to reduce tissue damage However, clinical practice guidelines for the management of chronic low back pain do not recommend such prescriptions because there is sufficient evidence showing that these actions do not help patients with this condition3.
One previous study29 reported strong beliefs in the relationship between chronic pain and disability among Dutch healthcare providers.
In that study, the majority of the sample were physical therapists, manual therapists, chiropractors and few 5. In contrast, the majority of physical therapists included in our sample did not use a specific treatment approach for the management of their patients, which probably explains why we were unable to indicate a direction for the beliefs of physical therapists about the relationship between chronic pain and disability.
Differences in the beliefs of healthcare providers with diverse educational training were also evident in another study8 comparing health professionals authors did not specify their professional background with 66 "functional restoration therapists".
It is worth noting that this study used a Likert scale ranging from while our study used a scale, therefore we can conclude that the Brazilian estimates of HC-PAIRS scores were higher than American health care professionals. Among the variables entered into the regression analyses, male gender and years of professional experience were significantly associated with the score on PABS. The number of patients with low back pain who were seen by the physical therapist per month was the only variable associated with the HC-PAIRS score.
Similar analyses were performed in two previous studies. In the study conducted by Houben et al. A common aspect between these studies and the present study is a greater biopsychosocial focus among female and more experienced healthcare providers considered either as the time in the profession or the number of patients with low back pain seen in a particular period of time. The present study is the first to evaluate the attitudes and beliefs of Brazilian physical therapists about patients with chronic low back pain.
One of the strengths of our study was the inclusion of physical therapists from various cities and with different levels of academic training. Although we think that our sample might be representative, there is no available demographic data from registration boards, for example to determine if our sample is truly representative of all Brazilian physical therapists.
Nonetheless, the sample size in this study was smaller than those of earlier studies16,33, which makes our study less representative when compared to European studies. It is critical that future studies evaluate ideal cut-off points for the PABS. PT in order to assist interpretation about the orientation biomedical or biopsychosocial of healthcare professionals towards the treatment of patients with chronic low back pain.
Additionally, it would be interesting to compare the attitudes and beliefs of Brazilian physical therapists to those of other healthcare professionals involved in the treatment of these patients. Finally, further investigations should focus on changing the attitudes and beliefs of healthcare professionals and patients and on their impact on patient recovery.
Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. Prognosis for patients with chronic low back pain: European guidelines for the management of chronic nonspecific low back pain. A systematic review of low back pain cost of illness studies in the United States and internationally.
European guidelines for prevention in low back pain: The prevalence of low back pain: National Sampling Study of Households.Mobile and Personal Technologies in Precision Medicine Workshop - July 27-28, 2015 - Day 1
A Panorama of Health in Brazil: Health care providers' attitudes and beliefs about functional impairments and chronic back pain.
Fear avoidance and prognosis in low back pain: Determinants of chronic disability related to low back pain: Turner JA, Clancy S. Strategies for coping with chronic low back pain: The importance of fear, beliefs, catastrophizing and kinesiophobia in chronic low back pain rehabilitation.
Ann Phys Rehabil Med. Fear-avoidance beliefs about back pain in patients with acute LBP. The correlation between pain, catastrophizing, and disability in subacute and chronic low back pain: Spine Phila Pa Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women.
How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists. Effect of a simple information booklet on pain persistence after an acute episode of low back pain: Buchbinder R, Jolley D.