Knowledge and Attitude towards Chronic Musculoskeletal Pain Treated with Osteopathy

Background: Chronic pain is a common clinical feature that accompanies osteopathy. Knowledge and attitudes of both patients and their treating clinicians would influence the patients' outcomes and pain control. Objective: This systematic review will provide an understanding of the knowledge and attitudes of patients and clinicians towards musculoskeletal pain accompanying osteopathy. Methods: Different keywords were used to search the medical literature, including: “knowledge” OR “Attitude” AND “Osteopathy” AND “Pain” AND “patient” OR “clinician." The search databases included Medline, Embase PubMed, and SCOPUS. The following step was reviewing the appearing results to ensure that they were original research articles that examined the knowledge and attitudes about chronic musculoskeletal pain with osteopathy. All the eligible studies should mention the type of participants examined (either patients or clinicians). Results: A total of 89 studies were obtained. After removing review articles and choosing original research studies solely, 11 studies appeared from the filtration process. Eight research articles were eligible. All the included studies had a quantitative cross-sectional design. Only health care Systematic Review Article Al-Shareef et al.; JPRI, 33(48B): 166-175, 2021; Article no.JPRI.73632 167 professionals were asked about osteopathy, where all the studies included osteopaths from different countries, except one study that included physiotherapists. Osteopaths knew about the benefits of osteopathy, particularly for lower back pain; however, their knowledge about biopsychosocial factors requires improvement. Conclusion: Knowledge about osteopathy benefits for controlling chronic musculoskeletal pain should be improved even among osteopaths. Awareness campaigns are also needed for patients in orthopedic and physiotherapy clinics about osteopathy.


INTRODUCTION
Chronic pain is regarded as a common condition that challenges physiotherapists and orthopedics [1]. Managing chronic pain necessitates an understanding of different contributors that affect chronic pain sensation in osteopathy patients. This is particularly crucial for musculoskeletal pain [2]. The prevalence of chronic pain is relatively high, with more than five million patients suffer from chronic pain annually in Europe, with an estimation of 28 million patients living with chronic pain [3].
Osteopathic techniques can play a pivotal role in reducing chronic musculoskeletal pain [4]. It has a particular benefit in pain associated with the low back. However, the knowledge of patients about the availability of osteopathic techniques and the attitudes and perceptions of clinicians towards using these techniques could significantly influence the use of osteopathy [5]. Osteopathy can also supplement the effect of medication, as biochemical explanations may not always be sufficient to explain the etiology of chronic pain [6].
There are multiple factors to consider with the assessment of Musculoskeletal chronic pain and the potential benefit from osteopathy [7]. Some socio-economic as well as psychological factors, would influence the perceptions of patients towards chronic pain [8]. However, improving patients' knowledge about chronic pain and their options to control pain would improve their experience [9,10].
There have been some proposals that clinicians who have positive attitudes towards using osteopathy to treat chronic pain through osteopathy have their patients with better clinical outcomes and more extended pain-free periods, compared to patients on pharmacological treatment solely. However, these data are still debatable and require further exploration [11].
Accordingly, this systematic review will understand what patients and clinicians know and how they behave towards chronic musculoskeletal chronic pain managed with osteopathy.

Methodology
This systematic review adhered to the PRISMA checklist forms for systematic review and metaanalysis [12]. This systematic review was done via reviewing electronic databases to select the eligible research studies between 2011 and 2021 through four databases: Medline, Embase, PubMed, and SCOPUS.

Search Strategy
The keywords used were: "knowledge" OR "Attitude" AND "Osteopathy" AND "Pain" AND "patient" OR "clinician". All the titles and abstracts resulting from this primary evaluation were assessed thoroughly to avoid losing any eligible research articles. The results were then evaluated to select only original research studies which examined the knowledge and attitudes about chronic musculoskeletal pain with osteopathy. All the included studies should mention the type of participants examined (either patients or clinicians). Only articles in English were considered studies of possible inclusion, which were then included in the second stage.

Eligibility Criteria
The following stage was identifying the inclusion criteria to select the eligible research articles. Abstracts were assessed manually to identify all the articles that can be included to be further reviewed. We set inclusion criteria which comprised a mentioning of the participants' population (patients or clinicians) as well as studies published during the last decade. The final stage was gathering the pre-defined extracted data from the pre-formed excel sheet to collect data from eligible articles and arrange them. Reviews and articles that contained missing or overlapped data were removed. Besides, unavailable full-text articles or poor study designs were removed. The full description of the search strategy is shown in Fig. 1.

Data Review and Analysis
The initial stage in the data review process was a fundamental review that used a pre-formed excel sheet to gather information. The selected information from eligible research studies was then revised via the excel sheet. In the case of multiple research studies designed by one research group assessing similar variables, an evaluation for duplication possibility was carried out.

RESULTS
After evaluating all abstracts and assessing them against the inclusion criteria to detect the abstracts for inclusion, eight research articles were eligible to be included [13][14][15][16][17][18][19][20]. All the included studies had a quantitative crosssectional design, where surveys were used to evaluate the knowledge and attitudes towards osteopathy for chronic musculoskeletal pain.
Only health care professionals were asked about osteopathy, where all the studies included osteopaths from different countries, except one study that included physiotherapists [14]. It has been shown that osteopaths knew about the benefits of osteopathy for chronic musculoskeletal pain, particularly for lower back pain; however, their knowledge about biopsychosocial factors requires improvement. It has also been shown that patients' demographics could affect their acceptance to being treated by osteopathy to control their pain but at a minimal level, as detailed in Table 1.  Musculoskeletal pain located in the spine, thorax, pelvis, and limbs was the most common reason for patients seeking osteopath's consultation among more than half of the patients. Females seeking osteopathy were significantly higher than males.

DISCUSSION
Patients with chronic musculoskeletal pain usually have an impaired quality of life and reduced productivity [16]. There are different methods for chronic pain; an effective approach is the use of osteopathy, particularly for chronic low back pain, though, evidence on its efficacy is still controversial for all patients with chronic pain [17]. Furthermore, knowledge and attitudes of patients and clinicians towards osteopathy for chronic musculoskeletal pain is unclear [7].
The present review examined the medical literature to identify the knowledge and attitudes of patients and clinicians from different specialities towards osteopathy. It has been shown that knowledge and attitudes of patients are understudied, and they were only examined from a clinicians' point of view. Additionally, only osteopaths and physiotherapists were considered.
The present review demonstrated that osteopaths and physiotherapists had inadequate knowledge and attitude about osteopathy, especially the biopsychosocial aspect of the strategy. It has been also revealed that female patients and those with lower back pain are the most common to seek medical advice for treating their chronic musculoskeletal pain with osteopathy. Also, socio-demographic factors of patients might have minimal influence on the decision to apply osteopathy strategies to control their chronic pain.
Interest in understanding the knowledge and attitudes towards osteopathy has dramatically increased in the past five years, as shown in this review. Four studies examined the knowledge and behaviours of osteopaths and physiotherapists during the last year [13][14][15][16]. Also, questionnaires were found the most used method for understanding the knowledge and attitudes about osteopathy.
Chronic low back pain was the most common cause for chronic musculoskeletal pain which required osteopathy. Van Biesen et al. [13] showed that Spanish osteopaths knowledge and attitudes about osteopathy for treatment of chronic low back pain did not differ significantly from other medical professionals. While Van Biesen et al. [13] highlighted that osteopaths may fear using osteopathy for controlling their patients pain due to limited evidence on its use [13].
On the contrary, Benny et al. [14] showed that the knowledge and attitudes of osteopathy for chronic low back pain could vary based on the professional characters of the physiotherapists. Less experienced and physiotherapists working in public institutions had significantly higher knowledge compared to their peers (p-value<0.05). Benny et al. [14] also endorsed more studies to find associations between improving knowledge and improved patients outcomes in terms of pain control. These findings came compliant to the findings from Abrosimoff et al. [15] which involved osteopaths rather than physiotherapists.
Moreover, Fitzgerald et al. [16] highlighted that patients need psychological support in addition to the osteopathic strategy, and that demographic variations among patients may affect their attitude and acceptance for osteopathy. Two additions for Fitzgerald et al. [16] was that patients with low back pain would need more osteopathy sessions, and that patients with pain control certification were significantly more aware of osteopathy (p-value<0.01). However, this review is limited by some obstacles. All the included studies used a quantitative design using surveys. Responses to surveys usually depend on the subjective opinion of the responders, which can affect the reliability of the assessed knowledge level. Other objective methods would be endorsed for future studies.

CONCLUSION
Knowledge and attitudes of healthcare professionals, including physiotherapists and osteopaths, about osteopathy use for controlling chronic musculoskeletal pain should be improved through early training programs and courses starting from medical schools. Awareness campaigns and patient education sessions are also needed for patients who suffer from chronic musculoskeletal pain in orthopedic and physiotherapy clinics. Future studies should investigate the correlation between knowledge and attitudes towards osteopathy with patients outcomes.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.