INTRODUCTION 

Physiotherapy is an independent and rapidly expanding healthcare profession that plays an important role in the prevention, treatment, and rehabilitation of various health conditions. Despite its well-established benefits, public awareness of physiotherapy remains limited.¹’² Neurological disorders encompass a wide range of conditions, from developmental to degenerative, often leading to lifelong disabilities.³ Global statistics reveal that stroke, migraines, and dementia are among the leading contributors to disability-adjusted life years (DALYs) worldwide.⁴ The prevalence of stroke is rising in India and remains one of the main causes of death and disability worldwide. Physical activity plays a key role in stroke rehabilitation, reducing disability and improving independence.⁵’⁶ Similarly, spinal cord injuries and traumatic brain injuries impose significant challenges to caregivers. Regaining even partial function can lead to improved quality of life.⁷’⁸ Neurological physiotherapy supports individuals with life-changing conditions. Neurorehabilitation, a core element that offers coordinated, interdisciplinary care enhances independence and reduces hospitalization, must be prioritised. Barriers include rurality, client unawareness, professional shortages, lack of accessible facilities, and insufficient community resources9. These issues increase the burden of disability, particularly in India. In developed countries, direct access to physiotherapy is common, but in India, it is still emerging.¹⁰’¹¹ Public awareness is limited to the role of physiotherapy in specific musculoskeletal and not extended to other specialities. Awareness and understanding are essential for better neurorehabilitation service utilisation, thereby reducing hospital stay and promoting functional recovery.¹²’¹³ In patients with progressive neurological conditions, physical activity has been shown to improve strength, flexibility, fitness, balance, and quality of life. Following rehabilitation, continued physical activity, customized evaluations, equipment adjustments, are all important for motor recovery, functional independence, and quality of life.¹⁴ Thus the aim of this study was to develop and conduct a preliminary psychometric evaluation of a questionnaire to assess awareness and perceived knowledge of neurophysiotherapy among individuals with neurological conditions. Improving awareness and promoting early identification of neurological disorders through education and community involvement may improve health outcomes. Home-based care and robust referral systems may improve adherence, reduce costs, and enhance quality of life, especially in low-resource settings. Community leaders, school teachers, health professionals, governmental and non-governmental organizations can engage in increasing awareness to support early detection and identification of individuals with neurological disorders in order to strengthen coverage of care. 

METHODOLOGY 

The study was approved by the Institutional Ethics Committee and was conducted in two phases. Phase I involved the development of the questionnaire and assessment of its content validity through expert evaluation. Phase II involved a pilot study to conduct a preliminary psychometric evaluation of the developed questionnaire by assessing its internal consistency and item performance among patients with neurological conditions.

PHASE I - Development of Questionnaire: This phase primarily concentrated on domain recognition and item generation. A thorough review of the existing literature was done to find out the current state of awareness and knowledge of neurophysiotherapy among patients with neurological conditions. We discovered that there is no specific tool that addresses awareness and perceived knowledge of neurophysiotherapy. Based on literature review and expert opinion, two theoretical domains i.e, Awareness and Perceived Knowledge were proposed. Their factorial structure was not examined in this preliminary psychometric evaluation because of the pilot sample size and therefore requires confirmation using exploratory and confirmatory factor analyses in future studies. The Awareness domain was designed to assess participants' awareness of neurophysiotherapy and their perspectives toward the profession. The Perceived Knowledge domain was developed to evaluate participants' self-perceived knowledge, beliefs, and understanding of neurophysiotherapy services. Each domain consisted of 13 items and the questionnaire was drafted. 

Content Validation:

Content validity of the questionnaire was established through expert evaluation. A panel of 10 experts in physiotherapy with a minimum of 10 years of clinical and academic experience reviewed the questionnaire for clarity, relevance, and appropriateness of the items. The experts were provided with a content validation form along with clear instructions for evaluation.

Evaluation of item relevance was performed using a 4-point Likert relevance scale where: 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = highly relevant. The Item-level Content Validity Index (I-CVI) was calculated by dividing the number of experts rating an item as either 3 or 4 by the total number of experts. The Scale-level Content Validity Index using averaging method (S-CVI/Ave) was computed as the average of all I-CVI values across the questionnaire. Based on expert recommendations, minor wording modifications were made to improve clarity and comprehensibility before finalization of the questionnaire.

The final version of the questionnaire consisted of two sections. The first section included demographic characteristics such as age, sex, highest educational qualification, and occupation. The second section consisted of 26 items divided into two theoretical domains: Awareness and Perceived Knowledge, each comprising 13 items. Each item was scored on a five-point Likert scale ranging from 1 (Fully unaware) to 5 (Fully aware). Therefore, the total score for each domain ranged from 13 to 65, with higher scores indicating greater awareness or perceived knowledge of neurophysiotherapy.

For descriptive interpretation, the total scores of each domain were classified into five categories using equal intervals across the possible score range. Scores of 13 were classified as Fully unaware, 14–26 as Unaware, 27–39 as Somewhat aware, 40–52 as Aware, and 53–65 as Fully aware. These categories were developed to facilitate interpretation of participants' responses and should not be considered empirically validated diagnostic cut-off values.

The overall questionnaire score ranged from 26 to 130. For descriptive purposes, total scores were categorized as Fully unaware (26), Unaware (27–52), Somewhat aware (53–78), Aware (79–104), and Fully aware (105–130). The same response descriptors "Fully unaware to Fully aware” were retained for both domains to maintain consistency in participant interpretation and scoring. The questionnaire copyright has been registered.

PHASE II – Preliminary Psychometric Evaluation of the Questionnaire:

A pilot study was conducted in Belagavi city among 26 patients with a neurological condition using a convenience sampling technique. Prior to data collection, the participants were informed about the purpose of the study and written informed consent was obtained. The developed questionnaire was administered through face-to-face interviews.

Patients aged 18 years and above diagnosed with a neurological condition and willing to participate were included in the study. Primary caregivers were included for participants who were unable to respond because of impaired consciousness or significant disorientation to obtain the required information. Participants unwilling to participate or unable to provide informed consent were excluded.

The pilot sample size was selected considering feasibility, time constraints, and availability of eligible participants during the study period. Similar sample sizes have been utilized in preliminary psychometric evaluation studies during early stages of questionnaire development. The predominance of male participants reflected the demographic distribution observed during recruitment at the study setting.

Statistical analysis: The content validity index for the expert review was analysed by using Microsoft Excel 2016. Descriptive Statistics were used to summarize the collected data. Internal consistency was evaluated using Corrected Item–Total Correlation and Cronbach's alpha. CITC assessed item discrimination, whereas Cronbach's alpha assessed the internal consistency reliability of the questionnaire. Data analysis was done using the SPSS software (SPSS Inc.; Chicago, IL) version 29.0.10. 

RESULTS 

Table 1: Demographic characteristics and diagnosis

Among the 26 participants, the age ranged from 18 to 72 years (mean ± SD: 45.04 ± 14.75 years). Seventeen participants (65.4%) were male and nine (34.6%) were female. Most participants lived in rural areas (57.7%). Eight participants (30.8%) had received no formal education, 15.4% had primary education, 23.1% had secondary education, 11.5% had higher secondary, 15.4% had bachelor’s degree, and 3.8% were masters. The occupational distribution of the participants was as follows: home maker 

(26.9%), farmer (23.1%), labourer (7.7%), student (7.7%), teacher (7.7%), army (3.8%), business (3.8%), engineer (3.8%), pharmacist (3.8%), shopkeeper (3.8%), tailor (3.8%), and hospital attendant (3.8%). 

The most common diagnosis was CVA (38.5%); followed by lumbar radiculopathy (19.2%), cervical radiculopathy (11.5%), TBI (11.5%), post operative craniotomy (7.7%), bell’s palsy (3.8%), and Parkinson's disease (3.8%). 

(n = 26)	Range	Mean	S.D.
Age (Years)	18 to 72	45.04	14.75
		Frequency	%
Gender	Male	17	65.4
Female	9	34.6
Residential category	Rural	15	57.7
Urban	11	42.3
Educational status	Illiterate	8	30.8
Primary	4	15.4
Secondary	6	23.1
Higher secondary	3	11.5
	Bachelors	4	15.4
Masters	1	3.8
Occupation	Army	1	3.8
Business	1	3.8
Engineer	1	3.8
Farmer	6	23.1
Homemaker	7	26.9
Labourer	2	7.7
Pharmacist	1	3.8
Shopkeeper	1	3.8
Student	2	7.7
Tailor	1	3.8
Teacher	2	7.7
Hospital attendant	1	3.8
Diagnosis	TBI	3	11.5
Bell's palsy	1	3.8
Cervical radiculopathy	3	11.5
Postop. craniotomy	2	7.7
CVA	10	38.5
Lumbar  radiculopathy	5	19.2
Motor neuropathy	1	3.8
Parkinson's disease	1	3.8

(TBI - Traumatic brain injury, CVA - Cerebrovascular accident)
The questionnaire content validity was assessed using the Item-level Content Validity Index (I-CVI). The I-CVI values ranged from 0.70 to 1.00 across the items, indicating acceptable to excellent item relevance. The Awareness domain demonstrated an S-CVI/Ave of 0.969, while the Perceived Knowledge domain showed an S-CVI/Ave of 0.992, indicating excellent content validity across both domains. The majority of items demonstrated complete expert agreement with I-CVI values of 1.00. Overall, the content validity assessment demonstrated excellent agreement among the expert panel, supporting the content relevance and representativeness of the questionnaire items.
Correlation of the domains: A Pearson correlation analysis was conducted between the 
Awareness and perceived Knowledge domain scores. The results demonstrated a moderate positive correlation (r = 0.576, p = 0.002), indicating a statistically significant association between the two domains. This suggests that participants with higher awareness of neurophysiotherapy also demonstrated greater perceived knowledge, indicating a statistically significant association between the two domains. (Table 2) 

Table 2: Correlation between awareness and knowledge domains

Domain 1	Domain 2	Pearson correlation coefficient (r)	p-value
Awareness	Knowledge	0.576	0.002

ITEM RELIABILITY: The internal consistency reliability of the NeuroPT-AKPC questionnaire was assessed using Cronbach's alpha. The questionnaire comprised 26 items, with 13 items each in the Awareness and Perceived Knowledge domains. The Cronbach's alpha coefficients were 0.971 for the Awareness domain and 0.970 for the Perceived Knowledge domain, indicating excellent internal consistency for both domains. The overall Cronbach's alpha coefficient for the questionnaire was 0.984, demonstrating excellent internal consistency reliability (Table 3).

Table 3. Reliability analysis : The obtained reliability coefficients are > 0.70 and hence the questionnaire is reliable. 

	Number of items	Cronbach's Alpha
Awareness	13	0.971
Perceived Knowledge	13	0.970
Overall	26	0.984

Internal Consistency: Reliability analysis was conducted separately for the Awareness and Perceived Knowledge domains using Corrected Item-Total Correlation (CITC) and Cronbach’s Alpha if Item Deleted (CAID).
Table 4. Awareness Item total correlation of the domains: 
In the Awareness domain, all 13 items demonstrated satisfactory internal consistency, with CITC values ranging from 0.691 to 0.929. The CAID values remained close to the overall Cronbach’s alpha value of 0.971, indicating that removal of individual items did not significantly improve domain reliability.

Items (A)	CITC	CAID
Q1A	0.745	0.9704
Q2A	0.918	0.9666
Q3A	0.845	0.9684
Q4A	0.691	0.9715
Q5A	0.929	0.9663
Q6A	0.887	0.9674
Q7A	0.710	0.9710
Q8A	0.854	0.9680
Q9A	0.862	0.9679
Q10A	0.901	0.9672
Q11A	0.813	0.9691
Q12A	0.893	0.9672
Q13A	0.852	0.9687

(CITC - Corrected Item - Total Correlation, CAID - Cronbach's Alpha if Item Deleted, A - Awareness)

Table 5. Perceived Knowledge Item total correlation of the domains: 
In the Perceived Knowledge domain, CITC values ranged from 0.694 to 0.916, demonstrating satisfactory item homogeneity. The CAID values remained stable around the overall Cronbach’s alpha value of 0.970. These findings suggest that all items contributed adequately to their respective domains and supported retention of the items in the final questionnaire. 

Items (PK)	CITC	CAID
Q1PK	0.862	0.9671
Q2PK	0.916	0.9657
Q3PK	0.856	0.9671
Q4PK	0.884	0.9664
Q5PK	0.866	0.9669
Q6PK	0.892	0.9663
Q7PK	0.778	0.9688
Q8PK	0.843	0.9673
Q9PK	0.694	0.9704
Q10PK	0.778	0.9688
Q11PK	0.863	0.9669
Q12PK	0.813	0.9680
Q13PK	0.777	0.9689

(CITC - Corrected Item - Total Correlation, CAID - Cronbach's Alpha if Item Deleted, PK - Perceived Knowledge)  
As seen in the above table 4 and 5, all corrected item-total correlation values exceeded 0.30, indicating acceptable item discrimination and satisfactory internal consistency within each domain. However, corrected item-total correlation alone should not be interpreted as evidence of construct validity.

Table 6: The level of awareness
The Awareness domain revealed that 26.9% of participants were unaware, 38.5% were somewhat aware, 11.5% were aware, and 23.1% were fully aware. No participants were classified as fully unaware.

Level of awareness	Frequency	%
Fully unaware	0	0
Unaware	7	26.9
Somewhat aware	10	38.5
Aware	3	11.5
Fully aware	6	23.1

Table 7: The level of Perceived Knowledge
For the Perceived Knowledge domain, 3.8% of participants were fully unaware, 23.1% were unaware, 38.5% were somewhat aware, 30.8% were aware, and 3.8% were fully aware.

Level of Perceived Knowledge	Frequency	%
Fully unaware	1	3.8
Unaware	6	23.1
Somewhat aware	10	38.5
Aware	8	30.8
Fully aware	1	3.8

DISCUSSION  
The present study aimed to develop and conduct a preliminary psychometric evaluation of the NeuroPT–AKPC questionnaire to assess awareness and perceived knowledge of neurophysiotherapy among patients with a neurological condition. Based on the responses, it was found that many participants had limited understanding of neurophysiotherapy, its role, and where these services are available. This highlights a clear gap in public awareness, especially in the context of neurological rehabilitation. The questionnaire demonstrated strong internal consistency across both domains, suggesting satisfactory reliability in this pilot evaluation. The tool may be useful in identifying gaps in awareness and perceived knowledge and could aid in planning educational initiatives and future research in larger populations. Similar tools have been developed earlier to assess awareness regarding physiotherapy in specific populations, such as in stroke patients. These studies showed that focused tools are useful in checking the understanding of physiotherapy's role in recovery and help identify gaps that can be addressed through awareness campaigns.¹⁵ Another study looked at awareness in caregivers of individuals with consciousness disorders, showing the importance of educating not just patients but also family members and caregivers who play a role in rehabilitation planning and support.¹⁶ Global reviews on physiotherapy awareness report that awareness levels remain low in many parts of the world. These studies emphasized the importance of improving the visibility of the physiotherapy profession through health education and media involvement.¹⁰ Our study findings support this and show that awareness related to neurophysiotherapy, in particular, is even more limited and needs attention. There have also been studies focused on youth awareness about stroke, which found that many young people lack knowledge about risk factors, treatment, and rehabilitation. These findings show how awareness-related tools can be important across different age groups and populations, not just those who are currently receiving treatment.¹⁷ From the professional perspective, research has shown that physiotherapists working in primary care face difficulties when patients do not know what neurophysiotherapy is or what it can offer. This often leads to delayed treatment or poor use of rehabilitation services.¹⁸ Additionally, studies have identified that many people with neurological disorders still face unmet needs in terms of rehabilitation. Lack of awareness among the public contributes to low utilization of physiotherapy services, especially in early recovery stages. There is also increasing focus on the role of physiotherapists in health promotion, not just in clinical care. Experts have suggested that physiotherapists should be involved in preventive and wellness programs to educate the community about managing and recovering from neurological conditions more effectively.¹¹ Finally, limited availability of trained neurophysiotherapists has been identified as a barrier to care in many regions of India. Along with improving public awareness, attention should also be given to expanding professional training and access to neurorehabilitation services across urban and rural areas.¹⁹ The findings of this pilot study suggest a potential need for awareness-focused tools in neurorehabilitation. The questionnaire may help identify gaps in awareness and perceived knowledge regarding neurophysiotherapy and encourage healthcare professionals, health systems, and policy makers to promote better awareness, early rehabilitation, and improved quality of life among individuals with neurological conditions. The findings of the present study suggest that many individuals with neurological conditions have limited awareness regarding the benefits and role of neurophysiotherapy. Early rehabilitation plays an important role in improving recovery, functional independence, and quality of life while reducing long-term disability.  

CONCLUSION 
The present study developed and conducted a preliminary psychometric evaluation of the NeuroPT–AKPC questionnaire to assess awareness and perceived knowledge of neurophysiotherapy among patients with a neurological condition. The questionnaire demonstrated preliminary evidence of satisfactory content validity and strong internal consistency across both domains. The findings suggest limited awareness and perceived knowledge among participants regarding the role and importance of neurophysiotherapy. The questionnaire may be useful for identifying awareness gaps and supporting future educational and neurorehabilitation initiatives in larger populations. Future research should apply this tool in larger, diverse populations and explore its utility in evaluating the effectiveness of awareness programs and early neurorehabilitation initiatives. One of the unexpected findings was the limited awareness of neurophysiotherapy even among patients receiving neurorehabilitation services, highlighting the potential need for targeted educational initiatives. This study was limited by a small sample size and predominantly male and single-center data, which may affect the generalizability of the findings. The inclusion of caregiver reported responses for participants who were unable to respond independently may have introduced proxy-response bias, which should be considered when interpreting the findings. Since this was an exploratory stage of tool development and validation, a formal power analysis was not conducted and small sample size precluded the use of EFA and CFA. Test-retest reliability was not assessed because this pilot study was designed to evaluate preliminary psychometric properties only. Future validation studies should examine temporal stability using repeated administration of the questionnaire and intraclass correlation coefficients. The scale's structure needs to be confirmed by larger studies.

FUNDING: This research received no external funding.

CONFLICT OF INTEREST: The authors declare no conflict of interest.