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Changes in physiotherapy students’ beliefs and attitudes about low back pain through pre-registration training

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Background Implementation of best-practice care for patients with low back pain (LBP) is an important issue. Physiotherapists’ who hold unhelpful beliefs are less likely to adhere to guidelines and may negatively influence their patients’ beliefs. Pre-registration education is critical in moving towards a biopsychosocial model of care. This study aimed to investigate the changes in 2nd year physiotherapy students’ beliefs about LBP after a module on spinal pain management and determine whether these changes were maintained at the end of academic training. Methods During three consecutive calendar years, this longitudinal cohort study assessed physiotherapy students’ beliefs with the Back Pain Attitudes Questionnaires (Back-PAQ) in their 1st year, before and after their 2nd year spinal management learning module, and at the end of academic training (3rd year). Unpaired t-tests were conducted to explore changes in Back-PAQ score. Results The mean response rate after the spinal management module was 90% (128/143 students). The mean (± SD) Back-PAQ score was 87.73 (± 14.21) before and 60.79 (± 11.44) after the module, representing a mean difference of − 26.95 (95%CI − 30.09 to − 23.80, p < 0.001). Beliefs were further improved at the end of 3rd year (− 7.16, 95%CI − 10.50 to − 3.81, p < 0.001). Conclusions A spinal management learning module considerably improved physiotherapy students’ beliefs about back pain. Specifically, unhelpful beliefs about the back being vulnerable and in need of protection were substantially decreased after the module. Improvements were maintained at the end of academic training one-year later. Future research should investigate whether modifying students’ beliefs leads to improved clinical practice in their first years of practice.
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R E S E A R C H A R T I C L E Open Access
Changes in physiotherapy studentsbeliefs
and attitudes about low back pain through
pre-registration training
Guillaume Christe
1,2*
, Ben Darlow
3
and Claude Pichonnaz
1,4
Abstract
Background: Implementation of best-practice care for patients with low back pain (LBP) is an important issue.
Physiotherapistswho hold unhelpful beliefs are less likely to adhere to guidelines and may negatively influence
their patientsbeliefs. Pre-registration education is critical in moving towards a biopsychosocial model of care. This
study aimed to investigate the changes in 2nd year physiotherapy studentsbeliefs about LBP after a module on
spinal pain management and determine whether these changes were maintained at the end of academic training.
Methods: During three consecutive calendar years, this longitudinal cohort study assessed physiotherapy students
beliefs with the Back Pain Attitudes Questionnaires (Back-PAQ) in their 1st year, before and after their 2nd year
spinal management learning module, and at the end of academic training (3rd year). Unpaired t-tests were
conducted to explore changes in Back-PAQ score.
Results: The mean response rate after the spinal management module was 90% (128/143 students). The mean (±
SD) Back-PAQ score was 87.73 (± 14.21) before and 60.79 (± 11.44) after the module, representing a mean
difference of 26.95 (95%CI 30.09 to 23.80, p< 0.001). Beliefs were further improved at the end of 3rd year (
7.16, 95%CI 10.50 to 3.81, p< 0.001).
Conclusions: A spinal management learning module considerably improved physiotherapy studentsbeliefs about
back pain. Specifically, unhelpful beliefs about the back being vulnerable and in need of protection were
substantially decreased after the module. Improvements were maintained at the end of academic training one-year
later. Future research should investigate whether modifying studentsbeliefs leads to improved clinical practice in
their first years of practice.
Keywords: Psychological factors, Low back pain, Education, Biopsychosocial
Background
Low back pain (LBP) is the leading cause of disability
worldwide and is associated with significant reduction in
quality of life and severe economic burden [1,2].
Unhelpful attitudes and beliefs about back pain have
been shown to be predictors of outcomes [3]. People
commonly believe that the back is vulnerable to injury
and needs protection [48] and these beliefs may con-
tribute to pain-related fear, catastrophizing and anxiety
[912]. These psychological factors are important pre-
dictors of unhelpful behaviours and elevated levels of
disability [1316].
Gaps between evidence and practice in the manage-
ment of LBP have been identified worldwide indicating
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* Correspondence: guillaume.christe@hesav.ch
1
Department of Physiotherapy, HESAV School of Health Sciences, HES-SO
University of Applied Sciences and Arts Western Switzerland, Lausanne,
Switzerland
2
Swiss BioMotion Lab, Department of Musculoskeletal Medicine, University
Hospital and University of Lausanne (CHUV-UNIL), Lausanne, Switzerland
Full list of author information is available at the end of the article
Christe et al. Archives of Physiotherapy (2021) 11:13
https://doi.org/10.1186/s40945-021-00106-1
that many patients receive sub-optimal care [17,18].
While there are many factors that influence implementa-
tion of best-practice care, evidence suggests that unhelp-
ful beliefs among health professionals is a significant
factor associated with reduced guideline adherence [19
22]. Therefore, addressing health professionalsunhelpful
beliefs has been strongly recommended to improve the
quality of care of LBP [11,17,18].
Physiotherapists are at the frontline of LBP manage-
ment and spend a considerable amount of time with pa-
tients [18,23]. Consequently, physiotherapists have the
opportunity to significantly influence patientsbeliefs
and behaviours (positively or negatively) and, in turn, in-
fluence recovery outcomes [11,12,19,22]. Physiothera-
pistsbeliefs can also strongly influence their clinical
decisions and delivery of core guideline recommended
treatments [22,24], such as movement, physical activity
and self-management.
While the biopsychosocial model of LBP is largely rec-
ognized, management of patients with LBP within a pre-
dominantly biomedical framework is still very frequent
among physiotherapists [17,18,22,24]. It has been ar-
gued that the focus of entry-level education on anatom-
ical, pathological and physical dysfunctions contribute to
this problem and hinder the transition towards a biopsy-
chosocial model of care [25], while teaching about the
multidimensional nature of LBP and current evidence is
an important step toward implementation of the biopsy-
chosocial model in future practice and, ultimately, im-
prove care for patients with LBP [17,18].
Unhelpful beliefs are prevalent amongst physiotherapy
students, albeit to a lesser extent than other health care
professions, but highly variable depending of the country
and the stage of training [2631]. There is limited infor-
mation on training approaches that are effective in im-
proving studentsbeliefs. Two studies found positive
changes in physiotherapy studentsbeliefs following
biopsychosocially-orientated LBP learning [29,32].
These studies assessed either studentsbeliefs about
whether pain justified activity limitation and disability or
that back pain is likely to have negative future conse-
quences. However, longitudinal changes in physiother-
apy studentsbeliefs about their own back or their
attitudes about movement, activity, and recovery behav-
iours or the impact of specific learning on these has not
been investigated.
The main objective of this study was to investigate
changes in 2nd year physiotherapy studentsattitudes
and beliefs about LBP following completion of a biopsy-
chosocially informed spinal pain management learning
module. The secondary objective was to determine
whether any changes following the module were main-
tained at the end of academic education (3rd year). We
hypothesized that helpful attitudes and beliefs would be
more prevalent among physiotherapy students after
completing the spinal pain management module (2nd
year) and that these changes would be maintained at the
end of academic education.
Methods
Study design
This study is a longitudinal observational cohort study
and was written according to the Strengthening the
Reporting of Observational Studies in Epidemiology
(STROBE) criteria [33].
Participants
During three consecutive years (2018 to 2020), three co-
horts of pre-registration physiotherapy students at Haute
Ecole Santé Vaud (HESAV) School of Health Sciences
(Lausanne, Switzerland) were invited to participate an-
onymously in the study. Students received an email invi-
tation for a Google Forms questionnaire at the
beginning of the second semester (first year students
BSc-1), before and immediately after a spinal pain man-
agement learning module (second year students Bsc-2)
and at the end of the last mandatory module of the pre-
registration training (third year students BSc-3) (Fig. 1).
Because the study was conducted from 2018 to 2020,
only one cohort (20182020) had data collected at all
timepoints. No BSc-1 data were collected for the 2017
2019 cohort and no BSc-3 data were collected for the
20192021 cohort. The local Research Ethics Committee
(CER-VD) confirmed that the project complied with
Swiss ethical regulations on studies without identifying
data collection (REQ-2018-00146). Participants received
information about the study and the right not to partici-
pate, and gave their informed consent before completing
the questionnaire.
Physiotherapy program
The physiotherapy course at HESAV is a three-year pre-
registration Bachelor of Science (BSc) program of 180
European Credits Transfer System (ECTS). Musculoskel-
etal content of each academic year is briefly described in
Fig. 1. The spinal pain management learning module,
taught in the second year of the program, is a 6-ECTS
module, that covers assessment and management of pel-
vic, lumbar, thoracic and cervical pain conditions.
Within this module, students had 9 lectures (90-min
each) about differential diagnosis, current understanding
of LBP, and recommendations for assessment and man-
agement of non-specific and specific LBP delivered by
medical doctors (5 lectures) and academic physiothera-
pists (4 lectures). In addition, there were 6 practical les-
sons (3 h each) that covered manual assessment and
treatment of clinical cases (2 lessons), progressive and
functional exercises (2 lessons), and management of low
Christe et al. Archives of Physiotherapy (2021) 11:13 Page 2 of 10
back-related leg pain (2 lessons). Finally, a three-hours
training activity with a focus on communication skills
and individual exercise prescription was conducted with
simulated patients. Important foci of the module were
developing a biopsychosocial understanding of LBP and
discussing common misconceptions about LBP (Table 1).
Furthermore, students were encouraged to move to-
wards a positive health concept that emphasised the cap-
acity of individuals to adapt and self-manage [17]. The
module encouraged progressive loading in daily-life
activities to increase tolerance and decrease sensitivity
to pain, rather than protecting the back to decrease
symptoms (as would be advocated in a traditional
biomedical approach). The final academic module of
third year students focussed on management of long-
term conditions (5-ECTS), particularly persistent pain.
In this module, students had two lectures on pain
mechanisms (90 min each) and multiple activities
based on complex clinical cases to foster a biopsycho-
social understanding of chronic pain. They also had a
learning activity with simulated patients to foster
communication skills (especially building a shared un-
derstanding). The BSc-2 spinal pain management
module was delivered exclusively online in 2020 due
to the COVID-19 pandemic. Online learning included
asynchronous lectures and group activities, in which
students had to answer questions about their under-
standing of spinal conditions, demonstrate video-
based exercises and propose optimal assessment and
management strategies for various patientssituations
based on clinical vignettes. They did not have any
practical manual therapy learning. The training activ-
ities with simulated patients were also cancelled.
Outcomes
The primary outcome was the validated French version
of the Back Pain Attitudes Questionnaire (Back-PAQ)
[5,80]. The questionnaire is composed of 34 items scor-
ing from 1 to 5 points on a Likert scale (False, Possibly
false, Unsure, Possibly true, True). Higher total score
(range 34 to 170) indicates more unhelpful beliefs and
attitudes about LBP. The questionnaire items and
themes were created based on findings from qualitative
studies with people with LBP [4,5]. The six different
themes are the vulnerability of the back(vulnerability),
the need to protect the back(protection), the correl-
ation between pain and injury(pain), the special nature
of back pain(special pain), activity participation while
experiencing back pain(activity) and the prognosis of
back pain(prognosis). Students also gave details about
their age and gender.
Statistical analysis
The mean Back-PAQ total score was calculated for each
study time (BSc-1, BSc-2 pre module, BSc-2 post module
and BSc-3). Unpaired t-tests were conducted to deter-
mine whether there were differences in Back-PAQ total
score before and after the module for the three cohorts
together and for each cohort separately. Because stu-
dents completed the questionnaire anonymously, paired
t-test could not be used. When possible, unpaired t-tests
were conducted to test differences in Back-PAQ score
Fig. 1 Assessment of attitudes and beliefs during the physiotherapy program. Only information relevant to this study are included in the figure.
BSc-1: first year students; BSc-2: second year students; BSc-3: third year students
Christe et al. Archives of Physiotherapy (2021) 11:13 Page 3 of 10
between the end of the module and the end of pre-
registration academic training as well as between BSc-1
and BSc-2 pre-module. Mean scores and mean differ-
ences per Back-PAQ item were also calculated before
and after the spinal pain management module. There
were no missing data in the questionnaires (all answers
were compulsory to submit the questionnaire). Statistical
analyses were performed with SPSS (Version 23, IBM,
NY, USA), using a significance level corrected for the
eight statistical tests and set a priori at α< 0.006.
Results
The response rate and number of students that partici-
pated in the study was 90% (95 students) in BSc-1, 92%
(132 students) in BSc-2 before the module, 90% (128
students) in BSc-2 after the module and 87% (80 stu-
dents) in BSc-3. Their mean age (SD) was 23.8 (2.9)
years and 68.3% were female. Participant characteristics,
response rates and mean Back-PAQ score at each time
point for each cohort are presented in Table 2. Mean
Back-PAQ scores reduced following the spinal pain
Table 1 Concepts targeted during the spinal management module in BSc-2
Unhelpful beliefs Messages delivered during the BSc-2 module
Back pain is due to structural damage Degenerative changes are frequent in asymptomatic population [2,34]
Little association between degenerative changes and the level of pain and
disability [35,36]
LBP is a serious condition LBP is very frequent and normal [2,37]
LBP due to serious pathology is rare [2,38,39]
Biomedical or biomechanical factors are the major cause of LBP LBP is a multidimensional condition [2,40]
It is necessary to find the source of pain to treat LBP It is difficult/impossible to accurately determine the tissue source of LBP [2]
Identifying the source of pain does not lead to better outcomes [2,41]
LBP is due to somethingout of place that needs to be corrected LBP is not due to somethingout of place [2,42,43]
Manual therapy has short term effect and works as a pain modulating
technique (no structural changes following manual therapy) [18,44]
Guidelines recommend active exercises as first line treatment [18,45]
Bending/lifting with round back is dangerous for the back Biomechanical studies do not consistently support that lifting with a straight
back is better [46,47]
Epidemiological studies do not support flexion as an independent risk factor
for LBP disability [48]
Manual handling training (doing less flexion) has no effect on LBP [51,52]
Patients with LBP move with a more rigid spine (less flexion and more muscle
activity) [5355]
Psychological factors are associated with a more rigid movement [16]
There is right and wrong ways to move Movement is very variable and there is no right or wrong way to move
[54,58,59]
Confidence to move seems more important than how you move [13]
If a movement is painful, you can temporarily adapt it. But in the long term,
all movements should be promoted and trained (improving tolerance) [60]
The back is vulnerable and needs to be protected Loading has positive effects on the back [61,62]
Disuse has negative effects on the back [63]
The back can positively adapt to load [64]
Bad postures (particularly slumped postures) cause back pain There is no right or wrong posture [65,66]
Posture is very variable [67]
Lumbar spine posture is not an independent risk factor for LBP [68]
Patients with LBP often show a hyperactivity of trunk muscles [55,69]
Core stabilisation exercises are important to treat LBP Patients with LBP move with a more rigid spine (and naturally adopt more
neutralpostures) [53]
There is no association between transversus abdominus or lumbar multifidus
activation and clinical outcomes [70,71]
Stabilisation exercises are not more effective than other types of exercises
[72,73]
The idea that the back needs to be stabilized may elevate fear avoidance
beliefs [11,72]
Important factors that need to be modified during physiotherapy
treatment are muscle strength and mobility (physical factors)
Improvement in physical factors alone do not explain improvement in
disability [74]
Self-efficacy, pain-related fear and psychological distress are important to
address [75,76]
Physiotherapy intervention can improve psychological factors through
education and active treatment (e.g. gradual exposure, promoting
self-efficacy) [78]
LBP Low back pain
Christe et al. Archives of Physiotherapy (2021) 11:13 Page 4 of 10
management learning module in the 20172019 (
27.36, 95%CI 33.04 to 21.68, p< 0.001), 20182020
(21.91, 95%CI 26.84 to 16.98, p< 0.001) and 2019
2021 (31.49, 95%CI 36.21 to 26.77, p< 0.001) co-
horts. The pooled mean Back-PAQ change across co-
horts following module completion was 26.95 (95%CI
30.09 to 23.80, p< 0.001).
The Back-PAQ score further reduced between the end
of the module and the end of BSc-3 for both the 2017
2019 (7.34, 95%CI 12.12 to 2.57, p= 0.003) and the
20182020 (7.43, 95%CI 11.67 to 3.19, p= 0.001)
cohorts (data not available for the 20192021 cohort).
The pooled mean Back-PAQ change of these two co-
horts was 7.16 (95%CI 10.50 to 3.81, p< 0.001).
Mean differences between BSc-1 and BSc-2 pre module
were also statistically significant for the 20182020 (
12.10, 95%CI 17.23 to - 6.98, p< 0.001) and the 2019
2021 (9.38, 95%CI 14.39 to 4.36, p< 0.001) cohorts
(Fig. 2). Pooled mean Back-PAQ change was 10.71
(95%CI 14.28 to 7.14, p< 0.001). Mean score per
item and mean differences before and after the module
are presented in Table 3.
Discussion
Physiotherapy students had predominantly unhelpful be-
liefs about back pain when they entered the course and
these beliefs improved during each year of their training.
Second year physiotherapy studentsbeliefs became con-
siderably more helpful after completing a learning
Table 2 Characteristics and Back-PAQ scores at each study time point
Cohort Study time Age (mean) Female (%) N Response rate (%) Back-PAQ score 95%CI
20172019 BSc-2 pre module (2018) 23.4 68.4 38/45 84 95.6 [91.7 to 99.4]
BSc-2 post module (2018) 23.5 75.7 37/45 82 68.2 [64.3 to 72.1]
BSc-3 (2019) 24.8 66.7 39/43 91 60.9 [57.1 to 64.7]
20182020 BSc-1 (2018) 22.4 62 50/52 96 94.8 [91.4 to 98.1]
BSc-2 pre module (2019) 23.3 68.1 47/50 94 82.7 [79.2 to 86.1]
BSc-2 post module (2019) 23.4 63.6 44/50 88 60.8 [57.2 to 64.3]
BSc-3 (2020) 24.8 65.9 41/49 84 53.3 [49.6 to 57]
20192021 BSc-1 (2019) 23.3 71.1 45/53 85 95.8 [92.3 to 99.4]
BSc-2 pre module (2020) 24.1 70.2 47/48 98 86.5 [83 to 89.9]
BSc-2 post module (2020) 24.3 78.7 47/48 98 55 [51.5 to 58.4]
N: number of participants included in the study (first number) in relation to the total number of students in this cohort (second number)
Fig. 2 Back-PAQ scores at each study time point for the three cohorts with longitudinal data. Cohorts are named based on their start and end
year of study (e.g 20192021 cohort is equivalent to 2019 BSc-1 and 2020 Bsc-2). *: p< 0.001; :p< 0.005 (colours are related to the
corresponding cohort)
Christe et al. Archives of Physiotherapy (2021) 11:13 Page 5 of 10
module that aimed to communicate recent evidence and
develop a biopsychosocial understanding of LBP.
While previous cross-sectional studies already demon-
strated differences in studentsbeliefs between different
academic years [26,30,31], with more experienced
students having more positive beliefs, our results showed
that the largest change occurred right after a spinal pain
management module, while smaller changes occur be-
fore and after this topic was specifically addressed. These
changes were consistent and large for the three cohorts
Table 3 Back-PAQ items score before and after the spinal pain management module
Question Bsc-2 pre-
module
Bsc-2
post-
module
Mean
difference
95%CI
Mean SD Mean SD
8) Good posture is important to protect your back 4.00 1.17 1.95 1.30 2.05 1.74 2.35
5) Lifting without bending the knees is not safe for your back 3.08 1.59 1.20 0.72 1.88 1.58 2.18
11) You could injure your back if you are not careful 3.62 1.22 1.74 1.04 1.88 1.60 2.16
6) It is easy to injure your back 3.10 1.46 1.53 0.93 1.57 1.27 1.87
22) If you ignore back pain, you may cause damage to your back 3.55 1.15 2.04 1.32 1.51 1.20 1.81
9) If you overuse your back, it will wear out 2.85 1.29 1.65 1.05 1.20 0.91 1.49
a
28) Most back pain settles quickly, at least enough to get on with normal activities 2.67 1.18 1.48 0.89 1.19 0.94 1.44
24) To effectively treat back pain you need to know exactly what is wrong 3.14 1.37 2.01 1.44 1.13 0.79 1.47
a
29) Worrying about your back can delay recovery from back pain 2.31 1.05 1.28 0.61 1.03 0.82 1.24
a
1) Your back is one of the strongest parts of your body 2.13 1.24 1.13 0.35 1.00 0.78 1.23
a
3) Bending your back is good for it 2.07 1.26 1.13 0.36 0.94 0.71 1.16
33) There is a high chance that an episode of back pain will not resolve 2.58 1.22 1.67 1.01 0.90 0.63 1.18
14) A twinge in your back can be the first sign of a serious injury 2.57 1.22 1.76 1.17 0.81 0.52 1.10
7) It is important to have strong muscles to support your back 4.37 1.01 3.56 1.45 0.81 0.50 1.12
23) It is important to see a health professional when you have back pain 3.99 0.98 3.19 1.40 0.80 0.51 1.10
a
30) Focussing on things other than your back helps you to recover from back pain 2.36 0.98 1.60 0.83 0.76 0.54 0.98
12) You can injure your back and only become aware of the injury sometime later 4.22 0.99 3.48 1.43 0.74 0.44 1.04
4) Sitting is bad for your back 2.42 1.20 1.69 1.14 0.73 0.44 1.02
10) If an activity or movement causes back pain, you should avoid it in the future 2.08 1.03 1.40 0.89 0.68 0.45 0.92
a
2) Your back is well designed for the way you use it in daily life 1.71 0.96 1.08 0.37 0.63 0.46 0.81
a
31) Expecting your back pain to get better helps you to recover from back pain 2.23 1.05 1.70 1.15 0.53 0.26 0.80
a
17) When you have back pain, you can do things which increase your pain without
harming the back
1.90 0.99 1.41 0.88 0.49 0.26 0.72
32) Once you have had back pain there is always a weakness 1.71 0.89 1.23 0.70 0.48 0.28 0.67
26) When you have back pain the risks of vigorous exercise outweigh the benefits 2.15 1.10 1.68 1.07 0.47 0.21 0.74
19) It is worse to have pain in your back than your arms or legs 3.24 1.25 2.81 1.47 0.43 0.10 0.76
20) It is hard to understand what back pain is like if you have never had it yourself 3.98 1.04 3.55 1.39 0.42 0.12 0.72
13) Back pain means that you have injured your back 1.58 0.91 1.19 0.60 0.40 0.21 0.58
18) Having back pain makes it difficult to enjoy life 4.14 1.00 3.75 1.25 0.39 0.11 0.66
a
15) Thoughts and feelings can influence the intensity of back pain 1.28 0.50 1.03 0.17 0.25 0.16 0.34
34) Once you have a back problem, there is not a lot you can do about it 1.26 0.57 1.03 0.22 0.23 0.12 0.33
a
16) Stress in your life (financial, work, relationship) can make back pain worse 1.26 0.52 1.07 0.26 0.19 0.09 0.29
a
27) If you have back pain you should try to stay active 1.19 0.48 1.02 0.12 0.17 0.09 0.26
25) If you have back pain you should avoid exercise 1.24 0.58 1.09 0.31 0.16 0.04 0.27
21) If your back hurts, you should take it easy until the pain goes away 1.76 0.94 1.66 1.19 0.10 0.16
0.36
The items are ordered from the largest change during the module to smallest change. Lowest scores at associated with more helpful beliefs (1 = false and 5=
true).
a
scores are reversed for items worded in the reverse direction so that a lower score also indicates that the helpful belief is more strongly held
Christe et al. Archives of Physiotherapy (2021) 11:13 Page 6 of 10
and were all above the minimal detectable change
(MDC) of the Back-PAQ (14.5 points) [80]. Conversely,
changes before and after the module were below the
MDC. These results suggest that a biopsychosocially-
orientated learning module with a targeted pedagogical
approach can effectively improve back pain beliefs
among future health professionals. Educators and pre-
registration programs should consider integrating similar
modules to foster their helpful beliefs that are associated
with guideline concordant practice.
The large changes in beliefs about LBP that occurred
as a result of the spinal pain management learning mod-
ule may have resulted from several factors. First, the
current multidimensional understanding of LBP and
evidenced-based management strategies were frequently
discussed to highlight the importance of active strategies
and self-care management. Moreover, the ideas that the
back can positively adapt to load and that protection
does not offer long-term positive effects were central.
These concepts were integrated during practical sessions
covering exercise progression and the activity with simu-
lated patients. This module used an active learning strat-
egy to foster reflection and discuss disruptive concepts
for students. As an example, how and why lumbar
flexion can be progressively included in progressive load-
ing exercises was frequently discussed with students as
beliefs about the danger with loaded flexion were very
prevalent before the module. This module used an inte-
grative approach of both scientific evidence and practical
courses to foster a positive image of the back and hinder
prevalent unhelpful messages about ergonomic, protec-
tion and vulnerability. This consistent message through-
out the module may have positively influenced students
beliefs.
Previous studies have demonstrated that studentsbe-
liefs about the relationship between LBP and physical
function can be improved with specific training [29,32].
Our findings extend these results by demonstrating posi-
tive changes in studentsbeliefs about their own back
and how they should respond to back pain and that
these changes were maintained one-year later. Import-
antly, while changes in beliefs occurred in all items of
the Back-PAQ, the questions with the largest changes
were mostly related to the beliefs that the back is easy to
injure (eg, questions 1, 5, 6, 9, 22 about vulnerability)
and needs protection (eg, questions 8, 11). These
changes are notable as physiotherapists who hold these
beliefs have been found to make less evidenced-based
clinical decisions and provide more advice that move-
ment should be avoided [24]. Thus, following the spinal
pain management training module, students may be
more prepared to deliver adequate messages concerning
these unhelpful beliefs, which are very prevalent in
people with and without LBP [48] and have been
associated with important contributors to LBP disability,
such as pain-related fear, catastrophizing and anxiety
[912].
The COVID-19 pandemic required rapid adaption of
the 2020 physiotherapy programmes and a transition to
exclusively online learning. For this cohort, the home-
based practical courses were exclusively dedicated to ex-
ercise progressions and no manual therapy was prac-
ticed. The improvement in Back-PAQ score that
occurred in this online-only cohort was larger than that
of the two previous cohorts with a face-to-face module.
While our design precludes any comparison between on-
line or face-to-face modules, this suggests that an online
module using active learning strategies is also an effect-
ive mechanism to improve physiotherapy studentsbe-
liefs about back pain.
Unhelpful beliefs were relatively prevalent in first year
students. These beliefs were more prevalent than
amongst practising physiotherapists but less prevalent
than in the general population from the same geographic
area [8,24]. These beliefs improved to a small degree
over the studentsfirst year of training (below the ques-
tionnaire MDC), suggesting that non-specific education
has only a small effect on unhelpful beliefs about LBP
and that specific training is needed. StudentsBack-PAQ
total and individual item scores following training indi-
cated that their beliefs were more positive than those
found in practising physiotherapists in Switzerland [24].
This change may enable these graduates to positively in-
fluence the beliefs of their patients and their peers and
improve the quality of LBP management.
Future research is necessary to determine whether the
changes in LBP beliefs among physiotherapy students
are associated with changes in their clinical decisions.
Ultimately, it is necessary to understand whether these
changes improve the implementation of evidenced-based
care in the first years of clinical practice and beyond.
Given all the factors that are known to influence guide-
line implementation [8184], further intervention may
be necessary post-graduation to maintain or further im-
prove beliefs about back pain and integration of
evidence-based care. Given the prevalence of unhelpful
beliefs in health care professionals and the efficiency of
targeted learning demonstrated in these student cohorts,
there may also be an opportunity to develop educational
strategies for practising physiotherapists. Online learning
may be an effective mechanism to deliver this at scale
given the positive changes observed in students who
learned exclusively online. Qualitative research on per-
ceived efficiency of educational interventions about LBP
beliefs may also improve our understanding of physio-
therapy studentslearning experience and identify op-
portunities to refine educational strategies or support
ongoing change.
Christe et al. Archives of Physiotherapy (2021) 11:13 Page 7 of 10
The finding that a targeted active educational pro-
gram positively modifies beliefs about LBP is likely to
be transferable, but the magnitude of change and final
level may have also been influenced by the global
training environment and module timing in curricu-
lum. The absence of a control group is a key limita-
tion of this study and leaves open the possibility that
the changes observed were due to other factors. How-
ever, measuring beliefs immediately before and after
the spinal learning module reduced the risk that other
learning had influenced these changes. It is often not
feasible in an educational environment to randomise
students to different learning interventions. The de-
sign of this study is analogous to a Single Case Ex-
periment Design (SCED). Within SCED, three
consistent replications of experimental are considered
to increase the internal validity of the study, which
was the case in this study for the three before-after
specific module significant differences above MDC
[85]. Students also completed a BSc-3 module that in-
cluded content about persistent pain within a biopsy-
chosocial framework, which may have reinforced the
messages delivered in the specific LBP management
module. This means that we cannot determine
whether the spinal pain learning module has a long
term effect or whether multiple interventions are re-
quired to maintain the positive beliefs developed. We
did not record the studentsidentification numbers
and this precluded the use of statistical analyses based
on paired tests such as repeated-measures models.
Nevertheless, the unpaired t-tests used in this study
demonstrated highly significant changes in beliefs,
despite the reduced statistical power of this technique,
making a type 2 error unlikely. The high response
rate at all time points increases confidence that the
findings represent real changes in beliefs across the
student cohort, rather than being biased by those
with less helpful beliefs selectively dropping out of
the study.
Conclusion
This study found that a biopsychosocially-orientated
learning module using active training methods signifi-
cantly and substantially improved physiotherapy stu-
dentsbeliefs about LBP. The largest changes
occurred in the beliefs that the back is vulnerable and
requires protection. Future research is necessary to
understand if these changes in beliefs lead to more
optimal clinical decisions and enhance high value care
for newly graduated.
Acknowledgements
Not applicable.
Authorscontributions
GC designed the study and collected data. All authors participated to the
analysis and interpretation of data, contributed significantly to the
manuscript and approved its final version.
Funding
This study was not funded.
Availability of data and materials
The data used in this study are available on request from the corresponding
author.
Declarations
Ethics approval and consent to participate
The local Research Ethics Committee (CER-VD) confirmed that the project
complied with Swiss ethical regulations on studies without identifying data
collection (REQ-2018-00146). Participants received information about the
study and the right not to participate, and gave their informed consent
before completing the questionnaire.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Physiotherapy, HESAV School of Health Sciences, HES-SO
University of Applied Sciences and Arts Western Switzerland, Lausanne,
Switzerland.
2
Swiss BioMotion Lab, Department of Musculoskeletal Medicine,
University Hospital and University of Lausanne (CHUV-UNIL), Lausanne,
Switzerland.
3
Department of Primary Health Care and General Practice,
University of Otago, Wellington, New Zealand.
4
Department of
Musculoskeletal Medicine, University Hospital and University of Lausanne
(CHUV-UNIL), Lausanne, Switzerland.
Received: 25 January 2021 Accepted: 17 March 2021
References
1. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos
T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of
low back pain: estimates from the global burden of disease 2010 study. Ann
Rheum Dis. 2014;73(6):96874. https://doi.org/10.1136/annrheumdis-2013-2
04428.
2. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy
D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M, Buchbinder R,
Hartvigsen J, Cherkin D, Foster NE, Maher CG, Underwood M, van Tulder M,
Anema JR, Chou R, Cohen SP, Menezes Costa L, Croft P, Ferreira M, Ferreira
PH, Fritz JM, Genevay S, Gross DP, Hancock MJ, Hoy D, Karppinen J, Koes
BW, Kongsted A, Louw Q, Öberg B, Peul WC, Pransky G, Schoene M, Sieper
J, Smeets RJ, Turner JA, Woolf A. What low back pain is and why we need
to pay attention. Lancet. 2018;391(10137):235667. https://doi.org/10.1016/
S0140-6736(18)30480-X.
3. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological
factors as predictors of chronicity / disability in prospective cohorts of low
Back pain. Spine (Phila Pa 1976). 2002;27(5):E10920. https://doi.org/10.1097/
00007632-200203010-00017.
4. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring
impact of what clinicians say to people with low back pain. Ann Fam Med.
2013;11(6):52734. https://doi.org/10.1370/afm.1518.
5. Darlow B, Perry M, Mathieson F, Stanley J, Melloh M, Marsh R, Baxter GD,
Dowell A. The development and exploratory analysis of the Back pain
attitudes questionnaire (Back-PAQ). BMJ Open. 2014;4(5):e005251. https://
doi.org/10.1136/bmjopen-2014-005251.
6. Darlow B, Perry M, Stanley J, Mathieson F, Melloh M, Baxter GD, Dowell A.
Cross-sectional survey of attitudes and beliefs about back pain in New
Zealand. BMJ Open. 2014;4(5):e004725. https://doi.org/10.1136/bmjopen-2
013-004725.
Christe et al. Archives of Physiotherapy (2021) 11:13 Page 8 of 10
7. Pierobon A, Policastro PO, Soliño S, Andreu M, Novoa G, Raguzzi I, Villalba F,
Darlow B. Beliefs and attitudes about low back pain in Argentina: a cross-
sectional survey using social media. Musculoskelet Sci Pract. 2020;49:102183.
https://doi.org/10.1016/j.msksp.2020.102183.
8. Christe G, Pizzolato V, Meyer M, Nzamba J, Pichonnaz C. Unhelpful beliefs
and attitudes about low back pain in the general population: a cross-
sectional survey. Musculoskelet Sci Pract. 2021;52:102342. https://doi.org/1
0.1016/j.msksp.2021.102342.
9. Bunzli S, Smith A, Watkins R, Schütze R, OSullivan P. What do people who
score highly on the Tampa scale of Kinesiophobia really believe? A mixed
methods investigation in people with chronic non specific low Back pain.
Clin J Pain. 2015;31(7):62132. https://doi.org/10.1097/AJP.
0000000000000143.
10. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to harm,
hard to heal: patient views about the back. Spine (Phila Pa 1976). 2015;
40(11):84250. https://doi.org/10.1097/BRS.0000000000000901.
11. Darlow B. Beliefs about back pain: the confluence of client, clinician and
community. Int J Osteopath Med. 2016;20:5361. https://doi.org/10.1016/j.
ijosm.2016.01.005.
12. Briggs AM, Jordan JE, Buchbinder R, Burnett AF, O'Sullivan PB, Chua JYY,
Osborne RH, Straker LM. Health literacy and beliefs among a community
cohort with and without chronic low back pain. Pain. 2010;150(2):27583.
https://doi.org/10.1016/j.pain.2010.04.031.
13. Crombez G, Eccleston C, Van Damme S, et al. Fear-avoidance model of
chronic pain: the next generation. Clin J Pain. 2012;28(6):47583. https://doi.
org/10.1097/AJP.0b013e3182385392.
14. Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S.
Catastrophizinga prognostic factor for outcome in patients with low back
pain: a systematic review. Spine J. 2014;14(11):263957. https://doi.org/10.1
016/j.spinee.2014.03.003.
15. Linton SJ. A review of psychological risk factors in back and neck pain.
Spine (Phila Pa 1976). 2000;25(9):114856. https://doi.org/10.1097/
00007632-200005010-00017.
16. Christe G, Crombez G, Edd S, Opsommer E, Jolles BM, Favre J. The
relationship between psychological factors and spinal motor behaviour in
low back pain. Pain. 2021;162(3):67286. https://doi.org/10.1097/j.pain.
0000000000002065.
17. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft
P, Buchbinder R, Hartvigsen J, Cherkin D, Foster NE, Maher CG, Underwood
M, van Tulder M, Anema JR, Chou R, Cohen SP, Menezes Costa L, Croft P,
Ferreira M, Ferreira PH, Fritz JM, Genevay S, Gross DP, Hancock MJ, Hoy D,
Karppinen J, Koes BW, Kongsted A, Louw Q, Öberg B, Peul WC, Pransky G,
Schoene M, Sieper J, Smeets RJ, Turner JA, Woolf A. Low back pain: a call
for action. Lancet. 2018;391(10137):23848. https://doi.org/10.1016/S0140-
6736(18)30488-4.
18. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH,
Fritz JM, Koes BW, Peul W, Turner JA, Maher CG, Buchbinder R, Hartvigsen J,
Cherkin D, Foster NE, Maher CG, Underwood M, van Tulder M, Anema JR,
Chou R, Cohen SP, Menezes Costa L, Croft P, Ferreira M, Ferreira PH, Fritz
JM, Genevay S, Gross DP, Hancock MJ, Hoy D, Karppinen J, Koes BW,
Kongsted A, Louw Q, Öberg B, Peul WC, Pransky G, Schoene M, Sieper J,
Smeets RJ, Turner JA, Woolf A. Prevention and treatment of low back pain:
evidence, challenges, and promising directions. Lancet. 2018;391(10137):
236883. https://doi.org/10.1016/S0140-6736(18)30489-6.
19. Darlow B, Fullen BM, Dean S, et al. The association between health care
professional attitudes and beliefs and the attitudes and beliefs, clinical
management, and outcomes of patients with low back pain: A systematic
review. Eur J Pain (United Kingdom). 2012;16:317.
20. Houben RMA, Ostelo RWJG, Vlaeyen JWS, Wolters PMJC, Peters M, Berg
SGMSV. Health care providersorientations towards common low back pain
predict perceived harmfulness of physical activities and recommendations
regarding return to normal activity. Eur J Pain. 2005;9(2):17383. https://doi.
org/10.1016/j.ejpain.2004.05.002.
21. Coudeyre E, Rannou F, Tubach F, Baron G, Coriat F, Brin S, Revel M,
Poiraudeau S. General practitionersfear-avoidance beliefs influence their
management of patients with low back pain. Pain. 2006;124(3):3307.
https://doi.org/10.1016/j.pain.2006.05.003.
22. Gardner T, Refshauge K, Smith L, McAuley J, Hübscher M, Goodall S.
Physiotherapistsbeliefs and attitudes influence clinical practice in chronic
low back pain: a systematic review of quantitative and qualitative studies. J
Physiother. 2017;63(3):13243. https://doi.org/10.1016/j.jphys.2017.05.017.
23. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJEM, Ostelo RWJG, Guzman
J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic
low back pain: Cochrane systematic review and meta-analysis. BMJ. 2015;
350(feb18 5):h444. https://doi.org/10.1136/bmj.h444.
24. Christe G, Nzamba J, Desarzens L, Leuba A, Darlow B, Pichonnaz C.
Physiotherapistsattitudes and beliefs about low back pain influence their
clinical decisions and advice. In Press.
25. Foster NE, Delitto A. Embedding psychosocial perspectives within clinical
Management of low Back Pain : integration of practice challenges and
opportunities. Phyiscal Ther. 2011;91(5):790803. https://doi.org/10.2522/ptj.2
0100326.
26. Ryan C, Murphy D, Clark M, Lee A. The effect of a physiotherapy education
compared with a non-healthcare education on the attitudes and beliefs of
students towards functioning in individuals with back pain: an
observational, cross-sectional study. Physiotherapy. 2010;96(2):14450.
https://doi.org/10.1016/j.physio.2009.09.010.
27. Briggs AM, Slater H, Smith AJ, Parkin-Smith GF, Watkins K, Chua J. Low back
pain-related beliefs and likely practice behaviours among final-year cross-
discipline health students. Eur J Pain. 2013;17(5):76675. https://doi.org/10.1
002/j.1532-2149.2012.00246.x.
28. Ferreira PH, Ferreira ML, Latimer J, Maher CG, Refshauge K, Sakamoto A,
Garofalo R. Attitudes and beliefs of Brazilian and Australian physiotherapy
students towards chronic back pain: a cross-cultural comparison. Physiother
Res Int. 2004;9(1):1323. https://doi.org/10.1002/pri.296.
29. Latimer J, Maher C, Refshauge K. The attitudes and beliefs of physiotherapy
students to chronic Back pain. Clin J Pain. 2004;20(1):4550. https://doi.org/1
0.1097/00002508-200401000-00009.
30. Leahy A, OKeeffe M, Robinson K, OSullivan K. The beliefs of healthcare
students about the harmfulness of daily activities for their back: a cross-
sectional study. Eur J Phys. 2019;23(1):3440. https://doi.org/10.1080/216791
69.2019.1630854.
31. Burnett A, Sze CC, Tam SM, Yeung KM, Leong M, Wang WTJ, Tan BK,
O'Sullivan P. A cross-cultural study of the Back pain beliefs of female
undergraduate healthcare students. Clin J Pain. 2009;25(1):208. https://doi.
org/10.1097/AJP.0b013e3181805a1e.
32. Domenech J, Sánchez-Zuriaga D, Segura-Ortí E, Espejo-Tort B, Lisón JF.
Impact of biomedical and biopsychosocial training sessions on the
attitudes, beliefs, and recommendations of health care providers about low
back pain: a randomised clinical trial. Pain. 2011;152(11):255763. https://doi.
org/10.1016/j.pain.2011.07.023.
33. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP.
The strengthening the reporting of observational studies in epidemiology
(STROBE) statement: guidelines for reporting observational studies. Lancet.
2007;370(9596):14537. https://doi.org/10.1016/S0140-6736(07)61602-X.
34. Brinjikji W, Luetmer PH, ComstockB, et al. Systematic literature review of
imaging features of spinaldegeneration in asymptomatic populations.
AJNRAm J Neuroradiol. 2015;36: 81116.
35. Berg L, Hellum C, Gjertsen Ø, etal. Do more MRI findings imply worse
disability or more intense lowback pain? A cross-sectional study of
candidates for lumbar discprosthesis. SkeletalRadiol. 2013; 42:1593602.
36. Suri P, Boyko EJ, Goldberg J, etal. Longitudinal associations between
incident lumbar spine MRIfindings and chronic low back pain or radicular
symptoms:retrospective analysis of data from the longitudinal assessment
ofimaging and disability of the back (LAIDBACK). BMCMusculoskelet Disord.
2014;15:152.
37. Hoy D, Bain C, Williams G, et al.A systematic review of the global prevalence
of low back pain.Arthritis Rheum.2012; 64: 202837.
38. Henschke N, Maher CG, RefshaugeKM, et al. Prevalence of and screening for
serious spinal pathologyin patients presenting to primary care settings with
acute low backpain. Arthritis Rheum.2009;60:307280.
39. Galliker G, Scherer DE,Trippolini MA, et al. Low Back Pain in the Emergency
Department:Prevalence of Serious Spinal Pathologies and Diagnostic
Accuracy ofRed Flags. Am J Med.2020;133:6072.e14.
40. OSullivan P, Caneiro JP,OKeeffe M, et al. Unraveling the Complexity of Low
Back Pain. JOrthop Sport Phys Ther.2016;46: 9327.
41. Jarvik JG, Gold LS, Comstock BA,et al. Association of early imaging for back pain
with clinicaloutcomes in older adults. JAMA- J Am Med Assoc. 2015;313:114353.
42. Balagué F, Mannion AF, PelliséF, et al. Non-specific low back pain.Lancet.
2011;379:48291.
43. Bialosky JE, George SZ, BishopMD. How Spinal Manipulative Therapy Works:
Why Ask Why? JOrthop Sport Phys Ther.2008;38:2935.
Christe et al. Archives of Physiotherapy (2021) 11:13 Page 9 of 10
44. Bialosky JE, Beneciuk JM, BishopMD, et al. Unraveling the Mechanisms
of Manual Therapy: Modeling anApproach. J OrthopSport Phys Ther.
2017;131.
45. NICE. Lowback pain and sciatica in over 16s: assessment and management.
2016; https://www.nice.org.uk/guidance/ng59.
46. Dreischarf M, Rohlmann A,Graichen F, et al. In vivo loads on a vertebral
body replacementduring different lifting techniques. JBiomech. 2015;49:
8905.
47. Khoddam-Khorasani P, Arjmand N,Shirazi-Adl A. Effect of changes in the
lumbar posture in lifting ontrunk muscle and spinal loads: A combined
in vivo, musculoskeletal,and finite element model study. JBiomech. 2020;
104:109728.
48. Lagersted-Olsen J, Thomsen BL,Holtermann A, et al. Does objectively
measured daily duration offorward bending predict development and
aggravation of low-back pain?A prospective study. ScandJ Work Environ
Health.2016;42:52837.
49. Wai EK, Roffey DM, Bishop P, etal. Causal assessment of occupational
bending or twisting and lowback pain: results of a systematic review.
SpineJ. 2010;10:7688.
50. Saraceni N, Kent P, Ng L, et al.To Flex or Not to Flex? Is There a Relationship
Between Lumbar SpineFlexion During Lifting and Low Back Pain? A
Systematic Review With Meta-Analysis. J Orthop Sports Phys Ther 2020;50:
12130. http://www.jospt.org/doi/10.2519/jospt.2020.9218.
51. Verbeek JH, Martimo K-P,Karppinen J, et al. Manual material handling advice
and assistivedevices for preventing and treating back pain in workers.
CochraneDatabase Syst Rev.2011;CD005958.
52. Hogan DAM, Greiner BA, OSullivanL. The effect of manual handling training
on achieving trainingtransfer, employees behaviour change and
subsequent reduction ofwork-related musculoskeletal disorders: a
systematic review.Ergonomics.2014;57: 93107.
53. Nolan D, OSullivan K, NewtonC, et al. Are there differences in lifting
technique between thosewith and without low back pain? A systematic
review. ScandJ Pain. 2019. https://doi.org/10.1515/sjpain-2019-0089.
54. Laird RA, Gilbert J, Kent P, etal. Comparing lumbo-pelvic kinematics in
people with and without backpain: a systematic review and meta-analysis.
BMCMusculoskelet Disord2014;15:229.
55. Geisser ME, Ranavaya M, Haig AJ,et al. A Meta-Analytic Review of Surface
Electromyography AmongPersons With Low Back Pain and Normal, Healthy
Controls. JPain. 2005;6:71126.
56. Christe G, Rochat V, Jolles BM,et al. Lumbar and thoracic kinematics during step
up :Comparison of three dimensional angles between patients withchronic low
back pain and asymptomatic individuals. JOrthop Res 2020;19.
57. Christe G, Redhead L, Legrand T,et al. Multi-segment analysis of spinal
kinematics duringsit-to-stand in patients with chronic low back pain.
JBiomech. 2016;49:20607.
58. Gatton ML, Pearcy MJ. Kinematicsand movement sequencing during flexion
of the lumbar spine. ClinBiomech .1999;14:37683.
59. Laird RA, Keating JL, Kent P.Subgroups of lumbo-pelvic flexion kinematics
are present in peoplewith and without persistent low back pain.
BMCMusculoskelet Disord. 2018;19:309.
60. Lehman GJ. The role and value ofsymptom-modification approaches in
musculoskeletal practice. JOrthop Sports Phys Ther.2018;48:4305.
61. Battié MC, Videman T, Kaprio J,et al. The Twin Spine Study: Contributions to
a changing view of discdegeneration. SpineJ. 2009;9:4759.
62. Belavý DL, Albracht K,Bruggemann GP, et al. Can Exercise Positively
Influence theIntervertebral Disc? SportMed. 2016; 46:47385.
63. Belavy DL, Adams M, Brisby H, etal. Disc herniations in astronauts: What
causes them, and what doesit tell us about herniation on earth? EurSpine J.
2016;25:14454.
64. Belavý DL, Quittner MJ, RidgersN, et al. Running exercise strengthens the
intervertebral disc. SciRep. 2017;7:45975.
65. Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the
normal variation in the sagittal alignment of the human lumbar spine and
pelvis in the standing position. Spine (Phila Pa 1976). 2005;30(3):34653.
66. Roussouly P, Pinheiro-Franco JL.Biomechanical analysis of the spino-pelvic
organization andadaptation in pathology. EurSpine J. 2011;20 (Suppl5): 609
18.
67. Schmidt H, Bashkuev M, Weerts J,et al. How do we stand? Variations during
repeated standing phases ofasymptomatic subjects and low back pain
patients. JBiomech. 2018;70:6776.
68. Been E, Kalichman L. Lumbarlordosis. spine. J Off JNorth Am Spine Soc.2014;
14:8797.
69. Dankaerts W, OSullivan P,Burnett A, et al. Altered patterns of superficial
trunk muscleactivation during sitting in nonspecific chronic low back
painpatients: importance of subclassification. Spine(Phila Pa 1976) .2006;31:
201723.
70. Mannion AF, Caporaso F, PulkovskiN, et al. Spine stabilisation exercises in
the treatment of chroniclow back pain: A good clinical outcome is not
associated withimproved abdominal muscle function. EurSpine J. 2012; 21:
130110.
71. Wong AYL, Parent EC, Funabashi M, et al. Do Changes in Transversus
Abdominis and Lumbar Multifidus During Conservative Treatment Explain
Changes in Clinical Outcomes Related to Nonspecific Low Back Pain? A
Systematic Review. J Pain. 2014;15:377.e1-377.e35.
72. Smith BE, Littlewood C, May S. An update of stabilisation exercises for low
back pain: a systematic review with meta-analysis. BMC Musculoskelet
Disord. 2014;15:416.
73. Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for
chronic non-specific low-back pain. Cochrane Database Syst Rev. 2016.
https://doi.org/10.1002/14651858.CD012004. Epub ahead of print 2016.
74. Steiger F, Wirth B, de Bruin ED, et al. Is a positive clinical outcome after
exercise therapy for chronic non-specific low back pain contingent upon a
corresponding improvement in the targeted aspect(s) of performance? A
systematic review. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc
Eur Sect Cerv Spine Res Soc. 2012;21:57598.
75. Lee H, Mansell G, McAuley JH, et al. Causal mechanisms in the clinical
course and treatment of back pain. Best Pract Res Clin Rheumatol. 2017;30:
107483.
76. Lee H, Hübscher M, Moseley GL, et al. How does pain lead to disability? A
systematic review and meta analysis of mediation studies in people with
back and neck pain. Pain. 2015;156:98897.
77. Vibe Fersum K, OSullivan P, Skouen JS, et al. Efficacy of classification-based
cognitive functional therapy in patients with non-specific chronic low back
pain: A randomized controlled trial. Eur J Pain. https://doi.org/10.1002/j.1
532-2149.2012.00252.x. Epub ahead of print 2012.
78. OSullivan PB, Caneiro J, OKeeffe M, et al. Cognitive Functional Therapy: An
Integrated Behavioral Approach for the Targeted Management of Disabling
Low Back Pain. Phys Ther. 2018;98:40823.
79. OKeeffe M, OSullivan P, Purtill H, et al. Cognitive functional therapy
compared with a group-based exercise and education intervention for
chronic low back pain: A multicentre randomised controlled trial (RCT). Br J
Sports Med. 2019;19.
80. Demoulin C, Halleux V, Darlow B, et al. Traduction en langue française de la
version longue du « Back Pain Attitudes Questionnaire » et étude de ses
qualités psychométriques. Mains Libr. 2017;4:1927.
81. Bekkering GE, Hendriks HJM, Van Tulder MW, et al. Effect on the process of
care of an active strategy to implement clinical guidelines on physiotherapy
for low back pain: a cluster randomised controlled trial. Qual Saf Heal Care.
2005;14(2):10712. https://doi.org/10.1136/qshc.2003.009357.
82. Bérubé MÈ, Poitras S, Bastien M, et al. Strategies to translate knowledge
related to common musculoskeletal conditions into physiotherapy practice:
a systematic review. Physiother (United Kingdom). 2018;104:18.
83. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current
evidence and future implications. J Contin Educ Heal Prof. 2004;24(Suppl 1):
S317. https://doi.org/10.1002/chp.1340240506.
84. Engers AJ, Wensing M, Van Tulder MW, et al. Implementation of the Dutch
low back pain guideline for general practitioners: a cluster randomized
controlled trial. Spine (Phila Pa 1976). 2005;30:595600.
85. Krasny-Pacini A, Evans J. Single-case experimental designs to assess
intervention effectiveness in rehabilitation: a practical guide. Ann Phys
Rehabil Med. 2018;61(3):16479. https://doi.org/10.1016/j.rehab.2017.12.002.
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Christe et al. Archives of Physiotherapy (2021) 11:13 Page 10 of 10
... This means better educating HCPs about LBP. A few studies have looked at this paradigm [33,34]. A study of Swiss Physiotherapy students showed that the beliefs around LBP changed through training "unhelpful beliefs about the back being vulnerable and in need of protection were substantially decreased after the module" [33]. ...
... A few studies have looked at this paradigm [33,34]. A study of Swiss Physiotherapy students showed that the beliefs around LBP changed through training "unhelpful beliefs about the back being vulnerable and in need of protection were substantially decreased after the module" [33]. ...
... It is vital that false beliefs are addressed during training so that these beliefs are not transmitted to the general public. Addressing the beliefs during HCP undergraduate training may help with better patient education after graduation [33][34][35]. This will ensure that patients receive evidence-based education, which may help them identify the correct information and help form reasonable beliefs around LBP. ...
Article
Back pain is a ubiquitous health issue across the globe. Beliefs of patients and health care providers play an important role in the development of chronic back pain and associated disability, as well as subsequent recovery. Recent published literature highlight that beliefs about back pain among the community and health care practitioners are inconsistent with current evidence. Presence of back pain myths negatively impacts individual's back-related behavior in general and may be amplified by the consulting health care provider. Our narrative of the sources of back pain is based on the current literature and reveals our position as practicing physiotherapists who are dealing with back pain patients.
... The Back-PAQ has also been used as an outcome measure in clinical trials and prospective intervention studies. Christe et al. (2021a) studied modification of physiotherapy students' beliefs using the 34-item Back-PAQ. They found an improvement in back beliefs of second year physiotherapy students after the implementation of a "spinal management module" which focused on a biopsychosocial understanding of LBP and discussing common misconceptions. ...
... When using the latter, total scale scores range from À68 to +68 with beliefs that are unhelpful for recovery from back pain attracting negative scores and vice versa. There is no clear advantage in using one scoring system over the other and both have been used in research studies (Christe et al. 2021a;Darlow et al., 2019). ...
... It has been reported that PT students had more positive beliefs about LBP than medical, OT, and pharmacy students [22], as well as more positive beliefs about the harmfulness of common daily activities than OT and nursing students, respectively [19], but there was no differentiation among academic year groups. Understanding the effect of the study year and its possible interaction across different degree programmes may be important given research has reported an improvement in positive beliefs about LBP across study years [25]. Beliefs about LBP can also be affected by the course, with one study reporting that PT students had more positive LBP attitudes than non-healthcare students, although the nature of non-healthcare programmes were not provided [21]. ...
... This was because the lack of female participants in the PT group was present across all year groups, but significance was detected largely in the 3 rd year group. The cross-sectional nature precludes making within-subject inferences about whether the back pain beliefs and fear levels of a student improve across study years [25]. Given that the study programmes investigated in this study may differ in their curricula across different HEIs, extrapolating our findings nationally and internationally should be done with caution. ...
Article
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Background Although low back pain (LBP) beliefs have been well investigated in mainstream healthcare discipline students, the beliefs within sports-related study students, such as Sport and Exercise Science (SES), Sports Therapy (ST), and Sport Performance and Coaching (SPC) programmes have yet to be explored. This study aims to understand any differences in the beliefs and fear associated with movement in students enrolled in four undergraduate study programmes–physiotherapy (PT), ST, SES, and SPC. Method 136 undergraduate students completed an online survey. All participants completed the Tampa Scale of Kinesiophobia (TSK) and Back Beliefs Questionnaire (BBQ). Two sets of two-way between-subjects Analysis of Variance (ANOVA) were conducted for each outcome of TSK and BBQ, with the independent variables of the study programme, study year (1st, 2nd, 3rd), and their interaction. Results There was a significant interaction between study programme and year for TSK (F(6, 124) = 4.90, P < 0.001) and BBQ (F(6, 124) = 8.18, P < 0.001). Post-hoc analysis revealed that both PT and ST students had lower TSK and higher BBQ scores than SES and SPC students particularly in the 3rd year. Conclusions The beliefs of clinicians and trainers managing LBP are known to transfer to patients, and more negative beliefs have been associated with greater disability. This is the first study to understand the beliefs about back pain in various sports study programmes, which is timely, given that the management of injured athletes typically involves a multidisciplinary team.
... Les questions sont formulées de manière à ce que l'instrument puisse convenir aux personnes souffrant de rachialgie, aux personnes sans rachialgie et aux professionnels de la santé. Ce questionnaire a notamment été utilisé dans plusieurs études récentes évaluant les croyances de différents types de professionnels : kinésithérapeutes (26)(27)(28) , étudiants en kinésithérapie (29) , étudiants en ostéopathie (30) et ostéopathes (31,32) . ...
... A noter dans cette étude que les kinésithérapeutes impliqués dans l'enseignement avaient un score légèrement meilleur (78,66 ± 18,43). Christe (29) a rapporté un meilleur score pour les étudiants en première année d'études de kinésithérapie : 94,8 versus 113 dans l'étude présente. Dans une autre étude explorant les croyances de la population générale suisse (42) , un score au Back PAQ de 113,2 a été retrouvé, ce qui est comparable au score de nos étudiants de première année qui commencent tout juste leur formation. ...
Article
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Les facteurs psychosociaux jouent un rôle essentiel dans le pronostic et la prise en charge des patients présentant une lombalgie non-spécifique (LNS). Les données scientifiques indiquent que les croyances d'un individu concernant la douleur sont associées aux attitudes et aux croyances du clinicien consulté. Cette étude a exploré les attitudes, croyances et orientations cliniques des étudiants, des nouveaux diplômés, des enseignants et praticiens non-enseignants issus de deux instituts français d'enseignement de l'ostéopathie en ce qui concerne la prise en charge de la LNS. Cette population a été étudiée au moyen d'une enquête transversale réalisée en ligne entre août et octobre 2021 comprenant un recueil des caractéristiques socio-démographiques, un questionnaire (Back-PAQ) et une vignette clinique. 798 participants ont répondu à l'enquête (556 étudiants, 47 nouveaux diplômés, 88 enseignants, 107 praticiens). Les résultats des étudiants au Back-PAQ ont montré une diminution progressive des scores (croyances plus adaptées) de la première année (113 ± 10,2) à la cinquième année (81,4 ± 12,1) (p < 0,001) avec une diminution plus importante entre les étudiants de 5ème année (81,4 ± 12,1) et les nouveaux diplômés (48,4 ± 7,5) (p < 0,001). Les orientations cliniques basées sur les questions de la vignette (score moyen : 1,7/3) étaient modérément corrélées au score du Back-PAQ (r =-0,489, p < 0,001). Ainsi, les participants ayant plus de croyances délétères étaient plus susceptibles d'encourager la limitation de l'activité physique ou professionnelle. Pour que les futurs cliniciens puissent aborder de manière adéquate les facteurs psychosociaux associés à la LNS, il semble crucial d'évaluer leurs attitudes pendant leur formation afin de mieux appréhender les croyances qui les sous-tendent.
... In order to evaluate students' knowledge of pain, different versions of the Neurophysiology of Pain Questionnaire (NPQ) have almost exclusively been used (Adillón et al., 2015;Alodaibi et al., 2018;Bareiss et al., 2019;Hush et al., 2018;Logan & Wicinski Reynolds, 2021;Mankelow et al., 2022b;Mukoka et al., 2019;Springer et al., 2018;Wassinger, 2021). The opposite is true for attitudes and beliefs about pain, which in turn has been studied with several different self-report questionnaires (Alshami & Albahrani, 2015;Augeard et al., 2019;Bareiss et al., 2019;Briggs et al., 2013;Burnett et al., 2009;Carroll et al., 2020;Christe et al., 2021a;de Jesus-Moraleida et al., 2021;Domenech et al., 2013;Ferreira et al., 2004;Kennedy et al., 2014;Latimer et al., 2004;Leysen et al., 2021;Mankelow et al., 2022b;Mukoka et al., 2019;Ryan et al., 2010;Springer et al., 2018;Wassinger, 2021). These self-report questionnaires on attitudes and beliefs about pain are listed in Table 4. ...
Thesis
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Despite the recognition of pain as a global health problem and advances in research evidence for effective pain management, pain education for undergraduate health care students, including physiotherapy students, remains insufficient. Understanding the biological mechanisms that underlie pain, as well as the physiotherapist's own attitudes and beliefs about pain, influence the treatment provided to patients. The aim of this dissertation was to provide research evidence and tools, that can be used to develop pain education for physiotherapists. The dissertation consists of three scientific articles that were based on quantitative research methods. Study I evaluated the amount and content of pain-related education on physiotherapy programs at bachelor’s level at Universities of Applied Sciences in Finland. In study II, the Health Care Providers’ Pain and Impairment Relationship Scale was translated and cross-culturally adapted into Finnish (HC-PAIRS-FI), and its psychometric properties and factor structure were assessed among Finnish physiotherapists and physiotherapy students. In study III, the revised Neurophysiology of Pain Questionnaire was translated and cross-culturally adapted into Finnish (RNPQ-FI), and its reliability was evaluated in the same sample as in study II. Study III also compared the knowledge of pain neurophysiology between physiotherapists and physiotherapy students, as well as the association between RNPQ-FI scores and background factors. The results showed an overall higher number of teaching hours devoted to pain education than previously reported in faculty surveys. Despite this, the number of hours differed greatly between the Universities of Applied Sciences. Additionally, some key pain learning contents (e.g. the biopsychosocial model of pain, cognitive behavioral methods, and interdisciplinary management) were inadequately covered. A separate pain course resulted in twice as much pain education compared to Universities of Applied Sciences that only offered integrated pain education. Furthermore, those physiotherapy students who had attended a separate pain course in addition to integrated pain education had more positive attitudes and beliefs towards chronic low back pain than other respondents, and their knowledge of the neurophysiology of pain was more comprehensive. The Finnish version, HC-PAIRS-FI, proved to be a reliable and valid tool for measuring attitudes and beliefs about chronic low back pain among Finnish physiotherapists and physiotherapy students, while the internal consistency of the RNPQ-FI questionnaire was low and the test-retest reliability moderate. One of the challenges of the RNPQ-FI questionnaire was that almost half of the physiotherapists and a third of the students reported difficulties understanding the items. According to our study, physiotherapy students and professionals had similar levels of knowledge about pain neurophysiology. Physiotherapists who had completed additional pain education showed higher knowledge of pain neurophysiology, compared to those without such education. This dissertation highlights both the challenges of undergraduate physiotherapy pain education and areas for improvement that can be implemented to enhance the pain education of physiotherapy students. Emphasis is placed on up-to-date pain education for both physiotherapy students and physiotherapists. The culturally adapted questionnaires examined in studies II and III can be used in; pain education at pre- and postgraduate levels of physiotherapists, in improving the clinical care of patients with chronic pain, and in future research on knowledge, attitudes and beliefs about chronic pain.
... As previously indicated, professional education behaves as a key element in introducing new biopsychosocial paradigms of LBP care paradigms into clinical practice. Currently, new works such as Leysen et al. (2021) and found useless beliefs about back sensitivity and the need for protection among physiotherapy students and developed crosssectional studies to evaluate changes in attitudes and beliefs during their training [22,23]. ...
Article
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Background The aim of this study is to investigate the attitudes and beliefs of Spanish physiotherapists towards the diagnosis and management of low back pain (LBP). A descriptive, cross-sectional study was conducted according to STROBE guidelines from December 18, 2021, to May 2022. An online survey was developed based on Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), a reliable and validated self-administered instrument developed to assess the strength of two possible treatment orientations of physiotherapists towards the diagnosis and management of LBP. Respondents were selected through a non-probabilistic convenience sampling technique, and the selection criteria were (1) active physiotherapists with no restrictions on gender and length of service, (2) physical therapists who have worked in both public and private environments, and (3) physiotherapists who have been officially registered with no restriction on the place of practice in Spain. Survey data was obtained and analyzed using the SPSS Statistic 28 (IBM®) statistical software. Results Three hundred eighty-one questionnaires were finally included (F; n =151, M; n =230). In relation to the diagnosis, the respondents indicated that the tissue damage was sufficient to explain widespread and lasting pain, but rather that it was due to psychological factors. In addition, for those surveyed, the diagnosis should not focus exclusively on imaging tests but on clinical symptoms and signs. However, the weak relationship between objective damage and perceived pain intensity, as well as the weak relationship between posture and the development or worsening of LBP, did not seem to be clear to physiotherapists. From the point of view of treatment, we can indicate that professionals are committed to maintaining adequate and individualized physical activity as a first-line treatment in pain management. Conclusions Most physiotherapists in Spain have up-to-date knowledge of the biopsychosocial model of pain care. However, regarding attitudes and beliefs towards LBP, there are still contents and behaviors based on spine protective paradigms that are not conducive to active pain management.
... Negative views regarding chronic pain have also been found in medical students [15]. Despite these findings, beliefs and attitudes towards pain and LBP amongst healthcare and medical students have been shown to improve during study, demonstrating the effectiveness of education [24,38,39]. For example, medical students have been found to believe LBP myths including 'back pain is likely to be caused by heavy lifting' . ...
Article
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Background Low back pain (LBP) is a common condition with substantial associated disability and costs, best understood using a biopsychosocial approach. Research demonstrates that beliefs about LBP are important, with biomedical beliefs influencing practitioner’s management and patient recovery. Beliefs about LBP can be inconsistent amongst healthcare and medical students. The aim of this study was to investigate graduate medical student’s beliefs of LBP and what influences them. Method A cross sectional mixed methods study of Phase 1 (first year) and Phase 3 (third and fourth year) current graduate medical students at the University of Warwick (MBChB) was conducted. Participants were recruited via voluntary response sampling. A survey investigated LBP beliefs, utilising the Back Beliefs Questionnaire (BBQ) and Health Care Providers’ Pain and Impairment Relationship Scale (HC-PAIRS). Qualitative data was collected on what influences beliefs about the causes and management of LBP, which was analysed descriptively using thematic analysis. Results Fifty-seven students completed the questionnaire (61% female), with a mean age of 27.2 years. Eighty two percent of participants reported a history of LBP. Median BBQ scores were 31.5 for phase 1 and 31 for phase 3, with median HC-PAIRS scores of 57 and 60 for phase 1 and phase 3 students respectively. Three main themes emerged from the qualitative data: Sources of influence, influence of personal experience and influence of medical education. Participants discussed single or multiple sources influencing their beliefs about the causes and management of LBP. Another main theme was the influence of experiencing LBP personally or through discussions with family, friends and patients. The final main theme described the influence of medical education, including lectures, seminars and clinical placements. Conclusions The HC-PAIRS and BBQ scores suggest graduate medical students in this sample tended to have positive beliefs about the outcome of LBP and functional expectations of chronic LBP patients, consistent with other healthcare students. The findings from qualitative data suggest how medical students form beliefs about the causes and management of LBP is complex.
Article
Background: Maladaptive fear of movement in individuals with low back pain may be associated with worse clinical outcomes. Objective: To explore beliefs about the perceived dangers regarding different spinal postures within the Czech Republic. Design: Exploratory cross-sectional study including physiotherapists and members of the general public. Methods: Self-reported perceived safety/danger of “straight” and “flexed” spinal postures regarding 1) sitting, 2) lifting of light and 3) heavy object from the floor based on three pairs of photographs was measured using numeric rating scales (0-10, safe to dangerous) without any given context and in the context of low back pain. The sum of differences between the ratings of flexed and straight postures were used to calculate Bending Safety Beliefs Thermometer (BSBThermometer) total score potentially ranging -60‒60 (higher values indicates evaluation of flexed spinal postures as more dangerous in comparison to straight postures). Results: 760 participants were included in the analysis. The mean BSBThermometer total score was 31.1 (SD 16.1) and higher scores were positively associated with being women (b=14.8, 95% CI [9.9-19.8]); non-medical profession (b=24.7, 95% CI [15.2-34.2]); age (b=0.38, 95% CI [0.16-0.6]; and their interactions. There was no significant association with current low back pain status or history of low back pain. Conclusions: On average, participants evaluated “flexed” spinal postures as significantly more dangerous when compared with “straight” spinal postures, with only subgroups of physiotherapists scoring lower than the general public. Clinically, these beliefs could be targeted by individualized education, exposure-based interventions and public campaigns; however, further research is required.
Article
Objective To explore how causal beliefs regarding non-specific low back pain (LBP) have been quantitatively investigated. Methods A scoping review based on the guidelines by the JBI (former Joanna Briggs Institute) was conducted. We searched Medline, Embase, Psychinfo, and CINAHL for relevant studies and included peer-reviewed original articles that measured causal beliefs about non-specific LBP among adults and reported results separate from other belief domains. Results A total of 81 studies were included, of which 62 (77%) had cross sectional designs, 11 (14%) were cohort studies, 3 (4%) randomized controlled trials, 4 (5%) non-randomized controlled trials, and 1 (1%) case control. Only 15 studies explicitly mentioned cause, triggers, or etiology in the study aim. We identified the use of 6 questionnaires from which a measure of causal beliefs could be obtained. The most frequently used questionnaire was the Illness Perception Questionnaire which was used in 8 of the included studies. The studies covered 308 unique causal belief items which we categorized into 15 categories, the most frequently investigated being causal beliefs related to “structural injury or impairment”, which was investigated in 45 (56%) of the studies. The second and third most prevalent categories were related to “lifting and bending“ (26 studies [32%]) and “mental or psychological” (24 studies [30%]). Conclusion There is a large variation in how causal beliefs are measured and a lack of studies designed to investigate causal beliefs, and of studies determining a longitudinal association between such beliefs and patient outcomes. This scoping review identified an evidence gap and can inspire future research in this field.
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Resumen. El dolor lumbar es un problema de salud global y su nivel de discapacidad depende, entre otras variables, de las creencias negativas de los pacientes respecto del dolor. Evidencia sostiene que dichas creencias están asociadas con las que poseen sus profesio-nales tratantes, por lo que es importante identificar cómo evolucionan durante la formación de pregrado de los profesionales sanita-rios. El objetivo de este estudio transversal fue determinar la presencia de creencias negativas sobre dolor lumbar en estudiantes de fisioterapia y compararlas entre distintos cursos del ciclo formativo. Participaron estudiantes de segundo a quinto año de fisioterapia de una universidad chilena, quienes completaron una encuesta basada en los siete mitos sobre dolor lumbar de Deyo y respondieron según su grado de acuerdo con los enunciados. Los resultados fueron comparados entre los diferentes niveles. 127 estudiantes com-pletaron la encuesta (57 hombres y 70 mujeres). Los mitos 1, 2, 4, 6 y 7 se presentaron con mayor frecuencia en segundo año y tendieron a disminuir progresivamente en los cursos superiores. Los mitos 3 y 5 presentaron un patrón distributivo menos claro. Los estudiantes de segundo nivel presentaron un mayor grado de acuerdo con los mitos, los de tercer nivel presentaron mayor inseguri-dad en las respuestas, mientras que los alumnos de cuarto y quinto nivel presentaron mayor desacuerdo con los mitos. En conclusión, las creencias negativas sobre dolor lumbar pueden encontrarse presentes en estudiantes de fisioterapia, pero éstas tienden a modifi-carse positivamente a lo largo de su proceso formativo. Palabras claves: Dolor; Dolor Lumbar; Creencias negativas sobre dolor lumbar; Mitos de Deyo; Estudiantes de fisioterapia. Abstract. Low back pain is a global health problem, and its level of disability depends, among other variables, on patients' negative beliefs regarding pain. Evidence supports that these beliefs are associated with those held by their treating professionals, so it is important to identify how they evolve during the undergraduate training of health professionals. This cross-sectional study aimed to determine the presence of negative beliefs about low back pain in physical therapy students and compare them between different courses of the training cycle. Second, to fifth-year physiotherapy students from a Chilean university participated; they completed a survey based on Deyo's seven myths about low back pain and responded according to their degree of agreement with the statements. The results were compared between the different levels. 127 students completed the survey (57 males and 70 females). Myths 1, 2, 4, 6, and 7 were presented more frequently in the second year and tended to decrease progressively in higher grades. Myths 3 and 5 presented a less clear distributional pattern. Second-level students presented a higher degree of agreement with the myths, and third-level students presented greater insecurity in the answers. In contrast, fourth and fifth-level students presented greater disagreement with the myths. In conclusion, negative beliefs about low back pain may be present in physical therapy students, but these tend to modify positively throughout their formative process. Introducción El dolor lumbar es uno de los problemas de salud más importantes y entre 1990 y 2019, los años vividos en dis-capacidad por esta causa han aumentado sustancialmente, alcanzando el primer lugar a nivel mundial en este indica-dor (Chen et al., 2022). La mayor prevalencia de dolor lumbar se presenta en personas entre 40 y 80 años (Hoy et al., 2012) y más del 80% de la población sufrirá a lo me-nos un episodio de dolor lumbar a lo largo de su vida (Fre-burger et al., 2009). El dolor lumbar crónico (duración ≥12 semanas) afecta aproximadamente al 20% de la pobla-ción mundial (Tagliaferri et al., 2020) y la tasa de preva-lencia específica por género es de 1.2:1 en favor de muje-res (Schneider et al., 2006). Actualmente, esta es la principal causa de discapacidad en el mundo y en los países de ingresos bajos y medianos es en donde más ha aumentado (Wu et al., 2020). Además, se prevé que los problemas asociados al dolor lumbar aumenten en las próximas déca-das (Hartvigsen et al., 2018). Un factor importante que puede favorecer el desarro-llo de discapacidad en personas con dolor lumbar es la presencia de creencias erróneas o negativas acerca de esta condición (Grøn et al., 2019). Se ha observado una asocia-ción entre creencias erróneas y estrategias pasivas de afrontamiento, siendo éstas un predictor de dolor persis-tente (Jones et al., 2006). Además, se ha descrito que las creencias negativas sobre el dolor lumbar son importantes en el proceso de cronificación del dolor y que incluso pueden influir significativamente en los resultados del tratamiento (Ramond et al., 2011). Un estudio que aplicó un cuestionario basado en mitos sobre dolor lumbar evidenció que las creencias negativas sobre dicha condición se encuentran ampliamente presen-tes en la población general. Un 61.2% de los encuestados declararon estar de acuerdo con cuatro de los siete mitos estudiados, siendo mayoritariamente las personas con menor nivel educacional las que presentaban dichas creen-cias (Munigangaiah et al., 2016). Además, las creencias negativas sobre el dolor de espalda se encuentran presentes consistentemente en personas de mayor edad y que tienen una autopercepción de salud general y mental baja (Mor
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Background Physiotherapists' biomedical orientation influences the implementation of evidenced-based care for low back pain (LBP) management. However, information on physiotherapists’ own beliefs about their back and LBP and the influence of these on clinical decisions and advice is lacking. Objectives To identify attitudes and beliefs about LBP among physiotherapists and to analyse the association of these beliefs with physiotherapists’ individual characteristics and clinical decisions and advice. Design Cross-sectional survey. Method Attitudes and beliefs about LBP were measured with the Back-Pain Attitudes Questionnaire (Back-PAQ) among French-speaking Swiss physiotherapists. Physiotherapists’ clinical decisions and advice were assessed with a clinical vignette to determine their association with the Back-PAQ score. Results The study included 288 physiotherapists. The mean Back-PAQ score (82.7; SD 17.2) indicated the presence of helpful beliefs in general, but unhelpful beliefs in relation to back protection and the special nature of LBP (nature of pain, impact, complexity) were frequently identified. Individual characteristics explained 17% of the Back-PAQ score. Unhelpful beliefs were associated with clinical decisions toward back protection and movement avoidance (r = - 0.47, p < 0.001). Conclusions While helpful beliefs and guidelines consistent decisions were generally identified, unhelpful beliefs about back protection and the special nature of LBP were frequently present among physiotherapists. These unhelpful beliefs were associated with less optimal clinical decisions. Educational approaches should challenge unhelpful beliefs and empower physiotherapists to provide explanations and management that increases patients’ confidence in the back. Future research should investigate the effect of educational strategies on implementation of best practice for LBP management.
Article
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Background Unhelpful beliefs about non-specific low back pain (LBP) are associated with poorer coping strategies and unhelpful behaviours. Furthermore, targeting unhelpful beliefs about back pain has been advanced as a major priority to decrease the burden of LBP. Therefore, studies exploring these beliefs are needed to adapt the message delivered to the population. Objectives To identify attitudes and beliefs about LBP in the general population in French-speaking Switzerland and to analyse their association with individual characteristics and the belief that exercise is an effective treatment for LBP. Design Cross-sectional study. Method Attitudes and beliefs were measured with the Back-Pain Attitudes Questionnaire (Back-PAQ). Individual characteristics and participants’ beliefs about the effectiveness of exercise for LBP were collected to determine their association with Back-PAQ score. Results The questionnaire was completed by 1129 participants. Unhelpful beliefs were widespread (mean (SD) Back-PAQ score: 113.2 (10.6)), especially those that the back needs protection, is easy to injure and that the nature of LBP is special. Only 55% of the participants believed exercise to be one of the most effective treatment for LBP. Individual characteristics only explained 4% of the Back-PAQ score variance. Conclusion French-speaking Swiss general population has high levels of unhelpful beliefs and moderate confidence in the effectiveness of exercise for LBP, though the message “staying active is good for LBP” was well understood. The messages to decrease the level of unhelpful beliefs about LBP in the population should specifically target the vulnerability, protection and special nature of LBP, and promote exercise therapy.
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This meta-analysis investigated whether more negative psychological factors are associated with less spinal amplitude of movement and higher trunk muscle activity in individuals with low back pain (LBP). Furthermore, it examined whether pain intensity was a confounding factor in this relationship. We included studies that provided at least one correlation coefficient between psychological (pain-related fear, catastrophizing, depression, anxiety and self-efficacy) and spinal motor behaviour (spinal amplitude and trunk muscle activity) measures. In total, 52 studies (3949 participants) were included. The pooled correlations coefficients (95% CI; number of participants) were -0.13 (-0.18 to -0.09; 2832) for pain-related fear, -0.16 (-0.23 to -0.09; 756) for catastrophizing, -0.08 (-0.13 to -0.03; 1570) for depression, -0.08 (-0.30 to 0.14; 336) for anxiety and -0.06 (-0.46 to 0.36; 66) for self-efficacy. The results indicated that higher levels of pain-related fear, catastrophizing and depression are significantly associated with reduced amplitudes of movement and larger muscle activity, and were consistent across subgroup and moderation analyses. Pain intensity did not significantly affect the association between these psychological factors and spinal motor behaviour, and had a very small independent association with spinal motor behaviour. In conclusion, the very small effect sizes found in the meta-analyses question the role of psychological factors as major causes of spinal movement avoidance in LBP. Experimental studies with more specific and individualized measures of psychological factors, pain intensity and spinal motor behaviour are recommended.
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Background One-size-fits-all interventions reduce chronic low back pain (CLBP) a small amount. An individualised intervention called cognitive functional therapy (CFT) was superior for CLBP compared with manual therapy and exercise in one randomised controlled trial (RCT). However, systematic reviews show group interventions are as effective as one-to-one interventions for musculoskeletal pain. This RCT investigated whether a physiotherapist-delivered individualised intervention (CFT) was more effective than physiotherapist-delivered group-based exercise and education for individuals with CLBP. Methods 206 adults with CLBP were randomised to either CFT (n=106) or group-based exercise and education (n=100). The length of the CFT intervention varied according to the clinical progression of participants (mean=5 treatments). The group intervention consisted of up to 6 classes (mean=4 classes) over 6–8 weeks. Primary outcomes were disability and pain intensity in the past week at 6 months and 12months postrandomisation. Analysis was by intention-to-treat using linear mixed models. Results CFT reduced disability more than the group intervention at 6 months (mean difference, 8.65; 95% CI 3.66 to 13.64; p=0.001), and at 12 months (mean difference, 7.02; 95% CI 2.24 to 11.80; p=0.004). There were no between-group differences observed in pain intensity at 6 months (mean difference, 0.76; 95% CI -0.02 to 1.54; p=0.056) or 12 months (mean difference, 0.65; 95% CI -0.20 to 1.50; p=0.134). Conclusion CFT reduced disability, but not pain, at 6 and 12 months compared with the group-based exercise and education intervention. Future research should examine whether the greater reduction in disability achieved by CFT renders worthwhile differences for health systems and patients. Trial registration number ClinicalTrials.gov registry (NCT02145728 ).
Article
Background low back pain (LBP) is highly prevalent, very disabling and carries an enormous economic burden. The multifactorial characteristic of LBP often does not allow identification of a single pathoanatomic driver of pain. Unhelpful beliefs are associated with elevated levels of pain and may have a negative impact on the recovery of an episode of LBP. Beliefs about the back and back pain have not been evaluated in the Argentine general population. Objective to assess the beliefs about the back and back pain of the Argentine population. The secondary objective was to compare the beliefs between respondents with and without LBP and between those who had and had not seen a health care professional (HCP). Study design cross-sectional study. Method we included Argentinians aged 18 years or more with or without LBP. The Argentine version of Back Pain Attitude Questionnaire (Back-PAQ) was used to assess back beliefs. Results one thousand and ninety-two participants responded the survey. Current LBP was reported by 42.3% of respondents and the life-time prevalence was 88.4%. The mean Back-PAQ score was 111.7. Significant differences were found when comparing the current pain group with past and never LBP groups (p < 0.001). There were no difference between respondents who were and were not exposed to a HCP. Conclusion Survey respondents sampled from the Argentine population had in general negative beliefs about back pain. Respondents with current pain have more unhelpful beliefs than pain free respondents in relation to the prognosis and recovery of an episode of LBP.
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Irrespective of the lifting technique (squat or stoop), the lumbar spine posture (more kyphotic versus more lordotic) adopted during lifting activities is an important parameter affecting the active-passive spinal load distribution. The advantages in either posture while lifting remains, however, a matter of debate. To comprehensively investigate the role on the trunk biomechanics of changes in the lumbar posture (lordotic, free or kyphotic) during forward trunk flexion, validated musculoskeletal and finite element models, driven by in vivo kinematics data, were used to estimate detailed internal tissue stresses-forces in and load-sharing among various joint active-passive tissues. Findings indicated that the lordotic posture, as compared to the kyphotic one, resulted in marked increases in back global muscle activities (∼14-19%), overall segmental compression (∼7.5-46.1%) and shear (∼5.4-47.5%) forces, and L5-S1 facet joint forces (by up to 80 N). At the L5-S1 level, the lordotic lumbar posture caused considerable decreases in the moment resisted by passive structures (spine and musculature, ∼14-27%), negligible reductions in the maximum disc fiber strains (by ∼0.4-4.7%) and small increases in intradiscal pressure (∼1.8-3.4%). Collectively and with due consideration of the risk of fatigue and viscoelastic creep especially under repetitive lifts, current results support a free posture (in between the extreme kyphotic and lordotic postures) with moderate contributions from both active and passive structures during lifting activities involving trunk forward flexion.
Article
While alterations in spinal kinematics have been repeatedly observed in chronic low back pain (CLBP) patients, their exact nature is still unknown. Specifically, there is a need for comprehensive assessments of multi‐segment spinal angles during daily‐life activities. The purpose of this exploratory study was to characterize three‐dimensional angles at the lower lumbar, upper lumbar, lower thoracic and upper thoracic joints in CLBP patients and asymptomatic controls during stepping up with three different step heights. Spinal angles of 10 patients with non‐specific CLBP (6 males; 38.7±7.2 years old; 22.3±1.6 kg/m2) and 11 asymptomatic individuals (6 males; 36.7±5.4 years old; 22.9±3.8 kg/m2) were measured in a laboratory using a camera‐based motion capture system. Seven out of the 12 angle curves had characteristic patterns, leading to the identification of 20 characteristic peaks. Comparing peak amplitudes between groups revealed statistically significantly smaller sagittal‐ and frontal‐plane angles in the patient group at the upper lumbar joint with the two higher steps and at the lower lumbar joint with the higher step. Significantly reduced angles were also observed in sagittal‐plane at the upper thoracic joint with the two smaller steps. Moreover, a higher number of significant differences between groups was detected with the two higher steps than with the smallest step. In conclusion, this study showed the value of a comprehensive description of spinal angles during step‐up tasks and provided insights into the alterations with CLBP. These preliminary results support prior research suggesting that CLBP rehabilitation should facilitate larger amplitudes of motion during functional activities. This article is protected by copyright. All rights reserved.
Article
Study design: Prognosis systematic review with meta-analysis. Objective: To evaluate whether lumbar spine flexion during lifting is a risk factor for low back pain (LBP) onset/persistence, or a differentiator of people with and without LBP. Literature search: Database search of Proquest, CINAHL, Medline and EMBASE until August 2018. Study selection criteria: We included peer-reviewed articles, investigating lumbar spine position during lifting as a risk factor for LBP onset or persistence, or as a differentiator of people with and without LBP. Data synthesis: Lifting task comparison data were tabulated and summarised. For meta-analysis, we calculated an n-weighted pooled mean (SD) of the results for each of the LBP and no LBP groups. Where a study contained multiple comparisons (i.e. different lifting tasks that used various weights or directions), only one result for each study was included in the meta-analysis. Results: Four studies (one longitudinal study and three cross-sectional studies) measured lumbar flexion with intra-lumbar angles and found no differences in peak lumbar spine flexion when lifting (longitudinal 1.5 degree (95%CI -0.7 to 3.7), p=0.19 and cross-sectional -0.9 (95%CI -2.5 to 0.7), p=0.29). Seven cross-sectional studies measured lumbar flexion with thoraco-pelvic angles and found people with LBP lifted with 6.0 degrees less lumbar flexion than people without LBP (95%CI -11.2 to -.89, p<0.01). Most (9 of 11) studies reported no between-group differences in lumbar flexion during lifting. The included studies were low quality. Conclusion: There was low quality evidence that greater lumbar spine flexion during lifting was not a risk factor for LBP onset/persistence, nor a differentiator of people with and without LBP. J Orthop Sports Phys Ther, Epub 28 Nov 2019. doi:10.2519/jospt.2020.9218.
Article
Background and aims To systemically review the literature to compare freestyle lifting technique, by muscle activity and kinematics, between people with and without low back pain (LBP). Methods Five databases were searched along with manual searches of retrieved articles by a single reviewer. Studies were included if they compared a freestyle lifting activity between participants with and without LBP. Data were extracted by two reviewers, and studies were appraised using the CASP tool for case-control studies. Results Nine studies were eligible. Heterogeneity did not allow for meta-analysis. Most studies (n = 8 studies) reported that people with LBP lift differently to pain-free controls. Specifically, people with LBP lift more slowly (n = 6 studies), use their legs more than their back especially when initiating lifting (n = 3 studies), and jerk less during lifting (n = 1 studies). Furthermore, the four larger studies involving people with more severe LBP also showed that people with LBP lift with less spinal range of motion and greater trunk muscle activity for a longer period. Conclusions People with LBP move slower, stiffer, and with a deeper knee bend than pain-free people during freestyle lifting tasks. Interestingly, such a lifting style mirrors how people, with and without LBP, are often told how to lift during manual handling training. The cross-sectional nature of the comparisons does not allow for causation to be determined. Implications The changes described may show embodiment of cautious movement, and the drive to protect the back. There may be value in exploring whether adopting a lifting style closer to that of pain-free people could help reduce LBP.
Article
Background: Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED. Methods: We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality. Results: We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess). Conclusion: We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed.