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R E S E A R C H A R T I C L E Open Access
Changes in physiotherapy students’beliefs
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.
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.
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 [4–8] and these beliefs may con-
tribute to pain-related fear, catastrophizing and anxiety
[9–12]. These psychological factors are important pre-
dictors of unhelpful behaviours and elevated levels of
disability [13–16].
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 professionals’unhelpful
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 patients’beliefs
and behaviours (positively or negatively) and, in turn, in-
fluence recovery outcomes [11,12,19,22]. Physiothera-
pists’beliefs 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 [26–31]. There is limited infor-
mation on training approaches that are effective in im-
proving students’beliefs. Two studies found positive
changes in physiotherapy students’beliefs following
biopsychosocially-orientated LBP learning [29,32].
These studies assessed either students’beliefs 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 students’beliefs 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 students’attitudes
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 (2018–2020) 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
2019–2021 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 patients’situations
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 “something”out of place that needs to be corrected •LBP is not due to “something”out 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) [53–55]
•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
“neutral”postures) [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 2017–2019 (−
27.36, 95%CI −33.04 to −21.68, p< 0.001), 2018–2020
(−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
2018–2020 (−7.43, 95%CI −11.67 to −3.19, p= 0.001)
cohorts (data not available for the 2019–2021 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 2018–2020 (−
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 students’beliefs 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
2017–2019 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]
2018–2020 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]
2019–2021 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 2019–2021 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 students’beliefs 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 students’be-
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 students’beliefs 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 [4–8] and have been
associated with important contributors to LBP disability,
such as pain-related fear, catastrophizing and anxiety
[9–12].
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 students’be-
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 students’first 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. Students’Back-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 [81–84], 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 students’learning 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 students’identification 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-
dents’beliefs 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.
Authors’contributions
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
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