Do health care providers' attitudes towards back pain predict their treatment recommendations? Differential predictive validity of implicit and explicit attitude measures

The influence of low back pain-related attitudes and beliefs on the clinical decision making of physical therapists

BACKGROUND

The LBP-related attitudes and beliefs of clinicians may impact the experience of patients by influencing clinician decision-making and by shaping the attitudes, beliefs, and actions of patients. The purpose of this study was to identify the specific LBP-related attitudes and beliefs of US-based physical therapists and determine if those beliefs correlate with clinical decision-making.

METHODS

An electronic survey was sent to US-based physical therapists. Attitudes and beliefs were measured using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain and Impairment Relationship Scale for Physiotherapists (PABS-PT). The survey also included 2 patient vignettes that collected information about clinical decision-making.

RESULTS

Complete survey responses were recorded from 420 physical therapists. Eleven of the 27 attitude and beliefs questions were answered in a more biomedically oriented way by at least 20% of respondents. Physical therapist low back pain-related attitudes and beliefs were associated with activity and management strategies for both vignettes in the expected direction. Higher scores on HC-PAIRS and PABS-BM were associated with more restrictive work and activity recommendations, lower-intensity exercise choices, biomechanical rationale for manual therapy and motor control exercises, pathoanatomical-focused education, and use of modalities.

CONCLUSION

Some physical therapists hold biomedically oriented beliefs about the connection between pain and physical activity. Clinician beliefs were associated with activity and work recommendations, and treatment choices. Physical therapists with more biomedically oriented beliefs were more likely to limit physical activity and work, and less likely to incorporate psychologically informed interventions.

Evaluation of the psychometric properties of the health care providers' pain and impairment relationship scale (HC-PAIRS) in health professionals and university students from Chile and Colombia

Background

Chronic back pain is a frequent and disabling health problem. There is evidence that ignorance and erroneous beliefs about chronic low back pain among health professionals interfere in the treatment of people who suffer from it. The Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) has been one of the most used scale to assess these misbeliefs, but no studies have been reported in Latin America. Method: We studied the factorial structure of the HC-PAIRS in health personnel and health sciences university students in two Latin American countries: Colombia (n = 930) and Chile (n = 190). Spain's data was taken of the original study of the Spanish version of the HC-PAIRS (171 Physiotherapy students). Additionally, the measurement invariance of this scale among Chile, Colombia and Spain was evaluated by calculating three nested models: configural, metric and scalar. We used a Confirmatory Factor Analysis (CFA) in both Latin American samples, with Maximum Likelihood Robust (MLR) estimation to estimate the parameters. For the final model in each sample, reliability was assessed with the Composite Reliability (CR) index, and to obtain the proportion of variance explained by the scale the Average Variance Extracted (AVE) was calculated.

Results

The one-factor solution shows an acceptable fit in both countries after deleting items 1, 6, and 14. For the resulting scale, the CR value is adequate, but the AVE is low. There is scalar invariance between Chile and Colombia, but not between these two countries and Spain.

Conclusions

HC-PAIRS is useful for detecting misconceptions about the relationship between chronic low back pain that would cause health personnel to give wrong recommendations to patients. However, it has psychometric weaknesses, and it is advisable to obtain other evidence of validity.

Transcultural Adaptation and Psychometric Validation of the Spanish Version of the Pain Attitudes and Beliefs Scale for Physiotherapists

Low back pain (LBP) is one of the main musculoskeletal pain conditions, and it affects 23-28% of the global population. Strong evidence supports the absence of a direct relationship between the intensity of pain and tissue damage, with psychosocial factors also playing a crucial role. In this context, the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) is a useful tool for evaluating physiotherapists' treatment orientations and beliefs regarding the management of low back pain (LBP). It helps identify practitioners who may benefit from additional education in modern pain neuroscience. However, there is not a Spanish validation of this scale for physiotherapists. Thus, the aims of this study were to translate and culturally adapt the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) into Spanish and to evaluate its psychometric properties. This validation study used three convenience samples of physiotherapists (PTs) (n = 22 for the pilot study, n = 529 for the validity study and n = 53 for assessing the instrument's responsiveness). The process of translating and adapting the PABS-PT into Spanish followed international guidelines and produced a satisfactory pre-final version of the questionnaire. Factor analysis confirmed the two-factor structure of the original version, with the biomedical (BM) factor explaining 39.4% of the variance and the biopsychosocial (BPS) factor explaining 13.8% of the variance. Cronbach's alpha values were excellent for the BM factor (0.86) and good for the BPS factor (0.77), indicating good internal consistency. Test-retest reliability was excellent for both factors, with intraclass correlation coefficients (ICCs) of 0.84 for BM and 0.82 for BPS. The standard error of measurement (SEM) was acceptable for both factors (3.9 points for BM and 2.4 points for BPS). Concurrent validity was moderate and in the expected direction and had significant correlations with the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and Revised Neurophysiology Pain Questionnaire (R-NPQ). Sensitivity to change was demonstrated by significant improvements in both factors after an educational intervention, with medium-to-large effect sizes. The PABS-PT also showed good discriminative ability, as it was able to distinguish between physiotherapists with and without pain education. Cut-off values for the BM and BPS factors were determined. In conclusion, the translated and adapted Spanish version of the PABS-PT demonstrated good psychometric properties and can be reliably used to assess the attitudes and beliefs of Spanish-speaking physiotherapists regarding LBP. The questionnaire is recommended for use in clinical and educational research in the Spanish language context.

Cross-cultural adaptation of the pain understanding and confidence questionnaire into Japanese

[Purpose] This study aimed to develop a culturally adapted Japanese version of the Pain Understanding and Confidence Questionnaire (PUnCQ). The first-factor structure describes management from 12 perspectives for a case vignette of chronic pain and determines whether the management is based on a biomedical or biopsychosocial perspective. The second-factor structure evaluates the confidence level in management skills for the same case from 21 perspectives. [Participants and Methods] We conducted a cross-cultural adaptation based on five stages according to Beaton's guidelines (two forward translations, creation of an integrated forward translation version, two backward translations, creation of a provisional Japanese version, and a pilot test). In the pilot test, we asked 40 Japanese physical therapists to rate their understanding of the PUnCQ descriptions on a five-point Likert scale (1, not at all understandable; 5, completely understandable) and provide comments when they rated 1 to 3. We repeated revisions and pilot tests until less than 10% of the respondents rated 1 for all descriptions. [Results] By conducting two rounds of the pilot test, all items of descriptions satisfied the preestablished criteria. [Conclusion] A Japanese version of the PUnCQ was developed.

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

A study protocol for the validation of a prognostic model with an emphasis on modifiable factors to predict chronic pain after a new episode of acute- or subacute nonspecific idiopathic, non-traumatic neck pain presenting in primary care

BACKGROUND

The primary objective of this study is to identify which modifiable and non-modifiable factors are independent predictors of the development of chronic pain in patients with acute- or subacute nonspecific idiopathic, non-traumatic neck pain, and secondly, to combine these to develop and internally validate a prognostic prediction model.

METHODS

A prospective cohort study will be conducted by physiotherapists in 30 primary physiotherapy practices between January 26, 2020, and August 31, 2022, with a 6-month follow-up until March 17, 2023. Patients who consult a physiotherapist with a new episode of acute- (0 to 3 weeks) or subacute neck pain (4 to 12 weeks) will complete a baseline questionnaire. After their first appointment, candidate prognostic variables will be collected from participants regarding their neck pain symptoms, prior conditions, work-related factors, general factors, psychological and behavioral factors. Follow-up assessments will be conducted at six weeks, three months, and six months after the initial assessment. The primary outcome measure is the Numeric Pain Rating Scale (NPRS) to examine the presence of chronic pain. If the pain is present at six weeks, three months, and six months with a score of NPRS ≥3, it is classified as chronic pain. An initial exploratory analysis will use univariate logistic regression to assess the relationship between candidate prognostic factors at baseline and outcome. Multiple logistic regression analyses will be conducted. The discriminative ability of the prognostic model will be determined based on the Area Under the receiver operating characteristic Curve (AUC), calibration will be assessed using a calibration plot and formally tested using the Hosmer and Lemeshow goodness-of-fit test, and model fit will be quantified as Nagelkerke's R2. Internal validation will be performed using bootstrapping-resampling to yield a measure of overfitting and the optimism-corrected AUC.

DISCUSSION

The results of this study will improve the understanding of prognostic and potential protective factors, which will help clinicians guide their clinical decision making, develop an individualized treatment approach, and predict chronic neck pain more accurately.

Concerns, beliefs and attitudes of pharmacists and pharmacy students on cannabis use in Canada

BACKGROUND

Since cannabis has been legalized in Canada for medical and recreational use, there has been an increased demand on pharmacists for cannabis counselling. The objective of this study was to determine the concerns, beliefs and attitudes of Canadian pharmacists and pharmacy students towards using cannabis.

METHODS

An online survey was synthesized under 3 broad themes: concerns, beliefs and attitudes about cannabis, consisting of 27 questions capturing demographics and Likert scale responding to survey questions. We examined whether there were differences in responses by geographic location (i.e., Ontario, Quebec, Canada), sex or practice setting (i.e., community, hospital).

RESULTS

Across Canada, there were 654 survey respondents, with 399 in Ontario and 95 in Quebec. Approximately 24% indicated they had used cannabis since legalization, 69% indicated they believed cannabis should be available for medical and recreational use and 34% indicated their perceptions towards cannabis had become more positive since legalization. Relative to Quebec or the rest of Canada, respondents from Ontario were significantly more likely to be comfortable providing counselling to and answering questions of patients on the safety and efficacy of medical cannabis use. Examining sex differences across Canada, male respondents were more comfortable than female counselling patients on the safety and efficacy of medical cannabis.

CONCLUSION

The current results reinforce the perceived need by pharmacists and pharmacy students for targeted education, and future research in cannabis education should consider potential gender differences in attitudes and beliefs surrounding cannabis therapy.

Management of people with low back pain: a survey of opinions and beliefs of Dutch and Belgian chiropractors

BACKGROUND

Chiropractors commonly provide care to people with low-back pain (LBP). The aim of this survey was to determine the opinions and beliefs of chiropractors regarding the support and management of LBP. We also investigated whether their management is in accordance with the three most commonly recommended approaches to LBP based upon international guidelines (i.e. advice regarding return-to-work, limit bedrest, and stay active).

METHODS

A web-based survey was sent out in 2013 to collect data from registered Dutch and Belgian chiropractors. In addition to providing a description of their sociodemographic and practice characteristics, chiropractors were asked to complete six patient vignettes representing people with LBP who typically present to a chiropractor. The respondents indicated which intervention(s) they would recommend or undertake. Based upon these vignettes, we were able to determine whether their management approach adhered to clinical guidelines. Generalized mixed models were used to explore guidelines adherence and their relationship to chiropractors' characteristics.

RESULTS

In total, 60% (n = 203/340) of the chiropractors who were invited, chose to participate. Chiropractors reported applying a chiropractic adjustment in 90% of all vignettes, while the advice to exercise varied from one-third in the chronic cases to approximately half of those with acute LBP. More than 75% of the chiropractors would initially treat LBP 1-2 times a week. More than 90% of the chiropractors advised against bedrest. Overall, self-reported adherence to clinical guidelines for all six vignettes was [64.5% (CI 58.7-70.0)]. Adherence in the chronic vignettes [73.4% (CI 66.7-79.2)] was better than in the acute vignettes [55.9% (CI 50.5-61.1)]. Importantly, regarding recommended approaches to LBP, chiropractors more consistently followed guidelines regarding advice to limit bedrest [98.5% (CI 97.3-99.1)] than advice to stay active [77.5% (CI 72.3-81.9)] or return-to-work [59.4% (CI 55.2-63.4)]. Finally, Dutch chiropractors were more likely to adhere to the guidelines than Belgian chiropractors.

CONCLUSIONS

Chiropractic adjustments were the most common self-reported treatment modalities supplemented by exercise in the management of LBP patients. Two-thirds of the chiropractors reported adhering to the guidelines regarding management and advice for LBP patients. Practitioners should improve guideline adherence, particularly for acute LBP cases, and when advising on return-to-work.

Factors associated with the low back pain-related attitudes and beliefs of physical therapists

BACKGROUND

Clinicians who believe in a strong connection between pain and disability, and who have biomedically oriented beliefs recommend less physical activity, more time off work, and promote unhelpful beliefs in patients. Understanding how these beliefs develop may assist in identifying ways to reduce unhelpful beliefs in clinicians.

OBJECTIVE

To identify factors that are associated with the LBP-related attitudes and beliefs of US-based physical therapists.

DESIGN

Cross-sectional design METHOD: An electronic survey was sent to US-based physical therapists. Attitudes and beliefs were measured using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), pain science knowledge was measured using the Neurophysiology of Pain Questionnaire (NPQ), and professional and demographic information were collected.

RESULTS

Completed surveys were obtained from 420 physical therapists. More helpful attitudes and beliefs were associated with board certification in orthopedics or sports, higher NPQ scores, and working in a hospital-based clinic. Less helpful attitudes and beliefs were associated with working in private practice and a personal history of LBP that had a minimum or significant impact on life. The factors included in this study explained 16.8% of the variability in HC-PAIRS scores (p < .001), 13% of the variability in PABS-BM scores (p < .001), and 8.3% of the variability in PABS-BPS scores (p < .001).

CONCLUSION

Several modifiable and non-modifiable factors are associated with the LBP-related attitudes and beliefs of US physical therapists.

The impact of physical therapist attitudes and beliefs on the outcomes of patients with low back pain

BACKGROUND

Low back pain (LBP) is a common problem that places a major burden on individuals and society. It has been proposed that patients treated by biomedically oriented clinicians will have worse outcomes than those treated by biopsychosocially oriented clinicians.

OBJECTIVE

To investigate the impact of physical therapist LBP related attitudes and beliefs on the outcomes of patients with LBP.

DESIGN

Retrospective cohort design.

METHOD

United States based physical therapists utilizing the Focus on Therapeutic Outcomes, Inc. (FOTO) database were surveyed using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT). Outcomes were measured using average Computerized Lumbar Functional Scale change scores (CLFS) and CLFS residual scores.

RESULTS

Analysis was performed on outcome data from 78 physical therapist and included 2345 patients. HC-PAIRS was a univariate predictor of average CLFS change scores and average CLFS residual scores. PABS-PT Biomedical subscale was a univariate predictor of average CLFS change scores. After adjusting for confounding variables, higher HC-PAIRS scores and PABS-BM scores were associated with a greater change in average CLFS score, and higher PABS-BM scores were associated with higher CLFS residual scores.

CONCLUSION

Physical therapists who believed in a stronger relationship between pain and disability had improved patient outcomes.

Effects of an e-learning programme on osteopaths' back pain attitudes: a mixed methods feasibility study

BACKGROUND

The biopsychosocial model is recommended in the management of non-specific low back pain but musculoskeletal practitioners can lack skills in assessing and managing patients using a biopsychosocial framework. Educational interventions have produced equivocal results. There is a need for an alternative educational tool to support practitioners' development in the application of biopsychosocial model to manage low back pain.

METHODS

A mixed methods study assessed the feasibility and acceptability of an e-learning programme on the biopsychosocial management of non-specific low back pain for osteopaths with more than 15 years' experience. A sequential explanatory design was conducted, with a feasibility randomised controlled trial and semi-structured interviews explored with thematic analysis.

RESULTS

A total of 45 participants participated in the RCT of which 9 also participated in the interview study. The a-priori sample size was not met (45 instead of 50). The recruitment strategies, randomisation, retention, data collection and outcome measures worked well and were found to be feasible for a main trial. The retention, satisfaction and participants' views of the programme demonstrated a good acceptability of the programme. Data from the semi-structured interviews were organised in three themes, the first two were related to the feasibility and acceptability of the e-learning programme (practical experience of following the course and engagement with the content) and the third relates to the impact of the intervention (perception of the BPS model).

CONCLUSION

A main RCT is feasible and the intervention was received well by the participants. A main RCT is required to assess the effectiveness of the e-learning programme. This work also provided data on aspects so far unreported, including osteopaths' views on continuing professional development, on e-learning as a form of continuing professional development and osteopaths' perceptions and challenges concerning the implementation of the biopsychosocial model in practice.

Attitudes and beliefs on low back pain in physical therapy education: A cross-sectional study

BACKGROUND

Prescription behavior in low back pain (LBP) differs between physical therapists with a biomedical versus a biopsychosocial belief, despite the presence of clinical guidelines.

OBJECTIVE

To examine (1) the beliefs of physical therapy students and their adherence to clinical LBP guidelines in Belgium and the Netherlands; (2) whether the beliefs and attitudes of physical therapy students change during education; (3) whether beliefs are related to guideline adherence; (4) whether beliefs and attitudes differ with or without a personal history of LBP.

METHODS

A cross-sectional design included students in the 2nd and 4th year of physical therapy education in 6 Belgian and 2 Dutch institutions. To quantify beliefs, the Pain Attitudes and Beliefs Scale, the Health Care Providers' Pain and Impairment Relationship Scale, and a clinical case vignette were used.

RESULTS

In total, 1624 students participated. (1) Only 47% of physical therapy students provide clinical guidelines' consistent recommendations for activity and 16% for work. (2) 2nd year students score higher on the biomedical subscales and lower on the psychosocial subscale. 4th year students make more guideline consistent recommendations about work and activity. (3) Students with a more biopsychosocial belief give more guideline adherent recommendations. (4) Personal experience with LBP is not associated with different beliefs or attitudes.

CONCLUSIONS

A positive shift occurs from a merely biomedical model towards a more biopsychosocial model from the 2nd to the 4th year of physical therapy education. However, guideline adherence concerning activity and work recommendations remains low.

Knowledge and attitudes toward musculoskeletal pain neuroscience of manual therapy postgraduate students in the Netherlands

BACKGROUND

Health care practitioners' knowledge and attitudes influence patients' beliefs and health outcomes in musculoskeletal (MSK) pain. It is unclear to what extent physiotherapists undertaking a postgraduate master in manual therapy (MT students) possess the knowledge and attitudes toward pain neuroscience to be able to apply the biopsychosocial model in patients with MSK pain.

OBJECTIVES

The aim of this study was to assess the knowledge and attitudes toward pain neuroscience in MT students.

DESIGN

A cross-sectional study.

METHOD

Self-reported knowledge and attitudes were measured among students (n = 662) at baseline and in all years of the MT postgraduate programs in the Netherlands. The Knowledge and Attitudes of Pain questionnaire (KNAP) was used as a primary measure. Difference in KNAP-scores between baseline (0), year 1, year 2 and year 3 was tested using a one-way ANOVA (hypothesis: 0 < 1<2 < 3). A two factor ANOVA was used to determine the interaction effect of focused pain education and year in the curriculum with KNAP.

RESULTS

There was an overall significant difference of KNAP scores with a medium effect size (F(3, 218.18) = 13.56, p < .001, ω² = 0.059). Differences between years ranged from small to medium. Interaction effect of knowledge and attitudes and focused pain education was significant with a small effect size (F(6) = 2.597, p = .017, ω² = 0.012). Sensitivity analyses were consistent with the main results.

CONCLUSIONS

Positive differences in knowledge and attitudes toward pain neuroscience in MT students occur between the progressing years of the curriculum. Differences may be related to the provision of focused pain education.

Assessing future health care practitioners' knowledge and attitudes of musculoskeletal pain; development and measurement properties of a new questionnaire

BACKGROUND

Healthcare practitioner beliefs influence patients' beliefs and health outcomes in musculoskeletal (MSK) pain. A validated questionnaire based on modern pain neuroscience assessing Knowledge and Attitudes of Pain (KNAP) was unavailable.

OBJECTIVES

The aim of this study was to develop and test measurement properties of KNAP.

DESIGN

Phase 1; Development of KNAP reflecting modern pain neuroscience and expert opinion. Phase 2; a cross-sectional and longitudinal study among Dutch physiotherapy students.

METHOD

In the cross-sectional study (n = 424), internal consistency, structural validity, hypotheses testing, and Rasch analysis were examined. Longitudinal designs were applied to analyse test-retest reliability (n = 156), responsiveness, and interpretability (n = 76).

RESULTS

A 30-item KNAP was developed in 4 stages. Test-retest reliability: ICC (2,1) 0.80. Internal consistency: Cronbach's α 0.80. Smallest Detectable Difference 90%: 4.99 (4.31; 5.75). Structural validity: exploratory factor analysis showed 2 factors. Hypotheses testing: associations with the Pain Attitudes and Beliefs Scale for Physiotherapists biopsychosocial subscale r = 0.60, with biomedical subscale r = -0.58, with the Neurophysiology of Pain Questionnaire r = 0.52. Responsiveness: 93% improved on KNAP after studying pain education. Minimal Important Change: 4.84 (95%CI: 2.77; 6.91).

CONCLUSIONS

The KNAP has adequate measurement properties. This new questionnaire could be useful to evaluate physiotherapy students' knowledge and attitudes of modern pain neuroscience that could help to create awareness and evaluate physiotherapy education programs, and ultimately provide better pain management.

Association Between Low Back Pain and Biomedical Beliefs in Academics of Physiotherapy

STUDY DESIGN

Observational cross-sectional study.

OBJECTIVE

To analyze the association between low back pain and biomedical beliefs in physiotherapy students of the first and last year.

SUMMARY OF BACKGROUND DATA

There is a hypothesis that the presence of low back pain may be a risk factor for biomedical beliefs in physiotherapy academics.

METHODS

Three hundred sixty-five students of first and last year of the physiotherapy course from three universities in city of Fortaleza completed a questionnaire with sociodemographic factors and a Pain Attitude and Beliefs Scale used to determine the orientation (biopsychosocial or biomedical approach) of practitioners to the management of people with low back pain.

RESULTS

The mean age of participants was 23.57 ± 4.77 years, with a predominance of females (80.27%, n = 239). Approximately 23.84% reported low back pain, 18.9% had undergone imaging tests at the site, and 36.71% reported that family members with low back pain also underwent these examinations. The means of the biopsychosocial subscale of the Pain Attitude and Belief Scale corresponded to 20.19 and 20.63 in the first and last year academics, respectively, whereas the biomedical subscale corresponded to 32.10 and 32.73 in the first and last year academics, respectively. There was no statistical difference between the scores of the first and last year students. Linear regression analyses showed that low back pain was associated with lower levels of biomedical beliefs in the students of the last year (beta coefficient = -2.17, 95% confidence interval = -3.95 to -0.3, P = 0.02). We did not find association between low back pain and levels of biomedical beliefs in academics of both years and with academics of the first year. Also, we did not find association between low back pain and levels of biopsychosocial beliefs.

CONCLUSION

First and last year physical therapy students did not present a difference between biomedical and biopsychosocial beliefs. Although biomedical beliefs were prevalent in both groups, the academics of the last year who had low back pain presented lower levels of biomedical beliefs than the academics of the last year without low back symptoms.

LEVEL OF EVIDENCE

4.

How do physiotherapists understand and interpret the "Pain Attitudes and Beliefs Scale"? A cognitive interview study

Background: The Pain Attitudes and Beliefs Scale (PABS) for physiotherapists aims to differentiate between clinicians' biomedical and biopsychosocial treatment orientations regarding nonspecific low back pain (LBP). Objective: To study the content validity of the Norwegian PABS by following international guidelines: exploring its relevance, comprehensibility and comprehensiveness. Methods: Cognitive interviews were performed using the Three-Step Test Interview, consisting of think-aloud techniques, retrospective probing and in-depth interviews. Eleven Norwegian physiotherapists with a diversity of professional backgrounds participated. Results: The participants encountered little difficulty in completing the PABS. All items were deemed relevant and important but five items had ambiguous formulations which can easily be handled. The biomedical subscale appeared to be a comprehensive representation of biomedical treatment orientation. The biopsychosocial subscale was found to lack items concerning cognitive behavioral aspects of LBP management, such as patient education, therapeutic alliance, shared decision making and graded exposure. Conclusions: This study provides empirical evidence that the Norwegian version of the PABS-PT is relevant and comprehensible, provided some minor adjustments. The biopsychosocial subscale, however, lacks comprehensiveness, as it is not able to capture important aspects of contemporary biopsychosocial best practice care. Measurement of biopsychosocial treatment orientation may therefore be incomplete.

Confidence, attitudes, beliefs and determinants of implementation behaviours among physiotherapists towards clinical management of low back pain before and after implementation of the BetterBack model of care

BACKGROUND

Implementing clinical guidelines is challenging. To facilitate uptake, we developed a model of care (BetterBack Model of Care) and an implementation strategy to support management of low back pain in primary care. The aim of this study was to evaluate physiotherapists´ confidence, attitudes and beliefs in managing patients with low back pain before and after a multifaceted implementation of the BetterBack Model of Care. A further aim was to evaluate determinants of implementation behaviours among physiotherapists.

METHODS

This clinical trial was an experimental before and after study within a hybrid type 2 effectiveness-implementation trial. The primary outcome was Practitioner Self-Confidence Scale (PCS), secondary outcomes were the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PT) and Determinants of Implementation Behaviour Questionnaire (DIBQ). Data was analysed using repeated measures ANOVA and pairwise comparisons.

RESULTS

One hundred sixteen physiotherapists answered a questionnaire before, directly after, as well as 3 and 12 months after implementation of the Model of Care. PCS improved over time with a large effect size post implementation (ηp2 = 0.197, p < 0.001). Changes in PABS-PT were only significant after 12 months with higher biopsychosocial orientation, (ηp2 = 0.071, p < 0.01) and lower biomedical orientation, (ηp2 = 0.136, p < 0.001). Directly after the workshop, after 3 and 12 months, physiotherapists had high ratings on all DIBQ domains, (scores > 50) implying that all were potential facilitators of the implementation. However, after 3 months, all domains had significantly decreased except for organisation, social influence and patient expectation domains. However, after 12 months, organisation and social influence domains had significantly decreased while domains such as knowledge, skills and beliefs about capabilities returned to initial levels.

CONCLUSIONS

Physiotherapists´ confidence and biopsychosocial orientation increased after implementation and may have the potential to improve management of low back pain in primary care. The implementation behaviour showed mostly facilitating patterns but changed over time, pinpointing a need to repeatedly monitor these changes. This can inform the need for changes of implementation efforts in different phases and support sustainability strategies.

TRAIL REGISTRATION

ClinicalTrials.gov NCT03147300 3 May 2017, prospectivly registered.

Behavioral Conceptualization and Treatment of Chronic Pain

Pain is considered a hardwired signal of bodily disturbance belonging to a basic motivational system that urges the individual to act and to restore the body's integrity, rather than just a sensory and emotional experience. Given its eminent survival value, pain is a strong motivator for learning. Response to repeated pain increases when harm risks are high (sensitization) and decreases in the absence of such risks (habituation). Discovering relations between pain and other events provides the possibility to predict (Pavlovian conditioning) and control (operant conditioning) harmful events. Avoidance is adaptive in the short term but paradoxically may have detrimental long-term effects. Pain and pain-related responses compete with other demands in the environment. Exposure-based treatments share the aim of facilitating or restoring the pursuit of individual valued life goals in the face of persistent pain, and further improvements in pain treatment may require a paradigm shift toward more personalized approaches.

Development and evaluation of interprofessional patient simulation activity for physiotherapy and occupational therapy students to assess and manage patients with chronic pain

Background/aims

Opportunities for interprofessional learning are a priority to prepare health professionals for the effective interprofessional assessment and management of patients with chronic pain, yet finding effective and sustainable approaches are a challenge for health professional programmes. The aim of this study was to develop and evaluate an ‘interprofessional management of pain’ learning activity using simulation for physiotherapy and occupational therapy students.

Methods

A total of 40 physiotherapy and 20 occupational therapy students undertook the interprofessional management of pain learning activity. Chronic pain attitudes and beliefs (HC-PAIRS) and perception of interprofessional practice (SPICE-R) were assessed before and following the intervention. A survey relating to content and format of the activity was completed following the intervention.

Results

There was a significant improvement in total HC-PAIRS and SPICE-R scores for both student groups. Both groups demonstrated satisfaction with the activity.

Conclusions

These findings support the use of an interprofessional simulated learning activity with facilitated planning and debriefing to enhance students’ attitudes to chronic pain and interprofessional practice.

Effects of Biopsychosocial Education on the Clinical Judgments of Medical Students and GP Trainees Regarding Future Risk of Disability in Chronic Lower Back Pain: A Randomized Control Trial

Background

Chronic lower back pain (CLBP) is a major health care burden and often results in workplace absenteeism. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions informed by the flags approach, which integrates cognitive and behavioral approaches via identification of biopsychosocial barriers to recovery, have resulted in reduced pain-related work absences and increased return to work for individuals with CLBP. However, research indicates that physicians’ adherence to biopsychosocial guidelines is low.

Objective

The current study examined the effects of a flags approach–based educational intervention on clinical judgments of medical students and general practitioner (GP) trainees regarding the risk of future disability of CLBP patients.

Design

Randomized controlled trial (trial registration number: ISRCTN53670726).

Setting

University classroom.

Subjects

Medical students and GP trainees.

Methods

Using 40 fictional CLBP cases, differences in clinical judgment accuracy, weighting, and speed (experimental N = 32) were examined pre- and postintervention, as were flags approach knowledge, pain attitudes and beliefs, and empathy, in comparison with a no-intervention control group (control N = 31).

Results

Results revealed positive effects of the educational intervention on flags approach knowledge, pain-related attitudes and beliefs, and judgment weighting of psychologically based cues; results are discussed in light of existing theory and research.

Conclusions

Short flags approach–based educational video interventions on clinical judgment-making regarding the risk of future disability of CLBP patients may provide opportunities to gain biopsychosocial knowledge, overcome associated attitude barriers, and facilitate development of clinical judgment-making more aligned with psychological cues.

Evaluation of pain knowledge and attitudes and beliefs from a pre-licensure physical therapy curriculum and a stand-alone pain elective

BACKGROUND

Adequate pain education of health professionals is fundamental in the management of pain. Although an interprofessional consensus of core competencies for health professional pre-licensure education in pain have been established, the degree of their incorporation into physical therapy curriculum varies greatly. The purpose of this study was to 1. Assess students' pain knowledge and their attitudes and beliefs in a pre-licensure physical therapy curriculum using a cross sectional comparison, and 2. Using a sub-sample of this population, we evaluated if an elective course on pain based on International Association for the Study of Pain (IASP) guidelines had an effect on students' knowledge and beliefs.

METHODS

The Neurophysiology of Pain Questionnaire (NPQ) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) was completed by first semester (n = 72) and final (n = 56) semester doctor of physical therapy (DPT) students. Final semester students completed surveys before and after participation in an elective course of their choosing (pain elective (PE) or other electives (OE)).

RESULTS

Participation rate was > 90% (n = 128/140). We found mean differences in NPQ scores between final semester (3rd year) students (76.9%) compared to first semester students (64%), p < 0.001. Third year students showed a mean difference on PABS-PT subscales, showing decreased biomedical (p < 0.001) and increased biopsychosocial (p = 0.005) scores compared to first semester students. Only final semester students that participated in the PE improved their NPQ scores (from 79 to 86%, p < 0.001) and demonstrated a significant change in the expected direction on PABS-PT subscales with increased biopsychosocial (p = 0.003) and decreased biological scores (p < 0.001).

CONCLUSIONS

We suggest that although core pre-licensure DPT education improves students' pain knowledge and changes their attitudes towards pain, taking a IASP based pain elective continues to improve their pain neurobiology knowledge and also further changes their attitudes and beliefs towards pain. Therefore, a stand-alone course on pain in addition to pain concepts threaded throughout the curriculum may help ensure that entry-level DPT students are better prepared to effectively work with patients with pain.

Pain Intensity And Attribution Mediate The Impact Of Patient Weight And Gender On Activity Recommendations For Chronic Pain

BACKGROUND AND PURPOSE

Despite the notable benefits of physical activity for chronic pain, a large proportion of patients with chronic pain report that they do not receive activity-related recommendations from their providers. Research suggests that patient factors such as weight and gender influence activity-related recommendations for chronic pain. Research also suggests that appraisals of the intensity and cause of pain may explain these weight and gender effects. We investigated the influence of patient weight and gender on observers' likelihood of recommending activity-related treatments for pain. We also explored the mediating effects of observers' ratings of pain severity and the extent to which pain was due to medical and lifestyle factors (pain attribution).

PATIENTS AND METHODS

Healthy young adults (N=616; 76% female) viewed videos (Ghent Pain Videos of Daily Activities) and vignettes of 4 patients with chronic back pain performing a standardized functional task. Patients varied by gender (female, male) and weight (normal, obese), but were otherwise equivalent on demographic characteristics and pain behaviors. Participants rated how much pain they perceived the patients to be experiencing, the extent to which they attributed the pain to medical and lifestyle factors, and their likelihood of recommending exercise, physical therapy (PT), and rest.

RESULTS

Patient weight and gender significantly interacted to influence exercise, PT, and rest recommendations. Both pain intensity and pain attribution mediated the relationships between patient weight and activity recommendations; however, these mediation effects differed across gender and recommendation type.

CONCLUSION

Patient weight and gender influenced laypeople's activity recommendations for chronic pain. Moreover, the results suggest that observers' perceptions of pain intensity and pain attributions are mechanisms underlying these effects. If these findings are replicated in providers, interventions may need to be developed to reduce provider biases and increase their recognition of the benefits of physical activity for chronic pain.

Discriminative Validity of the Pain Attitudes and Beliefs Scale for Physical Therapists

BACKGROUND

The Pain Attitudes and Beliefs Scale (PABS) for Physical Therapists aims to measure clinicians' biomedical and biopsychosocial treatment orientations regarding nonspecific low back pain.

OBJECTIVE

The objective of this study was to assess whether the PABS can differentiate between subgroups of physical therapists hypothesized to differ in treatment orientations.

DESIGN

This study was a cross-sectional survey.

METHODS

The PABS was completed by 662 Norwegian physical therapists with a diversity of professional backgrounds. Twenty-four a priori hypotheses on expected differences in PABS scores were formulated. Sufficient discriminative ability was defined as a minimum of 75% confirmed hypotheses. Hypotheses on differences in scores were tested for the biomedical and biopsychosocial subscales separately as well as for combinations of the 2 subscales, representing responders with high biomedical and low biopsychosocial PABS scores and vice versa.

RESULTS

Of the 24 hypotheses, only 15 (62.5%) were confirmed. Between-group differences concerning the separate subscales were small, varying from -0.63 to 1.70 scale points, representing values up to 6.0% of the total subscale ranges. Between-group differences were larger when combined subscales were used, varying from 1.80 to 6.70 points, representing values up to 25.1% of the total subscale ranges. Despite little spread in scores, 24% of respondents demonstrated extreme attitudes.

LIMITATIONS

The lack of convincing scientific evidence from previous research on differences in attitudes and beliefs between physical therapists was a limitation for the formulation of hypotheses.

CONCLUSIONS

Discriminative validity of separate subscales of the PABS was not supported. Combining the 2 subscales into global treatment attitudes enabled better discrimination. Little spread in biomedical and biopsychosocial orientations explains why more than one-third of the hypotheses were not confirmed. Either Norwegian physical therapists are basically similar in their treatment orientation or the PABS is not able to detect any differences between them.

Physiotherapists implicitly evaluate bending and lifting with a round back as dangerous

BACKGROUND

Beliefs can be assessed using explicit measures (e.g. questionnaires) that rely on information of which the person is 'aware' and willing to disclose. Conversely, implicit measures evaluate beliefs using computer-based tasks that allow reduced time for introspection thus reflecting 'automatic' associations. Thus far, physiotherapists' beliefs about back posture and safety have not been evaluated with implicit measures.

OBJECTIVES

(1) Evaluate implicit associations between bending lifting back posture (straight-back vs round-back) and safety (safe vs danger); (2) Explore correlations between implicit and explicit measures of beliefs towards vulnerability of the back.

DESIGN

Exploratory cross-sectional quantitative study.

METHODS

47 musculoskeletal physiotherapists completed explicit measures of fear of movement (TSK-HC), back beliefs (BackPAQ_Danger) and beliefs related to bending and lifting back posture and safety (BSB). An Implicit Association Test (IAT) was used to assess implicit associations between (i) images of people bending/lifting with a 'round-back' or with a 'straight-back' posture, and (ii) words representing 'safety' and 'danger'. A one-sample t-test assessed the degree and direction of the sample's IAT score. Cohen's d provided an effect size of the estimated bias. Correlation between IAT and each explicit measure was assessed using Pearson's coefficient.

RESULTS

The sample displayed an implicit association between 'round-back' and 'danger' (μ = 0.213, 95% CI [0.075-0.350], p = .003), with an effect size magnitude of 0.45. There were fair to moderate correlations between IAT and BSB (r = 0.320, 95% CI [0.036-0.556], p = .029) and, IAT and BackPAQ_Danger (r = 0.413, 95%CI [0.143-0.626], p = .004).

CONCLUSIONS

Physiotherapists displayed an implicit bias towards bending and lifting with a round-back as dangerous.

Translation and psychometric evaluation of the Hebrew version of the Health Care Providers' Pain and Impairment Relationship Scale

BACKGROUND AND PURPOSE

Physiotherapists' different attitudes towards low back pain (LBP) are associated with patients' attitudes towards pain and with patients' disability. The Health Care Providers' Pain and Impairment Relationship Scale (HC-Pairs) is a self-administered instrument that assesses the attitudes and beliefs of health care professionals regarding LBP and the patient's daily function. The aims of this study are to translate, culturally adapt, and asses the psychometric properties of the Hebrew version of the HC-Pairs.

METHODS

The English version of the HC-Pairs was forward-backward translated, pretested, and reviewed by a panel of experts. Reliability was determined by computing Cronbach's α, and validity by exploring the correlations between the HC-Pairs' scores and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) scores. Confirmatory factor analysis was performed. A convenience sample of 277 physiotherapists was invited to fill the HC-Pairs and PABS-PT questionnaires and a sociodemographic questionnaire.

RESULTS

The forward-backward translation process revealed minor discrepancies between the texts. After the pretest, the expert panel agreed on a final version. A sample of 241 physiotherapists completed the questionnaires (response rate of 87%; 241/277); 213 met the inclusion criteria. Factor analysis suggests that the Hebrew version of the scale fits the one-factor model. Cronbach's α was 0.81 after deletion of two items and indicated good internal consistency. The scores produced by the instrument showed a substantial correlation with those of the biomedical dimension of the PABS-PT, and poor correlation with the behavioural dimension, in the expected directions.

CONCLUSION

The findings of the present study on the psychometric properties of the HC-Pairs are positive. Nevertheless, the Hebrew version of the HC-Pairs is still in a developmental stage. Further psychometric research is needed to assess the attitudes and beliefs of Hebrew-speaking physiotherapists, which have been shown to be associated with treatment orientations and work recommendations.

Avoidance, pacing, or persistence in multidisciplinary functional rehabilitation for chronic musculoskeletal pain: An observational study with cross-sectional and longitudinal analyses

Background

Three main activity patterns have been distinguished in describing chronic pain (avoidance, pacing and persistence). However, their influence on patient outcomes remains a question of debate. This observational study aimed to measure the associations between the avoidance, pacing, and persistence (labelled overdoing) scales of the Patterns of Activity Measure–Pain (POAM-P), self-reported outcomes (pain-interference, depression, functional ability), and observational outcomes (walking, lifting test, physical fitness).

Methods

We conducted an observational study with cross-sectional and longitudinal analyses. The data were collected prospectively before and after treatment, which was a 5-week functional rehabilitation including vocational aspects. In addition to self-reported and observational outcomes, patients were asked if they thought they would be able to return to work at 6 months. Analyses were conducted with treatment effect sizes, correlations, and multiple regression models.

Results

In this sample (891 patients), we found on average small to moderate improvements for pain-interference and observational outcomes (Cohen’s d: 0.37 to 0.64). According to the multivariable models, overdoing was associated with most of the beneficial psychosocial and observational outcomes (β -0.13 to 0.17; all p<0.01). Avoidance was related to negative psychosocial outcomes before treatment (β -0.09 to 0.17; all p<0.015). Pacing, which had moderate correlation with avoidance (r = 0.46), was not associated with most of the outcomes. The feeling that the goal of returning to work was attainable was associated with lower avoidance scores (adjusted OR 0.97; p = 0.024).

Conclusions

The overdoing POAM-P scale probably measures a task-contingent persistence, which appears appropriate in the setting of this study. Persistent behavior was indeed related to small or moderate positive biopsychosocial outcomes, before and after treatment. Moreover feeling able to return to work was related to lower avoidance. Further studies should test the efficacy of motivational strategies that may promote functional task-contingent persistence and reduce avoidance of painful tasks.

Investigation of four self-report instruments (FABT, TSK-HC, Back-PAQ, HC-PAIRS) to measure healthcare practitioners' attitudes and beliefs toward low back pain: Reliability, convergent validity and survey of New Zealand osteopaths and manipulative physiotherapists

BACKGROUND

Healthcare practitioner beliefs influence advice and management provided to patients with back pain. Several instruments measuring practitioner beliefs have been developed but psychometric properties for some have not been investigated.

AIMS

To investigate internal consistency, test-retest reliability and convergent validity of the Fear Avoidance Beliefs Tool (FABT), the Tampa Scale of Kinesiophobia for Health Care Providers (TSK-HC), the Back Pain Attitudes Questionnaire (Back-PAQ), and the Health Care Pain and Impairment Relationship Scale (HC-PAIRS). A secondary aim was to explore beliefs of New Zealand osteopaths and physiotherapists regarding low back pain.

METHOD

FABT, TSK-HC, Back-PAQ, and HC-PAIRS were administered twice, 14 days apart.

RESULTS

Data from 91 osteopaths and 35 physiotherapists were analysed. The FABT, TSK-HC and Back-PAQ each demonstrated excellent internal consistency, (Cronbach's α = 0.92, 0.91, and 0.91 respectively), and excellent test-retest reliability (lower limit of 95% CI for intraclass correlation coefficient >0.75). Correlations between instruments (Pearson's r = 0.51 to 0.77, p < 0.001) demonstrated good convergent validity. There was a medium to large effect (Cohen's d > 0.47) for mean differences in scores, for all instruments, between professions.

CONCLUSIONS

This study found excellent internal consistency, test-retest reliability and good convergent validity for the FABT, TSK-HC, and Back-PAQ. Previously reported internal consistency, test-retest and convergent validity of the HC-PAIRS were confirmed, and test-retest reliability was excellent. There were significant scoring differences on each instrument between professions, and while both groups demonstrated fear avoidant beliefs, physiotherapist respondent scores indicated that as a group, they held fewer fear-avoidant beliefs than osteopath respondents.

Are They Complying? Physicians' Knowledge, Attitudes, and Readiness to Change Regarding Low Back Pain Treatment Guideline Adherence

STUDY DESIGN

Cross-sectional survey of 145 primary care practitioners (PCPs).

OBJECTIVE

To examine low back pain (LBP) guideline knowledge, readiness to implement (RTI) these guidelines, and LBP attitudes and beliefs among Israeli PCPs and determine whether physician age, guideline familiarity, and medical specialty affect these variables.

SUMMARY OF BACKGROUND DATA

LBP is a common condition managed primarily by PCPs. Little is known, however, about physician's LBP knowledge, attitudes, and beliefs and how these factors (knowledge, A&B) influence their practice behavior. Knowledge, attitudes, and beliefs of PCPs have been shown to influence the course of their patients' LBP, and guidelines were devised in an attempt to improve the effectiveness and quality of LBP care. Research worldwide and in Israel has shown that LBP guideline implementation is not yet optimal.

METHODS

Participants completed a questionnaire. Variables were measured using a translated, validated version of the Health Care Providers' Pain and Impairment Relationship Scale; demographic and professional characteristics were analyzed for correlation with the outcome variables.

RESULTS

The likelihood of PCPs having nonguideline-consistent attitudes and beliefs (A&B) was greater among those older than 50 years (P < 0.05). Family medicine specialists (family practitioners [FPs]) were more likely to have a high level of guideline knowledge as compared to nonfamily medicine specialists (general practitioners (83.8 vs. 61.9, respectively; P < 0.001). Differences between FPs and general practitioners were also observed for the mean Health Care Providers' Pain and Impairment Relationship Scale score (34.6 vs. 41.1, respectively, P = 0.00), indicating a higher consistency of attitudes and beliefs with guidelines among FPs. No significant association was found between PCPs' knowledge level and RTI the guidelines.

CONCLUSION

The present study showed that PCPs, especially FPs, had high levels of LBP guideline knowledge, although RTI was limited. The need for greater exposure to and understanding of the importance of implementation of LBP guidelines is essential for future guideline adherence.

LEVEL OF EVIDENCE

3.

Quiet dissent: The attitudes, beliefs and behaviours of UK osteopaths who reject low back pain guidance - A qualitative study

INTRODUCTION

Clinical guidelines are derived from best research evidence and aim to: improve quality of non-specific low back pain (nsLBP) management and identify patients at risk of suffering chronic pain. However, guideline discordant attitudes and beliefs have been identified in healthcare students and practitioners, including osteopaths.

DESIGN

A qualitative approach with elements of grounded theory was used to explore underlying attitudes and beliefs of practitioners/students working in a British osteopathic education institution. All participants rejected guideline recommendations for managing nsLBP. A constant comparative method was used to code and analyse emergent themes from transcript data.

SUBJECTS

Purposive sampling identified 5 clinic tutors and 7 students; all participated in semi-structured interviews.

INTERPRETATION

Our central theme was a 'Precedence of Osteopathy' over medicine and other manual therapies. Three subthemes were: 1) beliefs about self; 2) perceptions of others; 3) attitudes to guidelines and research.

CONCLUSION

Participants possess a strong professional identity fostered by their education. This bestows autonomy, authority and distinctness upon them. The central theme was modelled as a lens through which participants viewed research: the evidence pyramid appears inverted, explaining why participants value expert opinion above all other evidence. Guidelines and research are perceived to threaten professional identity. In contractual situations that oblige practitioners to follow guidelines management, perhaps reflecting a pragmatic response to health-care market forces, clinical practice is modified. Developing further understanding of osteopaths' attitudes and beliefs and behaviour in respect of evidence-based guidance in education is important to enhance the quality of clinical practice in osteopathy.

Using mixed methods evaluation to assess the feasibility of online clinical training in evidence based interventions: a case study of cognitive behavioural treatment for low back pain

BACKGROUND

Cognitive behavioural (CB) approaches are effective in the management of non-specific low back pain (LBP). We developed the CB Back Skills Training programme (BeST) and previously provided evidence of clinical and cost effectiveness in a large pragmatic trial. However, practice change is challenged by a lack of treatment guidance and training for clinicians. We aimed to explore the feasibility and acceptability of an online programme (iBeST) for providing training in a CB approach.

METHODS

This mixed methods study comprised an individually randomised controlled trial of 35 physiotherapists and an interview study of 8 physiotherapists. Participants were recruited from 8 National Health Service departments in England and allocated by a computer generated randomisation list to receive iBeST (n = 16) or a face-to-face workshop (n = 19). Knowledge (of a CB approach), clinical skills (unblinded assessment of CB skills in practice), self-efficacy (reported confidence in using new skills), attitudes (towards LBP management), and satisfaction were assessed after training. Engagement with iBeST was assessed with user analytics. Interviews explored acceptability and experiences with iBeST. Data sets were analysed independently and jointly interpreted.

RESULTS

Fifteen (94 %) participants in the iBeST group and 16 (84 %) participants in the workshop group provided data immediately after training. We observed similar scores on knowledge (MD (95 % CI): 0.97 (-1.33, 3.26)), and self-efficacy to deliver the majority of the programme (MD (95 % CI) 0.25 (-1.7; 0.7)). However, the workshop group showed greater reduction in biomedical attitudes to LBP management (MD (95 % CI): -7.43 (-10.97, -3.89)). Clinical skills were assessed in 5 (33 %) iBeST participants and 7 (38 %) workshop participants within 6 months of training and were similar between groups (MD (95 % CI): 0.17(-0.2; 0.54)). Interviews highlighted that while initially sceptical, participants found iBeST acceptable. A number of strategies were identified to enhance future versions of iBeST such as including more skills practice.

CONCLUSIONS

Combined quantitative and qualitative data indicated that online training was an acceptable and promising method for providing training in an evidence based complex intervention. With future enhancement, the potential reach of this training method may facilitate evidence-based practice through large scale upskilling of the workforce.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82203145 (registered prospectively on 03.09.2012).

Effectiveness of a biopsychosocial e-learning intervention on the clinical judgements of medical students and GP trainees regarding future risk of disability in patients with chronic lower back pain: study protocol for a randomised controlled trial

INTRODUCTION

Chronic lower back pain (CLBP) is a major healthcare problem with wide ranging effects. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions that identify biopsychosocial barriers to recovery have been observed to lead to successfully reduced pain-related work absences and increased return to work for individuals with CLBP. Modern conceptualisations of pain adopt a biopsychosocial approach, such as the flags approach. Biopsychosocial perspectives have been applied to judgements about future adjustment, recovery from pain and risk of long-term disability; and provide a helpful model for understanding the importance of contextual interactions between psychosocial and biological variables in the experience of pain. Medical students and general practitioner (GP) trainees are important groups to target with education about biopsychosocial conceptualisations of pain and related clinical implications.

AIM

The current study will compare the effects of an e-learning intervention that focuses on a biopsychosocial model of pain, on the clinical judgements of medical students and trainees.

METHODS AND ANALYSIS

Medical student and GP trainee participants will be randomised to 1 of 2 study conditions: (1) a 20 min e-learning intervention focused on the fundamentals of the flags approach to clinical judgement-making regarding risk of future pain-related disability; compared with a (2) wait-list control group on judgement accuracy and weighting (ie, primary outcomes); flags approach knowledge, attitudes and beliefs towards pain, judgement speed and empathy (ie, secondary outcomes). Participants will be assessed at preintervention and postintervention.

ETHICS AND DISSEMINATION

The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Ireland Galway Research Ethics Committee. The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN53670726; Pre-results.

Brief psychologically informed physiotherapy training is associated with changes in physiotherapists' attitudes and beliefs towards working with people with chronic pain

This study aimed to investigate the impact of a brief psychologically informed physiotherapy training (PIPT) course on physiotherapists' attitudes and beliefs towards working with people with chronic pain. Specifically, the training aimed to help the participants better recognise the role of psychosocial factors in chronic pain and to better target the key processes of the psychological flexibility (PF) model in their treatment interactions. A total of 26 physiotherapists working in an outpatient musculoskeletal (MSK) department participated in the 7-hour training session. A total of 25 participants completed self-report questionnaires on attitudes and beliefs, burnout and PF-relevant processes pre- and post-training. The pre- and post-measures were completed on the day of training. PIPT was associated with significant changes in the expected direction in physiotherapists' attitudes towards treatment of people with chronic pain, including a moderate effect size on the Health Care Provider-Pain and Impairment Relationship Scale (HC-PAIRS) (decreased biomedical scores) and a large effect size on the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) (increased biopsychosocial scores and decreased biomedical scores). In conclusion, brief PIPT could help physiotherapists working in non-specialist centres with complex patients, many of whom present with significant emotional distress and pain-related disability. Further research is required to determine whether the changes in attitudes detected in this study translate into clinical practice and whether changes are maintained over a follow-up period.

Patient satisfaction with treatment for alcohol use disorders: comparing patients with and without severe mental health symptoms

BACKGROUND

Previous studies suggest patients with co-occurring alcohol use disorders (AUDs) and severe mental health symptoms (SMHS) are less satisfied with standard AUD treatment when compared to patients with an AUD alone. This study compared patient satisfaction with standard AUD treatment among patients with and without SMHS and explored how standard treatment might be improved to better address the needs of these patients.

METHODS

Eighty-nine patients receiving treatment for an AUD either at an inpatient hospital, outpatient clinic, inpatient detoxification, or residential/therapeutic community services were surveyed. Patient satisfaction with treatment was assessed using the Treatment Perception Questionnaire (range: 0-40). Patients were stratified according to their score on the Depression Anxiety Stress Scale. Forty patients scored in the extremely severe range of depression (score >14) and/or anxiety (score >10) (indicating SMHS) and 49 patients did not. An inductive content analysis was also conducted on qualitative data relating to areas of service improvement.

RESULTS

Patients with SMHS were found to be equally satisfied with treatment (mean =25.10, standard deviation =8.12) as patients with an AUD alone (mean =25.43, standard deviation =6.91). Analysis revealed that being an inpatient in hospital was associated with reduced treatment satisfaction. Patients with SMHS were found to be significantly less satisfied with staffs' understanding of the type of help they wanted in treatment, when compared to patients with AUDs alone. Five areas for service improvement were identified, including staff qualities, informed care, treatment access and continuity, issues relating to inpatient stay, and addressing patients' mental health needs.

CONCLUSION

While findings suggest that AUD treatment services adequately meet the needs of patients with SMHS in treatment, patients with SMHS do feel that staff lack understanding of their treatment needs. Findings have important implications as to how current health care practice might be improved according to the patient's perspective of care.

Influence of Physical Therapists' Kinesiophobic Beliefs on Lifting Capacity in Healthy Adults

BACKGROUND

Physical therapists' recommendations to patients to avoid daily physical activity can be influenced by the therapists' kinesiophobic beliefs. Little is known about the amount of influence of a physical therapist's kinesiophobic beliefs on a patient's actual lifting capacity during a lifting test.

OBJECTIVE

The objective of this study was to determine the influence of physical therapists' kinesiophobic beliefs on lifting capacity in healthy people.

DESIGN

A blinded, cluster-randomized cross-sectional study was performed.

METHODS

The participants (n=256; 105 male, 151 female) were physical therapist students who performed a lifting capacity test. Examiners (n=24) were selected from second-year physical therapist students. Participants in group A (n=124) were tested in the presence of an examiner with high scores on the Tampa Scale of Kinesiophobia for health care providers (TSK-HC), and those in group B (n=132) were tested in the presence of an examiner with low scores on the TSK-HC. Mixed-model analyses were performed on lifting capacity to test for possible (interacting) effects.

RESULTS

Mean lifting capacity was 32.1 kg (SD=13.6) in group A and 39.6 kg (SD=16.4) in group B. Mixed-model analyses revealed that after controlling for sex, body weight, self-efficacy, and the interaction between the examiners' and participants' kinesiophobic beliefs, the influence of examiners' kinesiophobic beliefs significantly reduced lifting capacity by 14.4 kg in participants with kinesiophobic beliefs and 8.0 kg in those without kinesiophobic beliefs.

LIMITATIONS

Generalizability to physical therapists and patients with pain should be studied.

CONCLUSIONS

Physical therapists' kinesiophobic beliefs negatively influence lifting capacity of healthy adults. During everyday clinical practice, physical therapists should be aware of the influence of their kinesiophobic beliefs on patients' functional ability.

[Health care professionals' attitudes and beliefs towards older back pain patients. Analysis of the assessment methods and research gaps]

In recent years, the influence of doctors' and therapists' attitudes and beliefs for the treatment of chronic low back pain patients has been increasingly investigated. Attitudes and beliefs of health care providers have been identified as important contributors for an activity based, guideline-oriented therapeutic approach and different questionnaires were developed to evaluate this interaction. Recent reviews discuss the quality of those questionnaires as well as the impact of attitudes towards therapeutic choices and activity recommendations by health care professionals. This article summarizes these results and illuminates transferability of existing questionnaires to older patients with back pain. A literature review shows that most studies were conducted with physiotherapists and general practitioners. At present the most thoroughly investigated tool for its psychometric validity is the Pain Attitudes and Beliefs Scale (PABS). The PABS could be a suitable instrument for examinations regarding therapist attitudes towards older pain patients by using more age-neutral wording. Concluding from the literature, an additional methodological assessment tool could be the utilization of case vignettes. However, those case vignettes, which had been used in studies in England, should be translated and culturally adapted before its application in Germany. Overall, it must be assumed that attitudes and beliefs of clinicians are also important in the care of older patients in pain. With regards to activity recommendations, ageism and the special situation of older people should also be taken into account including possible risk of falling, multimorbidity, polypharmacy, and cognitive impairment. These topics should all be considered in adapted or newly developed questionnaires for the evaluation of attitudes and beliefs of health care providers regarding back pain in older persons.

Assessing knowledge, perceptions and attitudes to pain management among medical and nursing students: a review of the literature

INTRODUCTION

Chronic pain results in significant personal, societal and economic burden. Doctors and nurses have a pivotal role in patient pain management. In order to determine the effectiveness of current pain education on knowledge, attitudes and perceptions of medical and nursing students, there needs to be a valid measure to assess and quantify these domains. We reviewed the literature to identify approaches for assessing knowledge, perceptions and attitudes to pain management among nursing and medical students.

METHODS

Databases of peer-reviewed literature including CINAHL, EMBASE, ERIC, PsycInfo, Medline and PubMed were searched for articles published between 1993 and December 2014 using the following search terms: student, graduate, intern, junior, pain, pain management, analgesia, analgesic, pharmacology, pharmacological, knowledge, competence, attitude, preparedness, practice, nursing, medical, doctor, nurse.

RESULTS

The search revealed over 3500 articles, and on application of the inclusion criteria, 26 articles were included in the review. A total of 14 instruments were used in these studies with the Knowledge and Attitudes Survey Regarding Pain (KASRP) as the main instrument in 9 out of the 26 articles. The various instruments used different question formats such as multiple-choice questions (MCQs), true/false statements and Likert scales that went from 3 points to 7 points. Clinical skills examinations were also used in four studies to assess pain management.

CONCLUSION

There is no gold standard instrument currently used to assess knowledge, perceptions and attitudes to pain management. The results of this review showed, despite the diversity of standardised instruments that have been used to assess knowledge, perceptions and attitude to pain management, the literature has consistently reported that knowledge about pain management among nursing and medical students was generally poor among both groups.