Education of Municipality-based Physiotherapists in Managing Disabling Low Back Pain - an Observational Study
Conditions: Low Back Pain
Sponsor: Aalborg University Hospital

 
 
 
 
 
 
 
 
 
Education of Municipality-based Physiotherapists in Managing 
Chronic Low Back Pain - an Observational Study 
 
 
 
 
Date  
March 20th 2023  
 
 
 
Ethical committee reference number  
S-20222000 - 156 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Objective 
To investigate potential changes in patient outcomes following an educational intervention aimed 
at upskilling physiotherapists in individualized bio-psycho-social management of patients with 
disabling low back pain (dLBP) in municipality rehabilitation settings. Focus will both be on changes 
in patient reported outcomes as well as changes in clinician behavior. Likewise, the feasibility of 
implementing such changes within municipality settings will be evaluated 
 
 
Method 
Design 
A prospective, observational case-control study  
 
Participants 
Patients with dLBP referred to municipality-based rehabilitation from the Spine Centre of Southern 
Denmark. Eligibility is determined on the following criteria: 
Inclusion Criteria: 
• 
  Referred to municipality rehabilitation from the Spine Centre of Southern Denmark 
• 
  Over 18-65 years 
• 
  Speaks and comprehends Danish 
• 
  A score over 40 on the Örebro Musculoskeletal Pain Questionnaire 
• 
Low back pain as dominating cause for referral 
• 
Can receive digital mail in E-boks (electronic communication platform) 
Exclusion Criteria: 
• 
A current diagnosis of psychiatric illness that precludes participation in rehabilitation 
• 
a neurologic disorder or other disease that may affect the ability to participate in a municipality-
based rehabilitation program 
• 
neurological deficits related with radiographically confirmed lumbar spinal stenosis or radicular pain 
correlating with the clinical presentation 
• 
Recent (within 6 months) history of a stabilizing operation of the low back 
 
 
Procedures 
Data collection:  
All demographic information will be collected at baseline. This includes age, gender, weight, 
smoking (yes/no), diagnosis, duration of symptoms, job status (Working Yes/No. If Yes: normal 
capacity or reduced capacity because of back pain. If No: Full-time sick-listed because of back pain 
or sick-listed due to other reasons) if early retirement: due to back pain?), highest completed 
education beyond elementary school)  
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Schedule of procedures and assessments (for a schematic overview, see fig. 1) 
1. All participating physiotherapists (N=25) will recruit eligible patients (N=4 each, total N=100) 
who are asked to fill out project-specific questionnaires (see procedures) at the start and at 
the end of the rehabilitation program.   
2. The participating physiotherapists will undergo a 13-day educational intervention (see 
description below under intervention) focusing on management of low back pain within an 
individualized multidimensional framework.  
3. Point 1 is repeated on an additional 100 patients who undergo rehabilitation after the 
physiotherapists have completed the course 
4. Participating physiotherapists will be evaluated on the background of a competency 
checklist which is scored by clinical supervisors connected to the study. The checklist will be 
scored after watching a video recording of a patient consultation performed by the 
physiotherapist in focus. The checklist covers 6 domains: Subjective and objective 
assessment, cognitive-functional therapy intervention, style of communication, patient's 
unhelpful pain behavior, and an overall assessment 
5. Physiotherapists who demonstrate high and low competency (as determined by the 
evaluation of competency, point 4) are invited to participate in a semi-structured interview. 
The interview will explore the physiotherapists' experience of changes in management (if 
Primary Outcome 
Roland Morris Disability Questionnaire 3 months after entering the study 
Secondary outcomes 
• 
Pain intensity (lower back and leg) 3 months after entering the study with a numeric rating 
scale (NRS:0-10) 
• 
Örebro Musculoskeletal Pain Questionnaire 3 months after entering the study 
• 
Self-perceived ability to work (NRS: 0-10) 3 months after entering the study 
• 
Patient satisfaction, 7-point Likert scale 3 months after entering the study 
Other Pre-specified Outcome Measures: 
• 
Checklist to determine the competency of clinicians immediately after study completion 
• 
Barriers and facilitators for implementing new knowledge in clinical practice – qualitative 
interview 
3 month follow-up 
• 
Roland Morris Disability Questionnaire at 3 months after discharge 
• 
Pain intensity (lower back and leg) with a numeric rating scale (NRS:0-10) 
• 
Self-perceived ability to work (NRS: 0-10)  
• 
Patient Assessment of Transitions in Healthcare (PATH) 
• 
Patient satisfaction, 7-point Likert scale 
Other Pre-specified Outcome Measures: 
• 
Checklist to determine the competency of clinicians and to assess interrater reliability 
between clinical supervisors 
• 
Barriers and facilitators for implementing new knowledge in clinical practice – qualitative 
interview 

any) after the educational intervention. This includes challenges, barriers and facilitating 
factors. 
 
 
Intervention 
All procedures will be based on the physiotherapists assessment where individual needs and goals 
are embedded into the rehabilitation. The project will investigate whether priorities within 
assessment and choice of management change after the educational intervention. The educational 
program for the physiotherapists will run over 13 days and is divided into 3 overlapping modules.  
 
 
Module 1 (5 days) – Evidence-based theory  
The module will focus on theoretical and practical aspects of the management of patients with back 
pain within a multidimensional framework. This includes differential diagnostics, social medicine 
measures, communication training with a focus on motivational interview and management of 
patients with dominant cognitive and emotional factors. 
An evidence-based overview of contributing factors to the pain experience will be addressed 
including lifestyle, emotions, cognitions, response to pain including protective movement strategies, 
co-morbidity, activity level, physical/mental stress, patho-anatomy, nervous system sensitivity and 
social factors. 
 
 
Module 2 (3 days) – Masterclass 
Masterclass in where two experienced clinicians from the project group will demonstrate patient 
examinations and management of complex low back patients. The purpose is to help the 
participants gain insight into clinical application of relevant multi-dimensional management of dLBP. 
These demonstrations provide the platform for the following module 3.  
 
 
Module 3 (5 days) – Clinical supervision 
In the supervision sessions the participants receive training/guidance in integrating the theoretical 
and practical skills from the previous modules. Feedback/evaluation from supervisors ensures that 
the participants adapt a multi-dimensional perspective in their patient management. Competency 
is tested here 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
Figure 1 A schematic overview of the project timeline  

Statistics 
Statistical analysis will be performed using the appropriate statistical method according to the 
specific aims investigated. All demographic variables will be presented as means (± standard 
deviations), median [Interquartile range], or ratio (%) depending on type and distribution of data.  
All primary and secondary outcomes will be analysed using paired tests (parametric or non-
parametric based on normality), comparing baseline data and data 3 months after study start.  
The sample size calculation is based on the previous findings of Ussing et al (2020)1 which 
included a similar population and was conducted in a specialist spine clinic in a secondary setting.  
Based on these findings, we expect to find a 30% group difference in disability in favor of the post-
education group. With a mean of 36 (SD 18) pre-intervention and 28 (SD 18) post-intervention, we 
expect that N=100 participants in each group will be sufficient to achieve an alpha level of 0.05 with 
a 0.8 power assuming a 10-15% dropout-out rate.   
 
Ethical considerations 
Participation in the study does not imply any risks for the patients. All study related procedures are 
either clinically indicated or do not come with any risk or harm. The patient needs to spend a little 
extra time filling out project-specific questionnaires as compared with standard care.  The overall 
burden of participating is outweighed by the potential gain. This study is conducted in full 
conformance with the principles of the Helsinki Declaration. However, the project falls outside the 
scope of the ethical committee (regional and national) in Denmark as it falls under quality assurance.  
 
 
1 https://pubmed.ncbi.nlm.nih.gov/32221554/