Elsevier

Musculoskeletal Science and Practice

Volume 39, February 2019, Pages 107-114
Musculoskeletal Science and Practice

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

https://doi.org/10.1016/j.msksp.2018.12.002Get rights and content

Highlights

  • Physiotherapists generally reported mixed beliefs about bending posture and safety.

  • Physiotherapists displayed implicit associations between round-back bending and danger.

  • There was some concordance between explicit and implicit measures of beliefs.

  • This implicit bias may influence physiotherapists recommendations in practice.

Abstract

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 (BackPAQDanger) 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 BackPAQDanger (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.

Introduction

Beliefs that the back is vulnerable, and requires protection are common among people with (Darlow et al., 2015; Bunzli et al., 2015) and without (Munigangaiah et al., 2016; Darlow et al., 2014a; Briggs et al., 2010; Gross et al., 2006) LBP. Encounters with health care clinicians such as physiotherapists, who provide advice about LBP, are thought to play a role in the development of such societal beliefs (Darlow et al., 2013). Several studies have investigated beliefs of clinicians towards LBP (Synnott et al., 2015; Darlow, 2016; Bishop et al., 2007; Coudeyre et al., 2006). Despite limited evidence (Dreischarf et al., 2016; Roffey et al., 2010; Bazrgari et al., 2007), clinicians share the view that ‘improper’ posture (e.g. round-back) while bending and lifting is dangerous for the back (Synnott et al., 2015; Stevens et al., 2016; Darlow et al., 2012; Nijs et al., 2013), and possibly one of the causes of LBP (Synnott et al., 2015; Stevens et al., 2016; Darlow et al., 2012; Nijs et al., 2013). Specifically, physiotherapists have self-reported a perception of the back as vulnerable and a belief that adopting straight-back postures is safest (Nolan et al., 2018). Physiotherapist’ beliefs can strongly influence their advice to patients, potentially fuelling unhelpful protective and/or avoidance behaviours (Darlow et al., 2013; Darlow et al., 2012; Bishop et al., 2008; Vlaeyen and Linton, 2006; O'Sullivan et al., 2016). For example, Lakke et al. (2015) found that healthy adults' lifting capacity was significantly reduced when examined by physiotherapy students with high fear-avoidant beliefs (Lakke et al., 2015). Clinicians who hold such beliefs are also less likely to adopt evidence-based treatments (Coudeyre et al., 2006; Darlow et al., 2012). Not surprisingly, it has been proposed that disability associated with LBP may be in part iatrogenic (Darlow et al., 2013; Lin et al., 2013).

Beliefs can be assessed via explicit and implicit measures. Studies assessing beliefs of clinicians typically employed explicit measures (e.g. self-reported questionnaires (Darlow et al., 2014b; George et al., 2009; Houben et al., 2004)), which evaluate beliefs that are deliberately formed upon reflection. However, explicit measures are sensitive only to what people are aware of and are willing to disclose (Nosek et al., 2011; Fazio and Olson, 2003; Greenwald et al., 1998). Implicit measures on the other hand, assess beliefs based on ‘automatic’ associations in memory (e.g. bending posture and danger). These associations can be assessed via computer-based reaction-time tests, which reduce the person's ability to control their response, minimizing effects of social desirability (Greenwald et al., 1998; Gawronski and Bodenhausen, 2006). The Implicit Association Test (IAT), is a well-validated and extensively used measure (Greenwald et al., 2003; Harvard, 2011), which requires the person to associate words or images as quickly and as accurately as possible (Greenwald et al., 1998; Van Ryckeghem et al., 2013). The speed with which the person performs the task reflects the strength of the associations, and can indicate the degree of implicit bias (Nosek et al., 2011). Depending on factors such as time and context (Nosek et al., 2011; Fazio and Olson, 2003; Greenwald et al., 1998), implicit biases can influence behaviour (Nosek et al., 2011; Greenwald et al., 2009; Sabin and Greenwald, 2012) in a manner that a person may not be aware of (Greenwald et al., 1998; Gawronski et al., 2006).

Considering physiotherapists often make clinical decisions under contexts of pressure (e.g. consultation time, patient's expectations and distress), an implicit bias may influence their advice to patients with LBP on bending and lifting posture (Houben et al., 2005a). Thus far, physiotherapists' implicit associations between back posture and safety have not been investigated. Based on studies assessing explicit beliefs about bending/lifting (Darlow et al., 2014a, 2015; Nolan et al., 2018), we hypothesised that i) physiotherapists would display an implicit bias towards evaluating bending and lifting with a round-back as dangerous, and ii) this bias would correlate only moderately with their explicit beliefs. Therefore, the aims were:

  • 1)

    To evaluate implicit associations (IAT) between bending and lifting back posture (straight-back vs round-back) and safety (safe vs danger) in physiotherapists;

  • 2)

    To explore correlations between implicit (IAT) and explicit measures of beliefs towards vulnerability of the back (bending safety beliefs, back beliefs, and fear of movement).

Section snippets

Design

This was an exploratory cross-sectional quantitative study.

Participants and recruitment

This study used a sample of convenience. Potential participants were recruited in the period of April to June 2016 via email, phone call (to place of work) or approached in person by one of the investigators for participation in this study. Inclusion criteria: Physiotherapists, who were currently registered with the Australian Health Practitioners Registration Authority (AHPRA), practicing in the metropolitan area of Perth (Western

Participants

Data was collected for 51 participants; four participants were excluded due to difficulties understanding the words of the IAT (1), or breaching the test protocol (3) – e.g. asking for instructions during the test, being disrupted during the test. Forty-seven data sets were included in the analysis, and there was no missing data for any of the participants. Participants' demographic characteristics are summarized in Table 2.

Implicit measure

The mean IATD-score was 0.213 (SD = 0.470) and significantly larger

Discussion

This study aimed to evaluate physiotherapists' implicit associations between bending and lifting back posture (straight-back vs. round-back) and safety (safe vs. danger); and whether the implicit measure correlated with explicit measures of beliefs towards vulnerability of the back (bending safety beliefs, back beliefs, and fear of movement).

Our first hypothesis was supported. Results from the implicit measure (IAT), indicate that physiotherapists were faster to associate images of bending and

Conclusion

The current study demonstrated that physiotherapists displayed an implicit bias to associate bending and lifting with a round-back with danger, while generally reporting mixed explicit beliefs about bending safety. There was some concordance between explicit and implicit measures of beliefs. Considering implicit attitudes may influence behaviour, future studies investigating whether this implicit ‘round-back/danger bias’ is associated with physiotherapist's clinical advice on bending and

Authors' contribution

JP Caneiro, Peter O'Sullivan, Anne Smith and Ottmar Lipp provided concept/idea/research design. Ingrid Ovrebekk, Luke Tozer, Michael Williams and Magdalene Teng performed data collection. JP Caneiro, Peter O'Sullivan, Ottmar Lipp, Anne Smith, Ingrid Ovrebekk, and Magdalene Teng provided data analysis. All authors contributed to discussion of results and writing of the manuscript (including review of manuscript before submission).

Acknowledgements

During the execution of this study, JP Caneiro was supported by an Australian Postgraduate Award (APA) and a Curtin University Postgraduate (CUPS) Scholarship.

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