The effects of a brief educational intervention on medical students’ knowledge, attitudes and beliefs towards low back pain

1 Introduction

Low back pain (LBP) is the leading cause of disease burden in Australasia [1] in terms of both disability adjusted life year and years lived with disability. The condition is the leading chronic disease forcing older Australians to retire early from the workforce. It is commonly managed by general practitioners – being the 7th most common reason for a general practitioner (GP) visit in Australia [2, 3].

Several studies highlight a discord between guideline-endorsed recommendations for back pain management and actual practice among Australian physicians, including those with a special interest in LBP [4, 5, 6]. Reports from overseas suggest that inadequate training during medical school on how to examine, diagnose, and manage musculoskeletal conditions [7] could be an important attributing factor. A 2010 Australian study exploring back pain management among primary care physicians showed evidence practice gaps for key aspects of care including referral for imaging, provision of advice and analgesic medicines [3]. A more recent study found that many GPs skip key parts of the clinical assessment e.g. there was 22% compliance with performing a neurological examination, 21% compliance in screening for infection and only 12% compliance in screening for cauda equina syndrome [8].

One explanation for these findings is that there is a gap in back pain education in entry level medical training in Australia. To date, there has been no exploration of medical students’ knowledge, attitudes and beliefs towards LBP or the effectiveness of back pain education in this group. Given the time constraints and demands of medical programmes, there is a need to consider methods of education that would be both time-efficient and effective in relaying evidence-based messages regarding back pain management to medical students. The aim of this study was therefore to investigate first year medical students’ knowledge, attitudes and beliefs towards LBP before and after a brief 15-min educational video presentation on LBP. Prior to the intervention, the students had not received any formal LBP education through the programme.

2 Ethical approval

Ethics approval for this project was obtained from Western Sydney University Human Research Ethics Committee (HREC) Approval No. H9989.

3 Materials and methods

4 Results

A total of 93 medical students completed this study (response rate 97%). The mean age of participants was 20.2 years SD (3.6) and 43% of the cohort were male (n = 43). The distributions of age and gender in this group are broadly representative of medical students in NSW (mean age 24 years, 48.5% male) [15].

5 Key findings

Following the 15–min video on LBP management there was a favourable change in medical students’ knowledge, attitudes and beliefs towards LBP so that it more closely aligned with evidence-based guidelines. This was demonstrated by the significant shift towards correct responses on the post- workshop inevitability score compared with the pre-workshop inevitability score; mean [SD] 20.8 [4.9] and 26.9 [4.2] respectively (lower scores more favourable); mean difference (MD) 6.1, p < 0.001.There was also a marked improvement in post intervention composite score compared with pre-intervention composite score (20.2 [9.2] vs 5.8 [6.9] respectively; (higher composite score favourable) – see Table 2).

Compared with pre-intervention responses, by the end of the intervention there was a large and significant increase in the number of medical students responding correctly to items regarding return to work ‘2. Back trouble will eventually stop you from working’ (35% vs 58%), and the need to exercise the back ‘5. A bad back should be exercised’ (37% vs 61%), ‘18. Encouragement of physical activity is important in the recovery of LBP’ (49% vs 79%). The most notable changes centred around the need for imaging ‘17. X-rays of the lumbar spine are useful in the workup of patients with acute LBP’ (44% vs 74%), recovery ‘12. Once you have had back trouble there is always a weakness’ (25% vs 66%) and the need for bed rest in acute LBP ‘13. Back trouble must be rested’ (41% vs 75%). There was minimal change to attitudes regarding chronicity of LBP ‘14. Later in life back trouble gets progressively worse’ (11% vs 33%). The two items on the value of practice guidelines were answered similarly pre and post the video with most students endorsing their value (see Table 2). There was no significant effect of gender on questionnaire responses (p >0.05).

6 Discussion

This study has shown that medical students’ knowledge, attitudes and beliefs towards LBP improved following a 15–min educational video on the evidence-based management of LBP so that it more closely aligned with messages in LBP guidelines. Importantly following the video presentation the students were much less likely to endorse common misconceptions regarding the need for bed rest and imaging in acute non-specific LBP.

The intervention was relatively short (lasting approximately 15–min), and the findings would suggest that LBP educational interventions do not need to be extensive in order to be effective. A previous study targeting practising pharmacists employed an intervention which lasted 2-hours and yielded results similar to those observed here [12].

Following the video intervention less students held incorrect beliefs regarding bed rest and the need for imaging in acute LBP among medical students. The knowledge that imaging and bed rest can delay recovery in non-specific back pain [16, 17] may serve to inform their clinical decision making once they become practising clinicians. The impact of practitioner beliefs on treatment choices for their patients is well documented in the LBP literature [18, 19], therefore education and training designed to challenge existing beliefs and behaviours may serve to improve back pain care and alleviate the economic burden of this common condition.

A limitation of this study was that it was conducted at only one undergraduate medical school in Australia, therefore the findings may not be representative. The extent to which this favourable shift in knowledge, attitudes and beliefs towards LBP will be retained is also unknown. It is likely this information will need to be revisited, particularly in the latter years of the programme as the students prepare for entry into the workforce. Another limitation is the use of a pre post design which does not provide as robust evidence as a randomised controlled trial. It would also be interesting to replicate this study with practising GPs to see if the 15–min video has the same influence as we saw in this study of medical students.

7 Conclusion

Following a brief educational intervention medical students’ knowledge, attitudes and beliefs towards low back pain improved so that they more closely aligned with guideline endorsed recommendations.

Highlights

• Medical doctors are at the forefront of managing low back pain.

• There is a need to strengthen musculoskeletal education in medical training programmes.

• A brief back pain intervention improved medical students’ attitudes and beliefs towards back pain.

• Following the intervention beliefs regarding bed rest and the need for imaging in acute LBP improved.