Physiotherapy Research International Vol 28 Issue 4

Physiotherapy
VOLUME 28, ISSUE 4 October 2023

ISSN 1471-2865
Research
International
14712865, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pri.1956 by Nat Prov Indonesia, Wiley Online Library on [09/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
EDITOR
PHYSIOTHERAPY Qiang Gao, Sichuan University, China
RESEARCH DEPUTY EDITORS
INTERNATIONAL Karen Grimmer, University of South Australia, Australia
Gail Jensen, Creighton University, Omaha, USA
Gill Arbane, St. George’s University of London, UK
Lotte Janssens, Hasselt University, Belgium
Peter Malliaras, Monash University, Australia
Seng Kwee Wee, Singapore Institute of Technology, Singapore
Shashank Kaushik, Wiley, India
EDITORIAL ADVISORY BOARD
Christine Bithell, St George’s Jennifer Jelsma, University of Kathryn Refshauge, University of
Hospital Medical School, Cape Town, South Africa Sydney, Australia
Kingston University, UK Alice Jones, Hong Kong Fiona Reid, King’s College,
Sandra Brauer, University of Polytechnic University, Kowloon, London, UK
Queensland, Brisbane, Australia Hong Kong Karin Harms Ringdahl,
Andrew Butler, Emory University Lester Jones, La Trobe Karolinska Hospital, Stockholm,
School of Medicine, USA University, Victoria, Australia Sweden
Linda Denehy, University of Gwendolen Jull, University of Katherine Shepard, Temple
Melbourne, Australia Queensland, Brisbane, Australia University, Philadelphia, USA
Lorraine de Souza, Brunel Sheila Kitchen, King’s College,
Margot Skinner, Dunedin,
University, UK London, UK
New Zealand
Janine Dizon, University Bart Koes, Institute for Research in
Tori Smedal, Haukeland
of South Australia, Australia Extramural Studies, Amsterdam,
University Hospital, Norway
Brian Durward, Glasgow The Netherlands
Caledonian University, City Brad Stockert, California State
Stanislav Korobov, Odessa, Ukraine
Campus, Glasgow Gert Kwakkel, VU University University, Sacramento, California,
Jennifer Freeman, University of Medical Centre, Amsterdam, USA
Plymouth, UK The Netherlands André Thevenon, Hôpital
Rachel Garrod, Kings College Sheila Lennon, Flinders University, Gériatrique ‘Les Batliers’, Lille, France
Hospital, London, UK Adelaide, South Australia, Australia Sarah Tyson, University of
Leigh Hale, University of Otago, Alice Nieuwboer, Katholieke Manchester, UK
Dunedin, New Zealand Universiteit, Belgium Steven Wolf, Research Center for
Paul Hodges, University of Gita Ramdharry, St George’s Rehabilitation Medicine, Atlanta,
Queensland, Brisbane, Australia University of London, UK USA
AIMS AND SCOPE
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interventions.
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relevant Clinical and Professional Dilemmas. PRI encourages authors to use the standardized nomenclature such as the WHO
International Classification of Functioning Disability and Health and use of person-first language.
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Cover Image © Monkey Business Images/Shutterstock.
Received: 4 February 2023
DOI: 10.1002/pri.2039
REVIEW
- -
Revised: 10 May 2023 Accepted: 29 June 2023
Devices to measure calf raise test outcomes: A narrative

review
Ma. Roxanne Fernandez1,2 | Kim Hébert‐Losier1
1
Division of Health, Engineering, Computing
and Science, Te Huataki Waiora School of Abstract
Health, University of Waikato, Hamilton, New
Background: The calf raise test (CRT) is commonly administered without a device in
Zealand
2 clinics to measure triceps surae muscle function. To standardise and objectively
Department of Physical Therapy, College of
Rehabilitation Sciences, University of Santo quantify outcomes, researchers use research‐grade or customised CRT devices. To
Tomas, Manila, Philippines
incorporate evidence‐based practice and apply testing devices effectively in clinics,
Correspondence it is essential to understand their design, applicability, psychometric properties,
Ma. Roxanne Fernandez, University of strengths, and limitations. Therefore, this review identifies, summarises, and criti-
Waikato Adams Centre for High Performance,
52 Miro Street, Mount Maunganui, Tauranga cally appraises the CRT devices used in science.
3116, New Zealand. Methods: Four electronic databases were searched in April 2022. Studies that used
Email: mf182@students.waikato.ac.nz
devices to measure unilateral CRT outcomes (i.e., number of repetitions, work,
height) were included.
Results: Thirty‐five studies met inclusion, from which seven CRT devices were
identified. Linear encoder (n = 18) was the most commonly used device, followed by
laboratory equipment (n = 6) (three‐dimensional motion capture and force plate).
These measured the three CRT outcomes. Other devices used were electro-
goniometer, Häggmark and Liedberg light beam device, Ankle Measure for Endur-
ance and Strength (AMES), Haberometer, and custom‐made. Devices were mostly
used in healthy populations or Achilles tendon pathologies. AMES, Haberometer,
and custom‐made devices were the most clinician‐friendly, but only quantified
repetitions were completed. In late 2022, a computer vision mobile application
appeared in the literature and offered clinicians a low‐cost, research‐grade
alternative.
Conclusion: This review details seven devices used to measure CRT outcomes. The
linear encoder is the most common in research and quantifies all three CRT out-
comes. Recent advances in computer‐vision provide a low‐cost research‐grade
alternative to clinicians and researchers via a n iOS mobile application.
KEYWORDS
ankle plantar flexors, assessment, endurance, heel‐rise test, physiotherapy
-
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, pro-
vided the original work is properly cited.
© 2023 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
Physiother Res Int. 2023;28:e2039. wileyonlinelibrary.com/journal/pri 1 of 20

https://doi.org/10.1002/pri.2039
2 of 20
- FERNANDEZ and HÉBERT‐LOSIER
1 | INTRODUCTION (Nordenholm et al., 2022; J. A. Zellers et al., 2020). These CRT

metrics cannot be quantified clinically without a device. However,
The unilateral calf raise test (CRT) is a clinical tool that assesses calf clinicians typically only count the number of repetitions as the
muscle‐tendon unit function (Hébert‐Losier et al., 2009). The test primary outcome. This narrative review aimed to provide an over-
requires individuals to go up on their toes and back down as many view of the CRT devices used in the scientific literature to measure
times as possible standing on one leg and therefore requires repetitive CRT outcomes, namely the number of repetitions, peak height, and
concentric‐eccentric actions of the ankle plantar flexors until voli- total work performed. This review focused on the design, reli-
tional cessation. Clinicians document the total number of repetitions ability, concurrent validity, and perceived strengths and limita-
achieved as the primary outcome (Hébert‐Losier et al., 2009; Luns- tions of these devices for clinical use. It is anticipated that this
ford & Perry, 1995; Ross & Fontenot, 2000). The CRT is therefore narrative review will provide practitioners with a clear under-
considered a clinical‐friendly method to assess calf muscle‐tendon standing of CRT devices potentially available to them for quanti-
unit function that requires neither specialised equipment nor much fying outcomes.
time or space, which is advantageous for field‐based and in‐clinic
testing (André et al., 2016; Haber et al., 2004). The CRT is used
across disciplines, such as paediatrics (Maurer et al., 2007), cardiology 2 | METHODS
(Monteiro et al., 2013), neurology (Svantesson, Osterberg, Grimby, &
Sunnerhagen, 1998), orthopaedics (J. A. Zellers et al., 2020), and 2.1 | Search strategy
geriatric (André et al., 2018). However, Sman et al. (2014) advanced
that using a standardised CRT device and protocol across individuals Even though a narrative review was planned, a systematic process
would be ideal to monitor and replicate outcomes. In science, re- aligning with the Preferred Reporting Items for Systematic Reviews
searchers commonly use devices to assist in standardising the test and Meta‐Analyses (Page et al., 2021) was applied. A systematic
protocol and quantify additional outcomes other than the number of electronic search was conducted on April 9th, 2022, in the following
repetitions completed (Cibulka et al., 2017; Pereira, Schettino, databases: Cochrane, PubMed®, Scopus, Sports Medicine & Educa-
Machado, da Silva, & Neto, 2010; Van Cant et al., 2017). tion Index, and SPORTDiscus. The search terms used were “calf
Indeed, aside from the number of calf raises performed, other CRT raise”, “heel raise”, “heel rise”, “test$”, and “eval$”. The Boolean op-
measures are considered key outcomes and indicators of function; for erators “OR” and “AND” were used to combine the search terms.
example, total (concentric) work and maximum calf raise height during When available, search limiters applied included peer‐reviewed
the CRT are markers of functional recovery post Achilles tendon journal articles, the English language, and humans. The searches
rupture (ATR) (Byrne et al., 2017; Silbernagel et al., 2010; J. A. Zellers implemented for each database are provided in the supplementary
et al., 2020). More specifically, the amount of work completed during materials (Supplemental File S1). References of all studies meeting
the CRT has been shown to be a more sensitive metric in the presence inclusion criteria were screened to identify additional relevant
of ATR than the number of repetitions (Silbernagel et al., 2010), where studies that might have been missed.
work is computed considering calf raise height and body mass dis- The search results were imported into Endnote 20 (Clarivate
placed during repetitions. Given that work considers the positive Analytics, Boston, USA). After removing duplicates, all titles and
displacement of each repetition during the CRT, this measure is abstracts were transferred to Rayyan (Qatar Computing Research
deemed scientifically more rigorous and accurate than the number of Institute, Qatar), a free web application for systematic reviews
repetitions to quantify calf muscle‐tendon unit endurance (Byrne (Ouzzani et al., 2016). In Rayyan, titles and abstracts were
et al., 2017). In terms of peak height during the CRT, this measure screened against the inclusion criteria. The inclusion criteria were
expressed as a ratio of the involved to uninvolved limb (i.e., limb scientific peer‐reviewed original research of any analytical study
symmetry index) at 6‐months post ATR predicted patient‐reported design (i.e., observational or experimental) as defined by the Ox-
symptoms and physical activity levels at 12‐months as quantified us- ford Centre for Evidence‐Based Medicine (i) published in English;
ing the Achilles tendon Total Rupture Score (Olsson et al., 2014). (ii) that used the unilateral CRT (i.e., repeated concentric‐eccentric
Furthermore, both total work and peak height during the CRT have plantar‐flexor actions in unilateral stance to volitional cessation);
been identified as more sensitive metrics of residual impairments than and (iii) measured CRT outcomes using equipment (e.g., motion
the total number of repetitions at 6‐ and 12‐months post ATR. Spe- capture system, force plate, linear encoder, custom devices, or any
cifically, repetitions identified the percentage of patients with normal other device). Exclusion criteria were (i) editorials, commentaries,
function (defined as the limb symmetry index reaching 90% or higher) discussion papers, conference abstracts, and reviews; (ii) studies
as 38% and 63% at 6‐ and 12‐months, respectively. Comparatively, that did not describe their methods; and (iii) studies where uni-
these figures based on the limb symmetry index were 9% and 23% lateral CRT outcomes to volitional cessation were not assessed. All
when considering total work, and 6% and 22% when considering peak studies that met inclusion were retrieved in full text, and their
height (Silbernagel et al., 2010). eligibility criteria were assessed. A single reviewer (XXXX) con-
Hence, total work and peak height during the CRT are ducted all the screenings, which was verified by a second reviewer
deemed important measures of calf muscle‐tendon unit function (XXXX).
FERNANDEZ and HÉBERT‐LOSIER
- 3 of 20
2.2 | Data extraction and synthesis Of all the measuring devices, the linear encoder was used most
frequently in studies (n = 18, 51.4%) (Andreasen et al., 2020; Arch
Relevant information was extracted from each included paper in a et al., 2018; Annelie Brorsson et al., 2018; A. Brorsson et al., 2021; A.
custom‐made Excel (Microsoft Office, Microsoft, Redmond, WA, Brorsson et al., 2017; Byrne et al., 2017; Hamrin et al., 2020; Nor-
USA) data extraction form. The following data were extracted from denholm et al., 2022; Olsson et al., 2014; Silbernagel et al., 2015; Sil-
each study: authors, publication year, study location (based on where bernagel et al., 2006; Silbernagel et al., 2010; Silbernagel et al., 2012;
data were collected when stated explicitly or institutional ethics Svensson et al., 2019; Westin et al., 2018; Zellers et al., 2018; J. A.
approval), study aims, participant characteristics (i.e., healthy or Zellers et al., 2020; J. A. Zellers et al., 2017), followed by a 3D motion
pathologic population, age, gender, body mass, and height), CRT de- capture with (n = 4, 11.4%) (Hébert‐Losier et al., 2011; Hébert‐Los-
vice, and CRT outcomes (i.e., number of repetitions, peak height, and ier & Holmberg, 2013; Nawoczenski et al., 2016; Tengman et al., 2015)
work). In addition, data on the reliability of the identified CRT devices or without (n = 2, 5.7%) (Hébert‐Losier et al., 2011, 2012) force plate.
(i.e., test‐retest, intra‐rater, and inter‐rater) and their concurrent Four studies (11.4%) used the electrogoniometer alone (Jan
validity (i.e., agreement of outcomes between devices) were extrac- et al., 2005; Lunsford & Perry, 1995; Svantesson, Osterberg, Grimby, &
ted. Any stated strengths and limitations of devices were also Sunnerhagen, 1998; Svantesson, Osterberg, Thomeé, et al., 1998)
extracted. A single reviewer (RF) extracted all data, and a second three studies (8.5%), used the AMES (DeWolf et al., 2018; Sman
reviewer (KHL) verified the completeness of extraction. et al., 2014; Van Cant et al., 2017), and two studies (5.7% each) used
Data are summarised using tables for the characteristics of the the Häggmark and Liedberg light beam electronic device (Häggmark
reviewed studies, reliability and concurrent validity properties, and et al., 1986; Möller et al., 2005) and Haberometer (Haber et al., 2004;
perceived strengths and limitations of the CRT devices for clinical Pereira et al., 2010). Finally, one study (2.9% each) used the force plate
use. The reliability and concurrent validity of devices were deemed with an electrogoniometer (Österberg et al., 1998), 3D motion capture
excellent, good, moderate, and poor when corresponding intraclass with a linear encoder (Andreasen et al., 2020), and a custom made CRT
correlation (ICC) values were >0.90, >0.75 to 0.90, between 0.50 and device (Sara et al., 2021), as reported in Table 1. These devices were
0.75, and <0.50 (Portney, 2020). Additionally, it was possible to used most often in studies to examine Achilles tendon pathologies
group CRT devices under thematic headings; therefore, devices are (n = 18, 51.4%) (Andreasen et al., 2020; Annelie Brorsson et al., 2018;
presented thematically using a narrative synthesis format. No risk of A. Brorsson et al., 2021; A. Brorsson et al., 2017; Häggmark
bias assessment was undertaken as it was not relevant to the aims of et al., 1986; Hamrin et al., 2020; Nawoczenski et al., 2016; Norden-
this review. holm et al., 2022; Olsson et al., 2014; Silbernagel et al., 2015; Silber-
nagel et al., 2006; Silbernagel et al., 2010; Silbernagel et al., 2012;
Svensson et al., 2019; Tengman et al., 2015; Westin et al., 2018; Zel-
3 | RESULTS lers et al., 2018; J. A. Zellers et al., 2020) and healthy populations
(n = 17, 48.6%) (Arch et al., 2018; Byrne et al., 2017; DeWolf
3.1 | Selection of studies and study characteristics et al., 2018; Haber et al., 2004; Hébert‐Losier & Holmberg; Hébert‐
Losier et al., 2012; Hébert‐Losier et al., 2011; Jan et al., 2005; Luns-
Figure 1 presents a flowchart of the screening and selection pro- ford & Perry, 1995; Möller et al., 2005; Österberg et al., 1998; Pereira
cesses. Thirty‐five articles met inclusion criteria and were included in et al., 2010; Sara et al., 2021; Sman et al., 2014; Svantesson, Oster-
the narrative synthesis. The individual study characteristics are berg, Grimby, & Sunnerhagen, 1998; Svantesson, Osterberg,
presented in Table 1. Thomeé, et al., 1998; J. A. Zellers et al., 2017) but in one study each
(2.9%) for specific musculoskeletal [patellofemoral pain (Van Cant
et al., 2017)] or medical [stroke (Svantesson, Osterberg, Grimby, &
3.2 | Calf raise test measuring devices Sunnerhagen, 1998) and deep vein thrombosis (Haber et al., 2004)]
conditions.
It was possible to thematically group CRT devices into seven cate-
gories: Häggmark and Liedberg's light beam electronic device; elec-
trogoniometer; laboratory‐based devices—three‐dimensional (3D) 3.2.1 | Häggmark and Liedberg's light beam
motion capture and force plate (used separately or together); Hab- electronic device
erometer, linear encoder; Ankle Measure for Endurance and Strength
(AMES); and a custom‐made device. The timeline of the first use of In 1986, Häggmark and Liedberg reported using a light beam elec-
these devices in the scientific literature is presented in Figure 2. tronic device for measuring fatigue resistance in the calf muscles in
Furthermore, the reliability and concurrent validity of the CRT de- ATR individuals (Häggmark et al., 1986). Specifically, they con-
vices are summarised in Table 2, and their perceived strengths and structed a device with a light beam attached to vertical rods at a fixed
limitations from a clinical perspective are outlined in Table 3. height of 5 cm (Figure 2). Participants needed to lift their heels over
4 of 20
FIGURE 1 Flowchart of the search strategy and the selection process.
the light beam to the sound of a metronome that controlled and 3.2.2 | Electrogoniometer
monitored their pace. When the 5 cm heel target was reached, the
device emitted an audible signal to assist the researchers track the Researchers and clinics use electrogoniometers to measure joint
number of repetitions. Möller et al. (2005) developed a modified movement (Bronner et al., 2010; Shamsi et al., 2019). A sensor is
version of this device and tested it in healthy individuals, adding a positioned over the joint centre of rotation. In comparison to motion
foot block to prevent the foot from sliding during testing and to analysis, the electrogoniometer has a high level of reliability and
enhance participant safety (Möller et al., 2005). The test‐retest reli- validity (Bronner et al., 2010).
ability of the main outcome (i.e., number of repetitions) was good The electrogoniometer was first used by Lunsford and
when performed a week later in healthy individuals (Möller et al., Perry (1995) during the CRT in healthy individuals to determine the
2005) (Table 2). One limitation of this device is that it requires criterion for normal CRT performance. The recorded plantar‐flexion
electricity to function, which makes using the device in remote areas ankle measurements were used to quantify the number of repeti-
or in field settings challenging (Möller et al., 2005; Sman et al., 2014). tions as well as to determine when the test should end based on the
Furthermore, this device is not available for purchase, and only ankle plantar‐flexion range of motion decreasing by more than 50%
monitors the number of repetitions. from the initial range (Lunsford & Perry, 1995). Jan et al. (2005) used
- 5 of 20
TABLE 1 Summary of articles reviewed (n = 35).
Authors (year
of publication) CRT
Country Purpose Participants Device outcomes
Andreasen et al. (2020) To evaluate the concurrent validity of Sample: 45 patients with ATR (36 Linear encoder Work
Denmark the heel‐rise work test performed males, 9 females) Laboratory‐based
with use of the heel as surrogate Age: 41 � 9 y equipment (3D
for centre of body mass. Height: NR MOCAP)
Mass: NR
Arch et al. (2018) To evaluate the relationship between Sample: 24 healthy (15 males, 9 Linear encoder Number of
USA gait and clinical measures of females) repetitions
plantar flexor function for Age: 43.6 � 24.5 y
individuals with no neuromuscular Height: 1.74 � 0.08 m
injuries or diseases. Mass: 78.7 � 11.8 kg
A. Brorsson et al. (2021) To evaluate the possible differences in Sample: 90 patients with ATR Linear encoder Number of
Sweden foot structure between the injured repetitions
and the healthy limb and between Surgery Peak height
treatment groups 6 years after an Sample: 36 males, 9 females Work
ATR. Age: 50 � 9 y
Height: NR
Mass: NR
Non‐surgery
Sample: 39 males, 6 females
Age: 48 � 9 y
Height: NR
Mass: NR
Annelie Brorsson To evaluate calf muscle performance Sample: 66 patients with ATR (53 Linear encoder Number of
et al. (2018) and patient reported outcomes at males, 13 females) repetitions
Sweden least 5 years after an ATR in Age: 50 � 8.5 y Peak height
patients included in a prospective, Height: 178 � 9.7 cm
randomised controlled trial. Mass: 85.9 � 13.5 kg
A. Brorsson et al. (2017) To explore differences in ankle Sample: 34 patients with ATR Linear encoder Number of
Sweden biomechanics, calf muscle repetitions
recovery, tendon length, and ATR <15% difference in heel‐rise Peak height
patient‐reported outcome height
measurements at a mean of Sample: 15 males, 2 females
6 years after ATR between two Age: 40 � 5 y
groups with less than 15% and Height: NR
greater than 30% differences in Mass: NR
heel‐rise height at 1‐year follow‐
up, respectively. ATR >30% difference in heel‐rise
height
Sample: 16 males, 1 female
Age: 56 � 9 y
Height: NR
Mass: NR
Byrne et al. (2017) To measure and compare the Sample: 38 healthy individuals Linear encoder Number of
UK intrarater test‐retest reliability (18 males, 20 females) repetitions
and measurement agreement of Age: 22.7 � 3.13 y Peak height
the three heel raise endurance test Height: 1.73 � 0.104 m Work
outcome measures in healthy adult Mass: 74.9 � 15.1 kg
during a standardised and
computerised heel raise endurance
test employing a linear
displacement sensor.
DeWolf et al. (2018) To objectively compare Sample: 49 healthy females AMES Number of
USA musculoskeletal attributes of pre repetitions
pointe and recently end pointe Pre‐pointe
ballet dancers to identify Sample: 28 females
differences between those cohorts Age: 10.21 � 1.17 y
and secondarily to investigate ant Height: 124.05 � 13.45 cm
(Continues)
6 of 20
T A B L E 1 (Continued)
Authors (year
of publication) CRT
relationships between the Mass: 39.13 � 13.18 kg

resulting quantitative measures
and a qualitative pointe success Pointe
appraisal completed by each Sample: 21 females
dancer's experienced ballet Age: 11.42 � 0.81 y
teacher. Height: 136.91 � 16.04 cm
Mass: 40.79 � 8.77 kg
Haber et al. (2004) To assess the reliability of a protocol Short term test‐retest group (30 min) Haberometer Number of
Canada using an apparatus specifically and Intermediate term group repetitions
designed to standardised the (48 h)
standing heel raise test for triceps Sample: 40 healthy individuals (19
surae muscle fatigability on a males, 21 females)
healthy group of subjects without Age: 24 y (range 17–63)
a current injury. Height: NR
Mass: NR
Long term test‐retest group (7 days)

Sample: 38 patients with deep vein
thrombosis (21 males, 16 females);
unaffected side tested
Age: 51 y (range 25–76)
Height: NR
Mass: NR
Häggmark et al. (1986) To compare the muscle function in a Surgical ATR group (10 males, 5 Häggmark and Liedberg Work
Sweden group of patients with ATR treated females) light beam electronic
with surgery versus a group of Age: 35. 5 y (range 23–59) device
patients treated non‐operatively Height: NR
with a follow up time of three to Mass: NR
5 years.
Non‐ surgical ATR group (6 males, 2
females)
Age: 34. 9 y (range 25–55)
Height: NR
Mass: NR
Hamrin et al. (2020) To determine patient‐related and Sample: 285 patients with ATR (238 Linear encoder Number of
Sweden treatment related predictors of males, 47 females) repetitions
superior and inferior function in Age: 40.0 � 8.4 y Peak height
sport and recreational activities Height: 178.4 � 8.3 cm Work
1 year after an ATR. Mass: 83.3 � 13.1 kg
Hébert‐Losier To investigate with surface EMG the Sample: 48 healthy individuals Laboratory‐based Number of
et al. (2012) influence of knee flexion angles on equipment (3D repetitions
New Zealand the soleus, medial gastrocnemius Younger males MOCAP) Peak height
and lateral gastrocnemius fatigue Sample: 12 males Work
during the maximal numbers of Age: 22.4 � 1.8 y
unilateral heel raises. Height: 177.4 � 5.6 cm
Mass: 71.7 � 10.2 kg
Younger females
Sample: 12 females
Age: 22.7 � 2.0 y
Height: 165.1 � 4.2 cm
Mass: 61.1 � 10.7 kg
Middle aged males

Sample: 12 males
Age: 41.1 � 3.1 y
Height: 177.7 � 5.6 cm
Mass: 81.7 � 14.9 kg
- 7 of 20
Authors (year
of publication) CRT
Middle aged females

Sample: 12 females
Age: 41.5 � 3.4 y
Height: 166.5 � 8.1 cm
Mass: 66.6 � 10.3 kg
Hébert‐Losier To provide an estimate of the ability of Sample: 17 healthy individuals (9 Laboratory‐based Number of
et al. (2011) a healthy population to maintain males, 8 females) equipment (3D repetitions
New Zealand 0° and a 30° knee flexion angle Age: 25.6 � 4.6 y MOCAP) Peak height
during knee extension heel raise Height: 172.4 � 9.3 cm
test and knee flexion heel raise Mass: 71.1 � 10.0 kg
test, by investigating the average
knee angle maintained and the
absolute angular error in knee
flexion position during the two
versions.
Hébert‐Losier and To characterise and compare the Sample: 48 healthy individuals Laboratory‐based Number of
Holmberg (2013) biomechanics and clinical equipment (3D repetitions
Sweden outcomes of the single legged heel Males MOCAP and force Peak height
raise test performed on an incline Sample: 28 males plate)
with the knee straight and bent Age: 38 � 12 y
while considering age and sex as Height: 169 � 7 cm
cofounders. Mass: 82 � 9 kg
Females
Sample: 20 females
Age: 41 � 11 y
Height: 169 � 8 cm
Mass: 69 � 9 kg
Jan et al. (2005) To investigate the number of Sample: 180 healthy individuals Electrogoniometer Number of
Taiwan repetitions of the one‐leg heel‐rise repetitions
test required for normal plantar‐ Males 21–40y
flexor strength in different groups Sample: 30 males
of subjects categorized by age and Age: 29.0 � 4.8 y
sex. Height: 169.7 � 6.1 cm
Mass: 69.7 � 8.0 kg
Males 41–60y
Sample: 30 males
Age: 50.2 � 4.9 y
Height: 167.2 � 5.4 cm
Mass: 67.0 � 8.0 kg
Males 61‐80
Sample: 30 males
Age: 69.0 � 4.0 y
Height: 166.3 � 5.4 cm
Mass: 66.5 � 6.5 kg
Females 21–40y
Sample: 30 females
Age: 30.3 � 4.9 y
Height: 160.5 � 3.9 cm
Mass: 52.4 � 5.5 kg
Females 41–60y
Sample: 30 females
Age: 49.9 � 1.0 y
Height: 157.0 � 6.0 cm
Mass: 57.9 � 9.2 kg
(Continues)
8 of 20
Authors (year
of publication) CRT
Females 61‐80
Sample: 30 females
Age: 69.1 � 4.1 y
Height: 154.9 � 5.2 cm
Mass: 58.8 � 5.5 kg
Lunsford and To further refine the standing heel‐ Sample: 203 healthy individuals (122 Electrogoniometer Number of
Perry (1995) rise test by assessing the number males, 81 females) repetitions
USA of heel‐rises that can be
accomplished by both male and Males
female. Sample: 122 males
Age: 34.7 � 8.5 y
Height: 178.9 � 7.9 cm
Mass: 79.7 � 11.5 kg
Females
Sample: 81 females
Age: 29.3 � 5 y
Height: 164.8 � 6 cm
Mass: 60 � 8.6 kg
Möller et al. (2005) To evaluate the test‐retest intra tester Sample: 10 healthy males Häggmark and Liedberg Number of
Canada reliability of isokinetic Age: 37 y, range: 31–43 light beam electronic repetitions
measurements in three different Height: 184 cm, range: 172–195 device (modified)
positions for ankle plantar flexion Mass: 88 kg, range: 75–98
and dorsi flexion torque
production and to evaluate calf
muscle endurance with a
standardised heel raise test.
Nawoczenski To investigate muscle performance Sample: 24 participants Laboratory‐based Work

et al. (2016) (ankle plantarflexion power and Gastrocnemius recession group equipment (3D
USA endurance) during functional tasks 8 males, 6 females MOCAP and force
and patient‐reported outcomes Age: 52.8 � 7.9 y plate)
following an isolated Height: 1.7 � 0.7 m
gastrocnemius recession for Mass: 92.3 � 15.5 kg
individuals with recalcitrant
achilles tendinopathy and an Control group
isolated gastrocnemius Sample: 5 males, 5 females
contracture. Age: 53.3 � 3.3 y
Height: 1.7 � 1.0 m
Mass: 84.0 � 16.1 kg
Nordenholm To evaluate the one‐year Sample: 22 patients with ATR (14 Linear encoder Number of
et al. (2022) postoperative outcomes in males, 8 females) repetitions
Sweden patients with chronic ATR using a Age: 61 � 15 y Peak height
comprehensive battery including Height: 173 � 9 cm Work
several validated tests. Mass: 85 � 15 kg
Olsson et al. (2014) To investigate predictors of both Sample: 93 patients with ATR (79 Linear encoder Peak height
Sweden symptomatic and functional males, 14 females)
outcomes for both symptoms and Age: 39.7 � 9.3 y
function after ATR. Height: 179 � 8 cm
Mass: 84 � 12 kg
Österberg et al. (1998) To measure the torque influencing the Sample: 10 healthy males Laboratory‐based Number of
Sweden ankle joint during a standing heel Age: 25 � 3 y equipment (force plate) repetitions
raise test from force plate to Height: 179 � 3 cm Electrogoniometer Work
calculate work during the test. Mass: 76 � 7 kg
Pereira et al. (2010) To investigate the amplitude and sub‐ Sample: 22 healthy individuals (14 Haberometer Number of
Brazil 100 Hz frequency content of males, 8 females) repetitions
- 9 of 20
Authors (year
of publication) CRT
surface EMG signals obtained from Age: 21 � 1 y

several muscles during the Height: 171 � 2 cm
lowering and raising phases of a Mass: 65 � 2 kg
heel‐raise task performed until
failure.
Sara et al. (2021) To determine (1) associations between Sample: 28 healthy individuals Custom‐made device Number of
USA standing heel raise test repetitions repetitions
and measures of maximal plantar 14 males
flexion strength, assessed as Age: 21.5 � 8 y
baseline maximal voluntary Height: 1.81 � 0.08 m
isometric contraction, (2) Mass: 79.4 � 10.3 kg
associations between standing
heel raise test repetitions and the 14 females
reduction in maximum voluntary Age: 21.1 � 9 y
isometric contraction following the Height: 1.66 � 0.07 cm
standing heel raise test, and (3) Mass: 64.0 � 10.8 kg
whether sex differences exist in
performance of the standing heel
raise test.
Silbernagel et al. (2006) To evaluate if achilles tendinopathy Sample: 42 patients with achilles Linear encoder Number of
USA caused functional deficits on the tendinopathy (23 males, 19 repetitions
injured side compared with the females) Work
non‐injured side in patients. Age: 26 � 8 y
Mass: 74.9 � 15.1 kg
Silbernagel et al. (2010) To examine this heel‐rise test (that Sample: 78 patients with ATR (65 Linear encoder Number of
USA evaluates the height of each heel‐ males, 13 females) repetitions
rise along the number of Age: 42 � 9 y Peak height
repetitions) to evaluate its validity Height: 178 � 9 cm Work
and ability to detect differences in Mass: 85 � 13 kg
outcome and to compare this test
to the test that will be only
measures of ankle range of motion
and patient‐reported outcome.
Silbernagel et al. (2012) To evaluate if differences in heel raise Sample: 18 participants Linear encoder Number of
USA height are associated with Controls repetitions
differences in achilles tendon 7 males, 3 females Peak height
length after an ATR. Age: 28 � 8 y
Mass: 73 � 16 kg
Acute complete ATR

5 males3 females
Age: 46 � 13 y
Height: 176 � 7.7 cm
Mass: 83 � 13 kg
Silbernagel et al. (2015) To evaluate whether there are any Sample: 182 patients with ATR Linear encoder Peak height
USA differences in outcome between Surgical Work
men and women after an acute Sample: 76 males, 18 females
ATR. Age: 40 � 10 y
Height: NR
Mass: NR
Nonsurgical
Sample: 76 males, 12 females
Age: 39 � 14 y
Height: NR
Mass: NR
(Continues)
10 of 20
Authors (year
of publication) CRT
Sman et al. (2014) To document the construction and Sample: 40 healthy individuals (21 AMES Number of
Australia reliability of the AMES device. males, 19 females) repetitions
Age: 24 � 6.2 y
Height: 174 � 12.3 cm
Mass: 68 � 9.3 kg
Svantesson, Osterberg, To investigate the fatigue process of Sample: 10 healthy women. Electrogoniometer Number of
Thomeé, and the gastrocnemius and soleus Age: 24 � 3 y repetitions
Grimby (1998) muscles separately in a standard Height: 167 � 4 cm Work
Sweden heel raise test. Mass: 67 � 8 kg
Svantesson, Osterberg, To investigate the fatigue process in Sample: 16 males Electrogoniometer Number of
Grimby, and the triceps surae during the heel‐ repetitions
Sunnerhagen (1998) rise test (eccentric and concentric Hemiparesis Work
Sweden phases) in comparison with a Sample: 8 males
walking test and muscle strength. Age: 57 � 4 y
Height: NR
Mass: 82 � 10 kg
Reference (Healthy)
Sample: 8 males
Age: 59 � 3 y
Height: NR
Mass: 82 � 14 kg
Svensson et al. (2019) To examine muscle function, muscle Sample: 12 patients with ATR (8 Linear encoder Number of
Denmark architecture, and tendon length in males, 3 females) repetitions
persons who reported that they Age: 51 � 12 y Peak height
experience a functional deficit Height: 178 � 10 cm Work
more than 2 years after an ATR. Mass: 90 � 19 kg
Tengman et al. (2015) To evaluate muscle fatigue and Sample: 52 patients with ATR (46 Laboratory‐based Number of
Sweden determine whether fatigue could males,6 females) equipment (3D repetitions
be detected with a limited number Age: 47.8 � 10.2 y MOCAP and force Peak height
of heel raises after total ATR. Height: NR plate) Work
Mass: NR
Van Cant et al. (2017) To evaluate hip abductor, trunk Sample: 96 females AMES Number of
Belgium extensor, and ankle plantar flexor Patellofemoral pain repetitions
endurance in females and without 20 females
patellofemoral pain, using clinical Age: 21.1 � 2.6 y
tests. Height: 162.1 � 5.8 cm
Mass: 55.9 � 7.4 kg
Controls
76 females
Age: 20.5 � 2.8 y
Height: 165.5 � 5.8 cm
Mass: 58.3 � 7.4 kg
Westin et al. (2018) To perform a long‐term follow‐up of Sample: 391 patients with ATR (326 Linear encoder Number of
Sweden patients with an achilles tendon males, 65 females) repetitions
re‐rupture using established Age: 40.4 � 8.7 y Peak height
outcome measurements for Height: 178.5 � 8.6 cm Work
tendon structure, lower extremity Mass: 83.7 � 13.1 kg
function and symptoms, and to
compare the results with those for
the uninjured side.
J. A. Zellers, van To describe the achilles tendon Sample: 20 healthy individuals Linear encoder Number of
Ostrand, and structure and plantar flexor repetitions
Silbernagel (2017) function of classical ballet dancers Non‐dancers Peak height
USA compared to non‐dancers using 2 males, 8 females Work
Age: Range: 16 to 35 y
- 11 of 20
Authors (year
of publication) CRT
established, clinical achilles tendon Height: NR

examination methods. Mass: NR
Ballet dancers
2 males, 8 females
Age: Range 16 to 35 y
Height: NR
Mass: NR
Jennifer A. Zellers To determine the strength of the Sample: 42 patients with ATR (34 Linear encoder Work
et al. (2018) relationship of the achilles tendon males, 8 females)
USA resting angle in both knee Age: 45.9 � 16.2 y
extended and knee flexed Height: NR
positions with tendon length Mass: NR
measured using ultrasound as a
validation study; and to identify
the relationship between the
achilles tendon resting angle with
tendon material properties and
patient functional performance to
better understand its clinical
utility.
J. A. Zellers et al. (2020) To investigate the relationship Sample: 22 patients with ATR (17 Linear encoder Peak height
USA between early tendon morphology males, 5 females) Work
and mechanical properties to long‐ Age: 40 � 11 y
term function on heel‐rise and Height: NR
jumping tests in individuals after Mass: NR
ATR.
Abbreviations: 3D MOCAP, three‐dimensional motion capture; AMES, Ankle Measure for Endurance and Strength; ATR, Achilles tendon rupture; EMG,
electromyography; NR, not reported.
the device in a similar fashion to establish normative values for are still a low‐cost alternative to 3D motion capture systems. To
different ages and genders. apply this device to the CRT, however, requires a certain amount of
Studies in 1998 used electrogoniometers during the CRT in programming to compute work, as well as the recording of foot
healthy individuals (Svantesson, Osterberg, Grimby, & Sunnerha- length for work computation.
gen, 1998; Svantesson, Osterberg, Thomeé, et al., 1998; Österberg
et al., 1998) and stroke patients (Svantesson, Osterberg, Grimby, &
Sunnerhagen, 1998). These studies used an electrogoniometer to 3.2.3 | Laboratory‐based devices: Three‐dimensional
determine the concentric and eccentric parts of the calf raise motion motion capture and force plate
and inform electromyographic analysis. Furthermore, total (concen-
tric) work was calculated using the mass of individuals, gravitational Three‐dimensional (3D) motion capture systems (Jakob et al., 2021)
acceleration constant, length of the foot between the axis of rotation and force plates (Peterson Silveira et al., 2017) are considered the gold
of the ankle and metatarsophalangeal joints, and angular velocity standards for collecting biomechanical data in laboratory settings
(Svantesson, Osterberg, Grimby, & Sunnerhagen, 1998; Svantesson, (Figure 2). Österberg et al. (1998) were the first to use a force plate
Osterberg, Thomeé, et al., 1998). during the CRT alongside an electrogoniometer to quantify torque and
The main advantage of electrogoniometers over standard goni- work during the test in healthy individuals, while Hébert‐Losier et al.
ometers is their increased precision of joint angle measurements were the first to use 3D motion capture in isolation (Hébert‐Losier
(Bronner et al., 2010). Furthermore, the voltage signals recorded et al., 2011) and together with a force plate (Hébert‐Losier & Holm-
during dynamic motion can be immediately transferred to a computer berg, 2013) to quantify CRT outcomes in healthy individuals. The main
(Österberg et al., 1998) or data logger (Bronner et al., 2010) and advantages of these devices are their high accuracy in quantifying
provide joint displacement data in real‐time to inform CRT termi- biomechanical measures and ability to calculate metrics other than
nation (e.g., 50% of ankle plantar‐flexion range of motion). Although those traditionally reported for the CRT, such as joint angles and
it is more expensive than a standard goniometer, electrogonimoters torques. Force plates also provide an actual force measure, which can
12 of 20
F I G U R E 2 Timeline of when various calf raise test (CRT) devices were first used in the scientific literature. (a) Häggmark and Liedberg
light beam electronic device (Häggmark et al., 1986), (b) Electrogoniometer (van der Linden, Andreopoulou, Scopes, Hooper, & Mercer, 2018),
(c) Electrogoniometer and force plate (Österberg et al., 1998), (d) Haberometer (Haber et al., 2004), (e) Linear encoder (Arch et al., 2018),
(f) 3D motion capture system (Hébert‐Losier et al., 2011), (g) 3D motion capture and force plate (Hébert‐Losier & Holmberg, 2013), (h) Ankle
Measure for Endurance and Strength (Sman et al., 2014), (i) Custom‐made CRT device (Sara et al., 2021).
be used to calculate work as a product of (actual) force and based on ICC measures (Table 2). Haber et al. (2004) recommended
displacement rather than a (fixed) force based on the mass of in- the device for clinics and research because of its simplicity and
dividuals and gravitational acceleration constant. Although motion reliable outcomes. However, one of the perceived drawbacks of the
capture systems and force plates are common in research and have device is the rod placement over the foot, which may compromise
been used to assess CRT outcomes in healthy individuals (Hébert‐ safety if a loss of balance occurs during testing (Haber et al., 2004).
Losier et al., 2011; Hébert‐Losier & Holmberg, 2013) as well in pa- Furthermore, this device is not available for purchase and only
tients with ATR (Andreasen et al., 2020; Nawoczenski et al., 2016; monitors the number of repetitions.
Tengman et al., 2015), these devices have limited application in day‐
to‐day clinical practice because of their high costs, limited availabil-
ity, and time‐consuming setup requirements (Schurr et al., 2017). 3.2.5 | Linear encoder
Silbernagel et al. (2006) were the first researchers to introduce the use
3.2.4 | Haberometer of a linear encoder for measuring CRT outcomes, which was in ATR
patients. The linear encoder (Figure 2) contains a spring‐loaded
To aid in CRT standardisation, Haber et al. (2004) developed the displacement sensor which is attached to the heel and tracks verti-
Haberometer (Figure 2), a simple portable device that measures the cal displacement over time. The linear displacement data can be used
number of repetitions. The Haberometer is similar to the Häggmark to calculate work and velocity. Typically, the linear encoder is used to
and Liedberg light beam electronic devices but does not rely on measure the three main CRT outcomes: number of repetitions, peak
electric components. The Haberometer consists of two vertical rods height, and total work (Byrne et al., 2017; Silbernagel et al., 2010).
that set the height of calf raise repetitions to 5 cm and a horizontal These linear encoder‐derived outcomes have shown good test‐retest
block that prevents the foot from sliding forward, which are all reliability (Byrne et al., 2017) (Table 2). Furthermore, outcomes from
attached to a base platform (Haber et al., 2004). The device was used the linear encoder are the only ones which have been validated against
in both healthy individuals (Haber et al., 2004; Pereira et al., 2010) 3D motion capture, with the work from the linear encoder almost
and those with deep vein thrombosis (Pereira et al., 2010). perfectly correlated with the work from a 3D marker placed on the
The Haberometer demonstrated good short‐, medium‐ and long‐ heel (Andreasen et al., 2020). Since linear encoders can provide the
term test‐retest reliability for quantifying the number of repetitions three main outcomes of repetitions, peak height, and work, these
- 13 of 20
TABLE 2 Summary of reported reliability or concurrent validity of calf raise test (CRT) devices.
Authors (year
of publication) Reliability or concurrent
CRT devices Participants validity of outcomes Interpretationa
Andreasen et al. (2020) Patients with acute achilles tendon Total work measurement error The CRT performed using the heel as a
Linear encoder rupture (n = 45, 36 males and 9 (%) surrogate for centre of body mass
3D MOCAP females) Linear encoder heel versus MOCAP overestimates the total work by
heel 21.0%–24.7% versus the gold standard
Injured side = 1.5% (p = 0.163) (MOCAP pelvis), but can precisely
Non‐injured side = 2.9% detect the relative difference between
(p < 0.0001) limbs.
Linear encoder heel versus MOCAP Using the heel is considered valid for
pelvis injured side = 21% assessing relative differences between
(p < 0.0001) limbs.
Non‐injured side = 24.7%
(p < 0.0001)
Total work concurrent validity
(linear regression slope [95%
CI])
Linear encoder heel versus MOCAP
heel
Injured side = 0.95 [0.91, 1.00]
Non‐injured side = 1.00 [0.98,
1.03]
Lienar encoder heel versus MOCAP
pelvis
Injured side = 0.79 [0.70, 0.87]
Non‐injured side = 0.92 [0.86,
0.97]
Limb symmetry index (linear
regression slope [95% CI])
Linear encoder heel versus MOCAP
heel
0.98 [0.92; 1.02]
Lienar encoder heel versus MOCAP
pelvis
1.03 [0.90, 1.09]
Byrne et al. (2017) Healthy individuals (n = 38, 18 Test‐retest reliability (average Based on the ICC estimates
Linear encoder males, 20 females) 9 days) Linear encoder has “good” test‐retest
Number of repetitions (n) reliability for measuring number of
ICC = 0.77 repetitions, work, and peak height
SEM = 6.7 when tested in healthy individuals.
CV = 13.9% ‐
Work (J)
ICC = 0.84
SEM = 419
CV = 13.1%
Peak height (cm)
ICC = 0.85
SEM = 0.8
CV = 6.6%
Haber et al. (2004) Healthy individuals (n = 40, 19 Short term test‐retest reliability Based on the ICC estimates
Haberometer males, 21 females) (30 min) Haberometer has “good” short,
Patients with deep vein thrombosis Number of repetitions (n) intermediate, and long‐term test‐retest
(n = 38, 21 males, 16 females) ICC2,1 = 0.85 reliability for measuring the number of
SEM = 2.3 repetitions when tested in healthy
CV = 9% individuals and uninjured side of
Intermediate term test‐retest patients with deep vein thrombosis.
reliability (48 h)
Number of repetitions (n)
ICC2,1 = 0.79
SEM = 3.1
CV = 9%
(Continues)
14 of 20
Authors (year
of publication) Reliability or concurrent
CRT devices Participants validity of outcomes Interpretationa
Long term test‐retest reliability

(7 days)
Number of repetitions (n)
ICC2,1 = 0.88
SEM = 3.4
CV = 15%
Möller et al. (2005) Healthy individuals (n = 10 males) Test‐retest reliability (5–7 days) Based on the ICC estimates
Häggmark and Liedberg light Number of repetitions (n) right side Häggmark and Liedberg light beam
beam electronic device Difference in mean (right) = 1.2 electronic device (modified) has “good”
(modified) Limits of agreement = −15.3, 17.7 test‐retest reliability for measuring
ICC = 0.84 number of repetitions when tested in
CV = 19.1% healthy individuals.
Number of repetitions (n) left side
Difference in mean (left) = 1.7
Limits of agreement = −8.9, 12.3
ICC = 0.78
CV = 13.5%
Sman et al. (2014) Healthy individuals (n = 40, 21 Inter‐rater reliability Based on the ICC estimates
Ankle measure for endurance males, 19 females) Number of repetitions (n) AMES has “excellent” inter‐rater reliability
and strength ICC2,1 = 0.97 for measuring number of repetitions
SEM = 10.4 when the CRT is assessed
simultaneously by two examiners when
tested in healthy individuals.
Abbreviations: 3D MOCAP, three‐dimensional motion capture; AMES, Ankle Measure for Endurance and Strength; CI, confidence interval; CRT, calf
raise test; CV, coefficient of variation; ICC, intraclass correlation; SEM, standard error of the mean.
a
Reliability and concurrent validity “excellent”, “good”, “moderate”, and “poor” when the corresponding ICC was >0.90, >0.75 to 0.90, between 0.50 and
0.75, and <0.50 (Portney, 2020).
devices have been used the most in research to monitor CRT out- the need for electric current, computers, specialised software, or
comes in healthy individuals (Arch et al., 2018; Byrne et al., 2017; J. A. specialised hardware (e.g., light beams and linear encoders). The
Zellers et al., 2017) and patients with Achilles tendon pathologies AMES (Figure 2) consists of a platform, two blocks, two L‐shaped
(Andreasen et al., 2020; Annelie Brorsson et al., 2018; A. Brorsson brackets, and an elastic band. The elastic band is attached horizon-
et al., 2016; A. Brorsson et al., 2021; A. Brorsson et al., 2017; tally to the brackets using two spring clamps on either side. In
Hamrin et al., 2020; Nordenholm et al., 2022; Olsson et al., 2014; addition, the elastic band height is fully adjustable. To track the
Silbernagel et al., 2015; Silbernagel et al., 2006; Silbernagel et al., number of repetitions, individuals place their heels on the elastic
2010; Silbernagel et al., 2012; Svensson et al., 2019; Westin et al., band between the brackets and raise the heel as high as possible
2018; Zellers et al., 2018; J. A. Zellers et al., 2020). during testing (Sman et al., 2014). Hence, the height of the calf raise
Although CRT outcomes derived from linear encoders provide can be individually set and is not fixed to a certain threshold, such as
meaningful information on ankle plantar‐flexion function that can 5 cm. The AMES was originally tested in healthy individuals (Sman
assist in the assessment and management of individuals (Byrne et al., 2014), and later used in patients with patellofemoral pain (Van
et al., 2017), the associated cost of purchasing linear encoder hard- Cant et al., 2017) as well as in youth ballet dancers (DeWolf
ware and software prohibits their clinical use. Nonetheless, linear et al., 2018).
encoders are more affordable than 3D motion capture or force plate The AMES presented excellent inter‐rater reliability for the
systems and are considered a good option for research‐compatible number of repetitions completed (Table 2) when simultaneously
outcomes at a modest cost. assessed by two examiners (Sman et al., 2014). Sman et al. (2014)
advanced that AMES is ideal for assessing CRT outcomes in clinical
and research settings due to its simplicity. The authors further rec-
3.2.6 | Ankle Measure for Endurance and Strength ommended modifications to the AMES to ensure safety while using
the apparatus, such as replacing the L‐shaped brackets with curved
Sman et al. (2014) introduced the AMES to address some of the brackets and adding a foot fixation to minimise foot slippage during
shortcomings of other CRT devices that were used to date, such as testing, which could affect the CRT outcome (Sman et al., 2014).
- 15 of 20
TABLE 3 Perceived strengths and limitations of the various calf raise test (CRT) devices for use in clinical practice.
Outcomes Clinical
Devices Strengths Limitations measured friendlinessa
Häggmark and Liedberg light beam Simple Requires electricity Repetitions 2

electronic device Portable Set height of 5 cm
Good test‐retest reliability (healthy) Used to record repetitions
Used in ATR and healthy only
Not commercially available
Electrogoniometer Simple Requires electricity Repetitions 2

Portable Requires specific hardware Work
Used in stroke and healthy and software
Haberometer Simple Requires electricity Repetitions 1

Portable Set height of 5 cm
Good test‐retest reliability (healthy) Rod over foot may affect
Used in DVT and healthy balance
Used to record repetitions
only
Not commercially available
Linear encoder Relatively simple Medium cost Repetitions 2

Relatively portable Requires electricity Peak
Measures three CRT outcomes Requires specific hardware height
Good test‐retest reliability and software Work
Most frequently used Requires programming
Valid versus 3D MOCAP
Used in ATR, AT, and healthy
Laboratory‐based equipment (3D Measures three CRT outcomes High‐cost Repetitions 3

MOCAP and force plate) Gold standard for measuring biomechanical Requires electricity Peak
variables related to the CRT Requires specific hardware height
High accuracy and software Work
Used in ATR and healthy Requires programming
Can be used to record other biomechanical Requires user expertise
measure Time consuming to set‐up
Ankle measure for endurance and Simple Used to record repetitions Repetitions 1
strength Portable only
Low‐cost Not commercially available
Adjustable height
Excellent inter‐rater reliability (healthy)
Used in PFP and healthy
Custom‐made CRT Simple Used to record repetitions Repetitions 2

Portable only
Low‐cost Not commercially available
Adjustable height No studies on reliability and
Used in healthy validity findings
Abbreviations: 3D MOCAP, three‐dimensional motion capture; ATR, Achilles tendon rupture; CRT, calf raise test; DVT, deep vein thrombosis; PFP,
patellofemoral pain.
a
Rank‐ordered from most (1) to least (3) clinical‐friendly.
Noteworthy is that this device is not available for purchase and only used to aid in standardising the test. The device consists of a hori-
monitors the number of repetitions. zontal plate affixed above a standing surface by an upright support
bar. This horizontal plate acts as a visual and tactile guide that is
adjusted (vertical and anteroposterior) to the dorsal ankle crease at
3.2.7 | Custom‐made device the end‐range of a maximal single‐leg calf raise. Conceptually, this
device is similar to the AMES device. Although the device is easy to
Sara et al. (2021) investigated the correlation between the number of use, portable, and simple, there are no existing studies to support its
repetitions performed during the CRT and maximal plantar‐flexor validity and reliability, the device only monitors the number of rep-
strength in males and females. A custom‐made CRT device was etitions, and it is not available for purchase.
16 of 20
4 | DISCUSSION affordable option for clinical use and clinically based research.
Indeed, the linear encoder was the most frequent device used in the
In clinical practice and research, the CRT is used to assess the scientific literature, likely due to its ability to provide reliable (Byrne
strength‐endurance of the triceps surae muscles (Lunsford & et al., 2017) research‐grade outcomes (Andreasen et al., 2020) at a
Perry, 1995; Svantesson, Osterberg, Thomeé, et al., 1998). Despite moderate financial cost compared to 3D motion and force plate
being considered a reliable and valid clinical tool, there are concerns systems. However, this device still requires specialised software and
regarding the standardisation of its protocols (Hébert‐Losier knowledge to extract data, making the linear encoder less suitable for
et al., 2009; Sman et al., 2014) and that key clinical parameters are everyday clinical applications and explaining its lack of general up-
omitted when only counting the number of repetitions (Byrne take from a clinical standpoint.
et al., 2017). To address these shortcomings, a range of devices have The Haberometer, AMES, and custom‐made devices were
been developed and used to standardise and objectivise CRT per- considered as the most clinically friendly CRT devices (Table 3), fol-
formance. This review critically appraised 35 relevant studies that lowed by Häggmark and Liedberg's light beam electronic device
used measuring devices to evaluate CRT outcomes in healthy in- because of their simplicity, portability, affordability, and no require-
dividuals as well as those with medical conditions to inform evidence‐ ment of specialised hardware or software. These devices can assist in
based practice. Among the 35 studies included, the Haberometer, standardising CRT parameters, with the Haberometer and AMES being
AMES, and custom‐made devices were considered the most clinical‐ reliable for measuring the number of repetitions (Haber et al., 2004;
friendly, but these only recorded the number of repetitions. Möller et al., 2005; Sman et al., 2014). Though none of the reviewed
Laboratory‐based 3D motion capture and force plate systems are literature sought to quantify the work performed when using these
considered to provide the greatest precision of measurement and devices, because of the fixed calf raise height, the work completed can
offer the advantage of quantifying the three main CRT outcomes but be calculated based on the number of repetitions, known calf raise
are the least clinical‐friendly and most costly devices. The Häggmark height, and mass of individuals similar to the work computations used
and Liedberg light beam electronic device, electrogoniometer, and for the linear encoder, electrogoniometer, and motion capture sys-
linear encoder were all considered moderately clinically friendly from tems. The one drawback, however, is that peak height during each raise
a practical and cost perspective, with the linear encoder being the is not quantified and the proposed work computations from the set
most often used in the scientific literature and the only device re- height would therefore underestimate the actual work performed.
ported to quantify the three main outcomes. As such, the linear Furthermore, these devices are not readily available for purchase,
encoder method appears to offer the best compromise for clinicians again limiting their widespread uptake in clinical practice.
seeking research‐grade outcomes for the CRT at a modest cost. Since the systematic search in April 2022, CRT performance has
Although the number of calf raises performed is the primary test also been quantified using a mobile iOS application (Figure 3) that
outcome evaluated in clinics, Svantesson, Osterberg, Thomeé, relies on computer‐vision algorithms to track the displacement of a
et al. (1998) suggested assessing calf raise height during the test as marker placed on the foot (Fernandez et al., 2022; Hébert‐Losier &
shorter height ranges could lead to more repetitions since less work Balsalobre‐Fernández, 2020; Hébert‐Losier et al., 2022). Specifically,
is required per repetition. Furthermore, it is noteworthy from a the vertical position of a circular marker is tracked from a video
clinical perspective that the number of repetitions and height are recording via computer vision after calibration to a known distance.
related to different physiological and structural factors (Svensson The application has been used in athletes (Hébert‐Losier et al., 2022)
et al., 2019). The number of repetitions is determined by contractile and healthy individuals (Fernandez et al., 2022) and demonstrated
tissue and muscle endurance metabolism (Holloszy, 1967), while the good‐to‐excellent validity of CRT outcomes against 3D motion cap-
height of the calf raise is determined by tendon and muscle fiber ture and force plate (ICC ≥0.878) and inter‐rater, intra‐rater, and
length (Baxter et al., 2018). These triceps surae muscle properties test‐retest reliability. The Calf Raise application (Hébert‐Losier &
can all affect the total work performed during the CRT as both the Balsalobre‐Fernández, 2020) hence provides a valid and reliable
number of repetitions and height are used to compute work (Svan- method for assessing the three main CRT outcomes, and an innova-
tesson, Osterberg, Thomeé, et al., 1998). Furthermore, research tive clinical‐friendly low‐cost option to iOS users. Given that clini-
supports that peak height and work are more sensitive metrics in the cians (Galetsi et al., 2022) and practitioners (Shaw et al., 2021) are
presence of pathology and functional deficits (Baxteret al., 2018; increasingly using mobile applications and digital technologies, the
Svensson et al., 2019; J. A. Zellers et al., 2020). For these reasons, computer‐vision‐based mobile application is an appealing and
several researchers have advocated using peak height and work in accessible solution for quantifying CRT outcomes in clinics, although
addition to the number of repetitions as objective measures of tri- it still requires access to an iOS device.
ceps surae muscle‐tendon unit function during the CRT (Byrne This literature has a few limitations to acknowledge. First, this
et al., 2017; Fernandez et al., 2022; Silbernagel et al., 2006). Of the review focused on the single‐leg CRT performed to fatigue and did not
seven thematically grouped devices sourced from the literature consider other variations of this task, such as when calf raises are done
(Figure 1), only the linear encoder and laboratory‐based 3D motion bilaterally or for a set duration (André et al., 2016; Aruje Zahid
capture and force plate systems were used to quantify all three CRT et al., 2022). Different devices have been used for these task variations,
outcomes. Of the two methods, the linear encoder is the most including an overhead bar to set calf raise height (André et al., 2016)
- 17 of 20
F I G U R E 3 A computer‐vision algorithm is
used to track the vertical displacement of a
marker placed on the foot to calculate calf
raise test (CRT) outcomes, first introduced in
2022 (Hébert‐Losier et al., 2022).
and inertial measurement units (Aruje Zahid et al., 2022), which could 5.1 | Clinical message
be applicable to the single‐leg CRT. The former method would have
similar strengths and limitations than the Haberometer or AMES, � Research‐grade or customised devices are used to standardise and
whereas the latter still needs development and validation for the quantify CRT outcomes in science. Seven different devices were
single‐leg CRT. This review also focused on the CRT devices and their identified.
design, reliability, concurrent validity, and perceived strengths and � By understanding the design and properties of these CRT devices,
limitations for clinical use, not on other psychometric properties of the practitioners will be able to determine which ones are the most
assessment procedures, such as the responsiveness of outcomes, appropriate for their clinical needs and to use these devices to
sensitivity, or specificity. Despite our narrative review following a implement evidence‐based practice.
rigorous and systematic process in accordance with the PRISMA � Linear encoders appear to provide the best compromise for clini-
guidelines, no critical appraisal of the included studies was undertaken cians seeking research‐grade CRT outcomes at a modest cost.
due to the varied methods used in the studies. Furthermore, no risk of � Advances in computer vision technology have led to iOS mobile
bias assessment was completed as it was not relevant to the review applications that provide low‐cost research‐grade alternatives for
aims. Therefore, this review was limited to a narrative synthesis of the clinicians and researchers to quantify clinical outcomes, including
findings and conclusions drawn from the studies included. Nonethe- the CRT.
less, this approach was deemed suitable for the aims of the review and
to provide a comprehensive overview of the current CRT devices used, A U T H O R C O NT R I B U TI O NS
their strengths, and their limitations. Ma. Roxanne Fernandez and Kim Hébert‐Losier: Conceptualization,
methodology, formal analysis, investigation, data curation, writing—
5 | CONCLUSION original draft, writing—review & editing, visualization, project

administration. Kim Hébert‐Losier: Supervision.
This review provides clinicians and researchers insight into the de-
vices that have been used to assess the CRT, and the strengths and A CK N O W L E D GE M E NT S
limitations of these devices. The use of devices for the CRT has a dual The authors wish to thank Prof Masayoshi Kubo, Department of
purpose: to enhance the standardisation of procedures and to further Physical Therapy, Niigata University of Health and Welfare, and Dr
objective CRT outcomes beyond the number of repetitions. The Josie Athens, Department of Preventive and Social Medicine, Uni-
linear encoder and computer‐vision mobile application offer the best versity of Otago, for their valuable comments on drafts of the
compromise for clinicians seeking research‐grade outcomes for the manuscript and exceptional support during the research process.
CRT at a modest cost. Their valuable contributions to this paper are greatly appreciated.
18 of 20
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Received: 7 October 2022
DOI: 10.1002/pri.2007
RESEARCH ARTICLE
- -
Revised: 27 March 2023 Accepted: 3 April 2023
Adaptation of the person centered therapeutic relationship

patient version (PCTR‐PT) to a version for physiotherapists
(PCTR‐PHYS) and evaluation of its psychometric properties
Óscar Rodríguez‐Nogueira1 | Jaume Morera Balaguer2 | Abel Nogueira López3 |

Juan Roldán Merino4 | Víctor Zamora‐Conesa2 | Antonio R. Moreno‐Poyato5,6
1
Department of Nursing and Physiotherapy,
SALBIS Research Group, Universidad de León, Abstract
Ponferrada, León, Spain
Background and Purpose: The therapeutic relationship is a central component for
2
Physical Therapy Department, CEU
developing person‐centered care within physiotherapy services. However, it is
Universities, Universidad Cardenal Herrera‐
CEU, Alicante, Spain necessary to understand how this relationship is perceived by both parties involved.
3
Department of Physical Education and Sports, The Person Centered Therapeutic Relationship‐Patient scale (PCTR‐PT) was con-
Universidad de León, León, Spain
structed to identify patients' perceptions. No instruments are currently available to
4
Campus Docent Sant Joan de Déu‐Fundació
Privada, School of Nursing, University of correlate patients' and physiotherapists' perceptions of the therapeutic relationship.
Barcelona, Barcelona, Spain This study sought to adapt the PCTR‐PT to develop a version for physiotherapists,
5
Mental health, psychosocial and complex the Person Centered Therapeutic Relationship Scale for Physiotherapists (PCTR‐
nursing care research group (NURSEARCH),
Barcelona, Spain PHYS) and to determine its psychometric properties.
6
Facultat de Medicina i Ciències de la Salut, Methods: A three‐stage study was performed: (1) item generation, (2) pretesting of
Escola d´Infermeria Departament d’Infermeria
the questionnaire, (3) analysis of psychometric properties. Factor validity and psy-
de Salut Pública, Salut Mental I Materno
Infantil, Universitat de Barcelona, Barcelona, chometric properties were analyzed by confirmatory factor analysis (CFA).
Spain
Convergent validity was calculated. Internal consistency was verified using the
Correspondence Cronbach's alpha coefficient. The intraclass correlation coefficient (ICC) was used to
Óscar Rodríguez‐Nogueira, Department of examine temporal stability.
Nursing and Physiotherapy, SALBIS Research
Group, Universidad de León, Campus de
Results: Thirty‐three physiotherapists participated in two rounds of cognitive in-
Ponferrada, Av. Astorga, 15, Ponferrada, León terviews and 343 participated in the analysis of psychometric properties. The CFA
24401, Spain.
Email: orodn@unileon.es
confirmed the four‐structure model. Reliability of the tool was confirmed by
Cronbach's alpha (α = 0.863) for all four dimensions, as all were above 0.70, ranging
from 0.704 (relational bond) and 0.898 (therapeutic communication). Test‐retest
was performed with 2‐week intervals, indicating an appropriate stability for the
scale (ICC = 0.908).
Discussion: The Person Centered Therapeutic Relationship Scale for Physiothera-
pists is a useful, valid and applicable instrument to evaluate the person‐centered
therapeutic relationship during physiotherapy interventions. It will enable the
comparison of patients' and physiotherapists' perceptions. To provide person‐
centered care in physiotherapy services, there is a clear need to incorporate
-
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- RODRÍGUEZ‐NOGUEIRA ET AL.
specific resources into clinical practice to evaluate the quality of the therapeutic
relationship from the perspective of both the persons being treated and the pro-
fessionals providing care.
KEYWORDS
assessment, communication, person centered care, physical therapy specialty, therapeutic
alliance, therapeutic relationship
1 | INTRODUCTION dimensions (Relational Bond [RB], Individualized Partnership [IP],

Professional Empowerment [PE], and Therapeutic Communication
Person‐centered care refers to a holistic approach to provide [TC]), explaining 78.4% of the variance of the total variables. The
respectful and individualized care based on a therapeutic relationship variance not explained could be due to factors such as the environ-
between all care providers and individuals who are empowered to be ment or personal characteristics of the physiotherapist that seem to
involved in their health care decisions (Morgan & Yoder, 2012). influence the therapeutic relationship (Morera‐Balaguer et al., 2018,
Person‐centered care is a goal (Wagner et al., 2005) and a quality 2021). The reliability of the tool was approved by Cronbach's alpha in
standard in clinical practice (Sidani & Fox, 2014). Its implementation the four dimensions, since all are above 0.70, ranging from 0.84 (IP)
is a priority for improving health care (Institute of Medicine, 2001). to 0.91 (PE).
According to the World Health Organization (2018), the compre- To our knowledge, the PCTR‐PT was the first scale created to
hensive needs of individuals, and not just diseases, should be at the measure the person‐centered therapeutic relationship in physio-
center of health systems. Thus, professionals must empower in- therapy settings. Another scale exists, the Physiotherapy Therapeutic
dividuals to play a more active role in their own health. In addition, Relationship Measure (McCabe et al., 2021) designed to measure
relational aspects, individualization of care, empowerment, and the patients' experiences of their therapeutic relationship with
sharing of roles and responsibilities through the therapeutic alliance physiotherapists.
are important for carrying out person‐centered care (Mead & The therapeutic relationship has been defined as “the feelings
Bower, 2000; Morgan & Yoder, 2012; Scholl et al., 2014). Therefore, and attitudes that each participant has toward the other and the
in order to develop person‐centered care in physiotherapy, it is manner in which these are expressed” (Gelso & Carter, 2016). It is
necessary to establish an appropriate therapeutic relationship be- considered as a subjective phenomenon that occurs between
tween the professional and the person receiving care (Rodríguez‐ two individuals (the patient and the physiotherapist) (Street &
Nogueira, Botella‐Rico, et al., 2020). Mazor, 2017). This indicates the need to consider the experiences
The therapeutic relationship in physiotherapy can be defined as and perceptions of the two actors involved in the relationship, that is,
the safe relational space and affective bond between the patient and the patient and the physiotherapist (Bachelor, 2013).
the professional, where connections are established and collabora- There seems to be a low association between the perceptions
tive work takes place in terms of treatment and objectives (McCabe of the actors involved in the therapeutic relationship (Tryon
et al., 2021). The therapeutic relationship is beginning to be consid- et al., 2007), additionally, a high concordance is associated with
ered within physiotherapy treatments for its contribution to positive results and a low concordance is associated with stress and
improved clinical outcomes (Holmes et al., 2022; Kinney et al., 2020). poor results (Bachelor, 2013).
Despite the importance of the therapeutic relationship within Considering the importance of the therapeutic relationship in
person‐centered care, in the context of physiotherapy, assessment of physiotherapy services, and the need to have information to collate
the same is difficult. This is because of the lack of appropriate in- the perceptions of patients and physiotherapists, the aim of the
struments to measure the specific characteristics of physiotherapy present study was to adapt the PCTR‐PT to a version for physio-
procedures (Miciak et al., 2018; Morera‐Balaguer et al., 2021). The therapists (PCTR‐PHYS) and to determine the psychometric prop-
inability to evaluate this relationship makes it difficult to establish erties of this version.
actions aimed at improving it.
For this reason, Rodríguez‐Nogueira, Botella‐Rico, et al. (2020)
carried out the construction and content validation of the Person‐ 2 | METHODS
Centered Therapeutic Relationship Scale for Physiotherapists
(PCTR‐PT) psychometric properties were determined (Rodríguez‐ To adapt the PCTR‐PT (Rodríguez‐Nogueira, Botella‐Rico,
Nogueira, Morera Balaguer, et al., 2020). This scale, specific to et al., 2020; Rodríguez‐Nogueira, Morera Balaguer, et al., 2020) pa-
physiotherapy services, was designed to measure the experiences of tient version to the version for physiotherapists (PCTR‐PHYS), it was
rehabilitation patients. These experiences are useful for under- necessary to adapt the scale to the population of physiotherapy
standing how a participant interprets or evaluates the clinical inter- professionals. For this purpose, this study was conducted in three
action (Street & Mazor, 2017). It consists of 15 items and four stages (Figure 1): (1) item generation, (2) pretesting of the
RODRÍGUEZ‐NOGUEIRA ET AL.
- 3 of 11
questionnaire, (3) assessment of the psychometric properties of the the appropriateness and relevance of the content and the possible
instrument. lack of aspects that were not initially considered; (4) To review any
problems related to the order of questions or any interactions among
the same; (5) To examine the perception of length or overall burden
2.1 | Stage 1. Item generation of the assessment tool.
Individual interviews were conducted using the probing based
According to Bachelor (2013), to develop an instrument to measure paradigm, in which the inter viewer proactively guides the inter-
therapist experiences of the quality of the therapeutic relationship, action, asking questions and using probing questions (Willis, 2005).
the same scale structure of the instrument can be used as the For this purpose, retrospective probing (Willis, 2005) was used,
patient‐reported version, since the goal is to compare experiences of where the participant responds to the complete questionnaire
both participants in the therapeutic relationship. Because of this, four after which the interview takes place. Three physiotherapists
researchers (ORN, JMB, ARMP, VZC) independently revised the (ORN, JMB, VZC), members of the research team with experience
original version of the PCTR‐PT, and each developed a new version as interviewers, conducted the interviews. There was a consensus
aimed at physiotherapists while maintaining the four dimensions of meeting on the strategies to use in the interview (asking what the
the original instrument. The four reviewers were physiotherapists person had understood from the question or asking the partici-
with practical and academic experience in the study of the thera- pant to restate the questions using different wording). The re-
peutic relationship, with the aim of meeting the first of the Interna- searchers began by informing the participant of the study aim and
tional Test Commission guidelines (Hernández et al., 2020) for the provided an informed consent for the participant to sign. The
adaptation of questionnaires (ensuring that the adaptation process participant subsequently completed the questionnaire. The partic-
considered the linguistic and cultural differences between the pop- ipant was informed beforehand not to ask the researcher the
ulations to which the adapted versions of the test are addressed). For meaning of any question. Should any participant have a query,
each of the items, physiotherapists were asked about their percep- they were asked to write the same in a blank text box included in
tions of their own actions and behaviors. The four versions were the questionnaire. All interviews were recorded and transcribed
compared and the researchers agreed on a preliminary version. It verbatim.
was agreed that the item would be definitive when a minimum of
75% agreement was reached among the four participants (Finger
et al., 2006; Hamilton et al., 2018). 2.2.1 | Settings and participants
The following selection criteria was established: (1) physiotherapists

2.2 | Stage 2. Pre‐testing of the questionnaire who were currently working in a physiotherapy service; (2) physio-
therapists who had worked at least 15 days in their current work
With the preliminary version obtained after the stage 1, a cognitive center.
pre‐test was performed, with the following objectives: (1) To eval- The participants were recruited from two hospitals within
uate the understanding of the items and of the response options; (2) the Spanish public health system (Elche, Vinalopó), six private phys-
To evaluate the clarity of the language and format; (3) To evaluate iotherapy centers (Alicante, Orense, León), and two Universities
FIGURE 1 Study stages.

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(Cardenal Herrera CEU, Universidad deLeón), using convenience using the generalized least squares method, which has the same
sampling methods. properties as the maximum likelihood method but under less rigorous
multivariate normality considerations, being used mainly for items of
ordinal measurement level (Batista‐Foguet et al., 2004), which allows
2.2.2 | Data analysis robust calculation of the factor structure in terms of fit.
To determine the quality of the overall fit of the factorial
Two researchers (ORN and JMB) analyzed the participants' re- model, the selected indexes and their corresponding values were
sponses and coded any possible problems. For this purpose, a coding established according to those proposed by Marôco (2014) these
system was created, which corresponded with the four stages of the being: Normalized Chi‐square, defined as the ratio of the Chi‐
question‐response process of CASM (Schwarz, 2007), adding a square value to the number of degrees of freedom (χ2/df), root
category related to instrument logic (Supporting Information S1: mean square error of approximation (RMSEA), root mean square
Appendix A). Subsequently, the research team (ORN, JMB, ARMP, error index (RMR), Tucker‐Lewis index (TLI), comparative fit index
VZC), met, discussed, and reached an agreement by consensus on (CFI), goodness‐of‐fit index (GFI), and standardized root mean
whether to keep, modify, or remove each potentially defective item. square residual (SRMR). Thus, values below 0.08 are considered
Any potential problems were addressed from both a quantitative acceptable, and those equal to or below 0.05 excellent for the
point of view (items with a frequency of acceptance below 85% RMSEA, RMR and SRMR indices. Regarding TLI, CFI and GFI, re-
required revision) as well as a qualitative point of view. This collab- sults above 0.90 or 0.95 are interpreted as a good fit to the data;
orative approach sought to eliminate the potential bias of a single while to establish a correct model it is necessary for the relation-
researcher's perspective. ship χ2/df to be < than 3 (Hauck‐Filho & Valentini, 2020;
Schermelleh‐Engel et al., 2003)
2.3 | Stage 3. Analysis of psychometric properties

2.3.3 | Convergent validity
In this phase, the selection criteria were the same that in stage 2. An
online cross‐sectional survey of Spanish physiotherapists was con- This was carried out through the Average Variance Extracted (AVE),
ducted. Google Docs platform was used to create the survey, acti- which is considered adequate if a value greater than 0.50 is obtained
vating the option of one response per user to avoid duplicate (Hair et al., 2018; Ramos et al., 2018).
responses. The electronic form included a questionnaire with the
physiotherapists' sociodemographic and professional data and the
physiotherapist‐adapted version of the PCTR‐PHYS. To distribute 2.3.4 | Internal consistency
the questionnaire, we contacted various institutions involving phys-
iotherapists (professional associations, public and private health Cronbach's alpha coefficient was the index selected to verify internal
centers) as well as personal contacts of the researchers. consistency, both for the complete scale and for each of the sub-
scales, establishing as acceptable all values equal to or greater than
0.70 (Hu & Bentler, 1999). In addition, the composite construct
2.3.1 | Statistical analysis reliability value was also calculated, for which values above or equal
to 0.70 are associated with good internal consistency (Bagozzi &
To evaluate and conceptualize the demographic characteristics of the Yi, 1988; Hair et al., 2018).
professionals in the sample, the following analyses were performed.
2.3.5 | Temporal stability or test‐retest

2.3.2 | Construct validity
The temporal stability of the instrument was tested by administering
The factor structure of the scale, the number of subscales or di- the questionnaire to a subsample of n = 75 participants obtained
mensions and the total number of items, was verified by performing from the initial sample. This new data collection was carried out
an exploratory factor analysis of the instrument. To do so, the rec- 2 weeks after the first collection. The intraclass correlation coeffi-
ommendations of Lorenzo‐Seva were followed (Lorenzo‐Seva, 1999) cient (ICC) was used to verify the aforementioned stability, according
using the generalized least squares method for extraction and the to the two‐way mixed method and taking as values of acceptable
oblique rotation method (promin), in order to maximize the simplicity reliability those between 0.70 and 0.80; good for values between
of the factors. In addition, we obtained the values of the Kaiser‐ 0.80 and 0.90 and those above 0.90 as reflecting excellent reliability
Meyer‐Olkin index (KMO) and Bartlett's sphericity test (χ2). (Fleiss, 2011; Terwee et al., 2007).
The factorial validity, goodness of fit and psychometric proper- AMOS statistical software (v. 26, SPSS, An IBM Company) and
ties of the scale were analyzed by confirmatory factor analysis (CFA) EQS (Multivariate Software, Inc.) were used to carry out the analyses.
- 5 of 11
T A B L E 1 Sociodemographic characteristics of participants'

2.3.6 | Ethical considerations pre‐cognitive test.
Sex Nº %
All participants granted consent in stage 2 and 3 of the study. Par-
Male 17–51.5
ticipants provided informed written consent and indicated whether
they wanted to be explicitly acknowledged in this paper. This study Female 16–48.5
was approved by the Ethics Committee of the University of León. Age (years) n%
21–31 7–21.2
31–41 13–39.4
3 | RESULTS
41–51 10–30.3
3.1 | Stage 1. Item generation 51–62 3–9.1
Mean (years) 39
The participants in the adaptation of the scale items were 4 phys-
Professional experience (years) n%
iotherapists, all male with an average age of 47.5 years, an average of
16.5 years of clinical practice and 12.22 years of university teaching 1–11 8–24.2
practice. The four doctors, two of them in the field of therapeutic 12–22 19–57.6
relationship and other in the field of construction and validation of 23–33 3–9.1
scales. A meeting was held via meet to compare and agree on the
34–44 3–9.1
final version. A 100% agreement was reached on 14 items in the first
Mean (years) 18.08
round. Only on the item “I make my patient believe that he/she has the
ability to cope with his/her own effort” there was 50% agreement, so it Hospital type n%
had to be discussed in depth. After discussion, 100% agreement was Public 10–30.3
reached and the item was finally agreed: “I help my patient to believe in
Private 23–69.7
his ability to improve with his own qualities.”
Pathology n%
Traumatology 19–57.6
3.2 | Stage 2. Pretesting of questionnaire Pelvic floor 5–15.1
Neurology 2–6.1
Two rounds of cognitive interviews were performed with the
Geriatrics 2–6.1
preliminary version of the scale involving 33 participants (n = 21 in
the first round and n = 12 in the second round). The participants Rheumatology 2–6.1
were 17 men and 16 women with an average age of 39 years and Sporty 1–3
an average of 18 years of professional experience as physiother- Pediatrics 1–3
apists. Of these, 69.7% worked in private clinics and 57.6%
Mental health 1–3
worked with trauma patients. A table with the sociodemographic
characteristics of the sample used in the study is shown below
(Table 1). cognitive interviews was performed. In this second round, all the
Each interview lasted between 24 and 66 min. The mean time items fulfilled the quantitative acceptance criteria, no important
that participants took to complete the questionnaire was 2 min 58 s potential problem was detected from the qualitative point of view
(1 min the fastest and 5 min and 47 s the slowest). The perceived and there were no new suggestions, neither were there any potential
length of the same was deemed appropriate for all participants problems in the format of the document or with the order of the
(100%). The mean perceived difficulty of the questionnaire was 2 questions.
(0 = very easy; 10 = very difficult). The final tool includes 15 items divided into four domains. The
The qualitative analysis of the interviews revealed potential response format is based on a 5‐point Likert frequency scale.
problems affecting nine items during the first round, and six items Response options range from “strongly agree” to “strongly disagree.”
during the second round. These concerned the statement of the
items. Thus, 57 potential problems were detected in the first round,
and eight in the second round (the results of the cognitive pretest can 3.3 | Stage 3. Psychometric properties assessment
be consulted in Supporting Information S1: Appendix B).
After the analysis of the first round, three items were reformu- Of the total sample (n = 343) used in stage 3 (Table 2), 66.2% were
lated, based on the problems encountered and after discussion and female and 33.8% were male, with a mean age of 39.45 years
consensus among four members of the research team (ORN, JMB, (SD = 10.1), 26.2% held a master's degree and 6.1% held a PhD. The
ARMP, VZC). With the refined questionnaire, a second round of mean years of work experience was 18 years and the mean time in
6 of 11
TABLE 2 Socio‐demographic characteristics of the sample (n = 343).
Clinical and socio‐demographic characteristics of the sample n Percentage (%) Mean SD
Gender (n = 343)
Male 116 33.8
Female 227 66.2
Age (n = 343) 39.45 10.1
18–26 39 11.4
27–59 297 86.6
>60 7 2.0
Academic education (n = 343)
Degree 232 67.6
Masters 90 26.2
PhD 21 6.1
Professional experience (years) (n = 343) 18.0 17.0
1 year 5 1.5
1–5 years 67 19.5
6–10 years 46 13.4
>10 years 225 65.6
Current time in work position (years) (n = 323) 8.1 7.9
1 year 43 12.5
1–5 years 112 32.7
6–10 years 52 15.2
>10 years 116 33.8
Work environment (n = 343)
Public 134 39.1
Private 184 53.6
Privately managed with state funding 25 7.3
Type of employment (n = 343)
Self‐employed 83 24.2
Employed 260 75.8
Type of patients (n = 330)
Neurological patient 37 10.8
Geriatric patient 23 6.7
Mental health and disability patient 6 1.7
Sports patient 8 2.3
Traumatology patient 125 36.4
Pediatric patient 23 6.7
Gynecology/urology patient 7 2.0
Others 101 29.4
their current job was 8.1 years. Over half of the participants (53.6%) (36.4%) and neurological (10.8) needs; whereas 29.4% treated pa-
worked in the private sector and almost three‐quarters of the sample tients with a wide variety of symptoms.
(75.8%) were salaried employees. Almost 50% of the respondents A table with the sociodemographic characteristics of the sample
stated that most of the patients they see are related to trauma used in the study is shown below.
- 7 of 11
3.3.1 | Construct validity model. Given the problems associated with the use of this test, other
statistical tests were analyzed to evaluate the proposed theoretical
3.3.1.1 | Factorial structure model, indices that otherwise reflected an acceptable model fit.
The results of the exploratory factor analysis showed that the
dataset was adequate for EFA ([KMO] coefficient = 0.875, Barlett's
Test of Sphericity (χ2) = χ2 = 2387.431, p < 0.000). Subsequently, the 3.3.2 | Convergent validity
factor loadings of each of the items, overlap and the screen plot were
checked, and their factor loadings were greater than 0.40. Thus, the Analyzed using the AVE (Table 4), values >0.50 were obtained for the
structure of the scale consisted of four dimensions and 15 items (RB total scale (0.058) and for the dimensions PE (0.619) and TC (0.689),
[N items = 4]; IP [N items = 4]; PE [N items = 3] and TC [N items = 4]), while for the dimensions RB (0.362) and IP (0.388), these scores were
with a total explained variance of 67.6 (Kline, 2015; Lorenzo‐ below 0.50.
Seva, 1999). The final version of the PCTR‐PT is included as Sup-
porting Information S1: Appendix C (Spanish version) and Supporting
Information S1: Appendix D (English version). 3.3.3 | Internal consistency
The results of the factor analysis enabled the construction of a
model with four factors whose standardized solution is shown in Table 4 shows the values of internal consistency analyzed by Cron-
Figure 2 and whose overall fit indices are shown in Table 3. The result bach's alpha coefficient and by composite reliability. Regarding
of the chi‐square test was significant (χ2(81) = 136.958; p < 0.000), Cronbach's alpha, the values ranged between 0.70 and 0.89. As for
these values allow us to reject the hypothesis of a perfectly adjusted the composite reliability, these values ranged between 0.67 and 0.93.
F I G U R E 2 Factor loadings derived from

the LS estimation (least squares) CFA (λij). CFA,
confirmatory factor analysis; IP, individualized
partnership; PE, professional empowerment;
RB, relational bond; TC, therapeutic
communication.
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3.3.4 | Temporal stability or test‐retest occupational characteristics of the participating physiotherapists

being similar to those of other studies (Rodríguez‐Nogueira, Leirós‐
The ICC analysis revealed very good scores for both the total values Rodríguez, Pinto‐Carral, Álvarez‐Álvarez, Fernández‐Martínez,
(ICC = 0.908, F = 13.56, p < 0.000) and the 95% confidence intervals, et al., 2022; Rodríguez‐Nogueira, Leirós‐Rodríguez, Pinto‐Carral,
which ranged from 0.873 to 0.936 for the RCTP measurement. Álvarez‐Álvarez, Morera‐Balaguer, et al., 2022).
Regarding the scores for each of the dimensions, the values obtained In relation to the content validity of the instrument, it should be
ranged from 0.784 (RB) to 0.839 (TC) (Table 4). noted that both in the first stage, where the items were generated,
and in the second stage, where the cognitive pre‐test was carried out,
standard quality criteria determined by the International Test Com-
4 | DISCUSSION mission were followed (Hernández et al., 2020). Thus, thanks to the
two rounds of cognitive interviews conducted with physiotherapists,
The aim of this study was to adapt the patient version of the PCTR it was possible to identify difficulties in certain items, thereby
scale to a version for physiotherapists and to study its psychometric resolving the problems of understanding and the ability to respond to
properties. Both the adaptation process and the results obtained these items (Peterson et al., 2017).
confirm the PCTR‐PHYS scale as being a valid and reliable instrument Regarding construct validity, the results of the CFA show that
for assessing the quality of the person‐centered therapeutic rela- the instrument maintains the same four‐factor structure of the pa-
tionship from the physiotherapist's perspective. tient version with acceptable model fit indices (Rodríguez‐Nogueira,
The characteristics of the participating physiotherapists were Morera Balaguer, et al., 2020).
similar in each stage. In the case of the cognitive interviews, phys- Concerning the convergent validity, analyzed by means of the
iotherapists were selected intentionally in order to detect whether AVE, values >0.50 were obtained for the total scale and for two
the interpretation of the items was different from what was intended of the four dimensions. In the RB and IP dimensions, the values
by the team that generated the items (Peterson et al., 2017). The were lower than 0.05, which means that these dimensions present
psychometric properties were analyzed in a sample of 343 physio- some difficulty in sharing more than 50% of their variance with
therapists from different centers, with the sociodemographic and their elements (Hair et al., 2018; Ramos et al., 2018), however,
further studies are needed to determine the trend of these
values.
TABLE 3 Indices of goodness of fit of the confirmatory model. As for the reliability of the instrument, the results obtained for
composite reliability and internal consistency by means of Cron-
Index Value
bach's alpha were very similar with acceptable values for both the
CFI 0.976
instrument as a whole and for each of its factors. Finally, it should be
TLI 0.969 noted that excellent results were also obtained for test‐retest
GFI 0.950 reliability.
It should be noted that the PCTR scale, with its versions for
SRMR 0.040
patients (PCTR‐PT) and physiotherapists (PCTR‐PHYS), is the first
RMSEA 0.045
instrument that will enable the evaluation and comparison of the
RMR 0.027 experiences and perceptions of the two actors involved in the ther-
Goodness of fit test χ2 = 136.958; gl = 81; p < 0.0001 apeutic relationship in physiotherapy contexts. The concordance in
Reason for fit χ2/gl = 1.69 (<3)

these experiences and perceptions is related to treatment outcomes
(Bachelor, 2013; Tryon et al., 2007) which indicates the importance
Abbreviations: CFI, comparative fit index; GFI, goodness of fit index;
of being able to measure them, and to know in which parameters
RMR, Root Mean Residual; RMSEA, Root Mean Standard Error of
Approximation; SRMR, standardized root mean square residual; TLI, they differ in order to improve the therapeutic relationship in
Tucker‐Lewis index. physiotherapy services.
T A B L E 4 Internal consistency:
Factors ICC (95% CI) Composite reliability Cronbach's alpha AVE
Cronbach's alpha for each dimension and
F1. RB 0.784 (0.699–0.851) 0.673 0.704 0.343 after item‐reduction (n = 343),
test‐retest reliability comparing T1 with
F2. IP 0.746 (0.623–0.832) 0.692 0.710 0.365
T2: ICC on scale level (n = ) of the RCTP.
F3. PE 0.820 (0.749–0.877) 0.830 0.830 0.621
F4. TC 0.839 (0.772–0.891) 0.899 0.898 0.671
Total 0.908 (0.873–0.936) 0.938 0.863 0.508
Abbreviations: ICC, intra‐class correlation coefficient; IP, individualized partnership; PE, professional
empowerment; RB, relational bond; TC, therapeutic communication.
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This study is not exempt from some limitations. Firstly, it should CO N F L I C T O F I N T E R E S T S T A T E M E N T

be noted that the instrument was adapted in the Spanish context and Any potential conflicts of interest are disclosed. All individuals named
therefore cannot be generalized to other contexts. Secondly, it as authors qualify for authorship. All persons listed as authors have
should be considered that convenience sampling was carried out and participated sufficiently in the work to take public responsibility for
this may lead to a selection bias. However, the characteristics of the the content of the manuscript.
sample correspond to those of the Spanish population of
physiotherapists. DA T A A V A I L A B I L I T Y S T A T E M E N T
Future studies may compare measures of the quality of the The data extracted from each phase of the study is held by the au-
therapeutic relationship from the perspective of both patients and thors and is available on request.
physiotherapists at the same moment in the relationship. These re-
sults could provide insight into the gap between the two and identify E T HI C S S T A T E M E N T
areas for improvement in clinical practice. In addition, future studies The ethical approval of this study was obtained from the research
could adapt versions of the scale to other contexts and cultures and ethics committee of the University of León (SPAIN), reference
perform a multi‐group comparison to assess the scale's measurement number: ULE‐034‐2021. As this was not an experimental study, it
invariance. was not registered as a clinical trial.
In conclusion, the process of adapting the PCTR‐PT instrument
to a version for physiotherapists (PCTR‐PHYS) and the psychometric P A T I E NT C ON S E N T S T A T E M E N T
properties of the new instrument in a sample of Spanish physio- All participants granted informed consent in stage 2 and 3 of the
therapists are presented. It is a valid and reliable tool, which is easily study.
administered and allows the quality of the person‐centered thera-
peutic relationship to be assessed from the perspective of P E R M I S S I O N T O R E P R O DU C E M A T E R I A L F R O M OT H E R
physiotherapists. SOURCES
The authors have permission to reproduce the material included in
the study.
5 | IMPLICATIONS ON PHYSIOTHERAPY
PRACTICE OR CI D
Óscar Rodríguez‐Nogueira https://orcid.org/0000-0002-4203-5784
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How to cite this article: Rodríguez‐Nogueira, Ó., Balaguer, J.
probing, and other Techniques. In C. S. P. Thousand Oaks (Ed.),
Cognitive interviewing (pp. 42–65). SAGE Publications, Inc. https://doi. M., Nogueira López, A., Merino, J. R., Zamora‐Conesa, V., &
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to a version for physiotherapists (PCTR‐PHYS) and evaluation
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Additional supporting information can be found online in the Sup- International, 28(4), e2007. https://doi.org/10.1002/pri.2007
porting Information section at the end of this article.
DOI: 10.1002/pri.2011
RESEARCH ARTICLE
- -
Revised: 13 April 2023 Accepted: 19 April 2023
Transformational leadership vs. proactive personality:

Contributing factors to physiotherapists proactive behaviors
and burnout during the SARS‐COV‐2 pandemic
Vadim Myaskovetsky1,2 | Liora Shmueli1
1
Department of Management, Bar‐Ilan
University, Ramat‐Gan, Israel Abstract
2
Meuhedet Health Fund, Tel Aviv, Israel Background: In May 2019, the World Health Organization (WHO) added burn out
to the list of occupational phenomena in the 11th Revision of the International
Correspondence
Liora Shmueli, Department of Management, Classification of Diseases (ICD‐11). Soon thereafter, in March 2020, a global
Bar‐Ilan University, Ramat‐Gan 52900, Israel. pandemic of SARS‐COV‐2 was declared.
Email: liora.shmueli@biu.ac.il
Objective: To investigate the interplay between transformational leadership, a
proactive personality, employee proactive behaviors, and burn out in the field of
physiotherapy during the SARS‐COV‐2 pandemic.
Methods: Physiotherapists working at the Meuhedet Health Maintenance Organi-
zation (HMO) were asked to fill an online cross‐sectional survey, in which they were
asked to evaluate the transformational behavior of their manager and to assess
their own burn out rate, degree of self‐efficacy, proactive personality, and proactive
behaviors. Eighty‐one physical therapists (average age of 37.3 years (SD = 9.0))
responded to the survey, most of whom were female (67.9%, n = 55).
Results: Transformational leadership and proactive personality were negatively
associated with occupational burn out (β = −0.231, p < 0.05, β = −0.243, p < 0.05,
respectively) among physiotherapists. The effect of the interaction between
transformational leadership and proactive personality on proactive behaviors at
work was not significant. However, a strong, significant positive relationship was
found between proactive personality and proactive behaviors (β = 0.425, p < 0.001),
and between self‐efficacy and proactive behaviors (β = 0.479, p < 0.001).
Conclusions: This up‐to‐date survey of transformational leadership and proactive
personality among physiotherapists highlights these traits' important impact on
burn out and proactive behaviors during the SARS‐COV‐2 pandemic. Furthermore,
the transformational manager plays an important role in reducing burnout levels
among physiotherapists, especially during a crisis such as the SARS‐COV‐2
pandemic.
KEYWORDS
burnout, physical therapists, proactive behaviors, SARS‐CoV‐2, transformational leadership
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- MYASKOVETSKY and SHMUELI
1 | INTRODUCTION improve their well‐being, morale and ability to cope with challenges
and alleviate their stress—all factors that reduce the level of burnout
Burn out, a syndrome that results from chronic workplace stress, is a (Boamah et al., 2018; Hetland et al., 2007; Nielsen et al., 2009;
major concern among healthcare workers. Beyond directly affecting Raup, 2008). Previous studies have likewise found main, positive ef-
the employee, typically presenting as a lack of engagement (Hetland, fects of transformational leadership and role breadth self‐efficacy on
Sandal, and Johnsen, 2007), it also impinges upon the workplace and employee proactive behavior. Role breadth self‐efficacy denotes how
its goals, for example, in the form of reduced work efficiency, a sig- confident employees are to carry out a range of proactive, interper-
nificant decline in patient satisfaction, and poor patient outcome. The sonal, and integrative tasks (Den Hartog and Belschak, 2011).
growing awareness as to burn out's determinantal consequences led The importance of transformational leadership among HCWs is
the World Health Organization (WHO) to define it as an occupational being increasingly acknowledged, especially among physicians and
phenomenon in May 2019 and to include it in the 11th Revision nurses but also among other healthcare workers, such as physio-
of the International Classification of Diseases (World Health therapists. Yet, only a few studies have been conducted on leadership
Organization, 2019b). among physiotherapists. Consequently, there is insufficient knowl-
To date, most studies on burnout have focused primarily on edge concerning the mechanisms that link transformational leaders
physicians and nurses, with only a few shining a light on its impact on and employee outcomes such as burnout and proactive behavior
physiotherapists. Yet, as revealed by a large survey conducted by the among physiotherapists, especially during the SARS‐COV‐2 pandemic.
Israel Ministry of Health in 2017, there are high levels of burnout A proactive personality refers to the relatively stable tendency of
among physiotherapists. Their mean score in the survey was 3.35, an employee to effect environmental change, the outcome of which is
with any burnout score above 3 in studies of health systems around a proactive behavior (Crant, 2000), which could be at the individual,
the world is considered a high score that calls for immediate treat- team, or organizational level (Strauss et al., 2017). This trait is assessed
ment (Israeli Ministry of Health, 2018). using four of the highest loading items in Bateman and Crant's (1993)
Physiotherapy burn out can be attributed to the growing demand scale (e.g., “I am excellent at identifying opportunities”). The impor-
for physiotherapy services, primarily due to the increase in the aging tance of having a proactive personality is consistent with previous
population and prevalence of a sedentary lifestyle. The combination research showing significant links to proactive outcomes, higher
of these two factors has been shown to directly affect many types of physiotherapy health and well‐being and lower levels of burnout
morbidity and has been defined as the 4th leading risk factor for (Alarcon et al., 2009; Martinussen, Borgen, and Richardsen, 2011). Yet,
global mortality (World Health Organization, 2019a). The direct we are unaware of any study exploring how possessing a proactive
outcome is that physiotherapists need to treat more patients for personality can serve as a predictor of physiotherapist burnout and
longer periods of time, a trend reflected in their ever‐increasing proactive behaviors, including during SARS‐COV‐2, and the contri-
workloads. This state of affairs oftentimes leads to burnout, which bution of a proactive personality to these outcomes.
requires proactive behaviors from physiotherapists to cope with this Proactive behaviors and initiatives are also a critical determinant
phenomenon. of organizational success. This would suggest that recruitment prac-
The pressure on physiotherapists increased during the SARS‐ tices are more important than changes to the work environment.
COV‐2 pandemic, which broke out in the beginning of 2020. The in- Nevertheless, transformational leadership may also enhance
tensity and urgency of the SARS‐COV‐2 outbreak challenged employee proactive behavior (Strauss et al., 2017) when the empow-
healthcare workers, in addition to the standard demands of their job, erment of health care providers is needed. If successful, the health care
thereby negatively affecting their work environment (Mehta provider will be highly motivated, well informed, committed to the
et al., 2021). Specifically, this new environment included new protec- organization's goals—and will thus deliver patient care with greater
tion guidelines, limitations and restrictions on the types of treatments effectiveness (Pritchard and Kay, 1993; Rozenblum & Lev‐Ari, 2015;
that can be administered, and uncertainty—all of which affect the Shoji et al., 2016a; Strauss et al., 2017). Hence, it is unclear which factor
work environment of physiotherapists. For example, occupational contributes more to the outcomes of burnout and proactive behaviors
uncertainty, combined with the disease, may cause anxiety and stress, among physiotherapists. Is it the proactive personality of the employee
reduce job performance and increase burnout (Wu et al., 2020). or the transformational leadership of his/her manager?
Two factors that have been shown to reduce burnout levels, as The current study investigated the relationship between trans-
well as increase employee proactive behaviors (i.e., taking initiative in formational leadership (of the manager) and employees' proactive
improving current circumstances or creating new ones (Crant, 2000)), personality as associated factors of employee proactive behaviors
are transformational leadership and employees' proactive personality. and burnout among physiotherapists during the SARS‐COV‐2
Transformational leaders are managers who work to identify needed pandemic. Our main objectives of the study were:
changes and inspire and work together with their team to implement
these changes. Previous studies demonstrated that transformational 1. To evaluate the relationship between transformational leadership
leadership has a positive influence on work behavior (Avolio and burnout among physiotherapists.
et al., 2004) and on burnout. For example, a manager who implements 2. To evaluate the relationship between transformational leadership
a transformational leadership approach toward his employees can and proactive behaviors at work among physiotherapists.
MYASKOVETSKY and SHMUELI
- 3 of 10
3. To evaluate the role breadth of self‐efficacy as a moderating leadership style assessment instrument (7 questions); (2) burnout
variable in the relationship between transformational leadership assessment instrument (9 questions); (3) self‐efficacy assessment
and proactive behaviors at work among physiotherapists. instrument (7 questions); (4) proactive behavior assessment
4. To evaluate the relationship between demographic and profes- instrument (13 questions); (5) proactive personality assessment
sional variables and burnout and proactive behaviors at work instrument (4 questions) and (6) socio‐demographic and profes-
among physiotherapists. sional assessment instrument (14 questions). Each one of the in-
5. To evaluate the interaction between transformation leadership struments used in sections 1–6 were based on an existing reliable,
and proactive personality with burnout at work. valid questionnaire; the validity and reliability data are described
6. To evaluate the interaction between transformation leadership in detail below. The questionnaire took less than 10 min to
and proactive personality with proactive behaviors at work. complete.
2 | METHODS 2.5 | Measurement and variables
2.1 | Study design The two dependent variables were burnout at work and proactive
behaviors.
We conducted a cross‐sectional, online survey among physiothera- Burnout at work was measured using a short version of the
pists working at the Meuhedet Health Maintenance Organization Maslach Burnout Inventory (MBI), Cronbach's α = 0.87 (Iverson
(HMO) in Israel, at the end of May 2020, right after the first quar- et al., 1998). A 5‐point Likert‐type scale format (1‐ Strongly Disagree,
antine in Israel was announced. Participants were asked to evaluate 5‐ Strongly Agree) was used to measure employee perception to each
their manager using a transformational behavior questionnaire and of the nine items in the questionnaire (e.g., “I feel worn out in my
to assess their own burn out rate, degree of self‐efficacy, proactive work").
personality, and proactive behaviors. Proactive behavior was measured using the questionnaire pre-
sented by Parker & Collins (Parker & Collins, 2010), Cronbach's
α = 0.7. A 5‐point Likert‐type scale format (1‐ Low Frequency, 5‐
2.2 | Ethics Very High Frequently) was used to measure employee perception to
each of the thirteen items in the questionnaire (e.g., “How frequently
Exemption from the need for Helsinki approval was obtained from do you generate creative ideas?”).
the Meuhedet HMO Ethics Committee. At the beginning of the The three independent variables were as follows: (1) Trans-
questionnaire form, the participants were provided with a full formational Leadership, measured using the GTL questionnaire by
explanation of the structure and essence of the study and that it was Carless, Cronbach's α = 0.9 (Carless et al., 2000). A 5‐point Likert‐
anonymous. This explanation constituted informed consent to type scale format (1‐ Strongly Disagree, 5‐ Strongly Agree) was
participate in the study. used to measure employee's perception for each of the seven items
The participants were informed that participation was voluntary, in the questionnaire (e.g., “My manager gives encouragement and
and that they had the right to refuse to participate. recognition to staff”). (2) Proactive Personality, measured using the
Proactive Personality scale, Cronbach's α = 0.87 (Parker et al., 2006).
A 5‐point Likert‐type scale format (1‐ Strongly Disagree, 5‐ Strongly
2.3 | Participants and sampling Agree) was used to measure employee's perception using four of the
highest loading items in Bateman and Crant's scale (Bateman &
Inquiries were sent by email to the 250 physiotherapists employed Michael Crant, 1993) (e.g., “I am excellent at identifying opportu-
directly by the Meuhedet HMO in Israel. The staff works in 45 nities”). (3) Demographic and professional variables, which included
different clinics scattered throughout Israel, including in clinics that age, gender, marital status, work experience, seniority at present
provide services to specific ethnic groups. The clinics' locations were role, number of jobs, academic education and salary.
not collected from the participants to ensure the anonymity of the The moderating variable, role breadth self‐efficacy, was
respondents. The managers of these clinics are themselves physio- measured using a questionnaire by Parker et al. (2006), Cronbach's
therapists who have advanced to managerial roles. α = 0.93. A 5‐point Likert‐type scale format (1‐ Strongly Disagree, 5‐
Strongly Agree) was used to measure employee perception (e.g., “I
feel confident helping to set targets in my area”). The obtained data
2.4 | Evaluation instrument was then assessed using the seven highest loading items from
Parker's (1998) measure of this construct.
The questionnaire we used consisted of 54 questions, divided Figure 1 provides a visual representation of the study
into the following sections and instruments: (1) transformational hypotheses.
4 of 10
F I G U R E 1 The hypotheses of the study. Research Hypothesis. The relationship between transformational leadership and burnout at work.
H1: Transformational leadership is negatively associated with occupational burnout among physiotherapists, the more transformational the
leader is, lower level of burnout of the employee will be reported. H2: Proactive personality is negatively associated with lower burnout rate at
work among physiotherapists, the more proactive an employee is, the lower the level of burnout he will report. The relationship between
transformational leadership and proactive behavior at work. H3: Transformational leadership is positively associated with a higher rate of
proactive behaviors at work among physiotherapists, the more transformational the leader is, higher levels of proactive behavior of the
employee will be reported. H4: The relationship between transformational leadership and proactive behaviors at work will be mediated by the
role breadth self‐efficacy. H5: Among physiotherapists without a proactive personality, proactive work behavior is higher in the presence of a
manager with transformational leadership. H6: Among physiotherapists without a proactive personality, burnout at work is higher in the
presence of a manager with transformational leadership.
2.6 | Statistical analysis combination with NFI, CFI, and TLI above 0.95 indicate an excellent
fit, whereas values below 0.08 and above 0.90, respectively, indicate
The general model of the study is a quantitative model. The data from an adequate fit. Specifically, the PA included the direct effects of
the questionnaire file was exported to SPSS software (version 25.0; proactive personality and transformational leadership on burnout
SPSS Inc.), and all the statistical analyses were performed using this while simultaneously testing the direct effects of proactive person-
software. Descriptive statistics were used to characterize the sample. ality, transformational leadership, and self‐efficacy as well as the
Predications of burnout and proactive behavior were examined using moderating effect of self‐efficacy (via the use of an interaction term
hierarchical multivariate linear regression analyses. The interaction between transformational leadership and self‐efficacy) on proactive
terms were entered at the last step of the regression analyses, after work behavior.
the blocks of independent variables had been entered. Follow‐up A Cronbach's α internal reliability method revealed the internal
analyses for interaction effects were explored only if the last consistency of transformational leadership assessment to be Cron-
involving interaction effects resulted in a significant increase in the bach's α = 0.90, of burnout assessment.
2
explained variance (R ). Cronbach's α = 0.76, of self‐efficacy assessment Cronbach's
Path analysis (PA) was conducted as a robustness analysis to test α = 0.86, of proactive behavior assessment Cronbach's α = 0.91, and
the correlation of proactive personality and transformational lead- of proactive personality assessment Cronbach's α = 0.79.
ership with burnout while simultaneously testing the correlation of
proactive personality, transformational leadership, self‐efficacy, and
the interaction between transformational leadership and self‐efficacy 3 | RESULTS
with proactive work behavior (See Supplementary Material S1, Table
, Figure S1). In the model, correlations were specified between all 3.1 | Participant characteristics
exogenic variables and between the two endogenic variables. The
analysis was conducted using AMOS 25 (SPSS Inc.) with the About 32% (81/250) of the questionnaires were fully completed. The
maximum likelihood estimation procedure. Following accepted baseline characteristics of the respondents are presented in Table 1.
guidelines (Hoyle, 1995; Weston & Gore, 2006), the fit of the model Most of the respondents are female (67.9%, n = 55), with an average
to the data was evaluated using five goodness‐of‐fit indices. Two of age of 37.28 years (SD = 9.02), married (76.5%, n = 62), and 39.5%
these indices were absolute: the χ2 statistic, and the Root Mean hold an advanced degree. On average, the participants had been in
Square Error of Approximation (RMSEA). The remaining three indices their current workplace for 6.77 years (SD = 6.54) About 46% earn
were incremental: the Normed Fit Index (NFI), the Comparative Fit between 5001 and 10,000 NIS per month when combining all their
Index (CFI) and the Tucker Lewis Index (TLI). RMSEA below 0.06 in income resources.
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TABLE 1 Sociodemographic and professional variables—Descriptive statistics.
Variable Category Frequency = N Percent = % Mean SD
Gender Male 26 32.1
Female 55 67.9
Total 81 100
Age 26–31 25 30.9 37.28 9.02
32–37 31 38.2
38–63 25 30.9
Total 81 100
Family status Single 14 17.3
Married 62 76.5
Divorced 1 1.2
Living with a spouse 4 4.9
Total 81 100
Professional seniority 1–5 29 35.8 10.87 9.54
6–11 27 33.3
12–42 25 30.9
Total 81 100
Professional seniority in Meuhedet 1–3 31 38.3 6.77 6.54
4–7 23 28.4
8–30 27 33.3
Total 81 100
Advanced degrees MPT 19 23.5
DPT 3 3.7
Master's in management 7 8.6
Other 3 3.7
No advanced degree 49 60.5
Total 81 100
Average wages in Meuhedet Under 5000 13 16
5001–10000 43 53.1
10001–15000 22 27.2
15001–20000 3 3.7
Total 81 100
Average wages in all occupations Under 5000 8 9.9
5001–10000 37 45.7
10001–15000 25 30.9
15001–20000 6 7.4
20001–25000 3 3.7
25001–30000 2 2.5
Total 81 100
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3.2 | Univariate analysis explaining 18.1% of its variance. A strongly significant positive rela-
tionship was found between proactive personality and proactive
Table 2 presents the correlation analysis performed between the behaviors (β = 0.425, p < 0.001).
variables using the Pearson correlation coefficient. A normal distri- In the third and last step, we inserted the interaction between
bution of the data was ensured prior to performing the statistical transformational leadership and proactive personality and its rela-
analyzes. In addition, scale reversal was performed on questions with tionship with proactive behaviors. As this step was not significant, no
a positive wording, to obtain uniformity in the direction of the scores. further analyses were performed for this relationship. Demographic
The mean level of burnout reported by the physiotherapists was data were not included in the regression analysis as no significant
2.16 (SD = 0.67) and was significantly related to both proactive associations were found with the dependent variables in the uni-
personality (r = −0.245, p.<0.05) and transformational leadership variate analyses.
(r = −0.231, p.<0.05). The mean level of proactive behaviors reported In the third hierarchical regression (Table 5), we examined the
by the physiotherapists was 3.30 (SD = 0.72) and was significantly interaction between transformational leadership and self‐efficacy
related to self‐efficacy (r = 0.451, p < 0.01) and proactive personality and their relationship with proactive behaviors. In the first step
(r = 0.425, p < 0.01). alone, transformational leadership was inserted as a factor; it did not
significantly associate with proactive behaviors. In the second step,
self‐efficacy was inserted and was positively associated with proac-
3.3 | Multivariate analyses tive behaviors, explaining 2.6% of proactive behaviors' variance. A
strong significant positive relationship was found between self‐
Three hierarchical multivariate linear regression analyses were per-
formed. In the first hierarchical regression (Table 3), we tested
transformational leadership, proactive personality, the interaction T A B L E 3 Hierarchical multiple regression analysis for the
between them, and their association with burnout. In the first step association of transformational leadership and proactive
personality with burnout (N = 81).
alone, transformational leadership was inserted as a factor and
explained 5.3% of the predicted burnout (adjusted R square = 0.053). Burnout
In the second step, proactive personality was inserted as a factor, Variables β ΔR2 R2
which added 5.9% to the explained burnout. Namely, together,
Block 1: Transformational Leadership (T.L) −0.231* 0.053* 0.053
transformational leadership and proactive personality explained
Block 2: Proactive Personality (P.P) −0.243* 0.059* 0.112
11.2% of the variance in burnout. In the third and last step, we
inserted the interaction between transformational leadership and Block 3: Interaction effects T.L X P.P 0.110 0.011 0.123
proactive personality with burnout. The interaction was calculated by *p < 0.05, **p < 0.01.
multiplying the standard deviation of the variables. As this step was
deemed insignificant, no further analyses were performed for this
T A B L E 4 Hierarchical multiple regression analysis for the
relationship. Transformational leadership and proactive personality
association of transformational leadership and proactive
(steps 1 and 2 in Table 3) were negatively associated with burnout
personality with proactive behaviors (N = 81).
(β = −0.231, p < 0.05; β = −0.243, p < 0.05, respectively).
In the second hierarchical regression (Table 4), we tested Proactive behaviors
transformational leadership, proactive personality, the interaction Variables β ΔR2 R2

between them, and their association with proactive behaviors. In the Block 1: Transformational Leadership (T.L) −0.065 0.004 0.004
first step alone, transformational leadership was inserted as a factor;
Block 2: Proactive Personality (P.P) 0.425** 0.181** 0.185
transformation leadership did not significantly associate with pro-
Block 3: Interaction effects T.L X P.P −0.025 0.001 0.186
active behaviors. In the second step, proactive personality was
inserted and was positively associated with proactive behaviors, *p < 0.05, **p < 0.01.
T A B L E 2 Research variables
Variables Mean SD 1 2 3 4 5 6
univariate analyses.
1. Transformational leadership 3.93 0.95 ‐
2. Burnout 2.16 0.67 −0.231* ‐
3. Self‐efficacy 3.73 0.74 0.185 −0.263 ‐
4. Proactive behaviors 3.30 0.72 −0.065 −0.155 0.451** ‐
6. Proactive personality 3.42 0.75 0.009 −0.245* 0.200 0.425** −0.110 ‐
*p < 0.05, **p < 0.01.

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T A B L E 5 Hierarchical multiple regression analysis to evaluate

self‐efficacy as moderator in the relationship between leadership and proactive personality on burnout. No interaction
transformational leadership and proactive behaviors (N = 81). was found in this relationship (β = 0.110, p < 0.05) (step 3 in
Table 3).
Proactive behaviors
Variables β ΔR2 R2
Step 1: Transformational Leadership (T.L) −0.065 0.004 0.004 4 | DISCUSSION

Step 2: Self‐Efficacy (S.E) 0.479** 0.222** 0.226
The present study examined the relationship of transformational
Step 3: Interaction effects T.L X S.E 0.035 0.001 0.227
leadership and proactive personality with burnout and proactive
*p < 0.05, **p < 0.01. behaviors among physiotherapists during the SARS‐COV‐2
pandemic. To the best of our knowledge, this study is one of the
efficacy and proactive behaviors (β = 0.479, p < 0.001). In the third first to examine the impact of the SARS‐COV‐2 outbreak on phys-
and last step, we inserted the interaction between transformational iotherapists in Israel. We also assessed the moderating role of self‐
leadership and self‐efficacy and its relationship with proactive be- efficacy in the relationship between transformational leadership
haviors, to examine the moderating effect of self‐efficacy on proac- and proactive work behavior of physiotherapists and the interaction
tive behaviors. As this step was not significant, no further analyses between employees' proactive personality in the relationship be-
were performed for this relationship. tween transformational leadership and burnout at work and proac-
Summary of the Hypothesis Testing tive behaviors.
Overall, we found the mean level of burnout among the phys-
H1 A bivariate correlation analysis was performed to test the cor- iotherapists to be relatively low. A literature review conducted
relation between transformational leadership and burnout. Consis- before the SARS‐COV‐2 pandemic found varied burnout levels, from
tent with our hypothesis, transformational leadership was negatively low to high, in all three dimensions, of the Maslach Burnout Inventory
correlated with burnout (r = −0.231, p < 0.05). (Rozenblum & Lev‐Ari, 2015). It is possible that the reason for the
relatively low levels of burnout detected in this study is the timing at
H2 A bivariate correlation analysis was performed to test the cor- which it was conducted, right after the first quarantine was
relation between proactive personality and burnout. Proactive per- announced in Israel, as perhaps the volume of activity decreased
sonality was negatively correlated with burnout (r = −0.245, during this period.
p < 0.05). Our examination of several associated factors that may explain
burnout at work among physiotherapists supports our hypothesis
H3 A bivariate correlation analysis was performed to test the cor- that transformational leadership is negatively associated with occu-
relation between transformational leadership and proactive behav- pational burnout among physiotherapists. We found that the more
iors at work. Transformational leadership was not significantly transformational the leader, the lower the reported levels of burnout
correlated with proactive behaviors at work (r = −0.65, p > 0.05). among physiotherapists. A transformational leader encourages
achievement and problem‐solving, strengthens the commitment to
H4 A Hierarchical multiple regression analysis was performed to test the place of employment and the work team, and thereby influences
the moderating effect of self‐efficacy on the relationship between the employee's approach, well‐being, satisfaction and ability to face
transformational leadership and proactive behaviors at work. The challenges (Avolio et al., 2004; Boamah et al., 2018; Hetland
interaction analysis was not significant (step 3 in Table 5) and no et al., 2007). These results are compatible with previous studies
moderating effect was found (β = 0.035, p > 0.05). However, a suggesting that transformational leadership is associated with lower
strongly significant positive relationship was found between self‐ levels of burnout among employees and reduced burnout at work
efficacy and proactive behaviors (β = 0.479, p < 0.001) (step 2 in (Hetland et al., 2007; Nielsen et al., 2009).
Table 5). Our findings also support our proposed hypothesis that proactive
personality is negatively associated with occupational burnout among
H5 A Hierarchical multiple regression analysis was performed to test physiotherapists. We found that the more proactive the physio-
the effect of the interaction between transformational leadership and therapist, the lower the reported levels of burnout. A physiotherapist
proactive personality on proactive behaviors at work. No interaction with a proactive personality is one who is involved in his/her envi-
was found in this relationship (β = −0.025, p < 0.05) (step 3 in Ta- ronment, seeks opportunities, shows initiative and takes steps to
ble 4). However, a strongly significant positive relationship was found promote action. These traits allow him/her to be more flexible and
between proactive personality and proactive behaviors (β = 0.425, dynamic and reduce the chances of burnout. This relationship and the
p < 0.001) (step 2 in Table 4). positive effect of proactive personality on employee well‐being has
also been reported in previous studies (Alarcon et al., 2009; Marti-
H6 A Hierarchical multiple regression analysis was performed nussen et al., 2011) and, therefore, aligns well with the results ob-
to test the effect of the interaction between transformational tained in our study as well.
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We uncovered an interesting relationship between burnout and models vary in the literature. Second, caution is needed when inter-
self‐efficacy: a strong, significant negative association. We found that preting the results correlating the level of burnout with covariates,
the higher the physiotherapist's level of self‐efficacy, the lower his/ which depend on the time point at which they were measured. This
her reported level of burnout. A meta‐analysis of the data addressing survey was conducted right after the first quarantine in Israel, at the
this topic found a similar association between burnout and self‐ end of May 2020. At this point in time, the Israel Ministry of Health
efficacy. The relationship was particularly strong among older in- announced that physiotherapy is an essential profession and, there-
dividuals and those with higher seniority (Shoji et al., 2016b). These fore, allowed practitioners to return to work as usual, subject to social
findings may have a practical impact, given the understanding that distancing guidelines. We assume that at this point, physiotherapists
intervention aimed at strengthening self‐efficacy among physiother- felt less anxious. Third, as in any survey, selection and recall biases
apists will help reduce their burnout levels. may have occurred, as well as embarrassment and social desirability,
We also examined several associated factors that may explain as respondents might feel uncomfortable rating their manager or their
proactive behaviors at work. We found that transformational lead- own outcomes. Finally, our robustness analysis was based on path
ership was not associated with proactive behaviors at work among analysis. Path analysis is a useful tool for analyzing complex relation-
physiotherapists. In contrast, previous studies claimed that trans- ships among variables; still, there are some limitations that should be
formational leadership does encourage proactivity among employees considered, specifically regarding assumptions and sample size in the
(Avolio et al., 2004; Seltzer et al., 1989; Strauss et al., 2017) and that proposed path analysis model that should be aware of when inter-
team empowerment has a positive effect on proactive behaviors preting the results. One of the limitations of path analysis is that it
(Erkutlu & Chafra, 2012). requires a large sample size to obtain stable estimates of the param-
We did, however, find a significant positive relationship between eters. The sample size should be large enough to provide enough
proactive personality and proactive behaviors, consistent with pre- statistical power to detect the effects of the variables on each other
vious studies (Erkutlu & Chafra, 2012; Parker et al., 2006). A similar accurately. As a rule of thumb, a sample size of at least 100 cases is
relationship was observed between self‐efficacy and proactive be- necessary for path analysis (Kline, 2015). In our study, only 81 re-
haviors. Similarly, previous studies reported that self‐efficacy is spondents completed the questionnaire, which is a limited sample size
crucial for exhibiting proactive behaviors (Griffin et al., 2007; to test the hypothesis based on path analysis, hence we used separate
Parker & Collins, 2010; Parker et al., 2006). This finding is important, regression for each hypothesis based on only 3‐4 predictors in each
as it highlights that intervention that improves self‐efficacy can lead regression model. Another limitation is the assumption that the
to higher proactive behaviors among physiotherapists. dependent variables for all equations must be approximately normally
Importantly, our findings highlight that burn out and proactive distributed. However, in this study, we found a small right Asymmetric
behaviors may directly impact physiotherapists' work performance in distribution in the burnout variable.
times of crisis and significant changes, such as the SARS‐COV‐2
pandemic. Crises or adverse situations can offer opportunities for
employees to be proactive and innovative. This suggests two 4.2 | Conclusions
different strategies for obtaining a proactive workforce: recruiting
individuals with a proactive personality and changing organizational This study provides up‐to‐date survey data on transformational
practices to enhance the situation (Parker et al., 2006). leadership and proactive personality and highlights their impact on
To sum up, both self‐efficacy and proactive personality have burnout and proactive behaviors among physiotherapists during the
positive and significant correlation with proactive behavior. Thus, the SARS‐COV‐2 pandemic. The transformational manager plays a very
greater a person's self‐efficacy or proactive personality, the greater important role in reducing burnout levels among physiotherapists,
their proactive work behavior. This would suggest that recruitment especially during a crisis such as the SARS‐COV‐2 pandemic. Per-
practices are more important than changes to the work environment, sonal key variables of a physiotherapist, namely, a proactive per-
hence selecting people with proactive personalities may be a useful sonality and self‐efficacy, are associated with higher proactive
strategy for human resource managers seeking to enhance job behaviors, while a physiotherapist's proactive personality is associ-
performance. ated with lower levels of burnout.
We suggest that future leadership studies in the field of phys-
iotherapy be conducted on a routine basis, and on a larger and more
4.1 | Limitations heterogeneous population of physiotherapists from different orga-
nizations and work environments. Further research should also be
This study has several limitations and biases that should be considered conducted following many stages of quarantine and at different
in future surveys. First, this study was limited to a relatively small and stages of the pandemic, to examine their effect on burnout.
specific sample size, namely, physiotherapists working for a single It will be interesting to examine additional aspects in which
HMO. Hence, these results need to be confirmed in a larger study managers may influence the performance of physiotherapists and
population. Indeed, sample size recommendations for multi‐level consequent quality of care and service provided.
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Received: 26 January 2023
DOI: 10.1002/pri.2012
RESEARCH ARTICLE
- -
Revised: 24 March 2023 Accepted: 18 April 2023
The paediatric physiotherapy curricula landscape: A survey

of United Kingdom entry‐level programs
Paul Chesterton1 | Jennifer Chesterton2
1
School of Health and Life Sciences, Teesside
University, Middlesbrough, UK Abstract
2
Faculty of Health Sciences and Wellbeing, Background and Purpose: To identify the paediatric curriculum content covered in
University of Sunderland, Sunderland, UK
entry‐level physiotherapy programs within the United Kingdom (UK), and report
Correspondence faculties perceived importance. Strengths, weaknesses, barriers and facilitators, to
Paul Chesterton, School of Health and Life the implementation of paediatric content were explored.
Sciences, Teesside University, Middlesbrough
TS1 3BA, UK. Methods: A cross‐sectional online questionnaire captured entry‐level physio-
Email: p.chesterton@tees.ac.uk therapy programme leaders' perceptions of paediatric programs.
Results: Fifty‐five responses were submitted, providing a 67% completion rate.
Faculty perceived that students' felt the inclusion of paediatric content within the
curricula was ‘Important’ (Mean 3.60 � SD 0.74). Of 30 diagnoses surveyed, only
two were covered ‘Well’ within curriculums, despite 23 rated at least ‘Important’ by
respondents. Of the 18 assessment/examination components, 13 were covered
‘Well’ with five ‘Somewhat’. All were considered to be at least ‘Important’. Perceived
strengths were grouped into three main categories (1) integrated/lifespan approach,
(2) links to clinical specialists, and (3) a broad/detailed curriculum. Perceived
weaknesses included curriculum time pressures and paediatric placement
availability.
Discussion: The majority of paediatric conditions were only somewhat covered by
UK curriculums, despite respondents in the main believing they should be an
important element of the entry‐level syllabus. Some UK physiotherapy entry‐level
students may not be exposed to any paediatric teaching or clinical placements.
KEYWORDS
curriculum, entry‐level, paediatric, physiotherapy, University
1 | INTRODUCTION professionals who can engage in patient care from a range of envi-
ronments throughout the National Health Service (NHS) and Private,
In the United Kingdom (UK), entry‐level physiotherapy programs are Independent, Voluntary Organisations (PIVO) making the achieve-
accredited by the Health and Care Professions Council (HCPC) ment of core skills during education essential for patient safety
and the Chartered Society of Physiotherapy (CSP). Once qualified, (Cresswell et al., 2013). A key role of Higher Education Institutes
chartered physiotherapists are acknowledged as autonomous (HEI) is to adequately prepare students with graduate ready skills
-

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- CHESTERTON and CHESTERTON
(Chesterton et al., 2021; CSP, 2020), meeting the standards of pro- taught curriculum. A disparity of taught paediatric education across
ficiency relevant to the HCPC register (HCPC, 2018). Entry‐level the globe exists and has previously been reported throughout the
programs are required to reflect physiotherapy core values, skills past 2 decades within curricula in the United States of America
and knowledge while encompassing an evidence‐based approach (Cherry & Knutson, 1993; Cochrane et al., 1990; Golub‐Victor &
relevant to contemporary practice. The CSP accreditation guidelines, Dumas, 2015; Schreiber et al., 2011). Mistry et al. (2019) surveyed
through a nine key principle approach, aim to ensure entry‐level Australian universities to identify paediatric programme content,
programs prepare students for flexible working across a range of reporting key barriers to implementing paediatric content within the
contexts and subdisciplines (CSP, 2020). curriculum including a crowded syllabus, lack of specialist staff, lack
Whilst entry‐level students are not required to develop specialist of prioritisation and inadequate paediatric placement availability.
skills, they should achieve a theoretical understanding of human The publication of the UK KNOWBEST project indicated that a
sciences and fundamental therapeutic techniques to meet the needs greater awareness/knowledge of all specialities including paediatrics
of service users across their lifespan (CSP, 2020). Currently, no was required within the UK curriculums (Lowe et al., 2022). The
standardized approach to the content required to cover the field of project highlighted the broad and holistic nature of assessment and
paediatric physiotherapy in the UK, despite global competencies treatment strategies requiring specialist paediatric knowledge (Lowe
published of the inclusion of general content, school based practice, et al., 2022). HEI's in the UK are able to design their own specific
early intervention and neonatal intensive care (Chiarello & curricula independently of each other, and due to the lack of stand-
Effgen, 2006; Effgen et al., 2007; Rapport et al., 2014; Sweeney ardisation of content expected or published by governing bodies,
et al., 2009). A statement from the World Confederation for Physical there is a need to understand the variety of paediatric curriculums
Therapy outlines both essential and recommended content areas for UK students are exposed to (Anderson et al., 2019). Therefore, as per
a paediatric curriculum, which is relevant to all global entry‐level Mistry et al. (2019) the aim of this study was to (1) identify the
programs (Cech et al., 2019). Whilst the guidelines provide a mini- paediatric curriculum content covered in UK entry‐level physio-
mum standard for inclusion in entry‐level programs the UK accredi- therapy programs; (2) understand the perceived importance of pae-
tation system does not enforce its implementation. diatric content by teaching faculty, (3) identify the mode of delivery
Paediatric physiotherapists are involved with the care of infants, and assessment in entry‐level programs and (4) identify strengths,
children, adolescents and in some circumstances young adults. Pae- weaknesses, barriers and facilitators, to the implementation of pae-
diatric physiotherapists obtain specialist skills of child development diatric content in entry‐level programs.
and knowledge of childhood conditions following a family‐centered
approach to care (ACPC, 2021; NICE, 2022). Entry‐level graduates
must have developed underpinning knowledge of child development 2 | METHODS
and awareness of paediatric conditions (Kenyon et al., 2013),
particularly if they work in the PIVO sectors upon graduation. It is 2.1 | Design
reasonable to consider such knowledge would be a minimum
requirement to ensure patient and/or client safety, while ensuring A cross‐sectional questionnaire of UK HEI programme leaders of
the provision of effective and efficient healthcare. Developing stu- entry‐level physiotherapy programs was conducted between May
dents' knowledge of patient and family‐centered care across all 2022 and June 2022. The School of Health and Life Sciences Ethics
subdisciplines of physiotherapy is required in a broad context for commitee approved the study in accordance with the Helsinki
HEI's to achieve CSP accreditation, evidencing that future graduates Declaration (ID9279). This report is conducted with recommenda-
are prepared for specialized roles across this broad spectrum tions from CHERRIES (The Checklist for Reporting Results of
(CSP, 2020). Internet E‐Surveys) and STROBE (Strengthening the Reporting of
Throughout their entry‐level programme UK physiotherapy Observational Studies in Epidemiology) (Eysenbach, 2004; Von Elm
students are required to complete clinical placements which are et al., 2007).
considered as important as on campus academic learning and
teaching (CSP, 2020; HCPC, 2018). All students will generally access
clinical placements in an adult care environment covering three core 2.2 | Participants
areas (musculoskeletal, cardiorespiratory and neurology), however
the skills developed in these areas are not always directly trans- All UK HEI programme leaders of entry‐level physiotherapy pro-
ferrable to a paediatric context (Turner, 1993). Some students may grams were eligible to take part. The survey was sent to programme
complete training without accessing a paediatric placement and leaders but invited the recipient to identify an appropriate member
therefore do not undertake external assessment of paediatric service of staff to complete if they were unable to do so. We requested that
users across the entirety of their programme. Potentially students only one member of the teaching team complete the survey on behalf
may not be formally assessed regarding their safety, competence and of the programme to prevent duplication of responses.
confidence to provide appropriate assessment and effective treat- The lead author, as a member of the CSP the UK's professional,
ment of children and young people, unless it is explicit within their educational and trade union body, reviewed the ‘Find a Physiotherapy
CHESTERTON and CHESTERTON
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Programme’ information page (https://www.csp.org.uk/careers‐jobs/ registration). Respondents were instructed regarding the aims of the
career‐physiotherapy/physiotherapy‐degrees) as a means of cap- study, the length of time required for completion and the storage of
turing UK entry‐level programs. A total of 59 institutions were iden- anonymized data (Chesterton et al., 2022a). Participation was
tified as providing entry‐level physiotherapy curriculums. From here voluntary with respondents informed of their right to withdraw at
each higher educational institutional provider webpage was searched any point prior to submitting the final answers. Respondents were
for the ‘Programme Leader’ of the entry‐level physiotherapy degree. A instructed that by completing and submitting the survey they were
total of 82 pre‐entry programs were identified from providers consenting to take part (Chesterton et al., 2022a). No incentives
(44 Bachelor of Science [BSc], 1 BSc Apprenticeship, 34 Master of were provided for survey completion.
Science [MSc], 1 MSc Physiotherapy Leadership, 1 MSc Physiotherapy
Leadership (Apprenticeship), 1 Master in Science). Names and contact
details of programme leaders were obtained from the publicly acces- 2.5 | Data analysis
sible HEI websites. For institutional webpages which did not provide
contact details either the department leads were identified and con- Following survey closure the data were extracted from onlinesur-
tacted, or the University was sent an email via its general enquiries veys.ac.uk into Microsoft Excel (Microsoft Corp, Redmond, WA),
address requesting programme leader information. Department leads using the analysed function. All questions were required to be
were requested to forward the survey invitation request to the rele- completed before submission and therefore all submitted surveys
vant staff member(s). were included within the analysis. As the survey was not designed to
test for differences between respondents no such analysis was per-
formed. Likert scale questions were treated as numeric variables with
2.3 | Measures (instrumentation) mean and standard deviations (SD) calculated for combined re-
sponses across each potential answer (Hopkins, 2010). Likert scales
The survey was based upon the work of Mistry et al. (2019) who have questions asking respondents to rate the detail of content covered
performed a similar study of Australian entry‐level paediatric were scored as; 1 = Not at all; 2 = Not very well; 3 = Somewhat;
curricula. A pilot group of five UK physiotherapy academics reviewed 4 = Well; 5 = Very Well. Questions requesting respondents
the initial questionnaire for content validity (Stoszkowski & perceived importance of topic area utilised the following scale;
Collins, 2016). The survey was independently assessed with com- 1 = Not important at all; 2 = Low importance; 3 = Neutral;
ments on the format, content, wording, technical functionality and 4 = Important; 5 = Very important. Data from both the dichotomous
overall ease of completion requested to ensure transferability to the and multiple‐choice questions were converted into proportions with
UK target population. Following pilot testing, the order of questions lower and upper limits of the 95% confidence interval, presenting the
was altered with qualitative questions moved earlier in the sequence. uncertainty around the estimates, calculated using the Wilson pro-
The final online survey was hosted at Onlinesurveys.ac.uk and con- cedure (Greenland et al., 2016; Newcombe, 1998).
sisted of 29 main questions across 10 pages (Supplementary Material For qualitative responses, two investigators (PC and JC) analysed
1). The survey was split into four sections; (1) participant details, (2) the data separately, as part of an investigator triangulation process to
curriculum perceptions, (3) curriculum delivery, and (4) knowledge reduce the risk of observer and other experimenter biases (Guion
and importance of a range of paediatric content within the curricu- et al., 2011). Open coding identified themes for strength and weak-
lum. All questions were required to be completed prior to submission ness of the curriculum (Mistry et al., 2019) with both investigators
of the survey. Respondents were able to review and change their generating a set of sub and main themes from their analysis. Her-
answers by selecting the ‘back’ option on the surveys hosting plat- meneutic revisiting of the data reduced researcher prejudices which
form. To maintain participant anonymity no identifiable personal may have de‐valued theme generation (Chesterton et al., 2022a).
data, including the HEI respondents were employed by, was Following individual analysis, a de‐briefing session was held with
collected. findings discussed and redefined. The triangulation process high-
lighted the similarity of both researchers' conclusions, increasing the
credibility, validity, and trustworthiness of the findings (Carter
2.4 | Procedure et al., 2014).
The chief investigator sent a total of 77 email invitations to all

identified programme leaders (n = 71) and department contacts 3 | RESULTS
(n = 6). All universities with an entry‐level physiotherapy programme
were contacted. A reminder email was sent to the appropriate con- 3.1 | Participant demographics
tact approximately 4 weeks later.
Respondents were requested to complete the questionnaire only Fifty five responses were submitted, providing a completion rate of
once and not submit multiple entries, however, this was not moni- 67%. The number of visitors to the survey site or those who failed to
tored or controlled by the online platform (i.e., via cookies, IP checks, complete after starting was not captured. Of the total respondents
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35 (67%) identified as female and 20 (38%) male (ratio 1.75:1). Ages 3.60 � SD 0.74). In relation to typical development, Table 1 outlines
ranged from 32 to 64 (Mean 45.5 � SD 8.8) with mean years post respondents' rates of the content covered within their curriculum
qualification 21.7 (� SD 8.4, range 6–42). A total of 16 (29%) re- and its perceived importance.
spondents were paediatric physiotherapists. Of these physiothera- Figures 1–3 display the mean and SD responses for both content
pists the range of time within the paediatric discipline was 4– covered in curriculums and it's perceived importance by faculty
24 years (Mean 15 � SD 6.9), with the average length of time across a range of specific diagnoses (Musculoskeletal, Neurological,
teaching being eight years (� SD 4.4, range 3–16). Of all the re- Cardiovascular Respiratory and Other). Means and SD presented in
spondents the majority were in a Senior Lecturer position (n = 36, table format can be found in Supplementary Material 2. In total, re-
65%) followed by Lecturer (n = 10, 18%). Remaining respondents spondents were asked to cross reference 30 diagnoses against the
were employed as Associate Professors (n = 5, 9%), Assistant Pro- curricula delivered. Only two were covered within the syllabus ‘Well’
fessors (n = 3, 5%) or Principal Lecturer (n = 1, 2%). In total 80% of (Cerebral Palsy; Cystic Fibrosis) with two ‘Not at all’ (Brachial Plexus
respondents completed the survey in their capacity of programme Birth Injuries; Immune Deficiency). Thirteen were either ‘Somewhat’
leader (BSc: n = 26, 47%; MSc: n = 18, 33%) compared to 11 covered or ‘Not Very Well’ covered. In contrast, respondents
completing on behalf of their programme leader (BSc: n = 9, 16%; considered it was ‘Important’ to include 22 of the 30 diagnoses, with
MSc: n = 2, 4%). A total of five programs (9%) did not include any seven determined ‘Neutral’. Only, Cerebral Palsy was ‘Very Impor-
paediatric content within their current pre‐registration provision. tant’ to include within the curricula.
Figures 4 and 5 also display the means and SD for the curriculum
content covered and it's perceived importance for both paediatric
3.2 | Paediatric curriculum content and perceived assessment and intervention techniques. Means and SD presented in
importance table format can be found in Supplementary Material 3. Of the 18
assessment/examination components 13 were covered ‘Well’ with
Faculty within the study perceived that students' felt the inclusion of five ‘Somewhat’. All were considered to be at least ‘Important’ to
paediatric content within the curriculum was ‘important’ (Mean include within the curriculum with four rated as ‘Very Important’. In
TABLE 1 Content covered and perceived importance reported for the knowledge of typical development.
Content covered Perceived importance
% Of responses % Of responses
for scores, Likert for scores,
Mean (SD) Mode Median 1/2/3/4/5 scale Mean (SD) Mode Mean 1/2/3/4/5 Likert scale
Develop foundation 3.13 (0.96) 3 3 0/7/19/14/5 Somewhat 4.11 (0.76) 4 4 0/3/4/32/16 Important
knowledge of prenatal
development and birth
Develop foundation 3.51 (0.95) 3 3 0/9/19/17/10 Well 4.42 (0.66) 5 4 0/1/2/25/27 Important
knowledge of the
theories of childhood
development and
learning
Demonstrate knowledge of 2.33 (0.98) 1 2 20/11/12/10/2 Not very 3.42 (1.20) 2 3 0/17/13/10/15 Neutral
developmental motor well
milestones
Understand the importance 2.55 (1.09) 1 2 12/12/22/7/2 Somewhat 4.04 (0.64) 4 4 0/0/10/33/12 Important
of therapeutic play
within diverse family,
cultural, community and
societal context
Understand when a child 2.93 (1.32) 3 3 11/9/15/13/7 Somewhat 4.24 (0.72) 4 4 0/0/9/24/22 Important
should provide consent
and gaining parent/carer
consent
Demonstrate knowledge of 3.69 (0.94) 4 4 0/7/14/23/11 Well 4.89 (0.31) 5 5 0/0/0/6/49 Very
developmental important
milestones in the social‐
emotional, speech and
language domains
Note: Likert scale – 1 – Not at all; 2, Not very well; 3, somewhat; 4, well; 5, Very well; SD, Standard deviation.
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F I G U R E 1 Mean, standard deviation and

distribution of responses to questions about
content covered and perceived importance for
musculoskeletal conditions.

cardiorespiratory and other conditions.
relation to paediatric interventions five of the 11 components were Ten institutions (18%, CI 95% 10–30) also taught the syllabus across
‘Well’ and ‘Somewhat’ covered. Only prescription and application of modules, but within the same academic year assessing students at
equipment was deemed to be ‘Not Very Well’ included. All in- the same level. Only eight (15%, CI 95% 8–26) had a standalone
terventions were considered at least ‘Important’ with family/patient paediatric module within the curriculum. Of the 35 BSc entry‐level
centred care and therapeutic exercises judged ‘Very Important’. programs represented in this survey paediatric content was deliv-
ered to students in year one (n = 18, 52%), year two (n = 15, 44%)
and year three (n = 13, 36%). Within the 20 MSc programs seven
3.3 | Paediatric delivery and assessment (36%) introduced paediatric content within year one and six (32%) in
year two. Table 2 displays the methods of teaching adopted by fac-
The majority (n = 37, 67%, CI 95% 54–78) of curricula taught the ulty who primarily assessed students via practical examinations
paediatric syllabus across modules (a topical unit within a pro- (n = 20, 36%, CI 95% 25–50) or written assessments (n = 17, 30%, CI
gramme) spanning different academic years as a lifespan approach. 95% 20–44). However, respondents acknowledged that paediatric
6 of 13

neurological conditions.

content covered and perceived importance of
paediatric assessment/examination
techniques.
competencies were either assessed in an integrated way with weaknesses which include curriculum time pressures and paediatric
another module content (n = 10, 18%, CI 95%10–30) or not specif- placement availability.
ically assessed at all (n = 22, 40%, CI 95% 28–53). Respondents were asked which paediatric content/skills are not
currently covered by the entry‐level programme that should be
covered to adequately prepare a student for practice. Themes
3.4 | Strengths, weaknesses, barriers and generated suggested neurodevelopment aspects, specialised equip-
facilitators to the paediatric curriculum ment, mental health and practical handling skills were areas for
further curriculum development.
The perceived strengths and weaknesses of current paediatric cur- Potential barriers to the implementation and development of the
riculums by respondents are reported in Tables 3 and 4. Perceived paediatric physiotherapy curriculum within their institution are re-
strengths were grouped into three main categories (1) integrated/ ported in Table 5.
lifespan approach, (2) links to clinical specialists and, (3) a broad/ In addition to the questions posed in Table 5, respondents
detailed curriculum. Two main themes were generated for perceived identified under resourced academic staff teams in the area of
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content covered and perceived importance of
paediatric interventions.
TABLE 2 Teaching methods utilised by institutions. from teaching faculty whilst identifying delivery and assessment
modes. Finally, faculty were asked to identify strengths, weaknesses,
Teaching method n, %, (95% CI)
barriers and facilitators, to the implementation of paediatric cour-
Lectures 53, 96 (88–99)
sework curriculum in entry‐level programs. Novel findings suggest
Clinical placement 41, 75 (62–84) the majority of paediatric related conditions were only somewhat
Problem based learning classes 40, 73 (60–83) covered by HEI curriculums, despite respondents in the main
believing they should be an important element of the entry‐level
Independent study 36, 65 (52–77)
syllabus. Paediatric assessment and interventions were largely
Tutorials 24, 44 (31–57)
covered well which is associated with the importance placed upon
Workshops 14, 25 (16–38) these skills by respondents. The often‐implemented integrated life-
Online modules 10, 18 (10–30) span approach to paediatric education, linked to clinical specialists,
Flipped classes 8, 15 (8–26) across a broad syllabus was identified as curriculum strengths.
Several weakness and barriers were identified including curriculum
Other 7, 13 (6–24)
time pressures and specific paediatric placement availability. Impor-
Simulated learning – high fidelity 5, 9 (4–20) tantly, five HEI's did not include any paediatric content with the
Simulated learning – low fidelity 5, 9 (4–20) curricula and a further 22 failed to assess student competency in
the area.
paediatrics, as a particular barrier to curriculum implementation and

development. A lack of expertise within the academic team was 4.1 | Paediatric curriculum content and perceived
highlighted despite faculty's actively aiming to employ paediatric importance
lecturers. Key facilitators to the implementation and development of
paediatric curriculums included (1) additional specialised staff, (2) Faculty perceived that the inclusion of paediatric content within
greater links with paediatric service providers, (3) content guidance entry‐level curriculums was important to students and their devel-
from governing bodies in relation to key priorities and, (4) prioriti- opment. Findings of this study suggest UK entry‐level physiotherapy
sation of space within curriculum design. curricula do not cover musculoskeletal, cardiorespiratory and
neurological conditions ‘Well’. Overall, paediatric assessment and
examination techniques were broadly covered ‘Well’ as were treat-
4 | DISCUSSION ment and management interventions. The perceived importance of
content coverage was in the main greater for most topics compared
This is the first study to identify paediatric curriculum content to the level of actual coverage within the curriculum. A similar trend
covered in UK entry‐level physiotherapy programs. The study also was reported by Mistry et al. (2019) in their survey of Australian
aimed to understand the perceived importance of paediatric content entry‐level physiotherapy curriculums. Whilst the CSP publish
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TABLE 3 Perceived strengths of UK paediatric curriculums.

Theme: Integrated/lifespan approach
Emphasis on knowledge development ‘I'd like to think it provides a coherent framework to enable student learning and
development should the individual wish to practice in the area at sometime in the
future.’
‘We aim to give students an awareness of the typical conditions that children can face/
acquire and how to manage these effectively’
Content throughout curriculum levels ‘Paediatric content is integrated through as many modules as possible, rather than being
stand alone.’
‘Strong flow of material from year 1 to year 2, not quite equally balanced with adult
content but estimate approximately 30/70 split’.
‘Linked across modules. We do not have a specific paediatric modules, but link elements of
paediatric’ assessment/management across as many aspects of the curriculum as
possible.’
Theme: Links to clinical specialists
Academic faculty with specialisms ‘We have several lecturers who are from varied paediatric specialist areas who contribute’.
‘Academic staff with prior experience of working throughout the area of paediatrics’
Externals contribute to teaching ‘It is delivered by experts experienced in the specialism’.
‘Students have the opportunity to be taught by clinical specialist paediatric physiotherapist

from local teaching hospitals to support learning and opportunities.’
Placement opportunities ‘Paediatric placements available to students. Paediatric learning activities involve service
users.’
‘We aim to ensure students can apply taught skills to paediatric populations in preparation
for placements’.
Theme: Broad/Detailed curriculum
Range of theoretical content ‘We cover a range of neurodevelopmental conditions including cerebral palsy, spina bifida
and autism spectrum disorders. Also cover normal development.
‘Providing an overview of some main pathologies/conditions and how to assess and treat.
Application of skills to paediatric populations and preparation for placement.
‘A holistic approach to long‐term paediatric care.’
Transferable skills ‘The scope of the content and how it can be integrated into adult physiotherapy’
‘By covering a broad spectrum of conditions, we also aim to provide students with
transferable skills related to all physiotherapy disciplines.’
‘Using paediatric content as transferable skills, for example, to underline importance of

interpersonal skills and to communicate the strategies for dealing with chronic
conditions’
programme accreditation guidelines which include quality assurance survey. For example, brachial plexus birth injuries were suggested to
processes, no mention of specific paediatric based curriculum content be covered ‘Not at all’ by respondents but perceived to be ‘Important’
is published (CSP, 2020). Rather the guidance aims to ensure that to a paediatric curriculum. A lack of guidance for faculty in relation to
accredited programs prepare graduates for emerging physiotherapy the depth of content and the level of skill acquisition required upon
roles which meet the demands of the UK health service (CSP, 2020). graduation for this sub‐discipline of physiotherapy exists. The limited
The ‘Physiotherapy Framework’ (CSP, 2020) document, published in content across several areas suggests that potentially, as in other
2011 but updated in 2020, defines and describes the behaviours, international curriculums, students develop a taste of the subject
knowledge and skills required for on‐going contemporary physio- without the time, support and feedback to develop initial compe-
therapy practice. It could be argued that some of these principles tencies (Mistry et al., 2019).
around the implementation of physiotherapy knowledge and practice The KNOWBEST report (Lowe et al., 2022) discovered that out
skills are difficult for new graduates who have received little expo- of 34 role descriptors for newly qualified physiotherapists across a
sure to core paediatric curriculum teaching throughout their degree representative range of roles, paediatrics was one of five commonly
programme. Despite this, the value placed on the importance of these stated specialities listed. The challenge is to increase the awareness
concepts within the curriculum was noted by respondents in this and knowledge of all physiotherapy specialists including paediatrics
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TABLE 4 Perceived weaknesses of UK paediatric curriculums.

Theme: Time pressures
Limited time to integrate into curriculum ‘Curriculum squeeze ‐ limited time’.
‘There is insufficient time available to cover aspects that would be useful pre‐registration.’
Lack of depth/Superficial content ‘We only deliver a handful of sessions throughout the curriculum. Some more general
sessions will refer to both adult and paediatric populations but there is just not enough
time to cover everything we would like to.’
‘Curriculum volume is the issue ‐ it terms of being able to cover paediatric content in
greater detail. It is impossible to include ‘everything’ that would provide a
comprehensive address of all areas of what is a continuously evolving profession’
Theme: Placement availability
Placement not available to all ‘Not all students get a paediatric placement, due to limited access to placement
opportunities in area.’
‘We get very few paediatric placement offers which is reflective I suspect of service
division and the challenges practice colleagues face’
Limited exposure to service users ‘Only some students get to experience a placement in paediatrics.’
‘Real world engagement with service users as well as practicing clinicians is a weakness’
Challenges engaging with service users due to inadequate changing facilities and
reimbursement policies.’
TABLE 5 Perceived institutional barriers to the implementation and development of Paediatric curriculums.
Answered ‘yes’ n, %,
Potential institutional barrier (95% CI)
Crowded curriculum due to the requirements of the professional practice guidelines 55, 91 (80–96)
provided by the CSP to be eligible for registration
Lack of prioritisation of curriculum space for paediatric content 39, 71 (58–81)
Limited number of practical or placement opportunities available in hospital/clinics, private 37, 67 (54–78)
practice, school and community‐based programs with children with special needs
Lack of qualified personnel available to teach within the educational field of paediatric 28, 51 (38–64)
physiotherapy curriculum
Limited institutional or other financial resources 26, 47 (35–60)
Lack of coordination among institutions of higher education to develop a collaborative 22, 40 (28–53)
curriculum or standard of education to be taught within the curriculum
Organisational structure of the institution of higher education 12, 22 (13–34)
in an overcrowded curriculum (Lowe et al., 2022). Programme leaders are most likely to support student‐level competence (Rapport
represent 80% of the respondents to this survey, and clearly iden- et al., 2014). A myriad of experiences including practical, face‐to‐face
tified the importance of including a range of paediatric diagnoses, experience with children and their family support community, which
assessment and interventions to support students towards compe- includes differing disabilities, will optimally support student learning
tence upon graduation. in paediatrics (Rapport et al., 2014). This plethora of experiences
were reported by several institutions as part of their learning and
teaching strategies, however lectures were the most common
4.2 | Paediatric delivery and assessment method to provide paediatric content. The quality of care delivered
to children has previously been reported as suboptimal (Quinonez
A lifespan approach to teaching the curriculum was often employed et al., 2013) and therefore alongside medical colleagues, it is seminal
by UK institutions, with only 8% having a standalone paediatric that physiotherapy graduates are able to promote high quality evi-
taught module. Definitive evidence to support the need for a desig- denced based care. In a survey of UK new graduate physiotherapists,
nated amount of time dedicated to paediatrics teaching does not students revealed that practice placements were the preferred
exist, however, a range of active experimental learning experiences teaching method most applicable to practice (Chesterton
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et al., 2021). Our study found that only 41% of institutions offered weaknesses of UK curriculums. Such time pressures and a lack of
paediatric placements to students, and furthermore not all students prioritisation of curriculum space for paediatric content were iden-
were able to access these placements due to capacity. tified as key barriers to the development of the curriculum. The
Assessment is a complex construct which can be viewed through limited time allocation to paediatric content was also considered the
multiple lens' within the sphere of higher education. Often assess- greatest weakness of the Australian taught physiotherapy programs,
ment criteria define what is important to the student, how they plan despite no current best‐practice benchmark existing (Mistry
and navigate their way through their learning but also provides ed- et al., 2019)]. While a substantial amount of time of physiotherapy
ucators with a formalised method to gauge student competence and entry‐level programs are given to clinical skill development, UK
progression. While a range of assessment strategies were employed, students have identified a range of skills including exercise pre-
notably through practical or written assessment, interestingly over scription, psychosocial understanding and patient management, as
half (58%) of programs either integrated paediatric competency requiring further focus which currently do not prepare graduates for
assessment with another module content or did not assess these at practice (Chesterton et al., 2021; O’Donoghue et al., 2011). Such
all. Undoubtedly, this leaves a number of students, who have not had research highlights the competing interests from all stakeholders to
a specialised paediatric placement without any formal assessment of ensure that content is contemporary and prepares students for
their skill level or competency prior to graduation. Stoikov modern‐day healthcare practice. Data from our study suggests the
et al. (2022) reported that new graduates felt unprepared for inde- wider UK paediatric curriculum is limited as a consequence of
pendent clinical practice and managing expectations of themselves. It competing educational priorities. The difficulty for education pro-
is reasonable to conclude that this would be magnified in students viders is to deliver curricula which safeguards the assessment and
not experiencing a defined paediatric curriculum. No ‘gold standard’ management of paediatric patients' which students manage upon
model of physiotherapy education or assessment exists, however graduation. A minimum set of standards of paediatric proficiency
feedback has been acknowledged as the single most powerful influ- would guide and support curriculum designers to ensure student
ence on students' achievement (Hattie, 2008). Currently, the op- competency in this specialised area.
portunities for students to be exposed to feedback to influence Additionally, a lack of placement capacity meant that some
future learning and practice are variable in relation to the UK pae- providers could not offer all students a paediatric placement. This
diatric curriculum. was also identified as a key barrier to the development of the
curriculum. Through the NHS Long‐term plan, Health Education
England have mandated a 50% increase in placement funding to
4.3 | Strengths, weaknesses, barriers and meet the UK's capacity obligation for training health care students
facilitators to the paediatric curriculum (NHS, 2019). The demand for clinical placements against the
background of increasing HEI cohorts provides a real conundrum
The lifespan approach to curriculum delivery was considered a for educational providers. A collaborative approach to seek new
strength by participants. Other key strengths included the links and ways to provide students with the placement opportunities is on‐
associations of programs with clinical specialists, either within the going despite the reluctance for some to move away from the
academic teaching team or through external guest lecture networks traditional 1:1 supervision model (CSP, 2018). For instance, group
and placement opportunities. A lifespan approach allowed the placement models and online placement activity provides proactive
emphasis on knowledge development, ensuring constructive align- and innovative means of increasing placement capacity (Moseley
ment throughout the curriculum, allowing students to develop clini- et al., 2022). Different ratios of educator to student (1:1; 1:2)
cally relevant skills. Constructive alignment, based on the twin placement models have been positively evaluated by stakeholders
principles of constructivism in learning and alignment in teaching, in Ireland (Barrett et al., 2021). Digital placements have been
facilitates deep learning and is critical to student success and suggested as ways to increase the provision; however, UK students
therefore an essential element in curriculum design (Ali, 2018; have reported that online learning negatively impacts their disci-
Biggs, 1996). Providing students with a broad curriculum enriched by pline understanding and presents an overall disadvantage
links to clinical specialists were perceived as strengths across in- compared to face‐to‐face traditional teaching (Chesterton
stitutions. This holistic approach also allowed the development of a et al., 2022b). Authentic placement experiences in specialist
range of theoretical content which important participants felt built educational settings (e.g., school‐based physiotherapy) and inter-
confidence and competence in a range of transferable skills. Such a professional opportunities, can provide students with valuable
strategy also reflects the continuing evolving and emerging clinical multidisciplinary insights into the management of children, ado-
environment new graduates are exposed too. The access to external lescents and young adults with complex needs. Interweaving clin-
lectures and clinical specialists provides students with opportunities ical exposure in diverse paediatric settings improves student
to learn from currently practising therapists with an acute awareness confidence, interprofessional communication and enables the clin-
of contemporary physiotherapy. ical application of family‐centred care principles learned within the
Overwhelmingly, time pressures to include paediatric content classroom (Tovin et al., 2017). Further research is welcomed to
and additional placement availability were considered the two main specifically evaluate current and innovative models of paediatric
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placements, providing evidence‐based pedagogy for students linked 4.6 | Implications on physiotherapy practice
to competency outcomes.
Curriculum facilitators included employing greater numbers of An overcrowded entry‐level curriculum and limited placement
specialised paediatric staff within the programme team. This would availability are two acute challenges faced by UK HEI's in providing a
develop greater links with paediatric service providers across the comprehensive and stimulating paediatric curriculum. It is important
sector including hospital/clinics, private practice, school and to recognise that UK higher education entry‐level programs have
community‐based organisations. A step in the right direction would significant challenges in providing a contemporary physiotherapy
be to ensure all educational providers have paediatric specialist education experience for their students. This study suggested re-
experience within their academic teaching teams, as is generally the spondents value the importance of paediatric content within the
case for other subdisciplines of physiotherapy including musculo- syllabus and also perceived students valued its inclusion. Competing
skeletal and cardiovascular respiratory. interests are multiple and several barriers are highlighted in this
study in relation to the provision of a paediatric curriculum. Minimal
required standards set by accrediting bodies many facilitate the
4.4 | Call to action introduction of a formal paediatric curriculum to ensure parity across
the many institutions who offer entry‐level physiotherapy in the UK.
Due to the inconsistencies found across UK paediatric curriculum's it
may be appropriate to develop a minimum set of standards for stu- A U T HO R C O NT R I B U TI O N
dents in relation to their knowledge, skills and attributes required Paul Chesterton developed the concept of the study and contributed
upon graduating. Some UK physiotherapy entry‐level students may to all aspects of this manuscript including survey design, data
not be exposed to any paediatric teaching, assessment or experience collection, data analysis and drafting. Jennifer Chesterton contrib-
an external placement in the area. Subsequently, these graduates will uted to concept design, survey generation, data analysis and manu-
lack the competencies to assess and treat children and young adults script writing. Both authors approved the final manuscript.
in their care safely and effectively. Ensuring that minimum educa-
tional standards, rather than explicit syllabus mandates, are in place A C K NO W L E DG E M E NT
and that all students are exposed to paediatric education are the first This research did not receive any specific grant from funding agencies
steps to developing a competent future workforce. Further innova- in the public, commercial, or not‐for‐profit sectors.
tion in paediatric placement development would assist in providing a
greater number of UK physiotherapy students with first‐hand clinical C O N F L I C T O F I N T E R ES T S T A T EM E NT
experience. While it was beyond the scope of the study to investigate None declared.
how physiotherapy curriculums can increase paediatric knowledge
and skills, simulation (Lowe et al., 2022) and interprofessional D A T A A V A I L A B I L I T Y S TA T EM EN T
learning (Andrea et al., 2022) show promise and provide future Data available upon reasonable request to the authors.
research opportunities.
E T HI CS S T A T E M EN T
The School of Health and Life Sciences at Teesside University
4.5 | Limitations approved the study in accordance with the Helsinki Declaration
(ID9279).
Despite the response rate of 67%, participants who completed the
survey may not be representative of the entire target population. ORCID
Due to responder/non‐response bias we acknowledge this survey Paul Chesterton https://orcid.org/0000-0002-9432-0675
does not represent the views of all UK HEI physiotherapy programme
leaders (Chesterton et al., 2020). Due to the anonymous nature of R E F E R E NC E S
the survey, protecting both respondents and HEI programme iden- Ali, L. (2018). The design of curriculum, assessment and evaluation in
tity, it was not possible to ensure only one staff member per pro- higher education with constructive alignment. Journal of Education
gramme completed the questionnaire despite the explicit instruction. and e‐learning Research, 5(1), 72–78. https://doi.org/10.20448/
journal.509.2018.51.72.78
This UK study may also not reflect the nuances of international in-
Anderson, D. K., Furze, J. A., & Moore, J. G. (2019). Moving toward
stitutions who operate in a different educational context (Chesterton excellence in pediatric physical therapy education: A scoping review.
et al., 2022b). While this study provides an overview of paediatric Pediatric Physical Therapy, 31(1), 95–113. https://doi.org/10.1097/
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weaknesses and barriers identified can be addressed through a multi‐
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stakeholder approach is warranted, to continually develop and dents through remote simulation. Journal of Higher Education
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RESEARCH ARTICLE
- Accepted: 27 April 2023
Challenges of transforming evidence‐based management of

osteoarthritis into clinical practice in rural central Western
India. Perceptions of an educational program
Christina H. Opava1,2 | Kristina Kindblom1,2 | Keerthi Rao2 |

Carina A. Thorstensson3,4 | Emma Swärdh1
1
Division of Physiotherapy, Department of
Neurobiology, Health Care Sciences and Abstract
Society, Karolinska Institutet, Huddinge,
Purpose: Osteoarthritis (OA) is a major threat to public health worldwide and is
Sweden
2 predicted to increase. Existing interventions to implement clinical practice guide-
Dr. APJ Abdul Kalam College of
Physiotherapy, Pravara Institute of Medical lines (CPGs) seem to be used mainly in the Western world. We conducted a
Sciences – DU, Loni, Maharashtra, India
structured educational program on the evidence‐based management of OA (BOA)
3
Institute of Neuroscience and Physiology,
Gothenburg University, Goteborg, Sweden
for Indian physical therapists (PT). Our study aimed to describe Indian PTs'
4
Department of Research and Development, knowledge, attitudes and confidence on evidence‐based management of OA, and
Halland County Council, Varberg, Sweden their perceptions of a course on this subject.
Methods: The 2‐day course included didactic parts and practical skills training.
Correspondence
Emma Swärdh. Thirty‐five PTs participated and answered a questionnaire. Fourteen of them
Email: emma.swardh@ki.se
participated in focus group interviews. Questionnaire data are presented as me-
dians and full ranges. Manifest content analysis was used to analyze interview data
that are presented as catagories illustrated by interview quotes. The formal ethics
permission was granted.
Results: 74% of PTs agreed that radiography determines the type of treatment
required, and 69% agreed that a prescription for exercise is enough to ensure
adherence. PTs agreed (mean 5 on 6‐point scale) that exercises increasing pain
should be advised against. Confidence in guiding the physical activity was generally
high (≥5 on 6‐point scales). Five categories reflected participants' perceptions of
the course content: Shift in management focus, Need for cultural adaptation, Impor-
tance of social support, Development of organization and collaboration, and Feelings of
hesitation.
Discussion: Our results indicate that in order to facilitate the implementation of
CPGs, PT curricula may consider the inclusion of knowledge on CPGs, focus more
on students' own reflections on transforming theory into practice, and incorporate
training of basic skills required for implementation of self‐management, body
awareness, and neuromuscular fitness. If given access and mandates, PTs may play a
-

2 of 12
- OPAVA ET AL.
major role in the early diagnosis and treatment of OA and thus contribute to the
prevention of an epidemic of OA in India.
KEYWORDS
content analysis, education, intervention, questionnaire
1 | INTRODUCTION management among rural Indian people and PTs in Central Western
India (Swärdh et al., 2022a, 2022b). To our knowledge, no formal
Musculoskeletal diseases, particularly hip and knee osteoarthritis course on how to implement OA CPGs has been conducted in India
(OA), represent a major cause of disability and are ranked 11th of the or developed for use there.
291 most commonly disabling conditions globally (Cross et al., 2014). Challenges faced in the development and implementation of
Demographic changes and the exploding prevalence of obesity will musculoskeletal models of care in middle‐income and low‐income
result in a massive increase in OA (Turkiewicz et al., 2014). countries in Asia have been discussed, and suggestions for the
There is still no disease‐modifying treatment for OA, and pre- future outlined (Lim et al., 2016). However, while PTs and OTs may
vention is underdeveloped despite promising outcomes of lifestyle be important first‐line resources in such initiatives, their resources
interventions (Hunter & Bierma‐Zeinstra, 2019). Thus, Clinical Prac- and perceptions have not been explored much. More knowledge in
tice Guidelines (CPGs) primarily include rehabilitation interventions, this area would help in the development of OA models of care in one
mainly patient education, exercise, and weight control (Kolasinski of the world's largest populations and thus more effectively
et al., 2020). Major problems with the dissemination and imple- contribute to the prevention of OA‐related disability.
mentation of CPGs have been indicated (e.g., Nelson et al., 2014; The first study aim was to describe Indian PTs' self‐reported
Thorstensson et al., 2015). Many physical therapists (PTs) do not knowledge, attitudes, and confidence related to evidence‐based OA
adhere to them (Ayanniyi et al., 2016; Zadro et al., 2019; Battista management. The second aim was to identify perceptions of the BOA
et al., 2021) but rather apply inadequate diagnostic procedures, re- course's content.
ferrals, and treatment modalities with a lack of evidence for efficacy
(Bathia et al., 2013).
Formal interventions aiming to enhance the implementation of 2 | METHODS
CPGs for people with OA are available and effective (Goff
et al., 2021; Tan et al., 2021). One such intervention is the Swedish 2.1 | Study context and research team
national initiative “Better Management of Patients with OA” (BOA),
which was among the first to be introduced in 2008. BOA consists of The study was performed in a PT College in Ahmednagar District
three parts: (i) a Supported OsteoArthritis Self‐management Program with additional participants from another PT college in the same
(SOASP) for patients; (ii) a formal course for PTs and occupational district. Ahmednagar is the largest district of Maharashtra state,
therapists (OTs) on how to conduct the SOASP; and (iii) a national situated in Western Central India. The district population is over 4.5
register, based on structured pre‐ and post‐intervention data million, the main language is Marathi, the literacy rate is over 80%,
collection, to evaluate the quality of the SOASP (Thorstensson and around 80% of the population is rural, mainly occupied in farming
et al., 2015). The BOA course for PTs and OTs aims to provide and in sugar factories. Services at hospitals adjacent to participating
knowledge on OA and its evidence‐based management, to change PT colleges are free, which means that patients come from very low
attitudes about the harm of pain during exercise and the risk of economic strata and often have low literacy levels, hold traditional
increased joint damage, and to increase their confidence in guiding beliefs, and have a lack of basic amenities. Everyday life includes the
and facilitating physical activity to patients with OA (Thorstensson use of Indian toilets, sleeping on the floor, cooking in a squatting
et al., 2015). OA communicators, that is, trained people with OA position, and manual work in fields or factories.
share their lived experiences of OA and act as facilitators in the All research team members are PTs with PhDs and had, at the
SOASP program as well as in the education of PTs and OTs. Over time of the study, at least 5 years' clinical experience of working
3500 Swedish PTs and OTs have been trained within BOA, and more with patients with musculoskeletal conditions. Four of us (C.H.O., K.K.,
than 195,000 Swedish patients have participated in the SOASP and K.R., E.S.) were employed as university teachers, and one (C.A.T.)
been included in the BOA register (BOA, 2022). worked as a research and development manager in health care. Four
India has one of the world's largest populations, and the overall (C.H.O., K.K., C.A.T., E.S.) were trained and experienced in both quan-
prevalence of OA is reportedly 22%–39% (Pal et al., 2016). Higher titative and qualitative research methodology, while one (K.R.) mainly
life expectancy and increased prevalence of obesity will increase the had expertise in quantitative methods. One member (K.R.) was active
prevalence of OA to massive numbers of people affected (Luhar in India, and another two (C.H.O., K.K.) were formally affiliated with
et al., 2020; Wei et al., 2019). We have previously described ap- the PT college hosting the BOA course. One member (C.A.T.) is a co‐
proaches to OA that may represent barriers to evidence‐based OA founder of the Swedish BOA concept.
OPAVA ET AL.
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T A B L E 1 Demographics of the participating physical

2.2 | Study design therapists (n = 35).
Median (min‐max) n (%)

Both quantitative and qualitative data were used to address the
study aims. Data were gathered through a self‐reported question- Age, years 25 (22–47)
naire and focus group interviews. Gender, male/female 9 (26)/26 (74)
Workplace
PIMS, Loni 25 (71)

2.3 | Subjects
PIMS, Ahmednagar 8 (23)
Thirty‐five PTs were recruited, of which 33 were among the faculty Other 2 (6)
and graduate students of the APJ Abdul Kalam College of Physio- Academic status
therapy at Pravara Institute of Medical Sciences, Loni, of the
BPT 2 (6)
PDVVPF's College of Physiotherapy, Vilad, Ahmednagar, and another
two PTs were from other parts of the country (Table 1). MPT student 22 (63)
A subsample was purposefully selected for three focus group MPT 6 (17)
interviews to obtain a variation in age, gender, and years of profes- MPT/PhD scholar 3 (9)
sional experience. Two of the focus groups (#1 and #2) included six
PhD 2 (6)
PTs each. To facilitate a wider range of perceptions, the third focus
BPT, year 2014 (1995–2018)
group included three PTs and two orthopedic residents, one com-
munity/Ayurveda specialist, and one person with OA. They all MPT, year 2012 (2001–2018)
participated in the BOA course for PTs since they were considered as Area of specialization
important stake holders in future implementation of the concept.
Musculoskeletal 17 (49)
Community 7 (20)
2.4 | BOA course Obstetrics and Gynecology 1 (3)
Cardiorespiratory 2 (6)
The course was entirely based on a Swedish model. It comprised Neurology 5 (14)
2 days, approximately 10 h in total. The faculty was entirely Swedish
Pediatrics 2 (6)
and consisted of two PTs, one orthopedic surgeon, and one OA
communicator. None of them had previous knowledge of India or In- Sports 1 (3)
dian management of OA. The course content included information on Patients with knee/hip pain
OA, evidence‐based OA management (the SOASP), use of valid Daily 26 (74)
questionnaires, the importance of quality registers, interaction with a
Weekly 5 (14)
clinical PT experienced in applying the BOA concept, practical infor-
Monthly 2 (6)
mation on the BOA web page (BOA, 2022), registering data, practical
training in four selected neuromuscular exercises, and how to indi- Seldom 2 (6)
vidually tailor exercise programs (Appendix 1 Table A1). Course ma- Patients with confirmed hip/knee OA
terials, including PowerPoint presentations, manuals, and patient
Daily 14 (40)
questionnaires, were provided to each participant on a USB drive.
Weekly 17 (49)
All participating PTs, the community physician, and the patient
representative were present throughout the course. Orthopedic Monthly 2 (6)
residents were unable to be present throughout the duration of the Seldom 2 (6)
course due to clinical duties. They participated as much as they could
Own physical activity
and were provided with a USB drive loaded with all course materials.
Sedentary 1 (3)
Low impact 11 (31)
2.5 | The SOASP Moderate impact 21 (60)
High impact 2 (6)

The overall aim of the SOASP, which is part of the BOA concept, is to
increase patients' efficacy in self‐managing their OA and increase
their level of physical activity. It consists of two‐to‐three 90‐min content includes exercise and self‐management strategies to reduce
didactic group sessions on the pathology and etiology of OA, as pain and symptoms. Ideally, the lived experience of OA and personal
well as the available treatments, and treatment guidelines. Additional experience of non‐surgical interventions should be shared by an OA
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- OPAVA ET AL.
communicator, that is, a person with OA who has been trained in a The manifest content analysis of the interview data was per-
structured way (Thorstensson et al., 2015). formed in several steps (Elo et al., 2014) at a low abstraction level
Practical one‐on‐one sessions provide tailored introductions and and with a low degree of interpretation (Lindgren et al., 2020). One
instruction on a personal exercise program. Depending on patient of the team members (K.K.) first listened to the interviews in their
preferences, exercise programs can then be performed individually or entirety several times to familiarize herself with the content. Next,
in PT‐supervised classes twice a week for 6 weeks. Exercises for she extracted quotes related to the study phenomenon “perceptions
strength are individually tailored and based on biomechanical prin- of the BOA course content”, transcribed them, and noted the time of
ciples of neuromuscular exercise (Thorstensson et al., 2007). The their appearance in the respective interviews. She and another team
model of acceptable pain is used to cope with pain during exercise member (E.S.) then performed open coding of all written data by
(Thomee, 1997). A brief home exercise program consisting of one or noting codes and headings related to the phenomenon. The identi-
two exercises is introduced in parallel with the individual exercise fied codes representing different aspects of the phenomenon under
program (Thorstensson et al., 2015). study were then discussed to reach a negotiated consensus between
Written information, a three 3‐month follow‐up focusing on how the two team members, who then put them together in a coding
exercises and physical activity have been incorporated in daily life, sheet. Next, they compared the various codes regarding differences
and a mailed questionnaire at 12 months are used to support the and similarities, and manually grouped codes representing similar
maintenance of an active lifestyle (Thorstensson et al., 2015). aspects of the phenomenon into categories. At the end of the
analytical procedures, a third team member (C.H.O.) acted as a peer
expert, discussing and comparing the emerging categories until a
2.6 | Assessments consensus was reached and labels for the final categories were
assigned.
All participating PTs answered questions on demographic and back-
ground data (gender, age, educational background, and profession,
years of employment, current employment, area of specialization, 2.8 | Ethical considerations
experiences managing patients with diagnosed OA and with unspe-
cific knee and/or hip pain, and their own level of physical activity). The study was performed according to the Declaration of Helsinki.
At baseline, all participating PTs also answered, a 34‐item Thus, all participants were informed orally and in writing about the
questionnaire. Knowledge about OA and its evidence‐based man- aim of the study and their right to abstain from study participation, to
agement was assessed via 19 statements (11 correct and 8 incorrect) withdraw at any point in time without giving any reason, and that this
with which PTs could agree, disagree, or answer “do not know”. At- would not negatively interfere with their rights as employees/stu-
titudes about potential exercise‐induced pain and increased joint dents/patients. All data were treated confidentially and stored in
damage were assessed with seven statements (1 = “not at all” to locked places, only accessible to members of the research team. The
6 = “totally”). Confidence (1 = “not at all” to 6 = “totally”) in guiding identity of study participants was indicated by running numbers, and
and facilitating the physical activity was assessed via eight questions. the key to these numbers was stored separately from the data. Re-
The questionnaire format was based on a similar questionnaire used sults are presented at a group level, thus preventing the identification
and evaluated by us (Nessen et al., 2018), and its content was based of individual participants.
on our previous study on Indian PTs‘ approaches to OA (Swärdh,
Thorstensson, et al., 2022).
Three focus group interviews were performed to identify par- 3 | RESULTS
ticipants’ perceptions of the BOA course content. One of the authors
(K.K.) conducted the interviews within a week after the course. An 3.1 | Knowledge, attitudes, and confidence
Indian PT observed the interviews to later assist in recalling and
explaining what happened, if there was a need. The focus group in- Descriptions of knowledge, attitudes, and confidence before the
terviews were semi‐structured, based on an interview guide course are displayed in Table 3. The number of correct answers was
(Table 2), and tape‐recorded. highest for knowledge of patients' need for self‐management infor-
mation, that the best treatment for mild‐to‐moderate OA is exercise,
and that patients can be involved in the implementation of the OA
2.7 | Analytical procedures management. However, many wrongly believed that radiography
determines the type of treatment required and that exercise pre-
Quantitative data are described as median values with full ranges scription is sufficient for exercise adherence. Attitudes about po-
within parentheses. Agreements with incorrect knowledge state- tential exercise‐induced pain and increased joint damage were
ments and disagreements with correct statements were indicated as generally low‐to‐moderate, but the attitude that exercises that in-
incorrect, while the opposite was considered correct. “Do not know” crease pain should be avoided was rather high. Confidence in guiding
answers were considered incorrect. and facilitating the physical activity was generally high.
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TABLE 2 Interview guide.

Introduction
In this focus group interview I am interested in hearing experiences from all participants. My role is to involve everyone and keep focused. I will do
this by asking questions, inviting a specific participant to answer, and maybe also by interrupting discussions that may not be related to the study
topic. The interview will last for a maximum of 1.5 h. My colleague here will observe what happens and will later help me remember what
happened during the interview. The interview will be recorded and therefore we ask you to speak up.
Entry question
What will you particularly take home from your participation in this training program?
Questions
1. Please tell me, how you can make use of knowledge provided:
…on patient education of patients with OA?
…on OA as a condition?
…on basic treatment and evidence‐based management of patients with OA?
…on the role of surgery and drugs in the treatment of OA?
…on a registry as part of better OA management?
…on how to successfully implement a new concept for OA management?
…on the supported OA self‐management program?
…evidence‐based evaluation of patients with OA?
…on neuromuscular exercise for patients with OA?
2. What are your expectations for implementation of BOA into your daily practice?
3. What apprehensions do you have on implementing BOA into your daily practice?
4. Is there anything in the BOA concept that makes you feel uncomfortable or unwilling to use it?
5. Is there anything about the BOA concept that is particularly attractive to you?
6. What changes on an organizational level would be required for implementation of BOA?
7. How do you perceive teamwork on an equal level between representatives from different professions?
8. How do you perceive collaboration with patients as equals?
9. What are your thoughts about using the total BOA concept versus parts of it
10. Which adaptations would be necessary for use of BOA in India?
Follow‐up questions/probing questions

Repetition, request for clarification, request for confirmation, and summaries. For example:
Could you tell me something more about…?
Can you tell me how you thought…?
How do you mean?/Do you mean…?
You have told me about…is there anything you would like to add?
3.2 | Perceptions of the BOA course increasing body functions to improving activities. A new under-
standing of the importance of communication aspects of the
Based on the three focus group interviews, five categories were SOASP, such as asking patients what they know and influencing
identified as participants' perceptions of the BOA course content: their perceptions of taking responsibility for their bodies, and
Shift in management focus, Need for cultural adaptation, Importance clearly educating patients about OA and its consequences, was
of social support, Development of organization and collaboration, and expressed.
Feelings of hesitation. Categories are described below and support-
ing quotes can be found in Table 4.
3.2.2 | Need for cultural adaptation
3.2.1 | Shift in management focus Participants stated that goals and lifestyles differ between India and
Western countries. They expressed that while there was no need for
Participants suggested a shift toward physical activity, including cultural adaptation of the didactic parts of the BOA course, the entire
exercise, as a first‐line treatment for OA. Medical doctors indicated concept could not be implemented directly in India. They suggested
that they were now more aware of the benefit of drugs to enable that some specific exercises could be used immediately, but that
exercise and postpone or avoid surgery, drugs which many patients other aspects related to patient education and daily life would
cannot afford. Participants expressed that new knowledge provided require modification. They mentioned potential cultural barriers such
in the BOA course on how to use physical activity as a pain as beliefs on OA to be a lifelong, incurable disease that is a normal
modifier was inspiring and would reduce prior prescription of mo- part of aging, that many patients first arrive at the clinic with irre-
dalities, and advice regarding rest and avoidance of certain activ- versible joint damage, and that Indian patients might have difficulties
ities. Similarily, participants suggested that neuromuscular exercise breaking daily habits, such as sitting cross‐legged and toilet habits
might replace conventional thigh muscle training and a shift from that require squatting. Some parts of these cultural conflicts might be
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TABLE 3 Knowledge, attitudes, and confidence among 35 PTs before the SOASP, directly after, and 3 months later.
Correct answers,a n (%)
Knowledge (Agree/Do not agree/Do not know)
Radiographic examination is not necessary to start treatment (C) 21 (60)
Radiographic changes determine the necessary type of treatment (IC) 9 (26)
Total pain elimination is important before exercise initiation (IC) 20 (57)
Group treatment can, to a large extent, replace individual treatment (C) 21 (62)
OA is a modifiable disease (C) 18 (53)
All patients will need surgery, sooner or later (IC) 29 (83)
All patients need pain medication (IC) 22 (67)
All patients need information about self‐management (C) 33 (97)
Exercise is the best treatment for mild‐to‐moderate OA (C) 32 (91)
Pain during exercise can be used to determine exercise intensity (C) 28 (80)
Patients can manage their OA well with support from a PT (C) 28 (82)
OA affects all structures in and around the affected joint (C) 28 (80)
A meniscus injury around age 40 is likely the first sign of OA (C) 13 (39)
A quality register is only for research purposes (IC) 21 (62)
Prescription of an individually adapted program is enough for exercise adherence (IC) 11 (31)
Exercise should be performed at least 30 min each time (IC) 13 (37)
Exercise intensity should not be increased unless the patient can keep hip‐knee‐ankle 27 (77)
alignment (C)
Trained patients can be important resources in successful implementation of evidence‐ 32 (91)

based OA management (C)
Patient‐reported outcomes cannot be trusted (IC) 21 (60)
Attitudes (1 (not at all)–6 (totally))
Patients should avoid daily physical activity when in pain 3 (1–6)
Patients should avoid planned and structured exercise when in pain 3 (1–6)
Exercising when in pain may harm patients 2 (1–6)
Patients complaining about pain when exercising make me worried that it is harmful 3 (1–6)
If a certain exercise increases pain, I advise him/her to avoid that particular exercise 5 (1–6)
If exercise induces pain, I think that it is directly related to cartilage destruction 3 (1–6)
If a patient complains about increased pain after an exercise session, I feel worried that 2 (1–5)
he/she has contributed to increased OA progression
Confidence (How confident are you in your ability to…1 (not)–6 (totally))
…guide patients in how to adjust their physical activity? 5 (2–6)
…encourage patients to exercise despite pain? 5 (1–6)
…give positive feedback on patients' physical activity? 5 (3–6)
…motivate patients to physical activity? 6 (2–6)
…guide patients in problem solving to overcome barriers to physical activity? 5 (2–6)
…facilitate shifting to problem solving if patients get stuck in negative discussions on 5 (1–6)
previous bad experiences?
…guide patients in identifying possibilities for physical activity in daily life? 5 (3–6)
…encourage exchange of positive experiences between patients, for example, on how to 6 (2–6)
manage daily physical activity?
a
that is, agreement with correct statements and disagreement with incorrect statements.
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TABLE 4 Quotes supporting the five categories identified in the content analysis of focus groups.
Category Quotes
Shift in management focus “I realize the concept. Exercise should be the first‐line treatment, followed by pharmacy
treatment, and then surgery” (FG 3)
“You can start with the patient exercise protocol and not with modalities—teaching the patient”
(FG 1)
“Before the course we were telling the patients to take rest, avoid some activities. Now we say,
‘do exercises, they are a temporary pain reliever!’” (FG 2)
“Before we stopped exercise when pain occurred. Now, during pain, we should do exercises, now
we go for exercise” (FG 2)
“The first level, I already applied it on one patient. My patient was happy, and she completely
agreed with what I said about weight bearing exercises” (FG 2)
“The perception has changed. We were focusing on range of motion, now on how the function is
improving” (FG 2)
“We usually use the neuromuscular training just for the neurological patients. We never thought
of that before training, we never thought of using it with other patients. We focused on
motion and strength but now we will work on this with OA” (FG 1)
“We do not ask them what they want, what they know, or how OA occurred” (FG 1)
“Patient education is something new” (FG 1)
Need for cultural adaptation “Indian lifestyle is totally different from the Western world and population is small” (FG 1)
“No adaptation on the theoretical [didactic] part” (FG 1)
“Most patients are not aware it is a problem. They see OA as part of aging and no problem.
When they come to us their joints are deformed” (FG 2)
“Patient education is very difficult because of the cultural aspects…like sitting cross‐legged, and
toiler habits. There might be lots of things [that are] culturally accepted, difficult to break
them” (FG 1)
“This need to be adapted in the questionnaire; ‘put on socks’ should be removed. Standing up
and sitting down should not be modified” (FG 3)
Importance of social support “But when the patients who are suffering from OA share their knowledge they will be more, they
will be confident, trustworthy” (FG 3)
“Fear can also be reduced by giving a group exercise” (FG 1)
“We can videotape a good patient and show the others. It will also motivate the patient” (FG 1)
“The patient who participated in the workshop [patient communicator] will be called to show
other patients about exercises and treatment. Patients should tell patients” (FG 2)
Development of organization and collaboration “Every person, patient, PT, doctor, has a different perspective which can be involved in team-
work along with different professions and the patient's point of view.” (FG 3)
“Yes, we need to have open communication with professionals. There is a lot of conflict and
misunderstanding between us only. So that we need to sort out first. They often say you take
painkillers…we also tell them to take pain killers. There should be a common communica-
tion” (FG 3)
“During evaluation we use evidence‐based methods, but again we need documentation. We need
to do pre‐ and post‐treatment. We do not have the instruments [we need] to evaluate” (FG 2)
“Physical activity should be implemented in the education of doctors” (FG 3)
“Those who cannot attend physically could be offered Skype participation, online guidelines
should be provided.” (FG 3)
“Implementation needs support from the IT department, and they will not give us support until
management agrees. The consent of the organization. We need full support from organi-
zation ‐ management” (FG 2)
Feelings of hesitation “Lack of confidence for doing the exercises, [a] major lack of confidence is the issue” (FG 3)
“We understand the concept but lack the basic tools, where to start and so on, how we need to
start and…” (FG 1)
“If we ask the patient ‘what do you think about this and that?’, the patient may think that the
therapist is lacking knowledge” (FG 2)
“Difficult to get them to campus if they can train at home.” (FG 3)
“Connecting patients is the most important. The most difficult thing is to connect them to get
them together and educate them. That will be difficult to do. Connecting patients” (FG 2)
“All the research is in the Western world, there is no research in Asian countries or in India”
(FG 1)
“We have to manage the time: first, evaluation takes time, and we have to educate patients with
exercises. That is a minimum of 45 min” (FG 2)
Note: Focus group (FG) id within parentheses.

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solved by creating awareness on temporarily reducing and/or modi- cultural gap as a potential barrier to implementation, with Indian
fying old habits. patients' beliefs about OA differing from those of patients in the
Western world. They raised concerns about being regarded as
incompetent if they used patient‐centered communication. The par-
3.2.3 | Importance of social support ticipants suggested that Indian patients are hesitant to come to the
clinic for treatment, that exercise could not be performed with In-
The participants expressed an overall positive attitude towards group dian patients, who sometimes wear uncomfortable clothing, and that
training of patients. They described group management, peer‐ it may be difficult to assign patients to groups. The participants
teaching, and interaction between patients as new and important challenged the lack of evidence for OA management in an Indian
ways of improving OA management. They expressed that having context and questioned the transferability of results from non‐
patients share the difficulties and successes related to their OA is a Western countries. They also stated that questionnaires on daily
way of improving psychological health and creating confidence and activities developed outside India may not be appropriate for Indian
trust in the SOASP. Participants also mentioned support from other patients. The participants were also concerned about time
patients during group training as a strategy to reduce the fear of pain management.
and damage that could also serve as motivation for exercise main-
tenance. They highlighted the use of role modeling through video as
valuable in motivating patients and providing good examples of 4 | DISCUSSION
treatment success. They suggested that patient communicators are
important in OA management to develop a more personal re- To our knowledge, this is the first study to describe the challenges of
sponsibility for physical activity. transforming a standardized course for the implementation of OA
CPGs, developed in Europe, to be used among people of another
ethnicity, including barriers of culture, language, literacy, environ-
3.2.4 | Development of organization and ment, and daily living. Our findings indicate that Indian PTs felt
collaboration confident to guide patients' physical activity but were lacking knowl-
edge related to the role of radiographic findings and how to support
The participants suggested that well‐functioning teamwork is neces- exercise adherence. They were enthusiastic about BOA and recog-
sary to support the implementation of BOA. They thus stated that the nized the need for a shift in the management focus but also raised
establishment of multi‐professional teams is important, as is good concerns and hesitation related to culture and context, organization,
communication between professional groups and improved coordi- and their own skills.
nation of registration, referrals, and follow‐ups. Participants further Most participants agreed with the statement that patients need
suggested that better communication between health professional information about self‐management. However, many also thought
groups and patients could reduce common misunderstandings and that the prescription of an exercise program was enough for adher-
conflicts about treatment strategies. The focus should be on providing ence, and insecurity about how to use a more patient‐centered
similar basic information on pharmacological treatment and the communication without losing their patients' trust was identified in
importance of physical activity to increase health and postpone sur- the interviews. There was great enthusiasm about involving patients
gery. They described documentation as a prerequisite for the imple- in support groups but also concerns on how to connect them. No
mentation of evidence‐based practice, with registration of pre–post established models or techniques for self‐management support were
evaluations, management types, and collection of research data. The mentioned and patient education was “something new”. Altogether,
participants expressed a wish for the implementation of evidence‐ this indicates that “self‐management” is not understood according to
based OA management, for example, in MD education. They sug- established definitions (Lorig & Holman, 2003). In our previous study
gested that digital solutions for patient education would improve in- on Indian PTs' approaches to OA, it seemed to be mainly about
clusion. Full support from hospital management was considered advice on how to adapt daily life to reduce the impact of the disability
necessary for the successful implementation of BOA. caused by OA (Swärdh, Thorstensson, et al., 2022).
A majority of our participants agreed with the statement that
exercise is the best treatment for mild‐to‐moderate OA. However,
3.2.5 | Feelings of hesitation from our qualitative results, it seems that “exercise” was understood
before the course mainly as range‐of‐motion exercises and straight
The participants expressed uncertainty, causing ambivalence toward leg raises, while the dynamic neuromuscular training recommended
immediate implementation of the SOASP. They mentioned the lack of for patients with OA in the SOASP was novel to our participants.
on‐site professional support, basic treatment skills, and the ability to Thus, the high confidence in guiding patients in exercise and physical
translate theory into practice. Participants also expressed concerns activity that was indicated in the questionnaire before the course was
as to how to modify and adapt new and complicated exercises, and a obviously not related to dynamic neuromuscular training, as indi-
fear of inability to properly guide the patients. They described the cated in the focus group interviews after the course.
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It was found in our focus group interviews that deformities and people in educational materials may facilitate the BOA uptake.
bone destruction among the patients managed by our participants Concerns raised among the participants as to whether CPGs based
were generally more severe than among those targeted in the SOASP entirely on studies performed in Western countries are relevant in
who were in the earlier stages of the disease. Hence, the prevention of India and other non‐Western contexts seem sensible. Such concerns,
severe OA through early diagnosis, active management, and patient as well as the barriers to implementation of international CPGs in
education, which constitute the core idea in BOA and international OA India that were identified in the present results, need to be
CPGs (Kolasinski et al., 2020), also seemed new to our participants. A acknowledged and addressed in the future (Luhar et al., 2020).
lack of a preventive perspective on OA was also reflected in the One strength of our study is the combination of quantitative and
questionnaire, where over half of our participants disagreed with the qualitative data. Another is the involvement of multiple researchers in
statement that early meniscus injury is likely a first sign of OA and that the qualitative analysis and their prolonged engagement in similar
only one quarter of them disagreed with the statement that radio- study contexts. One limitation of this study is the small sample.
graphic changes determine the necessary type of treatment. This re- However, the quantitative data were still useful for describing
sembles our previous results (Swärdh, Thorstensson, et al., 2022), and knowledge, attitudes, and confidence at baseline, and for comparisons
results from another non‐Western country, Nigeria (Ayanniyi with qualitative data after the BOA course. Another potential limita-
et al., 2016). The idea that the radiological grade of OA is important for tion was the choice to use an existing, formal evidence‐based course
PTs' diagnostics and treatment planning needs to be abandoned since developed for Western conditions without any initial cultural adap-
radiology is not required for OA diagnosis and since waiting for tations. However, we feel that the use of the non‐modified BOA
radiological changes delays early preventive measures to reduce OA‐ course truly helped in identifying valuable perceptions to keep in mind
related disability (Hunter & Bierma‐Zeinstra, 2019). for future adaptations. It would perhaps have been valuable to indi-
Our qualitative results indicated that our participants understood cate single participants' identification numbers after each quote,
BOA as a concept but did not know how to transform it into practice, rather than that of the focus group. However, this was not possible,
lacked some basic skills, and had no one to ask. These hesitations do and while this may be considered a limitation of our study, we still
not represent failure on an individual level but may rather be a result think it is useful to indicate whether quotes came from groups that
of the traditional educational paradigm in India, with a learner‐ included PTs only or the group including other stakeholders as well.
centered rather than a learning‐centered approach (Brinkmann, 2019) One suggestion for future research would be to incorporate the
and with a focus on “rote and repetition” (Clarke, 2003) rather than on voices of users and those delivering the intervention in a co‐design
own reflection and problem‐solving. process (The Lancet, 2022) to address the challenges of implement-
Our participants' desire for the establishment of true teamwork ing evidence‐based OA management in India. The establishment of an
and better support from their organization to enhance the imple- Indian BOA register will offer an opportunity for epidemiological
mentation of BOA may reflect the Indian hierarchical society, which studies comparing the outcome of the BOA concept between India
pervades many areas of daily life. It has previously been reported and Western countries. The study of implementation of evidence‐
that Indian PTs do not always seem to get the respect they feel they based OA management by use of a behavior change model appli-
deserve in healthcare organizations (Grafton & Gordon, 2019). cable to organizational change such as the Diffusion of Innovations
One hesitation identified in the interviews relates to time con- (Greenhalgh et al., 2004) would be of great value for large‐scale
straints. Since the SOASP contradicts Indian patients' expectations of implementation in India and other non‐Western countries.
PT management for their OA (Swärdh, Jethliya, et al., 2022), extra
time is needed to explain the new ideas to patients so that they can
embrace and incorporate them into their daily routines. That extra 4.1 | Implications for physiotherapy practice
time is hard to find in busy clinics with many illiterate patients with
limited power to influence their home and work situations. Such One clinical implication of our results is that the implementation of the
barriers may also be found in certain immigrant groups with low current SOASP should possibly not initially target illiterate patients in
health literacy levels in Western countries. Unless this is recognized, India but rather the more educated. Implications for Indian PT
many health interventions, including BOA, will still leave people curricula are that the existence of CPGs and their content should be
behind (The Lancet, 2022). incorporated, and more focus should be placed on the PT students'
Hierarchical structures, educational systems, and literacy levels own reflections on how to transform theory into practice. Further-
cannot be easily changed. However, cultural and contextual adapta- more, training of basic skills required for implementation of self‐
tion of the BOA course, including the SOASP, may help in its management and of students' own body awareness and neuromus-
implementation as suggested by our participants. Thus, the expansion cular fitness in order to increase their confidence in tailoring individual
of the BOA course with an extra day or a follow‐up module to exercise programs and continuously adapt them to their patients'
incorporate more practical skills training may be necessary. improvements. One suggestion for this would be to use for example,
Furthermore, addressing difficulties related to crossed‐leg sitting and Transformative Learning to understand the process of, conditions for,
squatting among Indian patients with OA, offering advice on appro- and outcomes of learning (Mezirow, 1981). On an organizational level,
priate Indian clothing for exercise, and using photographs of Indian our results also imply that changes in hierarchical structures in
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healthcare and strong support from prominent management repre- global burden of hip and knee osteoarthritis: Estimates from the
sentatives is a prerequisite for the implementation of CPGs. PTs may global burden of disease 2010 study. Annals of the Rheumatic Diseases,
73(7), 1323–1330. https://doi.org/10.1136/annrheumdis‐2013‐20
then, if given access and mandates, play a major role in the early
4763
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Barton, C. J. (2021). Patient education improves pain and function in
people with knee osteoarthritis with better effects when combined
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Grafton, K., & Gordon, F. (2019). A grounded theory study of the narrative
providing resources for the BOA course. Thanks are also due to the
behind Indian physio‐therapists global migration. The International
course faculty members Przemyslaw Paradowski, Beryl Svanberg, Journal of Health Planning and Management, 342(2), 657–671. https://
and Kristin Wetterling, and to Nilashri Naik for assistance during the doi.org/10.1002/hpm.2725
focus group interviews. No external funding has been received for Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O.
this study. (2004). Diffusion of innovations in health service organisations. A
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C O N F LI C T O F I N T E R ES T S T A TEM E N T Hunter, D. J., & Bierma‐Zeinstra, S. (2019). Osteoarthritis. Lancet,
None of the authors report any conflict of interest related to the 393(10182), 1745–1759. https://doi.org/10.1016/s0140‐6736(19)
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Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J.,
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D A TA A V AIL AB IL I T Y S T A T EM EN T W. F., Hawker, G., Herzig, E., Kwoh, C. K., Nelson, A. E., Samuels, J.,
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41142
E T H IC S S T AT E M E N T Lim, K. K., Chan, M., Navarra, S., Haq, S. A., & Lau, C. S. (2016). Devel-
The study has been formally approved by the IEC at Pravara Institute opment and implementation of models of care for musculoskeletal
conditions in middle‐income and low‐income Asian countries. Best
of Medical Science (PIMS/IEC‐DR/2018/256) and all participants
Practice & Research Clinical Rheumatology, 30(3), 398–419. https://
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A PP E N DI X 1
T A B L E A1 BOA course program.

Day 1
09.30–10.00 Course inauguration
10.00–10.45 Why do we need patient education in osteoarthritis management? PT 1
10.45–11.45 What is osteoarthritis? OS
11.45–12.00 Break
12.00–13.00 The basic treatment of osteoarthritis PT1
13.00–14.00 Lunch break
14.00–15.30 Evidence‐based treatment OS
15.30–16.00 What about pills and surgery? OS
16.00–16.15 Break
16.15–17.15 Better management of patients with osteoarthritis, the BOA registry PT2
Day 2
9.30–10.00 Issues around successful implementation PT1
10.00–10.30 Keys to successful implementation PR
10.30–10.45 Break
10.45–11.45 The supported osteoarthritis self‐management program PT2
11.45–12.15 How do we know if we are successful? PT1
12.15–13.15 Lunch break
13.15–14.00 Evidence‐based evaluation PT2
14.00–14.30 Neuromuscular exercise principles PT1
14.30–14.45 Break
14.45–15.45 Neuromuscular exercise practise PT1 and 2
16.00–16.30 Discussion—potentials and barriers All
Note: Course faculty: PT1, PT, PhD, associate professor, co‐founder of BOA; OS, M.D., Ph.D., senior orthopedic surgeon; PT2, PT in primary health care,
MSc, development manager Swedish BOA register; PR, patient representative (OA communicator).
Received: 10 October 2022
DOI: 10.1002/pri.2015
RESEARCH ARTICLE
- -
Revised: 28 March 2023 Accepted: 5 May 2023
Physiotherapists' experiences on assisting physiotherapy

users during the COVID‐19 pandemic with lockdown
measures in Spain
Helena Fernández‐Lago1,2,3 | Carolina Climent‐Sanz1,2,3 | Cristina Bravo1,2,3 |

1,3 1,2,3 1
Pere Bosch‐Barceló | María Masbernat‐Almenara | Daniel Sanjuan‐Sánchez |
1,2,3
Erica Briones‐Vozmediano
1
Department of Nursing and Physiotherapy,
University of Lleida, Lleida, Spain Abstract
2
Grup d’Estudis Societat, Salut, Educació i Background: Physiotherapists had faced a new healthcare scenario characterised by
Cultura, GESEC, Department of Nursing and
the restrictions caused by the COVID‐19 pandemic.
Physiotherapy, University of Lleida, Lleida,
Spain Purpose: To explore the impact of the COVID‐19 pandemic on the physiotherapy
3
Health Care Research Group (GRECS), Lleida profession from the perspective of physiotherapists working in the public and pri-
Institute for Biomedical Research Dr. Pifarré
Foundation, IRBLleida, Lleida, Spain
vate sectors.
Methods: Qualitative study based on semi‐structured personal interviews with 16
Correspondence
physiotherapists working in public, private, or public‐private partnership sectors in
Cristina Bravo, Department of Nursing and
Physiotherapy, University of Lleida, Lleida, Spain. The data were collected between March and June 2020. Inductive qualitative
Spain. content analysis was performed.
Email: cristina.bravo@udl.cat
Results: The participants (13 women, 3 men; aged 24–44 years) had professional
experience in diverse healthcare settings (primary, hospital, home, consultations,
insurance companies, associations). Five categories were identified: (1) the impact of
lockdown on the health of physiotherapy users; (2) managing the demand for
physiotherapy services during lockdown; (3) introducing protocols and protective
measures in physiotherapy consultations; (4) changes in therapeutic approaches;
and (5) future expectations in the physiotherapy care model. Physiotherapists
perceived that lockdown caused a decline in the functionality of people with chronic
conditions, together with a reduction in the physiotherapy services. Difficulties in
prioritising users considered urgent became evident, and the inclusion of prophy-
lactic measures affected treatment duration differently depending on the care
setting and the pandemic prompted the use of telerehabilitation.
Discussion: The pandemic affected the functional status of chronic physiotherapy
users and made treatment time, quality of care and triage protocols visible. In
physiotherapy, technological barriers need to be solved, such as digital literacy,
families without resources, situations of dependency and cultural barriers.
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- FERNÁNDEZ‐LAGO ET AL.
KEYWORDS
COVID‐19, physiotherapy, practice patterns, quarantine, telerehabilitation
1 | INTRODUCTION Palacios‐Ceña et al., 2021). Another study showed that physiother-

apists perceived that the implementation of preventive measures was
The pandemic caused by the SARS‐CoV‐2 posed a new healthcare inadequate (Al Attar & Husain, 2021). However, the impact of the
scenario characterised by restrictions (Alpalhão & Alpalhão, 2020). In new healthcare scenario on the daily practice of physiotherapists and
Spain, a state of alarm was declared on 14 March 2020, which patient/user care is unknown. In Spain, 90% of physiotherapy is
included a mandatory strict home lockdown except for essential concentrated in the private sector. The physiotherapists' experience
services. On 4 May 2020, the strict lockdown ended and the ‘Tran- in other work sectors during the pandemic could contribute to future
sition to New Normality Plan’ was initiated, which was gradual ‐from healthcare resource planning.
phase 0 (preparation for de‐escalation) to the new normality‐ and The aim of this study was to explore the impact of the COVID‐19
asymmetrical among all regions in Spain based on the epidemiological pandemic on the physiotherapy profession from the perspective of
situation (Boletín Oficial Del Estado, 2020b). Regarding health ser- physiotherapists working in the public and private sectors.
vices, physiotherapy centres were not obliged to close but were free
to close or provide services according to the needs of urgent pa-
thologies and the availability of personal protective equipment 2 | MATERIALS AND METHODS
(Boletín Oficial Del Estado, 2020a).
In hospital settings, specifically in intensive care units, physio- 2.1 | Study design
therapy has responded to a new unknown disease through respira-
tory physiotherapy interventions, intensive care and early A phenomenology qualitative study conducted in Spain between
rehabilitation (Falvey et al., 2020; Thomas et al., 2020). However, March and October 2020.
focussing efforts on treating COVID‐19 has in turn limited or dis-
rupted outpatient rehabilitation services, which has had a negative
impact on other conditions requiring physiotherapy, such as post‐ 2.2 | Setting
surgical rehabilitation or rehabilitation of people with disabilities
(MacDonald et al., 2021). For instance, in patients with amyotrophic In Spain, physiotherapists carry out their professional activity in the
lateral sclerosis, discontinuation of treatment has accelerated the public health system (public sector), private physiotherapy clinics
functional deterioration of motor skills, increasing fatigue and leading (private sector), or with public‐private partnerships (insurance com-
to a reduction in their quality of life (Gonçalves & Magalhães, 2021). panies and associations). According to the General Register of Health
Physiotherapy as a profession has also had to manage strong Centres, Services and Establishments, there are currently 22,521
modifications in its work context, mainly related to COVID‐19 physiotherapy centres in Spain, of which 20,393 are private, including
transmission prevention measures. Since the virus can be trans- insurance companies. On the other hand, in Spain, there are 59,791
mitted by infected people to healthy people during the incubation physiotherapists registered as of 2021, 63% of which are women
period (2–14 days) before the onset of symptoms, prophylactic and (Instituto Nacional de Estadística, 2020).
protective measures were reinforced during the first months of the
pandemic. The World Health Organization (WHO) recommended
limiting human‐to‐human interaction during the first wave as a 2.3 | Participants
control measure (WHO, 2019). These limited physiotherapy in-
terventions are characterised by contact and close therapeutic re- Theoretical sampling was carried out based on the criteria of het-
lationships with users. World Physiotherapy reported that most of erogeneity of specialities (cardiorespiratory, geriatrics, musculoskel-
its member states suspended physiotherapy services between etal, neurology, paediatrics, pelvic floor, sports) sector (public, private
March and May 2021. The greatest impact was observed in the or public‐private partnership). The inclusion criteria were working as
private sector (Spanish General Council of Physiotherapists' a physiotherapist in two regions of Spain: Catalonia and Galicia. The
Associations, 2020). recruitment strategy with the first contacts was intentional, and then
Only two previous studies in public hospitals and intensive care by snowballing, whereby contacts facilitated others.
units in Spain investigated the experiences of physiotherapists
working on the front line during the first wave, as they had direct
contact with COVID‐19 patients. They reported changes in the or- 2.4 | Data collection
ganization and distribution of hospitals and that health services were
not prepared for the pandemic (Palacios‐Ceña, Fernández‐De‐las‐ Semi‐structured personal interviews were conducted by videocon-
peñas, Florencio et al., 2021; Palacios‐Ceña, Fernández‐de‐las‐Peñas, ference call at home (March–July 2020) during the first wave and
FERNÁNDEZ‐LAGO ET AL.
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part of the de‐escalation process of the pandemic in two regions of collection. Interviews were anonymised to preserve participant
Spain. The interviews lasted between 30 and 45 min, following an confidentiality. Consent was obtained from the Clinical Research
interview script with predefined open‐ended questions (Table 1) but Ethics Committee.
also allowing new topics emerging in the responses to be explored.
Field notes were taken after each interview.
2.6 | Data analysis
2.5 | Ethical considerations All interviews were digitally recorded and transcribed verbatim. The
transcriptions were imported into the Atlas‐ti v.9 software to help
This study followed the principles of the Declaration of Helsinki organise the information during the analysis. An inductive qualitative
and the Belmont Report. The researchers explained the purpose content analysis was performed following five steps: repeatedly
and procedure of the study to the participants and obtained reading of transcripts to obtain an overall impression of the data;
written informed consent from each participant prior to data identifying units of meaning (sentences or paragraphs with the same
TABLE 1 Demographic and professional data.
Working
Partici‐ Age experience State of
pant Gender (yrs) Specialisation (yrs) Sector Setting Position Province alarm
P1 M 26 Traumatology, sports 4 Private Consultation Permanent employee Zaragoza Lockdown

physiotherapy
P2 F 33 Respiratory 12 Semi‐public Insurance Company Permanent employee Lérida Lockdown
P3 F 30 Manual therapy, pilates 10 Private Consultation Salaried employee Pontevedra Lockdown
P4 F 31 Pelvic floor 10 Public Galician health Interim public A Coruña Lockdown

services employee
P5 F 42 Manual therapy 15 Private/ Consultation/ Self‐employed and A Coruña Phase 1

Semi‐ Insurance interim employee
public company
P6 F 38 Manual therapy, pelvic 18 Private Consultation Entrepreneur A Coruña Phase 1

floor
P7 F 41 Geriatrics 20 Public Regional semi‐public Permanent employee, Lérida Phase 1

hospital Hospitalisation
floor manager
P8 F 33 Geriatrics, disability 3 Sem‐ipublic Association Employee A Coruña Phase 1
P9 M 24 Respiratory, 3 Public Outpatient clinic Interim employee Lérida Phase 1

cardiorespiratory
P10 F 36 Pelvic floor, movement 15 Private Consultation Self‐employed Pontevedra Phase 1

therapy, postural
reeducation
P11 F 32 Respiratory 11 Public Primary Care Permanent employee Lérida Phase 1
P12 M 43 Neurology 17 Private Consultation Entrepreneur, self‐ Pontevedra Phase 2

employed
P13 F 28 Neurology 4 Private, Home Care, Parkinson Self‐employed Barcelona Phase 1

public, Association,
semi‐ Interim hospital
public
P14 F 44 Neurocognitive 22 Public Primary care Permanent employee Lérida Phase 3
P15 F 43 Paediatrics 21 Public Hospital Permanent employee Lérida Phase 3
P16 F 37 Paediatrics 14 Semi‐public Early Attention Employee Lérida Phase 2

Centre
Abbreviations: F, female; M, male; P, participant; yrs, years.

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meaning); open coding the meaning units with codes summarising the 3 | RESULTS
content; grouping the codes into categories and subcategories; and
synthesising and describing the categories and subcategories. The participants included 16 physiotherapists (13 women, 3 men)
aged between 24 and 44 years of age, with professional experience
ranging from 3 to 22 years in different settings (consultations, in-
2.7 | Rigour surance companies, primary care, hospital care, home care, and as-
sociations) and from two different regions of Spain (Catalonia and
The COREQ EQUATOR17 guidelines were followed as quality Galicia) (Table 2).
criteria. Triangulation of participants and perspectives enabled the Five categories were identified with their corresponding
credibility of the results, including physiotherapists with different subcategories.
professional profiles in relation to their speciality, work sector and
years of professional experience. The analysis was shared among all
authors: each author read and coded at least two of the interviews 3.1 | The health of physiotherapy users
and then they met to create groups of codes, discuss differences and
resolve possible discrepancies. Three of the authors discussed the The physiotherapists interviewed explained that, due to the strict 3‐
consistency of the final categories. month lockdown in Spain, some physiotherapy users showed an
The researchers in charge of qualitative data collection and improvement in their health status, while others reached a very weak
analysis process were physiotherapists except for one, which allowed physical condition and a great loss of functionality. Even completely
to combine the insider and outsider perspectives. Three of the re- autonomous people reached a state of dependency.
searchers were experienced in the use of qualitative methodology For instance, they described a worsening of the health condition
and trained the others to conduct interviews and analyse the data of people with neurodegenerative or cognitive pathologies who
(Berger, 2015). Verbatim quotes from the interviewees are provided developed medical complications such as sensory hemineglect. In the
to allow for confirmability of the results. We made an effort to case of geriatric users, apart from the impact of lockdown at an
describe the specific Spanish context during lockdown and the de‐ emotional level due to loneliness, they described large losses in
escalation phases in order to help the reader think how results functionality and quality of life, partly due to increased sarcopenia.
could be applied to its context, enhancing transferability (Lincoln & They reported that the impact on elderly people with chronic pa-
Guba, 1986). thologies has been devastating.
1. How do you think the COVID‐19 pandemic may affect physiotherapy? TABLE 2 Semi‐structured interview
script.
2. What do you think the impact of COVID‐19 may be on the model of care or physiotherapy
interventions?
3. How do you think the fear of contagion may affect physiotherapy interventions?
4. What impact do you think COVID‐19 may have on treatment and follow‐up of patients with
chronic pathologies? And on other patient populations?
5. What adaptations have been made in your work environment during the state of alarm? What
kind of adaptations will be required from now on? How has the functioning of the centre where
you work been conditioned? Has any type of computer adaptation been made? If yes, which one?
Do you do any kind of teleworking? If yes, how?
6. What has been the impact on your day‐to‐day work? Number of patients per day, economic
impact, material?
7. How do you think the work organization or business model can change?
8. How were your contractual conditions managed during lockdown? What is your perspective on
the professional legislation of physiotherapy? Do you think it may be affected by COVID‐19?
9. How do you feel about your theoretical and practical training to perform your job as a physical
therapist in the COVID‐19 pandemic?
10. What, if anything, do you think you would need to be reinforced in your training?
11. Have you done any training during the COVID‐19 pandemic situation? If yes, what and why?
12. How do you think the COVID‐19 pandemic may affect your work motivations?
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They also mentioned generalised worsening of the physical 3.2.2 | Changes in demand for physiotherapy
health condition of paediatric physiotherapy users. In addition, they services
commented that lockdown had a negative impact on their psycho-
logical health, increasing nervousness and sleep disturbances in At the time of the interviews, participants anticipated that the eco-
children (Table 3). nomic crisis resulting from both the pandemic and the fear of
contagion might reduce demand for private physiotherapy services.
In fact, there were users who during the state of alarm said ‘they
3.2 | Managing demand for physiotherapy services were going to go as little as possible’. However, they observed that
users had a greater fear of contagion in hospitals and they preferred
3.2.1 | What is classed as an emergency in to go to private services during lockdown and the first phases of the
physiotherapy? Prioritisation of users and waiting lists de‐escalation period (phases 0 and 1). They also stated that, as the
de‐escalation period progressed, demand increased. According to
When the state of alarm was declared by the government in Spain, participants, people with chronic spinal pain demanded the most
the participants reported that user care was reduced to emergency private physiotherapy services and self‐management advice during
cases in all sectors. As a result, they perceived a drastic drop in the lockdown, which they explained due to the worsening of their health
number of users. condition during lockdown, as well as the inability for public services
They noted difficulties in prioritising emergencies. Physiother- and insurance companies to treat many people.
apists in the private sector and insurance companies reported that
in the past, they did not even have the need to prioritise emer-
gencies. As a result, they do not have experience in how to identify 3.3 | Introducing protocols and protective measures
what is classed as an emergency. An example was provided in consultations
regarding the difficulty of conducting triage based on pain, since ‘it
has an enormous subjective component and fear is highly 3.3.1 | Changes in treatment times and their impact
conditioning’. on quality of care
Thus, the responsibility of prioritising patients on the waiting
list fell on the more experienced physiotherapists. For example, in The physiotherapists described that including protective measures
one private medical centre, they created the first protocol to and protocols increased the time needed between every session in
address the classification of users according to their severity or risk order to sanitise the room and material used. This implied change in
condition. the distribution of their offices and work centres to maintain safety
In the public sector, participants reported that waiting lists came distances. The consequences were less usable space in the consul-
to a standstill in the early phases of the pandemic (lockdown, phase tation rooms and a decrease in the number of users treated during
0 and 1). The main cause was stated as surgical interventions were the working day.
suspended, as only emergency cases, such as falls of elderly people Regarding the public sector and insurance companies, physio-
and people with tendon sections, were attended. Likewise, they re- therapists, including prophylactic and protective measures meant that
ported that chronic cases with ordinary pathologies have dis- each physiotherapist treated fewer patients, with longer times per
appeared from consultations and exercises are provided remotely session. They explained that in primary care centres the daily physio‐
without in‐person sessions. patient ratio was around 28 and was reduced to 5. This reduction was
In phase 2 (intermediate phase), waiting lists increased as perceived as an improvement in the quality of care, describing it as ‘a
surgeries were reactivated. They reflected that priority should be luxury that has benefited patients’. Treatments could be carried out in
given to those who had been previously treated and worsened a more efficient and individualised manner: with fewer sessions,
(Table 4). dedicating more time per session and performing telematic follow‐up.
TABLE 3 Subcategory and textual quotes for the category ‘The health of physiotherapy users’.
Subcategory Quotes
Impact of lockdown ‘In general, I could say that they've all improved thanks to what they've done at home, and
more mechanical pathologies have also improved as they've rested/…/In neurological
patients, not specifically (they haven't improved). Those with longer evolution, I didn't
see any improvement in them, more the opposite, they have had pathological patterns
[…]’. (P14) [public sector, primary healthcare, neurocognitive]
‘And with the elderly, it's true that they're a population at risk, so…[…]. There are so many
who are alone […]. So we have older people who were fantastically well, they came to
rehabilitation, then you lock them in their homes for 3 months and when you go to find
them they can't walk’. (P15) [public sector, hospital, paediatrics]
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TABLE 4 Subcategory and textual quotes for the category ‘Managing demand for physiotherapy services’.
Subcategory Quotes
What is an emergency in physiotherapy? Prioritisation of users and ‘It's like…I can't treat you because it isn't urgent […]. I'm afraid that
management of waiting lists physiotherapy will be considered as something not essential, so like it's
not necessary and it goes backwards’. (P4) [public sector, primary
healthcare—Pelvic floor]
‘In the end you say, we filter and we don't filter well, because there's no
triage protocol for physios or anything on the symptoms we treat, that
pain is fundamental you know…there's an enormous subjective
component and fear conditions pain a lot, so it gets complicated’. (P3)
[private sector, consultation—Manual therapy]
‘The patient knows pain, they know their needs, they know what to ask
professionals for when they need something or not. I Think they're
patients (chronic patients) that they do…they have known how to tell
us more than us to them’. (P5) [private sector, consultation—Semi‐
public, insurance company—manual therapy]
Changes in demand for physiotherapy services ‘Some people are completely unaware […] the telephone […] it rang
constantly about things, in situations that were urgent, and things that
were absurd, like things that I want a leg massage, they feel heavy’. (P3)
[private sector, consultation—Manual therapy]
‘Chronic patients are patients that the system has already […] given up on,
and they're the ones who demand the service, they're the ones who are
concerned about asking for the service’. (P5) [private sector,
consultation—Semi‐public, insurance companies—manual therapies]
In this sense, they considered that the circumstances imposed by the relationship, they explained that patients were sympathetic to the
pandemic forced physiotherapists to do things better for patients, and situation and adapted to it. However, they also stated that their use
also perceived the need to increase the number of physiotherapists. generated fear in paediatric users as well as hindered the interaction
In the private sector, where treatment times used to be longer, with people with COVID‐19. In turn, the establishment of proto-
they were reduced in order to be able to introduce disinfection colised cleaning and prevention routines contributed to increase both
measures. They highlighted the economic repercussions of the pro- the safety and trust for the users of the service. The fear of contagion
phylactic measures since they were obliged to treat fewer people decreased over time in both users and physiotherapists.
each working day (Table 5).
3.4 | Changes in therapeutic approaches: telecare,

3.3.2 | Limitations of manual therapy active participation and education
Protective measures and fear of contagion limited physical contact 3.4.1 | Opting for telecare
with the patient. For example, ‘sensitivity to touch was lost’ due to
the incorporation of the use of gloves. In addition, they acknowl- Telecare as a facilitating resource
edged that the initial information regarding protective measures and Participants explained how, as a result of lockdown, they began to
their use was confusing. In turn, in specialities such as pelvic floor use telecare in all sectors. More guidelines were provided to patients
physiotherapy, treatments of the temporomandibular joint, or dry to carry out by telephone or through information and communication
needling, prophylactic measures were previously established, so it did technologies (ICTs) (e‐mails, videoconferences, videos and info-
not affect their interventions. graphics) while at home. In particular, telerehabilitation used with
people with chronic musculoskeletal pathologies was perceived as
positive as it promoted a more active role. Telematic care also
3.3.3 | Accepting protective measures benefited the families of paediatric physiotherapy users as they were
directly involved in the treatment. In addition, it strengthened the
The protocols of action regarding prophylactic and protective mea- link between physiotherapists and the families by making routinary
sures were gradually developed by physiotherapists and were shared videoconferences or calls. Although the telematic follow‐up was a
with the users before they went to the appointment. Despite initially challenge because they were used to touch, they also valued the
not knowing how users would react to the use of protective mea- usefulness of remote intervention, especially for assessments and
sures and how this might affect the physiotherapist‐patient prescriptions or working in groups.
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T A B L E 5 Subcategory and textual quotes for the category ‘Introducing protocols and protective measures in physiotherapy
consultations’.
Subcategory Quotes
Changes in treatment times and their impact on quality of ‘I can't have the same amount of patients in the room because I need to separate them,
care then I have to disinfect the place, so the volume of work has gone down’. (P2)
[private sector, insurance companies—Respiratory]
‘The reasonable thing is now evident: One patient per physio and spend time on the
patient without interruptions’. (P3) [private sector, consultation—Manual therapy]
‘Colleagues have done almost a private treatment with a patient because it's 1 hour
with a patient, a space for you. This is a privilege and a luxury. So the patient in the
public system has benefited from the situation, because before there were so many
patients in the share space and now it isn't possible’. (P15) [public sector, hospital—
paediatrics]
‘Patients don't need 15 sessions of treatment at the hospital. Someone with cervicalgia
doesn't need to come to the hospital every day […] maybe with a couple of more
individualised sessions of 30 or 40 min, then with some exercise guidelines and then
monitoring telematically, it can be managed so as not to saturate the public health
system’. (P7) [public sector, semi‐private hospital—geriatrics]
Limitations to the practice of manual therapy ‘[The PPEs] affect us directly, because we can't work normally […] I don't work
comfortably at all, I can't manipulate the patient in the same way as I would because
I don't work comfortably’. (P2) [private sector, insurance companies—respiratory]
‘The first few weeks I worked with gloves when treating patients. In fact, I used two
pairs of gloves […] and many patients asked me if I could take the gloves off. Like,
hey, well, if you keep your hands clean, I'd rather you don't use them’. (P10) [private
sector, consultation—Pelvic floor]
Acceptance of protective measures ‘What's the only way to do it right? The patient has to wear a mask during treatment
and you have to be protected. That's that’. (P11) [public sector, primary healthcare
—respiratory]
‘We already have the protocol prepared to explain everything to them, to also convey
that confidence and calmness so that they realise that we're up‐to‐date with
everything that comes out and that we comply with the regulations so that they're
happy’. (P6) [private sector, consultation—Manual therapy and pelvic floor]
Barriers to telecare has resulted in changes in the way of working with patients: things
The use of ICTs posed a challenge, especially for professionals and have been done that could be done, but for fear they were not
users with low digital literacy. For instance, they described techno- attempted’.
logical barriers to carrying out telerehabilitation in families without
resources, in migrants, as well as language and cultural barriers, and
in neurological patients. They perceived a desire to return to in‐ 3.4.3 | Educating and empowering users as
person care in these users. physiotherapists' responsibility
Physiotherapists felt the responsibility to educate and reassure their

3.4.2 | Active participation of the patient for the users by providing them with health and rigorous information about
success of the interventions COVID‐19. At a time characterised by a lack of accurate information
and misinformation (e.g. in the media), they identified the elderly as a
One of the positive consequences of the pandemic at the level of care particularly vulnerable population (Table 6).
highlighted by the participants interviewed was the reinforcement of
the active participation of patients in the therapeutic process.
Physiotherapists were surprised how patients favourably reacted to 3.5 | Future expectations in the care model
the guidelines and the autonomous work when they experienced that
being more active in their treatment brings them benefits. 3.5.1 | Expectations regarding active user
In order to exercise at home and take care of themselves, users participation: the role of technologies
had to ‘find their own way’ and physiotherapists had to adapt to
guiding patients by giving them autonomy and becoming their The participants considered that COVID‐19 has had an impact on the
reference in the rehabilitation process. They reflected that ‘necessity long‐term user care paradigm and how treatments will be prescribed
8 of 12
TABLE 6 Subcategory and textual quotes for the category ‘Changes in therapeutic approaches: telecare, active participation and
education’.
Subcategory Quotes
Resorting to telecare Telecare as a facilitating resource
‘Telephone follow‐up … we adapt it to patients who can access video calls. We

could combine it with this or they would send us videos to see how they do an
exercise. Then make the necessary modifications’. (P14) [public sector, primary
healthcare—Neurocognitive]
‘As physiotherapists we've had to reinvent ourselves, make many infographics,

many exercise manuals, we're applying telematic rehabilitation, we do video
calls with patients, we teach them the exercises, they take responsibility in
doing them’. (P7) [public sector, semi‐private hospital—geriatrics]
Barriers to telecare
‘It's just that teleworking with neurorehabilitation is extremely complicated, eh […]

You end up with very little resources with them. Think that, the person who
doesn't have a hemineglect has an alteration of the dorsal horn. How do you
propose exercises so that they don't reach levels of frustration, how do you
propose exercises that you're really in control of what's happening’. (P12)
[private sector, consultation—neurology]
‘I don't like computers at all, the computer part. So there I did have a personal job
to do and no one gave me training on how to use them all… […] What's more…
do what you can and find out for yourself, but among our team, it's true that we
had a lot of support and one's ideas, you know, we shared them, how you do it,
how can we do it…’. (P16) [semi‐public sector, early healthcare—paediatrics]
‘They have to give you material and the patients have to be capable too, and have
that (technological material), otherwise… It seems that nowadays everyone has
it, but not everyone has it. Not everyone has Internet at home’. (P1) [private
sector, consultation—sports]
‘It's much more difficult because each culture also has its own way of doing things
and… […] not all of them, in general, but it's true that it’s more difficult. And on
top of that, if we haven't been able to see them, we haven't been able to have
this contact… […] well, this has been reflected in… for them on a negative level.
The majority are looking forward to coming back. And then what we found was
that many families, especially these families, who perhaps at a cultural level
were not… so rich, let's say, because they didn't know how to send me videos
because they were too large, and through email… or there are people who
didn't even have email’. (P16) [semi‐public sector, early healthcare—
paediatrics]
Active participation of the patient for the success of the ‘If we adapt and try to adapt and improve, we will consolidate what we're doing […]
interventions being a guide for the patient, being a point of reference for them. Not make the
patient dependent, but… empower the patient’. (P11) [public sector, primary
healthcare—respiratory]
Educating and empowering users as a responsibility of ‘As health professionals we have the responsibility to be informed and know how
physiotherapists to transmit a clear and correct message to the people we see […] I think it's
important that we send a common message, wash your hands, don't use gloves
in the wrong way, wear a mask when you're around people, don't touch your
face’. (P8) [semi‐public sector, association—geriatrics]
from now on. That is, the therapeutic approach will move towards a 3.5.2 | Expectations on quality of care
hands‐off model in which the physiotherapist will act as a guide, with
an emphasis on greater patient education and giving them an active The participants expressed the desire to maintain longer sessions per
role in the therapeutic process. They also considered that in the session in the public and insurance sectors because of its impact on
future, telematic tools and new technologies will be more widely improving the quality of care. However, they were also sceptical
used. about whether this would happen. They considered that in the long
- 9 of 12
term, extending sessions offered by insurance companies would their health condition worsening. This research reinforces the rele-
favour patients recovering more rapidly so that they can return to vance of physiotherapy services for the population, especially for the
work and not return to the previous model of 15‐min sessions per most vulnerable people affected by disability and dependency (Di
patient (Table 7). Stefano et al., 2021; Jesus et al., 2021; López‐Sánchez et al., 2020).
The results regarding the difficulties encountered in managing
demand in the pandemic have highlighted the need to standardise
4 | DISCUSSION prioritisation protocols in physiotherapy. Although previous research
is scarce, findings do suggest that the role of physiotherapists in
This study showed that the reduction in physiotherapy services for standardised triage protocols facilitates the access of priority pa-
emergencies in the first months of the pandemic in Spain, on the one tients (Valente et al., 2021). Fennelly et al. (2018) investigated the
hand, had a negative impact on the health of physiotherapy users as inclusion of the advanced clinical physiotherapists (Advanced Phys-
the disability and dependency of people with chronic neurodegen- iotherapy Practitioner, APP) in rheumatology and orthopaedic ser-
erative diseases and geriatric users increased; and on the other hand, vices (secondary care). They reported that the APP successfully
it also affected managing demand, making the problem of triage in intervened in the triage process of 77% of users in 1 year, reducing
physiotherapy visible. The introduction of protocols and protective the referral to the referring physician to 20%. In addition, another
measures implied changes in treatment times, which had an impact study validated the triage process by APP. It showed a concordance
on the quality of care and the therapeutic approach. As a result, the of 76% with respect to the rheumatologist and high sensitivity and
use of manual therapy was limited and telecare and the active specificity in decisions (Bignell et al., 2018). The results of this study
participation of the patient was promoted. agree that years of experience can facilitate decision‐making
Studies in other countries showed that people with chronic pa- regarding prioritisation of users.
thologies and disabilities, more than other populations, had limited or Including preventive and protective measures in daily clinical
restricted access to health services during the pandemic, including practice made the variability of treatment times depending on the
physiotherapy services (Aguiar de Sousa et al., 2020; Lebrasseur sector or setting visible and consequently its impact on the quality of
et al., 2021). For example, during lockdown in Italy, people with care in physiotherapy. They expressed a desire for longer session
neurological disorders (Parkinson, Huntington, Tourette, Multiple times, as was the case during the pandemic. Previous studies have
Sclerosis, Amyotrophy lateral sclerosis, among others) saw their ac- suggested that the standardisation of clinical practice, which depends
cess to physiotherapy services restricted by 30%, which worsened on session time in physiotherapy, can lead to improvements in pa-
the subjective perception of their symptoms by 19% (Piano tient outcomes and in their healthcare experience (Twose
et al., 2020). In turn, it seems that the reduction in physical activity et al., 2019; Verburg, 2019). On the other hand, the WHO called for
due to lockdown was more pronounced in dependent people (Jesus an increase in rehabilitation services worldwide as a challenge for
et al., 2021; López‐Sánchez et al., 2020). Our results showed that 2030 (WHO, 2017). Currently, ratios per population range from
people with chronic conditions but with greater autonomy, such as 0.002 physiotherapists per 1000 people to 2.82 per 1000 people
those with spinal pain, were the most proactive in requesting private (Sykes et al., 2014). However, the number of physiotherapists per
physiotherapy services and following self‐management advice. person in primary care in Spain can reach ratios of 1/27,780 (Spanish
Nonetheless, in paediatric physiotherapy users, people with chronic Ministry of Health, 2022) far from the needs to guarantee the safety
neurodegenerative diseases and geriatric users, lockdown resulted in of patients and health services (Schwartz et al., 2021). Participants in
TABLE 7 Subcategory and textual quotes for the category ‘Future expectations in the care model’.
Subcategory Quotes
Expectations regarding active user participation: The role of ‘From the point of view of physiotherapy there was already a very important
technologies hands off tendency […] less intervention, being much more like a professional
who guides the patient during their pathology. Before we had the perception
that if we didn't touch them we were not healing them’. (P15) [public sector,
hospital—paediatrics]
‘Treatments are being rethought, already from lockdown, transitioning to more

remote physiotherapy, with less frequency of in‐person treatment and more
remote monitoring, involving the patient more in their recovery’. (P14) [public
sector, primary healthcare—neurocognitive]
Expectations on quality of care ‘Insurance company treatment) are no longer going to be 15‐min treatments,
they're going to be at least half an hour, so the quality of care is going to
improve a lot, and I think that in that aspect the patient is going to notice it…! I
hope it'll last! and not when the health crisis is over, which it will, I hope this
won't go back to how it was planned’. (P5) [private sector, consultation—Semi‐
public, insurance—manual therapy]
10 of 12
this study reported that they were treating as many as 28 patients highlighted the advantages of telecare to improve the involvement
per day in the public sector even before the pandemic, thus limiting and follow‐up of patients and to increase their therapeutic options, it
the quality of care. also identified the barriers that some people face in accessing tele-
Lockdown and the limitation of in‐person clinical assistance has care. In physiotherapy, technological barriers to be resolved are
resulted in a trend towards hands‐off service, with a greater weight on digital literacy, families without resources, situations of dependency
education and boost in the use of teleassisted physiotherapy, which and cultural barriers.
was also reported in countries such as Italy, Brazil and the USA (Chen
et al., 2021; Dantas et al., 2020; Jiménez‐Rodríguez et al., 2020; Milani
et al., 2021). There is proven the effectiveness of telerehabilitation in 5.1 | Implications for physiotherapy practice
multiple musculoskeletal conditions (Cottrell & Russell, 2020; Jiang
et al., 2018; Shukla et al., 2017; Suso‐Martí et al., 2021), reporting Changes in the daily practice of physiotherapists in a health alarm
benefits during lockdown, due to the continuity of physiotherapeutic condition had the following implications for users/patients:
care, which has allowed for continued patient education and the
adaptation of therapeutic plans to the patient's environment. Likewise, � There is a need to ensure quality care for physiotherapy users in
advantages were reflected in the field of paediatric physiotherapy, public health emergencies.
with greater family involvement and proximity to daily life at home, � The most vulnerable physiotherapy users in a pandemic are people
which was reflected in a previous study (Chen et al., 2021), and in other with chronic pathologies.
specialities, such as cardiorespiratory physiotherapy (Ramachandran � In physiotherapy, technological barriers to be resolved are digital
et al., 2021). Although this modality of intervention is usually highly literacy, families without resources, situations of dependency and
accepted and satisfactory (Miller et al., 2021), some users continue to cultural barriers.
prefer in‐person sessions (Milani et al., 2021).
In agreement with our results, previous studies showed that the A CK N O W L E D GE M E NT S
greatest barriers to telerehabilitation are found in chronic neuro- No author of the article had received any funding that may be
logical diseases, older adults and people with cognitive deficits affected by the research reported in the enclosed paper.
(Chirra et al., 2019). Jiménez‐Rodríguez et al. (2020) added data
security and privacy to the identified barriers to telerehabilitation, C O NF L I CT O F I NT ER E S T S T A T E M E NT
which were technical difficulties and digital literacy by professionals No potential competing interest was reported by the authors.
and patients, especially older adults.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on
4.1 | Limitations request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.
Firstly, since physiotherapy specialities are not regulated in Spain, we
classified participants according to their self‐reported training. Sec- E T H I CA L C O N S I D E R A T I O N S A N D P A T I E N T C ON S E N T
ondly, the phases of the de‐escalation period were applied differently S T A T EM E N T
to each region, which may have made the integration and interpre- This study follows the principles of the Declaration of Helsinki and
tation of the results obtained more difficult. Nevertheless, our the Belmont Report. The researchers explained the purpose and
objective was not to compare regions or de‐escalation phases but to procedure of the study to the participants, provided the opportunity
have a snapshot of the overall situation of physiotherapy profiles and to ask questions and obtained written informed consent from each
sectors in Spain. This contributed to obtaining richer data and gaining participant prior to data collection. Interviews were anonymised to
a deeper understanding of the impact of the pandemic caused by preserve participant confidentiality. Consent was obtained from the
COVID‐19 on the physiotherapy care activity in Spain. Interviews Clinical Research Ethics Committee (CEIC) of the Arnau de Vilanova
were conducted until data saturation was reached, meaning that no University Hospital (CEIC‐2285).
new information emerged in the last interviews (Saunders
et al., 2018). However, additional participants from other specialities P E RM I S S I O N TO R EP R O D U C E M A T ER I A L F R OM O T H E R
and regions could have enhanced transferability. S O U R CE S
Not applicable.
5 | CONCLUSIONS S T U D Y R E GI S T R A T I O N
Not applicable.
The pandemic increased the evidence of the importance of defining
the physiotherapy triage process and protocols in emergencies. ORCID
There is a need to reach a consensus on minimum standards of Helena Fernández‐Lago https://orcid.org/0000-0002-0772-666X
clinical practice in physiotherapy based on sectors. While this study Cristina Bravo https://orcid.org/0000-0002-2962-8198
- 11 of 12
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https://doi.org/10.1093/PTJ/PZAB075
DOI: 10.1002/pri.2016
RESEARCH ARTICLE
- -Revised: 15 April 2023 Accepted: 5 May 2023
Scoring festination and gait freezing in people with

Parkinson's: The freezing of gait severity tool‐revised
Aileen E. Scully1 | Dawn Tan2,3 | Beatriz Ito Ramos de Oliveira1 | Keith D. Hill4 |
Ross Clark5 | Yong Hao Pua3,6
1
School of Physiotherapy and Exercise Science,
Curtin University, Bentley, Western Australia, Abstract
Australia
Background and Purpose: To improve existing clinical assessments for freezing of
2
Health and Social Sciences, Singapore
gait (FOG) severity, a new clinician‐rated tool which integrates the varied types of
Institute of Technology, Singapore, Singapore
3
Department of Physiotherapy, Singapore
freezing (FOG Severity Tool‐Revised) was developed. This cross‐sectional study
General Hospital, Singapore, Singapore investigated its validity and reliability.
4
Rehabilitation, Ageing and Independent Living Methods: People with Parkinson's disease who were able to independently ambu-
(RAIL) Research Centre, Monash University,
Melbourne, Victoria, Australia late eight‐metres and understand study instructions were consecutively recruited
5
School of Health, University of the Sunshine from outpatient clinics of a tertiary hospital. Those with co‐morbidities severely
Coast, Sunshine Coast, Queensland, Australia affecting gait were excluded. Participants were assessed with the FOG Severity
6
Medicine Academic Programme, Duke‐NUS
Tool‐Revised, three functional performance tests, the FOG Questionnaire, and
Graduate Medical School, Singapore,
Singapore outcomes measuring anxiety, cognition, and disability. The FOG Severity Tool‐
Revised was repeated for test‐retest reliability. Exploratory factor analysis and
Correspondence
Aileen E. Scully.
Cronbach's alpha were computed for structural validity and internal consistency.
Email: a.scully@postgrad.curtin.edu.au Reliability and measurement error were estimated with ICC (two‐way, random),
standard error of measurement, and smallest detectable change (SDC95). Criterion‐
Funding information
Mitsui Sumitomo Insurance Welfare related and construct validity were calculated with Spearman's correlations.
Foundation; Australian government Research Results: Thirty‐nine participants were enrolled [79.5% (n = 31) male; Median (IQR):
Training Program (RTP) stipend scholarship
age–73.0 (9.0) years; disease duration–4.0 (5.8) years], with fifteen (38.5%) who
reported no medication state change contributing a second assessment for reli-
ability estimation. The FOG Severity Tool‐Revised demonstrated sufficient struc-
tural validity and internal consistency (α = 0.89–0.93), and adequate criterion‐
related validity compared to the FOG Questionnaire (ρ = 0.73, 95% CI 0.54–
0.85). Test‐retest reliability (ICC = 0.96, 95%CI 0.86–0.99) and random measure-
ment error (%SDC95 = 10.4%) was acceptable in this limited sample.
Discussion and Conclusions: The FOG Severity Tool‐Revised appeared valid in this
initial sample of people with Parkinson's. While its psychometric properties remain
to be confirmed in a larger sample, it may be considered for use in the clinical
setting.
This study was presented as an oral presentation at the Singapore General Hospital Annual Scientific Meeting 2022.
-

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- SCULLY ET AL.
KEYWORDS
clinician‐rated tool, freezing of gait, Parkinson's disease, reliability, validity
1 | INTRODUCTION episodes of complete akinesia in addition to the type of gait freezing

included in the FOG score. However, the score which incorporated
Freezing of gait (FOG) is a disabling motor problem affecting frequency and duration was not more valid than the score which
approximately half of the people with Parkinson's disease (PD) solely rated freezing type. This could have been because shuffling and
(Zhang et al., 2021). Currently, there is no standardisation for the festination were not further differentiated into levels of severity
objective assessment of FOG severity in the clinical setting (Mancini despite being the more common type of gait freezing (Lewis
et al., 2019). The consensus FOG definition is a “brief, episodic et al., 2022).
absence or a marked reduction of forward progression of the feet Quantifying FOG‐related shuffling and festination through fre-
despite the intention to walk” (Nutt et al., 2011). Due to the lack of quency and duration metrics is challenging (D'Cruz et al., 2022; Shine
specification surrounding the terms “brief”, “episodic”, and “marked et al., 2011). It is difficult to accurately identify the start‐ and end‐
reduction”, there remains controversy surrounding what constitutes points of shuffling and festination without instrumentation. Brief
FOG (D'Cruz et al., 2022; Lewis et al., 2022). Different pathophysi- definitions, which state its beginning when step length falls below the
ologies may underlie these FOG presentations, but complete akinesia subject's healthy and ending when at least two steps are taken at or
(i.e., FOG with no observable movement), trembling‐in‐place, and near normal step length, provide insufficient detail for stand-
small shuffling steps which interrupt a person's usual gait (here ardisation and may reduce inter‐rater reliability (Chee et al., 2009).
termed, “shuffling” or “festination”, if the steps are hurried) have Yet, more elaborate definitions, such as at least five consecutive
been commonly considered part of FOG (D'Cruz et al., 2022; Lewis steps with acceleration measuring greater than two standard de-
et al., 2022). viations above the mean acceleration of the first five steps, are
Adequate clinical assessment of FOG is crucial for its successful impossible to apply based on clinical observation alone (Delval
management (Barthel et al., 2016). Although subjective, self‐reported et al., 2016). Thus, in the clinical setting, frequency and duration
assessments are convenient, not all people with FOG recognise the metrics may be unfeasible for shuffling and festination.
symptoms (Mancini et al., 2019; Snijders et al., 2008). Immediate As shuffling and festination influence step length, step count
caregivers may also miss very brief FOG episodes or mistake other could be an indicator of severity of shuffling and festination.
gait impairments for FOG (Mancini et al., 2019). Thus, more objective Counting the number of steps taken also extends use beyond experts.
clinical assessments are necessary to balance self‐reported assess- While step count has been proposed as an indicator of FOG severity,
ments (Barthel et al., 2016). it has not been validated (Fietzek et al., 2017). With an aim to pro-
For the clinical setting, the FOG score is arguably the best duce a valid and reliable objective clinical assessment for FOG
available objective assessment (Mancini et al., 2019). It evaluates severity, this study explored a clinician‐rated tool (FOG Severity
FOG through gait initiation, turning, and walking through a doorway, Tool‐Revised) which separately quantifies shuffling and festination
performed under single‐task, motor dual‐task, and combined cogni- with step count, and trembling‐in‐place and complete akinesia with a
tive and motor dual‐task conditions (Ziegler et al., 2010). For each composite score of frequency and duration of such episodes.
item, FOG severity is scored on a four‐point scale based on freezing
type, with shuffling or festination considered less severe than
trembling‐in‐place or complete akinesia (Ziegler et al., 2010). How- 2 | METHODS
ever, recognised limitations of the FOG score include its omission of
straight‐path walking, and frequency and duration of freezing epi- 2.1 | Participants
sodes (Barthel et al., 2016; Mancini et al., 2019). Additionally, its
ranking of severity based on freezing type is debatable (Barthel Consecutive patients with PD were recruited from the outpatient
et al., 2016; Giladi et al., 2000; Snijders et al., 2008). Festination does physiotherapy clinics of a tertiary hospital between 23 August 2021
not consistently precede FOG and a specific phenotype resulting and 20 June 2022. People with PD attending the outpatient
from a postural deficit, unrelated to FOG, was recently proposed neurology clinics and Movement Disorder clinics who expressed in-
(Barthel et al., 2016; Nonnekes et al., 2019). Thus, festination and terest and were eligible were also enrolled. Selection criteria included
FOG may be better scored separately—something the FOG score the following: age at least 30 years, ability to ambulate 8 m inde-
does not allow for. pendently regardless of walking aid use, ability to follow instructions
To address these limitations, a new clinician‐rated assessment for study procedures, and being without other neurological or or-
tool for FOG severity was developed through a Delphi process (Scully thopedic conditions that severely affected walking. This study
et al., 2022). The proposed assessment tool (FOG Severity Tool‐ received ethics approval and all participants provided written
Delphi) considered frequency and duration of trembling‐in‐place and informed consent.
SCULLY ET AL.
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2.2 | Study procedures The FOG Severity Tool‐Revised was repeated after the MDS‐UPDRS
Part III for estimation of its test‐retest reliability. This was decided
To abide by the coronavirus pandemic‐related conditions placed on because a separate testing occasion on a different day was not
research, enrolled participants underwent study procedures on the feasible due to pandemic‐related restrictions.
same day as their scheduled hospital appointments. After collection
of demographic information, including retrospective recall of the
number of falls in the past 12 months, participants completed the 2.3 | FOG severity tool‐revised
following:
The FOG Severity Tool‐Revised retains the same assessment course
‐ FOG Severity Tool‐Revised; used in the FOG Severity Tool‐Delphi (Scully et al., 2022), which was
‐ Three functional performance tests—five‐times sit‐to‐stand (Dun- previously found to be 6.2 times more likely to elicit FOG compared to
can et al., 2011), recording the number of stands per second; the Timed Up and Go. This assessment course involved starting to walk
backward‐walking (Hackney & Earhart, 2009), recording the on cue (i.e., a verbal command to “start”), walking forwards 6‐m at a
average step length; and Timed Up and Go (Podsiadlo & Richard- comfortable pace, turning on‐the‐spot 720° clockwise and anti‐
son, 1991), recording the time and number of steps taken; clockwise as fast as possible safely, and passing through a 50‐cm nar-
‐ A patient‐reported outcome measure of FOG severity, the FOG row space at a comfortable pace. These were conducted in single‐task
Questionnaire (Giladi et al., 2000), which was recently found as the and cognitive dual‐task conditions, with simultaneous performance of
best available measure of FOG severity (Scully et al., 2021); an auditory stoop task applied to increase cognitive load. The full
‐ A patient‐reported outcome measure of anxiety, the Parkinson assessment course was video‐recorded for post‐hoc analysis.
Anxiety Scale (Leentjens et al., 2014); In contrast to the FOG Severity Tool‐Delphi (Scully et al., 2022),
‐ A screening tool for cognitive function, the Montreal Cognitive the FOG Severity Tool‐Revised separately quantifies the freezing
Assessment (Nasreddine et al., 2005); types of shuffling and festination from trembling‐in‐place and com-
‐ A patient‐reported outcome measure of disability, the Movement plete akinesia. The differentiation between the scoring methods in
Disorder Society's revised Unified PD Rating Scale (MDS‐UPDRS) the FOG score, FOG Severity Tool‐Delphi, and FOG Severity Tool‐
Part II (Goetz et al., 2008); and Revised is illustrated in Figure 1.
‐ A clinician‐rated assessment of motor impairment related to PD, The FOG Severity Tool‐Revised required the assessor to manu-
the MDS‐UPDRS Part III (Goetz et al., 2008). ally count the number of steps taken and time observed episodes of
F I G U R E 1 Differences in scoring methods between the Freezing of Gait score, Freezing of Gait Severity Tool‐Delphi, and Freezing of Gait
Severity Tool‐Revised.
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- SCULLY ET AL.
trembling‐in‐place or complete akinesia using a lap stopwatch. This approximately 30‐minutes apart using the intraclass correlation co-
was performed by a single trained assessor and was confirmed efficient (ICC, two‐way random effects model of absolute agree-
through video‐analysis using the same methods. Step counts for each ment). An ICC of at least 0.70 was classified as sufficient reliability
item were ranked on 5‐point scales to reflect the severity of shuffling (Mokkink et al., 2009).
or festination. Similarly, frequency and duration of episodes of To assess measurement error, we derived the standard error
trembling‐in‐place or complete akinesia for each item were ranked of measurement (SEM) by taking the square root of the ICC error
on 5‐point scales for severity of akinetic freezing. An episode of variance (De Vet et al., 2011). The smallest detectable change
trembling‐in‐place or complete akinesia was considered to begin (SDC95) was calculated from the SEM, based on the 95% confi-
from the point of attempted initiation of the unsuccessful step and dence interval, according to the following equation: SDC95 = 1.96
end at the point of initiation of the first of two effective steps (D'Cruz x √2 x SEM (De Vet et al., 2011). SDC95 was then converted to a
et al., 2022). Inability to independently complete the task item was percentage by dividing by the maximum FOG Severity Tool‐
scored “9” with no scores for shuffling or festination and trembling‐ Revised score and multiplying by 100. A percentage under 30%
in‐place or complete akinesia. FOG severity was quantified by the was considered to be acceptable random measurement error (Chiu
sum of scores from all items, providing a score range between 0 and et al., 2022).
72. The template for scoring the FOG Severity Tool‐Revised and
details surrounding its revision is presented in Supplementary Mate-
rial 1. 2.4.4 | Criterion‐related validity
To assess criterion‐related validity, we correlated the FOG Severity

2.4 | Statistical analysis Tool‐Revised with the FOG Questionnaire using Spearman's corre-
lation coefficient with bootstrapped 95% confidence interval. A cor-
We used means with standard deviations (SD) and medians with relation of at least 0.70 was necessary to qualify as sufficient
interquartile ranges (IQR) for continuous variables, and frequencies (Mokkink et al., 2009).
with percentages for categorical variables.
2.4.5 | Hypotheses testing for construct validity

2.4.1 | Distributional properties
To assess construct validity, the following hypotheses were tested:
To assess distributional properties, we compared the floor and ceiling the FOG Severity Tool‐Revised would demonstrate at least moderate
effects of the FOG Severity Tool‐Revised by calculating the propor- correlations with objective, performance‐based outcomes measuring
tion of participants scoring minimum and maximum scores, respec- related constructs (i.e., five‐times sit to stand, backward‐walking,
tively. A proportion greater than or equivalent to 15% was Timed Up and Go, and MDS‐UPDRS Part III); the FOG Severity Tool‐
considered significant (Gulledge et al., 2019). Revised would demonstrate poorer correlations with patient‐
reported outcomes measuring related constructs (i.e., MDS‐UPDRS
Part II and number of falls reported in the preceding 12‐month
2.4.2 | Structural validity and internal consistency period); and the FOG Severity Tool‐Revised would demonstrate
low correlations with patient‐reported outcomes measuring unre-
To assess structural validity, we evaluated the “shuffling or festina- lated constructs (i.e., Parkinson Anxiety Scale and Montreal Cognitive
tion” and “trembling‐in‐place or complete akinesia” subscales using Assessment). We examined the listed hypotheses using Spearman's
exploratory factor analysis. A variance of at least 60% explained by correlation coefficient.
factor analysis was regarded to be acceptable (Hair et al., 2013). All analyses were done in R, version 4.2.0 (R Foundation, Vienna,
To assess internal consistency, we computed the Cronbach's Austria). Statistical significance was set at p < 0.05.
alpha. Cronbach's alpha of at least 0.70 was required for sufficient
internal consistency (Mokkink et al., 2009).
3 | RESULTS
2.4.3 | Reliability and measurement error After screening 143 people with PD for eligibility, 39 were enrolled.
The main reasons for exclusion were declining to participate (n = 56)
Data of participants reporting the same medication state and no and not meeting the study selection criteria (n = 47) (see Supple-
change in perceived FOG severity during both performances of the mentary Material 2 for detailed participant flow diagram). Table 1
assessment course for FOG were used for reliability analyses. summarises demographic information and descriptive statistics.
To assess test‐retest reliability, we compared scores of the FOG Thirty participants (76.9%) self‐reported to have experienced FOG,
Severity Tool‐Revised recorded over two testing occasions based on a score of at least one on the FOG Questionnaire's item 3
SCULLY ET AL.
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TABLE 1 Participants (N = 39) demographics and descriptive T A B L E 1 (Continued)

results.
Mean (SD) (25th, 50th, 75th
Mean (SD) (25th, 50th, 75th Characteristics percentile)a
Characteristics percentile)a
FOG severity tool‐revised, shuffling 12.0 (9.9) (5.0, 9.0, 20.0)
Age, years 70.9 (9.2) (67.0, 73.0, 76.0) or festination
Sex (male), n (%) 31 79.5 (64.5–89.2) % FOG severity tool‐revised, 6.0 (7.7) (1.0, 2.5, 10.0)
trembling or akinesia
Marital status, n (%) –
FOG severity tool‐revised, total 17.6 (16.7) (7.0, 11.5, 24.8)
Married 29 74.4 (58.9–85.4) %
Abbreviations: FOG, Freezing of Gait; MDS‐UPDRS II, Movement
Single 4 10.3 (4.1–23.6) %
Disorder Society's revised Unified Parkinson's Disease Rating Scale Part
Divorced 3 7.7 (2.7–20.3) % II,; MDS‐UPDRS III, Movement Disorder Society's revised Unified
Parkinson's Disease Rating Scale Part III; MoCA, Montreal Cognitive
Widowed 2 5.1 (1.4–16.9) %
Assessment; PAS, Parkinson Anxiety Scale.
a
Occupation, n (%) – Values are mean (SD) (25th, 50th, 75th percentile) unless stated
otherwise. Variables can be interpreted as being normally distributed if
Retired 29 74.4 (58.9–85.4) %
the median and mean are similar and the 25th and 75th percentiles are
Working 7 17.9 (9.0–32.7) % symmetrical compared to the median. For percentages, 95% confidence
intervals are presented in brackets.
Home‐maker 2 5.1 (1.4–16.9) %
Job‐seeking 1 2.6 (0.1–13.2) %
Lives with, n (%) – (Giladi et al., 2009). Among the nine participants who self‐reported to
not have FOG, eight (88.9%) were observed with akinetic FOG or
Family 34 87.2 (73.3–94.4) %
festination during the assessment.
Alone 5 12.8 (5.6–26.7) %
The FOG Severity Tool‐Revised demonstrated sufficient struc-
Mobility status, n (%) – tural validity and internal consistency, acceptable test‐retest reli-
Community ambulant 31 79.5 (64.5–89.2) % ability, and adequate criterion‐related and construct validity as
follows:
Home‐bound 8 20.5 (10.8–35.5) %
Hoehn & yahr stage, n (%) –
I 3 7.7 (2.7–20.3) % 3.1 | Distributional properties

II 14 35.9 (22.7–51.6) %
III 14 35.9 (22.7–51.6) %

Floor and ceiling effects were negligible for the total FOG Severity
Tool‐Revised score, while single‐ and dual‐task turning provided the
IV 8 20.5 (10.8–35.5) %
best score distributions among individual task scores (see Figure 2).
Medication state during testing, n
(%) –
On 32 82.1 (67.3–91.0) % 3.2 | Structural validity and internal consistency

Off 7 17.9 (9.0–32.7) %
Disease duration, years 5.0 (5.0) (1.0, 4.0, 6.8) For the subscale of “shuffling or festination”, exploratory factor
analysis produced four factors (narrow space, turn, open space,
Number of falls in the past 3.2 (5.5) (0.0, 1.0, 2.0)
12 months
start) with eigenvalues of 2.70, 2.10, 1.67, and 0.40, explaining
86.0% of the variability. Cronbach's alpha was 0.93 (95% CI 0.90–
PAS, total 9.5 (9.2) (2.0, 8.0, 16.0)
0.95). Similarly, there were four factors for the subscale of “trem-
MoCA, total 24.4 (4.5) (22.5, 25.0, 27.0) bling‐in‐place or complete akinesia” (start, turn, narrow space, and
FOG questionnaire, total 8.4 (6.1) (3.5, 9.0, 13.0) open space) with eigenvalues of 2.51, 1.91, 1.42, and 1.02,
MDS‐UPDRS II, total 12.9 (7.9) (8.5, 13.0, 16.0) explaining 86.0% of the variability. Cronbach's alpha was 0.89 (95%
CI 0.79–0.95).
MDS‐UPDRS III, total 55.3 (21.9) (44.5, 58.0, 68.0)
Five‐times sit‐to‐stand, stands/ 0.33 (0.23) (0.20, 0.31, 0.45)

second
3.3 | Reliability and measurement error
Backward‐walking step length, 0.16 (0.13) (0.08, 0.13, 0.22)
meters
Fifteen participants (38.5%) reported no change in medication state
Timed up and go, seconds 27.7 (26.8) (11.9, 14.9, 24.2) and perceived FOG severity across both testing occasions of the FOG
Timed up and go, steps 35.4 (29.2) (17.5, 20.0, 36.0) Severity Tool‐Revised [86.7% (n = 13) male; Median (IQR): age–71.0
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- SCULLY ET AL.
FIGURE 2 Score distributions for the Freezing of Gait Severity Tool‐Revised.
(13.0) years; disease duration – 4.0 (2.0) years; Hoehn and Yahr stage 3.4 | Criterion‐related validity
– 2.0 (1.0); FOG Questionnaire – 3 (8)]. Test‐retest reliability was
sufficient (ICC = 0.96) and random measurement error was accept- The FOG Severity Tool‐Revised correlated adequately with the FOG
able (Percentage of SDC95 = 10.4%) (see Table 2). Questionnaire (ρ = 0.73, 95% CI 0.54–0.85). Results were similar
SCULLY ET AL.
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T A B L E 2 Results for reliability, measurement error,

criterion‐related validity, and hypothesis testing for construct shuffling and festination are less severe forms of the gait disorder
validity. (Ziegler et al., 2010). The distinct quantification of “shuffling or fes-
tination” and “trembling‐in‐place or complete akinesia” subscales
FOG Severity Tool‐
facilitates discrimination between people with only “shuffling or
Reliability and measurement error (N = 15) Revised
festination”, people with only “trembling‐in‐place or complete aki-
Intraclass correlation coefficient (95% CI) 0.96 (0.86–0.99)
nesia”, and people with both “shuffling or festination” and “trembling‐
Standard error of measurement 2.71 in‐place or complete akinesia”. Given that these varied FOG pre-
Smallest detectable change95 (%) 7.52 (10.4%) sentations have different responses to treatment (Lewis et al., 2022),
this may have prescriptive value for clinicians. With the recent
Spearman's ρ (95% CI)
FOG severity tool‐ literature suggesting that festination can occur independently
Criterion‐related validity (N = 39) revised (Nonnekes et al., 2019), this tool's unique distinction of the freezing
FOG questionnaire 0.73 (0.54–0.85) types may also improve score interpretability.
While shuffling and festination have often been excluded in
Hypotheses testing for construct validity (N = 39)
quantifications of FOG severity based on frequency and duration
Five‐times sit to stand −0.76 (−0.89–−0.57)
metrics due to challenges associated with accurate identification
Backward‐walking −0.77 (−0.90–−0.55) (D'Cruz et al., 2022), the use of step count to reflect the severity of
Timed up and go, time 0.90 (0.79–0.95) shuffling and festination in the FOG Severity Tool‐Revised was
shown to be a valid and reliable solution. Counting steps negates the
Timed up and go, steps 0.85 (0.70–0.92)
need for elaborate definitions of start‐ and end‐points of shuffling
MDS‐UPDRS part III 0.59 (0.31–0.77)
and festination, and allows for ease of scoring based on observation
MDS‐UPDRS part II 0.57 (0.30–0.75) alone. Furthermore, manually counting has proven excellent reli-
Number of falls in past 12 months 0.14 (−0.21–0.44) ability against an instrumented walkway (GAITRite) as a method for
Parkinson Anxiety scale 0.17 (−0.17–0.49) measuring step count in people with PD (Bryant et al., 2013). Thus,
the FOG Severity Tool‐Revised could be a promising answer to the
Montreal cognitive assessment −0.14 (−0.46–0.19)
call for FOG severity outcomes that integrate the various types of
Abbreviations: FOG, Freezing of Gait; MDS‐UPDRS, Movement freezing, including shuffling and festination (D'Cruz et al., 2022). It
Disorder Society's revised Unified Parkinson's Disease Rating Scale.
should be noted that the use of step count limits the ability to
distinguish between a typical shuffling gait without FOG and FOG‐
when only the 30 participants who self‐reported to have FOG related shuffling which interrupts more‐normal gait. To satisfy con-
(ρ = 0.71, 95% CI 0.49–0.84) and the 32 participants who were in the cerns that the addition of shuffling and festination may overestimate
“on” medication state during testing (ρ = 0.73, 95% CI 0.45–0.87) FOG severity (D'Cruz et al., 2022), future studies could investigate
were considered. the ecological validity of the FOG Severity Tool‐Revised against the
percentage of time spent freezing over the span of a day (Mancini
et al., 2019). However, this will only be possible when a valid and
3.5 | Hypotheses testing for construct validity reliable 24‐h home‐based FOG monitoring system becomes available.
The FOG Severity Tool‐Revised presented a right‐skewed dis-
The FOG Severity Tool‐Revised showed stronger associations with tribution. This could have been due to the sample being milder in
objective outcomes measuring related constructs compared with terms of FOG severity. It has also been well established that FOG
patient‐reported outcomes measuring related and unrelated con- occurs less frequently during clinical assessments when increased
structs, fulfilling the hypotheses. Correlation coefficients between attention is paid and the FOG score similarly experienced a right‐
the FOG Severity Tool‐Revised and its comparator outcomes are skewed distribution (Barthel et al., 2016; D'Cruz et al., 2022; Man-
summarised in Table 2. cini et al., 2019; Ziegler et al., 2010). Among the tasks performed for
FOG severity assessment, turning produced the best distribution
regardless of single‐ or dual‐task conditions. This supports earlier
4 | DISCUSSION studies that large angle turning is the most effective for triggering
FOG because it poses a greater motor challenge, resulting in more
The FOG Severity Tool‐Revised appeared valid in this initial sample apparent deficits in motor automaticity (D'Cruz et al., 2022; Snijders
of people with PD and test‐retest reliability was acceptable in the 15 et al., 2008). The task of turning alone could be enough as a brief
participants examined. Being the first clinician‐rated tool to quantify screening tool for FOG. However, comprehensiveness is necessary
the freezing types of shuffling and festination separately from for content validity of an outcome measure (Mokkink et al., 2009).
trembling‐in‐place and complete akinesia, it distinguishes from Having only turning in a clinician‐rated tool for FOG severity could
existing clinician‐rated tools which adopt the assumption that limit the interpretability of results for those unable to independently
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complete the turns. This study sample had milder FOG severity based research restrictions, the repeat assessment for test‐retest reli-
on self‐report and two participants were unable to complete the ability was conducted approximately 30 min after the first assess-
turns without assistance. Further research in people with more se- ment. This may not be sufficient to confirm the tool's stability over
vere FOG is necessary to determine whether depending on turning time. The participants who reported no change in medication state
alone would result in a significant ceiling effect. and perceived FOG severity were also generally less advanced in the
Despite FOG being a major cause of falls in people with PD disease stage and had less severe FOG. Thus, test‐retest reliability
(Pelicioni et al., 2019), no association was found between the FOG should be examined further with a greater time interval, including
Severity Tool‐Revised and reported number of falls in the past participants with more advanced PD and more severe FOG.
12 months in this sample. This was not unexpected as the FOG
Questionnaire also showed no association with falls, measured based
on the original Unified PD Rating Scale Part II “Falling” item in the 5 | CONCLUSION
“on” medication state (Giladi et al., 2000). Moreover, falls were less
frequent in this sample, which could be a result of underreporting. The FOG Severity Tool‐Revised is a clinician‐rated tool for FOG
Retrospective collection of falls data is affected by recall bias and 12‐ severity which integrates the varied types of freezing. It appeared
month is a long period (Harris et al., 2021). Future investigations of valid in this initial sample of people with PD and test‐retest reliability
the relationship between FOG severity, quantified by the FOG was acceptable in a limited sample of 15 participants. While further
Severity Tool‐Revised, and falls should attempt to record falls pro- investigation of structural validity, test‐retest reliability, and
spectively with a diary instead if resources permit. The new PD‐ responsiveness of the FOG Severity Tool‐Revised is warranted,
specific falls questionnaire may also be a viable alternative if its current findings of its measurement properties are encouraging for
validity is demonstrated (Harris et al., 2021). its use in the clinical setting.
This study calculated individual‐level SDC to inform clinical
AC K NO W L E DG E M E NT S
identification of patients who have changed from those who have not
This work was supported by the Mitsui Sumitomo Insurance Welfare
(Geerinck et al., 2019). Although this met the criteria for accept-
Foundation Research Grant 2020. The funders played no role in the
ability, the sensitivity of the FOG Severity Tool‐Revised to change
study design, the collection, analysis and interpretation of data, the
remains unclear and its responsiveness needs to be studied. Since the
writing of this manuscript, or the decision to submit this article for
SDC95 reported in this study was derived from the SEM computed
publication. AS is supported by an Australian government Research
based on test‐retest reliability, inter‐rater reliability and its conse-
Training Program (RTP) stipend scholarship.
quent SDC should still be explored with a larger sample of raters,
Open access publishing facilitated by Curtin University, as part of
including those from different institutions.
the Wiley ‐ Curtin University agreement via the Council of Australian
University Librarians.
4.1 | Limitations
CO N F L I C T O F I N T E R E S T S T A TE M E N T
None.
This study has limitations. Firstly, the medication state could not be
controlled due to pandemic‐related restrictions to research. FOG has
DA T A A V A I L A B I L I TY S T A TE M E N T
varied responsiveness to dopaminergic medications, with the most
Data available upon reasonable request from the corresponding
common being a reduction in freezing severity when medication ef-
author. Videos of participants not available due to ethical approval
fects are at its best (Mancini et al., 2019). As such, medication state is
conditions.
typically controlled for in research by assessing FOG severity in “off”
medication states, defined by at least 12‐hour withdrawal of dopa-
E T HI CS S T A T E M E NT
minergic medications, and “on” states, defined by the intake of
This study was approved by the ethics committees of Sing Health and
dopaminergic medications at maximal dose (Mancini et al., 2019). In
Curtin University (CIRB 2019/2650, HRE2020‐0094).
this study, the medication state was solely based on participants' self‐
report and could not follow previous definitions. This could be more OR C I D
representative of assessments in the clinical setting but limited the Aileen E. Scully https://orcid.org/0000-0002-4578-2048
understanding of medication state effects on the FOG Severity Tool‐
Revised. However, though the majority rated themselves to be in the R E F E R E NC E S
“on” state, the FOG Severity Tool‐Revised had no significant floor Barthel, C., Mallia, E., Debu, B., Bloem, B. R., & Ferraye, M. U. (2016). The
effect. Secondly, for exploratory factor analysis, the sample size was practicalities of assessing freezing of gait. Journal of Parkinson's Dis-
less than that recommended to meet the threshold for good agree- ease, 6(4), 667–674. https://doi.org/10.3233/JPD‐160927
Bryant, M. S., Rintala, D. H., Hou, J. G., & Protas, E. J. (2013). Reliability of
ment between population and sample for a four‐factor solution. A
the non‐instrumented walk test in persons with Parkinson's disease.
sample size of 96 is required for study quality to be classified as Disability & Rehabilitation, 35(7), 538–542. https://doi.org/10.3109/
“adequate” (Mokkink et al., 2009). Finally, due to pandemic‐related 09638288.2012.709910
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gait in Parkinsonian patients. Movement Disorders, 25(8), 1012–1018.

How to cite this article: Scully, A. E., Tan, D., Oliveira, B. I. R.
https://doi.org/10.1002/mds.22993
d., Hill, K. D., Clark, R., & Pua, Y. H. (2023). Scoring festination
and gait freezing in people with Parkinson's: The freezing of
S U P P O R T I N G I N FO R MA T I O N gait severity tool‐revised. Physiotherapy Research International,
Additional supporting information can be found online in the Sup- 28(4), e2016. https://doi.org/10.1002/pri.2016
Received: 28 April 2022
DOI: 10.1002/pri.2032
RESEARCH ARTICLE
- -
Revised: 22 May 2023 Accepted: 16 June 2023
Attitudes towards people with disabilities across different

healthcare undergraduate students: A cluster analysis
approach
Theofani A. Bania1 | Maria Gianniki1 | Garyfalia Charitaki2 |

1 3 1
Sofia Giannakoudi | Velaoras I. Andreas | Charikleia Farantou |
Velaora I. Aliki4 | Evdokia A. Billis1
1
Department of Physiotherapy, University of
Patras, Rio, Greece Abstract
2
School of Humanities, Hellenic Open Background and Purpose: Negative attitudes towards disability amongst healthcare
University, Patras, Greece
professionals endanger social inclusion of people with disabilities (PwD). This study
3
Department of Medicine, University of Patras,
Patras, Greece
aimed to investigate the attitude of undergraduate healthcare students of various
4
Department of Business Administration, disciplines towards PwD, including specific aspects of their attitude.
University of Piraeus, Piraeus, Greece Methods: We assessed the attitudes of university students, including physio-
therapy, speech therapy, nursing, social work and medical students, through the
Correspondence
Theofani A. Bania, Department of Greek Interaction with Disabled Person Scale (IDPS) in a survey. Data were ana-
Physiotherapy, University of Patra, Building B,
lysed using a two‐step clustering technique.
Rio 26504, Greece.
Email: fbania@upatras.gr Results: Four hundred‐eighty undergraduate healthcare students (21.4 � 5.3 years‐
old; 135 males, 345 females) were recruited. Two‐step cluster analysis identified
three homogenous subgroups labelled Least positive attitude (42.3%), Moderately
positive attitude (26.9%), and Most positive attitude (30.8%) groups. Τhe main dif-
ferences in healthcare students' attitudes between the three distinct groups
appeared to be in feelings of sympathy, fear and susceptibility towards disability,
suggesting that these aspects of attitude needed to be primarily addressed. Results
also revealed that females, being in higher semester/year of studies, having
completed a clinical module with PwD and having frequent contact with PwD were
related to more positive attitudes.
Conclusion: Taking into account that the majority of the healthcare students'
sample yielded least and moderately positive attitudes, towards PwD, further ac-
tions should be taken for promoting more positive attitudes towards disability. A
social model in teaching to increase student's awareness of PwD and skills to work
with these people, having PwD themselves teaching such modules, focussing on
positive experiences and reminding the students of the benefits of having positive
attitudes towards PwD, as well as promoting ways to increase the contact of
healthcare students with PwD (such as teaching in co‐operation with organisations
-

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of PwD or finding alternative clinical placements with PwD), can be beneficial in

promoting more positive attitudes towards disability.
KEYWORDS
attitude, disabilities, Greek interaction with disabled persons scale, healthcare students
Implications for Practice

� The least positive attitude group appears to have more feelings of sympathy, fear and
susceptibility towards disability than the moderately or most positive attitude groups.
University academics should be aware of such variability and design their instruction in
order to address these negative feelings, for example, by focussing on positive experiences
at working with people with disabilities (PwD) and providing the students with systematic
and supported contact with PwD.
� A social model intending to reform society and accommodate all people (including those
with disabilities) should be taught as an adjunct to the medical model which allied health
education is, and will remain, deeply embedded in. This social model is suggested to focus in
teaching to increase students' awareness of PwD and skills to work with these people, and
having PwD themselves teaching such modules, as well as reminding the students of the
benefits of having positive attitudes towards PwD.
� Studying at a higher semester of studies, having completed a clinical module with PwD and
having frequent contact are significantly related with more positive attitude towards
disability. Therefore, equally important is to promote ways to increase the contact of
healthcare students with PwD (such as teaching in co‐operation with organisations of PwD,
or finding alternative clinical placements with PwD), which can also be beneficial in pro-
moting more positive attitudes and decrease negative feelings towards disability.
1 | INTRODUCTION early in their career development, that is, while they are still under-
graduate students (Peiris‐John et al., 2020). According to the func-
More than one billion of PwD live worldwide; one million live in tional symbolic interaction theory, people appear to build their
Greece with about one third of them having severe disabilities identities through interaction with others, and frequent contact may
(Ministry of Health, 2017; WHO, 2021). Disability refers to impair- help people to co‐create a social reality that embraces PwD (Fletcher &
ments of structure or function, limitations of activity or restrictions in Birk, 2020). Verbal communication is also critical during interaction,
involvement in life situations, which could be physical, intellectual, or while being able to envisage the situation of PwD can enhance
cognitive of any severity level (WHO, 2021). In Greece, about 39% communication with them (Fletcher & Birk, 2020). Therefore, for
of PwD are unemployed and, as a result, are excluded from an promoting a more positive attitude of the healthcare students towards
independent living and full participation in society (Drosos & Anto- people with PwD, it is important that healthcare students have
niou, 2020). Regarding health care provision, PwD are more likely to frequent contact and interaction with these people. During their un-
experience inequities due to either significant cost, difficulties with dergraduate studies, in Greece, healthcare university students interact
transportation, and long waiting lists (Rotarou & Sakellariou, 2016; with people with physical, intellectual and/or cognitive disabilities (of
WHO, 2021) or inadequate skills and specific knowledge of health- various severity levels) in their clinical placements, which normally
care professionals (WHO, 2021). take place during the last 2 years of their studies. According to the
Lacking disability‐specific knowledge leads to lack of under- Departments' curriculums, in some healthcare professions (i.e. phys-
standing of PwD, and of their health needs, and eventually may result in iotherapy, speech therapy) students are normally trained to assess/
negative attitudes towards them by healthcare professionals (Hogan treat PwD in clinical placements/practice for about 180 and 260 h,
et al., 2020; WHO, 2021). In turn, PwD may feel inferior and inade- respectively, while medical students are trained for more than 600 h
quate compared to people without disabilities, reinforcing their (Undergraduate Physiotherapy, Speech and Language Therapy and
exclusion from full participation in society (Hayward et al., 2019; Medicine programme curriculums, University of Patras). Nursing stu-
Marrocco & Krouse, 2017; United Nations General Assembly, 2018). dents appear to be trained less in clinical placements/practice for
Therefore, to avoid such negative consequences, and to better serve obtaining such skills (about 50 h), while social work students are mainly
patients with disabilities, it is of primary importance to build adequate trained only through lectures (Undergraduate Nursing and Social
positive attitudes towards disability across healthcare professionals Work programme curriculums, University of ..…..).
BANIA ET AL.
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The attitudes towards disability of Greek nursing, social work 2 | METHODS

and medical undergraduate students were explored in a previous
study through the Attitude Towards Disabled Persons‐(ATDP) (form 2.1 | Measure of attitude towards disability
B) and the Community Living Attitudes Scale‐Intellectual Disability
(Kritsotakis et al., 2017). That study's findings support that medical This study was a survey, and data was collected with the Greek
studies which devote more clinical‐based time with PwD (compared version of the Interaction with Disabled Persons Scale (IDPS), which
to nursing and social work undergraduate students) were related has recently been validated in Greek. The construct validity of the
with a more positive attitude towards physical disability. Previous Greek IDPS was shown through factor analysis, which demonstrated
contact and work with people with intellectual disabilities were also six stable dimensions, as identified across several studies (Forlin
related to more positive attitudes (Kritsotakis et al., 2017). There was et al., 1999; Gething & Wheeler, 1992; Yoshida et al., 2003). The
a significant negative effect of age and gender; older and male stu- Greek IDPS mean score of healthcare professionals and healthcare
dents had more negative attitudes, believing that it is difficult for students with frequent contact with PwD was shown to be different
PwDs to participate in everyday community life (Kritsotakis across those without frequent contact with PwD, demonstrating its
et al., 2017). discriminant validity (mean score difference = −4.5 and −11.0,
Another study also explored the attitudes of first‐year under- respectively) (Bania et al., 2019, 2020). Test‐retest reliability and
graduate and post‐graduate Greek‐speaking nursing students and internal consistency were also calculated: ICC ≥ 0.86 and Cronbach's
professional paediatric nurses with children with disabilities again a ≥0.87, respectively (Bania et al., 2019, 2020). The original English
through the ATDP (Matziou et al., 2009). The findings suggested that IDPS version is a well‐validated self‐administered instrument devel-
age was not significantly related with their attitude, but females had oped by the Community of Disability and Ageing in Australia. Psy-
more positive attitudes than males. Furthermore, postgraduate chometric development of the English version of the IDPS included
nursing students had significantly more positive attitudes than both content validity, which was established by a panel of experts,
first‐year nursing students and nurse professionals, while first‐year construct validity addressed via factor analysis showing the stable six
nursing students had significantly more positive attitudes than factor solution, and concurrent validity shown with the Attitudes
nurse professionals (Matziou et al., 2009). Towards Disabled Persons (r = 0.37, p < 0.001); test‐retest reliability
Interestingly, the above studies conducted in Greek academic or and internal consistency were measured at r = 0.51–0.82 and
healthcare settings do not investigate healthcare student familiarity Cronbach's a = 0.75–0.86, respectively (Forlin et al., 1999;
or prior exposure/contact with PwD; yet both these are considered Gething, 1994; Gething & Wheeler, 1992; Yoshida et al., 2003). The
as significant factors relating to the attitude towards disability scale consists of 20 items assessing attitudes towards PwD on a
(Bania et al., 2019, 2020; Kritsotakis et al., 2017). The above studies personal level, by giving emphasis to those attitudes considered
also did not investigate the healthcare students' attitudes on a negative. Items are scored with a six‐point scale response, ranging
personal level by a deeper analysis of specific feelings, such as from “very much agree” to “very much disagree”. High IDPS item scores
discomfort, fear or compassion, to determine which aspects of at- suggest a negative attitude, while low item scores indicate a positive
titudes (towards disability) should primarily be addressed for attitude towards PwD (items 10, 14, 15 are reversely scored) (Forlin
improvement. The aforementioned studies also did not investigate et al., 1999; Gething & Wheeler, 1992). Although a total score is
physiotherapy and speech therapy students' attitudes, who play a often calculated, six dimensions of the scale have been identified
major role in the treatment of PwD as these therapists promote through factor analysis across several studies, that is, discomfort in
functional independence, such as walking indoors/outdoors and social interaction, sympathy, fear, coping, vulnerability and knowl-
communicating. Close co‐operation across various healthcare disci- edge (Bania et al., 2020; Forlin et al., 1999; Gething & Wheeler, 1992;
plines, that is, medical doctors, physiotherapists, speech therapists Yoshida et al., 2003).
etc., is needed in order to optimally treat PwD. Therefore, exam-
ining attitudes towards PwD of various healthcare disciplines can
provide useful information for improving and promoting more pos- 2.2 | Data collection
itive attitudes towards them. All these issues seem to be of great
importance for providing efficient service to PwD. Accordingly, The Greek IDPS was distributed to undergraduate healthcare stu-
there seems to be a need to further explore this issue by also dents who were native Greek speakers in order to understand and
investigating specific aspects of healthcare students' attitudes, using answer the scale items. To investigate whether different stages of
a wider healthcare student sample and outcome measures that also undergraduate studies are related to the students attitudes towards
encompass prior contact with PwD. disability, the scale was distributed to healthcare students studying in
Considering the above, the primary aim of the study was to a variety of semesters. The scale was distributed and collected at
investigate the attitudes of Greek healthcare students towards PwD. three different universities, by four healthcare researchers who were
Secondary aim of the study was to explore whether attitude differ- not involved in teaching or marking the students. Informed written
ences were related to other factors such as gender differences, consent was provided by all students before their enrolment in the
discipline‐specific curriculum or educational issues. study. The study was approved by the University Ethics Committee
4 of 12
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(decision no: 41,257). Most of the data were collected in person with samples of 400 or 500 participants has found the number of
(66%) before the Covid‐19 pandemic and distributed by the re- clusters correctly (SPSS, 2001). Firstly, we estimated the total variance
searchers during the breaks between the students' classes, while the of each cluster. Then, we applied statistical tests of the separation of
remaining data were collected via an online Greek IDPS version due clusters, and identification of potential solutions. We assessed two‐
to restrictions to personal contact because of the outbreak of the cluster, three‐cluster, four‐cluster and five‐cluster solutions.
Covid‐19 pandemic. Mean scores of each of the six dimensions measured by the Greek
Demographics as well as other information were also collected, IDPS were used in cluster analysis. These six Greek IDPS dimensions
such as age, gender, healthcare discipline and semester of studies, were determined by Exploratory Factor Analysis (Principal Compo-
frequency of contact with PwD, and having a disability. Disability was nent Analysis with Varimax Rotation) model. Further, Multivariate
defined for the healthcare students as any type of disability, that is, Analysis of Variance was used to examine whether the clusters differed
physical, intellectual or cognitive and of any severity level. on the Greek IDPS dimensions, that is, coping behaviours, discomfort
with social interaction, vulnerability, fear, sympathy, as well as on
healthcare discipline, semester of studies, frequency of contact with
2.3 | Participants PwD, age, gender and having disability. Cluster membership was
defined as an independent variable, while the six Greek IDPS di-
Response rates of 99% and 58% were obtained with in‐person and mensions or demographic factors were the dependent variables.
on‐line data collection, respectively, which are considered accept- Moreover, if significant differences were found between clusters, we
able. Participants were 480 undergraduate healthcare students (135 assessed the attitudes for each cluster with Tukey's HSD (honestly
males) with a mean age of 21.4 � 5.3 years. The majority of the significant difference), based on the mean score of each Greek IDPS
undergraduate students were physiotherapy students (39.8%), while dimension. Sensitivity (cluster) analysis was also performed, including
the others were speech therapy (20.2%), nurse (20.6%), social work only the data collected in person and excluding the data collected on‐
(15%) and medical (4.4) students. Only 2.1% of the sample reported line. Lastly, in order to assess cluster stability of the solution extracted
having a disability. One third of the students (39.8%) were studying with two‐step clustering technique, we estimated the k‐means three‐
at 1st‐2nd semesters, while less than one third (28.3%) were at their cluster iterative solution (Fletcher et al., 1988).
7th semester or over (fourth year of study). Most healthcare disci-
pline courses typically last 4 years in Greece, except for the medical
course that lasts 6 years. However, 4‐year course students can 3 | RESULTS
extend their studies further than 4‐years if necessary, and such
students were included in the current study. Few healthcare students 3.1 | Factorial structure
had a daily contact (7.1%) and about one fifth of them had a weekly
contact (18.5%) with PwD during their studies, while half of the The Kaiser–Mayer–Olkin measure of sampling adequacy produced a
students (49.9%) had a less than one per 3 months contact. One third value of 0.811, while Bartlett's test of Sphericity with 190 degrees of
of the students (33.1%) reported having completed a clinical module freedom produced a statistically significant value of 1898.27
working with PwD during their studies (Table 1). Further, only 6% of (p < 0.001), suggesting the factorability of the data. Results indicated
the healthcare students in this study had contact with PwD (i.e. adequate commonalities and revealed six factors (dimensions of the
extracurricular work with PwD, family members/friends with Greek IDPS) with eigenvalues larger than one (Eigenvalues: Factor 1:
disability) besides the contact with them during their studies. 4.117, Factor 2: 2.332, Factor 3: 1.366, Factor 4: 1.204, Factor 5: 1.091,
Factor 6: 1.027) and 55.68% of the total variance explained. The first
factor included items 9, 11, 16, 17 and 18 explaining ‘Discomfort in
2.4 | Data analysis social interaction’. The second factor included items 2, and 3
explaining ‘Sympathy’ (i.e. compassion). The third factor included
Person‐oriented approaches suggest that there is significant hetero- items 7 and 20 explaining ‘Fear’. The fourth factor included items 4, 5
geneity in a sample of participants, which enables the identification of and 13 explaining ‘Vulnerability’. The fifth factor included items 14
multiple sub‐populations with different characteristics/attitudes and 15 explaining ‘Coping’ (i.e. associating or not associating PwD
(Howard & Hoffman, 2018). Revealing aspects of heterogeneity in with problems and tragedy) and the last factor included items 1, 6
different samples of university students could provide significant in- and 10 explaining ‘Lack of Knowledge’ (Table 2).
formation in order to reform placement and curriculum in the corre-
sponding university departments. Since, we suppose that there is a
significant heterogeneity in our sample, we employed a two‐step 3.2 | Cluster analysis
cluster analysis. With clustering techniques, heterogeneous samples
are reorganized into smaller, more homogenous clusters that have Two‐step cluster analysis supported three interpretable clusters of
similar characteristics within‐group and dissimilar characteristics students' attitudes towards PwD (Cluster 1, 2 and 3). Silhouette
across groups (Antonenko et al., 2012). A two‐clustering technique measure of cohesion and separation showed a ‘good’ cluster quality
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TABLE 1 Sample characteristics within clusters and for the entire sample.
Cluster 1 Cluster 2 Cluster 3

Least Moderately Most
positive positive positive Whole
MANOVA
attitude attitude attitude sample
Characteristics (n = 203) (n = 129) (n = 148) (n = 480) F (2, 476) ηp2 Post‐hoc Tests
Mean (SD)
Age (years) 20.9 (5.2) 21.8 (5.7) 21.9 (4.9) 21.4 (5.3) 1.646 0.090 ‐
Number (percentage)
Student with disability
Yes 3 (1.5%) 1 (0.8%) 6 (4%) 10 (2.1%) 2.138 0.005
No 200 (98.5) 128 (99.2%) 142 (96%) 470 (97.9%)
Students completed a clinical module with people with disabilities
Yes 45 (22.2%) 45 (34.9%) 69 (46.6%) 159 (33.1%) 12.197* 0.049 C3*>C2*>C1*
No 158 (77.8%) 84 (65.1%) 79 (53.4%) 321 (66.9%)
Gender:
Male 54 (26.6%) 53 (41%) 28 (19%) 135 (28.1%) 9.070* 0.003 C1*>C2*
Female 149 (73.4%) 75 (58%) 120 (81%) 344 (71,7%) C3*>C2*
Missing ‐ 1 (1%) ‐ 1 (0.2%)
Department of studies
Physiotherapy 74 (36.4%) 61 (47.3%) 56 (37.8%) 191 (39.8%) 2.453 0.030 ‐
Speech Therapy 33 (16.2%) 25 (19.4%) 39 (26.4%) 97 (20.2%)
Nursing 44 (21.7%) 27 (20.9%) 28 (19%) 99 (20.6%)
Medicine 10 (5.0%) 8 (6.2%) 3 (2%) 21 (4.4%)
Social work 42 (20.7%) 8 (6.2%) 22 (14.8%) 72 (15.0%)
Semester of studies
1st–2nd semester 91 (44.8%) 39 (30.2%) 46 (31.1%) 176 (36.7%) 8.457* 0.071 C2*>C1*
3–4th semester 36 (17.7%) 15 (11.6%) 16 (10.8%) 67 (14%) C3*>C1*
5–6th semester 34 (16.8%) 33 (25.6%) 34 (22.9%) 101 (21%)
7–8th semester 24 (11.8%) 25 (19.4%) 26 (17.6%) 75 (15.6%)
9th semester and over 17 (8.4%) 17 (13.2%) 26 (17.6%) 66 (12.7%)
Frequency of contact with people with disabilities
Daily 14 (6.8%) 5 (3.8%) 15 (10.2%) 34 (7.1%) 6.567* 0.060 C1*>C3*
Weekly 25 (12.3%) 31 (24%) 33 (22.3%) 89 (18.5%) C2*>C3*
Less than once a month 26 (12.8%) 12 (9.3%) 29 (19.5%) 67 (14.0%)
Once every 3 months 16 (7.8%) 12 (9.3%) 9 (6%) 37 (7.7%)
Less than once every 3 months 113 (55.7%) 67 (51.9%) 57 (38.5%) 237 (49.4%)
Missing data 9 (4.4%) 2 (1.5%) 5 (3.4%) 16 (3.3%)
Abbreviations: C1, cluster 1; C2, cluster 2; C3, cluster 3.

*, statistically significant.
and Ratio of Sizes [Larger Cluster (n = 203–42.3%) to Smallest Cluster Moreover, cluster solution was re‐estimated using 70% of the data set
(n = 129–26.9%)] = 1.57 < 3 (Everitt, 1993). Eighty‐nine percent of (random selection), and the solution indicated the stability of the
students remained in the same cluster across clustering techniques. clusters, with 91% of students remaining in the same cluster.
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TABLE 2 Rotated component matrix.
Component (factor)
Discomfort in social interaction Sympathy Fear Vulnerability Coping Knowledge

(1) (2) (3) (4) (5) (6)
IDPS 18 (tending to make only brief contact) 0.75
IDPS 17 (afraid to look) 0.75
IDPS 11 (staring at them) 0.69
IDPS 9 (feeling uncomfortable) 0.68
IDPS 16 (discomfort about my lack of disability) 0.67
IDPS 2 (it hurts me when I can't do something) 0.72
IDPS 3 (feeling frustrated) 0.59
IDPS 7 (grateful for nodisability) 0.76
IDPS 20 (afraid of beinglike that) 0.69
IDPS 4 (reminds me of my own vulnerability) 0.77
IDPS 5 (how I would feel if I had a disability) 0.73
IDPS 13 (admire them) 0.40
IDPS 15 (ignoring disabilityafter frequent contact) 0.67
IDPS 14 (don't pity them) 0.59
IDPS 10 (aware of their problems) 0.71
IDPS 6 (ignorant about disabled people) 0.68
IDPS 1 (rewarding when helping) 0.57
Abbreviation: IDPS, Interaction with Disabled Persons Scale.
We used the mean scores of the six Greek IDPS dimensions had completed a clinical module with PwD) and to being in contact
revealed by factor analysis (Figure 1) in order to interpret the profiles with PwD (55.7% had contact less than once per 3 months with PwD)
of the three clusters, with higher mean dimension scores suggesting compared to the other two groups. Furthermore, healthcare students
more negative attitudes towards disability and lower mean dimen- of this group were more likely to study social work or nursing
sion scores suggesting more positive attitudes towards disability compared to the other two groups (Table 1).
Figures 2–5.
3.2.2 | Cluster 2: Moderately positive attitude group

3.2.1 | Cluster 1: Least positive attitude group
A total number of 129 participants were clustered as moderately posi-
A total number of 203 participants were clustered as least positive tive attitude group, comprising 26.9% of the sample. The results suggest
attitude group, comprising 42.3% of the sample. This healthcare that these students have potential for a moderately positive attitude
group's scores suggest that these students have potential for the when interacting with PwD. More specifically, these healthcare stu-
least positive attitude when interacting with PwD compared to the dents had intermediate levels of knowledge about PwD, discomfort
other two groups. More specifically, we observed that these health- with social interaction, fear and sympathy about disability (Figure 1). In
care students had less knowledge about PwD and more discomfort contrast, they had lower levels of vulnerability compared to the other
with social interaction, sympathy, and vulnerability, as well as more two clusters. More students of this group were males and were
fear about disability than Clusters 2 and 3. Further, they had more studying physiotherapy compared to the other two groups. Further-
positive coping behaviour than Cluster 2 group but less positive more, students of this group were significantly less likely to be at the
coping behaviour than cluster 3 (Figure 1). Healthcare students of beginning of their studies and more likely to have completed a clinical
this group were more likely to be at the beginning of their studies and module with PwD compared to the students of the least positive atti-
less likely to be studying at the 9th semester or over (8.4%) tude group. On the other hand, students of this group were less likely to
compared to the other two cluster groups. They were also less likely be in the 9th semester or over and to have completed a clinical module
to have completed a clinical module working with PwD (22.2% only with PwD than the most positive attitude group students (Table 1).
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FIGURE 1 Attitudes towards people with disabilitie profiles for the three clusters (high scores are associated with less positive attitudes).
FIGURE 2 Attitudes towards people with disabilities profiles for the three clusters (Physiotherapy students).
3.2.3 | Cluster 3: Most positive attitude group 3.3 | Cluster differences in students' interaction
attitudes with PwD
A total number of 148 participants were clustered as most positive
attitude group, comprising 30.8% of the sample. The results suggest Results demonstrated that the three distinct healthcare students'
that these healthcare students have potential for the most positive groups differed statistically in their attitudes towards PwD (Table 3).
attitudes when interacting with PwD compared to the other two Moreover, post‐hoc analysis showed that the three student clusters
groups. The healthcare students in this group had more knowledge differed significantly between them in all the six Greek IDPS di-
about PwD, more positive views about coping disability, and less mensions. In particular, the discomfort in social interaction, sympa-
discomfort with social interaction, sympathy, and fear than the thy, fear and lack of knowledge scores in Cluster 1 were higher than
healthcare students of the two previous clusters, while vulnerability those in Cluster 2 and the lowest scores of all were those in Cluster
was at intermediate levels (Figure 1). In this group, healthcare stu- 3. For vulnerability, in Cluster 1 scores were higher than those in
dents were more likely to be females, to be studying at the 9th se- Cluster 3 and the lowest scores of all were those in Cluster 2. Finally,
mester or over, to have completed a clinical module with PwD for coping behaviours, scores in Cluster 2 were higher than those in
(46.6%), and to have more frequent contact with them (10.2% had Cluster 1 and Cluster 3 (Table 3).
daily contact) compared to the other groups. Also, more speech Equally, statistically significant results suggested that being fe-
therapy students (26.4%) were included in this group (Table 1). male, studying at a higher semester of studies, having completed a
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FIGURE 3 Attitudes towards people with disabilities profiles for the three clusters (Medical students).
FIGURE 4 Attitudes towards people with disabilities profiles for the three clusters (Speech‐therapy students).
FIGURE 5 Attitudes towards people with disabilities (PwD) profiles for the three clusters (Social Work students).
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TABLE 3 Dimensions of attitudes towards disability predicting group membership.
Student Clusters
Cluster 2 Cluster 3 (Most

Cluster 1 (Least (Moderately positive
positive attitude) positive attitude) attitude)
(n = 203) (n = 129) (n = 148) MANOVA
Greek IDPS variables M SD M SD M SD F(2,476) ηp2 Post‐hoc tests
Discomfort in social interaction −0.245 0.723 −0.740 0.556 0.989 0.958 9.817* 0.328 C1* > C2* > C3*
Sympathy 0.014 0.910 −0.489 1.223 0.317 0.846 25.976* 0.316 C1* > C2* > C3*
Fear 0.151 0.877 −0.916 1.064 0.359 0.765 31.908* 0.413 C1*, C2* > C3*
Vulnerability −0.056 0.958 −0.506 1.145 0.464 0.737 7.980* 0.235 C1* > C3* > C2*
Coping −0.019 0.974 −0.094 0.996 0.103 1.049 7.453* 0.237 C2* > C1* > C3*
Lack of knowledge 0.033 1.017 −0.442 0.960 0.249 0.893 4.376* 0.168 C1* > C2*
C1*> C3*
Abbreviations: C1, cluster 1; C2, cluster 2; C3, cluster 3; IDPS, Interaction with Disabled Persons Scale, Mean; SD, standard deviation.
*p = 0.001.
clinical module with PwD and having frequent contact were signifi- professionals, who normally have more frequent contact with PwD
cantly related with a more positive attitude towards disability (Ta- than first‐year students (Matziou et al., 2009).
ble 1). Age, Healthcare discipline, and Disability identity were not
related to cluster membership.
The cluster solution was re‐estimated using only the data 4.2 | Healthcare discipline and educational issues
collected in person (exclusion of online data) and the solution indi-
cated the stability of the clusters since 92% of students remained in There were no statistically significant differences across healthcare
the same cluster. disciplines in the clusters, but the least positive attitude group
included more social work and nursing students than the other two
clusters, who both appear to spend less time in clinical modules with
4 | DISCUSSION PwD compared to the other healthcare disciplines in Greek Uni-
versities (Figure 6). On the other hand, more speech therapy stu-
4.1 | Differences in healthcare students' attitudes dents (26.4%) were included in the most positive attitude group
than in the other two groups of healthcare students. Speech therapy
This study analysis revealed three student clusters: least positive students appear to spend a big amount of time in clinical modules
attitude, moderately positive attitude and most positive attitude towards with PwD than the other healthcare disciplines in Greek univer-
PwD. Although there was a statistically significant difference be- sities, and, although medical students appear to spend even more
tween the three groups for Lack of Knowledge, this across‐group time in such clinical modules, in the current study, they comprised
difference appeared to be small as all three groups fell close to the only a 4.4% of the total sample; thus, making extrapolations difficult
moderate level scores; grades 3.5‐4 in the 6‐point scale of the Greek for this group. Regarding physiotherapy students, who were the
IDPS (Figure 1). This could be explained by the fact that all healthcare largest respondent group (39.8%), the majority of them were in the
students were still studying and obtaining knowledge. Thus, the main moderately positive attitude group, suggesting that physiotherapy
differences in healthcare students' interaction attitudes between the students had a certain degree of potential for positive attitude, but
least positive attitude group and the other two groups appear to be they also demonstrated negative attitudes (i.e. sympathy, fear and
in feelings of sympathy, fear and susceptibility towards disability. vulnerability were scored above 4 in the 6‐point scale of the Greek
These differences could be attributed to the less frequent contact of IDPS) that needed to be addressed. The above findings also add to
these students with a clinical setting (as the group predominantly existing literature, supporting the fact that less frequent contact is
constituted first year students), and probably the low level of famil- related with more negative attitude, while more frequent to more
iarity with PwD. Previous studies have also reported that less positive attitude towards disability (Hayward et al., 2019; Kritso-
frequent contact was related with more negative attitudes; thus, takis et al., 2017). Further, only 6% of the healthcare students of
being in agreement with this study's findings (Gething & West- this study had contact with PwD (i.e. extracurricular work with
brook, 1983; Hayward et al., 2019; Kritsotakis et al., 2017). However, PwD, family members/friends with disability) besides the contact
in a Greek study, first‐year nursing students demonstrated signifi- with them during their studies, and this probably has not affected
cantly more positive attitudes than registered paediatric nurse the results.
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FIGURE 6 Attitudes towards people with disabilities profiles for the three clusters (Nursing students).
Additionally, the moderately positive attitude group included et al., 2020; Sahin & Aykol, 2010). To enhance benefits from teach-
significantly more males than the other two cluster groups, which is ing, the academic staff could ask PwD themselves to teach some of
in disagreement with two other studies that reported more negative these modules (Hogan et al. (2020)). Work in small groups of students,
attitudes towards disability in males compared to females (Kritso- role‐plays, self‐reflection and readings can also be used as educational
takis et al., 2017; Matziou et al., 2009). In the current study, however, strategies (Sahin & Akyol, 2010). Focussing on positive experiences at
males comprised a smaller proportion (28.1%) compared to female working with PwD and reminding the students of the benefits of having
participants. Furthermore, the nonsignificant results between clus- positive attitudes towards PwD are ways that help eliminate students'
ters for age in the current study are in agreement with previous negative attitudes (Hayward et al., 2019; Hogan et al., 2020;
studies (Kritsotakis et al., 2017; Matziou et al., 2009), reporting no Magsamen‐Conrad et al., 2016). Functional symbolic interaction
differences in attitudes across different age groups, yet our sample theory‐based interventions such as the students having systematic,
comprised a young and narrow age sample. and supported contact with PwD (e.g. through coursework), would also
This study also demonstrates that factors such as Sympathy, Fear gradually desensitise negative emotions and increase students' self‐
and Vulnerability are scored high (negative attitude) in the Greek IDPS esteem during interaction with PwD (Magsamen‐Conrad
by the least positive attitude group, which is comprised significantly of et al., 2016). Therefore, it is important that healthcare students have
first year students. Sympathy, Fear and Vulnerability are scored frequent contact with PwD to improve their attitude towards them.
significantly lower by the most positive attitude group, half of whom Thus, ways to increase the frequency of contact of the healthcare
had completed clinical modules with PwD, but this group scores are students with PwD can be teaching‐implemented in cooperation with
around 3 or 4 (in the 6‐point scale of the Greek IDPS), suggesting that social institutions or organisations with PwD. For example, promoting
even this group students are not yet completely ready to embrace an students' volunteer or clerkship actions in cooperation with nursing
inclusive perspective. Currently, the teaching including clinical mod- homes or other organisations for PwD (Sahin & Aykol, 2010). The ac-
ules is mainly on patients' disease, and healthcare students also do not ademic staff should also encourage the healthcare students to volun-
spend enough time with each individual patient with disability and, teer at institutions or organisations with PwD to promote students'
therefore, are not aware of the needs of PwD (Hayward et al., 2019). contact with PwD. No direct supervision, using parallel off‐site men-
Accordingly, it is strongly suggested that the healthcare undergradu- toring and allowing students to self‐regulate their skills development
ate students' curriculum to be developed on the basis of a social model have also been reported as helpful strategies in promoting students'
of patient care, which does not focus on patients' disease but on his/her knowledge and communication skills with PwD (Shields et al., 2013).
individual needs and rights to participate in the decisions made about Lastly, alternative avenues can be available for students and might be
him/her (Sahin & Akyol, 2010; Shields et al., 2013). considered for healthcare students as an option for clinical placements
(Shields et al., 2013).
4.3 | Implementing changes in teaching is needed

4.4 | Strengths and limitations of the study
A social model in teaching could be implemented by developing
particular modules based in increasing awareness of social issues and A strength of the current study is that analysis was performed using
having an impact on health and community as well as train students’ Cluster analysis, that is a simple solution to the problem of arbitrary
interaction and communication skills (Hogan et al., 2020; Peiris‐John cutoff methodologies, and may thus yield more meaningful findings.
BANIA ET AL.
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Also, the fact that the scale was administered to healthcare students by Educational Technology Research & Development, 60(3), 383–398.
researchers who were not involved in marking the students is another https://doi.org/10.1007/s11423‐012‐9235‐8
Bania, T., Antoniou, A. S., Theodoritsi, M., Theodoritsi, I., Charitaki, G., &
strength of the study. The variety of healthcare students participating
Billis, E. (2019). The interaction with disabled persons scale: Trans-
in the current survey is also an advantage. However, medical students lation and cross‐validation into Greek. Disability & Rehabilitation,
comprised only 4.4% of the total sample, and, therefore, the results of 43(7), 988–995. https://doi.org/10.1080/09638288.2019.1643420
this study cannot accommodate the generalization of these students. A Bania, T., Gianniki, M., Giannakoudi, S., Charitaki, G., Matzaroglou, C., &
Billis, E. (2020). The interaction with disabled persons scale:
limitation of the current study is that the three clusters derived from
Evidencing construct validity with factor analysis and measurement
the analysis were not equal in numbers, nor were the numbers of each invariance in Greek‐speaking healthcare students. Disability & Reha-
healthcare discipline. Therefore, future studies including similar bilitation, 44(13), 1–8. https://doi.org/10.1080/09638288.2020.185
across‐discipline proportions may provide further information. The 0890
Drosos, N., & Antoniou, S. A. (2020). Disability and occupational incor-
generalization of the study findings is also limited due to cultural
poration. EOS, 6(1), 109–123.
boundness as healthcare education in Greece may differ from Everitt, B. S. (1993). Cluster analysis (3rd ed.). Halsted Press.
healthcare education of some other countries. Fletcher, J. M., Francis, D. J., & Morris, R. (1988). Methodological issues in
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mechanisms of the human mind: A comparison of Selten’s social
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disability, a social model in teaching could be implemented by devel- Gething, L., & Wheeler, B. (1992). The interaction with disabled persons
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Examination of the short‐term impact of a disability awareness
reminding the students of the benefits of having positive attitudes
training on attitudes toward people with disabilities: A community‐
towards PwD can also be implemented to improve attitudes. Also, based participatory evaluation approach. Physiotherapy Theory and
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Kritsotakis, G., Galanis, P., Papastefanakis, E., Meidani, F., Philalithis, A.,
D A TA AV A I LA BI LI T Y S T A T E M E N T Kalokairinou, A., & Sourtzi, P. (2017). Attitudes towards people with
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Physiotherapy

VOLUME 28, ISSUE 4 October 2023

Devices to measure calf raise test outcomes: A narrative

Ma. Roxanne Fernandez1,2 | Kim Hébert‐Losier1

Physiother Res Int. 2023;28:e2039. wileyonlinelibrary.com/journal/pri 1 of 20

1 | INTRODUCTION (Nordenholm et al., 2022; J. A. Zellers et al., 2020). These CRT

FIGURE 1 Flowchart of the search strategy and the selection process.

TABLE 1 Summary of articles reviewed (n = 35).

relationships between the Mass: 39.13 � 13.18 kg

Long term test‐retest group (7 days)

Middle aged males

Middle aged females

Nawoczenski To investigate muscle performance Sample: 24 participants Laboratory‐based Work

surface EMG signals obtained from Age: 21 � 1 y

Acute complete ATR

established, clinical achilles tendon Height: NR

Long term test‐retest reliability

Häggmark and Liedberg light beam Simple Requires electricity Repetitions 2

Electrogoniometer Simple Requires electricity Repetitions 2

Haberometer Simple Requires electricity Repetitions 1

Linear encoder Relatively simple Medium cost Repetitions 2

Laboratory‐based equipment (3D Measures three CRT outcomes High‐cost Repetitions 3

Custom‐made CRT Simple Used to record repetitions Repetitions 2

5 | CONCLUSION original draft, writing—review & editing, visualization, project

Adaptation of the person centered therapeutic relationship

Óscar Rodríguez‐Nogueira1 | Jaume Morera Balaguer2 | Abel Nogueira López3 |

Physiother Res Int. 2023;28:e2007. wileyonlinelibrary.com/journal/pri 1 of 11

1 | INTRODUCTION dimensions (Relational Bond [RB], Individualized Partnership [IP],

The following selection criteria was established: (1) physiotherapists

FIGURE 1 Study stages.

2.3 | Stage 3. Analysis of psychometric properties

2.3.5 | Temporal stability or test‐retest

T A B L E 1 Sociodemographic characteristics of participants'

TABLE 2 Socio‐demographic characteristics of the sample (n = 343).

Clinical and socio‐demographic characteristics of the sample n Percentage (%) Mean SD

Male 116 33.8

Female 227 66.2

Age (n = 343) 39.45 10.1

27–59 297 86.6

Academic education (n = 343)

Degree 232 67.6

Professional experience (years) (n = 343) 18.0 17.0

1–5 years 67 19.5

6–10 years 46 13.4

>10 years 225 65.6

Current time in work position (years) (n = 323) 8.1 7.9

1–5 years 112 32.7

6–10 years 52 15.2

>10 years 116 33.8

Work environment (n = 343)

Public 134 39.1

Private 184 53.6

Privately managed with state funding 25 7.3

Type of employment (n = 343)

Employed 260 75.8

Type of patients (n = 330)

Neurological patient 37 10.8

Geriatric patient 23 6.7

Mental health and disability patient 6 1.7

Sports patient 8 2.3

Traumatology patient 125 36.4

Pediatric patient 23 6.7

Gynecology/urology patient 7 2.0

Others 101 29.4