Skip to main content

Simulation in physiotherapy students for clinical decisions during interaction with people with low back pain: randomised controlled trial

A Correction to this article was published on 09 August 2021

This article has been updated



Low back pain (LBP) is a condition with a high global prevalence, which is getting health professionals’ attention, including physiotherapists as they must have the skills to provide treatment that increases the patient’s quality of life. Clinical simulations could be a pedagogic strategy that facilitates adequate training for students to acquire skills to improve their professional reasoning in this clinical situation.


This study sought to determine the effects of clinical simulations with simulated patients (SP) on the physiotherapy students’ clinical decision-making within a role-playing (RP) scenario while caring of LBP patients.


This experimental study included 42 participants from two Colombian universities, randomized into two groups (SP, n = 21; RP, n = 21). The clinical skill of performing the Objective Structured Clinical Examination (OSCE-LBP) was evaluated while students cared for patients with LBP; after that, a pedagogical method was conducted that included clinical simulation and, finally, the OSCE-LBP was applied again to compare both groups.


Changes occurred in the OSCE-LBP among both groups of students: the scores increased (0.66 and 0.59 in RP and SP, respectively), and neither of the two was superior (p value 0.01; 95%CI − 0.21 to 0.23).


Both types of simulation favor decision-making in professional reasoning in physiotherapy students during interactions with individuals with LBP.

Trial registration Identifying number: NCT04428892. It was retrospectively registered.

Peer Review reports


Low back pain (LBP) is one of the principal reasons for consulting health services globally [1, 2]. Epidemiological reports state that the incidence of this symptom is between 60 and 90% in the Western population, affecting almost 80% of people at least once in their lives [3]. LBP is considered one of the principal causes of absenteeism and the risks associated with it are diverse, including lifestyle, work and emotional factors, among others [3, 4]. In physiotherapy, it is the most frequent reason for care [1], which is why professionals must have the necessary skills to offer those people who consult them a comprehensive approach that minimizes reoccurrence and improves their quality of life. To achieve this, it is necessary for physiotherapy programs to provide sufficient tools to prepare future professionals treating people with LBP.

For this interaction, physiotherapists must: (1) perform physiotherapeutic examinations and evaluations, including interviews, systems reviews, and the selection and application of tests and measurements; (2) discuss the examination findings, supported by professional reasoning; (3) formulate physiotherapeutic diagnosis and prognosis in line with the findings; (4) provide information to patients about a treatment plan according to the examination findings; (5) execute the treatment plan supported by scientific evidence; and (6) demonstrate patient-centred treatment and communication skills during the physiotherapeutic interaction [5].

The aforementioned elements are closely related to decision-making clinical skills during the physiotherapeutic practice [6], such as professional reasoning, which is supported by knowledge and values originating from high levels of quality-focused patient care [7]. This is a process of applying integrated knowledge that includes intuition and permits timely development of examinations or physiotherapeutic interventions [7], through constant reflection during professional interactions.

Simulations can be used as a pedagogic tool that enables students to hone their treatment decision-making skills for patients with LBP. It is a potential strategy for developing diverse skills focused on the safety of the patient and the therapist [8]. Moreover, it allows the inclusion of simulated patients [9]; these are people who act out a specific health condition to facilitate teaching interpersonal and/or clinical skills [10]. Simulations provide students with an authentic learning experience [10] and, given their closeness to the real scenarios, facilitate effective student performance evaluation.

Clinical simulations allow students to get involved in direct interaction with what they are studying, rather than an intellectual observation or description, and enables them to make significant progress in their development through their own experience [11]. The World Confederation for Physical Therapy (WCPT) states that students must be guaranteed clinical interaction opportunities, which should always be accompanied by qualified professionals. Simulations may be linked to this process, given that controlled scenarios promote clinical reasoning, and theoretical information can be used to consolidate learning [12].

The evidence around simulations suggest that this is an educational strategy that increases teamwork capabilities, and it should be aligned with the principles of interprofessional education [13, 14]. Clinical simulations also promote core values, communication skills among professionals and patients, and patient safety [15,16,17,18]. Simulations in physiotherapy have been widely used for cardiorespiratory practice for training specific manual skills and decision-making processes in intensive care units. Students trained with simulation develop better results in manual and instrumental procedures in general [19,20,21,22,23,24,25].

Additionally, clinical simulations have demonstrated that students improve ‘confidence in clinical skills, clinical decision-making, treatment preparation and planning, communication skills, evaluating and modifying interventions, and interprofessional practice’ [26].

Therefore, clinical simulations were used to generate a controlled scenario with LBP simulated patients, seeking students to put into practice the acquired knowledge to make clinical decisions and respond to these patients’ needs within a particular context. Thus, this study aimed to determine the effects of clinical simulations with standardised patients on clinical skills decision-making of physiotherapy students while caring for LBP patients.



A randomised controlled trial was performed with physiotherapy students from two Colombian universities. The students were randomised into two clinical simulation groups, simulated patients (SP) and role-playing simulations (RP). The study was approved by the ethics committee at the University of Boyacá under record number 164 on 09 June 2016, and by the subcommission on research and ethics at the University of La Sabana. The study was considered minimum risk and the students were assured that the research process would not affect their semester grades; hence, the evaluations were of a formative nature.


The study included 42 fifth-semester students from two physiotherapy programmes in two Colombian universities, based on the formula [27], in which \(n=\) size per group, \({Z}_{1-\frac{\alpha }{2}}=\) normal two-tail standard deviation, \(d=\) acceptable difference, and \(s\) = standardised standard deviation of both comparison groups.

$$n = 2\frac{{\left[ {\left( {Z_{{1 - \frac{\alpha }{2}}} + Z_{\beta } } \right)^{2} } \right]}}{{d^{2} }}~s^{2}$$

At the time of the study, the participants had taken a total of 87 credits and were actively enrolled in the participating programs. The study excluded students < 18 age, those who had been internally or externally transferred from another academic program in health, exchange students, and those repeating and with prior experience in simulated practice in other assignments.

The study established stratified sampling by blocks in each university using the Epidat program version 3.1 and assigning participants to one of the SP and RP groups, a procedure overseen by a professor not involved with the study. A record of the process was kept (Fig. 1).

Fig. 1
figure 1

Flow diagram of the study ‘Simulated practice in physiotherapy students from the University of Boyacá and University of La Sabana on decision-making in clinical skills while caring for a person with LBP’. Intervention group: simulated practice (SP); control group: ‘role-playing’ (RP)

Results measurements

The study considered the following variables: gender, percentage of attendance of academic activities in SP and RP, level of bilingualism, score on the Colombian ‘SaberPro’ state examination, and participants’ accumulated academic grade point average for their undergraduate formation.

The main outcome of this study was clinical reasoning assessed with the Objective Structured Clinical Examination for low back pain (OSCE-LBP). It was applied in a blinded format at the start (week 0) and end of the period for the SP and RP interventions (week 8) using the same case. This instrument was subjected to a content validity process with external experts in the study area [28]. Application of the OSCE-LBP, as an evaluation process, was conducted by professors that were external to the research process to minimise evaluation bias. OSCE-LBP training was carried out through systematic training in developing the OSCE-LBP in its different stages. Additionally, inter-rater correlation coefficient values were obtained [28], and the stages in which the professors had their best performance was identified compared with the denominated gold-standard evaluator [29].

The OSCE-LBP evaluates decision-making in clinical skills while caring for a person with LBP. It has seven stages, each with a specific weight, and assesses the skills or abilities described by the researchers regarding physiotherapeutic decision-making for a person with LBP, the stages are as follows:

  1. 1.

    Physiotherapeutic examination (stages 1, 2, and 3)

    1. I.

      Anamnesis: recognises the symptoms or antecedents, including red flags and personal aspects that can guide physiotherapists’ decision-making in relation to LBP.

    2. II.

      Systems Review: recognises physical symptoms that indicate red flags or signs of peripheral nerve involvement, or signs of LBP.

    3. III.

      Tests and measurements: applies tests and measurements related to mobility, articular integrity, strength of the lumbopelvic complex, and the integrity of the peripheral nerves of the lumbopelvic region.

  2. 2.

    Physiotherapeutic evaluation (stage 4)

    1. I.

      Explains to a person with LBP whether their condition is related to nociceptive LBP, neuropathic LBP, or another type (central sensitisation).

  3. 3.

    Diagnosis, prognosis, and intervention plan (stage 4)

    1. I.

      Proposes reachable objectives according to the characteristics of the person’s LBP.

    2. II.

      Provides information to the patient about the treatment plan to follow according to the findings obtained in the examination related to LBP prognosis.

    3. III.

      It is clear with the language used and in line with previous aspects of the interaction process.

  4. 4.

    Intervention (stages 5, 6, and 70,029)

    1. I.

      Includes therapeutic exercise according to the person’s needs and capacity.

    2. II.

      Includes manual techniques according to the needs.

    3. III.

      Includes specific physiotherapy techniques according to the needs.

    4. IV.

      Includes interpretation of scientific evidence that supports the decision-making process [30,31,32,33,34,35,36].

  5. 5.

    Demonstrates patient-centered care and communication skills during the process of professional interaction (all stages).

    1. I.

      Verbal and non-verbal communication includes touch and proximity, facial expression, eye contact, gesture and posture, observation, and listening use of silence [37].

The results method of scoring the OSCE-LBP was established on a scale from 0.0 to 5.0. This scoring was obtained with a specific weight for each stage. It was given by a research team in percentages as follows: stage 1, 17%; stage 2, 12%; Stage 3, 16%; stage 4, 15%; stage 5, 15%; stage 6, 13%; and stage 7%, 12%. An equivalency success was determined in the SP and RP interventions with a difference of 0.8 [38].


Initially, in the intervention of both groups, we developed a pedagogic process that was established to achieve the skills required to care for people with LBP in the following manner:

  1. I.

    Learning guide process of therapeutic interaction with a person with LBP (LG-LBP). The guide was given to students participating 2 weeks before they were assigned to the SP or RP. The LG-LBP intention was to serve as a facilitator of the following phases of the learning process. The guide was constructed by the research team. It includes information and independent activities for students to conduct a search for physiotherapeutic examinations and treatment for people with LBP, supported by scientific evidence.

  2. II.

    Development of skills through laboratory workshops for the prescription and application of manual techniques and therapeutic exercise for the health condition studied. Each session sought to develop the practical aspects of the learning guide (LG-LBP), which include the manual technique of therapeutic massage [30], and superficial technique of myofascial release for paravertebral muscles and those related to the lumbopelvic complex [39]. The exercise techniques included central stabilisation exercises [40], analytic stretching, and postural re-education principles [41]. We developed this activity in five sessions for 2 h each.

Subsequently, the students were randomised into two groups, SP and RP. The SP group consisted of clinical simulations with simulated patients, received in a class session, for clinical skills decision-making practice in caring for a person with LBP. Each session lasted approximately 120 min, with eight students per session, and the clinical case used for the SP sessions was subjected to face validity with experts in the area of study. Application of the simulated practice was conducted using the following sequence of elements:

  • Context of the scenario: standardised for a clinical scenario of external consultation for the care of a person with LBP using physiotherapy.

  • Simulation patient training: based on the clinical case elaborated and validated. A script was created for the actor to interpret a person with LBP. Three simulated patients were trained.

  • Guiding questions: the professor asked guiding questions supported by the LG-LBP to have students reflect on the clinical situation observed. Students were asked to imagine other clinical situations and how the intervention would vary according to this.

  • Concrete experience: students interacted with the simulated patients to carry out the reasoning process and thus provide care to them.

  • Debriefing: at the end of the SP, a meeting was held based on reflective conversation about the learning experience from the clinical simulation with simulated patient in which students and professor discussed the positive aspects and the learning opportunities. This process was mediated by dialogue and active listening. Students reflected on what they had done, their feelings and emotions, what was opportune, and what they would improve for subsequent opportunities with a person with LBP. This type of data was not used in the analysis of this study.

The RP group, in turn, received a class session based on a ‘role-playing’ simulation strategy for LBP patients. This session lasted approximately 120 min, and the learning environment was the classroom in which students assumed different roles. Some acted like people with LBP and others as physiotherapists. The role-playing strategy did not include specific training for acting like a patient. The study cases used for the RP group were different from the SP group but had a similar level of complexity in LBP. The sequence of elements taken into account in the RP group was:

  • Division of the students into two groups: one physiotherapist and one patient.

  • Three different case studies were given to students. Case one was about pregnancy LBP, while case two included posttraumatic LBP, and case three was about nonspecific LBP.

  • The students started the acting process as physiotherapists or patients.

  • At the end of the session, the students guided by a professor closed the simulation with a conclusion for each case study, in a non-extensive way, like the debriefing process in the SP group.

Statistical analysis

The purpose of the Shapiro–Wilks-Test was to demonstrate the normal distribution of the data. Then, descriptive results were presented as median and interquartile range (IQR) for ordinal Likert scale variables, and percentages for the nominal ones. The quantitative variables were the weighted average by academic credits, which value ranges from 0.0 to 5.0 according to the Colombian educational system (1 credit is equivalent to 48 h a week in academic activities), bilingualism, and age.

An intention-to-treat analysis was conducted to compare both groups, SP and RP. The OCSE-LBP scores were compared between baseline and post-intervention inside each group (SP and RP). In addition, the student's t-test for related samples was used to estimate differences. Finally, a hierarchical generalized linear model, with two levels of random intercepts and fixed coefficients (level 2: university; level 1: student) was implemented to estimate the effect of PR compared to SP on OCSE-LBP at the end of the intervention. In the linear model, \({y}_{ij}\) corresponds to the measurement of the OCSE-LBP after the pedagogical intervention in person ij; \({Y}_{1ij}\) corresponds to the baseline measurement in person ij; \({T}_{ij}\) is the treatment indicator variable (SP or RP); \({\beta }_{0}\) is the effect of the RP; \({\beta }_{1}\) is the effect of the baseline measurement; \({\beta }_{2}\) is the effect of the intervention and the focus of interest of the analysis; \({U}_{oj}\) is the differential of each university.

$$y_{{ij}} = \beta _{0} + \beta _{1} Y_{{1ij}} + \beta _{2} T_{{ij}} + U_{{oj}} + e_{{ij}}$$

To adjust for the baseline of the OCSE-LBP was applied because the comparison of the means between the study groups taking into account the baseline values generates a statistical power gain [42]. A confidence level of 95% was used in the estimation of parameters. Analyzes were performed using STATA version 14.


The participating population was mostly female, with a mean age of 21 years, an academic average of 3.6/5, and an average of 87 credits taken in the Physiotherapy programme at each university (Table 1).

Table 1 Characteristics of the participants

Students who had been trained with the SP and RP simulation approach displayed highly significant results in the OCSE-LBP performance. Table 2 shows that in both RP and SP, the final score increased, 0.66 and 0.59, respectively. When comparing the interventions, neither was superior (p-value 0.01, 95%CI − 0.21 to 0.23). The study reports 100% participant adherence.

Table 2 Comparing the interventions


The study results reveal that pedagogic strategies supported by simulations improve clinical skills in interacting with people with LBP. Both types of simulations generated positive changes in the examination, evaluation, diagnosis, prognosis, and physiotherapeutic intervention. To date, no publications have been found that use simulations to train physiotherapists to interact with people diagnosed with LBP. This could be a powerful tool for enhancing decision-making regarding one of the primary reasons for consulting health services, and high-quality physiotherapy could be a solution for reducing the reoccurrence of this symptom. On the other hand, the nursing profession has registered studies in different clinical conditions that prove clinical reasoning and professional decision-making benefits [42, 43].

Other clinical areas in which physiotherapists work, have already demonstrated the positive effects of simulation to promote other skills. Some antecedents mention that simulations improve teamwork and the understanding of professional roles [44]. Moreover, simulations can replace part of the time in clinical institutions [38], contribute to education in cardiorespiratory physiotherapy [20], improve confidence in students, and enhance the procedural skills in the different performance areas [45], not just in physiotherapy but also in the nursing profession as it has already shown an important effect on anxiety and self-confidence [46].

For performance skills in the musculoskeletal area, Wright et al. [45] reported that after a 100% immersion in clinical simulation for 18 days, students showed significant improvement in their confidence and, in general, in their performance regarding the clinical approach to patients. The authors report that students exposed to rotations in simulated scenarios demonstrated a significantly higher performance in clinical skills than those who did not undergo this immersion.

This study’s simulations were conducted with standardised patients for the SP group and the role-playing scenario in the RP group. Based on the results, both contributed to integrating knowledge developed along the pedagogical process used to achieve the learning objectives related to the therapeutic interaction with a person with LBP. For the SP group, the potential benefit is that direct interaction with others with a specific training can create a similar environment to the reality, which can become an alternative with effects comparable to conventional clinical practices [47]. Despite that both groups showed better clinical reasoning outcomes, Cooper et al. found a more positive perception regarding high fidelity simulations [48]. For the RP group, the literature also reports that it provides students with a better understanding of the patient’s condition and facilitates the integration of knowledge [49].

Although research on clinical simulations as a pedagogic strategy in physiotherapy has increased, it is necessary to continue with reports of this type to enhance student training in therapeutic interactions to improve clinical decision-making [50]. Also, data in the debriefing process should be considered in future studies to better understand the learning experience [51].

The pedagogic process with simulations in both groups (SP and RP) included other educational activities like literature review, retrospective searches about the examination of LBP, laboratory workshops, and classroom sessions. This aspect would be the main limitation of the present study because improvement in the final OSCE-LBP assessment is related to these interventions and not just the simulation activity itself. Additionally, OSCE-LBP has not been psychometrically tested therefore may not have had the ability to detect differences. Other limitations of the study were sample size and the number of sessions on clinical simulation with a simulated patient. Also, the professor that developed the clinical simulation was not blinded.


From the results herein, including the simulation in the pedagogic process activity resulted in improved decision-making by the physiotherapy students during the process of professional reasoning regarding a person with LBP. As for the design proposed, both types of simulations, RP and SP, were equivalent, both of them can be included like pedagogical practices for training physiotherapy students in LBP treatment. Further research is needed to determine whether this pedagogical process would result in improved physiotherapeutic reasoning skills in real clinical settings. However, this study’s pedagogical intervention material can be implemented in undergraduate physiotherapy education curricula to empower students in clinical reasoning skills for musculoskeletal pain.

Practice points

  • Physiotherapeutic reasoning training in LBP can be combined with simulation scenarios for learning enhancement.

  • Role-playing and simulation practice in physiotherapy are teaching strategies that can provide training for musculoskeletal disorders for practitioners of physiotherapy.

Availability of data and materials

The data collected is available in the public archive of the physiotherapy program of the Universidad de Boyaca.

Change history



Low back pain


Clinical simulation with simulated patients


Simulations with role-playing


Objective Structured Clinical Examination


  1. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018;6736(18):1–12.

    Google Scholar 

  2. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736–47.

    Article  Google Scholar 

  3. Delgado JÁG, Lara GV, del Torres JCM, Morales IP. Epidemiología del dolor de espalda bajo. Investig Medicoquirúrgicas. 2014;6(1):112–25.

    Google Scholar 

  4. Palomino Aguado B, Jiménez Cosmes L, Ferrero MA. El dolor lumbar en el año 2009. Rehabilitacion. 2010;44:69–81.

    Article  Google Scholar 

  5. American Physical Therapy Association. Guide to physical therapist practice; 2016.

  6. ASCOFI, ASCOFAFI, ASCOFI COLFI, and COLFI A. ASCOFAFI. Perfil profesional y competencias del fisioterapeuta en Colombia. Bogotá: 2015.

  7. Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using the international classification of functioning, disability and health (ICF) framework and patient management model. Phys Ther. 2011;91(3):416–30.

    Article  Google Scholar 

  8. Otálora MLA, et al. Simulación clínica: una experiencia en fisioterapia. Universidad de La Sabana; 2020;144.

  9. Phillips AC, Mackintosh SF, Bell A, Johnston KN. Developing physiotherapy student safety skills in readiness for clinical placement using standardised patients compared with peer-role play: a pilot non-randomised controlled trial. BMC Med Educ. 2017;17:1.

    Article  Google Scholar 

  10. Ruiz-Moral R, Caballero-Martínez F. Programa para seleccionar y entrenar pacientes estandarizados en el contexto de un currículo universitario de simulación clínica. FEM Rev la Fund Educ Médica. 2015;17:199–204.

    Google Scholar 

  11. Ariza MR. El Aprendizaje Experiencial Y Las Nuevas Demandas Formativas. Rev Antropol Exp. 2010;8:89–102.

    Google Scholar 

  12. World Confederation for Physical Therapy. Policy statement: education WCPT. London: World Confederation for Physical Therapy; 2017.

    Google Scholar 

  13. Van Wyk R, Labuschagne MJ, Joubert G. Simulation as an educational strategy to deliver interprofessional education. Afr J Heal Prof Educ. 2020;12(2):74–80.

    Article  Google Scholar 

  14. Brack P, Shields N. Short duration clinically-based interprofessional shadowing and patient review activities may have a role in preparing health professional students to practice collaboratively: a systematic literature review. J Interprof Care. 2019;33(5):446–55.

    Article  Google Scholar 

  15. Seefeldt TM, Mort JR, Brockevelt B, Giger J, Jordre B, Lawler M, et al. A pilot study of interprofessional case discussions for health professions students using the virtual world Second Life. Curr Pharm Teach Learn. 2012;4(4):224–31.

    Article  Google Scholar 

  16. Sabus C, Sabata D, Antonacci D. Use of a virtual environment to facilitate instruction of an interprofessional home assessment. Allied Heal. 2011;40(4):199–205.

    Google Scholar 

  17. Hayward LM, Blackmer B, Markowsky A. Standardized patients and communities of practice: a realistic strategy for integrating the core values in a physical therapist education program. J Phys Ther Educ. 2006;20(2):29–37.

    Article  Google Scholar 

  18. Hayward LM, Blackmer B, Hayward L. A model for teaching and assessing core values development in doctor of physical therapy students. Jopte. 2010;24(3):16–26.

    Article  Google Scholar 

  19. Marchal L, Barthod C, Goujon L, Büssing T. Design and development of a mechatronic infant torso simulator for respiratory physiotherapy learning. Mechatronics. 2011;22(1):55–64.

    Article  Google Scholar 

  20. Blackstock FC, Watson KM, Morris NR, Jones A, Wright A, McMeeken JM, et al. Simulation can contribute a part of cardiorespiratory physiotherapy clinical education: two randomized trials. Simul Healthc. 2013;8:32–42.

    Article  Google Scholar 

  21. Ohtake PJ, Lazarus M, Schillo R, Rosen M, Bourdin G, Barbier J, et al. Simulation experience enhances physical therapist student confidence in managing a patient in the critical care environment. Phys Ther. 2013;93(2):216–28.

    Article  Google Scholar 

  22. Silberman NJ, Panzarella KJ, Melzer BA. Using human simulation to prepare physical therapy students for acute care clinical practice. J Allied Health. 2013;42(1):25–32.

    Google Scholar 

  23. Shoemaker MJ, Riemersma L, Perkins R. Use of high fidelity human simulation to teach physical therapist decision-making skills for the intensive care setting. Cardiopulm Phys Ther J. 2009;20:13.

    Article  Google Scholar 

  24. Gough S, Yohannes A, Roberts P, Murrray J, Sixsmith J. Facilitating error recognition and patient safety awareness in pre-registration physiotherapy students using video reflexive ethnography and simulation-based education. Physiotherapy (United Kingdom). 2015;101:eS473.

    Google Scholar 

  25. Smith N, Prybylo S, Conner-Kerr T. Using simulation and patient role play to teach electrocardiographic rhythms to physical therapy students. Cardiopulm Phys Ther J. 2012;23(1):36–42.

    Article  Google Scholar 

  26. Hough J, Levan D, Steele M, Kelly K, Dalton M. Simulation-based education improves student self-efficacy in physiotherapy assessment and management of paediatric patients. BMC Med Educ. 2019;19(1):1–11.

    Article  Google Scholar 

  27. Zhong B. How to calculate sample size in randomized controlled trial? J Thorac Dis. 2009;1(1):51–4.

    Google Scholar 

  28. Carvajal A, Centeno C, Watson R, Martínez M, Sanz RA. How is an instrument for measuring health to be validated? An Sist Sanit Navar. 2011;34:63–72.

    Google Scholar 

  29. Campo-Arias A, Herazo E. Concordancia intra- e interevaluadores. Rev Colomb Psiquiat. 2010;39(2):424–32.

    Google Scholar 

  30. Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low back pain: an updated systematic review within the framework of the cochrane back review group. Spine (Phila Pa 1976). 2009;34:1669–84.

    Article  Google Scholar 

  31. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011.

    Article  Google Scholar 

  32. Parreira P, Heymans MW, van Tulder MW, Esmail R, Koes BW, Poquet N, et al. Back Schools for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;8:CD011674.

    Google Scholar 

  33. Engers AJ, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008.

    Article  Google Scholar 

  34. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006.

    Article  Google Scholar 

  35. Whitehead A, Gould Fogerite S. Yoga treatment for chronic non-specific low back pain. Explor J Sci Heal. 2017.

    Article  Google Scholar 

  36. Hayden JA, Van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med. 2005;142:765–75.

    Article  Google Scholar 

  37. Hargreaves S. the Relevance of non-verbal skills in physiotherapy. Aust J Physiother. 1982;28(4):19–22.

    Article  Google Scholar 

  38. Blackstock FC, Watson KM, Morris NR, Jones A, Wright A, McMeeken JM, et al. Simulation can contribute a part of cardiorespiratory physiotherapy clinical education. Simul Healthc J Soc Simul Healthc. 2013;8(1):32–42.

    Article  Google Scholar 

  39. Pilat A. Terapias miofasciales: induccion miofascial. Mcgraw-Hill Interamericana De España SL, editor; 2003.

  40. Wang XQ, Zheng JJ, Yu ZW, Bi X, Lou SJ, Liu J, et al. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS ONE. 2012;7:e52082.

    Article  Google Scholar 

  41. Paolucci T, Attanasi C, Cecchini W, Marazzi A, Capobianco SV, Santilli V. Chronic low back pain and postural rehabilitation exercise: a literature review. J Pain Res. 2019;12:95–107.

    Article  Google Scholar 

  42. Egbewale BE, Lewis M, Sim J. Bias, precision and statistical power of analysis of covariance in the analysis of randomized trials with baseline imbalance: a simulation study. BMC Med Res Methodol. 2014;14:49.

    Article  Google Scholar 

  43. Huang J, Tang Y, Tang J, Shi J, Wang H, Xiong T, et al. Educational efficacy of high-fidelity simulation in neonatal resuscitation training: a systematic review and meta-analysis. BMC Med Educ. 2019;19(1):323.

    Article  Google Scholar 

  44. Dennis D, Furness A, Duggan R, Critchett S. An interprofessional simulation-based learning activity for nursing and physiotherapy students. Clin Simul Nurs. 2017;13:501–10.

    Article  Google Scholar 

  45. Wright A, Moss P, Dennis DM, Harrold M, Levy S, Furness AL, et al. The influence of a full-time, immersive simulation-based clinical placement on physiotherapy student confidence during the transition to clinical practice. Adv Simul. 2018;3:3.

    Article  Google Scholar 

  46. Labrague LJ, McEnroe-Petitte DM, Bowling AM, Nwafor CE, Tsaras K. High-fidelity simulation and nursing students’ anxiety and self-confidence: a systematic review. Nurs Forum. 2019;54(3):358–68.

    Article  Google Scholar 

  47. Pritchard SA, Blackstock FC, Nestel D, Keating JL. Simulated patients in physical therapy education: systematic review and meta-analysis. (research report). Phys Ther. 2016;96(9):1342.

    Article  Google Scholar 

  48. Roberts F, Cooper K. Effectiveness of high fidelity simulation versus low fidelity simulation on practical/clinical skill development in pre-registration physiotherapy students: a systematic review, vol. 17, JBI database of systematic reviews and implementation reports. Lippincott Williams and Wilkins; 2019. p. 1229–55.

  49. Brauer S et al. Proceedings of the Australian and New Zealand Association for Health Professional Educators. In: improving clinical preparation, communication, confideence and satisfaction in physiotherapy students through role-playing. Launceston; 2009. p. 84.

  50. Judd BK, Scanlan JN, Alison JA, Waters D, Gordon CJ. The validity of a professional competence tool for physiotherapy students in simulation-based clinical education: a Rasch analysis. BMC Med Educ. 2016;16:196.

    Article  Google Scholar 

  51. Lee JH, Lee H, Kim S, Choi M, Ko IS, Bae JY, et al. Debriefing methods and learning outcomes in simulation nursing education: a systematic review and meta-analysis. Nurse Educ Today. 2020;87:104345.

    Article  Google Scholar 

Download references


The authors thank the students who participated as subjects in the experiment and professors who collaborated in the blind evaluation processes, as well as the University of La Sabana, the University of Boyacá that allowed the application in their facilities and the Colombian Association of Physiotherapy Faculties (known as ASCOFAFI in Spanish) as a funder of research processes.

Contribution of paper

This is an RCT that explores the use of clinical simulation with simulated patients as a teaching method in decision making by physiotherapists versus traditional use of role-playing


This study was funded by the Universidad de La Sabana, Universidad de Boyaca and the Colombian Association of Physiotherapy Faculties (known as ASCOFAFI in Spanish). Universities mentioned above developed the role of design, data recollection, outcome analysis, and results divulgations. ASCOFAFI founded the data recollections activities.

Author information

Authors and Affiliations



MLAM, CSC, ALCG, ADPV, and RPCV were responsible for the study’s design. EACM, RLGO, and MLAO advised on assessment, viability, and intervention process, respectively. All authors contributed to writing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Carolina Sandoval-Cuellar.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the ethical committee of clinical centre Universidad de Boyaca—Colombia in June of 2016. The study included signed informed consent for all participants according to the Helsinki declaration and 8430 Colombian law (1993). The informed consent of all participants was obtained by written.

Consent for publication

Not applicable.

Competing interests

The authors declare no conflict of interest regarding this manuscript.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The original version of this article was revised: The affiliation of author Elisa Andrea Cobo-Mejía has been updated.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sandoval-Cuellar, C., Alfonso-Mora, M.L., Castellanos-Garrido, A.L. et al. Simulation in physiotherapy students for clinical decisions during interaction with people with low back pain: randomised controlled trial. BMC Med Educ 21, 375 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: