
==== Front
Phys Ther Res
Phys Ther Res
Physical Therapy Research
2189-8448
Japanese Society of Physical Therapy

ptr.R0032
10.1298/ptr.R0032
Review
A Review of the Design of Multimedia Patient Educational Materials in Low Back Pain Research
Van Oirschot and Doherty
Reviewing Design of LBP Multimedia Patient Education
VAN OIRSCHOT Garett PT 1
DOHERTY Cailbhe PT, PhD 12
1School of Public Health, Physiotherapy & Sport Science, University College Dublin, Ireland
2Insight SFI Research Centre for Data Analytics, Ireland
Correspondence to: Garett Van Oirschot. A308 Health Sciences Centre, School of Public Health, Physiotherapy & Sports Science, University College Dublin, Stillorgan Road, Belfield, Dublin 4, D04 V1W8, Ireland
e-mail: garett.vanoirschot@ucdconnect.ie

28 6 2024
2024
27 2 5866
16 4 2024
8 5 2024
©2024 Japanese Society of Physical Therapy
2024
https://creativecommons.org/licenses/by/4.0/ This work is licensed under a Creative Commons Attribution International License.
Abstract

Low back pain guidelines recommend patient education as a component of management. Multimedia education materials to provide patient education are increasingly being used not only due to the convenience of digital services but also because this is an efficient way to deliver educational information to under-resourced or rural/remote regions without optimal healthcare services. To maximize the knowledge transfer of research findings and low back pain guidelines, scientifically backed information must evolve beyond journal prints, bland government websites, and the basic web design of budget-constrained advocacy groups. Materials must instead be engaging for the public and compete with the various sources of low back pain misinformation, which can appear attractive and eye-catching while being conveniently accessed. We discuss a data subset from a larger musculoskeletal healthcare review to highlight the educational materials used in low back pain randomized controlled trials found in the literature. While there is no standard way to appraise the effectiveness of such educational materials, potential options are discussed. Future research is needed to determine whether knowledge is being transferred and whether this is the avenue to improving patient outcomes.

Keywords

Health education
Patient education
Patient education materials
Multimedia
Low back pain
E-health
Self-management
==== Body
pmcIntroduction

Low back pain (LBP) has a significant burden on society, with worldwide prevalence reported as high as 84% and 11%–12%, with those with the condition considered disabled1). It continues “to be the greatest cause of disability burden worldwide, and two-fifths of this burden has been attributed to modifiable risk factors”2). Persistent cases are expected to have continued high levels of pain and disability3).

Mirroring best practice for most musculoskeletal healthcare4), the recommended management for LBP across many international guidelines includes patient education5). Patient education aspires to empower patients to participate in and adhere to their treatment4,6–8). Especially in an era when health systems must cope with chronic musculoskeletal (MSK) conditions, treatment approaches must pivot from curing to self-management9). While the content of any patient education materials (PEMs) will continue to be presented and discussed in all health-related literature, there is also a worthy discussion to be had surrounding the design characteristics of the educational materials provided to patients when they are given in multimedia formats, defined as any use of images and words10).

Images and words allow us to provide information that may be processed and remembered better than words alone10–12). Educational materials can complement the information relayed in clinical encounters, but in cases of understaffed or rural/remote healthcare systems, they offer an opportunity to relay information to patients when clinical encounters are delayed or not possible13–15). Once established, such materials are then relatively cheap to reproduce and easily distributed over a large, but digitally connected, geographical area14,16–19). They can also offer additional features like individual tailoring, remote support, and engagement tracking to allow for increased uptake20–22).

The Cognitive Theory of Multimedia Learning (CTML)23) is an evolving evidence-based framework for optimizing educational content24–26) that is derived from the pedagogical literature but has also been used in health research. It has informed the design of healthcare education materials provided to practitioners27–29), students30–34), and patients35–40), including patients with MSK-related conditions (hip)41). In trying to maximize the effectiveness of health education, it is incumbent upon researchers, policymakers, and clinicians to ensure the information they provide to patients and the general public is not just accurate but will be attractive and engaging enough to be seen by more people42) who might otherwise be easily swayed by equally attractive and engaging materials that are inaccurate or misinformation43–45). Unfortunately, this competition between scientific advice and misinformation is rife within the MSK healthcare field46–50), of which LBP is a part. Such shortcomings are more likely when research on PEMs lacks sufficient description and reporting standards13,51).

This review is a secondary analysis of a larger systematic review that examined the educational materials across all musculoskeletal conditions52). It seeks to discuss the LBP subset of studies to better understand what educational materials have been used in LBP research. While the content of LBP education materials has been previously investigated51), this review intends to discuss the types of multimedia used and the design formats preferred. Difficulty has already been noted when attempting to retrieve and examine PEMs used in LBP research51). Another study of LBP videos found a poor correlation between user engagement and location/setting, duration, conflict of interest risk, speaker’s professional designation, source of the video, and clinical recommendations50). This study then recommended future research should examine how audio-visual aspects may affect engagement, illustrating the importance of how reviews of LBP educational materials need to also consider their design and not just content. Theoretically, there may be optimal strategies to implement when designing multimedia PEMs. Such expertise could help to compete with any potential LBP misinformation in existence so examining not just the educational content but also how their design is reported and described could aid in future LBP research.

Materials and Methods

While described in more detail elsewhere52,53), a brief description of the methods is as follows: PubMed, CINAHL, PsycINFO, and Embase were searched from inception to 20 September 2023. Inclusion criteria were as follows: Randomized controlled trials of those ≥18 years of age used any multimedia-based education intervention and examined against any comparator. Multimedia education materials included any combination of reusable words and images that were delivered to patients with examples such as infographics, books, pamphlets, and videos. This narrative review is based exclusively on the studies of LBP, defined as pain between the lower edge of the ribs and the buttock54). Exclusion criteria consisted of any interventions that relied on clinician-delivered education with no provision of materials. No date or language restrictions were applied. A secondary reference list scan of included studies was also conducted. Title and abstract screening were conducted via Covidence55), and articles were advanced to full-text review when both authors agreed. All articles in agreement were advanced to the data extraction phase, and any conflicts throughout this process were resolved by consensus between the two authors.

In instances when an included study lacked sufficient detail about the PEMs used, a request for further information was emailed to the study authors. If there was no reply to the initial or follow-up request for study materials, then the study was classified as having interventions that were irretrievable.

Following Mayer’s CTML10) framework, all study interventions were evaluated using its 15 principles, described further in Table 1. In situations where multiple or lengthy PEMs were used in a study, then a sample of the materials was taken from the study with the evaluation of these materials agreed upon between both authors.

Table 1. Explanation of Mayer’s Cognitive Theory of Multimedia Learning design principles

Design principle	Explanation	
1. Multimedia principle	People learn better from words and pictures than from words alone.	
2. Coherence principle	People learn better when extraneous material is excluded rather than included.	
3. Signaling principle	People learn better when cues are added that highlight the organization of the essential material.	
4. Redundancy principle	People do not learn better when printed text is added to graphics and narration. People learn better from graphics and narration than from graphics, narration, and printed text when the lesson is fast-paced.	
5. Spatial contiguity principle	People learn better when corresponding words and pictures are presented near rather than far from each other on the page or screen. For example, in an animation on lightning formation, captions are presented at the bottom of the screen (separated presentation) or are placed next to the event they describe in the animation (integrated presentation).	
6. Temporal contiguity principle	People learn better when corresponding words and pictures are presented simultaneously rather than successively. For example, First, the learner views an animation on lightning formation and then hears the corresponding narration or vice versa (successive group), or the learner views an animation and hears the corresponding narration at the same time (simultaneous group).	
7. Segmenting principle	People learn better when a multimedia message is presented in user-paced segments rather than as a continuous unit.	
8. Pre-training principle	People learn more deeply from a multimedia message when they know the names and characteristics of the main concepts.	
9. Modality principle	People learn more deeply from pictures and spoken words than from pictures and printed words.	
10. Personalization principle	People learn better from multimedia presentations when words are in a conversational style rather than a formal style. For example, in a narrated animation on how the human lungs work, personalization involves using “you” and “your” in the narration script, such as “your nose” rather than “the nose” and “your throat” rather than “the throat.”	
11. Voice principle	People learn better from multimedia presentations when words are spoken in an appealing human voice.	
12. Image principle	People do not learn better from multimedia presentations when a static image of the instructor is added to the screen.	
13. Embodiment principle	People learn more deeply from multimedia presentations when an onscreen instructor displays high embodiment rather than low embodiment.	
14. Immersion principle	People do not necessarily learn better in 3D immersive virtual reality than with a corresponding 2D desktop presentation.	
15. Generative activity principle	People learn better when they are guided in carrying out generative learning activities during learning (e.g., summarizing, mapping, drawing, imagining, self-testing, self-explaining, teaching, or enacting). For example, after each of the six sections in a virtual reality simulation of the human bloodstream, students are asked to verbally summarize what they have learned.	

Results

The entire data can be found on Open Science Framework via https://osf.io/6j59s/?view_only=8d3cd39f67d1489f992f0ecb5e846684.

This review discusses 41 studies in which multimedia educational materials were provided to 12,011 participants with LBP. All 41 studies were conducted between 1995 and 2022, with over half (54%) conducted from 2018 onwards. Female names accounted for 15 (36%) of primary authors. Further information on these studies and on the participants is found in Tables 2 and 3.

Table 2. Summary of study characteristics

Country	N	%	
EUa (countries shaded below)	17	41.5%	
USA	5	12.2%	
UK	5	12.2%	
Spain	4	9.8%	
Germany	3	7.3%	
Australia	3	7.3%	
Brazil*	3	7.3%	
Iran**	3	7.3%	
France	2	4.9%	
Saudi Arabia	2	4.9%	
Denmark	1	2.4%	
Sweden	1	2.4%	
Ireland	1	2.4%	
China*	1	2.4%	
Finland	1	2.4%	
Korea	1	2.4%	
Thailand*	1	2.4%	
Jordan*	1	2.4%	
Turkey*	1	2.4%	
Nigeria**	1	2.4%	
Croatia	1	2.4%	
Total	41	100.0%	
High income	30	73.2%	
*Upper middle income	7	17.1%	
**Lower middle income	4	9.8%	
aEuropean Union

*Upper middle-income rating as per World Bank

**Lower middle-income rating as per World Bank

Table 3. Summary of patient characteristics

	N	%	
Gender			
 Male	6324	52.7%	
 Female	5376	44.8%	
 Not reported	311	2.6%	
Total	12,011	100%	
Age (rangea)	18–85		
Nationality			
 USA	4645	38.7%	
 EUb (countries shaded below)	4678	38.9%	
 France	2479	20.6%	
 UK	1283	10.7%	
 Germany	886	7.4%	
 Brazil*	638	5.3%	
 Finland	415	3.5%	
 Sweden	243	2.0%	
 Iran**	230	1.9%	
 Denmark	210	1.7%	
 Spain	209	1.7%	
 Ireland	206	1.7%	
 Australia	196	1.6%	
 Saudi Arabia	105	0.9%	
 Korea	43	0.4%	
 Thailand*	42	0.3%	
 Jordan*	41	0.3%	
 China*	40	0.3%	
 Turkey*	40	0.3%	
 Nigeria**	30	0.2%	
 Croatia	30	0.2%	
 Total	12011	100.0%	
High income	10950	91.2%	
*Upper-middle income	801	6.7%	
**Lower middle income	260	2.2%	
aRange was given due to heterogeneous reporting of age

bEuropean Union

*Upper middle-income rating as per World Bank

**Lower middle-income rating as per World Bank

The types of multimedia interventions used in LBP studies varied, but the most common form was a leaflet that contained images, and the breakdown of all types is shown in Table 3. As detailed in Figure 1, two (3%) of the studies included educational interventions or a way to access the educational interventions within the article, while three (7%) used materials that could be found online. Another six studies used materials that could be purchased and one (2%) study provided their materials when requests were sent to the authors. Note that for materials requiring purchase, this pertained to books (average cost = 11.55EUR per unit). The remaining 30 (73%) of studies contained unretrievable educational materials.

Fig. 1. Retrievability of multimedia educational materials in all 41 studies

The 11 (27%) studies with retrievable materials were assessed for their conformity to the CTML described earlier, and the results are shown in Table 4. The inter-rater agreement between both authors was 100% after the discussion took place following individual ratings.

Table 4. Conformity to Cognitive Theory of Multimedia Learning for the 11 (27%) studies with retrievable materials

Primary author	Description of educational intervention	Type	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	
Chenot 2019	German version of The Back Book (Rückenbuch)	Book	Yes	No	No	No	Yes	Yes	Yes	No	No	Yes	N/A	N/A	N/A	Yes	No	
Coudeyre 2006	The French version of The Back Book (Le Guide du Dos)	Book	Yes	No	No	No	Yes	Yes	Yes	No	No	Yes	N/A	N/A	N/A	Yes	No	
Coudeyre 2007	The French version of The Back Book (Le Guide du Dos)	Book	Yes	No	No	No	Yes	Yes	Yes	No	No	Yes	N/A	N/A	N/A	Yes	No	
Gardner 2019	Participant Handbook	Manual/Workbook	Yes	No	No	No	Yes	Yes	No	Yes	No	Yes	N/A	N/A	N/A	Yes	Yes	
George 2009	The Back Book	Book	Yes	No	No	No	Yes	Yes	Yes	No	No	Yes	N/A	N/A	N/A	Yes	No	
Gibbs 2022	Pain education TEDx video: https://www.youtube.com/watch?v=gwd-wLdIHjs	Video (or film)	Yes	Yes	No	Yes	N/A	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	
Lamb 2010	The Back Book	Book	Yes	No	No	No	Yes	Yes	Yes	No	No	Yes	N/A	N/A	N/A	Yes	No	
O’Keeffe 2020	CFT written info	Leaflet/Pamphlet/Booklet	Yes	No	Yes	No	Yes	Yes	Yes	Yes	No	Yes	N/A	N/A	N/A	Yes	Yes	
Saper 2017	DVD and home practice manual	Multiple	Yes	No	Yes	No	Yes	Yes	Yes	No	No	Yes	N/A	N/A	N/A	Yes	No	
Sherman 2005	Yoga & exercise leaflets	Leaflet/Pamphlet/Booklet	Yes	No	Yes	No	Yes	Yes	Yes	No	No	Yes	N/A	N/A	N/A	Yes	Yes	
Simula 2021	Booklet (www.mq.edu.au/about/about-the-university/our-faculties/medicine-and-health-sciences/departments-and-centres/department-of-health-professions/our-research/low-back-pain-management-booklet)	Leaflet/Pamphlet/Booklet	Yes	No	Yes	No	Yes	Yes	No	Yes	No	Yes	N/A	No	No	No	No	
N/A = not applicable due to the nature of educational materials or due to the inability to translate the language of materials

Links are included where materials were found freely online.

These 11 studies were appraised according to the CTML principles (Table 4). Where the multimedia contained audio, 100% of interventions abided by the voice principle using an appealing human voice and the personalization principle of addressing the listener personally as “you” in a conversational style. All interventions conformed to the principle of spatial contiguity by displaying text and graphics in close proximity, as well as temporal contiguity by presenting text and graphics simultaneously. Ten (91%) studies abided by the principle of immersion by avoiding virtual reality, and eight (73%) studies conformed to the segmenting principle by presenting educational material in shorter segments instead of continuously.

This was less conformity to the remaining CTML principles. Half of the studies showed adherence to the image principle using moving images of speakers on screen and the embodiment principle of displaying the speaker instead of having them “off-screen.” Four (31%) studies applied the signaling principle, where cues are used to organize the information, as well as the pre-training principle by familiarizing participants with the main concepts in advance. Three (27%) studies applied the principle of generative activity by including a generative learning activity for the learner.

The principles with the least presence were the principles of modality, where pictures are accompanied by spoken words over written words, coherence when excessive or extraneous information is excluded, and redundancy where redundant text alongside graphics is avoided. These were each only present in one study.

Outcome measures

Of the 41 included studies, one study reported on the primary outcome for this review, knowledge.

For the secondary outcome of any patient-reported measures, pain intensity was the most frequent and included visual analog or numerical ratings used in 28 (68%) studies. The next most common outcome measure was the Roland Morris Disability Questionnaire, used in 18 (43%) studies, followed by the Oswestry Disability Index in 15 (36%) studies, and the Fear Avoidance Beliefs Questionnaire, used in 10 (24%) studies.

Discussion

The authors express concern that multimedia PEMs could only be retrieved for 11 (27%) studies, and just 4 (10%) were available with the article or freely online. Conducting a review of PEM intervention used in LBP research is extremely hampered when the interventions cannot be examined. Nearly three-quarters of studies could not have their interventions appraised. This will additionally prevent replication studies from being conducted. While educational materials are often intertwined with intellectual property considerations, it should be pointed out that much of this type of academic research is publicly funded to inform clinical practice. A conflict of interest arises when public support is used to create interventions that cannot be shared, examined, or replicated for public benefit. Patient education is meant to be one pillar of management in a variety of guidelines in MSK healthcare8,56–64) and naming or describing the intervention in place of providing it does not help clinical practice.

If the reporting issues in patient education research for low back occurred in other areas like exercise prescription65,66) and pharmacologic mangement67), it would be justly criticized. The authors contend that patient education research must be held to the same standard. Open science principles should continue to be encouraged and researchers should heed these principles through the use of online repositories and persistent identifiers.

Patient education interventions for LBP also lack a standardized method of appraising their design and delivery. The authors wanted to evaluate the studies in this review using a framework focused on design and learning, and the CTML was the best option to be found that does not preclude a better method from being developed. It has been used in a body of healthcare research already50–63) with an appearance in musculoskeletal healthcare41) but not necessarily in the LBP domain. If a greater sample of interventions could be obtained and evaluated, it would be informative to examine if a larger sample lacked the similar CTML principles found in our small sample of 11 studies that provided their interventions. It would be even more informative to examine if implementing all of the CTML principles led to improved outcomes. What can be said is that if the CTML provided a way to ensure better learning for patients as found in its pedagogical historical foundations10), healthcare providers could provide more engaging and educational materials to patients. While advice exists on improving content68), delivery69), and understandability26) in healthcare, the CTML might also show how to improve the design quality of materials to maximize engagement and learning. In this relatively small sample where the educational materials of 11 studies were obtained, the same four principles of coherence, redundancy, and modality are commonly overlooked. These principles are relatively easy to adapt in the text and graphic design of websites, apps, or social media posts that are disseminated to patients and the general public. There is already advice in the musculoskeletal literature about segmenting into shorter portions70) or personalizing the narration/experience71) in line with CTML principles10).

One might question why such scientific advice on LBP needs to provide education that is engaging. The authors would point to the misinformation that exists in healthcare43,44) and that LBP education does not necessarily win this contest through debate or debunking alone72) but also needs to be presented with appeal and attraction in this current era of rapidly produced social media content71) where healthcare information must maximize engagement with multimedia such as videos70,73).

The authors acknowledge that knowledge improvement may not be the key ingredient in advancing clinical outcomes, but we contend that it has not been examined comprehensively in the PEM-related research on LBP. We noted that just one out of 41 studies tested knowledge as an outcome, despite all 41 studies using educational material as an intervention. This suggests that knowledge was rarely the outcome of interest in these studies, despite the aforementioned guidelines recommending patient education as part of LBP management5). The relationship between patient education and improved clinical outcomes for LBP should be supported by some sort of investigation into their association. It has already been noted that knowledge is under-assessed in LBP research51), and our review similarly found that disability, function, and pain were more heavily favored in the studies included here.

One limitation of reviewing the literature for this review was the lack of representation. jurisdictions with under-resourced or very remote healthcare systems are not well represented when examining the upper and lower-middle-income countries from Table 2. These are the precise situations where healthcare services may have a keen interest in the design of multimedia PEMs so that they can be leveraged when one-to-one clinical care is impeded by resources or geography.

Perhaps healthcare providers of LBP are ill-equipped to advance their expertise in designing engaging education materials for multimedia consumption. Smaller organizations may never be able to train such expertise with in-house staff. Perhaps it is worth considering the benefits of liaising with social media content creators to exploit this skill set.

Finally, the authors would strongly support more rigorous reporting standards when it comes to patient education research into LBP. It should be specified clearly whether the materials are used in the form of a graphic, video, leaflet, etc., and an indication of length like word count, time, or number of pages. While being described in detail is helpful, this should be in addition to the open science principles of providing the PEM interventions as an online appendix or supplemental information or within an online repository. Also, if education is being used as an intervention, then some evaluation of knowledge should be employed.

Conclusion

Multimedia PEMs are widely used in LBP research healthcare, yet this review outlines how they are frequently not supplied or sufficiently described to achieve adequate appraisability or reproducibility. Patient education should strive for better reporting standards so that its implementation in LBP care can be better replicated. While no studies in our small sample appeared to optimize the design of their multimedia PEMs in accordance with the CTML framework, this could be addressed by encouraging more design reconfigurations that incorporate generative learning activities, use of audio over text where possible, avoiding extraneous details, and avoidance of redundant text alongside graphical information. Knowledge transfer and retention must be better assessed to explore the mechanisms of patient education.

Funding

This research did not receive any specific funding.

Availability of Data and Materials

Data and materials are available at OSF at https://osf.io/6j59s/?view_only=8d3cd39f67d1489f992f0ecb5e846684.

Conflicts of Interest

The authors have no conflicts of interest to declare.
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References

1) Airaksinen O Brox JI , et al.: COST B13 Working Group on Guidelines for Chronic Low Back Pain: Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006; 15 (Suppl. 2) : s192–s300.16550448
2) GBD 2021 Low Back Pain Collaborators: Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: A systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023; 5 : e316–e329.37273833
3) Wallwork SB Braithwaite FA , et al.: The clinical course of acute, subacute and persistent low back pain: A systematic review and meta-analysis. CMAJ. 2024; 196 : E29–E46.38253366
4) Lin I Wiles L , et al.: What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review. Br J Sports Med. 2020; 54 : 79–86.30826805
5) Nicol V Verdaguer C , et al.: Chronic low back pain: A narrative review of recent international guidelines for diagnosis and conservative Treatment. J Clin Med. 2023; 12 : 1685.36836220
6) Gruman J Rovner MH , et al.: From patient education to patient engagement: Implications for the field of patient education. Patient Educ Couns. 2010; 78 : 350–356.20202780
7) Hoving C Visser A , et al.: A history of patient education by health professionals in Europe and North America: From authority to shared decision making education. Patient Educ Couns. 2010; 78 : 275–281.20189746
8) Zhang W Moskowitz R , et al.: OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008; 16 : 137–162.18279766
9) Lewis JS Stokes EK , et al.: Reframing how we care for people with persistent non-traumatic musculoskeletal pain. Suggestions for the rehabilitation community. Physiotherapy. 2021; 112 : 143–149.34102533
10) Mayer RE : Multimedia Learning. 3rd ed. Cambridge: Cambridge University Press, 2020.
11) Nijs J Meeus M , et al.: A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Phys Ther. 2014; 94 : 730–738.24481595
12) Enzenhofer M Bludau HB , et al.: Improvement of the educational process by computer-based visualization of procedures: Randomized controlled trial. J Med Internet Res. 2004; 6 : e16.15249265
13) Tom K Phang PT : Effectiveness of the video medium to supplement preoperative patient education: A systematic review of the literature. Patient Educ Couns. 2022; 105 : 1878–1887.35101307
14) Sharma S Traeger AC , et al.: Delivering the right care to people with low back pain in low- and middle-income countries: The case of Nepal. J Glob Health. 2019; 9 : 010304.30774940
15) Sharma S Blyth FM , et al.: Health system strengthening is needed to respond to the burden of pain in low- and middle-income countries and to support healthy ageing. J Glob Health. 2019; 9 : 020317.33274068
16) Hauser-Ulrich S Kunzli H , et al.: A smartphone-based health care chatbot to promote self-management of chronic pain (SELMA): Pilot randomized controlled trial. JMIR Mhealth Uhealth. 2020; 8 : e15806.32242820
17) O’Keeffe M O’Sullivan P , et al.: Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain: A multicentre randomised controlled trial (RCT). Br J Sports Med. 2020; 54 : 782–789.31630089
18) Eccleston C Blyth FM , et al.: Managing patients with chronic pain during the COVID-19 outbreak: Considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020; 161 : 889–893.32251203
19) Garcia LM Birckhead BJ , et al.: An 8-week self-administered at-home behavioral skills-based virtual reality program for chronic low back pain: Double-blind, randomized, placebo-controlled trial conducted during COVID-19. J Med Internet Res. 2021; 23 : e26292.33484240
20) Martorella G Boitor M , et al.: Tailored web-based interventions for pain: Systematic review and meta-analysis. J Med Internet Res. 2017; 19 : e385.29127076
21) Lin J Faust B , et al.: A web-based acceptance-facilitating intervention for identifying patients’ acceptance, uptake, and adherence of internet- and mobile-based pain interventions: Randomized controlled trial. J Med Internet Res. 2018; 20 : e244.30131313
22) Büttner F Ardern CL , et al.: Counting publications and citations is not just irrelevant: It is an incentive that subverts the impact of clinical research. Br J Sports Med. 2021; 55 : 647–648.33361277
23) Mayer R Mayer RE : The Cambridge handbook of multimedia learning: Cambridge University Press, 2005.
24) Ahmadzadeh K Bahrami M , et al.: Patient education information material assessment criteria: A scoping review. Health Info Libr J. 2023; 40 : 3–28.36637218
25) Mbanda N Dada S , et al.: A scoping review of the use of visual aids in health education materials for persons with low-literacy levels. Patient Educ Couns. 2021; 104 : 998–1017.33339657
26) Shoemaker SJ Wolf M , et al.: Development of the Patient Education Materials Assessment Tool (PEMAT): A new measure of understandability and actionability for print and audiovisual patient information. Patient Educ Couns. 2014; 96 : 395–403.24973195
27) Ferguson I Phillips AW , et al.: Continuing medical education speakers with high evaluation scores use more image-based slides. West J Emerg Med. 2017; 18 : 152–158.28116029
28) Grech V : The application of the Mayer multimedia learning theory to medical PowerPoint slide show presentations. J Vis Commun Med. 2018; 41 : 36–41.29381105
29) Iorio-Morin C Brisebois S , et al.: Improving the pedagogical effectiveness of medical videos. J Vis Commun Med. 2017; 40 : 96–100.28925762
30) Wyatt TH Krauskopf PB , et al.: Cooperative m-learning with nurse practitioner students. Nurs Educ Perspect. 2010; 31 : 109–113.20455369
31) Sait S Tombs M : Teaching medical students how to interpret chest X-rays: The design and development of an e-learning resource. Adv Med Educ Pract. 2021; 12 : 123–132.33574725
32) Nagmoti JM : Departing from PowerPoint default mode: Applying Mayer’s multimedia principles for enhanced learning of parasitology. Indian J Med Microbiol. 2017; 35 : 199–203.28681806
33) Issa N Mayer RE , et al.: Teaching for understanding in medical classrooms using multimedia design principles. Med Educ. 2013; 47 : 388–396.23488758
34) Dash S Kamath U , et al.: Audio-visual aid in teaching “fatty liver”. Biochem Mol Biol Educ. 2016; 44 : 241–245.26625860
35) Kayler LK Dolph B , et al.: Development of the living donation and kidney transplantation information made easy (KidneyTIME) educational animations. Clin Transplant. 2020; 34 : e13830.32072670
36) Javaid MA Schellekens H , et al.: eNEUROANAT-CF: A conceptual instructional design framework for neuroanatomy e-learning tools. Med Sci Educ. 2021; 31 : 777–785.34457925
37) Issa N Schuller M , et al.: Applying multimedia design principles enhances learning in medical education. Med Educ. 2011; 45 : 818–826.21752078
38) Abujarad F Peduzzi P , et al.: Comparing a multimedia digital informed consent tool with traditional paper-based methods: Randomized controlled trial. JMIR Form Res. 2021; 5 : e20458.34665142
39) Athilingam P Osorio RE , et al.: Embedding patient education in mobile platform for patients with heart failure: Theory-based development and beta testing. Comput Inform Nurs. 2016; 34 : 92–98.26765655
40) Choi J : Development and pilot test of pictograph-enhanced breast health-care instructions for community-residing immigrant women. Int J Nurs Pract. 2012; 18 : 373–378.22845637
41) Rini C Porter LS , et al.: Automated internet-based pain coping skills training to manage osteoarthritis pain: A randomized controlled trial. Pain. 2015; 156 : 837–848.25734997
42) Guo PJ Kim J , et al.: How video production affects student engagement: An empirical study of MOOC videos. Proceedings of the First ACM Conference on Learning @ Scale Conference. 2014; 41–50.
43) Hochlehnert A Richter A , et al.: A computer-based information-tool for chronic pain patients: Computerized information to support the process of shared decision-making. Patient Educ Couns. 2006; 61 : 92–98.16533681
44) Larsen ME Huckvale K , et al.: Using science to sell apps: Evaluation of mental health app store quality claims. NPJ Digit Med. 2019; 2 : 18.31304366
45) Chou WS Oh A , et al.: Addressing health-related misinformation on social media. JAMA. 2018; 320 : 2417–2418.30428002
46) Haidar LA Kortlever J , et al.: Misinformation in News coverage of professional and college athlete musculoskeletal ailments. Arch Bone Jt Surg. 2020; 8 : 33–37.32090143
47) Kingery MT Schoof L , et al.: Online direct-to-consumer advertising of stem cell therapy for musculoskeletal injury and disease: Misinformation and violation of ethical and legal advertising parameters. J Bone Joint Surg Am. 2020; 102 : 2–9.31770294
48) Smith C Martin-Lillie C , et al.: Challenging misinformation and engaging patients: Characterizing a regenerative medicine consult service. Regen Med. 2020; 15 : 1427–1440.32319855
49) Zheluk A Anderson J , et al.: Analysis of acute non-specific back pain content on TikTok: An exploratory study. Cureus. 2022; 14 : e21404.35198311
50) Maia LB Silva J , et al.: Popular videos related to low back pain on YouTubeTM do not reflect current clinical guidelines: A cross-sectional study. Braz J Phys Ther. 2021; 25 : 803–810.34332887
51) Furlong B Etchegary H , et al.: Patient education materials for non-specific low back pain and sciatica: A systematic review and meta-analysis. PLoS One. 2022; 17 : e0274527.36223377
52) Van Oirschot G Pomphrey A , et al.: An evaluation of multimedia patient education design for musculoskeletal healthcare: A systematic review. JMIR Preprints, 2023: 48154.
53) Van Oirschot G Pomphrey A , et al.: An evaluation of multimedia patient education design for musculoskeletal healthcare: A systematic review UK: PROSPERO; 2021 [updated 2023. International prospective register of systematic reviews]. Available from: https://www.crd.york.ac.uk/PROSPEROFILES/292134_STRATEGY_20211207.pdf.
54) WHO: Low back pain key facts 2024 [Available from: https://www.who.int/news-room/fact-sheets/detail/low-back-pain, accessed 28 March 2024, 2024.
55) Covidence systematic review software [program]. Melbourne, Australia, 2022.
56) Bannuru RR Osani MC , et al.: OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019; 27 : 1578–1589.31278997
57) Fernandes L Storheim K , et al.: Efficacy of patient education and supervised exercise vs patient education alone in patients with hip osteoarthritis: A single blind randomized clinical trial. Osteoarthritis Cartilage. 2010; 18 : 1237–1243.20633669
58) Morrissey D Cotchett M , et al.: Management of plantar heel pain: A best practice guide informed by a systematic review, expert clinical reasoning and patient values. Br J Sports Med. 2021; 55 : 1106–1118.33785535
59) Collins NJ Barton CJ , et al.: 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: Recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018; 52 : 1170–1178.29925502
60) Willy RW Hoglund LT , et al.: Patellofemoral Pain. J Orthop Sports Phys Ther. 2019; 49 : CPG1–CPG95.
61) Barrett E Larkin L , et al.: Physical Therapy management of nontraumatic shoulder problems lacks high-quality clinical practice guidelines: A systematic review with quality assessment using the AGREE II Checklist. J Orthop Sports Phys Ther. 2021; 51 : 63–71.33356772
62) Doiron-Cadrin P Lafrance S , et al.: Shoulder rotator cuff disorders: A systematic review of clinical practice guidelines and semantic analyses of recommendations. Arch Phys Med Rehabil. 2020; 101 : 1233–1242.32007452
63) Coombes BK Bisset L , et al.: Management of lateral elbow tendinopathy: One size does not fit all. J Orthop Sports Phys Ther. 2015; 45 : 938–949.26381484
64) Day JM Lucado AM , et al.: A comprehensive rehabilitation program for treating lateral elbow tendinopathy. Int J Sports Phys Ther. 2019; 14 : 818–829.31598419
65) Hansford HJ Wewege MA , et al.: If exercise is medicine, why don’t we know the dose? An overview of systematic reviews assessing reporting quality of exercise interventions in health and disease. Br J Sports Med. 2022; 56 : 692–700.35168956
66) Holden S Barton CJ : ‘What should I prescribe?’: Time to improve reporting of resistance training programmes to ensure accurate translation and implementation. Br J Sports Med. 2019; 53 : 264–265.29936430
67) Murray IR Murray AD , et al.: Infographic: we need minimum reporting standards for biologics. Br J Sports Med. 2019; 53 : 974–975.28831016
68) Zadro JR Ferreira GE , et al.: How do people use and view infographics that summarise health and medical research? A cross-sectional survey. BMC Med Educ. 2022; 22 : 677.36104815
69) Hoffmann TC Glasziou PP , et al.: Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014; 348 : g1687.24609605
70) Yang S Brossard D , et al.: The science of YouTube: What factors influence user engagement with online science videos? PLoS One. 2022; 17 : e0267697.35613095
71) Montag C Yang H , et al.: On the Psychology of TikTok Use: A first glimpse from empirical findings. Front Public Health. 2021; 9 : 641673.33816425
72) Viana da Silva P Kamper SJ , et al.: “Myths and Facts” education is comparable to “Facts Only” for recall of back pain information but may improve fear-avoidance beliefs: An embedded randomized trial. J Orthop Sports Phys Ther. 2022; 52 : 586–594.35802818
73) Desai T Shariff A , et al.: Is content really king? An objective analysis of the public’s response to medical videos on YouTube. PLoS One. 2013; 8 : e82469.24367517
