Prescribing exercise therapy for the management of musculoskeletal pain: new-graduate physiotherapists’ perceptions and perceived training needs

ABSTRACT

Background

Pain management is a challenging area of practice for new-graduate physiotherapists during the transition from student to clinician. The attitudes and beliefs of new-graduate physiotherapists toward the use of exercise therapy as part of the management of musculoskeletal pain remain relatively unknown.

Purpose

The aim of the study was to investigate the perspectives of new-graduate physiotherapists toward prescribing exercise therapy in musculoskeletal pain management, and their perceptions of training and support needs in this area of practice.

Methods

A qualitative study with a general inductive approach was used to investigate new-graduate physiotherapists’ perspectives. Semi-structured interviews were conducted with 16 participants. Interview data was subjected to thematic analysis.

Results

Four themes were generated following analysis: 1) Balancing the value of exercise with practical challenges; 2) Communication and education are inherent in exercise; 3) Influence of support and training; and 4) The benefits of direct experience.

Conclusion

New-graduate physiotherapists acknowledge the pivotal role of exercise in managing musculoskeletal pain. Direct learning experiences in pre-professional training that develop knowledge and skills required for delivering exercise therapy were highly valued. New-graduates recognize pain management as a skill that requires further development and identify the importance of opportunities for professional development in exercise therapy.

KEYWORDS:

• Physiotherapy
• new-graduate
• musculoskeletal pain
• exercise prescription

Introduction

Musculoskeletal pain is the largest contributor to years lived with disability globally (Abrams et al., 2020) and has increased by over 60% in the past 30 years (Cieza et al., 2020). Physiotherapists are well-placed to manage acute and chronic musculoskeletal pain (Holopainen et al., 2020) through a range of management approaches that often incorporate exercise therapy (Kunstler, Fuller, Pervan, and Merolli, 2019). Exercise therapy is defined as a “form of physical activity that is prescribed and progressed to achieve specific therapeutic goals” (Barton et al., 2021) and within physiotherapy, it is typically utilized as part of a multimodal approach (Ambrose and Golightly, 2015). Given the importance of improving function and reducing pain in individuals with musculoskeletal conditions health professional education programs including physiotherapy must provide graduates with the knowledge and skills to manage individuals with acute and chronic pain using a range of evidence-based approaches, including exercise therapy (Briggs et al., 2016; Lin et al., 2020).

The transition from physiotherapy student to clinician is often described as challenging (Atkinson and McElroy, 2016, Stoikov et al, 2022; Wells et al., 2021). The first two years of practice have been identified as a critical period for skill development where new-graduates require substantial support to transition into their professional role (Hayward et al., 2013). Preparedness for practice is a particularly salient issue for new-graduate physiotherapists, many of whom report feeling additionally ill-prepared for managing pain (Forbes and Ingram, 2019; Synnott et al., 2015). O’Donoghue, Doody, and Cusack (2011) identified gaps in Irish physiotherapy curricula relating specifically to exercise, suggesting new-graduates may not be adequately prepared for this particular aspect of pain management. A recent cross-sectional survey in the United Kingdom by Chesterton, Chesterton, and Alexanders (2023) indicated a lack of perceived preparedness for providing exercise therapy among new-graduate physiotherapists. An Australian survey has further highlighted that while most physiotherapists utilize exercise in the management of musculoskeletal pain, fewer reported perceived confidence in this area of practice (Barton et al., 2021). This survey-based research has provided a snapshot of the challenges that new-graduates may face in the use of exercise therapy. However, there has been little exploration of their experiences with or perceived preparedness for using exercise therapy. To date several studies have utilized qualitative research to explore the experiences and perceived training needs of new-graduate physiotherapists more deeply in different clinical practice domains including: pain assessment and management (Forbes and Ingram, 2019; Ingram, Forbes, and Jones, 2019); diagnostic uncertainty (Almond, Zou, and Forbes, 2021); and the use of clinical skills in private practice settings (Atkinson and McElroy, 2016). This research has highlighted that new-graduates are often challenged with the complexities of assessing, diagnosing, and managing pain in the clinical setting; however, their use of specific management approaches remains unknown.

Despite early work in this space, the attitudes, beliefs and perceptions of new-graduate physio-therapists toward the use of exercise as part of the management of musculoskeletal pain have not been explored. Addressing this gap may have implications for physiotherapy training, patient expectations, and outcomes. Furthermore, given that exercise is a ubiquitous part of physiotherapy practice (Barton et al., 2021) findings may have relevance for workplace satisfaction and retention of early career physiotherapists (Beattie and Silfies, 2015). By understanding the challenges faced by new-graduates and their perceived training needs, this research may help educators and employers in designing or enhancing pre-professional curricula and professional development opportunities to support students and new-graduates in the use of exercise therapy as part of their multi-modal management of musculoskeletal pain in the clinical setting. Therefore, the aim of this study was to investigate the perspectives of new-graduate physiotherapists toward prescribing exercise therapy in musculoskeletal pain management and their perceptions of training and support needs in this area of practice.

Methods

Design

A qualitative study design with a general inductive approach was utilized to investigate the study aims (Thomas, 2006). Thematic analysis was used to explore participants’ experiences and opinions (Braun and Clarke, 2021, 2022). A semi-structured interview framework with both open-ended and probing questions was developed by the research team following a review of the literature. Ethical clearance was gained from the University of Queensland Ethics Committee.

Participants

New-graduate physiotherapists were recruited via a convenience snowball sampling strategy. Inclusion criteria required participants to have graduated from an entry-level physiotherapy degree from an Australian university within the previous two years. Members of the research team (RF, RM, and AM) utilized professional networks of colleagues, previous graduates and practice employers to identify new-graduate physiotherapists who were considered to meet the inclusion criteria. A total of 30 potential participants received one e-mail from a member of the research team (RF and AM) to seek their interest in being involved in the study. Upon reply to the e-mail, they were then asked to provide consent to be contacted via telephone and to propose an interview time. Participants were encouraged to contact other professional contacts who met the inclusion criteria for further recruitment. Two members of the research team (LL and TM) then confirmed the interview time with eligible participants based on nominated availability. If no response was received within seven days of contact, then no further contact was made with that participant and the recruitment process continued.

Data collection

A semi-structured interview framework (Table 1) with open questions was curated by the research team following the review of previous literature. Interviews were conducted in June and July 2022. At the start of the interview, demographic details were collected, and participants were provided with a definition of exercise therapy being “a form of physical activity that is prescribed and progressed to achieve specific therapeutic goals” (Barton et al., 2021).

Table 1. Example interview questions.

Example interview questions

What have been your experiences of using exercise to manage pain? Why do you choose exercise as an intervention? Describe your feelings of how well you are prepared for giving exercise to patients with pain. Do you experience any challenges when prescribing exercise to patients with pain? If yes, what are they? Why is this a challenge? How do you overcome the challenges? What support have you had, or feel you might have needed in the workplace?

Probing questions

What do you think helped you to become competent or confident in that area? What particular aspects of exercise prescription do you find challenging? You said you feel confident (or not confident) to do this. Why do you feel this way? Can you elaborate on why you have this view?

Interview procedure

Interviews were undertaken by the lead researcher (LL) and conducted over remote teleconference with the selected platform based on participant preference. Audio data were recorded on a second device simultaneously for accurate transcription purposes. The interviews were transcribed verbatim with all data de-identified at this stage. The interviews were guided by the open-ended questions in the interview framework, with probing questions and clarifications sought throughout. The interview framework was refined before each interview based on the ability of the interview questions to capture data accurately in previous interviews (Braun and Clarke, 2021). Only minor changing to wording was undertaken. Concurrent data collection and data analysis were undertaken. Malterud, Siersma, and Guassora (2016) proposed that five principles must be considered when determining appropriate power for a qualitative study these being: 1) how broad the aims of the study are; 2) how sparse the potential participant group is; 3) any established theories that support the study; 4) quality of the dialogue; and 5) analysis strategy undertaken. Malterud, Siersma, and Guassora (2016) concept of information power appropriately encapsulated how the authors approached decision making regarding the sample size of the study.

Data analysis

Recordings were de-identified and transcribed verbatim. Initial thematic analysis was commenced by the lead researcher (LL) following the first interview. Data analysis followed the approach described by Braun and Clarke (2021, 2022). Data familiarization occurred through listening, transcribing, and repeatedly reading the transcripts. Noteworthy ideas were annotated with initial codes. Codes with similar ideas were subsequently grouped into subthemes, which were further synthesized into overarching themes. To further ensure accurate interpretation, the thematic analysis was repeated independently by a second researcher (RF) before all supporting quotes, codes and themes were reviewed by the research team to ensure accurate representation of data. Final themes were determined following discussion between researchers (LL and RF) and the whole team across six meetings. The lead researcher undertaking analysis (LL) is a final year physiotherapy student with introductory experience in management of musculoskeletal pain. The second researcher undertaking analysis (RF) is a lecturer, titled musculoskeletal physiotherapist, and a qualitative researcher of physiotherapy education and new graduate practice.

Several strategies were adopted to uphold data integrity to maximize robustness and reflexivity during data collection and analysis. Prior to analysis, the lead researcher (LL) underwent the process of epoche to identify and bracket any preconceptions related to the researched phenomenon (Neubauer, Witkop, and Varpio, 2019). This allowed the researcher to study the data intentionally to promote transparency of data analysis (Englander, 2016). Clear, rigorous documentation of data analysis was implemented to minimize researchers’ assumptions and potential biases. Personal questions were avoided, and the participants were not personally known to the interviewer. To uphold validity and reliability, the research team met on six occasions to discuss coding and proceeding themes. Transcripts were also sent to participants for member checking to confirm accuracy of transcribed data and verify if codes generated corresponded to their opinions (Birt et al., 2016).

Results

Sixteen participants met the inclusion criteria and consented to be interviewed. The participants were aged between 21 and 28 years (mean age = 23.82 years). All participants were working full-time as physiotherapists. Further demographic details are outlined in Table 2.

Table 2. Participant demographic information.

Participant #	Age (yrs)	Gender	Entry level physiotherapy program	Time since graduation (months)	Setting of practice
P1	21	M	Bachelor	6	Private practice
P2	22	M	Bachelor	6	Private practice and private hospital
P3	25	F	Masters	18	Private practice
P4	23	F	Bachelor	6	Public hospital
P5	28	M	Masters	18	Private practice
P6	22	F	Bachelor	6	Public hospital
P7	24	M	Bachelor	6	Private practice and residential aged care
P8	26	F	Bachelor	6	Private practice
P9	22	M	Bachelor	6	Private practice
P10	24	F	Bachelor	6	Private practice
P11	27	M	Masters	6	Private practice and community rehabilitation
P12	25	M	Masters	18	Private practice
P13	22	F	Bachelor	6	Public hospital
P14	23	F	Bachelor	7	Public hospital
P15	25	F	Masters	18	Public hospital
P16	22	M	Bachelor	6	Public hospital

Four themes were generated following analysis: 1) Balancing the value of exercise with practical challenges; 2) Communication and education are inherent in exercise; 3) Influence of support and training; and 4) The benefits of direct experience. Participants’ reflections on their training needs are embedded within each of the themes.

Balancing the value of exercise with practical challenges

There was an overwhelming impression from participants that exercise was central to the effective management of musculoskeletal pain. Exercise was an intervention that participants described as “reliable” and “effective” (P2) from first-hand experience, and it offered both a direct and immediate approach to helping patients manage their symptoms. The use of exercise in the management of musculoskeletal pain was not only viewed as valuable but was also prevalent. Almost all participants discussed routinely prescribing at least one exercise to most patients who presented with pain.

“For pretty much everyone I would say I give them at least one home exercise to do as appropriate for them that they can find easy enough to do.” (P3)

When reflecting on the benefits of exercise in the context of pain, participants drew from not only clinical experiences but also directly from patient feedback that reinforced their own perceived value. One participant recounted interactions with patients that for them reaffirmed their choice to use exercise in the future.

“Now, they’ll come in, and they’ll be like, ‘Wow, these exercises always make my pain a little bit better.’ And this gives you more reasons to keep going.” (P2)

Exercise was also perceived to be of value where it could be used to manage multiple impairments or achieve a range of goals. Some participants reflected on the value of exercise for its capacity to build patient “self-confidence” (P7) and empower patients toward self-management. Some participants went further, justifying their application of exercise as “psychological” (P16) with goals aimed at addressing fear avoidance. Exercise was also viewed by some as beneficial from a “mental health” perspective for those with pain (P4).

“I think (management) should always be paired with exercise from a self-empowerment point of view for the patient. For them to be able to go home and take control of their own health.” (P4)

Several participants reported challenges in using exercise in the management of patients who had little previous exposure to, or experience with, exercise. Some participants felt unprepared to manage such patients and this challenge was more concerning for participants where patients had difficulty performing movements correctly or were seen to be less likely to adhere to prescribed exercises.

“A lot of the people coming in have never done exercises before, and don’t have very good awareness of what they’re supposed to be feeling. So they just actually have difficulty performing certain movements.” (P9)

Some participants felt ill-prepared for progressing exercise past the initial stage of pain management, especially patients at a “higher level” (P2) of function who were thought to require more specific and challenging exercise prescription to meet their goals. As a result, participants advocated for an increased focus on how to progress exercise in their pre-professional training. Some participants felt that focusing on more “specific adaptations” (P5) and on “mid-stage to then end-stages” (P11) of exercise prescription for pain would help equip them with the skills needed in clinical practice.

“I think there should definitely be a lot more practical sessions where you’re just focusing on progression with exercises so you’re not trying to just rush everything and jam it into one and leaving the exercise to the very end like ‘okay, here’s one exercise.’” (P10)

Time constraints were identified as a barrier to the effective use of exercise. Participants stressed that it “takes time” (P14) to prescribe exercise and educate patients to undertake their exercises. Several participants felt pressured by high caseloads and a “fast turnover” of patients (P4), which left them with little time to prescribe exercise to patients in a way that they deemed effective.

“And I guess that’s a bit of a barrier to implementing your exercise and your treatment, you have to take it slow. But sometimes you can’t take it slow in acute settings, because you need to get stuff done and over faster.” (P6)

When participants were pressed for time, they continued to prioritize exercise for patients presenting with musculoskeletal pain, even if this resulted in feeling that prescription of exercise was often overly simple or repetitive.

“I think to a degree, you know, exercise is helpful and you’ve got a couple exercises up your belt, I think you can just get very repetitive and handing out a sit to stand and a wall push up.” (P4)

Communication and education are inherent in exercise

Participants overwhelmingly felt that their efforts and outcomes from using exercise would be ineffective as a standalone approach in the management of musculoskeletal pain. Participants emphasized the need to engage patients in their management to promote adherence and attain their “buy in” (P1, 8, 9, 11, 13). Participants felt that a combination of education, individualized exercise and the use of other relevant therapies all contributed to the success that would arise from the use of exercise.

“I think if you can tie that back into exercise, so do some components of the hands on, get that patient buy in so that when you do explain their condition or their diagnoses, if they understand their condition, they can appreciate why doing exercises might help fix that problem.” (P5)

Participants strongly recognized that exercise prescription and patient education were inherently linked, especially for exercise to be effective. The two often went hand in hand to be delivered together.

“I put emphasis on advice and education, around pain, because I feel like, if you can help someone understand why they’re experiencing pain, and why they’re in pain, then you can build that foundation.” (P9)

Participants strongly felt that communication skills were the foundation of effective exercise prescription. This was expressed due to a sense that physiotherapy is “as much of an art as it is a science” (P9). Some participants expressed that communication needed to be undertaken in a way to “instill confidence in the patient” (P1) and needed to be adapted to suit the patient in front of them.

“It’s just knowing who your patients are. It’s important, because not every patient is going to be receptive to what you’re saying. They’re not going to understand what you’re saying.” (P15)

Despite acknowledging the benefits of exercise therapy, several participants reported challenges in helping patients understand the benefits of exercise. A “barrier” (P6, 7, 11) was feeling unable to “convince” (P6) patients of the benefits, which was felt to impact subsequent adherence. Some participants even expressed “frustration” (P4) when patients were not adhering to the exercise program.

“It can be a real frustration when you don’t see someone for four weeks, they come back complaining of the exact same things. And it’s evident that they haven’t been doing their exercises.” (P4)

Noticeably, some participants recounted challenges in engaging patients with chronic pain and felt it was a particularly “tough sell” (P9) to engage those patients in exercise. One participant reflected on their first time managing someone with exercise who presented with chronic pain and expressed feeling “overwhelmed” (P8).

“I thought that I could sort of just go around how I normally treat someone that presents with pain. But quickly realized that probably the skills I had were not as tangible to this (chronic pain) patient population.” (P8)

Participants described several strategies that they felt helped them manage challenges with engagement. Most participants stressed the need to prescribe exercise that was tied closely to the patient’s goals. This was seen to have additional benefits through a “collaborative approach” (P9) to avoid patients just “being a passenger” (P9). Some participants recognized that they had to be careful about the use of exercise, especially where patients had previous negative experiences. Some participants had developed strategies aimed at “winning their trust” (P13) and introducing the concept of exercise in a graduated way.

“If a patient in the past has said, ‘I’ve gone to physio numerous times, and they’ve done a bunch of different exercises, but they didn’t help,’ I kind of plant the seed that eventually we’ll start to do exercises, but I won’t throw exercises to them right away, because in that case, I won’t get that buy in.” (P11)

Influence of support and training

Participants expressed an openness and initiative toward seeking support and training beyond their pre-professional education and they viewed this as integral for gaining confidence and competence in prescribing exercise for musculoskeletal pain. Upon entering the workforce, participants recognized the need to initiate ongoing learning as they no longer had their “hands held for everything” (P5). Informal professional development activities such as self-directed learning and discussion with colleagues were seen as an opportunity to add skills in a way that was “expanding (their) repertoire” (P4).

“I’m continually trying to pick up new strategies, do some extra research in, because it’s such a complex area. I’m always sort of searching for more information, and really open to further ideas.” (P8)

Some participants tended to draw on their own experiences with exercise and felt that this exposure aided in their preparedness. Several participants (P3, 11, 12) credited their previous undergraduate degree in exercise science in supplementing their exercise prescription “toolbox” (P4). Similarly, participants with a background in exercise from sports and previous study had a sense of being “more proficient” (P12) in exercise prescription.

“I feel privileged to come from a background where I enjoy going to the gym, and I enjoy exercising myself. But I could only imagine how hard it is for someone who doesn’t have that background as well.” (P4)

There was a strong consensus from participants that exercise therapy in the context of managing musculoskeletal pain was a skill that required further development in the workplace. Senior colleagues and mentors were seen to play an essential role in supporting these skills. One participant described the support from senior colleagues as a “safety net” (P12), which was felt to aid their transition from student to practicing physiotherapist. Workplace mentoring that offered “supervision” and “facilitation” (P16) was seen as highly desirable. Mentorship, together with other opportunities such as shadowing senior colleagues and doing “doubles” (P6), were seen as the building blocks of confidence and competence.

“I have one hourly weekly supervision session with a senior physio and then weekly in services within the team as well, which is really helpful to build and have that support as well as just so many smart people around to ask questions all the time.” (P4)

“I discussed with my boss who we have regular catch ups with any patients that aren’t progressing and what they do to deal with patients experiencing chronic pain.” (P8)

The benefit of direct experience

When reflecting on their pre-professional training, participants unanimously emphasized the importance of direct experience in clinical settings while as a student to gain knowledge and skills. Participants highly valued simulation-based activities and clinical placements, which allowed them to “learn by experience” (P11).

“I probably learned most of those skills from placement, I think it’s a difficult thing to teach theoretically. There’s more so just learning by trying and failing and getting experiences in placement and knowing when to try and push it.” (P9)

Participants also reflected on the gap between pre-professional curriculum and “real world” situations. While most participants acknowledged that their training before their placements provided theoretical knowledge for understanding and applying exercise, several participants felt that exercise prescription was often “brushed over” (P2, 10, 12).

“I think there’s maybe a bit of a downfall in university in not going through specific exercise ideas. Sometimes I’m kind of at a loss of my thoughts, like ‘what exercise can I do for this, I don’t have to draw on.’” (P10)

Participants felt there were limited opportunities to practice the communication and interpersonal skills required for effective exercise therapy authentically during their pre-professional training. They described feeling sometimes unprepared for how patients would react, having only practiced the skills with their peers in the “safety of the university” (P16).

“When you’ve actually got someone in front of you who is really, really sore. That’s a lot different when you’re just practicing on your friend, just parroting pain doesn’t mean pathology and your friends were like, ‘Ah, you’re right.’ Obviously, telling someone who’s incredibly sore is a lot different. So I think it’s really only having that, that real world example in front of you, which I guess would be pretty hard to do in uni.” (P12)

Participants strongly expressed the need for more practical experiences and training in how to identify and consider addressing psychosocial factors that contributed to their patient’s presentation or made their management more complex. Delivering exercise therapy using a biopsychosocial approach was perceived to result in better patient outcomes.

“Uni needs to catch up with the times and implement more psychological, empathetic treatments that we can do. Because if you can calm someone down, convince them that their body is not going to break down by doing exercise, you will have a lot better result. The biopsychosocial model, like time and time again, has proven to be the way forward for our profession.” (P7)

Discussion

This study has explored new-graduate physiotherapists’ perspectives on the use of exercise therapy in managing musculoskeletal pain and has provided insight into their perceived training and support needs. Overall, the results indicate that exercise therapy is highly valued by new-graduates within the current study; further, the results emphasize their perceived needs for direct learning experiences and workplace support to deliver successful exercise therapy within clinical settings.

Exercise therapy formed a ubiquitous part of clinical practice for new-graduates within the current study, which mirrored strong underlying beliefs of value in managing musculoskeletal pain. These findings reflect both the prevalence and perceived value of exercise therapy in the wider Australian physiotherapy population (Barton et al., 2021). Although the perceived value of exercise therapy was initiated during new-graduates’ pre-professional training, it was strengthened by first-hand clinical experiences, and for some, was influenced by the perspectives of their patients. Previous qualitative research has suggested that exercise therapy is perceived by patients as being the primary treatment strategy for physiotherapists and a preferred option for managing musculoskeletal pain (Bernhardsson, Larsson, Johansson, and Öberg, 2017). These findings reflect the wide range of influences on new-graduates’ perspective of exercise in managing musculoskeletal pain from both their pre-professional training and their direct clinical experiences.

Given the complex nature of chronic pain, approaches to management must be highly individualized (Calner, Isaksson, and Michaelson, 2021) and consider the multidimensional nature of pain for each individual (Meints and Edwards, 2018). Chesterton, Chesterton, and Alexanders (2023) revealed that while psychosocial factors may influence patient outcomes and adherence to exercise therapy, new-graduate physiotherapists report limited self-perceived competency, expressing a need for further training. Similarly, new-graduates within the current study conveyed feelings of under-preparedness for managing patients that were perceived to have complex factors contributing to their chronic pain. This was mostly attributed to a sense of insufficient practical exposure specific to the multidimensional nature of chronic pain during their pre-professional training. These findings are consistent with previous research which has suggested that physiotherapy students are often sheltered from assessing or managing patients with complex needs during clinical placements (Stoikov et al., 2022). As such, pre-professional training should aim to integrate learning experiences where students are exposed to challenging pain presentations, to better prepare for practice in this area. Research has demonstrated that students with exposure to pain neurophysiology education are more likely to make appropriate patient recommendations regarding the use of exercise (Colleary et al., 2017). Preprofessional training that integrates pain neurophysiology alongside experiential approaches to learning may therefore offer an avenue to prepare physiotherapy graduates more effectively for managing patients presenting with chronic or complex pain.

Our results suggest that new-graduates recognize that the effective use of exercise therapy in managing musculoskeletal pain encompasses a range of skills that require further development during their transition from student to clinician, highlighting the critical role of workplace learning and support. This echoes the findings from Forbes and Ingram (2019) where new-graduate physiotherapists reported seeking workplace assistance and further training in managing patients with chronic pain. Within our study, new-graduates similarly perceived mentoring and workplace support as integral in bridging the gap to successful clinical practice, especially in the area of communication skills to enhance patient engagement, and skills to individualize exercise therapy for better adherence. New-graduates within the current study reflected on building confidence and competence in using exercise therapy to manage musculoskeletal pain through mentorship and shadowing more senior colleagues, in line with findings of Black et al. (2010) where novice physiotherapists reported increased confidence following positive interactions with colleagues. This builds on previous research where new-graduate physiotherapists tend to have a preference for mentoring and support that is individualized and relates directly to their patient care (Lao, Wilesmith, and Forbes, 2022; Martin, Mandrusiak, Lu, and Forbes, 2021). Adequate workplace support and mentoring also plays a crucial role in improving retention of early career physiotherapists (Davies, Edgar, and Debenham, 2016). Considering the multiple challenges faced by new-graduate physiotherapists, our findings reiterate the role of workplace support in the transition into professional practice (Murray, Sundin, and Cope, 2018).

Considering the individualized nature of musculoskeletal pain (Cohen, Vase, and Hooten, 2021), our results suggest that new-graduates recognize the need to individualize exercise therapy to their patient’s goals and preferences. This is an important finding given that individualized approaches to exercise therapy are more effective in reducing pain and disability (Fleckenstein et al., 2022). In addition, new-graduates within the current study recognized the additional benefits of exercise therapy in moderating psychological factors (Booth et al., 2017) and supporting self-management (Hutting, Johnston, Staal, and Heerkens, 2019) in some patients, highlighting their consideration of exercise therapy for impairments beyond pain.

New-graduates within the current study also emphasized the importance of using individualized educational approaches alongside their use of exercise therapy. Meaningful and customized education can facilitate individuals to understand their condition (Daluiso-King and Hebron, 2022) and empower them toward effective self-management (Hoving, Visser, Mullen, and van den Borne, 2010). New-graduates reflected on using tailored education to target patient beliefs, with the goal to effectively engage the patient in exercise therapy and manage patient adherence to exercise, especially patients with severe or chronic pain. Further research should aim to explore the support needs of new-graduates in engaging individuals with musculoskeletal pain in long term management strategies such as tailored, formal exercise programming.

The findings from this study further support the value of experiential learning in pre-professional training to facilitate skills development and knowledge acquisition. Direct experiences, such as high-fidelity simulation and clinical placements, have been reported to be highly valued by new-graduates in their preparation for managing patients with pain (Forbes and Ingram, 2019). New-graduates within the current study similarly favored direct practice of clinical and communication skills with authentic approaches that replicate the demands of real clinical settings during their pre-professional training. Clinical placements that allow students to translate theoretical knowledge into practice are known to be highly beneficial in facilitating the transition into the profession (Stoikov et al., 2022) and previous research has emphasized the critical role of placements to support preparedness for the workplace from the perspective of new-graduates (Almond, Zou, and Forbes, 2021; Ingram, Forbes, and Jones, 2019). This previous research, together with the current findings, highlight the value of direct practical experiences in pre-professional training to better prepare new-graduate physiotherapists for using exercise therapy to manage individuals with musculoskeletal pain.

Implications

New-graduates within the current study advocated for training approaches that focus on a wide range of patient presentations, including both acute and chronic pain. An important implication from our study is that physiotherapy curricula should aim to maximize experiential learning opportunities targeted specifically at the use of exercise therapy in more complex and challenging clinical scenarios. In addition, new-graduates reported seeking informal support in the workplace, including observational opportunities and guidance from more experienced physiotherapists in delivering exercise therapy. These findings reinforce the importance of collaboration between new-graduates and their senior colleagues to engage in effective formal and informal mentoring and workplace support (Lao, Wilesmith, and Forbes, 2022; Martin, Mandrusiak, Lu, and Forbes, 2021). Further research should aim to investigate effective training approaches to enhance proficiency of new-graduates in delivering exercise therapy for patients with musculoskeletal pain.

Strengths and limitations

The use of semi-structured interviews allowed for open and authentic discussions to explore participants’ experiences. Limiting the number of participants to 16 allowed for detailed exploration of training needs and perceptions of new-graduates without compromising the quality and depth of the data collected (Smith, 2015). With consideration for the narrow aims of the study, the potential diversity of experiences among participants, and the robust discussion conducted during the interviews, the authors determined that adequate data was collected following 16 interviews (Malterud, Siersma, and Guassora, 2016; Varpio et al., 2017).

Several limitations must be considered. Participants with negative experiences during their pre-professional training might not have volunteered to participate in the study. Response bias might have impacted the results, as participants may have responded to questions by giving answers they deemed supportive. While de-identification was reassured prior to the interview, participants might not have disclosed negative experiences due to the potential sensitive nature around employment. The lead researcher had previous experience with the pre-professional training undertaken by some participants, leading to potential observer bias and reactivity, which may have influenced data interpretation. However, this was mitigated by ensuring the participants were not personally known to the interviewer and by carrying out a second independent analysis of the data.

Conclusion

New-graduate physiotherapists acknowledge the pivotal role of exercise in managing individuals with musculoskeletal pain. The results of this study support the use of direct learning experiences in pre-professional training to develop knowledge and skills required for delivering exercise therapy as a new-graduate. New-graduates also recognize pain management as a skill that requires further development and acknowledge the importance of opportunities for professional development in exercise therapy.

Acknowledgments

The authors would like to thank the physiotherapists who participated in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.