‘Seeing pain differently’: the impact of physiotherapists’ attitudes and treatment beliefs on postural assessment in neck pain – an eye-tracking study

Pérsia Nascimento Abrahão; Ney Meziat Filho; Erika Rodrigues; Talita Peixoto Pinto; Arthur de Sá Ferreira

doi:10.2478/advrehab-2026-0002

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‘Seeing pain differently’: the impact of physiotherapists’ attitudes and treatment beliefs on postural assessment in neck pain – an eye-tracking study

Advances in Rehabilitation

Volume 40 (2026): Issue 1 (March 2026)

By: Pérsia Nascimento Abrahão , Ney Meziat Filho , Erika Rodrigues , Talita Peixoto Pinto and Arthur de Sá Ferreira

Open Access

|Mar 2026

Figures & Tables

Experimental setup for data collection. Seated comfortably, physiotherapists were positioned 60 cm from the eye-tracking screen and instructed to position their face in a head support aligned with the monitor

Gaze plot in a schematic representation of a participant’s images for postural assessment in anterior, lateral and posterior (left, centre and right side of the screen) views. Notice the number of fixations and saccade events in each area of interest

Interaction plots for first- and third-order oculomotor metrics across Patient Group (asymptomatic vs. symptomatic) and Physiotherapist Group (biomedical [black] vs. biopsychosocial [grey]). Points show subject-level means; larger markers and 95% CIs show estimated marginal means from mixed-effects models

Interaction plots for fourth-order gaze-dynamics metrics across Patient Group (asymptomatic vs. symptomatic) and Physiotherapist Group (biomedical [black] vs. biopsychosocial [grey]). Panels display transition probabilities, mean first-passage times and recurrence times for ANT, LAT and POS views. Points represent subject means; larger markers and 95% CIs represent estimated marginal means from mixed-effects models. ANT - anterior, POS - posterior, LAT - lateral

Results of the linear mixed models for the main and interaction effects of patients’ and physiotherapists’ groups on forth-order eye-tracking output variables

Variable	Neck pain Biomedical	Neck pain Biopsychosocial	Asymptomatic Biomedical	Asymptomatic Biopsychosocial	Main effect ‘Patient group’	Main effect ‘Physiotherapist group’	Interaction effect
Transition matrix, probability
ANT-->ANT	0.90 (0.08)	0.90 (0.06)	0.90 (0.07)	0.90 (0.06)	0.00 (−0.01; 0.01)	−0.01 (−0.02; 0.00)	0.00 (−0.01; 0.02)
ANT-->LAT	0.08 (0.07)	0.08 (0.06)	0.08 (0.06)	0.09 (0.05)	0.00 (−0.01; 0.01)	0.01^a (0.00; 0.02)	0.00 (−0.01; 0.01)
ANT-->POS	0.02 (0.03)	0.02 (0.02)	0.02 (0.03)	0.02 (0.03)	0.00 (0.00; 0.00)	0.00 (0.00; 0.00)	0.00 (−0.01; 0.00)
LAT-->ANT	0.09 (0.07)	0.10 (0.07)	0.09 (0.07)	0.10 (0.07)	0.00 (−0.01; 0.01)	0.02^a (0.01; 0.02)	0.00 (−0.01; 0.01)
LAT-->LAT	0.81 (0.12)	0.78 (0.13)	0.81 (0.12)	0.78 (0.12)	0.00 (−0.02; 0.01)	−0.03^a (−0.05; −0.02)	0.01 (−0.02; 0.03)
LAT-->POS	0.11 (0.08)	0.11 (0.07)	0.10 (0.08)	0.12 (0.07)	0.00 (−0.01; 0.02)	0.02^a (0.01; 0.03)	−0.01 (−0.02; 0.01)
POS-->ANT	0.02 (0.03)	0.03 (0.04)	0.02 (0.03)	0.03 (0.04)	0.00 (0.00; 0.01)	0.01^a (0.01; 0.02)	0.00 (−0.01; 0.00)
POS-->LAT	0.07 (0.06)	0.08 (0.07)	0.07 (0.08)	0.08 (0.07)	−0.01 (−0.02; 0.00)	0.01^a (0.00; 0.02)	0.00 (−0.01; 0.01)
POS-->POS	0.90 (0.12)	0.88 (0.10)	0.90 (0.10)	0.88 (0.09)	0.00 (−0.02; 0.01)	−0.02^a (−0.04; −0.01)	0.01 (−0.01; 0.02)
Mean first time passage, events
ANT-->LAT	19.06 (12.81)	17.22 (12.05)	20.16 (15.47)	16.00 (10.14)	−1.10 (−2.91; 0.71)	−4.17^a (−5.82; −2.51)	2.32 (−0.02; 4.66)
ANT-->POS	37.68 (29.66)	31.09 (20.68)	38.81 (31.54)	30.49 (21.35)	−1.13 (−4.89; 2.64)	−8.32^a (−11.73; −4.92)	1.73 (−3.09; 6.54)
LAT-->ANT	35.10 (28.85)	25.73 (23.69)	34.23 (30.12)	24.24 (21.56)	0.87 (−2.56; 4.30)	−9.99^a (−13.42; −6.56)	0.62 (−4.23; 5.48)
LAT-->POS	24.79 (21.80)	20.52 (13.48)	26.15 (22.68)	20.26 (15.12)	−1.36 (−3.90; 1.19)	−5.89^a (−8.32; −3.45)	1.61 (−1.84; 5.06)
POS-->ANT	47.46 (38.13)	34.17 (32.05)	46.17 (39.29)	32.08 (28.88)	1.29 (−3.26; 5.84)	−14.09^a (−18.64; −9.54)	0.81 (−5.63; 7.24)
POS-->LAT	22.23 (17.37)	18.38 (15.06)	22.38 (19.46)	18.30 (15.24)	−0.15 (−2.45; 2.14)	−4.08^a (−6.28; −1.88)	0.23 (−2.88; 3.34)
Mean recurrence time, events
ANT	3.51 (2.26)	2.97 (1.32)	3.28 (1.52)	2.98 (1.30)	0.23^a (0.00; 0.46)	−0.30^a (−0.53; −0.08)	−0.23 (−0.55; 0.09)
LAT	4.24 (1.88)	4.13 (1.88)	4.16 (1.91)	4.17 (2.52)	0.07 (−0.22; 0.37)	0.01 (−0.27; 0.29)	−0.11 (−0.51; 0.29)
POS	2.69 (1.40)	2.95 (1.39)	2.85 (2.99)	3.07 (1.43)	−0.17 (−0.45; 0.12)	0.21 (−0.04; 0.46)	0.05 (−0.30; 0.41)

Descriptive statistics of the sample of physiotherapists, split by the main score on the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT)

Variables	Overall n = 30^a	Biomedical group n = 15^a	Biopsychosocial group n = 15^a	Cohen’s d [95%CI]	p-value^b
Age, years	38.2 (±11.4)	42.7 (±13.1)	33.7 (±7.3)	0.85 [0.09, 1.6]	0.029
Gender					>0.999
Women	20 (67%)	10 (67%)	10 (67%)
Men	10 (33%)	5 (33%)	5 (33%)
Professional training, years	7.8 (±8.8)	9.0 (±10.6)	6.5 (±6.5)	0.28 [0.45, 0.99]	0.457
Professional experience, years	6.8 (±7.5)	7.2 (±8.8)	6.3 (±6.4)	0.12 [−0.60, 0.83]	0.750
Workplace setting					0.492
Home/clinic	13 (43%)	7 (47%)	6 (40%)
Home	9 (30%)	6 (40%)	3 (20%)
Home/Ambulatory	4 (13%)	1 (7%)	3 (20%)
Hospital	3 (10%)	1 (7%)	2 (13%)
Clinic	1 (3%)	0 (0%)	1 (7%)
Glasses	5 (17%)	2 (13%)	3 (20%)		>0.999
PABS-PT, points
Biomedical subscore	27.9 (±7.2)	31.4 (±7.4)	24.5 (±5.2)	1.1 [0.31, 1.8]	^NT
Biopsychosocial subscore	21.2 (±5.6)	17.0 (±3.5)	25.3 (±4.0)	−2.2 [−3.1, −1.3]	^NT
PABS-PT,%
Biomedical subscore	69.8 (±18.0)	78.5 (±18.5)	61.2 (±12.9)	1.1 [0.31, 1.8]	^NT
Biopsychosocial subscore	66.1 (±17.5)	53.1 (±10.8)	79.2 (±12.5)	−2.2 [−3.1, −1.3]	^NT
Average error, ∘	0.3 (±0.1)	0.3 (±0.1)	0.3 (±0.1)	0.03 [−0.69, 0.74]	0.938
Maximum error, ∘	0.8 (±0.2)	0.8 (±0.2)	0.8 (±0.2)	0.04 [−0.67, 0.76]	0.905

Descriptive statistics of the sample of patients split by group with/without neck pain

Variables	Overall n = 60^a	Asymptomatic group n = 30^a	Neck pain group n = 30^a	Cohen’s d [95%CI]	p-value^b
Age, years	28.2 (±7.1)	27.1 (±7.0)	29.3 (±7.1)	−0.31 [−0.82, 0.20]	0.238
Gender					0.299
Women	50 (83%)	23 (77%)	27 (90%)
Men	10 (17%)	7 (23%)	3 (10%)
Neck pain intensity, mm	-	-	38.2 (±19.9)	-	^NT
Nordic Musculoskeletal Questionnaire, score					<0.001
Not applicable	26 (43%)	26 (87%)	0 (0%)
Acute	6 (10%)	4 (13%)	2 (7%)
Chronic	28 (47%)	0 (0%)	28 (93%)
Örebro Musculoskeletal Pain Questionnaire, score	32.2 (±19.0)	16.9 (±10.7)	47.6 (±11.4)	−2.8 [−3.5, −2.1]	<0.001
Örebro Musculoskeletal Pain Questionnaire, risk					<0.001
Low risk	46 (77%)	30 (100%)	16 (53%)
High risk	14 (23%)	0 (0%)	14 (47%)
Neck disability index, score	12.8 (±10.8)	4.1 (±4.1)	21.6 (±7.8)	−2.8 [−3.5, −2.1]	<0.001
Neck disability index, classification					<0.001
Nodisability	27 (45%)	26 (87%)	1 (3%)
Mild disability	27 (45%)	4 (13%)	23 (77%)
Moderate disability	6 (10%)	0 (0%)	6 (20%)

Results of the linear mixed models for the main and interaction effects of patients’ and physiotherapists’ groups on third-order eye-tracking output variables

Variable	Neck pain Biomedical	Neck pain Biopsychosocial	Asymptomatic Biomedical	Asymptomatic Biopsychosocial	Main effect ‘Patient group’	Main effect ‘Physiotherapist group’	Interaction effect
Fixation count, n
Anterior	43.26 (14.22)	43.92 (12.75)	43.12 (13.97)	43.64 (12.58)	0.13 (−1.70; 1.96)	0.51 (−1.23; 2.26)	0.15 (−2.32; 2.62)
Lateral	35.20 (12.07)	33.09 (11.45)	35.46 (12.16)	33.18 (11.13)	−0.26 (−2.04; 1.51)	−2.29^a (−3.80; −0.78)	0.18 (−1.96; 2.32)
Posterior	44.35 (15.44)	37.42 (12.89)	43.32 (13.53)	37.48 (12.94)	1.03 (−0.95; 3.01)	−5.84^a (−7.62; −4.06)	−1.09 (−3.61; 1.43)
Average fixation duration, seconds
Anterior	0.31 (0.07)	0.33 (0.09)	0.31 (0.07)	0.33 (0.08)	0.00 (−0.01; 0.01)	0.02^a (0.01; 0.03)	0.00 (−0.01; 0.01)
Lateral	0.30 (0.08)	0.33 (0.11)	0.30 (0.08)	0.33 (0.12)	0.00 (−0.01; 0.01)	0.04^a (0.02; 0.05)	0.00 (−0.02; 0.02)
Posterior	0.34 (0.08)	0.38 (0.15)	0.34 (0.08)	0.39 (0.15)	0.00 (−0.02; 0.01)	0.04^a (0.03; 0.06)	0.00 (−0.03; 0.02)
Saccade count, n
Anterior	53.11 (15.19)	54.43 (14.53)	52.91 (15.12)	54.66 (14.64)	0.20 (−1.74; 2.14)	1.75 (−0.19; 3.69)	−0.43 (−3.17; 2.32)
Lateral	43.21 (13.89)	41.92 (13.09)	43.44 (13.50)	42.38 (13.14)	−0.24 (−2.18; 1.71)	−1.07 (−2.81; 0.67)	−0.22 (−2.68; 2.23)
Posterior	54.47 (16.14)	48.36 (14.86)	53.34 (14.40)	48.82 (14.42)	1.14 (−0.91; 3.18)	−4.51^a (−6.46; −2.56)	−1.60 (−4.36; 1.15)

Results of the linear mixed models for the main and interaction effects of patients’ and physiotherapists’ groups on first-order eye-tracking output variables

Variable	Neck pain Biomedical	Neck pain Biopsychosocial	Asymptomatic Biomedical	Asymptomatic Biopsychosocial	Main effect ‘Patient group’	Main effect ‘Physiotherapist group’	Interaction effect
Eye blinks, n	14.29 (10.75)	14.89 (12.15)	14.19 (9.98)	14.75 (11.87)	0.10 (−1.53; 1.74)	0.56 (−0.89; 2.01)	0.04 (−2.02; 2.09)
Blinks, total (seconds)	2.22 (2.71)	2.36 (3.01)	2.26 (2.78)	2.27 (2.85)	−0.03 (−0.45; 0.38)	0.01 (−0.36; 0.38)	0.13 (−0.39; 0.65)

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Articles in this issue

DOI: https://doi.org/10.2478/advrehab-2026-0002 | Journal eISSN: 1734-4948

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Language: English

Page range: 16 - 35

Submitted on: May 5, 2025

Accepted on: Dec 3, 2025

Published on: Mar 31, 2026

Published by: University of Physical Education in Warsaw

In partnership with: Paradigm Publishing Services

Publication frequency: 4 issues per year

Keywords:

biopsychosocial models,

eye-tracking technology,

Related subjects:

Physical and rehabilitation medicine,

Rheumatology,

Cardiology,

Sports and recreation,

Sports and recreation, other

© 2026 Pérsia Nascimento Abrahão et al., published by Józef Piłsudski University of Physical Education in Warsaw
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Volume 40 (2026): Issue 1 (March 2026)

‘Seeing pain differently’: the impact of physiotherapists’ attitudes and treatment beliefs on postural assessment in neck pain – an eye-tracking study

Figures & Tables

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Results of the linear mixed models for the main and interaction effects of patients’ and physiotherapists’ groups on forth-order eye-tracking output variables

Descriptive statistics of the sample of physiotherapists, split by the main score on the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT)

Descriptive statistics of the sample of patients split by group with/without neck pain

Results of the linear mixed models for the main and interaction effects of patients’ and physiotherapists’ groups on third-order eye-tracking output variables

Results of the linear mixed models for the main and interaction effects of patients’ and physiotherapists’ groups on first-order eye-tracking output variables

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