Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain

The perceptions and knowledge of prognosis of physiotherapists in musculoskeletal practice: An exploratory qualitative study

QUESTION(S)

What are the perceptions and knowledge of physiotherapists who treat musculoskeletal disorders towards prognosis?

DESIGN

Exploratory phenomenological study.

PARTICIPANTS

15 physiotherapists involved in the treatment of musculoskeletal disorders.

DATA ANALYSIS

Data were collected through semi-structured interviews and analysed using inductive coding and thematic analysis.

RESULTS

Four themes were identified. First, participants perception of prognosis was influenced by how they defined prognosis. Participants often perceived that prognosis was the timeline to recovery related to function, tissue health, or pain. Second, some participants could not recall foundational knowledge about prognosis being taught during their entry-level physiotherapy program. Others recalled it being taught in relation to the tissue healing model. Third, participants described learning about prognosis through experience, professional development, or from peers. Finally, participants identified that a potential learning opportunity is to conceptualise prognosis as separate outcomes associated with function, tissue health, and pain. Each can impact upon prognosis, have a prognosis of their own, and can occur simultaneously.

CONCLUSION

How physiotherapists perceive and understand the concept of prognosis is influenced by their foundational knowledge. It appears for physiotherapists, prognosis may be conceptualised within the biomedical model of health. Indeed, physiotherapists may perceive that prognosis is the timeline for recovery determined by the tissue model of healing. Physiotherapists also rely on experiential knowledge gained from clinical practice, professional development, and their peers to enhance learning about prognosis. The understanding of prognosis may be enhanced if physiotherapists conceptualise prognosis in terms of the multifactorial outcomes associated with function, tissue health, and pain.

Will my shoulder pain get better? - secondary analysis of data from a multi-arm randomised controlled trial

OBJECTIVE

To determine whether higher level or improvements over time in pain self-efficacy (PSE) and expectations of intervention effectiveness lead to better outcomes and whether the intervention used to manage rotator cuff related shoulder pain (RCRSP) impacts PSE and expectations over time.

DESIGN

Secondary analysis of data from a randomised controlled trial.

PARTICIPANTS

123 individuals (48 [15] years old; 51% female) with RCRSP.

INTERVENTIONS

Participants randomised into one of three 12-weeks interventions (education; education and motor control exercises; education and strengthening exercises).

MAIN OUTCOME MEASURES

QuickDASH and Western Ontario Rotator Cuff Index (WORC) were administered at baseline and 12 weeks. Pain self-efficacy was assessed at 0 and 6 weeks. Patients' expectations regarding intervention effectiveness were assessed before randomisation and after the first and the last intervention sessions. NparLD were used for the analyses. A time effect indicated a significant change in patients' expectations or PSE over time, while a resolution effect indicated a significant difference in patients' expectations or PSE between those whose symptoms resolved and those whose did not.

RESULTS

Patients' expectations (-3 to 3) increased over time (0.33/3 [0.19 to 0.77]). Overall expectations were higher for those who experienced symptom resolution based on the WORC (0.19/3 [0.05 to 0.33]). PSE increased over time (5.5/60 [3.6 to 7.4]). Overall PSE was higher for those who experienced symptom resolution based on the WORC (7.0 [3.9 to 10.1]) and the QuickDASH (4.9 [1.7 to 8.2]).

CONCLUSION

Clinicians should consider monitoring PSE and patients' expectations as they are important indicators of outcome. CONTRIBUTION OF THE PAPER.

Clinimetric Properties of the Working Alliance Inventory and Credibility Expectancy Questionnaire: Screening Options for Musculoskeletal Pain

OBJECTIVE

To investigate clinimetric properties of 2 surveys used to evaluate common factors in the patient-provider relation and present screener options for the assessment of common factors and report their correlation with pain and functional outcomes.

DESIGN

Observational cohort.

SETTING

Outpatient physical therapy.

PARTICIPANTS

100 individuals (58% women, mean age=34, SD=15; N=100) presenting to physical therapy with musculoskeletal pain in the following regions: 44% lower extremity, 36% spine, 19% upper extremity, 1% undetermined.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Participants completed the Working Alliance Inventory (WAI) and the Credibility and Expectancy Questionnaire (CEQ). Exploratory factor analysis (EFA) explored factor structure of the WAI and CEQ. Internal consistency was evaluated for scales derived from items retained based on factor loadings. Finally, options for screener tools were proposed and assessed based on their correlation to original surveys as well as pain and functional outcomes.

RESULTS

The data supported a 4-factor structure for the surveys. Some WAI items were excluded due to cross-loading. The derived four-factor scales demonstrated strong correlations with the original surveys (r=.89-.99) and exhibited good internal consistency (α=.824-.875). Two screening options were suggested: 1 retaining 11 of the original 18 items and the other comprising just 3 items. Both screening tools correlated with the original surveys and showed associations with improvements in pain and functional outcomes (r=-.21-.34).

CONCLUSION

The proposed screeners provide concise measurement options to facilitate use in clinical practice. These tools can aid in facilitating patient communication specifically addressing patient expectation and understanding the tasks required to enact behavior change.

Evaluation of the Structural and Construct Validity of the Credibility and Expectancy Scale for Patients With Musculoskeletal Disorders

Background The Credibility Expectancy Questionnaire (CEQ) includes three items each on the credibility and expectancy subscales. Credibility indicates to what extent the treatment is reasonable, and expectancy indicates to what extent the treatment is expected to be effective. The CEQ has been assumed to have a two-factor structure: credibility and expectancy, among patients receiving psychotherapy. However, its internal structure has been unknown to patients receiving physical therapy for musculoskeletal disorders. This study aimed to explore the internal structure of the CEQ and preliminary investigate the construct validity of the CEQ among patients receiving physical therapy for musculoskeletal disorders. Methodology A multi-center prospective cohort study was conducted. Data from 100 patients receiving outpatient physical therapy for musculoskeletal disorders was collected using an anonymous paper-based survey. The initial survey was conducted immediately before the initial physical therapy session, and the second survey was conducted after the third to seventh physical therapy sessions. The Patient Specific Functional Scale 2.0 (PSFS 2.0) was collected in both surveys, and the CEQ and an 11-point global rating of change scale (GRCS) were collected in the second survey. Exploratory factor analysis was conducted for the CEQ, and internal consistency was assessed for each subscale and an identified factor structure. Convergent validity in construct validity was also assessed with the hypothesis that Pearson's r values of each CEQ factor score to the PSFS 2.0 change scores and GRCS would range from 0.4 to 0.6. Results An exploratory factor analysis revealed a one-factor structure, where the percentage of the variance for the extraction sums of squared loadings was 62.8%. Cronbach's alpha was 0.89 for all items, 0.91 for the credibility subscale, and 0.75 for the expectancy subscale. Hypothesized correlations to the PSFS 2.0 change score and GRCS were detected with the CEQ total score (r = 0.48 for the PSFS 2.0 change score and r = 0.59 for the GRCS) and each subscale score (credibility subscale, r = 0.48 for the PSFS 2.0 change score and r = 0.49 for the GRCS; and expectancy subscale, r = 0.43 for the PSFS 2.0 change score and r = 0.62 for the GRCS). Conclusion A single-factor internal structure of the CEQ was detected among patients receiving physical therapy for musculoskeletal disorders. Additionally, preliminary evidence of construct validity was detected with convergent validity between the CEQ and functional and perceived improvement.

Turkish cross-cultural adaptation, construct validity, and reliability of the treatment expectations in chronic pain scale

BACKGROUND

Measuring treatment expectations using the Treatment Expectations in Chronic Pain (TEC) scale has the potential to help clinicians and researchers better understand the role that treatment expectations play within the framework of multimodal pain management settings.

OBJECTIVE

The purpose of this study is to determine the cross-cultural adaptation, construct validity and reliability of the TEC Scale in the Turkish language.

METHODS

The study included 191 volunteers aged 22-65 with chronic musculoskeletal diseases. This study composed of a six-stage cross-cultural adaptation process, which included translation, translation synthesis, back-translation, expert committee review, pre-testing and documentation submission. The Positivity Scale and Illness Cognition Questionnaire were used to measure convergent validity while the Hospital Anxiety and Depression Scale was used to test divergent validity. The psychometric properties of the Turkish version of the TEC scale was examined by confirmatory factor analysis (CFA). Scale's internal consistency was examined using Cronbach's alpha. Pearson correlation coefficients were utilized to evaluate both convergent and divergent validity. The significance level was set at p < .05.

RESULTS

The results of the CFA showed that factor structure of predicted subscale fitted well the data (x2/df = 3,07;CFI = 0,91,IFI = 0,91 TLI = 0,87,RMSEA = 0,10). The results of the CFA indicated that factor structure of ideal subscale fitted well with the data (x2/df = 2,38;CFI = 0,92,IFI = 0,93,TLI = 0,90,RMSEA = 0,08). Both subscales of the TEC were strongly correlated. The predicted subscale had moderate relationships to depression, anxiety, and positivity (r = -0.37 to r = 0.55) but poor correlations with measures of acceptance, perceived benefits and helplessness (r = -0.24 to 0.35). The ideal subscale had moderate correlations with measures of positivity (r = 0.36) and depression (r = -0.38) but poor correlations with measures of acceptance, perceived benefits helplessness and anxiety (r = 0.14).

CONCLUSIONS

The Turkish version of the TEC scale is acceptable, valid, and reliable for use in Turkish patients with chronic musculoskeletal pain in physiotherapy outpatient practice.

Acceptability of multimodal and multidisciplinary group-based program for chronic low back pain: a qualitative study

BACKGROUND

The Programa d'Atenció Integral pels Pacients amb Dolor Crònic (PAINDOC) is a multimodal and multidisciplinary group-based program that integrates pain neuroscience education, mindfulness meditation, pain psychotherapy, Empowered Relief, and therapeutic exercise. It serves as a therapeutic option for individuals with chronic low back pain, providing them with comprehensive adaptive strategies for pain management.

OBJECTIVE

This qualitative study explores participants' retrospective acceptability of the PAINDOC Program.

METHODS

To ensure demographic variability and information power, a purposive sampling approach was applied. Twelve participants were interviewed through three focus groups, supplemented with four individual semi-structured interviews. Data was analyzed using reflexive thematic analysis and evaluated based on the Therapeutic Framework of Acceptability.

RESULTS

Participants provide positive feedback regarding active pain coping strategies and improved self-management. While certain aspects of the Program were more emphasized, participants integrated tools from all components. Strategies included pain reconceptualization, positive self-talk, or problem-solving. The Program's ethicality was closely linked to individual values and may also be influenced by time constraints of certain program elements, the immediate effects of specific approaches, participant perceptions, and individual preferences.

CONCLUSIONS

The findings provide valuable insights into the acceptability of the PAINDOC Program, guiding future improvements and the development of similar interventions.

Will you get what you want? Treatment goals and expectations of patients with femoroacetabular impingement syndrome regarding physiotherapist-led treatment

OBJECTIVE: To (i) investigate the goals and expectations of participants enrolled in a clinical trial of physiotherapist-led treatment for femoroacetabular impingement (FAI) syndrome and (ii) explore associations between their expectations and self-reported hip burden and kinesiophobia. METHODS: Data from 150 participants with FAI syndrome who participated in a clinical trial were analysed. Participants described their most important treatment goal and the expectation of achieving this goal throughout physiotherapy treatment. The International Hip Outcome Tool (iHOT-33) subscales were used to assess self-reported hip burden. The Tampa Scale for Kinesiophobia was used to assess kinesiophobia. Participants goals were qualitatively analysed using content analysis. Linear regression was used to explore associations between patient expectations and iHOT and Tampa Scale for Kinesiophobia scores. RESULTS: Participants with FAI syndrome reported goals relating to exercise (52%), improving activities of daily living quality (23%), improving physical function (15%), and reducing pain (10%). Negative expectations regarding physiotherapist-led treatment were reported by 68% of participants. Those with negative expectations reported worse scores for the iHOT-Total score (mean difference = 12 points, 95%CI = [4 to 19]), and iHOT-Symptoms (14 points, [7 to 21]) and iHOT-Social (11 points, [2 to 21]) subscales compared to those with positive expectations. Treatment expectations were not associated with iHOT-Sport, iHOT-Job, and Tampa Scale for Kinesiophobia scores (p > 0.05). CONCLUSION: Patients with FAI syndrome had a generally negative expectation of physiotherapist-led treatment. There was a mismatch between patients' goals and current treatment approaches. Participants with FAI syndrome and negative expectations reported worse quality of life, symptoms, and social concerns than those with positive expectations.

Patients' expectations surrounding revision total hip arthroplasty: a literature review

BACKGROUND

Revision total hip arthroplasties (RTHA) are associated with a higher complication rate than primary total hip arthroplasties (THA), and therefore it is important for patients to have realistic expectations regarding outcomes. The aim of this literature review was to gather and summarize the available evidence on patients' expectations following RTHA.

METHODS

A literature search was conducted in PubMed, PsycINFO, Cochrane, Google Scholar, Web of Science and Embase from inception to November 2023. Articles assessing patient expectations for RTHA were included. Methodological quality was assessed by two independent reviewers using the National Heart, Lung and Blood Institute (NIH) study quality assessment tool for observational cohort and cross-sectional studies. A qualitative analysis was performed involving the summarization of study characteristics and outcomes.

RESULTS

The search strategy generated 7,450 references, of which 5 articles met the inclusion criteria. Methodological quality scores ranged from 7-10. Patients had high expectations concerning future walking ability, pain and implant longevity relative to actual postoperative outcomes. A significant positive correlation was found between fulfilled expectations of pain and walking ability and patient satisfaction (r = 0.46-0.47). Only two studies assessed the fulfillment of patient expectations. Great variability was seen in the measurement of expectations.

CONCLUSION

Patients undergoing RTHA appeared to have high expectations for pain and functionality compared to postoperative outcomes. However, there was a paucity of high-quality data in this area, limiting the accuracy of the conclusion. Further research is needed, that emphasizes developing a sound theoretical framework for expectations, allowing for the consistent implementation of valid measurement tools for patient expectations.

Life-long music and dance relationships inform impressions of music- and dance-based movement therapies in individuals with and without mild cognitive impairment

Background

No effective therapies exist to prevent degeneration from Mild Cognitive Impairment (MCI) to Alzheimer's disease. Therapies integrating music and/or dance are promising as effective, non-pharmacological options to mitigate cognitive decline.

Objective

To deepen our understanding of individuals' relationships (i.e., histories, experiences and attitudes) with music and dance that are not often incorporated into music- and dance-based therapeutic design, yet may affect therapeutic outcomes.

Methods

Eleven older adults with MCI and five of their care partners/ spouses participated (4M/12F; Black: n=4, White: n=10, Hispanic/ Latino: n=2; Age: 71.4±9.6). We conducted focus groups and administered questionnaires that captured aspects of participants' music and dance relationships. We extracted emergent themes from four major topics, including: (1) experience and history, (2) enjoyment and preferences, (3) confidence and barriers, and (4) impressions of music and dance as therapeutic tools.

Results

Thematic analysis revealed participants' positive impressions of music and dance as potential therapeutic tools, citing perceived neuropsychological, emotional, and physical benefits. Participants viewed music and dance as integral to their lives, histories, and identities within a culture, family, and/ or community. Participants also identified lifelong engagement barriers that, in conjunction with negative feedback, instilled persistent low self-efficacy regarding dancing and active music engagement. Questionnaires verified individuals' moderately-strong music and dance relationships, strongest in passive forms of music engagement (e.g., listening).

Conclusions

Our findings support that individuals' music and dance relationships and the associated perceptions toward music and dance therapy may be valuable considerations in enhancing therapy efficacy, participant engagement and satisfaction for individuals with MCI.

Patients' expectations of physiotherapists before and after an intensive chronic low back pain rehabilitation programme: a qualitative study based on semi-structured interviews and observations

PURPOSE

To investigate the expectations regarding physiotherapists of patients attending an interdisciplinary CLBP rehabilitation programme and the response to these expectations.

MATERIALS AND METHODS

A thematic analysis was conducted, based on interviews of working-age patients with CLBP and without significant comorbidities.

RESULTS

Twenty patients participated (9 male, 11 female, aged 21-58 years; symptoms duration 4.3 ± 3.0 years; pain VAS 53 ± 21 mm). Patients expected to learn pain and activity management. Expected outcomes were a reduction of pain, increased well-being and a return to normality. A collaborative approach involving therapeutic and relational adaptation was expected. Despite divergences concerning emotional aspects, patients expected a large range of applied psychosocial skills.The programme met the expectations of most patients, especially when its goals matched those reported by the individuals. For most participants, the pain relief was below expectations. Active therapies were valued. After the programme, patients felt more ready to take responsibility for their back.

CONCLUSION

The expectation of developing self-management skills was prevalent. Expected treatments were mostly compatible with recommendations. Expectations to resume activities and decrease pain were in line with the rehabilitation goals, although the expected reduction in pain was overestimated. Relational expectations converged towards patient-centred care.

Health-related quality of life following trauma: Prevalence of problems and factors associated with six-month outcomes in a New Zealand cohort

Injury is a leading cause of health loss in Aotearoa me Te Waipounamu (New Zealand; NZ). The NZ Trauma Registry was established in 2015 to monitor outcomes in those experiencing severe injury and to identify ways of improving the quality of care for these patients. Few NZ studies have assessed outcomes in trauma patients using patient-reported outcome measures (PROMs) despite increasing recognition that the impacts of injury are better understood through PROMs. Our aim was to estimate the prevalence of self-reported problems with health-related quality of life (HRQoL) outcomes six months post-injury, and identify factors associated with these, in a cohort of Māori (the Indigenous population of NZ) and non-Māori individuals who had experienced major trauma. HRQoL outcomes were measured according to the five dimensions of the EQ-5D-5L. This information, along with sociodemographic data, was collected via structured telephone interviews. Participants (n = 870), aged 16 years or more, were recruited following admission to a trauma hospital in one of three (of NZ's four) trauma regions. Multivariable models were developed using modified Poisson Regression to identify factors associated with outcomes for both Māori and non-Māori patients. The prevalence and severity of problems across each of the five EQ-5D-5L dimensions was similar for Māori and non-Māori except for Anxiety/Depression. The prevalence and severity of problems with Anxiety/Depression was greater for Māori. Factors associated with HRQoL problems at six-months were also largely similar for each cohort. Those commonly associated with outcomes were age, hospital length of stay, adequacy of household income, and participants' expectations regarding recovery from injury. Further research examining recovery expectations in trauma patients to determine which factors contribute to formulating recovery expectations, and the potential impact of recovery expectations on treatment and rehabilitation, would be of value. Should expectations, at least in part, influence HRQoL outcomes, then routinely collecting data on patients' recovery expectations, adequacy of household income and potential barriers to treatment and rehabilitation, could help inform post-hospital treatment plans, and identify those who may require additional support following discharge from hospital.

"I Feel Like I Have Lost Part Of My Identity" - A Qualitative Study Exploring The Impact Of Chronic Ankle Instability

Introduction

Lateral ankle sprain is the most common ankle injury and up to 40% of those who sustain a lateral ankle sprain will develop chronic ankle instability (CAI). The aim of this study was to explore the thoughts and expectations of CAI-patients concerning their condition and expectations of care in an orthopedic setting. .

Study Design

Qualitative study.

Methods

Nine semi-structured one-to-one interviews were conducted with CAI-patients who were referred to an orthopedic setting. Interviews were recorded, transcribed, and analyzed using systematic text condensation with an inductive goal free approach. .

Results

Seven themes emerged. The themes were Injury history and symptoms (Lateral ankle sprain during sport, pain and instability), Information from health professional (conflicting information about management and prognosis), Management (mental and physical challenges), Expectation and hope (explanation of symptoms, prognosis and imaging to provide clarification of condition), Activity and participation (restriction in sport and daily life and feelings of uncertainty), Support (support from family/friends) and Identity (low ability to participate in sport and social life result in loss of identity). .

Conclusion

The impact of CAI exceeds an experience of pain and instability. Patients experienced loss of identity, having to manage uncertainty regarding their diagnosis and prognosis and had hopes of being able to explain their condition. .

Level of Evidence

Not applicable.

Collaborative care model versus usual care for the management of musculoskeletal and co-existing mental health conditions: a randomised feasibility mixed-methods study

OBJECTIVE

This study aimed to assess the feasibility of a future trial comparing the collaborative care model with usual care for patients with musculoskeletal conditions and co-existing symptoms of anxiety and depression.

DESIGN

A single-centre, parallel-arm, one-to-one, randomised controlled trial design using a mixed-methods approach was used. semistructured interviews and focus groups were conducted post intervention with all participants and staff respectively to explore acceptability towards the model and identify recommendations for improvements.

SETTING

An orthopaedic rehabilitation outpatient tertiary hospital.

PARTICIPANTS

Adult patients with musculoskeletal conditions and co-existing moderate or severe symptoms of anxiety and depression attending outpatient therapy appointments.

INTERVENTION

The collaborative care model consisted of a tailored management programme to facilitate the integration of care provided by physical and mental healthcare professionals. A case manager screened and coordinated targeted mental health support for participants. Participants allocated to usual care had no support from the case manager.

MAIN OUTCOMES MEASURE

Feasibility indicators (rates of recruitment, randomisation and retention), acceptability of clinical outcome measures, usage of additional resources and cost of intervention implementation.

RESULTS

Of the 89 patients who provided consent to take part, 40 participants who matched the eligibility criteria were randomised to either the intervention (n=20) or usual care arm (n=20). Overall adherence to the intervention was 58.82%, while the withdrawal rate was 37.5% at 6 months. All of the 27 participants who were retained completed self-reported outcomes. Qualitative data highlighted that integrated mental health support was favourably perceived. In addition to prenegotiating protected psychology time, the need for operationalised communication between the case manager and clinicians was identified as a recommendation for a future trial.

CONCLUSIONS

The trial and intervention were acceptable to patients and healthcare professionals. While the findings demonstrate the feasibility of trial recruitment, a future trial will require optimised retention strategies to improve adherence and withdrawal rates.

TRIAL REGISTRATION NUMBER

NCT05018039.

Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review

OBJECTIVE

To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy.

METHODS

We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized.

RESULTS

Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient's understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls.

CONCLUSION

Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain.

STUDY REGISTRATION

Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

Understanding the Postpartum Cesarean Pain Experience Among Individuals With Publicly Funded Insurance: A Qualitative Investigation

INTRODUCTION

Pain is the most common postpartum concern and has been associated with adverse outcomes, such as difficulty with neonatal bonding, postpartum depression, and persistent pain. Furthermore, racial and ethnic disparities in the management of postpartum pain are well described. Despite this, less is known regarding patients' lived experiences regrading postpartum pain. The purpose of this study was to assess patient experiences related to postpartum pain management after cesarean birth.

METHODS

This is a prospective qualitative study of patients' experiences with postpartum pain management after cesarean birth at a single large tertiary care center. Individuals were eligible if they had publicly funded prenatal care, were English or Spanish speaking, and underwent a cesarean birth. Purposive sampling was used to ensure a racially and ethnically diverse cohort. Participants underwent in-depth interviews using a semistructured interview guide at 2 time points: postpartum day 2 to 3 and 2 to 4 weeks after discharge. Interviews addressed perceptions and experiences of postpartum pain management and recovery. Data were analyzed using the constant comparative method.

RESULTS

Of 49 participants, 40.8% identified as non-Hispanic Black and 40.8% as Hispanic. The majority (59.2%) had experienced a cesarean birth with a prior pregnancy. Thematic analysis yielded 2 overarching domains: (1) experience of pain after cesarean birth and (2) pain management and opioid use after cesarean birth. Themes related to the experience of pain included pain as a meaningful experience, pain not aligned with expectations, and limitations caused by pain. All participants discussed limitations caused by their pain, voicing frustration with pursuing activities of daily living, caring for home and family, caring for neonate, and impact on mood. Themes related to pain management and opioid use addressed a desire for nonpharmacologic pain management, positive and negative experiences using opioids, and hesitancy and perceived judgement regarding opioid use. Several participants described experiences of judgement regarding the request for opioids and needing stronger pain medications, such as oxycodone.

DISCUSSION

Understanding experiences regarding postpartum cesarean pain management and recovery is essential to improving patient-centered care. The experiences identified by this analysis highlight the need for individualized postpartum pain management, improved expectation counseling, and the expansion of multimodal pain management options.

Development of a Multimodal, Personalized Intervention of Virtual Reality Integrated Within Physiotherapy for Patients With Complex Chronic Low-Back Pain

Background

Chronic low-back pain (CLBP) is the leading cause of years lived with disability. Physiotherapy is the most common treatment option for CLBP, but effects are often unsatisfactory. Virtual reality (VR) offers possibilities to enhance the effectiveness of physiotherapy treatment. Primary aim was to develop and test a personalized VR intervention integrated within a physiotherapy treatment for patients with CLBP.

Methods

This study describes an intervention development process using mixed methods design that followed the Medical Research Council (MRC) framework. This involved a cocreation process with patients, physiotherapists, and researchers. A draft intervention was constructed based on a literature review and focus groups, and subsequently tested in a feasibility study and evaluated in focus groups. Focus group data were analyzed using thematic analysis. This intervention development process resulted in a final intervention.

Results

Focus group data showed that VR and physiotherapy can strengthen each other when they are well integrated, and that VR needs to be administered under the right conditions including flawless technology, physiotherapists with sufficient affinity and training, and the right expectations from patients. The draft intervention was considered feasible after evaluation by four patients and three physiotherapists and was further complemented by expanding the training for physiotherapists and improving the protocols for physiotherapists and patients. The final intervention consisted of a 12-week physiotherapy treatment with three integrated VR modules: pain education, physical exercise, and relaxation.

Conclusion

Using the MRC framework in cocreation with the end users, a personalized VR intervention integrated within a physiotherapy treatment for patients with CLBP was developed. This intervention was found to be feasible and will subsequently be evaluated for (cost-)effectiveness in a cluster randomized controlled trial.

Endorsing a Biopsychosocial Perspective of Pain in Individuals With Chronic Pain: Development and Validation of a Scale

OBJECTIVES

Patients' beliefs about pain play an important role in their readiness to engage with chronic pain self-management. The central aim of this study was to validate a self-report instrument to assess a specific set of pain beliefs, patients' endorsement of a biopsychosocial model of chronic pain Patients' Endorsement of a Biopsychosocial Model of Chronic Pain Scale (PEB).

METHODS

Interdisciplinary experts in the field of pain were involved in creating an instrument, the PEB Scale, to operationalize patients' endorsement of a biopsychosocial pain model. A sample of 199 patients with chronic pain was recruited to evaluate the factorial structure (principal axis factoring), the internal consistency (Cronbach alpha), the convergent and discriminant validity (correlational analyses), incremental validity (multiple, hierarchical regression analyses), and construct validity (differential population analysis) of the instrument.

RESULTS

The factor analysis resulted in a unidimensional, 11-item instrument that explained 51.2% of the total variance. Cronbach alpha (=0.92) indicated high internal consistency of the created set of pain-related beliefs. Regression analyses demonstrated that PEB is a strong predictor of patients' engagement with pain self-management ( P < 0.001) after controlling for demographic variables, anxiety, depression, and other pain-related beliefs.

DISCUSSION

Our results show that the PEB Scale is a highly reliable self-report instrument that has the potential to predict patients' readiness to adopt pain self-management. Future research should focus on revalidating the scale to operationalize PEB. Moreover, the PEB Scale should be implemented in longitudinal study designs to investigate its ability to predict the transition from acute to chronic pain and patients' long-term pain management.

Factors associated with satisfaction with physical therapy services - a survey of patients with musculoskeletal pain at a federally qualified health center

PURPOSE

The objective of this cross-sectional survey-based study was to assess factors associated with patient satisfaction with physical therapy (PT) services received at a Federally Qualified Health Center (FQHC) in the United States (US) located near the US-Mexico border.

METHODS

Patients > 18 years of age, English or Spanish speakers, referred to PT were invited to complete an online survey. Factors that may influence PT satisfaction were examined for patients who attended PT. Variables associated with PT satisfaction from bivariate analyses (p < .15) were included in three separate ordinal logistic regression models.

RESULTS

Patients (N = 231) who reported more confidence that PT could help relieve their pain were more likely to have higher levels of satisfaction with PT communication, treatment, and outcomes than those who reported low confidence (p < .05). Patients who reported having more support from family and friends were more likely to have higher levels of satisfaction with PT communication and treatment than those with less support (p < .01). Patients with occasional or frequent pain after ending PT treatment were more likely to have lower satisfaction with PT outcomes than those reporting no pain (p < .05).

CONCLUSIONS

Findings suggest that addressing confidence in PT and promoting health support from family and friends may be important for satisfaction with PT. Additionally, PTs may consider addressing gaps between expected and achieved outcomes to improve PT satisfaction.

The experiences and preferences of individuals living with a musculoskeletal disorder regarding prognosis: A qualitative study

QUESTION(S)

What are the experiences and preferences of individuals living with a musculoskeletal disorder regarding prognosis?

DESIGN

Exploratory phenomenological study.

PARTICIPANTS

Individuals aged 18-year or older currently experiencing a musculoskeletal disorder and receiving treatment from a physiotherapist.

DATA ANALYSIS

Data were collected through semi-structured interviews and analysed using inductive coding and thematic analysis.

RESULTS

Five themes were identified. First, participants described seeking a cause for their pain. This influenced their experience of prognosis as they perceived a diagnosis was required to inform their prognosis. Second, whilst participants wished to receive a prognosis from their physiotherapist, this was often not their experience. Third, participants perceived that physiotherapists have the potential to impact prognosis through exercise prescription, management of conditions, and improving function. Fourth, receiving a prognosis can have both a positive and negative impact on the individual. Positive impacts include planning for the future, motivation, knowledge acquisition, and instilling hope. However, receiving a prognosis can be disheartening if a patient's expectations are unmet. Finally, participants have several preferences regarding receiving a prognosis including when and how often the prognosis is discussed, what prognostic information is provided, how the prognosis is presented, and what prognosis based on.

CONCLUSION

Individuals wish to receive a prognosis, although this is not always their experience. Individuals perceive that physiotherapists have the ability to provide a prognosis and impact their prognosis. Furthermore, receiving a prognosis has an impact on itself. To ensure patient-centred care, physiotherapists should explicitly discuss the prognosis with patients and consider their preferences when providing a prognosis.

Graded brain fMRI response to somatic and visual acupuncture stimulation

Increased stimulation can enhance acupuncture clinical response; however, the impact of acupuncture stimulation as "dosage" has rarely been studied. Furthermore, acupuncture can include both somatic and visual components. We assessed both somatic and visual acupuncture dosage effects on sensory ratings and brain response. Twenty-four healthy participants received somatic (needle inserted, manually stimulated) and visual (needle video, no manual stimulation) acupuncture over the leg at three different dosage levels (control, low-dose, and high-dose) during functional magnetic resonance imaging (fMRI). Participants reported the perceived deqi sensation for each acupuncture dose level. Blood-oxygen-level dependent imaging data were analyzed by general linear model and multivariate pattern analysis. For both somatic and visual acupuncture, reported deqi sensation increased with increased dosage of acupuncture stimulation. Brain fMRI analysis demonstrated that higher dosage of somatic acupuncture produced greater brain responses in sensorimotor processing areas, including anterior and posterior insula and secondary somatosensory cortex. For visual acupuncture, higher dosage of stimulation produced greater brain responses in visual-processing areas, including the middle temporal visual areas (V5/MT+) and occipital cortex. Psychophysical and psychophysiological responses to both somatic and visual acupuncture were graded in response to higher doses. Our findings suggest that acupuncture response may be enhanced by the dosage of needling-specific and nonspecific components, represented by different neural mechanisms.

The relationships between pain-associated psychological distress, pain intensity, patient expectations, and physical function in individuals with musculoskeletal pain: A retrospective cohort study

INTRODUCTION

The presence of pain-associated psychological distress (PAPD) in musculoskeletal disorders, including negative mood, fear-avoidance, and lack of positive affect/coping, is associated with prolonged disability. The importance of considering psychological influence on pain is well known, but practical ways of addressing it are not as straightforward. Identifying relationships between PAPD and pain intensity, patient expectations, and physical function may guide the development of future studies that assess causality and inform clinical practice.

OBJECTIVE

To assess the relationship between PAPD measured by the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag tool, and baseline pain intensity, expectations of treatment effectiveness, and self-reported physical function at discharge.

DESIGN

Retrospective cohort study.

SETTING

Hospital-based outpatient physical therapy.

PARTICIPANTS

Patients 18 to 90 years old with spinal pain or lower extremity osteoarthritis.

MAIN OUTCOME MEASURES

Pain intensity and patient expectations of treatment effectiveness at intake, and self-reported physical function at discharge.

RESULTS

A total of 534 patients, 56.2% female, median (interquartile range [IQR]) age 61 (21) years with an episode of care between November 2019 and January 2021 were included. A multiple linear regression showed a significant association between PAPD and pain intensity with 6.4% (p < .001) of the variance explained. PAPD explained 3.3% (p < .001) of the variance in patient expectations. One additional yellow flag present resulted in a 0.17-point increase in pain intensity and 1.3% decrease in patient expectations. PAPD was also associated with physical function with 3.2% (p < .001) of the variance explained. PAPD explained 9.1% (p < .001) of the variance in physical function at discharge in the low back pain cohort only when assessed independently by body region.

CONCLUSION

These findings support the theory that the pain experience is complex and multiple factors should be considered when evaluating a patient with musculoskeletal pain. Clinicians who have identified PAPD may consider these relationships when planning or modifying interventions and pursuing multidisciplinary collaboration.

Cross-Cultural Adaptation and Measurement Properties of the Expectations for Treatment Scale (ETS) for Greek-Speaking Patients

Introduction Patients' treatment expectations are key factors influencing the health outcomes in various medical conditions. Using validated measures to capture these expectations has been strongly suggested to improve the prognosis of the health outcome and promote research investigations. The Expectations for Treatment Scale (ETS) is a well-established questionnaire designed to accurately measure treatment expectations in patients with low back pain; however, it is not available in Greek yet. We aimed to translate and cross-culturally adapt the ETS in Greek (ETS-Gr) and evaluate its reliability and validity in a Greek-speaking population with musculoskeletal disorders. Methods We followed published recommendations for the translation and cross-cultural adaptation process of the scale. Face and content validity were evaluated using interviews with patients and experts. Internal consistency, test-retest reliability, and measurement error were evaluated in 52 patients with musculoskeletal conditions. Results During forward and backward translation minor linguistic discrepancies were detected and effectively adapted for Greek-speaking patients. The ETS-Gr presented a high level of content validity (item content validity index: 0.88-1; and average scale content validity index: 0.90), acceptable internal consistency (Cronbach's alpha: 0.84), and excellent test-retest reliability (intraclass correlation coefficient: 0.96, 95% confidence interval: 0.93-0.98). Conclusions The ETS-Gr is a short, reliable, and valid instrument to measure pre-treatment expectations in patients with musculoskeletal disorders. Future investigations including other medical conditions are required.

Dorsal root ganglion stimulation for the treatment of chronic pelvic pain: A systematic review

BACKGROUND

Chronic pelvic pain (CPP) is a difficult condition to treat. Due to complex pelvic innervation, dorsal column spinal cord stimulation (SCS) has not been shown to produce the same effect as dorsal root ganglion stimulation (DRGS) given emerging evidence suggesting that applying DRGS may result in favorable outcomes for individuals with CPP. The aim of this systematic review is to investigate the clinical use and effectiveness of DRGS for patients with CPP.

MATERIALS AND METHODS

A systematic review of clinical studies demonstrating the use of DRGS for CPP. Searches were conducted using four electronic databases (PubMed, EMBASE, CINAHL, and Web of Science) across August and September 2022.

RESULTS

A total of nine studies comprising 65 total patients with variable pelvic pain etiologies met the inclusion criteria. The majority of subjects implanted with DRGS reported >50% mean pain reduction at variable times of follow-up. Secondary outcomes reported throughout studies including quality of life (QOL) and pain medication consumption were reported to be significantly improved.

CONCLUSIONS

Dorsal root ganglion stimulation for CPP continues to lack supportive evidence from well-designed, high-quality studies and recommendations from consensus committee experts. However, we present consistent evidence from level IV studies showing success with the use of DRGS for CPP in reducing pain symptoms along with reports of improved QOL through periods as short as 2 months to as long as 3 years. Because the available studies at this time are of low quality with a high risk of bias, we strongly recommend the facilitation of high-quality studies with larger sample sizes in order to better ascertain the utility of DRGS for this specific patient population. At the same time, from a clinical perspective, it may be reasonable and appropriate to evaluate patients for DRGS candidacy on a case-by-case basis, especially those patients who report CPP symptoms that are refractory to noninterventional measures and who may not be ideal candidates for other forms of neuromodulation.

The relationship between psychological, cognitive, and contextual factors and rehabilitation outcomes in Achilles tendinopathy: A prospective feasibility cohort study

OBJECTIVES

This study aimed to investigate the feasibility of conducting a full-scale study investigating the influence of patient-related factors on rehabilitation outcomes in Achilles tendinopathy (AT). A secondary aim was to investigate preliminary relationships between patient-related factors and clinical outcomes at 12- and 26- weeks.

DESIGN

feasibility cohort.

SETTING

Australian healthcare settings.

METHODS

Participants with AT receiving physiotherapy in Australia were recruited via treating physiotherapists and online. Data were collected online at baseline, 12- and 26-weeks. Progression criteria for a full-scale study were recruitment rate of ≥10 per month, conversion rate ≥20%, and response rate to questionnaires ≥80%. The relationship between patient-related factors and clinical outcomes was investigated using Spearman's rho correlation coefficient.

RESULTS

The average recruitment rate was 5/month, conversion rate was 97%, and response rate to questionnaires was ≥97% at all timepoints. There was a fair to moderate correlation (rho = 0.225 to 0.683) between patient-related factors and clinical outcomes at the 12-week, but no to weak correlation at the 26-week (rho = 0.002 to 0.284).

CONCLUSIONS

Feasibility outcomes suggest a future full-scale cohort study is feasible with the caveat of utilizing strategies to improve recruitment rate. Preliminary bivariate correlations at 12-weeks warrant further investigations in larger studies.

The perceptions of individuals with musculoskeletal disorders towards prognosis: An exploratory qualitative study

QUESTION(S)

How do individuals living with musculoskeletal disorders perceive the concept of prognosis?

DESIGN

Exploratory phenomenological study.

PARTICIPANTS

Individuals aged 18 years or older currently experiencing a musculoskeletal disorder.

DATA ANALYSIS

Single semi-structured one-on-one interviews were conducted. Data was analysed using inductive coding and thematic analysis.

RESULTS

Five themes were identified. First, participants defined prognosis as the likely outcome associated with their diagnosis. Their prognosis was often associated with outcomes related to pain, tissue health, and function. Second, participants perceived pain as having a negative impact on their prognosis by limiting their function and having a psychological impact. Third, participants held biomedical views in that tissue health was perceived as a cause for their pain and that tissue healing was essential for pain cessation. It was also difficult for participants to distinguish between pain related to tissue damage, and pain that was not. Fourth, participants use their ability to complete leisure and functional activities to determine the success of their recovery. Finally, participants perceived receiving individual prognoses for pain, tissue health, and function that may be simultaneously occurring as both important and beneficial.

CONCLUSION

Overall, participants viewed receiving prognostic information as important and beneficial. When constructing their views on prognosis participants perceived that pain, tissue health, and functional ability could all impact upon prognosis, whilst having a prognosis of their own. Physiotherapists should consider conceptualising and discussing prognosis in terms of pain, tissue health, and function when managing musculoskeletal disorders.

Complexity theory in the management of patients with musculoskeletal pain

Nonlinear systems are not susceptible to research with a reductionist approach. In this sense, the complexity theory provides an alternative approach to quantify the importance of contextual factors in patients with musculoskeletal pain. The use of positive (placebo) or negative (nocebo) contextual factors in the therapeutic setting could largely account for the non-specific component of treatment efficacy, directly affecting the quality of patients’ health-related outcomes (e.g., pain, disability, or satisfaction). In recent years, there has been a better understanding of the effects of contextual factors. However, the knowledge and awareness of them is limited and heterogeneous among physical therapists, reducing their translational value in the field of physiotherapy. The purpose of this essay is to describe the management of patients with musculoskeletal pain from the complexity theory perspective.

Differences in balance control despite self-reported resolution of pregnancy-related pelvic girdle pain. A cross-sectional study

BACKGROUND

Motor control patterns are altered when women with pregnancy-related pelvic girdle pain (PGP) experience pain. In low back pain, these adaptations can persist after recovery.

OBJECTIVES

This study aimed to assess balance control in postpartum women with and without a history of PGP during pregnancy.

DESIGN

Cross-sectional study.

METHOD

Eighteen postpartum women who reported to be recovered from PGP, and twelve postpartum women without a history of PGP during pregnancy performed two clinical tests: the single leg stance and active straight leg raise test. Primary outcomes were ground reaction forces measured with a force platform.

RESULTS

Multiple linear regression analyses showed smaller lateral displacement (β = -11cm; 95%CI: 19 to -3; p = 0.008) and lower displacement velocity of the Centre of Pressure (COP) (Ratio of Geometric Means (RGM) 0.76; 95%CI: 0.59 to 0.99; p = 0.043) during single leg stance in the participants with a history of PGP compared to participants without a history of PGP. Push-off force (β = -4.8 N; 95%CI: 22.0 to 12.5; p = 0.57) and asymmetry of push-off force (RGM 1.77; 95%CI: 0.62 to 5.04; p = 0.27) did not differ between groups. During the active straight leg raise test, no differences in lateral displacement (β = 3 cm; 95%CI: 3 to 8; p = 0.30) and COP displacement velocity (RGM 1.03; 95%CI: 0.70 to 1.52; p = 0.87) were observed.

CONCLUSIONS

Although the women with a history of PGP considered themselves recovered, their balance control during single leg stance was poorer compared to those without a history of PGP. No differences were found during the active straight leg raise test.

Spinal pain patients seeking care in primary care and referred to physiotherapy: A cross-sectional study on patients characteristics, referral information and physiotherapy care offered by general practitioners and physiotherapists in France

Objectives

To describe spinal pain patients referred by their treating general practitioners to physiotherapy care, examine to which extent physiotherapy interventions proposed by general practitioners and physiotherapists were compliant to evidence based recommendations, and evaluate concordance between providers in terms of diagnosis and contraindications to physiotherapy interventions.

Methods

This study included spinal pain patients recruited from a random sample of sixty French physiotherapists. Physiotherapists were asked to supply patients’ physiotherapy records and characteristics from the general practitioner’s physiotherapy referral for the five new consecutive patients referred to physiotherapy. General practitioner’s physiotherapy referral and physiotherapists’ clinical findings characteristics were analyzed and compared to evidence-based recommendations using Chi-squared tests. Cohen’s kappas were calculated for diagnosis and contraindications to physiotherapy interventions.

Results

Three hundred patients with spinal pain were included from sixty physiotherapists across France. The mean age of the patients was 48.0 ± 7.2 years and 53% were female. The most common spinal pain was low back pain (n = 147). Diagnoses or reason of referral formulated by general practitioners were present for 27% of all patients (n = 82). Compared to general practitioners, physiotherapists recommended significantly more frequently recommended interventions such as education, spinal exercises or manual therapy. General practitioners prescribed significantly more frequently passive physiotherapy approaches such as massage therapy and electrotherapy. The overall proportion of agreement beyond chance for identification of a diagnosis or reason of referral was 41% with a weak concordance (κ = 0.19; 95%CI: 0.08–0.31). The overall proportion of compliant physiotherapists was significantly higher than for general practitioners (76.7% vs 47.0%; p<0.001).

Conclusions

We found that information required for the referral of spinal pain patients to physiotherapy is often incomplete. The majority of general practitioners did not conform to evidence-based recommendations in terms of prescribed specific physiotherapy care; in contrast to a majority of physiotherapists.

Trial registration

ClinicalTrials.gov: NCT04177121

What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment

BACKGROUND

Patient expectations related to physical therapy outcomes are commonly collected through surveys and close-ended questionnaires. These methods may not optimally capture patients' expectations for physical therapy, especially in the patients' own words. Louis Gifford identified four questions attempting to guide clinicians' understanding of patients' expectations for physical therapy. However, a qualitative assessment mapping the expectations that patients have prior to starting physical therapy appears to be undocumented.

OBJECTIVES

The aim of this study was to determine patient expectations prior to beginning physical therapy for individuals with musculoskeletal conditions.

DESIGN

Qualitative analysis with structured interviews and open-ended participant responses.

METHODS

Twenty-five people (18 female, 7 male; mean age: 47.04 years) were interviewed prior to their initial physical therapy evaluation using a pragmatic approach rooted in phenomenology. Data were transcribed, coded, and thematized using qualitative data analysis software.

RESULTS

Outcome, education, exercise, evaluation, and cause of pain were key themes expressed by participants. Participants appear to want to better understand their symptoms, how they can improve symptoms, what the clinician will do, and how long they will attend physical therapy. Many participants were not certain where physical therapy fit within their overall healthcare plan, and perceptions of manual therapy were vague.

CONCLUSIONS

These identified themes highlight what patients may expect from a physical therapy experience and clinicians should work to identify and satisfy each patient's individual expectations to optimize outcomes.

Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review

BACKGROUND AND OBJECTIVE

Chronic low back pain is pervasive, societally impactful, and current treatments only provide moderate relief. Exploring whether therapeutic elements, either unrecognised or perceived as implicit within clinical encounters, are acknowledged and deliberately targeted may improve treatment efficacy. Contextual factors (specifically, patient's and practitioner's beliefs/characteristics; patient-practitioner relationships; the therapeutic setting/environment; and treatment characteristics) could be important, but there is limited evidence regarding their influence. This research aims to review the impact of interventions modifying contextual factors during conservative care on patient's pain and physical functioning.

DATABASES AND DATA TREATMENT

Four electronic databases (Medline, CINAHL, PsycINFO and AMED) were searched from 2009 until 15th February 2022, using tailored search strategies, and resulted in 3476 unique citations. After initial screening, 170 full-text records were potentially eligible and assessed against the inclusion-exclusion criteria. Thereafter, studies were assessed for methodological quality using a modified Downs and Black scale, data extracted, and synthesised using a narrative approach.

RESULTS

Twenty-one primary studies (N = 3075 participants), were included in this review. Eight studies reported significant improvements in pain intensity, and seven in physical functioning, in favour of the contextual factor intervention(s). Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance.

CONCLUSION

This review identified influential contextual factors which may augment conservative chronic low back pain care. The heterogeneity of interventions suggests modifying more than one contextual factor may be more impactful on patients' clinical outcomes, although these findings require judicious interpretation.

The Role of Patient Recovery Expectations in the Outcomes of Physical Therapist Intervention: A Systematic Review

OBJECTIVE

The purpose of this study was to determine the association between baseline patient recovery expectations and outcomes following physical therapy care.

METHODS

PubMed, CINAHL Complete, PEDro, SPORTDiscus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and PsycINFO were searched from inception to February 2021. Concepts represented in the search included physical therapy, patient expectations, patient outcomes, and their relevant synonyms. Two reviewers independently screened studies of article abstracts and full texts. Eligibility criteria included English language studies that evaluated adults seeking physical therapist intervention for any health condition where both patient outcome (recovery) expectations and functional or other outcome measures were reported. Methodologic standards were assessed using the Critical Appraisal Skills Program criteria. Data were extracted using a custom template for this review with planned descriptive reporting of results. Vote counting was used to measure reported outcomes.

RESULTS

Twenty-one studies were included in this review, representing 4879 individuals. Studies were most commonly prospective cohort studies or secondary analyses of controlled trials. Varied expectation, outcome, and statistical measures that generally link patient recovery expectations with self-reported outcomes in musculoskeletal practice were used.

CONCLUSION

Patient recovery expectations are commonly associated with patient outcomes in musculoskeletal physical therapy.

IMPACT

Evidence supports measuring baseline patient expectations as part of a holistic examination process.

Multicenter study evaluating factors associated with treatment outcome for low back pain injections

BACKGROUND

There has been a worldwide surge in interventional procedures for low back pain (LBP), with studies yielding mixed results. These data support the need for identifying outcome predictors based on unique characteristics in a pragmatic setting.

METHODS

We prospectively evaluated the association between over two dozen demographic, clinical and technical factors on treatment outcomes for three procedures: epidural steroid injections (ESIs) for sciatica, and sacroiliac joint (SIJ) injections and facet interventions for axial LBP. The primary outcome was change in patient-reported average pain intensity on a numerical rating scale (average NRS-PI) using linear regression. For SIJ injections and facet radiofrequency ablation, this was average LBP score at 1 and 3 months postprocedure, respectively. For ESI, it was average leg pain 1- month postinjection. Secondary outcomes included a binary indicator of treatment response (success).

RESULTS

346 patients were enrolled at seven hospitals. All groups experienced a decrease in average NRS-PI (p<0.0001; mean 1.8±2.6). There were no differences in change in average NRS-PI among procedural groups (p=0.50). Lower baseline pain score (adjusted coefficient -0.32, 95% CI -0.48 to -0.16, p<0.0001), depressive symptomatology (adjusted coefficient 0.076, 95% CI 0.039 to 0.113, p<0.0001) and obesity (adjusted coefficient 0.62, 95% CI 0.038 to 1.21, p=0.037) were associated with smaller pain reductions. For procedural outcome, depression (adjusted OR 0.94, 95% CI 0.91, 0.97, p<0.0001) and poorer baseline function (adjusted OR 0.59, 95% CI 0.36, 0.96, p=0.034) were associated with failure. Smoking, sleep dysfunction and non-organic signs were associated with negative outcomes in univariate but not multivariate analyses.

CONCLUSIONS

Identifying treatment responders is a critical endeavor for the viability of procedures in LBP. Patients with greater disease burden, depression and obesity are more likely to fail interventions. Steps to address these should be considered before or concurrent with procedures as considerations dictate.

TRIAL REGISTRATION NUMBER

NCT02329951.

Using the PODCI to Measure Motor Function and Parent Expectations in Children With Cerebral Palsy

OBJECTIVE

Involving parents in the evaluation of their child with cerebral palsy (CP) is associated with enhanced neurodevelopmental outcomes. The pediatric outcomes data collection instrument (PODCI) is a patient-reported outcome measure primarily used to assess motor function following orthopedic surgical intervention or for older children with more independent motor function. The PODCI expectations scale has infrequently been reported in previous studies. This study aims to determine the relationship between parent-reported motor performance using the PODCI and motor capacity assessed by pediatric therapists for young children with CP across all ability levels and to explore the use of the PODCI expectations scale for quantifying therapy-related parent expectations.

METHODS

This prospective cohort study included 108 participants with CP, 2 to 8 years of age, gross motor function classification systems (GMFCS) levels I to V. Measures included the PODCI, gross motor function measure (GMFM), and GMFCS.

RESULTS

There were moderate (r = 0.513) to large (r = 0.885) relationships between PODCI and GMFM scores. PODCI scores were significantly different across GMFCS levels. Weak, significant relationships (r = -0.28) were found between function expectations scores and measures of function.

CONCLUSION

The PODCI, GMFM, and GMFCS provide different, but strongly related, information about the abilities of young children. The GMFM measures motor capacity. Parents report daily function and health-related quality of life for their child using the PODCI. Parent expectations for intervention outcomes may relate to a child's motor function.

IMPACT

These study results are consistent with those for older children with greater independent mobility, indicating an opportunity for expanded use of the PODCI for measuring motor performance for younger children with CP across all ability levels. A strategy is provided for using the PODCI expectations scale to quantify parent therapy-related expectations in future research and clinical settings. Therapy-related expectations may relate to child outcomes.

Patient expectations about a clinical diagnostic test may influence the clinician's test interpretation

BACKGROUND

With medical information widely available, patients often have preconceived ideas regarding diagnostic procedures and management strategies.

OBJECTIVES

To investigate whether expectations, such as beliefs about the source of symptoms and knowledge about diagnostic tests, influence pain perception during a clinical diagnostic test.

DESIGN

Cross-sectional study.

METHODS

Pain was induced by intramuscular hypertonic saline infusion in the thenar muscles. In line with sample size calculations, fifteen participants were included. All participants received identical background information regarding basic median nerve biomechanics and basic concepts of differential diagnosis via mechanical loading of painful structures. Based on different explanations about the origin of their induced pain, half of the participants believed (correctly) they had 'muscle pain' and half believed (incorrectly) they had 'nerve pain'. Pain intensity and size of the painful area were evaluated in five different positions of the median nerve neurodynamic test (ULNT1 _MEDIAN). Data were analysed with two-way analyses of variance.

RESULTS

/findings: Changes in pain in the ULNT1 _MEDIAN positions were different between the 'muscle pain' and 'nerve pain' group (p < 0.001). In line with their expectations, the 'muscle pain' group demonstrated no changes in pain throughout the test (p > 0.38). In contrast, pain intensity (p ≤ 0.003) and size of the painful area (p ≤ 0.03) increased and decreased in the 'nerve pain' group consistent with their expectations and the level of mechanical nerve loading.

CONCLUSION

Pain perception during a clinical diagnostic test may be substantially influenced by pain anticipation. Moreover, pain was more aligned with beliefs and expectations than with the actual pathobiological process.

Patient Expectations From Consultation and Treatment of Spine Pain in a Private Spine Rehabilitation Clinic in Urban India

Despite high prevalence of spine pain among the Indian population, patient expectations regarding consultation and its treatment are unknown. We aimed to determine consultation and treatment expectations among patients visiting a spine rehabilitation clinic in urban India. We included 194 consecutive patients who completed a consultation expectation (CE) and treatment outcome expectation (OE) questionnaires and the Patient-Centered Outcome Questionnaire (PCOQ). To learn about the most suitable treatment for their problem (98%), and to know what kind of activities they could do and should avoid (96%) were the most important CEs, and to achieve complete relief of symptoms (96%), and prevent recurrence of pain (95%) were the most important OEs. For successful treatment, patients expected PCOQ pain levels of 2.0 (96.5% reduction) and interference levels of 1.5 (96% reduction). Patients expected to know the most suitable treatment, activities they could do and avoid after consultation, and to achieve complete relief of symptoms and prevent recurrence after treatment. Incorporating and addressing these expectations may help improve outcomes and satisfaction with the consultation and treatment of spine pain.

Patient Expectations for Synchronous Telerehabilitation Visits: A Survey Study of Telerehabilitation-Naive Patients

Background: The current study evaluated patient expectations for synchronous telerehabilitation. Because the coronavirus disease 2019 (COVID-19) pandemic decreased regulatory barriers and increased accessibility of telehealth, improved understanding of expectations may direct future educational efforts, improve implementation strategies, and inform future analyses of consumer adoption and utilization of telehealth. Methods: A cross-sectional survey design was used to measure ideal expectations (what they want to happen) and realistic expectations (what they think will happen) of telerehabilitation-naive patients for synchronous telerehabilitation. Participants were recruited through e-mail and social media and in person from seven outpatient private practice physical therapy clinics across the United States. Patients completed an online anonymous adaptation of the Patients' Expectations Questionnaire (PEQ) and were asked whether they expected synchronous telerehabilitation to benefit them personally. Open-ended responses were collected and analyzed for categories and themes. Results: Of 178 participants, the greatest mean difference between ideal and realistic expectations among PEQ subscales was for outcomes (0.49; 95% confidence interval [CI], 0.37-0.60), and the greatest mean difference among individual items was for symptom reduction (0.53; 95% CI, 0.41-0.66). Although participants appeared to appreciate the value of telerehabilitation visits, with 69.7% indicating that it would benefit them personally, many expressed a preference for face-to-face visits when possible. Discussion: Expectations were mostly positive. Lower outcomes expectations may be a potential barrier to adoption and utilization of telehealth and other types of digital physical therapy in some patients. Conclusions: To improve beliefs and address potential barriers, physical therapy clinicians should discuss expectations with patients before recommending telerehabilitation visits.

Composite psychosocial risk based on the fear avoidance model in patients undergoing anterior cruciate ligament reconstruction: Cluster-based analysis

OBJECTIVES

To examine associations between preoperative fear-avoidance model (FAM) risk subgroup status and patient expectation of surgical success with postoperative outcomes at 6 and 12 months after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cohort study.

SETTING

Academic medical center.

PARTICIPANTS

54 patients (25 females) undergoing unilateral ACLR.

MAIN OUTCOME MEASURES

Cluster analysis distinguished FAM risk subgroups based on preoperative fear of movement/reinjury, self-efficacy, and pain catastrophizing. Preoperative expectation for surgical success was assessed with a numeric rating scale. Six and 12-month outcomes included Subjective Patient Outcomes for Return to Sport, Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life, and International Knee Documentation Committee (IKDC) Subjective Knee Form.

RESULTS

Thirteen (24%) patients were "moderate-to-high FAM risk." Moderate-to-high FAM risk patients had lower odds of return to sport at 12 months (OR = 0.3, p = .05) and lower KOOS sports/recreation at 6 months (st. beta = -0.27, p = .05), KOOS quality of life at 12 months (st. beta = -0.42, p = .007), and IKDC at 6 (st. beta = -0.29, p = .04) and 12 months (st. beta = -0.47, p = .001). Higher expectation was associated with lower 6-month IKDC (st. beta = -0.36, p = .008) and 12-month KOOS quality of life (st. beta = -0.29, p = .05).

CONCLUSIONS

Preoperative FAM risk influences patient-reported outcomes and return to sport at 6 and 12 months.

Exploring expectations and perceptions of different manual therapy techniques in chronic low back pain: a qualitative study

BACKGROUND

Chronic low back pain (CLBP) prevalence has steadily increased over the last two decades. Manual therapy (MT) is recommended within a multimodal management approach to improve pain and disability although evidence investigating the patients' experience of MT is scarce.

OBJECTIVE

To explore expectations and perceptions of MT techniques in people with CLBP.

METHODS

A qualitative study embedded sequential to an experimental trial using semi-structured interviews (SSI) explored participants' experiences of thrust, non-thrust and sham technique. Purposive sampling enabled variance in age and CLBP duration. An evidence informed topic guide was used. Data were analysed using thematic analysis (TA). Respondent validation and peer debriefing enhanced trustworthiness. The Consolidating Criteria for Reporting Qualitative Studies (COREQ) reported methodological rigour.

FINDINGS

Ten participants (50% male) with a mean age of 29.1 years (Standard Deviation (SD): 7.9, range: 19-43), a mean pain intensity of 4.5 on a Numeric Rating Scale (NRS) 0-10 (SD: 1.5, range: 2-7), a mean Oswestry Disability Score (ODI) of 9 (SD: 4.6, range: 2-17) and a mean Tampa Scale of Kinesiophobia (TSK) score of 38.6 (SD: 4.8, range: 30-45) participated. Four themes were identified: understanding of pain; forming expectations; perception of care; re-evaluation of body awareness and management. Understanding of CLBP is formed by an individuals' pain perception and exchange with social environment. This, combined with communication with physiotherapist influenced expectations regarding the MT technique.

CONCLUSION

Expectations for MT were formed by an individual's social environment and previous experience. A treatment technique is perceived as positive if its characteristics are aligned with the individual's understanding of pain and if care is delivered in an informative and reassuring manner.

Effect of pre-treatment expectations on post-treatment expectation fulfillment or outcomes in patients with distal radius fracture

BACKGROUND

The influence of patient expectations on patient-rated outcomes (PRO) after elective orthopedic procedures has been addressed in previous studies. However, the influence of pre-treatment expectations on post-treatment PRO was rarely examined in patients with extremity fractures.

PURPOSE

The purpose of this study was to determine if pre-treatment expectations have an effect on post-treatment expectation fulfillment or PRO in patients surgically and conservatively managed for distal radius fractures (DRFs).

STUDY DESIGN

Prospective cohort study METHODS: For this study, 114 consecutive patients treated for DRF between January 2017 and February 2018 were enrolled. Of the 114 patients, 81 underwent surgical treatment (surgical group), and 33 were managed conservatively (conservative group). All patients completed a 7-item pre-treatment expectation questionnaire initially. There were 66 patients in the surgical group and 25 patients in the conservative group available at the 1-year follow-up and completed a 6-item post-treatment expectation fulfillment questionnaire and patient-reported wrist evaluation (PRWE) questionnaire.

RESULTS

The surgical group showed a significantly higher median pre-treatment expectation score than the conservative group. However, no significant differences in post-treatment expectation fulfillment scores and PRWE scores were observed between groups. Higher pre-treatment expectation score was moderately correlated with higher post-treatment expectation fulfillment score (r = 0.36, P = 0.003) and lower PRWE score (r = -0.3, P = 0.02) in the surgical group. However, the pre-treatment expectation score was not significantly correlated with the post-treatment expectation fulfillment score (r = -0.09, P = 0.65) or PRWE score (r = -0.02, P = 0.93) in conservative group. In the surgical group, multivariable linear regression analysis showed that post-treatment expectation fulfilment score could be explained by the pre-treatment expectation score (Beta = 0.41, P = 0.001), accounting for 15% of the variance, and PRWE score was also explained by the pre-treatment expectation score (Beta = 0.39, P = 0.001), accounting for 14% of the variance.

CONCLUSIONS

In conclusion, higher pre-treatment expectation score was moderately correlated with higher the post-treatment expectation fulfillment score and lower PRWE score, and the pre-treatment expectation score could only explain a small amount of variance seen in the post-treatment expectation fulfillment and PRWE scores in the surgical group. However, there was no association between the pre-treatment expectation score and the post-treatment expectation fulfillment score or the PRWE score in the conservative group.

Patient Expectancy Does Not Predict Success or Failure of Thermal Neurotomy for Persistent Zygapophysial and Sacroiliac Joint Pain

OBJECTIVE

The placebo effect is important in determining the outcome of the treatment of pain for which expectancy and context are the main contributors. The variable success of thermal neurotomy spinal pain procedures is often seen as evidence of the placebo effect. Conversely, proponents of pain procedures explain poorer outcomes by technical procedure deficiencies, including inadequate diagnosis. This cohort study set out to determine whether patient expectancy is a contributing factor in the outcome of thermal neurotomy to the cervical, thoracic, and lumbar zygapophysial and sacroiliac joints.

DESIGN

This single-practitioner, single-site retrospective analysis of prospectively gathered cohort data of 549 patients evaluated the impact of patient preprocedure expectancy (rated on a simple 0-10 or 0-4 numerical rating scale) on outcomes in a large consecutive series of patients who had undergone thermal neurotomy treatment between 2009 and 2019. In addition, a portion of patients were asked to what extent they hoped for or desired a good outcome.

RESULTS

Successful pain relief (≥75% reduction from baseline) was not associated with a higher preprocedure expectancy than were failed procedures. Hope and desire demonstrated no impact on the positive or negative impact of the procedure.

CONCLUSIONS

Altogether, patient expectation of outcome, hope, and desire are not associated with the outcome of effective pain relief by thermal neurotomy that has been performed to the appropriate and commonly available technical standards. Further work is needed to determine the influence of patient expectation across a range of pain intervention modalities.

Can Patient Expectations Modulate the Short-Term Effects of Dry Needling on Sensitivity Outcomes in Patients with Mechanical Neck Pain? A Randomised Clinical Trial

OBJECTIVE

Dry needling is commonly used for the management of musculoskeletal pain patients. However, the effects of patient expectations are uncertain. Our aim was to determine the effect of patient expectations on short-term clinical outcomes after the application of a single session of dry needling in individuals with neck pain.

METHODS

We conducted a randomized, placebo controlled, clinical trial including fifty patients with mechanical neck pain. Participants received a single session of dry needling or sham needling in a blinded design. Predicted patient expectation was categorized as positive, neutral, or negative. Outcomes including neck pain intensity (visual analogue scale, 0-100), pressure pain thresholds (PPTs) and self-perceived improvement (Global Rating of Change [GROC], -7 to + 7) were assessed at baseline, one day (immediately post), and 7 days (one week) after the intervention by a blinded assessor. Repeated measures ANCOVAs were conducted to assess the effects of real/sham needling adjusted by patient expectations.

RESULTS

Individuals receiving dry needling exhibited better outcomes than those receiving sham needling immediately and one-week after (all, P < 0.01). No general effects of patient expectations, either related to pain recovery or function improvement, were observed on the clinical outcomes, except for a small association of questionable clinical relevance between positive expectations and localized PPTs in the dry needling group.

CONCLUSION

This study did not find a significant effect of predicted patient expectations on the short-term effects of dry needling on pain intensity and PPTs in people with mechanical neck pain.

Knowledge and attitudes toward musculoskeletal pain neuroscience of manual therapy postgraduate students in the Netherlands

BACKGROUND

Health care practitioners' knowledge and attitudes influence patients' beliefs and health outcomes in musculoskeletal (MSK) pain. It is unclear to what extent physiotherapists undertaking a postgraduate master in manual therapy (MT students) possess the knowledge and attitudes toward pain neuroscience to be able to apply the biopsychosocial model in patients with MSK pain.

OBJECTIVES

The aim of this study was to assess the knowledge and attitudes toward pain neuroscience in MT students.

DESIGN

A cross-sectional study.

METHOD

Self-reported knowledge and attitudes were measured among students (n = 662) at baseline and in all years of the MT postgraduate programs in the Netherlands. The Knowledge and Attitudes of Pain questionnaire (KNAP) was used as a primary measure. Difference in KNAP-scores between baseline (0), year 1, year 2 and year 3 was tested using a one-way ANOVA (hypothesis: 0 < 1<2 < 3). A two factor ANOVA was used to determine the interaction effect of focused pain education and year in the curriculum with KNAP.

RESULTS

There was an overall significant difference of KNAP scores with a medium effect size (F(3, 218.18) = 13.56, p < .001, ω² = 0.059). Differences between years ranged from small to medium. Interaction effect of knowledge and attitudes and focused pain education was significant with a small effect size (F(6) = 2.597, p = .017, ω² = 0.012). Sensitivity analyses were consistent with the main results.

CONCLUSIONS

Positive differences in knowledge and attitudes toward pain neuroscience in MT students occur between the progressing years of the curriculum. Differences may be related to the provision of focused pain education.

The nosological classification of whiplash-associated disorder: a narrative review

Whiplash-associated disorder (WAD) is the most common complaint and purported cause of chronic disability associated with motor vehicle collisions in North America. However, its construct validity remains controversial. This narrative review of the literature summarises the evidence underlying the most commonly theorised biological and psychosocial mechanisms of WAD pathogenesis. While the face validity of WAD is good, empirical evidence supporting the various constructs suggesting a causal link between a trauma mechanism and the development of symptoms is poor. Because individual expectations of recovery are outcome-predictive, future research is necessary to develop a better understanding of how to enhance expectancies in order to help affected motorists gain a greater sense of control over their health and wellbeing.

What Mediates Treatment Effects in a Presurgery Physiotherapy Treatment in Surgical Candidates With Degenerative Lumbar Spine Disorders? A Mediation and Conditional Process Analysis of the PREPARE Randomized Controlled Trial

OBJECTIVES

Treatment guidelines recommend targeting both physical and psychological factors in interventions for degenerative lumbar spine disorders. Studying the treatment mechanisms gives information on key factors explaining the outcome improvement that can refine treatments. This study explores treatment mediators in a physiotherapy treatment on disability, pain intensity, and health-related quality of life in surgical candidates with degenerative lumbar spine disorders compared with waiting-list controls. An additional aim was to evaluate patients' expectation as a moderator of treatment outcome.

MATERIALS AND METHODS

Data collected from 197 patients in a single-blinded randomized controlled trial comparing 9 weeks of multifaceted physiotherapy with waiting-list controls were used in this conditional process analysis. Analysis was carried out on group differences for change in Oswestry Disability Index, Pain Visual Analog Scale (VAS) back pain, EuroQol-5D, and EuroQol-VAS. The putative moderation role of expectations and mediation role of change in physical variables and psychosocial variables were tested.

RESULTS

Change in self-efficacy mediated improvement in all outcomes. Improvement in Oswestry Disability Index was also mediated by change in depression; VAS was mediated by change in fear-avoidance beliefs; and EuroQol-VAS was mediated by change in activity level and fear avoidance beliefs. Improvements were moderated by patients' treatment expectations.

DISCUSSION

Self-efficacy, fear-avoidance beliefs, physical activity level, and patients' treatment expectations were found to be important factors explaining treatment effects. Self-efficacy was the consistent mediator for effects of the presurgical physiotherapy on disability, back pain intensity, and health-related quality of life.

Analysis of Real-World Implementation of the Biopsychosocial Approach to Healthcare: Evidence From a Combination of Qualitative and Quantitative Methods

Aims: The modern medical model has been transformed into a biopsychosocial model. The integration of the biopsychosocial approach in healthcare can help improve the effectiveness of diagnosis and treatment. This study explored the actual application of the biopsychosocial approach in healthcare and provides a basis for targeted interventions to promote the biopsychosocial approach in healthcare. Methods: Study 1 involved one-on-one interviews with 30 medical staff and focus group interviews with 16 recent patients. Study 2 was a cross-sectional survey of 13,105 medical staff in Hangzhou, China that analyzed the status quo implementation of the biopsychosocial approach in healthcare. Results: Study 1 found that medical staff did not welcome patients to report information unrelated to their disease, hoping patients did not express their emotions. In the treatment process, patients believed that medical staff refused to attend to or did not encourage reporting of any information other than the disease, and that patients should have reasonable expectations for medical staff. Study 2 found that medical staff had a 37.5% probability of actively paying attention to the patient's psychosocial status. Female medical staff (38.5%) were actively concerned about the patient's psychosocial status significantly more than male medical staff (34.2%) (P < 0.01). The medical staff in the psychiatric department (58.4%) paid more active attention to the patient's psychosocial status than staff in the non-psychiatric departments (37.2%). Gender, department, hospital level, and professional title were the factors associated with the medical staff's attention to the patient's psychosocial status (P < 0.05). The influence of age on the probability of medical staff actively paying attention to the psychosocial status of patients increased with the number of years of employment. Participants that were 31-40 years old, had an intermediate professional title, and 11-15 years of employment were the least likely to actively pay attention to patients' psychosocial status. Conclusion: Although the biopsychosocial approach has been popularized for many years, it has not been widely used in medical care. Medical staff pay more attention to patients' physical symptoms and less attention to patients' psychosocial status. It is recommended that training will be provided to medical personnel on implementing a biopsychosocial approach with particular attention to the sociodemographic characteristics of medical personnel. Additionally, we propose helping patients set reasonable expectations, and formulating guidelines for implementing the biopsychosocial approach.

The inclusion of mobilisation with movement to a standard exercise programme for patients with rotator cuff related pain: a randomised, placebo-controlled protocol trial

Background

Rotator cuff related pain (RCRP) is one of the most common sources of musculoskeletal shoulder pain affecting the general population. Conservative treatment, in the form of exercise, is considered the first line approach, nonetheless, improvements seem to be modest. One therapeutic modality that might be an adjunct to the treatment of this condition is mobilisation with movement (MWM). MWM is a pain-free manual procedure that targets restricted and painful movements, commonly seen in patients with RCRP. The purpose of clinical trial is to determine whether MWM with exercise has benefits over sham MWM with exercise in RCRP.

Methods

A randomised, sham-controlled trial of 70 adults complaining of RCRP will compare the effects of MWM combined with exercise over sham MWM with exercise. Participants will be allocated to one of two groups: exercise and MWM (EG) or exercise and sham MWM (CG). Two weekly individual treatment sessions will be conducted over five weeks. All assessments will be performed by a blinded assessor. Primary outcome measures will be the shoulder pain and disability index (SPADI) and the numeric pain rating scale (NPRS), assessed at baseline, discharge and one-month follow-up. Secondary outcome measures will be active range of motion, self-efficacy and the global rating of change scale. The analyses will be conducted considering a statistically significant p-value ≤0.05. Normality will be assessed with the Kolmogorov-Smirnov test and homogeneity with the Levene’s test. For the primary outcome measures (SPADI and NPRS) and self-efficacy, a 2 × 3 ANOVA with treatment group (EG versus CG) and time (baseline, end of the treatment and follow-up) factors will be performed. Separate 2 × 2 ANOVA will be used for range of motion (baseline and end of the treatment). Global rating scale of change analysis will be conducted using descriptive statistics. Intention-to-treat analysis will be adopted.

Discussion

As there is a paucity of longitudinal studies investigating the use of MWM in patients with RCRP, this study will help to better understand its role together with a structured exercise programme.

Trial registration

Clinical Trials Registry number NCT04175184. November, 2019.

Are patient expectations associated with treatment outcomes in individuals with chronic low back pain? A systematic review of randomised controlled trials

AIM

The importance of patient expectations (PEs) on treatment outcomes is poorly understood in clinical practice. The aim of this review is to investigate the evidence behind association between pre-treatment PEs and treatment outcomes such as pain intensity (PI), level of function (LF) and health-related quality of life (HRQoL) among individuals with chronic low back pain (CLBP).

METHODS

A systematic search was conducted for randomised controlled trials published between 1946 and May 2019 across major databases using the key MeSH terminologies. The association between PEs and PI, LF and HRQoL were extracted and categorised into positive, negative or no association for analysing the data. A descriptive synthesis was conducted and the association between PEs and PI, LF and HRQoL were reported.

RESULTS

Among the total of seven trials, two trials demonstrated a positive association between PEs and PI in short (≤6 weeks) and long term (>6 months), while another two trials demonstrated no association at medium term (>6 weeks-≤6 months). About four trials demonstrated a positive significant association between PEs and LF, 2 at medium and 2 at long terms. The only available trial demonstrated no association between PEs and HRQoL at medium term.

CONCLUSION

PEs is associated with PI at short and long terms. Also, evidence suggests association between PEs and LF at medium and long terms. Currently, there is no evidence of association between PEs and HRQoL. Further studies with valid tools to measure PE are warranted among individuals with CLBP.