Author Names
Riley, S. P, Bialosky, J., Cote, M. P., Swanson, B. T., Tafuto, V., Sizer, P. S., & Brisme, J. M.
Reviewer Name
Jada Holmes, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Study design: Planned secondary analysis of a randomized clinical trial. Objectives: To examine: 1) patients’ baseline expectations for treatment outcome of thoracic high velocity low amplitude thrust manipulations (HVLATM) to the thoracic spine for shoulder pain; 2) if the message conveyed by the clinician changed the patients’ expectation; 3) any differences in outcome based on expectation independent of messaging.; and 4) any differences in outcome for those patients whose expectations significantly changed as a result of the messaging. Background: Thoracic HVLATM may be an effective intervention for patients suffering from musculoskeletal shoulder pain. The role of expectation in the treatment effectiveness of this intervention has not been established. Methods: Subjects’ expectations regarding the effectiveness of HVLATM on shoulder pain were recorded at baseline. This was reassessed immediately following the provision of positive or neutral instructional set. The subjects then received a thoracic or scapular HVLATM. The Shoulder Pain and Disability Index (SPADI) and the numeric pain rating scale (NPRS) were used as outcomes measures. Results: There was a 10-subject change (23%) in positive expectation that was statistically significant (p = 0.019) following a positive message. There was no statistically significant difference in pain and function when these subjects were compared to all other subjects. Conclusion: Although patients’ expectations of positive outcome significantly changed when providing a positive instructional set, these changes did not translate into clinically significant short-term changes in shoulder pain and function. Level of Evidence: 1b.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Cannot Determine, Not Reported, or Not Applicable
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- No
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
This study showed that the baseline expectations of success were low as compared to previous studies. By providing positive messaging, we were able to significantly alter patients’ expectations of treatment outcomes following thoracic spinal manipulation for musculoskeletal shoulder conditions.
Key Finding #2
Expectations may not be as important when the communication/interaction and alliance between the patient and clinician are removed.
Key Finding #3
Research should be done to evaluate the effect of both communication/interaction and expectations on outcomes. Additional research with larger sample size is needed to confirm these findings.
Please provide your summary of the paper
In general, studies show that patients reporting to PT have pretty high expectations for efficiency of treatments being done in clinic. This study shows that when treating shoulder pain with thoracic and placebo HVLATM treatment, patient’s expectations of a positive outcome was only at 20% at baseline. In comparison, when treating neck pain and LBP with manual therapy techniques, patient’s expectations of a positive outcome was 75% and 60%, respectively. Therefore, this study was looking to see if messaged conveyed prior to treatment could influence patient expectations of treatment effectiveness. The findings didn’t show any clinical differences in expectation of treatment to influence treatment outcome, however other researchers have found different clinical outcomes.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This idea in theory seems sound that messages conveyed could influence patient expectations of manual therapy outcomes. Perhaps because the message wasn’t from the clinician but via a video, they didn’t have as much confidence in the expectations being conveyed whereas if it came from the treating clinician, they might’ve felt more confident about their outcomes. However, this changing the internal validity of a study and makes things a lot more difficult. Regardless, more research is needed is this area to see how manual therapy done in the thoracic region can effect shoulder pain.
