The role of patient expectations in physiotherapy Part 2: How patient expectations can guide and enhance treatment.

In this second part of my blog I am going to discuss how patient expectations can help to guide and enhance treatment.

Expectations are a major factor that can influence clinical outcomes so if they are not established prior to treatment, not only treatment success, but also patient satisfaction may be affected (Bialosky et al 2010, Barron et al 2007). In order to establish patient expectations it is important firstly to understand the nature of these expectations and secondly, how the clinician may respond to these expectations to enhance treatment.  Thompson and Sunol (1995) carried out an analysis of literature in order to provide greater understanding regarding the relationship between expectations and satisfaction. Their analysis encompassed a wide field of literature and included 18 journals relevant to patient satisfaction. Although it was carried out over 20 years ago and therefore does not incorporate any current evidence in this area, there do not appear to be any more recent analyses of this type. Furthermore, this model of expectations as defined by Thompson and Sunol (1995) is referred to in more up-to-date literature such as Bialosky et al (2010). In their analysis they defined 4 types of expectations and, of these, predicted and ideal expectations are relevant to this blog.  Predicted expectations are what the patient believes is realistically likely to happen and are usually formed from a combination of previous personal experiences, the experiences of others and other sources of information such as the media. Ideal expectations are what patients would like to happen and may be more aspirational and less realistic (Thompson and Sunol 1995). Treatment may be more effective if patients’ expectations are predicted rather than ideal (Bialosky et al 2010). Bialosky et al (2010) wrote a perspective paper, which I understand to be an opinion paper, based on literature the authors have reviewed. In this paper the authors reviewed current literature, including some of the literature used in the first blog, and through this highlighted the role of expectation in influencing clinical outcomes. This review is particularly relevant to our clinical practice because, not only did the authors review a large amount of literature, but they also related it specifically to people experiencing musculoskeletal pain. They also base their model of expectations on that devised by Thompson and Sunol (1995). If expectations have been established prior to treatment and it is found that a patient’s expectations are ideal and unrealistic then there is the opportunity to provide appropriate education to encourage more realistic expectations. In turn, this may then provide the opportunity to encourage the patient to select, in conjunction with the therapist, treatment that is likely to achieve these more realistic expectations (Bialosky et al 2010). Therefore, not only has treatment been related directly to patient expectations but also patient choice has been taken into account.

Expectations are one of the main indicators of satisfaction and one of the main causes of dissatisfaction is that treatment did not meet expectations (Thompson and Sunol 1995, Verbeek et al 2004).  Therefore, if patients are helped to form realistic expectations before treatment, satisfaction can be enhanced by ensuring treatment meets their expectations (Hills and Kitchen 2007). Patients who are satisfied with their physiotherapy experience are more likely to comply with treatment and this in turn will improve treatment effectiveness (Verbeek et al 2004). Verbeek et al (2004) carried out a systematic review of qualitative and quantitative studies of patients with low back pain and their expectations of and satisfaction with physiotherapy treatment. They looked at 20 studies, 12 qualitative and 8 quantitative. Of these studies most were described as being of high quality with only 3 being of low quality. All studies were specifically on patients with low back pain so are directly relevant to our clinical practice. Hills and Kitchen (2007) developed and discussed a theory on patient satisfaction with physiotherapy based on their review of relevant literature. This, therefore, was more of an opinion piece but it was related specifically to physiotherapy and focused on the link between satisfaction and increased benefit from physiotherapy.  All this evidence suggests that if clinicians ensure that expectations are realistic, treatment is more likely to be effective and patients are more likely to be satisfied and therefore are more likely to comply with treatment.

As discussed in the first part of this blog, expectations are one of the mechanisms through which the placebo effect works and the amount of placebo-related hypoalgesia is related to what the patient thinks will happen (Bialosky et al 2011).  If someone believes that a treatment will be effective they will gain greater benefit from it than if they don’t believe it will be effective (Vase et al 2005, Myers et al 2007).  If this is the case, then treatment outcomes can be maximised by establishing patient expectations and preferences for different interventions. Treatment choice can then be based on the intervention for which the patient has the highest expectations.  Previous experience plays a significant role in this and a positive previous experience may strengthen the effects of a particular intervention (Klaber, Moffett and Richardson 1997; Bialosky et al 2011).  Klaber, Moffett and Richardson (1997) carried out a review of evidence on the influence the relationship between the physiotherapist and the patient can have on treatment outcomes. In this review they explored how the placebo effect may affect treatment outcome. Bialosky et al (2011) carried out a non-systematic review of literature and looked specifically at the role of placebo in managing musculoskeletal conditions and how it may be used to enhance treatment effects. Both papers agree that treatment choice should be based on the intervention for which the patient expresses the highest expectations. Therefore, if a patient has found a particular technique effective before and as a result has higher expectations for it, it may be beneficial to use this technique as long as it is appropriate and evidence-based or, conversely, to avoid a technique associated with negative experiences.  If there is a choice of more than one treatment and they are likely to be of equal benefit it may be helpful to choose the one that the patient has a previous positive experience of.

There are other ways therapists can influence clinical outcomes through expectations. For instance, therapists could enhance expectation for a particular intervention by suggesting the likelihood of a positive outcome if there is appropriate evidence to support this (Bialosky et al 2011).  If a patient has a strong likelihood of a positive response to a technique but has low expectations of it they may benefit from additional education regarding the likely benefits before treatment. Or therapists could give an instructional set (i.e. suggestion from the therapist as to the anticipated benefits of a treatment) to enhance a patient’s expectations as this has been shown to improve placebo-related hypoalgesia (Vase et al 2005). This theory was demonstrated by both Vase et al (2005) and Benedetti et al (2003). In both studies subjects were given verbal suggestions for either pain relief or an increase in pain and were then given a painful stimulus. Both studies found that subjects’ pain tolerance was related to the instructions they were given regarding likely outcome so there was a significant corresponding increase or decrease in pain tolerance respectively. Although neither of these studies were related to physiotherapy or considered subjects with musculoskeletal problems, the significant finding is that the suggestions that the subjects were given regarding the likely effect of the treatment they received affected the outcome. I believe that this can be carried over into our clinical practice and an instructional set used to suggest to a patient that an evidence-based treatment that is likely to be of benefit to them is likely to reduce their symptoms. As long as there is appropriate evidence and no contraindications then this may improve treatment outcomes.

I have learnt a great deal from writing this blog.  In particular, I have learnt how important it is to establish realistic patient expectations prior to treatment by drawing on patient preferences and past experiences.  This can then guide evidence-based treatment and provide the opportunity to offer appropriate education and support where necessary to enhance clinical outcomes. If expectations are met patients are more likely to be satisfied and more compliant and treatment is therefore more likely to be effective. As a result of writing this blog I will definitely be more specific about how I ask about patient expectations and more aware of how I respond to these expectations in terms of education, information and treatment choice.

 

 

References

 

Benedetti, F., Pollow, A., Lopiano, L., Lanotte, M., Bighetti, S. and Rainero, I. (2003) Conscious expectation and unconscious conditioning in analgesic, motor, and hormonal placebo/nocebo responses.  The Journal of Neuroscience, 2(10), pp 4315-4323.

Bialosky, J.E., Bishop, M.D., and Cleland, J.A. (2010) Individual expectation: An overlooked, but pertinent factor in the treatment of individuals experiencing musculoskeletal pain. Physical Therapy, 90(9), pp 1345-1355

Bialosky, J.E, Bishop, M.D., George, S.Z. and Robinson, M.E. (2011) Placebo response to manual therapy: something out of nothing?. Journal of Manual and Manipulative Therapy, 19(1), pp 11-19.

Flood, A.B., Lorence, D.P., Ding, J., McPherson, K. and Black, N.A. (1993). The role of expectations in patients’ reports of post-operative outcomes and improvement following therapy. Medical Care, 31(11), pp 1043-1056.

Hills, R. and Kitchen, S. (2007). Toward a theory of patient satisfaction with physiotherapy: exploring the concept of satisfaction. Physiotherapy Theory and Practice, 23(5), pp 243-254.

Klaber Moffett, J.A. and Richardson, P.H. (1997). The influence of the physiotherapist-patient relationship on pain and disability. Physiotherapy Theory and Practice, 13, pp 89-96.

Myers, S.S., Phillips, R.S., Davis, R.B., Cherkin, D.C., Legedza, A., Kaptchuk, T.J., Hrbek, A., Buring, J.E., Post, D., Connelly, M.T. and Eisenberg, D. (2007). Patient expectations as predictors of outcome in patients with acute low back pain.  Journal of General Internal Medicine, 23(2), pp 148-153.

Thompson, A.G.H. and Sunol, R. (1995). Expectations as determinants of patient satisfaction. International Journal for Quality in Health Care, 7(2), pp 127-141.

Vase, L., Robinson, M.E., Verne, G.N. and Price, D.D. (2005). Increased placebo analgesia over time in irritable bowel syndrome (IBS) patients is associated with desire and expectation but not endogenous opioid mechanisms. Pain, 115, pp 338-347.

Verbeek, J., Sengers, M-J., Riemends, L. and Haafkens, J. (2004). Patient expectations of treatment for back pain. Spine, 29(20), pp 2309-2318.