The role of patient expectations in physiotherapy Part 1: how expectations can influence clinical outcomes

When I first assess my patients I usually ask them what their expectations of physiotherapy are. I want to know what they think will happen during their physiotherapy treatment and, more importantly, what they want to get out of it.  If I can find this out this I am hopefully more likely to provide some pain relief and achieve their goals successfully.

But why is it important to ask about their expectations? And how is it relevant to clinical practice?  In this blog I’m going to explore this in more detail.  In this first part I’m going to discuss why patients’ expectations are important and how they can have an impact both on treatment choice and on clinical outcomes. In the second part I’m going to discuss the implications for clinical practice.

In terms of general expectations of physiotherapy there is evidence that patients with high expectations are likely to have greater improvement in their symptoms compared to those with lower expectations (Bishop et al 2013, Myers et al 2007, Linde et al 2007). These studies are secondary analyses of randomised controlled trials (RCTs) which all look at the influence of patient expectations of physiotherapy on outcomes of different musculoskeletal conditions including neck pain (Bishop et al 2013), low back pain (Myers et al 2007) and migraine, headache, low back pain and knee OA (Linde et al 2007). All three RCTs had a large number of participants – 140 in Bishop et al (2013), 444 in Myers et al (2007) and 864 in Linde et al (2007) which I believe adds credibility to the results. In all three studies subjects were randomised to different treatment groups but the type of treatment offered varied quite considerably. Treatment types included an exercise group or manipulation and exercise group (Bishop et al 2013), usual care (eg NSAIDs, education and activity modification) or usual care plus an intervention of the subject’s choice from acupuncture, chiropractic treatment or massage (Myers et al 2007) and acupuncture, sham acupuncture or no treatment (Linde et al 2007). Bishop et al (2013) was the only study to consider both exercise and manual therapy and therefore I feel that this study best reflects our clinical practice as physiotherapists, although most of us are also likely to include other treatment options such as education and activity modification as considered by Myers et al (2007). There were differences in the way that the studies assessed the effects of general expectations making it difficult to directly compare the results. Measures included rating expectations from ‘complete relief’ to ‘prevent future disability’ (Bishop et al 2013), ‘very effective’ to ‘not effective’ (Linde et al 2007) and rating general expectations using a scale of 0-10 (Myers et al (2007). A strength of this particular measure was that the expected outcome was timed (i.e. 6 weeks) which makes it easier to measure actual improvement accurately against expectations. Despite these differences all three studies concluded that subjects with higher general expectations of improvement had a greater chance of improvement than subjects with lower expectations. These findings have important implications for clinical practice and emphasise the necessity of establishing expectations prior to treatment. This will enable physiotherapists to identify any patients who have low expectations and to address the reasons for these low or negative expectations, hopefully resulting in improved outcomes for these particular patients.

In terms of specific expectations the effectiveness of an intervention may depend on the patient’s expectation for that particular intervention. There is evidence to suggest that patient beliefs about a particular treatment are more effective at providing pain relief than the treatment itself (Kalauokalani et al 2001, Bishop et al 2013, Bausell et al 2005). The first two papers were secondary analyses of RCTs and looked at whether patient expectations about the effectiveness of a specific treatment were associated with the outcome (Kalauokalani et al 2001, Bishop et al 2013). They both found that if patients had high expectations of a particular intervention and also received that intervention they had greater benefit than patients who had lower expectations of that intervention. In fact Kalauokalani (2001) found that patients with high expectations of a particular treatment were five times more likely to improve if they received that treatment than patients with low expectations for it and Bishop et al (2013) found that patients who expected manipulation to improve their neck pain and also received it as a treatment had a greater likelihood of improvement in pain after 1 month compared with those who did not believe it would be beneficial but also received it. In terms of comparability both studies looked at common musculoskeletal conditions (low back pain and neck pain) so in that respect are very relevant to our clinical practice. However, there were some differences in measurement tools. A numerical scale of 0-10 was used to rate how helpful a treatment would be by Kalauokalani et al (2001) whereas Bishop et al (2013) used a scale that ranged from ‘definitely agree’ to ‘definitely disagree’ when asked if they believed that the intervention would help. I think that it would be possible to use either of these in clinical practice with our patients but I personally prefer the numerical scale as I feel that it easier to gauge the impact that the condition is having on the patient at that time. The third paper by Bausell et al (2005) looked at the effectiveness of acupuncture on pain relief following dental surgery and also the amount of pain relief achieved based on patient expectations. They measured pain on a visual analogue scale and the amount of pain-free time experienced. This study is harder to relate to our clinical practice because it looks at dental surgery and pain experienced as a result of this. However, I think the important thing to take from it is that the subjects’ beliefs influenced the outcome. Subjects who believed they were receiving true acupuncture experienced less pain overall and took longer to experience moderate pain compared with subjects who were either unsure which group they were in or who believed they were receiving a placebo treatment. These papers demonstrates the importance of being aware that if we can match treatment to patients’ expectations it will lead to a more successful outcome for that patient. It also highlights the importance of discussing possible treatment options with patients and through this offering them the opportunity to participate in decision-making and choice about their treatment.

The clinician’s expectations about the likely effectiveness of an intervention can also influence how effective the patient thinks it is likely to be (Bialosky et al 2008). They investigated how patient expectations of spinal manual therapy would influence hypoalgesia. They hypothesised that there would be a greater hypoalgesic effect in patients who were given positive expectations about the procedure compared with subjects who were given either neutral or negative expectations.  The study does not discuss whether the subjects expectations matched those of the clinician. However, the results demonstrated that patients who received positive expectations from the clinician reported reduced pain perception and patients who received negative expectations reported increased pain perception. These findings support their hypothesis and demonstrate that the effects of manual therapy can be influenced by expectation.  Initially I felt that there may be some limitations in relating this study to clinical practice because it was conducted on healthy subjects with no musculoskeletal problems and no other medical conditions, plus they only received one session of treatment.  Obviously this group of subjects is not representative of our patients, and subjects who are experiencing clinical pain may have different expectations or different perceptions of pain.  However, Vase et al (2003) suggest that desire for pain relief may increase the effect of placebo analgesia.  Also Bialoskey et al (2008) suggest that if patients experience a positive outcome after one session of an intervention, the effect of expectation may increase over several sessions. So, if these two suggestions are correct it is possible that patients who are experiencing clinical pain will actually have a greater response that improves with several treatments compared with the subjects in this study. From this evidence we know that patients’ expectations regarding an intervention can have a more powerful effect than the actual treatment itself.  So not only can higher expectations lead to improved outcomes but, if a patient has a greater expectation for a particular treatment, it may also lead to improved outcome if they receive that treatment, although conversely a negative expectation may lead to a poorer outcome.

But how does this happen? Well, this is where the placebo effect has a role to play.  The placebo effect can be described as “a beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient’s belief in that treatment” (https://en.oxforddictionaries.com).  It is suggested that expectation is one of the mechanisms through which placebo works (Bialosky et al 2011).  Therefore, if a patient believes a treatment will work there is a strong likelihood that they will have a positive outcome from that treatment. From this we can assume that a sham treatment may improve a patient’s condition simply because the person has the expectation that it will be helpful.  Also, the more a person believes that they will gain benefit from a treatment the more likely they are to benefit.  This is something that can be utilised in clinical practice to maximise the effectiveness of our treatments and therefore really emphasises the importance of establishing a patient’s expectations prior to treatment – if we don’t, it is possible we may be missing out on a major factor that can positively influence clinical outcomes.

In this part of my blog I have looked at the effects expectation can have on clinical outcomes and why this may happen.  From this evidence I have learnt that patient expectations are extremely important and really can have a very significant impact on the outcome of an intervention. Considering all this evidence I understand more clearly just how important it is that we not only ask what our patients’ expectations are of physiotherapy, but that we utilise this information to guide our treatment.  I will discuss this aspect in more detail in the second part of my blog where I will consider the implications this has for clinical practice.

 

 

 

References

Bausell, R.B., Lao, L., Bergman, S., Lee, W.L. and Berman, B.M. (2005). Is acupuncture analgesia an expectancy effect? Evaluation & The Health Professions, 28(1) pp9-26.

Benedetti, F., Pollo, 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., Robinson, M.E., Barabas, J.A. and George, S.Z. (2008) The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskeletal Disorders, pp 9:19.

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.

Bishop, M.D, Mintken, P. Bialosky, J.E. and Cleland, J.A. (2013). Patient expectations of benefit from interventions for neck pain and resulting influence on outcomes. Journal of Orthopaedic & Sports Physical Therapy, 43(7), pp 457 – 465.

Kalauokalani, D., Cherkin, D.C., Sherman, K.J., Koepsell, T.D. and Deyo, R.A. (2001). Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. SPINE, 26(13), pp 1418-1424.

Linde, K., Witt, C.M., Streng, A., Weidenhammer, W., Wagenpfeil, S., Brinkhaus, B. Willich, S.N. and Melchart, D. (2007). The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain, 128, pp 264-271.

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.

Vase, L., Robinson, M.E., Verne, G.N. and Price, D.D. (2003). The contributions of suggestion, desire, and expectation to placebo effects in irritable bowel syndrome patients: an empirical investigation. Pain, 105, pp 17-25.

Oxford Dictionaries: https://en.oxforddictionaries.com