Running head: PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 1 Patient and Physical Therapist Healthcare Expectations for Musculoskeletal Pain Rebecca Chavarria, Joel E. Bialosky University of Florida
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 2 Abstract Outcomes in patients with musculoskeletal pain conditions are related to many factors We assessed the relationship between patient and provider interpretation of symptom severity, expectations and success criteria Patients with musculoskeletal pain and their physical therapists (PTs) completed the Patient Centered Outcome Q uestionnaire (P COQ) Independent t tests compared patient and PT ratings of usual pain and interference, success criteria for pain and interference, and expectations for changes in pain and interference Fifteen PTs and 91 patients participated PT and patient perception of pain intensity did not significantly differ (p= 0.46 ); however, PTs perceived the patients to have greater interference with daily activities than the patient reported (p= 0.01 ). PT and patient defined success criteria for pain did not signifi ca ntly differ from each other (p= 0.18 ) PT and patient defined success criteria for interference with daily activit y significantly differed (p=0.01 ) with PTs requiring a greater change for treatment to be considered successful. PT and patient expectations of pain (p=0.21 ) and interference with daily activity did not differ (p=0.48 ). The effectiveness of rehabilitation approaches to treating individuals with musculoskeletal pain is influenced by patient and provider specific factors. Our findings have implications for both prognostic factors related to musculoskeletal pain conditions and health care utilization.
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 3 Patient and Physical Therapist Healthcare Expectations for Musculoskeletal Pain Introduction Approximately 100 million Americans suffer from chronic pain, more than diabetes, heart disease and cancer combined (IOM, 2011). It is also one of the most common reasons for physician visits and sick leave from work. In fact, $560 635 billion are spe nt annually on healthcare for chronic pai n in the United States (IOM, 2011) encumbering families and th e nation with debt. As a result pain is a significant public health problem necessitating improved medical management. Although pain is a universal experience, individual differences in emotion al and cognitive contexts change its severity and response to treatment (IOM, 2011). For example, the amount of muscle damage is not associated with pain intensity following a delayed onset of muscle soreness protocol ( Bishop, Horn, Lott, Arpan, Geor ge, 20 11) and fear of pain corresponds more highly to pain related disability than does pain intensity (Crombez, Vlaeyen, Heuts, Lysen, 1999 ). Identifying the elements that shape the pain experience and subsequent clinical outcomes are necessary to maximize curr ent treatments and direct future ones. Healthcare expectations are a modifiable factor corresponding to clinical outcomes in individuals presenting with pain and represent both a prognostic factor and a potential treatment target (Constantino, Arnkoff, Glass, Ametrano, Smith, 2011; Soroceanu, Ching, Abdu, McGuire, 2012). Patient specific factors such as e xpectation are a significant factor in outcomes for comm on interventions for pain. For example, the effectiveness of proven pain medications is significantly influenced by the context in which the medication is provided (Benedetti et al. 2003; Bingel et al. 2011). Specifically, Bingel et al. (2011) investigate d how positive and negative expectations of treatment outcomes affect the analgesic effect of remifentanil Significant analgesia was observed in response of remifentanil and this effect was significantly greater when combined with positive expectation In terestingly, the analgesic effects of remifentan il were negated when participants were given a negative verbal expectation of treatment. Furthermore, t he clinical literature to date proposes that patient expectations may influence clinical outcomes corresp onding to musculoskeletal pain conditions (Harborow & Ogden 2004; Foster, Thomas, Hill, & Hay 2010; Lutz et al. 2001; Myers et al. 2008; Sderlund & Asenlf 2010; Sullivan et al.
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 4 2011;Vetti et al. 2010) As an example, Myers et al. (2008) compar ed usual ca re alone to usual care plus adjunctive complementary and alternative medical (CAM) therapy for acute low back pain. P atients with higher expectations for recovery were significantly more likely to show improvement over the five weeks of the study regardles s of the intervention group Foster, Thomas, Hill, & Hay (2010) also investigated the link between expectations and clinical outcomes in a trial of exercise and acupuncture for knee osteoarthritis. Patients who received the treatment for which they had hig h expectations of benefit were twice as likely to be classified as a treatment responder at six and 12 months. Collectively, the reviewed literature suggests a relationship between expectation and clinical outcomes in individuals presenting with musculoske letal pain complaints. Furthermore, the literature suggests expectation for treatment effectiveness is at times more influential in the treatment outcomes than the treatment itself. In addition to patient expectation, the h s for their patients presenting with musculoskeletal pain conditions may also play a role in the corresponding clinical outcomes. Witt, Martins, Willich, and Schutzler (2012) investigated the influence of physician expectations on clinical outcomes in a trial of ac upuncture and usual care for patients with chronic pain. Practitioner expectations of substantial improvement were associated with greater pain reduction than with expectations of moderate improvement and no improvement. Galer, Schwuartz, and T urner (1997) investigated whether both patient and provider pre treatment expectations on chronic pain were associated and concluded physician expectations of pain relief were associated with patient reported pain relief and change in pain ratings after a procedure. Harborow & Ogden (2004) found therapist baseline expectation of success to be a strong predictor of effectiveness for patients seeking acupuncture Incongruencies between practitioner and patient predicted expectations have also been correlated with poor outcomes. Parsons et al. (2007) examined that difference in beliefs, preferences, and expectations between providers and their patients made it more difficult for the patients to achieve positive m usculoskeletal outcomes. As an example, patients who predict to discuss their physical and
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 5 psychological aspects of pain with their providers, but are only asked about their physical symptoms, may neglect necessary treatments and hinder recovery. Aims and Hypotheses The purpose of this study was to consider patient and physical therapist perception of pain and interference with daily activities, success criteria for changes in pain and interference with daily activities, and expectations for changes in pain and interference with daily activities. We hypothesized significant differences in how patients and physical therapists perceived pain intensity and interference with daily activities. We hypothesize patients to base successful treatments on higher succe ss criteria than therapists. We also hypothesize patients to have higher expectations of outcomes than therapists. Method A convenience sample of physical therapists working in outpatient orthopedic clinics in Gainesville, Florida was recruit ed through posted flyers and word of mouth. Inclusion criteria for the physical therapists included licensed to practice physical therapy in the United States and English speaking. P hysical therapists meeting the criteria and agreeing to participate sign ed an informed consent form in accordance with the University of Florida Institutional Review Board and completed a demographic questionnaire pertaining to sex, age, years in practice, entry level physical therapy degree, and education beyond their entry l evel degree. Participating physical therapists introduced the study to consecutive new patients during the initial consultation. Inclusion Criteria for pati ents included: a) ages 18 60 years, b) presenting to physical therapy due to a musculoskeletal pa in complaint, and c) English speaking. Exclusion Criteria for patients included: a) presenting for physical therapy for post operative management, b) presenting for physical therapy for pre operative management, and c) presenting to physical therapy wit h multiple diagnoses of musculoskeletal pain complaints (i.e. shoulder and knee pain). Patients meeting the criteria for participation and agreeing to participate signed an informed consent form in accordance with the University of Florida Institutional R eview Board and completed a demographic questionnaire to account for sex, age, employment status, marital status, educational level, health history related to the musculoskeletal pain, duration of symptoms, and previous physical therapy
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 6 treatment. Next, p a tients and therapists each independently completed separate Patient Centered Outcome Questionnaires (PCOQ) (Robinson et al. 2004). The PCOQ is a five item questionnaire with separate 101 point numeric rating scales (0= no pain at all to 100= worst pain ima ginable) that measures the usual desired and expected levels of pain, fatigue, emotional distress, and interference with daily activities. Additionally, the PCOQ requests individuals indicate the level of each domain they would consider only the domains of pain and interference in this study Patients completed the PCOQ based on their own symptoms. In order to indicate patient portion of the PCOQ based upon how they believed the corresp onding patient rated each domain. Physical therapists wer e further instructed to complete the items related to expectation and success based upon their own feelings for that particular patient Data Analysis Descriptive statistics were performed related to relevant demographic information for the participating physical therapists and their patients. A mixed model analysis was performed to assess for therapist effect. N o therapist effect was observed, so the therapi sts were grouped and treated as independent. Next, we were interested in baseline PCOQ measures for the physical therapists and their patients. Independent t tests were used to compare the patient an rference with daily function. Paired t tests we re then used to compare the percentage of change in usual pain and interference both the patients and physical therapists considered a su ccessful outcome and expected. Results Descriptive statistics for physical therapist and patient demographics are listed in Table 1 and Table 2. PCOQ Domain Distributions for physical therapist and patient are listed in Table 3 (see Appendix) Physical therapists considered a 69% reduction in pain as successful and expected a 75% reduction in pain while patients consi dered a 59% reduction in pain as successful and expected a 65%
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 7 reduction in pain as successful. Physical therapist and patient defined success criteria for pain did not significantly differ from each other ( t (181) =1.36, p= 0. 18 ) nor did their expectations for treatment ( t (181) =1.26,p= 0.21 ). A significant difference was not present between physical therapist success criteria and expectations ( t (85) = 0.92, p=0.36) nor between patient success criteria and expectations ( t ( 89 ) = 0.78 p=0.44) i.e. both patients and physical therapists expected successful outcomes. Physical therapists considered a 78% reduction in interference with daily activities as successful and expected an 82% reduction in interference with daily activities. Patients considered a 71% reduc tion in interference with daily activities as successful and expected a 79% reduction in interference. Physical therapist and patient defined success criteria for interference with daily activities significantly differed ( t (1 70 ) = 2 5 6,p= 0. 0 1 ); however, expectation for treatment related to interference with daily activity did not differ ( t (170) = 0.71,p= 0.48 ). Patient success criteria and expectations related to interference with daily activity significantly differed ( t (85) =2.41, p=0.02) indicating they expected to exceed their success criteria. Physical therapist success criteria and expectation were not significantly different ( t (85) = 1.35, p=0.18) indicating they expected the patients to meet the success criteria. Discussion This study examined phy related to intervention and their relationship to each other. Clinical outcomes related to musculoskeletal pain conditions are dependent upon both patient and health care provider specific factors (Whyte & Har t, 2003). Therefore both patient and physical therapist interpretation of pain, success criteria, and expectations for treatment success could be important prognostic indicators for outcomes related to mus culoskeletal pain conditions. First, we consider not significantly differ from report of pain. Similarly, Kapoor agreement of pain severity ratings between patients and clinicians for people with acute low back pain.
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 8 Collectively, the Kapoor et al., study and our own suggest healthcare providers are relatively accurate in Interestingly, physical therapists considered their patients to have significantly greater interference with daily activity than actually reported by patients. These fi ndings are in contrast to other studi es showing Physical therapy practice is patterned after the disablement model and physical therap y practice focuses upon identifying limitations and restoring f unction (Childs et al. 2011; Guccione, 1991 ; Guide to Physical Therapy, 2001 ). Subsequently, physical therapists may focus upon the interference rather than sensory aspect of pain and may ove restimate its severity. Next, we measured patient and physical therapist success criteria for treatment. Patients considered a 59% reduction in pain and a 71% reduction in interference with daily activities as successful. Farrar, Young, LaMoreaux, Werth, & Poole (2001) proposed a clinically significant reduction in pain to be a two point, or 30% decrease, in the pain intensity numerical rating scale. However, our study corroborates findings that patients base success criteria on a much higher change in pai n Specifically, a minimum reduction of 45% and 51% for pain and interference was previously determined as necessary to meet success criteria for patients presenting with musculoskeletal pain (Robinson et al. 2005; Zeppieri et al. 2012). P roviders may need to accomplish larger reductions in pain in order for patients to consider treatment successful. Additional ly, we found physical therapist defined success criteria to differ from the patient for interference with daily activity and neared a significant di fference for pain with physical therapists requiring greater changes in pain and interference than their patients for interventions to be considered successful This is the first study t o consider health care provider defined success criteria for pain and interference. Our findings suggest that similar to their patients, p hysical therapists required greater changes in pain and interference than the 30% commonly advocated ( Farrar, 2001). Furthermore, physical therapists had significantly greater success cri teria for interference than their patients. While speculative, these findings have implications for health care utilization as the discrepancies could result in physical therapists treating patients longer than necessary for the patient to consider treatm ent successful
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 9 Third, we wished to consider patient and physical therapist expectation for treatment. Patients expected a 65% reduction in pain and a 79% reduction in interference with daily activities. Physical therapist expectation for treatment did no t differ from that of patients and both physical therapists and patients expected successful outcomes for both pain and interference with daily activities. Our findings are comparable to others reporting patient and provider expectations c oincide (Hassan et al. 2011 & Mancu so et al. 2007). The literature suggests that patient and provider baseline e xpectations for treatment are correlated with treatment outcomes (Galer, Schwarts, & Turner, 1997; Kapoor, Shaw, Pransky, & lich & Schutzler, 2012). Our findings suggest these two potential prognostic indicators are similar between patient and practitioner. Future studies may wish to consider mismatches between patient and clinician expectations at an individual level and thei r effect on clinical outcomes Also, expectations are capable of being modif ied (Hassan et al. 2011 & Mancu so et al. 2007). Future studies may wish to consider the effect on clinical outcomes when patients or practition er expectations are manipulated, or made to agree. Limitations of this study include a convenience sample of patients that may not be representative to other populations with musculoskeletal pain. Also, there may a fabricated significance of a d omain if p atients unintentionally carryover their high expectati ons from one target to another, such as interference or pain. Conclusion We found an alignment between physical therapist s and patient s in perception of pain but physical therapists interpreted their level of interference as higher than did the patients themselves. P hysical therapists defined higher success criteria for interference than patients and this relationship neared significance for pain Both physical therapists and patients had si milar expectations for the effectiveness of treatment. These findings have implications for prognostic factors related to musculoskeletal pain conditions and healthcare utilization by patients presenting with musculoskeletal pain conditions.
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 10 Appendix Table 1: Physical Therapist Demographics Variable Mean (SD) Age (y) 33.3 (5.0) Experience (y) 7.3 (5.9) Sex Female Male 7 8 Table 2: Patient Demographics Variable Mean (SD) Age (y) 38.7 (12.2) Sex Female Male 64 27 Location Neck Upper Extremity Low Back Lower Extremity 10 19 25 37 Duration of Symptoms (weeks) 47.3 (129.3)
PATIENT AND PHYSICAL THERAPIST EXPECTATIONS 11 Table 3: PCOQ Domain Distributions for Physical Therapist and Patient PCOQ Domain Variable Physical Therapist Mean ( SD ) Patient Mean ( SD ) p value difference Usual levels Pain Interference 47.82 ( 24.78 ) 54.25 ( 25.71 ) 49.88 (2 8.03 ) 45.46 ( 29.31 ) 0.46 0.01 Successful levels Pain Interference 12.14 ( 9.55 ) 10.71 ( 10.07 ) 14.96 ( 15.68 ) 10.75 ( 14.73 ) 0.09 0.98 Expected levels Pain Interference 12.25 ( 12.57 ) 9.72 ( 10.89 ) 15.53 ( 19.77 ) 9.18 ( 15.19 ) 0.10 0.69 Importance levels Pain Interference 87.25 ( 20.71 ) 93.02 ( 16.75 ) 89.40 ( 23.78 ) 83.19 ( 29.55 ) 0.50 <0.01
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