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Physiotherapy works better when you believe it will help you – new study

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Rachel Chester, University of East Anglia

People with shoulder pain who expect physiotherapy to help them are likely to have a better recovery than those who expect only minimal or no improvement, according to our latest study. We also found that people are likely to have a better recovery if they are confident they will be able to continue doing things that are important to them, such as socialising, hobbies and work.

Shoulder pain affects people of all ages and can become persistent. Injury and overuse are common causes of shoulder pain, but sometimes the cause is unclear. It can disturb sleep, interfere with work, leisure and everyday activities like washing and dressing. Exercise, prescribed by physiotherapists, is an effective treatment for shoulder pain, but not everyone benefits from physiotherapy.

Researchers from the University of East Anglia and the University of Hertfordshire in the south-east of England, together with local physiotherapists, wanted to find out more about the characteristics of people who benefit from physiotherapy compared with those who continue to experience persistent pain and disability.

Knowing the outcome is important for people with shoulder pain as it helps them decide whether or not to pursue a course of physiotherapy.

Our study, published in the British Journal of Sports Medicine, included 1,030 people attending physiotherapy for musculoskeletal shoulder pain in 11 NHS trusts across the east of England. We collected information on 71 patient characteristics, such as age, lifestyle and medical history, and clinical examination findings before and during the patients’ first physiotherapy appointment.

A total of 811 people provided information on their shoulder pain and function six months later.

Not everyone benefits from exercise to ease shoulder pain.
Vershinin89/Shutterstock

Surprise finding

What surprised us was that patients who had said they expected to “completely recover” as a result of physiotherapy did even better than patients who expected to “much improve”.

The most important predictor of outcome was the person’s pain and disability at the first appointment. Higher levels of pain and disability were associated with higher levels six months later. And lower baseline levels were associated lower levels six months later. But this relationship often changed for people who had high “pain self-efficacy”, that is, confidence in the ability to carry on doing most things, despite having shoulder pain.

Another surprise finding was that people with high baseline pain and disability, but with high levels of pain self-efficacy did as well as, and sometimes better than, people with low baseline pain and disability and low pain self-efficacy.

First study of its kind

This is the first study to investigate patient expectations of the outcome of physiotherapy for shoulder pain. Earlier research shows that high patient expectation of recovery predicts a better outcome following physiotherapy for back pain and neck pain, and a better outcome following orthopaedic surgery.

On a similar note, this is the first study to show that higher pain self-efficacy predicts a better outcome in non-surgically managed shoulder pain. Previous research has shown that self-efficacy predicts a better outcome for a range of other health conditions. Also, people with higher self-efficacy are more likely to do the home-exercise programme suggested by their physiotherapist.

If you have shoulder pain, there are several ways to increase your pain self-efficacy. Work with your physiotherapist to understand and manage your symptoms. Practice your exercises together and ask your physiotherapist for feedback, including how to adjust your exercises to make them harder or easier. Finally, make sure you discuss what you want with your physiotherapy and the activities that are important to you.The Conversation

Rachel Chester, Lecturer in Physiotherapy, University of East Anglia

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Needless treatments: spinal fusion surgery for lower back pain is costly and there’s little evidence it’ll work

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Back pain affects one-quarter of Australians.
from shutterstock.com

Gustavo Machado, University of Sydney; Christine Lin, University of Sydney, and Ian Harris, UNSW

From time to time, we hear or read about medical procedures that can be ineffective and needlessly drive up the nation’s health-care costs. This occasional series explores such needless treatments or procedures individually and explains why they could cause more harm than good in particular circumstances.


Back pain affects one in four Australians. It’s so common, nearly all of us (about 85%) will have at least one episode at some stage of our lives. It’s one of the most common reasons to visit a GP and the main health condition forcing older Australians to retire prematurely from the workforce.

Treatment costs for back pain in Australia total almost A$5 billion every year. A great proportion of this is spent on spinal surgical procedures. Recently, Choosing Wisely, the campaign to educate medical professionals and the public about tests, treatments and procedures that have little benefit, or lead to harm, added spinal fusion for lower back pain to its list.




Read more:
Australians are undergoing unnecessary surgery – here’s what we can do about it


This is because, despite rates of the procedure being on the rise, current evidence doesn’t support spinal fusion for back pain. Randomised trials (regarded as studies providing the highest-quality evidence) suggest spinal fusion has little advantage over a well-structured rehabilitation program, or psychological interventions, for back pain.

What is spinal fusion?

Spinal surgery is most commonly performed to remove pressure on nerves that causes pain and other nerve symptoms in the legs. This surgery is called decompression. The next most common procedure is spinal fusion, where two or more vertebrae are joined together (using such methods as transplanted bone from the patient, a donor or artificial bone substitutes) to stop them moving on each other and make one solid bone.

Spinal fusion may be performed for fractures, dislocations and tumours, and is commonly performed in conjunction with decompression. For back pain, it’s performed when the origin of the pain is thought to be related to abnormal or painful movement between the vertebrae (from degenerative joints and discs, for example).

Rates of spinal fusions have been rising and continue to increase, outstripping other surgical procedures for back pain. In the United States, rates of spinal fusion more than doubled from 2000 to 2009. In Australia, rates increased by 167% in the private sector between 1997 and 2006, despite almost no increase in the public sector.

Spinal fusion rates differ significantly between regions of Australia, with the highest being in Tasmania and the lowest in South Australia: a seven-fold variation. Significant variations are also seen between countries. For instance, spinal fusion rates in the United States are eight times those in the United Kingdom.

Rates of spinal surgery are on the rise, despite little evidence of effectiveness.
from shutterstock.com

The greatest increase in the use of spinal fusion has been in older Australians, often in conjunction with decompression surgery for spinal stenosis – a condition that causes narrowing of the spinal canal (the cavity that runs through the spinal cord).

Differences in clinical training, professional opinion, and local practices are likely to play a role in such variations.

Evidence for spinal surgery

There is little high-quality evidence to support the use of spinal fusion for most back-related conditions, including spinal stenosis. And there is disagreement between surgeons on when spinal fusion surgery should be performed, not only for back pain but also for more acute conditions such as tumours and spine fractures.

There have also been no studies comparing spinal fusion to a placebo procedure. Most research to date compares one fusion technique to another technique or to a form of non-surgical treatment, so we still don’t know whether spine fusion is effective against placebo.

We also know that spine fusion surgery is expensive and associated with more complications than decompression surgery. And the surgery often fails. Around one in five patients who undergo spine fusion will have revision surgery within ten years.

Research also shows most patients having spine fusion surgery under workers’ compensation won’t return to the usual job, will still be having physiotherapy and be on opioid medication two years after surgery.




Read more:
Thinking of taking opioids for low back pain? Here’s what you need to know


So why are rates going up?

There are several factors, including an ageing population, that may contribute to the rapid increase in spinal fusion despite the lack of evidence supporting its use. Financial incentives might also explain the differences in rates between private and public sectors in Australia and between the United Kingdom and the United States.

We don’t have high-quality evidence on the benefits and harms of spinal fusion. This means there is uncertainty, which allows practitioners to continue doing the procedures they were trained to do unchallenged. This then leads to overtreatment, particularly where reimbursement rates are high, such as in the workers’ compensation setting.

Uncertainty about the appropriateness of spine fusion results in practice variation, wastes scarce health care resources and leads to worse patient outcomes.

We need better research in this area. This means research efforts should shift from studies looking at different ways of performing the surgery and focus on investigating whether or not it works better than non-operative treatments or a placebo, and, if so, whether the benefits outweigh the harms.

In the absence of such evidence, patients can consider other evidence-based and less costly treatments, such as exercise, cognitive behavioural therapy and physiotherapy.




Read more:
Ouch! The drugs don’t work for back pain, but here’s what does


The Conversation


Gustavo Machado, NHMRC Early Career Fellow, University of Sydney; Christine Lin, Principal Research Fellow and Associate Professor, University of Sydney, and Ian Harris, Professor of Orthopaedic Surgery, UNSW

This article is republished from The Conversation under a Creative Commons license. Read the original article.