Patient expectations of benefit from interventions for neck pain and resulting influence on outcomes

Abstract

Study design: Retrospective cohort.

Objectives: The objectives of this study were (1) to examine patients' general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain, and (2) to assess the extent to which the patients' general and specific expectations for treatment, particularly spinal manipulation, affect clinical outcomes.

Background: Patient expectations can have a profound influence on the magnitude of treatment outcome across a broad variety of patient conditions.

Methods: We performed a secondary analysis of data from a clinical trial of interventions for neck pain. Prior to beginning treatment for neck pain, 140 patients were asked about their general expectations of benefit as well as their specific expectations for individual interventions. Next, we examined how these expectations related to the patients' ratings of the success of treatment at 1 and 6 months after treatment.

Results: Patients had positive expectations for treatment by a physical therapist, with more than 80% of patients expecting moderate relief of symptoms, prevention of disability, the ability to do more activity, and to sleep better. The manual therapy interventions of massage (87%) and manipulation (75%) had the highest proportion of patients who expected these interventions to significantly improve neck pain. These were followed by strengthening (70%) and range-of-motion (54%) exercises. Very few patients thought surgery would improve their neck pain (less than 1%). At 1 month, patients who were unsure of experiencing complete pain relief had lower odds of reporting a successful outcome than patients expecting complete relief (odds ratio [OR] = 0.33; 95% confidence interval [CI]: 0.11, 0.99). Believing that manipulation would help and not receiving manipulation lowered the odds of success (OR = 0.16; 95% CI: 0.04, 0.72) compared to believing manipulation would help and receiving manipulation. Six months after treatment, having unsure expectations for complete pain relief lowered the odds of success (OR = 0.19; 95% CI: 0.05, 0.7), whereas definitely expecting to do more exercise increased the odds of success (OR = 11.4; 95% CI: 1.7, 74.7). Regarding self-reported disability assessed with the Neck Disability Index, patients who believed manipulation would help and received manipulation reported less disability than those who did not believe manipulation would help and both received manipulation (mean difference, -3.8; 95% CI: -5.9, -1.5; P = .006) and did not receive manipulation (mean difference, -5.7; 95% CI: -9.3, -2.1; P = .014). There was also an interaction between time and the expectation for complete relief.

Conclusion: General expectations of benefit have a strong influence on clinical outcomes for patients with neck pain.

Level of evidence: Prognosis, level 2b-.

Figures

FIGURE 1

Participants’ general expectations of outcome from receiving interventions performed by a physical therapist. Participants responded to the statement, “What results do you expect from your treatment?” General expectations are rank ordered based on the proportion of participants indicating “yes,” which comprised “definitely yes” and “probably yes,” or those indicating “no,” which comprised “probably not” and “definitely not.” *Only 60% of participants responded to this item.

FIGURE 2

Participants’ specific expectations of benefit from common interventions for “this episode of neck pain.” Interventions are rank ordered based on the proportion of participants who “agreed” with the statement, “I believe [the intervention] will significantly help to improve this episode of my neck pain.” “Agree” included the collapsed categories “completely agree” and “agree.” “Disagree” included the collapsed categories “completely disagree” and “disagree.” Abbreviation: ROM, range of motion.

FIGURE 3

Interaction effect of “matched” intervention and time on self-reported disability. *BY greater than BN and DNBN (P = .001). Abbreviations: BN, believed manipulation would help and did not receive manipulation; BY, believed manipulation would help and received manipulation; DNBN, did not believe manipulation would help and did not receive manipulation; DNBY, did not believe manipulation would help and received manipulation.