An investigation of patients' expectations of outpatient physiotherapy for peripheral musculoskeletal conditions and their effect on treatment outcome
Little or no research has been conducted to explore patients' expectations of physiotherapy, or the effect that pre-conceived expectations might have on the outcome of treatment. This thesis aimed to fill that void. Stage one involved a review of the literature to develop a conceptual framework and understanding of expectations and how they may affect outcome. Stage two explored the evidence regarding the role of patients' expectations of physiotherapy and the impact that such expectations may have on the outcome of treatment. Three studies were carried out (1) a Delphi study with physiotherapists; (2) exploratory interviews with patients; and (3) the development and testing of a questionnaire. Stage three examined the relationship between patients' expectations of benefit and the outcome of physiotherapy using a postal survey of patients, with upper or lower limb musculoskeletal problems. Stage four consisted of a randomised-controlled trial aimed at determining whether manipulation of patients' expectations of benefit could influence treatment outcome in patients with non-traumatic knee problems. The results from stage one suggested that patient expectations were likely to be associated with patients' previous experiences of physiotherapy, anecdotal knowledge, preferences, expectation of benefit, time related issues, such as duration of condition (chronicity), educational level and work status. In stage two, the Delphi study with thirteen physiotherapists, resulted in a list of factors, ranked in order of importance, that they believed may influence the outcome of physiotherapy. The list concurred with the literature. Twelve patients were then interviewed. They generally had a positive view of physiotherapy, understood why they needed to have physiotherapy, but had limited knowledge of what physiotherapy is, what physiotherapists do or what level of involvement that they would have in their treatment. Their knowledge came mainly from first-hand or anecdotal experience of physiotherapy. Finally, a questionnaire was developed to gather information on patients' expectations and tested on 18 patients. The survey in stage three (n=289) found statistically significant positive relationships (p<0.002) between expectations of benefit before treatment and trauma, upper limb problems, locus of control and satisfaction with the health care received so far. Furthermore, negative relationships were found between the expectations variable and duration of condition and previous experience of physiotherapy. A statistically significant positive relationship (p<0.004) was also found between expectations of benefit and treatment outcome in terms of change in functional disability, perceived improvement, change in health status and satisfaction. Finally, 95 patients with nontraumatic knee problems participated in the randomised controlled trial in stage four. However, the results found no evidence that the intervention, through changes In expectations or locus of control, improved the outcome of physiotherapy. The research carried out in this thesis appears to support the notion that the characteristics that patients demonstrate in terms of their beliefs, perceptions and cognitions appear to have some influence on the course of their physiotherapy. The findings suggest that physiotherapists need to be more aware of the psychological attributes of their patients as well as the effect that their intervention (communication, handling and therapeutic) has on their patients' beliefs, perceptions and cognitions. However, further research is needed to determine whether, and by what means, patients' expectations can be influenced to improve the outcome of physiotherapy.