Factors other than Clinical Examination findings predict the Outcome of Physiotherapy for Shoulder Pain

The aim of this study was to identify which patient characteristics (baseline measures), commonly assessed at the first physiotherapy appointment are associated with the outcome of physiotherapy for musculoskeletal shoulder pain.


The results of this study indicate that lower baseline disability, a higher patient expectation of recovery as a result of physiotherapy, higher pain self-efficacy, lower pain severity at rest, no additional health problems, being in employment or education rather than being unemployed or on long term disability, and a shorter duration of symptoms were consistently associated with a better outcome.


The physiotherapist’s expectation of recovery, the patient’s age and clinical examination findings commonly associated with a structural diagnosis (for example, a painful or stiff restriction of external rotation or an external rotation lag), were not consistently associated with outcome. The only clinical examination finding consistently associated with outcome was a decrease in pain or increase in range of movement during manual facilitation of the scapula around the chest during arm elevation. This was associated with a better outcome.


Patients who returned their follow up questionnaires were twice as likely to participate in some form of weekly leisure time physical activity compared to those who did not return their questionnaires. This difference may have decreased the power of the study to detect a more consistent association between leisure time physical activity and outcome.


Prognostic factors may not simply be present or absent but may form a continuum. In our study, for example, patients expecting a “complete recovery” when they started their course of physiotherapy had better mean outcomes than those expecting to “slightly improve”; however, they also had better outcomes, albeit of lesser degree, than those expecting to “much improve”.


The International Classification of Functioning, Disability and Health (ICF) (World Health Organisation, 2001) states that the relative impact of body structure and function, activity, participation, personal and environmental factors, on our perceived health at any one time changes. As health professionals, in partnership with our patients, we aim to reduce pain and restore body movement and function in order to increase activity and participation. But contextual factors associated for example, with psychosocial health, are significantly and consistently associated with the success of these objectives.


The clinical examination and structural differentiation can account for a substantial proportion of the physiotherapy assessment. This predominantly biomedical assessment is facilitated by good communication and empathy. However, this is not the same as a biopsychosocial assessment. For example, we quantify different aspects of movement but don’t always quantify measures of psychological health. Yet for the patient in front of us, these factors may be associated with therapy adherence and modifiable predictors of outcome (Ashford et al, 2010; Greenberg et al, 2006; Lundahl et al, 2013; McGrane et al, 2015). Research suggests that some form of structure, such as the use of psychosocial screening questionnaires may improve physiotherapists’ ability to identify psychosocial factors that may influence recovery (Beales et al, 2016). In turn, this can guide healthcare professionals to implement and monitor interventions which target these psychosocial domains and assess for associated changes in outcome.



Dr Rachel Chester is a Lecturer in Physiotherapy at the University of East Anglia, UK. In addition to her teaching and research, Rachel also works as a Clinical Physiotherapy Specialist at the Norfolk and Norwich University Hospital, UK. She has worked in the NHS and privately.

Rachel completed her PhD on Prognostic Factors for Shoulder Pain in 2015. This was funded by a National Institute for Health Research Clinical Doctoral Research Fellowship.

Twitter: @ClinPhysioRes

UEA Webpage: https://www.uea.ac.uk/health-sciences/people/profile/r-chester

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