Physiotherapy is a common point of referral for many people with musculoskeletal shoulder pain. Although effective for many, not all people will benefit. This study identified which patient characteristics and baseline measures, commonly assessed at the first physiotherapy appointment, are associated with outcome six months later.

1,030 people attending physiotherapy for the treatment of musculoskeletal shoulder pain across the East of England were included in the study. We collected information on 71 patient characteristics and clinical examination findings.

A number of factors were associated with outcome. The most important predictor of outcome was the person’s pain and disability at the first appointment - higher levels were associated with higher levels six months later. However, high pain self-efficacy and a high expectation of recovery could change this to a better outcome. Pain self-efficacy is a person’s confidence in their ability to do things despite their pain. 

Key Research Questions

For people attending physiotherapy for the management of musculoskeletal shoulder pain:

  1. Which patient and clinical characteristics, commonly assessed at the first physiotherapy appointment, are associated with patient-rated shoulder pain and function, at six weeks and six months.
  2. Which prognostic factors are most influential in predicting outcome.
  3. What is a typical course of physiotherapy and the related outcome.

What is the relative responsiveness of the SPADI and QuickDASH and the correlation between the two measures.

Research Design 

This multicentre cohort study of 1030 participants at baseline is the largest in Europe and the first worldwide to investigate the association of a range of biopsychosocial factors at the start of treatment with the outcome of physiotherapy.

It is the first study to include 1) psychological and physical examination variables at baseline using validated measures and pre-defined, standardised operating procedures 2) the SPADI and QuickDASH the same cohort. These two instruments enable outcome to be measured in a range of categories from the International Classification of Functioning Disability and Health (ICF) (World Health Organisations, 2001)

This is the first study to demonstrate that patient expectation and pain self-efficacy are consistently associated with outcome and that clinical examination findings indicative of a structural diagnosis are not. This suggests that physiotherapists should incorporate patient expectations and beliefs into their management, and place less emphasis on a biomedical approach.

The Research Team

  • Chief Investigator: Dr Rachel Chester, UEA
  • Professor Christina Jerosch Herold,* UEA
  • Professor Lee Shepstone,* UEA
  • Dr Mizan Khondoker, UEA
  • Professor Jeremy Lewis,** University of Hertfordshire

*Academic and **Clinical Supervisors during Rachel’s PhD


Dr Rachel Chester was funded by the National Institute for Health Research (NIHR) Clinical Doctoral Research Fellowship (NIHR CAT CDRF 10-008).

Professor Christina Jerosch Herold was funded by the NIHR Senior Research Fellowship (NIHR- SRF-2012-05-119).

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