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FOTO Rehab Outcomes Blog

Risk of Persistent Shoulder Pain

We spend a lot of time performing thorough assessments. Are we missing something really, really important that can help with prognosis?

risk-persistent-shoulder-painThe research continues to strongly indicate exactly what FOTO team takes into consideration in the risk adjustment process. When a patient begins services, the amount of perceived disability matters with regard to the outcome of care.  The level of functional ability is a very strong predictor. The research below indicates it was the highest predictor of outcome.

 The next findings are interesting. How often do you ask if the patient believes services will be beneficial and that their condition will improve? This proves to be a powerful question. Patients who expected services to be beneficial had better outcomes.

Pain self-efficacy also proved to be valuable.  Although the patients were experiencing pain, their belief about their ability to complete tasks while in pain provided insight into outcomes. Those who had high pain self-efficacy beliefs tended to attain better outcomes.

The findings suggest that gaining information from patients about expectations and pain self-efficacy are helpful pieces of information to help in providing care or making care decisions. FOTO does have self-efficacy measures included as optional assessments for you to include when gaining baseline information.

The abstract is included below for you to review.

Self-efficacy and risk of persistent shoulder pain:results of a Classification and Regression Tree (CARTanalysis.




To (i) identify predictors of outcome for the physiotherapy management of shoulder pain and (ii) enable clinicians to subgroup people into risk groups for persistent shoulder pain and disability.


1030 people aged ≥18 years, referred to physiotherapy for the management of musculoskeletal shoulder pain were recruited. 810 provided data at 6 months for 4 outcomes: Shoulder Pain and Disability Index (SPADI) (total score, pain subscale, disability subscale) and Quick Disability of the Arm, Shoulder and Hand (QuickDASH). 34 potential prognostic factors were used in this analysis.


Four classification trees (prognostic pathways or decision trees) were created, one for each outcome. The most important predictor was baseline pain and/or disability: higher or lower baseline levels were associated with higher or lower levels at follow-up for all outcomes. One additional baseline factor split participants into four subgroups. For the SPADI trees, high pain self-efficacy reduced the likelihood of continued pain and disability. Notably, participants with low baseline pain but concomitant low pain self-efficacy had similar outcomes to patients with high baseline pain and high pain self-efficacy. Cut-off points for defining high and low pain self-efficacy differed according to baseline pain and disability. In the QuickDASH tree, the association between moderate baseline pain and disability with outcome was influenced by patient expectation: participants who expected to recover because of physiotherapy did better than those who expected no benefit.


Patient expectation and pain self-efficacy are associated with clinical outcome. These clinical elements should be included at the first assessment and a low pain self-efficacy response considered as a target for treatment intervention.

 2019 Jan 9. pii: bjsports-2018-099450. doi: 10.1136/bjsports-2018-099450. [Epub ahead of print]


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