Thoracic spinal manipulation for musculoskeletal shoulder pain: Can an instructional set change patient expectation and outcome?

Study design: Planned secondary analysis of a randomized clinical trial.

Objectives: To examine: 1) patients' baseline expectations for treatment outcome of thoracic high velocity low amplitude thrust manipulations (HVLATM) to the thoracic spine for shoulder pain; 2) if the message conveyed by the clinician changed the patients' expectation; 3) any differences in outcome based on expectation independent of messaging.; and 4) any differences in outcome for those patients whose expectations significantly changed as a result of the messaging.

Background: Thoracic HVLATM may be an effective intervention for patients suffering from musculoskeletal shoulder pain. The role of expectation in the treatment effectiveness of this intervention has not been established.

Methods: Subjects' expectations regarding the effectiveness of HVLATM on shoulder pain were recorded at baseline. This was reassessed immediately following the provision of positive or neutral instructional set. The subjects then received a thoracic or scapular HVLATM. The Shoulder Pain and Disability Index (SPADI) and the numeric pain rating scale (NPRS) were used as outcomes measures.

Results: There was a 10 subject change (23%) in positive expectation that was statistically significant (p = 0.019) following a positive message. There was no statistically significant difference in pain and function when these subjects were compared to all other subjects.

Conclusion: Although patients' expectations of positive outcome significantly changed when providing a positive instructional set, these changes did not translate into clinically significant short term changes in shoulder pain and function.

Level of evidence: 1b.