Using stakeholder perspectives to explore the implementation of evidence-based practice in the management of musculoskeletal shoulder pain

Background: Shoulder pain is a highly prevalent musculoskeletal condition, often resulting in persistent pain and disability frequently lasting beyond 6 months. Research in this area has identified numerous examples of stakeholders not adhering to best-evidence recommendations in the management of this condition, including an over reliance on imaging, growing surgery rates and inconsistencies in the provision of first-line treatments, such as exercise therapy. To address these evidence-practice gaps, researchers are increasingly advocating the need to explore stakeholder perspectives to better understand their experiences of managing this condition and the challenges they face when attempting to implement current evidence-based recommendations.

Objectives: 1) To review and synthesize qualitative research studies exploring the experiences of individuals living with shoulder pain, as well as healthcare providers (HCPs) involved in their care, 2) To explore the views and experiences of HCPs and people living with musculoskeletal shoulder pain on treatment decision‐making, 3) To identify the priorities of individuals with musculoskeletal shoulder pain and their HCPs that are perceived to foster adherence to evidence-based recommendations.

Methods: A mixed-methods approach was used. Firstly, a protocol was developed for a qualitative evidence synthesis, employing a meta-ethnographic approach, to synthesise the experiences of people living with shoulder pain, as well as HCPs involved in their care. Because of the large number of studies identified, the experiences of patients and of HCPs were analysed and synthesized separately (Chapters 2 & 3). A qualitative study was subsequently conducted, informed by a constructivist grounded theory approach, exploring the views and experiences of stakeholders relating to treatment decision-making. The final study was a mixed-methods design informed by concept mapping methodology which involved an online survey-based study to identify the priorities perceived by stakeholders to foster adherence to evidence-based recommendations for musculoskeletal shoulder pain. A public and patient involvement (PPI) panel assisted in the analysis and interpretation of findings within the two latter studies conducted.

Results: Findings from the first qualitative evidence synthesis highlighted the severe emotional and physical turmoil caused by this debilitating condition, with strongly held biomechanical beliefs negatively influencing engagement with exercise therapy. In the second synthesis study, a lack of consensus was expressed amongst HCPs on the optimal approach to managing shoulder pain, describing numerous perceived challenges to getting patients to buy-in to first-line treatment. HCPs admitted to knowingly deviating from evidence-based treatments when these conflicted with their clinical experience, beliefs, patient expectations and personal preferences. Exploring stakeholder treatment decision-making revealed the strong influence of biomechanical beliefs of pain and the therapeutic alliance on their treatment decisions. HCPs occasionally opted to provide less evidenced-based treatment to help cater for patient expectations and preserve this alliance. Despite the perceived importance of the alliance, few patients described experiencing a shared decision-making process, with HCP appraisal of patients sometimes being in direct conflict with the tenets of a positive alliance. In the final study, a consensus emerged amongst stakeholders on prioritising the need for education related to expected progress and recovery timelines as well as treatment options and supporting evidence to enhance adherence to evidence-based treatment. While a strong therapeutic alliance was highlighted as being of pivotal importance in supporting adherence to evidence-based treatment, neither stakeholder group prioritised a shared decision-making approach.

Conclusion: Stakeholders face many challenges and uncertainties in trying to manage shoulder pain. The predominance of a biomedical understanding of pain appears to act as a deterrent on patient engagement with first-line treatment and adversely affects HCPs’ attempts to sell this approach. A strong therapeutic alliance is considered by stakeholders to play an important role in facilitating the implementation of evidence-based recommendations. However, training is required for HCPs to facilitate more positive alliances and to employ a shared decision-making approach. The involvement of all stakeholders in future research, having a clear focus on guidance development and coherent policy implementation, is crucial for the development of best-practice evidence?based approaches for the management of musculoskeletal shoulder pain.