Discussion
This study explored the barriers and enablers to physiotherapist-prescribed rehabilitation exercises for people with RCRSP. Deductive thematic analysis was used to synthesise barriers and enablers to the following sections of the topic guide; initial consultation, HEP experience and patient education. Subthemes were then identified and included the patient’s previous knowledge and experience, their relationship with the physiotherapist and understanding of the condition, their beliefs about scans, the treatment pathway, their experience of doing the home exercise rehabilitation programme and the impact of seeing positive outcomes. Subthemes were then mapped to 10 TDF domains and linked to BCTs to illustrate relevant techniques for future intervention development. These findings will inform the development of a theoretically informed intervention to enhance adherence to shoulder rehabilitation exercises.
During the initial consultation, participants who reported successful previous physiotherapy treatment or were aware of a family member’s successful treatment indicated a belief in the benefit of physiotherapy exercises. It has previously been reported that patient expectation of benefit is a stronger predictor of conservative treatment outcomes than structural factors, such as a rotator cuff tear.22 In addition, it is recommended that healthcare professionals (HCP) monitor patients’ pain self-efficacy (the confidence one has to perform their activities and achieve their goals despite symptoms or pain) as it is a useful indicator of outcomes.23 For those presenting with an opposing view, White et al24 identified the need for HCPs to engage these patients early in the treatment process to address fear, misconceptions and expectations through appropriate educational strategies.24 Participants in our study who had no previous physiotherapy experience or poor experiences did not think that physiotherapy exercises worked. Studies in the UK25 and overseas26 report a lack of public awareness of physiotherapy, highlighting a clear need to raise awareness and knowledge of physiotherapy to encourage autonomous health-seeking behaviours. This approach is consistent with a growing evidence base and aligns with providing patient-centred care for musculoskeletal conditions.
In this study, the patient–therapist relationship was important to support the patient’s understanding of their condition and the importance of rehabilitation exercises. These findings are supported by Cridland et al,27 who conducted interviews with people with RCRSP (n=8) and found that trusting the HCP who provides education and guidance facilitates adherence to recommendations and reassurance that the condition will be effectively treated.27 Further evidence from a systematic review28 demonstrated that the therapeutic alliance’s role in physical rehabilitation positively affected treatment outcomes. Building on the patient–therapist relationship from the initial consultation, the BCT ‘social support ’ (unspecified) is suggested to increase adherence to exercise levels in patients with upper extremity musculoskeletal disorders.13 29 30 Supporting patients via telephone calls and text messages with positive reinforcement and encouragement may increase patient optimism and confidence in doing the exercises and self-efficacy.13 30 Higher self-efficacy has been linked to improved health behaviours such as adherence. These findings highlight the importance of establishing a strong therapeutic alliance. However, HCP admittedly expressed concerns that there were no formalised or consistent processes towards learning to deliver patient education.24 Our results provide preliminary data on key components to promote an effective therapeutic relationship. Specifically, helping patients understand the problem and address their treatment expectations.
Participants’ belief of a pathomechanical cause of their RCRSP and expectation for an unequivocal diagnosis involving imaging is incongruent with clinical guidelines.6 Yet the antithesis to this was seen where few patients were exasperated by subsequent investigations revealing relevant findings that they believed should have been scanned at the initial consultation. In a randomised control trial involving 1308 individuals, diagnostic labels used for rotator cuff disease were shown to encourage people to consider surgical treatment.31 Terms like subacromial impingement syndrome had a higher perceived need for imaging compared with bursitis, and those labelled with a rotator cuff tear had a higher perceived need for surgery and imaging compared with those labelled with bursitis. Diagnostic imaging for RCRSP is considered unnecessary as it cannot reliably identify a specific cause of the condition and does not inform management decisions.32 33 HCPs are encouraged to avoid such biomedical labels for RCRSP, which contribute to a perceived need for unnecessary care and a barrier to patient engagement in self-management. Considering that the evidence shows that diagnostic uncertainty for shoulder pain is apparent in clinicians and patients,34 pieces of advice and education need to expand beyond tissue pathology and include neurosciences, physical activity and lifestyle factors, as outlined in a recent scoping review.35
Patients voiced their frustrations about the lengthy waits for appointments, which was further compounded by the impact of COVID-19. An excessively convoluted and protracted pathway to treatment was described in a multicentre pilot randomised control trial by 20 patients listed for surgical repair of the rotator cuff.36 Better supporting patients awaiting follow-up consultation may improve their experience of the pathway to treatment.
The HEP was the option for some participants instead of surgery. An overview of 15 systematic reviews of RCTs found no differences in clinical outcomes between supervised exercise and surgery in people with shoulder impingement.37 Shoulder-specific exercises were recommended as the first line of conservative management to improve outcomes for people with shoulder impingement syndrome37 and is corroborated in another review for people with subacromial shoulder pain.5 A recent meta-analysis compared the effect of conservative and surgical management for rotator cuff tears on pain and shoulder function.38 No significant difference between the surgical and conservative groups in terms of function was found, while the benefit for pain was greater in the surgical repair group at 1-year follow-up. Variations in tendon tears, surgical procedure used and dose of rehab exercises contributed to extensive heterogeneity in the cohorts analysed. Given the burden of surgery and the lack of its superiority over conservative management for RCRSP, these findings provide important evidence for educating patients about their treatment options.
Pain was found to be both a barrier and an enabler for people with RCRSP to perform their HEP. Those unable to do the exercises due to pain justified their perceived need for a corticosteroid (CS) injection, which facilitated a pain-free period for them to engage with the HEP. Systematic reviews show that CS injection may have a short-term benefit over placebo in reducing pain and improving function39–41 while a recent meta-analysis found only a small transient pain relief in a small number of patients with RCRSP.42 These findings suggest that the application of CS injection may offer minimal benefit for some patients to allow them to do the HEP.
In some patients who reported that the HEP reduced their pain, it increased their motivation to continue exercising. In another study using semistructured interviews with people with RCRSP (n=12), some interviewees found reduced shoulder pain from doing the exercises.43 Similarly, improvements in the range of movement and ability to perform functional tasks were perceived as a benefit of doing the HEP in the current study. Our findings highlight the scope of developing a core set of meaningful patient outcomes to promote HEP adherence.
A recent systematic review of adherence to HEP showed that demonstration of the exercises facilitated patients doing the HEP.11 The systematic review of RCTs described HEP adherence and the use of BCTs to promote home exercise adherence for people with RCRSP. Though a low mean number of BCTs was used in the included studies (6% of the total 93 BCT44), the most used BCT was to teach patients how to perform their HEP. The literature highlights the importance of reporting BCTs’ use within interventions, and researchers and clinicians need to understand which BCTs might be most useful in promoting exercise and physical activity.
Further enablers to doing the HEP included the use of equipment and being able to incorporate the HEP into their daily routine. The perceived benefits of using equipment for the HEP concord with other qualitative research where participants reported that resistance bands were an enabler and a visual reminder for patients to do the exercises.43 Another enabler to doing the HEP was allowing patients the freedom to gradually fit the HEP into the patient’s day and usual activities. The evidence shows that not finding time to do a HEP is a recognised barrier to adherence.43 45 Collaboratively discussing with patients how these enablers can be included in their day could boost the chances of adherence to the HEP.
Research implications
This research is intended to improve clinicians’ understanding of patient support needs and inform the development of self-management interventions. Specifically, our findings highlight the need for a strong therapeutic relationship and to train HCPs in educating patients about patients’ misconceptions about the condition and the role of rehabilitative exercises. Clinicians should also be trained to identify BCTs relevant to individual patients, which can be used to support adherence to conservative management of RCRSP.
Strengths and limitations
This study is the first to use TDF and COM-B to explore the barriers and enablers to shoulder rehabilitation exercise in people with RCRSP. Using the TDF and COM-B during the analysis stage is a strength of this study as it helped to link findings to recognised BCTs relevant to supporting patients to engage with exercise. As no new themes were identified from the interviews, the richness of the data and the overlapping themes offer some confirmation of the conclusions. These data add to the knowledge base in this area and will be useful for future research and intervention development.
All of the participants in this study were white, and the majority were retired, which potentially limits the generalisability of findings to a broader population. This highlights the need for greater diversity and inclusion in health research.