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What do the research findings mean for patients?

The trend towards better informed patients

NICE has published specific guidance on understanding patients’ needs and helping them make decisions about treatment.

With ease of finding information on the internet, many patients now come well prepared to discuss treatment options. A large proportion expect to have a choice, in contrast to earlier decades where most expected to be told what would be done to them.

Explaining the treatment options

One of the byproducts from NIHR musculoskeletal research is to improve the way that healthcare professionals explain treatment options to patients.

“An important aspect of many NIHR trials is giving the patient a better explanation of whether a certain intervention, for example surgery, would benefit them more or less than a non-operative treatment,” says shoulder surgeon Neal Millar.

In the UKUFF trial, looking at keyhole vs open surgery, patients were comfortable with there being different options once it was explained to them that we needed research to find out which approach is better. It’s also important that all the options provide a high standard of care that is clearly explained.

In the ProFHER trial, comparing surgery with sling treatment, specialist physiotherapists designed a standard approach to be followed for all the trial participants. This trial also used a patient information sheet on how to look after yourself while your broken arm was immobilised in a sling, which participants said they found helpful.

The therapeutic relationship: motivating patients to do their rehab

Treatment involving techniques, such as surgery, physiotherapy or using casts or slings to aid healing, is different to drug treatment. Instructing someone to take tablets can be done in an objective way - all the tablets for a set dose of a drug are manufactured to be identical, and the healthcare professional plays a minor role in whether the treatment works or not.

In contrast, the interaction between a surgeon, physiotherapist or other healthcare professionals is (unavoidably) part of whether the treatment works or not. Each patient needs to be educated about the condition and the treatment options, help to make a decision on which is best for them, support to have the treatment and motivating to take responsibility for doing any preparation or rehabilitation.

“As a surgeon, in particular it’s our job to connect with our patients, to really explain what is expected of them after the surgery,” says Neal Millar, shoulder surgeon. “In my clinic, I commonly say to my patients that they don’t do the physio that is required of them after their shoulder surgery, I can pretty much guarantee that they will have a poor result. Because physiotherapy, and their participation in the rehab programme is so important to them getting the best surgical and patient result in the longer term.”

Dr Toby Smith, physiotherapist, says:

“In a programme of physiotherapy, the therapeutic relationship between the physiotherapist and the patient is particularly important. Physiotherapists clinically may ask patients to do potentially uncomfortable, repetitive or inconvenient exercises, so it is really important to be able to explain how the exercises will help and tailor them to fit into a person’s lifestyle.”

What do patients think about these alternatives to open surgery?

People have different views on any treatment, and everyone's experiences are different. Here are just some of the views of patients about alternatives to open surgery, from our interviews with patients and healthcare professionals.

  • Surgeons and physiotherapists agreed that to get the best result from their treatment, people need the options explaining in a way they can understand, including what it means for them. For example, explaining why they need to do their rehabilitation exercises helps motivate them to stick at it.
  • A shoulder surgeon found that people may have unrealistic expectations of their treatment. All treatment can have complications, some people have higher risks than others (for example, due to co-existing conditions such as high blood pressure). No one option is suitable for everyone.
  • Some trial participants with long-standing rotator cuff injuries had already had some physiotherapy or waited to see if the tendon tear would heal on its own. Many of these people asked for surgery. Few trial participants swapped between the options of treatment with a sling and surgery for upper arm bone fractures. However the time between breaking their arm to having treatment in the trial was short, less than three weeks.
  • One trial participant with treated broken ankle felt that follow up should run for some years after treatment, to study long term complications. 
  • Another said that they were not automatically referred for physiotherapy after their shoulder surgery. Once arranged, physiotherapy really helped them. Trial and service administration should be organised so no-one misses out on parts of the treatment. 


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