ArticleBMJ open2021
Direct and mediated effects of treatment context on low back pain outcome: a prospective cohort study.
Article in BMJ open, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 18 papers, 4 of them syntheses that pooled it.
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
18 citing papers in PubMed, 4 syntheses or guidelines pooled it.
- The impact of contextual effects in exercise therapy for low back pain: a systematic review and meta-analysis.BMC medicine · 2024Pooled it
- Acupuncture for the prevention of chemotherapy-induced nausea and vomiting in cancer patients: A systematic review and meta-analysis.Cancer medicine · 2023Pooled it
- Mixed methods systematic review of the literature base exploring working alliance in the chiropractic profession.Chiropractic & manual therapies · 2022Pooled it
- Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review.Chiropractic & manual therapies · 2022Pooled it
- Clinical Efficacy of Electroacupuncture in the Treatment of Chronic Neck Pain: A Randomized Clinical Trial.Journal of pain research · 2025Trial
- The increased inter-brain neural synchronization in prefrontal cortex between simulated patient and acupuncturist during acupuncture stimulation: Evidence from functional near-infrared spectroscopy hyperscanning.Human brain mapping · 2023Trial
- Prediction, pain, and the power of context: toward a contemporary identity for the chiropractic profession.Chiropractic & manual therapies · 2026Review
- 'It might help, but it won't fix me': a qualitative study of individuals' beliefs about manual therapy for low back pain.Chiropractic & manual therapies · 2026Article
- Exploring the process of making health behaviour changes in traditional acupuncture: a longitudinal qualitative study.Health psychology and behavioral medicine · 2026Article
- Article
- Integrated manual therapies: IASP taskforce viewpoint.Pain reports · 2024Article
- A new role for spinal manual therapy and for chiropractic? Part II: strengths and opportunities.Chiropractic & manual therapies · 2024Article
- The development of working alliance in early stages of care from the perspective of patients attending a chiropractic teaching clinic.Chiropractic & manual therapies · 2024Article
- Temporal summation does not predict the acupuncture response in patients with chronic non-specific low back pain.Frontiers in neurology · 2024Article
- Factors Associated with Treatment Outcome Satisfaction Six Months after Upper Blepharoplasty: A Large Cohort Study.Plastic and reconstructive surgery. Global open · 2023Article
- Musculoskeletal practitioners' perceptions of contextual factors that may influence chronic low back pain outcomes: a modified Delphi study.Chiropractic & manual therapies · 2023Article
- Methodological challenges in design and conduct of randomised controlled trials in acupuncture.BMJ (Clinical research ed.) · 2022Article
- "Chiropractic is manual therapy, not talk therapy": a qualitative analysis exploring perceived barriers to remote consultations by chiropractors.Chiropractic & manual therapies · 2021Article
Corrections and comments
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Authors and funding
9 authors.
Funding
Abstract
objectivesContextual components of treatment previously associated with patient outcomes include the environment, therapeutic relationship and expectancies. Questions remain about which components are most important, how they influence outcomes and comparative effects across treatment approaches. We aimed to identify significant and strong contextual predictors of patient outcomes, test for psychological mediators and compare effects across three treatment approaches.
designProspective cohort study with patient-reported and practitioner-reported questionnaire data (online or paper) collected at first consultation, 2 weeks and 3 months.
settingPhysiotherapy, osteopathy and acupuncture clinics throughout the UK.
participants166 practitioners (65 physiotherapists, 46 osteopaths, 55 acupuncturists) were recruited via their professional organisations. Practitioners recruited 960 adult patients seeking treatment for low back pain (LBP). PRIMARY AND SECONDARY OUTCOMES: The primary outcome was back-related disability. Secondary outcomes were pain and well-being. Contextual components measured were: therapeutic alliance; patient satisfaction with appointment systems, access, facilities; patients' treatment beliefs including outcome expectancies; practitioners' attitudes to LBP and practitioners' patient-specific outcome expectancies. The hypothesised mediators measured were: patient self-efficacy for pain management; patient perceptions of LBP and psychosocial distress.
resultsAfter controlling for baseline and potential confounders, statistically significant predictors of reduced back-related disability were: all three dimensions of stronger therapeutic alliance (goal, task and bond); higher patient satisfaction with appointment systems; reduced patient-perceived treatment credibility and increased practitioner-rated outcome expectancies. Therapeutic alliance over task (η
conclusionsEnhancing contextual components in musculoskeletal healthcare could improve patient outcomes. Interventions should focus on helping practitioners and patients forge effective therapeutic alliances with strong affective bonds and agreement on treatment goals and how to achieve them.
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