Does how you do depend on how you think you'll do? A systematic review of the evidence for a relation between patients' recovery expectations and health outcomes.

BACKGROUND: Most clinicians would probably agree that what patients think will happen can influence what does happen over the clinical course. Yet despite useful narrative reviews on expectancy of therapeutic gain and the mechanisms by which expectancy can affect health outcomes, we were unable to locate a systematic review of the predictive relation between patients' recovery expectations and their health outcomes. METHODS: We searched MEDLINE for English-language articles published from 1966 to June 1998 with a title or abstract containing at least 1 of the medical subject headings (MeSH) "self-assessment," "self-concept" or "attitude to health," or the MeSH subheading "psychology," and at least 1 word from each of 3 sets: "patient" and similar words; a form of "expectation," "belief" or "prediction"; and a form of "recover," "outcome," "survival" or "improve." Relevant articles contained original research data, measured patients' recovery expectations, independently measured a subsequent health outcome and analyzed the relation between expectations and outcomes. We assessed internal validity using quality criteria for prognostic studies based on 6 categories (case definition; patient selection; extent of follow-up; objective outcome criteria; measurement and reporting of recovery expectations; and analysis). RESULTS: A total of 1243 titles or abstracts were identified through the computer search, and 93 full-text articles were retrieved. Forty-one of these articles met the relevance criteria, along with 4 additional articles identified through other means. Agreement beyond chance on quality assessments of 18 randomly selected articles was high (kappa = 0.87, p = 0.001). Sixteen of the 45 articles provided moderate-quality evidence and included a range of clinical conditions and study designs; 15 of the 16 showed that positive expectations were associated with better health outcomes. The strength of the relation depended on the clinical conditions and the measured used. INTERPRETATION: Consistency across the studies reviewed and the evidence they provided support the need for clinicians to clarify patients' expectations and to assist them in having appropriate expectations of recovery. The understanding of the nature, extent and clinical implications of the relation between expectations and outcomes could be enhanced by more conceptually driven and methodologically sound research, including evaluations of intervention effectiveness.

Upper limb work-related musculoskeletal disorders among newspaper employees: cross-sectional survey results.

At a metropolitan newspaper office in Canada with extensive video display terminal (VDT) use, researchers carried out a survey (n = 1,007, 84% response) to establish baseline prevalence of work-related musculoskeletal disorders (WMSDs) and to identify demographic, postural, task, and psychosocial factors associated with WMSD symptoms. One-fifth of the respondents reported moderate or worse upper limb pain recurring at least monthly or lasting more than a week over the previous year. Logistic regression showed that employees who faced frequent deadlines and high psychological demands (fast work pace and conflicting demands), had low skill discretion and social support, spent more time keyboarding, or who had their screen in a non-optimal position were more likely to report moderate to severe symptoms. Women reported significantly higher levels of symptoms than men.

The effectiveness of an early active intervention program for workers with soft-tissue injuries. The Early Claimant Cohort Study.

STUDY DESIGN: A prospective cohort of approximately 1600 injured workers off work because of soft-tissue musculoskeletal problems was followed for 1 year through a series of structured telephone interviews. OBJECTIVE: To determine the effectiveness of a Workers' Compensation Board-sponsored early, active, exercise and education program based in the community in comparison to "usual" care. SUMMARY OF BACKGROUND DATA: The program established in 1990 was available in more than 100 clinics. Results from an earlier pilot study indicated lower overall claims costs for workers attending the program compared with non-attenders. METHODS: Subjects were recruited at the time of Workers' Compensation Board claim registration. Routinely collected data and self-reported responses to demographic, quality-of-life, functional status, pain, recovery expectations, and workplace response to injury questions were used to determine selection factors for community clinic attendance. Economic and non-economic outcomes were compared for clinic attenders and non-attenders. RESULTS: For the 885 male and female new back problem cases in the study, overall clinic attenders were not systematically different from non-attenders at baseline. Analysis of duration of benefits showed no significant difference between attenders and non-attenders, although health care costs for clinic attenders were significantly higher. Functional status, health-related quality-of-life, and pain measures all improved significantly throughout time for both groups, bit there were no statistically significant differences in rate of improvement. CONCLUSION: There was no advantage from the program compared with usual care on the outcomes measured-a finding consistent with recent studies that examined the longer-term effectiveness of other interventions in the first few weeks of back pain symptoms.

The temporal pattern of unconstrained drinking: Rats' responses to inversion and identity constraints.

Rats obtained all of their water by licking a metal tube during a series of daily 1-hour sessions. When the tube was freely available throughout, each rat showed the classic temporal pattern of unconstrained drinking: As the session progressed, drinking bouts generally grew shorter and pauses grew longer. In subsequent sessions the tube was opened and closed independently of the rat's behavior, on a schedule that gave the rat a chance to duplicate the exact inverse of its unconstrained baseline pattern. Thus, as the inversion session progressed, the opportunities to drink generally grew longer and the enforced pauses grew shorter. When the rats were forced away from their unconstrained patterns of drinking and pausing, their total time spent drinking consistently fell short of previous values, but total licks and volumetric intake remained at previous levels. The same results occurred under an identity schedule, a series of openings and closings that duplicated the unconstrained pattern of drinking and pausing. The results have implications for theories that assume that instrumental performance under schedule constraint derives from the animal's defense of a measured set-point.