The Black Box of Patient Education: An Expert Consultation on Patient Education Interventions and Strategies for the Management of Subacromial Pain Syndrome

Abstract

Purpose:

To identify patient education, interventions, and strategies to optimize the management of subacromial pain syndrome (SAPS) in physical therapy, based on the experiential knowledge of patient-partners and caregivers involved in the rehabilitation of this condition.

Method:

Using a semi-deductive approach building on the evidence extracted from the literature, an expert consultation using focus groups was conducted. The experts were physical therapists (n = 5) and an occupational therapist with extensive clinical experience, as well as a patient-partner. Analysis followed the Framework method.

Results:

Two main themes emerged: (1) interventions directly related to patient education, consisting of nine sub-themes, including symptom self-management and pain phenomenon, and (2) patient education strategies to broadly frame the interventions, consisting of 10 sub-themes, including educational materials and clinical teaching approaches.

Conclusion:

The consultation confirmed and expanded the knowledge from the literature by adding knowledge that emerged from the experts’ practical experience. It resulted in the development of preliminary statements on structured patient education interventions and management strategies for SAPS. These emerging statements are, to our knowledge, the first to inform patient education specifically as it relates to the management of SAPS taking into account psychosocial and contextual factors.

Musculoskeletal disorders have a significant and increasing prevalence in the general population worldwide.¹ These disorders often result in chronic pain, the course of which is influenced by various biopsychosocial factors.^2,3 The shoulder is a common site of musculoskeletal disorders, and subacromial pain syndrome (SAPS) is the most encountered shoulder disorder. Individuals affected by this syndrome are frequently exposed to an interdisciplinary approach including physical therapy.^4,5 However, the outcome of this condition has a high chronicity rate with up to half of individuals still reporting pain and function loss 1 year after initial symptoms.⁶

Biomedical factors, for example, symptom duration, assessed disability at baseline and more than one pain site, have historically been considered as predictors for persistent shoulder pain.⁷ However, recent findings suggest that psychosocial factors are also determinant in the course of this syndrome in terms of chronicity.^7,8 Shoulder musculoskeletal disorders should thus be managed with a tailored biopsychosocial perspective in order to address individuals’ needs.⁹

According to a randomized controlled trial comparing (1) patient education combined with individualized physical therapy (n = 64) with (2) psychomotor physical therapy (n = 64), the combined patient education intervention was found to be more effective in improving the health of patients with long-lasting musculoskeletal disorders, in terms of sleep quality, anxiety, depression, risk profile, fear of movement, and quality of life.¹⁰ Authors reported that patient education aimed to address patient’s thoughts, beliefs, and emotion related to shoulder pain.¹⁰ Patient education can help address the psychosocial aspects involved in the chronicity of shoulder pain.¹¹ For example, it can target empowerment aimed at encouraging individuals to self-manage their condition.¹² Education does not limit to the provision of knowledge, but also incorporates the process of facilitating learning for behavioural change regarding a health condition which could contribute to health satisfaction, increasing adherence to treatment, and achieving health care delivery more effectively.¹³

Clinical practice guidelines and several studies recommend incorporating patient education to optimize the management of individuals with SAPS.^12,14,15 Despite the relevance of patient education for managing SAPS and addressing biopsychosocial factors, there is a lack of studies describing educational interventions and strategies that should be performed in these individuals to optimize their rehabilitation. Yet, patient education is widely used in clinical setting to manage patients with SAPS. A better understanding and use of patient education interventions and strategies could lead to a better management of psychosocial factors involved in the chronicity of SAPS. In the absence of strong evidence from the literature, clinical experience could give insight to describe patient education for the management of SAPS and potentially guide decision-making regarding such interventions in physical therapy practice.

The objective of this study was to identify patient education interventions and strategies that should be used to optimize the management of SAPS in physical therapy, based on the experiential knowledge of patient-partners and caregivers involved in the rehabilitation of this condition. In this study, the term patient education refers to the concept of therapeutic patient education defined by the World Health Organization as

“education managed by health care providers trained in the education of patients, and designed to enable a patient (or a group of patients and families) to manage the treatment of their condition and prevent avoidable complications, while maintaining or improving quality of life. Its principal purpose is to produce a therapeutic effect additional to that of all other interventions (pharmacological, physical therapy, etc.)”¹⁶

This study focuses on patient education as a strategy to optimize the management of SAPS supporting the set of interventions for this condition, with the exception of therapeutic exercises. In this sense, education is conceptualized as one intervention among others in the therapeutic arsenal that can be used by physical therapists in the rehabilitation of this condition.

Methods

Design

A qualitative expert consultation based on a semi-inductive approach was used. The consultation process used a focus group method that aimed at obtaining experiential knowledge, and clinical and context feedback that describe patient education interventions used in physical therapy practice based on the perspectives of physical therapists’ experts but on also on the perspective of an expert occupational therapist and an individual living with SAPS. A focus group is relevant to gather participants’ perceptions and experience on a specific topic and allow discussion between participants to generate more new information than individual interviews.¹⁷ It is commonly used to explore deeply a topic not widely explained¹⁸ and guide decision-making.¹⁹

Theoretical basis

One main framework and one checklist, the International Classification of Functioning, Disability and Health (ICF) and the Template for Intervention Description and Replication (TIDieR), were used to inform the interview guide and structure data condensation and analysis. The ICF was used to ensure an understanding of the individuals with SAPS health condition using a biopsychosocial and contextual lens. The ICF provides a scheme to systematically code health information in a common language of disability, functioning, and contextual factor regarding a person’s health condition.²⁰ The ICF includes categories organized in four main (first level) elements: Body Functions, Body Structures, Activities and Participation, and Environmental factors. Personal factors are not yet described but are considered as contextual factors along with the Environmental Factor.²⁰ We thus included personal factors as a fifth main distinct category as this nuance is relevant for our study. Activities and Participation are two distinct elements but are considered as a single continuum of functioning in a single category.²⁰ The ICF is declined in second, third, and fourth level categories to describe functioning and contextual factors. Moreover, ICF categories were identified by Roe and colleagues to categorize the most relevant ICF elements to consider for each category with respect to health conditions affecting the shoulder.^21,22

The Template for Intervention Description and Replication (TIDieR) is a checklist used to describe interventions in detail based on 12 items to allow replication.²³ Items 1 to 9 only were used for the description of patient education interventions as they correspond specifically to intervention description (1. Brief name, 2. Why (rationale of the intervention), 3. What (materials), 4. What (procedure), 5. Who provided, 6. How (modes of delivery), 7. Where (location), 8. When and how much, 9. Tailoring). Items 10–12 are used in reporting interventions modifications and detail how they were planned and conducted which is not applicable to our study.

Study report

This study is reported based on the Standards for Reporting Qualitative Research²⁴ and an article from Salmon that guides qualitative research methods.²⁵ Ethical approval for the study was obtained from the Science and Health research Ethics Committee of the University of Montreal, Canada (15-129-CERES-D).

Participants and recruitment procedures

Experts including rehabilitation experts and individuals with SAPS were targeted to take part in the consultation. This study sought to recruit rehabilitation experts including physical therapists and rehabilitation professionals with substantial experience and peer recognition expertise in the management of individuals with musculoskeletal conditions of the shoulder. This study addresses specifically physical therapy practice, but other rehabilitation professionals, such as occupational therapists, also involved in the interdisciplinary rehabilitation of individuals with SAPS, having a distinct knowledge and experience of patient education and chronic pain could be included adding another perspective of the rehabilitation context. The decision to involve physical therapists and rehabilitation professionals in the focus group was intended to stimulate discussion in a way that would have provided a broader and more inclusive perspective on rehabilitation than a consultation that involved only physical therapists. In addition, the input of these other stakeholders aimed at allowing the physical therapists to deepen their perspective in relation to the opinion of the other stakeholders. In particular, this provided an opportunity to further explore aspects with interdisciplinarity in the context of patient education provided by physical therapists. Other rehabilitation professionals were invited to consider the practice perspective and roles of physical therapists.

Rehabilitation experts had to be able to share their experiential knowledge and opinion on patient education interventions on SAPS in physical therapy. Experts included were known to have extensive experience with the SAPS population, to have provided training on the topic and/or to have created programmes or projects related to chronic shoulder pain management. A purposive sampling,²⁶ was used to recruit rehabilitation experts for the expert group consultation.

Individual with SAPS, referred to in the following as a patient-partner, was recruited through the rehabilitation professionals contacted to participate in the consultation. The patient-partner had to have experience participating in focus group consultations or had to be trained to participate in such consultations in order to feel comfortable and able to contribute in a meaningful way. A descriptive study brochure with contact information was provided to potential participants if they wished to obtain more information about the study. The characteristics sought for the professionals and patient-partner are presented in Table 1.

Table 1.

Characteristics Sought for the Focus Group Consultation

	Rehabilitation professionals	Individuals with subacromial pain syndrome (SAPS)
Inclusion criteria	▪ Physical therapist or other rehabilitation professional working in physical health (e.g., occupational therapists); ▪ Have more than 5 years of clinical experience; ▪ Have extensive experience in the rehabilitation of musculoskeletal injuries of the shoulder.	▪ Received a diagnosis or physical therapy impression of SAPS; ▪ Consultation with a rehabilitation professional for SAPS in the last 12 months; ▪ Trained or experienced in focus group discussions
Exclusion criteria	▪ Inability to communicate in French	▪ Inability to communicate in French or to participate into a discussion; ▪ Presented another type of injury to the shoulder; ▪ Had another condition causing a disability or an activity limitation to the upper limb; ▪ Had another systemic or chronic illness influencing the shoulder condition
Diversity sough	Sector of practice (private/public)	Duration of symptoms Sector of practice consulted (private/public)

The joint participation of the two stakeholder groups, including professionals and the patient-partner, was intended to stimulate discussion about teaching and learning perspectives on patient education by allowing for the perspective of both groups.

In preparation to the consultation, each participant received a comprehensive email containing an explanatory overview of the research objectives and protocol, including a lay summary of the theoretical frameworks used for the consultation process, to familiarize themselves with the study material prior to the consultation. Experts were also provided with a list of preliminary themes based on the ICF that would be addressed and discussed during the consultation. Patients and professionals who knew each other could not be involved in the same consultation group. Informed consent was obtained from all participants.

Data collection and analysis

Prior to the expert consultation, a scoping review (unpublished), based on the PRISMA Extension guidelines for Scoping Reviews²⁷ was conducted. The objective of the review was to assess the extent of patient education interventions described in the literature that could be used for the management of SAPS. The components extracted from this scoping review were used to inform and structure the interview guide used to conduct the expert consultation.

The scoping review was conducted with the assistance of biomedical librarian in the databases Medline, Embase, Cochrane, Web of Science, PsycInfo, CINHAL, PubMed, and ERIC from their date of inception until December 2018. Key words related to SAPS (e.g., impingement syndrome, rotator cuff, tendinopathy) and patient education (e.g., empowerment, information, recommendation, teaching) were used. A total of 1468 references were found and, after applying eligibility criteria, 32 were included. Each of the included references contained patient education components which were extracted and classified according to the ICF categories and the items of the TIDieR framework.

The ICF categories for shoulder pain identified by Roe and colleagues were used to structure the collection and analysis of components extracted from the literature review into the suggested categories.^21,22 These initially included 61 second-level ICF categories from which the research team merged categories to form 33 broader ICF categories representing body functions, body structures, activities and participation, and contextual factors including environmental and personal factors. A 34th category standing as other components was also created to be able to categorize all data extracted from the literature. These broader categories were created in order to avoid ambiguity between multiple categories during data extraction and analysis which needed to classify data into a single category. The review identified, described, and classified components related to patient education interventions for SAPS found in the literature according to the ICF categories (see Table 2).

Table 2.

Patient Education Components from the Literature Classified in the International Classification of Functioning (ICF) Framework

ICF categories	Components from the literature
Body functions
Temperament and personality functions (b126), Energy and drive functions (b130)	Establish goals by the patient
	Enhance empowerment and patients’ responsibility regarding their condition
	Stimulate motivation, adherence and engagement
	Issues management
Sleep functions (b134)	Education on sleep functions
Attention functions (b140), Memory functions (b144), Emotional functions (b152), Higher level cognitive functions (b164)	Cognitive behavioural strategies (behavioural change)
Touch function (b265)	None
Sensation of pain (b280)	Pain reassurance and comprehension
	Pain management
Mobility of joint functions (b710), Stability of joint functions (b715), Mobility of bones function (b720)	Explanation on shoulder function limitations
	Biomechanics education
	Upper limb immobilisation
Muscle power functions (b730), Muscle tone functions (b735), Muscle endurance functions (b740)	None
Gait pattern functions (b770)	None
Sensations related to muscles and movement (b780), Sensation related to the skin (b840)	None
Body Structures
Structure of head and neck region (s710)	None
Structure of shoulder region (s720)	Anatomy, etiology, and diagnosis
	Healing process
Structure of upper extremity (s730)	None
Activities and participation
Writing (d170)	None
Undertaking a single task (d210), Undertaking multiple tasks (d220)	Strategies to reduce shoulder load (e.g., modify trunk position, manage loading, alternate limb use, and support limb)
Carrying out daily routine (d230)	None
Changing basic body position (d410), Maintaining a body position (d415)	Postural corrections and ergonomic advice
	Favour shoulder rest position
	Shoulder position during sleep
Transferring oneself (d420), Walking (d450), Moving around (d455), Moving around using equipment (d465),	None
Lifting and carrying objects (d430), Fine hand use (d440), Hand and arm use (d445)	Education on optimal shoulder movements
	Active progressive approach
	Pain management during activities/arm movements/shoulder exercises
	Self-management for return to activity/activity modification/lift loads
Using transportation (d470), Driving (d475)	None
Washing oneself (d510), Caring for body parts (d520), Toileting (d530), Dressing (d540), Eating (d550), Acquisition of goods and services (d620), Preparing meals (d630)	Adapt functional activities (e.g., shoulder position during activities)
	Symptoms management during activities of daily living
Looking after one’s health (d570), Assisting others (d660)	None
Doing housework (d640), Caring for household objects (d650)	None
Basic interpersonal interactions (d710), Complex interpersonal interactions (d720), Relating with strangers (d730), Formal relationships (d740), Informal social relationships (d750), Family relationships (d760), Intimate relationships (d770)	None
School education (d820), Higher education (d830)	None
Remunerative employment (d850), Work and employment, other specified/unspecified (d859)	Modifications/adaptations of work movements/loads/position
	General (not specific) work education
	Return to work
	Workstation adaptations, ergonomic advice related to work
Recreation and leisure (d920)	Mechanical stress management for sports or leisure (e.g., avoid, return to leisure and/or sports)
	General (not specified) recreation, sports and leisure education
	Corrections/adaptations of leisure and or sport gestures/positions
Environmental factors
Products or substances for personal consumption (e110)	Advice on opioids use
Products and technology for communication (e125)	Use of material or visual support (e.g., bone pieces, anatomy manuals, video…)
Immediate family (e310), Friends (e320), Acquaintances, peers, colleges, neighbours, etc. (e325)	Social support
Individuals in positions of authority (e330)	Pressure to perform at work
Health professionals (e355), Individual attitudes of health professionals (e450)	Establishing goals with health professional
	Therapeutic relation/alliance, positive reinforcement
	Health professionals or guide (e.g., coach)
	Therapists’ experience
Social security services, systems and policies (e570)	Rehabilitation stages and process
	Exercise/intervention rational
	Biopsychosocial management
Personal factors
	Prior beliefs
	High psychological demands at work, low job satisfaction
	Low personal control or self-efficacy
	Person’s expectations
	Mental health
	Comorbidities (e.g., diabetes, smoking ...)
	Lifestyle habits
	Influence of personal biopsychosocial situation (e.g., age, characteristics of imaging and compensation status (at work))
Other themes
	General education (not specified)
	Prevention (e.g., risk factors, pre-surgery)
	Chronicity

Based on the categories proposed by Roe and colleagues²¹

For each reference found in the literature, all extracted information related to patient education interventions was also classified according to the TIDieR checklist. This allowed for an account of how the interventions were described in the literature and to identify relevant and missing information in this description. For most interventions, many TIDieR items were only briefly specified or completely unspecified, demonstrating the lack of literature describing patient education interventions for the management of SAPS in sufficient details and completeness.

The interview guide was mainly informed by the results of this scoping review. It was separated in three main parts. The first part included the presentation of the participants. The second part included a description of the research objectives, the protocol, and the frameworks used for the study (ICF and TIDieR). The third part included a discussion on the use of these frameworks and sharing of participants’ experience in teaching patients or learning about SAPS. In this discussion, participants (experts and patient-partners), were encouraged to describe examples of teaching interventions for patients with SAPS that went well or presented challenges in the context of physical therapy follow-up. The examples were presented and discussed with consideration of the ICF categories and TIDieR items with the aim of filling gaps in the literature.

A visual presentation of the research protocol, the frameworks used in this study and a list of the ICF categories filled with components extracted from the literature were available during the focus group to support and inform participants’ discussion and reflections. The TIDieR was used as a basic template to help participants describe patient education interventions during the consultation. The interview guide can be found in Supplementary Material 1.

A first focus group was conducted with two experts to ensure the duration was adequate for a larger group. Additional focus groups with experts and patient-partners were planned, with the expectation that the number of focus groups needed would be determined by reaching data saturation.²⁸ Each focus group was scheduled to last approximately 3 hours. To facilitate participation, in-person attendance was strongly recommended, but some participants could also join the discussion by videoconference. The focus groups were facilitated by two team members (KMT and JOD) who have experience facilitating interviews and focus groups. A third team (AD) member took notes during the discussion to summarize and share key elements of the discussion for each topic discussed. The facilitators ensured that all participants (whether present online or in person) had the opportunity to share their opinions. In addition, the facilitators ensured that there was a diversity of interactions between the different professionals, but also between the patient-partner and the professionals. Both focus groups were recorded (audio and video) and were transcribed verbatim by a research team member (AD).

Targeted sample size and data analysis

Based on the resources available for this study, a first focus group including only two experts was planned and for each subsequent focus groups, five to seven expert participants were targeted. For all steps of data analysis (coding and data condensation), two assessors independently conducted the analysis and then compared it to reach a consensus. In case of disagreement, a third team member (JOD) was involved to make the final decision. Extensive discussions within the research team also took place until a consensus was reached.

Coding and TIDieR classification

Transcribed verbatim were qualitatively analyzed using QDA Miner software. Data collected from the focus groups through open-ended questions were linked to ICF based on the ICF Linking Rules for linking ideas or concepts to ICF categories.²⁹ Qualitative data were thus coded using a thematic analysis based on the Framework Method.³⁰ The coding was conducted using a primarily deductive approach, but new codes could be created inductively when a theme not covered by the ICF framework emerged from the data,³¹ as per a semi deductive approach.

An initial list of codes (n = 66) was generated incorporating the components found in the previous scoping review (n = 52) and the empty ICF categories that were not described in the literature but were part of the shoulder categories from Roe and colleagues^21,22 (n = 14). Those missing categories might be addressed by the experts in the consultation process to ensure to encompass all relevant components of patient education interventions related to the ICF categories. Coders could create new codes inductively while analyzing data. Agreement between coders was ensured through a comparison of 20% of the verbatim coding after a first cycle of coding.

The TIDieR checklist was used to describe each item retrieved from the expert consultation process regarding patient education interventions and strategies. Brief names identifying patient education interventions and strategies for SAPS were agreed upon, in this way, both assessors were able to continue the classification with the same structure of information for the final classification in the TIDieR table. All data describing physical therapy interventions AND patient education strategies that could be used for the management of SAPS were gathered and classified in the TIDieR table.

Data condensation

The coding and TIDieR classification condensed the data as patterns emerged. Both analyses helped extract the most meaningful statements from the data. By bringing together the coding results and the TIDieR checklist data, main themes and subthemes emerged.

Results

Sample characteristics

Two focus groups of three and half-hour were conducted. The first and second focus group included two and five participants, respectively. Together, the two groups included five physical therapists and one occupational therapist with extensive expertise in chronic musculoskeletal pain and patient education, as well as one patient-partner (see Table 3). One participant took part in the first focus group via web conference.

Table 3.

Characteristics of Focus Group Participants (n = 7)

Participants’ identification (Focus group number)	Main workplace (and clientele if specified)	Other or anterior workplace	Years of experience	Other training topics
PT1 (FG 2)	Private practice (orthopaedics and vestibular)	N/A	21	Chronic pain, manual therapy, and shoulder disorders
PT2 (FG 2)	Hospital	Private practice, long-term care, and humanitarian	19	Manual therapy, motor control, pain science, and shoulder disorders
OT (FG 2)	Academics (adults physical health)	Clinical research	19	Chronic pain, musculoskeletal disorders (including shoulder and upper limb), and therapeutic education
PT3 (FG 2)	Private practice (external orthopaedics)	Academics and sports	11	Manual therapy and shoulder disorders
PT4 (FG 1)	Rehabilitation centre	Academics, and coaching	9	Kinesiology, manual therapy, musculoskeletal disorders (including shoulder) and vestibular
PT5 (FG 1); videoconference	Private practice	Academics and sports	13	Dry needling, manual therapy and musculoskeletal disorders (including shoulder)

Identification	Shoulder condition	Professionals consulted	Symptoms duration (years)	Health-related training
PP (FG 2)	Rotator cuff tear	PT and physician	10	Chronic pain and neuromuscular conditions

FG = focus group, OT = occupational therapist, PP = patient-partner, PT = physical therapist.

Focus group themes

The two focus groups allowed to reach theme saturation. In coding the second focus group, only two new codes were created, and some other codes were only reworked. The TIDieR classification also showed redundancy between the two focus groups, and most items were described fairly. No new themes emerged after the first focus group, but the second focus group provided a more extensive representation and coverage of all pre-determined codes.²⁸

The experts addressed patient education as two main themes: (1) the interventions directly relating to patient education and (2) general patient education strategies needed to frame those interventions and to optimize rehabilitation using patient education. Main theme (1) was further composed of nine sub-themes (1A. Self-management of symptoms during functioning; 1B. Phenomenon of pain; 1C. Shoulder condition; 1D. Relative and temporary rest; 1E. Quantification of mechanical stress; 1F. Adaptations of functioning; 1G. Influencing factors; 1H. Preoperative education and 1I. Interdisciplinary context) and main theme (2) was composed of 10 sub-themes (2A. Importance of physical activities; 2B. Rationale for interventions; 2C. Prevention; 2D. Educational material; 2E. Promotion of active participation; 2F. Therapist’s attitude and communication skills; 2G. Therapeutic relationship and collaboration; 2H. Clinical teaching approaches; 2I. Time and quantity of information; 2J. Adjust teaching to patients’ preferences and profile) (see Table 4). These themes and sub-themes that emerged from the consultation process gather the priorities in terms of patient education for the management of SAPS stated by the participants.

Table 4.

Two Main Themes and their Sub-Themes with Illustrative Verbatim Excerpts

Main theme 1 – Patient education interventions for the management of subacromial pain syndrome (SAPS)

Sub theme 1A: Self-management of symptoms: prompts to help self-manage shoulder symptoms

PT2: “[Teaching] that small variations of symptoms are alright, but the problem is when variations get greater, [the PT] should tell to keep away from that and slow down activities and when to resume them.” OT: “When [the PT] strongly advocates the self-management approach… [they] should begin with a more directive approach to gain credibility and therapeutic alliance… [taking the person’s expectations into account… and adapt] as we can never do things in the same way.”

Sub-theme 1B: Phenomenon of pain

PT4: “Often in chronic pain or at the end of the rehabilitation process, patients still have pain according to the nature of the shoulder damage, so it is obvious, we address [the phenomenon of pain,]… basics notions that we call pain courses … so everyone at least have a notion on how pain is produced what are [pain] signals, what I should tolerate as pain level, what is alarming, why I still have pain [such time] after my accident, things like that, chronic pain also…” PP: “What I find difficult is when you have pain while doing a motion or exercise, do I aggravate my case? … I do not have a problem increasing my pain if it will improve my condition… [Pain management] surprisingly is not often well taught, explained and believe myself… often people will tell you should not feel pain, you should not feel pain, but sometimes it comes quickly… I think it should be well explained to patients…”

Sub-theme 1C: Shoulder condition: shoulder pathology, diagnosis, planned evolution, and prognosis

OT : “Teaching about the five dimensions of illness then to link on therapeutic teaching would be really relevant …” PT4: “Teaching about prognosis is done during the intervention plan in rehabilitation, we have meetings with the client as a patient-partner… we will not wait until the patient asks…it is part of the intervention plan.”

Sub-theme 1D: Relative and temporary rest: need to protect or move the shoulder

PT2 : “The first reflex of the patient is to protect [his shoulder], but it is always a story of relative rest, protect versus deconditioning…people catastrophize sometimes and with kinesiophobia, they move less bringing other problems. I think that teaching… is extremely important…” PT4 : “I do not want to teach to avoid activities that worsen symptoms [completely], because I want the patient to stay active.”

Main theme 1 – Patient education interventions for the management of SAPS

Sub-theme 1E: Quantification of mechanical stress: progressive process to manage motions, activities, and participation

PT4 : “It makes me thinking of daily routine for example for activities of daily living and domestic life activities and how to manage [mechanical stress] between all that. Not doing too much and split tasks.” PT2 : “For the quantification of mechanical stress, there is a graphic that we can find to show the patient and describe [what it is]… if they do small variations [of mechanical stress], it is alright, but if they begin doing large variations, we should stay away from this and slow down the activities a bit.”

Sub-theme 1F: Adaptations of functioning: adapt motion, activities, and participation

PT5 : “Things that causes an exacerbation of symptoms is not indicated and we should adjust, find another way to do [the movement or action]… Often, internal [shoulder] rotation is limited [for reaching] the fasteners, putting the belt on, tying the bra. Often with problems of impingement syndromes, only educating could help doing movements differently.” PT2: “For a person who likes playing ball with her grandchildren, she could play with a beach ball rather than a basketball, but still plays ball without load so she is able to continue her activity with an adaptation.”

Sub-theme 1G: Influencing factors: factors contributing to healing

PT5: “It often comes with sleep, diet, lifestyle habits in relation to physical exercises when I explain it… If all your environmental context around your shoulder is not conducive to healing… tissues will not be well nourished… you won’t be able to recover in a functional or optimal or satisfactory way.” PT3: “I think that it is also important if we are a health promoter, everything is related to comorbidities and then activities too. General activities help cardiovascular determinants which help everything else. Not just to target the shoulder but talk about the person as a whole. Life habits and all that.”

Sub-theme 1H: Preoperative education

OT: “There we see windows of opportunity to do therapeutic teaching, it is already done in some institutions. Sometimes do we do it in pre-op, in cardiology they do it with interesting results, or to fit into the continuum of care, in our care trajectory I think it is an important issue, when should we do therapeutic teaching.”

Sub-theme 1I: Interdisciplinary context

PT5: “We can teach, if we think there is another professional who could be of help, we could teach what this professional would be relevant for, we can teach in relation to our role, what we can bring to the person.” OT: “Interdisciplinarity, where we targeted and shared [educational] themes to really put forward our complementarity and all that. Sometimes, there were grey areas where we repeated but we all had a coherent speech. That was interesting to have this approach and codevelop all that.”

Main theme 2 – Patient education strategies for the management of SAPS

Sub-theme 2A: Importance of physical activities: promotion of physical activity (what?)

PT2: “I realize that people who have a shoulder problem will generally decondition themselves, that means they will walk less, won’t go outside, won’t go to work, won’t take the subway, the train. So there is deconditioning of the lower limbs and the trunk which contributes, and there is overload of the shoulder because the rest is deconditioned. There are plenty of reasons to stay active.”

Sub-theme 2B: Rationale of interventions: justify and explain reasoning for interventions (what and why?)

PT2: “I prepare my patient…For every intervention…I show them what is happening in the shoulder when they are doing an exercise. It increases compliance, understanding, so the management then extrapolating that to their function too making [exercises]. Understanding] what is happening and why we are doing it.’ PT3: “You should not lose yourself in details” … PP: “You explain what is happening when you [do the exercise] and why it is good or not.” PT1: “We always have to adapt [to the person]. I always give a minimum [of teaching] on what is happening to the shoulder and above all, why we are doing this or that and what it will bring them for their functioning and all. It changes adherence to treatment, and they understand why they do it.”

Sub-theme 2C: Prevention: prevent aggravation of the condition (what?)

PT1: “[In our milieu], we talk a lot about prevention. We started doing preventive assessment before people develop pain… Rehabilitation is getting more preventive; it evolves a lot.”

Sub-theme 2D: Educational material: material used for teaching (what material?)

PT4: “[Teaching about the structure affected], is often one of the first thing we will do… it will often be done with bone pieces, an anatomic book, with either my hands that I will place in certain positions or by making comparisons with an example.”

Sub-theme 2E: Promotion of active participation: empower the person in the rehabilitation process (how?)

PT5: “I think we can teach… ‘[so the person] understands well that we are there to support them, that is teamwork, that is partnership, it’s a proactive approach.” PT5: “I would say when it is possible, I try with their hands so they can autocorrect ‘[the motion by themselves] and take conscience … so they can bring that home if possible.”

Sub-theme 2F: Therapist’s attitude and communication skills: improve attitude and communication skills (how?)

PT1: “It is the way you will approach self-confidence … Confidence that you have when you explain something, your education, brings confidence to the client, at the patient level.’ PT2: ‘Yes, we see it in trainees, we see that trainees are able to have great [teaching] results.’ PT1: ‘It is sure that if a [professional] seems unsure, the person won’t get on board. It is in the words that we are going to use in the discussion that are going to make a difference, not just the number of years of experience. That sure helps, however there are experienced physical therapists who do not have good communication either, it does not always work.” PT2: “The confidence with which the teaching is given, you see I talk a lot I’m in a good mood, I’m dynamic that’s what I do with patients, the way it is taught, I don’t leave any doubt, I pay great attention to the choice of words, if there is one important thing in teaching it is the words, here I am going to say them but I have not said them for a long time, pinching, hanging, jamming, compression, shift. … If there is one important thing about patient education it is the wording… I am very very careful with the words.”

Sub-theme 2G: Therapeutic relationship and collaboration: involve and encourage a healthy relation (how?)

PT1: “We know that therapeutic alliance is a key point in a relation.’ OT: ‘Yes there is literature on the subject.’ PT2: ‘There is a lot of literature on that, and the basis is if talking about teaching, the first step in the canvas, if you make a canvas to follow a physical therapy structure, is active listening.’ PT3: ‘Exactly.”’

Sub-theme 2H: Clinical teaching approaches: good practices for teaching (how?)

Facilitator (F2): “The retention element, is there a way to work on it?’ PT2: ‘Reformulate... Reformulate what [the person] understood. Not only during the session, but from one session to another, at every session what they remember, what are the exercises. Then from one session to the other, show me what you did home, what did you recall.” Facilitator (F2): “Is this what we do from the outset, to ensure that the client understands, is this something that should be done from the outset?’ PT3: ‘I think so, that we make sure the patient understood.”

Sub-theme 2I: Time and quantity of information: (when and how much?)

PP: “I think patient education is essential to understand what is happening. Patients do not always have a good understanding. Professionals should repeat to have an incidence on patient’s involvement in the rehabilitation process. I say it is essential…”

Sub-theme 2J: Adjust teaching to patients’ preferences and profile: (tailoring)

OT: “… we can never do things the same way, we have to think about who is in front of us before starting.” PT2: “… basically, it depends on the patient … the goal is not to be right, the goal is to take care of my connection with the patient, even if I know a little, it does not prevent me from writing something in my analysis, but I mean, I think that the work of education must go with [the person’s] values and beliefs.”

For example, regarding the adaptation of functioning (sub-theme 1F, an occupational therapist participating to the focus group raised that the

“adaptation of activities is a key element of education in the context in which we want to use upper limb… We should focus on meaningful activities, advocate things that make sense, that are motivating…Workstation layout or home layout are part of the solution even if it is something temporary…to promote healing.”

On patient education strategies, sub-theme 2J on adjusting teaching to patients’ preferences and profiles, PT1 stated during the focus group:

“I think that [the PT should] adapt the teaching to the person, the language. Sometimes I talk about ball joint, I teach about the shoulder, and to someone else I will go further in details. … we should adapt to tools available.”

Discussion and Conclusion

Discussion

Main findings

This study aimed at exploring, through an expert consultation, the focus and description of educational strategies in the physical therapy management of individuals affected by SAPS. The consultation included the perspective of rehabilitation professionals with an extensive experience in shoulder musculoskeletal disorders, as well as the lived experience of a patient-partner. Our scoping review conducted prior to this consultation showed that patient education was not clearly and sufficiently described in terms of content and educational strategies in the literature. Indeed, it contained scarce evidence with mostly only brief statements on patient education targets that were poorly described. In almost none of the studies found, the patient education intervention mentioned was reproducible and was a main intervention; it was included as a component of a wider intervention plan.

This study provided insight into how expert rehabilitation professionals view what patient education should target and what patient education strategies should be considered for managing SAPS with a constructivist perspective. Constructivism theory focuses on the interpretation of the outcomes, how the knowledge is constructed in the human mind from experiences, mental structures and beliefs, and interprets how the knowledge is used and created throughout authentic situations.^32,33 The experts in the focus group suggested ways to construct a knowledge sharing approach with the patient for SAPS management. Because learning is an active approach, they provided advice on how physical therapists could deliver patient education by involving individuals in their rehabilitation process, supporting them build their own knowledge and giving them tools to better self-manage their condition using patient education.

Emerging patient education statements

Based on the understanding of the expert consultation analysis combined with the prior literature review, statements on patient education interventions and strategies for the management of SAPS arose. These correspond to the main themes and sub-themes that emerged from this study consultation. The emerging statements were organized as in the TIDieR checklist to provide a structured understanding of the results of the expert consultation. This study allowed to provide a first understanding of patient education interventions and strategies for the management of SAPS based on experiential knowledge and oriented by a previous literature review. These statements categorized by TIDieR items can be found in Tables 5 and 6.

Table 5.

Preliminary General Patient Education Strategies Recommendations for the Management of Subacromial Pain Syndrome (SAPS)

TIDieR items	Recommendations
On WHAT and WHY (Targets of the intervention and its use rationale(s))	The targets for general teaching interventions include: 1. The therapist should systematically discuss with all individuals the importance of physical activity in stimulating the healing process and general activation. 2. The therapist should discuss the rationale for interventions, in terms of their importance for function, to verify the person’s consent to the proposed care and service plan and to promote adherence to the rehabilitation treatment plan. 3. The therapist should act on prevention. (No reason was specified for this recommendation)
With WHAT (Teaching material)	General recommendations on educational material indicate that teaching tools should be used when relevant (e.g., technological equipment [videos, software], technological and telecommunications tools orfollow-up of individuals by email/tele-rehabilitation/telephone, etc.).
HOW (Teaching methods)	1. It is recommended for all teaching situations with this clientele to adopt a general teaching approach which promotes the active participation (empowerment) of the person in their treatment plan and which stimulates their motivation and adherence. This leads to:  a) Insisting on the contribution of the person in their rehabilitation  b) Using personal behaviour change strategies (unspecified)  c) Asking their opinion on what might help them  d) Encouraging them to work collaboratively with the therapist  e) Giving them tools for their self-care at home 2. General recommendations on teaching strategies include:  2.1. Recommendations related to the therapist’s attitude and communication skills:   a) The therapist should pay attention to the choice of words using a positive vocabulary (non-suggestive of injuries) and considering the person’s level of literacy.   b) The therapist should refer to and share their knowledge gained through experience (tacit experience).   c) The therapist should exude confidence in their teachings.   d) The therapist should use an inter/multidisciplinary approach in their teaching by adopting a common message with the other stakeholders, (e.g. relating to medical, pharmacological and rehabilitation treatment), good communication with the care team and avoiding redundancy and/or contradiction.   e) The therapist can reassure the person to avoid anxiety about the condition.  2.2. General recommendations related to the therapeutic relationship and the therapist-person collaboration:   a) The therapist should develop clear, person-centred and related to functioning rehabilitation goals in collaboration with the person and the interdisciplinary team.   b) The therapeutic relationship should allow an alliance with the person, promote active listening, and an honest approach (e.g., in relation to the prognosis)   c) The therapeutic relationship should stimulate the person’s confidence in the therapy (e.g., by explicitly defining roles in therapy)   d) The therapist should discuss the return to work and its benefits in addition to encouraging the person to be proactive towards a return to work.  2.3. General recommendations related to clinical teaching approaches   a) The therapist must enter or clearly record the targets and teaching methods in the physical therapy person’s chart.   b) The therapist must offer individual teaching.   c) The therapist should assess the person’s understanding during and after the teaching (repetition as needed by the therapist, rephrasing by the person, checking the level of understanding between sessions).   d) With the consent of the person, the therapist can involve one or more relatives to share with them the teachings and stimulate social support.   e) The therapist can also offer group education (especially in prevention and in waitlist situations).
WHERE (Location)	No general teaching recommendations for where interventions should be given have been specified for teaching (e.g., clinic, home, or otherwise).
WHEN and HOW MUCH (Times and Quantity)	General recommendations related to when and how much education should be used include: 1. The therapist should set aside time to properly teach. 2. Education must be part of the rehabilitation care of individuals with SAPS and be a priority in almost all cases. 3. Teaching should be used from the first contact with individuals. 4. A maximum of one to three key messages should be presented per session to facilitate learning. 5. Teaching should take a large part of physical therapy treatment.
TAILORING (Adaptations)	General recommendations suggest adjusting to the person and analyzing their learning preferences and profile for teaching by: 1. Letting the person describe their situation in an open manner 2. Documenting and considering their openness and interests 3. Adapting to their capacity for retention and understanding 4. Adjusting to their level of literacy and language barriers (interpreter as needed) 5. Considering their level of anxiety 6. Considering their level of involvement in the treatment plan (e.g., encourage the person to get involved in their therapy or slow it down if they do too much) 7. Adapting to its contextual factors 8. Adapting to the stage of change according to the transtheoretical model 9. Targeting anatomical factors more in the acute phase 10. Targeting psychosocial factors more in the chronic phase

Table 6.

Preliminary Specific Patient Education Interventions Recommendations for the Management of SAPS

TIDieR items	Recommendations
Recommendation 1. Teaching about self-management of symptoms (pain)
1.1. Self-management of symptoms during functioning
On WHAT and WHY (Targets of the intervention and its use rationale(s))	Teaching about self-management of symptoms by the person during functioning (body functions, activities and participation) should be encouraged to (1) facilitate the healing process, (2) prevent exacerbations symptoms, (3) reduce kinesiophobia and catastrophizing, and (4) empower the person.
With WHAT (Teaching material)	The Visual Analog Scale of Pain (VAS) should be used for symptom self-management. A logbook and visualization and breathing exercises can be used.
HOW (Teaching methods)	A Visual Analog Scale of Pain (VAS) should be used to guide the dosage of activities for symptom self-management (e.g., 0–2/10 symptoms accepted and within normal; 3–6/10, moderate symptoms, decreased intensity of activity or use painkiller; >7/10: severe pain, need for rest and pain management)
WHERE (location)	Not specified
WHEN and HOW MUCH (Times and Quantity)	As a priority, from the start of management, self-management of symptoms should be addressed in individuals with painful symptoms. The logbook could mainly be used in chronic phase.
TAILORING (Adaptations)	Self-management of symptoms should be adapted according to the person’s tolerance level, the risk of worsening the condition and the level of pain. A reference should be made when the limit of the professional’s skills or the scope of practice is reached in the consideration of psychological factors.
1.2. Phenomenon of pain
On WHAT and WHY (Targets of the intervention and its use rationale(s))	Teaching about the phenomenon of pain in general should be discussed with the person to optimize symptoms management.
With WHAT (Teaching material)	Documents, web links, books, and videos can be used to teach symptoms
HOW (Teaching methods)	Pain education can be done in person and handouts can be read at home. An in-person consultation should make it possible to review the documents consulted at home with the professional. Group teaching can be given (see TAILORING).
WHERE (location)	In clinics and at home (e.g., readings, videos ...)
WHEN and HOW MUCH (Times and Quantity)	Not specified
TAILORING (Adaptations)	The content of pain education should be targeted according to the person’s needs, understanding, level of literacy, level of education, and beliefs. In chronic cases and/or in prevention, group teaching may be preferred.
Recommendation 2: Education on the person’s condition
2.1. Specifics about the condition
On WHAT and WHY (Targets of the intervention and its use rationale(s))	Teaching about the condition should be discussed with the person including the specifics related to the diagnosis, the causes, the biomechanics of the disease, the course/prognosis, the consequences and the effect of expected treatments to (1) promote understanding of the condition, (2) stimulate adherence to treatment, and (3) de-dramatize the situation.
With WHAT (Teaching material)	Readings, videos, pamphlets, informative posters, and anatomical models can be used.
HOW (Teaching methods)	The prognosis should be discussed. The person’s beliefs should be addressed. The use of a visual approach targeting anatomy and movement rather than the injury and condition is recommended for teaching the condition and should be used. General information can be given.
WHERE (location)	In clinics and at home (e.g., readings, videos ...)
WHEN and HOW MUCH (Times and Quantity)	A minimum of education about the condition should be discussed with the person.
TAILORING (Adaptations)	Education on the condition should be tailored to the person and their level of literacy.
Recommendation 3: Teaching on the quantification of mechanical stress
3.1 Relative and temporary rest
On WHAT and WHY (Targets of the intervention and its use rationale(s))	Teaching about relative and temporary rest can be used to (1) promote the healing process, (2) temporarily reduce stress on tissues while avoiding the association between movement and injury in the person to (3) avoid kinesiophobia, the protective reflex, catastrophization, and deconditioning.
With WHAT (Teaching material)	A support, or cushion can be used to demonstrate the glenohumeral rest position.
HOW (Teaching methods)	The glenohumeral resting position can be demonstrated and then used as a non-pharmacological tool for pain management.
WHERE (location)	Not specified
WHEN and HOW MUCH (Times and Quantity)	Upper limb use should be addressed early in the management process. Relative and temporary rest can be used as needed, especially at the start of treatment, in acute cases and/or during severe or constant pain at rest.
TAILORING (Adaptations)	Relative rest should be used according to the individual’s needs, taking into account their tolerance versus the risks of worsening the condition or symptoms. The glenohumeral resting position should be used according to the individual’s needs as a non-pharmacologic relief tool and in cases of joint hyperlaxity, instability, or hypermobility.
3.2 Quantification of mechanical stress
On WHAT and WHY (Targets of the intervention and its use rationale(s))	Teaching on the quantification of mechanical stress during the continuation and/or the return to the functioning of the person (organic functions, activities, and participation, particularly during movements bringing the arm above the head). This teaching should be used to (1) improve activity and symptom management, (2) reduce the load on the shoulder and the risk of symptom exacerbation by overly intense activities and thus break the vicious cycle of symptoms, (3) empower the person, and (4) avoid kinesiophobia by continuing to move without aggravating the attack.
With WHAT (Teaching material)	A logbook or occupational schedule can be used (monitoring and organization of activities over a given period).
HOW (Teaching methods)	The teaching on optimal arm elevation should be given to the person (e.g., use of short lever arms, modify the plane of movement, use of tools, use of the lower limbs, positioning of the neck, arms and thorax, weight transfers, control of the scapula) by ensuring adequate and non-damaging movements in the shoulder and by optimizing function. Functional and meaningful activities should be given priority. The dosage for return to function should be gradually adjusted based on symptoms. The teaching could involve one or more relatives (e.g., spouse). Coaches could be consulted for the return to sports.
WHERE (location)	In clinic and at home (occupational schedule)
WHEN and HOW MUCH (Times and Quantity)	Education should encourage the individual to perform optimal arm elevation with each elevation motion. Teaching targeting functional and meaningful activities should be prioritized especially in the chronic phase and during repetitive movements. Return to work should be done early when possible with meaningful and progressive tasks. A meeting with colleagues and the employer could be held upon returning to work.
TAILORING (Adaptations)	The management of the continuation and/or return to functioning should take into account the profile of the person (e.g., avoidant, adaptive ...), their irritability and their needs (e.g., more or less specific, tasks at home, support of relatives). The movements should be adapted to the functioning relevant to the person (e.g., caregiver, parent ...) as well as to the nature of the activities (e.g., involves the upper limb or not ...).
Recommendation 4: Teaching on the adaptation of activities and participation
4.1 Adaptations of functioning
On WHAT and WHY (Targets of the intervention and its use rationale(s))	Teaching on the adaptation of the activities of the person and their participation in society should be used to (1) promote independence, (2) ensure optimal movement in the shoulder, and (3) improve adherence to exercises related to activities and participation.
With WHAT (Teaching material)	A photo/video of the posture taken by a family member or colleague (sitting, standing, sleeping, or other), a home assessment by a professional or the presentation of postures using anatomical pieces can be used to provide postural advice.
HOW (Teaching methods)	Movements and postures should be appropriate for activities and participation. Postural advice should be given to individuals promoting the positioning of the shoulder in general and during sleep. Adjustment of movement at work should be addressed when appropriate, promoting return to work, reducing pressure to perform at work and avoiding employee–employer conflict. During disabilities, other movements should be favoured while correction/modulation should be prioritized when resuming athletic movements. The postures can be reflected during the in-person session, using demonstrations, a mirror, images or videos (e.g., person’s cell phone) or during a home assessment.
WHERE (Location)	In clinic and at home (e.g., photo/video)
WHEN and HOW MUCH (Times and Quantity)	Functional counselling should be prioritized, and the adaptation of activities and participation favoured with each arm elevation motion. Return to work should be early when possible with meaningful tasks adapted to the person’s condition.
TAILORING (Adaptations)	Movements and postural advice should be adapted according to the activities and participation of the person (e.g., caregiver, parent…) and their needs (e.g., risk factors, understanding, and life habits). More specifically, the adaptation of sexual activities should be addressed when a problem is reported. More specifically, work-related tasks should be adapted to the individual’s condition, type of work and context. More specifically, sports movements should be adapted to the stress of the affected limb relating to sport.
Recommendation 5: Education on the factors potentially influencing the evolution of the condition
5.1 Influencing factors
On WHAT and WHY (Targets of the intervention and its use rationale(s))	Teaching about the various aspects of health promotion that should be discussed with the person, to promote health and avoid deconditioning, such as: Personal factors according to the ICF  a) Expectations and beliefs (e.g. active approaches, targeting teaching, and self-management rather than passive),  b) General health  c) Sleep (quality, number of hours, tips for promoting sleep) to understand the importance of having restful sleep for healing,  d) Lifestyle habits (e.g., diet to understand its effect on tissue repair, hydration, alcohol, tobacco, drugs),  e) Co-morbidities (e.g., obesity to understand its effect on the healing process and on the limitations of arm movement),  f) The level of physical activity to understand its effect on the vascularization of structures and consequently the healing process,  g) Mental health,  h) Social satisfaction/condition,  i) The feeling of self-efficacy,  j) The feeling of injustice to understand its influence on rehabilitation and return to work (limiting factor),  k) Understanding and using other treatments (e.g. medical, pharmacological, etc.) Environmental factors  l) The layout of the home and/or the workstation to promote healing, protect structures, facilitate symptom management and reduce load/stress and the limits of amplitude at the shoulder (e.g., repeated stress at activities and participation) during the healing process.  m) The environmental context at social and work levels (e.g., social support, attitude of those around them, conflictual situations, pressure to perform at work) to understand the influence of the role of colleagues and relatives in rehabilitation and factors limiting return to work,
With WHAT (Teaching material)	a), b), c), d), e), f), g), h), i), j), k), m): Not specified 1) A photo/video of the posture taken by a relative or colleague (sitting, standing, sleeping, or other) can be used for home and/or workstation layout. Documentation can be given to the person on workstation adaptations.
HOW (Teaching methods)	a), b), c), d), e), f), g), h), i), j), k), m): Not specified l) Advice may be given on the layout of the home and/or the workstation. A referral to another competent professional should be made when this is beyond the skills and scope of practice of the physical therapist.
WHERE (location)	Not specified for all
WHEN and HOW MUCH (Times and Quantity)	b), d), e), f), g), h), i), k), m): Not specified a) Expectations and beliefs must be addressed from the first contact. c) Sleep must be tackled as a priority and essential. d) Tobacco should be approached quickly when the person is a smoker. j) The feeling of injustice should be addressed with clients who are compensated or not. l) Home and/or work station adaptations must be made as soon as possible (temporarily or permanently).
TAILORING (Adaptations)	For all: The person should be referred when relevant or when the problem goes beyond the professional’s scope of practice. a), b), d), e), f), g), h), i), j), k), l), m): Not specified c) Sleep is important to address in individuals who have difficulty sleeping, have symptoms when they wake up or at night, or who have constant symptoms.
Recommendation 6: Education related to interdisciplinary management
6.1 Preoperative management
On WHAT and WHY (Targets of the intervention and its use rationale(s))	Preoperative education on postoperative interdisciplinary management should be discussed with the person to (1) increase adherence to rehabilitation, (2) adjust their expectations and inform them well about the postoperative period, and (3) reassure them.
With WHAT (Teaching material)	Not specified
HOW (Teaching methods)	Not specified
WHERE (location)	Not specified
WHEN and HOW MUCH (Times and Quantity)	Teaching about postoperative management should be discussed with the person before surgery.
TAILORING (Adaptations)	The teaching on postoperative management targets individuals awaiting surgery only.
6.1 Interdisciplinary management
On WHAT and WHY (Targets of the intervention and its use rationale(s))	In order to support it in an interdisciplinary context (e.g., meeting/referral to another professional) the person should receive instruction to (1) promote their active participation during meetings with other professionals by asking relevant questions and (2) reducing stress.
With WHAT (Teaching material)	Person communication can be used.
HOW (Teaching methods)	The person should receive education informing them of their condition to properly prepare for their meeting with the other professional. An explanation to the person what to discuss with the other professional can be used.
WHERE (location)	Not specified
WHEN and HOW MUCH (Times and Quantity)	Teaching to meet another professional should be done when the person is about to meet another professional.
TAILORING (Adaptations)	Teaching for meeting another professional should be given to individuals who need to meet another professional.

Strengths

Two renowned framework and checklist guided the design of the interview guide and data analysis for this expert consultation. The ICF was able to encompass most of the potentially important components for creating new knowledge on the management of SAPS through patient education. Indeed, this study allowed for the consideration of the overarching components to understand the targets of education by considering the condition as a whole including disability and functioning. The TIDieR was used to document patient education interventions and strategies to describe them using data collected from participants. A rigorous approach was used to code and condense the data, with two individual assessors compared each item. Meticulous tracking of all coding changes was performed and documented. A rigorous approach was used to report this qualitative study based on the Standards for Reporting Qualitative Research²⁴ and Salmon’s article.²⁵

Practice implications

The consultation process provided an understanding of how to promote active engagement and autonomy using patient education tailored to the needs of the individual with SAPS and potentially change behaviours to improve the person’s condition. It granted a broad perspective and comprehensive understanding of individuals’ health status individuals, including its psychosocial and contextual aspects, and clinical needs regarding patient education for individuals with SAPS.

The emerging statements for patient education developed in this study aim to empower individuals with respect to their condition and suggest tailoring, so that education interventions are focused on the needs and context of the individual. They mainly focus on self-management strategies, such as teaching how to self-manage symptoms during function or how to manage mechanical stress to return to function. They also consider biopsychosocial factors such as individuals’ beliefs, social support, tolerance level, literacy level, meaningful activities, and mental health (e.g., fear of movement). These statements, based on experiential knowledge, are consistent with the literature suggesting that psychosocial factors may influence the chronicity of SAPS and should be addressed.³⁴

Limitations

It would have been interesting to conduct additional focus groups to encompass more rehabilitation professionals and patient-partners perspectives. Given that only two new codes and no new themes emerged after the second focus group, we do not believe that adding more focus groups would have provided more new data to generate recommendations. A study on focus groups from Guest and colleagues shows that over 80% of saturation is often reached after two to three focus groups.³⁵ Patient-partners needed to be trained or experienced in focus group discussions to stimulate interactions between them and the rehabilitation experts. The consultation involved renowned rehabilitation experts in the field, who are few within an accessible radius with the resources available in this study. It would not have been possible to involve many more patient-partners or rehabilitation experts. Other health professionals involved in the management of SAPS could also have been included in the discussion, although this study aimed to focus on the perspective of rehabilitation interventions to understand physical therapy practice more specifically. We question if having more people participants in the first focus group, if excluding other professionals and if involving only one patient would have changed the results. This study was a first step in creating new knowledge based on a qualitative study that highlighted the experiential knowledge of experts on this topic that is undescribed in the literature, although further studies are needed to deepen knowledge on patient education for SAPS.

Conclusion

This study provided a first understanding of patient education interventions and strategies that are relevant to the management of SAPS. The emerging statements could help develop future recommendations for patient education in the management of SAPS. This study is part of a larger study, aiming at sharing these emerging statements with a broader panel of rehabilitation professionals and patient-partners to modify, adapt, and create new recommendations as necessary to guide the clinical reasoning of physical therapists when using patient education for SAPS management.

Key Messages

What is already known on this topic

Psychosocial factors are involved in the chronicization of subacromial pain syndrome. Patient education in physical therapy can help address chronicization factors. Experts’ clinical experience is useful in describing patient education strategies.

What this study adds

As the literature on patient education interventions for the management of subacromial pain syndrome (SAPS) is scarce, this study helped created concrete knowledge based on expert’s experience. From this consultation emerged statements on patient education interventions and strategies that would be relevant to begin structuring patient education interventions and promoting self-management of this condition in patients with SAPS engaged in physical therapy follow-up. This could therefore potentially contribute to reducing its burden by acting on the psychosocial factors in a more rigorous and structured manner.

Katherine Montpetit-Tourangeau, has a PhD in Rehabilitation Science at Université de Montréal. She is developing clinical reasoning tools to enhance the rehabilitation of people with musculoskeletal disorders. She is interested in patients' and therapists' education, knowledge translation, patient oriented research and clinical reasoning in rehabilitation and health disciplines. She is working as a consultant in health technology assessment.