Introduction Fatty infiltration (FI) of the rotator cuff (RC) muscles reflects chronic deterioration in muscle quality associated with tendon injury, disuse, ageing and nerve injury. Accurate and reliable assessment of FI based on imaging interpretation is essential for evaluating muscle degeneration, guiding rehabilitation planning and enabling meaningful comparisons across clinical and research settings. Several semi-qualitative grading systems and quantitative measurement approaches across imaging modalities, including CT, MRI, ultrasound and advanced techniques such as Dixon MRI have been used to assess FI; however, the reproducibility of FI grading or quantification at the level of image interpretation varies widely. This protocol outlines a systematic review and meta-analysis designed to evaluate the inter-rater and intra-rater reliability of imaging-based FI assessment at the level of image interpretation in RC disorders.Methods and analysis The review will follow the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P) guidelines and is preregistered in PROSPERO (CRD420251242564). Searches will be conducted in MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library from inception to the search date. Two reviewers will independently screen, extract data and assess study quality using the Quality Appraisal of Reliability Studies (QAREL) checklist. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) framework will be used to guide interpretation of reliability-related measurement properties. The primary outcomes will be inter-rater and intra-rater reliability reflecting the consistency of image-based FI grading or quantification. Where appropriate, pooled reliability estimates will be calculated separately by imaging modality (eg, MRI, CT and US) and by type of reliability (inter-rater and intra-rater). When quantitative pooling is not feasible because of limited studies or substantial heterogeneity, findings will be synthesised narratively and presented in summary tables. These will be synthesised using a restricted maximum likelihood random-effects model in R software, version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria) with the metafor package.Ethics and dissemination Ethical approval is not required as the review will use only published data. The results will be disseminated through a peer-reviewed publication and conference presentations to inform research and clinical practice in musculoskeletal imaging.PROSPERO registration number CRD420251242564.

IntroductionThere has been an emergence of evidence in the area of frozen shoulder (FS) within the past decade related to risk factors, etiology, diagnosis, and management. It has become increasingly challenging for clinicians and researchers to stay up to date in these areas, particularly with the clinical practice guidelines that are available being few and outdated. To this end, the aim of this study was to produce an international consensus on the risk factors, etiology, diagnosis and management for individuals with FS.MethodsDuring phase one a steering committee was formed in order to identify experts in the area of FS, examine the current evidence related to FS and identify key areas lacking consensus. Phase two consisted of inviting experts to participate in a three-round survey with a priori consensus level set at 80%. Descriptive statistics were utilized to determine the characteristics of the expert panel, response rate, and level of consensus.ResultsA total of 14 international experts responded to all three rounds of the Delphi survey with 100% response rate following round one. Consensus was reached for 101 items (57 in the first round, 37 in the second round and 7 in the third and final round). Specific to key topic areas, the following number of items reached consensus; etiology 9 items (diabetes mellitus, trauma, shoulder arthroscopy, thyroid disease, prolonged immobilization, adrenocorticotropic hormone deficiency, metabolic synderome, connective tissue disorders, and hyperlipidemia), risk factors 40 items (including biophysical factors for developing FS and biophysical and psychosocial factors influencing the Management and course of outcomes related to FS), diagnosis 19 items (4 confounding the diagnosis and 15 signs and symptoms associated with FS), Management 33 items overall and categorized into effectiveness for early and later stages of FS).ConclusionThe results of this international Delphi study help to provide a consensus on key elements to consider in clinical practice related to etiology, risk factors, diagnosis, and management for those with FS.

Objective: The Covid-19 pandemic changed education globally with a rapid reduction of in-person learning and increase in e-learning. This was challenging for students with themes of poorer motivation, reduced engagement, and difficulty translating knowledge into practical skills. Although Covid-19 restrictions have been removed in the UK, increased e-learning is likely to be permanently integrated in healthcare programmes by most UK universities. Therefore, programmes need to evaluate their e-learning to learn lessons for the future. This study aimed to understand physiotherapy students' experiences of e-learning and what, if any, specific topics were more challenging and why they felt this was the case to identify how e-learning can be developed to meet their needs. Methods: A descriptive phenomenological methodology and purposive sampling of physiotherapy students at a UK university was used. Two semi-structured focus groups were conducted, data was analysed using reflexive thematic analysis. Results: Four themes were constructed which were: connected but disconnected; collaborative disengagement; practicality for professional identity; and disembodiment with anatomy. Conclusions: For vocational healthcare courses with substantial practical skill development required to meet regulatory standards, the balance of online and in-person learning will continue to be a challenge. The changes to education delivery which occurred because of the Covid-19 pandemic have provided educators with an opportunity to reflect on the challenges facing both students and the profession itself in this increasingly online world. Recommendations from this study include integrating online communication skills within the curriculum, prioritising digital skills, and embracing emerging immersive technologies to enhance anatomy learning. Implications for educational practice: center dot The balance of online and in-person learning for professional healthcare programmes is challenging center dot Curriculums should include development of online communication skills to support students learning experience in the online classroom and to develop the skills required for the future workplace center dot Digital skill development should be integrated into programmes to reflect the changing professional climate of healthcare center dot MSK programmes using online anatomy learning needs to include embodied experiences with sensory-motor activities to support deep learning of the topic, digital tools such as iVR may be appropriate to support this

BACKGROUND:Persistent shoulder pain is common, and it is associated with substantial morbidity and healthcare costs. Approximately 21 to 50 % of people with shoulder pain treated in primary healthcare recover within six months. It is not known why at least half do not recover. One possibility is the manner underlying mechanisms related to persistent shoulder pain are managed. Being able to determine the predominant pain phenotype in people with persistent shoulder pain (i.e., nociceptive, neuropathic, or nociplastic pain) together with their underlying mechanism and tailoring management accordingly may improve outcomes for people seeking care for persistent shoulder pain. The International Association for the Study of Pain (IASP) recently developed clinical criteria and a grading system for the identification of nociplastic pain. OBJECTIVE:In this paper, we aim to provide suggestions to clinicians to assist in the evaluation of pain phenotypes, underlying mechanisms, and their causal relationships. DISCUSSION:Based on the IASP clinical criteria and grading system for nociplastic pain, we outline pain phenotype evaluation and provide a clinical reasoning framework. To facilitate this, three case studies involving people living with persistent shoulder pain are presented.

OBJECTIVE: Using an experience-based co-design (EBCD) approach, to co-design a treatment algorithm to support and enhance assessment, diagnosis, and treatment of people presenting with large to massive rotator cuff tendon tears (for ease of reading, we will use the term “rotator cuff tears”) in primary health care settings. DESIGN: Mixed-methods study underpinned by EBCD with involvement of clinicians and people with rotator cuff tears. METHODS: Using an EBCD process, people with rotator cuff tears and clinicians participated in 3 workshops. Then, the data were analyzed, summarized, and refined until a group consensus was reached, and synthesized to produce the final treatment algorithm. RESULTS: Eleven people with rotator cuff tears and 12 clinicians participated. The co-design group identified 10 clinical action points to support the clinical assessment and surgical and nonsurgical management of rotator cuff tears. The clinical action points included clinicians speaking with 1 voice, adopting a consistent approach to education, setting realistic expectations, collecting sufficient and relevant outcome measures, and using a common approach to shared decision making. The collective outcome was a comprehensive approach for large to massive rotator cuff tears (“CALMeR Cuff”), which serves as a shoulder pain care pathway. CONCLUSION: Our co-design approach involved people with rotator cuff tears and ensured that the CALMeR Cuff pathway can provide consistent, evidence-based care for people with rotator cuff tears. J Orthop Sports Phys Ther 2025;55(6):1-9. Epub 8 May 2025. doi:10.2519/jospt.2025.13342

INTRODUCTION:Frozen shoulder is a disabling condition characterised by severe pain and loss of shoulder movement. Corticosteroid injections are targeted at reducing pain in the earlier painful phase. There are multiple studies on the effectiveness of injections for frozen shoulder, but none were identified to assess if this guidance has been translated into clinical practice. The aim of this survey was to investigate the current practice and opinion of musculoskeletal health professionals regarding corticosteroid injections for frozen shoulder. DESIGN AND METHODS:The online survey was disseminated via the social media platform 'X' (at the time of the survey known as Twitter) over a 5-week period. Recruitment was by the 'snowball' effect. Responses to multiple choice survey questions were analysed with descriptive data. Free text questions were analysed using content analysis. RESULTS:The number of respondents to the survey was 235. Respondents felt injections have an important role in the management of frozen shoulder (155/235, 66%) and the best time to inject is during the pain predominant phase (191/233; 82%). The glenohumeral joint was the preferred anatomical site to inject (136/235; 58%) with triamcinolone as the preferred steroid (66/155; 43%). A steroid dose of 40 mg/mL was favoured by 55% (83/151) of respondents. CONCLUSION:Corticosteroid injections play an important role in the management of frozen shoulder. There was consensus for the type and dose of corticosteroid and anaesthetic; however, the range of preparations used indicated that many decisions may be based on personal preference or local guidelines.

BACKGROUND:Extended reality (XR) is increasingly used in the management of upper limb musculoskeletal conditions. PURPOSE:To systematically map reported interventions using XR, explore their effects, and identify gaps in knowledge. STUDY DESIGN:Scoping review. METHODS:Searches were conducted in CINAHL, ClinicalTrials.gov, Embase, MEDLINE, PEDro, and Web of Science, covering publication from 2006 to September 2024. Primary research studies were included if they focused on adults with upper limb musculoskeletal disorders, evaluated at least one XR intervention, and reported at least one outcome related to pain, range of motion, or function. The quality of the studies was assessed using the PEDro scale and Joanna Briggs Institute checklists. The present scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews guidelines. RESULTS:A total of 19 studies were included. Fifteen were randomized controlled trials, one was a nonrandomized controlled trial, two were case series, and one was a case report. The majority (n = 15) focused on shoulder conditions, with no studies identified for elbow, nontraumatic wrist, or hand conditions. Among the included studies, none evaluated mixed reality, only one investigated augmented reality, and 18 focused on virtual reality. XR interventions seem to be more effective at improving range of motion and upper limb disability than alleviating pain in people with upper limb conditions. CONCLUSIONS:While XR shows potential for improving range of motion and disability in people with upper limb musculoskeletal conditions, its clinical applications are hindered by methodological inconsistencies and limited evidence. Future research should prioritize high-quality randomized controlled trials with larger and more diverse populations.

# Introduction There is a high incidence of shoulder injuries among overhead athletes. Identifying and understanding risk factors for these injuries, particularly those that can be modified, is a necessary step towards being able to effectively develop and implement shoulder specific injury prevention programs. Therefore, the purpose of this systematic review was to identify risk factors associated with a new onset of shoulder pain and injury among the athletic population. # Design Systematic Review. # Methods A systematic review of the literature was performed within PubMed, Embase, AMED, CINAHL, and EmCare databases. Studies were screened utilizing the following inclusion criteria; (a) athletes currently pain free or no history of pain at baseline, (b) athletes with shoulder and or arm pain originating from a musculoskeletal shoulder problem (c) risk factors captured prospectively (d) pathoanatomy and biomechanics in isolation or in addition to personal characteristics, etc. (e) reporting relative risk, odds ratios, and/or hazard ratios and (f) follow up ≥ 6 months. Due to data heterogeneity, only a descriptive data synthesis was performed. Data were extracted and underwent risk of bias assessment utilizing the Quality in Prognosis Studies (QUIPS) tool. PRISMA guidelines were utilized throughout. # Results Nineteen papers were included. A total of four studies investigated baseball, five handball, three swimming, two tennis, two military, one cricket, one American football, and one with multiple sports, totaling 7,802 athletes. The risk of bias among the included studies was rated from moderate to low overall with no single study being identified as high risk of bias. All studies designs were a level of evidence of II except for two studies that were level III. The most significant risk factors included range of motion, reduced strength, history of local/regional musculoskeletal pain, previous injury, and training load. There are inconsistencies in how injury and pain are defined within studies. # Conclusion Many risk factors are easily objectifiable and modifiable which may help in developing shoulder injury mitigation strategies. Three of the five significant risk factors for injury can be identified by objective pre-screening measures. While previous pain and injury cannot be mitigated, training loads should be closely monitored and adapted according to other risk factors and the athlete's response. # Level of Evidence 2

Introduction Rotator cuff calcific tendinopathy (RCCT) involves calcific deposits in the rotator cuff. Non-surgical interventions such as extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) are recommended for its early management. Exercise therapy (ET) has shown to be an effective intervention for people with rotator cuff tendinopathy, but it has not been formally tested in RCCT. The main objective of this study is to compare the effectiveness of an ET programme with ESWT and US-PICT in people with RCCT. As a secondary aim, this study aims to describe the natural history of RCCT.Methods and analysis A randomised, single-blinded four-group clinical trial will be conducted. Adults from 30 to 75 years diagnosed with RCCT who accomplish eligibility criteria will be recruited. Participants (n=116) will be randomised into four groups: ET group will receive a 12-week rehabilitation programme; ESWT group will receive four sessions with 1 week rest between sessions during 1 month; US-PICT group will receive two sessions with 3 months of rest between sessions; and (actual) wait-and-see group will not receive any intervention during the 12-month follow-up. The primary outcome will be shoulder pain assessed with the Shoulder Pain and Disability Index at baseline, 2 weeks, 4 months, 6 months and 12 months from baseline. The primary analysis will be performed at 12 months from baseline. Secondary outcomes will include pain, range of motion, patient satisfaction and imaging-related variables. Moreover, the following psychosocial questionnaires with their corresponding outcome measure will be assessed: Central Sensitization Inventory (symptoms related to central sensitization); Pain Catastrophizing Scale (pain catastrophizing); Tampa Scale for Kinesiophobia 11 items (fear of movement); Fear Avoidance Belief Questionnaire (fear avoidance behaviour); Hospital Anxiety and Depression Scale (anxiety and depression); Pittsburgh Sleep Quality Index (sleep quality); and the EuroQol-5D (quality of life). An intention-to-treat analysis will be performed to reduce the risk of bias using a worst-case and best-case scenario analysis.Ethics and dissemination Ethics committee approval for this study has been obtained (reference number: 1718862). The results of the main trial will be submitted for publication in a peer-reviewed journal.Trial registration number NCT05478902.

Objective To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care. Design A qualitative descriptive study using reflexive thematic analysis. Setting In-person focus groups were undertaken in a clinical setting (private practice [ n = 1]; public outpatient [ n = 2]). Semi-structured interviews were conducted online via Microsoft Teams. Participants Patients diagnosed with these tears ( n = 12) and healthcare practitioners ( n = 11). Results Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears: 1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient–clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress. 2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient–clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty. Conclusions The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Abstract Background Throwing is one of the most important movement in handball. Throwing performance is crucial for success in handball. Objective Τo investigate the level of evidence for the effect of resistance training (RT) on throwing performance in handball players. Methods Systematic searches of Pubmed, Medline complete, Cinahl, Sport Discus and Scopus were undertaken for peer reviewed articles published between 18 March 1995 to 18 March 2023. Randomized, controlled, clinical studies, written in English, aiming to investigate the effect at least one modality of RT on throwing performance (velocity or/and accuracy) in handball players were considered for inclusion in the study. The eligible studies were assessed for methodological quality using the Physical Therapy Evidence Database (PEDRO) scale. The Best Evidence Synthesis (BES) approach was used for synthesizing and reporting the results. Furthermore, the random-effects model was used for the meta-analysis and the Q-statistic was used to test the null hypothesis that all studies in the analysis share a common effect size. Results One hundred ninety-eight studies were identified, of which 30 were included. A total of 727 handball players (males = 388, females = 292) were included. 28 of the 30 studies were rated as high methodological quality studies (PEDRO score > 70%) while the rest of the studies were rated as moderate methodological quality studies (PEDRO score ≤ 60%). The mean effect size for the effectiveness of resistance training (RT) in improving jumping throw, running throw, and standing throw velocity were 1.128 (95% CI 0.457 – 1.798), 1.756 (95% CI 1.111 – 2.400), and 1.098 (95% CI 0.689 – 1.507) correspondingly. Traditional weight training using barbells in mostly compound lifts yielded the most significant and robust results. Other RT modalities such as elastic bands, medicine balls, core training and ballistic training showed no significant results or positive effects due to the limited number of the studies. Conclusion Strong evidence exists only for the effectiveness of RT using barbells in increasing throwing velocity. In contrast, the remaining RT modalities, while yielding positive results, have limited support due to limited number of studies and the high heterogeneity between studies. Furthermore, there is insufficient evidence to support various forms of RT in increasing throw distance. Finally, medicine ball training and elastic band training demonstrated no benefits in improving throwing accuracy. Trial registration PROSPERO ID: CRD42023393574.

Background: The mechanistic response of rotator cuff tendons to exercises within the context of rotator cuff-related shoulder pain (RCRSP) remains a significant gap in current research. A greater understanding of this response can shed light on why individuals exhibit varying responses to exercise interventions. It can also provide information on the influence of certain types of exercise on tendons. The primary aim of this article is to explore if changes in supraspinatus tendon thickness (SSTT) ratio differ between exercise interventions (high load vs. low load). The secondary aims are to explore if changes in SSTT ratio differ between ultrasonographic tendinopathy subgroups (reactive vs. degenerative) and if there are associations between tendinopathy subgroups, changes in tendon thickness ratio, and clinical outcomes (disability). Methods: This study comprises secondary analyses of the combined dataset from two randomized controlled trials that compared high and low-load exercises in patients with RCRSP. In those trials, different exercise interventions were compared: 1) progressive high-load strengthening exercises and 2) low-load strengthening with or without motor control exercises. In 1 trial, there was also a third group that was not allocated to exercises (education only). Ultrasound-assessed SSTT ratio, derived from comparing symptomatic and asymptomatic sides, served as the primary measure in categorizing participants into tendinopathy subgroups (reactive, normal and degenerative) at baseline. Results: Data from 159 participants were analyzed. Two-way repeated measures ANOVAs revealed significant Group (P < .001) and Group x Time interaction (P < .001) effects for the SSTT ratio in different tendinopathy subgroups, but no Time effect (P = .63). Following the interventions, SSTT ratio increased in the "Degenerative" subgroup (0.14 [95% confidence interval {CI}: 0.09-0.19]), decreased in the "Reactive" subgroup (-0.11 [95% CI: -0.16 to -0.06]), and remained unchanged in the "Normal" subgroup (-0.01 [95% CI: -0.04 to 0.02]). There was no Time (P = .21), Group (P = .61), or Group x Time interaction (P = .66) effect for the SSTT ratio based on intervention allocation. Results of the linear regression did not highlight any significant association between the tendinopathy subgroup (P = .25) or change in SSTT ratio (P = .40) and change in disability score. Conclusion: Findings from this study suggest that, over time, SSTT in individuals with RCRSP tends to normalize, compared to the contralateral side, regardless of the exercise intervention. Different subgroups of symptomatic tendons behave differently, emphasizing the need to potentially consider tendinopathy subtypes in RCRSP research. Future adequately powered studies should investigate how those different tendinopathy subgroups may predict long-term clinical outcomes. Level of evidence: Level II; Randomized Controlled Trial; Treatment Study (c) 2024 The Author(s). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background The last phases of a competitive game are when shoulder injuries most commonly happen, and fatigue is thought to be a major contributing factor, perhaps because of reduced proprioception and motor control. The purpose of this study was to investigate the effect of concentric fatigue on proprioception, motor control, and performance of the upper limb in handball players. Methods Forty-six right-handed handball players (all males, age 26.1 ± 5.54 years) were included in this test-retest laboratory experiment. Proprioception was assessed using joint reposition sense (JRS), threshold to detection of passive movement (TTDPM), muscle onset latency (MOL), motor control using Y balance test upper quarter (YBT-UQ) and performance using the athletic shoulder test (ASH) before and immediately after fatigue intervention. The fatigue protocol consisted of concentric, maximal effort, isokinetic contractions at 900/sec with sets of 30 repetitions of the shoulder external and internal rotator muscles. Fatigue was determined by a 40% decline in the peak torque over three consecutive contractions despite reinforcing feedback and encouragement. Results A significant increase in absolute angular error (AAE) was observed in all target angles in both external rotation (ER) and internal rotation (IR) directions (p < 0.01). In addition, there was a significant increase in TTDPM in internal rotation after fatigue intervention (p = 0.020. Variable changes were found in YBT-UQ and ASH tests. Specifically, statistically significant differences were found in anteromedial (AM) (p = 0.041), superolateral (SL) reach directions (p = 0.005), composite score (p = 0.009) in the right hand and inferolateral (IL) reach direction in the left hand (p = 0.020) in the YBT-UQ. In addition, there was a significant reduction in isometric strength (ASH test) in the I position of the right hand (p = 0.010) and all positions of the left hand (p<0.05). Furthermore, there was an increase in MOL scores after fatigue but the increase was not significant (p > 0.05). Conclusions Concentric fatigue of the rotator cuff muscles induces notable deficits in joint position awareness, kinesthesia, motor control, and performance of the upper extremity in elite male handball players. Although fatigue reduces reflex reaction time the effect is only marginal.

Introduction Shoulder pain is common and associated with substantial morbidity. Different treatment strategies are being prescribed with equivocal results. Virtual reality (VR) is a novel technology and emerging research suggests that VR may be a promising alternative to current treatments. Prior to effectiveness research or any large-scale introduction, VR-applications require appropriate scrutiny including feasibility- and acceptability of clinicians and patients. Therefore, the aim of this study was to collect experiences of physiotherapists after using immersive VR. Methods A qualitative interpretive design was used to explore physiotherapists’ experiences related to the use of VR for people with shoulder symptoms. 17 physiotherapists were asked to use VR at home for five days prior to a focus group interview. Data from the focus group interviews were analyzed using a six-phase process of thematic analysis. Results Three main themes were identified, each divided into subthemes. The main themes were: 1. VR as an extension of contemporary physiotherapy care: physiotherapists were positive about the potential of VR and its applicability in daily care. 2. Physiotherapist uncertainties of future care using VR: participants expressed concerns about their professional identity, particularly as patients engage in independent home exercises. 3. Physiotherapist's requirements for implementation of VR: participants shared their needs for evidence regarding the effectiveness and parameters such as frequency, dosage and intensity of the VR intervention. Conclusion Physiotherapists were positive about VR as an intervention tool. However, they felt more knowledge is needed about parameters of VR. The findings of this study inform researchers and technology developers about optimal design of interventions and applications using VR.

ObjectiveTo investigate whether appointment adherence and frequency of home exercises mediates the association of baseline i) pain self-efficacy (PSE) or ii) patient expectation of recovery, with outcome at 6 months.Design: Multicentre longitudinal cohort study.MethodsSix-month outcome data (SPADI, QuickDASH) were provided by 810 of 1030 recruited participants. Daily frequency of home exercises over 6 weeks, were expressed as the proportion of days exercises were completed. Measures of adherence included proportion of appointments attended and completing a course of physiotherapy. Mediation analyses were conducted using Baron and Kennys’ four-step method, and for continuous variables, testing the indirect effect using a non-parametric version of Sobel’s test.ResultsAppointment adherence, completing a course of physiotherapy and frequency of home exercise did not mediate the relationship between PSE or patient expectation with 6 months SPADI or QuickDASH. Higher PSE was significantly associated with appointment adherence and completing a course of physiotherapy. Patient expectation was significantly associated with frequency of home exercise. However, none of the hypothesised mediators had a significant effect on outcome.ConclusionAppointment adherence and higher frequency of home exercise do not appear to be the mechanisms by which high PSE or expectation of recovery predict a good outcome. This study was not designed to address the effectiveness of a home exercise programme for which no conclusions should be drawn. However, our results do support the need for a greater emphasis on the assessment and incorporation of techniques to facilitate high pain self-efficacy and expectation of recovery.