[ EDITORIAL ]

SIMON DÉCARY, PT, PhD1 • JOSHUA R. ZADRO, PT, PhD2,3 • MARY O’KEEFFE, PT, PhD3,4
ZOE A. MICHALEFF, PT, PhD5 • ADRIAN C. TRAEGER, PT, PhD2,3 • FRANCE LÉGARÉ, MD, PhD1

Overcoming Overuse Part 5: Is Shared

Decision Making Our Excalibur?

S
hared decision making (SDM) involves clinicians and patients decision aids for chronic musculoskeletal
collaborating on health care decisions after considering the pain found that using these tools could
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best available evidence and patients’ values and preferences.16 improve knowledge and help to resolve
decisional uncertainty, but 7 of 8 trials
Shared decision making is increasingly promoted as a
found no benefit of reducing the use of
strategy to reduce overuse in health care, including in guidelines for surgery for osteoarthritis.3
musculoskeletal pain (eg, American Pain Society).2,12 In the previous The impact of SDM on other aspects
editorials, shared decision making offers on the effectiveness of patient decision of musculoskeletal health care remains
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

a potential solution to “misaligned care”13 aids—tools that help facilitate SDM in uncharted territory. Patients with mus-
and the beliefs and knowledge imbalances clinical consultations.16 Using decision culoskeletal conditions face decisions
that drive supplier-induced demand.14,18 aids can reduce the use of some elective concerning a plethora of low-value
Excalibur was the legendary sword of King surgeries,19 prevent unnecessary screen- medical (eg, opioids, injections, imag-
Arthur from the legends of fifth-century ing tests for prostate cancer,16 and reduce ing) and nonmedical options (eg, elec-
Britain that many believed to have magi- antibiotic use for acute respiratory tract trotherapy). Knowing whether SDM can
cal properties and contributed greatly to infections.11 Decision aids may help in- reduce the use of some of these options
victories in battle at the time. We believe crease uptake of options that are benefi- starts by understanding the expected
that SDM could be our Excalibur in the cial, such as diabetes medication.16 outcomes of SDM.
Journal of Orthopaedic & Sports Physical Therapy®

fight against overuse if clinicians commit Evidence on the use of SDM for reduc-
to learning how to wield it. ing invasive musculoskeletal care options Shared Decision Making Outcomes
is less certain. A comparative effective- Are Key to Understanding Overuse
Shared Decision Making to Reduce ness trial of 2 decision aids for hip/knee Current theories about SDM outcomes
Overuse in Health Care osteoarthritis led to informed patient- can help us understand how SDM could
The idea that SDM could reduce overuse centered decisions without reducing impact overuse. Elwyn et al4 categorized
gained traction after a Cochrane review surgery rates.15 A systematic review of SDM outcomes as proximal, distal, or
distant. Proximal outcomes are what
happens as a direct result of using SDM
! SUMMARY: Shared decision making is recom- evidence. Shared decision making could support
clinicians in promoting uptake of active rehabilita- (eg, increased knowledge of options,
mended as a strategy to help patients identify
what matters most to them and make informed tion options with a favorable balance of benefits informed decisions) (FIGURE 1). Distal
decisions about musculoskeletal care. In part to harms. Shared decision making facilitates outcomes are what happens after a con-
5 of the Overcoming Overuse series, we look at conversations about unnecessary tests or treat- sultation (eg, alignment of treatment
the evidence supporting shared decision making ments and could be a key strategy for overcoming choice with preferred options). Distant
as a strategy to help curb overuse. Using shared overuse. J Orthop Sports Phys Ther 2021;51(2):53-
56. doi:10.2519/jospt.2021.0103
outcomes are what happens in the longer
decision making in clinical consultations may
term, after a treatment strategy has been
help to reduce the overuse of options that are not ! KEY WORDS: musculoskeletal, patient experi-
beneficial and to increase use of care supported by ence, preferences, value-based care, values
decided (eg, utilization rates or health
outcomes). Shared decision making has a
1
Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Quebec, Canada. 2School of Public Health, Faculty of Medicine and Health,
The University of Sydney, Sydney, Australia. 3Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia. 4School of Allied
Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland. 5Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine,
Bond University, Robina, Australia. No funding was received for this editorial. The authors certify that they have no affiliations with or financial involvement in any organization
or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Simon Décary, Tier 1 Canada Research Chair
in Shared Decision Making and Knowledge Translation, VITAM – Centre de recherche en santé durable, Pavillon Landry-Poulin, Entrée A-1-2, bureau A-4578, 2525 chemin de la
Canardière, Québec, QC G1J 0A4 Canada. E-mail: [Link]@[Link] ! Copyright ©2021 JOSPT®, Inc

journal of orthopaedic & sports physical therapy | volume 51 | number 1 | january 2021 | 53
 [ EDITORIAL ]
proximal impact, while evidence regard- against overused options such as opioids conditions often requires a collaborative
ing distal and distant impacts of SDM or surgery. interdisciplinary approach between phy-
continues to evolve. sicians, physical therapists, and patients.
The musculoskeletal community now Implementing Shared Decision Making in A challenge to implementing SDM
has access to the Outcome Measures in Musculoskeletal Rehabilitation in musculoskeletal rehabilitation is that
Rheumatology (OMERACT) SDM core It is tempting to apply the findings from patients have diverse symptom severities,
outcome domains17 (summarized in the SDM studies of antibiotic use to other causes, and durations. Patients may have
TABLE), codesigned by patients, clinicians, prescription medications for musculo- acute pain due to trauma or chronic pain
and researchers. Knowledge and confi- skeletal pain. In the former, patients are that has flared up. The wait-and-see ap-
dence in the chosen options are proximal typically faced with 2 options: take the proach may be an acceptable option for
outcomes, while alignment and satisfac- antibiotic immediately or the wait-and- conditions that often resolve naturally
tion with the decision-making process see approach, an acceptable option with with advice and reassurance (eg, ankle
are distal outcomes. The fifth domain, few harms. When prescribing medica- sprain). For patients with chronic pain,
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“adherence to the chosen option,” is a tions for acute and debilitating musculo- tapering strong pain medicines (eg, opi-
distant outcome measured after a con- skeletal pain, patients may be reluctant oids) may increase flare-ups, making
sultation. Adherence to musculoskeletal to accept treatment options that provide it difficult to encourage a wait-and-see
rehabilitation is required to improve pain delayed symptom relief, such as exer- approach.
and function that may guard patients cise.1 Using SDM for musculoskeletal Decision aids for musculoskeletal
pain also need to integrate and balance
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Using a shared decision- Decision-making process outcomes Patient and system medication and rehabilitation options by
making approach (eg, tool • Greater knowledge about condition outcomes specifically reporting on the benefits and
or program during a clinical • Better informed about options • Greater patient-reported
consultation • Clearer about values and
preferences
? outcomes?
• Greater adherence to
harms, and levels of supporting evidence
for each treatment option.19 Providing
• Active role in decision making chosen options? many options increases the complexity
• Appropriate risk assessment • Less overuse or greater
• Value-congruent choices underuse of diagnostic of the decision and risks creating greater
• Greater satisfaction about decisions tests and treatments? decision uncertainty for patients. Newer
decision aids that use an online adaptive
FIGURE 1. Shared decision-making outcome categories. Using shared decision making improves decision-making
format that is based on patient pheno-
Journal of Orthopaedic & Sports Physical Therapy®

process outcomes (proximal outcomes; orange box), but the evidence concerning patient and system outcomes is
evolving (distant/distal outcomes; green box).4
types will help resolve this issue.
Not all patient decision aids are of
high quality. Patient educational mate-
Summary of OMERACT’s 17 Core rial is often mislabeled as a decision aid
TABLE
Outcome Domains and fails to engage patients in SDM. In
contrast, option grids present balanced
Domain Definition information on benefits and harms and
1. Knowledge of options and their A shared decision-making intervention helps patients understand the options encourage active engagement of patients
potential benefits and harms and their potential benefits and harms, and the probabilities of benefits in the decision-making process.6,10
and harms Clinicians may need training in SDM
2. The chosen option aligns with each A shared decision-making intervention helps patients choose the treatment to increase confidence and prevent po-
patient’s values and preferences option that matches their values and preferences, or the treatment that has
tentially negative consequences.9 Some
the benefits they value most or the harms they can accept
clinicians may worry that discussing pain
3. Confidence in the chosen option A shared decision-making intervention helps patients feel sure or confident they
made the best decision. It reduces their uncertainties toward a decision medication will threaten the clinician-
4. Satisfaction with the decision- A shared decision-making intervention helps patients feel satisfied about the patient relationship. Patients may feel
making process way they made the decision and about their level of involvement. Not all they are being stereotyped for preferring
patients want to be involved in the decision-making process medication over sometimes costly and
5. Adherence to the chosen option A shared decision-making intervention helps patients follow through with the difficult-to-access rehabilitation. Com-
chosen treatment option. It means that they should decide to continue munication skills are vital for navigating
using the option they chose until it is found to be ineffective
uncertainties concerning musculoskel-
6. Potential negative consequences A shared decision-making intervention may have potential negative conse-
etal rehabilitation. Clinicians need train-
of the shared decision-making quences, such as being difficult to use, time consuming, or stressful when
intervention given too many options to choose from ing to effectively use decision aids.9
Abbreviation: OMERACT, Outcome Measures in Rheumatology. Musculoskeletal rehabilitation clini-
cians, including physical therapists, have

54 | january 2021 | volume 51 | number 1 | journal of orthopaedic & sports physical therapy
 Mike explains that they need to decide about her rehabilitation plan. There are consequences. Implement Sci. 2016;11:114.
Identify the decision
1 to be made
many types of exercises and physical activities that can help her, and [Link]
perhaps other pain treatments. 5. Elwyn G, Pickles T, Edwards A, et al. Supporting
shared decision making using an Option Grid
Mike explains that strength and cardio exercises can help reduce pain to a for osteoarthritis of the knee in an interface
certain degree, and perhaps her need for tramadol. Some supervised musculoskeletal clinic: a stepped wedge trial.
Explain evidence about
2 benefits and harms
sessions may be beneficial to progress safely and learn the exercises, and
Patient Educ Couns. 2016;99:571-577. [Link]
she could do other sessions at home. However, exercises require time and
supervised sessions incur costs. org/10.1016/[Link].2015.10.011
6. Grande SW, Faber MJ, Durand MA, Thompson
Nicole understands the side effects of tramadol. Her insurance plan covers a R, Elwyn G. A classification model of patient
Ask about what matters
3 most to the patient
maximum of 5 physical therapy sessions. Her workplace offers yoga engagement methods and assessment of
sessions twice a week. their feasibility in real-world settings. Patient
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Nicole wants to manage her pain and reduce her stressful feelings about the org/10.1016/[Link].2014.01.016
Prioritize options based
4 on preferences
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a session once per month with Mike. of the benefits and harms of treatments, screen-
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ing, and tests: a systematic review. JAMA Intern

Nicole will try yoga and home exercises. Mike offers a follow-up plan at lower Med. 2017;177:407-419. [Link]
cost, including telerehabilitation to ensure exercises are done correctly and
Make a decision with jamainternmed.2016.8254
5 the patient
that her pain doesn't flare and phone calls to discuss adaptation to the plan
8. Hoffmann TC, Del Mar C. Patients’ expectations
during a flare. In-person visits could be required to assess her knee if a flare
does not resolve. of the benefits and harms of treatments, screen-
ing, and tests: a systematic review. JAMA Intern
Nicole will follow up with her family physician about her tramadol tapering. They Med. 2015;175:274-286. [Link]
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Consider facilitators and

6 barriers to the decision
will also discuss other pain treatment options and mental health support for jamainternmed.2014.6016
her stress. 9. Légaré F, Adekpedjou R, Stacey D, et al.
Interventions for increasing the use of shared
FIGURE 2. Outcome Measures in Rheumatology’s17 6-step shared decision-making process applied to a physical decision making by healthcare professionals.
therapy consultation in the context of reducing an opioid medication. A patient had knee osteoarthritis for 5 years. Cochrane Database Syst Rev. 2018;7:CD006732.
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She agreed to consult a primary care physical therapist to discuss rehabilitation options. 10. Légaré F, Hébert J, Goh L, et al. Do Choosing
Wisely tools meet criteria for patient decision
a central role to play in implementing rately compare the benefits and harms of aids? A descriptive analysis of patient materials.
SDM for musculoskeletal conditions. musculoskeletal tests and treatments.7,8 BMJ Open. 2016;6:e011918. [Link]
Journal of Orthopaedic & Sports Physical Therapy®

10.1136/bmjopen-2016-011918
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journal of orthopaedic & sports physical therapy | volume 51 | number 1 | january 2021 | 55
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