Navigating expectation-evidence tensions in musculoskeletal physiotherapy

Patient expectations influence clinical outcomes in musculoskeletal physiotherapy, acting both as prognostic factors and as active contributors to treatment effects. These expectations are shaped by previous healthcare experiences, digital and verbal information, and social context. However, patient expectations may be misaligned with evidence-informed care, creating ethical tensions between optimising contextual effects, supporting person-centred care, and maintaining professional integrity.

This professional practice article discusses the contextual and ethical foundations of patient expectations in musculoskeletal physiotherapy and introduces the Contextually Informed Expectation Alignment framework. This framework provides a structured approach to systematically elicit and classify patient expectations, including concordant, unrealistic but non-harmful, and conflicting expectations, and aligning these with evidence-informed care through shared deliberation and contextual optimisation.

The framework supports clinicians in making patient expectations explicit, differentiating between types of expectations, and responding accordingly within a person-centred and evidence-informed approach. By combining expectation elicitation, classification, and shared deliberation, clinicians can better navigate expectation-evidence tensions, strengthen the therapeutic alliance, and reduce low-value care. This requires attention not only to what patients expect, but also to the needs, values, and capabilities that may be expressed through those expectations. Implementation has implications for physiotherapy education, practice, and research. Clinicians require competencies in communication, ethical reasoning, value clarification, and contextual optimisation. Further research is needed to evaluate the feasibility and acceptability of the framework, determine longer-term effects, and identify which patients, settings, and clinical contexts may benefit most. Addressing patient expectations remains fundamental to high-quality musculoskeletal care.