Physiotherapy Theory and Practice, 23(1):37 46, 2007

ISSN: 0959-3985 print/1532-5040 online

DOI: 10.1080/09593980601147843

Patient expectations of physiotherapy: Definitions,

concepts, and theories
Caroline J. Barron, PhD, Grad Dip Phys, MCSP, SRP,1 Jennifer A.
Klaber Moffett, MSc, PhD, MCSP, SRP,2 and Margaret Potter,
1
BPhEd, DipPhys, MSc, PhD3
Physiotherapy Manager, Methley Park Hospital, Methley, Leeds, UK
2
Deputy Director, Institute of Rehabilitation, Hull, UK
3
Physiotherapist and Performance Management Consultant, Nedlands, Perth, Western Australia

Expectations are an integral part of the psychosocial makeup of each patient, and there is a growing
recognition among physiotherapists that psychosocial issues may impact the outcome of physiotherapy.
This article seeks to clarify the term ‘‘patient expectation’’ by providing some definitions and an over-
view of the literature describing the concepts and theories associated with patients’ expectations. These
concepts are then related to physiotherapy to highlight the impact that patients’ expectations may have
on the outcome of physiotherapy, and the implications for physiotherapy are discussed.

Introduction been proposed (Gifford, 1999). This model

Physiotherapists are faced with a multitude of
challenges from each patient who attends for
treatment, most notably how to achieve the best
possible outcome. The investigation of factors
that influence outcomes is essential for effective
clinical practice. Traditionally, the biomedical
model1 has been the starting point for health
care professionals when investigating clinical
effectiveness. However, despite the evidence to
support the expected physiological effects of
treatment and a clinician’s knowledge of their
chosen intervention, sometimes the patient still
fails to respond. In these circumstances, limita-
tions of the biomedical model are evident, and
an alternative, the biopsychosocial model, has
explores the patient and their problem from a
physical, social, and psychological perspective,
and there is a growing recognition among
physiotherapists that psychosocial issues may
impact the treatment plan and ultimately the
outcome of physiotherapy (Higgs and Jones,
2000; Jones, Edwards, and Gifford, 2002).
Expectations are an integral part of the psy-
chosocial makeup of each individual patient.
This is acknowledged in the Standards of Pro-
fessional Practice produced by the Chartered
Society of Physiotherapy (2005) in the United
Kingdom. This document refers to the patients’
expectations influencing all aspects of quality,
and physiotherapists need to identify these
unique attributes if quality of care and the best

1
Biomedical model assumes that 1) illness is biologically specific; 2) the individual is not responsible for the illness; 3) treat-
ment is biologically mediated; 4) responsibility for treatment lies with the medical profession; 5) there is no continuum
between health and illness; and 6) the mind and body function independently of each other (Ogden, 2000).
Accepted for publication 11 March 2006.
The rights in a contribution prepared by an employee of the U.K. government department, agency, or other Crown body
belong to the Crown and are not subject to United States copyright law.
Address correspondence to Dr. Caroline Barron, Physiotherapy Department, Methley Park Hospital, Methley Lane,
Methley, Leeds, LS26 9HG, UK. E-mail: cjbarron@btinternet.com

37
38 Barron et al./Physiotherapy Theory and Practice 23 (2007) 37 46
possible outcome is to be achieved. There is
some evidence in general medicine, nursing,
occupational therapy, and physiotherapy to sup-
port the importance of adopting a patient-
centred approach that seeks to identify patient
expectations (Gerteis, Edgman-Levitan, Daley,
Delbanco, 1993; Fulford, Ersser, and Hope,
1996; Law, 1998; Mondloch, Cole, and Frank,
1999; Potter, Gordon, and Hamer, 2003).
Indeed, it has been suggested that identifying
patient expectations has a number of benefits
including improving patient satisfaction and
adherence and reducing litigation risk in health
care (Levinson, 1994; May, 2001). This article
provides an overview of the literature describing
the definitions, concepts, and theories associated
with patients’ expectations and discusses the
implications for physiotherapists.
Definition
Expectation is (1) a strong belief that something
will happen or be the case in the future, (2) a belief
that someone will or should achieve something
(New Oxford Dictionary of English, 1998). Expec-
tation and hope should not be used synonymously
because they are conceptually quite different.
Expectation is cognitive, whereas hope is motiva-
tional. It could be argued that expectation requires
some degree of knowledge, possibly due to pre-
vious experiences, thus allowing for a weighing
up of the probability of ‘‘success’’ or ‘‘failure.’’
However, probability does not necessarily play a
part in hope because even the most improbable
outcome can still be hoped for. For example, a
person buys a lottery ticket in the hope of winning
but does not necessarily ‘‘expect’’ to win.
Several studies have explored the link between
expectations and satisfaction (e.g., Linder-Pelz,
1982; Thompson and Su~ nol, 1995; McKinley, Ste-
venson, Adams, and Maku-Scott, 2002) and
found expectations to be an extremely important
psychosocial variable, having an independent
effect on satisfaction (i.e., subjects were satisfied
with the encounter irrespective of what the doctor
did). Satisfaction is always relative to the patients’
expectations and changes when the patients’
expectations change, even though the object of
comparison (actual health care received) may stay
constant (Goldstein, Elliott, and Guccione, 2000).
This reinforces the need to access the patients’
expectations because these are closely linked to
patient satisfaction. Furthermore, Kalauokalani,
Cherkin, Sherman, and Koepsell (2001) hypothe-
sised that patient expectation for benefit from a
specific treatment would be associated with
improved functional outcomes when that treat-
ment was given. In this randomised trial of 135
patients with low back pain, acupuncture and
massage were compared, and improved function
was found for 86% of those with high expecta-
tions, compared to 68% with low expectations.
Types of expectation
Thompson and Su~ nol’s (1995) review of
expectations as determinants of satisfaction
encompassed concepts, theories, and evidence,
covering a variety of perspectives: psychology,
sociology, social policy, health care services
and management, and marketing. Four types
of expectations were proposed:
Ideal: an aspiration, desire, want, or preferred
outcome, essentially concerned with an ideal-
istic state of beliefs.
Predicted: the realistic, practical or anticipated
outcome, matching what users actually
believe will happen in a service encounter.
Normative: what should or ought to happen.
Unformed: this state occurs when users are
unable or unwilling, for various reasons, to
articulate their expectations, which may be
because they may not have any, or find it
too difficult to express their feelings.
To illustrate, a patient is referred for physio-
therapy following a recurrence of an old com-
plaint that in the past was managed with an
electrophysical modality. The patient’s predicted
expectation of the physiotherapist would prob-
ably be to use the same modality, although due
to recurrence of the problem and discussions
with friends or colleagues, his ideal expectation
may be for a more active approach such as an
exercise programme.
However, Thompson and Su~ nol (1995) sug-
gested that unformed expectations might be
extremely prevalent in health care. Their review
also identified a number of personal and social
influences at work in developing and modifying
 Barron et al./Physiotherapy Theory and Practice 23 (2007) 37 46
expectations. Personal influences included
experience, information, interest, emotions, and
perceived consequences of outcomes. They
further suggested that social influences, such as
sociodemography, social norms, group pres-
sures, and equity were strong enough to out-
weigh many of the personal influences.
From the definitions offered so far, the
concept of expectations may not easily be trans-
ferable from setting to setting. For example, a
GP is often recognised as the ‘‘gatekeeper’’ for
medical services (Wensing, Baker, Szecsenyi,
and Grol, 2004) including physiotherapy and
may be regarded as the authority on all things
medical until referral to a specialist is required.
Subsequently, the patient’s perception of the
capabilities of his GP will be changed. Thus,
the specialist now becomes the authority. This
is where medical and physiotherapy practices
diverge. In the United Kingdom, although phy-
siotherapists are autonomous professionals,
with the knowledge and expertise to diagnose,
assess, and treat many conditions, the patient’s
perception of the physiotherapist’s role in
Figure 1. The health belief model. Source: Rosenstock et al (1994).
39
his=her treatment may be simply ‘‘carrying out
doctor’s orders.’’ This may not be the case in
other countries, but perceptions such as these
form part of the background to expectation for-
mation and should be closely examined if inter-
ventions to change expectations are to be
effective. In addition, the patient-centred
approach recognises that all aspects of the
patient’s journey require negotiation between
patient and health professional. This negotiation
is also likely to influence perceptions, expecta-
tions, and ultimately satisfaction with care.
Health beliefs and behaviour
The concept of expectation has been used in a
variety of theories that have attempted to
explain and improve our understanding of health
behaviour. One of the most widely accepted
theoretical models of behaviour change is
the Health Belief Model (HBM), a value expect-
ancy theory that uses a systematic method to
explain and predict preventive health behaviour.
40 Barron et al./Physiotherapy Theory and Practice 23 (2007) 37 46
Figure 1 illustrates the key components of the
Health Belief Model.
Later versions of the HBM (Abraham and
Sheeran, 1997) acknowledged the role of health
motivation and recognised that personality,
social, and other demographic factors can affect
health motivation and perceptions, although not
directly causal. However, although the beliefs
specified by the HBM are prerequisites for pre-
ventive health behaviours, the HBM does not
explain the mechanism by which beliefs and
behaviour are translated into action. Other cog-
nitions such as expectations are likely to be
involved in promoting this behaviour and may
be explained by social cognitive theory.
Self-efficacy and social cognitive
theory
Self-efficacy and outcome expectancy are
two key constructs in social cognitive theory.
Self-efficacy refers to ‘‘the conviction that one
can execute successfully the behaviour that is
required to produce the outcome,’’ whereas out-
come expectancy is ‘‘a person’s estimate that a
given behaviour will lead to certain outcomes’’
(Bandura, 1986, p. 391). A strong sense of
personal efficacy has been shown to be related
to better health (Brekke, Hjortdahl, and Kvien,
2001), higher achievement (Moriarty, Douglas,
Punch, and Hattie, 1995), and more social inte-
gration (Conyers, Enright, and Strauser, 1998),
which can impede or promote motivation to
act (Kelly, Zynanski, and Alemagno, 1991).
Three main sets of cognitions represent Social
Cognitive Theory (Schwarzer and Fuchs, 1996):
. situation-outcome expectancies, in which out-
comes result without personal action
. action-outcome expectancies, in which out-
comes result from personal action
. perceived self-efficacy, which is the confidence
one has to perform a specific action required
to achieve a desired outcome.
For example, a patient may present to a
physiotherapist with a mildly arthritic knee.
Their situation-outcome expectancies may be
determined by their perception of the current
level of degeneration in the knee joint and their
vulnerability to increased damage; their action-
outcome expectancies could involve their
perception that exercises could be done to
strengthen the knee, thereby reducing the risk
of further damage; and their perceived self-
efficacy would relate to their confidence that
they could undertake the programme of exer-
cises effectively. In this scenario, the physio-
therapist would need to raise the patient’s
awareness of the risks involved if they do not
act, as well as the benefits of acting, and try to
increase the patient’s self-efficacy.
The Theory of Reasoned Action (Fishbein and
Ajzen, 1975) states that people learn to behave in
a specific manner to fulfil their expectations,
whereas the Theory of Planned Behaviour
(Ajzen, 1985) suggests that a negative attitude is
likely to lead to behaviour that achieves the
anticipated negative outcome. Hence, if a patient
attends with a negative attitude toward physio-
therapy based on previous experience, it is
hypothesised that their behaviour is unlikely to
be cooperative with the therapeutic regimen. To
overcome the patient’s negative attitude, the phy-
siotherapist’s communication skills would need to
be of a very high standard. This supports the
notion that a patient’s positive and negative
expectancies should be assessed as early as poss-
ible so that any potential motivators can be ident-
ified and addressed (Baranowski, Perry, and
Parcel, 1997).
Locus of control
Another concept closely related to self-
efficacy is locus of control (LOC), which is a
generalised belief about one’s ability to control
events by virtue of one’s own efforts (Rotter,
1966). Rotter, in his classic work on locus of
control, distinguished between two types of
causal attributions: internal, where an event is
perceived as being caused by the individual;
and external, where the cause is perceived to
be outside the person’s control. Based on this
concept, Wallston, Wallston, and DeVellis,
(1978) developed the Multidimensional Health
Locus of Control Scales, which measure expect-
ancy rather than beliefs about specific behaviour
in three main domains: internal, powerful others,
and chance. Locus of control may be of parti-
cular relevance in physiotherapy (e.g., Johnston,
 Barron et al./Physiotherapy Theory and Practice 23 (2007) 37 46
Morrison, Macwalter, and Partridge, 1999). For
example, patients who have strong beliefs that
their health is in the hands of powerful others
(i.e. physiotherapists) may not respond well to
a home exercise programme. On the other hand,
patients with a strong internal LOC may benefit
from self-management strategies and feel frus-
tration with more passive treatments (e.g., use
of electrophysical agents).
The literature about the relationship between
LOC beliefs and health-related behaviours is
contradictory, but there is sufficient evidence
to suggest that LOC beliefs may influence
patients’ psychological well-being and whether
they feel able to be an active participant with
treatment. Thus, physiotherapists should be
aware of individuals’ beliefs regarding personal
control. More recently, it has been proposed
that efficacy beliefs contribute more to the
decision to participate in preventative health
behaviours than LOC beliefs alone (Norman
and Bennett, 1996). Wallston (1992) has updated
his position and considers that the construct of
LOC on its own plays a far less significant role
in predicting health-related behaviour than
either health value or other control-related
expectancy constructs, such as self-efficacy.
Attitudes
In psychology, the literature on attitudes,
beliefs, and behaviour toward health-related
issues is extensive. Attitudes are said to be based
on beliefs that result from both observational
(direct) and inferred (indirect) experiences that
have formed in the course of a person’s life. A
Figure 2. The central role of patient expectations in the placebo effect. Source: Ogden (2000) p. 279.
41
person’s attitude at any particular moment is
determined by his salient beliefs at that time.
Intervention may influence those beliefs, thereby
altering a person’s attitude, expectation, and
subsequent behaviour (Fishbein and Ajzen,
1975). Furthermore, attitudes formed from
direct experience may be more predictive of sub-
sequent behaviour than those formed indirectly
(Johnston, 1995).
The ‘‘placebo effect’’
Closely linked to beliefs and expectations is
the so-called placebo effect, defined by Shapiro
(1959) as: ‘‘the psychological or psychophysiologi-
cal effect produced by placebos.’’ (cited by
Grünbaum (1989) p. 9), where a placebo is
‘‘any therapy or component of therapy that is
deliberately used for its non-specific, psychologi-
cal, or psychophysiological effect, or that is used
for its presumed specific effect, but is without
specific activity for the condition being treated.’’
[cited by Grünbaum (1989) p. 10]. Such defini-
tions fail to recognise the importance of the
placebo, particularly since the benefit attribu-
table to the placebo effect has been shown to
vary somewhere between 20% and 50% (e.g.,
French, 1989; Richardson, 1992).
Patient expectations have a central role in pla-
cebo effects as illustrated in Figure 2. Flood et al
(1993) described five ways in which expectations
may influence outcome via the placebo effect:
. triggering of a physiologic response
. acting to help motivate patients to achieve
better outcomes
42 Barron et al./Physiotherapy Theory and Practice 23 (2007) 37 46
Figure 3. Cognitive dissonance theory of placebo effects. Source: Ogden (2000) p. 284.
. conditioning the patient psychologically to
observe certain types of symptoms and ignore
others
. changing the patient’s understanding of the
disease
. acting in concert with anxiety to heighten or
reduce symptoms
Ogden (2000) concurred with most of these
themes while adding three others: experimenter
{clinician} bias, reporting error, and expectancy
theory. Experimenter bias describes how the
expectations of the experimenter (e.g., physio-
therapist or doctor) are communicated to the
patient, thereby changing the patient’s expecta-
tions. Reporting error suggests that when
patients expect to get better, they misattribute
spontaneous changes and report recovery.
Expectancy theory relates patient expectations
directly to previous experience.
Although the relationship between expecta-
tions and the placebo effect appears to be very
strong, Totman’s cognitive dissonance theory(-
Figure 3) suggested that justification and disson-
ance (difference between action and theory) may
override expectations (Totman, 1976).
Totman proposed that the investment by the
patient in terms of money, dedication, pain,
time, or inconvenience would act to justify the
results. Only a positive outcome would allow
individuals to justify their behaviour and appear
rational, thereby resolving dissonance. Certainly
the placebo effect appears to be stronger when
more effort, time, money, or risk is involved
(Moseley et al, 2002).
Health behaviour and
physiotherapy
Awareness and consideration of the theories
that have been outlined would be useful for phy-
siotherapists because patient participation
should be an essential component. However,
the degree to which the psychological attributes
of physiotherapy are acknowledged and incor-
porated in everyday clinical practice is not clear.
Some research has been carried out to explain
the relevance to physiotherapy of psychological
factors, such as attitudes and beliefs regarding
physiotherapy (e.g., Jette and Jette, 1996;
Kendall, Wright, Dewey, and Kerr, 1997a).
The interaction between the physiotherapist
and patient is also known to influence outcome
(Klaber Moffett, and Richardson, 1997), and
although some physiotherapists may gain insight
into patient expectations, unless they are
adequately addressed, the interaction and
thus treatment may not be optimised (Potter,
Gordon, and Hamer, 2003).
Jette and Jette’s (1996) detailed study of 426
patients in the United States with knee impair-
ments found that patient characteristics rather
than clinical presentation accounted for much
of the variance in health outcomes following
knee rehabilitation. Patients who were older,
had not had surgery, were on sick leave, or were
depressed, were more likely to have poor health
outcomes than patients without these character-
istics. In New Zealand, Kendall, Linton, and
Main (1997b) highlighted the importance of
 Barron et al./Physiotherapy Theory and Practice 23 (2007) 37 46
‘‘yellow flags’’2 (patients’ beliefs or behaviours)
with low back pain patients. Subsequently,
yellow flags have been included in two national
guidelines for the treatment of low back pain
as factors that may predict poor outcomes
(New Zealand Ministry of Health, 1997; Royal
College of General Practitioners, 1999). Patients
with higher levels of perceived control over
recovery have been shown to make better pro-
gress following Colles fracture (Partridge and
Johnston, 1989), and low back pain patients
with stronger internal beliefs gained more from
treatment, learned their exercises better and did
them more frequently than those with weak
internal beliefs (Harkapaa et al, 1991). These
studies seem to suggest that the sources of belief
in personal control, such as attitudes, experi-
ences and cognitions, such as expectations, are
important and therefore should be discussed
with the patient, so that any unhelpful beliefs
can be dispelled.
To bring the theories of health behaviour into
context, their relevance to physiotherapy per-
haps need to be more widely understood. Most
of the literature related to health behaviour is
aimed at understanding and changing a person’s
‘‘unhealthy’’ behaviour. In musculoskeletal
physiotherapy, ‘‘ill’’ health is rarely an issue.
Unhelpful health behaviour may be associated
with activities that cause or prevent resolution
of a physical impairment, (e.g., wearing high
heels with an unstable lateral ligament of the
ankle). Sometimes the patient will be completely
unaware that the behaviour is ‘‘unhealthy,’’ but
once ‘‘educated’’ is able to make simple altera-
tions to their lifestyle, to allow restoration of
normal function.
Adherence to a specific exercise programme
may be particularly susceptible to negative
health behaviours (e.g., Schneiders, Zusman,
and Singer, 1998). If health behaviour is to be
changed by patient-therapist interaction, knowl-
edge of health behaviours and how to facilitate
behaviour change would be very useful. In
addition, it would benefit physiotherapists to
recognise how their own beliefs and behaviour
can positively or negatively affect a patient’s
2
‘‘Yellow Flags’’ are factors that increase the risk of
developing, or perpetuating long-term disability and work
loss associated with low back pain (Kendall, Linton, and
Xnain, 1997b).
43
expectations. This is highlighted by Cedraschi,
Reust, Roux, and Vischer (1992) who found
that some patients’ erroneous beliefs can
remain unchanged despite being given correct
information.
Problems can also arise when patients’ expec-
tations are much lower than those of the physio-
therapist (Harding and Williams, 1995a). This is
of particular importance in the treatment of
chronic pain, where patients can misconstrue
their symptoms as an indication of underlying
serious pathology. Physiotherapists are in a
position to change inaccurate beliefs about the
pathology of the problem, reduce anxiety,
thereby increasing self-efficacy, and combating
depression. If physiotherapists can recognise
these opportunities and develop the skills
required to facilitate the use of basic cognitive
principles in the treatment of physical disabilities
there is benefit for both therapist and patient.
Certainly many of these principles are employed
in some areas of physiotherapy such as chronic
pain management. However, the same principles
could be readily applied in the acute setting (e.g.,
Harding and Williams, 1995b).
Physiotherapists are more likely to be success-
ful in applying the theories that have been
discussed, by identifying patient cognitions
(thoughts and beliefs), addressing any concerns,
and empowering patients to play an active role
in rehabilitation. It may be possible to adopt
some psychological screening questions, not
unlike the ‘‘Yellow Flag’’ assessment (Kendall,
Linton, and Main, 1997b). Examples of possible
questions include: How do you feel about the
care that you have received so far? What treat-
ments do you expect? How much benefit do
you expect to get from physiotherapy? How do
you think you can fit physiotherapy into your
daily routine? The answers to such questions
may highlight important factors for consider-
ation in patient care.
Techniques such as motivational interviewing
(Miller, 1996) are used by some physiotherapists
when assessing a patient’s readiness for change,
and such techniques have been shown to resolve
dissonance and increase internal locus of control
(Draycott and Dabbs, 1998). However, imple-
menting any of these strategies requires effective
communication skills, particularly active listening
(Ohlen, Holm, Karlsson, and Ahlberg, 2005).
Physiotherapists should be aware that the
44 Barron et al./Physiotherapy Theory and Practice 23 (2007) 37 46
consequences of poor communication are signifi-
cant with patient dissatisfaction, inaccurate diag-
nosis, poor adherence, suboptimal outcome, and
an increased risk of litigation as potential out-
comes (Davis and Fallowfield, 1991).
Conclusion
This article set out to clarify the term ‘‘patient
expectation’’ and to describe the concepts and
theories associated with patients’ expectations.
In addition, how these constructs may impact
on the therapist-patient interaction and ulti-
mately treatment outcomes in physiotherapy
has been highlighted. However, it is acknow-
ledged that this article was written primarily
with the UK National Health Service in mind
and that patient expectations are likely to be
affected by differences in health systems around
the world.
Expectations have been shown to be directly
linked to health beliefs, self-efficacy, locus of
control, and attitudes. The evidence base sup-
porting the impact of beliefs and perceptions
on behaviour is substantial, although the evi-
dence related specifically to physiotherapy is
limited. Nevertheless, there appears to be more
theoretical basis to the psychological effective-
ness of physiotherapy than many of the physical
modalities currently in use. Therefore, research
attempting to investigate the efficacy of physio-
therapy interventions that examine the psycho-
logical attributes mentioned in this article is
recommended.
In the meantime, physiotherapists should con-
sider patients’ expectations and related issues
knowing how expectations may affect the pro-
gress and outcome of treatment. For some phy-
siotherapists it may be necessary to undertake
further education so that they have the knowl-
edge and skills to more effectively deal with psy-
chosocial issues. In addition, providing
undergraduate students with more information
about psychosocial issues and their impact on
the effectiveness of physiotherapy would be ben-
eficial. However, given undergraduate education
programmes vary between institutions (Scudds,
Scudds, and Simmonds, 2001; Metcalfe, 2004),
further research to investigate the extent to which
psychosocial aspects of physiotherapy are already
being taught would be the next logical step.
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