Joshua Zadro

Hi everyone my name is Josh, and I'm here with Yanfei and Travis. And today I'm going to be looking at the effects of language and labels on people's beliefs about musculoskeletal pain. Before I start, we'd like to acknowledge the the Turrbal and Jagera peoples of the Meanjin as the original owners and custodians of the lands on which we meet work and learn.

We pay our respects to elders past, present and emerging. So I thought we'd start by just giving a brief introduction of who we are. So my name's Josh Zadro, I’m a research fellow at the University of Sydney, working at the Institute for Musculoskeletal Health. And I have a physiotherapy background, worked in private practice for a few years and with sports teams now I'm a full time researcher and in terms of research interests.

My main focus is looking at ways to improve access to effective and affordable care, particularly as that relates to physiotherapy interventions. So I might pass over to Yanfei and introduce ourselves.

Yanfei Xie 

Hello. My name is Yanfei Xie. I'm a postdoc research fellow at Recover Injury Search Centres at the University of Queensland. I'm also physio by background and have worked in public hospitals before. I jump into the research field, so currently I'm full time researcher, so my research mainly focussed on understanding the mechanisms of musculoskeletal pains and also developing and implementing effective and tailored treatments. Particularly we focus on neck pain after road traffic injuries.

Joshua 

Thanks Yanfei and we will pass over. To Travis.

Travis Haber

Yeah. I'm Travis so I'm a Ph.D. candidate. I’m In the last few months of my Ph.D. studies and I've been looking at basically how people's beliefs about hip pain in middle age and older adults influences the type of treatments that I think might be helpful and the type of care they seek out. I'm also a physiotherapist as well. I've worked primarily in private practice and I do some teaching with the University of Melbourne as well in the doctor physiotherapy program and I dunno if I mentioned, but I'm with the Centre of Health Exercise Sports Medicine. As part of my Ph.D.

Joshua 

Thanks, Travis. Okay, so today I guess we're all here to talk about studies that were recently done looking at the effects of labels on management strategies for musculoskeletal pain. I thought it'd be good to start with a brief look into how labels came into the MSK field because this is more of a recent movement that's been happening for many years.

That was kind of speculation that the labels people use for different musculoskeletal conditions may increase their fear and anxiety and push them towards more invasive treatments. But there was no real empirical evidence to support this. And so when we looked to other fields, we found a lot of research in medicine which showed that if you give people a more medicalised diagnosis for a range of conditions like breast cancer, polycystic ovary syndrome, conjunctivitis and gastroesophageal reflux, they're more likely to choose tests and treatments that have no supporting evidence.

And even when they were told that these treatments are not necessary, these labels would still push them towards choosing these compared to ones that were less medicalised and described more the prognosis rather than a specific structure. That was the problem. And so with this, me and my research group, we thought it would be interesting to investigate this for musculoskeletal conditions where we can't figure out the exact no specific cause of pain and the example that we've done a bit of research on is rotator cuff related shoulder pain, which is basically a umbrella diagnosis that captures a range of conditions affecting the shoulder.

And it's the most common presentation that people will see in the clinic. And so this diagnosis comes by many different labels. So some call it rotator cuff related shoulder pain and others call it Subacromial Pain Syndrome, Impingement syndrome, rotator cuff disease. And because imaging findings and clinical examination findings aren't reliable enough to tell us the exact cause of the pain, people tend to use a range of labels to suit their contexts.

Sometimes people call it a tear, a bursitis, or give it a more generalised label such as rotator cuff related shoulder pain. And so we thought, could we see which one of those labels helps patients choose more evidence based treatment options and avoids the need for low value care, such as surgery or imaging? And so that brings us to the first study we did, which looked at this and people with shoulder pain.

So we conducted an online randomised experiment where people with shoulder pain read a hypothetical scenario describing a case of rotator cuff related shoulder pain. Then at the end of the scenario, health professional would give them a label and then they would see how much the patient thought that they needed surgery or other interventions. And what we found was that if you label people with bursitis, this was the label that reduced people's perceived need for surgery the most compared to rotator cuff tear, and it also reduced perceived need for imaging compared to rotator cuff tear and Subacromial impingement syndrome.

And so this is the first quantitative study to look at this. It was also replicated in the back pain field where people found that if you call non-specific back pain a disc bulge disc herniation or arthritis, then it's going to increase their need for imaging and surgery compared to more non-specific labels such as non-specific back pain and lumbar spine.

So that's a brief overview of, I guess, my work but I might pass over to maybe Travis first to go over what he found in his study.

Travis 

So, yeah, we looked at a similar type of thing. It was based on some of that existing literature as well that about the anatomic or biomedical approach to communication might influence people to be, you know, wanting more invasive or surgical care. So what we did, we were looking at hip pain and sort of this came from a review as well that we did.

They actually found diagnostic information from health care professionals. So all those findings coming from X-rays and scans, one of the key things that was influencing people's beliefs and as we know from broader quality literature as well, the dominant or prevailing understanding of where of osteoarthritis or hip pain is one of wear and tear energy generation. So what we wanted to do was test that in experimental study.

So we had three groups, three labels with an explanation. One label of almost like a control label was hip degeneration. And that took on that wear and tear language or understanding that we found because it was prevailing discourse around hip pain. I use language like bone on bone inevitable aspect of ageing. Then we took hip osteoarthritis as our second label.

So this is, you know, probably the medical label, which I would say is most used among health care professionals. But we did find in our review and quality of literature that some people still attach negative emotions and concern to that label. So we wanted to test that. But what we did was we attached more of a contemporary understanding of hip osteoarthritis to that label as an explanation, just to see if you can see how that would affect people's beliefs basically about hip osteoarthritis as well.

So rather than describing it as something like wear and tear, we described it as, you know, that imbalance actually between, you know, all these changes and the repair processes over time. And then lastly, we wanted to provide them with basically a biopsychosocial explanation of hip pain that took away any or didn't emphasise structural pathology. So that was a persistent hip pain label.

And in that persistent hip pain label as the explanation, we did acknowledge things like, you know, can be due to changes in the hip, but also things like sleep, emotions, stress, fear, things of that nature. So we compared those randomised about 600 people to each of those groups and we looked for effects on beliefs about hip pain management, our primary outcomes were surgery and exercise harmfulness.

And yeah, indeed we found that we saw between group differences between both hip OA persistent hip pain label with that that generation and that wear and tear explanation and also across all of our secondary outcomes, for example, perceived helpfulness of physiotherapy, which again was higher in that hip OA label with that contemporary explanation and the persistent hip with the psychosocial explanation.

Joshua 

And I noticed you found quite large effects for this study and so I guess how important are these effects for clinicians and what would you recommend coming off the back of that?

Travis 

Knowing the clinical importance of these outcomes is difficult because we haven't got that, we haven't done that. Research has definitely a limitation on it by giving these sort of 10 to 20% changes. On baseline which is pretty comparable with other, what we'd say clinically important differences for other outcomes one to 0 to 11 and NRS. You might reason through that that some of these changes would be clinically worthwhile.

Well, I think the broader take home message here for clinicians is in some ways it's difficult to change a language because it's quite entrenched, but otherwise it's an extremely low cost intervention. And given we are seeing differences in something like two points in NRS scale for perceived native surgery and just given the societal implications and costs associated with overuse in surgery, you know in people with hip pain in older adults, I think the benefits certainly outweigh, you know, the perceived difficulty or costs associated with changing the language that we use to start diagnosing, explaining hip pain.

Joshua 

Yeah, definitely. Thanks, Travis. And Yanfei, you want to walk through your study and what you found?

Yanfei 

Yes, sure. We start this study because there's has been lots of discussions changing the names for neck pain after road traffic injuries. So usually when people experience neck pains after road traffic injuries, it's often called whiplash injuries or whiplash associated disorders. So in the views, lots of researchers and clinicians find that this might not be appropriate label.

But we are thinking to changes. But we firstly, we thought that we need to find out if we change it, what labels are we going to use and whether it is worth to change it. So that's how we start these studies. And this study is actually inspired by Josh  your shoulder studies. So we used similar study designs to an online randomised experimental study, so participants are randomly allocated to read one of defined hypothetical scenarios to describe neck pen after road traffic injuries.

So the only differences between the scenarios was the labels that health professionals use to describe neck pain. So the labels that we included are whiplash injuries, whiplash associated disorders, post traumatic neck pain to neck pain, and next strain. So our primary outcome is different from Josh studies and Travis studies. So we focus on recovery expectation as the primary outcomes because, you know, previous research from this recovery expectation is an important predictor in terms of how well people will recover after road traffic injuries.

And that's not you know, many people will choose full surgeries if they have neck pain after a road traffic crash. So that's why we focus on recovery expectation as the primary outcome. We also have up secondary outcomes, including the needs for imaging needs for second opinions, intensive treatment needs for avoiding physical activities and anxiety about the given diagnosis as well.

So what we found is that overall we found that the labels Whiplash Associated Disorders and neck pain led to lower recovery expectations compared to that label, Neck strain. So this is the overall findings. So in addition to the main labelling in first, we also found there's the influence of the labels on recovery expectations varies depending on whether participants have previous or currently neck pain or not.

So we found that among participants with no history, of neck pains the labels whiplash associated disorders led to lower recovery expectations compared to the labels whiplash injuries and neck strain. So this is quite interesting because among those, who are not familiar with neck pains, the label Whiplash associated disorders, actually lead to lower recovery expectation compared to Whiplash injuries. So we thought that maybe it's not the term whiplash caused the problems maybe to term disorders make people think that they are you know, slower to recover.

And then among participants who'd previously, experienced or currently experienced neck pain, when they do these studies, we found that the lable neck pain actually led to lower recovery expectations compared to the label neck strain. So this is also interesting as well is because this may be due to the fact that among those who already familiar with neck pain they may be seeking understanding of is that caused by the conditions?

So when they hear the diagnostic label neck pain, they might think this is too general. It doesn't pinpoint it. And if they so it doesn't tell them what exactly caused their neck pain so they might feel dismissed. And my view is that the health care provider did not know what exactly happened to them. So probably this mistrust led to the believed of lower recovery expectations. And this also reflect on the qualitative past that we collected from the participants as well.

Joshua 

So I want to ask you about the clinical importance of your findings. Before I do, I might summarise the overall direction of the different studies and labels. So there's been four conditions that have been investigated looking at the effect of labels on management intentions and the two ones that the biggest effects are in hip pain and low back pain.

So they found generally that clinicians should avoid labels like hip degeneration for people with hip pain and for back pain, people should avoid labels of disc bulge, disc degeneration and arthritis. Now research in the shoulder, we found smaller effects and to avoid rotator cuff tear and Subacromial impingement syndrome. And we found that the effects of giving good advice was additive to this.

But it was a lot bigger. So it was around 2 to 3 times bigger for those three conditions. The clinical implications seem to be that clinicians should still avoid those labels because it's low risk effort and cost. But for whiplash it seems more complicated because we've got compensable patients and also small effect sizes. So Yanfei would you like to talk me through, I guess, what your opinion is on the clinical importance of these findings and maybe why it's a bit more complicated in a compensable environment?

Yanfei 

I think yeah, it's definitely in the whiplash space is it's a little bit complicated and the results of our study is not straightforward is that, you know, one label is definitely is better compared to the labels. And then I guess the effect size we find is also small like only that for recovery expectations, the differences between labels is only one finds on the scale from 0 to 10.

So we are not sure about the clinical relevance of this finding. So we are not sure whether it is acceptable for clinicians and the insurance regulators to change the labels. And if we change like what labels, that would be appropriate. So among the labels that we find next strain seems to be the best ones. But even for this one, some participants still feel that.

This one is not for everyone. So we have qualitative, which sounds like preliminary, so we are still finalising the analysis. So I remember one of the participants spoke that they don't believe that they will recover completely recovers after three months because they feel neck strain is a wish washy diagnosis, so they don't trust the healthcare providers. I feel like there's no one labels that can satisfy to all people.

And Whiplash has been here for a long time, so I'm not sure whether it's easier to change if we want to ask people to change the label, whether it's easier for everyone's to made a change. But I think it is definitely important for the clinicians to be aware that the language that was used to describe, you know, musculoskeletal pain or neck pain after road traffic injuries can influence what people think about them and what they do, with them. we also found that the labels like Whiplash Associated Disorder and Whiplash injuries can lead to higher perception to often need to avoid physical activities compared to neck strain.

So we don't want this happens because we know the physical activities important for to how do people recover in the future. So I guess in my be more importance, like when we see the patients, it might be important to ask the patients about what that label means to them and like they are understanding about the labels and what the label means to their individual prognosis and how they think about the conditions.

And and then if we see some misconceptions among, you know, the patients, it's important that we clearly explain the diagnosis label and address the misconceptions related to the labels. I think that might be more acceptable among clinicians and regulators and, the insurance regulators and and the patients. Because for in compensations areas they need to have something to record in a the papers in terms of people's condition.

So if you ask them to change the labels, I'm not sure whether it would create chaos or something like that. So I guess we definitely if we we are looking to change the label, we definitely need to see opinions, discuss with all of the stakeholders to sort their thoughts in terms of we found these small differences like what do you think.

Do you think we should change the label or whether there's other ways to better tell the patients like explain the labels to the patients, to avoid patients, to have negative thoughts about the conditions and most good outcome.

Joshua 

You know, it's very interesting because it kind of brings up the issue which is relevant to the other fields of research and labelling, and that is what do we do when they've already received a label from another health professional and maybe I'll pass it over to Travis to say, if you're in the clinic and someone's already received a diagnosis from someone else of hip degeneration and that's what they present to you with, what would you recommend clinicians do?

Travis 

Yeah, it's a really good question. I think it's comes back to little bit, that conversation before our around, maybe some of the differences in the size of effects on beliefs as well. I do think maybe that pays to some extent is due to that while entrenched societal believe that if you have hip OA you need surgery and just that very common, you know, sort of societal belief around is due to degeneration, wear and tear.

So I think that in some ways explains why that wear and tear degeneration label did have such a large effect on beliefs about things like the potential damage from exercise or, you know, the need to see an orthopaedic surgeon. So I think the first thing to acknowledge is, you know, probably if you are in the clinic, like myself, most people that come to you with knee or hip pain, if they're over 55, 60, probably do think that they have some type of wear and tear or, you know, degeneration type issue.

Interestingly, though, based on our experimental data from our trial, we didn't actually find a moderating effect from people that had sought health care or not that actually had hip pain. So there might actually be some scope there based on, you know, at least those data alone that there might be some room still to shift or work with those existing beliefs.

Just to extend on that a little bit more on this program, getting a little bit better understanding about this issue is we're also doing qualitative interviews now as well. So we're taking people, some people at least, that have these existing understanding about what their pain is, which is usually a wear and tear one. Like I've said often that is coming from health care professionals, but not always.

You know, these types of things also come from observing neighbours with similar issues, discussions around the watercooler or that type of stuff. And you know, I'm putting this information to people and asking them, what do you think about it? You know, this to people, like I said, they think they're your parents, your generation, and it's just really mixed.

It's really mixed in. Some people have a very sticky, well entrenched belief, and no matter what information I present to them, they still view it through that lens of seeing there hip pain as wear and tear. And they just somehow, somehow that information, no matter what it is, gets turned back into. Oh this is going to be inevitable part of ageing.

I'm going to need surgery, sort of lacking hope around that potential improvement. But for other people they're extremely receptive to it as well. So they might have that existing understanding, but they really are open to this idea that other contributing factors could be playing into that, particularly if they can intuit themselves experiences that they've had or things that have come to realise in their own life whereby they've noticed that or their pain actually gets a little bit better when they're with their friends or their pain gets a little bit better when they've slept a little bit better and drawing on their own experiences rather than me having to sit there didactically and lecture them about these things. If I can get those experiences out of those people and get them to realise themselves these types of things that might actually be influencing their pain, that maybe contradict or challenge their existing beliefs around it is just this inevitable age and tear bone on bone. You know, that seems to be where I see the biggest scope to shift.

I'd say most people are open to that discussion. But you know, I know in the clinic myself and I know having spoken to people in depth now, that it can be extremely, extremely challenging and be naive and me to say, I think that we're always going to have 100% success if we are dealing with these well entrenched beliefs and trying to navigate that.

A last final thing I will say is you need to understand where these beliefs come from. And that's probably the biggest thing I'm coming to learn now is that obviously a lot of things goes into informing beliefs, but it's the more you unpack it, the more you realise the richness and depth that goes into these things. It's not just what health care professionals tell people that's a big part of it.

Findings x ray findings. But like I said, it's what they've observed from their neighbour, what experiences there mum might have had of joint pain, what they've seen on TV, Google, doctor, Google's a huge one, YouTube more increasingly, Twitter is extremely complex and unpacking that might also be important in the clinic as well. Just understand where people are coming from.

Joshua 

Yeah, I think that's great. And that mode of thinking kind of inspired the second study that we did in the field of labelling. So the first one we found an isolated effect of labels saying the slightest label that helps patients choose more evidence based options and rotator cuff tear isn't. But then we got a lot of comments from Twitter and the community saying that we only had everyone received guideline based advice.

And so the reason we chose good advice in that study was we wanted to see even if people get the right advice from a health professional, does the label have an independent effect? And then people were saying, if in the real world scenario, not everyone gives good advice and some people give advice that's going to increase fears and make them a lot more likely to choose non evidence based treatment options.

And so really the question was, is the effect of labels and advice which runs bigger. And so that led us to look at the effect of giving guideline based advice versus a recommendation for treatment and comparing that to the effect of labelling as bursitis and rotator cuff tear. And we found that the advice was a lot more important, but they both still have their independent effects.

So even if there's cases where you can give good advice, it's still important to also give a good label as well. I think it helps those scenarios when someone's already being given a label and it's very hard to change those entrenched beliefs that this is the diagnosis. But then I think in those cases you can look to the research and say, Well, the advice probably matters a bit more than that.

So even though I can't change the label that they've received, I can change the meaning that they attach to that label through some good advice and suggesting some evidence based treatment options. Another question I think would be interesting is maybe I’ll ask Travis first. Do you think labelling would change based on whether someone presents with an acute or chronic condition. I know Yanfei’s, was in whiplash, so they're all very acute patients, but it'd be interesting for hip pain.

Do you think labels have more or less of a role when someone's presenting with acute pain versus a condition that had for a long time?

Travis 

Yeah, I would say so. So we do. The people that we've included in our research are all people that have had pain for three months or longer. So yeah, just to say that all of our data is coming out of population that, you know, would simply be a, you know, wishy washy definition. But we have persistent hip pain based on that.

Yeah. So most definitely I would expect that potentially if someone is coming to you with an acute bout of pain particularly depends on their background. They probably aren't expecting you to give them a label of something like degeneration or hip arthritis, particularly if that pain maybe isn't as severe. You know, something like persistent hip pain or hip strain, which we haven't tested, but you know, based on both your research, that might be a little bit more palatable for that type of person.

But again, it would probably be based on their own experiences and existing beliefs, like if they thought for whatever reason that, you know, they had had some wear and tear because of X, Y and Z, then maybe they still would be expecting that more traditional, persistent hip pain diagnosis, like hip OA or hip degeneration or arthritis.

Joshua 

Yeah, it does all come back down to expectations. Doesn’t it, how they present to you in the clinic?

Travis 

100%, I think. Or at least something I do and I'm not saying this is the gold standard approach is you know the first question you know what what do you think the problem is or what's your understanding of the issue? And not everyone will have a coherent or strong belief around that. But often people do. And I think the least you can say to begin with and insert yourself, the more you can just try to understand where someone’s is coming from, the better.

And that first 3 minutes, 4 minutes might be vital. And just to gain understanding of what that person is actually expecting because like I said, a lot of people weren't particularly satisfied with a persistent hip pain label, but somewhere and even in interviewing people now some even though they have persistent hip pain, you know and based on other people I more expecting that hip OA type technical explanation some are totally fine with a persistent hip pain diagnosis and we're totally satisfied with that as an explanation for their pain.

So there's no one size fits all. And if you understand the person in front of you, I think you'd be much better positioned to give them the type of diagnosis that, A, they'll be satisfied with a B that will hopefully most favourably start to influence their beliefs about things. Recommended treatments, exercise, physical activity those types of things.

Joshua 

And I think that's where the research and clinical practice intersect because we are talking about trials or we're trying to isolate the effect of the label and we're getting an effect size, which is based on averages. But when you get to the clinic, it's very different and you have to make a decision as to which patient would be more inclined to accept a certain label.

So there's a bit of integration between the evidence and what people are doing in practice. I might wrap up with one more question about the research from here, so maybe Yanfei I'll ask you. So where's where's the next step in research related to labelling for whiplash going.

Yanfei 

And into next step? We actually think that this might not worth the resource to actually change the name and then we are not sure if we changed the name what exactly labels that can satisfy all peoples. So I guess the next step for in terms of labels and language maybe is not the business to whiplash, but one of the thought I was thinking that it would be importance to like language and communication.

Skill definitely importance among health professionals in managing musculoskeletal pain. So it would be important to come up with like or demonstrate whether some strategies or communication strategies with how to, how to reduce some of the unhelpful beliefs or empower people to engage with, more evidence based care.

Joshua 

And Travis future research directions for labelling in hip pain.

Travis 

Yeah, so I was sort of hoping by talking to some people, unpacking what we found in terms of those effects on beliefs, I might get somewhere close to the coming up with an alternative for that wear and tear way of explaining pain because I sort of feel like we know not what to do, but what's the good alternative there?

What's going to be palatable for, you know, the general public in terms of giving them, you know, a compelling, coherent explanation their pain is satisfied with that would hopefully start, you know, suggesting to them that things like exercise would be helpful and you know, that they don't necessarily need surgery. I'm coming to realise that that's going to be more difficult than I thought was probably very naive, thinking I'd get there in a few years.

Yeah. Again, a much better understanding now that the way people interpret this information is obviously and you know, it's an obvious point in hindsight is going to be very much be influenced by the types of beliefs and mindset that they're bringing on to that. It's not just saying that it’s impossible task of finding that satisfactory explanation that doesn't lean on things like wear and tear and degeneration.

I think there is going to be an individual you know or a tailoring that information required, but we are finding that certainly some terms and approaches are opening people up to that, and I think that's what needs to be explored more moving forward. This idea of repair does seem to suggest to people, and based on at least based on these early findings, that there might be some scope to actually improve things.

But we just need to work out how best to shape that language and implement it into practice. And then the final two things I would say is we need to work at like some of the work that you've been doing, how these things work are either independently but with advice or whether or not they actually interact. And I know you didn’t find that but you know it would be interesting to explore that in this space.

Oh, and then lastly, the main thing is how do these things actually implement the things that matter? Believe, okay, they're important, but what we really care about is behaviour are people actually doing more moving more exercising more surgery, referral rates or surgery rates coming down. You know, if we can start to implement this thing in the clinic.

So yeah, difficult research, but if we could actually get to that answer that question, I think that would put know would be excellent. That's what I'd be most interested in.

Joshua 

Yeah. And I think I agree with those two research avenues. I think talking to clinicians and understanding what is acceptable in terms of labelling for them, what are they willing to label these conditions for, would they give it to everyone that comes through the clinic? And then also some research conducted in the real world setting where we get patient outcomes, we see what labelling does to people's pain and function, but also what it actually does to the health care choices later down the track.

I think that's the next important things in the field and maybe the last thing we'll do is go around and just say some key takeaways for clinicians listening to this. So what would be your main suggestion going into the clinic next week?

Yanfei 

I think I meant message is that although we find, you know, small differences and we don't know the clinical relevance, but I think we should be aware of, you know, what we tell patients and the language that we use do have some influence on the patient's beliefs and how they would like to manage the condition. So I think it would be important to, you know, firstly check their understanding about the diagnostic labels that they're received and then chat what that means to their own recovery.

And if we find any, you know, misconceptions or unhelpful beliefs attached to the labels, make sure that we address it. I think that's the key take home message that I find from my own research and from the other research in this area as well.

Travis 

My most confident recommendation would be you're dealing with people middle age, or adult with hip pain. Now you really start to move away from describing and labeling that condition as wear and tear bone on bone degeneration based on, you know, qualitative and quantitative data. Now, pretty confident that's not having, you know, favourable effects on the type of things that people will think would be helpful.

Unfortunately, I don't have a recipe from there to say what what to do, but I would say opening that idea up of a more contemporary understanding hip OA does seem to be helpful in terms of people thinking things like exercise could be helpful. So yeah, you can engage with some resources around there and then finally, in a very tailored person, centre way, start exploring what psychosocial factors could be relevant for them, whether that sleep or stress emotions, and then opening that conversation up then about how that could actually be contributing to their pain, which then does seem to provide a platform to be offering or increasing their receptiveness to psychosocial treatments, you know, as relevant or needed for that person.

Joshua 

And if someone's coming into the clinic with shoulder pain the most, I guess the simple things you can do is avoid labels of rotator cuff tear and Subacromial impingement syndrome. If a patient's already got the labels, then I think it's worth exploring what they believe about these labels and what they think it means for their condition and potentially addressing any misconceptions they have about what that means for their management and prognosis of the condition.

And then I think we've also shown that the effect of advice is stronger than the effective label. So If you can also provide guideline based advice which is explaining shoulder pain in terms of a non-serious pathology, giving a positive outlook on the condition and recommending simple self-management strategies, then I think that's probably the best we can do at this stage regarding this field of work.

Thanks everyone for joining thanks Yanfei, thanks Travis.

Travis 

Thank you.

Yanfei 

Thank you.