Implementation of shared decision-making in the management of chronic musculoskeletal pain: A scoping review.

Abstract

OBJECTIVES: Shared decision-making (SDM) is increasingly recommended for managing chronic musculoskeletal pain, yet its routine use remains limited. This scoping review aimed to identify and synthesise the barriers and facilitators to both implementing and using SDM across healthcare settings and levels of care. METHODS: A comprehensive literature search was conducted in April 2025 across seven databases. Eligible peer-reviewed studies focused on factors influencing SDM in the context of chronic musculoskeletal pain. Two reviewers independently screened and extracted data. A deductive-inductive-deductive analytical approach was used, beginning with mapping to existing SDM taxonomies, followed by inductive coding, and finally synthesis using the Theoretical Domains Framework (TDF). RESULTS: Twenty-eight studies were included. We identified 16 themes and 46 subthemes spanning patient-, healthcare professional (HCP)-, interactional-, and system-level influences. Key facilitators included formal SDM training for HCPs, empathetic and cultural-sensitive communication, decision aids, therapeutic alliance, and trust between patients and HPCs. Barriers were equally multifaceted and included time constraints, lack of personalised care, limited patient and provider knowledge, conflicting beliefs about pain, and organisational or system-level limitations such as poor workflow integration or inadequate resources. The most prominent TDF domains influencing SDM were knowledge, skills, beliefs about consequences, and environmental context and resources. CONCLUSIONS: SDM in chronic musculoskeletal pain is shaped by a complex set of interacting factors. While many barriers and facilitators are shared across health conditions, our review highlights specific contextual challenges in musculoskeletal care, such as diagnostic uncertainty and fluctuating symptom patterns, that complicate implementation. PRACTICE IMPLICATIONS: Addressing these challenges requires tailored, multilevel implementation strategies. Future work should prioritise system-level solutions and context-sensitive knowledge translation interventions to embed SDM sustainably into musculoskeletal pain care.