Limitations
pain
RECRUITMENT
In addition to the aforementioned sample size and composition issues, the following limitations are worth noting. Patients were participants referred for a physical therapy treatment program for RCRSP; consequently, there is a high risk of selection bias (e.g., the patients expected physical therapy to work and did not feel surgery was necessary), which may also be the reason for the high baseline expectations for treatment. In order to remedy this recruitment issue, future research should be designed to target recruitment to individuals that are most likely to have lower expectations of physical therapy treatment). Another participant related limitation to consider is that the collection of data did not allow for differentiation of sex and gender identity. Depending on the research question, this distinction may be important to make in future research of interventions like PEERC.In this trial we intentionally used an A versus A + B design as it bested addressed our research question. However, this design could be considered a limitation by those interested in the isolated effects of PEERC. Therefore, future research could consider A versus B designs to address this design choice. PEERC was provided by two experienced, PhD-level physical therapists who had undergone formal external (e.g., educational certificate on pain management) and within-study (dedicated training sessions for the study) training. Nonetheless, both individuals were not psychologists and there is the chance that this influenced the overall quality of the interventions, particularly having the background, experience, and skills to optimize its effectiveness. Also, although a fidelity checklist and “daily coaching” sheets were used to maintain treatment fidelity, there is a risk that some therapist drift may have influenced the uniformity of the interventions. Another limitation is that the primary outcome was collected by self-report. Thus, patient reports of having had surgery or being scheduled for surgery were not verified via electronic medical record. This approach was determined to be acceptable for this trial because the trial team had ready access to this patient population and a manageable (