An exploration of clinical variables that enhance therapeutic alliance in patients seeking care for musculoskeletal pain: A mixed methods approach

Abstract

Introduction/Objectives Therapeutic alliance (TA) is an integral part of building a patient and clinician relationship. TA begins at the initial encounter; however, the specific TA behavioural practices that are most impactful and linked to pain reduction and improved function remain unclear. The primary objective of this study was to explore physical therapist behaviours and interactions during the initial physical therapy evaluation and how they related to the patient's perception of TA. A secondary objective was to explore the relationship between TA, pain intensity, and function. Methods A mixed methods study was conducted. Pain intensity, TA and self‐reported function were assessed at three time points. Spearman's Rho (ρ) was used to quantify if there was an association between increased TA and function and reduced pain intensity, while a checklist of TA themes and behavioural practices was used for the qualitative analysis. Results There was a statistically significant negative correlation between patient‐perceived TA and pain intensity immediately after the initial evaluation (ρ = −0.39 [p = 0.048]). Behavioural practices associated with higher TA included information gathering, pausing to listen, using humour and transitions, and use of clarifying questions. Behavioural practices associated with patient‐perceived lower TA interactions were lack of touch, the absence of pain neuroscience education, and not restating what the patient said during the interview. Conclusion This study highlights a relationship between TA and reduction of pain intensity after the initial evaluation and identifies key behavioural practices that could positively and negatively impact TA during the clinical encounter.

Are Improvements in Pain Neurophysiology Knowledge Following Pain Science Education Associated With Improved Outcomes in People With Chronic Pain?

“…48 In addition to clinician knowledge, contextual factors such as therapeutic alliance and treatment expectations are also likely to influence a patients' engagement and acceptance of the information. A recent study by Myers et al, 50 concluded that a lack of PSE was associated with lower patient-perceived therapeutic alliance. Thus, experienced clinicians delivering PSE may facilitate a greater change in patient understanding and in doing so greater confidence in patients to enact the learning.…”

Musculoskeletal Faculty Beliefs about the Therapeutic Relationship

“…Previous studies that have commented on the lack of contextual factor instruction in ELPT education have done so by gathering information from physical therapists about their abilities or their education experience. [23][24][25][26]35,[43][44][45] However, this is only one side of the coin. To the author's knowledge, this is the first study examining musculoskeletal faculty's perceptions of the therapeutic relationship and how that might influence the curriculum.…”

The development of working alliance in early stages of care from the perspective of patients attending a chiropractic teaching clinic

“…A mixed method study investigated (1) how physical therapist behaviours and interactions during the initial physical therapy assessment relate to the patient's perception of WA and (2) the relationship between WA, pain intensity, and function [16]. Mayers and colleagues used (1) qualitative analysis to develop a checklist of WA themes and behavioural practices and (2) Spearman's Rho (ρ) to quantify if there was an association between increased WA and improved clinical outcomes [16]. Patient-rated WA was stronger when the physical therapists used information gathering, paused to listen, used humour and transitions, and used clarifying questions [16].…”

“…Mayers and colleagues used (1) qualitative analysis to develop a checklist of WA themes and behavioural practices and (2) Spearman's Rho (ρ) to quantify if there was an association between increased WA and improved clinical outcomes [16]. Patient-rated WA was stronger when the physical therapists used information gathering, paused to listen, used humour and transitions, and used clarifying questions [16]. Patient-rated WA was weaker when the following behavioural practices were present: lack of touch, the absence of pain neuroscience education, and not restating what the patient had said during the interview [16].…”

“…Patient-rated WA was stronger when the physical therapists used information gathering, paused to listen, used humour and transitions, and used clarifying questions [16]. Patient-rated WA was weaker when the following behavioural practices were present: lack of touch, the absence of pain neuroscience education, and not restating what the patient had said during the interview [16]. The study findings demonstrated a statistically significant negative correlation between patient-rated WA and pain intensity immediately after the initial evaluation, highlighting the relationship between early WA and clinical outcomes [16].…”