The importance of therapeutic alliance

Physiotherapy has long focused on identifying specific treatment interventions for patients in the hopes of maximizing clinical outcomes. Despite our best efforts, specific treatments often demonstrate modest improvements when compared with competing interventions. This lack of consistent results has led to therapists developing complex treatment models in an attempt to make our clinical world make sense.  

Could it be that we have been looking in the wrong direction for far too long and need to make a paradigm shift where the process by which we interact and deliver our healthcare interventions is as important as the intervention itself? Are some of the significant treatment effects seen clinically the result of the therapist and patient relationship, rather than just a specific treatment intervention?

There is emerging evidence that a significant component of clinical outcomes is shaped by the therapeutic alliance (TA) established between patient and therapist. How do we go about maximizing these effects?

TA is defined as the collaborative and affective bond, or the positive social relationship between the physiotherapist and the patient. It’s believed that there are many aspects that contribute to the establishment of a therapeutic working relationship that include active listening, nonverbal behaviors, demonstration of empathy, respect and collaboration.

Accelerated Motion Physiotherapy

Although the research into this area is still limited with respect to physiotherapy, the results are promising. In one interesting study, patients with low back pain were randomized to one of four groups: standard encounter with IFC, enhanced therapeutic alliance with IFC, standard encounter with sham IFC, and enhanced therapeutic alliance with sham IFC with short-term pain relief as the outcome of choice.

As you might guess, those patients who received the enhanced therapeutic alliance (which simply consisted of listening to the patient and the story behind their pain), had greater pain relief than those who received the standard encounter. Now, the argument could be made that these were only short-term changes in pain, but what about the big picture? Fuentes et al. recently published a trial exploring the relationship between therapeutic alliance and outcome for patients with persistent low back pain. At visit two, a higher therapeutic alliance predicted better outcomes for pain, disability and function at eight-week follow-ups, and the effect size was not small.  Those who scored high on therapeutic alliance rating could expect a 20% improvement on their disability outcome scores compared to those with a low therapeutic alliance rating.

If these changes are not enough to convince you that it is worthwhile to foster a therapeutic alliance, consider some of the other benefits that come with a high therapeutic alliance. Patient’s satisfaction with physiotherapy treatment is generally based on their relationship with the clinician, not the clinical outcome. Heck, patients sue their physicians typically because of a fractured relationship with the clinician, not based on the clinical outcome. Finally, there is evidence that clinicians find their interactions with patients more satisfying when there is a higher level of therapeutic alliance.

One long held belief is that bedside manner is an innate quality that only some clinicians are born with. Although some individuals may be predisposed to having higher abilities to form a therapeutic relationship with their patients, there is good evidence that clinicians can be trained to improve their skills in this area. In one study, physicians were randomly assigned to either serve as a control group or provided with three hours of training that focused on improving awareness of the neurobiology of empathy, communication strategies and the ability to decode facial expressions. Not surprisingly, at one month follow-ups, those receiving the empathy training intervention demonstrated significantly improved empathy scores from their patients.

Curtis Tait, Accelerated Motion Physiotherapy

So what are some simple things that you can do to start improving therapeutic alliance? Here are three easy things to get you started:

  1. Shut up! Well maybe I’m being a little harsh and not achieving therapeutic alliance with the reader……  But every patient has a story to tell and it is imperative that they are heard and validated. I start most of my first assessments with the words, “so, tell me your story,” then I put my computer off to the side, lean in and listen. In a classic study, when observed, physicians only allowed their patients to complete their solicited reason for the visit without interrupting about 25% of the time, and the average time until the physician interrupted their patient was 18 seconds. Interestingly, no patient spoke for longer than 150 seconds if allowed to complete their opening statement, and they would often leave psychosocial components of their history to the end of their discussion. Based on our evolving understanding of pain sciences and its relationship to the psychosocial, I’d suggest that great value can be placed on not interrupting the patient and listening for an extra 132 seconds on their first visit!

  2. Ask patients what they are hoping to get from the clinical visit. Not meeting a patient’s expectations, or naively believing that they simply want what you are trained to provide, is often a recipe for disaster. Patient dissatisfaction occurs when their expectations are not met, irrespective of how reasonable those expectations may be. If we know what patients are expecting, we have an opportunity to help shape expectations and provide the exact service they are looking for.

  3. Practice shared decision making with your patients; this is the act of the clinician and the patient making a decision regarding treatment together, based on the best available evidence. After an assessment, summarize your findings and then give your patient potential treatment options with the possible costs and benefits of the interventions. Shared decision making does a few key things to help improve the clinical process; it increases patient self-efficacy as they actively participate in decision-making regarding their care.

Accelerated Motion Physiotherapy

Interestingly, shared decision making may also help more patients utilize physiotherapy than other more costly and invasive interventions. There is evidence that patients choose more conservative treatments when given the opportunity to participate in shared decision making.

This is by no means an exhaustive list, and the application of soft skills needs to be modified and altered appropriately with each individual patient. I would argue that the true “Art” of physiotherapy is not the ability to poke a patient with a needle, manipulate a joint or teach a fancy exercise, but rather the skillful interpersonal communication skills required to establish therapeutic alliance with our patients. It is time to get away from being enamored with just interventions and looking for that magic bullet treatment that will serve as a panacea. Regularly reflecting on our communication skills, and spending time learning how we can foster therapeutic alliance, is well worth the effort both from an outcome-based perspective and personal satisfaction as clinicians. A great place to start is with the timeless paper the four habits model.

What's old school?

We were asked a question about why we thought that speaking in pathoanatomical and biomechanical terms was a bit old school. With this being both a topical and important conversation, we wanted to share our response as a mini-blog. :) 

Our position that pathoanatomical and biomechanical reasoning is a bit old school is based on the evidence used to test these models and their limited ability to guide treatment interventions that improve clinical outcomes. For example, in the lumbar spine, we are able to conclusively identify the specific tissue or pathology at fault about 10 to 15% of the time and typically these conditions would include radiculopathies, inflammatory, conditions, fractures and cancers. I would argue that this is when pathology is important – in situations where we can identify and screen for those 10% of cases where patients have a medical pathology that requires further medical intervention. Equally important to physiotherapy practice is the ability to understand when the evidence identifies that our clinical tests and subjective questioning has limited utility in identifying a pathology and/or treatment. Sometimes using tests and historical questions that have limited utility can lead our reasoning astray and serve as red herring. Our traditional assessment that includes palpating for specific mobility deficits that guide our identification of tissue lesion or limited movement has limited support in the research1. Even if these findings were well supported in the literature, would it matter? There is evidence that demonstrates a limited ability to focus our treatment to a specific segmental level2. Furthermore, it would appear that from both an outcome and a neurophysiological perspective, specificity of manual therapy is both not required and unobtainable3,4. 

So where does this leave us? I don’t think we need to throw the baby out with the bathwater and doesn’t mean that our treatment interventions, at a glance, look all that different. What has changed is the reasoning behind choosing to implement manual therapy and, more importantly, the language used with patients regarding their diagnosis and why manual therapy is being used. Idealistically, I would use a system where we could reliably identify a specific pathology that leads to a specific treatment intervention that improves clinical outcomes but at this point it would appear that we are far from this and that the use of a model like this may give the clinician a false sense of security in their diagnosis. There is a risk that the use of a pathoanatomical model in the cases of mechanical low back pain leads to clinicians to provide patients with labels and language that create negative health beliefs and perpetuate fear and disability.  “Words That Harm and Words That Heal”5discusses the impact of clinician language on patients pain experience while this article by Lo et al discusses the changes in Australian Aboriginals beliefs secondary to exposure to Western based care of low back pain6. What has also changed is that our model for the assessment and treatment of patients has increased to include the biopsychosocial realm and its importance in the patients pain experience and prognosis. Things such as fear avoidance beliefs and pain catastrophizing have repeatedly been identified as impacting patients outcomes7,8and there is research to identify that we can include interventions such as education and graded exposure9,10.

With respect to the comment “Isn't this what the rehabilitation sciences were originally based on - empirical observations and anatomical understanding leading to testing and the 'evidence base'”, you are right that this is the starting point for research. We live in a dynamic time with medical literature being published at an extraordinary rate. Research will continue to answer questions and often for each question answered, two new ones will arise. Failure to keep up with these changes from a clinical perspective can lead to suboptimal treatment and from a professional perspective the risk of becoming obsolete. 

Finally, as was brought up, the “Art” of physiotherapy is fascinating. There is growing evidence that this art is likely not based on our use of a specific technique but rather the way with which we interact with our patients11, both clinician and patient expectations of treatment12,13 and an understanding of these factors and their implementation into clinical practice could serve to help improve patient outcomes.

We would very much be interested in people's thoughts regarding our response and would encourage you to discuss them with us on one of our social media platforms. We’d be particularly interested in any evidence you have that supports a pathoanatomical diagnostic model that demonstrates its use leads the clinician to a specific treatment that provides superior outcomes. We are always interested in thoughtful discussion!

1.    Spinal motion palpation: a review of reliability studies. J Man Manipulative Ther 2002;10:24-39. 

2.    Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J Manipulative Physiol Ther 2004;27:e2.

3.     Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of ‘‘therapist-selected’’ versus ‘‘randomly selected’’ mobilization techniques for the treatment of low back pain: a randomized controlled trial. Aust J Physiother 2003;49:233-41. 

5.    Bedell SE, Graboys TB, Bedell E, Lown B. Words that harm, words that heal. Archives of internal medicine. 2004 Jul 12;164(13):1365-8.

6.    Lin IB, O'Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ open. 2013 Jan 1;3(4):e002654.

7.    Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. The spine journal. 2014 May 1;14(5):816-36.

8.    Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S. Catastrophizing—a prognostic factor for outcome in patients with low back pain: a systematic review. The Spine Journal. 2014 Nov 1;14(11):2639-57.

9.    Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical journal of pain. 2004 Sep 1;20(5):324-30.

10.  George SZ, Fritz JM, Bialosky JE, Donald DA. The effect of a fear-avoidance–based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine. 2003 Dec 1;28(23):2551-60.

11.  Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy. 2014 Apr 1;94(4):477-89.

12.  Cook C, Learman K, Showalter C, Kabbaz V, O'Halloran B. Early use of thrust manipulation versus non-thrust manipulation: a randomized clinical trial. Manual therapy. 2013 Jun 1;18(3):191-8.

13.  Myers SS, Phillips RS, Davis RB, Cherkin DC, Legedza A, Kaptchuk TJ, Hrbek A, Buring JE, Post D, Connelly MT, Eisenberg DM. Patient expectations as predictors of outcome in patients with acute low back pain. Journal of general internal medicine. 2008 Feb 1;23(2):148-53.