Confidence in Your Rehab Team
If you lack confidence in your doctor, physical therapist, performance coach etc. find a new one. A 2013 study by Paulo Ferreira et al. showed that patients who had a supportive and trusting relationships with their physical therapist showed improved treatment outcomes. The study found that the relationship between a patient and a medical professional, also known as the therapeutic alliance, was a consistent predictor of treatment outcome across all measures.
The three main components of the therapeutic alliance include:
Patient and therapist agreement on goals
Patient and therapist agreement on interventions
The affective bond between patient and therapist
The impact of the therapeutic alliance on patient outcomes has been well documented, and supported in research related to medicine and psychology. While the importance of a healthy therapeutic alliance has often been suggested in relation to physical therapy, the research has been lacking.
Ferreira and his team studied patients who agreed to participate in a separate randomized controlled trial which investigated the effectiveness of common physical therapy interventions for the treatment of chronic low back pain. The interventions of this separate trial included general exercise, spinal manipulation and specific control exercises. Participants attended up to 12 treatments over 8 weeks. Outcome measures included pain, disability, function and perceived effect. Function and Global perceived effect were measured using the Patient Specific Functional Scale (PSFS) and the Global Perceived Effect Scale (GPE). Both scales are self reported and measure physical function and the subject’s assessment of their physical condition, respectively. The findings of the trial suggest that patients who performed specific motor control exercises and received spinal manipulation had better short term outcomes.
While the findings of this study are generally consistent with past research, the more interesting findings were attained by Ferreira’s “piggyback study”. Ferreira and his team measured the therapeutic alliance between the subjects and their physical therapist using the Working Alliance Theory of Change Inventory (WATOCI). Subjects completed the WATOCI questionnaire during their second treatment in order to allow prior interaction with their treating therapist.
A total of 182 subjects completed the WATOCI. The measured therapeutic alliance between the physical therapist and the patient predicted all of the final measured outcomes. Higher levels of alliance, meaning more positive interactions, were associated with even greater improvements. The strongest association was found between the therapeutic alliance and subject’s disability rating.
These findings suggest that regardless of the treatment intervention, patients suffering from low back pain that have a healthy and supportive relationship with their physical therapist, will demonstrate improved outcomes. When taking into account low back pain’s significant impact on global disability, its tremendous burden on the healthcare system, and the consistently poor treatment outcomes, these findings provide hope.
These findings are also consistent with the notion that the cause of chronic low back pain is not limited to physical impairments. While cliche, a holistic approach to treatment is likely the most appropriate for those suffering from chronic low back pain. Healthcare practitioners should not only address the physical impairments found, but they must also address their patient’s knowledge, outlook and understanding of the condition.
Those suffering from chronic low back pain need a “hype man”. They need to know that they are not fragile, their opinions matter, their goals matter and their outlook matters. While this study should not minimize the importance of proper assessment and treatment choice, it’s important to acknowledge that there is more to quality healthcare than the medicine or intervention.
Brian King, PT, DPT
Brian is a physical therapist and co-owner at Kauno
1. Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2012). The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Physical Therapy, 93(4), 470–478.
