The following is an article written for the online, video-based physical therapy continuing education company MedBridge…
Helping individuals with a chronic pain and significant functional limitations is a remarkably difficult and delicate task. Numerous treatment philosophies are available to clinicians from the overtly biomechanical (Cyriax, Kaltenborn, Sahrmann, etc.) to more patient-response driven (Maitland, Mckenzie, etc.). Unfortunately, no one approach has been proven superior to others. For instance, in one of the only comparison studies, Powers and colleagues1 investigated the acute effects of a common Maitland intervention (posterior-to-anterior mobilization) to a common McKenzie intervention (prone press-up) on patients with non-specific low back pain. The study concluded that both groups improved significantly in pain level and lumbar extension, but without significant differences between the two interventions.
If the approach isn’t the determining factor, what makes one clinician better than another?
Throughout my clinical education and professional career, I have been exposed to expert clinicians with varying interventions, personalities, and clinical reasoning. However, one aspect holds true for all the clinicians who achieve superior outcomes – they form a positive therapeutic alliance (TA) with their patients.
What is a therapeutic alliance?
Leach et al.2 defines a therapeutic alliance as “a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect”. Moreover, a TA involves working together to define goals and success criteria for the treatment. With trust and mutual understanding, your patients are more confident in the interventions and more positive in their expectations from the treatment, which goes a long way towards achieving positive outcomes3. While every patient and pathology is unique, your patients deserve for a positive TA to be integrated and nurtured within their care.
Is there evidence supporting the importance of a therapeutic alliance?
Quite a bit of literature links a trusting therapeutic relationship to superior patient outcomes. A recent systematic review found that amongst patients with musculoskeletal complaints a positive therapeutic alliance was associated with significant improvements in the patient outcomes, including global perceived effect of treatment and satisfaction with treatment, pain levels, physical function, depression, and general health status4. More recently several randomized controlled trials have found favorable associations between positive alliance and outcomes in patients with chronic low back pain.
Fuentez et al.5 investigated how varying levels of therapeutic alliance impact a single-session treatment of chronic low back pain when combined with interferential electrical stimulation. They found significant improvements when patients received enhanced TA as opposed to limited TA. In a randomized controlled trial, Ferreira and colleagues6 looked into the effect of TA as part of a longer-term treatment with a follow-up at 8 weeks. Once again, therapeutic alliance had a significant influence on patient outcomes. The therapeutic alliance at baseline was a nonspecific predictor for the 4 measures of treatment outcome (global perceived effect, pain, disability, function) regardless of intervention applied by the treating therapist (motor control, general exercise, or spinal manipulative therapy). These two studies give further credence for the importance of forming mutual collaboration and trust with your patients.
Sometimes, techniques or interventions we use play a lesser role than our relationship with the patient. Many therapists downplay one approach in lieu of their chosen technique or approach, however no one approach is effective or ineffective for all patients. Only one aspect of patient care – therapeutic alliance – translates to each and every patient.
In his course Teaching People About Pain, Adriaan Louw, PT, PhD, CSMT discusses how pain education and a positive TA can improve patient outcomes and satisfaction with treatment.
1. Powers CM, Beneck GJ, Kulig K, Landel RF, Fredericson M. Effects of a single session of posterior-to-anterior spinal mobilization and press-up exercise on pain response and lumbar spine extension in people with nonspecific low back pain. Phys Ther. 2008; 88(4): 485-93. doi: 10.2522/ptj.20070069.
2. Leach, Matthew J. Rapport: A key to treatment success. Complementary Therapies in Clinical Practice. 2005; 11(4): 262 – 265.
3. Joel E Bialosky, Mark D Bishop, Michael E Robinson, Josh A Barabas and Steven Z George. The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders. 2008; 9-19 doi:10.1186/1471-2474-9-19.
4. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010; 90(8): 1099-110. doi: 10.2522/ptj.20090245.
5. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross D. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014; 94(4): 477-89. doi: 10.2522/ptj.20130118.
6. Ferreira PH1, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013; 93(4): 470-8. doi: 10.2522/ptj.20120137.