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Introduction
Individuals may be placed in an intimidate environment when receiving musculoskeletal care from a provider. Yielding positive outcomes and enhancing the overall patient experiences is highly dependent on creating a professional relationship between the patient and the practitioner. Therapeutic alliance emphasizes a collaborative nature, the affective bond, and the goals between the patient and the practitioner.6 Building a therapeutic alliance is more than just establishing a sound rapport, but rather incorporating other elements that can contribute to the patient/practitioner relationship. Certain strategies need to be recognized to be able to build therapeutic alliance. Utilizing a biopsychosocial approach may provide a sense of collaboration, understanding, and support.1 Effective communication can enhance therapeutic alliance emphasizing a patient-centered approach as well as listening with focus on emotions.8 Understanding the individual will allow the clinician to be able to provide care from multiple perspectives. More importantly, the clinician will be able to be dynamic and identify how to handle specific clinical presentations. Each patient has their own unique characteristics; thus, each person needs to be handled solely based on that individual’s experiences. The ability to recognize contributing factors becomes a valuable instrument to determine how to effectively provide care from an individualistic standpoint.
1. Communication
Exploring core skills for interpersonal communication can be beneficial for clinicians to recognize potential barriers to establishing a therapeutic alliance. Communication between the patient and practitioner is essential to extrapolate vital data to guide clinical practice. Being an effective communicator will help identify key information that will be useful for creating a plan of care. Key characteristics of being an effective communicator should include active listening, understanding verbal/non-verbal communication, open-end versus close-ended questioning, being succinct, empathetic, and ability to build trust. Applying these concepts will ultimately guide the examination and throughout the episode of care. Efficient history taking, and a thorough physical examination can lead to a positive therapeutic effect, short-term decrease in pain, catastrophization, improved functional mobility, and decreased sensitivity to pressure.5 History taking may yield the most significant changes when compared to the physical examination alone.5 A holistic framework may potentially enhance overall clinical reasoning.
2. Language
The choice of words can positively or negatively ultimately desired clinical outcome.10 Specific words that we convey to a patient can have a huge impact and can influence the rehabilitation process. Patients can react to specific types of phrases or words. There could be a heavy emphasis on the biomedical model including such terminology as, “degeneration”, “wear and tear”, and “slipped disc”. There is a strong emphasis of the biomechanical model especially embedded in physical therapy programs.10 Focusing on the pathoanatomical nature of a patient’s symptoms may lead the clinician in the wrong direction and resulting in potentially poor outcomes.10 The patient can perceive this information and thus, changes their belief system, values, and expectations to receiving care. Therefore, we should learn how to frame our words differently to help the patient understand what they are experiencing. It becomes paramount that we use our words carefully as the patient’s perception should be taken into consideration.9
3. Motivational Interviewing
Motivational interviewing is a collaborative conversation between the patient and the practitioner for strengthening an individual’s own motivation and commitment.7 There are certain elements that encompass motivational interviewing in which will be beneficial to strengthening the bond between the patient and the practitioner: 1) open-ended questioning, 2) affirmations, 3) reflective listening, and 4) summarizing.7 The use of open-ended questioning allows the opportunity for patients to elaborate more on what they are experiencing.7 Too many closed-ended questions limits the answers that can be provided, and should be reserved for confirming information. Affirmations involve positive statements made to the patient demonstrating interest and understanding what the patient is experiencing.7 Reflective listening can allow the patient to share their own personal experiences and can also further test initial working hypotheses.7 Further insights can help confirm the patient’s belief system and understanding of their own perception. Summarizing allows the clinician to synthesize the data and learn how to use a more insightful approach to generate initial working hypotheses that will be tested throughout the episode of care.
4. Understanding Patient Experiences
Understanding pain can be a valuable instrument to facilitate the overall patient experience throughout the continuum of care. Clinicians need to find an approach that allows for understanding mechanisms of their symptomology and conceptualization of pain.1 Implementation of pain neuroscience education should immediately start from the initial interview and be utilized during the episode of care. The initial assessment can provide the foundation for a positive therapeutic alliance among the clinician and the patient.1 It becomes essential to understand contributing factors that may influence the patient’s perception of their pain. Contextual factors and allostatic responses can affect a patient’s recovery during the rehabilitation process thus recognizing fear avoidance, pain catastrophizing, functional mobility, and pain.10 Identifying biopsychosocial factors is a key factor for determining patient outcomes.1 Recognizing the patient’s belief system, values and expectations may be prognostic factors for individuals with musculoskeletal pain.2 Higher levels of therapeutic alliance were correlated with improvements in perceived effect of treatment, function, and reductions in pain and disability.8 Allowing for patient to be able to recognize of what they are experiencing can create a sense of well-being, but also create a stronger affinity with healthcare provider.
Discussion
Understanding these concepts will help clinicians synthesize the information more efficiently, but also make them dynamic and aware of other contributing factors which play a role in providing patient care. Clinicians can use past experiences to better recognize potential factors that may be correlated with building a foundational therapeutic alliance. The use of reflection strategies can help clinicians use their own previous experiences and allow them to develop clinical pattern.3 Pattern recognition can be achieved with repetition and interacting with many patient presentations. It is important to understand not just clinical presentations, but the ability of the clinician to be able to change their own respective teaching style. Recognizing one’s own teaching style can be beneficial to be able to effectively convey information with optimal patient retention. Being an autonomous practitioner allows the healthcare professional to have the ability to adapt, when necessary, as patients present with varying symptomology as well as personal experiences that contributes to their situation. Healthcare is individualized; therefore, the focus should be patient-centered and examine all the elements that can influence recovery. Recognizing maladaptive beliefs, pain catastrophizing, and perception may be helpful to facilitate self-efficacy.4 Strategies for positive outcomes should target biomechanical, psychological, and individual characteristics to address motivation in addition to adherence to a self-management program.4 Therefore, it becomes important to take into consideration all the relevant factors that affects patient outcomes.
In summary, there are many elements that are entailed within the patient/practitioner relationship. It is important that we are aware of these factors so that we can accommodate patients accordingly. Focusing on refining interpersonal communication skills is essential to be able to deliver care effectively. Adapting to learning/teaching styles of the patient and practitioner becomes essential to be able to provide the appropriate level of care. Allowing the patient to be an active participant in their own rehabilitation process is paramount so there can be adherence and compliance to a long-term management program. Establishing a professional relationship is one thing, but reinforcing it is truly a challenge that practitioners must be willing to face.
Key Points
A patient/practitioner relationship involves many elements including therapeutic alliance, communication, language, motivational interviewing, and understanding of the patient’s experiences.
Healthcare is individualized, in which requires a patient-focused approach.
The patient needs to be an active participant during their own episode of care as well as long-term self-management.
Article Written By Eric Trauber, PT, DPT, OCS, CSCS, FAAOMPT
References
- Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care. 2017: 1-9. http://dx.doi.org/10.1002/msc.1191 https://doi.org/10.1002/msc.1191.
- Bialosky JE, Bishop MD, and Cleland JA. Individual Expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Physical Therapy, 2010; 90(9): 1345-1355.
- Gilliland S, & Wainwright SF. Patterns of clinical reasoning in physical therapy students. Physical Therapy, 2017; 97(5): 499-511.
- Hutting N, Johnston V, Staal JB, Heerkens YF. Promoting the use of self-management strategies for people with persistent musculoskeletal disorders: The Role of Physical Therapists. Journal of Orthopaedic & Sports Physical Therapy, 2019; 49(4):212-215. doi:10.2519/jospt.2019.0605.
- Louw A, Goldrick S, Bernstetter A, Van Gelder LH, Parr A, Zimney K, and Cox T. Evaluation is treatment for low back pain. Journal of Manual & ManipulativeTherapy, 2020; DOI: 10.1080/10669817.2020.1730056.
- Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology, 2000; 68: 438–450.
- Miller and Rollnick. Motivational Interviewing: Helping People Change. 3rd ed Guilford Press. 2013.
- Pinto RZ, Ferreira ML, Oliveria VC, Franco MR, Adams R, Maher CG, and Ferreira PH. (2012). Patient-centered communication is associated with positive therapeutic alliance: a systematic review. Australian Physiotherapy Association, Volume 58, 77-87.
- Stewart M, Loftus S. Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation. J Orthop Sports Phys Ther. 2018 Jul; 48(7):519-522.
- Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual & Manipulative Therapy, 2013; 21(2):90–102.