Building therapeutic alliances with patients in treatment for low back pain: A focus group study

Abstract

Background and Purpose Low back pain is a multidimensional disorder and a biopsychosocial management approach is recommended. However, recent data indicates that physiotherapists mainly focus on biomechanical aspects in treatment and struggle with addressing psychosocial barriers for recovery. We wanted to explore how physiotherapists express their experiences of building therapeutic alliances within a biopsychosocial perspective of low back pain. Methods Qualitative focus‐group interviews were performed with five physiotherapists on two occasions with 6 months in between. Data were analyzed within a hermeneutical perspective with decontextualization and recontextualization, and identification of themes. Results Four main themes were identified from the analyses: (1) An ideal standard: Presence, empathy and applying the biopsychosocial perspective is central for building therapeutic alliance. (2) Time‐consuming: Active listening and personally adapted treatment is important and time‐consuming. (3) Challenging area: Advanced clinical reasoning is needed to understand and modify complex barriers for recovery. Clinical experience is sometimes necessary to integrate the psychological and social domains into physiotherapy management. (4) The art of balancing: Important to apply sensitive communication to help patients gain new insight. Some heavy psychosocial demands on patients may be outside physiotherapists' professional competence. Discussion The physiotherapists in this focus group study expressed a shared view that therapeutic alliance should build upon person‐centering, motivational communication, and facilitation of lifestyle adjustments within a biopsychosocial perspective of low back pain. Complex clinical reasoning necessary as the optimal cause‐corrective treatment strategies were often not obvious. Time and tools to uncover and modify relevant psychological obstacles for recovery were perceived challenging and partly dependent on clinical experience. Addressment of psychosocial obstacles for recovery should be included in basic as well as postgraduate curriculums for physiotherapists. Collaborative practice support strategies like peer guidance and better platforms for interprofessional collaboration and decision support could contribute to improve practice in the psychosocial domain.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

“…Twenty-two of the 75 included studies comprised qualitative research designs (12 patient perspective31 41–51; 5 physiotherapist perspective52–56; 5 mixed perspectives57–61), followed by quantitative designs (n=15) (longitudinal cohort studies n=11,22 62–71 secondary analysis of RCTs n=472–75), RCTs (n=15),76–90 systematic reviews (n=15),21 32 47 91–102 mixed methods (n=3),30 103 104 commentary (n=2),105 106 case reports (n=2)107 108 and narrative reviews (n=1) 109. See online supplement 4) for details of included studies and their quality appraisal.…”

“…We included the terms of mastery and self-efficacy under the umbrella term of confidence. There was evidence that the clinician’s confidence in managing LBP, and their perceived expertise and credibility, impacted the provision of information, reassurance and individualised prescription of exercise, which influenced the development and maintenance of positive therapeutic alliance 52 68 72 105. This was both in part due to patients perceiving greater attention from the clinicians, as well as the reinforcement of trust through patient’s perceptions of clinicians being highly credible.…”

“…Some of the features that predict positive therapeutic alliance (namely communication, individualisation, collaborative goal setting, relationship building and empathy and patient education) were identified within this review, highlighting the importance of the therapeutic alliance for successful therapeutic exercise prescription 30. In the field of LBP, the therapeutic relationship is recognised as an important component of treatment, however, it remains poorly operationalised 52 101. The therapeutic alliance is a dynamic construct, influenced by both the person seeking care and the clinician, moderated by communication and time 117 118.…”

“…The importance of addressing the ‘psychosocial’ elements of their pain experience have been documented in the literature for several decades,119–121 yet, despite this, many clinicians report feeling inadequately trained and lack confidence to manage psychosocial barriers to recovery, even though they have undergone dedicated training 122–124. There remains a need for clinicians to understand how best to define the therapeutic alliance within musculoskeletal consultations, and further, to operationalise it into clinical practice 52…”

The Relationship between Physiotherapist and Patient: A Qualitative Study on Physiotherapists’ Representations on This Theme

“…They came to the conclusion that more research is required to fully explore this issue, particularly from the perspective of therapists, in order to improve physical rehabilitation programs. In this light, Unsgaard-Tøndel and Søderstrøm [ 9 ] showed that PTs indicate four key elements for establishing a good therapeutic alliance with patients: (1) presence and empathy within a biopsychosocial perspective as central to building the therapeutic alliance; (2) active listening and the adaptation of the treatment to the specific patient; (3) clinical experience, which is important to integrate the psychological and social domains into physiotherapy management; and (4) the use of sensitive communications to assist patients in acquiring new insights about their possibilities. In the same direction, Brunner et al [ 10 ] found that PTs’ higher confidence in managing their patients was associated with higher patient-reported working alliances.…”