A framework for establishing connections in physiotherapy practice

An exploration of person-centredness among emergency department physiotherapists: a mixed methods study

PURPOSE

There is a growing number of primary contact physiotherapists based in United Kingdom emergency departments (ED) who are expected to deliver person-centred practices. Perceptions of physiotherapists working in these high-pressure environments on person-centredness are currently unknown. A mixed methods exploration of person-centredness among ED physiotherapists targeted this knowledge gap to inform future clinical practice.

METHODS

Online survey and semi-structured interviews followed a convergent mixed methods design with sequential explanatory features. Data sets were analysed separately using descriptive statistics and thematic analysis, respectively, before merged analysis using joint display.

RESULTS

Twenty-six surveys and 11 in-depth interviews were completed. The three overarching themes of ED patients, ED physiotherapists, and ED environment were generated. Themes were integrated and analysed alongside quantitative survey findings. This produced three novel contributions that further our understanding of person-centred practices among ED physiotherapists.

CONCLUSION

ED physiotherapists were mindful of an apparent, yet unspoken struggle between the competing philosophies of biomedicine and person-centredness. The results here support entering a patient's world as a person-centred approach to help navigate the line between what an ED attender wants and the clinical need of their visit.

The experiences of patients attending the emergency department who were managed by physiotherapists: a person-centred perspective

PURPOSE

The expectation for all clinicians to deliver person-centred practices extends to the growing number of primary contact physiotherapists based in United Kingdom emergency departments (ED). Research on ED patients' experience of this physiotherapy role has yet to consider this through the lens of person-centredness. A qualitative exploration of person-centredness among ED physiotherapists through the experiences of attending patients targeted this knowledge gap to inform future clinical practice.

METHODS

Semi-structured interviews with thematic analysis.

RESULTS

13 interviews were completed with four overarching themes generated: (1) patient experience of the ED; (2) the importance of connection, competence, and time; (3) recognising the benefits of being seen by a physiotherapist in ED; and (4) patient experience of the ED physical environment.

CONCLUSION

Novel contributions from the patient perspective, here, reflected a cognisance of certain environment limitations to PCP, as well as institutional challenges to their personhood, with a suggestion that ED patients anticipated a validation of their visit and valued the educational aspects that the physiotherapists provided. Considering this new knowledge can help ED physiotherapists to be more person-centred.

Social support from the physiotherapist and the therapeutic relationship in physiotherapy: bridging theory to practice

BACKGROUND/PURPOSE

Therapeutic relationship and social support are critical components in physiotherapy that shape patient outcomes. However, defining these constructs, discerning their similarities and differences, and measuring them pose challenges. This article aims to facilitate scientific and clinical advancement on social support and the therapeutic relationship in physiotherapy by (a) providing conceptual clarity, (b) discussing measurement tools, and (c) offering practical recommendations for the deliberate incorporation of these constructs in clinical practice.

METHODS

This is a perspective paper drawing on examples from existing research.

KEY RESULTS

Assessing the nature and strength of social support and promoting naturally occurring social support networks are practical ways for physiotherapists to foster social support in physiotherapy clinical practice. Physiotherapists can offer direct support, facilitate the development of an individual's social skills, and promote participation in group activities. To strengthen the therapeutic relationship, it is important to maintain good communication, foster connectedness with the patient, demonstrate professional skills, and adopt a reflective practice. Physiotherapists are encouraged to establish clear roles and responsibilities, prioritize individualized patient-centered care, and involve patients in shared decision-making, ensuring congruence in goals and expectations. Willingness to dedicate time and energy within and beyond direct patient-therapist interactions can foster connections. Moreover, using the body - which is the main point of contact with patients - and physical touch can help physiotherapists to connect with patients. Finally, physiotherapists must be prepared to address and mend any conflicts which can impact the relationship's trajectory.

CONCLUSION

Social support and therapeutic relationships are complementary aspects of one's health care, and it is crucial to purposefully account for both in physiotherapy practice to optimize person-centered care and rehabilitation outcomes.

How therapeutic relationships develop in group-based telehealth and their perceived impact on processes and outcomes of a complex intervention: a qualitative study

BACKGROUND

Therapeutic relationships are a key domain in healthcare delivery. While well-understood in in-person interventions, how therapeutic relationships develop in more complex contexts is unclear. This study aimed to understand (1) how therapeutic relationships are developed during the telehealth delivery of a group-based, complex intervention and (2) the perceived impact of these relationships on intervention processes, such as intervention delivery and engagement, and patient outcomes, such as patient safety and satisfaction.

METHODS

This qualitative study, nested within a randomised controlled trial, used an interpretivist approach to explore the perceptions of 25 participants (18 patients with shoulder pain and 7 clinicians) regarding developing therapeutic relationships in a group-based, complex intervention delivered via telehealth. Semi-structured interviews were conducted within 4 weeks of the telehealth intervention period and then analysed through in-depth, inductive thematic analysis.

RESULTS

We identified six themes: (1) 'Patients trust clinicians who demonstrate credibility, promoting the development of therapeutic relationships'; (2) 'Simple features and approaches shape the therapeutic relationship', including small talk, time spent together and social observation; (3) 'A sense of belonging and support fosters connections', facilitated by clinicians providing individualised attention within the group; (4) 'Developing therapeutic relationships can impact the delivery of core intervention components', reflecting challenges clinicians faced; (5) 'Therapeutic relationships can facilitate intervention engagement', through enhanced patient understanding and confidence and (6) 'Therapeutic relationships can contribute to patient safety and satisfaction', with patients feeling more comfortable reporting intervention-related issues.

CONCLUSIONS

Therapeutic relationships were developed during group-based telehealth sessions through a set of factors that may require additional skills and effort compared with in-person interactions. While these relationships have a perceived positive impact on intervention engagement and patient outcomes, clinicians need to find a balance between building relationships and delivering the telehealth intervention with fidelity.

TRIAL REGISTRATION NUMBER

ACTRN12621001650886.

Identifying central elements of the therapeutic alliance in the setting of telerehabilitation: A qualitative study

INTRODUCTION

Therapeutic alliance is a relevant aspect of healthcare and may influence patient outcomes. So far, little is known about the therapeutic alliance in telerehabilitation.

PURPOSE

To identify and describe central elements of therapeutic alliance in the setting of telerehabilitation and compare it to those in conventional rehabilitation.

METHODS

In this qualitative study, a literature search and in-depth semi-structured interviews with rehabilitation and telerehabilitation experts were conducted from 15.5.-10.8.2020 on elements influencing the therapeutic alliance in rehabilitation and telerehabilitation. Using a combined deductive and inductive approach, qualitative content analysis was used to identify categories and derive central themes.

RESULTS

The elements bond, communication, agreement on goals and tasks and external factors were identified in the literature search and informed the development of the interview guide. Twelve purposively sampled experts from the fields of physiotherapy, occupational therapy, speech and language therapy, psychology, general medicine, sports science and telerehabilitation software development participated in the interviews. We identified three central themes: building effective communication; nurturing a mutual relationship of trust and respect; and agreement on goals and tasks and drivers of motivation.

CONCLUSIONS

In this qualitative study, key elements of therapeutic alliance in rehabilitation confirmed those reported in the literature, with additional elements in telerehabilitation comprising support from others for ensuring physical safety and technical connectedness, caregivers acting as co-therapists and applying professional touch, and promoting patient autonomy and motivation using specific strategies.

What is Effective in Massage Therapy? Well, "It Depends…": a Qualitative Study of Experienced Orthopaedic Massage Therapists

Background

Massage has been used as a treatment for musculoskeletal pain throughout history and across cultures, and yet most meta-analyses have only shown weak support for the efficacy of massage. There is a recognised need for more research in foundational questions including: how massage treatments are constructed; what therapists actually do within a treatment, including their clinical reasoning; and what role therapists play in determining the effectiveness of a massage treatment.

Purpose

The aim of this study was to explore what experienced orthopaedic massage therapists consider to be the aspects of their work that contribute to effectiveness.

Setting and Participants

Semi-structured interviews were conducted via Zoom with six experienced orthopaedic massage therapists in Australia.

Research Design

The interviews were analysed using inductive thematic analysis, seeking insights that might be practically applied, rather than theory-driven interpretations.

Results

The participants focused on the underlying differences between clients, between therapists, and between treatments, and clearly indicated that this concept of "difference" was foundational to their view of their work and was the underlying context for the comments they made. Within that frame of "difference", three key themes were interpreted from the data: (1) "Everyone is different so every treatment is different": how they individualised treatment based on these differences; (2) "How therapists cope with difference": how they managed the challenges of working in this context; and (3) "What makes a difference": the problem-solving processes they used to target each treatment to meeting the client's needs.

Conclusions

Participants did not identify specific techniques or modalities as "effective" or not. Rather, a therapist's ability to provide effective treatment was based on an iterative process of treatment and assessment that allowed them to focus on the individual needs of the client. In this case "effectiveness" could be considered a process rather than a specific massage technique.

Social support and therapeutic relationships intertwine to influence exercise behavior in people with sport-related knee injuries

OBJECTIVE

Explore how social support influences exercise therapy participation and adherence before and after enrolling in an education and exercise therapy intervention (Stop OsteoARthritis, SOAR).

METHODS

Study design: Interpretative description. We sampled participants with sport-related knee injuries from the SOAR randomized controlled trial. SOAR is a virtual, physiotherapist-guided, education and exercise therapy-based knee health program that targets individuals at risk of early osteoarthritis. One-on-one semi-structured interviews were completed, and an inductive approach was guided by Braun & Clarke's reflexive thematic analysis.

RESULTS

Fifteen participants (67% female, median age 26 [19-35] years) were interviewed. Three themes were generated that encapsulated participants' social support experiences that fostered exercise participation: 1) Treat me as a whole person represented the value of social support that went beyond participants' physical needs, 2) Work with me highlighted the working partnership between the clinician and the participant, and 3) Journey with me indicated a need for on-going support is necessary for the long-term management of participants' knee health. A theme of the therapeutic relationship was evident across the findings.

CONCLUSIONS

Insight was gained into how and why perceived support may be linked to exercise behavior, with the therapeutic relationship being potentially linked to perceived support. Social support strategies embedded within an education and exercise therapy program may boost exercise adherence after sport-related knee injuries.

"Passion to do the right thing": searching for the 'good' in physiotherapist practice

BACKGROUND

Practitioners' perspectives of what constitutes a 'good' physiotherapist have not been explicitly examined despite their potential implications for the future practice of physiotherapy. Physiotherapists' perceptions may inform professional priorities including education curricula, professional practices, competency profiles, and patient interactions.

PURPOSE

The purpose of this research was to examine physiotherapists' perceptions of what constitutes a 'good' physiotherapist. The context of the study was musculoskeletal practice (MSK).

METHODS

A hermeneutic phenomenological investigation was undertaken. Semi-structured interviews were conducted with twelve experienced MSK physiotherapists to examine their perceptions of what constitutes a 'good' physiotherapist.

FINDINGS

Seven themes were identified. Good physiotherapists were depicted as: 1) oriented to care; 2) integrating knowledge sources; 3) competent; 4) responsive; 5) reflective; 6) communicative; and 7) reasoning. To deepen the understanding of these themes, we discuss the findings in relation to Joan Tronto's ethic of care theory.

CONCLUSIONS

Physiotherapists' perceptions of what constitutes a 'good' physiotherapist highlight practices that may underpin an ethic of care including the pivotal role of person-centered and relational dimensions of practice. The findings call into question the profession's emphasis on a technical rationalist approach to education and clinical practice and invites conversation about future directions that balance technical competence with relational dimensions of practice.

"We take on people's emotions": a qualitative study of physiotherapists' experiences with patients experiencing psychological distress

BACKGROUND

Previous research suggests that physiotherapists frequently engage with patients who experience psychological distress (e.g. feelings of depression and anxiety) and that physiotherapists find supporting these patients challenging.

OBJECTIVE

The aim of this study was to explore the experiences of Australian physiotherapists with patients they perceived were experiencing psychological distress.

METHODS

A 'Big Q' qualitative research approach was used. Twenty-three interviews with physiotherapists were conducted. The data were then analyzed using iterative thematic inquiry.

RESULTS

The analysis produced four interrelated themes: 1) encounters with patients in distress are common and varied; 2) becoming emotionally attuned with their patients meant that distress could invoke empathetic distress; 3) physiotherapists use emotional shields to protect themselves; and 4) physiotherapists found frequent encounters with patient distress to be emotionally exhausting. Viewed together, the themes highlight how patient distress can invoke transient empathetic distress in a physiotherapist; repeated experiences of empathetic distress may lead to empathetic distress fatigue.

CONCLUSION

While physiotherapists are sometimes viewed as 'physical' health professionals, the experiences of these physiotherapists suggest that patient psychological distress is highly relevant to physiotherapy practice. We recommend future research explores the relationships between patient distress, physiotherapists' empathy, and physiotherapists' wellbeing.

Reaching for connection: a qualitative study of communication and interaction in video-based physiotherapy

OBJECTIVE

Digital technology has become increasingly relevant in physiotherapy, but little is known about communication and interaction in video-based physiotherapy. Therefore, this study aimed to explore the experiences among patients and physiotherapists, of communication and interaction in digital, video-based physiotherapy.

METHODS

A qualitative interview study with a phenomenological approach was conducted. Participants were purposively recruited from primary health care clinics. Semi-structured, in-depth interviews were conducted with 10 physiotherapists and 6 patients. Interviews were recorded, transcribed, and analyzed using a phenomenological approach.

RESULTS

The analysis resulted in the overall theme Reaching for connection, which captured the central meaning of the participants' experiences. Four categories emerged from the analysis: 1) Closeness at a distance; 2) Overcoming limited bodily communication; 3) The technology as part of the meeting; and 4) Challenging the physical meeting as a norm. The results suggest that communication and interaction in digital settings differ from physical settings, but there is an ongoing adaptation process to this new paradigm.

CONCLUSIONS

The results of this study show that video-based physiotherapy, while having several benefits according to both patients and physiotherapists, affects the communication in several ways. Physiotherapists need to acknowledge these limitations and seek strategies to adapt and to compensate for the reduced non-verbal elements and lack of touch. Attention to the physical room and shifting between positions (face/full figure) are suggested practical strategies, but also to practice awareness and embodied communication to improve receptivity in the interaction.

A conceptual model for managing sexual pain with somatocognitive therapy in women with provoked vestibulodynia and implications for physiotherapy practice

Somatocognitive therapy is a multimodal physiotherapy treatment developed in the early 2000s to alleviate the burden of chronic pelvic pain. In recent years, somatocognitive therapy has been further developed to treat women with provoked vestibulodynia. This prevalent gynecological pain condition is a subgroup of chronic pelvic pain and the most common form of vulvodynia. Provoked vestibulodynia is a neglected multifactorial pain condition of unknown cause, adversely affecting women's sexual life, relation to their partners and their psychological health. Pain is located at the vulvar vestibule and is provoked by touch or pressure such as sexual intercourse. In the management of sexual pain, somatocognitive therapy combines bodily exploration, pain education, cognitive coping strategies and structured homework to improve sexual function and reduce pain. To support these processes, developing a sound therapeutic alliance with the patient is essential. The aim of this article is to provide a conceptual model for managing provoked vestibulodynia with somatocognitive therapy, including a theoretical rational for this treatment. We base our conceptual model on the biopsychosocial model, i.e., considering the complex interplay of biomedical, emotional/cognitive, psychosexual and interpersonal factors in provoked vestibulodynia management. In addition, implications for practice and a detailed description of somatocognitive therapy for provoked vestibulodynia will be provided, to allow replication in clinical practice and in clinical trials.

The 'responsive' practitioner: physiotherapists' reflections on the 'good' in physiotherapy practice

BACKGROUND

Being 'responsive' is named as an element of ethic of care theories, yet how it is enacted is not clearly described in health professional practice. Being 'responsive' is implied within patient-centered approaches and promoted as important to health care practices, including physiotherapy. However, ways of being a responsive practitioner have not been explicitly examined. Practitioners' perspectives about how a 'good' physiotherapist enacts responsiveness have potential implications for the future practice of physiotherapy. Physiotherapists' perceptions may inform professional priorities including education curricula, professional practices, and patient interactions.

PURPOSE

The purpose of this research was to explore experienced musculoskeletal (MSK) practitioners' perceptions of 'responsiveness' in the practice of a 'good' physiotherapist.

METHODS

A secondary analysis of data arising from a hermeneutic phenomenological study into physiotherapists' perceptions of what constitutes a 'good' physiotherapist was undertaken. The secondary analysis focused on 'responsiveness,' which emerged as a major theme in the original study.

FINDINGS

Six themes were identified related to 'Being responsive' in a 'good' physiotherapist: Being person-centered, Being attentive, Being open, Being a listener, Being validating, and Being positive.

CONCLUSIONS

As a relational way of practicing, being responsive may facilitate person-centered approaches including a relational understanding of autonomy, inviting dialogue, and sharing power and decision-making with patients. Pivotal to the practice of a 'good' physiotherapist, being responsive in the ways underscored by participants suggests researchers, educators, and practitioners consider relational ways of practicing as a balance to the technical aspects of physiotherapy.

The osteopath-parent-child triad in osteopathic care in the first 2 years of life: a qualitative study

Background

Enactivism and active inference are two important concepts in the field of osteopathy. While enactivism emphasizes the role of the body and the environment in shaping our experiences and understanding of the world, active inference emphasizes the role of action and perception in shaping our experiences and understanding of the world. Together, these frameworks provide a unique perspective on the practice of osteopathy, and how it can be used to facilitate positive change in patients. Since the neonatal period is a crucial time for development, osteopaths should aim to create a therapeutic relationship. Arguably, through participatory sense-making, osteopaths can help the baby build a generative model (with positive priors) to deal with stress and needs throughout their life.

Aim

Since the literature considers that interactions with the environment, which enact the patients' experiences, depending on contextual factors and communication between patient and caregiver, this research explored whether there is a correspondence between the indications in the literature and clinical practice in the management of the mother/parent-child dyad during osteopathic care on children aged 0 to 2 years old.

Methods

Semi-structured interviews were conducted with a purposive sample of nine osteopaths with experience in the field of pediatrics. Interviews were transcribed verbatim, and constructivist grounded theory was used to conceptualize, collect and analyze data. Codes and categories were actively constructed through an interpretive/constructionist paradigm.

Results

The core category was the idea of the pediatric osteopath as a support for the family, not only for the child. Four additional categories were identified: (1) Preparing a safe environment for both children and parents, (2) Communication, (3) Attachment and synchrony, and (4) Synchronization.

Conclusion

Through participatory sense-making, osteopaths manage contextual factors to establish an effective therapeutic alliance through the osteopath-parent-child triad to facilitate the construction of the child's internal generative model to promote healthy development. The therapeutic encounter is considered an encounter between embodied subjects, occurring within a field of affordances (ecological niche) that allows the interlocutors to actively participate in creating new meanings through interpersonal synchronization. Participatory sense-making and the establishment of a therapeutic alliance through the osteopath-parent-child triad are crucial to promote healthy development in the child.

Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management

BACKGROUND

The biomedical understanding of chronic musculoskeletal pain endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. Although the biopsychosocial approach is an important advancement, it has a limited theoretical foundation. As such, it tends to be misinterpreted in manners that lead to artificial boundaries between the biological, psychological, and social, with fragmented and polarized clinical applications.

OBJECTIVE

We present an ecological-enactive approach to complement the biopsychosocial model. In this approach, the disabling aspect of chronic pain is characterized as an embodied, embedded, and enactive process of experiencing a closed-off field of affordances (i.e., shutting down of action possibilities). Pain is considered as a multi-dimensional, multicausal, and dynamic process, not locatable in any of the biopsychosocial component domains. Based on a person-centered reasoning approach and a dispositional view of causation, we present tools to reason about complex clinical problems in face of uncertainty and the absence of 'root causes' for pain. Interventions to open up the field of affordances include building ability and confidence, encouraging movement variability, carefully controlling contextual factors, and changing perceptions through action according to each patient's self-identified goals. A clinical case illustrates how reasoning based on an ecological-enactive approach leads to an expanded, multi-pronged, affordance-based intervention.

CONCLUSIONS

The ecological-enactive perspective can provide an overarching conceptual and practical framework for clinical practice, guiding and constraining clinicians to choose, combine, and integrate tools that are consistent with each other and with a true biopsychosocial approach.

Massive Irreparable Rotator Cuff Tears: Which Patients Will Benefit from Physiotherapy Exercise Programs? A Narrative Review

Massive irreparable rotator cuff tears can cause significant shoulder pain, disability and reduction in quality of life. Treatment approaches can be operative or non-operative. Operative approaches include reverse total shoulder arthroplasty, arthroscopic debridement, partial rotator cuff repair, subacromial balloon spacers, superior capsule reconstruction, and tendon transfer procedures. Non-operative approaches include physiotherapy exercise programs and corticosteroid injections. There are no randomized controlled trials comparing the different treatment approaches. It is therefore challenging for clinicians to advise patients on what is their best treatment pathway. Physiotherapy exercise programs are less expensive and have lower risks for patients than surgical approaches. However, the success of physiotherapy in patients with massive irreparable rotator cuff tears is highly variable with published success rates of 32-96%. Several cohort studies have sought to identify if certain factors are predictive of success with physiotherapy. Several biomechanical factors were identified as possibly being related to a successful or unsuccessful outcome following physiotherapy, with complete tear of subscapularis demonstrating the strongest evidence. However, there were no appropriately designed prognostic studies. There has been a strong emphasis on biomechanical factors. Other domains such as psychosocial factors, which are important in similar patient populations, have not been explored. We recommend that further research is needed in this area and should include randomized controlled trials comparing treatment approaches and longitudinal prospective prognostic studies to identify predictors of treatment success.

An integrative review of the qualities of a 'good' physiotherapist

INTRODUCTION

Qualities of a physiotherapist may influence the therapeutic alliance and physiotherapy outcomes. Understanding what qualities constitute a 'good' physiotherapist has yet to be systematically reviewed notwithstanding potentially profound implications for the future practice of physiotherapy.

PURPOSE

The primary purpose of this review was to critically examine how physiotherapists and their patients describe the qualities of a 'good' musculoskeletal physiotherapist as depicted in peer-reviewed literature. The secondary aim was to synthesize qualities represented in the literature, and to compare patient and physiotherapist perspectives.

METHODS

An integrative review methodology was used to undertake a comprehensive literature search, quality appraisal of studies, and thematic analysis of findings. An electronic search of CINAHL, EMBASE, Nursing and Allied Health, PsycINFO, PubMed, and Scopus databases was conducted within a time range from database inception to June 14, 2019.

RESULTS

Twenty-seven studies met the inclusion criteria. Six qualities of a 'good' musculoskeletal physiotherapist were identified as: responsive, ethical, communicative, caring, competent, and collaborative.

CONCLUSIONS

The qualities of a 'good' physiotherapist identified in the review emphasize the human interaction between physiotherapists and patients and point to the centrality of balancing technical competence with a relational way of being.

Patient-centered consultations for persons with musculoskeletal conditions

Consultations between practitioners and patients are more than a hypothesis-chasing exploration, especially when uncertainty about etiology and prognosis are high. In this article we describe a single individual's account of their lived experience of pain and long journey of consultations. This personal account includes challenges as well as opportunities, and ultimately led to self-awareness, clarity, and living well with pain. We follow each section of this narrative with a short description of the emerging scientific evidence informing on specific aspects of the consultation. Using this novel structure, we portray a framework for understanding consultations for persistent musculoskeletal pain from a position of patient-centered research to inform practice.

Experiences and needs of physiotherapists and exercise therapists regarding the management of working people with complaints of the arm, neck and shoulder (CANS): A focus group study

BACKGROUND

Non-traumatic complaints of the arm, neck and/or shoulder (CANS) are difficult-to-treat musculoskeletal conditions. CANS treatment has varying degrees of success, particularly in the working population.

OBJECTIVES

To evaluate the experiences and needs of physiotherapists (PTs) and exercise therapists (ETs) regarding the treatment of working patients with CANS.

DESIGN

An exploratory qualitative focus group study was conducted.

METHOD

Qualitative data were collected from 27 therapists who were purposefully recruited for their broad range of experience and qualifications. The data was analysed using thematic analysis.

RESULTS

Both PTs and ETs assess CANS extensively by exploring their patients' psychosocial factors, work-related factors, illness beliefs, and working conditions. Therapists apply hands-off treatment interventions, such as coaching the patient to make behavioural changes and providing self-management support. However, therapists experience many difficulties in these areas, resulting in a need to learn more about coaching techniques for behavioural change, engaging in meaningful conversations about the patient's perspective, supporting patients in building a strong social network in the workplace, and creating a professional network for collaboration.

CONCLUSIONS

The treatment of working people with CANS is difficult for PTs and ETs. Therapists express a need to learn more about supporting self-management, applying coaching techniques and engaging in meaningful conversations. Moreover, therapists indicate a need to establish a professional multidisciplinary network to support collaborations with other disciplines to treat working patients with CANS.

Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect

INTRODUCTION

While the placebo effect is increasingly recognised as a contributor to treatment effects in clinical practice, the nocebo and other undesirable effects are less well explored and likely underestimated. In the chiropractic, osteopathy and physiotherapy professions, some aspects of historical models of care may arguably increase the risk of nocebo effects.

PURPOSE

In this masterclass article, clinicians, researchers, and educators are invited to reflect on such possibilities, in an attempt to stimulate research and raise awareness for the mitigation of such undesirable effects.

IMPLICATIONS

This masterclass briefly introduces the nocebo effect and its underlying mechanisms. It then traces the historical development of chiropractic, osteopathy, and physiotherapy, arguing that there was and continues to be an excessive focus on the patient's body. Next, aspects of clinical practice, including communication, the therapeutic relationship, clinical rituals, and the wider social and economic context of practice are examined for their potential to generate nocebo and other undesirable effects. To aid reflection, a model to reflect on clinical practice and individual professions through the 'prism' of nocebo and other undesirable effects is introduced and illustrated. Finally, steps are proposed for how researchers, educators, and practitioners can maximise positive and minimise negative clinical context.

Future-proofing the Profession: Physiotherapists' perceptions of their current and emerging role

OBJECTIVES

As healthcare systems continue to modernise, physiotherapists are required to transform their practice to remain contemporary and meet future population needs. The study aims to gain an insight into physiotherapists' perceptions of their current and emerging future role. The intention is to develop an understanding of the physiotherapist's role and how it can continue to evolve to support populations' needs in more sustainable and innovative ways.

DESIGN

A qualitative design using semi-structured interviews was undertaken informed by Gadamerian hermeneutic philosophy.

PARTICIPANTS

Participants were gained from a postgraduate physiotherapy programme in Northwest England that recruits physiotherapists from across the UK; via the research teams' professional networks and using snowball sampling. Interviews were digitally recorded and transcribed verbatim. Thematic analysis was undertaken. Ethical approval and informed consent was obtained.

RESULTS

23 participants (15 female). 4 themes were identified: 'An underpinning philosophy of practice' that promotes holistic care and supports patient wellbeing. An 'evolving role broadening the scope of practice' with many 'agents of change shaping the profession'. When 'preparing the future workforce and their transition into practice', graduates were seen as more adaptable and resilient. However, more affiliation between the university and placement providers to enhance learning environments is needed.

CONCLUSIONS

Physiotherapists need to re-evaluate their role so a clear vision for the future can be co-created to ensure they remain contemporary and continue to optimise their potential. An emerging role that re-envisages a holistic approach that incorporates health promotion as fundamental to this role could support physiotherapists' transformation in practice. CONTRIBUTION OF THE PAPER.

Person-centered care for musculoskeletal pain: Putting principles into practice

Person-centered care specifically focuses on the whole person and is an important component of contemporary care for people with musculoskeletal pain conditions. Evidence suggests however, that some clinicians experience difficulties with integrating person-centered care principles into their clinical practice. Therefore, the purpose of this masterclass is to provide a framework that enables clinicians to incorporate person-centered principles in their management of people with musculoskeletal pain conditions. To support clinicians in overcoming some of the reported obstacles, we provide practical recommendations aimed at putting principles of person-centered care into practice. The framework supporting clinicians' delivery of person-centered care in practice consists of three key-principles: A) a biopsychosocial understanding of the person's experience; B) person-focused communication; and C) supported self-management. The framework includes three phases: 1) identification and goal setting, 2) coaching to self-management, and 3) evaluation. Building a therapeutic relationship underpins these phases and is an overarching element that weaves through the key-principles and phases of the framework. We use a clinical case to illustrate the practical implementation of these recommendations.

Doing things you never imagined: Professional and ethical issues in the U.S. outpatient physical therapy setting during the COVID-19 pandemic

OBJECTIVE

Despite being the most prevalent physical therapy practice setting in the United States, no literature to date has examined the professional and ethical issues faced by outpatient physical therapists during the COVID-19 pandemic. The purpose of this study was to explore professional and ethical issues experienced by outpatient physical therapists in the United States during the COVID-19 pandemic.

DESIGN

An explorative semi-structured interview study using reflexive thematic analysis METHODS: Virtual semi-structured interviews explored physical therapists' experiences during COVID-19 in the OP setting. Data was analyzed using reflexive thematic analysis as described by Braun and Clarke.

RESULTS

Respondents worked predominantly with patients with orthopaedic impairments. Six primary themes and associated subthemes were identified: 1) Disruption of routine professional and personal life. 2) Negative impacts on health and wellbeing (physical, mental, and social). 3) Barriers to relationships, communication, and providing quality care. 4) Telehealth as a safe option to increase access with opportunities and challenges. 5) Discomfort practicing in an environment of misinformation, mistrust, and divisiveness. 6) New & pre-existing ethical issues in the COVID-19 context.

CONCLUSIONS

Results of this study indicate that physical therapists in the outpatient setting wrestled with critical questions regarding outpatient physical therapy practice during the COVID-19 pandemic: the role of touch in professional identity, challenges to the therapeutic alliance, effect of productivity and fiscal expectations and whether outpatient physical therapy is essential during public emergencies.

Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Biobehavioural Synchrony in Musculoskeletal Care

Touch is recognised as crucial for survival, fostering cooperative communication, accelerating recovery, reducing hospital stays, and promoting overall wellness and the therapeutic alliance. In this hypothesis and theory paper, we present an entwined model that combines touch for alignment and active inference to explain how the brain develops "priors" necessary for the health care provider to engage with the patient effectively. We appeal to active inference to explain the empirically integrative neurophysiological and behavioural mechanisms that underwrite synchronous relationships through touch. Specifically, we offer a formal framework for understanding - and explaining - the role of therapeutic touch and hands-on care in developing a therapeutic alliance and synchrony between health care providers and their patients in musculoskeletal care. We first review the crucial importance of therapeutic touch and its clinical role in facilitating the formation of a solid therapeutic alliance and in regulating allostasis. We then consider how touch is used clinically - to promote cooperative communication, demonstrate empathy, overcome uncertainty, and infer the mental states of others - through the lens of active inference. We conclude that touch plays a crucial role in achieving successful clinical outcomes and adapting previous priors to create intertwined beliefs. The ensuing framework may help healthcare providers in the field of musculoskeletal care to use hands-on care to strengthen the therapeutic alliance, minimise prediction errors (a.k.a., free energy), and thereby promote recovery from physical and psychological impairments.

Six-months outcome after fracture for working-age persons analyzed using the International Classification of Functioning, Disability, and Health - a prospective cohort observational study

BACKGROUND

Fractures following trauma affect physical and mental health for working-age persons, and the International Classification of Functioning, Disability, and Health (ICF) can help therapists understand the fractures' impact on daily lives.

PURPOSE

To examine self-reported functioning and outcomes six months after upper and lower body fractures and compare limitations using the ICF.

METHODS

Data were collected from 160 patients with fractures as part of a prospective cohort study. The primary outcome measure was the Short Musculoskeletal Function Assessment questionnaire that covers all domains of the ICF. Moreover, sick leave, sense of coherence, and physical activity were reported.

RESULTS

Six months after the injury, function had improved significantly, but patients reported problems on all domains in the ICF with few differences between the upper and lower body groups. Leisure activities caused problems for 63 (38.8%) of the patients and bothered 86 (53.8%). Problems performing work bothered 63 (39.4%) with no significant difference between the groups, although a significantly higher proportion in the upper body group had returned to work within two months (p < .001).

CONCLUSION

Six months after fractures, adults reported problems on all ICF domains, especially on the participation dimension, which therapists should address in the rehabilitation process.

An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, and Professional Roles

OBJECTIVE

The purpose of this study was to explore physical therapy through the stories of physical therapists who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other related identities (LGBTQIA+) to consider how the profession enacts and constructs gender and sexual orientation.

METHODS

Physical therapists with clinical, academic, and professional roles who identify as LGBTQIA+ were recruited from Australia, the United Kingdom, Canada, and the United States. In-depth data were collected via narrative interviews. An iterative group discourse analysis was used to examine key discourses underpinning interview narratives and how these relate to the physical therapy profession.

RESULTS

Twenty-two physical therapists were interviewed. Participants had between 1.5 and 40 years of experience across various clinical areas and settings. Participants identified with varying sexual orientations and gender identities. Analysis identified discourses discussed under the following headings: (1) normativity, which related to hetero-normative assumptions about sexual orientation and cisnormative assumptions about gender identity and the intersectionality among sexual orientation, gender identity, and other forms of marginalization; (2) stress and labor, which explored the stress experienced by physical therapists who are LGBTQIA+ (due to fear of discrimination or actual discrimination) and additional emotional and other types of labor or work done in the workplace to hide aspects of their lives to feel safe, educate colleagues, and be a role model; and (3) professionalism, which related to the heterosexual/cisnormative (and other) "norms" that comprised participants' ideas of presenting as "professional" and positioning physical therapists who are LGBTQIA+ as "unprofessional."

CONCLUSION

Findings suggest that cultural norms may need to be reconceptualized in physical therapy to promote inclusion and belonging of individuals who identify as LGBTQIA+. Approaches to upskill new and existing physical therapists may include elements such as individual and institutional reflexivity, learning and implementing appropriate terminology, displaying indicators of inclusivity, and cultural safety training. These elements may provide the first steps to promote inclusive and culturally safe environments for individuals who identify as LGBTQIA+ within the profession.

IMPACT

This is the first known study to explore the lived experiences of those who identify as LGBTQIA+ in the physical therapy profession. The findings highlight how prevailing normative discourses in Western society are also present in physical therapy and impact those who identify as LGBTQIA+.

Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Synchrony

Recognizing and aligning individuals' unique adaptive beliefs or "priors" through cooperative communication is critical to establishing a therapeutic relationship and alliance. Using active inference, we present an empirical integrative account of the biobehavioral mechanisms that underwrite therapeutic relationships. A significant mode of establishing cooperative alliances-and potential synchrony relationships-is through ostensive cues generated by repetitive coupling during dynamic touch. Established models speak to the unique role of affectionate touch in developing communication, interpersonal interactions, and a wide variety of therapeutic benefits for patients of all ages; both neurophysiologically and behaviorally. The purpose of this article is to argue for the importance of therapeutic touch in establishing a therapeutic alliance and, ultimately, synchrony between practitioner and patient. We briefly overview the importance and role of therapeutic alliance in prosocial and clinical interactions. We then discuss how cooperative communication and mental state alignment-in intentional communication-are accomplished using active inference. We argue that alignment through active inference facilitates synchrony and communication. The ensuing account is extended to include the role of (C-) tactile afferents in realizing the beneficial effect of therapeutic synchrony. We conclude by proposing a method for synchronizing the effects of touch using the concept of active inference.

Patient-centered care in musculoskeletal practice: Key elements to support clinicians to focus on the person

Musculoskeletal rehabilitation, including physiotherapy, needs to move towards a broader biopsychosocial understanding of musculoskeletal conditions and the delivery of high-value care for people with persistent pain conditions, in which a patient-centered approach is a key feature. However, it has been reported that clinicians experience difficulties with integrating patient-centered care principles into their clinical practice. Based on a focused symposium about patient-centered care for patients with musculoskeletal conditions, held during the online 2021 World Physiotherapy Congress, the purpose of this article is to share key elements of the content of this symposium with a wider audience, aimed at enabling clinicians to enhance patient-centeredness in their current practice. These key elements include establishing meaningful connections, deciding together and self-management support. Moreover, challenges on patient-centered care in low/middle income countries will be discussed and recommendations to implement patient-centered care in clinical practice will be provided.

Measuring therapeutic relationship in physiotherapy: conceptual foundations

The "therapeutic relationship" in physiotherapy refers to the beneficial or healing relationship between the patient and physiotherapist. Interest in researching therapeutic relationships in physiotherapy is growing and there is a need for a measure of therapeutic relationship with a strong conceptual foundation. Body of paper:We begin with a general discussion of the state of therapeutic relationship measurement in physiotherapy research - notably, how current research is based on measures borrowed and adapted from psychotherapy. Then, we introduce Miciak's physiotherapy therapeutic relationship framework, discuss why it offers a solid foundation for measurement development, and describe the key concepts in the framework. We then discuss various approaches to measuring therapeutic relationship, illustrating how Miciak's framework could be used to inform their development. We end by discussing current challenges in measuring therapeutic relationship and how these could be addressed.

Therapeutic relationships in speech-language pathology: a scoping review protocol

OBJECTIVE

The purpose of this scoping review is to provide an overview of empirical research regarding the therapeutic relationship between speech-language pathologists and their clients of all ages and clinical areas.

INTRODUCTION

The influence of a positive relationship between professionals and clients on the process and outcome of interventions is well documented for many health professions. However, research in speech-language pathology predominantly focuses on the outcome of specific treatment methods and techniques. The number of empirical research studies on the therapeutic relationship within this research area is increasing. At present, existing research has not been summarized and compared.

INCLUSION CRITERIA

The review will include all empirical research that addresses the therapeutic relationship between speech-language pathologists and their clients of all ages and clinical areas. Since speech-language pathologists often collaborate intensively with caregivers of their clients, such as parents or partners, these groups will also be included.

METHODS

Systematic searches will be conducted across seven research databases (ASHAWire, CINAHL, ERIC, Fachportal Pädagogik, LIVIVO, MEDLINE [PubMed], and PsycINFO) and four unpublished/gray literature databases (evidenssst, ndldt, OpenGrey, and SSOAR). Data will be extracted by two independent reviewers for author(s), year of publication, country of origin, research questions, participants, terminology and theoretical foundations, research design, and focus. Central findings concerning the therapeutic relationship on the input-, process-, outcome, and output-level of speech-language interventions will be analyzed. Results will be presented as a narrative summary.

THERapy-Related InterACTion (THER-I-ACT) in Rehabilitation-Instrument Development and Inter-Rater Reliability

Objective: To develop an instrument for the observation of therapeutic communication interactions during rehabilitation sessions and test its inter-rater reliability. Methods: The new instrument THER-I-ACT (THERapy-related Inter-ACTion) has been designed to assess both the frequency and timing of therapeutic interactions in the thematic fields information provision, feedback, other motivational interaction, and bonding. For this inter-rater reliability study, a sample of stroke survivors received arm rehabilitation as either arm ability training, arm basis training, or mirror therapy, or neglect training as individually indicated. Therapy sessions were video-recorded (one for each participant) and therapeutic interactions rated by two independent raters using THER-I-ACT. Results: With regard to the instrument's comprehensiveness to document therapeutic interactions with pre-defined categories the data from 29 sessions suggested almost complete coverage. Inter-rater reliability was very high both for individual categories of therapeutic interaction (frequency and time used for interaction) (intraclass correlation coefficient, ICC 0.91-1.00) and summary scores for the thematic fields of interaction (again for frequency and time used for interaction) (ICC 0.98-1.00). The inter-rater reliability for rating engagement and being focussed for both the therapist and patient was substantial (ICC 0.71 and 0.86). Conclusions: The observational study documented that by use of the newly designed THER-I-ACT various types of therapy-related communication interactions performed by therapists can be assessed with a very high inter-rater reliability. In addition, the thematic fields and categories of therapeutic interaction as defined by the instrument comprehensively covered the type of interaction that occurred in the therapeutic sessions observed.

"Sharing Success with Someone": Building therapeutic alliance in physiotherapist-delivered physical activity coaching for healthy aging

INTRODUCTION

Therapeutic alliance, a goal-orientated partnership between clients and practitioners, can enhance program engagement and adherence, and improve treatment outcomes and satisfaction.

OBJECTIVES

To develop an empirical model that describes how therapeutic alliances can be operationalized in clinical and research settings and use this in our evaluation of the Coaching for Healthy Ageing (CHAnGE) trial.

METHODS

Secondary analysis of interviews with participants in the CHAnGE trial (n = 32) and a focus group with the physiotherapists who delivered health coaching in that trial (n = 3). Analysis was inductive (thematic) and deductive (using a therapeutic alliance model derived from a literature review and informed by earlier analyses).

RESULTS

Data from participants and physiotherapists indicated that health coaching in CHAnGE built effective therapeutic alliances (i.e. it facilitated collaborative decision-making and trusting person-centered relationships) which were underpinned by professional skills and structural supports. Components of the intervention that strengthened therapeutic alliance were health coaching training, home visits, the coaching format, and provision of free activity monitors.

CONCLUSION

This study identifies key concepts and practical 'building blocks' of therapeutic alliance, showing how these were operationalized within an intervention. This may help those in clinical and research settings to recognize the importance and characteristics of therapeutic alliance and put it into practice.

"I've learned to look at things in a different way": exploring patients' perspectives on participation in physiotherapist delivered integrated stress inoculation training and exercise for acute whiplash

PURPOSE

To explore patient perspectives of the integrated intervention (intervention arm) of a recent randomised clinical trial that found clinically relevant and sustained benefits of a physiotherapist delivered integrated stress inoculation training (SIT) and exercise for people with acute whiplash-associated disorders (WAD) and at risk of poor recovery.

MATERIAL AND METHODS

Twelve patients from the 53 who participated in the SIT and exercise arm of a randomised controlled trial (StressModex RCT) participated in semi-structured interviews. Data were analysed using inductive thematic analysis.

RESULTS

Five main themes were identified: "balance between the physical and psychological components," "dealing with stress," "coping with the injury," "pain relief and return to function," and "elements enhancing therapeutic alliance."

CONCLUSIONS

The majority of patients found the SIT techniques to be helpful in managing stress and pain, coping with their injury, and returning to function. The patients also found the exercises useful and acknowledged the importance of both the physical and the psychological aspects of whiplash injury.IMPLICATIONS FOR REHABILITATIONPatients with acute WAD at risk of poor recovery welcomed the inclusion of psychological strategies as part of physiotherapy treatment.The patients nominated both the psychological (SIT) component and exercise as assisting them with their stress, pain, and recovery.Physiotherapists could consider including strategies targeting early stress responses in their management of patients with acute WAD.

Treating gynecological pain: key factors in promoting body awareness and movement in somatocognitive therapy (SCT). A case study of a physiotherapy student´s treatment approaches

Background: Longstanding gynecological pain affects large numbers of women in the Western world. Somatocognitive therapy (SCT), a hybrid of cognitive psychotherapy and physiotherapy, is an evidence-based approach that has been successfully applied in the treatment of women suffering from such disorders, for example chronic pelvic pain (CPP) and provoked vestibulodynia (PVD), both demanding pain conditions. The curriculum of Oslo Metropolitan University's Mensendieck physiotherapy bachelor's program includes SCT training for the management of PVD.Purpose: The purpose of this study is to describe and explore the content of a SCT session based on a body and mind approach as performed by a physiotherapy student at a student outpatient clinic.Methods: A video-based case study of the student-patient encounter was undertaken midway through an SCT treatment course and subjected to content analysis.Findings: Three categories illustrating the learning process of body awareness, associated with the three-phase SCT were identified: 1) demystifying genital and chronic pain; 2) concentration, and body and mind experiences; and 3) patience, persistence, and willingness to change.Conclusion: The observation of the somatocognitive therapy session illustrates the value of an empathic relationship with the patient, in order to encourage her to explore body sensations and become familiar with the vulvar area. The therapy engages the patient in understanding pain mechanisms, thus educating her to overcome the fear of pain.

The psychometric properties of the person-centered therapeutic relationship in physiotherapy scale

OBJECTIVE

To determine the psychometric properties of the Person-Centered Therapeutic Relationship in Physiotherapy Scale (PCTR-PT) in order to find the most appropriate fit for the tool.

METHODS

Patients who had received treatment at the physiotherapy service of nine hospitals in Spain were invited to complete the 31 items of the PCTR-PT scale. To select the most appropriate items of the PCTR-PT, an exploratory factorial analysis (EFA) was performed using the maximum likelihood and oblique rotation (promin) methods. Factor validity, goodness-of-fit and psychometric properties were analyzed by confirmatory factor analysis (CFA). Convergent (CFA) and discriminant validity were calculated. Internal consistency was verified using the Cronbach's alpha coefficient. The intraclass correlation coefficient (ICC) was used to examine temporal stability.

RESULTS

366 patients over 18 years old who had received, at least, 15 physiotherapy treatment sessions completed the questionnaire. The results of the exploratory factor analysis revealed a tool with 15 items in four factors [Relational Bond (N items = 4); Individualized Partnership (N items = 4); Professional Empowerment (N items = 3) and Therapeutic Communication (N items = 4)], explaining 78.4% of the variance of the total variables of this tool. The confirmatory factor analysis further confirmed the four-structure model. Reliability of the tool was approved by Cronbach's alpha in all four dimensions, as all were above .70, ranging from .84 (Individualized Partnership) to .91 (Professional Empowerment). = 0.94. Test-retest was performed with two-week intervals, indicating an appropriate stability for the scale (ICC = 0.900).

CONCLUSION

The Person-Centered Therapeutic Relationship in Physiotherapy Scale (PCTR-PT) is a useful, valid and applicable instrument to evaluate the person-centered therapeutic relationship during physiotherapy interventions. It would be interesting to investigate the predictive capacity (sensitivity and specificity) of the PCTR-PT scale.

Pain Neuroscience Education as the Foundation of Interdisciplinary Pain Treatment

Pain neuroscience education (PNE) can be applied as the foundational core of an interdisciplinary biopsychosocial approach to persistent pain. This article outlines a noninvasive, nonpharmaceutical, and collaborative approach to providing comprehensive pain care, applying evidence-based biopsychosocial treatment strategies within the framework of PNE. Through consistent messaging across all interdisciplinary team members, persistent pain patients can sustain a deeper level of understanding and empowerment, with goals of sustainable improvement and self-management. The application of adult learning theory by patient educators also is discussed.

Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy

Background

Placebo and nocebo effects embody psychoneurobiological phenomena where behavioural, neurophysiological, perceptive and cognitive changes occur during the therapeutic encounter in the healthcare context. Placebo effects are produced by a positive healthcare context; while nocebo effects are consequences of negative healthcare context. Historically, placebo, nocebo and context-related effects were considered as confounding elements for clinicians and researchers. In the last two decades this attitude started to change, and the understanding of the value of these effects has increased. Despite the growing interest, the knowledge and the awareness of using the healthcare context to trigger placebo and nocebo effects is currently limited and heterogeneous among physiotherapists, reducing their translational value in the physiotherapy field.

Objectives

To introduce the placebo, nocebo and context-related effects by: (1) presenting their psychological models; (2) describing their neurophysiological mechanisms; (3) underlining their impact for the physiotherapy profession; and (4) tracing lines for future researches.

Conclusion

Several psychological mechanisms are involved in placebo, nocebo and context-related effects; including expectation, learning processes (classical conditioning and observational learning), reinforced expectations, mindset and personality traits. The neurophysiological mechanisms mainly include the endogenous opioid, the endocannabinoid and the dopaminergic systems. Neuroimaging studies have identified different brain regions involved such as the dorsolateral prefrontal cortex, the rostral anterior cingulate cortex, the periaqueductal gray and the dorsal horn of spine. From a clinical perspective, the manipulation of the healthcare context with the best evidence-based therapy represents an opportunity to trigger placebo effects and to avoid nocebo effects respecting the ethical code of conduct. From a managerial perspective, stakeholders, organizations and governments should encourage the assessment of the healthcare context aimed to improve the quality of physiotherapy services. From an educational perspective, placebo and nocebo effects are professional topics that should be integrated in the university program of health and medical professions. From a research perspective, the control of placebo, nocebo and context-related effects offers to the scientific community the chance to better measure the impact of physiotherapy on different outcomes and in different conditions through primary studies.

Measuring therapeutic relationship in the care of patients with haemophilia: A scoping review

OBJECTIVE

We conducted a scoping review of the tools used to measure therapeutic relationship in patients with haemophilia.

BACKGROUND

Haemophilia is an inherited bleeding disorder caused by a deficiency of a clotting factor in the blood. Therapeutic relationship is foundational to the management of patients with chronic diseases like haemophilia. A reliable and valid measurement tool for assessing therapeutic relationship is needed to evaluate the quality of care received by these patients, and to rigorously study the association between therapeutic relationship and the outcomes of treatment.

METHODS

We adopted the Arksey and O'Malley framework for scoping studies. The following electronic databases were searched for studies that measured a construct related to therapeutic relationships in haemophilia care: MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus. We inventoried these studies, identified the measurement tools used, and described each tool by purpose, content, measurement properties and target population. We identified gaps in the current evidence and directions for future research.

RESULTS

There were 253 unique records retrieved in the search, and twenty studies were deemed relevant. Ten measurement tools were identified. None of the tools measured therapeutic relationship as a single entity; however, six tools measured constructs considered part of patient-provider relationship (eg trust, communication, working alliance). There has been little validation testing of these tools in haemophilia patient populations.

CONCLUSIONS

There is a need for a validated tool for measuring therapeutic relationship in the care of patients with haemophilia. This review provides a foundation for future research in this area.

The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study

Background

The therapeutic relationship between patient and physiotherapist is a central component of patient-centred care and has been positively associated with better physiotherapy clinical outcomes. Despite its influence, we do not know what conditions enable a physiotherapist and patient to establish and maintain a therapeutic relationship. This knowledge has implications for how clinicians approach their interactions with patients and for the development of an assessment tool that accurately reflects the nature of the therapeutic relationship. Therefore, this study’s aim was to identify and provide in-depth descriptions of the necessary conditions of engagement of the therapeutic relationship between physiotherapists and patients.

Methods

Interpretive description was the qualitative methodological orientation used to identify and describe the conditions that reflect and are practically relevant to clinical practice. Eleven physiotherapists with a minimum 5 years of clinical experience and seven adult patients with musculoskeletal disorders were purposively sampled from private practice clinics in Edmonton, Canada. The in-person, semi-structured interviews were completed in a location of the participant’s choice and were audio recorded and transcribed. Qualitative content analysis was used to analyze the textual data and constant comparison techniques were integrated to refine the categories and sub-categories. Rigour strategies used throughout the study were peer debrief, interview notes, reflexive journaling, memoing, member reflections, audit trail, and external audit.

Results

Four conditions were identified as necessary for establishing a therapeutic relationship: present, receptive, genuine, and committed. These conditions represent the intentions and attitudes of physiotherapists and patients engaging in the clinical interaction. Although distinct, the conditions appear related as being present and receptive create a foundation for being genuine and committed.

Conclusions

These conditions of engagement are needed for physiotherapist and patient to “be” in a therapeutic relationship. Although communication skills are important for advancing therapists’ relational abilities, awareness and integration of intentions and attitudes are essential for shaping behaviors that develop the therapeutic relationship. These findings also suggest there are characteristics of the therapeutic relationship specific to physiotherapy. Therefore, theories from other contexts (e.g., psychotherapy) should be used judiciously to guide physiotherapy practice and research.