Measuring therapeutic relationship in physiotherapy: conceptual foundations

Musculoskeletal physiotherapists' experiences of using remote consultations during the COVID-19 pandemic: A qualitative study

BACKGROUND

The coronavirus (COVID-19) pandemic resulted in the rapid implementation of remote consultations to maintain musculoskeletal physiotherapy services. However, little is known about UK musculoskeletal physiotherapists' experiences of providing services during the COVID-19 pandemic.

OBJECTIVES

To explore musculoskeletal physiotherapists' experiences of using remote consultations in one area of England during the COVID-19 pandemic.

DESIGN

Qualitative study using hermeneutic phenomenology based on the approach of Gadamer.

METHODS

Semi-structured interviews with twelve musculoskeletal physiotherapists were conducted online using Microsoft Teams. Data were analysed using frameworks based on the philosophical concepts of Gadamer's hermeneutics.

FINDINGS

Musculoskeletal physiotherapists' experience of using remote consultations during the COVID-19 pandemic was framed by three concepts: therapeutic relationship, transformational change, and uncertainty. These concepts are underpinned by four main themes capturing their experiences: (1) Disconnection: Difficulties building a rapport and reduced non-verbal communication affected building an effective therapeutic relationship, (2) Necessity: Transformation of services to remote consultations was positive, although technology and connectivity issues had a negative impact, (3) Loss of control: Diagnostic uncertainty, being unprepared, and experience affected physiotherapists' clinical practice, (4) Protection: Peer support and the use of technology facilitated a feeling of protection for physiotherapists.

CONCLUSION

The findings of this study contribute to a better understanding of musculoskeletal physiotherapists' experience of using remote consultations during the COVID-19 pandemic. Implications for practice include the need to provide training for all musculoskeletal physiotherapists and undergraduates to enable the effective delivery of remote physiotherapy. Furthermore, digital infrastructure should be optimised to support future delivery of remote musculoskeletal physiotherapy services.

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.

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.

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.

Looking at Both Sides of the Coin: Addressing Rupture of the Therapeutic Relationship in Musculoskeletal Physical Therapy/Physiotherapy

As physical therapists, we may have all experienced tense moments in our therapeutic relationships with patients. Whether small or large, implicit or explicit, relational breakdowns are a normal part of human interactions. Within the clinical encounter, these tensions are called "ruptures." In psychotherapy, ruptures have been associated with increased dropout rates and poor clinical outcomes. To increase the likelihood that physical therapists establish, maintain, and strengthen therapeutic relationships with their patients, recognizing and repairing ruptures would seem logical. However, we contend that relational tensions, although inevitable, are most often avoided by physical therapists, potentially to the peril of the therapeutic relationship. A responsive approach that involves adjusting our mind-set, being aware, and taking appropriate action could facilitate rupture repair. We provide clinical examples of rupture and repair and discuss the opportunities that "the other side of the coin" presents for professional and personal growth. J Orthop Sports Phys Ther 2022;52(8):500-504. Epub: 19 June 2022. doi:10.2519/jospt.2022.11152.

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.

Perceptions and Experiences of Individuals With Neck Pain: A Systematic Critical Review of Qualitative Studies With Meta-Summary and Meta-Synthesis

OBJECTIVE

This study aimed at exploring the perspectives and experiences of individuals with neck pain by synthesizing all available qualitative studies.

METHODS

A systematic, qualitative meta-summary and meta-synthesis was conducted following the 5-step methodology proposed by Sandelowski and Barroso. A systematic search of 9 electronic databases was conducted in May 2021. Methodological quality was assessed using the Critical Appraisal Skills Programme tool.

RESULTS

Nine studies were included in the meta-synthesis for a total of 103 participants (73 women). Eleven categories were identified as belonging to 3 main themes: physical ("My neck has gone wrong"); psychological ("I am worried about my recovery"); and social ("Pain limits my life"). In the physical theme, the categories with the highest frequency were symptoms (67%) followed by body perception (44%). The psychological theme frequencies from highest to lowest were psychological consequences (100%), coping strategies (100%), mindset (67%), expectations from health care professionals (44%), and gender influence (22%). In the social theme, frequencies from highest to lowest were social relationships (56%), work, and activities of daily living and physical activity (44%, respectively).

CONCLUSION

An individual's experience with neck pain is a multidimensional phenomenon in which physical, psychological, and social dimensions influence each other. These findings suggested that health care professionals should be aware of recognizing and evaluating all of the individual's experiences to offer a truly patient-centered care pathway.

IMPACT

This qualitative meta-synthesis responded to a call to action to explore perspectives and experiences of individuals with neck pain. These findings can provide crucial guidance for clinicians as they plan and implement evidence-based recommendations for neck pain.