The productive partnerships framework: harnessing health consumer knowledge and autonomy to create and predict successful rehabilitation outcomes

"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.

Rehabilitation for participation in life after spinal cord injury - clinician responses to a preliminary conceptual framework

PURPOSE

To explore face validity of a preliminary conceptual framework for rehabilitation (the HEAR Framework), which is grounded in the narratives of people with spinal cord injury.

METHODS

Using a quantitative online survey, experienced spinal cord injury rehabilitation practitioners were asked to compare the overall Framework, and its three components and nine elements, against usual practice. Participants rated the helpfulness and ease of implementation of each component. Perceived training needs, to support the implementation of the Framework were also explored. Respondents were given the opportunity to provide qualitative feedback about the Framework.

RESULTS

Thirty-four participants completed the survey. Median rating of congruence of the Framework with usual practice was 6 (out of 10). The Help component of the Framework was rated as more like usual practice than the Encourage and Accept components. Median rating of the potential helpfulness to practice, of all the elements of the Framework was 5 (out of 5). Participants rated the elements within the Help component of the Framework as easiest to implement. Teaching assertiveness, promoting flexible thinking and fostering responsive communication were the highest rated training topics related to implementation of the Framework.

CONCLUSIONS

Face validity testing suggests the preliminary HEAR Framework is promising as a basis for spinal cord injury rehabilitation theory. Broad-based testing is required to progress the promise of the Framework.IMPLICATIONS FOR REHABILITATIONSpinal cord injury rehabilitation lacks conceptual frameworks to guide practice.This validity study suggests moderate alignment between the preliminary HEAR Framework and usual practice (based on the perceptions of professionals in a spinal cord injury service).The Framework may be useful to individual rehabilitation practitioners as a basis for clinical reflection.The Framework may be useful as a practice development tool for teams of rehabilitation practitioners.

Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature

Background

Most conventional treatment for musculoskeletal conditions continue to show moderate effects, prompting calls for ways to increase effectiveness, including drawing from strategies used across other health conditions. Therapeutic alliance refers to the relational processes at play in treatment which can act in combination or independently of specific interventions. Current evidence guiding the use of therapeutic alliance in health care arises largely from psychotherapy and medicine literature. The objective of this review was to map out the available literature on therapeutic alliance conceptual frameworks, themes, measures and determinants in musculoskeletal rehabilitation across physiotherapy and occupational therapy disciplines.

Methods

A scoping review of the literature published in English since inception to July 2015 was conducted using Medline, EMBASE, PsychINFO, PEDro, SportDISCUS, AMED, OTSeeker, AMED and the grey literature. A key search term strategy was employed using “physiotherapy”, “occupational therapy”, “therapeutic alliance”, and “musculoskeletal” to identify relevant studies. All searches were performed between December 2014 and July 2015 with an updated search on January 2017. Two investigators screened article title, abstract and full text review for articles meeting the inclusion criteria and extracted therapeutic alliance data and details of each study.

Results

One hundred and thirty articles met the inclusion criteria including quantitative (33%), qualitative (39%), mixed methods (7%) and reviews and discussions (23%) and most data came from the USA (23%). Randomized trials and systematic reviews were 4.6 and 2.3% respectively. Low back pain condition (22%) and primary care (30.7%) were the most reported condition and setting respectively. One theory, 9 frameworks, 26 models, 8 themes and 42 subthemes of therapeutic alliance were identified. Twenty-six measures were identified; the Working Alliance Inventory (WAI) was the most utilized measure (13%). Most of the therapeutic alliance themes extracted were from patient perspectives. The relationship between adherence and therapeutic alliance was examined by 26 articles of which 57% showed some correlation between therapeutic alliance and adherence. Age moderated the relationship between therapeutic alliance and adherence with younger individuals and an autonomy support environment reporting improved adherence. Prioritized goals, autonomy support and motivation were facilitators of therapeutic alliance.

Conclusion

Therapeutic Alliance has been studied in a limited extent in the rehabilitation literature with conflicting frameworks and findings. Potential benefits described for enhancing therapeutic alliance might include better exercise adherence. Several knowledge gaps have been identified with a potential for generating future research priorities for therapeutic alliance in musculoskeletal rehabilitation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2311-3) contains supplementary material, which is available to authorized users.

The significance of social rules in group training sessions

PURPOSE

To identify what types of social rules are involved in group interventions led by physiotherapists (PTs), and how these rules influence individual recovery.

METHODS

Eight patients; six women and two men, which had recently undergone elective hip or knee replacement surgery, were recruited as informants from an intervention group that investigated effect of task specific exercise. The data comprise observational notes from group training sessions and one-on-one semi-structured interviews with the eight patients. Observational notes contributed to the development of the research questions. The interviews were audio-recorded and transcribed, and a theoretically-oriented analytical approach guided by performance theory was conducted to identify the rules.

RESULTS

Several implicit rules for behavior when attending this group intervention were identified. The compulsory style enhances recovery in an explicit manner.

CONCLUSION

When giving advice and home exercise PTs must acknowledge that the roles patients are subtly exposed to during the actual clinical encounter are probably quite different from the roles the patients can merge into outside the therapy context. This might shed some light on the notion of patient adherence/concordance. The significance of social rules in group training sessions. Implications for Rehabilitation Health professionals should be aware of the implicit social regulations of the clinical encounter. They will influence whether and how patients adhere to advice. By acknowledging that patients have different roles to merge into, depending on context, health professionals may significantly broaden our understanding of patient adherence and compliance. The social rules identified in this study contribute to individual recovery processes. We encourage health professionals to regard "group dynamics" as something that is going on during the group session, and worthwhile taking advantage of when planning and implementing group interventions.

Consumer's perceptions of Recovery-oriented mental health services: an Australian case-study analysis

Recovery approaches to health care now feature in the mental health policies of many Western countries. There are, however, continuing challenges to the operationalization of these approaches. This study aimed to identify the nature of these challenges for a public mental health service organization located in a major urban center in southeastern Australia, where Recovery-oriented services have been implemented; and to develop recommendations to address these challenges. These aims were achieved by asking mental health consumers about their experiences of the implementation of Recovery-oriented services. Research participants described an uncertainty in health professionals and consumers alike about how to practice within a Recovery model, with many health professionals taking a "hands off" approach in the name of Recovery, rather than working in partnership with consumers and other stakeholders, including the community managed organizations. Solutions to these challenges included more targeted, practice-focused education for consumers and health professionals, with this education provided by consumer representatives. Insights derived from this research add to the growing body of evidence related to the implementation of Recovery-oriented services in Western countries.

Rehabilitation outcomes: values, methodologies and applications

BACKGROUND

Just what defines a 'good' outcome in rehabilitation has been a much-debated issue. Indeed, this question remains a major focus in research, clinical practice and policy (with funding in many countries now being linked to outcomes achieved rather than outputs or services provided). Despite this rather constant attention, complexity, contention and confusion remain.

PURPOSE

This special issue presents 10 papers that take a fresh look at some of the long-standing problems concerning rehabilitation outcomes and, proposes novel ways to reconsider things and move forward.

RESULTS

In this article, we provide a brief commentary on key issues raised by authors all of which focus on one or more of the following three key themes: the place of values in selecting and targeting outcomes; novel methodologies that may usefully inform measurement of outcome and finally; application of the thinking about outcomes in specific examples.

CONCLUSION

The papers in this special issue address a number of key issues concerning the evaluation of outcomes in rehabilitation. In so doing, some of the prevalent assumptions underpinning common approaches are questioned and novel ways forward are proposed.