If you lack confidence in your doctor, physical therapist, or performance coach, find a new one. Research on chronic low back pain shows that a supportive, trusting relationship with your physical therapist, known as the therapeutic alliance, predicts better treatment outcomes. Here's what the study found and why it matters for your care.
What is the therapeutic alliance?
The therapeutic alliance is the relationship between a patient and a medical professional. A 2013 study by Paulo Ferreira and colleagues found that patients with supportive, trusting relationships with their physical therapist had improved treatment outcomes, and that the alliance was a consistent predictor of outcome across all measures.
The three main components of the therapeutic alliance are:
- Patient and therapist agreement on goals
- Patient and therapist agreement on interventions
- The affective bond between patient and therapist
The alliance's impact on patient outcomes is well documented and supported by research in medicine and psychology. Its importance has often been suggested in physical therapy, but the research there has been lacking.
How the low back pain study worked
Ferreira's team studied patients who had agreed to take part in a separate randomized controlled trial of common physical therapy interventions for chronic low back pain: general exercise, spinal manipulation, and specific motor control exercises. Participants attended up to 12 treatments over 8 weeks.
Outcome measures included pain, disability, function, and perceived effect. Function and global perceived effect were measured with the Patient Specific Functional Scale (PSFS) and the Global Perceived Effect Scale (GPE). Both are self-reported: one measures physical function, the other the subject's own assessment of their condition. That trial found that patients who did specific motor control exercises and received spinal manipulation had better short-term outcomes.
What the therapeutic alliance predicted
Those results are generally consistent with past research. The more interesting findings came from Ferreira's "piggyback study." The team measured the alliance between each subject and their physical therapist using the Working Alliance Theory of Change Inventory (WATOCI), completed during the second treatment so subjects had already worked with their therapist.
- A total of 182 subjects completed the WATOCI.
- The alliance between physical therapist and patient predicted all of the final measured outcomes.
- Higher levels of alliance, meaning more positive interactions, were associated with even greater improvements.
- The strongest association was with the subject's disability rating.
Why this matters for chronic low back pain
Regardless of the treatment, patients with low back pain who have a healthy, supportive relationship with their physical therapist demonstrate improved outcomes. Given low back pain's significant impact on global disability, its tremendous burden on the healthcare system, and its consistently poor treatment outcomes, these findings provide hope.
They also fit the idea that chronic low back pain is not caused by physical impairments alone. Cliché or not, a holistic approach is likely the most appropriate one. Practitioners should address the physical impairments they find, and also their patient's knowledge, outlook, and understanding of the condition.
Everyone with back pain needs a hype man
People with chronic low back pain need to know that they are not fragile, and that their opinions, goals, and outlook matter. This study should not minimize the importance of proper assessment and treatment choice, but there is more to quality healthcare than the medicine or intervention.
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book a sessionthe takeaway
A trusting relationship with your physical therapist predicts better outcomes, regardless of the treatment. If you lack confidence in your rehab team, find a new one.
Frequently asked questions
What is the therapeutic alliance in physical therapy?
It's the relationship between a patient and their clinician. Its three main components are agreement on goals, agreement on interventions, and the affective bond between patient and therapist.
Does your relationship with your physical therapist affect your results?
Yes. In a study of 182 patients with chronic low back pain, the therapeutic alliance predicted all of the final measured outcomes, and higher levels of alliance were associated with even greater improvements.
Which outcome was most strongly linked to the therapeutic alliance?
The strongest association was between the therapeutic alliance and the patient's disability rating.
What should I do if I don't trust my physical therapist?
Find a new one. A supportive relationship is linked to better outcomes regardless of the treatment you receive.
References
Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2012). The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Physical Therapy, 93(4), 470–478.
