How valuable is Therapeutic Alliance?
Therapeutic alliance (TA) has been proposed to be fundamental to the therapeutic process and the placebo effect.
Greater TA has been associated with improved treatment outcomes in patients receiving care from psychiatrists, physicians, nurses and now physiotherapists.
A 2010 systematic review has concluded “From this review, the alliance between therapist and patient appears to have a positive effect on treatment outcome in physical rehabilitation settings.” (Hall et al 2010)
This unique study took place at the U of Alberta and compared the effects of TA on pain and muscle tenderness in participants with chronic LBP.
Each participant received a single 30-minute session of either real or sham interferential current therapy (IFC).
Pain and tenderness scores were evaluated (with a mechanical algometer) by a blinded assessor immediately prior to and immediately after the intervention.
Participants were randomly allocated into 4 groups:
Group 1: Active IFC with limited TA
Group 2: Sham IFC with limited TA
Group 3: Active IFC with enhanced TA
Group 4: Sham IFC with enhanced TA
In the limited TA group, the PT simply introduced themselves and spent less than 5 minutes to explain that the purpose of the IFC was to reduce their pain. After setting up the IFC machine with minimal conversation, the PT left the room and returned in 15 minutes to quickly check up on the patient and again after 30 minutes to remove the IFC with minimal conversation.
In the enhanced TA group, prior to setting up the IFC the patient was questioned about his/her symptoms for 10 minutes using active listening skills. During this time, eye contact was made and at some point the patient was appropriately touched. The PT was instructed to show empathy when appropriate by saying, “I can understand how difficult this back pain must be for you.”
|Intervention||Change in Pain Score||Change in PPT Score|
|Group 1: Active IFC + limited TA||1.83 cm||1.2 kg|
|Group 2: Sham IFC + limited TA||1.03 cm||0.3 kg|
|Group 3: Active IFC + enhanced TA||3.13 cm||2.0 kg|
|Group 4: Sham IFC + enhanced TA||2.22 cm||1.7 kg|
The PT was present during the entire 30-minute IFC session while conversation between the patient and the PT continued. At the end of the session but prior to the pain and tenderness re-evaluation the PT gave final encouraging words, such as “I am sure you will get better.”
- Sham IFC with an enhanced TA (group 4) demonstrated better results than the active IFC with a limited TA (group 1).
- TA appears to be at least as important as IFC in pain modulation.
- Perhaps the subjects in the enhanced TA group were more willing to please their therapist; in other words not disappoint them.
Conclusion: When treating patients with chronic LBP, maximizing Therapeutic Alliance (TA) (active listening with empathy and encouragement) appears to be beneficial in the immediate improvement of pain scores in those receiving either real or sham IFC.
Personal comment: So in those instances where you forget to turn on the ultrasound machine, as long as you spent the 5 minutes talking to them empathetically you probably helped the patient to the same degree. It’s OK!
References: Hall AM, Ferreira PH, Maher CG, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010;90:1099–1110
Ferreira PH, et al The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. PhysTher. 2013Apr;93(4):470-8.