Are You Compatible with your Patient?

In the April Physical Therapy Journal, authors ask the question: does the relationship between the patient and the physical therapist impact patient outcome? This relationship, or therapeutic alliance, was measured through use of the Working Alliance Inventory at the second treatment session. The 182 patients included in the reporting were all diagnosed with chronic low back pain, and they completed outcomes before and after 8 weeks of treatment including the Patient-Specific Functional Scale, the Global Perceived Effect Scale, the visual analog scale, and the Roland-Morris Disability Questionnaire. The patients were divided among 7 experienced physical therapists.

The authors conclude that "Higher levels of therapeutic alliance...were associated with greater improvements in perceived effect of treatment, function, and reductions in pain and disability." Considering that this alliance was measured at the second visit, it clearly does not take a patient long to decide if there is a positive alliance formed. So how do we create that alliance? One of the reported limitations of the study is the lack of knowledge about the therapists' behaviors or interpersonal skills, therefore a correlation between such skills and patient's perceived alliance cannot be made. Another research article appearing in the same journal may offer some clues towards this issue.

An article titled "Measuring Verbal Communication in Initial Physical Therapy Encounters" suggests that clinical communication is critical in providing the patient with a positive experience. How can that be measured? 27 patient initial evaluations completed among 9 physical therapists were observed, audio recorded, and categorized using the Medical Communications Behavior System, a tool created to measure information-providing interactions. The results of the categorizations included that the therapists spoke for nearly 50% of the time compared to the patient's 33%. Emotional content was rarely included. Experienced clinicians were found to give more advice or suggestions, to utilize less restatement, and were also noted to be more likely to talk concurrently or interrupt the patient.

Documented negative therapist behaviors included being interrupted in the clinic, giving disapproval, or using jargon. These types of interactions or behaviors may be easily limited with setting standards for limiting interruptions (only in emergencies), or by being certain that each treatment room is stocked with similar equipment, that sort of thing. Avoiding disapproving statements or use of jargon requires that the therapist "listen" to him or herself, avoid falling into verbal habits, and make an effort to consciously choose language that is patient-centered and positive. The authors point out that basic clinical communication requires listening without interruption and making effort to hear what the patient is truly saying or is trying to say.

In our efforts to provide information in our clinic setting, where it seems there is never quite enough time to complete patient and clinician paperwork/documentation, share home program information and complete clinical interventions, it is easy to understand why the above tasks may be challenging. Both research articles are groundbreaking in that when evaluating some of the factors that are related to the patient/therapist relationship and communication, our profession is beginning to make connections among variables that appear to be less tangible. It is this information that can help explain why some patients are more adherent, why some respond better to particular interventions, or to a particular person. For our part, when outside of the research community, we can make efforts to attend to patient rapport, relationships, and communication, and look for more guidance on how to measure these variables and provide the optimal experience for our patients.