Post 87: Therapeutic Alliance

“Many common interventions for CLBP (chronic low back pain), based on the premise that structural or anatomical dysfunction underlies the pain experience, have failed to consistently produce significant long-term reductions in pain or improvements in function.”


This is where the chess match begins. Treating acute pain is relatively straight forward. Remove the aggravating factor, place the patient in the ideal position to heal based on patient response and let time take over. For patients with chronic pain, time has already taken place and they are still not better. For these patients, a mechanical assessment and treatment according to biomechanics may not be the best option. Obviously, all patients need to be assessed first in order to determine the possibility for a rapid reversal of the symptoms.


“Cognitive functional therapy (CFT)…focus is on reconceptualizing pain as a biopsychosocial problem, functionally retraining maladaptive and feared postures and movement patterns and addressing contributing lifestyle factors.”


This is very important. For some patients (read not all patients) they need to understand that pain may be a part of their life, but it shouldn’t be feared. There are multiple phrases thrown around in the PT world, or at least those that are much smarter than me throws them around. The first is “hurt doesn’t mean harm” and “no brain, no pain”.


I throw these phrases around more often now because if I mimic those smarter than I am, I may one day become more like them.


Some people fear pain because they feel that something bad is happening inside and they don’t want to be injured. Feeling pain doesn’t mean that there is an injury.


This is a good video that educates patients and some therapists alike regarding pain perception.


A big portion of sessions with patients that “always” have pain is to teach them that avoiding an activity may be no better for the pain than performing the activity, but avoiding activity has many other consequences on the cardiovascular system, musculoskeletal system and neurophysiological system.


“…successful intervention, which included the formation of a supportive and motivating bond with the therapist, provision of accessible education, pain redefinition, fear deconstruction, and the restoration of hope and an acceptable sense of self”


BOUT TO GET REAL: My father is/was an alcoholic. I was raised in a bar until the age of 10 when he remarried my step-mom. Because of this, I was essentially raised around many adults (varying from construction workers, military veterans, laborers, and other every day Joe’s). I learned as a kid how to communicate with adults because that was my world. That skill has greatly helped me in this profession. Along with reading the works of Paul Ekman (You may know him from the show “Lie to Me”), I am good at finding a bond with the patient. Anectdotally, I find that if I can bond to the patient in any way that my outcomes are better than those that I can’t find that bond with the patient. I work really hard during the first visit to find that common interest, knowledge, experience in order to gain the patient’s trust. Once I have the patient’s trust, I spend a lot of energy trying to educate. This could be unlearning what they were taught from a previous practitioner or teaching them with a fresh slate. The most important part of the above quote is “restoration of hope and sense of self”. I do my best to empower the patient. There are some quotes that I use frequently in the clinic and the one that I use most often is when a patient thanks me for helping them. I almost always say: “you put in the work…I am just a cheerleader”. I don’t want to play the role of the hero. In my opinion, by playing the role of Tonto, I empower the patient to take control of his/her pain limitations. This has lead to many referrals from former patients, which is the greatest compliment that I can receive. As a healthcare professional, you place your life in my hands. I know that it sounds a little over the top, but if you can’t do what you want in life, it is my responsibility to return you back to those activities to the best of my abilities. When a patient refers a friend or family member, that tells me that I did a good job with the patient that they now trust me with their valued relationships. For me, there is more pressure to get the friend better than there was to get the first patient better, if I can’t help, then I let two people down instead of one.


“All aspects of the intervention were underpinned by a strong therapeutic alliance, with an emphasis on an open and motivational communication style.”


Therapeutic alliance has to do with the patient’s relationship with the therapist. This has to be a team relationship where each participant has an equal stake in the relationship. There is no paternal relationship, in which the PT is in charge and the patient has to do what the therapist says.


“…the codes that appeared important in achieving an optimal outcome were grouped into 2 themes: (1) changing pain beliefs and (2) achieving independece…Changing beliefs included the codes therapeutic alliance, body awareness, and pain control. Achieving independence included the codes, problem solving , self-efficacy, fear, stress coping and normality.”


Essentially, if we can teach a patient how to change their beliefs about pain and then take control over how they react to their situation, the patients tend to do better.


“Acceptance of a biopsychosocial model for their pain differentiated the large improvers and small improvers from the unchanged participants…Although the large improvers still acknowledged their biomedical diagnoses, these diagnoses appeared to be part of their pain history and no longer caused them distress.”


By changing a patient’s mindset, we can improve a patient’s perception on their situation. By changing a patient’s perception, we can then improve their ability to function in spite of their pain.


“Although small improvers also described their current pain predominantly in biopsychosoccial terms, they found the idea of an underlying sinister cause more difficult to relinquish”


When a patient believes that there is “something” causing the aptient’s pain, then it becomes much harder to accept that pain is okay. If there is something wrong, then the patient will place him/herself into a position in which they can’t get better until that “something” is fixed.


“Therapeutic alliance appeared to play a role in challenging pre-existing beliefs. The establishement of a trusting relationship with the therapist appeared to be important in facilitating effective communication in which individuals felt comfortable airing their concerns and doubts, with the underlying faith that the therapist had their best interests at heart.”


This is amazing. There is that old saying: “ I don’t care how much you know until you know how much I care”. If you are a patient and when you show up to therapy your therapists says “jump on a bike” and doesn’t acknowledge your situation or makes conversation about how you feel live with your issues, then the therapist is doing a disservice. We need to speak to the patient and ensure that the patient understands that we are here to help. That’s why we got into this profession right…at least it’s the answer that most students give when applying to PT school. If that’s the case, then how does a student go from caring about people and wanting to help to treating 3 patients at a time and simply commanding the circus of multiple patients at once. It’s hard to convince a patient that you really care when you are talking to so many other patient’s at the same time.


“On the contrary, those who were unchanged appeared less likely to describe a strong relationship with the therapist than large improvers”


Is it a wonder why so many patients believe that therapy doesn’t help. There has to be a bond with the patient. The patient has to understand that you are there for the patient’s good…not their money.


“Large improvers and small improvers described how the therapist assisted them to gain a new perspective of the self both physically and mentally…crucial in providing a rationale for their pain and increasing their faith in the new explanatory model”


Changing a patient’s perspective can allow the patient to improve his/her overall well being. Giving the patient the education about how the body moves and what is considered “normal” is important. I don’t know how many times I say “that is normal” to a patient that has been suffering with pain for a long period of time. There is a difference between hurt and harm. Unfortunately, some patients have the belief that all pain is bad. This is not the case and the patient has to be educated that some pain is normal…as long as it doesn’t linger.


The article goes on to say that changing a patient’s pain belief system should be a priority for treatment and striving to ensure that a patient is independent with pain management is important for returning the patient to meaningful activity. There was a lot of information in this article, but the above statement is the general point.


It amazes me as to how little people understand of how their body acts. I realize that I went to school for 7 years in total (undergraduate plus masters and then the doctorate degree), to learn this stuff, but I already had a strong interest in this prior to going into school. I at least wanted to know about what I was experiencing, be that Delayed Onset Muscle Soreness (DOMS) or general pain from powerlifting. I remember reading in the books “Mechanical diagnosis and therapy: lumbar spine” that the top intervention that patient’s want is education. I believe this to be more and more true the longer that I practice. It’s amazing that in the world of Dr. Google, there is so much bad information issued to the general population that when they come to therapy, I have to spend so much time unteaching false material and then try to change their belief system from being inundated with false material. This is not more true than in the treatment of back pain.


On a side note, I don’t typically look at the authors until I am completing the post. Peter O’Sullivan is one of the authors of the study. He is one of the greats that has pioneered motor control paradigms for physical therapy. Also, Wim Dankaerts was at the MDT conference in Austin in 2013. I was able to sit with him at the airport and discuss pain science and lumbar rolls. It is exciting when I get to actually talk to those that are mountaintop researchers. I always have to restrain myself from asking for an autograph.


Excerpts taken from: Bunzli S, McEvoy S, Dankaerts W, et al. Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain. Phys Ther. 2016;96:1397-1407.





Categories Physical therapy

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