An exploration of clinical variables that enhance therapeutic alliance in patients seeking care for musculoskeletal pain: A mixed methods approach

Musculoskeletal Care. 2022 Sep;20(3):577-592. doi: 10.1002/msc.1615. Epub 2022 Jan 4.


Introduction/objectives: Therapeutic alliance (TA) is an integral part of building a patient and clinician relationship. TA begins at the initial encounter; however, the specific TA behavioural practices that are most impactful and linked to pain reduction and improved function remain unclear. The primary objective of this study was to explore physical therapist behaviours and interactions during the initial physical therapy evaluation and how they related to the patient's perception of TA. A secondary objective was to explore the relationship between TA, pain intensity, and function.

Methods: A mixed methods study was conducted. Pain intensity, TA and self-reported function were assessed at three time points. Spearman's Rho (ρ) was used to quantify if there was an association between increased TA and function and reduced pain intensity, while a checklist of TA themes and behavioural practices was used for the qualitative analysis.

Results: There was a statistically significant negative correlation between patient-perceived TA and pain intensity immediately after the initial evaluation (ρ = -0.39 [p = 0.048]). Behavioural practices associated with higher TA included information gathering, pausing to listen, using humour and transitions, and use of clarifying questions. Behavioural practices associated with patient-perceived lower TA interactions were lack of touch, the absence of pain neuroscience education, and not restating what the patient said during the interview.

Conclusion: This study highlights a relationship between TA and reduction of pain intensity after the initial evaluation and identifies key behavioural practices that could positively and negatively impact TA during the clinical encounter.

Keywords: pain; physical therapy; therapeutic alliance; working alliance.

MeSH terms

  • Humans
  • Musculoskeletal Pain* / therapy
  • Pain Measurement
  • Professional-Patient Relations
  • Self Report
  • Therapeutic Alliance*