Association Between Therapeutic Alliance and Outcomes Following Telephone-Delivered Exercise by a Physical Therapist for People With Knee Osteoarthritis: Secondary Analyses From a Randomized Controlled Trial.

Belinda Joan Lawford,Penny K Campbell,Rana S Hinman,Jessica Kasza,Kim L Bennell

doi:10.2196/23386

Abstract

BackgroundThe therapeutic alliance between patients and physical therapists has been shown to influence clinical outcomes in patients with chronic low back pain when consulting in-person. However, no studies have examined whether the therapeutic alliance developed between patients with knee osteoarthritis and physical therapists during telephonic consultations influences clinical outcomes.ObjectiveThis study aims to investigate whether the therapeutic alliance between patients with knee osteoarthritis and physical therapists measured after the second consultation is associated with outcomes following telephone-delivered exercise and advice.MethodsSecondary analysis of 87 patients in the intervention arm of a randomized controlled trial allocated to receive 5 to 10 telephone consultations with one of 8 physical therapists over a period of 6 months, involving education and prescription of a strengthening and physical activity program. Separate regression models investigated the association between patient and therapist ratings of therapeutic alliance (measured after the second consultation using the Working Alliance Inventory Short Form) and outcomes (pain, function, self-efficacy, quality of life, global change, adherence to prescribed exercise, physical activity) at 6 and 12 months, with relevant covariates included.ResultsThere was some evidence of a weak association between patient ratings of the alliance and some outcomes at 6 months (improvements in average knee pain: regression coefficient −0.10, 95% CI −0.16 to −0.03; self-efficacy: 0.16, 0.04-0.28; global improvement in function: odds ratio 1.26, 95% CI 1.04-1.39, and overall improvement: odds ratio 1.26, 95% CI 1.06-1.51; but also with worsening in fear of movement: regression coefficient −0.13, 95% CI −0.23 to −0.04). In addition, there was some evidence of a weak association between patient ratings of the alliance and some outcomes at 12 months (improvements in self-efficacy: regression coefficient 0.15, 95% CI 0.03-0.27; global improvement in both function, odds ratio 1.19, 95% CI 0.03-1.37; and pain, odds ratio 1.14, 95% CI 1.01-1.30; and overall improvement: odds ratio 1.21, 95% CI 1.02-1.42). The data suggest that associations between therapist ratings of therapeutic alliance and outcomes were not strong, except for improved quality of life at 12 months (regression coefficient 0.01, 95% CI 0.0003-0.01).ConclusionsHigher patient ratings, but not higher therapist ratings, of the therapeutic alliance were weakly associated with improvements in some clinical outcomes and with worsening in one outcome. Although the findings suggest that patients who perceive a stronger alliance with their therapist may achieve better clinical outcomes, the observed relationships were generally weak and unlikely to be clinically significant. The limitations include the fact that measures of therapeutic alliance have not been validated for use in musculoskeletal physical therapy settings. There was a risk of type 1 error; however, findings were interpreted on the basis of clinical significance rather than statistical significance alone.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12616000054415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369204

Highlights

BackgroundKnee osteoarthritis (OA) is highly prevalent and leading cause of functional limitation in older adults [1,2]
Higher patient ratings, but not higher therapist ratings, of the therapeutic alliance were weakly associated with improvements in some clinical outcomes and with worsening in one outcome
Metropolitan Nonmetropolitan Employment status, n (%) Working full- or part-time Unemployed or retired Education, n (%) Less than 3 years of high school 3 years or more of high school Some tertiary training Graduated from university or polytechnic Any postgraduate study Number of calls with physical therapist, mean (SD) Therapeutic alliance (WAIb) at week 4, mean (SD) Knee pain (NRSc) at baseline, mean (SD) Physical function (WOMACd) at baseline, mean (SD) Self-efficacy (ASESe) at baseline, mean (SD) Quality of life (AQoLf) at baseline, mean (SD) Fear of movement (BFMSg) at baseline, mean (SD) Treatment expectations, n (%) No effect Minimal improvement Moderate improvement Large improvement Complete recovery

Summary

Introduction

BackgroundKnee osteoarthritis (OA) is highly prevalent and leading cause of functional limitation in older adults [1,2]. Physical therapists are one of the most common providers of exercise management for people with OA [7] and traditionally, consultations occur in-person at a physical therapy clinic. There is a growing body of literature to support the safety and effectiveness of tele-rehabilitation, where physical therapists and patients consult remotely using telecommunication technologies, such as video conferencing or telephone [8,9,10]. The therapeutic alliance between patients and physical therapists has been shown to influence clinical outcomes in patients with chronic low back pain when consulting in-person. No studies have examined whether the therapeutic alliance developed between patients with knee osteoarthritis and physical therapists during telephonic consultations influences clinical outcomes

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