Abstract
BackgroundMost conventional treatment for musculoskeletal conditions continue to show moderate effects, prompting calls for ways to increase effectiveness, including drawing from strategies used across other health conditions. Therapeutic alliance refers to the relational processes at play in treatment which can act in combination or independently of specific interventions. Current evidence guiding the use of therapeutic alliance in health care arises largely from psychotherapy and medicine literature. The objective of this review was to map out the available literature on therapeutic alliance conceptual frameworks, themes, measures and determinants in musculoskeletal rehabilitation across physiotherapy and occupational therapy disciplines.MethodsA scoping review of the literature published in English since inception to July 2015 was conducted using Medline, EMBASE, PsychINFO, PEDro, SportDISCUS, AMED, OTSeeker, AMED and the grey literature. A key search term strategy was employed using “physiotherapy”, “occupational therapy”, “therapeutic alliance”, and “musculoskeletal” to identify relevant studies. All searches were performed between December 2014 and July 2015 with an updated search on January 2017. Two investigators screened article title, abstract and full text review for articles meeting the inclusion criteria and extracted therapeutic alliance data and details of each study.ResultsOne hundred and thirty articles met the inclusion criteria including quantitative (33%), qualitative (39%), mixed methods (7%) and reviews and discussions (23%) and most data came from the USA (23%). Randomized trials and systematic reviews were 4.6 and 2.3% respectively. Low back pain condition (22%) and primary care (30.7%) were the most reported condition and setting respectively. One theory, 9 frameworks, 26 models, 8 themes and 42 subthemes of therapeutic alliance were identified. Twenty-six measures were identified; the Working Alliance Inventory (WAI) was the most utilized measure (13%). Most of the therapeutic alliance themes extracted were from patient perspectives. The relationship between adherence and therapeutic alliance was examined by 26 articles of which 57% showed some correlation between therapeutic alliance and adherence. Age moderated the relationship between therapeutic alliance and adherence with younger individuals and an autonomy support environment reporting improved adherence. Prioritized goals, autonomy support and motivation were facilitators of therapeutic alliance.ConclusionTherapeutic Alliance has been studied in a limited extent in the rehabilitation literature with conflicting frameworks and findings. Potential benefits described for enhancing therapeutic alliance might include better exercise adherence. Several knowledge gaps have been identified with a potential for generating future research priorities for therapeutic alliance in musculoskeletal rehabilitation.
Highlights
Most conventional treatment for musculoskeletal conditions continue to show moderate effects, prompting calls for ways to increase effectiveness, including drawing from strategies used across other health conditions
This study represents a mapping of the breadth of the evidence for TA in PT and occupational therapy (OT) MSK practice and identified eight themes of therapeutic alliance valued by patients across different MSK settings and populations
Studies are required to increase therapist capacity at developing soft skills for enhancing TA in clinical practice. If these issues remain unaddressed, patients may continue to struggle to meet their rehabilitation potentials [63]. This scoping review maps out the available literature on TA conceptualization, measures and insights into professionals’ and patients’ experiences and perceptions of TA in MSK rehabilitation
Summary
Most conventional treatment for musculoskeletal conditions continue to show moderate effects, prompting calls for ways to increase effectiveness, including drawing from strategies used across other health conditions. The objective of this review was to map out the available literature on therapeutic alliance conceptual frameworks, themes, measures and determinants in musculoskeletal rehabilitation across physiotherapy and occupational therapy disciplines Conventional treatments such as exercise commonly used in the management of musculoskeletal (MSK) conditions continue to show only moderate effects [1,2,3]. Research aimed at improving the effectiveness of treatment for MSK conditions should extend beyond condition specific interventions to include more general mediators of treatment such as communication or psychological interactions between patients and clinicians One aspect of this is therapeutic alliance (TA) which has been described as the working relationship or positive social connection between the patient and the therapist [4] and established between therapist and client through collaboration, communication, therapist empathy, and mutual respect [5]. According to Bordin [4], TA can be applied to all change situations independent of the treatment modality and proposed a tripartite model of TA [8] consisting of three essential elements: agreement on the goals of the treatment, agreement on the tasks, and the development of a personal bond (reciprocal positive feelings) between the client and therapist
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