The initial interview provides most of the information needed to help guide clinical practice. However, sometimes it can be a challenge to extract the necessary information that is meaningful and pertinent to respective clinical presentations. We need to analyze these strategies, as they can be useful to help direct clinical reasoning throughout the episode of care. These approaches should remember to be person-focused, as healthcare is truly individualized. Therefore, we should further explore which strategies would be the most beneficial to generate positive outcomes.
Establishing a Strong Therapeutic Alliance
Building a therapeutic alliance is more than just establishing a sound rapport, but analyzing other elements that can contribute to the patient/practitioner relationship. Therapeutic alliance involves facilitation and the active participation of the patient in a collaborative effort through support and reciprocating involvement.1 The role of the clinician is to be able to facilitate and understand how to promote a positive patient experience. Higher levels of therapeutic alliance correlate with improvements in perceived effect of treatment, function, and reductions in pain and disability.1 Effective communication can enhance therapeutic alliance emphasizing a patient-centered focus as well as listening with focus on emotions.1 Exploring core skills for interpersonal communication can be beneficial for clinicians to recognize potential barriers to establishing a therapeutic alliance.
Utilizing Effective Communication
Communication between the patient and practitioner is essential to extrapolate vital data to guide clinical practice. There are certain characteristics that allow clinicians to be effective communicators: be an active listener, understand verbal/non-verbal communication, be succinct, be empathetic, and the ability to build trust. It becomes important to know how to engage with patients to gather information that will ultimately be meaningful to guide clinical reasoning. The initial interview will be an important element of the examination, in which the practitioner can start to generate working hypotheses. Efficient history taking, and a thorough physical examination can lead to a positive therapeutic effect, short-term decrease in pain, decreased catastrophizing symptoms, improved functional mobility, and decreased sensitivity to pressure.3 History taking may yield the most significant changes when compared to the physical examination alone.2 A holistic framework may potentially enhance overall clinical decision making.
Being Mindful of Our Language and Words
We Use The choice of words can positively or negatively affect desired clinical outcomes.3 Specific words we convey to a patient can have a huge impact and can influence the rehabilitation process. A heavy emphasis on the biomedical model including such terminology as, “degeneration,” “wear and tear,” and “slipped disc” may create a certain perception and bias. The patient can perceive this information and thus, change their belief system, values, and expectations to receiving care. Therefore, we should be mindful when framing our words to help the patients understand what they are experiencing. It becomes paramount that we use our words carefully as the patient’s perception should be taken into consideration.3
Emphasizing Motivational Interviewing
Motivational interviewing is a collaborative conversation between the patient and the practitioner for strengthening an individual’s own motivation and commitment.4 Motivational interviewing can be beneficial to help strengthen the bond between the patient and the practitioner: (1) open-ended questioning, (2) affirmations, (3) reflective listening, and (4) summarizing.4 The use of open-ended questioning allows the opportunity for patients to elaborate more on what they are experiencing.4 The use of too many closed-ended questions limits the answers that can be provided, and should be reserved for confirming information. Affirmations involve positive statements made to the patient demonstrating interest and understanding what the patient is experiencing.4 Reflective listening can allow the patient to share their own personal experiences and can also further test initial working hypotheses.4 Further insights can help confirm the patient’s belief system and understanding of their own perception. Summarizing allows the clinician to synthesize the data and learn how to use a more insightful approach to generate initial working hypotheses that will be tested throughout the episode of care.
Implementation of Pain Neuroscience Education
Understanding pain can be a valuable instrument to facilitate the overall patient experience throughout the continuum of care. Clinicians need to find an approach that allows for understanding and refine already perceived notions regarding an individual’s circumstances. Implementation of pain neuroscience education should immediately start from the initial interview and be used during the episode of care. The initial assessment can provide the foundation for a positive therapeutic alliance among the clinician and the patient.5 It becomes essential to understand contributing factors that may influence the patient’s perception of their pain. Contextual factors and allostatic responses can affect a patient’s recovery during the rehabilitation process thus recognizing fear avoidance, pain catastrophizing, functional mobility, and pain.6 Identifying biopsychosocial factors is a key factor for determining patient outcomes.5 Recognizing the patient’s belief system, values, and expectations may be prognostic factors for our patient’s presenting with musculoskeletal pain.7
Final Thoughts
Understanding these concepts will help clinicians synthesize the information more efficiently, but also make them dynamic and aware of other contributing factors, which play a role in providing patient care. The use of reflection strategies can help clinicians use their own previous experiences and allow them to develop clinical pattern recognition.8 Recognizing maladaptive beliefs, pain catastrophizing, and perception may be helpful in order to facilitate self-efficacy.9 Strategies for positive outcomes should target biomechanical, psychological, and individual characteristics to address motivation in addition to adherence to a self-management program.9 This may yield positive results and an overall sense of affinity to their health care team. Recognizing different strategies can help clinicians understand what approach is necessary based on specific individual clinical presentations. This will allow clinicians to be dynamic and adaptable in varying circumstances.
Key Words: active listening, therapeutic alliance, effective communication
References
- Pinto RZ, Ferreira ML, Oliveria VC, et al. Patient-centered communication is associated with positive therapeutic alliance: a systematic review. J Physiother. 2012;58(2):77-87. doi:10.1016/S1836-9553(12)70087-5
- Louw A, Goldrick S, Bernstetter A, et al. Evaluation is treatment for low back pain. J Man Manip Ther. 2021;29(1):4-13. doi:10.1080/10669817.2020.1730056
- Stewart M, Loftus S. Sticks and stones: the impact of language in musculoskeletal rehabilitation. J Orthop Sports Phys Ther. 2018;48(7):519-522. doi:10.2519/jospt.2018.0610
- Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. Guilford Press; 2013.
- Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care. 2017;15(4):413-421. doi:10.1002/msc.1191
- Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip Ther. 2013;21(2):90–102. doi:10.1179/2042618612Y.0000000027
- Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther. 2010;90(9):1345-1355.
- Gilliland S, Wainwright SF. Patterns of clinical reasoning in physical therapy students. Phys Ther. 2017;97(5):499-511. doi:10.1093/ptj/pzx028
- Hutting N, Johnston V, Staal JB, Heerkens YF. Promoting the use of self-management strategies for people with persistent musculoskeletal disorders: the role of physical therapists. J Orthop Sports Phys Ther. 2019;49(4):212-215. doi:10.2519/jospt.2019.0605
The author declares no competing interests.
Author Bio:
Eric Trauber, PT, DPT, OCS, CSCS, FAAMOPT received his Doctor of Physical Therapy from Utica University. Eric is a Board-Certified Orthopaedic Clinical Specialist through the American Board of Physical Therapy Specialties. He is a Fellow of the American Academy of Orthopaedic Manual Physical Therapists. He is currently an Advanced Clinician at Burke Rehabilitation Hospital.