A CONCEPTUAL FRAMEWORK AND DEFINITION OF THE THERAPEUTIC RELATIONSHIP IN PHYSIOTHERAPY

Miciak M.^1,2, Mayan M.³, Brown C.⁴, Joyce A.⁵, Gross D.P.⁶

¹University of Alberta, Faculty of Rehabilitation Medicine, Edmonton, Canada, ²Alberta Innovates, Edmonton, Canada, ³University of Alberta, Faculty of Extension, Edmonton, Canada, ⁴University of Alberta, Department of Occupational Therapy, Edmonton, Canada, ⁵University of Alberta, Department of Psychiatry, Edmonton, Canada, ⁶University of Alberta, Department of Physical Therapy, Edmonton, Canada

Background: The therapeutic relationship between patient and physiotherapist is considered a key contextual factor of successful physiotherapy interactions and a cornerstone of patient-centred care. Positively evaluated relationships have been associated with increased patient satisfaction, adherence to treatment, and improved clinical outcomes. Although aware of its potential to impact outcomes, we know very little about the key components that constitute the physiotherapy therapeutic relationship and lack a clear framework and definition. Up to this point, theories and outcome measures from psychotherapy have formed the foundation for research and education. A physiotherapy-specific framework and definition are essential for operationalizing ways of teaching, practicing and researching the therapeutic relationship.

Purpose: We aimed to identify and conceptually describe the key components of the physiotherapy therapeutic relationship in order to develop a conceptual framework and definition.

Methods: Interpretive description was used to generate findings useful to practitioners and researchers. The setting was private practice clinics in Edmonton, Canada given the high proportion of physiotherapists working in this sector. Physiotherapists working in private practice required 5 years of clinical experience to be eligible. Adult patients with musculoskeletal complaints were included if they had a minimum 3 treatments and had not received wage replacement benefits. Eleven physiotherapists and 7 patients were purposefully sampled and recruited via email (physiotherapists) and administrative staff from participating clinics (patients). Data generation and analysis were concurrent and iterative. Semi-structured interviews lasted 30-60 minutes and were audio-recorded. Data generation continued to a point of saturation. Qualitative content analysis involved an iterative process of coding and development of categories and sub-categories. Constant comparison principles were used to refine the analysis. Rigour strategies included journaling (reflexive, memoing, audit trail), peer debrief, member reflections, and external audit.

Results: Three components were identified: conditions of engagement; ways of establishing connections; and elements of the bond. Although distinct, the components influence one another and form a conceptual framework. The conditions of engagement impart attitudes and intentions necessary to establish connections, which involve acknowledging the individual, giving-of-self, and using the body as a pivot point. A positive affective attachment between patient and therapist, or a bond, based on rapport, respect, trust and caring is formed through the process. The framework is strengthened when considered in relation to 3 themes: mutuality, professional and personal characteristics, and the centrality of the body in relationship. From this framework, we propose a definition of the therapeutic relationship specific to physiotherapy.

Conclusion(s): The therapeutic relationship cuts across healthcare disciplines and contexts. However, there are aspects of the therapeutic relationship specific to physiotherapy that must be recognized in research, education, and practice. Furthermore, physiotherapy relationships are dynamic, requiring partners to engage in a responsive therapeutic process that is grounded in professionalism but can include a personal dimension.

Implications: Future efforts need to focus on: · operationalizing this framework in clinical practice and research · using the framework to inform the development of physiotherapy-specific tools for measuring the therapeutic relationship · refining the framework by studying the therapeutic relationship in other populations (neurological conditions) and contexts (e.g. workers’ compensation).

Funding acknowledgements: This research was supported by a Thesis Research Operating Grant from the Department of Physical Therapy, University of Alberta.

Topic: Professional issues

Ethics approval: The study was approved by the Health Research Ethics Board, University of Alberta, Edmonton, Canada.

All authors, affiliations and abstracts have been published as submitted.