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Table 6 Relationship between therapeutic alliance and adherence to treatment

From: Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature

Studies Aim Population Design Therapeutic Alliance Measure Adherence Measure Results
Bliss, 2010 (8 s) To examine psychosocial variables like attachment style, depression and the working alliance as predictors of treatment outcomes Chronic knee pain (n = 59) Correlational study Working Alliance Inventory 5-item self-report measure of treatment compliance (α = 0.83) The transformed WAI scores were significantly positively correlated to pain interference and severity, patient compliance and satisfaction. The transformed WAI accounted for 24% of the variance in patient compliance
Campbell et al., 2001 (48 s) To understand reasons for compliance and non-compliance with a home-based exercise regimen Knee osteoarthritis (n = 20) Grounded theory with thematic analysis Interviews Interviews Compliance were apparent initially when attending PT sessions and later when a number of factors combined to determine continued and long term compliance (or non-compliance). Continued compliance depends on a person’s perception of their symptoms, the effectiveness of the intervention, their ability to incorporate it into everyday life and support from physiotherapists.
A model of continued compliance was developed.
Chan and Can 2010 (11 s) To evaluate patients’ adherence to home exercise programs in clinical practice and understand factors that affect patients’ adherence to home exercises. Orthopaedic, sports injury, hand therapy, rheumatology (n = 82) Cross-sectional survey study 25 item questionnaire 5-item exercise performance questionnaire. Motivation, role of exercise, patients’ understanding of exercises, verbal and visual explanation and satisfaction with PT were found to have a strong effect on patient’s performance of home exercises.
Chan et al., 2009 (11 s) To investigate the impact of PT’s autonomy-supportive behaviors on patients’ motivation and rehabilitation adherence Anterior cruciate ligament injury (n = 115) Correlational study Healthcare Climate Questionnaire 15-item Sport Injury Rehabilitation Adherence Scale (SIRAS) Autonomous treatment motivation was associated positively with autonomy support but the relationship between autonomy support and controlled treatment motivation was not significant. Autonomous treatment motivation fully mediated the effect of physiotherapists’ autonomy-supportive behaviours on patients’ adherence.
Patient self-report home-based exercise adherence
Crook et al., 1998 (15 s) To report the problem experienced with patient engagement in PT-led groups undertaking either an aerobic exercise or a stretching and relaxation program. MSK disorders (n = 228) Mixed methods study (quasi randomized controlled trial, interviews, checklist) Individual interviews Home exercise diary for exercise activity PTs and patients acknowledge that listening was an importance part of the therapeutic relationship that improved adherence.
LBP [52], Neck pain [30];
Lower limb pain [25], Shoulder pain [12]
Escolar-Reina et al., 2010 (56 s) To explore perceptions of people pain about the characteristics of home exercise programs and care-provider style during clinical encounters may affect adherence to exercises. Chronic neck or low back pain (n = 34) Grounded theory approach Interviews NA Patient adherence to home-based exercise is more likely to happen when care providers’ style (clinical knowledge, feedback, giving reminders, monitoring adherence and promoting exercise feedback and the content of exercise programme) are positively experienced.
Freene et al., 2014 (96 s) To compare a PT-led home-based PA program to usual practice of community group exercise program to determine effectiveness in middle-aged adults for increasing physical activity levels over the short and long term. Sedentary community dwelling adults (n = 37) Mixed methods study (quasi randomized trial, focus groups) Interviews Self-report on Active Australia Survey Most participants agreed the physiotherapist was an enabling factor for the home-based intervention, although others did not think this was important. Participants reported a good interaction with the PT and felt they were expert and knowledgeable.
Reliable and valid national measure.
Advice and support and individually tailored program from the PT and a good relationship with the instructor was important for continued participation in physical activity at home.
Gleeson et al., 1991 (21 s) To develop policies and procedures about management of patient non-attendance in OT. Hand injuries, burns, rheumatology (n = 100) Cross-sectional survey study Survey instrument Patient and therapist comment on non-adherence 28% of patients believed that poor communication with the therapist was the reason for non-adherence.
PTs felt that non- attendance affected continuity of care due to difficulty in evaluating the overall effectiveness of treatment, unmet goals, inability to establish ongoing plans, and concern regarding discharge. PTs saw non-compliance as the result of a need to develop personal skills (empathy, warmth, concern), demonstrating a feeling of responsibility for non-attendance.
Harman et al., 2012 (63 s) To describe the approach used by a PT during a rehab programme for injured members of the military designed to enhance self-efficacy and self-management skills. Chronic low back pain (n = 12) Qualitative study with interpretive paradigm Interviews NA Trusting the physiotherapist helped patients continue with their programme despite it getting harder, challenging their confidence, and not showing immediate results.
Hinman et al., 2015 (65 s) To explore how patients, PTs and telephone coaches experienced, and made sense of an integrated program of PT-supervised exercise and telephone coaching. Knee osteoarthritis (n = 6) Grounded theory with symbolic interactionism Interviews Interviews Patients felt accountable and responsible for meeting goals when perceived attention from PT was individualized and genuine.
PTs appreciated providing clear information and monitoring progress, incorporation of exercise into daily routine. PTs recognized that collaboration, mutual understanding and emphasising the same treatment with the client as the central character were important.
Hurley et al., 2010 (66 s) To explore the health beliefs, experiences, treatment expectations of people with chronic knee pain, and investigate if, how and why these change after taking part on an integrated exercise-based rehabilitation programme Chronic knee pain (n = 29 Grounded Theory with thematic analysis Interview Attendance The care, support and guidance participants received during the informal discussions helped build a trusting, collaborative partnership between patient and PT. This increased participant’ confidence and trust in the PT and belief in the rehabilitation programme. The interpersonal qualities and professional skills of the supervising PT were considered as important to the success of the programme as the content of the programme itself.
Jackson et al., 2012 (25 s) To (i). explore potential relationship s between clients’ “tripartite” efficacy constructs, relationship quality with the therapist, and engagement in exercise and, (ii) model actor and partner effects or clients’ and therapists’ efficacy beliefs in relation to relationship quality Osteoarthritis, osteoporosis, bursitis (n = 68) Descriptive and Correlational study. 5-items from the 7-item Relation-ship adherence scale 3-item Engagement instrument Increase in perception of relationship quality were directly related to improvements in engagement scores, accounting for 18% of the variance in engagement ratings.
Jensen et al., 1994 (26 s) To integrate concepts from research, theory, and practice are integrated into a Process Model for Patient-Practitioner Collaboration for use in clinical practice Rheumatoid arthritis. Correlational survey study Interview NA Pleasing the therapist was a reason for adherence to exercises prescribed.
Osteoarthritis, low back pain (n = 305)
PTs (n = 568).
Karnad and McLean, 2011 (67 s) To explore PT’s perception of exercise adherence and interventions used in clinical practice. Chronic MSK conditions Interpretative Phenomenology Interviews Interviews Most PTs believe that clear communication, faith in the PT, realistic treatment plans, shared goals and pain education are important for adhering to exercise.
PTS (n = 5)
Kingston et al., 2014 (97 s) To determine whether compliance and understanding of a home exercise program is improved when patients are provided with a DVD. Traumatic hand injury (n = 53) Randomized controlled trial Follow up survey Compliance measures; diary recording of exercise, checklist for correctness and understanding of exercises, weekly attendance No significant differences were found in the overall mean exercise compliance score between the groups.
All participants reported that the instructions provided were easy to use (100%). All respondents (100%) felt that their appointment with their hand therapist was moderately to extremely important and 90.6% felt their appointment was moderate to extremely important in motivating them to do theirexercises.
Levy et al., 2008 (30 s) To investigate the relationship between perceived autonomy support, age, and rehabilitation adherence among sports-related injuries Tendon related injuries ankle, knee, shoulder, elbow) (n = 70) Prospective correlational study Healthcare Climate Questionnaire 15-item Sport Injury Rehabilitation Adherence Scale (SIRAS) High autonomy support provided by the physical therapist was related to better clinic-based adherence and attendance but not to home-based adherence. Age was related to all adherence indices and moderated the relationship between perceived autonomy support and clinic-based rehabilitation adherence.
Clinic attendance
Home exercise adherence
Liddle et al., 2007 (71 s) To explore the experiences, opinions and treatment expectations of chronic low back pain patients to identify what components of treatment they consider as being of most value. Chronic low back pain (n = 18) Narrative study using focus group Interviews NA Lack of faith in practitioner resulted in participants ignoring advice and failing to adhere to home exercises programs and continuing bad postural habits. Follow-up support and reassurance about correct exercise instructions and assistance with appropriate treatment progression improved exercise adherence.
Littlewood et al., 2014 (72 s) To increase knowledge and understanding of the experience of exercising and determine perception of facilitators and barriers to exercise. Rotator cuff tendinopathy (n = 6) Phenomenology with framework analysis Interviews NA PTs and patients agreed that ongoing support in the form of providing feedback, proactive follow-up and stimulating further engagement with the self-managed exercise programs when progress was slow were influential on successful outcomes
Lysack et al., 2005 (31 s) To compare computer-assisted video instruction and routine rehabilitation practice on compliance and satisfaction with home exercise. Total joint arthroplasty (n = 40) Randomized controlled trial 3-item tool on encouragement, courtesy, and, active involvement Self-report on exercise performance accuracy, difficulty in remembering exercises, exercise frequency, level of exercise when feeling poorly, and duration of each exercise session Statistical analysis showed there were no significant differences at follow-up between the video and control groups on any of the exercise compliance items or on any of the patient satisfaction items (p > 0.05 in all cases). Results of this randomized trial suggest that computerized patient education technology may not provide the benefits anticipated.
Hip [21]
Knee [19]
Rating of quality of exercise performance
Petursdottir et al., 2010 (81 s) To increase knowledge and understanding of the experience of exercising among individuals with osteoarthritis and to determine what they perceive as facilitators and barriers to exercising. Osteoarthritis (n = 12) Phenomenology Facilitator and barrier checklist NA Many participants placed emphasis on the fact that the encouragement and understanding they received from their PT were very important.
Hip/knee (n = 10)
Vertebral column (n = 9)
Clear communication and a sense of a positive connection were equally as important as the physical results of the therapy and adherence to exercise in physical therapy. Supervision by the PT facilitated exercise maintenance.
Hands [6]
Other joints [3]
Slade et al., 2009 (86 s) To understand the factors that participants in exercise programs perceive to be important to engage and participate Chronic low back pain (n = 18) Grounded theory with focus groups Audio-taped interviews Audio-taped interviews Helpful and empowering care-provider skills are those of the effective educator, motivator and communicator. Care-seekers are empowered by recognition of their own physical capability, motivators, time-management skills, and assertiveness to adhere to exercise
Sluijs et al., 1993 (38 s) To investigate whether patent compliance was related to characteristics of the patient’s illness, attitude or physical therapist’s behaviour. Trauma and postoperative conditions, Radiating back pain, Non-radiating back pain, Neck and shoulder pain (n = 1837) Correlation study 5-item questionnaire 1-item questionnaire The 5 forms of PT behavior showed no direct, statistically significant relationship with compliance.
Compliance was significantly related to the positive feedback (therapist satisfaction with and appreciation of exercise performance).
PT (n = 300)
Observers (n = 3)
Stenmar et al., 1994 (101 s) To find out the kinds of attributions PTs make regarding why PT works and the extent to which attributions are related to background variables. PTs (n = 140) Cross-sectional survey study 22 Likert-type items and various demographic variables. NA Majority of the respondents believed that the patient’s own resources and the patient-PT relationship rather than the treatment techniques are the most important factors in explaining why PT works. Other background factors had no relationship to the beliefs and attitudes expressed.
Veenhof et al., 2006 (91 s) To understand why patients who have received a behavioural graded activity program successfully integrate activities into their daily lives. Osteoarthritis (n = 12) Grounded theory approach Interview Self-report on integrating activities into daily life after discharge Initial motivation, active involvement in the whole process and that the PT coaching role during intervention facilitated adherence to exercises and activities:
Vong et al., 2011 (42 s) To examine whether the addition of motivational enhancement therapy (MET) to conventional PT produces better outcomes than PT alone Chronic low back pain (n = 76) Randomized, controlled trial Pain Rehabilitation Expectation Scale (PRES) Exercise log (frequency) The MET-plus-PT group produced significantly greater improvements than the PT group in proxy efficacy, working alliance, and treatment expectancy with significantly better performance in lifting capacity, general health and exercise compliance.
Wright et al., 2013 (43 s) To identify which factors best explain non-adherence to home rehabilitation for patients with musculoskeletal injuries. Musculoskeletal injuries (n = 87) Cross-sectional study Medical Interview Satisfaction Scale (MISS) Sports Injury Rehabilitation Scale (SIRAS) Patients are most likely to adhere to HRE when they perceive a positive relationship with their PT. Self-reported adherence is higher when patient perception of behavioural, cognitive and affective elements of the relationship are positive.