Lawford Belinda Joan, Bennell Kim L, Campbell Penny K, Kasza Jessica, Hinman Rana S
Department of Physiotherapy, Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, Australia.
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
JMIR Rehabil Assist Technol. 2021 Jan 18;8(1):e23386. doi: 10.2196/23386.
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. However, no studies have examined whether the therapeutic alliance developed between patients with knee osteoarthritis and physical therapists during telephonic consultations influences clinical outcomes.
This 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.
Secondary 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.
There 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).
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. 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.
Australian New Zealand Clinical Trials Registry ACTRN12616000054415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369204.
患者与物理治疗师之间的治疗联盟已被证明在面对面咨询时会影响慢性下腰痛患者的临床结局。然而，尚无研究探讨膝骨关节炎患者与物理治疗师在电话咨询期间建立的治疗联盟是否会影响临床结局。
本研究旨在调查第二次咨询后测量的膝骨关节炎患者与物理治疗师之间的治疗联盟是否与电话提供运动和建议后的结局相关。
对一项随机对照试验干预组中的87名患者进行二次分析，这些患者被分配在6个月内与8名物理治疗师之一进行5至10次电话咨询，内容包括教育以及制定一项强化和体育活动计划。单独的回归模型研究了治疗联盟的患者和治疗师评分（使用工作联盟量表简版在第二次咨询后测量）与6个月和12个月时的结局（疼痛、功能、自我效能感、生活质量、整体变化、对规定运动的依从性、身体活动）之间的关联，并纳入了相关协变量。
有一些证据表明，在6个月时，联盟的患者评分与一些结局之间存在弱关联（平均膝关节疼痛改善：回归系数-0.10，95%置信区间-0.16至-0.03；自我效能感：0.16，0.04 - 0.28；功能的整体改善：比值比1.26，95%置信区间1.04 - 1.39，以及总体改善：比值比1.26，95%置信区间1.06 - 1.51；但也与运动恐惧加剧有关：回归系数-0.13，95%置信区间-0.23至-0.04）。此外，有一些证据表明，在12个月时，联盟的患者评分与一些结局之间存在弱关联（自我效能感改善：回归系数0.15，95%置信区间0.03 - 0.27；功能的整体改善，比值比1.19，95%置信区间0.03 - 1.37；以及疼痛，比值比1.14，95%置信区间1.01 - 1.30；以及总体改善：比值比1.21，95%置信区间1.02 - 1.42）。数据表明，治疗联盟的治疗师评分与结局之间的关联并不强，除了12个月时生活质量的改善（回归系数0.01，95%置信区间0.0003 - 0.01）。
治疗联盟的患者评分较高（而非治疗师评分较高）与一些临床结局的改善以及一个结局的恶化存在弱关联。尽管研究结果表明，认为与治疗师联盟更强的患者可能会取得更好的临床结局，但观察到的关系通常较弱，不太可能具有临床意义。局限性包括治疗联盟的测量方法尚未在肌肉骨骼物理治疗环境中得到验证。存在I类错误的风险；然而，研究结果是基于临床意义而非仅基于统计学意义进行解释的。
澳大利亚新西兰临床试验注册中心ACTRN12616000054415；https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369204。
