Reciprocity in Low Back Pain Care and Its Role in Power Dynamics: A Give-and-Take Approach

Abstract

Objective

The shift toward patient-centered care in physical therapy fostered a deeper consideration of power-sharing in clinical interactions. Elements of reciprocity may enhance such power considerations between physical therapist and patients, but there has been little investigation into how reciprocity is enacted in physical therapy, its value, and how to improve it if required. This study investigates forms of reciprocity during physical therapist–patient interactions in low back pain (LBP) care with the aim of enhancing patient-centered approaches.

Methods

The qualitative design involved (1) ethnographic observations at a fee-for-service practice in Australia, and (2) reflexive discussions between researchers and participating clinicians. To understand reciprocity, the analysis drew from the concepts of “accepting’”(or “blocking”) “offers” that have been previously applied to physical therapy interactions. The analysis is a sub-study using a larger dataset and analyses in which we partnered with physical therapists and people living with LBP.

Results

Forty-nine observations and 13 reflexive discussions were undertaken with 42 people with LBP and 10 physical therapists. Analysis developed 3 themes suggesting that forms of reciprocity depended on physical therapists accepting or blocking patients’ offers, inviting patients to make an offer, and offering personal stories. These elements of reciprocity are relevant to power-sharing during interactions and may impact patient-centered care.

Conclusion

Our results suggest that attending to forms of reciprocity can help physical therapists shift power in clinical interactions. By inviting and accepting “offers,” physical therapists may build collaborative interactions, support individuals to guide the treatment narrative, and shift away from biomedically centered management approaches. Such recommendations create reciprocal environments that might enhance patient-centered care.

Impact

This is one of the few studies to explore how reciprocity is enacted in interactions between physical therapists and s with LBP. Our findings highlight how engaging with the concept of reciprocity could assist with sharing power, improving physical therapist–patient relationships, and enhancing patient-centered care.

Introduction

Low back pain (LBP) is the leading cause of global disability.^1,2 An estimated 16% of the Australian population lives with this condition, and approximately 70% to 90% of people experience LBP in their lifetime.³ As LBP negatively impacts quality of life,^4,5 it is essential to ensure that management is effective. Current clinical guidelines generally include self-management followed by non-pharmacological interventions (eg, physical therapy) as the first line of treatment.⁶ Efficacy of physical therapy management depends on the multifaceted nature of physical therapist–patient interactions,⁷ where care should be patient centered.⁸ Key elements of patient-centered care include active collaboration and shared decision-making between physical therapists and patients.^9,10 Such elements require power-sharing as integral to physical therapy encounters.¹¹ With growing attention to patient-centered care approaches in clinical practices, exploration of power-sharing between physical therapists and individuals becomes paramount.

Within the past 2 decades, the physical therapist profession has increasingly conceptualized and attempted to rework interactions with patients. The shift to patient-centered care increased attention to social elements of the biopsychosocial model¹² and greater attention to emotional¹³ and power^11,13 factors. This shift can be considered a resistance to biomedical norms, where physical therapists attend to biomedical and psychosocial needs of individuals, moving from a physical therapist–dominant power to a shared power approach.^11–14 Further, Pluut¹⁵ suggests that there are both clinician-led and patient-led approaches to patient-centered care, yet it is also possible for health professionals to respond to individuals’ needs, values, and context in power-sharing interaction. This research shows that physical therapy can rework its interactions to better consider power-sharing.

Interaction between individuals and clinicians is further explored by research examining “therapeutic alliance.” When considering physical therapist–patient interactions, therapeutic alliance refers to collaborative and emotional bonds between therapists and individuals,¹⁶ whereby mutual agreements on management are developed, creating affective relationships.¹⁷ These aspects are known to enhance LBP health care equity and treatment outcomes such as pain, disability, and treatment satisfaction.^7,18 Crom et al¹⁹ analyzed therapeutic alliance in a physical therapy context, suggesting individuals want to be included in discussions despite expecting clinicians to establish treatment programs. This collaborative decision-making provides further insights into interactions involving shared power. This work, taken together, suggests the importance of reciprocal interactions (shared/mutual) to forming positive therapeutic alliances.

Reciprocity in health care can be defined as the act of sharing feelings, recognizing and relating to one another as human beings, and maintaining an alliance despite known asymmetry in care-giver/care-receiver relationships.²⁰ Reciprocity can assist with effective decision-making,²¹ mutual connection between therapist and patient,²² and enhancing quality of care and therapists’ job satisfaction.²³ Conversely, power disparity and lack of reciprocity negatively affects development of therapeutic alliances²⁴ and likely reduces management success. For example, although individuals may contribute collaboratively to conversations, collaboration is restricted if interactions are mainly physical therapist led and biomedically focused.²⁵ Although elements of reciprocity can be found within existing approaches such as patient-centered care and therapeutic alliance, reciprocity has not been explicitly explored in physical therapy.¹⁴ Although Sandhu et al²⁰ touch on reciprocity in therapeutic relationships in another health professional context, they focus more on what is understood as reciprocity than how it is demonstrated in clinical interactions. Gaining insight into how reciprocity is exhibited in practice may assist physical therapists to attend to power dynamics and enhance individuals’ lives. Consequently, this study aims to investigate how reciprocity is displayed in physical therapist–patient interactions with people with LBP, providing possibilities for considering its value and how to improve it if required.

Methods

This study was reviewed and granted approval by the Human Research Ethics Committee of The University of Queensland (#2019002446).

Theoretical Framework

This paper was a sub-study of a 17-month project. We used an ethnographic methodology where researchers observed physical therapist–patient interactions within a private musculoskeletal physical therapy clinic, held collaborative dialogues with participant physical therapists, and consulted a panel of patient-experts.

This qualitative study was underpinned by a relativist epistemological approach—understanding that truth and reality vary between observers.^26,27 Specifically, we build on Johnstone’s theories about improvisation in theater²⁸ and Doran and Setchell’s application of these concepts to physical therapy.²⁹ In theatrical scenes, Johnstone²⁸ discusses the ability to shift status (someone of higher status has more power, whereas someone of lower status has less) by raising or lowering the status of oneself or another person. Johnstone²⁸ theorizes that character status can be shifted through numerous ways, such as by “accepting” or “blocking” “offers.” Doran and Setchell²⁹ suggest these components of theatrical performance are helpful to understand physical therapist–patient interactions and that these components influence power dynamics. Anything an actor (or physical therapist or patient) does or says can be considered an “offer” that could lead to further action. For example, if an individual starts to talk about their knee, but the physical therapist quickly moves the conversation back to the neck pain they had presented with previously, this could be considered “blocking” an “offer.” Johnstone argues that bad improvisers block action by acting in a way that eliminates another person’s offer (actions/ideas), whereas good improvisers develop action by “accepting” another person’s offer. Applying this theory to physical therapy, we consider how physical therapists can “accept” or “block” offers from individuals in clinical interactions.

To further conceptualize the influence “accepting” and “blocking” of “offers” has on status, we consider Doran and Setchell’s²⁹ work to explore the connection between reciprocity and power. Doran and Setchell²⁹ suggest the occurrence of power disparity in an interaction depends on the terms of giving and taking between people of high and low status. A dominating status may be created if power is not shared. Doran and Setchell²⁹ argue that “more successful clinical interactions likely rely on the consistent give-and-take of high and low status where both (or all) parties alternate positions.” In contrast, if physical therapists are continuously in a high-status position, patients are discouraged from bringing their own needs to clinical interactions. We use the combination of Johnstone’s improvisation theory and Doran and Setchell’s application in physical therapy to guide our analysis.

Participant Recruitment

We recruited physical therapists and patients with LBP from an urban private musculoskeletal physical therapy clinic in Australia. Our sampling strategy was purposive and aligned with our aim and the principles of ethnographic research.³⁰ As such, we included the broadest range of eligible participants from the investigated context (in this case, a physical therapy clinic) and the phenomenon studied (interaction between therapists and people with LBP). All clinic staff employed at the time of the study were invited to participate, and during data collection we ensured that a range of these participants was observed. Two physical therapists declined participation due to time constraints. The inclusion criteria for patient participants were (1) being 18 years or older, (2) having a diagnosis of LBP, and (3) having a scheduled session with the physical therapist participants during this study. All participants provided written informed consent. Researchers received physical therapist participants’ consent in an introductory meeting. Participant patients were first approached by clinic staff and later introduced to researchers who received their consent.

Data Collection

Data collection occurred between April 2019 and October 2020 using 2 methods as described in the following sections.

Ethnographic Observations

Trained qualitative researchers (2 physical therapists, 2 non-clinician research assistants, all female) observed 30- to 60-minute patient–physical therapist interactions throughout the consultation. Observers took field notes describing the environment, participants’ verbal and non-verbal interactions, as well as personal interpretation and reflections.³¹ During COVID-19 disruptions, video recordings were used instead of in-person observations (n = 10).

Clinician Dialogues

Physical therapists participated in 1-hour monthly group dialogues throughout the study. Due to time constraints, clinicians’ attendance at the dialogues varied. For example, we conducted 3 additional dialogues with individual clinicians interested in contributing to the discussion but who were unable to attend the scheduled group sessions. Between 3 and 6 therapists attended the group dialogues each time. Dialogues involved sharing findings from observation analyses, discussing researcher-guided key topics, and reflecting on clinical practice. According to Cunliffe,³² critical reflexivity in practice is defined as examining assumptions underlying actions and their impact on good practice. Critical reflexivity was used during these dialogues to support clinicians to re-evaluate their experiences and attempt to understand gaps in practice through joint reflection.^33–35 Dialogues were audio-recorded and transcribed verbatim.

Data Analysis

We employed a reflexive thematic analysis guided by our theoretical framework to identify patterns in the data with the research aim in mind.³⁶ Following Braun and Clarke’s 6 steps to thematic analysis,³⁶ first, M.T. (at the time, a final-year physical therapist student trained in qualitative analysis) read through the data, making notes of key concepts (Step 1: familiarization). During this analysis, M.T. identified the potential relevance of the concept of reciprocity and generated initial codes and provisional themes (Step 2: generating codes, and Step 3: constructing themes). M.T. manually coded the entire dataset using Microsoft Excel (Redmond, WA, USA). Initial themes were discussed with J.S. and K.M. (both experienced qualitative researchers and physical therapists), which prompted a second data reread and discussion (Step 4: reviewing themes). The 3 authors were raised in different countries with diverse cultural backgrounds and life experiences, which brought varying perspectives to the analysis. The team agreed that reciprocity was of interest and then reflected on theories that might enhance the depth of the analysis of this concept. Johnstone’s theory of accepting and blocking offers in improvisation theater²⁸ was introduced together with Doran and Setchell’s application of Johnstone’s work to physical therapy and power to drive the discussion and refinement of themes. Here the initial inductive approach became more theoretically driven (or “top-down”, according to Braun and Clarke).³⁶ The analysis was iteratively and reflexively refined during 5 cycles of meetings with J.S. and K.M. (Step 5: defining and naming themes, and Step 6: producing the report). Braun and Clarke’s checklist for reflexive thematic analysis³⁷ was used as a guide for reporting rigor.

Advisory Panel

As part of the larger study, 7 two-hour consultatory panels were held to explore the data and analyses with people with lived experience of LBP. The panel were advisors, not participants. Seven advisors were recruited via the researcher team’s networks (eg, had been participants in previous research and expressed interest in further research involvement) and had extensive lived experience of LBP. They were directly invited by the researchers in alignment with a traditional partnering recruitment model,³⁸ which follows a flexible structure and attends to a case-by-case basis. Advisors were all White Australians and most were middle class. During panels, researchers guided discussions about emerging findings from observations and gathered advice regarding areas for improvement, with their prior experiences in consideration.³⁹ Panel discussions informed our analysis.

Role of Funding Source

The funders played no role in the design, conduct, or reporting of this study.

Results

A total of 49 ethnographic observations, 13 clinician dialogues, and 7 advisory panels were conducted. Ten physical therapists and 42 individuals with LBP participated in this study. Most clinician participants described their gender as female (n = 8) and ranged in age from 25 to 59 years, with an average age of 44 years. Years in occupation ranged from 5 to 39 years, with an average of 22 years. For more detail, see Table 1. Most patient participants described their gender as female and worked in the health or educational fields. Their ages ranged from 25 to 80 years old, with an average age of 52 years. Patients had mainly mild pain (n = 23), with 16 participants having moderate or severe pain (see Tab. 2). We developed 3 themes through our analysis regarding reciprocity in clinical interactions: (1) accepting or blocking the patient’s “offer,” (2) inviting the patient to make an “offer,” and (3) sharing personal stories as psychosocial “offers.” See Table 3 for a summary of themes. We discuss our themes below and use pseudonyms (culturally similar to participants’ names) throughout.

Table 1.

Clinician Demographics^a

Physical Therapist Pseudonym	Age, y	Gender	No. of Years in Occupation	No. of Years Treating Patients With LBP
Mia	34	F	13	8
Rob	37	M	10	10
Jade	37	F	16	13
Ana	58	F	37	37
Carol	45	F	25	25
Prue	52	F	31	31
Tim	59	M	39	39
Christine	52	F	30	30
Daisy	N/A	F	N/A	N/A
Claire	25	F	5	5

^a LBP = low back pain; N/A = missing data.

Table 2.

Patient Demographics^a

Patient Pseudonym	Age, y	Gender	Nationality	Response to “How Long Ago Did You First Experience LBP?”	Current Pain Level b
Beatrice	43	F	Australian	>30 y	4
Luiza	51	F	Australian	21 y	Depends
Alice	66	F	Australian	14 y	6
Richard	43	M	Australian	10 y	0
Eva	57	F	Australian	20 y	0
Anika	32	F	Indian	8 to 10 y	3
Greg	25	M	Australian	Since childhood	2
Valeria	38	F	Colombian	1 wk	1
Grace	66	F	Australian	1 y 6 mo	8
Olivia	56	F	Australian	20 y	2
Alan	68	M	Australian	40 y	7
Sara	58	F	Australian	16 y	1
Doug	46	M	Australian	1 y	5
Linda	60	F	Australian	N/A	1–2
Rose	46	F	Australian	15 y	6
Elsie	61	F	Australian	44 y	0
Harriet	65	F	Australian	20 y	2
Susie	72	F	Australian	37 y	2
Sophie	45	F	Australian	20 y	> 8
Sally	40	F	Australian	9 y	3
Jack	26	M	South African	5 y	0
Nic	69	F	Australian	30 y	3
Jean	57	F	Australian	>40 y	0
Pete	80	M	Australian	20 y	5
Valma	77	F	Australian	35 y	N/A
Atsumi	48	F	Japanese	8 mo	7
Susan	19	F	Australian	6 mo	2
Mary	52	F	Australian	15 y	0–3
Sandra	64	F	Australian	9 y ago	8
Kia	30	F	Australian	10 y	5
Denys	54	F	Australian	1.5 y	5
Eunice	27	F	Australian	10 y ago	2
Nicole	†	F	Australian	N/Ac	N/Ac
Lysa	56	F	Australian	At age 12 y	5
Bridget	43	F	Australian	8 wk	2
Blake	50	M	Australian	15 y ago	7
Jake	57	M	Australian	>21 y	3
Angie	71	F	Greek	15 y	7
Chelsea	48	F	Croatian	>10 y ago	8
Lucy	62	F	Australian	>40 y ago	1–2
Jessica	53	F	Australian	5 wk ago	1
Samantha	48	F	Northern Irish	5 y ago	0

^a LBP = low back pain; N/A = missing data.

^b Pain level was rated on a scale from 0 to 10, where 0 = no pain and 10 = worst imaginable pain.

^c Patient withheld data.

Table 3.

Description of Themes

Theme	Description
Accepting or blocking patient’s “offer”	Theme is about act of participating physical therapist responding (either accepting or blocking) to what participating patient is saying (offer)
Inviting patient to make an “offer”	Theme involves participating physical therapists inviting participating patients to make “offer” to allow patients chance to guide narrative. May include offers about patient’s feelings, thoughts, or opinions.
Sharing personal stories as psychosocial “offers”	Theme describes reciprocal act of participating physical therapists and patients telling personal stories through dialogue

Accepting or Blocking the Patient’s “Offer”

This theme is about the act of participating physical therapists responding to (accepting/blocking) what the participating patient is saying (offer). As discussed above, “accepting” means the physical therapist listens to, acknowledges, and builds on the patient’s train of thought, whereas “blocking” is when they do not. For example, accepting a patient’s offer and building on it was observed in the subsequent interaction. The observer wrote:

Tim (physical therapist) and Beatrice (patient) started a conversation about the types of bags that would be better than the suitcase she came in with. Beatrice demonstrated how it would be better to have a backpack. Tim agreed, saying that it sounds like a good plan and adding that maybe using a bag that goes in front would be better for posture.

Tim accepted Beatrice’s offer about how the backpack would be better, thereby acknowledging Beatrice’s opinion before making another offer. This reciprocity involved both the physical therapist and patient collaborating to build the interaction.

There were other instances where participating physical therapists blocked offers, for example:

Carol (physical therapist) talked about doing acupuncture for Eva’s leg (patient). “I used to go to the acupuncturist for my foot but it never really did anything…so I dropped it.” Eva confessed. Carol proceeded with the acupuncture.

The observer noted that Eva seemed hesitant about the acupuncture during this interaction. By moving forward with the acupuncture even though Eva seems to be suggesting (offering) that acupuncture does not work for her, Carol blocks Eva’s offer. The physical therapist is thus guiding the narrative of this interaction, keeping herself in control, a less reciprocal arrangement. Contrastingly, we can observe how reciprocal acceptance of offers play out in a more shared power dynamic below:

Mia (physical therapist) said that Anika (patient) could use a stair [to complete a home exercise], but Anika did not have one at home. Mia suggested a chair, but when Anika tried to use it, she thought it was higher than the box they used for the exercise in the clinic and did not seem happy. Anika asked Mia if she could use a stool and showed her the height of the stool. Mia said she thought that it was creative and agreed that it was no problem for the exercise.

Here, we can see a reciprocal provision and acceptance of offers from physical therapist and patient. As a result, both parties seem to be guiding the narrative and sharing the power. Similarly, in one dialogue, clinicians reflected on the importance of reciprocal exchanges with participants even if more challenging discussions arose during consultations, such as mental health and sex concerns (related to patients’ pain). For example, physical therapist Carol mentioned, “I guess if it’s driven by them as well, if they’re bringing it up…you should just talk about it.” Although recognizing that some conversations could be confronting, it was important to address patients’ questions. Thus, “just talking about” elements that patients bring up can be a way for physical therapists to accept patients’ offers during consultations.

In summary, we noted many examples of how reciprocity through accepting offers is a way to share power in physical therapist–patient interactions. Comparatively, blocking offers or a lack of reciprocity seems to cause a shift away from shared power.

Inviting the Patient to Make an “Offer”

In this theme, we discuss another situation where reciprocity was evident in our analysis: when participating physical therapists invited patients to make an “offer.” Invitation was used in many contexts, often about the patient’s feelings, thoughts, or opinions, which may not have been freely given due to existing power differentials in health care interactions.

An example of participating physical therapists inviting offers was when physical therapist Christine asked Richard (participant) how he felt about trying massage for his back: Richard replied, “I think that would be okay…actually no, I don’t think I would like that.” Christine excluded massage from the treatment plan as a result. Here, physical therapist Christine invited input from Richard, indicating that his opinions and ideas were welcome. This invitation created a reciprocal environment whereby the patient could contribute to the narrative of the interaction, sharing the power.

Contrastingly, a lack of invitation to make an offer was observed at times, as in the following exchange:

“This should be quite comfortable for you,” physical therapist Tim says after asking Eunice (patient) to get into yoga “child’s pose” position. “It’s a little bit hum… tender,” Eunice mentions, going against what Tim said.

In this interaction, Tim did not invite the patient to make an offer but instead made a statement (an offer) about how the activity should feel for the patient. Eunice was able to negate this offer (hesitantly), saying that her experience was different. The tentative nature of Eunice’s response suggests that disagreeing with Tim’s offer was uncomfortable, and perhaps she underplayed how “tender” the exercise was for her. The lack of reciprocity in this interaction seemed to set up a possibility for either acquiescence (which might involve a patient engaging in a treatment they did not want) or a conflict, a fight for power.

Exercise prescription was another common part of the physical therapist–patient interaction that seemed to benefit from invitations to make an offer. Such invitations allowed participating physical therapists to gain greater insight into participating patients’ perspectives or context. In the following example, physical therapist Claire learned about the patient’s social context and was then able to work with her patient to adapt exercises to fit into her life rather than vice versa. For example:

“How did your exercises go?” asked physical therapist Claire. “I’m not that good,” answered Linda (patient). “What’s the barrier to doing them?” asked Claire. Linda explained that she was busy with work and lacked sleep, especially when the pain kept her up. At this point, Claire initiated a conversation about how movement and gentle exercises could be beneficial when this happens.

By Claire asking Linda the question “What’s the barrier to doing them?” this scenario invited Linda to explain her needs. Without the reciprocity engaged by inviting Linda to make an offer, physical therapist Claire would not know that Linda was busy and tired and might miss further discussion that could assist with recovery. With this reciprocal act of inviting offerings, both parties could share power while deciding Linda’s exercises.

Another example came from a dialogue. Clinicians and researchers discussed eliciting patients’ feedback throughout consultations and being attentive to patients’ verbal and non-verbal feedback and emotional concerns. Clinicians reflected on using more open-ended questions to invite patients’ thoughts and follow up on patients’ concerns in future sessions. For example, Claire said she would first acknowledge various aspects of the patient’s feedback and then ask open-ended questions as follow-up. Rob said he would “listen and observe, [going] back into the feedback … and then acknowledging client concerns.” Such strategies were ways that physical therapists could attend to patients’ feelings and thoughts and therefore encourage patients to make an offer.

In contrast, participating physical therapists sometimes took more authoritative approaches to exercise prescription. For instance, physical therapist Prue said, “I want you to practice 6 to 8 times every morning and night.” There was a lack of invitation to make an offer, and Prue was the sole decider. Moreover, the lack of invitation prevented Prue from exploring her patient’s individual context. During clinician dialogues, clinicians suggested that the ability to explore psychosocial factors through invitations to make an offer could be used to improve exercise adherence:

“I ask, ‘How many do you think you could do?’ or ‘How many times a week do you think you could realistically do this?’… because then maybe we get more of an idea of who that person is, and whether they are actually someone who’s going to do it 3 times a day, so we need to make sure that we don’t overdo it, or whether they’re really going to struggle to do them every day…finding a solution together, rather than just saying you must do it this time or actually you don’t have to.” (physical therapist, Jade)

Inviting patients to make an offer aids in developing reciprocity and appears to support shared power. Patients can then be supported to guide the treatment narrative, and the care proceeds more collaboratively.

Sharing Personal Stories as Psychosocial “Offers”

The final reciprocal act we noted in our analyses was when physical therapists and patient participants shared personal stories during the consultations. When participating patients revealed details about their personal lives (what we might call a “psychosocial offer”), a way in which some participating physical therapists seemed to accept that offer was by sharing their personal stories. Our analysis suggested that reciprocating the sharing of personal stories sometimes enabled the patient and physical therapist to understand each other better and see the other as a human being rather just another physical therapist or patient.

In some instances, shared experiences arose, which prompted both parties discuss similar life experiences. An example of this reciprocity can be observed in this interaction:

Physical therapist Ana started the soft tissue release and mentioned that Sophie (patient) was a little tight on one side. Ana asked what Sophie was going to do on the weekend, and Sophie said she was free. Ana seemed surprised with this fact of a “free Saturday.” She mentioned that her kids used to do sports on Saturdays and asked Sophie if her kids were into sports. Sophie said no, but that they wanted to get a job soon. Ana shared a story about her son’s casual job. Both proceeded to have a conversation about their children finding work.

Ana sharing stories about her personal life likely gave Sophie insight into Ana’s “human” side, allowing Sophie to see her beyond her role as a health professional, potentially reducing power differences.

In other instances, the lack of reciprocity in personal stories/psychosocial context was notable. An example was during physical therapist Carol and patient Sally’s interaction. Carol was giving Sally a massage and asked Sally about her family. Sally shared personal details about her work, but Carol did not engage in this topic and instead talked about how tight Sally’s muscles were. Whereas Sally made a “psychosocial offer” and shared aspects of her personal life, Carol focused on things she seemed to consider key to the interaction (tight muscles) despite the opening for her to make a reciprocal psychosocial offer with a personal narrative. This lack of reciprocity may have emphasized their roles as physical therapist and patient as well as their power differences.

When participants approached sensitive issues such as weight, sharing personal experiences seemed to make tackling the topic easier, for example:

“Yeah, I thought it might be my weight probably hasn’t helped. Because I’m not normally this size. I haven’t lost all of my baby weight,” Nicole (patient) said and seemed to be upset about her “unusual” body shape. “So, that’s a fair comment to say and I imagine that you have to be kind to yourself, and give yourself time still,” physical therapist Prue replied and then shared that she had been through a similar situation with her pregnancy.

Through reciprocal offers in the psychosocial context, participants were able to find a shared experience. Furthermore, this scenario suggests a more human–human relationship than a physical therapist simply telling a patient to lose weight in a biomedical physical therapist–patient relationship. The physical therapist appears to hold more power in the former; power is more equal in the latter.

Reciprocating psychosocial offers seemed to be helpful to allow both participating physical therapists and patients to see each other’s “human” side. Through this, there appeared to be a shift away from biomedical physical therapist–patient relationships, where roles are clearly defined and power differences intact, to human–human relationships, where power differences are reduced.

Discussion

In this study, we aimed to investigate how reciprocity is (or is not) enacted in physical therapist interactions with people with LBP. Our key finding is that reciprocity, or lack thereof, can be enacted through the micro-interactions between patient and physical therapist. This includes how each party responds to each other and what the interaction is about. The reciprocity with which physical therapists choose to interact with individuals, be it accepting or blocking a patient offer, inviting an individual to make an offer, or reciprocating the act of offering personal stories, appears to involve power dynamics. Power here is subtle and demonstrates the hierarchy of status that pervades physical therapist–patient interactions.^11,29 Our analysis suggests that engaging with reciprocity might be a valuable approach to share power and develop better physical therapist–patient relationships.

Our analysis suggests that when physical therapists can follow an individual’s lead (reciprocal acceptance of offers), there can be a shift towards a stronger physical therapist–patient interaction. Similarly, according to Miciak et al,⁴⁰ to cultivate therapeutic alliance, physical therapists must be “receptive,” being open to negotiate appropriate treatment plans. Likewise, an integrative review identified “responsive” and “collaborative” as key qualities of a good physical therapist.⁴¹ A good physical therapist listens and is attentive to patients as well as involves them in decision-making and adjusts treatment plans to an individual’s needs.⁴¹ Our study adds to this previous research by clarifying 3 key ways in which physical therapists can demonstrate their responsiveness, listening, and attentiveness—by showing reciprocity by (1) accepting offers, (2) inviting offers, and (3) offering personal stories.

Previous research strongly suggests that patient–physical therapist interactions in musculoskeletal practices are often physical therapist-led, with physical therapists’ (often biologically focused) plans frequently determining the narrative.^13,14,42 Such potentially paternalistic practices require physical therapists to reflect on how to better share power, a key aspect in shared decision-making,⁴³ and foster a deeper ethical awareness of power asymmetries during clinical encounters.⁴⁴ Our analysis from the current study suggests that Johnstone’s theory of improvisation²⁸ may help provide physical therapists with some suggestions on how to shift this pattern by accepting patient offers. When physical therapists block patient offers in physical therapist-led interactions, they create what Johnstone²⁸ calls “high status,” with physical therapists holding greater power than patients. Physical therapists might use a common improvisation technique developed from Johnstone’s ideas called the “yes, and” method²⁸ to shift status and develop shared power interactions. This method encourages physical therapists to say “yes,” literally or metaphorically, before adding to the conversation. This mutual acknowledgement and acceptance of offers is a form of reciprocity. This approach was supported by Vestol et al,⁴⁵ describing that patients felt they were in an alliance and had “co-ownership” of sessions when physical therapists encouraged patients to lead and make decisions on their own exercise program at times. Even when disagreeing, it is important to accept and acknowledge patients’ offers, rather than block, before making another offer. Approaches such as “yes and…” could foster reciprocity in clinical practices and a more patient-centered approach.

Our analysis also suggests that interactions can be more reciprocal when physical therapists invite patients to make offers. Miciak et al⁴⁰ theorize that physical therapists must have an open attitude and be invested in patients’ stories and preferences to enhance the therapeutic relationship. This adds to Toro and Martiny’s⁴⁶ study, where they discussed the importance of using open-ended, participatory, and holistic interactions to improve the active participation of a person in their care. One strategy for physical therapists to be open and invite patients to make offers, and therefore enhance reciprocity in physical therapists–patient interactions, is using open-ended questions.⁴⁷ Phrases such as “What do you think might be the best approach?” or “How do you feel about that suggestion?” or “What are your thoughts at this point?” are examples of inviting patient offers. Thus, having an open attitude and encouraging patients to make offers allows both parties to lead the interactions and allow physical therapists to explore patients’ perspectives and previously unknown contextual elements of their lives to allow for better patient-centered care. Although most research, including ours, suggests that generally there is a need for greater input from patients, some researchers are concerned that inviting more input will enable “negative” behaviors or produce “difficult patients.” However, we propose that reciprocity might help to mitigate this issue because it suggests that active involvement of both parties is key and reduces misunderstandings related to the key factors that arguably produce these difficulties in the first place⁴⁸—that is, power between physicians and patients and under-recognition of social factors impacting patients’ health.

Our research suggests that reciprocal offers of personal stories by physical therapists helped physical therapists and patients find shared experiences. This approach allowed a shift from biomedical foci toward more “human” interactions, a shift that has been discussed as difficult for physical therapists working with people with LBP.¹³ Finding a similar effect, an interview study by Miciak et al⁴⁰ indicated that individuals are interested in knowing their physical therapists stories and that it helps with building therapeutic relationships. Further, personal stories seemed to be shared when therapeutic touch was used. Although a deeper discussion on therapeutic touch is beyond the scope of this study, our previous work has also observed how this element allowed patients and physical therapists to discuss and attend to nonphysical aspects of LBP.¹³ Our finding adds to our previous work and that of Miciak by illustrating how this story-sharing happens in practice and its contribution to balancing power. Hiller et al¹⁴ observed that casual, non-medical conversation during sessions was a key component for relationship building, encouraging active patient participation, and developing trust, supporting our finding that reciprocating the exchange of personal stories is useful for shifting status between parties.

Although helpful in building therapeutic alliances, sharing personal stories needs to be done with caution. Sharing too much by making more psychosocial offers than patients can shift the focus away from the patient and toward the health care professional.⁴⁹ Furthermore, although our results indicate that sharing personal stories seemed to help shift power in an interaction, it is also likely that not everyone has similar stories to share. For example, Ross and Setchell⁵⁰ highlight how LGBTQI+ physical therapists might often find sharing personal stories challenging for fear of stigma. In this situation, physical therapists can return to the first theme of accepting the offer and letting actions develop from there. When teaching topics surrounding the code of conduct⁵¹ in physical therapist undergraduate courses, it may be helpful to highlight that sharing personal stories may not always be inappropriate. In some situations, sharing personal stories can help develop therapeutic alliances.

Methodological Considerations

There are a number of methodological considerations when applying our research to other contexts. For example, we acknowledge the impact of the experiences and perspectives of observers on the data produced and research team on the analysis and reporting. We were aware of this effect and sought to challenge our own assumptions and have endeavored to broaden perspectives by involving patients and clinicians in the analysis, which likely produced richer results. This involvement was also an attempt to reduce power inequities between researchers and research participants. The context of the study also matters; findings may only relate to countries with similar health care systems and cultural practices. Additionally, data were collected from a fee-for-service practice and may have represented a patient population from (relatively high) socioeconomic situations similar to that of the physical therapists they encountered at the study site. Further research might investigate reciprocity in other physical therapy settings such as publicly funded contexts and in different countries.

Our study demonstrates that reciprocity could be a valuable concept to attend to the psychosocial needs of patients and shift power in an interaction, which is likely beneficial for developing therapeutic alliances and enhancing management success. Although reciprocity can be achieved in numerous ways, our study suggests that accepting patients’ offers, inviting patients to make an offer, and offering personal stories can assist physical therapists to strive for more reciprocal interactions. The use of reciprocity in the context of “offers” (peoples’ actions or ideas) can be implemented in clinical practice to foster a more patient-centered approach.

Author Contributions

Concept/idea/research design: M. Tan, J. Setchell

Writing: K. Mescouto, M. Tan, J. Setchell

Data collection: K. Mescouto

Data analysis: M. Tan, J. Setchell

Project management: M. Tan, J. Setchell

Consultation: K. Mescouto, M. Tan

Acknowledgments

The authors acknowledge the traditional owners of the lands on which this study was conducted, the Turrbul and Yuggera peoples. The authors also thank the study participants, the advisory panel, and the following researchers who participated in the original study discussed in this paper: Kelly Walsh, Kerrie Evans, Paul Hodges, Rebecca Olson, Mary Anne Patton, and Tharuka Prematillake.

Funding

This study received funding from The University of Queensland. Dr Setchell is supported by a grant from the National Health and Medical Research of Australia (NHMRC: APP1157199).

Ethics Approval

This study was approved by the Human Research Ethics Committee of The University of Queensland (#2019002446).

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.