Abstract
[Purpose] Trust among patients and clinical suppliers is the foundation for achieving appropriate treatment. This double-blind randomized control trial aimed to determine whether providing patients a pre-treatment physical therapists’ introductions and positive appraisal can enhance the trust of patients in therapists. [Participants and Methods] This study included patients diagnosed with lumbar spine spondylosis or non-acute lower back muscle strain who were divided into intervention and control groups. The previously recorded video informed the intervention group patients that they were assigned to our best therapist because of their participation. The primary outcome was evaluated twice, once before and once after the treatment, and the secondary outcome was measured using the second time pain inventory evaluation. [Results] A total of 32 patients participated in this study. No significant difference was found in patients’ trust in therapists between the two groups, and a lower successful treatment rate with a higher pain influence level to daily life was noted in the intervention group. [Conclusion] Doctors who offer introductions with a positive assessment of physical therapists cannot change the trust of patients on therapists. Furthermore, this action may risk worse treatment outcomes.
Keywords: Persuasive communication, Propaganda, Trust
INTRODUCTION
Trust among patients and physicians is the foundation for achieving positive treatment outcomes1,2,3). Increasing trust can help achieve treatment consistency4,5,6), upgrade patient satisfaction7, 8), and improve treatment adequacy9, 10). Conversely, mistrust between healthcare providers and patients can result in ineffective treatment and excessive defensive medicine11, 12). These issues may cause clinical debate and lead to financial burden.
Previous literature has indicated that general interpersonal trust may come from a long time of living together, such as trust among family members13). However, most treatments are completed over a number of admissions and interventions; therefore, establishing trust between patients and doctors through such short interactions is challenging14). Several studies have reported that speech (including listening, showing compassion, and taking longer to explain)15,16,17), and reputation18, 19) are more important than physical appearance20), age, title, and sex21). Therefore, if physicians want to gain trust before the real treatment begins, they must try to build a good rapport with the patient.
Previous studies have been restricted to an unclear causal relationship, in that, it cannot be determined whether a good reputation creates a better doctor-patient relationship and establishes better trust, or vice versa22). Previous studies were also unable to clarify whether a high degree of trust results in improved treatment effects or whether a good relationship results from good medical outcomes8, 10, 23). Such studies were important but were rarely conducted for the following reasons: 1. In an observational study, it is very difficult to distinguish among causal relationships24). 2. Patients usually know or have already heard about their doctors before admission; hence, they first trust those doctors and then decide to visit them. 3. It is unethical to randomize patients’ physicians if they do not want to consult them25).
Fortunately, some medical providers, though not chosen by patients themselves, develop a close relationship with the patients during the course of treatment. In Taiwan, patients receive physical therapy by a physical therapist after they visit a rehabilitation ward. Doctors specializing in rehabilitation prescribe rehabilitation and then refer patients to their physical therapist; the patient does not get to choose the therapist.
Accordingly, we designed a double-blind randomized control trial to (1) determine whether provision of a pre-treatment physical therapists’ introduction and positive review can enhance the trust of patients in therapists and (2) verify whether a change in trust between therapists and patients will lead to different treatment outcomes.
PARTICIPANTS AND METHODS
All patients were recruited at Taoyuan General Hospital, Ministry of Health and Welfare, Taiwan. To avoid the influence of prior experience with doctors and therapists in the department, only patients who visited the rehabilitation department for the first time during the study period from 2016/07/01 to 2017/05/31 were recruited. In addition, only patients who were aged 18 years or older with a diagnosis of lumbar spine spondylosis or non-acute low back muscle strain were included. Patients with a visual analog scale (VAS) of <2 were excluded. Other exclusion criteria were as follows: 1. Patients not appropriate for physical therapy with hot packing, interference current therapy, pelvic traction, or therapeutic exercise26). 2. Patients with poor following of oral requests or patients who could not understand Chinese, including patients with aphasia or dementia. 3. Patients who could not maintain at least two weeks of physical therapy. 4. Patients with other causes of lower back pain not treatable with physical therapy, such as urinary tract stones, infection, and rapid disease progression, which require immediate operation. This investigation was conducted in accordance with the guidelines of the Human Subjects Committee of the Institutional Review Board of Taoyuan General Hospital, Taiwan (Approval Number: TYGH104046 date from 2016/06/01 to 2017/05/31) (Clinical trial registration number: NCT02799628).
The patients were approached with project invitations. Those who agreed to participate were well informed and signed a consent form. They were then prescribed hot packing, interference current therapy, pelvic traction, and therapeutic exercise three times per week. The department nurse assigned a number from 1 to 6 to each participant. According to the number, participants were classified into the intervention or control groups. Participants with numbers 1, 3, or 5 were assigned to the intervention group and those with numbers 2, 4, or 6 were assigned to the control group. The participants were treated by three physical therapists in the department. Each therapist had at least 10 years of clinical care experience. Previously recorded videos 1–6, which were matched to each group, were played by an assistant nurse. Thus, doctors, physical therapists, and evaluators were blinded to participants’ information. The video provided to the control group had contents on low back pain education, and the video provided to the intervention group included the same content on low back pain education, followed by introduction of the therapists. The introductions of all the three therapists, A, B, and C were the same, except for their name and photo. The video informed the intervention group patients that they were assigned to our best therapist because of their participation and that their therapist was very compassionate and experienced. In addition, the video informed the intervention group patients that their therapist specialized in low back pain treatment and had a good successful treatment rate. A flowchart of patients is shown in Fig. 1.
Fig. 1.
Flow diagram of patient selection.
After watching the video, the first evaluation of all the participants before treatment was conducted. Basic demographic data, such as name, age, and sex, were acquired from all the participants using an evaluation questionnaire. The questionnaire included the Chinese version of the Wake Forest Physician Trust Scale (C-WFPTS, Fig. 2)27) and the Chinese version of the Brief Pain Inventory (BPI-C, Fig. 3)28). C-WFPTS score is calculated by the sum of the 11 item scores, (items 2, 3, 7, 8 were reverse scores) ranging from 11 to 55, with a higher score indicating more trust. Our primary outcomes, the evaluation of the total trust score by C-WFPTS between the intervention and control groups, and the success of treatment proportion in the intervention and control groups, were carried out twice, once before and once after the treatment. Successful treatment was defined as a decrease in pain score of more than 2 points29,30,31,32). The secondary outcomes were measured using the second time pain inventory evaluation, with each item of the BPI-C between the intervention and placebo groups.
Fig. 2.
Chinese version of the Wake Forest Physician Trust Scale (C-WFPTS).
Fig. 3.
The Chinese version of the Brief Pain Inventory (BPI-C).
In the present form, this may not be very clear. Please explain this also so this may be revised appropriately.
The C-WFPTS and BPI-C data were presented in numbers. Descriptive and χ2 analyses were used to determine if the randomized process was complete. Student’s t-test was used to examine if the baseline pain scores were different in each group. The t-test was also used to evaluate the primary outcomes of trust. The χ2 test with sensitivity test was used for another primary outcome of successful treatment rate with adjustment of the loss-to-follow-up data. The t-tests were also used for secondary outcomes, whereas paired t-tests were used to examine the change from the first evaluation to the second evaluation. The variables included pain score and pain condition by the BPI-C. The significance threshold was set at 0.05. All statistical analyses were performed using the IBM software, SPSS Statistics version 20b (IBM SPSS® Statistics, Chicago, IL, USA).
RESULTS
A total of 32 patients (12 males and 20 females) with a mean age of 51.97 years participated in this study. The baseline characteristics are listed in Table 1. Of the 32 patients with newly diagnosed low back pain, no significant differences were noted in any characteristics, including age, sex, therapist assignment, painkiller use, and all items in the BPI-C. The loss to follow-up rates of the intervention and control groups were 40% and 58.33% (p=0.314), respectively.
Table 1. Baseline data of both groups.
| Intervention group (N=20) | Control group (N=12) | p-value | |||
| N | % | N | % | ||
| Sex | 0.288 | ||||
| Male | 6 | 30 | 6 | 50 | |
| Female | 14 | 70 | 6 | 50 | |
| Therapist | 0.697 | ||||
| A | 6 | 30 | 3 | 25 | |
| B | 7 | 35 | 6 | 50 | |
| C | 7 | 35 | 3 | 25 | |
| Drug use | 0.923 | ||||
| Yes | 7 | 35 | 4 | 33 | |
| No | 13 | 65 | 8 | 66.7 | |
| Mean | SD | mean | SD | p-value | |
| Age | 51.95 | 13.83 | 52 | 15.54 | 0.993 |
| Most pain in 24 h | 6.85 | 1.84 | 7.042 | 2.633 | 0.82 |
| Less pain in 24 h | 3.05 | 2.139 | 1.708 | 1.815 | 0.08 |
| Mean pain score | 5.263 | 1.821 | 4.542 | 2.126 | 0.32 |
| Pain score now | 3.925 | 2.129 | 3.708 | 2.598 | 0.8 |
| Pain influence on | |||||
| Daily life | 6.475 | 2.779 | 6.5 | 2.939 | 0.981 |
| Emotion | 5.775 | 2.628 | 5.083 | 3.704 | 0.541 |
| Walking | 5.225 | 3.197 | 5.917 | 3.801 | 0.585 |
| Work | 6.725 | 2.173 | 5.833 | 3.46 | 0.376 |
| Relationship | 3.625 | 3.631 | 2.5 | 3.802 | 0.411 |
| Sleep | 5.05 | 3.759 | 4.167 | 4.687 | 0.562 |
| Entertainment | 5.55 | 2.795 | 5.417 | 4.078 | 0.921 |
SD: standard deviation.
The first total trust scores by C-WFPTS immediately following the video presentation were 41.3 ± 4.1 and 41.9 ± 3.8 in the intervention and control groups, respectively (p=0.676). The total trust scores for the second evaluation were 42.67 ± 5.8 and 42.8 ± 0.83 in the intervention and control groups, respectively (p=0.961). A minor difference was noted in patients’ trust in therapists between the two groups. Successful treatment rates in the intervention and control groups were 33% and 60%, respectively (p=0.309) (Table 2).
Table 2. Primary outcome in both groups.
| Intervention group | Control group | p-value | |||
| mean | SD | mean | SD | ||
| Total trust score of first evaluation | 41.3 | 4.1 | 41.9 | 3.8 | 0.676 |
| Total trust score of second evaluation (PP) | 42.67 | 5.8 | 42.8 | 0.83 | 0.961 |
| Total trust score of second evaluation (ITT) | 41.45 | 5.27 | 42.8 | 3.21 | 0.419 |
| N | % | N | % | p value | |
| Successful treatment | 4 | 33 | 3 | 60 | 0.309 |
| Successful treatment | 12 | 60 | 10 | 83 | 0.168 |
| Sensitivity analysis (High/Low) | 4 | 20 | 3 | 25 | 0.740 |
SD: standard deviation.
BPI-C served as a secondary outcome, and the results are presented in Table 3. The lowest pain score in the past 24 hours was substantially higher in the intervention group (2.625 ± 1.92) than in the control group (0.2 ± 0.447, p=0.001). The pain influence levels of walking, work, and relationship were 5.25 ± 2.896, 5.36 ± 3.107, and 2.5 ± 2.939, respectively, in the intervention group, which were higher than the levels in the control group (1.2 ± 1.304, p=0.01; 2 ± 2.121, p=0.047; and 0 ± 0, p=0.013, respectively). The paired t-test showed that the change in the pain influence level of walking was greater in the control group (−4.6 ± 3.36) than in the intervention group (−0.45 ± 3.69, p=0.048). No significant difference was observed in the use of analgesics between the intervention (16.7%) and control (20%, p=0.87) groups (Table 4).
Table 3. Secondary outcome of second time evaluation by BPI-C.
| Intervention group | Control group | p-value | |||
| mean | SD | mean | SD | ||
| Most pain in 24 h | 5.625 | 2.035 | 3.6 | 1.14 | 0.056 |
| Least pain in 24 h | 2.625 | 1.92 | 0.2 | 0.447 | * |
| Mean pain score | 3.875 | 2.258 | 2.4 | 1.673 | 0.21 |
| Pain score now | 3.792 | 2.692 | 1.6 | 2.302 | 0.133 |
| pain release % | 60 | 35.86 | 50 | 47.61 | 0.69 |
| Pain influence for | |||||
| Daily life | 4.08 | 2.811 | 2.2 | 1.924 | 0.194 |
| Emotion | 3.5 | 3.205 | 1.8 | 1.924 | 0.202 |
| Walking | 5.25 | 2.896 | 1.2 | 1.304 | * |
| Work | 5.36 | 3.107 | 2 | 2.121 | * |
| Relationship | 2.5 | 2.939 | 0 | 0 | * |
| Sleep | 3.92 | 2.746 | 2.4 | 3.362 | 0.345 |
| Entertainment | 3.25 | 3.251 | 1.6 | 2.302 | 0.322 |
Analysis by t-test. BPI-C: Chinese version of the Brief Pain Inventory; SD: standard deviation.
Analysis of covariance: *p<0.05.
Table 4. Change from first time evaluation to second time evaluation by BPI-C.
| Intervention group | Control group | p-value | |||
| mean | SD | mean | SD | ||
| Most pain in 24 h | −1.292 | 2.261 | −2.9 | 3.435 | 0.268 |
| Less pain in 24 h | −0.292 | 1.712 | −1.5 | 1.5 | 0.191 |
| Mean pain score | −1.682 | 2.432 | −1.3 | 3.233 | 0.796 |
| Pain score now | 0.125 | 2.612 | −2.3 | 4.467 | 0.177 |
| Pain release % | 60 | 35.86 | 50 | 47.61 | 0.69 |
| Pain influence on | |||||
| Daily life | −2.25 | 3.596 | −3.8 | 4.438 | 0.514 |
| Emotion | −2.375 | 2.978 | −2 | 5.958 | 0.862 |
| Walking | −0.458 | 3.689 | −4.6 | 3.362 | * |
| Work | −1.318 | 3.196 | −2 | 4.848 | 0.741 |
| Relationship | −1.792 | 3.513 | −3.4 | 4.219 | 0.429 |
| Sleep | −0.875 | 3.491 | −0.2 | 4.438 | 0.741 |
| Entertainment | −2.125 | 3.885 | −4 | 3.674 | 0.372 |
Analysis by pair t-test. BPI-C: Chinese version of the Brief Pain Inventory.
Analysis of covariance: *p<0.05.
DISCUSSION
This study attempted to improve the patient’s trust in their physical therapists and ultimately improve the treatment outcomes by showing a film that recommends therapists with positive assessment. However, the preliminary results of the study revealed that the patient’s trust in the therapist did not improve, and even worse, the intervention group showed a lower successful treatment rate and more pain influence level in daily life than the control group. The trial enrolled 32 participants until the expiration of institutional review board permission. Preliminary results revealed that the intervention group may have a risk of adverse treatment of patient outcomes; therefore, we decided not to apply for institutional review board extension based on ethical considerations33).
It is very difficult to evaluate “trust” in a medical process34). In our study, the lack of difference in trust level between the two groups may be due to inefficiency of the C-WFPTS questionnaire. However, we believe that highlighting the therapists’ recommendations and expertise through the film could not improve the patient’s confidence in them. Because this was the first time that these patients visited the rehabilitation department, the patients may not have fully trusted the physicians and their recommendations. Although most of the patients decided to visit a particular physician, the time that they got with the respective physicians was very short. Moreover, it is controversial whether a conflict of interest exists because the recommenders and therapists were from the same institution. If the recommendation comes from non-stakeholders, it may be more trustworthy.
Interestingly, if trust did not increase with the positive assessment, what could the possible reasons for the worse outcomes in the intervention group be? We believe that deliberate recommendations may make some patients more wary or anxious, while increase the expectations in others35). Many patients expect meticulous or high quality treatment; however, when the treatment does not meet their expectations or the posttreatment sensations are worse than those before, it may cause increased anxiety and psychological stress, which may lead to muscle spasms and pain36, 37).
This study has some limitations. First, the proportion of patients who completed their treatment was low. Important reasons for patient dropout were that they did not have enough time to continue treatment or that they could not be traced by phone. A previous study demonstrated that a patient’s trust may affect the treatment alliance6). Furthermore, treatment alliances may influence the treatment effects. In our study, although the difference in the dropout rate between the intervention and control groups did not reach statistical significance, it may still have some influence on the results. Second, the small sample size decreased the power of this study. However, the treatment effects were significantly different. Based on the worse outcomes in the intervention group, we decided not to extend our study or recruit more participants. Third, we did not evaluate trust between patients and recommenders; therefore, we cannot confirm that the reason for decreased trust comes from the inappropriate contents of assessment or the inappropriate introducer.
Funding and Conflict of interest
The authors have no conflicts of interest, financial or otherwise. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors and did not have a previous presentation of the research, manuscript, or abstract in any form.
REFERENCES
- 1.Thom DH, Campbell B: Patient-physician trust: an exploratory study. J Fam Pract, 1997, 44: 169–176. [PubMed] [Google Scholar]
- 2.Street RL, Jr, Makoul G, Arora NK, et al. : How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns, 2009, 74: 295–301. [DOI] [PubMed] [Google Scholar]
- 3.Benedetti F: Placebo and the new physiology of the doctor-patient relationship. Physiol Rev, 2013, 93: 1207–1246. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Safran DG, Kosinski M, Tarlov AR, et al. : The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care, 1998, 36: 728–739. [DOI] [PubMed] [Google Scholar]
- 5.Trachtenberg F, Dugan E, Hall MA: How patients’ trust relates to their involvement in medical care. J Fam Pract, 2005, 54: 344–352. [PubMed] [Google Scholar]
- 6.Gupta S, Brenner AT, Ratanawongsa N, et al. : Patient trust in physician influences colorectal cancer screening in low-income patients. Am J Prev Med, 2014, 47: 417–423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Hall MA, Zheng B, Dugan E, et al. : Measuring patients’ trust in their primary care providers. Med Care Res Rev, 2002, 59: 293–318. [DOI] [PubMed] [Google Scholar]
- 8.Dugan E, Trachtenberg F, Hall MA: Development of abbreviated measures to assess patient trust in a physician, a health insurer, and the medical profession. BMC Health Serv Res, 2005, 5: 64. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Thom DH, Kravitz RL, Bell RA, et al. : Patient trust in the physician: relationship to patient requests. Fam Pract, 2002, 19: 476–483. [DOI] [PubMed] [Google Scholar]
- 10.Ferreira PH, Ferreira ML, Maher CG, et al. : The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther, 2013, 93: 470–478. [DOI] [PubMed] [Google Scholar]
- 11.Csiba L: [Thoughts on “defensive” medicine]. Orv Hetil, 2007, 148: 531–534 (in Hungarian). [DOI] [PubMed] [Google Scholar]
- 12.Hawley K: Trust and distrust between patient and doctor. J Eval Clin Pract, 2015, 21: 798–801. [DOI] [PubMed] [Google Scholar]
- 13.Mechanic D, Meyer S: Concepts of trust among patients with serious illness. Soc Sci Med, 2000, 51: 657–668. [DOI] [PubMed] [Google Scholar]
- 14.Dang BN, Westbrook RA, Njue SM, et al. : Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC Med Educ, 2017, 17: 32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ommen O, Janssen C, Neugebauer E, et al. : Trust, social support and patient type—associations between patients perceived trust, supportive communication and patients preferences in regard to paternalism, clarification and participation of severely injured patients. Patient Educ Couns, 2008, 73: 196–204. [DOI] [PubMed] [Google Scholar]
- 16.Keating NL, Gandhi TK, Orav EJ, et al. : Patient characteristics and experiences associated with trust in specialist physicians. Arch Intern Med, 2004, 164: 1015–1020. [DOI] [PubMed] [Google Scholar]
- 17.Robb N, Greenhalgh T: “You have to cover up the words of the doctor”: the mediation of trust in interpreted consultations in primary care. J Health Organ Manag, 2006, 20: 434–455. [DOI] [PubMed] [Google Scholar]
- 18.Willis WK, Ozturk AO, Chandra A: The impact of patient-to-patient interaction in health facility waiting rooms on their perception of health professionals. Hosp Top, 2015, 93: 13–18. [DOI] [PubMed] [Google Scholar]
- 19.Ward PR, Rokkas P, Cenko C, et al. : A qualitative study of patient (dis)trust in public and private hospitals: the importance of choice and pragmatic acceptance for trust considerations in South Australia. BMC Health Serv Res, 2015, 15: 297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Chung H, Lee H, Chang DS, et al. : Doctor’s attire influences perceived empathy in the patient-doctor relationship. Patient Educ Couns, 2012, 89: 387–391. [DOI] [PubMed] [Google Scholar]
- 21.Kurihara H, Maeno T, Maeno T: Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study. Asia Pac Fam Med, 2014, 13: 2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Torres E, Vasquez-Parraga AZ, Barra C: The path of patient loyalty and the role of doctor reputation. Health Mark Q, 2009, 26: 183–197. [DOI] [PubMed] [Google Scholar]
- 23.Earl TR, Beach MC, Lombe M, et al. : Race, relationships and trust in providers among black patients with HIV/AIDS. Soc Work Res, 2013, 37: 219–226. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Ejima K, Li P, Smith DL, Jr, et al. : Observational research rigour alone does not justify causal inference. Eur J Clin Invest, 2016, 46: 985–993. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Bracken-Roche D, Bell E, Macdonald ME, et al. : The concept of ‘vulnerability’ in research ethics: an in-depth analysis of policies and guidelines. Health Res Policy Syst, 2017, 15: 8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Geneen LJ, Moore RA, Clarke C, et al. : Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev, 2017, 4: CD011279. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Dong E, Liang Y, Liu W, et al. : Construction and validation of a preliminary Chinese version of the Wake Forest Physician Trust Scale. Med Sci Monit, 2014, 20: 1142–1150. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Wang XS, Mendoza TR, Gao SZ, et al. : The Chinese version of the Brief Pain Inventory (BPI-C): its development and use in a study of cancer pain. Pain, 1996, 67: 407–416. [DOI] [PubMed] [Google Scholar]
- 29.Isner-Horobeti ME, Dufour SP, Schaeffer M, et al. : High-force versus low-force lumbar traction in acute lumbar sciatica due to disc herniation: a preliminary randomized trial. J Manipulative Physiol Ther, 2016, 39: 645–654. [DOI] [PubMed] [Google Scholar]
- 30.Diab AA, Moustafa IM: The efficacy of lumbar extension traction for sagittal alignment in mechanical low back pain: a randomized trial. J Back Musculoskeletal Rehabil, 2013, 26: 213–220. [DOI] [PubMed] [Google Scholar]
- 31.Unlu Z, Tasci S, Tarhan S, et al. : Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniation measured by clinical evaluation and magnetic resonance imaging. J Manipulative Physiol Ther, 2008, 31: 191–198. [DOI] [PubMed] [Google Scholar]
- 32.Lee CH, Chung CK, Kim CH: The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine J, 2017, 17: 1770–1780. [DOI] [PubMed] [Google Scholar]
- 33.Yip C, Han NR, Sng BL: Legal and ethical issues in research. Indian J Anaesth, 2016, 60: 684–688. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Wilk AS, Platt JE: Measuring physicians’ trust: a scoping review with implications for public policy. Soc Sci Med, 2016, 165: 75–81. [DOI] [PubMed] [Google Scholar]
- 35.Graugaard PK, Holgersen K, Finset A: Communicating with alexithymic and non-alexithymic patients: an experimental study of the effect of psychosocial communication and empathy on patient satisfaction. Psychother Psychosom, 2004, 73: 92–100. [DOI] [PubMed] [Google Scholar]
- 36.Lewis S, Holmes P, Woby S, et al. : The relationships between measures of stature recovery, muscle activity and psychological factors in patients with chronic low back pain. Man Ther, 2012, 17: 27–33. [DOI] [PubMed] [Google Scholar]
- 37.Lee JE, Watson D, Frey-Law LA: Psychological factors predict local and referred experimental muscle pain: a cluster analysis in healthy adults. Eur J Pain, 2013, 17: 903–915. [DOI] [PMC free article] [PubMed] [Google Scholar]