Therapeutic Alliance: Patients’ Expectations Before and Experiences After Physical Therapy for Low Back Pain—A Qualitative Study With 6-Month Follow-Up

Abstract

Objective

The aim of this study was to explore patients’ expectations before and experiences after physical therapy for low back pain.

Methods

Qualitative in-depth, semi-structured interviews with patients attending physical therapy were performed before, immediately after, and 6 months after treatment. Data were analyzed from a hermeneutical perspective with decontextualization, recontextualization, and identification of themes.

Results

Patients’ pretreatment expectations to physical therapy focused around exercises and a body-oriented diagnosis. After treatment, reassurance, active listening with explanations, and personally adapted strategies for self-managing pain and regaining control over everyday activity were expressed as decisive for a meaningful therapeutic alliance.

Conclusion

Expectations before treatment focused on exercises and diagnosis. Empathetic and personally adapted education aimed at empowerment was experienced as a meaningful aspect of the therapeutic alliance after treatment. The therapeutic alliance provided a basis to integrate knowledge on the complexity of pain.

Impact

Our findings indicate that patients emphasize physical therapists’ interactional and pedagogical skills as meaningful aspects of the therapeutic alliance, which has implications for clinical practice and training physical therapist students.

Introduction

Low back pain is an increasing public health problem associated with decreased physical function, an unhealthy lifestyle, and reduced participation in work and other areas of social participation.¹ Given the multidimensional nature of low back pain, traditional biomedical approaches have not resulted in lasting improvement.² To improve long-term treatment outcomes, therapy must support behavioral change by fostering patient empowerment and self-efficacy. Therapeutic alliance may be a key to enhancing stable lifestyle modifications and treatment outcomes for musculoskeletal conditions and low back pain.^3–5

Therapeutic alliance refers to the relational processes at play in treatment that can act in combination with or independent of specific interventions.⁵ The concept of therapeutic alliance can be traced back to Freud’s theory of psychoanalysis.⁶ Three essential elements in the therapeutic alliance have been described: agreement on treatment goals, agreement on tasks, and development of a personal bond.⁷ A constructive therapeutic alliance can enable the patient to believe in, accept, and follow the treatment and, therefore, enhance the treatment outcome. In line with this, a qualitative study indicated that therapeutic alliance facilitated adherence to exercise and physical activity in patients with knee pain.⁸ Moreover, an experimental controlled study including 117 patients with low back pain indicated that an enhanced therapeutic alliance modulated pain intensity and muscle pain sensitivity.⁹ Additionally, an observational study of 182 patients with low back pain and their physical therapists indicated that therapeutic alliance was positively associated with a range of treatment outcomes, including functioning and disability.¹⁰ The authors recommended studies exploring the possible mechanisms behind this observed relation.

Self-determination theory is fundamental to the concept of therapeutic alliance.⁵ Research guided by self-determination theory focuses on social contexts that can catalyze motivation and optimize individuals’ performance and well-being. Self-determination theory describes how, when met, the psychological needs for competence, autonomy, and relatedness will enhance self-motivation.¹¹ Accordingly, individuals must not only experience competence for intrinsic motivation to be activated, but they must also experience their behavior as self-determined. Self-determination theory also hypothesizes that intrinsic motivation is more likely to flourish in contexts characterized by security and relatedness.

Though the importance of the relational aspects of therapy is acknowledged, physical therapists may find it hard to apply a biopsychosocial approach in the treatment of low back pain.¹² A recent review has suggested that advice and information are underused in the treatment of low back pain.¹³ One reason for this may be the sparse knowledge of how patients experience the role of and crucial elements in the patient-therapist relationship during and after the treatment process. Therefore, there is a need for more knowledge of the patients’ views about what factors constitute and improve the therapeutic alliance. On this background, we aimed to explore how patients with low back pain express their views on therapeutic alliance in physical therapy in stages before and after treatment. We aimed to focus on patients’ expectations before and experiences after physical therapy for low back pain.

Research Question

How do patients express their expectations before and experiences after physical therapy for low back pain?

Methods

Design

Investigating the research questions, we chose a qualitative hermeneutical study design with an interpretative approach. Hermeneutics is the theory and practice of interpretation.¹⁴ People’s experiences are always contextualized, and this requires interpretation within the situational context. Thus, when the researcher forms an interpretation of the meaning of the participants’ expressions, the study becomes interpretative.¹⁵ Thus, we sought to highlight and interpret the participants’ own voices in the context of current physical therapist practice. Our participants shared their views through stages in interviews before, immediately after, and 6 months after treatment. We followed patients attending physical therapy prospectively to explore how they experienced the process of developing a meaningful therapeutic alliance.

Participants

The study sample consists of consecutive physical therapy seekers included in a laboratory study¹⁶ with the following inclusion criteria: non-specific low back pain of any duration as the primary complaint, not yet having started physical therapist treatment, and age above 16 years. The exclusion criteria were already in treatment for low back pain and unable to understand or express oneself in Norwegian. Key personnel in primary care physical therapist services identified patients who met the inclusion criteria at their initial contact with the services and handed out letters of invitation. Those who did not respond to the invitation were not asked to give any reason for declining participation. Thus, this is a purposeful sample that can inform an understanding of the research questions.¹⁷ Recruitment stopped at the point of data saturation when the authors were unable to identify any new emerging elements of experiences in the transcripts. Thus, the sample consisted of 8 women and 5 men, aged 23 to 57 years, with pain duration ranging from 6 months to 20 years. Only 2 of the 13 participants had previous experience with physical therapist treatment, and for problems other than low back pain. All 13 participants completed the first interview, 11 participants completed the second interview, and 8 participants completed the third interview. The flow of participants through the study is shown in Table 1.

Table 1.

Flow of Participants^a

Participant	Interview 1	Interview 2	Interview 3
1	X	X	X
2	X	X	X
3	X	X	X
4	X	X	X
5	X	X	X
6	X	—	—
7	X	X	X
8	X	—	—
9	X	X	X
10	X	X	X
11	X	X	—
12	X	X	—
13	X	X	—

^aX = did participate in interview; — = did not participate in interview.

Data Collection

We used individual, semi-structured interviews to obtain participants’ perspectives. This method aims to collect descriptions of the participants’ individual experiences with respect to interpretation of these described experiences.¹⁸ Participants were interviewed 3 times: before attending physical therapy, immediately after the end of treatment, and 6 months after treatment. This prolonged engagement¹⁹ was undertaken to achieve credible findings on the process of attending physical therapy. We also kept a reflective journal as a log of logistics, personal diary, and methodological log.

The authors developed a semi-structured interview guide for the first interview. The guide built on dialogue with colleagues and patients, the authors’ clinical and scientific experience, and a literature review of topics related to patients’ expectations and experiences of physical therapist treatment. Because we aimed to explore individual perspectives on physical therapy as a process, the second and third interviews focused on topics emerging from the previous interview(s) with the individual participant, such as topics connected to the therapeutic alliance. In doing so, we performed member checking¹⁹ to ensure that our understanding of the participants’ expressions was in line with their experiences.

The interviews were carried out by the last author, who has extensive experience with qualitative data collection, or by an experienced research fellow. The interviewer and the participants had not met prior to the first interview, and the interviewer was presented as a researcher from the university. Before the interview started, information about the study was repeated, emphasizing the study’s aim and research question as well as research ethics, including volunteerism, informed consent, and confidentiality. The participants were interviewed individually and face-to-face for approximately 30 to 60 minutes. The interviews took place in sheltered rooms in clinics, the participant’s workplace, or the interviewer’s office, depending on the participant’s preference. All topics listed in the interview guide were discussed with each participant. All interviews were audio-recorded and transcribed verbatim in word. The transcriptions were anonymous, and each participant was assigned a number.

Data Analyses

The data were analyzed by both authors. The findings of the analysis were subjected to peer debriefing by fellow researchers.¹⁹ During the analytical process, we aimed to be open-minded, curious, and reflective and sought to promote the participants’ genuine voice. The data analysis draws on a hermeneutic strategy, which is a strategy aiming at developing new horizons of understanding while acknowledging and dealing with the researchers’ preconceptions. This strategy is characterized by the hermeneutical circle, which is constantly moving between the parts and the whole of the data, a de-contextualization and re-contextualization of data, with the object of gaining a growing understanding of the data.¹⁴ The hermeneutical circle strategy is inspired from hermeneutical phenomenology, which tries to be attentive to both terms of its methodology. It is descriptive by being attentive to how things appear, and it is interpretive, because lived experience needs to be captured in language. The latter is inevitably an interpretive process, investigating the personal and individual against the background of an understanding of the social.²⁰

First, the last author read and re-read the interview transcripts, highlighting significant excerpts, statements, and quotes. Statements illuminating the participants’ expectations and experiences of physical therapy were classified as significant. Such elements were often identified by the participants’ use of emotional or value-laden expressions, such as “take me seriously and be careful,” and “I hope I can get help and stop worrying so much.” This first reading and re-reading is called horizonalization.¹⁵ The authors independently read the excerpts that contextualized the highlighted statements and independently coded them. Further analyses were performed by both authors in close collaboration. We discussed our coding until we reached a consensus on clusters of meaning across transcripts. Examples of such clusters of meaning are “find out what is wrong,” “reassured that there was nothing seriously wrong,” and “now I feel much safer, I know my back.” Finally, we wrote a composite description that presented the essence of the participants’ experiences and the underlying structure or theme of their experiences.¹⁵ To increase the study’s dependability, examples of the analytical process are provided in Table 2.

Table 2.

Examples From the Analytical Process

Horizonalization	Cluster of Meaning	Essence	Structure
“I hope (s)he will find out what is wrong”	Find out what is wrong	Verification	Being an expert
“I expect to get some exercises”	Do exercises	Participation	Involving patient
“I feel that I know a lot more about my back now and about pain”	Know more	Transfer of knowledge	Explaining and empowering
“Now I know the pain is not dangerous and that makes me more relaxed”	More relaxed	Building trust	Trustworthy and reassuring
“I felt I was taken seriously and respected and that made me more willing to listen to him/her too”	Taken seriously	Acknowledgment	Autonomy

These findings are summarized in the Results section with respect to pretreatment expectations and experiences after treatment. Furthermore, in Table 3, the themes/structures emerging from the interview analyses are illustrated by the most meaningful quotations from the interviews. The quotations and the interview guide for the first interview (Fig. 2) enhance the study’s confirmability.¹⁹ All participants are represented through the quotations.

Table 3.

Themes and Quotations From the Interviews

Theme	Illustrative Quotations	Outcome a
Expectations before treatment
Being a body-oriented expert, identifying a tangible cause, and giving a diagnosis	“I hope the physical therapist can find the correct muscular exercises and get me back on track.”	Improvement
	“I hope the physical therapist will find a muscle or something to loosen up and that he/she will be confident in solving the problem.”	Improvement
	“I hope the physical therapist can tell me that ‘Here it is, this is the cause of your pain, and we can do something about it.”	Improvement
Involving the patient	“I expect to get some exercises to strengthen my muscles.”	Improvement
	“I want some exercises. Now I want to exercise to recover completely.”	Improvement
	“I am probably just told to do exercises.”	No improvement
	“Well, I thought I might try physical therapy to see if I could get some help. I am not sure what it will be like, probably just some exercises.”	No improvement
Experiences after treatment
Trustworthy and reassuring	“I felt that the physical therapist took me seriously and listened to me. When I told him/her things he/she really listened. This made me believe in him/her and I trusted him/her.” (after treatment)	Improvement
	“The physical therapist explained and showed me at the same time. He/she was very good at explaining and was very specific. This made him/her trustworthy.” (6 months)	Improvement
	“I was reassured that there was nothing seriously wrong, even though I had pain. I think that was a triggering factor for success. It is relaxing just to know that there is nothing wrong. That was important to get me started, to experience that I could get help, to learn about the back, pain and mobility, and to not be afraid to move and do exercises. It took a while after the treatment was completed before I realized how much it had helped me.” (6 months)	Improvement
	“The most important thing for me was that I learned things and was encouraged not to let the anxiety control me. To get to believe that I could get rid of the pain was very important. It is very psychological indeed. Getting to believe that you can manage on your own and then you master things better too.” (6 months)	Improvement
	“I wish the physical therapy was more specific, like finding out that the cause of my pain was this or that. I felt like the physiotherapist did not even have a plan, and then I did not even care to try so I dropped out. It is annoying.” (6 months)	No improvement
Explaining and empowering	“Now I know what is good for me and what is not. The physical therapist has taught me a lot about my own body and about my pain. Now I feel much safer, and I know my back.” (6 months)	Improvement
	“I am more aware of the importance of strength exercises.” (after treatment)	Improvement
	“We talked a lot. The physical therapist taught me how to ease the pain, and I have learned how to balance my energy.” (after treatment)	Improvement
	“I have learned what triggers the pain and what to do about the pain. Now I know how to avoid situations that trigger the pain, and the physical therapist has taught me exercises that support the back.” (after treatment)	Improvement
	“I only went once. I do not think the physical therapist knew how to help me with my problems. I don’t think he/she realized what my problem is, because I don’t have very much pain or pain all the time.” (after treatment)	No improvement
	“Physical therapy might be good for somebody, but it did not make any difference for me. Doing those exercises were incredibly boring. I did not see the point really.” (6 months)	No improvement
	“I have started to think differently. Now I know what to do and what not to do. The best part was to realize that the pain is not dangerous. It is very much in my mind; I have realized that the thinking is a very important factor.” (6 months)	Improvement
Autonomy, taking control	“It has a lot to do with your own attitude you have to decide to do the exercises.” (6 months)	Improvement
	“In the beginning I was very negative to the treatment, but the physical therapist said ‘Let us try for a month and see how it turns out’. So I tried to do what the physical therapist recommended for a month, and it worked, so I tried it for another month. Now I feel much more in control, and that is the most important.” (6 months)	Improvement
	“It is of course important with those strengthening exercises, but I have never enjoyed doing exercises, and it is actually quite demotivating.” (6 months)	No improvement

^a Improvement: patient stories about recovery or less back pain-related limitations in activity.

Figure 2.

Interview guide for the first interview.

Ethical Considerations

All participants were assured that participation was voluntary and that they could withdraw at any time without any consequences. The participants were provided with oral and written information about the study and signed an informed written consent. All personal information and quotes were anonymized. Gender was also concealed in the quotes to protect the identity of the participants. The study was approved by the Regional Committee for Medical and Health Research Ethics with registration number 2013/2244/REK midt.

Both authors are physical therapists and researchers. We are aware that our experiences as therapists influenced our pre-understanding of trust as an important part of successful physical therapist treatment. To avoid our pre-understanding governing our investigation, we consulted fellow researchers and previous research on the topic. Further, we aimed at transparency at all stages of the research process, describing every step of the research process and our interpretation of empiricism. Thus, we have strived to achieve dependability and confirmability.¹⁹

Results

Themes

The results are presented in 2 main themes with 5 sub-themes. The first theme illuminates the participants’ expectations before attending physical therapy. The second theme outlines the participants’ posttreatment and follow-up experiences of important elements after physical therapist treatment.

Expectations Before Treatment

At the first interview, all participants expressed expectations that the physical therapist would give them exercises to strengthen or loosen up their muscles. All participants except 1 said they expected the exercises to help them “get better.” When asked to elaborate on the meaning of “getting better,” participants mentioned experiencing less pain, improving flexibility and ease of movement, increasing strength, and gaining independence in exercising.

The Physical Therapist as the Body Expert, Identifying a Tangible Diagnosis

Several participants were explicit about their expectation that the physical therapist would determine why they were in pain and identify 1 specific cause of their low back pain.

The physical therapist was described as an expert regarding muscles, joints, and movements. In other words, the participants expected the therapist to be a body-oriented expert and give a diagnosis. This is illustrated in Table 3 through some of the quotations from the first interview. Participants believed that their low back pain was due to muscular problems and expected the physical therapist to identify which muscles were involved. Getting a precise answer as to what caused the pain seemed to be of importance. Some participants also expressed a top-down–oriented expectation for the physical therapist to take control, without focusing on their autonomy, which one participant explained:

“I hope the physical therapist will find a muscle or something to loosen up, and that he/she will be confident in solving the problem.”

Patient Involvement in Exercise Treatment

Before treatment, all participants expected to do exercises and to take an active part in their own treatment when they met with the physical therapist. As one participant explained:

“I want some exercises. Now I want to exercise in order to recover completely.” While this quote seems to reflect the presence of self-determination for active treatment, others did not initially suggest the same motivation. Another participant expressed: “I am probably just told to do exercises.”

The participants’ exercise expectations were mostly directed toward the physical therapist’s skills and competence around bodily structures and impairments, apparently reflecting a biomechanical understanding of physical therapy. Beyond performing exercises, participants did not express expectations about their own engagement in the therapy in the pretreatment interviews.

Below we will present results concerning the participants’ experiences as expressed in the interviews immediately after and 6 months after physical therapist treatment, with a special focus on potential success factors expressed as promotional and crucial for lasting functional improvement.

Experiences After Treatment

The first and second interviews focused on what the participants expressed as important elements in physical therapist treatment. During the third interview, special interest was focused on whether the participants had the same opinion as in the second interview. In the second and third interviews, participants emphasized other elements as important compared with their initial expectations about physical therapy expressed in the first interview. Typical statements in the second and third interviews are listed in Table 3.

A Trustworthy and Reassuring Physical Therapist

The physical therapist’s ability to win trust and reassure participants that their low back pain was not caused by an underlying threatening condition was the most prominent element expressed as triggering for improved function.

“I was reassured that there was nothing seriously wrong, even though I had pain. I think that was a triggering factor for success. It is relaxing just to know that there is nothing wrong. That was important to get me started, to experience that I could get help, to learn about the back, pain and mobility, and to not be afraid to move and do exercises. It took a while after the treatment was completed before I realized how much it had helped me.”

This may reflect a gradual increase in the development of competence and self-determination in parallel with decreasing fear. Many participants initially feared that their back pain was a symptom of something serious, such as cancer or a chronic progressive disease. In the interviews 6 months after treatment, several participants elaborated on the significance of the therapist’s reassurance in their confidence to relax, stop worrying, and resume everyday function and physical activity (Tab. 3).

Of the 11 participants interviewed after completing physical therapy, 8 perceived this reassurance, building on active listening, trust, and connectedness, as a crucial element contributing to improved function. “The physical therapist explained and showed me at the same time. He/she was very good at explaining and was very specific. This made him/her trustworthy” (6 months). However, not all participants experienced the therapist–patient relationship as trustworthy and reassuring, and lack of personally adapted management and engagement from the therapist was suggested as the reason for the lack of treatment success (Tab. 3). The physical therapist’s specific explanation of the probable mechanisms for their complaints was seen as a basis for building trust and for the outcome of the therapy, which is closely related to the next theme.

Explaining and Empowering

The participants expressed the importance of learning about their own body and its capacity in relation to their habits and roles and how this learning improved their function in everyday life. Learning to deal with the pain and how to gradually build tolerance for physical activity was expressed as valuable. “We talked a lot. The physical therapist taught me how to ease the pain, and I have learned how to balance my energy.” This transfer of competence from the physical therapists helped the participants manage choices in their everyday lives and enabled them with strategies to distribute their energy and participate in relevant social areas.

Though 8 participants experienced physical therapy as empowering via such transmission of competence, 3 participants expressed a lack of relevance in the information and management. This made some quit physical therapy, and others did not follow-up on recommendations. To embody new competence, the provision of self-management tools and autonomy through tailored advice was experienced as crucial (Tab. 3).

Autonomy, Taking Control

Being reassured that the back pain is not dangerous and learning strategies for self-management in everyday activity removed many obstacles for improvement.

“In the beginning I was very negative to the treatment, but the physical therapist said “Let us try for a month and see how it turns out.” So I tried to do what the physical therapist recommended for a month, and it worked, so I tried it for another month. Now I feel much more in control, and that is the most important.”

Additionally, the participants experienced that achieving improved capacity and physical function required substantial investments by adjusting their strategies and behavioral patterns for exercise and physical activity (Tab. 3). A condensation of the findings is presented in Figure 1. The figure illustrates patients’ stories on therapeutic alliance as a process with overlapping stages evolving during and after attending physical therapy and supporting empowerment.

Figure 1.

Patients’ view of physical therapy and therapeutic alliance as a process.

These results illuminate how the participants’ perceptions of important elements in physical therapy adapt during and after a series of treatments. Whereas their expectations before physical therapy reflect a perception of physical therapy as hierarchical expertise and body-oriented knowledge, their experiences after treatment reflects a perception of physical therapy as relational, interactional, and empowering. Participants explaining this change in their own opinion of important elements in therapy also presented stories about improvement in everyday physical function immediately after and 6 months after physical therapy.

Discussion

This study longitudinally explored patients’ expectations and experiences after physical therapy for low back pain before and short- and long-term after treatment. We found that whereas patients’ pretreatment expectations focused on exercises and a body-oriented diagnosis, their posttreatment expressions were more focused on reassurance, active listening, and personally adapted strategies for self-managing pain and regaining control over everyday activity. Participants described how their expectations and physical behavior gradually adjusted with the support provided by close communication with their physical therapist. Some participants described how new beliefs about low back pain gradually matured after the treatment ended and contributed to lasting improvement.

Reassurance about the benign nature of low back pain was described as a meaningful aspect of the therapeutic alliance and a triggering element for improvement. A recent review found that patients want consistent and personalized information on self-management strategies.²¹ We also found that receiving personally tailored strategies was experienced as important. The self-management advice obtained relevance by active listening. Meeting the patient and his/her beliefs and fears with tailored and empathetic communication was described as foundational in the therapeutic alliance and for learning and behavioral adjustment. This is in line with previous reviews indicating that communication, interpersonal aspects, and personalized therapy are central themes for therapeutic alliance in musculoskeletal rehabilitation.^5,22

Our findings suggest that precisely tailored management strategies help patients adopt more positive beliefs and behavior that lasts 6 months after treatment. Participants described how they regained faith that they could overcome pain and began the process of taking control of physical and everyday activity. Some participants explained how the physical therapists helped them overcome fear and avoidance by specifically addressing the situations and beliefs that triggered anxiety and symptoms and providing tools to master these situations. Six months after treatment, some participants presented fear management through the reassurance of benignity and positive prognosis as triggering improvement. This suggests that educational and empathetic techniques applied by the therapist met the patients’ need for competence and autonomy.¹¹

Our participants described a change in their view of low back pain and its relevant management toward a more bio-psycho-socially oriented perspective. The finding that patients adjusted their preferences during treatment is in line with previous reports.^23,24 Another qualitative study performed interviews with patients after physical therapist treatment, and patients described a gradual acceptance of self-management.²⁴ In our study, the shared expectations expressed before treatment reflected a biomechanical view of the cause and appropriate physical therapist treatment of low back pain. The body-oriented pretreatment expectations can be viewed in light of the data indicating that patients initially seek medical health care to obtain a diagnosis, management options, and legitimation of pain.²⁵ The need for a tangible diagnosis may have been an attempt to understand pain in order to regain autonomy, which is in line with self-determination theory.¹¹ Posttreatment stories, on the other hand, show that the treatment did not match these expectations. However, most participants experienced treatment success despite this mismatch between treatment expectations and content. Some participants even described the process of adjusting beliefs and expectations as part of the healing process. By widening their perspective on low back pain, the foundation for deeper understanding and more powerful self-management strategies was made in close collaboration with the therapist. Some of the quotations (Tab. 3) show how the therapeutic alliance provided a basis to integrating knowledge on the complexity of pain.

Participants described various types of physical behavior adjustments guided by the physical therapist, for instance, substituting intense and monotonous exercise with more balanced activity. Empowerment through increased knowledge about their own capacity, which led to confidence in everyday choices, was expressed as crucial in the process of improving physical function and social participation. This increase of relevant knowledge was expressed as important by avoidant patients as well as among those with more confronting behavioral patterns (active copers). These results are unlike results from another qualitative study, where participants did not report improvement in feelings of control after active rehabilitation, although fitness was improved.²⁶ In our study, on the other hand, data suggested that some participants embodied the new lifestyle and experienced independence when management had precisely met their needs.

Strengths and Limitations

To explore the expectations and experiences of the participants, we chose to perform serial interviews. This provides a potential window into the experienced change processes during and after physical therapy. The participants’ low back pain duration had substantial variation, which may have contributed to different prerequisites for developing a therapeutic alliance. On the other hand, this reflects the variation in pain duration among primary care physical therapy seekers.

We used a convenient sample recruited from participants in a quantitative study exploring prognostic factors for patients in treatment for low back pain. Therefore, our findings may not reflect a broad perspective from the whole range of patients attending primary care physical therapy for low back pain. Nevertheless, we consider it plausible that results are transferable to comparable patients and contexts.

Implications

This study indicated that patients adjusted their view on physical therapy after successful treatment and gave insights into patients’ experiences of the meaningful aspects of the therapeutic alliance. Reassurance and beliefs adjustment were experienced as crucial for improvement. To adjust their beliefs about low back pain and the components of adequate physical therapy for low back pain, trusting the therapist was essential. Active listening, individual tailoring, continuous monitoring and adjustment of treatment, empathetic communication, and sufficient time with the therapist were experienced as building blocks for a trusting therapeutic alliance.

The finding that patients consider reassurance and communication style to be important supports the view that strategies and techniques for therapeutic communication should be included in the training of physical therapists. A randomized trial has indicated that communication training of physical therapists, based on self-determination theory, improved the patient support given by the therapists.²⁷ Our findings indicate that patients experience the physical therapist’s communication style as essential for a meaningful therapeutic alliance. This has implications for the training of physical therapist students and for clinical practice.

Author Contributions

Concept/idea/research design: M. Unsgaard-Tøndel, S. Søderstrøm

Writing: M. Unsgaard-Tøndel, S. Søderstrøm

Data collection: S. Søderstrøm

Data analysis: M. Unsgaard-Tøndel, S. Søderstrøm

Project management: M. Unsgaard-Tøndel, S. Søderstrøm

Providing participants: M. Unsgaard-Tøndel

Providing facilities/equipment: M. Unsgaard-Tøndel

Providing institutional liaisons: M. Unsgaard-Tøndel

Acknowledgments

The authors thank the participants for sharing their experiences and Gard Myhre for language support.

Ethics Approval

This study was approved by the Regional Committee for Medical and Health Research Ethics in Norway (registration no. 2013/2244/REK midt). All participants gave written informed consent before data collection began.

Funding

There are no funders to report for this study.

Disclosures

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