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RESEARCH ARTICLE Open Access
Characteristics of therapeutic alliance inmusculoskeletal physiotherapy andoccupational therapy practice: a scopingreview of the literatureFolarin Babatunde1*, Joy MacDermid1,2,3 and Norma MacIntyre1
Abstract
Background: Most conventional treatment for musculoskeletal conditions continue to show moderate effects,prompting calls for ways to increase effectiveness, including drawing from strategies used across other healthconditions. Therapeutic alliance refers to the relational processes at play in treatment which can act in combination orindependently of specific interventions. Current evidence guiding the use of therapeutic alliance in health care ariseslargely from psychotherapy and medicine literature. The objective of this review was to map out the available literatureon therapeutic alliance conceptual frameworks, themes, measures and determinants in musculoskeletal rehabilitationacross physiotherapy and occupational therapy disciplines.
Methods: A scoping review of the literature published in English since inception to July 2015 was conducted usingMedline, EMBASE, PsychINFO, PEDro, SportDISCUS, AMED, OTSeeker, AMED and the grey literature. A key search termstrategy was employed using “physiotherapy”, “occupational therapy”, “therapeutic alliance”, and “musculoskeletal” toidentify relevant studies. All searches were performed between December 2014 and July 2015 with an updatedsearch on January 2017. Two investigators screened article title, abstract and full text review for articles meetingthe inclusion criteria and extracted therapeutic alliance data and details of each study.
Results: One hundred and thirty articles met the inclusion criteria including quantitative (33%), qualitative (39%),mixed methods (7%) and reviews and discussions (23%) and most data came from the USA (23%). Randomized trialsand systematic reviews were 4.6 and 2.3% respectively. Low back pain condition (22%) and primary care (30.7%) werethe most reported condition and setting respectively. One theory, 9 frameworks, 26 models, 8 themes and 42subthemes of therapeutic alliance were identified. Twenty-six measures were identified; the Working Alliance Inventory(WAI) was the most utilized measure (13%). Most of the therapeutic alliance themes extracted were from patientperspectives. The relationship between adherence and therapeutic alliance was examined by 26 articles of which 57%showed some correlation between therapeutic alliance and adherence. Age moderated the relationship betweentherapeutic alliance and adherence with younger individuals and an autonomy support environment reportingimproved adherence. Prioritized goals, autonomy support and motivation were facilitators of therapeutic alliance.
Conclusion: Therapeutic Alliance has been studied in a limited extent in the rehabilitation literature with conflictingframeworks and findings. Potential benefits described for enhancing therapeutic alliance might include better exerciseadherence. Several knowledge gaps have been identified with a potential for generating future research priorities fortherapeutic alliance in musculoskeletal rehabilitation.
Keywords: Therapeutic alliance, Musculoskeletal, Physiotherapy, Occupational therapy, Service delivery
* Correspondence: [email protected]; [email protected] of rehabilitation Science, McMaster University, 1400 Main StreetWest, Hamilton, ON L8S 1C7, CanadaFull list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Babatunde et al. BMC Health Services Research (2017) 17:375 DOI 10.1186/s12913-017-2311-3
BackgroundConventional treatments such as exercise commonlyused in the management of musculoskeletal (MSK)conditions continue to show only moderate effects [1–3].Research aimed at improving the effectiveness of treat-ment for MSK conditions should extend beyond conditionspecific interventions to include more general mediatorsof treatment such as communication or psychologicalinteractions between patients and clinicians. One aspectof this is therapeutic alliance (TA) which has beendescribed as the working relationship or positive socialconnection between the patient and the therapist [4] andestablished between therapist and client through collabor-ation, communication, therapist empathy, and mutualrespect [5]. TA is a central component of the therapeuticprocess and is a determinant of treatment outcome [6, 7].The origin of TA dates to back to Freud’s theory oftransference and countertransference [6]. According toBordin [4], TA can be applied to all change situationsindependent of the treatment modality and proposed atripartite model of TA [8] consisting of three essentialelements: agreement on the goals of the treatment,agreement on the tasks, and the development of apersonal bond (reciprocal positive feelings) between theclient and therapist.TA has been studied extensively across a range of psy-
chotherapy treatment modalities and aetiologies [9, 10]with recent findings showing a correlation with satisfac-tion, quality of life [11], psychological well-being [12],and symptom improvement [7]. Studies in medicineshow that TA influences chronic disease care [13],improves adherence, satisfaction and quality of life [14],enhances communication [15, 16] and impacts decisionquality [17]. This is opposed to recent interest in alliedhealth disciplines like physiotherapy (PT) [20, 21] andoccupational therapy (OT) [22]. Findings from physicalrehabilitation show that TA is linked to engagement instroke rehabilitation [16] and treatment outcomes incardiac [17] and musculoskeletal (MSK) [18, 19] re-habilitation. It is notable that many studies used a TAconceptualization and outcome measures developedfrom psychotherapy and did not address TA as aprimary research area. It also remains difficult to decideif outcomes are determined by specific techniques,mechanism of action or general processes like the TA[23]. This continues to limit the application of TAconceptualization from psychotherapy to PT and OT.Furthermore, it remains unclear whether patient or
therapist characteristics most determine outcome [24]and despite similarities, patient and therapist views ofthe key factors for effective TA may differ in importantways [25]. For example, it has been reported that clientsview the TA in terms of collaborative work relationship,active commitment, bond, productive work, confident
progress and agreement on goals/tasks while therapistsfocused on therapist confidence and dedication, clientcommitment and confidence, client working ability, andcollaborative work relationship [25]. Thus, clients placegreater emphasis on helpfulness, joint participation intherapy and negative signs of TA compared to therapists.Adherence is a patient characteristic linked to thera-peutic change and considered an area of priority in MSKresearch and practice [26–28]. In physical rehabilitation,adherence has the potential to unlock some of the prob-lems associated with understanding how TA exert itseffect. Recent evidence shows TA may be the best pre-dictor of adherence to exercise in MSK PT practice [29]and facilitator of patient engagement in OT practice[30]. Identifying the components of therapy responsiblefor symptomatic change would aid in the theoreticalunderstanding of the processes underlying therapeuticchange, improve practice and support development ofeffective practice [31]. Delineating the role of TA as amediator, predictor or moderator of adherence mayenhance understanding of TA as a therapeutic agent inMSK practice [32].Based on these shortcomings in the TA literature, a
comprehensive review of primary research in TA isrequired to map the breadth of literature for MSK con-ditions to advance knowledge in the following areas:conceptualization, active ingredients, psychometricallysound measures, mechanism of effect, and the mediat-ing, moderating or predicting effect of TA on adherence.To this end, we conducted a scoping review of TA inMSK practice informed by the disciplines of OT and PT.The purpose of the study was to describe the type ofresearch conducted to investigate the relationshipbetween TA and rehabilitation of MSK conditions. Specif-ically, this review intends to describe to what extent theliterature has theoretical underpinnings or a commonunderstanding of what constitutes TA, has addressed therelationship between TA and adherence to treatment ortreatment outcomes and how TA is measured.
MethodsThis scoping review was informed by Levac et al. [33]and Arksey and O’Malley [34] methodology. Scopingreviews are used to answer broad questions, synthesiseinformation from a heterogeneous data pool or assesswhether the literature is amenable to systematic review[35, 36]. This review employed the five-stage frameworkas outlined by Arksey and O’Malley: 1) identifying theresearch question, 2) identifying relevant studies, 3) select-ing the studies, 4) charting the data (data extraction), and5) collating, summarising and reporting the results. Report-ing the results includes the use of numerical summariesthat describe study characteristics. Levac et al’s recommen-dations focus on clarifying and enhancing each stage of the
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 2 of 23
framework as follows: (stage 1) expounding and linking theresearch purpose and question; (stage 2) harmonizingfeasibility, breadth and comprehensiveness of the scopingprocess; (stages 3 and 4) using an iterative team approachfor study selection and data extraction; (stage 5) integratinga numerical summary and qualitative thematic analysis,reporting results, and considering the implications of find-ings to policy, practice, or research; and (stage 6) incorpor-ating a knowledge translation strategy though consultationwith stakeholders.
Identifying relevant articlesIn consultation with a librarian, a search strategy wasdeveloped to identify publications addressing TA. Theevidence was searched using electronic databases, refer-ences lists, and by hand searching key journals. Litera-ture search for physiotherapy or occupational therapywere completed to identify experimental studies that dis-cussed or investigated the relationship between TA andadherence to exercise in the management of adults withMSK conditions. Using a combination of key words andmedical subject (MeSH) terms (Table 1) related to TA,eight databases were searched: MEDLINE, PsychINFO,Embase, AMED, SportDISCUS, REHABDATA, PEDroand OTseeker. The search strategy was customized toeach database. A manual search of the reference lists ofidentified articles was also conducted. A sample searchstrategy for the search is outlined in Table 1. Allsearches were performed between July 2015 and
September 2015 using a combination of search terms(Table 1). An updated search was done in January 2017.
Study selectionAfter the initial search was completed abstracts andtitles from the database searches were screened forrelevance by the first reviewer (F.B.) and selected if theymet the following criteria: [1] quantitative, qualitative ormixed methods data in a peer-reviewed journal, [2] system-atic reviews and meta-synthesis, [3] experiences and/orperspectives of the therapist, observer and/or patient,[4] highlight TA or an aspect of TA as the main con-ceptual focus of the article, [5] findings relevant toMSK rehabilitation from adult population, [6] Englishlanguage articles. Studies were excluded if they reportedmixed population data without clearly highlighting MSKconditions or involved surgical and medical interventionsalone. All references were imported to EndNote X7 soft-ware© and all duplicates deleted. Full texts of potentiallyrelevant articles were retrieved and scrutinized by the firstauthor (F.B.) and second author (J.M.) for consensusbefore final inclusion in the study.
Data abstractionData related to TA were extracted from articles meet-ing the inclusion criteria by the lead author (FB) andreviewed by a second author (JM). Each article wasfirst categorized based on study methods (quantita-tive, qualitative, mixed-methods, systematic review ormeta-synthesis, narrative reviews or discussion paper)
Table 1 Sample search Terms and Search Strategy
Therapeutic Alliance Adherence Rehabilitation Musculoskeletal Diseases (MSK)
Key words Key words Key words Key words
[1] Therapeutic alliance (MeSHexploded not focused) (keyword)
[12] Adherence (MeSH explodednot focused) (keyword)
[22] Rehabilitation (explodenot focused) (keyword)
[29] Musculoskeletal diseases(MESH exploded not focuses)(keyword)
[2] Patient therapist relationship [13] Adherea (keyword) [23] Physiotherapya [30] MSK (keyword)
[14] compliance [24] Physical therapya [31] List diseases if you like
[3] Working alliance [15] behaviour [25] Exercise Combine 29 or 30 or….. ➔ 31
[4] Therapeutic relationship [16] behavior [26] Exercise therapy
[17] concordance Combine 22 or 23 or 24 or25 or 26 ➔ 27
aCombine 28 and 31
[5] Collaboration Combine 12 or 13 or 14 or 15or 16 or 17 ➔ 18
aAdd limitations (Inception toMay, 2015, Adults aged 18 andabove, humans, English Language,real patient and therapists)
[6] Helping alliance 28. Combine 21 and 27
[7] Patient acceptance of healthcare (descriptors)
19. Combine 11 and 18
20. Adherence – MeSH + Group2 MeSH[8] Attitude
[9] Bond 21. Combine 19 or 20
[10] Collaboration
Combine 1 or 2 or 3 or 4 or 5 or6 or 7 or 8 or 9 or 10➔ 11aThis was substituted with occupational therapy or vocational rehabilitation in a separate search
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 3 of 23
and level of care (primary, secondary, rehabilitation,private, community, home care, long term care). Thefollowing information was extracted and synthesisedin summary format from the articles: authorship, pub-lication year, country, setting, discipline, aims, design,participants, themes, and findings. Secondary dataextracted included information on the conceptualizationof TA; frameworks, theories or models, relationshipbetween TA and adherence to exercise, measures of TAand participant perspectives on TA themes.
AnalysisDescriptive statistics were calculated to summarize thedata. Frequencies and percentages were used to describenominal data (study characteristics, themes, measures).A narrative synthesis approach [37, 38] facilitated themapping of the core themes of TA that emerged fromthis review. We used a thematic analysis to gather infor-mation and identify all TA themes. Inductive analysiswas adapted and followed 3 stages: 1) extracting findingsand coding findings for each article, 2) grouping of find-ings (codes) according to the topical similarity to deter-mine whether findings confirm, extend, or refute eachother; and 3) abstraction of findings (analyse groupedfindings to identify additional patterns, overlaps, compari-sons, and redundancies to form a set of concise state-ments that capture the content of findings).
ResultsThe initial literature search of the TA literature resulted inan identification of 2795 titles. Of these titles, 691 wereduplicates, 189 were book titles, 24 were non-Englishlanguage articles and 482 did include an exercise or phys-ical activity component. An additional 1279 were removedbecause they did not meet the eligibility criteria: letters,
commentaries, editorials or conference abstracts (n = 426),titles from nursing (n = 160) and medicine (n = 263) andtitles from psychotherapy (n = 430) literature. After finalabstract and full text screening, 130 articles were selectedas listed in (1 s–130 s) (See Additional file 1). The flow ofarticles through the review is shown in Fig. 1.
Study characteristicsParticipants included 7,018 patients, 1225 OTs and 994PTs. By country, most of the publications originatedfrom the USA (23%) or Australia (16.9%). By continent,Europe accounted for 44.6% of the studies as comparedto 30% from North America and 23% from Australasia.There was only one study published in South America,only 2 studies from Asia and none from Africa. Theearliest study dates to a 1981 with an increase in publi-cations (n = 46) between 2011 and 2016 and most of thestudies originated from the PT discipline as depicted inFig. 2. The most reported settings were primary care(34%) and outpatients (25%). Spinal (25%) and degenera-tive joint (21%) conditions were the most reportedhealth condition studied. In some cases (19%) the detailsof the condition treated were not reported. All but twoof the experimental studies were from the PT literature(Additional file 1).
Study designOverall, there were more quantitative (n = 43, 33%) thanqualitative studies (n = 51, 39%) as shown in Table 2.Mixed method studies accounted for 7% and the remain-der were narrative reviews and opinion papers (23%).Amongst PT studies there were similar amounts ofquantitative and qualitative research; 77% versus 80%respectively. Experimental studies represented 4.6% ofthe eligible studies as compared to correlational (9.2%)
Abstract Review (n=600)
Title Review (n=1350)
Full Text Screening(n=235)
Included Articles(n=130)(PT=93, OT=20, PT+OT=17)
Initial title screen (n=1445)
Excluded based on title (n=750)
Excluded based on full text (n=105)
Excluded based on abstract(n=335)
Papers identified and screened(n=2795)
Fig. 1 Search and screen of articles flow chart
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 4 of 23
and descriptive (17%) studies. Survey studies represented9.2% and measurement studies was 5.3%. There was var-ied qualitative study methodologies including groundedtheory (10%), phenomenology (16.9%), narratives (6.1%),ethnography (1.5%), case studies (2.3%), nominal grouptechnique (1.5%) and symbolic interactionism (0.7%).Semi-structured interviews (17.6%) and focus groups(7.7%) were the most reported data collection techniques.
Conceptualization of therapeutic allianceSeveral theories, models and frameworks related to TAwere identified from 16 studies in the literature asshown in Table 3. There were 18 models represented inthe literature including model of human occupation,health belief model, health locus of control, ecologicalmodel of adherence, transtheoretical model, self-regulationmodel, tripartite efficacy model, process model of collabor-ation, biopsychosocial model, consumer model, model ofempathic understanding, resource conservation model,self-management model, model of helping encounter, In-formation-Motivation-Behavioral model, Gelso andCater model, model of physiotherapist-patient interac-tions and independent living model. Eleven frameworkswere reported and represented concepts from healthbehaviour change, compliance, illness perception, self-efficacy, patient beliefs, patient-centred care, satisfaction,helping, and partnership (Table 3). Three theories werelinked to TA (Table 3) including self-determination theory(SDT), self-efficacy theory and social learning theory. SDTwas the only theory with reported empirical evidence ofeffectiveness for promoting therapists’ supportive behaviorduring clinical practice in MSK PT practice [63].
Therapeutic alliance themesThe initial coding of the 130 eligible articles resulted in44 codes, which were reduced and organized into 8themes: congruence, connectedness, communication,expectation, influencing factors, individualized therapy,
partnership, and roles and responsibilities and de-scribed in (See Additional file 2). Table 4 shows thatagreement on goals (32%) was the most reported aspectof congruence. Friendliness (21%) was the most re-ported characteristic of connectedness followed by aperception of a good relationship and genuine interestor concern at 14%. Clarity of information (26%), activelistening (39%) and nonverbal skills (24%) were themost represented characteristics of communication. Ex-pectation was approximately equally represented withregards to both therapy (25%) and outcome (22%). Ex-ternal factors (17%) and therapist skill and competence(30%) were the most identified influencing factors. Pa-tient life experiences (11%) and willingness to engage(11%) were the most reported patient prerequisite. Be-ing responsive and holistic practice were important toindividualized therapy (14.6%). Mutual understanding(23%) and active involvement (28%) were the most im-portant partnership characteristics. Therapist ability toactivate patient resources (13.1%) and motivating or en-couraging patients (26%) were the most reported role andresponsibility.
Therapeutic alliance outcome measuresTwenty-seven measures were identified in 37 studies asshown in Table 5. Six studies were from OT literatureand 4 involved both OT and PT participants. Psycho-metric properties were reported for 21 measures (77%)from 28 studies. The Working Alliance Inventory (WAI)[39, 40] was the most utilized measure (5 studies)among available studies. Other alliance-type measures(3 studies) were the working subscale of the PainRehabilitation Expectation Scale (PRES) [41], the HelpingAlliance Questionnaire (HAq) [42], communication pref-erences of patients with chronic illness questionnaire [43]and revised version of the Helping alliance questionnaire[44]. Four measures from 4 studies focused on satisfaction;Medical Interview Satisfaction Scale (MISS) [45], Health
0
5
10
15
20
25
30
35
40
45
1981-1985 1986-1990 1991-1995 1996-2000 2001-2005 2006-2010 2011-2017
Nu
mb
er o
f T
itle
sAll
PT
OT
PT/OT
Fig. 2 Number of studies published in each 5-year period from 1981 to 2016
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 5 of 23
Care Satisfaction questionnaire [46], MedRisk [47] andPhysiotherapy Outpatient Satisfaction questionnaire [48].Three measures that focused on empathy: Consultation
and Relational Empathy scale [49], Barett-Lennard Rela-tionship scale [50] and Truax Accurate Empathy Scale[51]. One measure focused on communication; the
Table 2 Study characteristics
Characteristics Frequency PT OT PT + OT
N (130) (%) (N = 92) (N = 21) (N = 17)
Source country of study
Australia 22 (16.9) 18 2 2
Brazil 1 (0.7) 1 - -
Canada 8 (6.2) 6 2 -
Germany 3 (2) 2 - 1
Hong Kong 2 (1.5) 2 - -
Iceland 2 (1.5) 1 1 -
Ireland 2 (1.5) 2 - -
Netherland 4 (3.1) 4 - -
New Zealand 8 (6.2) 6 - 2
Norway 2 (1.5) 2 - -
Spain 3 (2.3) 3 - -
Switzerland 2 (1.5) 1 - 1
Sweden 12 (9.2) 8 3 1
Turkey 1 (0.7)) 1 - -
United Kingdom 27 (20.8) 23 2 2
USA 31 (23.8) 12 11 8
Study design
Quantitative methods 43 (33.1) 32 6 5
Qualitative methods 51 (39.2) 41 8 2
Mixed methods 8 (6.2) 4 2 2
Narrative review articles/discussion papers 24 (18.5) 11 5 8
Systematic reviews 4 (3.1) 4 - -
Setting
Community 11 (10) 10 1 -
Long term care 1 (3) - 1 -
Outpatient 25 (21) 19 3 1
Occupational Health 3 (4) 3 - 1
Primary care 41 (34) 33 5 3
Private practice 17 (18) 14 3 -
Rehabilitation 15 (10) 8 5 2
Various (multiple settings) 7 (6) 4 3 -
Conditions
Spinal disorders 33 (25.3) 32 - 1
Degenerative disease 27 (20.7) 22 - 2
General Various 19 (14.6) 17 - 2
Wrist/Hand 10 (7.6) 10 - -
Traumatic injury 9 (6.9) 8 1 -
Upper Limb 15 (11.5) 12 2 1
Workplace injury 2 (1.5) 2 - -
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 6 of 23
Table
3Con
ceptualizationof
therapeutic
alliance
Autho
rCon
text
Orig
inCon
ceptualization
Descriptio
nTherapeutic
Alliance
Them
es
Chanet
al.,2009
(10s)
a Whitlo
cket
al.5A’s
framew
orkof
behaviou
rchange
Existin
gliteratureon
the
self-de
term
ined
motivationand
engage
men
tin
health-promoting
behavior.
bSelf-de
term
inationtheo
ryA.C
ONNEC
T1.Partne
rship
Com
mun
icationstyleand
exercise
compliancein
physiotherapy
2.Con
gruence
Levy
etal.,2008
(30s)
c Physiothe
rapistPsycho
logical
3.Com
mun
ication
4.Person
alized
therapy
Murrayet
al.,2015
(33s)
Supp
ort
B.Ask,A
dvise,Agree,
Assist,Arrange
Che
net
al.,1999
(13s)
a Com
plianceandsatisfaction
with
exercise
Existin
gliteratureandem
pirical
stud
yon
complianceto
home
exercise
inup
perextrem
ityrehabilitation
c Mod
elof
Hum
anOccup
ation
1.Inpu
t1.Com
mun
ication
2.Outpu
t2.Con
nected
ness
c Health
locusof
control
3.Environm
ent
3.Partne
rship
4.Theop
ensystem
4.Influen
cing
factors
c Health
beliefmod
el
Goren
berg
etal.,2014
(109
s)a The
rape
uticuseof
self
Con
ceptualp
racticemod
elfor
occupatio
nalthe
rapy
focused
onun
derstand
ingtherapeutic
useof
self.
c The
Intentional
Relatio
nshipMod
el1.Client
1.Con
nected
ness
2.Interpersonalevents
2.Rolesandrespon
sibilities
3.Practitione
r3.Partne
rship
4.Occup
ationaleng
agem
ent
4.Con
gruence
Harman
etal.,2012
(63s)
a Buildingblocks
ofhe
alth
behavior
change
Existin
gliteratureon
,empirical
stud
iesabou
tbe
haviou
rchange
andlow
back
pain
rehabilitation
c Transtheo
reticalmod
el1.Needforactio
n1.Con
nected
ness
2.Solutio
ns2.Partne
rship
3.Supp
ort
c Motivationalm
odelof
patient
self-managem
ent
3.Redu
cing
threat
4.Partne
rship
5.Con
gruence
Hinman
etal.,2015
(65s)
c Mod
elof
Health
Chang
eExistin
gliteratureon
motivational
interviewing,
solutio
n-focused
coaching
andcogn
itive
behaviou
ral
therapy.
c Dim
ension
sof
health
servicede
livery
1.Practiceprinciples,
1.Con
nected
ness
2.Essentialtechn
iques
2.Con
gruence
3.Step
framew
ork
Hurleyet
al.,2007
(66s)
a Und
erstanding
ofillne
ssParallelp
rocessingframew
orkwith
onearm
dedicatedto
cogn
itive
processing
ofinternalandexternal
stim
ulus
andtheprocessing
ofem
otionalaspectsof
that
stim
ulus.
c Levanthal’sself-regu
latio
nmod
elof
illne
ss1.Iden
tity
1.Con
nected
ness
2.Timeline
2.Partne
rship
3.Con
sequ
ence
3.Influen
cing
factors
4.Cause
5.Con
trol
andcure
6.Illne
sscohe
rence
Jacksonet
al.,2012
(25s)
a Trip
artiteefficacyframew
ork
inclient-the
rapistrehabilitation
interactions
Existin
gliteratureandem
pirical
stud
ieson
efficacybe
liefs
c Trip
artiteefficacymod
el1.Client-related
factors
1.Con
nected
ness
2.Roleandrespon
sibilities
2.Therapistrelatedfactors
bSelf-efficacytheo
ry;
relatio
n-inferred
self-efficacy
3.Person
alized
therapy
4.Em
otionalsup
port
5.Com
mun
ication
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 7 of 23
Table
3Con
ceptualizationof
therapeutic
alliance(Con
tinued)
Jensen
andLorish,1994
(26s)
a Beh
avioralthe
ory-
based
strategies
foren
hancing
patient
treatm
ent
coop
erationandpatient
beliefs
Existin
gliteratureon
compliance,
decision
-making,
cogn
itive
behavioral
therapyandtheexplanatorymod
elof
exercise
andmailedsurveysto
PTs
c Process
Mod
elof
collabo
ratio
n1.Therapeutic
relatio
nship
1.Con
nected
ness
2.Prob
lem
solving
3.Neg
otiatio
n
4.Mutualenq
uiry
Kidd
etal.,2011
(68s)
a Patient
centredcare
Existin
gliteratureandem
pirical
stud
ieson
patient-cen
tred
care
c Biopsycho
socialmod
el1.Abilityto
commun
icate
1.Con
nected
ness
2.Und
erstanding
ofpe
ople
andability
torelate
2.Partne
rship
c Patientspe
rcep
tionof
ago
odph
ysiotherapist
3.Kn
owledg
eandexpe
rtise
3.Influen
cing
factors
4.Con
fiden
ce4.Com
mun
ication
5.Transparen
tfocuson
prog
ress
andou
tcom
e5.Ro
leandrespon
sibility
Knight
etal.,2010
(29s)
a Client
Satisfaction
Existin
gliteratureon
satisfaction,
andph
ysiotherapyandem
pirical
stud
yon
patient
satisfaction.
c Con
sumer
mod
el1.Service
1.conn
ectedn
ess
2.Satisfaction
2.Influen
cing
factors
3.Dissatisfaction
3.Partne
rship
4.Quality
4.Con
gruence
5.Reason
sforseeking
therapy
5.Com
mun
ication
Neuman
etal.,2009
(116
s)c Effect
mod
elof
empathic
commun
icationin
clinical
encoun
ter
Existin
gliteratureandhypo
thesis
onclinicalem
pathy
c Mod
elof
empathic
unde
rstand
ingandadhe
rence
totreatm
entregimen
s(nature)
1.Cog
nitiveactio
noriented
effects
1.Com
mun
ication
2.Affectiveoriented
effects
2.Partne
rship
Niede
rman
etal.,2011
(34s)
a PictorialR
epresentation
ofIllne
ssandSelfMeasure
Existin
gliteratureon
stress,cop
ing
strategies
andresource
utilizatio
n
c Hob
fil’sresource
conservatio
nmod
el1.Self
1.Activatingresources
bSociallearning
theo
ry2.Resource
2.Treatm
entgo
als
3.Separatio
nc Selfmanagem
ent
Norby
andBellner,1994(76s)
a Dim
ension
sof
helping
Existin
gliteratureandem
piricalstud
yon
basicassumptions
ofoccupatio
nal
therapy
c Ten
tativemod
elof
thehe
lping
encoun
ter
1.BasicProfession
al-Oriented
helping
1.Con
nected
ness
2.Und
erstanding
-Oriented
helping
2.Partne
rship
3.Action-Oriented
helping
3.Rolesandresponsib
ilities
Rado
mski,2011
(118
s)c Ecologicalm
odelfor
adhe
rencein
rehabilitation
Existin
gliteratureon
adhe
renceand
occupatio
nalthe
rapy
c Transtheo
reticalmod
elof
change
1.Person
factors
1.Con
gruence
2.Provider
factors
2.Con
nected
ness
3.Interven
tionfactors
3.Com
mun
ication
bSelf-de
term
inationtheo
ry
4.Techno
logy
4.Influen
cing
factors
5.Social
6.Environm
ental
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 8 of 23
Table
3Con
ceptualizationof
therapeutic
alliance(Con
tinued)
Scho
ster
etal.,2005
(100
s)c In
form
ation
Existin
gliteratureandem
pirical
stud
ieson
pred
ictin
gHIV-preventive
behaviou
r
c Inform
ation-Motivation-
Behaviou
ralskills
mod
el1.Exercise
inform
ation
1.Con
nected
ness
MotivationandBehaviou
ral
mod
el2.Exercise
motivation
2.Rolesandresponsib
ilities
3.Exercise
behaviou
ralskills
3.Influen
cing
factors.
4.Barriers
4.Partne
rship
5.Exercise
behaviou
r
Szybek
etal.,2000
(121
s)c M
odelof
Physiotherapist-
patient
interactions
Existin
gliteratureon
Psycho
-therapeutic
encoun
ters,w
orking
alliance,transferen
ceandreal
relatio
nships
c Gelso
andCartermod
el1.Interactions
1.Partne
rship
2.Non
-insigh
toriented
therapist
2.Con
gruence
3.Insigh
toriented
therapist
Verkaaiket
al.,2010
(123
s)a Produ
ctivepartne
rship(P2)
framew
ork
Existin
gliteratureon
power
distrib
utionin
partne
rships
c Inde
pend
entlivingmovem
ent
mod
el1.Con
text
1.Partne
rship
2.Pred
ictedcharacteristics
c Con
sumer
directionmod
el3.Auton
omy
4.Kn
owledg
ea Framew
orks
(n=10
),bTh
eorie
s(n
=3),cMod
els(n
=19
)
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 9 of 23
Medical Communication Behaviour System [52]. Therap-ist support was the focus of 2 measures; the Health CareClimate Questionnaire (HCCQ) [53] (3 studies) and theRelationship Assessment Scale (RAS) (1 study). The Clin-ical Assessment of Modes [54] was used to assess thera-peutic use of self in one study from OT discipline.The Patients’ Experiences in Postacute OutpatientPhysical Therapy Settings [55] was the only measuredeveloped specifically for a rehabilitation setting. Theinformation about and content of each TA measurewas also coded against the themes of TA identified inliterature and the PRES [41] was the only measurereflecting all the eight TA themes. Ten measures(37%) reflected at least 5 TA themes.
Therapeutic alliance and treatment adherenceTwenty-six articles examined the relationship betweenTA and treatment adherence as summarized in Table 6.More quantitative studies (50%) examined adherencecompared to qualitative (42%) and mixed method stud-ies (7.6%). The WAI-12 [39], PRES [41], MISS [45] andHCCQ [53] were the validated TA measures reportedin the literature when investigating the relationshipbetween TA and adherence. The Sports Injury Rehabili-tation Adherence Scale (SIRAS) [56] was the mostreported exercise adherence measure. Two studies(7.6%) reported no change in adherence with enhancedTA compared to 3 studies (11.5%) where improvementin adherence was reported. Improved patient-therapistrelationship accounted for 18–23% of the variance inpatient adherence. Patients and therapists acknowledgethat effective communication improved adherence.Therapists (PT) reported that pleasing the therapist,activating patient resources and connectedness, faith inthe therapist and shared goals are reasons for improvedadherence. In, one study patients reported enhancedTA was not important for improved adherence. How-ever, in other studies (53.8%) patients, TA characteristicspredictive of exercise adherence included agreement ongoals and tasks, clear communication, sense of connected-ness, positive feedback, boosted, genuine interest, individ-ualized care, trust in therapist and feeling empowered areimportant for developing exercise adherence behavior.Moderators are “pre-randomized” baseline characteristicsthat interact with treatment to influence the direction ormagnitude of outcomes [57]. Levy et al. [58] showed that
Table 4 Core Themes of Therapeutic alliance
Themes (n = 8) Codes (n = 44) No of studiesN (%)
Congruence Agreement on goals 32 (24.6)
Problem identification 19 (14.6)
Agreement on tasks 27 (20.7)
Connectedness Perceived good relationship 14 (8.7)
Friendliness 21 (20.3)
Empathy 16 (9.7)
Caring 15 (15.5)
Warmth 13 (10)
Genuine interest/concerna 14 (10.7)
Therapist faith/beliefa inpatient
8 (7.7)
Honestya 2 (1.5)
Courtesya 4 (3.0)
Communication Nonverbal 24 (18.4)
Listening skills 39 (30)
Visual aids 7 (5.3)
Clear explanation andinformationa
26 (20)
Positive feedbacka 9 (6.9)
Expectation Therapy 25 (19.2)
Outcomes 22 (16.9)
Individualizedtherapy
Responsiveness 9 (6.9)
Holistic practice 8 (7.7)
Influencing factors
External factors Structures, processes andenvironment
17 (13.1)
Therapist prerequisite Skill and competence andexperience
30 (23.1)
Personal characteristics 13 (10)
Humor 7 (5.3)
Life experiences 7 (5.3)
Emotional intelligencea 3 (2.3)
Patient prerequisite Personal characteristics 6 (4.6)
Existing resources 10 (7.7)
Life experiences 11 (8.4)
Willingness to engage 11 (8.4)
Partnership Trust/dependability 23 (17.6)
Respect 19 (14)
Mutual understanding 24 (18.4)
Knowledge exchange 19 (14.6)
Power balance 6 (4.6)
Active involvement/engagement
28 (21.5)
Roles and responsibilities Activating patient’s resources 17 (13.1)
Motivator/Encouragera 26 (20)
Table 4 Core Themes of Therapeutic alliance (Continued)
Professional manner 13 (10)
Educator/Advisera/Guidea 11 (8.4)
Active follow-upa 5 (3.8)
Autonomy supporta 3 (2.3)aNew component descriptors identified from in this review
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 10 of 23
Table 5 Measures of Therapeutic Alliance
Articles Outcome Measure Therapeutic Alliance Themes Psychometrics
C Cm E I P Pt Co Rr
Adamson et al., 1994 (1 s) Attitude scale (19-item) X X X X X Yesa
Stenmar and Nordholm, 1994 (101 s)
Baker et al., 2001 (4 s) Participation Method AssessmentInstrument (21-item)
X X X X Yesb
Beattie et al., 2005 (6 s) MedRisk Instrument for Measuring PatientSatisfaction with Physical Therapy Care(MR-12) (12-item)
X X X X Yesa
Besley et al., 2010 (7 s) Health Alliance Questionnaire (HAQ)(19-item)
X X X X X Yesa
Bliss, 2010 (8 s) Working Alliance Inventory (WAI-12)(12-item)
X X X Yesa
Besley et al., 2010 (7 s)
Burns et al., 1999 (9 s)
Morrison, 2013 (98 s)
Chan and Can, 2010 (10 s) Self-developed questionnaire (5-item) X X No
Cole and McLean, 2003 (14 s) Self-developed questionnaire (10-item) X X X X X No
Eklund et al., 2015 (17 s) Working Relationship Questionnaire(HAqII) (19-item)
X X X X X X X Yesa
Farin et al., 2011 (57 s) KOPRA questionnaire (32-item) X X X X Yesa
Ferreira et al., 2013 (18 s) Working Alliance Theory of ChangeInventory (WATOCI) (16-item)
X X X X X Yesb
Hall et al., 2012 (23 s) Yesa
Cheing et al., 2010 (12 s) Pain Rehabilitation Scale (PRES) (54-item) X X X X X X X X Yesa
Fuentes et al., 2014 (20 s)
Vong et al., 2011 (42 s)
Gorenberg and Taylor, 2013 (109 s) Clinical Assessment of 5 Modes Scale(23-item)
X X X X X Yesa
Taylor et al., 2011 (39 s)
Grannis et al., 1981 (22 s) Q sort questionnaire (28-item) X X X X No
Hills and Kitchen, 2007 (24 s) Physiotherapy Outpatient SatisfactionQuestionnaire (38-item)
X X X X Yesa
Jackson et al., 2012 (25 s) Relationship Assessment Scale (RAS)(16-item)
X X X X X X Yesa
Kersten et al., 2012 (27 s) Consultation and Relational Empathy(CARE) (10-item)
X X X X Yesa
Kerssens et al., 1999 (28 s) Self-developed questionnaire (11-item) X X X X No
Knight et al., 2010 (29 s) Service dimension questionnaire (12-item) X X X X X Yesa
Lysack et al., 2005 (31 s) Self-developed questionnaire (3-item) X X X X No
Medina-Mirapeix et al., 2015 (32 s) Patient Experience in Post-Acute OutpatientPhysical Therapy (PEPAP-Q)
X X X X X X X Yesa
Murray et al., 2015 (33 s) Health Care Climate Questionnaire(HCCQ) (6-items)
X X X X Yesa
Chan et al., 2009 (10 s)
Levy et al., 2008 (30 s)
Roberts and Bucksey, 2007 (36 s) Medical Communication BehaviourSystem (23-item)
X X X Yesa
Roberts et al., 2013
Thomson et al., 1997 (40 s) Barrett-Lennard Relationship Inventory(BLRI) (64-item)
X X X X No
Thomson et al., 1997 (40 s) Truax Accurate Empathy Scale(TAES) (8-item)
X No
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 11 of 23
age moderated the relationship between TA and clinic-based adherence with younger and more autonomousindividuals being more adherent to treatment. Predictorsare baseline characteristics that predict response in bothtreatment and control groups [59]. Mediators are variablesresponsible for all or parts of the effects of a treatment oroutcomes. They change during treatment, are associatedwith treatment and must influence outcome to be consid-ered a mediator [57]. In this scoping review, prioritizationof goals, autonomy support and motivation mediated therelationship between TA and adherence.
Participant perspectives on therapeutic allianceTo better delineate the phenomenon of TA, we analyzedthe perspectives of TA among patients, therapists orobservers as shown in Fig. 3 in the interventional andnon-interventional studies. Observers were mostlyresearchers or other therapists not directly involved inpatient care. Overall, most of the views shared werefrom patients. Twenty articles (15.3%) represented viewson congruence out of which 9 reflected patient’s per-spectives. Thirty-five articles (26%) represented views oncommunication with patient perspectives alone account-ing for 65% of the articles. Sixteen articles (12%)reported perspectives on expectations with patient viewsrepresenting 75%. Eleven articles (8%) represented viewson individualized therapy out of which 7 studies por-trayed patient perspectives. Thirty-nine articles (30%)represented views on partnership with patients’ per-spective accounting for nearly half of all the articles.Fifty-two articles (40%) represented views on connect-edness of which 28 articles represented patient viewsalone. Thirty-three articles (25%) identified the therap-ist role and responsibilities as key determinants of TAwith patient perspective accounting for more than halfof the data. Fifty-one articles (39%) represented par-ticipant views on influencing factors; patient prerequi-sites (37%), therapist prerequisites (35%) and externalfactors (27%). Among the 8 themes, communication,interpersonal aspects, partnership and roles and re-sponsibilities were regarded as the most importantdeterminants of TA according to patients. A break-down of the code (subcategory) under each theme ishighlighted in (See Additional file 3).
Secondary synthesis of systematic reviewsThere were 3 articles in the PT literature focused onreviewing the evidence on TA in this scoping review.There were 2 systematic reviews with a total of 11 stud-ies. Besley et al. [60] examined a wide range of PT clin-ical practice but included 4 MSK studies and reportedthat there were 8 core components of TA includingpatient expectations, personalized therapy, partnership,therapist roles and responsibilities, congruence, commu-nication, relational aspects, and influencing factors. Theauthors reported that the WAI [39], [40] and HAq [42]measures of alliance did not adequately address all thecomponents of TA. The study by Hall et al. [61]included 6 MSK studies and reported 3 key componentsof TA including agreement in goals, agreement on inter-ventions and affective bond. Three outcome measures ofTA; WAI-12 [39], WAI-36 [40] and MedRisk [47] wereused in the MSK studies. Hall et al. [61] reported posi-tive associations between TA and global perceived effect,change in pain, physical function, patient satisfaction,depression and general health status. In a recent meta-synthesis of qualitative studies, O’Keeffe et al. [62] iden-tified 4 themes of TA from 12 codes across 13 MSKstudies. These included physical therapist interpersonaland communication skills (listening, empathy, friendliness,encouragement, confidence, nonverbal communication),physical therapist practical skills (patient education,physical therapist expertise and training), individualizedpatient-centred care (individualized, taking patient prefer-ences and opinion into consideration) and organizationaland environmental factors (time, flexibility with patientappointment and treatment).
DiscussionThis study represents a mapping of the breadth of theevidence for TA in PT and OT MSK practice and identi-fied eight themes of therapeutic alliance valued bypatients across different MSK settings and populations.Kayes and McPherson [63] identified that TA isincreasingly regarded as an important determinant ofengagement in physical rehabilitation but several gapsexists which hinder understanding of TA. This scop-ing review is an attempt to provide a foundation forfuture research by collating and summarizing thetheoretical and empirical evidence concerning the
Table 5 Measures of Therapeutic Alliance (Continued)
Tousignant, 2011 (41 s) Health Care Satisfaction questionnaire(26-item)
X X Yesa
Sluijs et al., 1991 (37 s), 1993 (38 s) Patient Education checklist (5-item) X Yesa
Wright et al., 2013 (43 s) Medical Interview Satisfaction Scale (26-item) X X X X X Yesa
Key: C-Congruence, Co-connectedness, Cm-Communication, E-Expectation, I-Influencing factors, P-Partnership, Pt-Personalized Therapy, Rr-Roles and ResponsibilitiesaPsychometric property tested in studybPsychometric property reported from another study
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 12 of 23
Table
6Relatio
nshipbe
tweentherapeutic
allianceandadhe
renceto
treatm
ent
Stud
ies
Aim
Popu
latio
nDesign
Therapeutic
Alliance
Measure
Adh
eren
ceMeasure
Results
Bliss,2010
(8s)
Toexam
inepsycho
social
variables
likeattachmen
tstyle,de
pression
andthe
working
allianceas
pred
ictorsof
treatm
ent
outcom
es
Chron
icknee
pain
(n=59)
Correlatio
nalstudy
Working
Alliance
Inventory
5-item
self-repo
rtmeasure
oftreatm
ent
compliance(α=0.83)
Thetransformed
WAIscores
weresign
ificantlypo
sitively
correlated
topain
interfe
rence
andseverity,patient
compliance
andsatisfaction.Thetransformed
WAIaccou
nted
for2
4%of
the
varianceinpatient
compliance
Cam
pbelletal.,2001
(48s)
Toun
derstand
reason
sforcomplianceand
non-compliancewith
aho
me-basedexercise
regimen
Knee
osteoarthritis
(n=20)
Groun
dedtheo
rywith
them
aticanalysis
Interviews
Interviews
Com
pliancewereapparent
initiallywhe
nattend
ingPT
sessions
andlaterwhe
na
numbe
rof
factorscombine
dto
determ
inecontinuedandlong
term
compliance(orno
n-compliance).C
ontin
ued
compliancede
pend
son
ape
rson
’spe
rcep
tionof
their
symptom
s,theeffectiven
essof
theinterven
tion,theirability
toincorporateitinto
everyday
life
andsupp
ortfro
mph
ysiotherapists.
Amod
elof
continued
compliancewas
develope
d.
ChanandCan
2010
(11s)
Toevaluate
patients’
adhe
renceto
homeexercise
prog
ramsin
clinicalpractice
andun
derstand
factorsthat
affect
patients’adhe
renceto
homeexercises.
Ortho
paed
ic,spo
rts
injury,handtherapy,
rheumatolog
y(n=82)
Cross-sectio
nalsurvey
stud
y25
item
questio
nnaire
5-item
exercise
perfo
rmance
questio
nnaire.
Motivation,roleof
exercise,
patients’un
derstand
ingof
exercises,verbalandvisual
explanationandsatisfaction
with
PTwerefoun
dto
have
astrong
effect
onpatient’s
perfo
rmance
ofho
meexercises.
Chanet
al.,2009
(11s)
Toinvestigatetheim
pact
ofPT’sautono
my-supp
ortive
behaviorson
patients’
motivationandrehabilitation
adhe
rence
Anteriorcruciate
ligam
entinjury
(n=115)
Correlatio
nalstudy
Health
care
Clim
ate
Questionn
aire
15-item
SportInjury
Rehabilitation
Adh
eren
ceScale
(SIRAS)
Auton
omou
streatm
ent
motivationwas
associated
positivelywith
autono
my
supp
ortbu
ttherelatio
nship
betw
eenautono
mysupp
ort
andcontrolledtreatm
ent
motivationwas
notsign
ificant.
Auton
omou
streatm
ent
motivationfully
med
iatedthe
effect
ofph
ysiotherapists’
autono
my-supp
ortive
behaviou
rson
patients’
adhe
rence.
Patient
self-repo
rtho
me-basedexercise
adhe
rence
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 13 of 23
Table
6Relatio
nshipbe
tweentherapeutic
allianceandadhe
renceto
treatm
ent(Con
tinued)
Crook
etal.,1998
(15s)
Torepo
rttheprob
lem
expe
rienced
with
patient
engage
men
tin
PT-ledgrou
psun
dertakingeither
anaerobicexercise
ora
stretching
andrelaxatio
nprog
ram.
MSK
disorders(n=228)
Mixed
metho
dsstud
y(quasirand
omized
controlledtrial,
interviews,checklist)
Individu
alinterviews
Hom
eexercise
diaryfor
exercise
activity
PTsandpatientsacknow
ledg
ethat
listening
was
anim
portance
partof
the
therapeutic
relatio
nshipthat
improved
adhe
rence.
LBP[52],N
eckpain
[30];
Lower
limbpain
[25],
Shou
lder
pain
[12]
Escolar-Reinaet
al.,2010
(56s)
Toexplorepe
rcep
tions
ofpe
oplepain
abou
tthe
characteristicsof
home
exercise
prog
ramsandcare-
provider
styledu
ringclinical
encoun
tersmay
affect
adhe
renceto
exercises.
Chron
icne
ckor
low
back
pain
(n=34)
Groun
dedtheo
ryapproach
Interviews
NA
Patient
adhe
renceto
home-
basedexercise
ismorelikelyto
happ
enwhe
ncare
providers’
style(clinicalknow
ledg
e,feed
back,g
ivingreminde
rs,
mon
itorin
gadhe
renceand
prom
otingexercise
feed
back
andtheconten
tof
exercise
prog
ramme)
arepo
sitively
expe
rienced
.
Freene
etal.,2014
(96s)
Tocompare
aPT-ledho
me-
basedPA
prog
ram
tousual
practiceof
commun
itygrou
pexercise
prog
ram
tode
term
ineeffectiven
essin
middle-aged
adultsfor
increasing
physicalactivity
levelsover
theshortand
long
term
.
Sede
ntarycommun
itydw
ellingadults(n=37)
Mixed
metho
dsstud
y(quasirand
omized
trial,
focusgrou
ps)
Interviews
Self-repo
rton
Active
AustraliaSurvey
Mostparticipantsagreed
the
physiotherapistwas
anen
abling
factor
fortheho
me-based
interven
tion,althou
ghothe
rsdidno
tthinkthiswas
impo
rtant.
Participantsrepo
rted
ago
odinteractionwith
thePT
andfelt
they
wereexpertand
know
ledg
eable.
Reliableandvalid
natio
nalm
easure.
Adviceandsupp
ortand
individu
allytailoredprog
ram
from
thePT
andago
odrelatio
nshipwith
theinstructor
was
impo
rtantforcontinued
participationin
physicalactivity
atho
me.
Gleeson
etal.,1991
(21s)
Tode
veloppo
liciesand
proced
ures
abou
tmanagem
entof
patient
non-attend
ance
inOT.
Handinjuries,bu
rns,
rheumatolog
y(n=100)
Cross-sectio
nalsurvey
stud
ySurvey
instrumen
tPatient
andtherapist
commen
ton
non-
adhe
rence
28%
ofpatientsbe
lievedthat
poor
commun
icationwith
the
therapistwas
thereason
for
non-adhe
rence.
PTsfeltthat
non-
attend
ance
affected
continuity
ofcare
due
todifficulty
inevaluatin
gthe
overalleffectiven
essof
treatm
ent,un
met
goals,inability
toestablish
ongo
ingplans,and
concernregardingdischarge.
PTssawno
n-complianceas
the
resultof
aneed
todevelop
person
alskills
(empathy,warmth,
concern),dem
onstratinga
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 14 of 23
Table
6Relatio
nshipbe
tweentherapeutic
allianceandadhe
renceto
treatm
ent(Con
tinued)
feelingof
respon
sibilityfor
non-attend
ance.
Harman
etal.,2012
(63s)
Tode
scrib
etheapproach
used
byaPT
durin
garehab
prog
rammeforinjured
mem
bersof
themilitary
design
edto
enhanceself-
efficacyandself-
managem
entskills.
Chron
iclow
back
pain
(n=12)
Qualitativestud
ywith
interpretiveparadigm
Interviews
NA
Trustin
gtheph
ysiotherapist
helped
patientscontinue
with
theirprog
rammede
spite
itgettingharder,challeng
ingtheir
confidence,and
notshow
ing
immediate
results.
Hinman
etal.,2015
(65s)
Toexploreho
wpatients,PTs
andteleph
onecoache
sexpe
rienced
,and
madesense
ofan
integrated
prog
ram
ofPT-sup
ervisedexercise
and
teleph
onecoaching
.
Knee
osteoarthritis
(n=6)
Groun
dedtheo
rywith
symbo
licinteractionism
Interviews
Interviews
Patientsfeltaccoun
tableand
respon
sibleformeetin
ggo
als
whe
npe
rceivedattentionfro
mPT
was
individu
alized
and
genu
ine.
PTsappreciatedprovidingclear
inform
ationandmon
itorin
gprog
ress,incorpo
ratio
nof
exercise
into
daily
routine.PTs
recogn
ized
thatcollabo
ratio
n,mutualund
erstanding
and
emph
asising
thesametreatment
with
theclient
asthecentral
characterw
ereimpo
rtant.
Hurleyet
al.,2010
(66s)
Toexplorethehe
alth
beliefs,
expe
riences,treatmen
texpe
ctations
ofpe
oplewith
chronicknee
pain,and
investigateif,ho
wandwhy
thesechange
aftertaking
parton
anintegrated
exercise-based
rehabilitation
prog
ramme
Chron
icknee
pain
(n=29
Groun
dedTheo
rywith
them
aticanalysis
Interview
Atten
dance
Thecare,sup
portandgu
idance
participantsreceived
durin
gthe
inform
aldiscussio
nshelped
build
atrustin
g,collabo
rative
partnershipbetweenpatient
and
PT.Thisincreasedparticipant’
confidence
andtrustinthePT
andbeliefintherehabilitation
prog
ramme.Theinterpersonal
qualities
andprofessio
nalskills
ofthesupervising
PTwere
considered
asimpo
rtantto
the
successof
theprog
rammeas
the
contentof
theprog
rammeitself.
Jacksonet
al.,2012
(25s)
To(i).explore
potential
relatio
nshipsbe
tween
clients’“trip
artite”
efficacy
constructs,relationship
quality
with
thetherapist,
anden
gage
men
tin
exercise
and,
(ii)mod
elactorand
partne
reffectsor
clients’and
therapists’efficacy
beliefsin
relatio
nto
relatio
nshipqu
ality
Osteo
arthritis,
osteop
orosis,b
ursitis
(n=68)
Descriptiveand
Correlatio
nalstudy.
5-itemsfro
mthe7-
item
Relatio
n-ship
adhe
rencescale
3-item
Engage
men
tinstrumen
tIncrease
inpe
rcep
tionof
relatio
nshipqu
ality
weredirectly
relatedto
improvem
entsin
engagementscores,accou
nting
for1
8%of
thevariancein
engagementratin
gs.
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 15 of 23
Table
6Relatio
nshipbe
tweentherapeutic
allianceandadhe
renceto
treatm
ent(Con
tinued)
Jensen
etal.,1994
(26s)
Tointegrateconcep
tsfro
mresearch,the
ory,andpractice
areintegrated
into
aProcess
Mod
elforPatient-Practition
erCollabo
ratio
nforusein
clin
icalpractice
Rheumatoidarthritis.
Correlatio
nalsurvey
stud
yInterview
NA
Pleasing
thetherapistwas
areason
foradhe
renceto
exercisesprescribed
.Osteo
arthritis,low
back
pain
(n=305)
PTs(n=568).
Karnad
andMcLean,2011
(67s)
ToexplorePT’spe
rcep
tionof
exercise
adhe
renceand
interven
tions
used
inclinical
practice.
Chron
icMSK
cond
ition
sInterpretative
Phen
omen
olog
yInterviews
Interviews
MostPTsbe
lieve
that
clear
commun
ication,faith
inthePT,
realistic
treatm
entplans,shared
goalsandpain
educationare
impo
rtantforadhe
ringto
exercise.
PTS(n=5)
King
ston
etal.,2014
(97s)
Tode
term
inewhe
ther
complianceand
unde
rstand
ingof
aho
me
exercise
prog
ram
isim
proved
whe
npatientsareprovided
with
aDVD
.
Traumatichand
injury
(n=53)
Rand
omized
controlled
trial
Follow
upsurvey
Com
pliancemeasures;
diaryrecordingof
exercise,che
cklistfor
correctnessand
unde
rstand
ingof
exercises,weekly
attend
ance
Nosign
ificant
differences
were
foun
din
theoverallm
ean
exercise
compliancescore
betw
eenthegrou
ps.
Allparticipantsrepo
rted
thatthe
instructions
provided
wereeasy
touse(100%).Allrespon
dents
(100%)feltthattheirappo
intm
ent
with
theirh
andtherapist
was
mod
eratelyto
extre
mely
impo
rtant
and90.6%felttheir
appo
intm
entw
asmod
erateto
extremelyimpo
rtant
inmotivating
them
todo
theirexercises.
Levy
etal.,2008
(30s)
Toinvestigatethe
relatio
nshipbe
tween
perceivedautono
mysupp
ort,
age,andrehabilitation
adhe
renceam
ongsports-
relatedinjuries
Tend
onrelatedinjuries
ankle,knee,sho
ulde
r,elbo
w)(n=70)
Prospe
ctivecorrelational
stud
yHealth
care
Clim
ate
Questionn
aire
15-item
SportInjury
Rehabilitation
Adh
eren
ceScale
(SIRAS)
Highautono
mysupp
ort
provided
bytheph
ysical
therapistwas
relatedto
better
clinic-based
adhe
renceandat
tend
ance
butno
tto
home-
basedadhe
rence.Age
was
relatedto
alladh
eren
ceindices
andmod
erated
therelatio
nship
betw
eenpe
rceivedautono
my
supp
ortandclinic-based
rehabilitationadhe
rence.
Clinicattend
ance
Hom
eexercise
adhe
rence
Lidd
leet
al.,2007
(71s)
Toexploretheexpe
riences,
opinions
andtreatm
ent
expe
ctations
ofchroniclow
back
pain
patientsto
iden
tify
whatcompo
nentsof
treatm
entthey
consider
asbe
ingof
mostvalue.
Chron
iclow
back
pain
(n=18)
Narrativestud
yusing
focusgrou
pInterviews
NA
Lack
offaith
inpractitione
rresultedin
participantsigno
ring
advice
andfailing
toadhe
reto
homeexercisesprog
ramsand
continuing
badpo
sturalhabits.
Follow-upsupp
ortandreassur
ance
abou
tcorrectexercise
instructions
andassistance
with
approp
riate
treatm
ent
prog
ressionim
proved
exercise
adhe
rence.
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 16 of 23
Table
6Relatio
nshipbe
tweentherapeutic
allianceandadhe
renceto
treatm
ent(Con
tinued)
Littlewoo
det
al.,2014
(72s)
Toincrease
know
ledg
eand
unde
rstand
ingof
the
expe
rienceof
exercising
and
determ
inepe
rcep
tionof
facilitatorsandbarriersto
exercise.
Rotatorcuff
tend
inop
athy
(n=6)
Phen
omen
olog
ywith
framew
orkanalysis
Interviews
NA
PTsandpatientsagreed
that
ongo
ingsupp
ortin
theform
ofprovidingfeed
back,p
roactive
follow-upandstim
ulatingfur
ther
engage
men
twith
theself-
managed
exercise
prog
rams
whe
nprog
ress
was
slow
were
influen
tialo
nsuccessful
outcom
es
Lysack
etal.,2005
(31s)
Tocompare
compu
ter-
assisted
vide
oinstructionand
routinerehabilitationpractice
oncomplianceand
satisfactionwith
home
exercise.
Totaljoint
arthroplasty
(n=40)
Rand
omized
controlled
trial
3-item
tool
onen
couragem
ent,
courtesy,and
,active
involvem
ent
Self-repo
rton
exercise
perfo
rmance
accuracy,
difficulty
inremem
berin
gexercises,
exercise
frequ
ency,
levelo
fexercise
whe
nfeelingpo
orly,and
duratio
nof
each
exercise
session
Statisticalanalysisshow
edthere
wereno
significantdifferences
atfollow-upbetweenthevideo
andcontrolgroup
son
anyof
theexercise
complianceitems
oron
anyof
thepatient
satisfactionitems(p>0.05
inall
cases).Resultsof
thisrand
omized
trialsug
gestthatcompu
terized
patient
educationtechno
logy
may
notprovidethebenefits
anticipated.
Hip
[21]
Knee
[19]
Ratin
gof
quality
ofexercise
perfo
rmance
Petursdo
ttiret
al.,2010
(81s)
Toincrease
know
ledg
eand
unde
rstand
ingof
the
expe
rienceof
exercising
amon
gindividu
alswith
osteoarthritisandto
determ
inewhatthey
perceive
asfacilitatorsand
barriersto
exercising
.
Osteo
arthritis(n=12)
Phen
omen
olog
yFacilitator
andbarrier
checklist
NA
Manyparticipantsplaced
emph
asison
thefact
that
the
encouragem
entand
unde
rstand
ingthey
received
from
theirPT
werevery
impo
rtant.
Hip/kne
e(n=10)
Verteb
ralcolum
n(n=9)
Clearcom
mun
icationandasense
ofapo
sitiveconn
ectionwere
equally
asimpo
rtant
asthe
physicalresults
ofthetherapy
andadherenceto
exercise
inph
ysicaltherapy.Supervision
bythePT
facilitated
exercise
maintenance.
Hands
[6]
Other
joints[3]
Sladeet
al.,2009
(86s)
Toun
derstand
thefactors
that
participantsin
exercise
prog
ramspe
rceive
tobe
impo
rtantto
engage
and
participate
Chron
iclow
back
pain
(n=18)
Groun
dedtheo
rywith
focusgrou
psAud
io-taped
interviews
Aud
io-taped
interviews
Helpful
andem
poweringcare-
provider
skillsarethoseof
the
effectiveed
ucator,m
otivator
andcommun
icator.Care-seekers
areem
powered
byrecogn
ition
oftheiro
wnph
ysicalcapability,
motivators,tim
e-managem
ent
skills,andassertivenessto
adhere
toexercise
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 17 of 23
Table
6Relatio
nshipbe
tweentherapeutic
allianceandadhe
renceto
treatm
ent(Con
tinued)
Sluijset
al.,1993
(38s)
Toinvestigatewhe
ther
patent
compliancewas
relatedto
characteristicsof
thepatient’sillne
ss,attitu
deor
physicaltherapist’s
behaviou
r.
Traumaand
postop
erative
cond
ition
s,Radiating
back
pain,N
on-
radiatingback
pain,
Neckandshou
lder
pain
(n=1837)
Correlatio
nstud
y5-item
questio
nnaire
1-item
questio
nnaire
The5form
sof
PTbe
havior
show
edno
direct,statistically
sign
ificant
relatio
nshipwith
compliance.
Com
pliancewas
sign
ificantly
relatedto
thepo
sitivefeed
back
(the
rapistsatisfactionwith
and
appreciatio
nof
exercise
perfo
rmance).
PT(n=300)
Observers(n=3)
Sten
mar
etal.,1994
(101
s)To
findou
tthekind
sof
attributions
PTsmake
regardingwhy
PTworks
and
theextent
towhich
attributions
arerelatedto
backgrou
ndvariables.
PTs(n=140)
Cross-sectio
nalsurvey
stud
y22
Likert-typeitems
andvario
usde
mog
raph
icvariables.
NA
Majority
oftherespon
dents
believedthat
thepatient’sow
nresourcesandthepatient-PT
relatio
nshiprather
than
the
treatm
enttechniqu
esarethe
mostim
portantfactorsin
explaining
why
PTworks.O
ther
backgrou
ndfactorshadno
relatio
nshipto
thebe
liefsand
attitud
esexpressed.
Veen
hofet
al.,2006
(91s)
Toun
derstand
why
patients
who
have
received
abe
haviou
ralg
rade
dactivity
prog
ram
successfully
integrateactivities
into
their
daily
lives.
Osteo
arthritis(n=12)
Groun
dedtheo
ryapproach
Interview
Self-repo
rton
integratingactivities
into
daily
lifeafter
discharge
Initialmotivation,active
involvem
entin
thewho
leprocessandthat
thePT
coaching
roledu
ring
interven
tionfacilitated
adhe
renceto
exercisesand
activities:
Vong
etal.,2011
(42s)
Toexam
inewhe
ther
the
additio
nof
motivational
enhancem
enttherapy(M
ET)
toconven
tionalP
Tprod
uces
better
outcom
esthan
PTalon
e
Chron
iclow
back
pain
(n=76)
Rand
omized
,con
trolled
trial
Pain
Rehabilitation
Expe
ctationScale
(PRES)
Exercise
log
(freq
uency)
TheMET-plus-PT
grou
ppro
ducedsign
ificantlygreater
improvem
entsthan
thePT
grou
pin
proxyefficacy,working
alliance,andtreatm
ent
expe
ctancy
with
sign
ificantly
better
perfo
rmance
inliftin
gcapacity,g
eneralhe
alth
and
exercise
compliance.
Wrig
htet
al.,2013
(43s)
Toiden
tifywhich
factorsbe
stexplainno
n-adhe
renceto
homerehabilitationfor
patientswith
musculoskeletal
injuries.
Musculoskeletal
injuries(n=87)
Cross-sectio
nalstudy
Med
icalInterview
SatisfactionScale
(MISS)
SportsInjury
RehabilitationScale
(SIRAS)
Patientsaremostlikelyto
adhe
reto
HRE
whe
nthey
perceive
apo
sitiverelatio
nship
with
theirPT.Self-rep
orted
adhe
renceishigh
erwhe
npatient
percep
tionof
behaviou
ral,cogn
itive
and
affectiveelem
entsof
the
relatio
nshiparepo
sitive.
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 18 of 23
construct “therapeutic alliance”, how it is currentlymeasured and its relationship to adherence in MSKpractice. This cataloguing of the evidence will assistin defining research questions and applying method-ology that enables quality appraisal which is not acomponent of scoping review methodology [33]. Theaccord around characteristics of partnership, personal-ized therapy, roles and responsibilities, congruence,communication, expectations and influencers acrossPT and OT literature for MSK conditions identifiedin this scoping review provides further credence thatthese key themes should be included and evaluated infuture studies or in clinical training. The synthesisfindings mirror those of the systematic reviews byBesley et a [60] exploring TA in PT literature but thiscurrent study further expanded the key qualitieslinked to each theme. For example, our findings re-vealed several new subcategories such as humour andemotional intelligence (therapist prerequisites), appre-ciation, honesty (connectedness), clarity of informa-tion and feedback (communication), support andfollow up (roles and responsibilities).Various models and frameworks with diverse origins
have been introduced to explain TA in PT and OT lit-erature. The productive partnership framework [64] isbased on power balance, the process model for patient-practitioner collaboration is based on shared-decisionmaking [65], effect model of empathic communication[66] is based on connectedness and tripartite efficacyframework [67] is based on self-efficacy. Moreover, mostof this conceptualization are yet to be empirically tested
in the MSK population. The tripartite efficacy frame-work [67] opines that patients and therapists develop a“tripartite” network of efficacy beliefs. Although, theframework explains the motivational and relational pro-cesses for improving TA between patient and therapistduring therapy encounters, it remains untested in MSKPT practice. The models of TA also had diverse originsranging from traditional healthcare quality principlessuch as patient-centred care [68, 69] and importanthealthcare outcomes such as patient satisfaction [70] tomodern models of emotion management such as emo-tional intelligence [71, 72]. This heterogeneity limits theapplication of this conceptualizations to broad MSKsettings and conditions.The construct of TA proposed by Bordin [8] is steeped in
psychotherapy [73, 74] and viewed as a “pan-theoretical”concept of TA due to its applicability to many therapeuticapproaches [75]. The question remains as to whetherBordin’s construct of TA is truly transferable to MSKrehabilitation. Findings from this scoping reviewhighlights the importance of other constructs such asexternal influencing factors in establishing patient-therapist relationship in MSK practice. Praestegaardand Gard [67] reported that patients in private PTpractice were not open to questions about their livedlives and therapists expressed difficulty in gainingimportant knowledge about their meaningful lives dueto the impact of organizational factors such as avail-able treatment time and design of treatment areas.Besley et al. [60] and O’Keefe et al. [61] also identi-fied the environment as a significant influence on TA
0 5 10 15 20 25 30 35 40 45 50
Congruence
Communication
Expectation
Personalized therapy
Partnership
Connectedness
Roles & Responsibilities
External factors
Therapist Prerequisite
Patient prerequisite
Number of studies
Th
erap
euti
c A
llian
ce T
hem
es
Patients
Therapists
Observer
Combined
Fig. 3 Perspectives of participants (patients, therapists, observers) on each theme of therapeutic alliance
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 19 of 23
in the studies on MSK PT practice. Individuals withmore adaptive styles and well developed social skillsmay form better alliances with their therapists andhave better prognoses according to Del Re et al. [76].In such instances, it is unclear whether the alliance-outcome relationship is influenced more by thepatient’s characteristics or something offered by thetherapist. Furthermore, the differences in therapistskills and competencies between psychotherapy andphysical rehabilitation professionals may affect howTA works in practice. For example, the application ofelectrophysical agents, manual therapy, exercise andphysical activity is commonly associated with thera-peutic procedures in PT and OT practice. Fuentes etal. [21] focused on empathetic communication and re-ported that the effect of TA on pain modulation inpatients with chronic low back pain was enhancedwhen applied with active interferential current andtheir interaction may produce clinical benefits.There was also a dearth of information on how the
themes identified could be developed as soft skills thatare practical for therapists to learn and adapt in clinicalpractice. Murray et al. [77] showed that physiotherapisttraining using self-determination theory based commu-nication skills training improved perception of autono-mous support among patients with low back pain.Similarly, the study by Fuentes et al. [21] highlightedhow physiotherapist communication skills training basedon empathy and roles and responsibilities can be used toenhance the patient-therapist relationship. In OT litera-ture, the Intentional Relationship Model [78] was devel-oped to increase occupational therapist’s capacity fordeveloping skills in therapeutic use of self or TA using self-reflection guide on therapeutic modes. Taylor et al. [79]examined occupational therapists use of self according tothe IRM when interacting with anxious or depressedpatients.Several of the TA measures identified are yet to be
validated in patients with MSK conditions and somerequire further development before adaptation to MSKpractice. Due to the complex nature of TA, availableoutcome measures were based on diverse TA themes.Only one measure covered all the themes of TAreported in this scoping review; the PRES [41]. The WAI[39, 40] was the most reported measure of TA anddeveloped using Bordin’s model [8]. However, Hall et al.[80] showed that measures developed from psychother-apy such as the WAI [39, 40] exhibit a ceiling effect andrequire re-contextualization for suitable use in MSKpractice. Several measures identified also had no evi-dence of psychometric evaluation which further limitsapplicability in MSK practice. Furthermore, some of thestudies reviewed used outcome measures based on theconstruct of satisfaction [29, 81–83] to evaluate TA. It is
unclear if these measures were assessing TA or satisfac-tion or both. A combination of measures may provide amore exact assessment of TA.Our synthesis of the evidence on the impact of TA on
adherence in MSK practice also focused on the relation-ship between TA and exercise adherence based on broadfindings showing correlation between TA and adherencein several disciplines including medicine [84], psycho-therapy [85] and physical rehabilitation [61]. However,the findings from the systematic review on adherence byHall et al. [61] only reported a correlation between TAand cardiac and/or neurological rehabilitation. Thisscoping review showed that TA exerts diverse influenceon treatment adherence as its predictor, moderator andmediator mostly in PT studies. Further studies are re-quired to appraise the evidence in OT discipline. It ispertinent to elucidate moderators and mediators ofRCTs because studying experimental intervention effectsis unable to explain the mechanisms of intervention suc-cess or identify participants who benefit most from anintervention [86]. Such studies provide a key step toguiding interpretation of trials and design of future in-terventions. TA was also correlated with improved pain,reduced disability, and higher satisfaction in MSK PTpractice [21]. TA was found to be more strongly associ-ated with disability and function compared with painoutcomes in chronic LBP [87]. In addition, an identifi-able “practitioner effect” was documented in MSK painintervention trials [87]. Clearly, the context in which PTinterventions are offered has the potential to dramatic-ally improve therapeutic effects [21]. Unfortunately,the adherence literature is plagued by lack of robustoutcome measures [88, 89] and calls to question theimpact of TA on adherence in MSK practice.
Study limitationsThis scoping review utilised rigorous and transparentmethods throughout the entire process. To ensure abroad search of the literature, the search strategyincluded nine electronic bibliographic databases, thereference list of thirty five different articles and ten rele-vant organizations. The relevant screening and datacharacterization forms were screened by two reviewersas needed prior to implementation. The greatest chal-lenge in conducting a review in a broad and complexfield like therapeutic alliance is not data collection butsummarizing the data. Current views on scoping meth-odology advocate engaging a large inter-professionalteam at every stage of process to improve the quality ofthe decision making [35]. Unfortunately, due to timeand financial constraints the authors were not able tobuild such a team for this review. Nonetheless, theauthors were careful to use an iterative approach to clar-ify concepts and revising questions and themes with
Babatunde et al. BMC Health Services Research (2017) 17:375 Page 20 of 23
increased familiarity with the literature. Due to thelanguage limit, we could have excluded studies that havedirect relevance to the purpose of this review.
Research opportunities and recommendationsFuture research needs to focus on a clear conceptualizationof TA in MSK rehabilitation with clear definition of termsin view of the broad complexity of TA. This approach hasbeen proposed for other complex aspects of health such asquality of care [90]. Similarly, TA measures used in MSKPT and OT practice and the construct they assess need tobe well-defined with evidence of psychometric properties.Furthermore, studies are required to increase therapistcapacity at developing soft skills for enhancing TA in clin-ical practice. If these issues remain unaddressed, patientsmay continue to struggle to meet their rehabilitation po-tentials [63].
ConclusionsThis scoping review maps out the available literature onTA conceptualization, measures and insights into profes-sionals’ and patients’ experiences and perceptions of TAin MSK rehabilitation. It appears that enhanced TA hassome beneficial effects on treatment adherence. The lim-itations identified in existing literature provides a road-map for designing future studies aimed at addressingkey gaps identified in the TA literature. We propose fur-ther research focused on developing a physical rehabili-tation themed framework of TA, psychometric testing ofexisting TA measures and designing trials to investigatethe effect of therapist TA training on long term treat-ment outcomes and treatment adherence in MSKpractice.
Additional files
Additional file 1: Characteristics of studies included in the scoping review.Study information from each article included in the review. (DOCX 96.9 kb)
Additional file 2: Therapeutic Alliance Terms. Description of therapeuticalliance terms detailed in included studies. (DOCX 54.2 kb)
Additional file 3: Perspectives on therapeutic alliance from participants.This file highlights the perspective and experiences of participants ontherapeutic alliance. (DOCX 605 kb)
AcknowledgmentsFB was supported by the Canadian Institute of Health Research (CIHR) JointMotion Program (JuMP) during the completion of this study.
Availability of data and materialsThe dataset supporting the conclusions of this articles are available from theauthors on reasonable request.
Authors’ contributionsThis study was completed as part of the graduate comprehensiveexamination work of FB who was the principal investigator in this study. Allauthors developed the idea for the scoping review and contributed to theconcept and design. FB conducted the searching and drafted the tables andfigures. All authors contributed to the drafting and reviewing of the manuscript
and provided feedback process during the final production of this manuscript.All authors read and approved the final manuscript.
Competing interestsThe authors declare that they have no competing interests.
Consent for publicationNot applicable.
Ethics approval and consent to participateNot applicable.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Author details1School of rehabilitation Science, McMaster University, 1400 Main StreetWest, Hamilton, ON L8S 1C7, Canada. 2Hand and Upper Limb Centre, StJoseph Hospital, London, ON, Canada. 3Department of Physical Therapy,University of Western Ontario, London, ON, Canada.
Received: 3 May 2016 Accepted: 16 May 2017
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