The role of therapist-patient relationships in facilitating engagement and adherence in upper extremity rehabilitation

3.1.1 Sources of power

Therapists agreed that collaboration within the therapist-patient relationship was ideal, though language choices did not always reflect an equal power balance. During interviews, therapists often identified patients by diagnosis or by which therapist was working with them (e.g., “the carpal tunnel syndrome patient” or “Therapist 2’s patient”). These identifiers were frequently used before more patient-centered ones such as patient roles, occupations, or interests. Therapists also noted the rare need for more authoritarian approaches, especially for patients they perceived as unmotivated or resistant to adhering to treatment plans. One therapist stated, “when people aren’t motivated… I usually just say to them, “You know if we’re not seeing progress, we can’t keep continuing to see you.” However, this approach was described as a last resort in response to a specific perceived patient need.

Though therapists reported being primary decision-makers throughout the therapeutic process, the plan of care and therapeutic approach were often influenced by patient personal factors such as complications from comorbidities, family responsibilities, or major life events or decisions. Specifically, patients demonstrated power through requests to review exercises or education, identification of specific difficulties during daily routines, affinity for certain exercises or activities, desire for novel experiences, or requesting measurements to track progress. Therapists reported that sessions were often structured around occupations meaningful to individual patients, and functional tasks related to these occupations were often simulated in-clinic. When discussing simulating a work task with a patient, one therapist said:

Aspects of the greater medical environment were identified as limiting the power of both the therapist and the patient within the therapeutic process. Physicians often dictated what activities were considered “safe” within and outside of therapy. Safety seemed to be a primary concern and a strong limiting factor for therapeutic activity choice and goal setting. As one therapist described, “…it’s safer for me to look at him and for me to give him feedback right now so that he knows… [he’s] not ready for this.” Additionally, insurance coverage was frequently identified as a limiting factor for duration of therapy, occasionally impacting prioritization of functional activities performed in-clinic, type of measurements taken, and goal setting.

3.1.2 Negotiation of power between competing interests

Occasionally these different loci of power would conflict, requiring the therapist to mediate between them. This most often resulted from mismatches between patients’ desires and doctors’ expectations. A therapist described one such situation:

The dynamic nature of power within the therapeutic relationship and environment was highlighted by therapists describing the need to encourage patients to actively participate in therapy. Patients were often scared to begin using their arms again or were acclimated to unidirectional relationships in healthcare environments from previous experiences. As a therapist noted, “I think our role is to have the patient believe that they are an active participant.” By taking action to change patients’ beliefs about their roles in therapy, therapists are attempting to increase patients’ agency within theserelationships.

Regardless of the dynamic ebb and flow of power throughout the therapeutic process, patients ultimately had the power to decide whether to continue participating in therapy or adhere to recommendations. Therapists acknowledged this with phrases such as, “I think if they show up to therapy, that’s like 50% of the battle” and discussed several situations in which patients ceased attending therapy due to changing life situations, decreased symptoms, or unknown reasons. In this way, what could be considered the most basic patient behavior is paradoxically also an expression of power.

3.2.1 Therapist and patient foundational roles in co-constructed engagement in therapy processes

The therapist’s comments indicated that they perceived their foundational role in constructing mutual engagement as relatively straightforward. Specifically, this role involved demonstrating and communicating clinical competence, expertise, and skills. As one therapist described, “[as a patient] you do have to trust to move forward with it if you’re scared… does the therapist know what they’re doing? Do they sound… professional?” As a complement to this therapist role, it was often noted that the patient role involved providing expertise on personal context and identifying specific challenges within daily routines.

Beyond personal context expertise, the patient’s role in mutual engagement was primarily characterized as physical and mental presence. There was consensus among the therapists that consistent therapy attendance was a sign of patient engagement. When discussing a patient, one therapist noted, “…this patient drove from far away to come here. He drove over an hour… he was making an effort to be here.” Conversely, there was some disagreement among therapists regarding mental presence as a sign of engagement. Factors contributing to this difference throughout the discussions included the level of mental attention required for engagement among different therapeutic activities (e.g. therapeutic ultrasound vs. home exercise program education), how mental attention could be secondarily assessed (e.g. visual or verbal interaction), and how to interpret signs of detractors or facilitators of mental attention (e.g. cellphone use to take notes vs. as a distraction).

3.2.2 Therapist and patient building blocks for co-constructed engagement in therapy processes

Therapists helped construct mutual engagement in therapy processes on the most fundamental level by directing supportive attention towards patients. That is, demonstrating they cared by actively listening to and acknowledging patients’ needs. As one therapist described, “…we really care about… the clients here and they know. They can tell we’re not checking out… We’re not… sipping coffee talking about our problems… We are focused on them.” In addition to demonstrating care, therapists felt adaptability and problem solving were critical to building and maintaining engagement in therapy. Therapists were able to change or tailor treatment approaches moment-to-moment based on evolving needs or circumstances. One therapist described changing her initial treatment approach to accommodate a patient’s persistent desire to perform a specific exercise: “… he said, ‘can I do a push up?’ I said no and he said, ‘okay fine I’ll just do it at home’… so then I said, ‘fine, let’s do push-ups’ because I’d rather see him do it versus him just be non-compliant and doing push-ups at home on his own.”

Though therapists universally agreed that flexibility was important, they did not agree on the degree of flexibility when it involved balancing competing interests such as patient preference and safety. In this way, adaptability was described as a skill developed through experience. As one OTD resident described:

Therapists believed that patients helped construct mutual therapeutic engagement through motivation to move beyond their current conditions. This meant anything from returning to work to learning to manage symptoms or adapting activities. The therapists felt that motivation alone would not ensure engagement in therapy and made a distinction between motivation in general and buying-in to the therapeutic process. That is, patients needed to believe that they would benefit from the specific approach being taken. A therapist describing one of her patients said, “…she was game, she was like yeah, I want to do it… and she really liked those activities, those simulated things and she understood why we’re working on proximal strengthening.”

3.2.3 Co-construction of mutual engagement in action

Patients’ and therapists’ ability to fulfill roles and enact behaviors needed to build mutual engagement were reciprocal and together constructed mutual engagement. Therapists identified that demonstrating clinical expertise and competence was crucial to facilitate patient motivation and gain trust and buy-in. Patients in turn communicated personal context details and priorities, which provided opportunity for problem-solving and adaptability from the therapists. Buy-in was thought to be further cultivated through this problem-solving and adaptability, as patients believed therapists were fully invested in their individualized care. This would hopefully result in patients taking initiative in therapy and incorporating therapy concepts into daily life. One OTD resident therapist illustrated the reciprocal, co-constructed nature of therapist and patient engagement in the therapy process when he described how patients’ perceived attitudes toward therapy encouraged him to be more creative in treatment planning: “when you have somebody in here who really wants to get back to what they’re doing… that really challenges you to come up with new ideas and ways for them to get to that point too.”

In contrast, when patients viewed therapists as less competent or skilled, or as only going through the motions during therapy, they may not have felt motivated or bought-in to the therapeutic approaches. Therapists described themselves as reverting to more textbook answers in response to patient questions or taking more rigid approaches to treatment when they perceived patients were in this state. In this situation both therapists and patients were generally described as closed off and less engaged.

3.3.1 Emotional states as barriers

Uncomfortable emotional states were often described as barriers to engagement and active participation in therapy for both therapists and patients. In patients, this included emotional states both related to and outside of recovery from conditions. Feelings of anxiety, frustration, and sadness could emerge from slower than expected progress, setbacks, or difficulty resuming meaningful activities. They could also result from life events such as the loss of a family member or pet. In one case, the two sources of emotion collided as a patient experienced a significant hand injury from a dog bite, requiring her dog to be euthanized, and then also was in the process of moving to a new home because she would no longer need the yard for the dog.

Therapists reported attempting to manage patient emotional states over the course of therapy through the processes of venting, reframing, and humor. Venting consisted of therapists absorbing patients’ expression of these emotions as a form of patient relief or liberation from them. One therapist described a patient who was afraid to return to daily activities and resume social relationships and how this was addressed: “The fear and anxiety, I mean a lot of it was just through talking with her, it was just socializing with her and letting her explain it, kind of venting her,” and “Sometimes they just want to vent. They don’t really have any other safe place, their family is sick of it, so they vent a little and then they get on with it.”

Reframing involved providing perspective to situate patients’ current circumstances within the greater context of therapy to highlight patients’ continued progress. Discussing the same patient, another therapist mentioned using this process:

Humor was used to distract patients from the weight of their emotions and promote what were perceived as positive emotional states. For example, therapists described a comical-looking green chicken that both served as a prop for simulation of feeding tasks as well as an object of humor. “[The patient] gave a good laugh when I offered her the chicken” one therapist remarked. The overall clinical environment was also described as promoting humor: “We make everything more light-hearted, and it takes the seriousness or the heaviness of injury out of the way.”

Therapists themselves also seemed to be affected by uncomfortable emotions, though they were not as explicit in their description of these within themselves. Therapists reported experiencing fear related to patient safety and frustration or uncertainty related to patient setbacks, lack of progress, and perceived lack of motivation or adherence. Therapists also seemed to internalize uncomfortable emotions from patients, especially when those patients had been through particularly traumatic experiences. They used phrases such as “sometimes it’s depressing you know for me.” Therapists did not discuss negative emotions arising from their personal lives as factors in the therapeutic process, though they also did not rule them out.

For therapists, strong emotions could sometimes lead to reverting to formulaic, rigid, or repetitive interaction with patients. An OTD resident described his experience with a patient that he perceived as being hostile:

Therapists’ uncomfortable emotions seemed to be modulated through current or anticipated patient progress. This progress could be biomechanical, functional, or even improved patient personal outlook or emotional state. Therapists also seemed to use humor to help themselves cope with the gravity of dealing with emotionally strenuous situations. At one point while describing a difficult situation with a patient, one therapist joked to the other, “you get all the criers”, and the two laughed. No explicit strategies to address therapists’ emotions werediscussed.

3.3.2 Emotional states as facilitators

In certain situations, uncomfortable emotions served as catalysts for mutual engagement. Therapists reported that, for some patients, fear of loss of function or uncertainty about symptoms was described as motivation to seek treatment and adhere to exercise routines: “they might have just enough… questions where it’s worrisome for them and they think something might be wrong. So, they go see… the doctor and the doctor refers them here.” Within treatment sessions, discomfort-provoking emotions sometimes prompted patients to take a more active role. One therapist described a situation in which a patient was fearful of flexing her wrist during activity after being told it would increase her symptoms, explaining, “she would always come in and ask, ‘can we review my exercises?… specifically, I want you to look at my wrists.”’ In this case the patient’s fear motivated her to request specific interventions. Therapists also described using consequences to induce uncomfortable emotional states with the goal of motivating patients, improving buy-in, or increasing adherence. This often involved warning patients that symptoms may worsen, impairments could become permanent, or discharge from therapy would be imminent if circumstances did not change.

For therapists themselves, emotions such as uncertainty about or dissatisfaction with current or anticipated patient progress could prompt further problem-solving and flexibility, such as modifying or fabricating an orthosis or updating exercise programs. While discussing a patient who was feeling depressed after a traumatic injury and a difficult family event, a therapist expressed that she was saddened by his circumstances and commented on how the patient’s demeanor impacted her motivation to help him: “I want to help him… I’m not turned off by that… it’s the reverse. Okay, how can I engage him… and let him know we care.”

Therapists also seemed to believe that expressions of uncomfortable emotions during therapy signified and reinforced patient trust. Rather than hide their emotions, patients were described as feeling safe enough to be vulnerable with or vent to therapists. Therapists could respond by validating patients’ feelings and providing comfort, release, or perspective. In this way, even emotions viewed as barriers to the therapeutic process provided opportunities to strengthen therapist-patient relationships.

3.3.3 Emotional states and perceived progress

Notably, when patients were thought to be experiencing emotional states as barriers, descriptions of these states seemed to take precedence over other descriptors of current status or progress (e.g., physical symptoms, range of motion, or functional use). In contrast, patients who were viewed as having a positive outlook were more often described in terms of these measurables, rather than by their psychological characteristics. In this way, barrier emotions seemed to be viewed as needing to be overcome before actual therapy could begin, rather than a legitimate focus of therapeutic intervention in and of themselves.

This phenomenon also extended to descriptions of activity participation. When discussing patients they believed were impaired by emotional states, therapists more often described engaging in meaningful activities as the general participation. However, when this was not the case, engagement in functional activity was described as achieving specific segments of activity, such as gripping a steering wheel or dog leash. Furthermore, patients described as “doing well” seemed to correlate with perceptions of more positive patient emotional states, even when progress with physical or functional aspects of recovery was less than ideal.

3.4.1 Social vs. private

In the clinic, the social environment existed within the communal treatment area where multiple therapist-patient pairs worked simultaneously. Therapists reported that relationships within this context involved camaraderie, socialization, and humor. The dyadic therapist-patient relationship was often described as expanding to include other patients and therapists, which could provide emotional support and encouragement. As one therapist explained: “we’ve created this… social fun environment… and everyone’s in conversation with each other.” Conversely, the private environment involved a separate room or space wherein the therapist-patient dyad could interact away from others. This space was described as calm and safe and was often where patients were taken to vent and confide in their therapists. One therapist described using this type of environment for a distressed patient: “he used to come in and just burst out crying and I’d have to put him in a private area, and I was really glad he felt safe.” Therapists emphasized the need for both spaces to balance changing patient emotional states, sometimes within a single therapy session. “If they look like they’re about to break down then we’ll move them to a private space,” a therapist explained.

3.4.2 Within vs. outside of the clinic

Therapeutic environments within vs. outside of the clinic seemed to create dramatically different balances of power and responsibility between therapists and patients. Within the clinic therapists reported that they engaged with patients in collaborative education and problem-solving. As previously noted, influence over the therapeutic process within the clinic setting was dynamic, though ultimately mediated by therapists. Therapists tailored this environment to each patient to facilitate positive patient outcomes. Outside of the clinic patients typically possessed more power, responsibility, and sometimes more control over the environment. In this context patients had to navigate the translation and carryover of clinic-learned education, skills, and adaptations to more complex and sometimes chaotic situations. This was evidenced by therapists’ responses of uncertainty when asked if certain patients were performing their therapeutic programs correctly (or at all) at home, especially for one particular patient who was described as perpetually focusing on barriers to performing exercises at home. Therapists also described the importance of patient problem-solving for integrating and prioritizing consistent performance of home programs within the flow of busy lives.

To transcend the barriers between these spaces and facilitate continued progress, therapists reported that they dynamically interacted with patients and negotiated treatment approaches. Actions taken within each space impacted what happened or what was possible in the other. This was demonstrated by a therapist describing a situation in which she had modified a patient’s splint:

Another therapist went on to say:

In general, treatment approaches were provided during therapy with the understanding that they would be then implemented outside of the clinic. After trialing these interventions outside of the clinic, patients assessed fit and reported back to therapists during follow-up visits. Patients and therapists then further problem-solved solutions, continuing the cycle. Any interruption of this process could interfere with the overall progression and continuity of therapy plans.

3.4.3 During therapy vs. after discharge

The time periods during therapy and after discharge juxtaposed intimate relationships with the sudden absence of any relationship. Over the course of therapy, therapists and patients often formed close bonds as the therapists helped guide patients toward recovery. The trust and vulnerability demonstrated by patients could reach similar levels to those of close personal relationships. After discharge, this connection abruptly disappeared. Navigating this change was sometimes difficult for patients, especially in the absence of strong external support systems. One therapist described this painful transition, “there are some people who, when we have to discharge them, [say,] ‘no, no I want to keep coming.”’ Therapists highlighted the importance of setting realistic expectations about the nature and progression of the relationship over the course of therapy to facilitate healthier discharge transitions. “I try to prepare them weeks prior to discharge,” one therapist noted.

Despite highlighting the importance of navigating multidimensional interactions, therapists had difficulty communicating how this was achieved and quantifying progress of patient agency, engagement, and emotional status. This contrasted with detailed descriptions of biomechanical or functional outcomes (e.g., ROM, symptom reduction, task-specific function, or using adaptive strategies).

Although therapists sometimes identified general techniques to manage patient emotional states and facilitate engagement (e.g., venting or reframing), they typically used vague descriptors such as “psych-OT.” When asked to elaborate on what these approaches involved, one therapist answered that she would tell the patient, “You’re safe to cry here that’s fine, it’s an outlet” adding, “just talking about stress in general and how it can affect your body.” She also described providing activity choices to give the patient “some control of what’s going on.” This explanation, while more precise than the original, still does not describe specific effects of stress on the body or why the patient should be aware of them, specific datapoints used to determine the need for these interventions, theories or frameworks informing them, or expected patient outcomes. Similarly, therapists did not discuss specific indicators for moving between social and private spaces (beyond the overt indicator of a patient crying), nor specific approaches to prepare patients for therapy discharge. Therapists also often expressed uncertainty about whether techniques were translated successfully from clinical to home environments.

Conversely, when therapists discussed addressing biomechanical factors, they detailed strategies such as specific exercises (often demonstrating or describing them without prompt), dynamic orthosis fabrication, or increasing force when mobilizing individual joints. They also discussed the specific rationale, timing, and appropriateness of these strategies, highlighting factors such as inflammation, tissue stiffness, pain, joint integrity, physical comorbidities, ease of use or performance, and expected tissue recovery timelines. One therapist described her approach for a patient with a stiff hand:

When therapists discussed progress with patient psychological status or active engagement, they used phrases such as “doing better,” while biomechanical progress was described as specific degree measurement gains. There was also uncertainty surrounding interpreting the emotional states of certain patients, with therapists sometimes disagreeing in their perceptions of them, or reporting that their initial impressions were incorrect.