Personalizing digital physical therapy: how we forge therapeutic alliance at Hinge Health

It’s impersonal. It’s transactional. These are some of the misconceptions about physical therapy (PT) in a digital health environment.

Creating rapport can feel more challenging in the virtual world. But at Hinge Health — a digital clinic for joint and muscle care — we provide high-quality, personalized care for each and every member. It starts with building therapeutic alliance, which is key to delivering personalized care in a digital musculoskeletal (MSK) clinic.

Consider “Sam,” a patient I (Chris Martin) treated last summer. Sam is 72 and had an acute flare-up of chronic low back pain a week before his first Hinge Health evaluation. He was struggling to stand or walk for longer than a few minutes. We’ll use Sam’s journey to illustrate how to build therapeutic alliance as a key component of digital physical therapy (the topic of our presentation at a recent American Physical Therapy Association (APTA) meeting). Before we follow Sam’s story, let’s explore the concept of therapeutic alliance.

The power of therapeutic alliance 

It’s about establishing a relationship. And it starts with building connection and rapport between the patient and therapist. But it doesn’t end there. Together, the patient and therapist create a shared story, plan, and commitment to an outcome. Therapeutic alliance is a collaborative partnership in which both parties agree and commit to work together toward a common goal — reducing the patient’s pain and improving their mobility and quality of life. 

As a profession, physical therapy places a lot of value on objective measures and manual skills. Didactic instruction includes rigorous training in anatomy, physiology, manual skills, and differential diagnosis. The clinical portion of PT training focuses on applying the “gold standard” manual skills, treatments, and interventions we learned in our didactic training.

But research on therapeutic alliance shows that it can lead to better outcomes than gold standard treatments alone — sometimes even in the absence of gold standard treatments. Enhancing therapeutic alliance also has a positive impact on pain intensity and sensitivity.

So let’s take a closer look at what goes into building therapeutic alliance with patients at Hinge Health. 

1. Understand the patient’s ‘why’

Every patient interaction at Hinge Health begins with curiosity to uncover the patient’s “why.” It sounds simple, but knowing the motivation for the patient’s visit is critical. When we make assumptions, we often miss their actual reason for seeking care. Maybe they really want someone to validate their feelings. Or they’re looking for an explanation for what’s going on. Or they just want to feel seen and heard.

Once we’ve found the patient’s “why,” the next step is to get a full understanding of their journey to this point. If we only focus on the here and now, we might miss crucial information that clarifies why the patient is experiencing pain or mobility issues. With the “why” in mind, we’re ready to work on trust.

2. Follow the ‘trust equation’

Trust is the cornerstone for all relationships — including a therapeutic alliance. To build trust with patients, we follow the “trust equation.” 

The goal is to maximize credibility, reliability, and intimacy (the numerator in the equation) and minimize self-orientation (the denominator). Here’s how each of those elements plays out in the patient care interaction:

• Credibility means demonstrating expertise in MSK care. We do this by showcasing our education, experience, training, and certifications — and through clear communication about the patient’s anatomy, physiology, and MSK concerns.

• Reliability is closely related to credibility. It means demonstrating competence and maintaining a commitment to continual learning and growth in our profession. When research brings new insights, we adapt our practice to reflect it.

• Intimacy means drawing patients in by demonstrating empathy, an understanding of their feelings and perspectives. When we convey empathy in our communication and body language, we invite conversation and collaboration and deepen intimacy. 

• Self-Orientation is when our focus is on ourselves; not on how we can best serve our patients. Self-orientation leads to authoritarian care, where the provider dominates and steers the conversation using closed or leading questions without demonstrating reflective listening. The opposite of this, which increases trust, is when we listen with curiosity, ask open-ended questions, and summarize and reflect often.

Let’s listen to Sam

During Sam’s first appointment, I discovered that his pain uptick (his ‘why’) started while on a long flight to a funeral for the unexpected passing of a family member. He noted no change in physical activity or anything else in his routine that could have led to the increase in pain, but he was aware that it tended to worsen with stress. He had also stated that he was dealing with irritable bowel syndrome (IBS) and some increased anxiety, for which he was also seeking treatment.

With this understanding of Sam’s journey, I built a customized exercise program for him. I also decided to introduce some concepts of pain neuroscience and movement optimism. I explained how to do a gentle somatic tracking and sensation awareness meditation. When his back pain was really high, I encouraged him to try to observe the sensations that he was feeling as just that — sensations. I challenged him to try to avoid labeling the sensations as good or bad, but to notice what he was feeling instead and try to breathe through it, reminding himself that he was safe where he was. I encouraged Sam to schedule a follow up visit in two weeks.

3. Use motivational interviewing

It’s a crucial part of building therapeutic alliance — especially in a digital environment. Motivational interviewing is a collaborative conversation that builds trust and strengthens a patient’s own motivation and commitment to change. Without this, there’s a risk that the patient will disengage and fail to complete their home exercise program (HEP). This can be problematic for digital PT because most of a patient’s exercise therapy is completed independently. Here’s a framework for using motivational interviewing with patients in a digital health environment:

Habits of motivational interviewing

1. Invest in the beginning. We create a welcoming atmosphere and effectively identify the “why” for their visit. We share how we prepared for their visit by reviewing their intake forms and demonstrating knowledge about what brings them here. We start with simple open-ended questions like, Tell me why you are here today, or What are you hoping to get out of our visit today?

2. Elicit the patient’s perspective. We explore contributing factors and the impact of the patient’s symptoms or condition on their life. We ask for permission when discussing sensitive topics. Consider: You mentioned that you enjoyed sitting on the floor and playing with your children — how has this been affected by your back pain? or You mentioned that you have been very stressed recently from working long hours; is it okay if we take a few minutes to discuss the relationship between stress and our pain experience? 

3. Demonstrate empathy. We look for opportunities to use empathetic comments or gestures or name a possible emotion, such as, That sounds really upsetting, or, I imagine that is frustrating to hear.

4. Invest in the end. We close the interaction by providing patients with education, tools, treatment options, and goals — always in collaboration and conversation with the patient. 

4. Engage in collaborative goal setting 

The final (and key) part of forging therapeutic alliance is collaborative goal setting. This is defined as “the formal process whereby a rehabilitation professional or a multidisciplinary team, together with the patient and/or their family, negotiate and collaborate on specific goals.”

Goals need to be meaningful for the patient, which is why we work to uncover their “why” (their overarching goal, or “North Star”), and then break it down into smaller, more achievable goals with set timeframes. 

Questions are a great way to initiate the goal setting process. We love these three:

• What can’t you do since your injury or pain uptick that you want to get back to?

• What are you finding more difficult since your injury or pain uptick that you’d like to be easier?

• How will you know when you’re ready to stop coming to see me?

Patients answers give us clarity about how the injury has impacted their life, meaningful activities they would like to resume, and an idea of how they measure success and their overall expectations for therapy. They let us have more specific conversations about the short-term goals that will lead to achievement of the patient’s long-term goal, or “North Star.”  

Goal setting in action with Sam

At Sam’s two-week follow-up, he reported diligently completing his exercises five to seven times per week. 

He could stand and walk longer (up to 10 minutes), but his pain was still at a six out of 10. We decided to use the session to dive more deeply into pain neuroscience education and I took him through a somatic tracking exercise. I chose to have him perform the session while standing, which had been challenging for him. After we finished, I asked for a pain rating. He shared that his pain was maybe a one out of 10. He had been standing for 30 minutes. It was his lightbulb moment. 

This visit opened the door for me to dive further into pain neuroscience education, lifestyle medicine factors like stress management and healthy sleep habits, and to continue to utilize somatic tracking exercises as part of his therapy program.

We collaborated on goals for the next two weeks and mutually agreed that he should continue his exercises at least five times a week and perform a somatic tracking exercise at least twice a day based on his pain symptoms. I could tell Sam felt encouraged, and so did I.

Over the following three months, Sam’s pain reports went from an 8.7 to zero with a full return to his normal activities. In his last interactions with me, he shared via email:  

“I am cured. No more pain into my lower lumbar. Feeling better in that part of my anatomy than even before the back pain episode began 10 years ago. This could be as close to a miracle as I get in my life. Although it would still be nice to win the lottery.” 

Personalized digital physical therapy at its best

If we show up for patients with empathy, acknowledge each other's humanity, and move forward as a collaborative team, we will get the outcomes we’re looking for. We are the MSK experts, but we acknowledge that our patients are, in fact, the experts of their own experience. When we work with their experience and understanding to create an action plan, we can better achieve the goals that are meaningful to them. 

As digital clinicians, we’re not looking to replace traditional in-person care or reduce the value or role of a physical therapist. Instead, we maintain that digitally-enabled and informed physical therapists can use therapeutic alliance and technology to drive better outcomes, while co-existing with traditional care. 

This is why we do what we do. This is what it’s all about.

How Hinge Health can help you

If you have joint or muscle pain that makes it hard to move, you can get the relief you’ve been looking for with Hinge Health’s online exercise therapy program.

The best part: You don’t have to leave your home because our program is digital. That means you can easily get the care you need through our app when and where it works for you.

Through our program, you’ll have access to therapeutic exercises and stretches for your condition. Additionally, you’ll have a personal care team to guide, support, and tailor our program to you.

See if you qualify for Hinge Health and confirm free coverage through your employer or benefit plan here.

This article and its contents are provided for educational and informational purposes only and do not constitute medical advice or professional services specific to you or your medical condition.

References

1. Brun-Cottan, N., McMillian, D., & Hastings, J. (2020). Defending the art of physical therapy: Expanding inquiry and crafting culture in support of therapeutic alliance. Physiotherapy Theory and Practice, 36(6), 669–678. doi:10.1080/09593985.2018.1492656 

2. Fuentes, J., Armijo-Olivo, S., Funabashi, M., Miciak, M., Dick, B., Warren, S., Rashiq, S., Magee, D. J., & Gross, D. P. (2014). Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy, 94(4), 477–489. doi:10.2522/ptj.20130118 

3. Understanding the trust equation | trusted advisor. (2012). Trusted Advisor Associates - Training, Workshops, Trust Education. https://trustedadvisor.com/why-trust-matters/understanding-trust/understanding-the-trust-equation