The therapeutic alliance (also referred to as the working alliance) is a description of the interaction between the physiotherapist and their patients. By establishing a therapeutic alliance, the therapist then seeks to provide patient-centered care, in which the therapist as seen as a facilitator for the patient to achieve their goals, rather than an authority figure. Previous research has highlighted the importance of providing patient-centered care not only in physiotherapy, but other medical professions as well.  This is accomplished by encouraging the patient to become more active in their treatment to engage them in a collaborative, active approach to recovery. By establishing a strong therapeutic alliance and encouraging patient participation, therapists can also seek to address psychosocial aspects of pain,  which are often overlooked in traditional unidirectional patient-therapist interactions. This is especially important as recent research supports that the physical treatment alone cannot fully account for improvement of patient outcomes. 
The therapeutic alliance was first described by Freud in 1912, in which he outlined the concepts of transference and countertransference, which are the unconscious feelings or emotions that a patient feels towards their therapist, and vice-versa.  Further research by Rogers (1951) was the first to highlight empathy as a core characteristic of this therapeutic alliance and Anderson (1962) conceptualized both empathy and rapport as qualities within the “therapeutic bond”.  Hougaard (1994) consolidated previous data into a conceptual structure composed of two branches, the personal relationship area and the collaborative area. The personal relationship area focuses on the socio-emotional aspect of the therapist-patient relationship, while the collaborative relationship area consists of more task-related aspects, such as goal-setting and treatment planning. It was Martin, Garske and Davis (2000) concretely described the therapeutic alliance as “…the collaborative and affective bond between therapist and patient – is an essential element of the therapeutic process.” 
Establishing a Therapeutic Alliance
Good communicative skills are an integral tool to achieving a strong therapeutic alliance and research has shown that effective communication also leads to increased patient adherence and satisfaction.  Mead and Bower (2000)  identified five key dimensions of patient-centered care which have been associated with a positive therapeutic alliance: 
- Utilizing a biopsychosocial perspective: Several conditions treated by physical therapists appear to have little relation to structural or physiological changes, which can themselves be interpreted with high variability.    Thus, an approach that considers not only biological, but also psychological and sociological factors as well, is needed to appreciate the full scope of the problems presented and provide patient-centered care. 
- The ‘patient-as-person': Although the biopsychosocial model seeks to address all of the factors surrounding the patient, it may not be sufficient to fully appreciate the patient experience.  We need to understand that each patient may perceive the same pain experience differently and that eliciting the individual patient’s fears, expectations and feelings of illness should be one of our primary concerns 
- Sharing power and responsibility: The patient-practitioner relationship has always been fundamentally seen as a ‘paternalistic’ relationship, which some see as an inevitability due to the competence gap between them.  By shifting patients from ‘consumers’ to active ‘participants’, we can help place patients in control of their own illness, and this has been correlated with better health outcomes. 
- The therapeutic alliance: Just as patient-centered care can strengthen the therapeutic alliance, the reciprocal relationship can also occur. Bordin (1979) described the three main components of the therapeutic alliance as 1) agreement on goals, 2) agreement on interventions, 3) effective bond between patient and therapist.  The only difference is that patient-centeredness has traditionally focused on the doctor’s role, whereas the therapeutic alliance is the relationship between doctor-patient.   In practice, the two concepts are intertwined and difficult to elicit as separate distinct components.
- The ‘doctor-as-person’: Since both the therapeutic alliance and patient-centered care acknowledge the relationship between both therapist and patient, it is thus logical to also place importance of the qualities of the therapist. The interaction between therapist and patient is constant, and the subjectivity of the therapist is something that cannot be separated from this interaction. 
Effect on patient outcomes
The therapeutic alliance has previously been shown to improve patient outcomes in both medicine as well as psychology.     It is only recently that investigation has been made into its effects in other rehabilitative sciences. Burns and Evon (2007) studied its effect in cardiac rehabilitation and found that increased self-efficacy is not enough of a factor to predict increase cardiorespiratory fitness, weight reduction and return to work.  Instead, it must be combined with a strong therapeutic alliance to achieve these outcomes, and a poor therapeutic alliance can undermine the potential for improvement. Ferreira and colleagues (2012) examined the relationship between therapeutic alliance and patient outcomes on rehabilitation of patients with chronic low back pain.  They found that a strong therapeutic alliance leads to increased perceived changes following a variety of conservative treatments. Interestingly, a strong therapeutic alliance was associated with improved disability and function outcome measures, but not pain. Fuentes et al (2013) also conducted a study utilizing patients with low back pain, this time measuring the therapeutic alliance’s effect on pain intensity and muscle pain sensitivity.  The results showed that a strong therapeutic alliance can significantly modify perceived pain intensity after IFC treatments, which are displayed below. Another point of interest is the active IFC with limited therapeutic alliance was not statistically different than a sham IFC with a strong therapeutic alliance.
Measuring the therapeutic alliance
Popular outcome measures for the therapeutic alliance include the Working Alliance Theory of Change Inventory, which itself is derived from the Working Alliance Inventory.  Hall et al (2011) found that there was some room for improvement in the WATOCI, specifically relating to the wording in certain sections.  The nine items that remained were found to be a uni-dimensional tool for measuring the therapeutic alliance, despite demonstrating a ceiling effect. Due to the complexity of the therapeutic alliance it may be difficult to find a perfect measurement, however patient-administered outcomes are a step in the right direction as patient perception of the therapeutic alliance has been found to be a better predictor of outcome than therapist perception. 
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