chapter will provide a brief overview of the clinical condition, management
strategies and therapeutic alliance in addition to the policies in place guiding
current practice. The introduction section will then conclude with the aims of
the present research paper.
of long-term conditions (LTC) is predicted to increase due to factors such as
the aging population and lifestyle choices adopted. Department of
Health (2012) reports 17% of people under the age
of 40 say they have a LTC, which rises to 60% in people, aged 65 or over.
Hence, due to the aging population, by 2025, it is estimated that there will be
an increase of 42% of the population over the age of 65. This significant rise
in the aging population proposes that the number of people with at least one
LTC will rise by 3 million. These growing concerns call for changes within the
health sector to minimise the increasing pressure and demand for resources.
Back pain is a widespread health problem
responsible for the growing use of healthcare services (Freburger et
al., 2009). It is the leading cause of
limitations in activity and absence from work throughout much of the world (Lidgren, 2003). Hoy et al.
(2014) sought to estimate the global
economic burden of low back pain (LBP) and found it to be the sixth highest
burden, which caused more disability globally than any other condition. In the
United Kingdom (UK), approximately one third of the adult population experiences
LBP every year (NICE, 2009). An estimate of 10%-20%
these individuals are at risk of developing chronic back pain (CBP), in
addition to disability. This clinical population accounts for the majority of
health and social costs associated with back pain (NICE, 2009). A report by Hong et al.
(2013) estimates an annual direct
spending of £2.8 billion annually, highlighting the substantial economic burden
the condition places on the government when direct costs are considered alone,
not to mention the burden when direct and indirect costs are considered
Physiotherapy has a primary role to play in the
management of CBP, yet the mechanisms by which physiotherapy interventions
influence clinical outcomes may be complex. Physiotherapists may offer treatments
from a range of conservative, non-pharmacological, traditional interventions in
addition to referrals for pharmacological and invasive interventions, to
patients with CBP (Foster, 2011). Although comprehensive,
these interventions are predominantly passive approaches permitting a
biomedical model. Government and health policies organisations are encouraging
a change in the delivery of healthcare when treating LTCs such as CBP, towards
a biopsychosocial model where patients are considered as experts in their own
care and should be included in all healthcare decisions thus promoting
independence (Kings Fund, 2014;NHS England, 2014).
Promoting self-management of LTCs is a key priority
outlined in the NHS Five Year Forward
View (NHS England, 2014). Self-management is an
‘individual’s ability to manage the symptoms, treatment, physical and
psychosocial consequences and lifestyle changes inherent in living with a
chronic condition’ (Barlow et al.,
2002, p. 178). As physiotherapist aim to
promote, prevent and rehabilitate conditions, they are ideally placed to,
facilitate self-management by equipping patients with the appropriate skills
and support their abilities to manage their LTC therefore promoting autonomy.
Self-management with guided support reduces the patients need for healthcare
providing a more sustainable healthcare system while providing patients with
the skills to obtain control of their condition in the long-term, improving
quality of life (QoL) (Coulter et al.,
This transference in healthcare from a biomedical
to a biopsychosocial model has made clear that, in CBP, there are
interdependent relationships between the physical, psychological and social factors
that present concurrently (Foster and Delitto, 2011). Thus, encouraging a
greater uptake of common therapies used within the psychotherapy field such as
cognitive behavioural therapy (CBT) and motivational interviewing (MI). Research
in psychotherapy has shown that non-specific factors, such as the therapeutic
alliance (TA), may influence treatment outcomes in addition to the specific treatment
intervention (Horvath et al.,
Therefore, there is increasing recognition that interventions in the
physiotherapy field comprises of specific and non-specific factors (Miciak,Gross and Joyce, 2012).
The aim of the
current systematic appraisal is to; critically review the current available
evidence on the influence of TA on treatment outcomes in the CBP population.
Secondly, identify where the research evidence lies in relation to patient-centred
treatment outcomes such as QoL and self-management.