I’m sure you would be familiar with this scenario. A 52-year-old with knee osteoarthritis nods along as you explain their exercise programme. They seem engaged, ask good questions, and leave with what appears to be a solid understanding of their treatment plan. Three weeks later, they return having done virtually none of their prescribed exercises.
Recent research published in the Journal of Physiotherapy offers some eye-opening insights into why this happens—and more importantly, what you can do about it. The findings challenge clinicians to look beyond their technical expertise and examine the quality of their therapeutic relationships.
What the Research Really Tells You
A comprehensive editorial by Goff and Elkins reviewing knee osteoarthritis management reveals something that might surprise you: it’s not the brilliance of your exercise prescription that determines success. It’s the strength of your therapeutic alliance with the patient.
The research found that “the presence and quality of a therapeutic alliance with a physiotherapist facilitated adherence to exercise and general physical activity.” Meanwhile, patients consistently cited barriers like “lack of motivation, time, physical environment and monitoring”—all issues that skilled communication can address.
Even more telling, the research confirmed that patient education combined with exercise therapy produces “statistically superior and clinically important improvements” compared to education alone. But here’s the catch: this only works when patients actually follow through.
As physiotherapists, podiatrists, and exercise physiologists, you’re trained to assess, diagnose, and prescribe. But how often were you taught to build the kind of therapeutic alliance that research proves is essential for long-term success?
The Hidden Communication Challenges
The research uncovered some uncomfortable truths about our profession’s communication gaps:
Weight Stigma is Real—and It’s Affecting Care The editorial references research showing “many physiotherapists demonstrate weight stigma,” with some perceiving weight loss as “outside their professional role.” This is problematic when you consider that diet-induced weight loss improves function as a standalone intervention and enhances pain reduction when combined with exercise.
Think about your last conversation with an overweight knee OA patient. Did you address weight management directly, or did you dance around it? The research suggests many clinicians avoid these crucial conversations entirely.
We’re Missing the Motivation Conversation When patients cite “lack of motivation” as a barrier, it’s easy to interpret this as patient defiance or laziness. But what if it’s actually a signal that you haven’t connected their treatment to what truly matters to them?
The Technical Excellence Trap The research confirms that your interventions work—when patients engage with them. Patient education is effective. Exercise therapy produces results. Apps with remote support improve adherence. But none of this matters if you can’t help patients move from understanding to action.
A Different Approach: Building Alliance Through Communication
Here’s where understanding the psychology of communication becomes essential. Let me share how proven frameworks can transform these challenging conversations.
The CLEAN Model in Action
When a knee OA patient presents barriers, try this approach:
Connect: “I can see you’re feeling overwhelmed about adding exercises to your routine.”
Label: “It sounds like time is your biggest concern right now.”
Echo: “So if I understand correctly, you want to improve your knee pain, but fitting exercises into your day feels impossible?”
Ask: “What else feels overwhelming?”
“What would need to change for these exercises to feel more manageable?”
Negotiate: “How many exercise do you feel you could confidently fit into your daily or weekly schedule?”
Addressing Weight Conversations with Confidence
Instead of avoiding weight discussions, try reframing:
“I notice your BMI puts additional stress on your knees. Would you be against exploring how some changes to your routine might reduce that load and improve your comfort?”
This approach acknowledges the issue while inviting collaboration rather than imposing judgment.
Creating Well-Formed Outcomes
The research shows education plus exercise works—when patients can visualise success. Use the Well-Formed Outcome model:
Patient: “I just want the pain to stop.”
You: “When your knee feels more comfortable, what’s the first activity you’ll enjoy doing again?”
Patient: “I’d love to garden without wincing.”
You: “Tell me more about what gardening means to you. How will it feel to be back in your garden, pain-free?”
Now you’re not just prescribing exercises—you’re helping them work towards something meaningful.
The Real-World Application
Consider Sarah, a 48-year-old teacher with knee OA who consistently cancels follow-up appointments and admits she’s “not great” with her exercises and feels guilty coming in if she hasn’t done them.
Traditional approach: “Sarah, you need to prioritise these exercises if you want to see improvement.”
Alliance-building approach: “Sarah, it sounds like teaching is demanding all your energy right now. What would need to change for you to feel confident about managing both your career and your knee health?”
The difference? The second approach invites collaboration and acknowledges her reality, rather than adding to her sense of failure.
What This Means for Your Practice
This research confirms what many of us suspect: technical excellence isn’t enough when treating knee OA. The real skill lies in building the therapeutic alliance that makes everything else possible.
Three Key Shifts to Consider:
- From Information to Alliance: Instead of focusing solely on what patients need to know, prioritise how they feel heard and understood.
- From Prescription to Collaboration: Rather than telling patients what to do, invite them to help design their treatment approach.
- From Avoiding to Addressing: Don’t shy away from difficult conversations about weight, motivation, or lifestyle barriers. These are opportunities to deepen trust.
Moving Forward
The research is clear: our interventions work when patients engage with them. Patient education combined with exercise therapy produces superior outcomes. Apps can improve adherence. Weight management enhances results.
But all of this hinges on one critical factor—the quality of your therapeutic relationships.
Replace frustration with curiosity. When a patient isn’t following through, get curious about what’s really happening in their world. What are they actually struggling with? What matters most to them? What would success look like in their daily life?
The next time you feel frustrated with a non-adherent knee OA patient, remember: the resistance isn’t a barrier—it’s a signal. It’s telling you exactly where your communication skills can make the difference between another failed treatment plan and a genuine therapeutic breakthrough.
Ready to strengthen your therapeutic alliance skills? The research shows it’s the key to everything else we do. Consider how developing these communication competencies might transform not just your patient outcomes, but your satisfaction as a clinician.
CONTACT ME for coaching and inservice workshops
Reference:
Goff AJ, Elkins MR. Knee osteoarthritis. Journal of Physiotherapy. 2021. https://doi.org/10.1016/j.jphys.2021.08.009
