More frequent empathic communication by physical therapists is associated with improved outcomes for low-impact chronic pain

Key points

1. 01Physical therapists responded empathically to 67% of patient emotional cues on average, but individual rates ranged widely from 27% to 84%.
2. 02Higher empathic response rates were associated with lower pain intensity (B = -1.29, 95% CI -2.23 to -0.36, P = .007) and lower pain interference (B = -1.07, 95% CI -2.11 to -0.03, P = .044).
3. 03The benefit of empathic communication grew over time - the inverse relationship between empathy and pain intensity emerged around 2 weeks and was most prominent at 6 weeks.
4. 04Patients with highly empathic therapists (top quartile, response rate 91% or above) had a 1.42-point decrease in pain intensity versus 0.47 points for the lowest quartile.
5. 05More empathic communication was also weakly to moderately linked to greater patient positive affect and therapeutic alliance, but not to exercise adherence or attendance.

How it was conducted

Design

Prospective cohort study with longitudinal audio recording of physical therapist-patient sessions

Participants

31 patients with chronic musculoskeletal pain (pain persisting 3 or more months) and 8 physical therapists at one outpatient clinic

Sessions recorded

99 audio-recorded visits across 6 weeks (initial examination plus follow-ups at approximately 2-week intervals)

Empathy measure

Ratio of physical therapist empathic responses to patient-initiated empathic opportunities, coded by trained reviewers (interrater reliability kappa = 0.76)

Primary outcomes

Brief Pain Inventory subscales for pain intensity and pain interference, collected within 48 hours of each recorded visit

Analysis

Repeated-measures conditional linear mixed-effects models adjusted for patient sex, age, and depressive symptoms

What they found

• Physical therapists responded empathically to 67% of patient emotional cues on average (range 27% to 84% across 8 providers).
• 899 empathic opportunities were identified across 99 visits (mean 7.3 per visit, range 0-24), with 603 empathic responses.
• More frequent empathic communication was associated with lower pain intensity: B = -1.29, 95% CI -2.23 to -0.36, P = .007.
• More frequent empathic communication was associated with lower pain interference: B = -1.07, 95% CI -2.11 to -0.03, P = .044.
• A significant empathic communication by time interaction for pain intensity was observed: B = -0.78, 95% CI -1.45 to -0.12, P = .022.
• Pain intensity decreased 0.47 points over 6 weeks for patients with low-empathy therapists (bottom quartile, response rate 51% or below) versus 1.42 points for those with high-empathy therapists (top quartile, response rate 91% or above).
• Empathic communication was moderately associated with patient positive affect (r = 0.48, 95% CI 0.22 to 0.67, P < .001) and weakly associated with therapeutic alliance (r = 0.26, 95% CI 0.054 to 0.45, P = .013).
• No significant associations were found between empathic communication and patient negative affect, exercise adherence, or attendance (P > .05).
• Empathic communication frequency was not predicted by physical therapist clinical experience (rho = -0.13, P = .49) or patient symptom chronicity (rho = -0.04, P = .82).

Limitations

• Small, convenience sample of 8 physical therapists and 31 patients at a single clinic, limiting generalizability.
• Observational design cannot establish causation - differences in treatment approaches between therapists may covary with communication style and independently affect outcomes.
• Patient sample had low baseline pain and no mood disorders, which is uncharacteristic of high-impact chronic pain populations; effects may differ in more severely affected groups.
• Audio-only recordings could not capture non-verbal empathic behaviors such as facial expressions and therapeutic touch, and did not cover all treatment visits.

Why it matters

For patients

Patients with chronic musculoskeletal pain may benefit from choosing or requesting care from physical therapists who actively acknowledge their emotional concerns during treatment.

For clinicians

Physical therapists should be aware that empathic responsiveness to patient emotions - regardless of years of experience - may meaningfully improve pain outcomes, suggesting that targeted communication training could be valuable.

For readers

This is the first longitudinal study linking observed empathic communication behavior by physical therapists to patient pain outcomes, supporting the case for integrating communication skills training into pain rehabilitation.