Research Report
Communicating With Patients:
L Roberts, PhD, MCSP, is Superin-
tendent Physiotherapist, Physio-
therapy Department, Southampton
University Hospitals NHS Trust,
Southampton, Hampshire, United
Kingdom, and Senior Lecturer,
School of Health Professions and
Rehabilitation Sciences, Southamp-
ton University, Southampton, Hamp-
shire, United Kingdom.
SJ Bucksey, MSc, MCSP, is Physio-
therapy Manager, West Dorset
Hospitals NHS Trust, Dorchester,
Dorset, United Kingdom. She was
a student in the School of Health
Professions and Rehabilitation Sci-
ences, Southampton University,
when this work was completed.
Address all correspondence to Mrs
Bucksey at: sally.bucksey@wdgh.
nhs.uk.
[Roberts L, Bucksey SJ. Communi-
cating with patients: what hap-
pens in practice? Phys Ther. 2007;
87:586 –594.]
© 2007 American Physical Therapy
Association
Post a Rapid Response or
find The Bottom Line:
www.ptjournal.org
586 f Physical Therapy Volume 87
What Happens in Practice?
Lisa Roberts, Sally J Bucksey
Background and Purpose
Communication is the most important aspect of practice that health care profession-
als have to master. The purpose of this study was to measure the content and
prevalence of verbal and nonverbal communications between physical therapists and
patients with back pain.
Subjects
Seven physical therapists and 21 patients with back pain participated in this study.
Methods
The first interaction following the initial assessment was recorded with a video
camera. The outcome measures were the Medical Communications Behavior System
(verbal communication) and frequencies of nonverbal behaviors (affirmative head
nodding, smiling, eye gaze, forward leaning, and touch). Semistructured interviews
were undertaken with the physical therapists to determine the perceived influence
of the video camera.
Results
A total of 2,055 verbal statements were made. Physical therapists spent approxi-
mately twice as much time talking as patients, with content behaviors (such as taking
history and giving advice) comprising 52% of verbal communications. The most
prevalent nonverbal behaviors were touch by physical therapists (54%) and eye gaze
by patients (84%).
Discussion and Conclusion
The prevalence and content of communication can be measured with video analysis
and validated tools. Communication is an extremely important but underexplored
dimension of the patient-therapist relationship, and the methods described here
could provide a useful model for further research and reflective practice.
Number 5 May 2007

C
ommunication has been de-
scribed as the most important
aspect of practice that health
professionals have to master1 and an
essential requirement underpinning
any successful encounter.2 It has
been widely studied within the fields
of medicine, nursing, psychology,
psychotherapy, and social science,
and the complexity of measuring
interactions between patients and
health care professionals is well
recognized.
It is important to consider not only
what is said but also the manner in
which it is conveyed, as communica-
tion traditionally incorporates verbal
and nonverbal behaviors. Depending
on the situation and the words used,
verbal communication may be used
for the transference of information
or instruction as well as for convey-
ing empathy in order to establish a
relationship.3 The effectiveness of
any verbal message conveyed to an-
other individual relies on his or her
ability to listen, hear, and assimilate
the message appropriately.4 Non-
verbal communication includes all
behaviors that convey messages with-
out the use of verbal language.5 At-
tempts have been made to quantify
the relative importance of verbal and
nonverbal behaviors, with estimates
of the nonverbal component com-
prising 55% to 97%,6 90%,7 and 93%8
of the message. Despite the varia-
tions in these values, nonverbal as-
pects of communication are consis-
tently thought to be more influential
than verbal behaviors. According to
Waddell,9 when the nonverbal mes-
sage conflicts with the verbal mes-
sage, people probably will not be-
lieve what is said.
Although the importance of commu-
nication in health care interactions is
undisputed, its influence on treat-
ment outcomes is less clear. Current
data suggest that positive effects oc-
cur when people feel empowered
and believe that they have been
May 2007
Communicating With Patients in Practice
“heard”10; therefore, a “good clinical
encounter”10 leads to better out-
comes. This view has been substan-
tiated by reports of increased patient
knowledge,11 improvements in ini-
tial beliefs about medications,11 im-
proved adherence to treatment regi-
mens,11–13 greater understanding of
information given,12 and enhanced
satisfaction.11,12,14 This view is not
universal, however, as some re-
searchers have argued that the ex-
planatory models used by health care
professionals intersect with the be-
liefs of patients and create relation-
ships that do not result in predict-
able, linear outcomes.15
Recently, interest has grown in ex-
amining the implications for clinical
care of more patient-centered ap-
proaches15 across the health care
professions. Within the psychother-
apy literature, the development of a
“strong therapeutic alliance”16 has
been widely considered, and it has
been stated that the relationship be-
tween the client and the psycho-
therapist, more than any other fac-
tor, determines the effectiveness of
psychotherapy.17 Similarly, within
the field of nursing, the importance
of communication has been recog-
nized, in particular, during the initial
phase of the nurse-patient relation-
ship, when roles are clarified and
rapport and standards are estab-
lished.18 Within the field of medi-
cine, it has been claimed that 80% of
patients’ complaints arise from a
breakdown in communication,19 a
finding that highlights the impor-
tance of this topic. Furthermore,
communication assumes a special
importance when things go awry; in
a study of 227 patients and relatives
who were taking legal action through
medical negligence solicitors, “expla-
nation and apology” was the most fre-
quently cited action after the incident
that might have prevented litigation.20
With regard to physical therapy, the
need to give attention to communi-
Volume 87
cation has been accelerated by the
emergence of patient-centered per-
spectives.21 When Stenmar and Nord-
holm22 investigated clinicians’ per-
ceptions of the most important
factors in successful treatment in
their sample of 187 Swedish physical
therapists, they found that the major-
ity perceived the patient-therapist re-
lationship and patients’ resources to
be more important to treatment suc-
cess than the treatment itself.
Despite the importance of communi-
cation, there is no gold standard in-
strument for measuring communica-
tion, and various methods have been
used within the health care fields;
qualitative methods have been used
to determine health care profession-
als’ and patients’ opinions of what
constitutes an effective interaction,23
and quantitative methods have been
used to measure verbal and nonver-
bal communications with an array
of classification schemes. Although
these methods have resulted in greater
insight into styles of communication,
relatively little still is known about the
content of health care consultations.24
To date, this work generally has fo-
cused on doctor-patient interactions
and has been reported less widely in
other health care professions.
Within the setting of physical ther-
apy, Talvitie3 investigated the inter-
action between the clinician and
the patient by using a form of inter-
action analysis to record verbal and
nonverbal communications. This
method involved the use of an ob-
servational instrument based on the
Didactic Process Analysis in the
Helsinki taxonomy, which was orig-
inally designed for use in a classroom
setting.25 The measure had been
adapted (without revalidation) to
suit the classification of verbal com-
munication and socioaffective char-
acteristics in the setting of physical
therapy. Despite its apparent valid-
ity, Talvitie3 considered this measure
to be inappropriate for use within
Number 5 Physical Therapy f 587
Communicating With Patients in Practice
Figure.
Summary of study design. GP⫽general practitioner.
the setting of physical therapy be-
cause of insensitivity within the cod-
ing categories.
Therefore, the search continues for
an appropriate, validated tool for
measuring the communication that
takes place during clinical encoun-
ters. Only when the content of this
communication is known can clini-
cians establish ways to optimize
the relationship, maximize the non-
specific treatment effects (eg, the
patient who experiences less pain
during a consultation with a warm,
empathetic health care profession-
al), and enhance the patient’s expe-
rience. Given this context, the pur-
pose of this study was to measure
the content and prevalence of the
verbal and nonverbal communica-
tions that occur between physical
therapists and patients with low
back pain in an outpatient setting.
588 f Physical Therapy Volume 87
Method
Study Design
A pragmatic, prospective, observa-
tional study was undertaken in an
acute care hospital and in a Primary
Care Trust in southern England to
identify the verbal and nonverbal
communications that occur between
physical therapists and patients with
low back pain during treatment ses-
sions. The study design included
mixed methods (quantitative and
qualitative), as outlined in the Figure.
Participants
All physical therapists (n⫽16) work-
ing in the participating departments
were given an information sheet out-
lining the study. Clinicians whose
caseload did not include patients
with low back pain were excluded
(n⫽2), ensuring that all participating
therapists were currently treating pa-
tients with low back pain. In addi-
Number 5
tion, any clinicians who had specific
knowledge of the outcome measures
to be used were excluded (n⫽1) to
minimize bias attributable to prior
knowledge of the communication
categories.
In an outpatient setting, people with
low back pain are among the most
prevalent consumers of physical
therapy. Although it is essential to
build rapport and develop a strong
patient-therapist relationship, there
are additional physical barriers that
can present a challenge in this pop-
ulation. First, patients frequently ex-
perience discomfort when sitting
(eg, to give a history), and the ther-
apist must remain sensitive to this
situation. Second, some components
of the initial assessment and subse-
quent treatment may involve palpat-
ing the spine (which usually occurs
with the patient lying prone). This
scenario potentially limits the oppor-
tunities for demonstrating nonverbal
behaviors, such as eye gaze, thereby
increasing the need for skillful verbal
communication.
Therefore, we decided to limit the
patient population to any adult pa-
tients referred to the physical ther-
apy departments with a diagnosis of
low back pain. The duration of back
pain was not specified in the inclu-
sion criteria, and patients were eligi-
ble to participate whether or not
their symptoms were referred into
the lower limb, as these factors were
assumed not to influence the com-
munication occurring during the in-
teraction. Patients with signs and
symptoms suggesting possible seri-
ous spinal pathology were excluded,
as were people whose first language
was not English, because of the ex-
ploratory nature of the study.
Of the 13 physical therapists (4 men
and 9 women) who agreed to take
part in the study, 7 female clinicians
(2 employed by an acute care hospi-
tal and 5 employed by the Primary
May 2007

Care Trust) successfully recruited
patients. Their mean number of
years of qualification was 9 (range⫽
0.5–33 years), with 3 clinicians
(43%) at the more experienced (se-
nior I) grade, 3 (43%) at the senior II
grade, and 1 (14%) at the least expe-
rienced (staff) grade. Twenty-one pa-
tients reporting low back pain were
recruited for the study (12 men
[57%] and 9 women [43%]). The
mean age of the patients was 48
years (range⫽21–76 years).
Data Collection
To measure communication, it is
necessary to directly observe the
interaction taking place between the
physical therapist and the patient.26
This interaction can be recorded
with either videotapes or audio-
tapes, although videotape recording
has the advantage of being able to
record nonverbal communication in
addition to verbal utterances. Con-
versely, recording patients in a state
of undress may deter potential par-
ticipants and could raise ethical is-
sues. For the purposes of this study,
recording nonverbal communication
was a priority; therefore, with ex-
press (written) consent from both
parties, the interaction between the
physical therapist and the patient
was recorded with videotape dur-
ing the first treatment session follow-
ing the initial assessment. This ses-
sion was chosen because it was a
less structured encounter than the
initial assessment but was still early
enough in the patient’s treatment to
capture the developing therapeutic
relationship.
A tripod-mounted Sony camera
(model CCD-FX200E/FX270E)* was
placed centrally along the side par-
tition of the treatment cubicle to
maximize the view of both the pa-
tient and the clinician as discreetly
as possible. Because of ethical con-
* Sony Corp, Pipers Way, Thatcham, Berk-
shire, United Kingdom RG19 4LZ.
May 2007
Communicating With Patients in Practice
straints, the camera was manually
operated by the researcher, who was
present in the treatment cubicle
(and confined the videotape record-
ing to the head and neck of partici-
pants throughout the data collection
process).
Following the treatment session, a
brief, semistructured interview was
undertaken with the physical thera-
pist to determine the perceived in-
fluence of the presence of the man-
ually operated video camera, in
comparison with the therapist’s
usual practice.
Outcome Measures
Verbal communication. In order
to explore the interaction between
the physical therapist and the pa-
tient, a validated outcome measure
of verbal communication, the Medi-
cal Communications Behavior Sys-
tem (MCBS), was used.27 The MCBS
was developed to measure the com-
munication occurring in situations
involving multiple health care pro-
viders27 and has categories for infor-
mational (content), relational (affec-
tive), and negative behaviors for
both clinicians and patients. These
categories were subdivided further
into 13 clinician behaviors, 7 patient
behaviors, and 3 miscellaneous cate-
gories (Tab. 1). In order to maintain
the use of the measure in its original
form, the term “behavior” was
adopted throughout instead of the
term “communication.”
Psychometrically, the interrater reli-
ability of the MCBS, assessed with
the Pearson correlation coefficient,
was greater than .70 for all behaviors
occurring more frequently than 2%
of the time during an observational
study of 101 genetic counseling ses-
sions.27 Factor analysis was done
and was found to provide some
construct validity, supporting the
a priori organization of the behaviors
into informational, relational, and
negative behaviors (but with further
Volume 87
subdivisions for informational behav-
iors).27 In addition, criterion validity
has been determined with the Roter
Interaction Analysis System.27
Trends in nonverbal communica-
tion. The frequencies of the 5 non-
verbal behaviors—affirmative head
nodding, smiling, eye gaze, forward
leaning, and touch— described by
Heintzman et al28 were recorded at
40-second intervals for both the
physical therapist and the patient.
This outcome measure was devel-
oped in the field of business and
was subsequently used by Caris-
Verhallen et al6 in the settings of
home nursing and care of older peo-
ple; the interrater reliability of the
nonverbal behaviors was calculated,
using the Pearson correlation coeffi-
cient, to be between .70 and .98.
Data Analysis
To determine the content and prev-
alence of the verbal and nonverbal
communications that occurred be-
tween the physical therapists and
the patients, the primary analysis in-
volved classifying the verbal commu-
nication by use of the MCBS and
measuring the frequencies of non-
verbal behaviors at 40-second inter-
vals. The videotapes were analyzed
by a trained, independent assistant,
who classified the verbal utterances
into the categories shown in Table 1.
An interrater reliability exercise for
coding these categories was done
by the researcher and the indepen-
dent assistant using the Pearson
correlation coefficient with 3 pilot
therapist-patient dyads.
In addition to recording the frequen-
cies of the MCBS categories, we re-
corded the durations of the treat-
ment sessions in minutes and seconds.
Because of variations in the length of
the treatment sessions, the propor-
tion of time that the physical thera-
pist and the patient spent talking was
determined as a percentage for each
category.
Number 5 Physical Therapy f 589
Communicating With Patients in Practice

Table 1. Interrater Reliability of Verbal

Examples of Categories Within the Medical Communications Behavior System27
Category
Physical therapist content
behaviors
Physical therapist affective
behaviors
Physical therapist negative
behaviors
Patient content behaviors
Patient affective behaviors
Patient negative behaviors
Miscellaneous
Analysis of verbal and nonverbal com-
munications was done with descrip-
tive statistics by use of the Statistical
Package for the Social Sciences (SPSS,
version 10.0).† As before, an interrater
reliability exercise for coding the non-
verbal behaviors was done prior
to data collection. The verbatim tran-
scripts of the semistructured inter-
views were analyzed independently
by the researcher and the assistant,
and a thematic analysis was used to
identify emergent themes.
†
SPSS Inc, 233 S Wacker Dr, Chicago, IL
60606.
Example
1. History and background probes
2. Checks for understanding
information
3. Advice and suggestions
4. Restatement
5. Clarification
1. Emotional probes
2. Reassurance and support
3. Reflection of feelings
4. Encouragement and acknowledgment
1. Disapproval
2. Disruptions
3. Jargon
1. Content questions
2. Content remarks
3. Checks for understanding
1. Encouragement
2. Emotional expressions
1. Disapproval
2. Disruptions
1. Social amenities
2. Silence
3. Nonclassifiable
Results
Duration
At the time of the study, follow-up
appointments were usually allocated
20-minute slots. From the 21 inter-
actions observed between patients
and physical therapists, 312 minutes
of videotape were recorded. The
mean durations of the treatment ses-
sions were 14 minutes 51 seconds.
The minimum duration noted was 8
minutes 26 seconds, and the maxi-
mum duration noted was 31 minutes
45 seconds.
and Nonverbal Behaviors
During pilot work, good interrater
reliability between the researcher
and the independent assistant was
demonstrated for both verbal com-
munication (r⫽.97) and nonverbal
communication (physical therapist
r⫽.98, assistant r⫽.86).
Verbal Communication
During the 21 sessions analyzed,
2,055 statements were recorded and
classified by use of the MCBS, with a
mean of 98 statements per session.
Overall, clinicians made approxi-
mately twice as many statements as
patients made. Each MCBS category
was recorded as a percentage of the
total verbal communication (Tab. 2),
demonstrating that overall, content
behaviors represented the highest
proportions of verbal communica-
tion carried out by both physical
therapists (52%) and patients (26%).
A secondary analysis took into ac-
count sex (of patients, given that all
physical therapists were women), se-
niority (ie, grade of staff), and pa-
tients’ ages. Of these 3 factors, se-
niority affected the MCBS categories
the most, with the more senior staff
members (senior I grade) showing a
higher proportion of physical thera-
pist affective behavior (20%) than
the senior II grade staff members
(12%) or the least experienced (staff
grade) staff members (12%). The re-
sults of analyses of patients’ ages and
genders were unremarkable.
Nonverbal Communication
The nonverbal behaviors, observed
at 40-second intervals during the
treatment sessions, are summarized
in Table 3. Among the 468 time
points observed, the highest propor-
tions of nonverbal behavior for the
physical therapists were represented
by touch (54%) and then by eye gaze
(32%), whereas for the patients, the
most frequent nonverbal behavior
was eye gaze (84%).

590 f Physical Therapy Volume 87 Number 5 May 2007


Perceived Influence of the
Camera on Communication
Although the physical therapists re-
ported that the more times they
were videotaped, the easier they
found it to relax, the majority con-
sidered that they had decreased the
amount of “non–physical therapy
chat” that occurred, in comparison
with their usual practice; this finding
resulted in an underrepresentation
of this aspect of communication dur-
ing this study.
Perceived Influence of the
Camera on Behavior
As determined by the thematic anal-
ysis, 5 of the 7 physical therapists
considered that the presence of the
manually operated video camera in-
fluenced their behavior. They identi-
fied 3 areas of perceived changes in
their behavior: the extent of treat-
ment planning beforehand, the se-
lection of treatment techniques, and
a reduction in the amount of time
during which the patient was in a
state of undress. With regard to treat-
ment planning, one clinician re-
marked: “I think that the thought of
the video camera makes you think
what you are going to include in the
treatment so that you are absolutely
clear about what you are going to do
in the treatment session before you
go in.”
Discussion
This exploratory study was designed
to measure the content and preva-
lence of the verbal and nonverbal
communications that occur between
physical therapists and patients with
low back pain in an outpatient set-
ting. For the 2,055 verbal statements
recorded, the ratio was 2:1 in favor
of the physical therapists. This ratio
differs from that found in previous
research by Ong et al,29 who re-
ported that, in a doctor-patient on-
cology setting, patients and doctors
communicated relatively equally dur-
ing their consultation. The higher
percentage of physical therapist con-
May 2007
Communicating With Patients in Practice
Table 2.
Medical Communications Behavior System Categories as Percentages of Total
Communicationa
Category
Physical therapist
Content behaviors
Affective behaviors
Negative behaviors
Patient
Content behaviors
Affective behaviors
Negative behaviors
Miscellaneous
Total statements
a
Frequency of each verbal behavior that occurred during the 21 interactions as a percentage of the
total communication. Miscellaneous behaviors included social salutations and nonclassifiable utterances
(eg, “ouch”).
tent communication in the present
study may have been attributable to
the fact that, after the initial assess-
ment, the first treatment session
usually involved giving advice and
information (eg, about posture, ergo-
nomic and lifestyle factors, and other
forms of self-management); discuss-
ing psychosocial factors; explaining
the risks, benefits, and alternatives
of any treatments offered; gaining
consent for any techniques per-
formed; and evaluating their out-
comes. Physical therapists are likely
to have longer appointment times
than doctors, make fewer referrals
to other health care professionals,
and spend more time applying treat-
ments; these factors may account for
the differences between the studies.
Previous research showed that con-
siderable affective behaviors are re-
quired for an effective interaction be-
tween a physical therapist and a
patient.30 In the present study, these
behaviors were shown to be less
common than content behaviors; a
possible explanation is that a consid-
erable amount of advice still was be-
ing imparted to the patients during
the early sessions. It is possible that
affective behaviors become more
Volume 87
Frequency (%)
1,065 (51.8)
272 (13.2)
0 (0.0)
541 (26.3)
43 (2.1)
13 (0.6)
121 (5.9)
2,055
prevalent in subsequent sessions,
when the therapeutic relationship is
more established; this issue is wor-
thy of further research. A more likely
reason for the underrepresentation
of empathic behaviors in the present
study, however, was the presence of
the video camera, as the therapists
reported that this decreased the
amount of nonclinical communica-
tion that occurred. This potential
limitation also was identified in pre-
vious studies.31,32 It is not known
from the present study what influ-
ence the camera was perceived to
have on the patients’ communica-
tion, as this factor was not measured;
this issue is worthy of further
research.
Further analysis of the data showed
that sex (of the patient) made little
difference in the categories of verbal
communication recorded in the
present study. From the pool of
4 male and 9 female physical thera-
pists, only 7 female clinicians suc-
cessfully recruited patients into the
study. Therefore, it was not pos-
sible in the present study to explore
the content and prevalence of inter-
actions involving male clinicians
and to compare them with those in-
Number 5 Physical Therapy f 591
Communicating With Patients in Practice
Table 3.
28,a
Nonverbal Behaviors
Behavior
Eye gaze
Affirmative head nodding
Smiling
Forward leaning
Touch
a
Types of nonverbal behaviors recorded at 40-second intervals.
volving female clinicians. This is a
topic for further research, as other
studies showed that, in general,
women (both patients and health
care professionals) spoke more dur-
ing a medical interaction than men33
and that female-female interactions
were likely to result in greater frequen-
cies of affective communications.34
The present study also showed that
experienced physical therapists dem-
onstrated affective behaviors more
readily than their junior colleagues. A
possible explanation is that therapists
with less experience often lack confi-
dence in their clinical abilities and so
tend to focus on treatment techniques
rather than on more affective compo-
nents, such as patients’ feelings. This
notion is supported by the qualitative
work carried out by Jensen et al,35 and
such sentiments are likely to be com-
592 f Physical Therapy Volume 87
Description
Either the patient or the physical
therapist gazes directly at the
face of the other party.
Head nods are defined as
nodding one or more times as
a sign of attentiveness in
conversation or as reinforcing
what has been spoken.
Smiling in this context is an
expression of friendliness.
Laughing aloud, in response to
a joke, is not considered a
nonverbal communication and
is coded in the verbal part of
the observation scheme.
Forward leaning is defined as
posture that involves bending
forward or sitting closer to the
patient when it is not
necessary to carry out a
physical therapy task. This
position conveys involvement
and a concentrated focus on
the interaction partner.
Either the physical therapist or
the patient has physical
contact with the other party.
pounded by the presence of the video
camera.
During the 21 treatment sessions
observed, the numbers of nonverbal
behaviors recorded at 40-second in-
tervals for patients and physical
therapists were 40 and 652, re-
spectively (a ratio of 1:16). Caris-
Verhallen et al6 and Ambady et al26
considered that viewing sections of
an interaction is an adequate indica-
tion of the interaction as a whole,
and in the present study, 468 time
points were sampled. The results
showed that the physical therapists
demonstrated nonverbal behaviors
that facilitated rapport building,
such as eye contact and head nod-
ding. This finding is in accordance
with the findings of previous re-
search carried out in the health care
Number 5
field,6 which suggested that nurses
use mainly eye gaze, head nodding,
and smiling to establish a good rela-
tionship with their patients.
With regard to touch, Gyllensten et
al36 suggested that physical thera-
pists use touch to positively influ-
ence their relationship with pa-
tients. Perhaps not surprisingly, the
highest proportion of nonverbal be-
havior recorded for clinicians in
the present study was represented
by touch, a result that may have
been expected as a consequence of
the hands-on contact that occurred
during physical therapy treatment
sessions. Unfortunately, it was not
possible to determine whether ther-
apists used affective, rather than
therapeutic, touch to facilitate rela-
tionships with their patients be-
cause of the lack of sensitivity in the
single category “touch” in the out-
come measure chosen. Within the
nursing literature, the category “touch”
has been subdivided into 2 catego-
ries: instrumental touch, which is de-
fined as deliberate physical contact
necessary to perform a task, and af-
fective or expressive touch, which is
relatively spontaneous and not nec-
essary for the completion of a task.6
In future research measuring interac-
tions within the setting of physical
therapy, we recommend that touch
be subdivided into instrumental
touch (eg, executing a manual ther-
apy technique), demonstration (eg,
when therapists demonstrate on
themselves how to modify an activity
or perform an exercise), and affec-
tive touch (eg, making tactile con-
tact with a patient to offer reassur-
ance). Any changes in the outcome
measure would require revalidation
prior to use.
The results also indicated that the
physical therapists and the patients
demonstrated high proportions of
eye contact (156 and 36 times, re-
spectively). Therapists learn at an un-
May 2007

dergraduate level about the impor-
tance of body language, in particular,
eye contact, which is reported to
promote a favorable treatment out-
come.7,37 More specifically, physical
therapists’ eye contact has been
shown to increase patients’ confi-
dence and demonstrate that the cli-
nician is interested in the patient’s
condition.37 During the treatment of
patients with low back pain, how-
ever, maintaining eye contact and
building this confidence may be-
come problematic if the patients
spend a significant amount of time
lying prone. Further underreporting
of nonverbal behaviors in the
present study may have arisen be-
cause of the presence of the re-
searcher and the video camera and,
on a practical level, it was not always
possible to observe both the clini-
cian and the patient simultaneously
with a single video camera.
Although the present study showed
that aspects of verbal and nonverbal
communications can be measured
with video analysis and validated out-
come measures, a number of limita-
tions were evident. The background
noise within the department, cou-
pled with the divergent positioning
of patients and physical therapists,
may have resulted in some under-
reporting of communications. The
use of 2 microphones helped to min-
imize this problem; however, multi-
ple wall-mounted cameras would
have been preferable but were not
permitted for ethical reasons.
Previous studies acknowledged the
importance of recording both the
verbal and the nonverbal behaviors
that occur during an interaction; how-
ever, few authors attempted to do
so,6 especially within the setting
of physical therapy.3 Although the
outcome measures chosen for the
present study had not been used pre-
viously in such a setting, they were
able to effectively record the content
and prevalence of verbal and nonver-
May 2007
Communicating With Patients in Practice
bal behaviors that occurred. Despite
being able to measure these aspects of
communication, however, they were
not able to determine sequences or
patterns of communication; this is a
topic for further research. In addition,
the most prevalent category in the
MCBS tool lacked sensitivity. In future
studies, it would be advantageous to
subdivide the verbal content category
into “offering advice” (such as when
modifying an activity) and “giving in-
struction” (such as when teaching an
exercise), as the balance of power
may be perceived differently during
these interactions. Any such modifica-
tions would need to be validated
against the original MCBS.
The methods used in the present study
for recording the prevalence and con-
tent of verbal and nonverbal commu-
nications could be applied to further
research (eg, mapping of entire care
episodes). In the present study, we
considered only the first follow-up
appointments for patients with low
back pain; however, it would be im-
portant to consider the initial assess-
ment as well as subsequent treatments
to record the content of the interac-
tions as the relationship develops.
Once this baseline is established, re-
search can be extended to include is-
sues of culture and patients’ needs and
expectations, as their effect on com-
munication is largely unknown.
In clinical practice, recording initial
assessments (with express consent)
can provide valuable information
and material for reflection, helping
to identify communication skills and
strategies and the impact that they
appear to have on patients.38 Such
reflection is important because com-
munication is a skill and, like all
skills, it requires practice to be per-
formed well.39
Conclusion
In the present study, we explored an
area of physical therapist practice
that is universally regarded as ex-
Volume 87
tremely important but is underrepre-
sented within the health care litera-
ture. It has been shown that it is
possible to reliably record the prev-
alence and content of verbal and
nonverbal communications with
video analysis and valid tools, such as
the MCBS and the positive nonverbal
behaviors of Heintzman et al.28 Al-
though the physical therapists in the
present study perceived that the
presence of the camera (operated by
the researcher) influenced their be-
havior and communication, this in-
fluence became less of an issue the
more times they were recorded on
videotape.
The methods described here could
be used in future research to further
explore the patient-therapist rela-
tionship (eg, mapping of entire care
episodes, patterns of communica-
tion, and issues such as sex and cul-
ture). Once the content of a physical
therapy encounter is established, the
next challenge is to use communica-
tion skills that maximally enhance
treatment outcomes. As part of this
process, video analysis could be used
for teaching purposes to provide
feedback to clinicians to improve
their communication skills, maxi-
mize the nonspecific treatment ef-
fects, and improve the patient’s
experience.
Both authors provided concept/idea/
research design and writing. Mrs Bucksey
provided data collection and analysis and
fund procurement, Dr Roberts provided
project management and institutional liai-
sons. The authors acknowledge Sue High,
Department of Social Statistics, Southamp-
ton University, for statistical advice; the
physical therapy outpatient staff at Stone-
ham Centre, Southampton City PCT; and
financial support from the Arthritis and
Rheumatism Campaign and the Chartered
Society of Physiotherapy.
This work was presented at the 14th Inter-
national Congress of the World Confedera-
tion for Physical Therapy; June 7–12, 2003;
Barcelona, Spain.
Number 5 Physical Therapy f 593
Communicating With Patients in Practice
Ethical approval for this study was granted
by the Southampton and South West Local
Research Ethics Committee.
This article was received March 9, 2006, and
was accepted January 8, 2007.
DOI: 10.2522/ptj.20060077
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