ORIGINAL RESEARCH| Volume 102, ISSUE 12, P2335-2342, December 2021

Patient- and Physical Therapist–Level Predictors of Patient-Reported Therapeutic Alliance: An Observational, Exploratory Study of Cohorts With Knee and Low Back Pain


      • Patient- and physical therapist–level factors predicted patient-reported therapeutic alliance.
      • Patient-reported therapeutic alliance can be influenced modifiable physical therapist factors (ie, physical therapist attitudes, beliefs, and self-efficacy).
      • These relationships may vary based on musculoskeletal pain condition.



      To identify patient- and physical therapist–level predictors for therapeutic alliance at the end of an episode of physical therapy for knee or low back pain (LBP).


      Secondary analysis of observational cohort.


      Outpatient physical therapy clinics.


      Patients receiving physical therapy for knee (n=189) or LBP (n=252) and physical therapists (n=19). Candidate predictor variables included demographics, patient clinical characteristics, and physical therapist attitudes and beliefs (Pain Attitudes and Beliefs Scale for Physical Therapists) and confidence in providing patient-centered care (Self-Efficacy in Patient-Centeredness Questionnaire).


      Not applicable.

      Main Outcome Measures

      Patient-reported therapeutic alliance was measured using the 12-item Work Alliance Inventory–Short Revised (WAI-SR).


      Final linear mixed models indicated different patient- and physical therapist–level factor contributions in predicting final WAI-SR scores across cohorts with knee and LBP. Female sex was a consistent patient-level predictor for both knee (estimated β=1.57, P<.05) and LBP (β=1.42, P<.05), with age (β=−0.07, P<.01) and baseline function (β=0.06, P<.01) contributing to cohorts with knee and LBP, respectively. Physical therapist–level predictors included female sex (β=6.04, P<.05), Pain Attitudes and Beliefs Scale for Physiotherapists behavioral (β=0.65, P<.01), and Self-Efficacy in Patient-Centeredness Questionnaire (SEPCQ) Exploring Patient Perspective (β=−0.75, P<.01) subscale scores for LBP, with SEPCQ Sharing Information and Power subscale scores (β=0.56, P<.05) contributing to both cohorts with knee (β=0.56, P<.05) and LBP (β=0.74, P<.01). Random effects for patients nested within physical therapists were observed for both cohorts.


      These findings provide preliminary evidence for inconsistent relationships among patient- and physical therapist–level factors and therapeutic alliance across cohorts with knee and LBP.


      List of abbreviations:

      CAT (computerized adaptive test), ICC (intraclass correlation coefficient), LBP (low back pain), LCAT (lumbar computerized adaptive test), PABS-PT (Pain Attitudes and Beliefs Scale for Physiotherapists), SEPCQ (Self-Efficacy in Patient-Centeredness Questionnaire), TA (therapeutic alliance), WAI-SR (Work Alliance Inventory–Short Revised)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Chou R
        • Deyo R
        • Friedly J
        • et al.
        Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline.
        Ann Intern Med. 2017; 166: 493-505
        • Rubinstein SM
        • de Zoete A
        • van Middelkoop M
        • Assendelft WJJ
        • de Boer MR
        • van Tulder MW.
        Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials.
        BMJ. 2019; 364: l689
        • Saragiotto BT
        • Maher CG
        • Yamato TP
        • et al.
        Motor control exercise for chronic non-specific low-back pain.
        Cochrane Database Syst Rev. 2016; 1CD012004
        • Eckenrode BJ
        • Kietrys DM
        • Parrott JS.
        Effectiveness of manual therapy for pain and self-reported function in individuals with patellofemoral pain: systematic review and meta-analysis.
        J Orthop Sports Phys Ther. 2018; 48: 358-371
        • Fransen M
        • McConnell S
        • Harmer AR
        • Van der Esch M
        • Simic M
        • Bennell KL.
        Exercise for osteoarthritis of the knee: a Cochrane systematic review.
        Br J Sports Med. 2015; 49: 1554-1557
        • van der Heijden RA
        • Lankhorst NE
        • van Linschoten R
        • Bierma-Zeinstra SMA
        • van Middelkoop M.
        Exercise for treating patellofemoral pain syndrome.
        Cochrane Database Syst Rev. 2015; 1CD010387
        • Rossettini G
        • Camerone EM
        • Carlino E
        • Benedetti F
        • Testa M.
        Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy.
        Arch Physiother. 2020; 10: 11
        • Cuijpers P
        • Reijnders M
        • Huibers MJH.
        The role of common factors in psychotherapy outcomes.
        Annu Rev Clin Psychol. 2019; 15: 207-231
        • Rossettini G
        • Carlino E
        • Testa M.
        Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain.
        BMC Musculoskelet Disord. 2018; 19: 27
        • Testa M
        • Rossettini G.
        Enhance placebo, avoid nocebo: how contextual factors affect physiotherapy outcomes.
        Man Ther. 2016; 24: 65-74
        • Rossettini G
        • Palese A
        • Geri T
        • Fiorio M
        • Colloca L
        • Testa M.
        Physical therapists’ perspectives on using contextual factors in clinical practice: findings from an Italian national survey.
        PLoS One. 2018; 13e0208159
        • Rossettini G
        • Palese A
        • Geri T
        • Mirandola M
        • Tortella F
        • Testa M.
        The knowledge of contextual factors as triggers of placebo and nocebo effects in patients with musculoskeletal pain: findings from a national survey.
        Front Psychiatry. 2019; 10: 478
        • Babatunde F
        • MacDermid J
        • MacIntyre N.
        Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature.
        BMC Health Serv Res. 2017; 17: 375
        • Taccolini Manzoni AC
        • Bastos de Oliveira NT
        • Nunes Cabral CM
        • Aquaroni Ricci N.
        The role of the therapeutic alliance on pain relief in musculoskeletal rehabilitation: a systematic review.
        Physiother Theory Pract. 2018; 34: 901-915
        • Joyce AS
        • Ogrodniczuk JS
        • Piper WE
        • McCallum M.
        The alliance as mediator of expectancy effects in short-term individual therapy.
        J Consult Clin Psychol. 2003; 71: 672-679
        • Fuentes J
        • Armijo-Olivo S
        • Funabashi M
        • et al.
        Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study.
        Phys Ther. 2014; 94: 477-489
        • Bordin ES.
        The generalizability of the psychoanalytic concept of the working alliance.
        Psychother Theory Res Pract. 1979; 16: 252-260
        • Allen ML
        • Cook BL
        • Carson N
        • Interian A
        • La Roche M
        • Alegría M
        Patient-provider therapeutic alliance contributes to patient activation in community mental health clinics.
        Adm Policy Ment Health. 2017; 44: 431-440
        • Corso KA
        • Bryan CJ
        • Corso ML
        • et al.
        Therapeutic alliance and treatment outcome in the primary care behavioral health model.
        Fam Syst Health. 2012; 30: 87-100
        • Artus M
        • Campbell P
        • Mallen CD
        • Dunn KM
        • van der Windt DAW.
        Generic prognostic factors for musculoskeletal pain in primary care: a systematic review.
        BMJ Open. 2017; 7e012901
        • de Vos Andersen NB
        • Kent P
        • Hjort J
        • Christiansen DH.
        Clinical course and prognosis of musculoskeletal pain in patients referred for physiotherapy: does pain site matter?.
        BMC Musculoskelet Disord. 2017; 18: 130
        • Green DJ
        • Lewis M
        • Mansell G
        • et al.
        Clinical course and prognostic factors across different musculoskeletal pain sites: a secondary analysis of individual patient data from randomised clinical trials.
        Eur J Pain. 2018; 22: 1057-1070
        • Hart DL
        • Wang YC
        • Stratford PW
        • Mioduski JE.
        Computerized adaptive test for patients with knee impairments produced valid and responsive measures of function.
        J Clin Epidemiol. 2008; 61: 1113-1124
        • Wang YC
        • Hart DL
        • Stratford PW
        • Mioduski JE.
        Clinical interpretation of computerized adaptive test-generated outcome measures in patients with knee impairments.
        Arch Phys Med Rehabil. 2009; 90: 1340-1348
        • Deutscher D
        • Hart DL
        • Stratford PW
        • Dickstein R.
        Construct validation of a knee-specific functional status measure: a comparative study between the United States and Israel.
        Phys Ther. 2011; 91: 1072-1084
        • Hart DL
        • Mioduski JE
        • Werneke MW
        • Stratford PW.
        Simulated computerized adaptive test for patients with lumbar spine impairments was efficient and produced valid measures of function.
        J Clin Epidemiol. 2006; 59: 947-956
        • Hart DL
        • Werneke MW
        • Wang YC
        • Stratford PW
        • Mioduski JE.
        Computerized adaptive test for patients with lumbar spine impairments produced valid and responsive measures of function.
        Spine (Phila Pa 1976). 2010; 35: 2157-2164
        • Wang YC
        • Hart DL
        • Werneke M
        • Stratford PW
        • Mioduski JE.
        Clinical interpretation of outcome measures generated from a lumbar computerized adaptive test.
        Phys Ther. 2010; 90: 1323-1335
        • Hart DL
        • Stratford PW
        • Werneke MW
        • Deutscher D
        • Wang YC.
        Lumbar computerized adaptive test and Modified Oswestry Low Back Pain Disability Questionnaire: relative validity and important change.
        J Orthop Sports Phys Ther. 2012; 42: 541-551
        • Hatcher RL
        • Gillaspy JA.
        Development and validation of a revised short version of the working alliance inventory.
        Psychother Res. 2006; 16: 12-25
        • Houben RM
        • Ostelo RW
        • Vlaeyen JW
        • Wolters PM
        • Peters M
        Stomp-van den Berg SG. Health care providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity.
        Eur J Pain. 2005; 9: 173-183
        • Mutsaers JH
        • Peters R
        • Pool-Goudzwaard AL
        • Koes BW
        • Verhagen AP.
        Psychometric properties of the Pain Attitudes and Beliefs Scale for Physiotherapists: a systematic review.
        Man Ther. 2012; 17: 213-218
        • Zachariae R
        • O'Connor M
        • Lassesen B
        • et al.
        The self-efficacy in patient-centeredness questionnaire - a new measure of medical student and physician confidence in exhibiting patient-centered behaviors.
        BMC Med Educ. 2015; 15: 150
        • Falkenström F
        • Hatcher RL
        • Holmqvist R.
        Confirmatory factor analysis of the patient version of the Working Alliance Inventory–Short Form Revised.
        Assessment. 2015; 22: 581-593
        • Araujo AC
        • Filho RN
        • Oliveira CB
        • Ferreira PH
        • Pinto RZ.
        Measurement properties of the Brazilian version of the Working Alliance Inventory (patient and therapist short-forms) and Session Rating Scale for low back pain.
        J Back Musculoskelet Rehabil. 2017; 30: 879-887
        • Paap D
        • Dijkstra PU.
        Working Alliance Inventory-Short Form Revised.
        J Physiother. 2017; 63: 118
        • Alodaibi F
        • Beneciuk J
        • Holmes R
        • Karehla S
        • Hayes D
        • Fritz J.
        The relationship of therapeutic alliance to patient characteristics and functional outcome during an episode of physical therapy care for patients with low back pain: an observational study.
        Phys Ther. 2021; 101: pzab026
        • Cicchetti DV.
        Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology.
        Psychol Assess. 1994; 6: 284-290
        • Tabachnick BG
        • Fidell LS.
        Using multivariate statistics.
        5th ed. Pearson/Allyn and Bacon, Boston2007
        • George SZ
        • Beneciuk JM
        • Lentz TA
        • Wu SS.
        The Optimal Screening for Prediction of Referral and Outcome (OSPRO) in patients with musculoskeletal pain conditions: a longitudinal validation cohort from the USA.
        BMJ Open. 2017; 7e015188
        • Meier W
        • Mizner RL
        • Marcus RL
        • Dibble LE
        • Peters C
        • Lastayo PC.
        Total knee arthroplasty: muscle impairments, functional limitations, and recommended rehabilitation approaches.
        J Orthop Sports Phys Ther. 2008; 38: 246-256
        • Mistry JB
        • Elmallah RDK
        • Bhave A
        • et al.
        Rehabilitative guidelines after total knee arthroplasty: a review.
        J Knee Surg. 2016; 29: 201-217
        • Jette DU
        • Hunter SJ
        • Burkett L
        • et al.
        Physical therapist management of total knee arthroplasty.
        Phys Ther. 2020; 100: 1603-1631
        • Nwachukwu BU
        • Adjei J
        • Rauck RC
        • et al.
        How much do psychological factors affect lack of return to play after anterior cruciate ligament reconstruction? A systematic review.
        Orthop J Sports Med. 2019; 72325967119845313
        • Brown OS
        • Hu L
        • Demetriou C
        • Smith TO
        • Hing CB.
        The effects of kinesiophobia on outcome following total knee replacement: a systematic review.
        Arch Orthop Trauma Surg. 2020; 140: 2057-2070
        • Coronado RA
        • Bird ML
        • Van Hoy EE
        • Huston LJ
        • Spindler KP
        • Archer KR.
        Do psychosocial interventions improve rehabilitation outcomes after anterior cruciate ligament reconstruction? A systematic review.
        Clin Rehabil. 2018; 32: 287-298
        • Coronado RA
        • Sterling EK
        • Fenster DE
        • et al.
        Cognitive-behavioral-based physical therapy to enhance return to sport after anterior cruciate ligament reconstruction: an open pilot study.
        Phys Ther Sport. 2020; 42: 82-90
        • Elwyn G
        • Frosch DL
        • Kobrin S.
        Implementing shared decision-making: consider all the consequences.
        Implement Sci. 2016; 11: 114
        • Montori VM
        • Brito JP
        • Murad MH.
        The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines.
        JAMA. 2013; 310: 2503-2504
        • Zhao C
        • Dowzicky P
        • Colbert L
        • Roberts S
        • Kelz RR.
        Race, gender, and language concordance in the care of surgical patients: a systematic review.
        Surgery. 2019; 166: 785-792
        • O'Keeffe M
        • Cullinane P
        • Hurley J
        • et al.
        What influences patient-therapist interactions in musculoskeletal physical therapy? Qualitative systematic review and meta-synthesis.
        Phys Ther. 2016; 96: 609-622
        • Hall AM
        • Ferreira PH
        • Maher CG
        • Latimer J
        • Ferreira ML.
        The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review.
        Phys Ther. 2010; 90: 1099-1110
        • Kinney M
        • Seider J
        • Beaty AF
        • Coughlin K
        • Dyal M
        • Clewley D.
        The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: a systematic review of the literature.
        Physiother Theory Pract. 2020; 36: 886-898
        • Burns JW
        • Higdon LJ
        • Mullen JT
        • Lansky D
        • Wei JM.
        Relationships among patient hostility, anger expression, depression, and the working alliance in a work hardening program.
        Ann Behav Med. 1999; 21: 77-82
        • Clayton JA
        • Tannenbaum C.
        Reporting sex, gender, or both in clinical research?.
        JAMA. 2016; 316: 1863-1864