Assessing therapeutic relationships in physiotherapy: literature review.
Abstract: The purpose of this review was to: (a) explore existing literature regarding the 'therapeutic relationship' in physiotherapy to identify what are considered the core components; and (b) critically appraise the conceptual basis of two commonly used measures of the therapeutic relationship: the Working Alliance Inventory and the Helping Alliance Questionnaire Version Two. A systematic approach to searching was utilised to identify relevant literature. Databases searched included: the Cochrane Library, EBSCO Health Databases, Scopus, Web of Science, and OVID. Sixteen studies were included in the review and key themes reflecting the key components of the therapeutic relationship in physiotherapy were extracted from each study. Eight key themes were identified including: patient expectations; personalised therapy; partnership; physiotherapist roles and responsibilities; congruence; communication; relationship/ relational aspects; and influencing factors. Each of the measures addressed some components of therapeutic relationship well (namely congruence, partnership, and physiotherapists roles and responsibilities), while some components were poorly addressed (communication, personalised therapy, and relational aspects). Future research could work towards the development of a more conceptually sound measure of therapeutic relationship for use in this context. In the absence of such a measure, further examination of the measurement properties of existing measures in the physiotherapy setting would be warranted.

Besley J, Kayes NM, McPherson KM. Assessing therapeutic relationships in physiotherapy: literature review. New Zealand Journal of Physiotherapy 39(2) 81-91.

Key words: therapeutic relationship, therapeutic alliance, working alliance, physiotherapy, physical therapy
Article Type: Report
Subject: Physical therapy (Analysis)
Physical therapy (Health aspects)
Therapeutics, Physiological (Analysis)
Therapeutics, Physiological (Health aspects)
Database searching (Analysis)
Database searching (Health aspects)
Internet/Web search services (Analysis)
Internet/Web search services (Health aspects)
Online searching (Analysis)
Online searching (Health aspects)
Online databases (Analysis)
Online databases (Health aspects)
Authors: Besley, Jessica
Kayes, Nicola M.
McPherson, Kathryn M.
Pub Date: 07/01/2011
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: July, 2011 Source Volume: 39 Source Issue: 2
Topic: Event Code: 389 Alliances, partnerships Computer Subject: Online database
Accession Number: 288537990
Full Text: INTRODUCTION

In many areas of health care, particularly psychotherapy and related fields, the development of a 'therapeutic relationship' or 'working alliance' has been established as a key component for successful treatment outcomes (Leach 2005, Roberts and Bucksey 2007, Schonberger et al 2006). For example, in psychotherapy it has been stipulated that the psychotherapist-client relationship determines the effectiveness of psychotherapy more than any other factor (Roberts and Bucksey 2007). However, despite the fact that a 'therapeutic relationship' is considered to be important, there is a paucity of literature regarding this concept within the field of physiotherapy (Bellner 1999, Leach 2005, Potter et al 2003a, Potter et al 2003b, Roberts and Bucksey 2007, Williams and Harrison 1999). Several authors (Potter et al 2003a, Potter et al 2003b, Roberts and Bucksey 2007) have reported that the therapist-patient relationship is underexplored in physiotherapy, and Leach (2005) suggests further research is needed to evaluate the impact of rapport on the outcomes of allied health interventions.

The concept of the 'therapeutic relationship' has been variably defined, and several terms such as 'working alliance', 'therapeutic alliance', and 'therapist-patient relationship' are often used interchangeably. The therapeutic relationship is commonly defined as "a means of communication wherein both therapist and patient interact to achieve a therapeutic goal" (Gartland 1984, p. 26). It has also been defined as "a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect" (Leach 2005, p. 262). The 'working alliance' is suggested to be one part of the therapeutic relationship, namely the agreement on therapeutic tasks and goals, and development of bonds (Bordin 1979, Gyllensten et al 2003). This lack of consensus regarding the appropriate definition of the therapeutic relationship in physiotherapy may suggest a lack of conceptual clarity, limiting research in this field.

Two commonly used and widely validated measures of the working alliance are the Working Alliance Inventory (WAI) and the Helping Alliance Questionnaire Version Two (HAQ-II) (Cecero et al 2001, De Weert-Van Oene et al 1999, Fenton et al 2001, Horvath and Greenberg 1989, Kermarrec et al 2006, Le Bloc'h et al 2006, Luborsky et al 1996). Although originally intended to be applicable to all kinds of health care professional relationships, the use of these measures has been largely limited to psychotherapy (Guedeney et al 2005, Hatcher and Gillaspy 2006). Nevertheless, these measures have recently been advocated for more widespread use, and indeed a recent review found the WAI to be the most commonly used measure in studies exploring the therapeutic relationship in physical rehabilitation (Hall et al 2010).

The aims of this project were to: (a) explore existing literature regarding the 'therapeutic relationship' in physiotherapy to identify what are considered the core components; and (b) critically appraise the conceptual basis of the WAI and the HAQ II.

METHODS

Databases

A conceptual review using a systematic approach was utilised to identify and review relevant literature. Databases searched included: the Cochrane Library, all EBSCO Health Databases (CINAHL, MEDLINE, PsychINFO), Scopus, Web of Science, and OVID.

Search terms

The PICOT framework (Fineout-Overholt and Melnyk 2005) was utilised to formulate key search terms. The population (P) was defined as physiotherapy or physical therapy, while the outcome (O) was defined as anything related to the therapeutic relationship and/or related terms (see Table 1). In this search, I (Intervention) and C (Control) were not relevant. The search strategy was tailored to each database.

Inclusion and exclusion criteria

The inclusion criteria for the review were that the research should: a) be explicitly related to either physical therapy or physiotherapy; and b) have sought to explore or discuss some aspect of the relationship between physiotherapist and patient/ client and/or identify aspects of the 'therapeutic relationship' as a key finding.

No time limits were placed on the original search. Reference lists of included studies were hand-searched for other relevant papers; however a time limit was set during this process such that articles published before 1990 were excluded. There was no limit placed on study design or article type in order to extend the scope of the review to include discussion or theoretical articles; however, theses were excluded due to the difficulties in accessing them. It was also required that the full version of the paper was available in English.

Procedures

Articles were initially assessed for relevance according to the inclusion criteria based on the title and abstract screening. Where there was uncertainty about relevance, full text of papers were obtained. Full text for all papers identified as potentially relevant were then obtained and a final decision about their inclusion made between the three authors. All included papers were reviewed and key themes reflecting the key components of therapeutic relationship extracted. The key themes were then inserted into a matrix for the purpose of reviewing the conceptual basis of the WAI and the HAQ-II.

Assessment of quality

Where there was an appropriate version available, the relevant Critical Appraisal Skills Programme (CASP) framework (Public Health Resources Unit 2007) was used to evaluate the quality of the included studies. Each CASP tool comprises a series of quality-assessment questions specific to the relevant methodology to assist with critically appraising research publications. In the absence of official guidelines to suggest what might be regarded 'high' or 'low' quality when using these tools, each paper was scored according to how many of the criteria were met. However, the resulting appraisal score should be interpreted with caution as each criterion within the tool may not be of equal importance. As there is no CASP tool available to assess the quality of the discussion/theoretical papers, these were not assessed for quality, although the inherent limitation of these being non-empirical studies was acknowledged. Lastly, the approach to synthesis in this review was thematic and, given the heterogeneity of study designs, limited to descriptive synthesis.

RESULTS

Figure 1 outlines the search results. In total, 601 papers were retrieved from the original search. Following title and abstract screening, 24 papers were assessed as potentially meeting the inclusion criteria. An additional nine papers were identified through checking the reference lists of the included studies. After an in-depth reading, 17 papers were excluded, leaving 16 remaining studies. Reasons for exclusion are detailed in Figure 1.

Table 2 shows the characteristics and details of the included studies. Of these, four were theoretical or discussion articles (Bellner 1999, Hargreaves 1982, Szybek et al 2000, Williams and Harrison 1999); one was a descriptive study with some qualitative elements (Payton and Nelson 1996); and the remaining eleven were qualitative studies (Bassett and Tango 2002, Gyllensten et al 2000, Gyllensten et al 1999, Gyllensten et al 2003, Hills and Kitchen 2007, May 2001, Potter et al 2003a, Potter et al 2003b, Talvitie and Reunanen 2002, Thornquist 1992, Westman Kumlin and Kroksmark 1992).

The specific focus of each study varied widely. For the qualitative/part--qualitative studies: six explored patient perceptions (Bassett and Tango 2002, Gyllensten et al 2003, Hills and Kitchen 2007, May 2001, Payton and Nelson 1996, Potter et al 2003b); four explored physiotherapist perceptions (Gyllensten et al 2000, Gyllensten et al 1999, Potter et al 2003a, Westman Kumlin and Kroksmark 1992); and the remaining two were observational (Talvitie and Reunanen 2002, Thornquist 1992). In those studies investigating patient perspectives, there was a wide range of study populations including private practice musculoskeletal (Bassett and Tango 2002, Hills and Kitchen 2007, Potter et al 2003b), back pain (May 2001), neurological (Payton and Nelson 1996, Talvitie and Reunanen 2002), cardiovascular (Payton and Nelson 1996), orthopaedic (Payton and Nelson 1996), burns (Payton and Nelson 1996), and psychiatric patients (Gyllensten et al 2003). Similarly there were a variety of therapist populations such as primary health care (Gyllensten et al 1999), psychiatric (Gyllensten et al 2000), private practice therapists (Potter et al 2003a), and various other occupational settings (Thornquist 1992, Westman Kumlin and Kroksmark 1992).

[FIGURE 1 OMITTED]

The methods of data collection included: in-depth conversations (Bassett and Tango 2002); interviews (Gyllensten et al 2000, Gyllensten et al 1999, Gyllensten et al 2003, May 2001, Payton and Nelson 1996, Thornquist 1992, Westman Kumlin and Kroksmark 1992); focus groups (Hills and Kitchen 2007); the nominal group technique (Potter et al 2003a, Potter et al 2003b); and observation (video-taping of sessions) (Gyllensten et al 2003, Talvitie and Reunanen 2002, Thornquist 1992). Further, the purposes and aims were variable. For example, some studies did not specifically focus on the therapeutic relationship (as defined for this study), but on a subcomponent that may reflect one part of that such as patient satisfaction (Hills and Kitchen 2007, May 2001). The key findings from the studies should be considered within the context of the specific study aim so as to avoid over-interpretation.

The quality of studies varied widely: some studies met most (seven or more) of the ten CASP criteria (Gyllensten et al 2000, Hills and Kitchen 2007, May 2001, Potter et al 2003a, Potter et al 2003b), while others met only a few (five or less) (Bassett and Tango 2002, Gyllensten et al 1999, Gyllensten et al 2003, Talvitie and Reunanen 2002, Thornquist 1992, Westman Kumlin and Kroksmark 1992). In almost all studies, there were some criteria for which it was unclear as to whether they were met due to inadequate information provided in the paper (Bassett and Tango 2002, Gyllensten et al 2000, Gyllensten et al 1999, Gyllensten et al 2003, Hills and Kitchen 2007, May 2001, Payton and Nelson 1996, Potter et al 2003a, Talvitie and Reunanen 2002, Thornquist 1992, Westman Kumlin and Kroksmark 1992).

Common weaknesses included: minimal or no clear justification of the methods and/or methodology utilised (Bassett and Tango 2002, Gyllensten et al 2000, Gyllensten et al 2003, Payton and Nelson 1996, Talvitie and Reunanen 2002, Thornquist 1992); no mention of whether data saturation was achieved if qualitative (Bassett and Tango 2002, Gyllensten et al 2000, Gyllensten et al 2003, Hills and Kitchen 2007, Payton and Nelson 1996, Talvitie and Reunanen 2002, Thornquist 1992, Westman Kumlin and Kroksmark 1992); minimal or no critical examination of the relationship between researcher and participants (e.g. consideration of researcher's own role/bias during formulation of research questions/data collection/choice of location) (Bassett and Tango 2002, Gyllensten et al 2003, Hills and Kitchen 2007, May 2001, Payton and Nelson 1996, Talvitie and Reunanen 2002, Thornquist 1992, Westman Kumlin and Kroksmark 1992); and minimal or inadequate consideration of ethical issues (Gyllensten et al 2000, Gyllensten et al 1999, Talvitie and Reunanen 2002, Thornquist 1992, Westman Kumlin and Kroksmark 1992).

There were also notable limitations specific to particular articles. For example, the themes identified in the paper by Gyllensten et al (2000) are almost exactly the same as those identified in their earlier paper (Gyllensten et al 1999), suggesting preexisting beliefs from their previous work may have biased their subsequent interpretation of findings. The external validity of Gyllensten et al's (1999) study was also limited by the fact that only female physiotherapists were included and so findings from that study cannot be generalised to male physiotherapists. Also, in two studies, the physiotherapists themselves recruited the participants, potentially biasing findings (Bassett and Tango 2002, Talvitie and Reunanen 2002). For example, the physiotherapists may have only selected clients with whom they perceived they had a 'good' relationship.

Table 3 outlines the key themes identified regarding core aspects of the therapeutic relationship in this review. Eight main themes were evident: patient expectations; personalised therapy; partnership; physiotherapist roles and responsibilities; congruence; communication; relationship/relational aspects; and influencing factors. There appeared to be subcategories within each theme which are also included in Table 3. Each key theme is discussed in more detail below.

1. Patient expectations

Patient expectations entail the patient's expectations of both physiotherapy itself and the outcomes of physiotherapy (Bassett and Tango 2002, Gyllensten et al 2000, Hills and Kitchen 2007, May 2001, Potter et al 2003a). Bassett and Tango (2002) and Hills and Kitchen (2007) explored Maori people's experiences of physiotherapy and the factors which affect patient's satisfaction with musculoskeletal physiotherapy respectively. They both found that expectations were dependent on whether clients had received previous physiotherapy. Those without previous experiences had either low expectations or no preconceived notions about therapy. On the other hand, people with past experience had definite expectations about physiotherapy in general and what they would achieve from their course of treatment. Some examples of expectations were: to be assessed, diagnosed; given an explanation of the problem and treatment; gaining self-management strategies; and gaining symptom relief or resolution.

A number of both therapist and patient perception papers implied that expectations may influence the therapeutic relationship. Gyllensten et al (2000) suggested patient expectations and hopes, along with other factors, may underlie what was to take place in the actual interaction between the patient and the therapist. Hills and Kitchen (2007) found if a patient was expecting a specific treatment that had been beneficial previously, but did not receive this treatment; disappointment resulted, particularly if the patient was not given the opportunity to discuss possible treatment options. Similarly, in Potter et al's (2003a) study, the therapists identified unrealistic patient expectations of the physiotherapist and/or physiotherapy treatment as being problematic: patients wanted "quick fixes in one session when that is not possible" or to have "all their physical problems treated today" which the therapist stated is an "unrealistic expectation" (p.56).

2. Personalised therapy

Personalised therapy relates firstly to being culturally responsive. Bassett and Tango (2002) discussed the concept of cultural sensitivity, and while their study participants believed M ori cultural practices were not necessary within the physiotherapy setting, emphasis was placed on the importance of being respected as people, regardless of cultural background. Another component of personalised therapy which seemed to be evident in the literature was holistic practice. This entails focussing attention on a patient's whole body and person the importance of understanding the context of the patient's whole situation, rather than just the physical problem with which the client presents (Gyllensten et al 2000, Gyllensten et al 1999, Thornquist 1992). Interestingly, it was only therapist perception papers which identified holistic practice as being important (Gyllensten et al 2000, Gyllensten et al 1999). One therapist said "it is important to me to get a grasp of the whole situation, that I understand some of the social circumstances in [the patient's] life" (Gyllensten et al 1999, p. 99). Gyllensten et al (1999) commented that therapeutic techniques are not singled out as important factors in the interaction with patients, although they are not unimportant, they need to be fully integrated in response to what happens in the actual situation and to patients as a whole. Gyllensten et al (1999) supported the hypothesis, postulated by Stenmar and Nordholm (1994), that holistically oriented physiotherapy; the focus on how things are done (rather than what is done), enhances the quality of the interaction in the physiotherapeutic treatment, and facilitates a successful outcome.

3. Partnership

Partnership between the physiotherapist and patient was widely referred to in the physiotherapy literature as a parameter which may be core to the therapeutic relationship (Bassett and Tango 2002, Bellner 1999, Gyllensten et al 2000, Gyllensten et al 1999, Gyllensten et al 2003, May 2001, Payton and Nelson 1996, Potter et al 2003a, Potter et al 2003b, Talvitie and Reunanen 2002, Thornquist 1992, Westman Kumlin and Kroksmark 1992, Williams and Harrison 1999). The partnership theme comprises several subcategories which seemed to be evident in the literature: trust, mutual respect, knowledge exchange, power balance, and active involvement and collaboration with the patient.

All the physiotherapist perception papers and almost all of the patient perception papers identified active involvement or collaboration as a component which may contribute to the therapeutic relationship. This may include active involvement in managing the condition as well as involvement in the treatment process (May 2001). This concept is linked to the holistic attitude to health care, in which patients are seen as active participants (Gyllensten et al 1999). In many ways, active participation is also linked to the 'power balance', a concept which was alluded to in a number of papers (Bellner 1999, Potter et al 2003b, Talvitie and Reunanen 2002, Thornquist 1992, Westman Kumlin and Kroksmark 1992, Williams and Harrison 1999). In a theoretical discussion paper, Bellner (1999) examines various relationship models as tools with which therapists can better understand their relationships. The guild model places the therapist in a power position in which they are the 'expert'. In this model, the therapist expects cooperation from the patient but does not seek active participation. Conversely, the interactive model was identified as preferable regarding the development of a good therapeutic relationship. This model considers the relationship between the therapist and the patient in terms of a collaboration of equals making differing contributions, and active participation is emphasised. This notion of the importance of equality is supported by Williams and Harrison (1999) who suggested that the result of a power imbalance is often conflict, dissatisfaction and an overall non-therapeutic effect.

4. Physiotherapist roles and responsibilities

The roles and responsibilities of the physiotherapist was also extensively referred to in the physiotherapy literature as a parameter which may be central to the physiotherapist-patient interaction (Bassett and Tango 2002, Bellner 1999, Gyllensten et al 2000, Gyllensten et al 1999, Gyllensten et al 2003, Hills and Kitchen 2007, May 2001, Potter et al 2003a, Potter et al 2003b, Szybek et al 2000, Talvitie and Reunanen 2002, Westman Kumlin and Kroksmark 1992). The subcategories within this theme included the therapist's role in activating the patient's own resources, in being a motivator, and an educator, and the professional manner of the therapist.

In particular, the concept of activating the patient's own resources was commonly referred to: all the therapist perception papers and half of the patient perception papers mentioned this concept. It relates to the importance of identifying and strengthening patients' resources, providing tools for self-management, and advice on what the patient can do for themselves; therefore heightening the patient's control over their own life (Bellner 1999, Gyllensten et al 1999, May 2001, Potter et al 2003b). In Gyllensten et al's (1999) study, one therapist said it is about "teaching patients to take responsibility for themselves and use what they have got" (p.100).

Activating the patient's own resources is inherently linked to another frequently mentioned subcategory within this theme: the role of the physiotherapist as educator. This relates to enhancing the patient's knowledge and providing information regarding all aspects of therapy: their condition, the assessment, the treatment approach and rationale behind it, self-management, and prognosis (Bassett and Tango 2002, Gyllensten et al 1999, Hills and Kitchen 2007, May 2001, Potter et al 2003a). Also linked to these concepts is the therapist's professional manner: this involves both patient education as already described, and inspiring confidence in patients (May, 2001). Gyllensten et al (1999) commented that it is by giving patients a tool to understand themselves, through enhancing knowledge and understanding, that their resources for self-help can be activated.

Potter et al's (2003b) findings suggest that the most important attributes of physiotherapists, from the patients' perspective, relate to the physiotherapist's interaction skills, professional manner, and teaching ability. They suggest effective use of these skills will optimise the physiotherapist-patient interaction.

5. Congruence

The congruence theme relates to the congruence between the therapist and patient regarding goals, problem identification, and treatment (Bellner 1999, Gyllensten et al 2000, Gyllensten et al 1999, Gyllensten et al 2003, May 2001, Payton and Nelson 1996, Potter et al 2003a, Szybek et al 2000, Westman Kumlin and Kroksmark 1992). Again, all the therapist perception papers identified congruence as an aspect which may be important to the therapeutic relationship. In contrast, only three patient perspective papers mentioned congruence: two regarding congruence in goal setting and treatment, while none mentioned congruence regarding problem identification (see Table 3).

Payton and Nelson (1996) commented that in their study, there appeared to be a tacit understanding that the goals of therapy were clear and commonly understood by patients and their physiotherapists. However, they highlight the danger in such tacit understandings and indicate that major errors can be made if patients are not consulted about their concerns and goals during therapy. Payton and Nelson (1996) also suggest patients may be motivated to work harder in rehabilitation when they have been involved in goal setting and treatment.

The therapists in both Gyllensten et al's (1999, 2000) studies identified the importance of having an oral 'contract' in which both parties agree on goals and treatment. One therapist said that a contract provides a "way to take it [our relationship] seriously. We both know why we are here...and when we have accomplished what we set out to do" (Gyllensten et al 2000, p.163).

6. Communication

Communication entails various aspects of communication between the therapist and the patient. In particular nonverbal communication, active listening skills, and visual aids were discussed as components which may contribute to the therapeutic relationship (Bassett and Tango 2002, Gyllensten et al 2000, Gyllensten et al 1999, Hargreaves 1982, May 2001, Potter et al 2003a, Potter et al 2003b, Szybek et al 2000, Thornquist 1992).

Hargreaves (1982) exclusively reviewed the relevance and importance of non-verbal skills in the physiotherapy setting. In particular non-verbal behaviours including touch and proximity, facial expression, eye contact, gestures, posture, observation, listening, and use of silence were discussed. Hargreaves (1982) suggests the effective understanding and use of these nonverbal skills should both enhance the physiotherapist-patient relationship, and the quality of treatment. For example, touch may show encouragement, support, or caring, enhancing the patient's perception of rapport. Similarly a facial expression of genuine interest and concern can also enhance rapport and trust (Hargreaves 1982). Further, active listening implies understanding of feelings as well as content (Gyllensten et al 1999, Hargreaves 1982, May 2001, Potter et al 2003b).

The other aspect of communication which was mentioned in two studies was the use of visual aids. Both Bassett and Tango (2002) and Potter et al (2003b) suggested the use of visual aids such as diagrams and additional written instructions may be useful to assist explanations and lead to more effective therapist-patient communication.

7. Relational aspects

The theme regarding relational aspects comprises several subcategories including: friendliness, empathy, caring, warmth, and faith that the physiotherapist believes in the patient. Nearly all the papers which identified these relational components as factors which may be important to the therapeutic relationship were patient perception papers (Gyllensten et al 2003, Hills and Kitchen 2007, May 2001, Potter et al 2003b), while only two were therapist perception papers (Gyllensten et al 2000, Gyllensten et al 1999).

It was suggested that these relational factors help to create a positive affective climate in the clinical environment and therefore may enhance the therapeutic relationship (Gyllensten et al 1999, May 2001). For example, friendliness helps patients to feel at ease, while empathy allows patients to feel they are being treated in a sympathetic and respectful way (May 2001).

8. Influencing factors

The theme regarding influencing factors comprises three subthemes: external factors, physiotherapist prerequisites, and patient prerequisites. Further, each subtheme is composed of subcategories. Firstly, several studies identified external factors such as structure, processes, and the environment as factors which may contribute to the therapeutic relationship (Gyllensten et al 2000, Gyllensten et al 1999, Hills and Kitchen 2007, May 2001, Potter et al 2003b, Williams and Harrison 1999). For example, the participants in Hills and Kitchen's (2007) study identified the structure of provision of physiotherapy as an important aspect of their care. This included factors such as waiting time, open access, and having enough time with their therapist. Patients appreciated a flexible appointment system, with quick and local access to a therapist, and not being kept waiting for more than ten minutes. Similarly, the studies of Potter et al (2003b) and Gyllensten et al (2000) identified a pleasant and welcoming environment within the physiotherapy practice as important to help put the patient at ease and to establish a good basis for treatment.

Secondly, prerequisites of the physiotherapist were identified by most of the patient perception papers and half of the therapist perception papers as factors which may contribute towards the therapeutic relationship (Gyllensten et al 2000, Gyllensten et al 1999, Gyllensten et al 2003, Hills and Kitchen 2007, May 2001, Potter et al 2003b). In particular, the skills and competence of the therapist was a commonly mentioned prerequisite (see table 3). Hills and Kitchen (2007) commented that patients valued a therapist who was knowledgeable and provided a good explanation of their problem, while participants were dissatisfied when this was lacking. Similarly, May (2001) reported that physiotherapists with a good knowledge base and good skills inspired confidence in their patients, and therefore enhanced satisfaction with physiotherapy. One therapist commented that a particular course she completed improved her knowledge, strengthened her credibility as a physiotherapist, and improved her interaction with patients (Gyllensten et al 1999). Other subcategories in this theme include the life experiences and personal characteristics of the physiotherapist.

Thirdly, some studies identified prerequisites of the patient, as factors which may contribute to the therapist-client relationship. This included the patient's personal characteristics, existing resources, life experiences, and willingness to engage (Bellner 1999, Gyllensten et al 2000, May 2001, Szybek et al 2000, Westman Kumlin and Kroksmark 1992)

Measures of therapeutic alliance

Conceptual basis of the WAI/HAQ

Table 4 summarises how well the WAI (short and long forms) and the HAQ-II address the above themes. The theme regarding congruence between therapist and client goals, problem identification, and treatment, was well addressed in both the WAI and the HAQ-II. Some aspects of the themes relating to partnership and the physiotherapist's roles and responsibilities were also addressed by both questionnaires. However the theme regarding communication was not addressed at all, and the personalised therapy and relational aspects themes were only addressed by the HAQ-II. The WAI (long form) was slightly more comprehensive than the short form in that it also addressed patient expectations, one relational aspect, partnership, and physiotherapy roles, more fully than the short form.

DISCUSSION

This study aimed to identify components of the 'therapeutic relationship' which have been identified as core within physiotherapy, and to critically appraise the conceptual basis and measurement properties of the two most commonly used measures of this concept; the WAI and the HAQ-II.

The literature review highlighted eight key themes which, according to the physiotherapy literature, seem core components of the physiotherapeutic relationship. The HAQII and the WAI appeared to address some of these themes well. Given that the WAI and the HAQ-II are considered to be measures of 'working alliance' it is not unexpected that the themes relating to congruence and partnership were well addressed by these measures. There were however, several themes such as 'communication', 'relational aspects', 'patient expectations' and aspects of 'personalised therapy', addressed poorly.

In contrast, there were several aspects of the WAI and the HAQ-II which did not seem to be reflected in the physiotherapy literature. For example, both measures contain a question related to whether the client believes the therapist likes them and vice versa, implying that this may be an important aspect of the working alliance. However this was not a factor highlighted in the physiotherapy literature and would suggest it may not be a priority in a physiotherapeutic relationship. On the other hand, most past research has been therapist driven so perhaps some key factors (particularly about what the client may regard as important) are missing. We have explored this question further in related work (Besley et al 2011).

Other examples of questions in the WAI/HAQ-II but absent from the physiotherapy literature include questions relating to: whether the therapist is honest about his or her feelings towards the patient; whether the therapist and patient have meaningful or unprofitable exchanges; and whether the therapist relates to the patient in a way that slows up the progress of therapy. This perhaps acknowledges that whilst there are a number of ways of relating which have the potential to progress therapy positively, there are also ways of engaging that can be detrimental to progress. Therefore, perhaps future research should not only explore what is core to a positive therapeutic relationship, but also factors which hinder this relationship.

Limitations

There were a number of limitations to the study which impact on interpretation of findings. Firstly, the truncation points of some search terms varied between databases, for instance, in one database the truncation used for the term 'physiotherapy' was 'physio*' while in another it was 'physiother*'. These inconsistencies may have limited the number of studies yielded, and, as they were noticed late in the research process were not able to be amended.

The literature review had one primary reviewer (JB), and this could introduce bias in study selection and critical appraisal. However this was managed by another researcher (NK) crosschecking included papers and all researchers reviewing the end note file with the studies yielded by the original literature search.

All studies were included despite variable quality, given the exploratory nature of the review, and as such caution should be exercised in interpreting findings. In addition, the CASP quality evaluation tool has several subcomponents for each criterion, requiring a subjective judgement as to whether the study had met the criteria (although this could be said for all reviews). Our review included both empirical studies as well as theoretical and discussion type papers and arguably less emphasis should be placed on the findings of non-empirical studies (and this is not reflected in the interpretation of studies presented here). Moreover, in this literature review, many of the included studies were not specifically designed to explore the therapeutic relationship per se. A specific focus on this in future studies may yield further detail about what is core to the relationship within physiotherapy. For all of the reasons cited above, the review findings should be interpreted with caution but we argue our conclusions are useful for moving forward the research in this domain.

CONCLUSION

Evidence is increasingly indicating that the nature of our relationship with patients is important for outcomes. This review of the physiotherapy literature identified key themes which appear core to a constructive physiotherapeutic relationship. The WAI (short form) and the HAQ-II addressed certain components of therapeutic relationship well, but some components were not addressed at all. The development of other measures may be necessary in order to address other components of the therapeutic relationship, such as communication, patient expectations, and aspects of personalised therapy. Despite disparities between the physiotherapy literature regarding the components of the therapeutic relationship which seem to be core, and those addressed by the WAI and the HAQ-II, these measures are reported to be easily administered and have been found to be reliable and valid in other populations (Cecero et al 2001, De Weert-Van Oene et al 1999, Fenton et al 2001, Horvath and Greenberg 1989, Kermarrec et al 2006, Le Bloc'h et al 2006). In the absence of other, more conceptually sound measures available for use in a physiotherapy setting, further exploration of their measurement properties in this population seems warranted.

KEY POINTS

* Eight key themes were identified which appear core to the physiotherapeutic relationship.

* The WAI (short form) and the HAQ-II addressed certain components of therapeutic relationship well, but some components were not addressed at all.

* The development of other measures may be necessary

in order to address other components of the therapeutic relationship, such as communication, patient expectations, and aspects of personalised therapy.

* In the absence of other, more conceptually sound measures available for use in a physiotherapy setting, further exploration of their measurement properties in this population seems warranted.

ACKNOWLEDGEMENTS

Thanks to AUT University Summer Studentship Scholarship for providing funding for this research. Thanks also to the Person Centred Research Team (PCRT) at AUT University for providing support and assistance throughout the research process.

ADDRESS FOR CORRESPONDENCE

Nicola M Kayes, AUT University, Northcote, Private Bag 92006, Auckland 1142, New Zealand; nkayes@aut.ac.nz Phone (09) 921 9999 extn 7309. Fax (09) 921 9620

SOURCE OF FUNDING

Funded by AUT University Summer Studentship Scholarship

REFERENCES

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Bellner AL (1999): Senses of responsibility: A challenge for occupational and physical therapists in the context of ongoing professionalization. Scandinavian Journal of Caring Sciences 13: 55-62.

Besley J, Kayes NM, McPherson KM (2011). Assessing the measurement properties of two commonly used measures of the therapeutic relationship in physiotherapy. New Zealand Journal of Physiotherapy 39(2): 75-80.

Bordin ES (1979): The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory Research, and Practice 16: 252-260.

Cecero JJ, Fenton LR, Frankforter TL, Nich C and Carroll KM (2001): Focus on therapeutic alliance: The psychometric properties of six measures across three treatments. Psychotherapy 38: 1-11.

De Weert-Van Oene GH, De Jong CAJ, Jorg F and Schrijvers GJP (1999): The Helping Alliance Questionnaire: Psychometric properties in patients with substance dependence. Substance Use & Misuse 34: 1549-1569.

Fenton LR, Cecero JJ, Nich C, Frankforter TL and Carroll KM (2001): Perspective is everything: the predictive validity of six working alliance instruments. The Journal Of Psychotherapy Practice And Research 10: 262-268.

Fineout-Overholt E and Melnyk B (2005): Building a culture of best practice. Nurse Leader 3: 26-30.

Gartland GJ (1984): Teaching the therapeutic relationship. Physiotherapy Canada 36: 24-28.

Guedeney N, Fermanian J, Curt F and Bifulco A (2005): Testing the Working Alliance Inventory (WAI) in a French primary care setting. Social Psychiatry and Psychiatric Epidemiology 40: 844-852.

Gyllensten AL, Gard G, Hansson L and Ekdahl C (2000): Interaction between patient and physiotherapist in psychiatric care-the physiotherapist's perspective. Advances in Physiotherapy 2: 157-167.

Gyllensten AL, Gard G, Salford E and Ekdahl C (1999): Interaction between patient and physiotherapist: a qualitative study reflecting the physiotherapist's perspective. Physiotherapy Research International 4: 89-109.

Gyllensten AL, Hansson L and Ekdahl C (2003): Patient experiences of basic body awareness therapy and the relationship with the physiotherapist. Journal of Bodywork & Movement Therapies 7: 173-183.

Hall AM, Ferreira PH, Maher CG, Latimer J and Ferreira ML (2010): The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Physical Therapy 90: 1099-1110.

Hargreaves S (1982): The relevance of non-verbal skills in physiotherapy. Australian Journal of Physiotherapy 28: 19-20.

Hatcher RL and Gillaspy JA (2006): Development and validation of a revised short version of the working alliance inventory. Psychotherapy Research 16: 12-25.

Hills R and Kitchen S (2007): Satisfaction with outpatient physiotherapy: Focus groups to explore the views of patients with acute and chronic musculoskeletal conditions. Physiotherapy Theory and Practice 23: 1-20.

Horvath AO and Greenberg LS (1989): Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology 36: 223-233.

Kermarrec S, Kabuth B, Bursztejn C and Guillemin F (2006): French adaptation and validation of the Helping Alliance Questionnaires for child, parents, and therapist. Canadian Journal of Psychiatry 51: 913-922.

Le Bloc'h Y, De Roten Y, Drapeau M and Despland JN (2006): New, but improved? Comparison between first and revised version of the Helping Alliance Questionnaire. Schweizer Archiv fur Neurologie und Psychiatrie 157: 23-28.

Leach MJ (2005): Rapport: A key to treatment success. Complementary Therapies in Clinical Practice 11: 262-265.

Luborsky L, Barber JP, Siqueland L, Johnson S, Najavits LM, Frank A and Daley D (1996): The revised Helping Alliance Questionnaire (HAQ-II): Psychometric properties. Journal of Psychotherapy Practice and Research 5: 260-271.

May SJ (2001): Patient satisfaction with management of back pain. Physiotherapy 87: 4-20.

Payton OD and Nelson CE (1996): A preliminary study of patients' perceptions of certain aspects of their physical therapy experience. Physiotherapy Theory and Practice 12: 27-38.

Potter M, Gordon S and Hamer P (2003a): The difficult patient in private practice physiotherapy: A qualitative study. Australian Journal of Physiotherapy 49: 53-61.

Potter M, Gordon S and Hamer P (2003b): The physiotherapy experience in private practice: the patients' perspective. Australian Journal of Physiotherapy 49: 195-202.

Public Health Resources Unit (2007). Critical Appraisal Skills Programme: Making sense of evidence.

Roberts L and Bucksey SJ (2007): Communicating with patients: What happens in practice? Physical Therapy 87: 586-594.

Schonberger M, Humle F, Zeeman P and Teasdale TW (2006): Working alliance and patient compliance in brain injury rehabilitation and their relation to psychosocial outcome. Neuropsychological Rehabilitation 16: 298-314.

Stenmar L and Nordholm LA (1994): Swedish Physical Therapists' Beliefs on What Makes Therapy Work. Physical Therapy 74: 1034-1039.

Szybek K, Gard G and Linden J (2000): The physiotherapist-patient relationship: applying a psychotherapy model. Physiotherapy Theory & Practice 16: 181-193.

Talvitie U and Reunanen M (2002): Interaction between physiotherapists and patients in stroke treatment. Physiotherapy 88: 77-88.

Thornquist E (1992): Examination and Communication: A study of first encounters between patients and physiotherapists. Family Practitioner 9: 195-202.

Westman Kumlin I and Kroksmark T (1992): The first encounter. Physiotherapists' conceptions of establishing therapeutic relationships. Scandinavian Journal of Caring Sciences 6: 37-44.

Williams S and Harrison K (1999): Physiotherapeutic interactions: A review of the power dynamic. Physical Therapy Reviews 4: 37-50.

Jessica Besley BHSc (Physiotherapy), BSc, NZRP

Physiotherapist (Counties Manukau District Health Board)

Nicola M Kayes BSc, MSc(Hons), PhD

Senior Research Officer, Person Centred Research Centre, Health and Rehabilitation Research Institute, AUT University

Kathryn M McPherson RN, BA(Hons), PhD

Professor of Rehabilitation, Person Centred Research Centre, Health and Rehabilitation Research Institute, AUT

University
Table 1: Key search terms for the literature search

Population            AND       Outcome

(OR)                            (OR)

Physiother *                     Therapeutic relationship *
Physical ther *                  Physiotherapeutic relationship *
                                 Therapeutic alliance *
                                 Physiotherapeutic alliance *
                                 Working alliance *
                                 Physiother*-patient relation *
                                 Physical ther*-patient relation *
                                 Physiother*-patient inter *
                                 Physical ther*-patient inter *
                                 Physiother *-patient communication
                                 Physical ther *-patient communication

Table 2: Characteristics of the included studies

                       Study Design                Perspective

Bassett &              Qualitative:                Patient perception
Tango (2002)           phenomenological
                       study
Bellner (1999)         Theoretical                 Expert opinion
                       discussion
Gyllensten et          Qualitative case            Therapist perception
al (1999)              study with
                       cross-case
                       analysis
Gyllensten et          Qualitative                 Therapist perception
al (2000)              case study
                       with cross-case
                       analysis
Gyllensten et          Qualitative                 Patient perception
al (2003)              case study
                       with cross-case
                       analysis
Hargreaves             Discussion                  Expert opinion
(1982)                 paper
Hills & Kitchen        Qualitative study           Patient perception
(2007)                 (multimethod
                       approach)
May (2001)             Qualitative                 Patient perception
Payton &               Descriptive study           Patient perception
Nelson 1996            with some
                       qualitative
                       elements
Potter et al.          Qualitative                 Therapist perception
(2003b)
Potter et al.          Qualitative                 Patient perception
(2003a)
Syzbek et al.          Theoretical discussion      Expert opinion
(2000)
Talvitie &             Qualitative (using          Observational
Reunanen               discourse analysis)
(2002)
Thornquist             Qualitative                 Observational &
(1992)                                             therapist
                                                   perception
Westman                Qualitative                 Therapist
Kumlin &                                           perception
Kroksmark
(1992)
Williams &             Systematic review           Expert opinion
Harrison               (discussion)
(1999)
                       Aim/purpose

Bassett &              Interpret/understand
Tango (2002)           Maori people's
                       experiences
                       of being physiotherapy
                       patients.
Bellner (1999)         Delineate different
                       senses of
                       responsibility
                       in the TR between
                       OT's and PT's & their
                       patients
Gyllensten et          Investigate expert
al (1999)              PT's perception of
                       important factors
                       influencing the
                       quality of the
                       interaction
                       in physiotherapeutic
                       treatment
Gyllensten et          Investigate what
al (2000)              factors PT experts
                       in psychiatric
                       physiotherapy believed
                       to be important in
                       the interaction
                       between patient
                       & PT.
Gyllensten et          Explore experiences of
al (2003)              pts undergoing BBT in
                       psychiatric physiotherapy
                       & to study the concept of
                       the working alliance in a
                       physiotherapy context
Hargreaves             Discuss the relevance of
(1982)                 non-verbal skills & the
                       importance of their
                       use in the physiotherapy
                       setting
Hills & Kitchen        Explore the factors that
(2007)                 affect patients' satisfaction
                       with musculoskeletal
                       outpatient physiotherapy
May (2001)             To generate the range of
                       dimensions of care that
                       patients believe are
                       important in their
                       satisfaction with an
                       episode of physiotherapy
Payton & Nelson        Discover how
(1996)                 physiotherapy
                       patients understand their
                       role in therapy, particularly
                       their role or involvement
                       in goal-setting, treatment
                       planning, & evaluation
                       of outcomes
Potter et al.          Gain an understanding
(2003b)                of PT's perceptions of
                       the difficult patient in
                       private practice &
                       determine
                       what strategies PT's use
                       & would like to improve,
                       when dealing with
                       difficult patients.
Potter et al.          Identify the qualities of
(2003a)                a 'good' PT & ascertain
                       the characteristics of
                       good & bad experiences
                       in private practice from
                       the patient's perspective
Syzbek et al.          Elaborate the concept
(2000)                 of the PT-patient
                       relationship, taking
                       counselling &
                       psychotherapeutic
                       encounters as the
                       model.
Talvitie &             Investigate dominant
Reunanen               forms of the interaction
(2002)                 that takes place between
                       PT's & patients in stroke
                       physiotherapy.
Thornquist             To ascertain what
(1992)                 happens in first
                       encounters between
                       patients & PTs
Westman                Delineate PT's conceptions
Kumlin &               of establishing therapeutic
Kroksmark              relationships with patients
(1992)                 and conceptions of
                       activating the resources
                       of the patients.
Williams &             Explore the power
Harrison               dynamic in PT interactions
(1999)
                                                   Method of data
                       Population                  collection

Bassett &              Maori patients              In-depth
Tango (2002)           (n=6; aged                  conversations
                       47 -77)                     guided by a
                                                   schedule of topics
Bellner (1999)                                     n/a
Gyllensten et          General                     Triangulation of
al (1999)              physiotherapy               important events,
                                                   an exemplar
                                                   (critical incident)
                                                   & key informant
                                                   interviews
Gyllensten et          Expert PTs in               Triangulation of
al (2000)              primary health              important events,
                       care (n=10,                 an exemplar
                       average of 24               (critical incident)
                       years of clinical           & key informant
                       experience)                 interviews
Gyllensten et                                      Videotaping &
al (2003)                                          interviewing
                       Psychiatric PT
                       experts (n=11),
Hargreaves             average of 19               n/a
(1982)                 years clinical
Hills & Kitchen        experience                  Four focus
(2007)                                             groups
May (2001)                                         Semi-structured
                                                   interviews
Payton & Nelson        Patients with               Semi-structured
(1996)                 schizophrenia
                       (n=6) & general             interview
                       psychiatric
Potter et al.          outpatients (n=5)           Nominal group
(2003b)                                            technique
Potter et al.          General                     Nominal group
(2003a)                physiotherapy               technique
Syzbek et al.                                      n/a
(2000)
Talvitie &                                         Treatment sessions
Reunanen               Musculoskeletal             with PT's were
(2002)                 patients: acute             videotaped
                       (n=14) & chronic
Thornquist             (n=16)                      Video-taped
(1992)                 Back pain patients          encounter between
                       (n=34)                      PT & patient as well
                                                   as semi-structured
                                                   interview

Westman                                            Semi-structured
Kumlin &               Patients with               interview
Kroksmark              multiple diagnoses *
(1992)
Williams &             (n=20)                      n/a
Harrison
(1999)
                       Experienced
                       (n=19) & less
                       experienced
Bassett &              (n=18) PT's in
Tango (2002)
                       private practice
Bellner (1999)
Gyllensten et
al (1999)              Patients (n=26)
                       from a private
                       practice setting
Gyllensten et
al (2000)              n/a
Gyllensten et
al (2003)
                       Stoke pts (n=9)
Hargreaves
(1982)
Hills & Kitchen
(2007)                 Physiotherapy:
May (2001)             2 PTs  (a
                       manual & a
Payton & Nelson        psychomotor
(1996)                 therapist) & their
                       respective 2
                       patients
Potter et al.          PTs (n=10) in
(2003b)                various
Potter et al.          occupational
(2003a)                settings
Syzbek et al.
(2000)
Talvitie &             General
Reunanen               physiotherapy
(2002)                 unclear; 2/10
                       not met
Thornquist             2/10 criteria
(1992)                 met; 2/10
                       unclear; 6/10
                       not met

Westman                4/10 criteria
Kumlin &               met; 5/10
Kroksmark              unclear; 1/10
(1992)                 not met
Williams               n/a
& Harrison
(1999)

Notes. (A) Study quality was rated using the CASP criteria. (PT)
Physiotherapist. (OT) Occupational Therapist. (TR) Therapeutic
relationship. (*) Diagnoses included cardiopulmonary (n=1),
neurological (n=10), soft tissue/orthopaedic (n=7), amputee
(n=1), and burn (n=1). (BBT) Basic Body Awareness Therapy

Table 3: Key themes and corresponding subcategories which may
be core to the therapeutic relationship (as Identified in the
Physiotherapy literature)

                                Patient
                             Expectations

                 Of physiotherapy     Of outcomes of therapy

Patient

Basset &
Tango
(2002)                                       [check]
Gyllensten
et al (2003)
Hill &
Kitchen
(2007)                [check]                [check]
May (2001)            [check]                [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)

Therapist perception papers

Gyllensten et
Al (1999)
Gyllensten et
Al (2000)             [check]
Potter et al
(2003b)               [check]
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)

                                Personalised
                                  Therapy

                 Culturally responsive     Holistic practice

Patient

Basset &
Tango
(2002)                [check]
Gyllensten
et al (2003)
Hill &
Kitchen
(2007)
May (2001)
Payton &
Nelson
(1996)
Potter
et al
(2003b)

Therapist perception papers

Gyllensten et
Al (1999)                                         [check]
Gyllensten et
Al (2000)                                         [check]
Potter et al
(2003b)               [check]
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)                                            [check]

                                          Partnership

                             Trust     Mutual respect     Knowledge
                                                          Exchange

Patient

Basset &
Tango
(2002)                                      [check]         [check]
Gyllensten
et al (2003)                 [check]        [check]
Hill &
Kitchen
(2007)
May (2001)                                  [check]
Payton &
Nelson
(1996)                                                      [check]
Potter
et al
(2003b)                      [check]

Therapist perception papers

Gyllensten et
Al (1999)                                   [check]
Gyllensten et
Al (2000)                                   [check]
Potter et al
(2003b)
Westman
Kumlin &
Kroksmark
(1992)                       [check]                        [check]

Discussion/opinion papers

Bellner
(1999)                                      [check]
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)                                                        [check]

                                          Partnership

                             Power balance     Active involvement/
                                                  Collaboration

Patient

Basset &
Tango
(2002)                                                [check]
Gyllensten
et al (2003)                    [check]               [check]
Hill &
Kitchen
(2007)
May (2001)                                            [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)                                               [check]

Therapist perception papers

Gyllensten et
Al (1999)                                             [check]
Gyllensten et
Al (2000)                                             [check]
Potter et al
(2003b)                                               [check]
Westman
Kumlin &
Kroksmark
(1992)                          [check]               [check]

Discussion/opinion papers

Bellner
(1999)                          [check]
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)                          [check]

Obser

Talvitie &
Ruenanen
(2002)                          [check]
Thornquist
(1992)                          [check]               [check]

                              PT Roles/responsibilities

                   Activating patient's     PT as motivator/
                      own resources           encourager

Patient

Basset &
Tango
(2002)
Gyllensten
et al (2003)                                    [check]
Hill &
Kitchen
(2007)                   [check]
May (2001)               [check]                [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)                  [check]

Therapist perception papers

Gyllensten et
Al (1999)                [check]                [check]
Gyllensten et
Al (2000)                [check]                [check]
Potter et al
(2003b)                  [check]                [check]
Westman
Kumlin &
Kroksmark
(1992)                   [check]

Discussion/opinion papers

Bellner
(1999)                   [check]                [check]
Hargreaves
(1982)
Syzbek et
Al (2000)                [check]
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)                                          [check]
Thornquist
(1992)

                            PT Roles/responsibilities

                       PT as educator     Professional manner

Patient

Basset &
Tango
(2002)                     [check]
Gyllensten
et al (2003)
Hill &
Kitchen
(2007)                     [check]              [check]
May (2001)                 [check]              [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)                    [check]              [check]

Therapist perception papers

Gyllensten et
Al (1999)                 [check]                [check]
Gyllensten et
Al (2000)                 [check]                [check]
Potter et al
(2003b)                   [check]                [check]
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)
Syzbek et
Al (2000)                                        [check]
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)                    [check]
Thornquist
(1992)

                                 Congruence

                   Goals       Problem     How to deal with problem

Patient

Basset &
Tango
(2002)
Gyllensten
et al (2003)       [check]
Hill &
Kitchen
(2007)
May (2001)                                          [check]
Payton &
Nelson
(1996)             [check]                          [check]
Potter
et al
(2003b)

Therapist perception papers

Gyllensten et
Al (1999)          [check]     [check]              [check]
Gyllensten et
Al (2000)          [check]     [check]
Potter et al
(2003b)            [check]                          [check]
Westman
Kumlin &
Kroksmark
(1992)                         [check]

Discussion/opinion papers

Bellner
(1999)             [check]     [check]              [check]
Hargreaves
(1982)
Syzbek et
Al (2000)                      [check]              [check]
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)             [check]
Thornquist
(1992)

                                  Communication

                    Non-verbal     Listening skills     Visual aids

Patient

Basset &
Tango
(2002)                                                     [check]
Gyllensten
et al (2003)
Hill &
Kitchen
(2007)
May (2001)                             [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)            [check]             [check]

Therapist perception papers

Gyllensten et
Al (1999)          [check]             [check]
Gyllensten et
Al (2000)          [check]             [check]
Potter et al
(2003b)                                [check]             [check]
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)             [check]            [check]
Syzbek et
Al (2000)                             [check]
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)             [check]            [check]

                             Relationship/relational aspects

                    Perceived good r/ship     Friendliness     Empathy

Patient

Basset &
Tango
(2002)
Gyllensten
et al (2003)                                                   [check]
Hill &
Kitchen
(2007)                                                         [check]
May (2001)                                      [check]        [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)                                         [check]        [check]

Therapist perception papers

Gyllensten et
Al (1999)                                                      [check]
Gyllensten et
Al (2000)                                                      [check]
Potter et al
(2003b)
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)                                                           [check]
Thornquist
(1992)

                             Relationship/relational aspects

                     Caring      Warmth     Faith PT believes in pt

Patient

Basset &
Tango
(2002)
Gyllensten
et al (2003)                     [check]            [check]
Hill &
Kitchen
(2007)
May (2001)
Payton &
Nelson
(1996)
Potter
et al
(2003b)              [check]

Therapist perception papers

Gyllensten et
Al (1999)                                                      [check]
Gyllensten et
Al (2000)                                                      [check]
Potter et al
(2003b)
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)

                           Influencing factors

                             External factor

Patient

Basset &
Tango
(2002)
Gyllensten
et al (2003)
Hill &
Kitchen
(2007)                           [check]
May (2001)                       [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)                          [check]

Therapist perception papers

Gyllensten et
Al (1999)                        [check]
Gyllensten et
Al (2000)                        [check]
Potter et al
(2003b)
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)                           [check]

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)

                           Influencing factors

                             PT Prerequisites

                     Skill and       Personal            Life
                     Competence      characteristics     experience

Patient

Basset &
Tango
(2002)
Gyllensten
et al (2003)          [check]
Hill &
Kitchen
(2007)                [check]           [check]
May (2001)            [check]           [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)                [check]

Therapist perception papers

Gyllensten et
Al (1999)              [check]          [check]            [check]
Gyllensten et
Al (2000)              [check]          [check]            [check]
Potter et al
(2003b)
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)

                               Influencing factors

                                 PT Prerequisites

                        Personal                      Existing
                     characteristics                  resources

Patient

Basset &
Tango
(2002)
Gyllensten
et al (2003)
Hill &
Kitchen
(2007)
May (2001)
Payton &
Nelson
(1996)
Potter
et al
(2003b)

Therapist perception papers

Gyllensten et
Al (1999)
Gyllensten et
Al (2000)              [check]                         [check]
Potter et al
(2003b)
Westman
Kumlin &
Kroksmark
(1992)

Discussion/opinion papers

Bellner
(1999)
Hargreaves
(1982)
Syzbek et
Al (2000)
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)

                               Influencing factors

                                 PT Prerequisites

                     Life experience     Willingness to engage

Patient

Basset &
Tango
(2002)
Gyllensten
et al (2003)
Hill &
Kitchen
(2007)
May (2001)                                      [check]
Payton &
Nelson
(1996)
Potter
et al
(2003b)

Therapist perception papers

Gyllensten et
Al (1999)
Gyllensten et
Al (2000)              [check]
Potter et al
(2003b)
Westman
Kumlin &
Kroksmark
(1992)                 [check]

Discussion/opinion papers

Bellner
(1999)                                          [check]
Hargreaves
(1982)
Syzbek et
Al (2000)              [check]
Williams &
Harrison
(1999)

Obser

Talvitie &
Ruenanen
(2002)
Thornquist
(1992)

Note: (PT) Physiotherapist. (Pt) patient.

Table 4: Conceptual basis on the WAI (short and long forms) and the
HAQ-II (how well these measures address the key themes, Identified
in the physiotherapy literature, which may be core to the therapeutic
relationship)

                            Patient
                          Expectations

           Of physiotherapy     Of outcomes of therapy

WAI SF
WAI LF       [check]                   [check]
HAQ-II

                           Personalised
                            Therapy

           Culturally responsive     Holistic practice

WAI SF
WAI LF                                 [check]
HAQ-II

                  Partnership

           Trist     Mutual respect

WAI SF     [check]      [check]
WAI LF     [check]      [check]
HAQ-II     [check]

                            Partnership

           Sharing of knowledge     Power balance

WAI SF
WAI LF
HAQ-II
                            Partnership

           Sharing of knowledge     Power balance

WAI SF                                [check]
WAI LF         [check]                [check]
HAQ-II         [check]

                   PT Roles/responsibilities

           Active patient's     Pt as motivator/
            Own resources        encourager

WAI SF         [check]
WAI LF         [check]
HAQ-II

                   PT Roles/responsibilities

          PT as educator     Professional manner

WAI SF                             [check]
WAI LF        [check]              [check]
HAQ-II                             [check]

                       Congruence

            Goals      Problem     How to deal with
                                       problem

WAI SF     [check]     [check]        [check]
WAI LF     [check]     [check]        [check]
HAQ-II                                [check]

                       Communication

           Non-verbal     Listening skills     Visual
                                                skills
WAI SF
WAI LF
HAQ-II

                  Relationship/relational aspects

           Friendliness     Empathy     Caring

WAI SF
WAI LF                                  [check]
HAQ-II                      [check]     [check]

               Relationship/relational aspects

           Warmth     Fait PT believes in pt

WAI SF
WAI LF
HAQ-II

                     Influencing factors

                       External factors

           Structures/processes     Skill and competence
                environment

WAI SF                                   [check]
WAI LF
HAQ-II                                   [check]

                      Influencing factors

                        External factors

             Personal            Life            Personal
          Characteristics     experience     characteristics

WAI SF
WAI LF
HAQ-II

                      Influencing factors

                       Pt Prerequisites

            Existing        Life        Willingness to
           resources     experience        engage

WAI SF
WAI LF
HAQ-II                                     [check]

Note: (WAISF)) Working Alliance Inventory Short Form.
(WAILF) Working Alliance Inventory Long Form.
(HAQ-II) Helping Alliance questionnaire Version 2. (PT)
Physiotherapist. (Pt) Patient.
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