Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20

The basic psychological need support in physical

therapy questionnaire

Morgan S. Hall, Leslie Podlog, Maria Newton, Nick Galli, Julie Fritz, Jonathan
Butner, Lindsey Greviskes & Chris Hammer

To cite this article: Morgan S. Hall, Leslie Podlog, Maria Newton, Nick Galli, Julie Fritz,
Jonathan Butner, Lindsey Greviskes & Chris Hammer (2019): The basic psychological
need support in physical therapy questionnaire, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2019.1692395

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Published online: 18 Nov 2019.

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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2019.1692395

The basic psychological need support in physical therapy questionnaire

Morgan S. Hall, PhDa, Leslie Podlog, PhDa, Maria Newton, PhDa, Nick Galli, PhDa, Julie Fritz, PT, PhDb,
Jonathan Butner, PhDc, Lindsey Greviskes, PhDd, and Chris Hammer, PhDa
a
Department of Health, Kinesiology, and Recreation, University of Utah, Salt Lake City, UT, USA; bDepartment of Physical Therapy and
Athletic Training, University of Utah, Salt Lake City, UT, USA; cDepartment of Psychology, University of Utah, Salt Lake City, UT, USA;
d
Department of Health, Physical Education, Recreation, and Coaching, University of Wisconsin-Whitewater, Whitewater, WI, USA

ABSTRACT ARTICLE HISTORY

Given the limitations of current inventories of basic psychological need measurement, and the Received 10 May 2019
importance of psychological need support within an injury rehabilitation context, there is an Revised 26 August 2019
evident need to develop the present inventory. Utilizing Self-Determination Theory (SDT) as Accepted 10 October 2019
a theoretical framework, two studies were conducted to develop and psychometrically test KEYWORDS
a measure of patients’ perceptions of basic psychological needs support in physical therapy: Self-determination theory;
The Basic Psychological Needs Support in Physical Therapy Questionnaire (BPNS-PT). In study 1, motivation; measurement;
a panel of Self-Determination Theory academics assessed a pool of items for content relevance, psychological need support
representativeness, and item clarity. In study 2, responses from 199 physical therapy patients were
used to identify the best fitting model through confirmatory factor analysis. A 3-factor 10-item
measure displayed good fit to the data and illustrated evidence of internal consistency. Findings
from these studies provide initial psychometric support (i.e. internal consistency and evidence of
construct validity) for the BPNSPT as a measure of patient perceptions of basic psychological
needs support in a physical therapy context.

Introduction need support within a physical therapy context,

a setting in which motivation to engage in rehabilita-
Researchers have documented numerous benefits of
tion exercises is of critical importance (Brewer et al.,
adherence to physical therapy programs such as
2000; Grindley, Zizzi, and Nasypany, 2008). In the
decreased pain, improved physical function, and overall
current studies, we present documentation of the devel-
health enhancements (Frih et al., 2009; Rutten et al.,
opment and validation of a measurement tool designed
2016). Unfortunately, patient adherence to physical
to assess psychological need support in physical ther-
therapists’ (PT) recommendations is notoriously low
apy; the Basic Psychological Need Support in Physical
(Bassett, 2003; Turk and Rudy, 1991). Poor adherence
Therapy Questionnaire (BPNS-PT).
has been linked with reduced treatment effectiveness,
diminished quality of life and functional abilities, and
increased treatment cost and rehabilitation time Basic psychological needs theory (BPNT)
(Forkan et al., 2006; Turk and Rudy, 1991).
Basic psychological needs theory, a sub-theory of SDT,
Given the benefits of rehabilitation adherence, as
proposes that the social contextual conditions that sup-
well as the adverse consequences of poor adherence,
port basic psychological need satisfaction undergird
there is an evident need to better understand factors
human function and development (Deci and Ryan,
that support patient adherence to physical therapy.
2000). Within BPNT, three basic psychological needs
Research guided by self-determination theory (Deci
are posited 1) competence; 2) autonomy; and 3) relat-
and Ryan, 1985, 2000) has shown that the extent to
edness. The need for competence refers to the belief
which individuals experience support for their basic
that one is capable and efficacious in relation to the
psychological needs, will have important implications
physical and social environment (Deci and Ryan, 2002).
for health behaviors such as exercise and rehabilitation
The need for autonomy refers to the belief that one is
adherence (Deci and Ryan, 2008). Unfortunately, no
agentic or volitional in his/her actions and implies self-
measurement tool exists to examine psychological
initiation and a sense of choice over one’s behavior

CONTACT Morgan S. Hall, PhD morgan.hall@utah.edu Department of Health, Kinesiology, and Recreation, University of Utah, 250 S. 1850 E., HPER
North, RM 241, Salt Lake City, UT 84112, USA
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
© 2019 Taylor & Francis Group, LLC
2 M. S. HALL ET AL.
(Deci and Ryan, 1985). Finally, the need for relatedness
refers to perceptions of connectedness to a community
or group, and the perception that one has a secure
relational base (Baumeister and Leary, 1995).
Relatedness involves feeling like one is cared for, con-
nected, and respected by others in one’s social environ-
ment (Deci and Ryan, 2000).
Within BPNT, three overarching propositions are of
particular relevance to the development of
a psychological need support scale in physical therapy.
First, important behavioral consequences are fostered
when all three basic psychological needs are satisfied
(Deci and Ryan, 2000, 2002; Ryan, 1995). Previous
research across a variety of contexts (e.g. sport, employ-
ment, and health care), has substantiated the value of
satisfying basic psychological needs (Chan et al., 2009;
Podlog, Lochbaum, and Stevens, 2010; Wilson et al.,
2006). The satisfaction of basic psychological needs has
been shown to influence internal motivation, beha-
vioral persistence, and psychological well-being.
Second, social environments may support or thwart
the basic psychological needs of competence (e.g. sup-
ports for challenge and mastery); autonomy (e.g. sup-
ports for choice and self-initiated behavior); and
relatedness (e.g., supports for caring and acceptance).
Third, social environments that support basic psycho-
logical needs enable individuals to experience satisfac-
tion of their psychological needs (Ntoumanis, 2001;
Vallerand, 1997, 2001). In essence, environments that
support basic psychological needs produce the nutri-
ments and required conditions to foster needs satisfac-
tion, which in turn, result in important behavioral
consequences (Deci and Ryan, 2000).
Given the aforementioned tenets of BPNT, two pro-
blematic issues are apparent when examining the devel-
opment of previous measures in this area. First,
conceptual distinctions between need satisfaction and
need support are often muddled; while the former
refers to perceptions of oneself as competent, autono-
mous, and connected, the latter refers to the feedback,
actions, and behaviors engaged in by significant others
that serve to support or undermine individual percep-
tions of competence, autonomy, relatedness. In prior
psychological need inventories (e.g. the basic need
satisfaction at work scale (Deci et al., 2001), some
items within particular scales seemingly refer to need
support while others ostensibly assess need satisfaction.
For example, on the basic need satisfaction at work
scale, the item “people at work tell me I am good at
what I do” seems to gauge need support more so than
need satisfaction. On the other hand, the item “most
days I feel a sense of accomplishment from working”
seems to capture the notion of need satisfaction. Hence,
a mixture of need satisfaction and support items appear
in one scale, thus blurring conceptual distinctions of
note.
A second problematic issue in psychological needs
measurement revolves around autonomy support.
Despite theoretical postulations that support for all
three basic psychological needs provide the necessary
conditions to facilitate need satisfaction (Deci et al.,
2001; Deci, Ryan, and Williams, 1996) previous
research has typically focused on autonomy support
(Black and Deci, 2000; Deci et al., 2001). Autonomy
support is central to psychological need satisfaction;
however, a unidimensional focus on autonomy support
overlooks the relevance of competence and relatedness
support. Additionally, the content of items used to
assess autonomy support is problematic. Inventories,
such as the Health Care Climate Questionnaire
(HCCQ) (Williams et al., 1996) were designed to eval-
uate the degree to which an environment is autonomy
supportive, however items on the questionnaire com-
bine theoretically distinct constructs. For example, an
item on the aforementioned questionnaire states: “I feel
that my physician cares about me as a person,” which
appears to conflate support for relatedness with the
theoretically distinct construct of autonomy.
In an effort to develop a need support scale for use
within a physical therapy context that addresses the
aforementioned issues, examination of need support
instruments developed in other contexts appears
instructive. For example, in a physical education set-
ting, Haerens et al. (2013) identified need supportive
teacher behaviors. Specifically, teachers were perceived
as autonomy, competence, and relatedness supportive
when they asked questions (i.e. autonomy support);
demonstrated activities (i.e. competence support); and
expressed empathy (i.e. relatedness support).
Additionally, prior research in the physical therapy
context revealed that PTs supported patient psycholo-
gical needs through specific behaviors and feedback
(Hall et al., forthcoming). For example, patients per-
ceived their need for competence was supported when
PTs aligned therapy goals with patient abilities, the
need for autonomy was supported when meaningful
rationales were given for therapy decisions, and the
need for relatedness was supported when a caring and
connected PT-patient relationship was developed.
Given limitations associated with current measures
of basic psychological needs support (Deci et al., 2001),
the benefits of need support for behavioral persistence,
well-being and optimal functioning (Deci and Ryan,
2000), and the importance of basic psychological need
support within an injury rehabilitation context, there is
an evident need to develop such an inventory. Further,

a physical therapy specific questionnaire that is able to
measure the extent to which patients perceive support
for their basic psychological needs may have important
implications for research and practice; PTs would have
a valuable tool to improve patient-centered outcomes
and researchers could use this questionnaire to investi-
gate important correlates, antecedents, and outcomes
associated with basic psychological need support. To
address this gap, 2 studies were conducted to develop
and evaluate a rehabilitation specific questionnaire
assessing patient perceptions of basic psychological
needs support. In study 1, an expert peer-review of
candidate items was conducted to establish content
validity, while in study 2, the psychometric properties
of the created scale were examined.
Study 1: item evaluation and content validity:
expert peer review
The initial set of questionnaire items were developed
utilizing interview data from physical therapy patients
and physical therapists (Hall et al., forthcoming), and
previously validated needs satisfaction and need sup-
port scales (Williams et al., 1996; Wilson et al., 2006).
The primary author of the current study interviewed
patients and PT practitioners to identify strategies,
feedback, and behaviors associated with basic psycho-
logical needs support in physical therapy. Following the
interviews, higher order and lower order themes were
analyzed to create the initial items for the current
study. For example, one theme that emerged from the
interviews, in reference to competence support, was
aligning rehabilitation goals with salient non-therapy
goals. A quote from one of the PTs epitomized this
theme: “If you bend your knee this much then you are
going to be capable of stepping in and out of a bath tub.”
Based on the interview theme ‘aligning therapy goals
with salient non-therapy goals,’ the item “I feel that my
physical therapist selects therapy goals that align with
personally important non-therapy activities (e.g. bath-
ing and gardening)” was created. In total 34 items were
developed and assessed by the expert panel. A full list of
initial items is available from the first author.
Following initial item generation, all items were sub-
jected to an expert peer review process using proce-
dures in line with the scale construction and
psychometric literatures (Crocker and Algina, 2006;
Dunn, Bouffard, and Rogers, 1999; Kaplan and
Saccuzzo, 2013). The purpose of the expert peer review
was to empirically evaluate the clarity, content rele-
vance, and representativeness of the initial set of
items. Specifically, an assessment of the content domain
relevance of each questionnaire item specified by the
PHYSIOTHERAPY THEORY AND PRACTICE 3
basic psychological needs support constructs (i.e. com-
petence, autonomy, and relatedness) and the represen-
tativeness of each of the survey items was conducted.
Utilizing previous scale construction recommendations
(Crocker and Algina, 2006; Dunn, Bouffard, and
Rogers, 1999) the content relevance (i.e. how germane
individual items are to the specified content domain, in
this case, basic psychological need support); representa-
tiveness (i.e. how well a set of items covers the breadth
of the content domain); and clarity (i.e. whether the
wording of the questions was understandable) of the
initial items was assessed. Following the expert review
of the candidate items, modifications were made to
produce a final set of items comprising the Basic
Psychological Need Support in Physical Therapy Scale
(BPNS-PT).
Study 1 methods
Participants
Participants were comprised of expert judges (n = 11)
selected to evaluate the content relevance, representa-
tion, and clarity of the initial set of BPNSPT items.
Although the number of experts necessary to ade-
quately evaluate the content relevance and representa-
tiveness of a set of questionnaires items has not been
firmly established (Dunn, Bouffard, and Rogers, 1999),
11 judges exceeds the number identified previously
(Lynn, 1986). The expert panel was comprised of aca-
demics who met the following inclusion criteria: 1)
a terminal degree in psychology or related discipline; 2)
an established record of publications on SDT or appli-
cations of SDT; and 3) a primary research focus
on SDT.
Measures
Expert rating scale. Utilizing the recommendations of
Dunn, Bouffard, and Rogers (1999) and Crocker and
Algina (2006) an expert rating scale for the initial pool
of items was constructed. First, in order to establish
the content domain (i.e. the conceptual definitions of
perceived competence, autonomy, and relatedness)
that the BPNSPT items were intended to measure,
a table of domain specifications was created. Next,
a Likert-type rating scale assessing the degree of con-
gruence between the BPNSPT items and the concep-
tual definitions of the basic psychological needs was
constructed. This measure asked participants to rate
the level of agreement between the BPNSPT items and
the domain specifications. SDT experts were asked to
evaluate the content relevance of each item to each of
the conceptual definitions of the basic psychological
needs using the following 5-point scale: “1” (Poor
4 M. S. HALL ET AL.
Match), “2” (Fair Match), “3” (Good Match), “4” (Very
Good Match), and “5” (Excellent Match). Experts were
also asked to indicate the clarity of each item by
responding “Yes” or “No” to the question, “Is the
item easily understood?” After rating each survey
item against the three basic psychological needs defini-
tions, experts were asked to provide written comments
for each of the BPNSPT items to enhance the breadth
and depth of information gathered about the items and
to help consider subsequent item modification
(Crocker and Algina, 2006). Finally, to assess item
content representativeness, SDT experts were asked
to respond to the following questions: 1) “How well
do feel all of the initial items represent the constructs
of competence, autonomy, and relatedness”; 2) “Do
you think the items are appropriate for use for patients
in rehabilitation”; and 3) “Are there any additional
items that you think should be included in the item
pool to represent perceived competence, autonomy, or
relatedness?” The first question was scored on a Likert-
type rating scale: (1) “Poor Representation”; (2) “Fair
Representation”; (3) “Good Representation”; (4) “Very
Good Representation”; and (5) “Excellent
Representation.” The second question was scored on
a Likert-type rating scale: (1) “Not at All”; (2) “Not
Really”; (3) “Somewhat”; (4) “Yes”; and (5) “Yes
Absolutely.” The third question was dichotomously
scored (0 = “No” and 1 = “Yes”). SDT experts were
also provided with an opportunity to comment on
their evaluations in an open-ended dialogue box as
an additional means for judging item content
representativeness.
Procedures
The initial step in the expert review process was to
contact academics who met the inclusion criteria listed
above. SDT experts were contacted via e-mail and sent
an invitation to participate and a secure link to the
questionnaire hosted by RedCap (Harris et al., 2009).
The RedCap link included documentation of the study
purpose and a consent form for participation. Experts
who consented were asked to complete an item content
review form which contained instructions for complet-
ing the content relevance, clarity, and representative-
ness questions. SDT experts were then asked to rate the
content relevance, clarity, and content representative-
ness of each of the BPNSPT items using the item
content review form outlined above. Next, the
reviewers were asked to provide written comments
about each of the BPNSPT items to clarify their ratings
of the content relevance and representativeness of the
questionnaire items and to improve the overall quality
of the measure.
Data analysis
Data analysis occurred in the following four stages.
First, SDT experts’ item content relevance responses
were screened to identify discrepant raters and missing
data. Discrepant ratings were determined by calculating
the distance of expert’s evaluation of each item from
the median rating (Dunn, Bouffard, and Rogers, 1999).
Values not approximating zero were identified and
expert’s comments were inspected to determine the
source of the discrepant rating. Second, descriptive
statistics were calculated to assess ambiguity in experts’
item-content match ratings. Specifically, item ambigu-
ity was evaluated through the calculation of the range
of ratings across items. Range values (highest rating
minus the lowest rating plus one) close to 1 indicated
minimal ambiguity whereas, range values greater than 4
indicated item ambiguity, with such items inspected for
item clarity (Dunn, Bouffard, and Rogers, 1999). Third,
to assess item-content relevance, Aiken’s item content
validity (V) coefficient (Aiken, 1985) and Cohen’s effect
size (ES) for dependent means (Cohen, 1977) was cal-
culated. V-coefficients range from 0–1 with values clo-
ser to 1 indicating congruence between the intended
domain of the questionnaire item and the content of
the item. Utilizing the ES for dependent means, a series
of planned contrasts between the mean content rele-
vance score of the intended domain and the mean
content relevance score of the other two unintended
domains was conducted to provide a gauge of the
extent to which items matched both intended and
unintended domains. Fourth, item content representa-
tiveness was assessed by calculating descriptive statistics
for an overall representativeness score for each con-
struct. Fifth and finally, a mean rating of item clarity
was calculated. Once the statistical evaluation of the
questionnaire items had been conducted, the written
comments from the expert judges were inspected and
utilized to make modifications.
Study 1: results
Thirty-four items (12 competence items, 11 autonomy
items, and 11 relatedness items) were initially assessed
by the expert panel. Thirteen of the initial items had
range values greater than 4 indicating ambiguity or lack
of clarity. Further, 4 of these ambiguous items had non-
significant V-coefficients indicating a lack of congru-
ence between the content of the item and the intended
need support construct. All items, except 2 competence
items and 1 relatedness item, had a large ES, when
comparing the intended and unintended domain rele-
vance scores. Complete results of the expert review are
depicted in Table 1. Items which were rated as having
 PHYSIOTHERAPY THEORY AND PRACTICE 5

Table 1. Expert peer review results.

Label/Statistic Item/Item Scores
Competence C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12
Range (ambiguity) 3 3 5 4 3 5 4 2 2 2 3 2
V-coefficient 0.82 0.7 0.4 0.72 0.72 0.47 0.67 0.82 0.8 0.9 0.77 0.8
Effect Size L/L L/L S/M L/L L/L M/L L/L L/L L/L L/L L/L L/L
Clarity 1.8 2 1.6 1.9 1.6 1.8 1.9 2 2 2 1.7 2
Autonomy A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11
Range (ambiguity) 3 3 2 4 4 2 3 3 4 2 5
V-coefficient 0.82 0.8 0.92 0.75 0.75 0.92 0.85 0.8 0.82 0.87 0.52
Effect Size L/L L/L L/L L/L L/L L/L L/L L/L L/L L/L L/L
Clarity 1.9 1.8 2 1.9 2 2 2 2 2 2 2
Relatedness R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11
Range (ambiguity) 2 2 3 4 3 4 5 2 5 4 3
V-coefficient 0.92 0.85 0.8 0.77 0.77 0.7 0.62 0.92 0.5 0.72 0.82
Effect Size L/L L/L L/L L/L L/L L/L L/L L/L L/S L/L L/L
Clarity 2 2 1.8 2 2 1.9 2 2 2 1.8 1.7

the strongest content-relevance, biggest effect size, Table 2. Patient demographics.

smallest margin of ambiguity, and highest rating of Rehabilitation Duration (%) n = 199
Less than 1 month = 29.7
clarity were retained for subsequent analyses. The 1–3 months = 42.1
final pool of items consisted of 10 questions assessing 3–6 months = 7.9
6 months to 1 year = 5
autonomy support (3 items), competence support (4 Longer than 1 year = 8.9
items), and relatedness support (3 items) in a physical No answer = 6.4
Gender (n = 199)
therapy context. The final pool of 10-items constituted Male = 56
the BPNSPT measure tested in study 2. Female = 143
Race (%) n = 199
White = 89.1
Asian = 3
Study 2: psychometric properties of the American Indian = 2
Pacific Islander = 1
BPNSPT: measurement model Prefer not to answer = 5
Age (n = 199)
The overall purpose of study 2 was to examine the 18–29 n = 17
30–39 n = 31
psychometric properties of the questionnaire created 40–49 n = 33
from the expert peer review process. Specifically, this 50–59 n = 40
60–69 n = 53
study employed confirmatory factor analysis (CFA) to 70 + n = 25
test the measurement model of the BPNSPT in
a sample of physical therapy patients. To address this
purpose, data was collected from a sample of PT with their PT to accurately assess the extent to which
patients who were currently undergoing rehabilitation. basic psychological needs were supported by their PT.
The specific hypothesis for addressing the aforemen- Participant demographics are displayed in Table 2.
tioned purpose was the BPNSPT questionnaire would
be multidimensional and comprised of three factors Measures
representing the three basic psychological need con- Basic psychological needs support in physical therapy
structs outlined in SDT (i.e. competence, autonomy, (BPNSPT). Participants were asked to complete the
and relatedness) (Deci and Ryan, 1985, 2002). final version of the BPNSPT developed in study 1
(Table 3). Subscales were calculated by averaging the
construct relevant items for competence, autonomy,
Study 2: methods
and relatedness. Descriptive statistics for the BPNSPT
Participants are displayed in Table 4.
A total of 199 male (n = 56) and female (n = 143)
patients participated in study 2. Participants were phy- Procedures
sical therapy patients who were currently undergoing Following Institutional Review Board approval, partici-
rehabilitation in a physical therapy clinic. To be pants were recruited through contacts at a University
included in the study, patients were required to meet Orthopedic Center. Further, contacts at the University
the following inclusion criteria: (a) the primary purpose Orthopedic Center were used to contact other large
for rehabilitation was a musculoskeletal injury, and (b) physical therapy centers to facilitate data collection.
patients were in rehabilitation for a minimum of Patients who met the inclusion criteria were emailed
2 weeks to ensure that they were sufficiently familiar a RedCap (Harris et al., 2009) link that led them to
6 M. S. HALL ET AL.
Table 3. Final items of the basic psychological needs support in
physical therapy questionnaire.
Competence
C8: I feel that my physical therapist provides me with exercises that
I can realistically achieve.
C9: I feel that my physical therapist helps me feel capable of doing
even the most challenging exercises.
C10: I feel that my physical therapist helps me feel good about my
ability to complete challenging exercises.
C12: I feel that my physical therapist shows me how to be effective
in completing rehabilitation exercises.
Autonomy
A3: I feel that my physical therapist provides me with choices in
rehabilitation.
A6: I feel that my physical therapist provides opportunities to be part
of the decision making process.
A10: I feel that my physical therapist gives me opportunities to voice
my opinion.
Relatedness
R1: I feel that my physical therapist tries to develop a caring
relationship with me.
R2: I feel that my physical therapist tries to make a connection with
me.
R8: I feel that my physical therapist makes an effort to get to know
me.
Table 4. Descriptive statistics, subscale reliabilities, and bivari-
ate correlations.
1 2 3 a RMSEA value closer to zero indicates better model
M (SD) M (SD) M (SD)
Subscales 4.17(0.79) 3.92(0.92) 4.12(0.90)
1. Competence 0.92
2. Autonomy 0.87 0.91
3. Relatedness 0.87 0.81 0.93
Note: Subscale reliabilities are on the diagonal
a secure online survey packet. The initial page of the
questionnaire packet included a participant consent
form, the study purposes, and a description of the
study. Patients were informed that participation was
completely voluntary and that they could discontinue
participation in the study at any time. Patients who
consented were asked to complete a basic demo-
graphics survey and the final version of the BPNSPT.
Data analysis
Data analysis proceeded in the following stages: First, data
were screened to identify potential outliers, missing values,
or other discrepancies that may adversely influence subse-
quent analyses. Second, demographic data were analyzed
to characterize and describe the sample. Third, relevant
descriptive statistics were calculated for the BPNSPT
items to ensure that assumptions of maximum likelihood
estimation were met. Fourth, a confirmatory factor analysis
was constructed to examine the fit of the measurement
model in the total sample of participants. Conventional
standards were specified for the CFA evaluating the mea-
surement model of the BPNSPT. Specifically, items were
loaded exclusively on relevant factors (i.e. competence
items were loaded on the latent factor labeled competence),
factors were allowed to correlate, error terms were not
allowed to correlate, and the variance of each latent factor
was constrained to define scaling for each latent variable.
Finally, descriptive statistics and reliability estimates were
calculated for the subscales of the BPNSPT.
Model fit criteria. A number of indices were utilized to
evaluate model fit. Initially, model fit was assessed
using the χ2 statistic. The χ2 statistic provides the
basis for tests associated with lack of model fit.
Utilizing the recommendations of Kline (2011), after
inspection of the model chi-square, the matrix of cor-
relation residuals was examined in an effort to diagnose
model misspecification. After examining the matrix of
correlation residuals a review of approximate fit indices
commenced. The indices used in the current study were
the root mean square error of approximation
(RMSEA), standardized root mean square residual
(SRMSR), the incremental fit index (IFI), and the
Tucker Lewis index (TLI). The RMSEA is a parsimony-
adjusted index scaled as ‘badness-of-fit.’ That is,
fit. RMSEA values below 0.08 designate adequate model
fit, whereas RMSEA values greater than 0.1 indicate
poor model fit. The SRMSR is an absolute measure of
fit that utilizes the standardized difference between the
observed correlations and the predicted correlations in
the model. A value less than 0.08 indicates good fit (Hu
and Bentler, 1999). The TLI and IFI are incremental fit
indices that compare the constructed model to a null
model. Both the IFI and TLI have a range of values
from 0 to 1, with values closer to 1 indicating better
model fit.
Study 2: results
Confirmatory factor analysis was used to assess the
measurement model fit of the data collected. The var-
iance of the latent variables (i.e. competence, auton-
omy, and relatedness) was constrained to 1 to
standardize the values. The initial measurement model
was constructed without allowing items to covary.
Loadings for the initial CFA are depicted in Table 5.
This model yielded adequate fit based on TLI, IFI, and
SRMR, χ2 (df = 32) = 165.16, p < .001 (TLI = 0.91;
IFI = 0.94; RMSEA = 0.14 90% CI 0.12–0.16; and
SRMR = 0.03). The significant chi-squared value may
indicate lack of model fit, however, the chi-squared test
is sensitive to sample size (Kline, 2011). Given the
recommendations of Kline (2011) the matrix of corre-
lated residuals was examined to diagnose model mis-
specification. The RMSEA value greater than 0.01 was
 PHYSIOTHERAPY THEORY AND PRACTICE 7

Table 5. Loadings for the initial confirmatory factor analysis. psychological well-being and motivation to engage in
Parameter Estimate S.E. C.R. P beneficial health behaviors (Deci and Ryan, 2008).
comp10 <— Competence .860 .050 17.054 <.01 Despite these important implications, no measurement
comp8 <— Competence .536 .044 12.162 <.01
comp12 <— Competence .770 .050 15.512 <.01 tool exists to examine psychological need support
comp9 <— Competence .881 .052 16.867 <.01 within a physical therapy context, a setting in which
auto6 <— Autonomy .845 .058 14.624 <.01
auto3 <— Autonomy .894 .062 14.502 <.01 motivation to engage in rehabilitation exercises is vital
auto10 <— Autonomy .846 .052 16.198 <.01 (Brewer et al., 2000; Grindley, Zizzi, and Nasypany,
relate1 <— Relatedness .837 .054 15.632 <.01
relate2 <— Relatedness .862 .050 17.236 <.01 2008). Over 2 studies, we presented documentation of
relate8 <— Relatedness .904 .057 15.978 <.01 the development, refinement, and testing of
*Note: S.E. = standard error, C.R. = critical ratio a measurement tool designed to assess psychological
need support in physical therapy; The basic psycholo-
gical need support in physical therapy questionnaire
problematic and may indicate poor model fit. However, (BPNSPT). Broadly, the current studies utilized
RMSEA values may be artificially large in models with a panel of content experts to review candidate items
small samples and low degrees of freedom. Further, the and assess the content relevance, representativeness,
co-variances between latent factors were high (0.90–- and clarity of the created items. Based on the assess-
0.96) in this initial model. Given these high co- ment from the expert peer review process, candidate
variances an alternative model with a single latent fac- items that scored as highly content relevant; covered
tor was constructed. This model yielded poorer model the breadth of the constitutive definition of compe-
fit, χ2 (df = 35) = 223.59, p < .001 (TLI = 0.89; tence, autonomy, and relatedness; and were the least
IFI = 0.91; RMSEA = 0.17 90% CI 0.14–0.18; and ambiguous, were retained for psychometric testing.
SRMR = 0.03). A chi-square difference test was then A sample of physical therapy patients were asked to
calculated (t = 58.69, p < .001). The significant chi- complete an assessment of basic psychological needs
squared difference test indicated that the 3-factor support in PT that included the retained items. Next,
model better represented the data. Finally, based on a confirmatory factor analysis of the patient’s data
the modification indices of the 3-factor model, indicated adequate model fit for the created question-
a second alternative model was tested (i.e. some items naire. Collectively, the findings from the current studies
measuring a single latent factor were allowed to corre- provide support for the factorial structure, reliability,
late to account for sample misfit). This decision seemed and content validity of the BPNSPT questionnaire.
reasonable given the breadth of the definitions of com- Despite these encouraging results, the utilization of
petence, autonomy, and relatedness. Following these modification indices to improve model fit in study 2
modifications, the subsequent CFA illustrated better identified room for improvement in the BPNSPT ques-
fit than the initial model, χ2 (df = 25) = 44.70, tionnaire. The modification of the measurement model
p = .009 (TLI = 0.98; IFI = 0.99; RMSEA = 0.06 90% to include correlated residuals may be interpreted as
CI 0.03–0.09; and SRMR = 0.01). However, these find- the presence of unexplained residual variance, or
ings would indicate that each factor may be multidi- a multidimensionality of a factor that could indicate
mensional, a finding not currently supported in Self- the need for additional latent factors (Tabachnick and
Determination Theory literature. Given that SDT does Fidell, 2007). Another interpretation suggests that resi-
not support the multidimensionality of competence, duals covary for reasons other than the shared effect of
autonomy, and relatedness, the initial model was the latent factor (i.e. a method effect) (Brown, 2015). It
retained. The standardized parameter loadings and could be that each of the basic psychological needs are
error variances for the 3-factor model are depicted in in fact multidimensional, however the multidimension-
Figure 1. All items loaded positively on the target factor ality of competence, autonomy, and relatedness has not
(range = 0.54 to 0.90; p-values < 0.05). The above been supported in past SDT research (Deci and Ryan,
indices provide an indication that the measurement 2000). In light of the current findings, future research
model sufficiently describes the BPNSPT data. The could investigate the multidimensional nature of basic
structural model is depicted in Figure 1. psychological needs support. It could also be, the
breadth of the definitions of what constitutes compe-
tence, autonomy, and relatedness needs support may be
akin to a method effect. That is, perceptions of needs
General summary and discussion support may be interpreted differently by different
Prior research has shown that supporting basic psycho- individuals. The sample of patients who participated
logical needs will have important implications for in the current studies were recruited from a single,
8 M. S. HALL ET AL.
Figure 1. The basic psychological needs support in physical therapy questionnaire structural model.
large orthopedic center. It is fair to assume that parti-
cipants may have shared the same PT, and a nesting
effect may be the underlying reason for the unexplained
residual variance. Future studies could collect data
across clinics/PTs and model this nesting effect.
Finally, the high correlations between factors may indi-
cate poor discriminant validity. Future studies could
investigate the convergent and divergent validity of
the BPNS-PT utilizing proxy measures of need support.
Two other possible limitations of the current stu-
dies are also worth considering. First, specific PT
actions, behaviors, and feedback were not collected
as part of the studies. Although the collection of PT
behaviors would add additional evidence of construct
validity, the purpose of the current studies was
focused on refinement and testing of the measurement
tool. However, the development of the initial items
that were refined and tested were procured from
extensive interviews with patients and PT practi-
tioners about specific behaviors that supported
patients’ perceptions of basic psychological needs sup-
port (Hall et al., forthcoming). Researchers could
remedy this limitation through observational studies
of PT-patient interactions, specifically focused on

ways in which PTs support the basic psychological
needs of their patients. Further, future studies could
assess additional construct validity evidence by
designing a multi-trait-multi-method matrix study to
compare observations of PT-patient interactions with
scores on the BPNSPT scale. Second, as stated pre-
viously, the data for the present studies were gathered
from a single, large orthopedic center. By utilizing
a single collection point the participants in the current
studies were fairly homogeneous (approximately 72%
female and 89% white). To increase the generalizabil-
ity of the questionnaire, future studies could allay this
limitation through purposeful sampling of a more
diverse set of participants. Further, the sample col-
lected for the current study involved patients with
primarily musculoskeletal injuries. Researchers could
collect data with different types of injuries and/or
different types of clinics or settings to examine the
validity of the BPNS-PT questionnaire in these differ-
ing contexts.
Notwithstanding the limitations discussed above, the
present studies provide initial evidence of construct
validity and internal consistency of the BPNS-PT ques-
tionnaire. Further, having a psychometrically sound
measure to assess the extent to which patients perceive
their basic psychological needs are supported by their
practitioner has valuable implications. First, it is appar-
ent that engagement levels in rehabilitation – particu-
larly among individuals in the general populace – are
particularly low and that motivation is a critical deter-
minant of adherence (Bassett, 2003; Brewer et al., 2000;
Duda, Smart, and Tappe, 1989; Hicks et al., 2012; Levy,
Polman, and Clough, 2008; Taylor, Dodd, McBurney,
and Graham, 2004; Turk and Rudy, 1991).
A measurement tool that is able to capture the levels
of basic psychological needs support of patients may
afford PTs a means by which they could improve
patient-centered outcomes. By knowing the extent to
which a patient perceives their psychological needs are
supported, physical therapists would have valuable
insight for optimizing the psychological environment
of their patients, which may impact overall adherence
to rehabilitation. Second, a psychometrically sound
instrument may aid future researchers interested in
studying correlates, antecedents, or consequences of
basic psychological needs support in a physical therapy
context. For instance, evidence suggests that patient-
centered outcomes are enhanced when patients adhere
to prescribed rehabilitation programs (Rutten et al.,
2016); adherence to prescribed therapies has been
shown to enhance physical function, augment psycho-
logical health, and diminish pain (Belza et al., 2002;
Brewer et al., 2000; Campbell et al., 2001). Researchers
PHYSIOTHERAPY THEORY AND PRACTICE 9
may be interested in the ways in which support for
patients’ basic psychological needs impacts patient
adherence, satisfaction, pain, and rehabilitation
duration.
Declaration of Interest
The authors declare they have no competing interests.
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