Physiotherapy Theory and Practice

An International Journal of Physical Therapy

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The correlation of trust as part of the therapeutic

alliance in physical therapy and their relation to
outcomes for patients with chronic low back pain

Kory J. Zimney, Emilio Puentedura, Morey J. Kolber & Adriaan Louw

To cite this article: Kory J. Zimney, Emilio Puentedura, Morey J. Kolber & Adriaan Louw (05
Apr 2024): The correlation of trust as part of the therapeutic alliance in physical therapy and
their relation to outcomes for patients with chronic low back pain, Physiotherapy Theory and
Practice, DOI: 10.1080/09593985.2024.2338428

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Published online: 05 Apr 2024.

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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2024.2338428

RESEARCH REPORT

The correlation of trust as part of the therapeutic alliance in physical therapy and
their relation to outcomes for patients with chronic low back pain
a
Kory J. Zimney PT, DPT, PhD , Emilio Puentedura PT, DPT, PhDb, Morey J. Kolber PT, PhDc,
and Adriaan Louw PT, PhDd
a
Department of Physical Therapy, University of South Dakota, Vermillion, SD, USA; bDepartment of Physical Therapy, Baylor University, Waco,
TX, USA; cDepartment of Physical Therapy, Nova Southeastern University, Fort Lauderdale, FL, USA; dEvidence in Motion, San Antonio, TX, USA

ABSTRACT ARTICLE HISTORY

Background: Previous qualitative research has listed trust as a component of the therapeutic Received 24 January 2024
alliance in physical therapy. Revised 27 March 2024
Objective: Quantitatively correlate trust and therapeutic alliance in physical therapy care for Accepted 28 March 2024
patients with chronic low back pain. The secondary aim was to investigate the relation of trust KEYWORDS
and therapeutic alliance with outcomes over the course of treatment. Trust; therapeutic alliance;
Methods: The Primary Care Assessment Survey was used to measure trust and the Working chronic low back pain;
Alliance Inventory-Short Revised tool measured therapeutic alliance. The patient recorded these physical therapy
measures after the initial visit and at discharge. Self-report patient outcome measures for pain,
function, and global rating of change were also measured at the same time points.
Results: A strong correlation (rs = 0.747 and rs = 0.801) was found between trust scores and
therapeutic alliance measures post-initial visit and at discharge, respectively. In addition, there
were moderate to strong correlations between trust and therapeutic alliance scores with the
various improved outcome measures of pain, function, and global rating of change.
Conclusion: There appears to be a connection between trust and therapeutic alliance along with
improved patient outcomes related to higher trust and therapeutic alliance scores in a cohort with
chronic low back pain.

Introduction maximize the benefits of the therapeutic alliance, an

Therapeutic alliance, also called working alliance
(Bordin, 1979) or therapeutic relationship (Miciak,
2015), can be defined as the working collaborative rela­
tionship between the patient and the healthcare provi­
der (Bordin, 1979). While this relationship has been
identified and studied in the healthcare professions of
psychology (Bachelor, 1995; Bordin, 1979; Horvath and
Luborsky, 1993) and medicine (Goold and Lipkin, 1999;
Speedling and Rose, 1985; Suchman and Matthews,
1988) for many decades, only in the past few decades
has this component of the therapeutic encounter been
getting more attention in the specific healthcare profes­
sion of physical therapy (Babatunde, Macdermid, and
Macintyre, 2017; Hall et al., 2010; Lakke and Meerman,
2016).
Evidence has shown the importance of enhancing the
therapeutic alliance to improve outcomes in physical
therapy (Fuentes et al., 2014; Hall et al., 2010; Lakke
and Meerman, 2016; Taccolini Manzoni, Bastos De
Oliveira, Nunes Cabral, and Aquaroni Ricci, 2018). To
ongoing understanding of this complex social interac­
tion is needed. One of the first steps in understanding
therapeutic alliance is further developing and under­
standing some key components. Bordin (1979) labeled
these critical features in a therapeutic alliance as agree­
ment on goals, assignment of tasks or series of tasks
(treatment), and the development of bonds. The agree­
ment on goals and treatment is a vital component of
patient-centered care (Laine and Davidoff, 1996; Wijma
et al., 2017). The other critical feature is the develop­
ment of the bond between the patient and physical
therapist, which is potentially slightly different from
other healthcare providers. The social interaction
between a physical therapist and a patient is unique, as
it is with each healthcare professional with a patient.
Miciak (2015) recently identified vital components of
the conditions of engagement for the therapeutic bond
to occur while also defining the key elements of that
bond between a physical therapist and patient. This
framework and identification were done through exten­
sive qualitative research studies with patients and

CONTACT Kory J. Zimney PT, DPT, PhD Kory.zimney@usd.edu Department of Physical Therapy, University of South Dakota, 414 East Clark St.,
Vermillion, SD 57069, USA
© 2024 Taylor & Francis Group, LLC
2 K. J. ZIMNEY ET AL.
physical therapists. The key elements for therapeutic
alliance found in this qualitative work were the nature
of rapport, respect, trust, and caring. While this frame­
work is valuable in our unique understanding of the
therapeutic alliance in physical therapy, further quanti­
tative work is needed to help validate the findings.
The element of trust has been studied in the medical
physician literature and found to be an essential aspect
related to therapeutic alliance and outcomes (Hall,
Camacho, Dugan, and Balkrishnan, 2002; Kao et al.,
1998; Thom et al., 2002). But only recently has trust
begun to be measured in physical therapy (Zimney,
Puentedura, Kolber, and Louw, 2022). Linking patient
trust in their physical therapist to the therapeutic alli­
ance will provide some validation to the framework
provided by Miciak (2015). This study aims to link
a trust measurement with the therapeutic alliance mea­
surement in caring for patients with chronic low back in
physical therapy. A secondary analysis will provide the
relationship between these constructs and outcomes
following care from the physical therapist.
Materials and methods
Participants
This cohort study of patients receiving physical therapy
care for chronic low back pain was recruited from
various outpatient physical therapy clinics in six states
(AZ, CA, RI, VA, WA, and WI). Human subject experi­
mentation was approved through a University
Institutional Review Board (Nova Southeastern
University IRB Protocol # 2018–43). Each patient com­
pleted informed consent before initiation into the study.
Inclusion criteria were low back pain with or without
radicular pain for three months or more, older than 18,
and speaking and writing in English. Exclusion criteria
were any patients with an active cancer diagnosis or
currently pregnant. Patients would also be excluded if,
at any point during the episode of physical therapy care,
they needed further medical attention outside of the
physical therapist’s care and needed to be discharged
before completion of therapy treatments. Also, if
patients did not receive a minimum of 80% of their
visits with the initial evaluating physical therapist their
data would be excluded from the final analysis.
Measures
Demographic data was collected on the patients and the
treating physical therapists. Each patient provided
information regarding age, gender, race, and educa­
tional level. Questions about whether the patient had
been seen in physical therapy at this specific site or by
this particular therapist were recorded during the initial
visit. Lastly, the choice of why the patient participant
selected physical therapy, the particular clinic, and the
physical therapist was asked. Each participating physical
therapist also completed a demographics form provid­
ing their age, gender, race, level of physical therapy
education, specialty certifications (if any), and years of
practicing as a physical therapist.
The trust measurement scale used was the Primary
Care Assessment Survey (PCAS), which has been used
previously in the physician literature (Safran et al., 1998)
and more recently in the physical therapy literature
(Zimney, Puentedura, Kolber, and Louw, 2022). The
PCAS was developed to measure seven different care
domains through 11 different summary scales. The trust
summary scale used in this study assesses the clinician’s
integrity, competence, and role as the patient’s agent.
The trust PCAS is measured using eight items with a low
score of 8 and a maximal score of 40, with higher scores
demonstrating greater patient trust in the clinician. The
first seven questions are scored with a five-point Likert
scale (1 = strongly agree, 2 = agree, 3 = not sure, 4 = dis­
agree, 5 = strongly disagree). Question #8 is scored on
an 11-point scale with endpoints (0 = not at all,
10 = completely). This question requires recalibration
to align with the 5-point scores of questions #1–7
(1 = 0–2 precoded item value, 2 = 3–4 precoded item
value, 3 = 5–6 precoded item value, 4 = 7–8 precoded
item value, 5 = 9–10 precoded item value). Four of the
seven Likert scale items (questions #1, #3, #5, #8) are
reverse-scored. They must be re-coded for final scoring
(5 = precoded item value 1, 4 = precoded item value 2,
3 = precoded item value 3, 2 = precoded item value 4,
1 = precoded item value 5). For this study, the word
“doctor” was replaced with “physical therapist” from the
original scale. The PCAS scoring algorithms calculate
a score if a respondent answers at least 50% of the items
(4 items on the trust scale). The missing whole values
are inputted as the respondent’s average score across all
completed items for the scale. The PCAS had
a Cronbach’s alpha at 0.86 upon scale development
(Safran et al., 1998). The initial study for the PCAS
showed skewness of −0.56 and kurtosis of 3.23.
The Working Alliance Inventory-Short Revised
(WAI-SR) (Hatcher and Gillaspy, 2006) is one of the
most commonly used therapeutic alliance measures in
physical therapy (Hall et al., 2010). The WAI-SR has
been developed to assess Bordin’s task, goal, and bond
dimensions. The scale is measured on a 5-point Likert
scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often,
5 = always). All items are positively worded, and higher
scores reflect higher levels of the therapeutic alliance.

The WAI-SR has been shown to have similar psycho­
metric properties to the original Working Alliance
Inventory, with similar total scores in two samples that
showed correlations of 0.95 and 0.94, respectively
(Hatcher and Gillaspy, 2006). Content and construct
validity have been supported in previous research
(Hatcher and Gillaspy, 2006; Tracey and Kokotovic,
1989). Good internal consistency has been reported
with Cronbach’s alpha of 0.83–0.97 (Hatcher and
Gillaspy, 2006; Munder et al., 2010). Test-retest relia­
bility has also performed well with a score of 0.93 (95%
CI 0.83–0.97) (Hanson, Curry, and Bandalos, 2002;
Paap and Dijkstra, 2017).
Outcome measures of physical therapy care were
measured for pain through the numeric pain rating
scale (NPRS), function with the Oswestry Disability
Index 2.0 (ODI), and overall change with the global
rating of change (GROC) scale. The NPRS is
a unidimensional measurement of pain intensity con­
sisting of an 11-point ordinal scale measuring pain from
“0” = no pain to “10” = worst pain imaginable (Downie
et al., 1978; Pengel, Refshauge, and Maher, 2004;
Williamson and Hoggart, 2005). The minimal clinically
important change for chronic pain has been reported to
be one point of reduction (Salaffi et al., 2004). The
respondents were asked to report on current, best, and
worst pain in the last 24 hours (Breivik et al., 2008). All
three scores (current, best, and worst) were recorded
along with a calculation of the average of all three being
reported. The ODI has shown good responsiveness for
patients with low back pain (Taylor, Taylor, Foy, and
Fogg, 1999). The ODI assesses function in 10 categories
(pain intensity, personal care, lifting, walking, sitting,
standing, sleeping, sexual activity, social life, and travel­
ing). Version 2.0 (Fairbank and Pynsent, 2000) was
utilized for the purposes of this study. Each of the 10
categories has six statements that are scored from 0 to 5;
the statement with the least disability is scored a 0 and
the greatest disability is scored a 5. If more than one
statement is marked, the highest score is recorded. The
overall score (index) is calculated by taking the total
points added up for items answered and dividing by
the total possible score (number of categories answered
× 5). This number is then multiplied by 100 and
rounded to a whole number. Overall index scores can
be interpreted for the range of 0–20% for minimal dis­
ability, 21–40% for moderate disability, 41–60% for
severe disability, 61–80% for crippled, and 81–100%
for individuals bedbound or exaggerating their symp­
toms (Davidson and Keating, 2005). The ODI has
shown to have a minimal clinically important difference
of 12 to 13 (Hägg, Fritzell, and Nordwall, 2003; Johnsen
et al., 2013). The GROC does not measure a specific
PHYSIOTHERAPY THEORY AND PRACTICE 3
dimension, such as pain or function, but allows the
patient to choose what they consider in totality their
change in status during care (Dworkin et al., 2005). The
minimal clinically important difference for the GROC is
reported at 2 points (Kamper, Maher, and Mackay,
2009). For purposes of this study, the recommended 11-
point scale was used (−5 = very much worse,
0 = unchanged, 5 = completely recovered) (Kamper,
Maher, and Mackay, 2009).
Procedures
The observational study was registered on
ClinicalTrials.gov protocol registration and results sys­
tem (Registration # NCT03443401). At each participat­
ing clinical site, subjects were recruited if they presented
with a chronic low back pain diagnosis. Patients who
provided informed consent were further screened for
appropriate inclusion and exclusion criteria. The
patients then completed an online PsychData (State
College, P.A., USA) link containing demographic ques­
tions, NPRS, and ODI. The online patient data collec­
tion allowed for blinding physical therapists to the
PCAS and WAI-SR scores during the study. Patients
then underwent a physical therapy evaluation and treat­
ment directed by the physical therapist without modifi­
cations to their regular clinical interaction. After
completing the initial visit, patients completed the
PCAS and WAI-SR scales through the PyschData link.
Patients continued to receive pragmatic physical ther­
apy care based on the therapist’s clinical decision-
making with no experimental manipulation of the care
provided. Upon discontinuation of the current episode
of care or the end of 6 months of care, the patient
completed the ODI, NPRS, GROC, PCAS, and WAI-
SR scales through another PsychData link to continue to
maintain blinding of the physical therapist to the results
of the patient responses. Patients were compensated $10
for completion of the scales from the initial visit and $15
upon competition of the discharge visit ratings.
Statistical analysis
The initial a priori was set for a total of 30 participants to
achieve 80% power to detect a Spearman Rank
Correlation Coefficient of 0.500 using a two-sided
hypothesis test with a significance level of 0.05 (May
and Looney, 2020). All data was coded from the
PsychData link into an Excel spreadsheet and visually
analyzed for completeness. The Excel data was then
uploaded into SPSS version 27.0 (IBM Corp., Armonk,
N.Y., USA) for statistical analysis. Patient and physical
therapist demographic data was reported with means,
4 K. J. ZIMNEY ET AL.
ranges, and standard deviations. Correlational statistics
between PCAS and WAI-SR measures, along with their
relation to the outcome measures of NPRS, ODI, and
GROC, were assessed with the Spearman rho. The inter­
pretation of Spearman’s correlation coefficient is set at
0.9–0.7 strong, 0.6–0.4 moderate, 0.3 to 0.1 weak
(Dancey and Reidy, 2007). Significance was set at
p < .050.
Results
Forty-three initial patient participants signed informed
consent to begin the study, with 13 participants only
completing initial pre-visit data collection and not fin­
ishing any additional measurements at post-initial visit
or discharge. Nine of the 30 remaining patient partici­
pants did not complete the final discharge measure­
ments. One subject was removed from the data after
analysis of linear regression assumptions, as the
patient’s data was an influential outlier, as observed
through scatter plots and Cook’s distance analysis.
(Figure 1) Independent sample t-test revealed no differ­
ences in age [t(41) = 1.6, p = .113], low back pain dura­
tion [t(37) = 1.5, p = .142], gender [t(41) = 0.3, p = .746],
pain [t(41) = 1.5, p = .140], or disability [t(41) = 1.5,
p = .142] at the pre-initial visit measure point for those
excluded from analysis compared to those included.
The average age of the patient participants was 49.3
years old, with a mean duration of low back pain at the
time of referral was about two years. Specific
Figure 1. Flow diagram of patient participants.
demographic data information for the patient partici­
pants’ characteristics are provided in Table 1. On aver­
age, patients saw about a 1-point improvement in pain
throughout the course of treatment, with an 11.1%
improvement in disability rating on the ODI, and
reported their GROC at a positive 2. Both the NPRS
and GROC scores reached the minimal clinically impor­
tant difference, whereas the ODI fell short by 2–3 points
of meeting this threshold (Table 2).
Sixteen different PT participants from eight various
clinic sites informed the analysis. Clinic sites were
located in Arizona, California (x2), Rhode Island,
Virginia, Washington (x2), and Wisconsin. The aver­
age age of PT participants was 34.2 (SD = 8.4) years,
ranging from 25 to 57 years old. There were eight
females and eight males, with 14 (87.5%) being of
white racial category and the other 2 PT participants
(12.5%) being of Asian racial descent. All but one of
the PT participants possessed an earned Doctorate of
Physical Therapy degree as their professional educa­
tional level. The one PT participant who did not have
a Doctorate of Physical Therapy degree graduated
with a Bachelor of Science in Physical Therapy degree.
Seven therapists (43.8%) noted they were in the 0–5
year career tenure range, another 6 (37%) in the 6–10
year range, and 2 with 16–20 years experience. One
PT reported more than 30 years of experience. A total
of eight therapists reported board certification, and
five had gone through a residency program, and
three completed fellowship training.
 PHYSIOTHERAPY THEORY AND PRACTICE 5

Table 1. Baseline demographic characteristics of patient participants.

Characteristics Initial (n = 29) Range
Age, mean (SD), years 49.3 (15.0) 23–86
Low back pain duration, mean (SD), months 24.9 (42.9) 3–180
Gender, Female, No. (%) 15 (52)
Race, No. (%)
Black/African American 3 (10.3)
Hispanic/Latinx 2 (6.9)
White 24 (79.3)
Not reported 1 (3.4)
Education, No. (%)
Less than high school 1 (3.4)
Graduated from high school 5 (17.2)
Some college 10 (34.5)
Graduated from college 7 (24.1)
Some post-graduate coursework 1 (3.4)
Completed post-graduate degree 5 (17.2)
Received some PT care in the past, No. (%) 23 (79.3)
Received care at PT care at current clinic in the past, No. (%) 10 (34.5)
Received care from current PT in the past, No. (%) 4 (13.8)
Decision to come to PT
Physician referral, No. (%) 23 (79.3)
Direct access to PT, No. (%) 6 (20.7)
Choice for PT clinic
Location (most convenient), No. (%) 3 (10.3)
Advertisement, No. (%) 1 (3.4)
Physician recommendation, No. (%) 13 (44.8)
Family/Friend recommendation, No. (%) 6 (20.7)
Insurance coverage, No. (%) 1 (3.4)
Received care previously, No. (%) 5 (17.2)
Choice of PT
Seen previously, No. (%) 4 (13.8)
Recommended by physician, No. (%) 8 (27.6)
Recommended by family/friend, No. (%) 4 (13.8)
Clinic choice by specialty of PT, No. (%) 6 (20.7)
Clinic choice by first available, No. (%) 6 (20.7)
Not reported, No. (%) 1 (3.4)
Abbreviations: SD, standard deviation; PT, physical therapy.

Table 2. Patient participant outcomes measurements at initial and discharge visits.

Outcome measure Initial (n = 29) Discharge (n = 20) Change (n = 20)
NPRS current, mean (SD) 4.2 (2.0) 3.2 (2.3) 1.0 (2.7)
NPRS best, mean (SD) 2.5 (1.7) 1.9 (2.0) 0.9 (2.5)
NPRS worst, mean (SD) 6.5 (2.6) 4.8 (2.7) 1.7 (3.3)
NPRS average, mean (SD) 4.4 (1.8) 3.3 (2.2) 1.1 (2.6)
ODI, mean (SD) 30.0 (16.4) 19.5 (16.1) 11.1 (17.7)
GROC, mean (SD) 2.4 (2.3)
Abbreviations: NPRS, numeric pain rating scale; SD, standard deviation; ODI, Oswestry disability index; GROC,
global rating of change.

The mean PCAS after the initial evaluation was
33.37 ± 4.51. The post-treatment mean PCAS score
was 34.55 ± 5.66, with the mean change in PCAS
throughout treatment 1.72 ± 3.14. The WAI-SR mean
score after initial evaluation was 55.39 ± 5.42. While the
post-treatment mean for the WAI-SR was 54.65 ± 8.93,
with the change from initial visit to discharge being
−1.16 ± 5.40. The trust measurement score (PCAS)
strongly correlated with therapeutic alliance (WAI-SR)
scores at both post-initial and discharge visits (Table 3).
The change in the PCAS score from post-initial to
discharge produced significant correlations with pain
outcomes at discharge and with change in pain over
the course of treatment (Table 4).
The PCAS scores also had a positive correlation with
ODI and GROC scores. For GROC scores, correlations

Table 3. Correlation of primary care assessment survey and working alliance inventory – short
revised score.
Time point Spearman’s correlation coefficient Significance (p-value)
Post-initial evaluation 0.747 <0.001
Discharge 0.801 <0.001
Change from initial to discharge 0.639 0.004
6 K. J. ZIMNEY ET AL.

Table 4. Correlation of change in primary care assessment survey from post-initial to discharge
with pain measurements.
Pain neasurement Spearman’s correlation coefficient Significance (p-value)
Current at discharge −0.635 0.005
Current change at discharge 0.612 0.020
Best at discharge −0.754 <0.001
Best change at discharge 0.797 <0.001
Worst at discharge −0.668 0.002
Worst change at discharge 0.688 0.002
Average at discharge −0.692 0.001
Average change at discharge 0.745 0.001

were found at discharge rs(28) = 0.756, p < .001, and
change for post-initial to discharge rs(28) = 0.517,
p = .023. The ODI at discharge correlated with PCAS
at discharge, rs(28) = −0.536, p = .015, along with the
change from initial to discharge, rs(28) = 0.569, p = .009.
Investigation into the correlation of the WAI-SR
scores to outcomes showed a few significant findings
with the change in the WAI-SR score from after the
initial visit to discharge with discharge pain scores in
Table 5. The individual WAI-SR post-initial and dis­
charge scores had no significant correlations to pain
outcome measures or change in pain outcomes at any
point in time. The GROC and ODI demonstrated sig­
nificant changes in the WAI-SR scores at both test
points and the change in WAI-SR scores from initial
to discharge. See Table 5 for significant findings. All
others were not significant to the p < .050 level.
Discussion
The results from this study helped add evidence that
a patient’s trust in their physical therapist has a strong
correlation to therapeutic alliance scores at initial and
discharge and a moderate correlation with the change in
scores from initial to discharge. A previous qualitative
study (Miciak, 2015) listed trust as a key element of the
therapeutic alliance, and the findings in this quantitative
study corroborated those findings.
While the number of patients in this study is small, the
diversity of clinical sites (eight different states) in various
regions in the United States helps add to the generalizability
of the findings. In addition, the variability of different
therapists’ years of experience also assists with generaliz­
ability. Unfortunately, because of the small numbers within
the study, additional analysis looking into various patient
types (race, education level, receiving PT care previously,
decision of clinic and PT) effects on trust and the thera­
peutic alliance could not be performed. Now that trust
measurement has been established in physical therapy
care utilizing the PCAS; additional analysis should explore
the effects of various confounding variables on the trust
levels of patients with their physical therapists.
The results from this study showed moderate to strong
correlations of trust scores to improved pain scores of
patients at both post the initial visit and discharge. The
strong correlations between improved outcomes with
trust and therapeutic alliance scores also support the
relationship between the two constructs. Previous studies
have shown the link to improved therapeutic alliance
scores and outcomes, which were similar to this study
(Lakke and Meerman, 2016). While this finding does not
generate causation, it does provide a connection to trust
scores with the patient outcome measure of pain. Patients
with higher levels of trust correlated with those with
lower pain scores over the course of the treatment.
Similar findings showed a moderate correlation between
functional outcomes with the ODI score and overall
GROC scores with the trust measurement.
Practice implications
This study provides quantitative evidence for the con­
nection of trust as a component of the therapeutic
alliance. This connection creates an initial step in

Table 5. Correlation of working alliance inventory – short revised with outcome measures.
WAI-SR measurement and outcome measurement Spearman’s Correlation Coefficient Significance (p-value)
Change in WAI-SR and current pain at discharge −0.503 0.028
Change in WAI-SR and best pain at discharge −0.554 0.014
Change in WAI-SR and worst pain at discharge −0.622 0.004
Change in WAI-SR and average pain at discharge −0.622 0.004
Post-initial WAI-SR and GROC at discharge 0.483 0.036
Discharge WAI-SR and GROC at discharge 0.773 <0.001
Discharge WAI-SR and ODI at discharge −0.483 0.031
Change in WAI-SR and GROC at discharge 0.498 0.010
Change in WAI-SR and change in ODI 0.475 0.040
Abbreviations: WAI-SR, Working Alliance Inventory – Short Revised; GROC, Global rating of change; ODI, Oswestry disability index.

further investigation into measuring trust within the
clinical encounter in physical therapy. Future studies
can explore potential confounders to trust levels and
their effects on outcomes. In addition, future studies
geared toward comparing the impact of different inter­
ventions on trust levels will help advance patient care
and further reveal information about the connection of
trust, therapeutic alliance, and outcomes in physical
therapy care.
Limitations
The study had limited participants, which does not
allow for a secondary analysis of the potential confound­
ing variables on trust outcome measures. In addition,
based on the delimitation of the study design, no spe­
cific causation inferences can be made regarding trust,
therapeutic alliance, and outcomes, only the correlation
connections. The study only looked at one particular
diagnosis, chronic low back pain, in outpatient physical
therapy clinics. Therefore, caution should be enter­
tained when generalizing to other diagnoses or clinical
settings for physical therapists.
Conclusion
This study provides the initial work to provide quanti­
tative evidence for the previous qualitative study of trust
as a key component of the therapeutic alliance. There is
a strong correlation between trust and therapeutic alli­
ance scores and moderate to strong relationships
between outcomes and trust measurement scores.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The study was funded by the University of South Dakota,
Department of Physical Therapy Internal Department Grant
and the Iowa Physical Therapy Foundation Grant.
ORCID
Kory J. Zimney PT, DPT, PhD http://orcid.org/0000-0002-
7513-2126
Declaration of generative AI and AI-assisted
technologies in the writing process
The authors have nothing to disclose, as no Generative AI or
AI-assisted technology was used in the writing process.
PHYSIOTHERAPY THEORY AND PRACTICE 7
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