Assessment of the therapeutic alliance in physical rehabilitation: a RASCH analysis

Abstract

Purpose: To investigate the psychometric properties of the Working Alliance Inventory Theory of Change Inventory (WATOCI) in physical rehabilitation. Methods: RASCH analysis was used to examine the validity, internal consistency, reliability and discriminative properties of the 16-item WATOCI. Data was obtained from a randomized controlled trial, which employed the WATOCI to measure the alliance between physical therapists and patients with chronic low back pain. Results: The results indicated that 7 items on the 16-item WATOCI should need to be improved for use in physiotherapy settings. The resulting 9-item version of the WATOCI was found to be a uni-dimensional tool for measuring alliance, however, demonstrated a ceiling effect. Conclusions: There are several items in the WATOCI that require re-wording and/or re-contextualization prior to its use in clinical practice. Specifically, items relating more to the element social interaction did not discriminate well in this population and one solution may be to provide a therapy-specific context. Items regarding how well the patient understood the purpose of the treatment discriminated best between patients and this area is recommended for further development in the tool’s assessment. It is recommended that future research address these issues prior to its use in clinical settings.

Implications for Rehabilitation

• Chronic low back pain is defined as a condition in which pain has persisted for greater than 12 weeks. It is considered a complex condition as many forms of treatment only provide small to moderate effects for pain relief.

• The relationship between a patient and therapist that develops during the course of treatment has been found to influence treatment effects in various settings including for patients with chronic low back pain undergoing physiotherapy. However, current tools for assessing the patient-therapist relationship have been developed for use in psychotherapy settings, and have not been validated for use in other rehabilitation settings.

• In a sample of chronic low back pain, patients undergoing physiotherapy in primary care in Australia, the WATOCI, a common assessment tool of the patient-therapist relationship was used. A RASCH analysis of the WATOCI in this population revealed that many of the items were not assessing the construct and in most cases need to be re-contextualized to suit a physical-rehabilitation setting.

• Previous research has highlighted that the patient-therapist relationship is an important concept that appears to influence treatment effects; however, this research shows that it is proving difficult to measure this concept in clinical research and practice. Further development of this construct through focus groups and expert opinion is needed to fully assess the construct underlying the patient-therapist relationship in physical rehabilitation.

Keywords::

• Physical rehabilitation
• therapeutic alliance
• WATOCI

Declaration of interest: A.M.H is funded by an Endeavour International Post-graduate Research Scholarship from the Australian Government. C.G.M. is funded by the National Health and Medical Research Council of Australia. J.L. is funded by the Australian Research Council.

Appendix A

Items removed from the scale for final analysis, reasoning and recommendations.

Table

Appendix B

Recommended items, instructions and scale to assess the Therapeutic Alliance in Physical Rehabilitation Settings

Reduced item version based on RASCH Analysis of the

Working Alliance/Theory of Change Inventory (WATOCI)

Table

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