Factors Associated with Therapeutic Alliance Among Outpatient Musculoskeletal Physiotherapy Patients in Saudi Arabia: A Cross-Sectional Study

Abstract

Background: Therapeutic alliance is an important component of physiotherapy rehabilitation and is associated with patient engagement, perceived improvement, and rehabilitation outcomes. However, limited evidence exists regarding factors associated with therapeutic alliance among physiotherapy patients in Saudi Arabia. Objective: To examine therapeutic alliance among adult outpatient musculoskeletal physiotherapy patients in Saudi Arabia and investigate its association with self-efficacy, quality of life, pain-related variables, and treatment-related factors. Methods: A cross-sectional study was conducted among adult outpatient musculoskeletal physiotherapy patients in Saudi Arabia. Data were collected using an electronic questionnaire including demographic and clinical characteristics, the Working Alliance Inventory–Short Form, General Self-Efficacy Scale, WHOQOL-BREF, and pain-related measures. Data were analyzed using descriptive statistics, Spearman’s rho correlation, Mann–Whitney U test, Kruskal–Wallis test, and hierarchical multiple regression. Results: A total of 174 participants were included. Participants reported generally high therapeutic alliance scores, with a median WAI total score of 57.0 (IQR = 8.0). Therapeutic alliance was positively associated with self-efficacy, quality of life domains, and perceived improvement (all p < 0.05). Participants treated by the same physiotherapist across sessions and those receiving longer treatment sessions reported significantly higher therapeutic alliance scores (both p < 0.05). The final model explained 40.6% of the variance in therapeutic alliance scores. Higher self-efficacy, greater perceived improvement, longer session duration, higher environmental quality of life, and treatment by the same physiotherapist across sessions were positively associated with higher therapeutic alliance scores. Conclusion: Therapeutic alliance among outpatient physiotherapy patients was associated with both patient-related and treatment-related factors, supporting the importance of a biopsychosocial and patient-centered approach in physiotherapy rehabilitation. Contribution of the paper: Limited research has examined the factors associated with therapeutic alliance in physiotherapy within an integrated biopsychosocial framework. This study identified psychosocial, symptom-related, environmental, and treatment-related factors associated with therapeutic alliance among outpatient musculoskeletal physiotherapy patients. Self-efficacy, perceived improvement, environmental quality of life, session duration, and therapist continuity emerged as important factors associated with therapeutic alliance, highlighting potential targets for patient-centered physiotherapy care.