Psychological Aspects of
Rehabilitation Adherence
MODULE 4
PSYCHOLOGY 310:
SPORT & INJURY PSYCHOLOGY
UNIVERSITY OF MARY
INSTRUCTOR:
DR. THERESA MAGELKY
SPRING 2016
Rehabilitation Adherence
 Sport injury rehabilitation adherence – the extent to
which an individual completes behaviors as part of a treatment
regimen designed to facilitate recovery from injury
 Nonadherence to rehabilitation is associated with poorer
overall rehabilitation outcomes
 Nonadherence to rehabilitation can have an impact on
increasing the risk of re-injury
 Patients with sport injuries have suboptimal rates of
rehabilitation adherence:
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Study by Taylor & May (1996) – 60% of patients were not fully adherent
with rehabilitation at home
54% were not fully adherent with rest as prescribed
Udry (1997) – Only 79% of athletes who had ligament reconstruction were
adherent with physical therapy
Brewer (1998) – Found adherence rates ranging from 40 to 91%
 Psychological interventions can improve rehabilitation
adherence
Definitions of Adherence
 Various definitions of adherence based on discipline
 Among exercise rehabilitation professionals - “an
active, voluntary collaborative involvement of the patient
in a mutually acceptable course of behavior to produce a
desired preventative or therapeutic result”
 Within general medicine & health - “the degree to
which patient behaviors coincide with the
recommendations of health care providers”
 Within areas of exercise psychology & behavioral
medicine – “maintaining an exercise regimen for a
prolonged period of time”… with the assumption that the
individual voluntarily & independently chooses to engage
in the activity
Definitions of Adherence
 The terms “adherence” and “compliance” have often
been used interchangeably
 However, “adherence” is typically associated as a
description of a behavior that is aimed at a particular
outcome
 “Compliance” can be defined as an individual’s
willingness to follow and engage in the required
behaviors
Theoretical Models of Rehabilitation Adherence
 Theoretical models serve as frameworks for
understanding rehabilitation process & guiding
research
 Understanding theoretical basis of rehabilitation
adherence sets a framework for sport medicine
professionals to conceptualize adherence
antecedents and resultant behaviors
 Theories that are useful in understanding adherence:
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Rehabilitation Schematic
Biopsychosocial Model
Theoretical Models of Rehabilitation Adherence
 Rehabilitation Schematic (Brewer et al., 2000) –
Rehabilitation adherence as a behavioral response can act as a
mediator between psychological factors and rehabilitation
outcomes, thus highlighting the importance as part of successful
rehabilitation
 Biopsychosocial Model – provides an inclusive framework
from which physical, psychological, and social factors influencing
the sport injury rehabilitation process
 Injury characteristics and socio-demographic factors influence
biological, psychological, and social/contextual factors
 Adherence, as a behavioral response to sport injury, can have an
impact on an individual’s range of motion, strength, joint laxity,
pain, endurance, and rate of recovery
Theoretical Models of
Rehabilitation Adherence (cont.)
 Biopsychosocial Model (cont.)
 It is important to consider the antecedents to adherence:
Biological factors – e.g., general health & nutrition
 Psychological factors – e.g., athlete’s personality, mood,
cognition, and behavior
 Social factors – e.g., status, within the team and family situation
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This framework can help sport medicine professionals to adopt
a holistic approach to rehabilitation and thus help them
recognize aspects influencing adherence beyond the moreobvious biological factors
Impact of Rehabilitation Nonadherence
 Nonadherence can be risky or harmful
 Performing fewer rehabilitation activities than prescribed
might slow recovery,
 Overdoing rehabilitation activities might result in re-injury or
injury to another part of the body
 As of now, the “appropriate dose” of adherence is
unknown – further research is needed
 Facilitating optimal levels of adherence for each
individual athlete can be enhanced through use of
psychological interventions
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When combined with physical rehabilitation, psychological
interventions can have an effect on adherence and
subsequently on rehabilitation outcomes
Role of Psychological Interventions
in Rehabilitation Adherence
 Athletes and others undergoing rehabilitation are
most likely to adhere to rehabilitation when they:
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Possess personal characteristics that facilitate adhering with a
potentially challenging rehabilitation program (e.g., selfmotivation & tough-mindedness
Experience an environment conducive to adherence (social
support for rehab, comfortable & convenient clinical setting)
Perceive their medical condition as sufficiently serious to
engender concern but are not overly hampered by pain or
emotional distress
Attribute their health to behaviors within their own control
Believe in the efficacy of their rehabilitation program and are
confident in their ability to complete the program
Role of Psychological Interventions
in Rehabilitation Adherence
 Educational approaches have been predominant
mode of attempting to enhance adherence
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Educational approaches that enhance adherence include:
supervision of therapeutic exercises
 oversight of rehabilitation by professionals with advanced conditionspecific training
 Augmentation of traditional instructional methods with use of
instructional media, eg., audio recordings and booklets, with written
and illustrated instructions for home exercise activities
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 Goal-Setting – positively associated with sport injury
rehab adherence
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Goal-setting includes:
Increasing rehab self-efficacy
 Attention to rehab protocol
 Attribution of recovery to personally controllable factors
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Role of Psychological Interventions
in Rehabilitation Adherence
 Other interventions that yet lack experimental support:
 Positive self-talk
 Provision of social support
 Multimodal interventions that combine multiple techniques into
a single treatment approach
E.g., a motivationally-focused intervention that combines
information/counseling, reinforcement of desired rehabilitation
behavior, behavioral contracting, and self-monitoring of
rehabilitation exercise behavior
 Combining behavioral contracting, cued recall of rehabilitation
program, education, goal-setting, homework, mental practice of
rehabilitation activities, and modeling
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Role of Sport Medicine Professionals
in Facilitating Adherence
 Knowledge of extent to which athletes are self-
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motivated and tolerant of pain can guide
professionals’ interaction with athletes & tailor rehab
regimens to personal strengths & weaknesses of the
athletes
Directly influence adherence behavior through use of
several common intervention approaches including
education, goal-setting, multimodal intervention, and
communication
Developing positive rapport
Communicating effectively
Listening to athletes
Measuring Rehabilitation Adherence
 SIRAS – Sport Injury Rehabilitation Adherence Scale
 Consists of 3 items in which sport medicine professional to rate:
Athlete’s intensity of rehabilitation completion;
 Frequency of following instructions and advice; and
 Receptivity to changes in rehabilitation on a five-point Likert scale
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 RAdMAT – Rehabilitation Adherence Measure for
Athletic Training
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Consists of 16 items with ratings on four-point Likert-type scale
with three subscales that measure:
Attendance/participation;
 Communication;
 Attitude/effort
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References
 Arvinen-Barrow, M., & Walker, N. (2013). The
Psychology of Sport Injury and Rehabilitation (1st
ed.). Routledege.
 Kremer, J., Moran, A., Walker, G., & Craig. C. (2012).
Key Concepts in Sport Psychology. Sage Publishing.