Psychological Skills and Adherence
to Rehabilitation After Reconstruction
of the Anterior Cruciate Ligament
Carrie B. Scherzer, Britton W. Brewer, Allen E. Cornelius,
Judy L. Van Raalte, Albert J. Petitpas, Joseph H. Sklar,
Mark H. Pohlman, Robert J. Krushell, and Terry D. Ditmar
Objective: To examine the relationship between self-reported use of psychological
skills and rehabilitation adherence.
Design: Prospective correlational design.
Setting: Outpatient physical-therapy clinic specializing in sports medicine.
Patients: Fifty-four patients (17 women and 37 men) undergoing rehabilitation after
anterior-cruciate-ligament reconstruction.
Main Outcome Measures: An abbreviated version of the Sports Injury Survey (Ievleva &
Orlick, 1991) was administered approximately 5 weeks after surgery to assess use of
goal setting, imagery, and positive self-talk. Four adherence measures were obtained
during the remainder of rehabilitation: attendance at rehabilitation sessions, practitioner ratings of patient adherence at rehabilitation sessions, patient self-reports of home
exercise completion, and patient self-reports of home cryotherapy completion.
Results: Goal setting was positively associated with home exercise completion and
practitioner adherence ratings. Positive self-talk was positively correlated with home
exercise completion.
Conclusions: Use of certain psychological skills might contribute to better adherence
to sport-injury rehabilitation protocols.
Key Words: compliance, knee surgery, psychology
Scherzer CB, Brewer BW, Cornelius AE, et al. Psychological skills and adherence to rehabilitation after reconstruction of the anterior cruciate ligament. J Sport Rehabil. 2001;10:165-172. © 2001 Human Kinetics
Publishers, Inc.
The sport-performance benefits of training in psychological skills such as
goal setting, imagery, and positive self-talk are well documented.1,2 There
is also evidence that psychological-skills training might have a beneficial
effect on the rehabilitation of sport injuries. For example, Ievleva and Orlick3
found in a retrospective correlational study that self-reported use of goal
Scherzer, Brewer, Cornelius, Van Raalte, and Petitpas are with Dept of Psychology
at Springfield College, Springfield, MA 01109. Sklar, Pohlman, and Krushell are with New
England Orthopedic Surgeons, Springfield, MA 01104. Ditmar is with Apex Rehabilitation of
Western New England, West Springfield, MA 01089.
165
166 Scherzer et al
setting, positive self-talk, and healing imagery was associated with rapid
recovery of functioning in athletes with knee or ankle injuries. Subsequent
experimental research has shown that psychological interventions featuring
training in goal setting,4,5 imagery/relaxation,6-7 and positive self-talk8 can
positively affect sport-injury-rehabilitation outcomes.
Another aspect of sport-injury rehabilitation that might be enhanced by
using psychological skills is adherence to prescribed rehabilitation protocols.
Using psychological techniques in an attempt to recover more rapidly and
completely from injury is presumably reflective of an athlete’s belief that he
or she can influence the outcome of rehabilitation. Beliefs regarding control
over rehabilitation outcomes have been positively correlated with both
adherence to sport-injury rehabilitation regimens9-11 and perceived rate of
recovery after knee surgery.9,11 Thus, when athletes believe that they have
some control over the rehabilitation process, they are more likely to take
action to exert such control (eg, by implementing psychological skills) and
follow their injury-rehabilitation programs more completely.
The purpose of this study was to examine the relationship between selfreported use of psychological skills and adherence to a sport-injury-rehabilitation regimen. Based on recent research indicating that goal setting can
enhance adherence to sport-injury rehabilitation12 and that control beliefs
are associated with sport-injury-rehabilitation adherence,9-11 it was hypothesized that positive associations would exist between athletes’ self-reported
use of psychological skills and their adherence to rehabilitation.
Methods
Participants
Participants in this study were 54 patients (17 women and 37 men) at an
orthopedic physical-therapy clinic specializing in sports medicine. All participants were undergoing rehabilitation after anterior-cruciate-ligament
(ACL) reconstruction performed by 1 of 3 orthopedic surgeons. The mean
age of participants was 28.00 (SD = 8.33) years. The racial/ethnic breakdown of the sample was as follows: 46 (85%) White, not of Hispanic origin;
5 (9%) Hispanic; and 3 (6%) Black, not of Hispanic origin. In terms of sport
involvement, 28 (52%) participants indicated that they were competitive
athletes, 25 (46%) indicated that they were recreational athletes, and 1 (2%)
reported being a nonathlete.
Measures
The goal-setting, healing-imagery, and positive-self-talk subscales of the
Sports Injury Survey3 were used to assess the extent of participants’ use
of psychological skills during rehabilitation. The goal-setting subscale has
3 items: “Do you set any daily goals for recovery?” “Have you set any
Psychological Skills and Adherence
167
long-term goals for recovery?” and “Have you set goals about your return
to sports?” Responses to the goal-setting items are rated on an 11-point
Likert-type scale, with 0 corresponding to never and 10 corresponding to
very much so. The imagery subscale consists of a single item, scored on an
11-point scale ranging from 0 (never) to 10 (all the time): “Do you ever do
any healing imagery, where you try to see (visualize) or feel your knee healing?” Positive self-talk was assessed by 1 item directed to participants who
responded affirmatively to the question “Do you find yourself ‘talking’ to
yourself about your injury?”: “To what extent is this self-talk positive in
comparison to negative?” Blanks were provided for respondents to indicate
the respective percentages of positive and negative self-talk. Although data
regarding the reliability and validity of the Sports Injury Survey were not
provided by the developers of the instrument,3 internal consistency was
adequate for the goal-setting scale (alpha = .70) in the current study.
Adherence to rehabilitation was assessed 4 ways. The first was to record
attendance at rehabilitation sessions. A ratio of sessions attended to sessions
scheduled was calculated, consistent with procedures used in previous
research.13 Second, adherence was assessed using the Sport Injury Rehabilitation Adherence Scale,14 which is a measure on which participants are
rated by their rehabilitation practitioners with respect to the following 3
items: “Circle the number that best indicates the intensity with which this
patient completed rehabilitation exercises during today’s appointment,”
“During today’s appointment, how frequently did this patient follow your
instructions and advice?” and “How receptive was this patient to changes
in the rehabilitation program during today’s appointment?” All 3 items
are scored on 5-point Likert-type scales. For the first item of the scale, the
endpoints are minimum effort and maximum effort. The latter 2 items are anchored with never/always and very unreceptive/very receptive, respectively.
In support of the construct validity of the Sport Injury Rehabilitation Adherence Scale, scores on the scale have been significantly correlated (r =
.21, P < .05) with attendance at rehabilitation sessions. A Cronbach alpha
coefficient of .82 has been obtained for the scale.14 Finally, adherence was
assessed by having participants rate how much of their prescribed home
rehabilitation exercises and home cryotherapy they had completed during
the previous week on separate scales from 1 (none) to 10 (all).
Procedure
The procedure of this study was approved by the Institutional Review
Board. Patients were recruited as participants by their orthopedic surgeon
prior to ACL reconstructive surgery. A research assistant described the purpose and procedures of the study to the patients who expressed interest in
participating in the study. Patients who agreed to participate in the study
(and their parents or guardians when appropriate) read and completed an
informed consent form at their preoperative physical therapy appointment,
168 Scherzer et al
held approximately 10 days before surgery.
Following surgery, measures of adherence to rehabilitation were taken at
each scheduled physical therapy appointment. Attendance/nonattendance
was documented, the Sport Injury Rehabilitation Adherence Scale was
administered to the patients’ physical therapist or athletic trainer, and
patients rated their completion of prescribed home exercises and cryotherapy since their last physical therapy appointment. The abbreviated
Sports Injury Survey was administered to all participants approximately
5 weeks postsurgery.
The accelerated rehabilitation protocol after ACL reconstruction developed by Shelbourne and colleagues15-19 was prescribed by the orthopedic
surgeons and was adhered to by the physical therapists affiliated with
the study. This physical-therapy protocol emphasizes early attainment of
range of motion (extension and flexion of the knee), quadriceps strength,
and normal gait.15,17,19
Statistical Analysis
Means were computed for scores on the Sport Injury Rehabilitation Adherence Scale and the items assessing adherence to home rehabilitation exercises and home cryotherapy across rehabilitation appointments. Descriptive
statistics and intercorrelations were calculated for the psychological-skills
and adherence variables. Scores on the goal-setting and imagery subscales
of the abbreviated Sports Injury Survey were used in regression analyses
to predict the 4 adherence indices (using scores obtained subsequent to
administration of the abbreviated Sports Injury Survey). We had intended
to use positive self-talk scores as an additional predictor variable, but only
20 participants indicated that they used self-talk in association with their
rehabilitation. Consequently, Pearson correlations were calculated between
positive self-talk and scores on each of their 4 adherence measures. All statistical analyses were computed using the Statistical Package for the Social
Sciences (SPSS for Windows).20
Results
Means and SDs of the psychological-skills and adherence measures are
presented in Table 1. The regression equation predicting home exercise
completion was statistically significant, F2,42 = 6.00, P < .01, R2 = .22. Goal
setting was a significant predictor of home exercise completion (beta =
.51, P < .005). The regression equation predicting Sport Injury Rehabilitation Adherence Scale ratings was also statistically significant, F2,42 = 3.49,
P < .05, R2 = .14. Goal setting was a significant predictor of Sport Injury
Rehabilitation Adherence Scale ratings (beta = .35, P < .05). Neither home
cryotherapy completion nor attendance was predicted by use of goal setting
and imagery. In the correlational analysis, a significant positive correlation
Psychological Skills and Adherence
169
Table 1 Means and Standard Deviations for Psychological Factors
and Adherence Measures
Goal setting
Imagery
Mean
SD
N
21.82
7.25
49
3.28
3.81
53
75.50
26.35
20
Attendance
0.80
0.23
53
Home cryotherapy
6.82
3.06
42
Home exercises
7.02
2.35
50
Sport Injury Rehabilitation
Adherence Scale
0.76
0.24
50
Positive self-talk
was found between positive self-talk and completion of prescribed home
exercises (r = .52, P < .05). There were no significant correlations between
positive self-talk and home cryotherapy completion (r = .28, P > .05), Sport
Injury Rehabilitation Adherence Scale ratings (r = .32, P > .05), and attendance (r = –.21, P > .05).
Discussion
In this study, self-reported use of goal setting was associated with homeand clinic-based measures of adherence to a postsurgical sport-injury-rehabilitation program. These results augment experimental evidence for the
beneficial effect of goal setting on sport-injury-rehabilitation adherence12 and
provide indirect support for research documenting enhancement of sportinjury-rehabilitation outcomes as a function of goal setting.4,5 A potential
explanation for the significant relations obtained between goal setting and
adherence in the current investigation is that by setting rehabilitation goals,
athletes become more focused on completing their rehabilitation tasks as a
means of achieving their goals and, therefore, are more likely to adhere to
the prescribed rehabilitation protocol.
Self-reported use of healing imagery was associated with none of the 4
indices of sport-injury-rehabilitation adherence (ie, attendance, home exercise completion, home cryotherapy completion, and Sport Injury Rehabilitation Adherence Scale). These findings suggest that the favorable impact
of imagery on sport-injury-rehabilitation outcomes6 occurs independent
of adherence to the particular rehabilitation program. Thus, imagery use
might contribute to better recovery from sport injuries without affecting
rehabilitation adherence.
Although most participants denied using self-talk with regard to their
rehabilitation, positive self-talk was positively correlated with adherence
170 Scherzer et al
(to home rehabilitation exercises) among participants who reported using
self-talk. This finding is based on a relatively small number of participants,
so caution is advised in interpreting the results. Nevertheless, in light of
research showing that a positive outlook on one’s rehabilitation was associated with faster recovery,3 it seems plausible that positive self-talk could
help athletes stay motivated to adhere to their rehabilitation regimen.
Several limitations of the current study warrant mention. First, the
correlational research design precludes drawing inferences of causality
regarding the relation between use of psychological skills and sport-injuryrehabilitation adherence. Although the prospective findings in the current
study provided evidence of a time–order relationship between use of psychological skills and rehabilitation adherence (a prerequisite for causality),
the possibility that a third variable (eg, a personality characteristic such as
self-motivation or internal locus of control) caused the occurrence of both
psychological-skills use and rehabilitation adherence cannot be ruled out.
Consequently, we recommend that future research incorporate experimental
designs in which use of one or more psychological skills is manipulated.
Such an approach would also obviate the problem of relying on self-report
to assess use of psychological skills.
Second, although we employed a standardized instrument that had
been used in a previous published study,3 the use of single-item scales for
imagery and positive self-talk is less than optimal from a psychometric
standpoint. We recommend that multiple-item scales be used in future
research to facilitate an assessment of the scales’ internal consistency and
to increase their reliability. The Athletic Injury Imagery Questionnaire
developed recently by Sordoni et al21 would be a good tool for assessing
imagery use in subsequent investigations.
Third, the findings of the current study are limited to athletes undergoing
rehabilitation after ACL reconstruction. Although it is likely that the results
would generalize to athletes with other types of injuries and rehabilitation
protocols, this possibility should be demonstrated empirically.
Fourth, although only 11 patients indicated that they did not want to
participate in the study during the 30 months in which the research was
carried out, it should be noted that the findings are representative only of
patients who consented to participate in a research investigation.
In conclusion, it appears that taking rehabilitation into one’s own hands
by setting rehabilitation goals and maintaining a positive internal dialogue
might have a favorable impact on adherence, a rehabilitation process that
can be problematic for athletes with injury13 and have important implications for rehabilitation outcomes.22-25 Receiving guidance in acquiring
and implementing psychological skills from a sport-injury-rehabilitation
professional might help facilitate adherence to the rehabilitation regimen
and, ultimately, further enhance the rehabilitation experience of athletes
with injuries.4-8, 26 Further inquiry in this area is needed to develop an even
Psychological Skills and Adherence
171
clearer picture of the potential utility of psychological skills during recovery
from sport injury.
Acknowledgments
This article was supported in part by grant number R15 AR42087-01 from the
National Institute of Arthritis and Musculoskeletal and Skin Diseases. Its contents
are solely the responsibility of the authors and do not represent the official views
of the institute. We thank Mark Andersen for his helpful comments on an earlier
draft and Marc Aconcio, Michael Astilla, Matt Bitsko, John Brickner, Chris Buntrock,
Wally Bzdell, Catherine D’Agostino, Doug Harvey, Ron Hokanson, Miriam Holmes,
Chris Izzo, Kelly Kane, Greg Kelleter, Dave LaLiberty, Jeff Laubach, Tara Nichols,
Julie O’Brien, Jeff Rice, Eric Rienecker, Trina Runge, Corinne Smith, Ken Tubilleja,
Faye Weiner, Jere Weinstock, Heidi Wolcott, Kathy Wurster, and Mark Yunger for
their assistance in data collection and gratefully acknowledge the cooperation of
NovaCare Outpatient Rehabilitation in conducting the investigation.
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