Review Article

Adherence to sport injury

rehabilitation: implications for
sports medicine providers and
researchers
Luke A. Spetch and Gregory S. Kolt

It is widely assumed that the success of rehabilitation programs is contingent on following or

adhering to prescribed regimens. Adherence to sport injury rehabilitation programs may
encompass a range of behaviours that vary across different injuries and rehabilitation protocols. It
appears, however, that adherence to such programs is commonly less than 100%. The purpose of
this review, therefore, is to critically evaluate the adherence literature related to sport injury
rehabilitation. Speci®cally, the predictors of sport injury rehabilitation adherence are discussed,
theoretical explanations of the adherence-outcome relationship are outlined and evaluated,
strategies to enhance rehabilitation adherence are reported, and considerations for future
research are suggested. * c 2001 Harcourt Publishers Ltd

Introduction strategies to enhance adherence rates, they often

feel they lack the knowledge to do so
Luke A. Spetch As regular involvement in sport, exercise, and
(Crossman 1997). Gordon et al. (1991a) reported
BAppSc(Physio), physical activity has increased, associated
MSportsPhysio that 84% of the sport physiotherapists surveyed
Healthfocus injury has emerged as an important public
in their study felt that their training in the
Physiotherapy, health issue (Caine et al. 1996). Based on survey
Albury, Australia results, Egger (1990) estimated that 1 in 17 psychological aspects of injury was inadequate.
Gregory S. Kolt Australians suffered some form of sport injury Research with athletic trainers has reported
PhD, BSc, BAppSc, every year, costing the community up to similar ®ndings (Wiese et al. 1991). By
GradDipEd,
$1 billion annually. Many injured athletes, as understanding the various psychosocial factors
GradDipBehav
HlthCare part of their treatment, receive a prescribed affecting the behaviour of an injured athlete,
Faculty of Health rehabilitation regimen from their practitioners. therapists may be more effective when
Studies, Auckland
Such regimens may involve a variety of designing and implementing rehabilitation
University of
Technology, behaviours requiring adherence by athletes. strategies. The aims of this literature review,
Auckland, New These include restriction of physical activity, therefore, were ®rst to analyse current research
Zealand
home and clinic-based rehabilitation exercises, and relevant theoretical issues dealing with
Correspondence to: and cryotherapy. Estimates of adherence to predictors of sport injury adherence; second, to
G. S. Kolt, Faculty of
such rehabilitation behaviours range from evaluate proposed adherence enhancement
Health Studies,
Auckland University 40±91% (Almekinders & Almekinders 1994; procedures; and ®nally, to discuss practical and
of Technology, Daly et al. 1995; Laubach et al. 1996; Taylor methodological recommendations for further
Private Bag 92006,
Auckland 1020, & May 1996). The assumption underlying much research. It should be noted, that due to the vast
New Zealand. of this research is that there is a direct link nature of this area, some sections are not dealt
Tel: ‡64 9 917 999; between adherence and rehabilitation outcome. with in detail but, rather, brie¯y discussed.
Fax: ‡64 9 917 9877;
E-mail: gregory. While medical professionals realise the Where available, references have been included
kolt@aut.ac.nz importance of incorporating psychological in these sections to assist the reader.

80 Physical Therapy in Sport (2001) 2, 80±90 *

c 2001 Harcourt Publishers Ltd
doi : 10.1054/ptsp.2001.0062, available online at http://www.idealibrary.com on

Predictors of sport injury
rehabilitation adherence
The study of adherence to sport injury
rehabilitation is in its infancy. The majority of
investigations in this area (e.g. Brewer et al.
1994; Brewer Van Raalte Cornelius et al. 2000;
Byerly et al. 1994; Daly et al. 1995; Duda et al.
1989; Fields et al. 1995; Fisher et al. 1988;
Lampton et al. 1993; Laubach et al. 1996; Taylor
& May 1996; Udry 1997; Wittig & Schurr 1994)
focused on identifying determinants of
adherence (e.g. self-motivation, pain tolerance,
social support). Many of these variables,
however, have been studied on the basis of their
effects on other types of treatment (e.g. medical
recommendations, cardiac rehabilitation) and
have been broadly categorized as personal or
situational factors (Brewer 1998a; Fisher 1990;
Meichenbaum & Turk 1987). Personal factors
re¯ect the personality traits of injured athletes
while those variables that pertain to interaction
of athletes with the social and physical
environment are considered situational factors.
Several studies (Byerly et al. 1994; Fields et al.
1995; Fisher et al. 1988) have retrospectively
assessed personal and situational factors in
relation to sport injury rehabilitation adherence.
Fisher et al. (1988) investigated a range of
variables in a group of 41 college-level athletes
who had sustained ankle, knee, or shoulder
injuries. Each athlete was categorized as
adherent or nonadherent by trainers, based on
their attendance at rehabilitation sessions, and a
comparison made between expected and actual
progress. The athletes then completed the
Rehabilitation Adherence Questionnaire (RAQ;
Fisher et al. 1988), that assessed a variety of
personal and situational factors. Analysis of
variance (ANOVA) revealed that the adherent
athletes were more self-motivated, tolerated
pain better, perceived that they worked harder
at their rehabilitation, and were less bothered
by scheduling of sessions and environmental
conditions than their nonadherent counterparts.
Two subsequent investigations (Byerly et al.
1994; Fields et al. 1995) used the RAQ and
attempted to replicate the work of Fisher et al.
(1988). Byerly et al. (1994) found that pain
tolerance and support from others were
signi®cant predictors of rehabilitation
adherence in college-level athletes. Fields et al.
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Adherence to sport injury rehabilitation
(1995) reported signi®cant differences between
adherent and nonadherent injured athletes on
self-motivation, scheduling concerns, and pain
tolerance. Although retrospective studies such
as these provide useful background information
on variables affecting rehabilitation adherence
in the athletic training environment, they are
limited in terms of the conclusions that can be
drawn. For example, many of the studies
appear to be culturally speci®c to North
American college athletes (Taylor & May 1996).
It is also suggested that personality
characteristics (e.g. self-motivation, pain
tolerance) should ideally be assessed prior to
commencing rehabilitation as they are
presumed to be independent of the
rehabilitation process (Brewer 1998a). Finally,
although signi®cant ®ndings were reported in
these investigations, the psychometric
properties of the adherence measure used
(RAQ) is questionable (Brewer et al. 1994).
In an early prospective study of adherence to
rehabilitation, Duda et al. (1989) assessed 40
injured intercollegiate athletes to identify
variables predictive of rehabilitation adherence.
Adherence, measured by attendance at
rehabilitation sessions, completion of prescribed
exercise, and exercise intensity as perceived by
the supervising athletic trainer, was
signi®cantly related to strong social support,
high levels of self-motivation, and a belief in the
effectiveness of treatment. Duda and her
colleagues also found that athletes who focused
on task mastery were more adherent to
treatment, while athletes who tended to be
more ego-involved in their sport were less
adherent to their programs.
In a later study, Lampton et al. (1993)
investigated the effects of self-esteem and ego
and task-involvement on rehabilitation
adherence in a group of 31 injured high school
athletes, recreational athletes, and injured
workers. It was reported that those who were
low in self-esteem and high in ego-involvement
missed a greater proportion of rehabilitation
appointments. As well, contrary to the ®ndings
of Duda et al. (1989), task-involvement was
found to be unrelated to treatment adherence.
Taylor and May (1996) examined the effects
of threat appraisal ( perceived severity of injury
and susceptibility to further injury) and coping
appraisal (self-ef®cacy and treatment ef®cacy)
Physical Therapy In Sport (2001) 2, 80±90 81
Physical Therapy in Sport
on adherence to home-based rehabilitation.
Although lacking a control group, they found in
their sample of 62 British university athletes,
support for the role of threat appraisal as a
motivating process in the decision to adhere to
home-based rehabilitation (i.e. home exercises,
cryotherapy, injury compression, and rest).
In a more recent study, Udry (1997)
investigated the role of coping and social
support in relation to adherence for anterior
cruciate ligament post-surgical rehabilitation.
They found that athletes who demonstrated
attempts to alleviate the sources of stress or
discomfort were more likely to attend for their
appointments. This ®nding should be
considered, however, in light of the notion that
using attendance as the sole index of adherence
provided no information as to what the athletes
did during or outside of rehabilitation sessions.
A number of studies (e.g. Brewer Van Raalte
Cornelius et al. 2000; Daly et al. 1995; Laubach
et al. 1996) have focused particularly on clinic-
based rehabilitation activities. For example, Daly
et al. (1995) investigated emotional adjustment
as a predictor of adherence to rehabilitation in
31 athletes who had undergone knee surgery.
Adherence was assessed in terms of attendance
at scheduled rehabilitation sessions and the
Sport Injury Rehabilitation Adherence Scale
(SIRAS; Brewer et al. 1995). The investigators
reported that low levels of perceived ability to
cope with the injury were associated with high
levels of mood disturbance (as assessed by the
Pro®le of Mood States, McNair et al. 1971). In
turn, mood disturbance was inversely correlated
with attendance at rehabilitation but not
adherence during rehabilitation sessions. As
noted by Daly et al. (1995), these ®ndings were
correlational, and thus, causal inferences
regarding the relationship between emotional
disturbance and attendance cannot be made.
Given these athletes may fail to attend
appointments, it is reasonable to suggest that
these athletes may bene®t from additional
interventions designed to enhance the
achievement of rehabilitation goals.
In a more recent study, Brewer Van Raalte
Cornelius et al. (2000) examined athletes
undergoing rehabilitation following
reconstructive knee surgery. Consistent with
previous research (e.g. Fisher et al. 1988; Duda
et al. 1989; Fields et al. 1995), self-motivation
82 Physical Therapy in Sport (2001) 2, 80±90
emerged as a signi®cant predictor of adherence
to a home exercise program.
The literature reviewed above indicates that a
large number of variables have been linked to
aspects of adherence. The personal factor most
consistently associated with adherence appears
to be self-motivation while several situational
factors have been linked including social
support, perceived exertion, convenience of
rehabilitation scheduling, and belief in the
effectiveness of treatment. It should be noted,
however, that all of these links have been
correlational and imply an association only.
Further, conclusions drawn must be considered
in light of the methodological limitations
(e.g. ability to generalise, use of measures with
questionable psychometric properties, lack of
control groups) of many of the studies
reviewed. It appears obvious, that until the
relationship between adherence and suggested
moderating variables are investigated using
experimental designs, causal inferences cannot
be drawn.
Theoretical considerations in the
link between adherence and
rehabilitation outcome
Several theoretical frameworks have been
proposed to explain the variables associated
with sport injury rehabilitation adherence.
Although it is beyond the context of this review
to describe each theory in detail, four of the
major theoretical approaches that have been
utilised to guide research will be brie¯y
discussed. These include the Personal
Investment Theory (Maehr & Braskamp 1986),
the Protection Motivation Theory (Maddux &
Rogers 1983; Rogers 1975, 1983), the Cognitive
Appraisal Model (Wiese-Bjornstal & Smith
1993) and the Grief Response Model (Kubler-
Ross 1969).
Maehr and Braskamp's (1986) Personal
Investment Theory re¯ects the interactive role
of personal and situational factors in predicting
behaviour and assumes that personal
incentives, sense-of-self beliefs, and perceived
options can determine motivation in a speci®c
situation. Duda et al. (1989) reported, in their
study of injured intercollegiate athletes, that
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each of these dimensions signi®cantly predicted
adherence behaviours.
A second theoretical approach, the Protection
Motivation Theory (Maddux & Rogers 1983;
Rogers 1975, 1983) suggests that adherence is
in¯uenced by the perceived severity of a
potentially harmful situation, susceptibility to
harm, perception of how likely the
recommended course of action will reduce or
prevent the threat, and the expectancy that the
individual can perform the desired behaviour
(self ef®cacy). Taylor and May's (1996)
investigation of injured British university
athletes provided partial support for the
Protection Motivation Theory, in that of the
components of the theory measured, those
related to threat appraisal were found to be the
most likely motives for adherence to
rehabilitation.
In Cognitive Appraisal Models of sport injury
(Gordon 1986; Weiss & Troxel 1986; Wiese-
Bjornstal & Smith 1993) it is proposed that
thoughts affect emotional responses to injury
(e.g. anger and depression) (Pearson & Jones
1992), which in turn can in¯uence behavioural
responses like rehabilitation adherence. Based
on this model, Daly et al. (1995) examined
athletes undergoing rehabilitation following
knee surgery and found that those who had
negative cognitive appraisals of their injury
experienced greater emotional disturbance than
their counterparts with a more positive
cognitive appraisal. In addition, emotional
disturbance was negatively correlated with
attendance at rehabilitation sessions but not
adherence during rehabilitation sessions. Low
correlations for each of these measures
suggested that only partial support for the
cognitive appraisal model was obtained.
The ®nal theoretical explanation to be
discussed, the Grief Response Model (Kubler-
Ross 1969), has been commonly applied to the
psychology of injury rehabilitation (Astle 1986;
Ford & Gordon 1997; Gordon et al. 1991a;
Horsley 1995; McDonald & Hardy 1990;
Pedersen 1986; Smith et al. 1990). This response,
which may manifest itself in observable
behavioural symptoms and reactions, can
include shock, anger, denial, depression, guilt
or fatigue. As in the Cognitive Appraisal
Model, mood disturbances, thoughts and
behaviours may be dysfunctional and
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Adherence to sport injury rehabilitation
exacerbate the potential dif®culties of
rehabilitation (e.g. adherence). Much of the
work in this area, however, has been based on
conjecture, with little empirical data published.
Theoretical frameworks, it appears, have
provided guidelines for a limited number of
studies. Additional research is clearly needed to
further adapt these or other cognitive-
behavioural models to the study of sport injury
rehabilitation adherence.
Strategies to enhance sport
injury rehabilitation adherence
Several investigators have proposed strategies
designed to enhance adherence to sport injury
rehabilitation. Such strategies have drawn from
theoretical models and previous investigations
dealing with predictors of adherence in
designing a range of treatment interventions.
Given the range of cognitive, emotional and
behavioural challenges faced by injured athletes
(Kolt 2000), it is not surprising that most
authors have suggested a multi-treatment
approach to rehabilitation (Fisher 1990;
Friedman & Litt 1987; Haynes 1984).
Based on surveys of athletic trainers and
athletes (Fisher & Hoisington 1993; Fisher
Mullins et al. 1993), Fisher Scriber et al. (1993)
outlined key aspects of a multitreatment
approach to be education, communication and
rapport, social support, goal setting, treatment
ef®cacy and tailoring, threats and scare tactics,
and athlete responsibility.
Education
Educating injured athletes about their
particular circumstances appears to be an
important step in the rehabilitation process.
Weiss and Troxel (1986) outlined several
important areas that need to be discussed with
the injured athlete prior to commencing
rehabilitation. These included an accurate
explanation of the nature of the injury,
treatment rationale, realistic expectations, and
an understanding of injury management as a
skill analogous to sport skills. Once these areas
have been discussed, practitioners may then
choose to provide speci®c details of the athlete's
rehabilitation program. Assessment of the
athlete's comprehension of both their program
Physical Therapy In Sport (2001) 2, 80±90 83
Physical Therapy in Sport
and condition may be required, and it has been
suggested that no assumptions of the athlete's
understanding should be made (Webborn et al.
1997).
A pilot study by Webborn et al. (1997)
examined athletes' understanding of their
rehabilitation programs by interviewing
22 athletes following their consultations at
several sport injury clinics. Findings suggested
that 77% of the participants misunderstood
some aspect of their programs while only 14%
were given written program instructions. All of
the participants who were given written
instructions were able to recall every detail of
their program. Webborn et al., however, did not
formally assess whether these factors were
related to treatment adherence.
Schneiders et al. (1998), in a randomized
controlled study, found that patients who were
given written exercise instructions reported
adhering to 77.4% of their exercise over a
2-week period, compared to 38.1% for the
group who received their exercises via verbal
instructions alone.
Communication and rapport
Effective communication and rapport between
the athlete and practitioner is considered an
essential element of the rehabilitation process
(Crossman 1997; Samples 1990). It has been
suggested, that athletes who feel that the
medical professionals treating their injury are
honest, genuinely interested in their well-being,
and aware of any psychological manifestations
relating to their injury may be more motivated
to adhere to their rehabilitation program
(Brewer 1998b; Heil 1993; Wiese & Weiss 1987;
Wiese et al. 1991; Yukelson 1986). Despite this
practical suggestion, no studies were found that
examined this relationship.
Social support and encouragement
Shumaker and Brownell (1984) described social
support as an exchange of resources between at
least two individuals perceived by the provider
or recipient to enhance the well being of the
recipient. Although the bulk of the literature
has focused on medically related adherence,
several studies (e.g. Byerly et al. 1994; Duda
et al. 1989; Ford & Gordon 1993) have found a
84 Physical Therapy in Sport (2001) 2, 80±90
positive relationship between social support
and sport injury rehabilitation adherence. On
this basis, strategies such as peer modelling and
injury support groups have been recommended
(e.g. Flint 1991; Gordon et al. 1991b; Weiss &
Troxel 1986; Wiese et al. 1991).
Peer modelling involves linking a currently
injured athlete with a successfully rehabilitated
athlete, possibly with a similar injury. Injury
support groups provide a forum for athletes to
periodically voice concerns and share ideas
among a group of peers. The mutual
understanding and support provided by such
strategies may help to motivate injured athletes
in light of knowing that they are not alone in
their quest for recovery (Weiss & Troxel 1986).
In one study, Flint (1991) examined the
effectiveness of a modelling intervention on
injury rehabilitation in 20 female basketball
players following surgical repair of the ACL.
She reported that athletes who watched a
videotape of basketball players undergoing
successful rehabilitation demonstrated higher
levels of self-con®dence and greater adherence
to rehabilitation than those who did not. This
®nding must be considered, however, in light of
behavioural observations being made
subjectively by the investigator without the use
of any standardized instruments. For a more
general account of the role of social support in
counselling injured athletes readers are referred
to Fisher (1999) and Schindler Zimmerman
(1999).
Goal setting and attainment
The use of goal setting as a strategy to
enhance adherence to sport injury rehabilitation
has received considerable attention in the
literature (see review by Fisher 1999). It has
been suggested that the utilization of speci®c
short-term functional goals to achieve the
long-term goal of return to activity is severely
underestimated and underutilised in the ®eld
of injury rehabilitation (DePalma & DePalma
1989; Worrell 1992). The process of goal
setting for injured athletes should involve
several components (Brewer 1998a; Cott &
Finch 1991; Fisher Scriber et al. 1993; Gould
1993; Heil 1993; Weiss & Troxel 1986). First,
athletes and practitioners must work together
to establish challenging yet realistic and
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positive goals for rehabilitation. These goals
should be speci®c and measurable, written
down, and posted where athletes will see
them (Wiese & Weiss 1987). Second, strategies
for achieving these goals should be decided
upon by both practitioner and athlete. This
may help to provide a sense of control over
recovery as well as a feeling of accomplishment
(Wiese & Weiss 1987). Finally, goals should be
closely monitored, evaluated periodically, and
modi®ed if necessary.
Ievleva and Orlick (1996) retrospectively
surveyed 39 injured athletes to determine the
effect of several psychological strategies,
including goal setting, on healing rate.
Although goal-setting was signi®cantly
correlated with recovery time, parallels cannot
be made with sports injury rehabilitation
adherence as healing rate provides no
information about what individuals are actually
doing with respect to their rehabilitation
program (Brewer 1998a).
Treatment ef®cacy and tailoring
In the rehabilitation adherence literature,
treatment ef®cacy has been described as the
rehabilitating athletes' belief that the treatment
will achieve desired goals (Fisher 1990). On the
basis of their investigation, Duda et al. (1989)
argued that treatment ef®cacy can have an
important impact on adherence behaviours. In
fostering treatment ef®cacy, practitioners
should ensure athletes are capable of
performing their rehabilitation tasks and
identifying the context of their rehabilitation as
meaningful.
Programmes should also be personalized
to suit the individual athletes' unique
characteristics and circumstances. Fisher
(1990) suggested considering the athletes'
effort, orientation, frustration and pain
tolerance, and level of optimism or pessimism.
Although it would be dif®cult to reliably
assess all of these variables in a clinical
setting, the practitioner should at least be aware
of how these issues affect individual athletes
when designed a rehabilitation approach. By
creating a manageable program that takes into
account an athlete's personality, daily routine,
and other commitments, adherence could be
enhanced. Also of note, is that complex
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Adherence to sport injury rehabilitation
regimens (e.g. those that involve activities
beyond the abilities of the athlete) tend to lead
to greater levels of nonadherence (Sluijs et al.
1993).
Athlete responsibility
It has been reported that athletes need to feel
responsible for their own rehabilitation (Fisher
et al. 1993). By encouraging an athlete's input
into his/her rehabilitation program, they might
feel some measure of control over the present
and immediate future (DePalma & DePalma
1989). Having this control can serve to increase
commitment and adherence to the developed
program. This view was supported by the
®ndings of Laubach et al. (1996) who used
standardized measures to identify a positive
relationship between personal control and
rehabilitation adherence in a sample of 34
athletes following knee surgery.
Threats and scare tactics
Taylor and May (1996) indicated that by
increasing an athlete's perception of the severity
of an injury and susceptibility to poor
rehabilitation, reinjury, or more serious
debilitation, the athlete's motivation to comply
will be enhanced. However, Fisher et al. (1993)
argued that although negative reinforcement
may be motivational for some athletes, it
should be used as a last resort when all other
strategies have failed. By using threats or
ultimatums, practitioners risk losing respect or
harming rapport with athletes (Fisher et al.
1993).
The strategies suggested by Fisher et al.
(1993) for enhancing athletic injury
rehabilitation adherence are by no means
exhaustive. Various other psychological
strategies such as imagery (Heil 1993; Weiss &
Troxel, 1986; Wiese & Weiss 1987) and
relaxation (Duda et al. 1989; Weiss & Troxel
1986; Wiese & Weiss 1987) have been put
forward. These strategies, like most others
discussed above, have received little empirical
attention. Therefore, few conclusions can be
drawn with certainty regarding their
effectiveness in enhancing rehabilitation
adherence.
Physical Therapy In Sport (2001) 2, 80±90 85
Physical Therapy in Sport
Considerations for future
research
Future research should be planned in light of
the key methodological issues that have
consistently limited previous investigations.
These include study design, sampling
procedures, and measurement of independent
and dependent variables. Further, researchers
should also focus on the adherence-outcome
debate.
Study design
Study design appears to be consistently ¯awed
in many previous investigations. Several
retrospective studies, for example, have
attempted to assess personality characteristics
of nonadherent athletes after rehabilitation
programs have begun (e.g. Byerly et al. 1994;
Fields et al. 1995; Fisher et al. 1998; Noyes et al.
1983). Retrospective studies such as these may
yield confounded results as many variables
may be in¯uenced by the rehabilitation process
(Brewer 1998a). It appears that prospective
designs, in which personal or situational
variables are measured prior to rehabilitation
and studied in relation to adherence during
rehabilitation (e.g. Brewer et al. 1994; Brewer
et al. 2000; Duda et al. 1989; Lampton et al.
1993; Taylor & May 1996; Udry 1997) are more
appropriate.
Another key research design issue involves
the use of surveys, interviews and retrospective
reports (e.g. Fisher & Hoisington 1993; Fisher
Scriber et al. 1993; Ford & Gordon 1993;
Webborn et al. 1997) to assess the effectiveness
of adherence enhancement strategies. Inherent
with this type of research is various sources of
potential bias or inaccuracy during the
administration of questionnaires, completion by
the participants, or interpretation of the survey
responses. Further research utilizing
randomized controlled trials (e.g. Schneiders
et al. 1998) is required to develop, implement
and evaluate the effectiveness of adherence
enhancement interventions.
A third area that needs to be considered
relates to the time frames over which variables
affecting rehabilitation adherence are assessed.
Several prospective studies have limited the
time period for assessing injured athletes.
86 Physical Therapy in Sport (2001) 2, 80±90
(e.g. Daly et al. 1995; Udry 1997). Udry (1997)
argued that it is possible that athletes faced
with lengthy rehabilitation processes may begin
to experience frustration and boredom after the
predetermined measurement period. Thus,
psychological, behavioural, or situational
factors that were not evident during early
stages of rehabilitation may develop with delay
in recovery. It would appear, therefore, that
longitudinal research designs spanning the
entire rehabilitation process might provide a
more comprehensive picture of the needs of the
injured athlete.
Sampling procedures
A number of different sampling procedures
have been used in studies of sport injury
rehabilitation adherence. Consequently,
participants have varied considerably in terms
of their athletic involvement and injury
characteristics. Studies that have included a
cross-section of participants with subgroups
containing athletes of varying levels of athletic
involvement (Brewer et al. 1994; Brewer Van
Raalte Cornelius et al. 2000; Daly et al. 1995;
Lampton et al. 1993; Laubach et al. 1996; Taylor
& May 1996; Udry 1997) may be the most
appropriate sampling technique to be
employed in future research. This approach
could help to ensure a representative sample of
the injured athletic population. Alternatively,
there could be factors that warrant
consideration that are speci®c to certain
sporting endeavors. In these cases, sampling
procedures will be restricted.
The issue of generalizability has also been
applied to injury type. Some studies have
focused solely on recovery from knee injuries
(e.g. Brewer et al. 1994; Brewer et al. 2000; Daly
et al. 1995; Laubach et al. 1996; Udry 1997),
while other studies have included athletes with
a wide range of musculoskeletal conditions
(e.g. Byerly et al. 1994; Duda et al. 1989; Fields
et al. 1995; Fisher et al. 1988; Lampton et al.
1993; McEvoy & Kolt 1998; Taylor & May 1996;
Webborn et al. 1997). It is reasonable to assume
that keeping research samples as homogenous
as possible with respect to injury type will
enhance internal validity (Brewer 1998a).
Although this strategy could affect
generalizability to other injury types, it is
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appropriate in that it has not been
demonstrated that in¯uences on adherence
associated with different sporting injuries
(e.g. knee reconstruction, ankle sprain) are
the same.
Measurement of personal and
situational variables affecting adherence
It is important to consider the instruments used
to measure personal and situational variables
in the adherence literature. Some studies
(e.g. Brewer Van Raalte Cornelius et al. 2000;
Daly et al. 1995; Duda et al. 1989; Taylor & May
1995, 1996; Udry 1997) used valid and reliable
scales (e.g. Pro®le of Mood States, McNair et al.
1971), while others (e.g. Byerly et al. 1994;
Fields et al. 1995; Fisher et al. 1988) relied on
questionnaires with questionable psychometric
properties (e.g. Rehabilitation Adherence
Questionnaire, Fisher et al. 1988). In order to
minimize measurement error, future researchers
need to establish the reliability and validity of
all measurement tools used on the populations
under study, or alternatively, employ
previously documented psychometrically
sound instruments. Standardization of
instruments employed may then assist in
comparing across studies.
Measurement of adherence
Adherence to sport injury rehabilitation usually
involves a variety of behaviours across a
number of settings. It is not surprising then,
that researchers have used a range of adherence
measures. It is beyond the context of this review
to describe each of these in detail. However, it
appears that the three most common indices of
adherence are attendance at rehabilitation,
clinic-based practitioner observations, and
reporting of home-based rehabilitation program
completion.
Attendance at rehabilitation
Attendance at rehabilitation sessions as a
measure of adherence has been employed by
several researchers (e.g. Brewer Van Raalte
Cornelius et al. 2000; Byerly et al. 1994; Daly
et al. 1995; Duda et al. 1989; Fields et al. 1995;
Fisher et al. 1988; Lampton et al. 1993; Laubach
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Adherence to sport injury rehabilitation
et al. 1996; Udry 1997). A ratio of rehabilitation
sessions attended to sessions scheduled is used
to obtain an objective measure. This method of
assessment would appear quite
straightforward, however, it has been criticized
on several grounds. Smith (1996) suggested that
attending appointments is only one measure of
commitment to rehabilitation, and that many
injured athletes rehabilitate successfully at
home, or in health clubs. Brewer (1998a)
questioned the validity of attendance measures
as attendance distributions tend to be
constricted and negatively skewed due to a
general tendency of patients to attend most
scheduled appointments. In addition,
attendance indices provide no information that
relates to behaviour during rehabilitation
sessions. Consequently, attendance should
ideally be used in conjunction with other
adherence measures.
Clinic-based rehabilitation
Two instruments, the Sports Medicine
Observation Code, (SMOC, Crossman & Roch
1991) and the SIRAS have received support as
valid measures to assess athletes' behaviour
during rehabilitation sessions. Although
Crossman and Roch (1991) reported only
preliminary support for the validity of the
SMOC, the psychometric properties of the
SIRAS have been well documented (Brewer Van
Raalte Petitpas et al. 2000). These instruments
should be considered for use in future research.
Home-based rehabilitation
The third commonly used adherence measure
has been completion of home-based
rehabilitation (Almekinders & Almekinders
1994; Brewer et al. 1994; Brewer Van Raalte
Cornelius et al. 2000; McEvoy & Kolt 1998;
Noyes et al. 1993; Taylor & May 1996). This
method of assessment, which usually involves
self-reporting, has been criticized, however, for
several reasons (Meichenbaum & Turk 1987).
First, athletes may want to be viewed positively
by their practitioner and thus overestimate their
frequency of exercise routine performance.
Second, subjective self-reports are subject to
distortion due to inaccurate recall. Finally, the
simple act of self-monitoring may serve as a cue
Physical Therapy In Sport (2001) 2, 80±90 87
Physical Therapy in Sport
(reminder) and thus alter behaviour (increase
adherence).
It appears that each index of adherence has
its strengths and weaknesses, and each measure
is designed to assess a speci®c behavioural
requirement of adherence to sport injury
rehabilitation. However, the validity of these
measures is subject to the limitations of
statistical analysis or subjective reporting.
Ideally, future researchers should develop more
valid, reliable, and clinically sensitive means of
assessing adherence to clinic and home-based
programs (e.g. video monitoring, biofeedback).
Until a `gold standard' for adherence
measurement is found, or it is clear whether the
various indices of adherence are intercorrelated,
a broad range of adherence measures should be
used.
Adherence-outcome relationship
As well as further research on the factors
related to adherence or adherence enhancement
procedures, it needs to be established whether
100% adherence is necessary to achieve
therapeutic goals (Brewer 1998a; Meichenbaum
& Turk 1987). Although research ®ndings
suggest a positive adherence-outcome
relationship for musculoskeletal conditions not
directly related to sport participation (e.g.
Hawkins & Switlyk 1993; Rejeski et al. 1997;
Rives et al. 1992), the data for sport injuries is
varied. For example, Shelbourne and Wilckens
(1990) documented an inverse relationship
between adherence and outcome in a group of
patients following knee surgery. In contrast,
Brewer Van Raalte Cornelius et al. (2000) found
that several aspects of adherence were
signi®cant predictors of functional ability but
not of rehabilitation outcome. Given these
discrepancies, and the lack of empirical data, it
seems imperative that further research identi®es
the level of adherence necessary to produce
optimal recovery for a variety of sport injuries.
Conclusions
Signi®cant challenges are presented to the
practitioner in the management of sport
injuries. Adherence to rehabilitation appears to
be one of these challenges. Unfortunately,
adherence literature in the area of sport injury
88 Physical Therapy in Sport (2001) 2, 80±90
rehabilitation is still limited. Consequently, the
major ®ndings of studies on exercise adherence
and medical treatment compliance have
frequently been generalised to the athletic
injury rehabilitation setting. Caution is needed
with this approach, as the factors that predict
adherence to medical treatment or exercise
activity among the general population may not
necessarily apply to rehabilitation adherence
among athletic participants.
Examination of factors relating to
rehabilitation adherence has been the primary
focus of research to date. One consistent ®nding
that has emerged is that athletes with high
levels of self-motivation tend to adhere better
than their poorly self-motivated counterparts.
Most of the studies in this area, however, are
correlational and therefore do not indicate
cause and effect. There is an obvious need for
further research of this link utilizing
prospective, experimental research designs with
standardized, psychometrically sound
measures of key constructs.
Several strategies such as education,
treatment ef®cacy, and social support have
obtained preliminary empirical support for
their role in facilitating rehabilitation adherence.
However, few investigations have effectively
evaluated the role of adherence enhancement
interventions using randomized-controlled
studies. Before these and other strategies are
developed further, the question must be
addressed as to what level of the performance
of recommended behaviour is necessary to
produce optimal recovery. Studies that focus on
rehabilitation outcomes and the relationship to
levels of adherence could help answer this
question. It is not until this is achieved that
appropriate intervention strategies can be
con®dently designed and implemented to
facilitate a more bene®cial rehabilitation
outcome.
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