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Adherence to Rehabilitation Programs
A. Craig Fisher
Laurie A. Bitting
Department of Exercise and Sport Sciences,
School of Health Sciences and Human Performance,
Ithaca College, Ithaca, NY.
The degree of injured athletes' participation in their
prescribed rehabilitation treatment programs is an ongoing
concern for the sportsmedicine professional (e.g., athletic
trainer). Athletes' return to competition does depend
somewhat on the nature of the rehabilitation (i.e., its type,
intensity, frequency, and duration). However, the
effectiveness of the rehabilitation process may depend on
injured athletes' commitment to their programs and the ability
of the sportsmedicine professional to raise that commitment to
the highest degree.
The topic of adherence to athletic injury rehabilitation
programs has been given attention by both clinicians and
researchers, and it is clear that adherence is a very complex
issue. Additional insight about sport injury rehabilitation
adherence has been derived from related areas such as exercise
adherence, cardiac rehabilitation adherence, diet adherence,
and psychotherapeutic treatment adherence. Considering the
fact that nonadherence is common among individuals involved in
treatment programs designed to prolong their lives (e.g.,
cholesterol control), it is understandable that athletes may
have difficulty adhering to treatment programs that focus on a
seemingly less important outcome, that being a return to
Athlete nonadherence leads to ramifications for both the
individual and the professional directing the rehabilitation.
Most obviously for the injured athlete, nonadherence results
decreased quality and effectiveness of the rehabilitation.
This, then, is directly reflected in the speed and ease with
athlete returns to competition. An athlete's future
in sport may hinge on how well she/he adheres to the injury
rehabilitation program. For the sportsmedicine professional,
injured athletes' nonadherence to rehabilitation programs
poses a dilemma. Athletic trainers, for example, are trained
to recognize and rehabilitate sport injuries. But when
athletes fail to demonstrate commitment to their
rehabilitation programs, trainers' experience and expertise
are at least partially nullified. Athletic trainers may even
begin to question their capabilities to assist athletes with
their injury rehabilitation.
Athlete nonadherence may be better understood by
examining the factors that create the problem. Only after
adequate reflection on the problem can any expected solutions
Variables Affecting Injury Rehabilitation
The complexity of the rehabilitation adherence issue is
confounded by the fact that there are over 200 potential
variables affecting one's degree of commitment to any
treatment program. These variables can be consolidated into
three main categories. Rehabilitation adherence can best be
understood in terms of injured athletes' characteristics,
sportsmedicine professional-athlete interactions, and
conditions surrounding the rehabilitation setting.
In the search for personality stereotypes of
adherers and nonadherers, none have been found. Apparently,
there are no traits that guarantee adherence or nonadherence.
Personality, by itself, is not an effective predictor of sport
injury rehabilitation adherence. However, there are certain
characteristics that are linked to athletes' adherence to
rehabilitation. Perhaps the most important are athletes'
beliefs about and attitudes toward their rehabilitation. The
belief that one is capable of meeting the demands of the
rehabilitation program in a manner that will lead to a return
to competition is a useful predictor of rehabilitation
adherence. Athletes must also have faith and trust in
sportsmedicine professionals administering rehabilitation
programs. Adherence will more likely occur when athletes have
the confidence that the proposed treatment program will indeed
Self-motivation is another personality characteristic
that tends to differentiate adherers from nonadherers. Self-
motivated individuals are better able to stick to their
prescribed rehabilitation and overcome the barriers that
promote reduced adherence in others not so internally
The ability to tolerate pain and discomfort is also
important for those undergoing injury rehabilitation.
Rehabilitation adherers tend to have somewhat higher pain
tolerance than nonadherers. Sportsmedicine professionals must
consider the varying pain tolerance levels existent among
injured athletes when rehabilitation programs are planned and
must be prepared to make adjustments when necessary (e.g.,
offer additional emotional support and/or impose less rigorous
Sportsmedicine Professional-Athlete Interactions
Contrary to the fatalistic viewpoint that adherence is
the sole responsibility of the athlete being treated,
adherence can be facilitated or inhibited by the attitudes and
actions of the sportsmedicine professional. The effectiveness
with which a positive message is conveyed to the injured
athlete is a key determinant of rehabilitation adherence. In
fact, the sportsmedicine professional's expectations, whether
they be positive or negative, may be self-fulfilling. The
more nonadherence is expected, the less motivated the
sportsmedicine professional may be to alter the athlete's
behavior because adherence is presumed to be the athlete's
Communication with injured athletes and the rapport it
generates is most important to promote adherence. Information
should include an explanation of the injury and the proposed
rehabilitation, the likelihood of pain, and the effort needed
for successful rehabilitation. Motivational support from the
sportsmedicine professional is also a significant factor in
While injury rehabilitation is not typically a
pleasurable experience, participation in the rehabilitation
program may be enhanced by removing as many environmental
barriers as possible. It may be difficult to alter the
constraints of a crowded training room with limited space, but
it is important that the setting be conducive to
Available time and other commitments often influence
athletes' decisions to attend rehabilitation sessions.
Ideally, for rehabilitation to have a high priority, the
rehabilitation schedule must mesh with athletes' other
commitments instead of attempting to fit the athletes to
rehabilitation professionals' schedules.
Strategies to Promote Adherence
The complexity of the rehabilitation adherence issue is
best understood by considering the number of challenges
athletes face in the time period immediately following injury
to the beginning of rehabilitation. Emotionally, injured
athletes have to deal with feelings of uncertainty, anxiety,
anger, and hopelessness--not a state of mind that typically
generates a positive outlook. Cognitively, athletes need to
understand the nature of their injury, the specifics of the
rehabilitation program, and the prognosis for recovery--a lot
to deal with in an emotionally troubled time. Behaviorally,
athletes need to commit themselves to their prescribed plans
of action if rehabilitation is to succeed--a difficult task
when negative feelings and defeating thoughts are so
Given the challenges facing injured athletes and
rehabilitation professionals, it should not be surprising that
any one simple strategy will fail to solve the problem.
Complex problems demand complex solutions, or at least varied
solutions. If injured athletes are to undergo successful
rehabilitation, then certain conditions must be satisfied.
Athletes must have a feeling of competence that the treatment
program will work and also that they are capable of meeting
all the demands of the prescribed rehabilitation. Without
this positive feeling, adherence will be questionable.
Athletes are going to face physical and emotional difficulties
during their rehabilitation but they must exercise as much
control of their thoughts, feelings, and actions as they can
muster. Either athletes take charge of the rehabilitation or
the demands of the rehabilitation will overwhelm them. Only
by having positive feelings and taking charge will athletes
have the necessary commitment to all aspects of the
rehabilitation program. The above three C's comprise self-
confidence, and without self-confidence adherence to
rehabilitation programs is extremely unlikely.
It is the responsibility of the sportsmedicine
professional to recognize the salient factors that influence
rehabilitation adherence and appropriately utilize those that
will aid each individual athlete's return to competition.
Educating athletes about the various aspects surrounding
their injury is a necessary first step in the rehabilitation
process. However, the amount of knowledge gained by the
athlete does not always parallel the degree of rehabilitation
adherence. Increased insight does not guarantee an increase
in motivated behavior, but failure to supply the athlete with
needed and expected information may well undermine
rehabilitation from the beginning and cause athletes to lose
There is a great deal of information that could be
relayed to the injured athlete by the sportsmedicine
professional, and there are different methods of presentation.
When trying to determine what to communicate, and how to
deliver the message, it is beneficial to key off the athlete's
reactions to the information being given. Some athletes will
desire specific details whereas others will want to move
immediately to the "action phase" of rehabilitation.
The educational phase should focus more on rehabilitation
methods as opposed to details of the injury. This conveys a
message of hope and recovery rather than despair and deficit.
How the information is communicated to the injured athlete may
well determine the degree to which the message is received and
processed. A positive and sincere communication style is
appreciated by injured athletes. Sportsmedicine professionals
need to present honest and realistic information regarding the
severity of the injury, the effort needed for proper
rehabilitation, and the difficulties to be encountered. Yet,
they need to intersperse this reality with healthy doses of
optimism (e.g., others have done it before you).
Effective communication necessitates two-way interaction.
It is important that sportsmedicine professionals and athletes
listen to each other. One of the most important
characteristics that allows athletes to cope with their
injuries is a willingness to listen to and heed sportsmedicine
professionals' directions and suggestions. To complete the
communication circle, sportsmedicine professionals must also
listen to their athletes' concerns (e.g., "I'm not sure I'm
going to be able to deal with the pain").
It should also be emphasized here that athletes need to
receive the same message from the sportsmedicine professional
as they do from the coach. Consistency of information,
particularly regarding injury prognosis and date of return to
play, is extremely important in building and maintaining
athletes' trust and avoiding undue confusion.
In addition to the typical rehabilitation information the
sportsmedicine professional discusses with injured athletes,
it may be appropriate in the early phases of treatment to
engage athletes in some relapse prevention training. Neither
sportsmedicine professionals nor athletes themselves should
expect their motivational and commitment levels to be at their
peak at all times throughout the entire rehabilitation
process. There will be normal ebbs and flows, and potential
temporary lapses in adherence should be anticipated. Not that
injured athletes should be given license to be irresponsible,
but an infrequent miss of a rehabilitation session does not
mean all is lost. Athletes must be made aware that
rehabilitation is continuous and ongoing, not dichotomous
(i.e., all-or-none), and previous progress made will not be
totally lost by the odd day off.
Sportsmedicine professionals should be aware that
different athletes possess different characteristics (e.g.,
pain tolerance, level of motivation) that will affect how each
will handle the rehabilitation program. Although there are
ideal protocols and timelines that may be used as models, the
key to rehabilitation effectiveness is that the work indeed
gets done. The rehabilitation program needs to be matched to
the individual athlete's qualities. It is preferable to set
up a manageable program, even if it is less than ideal, so
that the athlete may see the progress necessary to maintain
Crucial to rehabilitation adherence is the belief by
athletes that their prescribed programs are going to work and
allow them to achieve the desired final goal. To reassure
athletes, sportsmedicine professionals may relate some success
stories of previously rehabilitated athletes.
As mentioned previously, athletes must also have their
own sense of optimism. An estimate of the degree of
rehabilitation adherence and effort to be expected from the
athlete may be best gained by listening to the response to the
following question: "Do you think you can handle this
rehabilitation program?" If the athlete hesitates in giving
an affirmative reply, the sportsmedicine professional may
question whether adequate attention has been directed to
certain previous key aspects of the process (e.g., explanation
of the likelihood of pain, the time commitment required) and
whether additional amplification is needed.
Progress toward established goals is a key motivator for
rehabilitating athletes, particularly those involved in long-
term recovery. Although long-term goals (e.g., return to
practice, return to competition) should be kept in mind,
short-term goals are initially more important. The attainment
of short-term goals provides athletes with a sense of
accomplishment and allows them to see much needed immediate
improvement. Reaching goals is so significantly rewarding
that adherence is sometimes doubled for those individuals who
achieve their goals.
It is necessary to provide athletes with strategies for
goal attainment (e.g., focus on the immediate task), and
target dates are useful in determining if athletes are
progressing and reaching goals on schedule. However, goals
must be flexible. Once set, they are not permanent and
unchangeable. Inflexible goals may tend to frustrate and
perhaps demotivate injured athletes. Unrealistic goals may
create additional problems for athletes and may even aggravate
their injuries. Athletes, like all individuals, will commit
only to those goals they perceive as reachable.
There is a great deal of evidence that points to the
positive relationship between social support and
rehabilitation adherence. Injured athletes often experience a
grief response as they are dealing with the many consequences
of injury (e.g., disrupted lifestyle, unattainable season
goals, and separation from teammates). They need reassurance
that they still have support from coaches, teammates, as well
as the sportsmedicine professional, and that they still belong
to the team. Perhaps no one is in a more key position than
the sportsmedicine professional to orchestrate a very
influential social support system. In addition to the
encouragement that sportsmedicine professionals themselves can
offer, coaches and teammates can be requested to take an
active role in providing personal contact with and emotional
support for injured athletes.
Coaches and/or teammates can show up periodically at
rehabilitation sessions, and teammates can also be asked to
visit injured athletes at home. Peer modeling may be used to
link injured athletes with successfully rehabilitated
athletes, or injury support groups can be formed to bond those
athletes undergoing similar rehabilitation.
Minimizing the psychosocial distance between injured
athletes and the rest of the team is very often a key to
rehabilitation adherence. If athletes continue to feel like
part of the team, they are likely to work hard at getting back
to contribute to the team. Sometimes, it is possible to
relocate exercise equipment (e.g., stationary bicycle or free
weights) to the practice area for injured athletes' on-site
rehabilitation, thus keeping athletes physically involved with
As important as it is for injured athletes to experience
progress with their rehabilitation, it is equally important
for them to understand that physical gains (e.g., range of
motion) come in relatively small increments. And, at advanced
stages of rehabilitation, the increments become smaller and
smaller. This concept can be likened to how sport skills are
developed. Typically, there is more visible progress at the
beginning, then there are periods where no progress is evident
and a so-called plateau is reached, followed by additional
progress. However, as long as athletes continue to properly
stress the injured area, there is bound to be some
advancement. With the above in mind, it is important for the
sportsmedicine professional not to overdo progress
assessments. For example, quadriceps girth measurements
should not be done on a daily basis. Adequate time between
measurements is necessary to allow substantial positive
results to be realized.
Athlete involvement with monitoring of progress can
enhance adherence and also lend a sense of control and
responsibility to the athlete. Injured athletes can record
rehabilitation activities (e.g., exercises, weights used, and
repetitions completed) on a daily or weekly rehabilitation
report, which is then periodically checked by the
sportsmedicine professional. Feedback can be given to the
athlete as the sportsmedicine professional verifies that
satisfactory progress is being made. Success tends to breed
success, and the more emotionally involved rehabilitating
athletes are with the accomplishment of their goals, the more
likely they are to adhere.
Although viewed by some to be a successful motivational
tool, it appears that the drawbacks of utilizing this type of
negative reinforcement may be more detrimental than helpful.
One problem that might be realized is what to do if the threat
does not work. Giving an ultimatum to an injured athlete
(e.g., "Do this or else . . .") threatens to undermine the
rapport between the sportsmedicine professional and the
Whereas negative reinforcement works for some in
achieving rehabilitation goals, it has the potential to work
against the athlete and the sportsmedicine professional
administering the threat. For example, the sportsmedicine
professional may threaten to withhold preventive services
(e.g., taping ankles) unless the athlete continues to fully
participate in the ongoing rehabilitation. This motivational
strategy might instead result in injury aggravation, just the
opposite of what was intended.
Adherence to injury rehabilitation programs has great
impact for both athletes and sportsmedicine professionals
because less than satisfactory outcomes are costly to both
parties. Athletes hamper their return to competition and
normal functioning by not adhering to their exercise
prescriptions. Sportsmedicine professionals, particularly
athletic trainers, experience reduced effectiveness when their
athletes fail to commit the effort needed for quality
Although it might seem reasonable to conclude that
injured athletes' personality characteristics are the prime
factors leading to adherence or nonadherence, it must be
emphasized that there are many other factors that relate to
athletes' level of adherence. The quality of the interaction
that occurs between injured athletes and sportsmedicine
professionals plays a major role in rehabilitation adherence,
as does the conduciveness of the rehabilitation setting.
Adherence is not a static behavior; it can be altered
with an understanding of its causes and the strategies that
promote it. The challenge for sportsmedicine professionals is
to understand the demands that rehabilitation places upon
injured athletes and interact with them in ways that will
maximize the chances for successful rehabilitation outcomes.
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attitudes and judgments toward rehabilitation adherence.
J Athletic Training 28:48-54, 1993.
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trainers' attitudes and judgments of injured athletes'
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4. Fisher, A. C., K. C. Scriber, M. L. Matheny, M. H.
Alderman, and L. A. Bitting. Enhancing athletic injury
rehabilitation adherence. J Athletic Training (in press).
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Adherence. New York: Plenum Publishing, 1987.