Injury rehab adherance

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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.

                               USA



    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
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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

competition.

     Athlete nonadherence leads to ramifications for both the
individual and the professional directing the rehabilitation.

Most obviously for the injured athlete, nonadherence results

in

decreased quality and effectiveness of the rehabilitation.

This,   then, is directly reflected in the speed and ease with

which an

athlete returns to competition.     An athlete's future

performance

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.
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    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

arise.


Variables Affecting Injury Rehabilitation



                            Adherence

    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.


                     Athlete Characteristics

    In the search for personality stereotypes of
rehabilitation

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
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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

work.

    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

motivated.

    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

demands).


        Sportsmedicine Professional-Athlete Interactions

    Contrary to the fatalistic viewpoint that adherence is
the sole responsibility of the athlete being treated,
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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
responsibility.

    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

rehabilitation adherence.


                    Rehabilitation Setting

    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

rehabilitation progress.
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    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

prevalent.

    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
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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.


                     Education/Communication

    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
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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

motivation.

    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
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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.
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                      Personalize Treatment

    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

motivation.


                         Treatment Efficacy

    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
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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.


                              Goals

    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.
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                         Social Support

    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
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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

the team.


                          Monitor Progress

    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
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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.


                     Threats/Scare Tactics

    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

athlete.

    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.
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Conclusion



    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

rehabilitation.

    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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References



1. Fisher, A. C.   Adherence to sports injury rehabilitation

  programmes.   Sports Med 9:151-158, 1990.

2. Fisher, A. C. and L. L. Hoisington.   Injured athletes'

  attitudes     and judgments toward rehabilitation adherence.

  J Athletic Training 28:48-54, 1993.

3. Fisher, A, C., S. A. Mullins, and P. A. Frye.     Athletic

  trainers' attitudes and judgments of injured athletes'

  rehabilitation adherence.    J Athletic Training 28:43-47,

  1993.

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).

5. Meichenbaum, D. and D. C. Turk.   Facilitating Treatment

  Adherence.    New York: Plenum Publishing, 1987.

				
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