Preliminary psychometric evaluation of a measure of adherence to by kqxarzawuiwpx


									                         Original Research

                        Preliminary psychometric
                        evaluation of a measure of
                        adherence to clinic-based sport
                        injury rehabilitation
                        Britton W. Brewer, Judy L. Van Raalte, Albert J. Petitpas, Joseph H. Sklar,
                        Mark H. Pohlman, Robert J. Krushell, Terry D. Ditmar, Joanne M. Daly
Britton W. Brewer       and Jeremiah Weinstock
PhD, Judy L. Van
Raalte PhD, Albert J.
Petitpas EdD,
Joanne M. Daly MS,      Objectives: to examine the psychometric properties of the Sport Injury Rehabilitation Adherence
Department of           Scale (SIRAS), an instrument designed to assess adherence during clinic-based sport injury
Spring®eld College,     rehabilitation sessions. Design: rehabilitation professionals completed the SIRAS for their patients
Spring®eld,             on one occasion in Study 1, two occasions one week apart in Study 2, and multiple (range ˆ 6±48)
MA 01109, USA
                        occasions in Study 3. Setting: an orthopedic physical therapy clinic specializing in sports medicine.
Joseph H. Sklar MD,
                        Participants: one hundred and forty-®ve general physical therapy patients in Study 1, 31 patients
Mark H. Pohlman
MD, Robert J.           undergoing rehabilitation following knee surgery in Study 2, and 43 patients undergoing
Krushell MD, New        rehabilitation following anterior cruciate ligament reconstruction in Study 3. Main outcome
England Orthopedic
Surgeons,               measure: the SIRAS. Results: In Study 1, a Cronbach's alpha coef®cient of .82 was obtained for the
Spring®eld,             SIRAS, scores on the SIRAS were weakly correlated (r ˆ .21) with attendance at rehabilitation
MA 01109, USA
                        sessions, and the SIRAS items loaded on a single factor in a principal components analysis. In
Terry D. Ditmar
                        Study 2, a test±retest intraclass correlation coef®cient of .77 was obtained for the SIRAS and, in
BS PT, Baystate
Outpatient              Study 3, a modi®ed interrater intraclass correlation coef®cient of .57 was obtained for repeated
Rehabilitation,         administrations of the SIRAS across rehabilitation professionals. Conclusions: the results of this
3300 Main Street,
Spring®eld, MA,         study provide preliminary evidence in support of the internal consistency, unidimensionality,
USA                     discriminant validity, test±retest reliability, and interrater reliability of the SIRAS. # 2000 Harcourt
Jeremiah Weinstock      Publishers Ltd
BA, Department of
University of
Memphis, Memphis,
                        Introduction                                         positive associations between treatment
Correspondence to:                                                           adherence and rehabilitation outcomes have
Britton W. Brewer,
                        Patient adherence to prescribed rehabilitation       been obtained in studies of clinic attendance for
Center for
Performance             protocols is considered vital to achieving           various injuries (Derscheid & Feiring 1987),
Enhancement and         successful outcomes in physical therapy              exercise session attendance for knee
Applied Research,
                        (Clopton & McMahon 1992; Ice 1995; Merrill           osteoarthritis (Ettinger et al. 1997; Rejeski et al.
Department of
Psychology,             1994). Case history data have documented the         1997), activity restriction for humerus fractures
Spring®eld College,     adverse effects of poor treatment adherence on       (Hawkins & Switlyk 1993), and splint wearing
                        rehabilitation outcomes for rehabilitation           for hand dysfunction (Rives et al. 1992).
01109, USA.             regimens involving some combination of rest,            A number of predictors of adherence to sport
Tel: ‡1 413 748 3696;   immobilization, and cryotherapy for shoulder         injury rehabilitation programs have been
Fax: ‡14137483854;
E-mail: bbrewer@        injuries (Hawkins 1989) and leg injuries (Meani      identi®ed. These predictors include self-
sp¯             et al. 1986; Satter®eld et al. 1990). In addition,   motivation (Duda et al. 1989; Fields et al. 1995;

68    Physical Therapy in Sport      (2000) 1, 68±74                                                   * 2000 Harcourt Publishers Ltd
                                                                                   Psychometric properties of the SIRAS

                    Fisher et al. 1988; Noyes et al. 1983), belief in      treatment regimen when rehabilitation is not
                    the ef®cacy of treatment (Duda et al. 1989;            proceeding as expected.
                    Noyes et al. 1983; Taylor & May 1996), comfort            The purpose of this investigation was to
                    of the clinical environment (Fields et al. 1995;       examine the psychometric properties of a brief
                    Fisher et al. 1988), convenience of rehabilitation     measure of adherence during clinic-based sport
                    scheduling (Fields et al. 1995; Fisher et al. 1988),   injury rehabilitation that is suf®ciently general
                    social support for rehabilitation (Byerly et al.       to be applicable across diagnoses, rehabilitation
                    1994; Duda et al. 1989; Fisher et al. 1988), and       protocols, and patient populations. The
                    mood disturbance (Daly et al. 1995).                   measure's internal consistency, discriminant
                       As noted in a recent review of the literature       validity, and relationship to demographic
                    (Brewer 1998), attendance at rehabilitation            factors were assessed in Study 1. Study 2
                    sessions (i.e. number of rehabilitation sessions       examined the measure's test±retest reliability,
                    attended divided by number of rehabilitation           and Study 3 evaluated the measure's interrater
                    sessions scheduled) is the measure of adherence        reliability and internal consistency over
                    that has been used most frequently in sport            repeated administrations.
                    injury rehabilitation research investigations.
                    Although the attendance index is easily
                    obtained and calculated, it provides no                Study 1
                    information about what patients actually do            Method
                    during rehabilitations sessions and typically
                    produces negatively skewed distributions give          Participants: participants in this study were 145
                                                                           consecutive patients (82 males, 62 females, one
                    the general tendency for patients to attend most
                                                                           did not report gender) at an orthopedic
                    scheduled rehabilitation sessions (Brewer 1998).
                                                                           physical therapy clinic specializing in sports
                    Clinic-based sport injury rehabilitation
                                                                           medicine who had attended at least three
                    programs require patients not only to show up
                                                                           rehabilitation appointments (M ˆ 12.41,
                    for scheduled appointments, but also to
                                                                           S.D. ˆ 12.81). The mean age of participants was
                    participate actively in exercises and other
                                                                           43.95 (S.D. ˆ 15.54) years. In terms of sport
                    therapeutic activities (e.g. cryotherapy,
                                                                           involvement, 20 participants identi®ed
                    phonophoresis). A patient could have perfect
                                                                           themselves as competitive athletes, 64
                    attendance at rehabilitation sessions, yet given
                                                                           participants identi®ed themselves as
                    only minimal effort or cooperate less than fully       recreational athletes, and 60 participants
                    with rehabilitation practitioners during the           identi®ed themselves as nonathletes (one
                    sessions. Consequently, there is a need for a          participant did not respond to the sport
                    concise, psychometrically sound measure of             involvement item). Nonathletes were included
                    adherence during clinic-based sport injury             in the sample for purposes of comparison with
                    rehabilitation activities that re¯ects patients'       athletes and to examine the applicability of the
                    actual rehabilitation behavior.                        SIRAS to nonathletic populations. The injuries
                       By virtue of their close and frequent contact       for which participants were receiving treatment
                    with patients in the sport injury rehabilitation       varied extensively and included most of the
                    setting (Brewer et al. 1999), rehabilitation           diagnoses identi®ed by Derscheid and Feiring
                    practitioners are in an excellent position to          (1987) as common at a sports medicine clinic
                    evaluate what patients actually do during              (e.g. torn anterior cruciate ligament,
                    rehabilitation sessions. Consequently,                 patellofemoral syndrome, torn meniscus,
                    rehabilitation practitioners constitute an             shoulder impingement, chondromalacia
                    important potential resource in the assessment         patella).
                    of adherence to clinic-based sport injury                 Measures: a brief demographic questionnaire
                    rehabilitation programs. Further, knowledge of         was used to assess participants' age, gender,
                    patients' adherence to clinic-based activities can     and level of sport involvement (i.e. nonathlete,
                    help rehabilitation practitioners determine            recreational athlete, competitive athlete). Patient
                    whether to modify the treatment protocol or to         attendance at rehabilitation sessions was
                    attempt to enhance adherence to the current            monitored and, for each participant, a ratio of

* 2000 Harcourt Publishers Ltd
c                                                                                 Physical Therapy In Sport   (2000) 1, 68±74   69
Physical Therapy in Sport

                 sessions attended to sessions scheduled was                therapists and athletic trainers. Because the
                 calculated. Attendance has been used as an                 distribution for the attendance ratio was
                 adherence measure in previous research on                  negatively skewed, an arcsin transformation for
                 sport injuries (Byerly et al. 1994; Daly et al.            proportional data (Winer et al. 1991) was
                 1995; Derscheid & Feiring 1987; Duda et al.                performed on attendance scores.
                 1989; Fields et al. 1995; Fisher et al. 1988;                 Data analysis: a Cronbach's alpha coef®cient
                 Lampton et al. 1993; Laubach et al. 1996; Udry             was calculated for SIRAS item scores to
                 1997) and other medical conditions (Brookes                examine internal consistency. To evaluate the
                 1992; Ettinger et al. 1997; Rejeski et al. 1997).          factor structure of the SIRAS items and explore
                    Items for the Sport Injury Rehabilitation               the acceptability of summing the individual
                 Adherence Scale (SIRAS) were derived from the              items, a principal components analysis with
                 adherence literature (Duda et al. 1989;                    varimax rotation was performed. Discriminant
                 Meichenbaum & Turk 1987). The SIRAS is a                   validity was assessed by performing a Pearson
                 three-item measure in which rehabilitation                 correlation between the sum of the SIRAS item
                 practitioners rate participants' intensity of              scores and the attendance ratio. To identify
                 completion of rehabilitation exercises,                    potential differences in SIRAS scores as a
                 frequency of following practitioner instructions           function of gender and level of sport
                 and advice, and receptivity to changes in the              involvement, a 2 (Gender) by 3 (Level of Sport
                 rehabilitation program during that day's                   Involvement) analysis of variance (ANOVA)
                 appointment on 5-point Likert-type scales (see             was performed on total SIRAS scores. A
                 Table 1 for the complete scale with anchors).              Pearson correlation coef®cient was calculated
                    Procedure: in accord with institutional review          between age and the sum of the SIRAS scores to
                 board policy, patients completed an informed               determine whether scores on the SIRAS vary
                 consent form prior to participation in the study.          systematically with age. Finally, a oneway
                 The physical therapists (n ˆ 8), athletic trainers         ANOVA was performed on total SIRAS scores
                 (n ˆ 5), physical therapy assistants (n ˆ 2), and          to examine differences in adherence ratings
                 occupational therapist (n ˆ 1) at the clinic               across the various types of rehabilitation
                 completed the SIRAS for each of their patients             practitioners (i.e. physical therapist, athletic
                 participating in the study. Among the patients             trainer, physical therapy assistant, occupational
                 who were invited to participate in the study, 22           therapist) involved in the study.
                 declined, ®ve noted that they did not speak
                 English, and two stated that they could not read
                 or write. Participant attendance at rehabilitation         Results and Discussion
                 sessions over the course of their treatment to             Descriptive statistics for scores on the SIRAS are
                 date was also recorded by the physical                     presented in Table 2. The internal consistency
                                                                            of the SIRAS was found to be acceptable
                 Table 1 Sport Injury Rehabilitation Adherence Scale
                                                                            (Cronbach's alpha ˆ 0.82). Principal
                 1. Circle the number that best indicates the intensity     components analysis with varimax rotation
                    with which this patient completed rehabilitation        revealed a single factor accounting for 74% of
                    exercises during today's appointment:
                   minimum effort       1 2 3 4 5        maximum effort     Table 2 Means and Standard Deviations of Sport
                                                                            Injury Rehabilitation Adherence Scale Scores in Studies
                 2. During today's appointment, how frequently did this     1, 2, and 3
                    patient follow your instructions and advice?
                              never     1 2 3 4 5        always                                      N             M            S.D.

                                                                            Study 1                  145           12.55        2.30
                 3. How receptive was this patient to changes in the
                    rehabilitation program during today's appointment?      Study 2
                     very unreceptive    1 2 3 4 5        very receptive      Time 1                  31           11.68        2.43
                                                                              Time 2                  31           11.81        2.44
                 Note: The Sport Injury Rehabilitation Adherence Scale      Study 3
                 can also be used with reference to adherence tendencies      Primary provider        43           14.22        0.82
                 in general by using the present tense (without reference     Secondary provider      39           13.59        1.58
                 to `today's appointment').

70   Physical Therapy in Sport   (2000) 1, 68±74                                                         * 2000 Harcourt Publishers Ltd
                                                                                Psychometric properties of the SIRAS

                    the variance in SIRAS scores                        patellar realignment). To meet selection criteria,
                    (eigenvalue ˆ 2.21). Results of the principal       participants had to have been in physical
                    components analysis, along with the acceptable      therapy for at least one week, had to have at
                    Cronbach's alpha value, suggest that the three      least one week of rehabilitation appointments
                    items on the SIRAS can be summed to create a        remaining, and had to identify themselves as
                    single score representing adherence to clinic-      either a recreational athlete or a competitive
                    based sport injury rehabilitation. Rotated factor   athlete. Participants had attended an average of
                    loadings for the effort, following instructions,    11.27 (S.D. ˆ 9.16) sessions prior to and
                    and receptivity to change items were 0.84, 0.84,    including the sessions in which the SIRAS was
                    and 0.89, respectively.                             administered for the ®rst time.
                       Supporting the discriminant validity of the         Procedure: in accord with institutional review
                    SIRAS, scores on the instrument were                board policy, patients completed an informed
                    signi®cantly correlated with attendance at          consent form prior to participation in the study.
                    rehabilitation sessions (r ˆ 0.21, P 5 0.05). The   The invitation to participate in the study was
                    signi®cant positive correlation indicates that      accepted by all patients approached. The
                    there is enough overlap between SIRAS scores        physical therapists and athletic trainers
                    and attendance at rehabilitation sessions to        supervising the care of patients participating in
                    suggest that they tap related aspects of            the study completed the SIRAS immediately
                    rehabilitation, but the low positive magnitude      after two clinic-based rehabilitation sessions
                    of the correlation suggests that the SIRAS          approximately one week apart. The same
                    appears to provide unique information (over         practitioner completed the SIRAS on both
                    and above attendance) about how well patients       occasions.
                    adhere to the rehabilitation program.                  Data analysis: an intraclass correlation
                       The 2 (Gender) Â3 (Level of Sport                coef®cient (ICC) was calculated using the (2, 1)
                    Involvement) ANOVA performed on total               formula speci®ed by Shrout and Fleiss (1979) to
                    SIRAS scores revealed no signi®cant effects,        examine the test±retest reliability of the sum of
                    indicating that SIRAS scores did not vary as a      the SIRAS items for the two administrations of
                    function of participant gender and level of sport   the scale one week apart.
                    involvement (i.e. nonathlete, recreational
                    athlete, competitive athlete). Participant age
                    was not signi®cantly correlated with Sport          Results and Discussion
                    Injury Rehabilitation Adherence scores              Descriptive statistics for scores on the SIRAS are
                    (r ˆ 0.09, P 4 0.05). The oneway ANOVA              displayed in Table 2. A test±retest reliability
                    revealed no signi®cant differences in SIRAS         coef®cient (ICC [2, 1]) of 0.77 was found for the
                    scores across the four types of rehabilitation      SIRAS over a one-week period. The obtained
                    practitioner involved in the study. The ®ndings     value, which gives evidence of the temporal
                    of Study 1 provide evidence in support of the       stability of the SIRAS, is reasonably high given
                    internal consistency and discriminant validity      that adherence to rehabilitation inevitably
                    of the SIRAS and suggest that it may be useful      changes over time (Quinn 1996).
                    as a brief, unidimensional measure of
                    adherence during clinic-based sport injury
                    rehabilitation sessions.                            Study 3
                    Study 2                                             Participants: participants in this study were 43
                                                                        patients (33 males, 10 females) undergoing
                                                                        rehabilitation, following anterior cruciate
                    Participants: participants were 31 individuals      ligament (ACL) reconstruction, at an orthopedic
                    (19 males and 12 females) who, as a result of       physical therapy clinic specializing in sports
                    sport participation, acquired a knee injury         medicine.
                    requiring either arthroscopic or open surgery          Procedure: in accord with institutional review
                    (e.g. ACL reconstruction, meniscectomy,             board policy, patients completed an informed

* 2000 Harcourt Publishers Ltd
c                                                                             Physical Therapy In Sport   (2000) 1, 68±74   71
Physical Therapy in Sport

                 consent form prior to participation in the study.    providers and secondary providers are shown
                 The physical therapists (n ˆ 8), athletic trainers   in Table 2. The intraclass correlation between
                 (n ˆ 7), and physical therapy assistants (n ˆ 2)     primary and secondary provider mean ratings
                 supervising the care of the patients                 on the SIRAS was 0.57, suggesting that different
                 participating in the study completed the SIRAS       sport rehabilitation professionals use the scale
                 immediately following each of the patients'          in similar ways to observe the clinic-based
                 rehabilitation appointments. For any given           rehabilitation behavior of patients. Although
                 patient's rehabilitation appointment, only one       the correlation was in the moderate range, there
                 sport rehabilitation professional completed the      are two main factors that could have attenuated
                 SIRAS. Across multiple rehabilitation                the relationship. First, across patients, primary
                 appointments, however, SIRAS ratings were            and secondary providers were often different
                 obtained by at least two sport rehabilitation        individuals. For example, a primary provider
                 professionals for each patient, thus enabling an     for one patient could have been a secondary
                 evaluation of the interrater reliability of the      provider for another patient. Second, mean
                 SIRAS.                                               SIRAS scores across appointments were used.
                    Data analysis: because some patients were         This means that SIRAS scores assessed a
                 seen by more than two sport rehabilitation           general tendency to adhere and did not
                 practitioners over the course of their treatment,    correspond to patients' behavior for any
                 primary and secondary providers were                 particular appointment. Although the ®ndings
                 identi®ed on the basis of the frequency with         of Study 2 indicate reasonable stability of
                 which they supervised each patient. The              SIRAS scores across appointments, any patient
                 physical therapist or athletic trainer who had       inconsistencies in adherence behavior across
                 supervised the largest number of a given             rehabilitation sessions would have reduced the
                 patient's appointments was designated the            magnitude of the association between primary
                 primary provider. The professional who had           and secondary provider scores on the SIRAS.
                 supervised the second largest number of a              For participants who had attended all of their
                 given patient's appointments was considered          ®rst 10 sessions (n ˆ 32), a Cronbach's alpha
                 the secondary provider. For both primary and         coef®cient of 0.86 for the multiple
                 secondary providers, mean numbers of                 administrations of the SIRAS was obtained.
                 appointments supervised and mean SIRAS               This ®nding suggests that repeated assessments
                 scores across appointments were calculated. To       of adherence during sport injury rehabilitation
                 evaluate interrater reliability of the SIRAS, an     sessions using the SIRAS can be aggregated to
                 intraclass correlation coef®cient was calculated     produce an internally consistent index of
                 between primary and secondary provider mean          adherence to a clinic-based sport injury
                 ratings using the generic formula                    rehabilitation protocol.
                 recommended by Thomas and Nelson (1990).
                 The viability of aggregating scores on the
                                                                      General discussion
                 SIRAS across repeated administrations was
                 explored by computing a Cronbach's alpha             Studies 1±3 provide preliminary evidence for
                 coef®cient for patients who had attended all of      the psychometric integrity of the SIRAS. In
                 their ®rst 10 sessions using their summed scale      particular, the SIRAS is an internally consistent,
                 scores for each of the 10 sessions as individual     unidimensional measure of adherence for clinic-
                 `items'.                                             based sport injury rehabilitation (Study 1) that
                                                                      is reasonably stable over time (Study 2) and
                                                                      positively associated with attendance at
                 Results and Discussion
                                                                      rehabilitation sessions (Study 1). Moreover,
                 Patients were supervised by their primary            although a more accurate estimate of interrater
                 provider for a mean of 17.13 (S.D. ˆ 6.98,           reliability should be obtained through
                 range ˆ 5±32) appointments and by their              conventional means, it appears that based on
                 secondary provider for a mean of 3.85                the results of Study 3, the SIRAS can be reliably
                 (S.D. ˆ 3.09, range ˆ 1±12) appointments.            used by different rehabilitation practitioners to
                 Mean scores on the SIRAS for primary                 assess an individual's adherence to clinic-based

72   Physical Therapy in Sport   (2000) 1, 68±74                                               * 2000 Harcourt Publishers Ltd
                                                                                   Psychometric properties of the SIRAS

                    rehabilitation and that multiple administrations     injury rehabilitation. Should research continue
                    of the SIRAS can be combined to form a reliable      to demonstrate favorable psychometric
                    index of adherence to a clinic-based                 properties for the SIRAS, the measure could be
                    rehabilitation protocol. With regard to interrater   applied in clinical settings. Clinical practitioners
                    reliability, given the unconventional nature of      could use the SIRAS to identify patients
                    the research design in Study 3, there is a clear     adhering poorly to rehabilitation activities or
                    need for studies in which multiple practitioners     patients experiencing lapses in motivation to
                    observe the same sessions of patients. Such an       engage in clinic-based rehabilitation activities.
                    approach would not only enable a more                Interventions designed to enhance adherence to
                    accurate estimate of interrater reliability to be    sport injury rehabilitation (Fisher et al. 1993;
                    obtained, but would also facilitate an               Worrell 1992) could be directed toward patients
                    examination of the extent to which the               identi®ed as adhering poorly with the SIRAS.
                    psychometric properties of the SIRAS are
                    in¯uenced by the nature of the training and the
                    amount of clinical experience of the
                    practitioners using the scale.                       This research was supported in part by grant
                       The generally positive results obtained in this   number R15 AR42087-01 from the National
                    investigation for the SIRAS notwithstanding, it      Institute of Arthritis and Musculoskeletal and
                    is important to note that practitioner ratings of    Skin Diseases. Its contents are solely the
                    patient adherence involve subjective judgments       responsibility of the authors and do not
                    and are, therefore, susceptible to bias.             represent the of®cial views of the National
                    Consequently, to obtain a more complete              Institute of Arthritis and Musculoskeletal and
                    assessment of adherence to clinic-based sport        Skin Diseases.
                    injury rehabilitation, the SIRAS should be used        Portions of these data were presented at (a)
                    in conjunction with measures of attendance at        the 1994 annual meeting of the North American
                    rehabilitation sessions and other parameters         Society for the Psychology of Sport and
                    speci®c to particular rehabilitation protocol        Physical Activity, Clearwater Beach, Florida,
                    under consideration (e.g. percentage of              USA; (b) the 1995 annual meeting of the
                    prescribed repetitions completed, heart rate         Association for the Advancement of Applied
                    during rehabilitation exercises requiring            Sport Psychology, New Orleans, Louisiana,
                    exertion).                                           USA; and (c) the 1996 annual meeting of the
                       Further research should continue to evaluate      Association for the Advancement of Applied
                    the psychometric properties of the SIRAS. One        Sport Psychology, Williamsburg, Virginia,
                    potential avenue of inquiry with the SIRAS           USA. The authors thank Mark Andersen, Cary
                    would be to examine predictors of adherence          Gray, and Anastasia Syde-Carr for their helpful
                    during rehabilitation sessions. Correlations         comments on an earlier draft.
                    between scores on the SIRAS and factors linked
                    to adherence to sport injury rehabilitation
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* 2000 Harcourt Publishers Ltd
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74   Physical Therapy in Sport   (2000) 1, 68±74                                                               * 2000 Harcourt Publishers Ltd

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