Psychological Aspects of Rehabilitation Adherence Module 4 PSYCHOLOGY 310: Sport & Injury Psychology University of Mary Instructor: Dr. Theresa Magelky Spring 2016

Rehabilitation Adherence Sport injury rehabilitation adherence – the extent to which an individual completes behaviors as part of a treatment regimen designed to facilitate recovery from injury Nonadherence to rehabilitation is associated with poorer overall rehabilitation outcomes Nonadherence to rehabilitation can have an impact on increasing the risk of re-injury Patients with sport injuries have suboptimal rates of rehabilitation adherence: Study by Taylor & May (1996) – 60% of patients were not fully adherent with rehabilitation at home 54% were not fully adherent with rest as prescribed Udry (1997) – Only 79% of athletes who had ligament reconstruction were adherent with physical therapy Brewer (1998) – Found adherence rates ranging from 40 to 91% Psychological interventions can improve rehabilitation adherence

Definitions of Adherence Various definitions of adherence based on discipline Among exercise rehabilitation professionals - “an active, voluntary collaborative involvement of the patient in a mutually acceptable course of behavior to produce a desired preventative or therapeutic result” Within general medicine & health - “the degree to which patient behaviors coincide with the recommendations of health care providers” Within areas of exercise psychology & behavioral medicine – “maintaining an exercise regimen for a prolonged period of time”… with the assumption that the individual voluntarily & independently chooses to engage in the activity

Definitions of Adherence The terms “adherence” and “compliance” have often been used interchangeably However, “adherence” is typically associated as a description of a behavior that is aimed at a particular outcome “Compliance” can be defined as an individual’s willingness to follow and engage in the required behaviors

Theoretical Models of Rehabilitation Adherence Theoretical models serve as frameworks for understanding rehabilitation process & guiding research Understanding theoretical basis of rehabilitation adherence sets a framework for sport medicine professionals to conceptualize adherence antecedents and resultant behaviors Theories that are useful in understanding adherence: Rehabilitation Schematic Biopsychosocial Model

Theoretical Models of Rehabilitation Adherence Rehabilitation Schematic (Brewer et al., 2000) – Rehabilitation adherence as a behavioral response can act as a mediator between psychological factors and rehabilitation outcomes, thus highlighting the importance as part of successful rehabilitation Biopsychosocial Model – provides an inclusive framework from which physical, psychological, and social factors influencing the sport injury rehabilitation process Injury characteristics and socio-demographic factors influence biological, psychological, and social/contextual factors Adherence, as a behavioral response to sport injury, can have an impact on an individual’s range of motion, strength, joint laxity, pain, endurance, and rate of recovery

Theoretical Models of Rehabilitation Adherence (cont.) Biopsychosocial Model (cont.) It is important to consider the antecedents to adherence: Biological factors – e.g., general health & nutrition Psychological factors – e.g., athlete’s personality, mood, cognition, and behavior Social factors – e.g., status, within the team and family situation This framework can help sport medicine professionals to adopt a holistic approach to rehabilitation and thus help them recognize aspects influencing adherence beyond the more-obvious biological factors

Impact of Rehabilitation Nonadherence Nonadherence can be risky or harmful Performing fewer rehabilitation activities than prescribed might slow recovery, Overdoing rehabilitation activities might result in re-injury or injury to another part of the body As of now, the “appropriate dose” of adherence is unknown – further research is needed Facilitating optimal levels of adherence for each individual athlete can be enhanced through use of psychological interventions When combined with physical rehabilitation, psychological interventions can have an effect on adherence and subsequently on rehabilitation outcomes

Role of Psychological Interventions in Rehabilitation Adherence Athletes and others undergoing rehabilitation are most likely to adhere to rehabilitation when they: Possess personal characteristics that facilitate adhering with a potentially challenging rehabilitation program (e.g., self- motivation & tough-mindedness Experience an environment conducive to adherence (social support for rehab, comfortable & convenient clinical setting) Perceive their medical condition as sufficiently serious to engender concern but are not overly hampered by pain or emotional distress Attribute their health to behaviors within their own control Believe in the efficacy of their rehabilitation program and are confident in their ability to complete the program

Role of Psychological Interventions in Rehabilitation Adherence Educational approaches have been predominant mode of attempting to enhance adherence Educational approaches that enhance adherence include: supervision of therapeutic exercises oversight of rehabilitation by professionals with advanced condition-specific training Augmentation of traditional instructional methods with use of instructional media, eg., audio recordings and booklets, with written and illustrated instructions for home exercise activities Goal-Setting – positively associated with sport injury rehab adherence Goal-setting includes: Increasing rehab self-efficacy Attention to rehab protocol Attribution of recovery to personally controllable factors

Role of Psychological Interventions in Rehabilitation Adherence Other interventions that yet lack experimental support: Positive self-talk Provision of social support Multimodal interventions that combine multiple techniques into a single treatment approach E.g., a motivationally-focused intervention that combines information/counseling, reinforcement of desired rehabilitation behavior, behavioral contracting, and self-monitoring of rehabilitation exercise behavior Combining behavioral contracting, cued recall of rehabilitation program, education, goal-setting, homework, mental practice of rehabilitation activities, and modeling

Role of Sport Medicine Professionals in Facilitating Adherence Knowledge of extent to which athletes are self-motivated and tolerant of pain can guide professionals’ interaction with athletes & tailor rehab regimens to personal strengths & weaknesses of the athletes Directly influence adherence behavior through use of several common intervention approaches including education, goal-setting, multimodal intervention, and communication Developing positive rapport Communicating effectively Listening to athletes

Measuring Rehabilitation Adherence SIRAS – Sport Injury Rehabilitation Adherence Scale Consists of 3 items in which sport medicine professional to rate: Athlete’s intensity of rehabilitation completion; Frequency of following instructions and advice; and Receptivity to changes in rehabilitation on a five-point Likert scale RAdMAT – Rehabilitation Adherence Measure for Athletic Training Consists of 16 items with ratings on four-point Likert-type scale with three subscales that measure: Attendance/participation; Communication; Attitude/effort

References Arvinen-Barrow, M., & Walker, N. (2013). The Psychology of Sport Injury and Rehabilitation (1st ed.). Routledege. Kremer, J., Moran, A., Walker, G., & Craig. C. (2012). Key Concepts in Sport Psychology. Sage Publishing.