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www.JSR-Journal.comORIGINAL RESEARCH REPORT

Journal of Sport Rehabilitation, 2014, 23, 123-133http://dx.doi.org/10.1123/JSR.2013-0009© 2014 Human Kinetics, Inc.

Granquist is with the Dept of Kinesiology, and Engel, the Dept of Athletics, University of La Verne, La Verne, CA. Podlog and Newland are with the Dept of Exercise and Sport Sciences, University of Utah, Salt Lake City, UT. Address author cor-respondence to Megan Granquist at mgranquist@laverne.edu.

Certified Athletic Trainers’ Perspectives on Rehabilitation Adherence in Collegiate Athletic Training Settings

Megan D. Granquist, Leslie Podlog, Joanna R. Engel, and Aubrey Newland

Context: Adherence to sport-injury rehabilitation protocols may be pivotal in ensuring successful rehabilitation and return-to-play outcomes. Objectives: To investigate athletic trainers’ perspectives related to the degree to which rehabilitation adherence is an issue in collegiate athletic training settings, gain insight from certi-fied athletic trainers regarding the factors contributing to rehabilitation nonadherence (underadherence and overadherence), and ascertain views on the most effective means for promoting adherence. Design: Cross-sectional, mixed methods. Setting: Collegiate athletic training in the United States. Participants: Certified athletic trainers (n = 479; 234 male, 245 female). Main Outcome Measures: Online survey consisting of 3 questions regarding rehabilitation adherence, each followed by an open-ended comments section. Descriptive statistics were calculated for quantitative items; hierarchical content analyses were conducted for qualitative items. Results: Most (98.3%) participants reported poor rehabilitation adherence to be a problem (1.7% = no problem, 29.2% = minor problem, 49.7% = problem, 19.4% = major problem), while most (98.96%) participants reported that they had athletes who exhibited poor rehabilitation adherence (1% = never, 71.4% = occasionally, 22.5% = often, 5% = always). In addition, the majority (97.91%) of participants reported that overadherence (eg, doing too much, failing to comply with activity restrictions, etc) was at least an occasional occurrence (2.1% = never, 69.3% = occasionally, 26.3% = often, 1.9% = always). Hierarchical content analyses regarding the constructs of poor adherence and overadherence revealed 4 major themes: the motivation to adhere, the development of good athletic trainer–athlete rapport and effective communication, athletic trainers’ percep-tion of the coaches’ role in fostering adherence, and the influence of injury- or individual- (eg, injury severity, sport type, gender) specific characteristics on rehabilitation adherence. Conclusions: These results suggest that participants believe that underadherence (and to a lesser extent overadherence) is a frequent occurrence in collegiate athletic training settings. Strategies for enhancing rehabilitation adherence rates and preventing overadherence may therefore be important for optimizing rehabilitation outcomes.

Keywords: psychosocial, sport psychology, rehabilitation behaviors, underadherence, overadherence, non-adherence

For sport-injury rehabilitation, adherence to the rehabilitation protocol is considered integral in achieving optimal outcomes.1 In particular, after anterior cruciate ligament reconstruction, poorer patient adherence has been found to be significantly related to greater antero-posterior joint laxity and diminished functional ability (as measured by a single-leg hop for distance).2 As adherence is acknowledged as important for attaining successful clinical and return-to-play outcomes,3,4 it is important to examine rehabilitation practitioners’ perspectives of the factors contributing to adherence. Rehabilitation adher-ence in the athletic training setting has been defined as “the behaviors an athlete demonstrates by pursuing a

course of action that coincides with the recommenda-tions of the athletic trainer.”5 (p251) Given the time that athletic trainers spend with athletes and the nature of the athlete–athletic trainer relationship, athletic trainers may be ideally positioned to comment on the factors influencing rehabilitation adherence. Identification of the factors contributing to rehabilitation adherence will help rehabilitation practitioners tailor rehabilitation programs to enhance adherence rates with the aim of enhancing overall rehabilitation outcomes.

Although adherence to sport-injury rehabilitation protocols may be pivotal in ensuring successful reha-bilitation and return-to-play outcomes, limited data have been reported on adherence rates,6–9 and only 1 published report exists of adherence rates specifically in the athletic training context.9 In a review of sport-injury rehabilitation adherence in physical therapy settings, Brewer7 found rates ranging from 40% to 91%. While the physical therapy setting differs from the athletic training setting in terms of patient (eg, athlete vs nonathlete, etc) and

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environmental characteristics (eg, on campus location and convenient facility access versus a community facility that may not be as easily accessible, more frequent contact between athletic trainers and athletes versus less frequent contact between health care providers and patients at an off-campus community facility, etc), the lower estimate from Brewer’s findings suggests that adherence rates may be of concern. As indicated, however, limited data have been reported in athletic training settings, in particular, athletic trainers’ perspectives on rehabilitation adher-ence. Among 25 athletes receiving rehabilitation after anterior cruciate ligament reconstruction, Udry8 found a mean of 0.79 (scale range 0–1) on rehabilitation-session attendance, with the highest rates at the beginning of reha-bilitation. Byerly et al9 reported that among 44 NCAA Division II athletes receiving rehabilitation services, 63% were nonadherent based on attendance and athletic trainer reports. To further the research related to sport-injury rehabilitation adherence, it is important to understand athletic trainers’ perspectives on it. Moreover, a greater understanding of athletic trainers’ views on factors con-tributing to nonadherence, as well as the most effective means of fostering adherence, remains an important task in ensuring optimal adherence rates and clinical and return-to-play outcomes. Therefore, the purpose of this investigation was to investigate athletic trainers’ perspec-tives related to the degree to which rehabilitation adher-ence is an issue in collegiate athletic training settings, gain insight from certified athletic trainers regarding the factors contributing to rehabilitation nonadherence (underadherence and overadherence), and ascertain views on the most effective means for promoting adherence.

Methods

Design

Given the aim of ascertaining athletic trainers’ perspec-tives on the extent of the problem of rehabilitation adher-ence (ie, a quantitative issue), as well as their perceptions of the underlining contributing factors (ie, a qualitative issue), a mixed-method approach was deemed necessary to address the questions of interest. Problems most suit-able for mixed methods are those in which the quantitative approach or the qualitative approach, by itself, is inad-equate to develop multiple perspectives and a complete understanding of a research problem or question.10 For example, quantitative findings may be elucidated more fully by using qualitative information to better apprehend the meaning behind the numbers, to contextualize and give voice to participants’ numeric responses, and to elaborate on or uncover issues not represented in survey formats. For these reasons, a mixed-methods approach was selected. The design was cross-sectional.

Participants

Participants were 479 certified athletic trainers (234 male, 245 female) working in the collegiate athletic

training setting in the United States. This represented a 21% response rate of those recruited to participate in the study. Participants represented 46 states (excluding AL, VT, WY, and AR) and Washington, DC. Table 1 contains additional demographic information.

Procedures

After institutional review board (IRB) approval, 1000 eligible participants were sent a recruitment letter via e-mail from the National Athletic Trainers’ Association (NATA) national office (all members had previously granted NATA permission to contact them). Participants’ member type was either regular certified or student certified, and they were self-identified as working in a college or junior college setting in the United States. An additional 1251 certified athletic trainers who had a work e-mail address listed on their institution’s Web site were also sent a recruitment letter via e-mail. The recruitment letters contained a link to an Internet-based survey tool that contained the IRB-approved informed consent and questionnaire. All study procedures conformed to the first author’s university IRB procedures for ethical research conduct and standards. Participants were informed that their responses were confidential, that they could with-

Table 1 Participant Demographics

Item n

Highest academic degree

bachelor’s 54

master’s 409

doctorate 16

Athletics division

NCAA Division I 403

NCAA Division II 15

NCAA Division III 30

NAIA 11

othera 20

Job title

head athletic trainer 97

assistant athletic trainer 313

athletic trainer 31

ATEP director 5

ATEP clinical coordinator 1

faculty 15

otherb 17

Abbreviations: NCAA, National Collegiate Athletic Association; ATEP, athletic training education program,

a Included National Junior College Athletic Association and club sports. b Included intern, graduate assistant, assistant/associate athletics direc-tor, and director of sports medicine/rehabilitative services.

ATs’ Perspectives on Rehabilitation Adherence 125

draw from the study at any point without recrimination, and that they would not be identified in any publications resulting from the findings.

For the questionnaire, 3 questions pertaining to athletic trainers’ perspectives regarding issues of inter-est were designed for this study. Participants rated their responses on 4-point Likert-type scales. Open-ended comment sections were also provided after each ques-tion. Question 1 asked, “Do you think poor rehabilitation adherence is a problem in sport-injury rehabilitation?” (anchors: 1 = no problem, 2 = minor problem, 3 = problem, 4 = major problem). Question 2 asked, “Do you have athletes that have poor rehabilitation adher-ence?” (anchors: 1 = never, 2 = occasionally, 3 = often, 4 = always). Question 3 asked, “Do you have athletes that are overadherent (eg, do too much, do not comply with activity restrictions, etc)?” (anchors: 1 = never, 2 = occasionally, 3 = often, 4 = always).

Data Analysis

Quantitative descriptive statistics and ANOVA were cal-culated using SPSS version 18. Qualitative results were constructed using hierarchical content analyses and were triangulated by 3 researchers using methods described by Mason.11 Hierarchical content analyses proceeded through the use of inductive and deductive techniques to group meaningful text units (ie, statements, quotes) into raw data themes and more general abstract (ie, higher-order) themes. For example, statements (ie, raw data themes) made by several athletic trainers—“Creates a frustration between the coaches, athletes, and athletic trainers when the athlete is not motivated to return to play”; “Or when the athlete themselves is lacking the motivation, dedication or drive to get better”; and “I think it [adherence] is a major problem, especially in certain sports. Many athletes want to do the bare minimum just to get back to playing”—were grouped into the theme “motivation to adhere.” Once higher-order themes had been established, transcripts were again reviewed for specific text units that were reflective of the general categories previously established (ie, deductive analysis).

Several established qualitative techniques were used to ensure the “trustworthiness” of the data, including empathetic stance, investigator triangulation, and the use of “devil’s advocate.”12 Having the first, second, and third authors read through the transcripts on multiple occa-sions enabled the development of an empathetic stance by gaining a thorough understanding of participants’ perspectives and points of view. Empathetic understand-ing was further cultivated through ongoing discussions between the investigators regarding salient points emerg-ing from interview transcripts. Such discussions revealed that participants perceived rehabilitation adherence to be of clear importance for attaining successful clinical and return-to-play outcomes. Ongoing discussions also facilitated an empathetic understanding of participant viewpoints by underscoring the fact that some partici-pants clearly located the problem of adherence within

the individual (ie, a lack of motivation to adhere [theme 1] or injury- or individual-specific characteristics [theme 4]), while others suggested the problem to be an external environmental issue (ie, a lack of rapport and ineffective communication [theme 2] or a lack of coach support [theme 3]). Investigator triangulation was addressed by the independent analyses of the data using the hierarchi-cal content-analysis procedures described here. Finally, the second and third authors served as devil’s advocates by questioning, challenging, and discussing the appro-priateness of the independent theme classifications. Any disagreements resulted in a review of the written responses followed by further discussion, until points of contention were resolved and the key themes agreed on. For instance, discussion of participant comments that some athletes failed to “buy into” the rehabilitation pro-gram resulted in uncertainty as to whether the statements were reflective of an independent theme or should be categorized as part of the “motivation to adhere” theme. The process of critical reflection and questioning resulted in agreement that a “lack of buy-in” or wanting a “quick fix” ultimately reflected a motivational deficiency on the part of the athlete or an inability to conjure the requisite motivation to adhere to the rehabilitation program. As such, a lack of buy-in was categorized within the theme “motivation to adhere.” Devil’s advocate discussions took place on multiple occasions during the data analyses to ensure the accuracy of the themes.

ResultsQuantitative results indicated that 98.3% of participants reported poor rehabilitation adherence to be a problem in sport-injury rehabilitation. Most participants (98.96%) reported that they had athletes who exhibited poor reha-bilitation adherence, and the majority of participants (97.91%) reported that overadherence was at least an occasional occurrence among their athletes. Descrip-tive statistics for each question are provided in Table 2. Female participants reported rehabilitation adherence to be a significantly greater problem in sports-injury rehabilitation than male participants (F1,477 = 9.287, P = .002). No statistically significant differences were found between males and females in their reporting of athletes who exhibited poor rehabilitation adherence or athletes who were overadherent to rehabilitation.

Qualitative results regarding participants’ perspec-tives of poor adherence and overadherence yielded 121 and 49 comments, respectively. As not all participants provided written comments, the qualitative findings reported here are provided as a means of adding depth to the quantitative findings and in illuminating key findings emerging from the hierarchical content analyses. It is important to note that the comments that follow are not intended to represent the entirety of participants’ beliefs or perspectives across the sample as a whole. Rather, the intent is to reveal key perspectives, insights, and issues regarding the causes of poor adherence and overadher-ence in greater depth. Overall, participant comments

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revealed that rehabilitation adherence was perceived to be important in ensuring effective clinical rehabilitation and return-to-play outcomes. Comments such as “The athletes must adhere to the rehab to return to sport,” “I think that it [adherence] has a tremendous effect on their outcomes,” “I’ve yet to have an athlete successfully rehab when he/she did not adhere to the protocol,” or “lack of adherence is a major obstacle to ensuring proper progres-sion of our rehab protocols” highlighted this sentiment. Hierarchical content analysis revealed 4 major themes pertaining to poor adherence and overadherence. These included the motivation to adhere, the development of good athletic trainer–athlete rapport and effective com-munication, athletic trainers’ perception of the coaches’ role in fostering adherence, and the influence of injury- or individual-specific characteristics (eg, type of injury, length of rehabilitation, sport, age, level of competition) on rehabilitation adherence. Although each of these themes relates to the overarching theme of the causes of nonadherence (underadherence and overadherence), the themes are discussed under 4 separate theme labels rather than a single all-encompassing label reflecting the sources of nonadherence.

Theme 1: Motivation to Adhere

According to participants, one of the primary reasons, in their view, for poor adherence was insufficient motivation on the part of the athlete. Written comments revealed that athletes who lacked motivation, who failed to “buy into” the rehabilitation process, or who wanted “a quick fix” were less likely to adhere to the rehabilitation program. In terms of motivational deficits, 1 athletic trainer com-mented, “I think it [nonadherence] is a major problem, especially in certain sports. Many athletes want to do the bare minimum just to get back to playing. It is especially noticeable in any kind of preventive rehab.” This senti-ment was echoed by numerous others; for example, 1 athletic trainer commented that poor adherence was a problem “when the athlete themselves is lacking the motivation, dedication, or drive to get better.” It was noted by participants that athletes who lacked rehabilitation motivation also tended to display poor motivation in their general sport training and in other facets of their life (eg, attending classes or meetings). Along these lines, it was commented that “I think it’s [adherence is] completely dependent on the athlete’s personality and drive to be an athlete.”

Closely tied to the idea of motivation was the con-tention that injured athletes who failed to “buy into” the rehabilitation process or philosophy generally displayed poor adherence and diminished clinical outcomes. In the words of 1 athletic trainer, “If the athlete is not buying into the rehab philosophy then you are not going to get maximum results from the program regardless of how well put together it is.” It was also argued that many ath-letes wanted a “quick fix.” Finally, numerous participants indicated that many athletes were overcommitted in their various activities and obligations. As a consequence, it was suggested that rehabilitation regimens became of sec-ondary importance relative to other priorities. Comments such as “Most athletes have so much going on they see rehabilitation as an inconvenience” or “Making time for rehab seems to have become a problem with the increas-ing demands placed on student athletes” epitomized this sentiment. These observations suggest that role strain and a lack of commitment or sustained motivation to the rehabilitation process was seen as a primary reason for poor adherence.

Participants also suggested a number of negative consequences of poor adherence. First, it was suggested that athletes who were “lazy” or lacking in intrinsic motivation often got frustrated when they reached the target return date yet still had functional limitations. Such frustrations were suggested to exacerbate preex-isting adherence difficulties. Second, it was noted that athletes who lacked motivation to adhere had poor per-formance outcomes that could ultimately lead to cessa-tion of sport involvement. As 1 athletic trainer indicated, “Unmotivated, inattentive athletes, I find, have the worst outcomes and often do not last long in their sport at the college level.” Third, for some participants, motivational

Table 2 Descriptive Statistics for Each Question

Item Result

Do you think poor reha-bilitation adherence is a problem in sport-injury rehabilita-tion? (N = 479)

no problem 1.7% (n = 8)

minor problem 29.2% (n = 140)

problem 49.7% (n = 238)

major problem 19.4% (n = 93)

Do you have athletes who have poor rehabilitation adherence? (N = 479)

never 1.04% (n = 5)

occasionally 71.40% (n = 342)

often 22.55% (n = 108)

always 5.01% (n = 24)

Do you have athletes who are overadherent (eg, do too much, do not comply with activity restrictions, etc)? (N = 477)

never 2.09 (n = 10)

occasionally 69.60% (n = 332)

often 26.42% (n = 126)

always 1.89% (n = 9)

ATs’ Perspectives on Rehabilitation Adherence 127

deficiencies contributed to a sense of frustration between the coaches, athletes, and athletic trainers as rehabilitation progress was hindered and athlete limitations on return to play were apparent. In instances where a lack of effort or motivation was evident, participants commented that an unfortunate consequence was that athletes were often not strong enough to endure the rigors of competitive play. To illustrate this point, 1 athletic trainer stated that it “makes it very difficult to return an athlete to play if they only want to rehab when they feel like it.”

In sum, a collective sentiment was that much of the problem of poor adherence rested with athletes themselves, specifically that a lack of adherence was an intraindividual failure or shortcoming on the part of the athlete who lacked sufficient drive or effort. According to a number of participants, motivational deficiencies were hard to counteract, because, as 1 athletic trainer stated, “We cannot want the athlete to get better more than the athlete.”

Theme 2: Development of Good Athletic Trainer–Athlete Rapport and Effective CommunicationAlthough many participants commented that the prob-lem of poor adherence resided in the athlete, others attributed it to environmental (ie, external) factors. In particular, poor athletic trainer–athlete relations and a lack of effective communication were perceived barriers to rehabilitation adherence. While some acknowledged that “difficult” athletes were a challenge to work with, it was also recognized that the responsibility for creat-ing a good relationship largely resided with the athletic trainer. As 1 athletic trainer explained, “It’s hard to put work into someone who doesn’t want it, but as health care providers we have to, even if they don’t.” Developing positive athletic trainer–athlete rapport was seen as the key to adherence because it was felt that having a good relationship greatly enhanced the likelihood that “athletes will do what you ask them to do.”

One means by which rapport and subsequent adher-ence were enhanced was through the provision of 1-on-1 attention. As 1 athletic trainer commented “I feel most of the problem is lack of 1-on-1 attention. If they have personal attention the adherence goes way up.” In addi-tion, effective communication of rehabilitation guidelines and practitioner expectations was pivotal for fostering a positive athlete–therapist relationship and increasing adherence. A multitude of comments illustrated the rel-evance of communicating expectations. Statements such as “I make it a point to have a good relationship with [the athlete] and communicate well with them throughout the rehab process,” “In my opinion, educating them is vital to helping with rehab adherence and compliance,” or “I think adherence to the athlete’s rehab starts with the athletic trainer and making sure the athlete knows what is expected of them from the beginning” were indicative of this sentiment.

Communication of expectations and education, including the rationale for specific rehabilitation exercises and modalities, not only served to enhance adherence among those displaying underadherence but also was seen as crucial for restricting athletes exhibiting overadherence behaviors. Participants suggested that some athletes tried to expedite the rehabilitation process by doing too much too soon. As 1 athletic trainer indicated,

There are some athletes that I have to watch and really stay on top of them to make sure that they are not doing too much. But, again, if I have a good relationship with them, simply communicating with them and explaining the rehab process helps immensely.

Similarly, another participant stated, “There are athletes that think more is better. Most of the time the problem is easily solved with educating the athlete about the dangers of doing too much too soon.” In instances where athletes failed to comply with activity restrictions or attempted more exercises than prescribed, participants suggested that such overadherence usually resulted in injury-related setbacks. According to some participants, rehabilitation setbacks helped counteract future overad-herence occurrences by pointing out to the athlete the futility of such actions.

A perceived key to effective communication was the necessity of explaining the function of a particular exercise (or set of exercises) and why it was important to the rehabilitation process. In other words, providing a clear rationale for the benefits and importance of par-ticular exercises was perceived by participants as vital in facilitating adherence. When athletes understood the reasoning behind what they were doing, they generally had “more pride and ownership with their therapy than if they just came in and did what they were told to do.” In a similar vein, it was suggested that

We try and explain why a progression or plan is in place and that the ultimate goal is a return to full activity without setbacks—communication is key; as long as you can explain why you are doing some-thing, it seems to keep them in check and on task.

Theme 3: Athletic Trainers’ Perception of the Coaches’ Role in Fostering AdherenceThe importance of having coach support in fostering adherence was also described by participants such that when athletes were held accountable by coaches for their rehabilitation attendance, adherence was facilitated. Illus-trative of this was the comment of 1 athletic trainer, who noted, “I also have my coach’s support, so if athletes are missing appointments or are not getting the work done, then the coach has a talk with them, and attitudes and motivations improve.” Participants also suggested that when coaches ensured that there were consequences for a lack of rehabilitation adherence (eg, a no-rehabilitation–

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no-competition policy) or athletes were “disciplined for not coming to rehab,” then adherence challenges were minimized. In the words of 1 athletic trainer,

Due to a very supportive coaching staff, I rarely have any trouble with adherence. Our rehab sessions are treated just like a practice. So there is discipline for “no showing” to rehab sessions. I am fortunate though; I have been on the other side, and in that case, it is a major problem and ATCs [certified athletic trainers] tend to have more problems with nonadherence.

Consistent among participants was the belief that coaches who supported the athletic trainer were able to improve athletes’ rehabilitation attitudes and motivation. Conversely, coaches who did not support athletic trainer efforts had athletes who were less adherent. It was also suggested that adherence was also related to the coach’s particular coaching style, specifically, that “overbearing” coaches generally had less-compliant athletes, whereas “reasonable and responsible coaches” had more-adherent athletes. Overall, participant comments suggest the poten-tial value in striking a balance between having coaches ensure discipline and consequences without being over-bearing, controlling, or restrictive of athlete autonomy.

Theme 4: Influence of Injury- or Individual-Specific Characteristics

Finally, injury-specific factors such as injury severity and rehabilitation length were key factors suggested by participants to influence adherence. Divergent opinions emerged, however, regarding the influence of injury severity on adherence. Whereas some participants com-mented that adherence was increased in the case of a severe injury, others felt the opposite. For example, 1 participant commented, “I think that it is more of a problem with athletes who have sustained minor injuries, but I think that those sustaining major injuries usually understand that rehabilitation adherence is crucial to their return to activity.” Conversely, another suggested that adherence deficits were more evident “especially in third-degree or severe injuries; motivation seems lack-ing; hence the need for mental skills alongside physical skills.” It was suggested that with serious injuries and/or long-term rehabilitations, progress could be slow, and therefore the athletic trainer had to continue to challenge athletes to maintain their motivation.

A range of individual difference factors such as age, level of competition (ie, NCAA Division I, II, or III), scholarship, starting status, sport type, and gender were also suggested as influencing adherence. In terms of age, statements made by participants suggested that older, more mature athletes were typically more adher-ent than their younger counterparts. “It seems that the older the athlete the more adherence or better the effort that’s applied” stated 1 participant. Similarly, another commented, “I have had several younger athletes who

do not take rehab or strengthening protocols seriously enough after an injury.” Some participants also sug-gested that adherence was influenced by athletes’ level of competition, although most comments did not specify whether athletes at higher or lower levels displayed greater adherence. That said, 2 participants commented that attendance at the Division III and/or junior college level was a primary obstacle, suggesting the need for further research examining whether nonadherence is a greater issue at lower collegiate levels.

With regard to scholarship and starting status, par-ticipants perceived that nonstarters or athletes who were not key contributors were generally less motivated in their rehabilitation. In the words of 1 participant, “These individuals [nonadherers] I feel are normally not ‘star’ athletes or individuals who do not contribute a lot to the team. Key players and individual-sport athletes I feel have a tendency to be more compliant because they have a desire to return to play as soon as possible.” It was also suggested that scholarship athletes may be held more accountable given their value to the team, and hence adherence was greater. Finally, 2 other factors—sport type and gender—were mentioned as influential adher-ence variables. Several participants commented that athletes in certain sports, in particular, individual-sport athletes (eg, swimmers/divers) and football players, were less adherent. The reasons for this were not elaborated on in any detail, although 1 participant stated, “Football players at times are the worst due to what I perceive as the ‘mind-set’ of the sport, if they are injured and in rehab, coaches and players use derogatory comments, name calling, and such, so most will give up on rehab just so they don’t seem weak.” Finally, 2 participants suggested that females were more adherent than males. Once again, however, the reasons for such gender differ-ences were not clarified. Given the preliminary nature of such findings and the fact that only a few participants commented on the relevance of sport type and gender to adherence, further research on the topic is undoubtedly needed. Based on the variables highlighted in this section, participants acknowledged that adherence varied on a case-by-case basis and was often a reflection of different individual factors.

Discussion

Results suggest that participants view poor rehabilitation adherence (ie, underadherence) and, to a lesser extent, overadherence to be frequent occurrences in collegiate athletic training settings. Female participants reported rehabilitation adherence to be a significantly greater prob-lem in sports-injury rehabilitation than male participants did. Gender differences in perceptions of rehabilitation adherence have yet to be reported in previous research. A number of possible explanations for this finding exist. First, it may be that athletes are less likely to follow the recommendations of female versus male practitioners. In the general sport literature, it has been found that male

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and female athletes perceive male coaches to be more authoritative, knowledgeable, and capable of achiev-ing winning outcomes.13,14 Similarly, traditional gender biases may influence the extent to which injured athletes (both male and female) believe female athletic trainers to be knowledgeable, competent, and capable of facilitat-ing effective and expeditious recovery. Such beliefs may translate into different athlete behaviors when interacting with male versus female athletic trainers, which helps account for variable perceptions of adherence between male and female athletic trainers. Alternatively, differ-ences in perceptions of rehabilitation adherence may be accounted for by the fact that male and female athletic trainers may interpret patient actions in therapeutic set-tings differently. The reasons underlying differences in reports of rehabilitation adherence between male and female athletic trainers remains a question for further empirical scrutiny.

Overall, participants’ comments are consistent with previous research,6,7,9 such that participants viewed adherence to be essential in ensuring optimal clinical and return-to-play outcomes.1,15 In particular, statements made by participants parallel those of sport physiothera-pists regarding the importance of adherence in helping athletes recover and preventing a worsening of the injury.2 Qualitative findings provide insight into the underlining causes and/or factors associated with under adherence and overadherence and may suggest effective means for promoting optimal adherence levels.

Theme 1, “motivation to adhere,” supports past research16–18 highlighting the importance of athletes’ self-motivation in ensuring injury-rehabilitation adher-ence. In an effort to enhance athlete motivation for rehabilitation, commonly used psychosocial strategies such as goal setting and imagery may be implemented in the context of a rehabilitation session.19 For example, setting short- and long-term goals19 has shown efficacy in motivating athletes to complete rehabilitation and may be beneficial in encouraging overadhering athletes to stay focused on appropriate goal markers. Goal setting has also been found to be related to rehabilitation adher-ence.20 Rehabilitation practitioners can help athletes set short- and long-term rehabilitation goals in various areas and may be ideally positioned to revisit and reassess goals as athletes encounter rehabilitation progress and setbacks.21 Given these findings, it is not surprising that goal setting has been identified as a psychosocial strategy that rehabilitation practitioners (specifically certified athletic trainers) are expected to learn as part of their educational program.22 Suggestions for integrating goal setting into clinical practice are provided in the Practical Implications section.

The second theme, “development of good athletic trainer–athlete rapport and effective communication,” highlights a salient source of poor rehabilitation adher-ence and the solution for enhancing it. Statements made by participants indicated that poor athletic trainer–athlete relations and a lack of effective communication were perceived barriers to rehabilitation adherence. Notably,

it was suggested that rapport could be developed through the provision of 1-on-1 attention, communicating clear expectations and guidelines, and educating the athlete about his or her injury, the healing process, and the rehabilitation protocol. The importance of rapport building, patient education, and clear communication has been highlighted previously in the sport-injury domain.1,2,15,23,24 For example, Tracey’s15 interviews with 18 physical therapists and athletic trainers also revealed the importance of rapport building, education, and effective communication in facilitating holistic recovery (physical and psychological), positive rehabilitation out-comes, and athlete perceptions of support.

Providing social support in various forms is an important aspect of rehabilitation practitioners’ rapport with injured athletes. Robbins and Rosenfeld24 found that social support, especially listening and emotional support, is viewed as important by athletes to their well-being during rehabilitation. Similarly, Bianco25 found that infor-mational support is also important during this time. As such, it is important for rehabilitation practitioners to have the ability to listen to an athlete’s needs and, based on the athlete’s questions or concerns, provide information to the athlete about the rehabilitation program. Further information on effective listening techniques is provided in the Practical Implications section. When rehabilitation practitioners can focus on providing athletes with 1-on-1 attention, they are in a better position to guide the athletes to do as much as safely possible in rehabilitation while continually providing feedback with regards to the ath-letes’ progress. This informational support can include the rehabilitation practitioner providing a rationale for rehabilitation exercises and modalities.

The benefit of rehabilitation practitioners providing a rationale for rehabilitation exercises and modalities during rehabilitation sessions and interactions with recovering athletes is a finding that has not received much attention in the research literature. Participants suggested that providing a rationale fostered a better appreciation of why particular exercises were beneficial and increased athlete ownership over the rehabilitation process. Rehabilitation practitioners play a primary role in this educational process, and care should be taken throughout the injury and rehabilitation process to ensure that athletes understand the rationale for rehabilitation protocols. Motivational research outside the sport arena indicates the importance of providing a rationale in foster-ing perceptions of autonomy and enhancing task motiva-tion.26 Effective communication was also highlighted as important in limiting athlete overadherence behaviors, an issue that has received scant empirical attention.2 In one of the few empirical studies investigating overadherence, Niven3 found the issue to be consistently reported by sport physiotherapists. A novel finding from the current study was the suggestion that overadherence usually resulted in injury-related setbacks. Moreover, participants indicated that such setbacks helped counteract future overadher-ence occurrences by highlighting the ineffectiveness of such actions.

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A key finding emerging from the third theme, “ath-letic trainers’ perception of coaches’ role in fostering adherence,” was the importance of coach support in ensur-ing athlete accountability and consequences for nonad-herence. Previous research highlights the significant role of social support,8,24,25,27 and coach support28 in particular, in facilitating injured athletes’ adherence and recovery. The current study adds to the research literature by sug-gesting that coach support for rehabilitation adherence extended beyond athletes themselves to the rehabilitation practitioner, specifically the athletic trainer. Participants commented that when coaches supported athletic trainers’ messages to athletes and reinforced the importance and efficacy of treatment interventions, rehabilitation adher-ence was enhanced. Such findings speak to the relevance of positive coach–athletic trainer relations and reinforce the need for a team approach in optimizing adherence rates. Given the regularity of contact between coaches and athletic trainers, the latter can encourage coaches to take an active and supportive role in their athletes’ reha-bilitation process. Specifically, having coaches “check in” with athletes, participate in goal-setting meetings, and remain involved in ongoing discussions with athletes and athletic trainers may facilitate a collaborative approach to rehabilitation and increase adherence.

One other novel finding of note was that participants commented that coaches’ particular coaching styles contributed to rehabilitation adherence. In particular, coaches who were overly controlling versus those who were more “reasonable and responsible” were suggested to have a detrimental influence on adherence. This find-ing further reinforces the benefit of maintaining athlete autonomy during injury rehabilitation and suggests the need for future research examining optimal levels of coach involvement in the rehabilitation process.

The final theme, “influence of injury- or individual-specific characteristics,” highlights a range of personal factors influencing adherence, including injury severity, age, competitive level, scholarship/starting status, sport type, and gender. Consistent with previous research, each of these factors has been found to influence adherence and/or recovery outcomes (see Brewer29 for a review) and reinforces the patient-centered approach to rehabilita-tion that practitioners should strive for in their profes-sional practice. A number of departures from previous findings were, however, evident in the current data. For example, while positive associations between injury severity and adherence have been found previously,30 mixed statements regarding the injury severity–adherence relationship were made in the current study. Whereas some participants suggested that adherence was greater among more severely injured athletes, others suggested the opposite. Similarly, while males have been found to be more likely than females to recovery adequately or exceptionally from sport injury,31 2 participants in this study indicated that females were more likely than males

to adhere. While the gender difference reported in this study may be an artifact of this particular investigation, it is possible that female athletes are more adherent as a consequence of general gender differences in consci-entiousness and neuroticism,32 a suggestion requiring further empirical scrutiny. Although the statements of 2 among 479 participants do not amount to any conclusive evidence, these disparate findings highlight the need for further inquiry in unraveling the complex influence of individual-difference variables in rehabilitation adher-ence. Particular attention should be dedicated to the influence of injury type and severity, time out of com-petition, use of surgical versus nonsurgical techniques, sport type, level of competition, and gender. As indicated, examination of individual difference factors is consistent with a patient-centered approach to treatment advocated previously.33

Practical Implications

Although additional research is warranted related to factors influencing rehabilitation nonadherence, through the implementation of psychosocial strategies into the rehabilitation process, rehabilitation practitioners may decrease the incidence of rehabilitation nonadherence. These strategies may include psychological skills such as goal setting and imagery. For tips on integrating goal setting into clinical practice, rehabilitation practitioners should refer to Arvinen-Barrow’s practical guide.21 In particular, Arvinen-Barrow recommends that practitio-ners assist their patients in setting flexible goals, as the nature of injury recovery may have setbacks. Further-more, practitioners should have a conversation regarding goal setting with their rehabilitating athletes and should attempt to set goals in 3 areas: physical, psychological, and performance.21 For example, physical goals can be set in the areas of range of motion, strength, and functional ability. Psychological goals can be set in the areas of positive self-talk, motivation, confidence, and focus.21 Finally, performance goals can be set in relation to the tactical aspects of one’s sport, physical conditioning, and mental-skills training.21

As indicated, it is important for rehabilitation practitioners to have the ability to listen and respond to athletes’ needs during the rehabilitation process. Sport-medicine professionals in Tracey’s15 investigation highlighted the importance of listening by taking time to hear athletes’ concerns and to learn about each person and not simply the injury. Athletic trainers can enhance their listening skills through the use of nonverbal ges-tures such as head nodding, as well as clarifying athlete statements by asking open-ended questions to clarify content and gain more information. Active listening may also occur by paraphrasing and verifying athlete statements, by restating the message and reflecting or empathizing with the athlete (ie, letting the athlete

ATs’ Perspectives on Rehabilitation Adherence 131

know that both the content and intent/feeling behind the message is understood), and by summarizing what has been said.34

By building a positive rapport with their athletes, using effective communication techniques, and educating athletes on the injury and rehabilitation process, rehabili-tation practitioners may influence athletes’ motivation to adhere to their rehabilitation programs. Rehabilita-tion practitioners, specifically athletic trainers, can also work with coaches and encourage them to be a part of the athlete’s rehabilitation team. Finally, rehabilitation practitioners should take a patient-centered approach with rehabilitation that considers injury- and individual-specific characteristics.

Limitations

Several limitations in this study are noteworthy. Partici-pants who completed the survey may have been those who were already interested in rehabilitation adherence or viewed adherence as an important issue. Thus, there may have been a bias toward viewing rehabilitation as important in ensuring optimal rehabilitation outcomes and to view a lack of adherence as detrimental to such outcomes. In addition, participants may have under-reported the incidence of rehabilitation underadherence or overadherence in an attempt to be viewed as effective rehabilitation practitioners. In other words, self-presen-tation concerns over not wanting to appear ineffective as a practitioner may have influenced participant reports of rehabilitation underadherence and overadherence. Third, caution is warranted in generalizing the findings to all collegiate athletic trainers. While the 21% response rate is consistent with typical response rates of 20% to 30% for online surveys,35,36 the fact that 1 out of 5 participants responded suggests that those interested in the study/research area might be overrepresented in the sample. As such, a response bias may have influenced the results. The response rate may be a reflection of the lack of incentives for participation, the lack of follow-up emails, or the fact that some athletic trainers may have viewed the study e-mail as “junk” mail. Moreover, as this study focused on adherence issues in a collegiate athletic context, generalizations to other athlete populations and competitive levels cannot be made. Fourth, the fact that only a portion of the participants provided responses to the open-ended questions suggests that the qualitative findings reported here represent the views of a small to moderate percentage of the overall sample. That said, the number of athletic trainers providing comments (n = 121 and 49) enabled saturation (ie, repetition) of key themes,37 a key objective of any qualitative study. Finally, differences in athletic trainer perspectives might be pres-ent across different participation levels (eg, NCAA vs National Junior College Athletic Association [NJCAA]), an issue we did not examine, given the qualitative nature

of the study. Such differences remain a fruitful area for further research. These limitations notwithstanding, the findings from this investigation highlight important intra-individual (eg, motivation) and environmental factors (eg, patient–practitioner rapport, communication) influencing rehabilitation adherence and suggest strategies for achiev-ing optimal adherence levels.

Suggestions for Future Research

A number of promising avenues for future research arise from the present investigation. First, researchers should examine the prevalence of underadherence and overadherence among various athlete populations (eg, cross-cultural studies) and participation levels (eg, youth sport, college divisions including NCAA and NJCAA, and professional). Second, while findings from the current study suggest the potentially detrimental conse-quences of overadherence, further research correlating overadherence behaviors with maladaptive clinical or functional outcomes would be informative. Prospective designs following athletes over the course of their injury rehabilitation would be useful toward this end. Third, based on the high rates of rehabilitation underadher-ence and (to a lesser extent) overadherence reported by participants, additional investigation examining the effectiveness of interventions for ensuring optimal adherence with practitioner guidelines should be con-ducted. For instance, research examining the adherence benefits of providing a rationale for injury exercises and rehabilitation protocols is warranted. In assessing the effectiveness of particular interventions on rehabilitation adherence, researchers and practitioners should employ questionnaires that have been validated within the spe-cific context of intercollegiate athletics. To this end, we suggest using the Rehabilitation Adherence Measure for Athletic Training.5 The measure, consisting of 16 items and 3 subscales (attendance/participation, communica-tion, and attitude/effort), may be used to obtain overall rehabilitation rates and/or track individual athletes’ rehabilitation adherence. Overadherence, in particular, has received little attention in the literature1 and should continue to be investigated. In response to the lack of research related to overadherence, the Rehabilitation Overadherence Questionnaire38 was developed and may be useful for rehabilitation practitioners to identify overadherent athletes. The questionnaire contains 10 items in 2 subscales (ignore practitioner recommenda-tions and attempt an expedited rehabilitation). Fourth, a deeper appreciation of athlete perspectives regarding the reasons driving overadherence would help shed light on important overadherence antecedents. Theoretical models may be used to shape such research.39 Finally, gender differences in athletic trainers’ perception of athlete rehabilitation adherence remains a fruitful area for future research.

132 Granquist et al

One cautionary note for further research relates to the importance of establishing consistent and accurate terminology when describing athlete adherence. Although we have employed the terms underadherence and overad-herence, the terms may obscure the fact that both reflect a certain degree of nonadherence (ie, not following the athletic trainers’ instructions).5 The concepts of underad-herence and overadherence are important to distinguish as opposite points of the nonadherence continuum because they have not been differentiated thus far in the litera-ture and there are likely different factors driving these behaviors. Understanding the precursors of each remains a fruitful avenue for further empirical investigation and in the development of prevention strategies.

ConclusionsThe findings of this study underscore the importance of addressing intrapersonal (eg, motivation), interpersonal (eg, patient–practitioner interactions, coach support), and injury-specific factors (eg, injury severity, sport type) in fostering athlete rehabilitation adherence. The high incidence of athlete nonadherence reported by partici-pants in this investigation may be problematic insofar as rehabilitation outcomes may be compromised. Findings reinforce the need for the use of rehabilitation practitio-ner strategies in enhancing rehabilitation adherence. By educating athletes about their injuries and the rehabili-tation process, by developing good rapport through the provision of social support and effective communica-tion, by encouraging coaches to take a positive role in their athletes’ rehabilitation, and by addressing athletes’ intraindividual characteristics such as motivation toward rehabilitation, rehabilitation practitioners can promote optimal rehabilitation adherence.

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