URJHS Volume 7


The Psychological Aspect of Rehabilitation Adherence in Collegiate Athletes

Kristen Michelle Stash
California University of Pennsylvania

Keywords: adherence, injury rehabilitation, rehabilitation compliance, psychology of injury, athletic injury.


This paper discusses the role of the certified athletic trainer in social support and psychological counseling of athletes. The relationship of adherence to rehabilitation is defined, and the psychological components are described. The merits of two measures of adherence are reported.

The Role of the Certified Athletic Trainer

Successful athletic injury recovery and return to play are outcomes of adherence to the rehabilitation program set in place by the certified athletic trainer (ATC). The athlete needs to heal both the mental and physical aspects of the injury in order to fully recover. Very often the ATC is in the position to provide psychological support to the injured athlete and implement the rehabilitation program (Barefield, 1993). Therefore, the ATC needs to be educated on ways in which to provide emotional support to the athlete following an injury. Listening to the athlete without passing judgment is a way clinicians show that they care and understand what the athlete is going through (Barefield, 1993). The athlete may experience a variety of emotions after sustaining an injury, such as anger, fear, depression, stress, anxiety, and guilt, all of which contribute to noncompliance in rehabilitation. The ATC is frequently the person who comes in contact with the athlete on a daily basis and therefore will be in a position to provide counseling to the athlete throughout the injury rehabilitation process (Wagman, 1996).

Several guidelines have been proposed for the clinician to use when counseling injured athletes. Before the clinician can begin counseling, the clinician must have a good relationship with the athlete and the athlete must be able to trust the clinician. Once this is established, the clinician can begin the initial consultation with the athlete. The clinician can begin by asking athletes questions about the injuries: how they feel about it, how they feel about their future, the emotions they have, and what fears they may be experiencing (Wagman, 1996). Once this is accomplished the clinician can begin to affect management of the rehabilitation process, which involves athletes expressing and dealing with their emotions regarding their injuries. The next step of the counseling process is developing good communication between the athlete and the medical staff. The athlete should have a thorough understanding of his or her injury and the rehabilitation process for recovery (Wagman, 1996). It is further suggested that the clinician provide psychological support to the athlete in regards to the information that has already been provided thus far in the counseling process. Not only the clinician but also the athlete’s family, friends, and coaches can provide social and emotional support to the athlete. In the last step of the counseling process, the clinician’s role is to lessen any fears the athlete may have about returning to his or her sport (Wagman, 1996).

Psychological Factors that Enhance Adherence in Rehabilitation

Adherence is defined by De Heredia as “the injured person’s level of compliance with medically prescribed rehabilitation plans.” Duda describes it as “a composite of attendance at prescribed sessions, degree of completion of the prescribed protocol, and the athlete’s intensity of effort exerted in performing the prescribed exercise” (De Heredia, 1994, Duda, 1989).

Adherence to rehabilitation protocols provides successful recovery and return to play. Several factors have been suggested to enhance adherence in sport rehabilitation. Self–motivation has been suggested as a good predictor of rehabilitation adherence along with reinforcement from the ATC (Byerly, 1994). Another factor believed to influence adherence is patient education. Researchers suggest that well developed communication between the athlete and ATC also provides positive rehabilitation adherence (Byerly, 1994).

A research study conducted on fifty-two collegiate athletes and six athletic trainers revealed that 52% of the athletes did not believe that they understood the rehabilitation program that was associated with their injury (Kahanov, 1994). Conclusions from the study revealed that ATC’s need to be more aware of the possibility of miscommunication and need to provide athletes with a better understanding of their injury and rehabilitation process (Kahanov, 1994).

Mental toughness is another psychological component that was studied to determine its affect on rehabilitation adherence. It is suggested that mentally tough athletes will have better attendance rates than those that are not. However, a study also revealed that although being mentally tough has its benefits in rehabilitation attendance rates, having a high level of mental toughness could have a negative outcome on behavior in the rehabilitation setting and recovery (Levy, 2006). Communication and motivation have been found to be very important in adherence to rehabilitation programs. It is believed that if an athlete plays an active role in his/her rehabilitation process, commitment and motivation levels towards the rehabilitation program will increase (Wayda, 1998).

Another very important way to enhance rehabilitation in injured athletes is through the use of goal setting. Goal setting can assist in a faster return to play, motivate the athlete in persistence and effort, give the athlete a sense of accomplishment during the rehabilitation process, and increase adherence to the rehabilitation program. Successful goal setting is achieved through the use of a systematic approach (Wayda, 1998). The systematic approach is needed to increase the commitment and motivation of the athlete towards their rehabilitation program. Effective goal setting can also increase the athlete’s self-confidence, lower the level of anxiety of the athlete by centering on what needs to be accomplished, separate the rehabilitation process into smaller more manageable steps, and hold the athlete responsible for a given standard of performance (Wayda, 1998).

Measurements of Adherence in Athletes

Several methods have been used in various studies to measure sport rehabilitation adherence in injured athletes. These testing methods include surveys, questionnaires, self-reports, and clinician reports. The major issue with the measurement of adherence is the reliability of the methods (Brewer, 2002). The Sport Injury Rehabilitation Adherence Scale (SIRAS) is a three item questionnaire, scored on a five point Likert-type scale, which measures the level of exertion a patient puts forth, the degree to which the patient is compliant to the clinician’s instructions and advice, and how receptive the patient is to changes that the clinician incorporates into the rehabilitation program during a particular rehabilitation session (Brewer, 2002). Studies that used SIRAS as their method of measurement found the scale to be efficient and reliable in measuring sport rehabilitation adherence. This scale can be used in the clinical setting to assess the patient’s adherence to rehabilitation activities over a period of time, detect patients who may be experiencing difficulty in adhering to treatment protocols, and assess the correlation between adherence to clinical rehabilitation and rehabilitation outcomes (Brewer, 2002).

In several studies the RAQ was used to measure rehabilitation adherence. The RAQ is a self–report record with various subscales that are used to evaluate seven components. The seven components are perceived exertion, self-motivation, support from significant others, scheduling, and environmental conditions (Brewer, 1999). The RAQ has been limited in two ways in previous studies conducted. First, because of their design, the studies were not capable of establishing a time-order relationship amongst the psychological factors assessed by the RAQ and rehabilitation adherence. Secondly, it cannot be interpreted that the subscales and design of the RAQ are consistent measures of rehabilitation adherence because no reliability and validity data have been reported for the RAQ in previous studies (Brewer, 1999). Other reasons why the RAQ is not a strong measurement of adherence is the deficiency in internal consistency within the subscales of the questionnaire as well as the criterion related validity.

It is suggested that until validity and reliability are proven with use of the RAQ, researchers should proceed with caution in their use of this tool to measure sport rehabilitation adherence. By providing reliability testing and being more attentive to measurement problems in future research, consistency and validity can be established in future methods of sport rehabilitation measurements, thus improving the rehabilitation process for injured athletes (Brewer, 1999).


The Certified Athletic Trainer (ATC) plays an important role in injury recovery and return to play by focusing on the psychological aspect of rehabilitation. Collaboration among the athlete, the medical staff, and the ATC is required for adherence to the protocol and for a positive outcome of the rehabilitation process.


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Kahanov, L., & Fairchild,C. P. (1994). Discrepancies in perceptions held by injured athletes and athletic trainers during the initial injury evaluation. Journal of Athletic Training, 29 (1), 70-75.

Levy, A. R., Polman C. J., Clough, P. J., Marchant, D. C., & Earle, K. (2006). Mental toughness as a determinant of beliefs, pain, and adherence in sport injury rehabilitation. Journal of Sport Rehabilitation, 15, 246-254

Wagman, D., & Khelifa, M. (1996). Psychological issues in sport injury rehabilitation: current knowledge and practice. Journal of Athletic Training, 31, 257-261.

Wayda, K. V., Armenth-Brothers, & F., Boyce, A. B. (1998). Goal setting: a key to injury rehabilitation. Athletic Therapy Today, 21-25.



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