RUNNING HEAD: REHABILITATION ADHERENCE 1

A Literature Review of Rehabilitation Adherence in the Collegiate Athletic Training Setting

Justin Logan

Siena Heights University

October 9, 2016
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Background

The purpose of an athletic trainer is to provide health care for an athletic population

which includes everyone from children to elderly patients and third string high school athletes to

starting professional players. Having this broad of a population to work with comes with a wide

set of issues, one that seems to be the most common is an adherence to rehabilitation programs

set by either physical therapists, athletic trainers, or a similar sports medicine specialist.

Athletic Training Profession

Athletic Training Responsibilities. The field of athletic training is an allied health care

profession that is recognized by the American Medical Association. Athletic Trainers have a set

of domains that every athletic trainer needs to be proficient at and knowledgeable in, in order to

sit for their board of certification exam to become a certified athletic trainer (Board of

Certification, 2010).

Injury/Illness Prevention and Wellness Protection. This domain of athletic training is

what the general population think. It includes the responsibilities of taping, hydration and

nutrition, and over the counter medicine dispersal. Education is also a major part of this domain

in order to ensure that the athlete knows why these are important (Board of Certification, 2010).

Clinical Evaluation and Diagnosis. This domain is where the athletic trainer forms a

diagnosis of either a musculoskeletal injury, an illness, or a skin pathology using standard and

appropriate techniques and equipment. The athletic trainer must then determine the appropriate

course of action going forward; whether referral to a physician is necessary or setting the athlete

up with a rehabilitation plan (Board of Certification, 2010).

Immediate and Emergency Care. First aid and cardiopulmonary resuscitation (CPR)

techniques are the staples for this in domain. In the case of an emergency in the middle of either
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practice or a competition, an athletic trainer must be proficient in not only these techniques, but

also bracing techniques, splinting techniques, developing and implementing an emergency action

plan, etc (Board of Certification, 2010).

Treatment and Rehabilitation. The athletic trainer must be highly knowledgeable in the

response to injury, factors that predispose an athlete to injury, and how to safely and efficiently

rehabilitate an injury with therapeutic exercises and modalities (i.e. electrical stimulation).

(Board of Certification, 2010)

Organizational and Professional Health and Well-Being. The responsibilities of this

domain is the least known and thought of domain but one of the most important. This is where

the documentation and legalities are defined. This is where it is explained how an athletic trainer

must conduct himself or herself in regards to legalities. (Board of Certification, 2010)

Outline

1. What are collegiate athletes' perspectives on injury and rehabilitative exercises?

1. What are some factors that lead to injury?

2. How do athletes respond to injury?

3. How compliant are athletes according to themselves?

4. What do athletes not like about rehabilitation?

2. What are the certified athletic trainers perspectives?

1. How compliant are athletes according to athletic trainers?

2. What do athletic trainers think is the reason for non-compliance?

3. How can athletic trainers improve their problem?

3. What techniques can athletic trainers use to improve adherence rates?

1. What factors lead to adherence?

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2. What different aspects of athletic rehabilitation can be controlled better?

Literature Review

Athlete's Perspective

Factors that Lead to Injury. Weinberg and Gould (2011) suggest that athletes push

themselves to the point of injury and often times will ignore rehabilitation because of pressure of

the coaches and other athletes. The injured athlete will deny injury because they feel pressure to

be a winner and it gets misconstrued that an injury will prevent them from being a winner.

Wilkerson and Colston (2015) add that collegiate football players had a higher incident of

sprains and strains for simply playing longer than others. Verhagen, van Stralen, and van

Mechelen (2010) add say that the athlete's personality and behavior are some of the strongest

predictors for injury. If the athlete is more braggadocios, then they will be more likely to over

perform. Behavior also alludes to nutrition habits and lifestyle choices. Allowing the body to

gain the necessary nutrients and vitamins naturally will allow for the body to maintain proper

balance and optimum strength.

Mensch and Miller (2008) state that the athlete will push themselves farther than their

body is physically able to or stress the muscles and bones more than they can handle for a few

reasons. One of which is that they are a borderline player in either their own eyes or the coaches

eyes. This athlete will try to prove to himself, the coach, and the other athletes that they are better

than previously thought and over exert themselves. Another theory presented by Mensch and

Miller (2015) is that an athlete may feel too confident in their ability and choose to go easy

through the next play and then get hurt because everyone else was going all out. Cramer Roh and

Perna (2000) seem to agree with this and also add on that athletes are more prone to injury if
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they are distracted with life stressors. Regardless of gender or sport, athletes with a higher level

of stress in life had a positive correlation with injury occurrences.

Athletes' Response to Injury. Arvinen-Barrow, Massey, and Hemmings (2014)

interviewed professional athletes to find out what some of the psychosocial responses to injuries

are and what they expect of the sports medicine professionals they work with. Arvinen-Barrow et

al (2014) states that the most common themes following an injury is self-doubt and frustration.

That being said, the athletes understand and accept that injuries come with the territory, but this

still does not help with the emotional response to an injury. Rapport is also a big factor according

to the athletes. Arvinen-Barrow et al also suggest that the more rapport a sports medicine

professional has with an athlete, the more compliant the athlete will be because of the trust and

relationship.

Psychosocial Response. Clement, Arvinen-Barrow, and Fetty (2015) conducted

interviews with athletes that were injured for at least six weeks and fully recovered within the

average time recommended per specific injury. They found some commonalities in each athlete

and broke the psychological responses into three different phases.

Phase 1. The first phase is the initial reaction to the injury itself, which is overly negative

up until the athlete's injury is formally diagnosed. The injured athlete tends to seek out something

of a social support system (Clement et al, 2015).

Phase 2. The second phase is their reaction to the rehabilitation. The main feelings

initially in athletes about starting to enter the rehabilitation phase was frustration and caution.

The subjects had multiple worries about the process starting with questioning the process itself;

wondering if it was doing anything, if there was any value in completing the rehabilitation
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process, and the perceived difficulty of the exercises. Once again a common, strong theme is

social support from teammates, coaches, friends, and family (Clement et al, 2015).

Phase 3. The third and final phase is the reaction to their return to sport. The athletes

interviewed all had some sense of positive and negative reactions to being allowed to fully return

to their sport of choice after being fully rehabilitated. There was a nervousness in each about re-

injury and still doubt that the rehabilitation process was not fully successful. These feelings

evolved to fear and led to the athletes being overly cautious during the first few practices and not

exerting themselves (Clement et al, 2015).

Kbler-Ross Model. The Kbler-Ross model is the description of the five stages a

person goes through with grief, specifically with dying or an unexpected death. The stages go in

the following order; denial, anger, bargaining, depression, acceptance. Some athletes will follow

these steps following what they would perceive to be a devastating or catastrophic injury

(Prentice & Arnheim, 2009).

Athletic Trainer's Perspective

A study by Clement, Granquist, and Arvinen-Barrow (2013) attempted to use a mixed

method questionnaire to ask athletic trainers about the psychological responses athletes have

towards injury, the ways athletes cope, how athletic trainers help with psychosocial strategies,

which psychosocial strategies these athletic trainers feel are more important and effective than

others, and how/when athletic trainers refer athletes to counselors and sport psychologists. What

this study showed is that the athletic trainers in this study mostly agreed with what Clement et al

(2015) said. There were very similar results in the athletic trainers' perceptions of what the

athlete was going though. Clement et al (2013) states that the top three responses for what the
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psychological responses of an athlete, from the perspective of an athletic trainer, are stress/

anxiety, anger, and treatment compliance issues.

Although some athletes will have the responses already mentioned by Clement et al

(2013), Clement et al (2015), and Weinberg and Gould (2011), Prentice & Arnheim (2009)

suggest that an injured athlete has three different responses. The first way is that the athlete may

look at it as a catastrophic moment and ruin them. The second way is that the athlete can look at

it as a way to be strong and courageous and prove to themselves, their teammates, and the

coaches that they can come back from it as good if not better than pre-injury. The third reaction

is to embrace the injury as an excuse and reason for losing, performing poorly, or to reduce

pressure from outside sources.

Over-Adherence. Granquist, Podlog, Engel, and Newland (2014) found in a study that

97.1% of athletic trainers have reported that there is a problem with over-adherence. A

questionnaire was developed by Podlog, Gao, Kenow, Kleinert, Granquist, Newton, and Hannon

(2013) to attempt to determine how much over-adherence there is and what the reasons are. One

of these reasons is that the injured athlete that identifies themselves more as an athlete will try to

get back to being on the field faster. The athlete will ignore the athletic trainer and return to play

much sooner than recommended. The same type of athlete will also increase the amount of

rehabilitation done on their own because they think that if a little is good, then a lot must be

better. This will actually cause the injury to take longer to heal. Podlog et al (2013) suggests that

the main point of over-adherence is the high level of athlete-identity. If an athlete gets injured,

they will lose their sense of self and develop a sense of loss. In order to find that sense of self and

relocate the identity the athlete feels has been lost. This could lead to the athlete shortening
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rehabilitation without being cleared or doing too much rehabilitation (Mensch & Miller, 2008)

(Podlog et al, 2013) (Prentice & Arnheim, 2009).

Techniques to Improve Adherence

It is a standard concept that athletic trainers believe that rehabilitation adherence is an

issue and needs to be improved. In a study by Granquist et al (2014), 98.3% of almost 500

athletic trainers reported that they had a problem with rehabilitation adherence.

There are many different ways that athletic trainers have tried to develop in order to

increase rehabilitation compliance, but according to Beneka, Malliou, Bebetsos, Gioftsidou,

Pafis, and Godolias (2007) there are a few specific ways that can improve rehabilitation

adherence. These ways to improve patient compliance are education, progress recording, goal

setting, relaxation, and imagery.

Education. The first way is by educating the patient. In most cases, an educated patient is

a compliant patient because if they understand the methodology of the process, then they will be

more likely to adhere to the exercises (Prentice & Arnheim, 2009). Education does not only

mean to education about the process, but also about the different types of pain rehab can cause. If

the patient has not received many injuries, they may not understand the difference between what

sports medicine professionals call good pain and bad pain and this may need to be explained

to them. Another point of education should be about potential setbacks and delays in the

rehabilitation process. Making sure to talk about these possibilities will help alleviate any extra

stress and frustration an athlete may have with their attempt to get back into the game (Beneka et

al, 2007).

Goal Setting. Setting goals should be one of the first things that an athletic trainer and

their patient does after the initial diagnosis. Coming up with a plan of attack and following
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through with that plan will be much easier if the athlete has a say in what they want to

accomplish and by when (Coppack, Kristensen, & Karageorghis, 2012). Although Coppack et al

(2012) found that there was only a slight improvement in adherence rates when using goal

setting techniques, Beneka et al (2007) argues that setting goals give the athletes a marker to aim

for.

Progress Recording. Going hand in hand with goal setting, Beneka et al (2007) says that

progress records help motivate patients and athletes when they hit the goals set by both the

clinician and the patient. At the same time, if they are shy of a goal by a few degrees of range of

motion the shortcoming can help them push through to get to their goal. It has been found by the

interviews performed by Clement et al (2015) that some of the athletes, upon finding out they are

shy of their goals, will become discouraged about doing the rehabilitation so these researches

recommend that reasonable goal setting needs to be on the forefront of the patients minds when

collaborating on the goals.

Relaxation. Often times during and after an injury an athlete will become hesitant to let

the sports medicine professional touch the injury or attempt to use diagnostic tests and

equipment. The athlete will subconsciously perform what health care providers call muscle

guarding (Prentice & Arnheim, 2009). This does not only occur when being tested and

diagnosed, but also when the athletic trainer or physical therapist is doing a manual rehabilitation

technique, such as stretching or a sports massage (Beneka et al, 2007). A technique that is highly

effective is called progressive relaxation and is useful in not only stress and anxiety caused by

sports and rehabilitation, but in any facet of life. Progressive relaxation allows the patient to take

control of their breathing and muscles and helps to relieve built up tension through breathing

exercises and physical contraction of the muscles (Mensch & Miller, 2008)
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Imagery. The final technique recommended by Beneka et al (2007) is using imagery.

Mensch and Miller (2008) states that this technique can be used in a few ways. The first way is

to allow the patient to visualize them doing their sport or job the proper way before being able to

do it without restrictions, to take mental reps. The second way is to allow the athlete to imagine

what the body is doing on a cellular level as it can allow the athlete to focus on the good of what

the treatment is doing and take the focus away from the pain or other negative stressors.

Cressman & Dawson (2011) says that healing imagery can be an effective tool when used with

other internal techniques such as relaxation and positive self-talk. This study found in interviews

with athletes that the athletes did not necessarily reduce time to fully recover, but the athletes that

used healing imagery did report that there were many positive results from using this technique.

There was a much higher level of confidence, there was more motivation, increased awareness of

the injury, the athlete was more relaxed, a higher rate of rehabilitation adherence, there was

more focus on the goals, and a lower amount of frustration with the rehabilitation process.
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