EXAMINING REHABILITATION ADHERENCE. Jessica L. Kirby, MSEd, LAT, ATC Jessica L. Rager, MS, LAT, ATC, PES, CES

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1 EXAMINING REHABILITATION ADHERENCE Jessica L. Kirby, MSEd, LAT, ATC Jessica L. Rager, MS, LAT, ATC, PES, CES

2 Disclaimer Neither presenter of this seminar have financial or other associations with the tools used in this presentation The views presented in these slides and today s discussion are our own Participants should use discretion when using the information contained in this presentation

3 Objectives In this presentation, learners will Apply the Cognitive Appraisal Model to conceptualize rehabilitation adherence Interpret adherence assessment tools Implement interventions to address rehabilitation adherence 3

4 Understanding Adherence Adherence is an active, voluntary collaborative involvement of the patient in a mutually acceptable course of behavior to produce a desired preventative or therapeutic effect 1 Definition of adherence tends to vary (clinician to clinician; study to study) 2 Intuition vs Reality Intuitively believe adherence is important but not every patient is always a great adherer 4

5 Adherence in the Literature Much of the literature regarding adherence % was completed in the 1990s 61% % 4 Current literature tends to focus on the perceptions of the clinicians providing rehab services 98% of ATs reported adherence is an issue 5 99% of ATs reported they had worked with a patient who demonstrated adherence issues 5 Mixed results (qual) but physiotherapists suggest adherence can be an issue 1 5

6 Sue is a 20 y/o female, a junior, and the starting outside hitter on the volleyball team Her team is attempting to defend its 3 rd consecutive conference championship Midway through season, Sue suffered an Achilles Tendon rupture while loading to hit the ball Sheath intact- underwent open Achilles Tendon repair This is Sue s first season-ending injury every Today Sue is 1 month post-op and cleared to begin rehabilitation Significant atrophy of lower leg musculature Surgeon s protocol calls for a 6-8 month rehab Sue is very worried this is too long because she wants to return in the fall

7 Cultural Shift Following Injury Uninjured Athletes Familiar activity Familiar rules Familiar field Veteran player Familiar pain Coach in charge Instant feedback Control Measure success Vigorous 7

8 Cultural Shift Following Injury Uninjured Athletes Familiar activity Familiar rules Familiar field Veteran player Familiar pain Coach in charge Instant feedback Control Measure success Vigorous Injured Athletes In Rehab Unfamiliar activity Unfamiliar rules Unfamiliar area Rookie player Unfamiliar pain AT in charge Feedback deferred Loss of control Different measure Loss of vigor 8

9 Conceptualizing Injury To help us conceptualize injury and how injury influences function, we will use three models World Health Organization s International Classification of Function Disablement Model (ICF) 6 Cognitive Appraisal Model 7 Integrated Model of Response to Sports Injury 8 9

10 WHO s ICF Disablement Model 6 10

11 The Cognitive Appraisal Model 7 11

12 The Integrated Model of Response to Sport Injury 8 12

13 Understanding Adherence Adherence describes voluntary, active engagement with the protocol Over vs. Under adherence Under adherence: More commonly examined Poor attendance Noncompliance with protocol Over adherence: Over-motivated, do whatever it takes mentality Similar to overtraining Increased frequency, duration, or intensity with rehabilitation exercise 9 13

14 Poor Adherence Top They cheat! Don t complete all sets and reps 2. Don t follow instructions (e.g., leave their crutches in their room or wear heels to the club post-ankle sprain) 3. Workout with the team without approval (e.g., core workouts/lifting) 4. Complete exercises with terrible form 5. Come in late and/or leave early 6. No focus- distracted during rehab 7. Don t show up! 8. Rush through exercises 9. Don t complete HEP at all 10. Increase HEP 14

15 Now Sue is 4 months into her rehabilitation Full weight-bearing and ambulating normally without assistance Nearly normal ROM but you ve noticed a plateau in strength and proprioceptive gains Sue seems frustrated during treatment and expresses annoyance with length of rehab Complains exercises are boring and not hard enough Volleyball team has started spring workouts Team is supportive but Sue feels like she s missing out and was not voted team captain like she expected Sue complains of increased soreness following rehab You learn she doubled her HEP, started doing core workouts with the team, and began conditioning on her own at home without your consent 15

16 The Cognitive Appraisal Model 8 16

17 Personal Factors Personal factors are numerous and varied 5 Personality, athletic identity, pain tolerance, injury hx, etc. These are difficult to control or influence Research has linked several personal factors to adherence Motivation 5 Belief about the injury 10 Feelings towards the injury and rehab process 10 We are going to focus on a couple of examples, mental toughness and athletic identity Correlated to rehab adherence in literature

18 Mental Toughness Described in 4 factors 14 Control, commitment, challenge, and confidence Belief in ability to manage one s surroundings and influence them Individuals with high levels of mental toughness 12 Believe injuries are less severe and less likely to reoccur Cope with pain more easily Are not always compliant and exhibit poorer rehab performance Individuals with low levels of mental toughness 12 Have a harder time with pain Are more likely to adhere to rehab protocols and perform well in rehab 18

19 Athletic Identity Degree to which one s self is defined by participation in sport Linked to poor response to injury Correlated to overadherence behaviors 11,13 Injury disrupts a greater portion of an individual s identity Lack of participation Body changes (e.g., muscle atrophy, loss of fitness) Dynamics with team/social support change 19

20 Situational Factors Maybe a little easier to control than personal factors Should be noted, some of these examples are specific to athletics Influence of coach on environment 5 Does he/she hold the athlete accountable for attendance? What type of support does he/she provide? System of social support ATs can provide a pivotal source of support during rehab 5 Patient education 5 Level of understanding of the process as a whole Understanding each exercise- particularly HEP 5,10 20

21 So What Do We Do? Research suggests we recognize adherence can be a problem 5,15 It is important we do so early Addressing adherence concerns begins with identifying potential threats Determine best way to handle each concern and move forward Personal and situational factors may require different approaches 21

22 Adherence Assessment Clinical measures provide a simple way to measure progress and adherence Attendance Exercise progression (e.g., ROM, strength, etc.) Patient oriented measures may provide a supplement HRQL or Region/Condition specific PROs not specific to adherence Adherence specific outcomes quantify what is usually a quick reaction Sport Injury Rehabilitation Scale Rehabilitation Adherence Measure for AT 2 22

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25 Tips & Tricks - Personal Factors Addressing Mental Toughness 12,18 High levels of mental toughness may link to over-adherence Needs to be intentional and may involve other members of sports med team Teach mental skills and allow patients to practice them real-time Self-talk, relaxation, etc. Keeping patients connected Relaxation 19 Breathing Control: various exercises but provide ways for patients to relax and release stress and/or negative thoughts 25

26 Relaxation - Centering 19 Stand with your feet shoulder-width apart and bent the knees slightly. Relax your neck, arms, and shoulder muscles. Direct your thoughts inwards to check and later your muscle tension and breathing by focusing on the abdominal muscles and how they expand as you breathe in. Try to feel the heaviness in your muscles. Take a slow, deep breath (from the diaphragm), trying to limit the movement of the chest cavity. Concentrate on your breathing and the heaviness of your muscles, clearing the mind of all irrelevant thoughts, and say relax. Now focus your attention on the rehabilitation activity and what you need to do to perform it. 26

27 Tips & Tricks - Personal Factors Addressing Patient Characteristics Use of PROs may allow better understanding of individual concerns Important to treat patients individually Imagery 20 Several types (e.g., healing, pain management, performance, etc.) Pain management- encourage patient to create images of being pain free Performance (most common)- encourage patient to create images of performing sport specific skills Performance imagery may increase motivation 27

28 Tips & Tricks - Situational Factors Building Rapport & Making Rehab Understood Be open and up front with patients regarding rehab Explain the process fully and in easily understood terminology Allow time for the patient to ask questions Demonstrate new exercises and activities Be willing to including all members of the sports med team (e.g., coaches or sport psychologists) Goal setting 5,15 Combine short and long term Be realistic Keep them fresh 28

29 So What Do We Do About Sue? What concerns, if any, do we have about Sue at this point? What can we do to help Sue? What else might we want to know about Sue and her case? Are there other people we need to involve? Who? What might be some of our goals for Sue moving forward? 29

30 Now Sue is 4 months into her rehabilitation Full weight-bearing and ambulating normally without assistance Nearly normal ROM but you ve noticed a plateau in strength and proprioceptive gains Sue seems frustrated during treatment and expresses annoyance with length of rehab Complains exercises are boring and not hard enough Volleyball team has started spring workouts Team is supportive but Sue feels like she s missing out and was not voted team captain like she expected Sue complains of increased soreness following rehab You learn she doubled her HEP, started doing core workouts with the team, and began conditioning on her own at home without your consent 30

31 So What Do We Do About Sue? What concerns, if any, do we have about Sue at this point? Overadherance to protocol- doing too much, too fast without consulting us What can we do to help Sue? More education about the process as a whole (i.e., why these exercises and why this timing) Change up the exercises to help her feel more engaged Intentional about measuring Sue s adherence Are there other people we need to involve? Who? Sports psychologist if available Coaching staff Surgeon/team physician What might be some of our goals for Sue moving forward? Improve rehab adherence (via greater levels of education/understanding) Help Sue find new ways to engage with the team 31

32 Closing Remarks Don t write patients off based on adherence behaviors Interventions should be patient-centered and individualized, incorporating personal and situation factors Assessments/interventions typically not expensive or time consuming Have to be intentional about measuring adherence and addressing adherence concerns 32

33 References 1. Niven A. Rehabilitation adherence in sport injury: Sports psysiotherapists perspective. J Sport Rehabil. 2007;16: Granquist MD, Gill DL, & Appaneal RN. Development of a measure of rehabilitation adherence for athletic training. J Sport Rehabil. 2010;19: Byerly PN, Worrell T, Gahimer J, & Domholdt E. Rehabilitation compliance in an athletic training environment. J Athl Train. 1994;29(4): Brewer BW. Adherence to sport injury rehabilitation programs. J Appl Sport Psych. 1998;10(1): Granquist MD, Podlog L, Engel JR, & Newland A. Certified athletic trainers perspectives on rehabilitation adherence in collegiate athletic training settings. J Sport Rehabil. 2014;23: World Health Organization. Towards a Common Language for Functioning, Disability, and Health: ICF. Geneva, Switzerland: World Health Organization;

34 References 7. Brewer BW. Cognitive appraisal model of psychological adjustment to athletic injury. J Appl Sport Psych. 1994;6: Wiese-Bjornstal DM, Smith AM, & Morrey MA. An integrated model of response to sport injury: Psychological and sociological dynamics. J Appl Sport Psych. 1998;10(1): Frey M. The other side of adherence: Injured athletes who are too motivated. Athl Therap Today. 2008;13(3): Marshall A, Donovan-Hall M, & Ryall S. An exploration on athletes views on their adherence to physiotherapy rehabilitation after sport injury. J Sport Rehabil. 2012;21: Hilliard RC, Blom L, Hankemeier DA, & Bolin J. Exploring relationship between athletic identity and beliefs about rehabilitation overadherence in college athletes. J Sport Rehabil. 2017;26: Levy AR, Polman RCJ, Clough PJ, Marchant D, & Earle K. Mental toughness as a determinant of beliefs, pain, and adherence in sport injury rehabilitation. J Sport Rehabil. 2006;15(1): Podlog L, Gao Z, Kenow L, et al. Injury rehabilitation overadherence: Preliminary scale validation and relationships with athletic identity and self-presentation concerns. J Athl Train. 2013;48(3):

35 References 14. Clough P, Earle K, & Sewell D. Mental toughness: The concept and its measurement. In: Cockerill, I, ed. Solutions in Sport Psychology. London, UK: Thomson: 2002: Clement D, Granquist MD, & Arvinen-Barrow M. Psychosocial aspects of athletic injuries as perceived by athletic trainers. J Athl Train. 2013;48: Brewer BW, Avondoglio JB, Cornelius AE, et al. Construct validity and interrater agreement of the sport injury rehabilitation adherence scale. J Sport Rehabil. 2002;11: Brewer BW, Van Raalte JL, Petitipas AJ, et al. Preliminary psychometric evaluation of a measure of adherence to clinic-based sport injury rehabilitation. Phys Ther Sport. 2000;1(3): Weinberg R, Freysinger V, Mellano K, & Brookhouse E. Building mental toughness: Perceptions of sports psychologists. The Sports Psychologist. 2016;30: Walker N & Heaney C. Relaxation techniques in sport injury rehabilitation. In Arvinen-Barrow M & Walker N (Eds.), The psychology of sport injury and rehabilitation (86-102) New York, NY: Routledge. 20. Arvinen-Barrow, M., Clement, D., & Hemmings, B. (2013). Imagery in sport injury rehabilitation. In Arvinen- Barrow, M. & Walker, N (Eds.), The psychology of sport injury and rehabilitation (71-85). New York, NY: Routledge. 35

36 Questions?

Mental Toughness as a Determinant of Beliefs, Pain, and Adherence in Sport Injury Rehabilitation

J Sport Rehabil. 2006,15, 246-254 2006 Human Kinetics, Inc. Mental Toughness as a Determinant of Beliefs, Pain, and Adherence in Sport Injury Rehabilitation Andrew R. Levy, Remco C.J. Polman, Peter J.