Adherence to sport injury rehabilitation programs: an integrated psycho-social approach

Adherence of individuals with shoulder pain to home exercise booklets: Barriers, facilitators, and the impact of disability, self-efficacy, and treatment expectations

BACKGROUND

home exercise booklets offer several benefits to individuals with shoulder pain. However, it is necessary to investigate the factors that determine adherence to home exercises.

OBJECTIVES

1) To investigate the level of adherence of individuals with chronic shoulder pain to a home exercise booklet conducted without the mediation of a healthcare professional, 2) To describe the barriers and facilitators to adherence, and 3) to determine if shoulder disability, self-efficacy, and treatment expectations are predictors of the level of adherence.

DESIGN

prospective longitudinal study.

METHODS

A total of 47 individuals with chronic shoulder pain were recruited. The Numeric Pain Rating Scale (NPRS) was used to assess pain intensity, the Shoulder Pain and Disability Index (SPADI) to measure shoulder disability, the Pain Self-Efficacy Questionnaire (PSEQ-10) for self-efficacy, and a likert scale to measure treatment expectations. Adherence was measured by Exercise Adherence Assessment Scale (EAAE-Br).

RESULTS

A total of 23 individuals (48.93%) adhered to the home exercise program. The most commonly cited barriers were pain and health-related issues, while the most cited facilitators were pain improvement and symptom relief. Barriers associated with adherence were time constraints and other commitments, while the facilitator associated with adherence was enjoying the exercises. Binary logistic regression analysis revealed that shoulder disability, self-efficacy, and treatment expectations were unable to predict adherence to home exercises in individuals with shoulder pain [F (1,47) = 2.384; p = 0.130; R2 = 0.056].

CONCLUSION

The study revealed barriers and facilitators to home exercise in individuals with shoulder pain. Disability, self-efficacy, and treatment expectations were not able to predict adherence.

Behaviour change and rehabilitation adherence in adults with tendinopathy: a scoping review

PURPOSE

This scoping review aimed to identify behaviour change strategies influencing rehabilitation adherence in adults with tendinopathy, a common musculoskeletal condition requiring prolonged rehabilitation with poor adherence and variable outcomes.

METHODS

Following the Joanna Briggs Institute (JBI) methodology, seven databases were searched until April 2023. Records included reviews, intervention, and qualitative studies published in English. Behaviour change strategies were deductively coded and mapped to the capability, opportunity, and motivation model of behaviour (COM-B).

RESULTS

Eighty-six articles were retained. The primary behaviour change strategies in tendinopathy rehabilitation reports addressed Psychological Capability; from knowledge through education, instruction, and self-monitoring using exercise diaries. Also, Social Opportunity involves demonstration and monitoring of rehabilitation behaviour, and Physical Opportunity focuses on time-efficient programs with access to equipment and health professionals. Few reports addressed Automatic Motivation (positive reinforcement and habit formation). Barriers identified in the reports were Reflective Motivation (negative beliefs and fears), Physical Opportunity (time-constraints), and Physical Capability (pain and comorbidities).

CONCLUSIONS

Further research should explore the impact of education on beliefs, fears, and pain-management, as well as the effectiveness of teaching habit formation for improved time-management. Implementing these behaviour change strategies may enhance tendinopathy rehabilitation adherence, improving clinical trial efficacy, guiding clinical practice, and impacting patient outcomes.

Behaviour Change Techniques to promote self-management and home exercise adherence for people attending physiotherapy with musculoskeletal conditions: A scoping review and mapping exercise

BACKGROUND

Many patients with musculoskeletal problems do not adhere to home exercises or self-management advice provided by physiotherapists. This is due to numerus factors, many of which can be targeted by Behaviour Change Techniques.

OBJECTIVES

1) Undertake a scoping review to identify the modifiable determinants (barriers and facilitators) of home exercise adherence and self-management for the physiotherapy management of people with musculoskeletal problems and map them to the Theoretical Domains Framework and Behaviour Change Techniques. 2) For determinants with supporting evidence from ≥2 studies, provide examples of Behaviour Change Techniques for clinical practice.

DESIGN

This review follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

METHOD

Four electronic databases were searched from inception to December 2022. Two independent reviewers carried out manuscript selection, data extraction, quality assessment, and mapping, the latter using the Theory and Techniques Tool.

RESULTS

Thirteen modifiable determinants were identified in 28 studies. The most frequently identified were self-efficacy, social support, and task appreciation. Determinants were mapped to 7 of 14 Theoretical Domains Framework categories, which in turn mapped onto 42 of 93 Behaviour Change Techniques, the most common being problem solving and instruction on how to perform behaviour.

CONCLUSIONS

By identifying determinants to home exercise adherence and self-management and mapping these to Behaviour Change Techniques, this review has improved understanding of their selection, targeting, and potential application to musculoskeletal physiotherapy practice. This provides support for physiotherapists targeting the determinants of importance for the patient in front of them.

Evidence Review for Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement

CONTEXT

The Osteoarthritis Action Alliance formed a secondary prevention task group to develop a consensus on secondary prevention recommendations to reduce the risk of osteoarthritis after a knee injury.

OBJECTIVE

Our goal was to provide clinicians with secondary prevention recommendations that are intended to reduce the risk of osteoarthritis after a person has sustained an anterior cruciate ligament injury. Specifically, this manuscript describes our methods, literature reviews, and dissenting opinions to elaborate on the rationale for our recommendations and to identify critical gaps.

DESIGN

Consensus process.

SETTING

Virtual video conference calls and online voting.

PATIENTS OR OTHER PARTICIPANTS

The Secondary Prevention Task Group consisted of 29 members from various clinical backgrounds.

MAIN OUTCOME MEASURE(S)

The group initially convened online in August 2020 to discuss the target population, goals, and key topics. After a second call, the task group divided into 9 subgroups to draft the recommendations and supportive text for crucial content areas. Twenty-one members completed 2 rounds of voting and revising the recommendations and supportive text between February and April 2021. A virtual meeting was held to review the wording of the recommendations and obtain final votes. We defined consensus as >80% of voting members supporting a proposed recommendation.

RESULTS

The group achieved consensus on 15 of 16 recommendations. The recommendations address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models.

CONCLUSIONS

This consensus statement reflects information synthesized from an interdisciplinary group of experts based on the best available evidence from the literature or personal experience. We hope this document raises awareness among clinicians and researchers to take steps to mitigate the risk of osteoarthritis after an anterior cruciate ligament injury.

Barriers and Facilitators in Rehabilitation in Chronic Diseases and After Surgery: Is It a Matter of Adherence?

Although it has been generally acknowledged that participating in rehabilitation programs is better for chronic diseases or post-surgery, the adherence rates of these programs remain lower than expected. According to the World Health Organization (WHO), adherence has been defined as follows: "the extent to which a person's behavior corresponds with agreed recommendations from a healthcare provider." In general, rehabilitation is well investigated, and in chronic diseases like chronic obstructive pulmonary disease (COPD), cardiovascular disease, neuromuscular disease, cancer, and even psychiatric diseases like depression, it has been shown that exercise therapy, in particular, has beneficial effects on morbidity, mortality, and convalescence of these patients. The aim of this review is to give an overview of the barriers and facilitators in rehabilitation practices and possible reasons why adherence rates remain low. Regarding potential future research, barriers and facilitators also need to be taken into account. Despite promising research in the field of preoperative exercise therapy (PET) and preoperative rehabilitation (prehab) and the enormous body of evidence in postoperative rehabilitation or rehabilitation in chronic diseases, it is also needed to take into account the accessibility of these prehab facilities in research and in clinical practice.

Short-Term Effects of Balance Training with Stroboscopic Vision for Patients with Chronic Ankle Instability: A Single-Blinded Randomized Controlled Trial

Chronic Ankle Instability (CAI) is one of the most common musculoskeletal dysfunctions. Stroboscopic vision (SV) training has been deemed to enhance somatosensorial pathways in this population group; nevertheless, until recently no studies have addressed the additional effects of this treatment option to the traditional therapeutic approach.

METHODS

To evaluate the effectiveness of a partial visual deprivation training protocol in patients with CAI, a randomized controlled trial was carried out. Patients with CAI (n = 73) were randomized into either a balance training, SV training, or a control (no training) group. For participants assigned into training groups, they received 18 training sessions over 6 weeks. The primary outcome was dynamic balance as measured by the Star Excursion Balance Test assessed at baseline and after 6 weeks of intervention. Secondary outcome measures included ankle dorsiflexion range of motion, self-reported instability feeling, and ankle functional status.

RESULTS

Better scores in stroboscopic training and balance training groups in all outcome measures were observed in comparison with the control group with moderate to large effect sizes. Stroboscopic training was more effective than neuromuscular training in self-reported instability feeling (cohen's d = 0.71; p = 0.042) and anterior reach distance of the star excursion balance test (cohen's d = 1.23; p = 0.001).

CONCLUSIONS

Preliminary findings from the effects of SV Stroboscopic training in patients with CAI, suggest that SV may be beneficial in CAI rehabilitation.

Perceived Barriers and Facilitators of Sports Rehabilitation Adherence in Injured Volleyball Athletes: A Qualitative Study From Greece

Adherence to exercise rehabilitation has been shown to be an important factor that may influence successful treatment. In professional athletes, a significant reduction in exercise adherence delays recovery. The aim of this study was to explore barriers to and facilitators of exercise rehabilitation adherence in injured volleyball athletes. Eight professional volleyball athletes were recruited, and qualitative data were collected using semistructured interviews. All athletes had completed their rehabilitation program after they had suffered a musculoskeletal injury. All data were analyzed using thematic analysis after the investigators ensured that saturation had been reached. Pain was identified as a significant barrier to exercise adherence by all athletes. The provision of social support, including mental, practical, and task related, also had a significant positive impact. The athletes’ ability to develop the necessary coping strategies and confidence on performing exercises at home was also mentioned as a factor that affected exercise adherence, although less often.

The Relationship on Exercise Anticipation, Function and Self-efficacy in Patients After Knee Surgeries Over Six Months: An Observational Study

AIM

To explore the association between the exercise anticipation, function and self-efficacy in patients after knee surgeries over six months and to identify the predictors for rehabilitation.

METHODS

This observational study used the cross-sectional survey method and was divided into two stages: (1) designing the experimental video materials and answer cards about exercise anticipation, and (2) analyzing the correlation of the level of exercise anticipation, knee function, modified gait efficacy scale (mGES), self-efficacy for rehabilitation outcome scale (SER), self-efficacy for exercise scale (SEE), time up and go task (TUG) and knee joint angle in walking. We used IBM SPSS modeler 18.0 software for establishing the Bayesian network data mining model, which can identify strong positive and negative associations.

RESULTS

A total of 110 patients were included in this study. Our research confirmed that the exercise anticipation score exhibited the significant correlation with SER (r=0.552, P<0.01), SEE (r=0.457, P<0.01), TUG (r=-0.419, P<0.01) and knee joint angle in walking (r=-0.342, P<0.01). There is only one parent node of exercise expectation, that is, rehabilitation self-efficacy, which shows that the rehabilitation self-efficacy of patients after knee surgery is directly related to their ability to judge exercise expectation. Meanwhile this study verified the model results, and the area under the ROC curve (AUC) is 0.572 (755/1320), indicating that the prediction performance is acceptable.

CONCLUSION

This preliminary study confirmed that improving the exercise anticipation and rehabilitation self-efficacy is an important method of enhancing the knee function in patients after knee surgeries over six months. In the future, the long-term effect of the exercise anticipation and self-efficacy should be researched.

Do behaviour change techniques increase adherence to home exercises in those with upper extremity musculoskeletal disorders? A systematic review

OBJECTIVES

To investigate whether behaviour change techniques (BCTs) can influence adherence to home exercise in people with upper extremity musculoskeletal disorders (UEMD).

DESIGN

A systematic review of randomised control trials, non-randomised control trials, case-control studies and cohort studies. Results were presented narratively. Participants were those with UEMD. The intervention was any home exercise programme, alongside a BCT designed to increase exercise adherence. Any duration of intervention was accepted. The main outcome sought was adherence to home exercise. A systematic search was performed on four online databases. Grey literature was searched.

RESULTS

The search resulted in 28,755 titles. 77 full-text articles were assessed for eligibility. Six studies were included in the qualitative synthesis. Four studies had Some Concern of Bias, whilst two studies had High Risk of Bias. Three studies found statistically significant differences in exercise adherence (p < 0.05) between the Intervention group and Control group. The BCT 'Social Support (unspecified)' was used within all studies that found significant differences in adherence levels at outcome. However, multiple BCTs were received by the Intervention groups within all studies, making it impossible to identify the effects of any single BCT upon adherence levels.

CONCLUSION

Social support may be relevant in patients' adherence levels to HEPs. However, confidence in the results is uncertain given the small number of studies found, and their High RoB. Future studies should validate their measurement and definition of adherence, as well as the number of BCTs they use, to provide reproducible evidence.

Development and Validation of the AdT-Physio Scale: A Tool to Assess Adherence and Perception of Physical Therapist Intervention in Patients With Cystic Fibrosis

OBJECTIVE

The purpose of this study was to develop a scale to measure patient adherence to physical therapist intervention and to report psychometric properties in patients with cystic fibrosis (CF).

METHODS

This observational, multicenter, qualitative, and cross-sectional study was divided into 2 phases: development of scale items (content validity) and assessment of psychometric properties (construct validity, reliability, and convergent/discriminant validity). Recruited were 121 patients with CF (aged ≥16 years). Sociodemographic characteristics, lung function testing, Coping with Stress Self-Efficacy, brief Coping Orientation to Problems Experienced inventory, and the scale of Adherence to Treatment of Physiotherapy (AdT-Physio) scale were evaluated.

RESULTS

The final version of the AdT-Physio scale consists of 15 items distributed across 2 subscales: compliance and beliefs about treatment/therapist. The scale showed high internal consistency (Cronbach α = .897; 95% CI = 0.868-0.922) and subscales above 0.800. The 2-factor confirmatory factor analysis model fitted the data reasonably well: χ2 (76) = 111.96, comparative fit index = 0.982, Tucker-Lewis index = 0.978, root mean square error of approximation = 0.063, 95% CI = 0.036 to 0.086, and weighted root mean square residual = 0.720. No floor or ceiling effects were identified. There was a positive, significant, and moderate-low magnitude correlation with the total Coping Orientation to Problems Experienced inventory (r = .360) and Coping with Stress Self-Efficacy subscale efficacy expectations scores (r = .304). For discriminant validity, there was a positive, significant, and moderate correlation between the total and the age of the patients (r = .354).

CONCLUSIONS

The AdT-Physio scale is psychometrically valid and reliable for use in the clinic for the assessment of adherence to physical therapy in patients with CF.

IMPACT

Ultimately, the authors propose this documentary instrument to assess the evaluation of the therapeutic alliance in a valid and objective manner. The AdT-Physio scale provides us with a greater degree of understanding of the problems behind noncompliance with treatment to advance person-centered decisions in physical therapy and thereby enhance the effectiveness of care.

The Role of Optimism and Psychosocial Factors in Athletes Recovery From ACL Injury: A Longitudinal Study

Despite a growing interest into the role of psychosocial factors during the recovery period following sports injuries, there remains a paucity of longitudinal studies examining the indirect relationships between psychosocial factors, psychological responses, and recovery outcomes. The purpose of this study was to construct and test a conceptual model which examined the indirect relationships between optimism, psychosocial factors, rehabilitation adherence, and perceived knee function up to 12 months post anterior cruciate ligament (ACL) surgery. A prospective, longitudinal, and repeated measures design was employed, wherein 81 injured athletes (M_age 26.89, SD = 7.52) completed measures of optimism, psychosocial factors, rehabilitation adherence, and perceived knee function on seven occasions (pre-surgery to 1 year post-surgery). Bayesian structural equation modeling evaluated the hypothesized indirect relationships proposed within the conceptual model. The main findings from this study was empirical support for a time-ordered, conceptual model which demonstrated that pre-surgery optimism had a significant overall indirect effect on perceived knee function at 12 months post-surgery (sum of indirect; αβ = 0.08, post. SD = 0.05, CI [0.01, 0.04]), as well as a specific indirect effect through secondary appraisal at 1 month post-surgery, efficacy at 2 months post-surgery, and rehabilitation adherence at 6 months post-surgery (αβ = 0.03, post. SD = 0.03, CI [0.00, 0.10]). Collectively, this study provides support for a number of previously hypothesized, but not empirically examined, indirect relationships between optimism, psychosocial factors and recovery outcomes. In doing so, we provide a conceptual model which has the potential to help guide individualized treatment recommendations, as well as identify individuals at risk of compromised recovery outcomes following ACL surgery.

Gender Differences in Psychological Responses to Recovery After Anterior Cruciate Ligament Reconstruction Before Return to Sport

CONTEXT

Female patients with anterior cruciate ligament reconstruction (ACLR) are less likely to return to sport than males. Psychological readiness predicts successful return to sport, but it is unclear if psychological experiences differ between males and females during recovery.

OBJECTIVE

To explore gender differences in psychological readiness factors of return to sport after ACLR.

DESIGN

Qualitative study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 12 male (months since surgery = 6.2 ± 1.2) and 13 female (months since surgery = 6.4 ± 1.3) high school athletes with a history of ACLR.

DATA COLLECTION AND ANALYSIS

Participants were interviewed before physician clearance to return to activity. Transcribed interviews were analyzed using deductive thematic coding of 5 themes identified from previous research (psychological distress, self-efficacy, locus of control, athletic identity, and fear of reinjury) and inductive secondary subthematic coding. Gender comparisons were generated within primary themes and secondary subthemes.

RESULTS

All deductive themes were consistently reinforced. Male and female participants reported fear of movement, loss of athletic identity, and motivational mindsets for return to sport and self-improvement. Males reported a stronger sense of internal locus of control using positive internal reinforcement, whereas females described balancing internal and external control and valuing external support systems. Male participants described mood changes influenced by physical and social limitations. Female participants closely monitored their emotions throughout recovery and were influenced by rehabilitation fluctuations.

CONCLUSIONS

Male and female high school athletes described different psychological factors related to return to sport and locus of control as well as psychological distress. Gender-specific psychological interventions may be warranted to overcome psychological barriers after ACLR.

Patient and practitioner perspectives of psychological need support in physical therapy

PURPOSE

To examine strategies utilized by physical therapists that contributed to patient perceptions of basic psychological needs support articulated within Self-Determination Theory (SDT).

METHODS

Semi-structured interviews were conducted with physical therapists (n = 9) and physical therapy patients (n = 9) undergoing rehabilitation for a variety of musculoskeletal injuries.

RESULTS

Both patients and practitioners articulated the value of specific competence (e.g. matching rehabilitation challenges with patient abilities) and autonomy support strategies (e.g. active decision-making). Interestingly, both patients and therapists emphasized the salience of relatedness need support, a finding indicative of the potential importance of this need in a rehabilitation environment. The possibility that relatedness need support may be of equal - or potentially greater - importance than the other two needs in a rehabilitation setting, is however, antithetical to SDT contentions. Whether the primacy of relatedness need support is an artifact of the sample used in the current study or a reflection of a broader rehabilitation trend, is uncertain and remains a topic for further investigation.

CONCLUSIONS

Understanding the strategies physical therapists use to support patients' psychological needs may have substantial implications for patient motivation and rehabilitation adherence, such as, improved psychological well-being, enhanced function, and increased adherence to physical therapists' recommendations.

The basic psychological need support in physical therapy questionnaire

Given the limitations of current inventories of basic psychological need measurement, and the importance of psychological need support within an injury rehabilitation context, there is an evident need to develop the present inventory. Utilizing Self-Determination Theory (SDT) as a theoretical framework, two studies were conducted to develop and psychometrically test a measure of patients' perceptions of basic psychological needs support in physical therapy: The Basic Psychological Needs Support in Physical Therapy Questionnaire (BPNS-PT). In study 1, a panel of Self-Determination Theory academics assessed a pool of items for content relevance, representativeness, and item clarity. In study 2, responses from 199 physical therapy patients were used to identify the best fitting model through confirmatory factor analysis. A 3-factor 10-item measure displayed good fit to the data and illustrated evidence of internal consistency. Findings from these studies provide initial psychometric support (i.e. internal consistency and evidence of construct validity) for the BPNSPT as a measure of patient perceptions of basic psychological needs support in a physical therapy context.

The Self-Efficacy for Home Exercise Programs Scale: Development and Psychometric Properties

BACKGROUND

The Self-Efficacy for Home Exercise Programs Scale (SEHEPS) was developed to help clinicians evaluate patients' self-efficacy for performing prescribed home exercise programs. Prior to clinical adoption, the scale's psychometric properties need to be examined.

OBJECTIVE

To determine the psychometric properties of the SEHEPS.

METHODS

Eighty-one patients (32 men, 49 women; mean ± SD age, 42 ± 17 years) with varying musculoskeletal conditions participated in this cohort study. Patients were given a home exercise program at the initial physical therapy visit and completed the SEHEPS and a modified Self-Efficacy for Exercise (SEE) scale. The SEHEPS is a 12-item patient-reported questionnaire designed to assess self-efficacy for prescribed home exercise. Patients rated their confidence on a 7-point scale that ranged from 0 (not confident) to 6 (very confident). Total scores ranged from 0 (low self-efficacy) to 72 (high self-efficacy). We assessed the internal consistency of the SEHEPS using Cronbach's alpha and its test-retest reliability using an intraclass correlation coefficient. Convergent validity between the SEHEPS and SEE scale was evaluated with a Spearman correlation.

RESULTS

High internal consistency (α = .96) and good test-retest reliability (intraclass correlation coefficient = 0.88; SEM, 4; minimal detectable change at the 95% confidence level, 12) were demonstrated. The SEHEPS was strongly correlated with the SEE scale (ρ = 0.83, P<.01), indicating strong convergent validity.

CONCLUSION

The SEHEPS demonstrates excellent internal consistency and convergent validity with the SEE scale. Overall, the SEHEPS is a clinically useful tool to evaluate a patient's self-efficacy in home-based musculoskeletal exercise programs. This scale can be used prior to prescribing a home exercise program for patients with musculoskeletal conditions.

LEVEL OF EVIDENCE

Therapy, level 4. J Orthop Sports Phys Ther 2019;49(9):647-655. Epub 10 Jul 2019. doi:10.2519/jospt.2019.8779.

Well-Come Back! Professional Basketball Players Perceptions of Psychosocial and Behavioral Factors Influencing a Return to Pre-injury Levels

The psychological factors influencing a return to sport has gained increased research attention. In the current investigation, we explored professional basketball players’ perceptions of the psychosocial and behavioral factors facilitating a return to performance equal to or exceeding previous performance standards. We also sought to describe athletes’ experiences – both positive and negative – of returning to sport following injury recovery. Ten Italian professional male basketball players (age range 22–36 years), were retrospectively interviewed in relation to three time-periods: (1) from the commencement of rehabilitation to their first official competition, (2) the first official competition, and (3) the 6-months following the initial competition. Qualitative content analysis of the data revealed numerous themes across the three time periods. In regards to Period 1, participants indicated that social support, investment in rehabilitation and training programs, coping skills and motivation were fundamental in reaching pre-injury performance levels. During their first official game (i.e., Period 2), athletes reported that realistic performance expectations, focusing on the performance, positive emotions, motivation, arousal and social support facilitated their return to sport. Athletes, however, also described a predominance of factors that hindered their return to pre- injury levels (i.e., low confidence in personal abilities, decrements in skill execution and dysfunctional physical sensations). Moreover, participants typically described a substandard level of performance during their first competition back following injury. In recounting experiences during the 6 months following their first official game, basketballers reported improvements in skill execution and highlighted the importance of coping skills, motivation and social support. The process of restoring self-confidence in one’s ability to successfully perform was perceived as crucial in enabling participants to move beyond a mere return to sport to a return to high performance – that is, to reach a level of proficiency equal to or exceeding previous performance standards. Findings support the relevance of cognitive, emotional and behavioral responses highlighted in the Integrated Model and suggest the importance of addressing psychological factors throughout the return-to-sport process. Finally, results from the present study hold a number of practical implications for athletes’ aiming to achieve a return to pre-injury levels.

Measurements of self-efficacy in musculoskeletal rehabilitation: A systematic review

OBJECTIVES

Low self-efficacy is a barrier to rehabilitation adherence. Before an intervention can be implemented to improve self-efficacy, assessment is required. It is currently unknown if a standard measure of self-efficacy has been used to assess this in patients with musculoskeletal conditions, specifically for home exercise programmes (HEPs). The aim of the present study was to determine which self-efficacy scales are being used in conjunction with exercise adherence, identify if any scale has been developed to evaluate self-efficacy for HEPs and evaluate their psychometric properties.

METHODS

Data sources included CINAHL, MEDLINE, Pubmed, PsycInfo, and Sport Discus. Studies had to include patients suffering from a musculoskeletal injury, pain or disorder; a measure of rehabilitation adherence; and patient's self-efficacy. The study population, self-efficacy measurement used, study quality as identified with the Modified Downs and Black checklist, results pertaining to self-efficacy, and level of evidence were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and 29 articles were included.

RESULTS

A total of 14 scales assessing self-efficacy were identified but no scale to assess self-efficacy for HEPs was found. Many scales report internal consistency but lack test-retest reliability and validity.

CONCLUSIONS

The scales identified were specific to condition or tasks, and not applicable for all musculoskeletal patient populations. It is important, both for use in the clinic and for research, that outcome measures used are reliable and valid. Unfortunately, no scale was found to assess self-efficacy for HEPs, which is problematic as self-efficacy is task specific. As HEPs are essential to rehabilitation, there should be a scale designed specifically to assess self-efficacy for this task.

Perceived motivational factors for female football players during rehabilitation after sports injury - a qualitative interview study

Compliance with a rehabilitation program is significant among athletes following a sports injury. It is also one of the main factors that influence the rehabilitation process; moreover, the outcome is also influenced by the athlete’s motivation. It is primarily an autonomous motivation, resulting in rehabilitation adherence. The aim of this study was to investigate the perceived motivation of female football players during rehabilitation after a sports injury and the extent to which these motivating factors were autonomous. Qualitative interviews, based on a semistructured interview guide with injured female football players undergoing rehabilitation, were analyzed using content analysis. The motivational factors that were described were their set goals, social support as well as external and internal pressures during rehabilitation. The perceived autonomy varied somewhat but overall, they experienced external motivation; therefore, the behavior was not entirely self-determined. Results are expected to provide a better understanding of women football players’ motivation in relation to their rehabilitation; hence, physiotherapists and coaches who are part of the rehabilitation process can contribute by increasing the autonomous motivation, thus, improving the compliance and outcome of the rehabilitation.

Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?

Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere to a prescribed exercise program and explore how connected health technologies have the ability to offer numerous interventions to enhance adherence; however, it is hard to judge the efficacy of these interventions without a robust measurement tool. We highlight how well-designed connected health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as inertial measurement units, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy

PURPOSE

To describe individuals' expectations, motivation, and satisfaction before, during, and after rehabilitation for ACL reconstruction and to explore how these factors were associated with return to pre-injury sport activity at 1-year follow-up.

METHODS

Sixty-five individuals (34 males), median age 22 (15-45) years, scheduled for ACL reconstruction participated. Participants completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and questions about expectations, satisfaction, and motivation pre-operatively and at 16 and 52 weeks after surgery.

RESULTS

Prior to surgery, 86 % of participants stated that their goal was to return to their pre-injury sport activity. Those who had returned to their pre-injury sport activity at 52 weeks were more motivated during rehabilitation to return to their pre-injury activity level, more satisfied with their activity level and knee function at 52 weeks, and scored significantly higher on the IKDC-SKF [median 92.0 (range 66.7-100.0)] at 52 weeks, compared to those who had not returned [median 77.6 (range 50.6-97.7)].

CONCLUSION

Prior to ACL reconstruction, most participants expected to return to their pre-injury activity level. Higher motivation during rehabilitation was associated with returning to the pre-injury sport activity. The participants who had returned to their pre-injury sport activity were more satisfied with their activity level and knee function 1 year after the ACL reconstruction. Facilitating motivation might be important to support individuals in achieving their participation goals after ACL reconstruction.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Predictors of adherence to home-based physical therapies: a systematic review

PURPOSE

Self-managed, home-based physical therapy (HBPT) is an increasingly common element of physical therapy rehabilitation programmes but non-adherence can reach 70%. Understanding factors that influence patients' adherence to HBPTs could help practitioners support better adherence. Research to date has focussed largely on clinic-based physiotherapy. The objective of this review, therefore, was to identify specific factors, which influence adherence to home-based, self-managed physical therapies.

METHOD

A systematic review was conducted, in which eight online databases were searched using combinations of key terms relating to physical therapies, adherence and predictors. Matching records were screened against eligibility criteria and 30 quantitative articles were quality assessed and included in the final review. Relevant data were extracted and a narrative synthesis approach was taken to aggregating findings across studies.

RESULTS

There was relatively strong evidence that the following factors predicted adherence to HBPTs: intention to engage in the HBPT, self-motivation, self-efficacy, previous adherence to exercise-related behaviours and social support.

CONCLUSIONS

This review has identified a range of factors that appear to be related to patients' adherence to their self-managed physical rehabilitation therapies. Awareness of these factors may inform design of interventions to improve adherence. Implications for Rehabilitation Non-adherence to physical rehabilitation therapies is often high - particularly in self-managed, home-based programmes, despite good adherence being important in achieving positive outcomes. The findings of this systematic review indicate that greater self-efficacy, self-motivation, social support, intentions and previous adherence to physical therapies predict higher adherence to HBPTs. Assessment of these domains before providing individuals with their HBPT regimes may allow identification of 'risk factors' for poor adherence. These can then potentially be addressed or managed prior to, or alongside, the therapy. Interventions to support patients' self-managed physical rehabilitation should include elements designed to enhance patients' self-efficacy, self-motivation and social support given the evidence that these factors are good predictors of adherence.

Prediction of attendance at fitness center: a comparison between the theory of planned behavior, the social cognitive theory, and the physical activity maintenance theory

In the processes of physical activity (PA) maintenance specific predictors are effective, which differ from other stages of PA development. Recently, Physical Activity Maintenance Theory (PAMT) was specifically developed for prediction of PA maintenance. The aim of the present study was to evaluate the predictability of the future behavior by the PAMT and compare it with the Theory of Planned Behavior (TPB) and Social Cognitive Theory (SCT). Participation rate in a fitness center was observed for 101 college students (53 female) aged between 19 and 32 years (M = 23.6; SD = 2.9) over 20 weeks using a magnetic card. In order to predict the pattern of participation TPB, SCT and PAMT were used. A latent class zero-inflated Poisson growth curve analysis identified two participation patterns: regular attenders and intermittent exercisers. SCT showed the highest predictive power followed by PAMT and TPB. Impeding aspects as life stress and barriers were the strongest predictors suggesting that overcoming barriers might be an important aspect for working out on a regular basis. Self-efficacy, perceived behavioral control, and social support could also significantly differentiate between the participation patterns.

A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties

BACKGROUND

Adherence is an important factor contributing to the effectiveness of exercise-based rehabilitation. However, there appears to be a lack of reliable, validated measures to assess self-reported adherence to prescribed but unsupervised home-based rehabilitation exercises.

OBJECTIVES

A systematic review was conducted to establish what measures were available and to evaluate their psychometric properties.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO CINAHL (June 2013) and the Cochrane library were searched (September 2013). Reference lists from articles meeting the inclusion criteria were checked to ensure all relevant papers were included.

STUDY SELECTION

To be included articles had to be available in English; use a self-report measure of adherence in relation to a prescribed but unsupervised home-based exercise or physical rehabilitation programme; involve participants over the age of 18. All health conditions and clinical populations were included.

DATA EXTRACTION

Descriptive data reported were collated on a data extraction sheet. The measures were evaluated in terms of eight psychometric quality criteria.

RESULTS

58 studies were included, reporting 61 different measures including 29 questionnaires, 29 logs, two visual analogue scales and one tally counter. Only two measures scored positively for one psychometric property (content validity). The majority of measures had no reported validity or reliability testing.

CONCLUSIONS

The results expose a gap in the literature for well-developed measures that capture self-reported adherence to prescribed but unsupervised home-based rehabilitation exercises.

Evidence for the construct validity of self-motivation as a correlate of exercise adherence in French older adults

OBJECTIVES

Exercise adherence involves a number of sociocognitive factors that influence the adoption and maintenance of regular physical activity. Among trait-like factors, self-motivation is believed to be a unique predictor of persistence during behavior change. The aim of this study was to validate the factor structure of a French version of the Self-Motivation Inventory (SMI) and to provide initial convergent and discriminant evidence for its construct validity as a correlate of exercise adherence.

METHOD

Four hundred seventy-one elderly were recruited and administered the SMI-10. Structural equation modeling tested the relation of SMI-10 scores with exercise adherence in a correlated network that included decisional balance and perceived quality of life.

RESULTS

Acceptable evidence was found to support the factor validity and measurement equivalence of the French version of the SMI-10. Moreover, self-motivation was related to exercise adherence independently of decisional balance and perceived quality of life, providing initial evidence for construct validity.

Injury rehabilitation overadherence: preliminary scale validation and relationships with athletic identity and self-presentation concerns

CONTEXT

Evidence suggests that nonadherence to rehabilitation protocols may be associated with worse clinical and functional rehabilitation outcomes. Recently, it has been recognized that nonadherence may not only reflect a lack of rehabilitation engagement but that some athletes may "overadhere" to their injury-rehabilitation regimen or risk a premature return to sport. Presently, no measure of overadherence exists, and correlates of overadherence and risking a premature return to sport remain uncertain.

OBJECTIVE

To provide initial validation of a novel injury-rehabilitation overadherence measure (study 1) and to examine correlates of overadherence and risking a premature return to sport (study 2).

DESIGN

Cross-sectional study.

SETTING

High school athletes (study 1) and collegiate athletes (study 2).

PATIENTS OR OTHER PARTICIPANTS

In study 1, 118 currently injured US adolescent athletes competing in a range of high school sports participated. In study 2, 105 currently injured collegiate athletes (National Collegiate Athletic Association Divisions I-III) volunteered.

MAIN OUTCOME MEASURE(S)

The Rehabilitation Overadherence Questionnaire was a novel instrument developed to assess injured athletes' tendency toward overadherence behaviors and beliefs. We used an adapted version of the Injury Psychological Readiness to Return to Sport Scale to assess the tendency to risk a premature return to sport.

RESULTS

In study 1, the construct validity of the overadherence measure was supported using principal axis factoring. Moreover, bivariate correlation and regression analyses indicated that self-presentation concerns and athletic identity were positive predictors of adolescent rehabilitation overadherence and a premature return to sport. Study 2 provided support for the 2-factor structure of the overadherence measure found in study 1 via confirmatory factor analysis. Further support for the relationship among self-presentation concerns, athletic identity, and rehabilitation overadherence was also noted.

CONCLUSIONS

The Rehabilitation Overadherence Questionnaire is a valid and reliable measure of overadherence.

Perceived social support from strength and conditioning coaches among injured student athletes

Injuries suffered by student athletes not only affect their physical ability to perform in sport but also have psychological effects as well. The purpose of this study was to examine student athletes' perceptions, expectations, and satisfaction of the social support provided by their strength and conditioning coach (SC) during the later reconditioning stage of their rehabilitation and their views on the overall level of importance of each type of social support. One hundred and sixty-five participants aged 20.21 ± 1.32 years from 6 Division I Universities in the Midwest region of the USA completed the modified Social Support Survey. The results of a chi-square test assessing the responses for 6 types of social support provided by SCs based on athletes' age, gender, and sport revealed a significant difference (χ2[13,105] = 26.46, p = 0.015) for listening support differing by sport. A significant difference (χ2[13,105] = 267.74, p = 0.010) was also revealed for reported emotional challenge by sport. Results showed that the SC had a significant psychosocial impact on student-athletes' overall psychological well-being during reconditioning. This study provides evidence of the vital psychosocial role that SCs can play during an injured student-athlete's reconditioning program.

Use of a goal setting intervention to increase adherence to low back pain rehabilitation: a randomized controlled trial

OBJECTIVE

To examine the effects of a goal setting intervention on self-efficacy, treatment efficacy, adherence and treatment outcome in patients undergoing low back pain rehabilitation.

DESIGN

A mixed-model 2 (time) × 3 (group) randomized controlled trial.

SETTING

A residential rehabilitation centre for military personnel.

SUBJECTS

UK military personnel volunteers (N = 48); mean age was 32.9 (SD 7.9) with a diagnosis of non-specific low back pain.

INTERVENTIONS

Subjects were randomly assigned to either a goal setting experimental group (Exp, n = 16), therapist-led exercise therapy group (C1, n = 16) or non-therapist-led exercise therapy group (C2, n = 16). Treatment duration for all groups was three weeks.

MAIN MEASURES

Self-efficacy, treatment efficacy and treatment outcome were recorded before and after the treatment period. Adherence was rated during regularly scheduled treatment sessions using the Sports Injury Rehabilitation Adherence Scale (SIRAS). The Biering-Sørensen test was used as the primary measure of treatment outcome.

RESULTS

ANCOVA results showed that adherence scores were significantly higher in the experimental group (13.70 ± 1.58) compared with C2 (11.74 ± 1.35), (P < 0.025). There was no significant difference for adherence between the experimental group and C1 (P = 0.13). Self-efficacy was significantly higher in the experimental group compared to both C1 and C2 (P < 0.05), whereas no significant difference was found for treatment efficacy. Treatment outcome did not differ significantly between the experimental and two control groups.

CONCLUSIONS

The findings provide partial support for the use of goal setting to enhance adherence in clinical rehabilitation.

Patient motivation and adherence to postsurgery rehabilitation exercise recommendations: the influence of physiotherapists' autonomy-supportive behaviors

Chan DK, Lonsdale C, Ho PY, Yung PS, Chan KM. Patient motivation and adherence to postsurgery rehabilitation exercise recommendations: the influence of physiotherapists' autonomy-supportive behaviors.

OBJECTIVE

To investigate the impact of physiotherapists' autonomy-supportive behaviors on patients' motivation and rehabilitation adherence after anterior cruciate ligament (ACL) reconstruction surgery.

DESIGN

Retrospective study.

SETTING

Outpatient orthopedic clinic of a university medical center.

PARTICIPANTS

Postsurgery ACL reconstruction patients (N=115; minimum postsurgery interval, 6mo; mean +/- SD postsurgery interval, 1.77+/-0.8y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Questionnaires measuring autonomy support from physiotherapists (Health Care Climate Questionnaire), treatment motivation (Treatment Self-Regulation Questionnaire), and rehabilitation adherence (adapted from the Sport Injury Rehabilitation Adherence Scale and the Patient Self-Report Scales of Their Home-Based Rehabilitation Adherence).

RESULTS

Structural equation modeling analyses revealed that patients' treatment motivation mediated the relationship between physiotherapists' autonomy-supportive behaviors and rehabilitation adherence. Autonomy-supportive behavior positively predicted autonomous treatment motivation (beta=.22, P<.05). Rehabilitation adherence (R(2)=.28) was predicted positively by autonomous motivation (beta=.64, P<.05) and negatively predicted by controlled motivation (beta=-.28, P<.05).

CONCLUSIONS

These preliminary findings are promising and provide an empirical basis for further research to test the efficacy of autonomy support training designed to increase patients' rehabilitation adherence.