an exploration of athletes’ views on their adherence to injury rehab

7/29/2019 An Exploration of Athletes Views on Their Adherence To Injury Rehab

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Journal of Sport Rehabilitation, 2012, 21, 18-25

2012 Human Kinetics, Inc.

The authors are with the School of Health Science, Southampton

University, Southampton, UK.

An Exploration of Athletes Views on Their Adherenceto Physiotherapy Rehabilitation After Sport Injury

Andy Marshall, Maggie Donovan-Hall, and Steve Ryall

Objective: To explore athletes perceptions of the factors that they feel may affect their adherence to a physio-therapy intervention.Design:A qualitative design using semistructured interviews. Setting: Participants wereinterviewed at home or their athletic club.Participants: 8 participants, 5 men and 3 women with a mean ageof 30.4 y.Results: Thematic analysis revealed 2 main categories of themes. The rst relates to the athletesperceptions of factors affecting his or her own adherence, with themes including the impact of injury, justica-tion of adherence, and strategies used by the patient. The second relates to perceptions of the physiotherapistsimpact on adherence, with themes relating to characteristics of and strategies used by the physiotherapist.Conclusions: Findings demonstrate the importance of exploring patients perceptions of adherence. A number

of factors that affect adherence are identied, and strategies that may enhance adherence suggested.

Key Words: patient perspective, qualitative, sport

Rehabilitation usually involves adherence to someaspect of a treatment protocol and is therefore vital inachieving successful recovery from a sports injury.1Adherence can be divided into 2 components: (1) adher-ence to clinic sessions and the therapy that occurs inthem and (2) adherence to home exercise programs andself-instigated therapeutic modalities between treatmentsessions.2 Rates of adherence to the home-based compo-nents of physiotherapy programs were reviewed by Bas-

sett.3

The results are alarming, with evidence suggestingthat 65% of patients will demonstrate some degree ofnonadherence to their rehabilitation.

It has been shown that adherence to rehabilitation forsports injuries is vital for successful recovery and returnto sport.4 Fisher et al5 state that the key factor inuenc-ing the success of the rehabilitation process is an injuredathletes commitment to the program and the ability ofthe therapist to enhance that commitment. Poor levelsof adherence, undetected by physiotherapists providingintervention, have been said to be one reason for theunnecessary alteration of treatment programs, possiblycompromising the effectiveness of treatment.3

Predictors of adherence have been the focus of early

investigations into rehabilitation after sport injury. Thecurrent literature has identied a number of variables thatcan be broadly split into personal and situational factors.6Personal factors include self-motivation, pain tolerance,tough-mindedness, assertiveness, and self-assurance.Situational factors have been shown to encompass beliefin the efcacy of treatment, the clinical environment,

convenience of rehabilitation scheduling, perceived exer-tion during rehabilitation, and emotional adjustment.6 Ina study exploring athletes perceptions of the variablesassociated with adherence, Fisher et al5 state that 3 areasfor consideration are the injured athletes characteristics,conditions surrounding the rehabilitation setting, andathletetherapist interactions.

There are a number of other multifaceted factorsthat have been shown to be associated with adherence to

physiotherapy. Johnston and Carroll7

found that athletesperceived their recovery to be reduced toward the end oftheir rehabilitation, with Brewer et al,4 in a study explor-ing whether age and age-related differences could predictadherence after ACL reconstruction, nding a correlationbetween age and adherence to home-based rehabilitation.4Furthermore, in a retrospective study, Byerly8 discoveredthat adherent athletes experienced greater social support,highlighting the importance of psychosocial issues.Murphy et al9 showed a positive relationship betweeninjured athletes internal locus of control and treatmentadherence in their research, identifying rehabilitation-relevant variables affecting recovery. In another study,Levy et al10 found a weak correlation between percep-

tions of autonomy and supportiveness provided by thetherapists and attendance at clinical sessions.Patients adherence to rehabilitation has been shown

to be related to treatment success and speed of recovery,with recent research addressing the physiotherapists rolein facilitating this. Niven11 carried out research examin-ing sport physiotherapists perceptions of the factorsthat inuence rehabilitation adherence. The ndingshighlight factors that were associated with good andpoor rehabilitation adherence and provide strategies thatphysiotherapists can use to promote patient adherence.


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Athletes Views on Their Rehabilitation Adherence 19

Although it is useful to gain physiotherapists per-spectives on adherence, St Claire et al12 state that patientsand practitioners have been found to have different viewson health issues and therefore monitor rehabilitation indifferent ways. This therefore reinforces the importanceof examining these issues from both the physiotherapistand the patient perspective. There has been an increasing

body of research identifying factors that may play a partin determining a patients adherence to rehabilitation.However, most studies seem to employ a quantitativemethodology, and there is only a small body of qualita-tive research focusing on therapists views on athleteadherence.1315 In light of the ndings outlined herein,it appears that further research is needed to explore thepatient perspective.11 The main aim of this study wastherefore to explore athletes views on their adherence tophysiotherapy rehabilitation after sport injury. We hopethat a better understanding of patients reaction to injury,obstacles to adherence, and views of the therapists rolein promoting adherence may lead to the development ofstrategies that foster adherent behaviors.

Method

Design

A qualitative design was used employing a thematicanalysis approach, embedded in a phenomenologicalframework aiming to understand the essential truth ofthe participants lived experience.16 Thematic analysishas been described as a exible methodology that can beapplied to a wide range of theoretical and epistemologicalapproaches such as a phenomenological framework.17

ParticipantsThe initial intention of the study was to use a screeningtool18 to identify a purposive sample of participants witha diverse range of athletic identity scores and types ofinjury, ensuring a wide range of participant views. How-ever, because of the small number of respondents a con-venience sample was used.19 The nal sample included 8participants, 5 men and 3 women with a mean age of 30.4years (SD = 9.2). All were members of either a district- ora university-based athletic club and competed at both cluband international levels. All had suffered a sport injurywithin the last 5 years and had seen a physiotherapist fortreatment for this injury but were not currently receivingtherapy. Participants injuries had resulted from multiplemechanisms, but half the injuries treated were musclestrains. Injury durations varied from 2 weeks to over ayear. Six participants had had lower limb injuries and 2had had back injuries.

Procedure

Ethical approval was granted by the Southampton Schoolof Health Sciences Internal Research Ethics Committee.The recruitment process involved the researcher giving

a brief presentation explaining the study to each athleticgroup and leaving research packs for those who wereinterested in taking part. The packs included a partici-pant information sheet, reply slip, personal-details form,and athletic identity screening tool.18 Reply slips werereturned to the university, and interviews were conductedat a mutually convenient location, lasting 30 minutes

to 1 hour. Conrmation that participants were not cur-rently receiving physiotherapy was gained and consentobtained. A standard introduction was made at the startof each interview, providing a denition of adherence,ensuring that participants were aware of the interviewformat, and informing them of their right to withdrawfrom the study at any time.

Discussions with experts in the field led to thedevelopment of an interview schedule containing a seriesof open questions with prompts to explore the athletesviews on their adherence to physiotherapy rehabilitationafter sport injury. Discussions with experts ensured thatall important topic areas were included.19 If answersremained unclear, prompt questions were used for

clarication.20 Table 1 provides a brief overview of themain questions in the interview schedule.

All interviews were carried out by the primaryresearcher, who was an MSc preregistration physiother-apy student and therefore had not been involved in any ofthe patients treatment. A series of pilot interviews wascarried out before data collection. Modications werethen made to the interview schedule to ensure understand-ing and clarity of the questions.

All interviews were recorded and then transcribedverbatim, with condentiality and anonymity maintainedat all times. Although the nal sample size of 8 partici-pants could be viewed as relatively small for this typeof qualitative study, several similar points were raised in

the interviews and a point of saturation was achieved.

Data Analysis

Data analysis was carried out using a thematic approachand conducted following the process outlined by Braunand Clarke.17 The researchers read and reread the tran-scripts to become familiar with the data. Initial codeswere generated by collating prominent responses in thedata, and a coding document was developed. Themeswere then developed from collating codes, all relevantto each potential theme. A second researcher reviewedall transcripts and blindly coded them separately as aprocess of verication. The 2 researchers discussed thecodes and developing themes. Potential themes were thenreviewed and checked as to whether they worked in rela-tion to the coded extracts and research question, and nalthemes were generated. A clear paper trail outlining thedevelopment of the codes and themes was kept and usedto verify and nalize the themes. The nal stage involvedincorporating selected extracts and example quotationsinto the Results section to strengthen the analysis andhelp readers understand the authors interpretation of theparticipants experience.


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20 Marshall, Donovan-Hall, and Ryall

Results

The Results section outlines 2 categories of themes withrelated themes. The rst category of themes relates to thefactors reecting the athletes own adherence behavior,with themes including the impact of injury, justicationof adherence, and strategies implemented. The second

category of themes relates to perceptions of the physio-therapists impact on athlete adherence, with themesrelating to characteristics of and strategies used by thephysiotherapist. Figure 1 provides an outline of thesecategories of themes, showing that they were both relatedto adherent and nonadherent behavior.

Athletes Perceptions of FactorsInfluencing Their Adherence

Impact of Injury. The impact-of-injury theme containedcodes relating to both the physical and the psychological

impact of injury on athletes. The physical impact wasconsidered by participants to be principally the effecttheir injury had on their participation in competitionsand training and the pain they felt. It was not surprisingto nd that participants perceptions of their pain variedand that they attributed different causes to their injury.These included the amount and intensity of pain, or type

of training, and also biomechanical factors or personalbody mechanisms.

The psychological impact demonstrated was mul-tifactorial, with participants talking at length about thedepressive nature of being injured. Some participantsexpressed guilt about not being able to train or compete,with this causing associated stress. For example, oneparticipant stated,

When you have trained 5 days a week and you gofrom not being able to do much, it does demoralizeyou quite a bit. Some athletes I know do end up feel-

Table 1 Outline of the Questions Included in the Interview

Rational underpinning question Example questions

Foundations of the injury Tell me about the injury you had.

Understanding the treatment Can you tell me about the treatment you received? Now that treatment has nished whatare your general thoughts about it?

More specic to adherence Some people nd it difcult to carry out their physiotherapy because

it triggers their symptoms

they have doubts over the therapy

there are practical problems

Was this an issue with you?

Opportunity for participants to addother comments

If you were going to give advice to another athlete who had a similar injury, what wouldyou say? Is there anything else about your injury experience you would like to add?

Figure 1 Categories of themes and key themes relating to adherent and nonadherent behavior.


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ing guilty if theyre not training, but I used to nd thatI would be thinking about it so much that it wouldget me down. (participant 7, line 159)

The same participant also commented on the nega-tive impact the injury had on his athletic identity: Withthe injury it did really change me as a person in terms of

my athletic identity; I dont feel Im quite as addicted toathletics as I was (line 415).

Justification of Adherence Behavior. One of the mostfrequent comments from all participants was on an abil-ity to attribute their lack of adherence to a particularfactor and identied perceived reasons for the lack oftheir adherence. One participant stated simply beingfed up with the injury, and this limited the frequencywith which she was meant to be performing exercises.Conversely, a number of other participants perceivedthemselves as being better, no longer needing to adhereto their rehabilitation. This was a result of either beingable to run again or a decrease in pain: Whilst I wasstill injured and felt some pain effect from that injury,I was religiously doing my exercises (participant 1,line 139).

Some participants felt that a lack of support anddirection from the physiotherapist was detrimental to theiradherence, while others thought impairments in memorywere the main problem. This included forgetting to dotheir exercises or not remembering what they had to do:Its more of a case of remembering rather than ndingthe time (participant 2, line 62).

A prominent subcategory concerned the program ofexercises prescribed. The exercise programs were oftenviewed quite negatively, and participants provided clearreasons why they had not adhered to the exercises. Forexample, exercises were described as being too complex,with one participant becoming anxious over the correcttechnique. They were also said to be monotonous andcaused a few participants additional symptoms: You dofeel a bit stupid cause I really couldnt get some simplethings, some simple exercises (participant 1, line 239),and You can only do so much core before you get com-pletely sick of it (participant 8, line 80).

Some participants who admitted lower than expectedlevels of adherence indicated that reasons for this relatedto the high number of exercises given, their own timeconstraints, and the lack of social interaction because theexercises were home-based and were to be completed inisolation: Fitting in and around your day, probably that

was a problem (participant 1, line 295), and Whenyoure injured and a bit depressed anyway its not fun todo on your own (participant 4, line 76).

On the whole there appeared to be shared viewsthat a lack of adherence could be linked to a lack ofunderstanding of the rationales for treatment. This wasevident with participants not being aware of the impactof physiotherapy and perceiving it as not specic to theirsport. One participant commented, I think that can bewhy you stop, not really being able to see any difference(participant 1, line 220).

This highlighted the lack of understanding partici-pants had of the advice they had been given. Similarly, ifparticipants felt that were not fully trained or educated asto why the exercises were necessary, this had an impacton their level of adherence:

Ive had some physios that try to tell me that leg

extensions are good for your knee and a lot tell younot, and so after a while you just make your ownmind up and say well I think they probably are goodfor me, otherwise the machine probably wouldnthave been made. (participant 7, line 256)

It appeared that the overriding issue determining par-ticipants understanding of their rehabilitation protocoland the treatment techniques used was whether the under-pinning rationale was provided. For most participants itwas She was very clear what she was doing and whyshe was doing it (participant 8 line 61).

This resulted in participants having increasedknowledge, which may have had a positive impact on

their adherence. However, other participants felt that alack of rationale as to why they needed to carry out theexercises contributed to their level of adherence: I dontreally think I got a full rationale, in terms of saying ifyou do this, this will work on improving certain muscleareas. . . . Didnt really get that kind of explanation atall (participant 7, line 90).

For participant 4 this resulted in a passive approachto rehabilitation, with the athletes externalizing her locusof control, ultimately decreasing her adherence: I alwaysfound you just lay there and they poke at you and thentalk to your coach instead of you. . . . I think you just laythere and do as youre told (line 45).

Several participants also described how their miscon-

ceptions and lay beliefs before this injury, particularlyof the physiotherapy process itself, had a detrimentaleffect:

In some ways my previous experience sort of sittingthere and thinking well I do a bit of rehabilitationits going to get better now, its just going to getxed. . . . Unfortunately I probably had the wrongattitude towards it because of my previous experi-ences. (participant 7, line 328)

In addition, further highlighting how complex theinjury experience is for an athlete, half the participantscommented on either positive or negative coach involve-

ment while dealing with their injury. This includedliaising with the physiotherapist, issues surroundingreturning to training, and contact time during periods ofinjury and communication: If its an injury, my coachjust thinks thats something for the physio to deal with(participant 3, line 72).

It was not just strategies, either imposed by thephysiotherapist or independently devised by the ath-letes, that were shown to be signicant in affectingadherence. The internal beliefs and perceptions heldby the athletes are likely to inuence and affect their


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adherence. For example, the perception of the priorityand importance of rehabilitation was demonstrated withcomments such as

If its a priority for you, as my athletics is, maybeif I did this more socially, rather than taking it soseriously, then it may have been, but its my priority.

You do what you prioritize in life so; no, it wasntan issue at all. (participant 3, line 167)

This was supplemented by the intrinsic motivationother participants mentioned. Other recurring featuresincluded the self-discipline required to maintain highlevels of adherence: I had to get on and just do it andbe disciplined enough to set aside the time (participant6, line 119).

One participants perceived belief that she feltaffected her adherence was the thought that she would beletting down her physiotherapist. This was shown with thestatement If you dont do it youre almost letting themdown, as well, because they have given you that advice

(participant 6, line 254).Strategies Implemented to Increase Adherence. Mostof the participants identied strategies they had indepen-dently devised and used to promote adherence, which maysuggest that participants were goal oriented, adopting aninternal locus of control. The theme included codes relat-ing to memory and about time management. Participantsstated they used training times to complete their rehabili-tation program, used set times that were linked to theirdaily routine, and developed certain cues to help themremember to adhere: Where I wasnt training I have allthese big gaps of time to ll (participant 4, line 207).

We also found that social networks were important,with participants commenting on the importance of

involving the family in the rehabilitation process and alsodiscussing issues with other runners who may understandfeelings and emotions from a runners perspective: Myapproach to that was I said to my partner Im supposedto be doing these exercises (participant 1, line 121).

Perceptions of the PhysiotherapistsImpact on Adherence

Characteristics of the Physiotherapist. This themecan be divided into 4 areas linked to athletes physio-therapists characteristics, all of which participants feltpromoted adherence. Participants felt that an individual-ized personal approach should be taken by physiothera-pists, it being vital that physiotherapists be supportive,sympathetic, attentive, and approachable while ensur-ing that they listened to the athletes views. In essenceparticipants recognized that each injury experience isdifferent, and a tailored approach must be adopted bythe physiotherapist to best guide each participant throughthe process, ensuring optimal adherence throughout:Theyre actually treating you like a person and not just abody thats on the table (participant 7, line 220), and Itwas more a sympathetic, we will try and get you back as

soon as possible and I know its frustrating sort of thing(participant 2, line 142).

The second area concerned contextualizing physio-therapy in the sport setting. A number of participants feltit advantageous for the physiotherapist to have an interestin sport, with the ideal being a fellow athlete. This wasexpressed by participant 2, who said, Being a fellow

athlete she knows what I was going through (line 141).Other sport-related factors included the participants

being treated as an athlete, and the physiotherapistshaving the approval of the coach showed that he actuallydid value me as a person and as an athlete (participant7, line 297).

The third area involved the experience of thephysiotherapist. Most participants felt that a wealth ofexperience helped instill both condence and trust intheir physiotherapist. However, perceptions that theirphysiotherapist was experienced were not groundedin factual information and mainly based on judgmentsbecause that physio had worked so well when nothingelse had worked, and I guess that made me trust what a

physio was going to tell me (participant 5, line 172).The last area in this theme was the motivation

provided by the physiotherapist. Participants seemed torecognize that motivation is derived both intrinsicallyand extrinsically. However, they valued the motivationalinput provided and acknowledged that the physiotherapistwas suitably placed to increase motivation, thus aidingincreased adherence: It would probably motivate memore and make me feel more supported so that I couldadhere to my program (participant 7, line 400).

Strategies Used by the Physiotherapist. One of thefeatures most emphasized by participants was the needfor a clear explanation from the physiotherapist to ensure

their understanding. Participants perceived this to comefrom a number of strategies used by the physiotherapist,including drawing pictures, providing exercise sheets(writing exercises down), using a mirror, and demonstrat-ing the desired exercise:

You can look at something with a certain name, crosstwist or whatever, and you think what the hell is that,I cant remember for the life of me unless there isa drawing next to me, and then you think ActuallyI remember exactly what that is and you can pickup on it and do it again quite easily. (participant 7,line 147)

A minority of the participants mentioned that settingappropriate exercises was another strategy used by thephysiotherapist. This included ensuring that exerciseswere of a realistic length, therefore manageable withintime constraints, and were specic to the athlete and hisor her individual requirements: She only gave me 3 or4 exercises and I think I found that pretty easy to imple-ment at the time (participant 7, line 96).

A few participants commented that receiving regulartreatment was important in promoting their adherence.This provided a reminder and further reinforcement to


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complete their exercise program and adhere to the advicegiven. It also provided the chance for regular feedback,ensuring that exercise technique was correct: There wasa period when I seeing her every week or 2 weeks, andtherefore each time I went back she would reinforce theexercises (participant 6, line 74).

Discussion

The purpose of this study was to explore factors thatmay have an effect on rehabilitation adherence froma patient perspective. Two main categories of themeswere identied. The rst related to athletes perceptionsof factors relating to their own adherence and containedthemes relating to the impact of injury, justication ofadherence, and strategies used by the patient. The secondcategory related to the physiotherapist and the percep-tions of the physiotherapists impact on their adherence.This contained themes relating to strategies used by thephysiotherapist and characteristics of the physiotherapist.

The results further highlight the complex nature of

adherence, with psychological and physical componentspresent in both the reasons for lack of adherence and thestrategies used to prevent it. This concurs with the workof Murphy et al,9 in which 3 rehabilitation-relevant setsof variables were identied (the athletes physiologicalreactions, beliefs or cognitions, and observed behaviors),which in combination with factors such as treatmentcharacteristics and previous history all inuence theathletes recovery and return to competition. It appearedthat a central feature of a participants degree of adher-ence was whether a rationale for treatment was providedby the physiotherapist. The results of this study supportthe ndings of Spetch and Kolt,21 who found that animportant step in the rehabilitation process is educating

injured athletes about their particular circumstance. Thisincluded an accurate explanation of treatment rationales,as well as the nature of the injury, realistic expectations,and an understanding of injury management.

The amount and type of education physiotherapistsprovided were further highlighted by participants as keyin helping facilitate adherence. One explanation for thiscould be that athletes may generally have a better under-standing of the human body and therefore want a clearrationale of the rehabilitation prescribed. The importanceof education was also found by Fisher et al5; 91% of thephysiotherapists they questioned thought explanationof the injury was needed, and 83% thought explanationof the rehabilitation regimen was required when gettingathletes cooperation for their rehabilitation program.The study5 also found that a high proportion of physio-therapists thought they needed to be mindful of translat-ing medical terminology and disseminating importantinformation to rehabilitating athletes.

A signicant nding was that the priority participantsgave to their rehabilitation was fundamental in determin-ing their level of adherence. This was closely linked to theself-motivation they intrinsically had and supported theresearch of Fisher and Hoisington22 showing that athletes

reported rehabilitation adherence to be directly related totheir strength of character and intrinsic self-motivation.The personal-investment theory23 can be used to helpunderstand these ndings. This model proposes that 3facets of meaning are critical in determining motivation:personal incentives, sense of self, and perceived options.Previous research has shown that all 3 of these are related

to adherence behavior.24 Similarly, self-motivation is saidto exhibit the same proposed relationships posited forself-efcacy, a factor that seemed to reoccur throughoutthese ndings.25 However, it must be remembered thatmotivation is derived both intrinsically and extrinsically,and although a physiotherapist may be able to motivateexternally for optimal adherence, intrinsic motivation isalso required. Although a physiotherapist may be unableto directly affect intrinsic motivation, it is important torecognize when it is absent because this could be thereason behind less than desirable levels of adherence andproblems that may ensue. This was demonstrated with anumber of participants acknowledging the positive impactexternal motivation by the physiotherapist had, while also

being aware that intrinsic motivation was necessary.It appeared that the effect of the injury and associated

rehabilitation on a participants athletic identity was gen-erally negative. One athlete stated that his athletic identityhad been reduced by the injury and the resulting poorsupport he received from his coach and other athletes.He did comment that the rehabilitation received fromhis physiotherapist and the approach they had adoptedhad helped maintain it. This highlights the importance ofaddressing these patients as athletes and remembering andcontextualizing their rehabilitation in the sport setting.

Although the support networks used by athletesvaried tremendously, it appeared that those who reportedusing social-support sources seemed to illustrate more

effective adherence. This highlights the importance ofathletes using their support networks, but also physio-therapists being aware of the positive impact a supportnetwork can have on an athletes rehabilitation and edu-cating them accordingly. The relationship between thecoach and physiotherapist was an issue alluded to by anumber of participants. This suggests that for successfultreatment a team approach be used, with involvement ofthe coach and interaction between the coach and physio-therapist. This may produce the most favorable environ-ment for optimal adherence to rehabilitation.

Participants also stated that regular feedback wasimportant to increase their adherence. Reasons attributedto this were twofold: It provided feedback on their exercisetechnique and acted as a reinforcement to complete theirdesignated exercises. Levy et al10 found that by givingfeedback to patients performing exercises for a tendinitis-related overuse injury, adherence could be increased.Sluijs et al26 found that adherence to physiotherapyexercise programs was signicantly greater when physio-therapists asked patients for feedback about their progressand treatment, gave patients positive feedback, and regu-larly monitored their exercise performance. Regardingthe physiotherapists characteristics, participants noted


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that having condence and trust in their physiotherapistwith the physiotherapist listening to them and providingempathy was important in promoting adherence. Thesewere the same as factors identied by Potter et al,27 whosought the patients perspective on the qualities of a goodphysiotherapist. The ndings add to the work of Fisher etal5 showing the positive results when therapists use their

skills to enhance commitment to rehabilitation programs.Strategies that participants identied that were useful

to promote adherence were similar to those documentedin previous literature. Participants felt that having theexercises in a written format increased their understand-ing and also prompted their memory for completingtheir program. Memory impairment was an additionalperceived reason for lack of adherence. This correlates toSchneiders et al,28 who found that patients given writtenexercise instructions reported adhering signicantly moreover a 2-week period than those who received exercisesvia verbal instructions alone. It was also felt importantby participants that exercises be specic and of a realisticlength, with it being essential that these could be embed-

ded into their daily routine and lifestyle. Spetch and Kolt21commented that by creating a manageable program thattakes into account an athletes personality, daily routine,and other commitments, adherence could be enhanced.

With regard to the limitations to this study, it isimportant to reect on the sample size. Although the aimof qualitative research is not to recruit a large enoughsample and generalize the ndings to the wider popu-lation, we found that because of the small number ofrespondents17 we were unable to state that it was a truepurposive sample, as hoped, and was, rather, a conve-nience sample. However, it was noted during the inter-view process that several similar points were being raisedand a point of saturation was achieved. Furthermore, this

study used a retrospective design in which participantswere asked to reect back to previous injuries, whichmay have affected perceptions of their experiences. Inaddition, the study did not analyze the variance betweendifferent injury durations and the effect this may havehad on participants adherence and the resulting themesthat emerged. It is also important to note that the aimof the study was to explore issues related to adherenceto all forms of physiotherapy treatment, and thereforethere was no distinction between clinical or home-basedtreatments. The main form of rehabilitation performed byparticipants in this study was home-based exercises, forexample, core-strengthening exercises. We also recognizethat a student physiotherapist conducted the interviews,which could introduce a bias with his preconceptionstoward the importance of adherence to rehabilitation;however, the research team included other disciplines,so we hope this bias was eliminated.

Conclusion

The ndings of this study demonstrate the importance ofgaining patients perspective on the issues they perceiveto affect their adherence to rehabilitation. They also

indicate that for optimal adherence to rehabilitation,physiotherapists working in this eld need to provide aclear rationale for treatment and educate appropriately onthe injury and the rehabilitation provided. They shouldalso provide regular feedback, write down the exercisesgiven, and prescribe a rehabilitation program that can beembedded in the athletes daily routine. A team approach

should also be incorporated, with involvement of an ath-letes coach and support network. Finally, it is vital for thephysiotherapist to address the priority and self-motivationpatients place on their rehabilitation. These are derivedboth intrinsically and extrinsically, with physiotherapistsneeding to contribute externally where appropriate butalso to recognize when intrinsic levels are low becausethis can have a detrimental effect on adherence.

Acknowledgments

The authors would like to acknowledge Bridget Dibb for her

initial contributions and B Brewer for permission to use the

Athletic Identity Screening tool and thank collaborators for

their support and assistance, and of course all participants forvolunteering their time.

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