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‘I’m asking you to believe—not in my ability to create change, but in yours.’ Former US President Barack Obama provides a poignant message for sport and exercise medicine clinicians that relates to rehabilitation adherence (‘adherence’ in this paper): patients have to be their own agent of change; we can not do it for them.
At a time when patients can experience negative psychosocial and emotional responses to injury, their emotional integrity (eg, the honesty of information they share with their treating clinicians) and their ability to make rational decisions can be compromised.1 Think about your own practice; how many times have you had a conversation similar to that in box 1. We know that patients’ home and clinic-based adherence rates are often poor.2 Helping to improve adherence is important as it is associated with better return to sport (RTS) outcomes.3 Therefore, the aims of this editorial are to (a) provide psychologically informed suggestions that can enhance adherence and (b) based on principles of best evidence-synthesis, provide theoretical or empirical underpinning to these suggestions.
Example conversation between clinician and patient
Clinician: ‘Hi there. How are you doing today?’
Patient: ‘Good, thanks’
Clinician: ‘That’s great! Has the injury improved?’
Patient: <Dies a little bit inside> ‘No, not really’
Clinician: ‘Oh, that’s too bad. Have you been doing your rehab activities?’
Patient: ‘Kind of, but not really…I’ve done a bit’
Clinician: <Also dies a little bit inside>
Strategy 1: form strong relationships and provide high-quality social support
Strong clinician–patient relationships and higher levels of perceived social support are associated with improved adherence.1 2 A strong relationship is characterised by clinicians providing clear, honest and understandable informational support to patients. This can create a sense of shared goal commitment with potential to increase patients’ confidence and trust in their clinician, as well as improving patients’ understanding of the benefits of their rehabilitation activities.2 Consequently, the patient can feel more empowered to make informed decisions regarding their rehabilitation behaviours and develop greater autonomous motivation as a result. These factors can improve rehabilitation adherence.4
Strategy 2: encourage patients to maintain the social side of sport
When patients experience satisfaction of the basic psychological needs (see table 1) of autonomy, competence and relatedness, successful RTS postinjury is more likely.5 Advising patients to maintain the social aspect of their sport can help develop perceived social support and a sense of relatedness. Clinicians could facilitate this social aspect by scheduling rehabilitation sessions within the team environment wherever possible (eg, pitch side/in the vicinity of the team). By contrast, removal from both training and socialisation associated with sport can lead to patient isolation and frustration and reductions in adherence.3
Strategy 3: support the patient’s autonomy
We have all worked with the athlete who expects us to ‘make them better’. One way to support an athlete in transitioning away from this passive approach to their rehabilitation is to be a clinician who encourages the patient to be autonomous.6
An autonomy supportive approach is characterised by providing a clear rationale for rehabilitation activities, acknowledging the patient’s feelings and perspectives and providing opportunities for input and decision making.4 In experiencing these conditions, patients can feel like they are engaging in rehabilitation activities of their own volition.
Promoting the patient’s autonomy is positively associated with more autonomous motivation (eg, the patient believing that rehabilitation is important to them and it is in their best interest to adhere) and greater levels of observed and self-reported adherence. Adopting communication styles based on principles of autonomy support can enhance patients’ home-based rehabilitation adherence. Unfortunately, clinicians sometimes create a controlling climate that fails to fully consider patients’ views. The patient attends their rehabilitation session, takes part in a pre-planned exercise mode and has little choice in the activities. This type of climate can create a sense of pressure for patients and a view that clinicians are making decisions without patient consultation, which can reduce adherence.
Strategy 4: use goal-setting techniques with athletes
Prospective correlational evidence7 and randomised controlled trials (RCTs)8 demonstrate that goal setting interventions related to achieving specific rehabilitation criteria; attending a specific number of rehabilitation sessions; profiling improvements and re-adjusting goals improve adherence. Within the goal setting processes, having goals which relate to individual sessions, progression through stages of RTS, RTS goals and lifestyle goals can all benefit the patient. These goals will likely facilitate improved adherence via increases in patient self-efficacy and perceived treatment efficacy8 or simply the patient becoming more focused on achieving a specific outcome.7 Self-report measures are most commonly used to measure adherence, but can lack requisite psychometric properties. Combining psychometric measures with other methods (eg, session observations) can create a more realistic picture of adherence.
Conclusion
By being a source of high-quality social support, supporting the patient’s autonomy, making effective use of goal setting and encouraging relatedness satisfaction, clinicians can enhance patients’ beliefs in their ability to be their own agent of change. These strategies likely complement each other—for example, supporting the patient’s autonomy will likely facilitate greater perceived social support—and their adoption will likely improve in adherence, contributing to improved rehabilitation outcomes with patients as a result.
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Footnotes
Twitter @gleds13, @forsdyke_dale
Contributors AG, DF and TG produced the initial concept of the editorial. All authors contributed to the theoretical and applied considerations within the editorial. AG collated all ideas and produced the final version of the editorial, which was then critically revised by DF and TG to ensure meaningfulness for applied sports medicine practitioners.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests AG serves as an Associate Editor with BJSM.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.