Rehabilitation Psychology © 2000 by the Educational Publishing Foundation

February 2000 Vol. 45, No. 1, 20-37

For personal use only--not for distribution.

Psychological Factors, Rehabilitation Adherence, and Rehabilitation

Outcome After Anterior Cruciate Ligament Reconstruction

Britton W. Brewer
Center for Performance Enhancement and Applied Research , Department of
Psychology Springfield College
Judy L. Van Raalte
Center for Performance Enhancement and Applied Research , Department of
Psychology Springfield College
Allen E. Cornelius
Center for Performance Enhancement and Applied Research , Department of
Psychology Springfield College
Albert J. Petitpas
Center for Performance Enhancement and Applied Research , Department of
Psychology Springfield College
Joseph H. Sklar
New England Orthopedic Surgeons
Mark H. Pohlman
New England Orthopedic Surgeons
Robert J. Krushell
New England Orthopedic Surgeons
Terry D. Ditmar
Baystate Outpatient Rehabilitation
ABSTRACT

Objective: To examine prospectively the relationships among psychological factors,

rehabilitation adherence, and short-term rehabilitation outcome after knee surgery.
Study Design and Participants: Individuals with acute anterior cruciate ligament
(ACL) tears ( N = 95) completed measures of self-motivation, social support, athletic
identity, and psychological distress before reconstructive surgery. After surgery,
participants ( n = 93) reported on their completion of home rehabilitation exercises
and cryotherapy, and their rehabilitation practitioners indicated the patients'
attendance at, and adherence during, rehabilitation sessions. Rehabilitation outcome
measures were taken from participants ( n = 69) approximately 6 months postsurgery.
Main Outcome Measures: Knee laxity, functional ability, and subjective symptoms
were the primary outcomes assessed. Results: Self-motivation was a significant
predictor of home exercise completion; athletic identity and psychological distress
were significant predictors of knee laxity; and attendance at rehabilitation sessions
and home cryotherapy completion were significant predictors of functional ability.
Rehabilitation adherence did not mediate the relationship between psychological
factors and rehabilitation outcome. Conclusions: The prospective associations
obtained among psychological factors, rehabilitation adherence, and short-term
rehabilitation outcome after ACL reconstruction may inform the development of
interventions designed to enhance the rehabilitation of individuals with sport-related
orthopedic injuries.
Recent estimates indicate a high incidence of sport-related and recreation-related
injuries in the United States, with 3—17 million injuries sustained annually by
children and adults in sport and recreational activities ( Bijur et al., 1995 ; Booth,
1987 ; Kraus & Conroy, 1984 ). One of the more prevalent and debilitating sport
injuries is an acute tear of the anterior cruciate ligament (ACL) of the knee (
Derscheid & Feiring, 1987 ; Roos, Ornell, Gardsell, Lohmander, & Lindstrand, 1995
). The ACL is critical in providing stability to the knee joint ( Muller, 1983 ). There is
evidence that the incidence of ACL tears may be increasing ( Natri et al., 1995 ).

For young, active individuals who sustain ACL tears, reconstructive surgery is
considered the treatment of choice ( Marzo & Warren, 1991 ). After surgical
reconstruction of the ACL, physical therapy is considered essential to promote
optimal rehabilitation ( Blair & Wills, 1991 ; DeCarlo, Sell, Shelbourne, & Klootwyk,
1994 ; DeCarlo, Shelbourne, McCarroll, & Rettig, 1992 ; Shelbourne & Wilckens,
1990 ). Postoperative treatment typically involves clinic- and home-based cryotherapy
(icing) and exercises designed to promote strength and flexibility ( Blair & Wills,
1991 ; DeCarlo et al., 1994 ; Shelbourne, Klootwyk, & DeCarlo, 1992 ). Depending
on an individual's insurance coverage, it is not uncommon for the clinic-based
component of rehabilitation to include two to three sessions per week for 2 to 4
months. In contrast to the 9- to 12-month recovery time associated with traditional
postsurgical ACL rehabilitation programs, athletes may return to sport participation as
soon as 3 to 6 months after ACL reconstruction under the accelerated rehabilitation
protocols currently in use ( Blair & Wills, 1991 ; DeCarlo et al., 1994 ).

In contemporary models of psychological response to sport injury ( Brewer, 1994 ;

Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998 ), psychological factors (e.g.,
personal characteristics, situational variables, cognitive responses, and emotional
responses) are thought to influence both rehabilitation behavior (e.g., adherence) and
rehabilitation outcome. Theoretically, as shown in Figure 1 , psychological factors can
affect rehabilitation outcome both directly and indirectly, with the latter relationship
mediated by rehabilitation adherence.

Preliminary research on psychological aspects of sport injury rehabilitation has

provided support for each of the pathways proposed in Figure 1 . With regard to Path
a, a number of psychological factors have been associated with adherence to sport
injury rehabilitation programs (see Brewer, 1998 , for a review), including self-
motivation ( Duda, Smart, & Tappe, 1989 ; Fields, Murphey, Horodyski, & Stopka,
1995 ; Fisher, Domm, & Wuest, 1988 ; Noyes, Matthews, Mooar, & Grood, 1983 ),
social support ( Byerly, Worrell, Gahimer, & Domholdt, 1994 ; Duda et al., 1989 ;
Fisher et al., 1988 ), and mood disturbance ( Brickner, 1997 ; Daly, Brewer, Van
Raalte, Petitpas, & Sklar, 1995 ), a factor associated in previous research ( Brewer,
1993 ) with level of self-identification with the sport role among athletes sustaining
injuries.

As in the general health psychology literature ( Dunbar-Jacob & Schlenk, 1996 ; Hays
et al., 1994 ), findings with respect to Path b have been inconsistent. Case history data
have documented a positive relationship between rehabilitation adherence and
rehabilitation outcome ( Derscheid & Feiring, 1987 ; Hawkins, 1989 ; Meani,
Migliorini, & Tinti, 1986 ; Satterfield, Dowden, & Yasamura, 1990 ). Other studies,
however, have revealed nonsignificant ( Noyes et al., 1983 ) and inverse ( Shelbourne
& Wilckens, 1990 ) adherence—outcome relationships.

Although a number of studies have documented the role of psychological factors in

outcome after joint replacement surgery (e.g., Chamberlain, Petrie, & Azariah, 1992 ;
Orbell, Johnston, Rowley, Espley, & Davey, 1998 ; Sharma et al., 1996 ), Path c has
been examined in only two published studies involving sport injury rehabilitation. The
psychological factors that have been associated with sport injury rehabilitation
outcome are scores on the Minnesota Multiphasic Personality Inventory (MMPI;
Hathaway & McKinley, 1951 ) hypochondriasis and hysteria scales ( Wise, Jackson,
& Rocchio, 1979 ) and the self-reported use of selected coping skills ( Ievleva &
Orlick, 1991 ). Also relevant to Path c, psychological interventions (e.g., biofeedback,
guided imagery, and stress inoculation training) have been shown to enhance sport
injury rehabilitation outcome (see Cupal, 1998 , for a review).

No single sport injury rehabilitation study has examined Paths a, b, and c, and few
studies have tested any of the paths using prospective research designs. Consequently,
the purpose of the current study was to examine the relationships among
psychological factors, rehabilitation adherence, and rehabilitation outcome after ACL
reconstruction using a prospective research design. By collecting psychological,
adherence, and outcome data, it was possible to test the paths hypothesized in Figure
1 and to investigate the extent to which rehabilitation adherence mediates the
relationship between psychological factors and rehabilitation outcome.

METHOD

Participants

Consecutive patients scheduled for ACL reconstruction and subsequent physical

therapy at the clinic where the research was conducted ( N = 113) were recruited for
participation in the study over a 30-month period by their orthopedic surgeon and a
research assistant. Eleven patients refused to participate, 3 were unable to participate
(as a result of language difficulties or lack of parental consent), and 4 were eliminated
from the sample because they either did not have ACL surgery ( n = 2) or had
extensive missing data ( n = 2). The remaining 95 participants (28 female patients and
67 male patients) had a mean age of 26.92 ( SD = 8.23) years. The racial—ethnic
breakdown of the sample was as follows: 84 (88%) White, not of Hispanic origin; 7
(7%) Hispanic; 3 (3%) Black, not of Hispanic origin; and 1 (1%) Asian—Pacific
Islander.

In terms of sport involvement, 49 (52%) participants indicated that they were

competitive athletes, 41 (43%) indicated that they were recreational athletes, 3 (3%)
indicated that they were nonathletes, and 2 (2%) did not respond to the item
requesting this information. The majority of participants indicated that they sustained
their ACL injury while participating in sport ( n = 85; 90%) and that the ACL surgery
was the first time that they had had orthopedic surgery ( n = 60; 63%). Because all
participants had fully torn ACLs, severity of injury was constant across participants.
Of the 95 participants, 26 dropped out of the study before the 6-month postsurgery
assessment (2 participants did not complete any of the adherence measures, and 26
participants did not complete any of the outcome measures).
Measures

Demographic, injury-related, psychological, adherence, and rehabilitation outcome

variables were measured in this study.

Measures of demographic and injury-related variables.

A questionnaire was used to obtain demographic and injury-related information from

participants. The questionnaire included items requesting information on participants'
age, gender, race—ethnicity, date of ACL injury, source of ACL injury (i.e., sport-
related activity or non-sport-related activity), and level of sport involvement (i.e.,
nonathlete, recreational athlete, or competitive athlete).

Psychological measures.

The psychological variables assessed in this investigation were self-motivation, social

support, athletic identity, and psychological distress. Self-motivation was assessed
with the Self-Motivation Inventory (SMI; Dishman & Ickes, 1981 ). The SMI is a 40-
item questionnaire designed to measure "a behavioral tendency to persevere
independent of situational reinforcements" ( Dishman & Ickes, 1981 , p. 421).
Respondents are asked to rate the degree to which statements such as "I'm not very
good at committing myself to do things," "I can persist in spite of pain and
discomfort," and "I'm not very reliable" are characteristic of themselves on 5-point
Likert scales. Empirical support for the reliability, internal consistency, construct
validity, and predictive validity of the SMI in exercise settings has been found (
Dishman & Ickes, 1981 ).

Social support was measured by the Social Support Inventory (SSI; Brown, Alpert,
Lent, Hunt, & Brady, 1988 ; Brown, Brady, Lent, Wolfert, & Hall, 1987 ). The SSI is
a 39-item questionnaire that assesses satisfaction with support and help received from
others over the previous month. Ratings are made on 7-point Likert-type scales
ranging from 1 ( not at all satisfied ) to 7 ( very satisfied ). Examples of items are
"assurance that you are loved and cared about," "information and guidance about how
to cope with your situation," and "information on sources of financial assistance."
Brown et al. (1987 , 1988 ) have obtained evidence for the reliability, construct
validity, and criterion-related validity of the SSI.

The Athletic Identity Measurement Scale (AIMS; Brewer, Van Raalte, & Linder,
1993 ) was used to assess athletic identity, which is the degree to which an individual
identifies with the athlete role. The AIMS is a questionnaire consisting of 10 Likert-
type scales ranging from 1 ( strongly disagree ) to 7 ( strongly agree ). Examples of
items are "I am an athlete," "Sport is the most important part of my life," and "Most of
my friends are athletes." AIMS scores have been found to be predictive of postinjury
psychological distress in athletes ( Brewer, 1993 ). In the preliminary validation study
for the AIMS ( Brewer et al., 1993 ), the measure demonstrated high test—retest
reliability ( r = .89 over a 2-week period) and internal consistency (alpha coefficients
ranging from .81 to .93). AIMS scores increased with self-reported involvement in
sport and were positively correlated with perceived importance of sport but were not
significantly correlated with social desirability, self-esteem, self-rated sports
competence, and coach-rated sport skill ( Brewer et al., 1993 ).
Psychological distress was measured by the Brief Symptom Inventory (BSI;
Derogatis, 1992 ). The BSI consists of 53 items in a 5-point Likert format.
Respondents indicate the extent to which they have been distressed by psychological
and somatic symptoms over the previous 7 days. Published norms for nonpatient
adults, nonpatient adolescents, psychiatric inpatients, and psychiatric outpatients are
available. The reliability and validity of the BSI are well established ( Derogatis, 1992
).

Adherence measures.

Adherence to rehabilitation was measured in three ways. First, patient attendance at

rehabilitation sessions was monitored. For each participant, a ratio of sessions
attended to sessions scheduled was calculated. Attendance has been used as an
adherence measure in previous sport injury research ( Byerly et al., 1994 ; Daly et al.,
1995 ; Derscheid & Feiring, 1987 ; Duda et al., 1989 ; Fields et al., 1995 ; Fisher et
al., 1988 ; Lampton, Lambert, & Yost, 1993 ; Laubach, Brewer, Van Raalte, &
Petitpas, 1996 ; Udry, 1997 ).

Second, at each physical therapy appointment, the practitioner (e.g., physical therapist
or athletic trainer) responsible for the rehabilitation of each participant on that day
completed the Sport Injury Rehabilitation Adherence Scale (SIRAS; Brewer, Van
Raalte, Petitpas, Sklar, & Ditmar, 1995 ). The SIRAS is a three-item measure in
which practitioners rate, on 5-point Likert-type scales, patients' intensity of
completion of rehabilitation exercises, the frequency with which they follow the
practitioner's instructions and advice, and their receptivity to changes in the physical
therapy program during that day's appointment. Scale anchors for the three items are
minimum effort/maximum effort, never/always, and very unreceptive/very receptive,
respectively. The items, which were derived from the adherence literature ( Duda et
al., 1989 ; Meichenbaum & Turk, 1987 ), have been shown to constitute a single
factor accounting for approximately 74% of the variance in SIRAS scores ( Brewer et
al., 1995 ).

Cronbach's alpha coefficients of .81 and .82 ( Brewer et al., 1995 ; Daly et al., 1995 )
have been found for the SIRAS. A test—retest reliability coefficient of .65 has been
obtained for the SIRAS over a 1-week period ( Brewer, Daly, Van Raalte, Petitpas, &
Sklar, 1994 ). In support of the criterion-related validity of the SIRAS, attendance at
rehabilitation sessions has been positively correlated with SIRAS scores in two
studies ( Brewer et al., 1995 ; Daly et al., 1995 ). There is evidence that repeated
administrations of the SIRAS across physical therapy appointments provide an
internally consistent (α = .86) index of adherence during rehabilitation sessions (
Brewer, Van Raalte, Petitpas, Sklar, & Ditmar, 1996 ).

Third, patient self-reports of home exercise and cryotherapy completion were

obtained. At each rehabilitation session, patients reported their degree of completion
of prescribed home exercises and cryotherapy since their last appointment on a scale
ranging from 1 ( none ) to 10 ( all ). Mean SIRAS, home exercise completion, and
home cryotherapy completion scores were calculated for participants across all
rehabilitation sessions attended.

Rehabilitation outcome measures.

Consistent with previous investigations in which ACL rehabilitation outcome was
evaluated (e.g., DeCarlo et al., 1992 ; Engebretsen, Benum, Fasting, Molster, &
Strand, 1990 ; Marder, Raskind, & Carroll, 1991 ; Noyes et al., 1983 ; Shapiro,
Richmond, Rockett, McGrath, & Donaldson, 1996 ; Shelbourne & Nitz, 1990 ;
Shelbourne, Whitaker, McCarroll, Rettig, & Hirschman, 1990 ), multiple measures of
ACL rehabilitation outcome were taken. Specifically, laxity, functional ability, and
subjective symptoms were assessed.

An instrumented evaluation of anterior—posterior laxity of the knee joint was

conducted with a KT1000 knee arthrometer (MEDmetric Corporation, San Diego,
CA). Trials were conducted for both the involved and uninvolved knees, and values
were recorded at 15 pounds (6.75 kg) of force. A mean difference in KT1000 scores
between the involved and uninvolved knees was calculated for each participant. In
vitro and in vivo data support the reliability and validity of the KT1000 as a measure
of knee laxity ( Daniel, Malcom, et al., 1985 ; Daniel, Stone, Sachs, & Malcom, 1985
; Malcom, Daniel, Stone, & Sachs, 1985 ).

The one-leg hop for distance ( Daniel, Stone, Riehl, & Moore, 1984 ) was used as a
test of functional ability. In this test, patients hopped for distance on one leg, taking
off and landing with the same leg. Hop distances were recorded in centimeters. Both
the involved and uninvolved legs were tested three times in the one-leg hop. A mean
hop index score was calculated by dividing the mean distance hopped on the involved
leg across the three trials by the mean distance hopped on the uninvolved leg (
Kramer, Nusca, Fowler, & Webster-Bogaert, 1992 ). Kramer et al. have obtained
support for the test—retest reliability of the hop index (intraclass correlation
coefficient: .81). The index has been used effectively to evaluate the rehabilitation of
ACL injuries ( Tegner, Lysholm, Lysholm, & Gillquist, 1986 ).

Subjective symptoms were assessed with the Lysholm Knee Scoring Scale ( Lysholm
& Gillquist, 1982 ; Tegner & Lysholm, 1985 ), a patient self-report instrument. The
questionnaire has items pertaining to limping, support, locking, instability, pain,
swelling, stair climbing, and squatting. Responses to each of the eight items are
assigned a point value, and a total score is obtained by summing across the items.
Total scores can range from 0 to 100. Support for the test—retest reliability of the
scale (coefficient of variation: ±2.8% over a 3-day period) has been documented (
Lysholm & Gillquist, 1982 ). Scores on the Lysholm Knee Scoring Scale have been
shown to correlate positively with activity level after ACL injury ( Tegner &
Lysholm, 1985 ) and have been used to evaluate knee functioning after ACL
reconstruction ( Draper & Ladd, 1993 ).

Procedure

Patients were recruited as participants by the three orthopedic surgeons on the project
before their ACL reconstructive surgery. A research assistant described the purpose
and procedures of the study to the patients who expressed interest in participating.
Patients who agreed to participate in the study (and their parents or guardians when
appropriate) read and completed an informed-consent form at their preoperative
physical therapy appointment approximately 10 days before reconstructive surgery.
At this time, participants were administered a battery of psychological questionnaires
(including demographic and injury-related items, the SMI, the SSI, the AIMS, and the
BSI).

After reconstructive surgery, measures of adherence to rehabilitation were taken at

each scheduled physical therapy appointment. Attendance—nonattendance was
documented, the SIRAS was administered to the physical therapist or athletic trainer
most involved with the patient's rehabilitation, and patient ratings of home exercise
and cryotherapy completion in the time since the previous appointment were obtained.

The accelerated rehabilitation protocol after ACL reconstruction developed by

Shelbourne and his colleagues ( DeCarlo et al., 1992 ; Shelbourne et al., 1992 ;
Shelbourne & Nitz, 1990 ; Shelbourne & Wilckens, 1990 ) and recently updated (
DeCarlo et al., 1994 ) was prescribed by the orthopedic surgeons and followed by the
physical therapists affiliated with the proposed study. This physical therapy protocol,
which has been found superior to traditional, more conservative approaches ( DeCarlo
et al., 1992 ), emphasizes early attainment of range of motion (extension and flexion
of the knee), quadriceps strength, and normal gait ( DeCarlo et al., 1994 ; Shelbourne
et al., 1992 ; Shelbourne & Nitz, 1990 ).

Rehabilitation outcome measures were administered as a regular part of patients'

rehabilitation program approximately 6 months after reconstructive surgery. A
physician assistant and the physical therapist responsible for each patient's treatment
conducted the rehabilitation assessments. The physician assistant, who performed the
KT1000 tests, was unaware of participants' responses to the presurgical questionnaire
battery and adherence data. The physical therapist was unaware of participants'
responses to the presurgical questionnaire battery and the questionnaires requesting
information on completion of home exercises and cryotherapy.

Data Screening

Independent t tests were conducted to determine whether the participants who

dropped out differed from those who remained in the study in regard to variables
measured before surgery (e.g., age, self-motivation, social support, athletic identity,
and psychological distress). No significant differences were found, indicating the
presurgical equivalence of the participants who dropped out and those who remained
in the study on these variables. Although follow-up data are unavailable for most of
the participants who did not complete the study, several participants indicated that
they dropped out of the study for practical reasons, such as moving to another town or
transferring to a clinic closer to home.

Cronbach alpha coefficients for the self-motivation, social support, athletic identity,
and psychological distress measures used in the presurgical assessment were .92, .
97, .87, and .96, respectively. Because of skewed distributions, transformations were
applied to several variables. The distribution for the BSI was positively skewed, and a
log transformation produced a more normal distribution. The distribution for the
SIRAS was negatively skewed, and a reflection and an inverse transformation
produced a more normal distribution. As a result of missing data on some variables
for some participants, the number of participants available for each of the main
analyses varied slightly.
 RESULTS

Means, standard deviations, and intercorrelations of psychological, adherence, and

outcome measures are presented in Table 1 . To examine the potential influence of
demographic factors on the findings, we calculated Pearson correlations between age
and the adherence and outcome measures and performed t tests on the adherence and
outcome measures using gender, source of ACL injury, and prior orthopedic surgery
experience as independent variables. Age was significantly correlated with one-leg
hop scores ( r = −.36, p < .05). Participants with prior orthopedic surgery experience
had significantly lower KT1000 scores than participants without prior orthopedic
surgery experience, t (55) = −2.57, p < .05. All other correlations and t tests involving
demographic factors were not statistically significant. On the basis of these results,
age was used as a covariate in all analyses in which one-leg hop scores were the
criterion, and prior orthopedic surgery experience was used as a covariate in all
analyses in which KT1000 scores were the criterion.

To evaluate prospective relationships between psychological factors and adherence to

rehabilitation after ACL reconstruction, we calculated a set of regression analyses in
which the four psychological factors assessed before surgery (i.e., self-motivation,
social support, athletic identity, and psychological distress) were used to predict the
four adherence measures (i.e., attendance, SIRAS score, home exercise completion,
and home cryotherapy completion) in four separate regression equations. Separate
analyses were used for the four adherence measures because they were generally
uncorrelated with each other, with the exception of the home exercises and home
cryotherapy scores. The regression equation predicting home exercise completion was
statistically significant, F (4, 51) = 4.55, p < .005, R 2 = .26. Self-motivation (β = .39,
p < .05) was the sole significant predictor of home exercise completion from among
the psychological measures. The regression equation predicting SIRAS scores
approached statistical significance, F (4, 51) = 2.17, p < .10, R 2 = .15. Social support
(β = .27, p < .10) approached statistical significance as a predictor of SIRAS scores.
The regression equations predicting attendance and home cryotherapy completion
were not statistically significant.

To examine the relation between psychological factors and short-term postsurgical

rehabilitation outcome after ACL reconstruction, we calculated a set of regression
analyses in which the four psychological factors assessed before surgery (i.e., self-
motivation, social support, athletic identity, and psychological distress) were used to
predict the three rehabilitation outcome measures (i.e., KT1000, one-leg hop, and
subjective symptoms) in three separate regression equations. Separate analyses were
used for the three rehabilitation outcome measures because they were uncorrelated
with each other. The regression equation predicting KT1000 scores was statistically
significant, F (5, 34) = 4.88, p < .005, R 2 = .42. Psychological factors accounted for a
significant proportion of variance in KT1000 scores over and above prior orthopedic
surgery experience, F (4, 34) = 4.75, p < .005. Athletic identity (β = .36, p < .05) and
psychological distress (β = −.46, p < .01) emerged as significant predictors of KT1000
scores. The regression equations predicting one-leg hop performance and subjective
symptoms were not statistically significant.
To test the hypothesis that adherence to rehabilitation is positively associated with
short-term rehabilitation outcome after ACL reconstruction we conducted a set of
regression analyses in which adherence measures (i.e., attendance, SIRAS score,
home exercise completion, and home cryotherapy completion) were used to predict
rehabilitation outcome measures (i.e., KT1000, one-leg hop, and subjective
symptoms) in three separate regression equations. Only the regression equation
predicting the one-leg hop index was statistically significant, F (5, 44) = 4.70, p < .05,
R 2 = .35. Adherence measures accounted for a significant proportion of variance in
the one-leg hop index over and above age, F (4, 44) = 3.89, p < .01. Attendance (β = .
28, p < .05), SIRAS scores (β = .28, p < .05), and home cryotherapy completion (β =
−.36, p < .05) were significant predictors of the one-leg hop index. Because none of
the adherence measures were significantly correlated with both psychological and
outcome measures, the criteria for mediation were not satisfied ( Baron & Kenny,
1986 ), and further analyses were not carried out.

DISCUSSION

In this study, selected psychological factors were associated prospectively with

rehabilitation adherence and rehabilitation outcome after ACL reconstruction.
Consistent with previous research ( Duda et al., 1989 ; Fields et al., 1995 ; Fisher et
al., 1988 ; Noyes et al., 1983 ), self-motivation emerged as a significant predictor of
rehabilitation adherence (i.e., home exercise completion). Athletic identity and
psychological distress were significant predictors of rehabilitation outcome (i.e., knee
laxity) such that higher athletic identity and lower psychological distress were
associated with a more favorable outcome. Adherence, in the form of attendance at
rehabilitation sessions, and home cryotherapy completion were related to one of the
three rehabilitation outcomes assessed (i.e., functional ability). Contrary to the
hypothesized pattern of results, adherence did not mediate the relationship between
psychological factors and rehabilitation outcome. Thus, with reference to Figure 1 ,
partial support was obtained for Paths a, b, and c but not the mediated path from
psychological factors to rehabilitation outcome through rehabilitation adherence (by
way of Paths a and b).

The positive correlation between attendance at rehabilitation sessions and functional

ability augments similar findings by Derscheid and Feiring (1987) for ACL
reconstruction and suggests that patients benefit from participating in clinic-based
rehabilitation activities. A possible interpretation of the inverse relationship found
between home cryotherapy completion and functional ability is that patients who are
recovering better experience less pain and thereby initiate less direct treatment.

A logical explanation for the significant relationships of athletic identity and

psychological distress to knee laxity involves greater adherence–and, therefore, better
rehabilitation outcome (i.e., less laxity)–for patients more strongly self-identified as
athletes and less distressed. Because neither athletic identity nor psychological
distress was associated with rehabilitation adherence, however, this explanation is not
tenable. It is possible that the more athletically self-identified patients were more fit
before surgery and therefore responded more favorably to reconstructive surgery than
the less athletically self-identified patients. It is also possible that presurgical
psychological distress influenced immune functioning, which in turn affected
postsurgical healing ( Herbert & Cohen, 1993 ; Roitt, 1997 ). These explanations are
speculative, though, and warrant further exploration.

The current study has some limitations that should be addressed in future research.
First, although it was reasonable to select a 6-month period after ACL reconstruction
for the assessment of rehabilitation outcome based on the physical therapy protocol
used for participants ( DeCarlo et al., 1992 ; Shelbourne et al., 1992 ; Shelbourne &
Nitz, 1990 ), the study may have been of insufficient duration for the influences of
psychological factors and rehabilitation adherence on rehabilitation outcome to fully
emerge. In the Wise et al. (1979) study, associations between presurgical
psychological variables and rehabilitation outcome were evident 1 to 3 years after
knee surgery. Consequently, rehabilitation outcome should be assessed at regular
intervals over a longer time period in subsequent investigations.

Second, given the difficulties associated with having volunteer participants engaged
in research over a long period of time, it may be important to offer research
participation incentives. Such incentives, which would help curb participant attrition
(26% in this study) and the accompanying loss of statistical power, would be
especially critical for studies of longer duration than the present study.

Third, prospective assessment of rehabilitation outcome variables (e.g., knee laxity

and subjective symptoms) would allow participants to serve as their own controls and
would account for a large portion of error variance in the rehabilitation outcome
measures, thereby increasing the likelihood of obtaining significant relationships with
the outcome variables. Even without this preoperative assessment, however,
significant relationships were found with functional ability and knee laxity in the
current study.

Fourth, although the assessment of adherence to home rehabilitation regimens in the

current study represented an improvement over previous investigations of home-based
sport injury rehabilitation adherence ( Almekinders & Almekinders, 1994 ; Noyes et
al., 1983 ; Taylor & May, 1996 ), retrospective self-reports of adherence can be
subject to biased, distorted, or inaccurate recall ( Dunbar-Jacob, Dunning, & Dwyer,
1993 ; Meichenbaum & Turk, 1987 ). Further improvements are possible by obtaining
daily self-reports (cf. Stone, Kessler, & Haythornthwaite, 1991 ) and objective
measurements (e.g., Levitt, Deisinger, Wall, Ford, & Cassisi, 1996 ) of adherence to
home rehabilitation activities.

The preliminary results obtained in this study suggest the possibility that
psychological interventions designed to reduce psychological distress and enhance
rehabilitation adherence could enhance the rehabilitation of sport-related orthopedic
injuries in general and ACL tears in particular. Before such interventions are
developed, implemented, and evaluated (e.g., Fisher, Scriber, Matheny, Alderman, &
Bitting, 1993 ; Worrell, 1992 ), however, it is necessary to determine that improving
adherence also improves rehabilitation outcome. Research is needed to assess more
thoroughly the relationship between adherence to rehabilitation protocols and
outcome after ACL reconstruction. Further inquiry in this area has the potential to
provide an empirical basis for psychologists to better serve people undergoing
rehabilitation of sport- and recreation-related injuries.
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This article was supported in part by Grant R15 AR42087-01 from the National
Institute of Arthritis and Musculoskeletal and Skin Diseases. Its contents are solely
the responsibility of the authors and do not represent the official views of the National
Institute of Arthritis and Musculoskeletal and Skin Diseases.
We thank Mark Andersen for his helpful comments on an earlier version and Marc
Aconcio, Michael Astilla, Matt Bitsko, John Brickner, Chris Buntrock, Wally Bzdell,
Catherine D'Agostino, Doug Harvey, Ron Hokanson, Miriam Holmes, Chris Izzo,
Kelly Kane, Greg Kelleter, Dave LaLiberty, Jeff Laubach, Tara Nichols, Julie
O'Brien, Jeff Rice, Eric Rienecker, Trina Runge, Corinne Smith, Ken Tubilleja, Faye
Weiner, Jere Weinstock, Heidi Wolcott, Kathy Wurster, and Mark Yunger for their
assistance in data collection.
Correspondence may be addressed to Britton W. Brewer, Department of Psychology,
Springfield College, Springfield, Massachusetts , 01109.
Electronic mail may be sent to bbrewer@spfldcol.edu
Received: March 1, 1999
Revised: June 7, 1999
Accepted: August 13, 1999

Table 1. Means, Standard Deviations, and Intercorrelations of Psychological,

Adherence, and Outcome Measures
Figure 1. Schematic Representation of Hypothesized Relationships Among
Psychological Factors, Rehabilitation Adherence, and Rehabilitation Outcome.