Adherence to Anterior Cruciate Ligament Rehabilitation : A Qualitative Analysis

Objective: To investigate the subjective experience of anterior cruciate ligament (ACL) rehabilitation and identify variables that influence adherence as perceived by ACLreconstructed patients. Design: A qualitative study using in-depth interviews to gather data and thematic coding to analyze findings. Setting: Participants were interviewed at home or in their workplace. Participants: Eleven patients were interviewed at an average of 4.8 months (SD = 0.8) after ACL reconstruction. Results: Using thematic coding of the interview data, 3 categories of variables influencing adherence emerged: environmental factors, physical factors, and psychological factors. Variables specifically affecting adherence to home exercise were perceived lack of time and a lack of self-motivation. Fear of reinjury emerged as a significant consideration for those who were nonadherent. Factors such as therapist support, the rehabilitation clinic, and the progression of exercises were identified as being important for attendance at physiotherapy appointments and adherence during appointments.

Rehabilitation after anterior crudate ligament (ACL) reconstruction requires a substantial commitment over an extended period of time, and a perception exists that adherence to ACL rehabilitation is essential for an optimal outcome.'In recent years, research attention has focused on factors affecting adherence to sports-injury rehabilitation, including ACL rehabilitation.T he limitation of much of this research is that the variables that detennine the multifactorial construct of adherence have been identified using quantitative measurement scales, resulting in a somewhat fragmented representation of rehabilitation adherence.Across the medical, psychological, and physical domains of rehabilitation over 200 variables relating to adherence have been examined.*Quantitative investigations of rehabilitation adherence are generally restricted to the examination of a limited number of these variables and are further hampered by the need to identify and employ reliable and valid measurement tools.
A recent investigation attempted to address the scarcity of qualitative research in the area of adherence to orthopedic rehabilitation by interviewing and examining the rehabilitation experiences of 20 patients with knee osteoarthritis.^Data were thematically coded and a model developed to help identify reasons for adherence or nonadherence with physiotherapy rehabilitation for patients with knee osteoarthritis.The authors suggested that a sirrular method be undertaken during research into other areas of rehabilitation adherence.
The analysis of the experience of ACL rehabilitation and the various influences on its completion lends itself to a qualitative approach.Such an approach permits a comprehensive account of the rehabilitation experience and die many variables affecting adherence.In response to discrepancies in the literature regarding adherence detemunants and the dearth of qualitative analysis of such a complex issue, a qualitative investigation was undertaken.The aim of this qualitative study was to identify variables that influence adherence to rehabilitation after ACL reconstruction.

Method
Eleven ACL-reconstructed patients were interviewed at an average of 4.8 months (SD = 0.8) into the rehabilitation process.Participants were selected from a larger research project analyzing the adherence-outcome relationship in ACL rehabilitation.In the larger study, adherence was measured using scores of attendance at physiotherapy appointments, therapist ratings of patient adherence during appointments, and self-reported adherence to home-exercise programs (including self-directed gymnasium workouts).
To allow a comparison between factors that influence rehabilitation in adherers and nonadherers, a stratified purposive sampling technique was employed.Such a technique attempts to capture major variations by selecting a sample of above-average, average, and below-average cases.'Because participants attended most physiotherapy appointments and were judged by their therapists to be adherent during physiotherapy, the sample was stratified based on adherence to home-exercise completion.Home adherence rates were determined using self-report diaries over the first 12 weeks of rehabilitation.Diaries were returned weekly to the principal researcher and contained information regarding the ntmiber of exercises completed each day.Of the 11 participants, 5 were adherent (>80% completion of home exercises), 1 was moderately adherent (60% to 70% completion of home exercises), and 5 were nonadherent (<60% home-exercise completion) in the larger study.The classification of adherence percentages was based on previous literature.^' In addition to selecting a variable sample with respect to home-exercise adherence, we sought variation among participants with relation to gender, age, occupation, and sporting level.Participant characteristics are presented in Table 1.All participants had sustained a rupture of the ACL and had been treated with an ACL reconstruction by 1 of 3 participating orthopedic surgeons.Seven participants were treated with hamstring grafts, and 4 with patellar-tendon grafts, and rehabilitation was undertaken at 5 different physiotherapy clirucs.Participants were required to be between 16 and 55 years of age and were excluded if they displayed coinciding collateral ligamentous laxity greater than grade II, required repair of the posterior cruciate ligament, displayed chondral lesions with exposed subchondral bone or radiographic or arthroscopic evidence of osteoarthritis, had been ACL deficient for more than 12 months, or had had a prior ACL reconstruction.
After ethics-committee approval, 12 participants were contacted by telephone to determine their willingness to partake in the study and arrange a convergent interview time and location.Only 1 selected participant declined to be interviewed, citing study commitments as the reason, leaving 11 participants.The interviews lasted 45-90 minutes and took place between April and December 2000.The primary investigator conducted all interviews, and the participants chose the times and settings of the interviews.Nine of the interviews were conducted at participants' homes, and 2 were conducted at participants' workplaces.The primary investigator was known to all participants as a result of recruitment for the larger study and earlier testing in the rehabilitation process, but none of the investigators were involved in participant rehabilitation.Interviews were tape-recorded with permission from the interviewees.The tape recordings provided exact accounts of what was said in the interviews and enabled accurate transcription of the conversations.
In-depth interviews were chosen to allow exploration of the experience of ACL injury, ACL rehabilitation, and the various influences on the completion of rehabilitation.A preliminary schedule of questions was developed and was intended to guide the interview and ensure that important areas pertaining to the study aims were covered.The schedule contained broad areas to be discussed and was revised as new topics were raised during interviews.The broad areas included the injury and process to surgery, the rehabilitation experience, factors that made rehabilitation easy or difficult to complete, relationships with therapists and medical practitioners, and the impact of being in the larger study on rehabilitation.
Each interview was transcribed from tape recordings by the principal researcher.Copies of the transcripts were sent to all participants to check the accuracy of the transcription, with an invitation to make changes or additions.Member checking is a method used to enhance credibility by ensuring that data are accurate.'"Only minor modifications were offered (ie, spelling mistakes), and 1 participant expanded on details of the diagnosis of his ACL rupture.Transcripts were then edited to remove information that could reveal the identity of the interviewees.All participant names were changed to pseudonyms, and physiotherapy clinics, therapists, and surgeons were also coded.

Data Analysis
After the completion of all interviews, the schedule of questions was revisited by the principal researcher (TP) and one co-researcher (HMcB), and notes were made regarding possible emerging themes from the areas covered in the schedule.The transcripts were independently read and reread by the researchers and any thoughts about their content and general themes noted.Using QSR NUD*IST 4 (Nonnumerical Unstructured Data Indexing Searching and Theorizing) software (Qualitative Solutions & Research Pty Ltd, Australia), the principal researcher examined each interview individually, line by line, and freely developed categories to classify and sort ideas and comments.QSR NUD*IST 4 allows efficient storage of transcript data, coding of data in a flexible index system, and text and pattern searches and supports the organization and analysis of data."All passages were coded using a descriptive word to identify the category.Of particular interest were the comments relating to the 3 aspects of adherence (attendance, adherence during appointments, and home-exercise adherence).While the principal researcher was coding the data, one co-researcher (HMcB) independently categorized the data using a manual method of coding.This coder was blinded to the adherence status of the interviewees.
Once both researchers had completed initial coding, the codes were compared, and any discrepancies in the coding were discussed with a third independent researcher (NT).This technique of peer examination enhances the robustness of the findings.'"The themes identified by both researchers were very similar, and clarification was orUy necessary for naming categories where descriptors were different.Codes were collapsed by grouping together related or similar codes under new headings, and coding was redefined and tmited until 3 main themes emerged.

Results
The 3 categories of variables identified by participants as influencing rehabilitafion adherence were environmental, physical, and psychological factors.Figure 1 shows a flowchart derived from themafic coding of the variables and their themafic groupings.

Environmental Factors
The major environmental factor infiuencing the complefion of home exercise was reporfed to be lack of fime.An abundance of work, holiday, family, and social commitments depleted the amount of time available for rehabilitafion.With "just too much (going on) in life" (Belinda), some foimd that "trying to do rehab around that did get quite difficult" (Mary).This was mairJy true for the nonadherent parficipants in the study, but it was also noted that lack of fime was often used as an excuse for nonadherence despite adequate time being available.Adherent parficipants tended to idenfify fime availability as a factor in adhering to rehabilitafion but also emphasized the need for greater organizafion when fime was limited.
Being a mother ... you have to priorifize and you get to be good at doing that you know, so you sort of like think "I've got to do this, I've got to do that," and in your mind you're already thir\king "I've planned this and planned that," and we can do it you know....You just priorifize what you need to do and get the job done.(Jane) Other environmental factors such as the support provided by the treating physiotherapist, the comfort and convenience of the rehabilitafion clinic, and the constant progression of program exercises were important influences on attendance at rehabilitafion facilifies for all parficipants.These factors did not, however, influence adherence to home-exercise programs.
The most significant part of the rehabilitafion process for most parficipants was their interacfion with their physiotherapists.Physiotherapists were described as friendly, knowledgeable, and supporfive, and most respondents indicated that their posifive relafionship with the therapist helped with attending the clinic and completing rehabilitafion at appointments.The informafional and emofional support provided by physiotherapists throughout rehabilitafion was important to all parficipants.Parficularly in the inifial stages of rehabilitafion, informafion regarding the injury and rehabilitafion process was thought to be vital for adherence.When informafion was lacking, nonadherence resulted.I started physio 3 weeks after my operafion. . . .The people at the hospital didn't really iriform me of whaf I had to do.I mean maybe it was naive to think I'd get a phone call to say "You have to start physio," but I suppose thaf s what I was thinking at the fime.I wish I'd have known and I would have started it earlier.I mean, I knew I had that sheet from the hospital, but yeah I saw the physios actually twice in the hospital, on 2 separate occasions, and I wish they'd have stressed more that the first couple of weeks was the most important, just to keep it moving moving moving, because I don't think I moved it enough.And I think that... took me longer to get started.So, the first couple of weeks of physio was sort of like behind.(Belinda) Another idenfified method of obtaining progress informafion was comparing progress with that of other injured people, writh expected milestones, or with the opposite leg.This form of benchmarking played a significant role throughout the rehabilitafion process for nearly all parficipants.
And it was also encouraging for me because when I'd ask some people where they were at, and it got to a point probably after 3 weeks I found I was even better than most people who were so much further than me.Like there was 1 girl who was 8 weeks and I was at 3 weeks, and I honestly believed I was better than her, even That was really encouraging for me, sort of like my compefifive streak came out I had to be better than everybody.So, that made me work harder, too.(Jessica) Environmental program factors menfioned by nonadherent parficipants as affecting home-exercise adherence included the extended length of the rehabilitafion process, the isolafion of the program, the repefifion of exercises, the lack of perceived effecfiveness of the exercises, the cost of rehabilitafion (attending a private gym), and the lack of availability of equipment.Particularly significant was the availability of equipment.The percepfion that "there was just some things that I couldn't do (at home)" (Armie) was a result of lack of equipment such as weights, "just because I simply have to have them" (Leah) to perfonn the exercise.Individual exercises, or in some instances whole sessions, were relinquished, with nonadherent parficipants opting to "wait and do them in physio" (Annie) because of a lack of equipment: "I did no exercises at home.I strictly went to the physio to do them and then forgot about it for the rest of the fimes, which I don't know how good that is He had all the equipment" (James).
Lack of equipment was not idenfified as a problem for the adherers; in fact, 1 parficipant went to great lengths to ensure that lack of equipment would not hamper the rehabilitafion process.
I was pretty lucky because I've got one of the balls at home . . . the exercise balls ... and the gym I go to is pretty well equipped so I've got pretty much everything there....So I worked out what I had at the gym and what I could use for the rehab.And I constructed a few little things, I made a wobble board for myself and made a little strap for the leg to do some of the exercises at the gym, I played around and made a few things.(Jeff)

Physical Factors
A significant difference between adherers and nonadherers emerged when examining the irifluence of physical factors and coding ideas about return to sport and regaining normal function.Adherent respondents regarded return to sport as a mofivating and exciting prospect that helped drive their rehabilitafion."Oh yeah, the desire to get back to sport, because I realized that was my passion, has just driven me all the way" (Jessica)."That's sort of a mofivafion to keep going to the gym every day because you know if you do all the hard work that you'll be playing again"(Mark).
Conversely, 4 of the 5 nonadherent respondents spoke about their fear associated with return to sport and talked about delaying the return to sport despite advice from surgeons and physiotherapists promoting an early return."I'll see how I feel and how it goes.I'm not in a rush to get back because I know it's not worth it.I can sfiU feel the pain" (Leah).
Physical factors such as pain, fafigue, and illness were idenfified as having only a transient influence on adherence at various stages throughout rehabilitafion, typically for the nonadherent respondents."If I was sick I didn't do them" (Belinda).
Maintaining fitness and body weight was recognized by a few respondents as being a mofivating factor for exercising and completing rehabilitafion, and the percepfion of progress had a mixed affect on adherence.The belief that the knee rehabilitation was ahead of schedule or on track was enough for some nonadherent parficipants to relax rehabilitafion constraints somewhat: "Because L [physio] said I was ahead of things I felt like maybe I didn't have to work as hard" (Annie).For the adherent participants, however, being on track was further mofivation to work hard and progress through rehabilitafion milestones.

Psychological Factors
The most significant psychological characterisfic was that of self-mofivafion.The word motivation was used consistently by all respondents throughout the interviews, and mofivation was perceived to be extremely important for complefion of home exercises."Mofivation.I guess if they could sell mofivafion in a bottle it would be a gold rrune" (Colin).Mofivafion of the self appeared to be parficularly difficult for the nonadherent interviewees, most noting the need for an external influence to manufacture mofivafion.Exercising with a friend, a team, in physiotherapy, and under instrucfion from another person were all methods of promofing mofivafion and complefing rehabilitafion.Adherent respondents talked of being motivated throughout the rehabilitafion process whether external influences were present or not.
The adherent respondents displayed greater self-direcfion of rehabilitafion.They controlled the amount, intensity, and progress of rehabilitafion, relying less on physiotherapists' input.Self-efficacy (the belief in one's ability to perfonn a particular behavior),^^ however, was not an obvious influence on rehabilitafion adherence.
Enjoyment of rehabilitafion contributed to most of the adherent parficipants completing rehabilitafion outside of the clinic.Enjoyment of rehabilitafion for nonadherent parficipants was menfioned only with reference to completing the program in the clinic.In fact, lack of enjoyment was idenfified by nonadherent respondents as a factor contribufing to failure of home-exercise complefion.Home exercises were described as "boring more than anything" (Armie), "not quite as fun" (Colin) as team acfivifies, "mundane stuff, . . .not really that stimulating" (Leah), and "silly, stupid, . . .wasting my time" (Belinda).The lack of enjoyment evident from these comments had implicafions for complefion of home exercises, parficularly over an extended period of fime.
The desire to please either the treafing physiotherapist or the surgeon infiuenced adherence to some degree in half the respondents, although there was no difference in this respect between adherent and nonadherent parficipants.

Discussion
The 3 themes that emerged from the data are consistent with previous literature that separates determinants of rehabilitafion adherence into situafional factors (incorporating environmental and physical factors) and personal factors (incorporating psychological factors).^-^Considering the fact that over 200 variables have been idenfified in the literature as influencing rehabilitafion adherence,* it is not surprising that many of the variables idenfified in the present study are consistent with previous research.
Of the environmental factors, tim^e availability was the most significant influence on home-exercise complefion.Perceived lack of time has been identified consistenfiy in the exerdse literature as the most common reason for dis-continuing an exercise program.""^*Research on adherence to physiotherapy has also found that noncompliant patients idenfified lack of fime and busy daily roufines as a major barrier to completing rehabil-.^'' In the present study, nonadherent parficipants idenfified lack of time because of work, holiday, family, and social commitments as a major reason for nonadherence to home exercise.The percepfion of linnited fime availability could in fact be a consequence of poor organizafion of available fime.'^This hypothesis is supported by the work of Dishman, Sallis, and Orenstein,^* who found that regular exercisers in their study were as likely as the sedentary to view time as a barrier to exercise.
Although not significant for home-exercise adherence, the treating physiotherapist's provision of support was important to all parficipants and posifively infiuenced attendance at appointments.Other qualitative research into the provision of support to injured athletes has idenfified the physiotherapist as an important source of informafional support throughout the rehabilitation process."-^" Informafional support in the form of benchmarking, idenfified by nearly all parficipanfs as having an influence on mofivation and adherence, is consistent with the qualitafive research of Johnston and Carrol.^'Benchmarking was of use mairJy during appointments when other pafients were present or milestones were identified.Although most parficipants admitted to employing the technique of benchmarking to improve mofivation, there was no difference in this regard between adherers and nonadherers of home exercise.
The length, isolafion, repetifion, efficacy, and cost of the rehabilitafion program were issues for some of the nonadherent parficipants and did affect home-exercise complefion.These program factors and others have been idenfified in reviews of the rehabilitation-adherence literature.^'^The availability of equipment for rehabilitation emerged as one of the most significant program factors and has important implicafions for exercise prescripfion for ACL rehabilitafion.Home-equipment availability has been posifively correlated with self-reported physical activity in 1 study invesfigafing the effect of perceived physical environments on physical acfivity.^'Overall, environmental factors had a significant impact on adherence to physiotherapy appointments, adherence during physiotherapy, and adherence outside of physiotherapy.Lack of time and the availability of equipment were the most important variables infiuencing adherence to home exercise, whereas therapist support was important for attendance at physiotherapy sessions.
The analysis of the contribufion of physical factors to adherence identified arguably the most interesting finding from the interview data.Nonadherent parficipants spoke about the desire to delay a return to normal function and articulated that the fear associated with return to sport was considerable.This is an interesfing phenomenon in light of the fact that the decision to have surgery in the first place was based on the desire to return to sport or acfivity.Such a finding provokes a discussion of what came first.Is it that the fear of reinjury was already present and nonadherence is a method of delaying return to sport and funcfion, thus waylaying the negafive fear emofion?Or conversely, does nonadherence effecfively reduce confidence in the knee and inifiate the fear of reinjury?This is a fascinafing finding that deserves further investigafion.The fear of return to sport could be considered a psychological factor but was coded under physical factors because the fear was a response to the physical function of return to acfivity.Other physical factors appeared to have a limited infiuence on adherence.
Self-motivafion was the most important psychological factor affecting adherence, parficularly home-exercise adherence.Adherent participants were mofivated to complete rehabilitafion irrespecfive of exfemal factors, whereas nonadherent parficipants relied heavily on external mofivafion.External mofivating factors might not be consistent, parficularly over an extended period of fime, and at fimes when external factors are few (eg, when physiotherapy is disconfinued) the reliance on self-mofivafion is increased.At these fimes (for those with low self-mofivafion) rehabilitation adherence appeared to suffer.^This is consistent with the qualitafive research into reasons for adherence to physiotherapy rehabilitafion for knee osteoarthrifis.^Pafients with knee osteoarthrifis undertaking a rehabilitafion program found it difficult to continue rehabilitafion after being discharged from physiotherapy.The quanfitafive literature has also consistently linked self-mofivafion with improved adherence to rehabilitafion.^Variables closely linked with self-mofivafion and idenfified as determinants of adherence in this research were self-direcfion and enjoyment.^-Ŝelf-efficacy, however, a trait that is gaining attention in adherence research,^'^ was not an obvious factor contributing to adherence.None of the responses relating to adherence behavior could be coded under the selfefficacy heading.This might be because self-efficacy is a prospecfive belief related to a specific behavior.Because the interviews covered a retrospecfive analysis of the rehabilitation experience, self-efficacy beliefs regarding corrunitment to rehabilitafion might not have been recalled.
The desire to please was mentioned by a number of adherent and nonadherent parficipants as being important for all aspects of adherence.Considering the poor home-exercise completion levels of nonadherers, however, this desire might not have been strong enough to significantly affect home-exercise complefion.The experience of pafients feeling an obligafion toward their physiotherapist was also recognized by Campbell et aP as an important reason for high levels of adherence in the inifial stages of knee osteoarthritis rehabilitation.
Despite qualitafive methods becoming increasingly popular in areas of health and medical research,^*-^ they are often crificized for lacking reliability and validity.The terms reliability and validity are commonly referred to as rigor in qualitafive research.^*This invesfigation used several methods to enhance rigor.First, the purposive sampling technique used minimizes the potenfial bias arising from convenience sampling and improves the chance of coUecfing rich data relevant to the behavior being studied when compared with random sampling.^'Second, providing interviewees with transcribed interviews to check ensures that the informafion has been accurately translated.'"Third, the independent peer examinafion and coding of transcripts enhance the reliability of the analysis.^'Finally, the use of verbafim transcripts and direct quotafions when presenting data serves to improve the internal validity of the findings.^Ĉ

onclusion
The results provide a detailed descripfion of the ACL-rehabilitafion experience and the variables infiuencing adherence to rehabilitafion.The qualitafive approach allowed a greater discovery and analysis of variables than would be possible with a quanfitative approach.Perception of fime availability, equipment availability, fear of reinjury, and self-mofivafion emerged as the most noteworthy differences separating adherers and nonadherers with regard to home-exercise complefion.Program factors and physiotherapist support were idenfified as determinants of attendance at and adherence during appointments for all parficipants but did not differenfiate between adherers and nonadherers.
The findings of this study highlight the need for further research into the emofions associated with return to sport after ACL reconstrucfion.Such research might help explain the difference idenfified between the reinjury concerns of adherers and nonadherers.

Figure 1
Figure 1 Flowchart illustrating determinants of adherence to anterior cruciate ligament rehabilitation.