Rehabilitation Psychology February 2000 Vol. 45, No. 1, 20 !

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2000 by the Educational Publishing Foundation For #ersonal use only not $or distribution.

Psychological Factors, Rehabilitation Adherence, and Rehabilitation Outcome After Anterior Cruciate Ligament Reconstruction
Britton W. Brewer %enter $or Per$or&ance Enhance&ent and '##lied Research , (e#art&ent o$ Psychology )#ring$ield %ollege udy L. !an Raalte %enter $or Per$or&ance Enhance&ent and '##lied Research , (e#art&ent o$ Psychology )#ring$ield %ollege Allen ". Cornelius %enter $or Per$or&ance Enhance&ent and '##lied Research , (e#art&ent o$ Psychology )#ring$ield %ollege Albert . Petit#as %enter $or Per$or&ance Enhance&ent and '##lied Research , (e#art&ent o$ Psychology )#ring$ield %ollege ose#h $. %&lar Ne* England +rtho#edic )urgeons 'ar& $. Pohlman Ne* England +rtho#edic )urgeons Robert . (rushell Ne* England +rtho#edic )urgeons )erry *. *itmar ,aystate +ut#atient Rehabilitation AB%)RAC) Objective: -o e.a&ine #ros#ecti/ely the relationshi#s a&ong #sychological $actors, rehabilitation adherence, and short ter& rehabilitation outco&e a$ter 0nee surgery. Study Design and Participants: 1ndi/iduals *ith acute anterior cruciate liga&ent 2'%34 tears 2 N 5 654 co&#leted &easures o$ sel$ &oti/ation, social su##ort, athletic identity, and #sychological distress be$ore reconstructi/e surgery. '$ter surgery, #artici#ants 2 n 5 6!4 re#orted on their co&#letion o$ ho&e rehabilitation e.ercises and cryothera#y, and their rehabilitation #ractitioners indicated the #atients7 attendance at, and adherence during, rehabilitation sessions. Rehabilitation outco&e &easures *ere ta0en $ro& #artici#ants 2 n 5 864 a##ro.i&ately 8 &onths #ostsurgery. Main Outcome Measures: 9nee la.ity, $unctional ability, and sub:ecti/e sy&#to&s *ere the #ri&ary outco&es assessed. Results: )el$ &oti/ation *as a signi$icant #redictor o$ ho&e e.ercise co&#letion; athletic identity and #sychological distress *ere signi$icant #redictors o$ 0nee la.ity; and attendance at rehabilitation sessions and ho&e cryothera#y co&#letion *ere signi$icant #redictors o$ $unctional ability. Rehabilitation adherence did not &ediate the relationshi# bet*een #sychological $actors and rehabilitation outco&e. Conclusions: -he #ros#ecti/e associations obtained a&ong #sychological $actors, rehabilitation adherence, and short ter& rehabilitation outco&e a$ter '%3 reconstruction &ay in$or& the de/elo#&ent o$ inter/entions designed to enhance the rehabilitation o$ indi/iduals *ith s#ort related ortho#edic in:uries.

Recent esti&ates indicate a high incidence o$ s#ort related and recreation related in:uries in the <nited )tates, *ith !=1" &illion in:uries sustained annually by children and adults in s#ort and recreational acti/ities 2 ,i:ur et al., 1665 ; ,ooth, 16>" ; 9raus ? %onroy, 16>4 4. +ne o$ the &ore #re/alent and debilitating s#ort in:uries is an acute tear o$ the anterior cruciate liga&ent 2'%34 o$ the 0nee 2 (erscheid ? Feiring, 16>" ; Roos, +rnell, @ardsell, 3oh&ander, ? 3indstrand, 1665 4. -he '%3 is critical in #ro/iding stability to the 0nee :oint 2 Auller, 16>! 4. -here is e/idence that the incidence o$ '%3 tears &ay be increasing 2 Natri et al., 1665 4. For young, acti/e indi/iduals *ho sustain '%3 tears, reconstructi/e surgery is considered the treat&ent o$ choice 2 AarBo ? Carren, 1661 4. '$ter surgical reconstruction o$ the '%3, #hysical thera#y is considered essential to #ro&ote o#ti&al rehabilitation 2 ,lair ? Cills, 1661 ; (e%arlo, )ell, )helbourne, ? 9loot*y0, 1664 ; (e%arlo, )helbourne, Ac%arroll, ? Rettig, 1662 ; )helbourne ? Cilc0ens, 1660 4. Posto#erati/e treat&ent ty#ically in/ol/es clinic and ho&e based cryothera#y 2icing4 and e.ercises designed to #ro&ote strength and $le.ibility 2 ,lair ? Cills, 1661 ; (e%arlo et al., 1664 ; )helbourne, 9loot*y0, ? (e%arlo, 1662 4. (e#ending on an indi/idual7s insurance co/erage, it is not unco&&on $or the clinic based co&#onent o$ rehabilitation to include t*o to three sessions #er *ee0 $or 2 to 4 &onths. 1n contrast to the 6 to 12 &onth reco/ery ti&e associated *ith traditional #ostsurgical '%3 rehabilitation #rogra&s, athletes &ay return to s#ort #artici#ation as soon as ! to 8 &onths a$ter '%3 reconstruction under the accelerated rehabilitation #rotocols currently in use 2 ,lair ? Cills, 1661 ; (e%arlo et al., 1664 4. 1n conte&#orary &odels o$ #sychological res#onse to s#ort in:ury 2 ,re*er, 1664 ; Ciese ,:ornstal, )&ith, )ha$$er, ? Aorrey, 166> 4, #sychological $actors 2e.g., #ersonal characteristics, situational /ariables, cogniti/e res#onses, and e&otional res#onses4 are thought to in$luence both rehabilitation beha/ior 2e.g., adherence4 and rehabilitation outco&e. -heoretically, as sho*n in Figure 1 , #sychological $actors can a$$ect rehabilitation outco&e both directly and indirectly, *ith the latter relationshi# &ediated by rehabilitation adherence. Preli&inary research on #sychological as#ects o$ s#ort in:ury rehabilitation has #ro/ided su##ort $or each o$ the #ath*ays #ro#osed in Figure 1 . Cith regard to Path a, a nu&ber o$ #sychological $actors ha/e been associated *ith adherence to s#ort in:ury rehabilitation #rogra&s 2see ,re*er, 166> , $or a re/ie*4, including sel$ &oti/ation 2 (uda, )&art, ? -a##e, 16>6 ; Fields, Aur#hey, Dorodys0i, ? )to#0a, 1665 ; Fisher, (o&&, ? Cuest, 16>> ; Noyes, Aatthe*s, Aooar, ? @rood, 16>! 4, social su##ort 2 ,yerly, Correll, @ahi&er, ? (o&holdt, 1664 ; (uda et al., 16>6 ; Fisher et al., 16>> 4, and &ood disturbance 2 ,ric0ner, 166" ; (aly, ,re*er, Van Raalte, Petit#as, ? )0lar, 1665 4, a $actor associated in #re/ious research 2 ,re*er, 166! 4 *ith le/el o$ sel$ identi$ication *ith the s#ort role a&ong athletes sustaining in:uries. 's in the general health #sychology literature 2 (unbar Eacob ? )chlen0, 1668 ; Days et al., 1664 4, $indings *ith res#ect to Path b ha/e been inconsistent. %ase history data ha/e docu&ented a #ositi/e relationshi# bet*een rehabilitation adherence and rehabilitation outco&e 2 (erscheid ? Feiring, 16>" ; Da*0ins, 16>6 ; Aeani, Aigliorini, ? -inti, 16>8 ; )atter$ield, (o*den, ? Fasa&ura, 1660 4. +ther studies,

ho*e/er, ha/e re/ealed nonsigni$icant 2 Noyes et al., 16>! 4 and in/erse 2 )helbourne ? Cilc0ens, 1660 4 adherence=outco&e relationshi#s. 'lthough a nu&ber o$ studies ha/e docu&ented the role o$ #sychological $actors in outco&e a$ter :oint re#lace&ent surgery 2e.g., %ha&berlain, Petrie, ? 'Bariah, 1662 ; +rbell, Eohnston, Ro*ley, Es#ley, ? (a/ey, 166> ; )har&a et al., 1668 4, Path c has been e.a&ined in only t*o #ublished studies in/ol/ing s#ort in:ury rehabilitation. -he #sychological $actors that ha/e been associated *ith s#ort in:ury rehabilitation outco&e are scores on the Ainnesota Aulti#hasic Personality 1n/entory 2AAP1; Datha*ay ? Ac9inley, 1651 4 hy#ochondriasis and hysteria scales 2 Cise, Eac0son, ? Rocchio, 16"6 4 and the sel$ re#orted use o$ selected co#ing s0ills 2 1e/le/a ? +rlic0, 1661 4. 'lso rele/ant to Path c, #sychological inter/entions 2e.g., bio$eedbac0, guided i&agery, and stress inoculation training4 ha/e been sho*n to enhance s#ort in:ury rehabilitation outco&e 2see %u#al, 166> , $or a re/ie*4. No single s#ort in:ury rehabilitation study has e.a&ined Paths a, b, and c, and $e* studies ha/e tested any o$ the #aths using #ros#ecti/e research designs. %onseGuently, the #ur#ose o$ the current study *as to e.a&ine the relationshi#s a&ong #sychological $actors, rehabilitation adherence, and rehabilitation outco&e a$ter '%3 reconstruction using a #ros#ecti/e research design. ,y collecting #sychological, adherence, and outco&e data, it *as #ossible to test the #aths hy#othesiBed in Figure 1 and to in/estigate the e.tent to *hich rehabilitation adherence &ediates the relationshi# bet*een #sychological $actors and rehabilitation outco&e.

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Partici#ants %onsecuti/e #atients scheduled $or '%3 reconstruction and subseGuent #hysical thera#y at the clinic *here the research *as conducted 2 N 5 11!4 *ere recruited $or #artici#ation in the study o/er a !0 &onth #eriod by their ortho#edic surgeon and a research assistant. Ele/en #atients re$used to #artici#ate, ! *ere unable to #artici#ate 2as a result o$ language di$$iculties or lac0 o$ #arental consent4, and 4 *ere eli&inated $ro& the sa&#le because they either did not ha/e '%3 surgery 2 n 5 24 or had e.tensi/e &issing data 2 n 5 24. -he re&aining 65 #artici#ants 22> $e&ale #atients and 8" &ale #atients4 had a &ean age o$ 28.62 2 SD 5 >.2!4 years. -he racial=ethnic brea0do*n o$ the sa&#le *as as $ollo*sH >4 2>>I4 Chite, not o$ Dis#anic origin; " 2"I4 Dis#anic; ! 2!I4 ,lac0, not o$ Dis#anic origin; and 1 21I4 'sian=Paci$ic 1slander. 1n ter&s o$ s#ort in/ol/e&ent, 46 252I4 #artici#ants indicated that they *ere co&#etiti/e athletes, 41 24!I4 indicated that they *ere recreational athletes, ! 2!I4 indicated that they *ere nonathletes, and 2 22I4 did not res#ond to the ite& reGuesting this in$or&ation. -he &a:ority o$ #artici#ants indicated that they sustained their '%3 in:ury *hile #artici#ating in s#ort 2 n 5 >5; 60I4 and that the '%3 surgery *as the $irst ti&e that they had had ortho#edic surgery 2 n 5 80; 8!I4. ,ecause all #artici#ants had $ully torn '%3s, se/erity o$ in:ury *as constant across #artici#ants. +$ the 65 #artici#ants, 28 dro##ed out o$ the study be$ore the 8 &onth #ostsurgery assess&ent 22 #artici#ants did not co&#lete any o$ the adherence &easures, and 28 #artici#ants did not co&#lete any o$ the outco&e &easures4.

'easures (e&ogra#hic, in:ury related, #sychological, adherence, and rehabilitation outco&e /ariables *ere &easured in this study. 'easures of demogra#hic and in+ury,related -ariables. ' Guestionnaire *as used to obtain de&ogra#hic and in:ury related in$or&ation $ro& #artici#ants. -he Guestionnaire included ite&s reGuesting in$or&ation on #artici#ants7 age, gender, race=ethnicity, date o$ '%3 in:ury, source o$ '%3 in:ury 2i.e., s#ort related acti/ity or non s#ort related acti/ity4, and le/el o$ s#ort in/ol/e&ent 2i.e., nonathlete, recreational athlete, or co&#etiti/e athlete4. Psychological measures. -he #sychological /ariables assessed in this in/estigation *ere sel$ &oti/ation, social su##ort, athletic identity, and #sychological distress. )el$ &oti/ation *as assessed *ith the )el$ Aoti/ation 1n/entory 2)A1; (ish&an ? 1c0es, 16>1 4. -he )A1 is a 40 ite& Guestionnaire designed to &easure Ja beha/ioral tendency to #erse/ere inde#endent o$ situational rein$orce&entsJ 2 (ish&an ? 1c0es, 16>1 , #. 4214. Res#ondents are as0ed to rate the degree to *hich state&ents such as J17& not /ery good at co&&itting &ysel$ to do things,J J1 can #ersist in s#ite o$ #ain and disco&$ort,J and J17& not /ery reliableJ are characteristic o$ the&sel/es on 5 #oint 3i0ert scales. E&#irical su##ort $or the reliability, internal consistency, construct /alidity, and #redicti/e /alidity o$ the )A1 in e.ercise settings has been $ound 2 (ish&an ? 1c0es, 16>1 4. )ocial su##ort *as &easured by the )ocial )u##ort 1n/entory 2))1; ,ro*n, 'l#ert, 3ent, Dunt, ? ,rady, 16>> ; ,ro*n, ,rady, 3ent, Col$ert, ? Dall, 16>" 4. -he ))1 is a !6 ite& Guestionnaire that assesses satis$action *ith su##ort and hel# recei/ed $ro& others o/er the #re/ious &onth. Ratings are &ade on " #oint 3i0ert ty#e scales ranging $ro& 1 2 not at all satisfied 4 to " 2 very satisfied 4. E.a&#les o$ ite&s are Jassurance that you are lo/ed and cared about,J Jin$or&ation and guidance about ho* to co#e *ith your situation,J and Jin$or&ation on sources o$ $inancial assistance.J ,ro*n et al. 216>" , 16>> 4 ha/e obtained e/idence $or the reliability, construct /alidity, and criterion related /alidity o$ the ))1. -he 'thletic 1dentity Aeasure&ent )cale 2'1A); ,re*er, Van Raalte, ? 3inder, 166! 4 *as used to assess athletic identity, *hich is the degree to *hich an indi/idual identi$ies *ith the athlete role. -he '1A) is a Guestionnaire consisting o$ 10 3i0ert ty#e scales ranging $ro& 1 2 strongly disagree 4 to " 2 strongly agree 4. E.a&#les o$ ite&s are J1 a& an athlete,J J)#ort is the &ost i&#ortant #art o$ &y li$e,J and JAost o$ &y $riends are athletes.J '1A) scores ha/e been $ound to be #redicti/e o$ #ostin:ury #sychological distress in athletes 2 ,re*er, 166! 4. 1n the #reli&inary /alidation study $or the '1A) 2 ,re*er et al., 166! 4, the &easure de&onstrated high test=retest reliability 2 r 5 .>6 o/er a 2 *ee0 #eriod4 and internal consistency 2al#ha coe$$icients ranging $ro& .>1 to .6!4. '1A) scores increased *ith sel$ re#orted in/ol/e&ent in s#ort and *ere #ositi/ely correlated *ith #ercei/ed i&#ortance o$ s#ort but *ere not signi$icantly correlated *ith social desirability, sel$ estee&, sel$ rated s#orts co&#etence, and coach rated s#ort s0ill 2 ,re*er et al., 166! 4.

Psychological distress *as &easured by the ,rie$ )y&#to& 1n/entory 2,)1; (erogatis, 1662 4. -he ,)1 consists o$ 5! ite&s in a 5 #oint 3i0ert $or&at. Res#ondents indicate the e.tent to *hich they ha/e been distressed by #sychological and so&atic sy&#to&s o/er the #re/ious " days. Published nor&s $or non#atient adults, non#atient adolescents, #sychiatric in#atients, and #sychiatric out#atients are a/ailable. -he reliability and /alidity o$ the ,)1 are *ell established 2 (erogatis, 1662 4. Adherence measures. 'dherence to rehabilitation *as &easured in three *ays. First, #atient attendance at rehabilitation sessions *as &onitored. For each #artici#ant, a ratio o$ sessions attended to sessions scheduled *as calculated. 'ttendance has been used as an adherence &easure in #re/ious s#ort in:ury research 2 ,yerly et al., 1664 ; (aly et al., 1665 ; (erscheid ? Feiring, 16>" ; (uda et al., 16>6 ; Fields et al., 1665 ; Fisher et al., 16>> ; 3a&#ton, 3a&bert, ? Fost, 166! ; 3aubach, ,re*er, Van Raalte, ? Petit#as, 1668 ; <dry, 166" 4. )econd, at each #hysical thera#y a##oint&ent, the #ractitioner 2e.g., #hysical thera#ist or athletic trainer4 res#onsible $or the rehabilitation o$ each #artici#ant on that day co&#leted the )#ort 1n:ury Rehabilitation 'dherence )cale 2)1R'); ,re*er, Van Raalte, Petit#as, )0lar, ? (it&ar, 1665 4. -he )1R') is a three ite& &easure in *hich #ractitioners rate, on 5 #oint 3i0ert ty#e scales, #atients7 intensity o$ co&#letion o$ rehabilitation e.ercises, the $reGuency *ith *hich they $ollo* the #ractitioner7s instructions and ad/ice, and their rece#ti/ity to changes in the #hysical thera#y #rogra& during that day7s a##oint&ent. )cale anchors $or the three ite&s are minimum effort/ma imum effort! never/al"ays! and very unreceptive/very receptive! res#ecti/ely. -he ite&s, *hich *ere deri/ed $ro& the adherence literature 2 (uda et al., 16>6 ; Aeichenbau& ? -ur0, 16>" 4, ha/e been sho*n to constitute a single $actor accounting $or a##ro.i&ately "4I o$ the /ariance in )1R') scores 2 ,re*er et al., 1665 4. %ronbach7s al#ha coe$$icients o$ .>1 and .>2 2 ,re*er et al., 1665 ; (aly et al., 1665 4 ha/e been $ound $or the )1R'). ' test=retest reliability coe$$icient o$ .85 has been obtained $or the )1R') o/er a 1 *ee0 #eriod 2 ,re*er, (aly, Van Raalte, Petit#as, ? )0lar, 1664 4. 1n su##ort o$ the criterion related /alidity o$ the )1R'), attendance at rehabilitation sessions has been #ositi/ely correlated *ith )1R') scores in t*o studies 2 ,re*er et al., 1665 ; (aly et al., 1665 4. -here is e/idence that re#eated ad&inistrations o$ the )1R') across #hysical thera#y a##oint&ents #ro/ide an internally consistent 2 5 .>84 inde. o$ adherence during rehabilitation sessions 2 ,re*er, Van Raalte, Petit#as, )0lar, ? (it&ar, 1668 4. -hird, #atient sel$ re#orts o$ ho&e e.ercise and cryothera#y co&#letion *ere obtained. 't each rehabilitation session, #atients re#orted their degree o$ co&#letion o$ #rescribed ho&e e.ercises and cryothera#y since their last a##oint&ent on a scale ranging $ro& 1 2 none 4 to 10 2 all 4. Aean )1R'), ho&e e.ercise co&#letion, and ho&e cryothera#y co&#letion scores *ere calculated $or #artici#ants across all rehabilitation sessions attended. Rehabilitation outcome measures.

%onsistent *ith #re/ious in/estigations in *hich '%3 rehabilitation outco&e *as e/aluated 2e.g., (e%arlo et al., 1662 ; Engebretsen, ,enu&, Fasting, Aolster, ? )trand, 1660 ; Aarder, Ras0ind, ? %arroll, 1661 ; Noyes et al., 16>! ; )ha#iro, Rich&ond, Roc0ett, Ac@rath, ? (onaldson, 1668 ; )helbourne ? NitB, 1660 ; )helbourne, Chita0er, Ac%arroll, Rettig, ? Dirsch&an, 1660 4, &ulti#le &easures o$ '%3 rehabilitation outco&e *ere ta0en. )#eci$ically, la.ity, $unctional ability, and sub:ecti/e sy&#to&s *ere assessed. 'n instru&ented e/aluation o$ anterior=#osterior la.ity o$ the 0nee :oint *as conducted *ith a 9-1000 0nee arthro&eter 2AE(&etric %or#oration, )an (iego, %'4. -rials *ere conducted $or both the in/ol/ed and unin/ol/ed 0nees, and /alues *ere recorded at 15 #ounds 28."5 0g4 o$ $orce. ' &ean di$$erence in 9-1000 scores bet*een the in/ol/ed and unin/ol/ed 0nees *as calculated $or each #artici#ant. 1n /itro and in /i/o data su##ort the reliability and /alidity o$ the 9-1000 as a &easure o$ 0nee la.ity 2 (aniel, Aalco&, et al., 16>5 ; (aniel, )tone, )achs, ? Aalco&, 16>5 ; Aalco&, (aniel, )tone, ? )achs, 16>5 4. -he one leg ho# $or distance 2 (aniel, )tone, Riehl, ? Aoore, 16>4 4 *as used as a test o$ $unctional ability. 1n this test, #atients ho##ed $or distance on one leg, ta0ing o$$ and landing *ith the sa&e leg. Do# distances *ere recorded in centi&eters. ,oth the in/ol/ed and unin/ol/ed legs *ere tested three ti&es in the one leg ho#. ' &ean ho# inde. score *as calculated by di/iding the &ean distance ho##ed on the in/ol/ed leg across the three trials by the &ean distance ho##ed on the unin/ol/ed leg 2 9ra&er, Nusca, Fo*ler, ? Cebster ,ogaert, 1662 4. 9ra&er et al. ha/e obtained su##ort $or the test=retest reliability o$ the ho# inde. 2intraclass correlation coe$$icientH .>14. -he inde. has been used e$$ecti/ely to e/aluate the rehabilitation o$ '%3 in:uries 2 -egner, 3yshol&, 3yshol&, ? @illGuist, 16>8 4. )ub:ecti/e sy&#to&s *ere assessed *ith the 3yshol& 9nee )coring )cale 2 3yshol& ? @illGuist, 16>2 ; -egner ? 3yshol&, 16>5 4, a #atient sel$ re#ort instru&ent. -he Guestionnaire has ite&s #ertaining to li&#ing, su##ort, loc0ing, instability, #ain, s*elling, stair cli&bing, and sGuatting. Res#onses to each o$ the eight ite&s are assigned a #oint /alue, and a total score is obtained by su&&ing across the ite&s. -otal scores can range $ro& 0 to 100. )u##ort $or the test=retest reliability o$ the scale 2coe$$icient o$ /ariationH K2.>I o/er a ! day #eriod4 has been docu&ented 2 3yshol& ? @illGuist, 16>2 4. )cores on the 3yshol& 9nee )coring )cale ha/e been sho*n to correlate #ositi/ely *ith acti/ity le/el a$ter '%3 in:ury 2 -egner ? 3yshol&, 16>5 4 and ha/e been used to e/aluate 0nee $unctioning a$ter '%3 reconstruction 2 (ra#er ? 3add, 166! 4. Procedure Patients *ere recruited as #artici#ants by the three ortho#edic surgeons on the #ro:ect be$ore their '%3 reconstructi/e surgery. ' research assistant described the #ur#ose and #rocedures o$ the study to the #atients *ho e.#ressed interest in #artici#ating. Patients *ho agreed to #artici#ate in the study 2and their #arents or guardians *hen a##ro#riate4 read and co&#leted an in$or&ed consent $or& at their #reo#erati/e #hysical thera#y a##oint&ent a##ro.i&ately 10 days be$ore reconstructi/e surgery. 't this ti&e, #artici#ants *ere ad&inistered a battery o$ #sychological Guestionnaires

2including de&ogra#hic and in:ury related ite&s, the )A1, the ))1, the '1A), and the ,)14. '$ter reconstructi/e surgery, &easures o$ adherence to rehabilitation *ere ta0en at each scheduled #hysical thera#y a##oint&ent. 'ttendance=nonattendance *as docu&ented, the )1R') *as ad&inistered to the #hysical thera#ist or athletic trainer &ost in/ol/ed *ith the #atient7s rehabilitation, and #atient ratings o$ ho&e e.ercise and cryothera#y co&#letion in the ti&e since the #re/ious a##oint&ent *ere obtained. -he accelerated rehabilitation #rotocol a$ter '%3 reconstruction de/elo#ed by )helbourne and his colleagues 2 (e%arlo et al., 1662 ; )helbourne et al., 1662 ; )helbourne ? NitB, 1660 ; )helbourne ? Cilc0ens, 1660 4 and recently u#dated 2 (e%arlo et al., 1664 4 *as #rescribed by the ortho#edic surgeons and $ollo*ed by the #hysical thera#ists a$$iliated *ith the #ro#osed study. -his #hysical thera#y #rotocol, *hich has been $ound su#erior to traditional, &ore conser/ati/e a##roaches 2 (e%arlo et al., 1662 4, e&#hasiBes early attain&ent o$ range o$ &otion 2e.tension and $le.ion o$ the 0nee4, Guadrice#s strength, and nor&al gait 2 (e%arlo et al., 1664 ; )helbourne et al., 1662 ; )helbourne ? NitB, 1660 4. Rehabilitation outco&e &easures *ere ad&inistered as a regular #art o$ #atients7 rehabilitation #rogra& a##ro.i&ately 8 &onths a$ter reconstructi/e surgery. ' #hysician assistant and the #hysical thera#ist res#onsible $or each #atient7s treat&ent conducted the rehabilitation assess&ents. -he #hysician assistant, *ho #er$or&ed the 9-1000 tests, *as una*are o$ #artici#ants7 res#onses to the #resurgical Guestionnaire battery and adherence data. -he #hysical thera#ist *as una*are o$ #artici#ants7 res#onses to the #resurgical Guestionnaire battery and the Guestionnaires reGuesting in$or&ation on co&#letion o$ ho&e e.ercises and cryothera#y. *ata %creening 1nde#endent t tests *ere conducted to deter&ine *hether the #artici#ants *ho dro##ed out di$$ered $ro& those *ho re&ained in the study in regard to /ariables &easured be$ore surgery 2e.g., age, sel$ &oti/ation, social su##ort, athletic identity, and #sychological distress4. No signi$icant di$$erences *ere $ound, indicating the #resurgical eGui/alence o$ the #artici#ants *ho dro##ed out and those *ho re&ained in the study on these /ariables. 'lthough $ollo* u# data are una/ailable $or &ost o$ the #artici#ants *ho did not co&#lete the study, se/eral #artici#ants indicated that they dro##ed out o$ the study $or #ractical reasons, such as &o/ing to another to*n or trans$erring to a clinic closer to ho&e. %ronbach al#ha coe$$icients $or the sel$ &oti/ation, social su##ort, athletic identity, and #sychological distress &easures used in the #resurgical assess&ent *ere .62, . 6", .>", and .68, res#ecti/ely. ,ecause o$ s0e*ed distributions, trans$or&ations *ere a##lied to se/eral /ariables. -he distribution $or the ,)1 *as #ositi/ely s0e*ed, and a log trans$or&ation #roduced a &ore nor&al distribution. -he distribution $or the )1R') *as negati/ely s0e*ed, and a re$lection and an in/erse trans$or&ation #roduced a &ore nor&al distribution. 's a result o$ &issing data on so&e /ariables $or so&e #artici#ants, the nu&ber o$ #artici#ants a/ailable $or each o$ the &ain analyses /aried slightly.

R"%.L)%
Aeans, standard de/iations, and intercorrelations o$ #sychological, adherence, and outco&e &easures are #resented in -able 1 . -o e.a&ine the #otential in$luence o$ de&ogra#hic $actors on the $indings, *e calculated Pearson correlations bet*een age and the adherence and outco&e &easures and #er$or&ed t tests on the adherence and outco&e &easures using gender, source o$ '%3 in:ury, and #rior ortho#edic surgery e.#erience as inde#endent /ariables. 'ge *as signi$icantly correlated *ith one leg ho# scores 2 r 5 .!8, p L .054. Partici#ants *ith #rior ortho#edic surgery e.#erience had signi$icantly lo*er 9-1000 scores than #artici#ants *ithout #rior ortho#edic surgery e.#erience, t 2554 5 2.5", p L .05. 'll other correlations and t tests in/ol/ing de&ogra#hic $actors *ere not statistically signi$icant. +n the basis o$ these results, age *as used as a co/ariate in all analyses in *hich one leg ho# scores *ere the criterion, and #rior ortho#edic surgery e.#erience *as used as a co/ariate in all analyses in *hich 9-1000 scores *ere the criterion. -o e/aluate #ros#ecti/e relationshi#s bet*een #sychological $actors and adherence to rehabilitation a$ter '%3 reconstruction, *e calculated a set o$ regression analyses in *hich the $our #sychological $actors assessed be$ore surgery 2i.e., sel$ &oti/ation, social su##ort, athletic identity, and #sychological distress4 *ere used to #redict the $our adherence &easures 2i.e., attendance, )1R') score, ho&e e.ercise co&#letion, and ho&e cryothera#y co&#letion4 in $our se#arate regression eGuations. )e#arate analyses *ere used $or the $our adherence &easures because they *ere generally uncorrelated *ith each other, *ith the e.ce#tion o$ the ho&e e.ercises and ho&e cryothera#y scores. -he regression eGuation #redicting ho&e e.ercise co&#letion *as statistically signi$icant, # 24, 514 5 4.55, p L .005, R 2 5 .28. )el$ &oti/ation 2 5 .!6, p L .054 *as the sole signi$icant #redictor o$ ho&e e.ercise co&#letion $ro& a&ong the #sychological &easures. -he regression eGuation #redicting )1R') scores a##roached statistical signi$icance, # 24, 514 5 2.1", p L .10, R 2 5 .15. )ocial su##ort 2 5 .2", p L .104 a##roached statistical signi$icance as a #redictor o$ )1R') scores. -he regression eGuations #redicting attendance and ho&e cryothera#y co&#letion *ere not statistically signi$icant. -o e.a&ine the relation bet*een #sychological $actors and short ter& #ostsurgical rehabilitation outco&e a$ter '%3 reconstruction, *e calculated a set o$ regression analyses in *hich the $our #sychological $actors assessed be$ore surgery 2i.e., sel$ &oti/ation, social su##ort, athletic identity, and #sychological distress4 *ere used to #redict the three rehabilitation outco&e &easures 2i.e., 9-1000, one leg ho#, and sub:ecti/e sy&#to&s4 in three se#arate regression eGuations. )e#arate analyses *ere used $or the three rehabilitation outco&e &easures because they *ere uncorrelated *ith each other. -he regression eGuation #redicting 9-1000 scores *as statistically signi$icant, # 25, !44 5 4.>>, p L .005, R 2 5 .42. Psychological $actors accounted $or a signi$icant #ro#ortion o$ /ariance in 9-1000 scores o/er and abo/e #rior ortho#edic surgery e.#erience, # 24, !44 5 4."5, p L .005. 'thletic identity 2 5 .!8, p L .054 and #sychological distress 2 5 .48, p L .014 e&erged as signi$icant #redictors o$ 9-1000 scores. -he regression eGuations #redicting one leg ho# #er$or&ance and sub:ecti/e sy&#to&s *ere not statistically signi$icant.

-o test the hy#othesis that adherence to rehabilitation is #ositi/ely associated *ith short ter& rehabilitation outco&e a$ter '%3 reconstruction *e conducted a set o$ regression analyses in *hich adherence &easures 2i.e., attendance, )1R') score, ho&e e.ercise co&#letion, and ho&e cryothera#y co&#letion4 *ere used to #redict rehabilitation outco&e &easures 2i.e., 9-1000, one leg ho#, and sub:ecti/e sy&#to&s4 in three se#arate regression eGuations. +nly the regression eGuation #redicting the one leg ho# inde. *as statistically signi$icant, # 25, 444 5 4."0, p L .05, R 2 5 .!5. 'dherence &easures accounted $or a signi$icant #ro#ortion o$ /ariance in the one leg ho# inde. o/er and abo/e age, # 24, 444 5 !.>6, p L .01. 'ttendance 2 5 . 2>, p L .054, )1R') scores 2 5 .2>, p L .054, and ho&e cryothera#y co&#letion 2 5 .!8, p L .054 *ere signi$icant #redictors o$ the one leg ho# inde.. ,ecause none o$ the adherence &easures *ere signi$icantly correlated *ith both #sychological and outco&e &easures, the criteria $or &ediation *ere not satis$ied 2 ,aron ? 9enny, 16>8 4, and $urther analyses *ere not carried out.

*/%C.%%/O0
1n this study, selected #sychological $actors *ere associated #ros#ecti/ely *ith rehabilitation adherence and rehabilitation outco&e a$ter '%3 reconstruction. %onsistent *ith #re/ious research 2 (uda et al., 16>6 ; Fields et al., 1665 ; Fisher et al., 16>> ; Noyes et al., 16>! 4, sel$ &oti/ation e&erged as a signi$icant #redictor o$ rehabilitation adherence 2i.e., ho&e e.ercise co&#letion4. 'thletic identity and #sychological distress *ere signi$icant #redictors o$ rehabilitation outco&e 2i.e., 0nee la.ity4 such that higher athletic identity and lo*er #sychological distress *ere associated *ith a &ore $a/orable outco&e. 'dherence, in the $or& o$ attendance at rehabilitation sessions, and ho&e cryothera#y co&#letion *ere related to one o$ the three rehabilitation outco&es assessed 2i.e., $unctional ability4. %ontrary to the hy#othesiBed #attern o$ results, adherence did not &ediate the relationshi# bet*een #sychological $actors and rehabilitation outco&e. -hus, *ith re$erence to Figure 1 , #artial su##ort *as obtained $or Paths a, b, and c but not the &ediated #ath $ro& #sychological $actors to rehabilitation outco&e through rehabilitation adherence 2by *ay o$ Paths a and b4. -he #ositi/e correlation bet*een attendance at rehabilitation sessions and $unctional ability aug&ents si&ilar $indings by (erscheid and Feiring 216>"4 $or '%3 reconstruction and suggests that #atients bene$it $ro& #artici#ating in clinic based rehabilitation acti/ities. ' #ossible inter#retation o$ the in/erse relationshi# $ound bet*een ho&e cryothera#y co&#letion and $unctional ability is that #atients *ho are reco/ering better e.#erience less #ain and thereby initiate less direct treat&ent. ' logical e.#lanation $or the signi$icant relationshi#s o$ athletic identity and #sychological distress to 0nee la.ity in/ol/es greater adherenceMand, there$ore, better rehabilitation outco&e 2i.e., less la.ity4M$or #atients &ore strongly sel$ identi$ied as athletes and less distressed. ,ecause neither athletic identity nor #sychological distress *as associated *ith rehabilitation adherence, ho*e/er, this e.#lanation is not tenable. 1t is #ossible that the &ore athletically sel$ identi$ied #atients *ere &ore $it be$ore surgery and there$ore res#onded &ore $a/orably to reconstructi/e surgery than the less athletically sel$ identi$ied #atients. 1t is also #ossible that #resurgical #sychological distress in$luenced i&&une $unctioning, *hich in turn a$$ected

#ostsurgical healing 2 Derbert ? %ohen, 166! ; Roitt, 166" 4. -hese e.#lanations are s#eculati/e, though, and *arrant $urther e.#loration. -he current study has so&e li&itations that should be addressed in $uture research. First, although it *as reasonable to select a 8 &onth #eriod a$ter '%3 reconstruction $or the assess&ent o$ rehabilitation outco&e based on the #hysical thera#y #rotocol used $or #artici#ants 2 (e%arlo et al., 1662 ; )helbourne et al., 1662 ; )helbourne ? NitB, 1660 4, the study &ay ha/e been o$ insu$$icient duration $or the in$luences o$ #sychological $actors and rehabilitation adherence on rehabilitation outco&e to $ully e&erge. 1n the Cise et al. 216"64 study, associations bet*een #resurgical #sychological /ariables and rehabilitation outco&e *ere e/ident 1 to ! years a$ter 0nee surgery. %onseGuently, rehabilitation outco&e should be assessed at regular inter/als o/er a longer ti&e #eriod in subseGuent in/estigations. )econd, gi/en the di$$iculties associated *ith ha/ing /olunteer #artici#ants engaged in research o/er a long #eriod o$ ti&e, it &ay be i&#ortant to o$$er research #artici#ation incenti/es. )uch incenti/es, *hich *ould hel# curb #artici#ant attrition 228I in this study4 and the acco&#anying loss o$ statistical #o*er, *ould be es#ecially critical $or studies o$ longer duration than the #resent study. -hird, #ros#ecti/e assess&ent o$ rehabilitation outco&e /ariables 2e.g., 0nee la.ity and sub:ecti/e sy&#to&s4 *ould allo* #artici#ants to ser/e as their o*n controls and *ould account $or a large #ortion o$ error /ariance in the rehabilitation outco&e &easures, thereby increasing the li0elihood o$ obtaining signi$icant relationshi#s *ith the outco&e /ariables. E/en *ithout this #reo#erati/e assess&ent, ho*e/er, signi$icant relationshi#s *ere $ound *ith $unctional ability and 0nee la.ity in the current study. Fourth, although the assess&ent o$ adherence to ho&e rehabilitation regi&ens in the current study re#resented an i&#ro/e&ent o/er #re/ious in/estigations o$ ho&e based s#ort in:ury rehabilitation adherence 2 'l&e0inders ? 'l&e0inders, 1664 ; Noyes et al., 16>! ; -aylor ? Aay, 1668 4, retros#ecti/e sel$ re#orts o$ adherence can be sub:ect to biased, distorted, or inaccurate recall 2 (unbar Eacob, (unning, ? (*yer, 166! ; Aeichenbau& ? -ur0, 16>" 4. Further i&#ro/e&ents are #ossible by obtaining daily sel$ re#orts 2c$. )tone, 9essler, ? Daythornth*aite, 1661 4 and ob:ecti/e &easure&ents 2e.g., 3e/itt, (eisinger, Call, Ford, ? %assisi, 1668 4 o$ adherence to ho&e rehabilitation acti/ities. -he #reli&inary results obtained in this study suggest the #ossibility that #sychological inter/entions designed to reduce #sychological distress and enhance rehabilitation adherence could enhance the rehabilitation o$ s#ort related ortho#edic in:uries in general and '%3 tears in #articular. ,e$ore such inter/entions are de/elo#ed, i&#le&ented, and e/aluated 2e.g., Fisher, )criber, Aatheny, 'lder&an, ? ,itting, 166! ; Correll, 1662 4, ho*e/er, it is necessary to deter&ine that i&#ro/ing adherence also i&#ro/es rehabilitation outco&e. Research is needed to assess &ore thoroughly the relationshi# bet*een adherence to rehabilitation #rotocols and outco&e a$ter '%3 reconstruction. Further inGuiry in this area has the #otential to #ro/ide an e&#irical basis $or #sychologists to better ser/e #eo#le undergoing rehabilitation o$ s#ort and recreation related in:uries.

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'l&e0inders, 3. %. ? 'l&e0inders, ). V. 216644. +utco&e in the treat&ent o$ chronic o/eruse s#orts in:uriesH ' retros#ecti/e study. $ournal of Ort%opaedic and Sports P%ysical &%erapy! '(, 15" 181. ,aron, R. A. ? 9enny, (. '. 216>84. -he &oderator &ediator /ariable distinction in social #sychological researchH %once#tual, strategic, and statistical considerations. $ournal of Personality and Social Psyc%ology! )', 11"! 11>2. ,i:ur, P. E., -ru&ble, '., Darel, F., +/er#ec0, A. (., Eones, (. ? )cheidt, P. %. 216654. )#orts and recreation in:uries in <) children and adolescents. *rc%ives of Pediatric and *dolescent Medicine! '+(, 1006 1018. ,lair, (. F. ? Cills, R. P. 216614. Ra#id rehabilitation $ollo*ing anterior cruciate liga&ent reconstruction. *t%letic &raining! ,-, !2 4!. ,ooth, C. 216>"4. 'rthritis 1nstitute tac0les s#orts. Science! ,./, >48 >5". ,re*er, ,. C. 2166!4. )el$ identity and s#eci$ic /ulnerability to de#ressed &ood. $ournal of Personality! -', !4! !84. ,re*er, ,. C. 216644. Re/ie* and critiGue o$ &odels o$ #sychological ad:ust&ent to athletic in:ury. $ournal of *pplied Sport Psyc%ology! -, >" 100. ,re*er, ,. C. 2166>4. 'dherence to s#ort in:ury rehabilitation #rogra&s. $ournal of *pplied Sport Psyc%ology! '0, "0 >2. ,re*er, ,. C., (aly, E. A., Van Raalte, E. 3., Petit#as, '. E. ? )0lar, E. D. 216644. ' #sycho&etric e/aluation o$ the Rehabilitation 'dherence Nuestionnaire O'bstractP. $ournal of Sport and 1 ercise Psyc%ology! '-2Suppl34, )!4 ,re*er, ,. C., Van Raalte, E. 3. ? 3inder, (. E. 2166!4. 'thletic identityH Dercules7 &uscles or 'chilles heelQ 5nternational $ournal of Sport Psyc%ology! ,+, 2!" 254. ,re*er, ,. C., Van Raalte, E. 3., Petit#as, '. E., )0lar, E. D. ? (it&ar, -. (. 216654. ' brie$ &easure o$ adherence during s#ort in:ury rehabilitation sessions O'bstractP. $ournal of *pplied Sport Psyc%ology! /2Suppl34, )44 ,re*er, ,. C., Van Raalte, E. 3., Petit#as, '. E., )0lar, E. D. ? (it&ar, -. (. 216684. 1nternal consistency o$ &ultisession assess&ents o$ s#ort in:ury rehabilitation adherence O'bstractP. $ournal of *pplied Sport Psyc%ology! 62Suppl34, )181 ,ric0ner, E. %. 2166"4. Mood states and compliance of patients "it% ort%opedic re%abilitation3 2<n#ublished &aster7s thesis, )#ring$ield %ollege, )#ring$ield, A'4 ,ro*n, ). (., 'l#ert, (., 3ent, R. C., Dunt, @. ? ,rady, -. 216>>4. Percei/ed social su##ort a&ong college studentsH Factor structure o$ the )ocial )u##ort 1n/entory. $ournal of Counseling Psyc%ology! .), 4"2 4">. ,ro*n, ). (., ,rady, -., 3ent, R. C., Col$ert, E. ? Dall, ). 216>"4. Percei/ed social su##ort a&ong college studentsH -hree studies o$ the #sycho&etric characteristics and counseling uses o$ the )ocial )u##ort 1n/entory. $ournal of Counseling Psyc%ology! .+, !!" !54. ,yerly, P. N., Correll, -., @ahi&er, E. ? (o&holdt, E. 216644. Rehabilitation co&#liance in an athletic training en/iron&ent. $ournal of *t%letic &raining! ,(, !52 !55. %ha&berlain, 9., Petrie, 9. ? 'Bariah, R. 216624. -he role o$ o#ti&is& and sense o$ coherence in #redicting reco/ery $ollo*ing surgery. Psyc%ology and 7ealt%! /, !01 !10.

%u#al, (. (. 2166>4. Psychological inter/entions in s#ort in:ury #re/ention and rehabilitation. $ournal of *pplied Sport Psyc%ology! '0, 10! 12!. (aly, E. A., ,re*er, ,. C., Van Raalte, E. 3., Petit#as, '. E. ? )0lar, E. D. 216654. %ogniti/e a##raisal, e&otional ad:ust&ent, and adherence to rehabilitation $ollo*ing 0nee surgery. $ournal of Sport Re%abilitation! +, 2! !0. (aniel, (. A., Aalco&, 3. 3., 3osse, @., )tone, A. 3., )achs, R. ? ,ur0s, R. 216>54. 1nstru&ented &easure&ent o$ anterior la.ity o$ the 0nee. $ournal of 8one and $oint Surgery! -/*, "20 "25. (aniel, (. A., )tone, A. 3., Riehl, ,. ? Aoore, A. R. 216>44. ' &easure&ent o$ lo*er li&b $unctionH -he one leg ho# $or distance. *merican $ournal of 9nee Surgery! +, 212 214. (aniel, (. A., )tone, A. 3., )achs, R. ? Aalco&, 3. 216>54. 1nstru&ented &easure&ent o$ anterior 0nee la.ity in #atients *ith acute anterior cruciate liga&ent disru#tion. *merican $ournal of Sports Medicine! '., 401 40". (e%arlo, A. )., )ell, (. E., )helbourne, 9. (. ? 9loot*y0, -. E. 216644. %urrent conce#ts on accelerated '%3 rehabilitation. $ournal of Sport Re%abilitation! ., !04 !1>. (e%arlo, A. )., )helbourne, 9. (., Ac%arroll, E. R. ? Rettig, '. %. 216624. -raditional /ersus accelerated rehabilitation $ollo*ing '%3 reconstructionH ' one year $ollo* u#. $ournal of Ort%opaedic and Sports P%ysical &%erapy! '), !06 !18. (erogatis, 3. 216624. &%e 8rief Symptom 5nventory 28S54 administration! scoring : procedures manual;55 222nd ed.4. ,alti&oreH %linical Psycho&etric Research4 (erscheid, @. 3. ? Feiring, (. %. 216>"4. ' statistical analysis to characteriBe treat&ent adherence o$ the 1> &ost co&&on diagnoses seen at a s#orts &edicine clinic. $ournal of Ort%opaedic and Sports P%ysical &%erapy! (, 40 48. (ish&an, R. 9. ? 1c0es, C. 216>14. )el$ &oti/ation and adherence to thera#eutic e.ercise. $ournal of 8e%avioral Medicine! +, 421 4!>. (ra#er, V. ? 3add, %. 2166!4. )ub:ecti/e e/aluation o$ $unction $ollo*ing &oderately accelerated rehabilitation o$ anterior cruciate liga&ent reconstructed 0nees. $ournal of *t%letic &raining! ,6, !> 41. (uda, E. 3., )&art, '. E. ? -a##e, A. 9. 216>64. Predictors o$ adherence in rehabilitation o$ athletic in:uriesH 'n a##lication o$ #ersonal in/est&ent theory. $ournal of Sport and 1 ercise Psyc%ology! '', !8" !>1. (unbar Eacob, E., (unning, E. E. ? (*yer, 9. 2166!4. %o&#liance research in #ediatric and adolescent #o#ulationsH -*o decades o$ research.21n N. '. 9rasnegor, 3. E#stein, ). ,. Eohnson, ? ). E. Fa$$e 2Eds.4, Developmental aspects of %ealt% compliance be%avior 2##. 26=514. Dillsdale, NEH Erlbau&.4 (unbar Eacob, E. ? )chlen0, E. 216684. -reat&ent adherence and clinical outco&eH %an *e &a0e a di$$erenceQ21n R. E. Resnic0 ? R. D. RoBens0y 2Eds.4, 7ealt% psyc%ology t%roug% t%e life span: Practice and researc% opportunities 2##. !2!= !4!4. Cashington, (%H '&erican Psychological 'ssociation.4 Engebretsen, 3., ,enu&, P., Fasting, +., Aolster, '. ? )trand, -. 216604. ' #ros#ecti/e, rando&iBed study o$ three surgical techniGues $or treat&ent o$ acute ru#tures o$ the anterior cruciate liga&ent. *merican $ournal of Sports Medicine! '6, 5>5 560. Fields, E., Aur#hey, A., Dorodys0i, A. ? )to#0a, %. 216654. Factors associated *ith adherence to s#ort in:ury rehabilitation in college age recreational athletes. $ournal of Sport Re%abilitation! +, 1"2 1>0. Fisher, '. %., (o&&, A. '. ? Cuest, (. '. 216>>4. 'dherence to s#orts in:ury

rehabilitation #rogra&s. &%e P%ysician and Sportsmedicine! '-2/4, 4" 52. Fisher, '. %., )criber, 9. %., Aatheny, A. 3., 'lder&an, A. D. ? ,itting, 3. '. 2166!4. Enhancing rehabilitation adherence. $ournal of *t%letic &raining! ,6, !12 !1>. Datha*ay, ). R. ? Ac9inley, E. %. 216514. &%e Minnesota Multip%asic Personality 5nventory 22re/ised4. Ne* For0H Psychological %or#oration4 Da*0ins, R. ,. 216>64. 'rthrosco#ic sta#ling re#air $or shoulder instabilityH ' retros#ecti/e study o$ 50 cases. *rt%roscopy: &%e $ournal of *rt%roscopic and Related Surgery! ,, 122 12>. Days, R. (., 9ra/itB, R. 3., AaBel, R. A., )herbourne, %. (., (iAatteo, A. R., Rogers, C. D. ? @reen$ield, ). 216644. -he i&#act o$ #atient adherence on health outco&es $or #atients *ith chronic disease in the &edical outco&es study. $ournal of 8e%avioral Medicine! '/, !4" !80. Derbert, -. ? %ohen, ). 2166!4. (e#ression and i&&unityH ' &eta analytic re/ie*. Psyc%ological 8ulletin! ''., 4"2 4>8. 1e/le/a, 3. ? +rlic0, -. 216614. Aental lin0s to enhanced healingH 'n e.#loratory study. Sport Psyc%ologist! ), 25 40. 9ra&er, E. F., Nusca, (., Fo*ler, P. ? Cebster ,ogaert, ). 216624. -est retest reliability o$ the one leg ho# test $ollo*ing '%3 reconstruction. Clinical $ournal of Sport Medicine! ,, 240 24!. 9raus, E. F. ? %onroy, %. 216>44. Aortality and &orbidity $ro& in:ury in s#orts and recreation. *nnual Revie" of Public 7ealt%! ), 18! 162. 3a&#ton, %. %., 3a&bert, A. E. ? Fost, R. 2166!4. -he e$$ects o$ #sychological $actors in s#orts &edicine rehabilitation adherence. $ournal of Sports Medicine and P%ysical #itness! .., 262 266. 3aubach, C. E., ,re*er, ,. C., Van Raalte, E. 3. ? Petit#as, '. E. 216684. 'ttributions $or reco/ery and adherence to s#ort in:ury rehabilitation. *ustralian $ournal of Science and Medicine in Sport! ,6, !0 !4. 3e/itt, R., (eisinger, E. '., Call, E. R., Ford, 3. ? %assisi, E. E. 216684. EA@ $eedbac0 assisted #osto#erati/e rehabilitation o$ &inor arthrosco#ic 0nee surgeries. $ournal of Sports Medicine and P%ysical #itness! .), 21> 22!. 3yshol&, E. ? @illGuist, E. 216>24. E/aluation o$ 0nee liga&ent surgery results *ith s#ecial e&#hasis on use o$ a scoring scale. *merican $ournal of Sports Medicine! '0, 150 154. Aalco&, 3. 3., (aniel, (. A., )tone, A. 3. ? )achs, R. 216>54. -he &easure&ent o$ anterior 0nee la.ity a$ter '%3 reconstructi/e surgery. Clinical Ort%opaedics and Related Researc%! '(-, !5 41. Aarder, R. '., Ras0ind, E. R. ? %arroll, A. 216614. Pros#ecti/e e/aluation o$ arthrosco#ically assisted anterior cruciate liga&ent reconstructionH Patellar tendon /ersus se&itendinosus and gracilis tendons. *merican $ournal of Sports Medicine! '(, 4"> 4>4. AarBo, E. A. ? Carren, R. F. 216614. Results o$ nono#erati/e treat&ent o$ anterior cruciate liga&ent in:uryH %hanging #ers#ecti/es. *dvances in Ort%opaedic Surgery! '), 56 86. Aeani, E., Aigliorini, ). ? -inti, @. 216>84. 3a #atologia de so/raccarico s#orti/o dei nuclei di accresci&ento a#o$isari O-he #athology o$ a#o#hyseal gro*th centers caused by o/erstrain during s#ortsP. 5talian $ournal of Sports &raumatology! 6, 26 !>. Aeichenbau&, (. ? -ur0, (. %. 216>"4. #acilitating treatment ad%erence3 2Ne* For0H Plenu&4

Auller, C. 216>!4. &%e <nee: #orm! function! and ligament reconstruction3 2Ne* For0H )#ringer Verlag4 Natri, '., Ear/inen, A., 9annus, P., Niitty&a0i, )., 'arnio, E. ? 3indhol&, -. ). 216654. %hanging in:ury #attern o$ acute anterior cruciate liga&ent tears treated at -a&#ere <ni/ersity Dos#ital in the 16>0s. Scandinavian $ournal of Medicine and Science in Sports! ), 100 104. Noyes, F. R., Aatthe*s, (. )., Aooar, P. '. ? @rood, E. ). 216>!4. -he sy&#to&atic anterior cruciate de$icient 0nee. Part 11H -he results o$ rehabilitation, acti/ity &odi$ication, and counseling on $unctional disability. $ournal of 8one and $oint Surgery! -)*, 18! 1"4. +rbell, )., Eohnston, A., Ro*ley, (., Es#ley, '. ? (a/ey, P. 2166>4. %ogniti/e re#resentations o$ illness and $unctional and a$$ecti/e ad:ust&ent $ollo*ing surgery $or osteoarthritis. Social Science and Medicine! +/, 6! 102. Roitt, 1. 2166"4. Roitt=s essential immunology3 23ondonH ,lac0*ell )cience4 Roos, D., +rnell, A., @ardsell, P., 3oh&ander, 3. ). ? 3indstrand, '. 216654. )occer a$ter anterior cruciate liga&ent in:uryM'n inco&#atible co&binationQ ' national sur/ey o$ incidence and ris0 $actors and a " year $ollo* u# o$ !10 #layers. Scandinavian $ournal of Medicine and Science in Sports! ), 10" 112. )atter$ield, A. E., (o*den, (. ? Fasa&ura, 9. 216604. Patient co&#liance $or success$ul stress $racture rehabilitation. $ournal of Ort%opaedic and Sports P%ysical &%erapy! '', !21 !24. )ha#iro, E. -., Rich&ond, E. %., Roc0ett, ). E., Ac@rath, A. A. ? (onaldson, C. R. 216684. -he use o$ a generic, #atient based health assess&ent 2)F !84 $or e/aluation o$ #atients *ith anterior cruciate liga&ent in:uries. *merican $ournal of Sports Medicine! ,+, 168 200. )har&a, 3., )inacore, E., (augherty, %., 9uesis, (. -., )tulberg, ). (., 3e*is, A., ,au&ann, @. ? %hang, R. C. 216684. Prognostic $actors $or $unctional outco&e o$ total 0nee re#lace&entH ' #ros#ecti/e study. $ournal of >erontology! Series *! 8iological Sciences and Medical Sciences! )', A152 A15". )helbourne, 9. (., 9loot*y0, -. E. ? (e%arlo, A. ). 216624. <#date on accelerated rehabilitation a$ter anterior cruciate liga&ent reconstruction. $ournal of Ort%opaedic and Sports P%ysical &%erapy! '), !0! !0>. )helbourne, 9. (. ? NitB, P. 216604. 'ccelerated rehabilitation a$ter anterior cruciate liga&ent reconstruction. *merican $ournal of Sports Medicine! '6, 262 266. )helbourne, 9. (., Chita0er, D. E., Ac%arroll, E. R., Rettig, '. %. ? Dirsch&an, 3. (. 216604. 'nterior cruciate liga&ent in:uryH E/aluation o$ intraarticular reconstruction o$ acute tears *ithout re#air. -*o to se/en year $ollo*u# o$ 155 athletes. *merican $ournal of Sports Medicine! '6, 4>4 4>6. )helbourne, 9. (. ? Cilc0ens, E. D. 216604. %urrent conce#ts in anterior cruciate liga&ent rehabilitation. Ort%opaedic Revie"! '(, 65" 684. )tone, '., 9essler, R. ? Daythornth*aite, E. 216614. Aeasuring daily e/ents and e.#eriencesH (ecisions $or the researcher. $ournal of Personality! )(, 5"5 80>. -aylor, '. D. ? Aay, ). 216684. -hreat and co#ing a##raisal as deter&inants o$ co&#liance to s#orts in:ury rehabilitationH 'n a##lication o$ #rotection &oti/ation theory. $ournal of Sports Sciences! '+, 4"1 4>2. -egner, F. ? 3yshol&, E. 216>54. Rating syste&s in the e/aluation o$ 0nee liga&ent in:uries. Clinical Ort%opaedics and Related Researc%! '(6, 4! 46. -egner, F., 3yshol&, E., 3yshol&, A. ? @illGuist, E. 216>84. ' #er$or&ance test to &onitor rehabilitation and e/aluate anterior cruciate liga&ent in:uries. *merican

$ournal of Sports Medicine! '+, 158 156. <dry, E. 2166"4. %o#ing and social su##ort a&ong in:ured athletes $ollo*ing surgery. $ournal of Sport and 1 ercise Psyc%ology! '(, "1 60. Ciese ,:ornstal, (. A., )&ith, '. A., )ha$$er, ). A. ? Aorrey, A. '. 2166>4. 'n integrated &odel o$ res#onse to s#ort in:uryH Psychological and sociological dyna&ics. $ournal of *pplied Sport Psyc%ology! '0, 48 86. Cise, '., Eac0son, (. C. ? Rocchio, P. 216"64. Preo#erati/e #sychologic testing as a #redictor o$ success in 0nee surgery. *merican $ournal of Sports Medicine! /, 2>" 262. Correll, -. C. 216624. -he use o$ beha/ioral and cogniti/e techniGues to $acilitate achie/e&ent o$ rehabilitation goals. $ournal of Sport Re%abilitation! ', 86 "5. -his article *as su##orted in #art by @rant R15 'R420>" 01 $ro& the National 1nstitute o$ 'rthritis and Ausculos0eletal and )0in (iseases. 1ts contents are solely the res#onsibility o$ the authors and do not re#resent the o$$icial /ie*s o$ the National 1nstitute o$ 'rthritis and Ausculos0eletal and )0in (iseases. Ce than0 Aar0 'ndersen $or his hel#$ul co&&ents on an earlier /ersion and Aarc 'concio, Aichael 'stilla, Aatt ,its0o, Eohn ,ric0ner, %hris ,untroc0, Cally ,Bdell, %atherine (7'gostino, (oug Dar/ey, Ron Do0anson, Airia& Dol&es, %hris 1BBo, 9elly 9ane, @reg 9elleter, (a/e 3a3iberty, Ee$$ 3aubach, -ara Nichols, Eulie +7,rien, Ee$$ Rice, Eric Rienec0er, -rina Runge, %orinne )&ith, 9en -ubille:a, Faye Ceiner, Eere Ceinstoc0, Deidi Colcott, 9athy Curster, and Aar0 Funger $or their assistance in data collection. %orres#ondence &ay be addressed to ,ritton C. ,re*er, (e#art&ent o$ Psychology, )#ring$ield %ollege, )#ring$ield, Aassachusetts , 01106. Electronic &ail &ay be sent to bbre*erRs#$ldcol.edu
Recei/edH Aarch 1, 1666 Re/isedH Eune ", 1666 'cce#tedH 'ugust 1!, 1666

-able 1. Aeans, )tandard (e/iations, and 1ntercorrelations o$ Psychological, 'dherence, and +utco&e Aeasures

Figure 1. )che&atic Re#resentation o$ Dy#othesiBed Relationshi#s '&ong Psychological Factors, Rehabilitation 'dherence, and Rehabilitation +utco&e.