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Improving adherence to sport therapy rehabilitation

In this chapter, key findings from this research are summarised. The findings from the study linked to relevant literature in order to compare and contrast findings with previous work. The new findings that extend existing knowledge are also highlighted. A summary of recommendation about how adherence to sport therapy rehabilitation can be improved is given before the conclusion.

Adherence to sports injury rehabilitation programmes is a significant aspect, which can affect the result of the sports injury rehabilitation programmes (Hayden et al, 2005). World Health Organization (2003) suggested that patients who regularly attend their rehabilitation sessions might have improved injury rehabilitation results than those who were inconsistent in their rehabilitation. Campbell et al. (2001) argued that poor patients’ attendance to their schedule appointments have been identified in many health departments along with sports physiotherapy. The level of irregularity in attending to schedule sports physiotherapy appointments is indistinct. Vasey (1990) pointed out that 14% of players who have sports injury did not come back for their sports injury rehabilitation follow up.

Sluijs et al (1993) indicated that in some cases noncompliance could be 70% in the sports injury treatment programme at home and the sports therapy clinic. Inconsistency in sports injury rehabilitation programmes has entailments on sports injury rehabilitation success and cost. World Health Organization (2003) defined adherence as “the extent to which a person's behaviour… corresponds with agreed recommendations from a healthcare provider”.

In this study, qualitative methods were used with the main purpose of knowledge and awareness, from the amateur rugby player’s perception, how they perceive to take part injury rehabilitation programme regularly at club’s therapy clinic and then try to carry on with the home exercise programme.

Interviews were used as a data collection method. Participants might try to portray themselves as a decent and noble component of the the public. In the present study, participants may have been uncertain how to explain their non-adherence to a sports injury treatment programme to avoid emerging lethargic or unappreciative to the sports therapist.

The researcher, who carried out the study, assured the amateur rugby football players that all information would be kept anonymous and confidential. Certainly, these players were content to point out their original trustworthiness to the sports therapist, and then to acknowledge their own problems with adherence to a sports therapy injury management programme.

Over two hundred variables have been recognized in previous research as affecting compliance to sports injury management programmes. It is not unpredicted that most of variables acknowledged in this study are coherent with previous literature (Meichenbaum and Turk, 1987).

Of all the other factors, time availability was one of the most important effects on the ability to do exercises at home. Apparent shortage of time has been recognised constantly in the previous research, as the most frequent cause for noncompliance to an injury management program. Literature on compliance to sports therapy has also found that non-adherent athletes pointed out lack of time and too many busy activities of daily living as the main difficulty in completing the injury management programme (Sluijs, Kok, Van der, 1993). In the present study, participants who did not do exercises regularly at home, identified lack of time because of work, course of study and other social obligations as a main cause of noncompliance to the home programme. In previous research, therapist had noticed, that work and time management issues, negatively affect sports injury treatment (Gordon et al., 1991). Milne et al. (2005) results indicated that professional and amateur players did not differ in their coping self-efficacy. However, there could be a possibility that amateur and professional players face different types of difficulties as they play in different types of environment. This is consistent with Fisher and Hoisington’s (1993) recommendation that therapy appointments times be tailored to the player’s schedules and not vice versa. The observation of less time available could in fact be a result of inappropriate management of time available (Shephard, 1985). This assumption is corroborated by the research of Dishman, Sallis, and Orenstein (1985), who pointed out that participants who have done exercises regularly in their study were as likely as the noncompliant to view time as a barrier to home rehabilitation programmes. The results from this study are in concurrent with the previous research.

Pizzari et al (2002) argued that in order to establish an efficacious mutual understanding, communication between sports physiotherapist and athlete is regarded to be significant. The significance of communication in the success of a sports injury treatment programme has been recognized in previous literature (Fisher, et al., 1993). Researchers further suggested that positive relationships between patients and sports physiotherapists resulted in a high adherence rate. In a retrospective study, Sluijs et al (1993a) reported that significantly high rates of adherence to a rehabilitation programme found when sports physiotherapist motivate their patients to do their home exercises, gave patients constructive feedback, ask for their comments about rehabilitation progress and regularly monitor their exercise. In the present study, support provided by the club’s therapist was acknowledged as an important factor for all participants and certainly effected attendance at therapy sessions. Previous qualitative research relating to support provided to athletes who were injured has acknowledged the therapist as a significant basis of knowledge and understanding right through the sports injury treatment programme (Johnston and Carrol, 1998).

Information provided by the club’s therapist to most of participants in this study regarding their injury and sports therapy rehabilitation programme have an effect on their motivation and compliance corroborate the qualitative research of Johnston and Carrol (1998). Benchmarking was of use primarily during sports therapy sessions when other players were there or goal and objectives were identified. Even though the majority of the participants acknowledged using the method of benchmarking to enhance motivation, in this regard compliant and noncompliant players to home exercises were not different.

Sports injury rehabilitation compliance is firmly linked with self belief, of which sports physiotherapy treatment is fundamental (Brewer et al, 2000). Motivation was the very important feature influencing compliance, predominantly home exercise compliance. Compliant participants were motivated to carry out home exercises irrespective of external influences, whereas noncompliant participants relied profoundly on external motivation. External motivating factors might not be dependable, specifically over a long period, and at times when external factors are few the dependence on motivation is improved. In this situation, compliance to the injury treatment programme seemed to decreased. This is in corroboration with the qualitative research carried out by Cambell, Evans, and Tucker (2001). Cambell, Evans, and Tucker (2001) tried to understand the reasons for compliance and noncompliance to therapy rehabilitation for patients with knee osteoarthritis. Patients, who suffered with osteoarthritis of the knee joint, have undergone a physiotherapy treatment programme. They found it difficult to adhere to a home exercise programme after being released from the therapy programme. Improved compliance to an exercise programme is consistently linked with motivation (Brewer, 1999).

In a recent study, Brewer et al. (2000) have investigated personal and emotional issues, after anterior cruciate ligament reconstruction. Brewer et al. (2000) findings pointed out that for the home based rehabilitation player’s motivation was one of the important predictor of compliance, while player’s individuality, mental concerns, social help and assistance were not connected to any determinant of compliance.Variables associated with motivation and acknowledged as determinants of compliance in this study were love and passion for the rugby game.

In the present study, contradictory perceptions of motivation have been shown by amateur rugby football players. Some participants argued that they were more interested in doing exercises in therapy sessions at the clinic while others pointed out that they had difficulty to motivate themselves to do exercise at home after work. In previous research, the therapist has recognized poor motivation as an important issue that played a role in poor compliance, specifically in amateur palyers’ (Niven, 2007).

The present study suggests, however, amateur rugby football players were usually motivated to comply with the therapy treatment at the club’s therapy clinic. Amateur rugby football players in particular had struggled to motivate themselves to do exercises at home. This may be because amateur players are more busy with work or other commitments and do not want to comply with a sports injury treatment plan (Fields et al., 1995). In agreement the Field et al (1995) statement, in this study most of amateur players indicated that they did not manage to do exercises at home due to lack of time. In contrast to the Field et al (1995) statement, some of the results from this study showed that an absence of therapists’ command, support, and encouragement was fundamental to decreased motivation when doing home exercises and following compliance. One explanation for this maybe due to the fact that the amateur player did not have confidence to be capable to do home based exercise. One of the participants clearly pointed out that he was not very confident in doing exercise alone. Since, the therapist never at home with the player, he might think that doing exercises might aggravate his symptoms so could result in poor compliance.

Milne at al. (2005) argued that weight and strength training is less likely to be part of the amateur players training programmes as compared to professional rugby players who mostly include strength and weight training in their training programme. In support of this statement, Milne et al (2005) state professional rugby players do home base exercises with greater quality and regularity than amateur players. Therapists need to have knowledge and understanding that offering more help for the home exercise programme might positively affect motivation to adhere to the home exercise programme.

Many particular features, specially linked to the subject of over adherence, were recognized. For example, being very eager and keen to get back to rugby were linked with over adherence. It was also proposed that professional players, long distance runners particularly, and individuals with a strong character might be more likely to over adhere. There has been limited previous research focusing particularly on the topic of over adherence in the sports injury treatment. In this study, one of the participants stated that he was too keen and eager to play. He came back from his injury too early and reinjured hiself. Therefore results suggest that too much motivation could cause re-occurance of the same injury.

The significance of communication in the achievement of compliance to injury treatment program has been acknowledged in previous research (Fisher, et al., 1993). This communication is also a key element in the education of an amateur player about their injury treatment programme. Educating amateur rugby player is a vital element in creating an autonomy-supportive environment. If the amateur player is given full information about the exercises and the process to get better, they can then make well-informed choices about their own program. If players are discouraged from communicating with their therapists when times are tough, they may choose to discontinue their courses of action and be unable to negotiate problems they face in their rehabilitation programs. However, when the player talks about the rehabilitation program, the player can begin to see the value in remaining consistent in the program and believe that if they adhere to the programme, they will fully recover. In the present study, the therapists were described as gracious, friendly, knowledgeable and supportive, and most participants pointed out that their positive relationship with the therapist helped with attending the clinic and completing therapy sessions. This is consistent with the Ryan and Deci’s (2000) findings that a confidence in the relationship with their therapist seemed important for participants to display motivated behaviours.

In this study the results are consistent with the findings, about medication compliance behaviours in a study by Williams, et al., (1998). They identified that treatment plans should be patient centered, which increased compliance to their medication regimens. Promoting option and choices of sports specific rehabilitation exercises would improve rehabilitation adherence.

Many times during the interviews, all amateur rugby players referred to the significance of having family, friends, and teammates involved during the injury rehabilitation process. Members of the squad, coaches, the therapist, or family members were recognised as having significant effects on the attempt and performance in therapy session programme. Other players pointed out that they think others enhanced their motivation when they were around and supported them to work harder with their injury rehabilitation programmes. Support from significant others has been attached to higher levels of motivation, which has in turn been linked with increased compliance levels (Williams, et al., 1998).

The results of this study are consistent with previous research, where the participants felt that friends, family, and teammates could be significant as a coping resource for recovering players (Bianco, 2001). The participants in the Bianco (2001) research pointed out that their family and friends support decreased concern and they remained motivated throughout the sports injury rehabilitation.

The amateur rugby players in the present study showed preference in doing exercises in the clinic compared to home exercise. This is agreement with Bandura (1986), who emphasises that the degree of supposed task self-efficacy can decide effort invested and determination in a particular conduct. In this study, poor exercise techniques, no supervision, and no written rehabilitation programme could be important reasons of low motivation for home exercise programme. Previous research has indicated the importance of making sure that players feel capable of doing different types of exercises at home. Players motivation found to be a key interpreter of clinic and home exercise programme (Brewer et al., 2003), Taylor and May (1996). In particular, this study proposes sport psychologists may need to take concrete steps to increase motivation among amateur rugby football players in a home exercise programme.

Results from previous research have indicated that athletes are not as concerned as members of the general public regarding their injuries (Gordon et al., 1991). There is a dearth of literature investigating pain in amateur rugby football players. Fields et al. (1995) investigated the factors related to compliance to sports therapy treatment in amateur athletes found that compliant athletes were not much concerned regarding their pain during exercises. Noncompliant athletes have always stopped doing exercises as soon as they feel pain. Expanding Fields et al. (1995) findings, Levy et al (2009) study results suggested that amateur athletes felt difficulty in assessing the severity of pain during the therapy clinic and home based exercise programme. In contrast to Fields et al. (1995), the results of this study indicated that pain did not affect participants attendance for the therapy session at the clinic. Most of the participants argued that if they have pain in doing exercise at home, they would like to see the therapist to find out the cause of the pain. Similarly, some participants pointed out that increased pain might be due to the wrong exercise technique or too much exercise, subsequently influencing their adherence to rehabilitation in a positive way.

Byerly et al (1994) argued that patients with low level of pain tolerance were less likely to be adherent to sports therapy rehabilitation programme then those with high pain tolerance. In contradiction, Sluijs et al., (1993a) did not find any meaningful dissimilarity between the pain experiences of compliant and non-compliant sports physiotherapy patients. The researcher, in the present study also did not find any difference in relation to pain tolerance among compliant and noncompliant amateur rugby football players, consistent with the qualitative research of the Sluijs et al., (1993a).

Pizzari et al (2005) suggested that there is a growing manifestation that players consistency to sports specific injury rehabilitation is vital to accomplish the early return to the rugby football game. Niven (2007) in his current study, investigated the sports physiotherapists perceptions of rehabilitation adherence, concluded that athletes at the highest level are highly consistent in their rehabilitation programmes. Niven’s (2007) results advocated that players at the highest level of the game, who are professional, are usually more encouraged to return to their highest level of match fitness. Regardless of this, Heaney (2006) pointed out that along with many other factors, noncompliance accounted as an important factor among amateur players. It has been advocated in current literature that elite players participate in their sports specific rehabilitation session with high motivation as compared to amateur players (Milne et al., 2005). In consistent with Milne et al, (2005), the researcher found that amateur players’ are highly inconsistent in their sports injury rehabilitation programmes (Udry, 1997).

Gould et al (1997) research suggested that problems of inconsistency in sports injury treatment attendance are much more common in amateur players. Daly et al (1995) argued that the level of game (amateur or professional) at which athletes perform has not been found to affect sports physiotherapy clinic attendance. In contrast, Taylor and Marlow (2001) suggested that the level of rugby, the players play might affect the consistency in injury rehabilitation sessions. Consistent with Daly et al (1995) results, the present study findings suggested that all the participants (amateur rugby football players) found to be compliant with clinic based injury based therapy treatment. However, in agreement with Heaney (2006), and Taylor and Marlow (2001), as an amateur player, some of the participants in this study found to be non-adherent in home based exercise programme.

In a recent study Niven (2007) investigated the physiotherapists personal experiences associate with sports physiotherapy treatment compliance reported players pessimistic characteristic such as inadequate self belief, depressing mental reaction to sports injury, low self-confidence, lack of assistance and help from community, to be the important aspects of inconsistency and non compliance. In the present study, one of the participant indicted that her low confidence and self-doubts regarding performing exercises alone without the therapist supervision exacerbated her fears of further damaging her injury and ultimately led to avoidance of home-based exercises.

The extent of belief in the therapist and the recommended therapy exercises programme appeared as being recognized as significant features on compliance. If a player does not like the therapist and does not believe that the suggested treatment exercises would be helpful then it was suggested that compliance would be poor. In contrast, the findings of this study indicated that, if the player has a good working relationship with the therapist and values suggestions made, then it was suggested that compliance would be good. Earlier study has noted the effect of confidence in sports therapy management effectiveness in compliance (Taylor and May, 1996). The quality of therapist–patient relationship is significant in effecting compliance level and has been discussed with in general physiotherapy by Petitpas and Cornelius (2004), but there seems to be limited research within sports therapy environment.

Fields et al (1995) have reported high level of compliance amongst the patients who experienced comfortable clinic atmosphere. Non compliance levels have been associated with complicated, inquisitive and endless rehabilitation programme that need help and assistance from other people for their successful completion. Brewer et al (2003) suggested that player’s beliefs in positive effects of injury rehabilitation, motivation, and capability to deal with rehabilitation obligation are linked with good compliance. In the present study, one of the participants stopped the exercises because as he had not noticed much improvement in her symptoms, she did not believe that the exercises and treatment were working, therefore, there did not seem to be a strong rationale for continuing the sports injury rehabilitation program.

Nevertheless, to date only, Pizzari et al (2002) have used qualitative research methods to investigate the conceptual understanding of the players’ compliance to sports physiotherapy treatment. Pizzari et al (2002) investigated factors that affect compliance in sports therapy treatment sessions in eleven participants with anterior cruciate ligament surgery. Inductive analysis has shown three vital variables affecting sports injury treatment compliance, including emotional, environmental, and physical issues. Particularly, results have suggested that different understanding of fitness level on return to rugby, self-inspiration and busy at work or rehabilitation sessions issues distinguish compliant and noncompliant behaviours in relation to home exercise programme. Pizzari et al (2002) investigation, nevertheless, is not in agreement with early research by Byerly et al., (1994), which reported that friends and family support, injury rehabilitation presumptions, sports injury appointment schedule and pain endurance (Taylor and May, 1996) to distinguish among compliant and inconsistent players' attitudes at sports injury clinic. Since, Pizzari et al (2002) used diverse sample in relation to players' participation in sports, it is too difficult to formulate results from it.

It has been argued that sports physiotherapy home exercise programme success based on players attempting sports specific treatment exercises at home. The player’s compliance history, self-belief, support from family and friends, and socio demographics are the personal attributes found to be associated with his/her compliance and consistency. Byerly et al (1994) stated that high level of compliance is strongly related to family and friend support that give the confidence to proceed with their sports injury exercise programme. In agreement with Byerly et al (1994) research findings with most of the participants, in present study acknowledged that their family support helped them to attend therapy sessions at the clubs sports clinic and exercise at home regularly. However, some participants pointed out that the family and friends support did not have any effect on their compliance to carry out exercise programme at home or in the clinic.

Taylor and May (1996) argued that when the patient realises that they are not getting well and their injury is serious, they became more compliant and consistent in their sports specific injury rehabilitation programme. In addition, Brewer et al (2003) suggested that if patients were not compliant then they are susceptible to additional problems associated to the injury as a result of not carrying out the recommended sports injury rehabilitation exercises. Consistent with Taylor and May (1996) findings, the results in the present study suggested that participants were more keen and eager to see the therapist and attend therapy sessions, when their pain increased due to over exercise or wrong exercise technique.

The injured players behaviours to the rehabilitation, types of exercises, modalities used, environment of sports physiotherapy clinic and appointment times found to be associate with the adherence to rehabilitation. Fields et al (1995) suggested that inconvenient treatment appointment times were recognised as an important non-adherence factor. In contrast to Fields et al (1995) study, the present study findings suggested that occasional a long wait for treatment, difficulty in getting an appointment from the therapist, a bigger team squad, and in some cases long travel distance to attend therapy appointments did not affect the adherence to the sports therapy treatment session in amateur rugby players.

Features of the amateur players’ environment in this study emerged as influencing adherence, which is consistent with Brewer (1998) findings. Having poor social support from important people around, including the therapist, the coach, parents and teammates was believed to decrease compliance, whereas good support was linked with improved compliance. In the present study, having good access to the therapy clinic and the therapist, being in an environment that is conducive to doing exercises and having no external demands to deal with, were all environmental factors that resulted in good compliance among amateur rugby players. These findings are in agreement with previous research that suggests that compliance would be influenced by the time available to rehabilitate, convenience and the comfort of the facilities (Brewer, 2003).

Findings of Field et al (995) study indicated that amateur athletes found the therapy room comfortable and conducive to sports injury rehabilitation. A considerable number of athletes in a study carried out by Fisher and Hoisington (1993) pointed out that a crowded therapy room reduces the attendance at the therapy sessions. A busy club’s sports therapy clinic appears to reduce compliance to exercise workout, at least in the minds of more than one third of the athletes. In contrast to the previous research, in this study the results suggested that, although, the participants complained about the busy schedule of the therapist at the club, it did not affect their attendance at the club’s sports therapy clinic. Location of the therapy clinic may have contributed to good compliance in the present study, as therapy rooms are located at the rugby clubs premises, which make it convenient for amateur players to receive treatment before, after, or during training sessions.

Johnson (1996) pointed out that less knowledge about therapy treatment can weaken the belief of a player, who was injured the first time, in his or her own intrinsic capabilities to recover. In contrast, because of the prior experience previously injured players are better able master the initial feelings of fear and anxiety and concentrate on their injury treatment (Milne, Hall and Forwell, 2005). In addition, previous injury experience is one of the significant sources of the motivation (Bandura, 1997). In consistent with Johnson (1996) and Milne, Hall and Forwell, (2005), the results from this study indicated that earlier experience of a player was valuable because the player has a better understanding of the rehabilitation process and knew the level of compliance essential to rehabilitate effectively.

Granito (2002) investigated the differences between male and female athlete’s experiences of an injury. The researcher used in-depth interview as a data collection tool. Granito (2002) inductively analysed the data, in order to compare the themes between male and female athletes’. The findings suggested that both male and female athletes stated the same concerns. The results of the present study are consistent with Granito (2002) findings. However, three themes appeared different, female athletes tend to identified the coaches much more negative following their injury, less likely to talk about significant people (parents, girlfriend or boy friend) and are much more worried about how the injury would affect their health in future.

Milne, Hall and Forwell, (2005) study results suggested that gender was not a significant factor in any of the self efficacy analyses performed. Lirgg et al (1996) argued that there could be disparities among men’s and women’s self efficacy level depending on the requirement of the rehabilitation exercise. The more masculine an exercise was perceived to be, the less self efficacy a women would have in relation to a man. It is likely that this principle can be translated into the sports therapy environment. There are some sports rehabilitation exercises such as weight lifting or balancing exercises which might be perceived as either masculine or feminine. However, in general the sports therapy rehabilitation program included a mixture of different exercises. Therefore sports therapy rehabilitation exercises can be considered as a gender neutral action. In relation to doing sports therapy exercises, in this study, no disparities were found in reported self-efficacy between males and female players.

Webborn et al (1997) carried out a pilot study to investigate the athletes understanding of their rehabilitation programme. Results indicated that 77% of the participants did not fully understand some exercises of their injury rehabilitation programme, while the therapist has given a written rehabilitation program to only 14% of participants. The participants who received a written programme were able to recall all the exercise instructions. The results of the randomised controlled trial carried out by Schneiders (1998) indicated that 77.4% compliance was reported by the participants who received written exercise instructions. The participants who received their exercise instructions verbally only reported compliance 38.1%. The findings of this study indicated that none of the participants received written exercise rehabilitation program instruction during their injury rehabilitation. This might be one of the reasons for poor compliance among amateur rugby football players.

Strengths of the study

The use of qualitative methodology constitutes strength in the design of this study allowing a deeper exploration to understand the amateur rugby player’s experiences of adhering to the injury rehabilitation programme. The phenomenological design also allowed for the exploration of the research area as viewed by the study participants with limited outside bias (Sim and Wright, 2000). Interviews were an appropriate method of data collection providing in-depth insights that could not be obtained solely through the questionnaires. In addition, piloting the data collection highlighted problems with the methodological design of the study prior to completion and enabled the novice researcher to develop his interviewing style.

Although small sample sizes are frequently cited as a weakness of qualitative studies, they can also represent strength. The narrow and detailed focus of this dissertation has yielded rich data, which, when taken in context of the previous findings, has expanded our understanding of the amateur rugby football player’s experiences and perceptions of adhering to a sport injury rehabilitation programme.

The term reliability and validity are commonly referred to as rigour in qualitative research (Pope, 1995). This investigation used several methods to enhance rigor. Purposive sampling technique used minimizes the potential bias arising from convenience sampling and improves the chance of collecting rich data relevant to the behaviour being studied when compared with the random sampling (Pope, 1995). Providing interviewees with transcribed interviews to ensure that the information has been accurately transcribed (kerfting, 1991). Use of verbatim transcripts and direct quotations when presenting data serves improve the internal validity of the findings (Shepard et al, 1993).

Several steps were taken to reduce my personal bias: neutral prompts, during interviews, emerged through progressive focusing; I maintained neutral body language and wrote field notes. Each interview was fully transcribed before collecting further data. Silverman (2000) maintains this ensures the robustness of the data and quality of the analysis. Digital Voice recordings were of a good quality and they were completely transcribed by the researcher. The quality of data elicited improved as a result of the researcher becoming more experienced in conducting interviews.

Tone relate to the volume and sound characteristic of a individual’s voice and can show biases such as enthusiasm, appreciation and dissatisfaction, scorn, shock, and disbelief. Intellectual context affects how the tone of voice will be understood (Mack et al, 2005). What is reasonable in one context may seem unsuitably loud in another. In an attempt to reduce researcher tone of voice bias, digital pre-recorded questions were used.

Asking leading questions endangers communicating your own value judgements and biases inflicting a perception on participants. When asked a leading question, participants are likely to provide a reply that agrees with the question simply because they are afraid to disagree with the interviewer. To avoid this, the researcher asked neutral questions free of preconceptions.

Limitations

Though the results of the current study widened the knowledge and understanding relating to rehabilitation compliance problems particular to amateur rugby football players, there are some limitations that warrant mention.

The findings of this study are limited by the lack of independent verification of the data analysis process and the themes that emerged from this due to there being no consent of independent code checks from ethical committee.

Due to the retrospective nature of the study, care should be used, when translating the results, as it can restrict the recall capability of the participants. Due to the time constraints for this study, no action was taken to regulate the time between the injury onset and the timings of the interview. This gives a sample of participants who are in different phases of the injury process.

Although, interviews were an appropriate method of data collection for this study, however, it is important to acknowledge that the amateur rugby football players may have attempted to present themselves to the interviewer as a good player and regular in rehabilitation appointments. The participants in this study might have been hesitant to reveal their lack of adherence to avoid appearing lazy or ungrateful for the time that the sports physiotherapist had spent with them.

The findings of this study only report amateur rugby football player’s understanding and insight in compliance to a sport injury management program. Although, by restricting the sample to only amateur rugby football players, it provided a more controlled exploration of understanding and insight into compliance to a sport injury management programme. However, such homogeneity decreases the generalisation of the results. Therefore, caution should be taken to generalising these results to the rest of the athletic population.

The researcher recognises that inevitably, their emotions and values were engaged throughout the study, however they aimed to be as non-judgemental as possible, which was aided by the completion of field notes and a reflective research diary.

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