Journal of Clinical Sport Psychology, 2016, 10, 192  -205

http://dx.doi.org/10.1123/jcsp.2014-0023
© 2016 Human Kinetics, Inc. ORIGINAL RESEARCH

The Role of Psychological Flexibility

in Injury Rehabilitation
Jessica J. DeGaetano, Andrew T. Wolanin,
Donald R. Marks, and Shiloh M. Eastin
Kean University

The purpose of this study was to explore the influence of psychosocial factors
and psychological flexibility on rehabilitation protocol adherence in a sample of
injured collegiate athletes. Self-report measures were given to injured athletes
before the start of a physical rehabilitation protocol. Upon completion of rehabili-
tation, each athlete was assessed by the chief athletic trainer using a measure of
rehabilitation adherence. Correlational analyses and bootstrapped logistic regres-
sion analyses were conducted to determine whether broad psychosocial factors
and level of psychological flexibility predicted engagement and adherence to a
rehabilitation protocol. Psychological flexibility, as measured on the Acceptance
and Action Questionnaire (2nd ed.; Bond et al., 2011), contributed significantly
to the overall logistic regression model. Study findings suggested that assessment
of psychological flexibility could give medical providers a way to evaluate both
quickly and quantitatively potentially problematic behavioral responding among
injured athletes, allowing for more effective adherence monitoring.

Keywords: AAQ-II, psychological flexibility, medical rehabilitation, rehabilitation

adherence, injury rehabilitation

In the past two decades, sports medicine professionals have begun to emphasize
the importance of monitoring an athlete’s adherence to injury rehabilitation proto-
cols. The American College of Sports Medicine (ACSM), for example, has released
several consensus statements (ACSM, 2002, 2006, 2007) highlighting the influence
of psychological factors on injury recovery and noting the lack of evidence-based
methods for evaluating an athlete’s readiness to return to play. Psychologically,
injury has been associated with significant distress levels, and those who return
before they are psychologically ready are at greater risk for both psychological
and physical difficulties (e.g., depression, anxiety, reinjury; Creighton et al., 2010).
Sports medicine professionals and sport psychologists have attempted to address
the role of psychosocial factors in the injury process, particularly with regard to

Jessica J. DeGaetano, Andrew T. Wolanin, Donald R. Marks (Editor of JCSP), and Shiloh M. Eastin
are at Kean University. Address author correspondence to Jessica J. DeGaetano at mccarthy.jessica@
gmail.com.

192
 Injury Rehabilitation   193

physical rehabilitation adherence (e.g., Byerly, Worrell, Gahimer, & Domholdt,

1994; Fisher, Scriber, Matheny, Alderman, & Bitting, 1993; Levy, Polman, Clough,
Marchant, & Earle, 2006; Marshall, Donovan-Hall, & Ryall, 2012).
A number of themes have been observed regarding injury rehabilitation within
the sport psychology literature. Flint (1998) addressed some of these; in particular,
he noted the lack of methodological rigor from the sport psychology side of research
(e.g., use of anecdotal reports, retrospective survey studies of past unpleasant or
painful events), along with difficulty in operationalizing components of injury
that allow generalizability of findings across studies. In addition, the definition of
“injury” has varied across studies, resulting in isolated bodies of work that paint an
inconsistent picture of what “being injured” entails. For example, Flint also noted
numerous factors that affect how injury impacts an athlete: severity, time missed,
timing of the injury, nature of the sport of the athlete, availability of sports medicine
practitioners, social supports, pain tolerance, and whether the athlete chooses to
report the injury in the first place.
Perhaps most importantly, Flint (1998) highlighted the lack of clarity regarding
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the intent of sport psychology interventions in the injury rehabilitation process: Are
the goals of these interventions to return the athlete to play as quickly as possible or
to increase adherence to rehabilitation protocols and promote a thorough recovery?
These questions continue to vex sport psychologists tasked with treating injured
athletes. In effort to address them more effectively, several different psychological
models for examining response to sports injury have been advanced. For example,
the integrated model of response examines sports injury from psychological, physi-
cal, and social perspectives (Wiese-bjornstal, Smith, Shaffer, & Morrey, 1998). More
recently, there has been increased interest in developing assessment and recovery
protocols for head injury and concussion at all levels of sport, suggesting greater
emphasis on rehabilitation and recovery (McCrory et al., 2013). This model, though
growing in acceptance, has not generalized to treatment responses for other types of
injuries, such as those of the upper and lower extremities (Craton & Leslie, 2014).
It should be noted that sports medicine professionals long have acknowledged
the importance of adherence to treatment within rehabilitation and the potential
ramifications of inadequate adherence from both competitive and community
samples (Bassett, 2003; Fisher, Mullins, & Frye, 1993; Granquist, Gill, & Appaneal,
2010). Poor adherence or nonadherence to treatment (i.e., the degree to which an
athlete fails to adhere to a treatment plan across medical and nonmedical settings)
can have direct implications for treatment outcomes (Bassett, 2003). Although
injured athletes have access to facilities and personnel that injured nonathletes
typically do not, treatment nonadherence among athletes remains a significant
problem (Fisher, Mullins, & Frye, 1993; Fisher, Scriber, et al., 1993). Byerly et al.
(2003) reported a 63% nonadherence rating based on attendance and the ratings
of athletic trainers for a sample of Division II athletes. Although research attention
primarily has been focused on physical consequences of injury and their contri-
bution to treatment nonadherence, some recent research has noted psychological
influences on nonadherence. Jack, McLean, Moffett, and Gardiner (2010), for
example, conducted a systematic review of major electronic databases including
MEDLINE, PubMed, PsycINFO, and SPORTDiscus, which revealed seven recent
studies regarding the negative impact of depression and anxiety on rehabilitation
adherence across settings, as well as overall quality of life.

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 194  DeGaetano et al.

One persistent obstacle to rehabilitation adherence research among athletes has

been the absence of an agreed upon means of assessing adherence. While there are
numerous adherence assessment tools used for monitoring engagement in outpatient
physical rehabilitation (e.g., Granquist et al., 2010; Kolt, Brewer, Pizzari, Schoo,
& Garrett, 2007; Kortte, Falk, Castillo, Johnson-Greene, & Wegener, 2007; Lenze
et al., 2004), none of these measures were developed for use with athletes. There
is also disagreement regarding the most efficient and least burdensome measure
to gain quantitative feedback about adherence.

Psychological Flexibility and Injury Rehabilitation

Psychological flexibility refers to the willingness to remain in contact with unde-
sirable internal experience in the service of one’s values or important goals (Bond
et al., 2011). Absence of psychological flexibility has been associated with expe-
riential avoidance, which refers to a variety of strategies used to escape or avoid
events that occur “within one’s skin” (O’Donohue & Ferguson, 2001, p. 133). In
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addition, lack of psychological flexibility can contribute to patterns of evading even

the antecedent cues associated with the onset of these private events (S.C. Hayes,
2004; S.C. Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). While avoidant
strategies for managing inner experience (e.g., calling in sick on the day of a rehab
appointment) may provide temporary relief, they also reinforce disengagement
from both external situations and internal experience. Experiential avoidance can
lead to an increase in social, health, and psychological risks over the longer term,
including increased anxiety, depression, and drug abuse (S.C. Hayes et al., 2004;
S.C. Hayes et al., 1996; Kashdan, Barrios, Forsyth, & Steger, 2006). Ironically, it
can also lead to increases in the very internal experiences that the avoidant behavior
was intended to diminish (Barlow, Allen, & Choate, 2004). For example, avoiding
a rehab appointment on one day may contribute to increased pain or apprehension
associated with engaging in rehab on subsequent days.
It is worth noting, however, that psychologically flexible behavior is not always
and everywhere conducive to the most desired outcome, and experiential avoidance
may, at times, prove to be a useful behavioral strategy. Persisting in a behavior despite
discomfort because of that behavior’s relevance to one’s values (e.g., finishing a
race while experiencing knee pain to support one’s team) could contribute to the
exacerbation of injury or a less than optimal performance. Similarly, avoiding the
fear-inducing stimuli and unwanted internal experiences associated with making a
headfirst diving catch could be useful in some circumstances (e.g., practice, training
game) by preventing injury or reinjury. At the same time, however, the reinforcement
of active avoidance of aspects of experience can prevent an individual from engaging
in more effective behavioral strategies, including progressing in injury rehabilitation.
To date, only two studies have attempted to measure experiential avoidance
(i.e., absence of psychological flexibility) in a rehabilitation population (Kortte
et al., 2009; Skinner, Robertson, Allison, Dunlop, & Bucks, 2010). Skinner and
colleagues (2010) evaluated mindfulness and avoidance as contributors to depres-
sion symptoms in 62 patients with spinal cord injury and found that experiential
avoidance significantly mediated the relationship between mindfulness and depres-
sion. This relationship suggested that low levels of mindfulness and high levels of
experiential avoidance were both related to higher rates of depression.

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 Injury Rehabilitation   195

Kortte and colleagues (2009) investigated experiential avoidance in 193 adults

with spinal cord dysfunction, stroke, amputation, or orthopedic surgery in an acute
inpatient rehabilitation setting. The authors found that experiential avoidance
predicted life satisfaction across the initial phase of recovery, as well as level of
handicap (particularly social reintegration) 3 months following discharge. This
study is particularly relevant to the current study because results did not support the
researchers’ hypothesis that avoidance would predict rehabilitative engagement. The
authors noted, however, that the “inherent structure and ‘culture’ of participation
that is present in the acute, inpatient rehab setting” (Kortte et al., 2009, p. 96) may
have prevented avoidant strategies from interrupting progress through a rehabilita-
tion protocol. In addition, findings indicated a relationship between experiential
avoidance and negative outcomes (e.g., lower life satisfaction).

The Present Study

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The purpose of the current study was to explore psychosocial factors and psycho-
logical flexibility as predictors of rehabilitation protocol adherence in a sample
of recently injured student-athletes. It was hypothesized that broad psychosocial
factors, including psychological distress and lack of psychological flexibil-
ity, would predict degree of engagement in and adherence to a rehabilitation
protocol.

Method
Participants
Approval for study recruitment was granted from the Institutional Review Board
and the Department of Athletic Training of a university located in the north-
eastern United States. A total of 68 injured student-athletes were recruited (40
male, 28 female) for the study. Participants whose scores on the Brief Battery
for Health Improvement (2nd ed.; BBHI-2; Disorbio & Bruns, 2002) indicated
elevated defensiveness were removed (n = 20), leaving a total of 48 participants.
Participants were at least 18 years of age (M = 19.9 years, SD = 1.35 years, age
range = 18–24 years). Academic year was proportionately represented across
the sample, and the sample was diverse with regard to ethnicity and range
of athletic teams represented. To be eligible for participation in the study, a
student-athlete had to have experienced an injury requiring treatment beyond ice
or electrical stimulation and had to have lost practice or playing time because
of the injury.

Procedure
Eligible student-athletes were identified by the chief athletic trainer and core mem-
bers of the athletic training staff. Researchers recruited eligible student-athletes
through face-to-face solicitation in the athletic training room after the occurrence
of the injury and before the initial rehabilitation session. Participants were informed
that their involvement in the study was confidential and voluntary, that it would

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 196  DeGaetano et al.

not affect standing on the team or playing time, that it would not be reported to
coaching staff, and that it would not influence the rehabilitation plan or outcome.
After consenting to participate, student-athletes completed a paper-and-pencil bat-
tery consisting of a demographics form, standardized self-report questionnaires,
and a debriefing form, while waiting to begin their rehabilitation sessions or while
receiving ice or electric stimulation. The chief athletic trainer completed a brief
standardized rehabilitation adherence measure for each student-athlete receiving
treatment.

Measures
Acceptance and Action Questionnaire (2nd ed.). The Acceptance and Action
Questionnaire (2nd ed.; AAQ-II; Bond et al., 2011) is a seven-item self-report
questionnaire that measures the construct of psychological flexibility, including
the degree to which a person avoids distressing thoughts, emotions, behaviors, or
memories. Items use a Likert-type scale ranging from 1 (never true) to 7 (always
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true). Bond et al. obtained a Cronbach’s α of .84 for the measure.

Brief Battery for Health Improvement (2nd ed.). The BBHI-2 (Disorbio
& Bruns, 2002) is a self-report measure consisting of 63 items. The BBHI-2
includes the following subscales: Somatic Complaints, Pain Complaints, Other
Pain Complaints, Functional Complaints, Depression, Anxiety, and Defensive-
ness. Cronbach’s α for the various subscales ranges from .69 to .87. The BBHI-2
is designed to identify biopsychosocial factors that may interfere with recovery
from an injury or chronic pain. The Defensiveness subscale reveals minimizing
or exaggerating of somatic symptoms, cognitive problems, emotional distress,
or psychiatric issues. For purposes of this study, participants with Defensiveness
scores above 20 (T > 65) were excluded from the analyses. The BBHI-2 provides
normative data for both medical and community samples. Medical normative data
were used for purposes of this study.
Hopkins Rehabilitation Engagement Rating Scale. The Hopkins Rehabilitation
Engagement Rating Scale (HRERS; Kortte et al., 2007) is a five-item scale for use
by rehabilitation staff to evaluate behavioral performance of the patient during
rehabilitation. Evaluated elements of engagement in rehabilitation include atten-
dance, attitude toward therapy, need for verbal or physical prompts, acknowledg-
ment of need for therapy, and level of active participation in therapy. The HRERS
is completed at the conclusion of rehabilitation and summarizes participation
across the entire course of treatment. Cronbach’s α for the HRERS is .90. For
the purposes of this study, a dichotomous dependent variable was created from
the HRERS using cutoffs provided by Kortte et al. (2007), who concluded that
participants scoring less than 20 on the HRERS were in need of clinical interven-
tion due to high number of absences and refusal to participate or low engagement
in physical therapy.
Demographics Questionnaire. A brief demographics questionnaire asked par-
ticipants to indicate information including gender, age, ethnicity, academic year,
sport(s) played, and playing time (anticipated playing time if freshman or if injury
occurred during preseason).

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 Injury Rehabilitation   197

Results
As noted, 20 participants’ data were removed because of high levels of defensive-
ness, leaving 48 participants in the analyses. Demographic information regarding
the sample can be found in Table 1. Bivariate correlations between the AAQ-II,
subscales on the BBHI-2, and the HRERS are presented in Table 2. Five subscales
of the BBHI-2 were moderately correlated with the AAQ-II, including Somatic
Complaints, r(46) = .43, p < .01; Other Pain Complaints, r(46) = .31, p < .05; Func-
tional Complaints, r(46) = .31, p = .04; Depression, r(46) = .52, p < .01; Anxiety,
r(46) = .48, p < .01; and Defensiveness, r(46) = –.50, p < .01. Furthermore, the
AAQ-II was significantly correlated with rehabilitation adherence as measured by
the HRERS, r(46) = –.31, p = .03. No other variables significantly correlated with
the HRERS, contrary to the study hypotheses.

Binary Logistic Regression With Bootstrapping

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Bootstrapped binary logistic regression (10,000 bootstrapped samples) analyses were

used to evaluate the extent to which psychological flexibility (AAQ-II) and psycho-
logical distress (subscales from the BBHI-2) predicted rehabilitation adherence and
engagement (HRERS). Bootstrapping allows for case resampling with replacement
from within the data set, providing a more accurate estimate of the population in
instances when sample size is small (Efron, 1979; A.F. Hayes, 2013). Participants
with a HRERS score of less than 20 were coded as 1, and the remaining participants
were coded as 0. A total of 35 participants (72.9%) were considered not at risk while
13 (27.1%) were considered to be at risk for poor rehabilitation adherence (Table 3).
The first logistic regression model of variables on the BBHI-2 did not predict
rehabilitation engagement and adherence, χ2(6, N = 48) = 2.38, p = .89. While
this model was 97% successful in predicting who was not at risk with regard to
engagement and adherence, it was only 15% successful in predicting who was at
risk (overall percentage correct = 75%). None of the variables were significant
as individual predictors within the model. The second logistic regression model
included BBHI-2 variables as well as the AAQ-II total score. This model also failed
to achieve significance, χ2(7, N = 48) = 7.83, p = .35. Table 4 shows the bootstrapped
B, standard error, odds ratio, and confidence interval (CI) for each predictor. Of
note, the AAQ-II was the only significant predictor within this model, B = .178,
p = .04, 95% bias-corrected and accelerated CI [0.03, 17.35]. The odds ratio sug-
gested that having a high AAQ-II score (indicative of psychological inflexibility)
increased the odds of poor engagement or adherence in rehabilitation by 20%,
Exp(B) = 1.195. In addition, the model increased to 30% successful in predicting
who was at risk and 94% successful in predicting who was not at risk (overall
percentage correct = 77%).

Discussion
Findings from this study supported the hypothesized relationship between psycho-
logical flexibility and rehabilitation adherence but did not support the anticipated
relationships between forms of psychological distress and poor rehabilitation adher-
ence. While the psychosocial symptom variables as measured by the BBHI-2 were

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 Table 1 Total Sample Demographics
Characteristic n %
Gender
Male 40 58.8
Female 28 41.2
Age
18 13 19.1
19 13 19.1
20 17 25.0
21 18 26.5
22 6 8.8
24 1 1.5
Ethnicity
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Caucasian 47 69.1
Black or African American 9 13.2
Hispanic 9 13.2
Asian 3 4.4
Academic year
Freshman 15 22.1
Sophomore 18 26.5
Junior 25 36.8
Senior 9 13.2
Fifth-year senior 1 1.5
Men’s athletic teams
Football 20 29.4
Baseball 9 13.2
Lacrosse 5 7.4
Basketball 2 2.9
Soccer 2 2.9
Volleyball 2 2.9
Women’s athletic teams
Soccer 8 11.8
Softball 6 8.8
Lacrosse 4 5.9
Tennis 3 4.4
Volleyball 3 4.4
Basketball 2 2.9
Field hockey 2 2.9

198 JCSP Vol. 10, No. 3, 2016

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Table 2 Correlations for AAQ-II Total Score, HRERS Total Score, and BBHI-2 Subscales
AAQ-II HRERS Def Som Pain Other Functl Dep Anx
AAQ-II — –.31* –.50** .43** .20 .31* .31* .52** .48**
HRERS — –.04 –.17 –.11 –.20 .03 .09 .02
Def — –.20 .07 –.11 –.54** –.66** –.57**
Som — .54** .50** .40** .30* .35*
Pain — .36* .25 –.10 –.05
Other — .22 .17 .15
Functl — .40** .32*
Dep — .61**
Anx —

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Note. Participants were removed from the database if the BBHI-2 Defensiveness raw score was ≥ 20 (N = 48 for all analyses). Cutoff for
the Defensiveness subscale was based on the normative data for the medical population (Disorbio & Bruns, 2002). AAQ-II = Acceptance
and Action Questionnaire (2nd ed.); BBHI-2 = Brief Battery for Health Improvement scale (2nd ed.); HRERS = Hopkins Rehabilitation
Engagement Rating Scale; Def = BBHI-2 Defensiveness subscale; Som = BBHI-2 Somatic Complaints subscale; Pain = BBHI-2 Pain
Complaints subscale; Other = BBHI-2 Other Pain Complaints subscale; Functl = BBHI-2 Functional Complaints subscale; Dep = BBHI-2
Depression subscale; Anx = BBHI-2 Anxiety subscale.
*p < .05 (two-tailed). **p < .01 (two-tailed).

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 200  DeGaetano et al.

Table 3 Means Based on HRERS Cutoff Score

(Not at Risk vs. At Risk for Poor Adherence) for Valid
Profiles (< 20 on BBHI-2 Defensiveness Subscale)
Not at risk At risk
Variable (n = 35) (n = 13)
AAQ-II total score* 11.80 16.31
HRERS total score** 24.66 15.23
BBHI-2 Defensiveness 17.06 17.08
BBHI-2 Somatic Complaints 4.14 5.31
BBHI-2 Pain Complaints 15.89 20.31
BBHI-2 Other Pain Complaints 17.00 19.00
BBHI-2 Functional Complaints 9.34 10.69
BBHI-2 Depression 3.83 4.00
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BBHI-2 Anxiety 3.46 3.54

Note. HRERS = Hopkins Rehabilitation Engagement Rating Scale; AAQ-II = Acceptance
and Action Questionnaire (2nd ed.); BBHI-2 = Brief Battery for Health Improvement
scale (2nd ed.). Participants were considered at risk if their HRERS score was less than 20.
*p < .05 (two-tailed). ** p < .01 (two-tailed).

correlated with psychological flexibility, these variables did not predict treatment
engagement as effectively as psychological flexibility, as measured by the AAQ-II.
For the purposes of predicting rehabilitation adherence, identifying psychological
flexibility may be more useful than identifying specific psychological symptoms.
A brief seven-item measure, the AAQ-II, could give medical providers a quick
quantitative assessment for potentially problematic behavioral responding without
requiring in-depth knowledge of psychopathology or the variety of diagnoses that
have been associated with absence of psychological flexibility.
The emotional response to the injury and rehabilitation process is complex,
varies from athlete to athlete, and underscores the fluctuations in emotions char-
acterized by feelings of loss, decreased self-esteem, frustration, and anger (Tracey,
2003). Assessment and intervention in injury rehabilitation can be more parsimoni-
ous and effective when a core behavioral process (e.g., psychological flexibility)
that affects rehabilitation adherence and engagement is identified. Integrating this
concept into injury rehabilitation may provide an effective, data-driven means to
evaluate potential adherence problems. The findings of the current study suggested
that measuring an indirect variable like psychological flexibility (as opposed to a
more overtly stigmatized symptom variable such as depression) may also minimize
defensive responding.
Allied health professionals, such as athletic trainers and physical therapists,
are in a unique position to influence physical and psychological variables during
rehabilitation. They spend substantial time with injured athletes throughout reha-
bilitation, and they have often have the trust and confidence of the athletes with
whom they work (Washington-Lofgren, Westerman, Sullivan, & Nashman, 2004).
Nevertheless, directly assessing psychological symptoms during rehabilitation

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Table 4 Summary of Logistic Regression Analysis With Bootstrapping for Variables Predicting
Engagement and Adherence to a Physical Rehabilitation Protocol for Injured College Athletes
Predictor B SE Exp(B) 95% CI
BBHI-2 Somatic Complaints –0.02 16.69 0.98 [–0.99, 0.89]
BBHI-2 Pain Complaints –0.00 17.93 1.00 [–0.85, 0.19]
BBHI-2 Other Pain Complaints 0.06 37.90 1.06 [–0.40, 3.36]
BBHI-2 Functional Complaints 0.04 17.89 1.04 [–0.54, 0.92]
BBHI-2 Depression –0.20 113.92 0.82 [–20.79, 0.76]
BBHI-2 Anxiety –0.16 51.64 0.86 [–11.06, 0.70]

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AAQ-II total score* 0.18 57.90 1.20 [–0.03, 17.35]
Note. CI = confidence interval; AAQ-II = Acceptance and Action Questionnaire (2nd ed.); BBHI-2 = Brief Battery for Health Improvement scale
(2nd ed.).
*p < .05 (two-tailed).

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 202  DeGaetano et al.

may be outside the scope of practice for these professionals and could introduce
unwanted cause for caution or reticence on the part of athletes. While addressing
potential threats to effective rehabilitation is imperative, doing so in a way that
minimizes stigma and maximizes participation in treatment would be ideal. Using
a brief measure of psychological flexibility, such as the AAQ-II, may help trainers
and therapists strike this balance.
Understanding factors that contribute to rehabilitation adherence could help
identify interventions and strategies that improve adherence. The use of nonstig-
matizing measures, which address behavioral processes rather than psychiatric
symptoms, could result in more reliable and valid data about adherence. To this
end, the current study suggests that the AAQ-II has utility as a brief, sensitive, and
subtle measure for assessing a key behavioral variable that predicts rehabilitation
engagement and adherence—psychological flexibility. Future studies could explore
other pertinent process variables such as mindfulness, as well as consider alternate
ways of collecting data from athletes receiving physical rehabilitation services
from an athletic training department. In addition, additional research regarding
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psychological flexibility and experiential avoidance could include tracking change

in avoidant behaviors over the course of rehabilitation.

Limitations
Participant recruitment and measure selection continue to pose challenges in sport
psychology. One perennial concern is the context in which data are collected. For
the current study, it is possible that the face-to-face nature of recruitment and data
collection led to increased impression management and scores on the BBHI-2 that
did not accurately reflect participants’ psychosocial distress. It is worth noting that
a recent study conducted by Wolanin, Gross, and Hong (2013) found the preva-
lence rate for depression to be as high as 45% for the greater athlete population
at the same institution where this study was completed. It seems unlikely that an
injured sample from this athlete population would be less depressed, anxious, or
functionally impaired than their noninjured counterparts, and it is possible that
the data collection method and associated impression management contributed to
this discrepancy. In these relational contexts, student-athletes may believe that by
endorsing as few negative items as possible, they convey the impression that they
are psychologically healthy.
Given that one of the goals of this study was to expand on Kortte and colleagues’
(2009) work by extending it to an outpatient physical rehabilitation setting, it is
only fitting to consider other directions in which to extend this line of research.
Variations of this study can be conducted within other sport-related injury contexts,
including club, high school, collegiate, elite, and professional athletes, as well as
recreational/community-based athletes. Assessment and intervention can include
baseline identification of those considered at risk of poor adherence during rehabili-
tation via the AAQ-II, and brief, experientially based sessions focused on increasing
psychological flexibility. A similar intervention protocol, using acceptance and
commitment therapy (ACT), was initially attempted by Mahoney and Hanrahan
(2011), who commented on the problems of an educational, more didactic-based
delivery format and called for a more experiential approach to dissemination with
injured athletes. The present study provides empirical support for the relevance of

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 Injury Rehabilitation   203

this work within the field of injury rehabilitation and suggests the potential utility in
using acceptance-based interventions such as ACT to target psychological flexibility.
In conclusion, the fields of sports medicine and rehabilitation psychology have
a unique opportunity to capitalize on the tremendous growth seen within clinical
psychology regarding transdiagnostic behavioral processes such as psychological
flexibility and engagement in avoidance. This study provides evidence concerning
potential utility of a specific method for highlighting behavioral concerns within the
injury rehabilitation process. Examination of psychological flexibility could prove
beneficial to athletic trainers, sports medicine staff, and most of all, the athletes
that these professionals serve.

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