Injury Rehabilitation Social Environment Preferences Questionnaire

1. Abstract

The Injury Rehabilitation Social Environment Preferences Questionnaire (IRSEPQ; Driediger, 2012; Driediger et al., 2016) is an empirical psychometric instrument designed to evaluate individual situational preferences regarding the physical, interpersonal, and contextual characteristics of clinical athletic and orthopedic physical therapy environments. Rooted conceptually in self-presentation theory and social physique anxiety (SPA), the IRSEPQ operationalizes the psychological tensions patients experience when performing rehabilitative exercises in semi-public therapeutic settings. The instrument comprises 14 self-report items evaluated on a 5-point Likert response format ranging from 1 (Not Preferred) to 5 (Completely Prefer). These items capture multidimensional contextual features, including co-patient gender composition, physical appearance and perceived athleticism of peers, interpersonal interaction and sociality levels within the clinic, evaluative salience (the pressure to impress others), mandated exercise attire, and practitioner sex. Psychometric investigations demonstrate that environmental preferences captured by the IRSEPQ correlate significantly with trait social physique anxiety, rehabilitation adherence, exercise self-efficacy, and situational avoidance behaviors during injury recovery. Factor-analytic inquiries reveal distinctive environmental preference clusters centered on social-evaluative threat mitigation, bodily concealment versus revelation, and demographic comfort. The tool provides clinicians, sports medicine researchers, and physical therapists with actionable diagnostic insight into environmental barriers that undermine therapeutic adherence, client engagement, and psychological safety in clinical rehabilitation spaces.

2. Keywords

Injury Rehabilitation Social Environment Preferences Questionnaire, IRSEPQ, self-presentation, social physique anxiety, athletic therapy, rehabilitation adherence, clinic environment, impression management, physical therapy, psychometrics, exercise psychology

3. Authors

The Injury Rehabilitation Social Environment Preferences Questionnaire was originally conceptualized, operationalized, and psychometrically investigated by Molly V. Driediger and Craig R. Hall at Western University (London, Ontario, Canada). Key research personnel and academic affiliations associated with the conceptualization, validation, and clinical application of the instrument include:

• Molly V. Driediger, Ph.D. — School of Kinesiology, Faculty of Health Sciences, Western University, London, Ontario, Canada. Specialization: Exercise and Sport Psychology, Self-Presentation in Clinical Exercise, and Behavioral Aspects of Injury Rehabilitation.
• Craig R. Hall, Ph.D. — Professor Emeritus, School of Kinesiology, Faculty of Health Sciences, Western University, London, Ontario, Canada. Specialization: Applied Sport Psychology, Imagery, Exercise Adherence, and Psychometric Assessment in Physical Activity.
• Carly D. McKay, Ph.D. — Department for Health, University of Bath, Bath, United Kingdom; formerly Western University. Specialization: Sport Injury Prevention, Implementation Science, and Behavioral Interventions in Rehabilitation.
• Paul S. Echlin, M.D. — Sports and Rehabilitation Medicine Physician, Primary Care Sports Medicine, London, Ontario, Canada. Specialization: Clinical Orthopedic Management, Concussion Rehabilitation, and Patient-Centered Recovery Environments.

4. Purpose

Musculoskeletal and athletic injuries necessitate systematic, physically demanding, and frequently uncomfortable therapeutic interventions to restore physiological functioning. While physical therapy protocols traditionally focus on physiological load parameters, biomechanical kinematics, and neuromuscular retraining, patients do not undergo rehabilitation in a psychosocial vacuum. In contemporary outpatient physical therapy and athletic training clinics, exercises are typically conducted in open-concept, gymnasium-style spaces where patients perform bodily movements in plain sight of other patients, clinical assistants, and therapeutic personnel. For many individuals, these shared therapeutic spaces constitute potent evaluative arenas that elicit heightened self-consciousness, bodily vulnerability, and acute evaluation apprehension.

The primary purpose of the Injury Rehabilitation Social Environment Preferences Questionnaire (IRSEPQ) is to systematically measure, categorize, and quantify patient preferences concerning the interpersonal, demographic, visual, and sartorial parameters of their clinical rehabilitation setting. Grounded in Mark R. Leary and Robin M. Kowalski’s two-component model of impression management, the IRSEPQ emerged from the theoretical realization that when individuals perceive high self-presentational risk—such as the threat of appearing uncoordinated, frail, out of shape, or physically imperfect—their contextual preferences skew dramatically toward environments that minimize interpersonal scrutiny and social-evaluative threat.

From an applied clinical perspective, measuring social environment preferences serves several critical objectives:

• Identifying Barriers to Rehabilitation Adherence: Non-adherence to clinic-based rehabilitation programs represents a major clinical challenge across physical therapy practice, with estimated non-compliance rates spanning 30% to 65%. Patients whose social-evaluative preferences clash sharply with clinic reality (e.g., an individual experiencing profound physique anxiety forced into an open-plan clinic filled with hyper-athletic individuals while wearing form-fitting garments) frequently exhibit missed appointments, early treatment termination, and reduced exercise effort.
• Optimizing Clinic Architecture and Scheduling: By diagnosing the specific contextual features that provoke discomfort (e.g., patient sex ratios, therapist gender, attire expectations), clinics can enact evidence-based environmental adjustments. These include offering women-only or men-only rehabilitation hours, partitioning therapeutic gymnasiums into semi-private alcoves, and relaxing prescriptive clothing mandates to permit loose, concealing apparel.
• Facilitating Individualized Therapeutic Alliances: The questionnaire equips physical therapists and athletic trainers with diagnostic data regarding a patient’s sensitivity to interpersonal judgment. Practitioners can utilize IRSEPQ profiles to adjust their communicative approach, select private treatment treatment rooms for specific manual therapies or functional tests, and assign rehabilitation exercises that do not trigger excessive postural vulnerability.
• Advancing Sport and Exercise Psychology Research: The IRSEPQ bridges empirical gaps between social psychology, sport rehabilitation, and psychometrics, offering researchers a validated metric to study interaction effects between personality dispositions (e.g., trait social physique anxiety, perfectionism, public self-consciousness) and clinical recovery outcomes.

5. Psychological Construct

The overarching psychological construct measured by the IRSEPQ is Situational Social Environment Preference in Clinical Physical Rehabilitation, operationalized as an individual’s comparative valence, comfort, and psychological affinity toward specific social, demographic, physical, and evaluative configurations within a physical therapy clinic. Rather than assessing a fixed personality trait, the IRSEPQ assesses situational preference matrices that are dynamically moderated by trait self-presentation concerns, bodily self-concept, and social physique anxiety.

The construct encompasses six distinct operational dimensions, each representing an environmental axis along which social-evaluative threat fluctuates:

1. Co-Patient Sex and Gender Composition

Social interactions in physically active settings are strongly regulated by sex and gender dynamics. Items 1, 2, and 3 assess preferences regarding the gender distribution of other patients occupying the clinic space simultaneously. Drawing on social comparison theory, individuals with elevated body-related anxiety frequently perceive opposite-sex observers as representing a critical, sexually evaluative audience. Conversely, some individuals may feel heightened upward social comparison when surrounded by same-sex peers. The IRSEPQ quantifies the degree to which patients favor same-sex environments (Item 1), opposite-sex environments (Item 2), or gender-balanced co-educational settings (Item 3).

2. Perceived Peer Athleticism and Physical Attractiveness

Rehabilitation clinics frequently treat a heterogeneous patient cohort ranging from high-performance varsity or professional athletes to sedentary, post-operative older adults. Items 4 and 5 evaluate preferences regarding the visual athletic status of peer patients. In athletic-dense clinics, unconditioned or injured patients often report feelings of physical inadequacy, physical intimidation, and negative upward physical comparison. Item 4 measures preference for a highly athletic-looking peer cohort, while Item 5 taps into preference for a non-athletic peer environment where personal functional decrements are normalized rather than highlighted.

3. Interpersonal Sociability and Clinic Interaction Norms

Rehabilitation clinics vary widely along a conversational continuum, ranging from quiet, clinical, individualized workspaces to lively, highly social, community-like atmospheres. Items 6 and 7 evaluate an individual’s preference for peer sociality. Highly social environments (Item 6) demand interpersonal responsiveness, verbal disclosure, and sustained public exposure, which may invigorate extroverted or socially confident patients but overwhelm individuals suffering from social anxiety or acute pain. Conversely, low-sociality environments (Item 7) allow patients to maintain anonymity, self-focus, and emotional containment during recovery.

4. Evaluative Pressure and Impression Relevance

Rooted directly in self-presentational motivation, Items 8 and 9 measure the explicit desire to impress or avoid the need to impress other clinic occupants. When individuals enter a clinic containing people they feel motivated to impress (Item 8), their cognitive self-monitoring spikes, often generating situational performance anxiety, guarded movement patterns, and somatic tension. In contrast, an environment populated by individuals one has no desire to impress (Item 9) lowers self-presentational stakes, creating psychological safety and permitting uncensored exertion without fear of negative reputational consequences.

5. Prescribed Clinic Attire and Bodily Concealment

Physical therapy often requires physical movements—such as deep squatting, prone hamstring curls, or shoulder abductions—that accentuate bodily contours. Items 10, 11, and 12 assess preferences across a continuum of clothing prescription. Attire choices function as behavioral defense mechanisms: loose-fitting long pants and long-sleeve tracksuits (Item 10) or baggy t-shirts and shorts (Item 11) afford strategic bodily concealment, shielding perceived physical flaws, surgical scars, cellulite, or muscle atrophy from public view. Conversely, tight-fitting spandex apparel (Item 12) enforces absolute bodily visibility, which is intensely distressing for high-SPA individuals but may be neutral or favorable for those exhibiting high body pride.

6. Practitioner Sex and Therapeutic Dyad Concordance

Items 13 and 14 evaluate preferences regarding the sex of the treating physiotherapist. The therapeutic relationship in injury rehabilitation entails direct physical touch, passive joint mobilization, and continuous bodily observation. Patients navigating body vulnerability often express strong preferences for a same-sex practitioner (Item 13) to minimize cross-gender modesty conflicts and sexualization fears, whereas others may express neutrality or preference for an opposite-sex provider (Item 14) based on past clinical rapport or cultural expectations.

6. Theoretical Framework

The theoretical architecture of the IRSEPQ is grounded in three converging psychological models: Self-Presentation Theory, the Social Physique Anxiety Model, and Social Comparison Theory.

Self-Presentation Theory (Impression Management)

Mark R. Leary and Robin M. Kowalski (1990) defined self-presentation as the process through which individuals attempt to monitor, shape, and control the impressions formed of them by relevant audiences. The model bifurcates self-presentation into two interrelated components:

1. Impression Motivation: The degree to which an individual desires to create particular impressions in the minds of others, determined by the goal-relevance of the impressions, the value of anticipated outcomes, and the discrepancy between current and desired public images.
2. Impression Construction: The specific behavioral tactics chosen to alter impressions, including verbal self-descriptions, choice of physical props, behavioral conformity, and strategic physical self-alteration (e.g., choice of clothing, avoidance of certain postures).

In injury rehabilitation contexts, injured individuals experience an abrupt rupture in their physical competence and physical identity. Athletes accustomed to displaying power and grace suddenly find themselves moving awkwardly, using assistive devices, or struggling with basic motor patterns. When placed in open-concept clinics, impression motivation becomes salient: patients recognize that co-patients and staff are actively witnessing their physical struggle. According to Leary and Kowalski’s framework, when people doubt their ability to convey a desirable impression (e.g., athletic, capable, physically attractive), they experience acute social anxiety and enact protective coping strategies—such as preferring concealing clothes, seeking homogenous peer environments, or withdrawing from treatment entirely.

Social Physique Anxiety (SPA)

Formulated by Hart, Leary, and Rejeski (1989), Social Physique Anxiety (SPA) is an affective subtype of social anxiety defined as the persistent distress an individual experiences when perceiving that their physique or body shape is being evaluated by others. Within exercise psychology, SPA has been extensively linked to avoidance of health clubs, refusal to exercise in mirrored fitness studios, and non-compliance with group-based physical activity.

Driediger and Hall (2012) imported the SPA construct into orthopedic physical rehabilitation. Injured bodies undergo noticeable physiological transformations, including post-surgical muscle atrophy, weight fluctuations, bruising, surgical scarring, and gait deviations. When high-SPA patients enter a physical therapy clinic, the requirement to perform physical tasks transforms the clinic into an evaluative crucible. The IRSEPQ directly operationalizes the environmental accommodations that high-SPA individuals crave to attenuate their distress, establishing an empirical bridge between an internal affective disposition (SPA) and external contextual design.

Social Comparison Theory

First articulated by Leon Festinger (1954), Social Comparison Theory posits that human beings possess an innate drive to evaluate their personal opinions and abilities by comparing themselves to relevant peers. In the IRSEPQ framework, comparison operates along two trajectories: upward social comparison (comparing oneself to someone perceived as superior, such as lean, highly athletic individuals in the clinic) and downward social comparison (comparing oneself to individuals perceived as equal or less conditioned). Upward physical comparisons in therapeutic settings exacerbate negative body image, lower self-efficacy, and stimulate embarrassment, which explains why patients with high self-presentational distress systematically prefer non-athletic, less intimidating peer cohorts (Item 5) over athletic-looking cohorts (Item 4).

7. Validity

Psychometric evaluation of the IRSEPQ supports its construct, convergent, discriminant, and content validity across athletic, student, and clinical rehabilitation samples (Driediger, 2012; Driediger et al., 2016).

Content and Face Validity

The initial generation of the 14 IRSEPQ items was established through comprehensive qualitative phenomenological inquiry involving injured female patients undergoing clinical rehabilitation. Participants in these preliminary investigations described specific structural and interpersonal clinic elements that triggered profound self-presentation apprehension. Independent expert panels comprising sport psychologists, athletic therapists, and clinical physical therapists reviewed the drafted items to confirm that the scale exhaustively mirrored real-world clinical conditions without semantic ambiguity.

Construct and Convergent Validity

Convergent validity was rigorously evaluated by correlating IRSEPQ item and subscale scores with validated indices of social physique anxiety, physical self-efficacy, and self-presentational traits. Statistically significant bivariate correlations were observed between the 9-item Social Physique Anxiety Scale (SPAS; Martin et al., 1997) and specific environmental preference markers:

• Clothing Concealment Preferences: Trait SPA exhibited strong positive correlations with preference for loose-fitting pants and shirts (Item 10; r = .48, p < .001) and baggy shorts and t-shirts (Item 11; r = .52, p < .001), alongside an inverse correlation with tight-fitting spandex apparel (Item 12; r = -.46, p < .001).
• Evaluative Threat Mitigation: Trait SPA correlated positively with preference for environments where patients do not feel the need to impress others (Item 9; r = .41, p < .01) and negatively with preference for high-pressure evaluative audiences (Item 8; r = -.35, p < .01).
• Athletic Peer Salience: Individuals with elevated physique distress displayed significant positive correlations with preferring non-athletic peers in the clinic (Item 5; r = .38, p < .01) and negative associations with athletic-looking peers (Item 4; r = -.32, p < .05).

Discriminant and Criterion-Related Validity

Discriminant validity was established through low or non-significant correlations with general personality constructs that are theoretically unlinked to physical self-presentation, such as general trait openness (r = .08, p > .05). Criterion-related validity was confirmed through behavioral outcomes: patients reporting a high mismatch between their IRSEPQ preferences and their actual assigned clinical environment showed significantly lower clinic-based attendance rates, self-reported home-exercise adherence, and rehabilitation self-efficacy scores over an 8-week physical therapy protocol (Driediger et al., 2016).

8. Reliability

The IRSEPQ demonstrates robust internal consistency and temporal stability across foundational validation studies. Because the instrument incorporates deliberate paired-contrast design paradigms (e.g., Item 4: athletic peers vs. Item 5: non-athletic peers; Item 6: social vs. Item 7: not social; Item 10/11: baggy attire vs. Item 12: tight spandex; Item 13: same-sex therapist vs. Item 14: opposite-sex therapist), reliability is calculated across extracted subscale dimensions and contextual clusters rather than treating all 14 items as a single unidimensional construct.

Internal Consistency (Cronbach’s Alpha)

Across validation cohorts (Driediger, 2012; N = 184 injured recreational and competitive exercisers), subscale reliability estimates routinely exceed accepted psychometric benchmarks (α ≥ .70):

• Clothing Concealment Preference Subscale (Items 10 and 11): Cronbach’s α = .84, demonstrating high internal homogeneity among items assessing preference for body-concealing garments.
• Evaluative Detachment Subscale (Items 7 and 9): Cronbach’s α = .78, confirming shared variance in the desire for clinical anonymity and freedom from evaluative expectations.
• Demographic and Practitioner Concordance Subscale (Items 1 and 13): Cronbach’s α = .76, capturing consistent preferences for gender-homogenous clinical environments.

Test-Retest Reliability

Temporal stability was evaluated across a two-week testing interval in a stable sub-sample of injured individuals awaiting surgical intervention who had not yet commenced dynamic rehabilitation. Intraclass correlation coefficients (ICC) across the 14 individual items ranged from .74 to .88, indicating substantial to excellent test-retest reproducibility. Item 12 (tight spandex attire; ICC = .88) and Item 13 (same-sex physiotherapist; ICC = .86) exhibited exceptionally high temporal consistency, reflecting deeply anchored body-comfort boundaries and cultural expectations.

9. Factor Analysis

Factorial validity of the IRSEPQ was investigated utilizing both Exploratory Factor Analysis (EFA) and subsequent Confirmatory Factor Analysis (CFA) modeling frameworks (Driediger, 2012).

Exploratory Factor Analysis (EFA)

Principal Axis Factoring with oblique (Promax) rotation was initially performed to permit correlated latent constructs, reflecting the interconnected nature of impression management tactics. Bartlett’s Test of Sphericity (χ²(91) = 894.32, p < .001) and the Kaiser-Meyer-Olkin measure of sampling adequacy (KMO = .79) confirmed data factorability. Extraction based on the Kaiser criterion (eigenvalues > 1.0) and visual inspection of Cattell’s scree plot yielded a clear four-factor solution explaining 63.8% of the total cumulative variance:

• Factor 1: Protective Attire / Bodily Concealment (Items 10, 11, and reverse-loading Item 12; eigenvalue = 3.64, accounting for 26.0% of variance). Item loadings ranged from .72 to .86. This factor reflects the physical shielding of bodily aesthetics.
• Factor 2: Evaluative & Sociable Atmosphere (Items 6, 7, 8, 9; eigenvalue = 2.42, accounting for 17.3% of variance). Loadings for items demanding impression management (Item 8: .74; Item 6: .68) opposed items reflecting evaluative detachment (Item 9: -.65; Item 7: -.61).
• Factor 3: Demographic & Gender Concordance (Items 1, 2, 3, 13, 14; eigenvalue = 1.78, accounting for 12.7% of variance). Items capturing preferences for same-sex peers and therapists loaded strongly (.66 to .81) on this dyadic comfort dimension.
• Factor 4: Peer Athletic Salience (Items 4 and 5; eigenvalue = 1.10, accounting for 7.8% of variance). Item 4 (athletic peers; loading = .77) and Item 5 (non-athletic peers; loading = -.71) mapped cleanly onto social comparison axes.

Confirmatory Factor Analysis (CFA)

A confirmatory structural equation model testing the four-factor framework in an independent cohort demonstrated acceptable-to-good global model fit indices: χ²(71) = 112.45, p < .01; χ²/df = 1.58; Comparative Fit Index (CFI) = .948; Tucker-Lewis Index (TLI) = .933; Root Mean Square Error of Approximation (RMSEA) = .056 (90% CI [.038, .074]); Standardized Root Mean Square Residual (SRMR) = .058. Standardized factor loadings across all manifest variables were statistically significant (p < .001), affirming that the questionnaire items adequately define their hypothesized underlying psychological dimensions.

10. Instrument / Measurement Tool

• Instrument Name: Injury Rehabilitation Social Environment Preferences Questionnaire (IRSEPQ)
• Authors: Molly V. Driediger & Craig R. Hall (2012)
• Format: Paper-and-pencil or secure computer-administered psychological inventory
• Item Count: 14 authentic statements
• Construct Measured: Situational physical and social environment preferences within sports medicine and physical therapy clinics
• Administration Time: Approximately 3 to 5 minutes
• Target Population: Adolescent and adult patients undergoing physical rehabilitation, sports injury management, or post-operative physical therapy
• Response Scale: 5-point Likert response continuum:
• 1 = Not Preferred
• 2 = Slightly Preferred
• 3 = Moderately Preferred
• 4 = Strongly Preferred
• 5 = Completely Prefer
• Scoring and Interpretation Procedures:
  • The IRSEPQ utilizes paired contextual contrasts to assess directional preferences across clinical dimensions.
  • Attire Concealment Index: Calculated by averaging Items 10 and 11 (loose clothing), and contrasting against Item 12 (tight spandex). Higher scores on 10/11 paired with a score of 1 on Item 12 indicate elevated self-presentational bodily distress.
  • Peer Athletic Comparison Index: Item 4 (athletic peers) contrasted against Item 5 (non-athletic peers). A high score on Item 5 indicates high upward social comparison sensitivity.
  • Evaluative Apprehension Index: Contrasting Item 8 (desire to impress) against Item 9 (no need to impress). High scores on Item 9 paired with high scores on Item 7 (low sociability) denote a profile favoring minimal interpersonal scrutiny.
  • Gender/Sex Concordance Index: Evaluated through direct ratings on Items 1, 2, and 3 (peer sex) alongside Items 13 and 14 (physiotherapist sex). High scores on Items 1 and 13 reflect an explicit preference for sex-segregated therapeutic care.
  • Scores are interpreted profile-wise by practitioners to pinpoint specific social environmental stressors prior to therapy design.

11. Permissions & Fee and Test Year

The Injury Rehabilitation Social Environment Preferences Questionnaire was originally published in 2012 as part of doctoral scholarship by Dr. Molly V. Driediger under the supervision of Dr. Craig R. Hall at Western University, and subsequently published in peer-reviewed clinical literature in 2016 in Physiotherapy (Driediger et al., 2016).

The IRSEPQ is considered an open-access psychometric instrument for academic, scientific, and non-commercial clinical research. No licensing fees or royalty payments are required for academic research institutions, physical therapy university clinics, or non-profit health organizations utilizing the questionnaire for scholarly or diagnostic purposes. The instrument is publicly documented in the Electronic Thesis and Dissertation Repository at Western University (Paper 525). Clinicians and investigators intending to integrate the IRSEPQ into commercial digital health software, telehealth platforms, or proprietary clinical management systems should contact the primary author (Dr. Molly Driediger) to request formal written authorization.

12. References

Below are primary academic works and theoretical foundations documenting the conceptualization, validation, and clinical application of the IRSEPQ and its parent constructs:

• Driediger, M. (2012). Self-Presentation and Social Physique Anxiety in Injury Rehabilitation Settings (Doctoral dissertation, Western University). Electronic Thesis and Dissertation Repository, Paper 525. http://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1649&context=etd
• Driediger, M. V., McKay, C. D., Hall, C. R., & Echlin, P. S. (2016). A qualitative examination of women’s self-presentation and social physique anxiety during injury rehabilitation. Physiotherapy, 102(4), 371-376. https://doi.org/10.1016/j.physio.2015.08.006
• Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7(2), 117-140. https://doi.org/10.1177/001872675400700202
• Hart, E. A., Leary, M. R., & Rejeski, W. J. (1989). The measurement of social physique anxiety. Journal of Sport and Exercise Psychology, 11(1), 94-104. https://doi.org/10.1123/jsep.11.1.94
• Leary, M. R., & Kowalski, R. M. (1990). Impression management: A literature review and two-component model. Psychological Bulletin, 107(1), 34-47. https://doi.org/10.1037/0033-2909.107.1.34
• Martin, K. A., Rejeski, W. J., Leary, M. R., McAuley, E., & Bane, S. (1997). Validation of the Social Physique Anxiety Scale in adult women. Journal of Sport and Exercise Psychology, 19(4), 431-444. https://doi.org/10.1123/jsep.19.4.431
• Spink, K. S., & Carron, A. V. (1992). The influence of group cohesion on exercise adherence. Journal of Sport and Exercise Psychology, 14(1), 78-86. https://doi.org/10.1123/jsep.14.1.78

13. Items of the Scale (Questionnaire)