Psychological Responses to Sport Injury
- Britton W. BrewerBritton W. BrewerSpringfield College
In addition to the disruptive impact of sport injury on physical functioning, injury can have psychological effects on athletes. Consistent with contemporary models of psychological response to sport injury, aspects of psychological functioning that can be affected by sport injury include pain, cognition, emotion, and behavior. Part of the fabric of sport and ubiquitous even among “healthy” athletes, pain is a common consequence of sport injury. Postinjury pain is typically of the acute variety and can be exacerbated, at least temporarily, by surgery and some rehabilitation activities. Cognitive responses to sport injury include appraising the implications of the injury for one’s well-being and ability to manage the injury, making attributions for injury occurrence, using cognitive coping strategies, perceiving benefits of injury, and experiencing intrusive injury-related thoughts and images, increased perception of injury risk, reduced self-esteem and self-confidence, and diminished neurocognitive performance. Emotional responses to sport injury tend to progress from a preponderance of negative emotions (e.g., anger, confusion, depression, disappointment, fear, frustration) shortly after injury occurrence to a more positive emotional profile over the course of rehabilitation. A wide variety of personal and situational factors have been found to predict postinjury emotions. In terms of postinjury behavior, athletes have reported initiating coping strategies such as living their lives as normally as possible, distracting themselves, seeking social support, isolating themselves from others, learning about their injuries, adhering to the rehabilitation program, pursuing interests outside sport, consuming alcohol, taking recreational and/or performance-enhancing substances, and, in rare cases, attempting suicide. Psychological readiness to return to sport after injury is an emerging concept that cuts across cognitive, emotional, and behavioral responses to sport injury.
Inherent in sport participation is the risk of injury. Although the physical effects of sport injury (e.g., tissue damage, initiation of healing processes, increased body mass index and body fat percentage) are especially salient (Myer et al., 2014; Prentice, 2011), sport injury can also have psychological consequences. Aspects of psychological functioning that can be affected by sport injury include pain, cognition, emotion, behavior, and readiness to return to sport. These aspects can be considered in terms of theoretical, empirical, and practical perspectives.
To describe and explain how athletes respond psychologically to injury, researchers have borrowed and, in some cases, adapted theories and models from other areas of psychology. For example, the most comprehensive attempt to represent psychological responses to sport injury and their antecedents conceptually—the integrated model of psychological response to sport injury (Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998)—is based largely on principles from the literature on stress and coping (Lazarus & Folkman, 1984) and is an extension of several previously adapted models (e.g., Gordon, 1986; Weiss & Troxel, 1986). In the integrated model, sport injury is conceptualized as a stressor that athletes interpret (or “appraise”) in terms of its impact and their ability to deal with its effects. This cognitive appraisal process is thought to be influenced by a multitude of personal and situational factors. Personal factors include injury characteristics (e.g., severity, type) and individual difference variables in the psychological (e.g., personality, motivation, identity), demographic (e.g., age, gender), and physical (e.g., health status, eating behavior) domains. Situational factors pertain to aspects of the sport (e.g., level of competition, time of the competitive season), social (e.g., family dynamics, social support), and physical (accessibility to rehabilitation, comfort of rehabilitation sessions) environments. The resulting cognitive appraisals are posited to influence cognitive, emotional, and behavioral responses to sport injury, which are themselves proposed to be dynamic, reciprocally related, and potentially influential on injury recovery outcomes (Wiese-Bjornstal et al., 1998). Research has provided consistent support for predictions generated from the integrated model (for a review, see Brewer, 2007). Although the integrated model does not include pain and psychological readiness to return to sport, it could easily be expanded to do so.
Another group of models has adapted the widely known ideas of Kübler-Ross (1969) regarding adjustment to terminal illness to psychological responses to sport injury. Such grief-based “stage models” hold that athletes proceed through an invariant, predictable sequence of stages after injury. For example, several authors (Astle, 1986; Rotella, 1985) proposed that athletes display denial, anger, bargaining, depression, and, finally, acceptance after they become injured. Although athletes have exhibited grief-like reactions to serious injury (Macchi & Crossman, 1996) and tended to display more favorable psychological responses over time after injury (e.g., McDonald & Hardy, 1990; Smith, Scott, O’Fallon, & Young, 1990), the notion of an invariant series of psychological reactions to sport injury has not been supported by research (Brewer, 1994). As with the integrated model, stage models do not address pain and psychological readiness to return to sport.
Focused on the types of pain that athletes might encounter both before and after injury, Addison, Kremer, and Bell (1998) developed a model of sport-related pain that incorporates ideas from the gate control theory of pain (Melzack & Wall, 1965), the parallel processing model of pain (Leventhal & Everhart, 1979), and the literature on cognitive appraisal processes in stress and coping (Lazarus & Folkman, 1984). As specified in the model, which neatly dovetails with the integrated model of Wiese-Bjornstal et al. (1998), athletes experience postinjury pain when they interpret physiological sensations as indicating a threat to their health and ascribe the sensations to injury. Individual differences in age, attention to bodily symptoms, fitness, and physiology are thought to influence the detection of physiological sensations. Both intrinsic factors (e.g., affect, cognition, pain tolerance, personality) and extrinsic factors (e.g., culture, prior experience, social/situational context) are proposed to affect the appraisal process. The model holds that when athletes with injury appraise physiological sensations as pain due to their injury, their responses (e.g., reducing physical activity, seeking assistance, implementing a coping strategy) are subject to the influence of factors such as culture and motivation. Although the model is of potential utility in understanding pain after the occurrence of sport injury, research support for the model is scant.
One particular behavioral response to sport injury—adherence to sport injury rehabilitation—has been examined from a variety of theoretical perspectives. Because adherence to medical regimens has been a widely studied topic for many decades (Meichenbaum & Turk, 1987), investigators of adherence to sport injury rehabilitation have had numerous theories and models of adherence available to guide their research. Among the perspectives that have been applied in studies of sport injury rehabilitation are, in addition to the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998), personal investment theory (Maehr & Braskamp, 1986), protection motivation theory (Prentice-Dunn & Rogers, 1986), self-determination theory (Ryan & Deci, 2000), the transtheoretical model (Prochaska & DiClemente, 1983), and an adaptation of the theory of planned behavior (Levy, Polman, & Clough, 2008). In general, the perspectives have strong cognitive and motivational components, which is not surprising given the effort and persistence that adherence to sport injury rehabilitation programs can require.
Although psychological readiness to return to sport is a concept that is still being defined, it has not been completely atheoretical. In particular, it has been suggested that self-determination theory (SDT; Ryan & Deci, 2000) offers a viable explanation for why athletes might or might not be psychologically ready to return to sport after injury. Podlog and his colleagues (e.g., Podlog & Eklund, 2005, 2007; Podlog, Lochbaum, & Stevens, 2010) have provided empirical support for the contention that, consistent with SDT, athletes can be considered less psychologically ready to return to sport when their basic psychological needs for competence, relatedness, and autonomy are not being satisfied than when those needs are being met.
Although the first empirical study on psychological responses to sport injury was conducted by Little (1969) more than a half-century ago, it wasn’t until the 1990s that a steady stream of empirical investigations began to appear in the literature. Over the past quarter-century, a sizable body of research on the topic has accumulated. The primary foci of scientific studies have varied over time, but pain, cognition, emotion, behavior, and readiness to return to sport have all been examined by investigators.
Pain is ubiquitous in sport. It not only can signal the occurrence of sport injury and feature in its aftermath, but it also can be a central aspect of sport training and competition. Reflecting the prominent role of pain in sport, scholars have investigated multiple aspects of the phenomenon in the context of sport. Research has progressed along four main lines of inquiry. One line of research has examined pain from a sociological perspective, yielding the important finding that sport is a culture in which athletes can be reinforced (or even glorified) for ignoring, denying, and playing through pain and injury (e.g., Hughes & Coakley, 1991; Nixon, 1992). Pain, therefore, appears to be a socially charged psychological response to sport injury that athletes may be discouraged from expressing, even to those responsible for treating the conditions that precipitated it (Safai, 2003; Walk, 1997).
A second line of research has compared athletes and nonathletes on laboratory measures of pain tolerance and pain threshold. Results of a meta-analysis of 15 studies indicated that (1) athletes had higher pain tolerance than nonathletes for cold, electrical, heat, ischemic, and pressure stimul; and (2) athletes had higher pain threshold than nonathletes for cold and pressure stimuli (Tesarz, Schuster, Hartmann, Gerhardt, & Eidt, 2012). The relevance of these findings for pain in response to sport injury, however, is not clear.
A third line of research has focused on assessing the prevalence and identifying anthropometric, biomechanical, strength, training, and, in rare cases, psychological predictors of pain in athletes. Many of the studies in this area of inquiry have examined pain in particular parts or regions of the body experienced by athletes participating in sports in which such pain is likely. For example, investigators have studied shoulder pain in swimmers (Walker, Gabbe, Wajswelner, Blanch, & Bennell, 2012); leg pain in cross country runners (Reinking, Austin, & Hayes, 2010); wrist pain in gymnasts (DiFiori, Puffer, Aish, & Dorey, 2002); knee pain in athletes across a variety of sports (Hahn & Foldspang, 1998); patellofemoral pain in basketball, soccer, and volleyball players (Myer et al., 2015); low back pain in cross country skiers, orienteers, and rowers (Foss, Holme, & Bahr, 2012); and pain in various body locations in cyclists (Dahlquist, Leisz, & Finkelstein, 2015). Although the methods and criteria used to examine pain have varied considerably across studies, prevalence rates in excess of 80% for at least mild pain have been documented (e.g., DiFiori et al., 2002; Reinking et al., 2010). Overall, the findings in this area of research attest to the ubiquity of pain in sport, but they do not have clear implications for understanding pain as a psychological response to injury because many of the participants who reported experiencing pain were not necessarily injured per se and, even when injured, may have been training as much as those who were not injured (Dahlquist et al., 2015).
The fourth main line of research has explored pain experienced by athletes after anterior cruciate ligament (ACL) reconstruction. In addition to examining associations of factors such as surgical procedures (Beck et al., 2004; Benea et al., 2014; Niki et al., 2012), anesthesia (Ekmekci et al., 2013), clinical variables (Niki et al., 2012), and cryotherapy (Raynor, Pietrobon, Guller, & Higgins, 2005) with postoperative pain, researchers have obtained descriptive data on the quality of pain over the first 48 hours postsurgery (Tripp, Stanish, Coady, & Reardon, 2004) and the intensity of pain over the first 6 weeks postsurgery (Brewer et al., 2007; Oztekin, Boya, Ozcan, Zeren, & Pinar, 2008 Tripp et al., 2004; Tripp, Stanish, Reardon, Coady, & Sullivan, 2003). Athletes’ endorsement of adjectives to describe their pain (e.g., sharp, tender, throbbing, aching, tiring, pulling) seems to change slightly from 24 to 48 hours postsurgery (Tripp et al., 2004), and pain intensity tends to decrease steadily from 24 hours to 6 weeks postsurgery (Brewer et al., 2007; Oztekin et al., 2008; Tripp et al., 2004). Pain intensity is higher for adolescents than adults at 24 hours postsurgery (Tripp et al., 2003) but is higher for older individuals than younger individuals over the first 6 weeks postsurgery (Brewer et al., 2007). Pain intensity is positively associated with anxiety at 24 hours postsurgery (Tripp et al., 2004) and negative mood over the first 6 weeks postsurgery (Brewer et al., 2007). In general, research in this line of inquiry is more concentrated on pain as a psychological response than that in the other three lines, but the narrow focus on a single type of injury and approach to treatment limits its generalizability. Thus, although the four lines of research have been informative, limitations with each of them preclude a thorough understanding of pain responses to sport injury.
As noted in the general section on theoretical perspectives, the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998) and earlier models emanating from the Lazarus and Folkman (1984) approach to stress and coping (e.g., Gordon, 1986; Weiss & Troxel, 1986) ascribe a temporally primary role to cognitive appraisals of the impact or personal relevance of sport injury in determining the cognitive, emotional, and behavioral responses that follow. In light of the physical damage induced by injury and the ramifications of that damage for subsequent sport participation, it is not surprising that interpretations of sport injury as threatening or involving harm or loss are common (Clement & Arvinen-Barrow, 2013; Ford & Gordon, 1999; Gould, Udry, Bridges, & Beck, 1997a). Cognitive responses beyond the primary appraisals of the injury can be grouped into three potentially overlapping categories of cognitive content (i.e., injury-related, self-related, and coping-related) and one general category of cognitive processes.
Given that sport injury is the kind of event that elicits the psychological responses addressed in this article, it is logical to expect the cognitive content of athletes with injuries to reflect their experiences and pertain at least partially to the injuries themselves. The unexpected nature of sport injuries may prompt athletes to engage in attributional thinking (Wong & Weiner, 1981) in which they attempt to identify the cause (or causes) of their injuries. A trio of studies identified behavioral factors (San José, 2003; Tedder & Biddle, 1998) and mechanical/technical factors (Brewer, 1999a) as common explanations given by athletes for injury occurrence. In addition to cognitions about the causes(s) of their injuries, athletes have reported experiencing recurrent, distress-producing, recurrent, intrusive thoughts and images of the injury event (Newcomer & Perna, 2003; Shuer & Dietrich, 1997; Vergeer, 2006). Later, after the immediate impact of injury has passed, athletes have shown a propensity for experiencing more positively tinged cognitive content, reporting perceptions of benefits they have accrued as a result of their injuries (e.g., Ford & Gordon, 1999; Podlog & Eklund, 2006; Tracey, 2003; Udry, Gould, Bridges, & Beck, 1997; Wadey, Evans, Evans, & Mitchell, 2011). Common themes of the injury-related benefits identified by athletes include personal growth, psychologically based performance enhancement, and physical/technical development (Udry et al., 1997). After experiencing injury, athletes may also harbor negative cognitive content about their prospects with respect to future injury, reporting less confidence in their ability to avoid injury and higher levels of perceived risk of injury and worry about sustaining an injury than athletes without a recent injury (Reuter & Short, 2005; Short, Reuter, Brandt, Short, & Kontos, 2004).
For many athletes, injury threatens their involvement in a self-defining activity that serves as a significant source of self-worth (Brewer, Van Raalte, & Linder, 1993). Consequently, it is reasonable to expect that injury might have an impact on self-related cognitive content. Consistent with this notion, athletes have reported decreases in self-esteem after injury (Leddy, Lambert, & Ogles, 1994), increases in self-confidence and self-efficacy over the course of rehabilitation (Quinn & Fallon, 1999; Thomeé et al., 2007), and decreases in self-identification with the athlete role (Brewer, Cornelius, Stephan, & Van Raalte, 2010). Substantial changes in self-definition, which reflects how athletes think about themselves, have been reported by athletes with severe injuries (Vergeer, 2006).
In taking an active role to deal with the adverse physical and psychological effects of injury, athletes have reported that they sometimes initiate cognitive coping strategies. Among the common themes of the cognitive content used by athletes to cope with injury are acceptance of injury, disengagement from injury, imagery, positive thoughts, and recovery (Bianco, Malo, & Orlick, 1999; Carson & Polman, 2008, 2010; Gould, Udry, Bridges, & Beck, 1997b; Ruddock-Hudson, O’Halloran, & Murphy, 2014; Tracey, 2003; Udry et al., 1997). It appears that the cognitive strategies deployed by athletes are at least in part influenced by the specific qualities of the injury-related stressors (e.g., physical symptoms, rehabilitation requirements) with which they are dealing, as the use of various coping strategies fluctuates over the course of rehabilitation (Johnston & Carroll, 2000; Udry, 1997) and differs as a function of whether athletes have chronic or acute injuries (Wasley & Lox, 1998).
The literature suggests that, in addition to affecting cognitive content, sport injury has an adverse effect on cognitive processes such as attention, memory, processing speed, and reaction time (Moser, 2007). Postinjury impairment of cognitive functioning has also been found for musculoskeletal injuries in one study (Hutchison, Comper, Mainwaring, & Richards, 2011), but not in another (Mrazik, Brooks, Jubinville, Meeuwisse, & Emery, 2016). Presumably, the intrusive images of injury occurrence (Shuer & Dietrich, 1997; Vergeer, 2006) noted in the section on injury-related content occupy some of the cognitive resources that would otherwise be devoted to processing other information and, along with postinjury emotional disturbance, may partially explain how musculoskeletal injuries might produce impaired cognitive functioning.
The largest share of research on the psychological consequences of sport injury has been devoted to emotional responses. Findings from an abundance of qualitative and quantitative studies have converged to produce a rich description of how athletes respond emotionally to injury and identify a variety of personal, situational, cognitive, and behavioral factors associated with those responses.
From a descriptive standpoint, athletes have tended to use a variety of negative terms (e.g., anger, bitterness, confusion, depression, fear, frustration, helplessness, shock) to characterize their emotions after injury (e.g., Bianco et al., 1999; Wadey, Evans, Hanton, & Neil, 2012a). Although common, reports of negative emotions are not inevitable and may fluctuate widely over the course of the rehabilitation (Bianco et al., 1999; Carson & Polman, 2008; Johnston & Carroll, 1998). In general, however, there is evidence that athletes tend to report higher levels of emotional disturbance after sustaining an injury than they do before being injured (Appaneal, Levine, Perna, & Roh, 2009; Leddy, Lambert, & Ogles, 1994; Mainwaring et al., 2004; Mainwaring, Hutchinson, Biscchop, Comper, & Richards, 2010; Olmedilla, Ortega, & Goméz, 2014; Smith et al., 1993) and that athletes with injury tend to report higher levels of emotional disturbance than athletes without injury (Abenza, Olmedilla, & Ortega, 2010; Appaneal et al., 2009; Brewer & Petrie, 1995; Johnson, 1997, 1998; Leddy et al., 1994; Mainwaring et al., 2004; Pearson & Jones, 1992; Smith et al., 1993). Estimates of the prevalence of athletes with injury who report clinically meaningful levels of emotional disturbance have ranged from 5 to 42% (Appaneal et al., 2009; Brewer, Linder, & Phelps, 1995; Brewer, Petitpas, Van Raalte, Sklar, & Ditmar, 1995; Brewer & Petrie, 1995; Garcia et al., 2015; Leddy et al., 1994; Manuel et al., 2002). Most of the psychological distress reported by athletes would be classified as “subclinical,” lacking the severity and/or duration to be considered a clinical condition.
In addition to the large body of research that has provided a thorough description of emotional responses to sport injury, numerous studies have investigated potential predictors of such responses. As proposed in the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998), associations have been documented between postinjury emotional responses and a wide variety of personal and situational factors (which presumably affect emotional responses through cognitive appraisals), cognitive responses, and behavioral responses (the latter of which will be discussed in the section on behavior that follows). Regarding personal factors, positive associations have been obtained between postinjury emotional disturbance and pain (Brewer et al., 2007), pain catastrophizing (Baranoff, Hanrahan, & Connor, 2015), neuroticism (Brewer et al., 2007), impairment in performing daily activities (Crossman & Jamieson, 1985), injury acuteness (Alzate, Ramírez, & Artaza, 2004; Brewer, Linder, & Phelps, 1995), injury severity (Alzate et al., 2004; Manuel et al., 2002; Smith, Scott, O’Fallon, & Young, 1990), self-identification with the athlete role (Baranoff et al., 2015; Brewer, 1993; Manuel et al., 2002), and investment in playing sports professionally (Kleiber & Brock, 1992). Negative association has been documented between postinjury emotional disturbance and age (Brewer, Linder, & Phelps, 1995; Smith, Scott, O’Fallon, & Young, 1990), hardiness (Wadey, Evans, Hanton, & Neil, 2012b), injury recovery (McDonald & Hardy, 1990; Smith, Young, & Scott, 1988), and acceptance of uncomfortable experiences (Baranoff et al., 2015).
With respect to situational factors, the variable most consistently associated with postinjury emotional responses is the amount of time that has passed since occurrence of the injury. With the exception of a possible increase in the intensity of negative emotions and a decrease in the intensity of positive emotions at the end of rehabilitation with a return to sport looming (Morrey, Stuart, Smith, & Wiese-Bjornstal, 1999), negative emotions tend to decrease in intensity, and positive emotions tend to increase in intensity as time passes after injury (Appaneal et al., 2009; Brewer et al., 2007; Garcia et al., 2015; Leddy et al., 1994; Macchi & Crossman, 1996; Mainwaring et al., 2004, 2010; Manuel et al., 2002; McDonald & Hardy, 1990; Olmedilla et al., 2014; Quinn & Fallon, 1999; Smith, Scott, O’Fallon, & Young, 1990). Other situational factors for which associations with high levels of emotional disturbance have been documented in multiple studies include high levels of life stress (Albinson & Petrie, 2003; Brewer, 1993; Brewer et al., 2007; Manuel et al., 2002) and low levels of both social support for rehabilitation (Brewer, Linder, & Phelps, 1995; Rees, Mitchell, Evans, & Hardy, 2010) and satisfaction with social support (Green & Weinberg, 2001; Manuel et al., 2002).
Cognitive responses related to greater postinjury emotional disturbance in athletes include perceptions of being unable to cope with injury (Albinson & Petrie, 2003; Daly, Brewer, Van Raalte, Petitpas, & Sklar, 1995), high levels of avoidance-focused (Gallagher & Gardner, 2007) and low levels of instrumental coping strategies (Wadey, Clark, Podlog, & McCullough, 2013), and causal attributions for sport injury occurrence (Brewer, 1999a; Tedder & Biddle, 1998). Emotional disturbance was positively associated with attributing the cause of injury to internal factors in one study (Tedder & Biddle, 1998) but negatively associated with attributing the cause of injury to internal and stable factors in a second study (Brewer, 1999a). Behaviors associated with athletes’ emotional responses to injury are identified next.
Because pain, cognition, and emotion can be readily concealed from view, behavior is undeniably the most overt psychological response to sport injury. Further, even though the behavior of athletes may reflect or be a manifestation of their experience of pain, cognitive, or emotional responses to injury, it is behavioral responses that have the greatest potential to affect the rehabilitation process. Some of the behaviors that athletes have reported themselves as engaging in after injury can be interpreted as attempts to cope with the challenges of the situation. For example, such active, instrumental, “problem-focused” coping behaviors as pursuing rehabilitation vigorously, learning about the injury, trying alternative treatments, building physical strength, and cultivating or enlisting social resources (Bianco et al., 1999; Gould et al., 1997b; Johnston & Carroll, 2000; Quinn & Fallon, 1999; Ruddock-Hudson et al., 2014; Wadey et al., 2012a, 2012b) tend to be deployed under conditions of elevated stress and mood disturbance (Albinson & Petrie, 2003) and conceivably can be of utility in helping athletes to recover from their injury and return to sport. Even some avoidant or “emotion-focused” coping behaviors such as distracting oneself (e.g., keeping busy, watching television) and isolating oneself from others (Bianco et al., 1999; Carson & Polman, 2010; Gould et al., 1997b; Ruddock-Hudson et al., 2014; Wadey et al., 2012a, 2012b) may be useful in the regulation of postinjury emotions (Carson & Polman, 2010). Other behavioral responses to sport injury, however, such as attempting suicide (Smith & Milliner, 1994), engaging in disordered eating (Sundgot-Borgen, 1994), consuming banned substances (National Collegiate Athletic Association, 2012), and drinking alcohol (Martens, Dams-O’Connor, & Beck, 2006) may have less adaptive consequences.
The behavioral response to sport injury that has garnered the most attention from investigators is adherence to rehabilitation. Considered vital to the success of sport injury rehabilitation programs (Fisher, Domm, & Wuest, 1988), adherence in this context refers to the extent to which athletes follow the prescribed course of treatment. The specific behaviors involved in adhering to rehabilitation vary substantially across the range of injuries that athletes incur, but some of the more common behavioral requirements of sport injury rehabilitation programs include “attending and actively participating in clinic-based rehabilitation appointments, avoiding potentially harmful activities, wearing therapeutic devices (e.g., orthotics), consuming medications appropriately, and completing home rehabilitation activities (e.g., exercises, therapeutic modalities)” (Brewer, 2004, pp. 39–40). Although athletes engage in some of the rehabilitation behaviors in supervised clinical settings, they complete other of the behaviors at home, away from the direct oversight of rehabilitation professionals. The considerable variation in average adherence levels reported in research investigations (ranging from 40 to 91%, as reported in a review of the literature [Brewer, 1999b]) is not surprising in light of the vast array of injuries, rehabilitation programs, clinical settings, and methods of assessment (e.g., self-report, practitioner rating, attendance log) that have been examined. Further complicating the estimation of adherence in the context of sport injury rehabilitation is that some highly motivated athletes may “overadhere” to their rehabilitation program by engaging in rehabilitation activities to a greater extent than recommended by the sports health care professional treating them (Niven, 2007; Podlog, Gao et al., 2013). Although such behavior is technically nonadherent, it is fundamentally different from failing to complete one or more aspects of a rehabilitation program.
Given the potential importance of adherence in achieving desired sport injury rehabilitation outcomes, investigators have attempted to identify factors associated with adherence to sport injury rehabilitation. As in the general medical literature, in which literally hundreds of predictors of treatment adherence have been identified (Meichenbaum & Turk, 1987), research has documented numerous correlates of sport injury rehabilitation adherence that can be grouped into the main conceptual categories of the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998). Examples of personal factors for which positive associations with sport injury rehabilitation adherence have been found in multiple studies include (perceived) injury severity (Grindley, Zizzi, & Nasypany, 2008; Taylor & May, 1996), athletic identity (Brewer, Cornelius, Van Raalte, Petitpas, Sklar et al., 2003b; Brewer, Cornelius, Van Raalte, Tennen, & Armeli, 2013), pain tolerance (Byerly, Worrell, Gahimer, & Domholdt, 1994; Fields, Murphey, Horodyski, & Stopka, 1995; Fisher et al., 1988), and self-motivation (Brewer, Van Raalte, Cornelius et al., 2000; Duda, Smart, & Tappe, 1989; Fields et al., 1995; Fisher et al., 1988; Levy et al., 2008). With respect to situational factors, findings from multiple investigations have shown that athletes display higher levels of adherence to sport injury rehabilitation programs when they consider themselves as receiving support from others for their rehabilitation (Byerly et al., 1994; Duda et al., 1989; Fisher et al., 1988; Johnston & Carroll, 2000; Levy et al., 2008), perceive the clinic setting in which they do their rehabilitation as comfortable, and view their clinic-based rehabilitation appointments as conveniently scheduled (Fields et al., 1995; Fisher et al., 1988).
Several cognitive and emotional responses have also been found to predict adherence to sport injury rehabilitation programs across multiple studies. From a cognitive standpoint, athletes have demonstrated higher levels of adherence to rehabilitation when they report believing that their treatment will be effective (Brewer, Cornelius, Van Raalte, Petitpas, Sklar et al., 2003a; Duda et al., 1989; Taylor & May, 1996), profess a strong intention to adhere to rehabilitation (Bassett & Prapavessis, 2011; Levy et al., 2008), and indicate that they are confident that they can cope with their injuries (Daly et al., 1995; Levy et al., 2008) and complete their rehabilitation program (Brewer, Cornelius, Van Raalte, Petitpas, Sklar et al., 2003a; Levy et al., 2008; Taylor & May, 1996; Wesch et al., 2012). In terms of emotional responses, negative associations have been documented between mood disturbance and sport injury rehabilitation adherence (Alzate et al., 2004; Daly et al., 1995).
Psychological Readiness to Return to Sport
The lack of a universally accepted definition of psychological readiness to return to sport after injury has not prevented researchers from investigating the topic through two main approaches. One approach involves comparing athletes who return to sport after injury with those who do not return to sport after injury on psychological variables measured during or after rehabilitation. The other approach involves asking athletes who have returned to sport after injury to describe their experience of returning. Reviews of research in which the two approaches have been implemented have yielded a consistent set of psychological factors associated with athletes’ return to sport after injury (Ardern, Taylor, Feller, & Webster, 2013; Czuppon, Racette, Klein, & Harris-Hayes, 2014; Podlog & Eklund, 2007). Specifically, the empirical findings of prospective and retrospective studies have dovetailed, suggesting that factors involved in psychological readiness to return to sport after injury include a lack of fear or anxiety regarding reinjury, confidence in the injured body part and in one’s ability to perform, and intrinsic motivation to return to sport.
The consequences of an absence of psychological readiness to return to sport are not fully understood. Beyond being less likely to return to sport in the first place, athletes who are not psychologically ready to return to sport but do so anyway may be at increased risk for such consequences as injury (or reinjury), poor sport performance, and a lower quality sport experience. Prospective longitudinal research is needed to investigate these possibilities.
From an applied standpoint, numerous interventions have been implemented to affect athletes’ psychological responses to sport injury. Common treatment approaches for pain differ somewhat from those for problematic cognitive, emotional, and behavioral responses, and treatments designed to enhance psychological readiness to return to sport have not been evaluated explicitly. Consequently, interventions to treat pain and improve psychological readiness to return to sport are discussed separately from the other three main types of psychological response and from each other.
An important aspect of postinjury pain among athletes is that it often can be escaped or reduced by ceasing, reducing, or modifying involvement in activities that produce or exacerbate the pain. For postinjury pain that is especially intense or long-lasting, formal pain management interventions can be initiated. Such interventions are likely to involve a combination of analgesic medications and physical therapies (Kolt, 2004). Aspirin, ibuprofen, and paracetamol (acetaminophen) are the analgesic medications most likely to be recommended, with opioids (e.g., codeine) and corticosteroids prescribed less frequently (Garnham, 2007). Physical therapies used to treat postinjury pain in athletes include electrophysical agents (e.g., transcutaneous electrical nerve stimulation [TENS], interferential electrical stimulation, ultrasound), manual techniques (e.g., massage, chiropractic manipulation), exercise, cryotherapy, heat, and acupuncture (Kolt, 2007; Snyder-Mackler, Schmitt, Rudolph, & Farquhar, 2007; Wadsworth, 2006). Although a wide variety of psychological techniques have been recommended to help athletes cope with postinjury pain (Kolt, 2004, 2007), the effectiveness of such techniques in the context of sport injury has been evaluated in very few controlled experimental studies (Cupal & Brewer, 2001; Ross & Berger, 1996). The lack of research on psychological pain management techniques in sport injury rehabilitation suggests that the techniques are not implemented on a widespread basis in clinical settings.
Cognitive, Emotional, and Behavioral Responses
As for postinjury pain, many psychological interventions have been advocated to affect cognitive, emotional, and behavioral responses to sport injury. Only a few of the interventions, however, have received experimental support for influencing cognitive, emotional, and/or behavioral responses in sport injury rehabilitation. Interventions found effective relative to a control condition include goal setting (Evans & Hardy, 2002; Penpraze & Mutrie, 1999), imagery (Cupal & Brewer, 2001), modeling (Maddison, Prapavessis, & Clatworthy, 2006), and multimodal interventions (Johnson, 2000; Ross & Berger, 1996). These interventions (Christakou, Zervas, & Lavallee, 2007; Cupal & Brewer, 2001; Maddison et al., 2006, 2012; Newsom, Knight, & Balnave, 2003; Ross & Berger, 1996; Theodorakis, Beneca, Malliou, & Goudas, 1997; Theodorakis, Malliou, Papaioannou, Beneca, & Filactakidou, 1996) and others, including biofeedback (Silkman & McKeon, 2010) and self-talk (Beneka et al., 2013), have been found to influence physical outcomes in sport injury rehabilitation.
Psychological Readiness to Return to Sport
As an emerging construct, psychological readiness to return to sport after injury has received minimal attention from researchers attempting to evaluate the effectiveness of interventions designed explicitly to foster psychological readiness in athletes resuming sport participation after injury. Nevertheless, interventions that have produced increases in confidence (e.g., Maddison et al., 2006) and decreases in anxiety (e.g., Cupal & Brewer, 2001; Ross & Berger, 1996), for example, may have enhanced the readiness of the athletes receiving the interventions to return to sport with or without the intention of actually doing so. As a fuller understanding of the composition of what it means to be psychologically ready to return to sport emerges, inquiry into the effects of interventions developed to enhance readiness is likely to ensue.
Sport injury can affect athletes both physically and psychologically. Pain, cognition, emotion, and behavior are primary areas of psychological functioning affected by injury. Psychological responses to sport injury tend to be strongest in close temporal proximity to injury occurrence and fluctuate over the course of rehabilitation. Psychological readiness to return to sport after injury is an emerging concept that incorporates aspects of cognition, emotion, and behavior, including anxiety, confidence, motivation, and postreturn expectations. A variety of theoretical perspectives have been used to guide a body of research on psychological responses to sport injury. Relatively few controlled investigations of interventions designed to influence psychological responses to sport injury have been conducted.
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