Psychologic Factors in Rehabilitation

Chapter objectives

  • Explain the relationship between psychosocial factors and the potential for sports-related injury.

  • Identify signs of psychologic distress in the injured athlete.

  • Describe the psychologic response to athletic injury.

  • Explain psychologic coping strategies.

  • List psychosocial interventions for enhancing rehabilitation.

Sports-related injury is a major concern for athletes, coaches, and teammates. The incidence of sports injuries continues to increase at every level of participation. A great deal of information is available about injury prevention, improved athletic equipment and facilities, and increased safety precautions in most sports. Much less attention has been devoted to understanding the psychologic factors associated with sports-related injuries and rehabilitation, yet the role of psychologic factors has been considered a critical variable.

Sports psychology began as a discipline in the 1960s with the goal of expanding research related to psychologic factors as they relate to athletes and the sports context. Advances in applied psychology in sports did not flourish until years later. MacIntoch et al conducted research in the early 1970s on sports injuries at the University of Toronto over a 17-year time frame that led him to postulate that psychologic factors were critical for understanding sports injuries. A few years later, Taerk continued this line of thinking and offered a multifaceted perspective in which psychosocial factors were proposed as 1 of 10 key elements associated with sports injuries. The 1980s was fertile ground for both evidence-based research and theoretic conceptualizations that served to further advance our understanding of the psychologic factors associated with sports injury and rehabilitation. Figure 1-1 depicts the predominant model of stress and athletic injury in the field today. The purpose of this chapter is to provide an overview of the psychologic factors associated with rehabilitation.

Figure 1-1

A model of stress and athletic injury.

(Modified from Anderson, M.B., and Williams, J.M. [1988]: A model of stress and athletic injury: Prediction and prevention. J. Sport Exerc. Psychol., 10:297. Copyright 1988 by Human Kinetics Publishers, Inc. Reprinted by permission.)

Psychosocial factors associated with injury and rehabilitation

The stress-injury model developed by Anderson and Williams in 1988 and updated in 1998 (see Fig. 1-1 ) is the most widely accepted model and depicts an interrelationship between three psychosocial factors: personality traits, history of stressors, and coping resources as risk factors associated with preinjury vulnerability. These risks factors are believed to influence the stress response of the athlete, which in turn increases the risk for sports injury.

Personality Factors

In the stress-injury model, the authors assert that certain personality characteristics influence the stress response. Various personality characteristics have been studied over the years, yet only a few are believed to temper the effects of stress, including hardiness, locus of control, trait anxiety, motivation, and sensation seeking. More recently, Johnson conducted a review of the literature for empiric findings from studies investigating personality variables in the stress-injury model and determined that personality characteristics may serve to moderate the effects of stress for some athletes and, for others, predispose them for risk for injury. This review of the literature revealed evidence in support of the following personality variables as antecedents of sports injury: locus of control, competitive trait anxiety, perfectionism, mood states, and self-confidence/self-esteem. Competitive anxiety has received the most attention, with athletes having high trait anxiety being more prone to injury.


A large body of knowledge supports the relationship between life stress and risk for injury. Although terminology such as stress and stressors is widely used, it is always helpful to convey clarity with reminders of their meanings. Selye defined stress as “the nonspecific response of the body to any demand.” The stimulus that evokes a stress response in individuals is what is referred to as a stressor. There are two types of stressors, acute and chronic. Acute stressors are associated with stressful life events, such as the death of a loved one, natural disasters, or terrorist-related activity. Chronic stressors are longer lasting, with the stressor lasting for months or years. Examples of chronic stress include homelessness, loss of job, or living in a neighborhood with high crime. Athletes experiencing increased stress levels may turn to alcohol, substance use/abuse, disordered eating, high-risk behavior, or other injurious stress-relieving activity.

Assessment of an athlete’s history of stressors provides crucial information about key variables related to life events, daily stressors, and previous history of stress. Holmes and Rahe developed the well-known Social and Readjustment Rating Scale in 1967, and it has been widely used to assess an individual’s level of stress. This early work laid the groundwork for the development of instruments to assess stress in athletes, such as the Social and Athletic Readjustment Rating Scale and the Athletic Life Experience Survey, as well as the Life Events Survey for Collegiate Athletes, to measure an athlete’s history of stressors. See Box 1-1 for examples of positive and negative stress factors.

Box 1-1

Examples of negative life stress:

  • Death of a significant other

  • Illness of a significant other

  • Breakup of a relationship

  • Loss of job/team position

  • Illness or injury to self

  • Previous injury

  • Academic failure or threat of failure

  • Daily hassles

Examples of positive life stress:

  • Made captain of the team or a starter

  • Moved up a competitive level (e.g., junior varsity to varsity)

  • Received media recognition for previous performance

  • Experienced changes in what others expect because of success of a sibling

  • Made all-star team

  • Had a new significant other (boyfriend/ girlfriend)

Sources of Life Stress *

* Remember that it may not be the event itself, such as those listed, but how the athlete perceives the demands of the event and his or her ability to cope with it.

To further understand the relationship between stress and injury, Nideffer developed a model to describe two potential scenarios, the first being the injured athlete and subsequent considerations regarding the rehabilitation process and the second concerning the athlete with anticipatory anxiety around the possibility of injury. This model ( Fig. 1-2 ) attempts to depict the impact of situational stressors, physiologically and psychologically, as well as potential performance problems. Nideffer contends that athletes’ performance will be hindered if they are worried about the possibility of sustaining an injury or getting reinjured. These situational stressors are thought to have a direct impact on physiologic and psychologic flexibility, which in turn has a negative impact on concentration. This cycle can become a chronic condition resulting in an increase in frustration and anxiety and lower performance for the athlete.

Figure 1-2

Physical and psychologic changes accompany increases in pressure as a result of injury or the fear of injury. Problems in performance resulting from stress and reduced physiologic and psychologic flexibility can become chronic. Disturbances in physical flexibility affect concentration, and as the athlete becomes upset at his or her own failure (frustration or anxiety increases), the attentional and physiologic disturbances become stronger and more intractable.

(Modified from Nideffer, R.M. [1983]: The injured athlete: Psychological factors in treatment. Orthop. Clin. North Am., 14:373–385.)

Coping Resources

Cohen and Lazurus define coping as “efforts, both action-oriented and intrapsychic, to manage (that is, master, tolerate, reduce, minimize) environmental and internal demands, and conflicts among them, which tax or exceed a person’s resources.” Individuals have two ways of coping. The first, problem-focused coping, is coping by managing the stressor—that is, reducing the demands being made on the athlete. The second, emotion-focused coping, is managing the feelings related to the stressor, which requires the acquisition of additional skills for working with stress. Coping resources refer to coping behavior, social support, and psychologic skills and are believed to moderate the effects of stress and therefore reduce the risk for injury; they can be used for both problem-focused and emotion-focused coping. Box 1-2 lists some of the commons signs and symptoms associated with stress.

Box 1-2


  • Confusion in thinking

  • Difficulty making decisions

  • Decrease in concentration

  • Memory dysfunction

  • Poor judgment

  • Lowered academic performance


  • Emotional shock

  • Feelings of anger, grief, loss, or depression

  • Feeling overwhelmed

  • Presents with flattened affect

  • Displays inappropriate and/or excessive affect


  • Excessive sweating

  • Feeling dizzy

  • Increased heart rate

  • Elevated blood pressure

  • Rapid breathing

  • Increased symptoms of anxiety


  • Changes in behavior patterns

  • Changes in eating

  • Decreased personal hygiene

  • Withdrawal or isolative behavior

  • Less attention to presentation

Common Signs and Symptoms Associated with Stress

From Bacon, V., and Anderson, M. (2007): The Athletic Trainer’s Role in Facilitating Healthy Behavior Change: the Psychosocial Domain. Unpublished study. (Reprinted by permission.)

Coping behavior encompasses a wide range of behavior and can serve to potentiate the stress response when the athlete lacks good coping behavior. For others, it appears to enhance their ability to cope with stress as a result of using effective ways of coping. An assessment is initiated with an intake interview conducted by a mental health professional. The use of assessment instruments may assist in this process. An appraisal of coping behaviors often includes behaviors associated with health-related factors, such as nutrition and sleep; personal attributes that have an impact on academic success, such as study skills and time management; and overall self-esteem.

A wealth of evidence-based research supports the significance of social support as it relates to health and well-being. In addition, numerous studies have explored social support and risk for injury. Study findings have shown that athletes with high social support have fewer injuries than athletes with little or no social support. Social support is defined as “an exchange of resources between at least two or more individuals perceived by the provider or the recipient to be intended to enhance the well-being of the recipient.” The Social Support Survey (SSS) assesses an individual’s perception of social support on eight scales. Key support factors measured on the SSS include listening support, emotional support, assistance, and reality confirmation. Social support typically comes from key persons in the athlete’s family, circle of friends, teammates, coaches, and medical staff. Begel and Baum contend that the potential for increased social support may be jeopardized because athletes spend numerous hours each week on their sport, which in turn places them at risk for social isolation.

Coping resources also include psychologic coping skills. Examples of psychologic skills that may reduce the risk for sports injury are having the ability to concentrate, remain positive, and regulate arousal states. Social support has been shown to have a positive influence on rehabilitation and recovery. Given the significance of social support, it is essential that key players on the rehabilitation team provide the injured athlete with ample support and connection to additional support resources to ensure better health outcomes.

It appears that a positive relationship exists between stressful life events, especially those with high negative stress, and the occurrence of injury and disease.

Clinical Pearl #1

Although life stress is most often thought to result from negative events, positive events can also produce stress that can influence life experiences.

Clinical Pearl #2

Psychologic sequelae of injury

When an athlete is injured, the immediate response of the coach, medical staff, teammates, and family is to assess the severity of the injury and medical needs. Although the physical concerns and welfare of the athlete take precedent, it is essential to remember that psychologic reactions accompany the sports injury. It is important to note that the athlete will experience a range of emotions (e.g., sadness, anger, frustration, fear), which will then be perceived by the athlete as a major stressor. The more serious the injury, the more likely that the athlete will experience intense emotions, as well as the potential loss of primary coping mechanism—that is, exercise, physical activity, and sport involvement—which in turn, creates even more emotional stress for the injured athlete.

Feltz contends that a sports injury has three psychologic effects on an athlete: (1) emotional trauma of the injury, (2) psychologic factors associated with rehabilitation and recovery, and (3) the psychologic impact of the injury on the athlete’s future. Box 1-3 lists some of the possible consequences of emotional trauma. Of particular importance are young athletes because adolescents are more likely to experience psychologic distress after injury.

Box 1-3

  • Loss of confidence

  • Fear

  • Difficulty concentrating

  • Changes in appetite

  • Sleep disturbances

  • Feeling sad, angry, and/or frustrated

  • Lack of motivation

  • Substance use

  • Engaging in high-risk behavior

  • Decrease in self-esteem

  • Negativity

Possible Consequences of Emotional Trauma

Various stage or phase theories have been offered about sports injury and the grief response ( Table 1-1 ). Evans and Hardy conducted an extensive literature review of grief response models that have been offered to account for the psychologic responses to sports injury. After a careful review of the literature, the authors concluded that no one model addressed the atypical grief reaction experienced by injured athletes. The most well-supported grief model in sports is Kubler-Ross’s stages—(1) disbelief, denial, and isolation; (2) anger; (3) bargaining; (4) depression; and (5) acceptance—because these stages may be at play in the grief process experienced by the injured athlete ( see Table 1-1 ). Additionally, the cognitive-appraisal model further explains why athletes’ response to being injured cannot be explained by using a grief model. The cognitive-appraisal model asserts that both emotional and behavioral responses are shaped by the athlete’s appraisal of the incident, as well as throughout rehabilitation. It is therefore postulated that the injured athlete’s experience is a complex interrelationship of thoughts, feelings, and behaviors. It would be helpful for health care practitioners to be mindful that each individual’s experience is unique; consequently, no single theory or model can be applied indiscriminately.

Table 1-1

Summary of Three Injury/Grief Response Models

Model Description
Stage Characteristics
Kubler-Ross’s Grief Model Denial Experiences state of disbelief that something happened
Anger Asks “why did this happen and what did I do to deserve it?”
Bargaining Negotiates with God: “If you only allow this injury to not be as bad as they think, then I will _____.”
Depression Comes to terms with what has happened and is able to be sad about the situation
Acceptance Accepts what has happened
Affective Cycle of Injury Distress Exhibits anxiety and depression, fear, guilt, bargaining
Denial Does not acknowledge distress, such as pain, feeling of loss, separation from teammates
Determined coping Looks for possibilities, seeks out resources, sets goals, manifests commitment
Cognitive-Appraisal Theory Process of how people perceive a situation and assign an emotion to it, such as anger, fear, guilt, joy

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Apr 13, 2019 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Psychologic Factors in Rehabilitation

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