Participation in athletics involves physical risk that can result in the limited ability or inability to continue sports play. Psychological variables influence how persons cope with physical injury; therefore, understanding and effectively managing the psychological reaction to injury can enhance recovery from injury, facilitate return to play, and aid athletes in adapting to changing roles.
Medical advances have led to improved diagnosis of athletic injury and formulation of rehabilitative treatment plans. Adherence to treatment plans depends greatly on psychological variables. Therefore the influences of nonbiologic factors in recovery, as well as the interplay of biologic and social factors (e.g., the influence of stress on the immune system and recovery) merit attention in evaluating the return-to-play (RTP) process. Dedicated efforts to improve psychosocial factors in the context of sports can improve RTP preparation and decision making. Attending to these aspects of healthy recovery supports athletes in adhering to treatment and rehabilitation recommendations and sets the stage for handling the adjustment to returning to sport.
The age of the participant, the level of competition (e.g., youth, high school, club, collegiate, professional, or weekend warrior), and the degree of investment in the role by the participant are important factors in how the psychological response to injury is conceptualized. This chapter does not provide a comprehensive review of the developmental conceptualizations of the psychological impact of injury or a comprehensive discussion of how competition level influences psychological variables. Rather, the psychology of injury is discussed more broadly, reviewing some of the general psychological paradigms for understanding how injury psychologically affects athletes and the literature on utilization of psychological principles to enhance recovery. A specific application of these efforts is also presented.
Sports Injury: A Broad Issue
The number of persons participating in sports continues to grow. According to the National Federation of High School Sports, high school student participation has increased during the past 22 years, with nearly 7.7 million participants in 2010-2011. The largest participation gains were observed in soccer, basketball, and lacrosse for boys and in lacrosse and outdoor track and field for girls. These figures, importantly, only account for students playing scholastically; the number of youth participating in sports through clubs has been estimated to be between 30 and 44 million annually.
Overall injury rates in high school sports were 1.71 per 1000 athlete exposures, or roughly 3.7 million for the 2010-2011 school year. The rate of injury during competition (3.64 per 1000 athletic events) exceeded that of the rate during practice (1.06 per 1000 athlete exposures). Sports-related injuries accounted for up to one in five of all emergency department visits in persons younger than 18 years and for 19% of visits to the pediatrician’s office.
In collegiate sports during the 2011-2012 year, participation was 261,150 for men’s sports across Divisions I through III, and 198,103 for women’s sports across Divisions I through III, reflecting increased participation for both genders from 2010-2011. Injuries during athlete exposures ranged as high as 36.5 per 1000 for football to 0.8 per 1000 for men’s swimming and diving. As in high school sports, injury rates were higher in competition versus practice exposures.
Historical Perspective and Evolution
Psychological models of injury were initially divided into two categories: stage models and cognitive models. Stage models were largely adapted from an examination of psychological reactions to terminal illnesses. Injury is conceptualized as triggering grief and loss because of the resulting perceived loss of an aspect of the self. Commonly applied models of the stages of grief are adapted from Kubler-Ross. Limitations included the reduced inability to incorporate the variety of athletes’ perceptions of injury and the contextual differences that dictate the psychological consequence of the injury. These limitations gave rise to cognitive models, which borrowed significantly from stress and coping theory. Rather than stages, the interpretations of the injury itself are the focal point. These interpretations include cognitive attributions for injury, self-perceptions after injury, methods of coping, and perceived benefits of injury. Subsequently, these models have been integrated to include biopsychosocial influences and have been updated to reflect the bidirectional relationship between individual athlete coping tendencies and contextual factors. See the Handbook of Sport Psychology for a more detailed review of this history.
Impact of Anxiety and Fear
Negative affect can reduce the resources one has available for engaging fully in the recovery process. The Stress Injury Model posits that heightened distress associated with the fear of reinjury saps available attention resources and peripheral vision, leading to increased muscular fatigue and reduced timing and coordination. These cognitive and resulting physical effects have the potential to undermine performance, increase the chances of injury and/or reinjury, and interfere with the rehabilitative process. Fear of being unable to perform at a previous level is a barrier to engaging in treatment after injury. To intervene in these cognitive effects, Williams and Andersen recommended a two-pronged approach to prevent injuries from the increased stress reactivity of at-risk persons.
First, helping athletes identify and challenge their cognitive appraisals of stressful events can minimize the risk of a maladaptive stress response pattern. Using traditional cognitive therapy techniques such as “thought stopping” and replacement of “all or nothing” expectations with realistic perspectives fosters a more confident and healthy psychological approach to injury. Stress inoculation training has also been proposed as an intervention using cognitive restructuring, thought control, imagery, and simulation. Steps to enhance communication and cohesion with the team and the coaching staff further promote an adaptive response.
Second, interventions that modify physiological arousal after injury are thought to reduce the attentional disruption associated with a stress response to injury and improve focus. These benefits have been explored in using progressive muscle relaxation, meditation, autogenic training, and diaphragmatic breathing exercises. They have been shown to enhance concentration and decrease distractibility during the recovery process.
Despite these efforts, real or imagined time pressure in the RTP setting can influence the psychological and physical response to injury. Athletes may perceive direct pressure from coaches and indirect pressure on their coaches from others, or they may project their own desire for rapid RTP onto their coaches, placing athletes in a vulnerable position to rush their RTP timeline ineffectively and dangerously. Coaches themselves may directly or indirectly convey perceived time pressure (from administrations, team owners, parents, or even the press) to have their athletes ready for the next competition. Pressures can exacerbate an athlete’s fears of losing abilities, “losing ground” relative to others who are not injured, losing a spot on team, and losing “right of membership” on the team, thus leading them to rush the RTP timeline and paradoxically extending the RTP process.
Intervening on the Psychological Level: Competence, Relatedness, and Autonomy
It has been proposed that improving social support and teaching coping skills by training injured athletes (as well as coaches) and building confidence will increase resiliency to athletic injury. Growing evidence in other related recovery areas argues for the benefit of combining biologic and psychosocial approaches—areas as diverse as behavioral research in oncology, as well as premorbid and comorbid psychological contributions to mild traumatic brain injury. Evidence indicates that in spite of the fact that social support shows great value in the psychological recovery from sports injury, it may not be perceived as available. Ensuring that education and information are not only available but perceived as available is key in managing sports injury recovery.
Interventions that have an impact on the motivational, performance, and anxiety-related issues that affect the rehabilitation process and ultimately RTP have great utility. Using the initial formulations of the Self-Determination Model by Ryan and Deci, an RTP model has been proposed to meet the psychological needs of injured athletes while optimizing the RTP process. Podlog, Dimmock, and Miller describe competence, relatedness, and autonomy as the three essential needs to be addressed in return to sport.
Competence needs include those created by fears of reinjury and the fear of not being able to live up to previous levels of ability. Meeting these needs can be achieved by maximizing confidence in performance capabilities and minimizing the influence of self-presentational concerns. The SMARTS principle is a pragmatic approach. An injured athlete’s attention is directed to S pecific, M easurable, A ction-oriented, R ealistic, T ime-based, and S elf-determined indicators of progress to enhance perceptions of competence and facilitate healthy and efficient RTP. When goals do not meet the SMARTS criteria, the normal anxiety and fear experienced by the injured athlete may undermine adherence to treatment and lengthen the RTP timeline.
Addressing affiliation needs through various social supports, particularly with the sport team itself, becomes another vehicle for enhancing the psychological adjustment to injury and maintaining a focus on safe and expedient RTP. Podlog, Dimmock, and Miller highlight the importance of promoting a perspective shift from active sport participation as the sole basis for team membership. Affiliation can be redefined in the context of reexamining the intrinsic value of sport participation, redefining competence as a contributing teammate, and exploring the notion that active sport participation is only one facet of the athlete’s identify (i.e., what else is part of who you are?). In some instances, this redefinition can be supported by creating a new interim or permanent role on the team (e.g., volunteer coach or training partner). Additionally, it can be facilitated by building relationships with other injured athletes in an RTP group in sports medicine. The RTP process often creates close affiliations with sports medicine physicians, certified athletic training staff (ATCs), and other professionals, such as a sports psychologist. The importance of these relationships in assisting injured athletes during their role transition cannot be overstated.
Yang and colleagues highlight the importance of gender differences after sports injury and the need for different types of support at different stages (emotional support at first, and then information/education). They also investigated the surge of perceived support that injured athletes experience from coaches, sports medicine physicians, and ATCs after injury, with the last group showing the greatest change. Continuing education is critical for ATCs and other training room personnel so they can recognize and respond to the psychological issues associated with injury. Stiller-Ostrowski, Gould, and Covassin found increased knowledge of the psychology of injury and applied skill use for student ATCs during the course of the study. Although these gains diminished over a 14-week period after training, the students’ skills and knowledge base remained significantly above baseline, suggesting that curricula of this nature are not only important but attainable and memorable.
Lastly, relieving autonomy concerns can lessen pressures that risk premature or unhealthy RTP. Providing frequent communication and education about why a particular rehabilitation process is used supports injured athlete autonomy. Updates about measured progress (SMARTS goals) and offering an injured athlete regular choices about the rehabilitation plan can reduce pressure and enhance the perception of an internal locus of control. Restoring some balance of control when competence and identity have been threatened may help athletes communicate openly about their fears, adhere to treatment plans, and maintain focus on their progress rather than their losses.
It is important that all front-line sports injury professionals recognize these variables. Rather than treating such issues as taboo, open discussion among all providers in the training room setting can validate the importance of psychological issues, the active role we each take in directly intervening, and the importance of referring to other resources when they are available. Taking an active role in supporting athletes directly makes a difference in their recovery. Consulting with other professionals, including sports nutritionists, qualified sports psychologists, and licensed clinical and counseling psychologists, can further proactively address the psychological issues related to sports injury. Professionals can also address pressures (direct or indirect) from coaches, parents, teammates, and the administration and shape the influence of these assets to enhance a healthy RTP process.