The process starts with an injury. Injury characteristics (type, cause and severity, history of previous injuries) and athlete characteristics (age, gender, ethnicity, socioeconomic status) affect athlete’s biological, psychological, and social-contextual dimensions.
Subsequently, these three dimensions influence the biopsychological intermediate outcomes, such as strength and endurance of a muscle and perception of pain. Finally, these intermediate outcomes will contribute to better outcomes in rehabilitation, such as satisfaction on the treatment and functional performance after injury.
55.5.2 Cognitive Appraisal Models
The cognitive appraisal models attribute a central role to cognition in determining individual reaction to sport injury [29]. According to this model, personal and situational factors influence cognitive appraisal of the individual (coping, beliefs, and attributions), which determine their emotional response (e.g., fear of reinjury, anger, or depression). This emotional response influences the athlete’s behavior that consequently contributes to the success of the program [30].
55.5.3 Stage Models
Stage models provide a succession of emotions and attitudes occurring following sport injury. At the beginning, authors defend five different stages: denial, anger, bargaining, depression, and acceptance [32].
More recently, O’Connor et al. [1] have proposed the “affective cycle of injury” that includes three different responses to injury: denial, distress, and determined coping, as a more flexible and general way.
By denying, the athlete refuses and negates the consequences, the severity, and the impact of the injury on quality of life. Normally this stage occurs at the beginning of rehabilitation, and it’s adaptive to the injury. If it persists during the following stages, the psychological intervention is required.
Negative emotions such as anxiety, depression, anger, fear, and feeling of loss contribute to distress stage. Despite being more common at the earlier stages of rehabilitation, distress may occur during the later stage because of the frustration of recovery against the desire to return to sport.
After a passive attitude, the athlete starts to cope with the new situation by evaluating resources, setting realistic goals, maintaining commitment, and cooperating with the staff. Determined coping occurs generally at the latter stages of the rehabilitation, when the athlete has overcome denial and has become able to manage distress.
Emotional response to injury may change during a month, a week, and also in the course of the day [30].
55.5.4 Motivation-Based Models
Motivation is an essential aspect influencing on successful recovery process [33], and it could be divided into internal and external motivation.
Agreeing to self-determination theory, there is a continuum from demotivation (lack of intention to act) to intrinsic motivation (internal satisfaction). Between this continuum, there exist external factors (team influence, punishments, and rewards) that control athlete’s motivation and behaviors during the process. The highest level of self-determination is characterized by internally regulated behaviors translating intrinsic satisfaction and enjoyment in the performing action [30].
Another motivational-based model is the trans-contextual model [34], which explains how motivation is transferable from a context to another one and how sport motivation and injury rehabilitation are related. This relationship occurs in three different levels [35]: specific, contextual, and global.
The first considers that the athlete is autonomous and independent and enjoys exercising to succeed in the recovery process. At the contextual motivation, social agents (coach, psychologist, teammates) influence the behavior of athletes. If injured athletes perceived autonomy support from them, they may increase their autonomous motivation in following the treatment. At a global level, specific and contextual motivations are presented, and the causality orientation of the athlete determines their type of motivation for the rehabilitation.
According to the type of motivation, a different reaction to the treatment occurs in terms of commitment, persistence, and satisfaction [30].
55.6 Psychological Skills
A variety of psychological strategies may be useful during the rehabilitation and in the reentry period. Santi and Pietrantoni [30] describe different types of interventions: educational interventions, goal setting, imagery, self-talk, biofeedback, and social support-based interventions. Relaxation is another cognitive strategy that has been used to reduce stress, anxiety, and mental/physical strain [36].
According to the models previously presented, we can intervene on cognitive appraisal of athletes through self-talk, but also providing them biological information and feedback about their recovery. Emotions can be managed through education and imagery. Finally athletes’ motivation may be enhanced by intervening directly on the athlete through goal setting or with the provision of social support [30].
These techniques can be provided and educated during rehabilitation to help the athlete cope with pain, anxiety, and negative and irrational thinking and to maintain or regain motivation and compliance [37].
The use of psychological skills training during rehabilitation from the sport injury has been found to be beneficial during the recovery.
55.6.1 Educational Intervention
Research has shown how the athletes do not have a clear vision of the rehabilitation process immediately after the injury, and this can determine negative emotion and demotivation. On the other hand, an athlete that has shown better knowledge of the rehabilitation process is more realistic toward their situation reducing depressive symptoms [38].
The injured athletes often have irrational thoughts about their injury: some injured athletes tend to either exaggerate the extent of their injury or downplay it [36]. To minimize the risk for this to happen, it is important that the medical staff educates the athlete realistically about the injury, rehabilitation process, and prognosis [18].
55.6.2 Goal Setting
Setting goals determines an enhancement in motivation and commitment and provides a direction in order to optimize the recovery. The goal setting should include short-term, medium-term, and long-term goals depending on the injury severity and the prognosis of it. The goals set should be specific, measurable, acceptable, realistic, time based, evaluated, and recorded [37]. A goal setting satisfies the need for athletes, coaches, and other sport professionals to manage the return to sport, avoiding unrealistic goals and overexpectations. An effective goal setting reduces athletes’ anxiety and improves their self-confidence. As a result, the athlete adheres more to the program and perceives the treatment as more effective [39].
55.6.3 Imagery
This specific technique is used to create mental images, feelings, and sensations related to a desired outcome that is happening now or has already happened. Imagery can be an audio, kinesthetic, smell, and taste experience, divided in internal (the athlete feels inside) or external (the athlete views oneself from outside). By using all senses, mentally and physically, the athlete rehearses the desired state [18].
Research has shown how athletes adopting this technique during the rehabilitation have a better return to the competition [40].
55.6.4 Self-Talk
Athletes are used to battle with their feelings during the games and competitions and trying to set their feelings on optimal level for their best performance [18].
This kind of inner conversation is called self-talk as a psychological technique, and it is an active process, which can be affected. Self-talk influences a person’s thoughts which are linked to one’s emotions.
The process of changing the negative thoughts to positive is called thought stopping, and, as the name tells, it involves stopping the negative thoughts and replacing them with positive ones using a mental cue [36].
Naoi and Ostrow [6] propose a protocol for the implementation of these cognitive interventions following sport injury:
- 1.
Expressing feelings and thoughts – in this phase the psychologist uses techniques such as active listening, reflection, and clarification
- 2.
Identifying negative thoughts – athletes are asked to write down or talk about their thoughts and identify the negative ones
- 3.
Looking in a positive light – athletes try to find positive aspects of the injury, and the psychologist helps them in providing examples and changing them into positive ones
- 4.
Selecting statement – athletes identify three positive thoughts and write them on a paper
- 5.
Reading statements – athletes read the three positive thoughts to the researcher, and after this they practice self-talk
- 6.
Maintaining – participants keep the paper and should read and repeat to themselves at least once a day; they should also monitor their thoughts during the following sessions
55.6.5 Biofeedback
Biofeedback interventions are based on the use of computerized equipment, which provides immediate feedbacks.
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