Psychosocial Considerations for Rehabilitation of the Injured Athletic Patient

Monna Arvinen-Barrow, PhD, CPsychol, AFBPsS, UPV Sert Megan Granquist, PhD, ATC

The current and most evidence-based practice indicates that adopting a holistic, patient-centered biopsychosocial approach to injury rehabilitation and recovery should be the gold-standard.7,37 A biopsychosocial approach appreciates and addresses biological (eg, nutrition, tissue repair, immune functioning), psychological (eg, personality, cognition, affect, behavior), and social (eg, life stress, social support, rehabilitation environment) factors related to injury and its subsequent rehabilitation.³⁴ This chapter aims to focus on the psychosocial factors related to the rehabilitation of the injured athletic patient. We set the foundation of this chapter by introducing the reader to the relevant theoretical frameworks developed to explain the psychosocial process of sport injury occurrence, rehabilitation, and return-to-participation. This is followed by an introduction to prominent psychosocial responses to musculoskeletal and concussion injury, and how to assess them with a specific focus on rehabilitation adherence. Next, the chapter introduces specific psychosocial strategies that are appropriate for athletic trainers to use during rehabilitation. Finally, the chapter highlights the importance of psychosocial and mental health referral, and outlines the steps needed to make an appropriate referral.

BIOPSYCHOSOCIAL MODELS OF INJURY OCCURRENCE, REHABILITATION, AND RETURN TO PARTICIPATION

Similar to selecting physical rehabilitation techniques and treatment modalities for injured athletic patients, the selection and implementation of psychosocial strategies should be grounded in appropriate psychosocial theory and empirical evidence. What follows is a brief description of existing theoretical frameworks developed to explain the psychosocial processes associated with athletic injury; namely, the model of stress and athletic injury,¹⁵⁵ the integrated model of psychological response to sport injury and rehabilitation,¹⁵² the biopsychosocial model of sport injury rehabilitation,³⁴ and the integrated model of psychological response to sport concussion injury and rehabilitation process.¹⁵³ This section will also introduce the reader to 3 phases of rehabilitation⁹² and self-determination theory.⁵⁶ These theoretical conceptualizations will help the athletic trainer to better understand potential biopsychosocial factors that may have contributed to injury occurrence, as well as its subsequent rehabilitation and return-to-participation process.

Originally developed in 19882 and revised a decade later,155 the model of stress and athletic injury is seen as the foundation for psychosocial injury theory and research.⁴ The model assumes that risk of athletic injury is amplified as a result of an unwanted psychophysiological response to a potential stressful situation. This stress response consists of 2 interdependent parts: (1) an individual’s cognitive appraisals (eg, interpretations) of the potentially stressful external situation, its demands, consequences, and available resources; and (2) potential physiological changes to the body such as shifts in attentional focus and muscle tension. The model also assumes that a number of antecedents (eg, personality, history of stressors (Table 4-1), and coping resources) can influence the stress response both negatively and positively, and that a range of cognitive-affective-behavioral interventions (eg, cognitive restructuring, thought stopping, relaxation strategies, and autogenic training) can be beneficial in alleviating both psychological and physical stress responses. The central hypothesis of the model states that individuals with personality characteristics that tend to intensify the stress response, who have a history of stressors, and who do not possess appropriate coping skills, will appraise a stressful situation as more intense, and consequently experience greater physiological activation and attentional disruptions compared to those with the opposite characteristics; thus, leading to a greater risk for injury.155

Although empirical evidence in support of the model of stress and athletic injury is somewhat limited, its core remains uncontested. A recent meta-analysis provided support for the role of stress response as a mediator between history of stressors and actual injury occurrences.⁸⁷ It was also found that stress-response and history of stressors have the strongest associations with injury incidences,⁸⁷ meaning that athletes who experience a range of major and minor life stressors are more likely to appraise their athletic situation as stressful, which in turn leads to increased likelihood of encountering an injury.⁴⁶ Only 7 studies to date have explored the effectiveness of cognitive-affective-behavioral interventions on the reduction of stress response, all of which showed decreases in injury occurrence.⁸⁷

The Integrated Model of Psychological Response to Sport Injury and Rehabilitation

The most prominent psychosocial theoretical model to date, the integrated model of psychological response to sport injury and rehabilitation (from now on, referred to as the integrated model),¹⁵² incorporates the model of stress and athletic injury in its conceptualization. The integrated model is based on the premise that any preinjury factors, which may have contributed to the injury occurrence, will continue to influence subsequent post injury responses.¹⁵² The model assumes that following an injury, the injury itself becomes a stressor, resulting in a number of cognitive appraisals, emotional, and behavioral responses interacting in a bidirectional manner, ultimately affecting the overall psychosocial and physical rehabilitation and return-to-participation outcomes.¹⁵² Known as the dynamic core, these thoughts, emotions, and behaviors are also influenced by a number of personal and situational factors, such as characteristics of injury, and a range of psychological, physical, social, environmental, and activity specific factors.

The integrated model is regarded as the most comprehensive theoretical model explaining the psychosocial process of injury occurrence, rehabilitation, and to return-to-participation.¹⁴⁹ It has ample empirical support for its components (for more details see),^37,151 and has been used extensively by sport psychology researchers and practitioners alike.⁵ Recently, it has been adapted to conceptualize the psychological process of concussion injuries.¹⁵³ However, the model has also been critiqued for not incorporating the biological aspects of injuries,¹⁵⁰ a gap which was addressed in the biopsychosocial model of injury rehabilitation few years later.³⁴

The Biopsychosocial Model of Sport Injury Rehabilitation

One of the core tenets of the biopsychosocial model of sport injury rehabilitation (from now on, referred to as the biopsychosocial model)³⁴ is to demonstrate interrelated, bidirectional relationships between biological, psychological, and social/contextual factors. These biological, psychological, and social/contextual factors are influenced by injury characteristics and a range of sociodemographic factors, and the model assumes that they also influence both intermediate (eg, range of motion, pain) and overall rehabilitation outcomes (eg, functional performance, quality of life). Novel addition to this conceptualization is also the bidirectional relationship between intermediate rehabilitation outcomes and psychological factors, a relationship not explicitly recognized in the other psychosocial sport injury models.

Although the model fails to explain the details of the cyclical interaction between thoughts, emotions, and behaviors to the extent that the integrated model does,5 the biopsychosocial model is an appealing model to use as a framework for practitioners and researchers alike. In particular, the model can be useful for designing and evaluating injury rehabilitation interventions that incorporate physical, psychological, and social/contextual factors as variables,¹⁶ as well as making sense of how these factors interact during injury.²⁶ Similar to the integrated model, ample support for the different components of the biopsychosocial model exist (for more details see),³⁷ however, due to its complexity, research investigating the model in its entirety is limited.

The Integrated Model of Psychological Response to Sport Concussion Injury and Rehabilitation Process

The integrated model of psychological response to sport concussion injury and rehabilitation process (from now on, referred to as the concussion model)¹⁵³ uses the original integrated model¹⁵² as its foundation, but incorporates range of neurobiological, psychogenic, and pathophysiological causes/responses to the original conceptualization. More specifically, the model highlights that presence of existing personality factors (eg, ADHD, learning disabilities), history of stressors (eg, PTSD), coping resources (eg, coping style, social support), and interventions (eg, concussion education) can influence stress response that potentially leads to sport concussion injury occurrence. These pre-concussion factors, along with a number of other personal and situational factors, are proposed to influence a range of neurobiological, psychogenic, and pathophysiological causes of concussion. These will, in turn, influence the bidirectional cyclical cycle of cognitive, affective, and behavioral symptoms and responses to concussion. The model also proposes that incorporating an appropriate interprofessional post-concussion psychological care can be used to influence the cognitive-affective-behavioral symptoms and responses to concussion, all of which can influence the overall psychological outcomes of concussion (Figure 4-1).¹⁵³

The concussion model’s conceptualizations are strongly grounded in existing empirical evidence,¹⁵³ albeit, much of the literature has not explicitly named the model as its framework. It can be, however, a very useful framework for practitioners to conceptualize the range of psychological symptoms and responses to a concussion injury, identify appropriate psychological interventions needed to address, such symptoms and responses, and determine which professionals should be involved in a holistic, interprofessional concussion care.⁷⁸

To best understand and guide the psychosocial injury rehabilitation, it is also helpful to consider the psychosocial rehabilitation in a phase-like manner to optimize recovery.92 The 3 phases of rehabilitation⁹² is a conceptual framework aimed to help practitioners better understand how psychosocial responses to injuries may manifest itself during different phases of rehabilitation. These phases are: (1) reaction to injury, (2) reaction to rehabilitation, and (3) reaction to return to (sport) participation. In each phase, an athletic patient will make cognitive appraisals of the demands, available resources, and consequences related to the situation, and depending on the appraisals, will experience recovery facilitating or recovery debilitating emotional and behavioral responses.

Thus far, empirical evidence is limited, but what exists strongly supports the phase-like approach to psychosocial rehabilitation. Two recent studies, both using qualitative, inductive approaches, found that the psychosocial responses to musculoskeletal injuries did indeed evolve in a cyclical manner and varied depending on the phase of the injury.^45,127 As a rule of thumb, athletic trainers should consider athletes’ potential psychosocial responses every time they expect the athlete to engage in new behaviors related to a new phase of physical rehabilitation. With each new expected behavior comes a new cognitive appraisal of the situation and its demands, available resources, and consequences, which in turn results in new emotional and behavioral responses.

Self-Determination Theory

Although not injury specific, the self-determination theory⁵⁶ is an important theory for athletic trainers to consider, particularly in relation to fostering athletic patients’ readiness to return to participation. The self-determination theory (SDT) is a theory of human motivation and personality, which proposes 3 innate psychological needs as the foundation for intrinsic self-motivation: sense of autonomy, sense of competence, and sense of relatedness. The model proposes that by fulfilling these needs, conditions that “facilitate natural propensities for growth and integration and as well as for constructive social development and personal well-being” are created.¹²⁹

In the context of sport injury rehabilitation, promoting athletic patients’ sense of autonomy, competence, and relatedness have been found to be beneficial (Table 4-2). For example, sense of competence and relatedness factors have been found to be important among adolescent athletes’ return to sport.¹²⁰ In a similar manner, among Australian, Canadian, and English elite/subelite athletes, having intrinsic motivations for returning to competition have been associated with a positive renewed perspective on sport participation.^40,117,118

PSYCHOSOCIAL RESPONSES TO INJURIES

As demonstrated in the above models, a number of factors can influence injury occurrence, rehabilitation, and return-to-participation, resulting in each injury experience being unique to the individual in question. At the core of the models presented lies the notion that individual responses are cyclical in nature, and that this cycle typically starts before injury occurrence, and continues throughout the rehabilitation, return to participation, and beyond.^5,151,152 The theoretical models, and the empirical evidence in support of them, also highlight that injuries do have psychosocial antecedents and consequences, which influence, and are influenced by, the physical characteristics of the injury itself. As such, to ensure successful return to sport and reducing the risk of reinjury, identifying and assessing psychosocial responses to injuries becomes an important part of athletic trainers’ work with athletic patients. In the sections that follow, a range of psychosocial responses to both musculoskeletal and concussion injury are introduced to the reader.

Thus far, a significant body of research exists exploring psychosocial responses to musculoskeletal injury.37 What follows is a brief summary of the most commonly identified psychosocial responses as they relate to the injured athletic patients’ thoughts, emotions, and behaviors.

Cognitive Appraisals

Typically defined as a process by which potentially stressful events are evaluated for meaning and significance to individual well-being,⁹⁸ cognitive appraisals are an integral part of psychosocial responses to injury and play a significant role in different phases of injury. Consistent with the theoretical models presented above^2,152,155 upon encountering an injury, the injured athletic patient typically makes a primary cognitive appraisal of the injury and its implications. According to Brewer and Redmond,³⁷ such primary appraisals generally fall under 3 main categories: irrelevant (ie, this is no big deal), benign-positive (ie, I was in need of a rest anyway), or stressful (ie, this could not have happened at a worse time).

If the injured athletic patient appraises their injury as stressful, then the cognitive appraisal related to the injury is typically either that of harm/loss (ie, I cannot believe this happened to me), a threat (ie, this will put my career in jeopardy), or a challenge (ie, I have been through worse, I can rise from this too).³⁷ Typically, the primary appraisals will lead to secondary appraisals, where the injured athletic patient will make sense of what he or she can do to manage his or her injury situation. Lastly, these secondary appraisals will also be followed by potential reappraisals—where, upon receiving new information (eg, confirmed diagnosis), the injured athletic patient will reevaluate his or her initial appraisals in light of the new evidence.^37,98

The content of these cognitive appraisals vary greatly, depending on the individual in question. Some of the common responses include attributions related to the cause of injury, perceptions of the injury itself and its related pain, flashbacks related to the injury occurrence, perceived benefits of injury, self-identity, self-confidence, self-efficacy related thoughts, and a range of cognitive coping strategies (for more details, see).³⁷ Equally, these cognitive appraisals can be related to the expectations of the care received, as well as the competency of the athletic trainer.^8,10,48 What is known is that injured athletic patients will make a range of primary, secondary, and reappraisals throughout the rehabilitation in a cyclical manner,^45,127 with typically each new rehabilitation situation (be it stressful or not) eliciting new cognitive appraisals, subsequently influencing emotional and behavioral responses.

Emotional Responses

Defined as “the a reaction to a particular intrapsychic feeling or feelings, accompanied by physiological changes that may or may not be outwardly manifested but that motivate or precipitate some action or behavioral response,”¹⁰⁹ emotional (affective) responses are an area of psychosocial responses to musculoskeletal injuries that has generated the most research to date.³⁷ Studied extensively from the injured athletic patients’ perspective and the sport medicine professionals’ perspective^{14,47,68–71,81,83,85,96,1,3,31,39,55,63–66,88,99,102,104,114,122,126,136,144,148} worldwide, it is known that injured athletic patients will experience emotional responses to their injuries throughout the different phases of rehabilitation, which can vary greatly depending on a range of personal and situational factors (Table 4-3).

In the context of musculoskeletal sport injury rehabilitation, behavioral responses can be defined as actions an athletic patient displays during reactions to injury, rehabilitation, and return-to-participation phases that can either facilitate or hinder successful healing and recovery. Consistent with the theoretical models to date, these behaviors can include, but are not limited to: adherence to rehabilitation, use of psychosocial strategies, use or disuse of social support, range of risk taking behaviors, malingering, effort and intensity, and behavioral coping.152 In addition, other behavioral responses, such as the use of ergonomic aides,³³ regular sleep,⁵⁹ and nutrition,^21,60,143 are all behaviors that can influence overall rehabilitation and recovery outcomes.

REHABILITATION ADHERENCE

Of all the behavioral responses to injuries, one particularly relevant to athletic trainers is rehabilitation adherence. Defined as the “extent to which an individual completes behaviors as part of a treatment regimen designed to facilitate recovery from injury,”⁷² rehabilitation adherence has been identified as necessary for a full and timely recovery (for a review, see Brewer).³² For example, sport medicine professionals worldwide perceive adherence as a key psychosocial characteristic determining between unsuccessful and successful coping with injury rehabilitation.^{14,47,81,83,96} While the dose-response relationship between rehabilitation adherence and recovery outcomes needs additional study,⁷³ a general consensus exists in support of adherence being instrumental in ensuring successful rehabilitation outcomes.^{25,30,35,38,54,58,61,67,72,97,107,115,116,132}

Where rehabilitation adherence is seen as a behavior that can facilitate a successful rehabilitation process and positive recovery outcomes, rehabilitation non-adherence can be risky, or at times, harmful.⁷² In general, rehabilitation non-adherence includes both under-adherence (ie, doing less than is prescribed in the rehabilitation program) and over-adherence (ie, doing more than is prescribed in the rehabilitation program; Table 4-4).⁷³

While a plethora of research has focused on rehabilitation under-adherence,30 rehabilitation over-adherence is a newer concept in the literature^73,119 and has, therefore, received less attention. However, it is important for athletic trainers to recognize that both under-adherence and over-adherence may be related to overall rehabilitation outcomes, and may be influenced individually by different factors.

Psychosocial Responses to Concussion Injury

When it comes to psychosocial responses to concussion injury, much research to date has identified somewhat similar responses to that of musculoskeletal injury.¹²⁴ While most of the concussion related research has focused on the neurological signs and symptoms of concussion, a substantial body of literature has also highlighted cognitive appraisals, emotional and behavioral responses as pertinent and typical following a concussion injury.

Cognitive Appraisals

Similar to musculoskeletal injury, the injured athletic patient typically makes a primary cognitive appraisal of the concussion injury and its implications. These primary appraisals are generally followed by secondary appraisals and potential re-appraisals, where, upon receiving new information (eg, confirmed diagnosis, emergence of new symptoms), the injured athletic patient will reevaluate his or her initial appraisals in light of the new evidence.^37,98

When it comes to concussion injury, however, the initial appraisals often include content that appears to downplay the injury severity and its subsequent symptoms. Given that concussion injury is commonly known as the “invisible injury,”⁹⁵ and is often casually referred to as a “knock to the head” in media and in various sport cultures,⁹⁴ “talking down” concussion is not surprising. It is known that many athletes who encounter concussion choose not to report their symptoms, or choose to downplay symptoms due to not wanting to let their teammates and coaches down, or to be removed from the field of play.^93,105 Other typical appraisals include those related to the cause of concussion (ie, was the injury unavoidable, or within his or her own control), the traumatic nature of the injury occurrence, and a range of appraisals focused on how to cope with the injury and its symptoms.

Since concussion injuries are typically caused by a direct impact to the head, neck, or face, or a force that reverberates in the head,³⁷ many of the causes and symptoms of concussion are neurobiological, psychogenic, and pathophysiological in nature. The cognitive responses and symptoms of concussion typically extend beyond the content of the thought, as injured athletic patients have reported decreases in their quality of cognitive performance.³⁷ Existing research has documented impairments in attentional focus, memory, speed of cognitive processing, and reaction time.³⁷ Similarly, recent systematic review of the literature also found an association between concussion and attention deficit hyperactivity disorder as a symptom of concussion.¹²⁴

Typical emotional responses to concussion injury are also similar to those experienced with musculoskeletal injury. A recent comprehensive systematic review, exploring an association between concussion and mental health outcomes among elite athletes, found that most studies included in the review reported depression as the most common emotional response/symptom of concussion.124 They also found a relationship between concussion and anxiety, although this was not as commonly reported an outcome as depression.¹²⁴ Other emotional responses to look for include changes in injured athletic patients’ general mood states (ie, anger, confusion, depression, fatigue, tension, and vigor).^103,104 It is also important for athletic trainers to monitor any possible atypical, passive emotional coping strategies across the different phases of concussion rehabilitation, to be able to facilitate appropriate referral when necessary, and to ensure comprehensive patient care.

Behavioral Responses

Behaviorally, a concussed athletic patient may exhibit a range of responses. Consistent with the theoretical models and empirical evidence to date, these can include but are not limited to; sleep-wake disturbances, poor social functioning, social isolation, communication difficulties, behavioral disinhibition, avoidant coping, aggression and verbal outburst, illness behavior, substance abuse, and suicide.^{77,106,124,134,153}

PSYCHOSOCIAL ASSESSMENT DURING INJURY REHABILITATION

To ensure patient-centered holistic care, it is imperative to assess the injured athletic patient’s psychosocial responses to injury and rehabilitation.¹² According to Arvinen-Barrow et al,¹² the following should be considered when planning to use psychosocial assessments with injured athletic patients:

1. The injured athletic patient’s overall health and well-being should be central in determining assessment needs.
   
2. The person administering and interpreting the assessment should be qualified to do so. It is imperative for athletic trainers to note that most psychological assessments related to personality and mental health require clinical training or licensure. In other words, assessing most cognitive appraisals and emotional responses are beyond the scope of practice for athletic trainers, thus highlighting the need for interprofessional care.
   
3. If an athlete displays any signs of psychopathology, it is important to ensure appropriate referral practices are in place.
   
4. To ensure athletic patients are not over-assessed during injury rehabilitation, awareness of any physical assessments taking place concurrently with psychosocial assessments should be of primary importance.

Assessing Rehabilitation Adherence

Taking the above into consideration, one psychosocial response athletic trainers should be focused on assessing is rehabilitation adherence. As noted above, sport medicine professionals worldwide perceive adherence as a key psychosocial characteristic determining between unsuccessful and successful coping with injury rehabilitation.^{14,47,81,83,96} In particular, athletic trainers may wish to measure patients’ adherence, as tracking it may serve to motivate the patient, as well as give the patient concrete examples of rehabilitation behaviors they should and should not be engaging in during rehabilitation.

The most widely-used measure of adherence is the Sport Injury Rehabilitation Adherence Scale.³⁸ The Sport Injury Rehabilitation Adherence Scale (SIRAS) is a brief, user-friendly measure that contains three items where the athletic trainer rates the injured athletic patients’ behaviors in relation to the following: (a) intensity of rehabilitation completion, (b) frequency of following rehabilitation instructions and advice, and (c) receptivity to changes within the rehabilitation program. The SIRAS can also be adapted to a self-report measure for the injured athletic patient, which may also serve as a means to build patient awareness of positive rehabilitation behaviors and thus, enhance their rehabilitation adherence.

Specific to athletic training, the Rehabilitation Adherence Measure for Athletic Training74 can also be a useful tool for athletic trainers. The Rehabilitation Adherence Measure for Athletic Training (RAdMAT) contains 16 items across 3 subscales: attendance/participation, communication, and attitude/effort. Although longer than the SIRAS, the RAdMAT can be helpful in guiding athletic trainers’ work with injured athletic patients, as it separates specific adherence related behaviors (participation, communication, effort), thus providing specific feedback on where the potential issues in adherence are occuring.

In addition to the rehabilitation adherence measures introduced above, the Rehabilitation Over-Adherence Questionnaire¹¹⁹ can also be beneficial when working with athletic patients who are not complying with their rehabilitation as instructed. The Rehabilitation Over-Adherence Questionnaire (ROAQ) contains 10 items across 2 subscales: Ignore practitioner recommendations and attempt an expedited rehabilitation.

For further details on psychosocial assessment for musculoskeletal¹² and concussion⁵⁰ injury, and a list of valid and reliable assessment tools, please see a recent text on assessment in applied sport psychology by Taylor.¹³⁸

PSYCHOSOCIAL STRATEGIES

Consistent with the existing theoretical conceptualizations,^{34,152,153,155} to ensure successful physical and psychosocial injury rehabilitation outcomes, injury treatment plans should incorporate psychosocial strategies as part of the treatment plan. Existing evidence has identified a number of psychosocial strategies as beneficial during injury rehabilitation, including but not limited to: goal setting, imagery, patient education, relaxation strategies, self-talk, social support and stress-management (for more details, see core texts such as).^19,20,37,75 When implemented appropriately to address a particular psychosocial concern, the above psychosocial strategies can be effective in controlling, modifying, and alleviating maladaptive cognitive appraisals, emotional, and behavioral responses to injury, rehabilitation, and return-to-participation.

To ensure safe, ethical, and practitioner competent care, selecting appropriate psychosocial strategies may be a challenge for athletic trainers.⁵² Most athletic trainers have not received extensive training in rehabilitation psychology or the use of psychosocial strategies in their work with athletic patients, and as such, feel underprepared and untrained to implement such strategies in their work.^{43,47,156,157} What follows is an introduction of 4 psychosocial strategies that athletic trainers can and should use in their work with injured athletic patients to ensure patient-centered, holistic care: goal setting, patient education, self-talk, and social support.

Defined as a “dynamic process of systematic pursuit of the attainment of a specific standard of proficiency on a task, usually within a specified time limit,”100 goal setting is a psychosocial strategy than can provide athletic patients a direction and plan of action for their rehabilitation. Goal setting is perhaps the most commonly used,⁹ and frequently researched, psychosocial strategy in rehabilitation, and it has been found to have a direct influence on athletic patients’ rehabilitation related behaviors, cognitive appraisals, and emotional responses.¹³ It is also an important psychosocial strategy for athletic trainers to use with athletic patients, given that the Commission on Accreditation of Athletic Training Education¹¹¹ 2020 core competencies expect athletic trainers to be prepared to consider the patient’s goals when developing their care plan (Commission on Accreditation of Athletic Training Education [CAATE], Standard).⁶⁹

Setting goals during rehabilitation can facilitate injured athletic patient’s physical and psychological healing,^27,86 resulting in faster recovery.⁵⁷ When used as a motivational strategy to assist injured athletic patients in maintaining control over their situation (ie, sense of autonomy⁵⁶),⁷³ goal setting has also shown both to predict¹³² and improve⁶¹ injured athletic patients’ rehabilitation adherence. Thus far, a number of recommendations on how to set goals with injured athletic patients exist in the literature. While differences in such recommendations exists, they all call for the goal setting process to be collaborative in nature (Figure 4-2). Heil⁸² proposed 9 key points for effective goals and goal setting:

1. Goals should be specific and measurable
   
2. Use positive rather than negative language when setting goals
   
3. Be challenging but realistic in setting goals
   
4. Have a timetable for goal completion
   
5. Integrate short-, medium-, and long-term goals
   
6. Link outcome goals to process goals
   
7. Involve internalized goals
   
8. Involve monitoring and evaluating goals
   
9. Link sport goals to life goals

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