Cognitions

A range of cognitions has been identified that influence athletes’ emotions and behaviors in rehabilitation settings, including attributions for injury occurrence, self-perceptions following injury, cognitively based coping strategies, and perceived injury benefits. Self-perceptions of esteem and worth have also been shown to diminish following injury in some studies (eg, Leddy and colleagues, 1994) but not in others (eg, Smith and colleagues, 1993). Cognitive appraisals of the potential benefits of injury have been described, including opportunities to develop nonsport interests, viewing injury as a test of character, enhanced appreciation for sport, greater resilience, and enhanced knowledge of the body and technical mastery. Quinn and Fallon (1999) found differences in sport self-confidence over the course of rehabilitation, with confidence levels high at the onset of injury, declining during rehabilitation, and increasing with recovery. However, there is little other study of change in appraisal over time and how this is related to recovery.

Emotions

Athletes’ emotional reactions to injury include feelings of loss, denial, frustration, anger, and depression (eg, Tracey, 2003). Positive emotions such as happiness, relief, and excitement have been reported as well. The attainment of rehabilitation goals and the prospect of recovery may engender a host of positive emotional responses throughout the course of rehabilitation. It seems that these responses are influenced by a wide array of personal factors (eg, athletic identity, previous injury experience, injury severity, injury type, current injury status) and situational factors (eg, life stress, social support satisfaction, timing of the injury).

Emotions typically fluctuate in response to rehabilitation progress and/or setbacks (see Brewer, 2007, for a review). Emotional states typically move from negative to positive as athletes progress through their rehabilitation and a return to competition draws nearer. Studies have shown an increase in negative affect as the return to sport approaches, possibly because of anxieties over reinjury, the uncertainty of what lies ahead, as well as concerns that postinjury goals may be unrealized. Return to sport may alternatively be viewed as a functional reality check challenging denial that may have falsely bolstered athlete expectation. In summary, individual differences in emotional response over the course of rehabilitation are varied, complex, and fluctuate with rehabilitation progress and setbacks.

Behaviors

The extent to which athletes use various coping skills (eg, goal setting, imagery, seeking out social support) and adhere to rehabilitation have received the greatest amount of research attention. Personal factors linked to adherence including pain tolerance, self-motivation, tough-mindedness, perceived injury severity, internal health locus of control, self-efficacy, and self-esteem have all been positively associated with rehabilitation adherence, whereas mood disturbance and fear of reinjury are negatively associated. Demographic factors such as age have also been found to influence rehabilitation adherence. For example, Brewer and colleagues found that age moderated the relationship between psychological factors and 2 kinds of adherence: home exercise completion and home cryotherapy completion. Older patients were more adherent when they were self-motivated and perceived high levels of social support, whereas younger patients were more adherent when they were highly invested in the athlete role as a source of self-worth.

Adherence has been positively associated with enhanced clinical outcomes such as proprioception, range of motion, joint/ligament stability, muscular strength and endurance, as well as reductions in the subsequent risk of reinjury. However, nonsignificant and negative relationships have also been found. The negative relationship in particular is likely a function of methodological problems. Although it is a simple matter to get measures of compliance such as attendance, assessing the more subtle elements such as motivation and psychological coping behaviors is more difficult. Active coping responses such as use of positive self-talk, imagery, goal setting, and seeking out additional information about injury are also associated with adherence. In addition, situational factors, mostly related to perception of treatment, also predict adherence, including a belief in the efficacy of the treatment, information about rehabilitation, the clinical environment, value of rehabilitation to the athlete, and hours a week of sport involvement.

Psychological interventions that have shown efficacy in enhancing the rate or quality of sport injury rehabilitation include goal setting, imagery and relaxation, and stress inoculation. The use of self-directed cognitive coping strategies similarly predict favorable psychosocial outcomes such as accepting injury, focusing on getting better, thinking positively, and using imagery. There is also speculation that psychological factors may expedite the recovery process through neurochemical or physiologic changes such as increased blood flow and enhanced proprioception, muscular endurance and strength, and coordination. However, empirical support for such contentions is lacking.

Patient-practitioner interactions

Patient-practitioner interactions, specifically those between the athlete and athletic trainer/sport physiotherapist, have been found to be crucial factors influencing athletes’ psychological state, the quality of their rehabilitation experiences, and eventual treatment outcomes. Given the close proximity and regularity of contact, sport medicine professionals are uniquely positioned to play an influential role in the psychological well-being of injured athletes through behavioral intervention as well as through effective psychological triage and referral. Positive behaviors shown by rehabilitation specialists include building patient alliances based on acceptance, genuineness, and empathy ; effective communication ; counseling ; and the provision of social support (discussed in greater detail later). The delineation of athletes’ roles (eg, motivation, compliance, communication of concerns) and the establishment of clear expectations also seem to be crucial in optimizing athletes’ rehabilitation motivation and adherence. Practitioners may also facilitate rehabilitation by clarifying their own role in the treatment process; specifically, providing clear information about treatment, adequate pain control, and participation in key decisions.

Social support

A wealth of evidence highlights the benefit of social support in coping with difficult life events and facilitating rehabilitation from a variety of ailments (eg, cardiac rehabilitation). The value of social support in a sport injury context is no exception. Social support and assistance from a variety of sources, including sport medicine practitioners, coaches, teammates, and family, may be vital in enhancing injured athletes’ resilience and facilitating adaptive coping (eg, Bianco and Eklund, 2001). The athlete may benefit from support expressed by listening to the athlete, acknowledging advances in rehabilitation progress (eg, greater range of motion), providing emotional support, encouraging the achievement of physical-rehabilitation goals, encouraging positive coping, and the personal sharing of practitioners’ own experiences and opinions. Initial research suggests that gender differences may exist with regard to perceptions of available social support. Using a sample of 207 injured athletes (male, 111; female, 96), Mitchell and colleagues found that women reported significantly higher scores than men on the availability of emotional and esteem support, whereas no significant differences were reported for the information and tangible forms of support. The investigators suggested that their findings enhance understanding of the moderating role of gender within the social support process and potential coping actions of male and female athletes during rehabilitation. Further research is needed to examine the moderating influence of other variables influencing perceived social support availability and preferences, including type of sport (team vs individual), level of competition, and cultural differences.

Highlighting the value of social support, Canadian national team skiers reported that social support from coaches and rehabilitation practitioners was important in providing reassurance about getting better, keeping things in perspective, focusing on future opportunities, and encouragement to adhere to the rehabilitation program. US alpine and freestyle skiers in Gould and colleagues’ (1997) study similarly thought that their injury recovery was facilitated by coach interest and assistance. Johnston and Carroll (1998) also found that social support from several sources, including coaches and rehabilitation specialists, was beneficial in assisting athletes throughout the injury rehabilitation period. Athletes reported that they needed various forms of social support from the coach and sport medicine practitioner (ie, informational, emotional, and practical) at different points in the recovery period. For example, emotional support was particularly important at the beginning of rehabilitation when athletes were trying to adjust to the severity of their injuries. At the end of rehabilitation, the need for informational support was most salient in ensuring that athletes did not return to sport prematurely. One athlete stated: “At this stage you are raring to go and just want to get back into playing your sport competitively, but you need someone to monitor your re-entry into sport and your training and to make sure you ease back into it and don’t re-injure yourself.” ^(p277) It was at this time that some athletes indicated a lack of sport-specific advice, encouragement, and feedback, especially from physiotherapists and coaches. For example, athletes indicated that they perceived their coaches to be distant and insensitive to injury, did not provide sufficient or appropriate rehabilitation guidance, and did not show a belief in them. Athletes in a later investigation similarly indicated a lack of (informational) support from coaches and physiotherapists as they were returning to play. Athletes reported receiving insufficient advice, guidance, and information from their coaches about how to train as they reentered the competitive arena. These findings are supported by more recent work that reveals that injured athletes in National Collegiate Athletic Association division II to III were significantly more satisfied with the social support provided by certified athletic trainers (ATCs) than that provided by coaches and teammates. In addition, injured athletes reported that social support provided by ATCs contributed significantly more to their overall well-being.

A lack of social support from relevant individuals such as coaches contradicts the substantial evidence of the benefits discussed earlier. Social support from coaches, family members, and medical practitioners may be essential in assisting athletes in dealing with the demands of injury recovery and complying with the rigors of their rehabilitation regimens. Coaches and sport medicine practitioners are encouraged to stay involved and to provide alternative activities (such as developing special practice routines) so athletes can achieve appropriate clinical outcomes and sport-specific skills as they transition back into training and competition. This ongoing involvement diminishes feelings of isolation from the team, allows athletes to continue to develop in their sports, reduces feelings that athletes are falling behind, and helps maintain confidence in their capabilities when they are returning to their sports.

Cognitions

A range of cognitions has been identified that influence athletes’ emotions and behaviors in rehabilitation settings, including attributions for injury occurrence, self-perceptions following injury, cognitively based coping strategies, and perceived injury benefits. Self-perceptions of esteem and worth have also been shown to diminish following injury in some studies (eg, Leddy and colleagues, 1994) but not in others (eg, Smith and colleagues, 1993). Cognitive appraisals of the potential benefits of injury have been described, including opportunities to develop nonsport interests, viewing injury as a test of character, enhanced appreciation for sport, greater resilience, and enhanced knowledge of the body and technical mastery. Quinn and Fallon (1999) found differences in sport self-confidence over the course of rehabilitation, with confidence levels high at the onset of injury, declining during rehabilitation, and increasing with recovery. However, there is little other study of change in appraisal over time and how this is related to recovery.

Emotions

Athletes’ emotional reactions to injury include feelings of loss, denial, frustration, anger, and depression (eg, Tracey, 2003). Positive emotions such as happiness, relief, and excitement have been reported as well. The attainment of rehabilitation goals and the prospect of recovery may engender a host of positive emotional responses throughout the course of rehabilitation. It seems that these responses are influenced by a wide array of personal factors (eg, athletic identity, previous injury experience, injury severity, injury type, current injury status) and situational factors (eg, life stress, social support satisfaction, timing of the injury).

Emotions typically fluctuate in response to rehabilitation progress and/or setbacks (see Brewer, 2007, for a review). Emotional states typically move from negative to positive as athletes progress through their rehabilitation and a return to competition draws nearer. Studies have shown an increase in negative affect as the return to sport approaches, possibly because of anxieties over reinjury, the uncertainty of what lies ahead, as well as concerns that postinjury goals may be unrealized. Return to sport may alternatively be viewed as a functional reality check challenging denial that may have falsely bolstered athlete expectation. In summary, individual differences in emotional response over the course of rehabilitation are varied, complex, and fluctuate with rehabilitation progress and setbacks.

Behaviors

The extent to which athletes use various coping skills (eg, goal setting, imagery, seeking out social support) and adhere to rehabilitation have received the greatest amount of research attention. Personal factors linked to adherence including pain tolerance, self-motivation, tough-mindedness, perceived injury severity, internal health locus of control, self-efficacy, and self-esteem have all been positively associated with rehabilitation adherence, whereas mood disturbance and fear of reinjury are negatively associated. Demographic factors such as age have also been found to influence rehabilitation adherence. For example, Brewer and colleagues found that age moderated the relationship between psychological factors and 2 kinds of adherence: home exercise completion and home cryotherapy completion. Older patients were more adherent when they were self-motivated and perceived high levels of social support, whereas younger patients were more adherent when they were highly invested in the athlete role as a source of self-worth.

Adherence has been positively associated with enhanced clinical outcomes such as proprioception, range of motion, joint/ligament stability, muscular strength and endurance, as well as reductions in the subsequent risk of reinjury. However, nonsignificant and negative relationships have also been found. The negative relationship in particular is likely a function of methodological problems. Although it is a simple matter to get measures of compliance such as attendance, assessing the more subtle elements such as motivation and psychological coping behaviors is more difficult. Active coping responses such as use of positive self-talk, imagery, goal setting, and seeking out additional information about injury are also associated with adherence. In addition, situational factors, mostly related to perception of treatment, also predict adherence, including a belief in the efficacy of the treatment, information about rehabilitation, the clinical environment, value of rehabilitation to the athlete, and hours a week of sport involvement.

Psychological interventions that have shown efficacy in enhancing the rate or quality of sport injury rehabilitation include goal setting, imagery and relaxation, and stress inoculation. The use of self-directed cognitive coping strategies similarly predict favorable psychosocial outcomes such as accepting injury, focusing on getting better, thinking positively, and using imagery. There is also speculation that psychological factors may expedite the recovery process through neurochemical or physiologic changes such as increased blood flow and enhanced proprioception, muscular endurance and strength, and coordination. However, empirical support for such contentions is lacking.

Patient-practitioner interactions

Patient-practitioner interactions, specifically those between the athlete and athletic trainer/sport physiotherapist, have been found to be crucial factors influencing athletes’ psychological state, the quality of their rehabilitation experiences, and eventual treatment outcomes. Given the close proximity and regularity of contact, sport medicine professionals are uniquely positioned to play an influential role in the psychological well-being of injured athletes through behavioral intervention as well as through effective psychological triage and referral. Positive behaviors shown by rehabilitation specialists include building patient alliances based on acceptance, genuineness, and empathy ; effective communication ; counseling ; and the provision of social support (discussed in greater detail later). The delineation of athletes’ roles (eg, motivation, compliance, communication of concerns) and the establishment of clear expectations also seem to be crucial in optimizing athletes’ rehabilitation motivation and adherence. Practitioners may also facilitate rehabilitation by clarifying their own role in the treatment process; specifically, providing clear information about treatment, adequate pain control, and participation in key decisions.

Social support

A wealth of evidence highlights the benefit of social support in coping with difficult life events and facilitating rehabilitation from a variety of ailments (eg, cardiac rehabilitation). The value of social support in a sport injury context is no exception. Social support and assistance from a variety of sources, including sport medicine practitioners, coaches, teammates, and family, may be vital in enhancing injured athletes’ resilience and facilitating adaptive coping (eg, Bianco and Eklund, 2001). The athlete may benefit from support expressed by listening to the athlete, acknowledging advances in rehabilitation progress (eg, greater range of motion), providing emotional support, encouraging the achievement of physical-rehabilitation goals, encouraging positive coping, and the personal sharing of practitioners’ own experiences and opinions. Initial research suggests that gender differences may exist with regard to perceptions of available social support. Using a sample of 207 injured athletes (male, 111; female, 96), Mitchell and colleagues found that women reported significantly higher scores than men on the availability of emotional and esteem support, whereas no significant differences were reported for the information and tangible forms of support. The investigators suggested that their findings enhance understanding of the moderating role of gender within the social support process and potential coping actions of male and female athletes during rehabilitation. Further research is needed to examine the moderating influence of other variables influencing perceived social support availability and preferences, including type of sport (team vs individual), level of competition, and cultural differences.

Highlighting the value of social support, Canadian national team skiers reported that social support from coaches and rehabilitation practitioners was important in providing reassurance about getting better, keeping things in perspective, focusing on future opportunities, and encouragement to adhere to the rehabilitation program. US alpine and freestyle skiers in Gould and colleagues’ (1997) study similarly thought that their injury recovery was facilitated by coach interest and assistance. Johnston and Carroll (1998) also found that social support from several sources, including coaches and rehabilitation specialists, was beneficial in assisting athletes throughout the injury rehabilitation period. Athletes reported that they needed various forms of social support from the coach and sport medicine practitioner (ie, informational, emotional, and practical) at different points in the recovery period. For example, emotional support was particularly important at the beginning of rehabilitation when athletes were trying to adjust to the severity of their injuries. At the end of rehabilitation, the need for informational support was most salient in ensuring that athletes did not return to sport prematurely. One athlete stated: “At this stage you are raring to go and just want to get back into playing your sport competitively, but you need someone to monitor your re-entry into sport and your training and to make sure you ease back into it and don’t re-injure yourself.” ^(p277) It was at this time that some athletes indicated a lack of sport-specific advice, encouragement, and feedback, especially from physiotherapists and coaches. For example, athletes indicated that they perceived their coaches to be distant and insensitive to injury, did not provide sufficient or appropriate rehabilitation guidance, and did not show a belief in them. Athletes in a later investigation similarly indicated a lack of (informational) support from coaches and physiotherapists as they were returning to play. Athletes reported receiving insufficient advice, guidance, and information from their coaches about how to train as they reentered the competitive arena. These findings are supported by more recent work that reveals that injured athletes in National Collegiate Athletic Association division II to III were significantly more satisfied with the social support provided by certified athletic trainers (ATCs) than that provided by coaches and teammates. In addition, injured athletes reported that social support provided by ATCs contributed significantly more to their overall well-being.

A lack of social support from relevant individuals such as coaches contradicts the substantial evidence of the benefits discussed earlier. Social support from coaches, family members, and medical practitioners may be essential in assisting athletes in dealing with the demands of injury recovery and complying with the rigors of their rehabilitation regimens. Coaches and sport medicine practitioners are encouraged to stay involved and to provide alternative activities (such as developing special practice routines) so athletes can achieve appropriate clinical outcomes and sport-specific skills as they transition back into training and competition. This ongoing involvement diminishes feelings of isolation from the team, allows athletes to continue to develop in their sports, reduces feelings that athletes are falling behind, and helps maintain confidence in their capabilities when they are returning to their sports.