Injury is a common occurrence in association with sport participation. Most sport injuries are minor, require minimal medical intervention, and have limited impact on the sport involvement of athletes. However, a substantial number of injuries are of sufficient severity to require more extensive medical treatment (e.g., immobilization, surgery), rehabilitation, and restriction of sport involvement. In addition to the physical effects, there can also be psychological consequences of sport injury. Numerous models have been proposed and evaluated to document and predict psychological responses to sport injury. Based on these models, interventions have been developed to facilitate psychological adjustment to sport injury.
Models of Psychological Response to Sport Injury
Beginning in the late 1960s, empirical studies of the psychological consequences of sport injury began to appear in the scientific literature. By the mid-1980s, scholars had adapted theoretical models from psychiatry and general psychology to describe and explain how athletes respond to sport injury. Stage models, which were derived from research on terminally ill patients, were also used to attempt to predict psychological responses to sport injury. In stage models, athletes were posited to experience a sequential series of stages of adjustment (e.g., denial, bargaining, anger, depression, acceptance) following injury. Despite their popular appeal, these models fell out of favor as research findings indicated that athletes’ psychological responses to injury are highly variable and follow no universal pattern.
Scholars borrowed another theoretical perspective from research on stress and coping in the form of cognitive appraisal models. According to cognitive appraisal models, an athlete’s cognitive, emotional, and behavioral responses to injury are interrelated. Athletes’ responses are influenced primarily by their appraisals or interpretations of the injury and their ability to cope with the injury. Characteristics of the athlete (e.g., personality), the situation (e.g., life stress, social support), and the injury (e.g., severity, duration) are thought to affect athletes’ cognitive appraisals. Cognitive appraisal models have accommodated the results of numerous studies in which individual differences in psychological responses to sport injury have been found. With consistent empirical support for their basic tenets, cognitive appraisal models provide a useful framework for examining psychological consequences of sport injury.
Psychological Responses to Sport Injury
Researchers have documented a wide variety of psychological responses to sport injury. In accord with cognitive appraisal models, the psychological responses can be grouped into cognitive, emotional, and behavioral responses.
Causal attributions, cognitive coping strategies, injury-related cognition, cognitive performance, self-related cognition, and perceived benefits of injury are among the aspects of cognition associated with the occurrence of sport injury. Athletes who have been injured readily generate causal explanations for why they experienced their injuries. Athletes may also experience intrusive injury related thoughts and images. They often report applying cognitive strategies to cope with their injuries, such as accepting their injuries, focusing on healing, thinking positive thoughts, using imagery, and avoiding negative thoughts. Even with the use of coping strategies, athletes who have experienced a recent injury tend to perceive greater risk of sustaining an injury, greater worry about injuries, and less confidence in the ability to prevent injury than athletes without a recent injury. With regard to cognitive performance, neurocognitive functioning (e.g., attention, memory, processing speed, reaction time [RT]) can be impaired not only by concussions but by musculoskeletal injuries as well.
Thoughts about the self-appear to be particularly affected by sport injury. Changes in self related cognitions over the course of sport injury rehabilitation have been documented. Post-injury levels of self-esteem tend to be lower than preinjury levels of self-esteem. Self-confidence and self-efficacy tend to increase as athletes recover from their injuries. For serious injuries with a long and arduous rehabilitation, self-identification with the athlete role (i.e., athletic identity) may decline over the recovery period, especially for those who are not recovering quickly or well.
Not all cognitive responses to sport injury are negative. Apparently, some athletes derive benefits from their injury experiences. Perceived benefits of injury tend to involve themes associated with growing as a person, enhancing mental skills for sport performance, and developing physical and/ or technical skills. Experiencing benefits from injury likely requires athletes to expend effort in acquiring skills or viewing their situation from a new perspective. Full recognition of the benefits of injury may not occur until well after the recovery process has concluded.
Given that injuries often disrupt athletes’ pursuit of sport-related goals, it is not surprising that athletes report experiencing a variety of negative emotions following injury (e.g., anger, anxiety, bitterness, confusion, depression, disappointment, devastation, fear, frustration, helplessness, resentment, shock). Evidence indicates that compared with their pre-injury emotional states, athletes experience post-injury emotional disturbance. Injured athletes report experiencing greater mood disturbance than athletes without injuries. Estimates suggest that approximately 5% to 27% of athletes with injuries have clinically meaningful levels of emotional distress. Negative emotions tend to dissipate and positive emotions tend to become more prominent over the course of rehabilitation. Although the general pattern of post injury emotional adjustment is similar to that what might be predicted by stage models, athletes vary tremendously in the emotions they report experiencing and the order in which they experience them. With such variability in responses across individuals, the concept of stages does not apply and is, therefore, not useful. Cognitive appraisal models provide a more parsimonious explanation for the emotional responses to injury exhibited by athletes. In accord with cognitive appraisal models, numerous personal, situational, and cognitive factors are associated with emotional responses to sport injury.
Personal factors refer to relatively stable characteristics of athletes and, for the purposes of this discussion, characteristics of the injuries that athletes sustain. In general, higher levels of post-injury emotional disturbance have been documented in athletes who are (a) young, (b) in pain, (c) high on neuroticism, (d) less recovered from their injury, (e) injured more acutely, (f) injured more severely, (g) more impaired in their ability to perform everyday tasks, (h) more strongly identified with the role of athlete, and (i) more heavily invested in playing sport professionally.
Situational factors refer to characteristics of the social and physical environments inhabited by athletes. Levels of post-injury emotional disturbance appear to be highest among athletes who (a) commit a large amount of time to their sport activities, (b) experience a high amount of life stress, (c) participate at a low level of competition, and (d) perceive themselves as having little social support for their rehabilitation and lives in general. High perceptions of social support are not only associated with lower levels of emotional disturbance but may also help to reduce the adverse effects of life stress on emotional functioning.
Cognitive appraisals, cognitive coping strategies, cognitive structures, self-related cognition, and causal attributions are among the aspects of cognition for which associations with emotional adjustment to sport injury have been documented. Athletes who appraise themselves as being unable to cope with their injuries tend to show greater emotional disturbance than those without such appraisals. Similarly, athletes who report that they use avoidant cognitive coping strategies, possess dysfunctional schemas that are used to process self and world-related information, and/ or rate themselves as low in physical self-esteem are at increased risk for experiencing post-injury emotional disturbance. Significant relationships between attributions regarding the cause of the injury and emotional adjustment to injury have also been obtained. The direction of the attribution– adjustment relationship is unclear, however, as internal attributions for injury were associated with better emotional adjustment in one study and worse emotional adjustment in another.
As indicated by cognitive appraisal models, sport injury can produce behavioral as well as cognitive and emotional reactions. Some behavioral reactions are maladaptive, such as those involving suicidal behavior, disordered eating, alcohol abuse, and consumption of banned substances (e.g., amphetamines, anabolic steroids, ephedrine, marijuana). Other observed behavioral reactions are far more benign, including pursuing academic and occupational goals (with the increase in free time), visiting friends and family members, and building networks for social support.
To help deal with the physical, cognitive, and emotional consequences of injury, some athletes with injuries initiate behavioral coping strategies. Common behavioral responses of athletes with injuries include (a) trying to maintain as normal a life as possible while working hard at completing a prescribed rehabilitation regimen (“driving through”), (b) keeping their mind off the situation by staying busy (i.e., distraction), (c) attempting to use social resources as means of support, (d) staying away from others (i.e., isolation), (e) adopting an aggressive stance toward rehabilitation activities, (f) learning about their injuries, (g) trying unconventional treatments (e.g., alternative therapies), and (h) becoming physically stronger. Some of the behavioral coping strategies are instrumental or problem-focused in that they reflect attempts to address the athletes’ concerns directly. Other behavioral coping responses are emotion-focused, as they involve attempts to manage the stress associated with sport injury.
Adherence to rehabilitation programs represents the most researched behavioral response to sport injury. Adherence to prescribed treatment regimens is an area of concern across the health care spectrum, and sports health care is no exception. Adherence to treatment is considered important because of the presumed positive association between adherence and treatment outcomes. Specifically, better adherence is thought to contribute to more favorable outcomes. Actual dose-response relationships between sport injury rehabilitation activities and functional treatment outcomes are known for only a few treatments. Positive adherence-outcome relationships have been demonstrated for relatively few sport injury rehabilitation programs. In the absence of evidence to the contrary, however, adherence to sport injury rehabilitation programs is typically viewed as a worthy aim.
Rates of adherence to sport injury rehabilitation vary considerably depending on the nature of the rehabilitation program under consideration. Generally, high levels of adherence are obtained for clinic-based rehabilitation activities, which typically occur under the supervision of rehabilitation professionals. In clinical settings, adherence is commonly defined operationally in terms of the extent to which athletes attend rehabilitation sessions, expend effort during the sessions, follow the instructions of rehabilitation professionals, and complete prescribed rehabilitation exercises during the sessions they attend. Adherence rates are considerably more variable for home-based aspects of rehabilitation programs, ranging from complete nonadherence (in which athletes complete none of the prescribed regimen or even engage in contraindicated behavior) to gross over adherence (in which athletes do substantially more of the regimen than prescribed). Home-based rehabilitation programs may include elements such as (a) appropriate restriction of physical activities, (b) completion of rehabilitation exercises, (c) consumption of medications, and (d) use of therapeutic devices (e.g., splints, orthotics) and modalities (e.g., ice, transcutaneous electrical nerve stimulation [TENS]).
Consistent with hypotheses generated from cognitive appraisal models, a variety of personal, situational, cognitive, and emotional factors have been found to predict levels of adherence to sport injury rehabilitation programs. Athletes high on self-motivation, self-identification with the athlete role, pain tolerance, and tough-mindedness tend to adhere better to sport injury rehabilitation than athletes low on these personal factors. With respect to situational factors, adherence levels tend to be high when athletes perceive (a) others as supporting their rehabilitation, (b) their rehabilitation professionals as expecting them to adhere, (c) the clinical setting as comfortable, and (d) the scheduling of their rehabilitation sessions as convenient. In terms of cognitive factors, adherence levels tend to be higher when athletes report believing that (a) their injuries are severe, (b) they are susceptible to additional health problems if they do not complete rehabilitation activities, (c) they can exercise control over their health in general and their injury status in particular, (d) their rehabilitation program is effective, and (e) they are capable of completing the tasks associated with rehabilitation. Athletes experiencing high levels of mood disturbance and fear of re-injury tend to adhere more poorly to sport injury rehabilitation programs than those without such distress.
Interventions to Affect Psychological Consequences of Sport Injury
Many of the cognitive, emotional, and behavioral consequences of sport injury are aversive and can have an adverse impact on athletes’ quality of life (QOL) and recovery from injury. Consequently, researchers have developed, implemented, and evaluated interventions to prevent or reduce these circumstances. A small body of controlled experimental studies has documented the effects of the interventions on psychological outcomes. These studies indicate that goal setting, modeling, and several multimodal interventions are effective relative to a control condition not only for certain functional or physical rehabilitation outcomes (e.g., strength, endurance, recovery time) but also for one or more psychological response to sport injury.
Interventions in which goal setting is the primary focus have a beneficial effect on adherence to sport injury rehabilitation programs. A modeling intervention was found useful in promoting self-efficacy for the use of crutches in rehabilitation. Multimodal interventions with components such as relaxation and guided imagery, or stress management, cognitive control, goal setting, relaxation, and guided imagery, have produced improvements in tension, extraversion, social orientation, security, rehabilitation attitude, readiness for physical activity (PA), and reinjury anxiety. Cognitive behavioral interventions are still in the infancy of their application in the context of sport injury rehabilitation. Nevertheless, informed by research findings and guided by cognitive appraisal models, they offer considerable promise in enhancing psychological responses to sport injury and, potentially, recovery and return-to-sport outcomes.
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