Psychological Consequences Of Sport Injury

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.

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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.

Cognitive 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.

Emotional Responses

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.

Behavioral Responses

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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