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THE PSYCHOLOGY OF SPORT INJURY

AND REHABILITATION
Athletes routinely use psychological interventions for performance enhancement

but, perhaps surprisingly, not always to assist in recovery from injury. This book
demonstrates the ways in which athletes and practitioners can transfer psycholog-
ical skills to an injury and rehabilitation setting, to enhance recovery and the
well-being of the athlete.
Drawing on the very latest research in sport and exercise psychology, this book
explores key psychological concepts relating to injury, explaining typical psycho-
logical responses to injury and psychological aspects of rehabilitation. Using case
studies in the chapters to highlight the day-to-day reality of working with injured
athletes, it introduces a series of practical interventions, skills and techniques,
underpinned by an evidence base, with a full explanation of how each might affect
an athlete’s recovery from injury.
The Psychology of Sport Injury and Rehabilitation emphasises the importance of a
holistic, multi-disciplinary approach to sport injury and rehabilitation. No other
book examines the psychological aspects of both sport injury and the rehabilitation
process from such a holistic perspective, and therefore this is an essential resource for
students, scholars and practitioners working in sport psychology, sport therapy, sport
medicine or coaching.
Monna Arvinen-Barrow is a British Psychological Society chartered psycholo-

gist working as an Assistant Professor at the University of Wisconsin-Milwaukee,
USA. Monna has a number of peer-reviewed publications on the psychology of
sport injuries and has taught psychology of sport injuries in the United Kingdom,
United States and Finland.
Natalie Walker is a British Psychological Society chartered/Health and Care
Professions Council registered psychologist working as a Senior Lecturer at the
University of Northampton, UK, and an Associate Lecturer at the Open University.
Natalie has written a number of publications, as well as examining and supervising
postgraduate/doctoral research in the area of the psychology of sport injuries.
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THE PSYCHOLOGY OF
SPORT INJURY AND
REHABILITATION
Edited by Monna Arvinen-Barrow and

Natalie Walker
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First published 2013

by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
Simultaneously published in the USA and Canada

by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor and Francis Group, an informa business
© 2013 Monna Arvinen-Barrow and Natalie Walker
The right of the editors to be identified as the authors of the editorial material, and
of the authors for their individual chapters, has been asserted in accordance with
sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised
in any form or by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered

trademarks, and are used only for identification and explanation without intent to
infringe.
British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data

The psychology of sport injury and rehabilitation / edited by Monna Arvinen-
Barrow and Natalie Walker.
pages cm
1. Sports injuries–Psychological aspects. I. Arvinen-Barrow, Monna. II.Walker,
Natalie.
RD97.P79 2013
617.1’027–dc23
2012042544
ISBN: 978-0-415-69495-7 (hbk)

ISBN: 978-0-415-69589-3 (pbk)
ISBN: 978-0-203-55240-7 (ebk)
Typeset in Bembo
by FiSH Books Ltd, Enfield
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Äidin pienelle enkelille, Amielle (to Mommy’s little angel, Amie) and in memory
of my Dad. I wish you could have seen this in print.
Monna
To my family, I love you all so much Mum, Chris, Kieron,Ashleigh, Perry, Kaydee-
Jayne, Maci-Ann, Keaton-Lee, Bailey and Ruby.
Natalie
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CONTENTS
Figures and tables ix

Contributors xi
Foreword xv
Preface xvii
Acknowledgements xxi
PART 1
Introduction to the psychology of sport injuries:
theoretical frameworks 1
1 Introduction to the psychology of sport injuries 2

Monna Arvinen-Barrow and Natalie Walker
2 Psychological antecedents to sport injury 6

Renee N. Appaneal and Stephanie Habif
3 Psychological responses to injury: a review and critique of

existing models 23
Natalie Walker and Caroline Heaney
4 Psychological aspects of rehabilitation adherence 40

Megan D. Granquist and Britton W. Brewer
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viii Contents
PART 2
Psychological interventions in sport injury rehabilitation 55
5 Goal setting in sport injury rehabilitation 56

Monna Arvinen-Barrow and Brian Hemmings
6 Imagery in sport injury rehabilitation 71

Monna Arvinen-Barrow, Damien Clement and Brian Hemmings
7 Relaxation techniques in sport injury rehabilitation 86

8 Self-talk in sport injury rehabilitation 103

Natalie Walker and Joanne Hudson
9 Social support in sport injury rehabilitation 117

Monna Arvinen-Barrow and Stephen Pack
PART 3
Delivering psychological interventions in sport injury
rehabilitation 133
10 Integrating the psychological and physiological aspects of sport

injury rehabilitation: rehabilitation profiling and phases of
rehabilitation 134
Cindra S. Kamphoff, Jeffrey Thomae and J. Jordan Hamson-Utley
11 Sport medicine team influences in psychological rehabilitation:

a multidisciplinary approach 156
Damien Clement and Monna Arvinen-Barrow
12 Using a psychological model and counselling skills in sport injury

rehabilitation 171
Julie A.Waumsley and Jonathan Katz
13 Psychology of physical activity-related injuries 185

Elaine A. Hargreaves and Julie A.Waumsley
14 Conclusions and future directions 199

Natalie Walker and Monna Arvinen-Barrow
Index 203
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FIGURES AND TABLES
Figures
2.1 An amalgamated version of the stress and injury model 8
3.1 Typical cognitive appraisal model of psychological adjustment to athletic
injury 27
3.2 The integrated model of psychological response to the sport injury and
rehabilitation process 30
3.3 Critique of the dynamic core of Wiese-Bjornstal et al. (1998) integrated
model 32
3.4 A biopsychosocial model of sport injury rehabilitation 34
4.1 Schematic representation of hypothesised relationships among
psychological factors, rehabilitation adherence and rehabilitation
outcome 43
5.1 Types and levels of goals for rehabilitation 60
5.2 An example of a rehabilitation contract 65
6.1 Application of the applied model of imagery use in sport into sport
injury rehabilitation imagery 80
9.1 The stress-buffering effect model of social support adapted to sport
injury settings 119
9.2 The main effects model of social support adapted to sport injury
settings 120
9.3 Types and sources of social support proposed as beneficial during the
sport injury rehabilitation process 123
10.1 Rehabilitation profiling: personal profile 138
10.2 Rehabilitation profiling: physical profile 140
10.3 An example of changes in the rehabilitation profile across the three
phases of rehabilitation 142
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x Figures and tables
10.4 Rehabilitation goal sheet 144

11.1 Structure of multidisciplinary team to rehabilitation: primary and
secondary teams 158
11.2 An example of a sociogram in injury rehabilitation setting 161
12.1 Integrated theoretical and applied model of stress and coping 177
12.2 Overview of factors associated with the 1:1 consultation 179
Tables
8.1 A conceptual framework of self-talk 107
8.2 Reframing during the three phases of rehabilitation 111
8.3 Examples of self-talk serving different functions in injury rehabilitation 112
9.1 Different types of social support during sport injury rehabilitation 122
10.1 Rehabilitation profiling: definition of personal factors 139
10.2 Rehabilitation profiling: definition of physical factors 141
12.1 Freud’s stages of psychosexual development 173
13.1 Injury prevalence from common physical activities 187
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CONTRIBUTORS
Renee N. Appaneal is an Associate Professor in Kinesiology at the University of

North Carolina at Greensboro, USA. In addition, Renee is a Certified Consultant
with Association for Applied Sport Psychology, member of the US Olympic
Committee’s Sport Psychology Registry, and a Licensed Professional Counsellor
(LPC) in North Carolina, USA. She consults with sport medicine professionals and
other healthcare providers as well as provides sport and performance psychology
services across a variety of settings and competitive athletic levels.
Monna Arvinen-Barrow is an Assistant Professor at University of Wisconsin-

Milwaukee,USA.Monna recently moved to the USA from the UK,where she worked
as a Senior Lecturer in Sport and Exercise Psychology at the University of
Northampton and as an Associate Lecturer for the Open University. In addition to
teaching sport and exercise psychology courses in the UK and US, Monna has also
been teaching psychology of sport and exercise injury courses as a Visiting Scholar at
the University of Jyväskylä, Finland. She is a British Psychological Society Chartered
Psychologist, and an elected expert member of the Finnish Sport Psychology
Association. She has a specialist interest and expertise in psychological rehabilitation
from sport and exercise injuries and has completed her PhD entitled Psychological
Rehabilitation from Sports Injury: Issues in Training and Development of Chartered
Physiotherapists in 2009. In addition, she has published a number of peer-reviewed jour-
nal articles in the area of sport psychology, including several related to psychology of
sport injury rehabilitation. Her sporting background comes from figure and synchro-
nized skating where she has also been working as a professional coach for several years.
Britton W. Brewer is a Professor of Psychology at Springfield College in

Springfield, Massachusetts, USA, where he teaches undergraduate and graduate
psychology courses and conducts research on psychological aspects of sport injury.
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xii Contributors
Damien Clement is an Assistant Professor at West Virginia University’s College of

Physical Activity and Sport Sciences in Morgantown, USA, where he teaches
undergraduate and graduate sport and exercise psychology courses and graduate
athletic training courses. He is a Certified Athletic Trainer, National Certified
Counselor, and Certified Consultant with Association for Applied Sport
Psychology, as well as listed on the United States Olympic Committee Sport
Psychology Registry.
Megan D. Granquist is an Assistant Professor of Movement and Sports Science at

the University of La Verne in Southern California, USA. She teaches courses in
sport psychology and kinesiology. She is a Certified Athletic Trainer and her
research is focused on psychosocial factors related to sport injury and rehabilita-
tion.
Stephanie Habif is a Lecturer at the Hasso Plattner Institute of Design at Stanford

University in Palo Alto, California, USA. Stephanie conducts health behaviour
change research with the Stanford Persuasive Technology and Calming Technology
Labs, provides performance psychology services to injured and obese people, and
consults with health technology start-ups and healthcare corporations.
J. Jordan Hamson-Utley is an Assistant Professor and director of athletic training

education programme at Weber State University, Ogden, Utah, USA, where she
continues her research on examining the effects of psychological strategies on
physiological biomarkers associated with symptom resolution and return to play in
injured athletes. Jordan is also a certified athletic trainer who gained her PhD in
Experimental Psychology, where she implemented various cognitive interventions
with athletes rehabilitating from sport injury. She has worked with athletes from all
levels, including the US men’s and women’s soccer teams and Olympic athletes at
the Olympic Training Center in Colorado Springs and the Pan Am Games in Santo
Domingo (2003).
Elaine A. Hargreaves is a Senior Lecturer in Exercise and Sport Psychology at the

University of Otago, New Zealand. Her research is focused on understanding the
motivational forces behind the decision to adopt and maintain a physically active
lifestyle.
Caroline Heaney is a Senior Lecturer in Sport and Exercise Science at the Open
University, UK. She is a British Association of Sport and Exercise Sciences accred-
ited and Health and Care Professions Council registered Sport Psychologist.
Caroline has provided sport psychology support to a wide range of performers.
Brian Hemmings is a Consultant Sport Psychologist and a Visiting Researcher at

the School of Human Sciences, St. Mary’s University College, Twickenham, UK.
Brian is a British Psychological Society Chartered Psychologist, and a Health and
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Contributors xiii
Care Professions Council Registered Sport and Exercise Psychologist working

full-time in private practice. Brian has worked extensively with a range of
Olympic, professional and amateur sports for twenty years and is currently involved
with élite performers in international golf, cricket and motorsport.
Joanne Hudson is Head of the Department of Sport and Exercise Science and a
Senior Lecturer in Sport and Exercise Psychology at Aberystwyth University, UK.
She is British Psychological Society Chartered Psychologist and Associate Fellow,
as well as British Association of Sport and Exercise Sciences accredited and Health
and Care Professions Council Registered. She has co-authored and co-edited four
texts on sport and exercise science and psychology and has published in a number
of national and international peer-reviewed journals.
Jonathan Katz is a Consultant Psychologist working full time in private practice.

Jonathan is a British Psychological Society Chartered Psychologist and Associate
Fellow, as well as Health and Care Professions Council Registered. Jonathan has
provided psychological coaching support to a range of individuals (athletes,
coaches, managers and performance directors), competing at national and interna-
tional levels including World Cup Events, European and World Championships and
Commonwealth, Olympic and Paralympic Games across a wide range of individ-
ual, team, amateur and professional sports. He was also the Great Britain Head
Quarters Psychologist for ParalympicsGB at both the Athens 2004 and Beijing
2008 Summer Paralympic Games and the lead psychologist for the Turin 2006
Winter Paralympic Games. He has also been the team psychologist to the British
Disabled Ski Team at the Vancouver 2010 Winter Paralympic Games and squad
psychologist for Disability Target Shooting GB at the London 2012 Summer
Paralympic Games.
Cindra S. Kamphoff is an Associate Professor in Sport and Exercise Psychology at

Minnesota State University, Mankato, USA. Cindra is a Certified Consultant with
the Association for Applied Sport Psychology and serves on the AASP Executive
Committee. She works with all athletes and performers, and specialises in the
psychology of running. She enjoys running marathons in her spare time.
Stephen Pack is a Senior Lecturer in Sport and Exercise Psychology at the

University of Hertfordshire, UK. Stephen is a British Psychological Society
Chartered Psychologist, is Health and Care Professions Council registered, as well
as being accredited by the British Association of Sport and Exercise Sciences. He
has worked with athletes and performers in a variety of contexts including archery,
cycling, golf, and polar exploration.
Jeffrey Thomae is an instructor in the Department of Human Performance at

Minnesota State University, Mankato, USA, teaching courses in both sport
psychology and sport sociology. In addition, Jeffrey is a Performance Consultant for
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xiv Contributors
the Center for Sport and Performance Psychology at MSU, Mankato, drawing on
experience in coaching, counseling, and mental skills training to assist athletes,
coaches, exercisers, and performing artists alike.
Natalie Walker is a Senior Lecturer in Sport and Exercise Psychology at the

University of Northampton and an Associate Lecturer for the Open University,
UK. Natalie is a British Psychological Society Chartered and Health and Care
Professions Council Registered Sport and Exercise Psychologist. Natalie also works
as an applied sport psychology consultant to various sporting individuals and teams.
She has a specialist interest and expertise in psychological rehabilitation from sport
injuries and has completed her PhD entitled The Meaning of Sports Injury and Re-
injury Anxiety Assessment and Intervention in 2006. In addition, she has a number of
peer-reviewed journal and book chapter publications in this area, and has also
examined postgraduate theses related to psychology of injuries and is currently
supervising PhDs in this field. Her sporting background comes from association
football and martial arts.
Julie A. Waumsley is a Senior Lecturer and Course Leader for the undergraduate
and postgraduate degree programmes in counselling at The University of
Northampton, UK. Julie’s expertise in counselling and performance issues is rele-
vant in the sport domain, where she is a British Psychological Society Chartered
and Health and Care Professions Council registered Sport and Exercise
Psychologist. Her background is in sport and leisure, having spent ten years as an
Army Physical Training Instructor and ten years in leisure management before
embarking on her academic career.
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FOREWORD
A book on the psychology of sport injuries is not groundbreaking. I start with this
not as a criticism but as an acknowledgement of how this area of study has
advanced in recent years. In 1993, two edited texts which could be described as
groundbreaking were published in this area, namely Psychological Bases of Sport
Injuries (edited by David Pargman and published by Fitness Information
Technology) and Psychology of Sport Injury (edited by John Heil and published by
Human Kinetics).These books were the first to focus on sport injuries purely from
a psychological perspective to assist practitioners in working with athletes. They
were highly successful in reviewing material at the time. Considering the respec-
tive content lists of the two 1993 texts alongside the current edition by Monna
Arvinen-Barrow and Natalie Walker shows how much has advanced over the past
20 years. Indeed, the preface in Pargman’s 1993 text noted how its goal was to
provide ‘caveats and clues’ to practitioners (and those preparing for such careers) in
the field.The current edition is able to draw on a far more diverse and established
literature and thus to provide clearer evidence-based recommendations with regard
to sport injury and rehabilitation.
A consequence of having a greater breath of coverage is the challenge of not
neglecting anything in one volume.The Editors have chosen their chapter authors
well, as they have collectively delivered on this challenge. The book impressively
considers relevant psychological theories (behavioural, cognitive, developmental,
personality, humanist, social psychology and learning theories), major psychological
concepts (cognition, attention, emotion, motivation, personality, behaviour, anxiety,
interpersonal relationships) and takes into account relevant groups who influence
and are influenced by sport injuries (athletes, coaches, psychologists, parents, friends,
organisations, doctors, physiotherapist, lifestyle advisors, team mates and others).
The accessibility of The Psychology of Sport Injury and Rehabilitation for a range
of professionals is one of its greatest strengths. Case studies and testimonies allow
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xvi Foreword
the reader to appreciate and understand the sport experience from the athlete’s
perspective. Although it was not the objective of the Editors to bring conclusions
to the debates associated with how injuries are defined, the book makes a strong
case for psychology to be explicitly referred to in such definitions.Without doubt,
the book will help further promote interest in the area and stimulate work over the
next 20 years and beyond.
David Lavallee
University of Stirling
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PREFACE
I just expect to be able to play. . . back at the level that I was before I
think . . . just . . . just to go back to what I did before, I think you just want to be back
and able to do what you did before the injury.
(An injured association football player)
The sport injury experience from an athlete’s perspective is as diverse as the

number of athletes sustaining injuries and types of injuries encountered. Each
injury experience is unique, and is influenced by a range of personal and situational
biopsychosocial factors that interact not only during but also before and after the
injury occurrence. Nevertheless, the above quote in its simplicity may summarise
the key hopes and dreams of those injured – to be able to return back to pre-injury
levels of function.
As varied as the injury experiences themselves is the terminology surrounding
the sport injury literature, research and applied work. For example, sport injuries
still lack a unified definition but, given that there are a number of ways in which
sport injuries can be classified, such may not be surprising. It is not our aim to
bring conclusions to such debates but rather to adopt one view from which this
book has been written. As such, for the purposes of this book, sport (and physical
activity) injuries will be defined as ‘trauma to the body or its parts that result in at
least temporary, but sometimes permanent physical disability and inhibition of
motor function’ (Berger, Pargman and Weinberg, 2007: 186).
Based on the definition above, we see sport injuries as being physical in nature,
which, depending on severity, may require assistance from medical professionals to
ensure appropriate healing and recovery.To expand the applicability of the content
presented in this book across different cultures, in this book, we have adopted the
term sport medicine professionals as an overarching title for all those working with
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xviii Preface
injured athletes.This can include (but is not limited to) all those required to assist
the injured athlete to return to their pre-injury level physically and psychologi-
cally: the physiotherapist, athletic trainer, sport therapist, massage therapist,
orthopaedic surgeon, other medical doctors, sport (and exercise) psychologist,
counselling and clinical psychologist, psychiatrist, counsellor and other allied health
professionals.
Throughout the book, we address the notion that sport injuries, despite being
physical in nature, also have psychological facets. It is also believed that psycholog-
ical skills (that is, mental abilities of athletes) can assist athletes in the rehabilitation
process.These skills can be facilitated and enhanced through the use of psycholog-
ical techniques (that is, methods an athlete can use to rehearse or improve
psychological skills). For the purposes of this book, when referring to these
psychological techniques (for example, goal setting, imagery, relaxation techniques,
self-talk and social support) collectively, the term psychological interventions will be
used.The book is also underpinned by the notion that psychological interventions
are most successful if used as part of a wider rehabilitation programme incorporat-
ing a number of aspects deemed important for successful recovery.When discussing
the term rehabilitation in this book, we consider it to include the treatment provided
during all of the different phases of rehabilitation, from the injury onset through
the rehabilitation process and up to and including the return to training and
competition (including minimising the risk of re-injury). It is also believed that the
use of psychological interventions should only be facilitated by professionals who
are appropriately trained and skilled to do so.
To assist those interested in learning how to incorporate psychology into the
sport injury process, this book demonstrates ways in which this might be achieved.
We provide some suggestions as to how sport medicine professionals may amalga-
mate physical and psychological rehabilitation for it to become an accepted part of
a holistic sport injury rehabilitation process, rather than an addition to it. More
specifically, the book provides a contemporary overview of the subject area from
experts within the field from across the world.The objective of this book is to offer
scholars and practitioners alike a text that they will not only find invaluable in
terms of knowledge gained but unique and contemporary in terms of practice.
To this end, this book is divided into three parts. Part 1, ‘Introduction to the
psychology of sport injuries: theoretical frameworks’, introduces the key terminol-
ogy, theories and models used in the book, and highlights the importance of
addressing psychological issues during rehabilitation to ensure a full and holistic
recovery. More specifically, Chapter 1 provides the reader with a rationale for the
book by introducing the concept of psychology of sport injuries, and by providing
awareness of the importance of psychology in the sport injury process. Chapter 2
provides an overview of psychological and social factors that can contribute to the
onset of injury. It outlines Andersen and Williams’ (1988) pre-injury model and
provides a summary of a contemporary systematic review of the literature explain-
ing psychological factors affecting the incidence of sport injury. Moreover, the
chapter highlights the importance of understanding pre-injury factors in relation
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Preface xix
to sport injury rehabilitation and the ways in which these factors can help to
facilitate or, in some cases, hinder any subsequent rehabilitation. Chapter 3 then
provides a critical overview of the models of response to injury to date.The major
focus of the chapter is on the integrated model of response to sports injury and
rehabilitation (Wiese-Bjornstal, Smith, Shaffer and Morrey, 1998) with a discussion
of its application to real-life injury rehabilitation on a more practical level. This
model serves as a foundation for subsequent chapters as, within the model, the idea
of interactions between injured athletes’ cognitive appraisals, emotional responses
and behavioural responses can be used as a framework when designing rehabilita-
tion programmes and choosing appropriate psychological interventions to meet
the injured athletes’ needs. Chapter 4 concludes Part 1 by outlining adherence to
sport injury rehabilitation as a prime area of interest in the psychology of sport
injury. As adherence issues are seen as one of the main influences on athletes not
recovering successfully, this chapter highlights the importance of addressing adher-
ence during rehabilitation, and thus provides a rationale for Part 2 of the book,
‘Psychological interventions in sport injury rehabilitation’.
Part 2 has its focus on the five most popular psychological interventions (goal
setting, imagery, relaxation techniques, self-talk and social support). Presented in
five distinct chapters, each of the interventions is introduced by discussing the key
concepts and demonstrating their usefulness and applicability to sport injury reha-
bilitation. Each chapter discusses the theoretical underpinnings of the intervention
and their use for promoting holistic recovery.
Part 3, ‘Delivering psychological interventions in sport injury rehabilitation’
introduces the reader to some of the practicalities of integrating psychological and
physical rehabilitation. More specifically, Chapter 10 demonstrates the relationship
between different phases of physical rehabilitation and how to use rehabilitation
profiling as a foundation for designing, planning and implementing appropriate
psychological interventions alongside physical rehabilitation. Following on,
Chapter 11 highlights the importance of multidisciplinary teams and the integra-
tion of sport medicine professionals and significant others as part of psychological
rehabilitation from sport injuries. Chapter 12 then discusses the ways in which
basic counselling skills could also be beneficial in assisting sport injury rehabilita-
tion. Chapter 13 applies the existing knowledge of psychology of sport injuries in
the context of physical activity related injuries, taking into account the differences
in personal and situational factors between sport and physical activity participants.
Moreover, the possible impact of physical activity related injuries on an individual’s
future participation will be discussed (such as barriers to physical activity). Finally,
Chapter 14 provides conclusions on the psychological processes of sport injury
rehabilitation. It draws on the chapters presented in the three distinct parts of the
book and summarises the existing knowledge, as well as provides some broad over-
arching recommendations for applied work, and future research in the field.
Chapters 2–13 are also enhanced with individual case studies specifically focus-
ing on the issues presented in the corresponding chapter. These case studies are
accompanied by questions that are aimed to assist the reader to explore their
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xx Preface
understanding of the theory and application of the topic discussed. The link
between theory and practice will be further enhanced through the use of real-life
quotes from sport medicine professionals and injured athletes alike. Moreover, each
of the chapters will also highlight some of the key points to be drawn from the
chapter by framing them within the text. By doing so, this book aims to provide
the reader with a comprehensive view of the process of psychological rehabilita-
tion from sport injuries, by adopting a holistic perspective incorporating theory,
research, and applied knowledge.
References
Andersen, M. B. and Williams, J. M. (1988) A model of stress and athletic injury: prediction
and prevention. Journal of Sport and Exercise Psychology, 10, 294–306.
Berger, B. G., Pargman, D. and Weinberg, R. S. (2007) Foundations of exercise psychology, 2nd
edn. Morgantown,WV: Fitness Information Technology.
Wiese-Bjornstal, D. M., Smith, A. M., Shaffer, S. M. and Morrey, M. A. (1998) An integrated
model of response to sport injury: Psychological and sociological dynamics. Journal of
Applied Sport Psychology, 10, 46–69.
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ACKNOWLEDGEMENTS
It is with great appreciation that we thank several people for playing central roles
in the completion of this book. First, our sincere gratitude goes to the authors of
each chapter, who produced thoughtful and significant contributions in a timely
manner throughout the process.Without your wealth of expertise in this field, this
book would not have been possible, so many thanks for going the extra mile and
making the editorial process ‘injury’ free.
We would also like to say a very special thank you to Dr Julie Waumsley. Both
of us are greatly indebted to your initial spark for the idea of this book and for
maintaining momentum in the initial stages. Moreover, we thank you for your
valuable time in making important early contributions to the administrative and
structural aspects of the book in addition to co-authoring two chapters.
We are also indebted to Stephen Worrall for giving up his time to review each
chapter in detail and provide comprehensive feedback – and for making sure our
apostrophes are now in right places!
Finally, our gratitude is extended to Routledge for commissioning the book. In
particular, we would like to thank Joshua Wells and Simon Whitmore for being
invaluable in guiding us throughout the publication process.
Monna and Natalie
I would like to say KIITOS to all of my academic friends and colleagues who have
had an impact on my career. Natalie, thank you for six great years working
together, it has been fun. A special acknowledgement goes to my dear
friend/mentor/colleague Dr Brian Hemmings. Thank you for your continued
support and guidance, and for always believing in me. A huge thank you goes to
my family, who never fail to support me in my crazy endeavours like moving across
the world or editing a book. In particular, ISO KIITOS to my little angel Amie.
The power of your smile always keeps me going.
Monna
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xxii Acknowledgements
I would like to thank those in academia who I have had the pleasure of working
with. Particular thanks to Nichola Kentzer, who has been my sounding board for
the latter part of this book. Of course, a huge thank you goes to my co-editor,
Monna. We have shared an office for six years and have ended our office sharing
by completing this book. What a way to end! I wish you the very best overseas.
Thanks also to Dr Jo Hudson: you have played a significant role in shaping my
academic career and for that I will always be grateful. Finally, I must thank my
amazing family. Mum, you have always believed in me and I hope I continue to
make you proud, I love you so much. Chris, Kieron,Ashleigh, Perry, Kaydee-Jayne,
Maci-Ann and Keaton-Lee, you are my world and thanks for always being there
and believing in me.
Natalie
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PART 1
Introduction to the
psychology of sport injuries:
theoretical frameworks
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1
INTRODUCTION TO THE
PSYCHOLOGY OF SPORT INJURIES
In society today, sport can form an important part of the ways in which an indi-
vidual identifies themselves, how they interact with one another and reflect on
their position amongst those around them. According to the Council of Europe
(2001), the term sport refers to ‘all forms of physical activity which, through casual
or organised participation, aim at expressing or improving physical fitness and
mental well-being, forming social relationships or obtaining results in competition
at all levels’. At its best, sport can provide opportunities for physical, psychological
and economic growth, and be a vehicle for providing exciting, challenging, reward-
ing and memorable experiences for all those involved. Despite such positive
benefits, unfortunately some experiences gained through sport are in fact the
opposite (Brown, 2005). Involvement in sport frequently places the participants
under immense physical and psychological pressure and stress, which in turn ampli-
fies the likelihood of negative outcomes, such as injuries. Although injuries are an
experience that athletes are trying to avoid (Pargman, 1999), virtually all athletes
will experience an injury that can temporarily (or permanently) impede any subse-
quent sport participation (Taylor and Taylor, 1997). In fact, Brown (2005) argues
that ‘serious athletes come in two varieties: those who have been injured, and those
who have not been injured yet’.
Such a claim is supported in the literature. For example, in Australia, it has been
estimated that 20 per cent of all child/adolescent and 18 per cent of adult hospital
accident and emergency room consultations were sport injury related (Finch,Valuri
and Ozanne-Smith, 1998). In 2002, approximately 20.3 million Americans suffered
a sport injury, of which half required medical attention (Conn, Annest and
Gilchrist, 2003). In the UK, it has been estimated that nearly 30 million sport-
related injuries occur every year (Nicholl, Coleman and Williams, 1995),
accounting for nearly 33 per cent of all injuries nationwide (Uitenbroek, 1996).
More recently, in Finland, it was found that amongst adolescent male and female
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Introduction to the psychology of sport injuries 3
athletes involved in association football, ice hockey, basketball, cross-country skiing,

figure skating, gymnastics and athletics, 50.4 per cent of all that responded reported
having suffered sport-related injuries in the past 12 months (Konttinen, Mononen,
Pihlaja, Sipari, Arvinen-Barrow and Selänne, 2011).
With the aid of advanced medical knowledge and technology, most injured
athletes have the potential for full recovery to their pre-injury (or in some cases
higher) level of fitness and performance. However, numerous athletes fail to recover
back to their pre-injury level of play (Taylor and Taylor, 1997) and often this fail-
ure is attributable to psychological factors. It has been highlighted that
psychological factors can influence injury onset and can also determine the extent
to which an athlete is able to cope successfully with injury and its subsequent reha-
bilitation (see, for example, Arvinen-Barrow, Hemmings, Weigand, Becker and
Booth, 2007; Clement, Granquist and Arvinen-Barrow, 2013; Heaney, 2006;
Hemmings and Povey, 2002; Larson, Starkey and Zaichkowsky, 1996).
Furthermore, research has also found links between sport injuries and reduced
levels of self-esteem, loss of personal identity, anxiety (for example, pre-injury anxi-
ety; Walker, 2006), depression and, on occasions, feelings of isolation (Leddy,
Lambert and Ogles, 1994; Petitpas and Danish, 1995).
Drawing from existing sport injury literature, it is apparent that both physical and
psychological factors can have a significant impact on sport injury susceptibility,
injury occurrence, cognitive appraisals of injury, emotional and behavioural
responses to the injury, the overall injury recovery outcomes and the return to sport
(see, for example, Ievleva and Orlick, 1991; McDonald and Hardy, 1990; Wiese-
Bjornstal, Smith, Shaffer and Morrey, 1998). It has also been suggested that the use
of psychological interventions can be beneficial in the context of sport injuries as
they have the potential to: (a) reduce athletes injury susceptibility (Williams and
Andersen, 1998), (b) facilitate injury recovery (Ievleva and Orlick, 1991), (c) provide
a sense of control over the rehabilitation process subsequently enhancing motivation
and rehabilitation adherence (Flint, 1998), and (d) increase communication between
the athlete and the medical professional working with the athlete (Ray and Wiese-
Bjornstal, 1999). These can facilitate injured athletes’ greater understanding of the
injury, the injury process and possible recovery outcomes (Heaney, 2006; Hemmings
and Povey, 2002). A greater understanding of the injury can also affect treatment
compliance, which is also believed to have an effect on athletes’ coping skills and
injury recovery (see, for example, Arvinen-Barrow et al., 2007; Hemmings and
Povey, 2002). Moreover, athletes who engage in psychological interventions which
enable them to perceive themselves as active agents in their recovery are more likely
to have better physical recovery outcomes (Durso-Cupal, 1996).
The most popular and prominent psychological interventions used in sport
today are goal setting, imagery, relaxation training and positive self-talk (Brown,
2005; Vealey, 1988). Encouraging and employing the use of social support has also
been identified as important and beneficial for injured athletes (Brown, 2005; Heil,
1993). However, despite the widely accepted view that all of the above psycholog-
ical interventions are extremely useful in assisting athletes to achieve performance
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4 Monna Arvinen-Barrow and Natalie Walker
gains, they are often underused in sport injury prevention and rehabilitation by
both the injured athlete and the medical professionals alike (see, for example,
Arvinen-Barrow, Penny, Hemmings and Corr, 2010).
Such underuse could be attributable to number of reasons. Firstly, it has been
proposed that both athletes and sport medicine professionals working with injured
athletes may be unable to transfer existing skills from performance enhancement
settings to the injury rehabilitation context. Secondly, those working with injured
athletes may possess limited knowledge on how to use psychological interventions
during injury rehabilitation, as it appears that only a few professionals have been
extensively trained to use such skills during sport injury rehabilitation. For exam-
ple, in the UK, physiotherapy educators profess to deliver their psychology content
through an integrated approach, with a view that this approach would lead to a
more applied understanding of the topic. However, there is often a disparity
between knowledge of the subject and the ability to apply this knowledge to bene-
fit individuals (Heaney, Green, Rostron and Walker, 2012). Thirdly, it may be that
psychological interventions are underused simply because of lack of adequate
understanding of how psychological interventions can be integrated seamlessly
into physical rehabilitation. As such, the principle aim of this book is to demon-
strate ways in which psychology plays a role in the sport injury process and how
psychological interventions can be used in sport injury rehabilitation. After all, by
attending to the psychological needs of the athlete, the practitioners working with
injured athletes are treating the whole person, and not just the injury, and thus
offering a more holistic approach to recovery.
References
Arvinen-Barrow, M., Hemmings, B., Weigand, D. A., Becker, C. A. and Booth, L. (2007)
Views of chartered physiotherapists on the psychological content of their practice: A
national follow-up survey in the United Kingdom. Journal of Sport Rehabilitation, 16,
111–121.
Arvinen-Barrow, M., Penny, G., Hemmings, B. and Corr, S. (2010) UK Chartered
Physiotherapists’ personal experiences in using psychological interventions with injured
athletes: an interpretative phenomenological analysis. Psychology of Sport and Exercise, 11,
58–66.
Brown, C. (2005) Injuries: The psychology of recovery and rehab. In S. Murphy (ed.), The
sport psych handbook. Champaign, IL: Human Kinetics, pp. 215–35.
Clement, D., Granquist, M. and Arvinen-Barrow, M. (2013) Psychosocial aspects of athletic
injuries as perceived by athletic trainers. Journal of Athletic Training.
Conn, J. M.,Annest, J. L. and Gilchrist, J. (2003) Sports and recreation related injury episodes
in the US population, 1997–99. Injury Prevention, 9(2), 117–23.
Council of Europe. (2001) The European Sports Charter (revised). Brussels: Council of Europe.
Retrieved from http://www.sportdevelopment.info/index.php/subjects/59-
inter national-documents/87-council-of-europe-2001-the-european-sports-
charterrevised-brussels-council-of-europe-
Durso-Cupal, D. (1996) The efficacy of guided imagery for recovery from anterior cruciate
ligament (ACL) replacement. Journal of Applied Sport Psychology, 8(suppl), S56.
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Introduction to the psychology of sport injuries 5
Finch, C., Valuri, G. and Ozanne-Smith, J. (1998) Sport and active recreation injuries in
Australia: evidence from emergency department presentations. British Journal of Sports
Medicine, 32(3), 220–5.
Flint, F. A. (1998) Specialized psychological interventions In F. A. Flint (ed.), Psychology of
Sport Injury. Leeds: Human Kinetics, pp. 29–50.
Heaney, C. (2006) Physiotherapists’ perceptions of sport psychology intervention in profes-
sional soccer. International Journal of Sport and Exercise Psychology, 4(1), 67–80.
Heaney, C., Green, A. J. K., Rostron, C. L. and Walker, N. (2012) A qualitative and quantita-
tive investigation of the psychology content of UK physiotherapy education programs.
Journal of Physical Therapy Education.
Heil, J. (1993) Psychology of Sport Injury. Champaign, IL: Human Kinetics.
Hemmings, B. and Povey, L. (2002) Views of chartered physiotherapists on the psychologi-
cal content of their practice: A preliminary study in the United Kingdom. British Journal
of Sports Medicine, 36, 61–4.
Ievleva, L. and Orlick,T. (1991) Mental links to enhanced healing:An exploratory study. The
Sport Psychologist, 5, 25–40.
Konttinen, N., Mononen, K., Pihlaja,T., Sipari,T.,Arvinen-Barrow, M. and Selänne, H. (2011)
Urheiluvammojen esiintyminen ja niiden hoito nuorisourheilussa – Kohderyhmänä 1995
syntyneet urheilijat. [Sport injury occurence and treatment in youth sports – athletes born
in 1995 as a target population]. KIHUn julkaisusarja nro 25 (PDF-julkaisu), 1–16. Retrieved
from http://www.kihu.jyu.fi/tuotokset/haku/index.php?hae=Tee+haku#TOC2011.
Larson, G. A., Starkey, C. and Zaichkowsky, L. D. (1996) Psychological aspects of athletic
injuries as perceived by athletic trainers. The Sport Psychologist, 10, 37–47.
Leddy, M. H., Lambert, M. J. and Ogles, B. M. (1994) Psychological consequences of athletic
injury among high level competitors. Research Quarterly for Exercise and Sport, 65, 347–54.
McDonald, S. A. and Hardy, C. J. (1990) Affective response patterns of the injured athlete:
An exploratory analysis. The Sport Psychologist, 4, 261–74.
Nicholl, J. P., Coleman, P. and Williams, B. T. (1995) The epidemiology of sports and exer-
cise related injury in the United Kingdom. British Journal of Sports Medicine, 29, 232–38.
Pargman, D. (ed.) (1999) Psychological Bases of Sport Injuries, 2nd edn. Morgantown, WV:
Fitness Information Technology Inc.
Petitpas, A. and Danish, S. J. (1995) Caring for injured athletes. In S. Murphy (ed.), Sport
Psychology Interventions. Champaign, IL: Human Kinetics, pp. 255–81.
Ray, R. and Wiese-Bjornstal, D. M. (eds). (1999) Counseling in Sports Medicine. Champaign,
IL: Human Kinetics.
Taylor, J. and Taylor, S. (1997) Psychological Approaches to Sports Injury Rehabilitation.
Gaithersburg, MD: Aspen.
Uitenbroek, D. G. (1996) Sports, exercise, and other causes of injuries: Results of a popula-
tion survey. Research Quarterly for Exercise and Sport, 67, 380–5.
Vealey, R. S. (1988) Future directions in psychological skills training. The Sport Psychologist,
2(4), 318–336.
Walker, N. (2006) The Meaning of Sports Injury and Re-injury Anxiety Assessment and
Intervention. (Unpublished PhD dissertation), University of Wales, Aberystwyth.
Williams, J. M. and Andersen, M. B. (1998) Psychosocial antecedents of sport injury: Review
and critique of the stress and injury model. Journal of Sport and Exercise Psychology, 10,
5–25.
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2
PSYCHOLOGICAL ANTECEDENTS TO
SPORT INJURY
Renee N. Appaneal and Stephanie Habif
Introduction
Sport-related injuries are a significant public health concern for physically active
individuals (Centers for Disease Control and Prevention, 2002; Conn, Annest and
Gilchrist, 2003; Marshall and Guskiewicz, 2003). As a result, it is not surprising that
sport injury surveillance and prevention efforts have included national and organ-
isational monitoring systems, safer equipment and playing environments and
policies. Yet, among those widespread changes, psychological factors are rarely
considered within comprehensive sport injury prevention recommendations
(Engebretsen and Bahr, 2009). Derived from work conducted in the stress-illness
domain, initial evidence for the stress–injury relationship came from two key stud-
ies in the 1970s (Bramwell, Masuda, Wagner and Holmes, 1975; Holmes, 1970).
Both studies conducted psychological screenings with football players and found
that the greater the stress, the greater the likelihood of injury. Studies were later
replicated with American collegiate football players and their results yielded signif-
icant associations between life stress and sport injury (Coddington and Troxell,
1980; Cryan and Alles, 1983; Passer and Seese, 1983). However, findings from stud-
ies with other sports such as volleyball failed to demonstrate a relationship between
life stress and injury (Williams,Tonymon and Wadsworth, 1986). In reviewing this
body of research, Andersen and Williams (1988) noted the inconsistency and
atheoretical nature of this work and offered a potentially unifying framework for
psychological prediction and prevention of sport injury.
To ensure continued participation in sport and physical activity while minimis-
ing the risk of sport-related injury, it is important to understand psychological
factors which may predispose an individual to injury. Therefore, the purpose of this
chapter is to outline the psychological factors that are seen to be influencing the
onset of sport injury. The chapter is based on the authors’ own systematic review
of 70 published and unpublished studies which examined the relationship between
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Psychological antecedents to sport injury 7
psychosocial factors and sport injury outcomes among competitive athletes

between 1965 and 2009 (Appaneal, Habif,Washington and Granquist, 2009). More
specifically, this chapter (a) introduces the stress and injury model (Andersen and
Williams, 1988;Williams and Andersen, 1998); (b) reviews the different antecedents
associated with athlete’s stress response; (c) highlights the role of stress–response
mechanisms in increasing sport injury occurrence; (d) summarises the evidence
supporting the use of psychological interventions to prevent sport injuries; and (e)
throughout the different sections of the chapter, suggests practical strategies for
those wishing to translate this knowledge into professional practice (for example,
for sport/performance psychology and sport medicine professionals).
The stress and injury model

The model of stress and injury (Andersen and Williams, 1988) was developed to
organise research and direct future interest by explaining the psychology underly-
ing the occurrence of sport injuries. According to the model, the likelihood of
injury will be influenced by an athlete’s perception of stress in a given situation.
The model presumes that an athlete's personality, stress history, and coping
resources all influence the athlete's cognitive appraisal of stress, which may either
intensify or mitigate their response to stress within the athletic environment and
subsequently enhance their risk of sustaining an injury. The cognitive appraisal
process plays a key role in stress reactivity and involves a balance (or imbalance)
between two individually based perceptions, the primary and secondary appraisals
(Lazarus and Folkman, 1984). Both of these perceptions are largely subconscious
and dynamic, where the primary appraisal reflects the perception of a stressor (or
event) as threatening and/or harmful and having important consequences. The
secondary appraisal involves the degree to which s/he perceives having adequate
coping resources to manage the demands of that stressor.The basic premise of this
model, then, is that athletes who have a personality that amplifies stress, history of
many stressors and few available or effective coping resources to buffer stress, are
more likely to have cognitive appraisals of athletic situations that heighten their
stress responses and increase their risk of sustaining an injury. For example, athletes
who appraise stressors as threatening/harmful and perceive a lack of adequate
coping resources will likely experience heightened stress reactivity, which in turn
influences physiological/attentional functioning. Stress-related impairments may
include, but are not limited to, increased muscle tension, peripheral narrowing,
and/or increased distractibility.The first may result in poor coordination of move-
ment and the latter two may result in poor cue recognition, delayed decision
making, increased reaction time or other sensorimotor disruptions. For athletes,
according to this model, consequences of heightened stress reactivity experienced
within a sporting environment, increases their risk of injury.
In addition to identifying factors guiding sport injury prediction, the stress and
injury model (Andersen and Williams, 1988) also included potential psychological
interventions to assist athletes in adapting to stress, which might serve to prevent
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8 Renee N. Appaneal and Stephanie Habif
sport injury from occurring.The intervention strategies reflect a cognitive behav-

ioural approach to stress management (Meichenbaum, 1977), where skills training
and support is provided to develop effective cognitive appraisals (for example,
thought stopping, cognitive restructuring) and enhance personal control over vari-
ous physiological/attentional effects of stress (such as relaxation, mental rehearsal,
attention control training).
After Andersen and Williams (1988) proposed their framework, not surprisingly,
research proliferated examining various aspects of the stress–injury model. A
decade later, Williams and Andersen (1998) provided an updated review of the
literature and proposed several revisions to their original model. These changes
included the addition of several bidirectional arrows (that is, between personality
and stress history, between stress history and coping resources, and between coping
resources and personality).The changes also included limiting the model to explain
the process of prediction and prevention of acute injuries and not chronic or over-
use injuries, which were seen as likely to involve different stress–response processes
(Williams and Andersen, 1998). Figure 2.1 displays an amalgamation of the origi-
nal (Andersen and Williams, 1988) and the revised (Williams and Andersen, 1998)
stress and injury models.
Personality Stress history Coping resources

Competitive trait anxiety, Prior injury, Psychological/mental skills,
locus of control, major life events, coping behaviour,
hardiness, etc. and daily hassles general self-care,
and social support
Stress response
Potentially
stressful athletic Cognitive Physiological and/or Injury
situation appraisal attentional changes
Psychological intervention:
cognitive behavioural stress management
Cognitive restructuring Relaxation training
Thought stopping Focus/refocus training
Confidence training Coping skills training
Fostering team cohesion Enhanced social support
FIGURE 2.1 An amalgamated version of the stress and injury model

Source: adapted from Andersen and Williams’ (1988) original model and Williams and Andersen’s
(1998) revised model
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Drawing from the existing literature, it can be argued that, although the stress
and injury model was introduced over 20 years ago, it still remains the single most
dominant framework guiding today’s research in psychology of sport injury predic-
tion and prevention.The following sections discuss each of the components of the
model in more detail by (a) reviewing the research conducted to date and (b)
providing applied suggestions on the implications of such findings to those work-
ing with athletes.
In stressful athletic situations, individuals with certain personality characteris-

tics (such as trait anxiety), high levels of stress and few coping resources (for
example, lack of social support) appraise the situation as potentially threaten-
ing and perceive an inability to manage demands. As a result, those athletes
will likely exhibit heightened stress reactivity, reflected by poor physiological
(for example, increased muscle tension) and/or attentional functioning (for
example, peripheral narrowing, increased distractibility), which, in turn, places
them at greater risk of incurring athletic injury.
The stress response

According to the stress and injury model, stress responses may involve disruptions
in athletes’ cognitive/attentional and physiological functioning. In our review of
the literature, we found only seven studies that were inclusive of both the stress
responses and antecedents. Of those that did, stress responses were typically meas-
ured through athletes’ perceptions of stress-related vulnerability, reaction time and
attentional/visual indices (Andersen and Williams, 1999; Bergandi and Witting,
1988; Dahlhauser and Thomas, 1979; Dvorak et al., 2000; Kleinert, 2007; Rogers
and Landers, 2005; Thompson and Morris, 1994). The results from these studies
indicate that some of the factors contributing to poor stress response which may
have facilitated a higher risk of sport injury include: low perceptions of health (may
reflect either low resistance to stress or low confidence; Kleinert, 2007); slower
reaction times (Dvorak et al., 2000) and peripheral narrowing (Andersen and
Williams, 1999; Rogers and Landers, 2005). More specifically, peripheral narrow-
ing was found to mediate the relationship between injury outcomes and high stress
in college athletes (Andersen and Williams, 1999) and negative life stress in high-
school athletes (Rogers and Landers, 2005). Further support (Bergandi and
Witting, 1988; Dahlhauser and Thomas, 1979; Thompson and Morris, 1994) for
the association between injury and visual/attentional aspects has also been docu-
mented among both high-school and college athletes and therefore supports the
multidimensional nature of athletes’ stress responses as outlined in the revised stress
and injury model.
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Impact of stress response research on injury occurrence: implications for

sport medicine professionals
When working with athletes, sport medicine professionals should consider educat-
ing athletes about the importance of stress management and a healthy lifestyle
(such as training, recovery, nutrition and sleep) for minimising the risk of sport
injury. Athletes and coaches should be informed that, by balancing stress and recov-
ery and consistently eating and sleeping well, they can minimise sensorimotor
impairments and maintain energy and alertness, which in turn may promote
health, support training adaptation, and enhance sport performance.
Antecedents of sport injury

As identified above, stress reactivity is the central link between stress and injury
incidence. In the attempt to prevent injuries occurring, the principal aim of any
psychological injury prevention efforts should be to determine what factors influ-
ence athletes’ stress responses (Williams and Andersen, 1998, 2007).While there are
three main factors identified in the model (personality, stress history and coping
resources), each encompasses a variety of specific variables. Further, these variables
are seen as antecedents influencing sport injury onset, in that that they precede
stressful encounters in sport.They also reflect both risk factors and resources, in that
they may buffer and/or or heighten athletes’ stress reactivity and subsequent sport
injury risk. To date, a breadth of research has examined psychological antecedents
to sport injury. In our review, 65 of the 70 studies explored psychological factors
associated with sport injury risk and 86 per cent of those reported significant find-
ings between one or more risk factors and sport injury outcomes. The following
sections provide a brief review of the literature, examining each of the antecedents
of the stress and injury model presented above.
The body of literature has generally supported all three injury antecedent areas
as significant predictors of injury, albeit with incredible variance in methodol-
ogy. Psychosocial factors receiving the most attention that have been
consistently tied to injury risk include competitive trait or sport anxiety and life
event stress, both of which resulted in vulnerability to injury. Additionally, the
presence of coping resources appears to protect against injury risk, whereas
the lack of these resources heightens injury risk.
Personality
In their original model, Andersen and Williams (1988) hypothesised that certain
positive personality traits (such as hardiness) enabled athletes to view athletic
situations as challenging rather than threatening, resulting in a lower stress response
and subsequently lower injury risk. Moreover, it was hypothesised that negative
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personality traits (for example, competitive trait anxiety) will increase stress reac-
tivity. Based on the knowledge available, Andersen and Williams (1988) proposed
five specific personality variables that influence stress reactivity: 1) hardiness; 2)
locus of control (who or what is responsible for what happens); 3) sense of coher-
ence (a belief that the world is predictable and meaningful); 4) competitive trait
anxiety; and 5) achievement motivation (the need to meet goals and experience a
sense of achievement).
Across 45 studies in our review examining personality, we documented more
than 20 different personality characteristics. Approximately 69 per cent of those
studies reported at least some significant relationship between personality and
injury outcome. Personality characteristics that have been studied in the stress and
injury literature included anger, depression, anxiety (that is, general,
competitive/sport anxiety, sport injury anxiety), mood, athletic identity, self-
esteem, sport confidence, self-efficacy (both general and physical), physical
self-perception, locus of control, mental toughness, optimism, hardiness, motivation
(that is, athlete goal orientation), narcissism, neurosis, perceived risk taking, sensa-
tion seeking, social desirability, type A (anger, hostility, and so on), exercise
dependence, competitiveness and psychological wellbeing. While the breadth of
this work is impressive, any synthesis of the work is difficult to draw, as replication
studies are rare. Nevertheless, three personality characteristics have received more
attention than others in the literature: anxiety, locus of control and
mental/emotional states.
Anxiety
Drawing from the literature, anxiety (competitive anxiety in particular) is by far the
most frequently examined personality variable seen as affecting injury onset
(Blackwell and McCullagh, 1990; Ford, Eklund and Gordon, 2000; Hanson,
McCullagh and Tonymon, 1992; Kolt and Kirkby, 1994; Lavallee and Flint, 1996;
Petrie, 1993; Sibold, 2004). Competitive anxiety has been defined as an athlete’s
tendency to perceive competitive situations as threatening and to respond to these
situations with heightened anxiety or feelings of fear and tension (Martens,Vealey
and Burton, 1990). Athletes exhibiting competitive anxiety might report racing
thoughts, an inability to focus, trouble falling asleep the night before competition
and inability to eat anything leading up to a competition, among other symptoms.
Much of the research appears to suggest that athletes who display increased levels
of competitive anxiety are more likely to incur a sport injury.
Locus of control
Locus of control refers to an athlete’s perception of who or what is responsible for
what happens to them (Kolt and Kirkby, 1996). In our review, nine studies exam-
ined locus of control (Dahlhauser and Thomas, 1979; Ekenman, Hassmen, Koivula,
Roll and Felliinder-Tsai, 2001; Hanson et al., 1992; Kerr and Minden, 1988; Kolt
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and Kirkby, 1994; Pargman and Lunt, 1989; Passer and Seese, 1983; Plante and
Booth, 1997; Tyler, 1986). However, only two studies found relationships indicat-
ing that a higher internal locus of control was associated with a greater number of
injuries (Kolt and Kirkby, 1994; Plante and Booth, 1997).
Mental and emotional states

A number of mental and emotional states have also been significantly associated
with injury onset (Junge, 2000).Thus far, the most commonly examined mental and
emotional states include mood (Amato, 1995; Falkstein, 1999; Galambos, Terry,
Moyle, Locke and Lane, 2005; Lavallee and Flint, 1996; Meyers, LeUnes, Elledge and
Sterling, 1992; Rozen and de L Horne, 2007; van Mechelen et al., 1996), anger
(Dvorak et al., 2000; Plante and Booth, 1997;Thompson and Morris, 1994) and type
A (Ekenman et al., 2001; Fields, Delaney and Hinkle, 1990; Schafer and McKenna,
1985). Based on the findings, athletes who report negative mood states (for exam-
ple, anger) appear to be more likely to become injured (Dvorak et al., 2000;
Ekenman et al., 2001; Fields et al., 1990; Schafer and McKenna, 1985;Thompson and
Morris, 1994) or sustain more severe injuries (Lavallee and Flint, 1996). Also,
athletes with higher negative mood or overall mood disturbances (such as tension,
anxiety, depression) appear more likely to become injured (Amato, 1995; Galambos
et al., 2005; Lavallee and Flint, 1996; van Mechelen et al., 1996).Yet, desirable mood
states have also been positively associated with injury, such as vigour (energy; Rozen
and de L Horne, 2007) and low anger (Plante and Booth, 1997).
One time, I actually looked up in some book the ‘psychology’ behind an injury and
it stated something like, ‘Some injuries are the result of having a fear of failure’. It
only validated what I knew all along; the stress, anticipation and the exaggerated
level of fear I felt for this fantastic opportunity was silly. Over the course of the
summer, pain in my right shin was unbearable; no amount of Biofreeze and ice
was helping. Soon, pulling my foot up to properly strike a soccer ball was next to
impossible. I was in trouble, but I was too afraid to stop training.
(Lyndsie, a female soccer player, speaks about the impact of personality
on her injury)
Impact of personality research on injury occurrence: implications for

Research identifying an injury-prone personality has not been fruitful thus far but
certain personality characteristics do seem to warrant attention. Based on available
evidence to date, it seems appropriate for professionals to give special consideration
to those athletes exhibiting competitive anxiety, negative mood states and perhaps
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also patterns of anger/hostility. This literature underscores the importance of

getting to know your athletes. It would be important for sport medicine profes-
sionals to be mindful observers of athletes entrusted in their care, taking note of
individual dispositions (general patterns of behaviour), so as to be in a better posi-
tion to determine how an athlete’s ‘personality’ may heighten or reduce injury risk
as stress ebs and flows (or evolves) over the season.
Stress history
Of the three antecedents in the stress and injury model, stress history continues to
be the most commonly examined. In our review, the majority of the studies (49 of
a possible 65) measured stress history (comprising major life events, daily hassles
and prior injury history;Williams and Andersen, 1998) and, of those, nearly 80 per
cent reported significant relationships between stress history and injury.
Major life events

Within stress history, the majority of research has examined significant life- and
sport-related stressful events that may predispose an athlete to injury.The evidence
supporting a relationship between life event stress and injury is by far the clearest
and most consistent. The more life event stress an athlete experiences, the more
likely s/he will suffer injury.Williams and Andersen’s (1998) paper reported 27 of
30 studies examining life stress and sport injury found some significant relation-
ship. In their updated review (Williams and Andersen, 2007), they reported that 34
of 40 studies had found some association between life event stress and injury. In our
own review, 36 of 46 studies reported significant relationships between life event
stress and sport injury.
Daily hassles
Daily hassles or minor life events are also considered part of one’s stress history.
These occur more frequently than major events and thus can also create demands
for resources and influence stress reactivity. By definition, daily hassles occur often,
yet researchers have not always measured this variable accordingly. It simply may
not always be feasible for medical personnel or researchers to take frequent meas-
urements of stress events from athletes, especially while in training. When daily
hassles have been measured frequently (weekly or monthly), findings consistently
demonstrate significant associations with injury (Byrd, 1993; Fawkner, McMurray
and Summers, 1999; Luo, 1994).
Prior injury history

An athlete’s injury history (and current injury status) may also contribute to the
stress–injury relationship. In one of the few studies to examine multiple stress
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history factors, van Mechelen et al. (1996) found that athletes with a prior injury
history were over nine times more likely to become injured than athletes without
an injury history. Furthermore, prior injury history was also found to be the
strongest predictor of more than 20 different psychological and physical risk factors
they examined.
In the summer of 2002, I left my NCAA Division II programme to pursue the chal-
lenge of a Division I soccer programme. This was extremely anxiety-provoking, but
the training schedule was much more intense than I was used to and was over-
whelming. I trained very hard all summer, terrified of walking into preseason
unprepared and under-trained and basically, failing. This experience was not a
challenge; it was a death wish. Why would I leave the cushion and comfort of the
Colorado Mountains for the South (which I knew nothing about) and step up a
Division? I knew I was becoming complacent in my Division II play, coming in as a
freshman and earning a starting spot right away. I was also cranky for selling
myself short in the first place and not going Division I to begin with.
(Lyndsie, speaks about the impact of prior life event stress on her injury)
Impact of stress history research on injury occurrence: implications for

Existing literature seems to indicate a strong relationship between stress history and
sport injury risk. Across three different reviews (Appaneal et al., 2009;Williams and
Andersen, 1998, 2007), approximately 80–90 per cent of studies have demonstrated
significant associations between stress and sport injury, thus supporting the central
role of stress reactivity as underpinning the stress and injury relationship.Therefore,
to minimise the possible risks of injury, athletes, coaches and sport medicine profes-
sionals should be particularly sensitive to increased stress levels, including both
major and minor events, and regardless of whether events are perceived to be posi-
tive or negative. Specific ways to monitor stress may include the use of a stress
journal or log, or simply ensuring frequent interactions and/or continuous open
communication between athletes and their preferred support network (coaches,
team physicians, sport psychologists, and so on). Should there be a need to imple-
ment systematic programmes for monitoring stress, appropriately trained staff could
integrate this into commonly used protocols for monitoring physical training loads
and balancing athletes’ intensity of effort and rest to maximise performance and
avoid overtraining (Kellmann, 2010).
Coping resources
In comparison to personality and stress history antecedents, fewer studies (n = 31)
have examined athletes’ coping resources of which less than 60 per cent reported
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some significant relationship between coping resources and athletic injury.

Inconsistent methodology and lack of replication of research on coping resources
make it difficult to extract meaningful findings and to translate them into practical
guidelines. For the purposes of this chapter, and to enable us to make sense of the
information available, we consider the varied definitions and multifaceted nature of
coping resources. Specifically, coping resources in this chapter reflect internal
factors such as general coping behaviours (for example, self-care, sleep, nutrition),
psychological coping or mental skills (for example, management of thoughts,
energy/emotion, attention/focus), as well as external factors (such as social
support). Simply stated, coping resources includes an athletes’ personal and envi-
ronmental strengths and vulnerabilities in managing the demands of stress.
Among ten studies that examined stress history and coping resources, seven
reported significant findings and five of those reported moderating effects of coping
resources (Hardy, Richman and Rosenfeld, 1991; Luo, 1994; Petrie, 1992, 1993;
Smith, Smoll and Ptacek, 1990). Among these five studies, stress history accounted
for up to 32 per cent of the variance in injury outcome variables when samples were
split according to high or low coping resources. Generally, findings suggest that,
among athletes with high life stress, those with low social support were most vulner-
able to injury, whereas high social support appeared to protect athletes from injury
(Hardy et al., 1991; Luo, 1994; Petrie, 1992, 1993). Further, Smith et al. (1990) found
that athletes who were most vulnerable to stress-mediated injury were those who
were low in both coping skills and social support, reflecting a conjunctive moderat-
ing effect. Interestingly, a few of these studies also demonstrated that, among athletes
with low stress, those with high social support were likely to be injured, suggesting
that social support may enable athletes to take risks and/or achieve elevated arousal,
which in turn may increase injury vulnerability. Overall, from what limited research
is available, evidence suggests that coping resources may serve to protect some athletes
from injury while, for others, they may result in increased injury vulnerability.
Before I got injured, I had zero social support. Looking back now, it was the begin-
ning of the end for my parents, they began a bitter three-year divorce battle that
summer. It was difficult to socialise with the team, being older than the incoming
freshmen and yet still wanting to fit in. Plus, the entire culture was a shock to me,
a Midwesterner. I had never experienced anything the South had to offer; the
people, the churches, the dry counties.
(Lyndsie speaks about a lack of coping resources prior to her injury)
Impact of coping resource research on injury occurrence: implications for

The limited and mixed findings for coping resources merely reinforce the need for
sport medicine professionals to get to know individual athletes to better understand
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his or her own unique coping resources within their own sporting environment.
Drawing from social support literature, however, it is clear that having a supportive
network can enhance an individual’s physical and psychological wellbeing. As such,
sport medicine professionals should have an awareness of any athletes who may not
have a supportive network around them or who appear to be coping with the
demands of personal and athletic life in relative isolation.
Psychological interventions
Of the components of the stress and injury model, the most exciting and promis-
ing avenue of research is the usefulness of psychological interventions to prevent
athletic injury (Johnson, 2007;Williams and Andersen, 2007), yet it continues to be
the least investigated area to date. Only five of the 70 studies we reviewed exam-
ined the impact of psychological interventions on injury risk (Johnson, Ekengren
and Andersen, 2005; Kerr and Goss, 1996; Kolt, Hume, Smith and Williams, 2004;
Maddison and Prapavessis, 2005; Perna,Antoni, Baum, Gordon and Schneiderman,
2003).Three of the five studies demonstrated statistical significance (Johnson et al.,
2005; Maddison and Prapavessis, 2005; Perna et al., 2003) and the two studies
which did not (Kerr and Goss, 1996; Kolt et al., 2004) likely did not have sufficient
power (c.f. Andersen and Stoove, 1998;Williams and Andersen, 2007). Importantly,
however, all five intervention studies demonstrated a reduction in injuries, which
is noticeably and clinically meaningful.
Each of the five intervention studies were grounded in cognitive behavioural
stress management (c.f. Meichenbaum, 1977) principles and involved a series of
educational and supportive meeting with athletes. Information was targeted at
athletes’ cognitive appraisals and stress–response symptoms and included providing
skills training for enhanced self-awareness, reducing negative effects of stress and
promoting self-regulation or self-control through using psychological coping skills.
While psychologically based injury prevention programmes may be limited in
number, the evidence is clear. Intervention effects provide strong support for
psychological services for athletes to mitigate negative health-related consequences
of sport participation (such as reduced injury/illness, time loss due to injury).
Impact of psychological intervention research on injury occurrence:

implications for sport medicine professionals
Drawing from the limited research presented above, as well as research on use of
psychological interventions in sport performance context, there are number of
things that should be considered when designing and delivering effective inter-
vention programmes. These include decisions regarding who is best suited to
deliver the programme, when and for how long the programme should be offered
and which is the best approach to meet the athlete’s needs.
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Who is responsible for delivery?

While the provision and evaluation of psycho-educational programmes for
athletes’ health is certainly warranted, those services should be provided by appro-
priately trained professionals. Specifically, to best ensure that athletes’ psychological
information is not misused and that their interests remain protected and respected,
such professionals should hold credentials from governing sport psychology organ-
isations, state and/or national regulatory boards for sport psychologists. Thus,
professionals who have appropriate credentials are most likely going to work ethi-
cally and effectively but, most importantly, know how to do so within a
competitive sport environment.
When should the programme be offered and for how long?

Researchers have generally agreed that psychological interventions may be most
effective if provided prior to the start of athletes’ competitive sport seasons (Kerr
and Minden, 1988; Maddison and Prapavessis, 2005). Evidence also indicates that
health benefits can be achieved with limited contact over a relatively brief
period of time. Perna et al. (2003) involved seven sessions over three and a half
weeks, Johnson et al. (2005) conducted six sessions and two follow-up phone
calls, and Maddison and Prapavessis (2005) involved six sessions over a four-
week period.
What is the best approach?

There are numerous intervention approaches that may be beneficial to assist athletes
in dealing with stressful situations. However, as with any psychological interven-
tions, these should be designed and implemented with an individual athlete in mind
to ensure a personalised approach to service delivery. For example, programme
content delivered to athletes might reflect a cognitive behavioural approach.
Intervention such as stress inoculation training (Meichenbaum and Novaco, 1985),
involves three distinct phases: conceptualisation, skill acquisition and application.
Several other interventions may be suitable to assist athletes in minimising the risk
of sport injury, including (but not limited to): cognitive and somatic-based relax-
ation strategies (for example, diaphragmatic breathing, progressive muscle relaxation,
autogenic training); cognitive interventions (for example, self-talk, visual motor
behavioural rehearsal, cognitive restructuring); and other common mental skills for
performance excellence (goal setting, attribution and self-confidence). For more
details on psychological interventions, see Chapters 5–9.
Conclusion
This chapter has (a) introduced the stress and injury model (Andersen and
Williams, 1988; Williams and Andersen, 1998); (b) reviewed the different
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antecedents associated with athlete’s stress response; (c) highlighted the role of
stress-response mechanisms in increasing sport injury occurrence; (d) summarised
the evidence supporting the use of psychological interventions to prevent sport
injuries; and (e) throughout the different sections of the chapter, suggested practi-
cal strategies for those wishing to translate this knowledge into professional practice
(such as sport/performance psychologists and sport medicine professionals).
Since early work in the 1970s, considerable interest in examining the relation-
ship between psychosocial factors and sport injury has taken place. However, this
has not typically occurred in a systematic fashion (Johnson, 2007; Junge, 2000;
Petrie and Falkstein, 1998;Williams and Andersen, 2007). As a result, the collective
impact of this work remains rather elusive for those not well versed in the psychol-
ogy of sport injury. Methodological inconsistencies and limited replication may be
responsible for disparate findings and ultimately hinder any meaningful application
of this work into sport injury prediction and prevention efforts. Nonetheless, it is
believed that the clinical and practical implications of this work are rarely doubted
and thus are of valuable benefit to athletes’ health. Specifically, there are no known
adverse health consequences or potential drawbacks to offering psychological
interventions to reduce athletes’ risk of sport injury. As noted by Williams and
Andersen (2007), there have only been positive effects of psychosocial intervention
programmes and perhaps such efforts may result in added benefits to sport
performance and enjoyment.The field of psychological prediction and prevention
of sport injury has an opportunity to guide effective programming for sport medi-
cine professionals. Efforts to promote awareness of psychosocial stress in sport and
develop ways to minimise or perhaps even avoid sport injury are important, cost
effective, associated with no additive risks and may even enhance the athletes’ over-
all sport experience.
CASE STUDY
MaryEllen has coached a women’s soccer team as their head coach for over ten
years. The team has been consistently successful for the last five years. The
women’s soccer team has a long tradition of being nationally ranked and the
university has a reputation for producing exceptional world leaders. Over the
past three years, MaryEllen and the sport medicine staff have observed a rise
in illness and injury complaints. These complaints emerge around the last, and
usually most important, four weeks of their competitive season. Students are
also taking university exams at this time and it has always been a struggle for
members of the team to get exams completed when they are travelling on
long road trips during the middle of the week. Sarah, one of the team’s co-
captains, has shared with MaryEllen that many of her team mates feel
constantly tired and are having difficulty staying focused on the field. Sarah,
herself, has noticed that it has become more challenging to study for
prolonged periods of time these last few days. After meeting with a few of the
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other athletes, MaryEllen decides to call a meeting with the sport medicine
staff to come up with a plan for how they might be able to assist the team in
staying healthy and strong through the entire season, both currently and
perhaps in the future.
–––––––– ? ––––––––
1. Briefly describe how psychological antecedents might increase athletes’
risk of injury.
2. Identify potential psychosocial factors present among the soccer team and
within the sport environment that may be contributing to an increased
injury and illness complaints.
3. In addition to psychosocial risks, are there any potential psychosocial
strengths among this team which may provide them with resilience to
adverse effects of stress? If so, identify and describe what these strengths
might be.
4. Suggest two possible psychosocial strategies for reducing injury risk among
this team.
5. Identify potential advantages and drawbacks to implementing system-
wide (or team) psychosocial interventions for health maintenance and
injury prevention.
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3
PSYCHOLOGICAL RESPONSES TO
INJURY
A review and critique of existing models
Introduction
Anyone who has ever experienced a sport injury, whether it be an athlete who has
sustained an injury, a coach of an injured athlete or sport medicine professional
treating an injured athlete, will be aware that the occurrence of an injury can have
both a physical and psychological effect on the athlete. In addition to the physical
effects, sport injury may, for example, lead to feelings of frustration, anxiety, depres-
sion, anger or isolation ( Johnston and Carroll, 1998). Consideration of the
psychological responses to injury is important as they can potentially impact on the
athlete’s rehabilitation behaviour, the overall rehabilitation outcomes and the subse-
quent return to training and competition (De Heredia, Munoz and Artaza, 2004).
Therefore, understanding the process in which athletes psychologically respond to
injuries is of importance. According to Walker,Thatcher and Lavallee (2007), sport
medicine professionals should be aware of psychological factors impacting on the
injury experience if complete holistic recovery is to occur. Such an understanding
is vital in an applied context and can be gained through considering the under-
pinning psychological theory (Cranney et al., 2009;Thompson, 2000). However, it
appears that sport medicine professionals rarely receive adequate training in
psychological aspects of sport injuries (for example, Arvinen-Barrow, Penny,
Hemmings and Corr, 2010) and these aspects are seldom taught at degree level. For
example, Heaney, Green, Roston and Walker (2012) examined the current psychol-
ogy provision within physiotherapy programmes in UK universities with the
intention of exploring the nature and extent of psychology covered in physiother-
apy programmes, the delivery and perceived importance of any psychology content
and the factors influencing psychology provision. The authors found that 41 per
cent of participants indicated that their psychology provision did not contain any
theoretical underpinning.
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24 Natalie Walker and Caroline Heaney
Given the importance of understanding the underlying mechanism and theory

of psychological reactions to sport injuries, this chapter outlines existing theoreti-
cal models that have been developed to describe and explain psychological
responses to sport injury. These models provide a framework to help those inter-
acting with injured athletes (for example, sport medicine professionals) to
understand psychological responses to injury and their potential impact.They may
also help sport medicine professionals in assisting the injured athlete appropriately
to allow for holistic recovery. Specifically, grief-response models (see, for example,
Kübler-Ross, 1969), cognitive appraisal models (for example, Brewer, 1994), the
integrated model of response to athletic injury and rehabilitation process (Wiese-
Bjornstal, Smith, Shaffer and Morrey, 1998) and the biopsychosocial model of sport
injury rehabilitation (Brewer,Andersen and Van Raalte, 2002) are introduced to the
reader and outlined in detail.
Grief-response models
Grief-response models, or stage models as they are sometimes called, have been
taken from other areas of research, such as death and dying (for example, Kübler-
Ross, 1969) and applied to sport injury (for example, Mueller and Ryan, 1991).
The application of grief-response models to sport injury assumes that injury
constitutes a form of loss to the individual (for example, the loss of daily practice
routines) and thus the onset of a grieving process.They suggest that an athlete will
respond to injury in the same way in which people respond to other significant
losses, such as the death of a loved one (Brewer, 1994; Evans and Hardy, 1995).This
involves progressing through a series of sequential stages. The number of stages
varies from model to model but, in Kübler-Ross’s (1969) grief-response model,
which is the most commonly applied model in the sport injury psychology litera-
ture (Walker et al., 2007), there are five stages: denial, bargaining, anger, depression
and acceptance.
There is some support for grief-response models in the sport injury domain (see
McDonald and Hardy, 1990; Mueller and Ryan, 1991) and there is evidence to
show that sport medicine professionals are aware of ‘stage-like’ responses to sport
injury (Arvinen-Barrow et al., 2010). In their theoretical discussion of response to
injury, Mueller and Ryan (1991) offered support for the application of the Kübler-
Ross (1969) model of recovery from sport injury. Similarly, Gordon (1986)
reviewed the clinical and injury literature and found that there was a typical
response to sport injury that is very much like the five-stage Kübler-Ross (1969)
model. Furthermore, McDonald and Hardy (1990) supported the grief-like
response to sport injury in their research exploring the affective, cognitive and
behavioural responses of five university-level injured athletes across a four-week
injury period. Despite the vast majority of the literature supporting the grief
response in the sport injury domain being somewhat dated, there has been some
more contemporary literature identifying that sport injury evokes a grief-like
response for injured athletes (Mankad and Gordon, 2010).
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Psychological responses to injury 25
I’ve definitely seen evidence of all five of these stages in some of the athletes I’ve
worked with. When an injury first occurs it’s quite common for an athlete to under-
play or ‘deny’ the injury to themselves and others. That makes treatment at that
stage difficult. Anger can come in when they can no longer deny the injury, owing
to the impairment it brings. I certainly have athletes who try and bargain with me
about my diagnosis and treatment regime, and depression is fairly common once
people start to acknowledge the impact of an injury on their world. Acceptance is,
I believe, inevitable although it takes different people different amounts of time to
accept, but it’s only at that point that you really have the athlete ‘on board’ in
their rehabilitation programme.
(Janice, sport medicine professional)
The application of Kübler-Ross’s (1969) model to sport injury is intuitively

appealing and can describe the responses of some athletes to sport injury. However,
not all research is fully supportive of the predictions of the model. Whilst not
accepting the grief-response models in their entirety, several researchers have found
partial support for grief-response models (Gordon, Milios and Grove, 1991; Udry,
Gould, Bridges and Beck, 1997). For example, Udry et al. (1997) when examining
psychological responses to season-ending injuries amongst national team skiers,
provided only partial support for Kübler-Ross’s (1969) grief-response model, as
they found no support for the bargaining stage and only minimal support for the
denial stage but did support the anger, depression and acceptance stages.
Criticisms of the model include the assumption that the stages are sequential
and the failure of the model to account for oscillation between the stages (Brewer,
1994; Evans and Hardy, 1995). There has also been a debate over the mislabelling
of the term ‘denial’, where this is proposed to be a term that should be reserved for
noncompliant athletes who, despite education about the nature and severity of
their injury, refuse to accept its existence (Udry et al., 1997; Walker et al., 2007).
Athletes typically do not deny that an injury exists but tend to downplay its sever-
ity and limiting factors and, hence, could be denying the severity and not the injury
itself (Pearson and Jones, 1992). Furthermore, the model lacks empirical rigour and
is not sport-injury specific (Walker et al., 2007).
Grief-response models fail to account for individual differences in responses to
injury (Brewer, 1994; Evans and Hardy, 1995; Harris, 2003; Walker et al., 2007). It
seems inflexible to suggest that all injured athletes, regardless of their previous expe-
riences and circumstances, will react to injury in the same stereotypical way,
progressing through each of the stages in turn. In fact, not all athletes will demon-
strate negative psychological responses to injury. It is important to acknowledge that
the occurrence of an injury can actually lead to positive as well as negative reactions
(Udry et al., 1997;Wrisberg and Fisher, 2004). For example, an athlete who has been
experiencing a run of poor performance may welcome the onset of an injury, as it
may provide a valid excuse for underperformance. Such an athlete is more likely to
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experience feelings of relief than the feelings of anger and depression predicted by
Kübler-Ross’s (1969) model. Equally, an athlete who initially had negative reactions
to injury may in time be able to derive positive consequences from the injury expe-
rience such as an enhanced perspective, increased motivation or the development of
other skills such as coping strategies (Podlog and Eklund, 2006; Udry et al., 1997).
Such positive consequences are sometimes referred to as secondary gain (Heil, 1993;
Taylor and Taylor, 1997). Owing to a lack of support for discrete emotional reac-
tions to sport injury, research has moved away from investigating grief-response
models and has instead focused on examining alternative models not based on the
process of grieving. Moreover, research in sport setting has paid very little attention
to more contemporary grief-response models, such as the dual process model of
coping with bereavement (Stroebe and Schut, 1999), which addresses some of the
limitations of the Kübler-Ross’s model above and has been widely accepted outside
the sport injury context as a means of explaining individual reactions to loss.
• Grief-response models assume that a sport injury constitutes a form of loss

and thus requires a process of grieving.
• Grief-response models suggest that all injured athletes will pass through
the same stages of grieving in the same order and thus do not allow for
individual differences in the injury experience.
• It might be worthwhile for researchers to explore more the application of
contemporary models of grief (such as the dual process model of coping
with bereavement; Stroebe and Schut, 1999) to describe responses to
sport injury.
Cognitive appraisal models

As a result of the limitations of grief-response models, cognitive appraisal models
came to be more widely accepted as a means of explaining psychological reactions
to injury, since they take individual differences into consideration (Brewer, 1994;
Evans and Hardy, 1995;Walker et al., 2007). Similar to the models explaining sport
injury occurrence (Williams and Andersen, 1998; for more details see Chapter 2),
the roots of cognitive appraisal models are found in theories of stress and coping.
According to cognitive appraisal models, emotional and behavioural responses to
injury are dictated by the individual’s cognitive appraisal or subjective interpreta-
tion of their injury (Brewer, 1994; Evans and Hardy, 1995). Importance is therefore
placed on how the injury is perceived (cognitively appraised) by the individual
rather than on the injury itself. An appraisal is a process through which a poten-
tially stressful situation (sport injury) is assessed and the individual’s evaluation of
the extent of that stress. These appraisals are proposed to occur in two forms,
primary and secondary appraisals (Lazarus, 1991). Primary appraisals involve an
assessment of what is at stake taking into account challenge, benefit, threat,
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harm/loss (Lazarus, 1991), whereas secondary appraisals involve an assessment of

the coping options available to manage the demand. This would suggest that two
athletes with the same injury could appraise the injury in different ways; for exam-
ple, one could perceive it as a disaster and the other could perceive it as an
opportunity to take a break from intensive training (Udry et al., 1997).
I currently have two athletes in my squad with very similar injuries, but their reac-
tions to the injury are poles apart! Athlete A, who is fairly young, is being quite
emotional about the injury and is quite down about it and is not so good at
attending her rehabilitation appointments. In contrast, athlete B, who is a lot more
experienced, is taking being injured in her stride – she is positive about her recov-
ery, and is quite proactive in seeking treatment and doing all of the right things to
get better. She never misses a rehabilitation session.
(Xavier, coach)
Cognitive appraisal models consequently tend to have four key components: the
stressful situation (the injury), cognitive appraisal, emotional responses and conse-
quences (Kolt, 2003). Our appraisals are believed to influence the way in which we
cope with a stressful situation. Brewer (1994) proposed a typical model of cogni-
tive appraisal that can be used to explore and describe psychological responses to
injury (Figure 3.1). Personal (for example, dispositional or historical attributes of
the individual) and situational (for example, injury-related characteristics, variable
aspects of the social and physical environment) factors are proposed to mediate
how an athlete appraises their injury (Brewer, 1994). Appraisals are proposed to
subsequently affect emotional responses (such as anger, depression) and further
influence behavioural responses (like adherence to rehabilitation).
Personal factors Situational factors
Cognitive appraisal
Emotional response
Behavioural response
FIGURE 3.1 Typical cognitive appraisal model of psychological adjustment to athletic

injury
Source: adapted from Brewer, 1994; reproduced with permission from Taylor & Francis
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Given that situational factors impact upon cognitive appraisals, the role of the
sport medicine professional and others around the injured athlete should not be
underestimated (Wiese-Bjornstal et al., 1998).The sport medicine professional has
the capacity to influence the individual’s cognitive appraisal of their injury and
subsequent emotional reactions and behavioural responses.Walker (2006) identified
that the appraisal of the risk of re-injury and the perceived consequences of re-
injury caused anxieties about becoming re-injured during rehabilitation and also
during re-entry into training and competition in a sample of injured case partici-
pants. The athletes stated that re-injury anxieties caused them to be hesitant,
cautious and to adopt protective behaviours (such as applying strapping). By using
psychological strategies (such as reframing) appraisals can be challenged and adverse
responses to athletic injury (like re-injury anxiety) can be reduced (Walker, 2006).
Sport medicine professionals might use their understanding of this model to assist
an athlete to develop more constructive interpretations of their injury and/or reha-
bilitation via restructuring to influence more positive emotions and behaviours (for
more details on restructuring, see Chapter 8).
Research using cognitive appraisal models in sport injury rehabilitation is
considered to be fairly limited (Levy, Polman, Clough and McNaughton, 2006).
However, there are studies which support the use of these models. For example, in
their study of athletes recovering from knee surgery, Daly, Brewer, Van Raalte,
Petitpas and Sklar (1995) found that cognitive appraisal was associated with
emotional disturbance, which in turn was inversely related to a measure of adher-
ence.This would suggest that those who cognitively appraise their injury such that
it leads to emotional disturbance are less likely to adhere to rehabilitation sessions
(Daly et al., 1995) – an important observation for those involved in rehabilitating
injured athletes. Similarly, Albinson and Petrie (2003), in their study of 84 US
college footballers, reported that they found support for cognitive appraisal models.
They found that cognitive appraisal influenced the choice of coping strategy, with
those with more negative appraisals tending to adopt more negative coping strate-
gies (Albinson and Petrie, 2003). Whilst cognitive appraisal models have received
support, they have not been without their critics, with some suggesting that athlete
appraisals are far more complex than many cognitive appraisal models suggest
(Johnston and Carroll, 1998).
• Cognitive appraisal models suggest that the way in which an athlete

responds to injury is dictated by their cognitive appraisal of injury and,
hence, sport medicine professionals can work with the injured athlete to
assist them in more positive appraisals of their injury and rehabilitation.
• Cognitive appraisal is thought to be influenced by both personal and situ-
ational factors.
• Cognitive appraisal models explain why two athletes may respond to the
same injury in different ways.
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The integrated model of psychological response to the sport

injury and rehabilitation process
Following the development of stage and cognitive appraisal models,Wiese-Bjornstal
et al. (1998) proposed that cognitive appraisal and grief-response models are not
mutually exclusive.They stated that the sense of loss identified in response to athletic
injury is a process that has occurred following a cognitive appraisal and leads to
emotions commonly associated with grief (such as depression, anger).They therefore
proposed a broader integrated stress-process model, which also subsumes grief as an
emotional response; the integrated model of psychological response to the sport
injury and rehabilitation process (also known as the integrated model; see Figure
3.2). As well as addressing post-injury factors, this particular model also incorporates
pre-injury factors adapted from the model of stress and athletic injury (Andersen and
Williams, 1988) discussed in Chapter 2.Wiese-Bjornstal and Smith (1993) reported
that the precursors to athletic injury, as outlined in Andersen and Williams’ (1988)
model, also moderate post-injury responses. For example, high life-stress levels are
proposed to not only increase the risk of actual injury but also amplify post-injury
mood disturbance. Similarly, Brewer (1994) proposed that the personality traits of
hardiness, trait anxiety, extraversion, neuroticism and a pessimistic explanatory style
amplified post-injury mood disturbance. It is interesting to note that the modifica-
tions to the stress-response model by Williams and Andersen (1998) have not been
incorporated into the integrated model (that is, bi-directional arrows between
personality, history of stressors, and coping resources; for more details, see Chapter 2).
The remaining sections of Wiese-Bjornstal et al.’s (1998) model extend the
theme of the stress response to the post-injury phase, where the injury itself is
considered the stressor and the extent of the stress is determined by the athlete’s
cognitive appraisals, which are influenced by a range of personal and situational
factors. The relationship between cognitive appraisal, behavioural response and
emotional response is illustrated by the cyclical core of the model (known as the
‘dynamic core’). The dynamic core of the model should be viewed as a three-
dimensional spiral that heads in an upward direction towards full recovery or in a
downward direction away from full recovery if the recovery outcomes (that is,
physical and psychosocial outcomes) are negative (Wiese-Bjornstal et al., 1998).
The recovery outcomes are centred between the athlete’s cognitive appraisal,
emotional responses and behavioural responses, implying that all three can directly
impact recovery outcomes. The bi-directional arrows in this core represent the
dynamic nature of the rehabilitation process. The clockwise arrows indicate that
cognitive appraisals affect emotions, which in turn affect behaviour, whilst the anti-
clockwise arrows acknowledge that at times the reverse can occur and that changes
in direction are possible during rehabilitation (Brewer, 1994;Wiese-Bjornstal et al.,
1998). For example, appraisals can affect behaviours, which affect subsequent
emotions and appraisals.The dominant process is said to be the appraisals affecting
emotions, which subsequently affect behaviours, as seen via the bolder arrows in
the dynamic core (Figure 3.3).
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pre-injury factors
Stress response
Sport injury
Personality History of Coping Intervention
stressors resources
Response to sport injury and rehabilitation process
Personal factors Situational factors
• Injury • Sport
• History Cognitive appraisal • Type
• Severity • Goal adjustment • Level of competition
• Type • Rate of perceived recovery • Time in season
• Perceived cause • Self-perceptions • Playing status
• Recovery status • Belief and attributions • Practice vs. game
• Individual differences • Sense of loss or relief • Scholarship status
• Psychological • Cognitive coping • Social
• personality • Teammate influences
• self-perceptions • Coach influences
• self-motivation • Family dynamics
• motivational orientation • Sports medicine team influences
• pain tolerance • Social support provision
• athletic identity • Sport/ethic philosophy
• coping skills • Environmental
• psychological skills • Rehabilitation environment
• history of stressors • Accessibility to rehabilitation
• mood states
• Demographic
• gender
• age
• ethnicity
• socioeconomic status Recovery outcomes
• prior sport experience • Psychosocial
• Physical • Physical
• use of ergogenic aids
• physical health status
• disordered eating
Behavioural response Emotional response

• Adherence to rehabilitation • Fear of unknown
• Use of PST strategies • Tension, anger, depression
• Use/disuse of social support • Frustration, boredom
• Risk-taking behaviours • Positive attitude/outlook
• Effort and intensity • Grief
• Malingering • Emotional coping
• Behavioural coping
PST = psychological skills training
FIGURE 3.2 The integrated model of psychological response to the sport injury and
rehabilitation process
Source: adapted from Wiese-Bjornstal et al., 1998; reprinted with permission from Taylor & Francis
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To me, a model like this is really useful, as it helps me to recognise all of the factors
that can impact on an athlete’s recovery. Before I became aware of this model, I
don’t think I fully appreciated how influential psychological factors can be on
rehabilitation outcomes. I now include psychological assessment and intervention
into my work with injured athletes as a matter of course and I often refer athletes
to a sport psychologist.
(Kemal, sport medicine professional)
The integrated model of psychological response to the sport injury and rehabilita-
tion process is reportedly the most accepted and well-developed model within the
sport injury psychology literature (Anderson,White and McKay, 2004; Kolt, 2003;
Walker et al., 2007) and, to date, seems to provide the best framework for under-
standing psychological responses to sport injury. Despite the limited empirical
support for the model as a whole, there is some evidence to support some of the
individual components of the model. For example, in her in-depth study of the
lived experiences of injured athletes, Walker (2006) found support for a range of
the personal factors and situational factors identified in the integrated model
thought to influence cognitive appraisals. Under ‘personal factors’ all five injury
characteristics listed within the model (history, severity, type, perceived cause,
recovery status) were demonstrated, as were the ‘individual differences’ of person-
ality, pain tolerance, athletic identity, coping skills, history of stressors (Walker,
2006). Under ‘situational factors’, with the exception of scholarship status, all sport
characteristics were evident, as were all of the social mediators. However, she
suggested that additional research was needed to determine the similarities and
differences in meaning that athletes derive from their lived injury experiences. In
an attempt to extend Walker’s (2006) study, Grindstaff,Wrisberg and Ross (2010)
employed an interview technique based on the philosophical tenets of phenome-
nology. These authors used a deductive procedure to determine the possible
location of the meaning of the injury to each athlete within the framework of the
integrated model. Support was offered for a variety of the personal factors (for
example, previous injury history, pain tolerance), situational factors (such as playing
status, team support), appraisals (for example, uncertainty, knowledge that their
present injury state was not permanent), emotions (for example, mild fear of re-
injury, trying to stay positive) and behaviours (for example, adherence to
rehabilitation) in the model. In contrast, other factors were identified that were not
evident within the model (spirituality and religion, belief system, state of the art
facilities). Similarly, a wider range of appraisals was identified (for example, believ-
ing that the injury is part of God’s plan or thinking about the coach’s perspective).
A broader emotional and behavioural response was also outlined (for example,
pleased over timing of injury, surgery anxiety, supporting team mates whilst
injured, information gathering, making rehabilitation competitive). Furthermore,
whilst support was offered for a range of recovery outcomes evident in the
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integrated model (for example, discovering meaning in injury) an array of addi-

tional recovery outcomes were also discussed (for example, helping team mates to
understand the coach’s perspective, trusting God) two aspects were outlined as
missing from the model: 1) the role of managing medication in the athlete’s injury
experience; 2) the search for knowledge whilst injured is not limited to the sport
medicine professionals (Grindstaff et al., 2010).
Support for the influence of cognitive appraisals on athletes’ emotional
responses and behavioural responses (the dynamic core of the model) has also been
provided by studies that suggest that maintaining a positive outlook has a positive
impact on rehabilitation behaviour and recovery (Arvinen-Barrow, Hemmings,
Weigand, Becker and Booth, 2007; Heaney, 2006; Tracey, 2003). Walker et al.
(2007), however critique, the ‘dynamic core’ of the model and suggest that the rela-
tionship between appraisals, emotions, behaviours and recovery outcomes is more
complex than the model indicates. As depicted in Figure 3.3.Walker’s (2006) results
did not lend support for the notion that behavioural responses to injury directly
affect subsequent cognitive appraisals and they suggested that this only occurs
following an appraisal of the behavioural response. It was also suggested that
emotional responses only influence psychosocial recovery outcomes and not phys-
ical recovery outcomes. However, physical and psychosocial recovery outcomes
were both proposed to be influenced by behavioural responses. The recovery
outcomes themselves were also reported to influence subsequent appraisals and
appraisals reported to only influence psychosocial recovery outcomes directly (see
Walker et al., 2007 for full critique).
Cognitive appraisal
Recovery outcomes: Recovery outcomes:

physical psychosocial
Behavioural Emotional
responses responses
FIGURE 3.3 CritiqueBi-directional

of the dynamic core of(this
relationship Wiese-Bjornstal
direction is notetasal.strong)
(1998) integrated
model
Source: adapted from Walker et al., 2007; reprinted with permission from Sage Publications
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• Wiese-Bjornstal et al.’s (1998) model considers both pre-injury and post-

injury factors and does not consider grief-response and cognitive appraisal
models to be mutually exclusive.
• The model suggests that there is a cyclical relationship between cognitive
appraisal of an injury, emotional response to injury and behavioural
response to injury that influences, and is influenced by, recovery outcomes.
• The model offers sport medicine professionals a useful framework through
which to examine the psychological aspects of sport injury.
A biopsychosocial model of sport injury rehabilitation

One of the main limitations of the integrated model of psychological response to the
sport injury and rehabilitation process is that it does not explain how psychological
factors influence physical sport injury rehabilitation outcomes (Brewer, 2001; Brewer
et al., 2002). Consequently, Brewer et al. (2002) proposed the biopsychosocial model
of sport injury rehabilitation (Figure 3.4). This model draws upon the approaches
increasingly adopted in the healthcare professions, which suggest that health, illness
and injury are best understood in terms of an interaction between biological, psycho-
logical and social factors, rather than in purely biological terms as is traditional in
medicine. Heaney et al. (2012) suggest that the biopsychosocial model can have a
positive impact on patient satisfaction, empowerment and pain management.
As can be seen in Figure 3.4, the model comprises numerous variables associ-
ated with the sport injury rehabilitation process. According to the model, the
characteristics of injury and sociodemographic factors influence the biological,
psychological and social/contextual factors, which in turn are thought to interact
and have an effect on the ‘intermediate biopsychological outcomes’ such as the
pain, rate of recovery and range of motion. The arrow between psychological
factors and intermediate biopsychological outcomes is bi-directional, indicating
that the biopsychological outcomes can also influence psychological factors.
Finally, the model suggests that along with psychological factors, the intermediate
biopsychological outcomes affect sport injury rehabilitation outcomes. Again these
arrows are both bi-directional indicating that the rehabilitation outcomes can also
affect psychological factors and biopsychological outcomes.
I think it’s really important to consider an injury and its potential impact from a
biopsychosocial perspective. Too many sport medicine professionals look at physi-
ological and psychosocial factors as separate entities when in fact they are
undeniably interlinked and interdependent. We’re dealing with people and their
reactions and so a more holistic approach is required.
(Freda, sport medicine professional)
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Sociodemographic
Characteristics
factors
of the injury
• Age
• Type
• Gender
• Cause
• Race/ethnicity
• Severity
• Socioeconomic
• Location
status
• History
Biological factors Psychological

Social/contextual factors
• Endocrine • Sleep factors
• Social network
• Metabolism • Circulation • Personality
• Life stress
• Neurochemistry • Respiration • Cognition
• Situational characteristics
• Tissue repair • Immune • Affect
• Rehabilitation environment
• Nutrition functioning • Behaviour
Intermediate
biopsychological
outcomes
• Range of motion
• Strength
• Joint laxity
• Pain
• Endurance
• Rate of recovery
Sport injury rehabilitation outcomes

• Functional performance
• Quality of life
• Treatment satisfaction
• Readiness to return to sport
FIGURE 3.4 A biopsychosocial model of sport injury rehabilitation

Source: adapted from Brewer et al., 2002; originally published in D. L. Mostofsky and L. D.
Zaichkowsky (eds), Medical and Psychological Aspects of Sport and Exercise (2001); reprinted with
permission from Fitness Information Technology
A key strength of the model is that it acknowledges that recovery from sport
injury occurs in a complex biological, psychological and social matrix and that the
interaction of these complex factors is changeable and dynamic (Andersen, 2007).
It therefore offers a broad-based framework for understanding responses to sport
injury (Brewer, 2001) – one that serves to remind sport medicine professionals of
the myriad factors that influence rehabilitation and recovery (Andersen, 2001).
Research directly examining Brewer et al.’s (2002) biopsychosocial model of
sport injury rehabilitation is sparse; however, there is support available for elements
of the model. For example, Brewer (2001) suggested that the correlational rela-
tionship seen between emotional reactions to injury and rehabilitation outcomes is
consistent with the predictions of the biopsychosocial model. Andersen (2007) has
used the ‘social/contextual factors’ element of the model to examine collaborative
relationships during rehabilitation, whilst Andersen (2001) has successfully used the
model to examine return to sport participation following injury. Others have
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provided support more indirectly by advocating a biopsychosocial approach to

understanding sport injury, without specifically referencing Brewer et al.’s (2002)
model (Wiese-Bjornstal, 2009, 2010).
The model does, however, have limitations. Firstly, whilst the model provides
explanations for how psychological factors can influence rehabilitation outcomes,
it fails to describe the relationships between various psychological factors, particu-
larly in comparison to more psychologically based models (Brewer et al., 2002).
Secondly, it has been suggested that, even though the model identifies relevant vari-
ables and general relationships, it is not a theory and consequently does not provide
a comprehensive explanation as to how different components interact to produce
different outcomes (Podlog and Eklund, 2007). Podlog and Eklund (2007) also crit-
icise the model for failing to indicate which factors are most significant in
producing various outcomes and why. Heaney et al. (2012), in their exploration of
current psychology provision within physiotherapy programmes in UK universi-
ties, reported that, within the learning outcomes of participant universities’
modules and programmes, there is often reference made to the biopsychosocial
model but detailed guidance on its interpretation appears to be lacking.
Furthermore, there is often a lack of confidence to use a biopsychosocial approach
effectively, perhaps owing to inadequacies in training in this area (Green, Jackson
and Klaber Moffett, 2008).
Brewer et al’s. (2002) model is based on the biopsychosocial approach, which

suggests that rehabilitation outcomes are a consequence of a dynamic and
complex biological, psychological and social interaction.
Conclusion
The aim of this chapter was to provide a review and critique of the theoretical
frameworks of psychological responses to injury to help the sport medicine profes-
sional better understand the athlete’s injury experiences and factors that might
impact their rehabilitation. A range of models have been proposed that seek to
describe and explain athlete responses to sport injury each with its own inherent
strengths and weaknesses. However, as has been described in this chapter, to date it
is Wiese-Bjornstal et al.’s (1998) integrated model of psychological response to the
sport injury and rehabilitation process that has been acknowledged as the most
comprehensive framework.
All of the models have one thing in common – they help to emphasise the
importance of psychological responses to the rehabilitation process.This is perhaps
the most salient point as, once those around the injured athlete recognise the
potential impact of psychological responses, they are more likely to employ inter-
ventions aimed at addressing any adverse psychological responses.
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CASE STUDY
Gabriella, aged 35, is a Spanish international 400-metre hurdler who has

recently sustained an Achilles tendon injury. Gabriella is in the twilight of her
international career but has one unfulfilled ambition – to compete in an
Olympic Games. Gabriella missed out on selection for the last Olympics owing
to injury and realises that, given her age, qualifying for the next Olympics is
likely to be her last chance. Consequently, Gabriella has been feeling extremely
angry and frustrated about the injury and is anxious to return to full training
as soon as possible, to maximise her chances of selection. Before the injury,
Gabriella’s training had been going extremely well – she has been training with
a new coach for a year and her performances had been improving. Gabriella
has experienced a similar injury in the past, from which she did recover rela-
tively quickly, but she has been told by her sport medicine professional that
because of her age and injury history, her recovery may take a little longer this
time. Gabriella feels that this is time that she just doesn’t have and she is eager
to get a second opinion. The sport medicine professional is concerned that
Gabriella is trying to rush her rehabilitation and she will try to return to full
training too soon, thus making the injury worse.
–––––––– ? ––––––––
1. Which factors outlined in the case study may affect Gabriella’s cognitive
appraisal of her injury?
2. What impact might her cognitive appraisal have on her emotional and
behavioural responses?
3. Consider how Gabriella’s cognitive appraisal of the injury and consequent
responses may be different to an athlete sustaining the same injury but at
a different stage in their career.
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4
PSYCHOLOGICAL ASPECTS OF
REHABILITATION ADHERENCE
Megan D. Granquist and Britton W. Brewer
Introduction
Existing theoretical frameworks (for more details, see Chapter 3) and empirical
evidence are in agreement that rehabilitation adherence is an essential component
for successful sport injury rehabilitation (Arnheim and Prentice, 2000; Bassett,
2003; Bassett and Prapavessis, 2007; Fisher, Mullins and Frye, 1993; Flint, 1998;
Kolt, Brewer, Pizzari, Schoo and Garrett, 2007;Taylor and May, 1996; Udry, 1997).
More specifically, rehabilitation nonadherence has been associated with poorer
overall rehabilitation outcomes (for example, functional ability, strength, range of
motion; (Brewer, 1998; Brewer et al., 2000) and potentially has an impact on
increasing the risk of re-injury (Arnheim and Prentice, 2000).
Despite the importance of adherence for physical and psychological recovery,
suboptimal sport injury rehabilitation adherence rates of patients have been found
for clinics working with sport injuries. For example, in a study by Taylor and May
(1996), 60 per cent of patients reported that they were not fully adherent with
prescribed home modalities (such as cryotherapy) and 54 per cent reported that
they were not fully adherent with prescribed rest. Udry (1997) reported adherence
at 79 per cent for athletes receiving physical therapy following anterior cruciate
ligament reconstruction, with highest rates at the beginning of rehabilitation. In a
review of the literature, Brewer (1998) reported adherence rates ranging from
40–91 per cent.
One of the ways in which rehabilitation adherence can be improved is through
the use of psychological interventions (see, for example, Garza and Feltz, 1998).
Existing literature, albeit limited, has suggested that comprehensive psychological
skills training programmes that include goal setting, stress management techniques
and a range of coping strategies may be transferable to the rehabilitation setting
with the aim of improving adherence. Given the importance of adherence in sport
injury rehabilitation, this chapter outlines the psychological aspects of sport injury
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Psychological aspects of rehabilitation adherence 41
rehabilitation adherence. More specifically, the chapter (a) defines adherence; (b)
provides a theoretical basis to rehabilitation adherence; (c) highlights the impor-
tance of rehabilitation adherence/nonadherence; (d) provides an outline of the role
of psychological interventions in facilitating rehabilitation adherence; (e) discusses
the role of sport medicine professionals in facilitating adherence; and (f) introduces
different ways in which adherence could be measured.
Rehabilitation adherence: conceptual clarity

When defining adherence, researchers across discipline boundaries appear to be in
agreement of what it entails. However, there are inconsistencies in defining adher-
ence. An accepted definition of adherence among professionals who use exercise
as rehabilitation from disease is ‘an active, voluntary collaborative involvement of
the patient in a mutually acceptable course of behaviour to produce a desired
preventative or therapeutic result’ (Meichenbaum and Turk, 1987: 20). The above
definition can also be beneficial in the sport injury rehabilitation context. Similar
to exercise prescribed for a specific medical condition or disability to facilitate
recovery from a condition (such as heart attack or knee injury), the driving moti-
vation for sport injury rehabilitation is to return back to a pre-injury level of ability
and fitness. In general medicine and health, adherence has been defined as ‘the
degree to which patient behaviours coincide with the recommendations of health-
care providers’ (Vitolins, Rand, Rapp, Ribisl and Sevick, 2000: 188S). These
definitions both highlight the importance of the patient’s voluntary action in
following professional recommendations.
Within the broader areas of exercise psychology and behavioural medicine,
‘[a]dherence refers to maintaining an exercise regimen for a prolonged period of
time . . . Central to adherence is the assumption that the individual voluntarily and
independently chooses to engage in the activity’ (Lox, Martin Ginis and
Petruzzello, 2006: 6–7). This definition of exercise adherence is in line with the
medical and health areas and can be applied to sport injury rehabilitation. In both
exercise and injury rehabilitation contexts, the desired behaviours must be main-
tained for a period of time. However, while exercise adherence behaviour may be
motivated by long-term health promotion, in the sport rehabilitation context there
is arguably an immediate motivating component (for example, recovery from
injury, return to competitive sport, return to play pressures). Similar to exercise
adherence, rehabilitation adherence also relies on an individual choosing to engage
in the rehabilitation and to what degree. However, exercise adherence applies to
behaviour to be maintained continuously over the lifespan, whereas rehabilitation
is a time-limited set of behaviours aimed at returning to normal function.
It appears that the terms adherence and compliance have been often used inter-
changeably (Bassett and Prapavessis, 2007; Taylor and May, 1996). The term
adherence is typically associated as a description of a behaviour that is aimed at a
particular outcome, whereas compliance can be defined as an individual’s willing-
ness to follow and engage in the required behaviours.Thus, in the context of this
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42 Megan D. Granquist and Britton W. Brewer
chapter, sport injury rehabilitation adherence is seen as the extent to which an

individual completes behaviours as part of a treatment regimen designed to facili-
tate recovery from injury.
Rehabilitation adherence: theoretical basis

Theoretical models serve as frameworks for understanding the rehabilitation process
and for guiding research. Understanding psychological models of sport injury are
useful because they provide a conceptual overview from which the antecedents and
outcomes of rehabilitation adherence can be investigated. Thus far, a number of
theoretical approaches have been found useful in understanding rehabilitation adher-
ence (Brewer, 1998), of which the rehabilitation schematic (Brewer et al., 2000) will
be introduced first as it shows the mediating and moderating roles of adherence in
sport injury rehabilitation, followed by a biopsychosocial model of sport injury reha-
bilitation (Brewer, Andersen and Van Raalte, 2002). These two models are seen as
useful to sport medicine professionals, sport psychology consultants and other
professionals interested and involved in conceptualising rehabilitation adherence in
the context of both psychological and physical rehabilitation and recovery.
Rehabilitation schematic: the role of adherence

Several theoretical frameworks (for example, Wiese-Bjornstal, Smith, Shaffer and
Morrey, 1998) have proposed that a person’s cognitive appraisals of and emotional
responses to the injury are seen as factors influencing behaviour during rehabilita-
tion. These models also propose that cognitive appraisals, emotional and
behavioural responses are all influenced by a number of personal and situational
factors. The interaction between individuals’ cognitive appraisals, emotional
responses and behavioural responses is thought to have an impact on the rehabili-
tation process and overall physical and psychological outcomes. Brewer et al. (2000)
proposed that rehabilitation adherence as a behavioural response can also mediate
the relationship between psychological factors and rehabilitation outcomes.
According to Brewer and colleagues, rehabilitation adherence can act as a media-
tor between psychological factors and rehabilitation outcomes, thus highlighting
the importance of adherence as part of successful rehabilitation (Figure 4.1).
The biopsychosocial model of sport injury rehabilitation

In general medicine and health, as well as in sport injury rehabilitation, physical
factors (for example, type and severity of injury, health status of patient) affect over-
all recovery following an injury; however, more recently, psychological and social
factors have also received attention as contributors to recovery. The biopsychoso-
cial model of sport injury rehabilitation can serve as a guide for sport injury
rehabilitation professionals by providing an inclusive framework from which phys-
ical, psychological and social factors influencing the sport injury rehabilitation
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Psychological factors
• Self-motivation
• Social support
• Athletic identity
• Psychological distress
Rehabilitation adherence
• Appointment attendance c
• Practitioner ratings
• Home exercise completion
• Home cryotherapy completion
Rehabilitation outcome
• Knee laxity
• Functional ability
• Subjective symptoms
FIGURE 4.1 Schematic representation of hypothesised relationships among

psychological factors, rehabilitation adherence and rehabilitation
outcome
Source: adapted from Brewer et al., 2000; reprinted with permission from the American Psychological
Association
process and outcomes can be better understood (Brewer,Andersen, et al., 2002). As

discussed in Chapter 3, the biopsychosocial model provides a conceptual frame-
work that ties biological, psychological and social factors to rehabilitation
outcomes.This model acknowledges injury characteristics and socio-demographic
factors as influencing biological factors, psychological factors and social/contextual
factors. The model proposes that biological, psychological, and social/contextual
factors are interrelated and reciprocally affect intermediate biopsychological
responses, which, in turn, are proposed to directly influence sport injury rehabili-
tation outcomes. In other words, adherence, as a behavioural response to sport
injury, can have an impact on an individual’s range of motion, strength, joint laxity,
pain, endurance and rate of recovery (Brewer, Andersen, et al., 2002).
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Although the biopsychosocial model does not specifically list adherence as one
of the contributing factors, it is logical to situate adherence, among other psycho-
logical factors (including behaviours), immediately prior to intermediate
biopsychological outcomes. This placement of adherence in the biopsychosocial
model is clearly acknowledged by Brewer and colleagues when describing how
social/contextual factors influence outcomes:‘For example, disruptive life circum-
stances may interfere with adherence to a rehabilitation protocol, thereby
hampering achievement of favorable intermediate biopsychological outcomes and,
ultimately, desired functional performance at the end of rehabilitation’ (Brewer,
Andersen, et al., 2002: 50). Such would imply a nice fit for adherence because these
behaviours may also be influenced by injury characteristics, biological factors,
sociodemographic factors and other psychological factors (such as cognition,
emotion). It is also consistent with the integrated model of psychological response
to sport injury and rehabilitation process (Wiese-Bjornstal et al., 1998), which
holds that adherence, as a behavioural response to sport injury, is affected directly
by cognitive and emotional responses to injury and indirectly by a host of personal
and situational factors (for more details, see Chapter 3). As such, it can be suggested
that adherence can be a mediator of the relationship between biopsychosocial
factors and rehabilitation outcomes (both intermediate and overall).
Research has documented the association between psychological factors and
adherence and adherence being correlated with rehabilitation outcomes (for a
review, see Brewer, 2007). However, conclusive evidence of the role of adherence
as a mediator of the biopsychosocial factors–rehabilitation outcome relationship is
still limited. Nevertheless, being aware of the potential mediational role of adher-
ence, sport medicine professionals should take care to consider the antecedents to
adherence. For example, biological factors, such as general health and nutrition,
should be considered along with psychological factors, such as an athlete’s person-
ality, mood, cognition and behaviour, and social factors, such as status within the
team and family situation. Using the biopsychosocial model of sport injury reha-
bilitation (Brewer, Andersen, et al., 2002) as a framework for treating injured
athletes, can help sport medicine professionals to adopt a holistic approach to reha-
bilitation and thus help them recognise aspects influencing adherence beyond the
more-obvious biological factors.
Understanding the theoretical basis of rehabilitation adherence sets a frame-

work from which sport medicine professionals can conceptualise adherence
antecedents and resultant behaviours.
The impact of rehabilitation nonadherence

Although researchers and sport medicine professionals commonly agree that reha-
bilitation adherence is useful to achieve successful recovery from a sport-related
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injury, many questions remain to be answered surrounding the role of rehabilita-

tion adherence in overall recovery outcomes. Indeed, research on the relationship
between rehabilitation adherence and rehabilitation outcomes in the sport injury
domain has produced mixed findings, with multiple examples of positive,
nonsignificant and negative adherence–outcome associations (for a review, see
Brewer, 2007). If the adherence–outcome relationship for a given rehabilitation
programme is nonsignificant or positive, nonadherence to rehabilitation is unlikely
to be harmful (and might even be helpful).When the appropriate level of rehabil-
itation activities required to achieve desired rehabilitation outcomes is known (for
example, Bohannon et al., 2008; Boyce and Brosky, 2008; Ryan et al., 2009), nonad-
herence can be risky or harmful. For example, doing fewer rehabilitation activities
than prescribed might slow recovery, whereas overdoing rehabilitation activities
might result in re-injury or injury to another part of the body. To date, the appro-
priate dose of adherence remains unknown; it is important to call for further
research. Identifying dose–response relationships for commonly prescribed rehabil-
itation protocols would be of importance, as such inquiry could provide an answer
to the clinically important question of ‘to what degree do athletes need to adhere
to their rehabilitation protocols to achieve optimal rehabilitation outcomes?’ This
information would be useful to sport medicine professionals in guiding their
expectations for athletes’ rehabilitation behaviours and subsequently affecting over-
all rehabilitation outcomes. Nevertheless, in the absence of such information, it is
important to monitor and measure adherence. By doing so, those working with
injured athletes can get a clear picture of the rehabilitation process as a whole
(including personal and situational factors) and thus plan their treatment more
effectively. Moreover, facilitating optimal levels of adherence for each individual
athlete can be enhanced through the use of psychological interventions, which
when combined with physical rehabilitation can have an effect on adherence and
subsequently to rehabilitation outcomes.
I think adherence to the athlete’s rehab starts with the athletic trainer and making
sure the athlete knows what is expected of them from the beginning. I have very
few athletes that have poor adherence to rehab. I make it a point to have a good
relationship with them and communicate well with them throughout the rehab
process. I am fortunate because I have the coach’s support. If athletes miss rehab
sessions or are not putting forth the effort, then they are talked to by the coach
and I’ve noticed that the athletes’ behaviors improve. There are some athletes that
I have to watch and really stay on top of them to make sure that they are not
doing too much. But, again if I have a good relationship with them then simply
communicating with them and explaining the rehab process helps immensely.
(Athletic trainer working at a Division I university in the
National Collegiate Athletic Association, USA)
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Rehabilitation adherence: the role of psychological interventions

Given the potential key role of adherence in achieving desired rehabilitation
outcomes, it would seem important to be able to foster athletes’ adherence to
injury rehabilitation programmes shown to have a beneficial impact on rehabilita-
tion outcomes. The literature on empirically supported treatments to boost
adherence to sport injury rehabilitation, however, is extremely limited, consisting
of a few studies in which goal setting interventions were applied successfully to
enhance adherence (Evans and Hardy, 2002a; Penpraze and Mutrie, 1999).
Fortunately, it is possible to draw upon findings from research on predictors of
adherence to sport injury rehabilitation and enhancement of adherence to rehabil-
itation of medical conditions other than sport injury for guidance. In a synthesis of
research on factors associated with adherence to rehabilitation, Brewer (2004: 44)
concluded that athletes and other clients undergoing rehabilitation are most likely
to adhere when they:
• possess personal characteristics that facilitate adhering with a potentially chal-

lenging rehabilitation programme (such as self-motivation, tough mindedness);
• experience an environment conducive to adherence (for example, social
support for rehabilitation, comfortable and convenient clinical setting);
• perceive their medical condition as sufficiently serious to engender concern
but are not overly hampered by pain or emotional distress;
• attribute their health to behaviours within their own control; and
• believe in the efficacy of their rehabilitation programme and are confident in
their ability to complete the programme.
In the general rehabilitation literature, educational approaches have been the

predominant mode of attempting to enhance adherence. A meta-analysis of patient
education interventions for people with back pain indicated a beneficial effect on
adherence (DiFabio, 1995). Educational features that have been found to improve
the adherence-enhancing impact of rehabilitative interventions include supervision
of therapeutic exercises, oversight of rehabilitation by professionals with advanced
condition-specific training and augmentation of traditional instructional methods
with use of instructional media, such as audio recordings and booklets, with writ-
ten and illustrated instructions for home exercise activities (for a review, see
Brewer, 2004).
Augmented by correlational research (Scherzer et al., 2001) indicating that use
of goal setting is positively associated with sport injury rehabilitation adherence,
there is experimental evidence (Evans and Hardy, 2002a; Penpraze and Mutrie,
1999) that goal setting can enhance adherence to sport injury rehabilitation
programmes. Consistent with the list of circumstances correlated with favourable
levels of adherence, goal setting appears to be effective by increasing rehabilitation
self-efficacy, attention to the rehabilitation protocol and attribution of recovery to
personally controllable factors (Evans and Hardy, 2002b).
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A variety of other interventions has been advocated for the enhancement of

adherence to sport injury rehabilitation but these interventions lack experimental
support for their use. Correlational findings suggest that the use of positive self-talk
(Scherzer et al., 2001) and provision of social support (Byerly,Worrell, Gahimer and
Domholdt, 1994; Duda, Smart and Tappe, 1989; Fisher, Domm and Wuest, 1988;
Johnston and Carroll, 2000) might have a favourable effect on sport injury reha-
bilitation adherence. In the general rehabilitation literature, multimodal
interventions that combine multiple techniques into a single treatment approach
have shown potential as a means of enhancing adherence to rehabilitation. For
example, a motivationally focused intervention that combined information/coun-
selling, reinforcement of desired rehabilitation behaviour, behavioural contracting
and self-monitoring of rehabilitation exercise behaviour achieved short-term gains
in physiotherapy attendance for people with low back pain (Friedrich, Gittler,
Halberstadt, Cermak and Heiller, 1998). Similarly, combining behavioural contract-
ing, cued recall of the rehabilitation programme, education, goal setting,
homework, mental practice of rehabilitation activities and modelling had a benefi-
cial impact on adherence to a rheumatoid arthritis joint protection programme
(Hammond and Freeman, 2001).
Practical issues related to rehabilitation adherence, including psychological

and psychosocial intervention strategies, should be considered by sport medi-
cine professionals.
Role of sport medicine professionals in facilitating adherence

Although several personal characteristics of the athlete are correlated with sport
injury rehabilitation adherence, these factors are not readily manipulated.
Nevertheless, knowledge of the extent to which athletes are self-motivated and
tolerant of pain can be used by sport medicine professionals to guide their interac-
tions with athletes and to tailor the rehabilitation regimens that they design to the
personal strengths and weaknesses of the athletes. Sport medicine professionals can
directly influence adherence behaviour through their use of several common inter-
vention approaches, including education, goal setting, multimodal intervention and
communication.
Sport medicine professionals can exert a positive influence on the adherence of
the athletes with whom they are working by developing a positive rapport and by
simply communicating effectively. Listening to athletes, explaining rehabilitation
activities clearly, avoiding jargon and overly technical terminology, controlling
nonverbal behaviour, and recognising athletes’ needs for informational as well as
socio-emotional communication are some ways that sport medicine professionals
can interact with athletes to create an environment that is conducive to adherence
to rehabilitation.
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The injury and year of physical therapy took place when I was 16 and 17. Without
physical therapy I wouldn’t have the use of my arm. Though it seemed I had so far
to go when I first began and I was so frustrated by the pain that I wanted to quit,
I look back now and am so grateful for my therapist and the work I did. It even
opened a whole new area of academic interest for me and inspired me to major in
biology . . . From a mental standpoint, having a regimented rehabilitation
programme and having to go to therapy each day was like a form of training. The
only thing I wish was that I had more of a support group of people my own age or
of athletes who were also involved in therapy, I felt a bit isolated. My therapist kept
me motivated by providing performance-based goals and having high expecta-
tions that I had to work hard to meet.
(A former gymnast reflecting on rehabilitation following surgery for complications
from a dislocated elbow)
Measuring rehabilitation adherence

Given the importance of facilitating rehabilitation adherence, a number of
researchers have used a range of methods to measure adherence. These include
attendance at rehabilitation sessions, home exercise completion, compliance with
activity restrictions, healing rate and sport medicine professional reports.
Attendance at rehabilitation sessions is an objective, easily obtained measure of
adherence. Many studies have used attendance either on its own or in conjunction
with other adherence measures (Bassett and Prapavessis, 2007; Brewer et al., 2003;
Brewer et al., 2000; Daly, Brewer,Van Raalte, Petitpas and Sklar, 1995; Scherzer et
al., 2001; Udry, 1997). Home exercise completion has been measured with retro-
spective self-report questionnaires, daily exercises logs (Bassett and Prapavessis,
2007; Brewer et al., 2003; Brewer et al., 2000; Scherzer et al., 2001;Taylor and May,
1996) and electronic monitoring devices (see, for example, Belanger and Noel,
1990; Levitt, Deisinger, wall, Ford and Cassisi, 1995). Completion of home
cryotherapy (that is, icing) has also been collected via self-report measures (Bassett
and Prapavessis, 2007; Brewer et al., 2003; Brewer et al., 2000; Scherzer et al., 2001;
Taylor and May, 1996). Patient self-report of compliance with activity restrictions
(Bassett and Prapavessis, 2007; Taylor and May, 1996) and compliance with strap-
ping/bracing and compliance with elevation (Bassett and Prapavessis, 2007) have
also been used to measure sport injury rehabilitation adherence. Some studies have
also used healing rate as a measure; however, such can be viewed as totally inap-
propriate for assessing adherence because it corresponds to a treatment outcome,
not to the behavioural process (that is, adherence) that underlies it (Brewer, 1998).
In addition to the above, sport medicine professional’s reports have been used
regularly in rehabilitation adherence research. For example,Taylor and May (1996)
had physiotherapists estimate patients’ compliance with home-based rehabilitation
protocol (such as mobility, stretching and strengthening exercises, hot/cold therapy,
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application of compression). Such estimates are unlikely to be any more accurate

than patient self-report and, indeed, may be less accurate because the sport medi-
cine professionals are not present when the rehabilitation activities are carried out.
However, sport medicine professional ratings of patients’ behaviour in clinical
settings are wholly appropriate, as the professionals are able to directly observe the
behaviour taking place. Several instruments have been developed to record sport
medicine professionals’ observations of athletes’ rehabilitation behaviour in clinical
settings, including the sports medicine observation code (Crossman and Roch,
1991), the sport injury rehabilitation adherence scale (SIRAS; Brewer et al., 2000),
and the rehabilitation adherence measure for athletic training (RAdMAT;
Granquist, Gill and Appaneal, 2010). For the purposes of this chapter, both the
SIRAS and the RAdMAT are discussed and presented in more detail.
The sport injury rehabilitation adherence scale (SIRAS)

The SIRAS is a widely used measure of adherence to clinic-based activities. It has
demonstrated strong psychometric properties and has been used in research with
rehabilitation clinics (see, for example, Bassett and Prapavessis, 2007; Brewer et al.,
2003; Brewer et al., 2000; Daly et al., 1995; Kolt et al., 2007; Scherzer et al., 2001).
The SIRAS was developed by the authors from existing literature on adherence. It
is a brief measure consisting of three items that ask the sport medicine professional
to rate: (1) the patient’s intensity of rehabilitation completion; (2) frequency of
following instructions and advice; and (3) their receptivity to changes in rehabili-
tation on a five-point Likert-type scale (range 3–15, with higher scores indicating
greater adherence). The instructions of the SIRAS can be modified to refer to a
single rehabilitation session or to multiple rehabilitation sessions over a period of
time. Research in clinical and clinical analogue settings in Australia, New Zealand
and the United States (Brewer, Avondoglio, et al., 2002; Kolt et al., 2007) has
yielded high levels of interrater agreement for the SIRAS and shown the ability of
the SIRAS to discriminate among low, moderate and high levels of adherence to
clinic-based rehabilitation activities.
The rehabilitation adherence measure for athletic training (RAdMAT)

The RAdMAT contains 16 items with ratings on a four-point Likert-type scale
(range 16–64, with higher scores indicating greater adherence) with three
subscales: (a) attendance/participation (subscale range 5–20); (b) communication
(subscale range 3–12); and (c) attitude/effort (subscale range 8–32). Some of the
items in the attendance/participation subscale include, ‘arrives at rehabilitation on
time’ and ‘follows the prescribed rehabilitation plan’. Items in the communication
subscale include,‘communicates with the athletic trainer if there is a problem with
the exercises’ and ‘provides the athletic trainer feedback about the rehabilitation
program’. Items in the attitude/effort subscale include,‘gives 100 per cent effort in
rehabilitation sessions’ and ‘is self-motivated in rehabilitation sessions’. Although
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the RAdMAT was developed for use within athletic training sports medicine
settings, the items on the RAdMAT are not specific to the athletic training context
and thus may be useful in other sport rehabilitation (such as physiotherapy, sports
therapy) settings. The RAdMAT differentiates between the most, average and least
adherent athlete, providing evidence for its validity. Furthermore, total scores and
subscales for the most, average and least adherent athletes were significantly related
to the SIRAS. Both the SIRAS and RAdMAT discriminate among the most, aver-
age, and least adherent athletes. With its three subscales, the RAdMAT may be
useful for guiding practice and interventions aimed at enhancing rehabilitation
adherence. Low ratings on any one of the three subscales might inform interven-
tion efforts during rehabilitation. For example, if a patient rates low on the
communication subscale, physiotherapists and/or sport psychology consultants
working with the patient might introduce skills to enhance communication.
Conclusion
This chapter has provided the reader with an overview of the psychological aspects
of sport injury rehabilitation adherence. First, the concept definitions of adherence
were discussed, followed by theoretical explanations of rehabilitation adherence.
This was followed by a section highlighting the importance of rehabilitation adher-
ence/nonadherence and a description of the proposed role of psychological
interventions in facilitating rehabilitation adherence. The role of sport medicine
professionals in facilitating adherence was introduced to the reader and examples
of how to measure adherence in a sport injury rehabilitation context were
presented. Drawing from the existing literature, it is clear that athlete behaviour in
the form of adherence to rehabilitation regimens is a prominent psychological
aspect of sport injury rehabilitation. Although adherence is thought to contribute
to rehabilitation outcomes, nonadherence is a common problem for clinic-based
and, especially, home-based rehabilitation activities. Personal and situational or
environmental factors associated with sport injury rehabilitation adherence have
been identified and can inform the implementation of adherence enhancement
interventions such as education, goal setting and effective sport medicine profes-
sional communication. Adherence can be measured in both subjective and
objective ways depending on the specific behavioural requirements of the rehabil-
itation programme in question.
CASE STUDY
Michael is a 22-year old collegiate baseball pitcher attending college approxi-

mately 1,500 miles away from home. He comes from a middle-class family in
a mid-western state in the United States and his athletic goal is to play base-
ball in a minor league following college, with the hopes of having a
professional baseball career. Last year, Michael’s junior year, he sprained the
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ulnar collateral ligament in his elbow and had subsequent surgery to repair the
ligament. Michael has successfully overcome previous injuries but this surgery
is his first.
Now, four months following the reconstructive surgery, despite his lack of
pain, rehabilitation protocols specify limited activity to limit stresses on the
elbow and allow proper tissue healing. Michael is frustrated at his restricted
activity (such as limited throw distance, limited throw intensity and limited
pitch count). As an athlete, Michael has learned to push his body until he is
fatigued or experiencing pain; it is difficult for him to accept that he cannot
push himself in rehabilitation as he would on the playing field. Michael is also
concerned about his minor league recruitment possibilities because he is not
able to demonstrate his pitching skill while he is sidelined. Fortunately, Michael
has confidence in and good rapport with the sports medicine professional that
is leading his rehabilitation. However, he has considered incorporating addi-
tional self-guided throwing exercises to supplement his rehabilitation.
–––––––– ? ––––––––
1. Consider the biopsychosocial model of rehabilitation. In addition to biolog-
ical factors and injury characteristics, list specific sociodemographic,
psychological and social/contextual factors that may influence the sport
injury rehabilitation process for Michael.
2. Describe a multimodal intervention that could serve to keep Michael moti-
vated towards his rehabilitation and target rehabilitation adherence.
Michael is frustrated at his restricted activity; this may cause him to be
nonadherent to the rehabilitation protocol by engaging in activities not
recommended by his sport medicine professional.
3. What strategies can the sport medicine professional incorporate into reha-
bilitation to keep Michael on track with his rehabilitation protocol?
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PART 2
Psychological interventions in
sport injury rehabilitation
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5
GOAL SETTING IN SPORT INJURY
REHABILITATION
Monna Arvinen-Barrow and Brian Hemmings
Introduction
Since the original work of Locke and Latham (1985), goal setting has become one
of the most popular and widely used psychological interventions in sport and is
often implemented by athletes with the aim of improving performance (Weinberg
and Gould, 2011). Research has identified three different types of goals; namely
outcome, performance and process goals (for example, Cox, 2007; Hardy, Jones and
Gould, 1996). Outcome goals are usually focused on the outcome of an event such
as winning or earning a medal and involve interpersonal comparison. In contrast,
performance goals often involve intrapersonal assessment, as they are typically
focused on achieving a particular level of performance in comparison to one’s
previous performances and not to that of other competitors. Process goals are
focused on the actions and required tasks in which an individual must engage to
achieve the desired performance outcome (for example, Cox, 2007; Hardy et al.,
1996; Weinberg and Gould, 2011). According to Cox (2007), when all outcome,
performance and process goals are used in combination, athletes are more likely to
experience higher levels of performance improvement and psychological develop-
ment in comparison to when different goals (for example, outcome goals) are used
in isolation.
Moreover, the mechanistic goal setting theory (Locke and Latham, 1990)
proposes that a linear relationship exists between the above-mentioned goals and
performance. According to the model, goals which are difficult yet realistic, specific
and measurable lead to greater performance improvement than vague, easy and do-
your-best goals, provided that the person who is trying to achieve the goals has
accepted and taken ownership of the set goals. These theoretical principles have
since been applied to the rehabilitation setting and research has shown that goal
setting can also be of benefit to athletes when injured (see, for example, Beneka et
al., 2007). Since athletes are naturally goal driven (Heil, 1993b) and often
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Goal setting in sport injury rehabilitation 57
accustomed to use goal setting on a frequent basis, using this technique in injury
rehabilitation should not be difficult but may not always be apparent.The purpose
of this chapter is therefore to discuss how goal setting might be applied within the
sport injury rehabilitation context. More specifically, the chapter: (a) introduces the
purpose of goal setting within the sport injury context; (b) discusses the ways in
which injured athletes can benefit from using goal setting during rehabilitation; (c)
introduces different types and levels of goals that might be beneficial during reha-
bilitation; and (d) outlines the basic principles of goal setting during rehabilitation.
Rehabilitation goal setting: the purpose

According to the integrated model of psychological response to the sport injury
and rehabilitation process (Wiese-Bjornstal, Smith, Shaffer and Morrey, 1998), the
use of goal setting during rehabilitation is a multifaceted construct. In short, the
model proposes that injured athletes’ use/disuse of psychological strategies (for
example, goal setting, a behavioural response) can have an impact on an athlete’s
cognitive appraisal of the injury (for example, ability to adjust their goals or rate of
perceived recovery), which can have an impact on their emotional responses to the
injury (for example, feelings of frustration, anger and attitude). In a similar manner,
the cyclical relationships between cognitions, emotions and behaviours also func-
tions in reverse; the use of psychological strategies such as goal setting can also have
a direct impact on an athlete’s emotional response (for example, facilitate emotional
coping), which, in turn, can then impact an athlete’s cognitive appraisal of the
injury (for example, facilitate cognitive coping), which, in turn, can affect behav-
ioural responses (for example, facilitate behavioural coping). The model also
proposes that these cognitive, emotional and behavioural responses are mediated by
a range of personal (for example, motivation, existing psychological skills) and situ-
ational factors (for example, level of competition, sport medicine team influences;
for more details on the model, see Chapter 3).
Given the above, it is apparent that rehabilitation goal setting can serve multiple
purposes for the athlete. Since goal setting is a motivational tool that can effectively
energise athletes to become more productive and effective (Locke and Latham,
1990), its main aim should be to identify clear objectives for the rehabilitation
process to enable athletes to return back to full fitness both mentally and physically.
At its best, a well-planned and structured goal setting programme facilitates full
physical, psychological and performance recovery, and allows athletes the possibil-
ity to make substantial performance gains (Taylor and Taylor, 1997).
Rehabilitation goal setting: benefits to the athlete

Research on the goal setting process during sport injury rehabilitation has shown
that it has multiple benefits to the athlete. For example, setting goals during reha-
bilitation has been found to have a positive effect on the athlete’s physiological and
psychological healing (Ievleva and Orlick, 1991; Taylor and Taylor, 1997).
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58 Monna Arvinen-Barrow and Brian Hemmings
According to Beneka et al. (2007), some of the benefits include pain management
when obtaining normal range of motion, muscular strengthening and numerous
sport-related skills. Moreover, it appears that goal setting has a positive effect on the
overall injury recovery process, as it has also been found to enable faster recovery
and return back to sport (DePalma and DePalma, 1989). More recently, goal setting
has been found to impact injured athletes’ attitude, successful appraisal/acceptance
of the injury, overall confidence in the injury recovery, as well as adherence to the
rehabilitation programme (Armatas, Chondrou, Yiannakos, Galazoulas and
Velkopoulos, 2007).
Of all the benefits mentioned above, it has been suggested that the main reasons
why goal setting appears to be useful for injured athletes during rehabilitation, is
its positive effects on adherence (for example, Arvinen-Barrow, Penny, Hemmings
and Corr, 2010; Niven, 2007). The relationship between rehabilitation adherence
and goal setting has been well documented in the literature and research has found
it to provide the athlete with a sense of achievement and accomplishment, which
further increases adherence (Fisher, Mullins and Frye, 1993). Moreover, goal setting
has also been found to facilitate athletes’ levels of motivation, effort and persistence
(Brewer, Jeffers, Petitpas and Van Raalte, 1994; Weiss and Troxel, 1986), which can
also be seen as beneficial in enhancing adherence. Over time, the use of goal setting
during injury rehabilitation is also thought to increase athletes’ levels of self-effi-
cacy and self-confidence, as well as decrease athletes feelings of ‘unspiritedness’ (for
example, loss of motivation and apathy; Evans and Hardy, 2002a), which have been
linked with increased adherence. Moreover, goal setting has been found to impact
common rehabilitation objectives such as communication, rehabilitation outcome
assessment, as well as increasing overall adherence (Playford, Dawson, Limbert,
Smith and Ward, 2000). As research suggests that adherence is a key determinant of
whether or not an athlete is able to cope successfully with their rehabilitation
(Arvinen-Barrow, Hemmings, Weigand, Becker and Booth, 2007; Clement,
Granquist and Arvinen-Barrow, 2013; Heaney, 2006; Lafferty, Kenyon and Wright,
2008), it would seem that the use of goal setting to increase adherence is positively
indicated.
Goal setting is vital. . . and very useful, very effective . . . because it is certainly for
something where they (the athletes) can measure it themselves and see how they
are doing Monday, Tuesday, Wednesday, Thursday and then by Friday they are
getting the results that they want, so I think that’s, that’s certainly vital.
(A Chartered Physiotherapist, cited in Arvinen-Barrow et al., 2010)
Types and levels of goals

As sport injury can impact an athlete physically (that is, restricts movement and use
of the injured and/or the surrounding area), psychologically (that is, changes in
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mood), tangibly (that is, restricts the accomplishment of typical daily tasks) and
even financially (that is, loss of income owing to inability to work), an awareness
of different types of rehabilitation goals is imperative. According to Taylor and
Taylor (1997), physical goals can enable a clear direction for the physical aspects of
recovery, whilst psychological goals can assist with issues associated with motiva-
tion, self-confidence, focus, stress and anxiety. Equally, performance-related goals
can benefit the athlete by identifying potential areas for improvement in different
areas of performance (for example, technical and tactical development, specific
physical conditioning, mental training, and return to form), which, during regular
training, might not have received priority.
Although setting different types of goals can provide injured athletes with clear
objectives (Flint, 1998), it is also necessary to think about how these goals can be
accomplished. Given that the ultimate aim of any rehabilitation is to return back
to full fitness and often this can be a long-term process, injured athletes also need
daily encouragement to ensure adherence to the rehabilitation programme
(Hamson-Utley and Vazques, 2008).Taylor and Taylor (1997) propose that, during
sport injury rehabilitation, different levels of goals should also be considered (see
Figure 5.1). Hence, they propose four levels of goals; namely recovery, stage, daily
and lifestyle goals. Recovery goals are associated with the final level of recovery
(long-term goals), stage goals consist of specific objectives for each of the different
stages of rehabilitation (medium-term goals) and daily goals relate to daily objec-
tives and targets for each rehabilitation session (short-term goals). Often, daily goals
can be overlooked in a goal setting programme; however, they should be set to
ensure that stage and recovery goals will be successfully attained. In addition,Taylor
and Taylor (1997) recommend that goals related to the athlete’s lifestyle should also
be considered, as, often, existing lifestyle (that is, sleep, diet, alcohol and drug use,
relationships, work and school commitments) can either assist or hinder rehabilita-
tion adherence and, ultimately, have an adverse effect on recovery outcome.White
and Black (2004) also recommend identifying and setting goals for employment,
social and leisure activities and general household tasks as useful for injured
athletes.
Using goal setting for rehabilitation: the process

Setting goals during injury rehabilitation should follow a systematic and organised
sequence of events to increase its effectiveness.These events can be conceptualised
in terms of four phases: 1) assess and identify athletes’ personal and physical needs
for successful rehabilitation and recovery; 2) identify and set appropriate physical,
psychological and performance goals; 3) consider factors that may influence goal
setting effectiveness; and 4) follow a step-by-step programme to integrate goal
setting into injury rehabilitation.What follows is a more detailed description of the
steps above to provide the reader with guidelines on how to improve the useful-
ness of goal setting in injury rehabilitation.
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RECOVERY GOALS (long term)

LIFESTYLE
Used to specify the ultimate level of recovery at the conclusion of rehabilitation. GOALS
Includes physical, psychological and performance goals
Issues in
L
relation to
E
sleep, diet,
V
alcohol or
E
drug use,
L
relationships,
S
STAGE GOALS (medium term) work and
school
O Consists of objectives for each stage of rehabilitation, thus making recovery goals
F more manageable. Includes physical, psychological and performance goals
G
O
A
L
S DAILY GOALS (short term)
These goals are aimed to specify what will be done in each physiotherapy session.
Usually not prepared as part of the goal setting but evolve during the session.
Should be clear and leading towards stage and recovery goals
T
Y
P PHYSICAL GOALS PSYCHOLOGICAL GOALS PERFORMANCE GOALS
E Including goals in relation to Including goals regarding Including goals in relation to
S
range of motion, strength, issues in relation to technical and tactical
O stability, stamina, flexibility, confidence, motivation, development, physical
F coordination and other focus, anxiety, pain tolerance conditioning, mental
relevant physical parameters training and return to form
G
O
A
L
S
FIGURE 5.1 Types and levels of goals for rehabilitation

Source: adapted from the works of Taylor and Taylor, 1997 (Arvinen-Barrow, 2009)
Phase 1: Assess and identify athletes’ personal and physical needs

One of the ways in which the assessment and identification of injured athletes’
personal and physical needs can be facilitated is through the use of rehabilitation
profiling (Taylor and Taylor, 1997). Founded in the principles of performance
profiling (Butler, Smith and Irwin, 1993), rehabilitation profiling can help to gain
an understanding of an athlete’s perceptions of their current personal and physical
factors influencing rehabilitation and recovery. Profiling enables injured athletes
and sport medicine professionals to gain a visual display of a range of factors that
are deemed to be important during the rehabilitation. Once these areas have been
identified, they can then provide a foundation for subsequent goal setting for the
sport medicine team (for more details, see Chapter 10).
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Phase 2: Identifying and setting effective goals: key characteristics

Once the athlete’s personal and physical needs have been identified, it is important
to ensure that the subsequent goals are appropriate. A number of guidelines on
effective goals have been proposed in the literature (for example, Cox, 2007; Gould,
1986; Heil, 1993b;Taylor and Taylor, 1997) and follow these general principles:
• understand the importance of setting the right type of goals;

• set goals that are specific and measurable;
• set challenging but realistic and attainable goals;
• focus on the degree of, rather than on the absolute, attainment of goals;
• set goals that are stated in a positive manner.
Understand the importance of setting the right type of goals

Flint (1998) argues that it is important to set both short- and long-term goals and,
when possible, to link goals with aspects of the athlete’s performance with which
he/she is familiar (for example, designing goals to enhance important aspects of the
athlete’s sport). Flint also suggests that greater emphasis should be placed on process
goals, since they are more likely to be within the athlete’s own control and are
directly linked with effort. More specifically, process goals should be linked with
outcome goals and, as such, should be set for all levels of rehabilitation (short, inter-
mediate and long term; Taylor and Taylor, 1997). Indeed, Evans Hardy, and
Flemming (2000) found support for the use of long- and short-term goals, as well
as process and performance goals.
Set goals that are specific and measurable

Locke and Latham (1990) proposed that vague and immeasurable goals are not as
effective as specific and measurable goals.Without the ability to measure progress,
the athlete may easily feel that rehabilitation is not progressing, thus leading to
decreased levels of motivation and disengagement (a behavioural response), as well
as negative changes in mood (an emotional response) and irrational thoughts asso-
ciated with injury, recovery and self (a cognitive appraisal). Ensuring the goals are
specific and measurable allows the injured athlete to evaluate progress and there-
fore sustain effort throughout the different phases of rehabilitation.
Set challenging but realistic and attainable goals

A number of researchers appear to be in an agreement that goals that are too easy
or too difficult can lead to decreased levels of motivation and thus lead to the
athlete ‘giving up’ before they even start (for example, Cox, 2007; Gould, 1986;
Heil, 1993b;Taylor and Taylor, 1997). Ensuring that goals meet the athlete’s needs
is of particular importance during injury rehabilitation when their thoughts,
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emotions and behaviours may already be uncharacteristic to their typical responses,

owing to the injury.
Focus on the degree of, rather than on the absolute attainment of goals
Despite the importance of setting goals with a clear timetable for completion, it is
common for a rehabilitation process to progress faster or slower than originally
predicted. According to Gilbourne and Taylor (1998), ‘recovery is typified by an
unpredictable mix of rapid progress and disappointing setbacks’ (p. 135) and, as
such, research tends to be in favour of adopting a flexible approach to goal setting
during rehabilitation (Heil, 1993a). Therefore, emphasis should be on the degree
of, rather than absolute, attainment of goals to ensure that they remain reachable
and meaningful for the athlete (for example, making gradual percentage gains in
range of motion). A qualitative study by Evans et al. (2000) found goal flexibility
to be greatly beneficial during recovery setbacks and in dealing with unpredictable
physical factors such as swelling, soreness and pain.
Set goals that are stated in a positive manner

Rehabilitation goals should also be set in a positive manner. Given that injured
athletes may engage in negative self-talk during rehabilitation, using positive
terminology in goal setting can also assist in challenging negative thoughts (for
more details on self-talk in rehabilitation, see Chapter 8).
Phase 3: Identify and consider factors affecting goal setting

effectiveness
In addition to ensuring that goals are set in an appropriate manner, there are a
number of other factors that can have an impact on goal setting effectiveness that
should be considered by those involved in the goal setting process.
Ensure that goal setting is fully integrated into rehabilitation

In order for goal setting to be successful, it is vital that injured athletes and sport
medicine professionals both regard it as an integral part of rehabilitation. Goal
setting as a psychological technique is easily paired with a behavioural outcome
that can be directly linked to rehabilitation process or outcome (for example,
setting appropriate rehabilitation goals will help speed up the recovery process and
improve adherence). Motivating athletes and sport medicine professionals to use
systematic goal setting should not, therefore, be difficult, provided that they are
appropriately educated about the process and benefits of goal setting. Indeed, it
appears that sport medicine professionals already display positive attitudes towards
the use of goal setting (Arvinen-Barrow et al., 2007; Arvinen-Barrow et al., 2010;
Hamson-Utley, Martin and Walters, 2008) and, owing to their usual close daily
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proximity to the injured athlete, they are in an ideal position to use systematic goal
setting procedures effectively during rehabilitation.
Consider goal setting as an individualised mutual sharing and dynamic

process
Flint (1998) believes that goal setting should include specific details on how goals
are to be achieved and that this process should be educational. Sport medicine
professionals involved in the process need to work together with the injured athlete
to establish realistic goals for the rehabilitation programme (Kolt, 2004).Through a
good understanding of the goal setting process and desired outcome, an athlete is
more likely to comply with the rehabilitation programme. Involving the athlete
will also facilitate greater levels of communication and increase understanding and
awareness of the injury and rehabilitation process. Likewise, enhanced communi-
cation leads to better trust and rapport between athlete and support personnel.
Moreover, goal setting during rehabilitation is also a process which evolves over
time and is impacted by a number of personal (for example, injury factors and indi-
vidual differences) and situational (for example, rehabilitation team influences)
factors. Owing to this dynamic process, any goal setting during rehabilitation
should be individualised and should attempt to incorporate all factors needed for
a successful return to sport.
It appears that goal setting is often used during rehabilitation, although this may
be in an unstructured way (for example, Arvinen-Barrow et al., 2010). It appears
that setting goals during rehabilitation is often sport medicine professional
mandated, rather than a result of a mutual dialogue between the athlete and the
sport medicine professionals (Arvinen-Barrow et al., 2010). Moreover, sport
coaches have reported the need to use goal setting during injury rehabilitation but
their assistance has not been systematic in nature (Podlog and Dionigi, 2010). For
goal setting to be effective, including the athlete, coach and relevant members of
the rehabilitation team in the goal setting process is vital.
Understand the importance of goal acceptance/commitment

Gilbourne,Taylor, Downie, and Newton (1996) believed that, for goal setting to be
successful, the athletes involved would have to accept the set goals, as, without goal
commitment, goal setting would be ineffective. To increase commitment to
rehabilitation goals, injured athletes need to feel that their opinions are valued and
that their input is an integral part of the rehabilitation process as a whole (Wauda,
Armenth-Brothers and Boyce, 1998). These feelings of shared ownership of a
programme can facilitate higher levels of commitment and motivation, which, in
turn, can increase rehabilitation adherence. Moreover, as goal setting is a process
which should involve all those involved in the rehabilitation, it is equally impor-
tant to ensure sport medicine professionals working with the athlete are also
committed to the goals (Flint, 1998).
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Monitor and evaluate set goals regularly

To maintain athlete and sport medicine professional commitment, to assess goal
setting effectiveness and to ensure that goal setting is continually appropriate for
the injured athlete in the different phases of rehabilitation, it is important to moni-
tor, evaluate and adjust goals during the course of rehabilitation (Flint, 1998;
Gould, 1986; Heil, 1993b).Through monitoring, evaluation and regular feedback,
the injured athlete could be helped to understand and appreciate their progress and
subsequently increase their feelings of personal achievement, motivation and atti-
tude towards recovery. This can positively influence commitment, treatment
compliance and adherence as well as overall recovery outcomes.
Prepare a written contract with the injured athlete

Commitment, adherence and motivation to work towards the set goals can be
influenced by preparing a written contract to which both the athlete and the sport
medicine professionals are bound. Moreover, when both parties are clear of the
expectations placed upon them during rehabilitation, the recovery is likely to
progress with fewer complications (Figure 5.2).
Be aware of variability in goal setting effectiveness

Despite the apparent benefits of goal setting during rehabilitation, it is important
to note that it is not always effective. For example, Johnson (2000) investigated the
effects of short-term psychological interventions on injured athletes’ mood and
found that when used in isolation, goal setting had no significant effects. However,
when used in combination with other psychological interventions (for example,
stress management strategies, self-talk, relaxation techniques or imagery), goal
setting was found to have the potential to help elevate athletes’ mood during
rehabilitation.
Moreover, it is also important to note that not always do athletes and sport
medicine professionals view the effectiveness of psychological interventions
equally. For example, Francis, Andersen, and Maley (2000) found that sport medi-
cine professionals regarded the use of short-term goals as an effective technique for
treatment and believed that athletes who set goals during rehabilitation were more
likely to cope better with their injuries. Conversely, the athletes in this study
viewed goal setting as useful for coping with injuries but rated the importance of
setting short-term goals considerably lower than the sport medicine professionals.
Nevertheless, if the basic guidelines of systematic goal setting are followed, these
differences in opinions about the effectiveness will be highlighted and, as a result,
adjustments to the goal setting programme can be made to ensure that it meets the
needs of all parties involved.
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Injured athlete
I, ___________________________ agree to diligently fulfil my responsibilities in the

rehabilitation of my injury. These responsibilities include:
1. Taking full control of all aspects of my rehabilitation.

2. Precise adherence to the rehabilitation programme designed for me.
3. Attendance at all scheduled physiotherapy sessions.
4. Completion of all exercises outside the rehabilitation facility.
5. Full effort, focus and intensity with all aspects of my rehabilitation regimen.
6. Consistent pursuit of the goals I set in my rehabilitation goal setting programme.
7. Developing psychological areas that impact my recovery and return to sport
(e.g. addressing re-injury anxieties).
8. Improving myself as an athlete during rehabilitation.
9. Seeking assistance from others when difficulties arise.
Rehabilitation professional
I, ___________________________ agree to diligently fulfil my responsibilities as the

rehabilitation professional in the rehabilitation of ___________________’s injury. These
responsibilities include:
1. Designing an individualised rehabilitation programme for the injured athlete.

2. Educating the athlete about all relevant aspects of the rehabilitation process.
3. Helping to establish a series of goals that will progressively lead to full recovery
and return to sport.
4. Creating a rehabilitation team with other relevant professionals.
5. Being sensitive and responsive to psychological and emotional needs.
6. Assisting the athlete in overcoming physical and psychological obstacles that may
arise during rehabilitation.
7. Providing the athlete with the information and skills to facilitate physical,
psychological and performance contributors to a successful return to sport.
______________________________ __________________________
Athlete Date
______________________________ __________________________
Rehabilitation professional Date
FIGURE 5.2 An example of a rehabilitation contract

Source: adapted from Taylor and Taylor, 1997
Phase 4: A step by step programme to integrate goal setting into

injury rehabilitation
When setting goals for rehabilitation, the above principles can ensure goals are set
appropriately for each individual in question. According to Taylor and Taylor
(1997), the process for setting such goals should begin with a conversation between
the rehabilitation professionals and the athlete in which critical physical aspects of
rehabilitation are discussed and explained.This should then be followed by setting
clear goals for each of the components of physical recovery: range of motion,
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strength, stability, stamina, flexibility, and any other relevant physical parameters.
Psychological goals should then be discussed in a similar manner. One of the most
effective ways to initiate psychological rehabilitation goals is through rehabilitation
profiling (Taylor and Taylor, 1997). Secondly, strategies for achieving goals need to
be agreed upon and learned by athletes. By doing so, the athlete is more likely to
feel a sense of control (Boyle, 2003; Kolt, 2004), which has been found to have an
effect on rehabilitation adherence. Thirdly, and perhaps most importantly, the set
goals need to be revised and assessed on a regular basis in order for them to be
effective (Gould, 1986). Butler (1997) indicates that this could be done through
various methods, such as diaries, meetings, graphs, and rehabilitation contracts.
Process of goal setting during sport injury rehabilitation
1. Start with a conversation between the rehabilitation professionals and the

athlete.
2. Set clear goals for each of the components of physical recovery: range of
motion, strength, stability, stamina, flexibility and any other relevant phys-
ical parameters.
3. Discuss psychological goals in a similar manner by using a tool such as
rehabilitation profiling (for more details, see Chapter 10).
4. Agree upon any strategies needed for achieving goals.
5. Remember to revise and assess your goals regularly.
(Taylor and Taylor, 1997)
Conclusion
The importance of setting goals during rehabilitation has been highlighted in the
literature. Support for goal setting can be found in various studies investigating
athletes representing a range of sports, and various competitive levels (for example,
Bassett and Petrie, 1999; Brewer et al., 1994; Evans and Hardy, 2002a, 2002b; Evans
et al., 2000; Francis et al., 2000; Gilbourne et al., 1996; Gould, Udry, Bridges and
Beck, 1997; Ievleva and Orlick, 1991; Johnson, 2000). In summary, studies to date
have indicated that using goal setting during sport injury rehabilitation is benefi-
cial. For many injured athletes, the hardest thing is to try and pace their recovery
appropriately and not to progress too fast (Samples [1987] cited in Wagman and
Khelifa, 1996: 257). Through goal setting, appropriate pace of progression can be
identified and monitored. Furthermore, goal setting often forms an integral part of
an athlete’s everyday training programmes. Thus, it makes sense to continue simi-
lar procedures during rehabilitation. For that reason, the integration of goal setting
into the rehabilitation process is not only profitable but, with the right guidance
and support, should also be easily transferable (Taylor and Taylor, 1997).
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CASE STUDY
Marika is a 16-year-old, international-level synchronized skater who has

recently suffered a grade III hamstring injury to her left leg. Her doctor and
physiotherapist have told her that the recovery would take up to five weeks
and she has been advised to use crutches to help her walk. Marika is ignoring
her doctor’s and physiotherapist’s advice and is often found walking without
using her crutches, particularly when at school. When asked about reasons as
to why she is not using crutches, Marika replies: ‘it’s so much easier not to use
the crutches, as that way I don’t have to ask my friends to help me with minor
things like carrying my lunch tray to the table . . . I mean, I am not crippled you
know. And at school, the breaks are so short that by the time I call the lift, and
it comes to my floor, and takes me downstairs, I would have walked the stairs
up and down several times, and the break is nearly over. Yes, I do have an
injury in my leg, but it’s really not a big deal. I will be back skating in no time’.
Six weeks later, Marika is still not fit to train. Her hamstring has not fully healed
and it keeps swelling up after completing her rehabilitation exercises. Marika is
getting frustrated and angry with the process and often takes this out on her
mother and her 13-year-old brother Matti. This has obviously impacted on the
overall mood in their home and resulted in Marika being really distant and
uncooperative when at home. Marika is now refusing to do her home exercises
and thinks watching daytime TV, eating crisps and chocolate is much more fun
than doing the ‘boring’ rehabilitation exercises. The season is fast approaching
and Marika does not think she is going to be ready to go back on the ice and
does not believe that she will be selected to skate at the first competitions in
three months time. ‘I am just not good enough to skate; others know the
programme much better than I do . . . so what is the point of even going to the
rink if I can’t compete?’ These thoughts, along with spending time with her
classmates who do not skate but spend their afternoons at the local shopping
centre, has led to her thinking about quitting skating altogether. Marika’s
mother and father are obviously not happy with the situation, especially after
they got a letter from her physiotherapist enquiring why Marika had missed her
last three physiotherapy sessions, despite her parents paying them in advance.
–––––––– ? ––––––––
1. With reference to the integrated model of psychological response to sport
injury and rehabilitation process (Wiese-Bjornstal et al., 1998), what factors
described in the case study may have affected Marika’s cognitive appraisal
of her hamstring injury?
2. What types of goals might be beneficial for Marika and why?
3. Following goal setting principles (Gould, 1996), set a variety of daily, stage,
recovery and lifestyle goals to help Marika get back to skating and be ready
to compete in three months.
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6
IMAGERY IN SPORT INJURY
REHABILITATION
Monna Arvinen-Barrow, Damien Clement and

Brian Hemmings
Introduction
Many athletes, coaches and sport psychology professionals appreciate the usefulness
of mental imagery in enhancing sport performance (Hall, 2001). A wealth of
research evidence exists in support of imagery as being one of the most popular
performance-enhancement techniques in sport (for example, DeFrancesco and
Burke, 1997; Hall and Rodgers, 1989; Pain, Harwood and Anderson, 2011;
Weinberg and Gould, 2011). It appears that athletes of all levels frequently use
imagery (for example,Arvinen-Barrow,Weigand, Hemmings and Walley, 2008) and
that élite, high-level and successful athletes use significantly more imagery than
their novice, lower-level and less successful counterparts (for example, Arvinen-
Barrow et al., 2008; Callow and Hardy, 2001; Cumming and Hall, 2002a, 2002b).
It has also been found that the use of imagery goes beyond sport type classification
(for example, team vs. individual, open vs. closed, and fine vs. gross skill) as athletes
involved in a range of sports such as gymnastics, dance, figure and synchronised
skating, field hockey, rugby and martial arts appear to use imagery extensively (for
example, Arvinen-Barrow et al., 2008; Arvinen-Barrow, Weigand, Thomas,
Hemmings and Walley, 2007; Hall, Rodgers and Barr, 1990; Munroe, Hall, Simms
and Weinberg, 1998) and do so at different times of the season (for example,
Arvinen-Barrow et al., 2008; Cumming and Hall, 2002a; Munroe et al., 1998).
However, despite the documented use of imagery by athletes of different levels in
a variety of sports, using imagery during sport injury rehabilitation appears to be
largely underutilised (Walsh, 2005).This could be because of a lack of understand-
ing of how imagery works in a rehabilitation setting (Arvinen-Barrow, Penny,
Hemmings and Corr, 2010; Brewer, Jeffers, Petitpas and Van Raalte, 1994; Walsh,
2005;Wiese,Weiss and Yukelson, 1991) or simply an indication of athletes’ inabil-
ity to transfer skills that they normally use for performance enhancement into
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72 Monna Arvinen-Barrow, Damien Clement and Brian Hemmings
injury rehabilitation. This chapter discusses how imagery could be applied within
sport injury rehabilitation context. More specifically, the chapter: (a) introduces
existing definitions; (b) discusses the ways in which injured athletes can benefit
from using imagery during rehabilitation; (c) presents the different types of imagery
that might be beneficial during rehabilitation; (d) provides an overview of the
existing research findings on each of the imagery types; (e) introduces the different
functions of imagery; and (f) outlines the process of using imagery during rehabil-
itation.
Rehabilitation imagery: concept definitions

Morris, Spittle, and Watt defined imagery in the context of sport as:
the creation or re-creation of an experience generated from memorial infor-

mation, involving quasi-sensorial, quasi-perceptual, and quasi-affective
characteristics, that is under the volitional control of the imager, and which
may occur in the absence of the real stimulus antecedents normally associ-
ated with the actual experience.
(Morris, Spittle and Watt, 2005: 19)
Similarly, Dent described imagery as:
cognitively reproducing or visualizing an object, scene or sensation as though

it were occurring in overt, physical reality. It evokes the physical characteris-
tics of an absent object, event or activity that has been perceived in the past,
or may take place in the future.
(Dent [1985] cited in Driediger, Hall and Callow, 2006: 262)
Based on these definitions, imagery can be described in ‘lay terms’ as an activity

which involves creating a clear mental picture of the sporting situations, which can
mean the venue, the performance, the conditions, the people, the emotions and the
feelings.
When applied to sport injury rehabilitation, imagery can be seen as an activity
in which the athlete can create images of (but not limited to): the healing process,
the injured body part fully healed and restored to normal levels of functioning, the
rehabilitation setting, successfully completing rehabilitation exercises, dealing with
pain and any emotions associated with the injury and recovery process.
Rehabilitation imagery: benefits to the athlete

As stated earlier, imagery has been found to be quite useful in the sporting context
for maintaining and/or improving athletic performance. Furthermore, its applica-
bility to injury rehabilitation is increasingly being documented in the literature,
since imagery has been associated with facilitating the speed of physical recovery
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Imagery in sport injury rehabilitation 73
(Beneka et al., 2007; Ievleva and Orlick, 1991; Walsh, 2005), in addition to being
deemed useful for athletes during the rehabilitation process. More specifically,
imagery within in the context of injury rehabilitation has been found to:
• facilitate athletes’ ability to better cope with their injuries (Gould, Udry,
Bridges and Beck, 1997; Rotella, 1982) in addition to facilitating closure to
their injury experience (Green, 1992; Green and Bonura, 2007);
• help athletes to manage the emotions, anxiety, worry and stressors typically
associated with their injuries and the rehabilitation process (Hamson-Utley
and Vazquez, 2008; Monsma, Mensch and Farroll, 2009);
• help injured athletes to deal with the pain associated with injuries (Hamson-
Utley and Vazquez, 2008);
• assist athletes in eliminating counterproductive thoughts and aid in the devel-
opment of a ‘positive self ’ (Driediger, et al., 2006);
• increase injured athletes’ rehabilitation motivation and subsequently rehabilita-
tion adherence and compliance (Hamson-Utley and Vazquez, 2008);
• prepare athletes for successful return back to pre-injury level of performance,
both physically (that is, maintain sport-specific skills through the use of
performance imagery) and psychologically (for example, assist in increasing
levels of confidence, decreasing levels of re-injury anxiety; see, for example,
Walsh, 2005).
Using imagery during rehabilitation
I think it’s big. Especially just while doing the exercises and stuff because inevitably,
well, especially after mine where I had the surgery and the muscles kind of went
into atrophy. . . I had to reteach myself how to do things. And the only way I could
do it, it’s not like it’s just going to happen and you can’t rely on that. Or, if you do
then it’s just going to take a lot longer. So, it’s kind of the same thing as with
weight training, if you visualize it before, then you’ll progress a lot faster and you’ll
start to see better results.
(An injured athlete, cited in Driediger et al., 2006: 267)
Types of imagery
Thus far, a number of different types of imagery have been proposed as suitable and
beneficial for rehabilitation. Drawing from the literature (Flint, 1998; Rotella, 1982,
1985; Rotella and Heyman, 1993;Taylor and Taylor, 1997),Walsh (2005) compiled
the existing information and listed four main types of imagery beneficial to sport
injury rehabilitation: (1) healing imagery (that is, visualising and feeling the injured
body part healing), (2) pain management imagery (that is, assisting the athlete to
cope with the pain associated with the injury), (3) rehabilitation process imagery
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(that is, assisting in dealing with challenges that athletes may encounter during the
rehabilitation programme), and (4) performance imagery (that is, practising physi-
cal skills and imagining themselves performing successfully and injury free). The
following section provides an introduction to each of these types of imagery.
Healing imagery
Healing imagery refers to images in which the athlete will see the injured body
part healing (for example, imagining seeing ruptured muscle tissue getting better).
According to Walsh (2005), healing imagery can be used to envision the internal
processes and anatomical healing that take place during rehabilitation. Taylor and
Taylor (1997) claim that, for effective healing imagery, an athlete must possess a full
understanding of their injury and have the ability to recreate a realistic picture of
the injured area. An awareness of the anatomical healing process and knowledge of
the treatment modalities employed during rehabilitation is also essential.
Furthermore, an athlete should know what the injured body part should look like
once healed. Given the above, it can be assumed that engagement in successful
healing imagery requires a fair amount of knowledge and training, which unsur-
prisingly requires some time and effort from the individual athlete and those
involved.
Pain management imagery

Pain management imagery requires the injured athlete to create images of them-
selves free of pain. Of the six pain management techniques identified by Fernandez
and Turk (1986; cited in Heil, 1993b: 163), pleasant imagining (visualising yourself
in a comfortable and relaxed setting such as lying on a beach), pain acknowledge-
ment (assigning the pain physical properties, such as colour, size, shape, sounds,
feelings) and dramatised coping (pain seen as part of a challenge and reframing it
as a motivational tool) are seen as most appropriate for sport injury rehabilitation
(Walsh, 2005). All of the aforementioned types of pain management imagery can
help injured athletes better cope with pain, reduce pain levels experienced and
subsequently assist the athlete in dealing with a number of emotional and behav-
ioural responses sometimes associated with injury.
Rehabilitation process imagery

Rehabilitation process imagery allows the injured athletes to create images of the
many different aspects of rehabilitation process they could potentially experience
such as completing exercises, adhering to the rehabilitation programme, overcom-
ing setbacks and obstacles, maintaining a positive attitude and staying focused (Heil,
1993a; Ievleva and Orlick, 1991;Wiese et al., 1991). Moreover, this type of imagery
can assist athletes in dealing with the challenges they may encounter during the
course of the rehabilitation (Walsh, 2005). One of the ways in which rehabilitation
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process imagery is proposed to facilitate recovery is through self-efficacy. If an

athlete believes and is able to visualise their ability to successfully complete an
assigned rehabilitation task and/or exercise, he/she is more likely to be able to
perform well and succeed. Green and Bonura (2007) argue that rehabilitation
process imagery is central in a sport injury rehabilitation programme, as it can
enhance athletes’ motivation and subsequently have a positive effect on adherence.
Performance imagery
Performance imagery, through the mental rehearsal of sport-specific skills during
rehabilitation, can help increase injured athletes’ confidence in their ability to
return to sport (Walsh, 2005). Furthermore, by imagining themselves back at play,
injured athletes may report a decrease in the stress and anxiety that some may expe-
rience in the lead up to their return to play (Walsh, 2005). However, caution in the
use of arousal-provoking images during rehabilitation is warranted, as they can
result in heightened levels of somatic anxiety before returning back to sport
(Monsma, et al., 2009). Performance imagery can also help athletes to achieve
major performance gains in areas which may not receive priority during regular
training (Walsh, 2005). Moreover, as athletes often view injury as a hindering
setback and as an obligatory and sometimes unnecessary time away from their sport
(Taylor and Taylor, 1997), performance imagery can be useful in allowing athletes
to recognise performance gains that are likely to increase their motivation and
potentially improve the rehabilitation process (Richardson and Latuda, 1995).
Review of the literature of imagery type: an overview

This section provides a brief review of the literature on each of the imagery types
presented above. While this review is not exhaustive, the primary goal of this
section is to provide the reader with an overview of the research on imagery types
and their effectiveness during rehabilitation.
To date, only a few studies have examined the possible benefits and effects of
healing imagery in the rehabilitation context and on the recovery process (Cupal
and Brewer, 2001; Handegard, Joyner, Burke and Reimann, 2006; Ievleva and
Orlick, 1991; Loundagin and Fisher, 1993). The literature indicates that athletes
who recovered faster have reported using significantly more healing imagery
during the rehabilitation process than those who recovered more slowly, and that
fast healing athletes also tended to take personal responsibility for their healing
through the use of creative visualisation. When used in combination with relax-
ation and as an adjunct to physical rehabilitation, healing imagery has also been
found to be beneficial in increasing knee strength, decreasing re-injury anxiety and
lowering pain (Cupal and Brewer, 2001). Thus far, evidence (albeit very limited)
exists in support of healing imagery facilitating physical healing. However, rather
than focusing on the physical aspects of recovery, it has also been suggested that the
effectiveness of healing imagery could also include psychological benefits.
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However, to date, these have not been empirically tested (Walsh, 2005). More
specifically, healing imagery may be beneficial to injured athletes in increasing self-
confidence, motivation, rehabilitation adherence, anxiety control and ability to
manage pain but, thus far, the beneficial effects of the above are merely anecdotal.
Similarly to healing imagery, little research has examined the effectiveness of
pain management imagery in sport injury rehabilitation. Until now, existing stud-
ies have used different types of imagery as a means to alleviate pain but not
specifically employed what is considered as pain management imagery. For exam-
ple, Cupal and Brewer (2001) found reduction in pain as one of the main benefits
of using a combination of relaxation and guided imagery when used in addition to
physiotherapy. In contrast, a study by Christakou and Zervas (2007) investigated the
effects of relaxation, together with pain management and rehabilitation process
imagery and found no demonstrable effects of imagery on the reduction of pain.
Despite the lack of empirical findings to support the use of pain management
imagery for rehabilitation, leading authors in the field advocate the use of imagery
(be it healing, pain management or other) as a means of alleviating pain during
injury recovery and rehabilitation (Crossman, 2001;Taylor and Taylor, 1997;Walsh,
2005).
Research into rehabilitation process imagery also appears to be in its infancy.
One of the few studies investigating the effects of rehabilitation process imagery
was a longitudinal intervention study with a male rugby player with a severely
dislocated shoulder injury (Vergeer, 2006).This study provided support for the use
of rehabilitation process imagery, as the participant reported visualising himself
making full(er) use of his shoulder. In addition, the participant also reported seeing
himself performing at his pre-injury level of performance and imagining his
injured arm copying the movements of his healthy arm during and after gym train-
ing. During the early stages of his rehabilitation, the participant often experienced
involuntary replay images of the accident but, over the course of the rehabilitation,
such images had virtually disappeared. He also explained how some of the images
he was visualising were associated with physical sensations, such as visualising the
movement of his ‘bone ripping’. According to the participant, such images were
also helping him to understand what had happened to his body, which, in turn, he
felt was facilitating his recovery. Interestingly, over the course of the physiotherapy,
these images diminished as the healing progressed. Despite being able to see his,
head-of-the-humerus, bone ripping, the participant reported no use of healing
imagery and, despite appropriate training, he was not interested in trying healing
imagery as he felt that his injury was too complex and he was not physiologically
knowledgeable enough to envisage the healing process appropriately.
Limited research measuring the effectiveness of performance imagery during
rehabilitation exists (Monsma et al., 2009); however, the available research has typi-
cally been in support of its applicability for injured athletes. For example,Weiss and
Troxel (1986) has highlighted the usefulness of visualising successful recovery (that
is, performance imagery) during injury rehabilitation. Ievleva and Orlick (1991)
found that athletes who engaged in performance (and healing) imagery recovered
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faster than those who reported less frequent or no use of imagery. Johnson (2000)
found significant differences between the control group and the relaxation/guided
imagery group (which consisted of mainly performance imagery with some
elements of healing imagery). Some partial support for performance imagery was
found by Christakou, Zervas and Lavalle (2007) as their results revealed signifi-
cantly higher functional performance gains for muscular endurance for the
imagery intervention group. In contrast, no significant differences for dynamic
balance and functional stability were found. Imagery and relaxation techniques
have also been found to be beneficial for the process of gaining a normal range of
movement and during joint restoration process (Beneka et al., 2007). Moreover,
Monsma et al. (2009) found that imagining sport-specific images was more
common amongst males than females and that it was more common before return-
ing to sport than at the earlier stages of the rehabilitation.
Research findings have shown that there are four types of imagery which have
been found to be useful in injury rehabilitation:
• healing
• pain management
• rehabilitation process
• performance
Sport injury rehabilitation: functions of imagery

Not only is it important to understand what (that is, the imagery type) is being
imagined during rehabilitation, it is also useful to understand the different func-
tions of imagery (that is, for what purpose is imagery used). Typically, the sport
psychology literature has identified five types of imagery content as useful to
athletes (Hall, Mack, Paivio and Hausenblas, 1998), namely cognitive specific
imagery (imagining specific sport skills), cognitive general imagery (imagining
executing entire plays/routines and sections of a performance), motivational
specific (imagining winning a medal), motivational general arousal imagery (imag-
ining controlling stress, anxiety and arousal) and motivational general mastery
imagery (imagining feeling confident). However, very seldom have these imagery
types been described in an injury rehabilitation setting (Monsma et al., 2009) but
rather the focus of rehabilitation imagery has been on the usefulness and effec-
tiveness of healing, pain management, rehabilitation process and performance
imagery during sport injury rehabilitation. The following section will introduce
the research into the functions of imagery an individual athlete may use during
injury rehabilitation.
Sordoni, Hall, and Forwell (2000) were the first to explore the functions of
imagery use during rehabilitation. Their findings indicate that rehabilitation
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imagery serves both a cognitive and motivational function. In a subsequent study,

Sordoni, Hall, and Forwell (2002) extended their earlier work by stating that
injured athletes used imagery for cognitive, motivational and healing purposes.
Milne, Hall, and Forwell (2005) supported the three-functional approach, as they
found that athletes used significantly more imagery for motivational and cognitive
purposes than for healing purposes. A link between imagery and self-efficacy was
also found, as cognitive imagery was a significant predictor of task self-efficacy.
Interestingly, in contrast, motivational imagery was not found to be a predictor for
athletes coping self-efficacy, thus implying that motivational imagery is not as an
important source of self-efficacy during injury rehabilitation as it is in a sport
performance context. Driediger, et al. (2006) provided important information
about how to build a foundation for imagery use during rehabilitation, as their
findings revealed that athletes used imagery for motivational purposes, mainly in
the form of reinforcing recovery goals (that is, imagining being fully recovered).
Their findings also suggested that the actual imagery content also varied, as the
athletes reported using different types of imagery; that is, healing, pain management
and performance imagery (to learn and properly perform the rehabilitation exer-
cises). In support, Evans, Hare and Mullen (2006) found that functions of imagery
and imagery use varies depending on the rehabilitation stage of the athlete. It
appears that during the early and mid-stages of rehabilitation, athletes appear to use
healing, pain management and performance imagery, and that the performance
imagery (cognitive specific imagery) is typically used for performance enhance-
ment and not for rehabilitation. The use of cognitive specific imagery (that is,
imagining successful execution of technical skills) was found to be as having a posi-
tive effect on the athletes’ motivation, attitude and levels of self-confidence. During
the latter stages, however, athletes appeared to use cognitive specific, cognitive
general and motivational general mastery imagery and, overall, imagery was used
mainly to maintain positive attitude and to increase self-confidence.
Drawing from the above, it is clear that imagery during rehabilitation can serve
motivational, cognitive and healing functions. This can vary depending on the
desired outcome and an athlete’s personal and situational factors. Understanding
the purpose of imagery use is important, as it can have an impact on the effective-
ness of the chosen imagery type in achieving the desired outcome.
Using imagery for rehabilitation: the process

The incorporation of imagery into injury rehabilitation should follow a systematic
and organised sequence of events to increase its effectiveness within the rehabilita-
tion context.These events can be conceptualised in terms of two phases: 1) using
a theoretical approach to determine the type of imagery to be used; and 2) follow-
ing a step-by-step programme to integrate imagery into injury rehabilitation. It is
advised that the above mentioned phases should be followed to increase the
chances of injured athletes being able to maximise the benefits of imagery used
during the course of injury rehabilitation. What follows is a description of the
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introductory steps and a brief discussion of guidelines to improve the usefulness of

imagery in injury rehabilitation.
Using a theoretical approach to determine the appropriate type of

imagery
Thus far, no clear theoretical framework for integrating imagery into rehabilitation
exists. However, it is believed that, for the chosen imagery to meet athletes’ needs
and to ensure the effectiveness of the implemented imagery type, understanding
how imagery works is essential. One of the most prominent frameworks for
imagery use in sport is the applied model of imagery use in sport (AMIUS; Martin,
Moritz and Hall, 1999).The model is centred around imagery type, which acts as
a determinant to the possible cognitive, affective and behavioural outcomes of the
imagery use.The model also proposes that the type of imagery used by athletes is
dependent on the situation in which the imagery use occurs (that is, competition
or training) and that athletes’ imaging ability can act as a moderating factor affect-
ing the imagery outcomes. It is believed that AMIUS could be also applied to
injury rehabilitation imagery setting, namely to provide a framework for explain-
ing the imagery phenomenon in injury rehabilitation and how to select
appropriate imagery type during rehabilitation.Very similar to AMIUS, the aim of
the adapted model is simply to describe how athletes use imagery during rehabil-
itation, rather than provide an explanation of the underlying processes of athletes’
imagery use during rehabilitation (Figure 6.1).
When applying AMIUS to injury rehabilitation context, it is believed that the
types of imagery (that is, what is imagined) would include healing imagery, pain
management imagery, rehabilitation process imagery and performance imagery.
These imagery types are directly linked with outcomes, which can include (but is
not limited to): facilitating the process of physical healing, assisting the athlete in
coping and dealing with pain, increasing rehabilitation motivation, adherence and
compliance, maintaining sport-specific skills and strategies and assisting in physical
and psychological preparation for returning back to sport. Moreover, the imagery
types are also determined by the rehabilitation situation, which is closely influ-
enced by the actual phases of rehabilitation and the stages of physical recovery (for
more details, see Chapter 10). It is also believed that the effectiveness of the
imagery type on the actual imagery outcome is mediated by imagery functions
(that is, what purpose does the imagery serve?) as well as athletes’ imagery ability
(that is, what modalities are used for imagery?).
Sport medicine professionals who are interested in introducing imagery to

their injured athletes need to consider the athletes’ rehabilitation situation,
imagery ability, imagery function and potential outcomes before selecting a
specific type of imagery.
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Imagery function
• Motivational
(MS, MG-A,
MG-M)
• Cognitive
(CS, CG) Outcome*
• Healing
• Facilitate the
process of
physical healing
Rehabilitation Imagery type • Assist the
situation athlete in
• Healing
Different phases • Pain coping and
of rehabilitation: management dealing with
• Injury and • Rehabilitation pain
illness phase process • Increase
• Rehabilitation • Performance rehabilitation
phase motivation,
• Return to sport adherence and
phase compliance
• Maintain
sport-specific
Imagery ability skills and
strategies
• Visual (internal/ • Assist in
external) physical and
• Kinaesthetic psychological
• Auditory preparation in
• Olfactory returning back
• Gustatory to sport
Note: * These are examples of potential outcomes and are by no means comprehensive;
CG = cognitive general, CS = cognitive specific, MG-A = motivational general arousal,
MG-M = motivational general mastery, MS = motivational specific
FIGURE 6.1 Application of the applied model of imagery use in sport into sport
injury rehabilitation imagery
Source: adapted from Martin et al., 1999
To determine which imagery type is most suited to the injured athlete, all of the
above should be considered by those working with the injured athlete. It is
proposed that those implementing imagery into rehabilitation should consider
selecting the type of imagery based on the desired outcomes. This should also be
affected by the rehabilitation situation, to ensure that the desired outcomes are real-
istic and purposeful for the phase of recovery. Moreover, consideration of the
functions of imagery (that is, is the purpose of the imagery motivational, cognitive
or healing?) as well as athletes’ ability to imagine should be considered when
designing and implementing imagery scripts during rehabilitation. Once the
correct imagery type has been identified, those involved in the imagery process can
move on to the second phase of the implementation by using a step-by-step
programme to integrate imagery into the rehabilitation.
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A step-by-step programme to integrate imagery into injury

rehabilitation
Richardson and Latuda (1995) proposed a four-step programme showing how
imagery could be integrated into injury rehabilitation. While this programme is
very useful, the authors of this chapter have modified it to include an additional
step, to ease any associated fears and concerns that sport medicine professionals may
have about the incorporation of imagery into injury rehabilitation programs. The
five steps are as follows:
1. Imagery should be introduced to the injured athlete with the intention of

educating him/her about the practical application and potential benefits which
could be derived from its incorporation into injury rehabilitation. Richardson
and Latuda emphasised the importance of this step as they believe that
‘imagery works the best when the athlete believes it will be beneficial to the
healing process’ (p. 11).
2. The athlete’s imagery ability needs to be informally assessed. This can be
achieved by asking the athlete some, if not all, of the following questions:
a) what is your current use of imagery?
b) describe your previous history with imagery.
c) how often have you used imagery and in what context?
d) how effective has your past use of imagery been?
The information obtained from this assessment can then be used in the devel-
opment of an imagery programme to be incorporated into the athletes’ injury
rehabilitation.
3. The athlete, depending on his/her history and experience with imagery, needs
to be assisted in the development of basic imagery skills. Richardson and Latuda
propose 15-minute training sessions twice daily.These sessions should focus on
imagery vividness (the ability to create images that are vivid, clear and realistic
in addition to incorporating all the senses; Taylor and Taylor, 1997) for a total
of five minutes. Next, focus should be switched to image controllability (the
ability to manipulate the image, making it do what they want it to; Taylor and
Taylor, 1997) for five minutes as well. Finally, athletes should be exposed to self-
perception of the image (for example, imagining their best ever performance, if
relevant) also for five minutes.
4. Once the athlete is able to grasp a basic understanding of the skills introduced
in the previous step, he/she needs to commit to practising the use of this skill
until it becomes automatic. Practice should be encouraged in a variety of
settings such as before, during and after rehabilitation-related activities and
even in their personal time as well.
5. Once the athlete has put in the necessary time practising their use of imagery,
it can be incorporated into their injury rehabilitation programme, making sure
to keep the process as simple and concise as possible.
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The incorporation of imagery into injury rehabilitation should follow a system-

atic and organised sequence of steps to increase its effectiveness within this
context.
Despite the aforementioned steps suggested above, it is also suggested that when
integrating imagery in injury rehabilitation, sport medicine professionals should
also be mindful of the following guidelines proposed by Taylor and Taylor (1997),
which offer specific tips on how to maximise the rehabilitation imagery usefulness.
These guidelines suggest that sport medicine professionals have the athletes:
• choose the imagery perspective (internal/external) which is most natural to

him/her and then experiment with the other perspective;
• reproduce total performances.This means using all physical and psychological
aspects of the injury rehabilitation experience;
• combine imagery with relaxation.The most important part of imagery should
be to feel it physically and emotionally and such can only be achieved if your
body is relaxed and your mind is calm;
• use imagery to facilitate physical and emotional wellbeing and feeling good.
Conclusion
Despite existing research being limited and on occasions lacking empirical rigour,
rehabilitation imagery has the potential to be a practical psychological intervention
technique to be used during sport injury rehabilitation. It has been argued that,
during sport injury rehabilitation, imagery seems to serve four main purposes: to
facilitate the actual healing process, to promote positive and relaxed outlook
towards recovery, to create the required mind-set for optimum performance and to
provide a closure to the injury experience (Green, 1992).This chapter has provided
the reader with definitions of imagery in a sport injury rehabilitation context,
highlighted the benefits of rehabilitation imagery to injured athletes and intro-
duced the different types of imagery that might be beneficial during rehabilitation
in addition to providing a brief overview of the research findings relative to each
type of imagery. Moreover, the chapter introduced the different functions of
imagery and outlined the process of integrating imagery into rehabilitation.
CASE STUDY
Stacey is a 25-year-old amateur golfer hoping to turn professional in the next

12–18 months. Her current handicap is 1, which according to her coach, is
right on target with her long-term plans of turning professional. She has
recently been diagnosed with a hernia in her groin and is now waiting for
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surgery scheduled for next week. She is experiencing a lot of pain and is
worried that time away from practising before and after surgery will have an
impact on her golf, particularly her short game routines. Until very recently,
she has lacked confidence in her short game and the thought of not playing
and practising makes Stacey feel very anxious. Her body feels tense and as she
is constantly experiencing so much pain that her sleep pattern has become
disturbed and the lack of sleep is making her irritable. ‘I know I am very diffi-
cult to live with at the moment, but I just cannot help it. The pain at the
moment is really bad and I think the pain relief is not helping. And what I think
makes the matters worse, is the worry over losing my form. I just wish there
was something I could do to make the situation a little more bearable at least’.
Her boyfriend is also a golfer, who has recently turned professional. Based
on his own experiences, he thinks that Stacey might benefit from using some
imagery to help her cope with the current situation. As Stacey has very little
experience of using psychological skills, her boyfriend suggests that Stacey
should talk to a sport psychologist he knows. Stacey reluctantly agrees, as she
now thinks anything would be better than her current situation.
–––––––– ? ––––––––
injury and rehabilitation process (Wiese-Bjornstal et al., 1998), outline key
factors from Stacey’s case study.
2. What types of imagery might be beneficial for Stacey and why?
3. Following the Taylor and Taylor (1997) suggestions, how could Stacey’s
imagery use during rehabilitation be maximised?
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7
RELAXATION TECHNIQUES IN SPORT
INJURY REHABILITATION
Introduction
Several studies have explored the different stressors that athletes may have to cope
with when participating in sport. The literature suggests that aspects of competi-
tion (for example, thinking about mistakes), interpersonal relationships (for
example, expectations from coaches, team mates, or the media), financial concerns
(for example, sponsorship), environmental conditions (such as the weather), and
traumatic experiences (for example, enduring an injury), can all test an athlete’s
coping resources.The key to coping with these stressors is for the athlete is to learn
to become self-aware of their responses to stressors and then adopt appropriate
techniques (such as relaxation techniques) to facilitate coping. Thus far, a number
of psychological interventions have been identified as being beneficial in helping
athletes to deal with stressors, one of which is relaxation techniques. The use of
such psychological interventions expands beyond the performance-enhancement
context to also include sport injury rehabilitation (for example, Arvinen-Barrow,
Hemmings, Weigand, Becker and Booth, 2007; Heaney, 2006). It has been docu-
mented that both athletes and sport medicine professionals use psychological
interventions, including relaxation techniques, as part of rehabilitation programmes
as well as during the process of returning to training and sporting competition
following an injury. This chapter (a) introduces the purpose of relaxation tech-
niques in sport injury rehabilitation; (b) outlines the types of relaxation techniques
used in sport injury rehabilitation; (c) summarises the literature related to the use
of relaxation techniques in sport injury rehabilitation; (d) discusses the ways in
which relaxation techniques can be combined with other psychological interven-
tions; and (e) provides practical advice to those working with injured athletes on
how to maximise the use of relaxation techniques.
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Relaxation techniques in sport injury rehabilitation 87
Relaxation techniques in rehabilitation: the purpose

Relaxation can be defined as a temporary deliberate withdrawal from everyday
activity that aims to moderate the functions of the sympathetic nervous system
which is usually activated under stress (Hill, 2001).When relaxed, individuals typi-
cally exhibit normal blood pressure and decreases in oxygen consumption,
respiratory rate, heart rate and muscle tension (Benson and Klipper, 2000; Jacobs,
2001). When using relaxation techniques, the person should aim to learn how to
voluntarily decrease the amount of tension in their muscles, calm their mind and
decrease autonomic responses (heart rate and blood pressure).
It has been argued that relaxation techniques should form an integral part of the
rehabilitation process (Flint, 1998) and a range of relaxation techniques have been
identified as useful for injured athletes. For example, Flint (1998) suggests that
progressive muscular relaxation (PMR), meditation, yoga, breath control tech-
niques and autogenic training are useful. The literature proposes that these
relaxation techniques are useful during injury rehabilitation for two primary
reasons: firstly, to alleviate, control and assist athletes in coping with pain and,
secondly, to reduce symptoms of stress and anxiety. Using relaxation techniques can
also help to focus the athlete’s attention, enhance confidence and aid healing, as
well as to provide the athlete with a sense of control over rehabilitation.
Furthermore, many of the other psychological techniques that have been found
to be useful during rehabilitation (such as imagery) actually rely on a foundation
of relaxation to enhance effectiveness. Although presented separately in this book,
the four principle techniques (goal setting, imagery, self-talk and relaxation) are
readily integrated within a psychological skills training package when appropriate
(for example, pairing relaxation with self-talk) and these methods are actually
complementary. For example, relaxation training can be used to produce a relaxed
state that is conducive to generating mental images for adopting healing imagery
(see Chapter 6 for more details).
Useful relaxation techniques during sport injury rehabilitation

In sport, the term ‘relaxation’ or ‘relaxation techniques’ has been used to describe
a range of methods through which an athlete can facilitate physical and psycho-
logical wellbeing.These methods are commonly split into two categories: physical
(somatic) and mental (cognitive) relaxation (Flint, 1998).The primary aim of phys-
ical relaxation is to release physical tension in the body. In sport, the most
commonly used physical relaxation techniques adopted are PMR (Jacobson, 1938),
applied relaxation technique (ART; Ost, 1988), breath control techniques such as
centering (see, for example, Harwood, 1998), diaphragmatic breathing (for exam-
ple, McConnell, 2011), ratio breathing (for example, Dosil, 2006), and biofeedback
(for example, Crews, 1993). In contrast, mental relaxation techniques focus more
specifically on the mind rather than the body, with the belief that a relaxed mind
will in turn relax the body. In sport, the main mental relaxation techniques
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employed are autogenic training (Schultz and Luthe, 1969) and transcendental
meditation (Benson and Proctor, 1984). For the purpose of this chapter, the phys-
ical relaxation techniques of PMR and breath control (that is, centering,
diaphragmatic and ratio breathing) are outlined, since these techniques have been
shown to be particularly effective during sport injury rehabilitation (for a more
detailed overview of the relaxation techniques, see Weinberg and Gould, 2011). In
addition, the concept of mindfulness is also introduced to the reader as, within
recent years, it has become increasingly popular amongst athletes. Mindfulness aims
to increase awareness and attention, which is considered a predisposition for
enhancing wellbeing.
Progressive muscular relaxation

PMR is the most commonly used and taught relaxation technique in sport (Flint,
1998). Based on the early work of Jacobson (1938), PMR aims to teach the indi-
vidual what it feels like to relax, by contrasting the feeling of tension in specific
muscle groups with the feeling of relaxation in those same muscle groups. Thus,
the athlete becomes aware of when muscles are tense and, hence, when to relax
them. PMR consists of learning to sequentially tense and then relax groups of
muscles, while at the same time paying attention to both the feelings of tension and
relaxation (Hill, 2001). Athletes are encouraged to observe early signals of stress and
anxiety and to scan the muscles frequently for any tension experienced through-
out the situation (for example, a rehabilitation session; Hill, 2001). The scanning
required to perform PMR involves having the athlete note signs of muscular
tension during the day and, by scanning the body at least twice a day, the athlete
should be able to implement the relaxation response in a short time by using deep
breathing (Crossman, 2001). When any tension is experienced, the athlete is
instructed to tense these muscles, hold this tension for a count of seven and then
release the tension, noticing the difference in sensation between tension and relax-
ation (Hill, 2001). In relaxing the musculature, it is believed that a calming effect
occurs on the individual via the neuromuscular network (Payne, 2004).
When implementing PMR, after the initial deep breaths, subsequent breaths
should be steady and shallow, with inhalations coming in through the nose and
exhalations going out through the mouth (Crossman, 2001).The inhalation should
lead smoothly into exhalation and not be forced or include a pause between the
two (holding one’s breath). The tension phase should last approximately seven to
ten seconds and the relaxation phase should last approximately 25–30 seconds
(Crossman, 2001). During the relaxation phase, the facilitator of the PMR (that is,
the sport medicine professional) should have a lowered tone of voice compared
with the tension phase (Crossman, 2001).
The first few sessions of PMR can take up to 30 minutes and it is recommended
that athletes follow the PMR script for 16 muscle groups specifically when an
athlete is learning PMR for the first time (Crossman, 2001).With practice, less time
is necessary and the aim is for the athlete to be able to develop the ability to relax
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quickly (for an example PMR script see Weinberg and Gould, 2011). PMR is also
commercially available in various audio formats (for example, CD, MP3, mobile
applications) which could be used in sport settings and these may be facilitative
(Taylor and Taylor, 1997). However, caution must be taken when selecting these
sources to ensure that they are fit for purpose and should consider the perceptions
of the athlete of the source.
Ost (1988) developed an applied variant of the PMR technique with the aim
of teaching an athlete to relax within 20 minutes to 30 seconds. The first phase
of training involves a 15-minute PMR routine practised twice a day. The indi-
vidual then moves on to a ‘release-only’ phase (that is, muscle relaxation without
deliberate prior muscle tension) that takes five to seven minutes to complete.This
time is then reduced to two to three minutes, using the instructional cue ‘relax’.
This time is then further reduced until only a few seconds are required and then
the technique is practiced for specific situations (between rehabilitation exer-
cises). Eventually, the athlete is able to initiate a fast relaxation response as and
when required, which is clearly of benefit to the rehabilitation process and
beyond.
Learning to use PMR takes time and practice. PMR involves learning how to
relax the whole body, and can take up to 30 minutes to complete.
Breath control techniques

Correct breathing is fundamental to achieving a relaxed state. A link exists between
breathing and the system controlling our physiological arousal system. Stimulation
of the sympathetic nervous system (when anxious) leads to breaths that are short,
shallow and irregular and stimulation of the parasympathetic nervous system (calm
and confident) is associated with smooth, deep and rhythmic breaths (Keable,
1989). This connection has created a perception that slow breathing has stress-
relieving properties and, as such, one of the easiest yet most effective ways to
control stress, anxiety and muscle tension (Weinberg and Gould, 2011).
Breath control techniques typically begin with exploring thoracic and abdom-
inal movements when breathing leading up to a variety of different methods of
breathing (for example, slow rhythmic breathing, deep breathing, diaphragmatic
(abdominal) breathing, breathing meditation and ratio breathing; Payne, 2004). For
the purposes of this chapter, centering, diaphragmatic and ratio breathing are
described, as they are particularly effective during sport injury rehabilitation.
Centering
Centering is about focusing ones attention on the task at hand.There is a variety
of different ways to centre but the most common appears to be changing the focus
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of attention from the athlete’s head to their centre of gravity, hence giving a feeling
of stability and balance.This feeling of stability, balance and control is the prompt
to relax (Harwood, 1998). One key feature of centering is that, over time, with
practice, it provides a method of relaxing quickly. A deep breath is all that is needed
for the athlete to remove the feelings of anxiety (for example, on a new, more chal-
lenging rehabilitation exercise producing re-injury anxiety) and they can then
refocus their attention on what needs to be done and how they are going to do it
rather than on the possible negative consequences.
Sample centering exercise

• Stand with your feet shoulder-width apart and bend the knees slightly.
• Relax the neck, arms and shoulder muscles.
• Direct your thoughts inwards to check and alter your muscle tension and
breathing, by focusing on the abdominal muscles and how they expand as
you breath in.Try to feel the heaviness in your muscles.
• Take a slow, deep breath (from the diaphragm), trying to limit the move-
ment of the chest cavity.
• Concentrate on your breathing and the heaviness of your muscles, clear-
ing the mind of all irrelevant thoughts, and say ‘relax’.
• Now focus your attention on the rehabilitation activity and what you
need to do to perform it.
(Adapted from Harwood, 1998)
Diaphragmatic breathing
Diaphragmatic breathing emphasises the downward expansion of the chest cavity
that causes the abdomen to swell.The first step in diaphragmatic breathing (and in
all other breath control techniques) is to guide the athlete to become aware of their
regular breathing patterns. Such can be achieved by completing the diaphragmatic
breathing exercise steps shown here.
When engaging in diaphragmatic breathing exercises, if the athlete’s chest rises
more than their abdomen they should be shown how they might breathe differently
and should have the benefits of this change explained to them.The aim of diaphrag-
matic breathing is for the athlete to try to feel their ribs expanding and moving as air
is inhaled and then the ribs recoiling as they exhale.The athlete should be aware of
how the lungs and diaphragm work. For example, athletes should know that the
diaphragm forms the roof of the abdomen and, at rest, it is domed in shape.When it
is contracted, it flattens, making more room in the chest for air to be inhaled.When
the diaphragm is relaxed, it returns back to its dome shape, helping to force the air
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out.The movement of the diaphragm affects the position of the internal organs and,
hence, when contracted it pushes down on these organs and causes the abdomen to
swell a little. Injured athletes might find diaphragmatic breathing useful just prior to
a rehabilitation exercise, to relax them in preparation for the exercise and to focus
their attention on the task at hand. Diaphragmatic breathing can also be encouraged
during the rehabilitation activities itself (the speed, agility, quickness work in the
functional phase of rehabilitation) to improve the intensity and effort of the work.
Diaphragmatic breathing exercise

• Lie on your back (no postural effort needed from breathing muscles and
organs shift, so diaphragm has something to work against and it is easier
to learn in this position) and take small breaths in via the nose and exhale
out of the mouth letting air just fall out of the lungs (do not force it).
• Gradually increase the size of your breaths until slow and deep (no hold-
ing of breath).
• You should be taking a maximum 12 breaths (inhale/exhale) per minute.
• Place the palm of your hands on the bottom of your ribs with the finger-
tips touching.
• On exhaling, relax the abdomen, shoulders and chest.
• Take in a big breath via the nose and notice what happens to the
abdomen and ribs (for many, the chest will rise more than the abdomen).
Note: It is also possible to use paper or plastic cups instead of using the hands, for a more visual
impact of current breathing patterns. Similarly, it is possible to replicate this exercise standing.
For example, in front of mirror without upper body clothing; place your hands flat against your
stomach (palms on bottom of ribs with finger tips touching).
(Adapted from McConnell; 2011)
Ratio breathing
Ratio breathing is a deep-breathing technique, with a focus on the number of
inhalations compared with exhalations (for example, a ratio of four inhalations to
seven exhalations).The individual counts the ratio of breaths and this is particularly
useful for distracting from negative automatic thoughts. This can be easily
explained to an athlete by using visual images. So, for example, asking the athlete
to think of an open palm and to think of the counting of their breaths as the gaps
between their fingers acting as a distraction to counterproductive thoughts. To
demonstrate the opposite scenario, ask them to view the process by thinking of a
fist and explaining that, when they are anxious, their negative thoughts enter their
brain in quick succession and there is no intervention to slow them or stop these
counterproductive thoughts.
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It is also useful for the athlete practising ratio breathing to understand the
arousal mechanism that ratio breathing is aimed to affect. The athlete engaged in
ratio breathing should understand that an individual’s levels of arousal are
controlled by our autonomic nervous system, which is not under our conscious
control. As such, what happens in our bodies is not typically what an individual
might want to happen (for example, increased heart rate, increased breathing rate).
When arousal levels are heightened, an individual needs to activate the parasympa-
thetic nervous system, which is associated with a relaxed state.This can be achieved
through taking slow, controlled longer ‘out’ breaths (hence, the longer exhale ratio
compared with inhalation). One analogy that might be useful in explaining the
above is the ‘throttle and brake in a car’ example.
Being anxious is like putting your foot down on the throttle and letting the car
get out of control. What you need to do is to put your foot on the brake and
slow it down. Using ratio breathing is like pushing on that brake pedal and
gaining control of the situation again.
Unfortunately, many individuals do not know how to breathe correctly. Some sport
participants (for example, golf, pistol shooting, archery) are accustomed to engag-
ing in such techniques, as correct breathing is often an integral part of successful
skill execution. The sport medicine professional should pay attention to the indi-
vidual’s experience of such techniques when discussing breath control
interventions during injury rehabilitation.
Mindfulness
In recent years, mindfulness has become increasingly popular amongst athletes.
Cottraux (2007; cited in Bernier, Thienot, Codron and Fournier, 2009: 320) has
defined mindfulness as ‘a mental state resulting from voluntarily focusing one’s
attention on one’s present experience in its sensorial, mental, cognitive and
emotional aspects, in a non-judgmental way’. Mindfulness has its roots in Eastern
meditational practice and, until recently, has been a relatively unfamiliar concept in
Western culture. As previously stated, it is said to be a distinct form of awareness
and attention, which could be considered a predisposition for enhancing wellbe-
ing (Brown and Ryan, 2003). It uses breathing methods, guided imagery and other
practices to relax the body and mind and help to reduce stress. Meditation exer-
cises encourage individuals to engage in non-judging awareness of their internal
experience occurring at each moment, such as bodily sensations, cognitions and
emotions, and to environmental stimuli, such as sights and sounds (Baer, 2003;
Kabat-Zinn, 1994). Researchers who have introduced mindfulness practice in
mental health treatment programmes have taught these skills independently of the
religious and cultural traditions (Linehan [1993] cited in Moore, 2009: 292; 295)
and have developed several clinical interventions based on mindfulness training for
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anxiety, chronic pain, depression and post traumatic stress disorder (Garcia, Villa,
Cepeda, Cueto and Montes, 2004; Ma and Teasdale, 2000).
Recent studies in sport psychology have also established a relationship between
mindfulness and peak performance (Gardner and Moore, 2004, 2006; Kee and
Wang, 2008). The ability to remain focused on the present has been found to be
particularly important for performance outcomes. In the context of injury reha-
bilitation, mindfulness can be seen as beneficial to help injured athletes in achieving
a relaxed state of mind and body and to become more aware of their injury situa-
tion. It may be useful in drawing an athlete’s focus to the private events that they
are experiencing throughout their rehabilitation, as well as encouraging such events
to come and go without trying to control the experiences (Mahoney and
Hanrahan, 2011). Mindful attention may also be useful to draw their focus to reha-
bilitation exercises to ensure correct execution of movements and to gain
maximum benefits from physical interventions (Mahoney and Hanrahan, 2011).
Thus far, one study has explored the experiences of injured athletes during their
rehabilitation from anterior cruciate ligament injuries and examined the usefulness
of a mindfulness intervention, namely an adapted acceptance–commitment therapy
(ACT) intervention in addressing individuals’ adherence to rehabilitation protocols
and their general psychological wellbeing (Mahoney and Hanrahan, 2011). Results
highlighted that mindfulness was useful in accepting emotions such as frustration,
boredom and anxiety. The authors also proposed that their findings tentatively
suggest that an ACT-based educational programme may assist in the development
of committed rehabilitation behaviours and the wellbeing of injured athletes.
It has made me more aware of what is going on . . . it’s like you can pull away and
be like, ‘okay, it’s just a thought, that’s all it is’ and then look at it a different way.
(An injured athlete, cited in Mahoney and Hanrahan, 2011: 266)
However, as the research on the usefulness of mindfulness in sport injury rehabili-

tation context is in its infancy and as mindfulness is not a technique as such but a
mental state which requires practice, encouraging athletes to use mindfulness to
help in coping with injury rehabilitation should be reserved for those who have
prior experience of using it.
A brief review of literature on relaxation techniques in sport

injury rehabilitation
As stated above, a number of rehabilitation techniques have been found to be bene-
ficial during injury rehabilitation. Based on the findings, these techniques can be
typically grouped into three main areas: (1) dealing with pain, (2) alleviating stress
and anxiety, and (3) increasing an injured athlete’s focus, self-confidence and
personal control during rehabilitation. This section provides a brief review of the
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literature in these areas and offers suggestions on how to use relaxation techniques
during sport injury rehabilitation.
The use of relaxation for dealing with pain

Several studies exploring the effects of pain management techniques in a wide range
of settings have indicated that an individual’s overall pain tolerance can be improved
and perceptions of pain reduced via the use of relaxation training (Caroll and Seers,
1998; Jessup and Gallegos, 1994; Linton, 1994; Owens and Ehrenreich, 1991), which
may reduce the need for pain relieving medication (Payne,2004).Pain inhibits breath-
ing, reduces blood flow and can cause muscle spasms and tension.This can actually
serve to increase pain in the long term (Cousin and Philips, 1985). Relaxation is
hypothesised to affect pain via: 1) reducing the demand for oxygen in the tissue and
lowering levels of chemicals (such as lactic acid) that can trigger pain, 2) releasing
tension in the skeletal muscle that can exacerbate pain, and 3) the release of endor-
phins which interact with the opiate receptors in the brain to reduce perceptions of
pain (McCaffery and Pasero, 1999). Another mechanism by which relaxation might
reduce pain is via acting as an internal distraction. For example, if an injured athlete is
engaging in ratio breathing, they might focus less on the pain itself and more on the
breathing technique. For an individual experiencing pain during the night, relaxation
techniques might also be particularly useful in facilitating sleep. Muscle relaxation can
reduce the pain experienced and produces both a physiologically and psychologically
induced relaxed state, making sleep more likely for the individual.
Injured athletes are likely to experience anxieties and fears associated with pain,
which could potentially inhibit rehabilitation. Sport medicine professionals can
therefore use relaxation techniques to reduce these anxieties (Christakou and
Lavallee, 2009). Improvements have also been reported for pain, oedema and range
of motion after a relaxation, pain management and imagery intervention
(Christakou and Zervas, 2007). More recently, Naoi and Ostrow (2008) explored
the effects of breathing techniques and autogenic training on injured athletes’
mood and pain during rehabilitation. Improvements in mood and/or levels of pain
were reported during the treatment period in comparison with the baseline
control period. There was also some further benefit reported by the athletes with
claims of improved physical and psychological recovery.
I find that integrating relaxation techniques into my treatment sessions really helps
get the most out of a session. I get my athletes to use a breathing technique before
I start a treatment that might be a little painful and I find that it allows me to go
a little deeper or a little longer. I don’t know if it’s the breathing itself or just giving
the athlete something to focus on, but it definitely works!
(Megan, sport medicine professional)
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The use of relaxation to alleviate stress and anxiety

In addition to managing pain, relaxation techniques have also been found useful
for controlling stress and anxiety symptoms (Taylor and Taylor, 1997). Relaxation
techniques represent one of the most commonly used approaches in anxiety
management worldwide, both as a stand-alone treatment or included in a more
multimodal treatment (Manzoni, Pagnini, Castelnuovo and Molinari, 2008).
Despite ones’ best efforts, it is likely that at some time during rehabilitation the
athlete will experience some form of stress and anxiety associated with their injury
experience (Taylor and Taylor, 1997).Typical anxieties with which an athlete might
have to cope include those related to the pain they are experiencing, lengthy reha-
bilitation anxieties, the loss of their starting place and change in daily routines,
performance outcome anxieties (team doing well or poorly whilst injured), pre-
and/or postoperative stress, anxieties related to fitness demands and returning to
peak performance and also anxieties related to re-injury during rehabilitation or
return to training and competition. These stressors can interfere with recovery
because the healing mechanisms of body cannot work properly and to maximise
the effects of treatment an athlete should be relaxed (Payne, 2004).When someone
is anxious, one symptom experienced is excessive muscle tension and this might
prevent the sport medicine professional from treating the injured area effectively.
In addition, the injured athlete might also brace their muscles during a rehabilita-
tion exercise in an attempt to protect their injured limb (Heil, 1993).This muscle
tension can have a pain-enhancing effect in addition to reducing the flow of blood,
reducing range of movement and increasing the risk of re-injury (Heil, 1993). As
a consequence, the athlete might also experience lowered confidence, as they have
little perceived control over their own body, and these symptoms might also inter-
fere with their attention and concentration during rehabilitation exercises and,
hence, increasing the risk of re-injury further.
As detailed earlier, an athlete might experience anxieties related to their injury
rehabilitation and return to training and competition following injury.The use of
relaxation techniques during these circumstances is vital. Relaxation training, such
as PMR, is useful, as it increases the athletes’ awareness of their muscle physiology.
For example, an athlete might inappropriately believe that they are relaxed when
in fact they are very tense but with the use of relaxation training they are able to
gain greater sensitivity to their body and are hence enabled to become more in
control. The use of breathing techniques and PMR are reported to be the most
beneficial techniques for coping with stress and anxiety associated with injury
(Wagman and Khelifa, 1996).
Deep breathing has been proposed as one of the simplest and most effective
ways to reduce anxiety during rehabilitation by relaxing the muscles and subse-
quently relieving muscle tension (Taylor and Taylor, 1997, 1998). Cupal and
Brewer (2001) investigated the effects of breath-assisted relaxation and guided
imagery on knee strength, re-injury anxiety and perceived pain for athletes with
anterior cruciate ligament injuries. They found that increased knee strength,
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decreases in re-injury anxiety and lowered perceptions of pain were evident in the
treatment condition compared with the placebo and control conditions.
Relaxation paired with imagery exercises can also be used to enable injured
athletes to see themselves performing without anxieties (Flint, 2007; Green and
Bonura, 2007; Walker, 2006; Williams and Andersen, 2007). The reduction in the
negative effects of anxiety (reducing tension, decreasing blood pressure, lowering
the heart rate, slowing breathing and increasing blood flow) can also have the
potential to promote recovery.
The use of relaxation to enhance healing, increase focus, self-

confidence, and personal control
Relaxation techniques can be useful in promoting blood flow to the injured limb,
thus promoting healing and reducing the likelihood of re-injury (Heil, 1993;Taylor
and Taylor, 1997). Furthermore, Beneka et al. (2007) suggest that relaxation tech-
niques are also useful when the aim of the rehabilitation exercise is to obtain
normal range of movement or restore joint stability and, hence, these techniques
are very useful for promoting physical recovery. As a result of the direct impact of
relaxation techniques on injury recovery, it is likely that an athletes’ ability to focus,
their feelings of self-confidence and personal control will be enhanced.The ability
to adopt relaxation techniques can help the athlete to have a greater focus on the
task at hand during rehabilitation by redirecting their attention away from discom-
fort, pain or anxiety and, ultimately, reducing the risk of re-injury. By controlling
pain, discomfort and anxiety, it will provide the athlete with a sense of achieve-
ment, which in turn can enhance confidence. Moreover, all of the above will give
the athlete a sense of personal control, which is often desired by injured athletes
(Walker, 2006).Yukelson and Murphy (1993) stated that being an active participant
in and having some responsibility for rehabilitation encourages positive involve-
ment in the process.
An additional advantage of using relaxation techniques during rehabilitation is
that when returning to their sport following recovery the athlete can also use these
techniques in training and competition.These techniques can also help athletes in
coping with other stressful situations and thus prevent any future injury/re-injury
(for more details on stress-injury relationship, see Chapter 2).
Relaxation techniques can aid rehabilitation from injury by:
• helping the injured athlete deal with pain

• alleviating stress and anxiety, and
• increasing the injured athlete’s focus, self-confidence and personal control
during rehabilitation.
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Pairing relaxation techniques with other psychological techniques

As previously stated, relaxation techniques are often used with other psychological
techniques. For example, an injured athlete might be encouraged to select a word
that is synonymous with relaxation (for example, relax, calm, healing, curing, peace,
harmony) and to recite this cue word on exhaling (that is, pair relaxation with self-
talk/cue words). The idea is that an association builds between the state of
relaxation and the cue word and, over time, the cue word on its own can induce a
relaxed state. The stronger the association between the word and the notion of
relaxation, the greater the power of the cue word for the athlete. It has been recom-
mended that the cue word should be paired at least 20 times a day with exhaling
to build this skill over time (Payne, 2004). The use of an appropriate cue word is
also often used as part of centering. It should also be noted that when using
imagery techniques relaxation is also commonly used in combination.Whilst it is
not the intention of the authors to outline every possible intervention paired with
relaxation, it is hoped that the athlete’s and the sport medicine professionals’ atten-
tion is alerted to the possibilities of pairing each of the psychological intervention
techniques from Chapters 5–9.When deciding on the most appropriate interven-
tion or intervention package, the expertise of the professional working with the
athlete, as well as the preference of the athlete should be taken into account (Payne,
2004). Techniques that appeal to an individual are more likely to gain their co-
operation and result in more effective rehabilitation.
Relaxation techniques that can be beneficial during injury rehabilitation

include PMR, breath control techniques and passive relaxation. To maximise
rehabilitation, these techniques can be paired with other techniques such as
functional self-talk and imagery.
Practical advice for sport medicine professionals when

implementing relaxation techniques
Regardless of the relaxation technique employed, there are several prerequisites
necessary to facilitate effective relaxation. These include educating the injured
athlete, providing a suitable environment for the relaxation to take place, ensuring
that there is an appropriate structure to the relaxation programme, measuring
relaxation effectiveness and adopting appropriate relaxation techniques in accor-
dance with the phase of rehabilitation.
Educating the athlete

Education is vital as a first step for any relaxation training (Rotella, 1982). The
athlete should be educated about the purpose, the benefits and the reasons for the
use of relaxation. The athlete should also be given opportunities to ask questions
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and share any apprehensions about the technique and these should be resolved
with the athlete’s best interests in mind. For example, the sport medicine profes-
sional might explain to the injured athlete that a relaxation technique may help
them because it promotes blood supply to the injured site and blood has healing
properties. They might also be informed that these techniques will give them a
sense of being in control of their recovery.They do, however, need to be reminded
when using PMR, for example, to take care on the tension phase when the injury
location is being used and to only continue as long as they are pain free.
Providing a suitable environment for relaxation

Ensuring the environment is suitable for relaxation is also important. A quiet,
comfortable atmosphere is considered more facilitative to relaxation (Crossman,
2001; Rotella, 1982;Taylor and Taylor, 1997). However, this is not always practical
in a sport or rehabilitation setting. The athlete should be positioned comfortably
(ideally lying down or seated in a chair). Particularly in the initial stages of learn-
ing, it is useful for the eyes to be closed and for the individual to concentrate on
how their body feels and rid the mind of all other thoughts (Crossman, 2001).
Ensuring that there is an appropriate structure to the relaxation

programme
Relaxation is also said to be most effective when integrated into the structure of
daily sessions (for example, using ratio breathing during the times when pain is
high; Taylor and Taylor, 1997). Relaxation is a skill and, like all other skills, it
requires practice (Flint, 1998) and the ability to use these techniques is directly
related to the amount of time spent practising them. It is also important that the
athlete does not expect too much too soon.
Measuring relaxation effectiveness

It might also be useful to use physiological (heart rate, respiration rate, blood pres-
sure) and psychological self-rating scales for assessing pain and anxiety reduction
when using relaxation techniques.These measurements might help the sport medi-
cine professional in determining the effectiveness of the technique and also help
the injured athlete see the benefits of the technique too. Ending rehabilitation
sessions with a relaxation session is also perceived as being beneficial, since it can
be a rejuvenating experience following a painful and possibly unpleasant experi-
ence (Taylor and Taylor, 1997).
Using appropriate relaxation techniques during different phases of

rehabilitation
As rehabilitation consists of three main phases (the injury phase, rehabilitation
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phase and return to sport phase; for more details see Chapter 10), ensuring the
appropriateness of relaxation techniques in each phase is of importance. For exam-
ple, during phase I, when pain is at its worst, using physical relaxation is important
to help manage pain. In this phase, the sport medicine professional might teach an
injured athlete deep breathing techniques and encourage the use of cue words that
induce a state of relaxation (Walsh, 2011). During phase II, the focus might be to
reduce the stress response to injury. By integrating relaxation techniques into reha-
bilitation, the athlete may be more able to manage their anxieties. In this phase, the
pairing of relaxation with imagery can increase effort and persistence in rehabili-
tation, as well as continuing to be used to manage pain associated with
rehabilitation exercises. In phase III, the athlete will be eager to return to training
and competition and re-injury anxiety might be salient at this time (Walker and
Thatcher, 2011).The ability to induce a state of relaxation is an important skill and
should be emphasised in response to the increase of anxiety during this phase.
Conclusion
This chapter has introduced the importance of relaxation techniques in sport
injury rehabilitation and outlined the types of relaxation techniques used in sport
injury rehabilitation. The chapter then summarised the literature pertinent to use
of relaxation techniques in sport injury rehabilitation and discussed the ways in
which relaxation techniques can be combined with other psychological interven-
tions. Moreover, the chapter provided practical advice to those working with
injured athletes on how to maximise the use of relaxation techniques with injured
athletes. Based on the evidence presented, a range of relaxation techniques can be
of use for injured athletes during rehabilitation and on their return to training and
competition. Relaxation can facilitate athletes’ ability to manage and alleviate pain,
to deal with stress and anxiety, and enhance physiological recovery.
CASE STUDY
Hari is a 21-year-old male international cricketer (right-hand batter, right-arm

fast bowler), who has a torn anterior cruciate ligament. Hari is a bright
prospect who is expected to fill in the vacancies created by the retirement of
more experienced internationals. Before his injury, he became only the third
Indian batsman to hit back-to-back centuries in one day internationals. Since
sustaining his injury, Hari feels under pressure to return to his previous fitness
and form as soon as possible and is finding being injured very frustrating. He
has recently had reconstructive surgery and is experiencing high levels of
anxiety and is feeling very stressed in response to the injury. He is frustrated at
the limitations that the injury had imposed and feels very angry that the injury
occurred at a time when he was in good form. He has stated that he feels very
tight around the shoulders and jaw and did not feel this way before the injury.
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When informed that he would be on crutches for at least six weeks and
approximately six to eight months of further rehabilitation, he also described
feeling his heart race and feeling sick. He feels that the injury is out of his
control and that there is very little he can do to aid his rehabilitation.
–––––––– ? ––––––––
1. Outline which relaxation techniques might be beneficial for Hari’s recovery.
2. Outline how and why these relaxation techniques might be beneficial for
Hari’s recovery.
3. How might using a multiple intervention package, such as self-talk and
progressive muscular relaxation, be useful to help Hari with his recovery?
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8
SELF-TALK IN SPORT INJURY
REHABILITATION
Natalie Walker and Joanne Hudson
How you think affects how you perform and how you rehabilitate.
(Phil, sport medicine professional)
Introduction
It is understood that most athletes engage in some form of self-talk.The thoughts
an injured athlete has and the things they say to themselves regarding their injury
are proposed to influence their emotions, behaviours and recovery outcomes
(Wiese-Bjornstal, Smith, Shaffer and Morrey, 1998). However, the extent,
frequency, content and type of self-talk can vary depending on the situation and
the individual (Zinsser, Bunker and Williams, 2006). For example, the level at
which the athlete competes at and skill type have been suggested as moderators of
self-talk use (Tod, Hardy and Oliver, 2011). This chapter outlines the role of self-
talk in sport injury rehabilitation by: (a) initially outlining the concept of self-talk
in the wider context of sport, (b) introducing the different types of self-talk used
in sport, (c) describing the functions of these different types of self-talk, (d)
discussing the use of self-talk during rehabilitation and finally concluding with (e)
an outline of the process of self-talk use during rehabilitation.
The concept of self-talk

Based on considerable lack of clarity in the literature, it has been argued that a
consensus was needed regarding an accepted definition of self-talk (Hardy, Jones
and Gould, 1996). It was not until a decade later that such discussions began to take
place (Hardy, 2006). A number of definitions of self-talk have since been proposed
and are outlined in this section. According to Theodorakis, Weinberg, Natsis,
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104 Natalie Walker and Joanne Hudson
Douma, and Kazakas (2000), self-talk is ‘what people say to themselves either out
loud or as a small voice inside their head’ (p. 254). This definition highlights two
aspects of self-talk.That self-talk is expressed either overtly or covertly and that self-
talk is composed of statements that are addressed to oneself and not to other people
in the form of conversation. Hackford and Schwenkmezger (1993) proposed that
self-talk is a ‘dialogue [through which] the individual interprets feelings and
perceptions, regulates and changes evaluations and convictions, and gives
him/herself instructions and reinforcement’ (p. 355).This definition offers both the
notion that self-talk is concerned with making self-statements but also alludes to
some of the uses of self-talk.We are therefore encouraged to define self-talk by the
following guidelines: (a) it represents verbalisations or statements addressed to the
self; (b) it is multidimensional in nature (for example, with frequency and valence
properties); (c) it has interpretive elements associated with the content of state-
ments employed; (d) it is dynamic; (e) it serves a function for the athlete (that is, it
can be instructional and/or motivational; Hardy, 2006).
An overview of the types and functions of self-talk in sport

Overt/covert self-talk
As outlined previously, there is some discussion related to how the individual’s self-
statements are verbalised. At one end of the continuum, an individual might talk
to themselves in a very overt fashion (externally verbalised statements), allowing
others to hear what is said. At the other end of the continuum, covert self-talk is
located, and is defined as verbalisations that are made by a small voice inside one’s
head or as an inner dialogue that cannot be heard by others. It is likely that an
athlete engages in one or both types of self-talk.To date, research has yet to provide
any conclusive evidence related to the effectiveness of overt compared with covert
self-talk in the sport domain. However, based on similar principles in goal setting,
where public goals are more effective than private goals (Kyllo and Landers, 1995),
it might be expected that when statements are overt there could be some evalua-
tion of the individual’s performance related to those statements. Therefore, the
individual might exert more effort to achieve the desired behaviours associated
with overtly expressed statements.
Assigned and self-determined self-talk

There is also some discussion concerning the level to which an individual’s self-
talk statements are self-determined; that is, if their self-talk is ‘assigned’ or ‘freely
chosen’ (Hardy, 2006). Assigned self-talk is where the individual has no self-deter-
mined control over the statements (that is, the statements are given to the athlete
by someone else such as the sport medicine professional) and freely chosen self-talk
is where the individual has completely determined their self-talk (that is, composed
of their own statements). Despite limited examination of whether assigned or self-
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Self-talk in sport injury rehabilitation 105
determined self-talk is more effective, it is more likely that an athlete would use
self-talk that they determine themselves in performance settings (Hardy, 2006). It
is also likely that, based on the principles of Deci and Ryan’s (1985) cognitive eval-
uation theory, self-determined self-talk will offer more motivational benefits for
the athlete (Hardy, 2006). Cognitive evaluation theory proposes that we have an
innate desire to feel competent and self-determined and that an athlete’s feeling of
self-determination for their actions is related to their perceptions of choice. Hence,
self-talk chosen by the athlete, theoretically, should have positive effects on their
self-determined motivation.
I’ve heard injured athletes I’ve worked with say some pretty awful and unhelpful
things to themselves in my years as a physio. They can be their own worst enemy
at times.
(Phil, sport medicine professional)
Negative and positive self-talk

Traditionally, self-talk has been conceptualised as either positive or negative (Tod
et al., 2011). Self-talk as a form of praise (Moran, 1996), that is used to keep
one’s focus of attention in the present has been commonly termed positive self-
talk (Weinberg, 1988). However, self-talk, in the form of criticism (Moran, 1996)
and which presents barriers to achieving because it is inappropriate, anxiety-
provoking and/or irrational, has been called negative self-talk (Theodorakis et
al., 2000). It is suggested that positive self-talk is performance facilitating
whereas negative self-talk is performance debilitating (Hardy, 2006; Zinsser,
Bunker and Williams, 2010). Following their systematic review of the literature,
Tod et al. (2011) found evidence to confirm the proposed positive effect of self-
talk on performance. No support was found, however, for an effect of negative
self-talk. Sixty per cent of the research in their review indicated that positive
self-talk was more beneficial for performance than negative self-talk and the
remaining 40 per cent reported no performance differences between positive
and negative self-talk (Tod et al., 2011).
Instructional and motivational self-talk

A more contemporary conceptualisation has been to view self-talk in relation to
its function: instructional and/or motivational. The execution of precision-based
tasks that require skill, timing and accuracy can be aided through instructional self-
talk that increases attentional focus on relevant technical aspects of performance
(Hatzigeorgiadis, Theodorakis and Zourbanos, 2004; Theodorakis et al., 2000). In
contrast, motivational self-talk is suggested to be more effective than instructional
self-talk for the execution of strength and endurance based tasks as this type of
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self-talk is used to increase effort, enhance confidence, and/or create positive

moods (Tod et al., 2011).
The two broad functions of self-talk (instructional and motivational) have been
further refined into more specific functions. Instructional self-talk has been refined
into two more specific instructional functions – skills and general related (Hardy,
Gammage and Hall, 2001). Skill-specific instructions focus on the technique of a
skill and might include statements such as ‘keep the hands together’. Instructional
general self-talk includes statements about strategies that are important for
performance. For example, ‘stay in second until the last bend’. With respect to
motivational self-talk, this has been further refined into three more specific moti-
vational functions – arousal, mastery, and drive (Hardy et al., 2001).The motivational
arousal function refers to the use of self-talk in psyching up, relaxing and control-
ling arousal. The motivational mastery function relates to mental toughness, focus
of attention, confidence and mental preparation.The motivational drive function is
concerned with goal achievement and consequently is associated with maintaining
or increasing drive and effort.
The findings from Tod et al.’s (2011) systematic literature review suggest that
both instructional and motivational self-talk had a positive effect on precision-
based tasks. Similarly, they reported that instructional and motivational self-talk had
a positive effect on gross motor-skill performance (Tod et al., 2011). They
concluded therefore that, contrary to what has previously been suggested, instruc-
tional self-talk was not consistently more effective than motivational self-talk for
the execution of precision-based tasks and that motivational self-talk was not more
effective than instructional self-talk for gross motor-skill tasks (Tod et al., 2011).
A conceptual framework was proposed by Hardy, Oliver, and Tod (2009) to
explain factors which they believe mediate the self-talk performance relationship
(Table 8.1). This framework highlights why simple relationships between self-talk
and performance do not exist and why they are not consistent. It also allows prac-
titioners to use self-talk interventions more effectively in practice.
It should be noted that more research is needed on this conceptual framework
of self-talk. Similarly, more research is needed on self-talk in injury rehabilitation.
The following section provides a brief summary of the key studies on self-talk in
rehabilitation to date.
Key research from the self-talk literature in sport injury

rehabilitation
A limited amount of empirical research has investigated the use of psychological
intervention strategies in a sport injury context (Evans, Mitchell and Jones, 2006).
The literature that does exist suggests that self-talk is useful for joint restoration,
muscular strengthening and rehearsing sport-related skills whilst injured (Beneka et
al., 2007). Ievleva and Orlick (1991) were the first authors to study the impact of
psychological interventions on athletes’ recovery from sport injury. In their retro-
spective study with rehabilitated athletes, they reported a link between recovery
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TABLE 8.1 A conceptual framework of self-talk
Self-talk factor Influence on performance

Cognitive Athletes adopt self-talk for a variety of attention-based outcomes (e.g.
concentration) thus manipulating self-talk may also be useful to alter
attentional foci.
Motivational The use of self-talk is thought to affect the persistence or long-term goal
commitment of an individual via self-talk acting as an antecedent to self-
efficacy (Tod et al., 2011).
Behavioural There is evidence of improvements in technique with the use of self-talk
(Hardy et al., 2009). During the early phases of learning, it has been
proposed that novices may ‘talk’ themselves through movements,
resulting in changes in movement patterns or technical execution which
could then underlie performance improvements (Hardy et al., 2011).
Affective There is a wealth of literature suggesting a link between cognitive
content and affect and, in turn, affect and performance. For example,
there is widespread support that self-talk might influence anxiety in
sporting performance (e.g. Maynard et al., 1995).
Source: Hardy et al. (2009)
time and the use of positive self-talk.The fast healers reported greater use of goal
setting, imagery and self-talk than their slower healing counterparts. The qualita-
tive findings identified that the fast-healing athletes had a tendency to be more
positive than the slower healers.These findings show some support for an athlete’s
ability to influence and control their thoughts during the injury and rehabilitation
process and the positive use of self-talk during rehabilitation.
In a series of studies exploring the use of coping strategies by injured athletes,
further support for the benefits of self-talk were suggested (Gould, Eklund and
Jackson, 1993). Eighty per cent of Olympic wrestlers who were interviewed in this
study stated that they used thought control strategies as a means of coping with their
injuries. Rational thinking and self-talk were also reported as the most popular
coping strategies employed by injured national championship-level figure skaters in
a study by Gould, Finch, and Jackson (1993). Similar findings were reported by
Gould, Udry, Bridges, and Beck (1997) in relation to exploring coping with season-
ending injuries.
Positive self-talk has also been found to generate positive emotions that are asso-
ciated with an enhanced quality of rehabilitation (Udry, Gould, Bridges and Beck,
1997). Rock and Jones (2002) provided support for the use of reframing an athlete’s
cognitions as part of the rehabilitation process during counselling sessions. More
specifically, it was concluded that engaging in such interventions during
rehabilitation could have a positive effect on athletes’ psychological wellbeing,
particularly during setbacks in the recovery process (Rock and Jones, 2002).
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In her doctoral thesis,Walker (2006) also provided support for the use of refram-
ing paired with progressive muscular relaxation during rehabilitation from sport
injury. She measured injured athletes’ re-injury anxiety using the re-injury anxiety
inventory (RIAI; Walker, Thatcher and Lavallee, 2010). Using a multiple-baseline
design, the players’ re-injury anxieties were explored before and after the intro-
duction of the intervention. Following the introduction of the intervention, there
was a quick reduction in trend, mean and level for both re-injury anxiety related
to rehabilitation (RIA-R) and re-injury anxiety related to returning to
training/competition (RIA-RE). Social validation results also showed that the
participants perceived positive changes in re-injury anxieties as a consequence of
using the intervention.
The most recent published investigation exploring the use of self-talk for
injured athletes was conducted by Naoi and Ostrow (2008). A single-subject
design was employed, similar to that adopted by Walker (2006), and changes in
mood and pain responses were measured via standardised psychological instru-
ments (Naoi and Ostrow, 2008). Three of the five injured athletes showed an
improvement in mood during the intervention phase compared with the baseline
phase but all athletes reported that the intervention was an aid to their physical and
psychological recovery.
Self-talk techniques in sport injury rehabilitation

Positive self-talk has generally been advocated as being more useful than negative
self-talk (Zinsser et al., 2010); hence, it has been proposed that athletes should be
helped to reduce their use of negative self-talk and increase their use of more posi-
tive self-talk. However, as previously outlined,Tod et al. (2011) suggest that, despite
support for the use of positive self-talk compared with no self-talk, an inconsistent
effect has been detected for the possible benefits of positive self-talk over the use
of negative self-talk. Hamilton, Scott, and MacDougall (2007) describe negative
self-talk as ‘challenging’ self-talk in some circumstances and for some athletes rather
than negative self-talk. Therefore, the interpretation of the content of self-talk is
more important than the actual type of self-talk itself (that is, positive or negative;
Hamilton et al., 2007). For example, following an inappropriate behaviour (for
example, missing a rehabilitation session) an athlete might give themselves a ‘talk-
ing to’ (for instance, ‘You idiot! This will not help you’) and hence be motivated
not to repeat the same behaviour in the future.This type of self-talk (negative state-
ments) might only be harmful to some athletes but for others it might actually be
facilitative (Goodhart, 1986;Van Raalte, Cornelius, Brewer and Hatten, 2000). For
this reason, from here onwards we use the term ‘functional self-talk’ in this chap-
ter. The following section outlines the use of thought stopping and reframing as
two potential techniques for encouraging functional self-talk in rehabilitation.
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Thought stopping
Thought stopping has been proposed to be useful by some authors (for example,
Bull, Albinson and Shambrook, 1996) to initially stop an inappropriate thought
and then allow a more functional thought to be used in its place. Thought stop-
ping has been advocated as a deliberate self-talk technique to direct sport-related
thinking (Zinsser et al., 2006).
Thought-stopping steps
1. Increase the athlete’s awareness of the inappropriate self-talk they are
using. For example, they might keep paperclips in one pocket and trans-
fer a paperclip to the opposite pocket on each use of inappropriate
self-talk in rehabilitation (Owens and Bunker, 1989). At the end of the
session, the athlete can see how many paperclips they have in the ‘inap-
propriate self-talk’ pocket, increasing their awareness of its use.
2. Once the injured athlete is aware of their use of inappropriate self-talk,
the second step is to use a trigger to stop the thoughts/talk (cue word,
image or action). For example, an athlete might say ‘wait’ or might visu-
alise an image of a stop sign or snap their fingers as a trigger to stop their
inappropriate self-talk statements.
3. Finally, a more functional self-talk statement is then used to replace the
previous inappropriate self-talk.This final step is important because, when
thought-stopping techniques are used on their own without supplemen-
tary techniques, this is likely to exacerbate the problem of inappropriate
self-talk.
(Hardy et al., 2009)
Some self-talk that is perceived as negative might in fact be challenging, and

therefore motivational, and might not need to be stopped or changed. The
key for the practitioner is to initially explore the athlete’s interpretation of their
self-talk.
Reframing technique
A common response to injury is anxiety (for example, anxieties related to pain
experienced, lengthy rehabilitation anxieties, the loss of a starting place and changes
to daily routines, performance outcome anxieties, pre and/or post-operative anxi-
ety, fitness demands and returning to peak performance anxiety and re-injury
anxiety).When faced with a potentially anxiety-provoking situation, there is a need
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to challenge these appraisals. This can be achieved via modifying the athlete’s
thoughts and self-statements associated with the situation, a technique called
reframing. Here the event or behaviour stays the same but the athlete’s appraisal is
changed (Jones, 2003).
There is a substantial amount of anecdotal evidence reporting the benefits of
reframing in the field of sport and exercise psychology (see, for example, Bull et al.,
1996; Porter, 2003; Syer and Connolly, 1998). However, there appears to be
substantially more empirical research using the reframing technique in counselling
psychology.
• The key to reframing begins with awareness of the nature of the self-
talk/thought. The first stage is, therefore, developing awareness of current
thoughts/talk.
• Once the inappropriate cognitions are exposed, the athlete can challenge
them by reframing the appraisal to a more functional counter response. The
reframing technique involves reappraisal of a situation to programme the
subconscious for success and lay the foundations for future progress and
change (Hill, 2001). Altering the appraisal of an event or situation effects a
change in the way feelings and emotions are attached to that situation (Hill,
2001). As a result of the change, behaviour and responses will change.
An injured athlete’s thoughts and statements before, during and after injury, includ-
ing rehabilitation, have been shown to be a critical element of the psychological
response to injury (see Chapters 2 and 3). It is reported that injured athletes often
engage in inappropriate self-talk and that this is often counterproductive.The liter-
ature outlined earlier discusses evidence that self-talk is a psychological
intervention that is useful for aiding recovery from an athletic injury. By challeng-
ing an injured athlete’s inappropriate thoughts and statements practitioners can
reduce the potential detrimental impact that they can have on emotions, rehabili-
tation compliance and adherence, and recovery outcomes. In chapter 10, the
authors outline three phases of rehabilitation.Table 8.2 outlines examples of the use
of reframing during these three phases.
It is important to offer functional self-talk, or indeed any intervention, early in

rehabilitation to allow the athlete time to become familiar with it (Walker, 2006).
Functional self-talk might be particularly useful at phase III for focusing the
injured athlete on thoughts associated with successfully performing the skills
they need for their sport.
Using self-affirming functional self-talk to build confidence for the return to
training and competition is also critical during rehabilitation.
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TABLE 8.2 Reframing during the three phases of rehabilitation
Phase of Injury experience Self-talk Reframed self-talk

rehabilitation
I Unhelpful negative thoughts ‘This is agony! I can’t ‘I can handle this I’m
about injury severity; the believe I went in for tough. I am not the
significance of the injury to that tackle.’ only person ever to be
their future; blame injured.The pain
themselves for injury onset; prevents me from
struggling to cope with the doing more damage.’
pain of the injury;
concerned about the
prospect of a difficult and
possibly long rehabilitation
process
II Loss of motivation; coping ‘I can’t go on the ‘I’ve balanced on an

with difficult and/or lengthy board. I can’t balance. uneven surface.The
rehabilitation; anxieties I’m going to fall off board is no different.
about becoming re-injured and twist it again.’ It’s just the same, I can
during rehabilitation do it!’
III Anxieties and doubts about ‘It’s not strong ‘It has been tested
their return to training and enough. I need more throughout
competition rehab before testing it rehabilitation and it has
in training.’ survived. It is ready.’
Functional self-talk in sport injury rehabilitation

The types and functions of self-talk outlined in the opening of this chapter are also
appropriate in the context of injury rehabilitation. An injured athlete is likely to
engage in some inappropriate self-talk at some period of their injury experience.
For example, they might say, ‘I’m never going to recover from this injury’. They
may also engage in more functional self-talk; for example, when struggling with
motivation during rehabilitation they might say,‘You can do this! Only four more
reps!’ It could be expected that a mixture of both positive and negative self-talk said
both overtly and/or covertly are used by an injured athlete throughout their reha-
bilitation. Whilst not all negative self-talk is always debilitative, as outlined earlier,
athletes should try to engage in more functional self-talk because it is likely to be
more facilitative in rehabilitation settings.
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I don’t care whether the athlete says things about their recovery out loud or to
themselves. For me the importance is what they are saying. They have to believe
seeing their injury and recovery in a more positive light is far better than beating
themselves up. Some find positive things to say to themselves and others need
some help when they say really bad things to see a more positive view to the situ-
ation. I can help them with that, I like to challenge what they are thinking and
saying about their injury.
(Sally, sport medicine professional)
The sport medicine professional might encourage an injured athlete to engage in

many types of functional self-talk for a variety of purposes (to motivate or to
instruct). Table 8.3 demonstrates some example self-talk statements for the five
different functions of self-talk.
TABLE 8.3 Examples of self-talk serving different functions in injury rehabilitation
Type of self-talk Example

Instructional:
Skills ‘Keep the heel flat’
Strategy ‘This is boring but small steps lead to recovery’
Motivational:
Arousal ‘Come on! You can do this.’
‘Stay relaxed, breathe slow.’
Mastery ‘The ankle is strong like a brick, I’m ready!’
Drive ‘Push on, only 3 more reps!’
Self-determined and assigned self-talk in sport injury rehabilitation

It might also be appropriate for the sport medicine professional to consider the
implications of assigning an athlete self-talk statements. Where possible an athlete
should determine their own statements. However, where an athlete’s appraisals of
their injury are debilitative they may need help in challenging their appraisals and
further assistance in restructuring their self-talk so that it is more functional. It
would be unrealistic to expect the athlete engaging in inappropriate self-talk to
come up with restructured self-talk independently and spontaneously. It might not
be wise, however, to assign the athlete new self-talk statements. Collaborating with
the athlete is vital in this instance.To do this, a practitioner might use the technique
of reframing and encourage the athlete to record their negative thoughts regarding
their injury and explore them during rehabilitation sessions, challenging the
thoughts the athlete has. An awareness of self-talk patterns is often seen as the most
difficult part of self-talk techniques (Taylor and Taylor, 1997). After raising the
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athlete’s awareness, the sport medicine professional would encourage the athlete to
reframe these statements into more personal functional affirmations (Porter, 2003).
It is crucial that the reframed statements are true or, at least, probable and realistic
(Crossman, 2001).The athlete might also be encouraged to destroy the debilitative
statements and place them in a waste bin (Porter, 2003) and to re-read the restruc-
tured functional affirmations daily, reframing any debilitating thoughts that arise.
For example, the injured athlete might say ‘I can’t attack the ball anymore because
it [head injury] will happen again’.They might be helped to challenge this appraisal
and restructure the statement to,‘I can attack the ball, I’ve done it loads before, and
can make a difference to this game’.
Self-talk might be self-determined and this is usually what we would encour-

age. However, some support and assistance might be needed to help injured
athletes to develop functional self-talk statements.
Intervention efficacy beliefs

It is suggested that a belief or expectancy about intervention effectiveness may be
a precondition for it to be effective (see, for example, Oikawa, 2004). It would be
ineffective to use self-talk techniques with an injured athlete who does not expect
them to be useful for their injury rehabilitation. It is also important to note that
the sport medicine professional’s belief in the intervention is also likely to be a
precondition for self-talk to be effective. Thus, practitioners need to be aware of
this before employing any intervention in rehabilitation. In addition, the working
alliance or collaborative relationship between the sport medicine professional and
the injured athlete may influence the athlete’s belief in and willingness to use self-
talk (see Tod and Andersen, 2005).
Conclusion
Self-talk can have a number of functions (such as to instruct on skill execution and
skill strategy, to regulate arousal, focus attention and concentration and to aid in
goal attainment). Its interpretation by the user is a critical determinant of outcomes
of its use (not all negative self-talk has a negative consequence). Research supports
the use of self-talk in sport generally but its use with injured athletes has less
support currently. Early discussions from the small research base suggest that it can
be used throughout rehabilitation for reducing recovery time, enhancing coping
resources and the perception of quality of rehabilitation, improving joint restora-
tion, increasing muscular strength, enhancing positive mood state and psychological
wellbeing, reducing re-injury anxieties and allowing the athlete to rehearse sport-
related skills whilst injured. However, further research is needed and should explore
the athlete’s experiences of using self-talk as part of the rehabilitation process.
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Furthermore, the different motivational and cognitive functions of self-talk (as

identified by Hardy et al., 2001) should be explored in the sport injury rehabilita-
tion setting.
CASE STUDY
Max is a 23-year-old martial artist who competes in Ju-Jitsu and has been
engaging in rehabilitation after sustaining a grade II anterior talofibular liga-
ment (ATFL) injury he suffered in training six weeks ago, after jumping to
complete a spinning roundhouse kick and landing awkwardly on the mat. He
has passed through the required three phases of rehabilitation (i.e., phase I the
acute phase, phase II the rehabilitative phase, and phase III the functional
phase) and he is approaching re-entry to training. However, he is demonstrat-
ing some anxieties about re-injury when he discusses his imminent return to
sport. Sally, the sport medicine professional responsible for Max’s care, has
assured Max that he is physically rehabilitated from his injury and, based on
the discussions between Sally and Max about his anxieties, she has asked Max
to complete the RIAI (Walker et al., 2010). His re-injury anxiety score regard-
ing rehabilitation was 0 (indicating an absence of re-injury anxiety). However,
his re-injury anxiety score regarding the return to training and competition
was 40, indicating high re-injury anxieties in these environments (a maximum
score of 45 is possible on this scale). Max has expressed his doubts to Sally, ‘I
am going to set myself up for a jump and it’s just going to go again, I know
it!’ and has questioned, ‘What if he blocks it [opposition] and that’s enough to
set me back to square one?’ and ‘A sharp change of direction or a sweep to it
and what if it happens again?’. Although Sally has informed Max that he is
ready to return to training, he responded, ‘I’m not convinced it’s ready, I need
to put it to the test more. I might just tape it to give it added strength’. He has
also made claims related to a perceived long-term weakness in the injured site.
He said, ‘I’ve just got this feeling it’s always going to be weak now and that’s
going to play on my mind before competing’. More recently, he has informed
Sally that his anxieties about becoming re-injured in training or competition
have caused him to feel tense and that his breathing and heart rate increase
when he thinks about the possibility of re-injury.
–––––––– ? ––––––––
injury and rehabilitation process outlined in Chapter 3 (Wiese-Bjornstal et
al., 1998), how might the technique of reframing reduce Max’s re-injury
anxieties?
2. How might using a multiple intervention package, such as reframing and
progressive muscular relaxation, be useful to help Max with his holistic
return to ju-jitsu training and competition?
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3. Using the suggestions in this chapter, outline the procedure you would
take when using reframing with Max.
4. Using the quotes from the case study, reframe the statements into more
personal functional statements that Max might consider using.
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9
SOCIAL SUPPORT IN SPORT INJURY
REHABILITATION
Monna Arvinen-Barrow and Stephen Pack
Introduction
Social support has been one of the most rigorously and frequently researched
psychosocial resources (Thoits, 1995). The notion that people feel the need to be
associated with others who provide love, warmth, social ties and a sense of belong-
ing has long been considered as an emotionally satisfying aspect of life. Indeed,
many philosophers have discussed the social needs of people and psychologists have
postulated needs for social caring and nurture (Fromm, 1955; Litwak and Szelenyi,
1969; Maslow, 1954, 1968). It has also been suggested that social support mediates
the stress–health link, enabling individuals to better cope with stressful events,
thereby reducing the likelihood that stress will lead to ill health (Sarason, Sarason
and Gurung, 1997). A great deal of evidence exists regarding the availability of
social support and the reduced risks of mental and physical illness (for example,
Berkman, 1984; Cohen and Wills, 1985;Thoits, 1995).
In sporting contexts, social support has been identified as a useful coping
resource when dealing with a variety of stressors (such as performance pressures,
relationship problems, unexpected disruption to performance routines and depres-
sion arising from unfulfilled expectations; Gould, Finch and Jackson, 1993).
Similarly, high levels of particular types of social support have been linked to the
maintenance of flow states (Rees and Hardy, 2004), as well as direct and indirect
reductions in the effects of stress consequently enhancing self-confidence (Rees
and Freeman, 2007). Research has also demonstrated social support as beneficial to
athletes when dealing with sport related burnout (Rees, 2007). Sarason, Sarason
and Pierce (1990) also proposed social support as having a direct influence on
performance, a notion which, for example, has recently received empirical support
in tennis (Freeman and Rees, 2009; Rees and Freeman, 2010; Rees and Hardy,
2004; Rees, Hardy and Freeman, 2007).
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118 Monna Arvinen-Barrow and Stephen Pack
Despite many athletes preferring to ‘go it alone’ (Hardy, Jones and Gould, 1996:
234), research literature seems to support the importance of social support provi-
sion, particularly during ‘times of need’ (Rees, 2007: 224); such as when an athlete
becomes injured. Indeed, within the literature related to sport-related injury, social
support has been proposed as being integral to the coping process and therefore
has been considered as a beneficial adjunct within the rehabilitation process
(Bianco, 2001; Podlog and Eklund, 2007a; Rotella and Heyman, 1993; Weiss and
Troxel, 1986). This chapter discusses how social support might be applied within
sport injury rehabilitation. Specifically, the chapter: (a) introduces existing concept
definitions and purposes of social support within the injury context; (b) describes
the mechanisms of social support; (c) introduces different types of social support
that might be beneficial in sport injury rehabilitation; (d) discusses a range of
potential sources of social support in sport injury rehabilitation; (e) outlines the
process of providing social support in sport injury rehabilitation; and (f) highlights
some issues to consider when providing social support to injured athletes.
Social support in rehabilitation: concept definitions and purpose

Within the sport context, social support has received a high level of research atten-
tion, yet there is currently little consensus with regard to defining it as a concept.
However, proposed definitions have included ‘knowing that one is loved and that
others will do all they can when a problem arises’ (Sarason et al., 1990: 119).
Specifically relating to the injury context, social support has been defined as a ‘form
of interpersonal connectedness which encourages the constructive expression of
feelings, provides reassurance in times of doubt, and leads to improved communi-
cation and understanding’ (Heil, 1993a: 145). Rees (2007) also described social
support as a multifaceted process in which an athlete is aided by the existence of a
caring and supportive network, as well as by their perception of other people’s
availability to provide help in times of need and by the actual receipt of support.
These definitions appear to centre upon a common theme with regard to
people acting as a provider of resources when needed. In succinct terms, social
support might be considered a coping resource; a social ‘fund’ from which people
may draw when dealing with stressors (Thoits, 1995). Moreover, it has been argued
that the primary purpose of social support during injury rehabilitation is to afford
an athlete a sense of belonging and assurance, which might help to convey in real
terms that they are not isolated in their experience of injury, and instead have a
support network readily available to assist them in the rehabilitation process (Taylor
and Taylor, 1997).
Mechanisms of social support

It is commonly accepted that social support influences injury rehabilitation by
impacting on an individual’s response to the injury process; thus, it is appropriate
to discuss the mechanisms of social support acknowledged within the integrated
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Social support in sport injury rehabilitation 119
model of psychological response to sport injury and rehabilitation process (Wiese-

Bjornstal, Smith, Shaffer and Morrey, 1998) as outlined in Chapter 3. This model
highlights social support as a situational factor affecting an injured athlete’s cogni-
tive appraisal of their injury, which in turn may influence their emotional and/or
behavioural responses to the injury. In addition, engagement (or lack of engage-
ment) with social support has been highlighted as a behavioural response to injury,
which in turn might also influence an athlete’s cognitive appraisal and/or
emotional response to the injury (Wiese-Bjornstal et al., 1998; for more details on
the model, see Chapter 3).
To date, it is thought that social support facilitates injury rehabilitation through
two mechanisms: by ‘buffering’ athletes from harmful effects of injury related stres-
sors and by directly influencing the rehabilitation process without any association
with stress (Mitchell, Neil, Wadey and Hanton, 2007; Rees, 2007) (Figure 9.1).
Thus, the stress-buffering model proposes that high levels of support can provide a
‘shield’ and an indirect support mechanism against potential negative effects of
injury, such as unrealistic/negative cognitive appraisal (for example, unrealistic rate
of recovery expectations or decreased self-perception), undesired emotional
responses (for example, feelings of depression or frustration and poor emotional
coping skills) and undesired behavioural responses (for example, lack of rehabilita-
tion adherence, substance abuse and malingering), each having been found to have
a negative effect on overall recovery outcomes of injury. Consequently, the stress-
buffering model also assumes that social support is not relevant to those who do
not perceive their situation (that is, the injury) as stressful.
Social support
Stressor Individual’s response

(i.e. the injury) to sport injury and
FIGURE 9.1 The stress-buffering effect model of social support adapted to sport
injury settings
Source: adapted from Rees, 2007
In contrast, the main effect model proposes that social support can directly
influence an individual’s response to the injury and rehabilitation process (e.g., how
an individual appraises the injury situation cognitively, emotionally, and behav-
iourally) (Figure 9.2). That is, having a supportive network offers the potential to
increase positive affect, therefore increasing the likelihood of an athlete being more
realistic about the rate of perceived recovery (cognitive appraisal), and subsequently
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Individual’s response
Social support to sport injury and
FIGURE 9.2 The main effects model of social support adapted to sport injury settings
Source: adapted from Rees, 2007
experiencing decreased levels of frustration and a more positive attitude towards

rehabilitation (emotional response), leading to the potential for enhanced treatment
compliance and rehabilitation adherence (behavioural response).
Whilst each model describes different causal explanations regarding how social
support works, the two are considered as complementary (Bianco and Eklund,
2001). For example, an athlete may view injury as stress-provoking and, based upon
the number of personal and situational factors (such as type/severity of injury and
the rehabilitation environment) social support might help both directly and indi-
rectly. Having assistance with everyday life chores (for example, food preparation)
might directly impact athletes’ responses to the injury and rehabilitation process by
reducing potential daily hassles. Such support can also enable athletes to avoid
unnecessary (potentially harmful) physical movement and thus directly impact the
rate of physical recovery and recovery outcome. Similarly, having a supportive sport
medicine professional to work with can also help athletes to approach the rehabil-
itation process with a more positive outlook, thus reducing the level of stress. In
contrast, a lack of tangible day-to-day support might increase the stress felt by
athletes.Therefore, not only is it important to understand how social support works
during rehabilitation but also to understand what types of social support can be
beneficial to athletes during the rehabilitation and recovery process.
Social support is a form of resource provision, arises from interpersonal connec-

tions, and its presence is consistently linked to beneficial health outcomes. For
example, social support might ‘buffer’ injured athletes from potentially harm-
ful effects of stress, directly influence appraisal of their injury in a helpful
manner and aid the management of emotional and behavioural responses
during the injury and rehabilitation process.
Types of social support

Existing literature generally considers social support as a multidimensional
construct (Rees and Hardy, 2000). However, there is an ongoing disagreement
regarding how many dimensions (or types of support) social support might
comprise (Cutrona and Russell, 1990). Thus far, based on the works of Pines,
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Aronson, and Kafry (1981), Hardy and Grace (1991, 1993) and Udry (1997, 2002)
five distinct types of social support are considered as beneficial during sport injury
rehabilitation: (1) emotional support, (2) technical support, (3) informational
support, (4) tangible support and (5) motivational support. These can be further
subdivided into more specific types of support: esteem support, listening support,
emotional support, emotional challenge support, shared social reality support, tech-
nical appreciation support, technical challenge support, personal assistance support
and material assistance support (Table 9.1).
As demonstrated above, there are a number of, often overlapping, types of social
support that are said to be applicable to the sport injury context. Depending on
the athlete and their personal situation, different types of support may be appro-
priate for different phases of rehabilitation (for more details on rehabilitation
phases, see Chapter 10). For example, an athlete in phase I (reaction to injury) is
often mostly concerned about the pain they are experiencing.Thus the provision
of listening and emotional support, and possibly material assistance, might be most
appropriate. During phase II (reaction to rehabilitation), an athlete is more likely
to benefit from emotional challenge, technical appreciation and challenge support,
as well as motivational support to help sustain/or increase motivation, rehabilita-
tion adherence and/or treatment compliance. During phase III (reaction to return
to play), esteem support and different forms of technical and informational support
can help an athlete feel more confident in their ability to return to sport and
address anxiety related concerns.
Straight after the operation I was stuck at home, couldn’t really do anything, um,
driving, couldn’t drive anywhere, couldn’t really do, do anything for myself, so it
was, my life had to change significantly. Like where other people being like my
parents and my brother helped me a lot more than they had done, you know I kind
of went back to being like not a baby, but a toddler, that needed help with basic
things like picking things up from the floor and stuff like that
(Professional football player, cited in Arvinen-Barrow, 2009)
Sources of social support

As suggested, the type of social support required may vary greatly, depending on
various personal and situational factors surrounding individual athletes. Not only is
it important to understand the types of support that might be beneficial and how
these might meet an injured athlete’s needs, it is also important to consider poten-
tial sources of social support (Figure 9.3).
During injury rehabilitation, athletes often associate and work with, a range of
individuals who might act as sources of social support. These sources might be
members of the athlete’s immediate family, friends, sport team members (for
example, coach, team mates) and sport medicine professionals (Heil, 1993b;Taylor
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TABLE 9.1 Different types of social support during sport injury rehabilitation
Type of Description References

support
Esteem Enacting behaviours that bolster an athlete’s Freeman and
self-confidence, sense of competence or self-esteem, Rees (2009)
perhaps through provision of positive feedback or by Rees (2007)
demonstrating belief in the athlete’s ability to cope
with injury
Listening Actively listening to the athlete whilst refraining from Taylor and
giving advice or making judgement.This should involve Taylor (1997)
sharing both positive (e.g. joys of rehabilitation success)
and negative (e.g. setback frustrations) thoughts and
feelings associated with rehabilitation
Emotional Providing an athlete with impartial assistance during Freeman and
emotionally difficult times and demonstrating Rees (2009)
acceptance, empathy and encouragement should they Rees, Mitchell,
experience setbacks, thus facilitating a sense of comfort Evans, and
and security Hardy (2010)
Emotional Challenging the athlete to do their utmost to overcome Taylor and
challenge obstacles to goal-achievement, and structuring support Taylor (1997)
so as to facilitate motivation toward rehabilitation
Shared social Acting as a ‘reality-touchstone’ by verifying an athlete’s Taylor and
reality perception of the current situation, and social context, Taylor (1997)
thus potentially providing a sense of ‘normalisation’
Technical Demonstrating an acknowledgement of an athlete’s Taylor and
appreciation achievements, or reinforcing effort and intensity during Taylor (1997)
a rehabilitation session
Technical Encouraging athletes to achieve more, to be excited Taylor and
challenge about their work and progress, and to seek new ways Taylor (1997)
in which they might rehabilitate
Personal Providing advice, guidance, and assistance in the form Rees et al.
assistance of time, skill, knowledge and expertise targeted directly (2010)
at problem-solving or feedback relating to rehabilitation
Material Providing tangible assistance such as the provision of Rees (2007)
assistance transport to rehabilitation, assistance with general Rees et al.
household duties, and financial support thus directly (2010)
facilitating an athlete’s chances of goal achievement
Motivational Encouraging athletes to overcome, or give into, various Udry (2001,
barriers during the rehabilitation process 2002)
and Taylor, 1997; Wagman and Khelifa, 1996). Depending on the role of each of
these members during rehabilitation, together they will form the foundation for
the primary and secondary rehabilitation teams working with the athlete during
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rehabilitation (for more details, see Chapter 11) in the hope of ensuring a fast
return to pre-injury (or higher) levels of fitness and performance.
Esteem
support
Listening
Emotional
Family and
support
friends
EMOTIONAL Emotional
SOCIAL challenge
SUPPORT
Shared social
reality
Technical
TECHNICAL appreciation
SOCIAL
SUPPORT Sport
Technical
team
challenge
members
Personal
assistance
SOCIAL INFORMATIONAL
SUPPORT SOCIAL
SUPPORT Technical
assistance
Material Sports
TANGIBLE assistance medicine
SOCIAL team
SUPPORT Technical members
challenge
MOTIVATIONAL
SOCIAL
SUPPORT
FIGURE 9.3 Types and sources of social support proposed as beneficial during the
sport injury rehabilitation process
Source: collated from the works of Pines et al., 1981; Udry, 1997, 2002
Family and friends

According to Taylor and Taylor (1997), family and friends are best suited to provid-
ing emotional and listening support, as well as support in the form of emotional
challenge and shared social reality. Amongst professional rugby players, parents
were also found to provide listening support, and emotional challenge support, to
help players regain emotional control during difficult periods (Carson and Polman,
2008). Similarly, Arvinen-Barrow (2009) found that, amongst professional football
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and rugby players, families were seen as essential sources of emotional and motiva-
tional support. Moreover, when the injury resulted in major physical limitations,
their role as a form of tangible support also increased (Arvinen-Barrow, 2009).
Um, well I suppose I had my family behind me, and my girlfriend as well, so . . . they
help you an awful lot this um, cause it’s a lonely time that you’re in especially, I
was in bed for two weeks I couldn’t do anything just lying on my back for two
weeks, so you’ve got a lot of time to think about things. Yeah I suppose, it can be
a very depressing time and er, yeah you just need friends and family, it’s essential,
I think that you have that and without them you’d go mad, you’d go crazy you
know
(Professional rugby player, cited in Arvinen-Barrow, 2009)
Sport team members

It has been suggested that team mates and coaches are best positioned to provide
athletes with support in the form of technical appreciation, technical challenge and
shared social reality (Taylor and Taylor, 1997). Research has demonstrated that team
mates are also a source of inspiration (Carson and Polman, 2008) and a source of
motivational support (Arvinen-Barrow, 2009). The coach’s role has also been
discussed in research literature, as professional coaches themselves view the provi-
sion of support as an important part of their role by providing emotional, material
and informational support (Podlog and Eklund, 2007b).
I think that having another person, another injured player with you is quite vital.
It makes it real to motivate yourself into training . . . because some days you feel
like, I can’t, I can’t do it, I’m really too tired, but then your mate’s, your mate’s fine
and he gets you through it.”
(A professional football player, cited in Arvinen-Barrow, 2009)
Sport medicine team members

Much research suggests that sport medicine professionals may provide all types of
social support, owing to their close relationship with athletes during injury reha-
bilitation (Taylor and Taylor, 1997). For example, Bianco (2001) found that sport
medicine professionals were best suited to provide various types of emotional,
informational and tangible support. A doctoral thesis by Arvinen-Barrow (2009)
also found that, amongst professional rugby and association football players, those
working with athletes on a daily basis were seen as important sources of emotional,
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informational and motivational support. Similarly, sport medicine professionals

have been viewed as important sources of informational support, which enhances
understanding of the injury and the rehabilitation process (Carson and Polman,
2008; Rock and Jones, 2002).
Researchers have also indicated that sport medicine professionals might facili-
tate athletes in seeking social support from additional sources, such as providing
contacts to other injured athletes (see, for example, Arvinen-Barrow, Penny,
Hemmings and Corr, 2010) or with allied health professionals. Other professional
staff (typically classed as members of the secondary rehabilitation team; for more
details, see Chapter 11) might also be important sources of social support. For
example, Evans, Hardy and Flemming (2000) found that when setbacks occurred
during rehabilitation, the use of a sport psychology consultant was particularly
important.
Using social support for rehabilitation: the process

It appears that social support can influence reactions to the sport injury rehabilita-
tion process directly and/or indirectly. It is also evident that there are different types
of social support that are beneficial for injured athletes and that a number of indi-
viduals might represent useful sources of support. However, the extent to which
each type of support is required and used by athletes can be dependent upon the
support provider and the actual stage of rehabilitation (Bianco, 2001). It has also
been suggested that having multiple sources of support available is important, as an
athlete may then not feel limited to the potentially biased and/or unhelpful advice
of one person (Carson and Polman, 2008).
There is currently little research that has examined how best to implement
social support effectively within an injury context (Rees and Hardy, 2004) but it
appears that social support might be provided in a number of ways (Freeman,
Coffee and Rees, 2011). Mitchell (2011) and Rees (2007) have indicated that
differing social support needs of injured athletes should be met through corre-
spondingly different types of support, which should be provided at the right time
and the right level for the process to be effective (Sarason et al., 1990; Udry, 2001).
This is supported by earlier suggestions from Richman, Hardy, Rosenfeld, and
Callanan (1989), who proposed three general recommendations regarding the
provision of support. According to the authors, social support:
1. is best provided by a network of individuals

2. needs to be developed and nurtured, and
3. works best as part of an ongoing programme rather than when employed
purely as a reaction to a crisis.
Consequently, it has been suggested that support might be provided via peer
modelling, which Kolt (2004) describes as the process of linking a currently injured
athlete with another athlete who has undergone a similar rehabilitation process and
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who has recovered (or is nearly recovered) to their pre-injury performance level.
Support for the use of peer modelling has been found in studies (for example,
Wiese, Weiss and Yukelson, 1991) conducted with athletic trainers and injured
athletes in the form of ‘buddy systems’ (Walker, 2006).
A further useful means of introducing social support is via injury support groups
(Wiese et al., 1991) or performance enhancement groups (Clement, Shannon and
Connole, 2011). Often employed with athletes undergoing lengthy rehabilitation
programmes, such groups can facilitate the establishment of important networks
with other athletes and can offer opportunities to discuss experiences of injury and
rehabilitation. Support groups have also been found to facilitate motivation (Weiss
and Troxel, 1986), which can be a major factor in assisting athletes in reaching full
recovery. Being part of a performance enhancement group can also teach athletes
important psychological skills to help them cope with the distress caused by injury
(Clement et al., 2011). Given that social support as a concept, however, considers a
range of social networks as potential sources of support, and that injured athletes
have individual preferences for the sources of social support they consider benefi-
cial, the use of peer modelling and injury support groups may not suit all.Thus, an
alternative approach is one-to-one intervention (Freeman and Rees, 2009), which
will often resemble a typical counselling relationship, whereby the effectiveness of
the intervention is highly dependent on the nature of the working-alliance
between the athlete and the support provider.
Social support: issues to consider

In addition to considering the potential types, sources, processes and mechanisms
in which social support is best provided, we believe that those involved in social
support provision should also consider:
• the characteristics of the support provider;

• the concept of perceived versus received support; and
• the negative effects of social support.
Characteristics of the support provider

Literature seems to suggest that individuals providing social support should possess
certain intra- and interpersonal characteristics, skills and techniques in order for
social support provision to be effective. Specifically, a person providing social
support should: (1) be a good listener; (2) have the ability to identify personal and
gender differences in athletes receiving support; (3) be able to acknowledge both
effort and mastery; (4) with the help from systematic goal setting, be able to balance
the use of technical appreciation and technical challenge; (5) possess awareness of
social support as being the most necessary yet least available technique in relation
to injury requiring surgery and lengthy rehabilitation; and (6) be able to identify
correct intervention (such as support group or peer modelling) for individual
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athletes (see, for example, Heil, 1993a; Rees, 2007; Richman et al., 1989;Taylor and
Taylor, 1997; Udry, 2001).
The concept of perceived versus received support

In addition to the individual characteristics of the support provider, another
consideration is the difference between perceived and received support. Bianco and
Eklund (2001) highlighted that, for social support behaviours to occur, support
networks must firstly be in place. Furthermore, the effectiveness of a support
network is not necessarily associated with just the number of support providers
available (Sarason et al., 1990;Thoits, 1995) but, instead, is related to the extent to
which various individuals recognise the need to provide support and are willing
and able to provide support when necessary (Bianco and Eklund, 2001).
Consequently, there are likely to be differences in the type of support that athletes
require, expect to receive and actually receive, thus there will be variations depend-
ing upon the support provider and their role in the injured athlete’s life, as well as
the actual stage of rehabilitation (Bianco, 2001; Handegard, Joyner, Burke and
Reimann, 2006). In addition, the timing of the support, injury type and injury
severity can also impact upon an athlete’s perception of required, provided and
received social support (Taylor and Taylor, 1997). It has also been suggested that
there might be gender differences in relation to the perceptions and use of social
support; for example, female athletes have been perceived as having more
emotional support available from their networks than male athletes (Hardy,
Richman and Rosenfeld, 1991; Mitchell et al., 2007; Rock and Jones, 2002).
Understanding the differences between perceived and actual support is impor-
tant, as having a positive perception that support will be available when needed can
influence appraisal of rehabilitation, as well as facilitate the development and use of
effective coping skills. Increases in a supportive network, such as an increase in
social integration, network size and frequency of contact with others in the
network, are also associated with corresponding increases in positive outcomes
(Rees, 2007). These positive outcomes might result from an athlete simply being
part of a network, and as such their self-concept, self-worth and personal control
might be enhanced.
Negative effects of social support

Although social support generally appears to have a positive influence, if provided
insufficiently and inappropriately, it can have a negative effect on the athlete’s over-
all health and wellbeing. Insufficient rehabilitation guidance, lack of sensitivity to
the injury and lack of concern from those surrounding the athlete have been found
to be negatively perceived by athletes (Udry, Gould, Bridges and Tuffey, 1997) and,
as such, can be detrimental to the overall recovery process. Similarly, if the provider
is not adequately skilled to provide the support needed or, indeed, is not aware of
their role as a source of support, this could also have a negative effect on the athlete
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and the overall rehabilitation. Thus, those involved with athletes during injury
rehabilitation should possess awareness of their possible role as a source of social
support and also acknowledge their own competencies and limitations as potential
providers of social support including an understanding of when to provide support
and when not to.
Conclusion
Despite the lack of a distinct definition of social support, of all the psychological
interventions available, social support appears to be one of the most used tech-
niques during injury rehabilitation. Injured athletes appear to benefit from a range
of different types of social support, provided by a number of individuals they typi-
cally associate with.This chapter has provided details of the mechanisms underlying
the concept of social support, the different types and sources of social support that
might be beneficial during rehabilitation and has discussed the range of potential
sources of social support available during rehabilitation. Moreover, the chapter has
outlined the process of using social support during rehabilitation and highlighted
potential issues to consider when using social support with injured athletes.
CASE STUDY
John is a 35-year-old British international wheelchair tennis player. He lives

with his wife, Emma, and their 24-month-old daughter, Elizabeth. Two and a
half years ago, John was in a car accident and suffered a spinal cord injury and
was later diagnosed with paraplegia. As a result, John has a total loss of move-
ment and sensation in both legs. Before his accident, John was an amateur
tennis player who just played for fun. After his accident, John has slowly come
to terms with his lack of mobility and credits much of that to his tennis coach:
‘if it wasn’t for my coach helping me to discover wheelchair tennis, I am not
sure where I would be now. I mean, after the accident I was in such a dark
place. My wife was pregnant and I wasn’t able to work, or provide, or even
climb to bed without her help. What sort of a man was I, and what sort of a
father would I be?’
Last week, John fell during a friendly match against his training partner and
dislocated his right shoulder. Luckily, the team physiotherapist was at hand
and John was able to receive appropriate first aid immediately. Following a
doctor’s consultation, it seems that John will not need surgery, provided that
he is able to keep his arm resting and immobilised in a sling for at least a week.
This should then be followed by mobility exercises and the use of the sling for
at least another three to five weeks. The doctor also advised John that full
return back to sport will take anywhere between 10 and 16 weeks, if he is able
to ensure appropriate amounts of rest and immobilisation during the rehabili-
tation and recovery process.
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John is obviously pleased about the possibility of avoiding surgery but also
worried about his ability to cope with the injury appropriately. ‘I mean, this is
bad . . . how am I going to cope with all of this? Elizabeth is only small and I
can’t even pick her up now. . . or indeed wheel myself from one room to
another! Why did my coach tell me to play this stupid friendly match anyway?
It was so unnecessary and look where it got me!’
–––––––– ? ––––––––
injury and rehabilitation process (Wiese-Bjornstal et al., 1998, see Chapter
3), highlight any key pre-injury factors and any possible personal and situ-
ational factors that can be seen as affecting John’s appraisal of his injury?
2. Describe the types of social support that might be beneficial for John and
explain why?
3. Describe who could be best suited to provide John with the different types
of social support identified in question two to help facilitate his return to
full fitness?
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104–10.
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PART 3
Delivering psychological
interventions in sport injury
rehabilitation
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10
INTEGRATING THE PSYCHOLOGICAL
AND PHYSIOLOGICAL ASPECTS OF
SPORT INJURY REHABILITATION
Rehabilitation profiling and phases of
rehabilitation
Cindra S. Kamphoff, Jeffrey Thomae and

J. Jordan Hamson-Utley
Introduction
Over the last 20 years, the use of psychological interventions to speed recovery has
become increasingly popular and vital in ensuring an athlete’s a successful recovery
and return to play (Ievleva and Orlick, 1991; Kamphoff et al., 2010; Williams and
Scherzer, 2010).The same psychological interventions that are used to help athletes
to be successful in sports are being recommended to be implemented in the reha-
bilitation process (Williams and Scherzer, 2010). For non-injured athletes,
psychological interventions like goal setting, positive self-talk, relaxation and
imagery can be used consistently to enhance performance, increase enjoyment and
achieve greater satisfaction in sport (Weinberg and Gould, 2007). Injured athletes
may use psychological interventions for similar reasons, such as to increase enjoy-
ment and satisfaction with the rehabilitation process, but they can also use
psychological interventions to improve recovery time, facilitate physical recovery
following surgery, buffer immune system deterioration, manage pain, prevent future
injuries and improve adherence to rehabilitation (Ievleva and Orlick, 1991; Petrie
and Hamson-Utley, 2011).
More specifically, researchers have found that athletes who used goal setting,
imagery and positive self-talk recovered faster than athletes who did not use these
psychological interventions in the rehabilitation process (Ievleva and Orlick, 1991).
Other researchers have found that when injured athletes use psychological inter-
ventions, they experience a reduction in stress, pain, state anxiety and re-injury
anxiety (Cupal, 1998; Loundagin and Fisher, 1993). Gould, Udry, Bridges and Beck
(1997), for example, found that injured athletes who were able to return to pre-
injury rankings thought that cognitive restructuring, positive self-talk and mental
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Integrating the psychological and physiological aspects of sport injury rehabilitation 135
imagery were an essential part of their rehabilitation. Lastly, athletes who use these
psychological interventions show a better adherence to rehabilitation (Evans and
Hardy, 2002a; 2002b; for more details on different psychological interventions, see
Chapters 5–9).
Sport medicine professionals and students have been taking note that being
psychologically ready for competition may be as important as being physically
ready to play (Hamson-Utley, Martin and Walters, 2008; Kamphoff et al., 2010;
Stiller-Ostrowski and Ostrowski, 2009).Yet, the majority of sport medicine profes-
sionals have tended not to incorporate psychological interventions into the
rehabilitation programs of injured athletes (Arvinen-Barrow, Hemmings,Weigand,
Becker and Booth, 2007; Clement, Granquist and Arvinen-Barrow, 2013; Larson,
Starkey and Zaichkowsky, 1996; Washington-Lofren, Westerman, Sullivan and
Nashman, 2004). Sport medicine professionals are in an important position to
implement psychological interventions. Therefore, it is important for sport medi-
cine professionals to be trained to understand and be able to use a wide array of
psychology skills and interventions throughout the rehabilitation process (for
example, Arvinen-Barrow, Hemmings, Becker and Booth, 2008).
To provide sport medicine professionals with the tools necessary to implement
psychological interventions into the rehabilitation process, this chapter includes
three distinct sections. Firstly, three phases of rehabilitation are outlined so that the
sport medicine professional can create a plan of interventions based on typical
physical and psychological aspects that pose challenges during each phase.
Understanding these three phases allows sport medicine professionals to better
assist the athlete and design psychological interventions specific for them to opti-
mise recovery. Secondly, the concept of rehabilitation profiling (Taylor and Taylor,
1997) is outlined and how it can be used to better understand both the physical
and psychological factors impacting the athlete and to effectively design interven-
tions to buffer the negative effects of injury. It is recommended that rehabilitation
profiling be implemented at several times during the rehabilitation process to better
understand the athlete’s perspective as well as the progress the athlete has made
throughout rehabilitation. Lastly, and to support Part 2 of this book, five common
psychological skills (goal setting, imagery, relaxation techniques, self-talk and social
support) are discussed and specific recommendations are provided on when to
introduce them into the different phases of rehabilitation.
I had worked so hard. I had left home when I was eleven for this sport. It’s some-
thing that I love to do . . . I love it. I would think about not being able to play and
break down completely; I would just be sobbing. I couldn’t help myself, and I am
not a crier. . . I took it really, really hard.
(Nicholle’s reaction to her injury, which demonstrates the importance of
addressing rehabilitation from a holistic perspective
[cited in Stoltenberg, Kamphoff and Lindstrom Bremer, 2010: 5])
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136 Cindra S. Kamphoff, Jeffrey Thomae and J. Jordan Hamson-Utley
Three phases of rehabilitation: a holistic approach to healing the

injured athlete
As demonstrated in Chapter 3, athletes will respond to injury in highly varied ways
and it is helpful to consider a framework within which to facilitate an effective
return to sport.When considering the rehabilitation process for the injured athlete,
it is helpful to break it down into manageable phases, guided by distinct aspects of
the healing process that may direct the use of specific psychological interventions
to optimise recovery.There are three distinct phases: I) reaction to injury; II) reac-
tion to rehabilitation; and III) reaction to return to play.
Phase I: reaction to injury

Phase I encapsulates the athlete’s response to the injury, including physical and
psychological factors (Hamson-Utley, 2010). Physically, the athlete will typically
experience swelling, discoloration and pain resulting from tissue damage, which is
dependent on the severity of injury. Also accompanying this stage is physical
immobility, by which the athlete is forced to become inactive to a small or greater
extent and may become dependent on others. Psychologically, during phase I, the
athlete forms cognitive appraisals of the injury occurrence (positive or negative)
and is consumed with the pain that the injury has produced.The athlete’s lifestyle
often changes to become more reliant on others, so less independent. As a result of
the physical aspects of phase I, the athlete may experience anxiety and negative
emotions surrounding the injury and be anxious about the recovery process.
Highly useful psychological interventions in this phase include injury education
and pain management which can be facilitated through goal setting, imagery and
relaxation techniques.
Phase II: reaction to rehabilitation

When swelling, the range of motion (mobility) and levels of pain improve, this acts
as a marker for the sport medicine professional that the athlete has progressed into
phase II.This phase is characterised by the physical factors of strength, balance and
mobility, and the psychological factors of motivation and hardiness (Hamson-
Utley, 2010). Phase II of rehabilitation tends to be the most challenging for athletes
as it is the longest phase for more severe injuries; an athlete with a ruptured liga-
ment for example, may spend an average of three to four months in phase II.
Psychologically, strategies that promote rehabilitation adherence and treatment
compliance, motivate the athlete to work hard and highlight qualities of resilience
in the athlete are best suited for this phase. Goal setting and self-talk would be the
most relevant psychological interventions to use with the athlete to address these
psychological concerns.
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Phase III: reaction to return to play

The final phase of the rehabilitation process, phase III is marked physically by
completing strength and proprioceptive (balance) gains and beginning sport-
specific agility drills and movements (Hamson-Utley, 2010). Athletes may face
additional physical roadblocks, such as the development of scar tissue in the injured
joint, which causes a temporary setback in rehabilitation progress. How the sport
medicine professional handles this is of upmost importance and is best managed
through patient education and social support. Psychologically, in phase III the
athlete deals primarily with self-confidence issues and managing their fears of re-
injury as they approach their return to play. Useful psychological interventions for
use during this phase include positive self-talk, performance imagery and goal
setting.
Understanding the rehabilitation process through the athlete’s eyes is important
for those who are leading their injury recovery process to ensure an optimised
approach. Methods should be both individualised and comprehensive to ensure
that the athlete will heal at their body’s physiological rate.The impact of roadblocks
presented by physiological and psychological issues at each phase can be minimised
through pairing the issue with an effective psychological intervention, thereby
creating a holistic approach to injury rehabilitation.
Rehabilitation profiling
Performance profiling was introduced in the sport psychology literature in the
early 1990s by Richard Butler and colleagues, as a way to better understand an
athlete’s perception of their ability and their preparation for performance (Butler,
Smith and Irwin, 1993). The method includes two key concepts of applied sport
psychology which are fundamental to performance: self-awareness and goal setting.
Embedded in the framework of the personal construct theory (Kelly, 1963), the
profiling system helps to determine the athlete’s unique dimensions of their peak
performance and their perception on these dimensions. Once the athlete
completes the profiling, a goal setting process is followed.
The method has been applied to sport in various ways, including in the reha-
bilitation process (Taylor and Taylor, 1997).Within the rehabilitation process,Taylor
and Taylor suggest assessing both the athlete’s personal and physical factors that
have an impact on both the time and quality of the rehabilitation process. Assessing
both the personal and physical factors allows the sport medicine professional and
athlete to gain a better sense of where the athlete rates him/herself on important
factors that impact the rehabilitation process. The personal profile includes 12
psychological, emotional and social factors including confidence, motivation, anxi-
ety, focus, expectations, worry, emotions, identity, adherence, understanding, pain
tolerance and social support (Figure 10.1 and Table 10.1).
The physical profile includes 12 injury-specific and health-related factors,
including range of motion, strength, stability, coordination, balance, swelling, pain,
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iety Focus
Anx 10
9
Ex
ion pe
at 8
ct
iv a
ot 7
M
tio
ns
6
4
ence
Worr
3
Confid
y
2
1
S ocial s
ti o n s
E mo
up p
or t
Pa
in
ity
ol
t
nt
er e
an Id
ce
U nd
ersta
en c e
nding Adh er
FIGURE 10.1 Rehabilitation profiling: personal profile

function, daily activities, sports participation, health and sleep (Figure 10.2 and
Table 10.2).
To begin the assessment, the factor descriptions should be read and understood
by both the athlete and the sport medicine professional (see Tables 10.1 and 10.2).
The athlete assesses their current perceptions, shading from the middle toward the
outside of each of the 12 scales (see Figure 10.3 for an example).
There are many benefits of using the profile system when working with an
athlete through the rehabilitation process. By taking into account the athlete’s
strengths and weakness, the sport medicine professional can tailor a unique set of
interventions to the individual according to the current phase of rehabilitation and
positively impact the athlete’s adherence to the rehabilitation program. Additional
benefits of such a process include:
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TABLE 10.1 Rehabilitation profiling: definition of personal factors
Personal factor Description Score

Confidence The degree of how much you believe in 0 = very low
your ability during rehabilitation 10 = very high
Motivation Your current level of motivation in 0 = very low
your rehabilitation 10 = very high
Anxiety The degree of physical anxiety you 0 = considerable
experience about your recovery 10 = none
Focus The degree to which you stay focused 0 = negative or distracted
on your rehabilitation 10 = positive or focused
Expectations The degree of positive expectations you 0 = low
have about your recovery 10 = high
Worry The degree of uneasiness, concern, and 0 = considerable
doubt you have about your recovery 10 = none
Emotions The degree you feel emotional about 0 = very low or negative
your rehabilitation 10 = very high or positive
Identity The degree you currently view yourself 0 = very negatively
as a physical being and athlete 10 = very positively
Adherence The degree to which you adhere to 0 = very negatively
your rehabilitation programme 10 = very positively
Understanding The degree of understanding you have 0 = none
of the rehabilitation process 10 = considerable
Pain tolerance The degree to which you can tolerate 0 = very poorly
and control pain during rehabilitation 10 = very well
Social support The degree of social support you are 0 = none
receiving from others including the 10 = considerable
sport medicine professionals, family,
friends, coaches and team mates
• The rehabilitation profiling system allows the sport medicine professional and
athlete to better understand their psychological and physical needs of the athlete.
• Once completed, the athlete has a graphic representation of where they are in
the rehabilitation process, both physically and psychologically, and it can then
be used to determine the athlete’s needs and goals.
• The athlete will increase their knowledge of the physical and psychological
factors impacting the rehabilitation process which could impact their self-
determination or their belief that they have control over their own actions and
destiny.
• The profiling system provides an understanding of which psychological issues
will both help and hinder the rehabilitation process.
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ility Coord
Stab 10
inati
on
9
h Ba
n gt 8
l
re
an
7
ce
St
5
n
otio
Swe
of m
lling
Range
1
Sleep
P ai n
n
io
He
al
th
Fuct n
Spo
rts p ies
articip tivit
ation D aily ac
FIGURE 10.2 Rehabilitation profiling: physical profile

• Over time, a series of profiles can demonstrate goal achievement to the athlete
and can help with persistence throughout rehabilitation and in the return to
competition.
• The profiling system is based on the athlete’s perception of factors that are
impacting the rehabilitation process. This provides a window into the lived
experience of the injured athlete and, at the same time, provides an inroad for
further development of the helping relationship.This insight can also provide
important clues to potential barriers to the rehabilitation process.
• If an assessment such as the profiling system is not used, the sport medicine
professional may miss important information that impacts the athlete and their
engagement in rehabilitation.
• It is suggested that the sport medicine professional will be more effective in
working with the athlete if an assessment like the rehabilitation profiling
system is used.
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TABLE 10.2 Rehabilitation profiling: definition of physical factors
Physical factor Description Score

Range of The degree of quantity and quality of 0 = 0%,
motion movement that you have in the injured 10 = 100%
area of the proximal or distal joint
Strength The degree or amount of force you can 0 = 0%,
generate through the injured area 10 = 100%
Stability The degree of firmness and steadiness 0 = 0%,
you feel in the injured area 10 = 100%
Coordination The degree to which you use different 0 = none;
muscle groups together to produce a 10 = completely
certain movement
Balance The degree to which you can maintain 0 = none;
equilibrium that is required to the injured area 10 = completely
Swelling The degree of amount of fluid you have 0 = considerable,
in the injured area 10 = none
Pain The degree of discomfort and soreness 0 = considerable,
that you feel in the injured area 10 = none
Function The degree to which you can carry out 0 = not at all;
sport-related activities involving the 10 = completely
injured area
Daily activities The degree to which you can carry out 0 = not at all;
typical daily activities 10 = completely
Sports The degree to which you can participate 0 = none;
participation in your normal sport activities 10 = completely
Health The degree of general good health you 0 = poor;
have, free of fatigue, illness, or minor injuries 10 = excellent
Sleep The degree of how much you are sleeping 0 = very poorly;
10 = very well
Reasons to use rehabilitation profiling
1. The sport medicine professional will be able to better design a more effec-
tive rehabilitation programme for the athlete.
2. The sport medicine professional will have a better understanding of the
psychological and physical needs of the athlete.
3. The athlete will have a graphic representation of where they are in the
rehabilitation process both physically and psychologically.
4. The sport medicine professional will be able to determine the athlete’s
needs and goals.
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5. The sport medicine professional will have a better understanding of which

psychological issues will both help and hinder the rehabilitation process.
6. If an assessment is not used, the sport medicine professional may miss
important information that impacts the athlete and their engagement in
rehabilitation.
7. In general, the sport medicine professional will be more effective in work-
ing with the athlete.
(Gould, 1993)
iety Focus
Anx 10
9
Ex
ion pe
at 8
ct
iv a
ot
7
M
tio
ns
6
4
ence
Wor
3
Confid
ry
2
1
S ocial s
ti o n s
E mo
up p
or t
Pa
in
ity
ol
t
nt
er e
an Id
ce
U nd
ersta e
en c
nd in g Adh er
Key: dark grey = phase 1, middle grey = phase 2, light grey = phase 3
FIGURE 10.3 An example of changes in the rehabilitation profile across the three
phases of rehabilitation
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Once the athlete has completed the two profiles, it is suggested that the sport
medicine professional and the athlete discuss the athlete’s ratings on each of the
factors, beginning with those rated highest.This allows the athlete to explore their
strengths and may provide an opportunity for additional development of the rela-
tionship between the sport medicine professional and the athlete. Then, the sport
medicine professional should discuss the factors which the athlete rated lower.
Once that discussion has taken place, together the athlete and sport medicine
professional should determine where the athlete would like to improve within a
specified timeframe. The sport medicine professional and athlete could use the
form available as Figure 10.4 to set goals, after determining and discussing the
athlete’s strengths and weaknesses (for an overview of the goal setting process, see
Chapter 5).
Furthermore, the rehabilitation profiling system has an advantage of providing
a means of having one format for the athlete and sport medicine professional to
periodically assess and record the athlete’s progress. We suggest that the first reha-
bilitation profile should be completed by the athlete at least 72 hours following the
injury occurrence.This allows the athlete to gain perspective regarding the injury
and to attend to immediate physical and psychological needs, so as to be able to
attend to learning a new psychological skill as a coping mechanism for healing. It
would be appropriate for the athlete to complete the rehabilitation profiling system
again between phases I and II as well as between phases II and III (see section
below describing the three stages of the rehabilitation process). Additionally,
depending on how long the athlete’s phase II lasts, the athlete could take the assess-
ment multiple times throughout the phase.The sport medicine professional should
look for changes in the athlete’s behaviour and use this as a guide for distributing
the profile again.
It is suggested that the first rehabilitation profile should be completed by the

athlete at least 72 hours following the injury occurrence.
By continuing to use the rehabilitation profile throughout the rehabilitation

process, it provides a means of monitoring change. The athlete will also see the
changes they have made throughout the stages of rehabilitation, potentially build-
ing their self-efficacy. By repeating the rehabilitation profiling system, the sport
medicine professional and athlete will also be able to see visually which goals have
been met.The hope is that, throughout the rehabilitation process, the athlete would
cover more of the circle or profile. Figure 10.3, for instance, provides an example
of an athlete who has made several perceived changes in her personal profile
throughout her three phases of rehabilitation, including a higher confidence, focus,
positive expectations, positive emotions, adherence and pain tolerance.The athlete
has also experienced less anxiety and worry towards the end of her rehabilitation
(note that anxiety and worry is reversed scored on the profile so that more covered
on the profile indicates less of both concepts). Many of the variables remained
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Directions: In the space below, indicate up to five factors from the personal profile on
which you want to focus in your psychological rehabilitation. Then specify several
strategies you will use to improve these areas and the timeframe in which you would like
to improve.
Personal profile area Strategies for improvement Timeframe of goal

identified
FIGURE 10.4 Rehabilitation goal sheet

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consistent in this athlete’s rehabilitation including motivation, social support,

understanding and identity.
We would expect that many important changes would occur in both the
personal and physical profiles of which it is important to take note as a sport medi-
cine professional. Meaning, all of the physical factors should improve throughout the
three phases, such as the athlete’s range of motion, strength, stability, coordination
and balancing. Similarly, it is also expected that the athlete’s confidence would
increase throughout the three phases of rehabilitation, whereas their worry may or
may not be steady. Based on research, the sport medicine professional may also
expect some gender and cultural differences when working with athletes during the
rehabilitation process. Clement et al. (2012), for example, found that male athletes
with no past experience working with a sport medicine professional had lower
expectations of personal commitment to the rehabilitation process and did expect
sport medicine professionals to provide a facilitative environment. Furthermore,
female athletes with experience of working with a sport medicine professional were
least likely to have realistic expectations of sport medicine and injury rehabilitation.
In addition, Clement et al. (2013) found a significant difference in mental skills
usage during rehabilitation by country.That is, a greater proportion of athletes from
the United States (33.4%) reported that they used mental skills during rehabilitation
compared with athletes from the United Kingdom (23.4%) and Finland (20.3%).
Incorporating psychological skills into the three phases of

rehabilitation
As has been established throughout this chapter, individual interventions should be
tailored to the specific phase of rehabilitation for injured athletes and which reflect
their unique personal and physical profiles. The following brief discussion of five
common psychological interventions, in combination with later chapters in this
text, provides the sport medicine professional with tools to match the psychologi-
cal intervention to the needs of the athlete within each phase.
Incorporating goal setting into the three phases of rehabilitation

As demonstrated in Chapter 5, goal setting can play an important role in the injury
rehabilitation process. Goal setting as a psychological intervention can be used
throughout the three phases of rehabilitation. Understanding the types of goals,
their relationship to an increased sense of control and self-determination and
educating athletes on how to construct effective goals are all relevant concepts
throughout the three phases of rehabilitation.
Phase I
As discussed above, injury education and the management of pain are critical
psychological aspects of this phase. Thus, goal setting in this phase is likely to be
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broad in scope (for example, surgery to repair a torn labrum is likely to last three
to four months and should allow for some sport-related exercise after about six
weeks) as sport medicine professionals work with the athlete to understand the
injury as well as the process of rehabilitation and the return the sport. Athletes must
be told (and reminded) that their success in meeting goals for these broad recov-
ery outcomes is contingent upon their effort and engagement in the rehabilitation
process on a daily basis. Regarding the management of pain, athletes could use
either association or disassociation techniques to manage their pain. Exercises can
be as simple as diverting their attention to an informational video on an iPad or to
the ESPN broadcast on the television wall while completing a painful range of
motion exercise (disassociation) or teaching the athlete to gain control over their
pain by imaging their pain as the volume on a stereo on which they can turn down
the dial when pain is too much to handle (association). Either way, teaching the
athlete pain coping skills during phase I will likely come in handy in future phases.
Phase II
Generally the longest phase of rehabilitation, phase II is when athletes will benefit
significantly from goal setting. Using the principles of successful goals (see Chapter
5) can help to create a positive motivational climate in which athletes engage more
fully in the rehabilitation process and adhere to a rehab program. Goal setting in
this phase allows athletes to have measurable evidence of their progress and should
be flexible enough to encourage adherence even in the face of setbacks. It is
important to involve athletes in the goal setting process throughout this phase, to
increase their sense of autonomy and self-determination over the process.
Motivation is of utmost importance in this phase of rehabilitation and setting accu-
rate goals will assist in motivating the athlete to continue therapy.
Phase III
One of the benefits of successful goal setting in phases I and II is that it can serve
as evidence of the athlete’s effort and success in rehabilitation to leverage into their
return to sport. Goal setting in this phase can also be used during the transition
back to practice or competition so that athletes do not apply an inappropriate
amount of stress too early in their return. It can provide them with a period to
build confidence as they test their injury.
Incorporating imagery into the three phases of rehabilitation

As Chapter 6 demonstrates, imagery is an important tool injured athletes can use
in their injury rehabilitation, particularly because it can be done when time spent
‘on the court’ is limited by injury. Imagery can be used in any of the three phases
of injury rehabilitation, shifting focus with each phase.
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Phase I
In the initial wake of an injury, pain management and dealing with the loss of func-
tion is particularly salient to athletes. Imagery interventions during this phase
should focus on two major areas: pain management and healing. There are a
number of ways in which imagery can be used to assist in the management of pain.
Imagery for pain management should emphasise vivid, polysensory images that can
help athletes to exhibit control over the perception of the pain they are feeling.
Imagery scripts in this phase might emphasise the reduction of swelling (imagin-
ing superabsorbent materials drawing fluid away from the injured area), muscle
repair (imagining muscle fibres knitting back together, weaving strong and resilient
new fibres into the healing muscles) or mending bones (imagining the bone heal-
ing with super-strong carbon fibre materials). Additionally, imagery exercises can
help athletes ‘dial down’ a hot colour or loud sound associated with the pain they
are feeling, shifting to cooler colours or quieter sounds associated with less pain
(Hamson-Utley, 2012). Similarly, imagining the ability to expel pain with each
breath the athlete exhales can provide another image for pain management.
Phase II
During the main rehabilitation phase of the injury, the athlete has regained much
of the function from the injury but continues to engage in sometimes gruelling
rehabilitation exercises and interventions. In addition to continuing healing
imagery during this phase, one can also shift to imagery focused on success in reha-
bilitation sessions. For example, an athlete could use imagery the night before or
the day of rehab to rehearse success in completing individual rehabilitation exer-
cises with proper form. Similar to healing imagery mentioned above, athletes can
spend time focusing on how rehabilitation sessions are continuing to strengthen
the injured area and building the confidence for phase III, the return to sport.
Phase III
In preparing for a return to their sport, imagery should focus on the sensations
associated with successfully performing skills at the level they did prior to the
injury. In a sport like basketball, for example, with many sharp direction changes in
response to opponents’ movements, rich images of success in those actions can alle-
viate the anxiety many athletes have about re-injury and can build confidence.
Performance imagery that recalls successful sport images is often used in this phase
to build confidence in the athlete that they are ready to take the field.The athlete
can also benefit from positive self-talk and pre-practice or pre-game imagery
routines.
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Incorporating relaxation techniques into the three phases of

rehabilitation
The ability to produce physical relaxation throughout the body and specifically in
the injured area is a foundational skill to other psychological interventions
discussed throughout this text (for more details on relaxation techniques, see
Chapter 7). Relaxation is a must for imagery interventions, for example, because it
reduces both cognitive and somatic anxiety, allowing the athlete to focus fully on
rehabilitation (Flint, 1998). Athletes may have little or no experience with physi-
cal relaxation as a skill when they first become injured and start the rehabilitation
process. Sport medicine professionals delivering rehabilitation services to injured
athletes should, therefore, become skilled in helping athletes gain competence in
physical relaxation.
Phase I
Physical relaxation is an important initial intervention immediately after athletic
injury because muscle tension contributes to increased experience of pain. This
experience of pain, and efforts to manage it, can be consuming to an athlete and
efforts to develop relaxation skills should focus on pain management during phase
I. Physical relaxation interventions are predicated on having calm, quiet, inviting
spaces in which to learn and practice and pose a challenge to professionals whose
rehabilitation facilities have significant traffic and noise (Walsh, 2011). Carving out
spaces away from the hustle and bustle within rehabilitation facilities is critical to
the success of a relaxation intervention. In this phase, sport medicine professionals
can teach athletes deep-breathing techniques and the repetition of words, phrases,
sounds or prayers to induce a state of relaxation (Walsh, 2011).
Phase II
While relaxation interventions during phase I focus on pain management, inter-
ventions during Phase II should focus on the stress response to injury. Building
on the skills developed in phase I, athletes are more efficient in inducing relax-
ation in the body, which can help to manage cognitive anxiety associated with
the uncertainty of knowing when they will be able to return to competition or
if they will make it back at all (Walsh, 2011). In phase II, athletes can use physi-
cal relaxation techniques in tandem with imagery to increase effort and
persistence, as well as manage soreness and pain associated with the long hours
of rehabilitation exercises.
Phase III
As athletes look forward to returning to competition in their sport, anxiety and
stress responses can increase. As discussed above, the ability to induce a state of
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physical relaxation is an important skill and should be emphasised in response to

the normal increase of anxiety during this phase. Once physical relaxation is
mastered, more emphasis can be directed toward imagery and self-talk.
Incorporating positive self-talk into the three phases of rehabilitation

The quality of an injured athlete’s cognitions before, during and after injury,
including rehabilitation and return to sport, has been shown to be a critical piece
of the psychological response to injury (see Chapter 3 for a discussion of relevant
models). An athlete’s self-talk is likely to change a great deal throughout the process
and interventions can be targeted accordingly (see Chapter 8 for more details).
Phase I
In the immediate aftermath of an injury, an athlete is likely to experience a vari-
ety of normal but unhelpful negative thoughts about the significance of his or her
injury (‘My knee is gone.’), the significance of the injury to future success (‘My
career is over.’) and may blame others (‘Coach made me do that vault even thought
I didn’t want to.’) (Flint, 1998). In addition, the athlete may be struggling to cope
with the pain of the injury and the prospect of a difficult rehabilitation process.
Self-talk interventions in this early stage should focus on the ability to manage pain
successfully, and should begin to focus on an optimistic approach and adherence to
rehabilitation. Affirmations can be helpful self-talk strategies (‘I’m strong’ or ‘I can
handle this’). In addition, distraction can help direct thoughts away from the expe-
rience of pain, lessening its impact.
Phase II
Throughout the bulk of rehabilitation, self-talk should focus on motivation to
persist in the face of difficult rehabilitation exercises.While the general progress of
rehabilitation is positive, that process will not be without its good days and bad days
and can challenge athletes to remain positive. Focusing on self-talk that reinforces
effort, persistence and success is critical. An athlete might focus on thoughts like
‘I’m choosing to rehab today, and will try my hardest at each rep!’.
Phase III
Self-talk interventions can help athletes to manage anxiety and doubt about their
return to competition. In particular, self-talk can focus athletes on thoughts associ-
ated with successfully performing the skills they need. Similarly, building a
self-affirming self-talk that builds confidence for the return is critical. Focusing on
thoughts like ‘I worked hard at rehabilitation’, ‘My knee is strong’, ‘I’m excited to
come back and show my team mates I’m ready!’ can reduce doubt and uncertainty
that is often experienced as athletes face the return to sport.
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Incorporating social support into the three phases of rehabilitation

Social support has been shown to have a significant role in both predicting injury
(Williams and Andersen, 2007) and the psychological response to injury (Wiese-
Bjornstal, Smith, Shaffer and Morrey, 1998). Throughout the phases of
rehabilitation, strong support from an athlete’s family, friends, team mates, coaches
and/or sport medicine professionals can facilitate positive rehab outcomes by
reducing stress and increasing motivation (for more details, see Chapter 9).
Phase I
Injury challenges athletes in many ways, not the least of which is the potential loss
of their athletic identity, owing to an inability to compete in their sport. In addi-
tion, athletes facing first-time and/or serious injury may struggle to understand the
injury itself, as well as the process of rehabilitation and return to sport. Depending
on the location and severity of an injury, athletes may struggle to meet the demands
of day-to-day living because of mobility concerns. All of this can cause significant
stress to an injured athlete. Helping him or her identify meaningful sources of
support becomes a focus during this phase.
After injury, college athletes reported an increase in perceived social support from
athletic trainers, coaches and physicians (Yang, Peek-Asa, Lowe, Heiden and Foster,
2010).While this finding is unsurprising, given the increased time spent with those
professionals, it underscores the importance of attending to an athlete’s social
support needs throughout the process and particularly during the initial stages of
injury rehabilitation. Sport medicine professionals delivering rehab services need to
take time early on to ensure that athletes have identified sources of support and
provide informational support if athletes’ support needs are not being met.
Phase II
Throughout the lengthy middle phase athletes’ rehabilitation process, healing
continues, athletes gain use of the injured area and thus early concerns about day-
to-day functioning lessen. Sources of social support during this phase should focus
on helping athletes to cope with the daily challenges of being successful in meet-
ing rehabilitation goals and dealing with normal setbacks throughout the process.
Of particular concern to many team-sport athletes is the continued connection to
team mates and the redefinition of their role on the team. Team captains who
become injured, for example, may find their leadership role shifting to others and
may struggle with less contact and the feeling of not being ‘in the trenches’ with
team mates. Rehabilitation professionals should be aware of the potential for injury
and rehabilitation to contribute to an athlete’s sense of estrangement. Collaborating
with coaches to help injured athletes continue to contribute in meaningful ways
to the team can help maintain the social cohesion with team mates and, in turn,
maintain critical sources of social support.
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Phase III
As rehabilitation progresses to the point where strength and agility are dominant
physical concerns, athletes may continue to experience the ups and downs of reha-
bilitation. With the return to sport close at hand, doubts about readiness and
self-confidence about competitive success require sport medicine professionals to
take the role of encouragers and confidence-builders. When doubt appears, sport
medicine professionals can redirect athletes to focus on the effort they have put
into their rehabilitation and the success they have had in that process. Research has
shown that when sport medicine professionals provide a productive optimism and
listen closely to the athlete this can be helpful (Naylor, 2007). For example, a sport
medicine professional in this phase who sighs and avoids eye contact when she/he
says,‘Well, we’ll see how it goes’ communicates a great deal to the athlete that can
affect the way that athlete perceives the support of the sport medicine professional.
On the other hand, the athlete would likely rate the sport medicine professional’s
support differently if she/he says, ‘The ups and downs you are experiencing are
normal and if you continue to put the effort I’ve seen so far, I’m confident you’ll
make it back physically and psychologically stronger than you were before your
injury’.
Implications for sport medicine professionals: the conclusion

The responsibility of the professionals treating the athletes during rehabilitation is
to support the athlete to return to play in the best possible way. To do this, the
athlete must be both physically and mentally ready and the professionals responsi-
ble for the rehabilitation should have a role in ensuring this takes place. In fact, the
current trend in sport-injury rehabilitation suggests focusing on a holistic
approach, in which the sport medicine professional must integrate the physical and
psychological skills in the three phases of rehabilitation (Hamson-Utley, 2010).
This chapter has provided direction for the sport medicine professional so they
can better understand the athlete’s perception and factors that would impact their
rehabilitation, by describing the three phases of rehabilitation. In addition, by using
rehabilitation profiling, the sport medicine professional can better understand the
athlete’s perception of both personal and physical factors that impact on the reha-
bilitation process and to ensure an optimised approach. Once the profile is
complete, a discussion can take place and together, the athlete and sport medicine
professional can determine where the athlete would like to improve within a spec-
ified timeframe.
Rehabilitation profiling can also be used throughout the three phases of reha-
bilitation to track the athlete’s progress and set new goals. Using rehabilitation
profiling, the psychological interventions could be chosen to ensure the athlete
receives the most out of the rehabilitation process. Psychological interventions
should also be introduced to create a holistic approach to injury rehabilitation
which will increase adherence, improve their positive outlook, reduce pain, increase
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satisfaction, improve relaxation and decrease recovery time (Driediger, Hall and
Callow, 2006; Evans, Hare and Mullen, 2006; Monsma, Mensch and Farroll, 2009;
Rotella, Hedgpeth and Pickens, 1999).
The sport medicine professional can provide a key role in introducing the five
common psychological interventions (goal setting, imagery, relaxation techniques,
self-talk, and social support) discussed in this chapter to address these benefits. As
more and more athletes use psychological interventions regularly in their season,
they bring prior experience with psychological interventions to incorporate in the
rehabilitation process (Hamson-Utley, 2010).This prior experience makes it more
straightforward for the sport medicine professional to address both the physical and
mental components to fully rehabilitation the injured athlete.
Using psychological interventions in the three phases of rehabilitation
Phase I: Reaction to injury. Physical relaxation is an important initial intervention

immediately after athletic injury because muscle tension contributes to
increased experience of pain. Similarly, healing imagery is a particularly potent
psychological intervention in the initial stages as athletes deal with the pain
and swelling associated with injury. Goal setting can assist athletes gain
perspective and focus on a plan for recovery.
Phase II: Reaction to rehabilitation. Measuring progress toward goals set initially
is critical for maintaining motivation during rehabilitation. Confronting nega-
tive or irrational thoughts and replacing them with affirming and positive
thoughts is also an important part of this phase. Sport medicine professionals
can also provide social support during this phase to help athletes to cope with
the daily challenges of meeting rehabilitation goals and dealing with normal
setbacks throughout the process.
Phase III: Reaction to return to play. The use of imagery and self-talk to build
confidence can help an athlete be as mentally ready to return to sport as reha-
bilitation has helped prepare their body. During this stage, it is also important
that the sport medicine professional takes on a role of encourager and confi-
dence-builder by providing social support and reassurance.
CASE STUDY
Kerri is a talented ice hockey goalkeeper starting her fourth and last year of
collegiate eligibility. After a history of problems with shoulder dislocations, she
opted to have surgery to repair her labrum during the summer. The surgery
was successful and doctors seemed confident that Kerri would be able to
return to hockey-related exercises within about six weeks and fully healed
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within three to four months. The only complicating factor in this early stage
was the intensity of the post-surgical pain she experienced, which she strug-
gled to manage. She said that she often dreams about hockey, often with
images of watching opponents making shots on goal while she can’t move her
arms to stop them.
In early rehabilitation sessions, Kerry talked at length with the sport medicine
staff that she was driven to return quickly. In fact, the sport medicine profes-
sional working with her has had to talk to her about not pushing too hard too
early in her rehab. She mentioned that she’s thinking about rehabilitation all
the time and is anxious about making a full recovery. She reports struggling
with sleep because she’s worried that losing the starting position as the team’s
goalkeeper would mean that she’ll lose an opportunity to be scouted for the
upcoming Olympic team.
–––––––– ? ––––––––
1. How would you use the rehabilitation profiling as a sport medicine profes-
sional when working with Kerri?
2. What would you expect that Kerri would experience as she progresses
through the three stages of rehabilitation? Why?
3. Which psychological skills would be important for you to introduce to Kerri
as she progresses through the three stages of rehabilitation? Why? How
would you introduce these psychological skills?
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11
SPORT MEDICINE TEAM INFLUENCES
IN PSYCHOLOGICAL REHABILITATION
A multidisciplinary approach
Damien Clement and Monna Arvinen-Barrow
Introduction
Injured athletes often enter the sport injury rehabilitation process with the hopes
of returning to pre-injury level of fitness and performance as rapidly and safely as
possible. However, research has highlighted the need to also address the psycho-
logical consequences that injured athletes often experience, to ensure their full
holistic recovery (Booher and Thibodeau, 2000). Research findings to date have
suggested that injured athletes’ cognitive appraisal, emotional and behavioural
responses to injury can have an impact on the physical and psychological recovery
outcomes (for more details, see Chapter 3). In addition, the use of psychological
interventions (such as goal setting, imagery, relaxation techniques, self-talk and
social support) during rehabilitation can help injured athletes in dealing with a
range of psychological issues that occur as a consequence of their injuries (Beneka
et al., 2007; Flint, 1998; Ievleva and Orlick, 1991; for more details on how to
integrate psychological interventions during rehabilitation, see Chapters 5–10).
Given the importance of addressing both physical and psychological aspects of
injuries during rehabilitation, there is a need to provide well-rounded and holistic
care to athletes when they are injured.The process of rehabilitation, at its best, will
involve a number of people working closely together for the benefit of the athlete,
with the aim of ensuring a full and safe return to pre-injury (or higher) level of
health, wellbeing and performance. The care provided should entail the involve-
ment of relevant sport medicine professionals, as well as the use of sport
psychologists or those equipped to provide psychological support (Green, 1992).
According to Wiese-Bjornstal and Smith (1999), having a multidisciplinary team
working with injured athletes is often common practice in professional sports.
However, such is thought to be rarely the case amongst athletes involved in lower
levels of participation. Recognising the importance of adopting a multidisciplinary
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Sport medicine team influences in psychological rehabilitation 157
approach to rehabilitation at all levels, this chapter discusses the concept of a multi-
disciplinary approach to rehabilitation and demonstrates the ways in which it could
be applied to various sport injury rehabilitation situations. More specifically, the
chapter: (a) introduces the multidisciplinary approach to rehabilitation through
primary and secondary teams, (b) details the interactions between members of the
multidisciplinary team, (c) describes the process of setting up a multidisciplinary
team; (d) explains the benefits of adopting a multidisciplinary approach; (e)
describes the role of sport medicine professionals within this approach; (f ) presents
potential problems with a multidisciplinary approach; and (g) makes recommenda-
tions about the utility of a multidisciplinary approach.
The multidisciplinary approach to rehabilitation

Given the varied nature in which athletes train and compete, it is not surprising
that, when injured, the rehabilitation environment and those involved in the reha-
bilitation process may also vary greatly. According to the psychology of injury
literature, the sport medicine professionals on whom injured athletes rely during
the course of their rehabilitation continue to evolve beyond the traditional phys-
iotherapist, athletic trainer and physician (Kolt, 2000; Wiese-Bjornstal and Smith,
1999). Kolt (2000) further stated that it is not uncommon for a variety of sport
medicine professionals (sport psychologists, clinical psychologists, sport therapists,
massage therapists, strength and conditioning coaches and nutritionists, to name a
few) to also work with injured athletes in this context, thus providing the injured
athletes with access to a wide range of services to enhance, and possibly accelerate,
their sport injury rehabilitation.While the notion of including sport medicine and
allied health professionals within injured athletes’ rehabilitation has been docu-
mented by Wiese-Bjornstal and Smith (1999), this section will introduce a
development of the multidisciplinary approach to injury rehabilitation. More
specifically, the notion of multidisciplinary team approach to rehabilitation will be
considered through the concept of primary and secondary rehabilitation teams.
Primary and secondary rehabilitation teams

When considering rehabilitation teams, the primary rehabilitation team often
consists of those sport medicine professionals who will work closely with the
injured athlete from injury occurrence through the entire rehabilitation process
until their successful return to the field of play. Typically, these would be the
primary treatment providers (the physiotherapist/athletic trainer and the physi-
cian/orthopaedic surgeon). A number of researchers (Gordon, Potter and Ford,
1998; Gordon, Potter and Hamer, 2001; Pearson and Jones, 1992;Wiese and Weiss,
1987; Wiese, Weiss and Yukelson, 1991) are in support of the above, as they have
suggested that medical professionals in regular contact with the athlete during
treatment are in an ideal position to inform, educate and assist with both the
psychological and physical process of injury. Indeed, it appears that members of the
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158 Damien Clement and Monna Arvinen-Barrow
sport medicine team are the first to attend to injured athletes’ needs (Wiese-
Bjornstal and Smith, 1993) and are often available immediately after the injury
occurrence. Moreover, these professionals interact with injured athletes regularly
and almost exclusively during the initial stages of injury (Tunick, Clement and
Etzel, 2009), at the time when the levels of pain and confusion experienced as a
result of the injury by the athlete are at their worst.
In addition to the above, during rehabilitation, often those outside of primary
rehabilitation team can also play a significant role in assisting the injured athletes
towards successful recovery. The secondary rehabilitation team should ideally
consist of a range of sport medicine and allied health professionals, as well as related
others with whom injured athletes will have varying degrees of interaction
throughout the course of their injury rehabilitation (Figure 11.1). It must be noted
that, although the individuals who are deemed members of this team may not be
directly involved in the physical treatment of the injured athlete they often
Athletic
coaches Team mates
Physical/
sport/massage Friends
therapist
Physiotherapist/ Parents/
Strength and Athletic trainer family
conditioning
coach Spouse/
partner
Sport/ Injured
exercise athlete
Sport
physiologist
psychologist
Biomechanist Physician/
Clinical/
(orthopaedic)
counselling
surgeon
psychologist
Podiatrist
Psychiatrist
Dentist Sport
nutritionist
Primary rehabilitation team Secondary rehabilitation team
FIGURE 11.1 Structure of multidisciplinary team to rehabilitation: primary and

secondary teams
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contribute to the injured athlete’s rehabilitation experience in myriad different

ways. The individuals that should make up this team include, but are not limited
to: sport nutritionist; podiatrist; dentist; sport psychologist; clinical/counselling
psychologist; psychiatrist; sport/exercise physiologist; biomechanist; strength and
conditioning coach; physical/sport/massage therapist; athletic coaches;
parents/family; friends; spouse/partner; and team mates. Evidence exists in support
of the inclusion of some of the above-mentioned professionals and significant
others in facilitating sport injury rehabilitation process. For example, the role of
sport psychologists in injury rehabilitation has been highlighted as important but
very seldom is such used to its full capacity (see, for example, Arvinen-Barrow,
Hemmings,Weigand, Becker and Booth, 2007;Arvinen-Barrow, Penny, Hemmings
and Corr, 2010; Brewer, 1998; Clement, Granquist and Arvinen-Barrow, 2013;
Heaney, Green, Rostron and Walker, 2012; Larson, Starkey and Zaichkowsky,
1996). The role of coaches has also received some attention in the literature.
However, the usefulness of research findings is equivocal. It appears that coaches
may serve multiple roles (teachers, parental figures, disciplinarians) and therefore
may have both direct and indirect influences over the injury rehabilitation and
subsequent playing status once returning back to sport (Tunick et al., 2009;Yang,
Peek-Asa, Lowe, Heiden and Foster, 2010). The importance of parents/family,
friends, spouses and partners has also been recognised in the literature, as a number
of studies have found them to be a significant source of different forms of social
support during injury rehabilitation (for example, Johnston and Carroll, 1998;Yang
et al., 2010; for more details see Chapter 9). In a similar manner, support from team
mates or other athletes who have since recovered from similar injuries or the use
of performance-enhancement groups consisting of injured athletes has also been
found to be beneficial (Clement, Shannon and Connole, 2011;Yang et al., 2010).
Medical professionals in regular contact with the athlete (that is, the primary
team) during treatment are in an ideal position to inform, educate and assist
with both the psychological and physical process of injury. Whilst members of
the secondary team may not be directly involved in the physical treatment of
the injured athlete they often contribute to the injured athlete’s rehabilitation
experience in numerous ways.
Interactions within and between the different members of the

rehabilitation teams
Despite the obvious distinction between the two rehabilitation teams, the roles of
the various members of each team may interact and intertwine in a number of
ways. Some of the roles may be direct (that is, the ways in which family members
and spouse/partner can facilitate recovery), whereas others may be more indirect
(that is, the podiatrist may influence the rehabilitation process through the
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physiotherapist/athletic trainer). Moreover, the strength and nature of these rela-

tionships may change across the rehabilitation stages, depending on the injured
athlete’s needs and the athlete’s personal and situational factors. For example, the
type of injury (a personal factor) can impact the extent of tangible support an
athlete may need from those close to them. In a similar manner, an athlete with
recurrent injuries may need direct or indirect involvement from various members
of the sport medicine team (a situational factor). For instance, an athlete with
recurrent problems with shin splints and the physiotherapist/athletic trainer with
whom they are working may need to consult a podiatrist and/or a biomechanist
to ensure the underlying cause for the shin splints will be treated appropriately. In
a similar manner, an athlete may require regular consultations with a sport psychol-
ogist to deal with self-confidence issues that may have amplified as a result of the
injury. Moreover, access (or lack of ) to appropriate support from sport medicine
and allied health professionals may also change the roles and relationships of those
involved with the injured athlete on a day to day basis.
One of the ways in which these relationships could be examined is through the
use of sociograms. A sociogram is a tool to measure social cohesion by disclosing
affiliations and attractions within a group (Weinberg and Gould, 2011) but it could
also be modified to sport injury rehabilitation settings with the aim of establishing
and gaining clarity of the roles, relationships and interactions between the different
members involved in the rehabilitation process (Figure 11.2). It is also believed that
a sociogram could be used to highlight the impact (direct/indirect) that different
members of the multidisciplinary team may have on injured athletes. It is hoped
that this increased awareness could help facilitate improved communication and
consequently build trust and rapport among all those involved in the process.
Setting up a multidisciplinary team: the process

In most cases, injured athletes, depending on their sporting level, would have a
primary rehabilitation team in place.This assumption is based on the fact that it is
common knowledge that physiotherapists/athletic trainers and physicians are all
intricately involved in the care and ultimate rehabilitation of the injured athlete
(Wiese-Bjornstal and Smith, 1993). The members of the secondary team, on the
other hand, are often sport medicine and allied health professionals and relevant
(significant) others who have been used on occasions but have not been tradition-
ally considered part of the rehabilitation team.
However, in the hope of establishing a secondary rehabilitation team, the phys-
iotherapist/athletic trainer who will serve as the point person for the injured
athlete’s rehabilitation programme will first determine who needs to be involved
from the sport medicine and allied health professionals and significant others previ-
ously mentioned.This decision should be made in consultation with the physician
and possibly the injured athlete. Once a potential list has been generated and the
merits for the involvement of each of these individuals have been thoroughly given
consideration, the physiotherapist/athletic trainer will need to contact each
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Athletic
Biomechanist coaches Physician/
(orthopaedic) Team mates
surgeon
Strength and
conditioning
coach Friends
Physio-
therapist/ Injured
athletic athlete
Podiatrist trainer
Parents/
family
Sport
nutritionist
Sport
psychologist Spouse
Clinical/
counselling Direct relationship
psychologist
Indirect relationship
FIGURE 11.2 An example of a sociogram in injury rehabilitation setting
individual to determine their level of interest in being involved as a member of a

secondary rehabilitation team for a specific athlete. Assuming that each potential
member agrees to participate, their roles and responsibilities within the secondary
rehabilitation team should be thoroughly explained. Following this, it is advised
that a meeting should be organised to formalise and identify (and introduce in
person, if possible) all members of both the primary and secondary rehabilitation
teams. This meeting will serve three purposes: (1) to introduce members to each
other; (2) to educate each member about the possible resources at the injured
athlete’s disposal; and (3) enable all members to establish and come to an agreement
on a referral protocol for the involved injured athlete. Finally, it would seem imper-
ative that the injured athlete be introduced to all members of the secondary
rehabilitation team.
Benefits of multidisciplinary approach to rehabilitation

Adopting the multidisciplinary approach to injury rehabilitation has the potential
to offer a number of benefits to injured athletes. Firstly, this approach allows injured
athletes to be exposed to a holistic approach to injury rehabilitation. Using this
approach could potentially enable injured athletes to be exposed to a rehabilitation
protocol that no longer focuses solely on the physical aspect of injury rehabilita-
tion but instead offers opportunities for once neglected areas, such as the
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psychological and social aspects, to be afforded some attention. Other professionals

(such as a sport psychologist or a nutritionist) can bring a new perspective into the
rehabilitation and, as such, offer athletes an alternative outlook or, indeed, a needed
addition to the process of rehabilitation to ensure a rapid return to full fitness.
Secondly, such a multidisciplinary approach could make the referral process more
efficient. More specifically, it is assumed that, by using this approach, injured
athletes will, at the very least, have periodic interactions with the individuals who
comprise the secondary rehabilitation team.Thus, in the event that referral is made
to one of these individuals, the injured athlete may be less resistant to or appre-
hensive about the process. It is assumed that the injured athlete will, at the very
least, have met the sport medicine/allied health professional and will know the
services that they can provide with the aim of helping them (the athlete) return to
sport in a timely fashion. Finally, the use of a multidisciplinary approach has the
potential to improve communication between those individuals who are
concerned about the injured athlete’s wellbeing. Communication between sport
medicine professionals, allied health professionals and related others, all of whom
have the injured athlete’s best interest at heart, can sometimes be difficult if each
individual is working from a solitary view. However, with the use both of the
primary and secondary rehabilitation teams all members should, it is hoped, be ‘on
the same page’ with regard to the injured athlete. It is anticipated that increased
interaction between both teams will not only promote the aforementioned holis-
tic approach but will open, and ultimately improve, lines of communication. For
example, coaches (members of the secondary rehabilitation team) could be
consulted by the physiotherapist/athletic trainer (members of the primary rehabil-
itation team) about sport-specific drills and exercises which could be incorporated
into an athlete’s rehabilitation programme as he/she readies themselves for return
to play. By doing this, the coach would be kept abreast of the athlete’s progress and
the physiotherapist/athletic trainer would be able to incorporate appropriate sport
specific exercises to prepare the athlete for his/her return to the field of play.
A multidisciplinary approach in action
When I was injured for the second time during the season, I must admit I was a
bit blasé about the whole thing. I didn’t really follow the physio’s instructions, and
I know I was a pain to live with. I was lucky my girlfriend did not leave me because
of how I was back then. But then one day I got dragged into a team meeting, and
got a big telling off, and the coaches were like, what are you doing, and I thought
oh no, and then from then on end I was sort of a bit more . . . engaged . . . I mean
I wanted to know what was going on, and the team physio, coach and the psych
people all helped me to understand the full picture . . . So I snapped back into
reality from there on really.
(Professional rugby union player, cited in Arvinen-Barrow, 2009)
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Role of sport medicine professionals

As highlighted in previous chapters of this book, research findings to date have
provided support for the use of goal setting, imagery, relaxation, self-talk and social
support as a means of assisting injured athletes with the range of injury-related
emotional issues they may experience. Thus, given the increased importance of
addressing both the physical and psychological aspects of injury rehabilitation,
members of the primary rehabilitation team should take a leading role in the incor-
poration of a psychological component within injury rehabilitation, since a trained
and qualified sport psychologist may not always be available to injured athletes.
It has been suggested that sport medicine professionals who deal with athletes on
a day-to-day basis play an integral part of the sport injury rehabilitation process and
that they are best suited to inform, educate and assist injured athletes with the psycho-
logical and physical processes of injury (Pearson and Jones, 1992; Wiese and Weiss,
1987; Wiese et al.,1991). As the sport medicine professional’s job often involves work-
ing with injured athletes on a one-to-one basis, the likelihood of effective
communication, building trust and rapport with the athletes will be increased, subse-
quently having the potential to facilitate greater levels of rehabilitation adherence and
treatment compliance, to increase motivation and ultimately having a positive impact
on the overall recovery process (see, for example,Arvinen-Barrow, 2009).
Kolt (2003) supported this assertion by stating that sport medicine professionals
are best suited to provide psychological assistance for injured athletes for three
main reasons:
1. Psychological issues which often present themselves as a result of injury are often
discussed in conjunction with physical aspects of rehabilitation (Kolt, 2003);
2. The treatment and rehabilitation of injured athletes typically involves touch,
which can often facilitate athletes opening up to their sport medicine profes-
sional about psychological issues in their recovery (Nathan, 1999);
3. Existing studies suggest that athletes themselves feel that sport medicine
professionals are in an ideal situation to address the psychological aspects of
injury (Larson et al., 1996;Wiese and Weiss, 1987;Wiese et al., 1991).
Based on the aforementioned, it appears that sport medicine professionals are well
suited to provide psychological support to injured athletes, owing to their adjacent
position with the athlete during the recovery process. Moreover, sport medicine
professionals also have a substantial role in providing both direct and indirect
psychological support to injured athletes, to ensure full recovery.
Recommendations for promoting and using a multidisciplinary

approach
It is suggested that, in the absence of an access to a sport psychologist, sport medi-
cine professionals are not only in an ideal position to address psychological aspects
of sport injuries but are also best positioned to facilitate a multidisciplinary
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approach to sport injury rehabilitation. This section includes a number of recom-

mendations on how sport medicine professionals can not only incorporate a
multidisciplinary approach to rehabilitation but also address the psychological
component in their work with injured athletes. As such sport medicine profes-
sionals should:
• know their role in cultivating a multidisciplinary approach to rehabilitation;

• recognise the importance of significant others (such as team mates, friends,
family/parents, spouse) in ensuring a holistic approach to recovery;
• demonstrate increased awareness of psychological issues which athletes may
experience as a result of athletic injuries;
• think about ways in which psychology could be integrated into rehabilitation
as part of the process rather than an addition to it;
• continue to seek out additional training in the area of psychological rehabili-
tation;
• know professional boundaries and competencies;
• know when and to whom to refer athletes;
• have access to a network of other sport medicine and allied health profession-
als and related others.
Know their role in cultivating a multidisciplinary approach to

rehabilitation
As the individuals who play a leading role in the treatment and rehabilitation of
injured athletes, sport medicine professionals should understand that they alone
cannot provide all the services these individuals may require. Part of ensuring full
recovery, both psychologically and physically, is to ensure that all areas affecting
the injury recovery (nutritional, biomechanical and social) are addressed
appropriately by relevant professionals. Thus, the onus should be on the primary
treatment providers to attempt to involve as many other sport medicine and allied
health professionals and related others as needed in athletes’ treatment and
rehabilitation.
Recognise the importance of significant others in ensuring a holistic

approach to recovery
As the above-mentioned significant others typically spend a considerable amount
of time with the injured athlete, they are in a position to impact athletes’ think-
ing, emotions and behaviour. As such, it is imperative for the members of the
primary rehabilitation team to have an awareness of those individuals and to have
the ability to educate them about the importance of their role in the athlete’s
recovery.
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Demonstrate increased awareness of psychological issues which

athletes may experience as a result of athletic injuries
Sport medicine professionals, by virtue of their interactions with injured athletes,
should be acutely aware that the ramifications of athletic injuries go beyond the
physical domain. Furthermore, injured athletes, depending on the severity of their
injuries, often experience a range of thoughts, feelings, emotions and behaviours,
some of which can have a negative effect on injury recovery (see, for example,
Fisher and Wrisberg, 2006). By demonstrating increased awareness of the potential
psychological issues that athletes may experience, sport medicine professionals
could possibly help facilitate the incorporation of a psychological component
within rehabilitation programmes.
Think about ways in which psychology could be integrated into

rehabilitation as part of the process rather than an addition to it
While it is acknowledged and appreciated that sport medicine professionals are not
traditionally trained to integrate psychology into rehabilitation, they should be
encouraged to start thinking of ways of promoting a more holistic approach to
rehabilitation. Sport medicine professionals may want to consider asking questions
related to injured athletes’ thoughts, feelings, emotions and behaviours as a result of
injury. In addition, they should seek to gain an understanding of injured athlete’s
expectations of the rehabilitation process, as these should be in line with those of
the sport medicine professionals (Clement et al., 2012). By asking these questions,
sport medicine professionals would be taking a step in the right direction with
regards to integrating a psychological component appropriately within injury reha-
bilitation. More importantly, asking these questions could also help to build trust
and rapport between the athlete and the sport medicine professional, as well as rais-
ing the injured athlete’s awareness of the importance of the psychological aspect of
sport injury.
Continue to seek out additional training in the area of psychological

rehabilitation
As mentioned above, sport medicine professionals are not trained in psychological
aspects of sport injuries and how to use psychological skills and techniques in their
work. However, as they are often required to address psychological issues in their
work, they should seek out avenues, such as continuing education courses, confer-
ences, lectures or training modules, that could help increase their knowledge in this
area (Arvinen-Barrow, Hemmings, Becker and Booth, 2008).
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Know professional boundaries and competencies

Although sport medicine professionals should be encouraged to demonstrate
increased awareness with regard to psychological issues, it must be reiterated that
they should strive to continue to provide services that are consistent with their
training and level of competence.
Know when and to whom to refer athletes

Sport medicine professionals, at the very least, should be able to recognise the signs
and symptoms of psychological issues that should be referred to trained profes-
sionals (Arvinen-Barrow et al., 2010). Of greater importance, sport medicine
professionals should possess the ability to acutely communicate the need for a
referral to the injured athlete and the appropriate sport medicine professionals and
allied health professionals required and to be able to facilitate the referral process
in a timely fashion.
Have access to a network of other sport medicine and allied health

professionals and related others
Sport medicine professionals should also develop a network of trusted referrals that
they can utilise in times of need. Developing these professional relationships will
increase the ease at which these individuals can become involved in a multidisci-
plinary team.
When dealing with psychological issues sport medicine professionals should:
• know their role in cultivating a multidisciplinary approach to rehabilitation;

• be able to recognise the importance of significant others;
• be able to demonstrate increased awareness of psychological issues with
which athletes may present;
• think about ways in which psychology could be integrated into physical
rehabilitation;
• continue to seek out additional training in the area;
• engage in networks with other relevant professionals and related others;
• know their professional boundaries and competencies;
• know when and to whom to refer athletes when deemed necessary.
Possible problems in multidisciplinary approach to rehabilitation

Despite the previously mentioned benefits which could be derived from a multi-
disciplinary approach to injury rehabilitation, some concerns with regard to sport
medicine professionals’ ability to effectively facilitate this process must be taken
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into consideration.These problems may include: (a) a lack of awareness of the sport
medicine professional’s prominent role in the multidisciplinary approach to reha-
bilitation; (b) the sport medicine professional’s lack of confidence and ability to take
the lead in a multidisciplinary approach to rehabilitation (for example, Hamson-
Utley, Martin and Walters, 2008; Kamphoff et al., 2010); (c) the sport medicine
professional’s lack of appropriate training and understanding of the importance of
the psychological aspects of sport injury rehabilitation (Arvinen-Barrow et al.,
2010; Heaney et al., 2012); (d) the sport medicine professional’s lack of appropriate
referral procedures and skills in making referrals (Larson et al., 1996); and (e) the
sport medicine professional’s lack of access to other relevant allied health profes-
sionals (Arvinen-Barrow et al., 2007; Clement et al., 2013).
Conclusion
Despite the various innovations made to training philosophies and equipment,
athletes at various levels of competition continue to sustain injuries which can
limit, and in some cases prevent, their subsequent athletic participation temporar-
ily or for a prolonged period of time. While the treatment of the physical aspects
of these injuries have typically been the main focus of traditional rehabilitation
programmes, sport medicine professionals are beginning to give increasing atten-
tion to the psychological consequences of injuries. Thus, the use of a holistic
approach to injury rehabilitation is becoming increasingly common and should be
advocated more widely across varying rehabilitation settings. Consequently, it is
suggested that a multidisciplinary team composed of sport medicine professionals,
allied health professionals and related others should apply. This chapter has
provided details regarding the process of setting up a multidisciplinary team, the
role of the sport medicine professional within such a team and the many benefits
which can be derived from using this approach. Finally, possible problems were
presented which could arise with a multidisciplinary approach in addition to
recommendations to promote the use of such teams.
CASE STUDY
Devin is a 20-year-old African American collegiate soccer player who suffered

an anterior cruciate ligament injury to his right knee 16 months ago and has
since returned back to field in full fitness as scheduled. However, just over a
month ago, Devin suffered his second anterior cruciate ligament injury to the
same knee. Upon the diagnosis of the injury, Devin’s surgery was scheduled
and completed within three weeks. Since both injuries occurred at college,
Devin will once again be completing his rehabilitation under the guidance of
his college’s team physician and athletic trainer. Despite the fact that Devin
was able to rehabilitate his first injury successfully, he has admitted to his
family, team mates and girlfriend that he lacks confidence in his rehabilitation
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programme. He reports that having sustained the same injury again has
created major doubts in his mind with regards to the skills and competence
level of his athletic trainer.
Devin also reports anxiety-related symptoms, which he feels are linked to his
impending rehabilitation. Devin has also admitted that, on a number of occa-
sions, he has been using alcohol to help him deal with the pain and potential
lost season. ‘I mean I am just so frustrated about the thought of not playing this
season . . . this could really end my career as a professional before it has even
started . . . and getting drunk just helps me forget for a while.’ He further admits
that his eating habits have become very inconsistent, owing to his lack of mobil-
ity. Devin has also been interacting with his team mates a lot less than usual and
is choosing to be by himself. He has even mentioned that the fact that he is an
African American at a predominately white college is beginning to bother him.
In fact, he is the only ethnic minority player on his team and he now feels like
an ‘outsider’ within the team and in university life as a whole.
–––––––– ? ––––––––
1. What multidisciplinary team members would the athletic trainer/physio-
therapist want to incorporate into this athlete’s rehabilitation programme?
2. What are some of the psychological issues the athlete is presenting with that
may go beyond the athletic trainer/physiotherapist’s competence level?
3. As an athletic trainer/physiotherapist, please explain how you would
proceed in dealing with this athlete?
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Doing Sport Psychology. Champaign, IL: Human Kinetics, pp. 223–36.
Kolt, G. S. (2003) Psychology of injury and rehabilitation. In G. S. Kolt and L. Snyder-Mackler
(eds), Physical Therapies in Sport and Exercise. London: Churchill Livingstone, pp. 165–83.
Nathan, B. (1999) Touch and Emotion in Manual Therapy. London: Churchill Livingstone.
Pearson, L. and Jones, G. (1992) Emotional effects of sports injuries: Implications for phys-
iotherapists. Physiotherapy, 78(10), 762–70.
Tunick, R., Clement, D. and Etzel, E. F. (2009) Counseling injured and disabled student-
athletes: a guide for understanding and intervention. In E. F. Etzel (ed.), Counseling and
Psychological Services for College Student-athletes. Morgantown, WV: Fitness Information
Technology.
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Weinberg, R. S. and Gould, D. (2011) Foundations of Sport and Exercise Psychology.

Wiese, D. M. and Weiss, M. R. (1987) Psychological rehabilitation and physical injury:
Implications for the sportsmedicine team. The Sport Psychologist, 1, 318–30.
ery of injured athletes within a team approach. In D. Pargman (ed.), Psychological Bases of
Sport Injuries. Morgantown,WV: Fitness Information Technology, pp. 149–82.
ery of injured athletes within team approach. In D. Pargman (ed.), Psychological Bases of
Sport Injuries, 2nd edn. Morgantown,WV: Fitness Information Technology, pp. 125–55.
Yang, J. Z., Peek-Asa, C., Lowe, J., Heiden, E. and Foster, D. (2010) Social support patterns
of collegiate athletes before and after injury. Journal of Athletic Training, 45, 372–80.
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12
USING A PSYCHOLOGICAL MODEL
AND COUNSELLING SKILLS IN SPORT
INJURY REHABILITATION
Julie A. Waumsley and Jonathan Katz
Introduction
Harry is a 27-year-old male basketball player. His coach suggested he see a

sport psychologist because he has recently recovered from an elbow injury but
can’t seem to get back into training properly. He’s worked with a sports
psychologist on motivation issues and has used goal setting, self-talk and
imagery but is still having problems. He keeps avoiding the hard training
sessions and wants to be on his own more than he used to be. He has said
more often of late that none of the psychological work he’s doing is making
any difference.
Harry’s quote highlights several issues that present for consideration over and above
the obvious. First, there is persistence avoidance to training following injury recovery
indicating the need for further in-depth work. Second, the athlete acknowledges that
he is experiencing social withdrawal.Thirdly, there is a sense of persistent low mood
accompanying the negative language in this athlete’s presentation.
Working with the unsaid, implied issues that lie between the athlete and what
he/she is presenting requires an ability to recognise and work within the process.
Further, a willingness to gain a depth of understanding of issues such as personal-
ity characteristics, emotional reactions, coping mechanisms, past behaviours
impacting current ones and thinking patterns is helpful. Moreover, recognising
clinical features within an athlete presentation, such as anxiety, depression, and
post-traumatic stress disorder, and the ways in which these might manifest in an
athlete following injury will require the professional knowledge that underpins a
process of working within a trustworthy working alliance. This therapeutic ‘-
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172 Julie A. Waumsley and Jonathan Katz
difference’ from sport psychology echoes a way of working that various models of
counselling and therapy underpin and define in contrasting ways, which makes it
difficult to offer just one definition.
McLeod (2011) offers that counselling is ‘an activity that takes place when some-
one who is troubled invites and allows another person to enter into a particular kind
of relationship with them’ (p.12). Given that injured athletes are often ‘troubled’ by
the changes their injury imposes on them, the philosophy and underpinning of the
approach of the professional applied work offered may be broader or different from
that of a cognitive behavioural approach to mental skill straining, which is often the
adopted approach by sport psychologists (Katz and Hemmings, 2009).Within coun-
selling, the psychodynamic, cognitive behavioural and humanistic approaches are
generally recognised as the three primary models. A counsellor’s applied work will
often be underpinned by one such approach, although it is true to say that the inte-
grative approach, where several models integrate to form one theory (Katz and
Hemmings, 2009) has been adopted by many practitioners.
This chapter offers an account of the process of working within an injury-and-
rehabilitation environment. More specifically, the chapter demonstrates the usefulness
of using a psychological model and counselling skills in sport injury rehabilitation
context.The chapter: (a) offers a summary of the key theoretical and applied models
that underpin a counselling approach; (b) introduces the key counselling skills
deemed as useful in sport injury rehabilitation context, c) offers an account of the
process of working within an injury and rehabilitation environment, and (d) discusses
some of the key issues to consider when using counselling skills with injured athletes.
For the purposes of clarity within this chapter, the term ‘practitioner’ is gener-
ically used in places to avoid confusion between the terms ‘sports psychologist’,
‘counsellor’, or ‘therapist’. In addition, the term ‘athlete’ will be used to avoid
confusion between ‘patient’ or ‘client’.The concept of ‘relationship’ in this context
refers to the therapeutic element of the work where there is an unconditional,
non-judgemental and congruently empathic respect for the athlete and the
‘process’ that occurs in the space in between the content of what is being verbally
articulated and what is being experienced by the athlete internally.
It’s great to work with a counsellor and to also know that she’s working with the
psychologist. I really feel that she ‘gets’ me. I can’t really talk about this stuff to
anyone else for all sorts of reasons. People will think I’m a freak or disgusting, or
both. I’m scared that sports people will think I’m not worth investing in any more.
My counsellor just accepts me and it’s funny, but we don’t talk much about food;
we talk about what it all means so that makes me feel that I’m not so much a
disgusting freak but more someone who is worthwhile listening to. My counsellor
helps me to understand why I do what I do. She doesn’t invest in my performance
at all and that’s refreshing. I feel much more motivated and unburdened after I
have seen my counsellor.
(Jill, female 15-year-old gymnast)
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Using a psychological model and counselling skills in sport injury rehabilitation 173
Theoretical approaches
The psychoanalytical/psychodynamic approach
Psychoanalysis is defined as a theory of the mind or personality, a method of inves-
tigation of unconscious processes and a method of treatment (Freud, 1949). Much
of Sigmund Freud’s theorising was on the development of personality and of the
consequences of what he regarded as abnormal development, with the emphasis on
the unconscious.This is the notion that unconscious motivations and needs have a
role in determining behaviour. Freud’s theory might perhaps be divided into three
main parts: a description of the mind or psyche, a description of the development
of the psyche and a description of the way in which the psyche defends itself.
Freud’s topographic model of the psyche view the mind as having three levels of
consciousness: the conscious, the pre-conscious and the unconscious. He saw the
conscious as everything we are aware of.The pre-conscious is the area of the mind
containing thoughts and ideas which are available to recall but are currently ‘at the
back of ones mind’.This is quite different from the unconscious, which Freud saw
as holding all the early thoughts and feelings that might cause anxiety, conflict or
pain, and which are the motivating factors, out of awareness and not generally
accessible, that drive behaviour. The id functions at an unconscious level, driving
primitive needs and is ‘controlled’ by the ego. The superego brings a moral sense
to behaviour. Freud’s complex view of the ‘inner self ’ describes the ego as battling
against the id and the superego; the ‘three aspects of ‘self ’ ( Jacobs, 1991). Freud
believed that personality develops through a stage theory of psychosexual devel-
opment, as shown in Table 12.1.
TABLE 12.1 Freud’s stages of psychosexual development
Psychosexual stage Time frame (years) Behaviour

Oral Birth to Child is focused on oral pleasures (sucking)
12–18 months
Anal 12–18 months Pleasure is on eliminating and retaining
to 3 years faeces, learning control and stimulation
Phallic 3–6 Pleasure zone becomes the genitals. Oedipus
complex develops (boys develop unconscious
desires for their mother). More recent
psychoanalysis’s describe the same process for
girls as the Electra complex
Latency 7–12 Sexual urges remain repressed. Children
interact mostly with same-sex peers
Genital 12–18 Primary focus of pleasure is genitals and
sexual urges are awakened. Adolescents direct
their sexual urges to opposite sex peers
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In Freud’s stages of psychosexual development he contends that various crises are

resolved at each stage, leading to a healthy or unhealthy personality. If these crises
get ‘stuck’ at a specific stage they will be apparent and manifest in adult behaviour.
Consistent with this, the concept of anxiety is central to Freud’s theory. According
to Freud, the dynamics of all human behaviour were conflicts between the expres-
sion of and inhibition of desires and needs. To deal with this conflict between
inhibitions and desires and needs, Freud developed a series of defence mechanisms,
such as denial, repression, projection, regression, which would prevent immediate
goal gratification and resolve the conflict by transferring it into a socially acceptable
form.Thus, when anxiety cannot be dealt with by realistic methods that are socially
acceptable, the ego calls on various defence mechanisms to release the resultant
build-up of tensions. These defence mechanisms defy, alter or falsify reality, work
unconsciously and are not immediately obvious to ourselves or other people.
Working with individuals in a psychoanalytical way will involve working with
the unconscious drives through free association and dream work, when the analyst
interprets what is being said to make sense of it to the athlete. Central to this
approach are the concepts of transference and countertransference. Transference
refers to the way our athletes relate to us based on experiences with those who
cared for them in their formative years. Thus, they bring with them expectations
and assumptions based on their experiences of life that will influence the way they
perceive the practitioner (Gray, 2007). The practitioner can begin to learn about
these previous experiences by listening to what the athlete is saying and by notic-
ing the ways in which they relate to us. Countertransference can be useful in
learning about how athletes relate to others but the practitioner must be suffi-
ciently skilled and self-aware to, sometimes painfully, recognise some feelings
within a therapeutic alliance do not belong to the athlete but to the practitioner’s
own unresolved difficulties (Gray, 2007).
The cognitive behavioural approach

Behaviour therapy evolved from the theories of human learning (Hough, 2006).
However, ‘pure’ behaviourism left little room for any cognitive aspects associated
with human behaviour.Thus, taking note of both behaviour and cognition led on
to a cognitive behavioural approach. The Freudian approach was emphatic in the
belief that unconscious forces and unseen impulses were at the root of most human
problems.To deal with this, it was necessary to shed light on these hidden areas of
personality in therapy. In contrast, the behavioural approach adopts an alternative
philosophy. Within the behavioural approach, the focus is placed directly on the
athlete’s inappropriate behaviour and the associated contingencies reinforcing this
behaviour.Thus, behavioural change is central within behavioural therapy, with an
emphasis on targeting undesirable behaviour adapting the athlete to promote
appropriate behavioural change.
Ivan Pavlov (1849–1936) is perhaps the most well-known behavioural psychol-
ogist. His work conditioned dogs to salivate at the sound of a bell that they had
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learned to associate with food, a sequence of events Pavlov called the ‘conditioned
response’ and the concept of ‘classical conditioning’. Watson (1878–1958)
contended that conditioning could also be reversed through unconditioning and
Thorndike (1874–1949) suggested the ‘law of effect’ when, if a response to a
specific stimulus is followed by a reward, the bond between the stimulus and
response will be strengthened; if the response is followed by a negative outcome,
the bond will be weakened. According to Thorndike, therefore, behaviour is
dependent upon its consequences, which may be either reward or punishment.
Skinner (1904–1990) developed Thorndike’s law of effect further to suggest that
‘operant conditioning’ reinforces reward or punishment and the principle of rein-
forcement is important to both behavioural change and maintenance of
appropriate behaviour.
Ellis (1913–2007) and Beck (born 1921) started their careers as psychoanalysts
but came to believe that cognitions (thoughts, attitudes, beliefs, and so on) played
an important role in emotional and behavioural consequences or outcomes. Ellis’s
approach, currently known as rational emotive behaviour therapy, is operationalised
using the A-B-C model, with A being the activating event, B being the belief and
C being the emotional and behavioural consequence. Ellis argued that emotional
difficulties are a consequence of ‘distorted thinking’ and problems occur when
people’s interpretation of situations and events around them is excessively biased
from the ‘reality’ of those situations or events. More rational (realistic) belief state-
ments allow a person to cope with relationship difficulties in a more constructive
and balanced fashion with their interpretation being consistent with ‘the facts’.
Beck suggests some commonalities between cognitive and behavioural
approaches: ‘both employ a structured, problem solving or symptom reduction
approach with a highly active therapy style and both stress the “here-and-now”
rather than making speculative reconstruction of the patient’s childhood relation-
ships and early family relationships’ (Beck, 1976: 321). The cognitive behavioural
approach concentrates on the stimulus, the cognitions and emotions and the
behavioural outcome. Three key features of this approach are its problem-solving
delivery style, with change in focus from interpretative in the psychoanalytic model
to working collaboratively with clients, a respect for scientific values and a close
attention to the cognitive processes through which people monitor, control and
mediate their behaviour.
Kelly (1905–1967) has also been categorised as a cognitive theorist. Kelly sought
to investigate the world as constructed by the individual. Personal construct
psychology is concerned with the ways in which clients represent or view their
own experiences rather than seeing them as victims of impulses and defences.
Kelly’s therapeutic process is concerned with helping the client to find appropri-
ate or useful constructs rather than to be concerned with diagnosis and
categorisation. This approach aims to help clients to expand and articulate mean-
ings by which they construct a sense of self. Becoming aware of their personal
constructs and thereby of their ways of thinking and feeling, leads to modifying
behaviour in a similar way to the aims of cognitive behavioural therapy (CBT).
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Working with athletes using a cognitive behavioural therapeutic approach will

often involve establishing a rapport and building the therapeutic alliance, explain-
ing rationale for treatment, assessing the problem, setting goals and targets primarily
for cognitive and behavioural change and monitoring progress. Some ways of
executing this might be through challenging irrational beliefs, reframing issues
using cognitive restructuring techniques, scaling feelings, in vivo exposure and
homework assignments (for more details on how CBT has been applied in the
sport injury context, see the description of Wiese-Bjornstal, Smith, Shaffer and
Morrey’s (1998) integrated model of response to athletic injury and rehabilitation
process presented in Chapter 3 and Chapters 5–8 on different psychological inter-
ventions).
The humanistic approach

Perhaps the most well-known humanist or phenomenological theorist is Carl
Rogers (1902–1987). In Roger’s view, behaviour is typically an attempt by human
beings to meet their own needs as they perceive them (Rogers, 1980).The empha-
sis of this approach to counselling is on the athlete’s perceptions as determinants of
their actions. Rogers abandoned specific motivational constructs and viewed indi-
viduals as functioning as an organised whole. He suggested, ‘there is one central
force of energy in the human organism; that is a function of the whole organism
rather than some portion of it; and that is perhaps best conceptualised as a tendency
toward fulfilment, toward actualisation, toward the maintenance and enhancement
of the organism, (Rogers, 1963: 6). According to Rogers, people who are self-
actualising are fully functioning individuals who are open to new experiences and
trust their feelings rather than being threatened by them.Within this approach, self-
actualisation is seen as the fundamental motivation and underpins the notion that
athletes have the necessary resources for dealing with their own problems effec-
tively. Thus, athletes are encouraged, in a non-directive way, to explore their own
solutions to their issues or problems.
Working with athletes using this approach will be underpinned by what Rogers
called the ‘core conditions’ of empathy, unconditional positive regard and congru-
ence, without which self-actualisation will not be achieved. The core conditions
allow a therapeutic relationship of trust and non-judgement to develop, within
which the process of work between athlete and practitioner allows the space for
self-actualisation to be realised. The development of this therapeutic relationship
requires the use of various counselling skills, which are highlighted in the next
section of this chapter.
The integrative approach

There are many integrative approaches that underpin athlete work in different
ways (see, for example Clarkson, 2007; Lapworth, Sills and Fish, 2007; Moursund
and Erskine, 2004). However, integrating the three primary models is suggested as
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one way of working and it is attractive because this allows not only to work with
presenting issues but to better understand why past experiences impact on current
mechanisms of coping and behaviour, and to do so within a relationship or ‘work-
ing alliance’ that is conducive to positive change. To illustrate this, a model is
suggested in Figure 12.1.
HISTORICAL HISTORICAL FACTORS

FACTORS personal past; early learning;
psychosocial development and
range of life experience
CHARACTERISTIC PERSONAL OUTLOOK

core cognitions related to how self,
others, the world, and the future
are viewed
CURRENT CURRENT PERCEPTION

CONTEXT situation specific cognitions
(interpretative and evaluative)
SITUATION COGNITION x EMOTION BEHAVIOUR
FIGURE 12.1 Integrated theoretical and applied model of stress and coping
Source: adapted from Katz and Hemmings (2009); reproduced with the permission of the British
Psychological Society
This theoretical framework underpins interventions providing practitioners

with a systematic understanding of athletes’ presentations.This robust understand-
ing is helpful to practitioners as it assists them with individual athlete case
conceptualisations and intervention formulations.
This model is designed to be viewed as if it is three-dimensional, with the
bottom level being most superficial and relating to what is being experienced in
the current situation ‘here and now’. This bottom level comprises environmental
and psychological factors and the interactions between them. The psychological
factors, represented within the rectangles, is further made up of cognitions and
emotions and the interactions between them.The psychological factors are layered
from current to historical psychological factors. Each layer has specific types of
experience associated with it and the more general or global an athlete experiences
something, the more important it is to them as a person, not ‘just as an athlete’.
Finally, each of the layers is located with the context in which that experience
occurred.
It is sometimes argued that the theories and techniques of counselling are deliv-
ered through the presence and ‘being’ of the counsellor as a person (McLeod,
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2011). No matter what the theoretical approach, much research suggests that the
usefulness of the intervention of counselling comes from the quality of the rela-
tionship between client and practitioner (see, for example, Clarkson, 2007; Erskine,
Moursund and Trautmann, 1999; McLeod, 2011; Moursund and Erskine, 2004).
This relationship will usually convey trust and a deep sense of being special in the
presence of another who demonstrates deep caring. Within an integrative
approach, this is a safety felt where transference and countertransference are often
played out between two people and where understanding over specific behaviours
and emotions can be mediated through thought, words and ‘being’ in an environ-
ment of unconditional positive regard, acceptance and congruence.
Counselling models
Psychodynamic A developmental stage approach examining

unconscious processes and bringing to light
past experiences that impact the present.
Humanistic An approach highlighting phenomenologi-
cal issues and self-actualising.
Cognitive behavioural therapy An approach concentrating on the way that
thoughts and schemas impact emotion and
behaviour.
Integrative A theoretical approach examining the way
that past and present collide in thought,
emotion and behaviour.
Key skills
Each practitioner faces the challenge of translating their chosen therapeutic
approach into practice. The application of theory into practice is achieved by the
practitioner using a set of techniques or skills. The ‘doing’ of counselling, as
opposed to the ‘being’ of counselling, can be seen as the skills used to build rapport
and a strong working alliance with athletes. These attributes are represented in
Figure 12.2. The main foundation skills recognised by practitioners of humanistic
and integrative orientation are attending, observing, active listening, reflecting,
probing, immediacy and challenge, all of which will be discussed below.
Attending skills
Attending skills refers to the set of skills the practitioner adopts to ensure an effec-
tive professional relationship. Attending acts as a basis for listening to and observing
athletes; the means by which the practitioner communicates ‘non-verbally’ that
they are ‘with’ their athlete and interested in them (Culley and Bond, 2007).
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Historical and Current Context
Relationship
Process Content
FIGURE 12.2 Overview of factors associated with the 1:1 consultation

Source: Katz & Hemmings (2009); reproduced with permission of the British Psychological Society.
Attending communicates acceptance and congruence. Attending and listening are

inter-related; it is not possible to fully attend to athletes without listening to them.
Attending to athletes allows verbal and non-verbal messages, and their contradic-
tions between these verbal messages and behaviour, to be noticed (Egan, 2002). An
open, upright and relaxed posture and good eye contact, without staring, are
important (Culley and Bond, 2007).
Observing
Observing is the set of skills the practitioner uses to better understand the athlete’s
non-verbal behaviour and how this behaviour correlates, or not, with the athlete’s
verbal expression. Athletes communicate non-verbally through their dress, their
tone of voice, facial expressions, gestures, postures, and so on, all of which inform
the practitioner of inconsistencies between what athlete’s verbalise and their behav-
iours. These observations offer opportunities for the practitioner and athlete to
further explore inconsistencies for better understanding of presenting issues.
Active listening
Listening actively means listening with explicit purpose, using silences appropri-
ately and communicating that you have listened and understood; it is about
listening to, receiving and understanding messages whilst clarifying and organising
information that is heard, checking what to respond to and asking for clarity on
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what is unclear (Culley and Bond, 2007). Active listening enables the practitioner
to gain empathic understanding of the athlete’s situation from their perspective. It
provides useful insight into both what the athlete thinks and feels and the process
of how these thoughts and feelings arise.
Using silences to further inform the process between practitioner and athlete is
a necessary active listening skill that necessitates practitioners to be ‘tuned in’ to
their athlete’s emotional state. Listening to silences informs greatly about what is
happening in the moment. Breaking silences should be for the client’s benefit, used
purposefully by the practitioner with a view to enhancing the therapeutic session,
not to ease the practitioner’s feelings of discomfort with silence or because of a lack
of skill in working effectively with silence (Culley and Bond, 2007).
Reflective skills
The three reflective skills are restating, paraphrasing and summarising and these offer
a way for the practitioner to construct how they communicate their empathic under-
standing (that is, from the athlete’s perspective). Reflective skills help in the building
of trust and empathy by offering to the athlete the practitioner’s empathic under-
standing through active listening. This takes place with the professional relationship
that provides ‘time and space’ within a safe environment and without imposing
direction from the practitioner’s frame of reference (Culley and Bond, 2007).
Restating involves repeating single key words or phrases back to the athlete to
emphasise a point or an emotion. Paraphrasing lets the athlete know that the prac-
titioner understands what they are saying by communicating back to them, in the
practitioner’s own words, the main message expressed by the athlete. Summarising
organises the athlete’s, sometimes disorganised, content by bringing together the
salient aspects of their story (Culley and Bond, 2007).The consequence for athletes
by practitioners using these skills is that they feel that they’ve been ‘listened to’ with
their ‘story’ being valued, appreciated and understood.
Probing skills
Practitioners are sometimes required to question or gently challenge what athletes
express and these are collectively referred to as ‘probing skills’.‘We should use these
skills with care; we may be going into areas where we haven’t been invited’ (Culley
and Bond, 2007: 42). Probing offers opportunities for the client to explore issues that
the practitioner thinks are important. The most helpful type of probing questions
often begin with ‘what, how, when, where and who’ because they offer opportunity
for open dialogue from the client rather than providing one-word responses.
Immediacy
Immediacy is a skill that involves listening to your own reactions as the practitioner
and to use this to invite the athlete to look at what is happening between you and
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them. It is a very powerful tool because it invites immediate exploration of the

athlete’s feelings, thoughts and somatic responses. Using the skill of immediacy
often feels risky for the practitioner because it involves verbalising a ‘hunch’ and,
in so doing, inviting the client in to clarify what they are feeling or thinking in
light of their immediate behaviour.Thus, it can be described as a coming together
of the practitioner’s feelings in the moment, and the athlete’s behaviour in the
moment, to make sense of what is going on in the relationship in that moment.
In much the same way as understanding transference and countertransference
does within the psychodynamic approach, immediacy offers a way of interpreting
what is going on in the therapeutic relationship. In relation to the humanistic
approach, it is a way of focusing on the here and now of the practitioner and
athlete.When relating it to a cognitive behavioural approach, it may be interpreted
as using constructs to address patterns of relating between practitioner and athlete.
Of all the skills discussed, immediacy is a more advanced skill that tends to be
used by more experienced practitioners, who will rely on their own highly tuned
and acute self-awareness to provide valuable information to aid understanding of
the client.
Fundamental counselling skills
• Attending skills.
• Observing clients.
• Active listening skills.
• Reflective skills (restating, paraphrasing, summarising).
• Probing skills (questioning).
• Immediacy.
A process of working
When injured, an athlete’s physical injury is given primary attention, with the objec-
tive of providing diagnosis and subsequent medical and/or physical treatment.
Thereafter, a process of recovery begins, which involves structured rehabilitation.This
process is generally not linear but includes a variety of fluctuations associated with
how the treatment and rehabilitation process meanders with ups and downs over time.
The continuous medical focus of the injury during treatment and rehabilitation
can mask or hide underlying doubt and associated anxiety. Over time, and if this
process is prolonged, the athlete can experience a disassociation between their
medical care and how they feel psychologically about the impact and consequence
of their injury.When anxiety expressed over an injury coincides with a pre-existing
anxiety there may be a pattern of unhelpful behaviour that presents as challenging
and confusing and that appears non-responsive to the more traditional mental skills
work of sports psychology. As athletes’ sense of identity is strongly associated with
their sporting prowess, serious injury can be experienced as threatening to who
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they are as people and not just as athletes. Consequently, psychological recovery
post-injury needs to support the athlete in re-establishing a sense of worth and
value as a person before restoring their ‘sporting confidence’.
Becoming injured can interrupt the usual physical and psychological homeostasis
of the athlete. As discussed above, the physical aspects of the injury is the initial focus.
Having identified potential long-term and significant psychological consequences to
injury for some athletes, it is important to introduce psychological support as early
in the process as is practical. Consequently, the earlier the practitioner can get
involved within the treatment and rehabilitation process, the sooner the psychologi-
cal and emotional needs of the athlete can be met, resulting in a more holistic process
for the athlete. In this way, the person behind the athlete is also receiving support.
This approach offers an environment within which the athlete can discuss the diffi-
culties that their injury presents without fear of judgement and aside from the aspects
of sporting performance within their rehabilitation. This type of psychological
support places significance and importance of practitioner observation to ensure the
practitioner is aware of the complete impact that the injury has had on the person
behind the athlete and on their broader lifestyle. Further, good observation provides
the opportunity for the practitioner to explore with athletes any potential secondary
or underlying issues that may arise consequent to the physical injury.
Working with athletes requires a beginning, middle and an end to both the
whole process and to each individual session.Typically, within the counselling rela-
tionship, the beginning of the whole process involves making an assessment,
negotiating a contract, establishing boundaries, building trust and a working
alliance, clarifying and defining difficult areas to explore together. The middle
aspect of the process of counselling largely works to the contract negotiated at the
beginning, maintains the working relationship and reassesses difficulties and
concerns as they are worked through. Any end to the work, or part thereof,
requires planning with mutual consent between practitioner and athlete. It is
important to discuss the way in which this will occur, given that there may be
consequences of ending the bond developed throughout working together. Thus,
the process of emotional disengagement between practitioner and athlete requires
respect within the work of ‘ending’ with an athlete. Some basic assumptions within
this process are that people deserve acceptance and understanding, are capable of
change, are experts on themselves, demonstrate behaviour that is purposeful and
will work harder to achieve goals that are meaningful to them (Culley and Bond,
2007).Within all this, the individual, rather than their injury, is at the forefront of
the work and this thereby allows for recognition of the athlete behind the injury.
An important aspect of working with clients is the recognition of attachment
issues within the journey of eventual self-empowerment. Attachment can be seen
as a bond between two people that involves a desire for regular contact with that
person and experiencing discomfort when separated from that person (Ainsworth,
1989; Bowlby, 1979). An athlete’s attachment style may present as dependency and
some knowledge of how and when to gradually encourage them to regain control
of their own choices about their treatment is a necessity for the aware practitioner.
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Future directions
The role of the sport and exercise psychologist is changing (Aoyagi, Portenga,
Poczwardowski, Cohen and Statler, 2012). Coaches are increasingly delivering
mental skills training with their athletes, owing to developments in coach educa-
tion. Increasingly, sports psychologists are supporting athletes who have concerns
that have not been adequately or successfully managed through mental skills train-
ing alone. Thus, sports psychologists have a need for greater awareness of these
issues within situations such as injury and rehabilitation. Working with peer
support that allows space for discussion between practitioners about issues that may
present in their athletes, is one way for the practitioner to reflect on their practice.
It must be stressed that any practitioner adopting such an approach should have
a combination of high levels of self-awareness and the appropriate theoretical and
applied training to be able to recognise the different aspects of the counselling
‘process’ that are inherent in an integrative theoretical underpinning and played out
within the working alliance.
Conclusion
This chapter has highlighted a way of working with an athlete following injury that
departs from the more traditional mental skills approach adopted to injury rehabil-
itation.The main aim of this chapter has been to offer an overview of theoretical
approaches and skills to inform the practitioner when carrying out applied work
with an injured athlete, and as such, it has suggested an alternative approach based
on a counselling psychology model.To this end, the importance of ‘the professional
relationship’ is paramount, since it bears the fruit of renewed hope for an athlete
whose future has often been put in jeopardy through injury. This ‘professional rela-
tionship’, underpinned by an integrative theoretical approach within which
specific skills can operate, is the framework within which practitioners might work
should they be faced by an athlete who is either not responding to a mental skills
approach or whose more complex range of underlying psychological issues
requires a greater understanding through in-depth work.
CASE STUDY
Jill is a 15-year-old gymnast who injured her ankle during competition. She
was referred to counselling by her sports psychologist, who recognised that Jill
was presenting in a way that was posing a challenge for the sport psychologist
and her physiotherapists, as she did not appear to recover as predicted. In
essence, Jill’s behaviour was making them feel as though they were out of their
competency range; Jill was showing increasing amounts of erratic mood and
resistance towards training and she appeared to present a tendency towards
social avoidance. During the counselling sessions, Jill’s eating behaviours and
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bodyweight issues came to light when Jill said ‘it’s hard to carry on in rhyth-
mic gymnastics when girls start so young and are waif like. I used to be like
that but once I got to fourteen, my body started to change and it was hard for
me to eat the same things and keep my hips and legs slim’.
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1. How might the models described in this chapter be used by different
members of a multidisciplinary team?
2. When reading Jill’s case study, how do you think counselling might help,
over and above mental skills training?
3. Discuss what is meant by ‘relationship’. Notice what emotions and physi-
cal feelings are evoked within you as you discuss this topic.
References
Ainsworth, M. (1989) Attachment beyond infancy. American Psychologist, 44, 709–16.
Aoyagi, M., Portenga, S., Poczwardowski,A., Cohen,A. and Statler,T. (2012) Reflections and
directions: The profession of sport psychology past, present, and future. Professional
Psychology, Research and Practice, 43(1), 32–38.
Beck, A. (1976) Cognitive Therapy and the Emotional Disorders. Harmondsworth: Penguin.
Bowlby, J. (1979) The Making and Breaking of Affectional Bonds. London:Tavistock.
Clarkson, P. (2007) The Therapeutic Relationship. London:Whurr.
Culley, S. and Bond,T. (2007) Integrative Counselling Skills in Action, 2nd edn. London: Sage.
Egan, G. (2002) The Skilled Helper:A problem-management and opportunity-development approach
to helping, 7th edn. Pacific Grove, CA: Brooks/Cole.
Erskine, R., Moursund, J. and Trautmann, R. (1999) Beyond Empathy: A therapy of contact-in-
relationship. London: Routledge.
Freud, S. (1949) An Outline of Psychoanalysis. London: Hogarth Press.
Gray, A. (2007) An Introduction to the Therapeutic Frame. London: Routledge.
Hough, M. (2006) Counselling Skills and Theory, 2nd edn. London: Hodder Arnold.
Jacobs, M. (1991) Psychodynamic Counselling in Action. London: Sage.
Katz, J. and Hemmings, B. (2009) Counselling Skills Handbook for the Sport Psychologist.
Leicester: British Psychological Society.
Lapworth, P., Sills, C. and Fish, S. (2007) Integration in Counselling and Psychotherapy: Developing
a personal approach. London: Sage.
McLeod, J. (2011) An Introduction to Counselling, 4th edn. Glasgow: McGraw Hill.
Moursund, J. P. and Erskine, R. G. (2004) Integrative Psychotherapy:The art and science of rela-
tionship. Pacific Grove, CA:Thomson: Brooks/Cole.
Rogers, C. (1963) The concept of the fully functioning person. Psychotherapy:Theory, Research
and Practice, 1, 17–26.
Rogers, C. (1980) A Way of Being. Boston, MA: Houghton, Mifflin.
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13
PSYCHOLOGY OF PHYSICAL
ACTIVITY-RELATED INJURIES
Elaine A. Hargreaves and Julie A. Waumsley
Introduction
The physical and psychological benefits of participating in regular physical activ-
ity are well documented (see Powell, Paluch and Blair, 2011, for a review).
Consequently, national health organisations and agencies (such as the World
Health Organization; US Department of Health and Human Services, UK
Department of Health) are directing health promotion efforts at encouraging the
general population to engage in a physically active lifestyle. Current physical activ-
ity guidelines indicate that 150–300 minutes per week of moderate intensity
activity (like walking) provides substantial health benefits, while similar benefits
can also be achieved by 75 minutes per week of vigorous intensity activity or a
combination of both moderate and vigorous intensity (Garber et al., 2011; Powell
et al., 2011). Although the benefits of activity outweigh any risks, with the adop-
tion of an active lifestyle or when the volume/intensity of activity being
undertaken is increased suddenly (subsequently placing the individuals body
under increased levels of stress) comes a greater exposure to the risk of injury
(Andersen and Williams, 1988; Colbert, Hootman and Macera, 2000; Jones and
Turner, 2005; Morrow, DeFina, Leonard,Trudelle-Jackson and Custodio, in press;
Nicholl, Coleman and Williams, 1995).
Musculoskeletal injury is the most commonly reported adverse effect of physi-
cal activity (Hootman et al., 2002; Janney and Jakicic, 2010; Powell et al., 2011) and
is frequently reported as the reason for ceasing involvement in activity (Hootman
et al., 2002; Sallis et al., 1990) or as a barrier to increasing physical activity (Finch,
Owen and Price, 2001; Toscos, Consolvo and McDonald, 2011). Additionally,
simply having a fear of injury has been reported as a major barrier to the adoption
of an active lifestyle (Booth, Bauman, Owen and Gore, 1997; Eyler, Brownson,
Bacak and Housemann, 2003).
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186 Elaine A. Hargreaves and Julie A. Waumsley
Consequently, it is surprising that, thus far, very little research has focused on the
response to injury in a recreationally active population. Research related to the
psychological responses to injury has predominately focused on recreational sport
and competitive athletes (see Walker,Thatcher and Lavallee, 2007;Wiese-Bjornstal,
2010, for reviews of this literature; Wiese-Bjornstal, Smith, Shaffer and Morrey,
1998) or on clinical populations (for example, chronic low back pain, Vlaeyen,
Kole-Snijders, Boeren and van Eek, 1995). Given the direct impediment to physi-
cal activity participation that results from injury (or simply having fear of injury)
and the likely adverse effect on motivation for activity following an injury in this
population, a discussion of these issues is warranted.
This chapter discusses the existing research on the psychological responses to
injury in recreationally active populations and draws from sport injury response
models to study the psychology of activity-related injury. More specifically, the
chapter: a) discusses injury prevalence from physical activity; b) identifies the
psychological consequences associated with physical activity related injuries;
c) applies the integrated model of psychological response to the sport injury and
rehabilitation process (Wiese-Bjornstal, et al., 1998) into the physical activity injury
context; d) examines the existing literature on the appraisal processes and
emotional and behavioural responses to physical activity-related injuries; and e)
introduces psychological interventions that can be used when recovering from
physical activity related injuries.
Physical activity-related injuries: prevalence

Reporting the prevalence of activity-related injuries is not straightforward because
reports typically combine sport and physical activity-related injuries together in one
category and the method used to report prevalence differs (see, for example, Burt and
Overpeck, 2001; Carlson et al., 2006; Uitenbroek, 1996). Studies which have reported
injury prevalence in physically active and sedentary individuals show that the type
and intensity of physical activity are important considerations (Garber et al., 2011).
Walking and moderate-intensity activity are associated with lower risk of injury
compared with jogging/running and more vigorous intensity activities (Table 13.1).
Despite a perception by exercisers that participation in physical activity is not
associated with a high risk of injury (Finch, Otago, White, Donaldson and
Mahoney, 2011), these statistics would suggest that injuries resulting from physical
activity are just as prevalent as those that result from sport. Risk factors for injury
in a physically active population include engaging in more than 1.25 hours of
activity per week (Hootman et al., 2001), having a higher level of fitness (Colbert,
Hootman and Macera, 2000; Hootman et al., 2002; Hootman et al., 2001), having
had a previous injury (Colbert et al., 2000; Hootman et al., 2002; Morrow, DeFina,
Leonard, Trudelle-Jackson and Custodio, 2012; Requa, DeAvilla and Garrick,
1993) and having a higher body mass index (Janney and Jakicic, 2010).When injury
statistics are adjusted for actual physical activity exposure time, there is an increased
risk of injury and prolonged healing time with increasing age (Finch et al., 2001).
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Psychology of physical activity-related injuries 187
TABLE 13.1 Injury prevalence from common physical activities
Type of physical Intensity Prevalence (%) Reference

activity Men Women
Walking Moderate 7–17 18–20 Colbert et al., (2000);
Hootman et al., (2002;
2001)
Jogging/running Vigorous 25–64 23–44 Colbert et al., (2000);
Hootman et al., (2002;
2001)
Gardening; DIY; Moderate Relatively low, but high Powell et al., (1998),
cycling participation rates = higher Parkkari et al., (2004)
injury rates
Fitness activities: Moderate > 2 million exercise-related Nicholl et al., (1995);
running, weight to vigorous incidents annually in the UK Lubetzky-Vilnai et al.
training and 49.6 33.8 (2009)
keep fit
As more individuals answer the call by national health organisations and agen-
cies to participate in physical activity, and with a high proportion of those
individuals likely to be at risk of injury (for example, older in age, overweight), it
is likely that the prevalence of injuries will increase (Green and Weinberg, 2001;
Parkkari et al., 2004).
Physical activity related injuries: consequences

Finch, Owen and Price (2001) highlighted the myriad adverse outcomes that can
be experienced as the result of a physical activity-related injury. Similarly to athletic
injuries, an individual’s overall health can be affected through physical and psycho-
logical impairment. On occasions, there can be financial implications if the injury
influences the individual’s ability to work. For the majority of individuals, an
activity-related injury results in a temporary cessation or reduction of physical
activity levels but for some it can put a more permanent stop to their activity levels,
despite the injury only being a temporary impairment (Hootman et al., 2002;
Janney and Jakicic, 2010; Powell, Heath, Kresnow, Sacks and Branche, 1998; Sallis
et al., 1990). Furthermore, only 25 per cent experiencing an activity-related injury
seek treatment (Nicholl, Coleman and Williams, 1995; although this number was
greater in those who meet the physical activity guidelines, Morrow et al., 2012;
Powell et al., 1998) and only 30–40 per cent perform rehabilitation exercises
(Hootman et al., 2002). Thus, the risk of future injury is increased, owing to the
lack of proper injury treatment and rehabilitation. More importantly, perhaps,
owing to the reduction or permanent cessation of physical activity behaviour, indi-
viduals will no longer be able to gain the widespread physiological and
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psychological health benefits of an active lifestyle.Therefore, if an injury occurs the

main concerns are to ensure individuals rehabilitate properly and return to a phys-
ically active lifestyle.
Sallis et al. (1990) showed that some individuals will return to activity follow-
ing an injury related relapse and others will not, suggesting that there are some
underlying psychological mechanisms that explain post-injury activity behaviour.
The study of psychological responses to injury in the sport context has drawn
mainly from cognitive appraisal and stress process frameworks (see, for example,
Wiese-Bjornstal, 2010;Wiese-Bjornstal, Smith and LaMott, 1995;Wiese-Bjornstal
et al., 1998; see also Chapter 3). In the physical activity context, whether or not an
individual returns to their pre-injury physical activity patterns and/or adheres to
any necessary injury rehabilitation will be influenced by his or her cognitive
appraisal of, and affective reactions to, their injury. These behavioural attempts then
have their own set of consequences (for example, success, experience of pain) that
will feed back into the cognitive and affective appraisal process (Wiese-Bjornstal,
2010). Although there is limited direct research to support the proposals of the
framework in an activity-related injury context, indirect support can be drawn
from sport and general injury contexts, as well as related research from the psychol-
ogy of physical activity.
Physical activity-related injuries: an integrated model of

psychological response to the sport injury and rehabilitation
process (Wiese-Bjornstal et al., 1998)
Discrete aspects of the consequences to injury resulting from physical activity are
difficult to tease apart.The cognitive appraisals of the initial injury followed by the
emotional and behavioural responses that result, interact and, additionally, are
moderated by personal and situational factors. This is illustrated in the following
discussion and in the case study at the end of the chapter.
Goals
For those individuals who are trying to become regularly active, physical activity is
typically a goal-directed behaviour (Sebire, Standage and Vansteenkiste, 2009).The
nature of, and reasons for, the goal achievement influence psychological outcomes
(Sebire et al., 2009) and thereby the cognitive appraisal of an injury. For those moti-
vated to achieve tangible rewards from their activity, such as enhanced appearance,
the occurrence of an injury will suspend the achievement of those goals.
Perceptions of not making progress towards achieving goals produces distressing
emotional states and disrupts self-regulation of behaviour (Berger, Pargman and
Weinberg, 2006; Maddux and Gosselin, 2003).This extrinsic form of motivation is
more prevalent in individuals who are in the early stages of physical activity behav-
iour change (Wilson, Mack and Grattan, 2008) and this appraisal will put them at
risk of ceasing their involvement in physical activity.
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In comparison, for individuals who are regularly active, motivation for physical
activity often comes from a sense of enjoyment and because it is a valued behav-
iour (Wilson et al., 2008). For these individuals, the occurrence of an injury may
carry a great sense of loss. From a cognitive appraisal perspective individuals who
have higher commitment to physical activity will experience greater negative
emotional responses including, guilt, depression, irritability, restlessness, tension,
stress, anxiety and sluggishness because the injury prevents them from being active
(Chan and Grossman, 1988; Green and Weinberg, 2001; Hausenblas and Symons
Downs, 2002; Johnston and Carroll, 2000b). Despite having a negative affective
response to forced inactivity, it is likely that regularly active individuals will take the
steps necessary to return to their pre-injury activity levels and will adhere to treat-
ment because of the value and positive benefits they experience from being active
(King-Chung Chan, Hagger and Spray, 2011; Levy, Polman, Nicholls and
Marchant, 2009).
Identity
An individual’s self-identity can be encapsulated within their role as an exerciser
(Strachan, Flora, Brawley and Spink, 2011). With injury comes an inability to fulfil
this role, resulting in a challenge to this identity which can lead to cognitive and
affective reactions (Collinson and Hockey, 2007; Strachan et al., 2011; Wiese-
Bjornstal, 2004). Strachan et al. (2011) found that, with a strong exercise identity,
being unable to exercise led to a negative affective response, which they suggested
acts as a motivator to return to activity so as to regain consistency between identity
and behaviour. Research in the sport context has shown that with a particularly
severe injury or if recovery is slower than hoped, then athletic identity decreases over
time (Brewer, Cornelius, Stephan and Van Raalte, 2010).This decrease is suggested to
protect self-concept and reduce the experience of negative affect because the indi-
vidual devalues that aspect of themselves to reduce the discrepancy between identity
(for example,‘I am an exerciser’) and actual behaviour (for example,‘I am not exer-
cising’). However, this change in identity may compromise the return to activity.
Self-efficacy
Self-efficacy is an individual’s belief in his or her abilities (Bandura, 1997). Self-
efficacy is one of the strongest determinants of participation in physical activity and
influences affective and cognitive outcomes of physical activity (Biddle and Mutrie,
2008;Trost, France and Thomas, 2011). Consequently, following an injury, the indi-
vidual’s appraisal of their self-efficacy will be prominent in the psychological
response to injury and will influence future behaviour, including adherence to
rehabilitation.There are a variety of self-efficacy beliefs that operate in the physi-
cal activity domain. Task self-efficacy refers to the individual’s ability to complete
certain activities (for example, walk for 30 minutes, perform strength training exer-
cises).The period of inactivity caused by the injury is likely to reduce perceptions
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of task self-efficacy such that the individual will not feel as able to perform
activities to the same level after the injury as they did before injury. Importantly,
task self-efficacy is negatively associated with a fear of re-injury (Tripp, Stanish,
Ebel-Lam, Brewer and Birchard, 2007). Barrier self-efficacy refers to the individ-
ual’s ability to overcome environmental and personal barriers that exist to being
active. With an injury comes new barriers to negotiate (such as changing to
another form of activity). Recovery self-efficacy (an ability to resume a behaviour
after a lapse) also influences future activity levels (Luszczynska, Mazurkiewicz,
Ziegelmann and Schwarzer, 2007) and adherence to rehabilitation (Levy, Polman
and Clough, 2008).The individual’s ability to maintain and/or build their self-effi-
cacy following injury will influence the likelihood of returning to regular activity
and adhering to rehabilitation.
It’s been brilliant to work with a specialist in exercise psychology through my injury.
I didn’t actually know they existed, or what they did, and I was a bit sceptical at
first! But speaking with Lisa has helped me recognise the negative thought patterns
I have had since my injury and how they have contributed to me feeling frustrated,
moody and lacking motivation for rehab. I felt so overwhelmed with all the exer-
cises the physio gave me and they were so painful to begin with that I did
everything possible to avoid doing them. I couldn’t see I would ever get back to my
old running routine.
But with Lisa I set some achievable goals for doing my exercises, we worked on
changing my negative thoughts about the pain into positive ones so I could cope
with the pain better and she got me to realise that getting injured wasn’t the end
of the world. I think the sense of control I got back from a situation that I didn’t
really feel in control of really helped. I have learned so much about myself and now
much better understand why I react to things the way I do and what the conse-
quences are. It’s still hard work and I still catch myself following old patterns, but
I can now recognise when I go into a slump and I can give myself a good talking
too! So it’s been worth it really, if I hadn’t spoken to a specialist in exercise psychol-
ogy and got her support I probably wouldn’t have stuck with the rehab and got
back to being active.
(John, recreational runner)
Causal attributions
Physical activity-related injuries can result from a number of situations and can
activate thoughts related to the cause of the injury which will influence the affec-
tive and behavioural response (Wiese-Bjornstal, 2004).The cause of injury can be
attributed to internal or external (personal/environmental) factors, can be stable or
unstable (unchangeable/ changeable) and can be perceived as personally control-
lable or not. Extrapolating findings in sport to the context of activity–injury
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suggests that if the individual takes personal responsibility for the injury, perceives
that the causal factors do not change over time but are personally controllable then
an adaptive psychological and behavioural response will result (Brewer, 1999;
Coffee and Rees, 2009; Shields, Brawley and Lindover, 2005).
Coping skills
The extent to which the individual feels they have appropriate coping resources
and skills is proposed to influence their cognitive appraisal of the injury (Wiese-
Bjornstal et al., 1998). Additionally, the extent to which the individual
implements strategies to manage the stress presented by the injury is suggested as
a behavioural outcome of the stress appraisal process (Wiese-Bjornstal, 2010).
Coping skills are typically defined according to two main processes: problem-
focused coping, which refers to cognitive and behavioural attempts to manage or
change the problem that is causing the stress (for example, accepting the injury
and focusing on rehabilitation) and emotion-focused coping, which refers to
attempts to regulate the emotional response to the problem (for example,
expressing negative emotions; Lazarus and Folkman, 1984). Research would
suggest that problem-focused coping strategies are more advantageous compared
with emotion-focused coping (Johnston and Carroll, 2000a; Quinn and Fallon,
1999). For a review of common coping strategies employed in medical situations,
see Wiese-Bjornstal (2004).
Social support
Social support is a key situational factor that can influence the psychological
response to physical activity related injury in a number of ways. In the initial cogni-
tive appraisal, it can reduce the perceptions of stress posed by the injury (Uchino,
2009), improve affective reactions (Rees, Mitchell, Evans and Hardy, 2010) and
build self-efficacy (Podlog and Eklund, 2007).The nature and provider of the social
support is important (Collinson and Hockey, 2007; DiMatteo, 2004; Podlog and
Eklund, 2007; Uchino, 2009). Sport medicine professionals will likely provide
informational support, while family and friends will likely provide emotional
support and, if the injury is severe, will provide practical support (for more details
on providers of social support, see Chapter 9). Importantly, with a physical activity-
related injury comes the potential loss of support provided by those who the
individual regularly exercises with and the possibility to feel socially isolated
(Podlog and Eklund, 2007). Thus, the individual’s ability to mobilise appropriate
social support from other sources will influence their appraisal of their injury.
Uchino (2009) explains that the effects of social support are not always positive,
particularly if it reduces the individuals sense of independence or if the provider of
social support does not provide the right kind of support.
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A response to physical activity-related injuries typically follows a pattern of:
• cognitive appraisal (e.g. goal adjustment; self-perceptions);

• emotional responses (e.g. re-injury anxiety; loss);
• behavioural responses (e.g. activity continuation; adherence to rehabilita-
tion);
• in response to the injury, an exerciser’s cognitive appraisals, emotional and
behavioural responses interact (known as the dynamic core);
• the dynamic core responses are all moderated by personal (e.g., activity
experience) and situational (e.g. social support) factors;
• the dynamic core will have an impact on the overall physical and psycho-
logical recovery, and vice versa.
Pain perceptions and fear of re-injury/re-injury anxiety

Injuries can often result in pain. Individuals who engage in catastrophising focus
excessively on pain sensations (rumination), exaggerate the threat of pain sensations
(magnification) and doubt their ability to cope effectively with situations that
induce pain (helplessness) (Sullivan, Bishop and Pivik, 1995).The extent to which
individuals engage in catastrophising may influence the intensity of pain experi-
enced as a result of injury, influence adherence to injury rehabilitation exercises
(particularly if they result in some pain) and may influence confidence in being
able to return to physical activity. Fear of injury, and/or re-injury anxiety are a
common response in those who return to sport following an injury and these can
be a major barrier to participation in physical activity (e.g., Finch et al., 2001;
Toscos et al., 2011). The experience of pain from the initial injury contributes to
fears and/or anxieties about re-injury because the individual is worried that they
will suffer further pain (Sullivan et al., 2002). It is useful here to recognise that ‘fear’
and ‘re-injury anxiety’ are two separate concepts, yet they might be experienced
independently or concurrently during rehabilitation and return to training and
competition (Walker and Thatcher, 2011).
Suggested psychological interventions for rehabilitation and

resuming physical activity
The following practical strategies are based on the previous discussion and sports
injury literature, which suggests that, to help individuals overcome their activity-
related injury, the focus should be to reduce the threat appraisal presented by the
injury (Levy et al., 2008).The rationale being:
1. It will enable a more positive psychological response to the injury.

2. It will enable the individual to feel more optimistic about recovery.
3. It will enable a return to pre-injury levels of activity.
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Key strategies for promoting adherence to injury rehabilitation and the

resumption of physical activity
Goal setting:
• Suspend previous activity-related goals while injured to reduce the sense of
non-accomplishment of goals and create new ‘achievable’ goals for the
rehabilitation period.
• Replace old physical activity routines with a new rehabilitation routine.
• On return to activity, new activity goals should acknowledge the individu-
als lowered level of functioning post-injury to limit the risk of re-injury and
build self-efficacy.
• Recognise the enjoyment and value gained from being active and not just
the extrinsic rewards.
Imagery:
• Imagine successfully performing rehabilitation exercises.
• Imagine being active without pain.
• Imagine being active at pre-injury capabilities.
Positive self-talk:
• Reframe negative thoughts.
• Celebrate successes; give positive feedback.
Personal control:
• Identify how to overcome new barriers to activity presented by injury.
• Take responsibility for the occurrence of injury and the rehabilitation.
Social support:
• Seek out appropriate social support from general practitioners, physiother-
apists, family and friends to provide emotional and practical support.
• Connect with activity friends in other ways (for example, attend the after
activity social occasion).
Self-identity:
• Maintain pre-injury habits where possible (for example, wear exercise attire
during rehabilitation, use the same activity locations during recovery).
• Recognise other aspects of life that bring meaning and enjoyment.
• Maintain identity as an exerciser. The break is only temporary.
Conclusion
This chapter has discussed research on psychological responses to injury in recre-
ationally active populations and has used sport injury response models and other
health behaviour theories to study the psychology of activity-related injury.
Drawing from a cognitive appraisal and stress framework and injury research from
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sport and clinical populations, this chapter has highlighted the interactions that
exist between the cognitive appraisal of the initial injury and the resulting
emotional and behavioural responses, as well as the role that personal and situa-
tional factors play in moderating those responses. Owing to the lack of direct
research on the topic, it is by no means an exhaustive account and other factors
identified as important to the psychological outcomes of sport injury (for exam-
ple, personality factors; Wiese-Bjornstal, 2010; Wiese-Bjornstal et al., 1998) have
not been discussed but may be important to the appraisal of an activity-related
injury. Furthermore, most of the outcomes proposed throughout have still to be
confirmed through experimental research and would make for an exciting
programme of research.
CASE STUDY
Amanda is a 33-year-old white female who, after being relatively inactive for
the last five years (personal factor), has been attending a weekly ‘spinning’ class
for the last month. She goes for several reasons (goals): she wants to lose a bit
of weight and to feel fitter and mentally healthier. She has recognised that she
feels more ‘upbeat’ when she’s active and because she meets her friends at the
class, she enjoys it as a social occasion. When Amanda suffered a calf injury, it
became too painful for her to cycle and she had to rest. As a consequence, she
gained weight, she felt less healthy and she missed out on socialising with her
friends. The forced rest from the injury meant that she could not achieve her
goals (cognitive appraisal) and this resulted in her feeling frustrated, irritable
and a little ‘down’ (emotional response). She also missed the motivational
support she got from her friends (situational factor). As time drifted on,
Amanda’s motivation to return to the class waned because she no longer saw
the point in being active, wasn’t getting any emotional or practical support
and she was worried that she would just get injured again.
–––––––– ? ––––––––
1. What do you consider to be the most important aspects that an exercise
psychology specialist should consider when working with a recreationally
active individual with an injury?
2. If putting together a psychological programme of rehabilitation for a
recreationally active individual with an injury, what would you consider?
3. How do you see Wiese-Bjornstal’s (2010) model contributing to activity-
related injury?
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14
CONCLUSIONS AND FUTURE
DIRECTIONS
Natalie Walker and Monna Arvinen-Barrow
It has been the aim of this book to demonstrate the ways in which psychology can
play a role in the sport injury process. Moreover, the book has aimed to provide
the reader with a comprehensive view of the subject matter by adopting a holistic
perspective incorporating theory, research and applied knowledge when discussing
the usefulness of psychological interventions and counselling skills in sport injury
rehabilitation. By doing so, the text has also demonstrated how much the subject
area involving psychology of sport injuries has advanced since the early 1990s, at
which time several text books focusing on this topic emerged. Collectively, the
three parts within the current text draw on some of the early work and present an
outline of the more diverse and established literature and practitioner suggestions,
thus allowing a provision of evidence-based suggestions for sport medicine practi-
tioners, athletes, and researchers.
In Part 1, Chapter 1 highlighted the importance of addressing psychological
issues during rehabilitation to ensure a full and holistic recovery. The subsequent
chapters then introduced the key terminology and relevant theories and models.
The models outlined provided useful frameworks that can be used by those inter-
acting with injured athletes and help them to understand the athletes’ experiences
and the potential impact of such experiences on the individual – from injury onset
to full recovery. Chapter 2 introduced the stress and injury model and, although it
was introduced over 20 years ago, this model still remains the single most dominant
framework in guiding researchers today in the prediction and prevention of sport
injury. With this in mind, those working in the applied setting should consider
educating athletes about the importance of good health and adopting a healthy
lifestyle for minimising the risk of injury. Moreover, coaches and sport medicine
professionals alike should get to know their athletes, should be sensitive to any
increased stress levels and should subsequently assist them in using relevant skills and
techniques to help manage their cognitive appraisals, emotions, and behaviours.
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200 Natalie Walker and Monna Arvinen-Barrow
As demonstrated in Chapter 3, the importance of theoretical frameworks should

not be limited to injury onset but should extend to psychological responses to
injury, the impact of these responses on rehabilitation and subsequent return to
sport.Whilst much of the early work on responses to injury was adopted from the
grief domain, and subsequently heavily criticised, it would still be advantageous to
explore the usefulness of more contemporary grief models as a framework in this
area. Researchers are encouraged to continue to use the cognitive appraisal and
biopsychosocial models as frameworks for exploring the athlete’s responses to sport
injury and to generate more information to help guide sport medicine profession-
als in addressing adverse psychological responses to injuries and enhancing
adherence to rehabilitation.The latter is vitally important, as highlighted in Chapter
4, the significance of rehabilitation adherence as an essential component for success-
ful rehabilitation cannot be doubted. It is also evident that non-adherence is
associated with poor rehabilitation outcomes and increases the risk of re-injury.
Thus, applied practitioners are encouraged to create an environment that is
conducive to adherence (see Chapters 11 and 12 for more details on rehabilitation
teams and building a working alliance) and to encourage the use of psychological
interventions (see Chapters 5–9) with the aim of improving adherence. However, as
the research in this area is sparse, researchers are also encouraged to continue to
examine the effects of such interventions on rehabilitation adherence.
In Part 2, the five key psychological interventions typically used in sport were
outlined and the literature exploring the usefulness of these interventions in sport
injury contexts was explored. In addition, a number of practical suggestions on
how to use these to facilitate physical and psychosocial recovery were made, an
aspect which is undoubtedly one of the unique aspects of this text. All of the chap-
ters in Part 2 extended existing literature by the linking of models and theoretical
frameworks with the interventions and making them sport injury specific. With
respect to goal setting, the most widely adopted of the psychological interventions
in rehabilitation, specific types and levels of goals for rehabilitation were suggested.
It would be advantageous to explore the usefulness of this framework both in
applied and research environments in the future. Similar suggestions were made for
imagery where an established model was adapted and applied from sport perform-
ance into sport injury rehabilitation settings. Furthermore, this framework could be
useful for researchers aiming to explore the use of imagery during rehabilitation in
the future, in addition to providing guidance to sport medicine professionals and
athletes alike when choosing an appropriate imagery type to meet the desired
rehabilitation outcome.
Despite limited empirical evidence from an applied setting, a strong argument
was presented to readers for the usefulness of adopting relaxation techniques as an
integral part of sport injury rehabilitation. It was recommended that such techniques
should be used as a foundation from which other psychological interventions could
be built on (for example, imagery). Whilst not a relaxation technique as such, the
introduction of mindfulness to sport injury rehabilitation contributed to the
contemporary nature of the relaxation chapter. As the application of mindfulness in
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Conclusions and future directions 201
sport injury rehabilitation is in its infancy, researchers are encouraged to explore

mindfulness interventions in the future, particularly its use in managing anxiety, pain
and adverse emotions in response to sport injury.
The chapter on self-talk (Chapter 8) introduced the reader to new and innova-
tive concepts. Although existing literature discusses the advantages of positive
self-talk over negative self-talk, the current text has explored the importance of
considering the interpretation of the content of what is being said, over a simple
description of positive/negative and has outlined the key use of ‘functional’ self-
talk during sport injury rehabilitation. That is, when implementing self-talk in
rehabilitation, the idea of self-talk being purposeful (motivational or instructional)
can be useful in guiding the athlete towards recovery. However, further research in
this area is recommended and could focus on the athlete’s use of self-talk as part of
the rehabilitation process with the aim of seeking further insights into the actual
functions of the intervention.
In addition to the four interventions presented above, the value of integrating
social support as a key intervention for rehabilitation was presented. Chapter 9
discussed the importance of different types of social support from a range of signif-
icant individuals involved with the athlete that can be beneficial during the
different phases of rehabilitation.The chapter also described how personal and situ-
ational factors that have influence on the athlete impacts on the need for social
support. It appears that social support is one of the most researched intervention
within sport injury realm, however to understand it fully in the applied settings
future research is certainly warranted.
In Part 2 of the book, some key points are worth noting. Firstly, it was empha-
sised that psychological interventions are most successful if used as part of a wider
rehabilitation programme. Secondly, each chapter highlighted a number of key
practitioner suggestions, of which a number were directly related to the practical
implementation of the interventions. At the core of these suggestions was the need
to amalgamate both physical and psychological rehabilitation in such a way that it
becomes an accepted part of a holistic sport injury rehabilitation process. Finally,
all of the chapters were underpinned by the assumption that all psychological
interventions should only be led by professionals who are appropriately skilled and
trained to do so.
Following on, Part 3 further emphasised the above. Firstly, Chapter 10 intro-
duced the reader to some of the important practicalities of integrating
psychological and physical rehabilitation. Chapter 11 then continued this theme by
demonstrating how different members of a rehabilitation team can work together
to provide effective holistic recovery. Throughout the book, and particularly in
Chapter 11, evidence was provided in support of sport medicine professionals often
reporting inadequate training in the psychological aspects of sport injuries. It is the
belief of the editors of this text that this is a key area for continued investigation
and an area in need of development.
A second novel contribution of this text is the inclusion of the use of coun-
selling skills in sport injury rehabilitation. It was noted that much of the delivery
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202 Natalie Walker and Monna Arvinen-Barrow
of psychological services in sport (and possibly during rehabilitation) tends to be

heavily focused on psychological interventions. It is not disputed that this is a vital
component of rehabilitation, as highlighted in Part 2; however, emphasising the
importance of the working relationship between the athlete and the practitioner
and how such can be facilitated was also deemed important for a number of
reasons. Working with an injured athlete might lend itself to the professional
knowledge and philosophy of a counselling approach that is underpinned by a
process of operating within a trustworthy working alliance and goes far beyond
delivering psychological skills alone. Key counselling models have been highlighted
and the reader advised of the application of these frameworks when working with
injured athletes and how these approaches can then be translated into practice
using a set of key counselling skills to build rapport and a working alliance with
the injured athlete. Again, it must be pointed out that any practitioner adopting
such an approach should have a combination of high levels of self-awareness and
the appropriate training.
Finally, Part 3 concluded with a unique chapter on the psychology of physical
activity-related injuries, an area currently lacking in empirical research evidence.
This chapter applied some of the knowledge from the sport injury research domain
and highlighted the need to advance this avenue of investigation further. In soci-
ety today, there is a clear health promotion agenda encouraging individuals to
adopt a more physically active lifestyle. Despite the benefits of adopting such an
active lifestyle far outweighing the risks, there is still an increased probability of
injury associated with engaging in physical activity. Surprisingly, very little research
has been conducted to date focusing on the response to injury in the physically
active population. An exciting avenue for future research would include exploring
the usefulness of the response to injury frameworks for explaining responses to
exercise-related injuries. Furthermore, as we seek to explore enhancing motivation
to engage in an active lifestyle, we might consider adopting some theories and
practical ideas from this domain and apply them to motivation for rehabilitation.
For example, the application of the transtheoretical model to rehabilitation has
been proposed as a useful framework; however, this has not yet been empirically
explored.The usefulness of active video gaming as a motivational tool for rehabil-
itation could also be explored in future research.
Despite meeting its aims, this book can be considered a continuation of core
texts published 20 years ago and so is still somewhat in its infancy. By providing a
description of ‘what we know to date’, it is hoped that this text will be used to
inform practice, to encourage consideration of the implementation of the key
suggestions made, as well as serving as a guide for future research by promoting
further interest in the area of psychology of sport and physical activity-related
injury.
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INDEX
abdomen 90–1 appraisal; primary appraisals; secondary

acceptance, goal setting 63 appraisals
ACT (adapted acceptance-commitment Aronson, E. 120–1
therapy) 93 arousal mechanism 92
active lifestyle see physical activity arousal, motivational self-talk 106, 112
active listening skills 179–80 arousal system 89
adapted acceptance-commitment therapy ART (applied relaxation technique) 87
(ACT) 93 Arvinen-Barrow, M. 63, 124–5
adherence 28; rehabilitation profiling 137, assigned self-talk 104–5, 112–13
138, 139; see also rehabilitation adherence association techniques 146
affirmations 149 athletes: appraisal theory 7; assessment of
agility drills 137 personal and physical factors 137–42;
Albinson, C. B. 28 college 150; coping with injury 3;
American footballers 6 different responses to injury 25–6, 30;
AMIUS (applied model of imagery use in friends 158, 159; healthy lifecycle 10;
sport) 79 identity issues 150, 181–2, 189; loss of
Andersen, Mark B. 8, 11, 13, 64, 150 independence during injury 136; negative
anger 12 thoughts after injury 149; parents/family
antecedents, sport injury: anxiety 11; coping 158, 159; phases of rehabilitation 136–7;
resources 14–16; daily hassles 13; locus of profiling assessments 143; propensity to
control 11–12; major life events 13; mental injury through stress 7, 9; psychological
and emotional states 12; personality issues of rehabilitation 139; rehabilitation
10–13; prior injury history 13–14; stress contracts 64, 65, 65–6; response to stress
history 13–14 9–10; spouse/partner 158, 159; team mates
anxiety: antecedent of sport injury 11; 158, 159; understanding of injury 3; see
Freudian theory 174; management 95; also goal setting; imagery; psychological
muscular tension 88; during recovery interventions; relaxation techniques;
process 136; reframing technique 109–10, self-talk; social support; stress
111; rehabilitation profiling 137, 138, 139; athletic identity 43
relaxation techniques 87; use of imagery attachment 182
73, 75 attainment of goals 62
applied model of imagery use in sport attendance at rehabilitation sessions 48
(AMIUS) 79 attendance/participation subscale of
applied relaxation technique (ART) 87 RAdMAT 49
applied sport psychology 137 attending skills 178–9
appointment attendance 43 attitude/effort subscale of RAdMAT 49
appraisal theory 7, 26–7; see also cognitive Australia, sport-related injury rates 2
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204 Index
autogenic training 88 models 26–8, 27 Fig 3.1; rehabilitation

automatic nervous system 92 adherence 42; research on 28; skills
training and support 8; social support 191;
back pain 46, 47 stress reactivity 7; see also appraisal theory
balance: centering 90; cognitive appraisal cognitive behavioural approach 174–6
process 7; performance imagery 77; cognitive evaluation theory 105
rehabilitation profiling 136, 137, 140, 141, cognitive general imagery 77, 78, 80
145 cognitive interventions 17
barrier self-efficacy 190 cognitive relaxation 17, 87
Beck, Aaron Temkin 175 cognitive specific imagery 77, 78, 80
Beck, L. 134–5 cognitive value of self-talk 107
behavioural responses: rehabilitation commitment, goal setting 63
adherence 42; social support 119; to sport communication: between athlete and sport
injury 30 Fig 3.2, 32; see also emotional medicine professional 63, 65–6; in
responses multidisciplinary teams 162; subscale of
behavioural value of self-talk 107 RAdMAT 49
behaviour, in Freudian theory 173 competitive trait anxiety 8, 11
behaviour therapy 174–6 compliance 48
Bianco,T. 120, 124, 125, 127 conditioning 175
biological factors of injury 34 Fig 3.4 confidence, rehabilitation profiling 137, 138,
biomechanists 158, 159 139
biopsychosocial model 33–5, 34 Fig 3.4; conscious mind 173
adherence 44; complexity of sport contracts, rehabilitation 64, 65 Fig 5.2
recovery 34; holistic approach 33; coordination 137, 140, 141, 145
limitations of 35; outcomes 35; coping resources 8; cognitive appraisal and
rehabilitation outcomes 42–3, 43; research 28; dramatised 74; low/high stress levels
on 34–5; variables of model 33 15; research on 15; skills 191; social
blood flow 96 support 15; stressors 86
blood pressure 87 coping strategies: association and disassociation
body mass index 186 techniques 146; self-talk and 107
bones, mending 147 Council of Europe 2
breath control techniques 87; centering counselling: case study 183–4; cognitive
89–90; diaphragmatic breathing 90–1; behavioural approach 174–6; humanistic
diaphragmatic breathing exercise 91; approach 176; integrative approach 176–8;
mindfulness 92–3; ratio breathing 91–2; primary models 172; process of working
sample centering exercise 90 181–2; psychoanalytical/psychodynamic
Brewer, B.W.: biopsychosocial model 33–5, approach 173–4; psychology 110; skills of
42–4; breath-assisted relaxation and guided practitioners 178–81, 179 Fig 12.2
imagery 95–6; cognitive appraisal model countertransference 174, 178
27; healing imagery 76; rehabilitation covert self-talk 104
adherence 42, 43 Crossman, J. 88
Bridges, D. 134–5 cryotherapy 43, 48
Burke, K. L. 127 cue words 97
burnout, sport 117 culture, differences in rehabilitation process
Butler, Richard 137 145
Cupal, D. D. 76, 95–6
Callanan, R. A. E. 125 Cutrona, C. E. 120
Carson, F. 125 cycling 187
causal attribution 190–1
CBT (cognitive behavioural therapy) 175–6 daily activities, rehabilitation profiling 137,
centering 87, 89–90 140, 141
Christakou, A. 76, 77 daily goals 59, 146, 150
Clement, D. 145 daily hassles, antecedent of sport injury 13
coaches: athletic 158, 159; strength and Deci, E. L. 105
conditioning 158, 159; see also sport deep breathing 88, 95; see also ratio breathing
medicine professionals denial, stage of grief-response model 25
cognitive appraisal: components of models 27; dentists 158, 159
goals of the recreationally active 188–9; diaphragmatic breathing 87, 90–1
individual perception of injury 26, 136; disassociation techniques 146
integrated model 30 Fig 3.2, 32 Fig 3.3; discoloration 136
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Index 205
DIY 187 gender, differences in rehabilitation process

dose-response relationships 45 145
doubt, phase of rehabilitation 151 general medicine, recovery from injury 42
Douma, I. 103–4 goal setting: assessing athletes’ needs 60;
dramatised coping 74 benefits to athletes 57–8; case study 67;
Driediger, M. 73, 78 characteristics of effective goals 61–2;
drive, motivational self-talk 106, 112 factors affecting effectiveness 62–5;
dual process model of coping with outcome goals 56; performance goals 56;
bereavement 26 process goals 56; promoting adherence
dynamic core 29, 32, 32 Fig 3.3 193; psychological interventions 46, 134;
purpose of 57; reaction to rehabilitation
education: application of imagery 81; phase 136; reaction to return to play phase
approaches to adherence 46; reaction to 137; rehabilitation profiling 143; step-by-
injury phase of rehabilitation 136; step program 65–6; in three phases of
relaxation techniques 97–8 rehabilitation 145–6; types and levels of
ego 173 58–9
Eklund, R. C. 107, 120 goals, physical activity 188–9
Ellis, Albert 175 Gould, D. 107, 134–5
emotional challenge support 121, 122, 123 Gray, A. 174
emotional disturbance 28 grief-response models: criticisms of 25; dual
emotional responses: adherence 44; cognitive process model 26; individual differences
appraisal 32, 42, 57, 189; rehabilitation 25–6; modern research 26; partial support
adherence 42; to sport injury 27, 29, 30 for 25; sequential stages of 24
Fig 3.2, 32, 73; stress-buffering model 119; Grindstaff, J. S. 31
see also behavioural responses gross motor-skill performance 106
emotional social support 121, 122, 123
emotional states, antecedent of sport injury Hackford, D. 104
12 Hall, C. 77–8
emotion-focused coping 191 Hamilton, R. A. 108
emotions: positive 107; rehabilitation profiling Hamson-Utley, J. J. 136, 137, 147, 151, 152
137, 138, 139 Handegard, L. A. 127
endorphins 94 Hanrahan, S. 93
endurance-based tasks 105–6 Hanton, S. 119
environments, adherence and relaxation 46, hardiness 136
98, 148 Hardy, C. 125
esteem support 121, 122, 123 Hardy, J. 103, 105, 106, 107, 109
estrangement, sense of 150 Hardy, L. 125
evaluation of goal setting 64 Hare, R. 78
Evans, L. 78, 125 healing: imagery 73, 74, 75–6, 76, 78, 147;
exercise: completion at home 43, 48; impact of self-talk 107; process 72, 74;
relaxation techniques for 146 rates 48; see also phases of rehabilitation
expectations, rehabilitation profiling 137, 138, health: professionals 157, 158; promotion 185;
139 public concerns about; recovery from
injury 42; rehabilitation profiling 137, 140,
family and friends, social support 123–4 141
Finland: mental skills used in rehabilitation healthcare professions 33
process 145; sport-related injury 2–3 heart rate 87
Flemming, S. 125 Heil, J. 95, 118
Flint, F. A. 61, 63, 87 helplessness 192
focus, rehabilitation profiling 137, 138, 139 Hill, K. L. 110
footballers 6 holistic approach: biopsychosocial model 33;
Forwell, L. 77–8 integration of psychology 165, 182;
Francis, S. R. 64 multidisciplinary approach 161–2; phases of
Freud, Sigmund 173–4 rehabilitation 136–7, 151; physical and
functional self-talk 108, 110, 111–12; see also psychological aspects of injuries 156; to
negative self-talk; positive self-talk recovery 4, 23; to rehabilitation 44; support
function, physical factor of rehabilitation network 164; theoretical models 24
profiling 137, 140, 141 humanistic approach 176
gardening 187 identity: loss of 150, 181–2, 189;
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206 Index
rehabilitation profiling 137, 138, 139 lungs 90

Ievleva, L. 106, 134
imagery: ability 80; application to sport injury MacDougall, M. P. 108
rehabilitation 72; athletes’ use of 71; magnification 192
benefits to athletes 72–3; definition 72; Mahoney, J. 93
exercises 147; functions of 77–8; healing main effect model, social support 119–20,
73, 74, 75–6, 76, 78, 147; pain 120 Fig 9.2
management 74; performance 75; process major life events, antecedent of sport injury
of 78–82; promoting adherence 193; 13
psychological interventions 134; Maley, B. 64
rehabilitation process 74–5; review of Martin, K. A. 80
literature 75–7; skills 81; step-by-step mastery, motivational self-talk 106, 112
programmes 81–2; theoretical approaches material assistance support 121, 122, 123
79–80; in three phases of rehabilitation measurable goals 61; see also daily goals
146–7; types of 73–5, 80; underutilisation measurement: of rehabilitation adherence 48;
during rehabilitation 71–2 of relaxation effectiveness 98
immediacy skills 180–1 medical conditions, rehabilitation adherence
immobility 136 46
individual differences, athletes’ response to medication 32
injury 25–6, 30 Fig 3.2 meditation 87, 92
informational social support 121, 123, 125 medium-term goals 59
instructional general self-talk 106 mental imagery see imagery
instructional self-talk 105–6 mental relaxation 87
integrated model 29–33, 30 Fig 3.2; appraisals mental states, antecedent of sport injury 12
31; dynamic core 29, 32, 32 Fig 3.3; pre- mindfulness 88, 92–3
injury factors 29 Mitchell, I. D. 119
integrative approach 176–8; integrated mobility 136, 150
theoretical and applied model 177 Fig monitoring systems 6; of goal setting 64
12.1 Monsma, E. 77
intermediate biopsychological outcomes of mood 12, 108
injury 34 Fig 3.4 Morrey, M.A. 119, 150
intervention efficacy beliefs 113 Morris,T. 72
motivation: in reaction to rehabilitation phase
Jackson, S. A. 107 136, 146; rehabilitation profiling 137, 138,
Jacobson, E. 88 139; social support groups 126; see also
jogging/running 187 goal setting
Johnson, U. 64 motivational imagery 78; general arousal 77,
joint restoration process 77 80; general mastery 77, 78, 80; specific 77,
Jones, M.V. 110 80
Joyner, A. B. 127 motivational self-talk 105–6, 107
motivational social support 121, 123
Kafry, D. 120–1 Mullen, R. 78
Kazakas, P. 103–4 multidisciplinary approach: benefits of 161–2;
Kelly, G. A. 137 case study 167–8; interaction between
Kelly, George 175 members 159–60; possible problems of
knee strength 75, 95–6 166–7; primary and secondary
knowledge, quest for 32 rehabilitation teams 157–9, 158 Fig 11.1;
Kolt, G. S. 125–6 process of setting up a team 160–1;
Kübler-Ross grief-response model 24, 25, 26 promotion of 163–6; variety of sport
Kyllo, L. B. 104 medicine professionals 156
muscle: repair 147; tension 95, 148
Landers, D. M. 104 muscular endurance 77
Latham, G. P. 56, 61 musculoskeletal system 94; injury 185
Latuda, L. M. 81
Lavallee, D. 77 Naoi, A. 94, 108
lifestyle goals 59 National Collegiate Athletic Association 45
listening support 122, 123 Natsis, P. 103–4
Locke, E. A. 56, 61 Naylor, A. H. 151
locus of control 11–12 negative affective response 189
long-term goals 59, 78 negative personality traits 10–11
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Index 207
negative self-talk 105, 108, 111; see also phases of rehabilitation: goal setting 145–6;
functional self-talk; positive self-talk imagery 146–7; incorporating social
Neil, R. 119 support 150–1; positive self-talk 149;
networks, for social support 126, 127 reaction to injury 136, 145–6, 147, 148,
neuromuscular network 88 149, 150, 152; reaction to rehabilitation
nonadherence, rehabilitation 44–5 136, 146, 147, 148, 149, 150, 152; reaction
to return to play 137, 146, 147, 148–9,
observing skills 179 149, 151, 152; relaxation techniques
Oikawa, M. 113 147–8; social support 121
Oliver, E. 106 phenomenology 31
one-to-one interventions 126 physical activity: case study 194; causal
Orlick,T. 106, 134 attributions 190–1; consequences of injury
Ost, L. G. 89 187–8; goals 188–9; identity 189; intensity
Ostrow, A. 94, 108 of 185; pain perception 192; prevalence of
outcome goals 56; use of imagery 79, 80 injury 186–7, 187 Tab 13.1; psychological
overt self-talk 104 interventions 192–3; self-efficacy 189–90;
oxygen consumption 87 social support 191–2; strategies for
promoting adherence 192–3
pain: acknowledgement 74; perception 192; physical goals 59
rehabilitation profiling 137, 140, 141 physical recovery outcomes 32
pain management: goal setting 58, 146; physical rehabilitation 75
imagery 73, 74, 76, 78, 147; positive self- physical relaxation 87
talk 149; reaction to injury phase of physiologists, sport/exercise 158, 159
rehabilitation 136; relaxation techniques physiotherapy: healing imagery 76; integrated
87, 94, 148 approach to psychology 4; psychology
pain tolerance, rehabilitation profiling 137, training programmes 23, 35
138, 139 Pines, A. M. 120–1
paraphrasing 180 pleasant imagining 74
parasympathetic nervous system 89, 92 PMR (progressive muscular relaxation) 87,
patients, self-reporting on adherence 49 88–9, 95
Pavlov, Ivan 174–5 podiatrists 158, 159
Payne, S. 95 Polman, C. J. 125
peer modelling 125–6 Porter, K. 113
perceived and received social support 127 positive reactions to sport injury 25–6; use of
perception, factors impacting the imagery 73
rehabilitation process 138, 139, 140 positive self-talk 105, 108; comparison to
perceptions, appraisal theory 7 negative self-talk 108; impact on recovery
performance: enhancement groups 126; gains time 106–7; positive emotions 107;
75; goals 56, 59; impact of self-talk 105; promoting adherence 193; psychological
outcomes 93 interventions 134; reaction to return to
performance imagery 74, 75, 76–7, 78; play phase 137; in three phases of
reaction to return to play phase 137 rehabilitation 149; see also functional self-
performance profiling see rehabilitation talk; negative self-talk
profiling practice 81
peripheral narrowing 9 practitioner ratings 43
persistence 149 precision-based tasks 105, 106
personal assistance support 121, 122, 123 pre-conscious mind 173
personal construct psychology 175 prediction, injury 7, 8; see also antecedents,
personal construct theory 137 sport injury
personal control, promoting adherence 193 predictors of adherence to sport injury 46
personal factors, psychological response to pre-injury levels: failure to recover to 3;
injury 27, 30 Fig 3.2, 31 motivation of sport injury rehabilitation
personality: antecedent of sport injury 10–13; 41; use of imagery 73, 147
anxiety 11; case study 12; characteristics prevention, injury 8
related to stress injury 11; Freudian theory primary appraisals 7, 26–7
173; locus of control 11–12; mental and primary rehabilitation teams 157–9, 159–60,
emotional states 12; research on 12–13; 162; initial stages of athletes’ injuries 158
stress and injury model 8; variables that prior injury history, antecedent of sport
influence stress reactivity 11 history 13–14
Petrie,T. A. 28 probing skills 180
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208 Index
problem-focused coping 191 relaxation techniques 148–9; social support

process goals 56, 61 151
professionals see sport medicine professionals realistic goals 63
profiling 60, 66; see also rehabilitation received and perceived social support 127
profiling recovery: biopsychosocial model 34; goals 59,
programmes for goal setting 65–6 78; integrated model and 29, 30 Fig 3.2;
progressive muscular relaxation (PMR) 87, outcomes 31–2; physical 32; psychosocial
88–9, 95 32; roadblocks 137
psyche 173 recovery self-efficacy 190
psychiatrists 158, 159 recreational physical activity see physical
psychoanalysis 173–4 activity
psychoanalytical/psychodynamic approach Rees,T. 117, 118, 119, 127
173–4 referral approach 162, 166
psychological distress 43 reflective skills 180
psychological factors of sport injury 43 reframing technique 107, 109–10, 111 Tab
psychological goals 59, 66 8.2, 112–13
psychological interventions: approaches 17; rehabilitation adherence: as behavioural
benefits 3, 134; case study 152–3; response 43; biopsychosocial model 42–4;
combining multiple techniques into single case study 49–50; definition of 41–2;
treatments 47; goal setting 64, 145–6; education and 46; factors associated with
growth in popularity of 134; imagery 46; impact of nonadherence 44–5;
146–7; incorporating psychological skills improvement through psychological
into phases of rehabilitation 145–51; lack interventions 40–1; measurement of
of knowledge by professionals 4; most 48–50; mediator of the biopsychosocial
popular 3–4; positive effects of 18; positive factors-rehabilitation outcome relationship
self-talk 149; rehabilitation adherence 46; 44; monitoring 45; outcomes 43; personal
relaxation techniques 147–8; responsibility characteristics that facilitate 46; positive
for programme delivery 17; social support effects of goal setting 58; psychological
150–1; three phases of rehabilitation interventions 46–7; rehabilitation
136–7, 152; timing of programmes 17; schematic 42; schematic representation of
underuse 4 relationships 42–4, 43 Fig 4.1; sport
psychological responses to injury: medicine professionals 47–8; suboptimal
biopsychosocial models 33–5; case study rates of 40; time-limited behaviours 41
36; cognitive appraisal models 26–8; grief- rehabilitation process imagery 73–4, 74–5, 76
response models 24–6; importance of rehabilitation profiling 60, 66, 135; adherence
understanding 23–4; integrated model 137, 138, 139; anxiety 137, 138, 139;
29–33, 30 Fig 3.2 assessments 144–5; benefits of 138–42;
psychologists, clinical/cancelling 158, 159 changes across three phases of
psychosexual development 173 Tab 12.1, rehabilitation 142 Fig 10.3; personal
173–4 profile 137, 138 Fig 10.1, 139 Tab 10.1;
psychosocial recovery outcomes 32 physical profile 137–8, 140 Fig 10.2, 141
Tab 10.2; ratings 143
RAdMAT (rehabilitation adherence measure Reimann, B. 127
for athletic training) 49–50 re-injury: cognitive appraisal 28; fear of 192;
RAI (re-injury anxiety inventory) 108 reaction to return to play phase 137
range of motion 137, 140, 141 re-injury anxiety inventory (RAI) 108
ratio breathing 87, 91–2 re-injury anxiety related to rehabilitation
rational emotive behaviour therapy 175 (RAI-R) 108
reaction to injury, phase of rehabilitation 136, re-injury anxiety related to returning to
152; goal setting 145–6; imagery 147; training/competition (RAI-RE) 108
positive self-talk 149; relaxation techniques relaxation techniques: advice for sport
148; social support 150 medicine professionals 97–9; alleviating
reaction to rehabilitation, phase of stress and anxiety 95–6; case study 99;
rehabilitation 136, 152; goal setting 146; centering 89–90; dealing with pain 94;
imagery 147; positive self-talk 149; diaphragmatic breathing 90–1;
relaxation techniques 148; social support enhancement of healing, focus, self-
150 confidence and personal control 96; joint
reaction to return to play, phase of restoration process 77; literature on 93–6;
rehabilitation 137, 152; goal setting 146; measurement of 98; mindfulness 92–3;
imagery 147; positive self-talk 149; pairing with psychological techniques 97;
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Index 209
phases of rehabilitation 98–9, 148–9; sleep, rehabilitation profiling 137, 140, 141
physical relaxation 148; programme Smith, A. M. 119, 150
structure 98; progressive muscular social/contextual factors of injury 34 Fig 3.4
relaxation (PMR) 88–9; psychological social support: alleviation of stress 117; case
interventions 134; purpose of 87; ratio study 128–9; characteristics of support
breathing 91–2 provider 126–7; as coping resource 117,
resilience 136 118; definition and purpose 118; family
responses, behavioural and emotional see and friends 123; high and low 15;
behavioural responses; emotional responses mechanisms of 118–20; perceived and
response to injury see psychological responses received support 127; physical activity
to injury 191–2; process of 125–6; promoting
restating 180 adherence 193; psychological factors of
rewards 188 sport injury 43; rehabilitation profiling
rheumatoid arthritis 47 137, 138, 139; sources of 121–5; sport
Richardson, P.A. 81 medicine team members 124–5; sport
Richman, J. M. 125 team members 124; in three phases of
Rogers, Carl 176 rehabilitation 150–1; types of 120–1, 122
Rosenfeld, L. B. 125 Tab 9.1, 123 Fig 9.3
Ross, J. R. 31 sociodemographic factors of injury 33, 34 Fig
rugby 76 3.4
rumination 192 sociograms 160, 161 Fig 11.2
Russell, D.W. 120 somatic relaxation 17, 87
Ryan, R. M. 105 Sordoni, C. 77–8
specific goals 61; see also daily goals
scar tissue 137 sport, definition 2
Schwenkmezger, P. 104 sport medicine professionals 4; advice about
Scott, D. 108 relaxation techniques 97–9; application of
secondary appraisals 7, 27 goal setting 62–3; benefits of rehabilitation
secondary gains to injury 26 profile system 138–42; communication
secondary rehabilitation teams 158–9, with athletes 45; consideration of
159–60, 160–1, 162 antecedents to adherence 44; coping
self-actualisation 176 resources of athletes 15–16; delivery of
self-awareness 137 psychological intervention programmes 17;
self-confidence 78, 137 design of rehabilitation regimens 47, 48;
self-determined self-talk 104–5, 112–13 discussion of profiling ratings with athlete
self-efficacy 78, 143, 189–90 143; education of athletes 10; facilitation of
self-identity, promoting adherence 193 multidisciplinary approaches 163–6;
self-motivation 43 functional self-talk 112, 112 Tab 8.3;
self-statements 104 guidelines for application of imagery 82;
self-talk: affective 107; assigned 104–5, incorporating psychology into
112–13; awareness of patterns 111–12; case rehabilitation 165; information on
study 114–15; concept 103–4; instructional appropriate dosage of adherence 45;
and motivational 105–6; interpretation of intervention efficacy beliefs 113;
content 108; intervention efficacy beliefs introducing imagery to rehabilitation
113; negative and positive 105; programmes 79, 80; measurement of
overt/covert 104; positive 47; reaction to adherence 48–50; monitoring of athletes
rehabilitation phase 136; reframing 13, 14; phases of rehabilitation 135; PMR
technique 109–10; research on 106–8; self- technique 88; positive influence of
determined 104–5, 112–13; self-statements adherence 47; productive optimism for
104; thought stopping 109 athletes 151; profiling assessments 143;
Shaffer, S.M. 119, 150 programme for recovery 137; psychological
shared social reality support 121, 122, 123 interventions 135; psychological support
short-term goals 64; see also daily goals for athletes 163, 182; raising athletes’
silences 179–80 awareness of self-talk patterns 112–13;
SIRAS (sport injury rehabilitation adherence reframing technique 109–10; rehabilitation
scale) 49, 50 contracts 64, 65; rehabilitation services 150;
situation factors, psychological response to responsibility for athletes’ physical and
injury 27, 30 Fig 3.2, 31 mental readiness 151, 152; setting goals 144
skills-specific self-talk, instructional 106, 112 Fig 10.4; short-term goals 64; social
Skinner, Burrhus Frederic 175 support to athletes 124–5; stages of grief-
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210 Index
response model 25; step-by-step imagery team mates 150, 158, 159
programmes 81; understanding of technical appreciation support 121, 122, 123
psychology of sports injury 23, 24; use of technical assistance support 123
cognitive appraisal model 28; see also technical challenge support 121, 122, 123
coaches; counselling; multidisciplinary technical social support 121, 123
approach; psychological responses to injury Theodorakis,Y. 103–4
sport medicine team members, social support therapists, physical/sport/massage 158, 159
124–5 Thoits, P. A. 118
sport nutritionists 158, 159 Thorndike, Edward 175
sport psychologists 158, 159, 183 thought stopping 109
sports participation, rehabilitation profiling tissue damage 136
137, 140, 141 Tod, D. 105, 106
sport team members, social support 124 trainers see sport medicine professionals
stability 137, 140, 141, 145 transcendental meditation 88
stage goals 59 transference 174, 178
stage models see grief-response models
strength: phases of rehabilitation 136, 137; Uchino, B.N. 191
rehabilitation profiling 137, 140, 141 Udry, E. 134–5
strength-based tasks 105–6 unconscious mind 173, 174
stress: alleviation through imagery 73, 75; understanding, rehabilitation profiling 137,
history 8; and injury see stress and injury 138, 139
model; journals 14; monitoring 13, 14; United Kingdom: mental skills used in
muscular tension 88; relationship to injury rehabilitation process 145; sport-related
6; relaxation techniques 87; response 8, injury rates 2
9–10; sport involvement 2 United States: mental skills used in
stress and injury model: amalgamated version rehabilitation process 145; sport-related
8 Fig 2.1; antecedents of sport injury injury rates 2
10–16; appraisal theory 7; framework 8–9;
psychological intervention strategies 7–8; verbalisations 104
stress response 8, 9–10 Vergeer, I. 76
stress appraisal process 191 volleyball players 6
stress-buffering model, social support 119,
119 Fig 9.1, 120 Wadey, R. 119
stress history: case study 14; daily hassles 13; Walker, N. 28, 31, 32
major life events 13; prior injury history walking 187
13–14; research on 14 Walsh, M. 73–4, 75, 148
stress inoculation training 17 Watson, John B. 175
stress management, cognitive behavioural Watt, A. P. 72
approach 8 weight training 187
stress reactivity see stress and injury model 7, Weinberg, R. 103–4
9 wellbeing 92
summarising 180 Wiese-Bjornstal, D. M.: coping strategies 191;
swelling: phases of rehabilitation 136, 147, integrated stress-process model 29, 30 Fig
152; rehabilitation profiling 137, 140, 141 3.2, 32–3, 119, 186; physical activity 188;
sympathetic nervous system 87, 89 self-identity 189; social support 150
Williams, Jean M. 8, 11, 13, 150
tangible social support 121, 123 worry 73; rehabilitation profiling 137, 138,
task self-efficacy 189–90 139
Taylor, J.: goal setting 59, 60, 65; guidelines Wrisberg, C. A. 31
for application of imagery 82; healing
imagery 74; integrating imagery into yoga 87
injury rehabilitation 81; rehabilitation
profiling 137–42 Zervas,Y. 76, 77
Taylor, S.: goal setting 59, 60, 65; guidelines
for application of imagery 82; healing
imagery 74; integrating imagery into
injury rehabilitation 81; rehabilitation
profiling 137–42
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THE PSYCHOLOGY OF SPORT INJURY

Athletes routinely use psychological interventions for performance enhancement

Monna Arvinen-Barrow is a British Psychological Society chartered psycholo-

Edited by Monna Arvinen-Barrow and

First published 2013

Simultaneously published in the USA and Canada

Routledge is an imprint of the Taylor and Francis Group, an informa business

© 2013 Monna Arvinen-Barrow and Natalie Walker

Trademark notice: Product or corporate names may be trademarks or registered

British Library Cataloguing in Publication Data

Library of Congress Cataloging in Publication Data

ISBN: 978-0-415-69495-7 (hbk)

Figures and tables ix

1 Introduction to the psychology of sport injuries 2

2 Psychological antecedents to sport injury 6

3 Psychological responses to injury: a review and critique of

4 Psychological aspects of rehabilitation adherence 40

5 Goal setting in sport injury rehabilitation 56

6 Imagery in sport injury rehabilitation 71

7 Relaxation techniques in sport injury rehabilitation 86

8 Self-talk in sport injury rehabilitation 103

9 Social support in sport injury rehabilitation 117

10 Integrating the psychological and physiological aspects of sport

11 Sport medicine team influences in psychological rehabilitation:

12 Using a psychological model and counselling skills in sport injury

13 Psychology of physical activity-related injuries 185

14 Conclusions and future directions 199

FIGURES AND TABLES

10.4 Rehabilitation goal sheet 144

Renee N. Appaneal is an Associate Professor in Kinesiology at the University of

Monna Arvinen-Barrow is an Assistant Professor at University of Wisconsin-

Britton W. Brewer is a Professor of Psychology at Springfield College in

Damien Clement is an Assistant Professor at West Virginia University’s College of

Megan D. Granquist is an Assistant Professor of Movement and Sports Science at

Stephanie Habif is a Lecturer at the Hasso Plattner Institute of Design at Stanford

J. Jordan Hamson-Utley is an Assistant Professor and director of athletic training

Elaine A. Hargreaves is a Senior Lecturer in Exercise and Sport Psychology at the

Brian Hemmings is a Consultant Sport Psychologist and a Visiting Researcher at

Care Professions Council Registered Sport and Exercise Psychologist working

Jonathan Katz is a Consultant Psychologist working full time in private practice.

Cindra S. Kamphoff is an Associate Professor in Sport and Exercise Psychology at

Stephen Pack is a Senior Lecturer in Sport and Exercise Psychology at the

Jeffrey Thomae is an instructor in the Department of Human Performance at

Natalie Walker is a Senior Lecturer in Sport and Exercise Psychology at the

Monna Arvinen-Barrow and Natalie Walker

The sport injury experience from an athlete’s perspective is as diverse as the

Monna Arvinen-Barrow and Natalie Walker

athletes involved in association football, ice hockey, basketball, cross-country skiing,

Renee N. Appaneal and Stephanie Habif

psychosocial factors and sport injury outcomes among competitive athletes

The stress and injury model

sport injury from occurring.The intervention strategies reflect a cognitive behav-

Personality Stress history Coping resources

FIGURE 2.1 An amalgamated version of the stress and injury model