Whether its recreational or professional, injury is a common occurrence at all levels of sport and exercise. Evidence has shown that physical factors such as over-training, equipment and playing conditions are the major contributors towards an athlete’s injuries. However, there are many other psychological factors that play a huge role in the gaining, prevention and rehabilitation of injuries. Factors that predict and moderate injury including personality (i.e. mental toughness, internal locus of control, trait anxiety etc.), history of stressors (i.e. life stress, previous injury), and coping resources (i.e. coping behaviours, social support, stress management, attentional strategy, medication).
Wiese-Bjornstal, Smith, Shaffer, & Morrey (1998) developed the integrated model of psychological response to injury and rehabilitation which comprise three main components: cognitive appraisal, emotional response, and behavioural response. These three components a underpinned by personal (i.e. injury components, individual difference in psychology, demographic and physical) and situational factors (i.e. Sport, social and environment) but initial impact the cognitive appraisal of an injury. Adherence to rehabilitation for full recovery from an injury predominantly follows the path of the Black arrows, whereas non-adherence is follows the path of the Red arrows:
Previous research has shown that cognitive appraisals such as self-worth, self-esteem and self-confidence have been found to decrease following an injury, but increase during and following a rehabilitation intervention.
Emotional responses to injuries can be monitored using the Profile of Mood States (POMS) and other related inventories such as the Brunel Mood Scale (BRUMS), the Sport Emotion Questionnaire (SEQ) or the Individual Zones of Optimal Functioning (IZOF). Studies have previously shown that although negative mood states generally decrease across a successful rehabilitation period, the improvements are not necessarily steady and predictable. Furthermore, emotional coping strategies such as avoidance, denial, impaired autonomy, support dissatisfaction and inhibition lead to higher levels of negative emotions. Mankad, Gordon & Wallman (2009) found that the simple intervention of logging emotional thoughts and feelings that have been experienced can reduce mood disturbances.
The first and second factors lead to appropriate behavioural response such as adherence to rehabilitation, coping, social support, interventions, pain management and return to competition.
Adherence to rehabilitation programs
Plenty of research has proven that adhering to a injury rehabilitation program is a hugely important aspect of recovery. Brewer (1998) outlined typical behaviours that are associated with adherence including:
- Instruction to restrict physical activity and medical prescription compliance
- Home rehabilitation exercises, cryotherapy and icing schedule completion
- Regular and keen involvement in clinic-based rehabilitation programs
Successful adherence to a rehabilitation program can be measured using the Sports Injury Rehabilitation Adherence Scale (SIRAS) and the Sports Injury Rehabilitation Beliefs Scale (SIRBS).
The are several predictors to adherence to rehabilitation include personal factors such as self-motivation, self-assurance, assertiveness, independence and goal perspective. The most poignant personal factor that influences the behavioural response to athletic injury is athletic identity which can be measured using the Athletic Identity Measurement Scale (AIMS). Research by Brew et al. (2010) showed that athletic identity decreased dramatically from pre- and post-anterior cruciate ligament surgery and in those who struggled with their rehabilitation program. The former was suggested to be a self-protecting mechanism to curb the individuals athletic identity.
Additionally, an individual’s coping ability, social support availability, and cognitive behavioural interventions are shown to be effective in an athletes adherence to rehabilitation programs. Interventions such as guided imagery (i.e. mental rehearsal), relaxation, goal setting and biofeedback can be used to improve emotion regulation and reduce the emotional trauma that accompanies injury.
Personality characteristics, especially an individuals ability to tolerate and manage pain, is a rather overt characteristic that effects adherence. An individual with a low pain tolerance will find it difficult to remain upbeat and adhere to a rehabilitation program. However, Pain can be categorised into many forms such as performance, injury, acute, chronic, benign or harmful and is largely a subjective experience. The Sport Inventory for Pain (SIP) measures five aspects of the perception of pain including:
- Direct action coping strategies
- Mental coping strategies
- Catastrophising and despair
- Avoidance coping strategies
- Somatic stimuli sensitivity
Pain reducing strategies used in rehabilitation today include techniques of deep, controlled breathing, relaxation and meditation. More recently, research has shown that music with a low tempo reduces perceived intensity and unpleasantness of pain experienced. Other strategies can include refocusing attention away from an acute pain due to injury towards an external stimuli. When chronic pain is present, focusing internally can heighten bodily awareness and an individuals perceived control over pain.
Situational factors such as a mastery-orientated climate, belief in the efficacy of treatment, comfortable clinical environment, convenience, exertion of exercises and social support are associated with adherence to rehabilitation. It is therefore crucial to provide a rehabilitation environment that takes advantage of all these factors for optimal rehabilitation progress.
At the end of the day, the ultimate goal of all athletes rehabilitation program is to return to competitive action. With the variability of injury, the rehabilitation process can be anything between a week to a year in the making. It is not uncommon to find an injured athlete that enters the final step of rehabilitation with a degree of worry and trepidation. These negative associations with a return to competition can be attributed to the fear of re-injury or believing their not strong enough to return. A review by Podlog and Eklund (2007) suggested that athletes with high competence, autonomy and relatedness tend to be have higher intrinsic motivation towards rehabilitation goals. In addition, athletes who were successful in returning to full competition recognised both the positives and negatives of injury to cope and overcome adversity which resulted in higher motivation to return to competition.
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About Jack Marlow
Sport Psychologist in training working in a range of sports including county cricket, AASE rugby, athletics, golf and shooting. Keen rugby player and golf enthusiast.