Approximately seventeen million sport injuries yearly among American athletes (11). The process of rehabilitation begins immediately after injury and an athletic trainer and/or physical therapist has the responsibility of creating and implementing the rehabilitation program for the injured athlete. A solid understanding and competence in providing correct and appropriate care when injury occurs is critical because as William Prentice states, "the approach to rehabilitation in a sports medicine environment is considerably different than in most other rehabilitation settings," (10). An aggressive approach to the rehabilitation of athletes is demanded by the competitive nature of athletics (10). A competitive season in most sports is relatively short and the athlete cannot passively wait for the injury to heal because usually their goal is to return to activity as soon as possible, (10).
Recently, the role of psychological intervention in sports performance has emerged as important to the sports medicine team for injury management and rehabilitation. Researchers and practitioners have recognized that psychological variables play a critical role in the onset and recovery from injury. Therefore, "understanding and incorporating psychological principles can make a difference in rehabilitation. Effective injury management requires an understanding of the psychological processes involved and the knowledge of strategies that affect healing, " (4). A recent study by Ahern and Lohr et. al. (1), shows that almost ninety percent of athletic trainers reported it "relatively important" or "very important" to treat the psychosocial aspect of an athletic injury. The mind and body work together, therefore, "an appreciation of mind-body interactions and how they function regarding stress, sports performance, and injury is fundamental to the acceptance of psychological techniques in the medical arena," (1). These fundamental issues regarding mind-body interaction are essential to those in both sports and medicine.
In the past, psychological aspects of injury and athletic rehabilitation have often been overlooked. Health care professionals typically focused on the physical state of the athlete (2). However, as Ahern and Lohr say, "psychosocial factors are increasingly becoming recognized as significant factors in sports…rehabilitation" (1). A psychological aspect for injury exists and the psychologic state of an injured athlete is equally important, if not more important than the physical state. Effective rehabilitation of an injured athlete warrants a holistic approach, providing total care to the athlete, both physically and mentally. In numerous sports, both athletes and coaches commonly believe the mind is equally important to overall sport performance as physical abilities and talent. In fact, for the athlete, the mental game often provides the competitive edge necessary for winning (1). The significance of an athlete's mentality to sport performance may be paralleled with the crucial role of psychologic factors in the recovery from an injury. In fact, Grove et. Al. indicated that psychological factors are critical to injury rehabilitation and recovery and to the ultimate rehabilitation outcome (9).
An athlete's reaction to injury is dependent upon numerous factors. In general, injury is viewed as a negative experience to be avoided at all costs. Some athletes may be completely traumatized or devastated while others may see injury as an opportunity to show courage or assume a respected role as "the hero" by trying to play through the pain (11). On the other hand, some athletes may even enjoy the injury because it provides them with an escape from embarrassment over poor physical performance (10).
After sustaining an injury, an athlete will experience changes in their athletic status, as well as in their lifestyle and daily routine. For example, Crace and Hardy explain, "injury may force athletes to accept a new definition of their abilities, redefine their role on the team, withdraw from or change one's level of involvement and redirect future career opportunities both within and outside of sport," (11).
Following and injury, an athlete may not be able to compete at their normal level of play, if they can compete at all. Additionally, an injury has the potential to limit an athlete's contact with their teammates and coaches and exclude them from team events or activities. Furthermore, training for a sport may involve the entire day apart from eating, sleeping, and going to school or work. Few high performances athletes have free time. As a result, after an injury, athletes must learn to manage their time and energy when they can no longer train as long, or as hard (if at all) as usual (4). With this sudden change in daily activities, physical exertion, and social interactions, the athlete may experience severe psychological imbalance (3). Chan and Grossman assessed the moods of injured runners to determine what happens when a running routine is interrupted as a consequence of injury. They found injured runners prevented from running for at least two weeks had significantly more tension, depression, and confusion compared to a normative sample of non-injured long distance runners. As a change in a daily routine would affect most people, Chan and Grossman's findings are consistent with earlier work on runners showing that fitness fanatics, once injured, had more depression than their non-athletic counterparts (12). A runner may experience more depression when they are injured and unable to run than someone who does not run or is non-athletic because a runner has made running a part of their daily routine/lifestyle and has invested part of their identity to running. To further illustrate this point, a leg injury may be extremely devastating to a runner who is no longer able to run, however it would most likely not be as devastating to a pianist who would still be able to play the piano. On the other hand, a hand injury may be extremely devastating to a pianist, whereas it most likely would not be as crushing to a runner who would still be able to run.
In general, a more traumatic response to injury will be demonstrated by a more severely injured athlete or an athlete who has strongly invested their identity in being an athlete (3). In other words, injury may pose a more significant threat to an athlete whose identity is solely based on athletics and athletic achievement. An injury may not be as devastating to a person who leisurely competes in athletics or someone who considers being an athlete as only part of their identity.
According to numerous sources, an athlete's emotional response and reaction to injury may be influenced by their injury history. Botterill et. al. (3) states that an athlete experiencing their first major injury, as opposed to an athlete who has previously experienced one or more injuries, has little understanding of what the future holds and suggests the athlete may feel lost and alone in unfamiliar territory. A study performed by Johnson found that athletes severely injured for the first time showed more signs of psychosocial risk and experienced their injury situation as being more threatening and anxiety inducing than those athletes who had been injured previously, particularly than those who had been injured at least three times (8). The initial experience of injury may result in feelings of helplessness and frustration and a fear of the unknown. Some unknown factors include a knowledge of the healing process, how much pain there will be, what rehabilitation involves, whether the athlete can return to preinjury skill levels, and fear of disfigurement (3).
The athlete's injury history can be a psychosocial risk factor in rehabilitation, and is influential in the individual's assessment of their ability to manage injuries successfully (12). Shaffer et. al. examined the relationship between perceived efficacy, or producing desired rehabilitation results with minimal expense, and cognitive appraisal, which is an estimation or judgment of the value or quality of their rehabilitation. Individuals with Grade II ankle sprains, who had previously successfully rehabilitated an ankle injury, a learned behavior, had greater perceived self-efficacy during the first week of rehabilitation than individuals who had not been injured before (8).
Literature sources compare the psychological reactions of injured athletes to the reactions of someone who has lost a loved one. Kubler-Ross, in the classic study On Death and Dying (1969), described the progression of reactions to death as denial, anger, bargaining, depression, and acceptance, (3). Rotella and Heyman equate these reactions to the progression of responses elicited by injury. They describe the progression as a downplaying of the reality of the injury, followed by the expression of anger toward the perceived cause of the injury, followed be a psychological surrender due to perceived loss of control, followed finally by an acceptance of the reality of the injury and the rehabilitation process (11).
The literature also presents substantial opposition to the parallel proposed by Rotella and Heyman. Jane Crossman (4) states the post-injury reactions of athletes are more complex and varied than originally thought. According to her article, what is certain is that an injured athlete will oscillate between a series of emotional highs and lows through the process of rehabilitation. Botterill et. al. (3) states that certain emotions and behaviors, associated with the death of a loved one appear to be fairly common among injured athletes, and also states it may intuitively seem reasonable to expect some of these same feelings in injured athletes who are suffering from the loss of their normal (and loved) athletic lifestyles and sometimes, the temporary loss of a meaningful identity. However, Botterill et. al. (3) continues, regardless of the severity of the injury, injured athletes should still consider themselves athletes and worthy human beings. In most cases, they have every intention of returning to sport once the rehabilitation process in complete. Thus, Botterill et. al. argues, it may be unreasonable to extrapolate from the death and dying literature to the realm of injured athletes.
Whatever stages an athlete goes through, numerous psychological factors can significantly influence an athlete's rehabilitation and recovery, specifically its length and success. According to Lampton et. al. (9), the progress of rehabilitation is largely determined by the cognitive and emotional responses to the stress caused by an injury (9). Johnson et. al. identified psychological risk factors that are potentially detrimental to rehabilitation. These risk factors include a dependence on coping strategies that offer emotional relief, the lack of a well-functioning social network, a tendency toward negative self-talk, chronic denial of injury, and a general pessimistic style. Their article reviewed previous documentation showing that injured athletes who have access to social support and help during rehabilitation tend to improve more quickly after injury. Consequently, injured athletes with a generally pessimistic attitude felt worse and required more time for rehabilitation that injured athletes with equally serious injuries without such an attitude. Johnson et. al. (8) also indicated the athletes who rehabilitated more slowly had a generally pessimistic attitude, expressed especially in the form of negative self-talk. In addition they had vague goals for the rehabilitation period and were less able to imagine themselves recovering.
Ford et. al. (5) assessed six variables as possible moderations of the relationship between life stress and injury among athletes. The Athletic Life Experience Survey was administered to measure negative life change, positive life changes, total life change and object loss by each subject. The nature of injury sustained , the total number of days the athlete was unable to complete full training or competing in a scheduled game were also recorded. The results indicated that athletes with more optimism, hardiness, or global self-esteem may cope more effectively with life change stress, resulting in reduced recovery rates. Optimism was measured by Scheier and Carver's (1985) Life Orientation Test which consists of 12 statements/responses of which eight are used. Of the eight, three were key: optimism, hardiness and global self- esteem. Athletes possessing optimism, which Ford et. al. (5) defined as "a generalized tendency to anticipate the best possible outcome," were more likely to react effectively to the added stress of injury. For example, "optimists reported fewer physical symptoms (e.g. dizziness, blurred vision, muscle soreness, fatigue) and a stronger sense of well being than pessimists, because of more adaptive coping mechanisms and a greater tendency to engage in positive health practices, " (5). Hardiness was defined as " a constellation of personality characteristics thought to function as a resistance to stress." Hardiness was measured be The Personal Views Survey (Maddi, 1987), a 50 item inventory that yields scores for three hardiness subcomponents (commitment, control, challenge). The article states that hardy individuals tend to interpret circumstances in less stressful ways because they tend to view them as desirable and controllable, an attitude which would be instrumental in significantly decreasing injury-time loss. Global self-esteem was defined as "the extent to which individuals feel negative or positive about themselves as a totality, and is strongly related to measures of psychological well-being," and was also found to be strongly associated with decreased injury-time loss. Global self esteem was measured by Rosenburg's (1979) Self Esteem Scale which asks respondents how they feel about themselves.
The athlete's adherence to his/her rehabilitation and individualized program may also be influenced by a number of psychosocial variables (12). The research of Fisher et. al. indicated the adherence or rehabilitation was positively related to the injured athlete's social support, self motivation, and pain tolerance. Duda et. al. found similar results, reporting highly motivated individuals with strong social support had better compliance to their rehabilitation program (8).
A physical therapist's communication skills plays a crucial role in the rehabilitation of an injured athlete especially because the athlete does not know what their rehabilitation will involve. According to Wiese et. al., "Effective communication skills can be the most important psychological 'bandages' health care professionals can possess." It is essential for the health care professional to provide the injured athlete with details of the extent of the rehabilitation and its procedures which will aid the patient in forming accurate expectations and assist in mentally preparing for whatever they are about to experience physically. Without the accurate and honest details of their rehabilitation, patients may develop complicating misperceptions and behaviors (3).
A common strategy used by therapists to ensure the injured athlete is receiving appropriate information about the recovery process is observational learning, or modeling. Modeling, in theory, facilitates the transmission of socialization information and cognitive skills through behavioral and verbal cues provided by the model. When a patient sees someone similar to themselves complete a new task or demonstrate a particular behavior, it shows them that they too can recreate the action(3). Botterill et. al.(3) also explained that through modeling the athlete is able to gain an understanding of the task ahead and, more importantly, what strategies can be used to overcome any obstacle in the rehabilitation process.
Goal setting is also an effective way to increase of maintain motivation during rehabilitation process (11). "Goal setting is the first step toward applying mental training skills to performance enhancement or recovery from sports injury. The importance of goal setting and striving for goals has long been recognized in sports and rehabilitation,"(1). Goal setting should involve close collaboration between the therapist and the athlete. The goals about recovery they establish should incorporate every dimension of the recovery process, both the psychological and the physical. These goals should include short-term and long-term goals, be specific and measurable, challenging but realistic, and be given a flexible timetable for completion(1,11). Each goal accomplished will bring the athlete a step further to his or her final goal of recovery.
According to Ahern et. al.(1), and information previously presented, injury to the athlete is inherently stressful, which complicates rehabilitation of the athlete. Thus, stress management techniques potentially play an important role in prevention and intervention of sports injury. Hedgpath et. al. (7) concludes that stress management techniques are necessary to help athletes effectively cope and adjust to injury, as well as to the rehabilitation process. The article explains a transactional theory comprised of four components which incorporate a person's beliefs as well as his/her appraisal of the event. The first component is increased awareness in which the athlete develops a clear understanding of the stress associated with the injury. The second component is information processing and appraisal in which the athlete develops an awareness of his/her personality and how it interacts with injured his/her appraisal of the information related to injury and rehabilitation. The appraisals assess the existing harm or loss that the stressor elicits and determine existing coping strategies that can be reduce the stress. The third component is modified behavior in which the therapist engages in an interactive process with the athlete that matches stress symptoms to specific coping strategies. The final component is a resolution which should produce peace of mind.
Positive thinking may also be beneficial for athletes as they recover from their injury. Botterill et. al. (3) states a positive outlook indicates adjustment to the new condition and an orientation towards improvement. On the other hand, a negative outlook indicates preoccupation with the implication of injury which can lead to reduced effort toward improvement (3). Examples of positive self-talk include: "How can I make the most out of what I can do now?", "I can beat this thing", and "I can do anything". Negative self-talk includes: "It's probably going to take forever to get better", "It will never be as strong again", and "Why me?" (3). Ievleva and Orlick found that injured athletes whose self-talk was more positive, self encouraging, and determined healed much more quickly than those whose self-talk was negative, self , depressatory, and unforgiving (1). Although the fact of injury or the length of rehabilitation cannot be controlled, Botterill et. al. (3) states that thinking about it can be directed and controlled. They further explain that monitoring internal dialogue can be effective in taking control, guiding positive thoughts and reducing negative thoughts. This can be accomplished in two steps: First plan to think in positive terms and second, respond to any negative thoughts that may still occur using them as cues to switch to positive self-talk and explain its beneficial implications for rehabilitation.
It is essential for health care providers, including physical therapists to gain knowledge of the psychology of injury. As previously discussed, numerous psychological factors influence an athlete, and the processes and outcomes of their rehabilitation. A knowledge of these factors will enable a therapist to treat the athlete as a whole individual and provide a quality rehabilitation program which encompasses the body as well as the mind. This holistic rehabilitation may also be provided for a non-athlete, however, what may set an athlete and their needs apart is their typically high level of motivation, strong goal orientation, good physical training habits and a built up pain tolerance associated with training and competition to a certain degree (11). After sustaining an injury an athlete may also experience "a sense of loss, a threat to their self-esteem, the high demands of sport performance that require more than a return to normal daily functioning, and pressures expectations that may exist for a quick recovery," (11). Assessing and treating the needs of an athlete both physically and mentally will potentially aid the therapist and athlete in a successful recovery.