Effectiveness of psychological intervention following sport injury

Lur M.Schw Reese ,Ryn Pittsinger,Jingzhen Yng ,*

a Department of Community and Behavioral Health,The University of Iowa,Iowa City,IA 52242,USA

b Department of Psychological and Quantitative Foundations,The University of Iowa,Iowa City,IA 52242,USA

Effectiveness of psychological intervention following sport injury

Laura M.Schwab Reesea,Ryan Pittsingerb,Jingzhen Yanga,*

aDepartment of Community and Behavioral Health,The University of Iowa,Iowa City,IA 52242,USA

bDepartment of Psychological and Quantitative Foundations,The University of Iowa,Iowa City,IA 52242,USA

With increasing attention given to the development and implementation of psychological interventions during the sport injury rehabilitationprocess, there is a need to document the effectiveness of these interventions. The purpose of this review was to summarize the empirical findingsof the effects of psychological interventions in reducing post-injury psychological consequences and improving psychological coping during theinjury rehabilitation process among competitive and recreational athletes. In February 2012, utilizing a comprehensive search strategy, weconducted electronic searches of multiple electronic databases for randomized and nonrandomized control trials that evaluated interventionstargeting populations of injured competitive and recreational athletes age 17 years and older. We included interventions that directly intervene oninjured athletes’ psychological outcomes (e.g., psychological consequences, psychological coping and re-injury anxiety) and utilized psychologicalstrategies including imagery, goal-setting, relaxation, and other common techniques during the post-injury rehabilitation period. Sixstudies, described in seven peer-reviewed published articles, met study inclusion criteria and were included in this review. Of those studies, twoincluded randomized control trials, two used before and after study designs and two were case study designs. Two interventions utilized guidedimagery and relaxation, two interventions utilized goal-setting and one each utilized microcounseling, written disclosure, and acceptance andcommitment therapy. Guided imagery/relaxation was shown to be associated with improved psychological coping and reduced re-injury anxiety.Goal setting, however, was not directly associated with the reduction of negative psychological consequences. Other psychological techniquessuch as microcounseling skills, acceptance and commitment therapy, and written disclosure have demonstrated effectiveness in reducingnegative psychological consequences, improving psychological coping, and reducing re-injury anxiety. Our findings suggest a significant need todevelop and implement well-designed intervention studies that target improvement of post-injury psychological outcomes in order to assistinjured athletes successfully recovery from sport injury.

Copyright?2012,Shanghai University of Sport.Production and hosting by Elsevier B.V.All rights reserved.

Intervention;Psychological consequence;Psychological coping;Sport injury

1.Introduction

Sport injuries frequently have profound negative consequences on the physical health of sports participants.1,2Theyalso have the potential to cause a greatdeal of psychological disturbance through increased anger,depression,anxiety, tension,fear,and decreased self-esteem.3—23Sport injuries often result in an immediate imbalance and disruption to the lives of the injured athletes including loss of health and achievement of athletic potential.24,25In extreme cases, injuries result in a permanent disability or even death.26—31Such functional loss or the inability to continue sports participation can be devastating and hinder the recovery process,and consequently affect the way athletes mentally deal with future injuries.15,23Thus,including a component that addresses psychological recovery from a sport injury in the traditional injury rehabilitation program becomes critical to preventing and/or reducing negative psychological consequences resulting from the injury and promoting return to active involvement in sport-related activities.

Increasing attention has been given to the development and implementation of psychological interventions during the sport injury rehabilitation process in recent years.32Many sportinjury rehabilitation programs are beginning to integrate psychological interventions into the treatment regimens in order to expedite both physical and psychological recovery from injury.33—41The psychological techniques commonly used with injured athletes in these interventions include relaxation,35,38mindfulness,imagery,34,35,38goalsetting,36—38and stress management.34,38—41Existing studies indicated these psychological interventions help reduce negative psychological consequences,36—40improved coping skills,36,37,39—41and reducing re-injury anxiety.35,41As a result of improved psychological well-being,injury recovery period is shortened and injured athletes frequently return to play sooner.42Despite growing interest in utilizing psychological interventions,few controlled outcome studies have been published.Empirical evidence demonstrating that psychological interventions decrease negative psychological consequences or increase psychological coping still remains limited.

Advances in medical treatments have reduced the time required for physical healing,which may result in athletes who are physically healed and ready to return to play but not yet psychologically recovered.43,44This potential discrepancy between psychological and physical recovery calls for increased attention to the recovery process for injured athletes.Understanding the role of psychological and other factors contributing to injury recovery will provide a critical foundation for the development,implementation,and evaluation of psychological interventions,which will subsequently improve the recovery process forinjured athletes.The objective of this review was to summarize the empiricalfindingson the effects of psychological interventions in reducing post-injury psychological consequences,and/or improving psychological coping during the injury rehabilitation process among competitive and recreational athletes.

2.Materials and methods

2.1.Types of studies

We included randomized control trials(RCTs),nonRCTs thatutilize a comparison group,before and after study designs, and qualitative methods.

2.2.Types of participants

We included intervention studies with targetpopulations of severely injured competitive and recreational athletes age 17 years and older.Severe injury is defined as an injury which results in at least 3 weeks away from play.45We excluded interventions among children and adolescents due to significant differences in psychological intervention strategies employed to youth and adult population related to developmental differences.

2.3.Types of interventions

We included studies that evaluated the effectiveness of psychological interventions with the aims of reducing postinjury psychological consequences(including symptoms related to depression,anxiety,and generalized psychological distress)and/or improving psychological coping(including reducing re-injury anxiety)among injured athletes.We defined psychological interventions as those that utilized psychological strategies including imagery,goal-setting,relaxation,and other common techniques that were implemented during the post-injury rehabilitation period.

We excluded studies that did not include interventions that directly intervened with injured athletes’psychological consequences or the psychological coping process.This exclusion included programs that taught athletic trainers and/ or other professionals to use psychological techniques with injured athletes but did not evaluate the effect of the intervention specific to outcomes in injured athletes.

2.4.Types of outcome measures

We included studies that reported any of the following outcome measures:

1.Reduction in psychological consequences including decreased anxiety and feelings of devastation,restlessness, and dispiritedness;

2.Increase in psychological coping including improved mood,self-efficacy,and psychological flexibility;

3.Reduction in re-injury anxiety.

2.5.Search methods ofidentification of studies

We conducted comprehensive electronic searches and searched the following electronic databases:

·Academic Search Elite

·ERIC

·Health Source:Nursing/Academic Edition

·PubMed

·PsychINFO

We searched these databases,with a restriction to English language.The initial searches were based on the following keywords:

1.Psychological recovery AND athletic injury or sports injury;

2.Psychologicalfactors AND athletic injury orsports injury;

先天性上瞼下垂和先天性心臟病在致病因素或易感因素上可能存在聯系，如胚胎期的某些致病因素同時影響了軸旁中胚層(分化形成頭部結締組織和面部肌肉)和內臟中胚層(分化形成腸系膜和心臟)的發育，導致眼瞼下垂和心血管畸形同時發生。然而，這些推測需進一步的研究證實。本課題組后續將從基因或表觀遺傳學水平，進一步探討先天性上瞼下垂合并先天性心臟病的發病基礎，以輔助產前診斷和篩查，并為這類疾病提供精準治療的基因靶點。此外，本研究為單中心的觀察性課題，入選人群具有明顯的局限性，期待通過大規模、多中心、多區域的流行病學調查來得出更準確的發病率數據。

3.Psycholog*AND sports injury rehabilitation or athletic injury rehabilitation.

A total of 991 relevant articles were identified through these search terms.We excluded articles that were published prior to the year 2000(n=311)and conducted second round searches among the remaining 680 articles using the following 10 search terms:“intervention”,“interv*”,“cognitive therapy”,“behavior*therapy”,“relaxation”,“goal-setting”,“guided imagery”,“acceptance”,“commitment”,“ACT”(acceptance and commitment therapy).A totalof 157 relevant articles remained after the second round search.We reviewed the titles andAbstracts of the 157 articles and furtherexcluded 128 studies that did not report the study population of interest or the outcome of interest.All three authors reviewed the remaining 29 articles for relevance and the agreement was reached to exclude 22 articles that did not meet the study inclusion criteria based on the type of participants,intervention,or outcome measures.Thus,the remaining seven articles that met the study inclusion criteria regarding the type of participants,intervention,and outcome measures were included(Fig.1).For the purposes of this review,two publications,which reported the findings of a single study,are treated as one study.

3.Results

3.1.Types of studies

The seven included articles published on six studies were evenly divided between three research designs(Table 1).Two studies(33%)included RCTs.35,36Evans and Hardy37included an in-depth qualitative follow-up after completion of the initial RCT.Two studies used before and after study designs.38,39Two studies were case study designs.40,41Two studies(33%)were conducted in Australia and one study (17%)in each the USA,England,Wales,and Sweden.

3.2.Types of participants

All six studies included competitive athletes as study participants and two studies also included recreational level athletes.35—37Allstudies included adult participants with one study also including 17-year-old minors.36Participants in the studies ranged from age 17 to 50.Fourstudies(66%)recruited men and women approximately evenly,while two additional studies(33%)recruited many more male participants than female participants.Three studies(50%)recruited only athletes with anterior cruciate ligament(ACL)injuries.35,40,41Three studies(50%)recruited athletes with any long-term injury.36—39Knee injuries,including ACL injuries,were the most common injury.Other injuries included in these studies were neck,shoulder,leg,and/or foot injuries.All six studies recruited participants who played a variety of sports with football(soccer)as the most common sport played,followed by basketball,rugby,skiing,and tennis.

3.3.Types ofinterventions

Three studies(50%)included multiple intervention techniques.35—38In Johnson,38participants in the intervention group received three brief psychological intervention sessions focusing on stress management,goal-setting,and relaxation/ guided imagery,respectively.Each session lasted 15—25 min. The control group received regular rehabilitation programs with no form of psychological intervention.

Evans and Hardy36,37had three intervention levels.Participants were randomly assigned to one of three groups:goalsetting intervention,socialsupportcontrol,and control group. Participants were matched according to physiotherapist,injury type,rehabilitation stage,sport,level of participation,and gender.36Participants assigned to the goal-setting intervention met with a sports psychologist for 60—105 min four to five timesovera 5-week period,in orderto setprocess and outcome goals based upon the participants’specific situations.During each session,progress toward goals was reviewed and served as the basis for the next set of goals.Participants in the social supportcontrolgroup met with a sports psychologistfourto five times over a 5-week period for 40—60 min.During each session,the sports psychologist provided social support consistentwith the type of socialsupportprovided in the goalsetting group.Participants in the controlgroup received a telephone callevery 10 days,ranging in duration from 5 to 10 min.

Fig.1.Flowchartof article selection process.#Search terms included:interv*or cognitive therapy or behavior*therapy or relaxation orgoal-setting or imagery or guided imagery or acceptance or commitmentor ACT*(acceptance and commitmenttherapy).

Table 1Characteristics and core componentof included intervention studies.

Table 1(continued)

Rock and Jones,40Mankad and Gordon,39and Mahoney and Hanrahan41each implemented a single type of intervention technique among injured athletes.Rock and Jones40conducted a series of case studies in the United Kingdom among three competitive athletes who had ACL damage but no history of surgical treatment.The participants received a microcounseling skills intervention initially 3 days after surgery,and then every otherweek thereafter.The intervention provided active listening,reflection,paraphrasing,and summarization in order to build rapport and develop an empathic,accepting,and genuine environment.

Mankad and Gordon39conducted a written disclosure intervention among injured athletes on 3 consecutive days 3 months after surgery.Participants were instructed to think aboutthe injury experience and to write for 20 min abouttheir negative injury-related thoughts,emotions,and feelings.The intervention provided injured athletes the opportunity to reflect on the injury experience and related emotions which increased the perceived sense of control.

Mahoney and Hanrahan41completed a case series in Australia with four competitive athletes who experienced ACL injuries.Following reconstructive knee surgery,participants attended weekly individual education sessions for 4 weeks. During each session,a different component of ACT was introduced including,cognitive defusion,mindfulness-based strategies,acceptance,and values clarification.Two additional components of ACT,using the self as context and committed action,were implicit during allfour sessions.

3.4.Types of outcomes

Four(66%)studies measured participants’negative psychological consequences related to injury including mood disturbance,devastation,restlessness,and feelings of being cheated.36—40Five(83%)studies measured participants’abilities to psychologically cope with injury and rehabilitation, including psychological flexibility,mood,self-efficacy, mindfulness,and perceived social support.36—41Two(33%) studies measured participants’re-injury anxiety.35,41Re-injury anxiety is defined broadly as concern aboutinjury upon return to regular physical activity.

3.5.Effects of interventions

3.5.1.Negative psychological consequences

Four reviewed studies focused on reduction of negative psychological consequences.36—40In a RCT conducted by Evans and Hardy,3677 enrolled seriously injured recreational and competitive athletes in Wales were randomly assigned to one of three groups:goal-setting intervention,social support control,and control group.Results showed that while all three groups experienced decreased dispirited feelings defined as the loss of motivation and apathy at the end of the study,no significant differences were found between the three groups for dispirited feelings.

Following completion of the RCT,three participants from each of the intervention groups and the control group(totalof nine participants),were further purposefully selected to complete a semi-structured interview lasting 50—105 min.37Results revealed all participants in all three groups experienced periods of positive emotions alternating with periods of depression and frustration.

The Evans and Hardy results36,37are consistent with findings from Johnson’s study38which showed no significant differences in feelings of stress and worry after injury between intervention and control group.However,in contrast to Evans and Hardy36,37and Johnson,38the findings from Rock and Jones40and Mankad and Gordon39included in this review support the role of psychological interventions in decreasing negative consequences associated with sport injury.The results from Rock and Jones40and Mankad and Gordon39revealed participants experienced decreased mood disturbance and fewer negative feelings and emotions related to injury following intervention.Following Rock and Jones’s40microcounseling skills intervention,setbacks in rehabilitation progress stillresulted in increases in mood disturbance butthe intervention reduced the severity of the mood disturbance. Mankad and Gordon39also found that after engaging in written disclosure,athletes reported decreased feelings of being cheated,devastated,restlessness,tension,emptiness, and difficulty accepting the injury as well as fewer exhibited avoidance behaviors.

3.5.2.Psychological coping

Five studies reported on increases to positive psychological coping including psychological flexibility,mood,self-efficacy, mindfulness,and perceived social support.36—41Johnson38conducted a RCT among 58 Swedish national competitive levelathleteswho sustained traumatic and severe sportinjuries thatrequired,on average,12.4 weeks of rehabilitation priorto returning to play.Results showed that athletes in the intervention group(n=14)reported significantly better mood scores compared with athletes in the control group(n=44), including increased feelings of pleasure,social orientation, and security.Athletes in the intervention group also reported feeling more prepared for competition at the end of rehabilitation when compared to athletes in the controlgroup.

Increased psychological coping skills following psychological intervention is consistent with the results from four other studies reviewed.36,37,39—41Social support and support seeking behaviors increased in participants who completed psychological intervention.Evans and Hardy37found participants who received a goal-setting intervention or a social support intervention had higher levels of perceived social support.Following a written disclosure intervention,confidence and general enjoyment increased39and participants reported an increased ability to accepttheirsituation and injuryrelated emotions after completing an educational ACT intervention.41However,Johnson38found no differences between the participants in the intervention and control groups with regard to positive feelings toward rehabilitation or feelings of stress/worry.

3.5.3.Re-injury anxiety

Cupal and Brewer35conducted a RCT among 30 recreation and competitive athletes in the USA who had undergone ACL reconstructive surgery,but experienced no other lower extremity trauma,and were expected to take part in rehabilitation for at least 6 months.Results showed a significant decrease in re-injury anxiety among participants who received a relaxation and guided imagery intervention compared to participants in the placebo and control groups.Participants in the intervention group also reported lower perceived pain compared to the placebo and control groups.35However,this finding was not consistent with the results of Mahoney and Hanrahan’s41investigation,which found re-injury anxiety was not altered in participants after engaging in a brief ACT educational intervention.

4.Discussion

Psychological factors are being increasingly recognized by sports medicine professionals as important during the rehabilitation process from sportinjury.46—50Using a comprehensive search strategy,this review of psychological techniques employed with injured athletes illustrates a significantlack of well-designed intervention studies targeting this population. Only six intervention studies specifically addressed the effectiveness of the psychological interventions in the context of psychological rehabilitation from sport injury.Our findings showed that psychological interventions utilizing guided imagery,goal setting,or relaxation are often associated with decreased negative psychological consequences,improved coping,and reduced re-injury anxiety.This review adds to the literature on psychological recovery from sports injury and has implications for future research and practice.

Guided imagery was used in two out of the six studies included in this review and was applied with injured athletes along with relaxation and other psychological techniques in orderto facilitate increased concentration and vividnessspecific to a given task.35,38Imagery was traditionally defined as“the process of imaging the performance of a skill with no related overtactions”.51More recently,imagery has been also defined as the creation orre-creation ofan experience thatis underthe control of the imager and may occur without the stimulus antecedents associated with the experience.52The practice of imagining or visualizing an experience without physically completing the task increases the ability to mentally prepare by imagining successful completion.53During an imagery intervention,injured athletes are asked to image a scenario directly or indirectly related to injury recovery.They may be prompted to imagine the process they will embark on during their injury rehabilitation including the different phases of rehabilitation, their progress during each of the phases,the emotionsthey may experience,as wellas the successful completion and return to full sport engagement after completing the rehabilitation process.In Johnson’s study,38injured athletes were taughthow to mentally connect their mind with the injured body part and imagine healing taking place,as wellas imagining their body functioning perfectly and performing their desired activities well.The results showed thatinjured athletes’overallmood was improved after the intervention.38

Relaxation is another cognitive strategy that has been used to reduce stress,anxiety,and mental/physical strain in the studies reviewed.By increasing the athletes’awareness of their physiological and psychological arousal level,relaxation techniques can help injured athletes regulate their levels of arousal for achieving optimal outcomes.Evidence showed that relaxation can reduce the feelings of depression,frustration, and anger through lowering heart rate,breathing rate,metabolic rate,and blood pressure.54

One useful relaxation technique often taught to athletes is engaging in deep breathing.In the Johnson38and Cupal and Brewer35studies,injured athletes were taught to take deep diaphragmatic breaths instead of breathing simply from the lungsin orderto assistin calming down and/orrefocusing their attention to the immediate experience of the here-and-now. Deep breathing could also assist in the physiological shift of lowering heart rate,blood pressure,as well as salient psychologicalfactors.55Through this refocusing,injured athletes are betterprepared to face the challenges ofa specific task instead of merely thinking about the challenges that may cause unwanted pressure and anxieties due to the injury.In Cupaland Brewer’s study,35athletes were taught to breathe deeply as a method of relaxation to help reduce anxiety and decreasing affective distress among athletes with ACL injuries.

Incorporating goal setting as a technique to reduce psychological distress during the rehabilitation process was implemented in studies conducted by Johnson38and Evans and Hardy.36,37Goal setting is believed to enhance an individual’s ability to accomplish a given task by providing individuals with a sense of direction to focus their efforts,by increasing the degree of persistence,and by furthering the development and refinement of new strategies aimed to successfully completing a task.56In the Johnson38and Evans and Hardy36,37studies,goalsetting also led to an increase in selfefficacy and/or self-confidence as a result of accomplishing a set goal during the rehabilitation process.56

Other techniques such as education ACT sessions,basic microcounseling skills and written expression have been found to be effective in mitigating the post-injury psychological distress among injured athletes.41ACTisa third-wave cognitive behavioral therapy(CBT)approach,which has received considerable attention and support in current literature for its usefulness and effectiveness in both clinicaland sportspecific settings.41,57,58ACT emphasizes the importance of increasing mindfulnessand psychologicalflexibility.57Asa result,injured athletes improve their“ability to connect with the present moment fully as a conscious human being and to change or persist in behavior when doing so serves valued ends”.41The implementation of basic microcounseling skills(attending, active listening,empathy,and reflection)by a mental health professionalhas also been shown to have the effect of enhancing the psychological well-being of injured athletes during the rehabilitation process.40Through the use of basic microcounseling skills,injured athletes are provided emotionaland listening support,which are empirically-supported key functions of the counseling process.40Similarly to engaging in verbal expression,one of the hallmark elements of“talk therapy”,written expression has also been shown to be an effective form of emotional disclosure that contributes to improving the psychologicalrehabilitation of injured athletes. Expressive writing allows injured athletes to constructwritten narratives depicting their emotional experiences as well as engage in a self-regulatory process facilitating an increased sense of control over their emotions.59

4.1.Strengths and limitations ofstudies included

While the studies included in this review demonstrate growing empirical evidence of integrating psychological techniques into the rehabilitation process following sport injury,these studies are limited by small sample size,which makes itdifficultto detectintervention effects due to a lack of statisticalpower.Furthermore,these studies often have a short follow-up time,thus the long-term effects of these interventions often are unknown.Despite these limitations,the reviewed studies demonstrated positive intervention effects specific to severalaspects ofpsychologicalrecovery including reducing negative psychological consequences,increasing positive coping,and decreasing re-injury anxiety.Our findings provide empirical data for future studies that examine the effects of psychological interventions.Our findings demonstrate the urgent need for additional research examining the effects of psychological interventions utilizing rigorous methodology which includes utilizing RCT or prospective study design,inclusion of a control group,consistent and improved outcome measures,accounting for potential confounders in the analysis,and increased diversity of study populations to increase generalizability.

4.2.Limitations of this review

Despite the wide research design inclusion criteria,only six interventions were included in this review.While the variations in research designs and intervention outcomes provide insight into the wide range of techniques available to sports psychologists and other professionals involved in the rehabilitation process,35—41the limited number of studies employing each type of technique prevented further comprehensive analysis.Thus,our ability to draw a conclusion on effectiveness of psychological interventions was limited. Furthermore,this review only included intervention strategies with individual injured athletes.Many intervention strategies thattargetchanges atinterpersonal,organizational,and policy level(s)to improve outcomes of psychological rehabilitation, such as increased social support from the team or athletic trainers,or psychological counseling services at athletic department,were not included.60—64

5.Conclusion

In conclusion,the results of this review support the effectiveness of psychological intervention in reducing post-injury psychological consequences and improving psychological coping during rehabilitation.Specifically,guided imagery/ relaxation was shown to be associated with improved psychological coping and reduced re-injury anxiety.Goal setting however,was not directly associated with reduction of negative psychological consequences.Other psychological techniques such as microcounseling skills,ACT,and written disclosure included in this review have demonstrated reduced negative psychological consequences,improved psychological coping,and reduced re-injury anxiety.

Many techniques discussed in this review are routinely employed by applied sportpsychologists and there is an abundant amount of empirical data supporting the use of abovementioned psychologicalstrategies to aid in orenhance athletic performance.47—50,61—73Research examining the effectiveness of employing the psychological intervention with injured athletes during sportinjury rehabilitation is significantly lacking.Our findings highlight the importance of development, implementation and evaluation of the effectiveness of intervention strategies through research so these evidences can be utilized to assistinjured athletes’successfulrecovery.

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Received 21 April2012;revised 4 June 2012;accepted 6 June 2012

*Corresponding author.

E-mailaddress:jingzhen-yang@uiowa.edu(J.Yang)

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