Sports Medicine Research: In the Lab & In the Field: Nothing to Fear but Fear Itself: Psychological Factors Related to Return to Sport Post-injury (Sports Med Res)
Wednesday, November 28, 2012

Nothing to Fear but Fear Itself: Psychological Factors Related to Return to Sport Post-injury

A Systematic Review of the Psychological Factors Associated with Returning to Sport Following Injury

Ardern C, Taylor N, Feller J, Webster K. Br J Sport Med 2012; 0: 1-8

An often overlooked aspect of a clinician’s responsibility is to manage and mitigate an athlete’s psychological response to injury throughout the rehabilitation process, which is often associated with tension, low self-esteem, depression, and anxiety. Self-determination theory has been applied to identify factors that may influence an athlete’s psychological response, particularly emphasizing the basic needs of autonomy (motivation), competence (fear and confidence), and relatedness (social belonging). When all three needs are met, self-motivation and psychological development are augmented and may complement our physical rehabilitation to influence a successful return to play. Ardern and colleagues performed a systematic review to evaluate if psychological factors are associated with returning to sport within the context of self-determination theory. The authors used nine electronic databases to identify studies in which participants were evaluated following a sport-related injury, participated in rehabilitation, return to sport rate was reported or could be calculated, and data were reported for at least one psychological variable. Based on these criteria, 11 articles were eligible for full review and included in the systematic analysis, totaling 983 athletes and 15 psychological factors. The authors found that the three central needs of self-determination theory were related to return to sport (autonomy, competence, and relatedness). Positive responses such as motivation, confidence, and low levels of fear were associated with better return to sport outcomes. Fear associated with re-injury and return to sport persisted over time despite a decline in other negative emotions throughout the rehabilitation process.

While not always addressed, these results suggest that it is imperative for clinicians to consider the psychological response of athletes not just post-injury, but in anticipation of return to sport as well.  The intention of sport-specific tasks and rehabilitation techniques should not just be about the preparing the athlete for the physical demands of competition but also reducing fear and anxiety that the athlete may possess related to their ability to perform the task and/or risk of re-injury. Setting goals for the athlete that allow them perceive their return to sport as positive may reduce fear about their first few times back to competition. How do you manage an athlete who is fearful about return to sport? Do you address psychological factors throughout your rehabilitation process with an athlete?

Written By:  Laura McDonald
Reviewed by: Jeffrey Driban

Related Posts:
Ardern CL, Taylor NF, Feller JA, & Webster KE (2012). A systematic review of the psychological factors associated with returning to sport following injury. British Journal of Sports Medicine PMID: 23064083

7 comments:

Aaron said...

I think it is crucial for an athlete to be completely aware of each aspect of rehabilitation throughout the entire process, especially approaching return to play. A great way to accomplish this is through both short and long-term goal setting. I believe the more knowledge an athlete has on what is expected of them and their progress, the less anxiety and fear they may have. At the initiating of rehabilitation, I try to establish goals with the help of the athlete. These consist of both patient-oriented and clinically oriented goals.
Besides goal setting, there are other methods to combat an athlete’s fear about return to sport. I think it is possible for athletic trainers to forget just how scary an injury can be, especially with higher-level athletics where performance can result in financial implications. It is vital to constantly communicate with them, to ensure they are feeling comfortable.
The athletes at the university I currently work at have a sports psychologist they can utilize. Typically we send every athlete who suffers an injury that results in time missed to meet with him. I have seen the benefits of professional consoling for athletes suffering from long-term injuries. Has anyone else worked with a sports psychologist? Are there other methods you find effective in treating an athletes anxiety stemming from injury?

Laura M. McDonald, PhD, ATC said...

Hi Aaron -- thanks for your comment! I find it very impressive that you have a sports psychologist actively involved with your injured athletes. Can you elaborate more on the benefits you've experience with your athletes that have worked with him/her?

Goal-setting is a priority for any rehabilitation I deal with. I agree with you -- the more knowledge and education an athlete possesses, the more in control they are likely to feel. I try and incorporate coaching staff as much as possible on the goal-setting process. It helps the athlete and the coach to be on the same page about progress.

Nate said...

I can elaborate on some of the benefits that Aaron is referring to, as I work at the same university. The sports psychologist will meet with the athlete one on one and discuss goals, expectations, fears, etc. In addition to one on one meetings, athletes that will require extensive rehab are invited to attend a once a week group meeting. This can help the athletes mentally because the group consists of people with similar injuries at all different stages of rehab and they can give each other comments on things that worked on addressing their fears and it shows the athlete that they aren't alone and it is normal to have a lack of confidence and fear after a serious injury. Having a place to discuss these fears and set goals on how to address them is critical for full return to play. Athletic trainers must address this in the rehab by educating the athlete and discussing expectations. Coaches can also be helpful in this situation if a sports psychologist is not available. I agree that having everyone on the same page as far as goals, progress, and expectations.

Megan said...

Aaron and Nate have made a few really good points in regards to managing the pschological factors associated with injury at the university level. Access to a sports pschologist would be an ideal situation for the athletic training community, however, this is not always the case. Therefore, I believe we as athletic trainers without access to a sports pschologist need to be aware of the impact injury can have on pschological health as well as keeping ourselves educated on new and other ways to help athletes deal with their injury.

I currently work in the high school setting as an athletic trainer, and I have found that working with this specific age group can be a challenge in conveying what the injury is and how we can go about treating it compared to other populations. In addition, I have very little time to spend with my athletes after school which can also make it difficult in communicating with an athlete effectively and helping them through their pschological fears. Has anyone else experienced this working in the high school setting?

Laura M. McDonald, PhD, ATC said...

Hi Nate - thanks for commenting and providing insight on how your university utilizes a sport psychologist. The inclusion of group sessions sounds like it could be very beneficial to the athlete's sense of a shared experience. Very neat!

Megan - I absolutely agree that a collaborative relationship as Nate and Aaron experience is not the norm, especially at the high school level. I've found that some sports psychologists aren't thrilled with the idea that we attempt to mitigate psychological response to injury. As you said, without access, we have to use the tools provided in our educational programs to address a very real issue with these athletes.

William T. said...

An interesting experience that I have been a part of this year working with a D-I football program aside from the sport psych what I have found to be helpful is rehabbing with other indivudals who have the same if not similar injury. Unfortunately, yet fortunately, I’ve been a part of rehabbing 3 ACLr’s and a PCL; we kind of turned it into a “rehab buddy” sort of approach in that all 4 of the guys come in together and rehab together. Sure they aren’t all ACL isolated reconstructions but they all are friends and compete based on their progression compared to the next. Kind of keeps the competitive nature of sport and translates it over to rehabilitation. I’ve found it to be productive and effective, that is of course until holiday breaks hit and compliance starts to go down..

Aside from rehabbing in groups another way that I have addressed RTP issues is through constant measurements and inquiring to the athlete if they have concerns and what their goals are and if they have any specific doubts about RTP. For example, I’ve been working with a SLAP bankhart repair for the past few months and I’ve used the aforementioned tasks in conjunction with the surgeon’s orders of course. Over the course of the past month he’s come along and most of the rehab work is going to be done in the weightroom; everything I’ve been doing has been focused on deficits and concerns of the athlete. We talk frequently about his return and how his injury occurred in the first place. Turns out his biggest concern is reaching overhead and really reaching for a ball. Having heard that we’ve been working on PNF, dynamic and real game-like/football-like activities gradually progressing. I reassured him that the goal and plan was to strengthen and make sure his shoulder was in the best position and condition for RTP given that within football there are so many unplanned events that can occur especially as being a receiver catching passes.

Laura M. McDonald, PhD, ATC said...

Thanks for your perspective, William. It sounds like you and your staff take a very patient-oriented approach to your rehabilitation, both physically and mentally.

With your group rehabs, how do you manage if one athlete begins to lag (say, ROM isn't where it "should" be for an ACLr)? We tell an athlete not to compare themselves to others, but we all know they will despite explaining individualized healing time frames!

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