A growing body of evidence suggests that psychological factors play an important role in determining whether an athlete makes a successful return to sport following injury, finds a new study, which recommends that clinicians take them into account during injury rehabilitation and the period before an athlete returns to competition.
Reviewing the literature, researchers at Latrobe University in Australia found that:
- Emotions shift over time: As athletes progress through the rehabilitation phase towards a return to sport, they experience a lessening of the negative emotions associated with sustaining the initial injury (such as depression, anger, and anxiety), and a shift towards a predominance of positive emotions (such as confidence and readiness to return to sport), provided the period of rehabilitation has progressed as anticipated;
- A positive psychological response improves outcomes: A positive psychological response is associated with a higher return to sport rate after injury, a faster return and a greater likelihood of returning to the pre-injury participation level. An athlete's ability to cope with stress while injured influences recovery and progression through the rehabilitation process. Motivation is key factor in influencing the transition back to sport following injury;
- A negative psychological response increases the chances of a poor outcome: A negative outlook regarding injury and a negative attitude toward rehabilitation were predictive of not returning to sport, and increased risk of reinjury if they do return. Athletes with more severe injuries may exhibit more prolonged and severe negative psychological responses, which may carry over to the return to sport phase;
- Fear is an ever-present concern: Fear remains a prominent emotion at the time athletes returning to sport and is commonly given as a reason for not returning. Athletes who perceive themselves as having made a successful return to sport describe an associated dissipation of this fear upon testing the injured body part by returning to play; and
- External pressures may prompt premature return: Athletes who feel pressure to maintain their spot on the team, not let teammates or coaches down by not playing, and are concerned about being able to perform at their preinjury level, may return to sport prematurely, and before they are psychologically ready to do so, which may subsequently increase the likelihood of re-injury.
The study recommends that, in order to increase the chances an athlete will make a successful return to sport after injury, clinicians consider:
- Screening athletes during the rehabilitation phase to identify those at risk of developing potentially maladaptive psychological responses to injury, and implement strategies to address these issues, including measuring motivation, confidence and fear;
- Setting realistic performance expectations and recognizing improvements, and using goal setting and visual imagery throughout the active rehabilitation period to build confidence in the injured body part and self-esteem to promote a sense of competence and assist the transition back to sport;
- Determining whether athletes perceive support from coaches, teammates, and other significant individuals as they are returning to sport, and if they perceive external pressure to return to sport:
- Involving them in the identification of a realistic date for a potential return to sport to promote a sense of autonomy.
- Improving confidence by ensuring strong social support for the athlete in their return, which at the same time may assist in easing athlete fears about overstressing the recovered body part; and
- Monitoring the athlete closely at the time of transition back to full sports participation to ensure they feel adequately supported in their return.
Athletes who do not return to their preinjury level may require additional support to cope with the associated lifestyle adjustment, says the study.
"When it comes to injury rehabilitation, it's really impossible to separate what's going on in the athlete's brain from what happens in the rest of the body," said Douglas D. Glazer, DPE, ATC, Assistant Professor of Sports Science at Endicott (MA) College, and author of a 2009 study which proposed a new test called the Psychological Readiness to Return to Sport Scale (PRRS) for use by athletic trainers, other health care professionals, and even parents to assess psychological readiness of injured athletes to return to sport participation.
"Psychological readiness usually increases as athletes progress through the rehabilitation process; however, if an athlete's psychological readiness before competition is low, waiting a little longer before returning to the playing field may be the most safe course of action," said Glazer.
Advice from a physical therapist
"In my practice, one of the first things I assess is the psychological well being of the hurt athlete," says Keith Cronin, DPT, OCS, CSCS. "This ranges from how they respond to questions, eye contact, body posture, attitude, whether they fidget with their hands or feet, and finally also how they respond to their parents who are usually just trying to be helpful."
"Particularly with athletes with chronic injuries, I will spend more time making them believe they have the power to get better than actually doing the manual techniques, exercises, and modalities that have been shown to improve healing."
"With children it is far more important than just healing a body part, it is supporting an attitude and belief that they have the power to get better. I have had young athletes with lower back pain, just 12 or 13 years old tell me, 'I just have a bad back.' That is what 80 year war vets say, not children! If this is what they believe, that they will always hurt it is far more a concern than just returning to sport; its setting up a child for an adulthood of pain."
To provide the best care for hurt athletes, Dr. Cronin suggests:
- Treat them like an adult: Do not coddle or baby them. This usually only reinforces what they perceive as positive attention for having pain or problems. Be supportive, but don't treat them like they should be covered in bubble wrap
- Let the professionals take the blame: Doctors, physical therapists, athletic trainers, etc. deal with your hurt child in small doses. We have a huge advantage; you take them home! Let the rehab team be the bad guys. Don't try to step in and be a therapist. If your child complains, just say, "Your heard the physical therapist."
- Be a safety net, not the Secret Service: With any injury, there is going to be pain, setbacks, disappointment, and maybe even a few tears during the rehabilitation process. As a parent, be there to support your child, catching them when they seem to be spiraling into the dumps. But with injuries, as with sports, and in life, kids have to learn to pick themselves up when they fall down. If your child is on crutches, if they are physically able, let them figure out how to open the door, pull out the chair, or get in and out of the shower (if they can do so safely). In a parent's rush to comfort their hurt child, they sometimes prevent them from achieving their own mini-milestones. These small accomplishments create a positive outlook that will only increase the chances and speed at which they return to the sport they love.
1. Ardern CL, Taylor NF, Feller JA, Webster KE. A systematic review of the psychological factors associated with returning to sport following injury. Br J Sports Med. 2013;47:1120-1126.
2. Glazer DD. Development and preliminary validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale. J Athl Tr. 2009;44:185-189.
Posted October 29, 2013; updated and revised October 31, 2013 to include Dr. Cronin's comments and suggestions.