The physical challenges associated with participating in sports activities are risky enough to warrant that an athlete will encounter some consequences of injury at some point during their career. In addition to decreasing confidence, self-esteem, and mood, physical injuries can lead to increased levels of anxiety among athletes. As such, any serious injury can be a significant form of distress for athletes, and real threat to their focus and confidence after resuming their official duties in sports. Various scholars have explored the social and psychological variables associated with the three stages of injury in sports: onset, rehabilitation, and return to sports.
Re-injury anxiety ranks as the most significant threat to an athlete’s performance because it can lead to psychological decrements such as low levels of self-confidence. This paper will focus on rehabilitation and returning to sports after an injury, focus on the psychological reactions and factors experienced by injured athletes and discuss recommended psychological interventions.
Despite the technological advancements in sports equipment, coaching, and training techniques, sports injuries are still prevalent.
An explanation for the high rate of injuries in sports is due to the athlete’s aspirations to be elite athletes engaging in risky behaviors such as extended periods of training, ignoring minor pain to succeed in their sports, increasing the chances of serious injuries (Wadey & Evans, 2011). Because the rate of injury in sports is still high and the consequences of anxiety involved, it is crucial to find ways to help athletes cope physically and mentally before returning to their sport.
When investigating the factors that influence an athlete’s risk of injury, most studies have focused on physiological damage without considering the effects of psychological risk factors. As such, it is important to consider psychological factors that put an athlete at risk of an injury and the relationship between psychological and physiological responses of an injured athlete.
There are two models associated with the process of injury rehabilitation: grief-loss models and cognitive appraisal models. The grief-loss model is essential in explaining the reactions of athletes when they are injured; they may experience grief linked to loss of social contact, loss of fitness, and non-participation in sports activities that they previously enjoyed (Sheinbein, 2016). Such losses and grievances may adversely affect the rehabilitation process involving the athlete. Contrastingly, the cognitive appraisal model incorporates the individual differences of an athlete, whereby every athlete is expected to have a unique reaction to the stressors related to athletic injury rehabilitation.
Grief-loss model. Most grief-loss models that have been recommended for athletic injury rehabilitation are derived from the influential study performed by Kubler-Ross in 1969, On Death and Dying. The study gained much acclaim in sports circles where anxiety takes center stage such as fears associated with re-injury. In the study, Kubler-Ross (1969) interviewed patients that were terminally ill and found out that patients moved through stages as they slowly came to accept their death: disbelief, denial and isolation, anger, bargaining, depression and acceptance, and resignation. The main supposition with the grief-loss model is that an injury represents a loss of some aspect of self that is usually followed by predictable responses. The model was first used by Rotella (1982), a sports psychologist that specialized in sports injuries. Rotella (1982) established that athletes experience a similar emotional reaction, mainly anxiety, to an injury to that of a terminally ill patient. The findings were accurate because athletes report a sense of loss and anxiety when not participating and when they resume sports, which may inspire some feelings of isolation or alienation from the rest of the team.
Cognitive appraisal models. The biofeedback theory for the mind and body self-regulation is a well-documented model that supports individualized responses to injuries (Schwartz & Andrasik, 2017). The theory was based on the supposition that there is a correlation between a person’s physiological and psychological states. The central precept of the theory is that when a physiological change occurs in the body, there are subsequent changes in the mental-emotional state of a person who sustains an injury (Schwartz & Andrasik, 2017). Examining the theory through the injury scope shows that a physiological change in the body such as an injury affects the psychological well-being of an athlete. As such, re-injury anxiety is a combination of physiological and psychological states in an athlete’s body and mind.
Correspondingly, the integrated model of response to injuries that occur in sports focuses on individual differences in how athletes respond to their injuries. The important aspects to consider in this model are the relationship between pre-injury, post-injury, personal and situational factors that influence an athlete’s psychological perception of their injury (Clement, 2015). Pre-injury factors such as personality, stressors, and the ability to cope with stressful situations, in addition to post-injury factors such as the severity of the injury, and recovery status affects an athlete’s cognitive judgment of an injury such as fear of re-injury. According to Clement (2015), the integrated model of response is essential in studying re-injury anxiety in sports because it explains the change in an athlete’s cognitive appraisal of their injury, which in turn affects their outward behaviors and emotions in regards to their injury. Furthermore, the cognitive factors that lead to added anxiety influence the physical and psychosocial rehabilitative outcomes of an athlete with an injury.
The willingness of an athlete with an injury to commit to rehabilitation, and the value they associate with the rehabilitation process influences their behavioral, emotional, and cognitive reactions to injury rehabilitation. Hence, the perceptions of an athlete about their injury rather than they have an injury that needs attention are essential in understanding the athlete’s anxiety (Sheinbein, 2016). As such, athletes with a high fear of re-injury are susceptible to specific behavioral responses such as not giving their best efforts and being cautious in situations that may cause another injury such as during sports activities and rehabilitation. It is also important to note that recent studies have established a correlation between positive attitudes such as feeling relief and happiness during injury rehabilitation and increased adherence to rehabilitation by athletes with injuries (Sheinbein, 2016). Conversely, athletes with negative attitudes during their rehabilitation period feel cautious and hesitant towards completing their sports exercises for fear of re-injury.
Although the biggest concern about returning to sports for athletes that have sustained an injury is the fear of re-injury, state-anxiety also dominates as an alternative dominating factor concerning resuming to a sport. Different from fear, anxiety is not a response to a situation that inspires fear but a conditioned response from experience to anticipating that something is bound to happen. For instance, Walker et al. (2010) have established that athletes experience a feeling of nauseous, sweaty, and clammy when they think about returning to the sport, or involuntarily deliberate the distressing images from the injury.
As such, Walker et al. (2010) attempted to measure an athlete’s anxiety level when returning to sport after an injury and ended up developing the Re-Injury Anxiety Inventory (RIAI) scale. The focus of the research was to test rehabilitation re-injury anxiety, re-injury anxiety, and re-entry into competition anxiety. For the scale to be useful, it is recommended to be administered 30 minutes before the participant start their rehabilitation session, with the object to evaluate state-anxiety, or how the participants felt at that moment. Nonetheless, it is essential for sports psychologists to consider administering a questionnaire before potentially anxious situations. This is because some athletes may not experience anxiety before their rehabilitation sessions but may feel extremely anxious immediately before their first game after the injury because of their previous experience with an injury during a game situation, and the accompanying thoughts of what might happen.
It is possible to know the anxieties of an athlete when returning to the sport by expressing concerns through the application of the self-determination theory (SDT). The approach is applied by sports psychologists interested in evaluating an athlete’s inherent psychological needs and intrinsic motivation that motivates an individual’s preference for returning to the sport. The three psychological needs that are examined within the theory are relatedness, autonomy, and competence (Podlog et al., 2013). Sports psychologists speculate that athletes must achieve high levels of confidence and aim to satisfy the three psychological needs so that that they can experience a triumphant return to sport.
Although most studies have focused on the psychological factor of competence, an important aspect, relatedness, has been ignored although it has a lot of significance to the fear of re-injury. When applying the SDT theory, relatedness is meant to represent the isolation experienced by the athlete and the feeling of loss of athletic identity (Podlog et al., 2011). It is important to note that relatedness is an innate human need especially the feeling of a sense of interconnectedness to the social environment, and losing such a perception may adversely affect an athlete’s return to sport. Thus, it is essential for rehabilitation professionals to consider creating stimulating environments, encourage continued participation in their sport, and provide varying types of social support to promote a sense of belonging within the sport or team.
Because the self-determination theory focuses on competency and relatedness to re-injury anxiety, Bandura’s theory of self-efficacy is a conceptual theory that explains lack of self-confidence among athlete’s post-injury. This theory is situation specific in that one may have the belief that they can produce outstanding results in a particular situation, despite whether they have the required skills or not. A person’s sense of self-efficacy can either negatively or positively affect their performance, perspectives, and motivation (Podlog et al., 2010). In a sports context, the situations may involve a successful execution of a side-step maneuver in a basketball game. Nevertheless, an athlete may have attempted the maneuver a couple of times all the while falling and tripping and even sustained a severe injury. To the individual, the experiences were failures, and when confronted with the situation, they have a low self-efficacy. Because of the low self-efficacy, the individual may choose to take alternative actions to avoid such a situation, such as being hesitant to perform a maneuver.
As such, self-confidence is an essential area of focus in athlete rehabilitation sessions because lack of confidence may lead to decreased performance, increase the risk of re-injury due to disruptions to focus, muscle tension, and concentration and various psychological changes (Walker et al., 2010; Podlog et al., 2010). Nonetheless, it may be argued that re-injury anxiety may not be associated with the changes. Instead, it may be explained by re-learning and reconditioning of basic movement patterns. To manage an athlete’s competency, rehabilitation professionals should consider the importance of employing goal setting and common modeling strategies to increase confidence levels. For instance, an athlete may be required to attend rehabilitation sessions with another athlete with the same injuries and more skill and confidence in participating in the rehabilitation exercises. Additionally, models may promote the athlete’s sense of relatedness and diminish feelings of isolation, boost their confidence levels, and motivate them to carry on with the rehabilitation.
The theory is a conceptual model that was popularized by Williams and Anderson in 1998 focused on psychological factors associated with injury occurrence that proposes that an athlete’s judgment and response to a high-stress situation affects the athlete’s predisposition to injury. The fundamental aspect of the model is that the stress response of an individual’s cognitive judgment of a potentially high-stress situation occupies the mind of an athlete with an injury (Evans & Redgrave, 2016). In other words, an athlete is more likely to be re-injured if the damage creates a physiological or attentional response to the stressor. If the athlete perceives a situation as stressful, negative attentional factors such as peripheral narrowing and distraction follow suit while the physiological changes may include coordination, fatigue, and muscular tension (Evans & Redgrave, 2016). Athletes who report negative mood states such as anger and anxiety or mood disturbances such as depression are likely to be re-injured. History of the athlete with an injury affects the stress response, individuals who have experienced massive injuries in the past and stressful life events are more vulnerable to future injuries. This theory postulates that athletes who utilize adaptive coping strategies are less likely to be re-injured.
In sports, it is some athletes require specific interventions for re-injury anxiety to improve function and complete a successful return to sports. Most sports injury rehabilitation protocols focus on correcting physical impairments without addressing re-injury anxiety (Hsu et al., 2017). For instance, the most applied protocols in sports injury rehabilitation is to resolve post-injury severe impairments such as muscle activation, pain, and range of motion deficits followed by progression to advanced exercises to fix remaining physical impairments. The approach is successful in most cases, but athletes with re-injury anxiety require specific interventions for a successful return to sport.
Psychologically-backed interventions are mostly recommended for patients with low back pain and may have the necessary principles required in the rehabilitation of athletes. Such treatment approaches require measuring critical psychological factors that may affect the results, including them in rehabilitation sessions as intervention targets, and providing specialized care that matches the need of the injured athlete (Hsu et al., 2017). Success treatment options that are used by sport medical specialists for low back pain include graded exposure, quota-based exercises, and education to reduce fear-avoidance beliefs. Such interventions have also proved to be useful for athletes with knee osteoarthritis and chronic musculoskeletal pain (Hsu et al., 2017). Implementation of psychologically informed interventions in sports rehabilitation requires measurement of re-injury anxiety using RIAI and application of the appropriate adjunctive practices for athletes with re-injury anxiety.
The progressive nature of sports injury rehabilitation may coincide with graded exposure treatment, especially during strenuous exercise. Temporarily, the graded exposure treatment may feature continuous exposure to some activities or situations that inspire fear to show injured athletes that such intervention can be completed without causing any harm (Hsu et al., 2017). The main difference is that, rehabilitation sessions that feature exercise progression is focused on the estimated application of physiological or biochemical forces that aid in the healing of body tissues while the exercise is for exposing patients on increasing activities or situations that cause anxiety. Thus, a rehabilitation exercise becomes a graded exposure intervention when it has been ascertained that activity causes re-injury anxiety and develop a strategy that increases fear to the activity that causes anxiety. It is possible to reduce fear or re-injury using some advanced exercises by exposing athletes to challenging activities and environments (Hsu et al., 2017). Nonetheless, a more direct intervention for athletes with re-injury anxiety is needed to strategize activities that are consistent with a graded exposure to prevent situations where athletes are willing to participate in high-level activities and avoid others that cause anxiety.
Few medical specialists know about the most effective interventions that help athletes cope with the mental consequences of injury including the value of goal setting for rehabilitation sessions and the importance of imagery. Goals setting involves the attainment of a specific level of proficiency on a task in a specified period. A study performed by Podlog & Eklund (2009) found that among 12 elite athlete participants in a period of between six to eight months, the athletes with injuries adjusted their goals based on their progress in the rehabilitation sessions. The athletes reported feeling more successful when they returned to sport compared to other athletes who did not participate in goal setting (Sheinbein, 2016). A successful goal setting intervention should include goals that provide motivation, structure, and steps for achieving goals in the rehabilitation sessions, and customizing the goals to fit the needs of the injured athletes.
Besides, more studies are focusing on the importance of mindfulness as an intervention for injured athletes. Meditation is a form of meditation that focuses on breath, being present in the moment, and eliminating any judgmental thoughts and feelings from the mind during meditation (Sheinbein, 2016). According to Sheinbein (2016), researchers are interested in finding out how mindfulness can help athletes with stress, pain, and anxiety management. Furthermore, researchers believe that self-compassion exercises help athletes in addressing self-critical thoughts, stress, and anxiety, and difficulty with pain and focus, which tend to arise when an individual has an injury.
In summary, understanding re-injury anxiety in sports requires a discussion on rehabilitation and returning to sports after an injury, focus on the psychological reactions and factors experienced by injured athletes and discuss recommended psychological interventions. In most cases, psychological factors that put an athlete at risk of an injury and the interplay between psychological and physiological responses of an injured athlete. Injury rehabilitation can be conducted using various methods that focus on the feelings of the injured athlete and the cognitive effects of the injury. There are various psychological factors associated with how an injured athlete may cope during the rehabilitation process. For instance, the self-determination theory shows that athletes must acquire high levels of confidence and aim to satisfy the three psychological needs so that they can experience a successful return to sport. Some of the psychological interventions for athletes with re-injury anxiety include mindfulness, imagery, and graded exposure treatment, all of which have high likelihoods to inspire reduced re-injury anxiety.