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Athletes’ Use of Mental Skills During Sport Injury Rehabilitation

Article  in  Journal of sport rehabilitation · January 2015

DOI: 10.1123/jsr.2013-0148 · Source: PubMed

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Monna Arvinen-Barrow

University of Wisconsin – Milwaukee

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Jordan Utley

University of St. Augustine

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Rebecca Zakrajsek

University of Tennessee

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Sae-Mi Lee

California State University, Chico

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ORIGINAL RESEARCH REPORT

Journal of Sport Rehabilitation, 2015, 24, 189 -197 http://dx.doi.org/10.1123/jsr.2013-0148 © 2015 Human Kinetics, Inc.

Arvinen-Barrow is with the Dept of Kinesiology Integrative Health Care & Performance Unit, University of Wisconsin- Milwaukee, Milwaukee, WI. Clement and Lee are with the Dept of Sport Sciences, West Virginia University, Morgantown, WV. Hamson-Utley is with the University of St Augustine for Health Sciences, St Augustine, FL. Zakrajsek is with the Dept of Kinesiology, Recreation, and Sport Studies, University of Tennessee, Knoxville, TN. Kamphoff is with the Dept of Human Performance, Minnesota State University, Mankato, Mankato, MN. Lintunen is with the Dept of Sport Sciences, University of Jyväskylä, Jyväskylä, Finland. Hemmings is with the School of Sport, Health and Applied Science, St Mary’s Uni- versity, London, UK. Martin is with the College of Education, University of North Texas, Denton, TX. Address author cor- respondence to Monna Arvinen-Barrow at arvinenb@uwm.edu.

Research across the world has shown that mental skills (ie, strategies used to trigger and sustain ideal performance)1 can be helpful to athletes in the process of achieving optimal athletic performance.2 More spe- cifically, mental skills such as imagery,3 goal setting,4

self-talk,5 and relaxation techniques6 have all been documented as useful in facilitating, maintaining, and improving athletic performance. In accordance with these findings, the integrated model of psychological response to sport injury and rehabilitation7 asserts that mental skills are beneficial during sport injury rehabilitation. This model posits that personal and situational factors combine to influence athletes’ cognitive appraisal of their injury situation and, depending on their assessment (ie, thoughts about being injured), they exhibit emotional (ie, feelings about being injured) and behavioral (ie, actions and reactions to being injured) responses, both of which may influence their subsequent cognitive appraisals. The same process (cognitions affecting emotions, and emo- tions affecting behaviors) can also occur in the opposite direction. According to the model, the use of mental skills is deemed important during the sport injury process in a number of ways: (1) as a mediating factor influencing injury occurrence, (2) as a personal factor influencing cognitive appraisals, and (3) as a behavioral response potentially influencing both the cognitive appraisals and emotional response to the injury situation.

Athletes’ Use of Mental Skills During Sport Injury Rehabilitation

Monna Arvinen-Barrow, Damien Clement, Jennifer J. Hamson-Utley, Rebecca A. Zakrajsek, Sae-Mi Lee, Cindra Kamphoff, Taru Lintunen, Brian Hemmings, and Scott B. Martin

Context: Existing theoretical frameworks and empirical research support the applicability and usefulness of integrating mental skills throughout sport injury rehabilitation. Objective: To determine what, if any, mental skills athletes use during injury rehabilitation, and by who these skills were taught. Cross-cultural differences were also examined. Design: Cross-sectional design. Setting: College athletes from 5 universities in the United States and a mixture of collegiate, professional, and recreational club athletes from the United Kingdom and Finland were recruited for this study. Participants: A total of 1283 athletes from the United States, United Kingdom, and Finland, who participated in diverse sports at varying competitive levels took part in this study. Main Outcome Measures: As part of a larger study on athletes’ expectations of injury rehabilitation, participants were asked a series of open-ended and closed-ended questions concerning their use of mental skills during injury rehabilita- tion. Results: Over half (64.0%) of the sample reported previous experience with athletic training, while 27.0% indicated that they used mental skills during injury rehabilitation. The top 3 mental skills reported were goal setting, positive self-talk/positive thoughts, and imagery. Of those athletes that used mental skills, 71.6% indicated that they felt mental skills helped them to rehabilitate faster. A greater proportion of athletes from the United States (33.4%) reported that they used mental skills during rehabilitation compared with athletes from the United Kingdom (23.4%) and Finland (20.3%). A small portion (27.6%) of the participants indicated that their sports medicine professional had taught them how to use mental skills; only 3% were taught mental skills by a sport psychologist. Conclusions: The low number of athletes who reported using mental skills during rehabilitation is discouraging, but not surprising given research findings that mental skills are underutilized by injured athletes in the 3 countries examined. More effort should be focused on educating and training athletes, coaches, and sports medicine professionals on the effectiveness of mental training in the injury rehabilitation context.

Keywords: injured athletes, psychological interventions, survey design, cross-cultural

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Existing empirical evidence suggests that the application of mental skills during rehabilitation sup- ports this model.8–11 Sports medicine professionals (SMPs), such as athletic trainers and physiotherapists, use a range of mental skills with athletes during reha- bilitation,9–13 and research indicates that goal setting is the most popular technique used by both athletic trainers and physiotherapists, regardless of the cultural context.9–13 Research conducted in the United States indicates that SMPs’ attitudes toward the effective- ness of mental skills vary, depending upon their level of formal training with cognitive skills application.14 Hamson-Utley et al found that athletic trainers held more positive attitudes toward the usefulness of mental skills than physiotherapists.14 Although studies dem- onstrate that adopting mental skills during rehabilita- tion is warranted and welcomed by the SMPs, there is limited research on athletes’ actual accounts of its use. Moreover, previous investigations on the performance context indicate varying cross-cultural differences.15,16 Thus, further investigation is required to determine if these cultural influences dictate the application of such skills in a sport injury rehabilitation context.

In addition to the sparse research available on the prevalence of athletes’ use of mental skills during reha- bilitation, there is limited information on which sports professionals are best positioned to assist athletes to use mental skills during sport injury rehabilitation. Ideally, injured athletes should have access to a sports medicine team that includes a credentialed sport psychology pro- fessional,17,18 however, most athletes and SMPs typically have limited access to sport psychology services.19,20 As a result, other professionals, such as athletic trainers and physiotherapists, are often implementing mental skills during rehabilitation. Whether SMPs or other allied health professionals are teaching mental skills to athletes during rehabilitation warrants further research.

To address these gaps in the literature, we attempted to preliminarily determine: (1) what, if any, mental skills athletes use during injury rehabilitation; (2) if there were any possible cross-cultural differences in athletes’ use of mental skills during injury rehabilitation; and (3) who teaches mental skills to athletes during rehabilitation.

Methods Research Design and Setting A cross-sectional research design was used to sample participants from both the United States and Europe. The US-based participants were collegiate athletes who were recruited from 5 universities across the country. The Euro- pean athletes were a mixture of collegiate, professional, and recreational club athletes from the West and East Midlands regions of the United Kingdom and Finland.

Participants A total of 1283 athletes (62.4% male; 36.0% female; 1.6% did not identify their sex) participated in the study. Age ranges spread across the following categories (1.6% did not specify their age): 12 to 17 (n = 67; 5.2%); 18 to 21 (n = 754; 58.8%); 22 to 25 (n = 234; 18.2%); 26 to 35 (n = 101; 7.9%); 36+ (n = 107; 8.3%). Of the sample, 699 (54.5%) were classified as US athletes and 584 (45.5%) were classified as European athletes (332 from the United Kingdom and 252 from Finland; for more details on the participant demographics, see Table 1). The vast majority (752, or 58.6%) identified themselves as student-athletes, with a smaller number (135, or 10.5%) indicating that they had a college/university degree or other qualifica- tions (30.9% nonresponse). Participants described their highest level of competition as (1) collegiate/university (705, or 54.9%); (2) recreational or not competing at all (240, or 18.7%); (3) national (166, or 12.9%); (4) at either county, regional, or state level (74, or 5.8%); (5) international (38, or 3.0%); (6) professional (24, or 1.9%); or (7) no indication (36, or 2.8%). The 3 most cited sports were American football (216, or 16.8%), soccer (211, or 16.4%), and track and field (161, or 12.5%). A total of 373 (29.1%) reported having a past history of acute injuries, 128 (10.0%) indicated that they experienced chronic injuries, and 501 (39.0%) had suffered both acute and chronic injuries, whereas 281 (21.9%) reported having no history of injuries. Of the participants, 821 (64.0%) indicated that they had prior experience working with SMPs, whereas 406 (31.6%) indicated that they had no prior experience working with SMPs (4.4% nonresponse).

Table 1 Participants’ Age Range and Sex by Country

Age, y

United States United Kingdom Finland Total Male Female Male Female Male Female Male Female

n % n % n % n % n % n % n % n % 12–17 1 0.2 0 0.0 2 0.9 0 0.0 48 33.3 16 14.8 51 6.4 16 3.5 18–21 319 71.7 221 88.0 90 42.7 55 53.4 26 18.1 43 39.8 435 54.4 319 69.0 22–25 113 25.4 28 11.2 23 10.9 7 6.8 33 22.9 29 26.9 169 21.2 64 13.9 26–35 11 2.5 2 0.8 22 10.4 15 14.6 32 22.2 18 16.7 65 8.1 35 7.6 36+ 0 0.0 0 0.0 74 35.1 26 25.2 5 3.5 2 1.9 79 9.9 28 6.1 Total 444 55.6 251 54.3 211 26.4 103 22.3 144 18.0 108 23.4 799 62.4 462 36.0

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Measure

As part of a larger study on athletes’ expectations of injury rehabilitation,21,22 participants were asked a series of questions regarding their use of mental skills during injury rehabilitation. These inquiries contained both open-ended and closed-ended questions. More specifi- cally, the first question participants were asked relative to their use of mental skills in injury rehabilitation was a closed-ended question: “Have you ever used mental skills as part of your sport rehabilitation?” Question 2, an open-ended question, allowed participants to list up to 3 mental skills they had used during their injury rehabilita- tion. Question 3, a closed-ended question, was: “Did the athletic trainer(s) teach you how to use the skills?” The fourth question, a follow-up to the previous question, was open-ended: “If no, who did?” The final question was closed-ended: “Do you believe that the use of mental skills helped you to rehabilitate faster?”

The survey items were modified for the UK and Finn- ish sample to take into account cultural differences. For the UK survey, the term, “athletic trainer,” was changed to “physiotherapist” to reflect the differences in professional titles used in these different cultural contexts. In Finland, the original questions were translated into Finnish follow- ing a commonly employed back-translation procedure23,24 used in cross-cultural research:

1. The original questions were translated from Eng- lish to Finnish by an independent sport psychology researcher who is fluent in both languages. At this stage, the term, “athletic trainer,” was also changed and translated to “physiotherapist” to reflect the differences in professional titles used in different cultural contexts.

2. The Finnish translated version was then translated back into English independent of the original ques- tions by a sport psychology professional who is fluent in both languages but was not involved in the initial translations.

3. The differences in the content and meanings between the back-translated and the original questions were then identified.

4. Due to the simplicity of the questions, no items displaying discrepancy in either content or meaning were identified.

Procedure After institutional review board approval and before administration of the surveys, all of the participants were given a cover letter informing them of the purpose of the study. The surveys were administered in a range of ways, depending on the country in which the data were collected. Participants at the US and UK universi- ties received the questionnaires in person, either before or after practices or classes. Some of the athletes in the United Kingdom received the survey via SurveyMonkey

(Palo Alto, CA) through the national governing body member mailing list. In Finland, surveys were adminis- tered in person to a convenient sample of both nonuni- versity competitive athletes (club athletes) and university athletes studying sport-related courses. In the cases of participants under 18 years of age, parental consent was also obtained. However, due to both the diversity of the sample size and the diversity in data collection methods, we were not able to calculate an overall response rate for the study. Following completion of the questionnaires, which took approximately 15 minutes, the participants were thanked for their participation.

Statistical Analyses

Descriptive statistical analyses (ie, percentages and fre- quencies) were calculated for the closed-ended questions. For the open-ended questions, multiple response sets were created and then frequencies were calculated. Finally, a chi-square analysis was conducted (with both sex and country as a categorical level variable) to determine if significant cultural differences existed when using mental skills during injury rehabilitation. The qualitative open- ended answers were coded based on the commonly-used categorization of mental skills (eg, imagery, goal setting, self-talk, relaxation techniques).

Results Of the 1283 participants, 346 (27.0%) indicated that they had applied mental skills during injury rehabilita- tion, whereas 880 (68.6%) stated that they had not used mental skills during rehabilitation (4.4% nonresponse). Among those who reported using mental skills, the top 4 mental skills used were (1) goal setting (162, or 46.8%), (2) positive self-talk/positive thoughts (115, or 33.2%), (3) imagery (110, or 31.8%), and (4) relaxation (84, or 24.3%). Table 2 displays the athletes’ use of specific mental skills by country. Of the 346 athletes who used mental skills, 249 (72.0%) indicated that the use of mental skills helped them to rehabilitate faster, whereas 48 (13.8%) felt that using mental skills did not facilitate the speed of their injury recovery (14.2% chose not to answer this question).

A significant difference (χ2 = 20.08, df = 2, P < .001) was obtained based on the athletes’ country (see Table 3). That is to say, a greater proportion of athletes from the United States (33.4%) reported that they used mental skills during rehabilitation compared with the proportion of athletes from the United Kingdom (23.4%) and Finland (20.3%). No significant difference (χ2 = 0.378, df = 2, P > .05) was found between the percentage of use of mental skills by males and females during injury rehabilitation.

Of the participants who reported using mental skills as part of their sport injury rehabilitation, 96 (27.7%) indicated that their SMPs (ie, athletic trainer, physiothera- pist or equivalent) had taught them how to apply mental

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skills. Other sources included a coach (52, or 15.0%), the athlete themselves (28, or 8.1%), the athlete’s family (26, or 7.5%), or a sport psychologist (10, or 2.9%). There was a 38.7% nonresponse rate.

Discussion The primary purpose of this study was to determine what, if any, mental skills athletes use during injury rehabilita- tion. Results indicated that 27.0% of athletes surveyed reported using mental skills during injury rehabilitation. Given that the use of mental skills in sport performance has been supported by research for a long time,25 and that these same skills are frequently being recommended by SMPs for use in the rehabilitation setting,26,27 overall the low number of athletes who reported using mental skills during injury rehabilitation is a discouraging revelation. According to Arvinen-Barrow and Walker,28 mental skills are commonly underutilized during injury rehabilitation. This may happen because athletes, and those who work with them, are often unable to see a clear transfer of mental skills from performance enhancement to sport injury rehabilitation due to their limited knowledge on how to use these mental skills when recovering from injury. Of the athletes who did report using mental skills during rehabilitation (n = 346, or 27.0%), goal setting (46.8%), positive self-talk (33.2%), imagery (31.8%), and relaxation techniques (24.3%) were listed as the 4 main strategies employed. This is not surprising, because these skills are among the most commonly used mental skills in sport,29 with goal setting being the most widely used by athletes overall.30 Frequent use of goal setting is also supported by studies conducted with SMPs. One study on SMPs’ atti- tudes about the effectiveness of mental skills used within injury rehabilitation indicates that goal setting is perceived as the most effective skill.14 Furthermore, results from 4

additional studies9–12 indicate that when working with injured athletes, setting short-term goals appears to be the second-most used technique by SMPs overall (second to creating variability in rehabilitation exercises).

However, research remains unclear on the use, perceptions, and effectiveness of self-talk and imagery during injury rehabilitation. Hamson-Utley and col- leagues14 reported that among SMPs, use of self-talk and imagery was perceived as less effective than goal setting in sport injury rehabilitation. Nevertheless, other studies9–12 that explored the views and experiences of SMPs who use mental skills show that, along with setting goals, encouraging positive self-talk appears to be one of the most advocated mental skills by SMPs, whereas the use of imagery is among the 3 least-used mental skills that SMPs employ during sport injury rehabilita- tion. Estepp’s31 research on National Collegiate Athletic Association (NCAA) division I athletic trainers pro- vided further insight into the use of mental skills during rehabilitation, in that they reported using goal setting, communication, and time management more often than self-talk, relaxation, or imagery when working with injured athletes during rehabilitation.

Of the athletes in the current study who had reported using mental skills during rehabilitation, 72.0% believed that the use of such skills influenced the speed of their recovery and that the mental skills had a positive impact on their injury recovery. Research on the effects of mental skills in improving performance may influence athletes’ perceptions or beliefs that such skills will likely be beneficial during their injury rehabilitation. In addi- tion, research that highlights the mind–body connection suggests that patients who believe in and commit to their therapy perceive it as much more effective.32 Since only 27.0% reported that they used these tools during their rehabilitation, further understanding of why mental

Table 2 Specific Mental Skills Used During Rehabilitation

Mental skill

United States (n = 222)

United Kingdom (n = 74)

Finland (n = 50)

Total (N = 346)

n % n % n % n % Goal setting 115 51.8 24 32.4 23 46.0 162 46.8 Positive self-talk/positive thoughts 88 39.6 21 28.4 6 12.0 115 33.2 Imagery 70 31.5 22 29.7 18 36.0 110 31.8 Relaxation 57 25.7 6 8.1 21 42.0 84 24.3 Other 15 6.8 2 2.7 1 2.0 18 5.2

Table 3 Use of Mental Skills During Sport Injury Rehabilitation by Country (N = 1226)

Use or nonuse

United States (n = 664)

United Kingdom (n = 316)

Finland (n = 246)

n % n % n % Use mental skills during injury rehabilitation 222 33.4 74 23.4 50 20.3 Do not use mental skills during injury rehabilitation 442 66.6 242 76.6 196 79.4

Note: Due to missing variables, the number of participants in each country is different than as presented in the text.

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skills are underutilized during rehabilitation warrants further investigation.

A secondary purpose of the current study was to investigate whether possible cross-cultural differences existed in athletes’ use of mental skills during injury rehabilitation. Results indicated a significant difference in mental skill use, as US athletes (33.4%) used mental skills more within injury rehabilitation contexts compared with their UK (23.4%) and Finnish (20.3%) counterparts. It is likely that this difference may be attributed to (1) athletes’ receptiveness toward sport psychology, (2) pos- sible cultural differences that exist in sporting cultures among the countries represented in this analysis, and (3) athletes’ exposure to athletic training services in the United States.

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