Psychological Aspects of Athletic Training
Summary and Keywords
The practice of athletic training involves both physical and psychological strategies when leading patients through the injury recovery process. Research on the psychology of injury offers theoretical foundations that guide the application of strategies to assist the patient with stressors that emerge during rehabilitation. This article applies theory to athletic training practice during injury recovery by examining the stressors that patients experience across the phases of rehabilitation. Addressing both physical and psychological aspects of injury recovery is expected by patients and provides a holistic care model for healthcare practitioners.
Athletic trainers are members of an interprofessional healthcare team that specializes in providing care to the athletic population. In the early 21st century, athletic trainers began practicing clinically in many nonathletic settings, such as the military, physician’s offices, corporate wellness programs, and mobile healthcare, to name a few. The patient and client population for athletic trainers is not the only thing that has changed; the incorporation of psychological exercises shown to alleviate stressors associated with rehabilitation and recovery has emerged (Commission on Accreditation of Athletic Training Education [CAATE], 2015).
Over the past decade, patient care has expanded in scope and has extended to include psychosocial aspects of healing and rehabilitation, allowing athletic trainers to provide a more comprehensive care plan (CAATE, 2015). Healthcare providers, specifically athletic trainers, are gaining formal education on psychosocial strategies to facilitate patient care, beyond physical treatment alone. Additionally, today’s patients have expectations of the care they will receive, including education on various psychological strategies for improving recovery (Clement, Hamson-Utley, Arvinen-Barrow, Kamphoff, & Martin, 2012). Stressors that may affect the patient include, but are not limited to, pain, lack of sleep secondary to pain, immobility, isolation, and difficulty engaging in work due to injury or illness. The stressors may surface as lack of adherence to, or compliance with, therapy due to associated anxiety and/or negative mood.
Before applying psychosocial strategies in the injury/illness recovery plan, a guide or model is instrumental in mapping out the potential impact of various stressors on emotional and behavioral responses; this will aid the athletic trainer in providing the best patient care. It is also essential to make connections between the patient’s current coping skills, previous history with psychosocial interventions, and personality and the current injury or illness situation. Moreover, learning what the patient brings to the recovery, as well as what worked in the past, is often the key to success.
Using a model to frame the patient’s personal and situational characteristics enables practitioners to provide the best care and to facilitate the recovery process. Usually, athletic trainers know their patients very well, because they see them often (on a daily basis). As athletic trainers move into nontraditional work settings (e.g., the military, corporate settings, mobile health), this advantage may diminish, and efforts to get to know the patient will resurface as a priority. Understanding an individual patient’s needs by referencing a stress-based model, such as the cognitive appraisal model, the biopsychosocial model, or self-determination theory, facilitates a plan of recovery that is comprehensive, including implementation of psychosocial skills.
Selecting a model to guide patient care is only half the battle; once the model is selected, the athletic trainer must identify the areas of impact on patient care. Generally, areas of impact are the elements of the recovery experience that the athletic trainer can intervene in, or improve for the patient. For example, when a postsurgical patient is experiencing pain, the athletic trainer can implement a relaxation or breathing technique with the patient that has the potential to minimize the perception of the pain. Additionally, the athletic trainer could educate the patient about pain control using association or dissociation techniques. Either way, this is an area in which care providers can affect the patient experience positively, potentially improving patient adherence to, and compliance with, the therapy regimen. Each of the aforementioned models is thoroughly reviewed in this article.
Another area of impact might be biological, such as poor nutrition or hydration. In this case, the athletic trainer educates the patient on how the biological factor plays a role in the recovery process and how the patient has control over this feature of healing. In this example, patient education is the psychosocial strategy applied to facilitate recovery. (More examples of areas of impact are given in the description of each model.)
Assessing stressors is also part of comprehensive patient care, but it is often isolated to assessing pain in the early phases of rehabilitation. Another example would be stress measured across the recovery timeline, including when the patient is readying to return to sport, to work, or to normal activities. At times, the stress of the injury or illness outweighs the patient’s coping skills and negative mood or behavior results. The role of the athletic trainer becomes that of a detective, looking for red flags in actions or conversation that may indicate the need for referral. Assessing the stressors and comparing scores across time will enable the athletic trainer to make an on-time referral, minimizing any negative outcomes. A referral team is essential and should be established well in advance of need.
The typical interprofessional care team today has advanced to include many members across healthcare disciplines who collaborate to rehabilitate a patient, including a medical doctor, an athletic trainer, a dietitian, a sport psychologist, a strength coach, and a counselor or psychologist. When cognitive appraisal and biopsychosocial models of patient care are used, the team can extend to include the coach, significant others, family, teammates, and friends of the patient. Calling on members of the team may be essential to provide optimal care for the injured or ill.
In summary, this article covers the psychological aspects of athletic training using a theoretical approach to patient care. Furthermore, the cognitive appraisal model, the biopsychosocial model, and the self-determination theory are used as guides to comprehensive patient care. Finally, the article highlights the athletic trainer’s areas of influence and suggests evidence-based psychosocial strategies to facilitate the patient’s successful recovery and return to sport, work, or normal activities.
Cognitive Appraisal Model
The cognitive appraisal model considers the individual’s personality traits, as well as prior experience with various stressors, to determine how he or she will respond to new situations and stressors (Granquist, Hamson-Utley, Kenow, & Stiller-Ostrowski, 2015). The model was developed due to the inability of the stages-of-grief model to describe a patient’s psychological response to injury (Chung, 2012; Denegar, Saliba, & Saliba, 2016). The cognitive appraisal model explains that an individual’s response to a current injury is likely influenced by past experiences, which can be utilized to predict the person’s reaction to future stressors (see Figure 1). For example, an individual who has had a negative response to previous injury is more likely to respond negatively to future injury. The model is circular: appraisals influence emotional responses, which in turn influence behavioral responses (Denegar et al., 2016; Weise-Bjornstal, White, Russell, & Smith, 2015). The cognitive appraisal model also accounts for individual differences in response to injury (Chung, 2012). For example, in contrast to the premises of the traditional grief-stage model, individuals may not experience anger or depression about the injury itself, but may feel those emotions in response to setbacks in the rehabilitation process.
Cognitive appraisals are the focal points of the model and are classified as primary or secondary appraisals. Primary appraisal occurs as individuals evaluate whether a stressful situation is a threat to their well-being. Secondary appraisals involve the assessment of coping resources and address possible behavioral responses (Carpenter, 2016). It is important to note that these appraisals are not mutually exclusive, and they do not always occur in the same order (Carpenter, 2016). According to the model, there are four pre-injury factors that may affect the perceptions of injury and the resulting rehabilitation process (see “Pre-Injury Factors”). In conjunction with pre-injury factors, personal and situational factors may also affect a patient’s perception of the injury and rehabilitation process. The personal and situational factors are classified as primary appraisals; as a result, they not only can influence how the individual reacts and responds to injury and the rehabilitation process, but also can be viewed as a threat to the individual’s overall well-being (Carpenter, 2016). Athletic trainers should be able to understand and address how these factors can affect the individual’s reactions to the injury and rehabilitation process.
There are four pre-injury factors that strongly influence how patients respond to injury: personality, history of stressors (including past injury, anxiety, and pain), coping resources, and interventions (Hamson-Utley, Arvinen-Barrow, & Clement, 2017; Wiese-Bjornstal et al., 2015). While some pre-injury factors may be unknown to the athletic trainer, it is important to understand how the factors are interrelated and may affect a patient’s response to injury.
Personality factors include prior psychological diagnoses (Weise-Bjornstal et al., 2015), demeanor, personality (Denegar et al., 2016), impulsivity, sensation-seeking behaviors, and negative affect (Weise-Bjornstal et al., 2015). Specifically, depression, attention deficit hyperactivity disorder (ADHD), anger, tension, and frustration may influence a patient’s response. Other constructs, including mental toughness, hardiness, optimistic or pessimistic perspectives, enthusiasm, and fear, may also influence the patient’s appraisal of the injury and rehabilitation process (Denegar et al., 2016; Madrigal, Gill, & Willse, 2017). It is important to be mindful that the patient’s emotional state may fluctuate throughout the injury and rehabilitation process as the patient processes the extent of the injury (Denegar et al., 2016; Tracey, 2003).
The patient’s injury history may influence how he or she will react to future injury. For example, a patient who has had multiple knee injuries may have a better understanding of the injury and rehabilitation process due to these past experiences. However, this may not always be the case, and athletic trainers should not assume that the patient will respond the same way to each subsequent injury. External factors, such as the severity and timing of injury, may affect the patient’s reaction to injury (Denegar et al., 2016). In conjunction with injury history, access to effective coping resources and social support can influence how a patient will react to future injury. (The influence of social support and the role of the athletic trainer in that support system are addressed in “Coping Skills for Situational Factors.”) It is important to note that patients who lack social support are at risk for future injury (Grandquist et al., 2015) and have poor injury outcomes (Weise-Bjornstal et al., 2015).
The last pre-injury factor to consider is intervention. For the athletic trainer, preventative education is the best intervention strategy he or she can employ. Weise-Bjornstal et al. (2015) reported that preventative education on concussions can reduce the frequency of future concussion. Athletic trainers can utilize the same preventative strategy to engage in discussions on a variety of topics, such as nutrition and healthy eating habits, self-mobilization techniques, proper sleep habits, and personal hygiene. (Weise-Bjornstal et al. reported that the above listed pre-injury factors negatively affected patients’ rehabilitation outcomes in recovery from concussion.) While the exact influence of pre-injury factors on the patient may be unknown to the athletic trainer, they should be taken into consideration when developing a rehabilitation program.
Personal factors, such as history of injury, severity of injury, and previous development of necessary coping skills, all affect the individual’s response to injury. Personal factors are highly individualized and are unique elements that the patient brings to the injury and rehabilitation situation. The cognitive appraisal model proposes that personal factors influence emotional and behavioral responses throughout the rehabilitation process. Hitchcock, Ellis, Williamson, and Nixon (2015) found that appraisals of traumatic events play a significant role in posttraumatic reactions; negative appraisals are associated with extended recovery times. The patient’s appraisal should be considered when determining injury prognosis and may prove to be helpful in guiding future interactions between the athletic trainer and patient (Hitchcock et al., 2015).
Coping Skills for Personal Factors
While some of the patient’s personal attributes will be unknown to the athletic trainer until the time of injury, knowledge of how these attributes can affect patients may be helpful in the injury recovery process. As discussed in “Personal Factors,” past experiences affect the cognitive appraisal of the current injury. Athletic trainers can use their skills in the education and dissemination of information related to the injury and rehabilitation process to provide valuable feedback related to the current injury appraisal (Clement, Granquist, & Arvinen-Barrow, 2013). Positive social support is one method for modifying post-traumatic reactions (Hitchcock et al., 2015). Athletic trainers have been identified as an integral member of the patient’s post-injury social support system (Granquist et al., 2015) and have been trained to implement psychosocial tools and skills (Arvinen-Barrow, Hamson-Utley, & DeFreese, 2017; CAATE, 2015). It can be helpful to athletic trainers to assess the patient’s perceived level of stress (Carpenter, 2016) prior to injury by employing inventories like the Cognitive Appraisal of Health Scale (CAHS) and the Primary Appraisal/Secondary Appraisal Scale (PASA). These tools, which have been proven to be valid and reliable, in conjunction with creating a sense of trust and rapport with the individual, may help lessen the negative effects of personal factors on the appraisal of the injury and rehabilitation process (Carpenter, 2016).
Situational factors, such as adherence to the prescribed rehabilitation plan, access to a support system, time of injury within the sport season, and influence of the coach and sports medicine team, can also affect the individual’s response to injury. (A complete list of personal and situational factors is found in Figure 1.) The largest area of impact is improving adherence to the prescribed rehabilitation program (Denegar et al., 2016). Roy, Mokhtar, Karim, and Mohanan (2015) stated that a positive attitude is influenced by social support and visible progress. The authors continued by reiterating the importance of building trust between patient and therapist, and how that relationship serves as a means of support during the injury process (Roy et al., 2015). This relationship is crucial throughout the injury process and can have a lasting impact on the rehabilitation progression. If the individual believes that his or her needs are being met and he or she trusts the athletic trainer, there is a greater likelihood that the person will adhere to the rehabilitation plan (Roy et al., 2015).
Coping Skills for Situational Factors
Athletic trainers can influence the patient’s appraisal by engaging in open and honest dialogue across the injury and rehabilitation processes. Developing short- and long-term goals in conjunction with input from the patient is important and can lead to increased adherence to the rehabilitation plan (Denegar et al., 2016). The goals should be fluid (Evans, Hardy, & Fleming, 2000) in order to respond to potential setbacks and changes to the overall outcome. Athletic trainers should also assist the patient in setting performance goals (goals that focus on the intricacies of the given task), and process goals, which provide a targeted approach and structure to the rehabilitation plan (Evans et al., 2000). By engaging in the goal-setting process with the patient, the athletic trainer can continue to educate the patient on the nature and severity of the injury and provide a clearer overview of the rehabilitation process (Denegar et al., 2016). This dialogue can provide direction and education throughout the rehabilitation process, which in turn may help with adherence to the prescribed rehabilitation plan (Denegar et al., 2016).
Athletic trainers should also garner input from the patient regarding the intensity of the prescribed rehabilitation plan. If the plan is too challenging, the individual may be unwilling to complete the plan, which could lead to further setbacks. If the rehabilitation plan is too easy, the individual may become bored and may be less inclined to complete the plan (Denegar et al., 2016; Roy et al., 2015).
Athletic trainers should also gauge the level and type of motivation the patient displays. Motivation can be either intrinsic, which is doing tasks for the enjoyment of doing them, or extrinsic, which is completing tasks as part of a larger goal (Schunk, Meece, & Pintrich, 2014). People who are intrinsically motivated complete tasks without needing a reward, such as praise or accolades (Schunk et al., 2014).
Finally, athletic trainers should assess the availability and type of support systems the patient has access to that may be helpful in increasing compliance and motivation. Current literature supports the implementation of social support throughout the rehabilitation process. Evans et al. (2000) stated the importance of emotional support during setbacks, lack of progression, and when situational factors negatively influence the rehabilitation process. Tracey (2003) acknowledged the importance of the athletic trainer and medical staff in the social support system, and how that relationship affected the patient’s ability to emotionally deal with their injury. Coaches, parents, teammates, friends, and other members of the patient’s social circle may be helpful resources to employ, especially during challenging moments in the rehabilitation process.
Application to Athletic Training
Using the cognitive appraisal model as a guide allows for a comprehensive, evidence-based approach to patient care. Gaining an awareness of a patient’s personality, history of stressors, use of coping skills, and successful interventions used in the past to overcome injury promotes the rehabilitative relationship with a solid foundation. Recognizing these factors provides the athletic trainer with an understanding of why the patient responds in specific ways or what methods to deploy first in the therapy regimen, potentially shaving off days or weeks of recovery time.
Consider Sam, a 25-year-old soccer player, who is working full-time and taking classes to advance his career. Playing soccer helps him to alleviate stress from work, school, and life. Over the last 3 months, Sam has developed low back pain, which has progressively gotten worse, and the pain is now prohibiting Sam from playing in his indoor soccer league. Using the CAHS and PASA will assist the athletic trainer in identifying Sam’s personality and perceived level of stress. In turn, the athletic trainer will refer Sam to the appropriate doctor, if needed, and will continue to provide care within the athletic trainer’s scope of practice. By reviewing the results of the CAHS and PASA with Sam, the athletic trainer can have a better understanding of the stressors involved, and work with Sam to set realistic rehabilitation goals and to provide a more comprehensive course of care.
The biopsychosocial model includes the biological element of healing and illustrates various areas of impact for the athletic trainer (Granquist et al., 2015). The biopsychosocial model was developed in response to the cognitive appraisal model, integrating biological factors in a way that they had not been incorporated previously. The biopsychosocial model explores injury recovery characteristics within a biological, psychological, and sociological interactive framework (Granquist et al., 2015). The model is broken into seven components; biological variables, injury characteristics, psychological variables, sociodemographic variables, social/contextual variables, intermediate biopsychological responses, and rehabilitation outcomes (Figure 2). The seven components can be grouped into three categories; biological, psychological, and social (Podlog & Eklund, 2007). This complex perspective on emotional response permits the athletic trainer to view the injury from a holistic approach that involves physical, psychological, and social constituents (Granquist et al., 2015).
After injury, injury characteristics and sociodemographic factors (see Figure 2) are considered to have a direct effect on biological (affected tissues), psychological (thoughts, emotions, and actions), and social (life stress and rehabilitation environment) factors (Granquist et al., 2015). Tissue damage and resulting inflammation (biological) can cause increased stress (social) by way of increased fear (psychological). When increased inflammation and stress cause a rise in fear, that causes hormonal responses (increased cortisol) and a subsequent increase of stress and inflammation (Granquist et al., 2015). Evidence has shown that cortisol is released in individuals experiencing stress, and cortisol has been connected to chronic stress, depression, and a suppressed immune system (Granquist et al., 2015).
Biological factors affecting injury include the extent of tissue damage, nutrition, age, and health of the individual (see Figure 2; Denegar et al., 2016). Tissue healing is affected by the type, location, and severity of damage and results in inflammation, causing pain (Denegar et al., 2016). Pain is unique because it has a biological and a psychological component and has clear emotional and behavioral implications for injury rehabilitation (Linton & Shaw, 2011). (Emotional and behavioral outcomes are discussed in “Psychological Factors.”)
Biological healing processes are limited when patients fail to maintain proper nutrition and sleep hygiene (Denegar et al., 2016). Patients may decrease caloric intake after injury as a result of decreased training and an increased concern about body image (Baker, 2014). Muscle atrophy may also occur as a result of injury and can be related to a breakdown of muscle protein (Rennie, 2007). Decreased amino acid intake, hormone levels, and physical activity may further cause atrophy (Baker, 2014). Amino acid supplementation, specifically leucine supplementation, decreases the likelihood of atrophy in the injured patient (Baker, 2014). In females, appropriate iron levels should be maintained throughout the healing process to assist in energy production (Alaunyte, Stojceska, & Plunkett, 2015). Important foods to consider throughout the healing process include those high in amino acids, rich in iron, and containing vitamins and minerals, such as copper, zinc, vitamins A, B, C, and D, and manganese (Curtis, 2016). Foods rich in omega-3 fatty acids, such as fish, may also benefit the healing process (Medina, Lizarraga, & Drobnick, 2014). Diets that are high in protein and low in carbohydrates should be encouraged in the acute phase of response to injury (Milsom, Barreira, Burgess, Iqbal, & Morton, 2014). In the response to rehabilitation and response to return to activity phases, the patient should be encouraged to eat a diet with medium carbohydrate and high protein content (Milsom et al., 2014). This dietary change is expected to minimize fat gain throughout rehabilitation.
Sleep has been reported to have restorative functions that promote health and well-being (Radtke, Obermann, & Teymer, 2014). Lack of sleep caused by pain, discomfort, or anxiety can have a detrimental effect on metabolism, which can influence range of motion, pain reduction, and rate of recovery (Brewer, Andersen, & Raalte, 2002; Hamson-Utley et al., 2017). Unsal and Demir (2012) reported that fatigue and sleep share a parallel relationship, where one affects the other. Unsal and Demir further stated that fatigue affects health, decreases performance, and lowers energy levels, which affect activities of daily living. Insomnia, which may be caused by anxiety or other external factors, has been associated with increased fatigue, irritability, aggressiveness, and decreased pain tolerance (Unsal & Demir, 2012). Age also affects the healing process: older individuals heal at a slower rate (Denegar et al., 2016). While age and health (disease and illness) are not affected by coping skills, the psychological and behavioral effects of injury can be.
Coping Skills for Biological Factors
As discussed in the cognitive appraisal model, the athletic trainer can engage in patient education. Patient education may be about injury or recovery and assists in the reduction of anxiety (Granquist et al., 2015). Reduced anxiety leads to pain reduction as the patient begins to understand the healing process and what to expect (Granquist et al., 2015). Furthermore, educating the patient about injury and the rehabilitation process can assist in rehabilitation adherence. Athletic trainers may also educate the patient about proper nutrition, sleep habits, and stress-reduction techniques to mitigate biological impedance factors. Patient education occurs via video and face-to-face discussions, and it may include diagrams or mobile application software (apps). Pain and stress have been shown to impede sleep; therefore, it is necessary to educate the injured patient on stress and coping skills (Denegar et al., 2016). A healthy diet also supports the healing process and aids in quicker recovery (Denegar et al., 2016). As previously discussed, diets containing copper, zinc, vitamins A, B, C, and D, manganese, and omega-3 fatty acids may assist in the healing process. Lack of sleep weakens the body’s immune system, which may result in illness or infection and impede the healing process (Denegar et al., 2016). Providing sleep education or tools, such as apps, to assist the patient with sleep hygiene is another task for the athletic trainer.
It is important for the athletic trainer to be aware of the stress the patient is experiencing (Granquist et al., 2015). Stress inventories, such as the Holmes-Rahe Stress Inventory (StressMarket.com, n.d.) or the Perceived Stress Scale (Cohen, Kamarck, & Mermelstein, 1983), can assist the athletic trainer in identifying the active stressors that need to be addressed through coping skills. As each area is addressed either through education or rehabilitation, the patient will begin to experience a reduction in pain and increased muscle relaxation, leading to improved healing (Granquist et al., 2015).
Psychological factors affecting injury include personality traits and emotional, behavioral, and cognitive responses (Granquist et al., 2015). Five to nineteen percent of injured patients have reported psychological symptoms comparable to those receiving treatment for mental health disorders (Glazer, 2009). Attention, cognition, emotion, and behavior all influence the patient’s pain and perception of it. While a person’s affect and other personality traits may be difficult to influence in the rehabilitation setting, self-motivation and self-esteem may be modifiable using coping skills (Denegar et al., 2016). Furthermore, injury history, severity, type, and cause, as well as athletic identity and pain tolerance, affect the patient’s response to injury (Granquist et al., 2015; Linton & Shaw, 2011). Other aspects to consider are the patient’s stress level prior to injury and preexisting or new disease processes.
Factors that can be affected by intervention from the athletic trainer include stress and behavioral responses to injury. Stress is both physical and psychological. Granquist et al. (2015) reported physiological, cognitive, emotional, and behavioral changes as a result of psychological stress. Linton and Shaw (2011) identified five psychological models of pain: the fear-avoidance, acceptance and commitment model, misdirected problem-solving model, self-efficacy model, and stress-diathesis model. Each model has varying cognitive, behavioral, emotional, or attentional processes that can be identified to treat the patient holistically. These and other responses to injury can be modified through properly educating the patient and facilitating a positive coping response to their injury.
Coping Skills for Psychological Factors
Glazer (2009) reported that returning patients to activity too soon after injury can be detrimental to their physical and mental health and wellness if they are experiencing psychological stress prior to their return. As previously stated, providing patients with facts, such as the severity of their injury, can affect the rehabilitation process and can help in gauging how injured patients will respond to returning to play. A patient may have concerns about re-injury or about not being able to return to pre-injury status. Likewise, a patient who has never suffered this type of injury before may have a hard time adapting to the challenges of returning to competition (Podlog & Eklund, 2007). Therefore, it is imperative that the athletic trainer identify and develop coping resources early. Stress inventories and pain disability indexes are two tools that aid in identifying stress and monitoring the patient. The inventories can assist the athletic trainer in making the appropriate referral or in deploying the appropriate coping skill. Stress inventories and pain disability indexes are within the scope of practice for athletic trainers and are a part of the educational competencies (CAATE, 2015). According to Linton and Shaw (2011), distraction techniques, cognitive restructuring, relaxation techniques, and coping skills training are examples of approaches that address the psychological aspects of the patient. Athletic trainers can utilize breathing exercises, positive self-talk, relaxation imagery, and goal-setting for stressful situations to reduce the patient’s anxiety, improve the patient’s attitude, and increase the patient’s motivation (Granquist et al., 2015).
However, in some instances, a team approach to care is warranted and a referral may be necessary. The first step in the referral process is recognizing the red flags of depression, anxiety, posttraumatic stress disorder, panic attacks, and eating disorders, as well as substance dependence and abuse (Granquist et al., 2015). The athletic trainer should be familiar with such disorders and refer appropriately. Each condition may involve multiple referrals to other members of the care team, including a medical doctor (MD), psychologist, sport psychologist, psychiatrist, counselor, and/or social worker (Granquist et al., 2015).
Family, finances, work, and school are some of the social factors that affect the patient’s rehabilitation. (Figure 2 offers a complete list of social factors.) While these factors are not something the athletic trainer can directly affect, coping skills can be taught. The athletic trainer can review the patient’s social support network and identify areas of impact. A patient’s social network may include, but is not limited to, family, peers, coaches, and educators (Podlog & Eklund, 2007). The rehabilitation environment is another social factor to be considered when treating the patient. The rehabilitation environment should be inviting, positive, and supportive (Granquist et al., 2015). For example, the patient may respond better in the quiet environment that exists in the early hours at an athletic training facility. A crowded facility may indicate to the patient that the athletic trainer does not care and may affect the athletic trainer’s ability to identify maladaptive behaviors in the patient (Denegar et al., 2016).
Financial constraints may occur as a result of job loss or missed time related to the injury. Anxiety related to missed work and school, as well as loss of a scholarship or starting position (Hamson-Utley et al., 2017), may cause the patient to withdraw from peers and teammates (Brewer et al., 2002). Withdrawal or isolation may be an indication of depression, substance use or abuse, or another condition that warrants referral (Granquist et al., 2015). Anxieties may also affect the patient’s sleep and cause fatigue. Issues left unresolved can have a negative impact on the recovery process (Hamson-Utley et al., 2017).
Coping Skills for Social Factors
Social stressors, such as family, finance, work, and school, can be managed through referral to counselors, psychologists, and/or social workers, and referral may be necessary to provide the best coping skills for some sociological factors. Financial and family stress may indicate the need for a social worker, while work and school stress may require the assistance of a counselor or psychologist.
Areas where the athletic trainer can have the most impact are providing social support through scheduling patients during quieter hours, providing a rehabilitation partner, and encouraging coaches to support their athletes throughout the rehabilitation process. Scheduling patients during the quieter hours in an athletic training room or clinic is one way to modify the rehabilitation environment (Denegar et al., 2016). As discussed previously, athletic trainers can also affect the patient’s recovery through helping the patient set weekly or daily goals, which may assist in improving the patient’s focus and motivation, thereby decreasing social stress (Granquist et al., 2015) and increasing rehabilitation adherence. As described by Granquist et al. (2015), rehabilitation menus, where patients select their exercises and involve teammates in rehabilitation settings, may improve the patient’s focus, motivation, and overall environment. Podlog and Eklund (2007) also indicated the need for social support from family members, medical practitioners, and coaches, because pressure from coaches or significant others may adversely affect the patient’s recovery process, and support from these individuals is important (Podlog & Eklund, 2007). Podlog and Eklund indicated a need to educate the social support network about these pressures in an effort to avoid the possible detrimental effects. Positive social support increases the patient’s confidence in the return from injury. Equally, a patient who is afraid of losing his or her position on the team or who is isolated may lose confidence and feel anxious about returning to competition (Podlog & Eklund, 2007). Providing positive social support can be key to achieving positive outcomes in the rehabilitation process.
Application to Athletic Training
Athletic trainers should consider the entire person as they apply a biopsychosocial approach to rehabilitation (Granquist et al., 2015). Taking the seven factors of this model into consideration when creating a rehabilitation plan can help to improve the outcome as the patient returns to competition (Podlog & Eklund, 2007). Awareness of the patient as a whole person promotes a solid rehabilitation foundation. The athletic trainer should focus on educating the patient about injury and rehabilitation expectations in an effort to mitigate anxiety and improve sleep (Hamson-Utley et al., 2017).
Consider the patient Sam again: providing him with education about the causes of low back pain, the treatments available, and expected recovery can decrease his anxiety. Relaxation techniques, which may also be beneficial for Sam, have been proven effective for the reduction of anxiety and worry in multimodal interventions and can be reinforced by the athletic trainer (Hamson-Utley et al., 2017). An athletic trainer who is educated about relaxation techniques should teach Sam the appropriate techniques, which may allow him to practice relaxation on his own and may assist in decreasing Sam’s anxiety and worry.
The athletic trainer may also provide a positive rehabilitation environment through proper scheduling and goal-setting. In Sam’s case, time available for rehabilitative therapy may be limited due to his career and coursework. This needs to be considered as the athletic trainer works with Sam to schedule rehabilitation. When setting rehabilitation goals, it is important that the athletic trainer involve Sam, to help minimize Sam’s self-doubt and to improve his rehabilitation outcomes. Athletic trainers may also influence the environment by curbing pressures the patient may be experiencing as a result of communication with his or her social network (Hamson-Utley et al., 2017).
Self-determination theory (SDT) is a motivational theory that examines the environmental components that influence a patient’s self-motivated behavior, mental health, mental well-being, and task-related performance (Granquist et al., 2015). Figure 3 illustrates the SDT model. SDT focuses on human motivation and the patient’s personality. Many types of motivation exist, but the most common are intrinsic and extrinsic motivation (Deci & Ryan, 2015; Hrbackova & Suchankova, 2016). Hrbackova and Suchankova (2016) identified motivation as the relationship between the individual and learning. Intrinsic motivation is evidence of the patient’s interest in the activity and is a method of self-regulation (Hrbackova & Suchankova, 2016). Patients need both support to help them physically return to play and psychosocial support as well (Granquist et al., 2015). Utilizing SDT in the rehabilitation process helps ensure a holistic approach to patient care by focusing on the basic psychological needs of the patient, including competence, relatedness, and autonomy, as well as the physical rehabilitation of the injury.
An important psychological prerequisite for effective human functioning is competence (Granquist et al., 2015). Competence can be defined as the knowledge of proficiency in one’s quests (Granquist et al., 2015), the achievement of an individual’s goals (Hrbackova & Suchankova, 2016), or the feeling of effectiveness (Ng et al., 2012). The athletic trainer can identify the injured patient’s competence through the patient’s concerns about their role on the team, anxieties regarding diminished post-injury performance, and fitness-level anxiety (Granquist et al., 2015). These concerns relate to the patient’s self-efficacy levels and may affect the patient’s psychological ability to return to play (Granquist et al., 2015). Lack of competence results in decreased motivation (Hrbackova & Suchankova, 2016). Motivation is related to the autonomy of the individual (Hrbackova & Suchankova, 2016) and is also addressed under “Autonomy.”
Coping Skills for Competence
The athletic trainer can gauge the patient’s interest in rehabilitation by assessing the patient’s interest in rehabilitation activities (Deci & Ryan, 2015; Hrbackova & Suchankova, 2016). The athletic trainer must be careful not to put pressure on the injured patient to meet unrealistic standards of excellence. Patients may feel pressure, from themselves or others, to be perfect at a skill right away.
Podlog and Eklund (2007) reported that patients who were involved in sport and exercise prior to injury experienced more confusion than their less active counterparts experienced when they returned to activity. The confusion stemmed from not receiving pertinent information about their injury and about alternative methods of maintaining their pre-injury aerobic conditioning levels. While pre-injury conditioning levels are not typically reached by the time the patient is ready to return to play (Podlog & Eklund, 2007), working with the athletic trainer can help minimize the deficit.
The patient may also develop fears about re-injury, and the fears can cause the patient to hold back, show hesitation, and avoid any situation that could cause an injury (Podlog & Eklund, 2007). Fear of re-injury can be increased in patients who have a history of an injury to a specific body part and may cause them to be more aware of their physical weakness (Podlog & Eklund, 2007). This can be a challenge for patients when they do not meet the expectations or goals they set for themselves. Deep muscle relaxation and imagery are great tools for increasing a patient’s competence (Podlog & Eklund, 2007). The athletic trainer should also make sure that the patient has full confidence in the injured body part before the return to play. Having a sport psychologist as a member of the rehabilitation team may also be useful in helping the athlete regain confidence. The athletic trainer should provide the patient with the information needed to set realistic goals and expectations during the rehabilitation process (Podlog & Eklund, 2007). A lowered sense of self-efficacy can be the cause of the patient’s fears about return to play; if the athletic trainer helps to reduce the fears, the patient will have more confidence in a return to competition (Podlog & Eklund, 2007).
Relatedness is feeling a sense of self and of belonging (Granquist et al., 2015) or a feeling of being cared for and understood (Ng et al., 2012). Both intrinsic and extrinsic aspirations may contribute to the sense of self and belonging (Ng et al., 2012). Intrinsic aspirations are defined as personal growth, community involvement, and physical fitness (Ng et al., 2012). Extrinsic aspirations include wealth, fame, and image (Ng et al., 2012). Research has shown that, when individuals emphasize extrinsic aspirations, they have inferior health outcomes (Ng et al., 2012). In the injured population, the patient may lose his or her sense of self through failing to meet short-term goals. The injured patient may feel isolated from coaches or the team as a result of the injury, which may contribute to the loss of a sense of belonging (Podlog & Eklund, 2007). Ng et al. (2012) reported that intrinsic aspirations are associated with healthy decisions more often than extrinsic aspirations are. Conversely, a negative view of intrinsic aspirations can decrease the individual’s sense of self and belonging.
Coping Skills for Relatedness
Social support from teammates and coaches can help injured patients feel like they are still an integral part of the team (Granquist et al., 2015; Podlog & Eklund, 2007). It is important that the athletic trainer communicate with coaches about the importance of incorporating the patient as an integral team member. For example, the patient can help with coaching duties or managerial tasks to maintain their sense of belonging or relatedness. Assigning a rehabilitation buddy (from the team) for social support can assist in decreasing frustration, anxiety, and feelings of isolation, and may improve (extrinsic) motivation (Deci & Ryan, 2015; Hrbackova & Suchankova, 2016). If patients are matched as rehabilitation buddies, the more able peer can help guide and support the one who is struggling, and peer support increases the patient’s sense of relatedness (Granquist et al., 2015). A team member may be able to assist in sport-specific rehabilitation, as team members are more familiar with the skills necessary to perform at higher levels. Having a strong social support system can also help in alleviating the patient’s fears about re-injury, in setting realistic performance goals, in recognizing improvements the patient has made, and in restoring confidence (Podlog & Eklund, 2007). The athletic trainer can provide social support and may be an effective buffer in maintaining the patient’s sense of self and belonging (Podlog & Eklund, 2007).
Autonomy is an awareness of control over one’s own activities (Granquist et al., 2015). An autonomous individual is more likely to seek opportunities to satisfy his or her needs (Ng et al., 2012). Ng et al. (2012) identified three ways that autonomy functions: in regulating behavior based on personal interests and values, in external direction, and in operating outside of self-control. Individuals who have high levels of autonomy are expected to be more motivated (Ng et al., 2012), and each facet of autonomy may be related to intrinsic and extrinsic motivation. Many patients are intrinsically motivated and want to return to competition to help achieve victory or to experience the positive feelings they get from playing their sport (Podlog & Eklund, 2007). Podlog and Eklund (2007) found that patients who were more extrinsically motivated had lower confidence, more performance anxiety, and an increased fear of re-injury. Autonomy can be a significant issue for patients as they transition back to full participation in their sport (Podlog & Eklund, 2007).
Coping Skills for Autonomy
As previously discussed, rehabilitation menus give patients a sense of control over their rehabilitation (Granquist et al., 2015). Ng et al. (2012) identified that an autonomy-supportive or choice-based healthcare atmosphere improves patient satisfaction through autonomous fulfillment, and these researchers also expected greater autonomy to relate to higher or greater motivation (Ng et al., 2012). Denegar et al. (2016) suggested four ways to improve a patient’s compliance with a home exercise program. The athletic trainer should have the patient perform each exercise before the patient leaves the athletic training room and should give the patient written instructions and illustrations for each of the exercises (Denegar et al., 2016). In addition, the patient should be given an exercise log to record performance (Denegar et al., 2016). Finally, at the start of the patient’s next scheduled rehabilitation session, the athletic trainer should have the patient perform the home exercise program (Denegar et al., 2016). This allows for remediation of mistakes in performance and ensures that the patient is executing the exercises correctly. This not only aids in improving patient compliance but also increases the patient’s motivation during the rehabilitation process. The type of motivation to return to play can have a profound impact on the patient’s psychological outcomes (Podlog & Eklund, 2007); therefore, the athletic trainer should remind the patient of the intrinsic motivations for return to play and should attempt to curb external pressures from coaches, fans, or other teammates (Podlog & Eklund, 2007).
Application to Athletic Training
Athletic trainers should use psychosocial interventions in conjunction with injury rehabilitation protocols when caring for an injured patient. This is important because a patient’s physical and psychological readiness to return to play do not always coincide (Podlog & Eklund, 2007). The athletic trainer not only focuses on the injury, but also helps to fulfill the patient’s basic needs for competence, autonomy, and relatedness (Granquist et al., 2015; Podlog & Eklund, 2007). Determining the patient’s intrinsic motivators can help the athletic trainer develop the best rehabilitative plan for the patient (Ng et al., 2012). Methods to improve patient motivation should incorporate extrinsic motivators to help reduce anxiety, to help the patient identify with rehabilitative activities by showing their benefits, to engage the patient with others, and to provide social support (Deci & Ryan, 2015; Hrbackova & Suchankova, 2016). Granquist et al. (2015) reported that environments supporting the individual’s competence, relatedness, and autonomy may greatly contribute to a reduction in anxiety and in fears about return to play. When patients are physically able to return to play after an injury, they are eager to get back to their sport (Podlog & Eklund, 2007), but, although the patients are physically able, they may be afraid of being in the same situation that caused their injury. The athletic trainer needs to create an environment where a patient can feel comfortable discussing the fear of re-injury. If the athletic trainer can redirect the patient’s attention to the positive components of returning to play, it can help with the patient’s psychological readiness to return to competition (Podlog & Eklund, 2007).
Again, considering the patient Sam, Sam will have a more successful return to play outcome if he completes his rehabilitation in an environment that supports his need for competence, relatedness, and autonomy. If his needs are met, Sam will return physically ready and with increased confidence, less anxiety, and more satisfaction with his performance (Podlog & Eklund, 2007).
Podlog and Eklund (2007) suggested that athletic trainers use four steps when deciding if the patient is able to return to play. The first step is the patient’s mental preparation for return to play, which is aided by talking with the patient about potential dates for return to play. The second step is to make sure that the patient is physically able to meet the demands of the sport or activity, and this includes involving the patient in the rehabilitation planning process so that the patient feels he or she is a part of the rehabilitation team. The third step is to assess the patient’s level of confidence and any fear the patient may have about returning to play. Finally, the athletic trainer should talk with the patient about how the final decision about return to play will be made and implemented (Podlog & Eklund, 2007). Including these four steps in the decision will help to ensure that the patient is both psychologically and physically prepared to return to competition.
Comparison of the Three Models
The three psychological models/theories presented aim for holistic treatment of the recovering patient, and each model addresses consideration of individual patient needs to improve the success of the rehabilitation process The athletic trainer should select an appropriate model based on his or her individual philosophy of patient care.
The cognitive appraisal model considers personality traits and prior experiences with stress to predict the individual’s response to the new injury or situation. This model can be divided into personal and situational components, and focuses on psychological and social effects on these components. The cognitive appraisal model emphasizes the importance of how the patient views the situation or injury. The athletic trainer’s role is to focus on the personal and situational aspects and to provide social support for the patient.
The biopsychosocial model encompasses biological, psychological, and social factors. The unique contribution of this model is the influence of biological factors on the patient’s rehabilitation process. The largest role for the athletic trainer in this model is patient education, in an effort to mitigate anxiety, worry, and stress. Education may address the nature and severity of the injury, the rehabilitation process, the healing process, and associated impedance factors.
Self-determination theory focuses on patient motivation and is broken into competence, relatedness, and autonomy. The largest role for the athletic trainer in this theory is to improve patient confidence and to decrease anxiety by increasing motivation. An increase in intrinsic motivation has been shown to have more positive outcomes during the rehabilitation process. The athletic trainer needs to create an environment to support the patient’s basic needs. When athletes are involved in the rehabilitation process and are given all the information needed, they are able to mentally prepare for their return to competition. Creating an environment in which patients feel fully supported and no pressure to return to sport earlier than recommended will result in patients who are more physically and psychologically prepared to return to the playing field, with higher confidence in both their skills and their injured body part.
Research indicates that a holistic approach to patient care provides a better recovery outcome (Wright, Zeeman, & Biezaitis, 2016). Multiple models of psychosocial aspects exist that allow practitioners to best incorporate holistic care based on their own philosophy and appraisal. The most significant differences among the three models presented are psychological and social stressors, biological influences on psychosocial aspects, and motivation. While each of the presented models has their unique aspects, they all share the common goal of treating the patient as a whole person rather than just an injury. The model of holistic care can be selected based on the athletic trainer’s expertise and philosophy. Coping skills or interventions (including referrals) should be selected by the athletic trainer based on the patient’s presentation.
Application of Injury Responses to the Practice of Athletic Training
The three models presented reflect the theoretical underpinnings of the psychology of injury. A three-phase model of reaction to injury, reaction to rehabilitation, and reaction to return to play aims to explain the reactions of an injured patient. Individual reactions are unique and will vary based on intrinsic motivation, extrinsic motivation, pain tolerance, mood state, coping skills, and psychological skills (Granquist et al., 2015). Athletic trainers can utilize the strategies outlined in the previous models, as well as an objective assessment of the patient’s response to injury, to identify the best method for intervention (Denegar et al., 2016).
A patient’s emotional response to injury may display the greatest emotional disturbances immediately after injury and before return to play, when anxiety may be high and confidence may be low (Granquist et al., 2015). While patients typically progress from negative to positive emotional responses, this is not always the case, and psychosocial intervention may be warranted. Response to the injury process is affected by psychological, social, and physical aspects. Research shows that individuals with high stress or anxiety levels are at a higher risk for injury, while those with lower stress or anxiety levels have a lower risk of injury (Granquist et al., 2015). Other psychological stressors include: cognitive factors (increased worrying, thoughts, focus), emotional states (anxiety, depression), behavioral factors (poor choices, rehabilitation nonadherence), social factors (family dynamics, social support networks, rehabilitation environments, and accessibility to services), and physical factors (physiological processes, tissue damage, extent of injury, and physical and nutritional health; Denegar et al., 2016). Athletic trainers report that patients with a positive outlook adhere to treatment and rehabilitation, show up for their treatment appointments, and cope better with their injury than those who do not (Clement et al., 2013). The following sections of this article aim to identify the common stressors, assessment techniques, and intervention tools to use in such situations and injury responses. The tools and techniques identified may also assist in early recognition of psychosocial issues and in providing overall improved care for the patient.
Response to Injury
Many of the stressors in the response to injury phase can be alleviated by open and honest communication between the patient and athletic trainer, as described. As discussed under the biopsychosocial model, educating the patient about his injury and expectations assists in improving rehabilitation outcomes. Furthermore, stressors, such as pain, physical limitations, anxiety, and confusion, may all affect the patient’s response to injury and can be objectively measured. The Holmes-Rahe Stress Inventory (Stressmarket.com, n.d.) can assist the athletic trainer in identifying the patient’s perceived stress level and stressors. Once they have been identified, the athletic trainer can then act within his or her scope of practice and address the stressors. As previously stated, pain affects a patient’s emotional and behavioral responses. Linton and Shaw (2011) reported that these responses are not typically evaluated, and therefore are not utilized appropriately to improve treatment outcomes. In this phase, it is important not only to assess pain, but also to assess the effect pain has on the individual, because this knowledge helps with completing the rehabilitation process and improving patient outcomes (Linton & Shaw, 2011). The athletic trainer can impact this phase by deploying a holistic approach to patient care that uses one of the psychosocial models and the various tools previously described.
Physical limitations, such as deformity and swelling, may affect the patient’s response to injury. An individual with a torn anterior cruciate ligament (ACL) may have a negative response to injury, whereas an individual with a grade 1 ankle sprain may display a more positive response. The varying responses may be due to the physical limitations associated with each injury. Alternatively, anxiety and confusion, compounded by a lack of understanding of the injury, may also contribute to the patient’s response to injury (Granquist et al., 2015). Anxiety is commonly experienced after injury (Clement, Arvinen-Barrow, & Fetty, 2015; Covassin, Beidler, Ostrowski, & Wallace, 2015; Forsdyke, Smith, Jones, & Gledhill, 2016) and removal from a sport or activity can increase anxiety (Tatsumi & Takenouchi, 2014). Abrupt removal from a sport or activity may create athletic identity issues, which the athletic trainer should be aware of early in the response to injury phase (Granquist et al., 2015). After injury, a strong athletic identity may negatively affect the patient’s feeling of self-worth, and this can be addressed through rehabilitation (Granquist et al., 2015). In patient Sam’s case, this may be the first time he has had to stop playing soccer, which may cause him to experience a decrease in self-worth and an increase in anxiety. The athletic trainer can address this through education and patient-oriented goal setting. As previously discussed, social factors can also affect the response to injury phase (Covassin et al., 2015). The aforementioned psychosocial models describe how athletic trainers can use their skills to educate the patient about the exact nature and severity of an injury, which may be helpful in mitigating the feelings of anxiety and confusion.
The CAATE (2015) requires that athletic trainers be taught how to properly use and implement such tools described in this article, to ensure that athletic trainers can appropriately utilize psychosocial strategies. Athletic trainers should employ objective measures, such as a disability index, goniometric measurements, and girth measurements, to assist in identifying and monitoring physical factors (Arvinen-Barrow, Hamson-Utley, & DeFreese, 2017). Numeric rating scales (Denegar et al., 2016), Wong-Baker Faces (Garra et al., 2010), the Visual Analog Scale (VAS; Denegar et al., 2016), and pain disability indexes (Denegar et al., 2016) are tools for objectifying pain. Numeric pain scales are used frequently and are considered reliable and valid (Williamson & Hoggart, 2005). The VAS has also been shown to be valid (Ferreira-Valente, Ribeiro, Jensen, & Almeida, 2011; Williamson et al., 2005) and reliable (Williamson et al., 2005) as a measure of pain intensity. Pain disability indexes are a valid and moderately reliable method for determining the effect pain has on the patient (Cleland, Childs, & Whitman, 2008; Chiarotto et al., 2016; Macdermid et al., 2009). Depression and anxiety scales also help determine the patient’s level of anxiety. One such validated and reliable scale is the Hospital Anxiety and Depression Scale (HADS; Ferreira-Valente et al., 2011). The Athletic Identity Scale (AIMS) is a valid scale that can be used to measure athletic identity and to assist in determining the psychosocial approach to treatment (Martin, Eklund, & Mushett, 1997; Visek, Hurst, Maxwell, & Watson, 2008). These assessment scales can be used throughout the injury and rehabilitation process by the athletic trainer and can be helpful in gauging progress. These tools may be important for a postsurgical patient whose rehabilitation is progressing slowly and who is still suffering from high levels of pain (Arvinen-Barrow et al., 2017). The postsurgical patient may display higher levels of anxiety associated with the loss of athletic identity than are displayed by the patient suffering a low-grade ankle sprain.
Patient education, through podcasts, informational pamphlets, and personal conversations, can result in a more positive response to injury. Decide apps (Orca Health Inc., 2017b) are created for healthcare professionals and may be beneficial in educating the injured patient. These apps contain anatomical diagrams and highlight multiple medical conditions. Other mobile apps may assist in the identification or extent of psychological factors, such as those that address pain, sleep, and anxiety. Examples of such apps are Catch My Pain (Sanovation AG, 2016), Meditation Music (Avryx, 2016), and The Stress & Anxiety Companion, discussed in Response to Rehabilitation (Companion Apps Limited, 2017). Catch My Pain (Sanovation AG, 2016) is an app that can be used by the athletic trainer to track pain, diagnosis, and symptoms and can be shared with the athlete. Meditation Music (Avryx, 2016) is an app that provides music conducive to meditation and even sleep. Relaxation techniques that assist in pain management and decrease the patient’s anxiety about injury may also aid with rehabilitation success. Imagery, thought stoppage, and positive self-talk can be effective in pain management and the reduction of anxiety. The tools may be useful throughout the phases of response to rehabilitation and response to return to play—at each phase, the focus of the tools is shifted onto the specific needs at that phase.
Response to Rehabilitation
Patient response to rehabilitation is the next phase. Many of the stressors found in the response to injury phase carry over into the response to rehabilitation. However, the biggest difference in this phase is the patient’s emotional responses. (Refer to the previous sections describing the psychosocial models for a complete list of emotional responses to injury.) Tracey (2003) reported that patients internalize and process the emotions of anger, anxiety, hope, and depression. In their qualitative study, Clement et al. (2015) found that the emotion most commonly reported by patients during this phase was frustration. Participants in the study reported feelings of frustration related to lack of progress and loss of pre-injury abilities (Clement et al., 2015). Another important distinction in this phase is the increase in issues related to adherence to the prescribed rehabilitation plan. As previously discussed, Clement et al. suggested that nonadherence could be due to lack of motivation or it could be a sign of eagerness to return to sport. Denegar et al. (2016) reported that patients’ boredom and the lack of challenging programs contributed to lack of adherence to a prescribed rehabilitation plan. In this phase, athletic trainers play a greater role in social support, and therefore they can help increase motivation and adherence (Clement et al., 2015).
In this phase of response, the focus shifts from pain control and management to the management of the stressors in the rehabilitation process itself. Athletic trainers can use objective measures utilized in the response to injury phase, such as range of motion, strength testing, girth measurements, and manual muscle testing, to provide tangible clinical information to guide the rehabilitation process (Arvinen-Barrow et al., 2017). Rehabilitation protocols from a physician are useful in outlining the overall rehabilitation process. Setting short- and long-term goals in conjunction with the patient help to create a sense of achievement and aid in adherence to a rehabilitation plan, especially when in long-term rehabilitation (Denegar et al., 2016). Open and honest communication among parties, including positive self-talk and encouragement from the athletic trainer, can also be helpful in this phase (Clement et al., 2015). As discussed in the biopsychosocial model, communication affects the behavioral and emotional outcomes—specifically, the social and psychological aspects outlined in Figure 2.
This phase, like the response to injury phase, can benefit from the use of technology to engage patients and to keep them motivated as they progress through rehabilitation (Arvinen-Barrow et al., 2017). Utilizing videos of the patient during certain exercises may be helpful in providing clearer feedback and corrections. Journaling apps, such as MindShift (Anxiety Disorders Association of British Columbia, 2017), may aid in communication between athletic trainer and patient. The MindShift app provides important tools, such as an anxiety checklist, active steps the individual can take to feel less anxious about the situation, and positive self-talk examples to quell any anxiety the individual may be feeling. The Stress & Anxiety Companion app (Companion Apps Limited, 2017) can also be used to help the patient engage in relaxation techniques and reframing negative thoughts. Use of technology should not replace interactions with the athletic trainer, but technology can enhance communication and progress in rehabilitation.
Response to Return to Activity
The final phase is the patient’s response to return to activity. The stressors found in the first two phases carry over into this final phase, especially anxiety. In this phase, patients may feel anxiety regarding return to activity or re-injury (Clement et al., 2015). While the injury may be fully healed according to medical standards, the patient may not have a pre-injury level of confidence or the readiness to return. The lack of confidence can affect the patient negatively if he or she is forced to return to activity too quickly and can expose the person to a higher risk of re-injury (Podlog & Eklund, 2007).
Other emotional reactions include excitement and enthusiasm about return to activity, as well as personal reflection on the injury process (Denegar et al., 2016). According to Clement et al. (2015), the overall theme found in this phase is “lessons learned.” Patients surveyed by Clement et al. reflected on the personal perspective they gained throughout the injury and rehabilitation process, including an appreciation for the sport they played and personal strength gained from being away from their sport.
As in the preceding two phases, many stressors can be alleviated with open and honest communication. In this phase, the patient may benefit from speaking with a sport psychologist about techniques that equip an athlete for return to play after injury. Athletic trainers should encourage patients to talk to their coaches, so they can understand what the expectations are once they return to play. Athletic trainers can help their patients by following a progressively challenging rehabilitation protocol, implementing sport-specific activities early in the rehabilitation process, and by breaking down larger challenges into smaller, more manageable components (Arvinen-Barrow et al., 2017). This practice is imperative in longer rehabilitation processes, such as those after ACL reconstruction. Mental imagery and other psychological techniques may also be helpful in this phase, especially when a patient feels pressured to return to activity (Hamson-Utley, Martin, & Walters, 2008).
In conjunction with the clinical techniques previously discussed in each model, there are a variety of tools that the athletic trainer and patient can utilize to facilitate the return to activity (Arvinen-Barrow et al., 2017). Stress management can be accomplished using stress-level scales and apps, such as the Perceived Stress Scale (Cohen, Kamarck, & Mermelstein, 1983), Coping with Stress Scale/Strategies (Coping with Stress, n.d.), the Holmes-Rahe Stress Inventory (StressMarket.com, n.d.), Mood Tools app (Liu, 2017b), Stress and Anxiety Companion app (Companion Apps Limited, 2017), Relax Lite: Stress, and Anxiety Relief app (Saagara, 2016), and the Pacifica Anxiety, Stress, & Depression Relief app (Pacifica Labs, Inc., 2017). The last three apps listed also help with managing anxiety, as their titles imply. The BellyBio Interactive Breathing app (RelaxLine, 2015), MindShift app (Anxiety Disorders Association of British Columbia, 2017), and SAMapp (University of the West of England, 2017) are also useful for reducing anxiety. Aside from the use of drills specific to the patient’s sport, there are many Decide apps (Orca Health Inc., 2017b) made for healthcare professionals. Foot Decide (Orca Health Inc., 2017a) provides an overview of various foot injuries, explaining treatment plans. A few apps that help with confidence and motivation are CBT Thought Record Diary (Liu, 2017a), Smiling Mind (Smiling Mind, 2017), and Unique Daily Affirmations (Gopher Apps LLC, 2017). The use of these apps can create a positive state of mind and be relaxing to the patient. The use of meditation, such as through the Smiling Mind app (Smiling Mind, 2017), can help to calm a patient who becomes frustrated with not being able to return to pre-injury skill levels after they have been physically cleared to return to sport.
Holistic Patient Care
Patient care in the United States has altered since the 1990s, owing to a greater acceptance of the use of psychosocial skills (Hamson-Utley et al., 2008). McEvoy and Duffy (2008) reported on articles from the 1990s stating that holism includes the whole person─mind, body, and spirit─and identifying harmony as an integral piece of holism. Until recently, the nonphysical aspects of pain were often ignored. Research in the last decade has examined the effects of nonphysical agents on patient care. McEvoy and Duffy proposed a definition of holistic nursing to include the patient’s mind, body, and spirit and the provision of individualized care. Wright et al. (2016) reported that research shows that a holistic approach, or one that incorporates all aspects of function, provides a better patient outcome. In some instances, a holistic approach has been identified as a key component in quality care (Wright et al., 2016). New changes are being implemented in athletic training education programs to instruct and evaluate students on their ability to incorporate psychosocial skills in their rehabilitation programs (Hamson-Utley et al., 2008).
According to Granquist et al. (2015), in 1991 most athletic trainers believed the only method for facilitating recovery was to focus on short-term goals and to encourage positive self-talk. The authors also report that in 2001, physiotherapists ranked relaxation, imagery, and concentration as less important methods of facilitating recovery. By 2008, athletic trainers and physical therapists reported more positive attitudes toward the use and effectiveness of psychosocial strategies (Granquist et al., 2015). Similarly, Hashemy, Zakerimoghadam, and Neisi (2015) offered evidence that the use of muscle relaxation decreases anxiety in patients waiting for cardiac catheterization.
It is important that athletic trainers consider the patient beyond physiological, biological, and cognitive needs, and extend care to the patient’s social, emotional, and spiritual needs. One of the most positive attributes of a holistic approach is the individuality and flexibility of care (Hamson-Utley et al., 2008). The use and implementation of therapeutic modalities and the planning of rehabilitation are individualized, rather than using a single approach to fit every patient’s needs.
The implementation and use of the discussed models in clinical practice enhance the ability of the athletic trainer to approach healthcare from a holistic perspective. While some research has already been done on each of the individual models, more research needs to be done on best practices for the implementation of the models in clinical practice. Each of the discussed models approach healthcare and patient well-being from a holistic perspective, but strategies on how to best utilize the holistic approach need to be clearly outlined. The models need to be adapted and implemented to reflect the specific needs and challenges found in the various clinical settings in athletic training. The biopsychosocial model needs to be further expanded and implemented in athletic trainers’ education programs, so that students can become familiar with the techniques early in their training. As technology continues to develop and advance, new apps and tools need to be developed and investigated for their usefulness and effectiveness in clinical practice. Apps that can reflect strategies to best address the three phases of the recovery process may be helpful in clinical practice. Other areas of future research should address the effects of age and level of psychological maturity at the onset of injury, the individual’s competition level at the onset of injury, and the needs of individuals who are not familiar with, or comfortable using, technology.
Athletic trainers are allied healthcare professionals who take a holistic approach to treating their patients. It is important to care for the whole person and not just the area of the body that is injured. Special attention should be paid to cognitive theories, such as the cognitive appraisal model, biopsychosocial model, and self-determination theory. Caring for a patient’s basic psychological needs will create a better rehabilitation plan and a more successful return to play for the patient. With the use of new tools, such as apps, athletic trainers have more resources to ensure they are providing optimal care for their patients.
The cognitive appraisal model takes into account the patient’s personality traits and previous experiences with stress to predict how the person will respond to the new injury (Granquist et al., 2015). There are both personal and situational components, and they are focused on psychological and social effects (Denegar et al., 2016; Weise-Bjornstal et al., 2015). The athletic trainer who utilizes this model during rehabilitation is making an effort to consider the patient’s views of the injury situation. The athletic trainer then can provide effective social support to the patient in the situational and personal aspects of the rehabilitation process.
The biopsychosocial model is based on biological, psychological, and social factors (Granquist et al., 2015), which are influenced by how the patient responded to a previous injury, in addition to any learned coping mechanisms. An athletic trainer who uses the biopsychosocial model is considering how biological factors, in combination with psychological and social factors, affect the patient’s rehabilitation process. The athletic trainer should focus on patient education when using this model. When the patient is aware of, and understands, the nature and severity of the injury, rehabilitation process, healing process, and associated impedance factors, the patient will experience decreased anxiety and an improved healing process.
Self-determination theory places its core emphasis on patient motivation (Deci & Ryan, 2015; Granquist et al., 2015; Hrbackova & Suchankova, 2016; Podlog & Eklund, 2007). The theory is divided into the psychological aspects of competence, relatedness, and autonomy (Deci & Ryan, 2015; Granquist et al., 2015; Hrbackova & Suchankova, 2016; Podlog & Eklund, 2007). The athletic trainer should focus on improving the patient’s confidence and decreasing anxiety through the positive reinforcement of intrinsic motivators (Podlog & Eklund, 2007). This can be done by creating an environment that supports the patient’s basic needs of competence, relatedness, and autonomy. The patient’s involvement in the rehabilitation process helps them to be more confident and psychologically ready to return to play.
It has been shown that a holistic approach to patient care provides the best outcomes. The models described are the leading models that guide the practice of athletic training today. Athletic trainers can decide which model to utilize based on their own philosophy and their appraisal of their patients. Each of the models discussed proposes that the patient should be treated as a whole person rather than as just an injury. The athletic trainer and the patient should decide, together, which coping skills or interventions will be most effective for the patient.
Alaunyte, I., Stojceska, V., & Plunkett, A. (2015). Iron and the female athlete: A review of dietary treatment methods for improving iron status and exercise performance. Journal of the International Society of Sports Nutrition, 12(1), 38.Find this resource:
Anxiety Disorders Association of British Columbia. (2017). MindShift. (Version 1.22) [Mobile application software].
Arvinen-Barrow, M., Hamson-Utley, J., & DeFreese, J. D. (2017). Sport injury, rehabilitation, and return to sport. In J. Taylor (Ed.), Assessment in applied sport psychology (pp. 183–198). Champaign, IL: Human Kinetics.Find this resource:
Avryx. (2016). Mediation Music. (Version 5.52) [Mobile application software].
Baker, D. F. (2014). Return to play after soft tissue injury: The role of nutrition in rehabilitation. New Zealand Journal of Sports Medicine, 41(2), 48–53.Find this resource:
Brewer, B. W., Andersen, M. B., & Van Raalte, J. L. (2002). Psychological aspects of sport injury rehabilitation: Toward a biopsychosocial approach. In D. L. Mostofsky & L. D. Zaichkowsky (Eds.), Medical and psychological aspects of sport and exercise (pp. 41–54). Morgantown, WV: Fitness Information Technology.Find this resource:
Carpenter, R. (2016). A review of instruments on cognitive appraisal of stress. Archives of Psychiatric Nursing, 30, 271–279.Find this resource:
Chiarotto, A., Maxwell, L. J., Terwee, C. B., Wells, G. A., Tugwell, P., & Ostelo, R. W. (2016). Roland-Morris Disability Questionnaire and Oswestry Disability Index: Which has better measurement properties for measuring physical functioning in nonspecific low back pain? Systematic review and meta-analysis. Physical Therapy, 96(10), 1620−1637.Find this resource:
Chung, Y. (2012). Psychological correlates of athletic injuries: Hardiness, life stress, and cognitive appraisal. International Journal of Applied Sports Sciences, 24(2), 89–98.Find this resource:
Cleland, J. A., Childs, J. D., & Whitman, J. M. (2008). Psychometric properties of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain. Archives of Physical Medicine and Rehabilitation, 89(1), 69–74.Find this resource:
Clement, D., Arvinen-Barrow, M., & Fetty, T. (2015). Psychosocial responses during different phases of sport-injury rehabilitation: A qualitative study. Journal of Athletic Training, 50(1), 95–104.Find this resource:
Clement, D., Granquist, M. D., & Arvinen-Barrow, M. M. (2013). Psychosocial aspects of athletic injuries as perceived by athletic trainers. Journal of Athletic Training, 48(4), 512–521.Find this resource:
Clement, D., Hamson-Utley, J. J., Arvinen-Barrow, M., Kamphoff, C., & Martin, S. (2012). College athletes’ expectations about athletic training and injury rehabilitation. International Journal of Athletic Therapy & Training, 17(4), 18–27.Find this resource:
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 386–396.Find this resource:
Commission on Accreditation of Athletic Training Education. (2015). Athletic training education competencies (5th ed.).
Companion Apps Limited. (2017). Stress & Anxiety Companion. (Version 1.2.1) [Mobile application software].
Coping with Stress. (n.d.). Coping with stress.
Covassin, T., Beidler, E., Ostrowski, J., & Wallace, J. (2015). Psychosocial aspects of rehabilitation in sports. Clinics in Sports Medicine, 34(2), 199–212.Find this resource:
Curtis, L. (2016). Nutritional research may be useful in treating tendon injuries. Nutrition, 32(6), 617–619.Find this resource:
Deci, E. L., & Ryan, R. M. (2015). Self-determination theory. International Encyclopedia of the Social & Behavioral Sciences, 21, 486–491.Find this resource:
Denegar, C. R., Saliba, E., & Saliba, S. (2016). Therapeutic modalities for musculoskeletal injuries (4th ed.). Champaign, IL: Human Kinetics.Find this resource:
Evans, L., Hardy, L., & Fleming, S. (2000). Intervention strategies with injured athletes: An action research study. Sports Psychologist, 14, 188–206.Find this resource:
Ferreira-Valente, M. A., Pais-Ribeiro, J. L., & Jensen, M. P. (2011). Validity of four pain intensity rating scales. PAIN, 152(10), 2399–2404.Find this resource:
Forsdyke, D., Smith, A., Jones, M., & Gledhill, A. (2016). Psychosocial factors associated with outcomes of sports injury rehabilitation in competitive athletes: A mixed studies systematic review. British Journal of Sports Medicine, 50(9), 537–544.Find this resource:
Garra, G., Singer, A., Taira, B. T., Chohan, J., Cardoz, H., Chisena, E., & Thode, H. C. (2010). Validation of the Wong-Baker FACES pain rating scale in pediatric emergency department patients. Academic Emergency Medicine, 17(1), 50–54.Find this resource:
Glazer, D. D. (2009). Development and preliminary validation of the Injury−Psychological Readiness to Return to Sport (I−PRRS) scale. Journal of Athletic Training, 44(2), 185–189.Find this resource:
Gopher Apps LLC. (2017). Unique Daily Affirmations. (4.0.4) [Mobile application software].
Granquist, M., Hamson-Utley, J., Kenow, L. J., & Stiller-Ostrowski, J. (2015). Psychosocial strategies for athletic training. Philadelphia: F.A. Davis.Find this resource:
Hamson-Utley, J., Arvinen-Barrow, D., & Clement, M. (2017). Managing mental health aspects of post-concussion syndrome in college athlete: Applying theory to practice. Athletic Training and Sports Health Care, 9(6), 263–270.Find this resource:
Hamson-Utley, J. J., Martin, S., & Walters, J. (2008). Athletic trainers’ and physical therapists’ perceptions of the effectiveness of psychological skills within sport injury rehabilitation programs. Journal of Athletic Training, 43(3), 258–264.Find this resource:
Hashemy, S., Zakerimoghadam, M., & Neisi, L. (2015). Palliative nursing care impact on anxiety outcomes in patients waiting for cardiac catheterization. Advances in Environmental Biology, 9(4), 401–407.Find this resource:
Hitchcock, C., Ellis, A. A., Williamson, P., & Nixon, R. D. V. (2015). The prospective role of cognitive appraisals and social support in predicting children’s posttraumatic stress. Journal of Abnormal Child Psychology, 43, 1485–1492.Find this resource:
Hrbackova, K., & Suchankova, E. (2016). Self-determination approach to understanding of motivation in students of helping professions. Procedia−Social and Behavioral Sciences, 217, 688–696.Find this resource:
Liu, E. (2017a). CBT Thought Record Diary. (Version 1.2.1) [Mobile application software].
Liu, E. (2017b). MoodTools. (Version 1.3) [Mobile application software].
Linton, S. J., & Shaw, W. S. (2011). Impact of psychological factors in the experience of pain. Physical Therapy, 91(5), 700–711.Find this resource:
Macdermid, J. C., Walton, D. M., Avery, S., Blanchard, A., Etruw, E., Mcalpine, C., & Goldsmith, C. H. (2009). Measurement properties of the Neck Disability Index: A systematic review. Journal of Orthopaedic & Sports Physical Therapy, 39(5), 400–417.Find this resource:
Madrigal, L., Gill, D. L., & Willse, J. T. (2017). Gender and the relationships among mental toughness, hardiness, optimism, and coping in college athletics: A structural equation modeling approach. Journal of Sport Behavior, 40(1), 68–86.Find this resource:
Martin, J. J., Eklund, R. C., & Mushett, C. A. (1997). Factor structure of the Athletic Identity Measurement Scale with athletes with disabilities. Adapted Physical Activity Quarterly, 14(1), 74–82.Find this resource:
McEvoy, L., & Duffy, A. (2008). Holistic practice: A concept analysis. Nurse Education in Practice, 8(6), 412–419.Find this resource:
Medina, D., Lizarraga, A., & Drobnick, F. (2014). Injury prevention and nutrition in football. Sports Science Exchange, 27(132), 1–5.Find this resource:
Milsom, J., Barreira, P., Burgess, D. J., Iqbal, Z., & Morton, J. P. (2014). Case study: Muscle atrophy and hypertrophy in a premier league soccer player during rehabilitation from ACL injury. International Journal of Sport Nutrition and Exercise Metabolism, 24(5), 543–552.Find this resource:
Ng, J. Y., Ntoumanis, N., Thogersen-Ntoumanis, C., Deci, E. L., Ryan, R. M., Duda, J. L., & Williams, G. C. (2012). Self-determination theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7(4), 325–340.Find this resource:
Orca Health Inc. (2017a). Foot Decide. (Version 6.0.9) [Mobile application software].
Orca Health Inc. (2017b). Maximizing patient-provider engagement.
Pacifica Labs Inc. (2017). Pacifica−Anxiety, Stress, & Depression Relief. (Version 5.1.1). [Mobile application software].
Podlog, L., & Eklund, D. (2007). The psychosocial aspects of a return to sport following serious injury: A review of the literature from a self-determination perspective. Psychology of Sport and Exercise, 8(4), 535–566.Find this resource:
Radtke, K., Obermann, K., & Teymer, L. (2014). Nursing knowledge of physiological and psychological outcomes related to patient sleep deprivation in the acute care setting. Medsurg Nursing, 23(3), 178.Find this resource:
RelaxLine. (2015). BellyBio Interactive Breathing. (Version 1.1.3) [Mobile application software].
Rennie, M. J. (2007). Exercise- and nutrient-controlled mechanisms involved in maintenance of the musculoskeletal mass. Biochemical Society Transactions, 35(5), 1302–1305.Find this resource:
Roy, J., Mokhtar, A. H., Karim, S. A., & Mohanan, S. A. (2015). Cognitive appraisals and lived experiences during injury rehabilitation: A narrative account with personal and situational backdrop. Asian Journal of Sports Medicine, 6(3), 1–4.Find this resource:
Saagara. (2016). Relax Lite: Stress and Anxiety Relief. (Version 4.3) [Mobile application software].
Sanovation AG. (2016). Catch My Pain (Version 3.5.6) [Mobile application software]. Retrieved from https://www.catchmypain.com/.
Schunk, D., Meece, J., & Pintrich, P. (2014). Motivation in education: Theory, research, and applications (4th ed.). Boston: Pearson Education.Find this resource:
Smiling Mind. (2017). Smiling Mind. (Version 3.1.4) [Mobile application software].
StressMarket.com. (n.d.). Holmes-Rahe Stress Inventory.
Tatsumi, T., & Takenouchi, T. (2014). Causal relationships between the psychological acceptance process of athletic injury and athletic rehabilitation behavior. Journal of Physical Therapy Science, 26(8), 1247–1257.Find this resource:
Tracey, J. (2003). The emotional response to the injury and rehabilitation process. Journal of Applied Sport Psychology, 15, 279–293.Find this resource:
University of the West of England. (2017). Self-help for Anxiety Management. (Version 1.2.8) [Mobile application software].
Unsal, A., & Demir, G. (2012). Evaluation of sleep quality and fatigue in hospitalized patients. International Journal of Caring Sciences, 5(3), 311–319.Find this resource:
Visek, A. J., Hurst, J. R., Maxwell, J. P., & Watson, J. C. (2008). A cross-cultural psychometric evaluation of the athletic identity measurement scale. Journal of Applied Sport Psychology, 20(4), 473–480.Find this resource:
Weise-Bjornstal, D. M., White, A. C., Russell, H. C., & Smith, A. M. (2015). Psychology of sport concussions. Kinesiology Review, 4(2), 169–189.Find this resource:
Williamson, A., & Hoggart, B. (2005). Pain: A review of three commonly used pain rating scales. Journal of Clinical Nursing, 14(7), 798–804.Find this resource:
Wright, C. J., Zeeman, H., & Biezaitis, V. (2016). Holistic practice in traumatic brain injury rehabilitation: Perspectives of health practitioners. PLoS One, 11(6).Find this resource: