Psychological Aspects of Athletic Injuries as Perceived by … · 2012-09-19 · Psychological...

The Sport Psychologist, 1996,10,3747 O 1996 Human Kinetics Publishers, Inc.

Psychological Aspects of Athletic Injuries as Perceived by Athletic Trainers

Gerald A. Larson Tabor Academy

Chad Starkey Northeastern University

Leonard D. Zaichkowsky Boston University

This study investigated the perceptions of certified athletic trainers concerning their attitudes, beliefs, and application of a variety of psychological strategies and techniques used in the treatment and rehabilitation of athletic injuries. The Athletic Training and Sport Psychology Questionnaire (ATSPQ) was adapted from instruments developed by Wiese, Weiss, and Yukelson (1991) and Brewer, Van Raalte, and Linder (1991). The ATSPQ, a letter of introduc- tion, and a self-addressed stamped envelope were distributed to 1,000 certified athletic trainers randomly selected from the membership database maintained by the National Athletic Trainers' Association (NATA). Only 482 (48.2%) of these questionnaires returned were usable. 47% of athletic trainers who responded believe that every injured athlete suffers psychological trauma. 24% reported that they have referred an athlete for counseling for situations related to their injury, and 25% reported that they have a sport psychologist as a member of their sports medicine team. This study concludes that future education of athletic trainers should address the psychological aspects of injury treatment as well as the development of a sport psychology referral network.

Athletic trainers are the primary health care professional for injured athletes (NATA, 1992a). As many advocates of psychological intervention strategies have stated, the athletic trainer is in the ideal position to handle the psychological aspect of athletic injuries and rehabilitation (Pedersen, 1986; Tuffey, 199 1; Weiss & Troxel, 1986; Wiese & Weiss, 1987; Wiese et al., 1991; Wiese-Bjorns- tal & Smith, 1993).

Gerald A. Larson is with Tabor Academy, Marion, MA 02738-1599. Chad Starkey is with the Department of Physical Therapy in the Bouve College of Pharmacy and Health Sciences at Northeastern University, Boston, MA 021 15. Leonard D. Zaichkowsky is with the School of Education at Boston University, 605 Commonwealth Ave., Boston, MA 02215.

38 Larson, Starkey, and Zaichkowsky

During the past 20 years, many sports medicine personnel and sport psychology researchers have postulated that a relationship exists between a number of psychological variables, the onset of athletic-related injuries, and the athlete's compliance with a rehabilitation program (Williams & Roepke, 1993). In their survey of athletic trainers, Wiese et al. (1991) found that specific psychological skills (e.g., interpersonal communication, positive reinforcement, continued team involvement, and realistic goal setting) were important factors in facilitating an athlete's ability to cope with injury rehabilitation. In addition, athletic trainers rated the following as the most important factors in assisting injured athletes with their injury: knowledge of positive communication style, setting realistic goals, encouraging positive self-thought, and understanding individual motivation.

Wiese-Bjornstal and Smith (1993) stated that clear, controlled communication is the primary responsibility of athletic trainers during the initial management of the injury. Also of emphasis was the athletic trainer's role in ensuring that injured athletes have realistic goals and expectations for their recovery.

Athletic trainers have experiential knowledge about psychological responses to injury but often lack systematic and specific educational preparation in these areas (Wiese-Bjornstal & Smith, 1993). In agreement with this point, athletic trainers have indicated a need for more formal education on the psychological factors and strategies associated with the rehabilitation of athletic injuries (Wiese et al., 1991).

Entry-level athletic trainers spend 74% of their time preventing, evaluating, managing, and rehabilitating athletic injuries (NATA Board of Certification, 1990). Based on the findings of the Role Delineation Validation Study for the Entry-Level Athletic Trainer's Certification Examination (NATA Board of Certi- fication, 1990), the National Athletic Trainers' Association (NATA) Professional Education Committee has determined 191 different competencies in athletic training, encompassing six performance domains. Of those, 12 competencies are related to the psychological aspect of athletic injuries. Given this fact, most entry- level athletic trainers should have spent approximately 6% of their professional preparation in the area of psychological considerations in sport (NATA, 1992b).

Since 1986, much has been written about the psychological aspect of athletic injuries and the use of psychological intervention skills in the treatment of those injuries. Several researchers have indicated the ideal position of athletic trainers in dealing with the psychological aspect of athletic injuries (Pedersen, 1986; Tuffey, 1991; Weiss & Troxel, 1986; Wiese et al., 1991; Wiese-Bjornstal & Smith, 1993). Most of these studies, however, have been anecdotal in nature and have not actively included a practicing certified athletic trainer (ATC). The focus of this study is to understand what psychological principles and strategies certified athletic trainers believe to be important in the assessment and management of athletic injuries.

To date, only one study (Wiese et al., 1991) has investigated the use of sport psychology skills by athletic trainers in their work with injured athletes. This study, however, included student athletic trainers as well as ATCs, with only 22.6% employed full-time as athletic trainers. Further, no information was gathered concerning formal education in sport psychology or the availability and utilization of sport psychology services.

Psychological Aspects of Athletic Injuries 39

The purpose of this study was to survey the perceptions of practicing ATCs concerning the attitudes, beliefs, and application of a variety of psychological strategies and techniques they use in their work with injured athletes. The results from this study will further enhance the practicing sport psychologist's understanding of the athletic trainer's use of sport psychology skills. This knowledge will enable the sport psychologist to become a more effective member of the sports medicine team and will advance the utilization of psychological skills in treatment of injured athletes.

Method Subjects

One thousand subjects were randomly selected from the database of certified athletic trainers who maintained active membership in the NATA during 1993. A cover letter was included with the survey instrument informing the members about the purpose of this study, that participation was voluntary, and that confiden- tiality would be maintained.

Of the 1,000 surveys mailed, 499 (49.9%) were returned. Of those returned, 17 (1.7%) were omitted from the analysis because respondents either did not consider themselves to be currently employed as an athletic trainer, or the returned survey contained too many missing data. Therefore, 482 (48.2%) surveys were used in the analysis.

Females comprised 202 (41.9%) of the 482 respondents; 280 (58.1%) were male. The education level of respondents was as follows: 181 (37.6%) held bachelor's degrees, 287 (59.5%) had earned master's degrees, and 14 (2.9%) had earned doctorates. ATCs employed at the high school level comprised 38.2% of the sample, with clinics employing 25.9%; collegesluniversities, 24.7%; and professional or amateur sports organizations, 11.2%.

Athletic trainers in this study reported having an average of 7.58 years experience, with 68.7% indicating between 1-9 years experience as an ATC. A majority (75.9%) of the athletic trainers reported working primarily with interscholastic/intercollegiate athletes, with 19.1% and 4.6% having indicated that they work with recreational and world classlelite athletes, respectively. ATCs indicated that they evaluate an average of 19.35 (SD = 7.48) injuries a month, with 40.7% reporting they assessed 26 or more injuries per month.

Questionnaire

The Athletic Training and Sport Psychology Questionnaire (ATSPQ) was adapted from instruments developed by Wiese et al. (1991) and from Brewer et al. (1991). The first question asked how frequently ATCs encounter specific conditions associated with athletic injuries. They were asked to respond to a 5-point Likert scale ranging from never to very often.

The second question consisted of two open-ended questions, asking athletic trainers to identify the top 4 behaviors present in athletes who do and do not cope successfully with an athletic injury. The third question asked if the ATC had referred an injured athlete for counseling for situations related to their injury and, if so, how many times.


The fourth question asked if the athletic trainer had a written procedure for referring athletes for counseling services. According to Role Delineation Validation Study for the Entry-Level Athletic Trainer's Certification Examirzation (NATA Board of Certification, 1990), most, if not all, athletic trainers should have responded "yes" to this question.

The fifth question consisted of 13 psychological skills and techniques that sport psychology researchers have suggested might be important in assisting an injured athlete in their recovery from an injury. ATCs were asked to rate on a 5-point Likert scale how often they personally had used a specific skill or technique in their work with injured athletes. The scale ranged from never to 100% of the time, with 25%, 50%, and 75% serving as intervals.

The sixth question asked how often the athletic trainer believed an athlete to be affected psychologically by an injury. They were asked to use the 5-point Likert scale employed in the previous question. Space was also indicated for additional comments.

Question 7 asked athletic trainers which of the psychological skills or techniques they believed would be important in learning more about enhancing work with an injured athlete. In addition to listing the 13 skills and techniques in Question 5, listening skills of the athletic trainer were included. A 5-point Likert scale was used with the anchors of not important and very important.

The last two questions asked how important treating the psychological aspect of an athletic injury was and how important a course in sport psychology was in the education of an athletic trainer. The Likert scale from the previous question was utilized in answering the last two questions.

A pilot study with 18 ATCs from five institutions was conducted utilizing the ATSPQ. The ATCs were given the questionnaire, along with a brief descrip- tion of purpose, and asked to complete the form. Upon completing the ATSPQ, comments about the survey instrument were solicited and appropriate adjustments based on those comments were made.

Procedure and Analysis The ATSPQ was mailed to ATCs with a letter of informed consent and a postage- paid return envelope. Descriptive statistics were computed for each item on the questionnaire. A qualitative analysis was performed on the open-ended responses of the ATSPQ using the method of tagging and regrouping suggested by Cote, Salmela, and Baria (1993). This technique involved three series of analyses.

The first involved dividing the responses into meaning units. Cote et al. (1993) described a meaning unit as a segment of text that contains one idea or piece of information. It was suggested that the coder look for in vivo tags used by the subjects. The second step involved creating specific categories or characteristics for grouping the meaning units. In this study, 16 characteristic groups were created. The final step involved quantifying observed characteristic groups.

Results Athletic trainers in this study reported that they observed psychological influences associated with athletic injuries. They also reported utilizing a variety of psychological skills and techniques and expressed a desire to become more acquainted with applied psychological skills to enhance their work with athletes.


Of the 482 certified athletic trainers in this study, 261 (54.1%) had taken a formal sport psychology course, with close to half (5 1.7%) taking the course as an undergraduate preparing for the NATA Certification Examination. A majority (76.1%) of athletic trainers surveyed had never referred an athlete for counseling as a result of their injury; the remaining athletic trainers (23.9%) reported they had referred at least one athlete for injury-related counseling.

Athletic trainers who had referred an injured athlete for counseling did so in 8.2% of the cases they saw. Survey responses revealed that 8.8% of the 482 athletic trainers had a standard written procedure for referring athletes for counseling services and 25% had a sport psychologist available to them as a member of the sports medicine team.

Many athletic trainers (47%) reported that athletic injuries affected the athlete psychologically as well as physiologically and recognized the need to address both responses during the athlete's rehabilitation. The condition of stress and anxiety was encountered by 71% of the athletic trainers. Over half (53%) reported that anger was often encountered with the injured athlete. Treatment compliance problems and depression were also frequently encountered conditions (Table 1).

Athletic trainers observed a variety of traits in athletes who successfully cope with an athletic injury. Those traits included compliance with treatment and rehabilitation programs; positive attitude about the injury and life; motivation to work hard during rehabilitation; dedicated, determined, or a strong desire to return to sport; asking questions and seeking knowledge about injury and rehabilitation; and employed focused goals during rehabilitation. Table 2 provides the frequencies with which athletic trainers observed particular characteristics in athletes who cope successfully with an athletic injury.

Athletic trainers also observed a variety of traits in athletes who do not cope well with an athletic injury (Table 3). The top 5 characteristics in athletes who do not cope well with an athletic injury as reported by ATCs were, noncompli- ance with the treatmentlrehabilitation program; apathy, depression, feelings of hopelessness or indifference, or self-pity; no motivation, laziness, poor work effort with rehabilitation; blaming others or using the injury as an excuse; anger, aggressive behavior; and withdrawing from the team or other activities- introverted behavior.

Table 1 Conditions Associated With Athletic Injuries (N=482)

Condition M SD

Stresslanxiety 3.91 0.926 Anger 3.48 1.062 Treatment compliance problems 3.36 0.994 Depression 3.06 1.087 Problems with attentionlconcentration 2.63 0.940 Exercise addiction 2.21 1.032

Note. 1 = Never encounter condition; 5 = very often encounter condition.

42 Inrson, Starkey, and Zaichkowsky

Table 2 Behaviors, Characteristics, and Attitudes of Athletes Who Cope Success- fully With Injury (N=429)

Characteristics %

Comply with rehabilitationltreatment program Positive attitude about injury and life Motivated to work hard during rehabilitation Dedicated, determined, or strong desire to return to sport Asks questions, knowledgeable about injury and rehabilitation Is focused, uses goals in rehabilitation process Confident in their ability as an athletelperson Stays involved with their team Involved with activities outside of athletics Accepts, copes with injury Good family, coach, peer support Good communication with athletic trainer and/or coach Good student academically Socially outgoing Good time management skills Good pain tolerance

Note. This was an open-ended question in which athletic trainers were asked to list the top 4 observed behaviors/characteristics.

The top 5 intervention techniques used by athletic trainers in their work with injured athletes were, keeping the athlete involved with the team; the use of short-term goals; encouraging positive self-thoughts; creating variety in rehabilitation exercises; and encouraging effective communication skills. Table 4 provides a summary of the skills and techniques utilized by the athletic trainers in this study in their work with injured athletes.

Athletic trainers identified learning the following very important skills in order to enhance their work with injured athletes (see Table 5): setting realistic goals; using effective communication; creating variety in rehabilitation exercises; enhancing the listening skills of the athletic trainer; and understanding individual motivation.

Discussion

Almost 90% of the athletic trainers surveyed reported it was "Relatively important" or "Very important" to treat the psychological aspect of an athletic injury. This is a significant finding that would indicate, when considered with the previous two research questions, that athletic trainers desire more information on how to treat the psychological aspect of athletic injuries. A majority (85%) of athletic trainers surveyed believe that a course in sport psychology is "Relatively important" or "Very important" in the education of athletic trainers.


Table 3 Behaviors, Characteristics, and Attitudes of Athletes Who Do Not Cope With Injury (N=429)

Characteristics %

Do not comply with rehabilitationltreatment program Apathetic, depressed, feel hopeless or indifferent, self-pity No motivation, lazy, poor work effort with rehabilitation Blame others or use injury as an excuse Anger, aggressive behavior Withdraw from team, other activities-introverted behavior Poor communication with athletic trainer or coach Deny injury severity, fail to cope with injury Lack self-confidence Negative attitude toward injury and life Frustrated, impatient with injurylrehabilitation Lack of focus or goals in rehabilitation High level of anxiety, stress Decreased effortlachievement with school work Poor pain tolerance No family, coach, peer support

Note. This was an open-ended question in which athletic trainers were asked to list the top 4 observed behaviorslcharacteristics.

If athletic trainers believe athletes are psychologically affected by an athletic injury, it stands to reason they believe sport psychology has a place in the formal education of an athletic trainer. Through their written comments on the ATSPQ, respondents indicated that a sport psychology course for athletic trainers should be practical in nature and be specifically designed to meet the needs of athletic trainers in their work with injured athletes. Others reported that on-the-job experience and "people skills" were more important than formal training.

Many athletic trainers commented there could be many different factors contributing to the psychological involvement of athletes in their reaction to an athletic injury. Interestingly, many of the responses took individual differences into account, such as type of athlete, time of the season, career status, and involvement of others (e.g., coach, peers, parents). Additionally, many thought that an injury could affect an athlete in a positive psychological manner, though no examples were given.

The athlete's stress, anxiety, and anger were reported as the most frequently encountered psychological conditions associated with injury. Techniques to re- duce these conditions, however, were not frequently used in treating injured athletes. Several factors may explain this finding.

First, ATCs may be unfamiliar with the strategies or have inadequate time to treat stress, anxiety, and anger. Second, ATCs may not address these conditions because of lack of a referral protocol. Finally, ATCs may believe that by treating


Table 4 Skills and Techniques Used by Athletic Trainers in Working With Injured Athletes (N=482)

Keeping the athlete involved with the team Using short-term goals Creating variety in rehabilitation exercises Encouraging positive self-thoughts Encouraging effective communication skills Enhancing self-confidence Reducing stresslanxiety Improving social support Reducing depression Teaching muscular relaxation techniques Usinglteaching relaxation techniques Using mental rehearsal/visualization Teaching emotional control strategies

Note. 1 , Never use; 2, use 25% of the time; 3, 50% of the time; 4, 75% of the time; 5, 100% of the time.

Table 5 Important Skills and Techniques for Athletic Trainers to Learn (N=482)

Understanding individual motivation Setting realistic goals Using effective communication Enhancing listening skills of the AT Creating variety in rehabilitation exercises Enhancing self-confidence of injured athlete Encouraging positive self-thoughts Reducing stress/anxiety Reducing depression Teaching concentration skills Teaching emotional control strategies Teaching muscular relaxation techniques Teaching the use of mental imagery Improving social support for injured athlete

Note. 1 = Not important; 5 = very important.


the physical injury, they are treating the stress, anxiety, and anger they observe in their injured athletes as well.

Those skills identified by the athletic trainers as leading to a successful rehabilitation program support most of the findings by Wiese et al. (1991). The athletic trainers in this study, however, rated listening skills of athletic trainers higher in importance than did those in the study by Wiese et al. (1991). Supporting the earlier findings of Wiese et al. (1991), athletic trainers in this study expressed strong interest in learning more about each of the skills presented in the ATSPQ.

A high percentage (89%) of athletic trainers listed a variety of characteristics and attitudes that they observed in athletes who coped, or did not cope, with an athletic injury. These results support the findings of Wiese et al. (1991), who reported a willingness to listen to the athletic trainer, a positive attitude, intrinsic motivation, a willingness to learn more about the injury and rehabilitation technique, determination (mental toughness), and high self-esteem or self-confidence to be positive traits.

Few of the athletic trainers (24.5%) surveyed had a sport psychologist at their disposal. This information is contrary to the current research (Heil, 1993; Henderson & Carroll, 1993; Pargman, 1993; Smith, Scott, & Wiese, 1990; Wiese et al., 1991; Wiese-Bjornstal & Smith, 1993) that suggests the sport psychologist plays an integral role on the sports medicine team.

If athletic trainers are recognized as the primary health care professional caring for injured athletes (NATA, 1992a), and 75% of athletic trainers surveyed do not have access to a sport psychologist, it would be advantageous for the practicing sport psychologist, as well as for the Association for the Advancement of Applied Sport Psychology (AAASP), to develop a referral network. This could be achieved by establishing formal relations between AAASP and the NATA.

Applied sport psychology designed specifically for athletic trainers should be integrated into all athletic-training education programs. Sport psychologists offering courses and workshops for athletic trainers should emphasize practical skills and techniques rather than theoretical or abstract concepts. Additionally, course work for athletic trainers in therapeutic exercise should address sport psychology skills and techniques, such as goal setting, communication skills, relaxation techniques, and imagery. Sport psychologists can assist the athletic trainer by forming a referral network, marketing sport psychology services, and establishing criteria that establish when and how to make a referral.

This study was designed to investigate the athletic trainers' practical application of sport psychology skills and techniques. Athletic trainers appear to be very interested in sport psychology. They reported observing several emotional conditions in athletes associated with athletic injuries, such as stress, anxiety, and anger and recognized the need to address the psychological ramifications of injury. This is accentuated by the fact that athletic trainers reported using many sport psychology interventions in their work with injured athletes and expressed a desire to learn practical measures to more effectively utilize those intervention strategies.

Athletic trainers observed a variety of psychological conditions in athletes with an athletic injury. Those athletic trainers, however, did not utilize specific strategies to address those observed conditions. Although athletic trainers empha- sized the importance of a sport psychology course in their education, many


expressed a frustration that few sport psychology courses had practical application to the athletic training profession.

Much of the research in the area of the psychological aspect of athletic injuries has been conducted and reported by sport psychologists. Athletic trainers are the primary health care professional involved with athletic injuries. As this study shows, few athletic trainers have any involvement with a sport psychologist.

If the psychological aspect of athletic injuries is to be better understood, both sport psychologists and athletic trainers need to work cooperatively for the benefit of their primary concern, the athlete. In order to advance this knowledge, both empirical research into the psychological aspect of athletic injuries and practical application of sport psychology skills for athletic trainers need to be promoted.

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Wiese-Bjornstal, D.M., & Smith, A.N. (1993). Counseling strategies for enhanced recovery of injured athletes within a team approach. In D. Pargman (Ed.), Psychological bases of sports injuries (pp. 149-1 82). Morgantown, WV: Fitness Information Technology.


Williams, J.M., & Roepke, N. (1993). Psychology of injury and injury rehabilitation. In R.N. Singer, M. Murphy, & L.K. T e ~ a n t (Eds.), Handbook of research on sport psychology (pp. 815-839). New York: Macmillan.

Acknowledgment

The authors would like to acknowledge Britt Brewer for his comments in the development of this manuscript.

Manuscript submitted: July 29, 1994 Revision received: April 5, 1995

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